OBSTETRICAL ULTRASOUND

NAME:_______________________________________ DATE: __________ MR #:_______________

REASON FOR EXAM: ______________________________ LMP: _______ EDD _____ GA ______
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CERVIX: closed open Length: ______________

PLACENTA Ant Post Fundal Previa Partial previa Low lying Grade: 0 1 2 3
CORD: 3V 2V
AMNIOTIC FLUID VOLUME: normal high normal increased decreased AFI: __________

FETUS Sex: M F Biophysical profile Breathing 0 1 2

Position cephalic breech transverse variable Tone 0 1 2
Movement 0 1 2
Situs:…………………… nl abnl
Face…………………… nl abnl not seen
Orbits…………………nl abnl not seen
Profile……………….. nl abnl not seen Chin ______
Lips/nose…………… nl abnl not seen Nasal bone ____ mm
Neck…………………… nl abnl not seen Nuchal thickness ______ mm
Brain…………………… nl abnl not seen Ventricles R _____mm L ______mm Third _____ mm
C septum pellucidum nl abnl Hanging choroid Y N
Corpus callosum nl abnl
Cerebellum……………. nl abnl not seen Cbl diameter ______ mm Cisterna magna _______ mm
Spine…………………… nl abnl not seen
Lungs nl abnl
Heart 4 chamber…….. nl abnl not seen
Outflow tracts…… nl abnl not seen
Stomach ………………. nl abnl not seen
Bowel………………… nl abnl not seen
Cord insertion………… nl abnl not seen
Kidneys R………… nl abnl not seen length_______ AP pelvis_______ Renal AA Y N
Caliectasis Y N Hydroureter Y N
L………… nl abnl not seen length_______ AP pelvis_______ Renal AA Y N
Caliectasis Y N Hydroureter Y N
Bladder………………… nl abnl not seen
Extremities arms - R nl abnl not seen legs - R nl abnl not seen
-L nl abnl not seen -L nl abnl not seen
hands- R nl abnl not seen feet - R nl abnl not seen
-L nl abnl not seen -L nl abnl not seen

DOPPLER Heart rate ____________

MCA PSV______cm/sec RI ________ PI _______
Umbilical artery S/D _____ abn nl RI ______ PI _______ CerebroPlacental ratio ______ abn nl
Umbilical vein nl pulsatile Ductus venosus nl pulsatile

ADDITIONAL MEASUREMENTS FOR SKELETAL DYSPLASIA

Humerus R____ __% nl abnl Femur R____ __% nl anbl Chest circumference ________
L ____ __% nl abnl L ____ __% nl abnl Clavicles __________
Radius R____ __% nl abnl Tibia R____ __% nl abnl Scapula __________
L ____ __% nl abnl L ____ __% nl abnl Foot length ________
Ulna R____ __% nl abnl Fibula R____ __% nl abnl OOD _______
L ____ __% nl abnl L ____ __% nl abnl IOD _______

ESTIMATED GESTATIONAL AGE ____ weeks ____days ESTIMATED FETAL WEIGHT_______gms, ________%
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COMMENTS : ____________________________________________________________________________________
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Modified on 2/20115/18/2011 4:16:00 PM