DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

COURSE NAME: Obstetrical Ultrasound

MS DIAGNOSTIC ULTRASOUND

COURSE CODE: MSDUOU-514|1

CREDIT HOURS: 3
0BSTETRICAL ULTRASOUND
The First Trimester
DR ANJUM TAZEEN
ASSISTANT PROFESSOR,
UIRSMIT, FAHS
The First Trimester Obstetrical Ultrasound
LEARNING OUTCOMES
• TYPES OF OBSTETRICAL ULTRASOUNDS

• AIUM GUIDELINES FOR STANDARD FIRST TRIMESTER

ULTRASOUND

• DIAGNOSTIC AND CONCERNING SIGNS OF A FAILED

PREGNANCY
DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS
 DETAILED FETAL ANATOMIC SURVEY-
LECTURE CONTENT

• COMPONENTS OF AND NORMAL FINDINGS OF FIRST

TRIMESTER ULTRASOUND

• ABNORMALITIES THAT MAY BE DETECTED ON FIRST

TRIMESTER ULTRASOUND INCLUDING CONCERNING
AND DIAGNOSTIC SIGNS OF A FAILEDPREGNANCY

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

OBSTETRICAL ULTRASOUND-TYPES
According to AIUM guidelines there are four types of
obstetric ultrasound examinations:
• First trimester ultrasound
• Standard second and third trimester ultrasound
• Limited obstetric ultrasound
• Specialized obstetric ultrasound

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

First trimester ultrasound includes an evaluation of the
uterus and adnexa to:

• see whether a gestational sac is present and, if

present, its location
• visualization of the yolk sac
• visualization of the embryo

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

GESTATIONAL SAC (5 weeks)

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

GESTATIONAL SAC (5 weeks)

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

YOLK SAC

• Five and a half

weeks

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

 EMBRYO

• Around six weeks

• Look for cardiac
flicker
• Measure CRL if
possible

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS
DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS
PRESENCE OR ABSENCE OF CARDIAC ACTIVITY SHOULD BE
DOCUMENTED WITH A VIDEO CLIP OR M-MODE IMAGE

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

 DOCUMENTATION OF FETAL NUMBER

• ESTABLISH
CHORIONICITY AND
AMNIONICITY IN
CASE OF MULTIPLE
PREGNANCY

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

DOCUMENTATION OF FETAL NUMBER

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

ASSESSMENT OF EMBRYONIC / FETAL ANATOMY

BY 11 -13 WEEKS
• CHOROID PLEXUS
• STOMACH
• ARMS
• LEGS
• CORD INSERTION

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

NUCHAL TRANSLUCENCY

• 10 – 14 WEEKS

• SHOULD NOT BE
MORE THAN 3mm

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

EXAMINATION OF PELVIC STRUCTURES

• UTERUS

• ADNEXA

• CUL-DE SAC

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

 ASSESSMENT OF GESTATIONAL AGE

• MSD : Mean Sac

Diameter

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

ASSESSMENT OF GESTATIONAL AGE

CRL : Crown
Rump Length

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

ASSESSMENT OF GESTATIONAL AGE

• ULTRASOUND DATING OF PREGNANCY IS MOST

ACCURATE IN THE FIRST TRIMESTER OF PREGNANCY

• CRL IS A MORE ACCURATE FIRST TRIMESTER

INDICATOR OF GESTATIONAL AGE ESTIMATION

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

ASSESSMENT OF GESTATIONAL AGE
• ESTIMATION OF GESTATIONAL AGE IS BASED UPON LMP IF IT IS
SIMILAR TO CRL (WITHIN 5 DAYS)
• IF THE DIFFERENCE IS MORE THAN 5 DAYS THEN GEST. AGE IS BASED
UPON CRL
• IN CASE OF ASSISTED FERTILITY PROCEDURES (eg IVF) THE KNOWN
DATE OF CONCEPTION IS USED TO ASSIGN GA INSTEAD OF LMP AND
CRL

