I Name

.
Date of exam: Cf-nte-r Patient ID:
Patient name: Birth date:

ISUOgo,g
Sonographer: Detailed first-trimester examination
Ultrasound machine:
Transabdominal DTransvaginalD Sonographic appearance of fetal anatomy
Indication for scan: Normal = N Abnormal = A Not visualized = N A NV
Screening 0Other: NV

Head and brain

Relevant risk factors:
Intact cranium I normal shape
ART pregnancy: N I Y ..................
Midline falx

Singleton: D Choroid plexus / lateral ventricles

Twins**:0 monochorionic I dichorionic IT I brainstem I cisterna magna

Adnexa: Normal 0 Abnormal 0 Not examined 0 Cerebral peduncles with AoS
Placenta: Normal DAbnormal D
Face and neck

Nuchal translucency

Retronasal triangle

Maxilla I mandible

Orbits
Biometry mm
Thorax
Crown-rump length (CRL)
Thorax shape with lung
Biparietal diameter (BPD) fields Diaphraqmatic
continuity
Head circumference (HC) Heart

Abdominal circumference (AC) Heart intrathoracic with regular rhythm

Femoral diaphysis length (FL) Cardiac size and axis

Risk assessment Four-chamber view

Nuchal translucency (NT) (mm) Nasal bone (NB) Left ventricular outflow tract
(mm)
Right ventricular outflow tract
Ductus venosus A-wave(positive/negative/Pl)
Three-vessel-and-trachea view

Abdomen
Tricuspid valve regurgitation N/
Y
Stomach filled
Right uterine artery Pl:
Bladder filled (length < 7 mm)
Left uterine artery Pl:
Intact abdominal wall

Gestational age based on ultrasound: . .. ... ..weeks ... ...days Two umbilical arteries

CVS I Amnio Kidneys

: planned D
cfDNA: planned D Spine

Limbs
CONCLUSION:
D Normal and complete examination. Upper limbs with three segments

D Normal but incomplete examination . Lower limbs with three segments

D Abnormal examination *
D Plans: D No further ultrasound scans required
D Follow up planned in ..... weeks.
D Referred to ...............
D Other:
 Remarks: (* Describe here any abnormal findings)

Signed: .................................. ..... ........ ......... ......... .

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