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Normal Uterine Size: By ultrasound, the normal postmenarchal nulliparous uterus is 5-8 cm in length, 1.5-3 cm thick, 2.5-5 cm. wide. Myometrium: The normal myometrium is hypoechoic, homogeneous, and reasonably well demarcated from the endometrial echos. Endometrial Structure: The endometrium consists of a constant basal layer (basalis), and a cycling functional layer (functionalis). The Functional layer includes a thin compactum layer and a thick spongiosum layer. Name of phase menstrual phase follicular phase (also known as proliferative phase) ovulation (not a phase, but an event dividing phases) luteal phase (also known as secretory phase) Days 1-4 4-14 14 15-26 Gestational Sac first appears in the substance of the decidua (intradecidual) at 4.5 weeks, and should be seen in virtually all normal 5 week intrauterine pregnancies. The yolk sac is a definite evidence of a true gestational sac, first seen at 5 weeks. It is a landmark to the early embryo, which develops along it's outer margin . Yolk sac should be seen when sac is 8-10mm. MSD by vaginal probe, or 20 mm. MSD by abdominal probe. By vaginal probe high resolution scanning the embryo is first seen between 5.7-6.1 weeks, with heartbeat appearing at 6.2 weeks. Small normal embryos may not have a heartbeat. Embryo should be seen by High resolution scan at 18mm MSD, or 25 mm MSD by abdominal scan. Anembryonic Gestation (Blighted Ovum) By High Resolution Vaginal Scanning a sac >13 mm MSD (Mean Sac Diameter) with no yolk sac is often considered abnormal, but occasional normal pregnancies do not show yolk sac up to 20mm. By Lower Resolution Abdominal Scanning a sac >20 mm. MSD with no yolk sac is abnormal. Vaginal Scanning to improve certainty should then be done. By High Resolution Vaginal Scanning a sac >18 mm. MSD without an embryo is often considered abnormal, however normal sacs up to 20 mm. may show no embryo. By Lower Resolution Abdominal Scanning a sac >25 mm. MSD without an embryo is abnormal. At this sac size, if subsequent Vaginal Scan also negative, anembryonic nature is virtually assured.
ischemic phase (some sources group this 27-28 with secretory phase) Phase menstrual phase proliferative phase secretory phase Days 1-4 4-14 Thickness thin Trilaminar
From the standpoint of Hemorrhage volume (Estimated from formula Length (cm) X Height (cm) X Depth (cm) X 0. Since almost half of these pregnancies will be lost. but is less reliable in small embryos. Incomplete Spontaneous Abortion (Embryo Dead): In many cases.1. though it may be seen to slowly migrate from the initial fundal location toward the uterine cervix Obstetrical Ultrasound Measurements Gestational Sac: The first element to be measurable is the gestation sac of the early pregnancy. the MSD + 30 = Menstrual Age in days. This is among the best documented parameters to date the embryo. The BPD best used after 12 weeks. because this leading interface is most distinct. the CRL + 6. The gestational sac is measured in three dimensions. +/. is often associated with continued development.2. As a rough rule of thumb. We measure from the the leading edge to leading edge of the bones. Embryonic Crown-Rump Length • The length of the embryo on the longest axis (excluding the yolk sac) constitutes the crown-rump length. Expulsion of the sac is often delayed several days.4 week 26-30 weeks. and +/. the embryo will have already died. As long as the placental (Decidua Vera) interface of the gestational sac and decidua remain intact.0. A true circumference is not actually measured though.52 = Volume ml). however this "small sac" sign occurs only 2% of the time. less then 75-200 ml.It is useful between 5 and 8 menstrual weeks with accuracy of +/. with accuracy of +/. Slow Heartbeat: Embryonic heart rate < 85 BPM is a negative prognostic sign. it is a source of great concern.2 Associated Findings in threatened Abortion Subchorionic Bleeding : Often visible as endometrial fluid surrounding the external (Decidua Capsularis) aspect of the gestational sac.1. The BPD and APD (anterior/posterior diameter) are measured and the circumference of the resulting oval calculated. usually recognized by a symmetric demonstration of the fetal thalmus. Small Sac: When the mean sac diameter (MSD) exceeds Crown Rump Length (CRL) by less then 5 mm. Head Circumference a measurement which considers both transverse (BPD) and front to back (APD) will be more accurate.3-4 weeks after 30 weeks.1 week 14-20 weeks. +/. As a rough rule of thumb. the pregnancy often continues.5 week (95% CI).6 weeks 20-26 weeks. Threatened Abortion: Bleeding in the First Trimester. persistent chorionic function maintains a positive HCG assay. Biparietal diameter (BPD): The transverse width of the head at it's widest. . and a major indication for ultrasound examination. and the average. the Mean Sac Diameter (MSD) used for estimating gestational age. Accuracy is +/..5 = Menstrual Age in Weeks. This combined measurement is called the head circumference. Vaginal bleeding occurs during the first 20 weeks in nearly 25% of clinical pregnancies.3-5 days. loss rate is 80%.