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

ABNORMAL INTRAUTERINE
PREGNANCY
(FIRST TRIMESTER)

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

GENERAL CONCEPTS

Viable pregnancy is a gestation that can potentially

result in a live infant
Ultrasound plays an important role in distinguishing
between viable and nonviable intrauterine pregnancies

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

GENERAL CONCEPTS

The pregnancy should always be given the benefit of

the doubt
Even when features favor a non viable/failed
pregnancy, if there is even a slight chance of viability a
failed pregnancy should not be reported

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

FAILED PREGNANCY: Diagnostic Findings (TV US)

SINGLE STUDY:

• CRL 7mm or larger with no cardiac activity

• MSD 25mm or larger with non visualization of embryo

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

FAILED PREGNANCY: Diagnostic Findings (TV US)
FOLLOW-UP SONOGRAM:
No embryo with cardiac activity:
• 2 weeks or more following visualization of the gestational
sac without yolk sac
• 11 days or more following visualization of the gestational
sac with yolk sac
DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS
FAILED PREGNANCY: Concerning Findings (TV US)

SINGLE STUDY:
• CRL less than 7mm with no cardiac activity
• MSD 16-24mm with nonvisualization of embryo

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS
FAILED PREGNANCY: Concerning Findings (TV US)

Abnormal
appearing yolk sac:
large (>7mm),
calcified,
misshapen

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

FAILED PREGNANCY: Concerning Findings
• Empty amnion sign

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

 FAILED PREGNANCY: Concerning Findings

• Double bleb sign

• Slow embryonic HR
(first trimester
bradycardia)
<90 bpm before 6.3
weeks
<110bpm after that

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

 FAILED PREGNANCY: Concerning Findings(TV US)
FIRST TRIMESTER OLIGOHYDRAMNIOS:

small GS relative to the size of the

embryo

MSD – CRL should be equal to or

greater than 5mm

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

FAILED PREGNANCY: Concerning Findings

• No embryo 6
weeks after LMP
• Low position of
GS
• Distorted contour
of GS
• Thin irregular rim
DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS
 FAILED PREGNANCY: Concerning Findings

Large amniotic sac

relative to the embryo
(normally within 1-2mm
of each other)

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

FAILED PREGNANCY: Concerning Findings
• Chorionic bump

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

FAILED PREGNANCY: Concerning Findings
(Follow up study)
No embryo with cardiac activity seen
• 7-13 day after visualization of the gestational sac
without the yolk sac
• 7-10 days after visualization of the gestational sac
with yolk sac
DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS
 SUBCHORIONIC HEMATOMA

More than half of

the circumference –
poor prognosis

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

SUBCHORIONIC HEMATOMA

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

SUBCHORIONIC HEMATOMA

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

 SUBCHORIONIC HEMATOMA
(More than half of
the circumference –
poor prognosis)

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS
REFERENCES
1. Hertzberg BS, Middleton WD. Ultrasound: the requisites. Elsevier
Health Sciences; 2015 Jul 17.
2. ACR-ACOG-AIUM-SRU Practice Parameter for the Performance of
Obstetrical Ultrasound, American College of Radiology, 2013. at
http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/U
S_Obstetrical.pdf. Accessed 13 Sept 2013.
3. Doubilet PM, Benson CB: Double sac sign and intradecidual sign in
early pregnancy: interobserver reliability and frequency of
occurrence, J Ultrasound Med 32:1207-1214, 2013.
4. Jeve Y, Rana R, Bhide A, et al: Accuracy of first-trimester
ultrasound in the diagnosis of early embryonic demise: a
systematic review, Ultrasound Obstet Gynecol 38:489-496, 2011.

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS

THANKYOU FOR YOUR KIND
ATTENTION

DR ANJUM TAZEEN ASSISTANT PROFESSOR, UIRSMIT, FAHS