@ I Name of Center I

.
ISU09°•g Basic first-trimester examination

Date of exam: Sonographic appearance of fetal

Patient
Patient name: anatomy
ID: Birth
Normal = N N A NV
Sonographer: date:
Abnormal =
Ultrasound machine: A
Transabdominal D Not visualized = NV
Indication for scan: Head and brain
Transvaginal D
Screening D Head shape, ossification
Faix present, butterfly-shape choroid plexus
Other:
Heart
Relevant risk factors: lntrathoracic position
Regular rhythm
ART pregnancy: N I Y
Abdomen
.............. Singleton: D Stomach present, abdominal wall
Twins**: D monochorionic I dichorionic intact Bladder not dilated
Adnexa: Normal D Abnormal D Not examined D
Extremities
Measurement mm Upper limbs with three
segments Lower limbs with
Crown-rump length (CRL) three segments
Placenta
Biparietal diameter (BPD) Normal appearance without cystic structures

Nuchal translucency (NT) Other

Other

Gestational age based on ultrasound: . ..... ..weeks ......days

I Remarks:
(* Describe here any abnormal findings)
CONCLUSION:
0 Normal and complete examinat ion.
0 Normal but incomplete examination.
O Abnormal examination*
0 Plans: 0 No further ultrasound scans required
0 Follow up planned in ..... weeks.
0 Referred to ...............
0 Other:

cfDNA test: planned D Signed: . .. .. ............. ................................. ......... ......

**: For multiple pregnancy, specify chorionicity and fill out one sheet for each fetus (labeled Fetus A, B, C, . . . )