through the liver at the level of the left portal vein or stomach. and if negative. Sonographic Findings: 1) Pyosalpinx ö pus-filled. 6) Ovarian malignancy ö a solid component to an ovarian lesion is the most significant predictor of malignancy. Abdominal circumference The abdominal circumference is another circumference estimate made by averaging the anterior-posterior and transverse diameters times 3. although 1-2% of tubo-ovarian abscesses are reported in postmenopausal women. 5) Ovarian Torsion . most commonly chlamydia or gonorrhea or both. and post-abortion or post-delivery infection. more specific All pregnancies 26 weeks or more must show motion during routine ultrasound. it is a reliable measurement which confirms measurements of the head. and fluid-fluid levels. Sensitive but not Specific. sexually active women.5 cm. False + in Sleep Fetal Trunk and Extremities Movements: Moderate Complexity. Amniotic Fluid Volume: Not neural reflex. round. fishnet appearance. PID Pelvic inflammatory disease (PID) is caused by sexually transmitted infection. diverticulitis. Biophysical Profile Fetal Breathing Movements: Complex Reflex. Fetal Tone: Simple maintenance of flexion "Fetal Position" posture.diagnosis rests on ovarian enlargement with normal ovarian volume being up to approximately 15 cc. PID also occurs as a complication of appendicitis.homogeneous internal echoes. you can do it easily with the formula (APD + BPD)/2 X 3. anechoic. but ominously specific often for more advanced distress. It is made at the widest point in the abdomen. Other suggestive findings are multiple peripherally based follicles. pelvic abscess. 2) Tubo-ovarian complex ö dilated fallopian tube and inflamed ovary within a mass formed by adhesions. but a physiologic reflection of urine production and uterine retention. further evaluation is done. less Sensitive. pelvic tenderness. Formal Biophysical Profile. Adenexal Mass Sonographic Findings: 1) Functional cyst ö smooth. Pus appears as layering echogenic fluid and gas within mass.3 If the machine does not calculate Head Circumference.14. patients present with fever. irregular thick wall and septa > 3mm. Acutely. and heterogeneous tissues. . Doppler demonstration of central blood flow within a solid component. hyperechoic mass with dark acoustic shadow. retracting clots and fibrous strands. 4) Endometrioma ö adnexal cystic mass with diffuse. and vaginal discharge. The inflammation commonly becomes chronic and patients present with pelvic mass and dyspareunia. but since these are rare. 3) Cystic teratoma ö tip of iceberg sign. 2) Hemorrhagic cyst . Relatively insensitive. It is affected by skeletal dysplasias. dilated fallopian tube is recognized by the echogenic particulate matter that fills or layers within the tube. first Acoustic stimulation. It is best measured after 14 weeks. if not. low-level internal echoes and hyperechoic foci in the wall. thin-walled ovarian cyst larger than 2. Most cases occur in young.14 = Head Circumference Femur Length The femur length is a repeatable measurement with accuracy similar to the BPD.
> 25 TA Fetal heartbeat Embryo > 5mm EV.5 . Ectopic pregnancy is much less likley if an IUP is found.6 6 . 3) An acute bleed may be very echogenic and blend in with the pelvic fat in the cul-de-sac and be missed unless you're specifically looking for it. Usually bleeding or pain in a patient with a positive BHCG is the common presentation. . complex fluid. an ectopic always has an echogenic ring. Ultrasound Landmarks in Normal Pregnancy Finding Expected Visualization Approximate Weeks 4. Acute blood can also be anechoic.6.5 5. Beware of calling an ovarian follicle an ectopic.6.5 6 .5 . 4) An ectopic will often be on the side of the corpus luteum cyst but does not have to be. BHCG > 1800 by TA Yolk sac Mean sac diameter > 8 EV. Ectopic pregnancy can never be excluded.5 Gestational sac BHCG > 1000 by EV.4 Ectopic Pregnancy An ectopic pregnancy is implantation of a fertilized ovum outside of the fundus or body of the uterine cavity. We can confirm an intrauterine pregnancy (IUP) by documenting a yolk sac or a live embryo with a heartbeat. any size TA Sonographic Findings: 1) Any abnormality outside the uterus significantly increases the risk of ectopic pregnancy. 2) Signs of an ectopic include adnexal masses. > 18 TA Embryo Mean sac diameter > 16 EV. a ring of echogenic decidualized tissue involving the fallopian tube (tubal ring sign) or fluid in the cul-de-sac or Morrison's pouch.
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