كتاب دكتور حبشي- جزء 2 ;كامل- مجانا PDF

Author:
Dr. Ahmed Mahmoud El-Habashy, MD
Lecturer of Obstetrics and Gynecology

Faculty of Medicine, Alexandria University, Egypt
Director of Habashy 4D-Scan Center
Editor
Asst. Prof. Manal Shafik Swelem
Assistant Professor of Obstetrics and Gynecology
Copyright © 2020
Any copy, photocopy or re-publishing of this book without a
written permission from Dr. Ahmed El-Habashy is considered
piracy, and committer shall be accused legally according to the
proper regulations.
Author:
Director of Habashy 4D-Scan Center for OB-GYN Sonography
Copyright © 2020
ISBN: 978-977-6551-69-5
Deposit NO: 2020 / 4814
Habashy Sono-Tricks Vol.II
To my parents
who extended their unconditional support
& to
Department of Ob/Gyn,
where my sonographic knowledge shaped and improved

It gives me great pleasure to introduce this book

which is designed for easy understanding of ultrasound in
obstetrics with a clear to-the-point approach. This book has a
practical and an algorithmic way of display that I am sure that
the readers will enjoy.
The author of this book; Dr. Ahmed El-Habashy is one

of the eminent sonographers in Alexandria and one of the main
pillars of the ultrasound unit in Shatby Maternity University
Hospital where he gained his experience in the field of OB-GYN
sonography which is apparently evident in his appealing series of
books; Habashy’s Sono-Tricks which are the first structured
books in that field in the middle east.
This book will aid obstetricians to reach a proper

diagnosis that will definitely guide them to an appropriate
management. It is a reliable reference for obstetric sonography
for postgraduate candidates and practitioners.
Prof. Tarek Abdelzaher Karkour
Head of OB/GYN Department

Faculty of Medicine
Alexandria University, Egypt
2020
The tremendous improvement in the field of

sonographic technology in the last two decades made it an
integral part of management of almost all obstetrical and
gynecological disorders. This emphasizes the fundamental
importance of the sonographic background knowledge that each
OB-GYN specialist or consultant has to build up.
In view of the paucity of the simplified books about

ultrasound in obstetrics and gynecology; it’s my pleasure to
introduce Habashy’s Sono-Tricks series that will tackle this field
in a handy fashion. I tried as much as I can to present each Sono-
Trick in a simple, practical and illustrative manner.
This book is the 2nd volume of Habashy’s Sono-

Tricks series and it includes 10 obstetrics chapters. After
completion of all volumes of this series, they will be collected in
a comprehensive text-book of OB-GYN sonography; “Habashy’s
Sono-Sign”.
Author:
I heartedly thank Prof. Elsayed Elbadawy

(Professor of Ob.Gyn, Alexandria Univ.) who guided me
enthusiastically in my early phase of sonographic
experience.
No words can express my gratitude towards Asst.

Prof. Manal Swelem (Associate Professor of Ob.Gyn,
Alexandria Univ.) who guided me through both my MS and
MD sonography based theses and who revised this book
thoroughly before its release.
I greatly appreciate the efforts done by the

employees of Habashy 4D-Scan center for Ob.Gyn
sonography, especially Eng. Mahmoud Kassem in order to
print this book in its splendid guise.
Author:
OBSTETRICS SONO-TRICKS
Page
1- Failed Pregnancy 1
2- Gestational Trophoplastic Disease 48
3- Placental Abruption 84
4- Placental Lakes, Infarcts & Calcification 103
5- Placental Tumors 126
6- Succenturiate & Circumvallate Placentas 142
Marginal / Velamentous Cord Insertion & Vasa

7- 165
Previa
8- Fetal Abdominal Wall Defects 179
9- Fetal GIT Anomalies 212
10- Cervix in Obstetrics 286
References 316
XI
Page
1- Failed Pregnancy 1
Early 1st trimester milestones - TVUS
Pseudogestational sac
TVUS criteria of failed pregnancy
Perigestational hemorrhage (PGH)
Chorionic bump (CB)
Impending pregnancy failure
HCG calculator
2- Gestational Trophoblastic Disease 48
Molar sonographic pattern
Types of molar pregnancies
DD
Phantom HCG
Post-partum GTD
Non-GTD moles
Triploidy
XII
Page
3- Placental Abruption (PA) = Accidental Hemorrhage 84
Clinical picture & risk factors
Site of abruption
Age of abruption
DD
Chronic abruption oligohydramnios sequence (CAOS)
Massive subchorionic Hematoma MSH (Breus’ mole)
4- Placental Lakes, Infarcts & Calcification 103
Lakes and infarcts Placental Calcifications
Lakes VS Infarcts Classification
Significance Significance
DD DD
5- Placental Tumors 126
Chorioangioma
Placental teratoma
Placental mesenchymal dysplasia (PMD)
XIII
Page
6- Succenturiate Lobe & Circumvallate placenta 142
Succenturiate lobe Circumvallate placenta
US features US features
Significance Significance
DD DD
Marginal /Velamentous Cord Insertion &

7- 165
Vasa Previa
Marginal & Velamentous

Vasa Previa
Cord Insertion
US features
US features
Types
DD
Significance
Significance
XIV
Page
8- Fetal Abdominal Wall Defects 179
Physiological Gut Herniation

Omphalocele
Gastroschisis
Cantrell Pentalogy
Bladder Exstrophy
Cloacal Exstrophy
Body Stalk Anomaly
DD
9- GIT anomalies 212
Esophageal atresia Meconium peritonitis

Duodenal atresia Mesenteric cyst
Small bowel atresia Enteric Duplication Cyst
Colonic atresia Hepatic Hemangioma
Anal atresia Hepatic Hamartoma
Cloacal malformation Hepatoblastoma
Volvulus GB Stone
XV
Page
GIT anomalies - Continued
Choledochal cyst
Biliary Atresia
Absent stomach
Echogenic bowel
Abdominal calcification
Hepatosplenomegaly
Ascites
10- Cervix in Obstetrics 286
Preterm birth & the cervix

TVUS cervical assessment technique
Pitfalls & timing
Cervical funneling
Cervical glandular area & amniotic fluid sludge
3D-TVUS cervical assessment
Prophylactic cerclage
Benefits of TVUS assessment of the gravid cervix
Uterocervical angles
XVI
• 3D Three dimensional
• ABS Amniotic band syndrome
• AC Abdominal circumference
• ACA Anterior cervical angle
• ACC Agenesis of the corpus callosum
Obstetric Sono-Tricks
American College of Obstetricians and

• ACOG
Gynecologists
• AD Autosomal dominant
• AF Amniotic fluid
• AMC Arthrogryposis multiplex congenita
• APH Antepartum hemorrhage
• ARPCK Autosomal recessive polycystic kidney
• A-V Arterio-venous
• BA Biliary atresia
• BE Bladder exstrophy
• BPP Biophysical profile
• BRA Bilateral renal agenesis
• BWS Beckwith Wiedeman syndrome
• C/O Complain
• CA Colonic atresia
• CAOS Chronic abruption oligohydramnios sequence
XVIII
Habashy Sono-Tricks Vol.II Abbreviations
• CB Chorionic bump
• CDH Congenital diaphragmatic hernia
• CE Cloacal exstrophy
• CF Cystic fibrosis
• CGA Cervical glandular area
• CHAOS Congenital high airway obstruction syndrome
• CHD Congenital heart disease
• CHM Complete hydatiform mole
• CHMF Complete hydatiform mole with co-existing fetus
• CI Cervical incompetence
• CL Cervical length
• CMV Cytomegalovirus
• COCs Combined oral contraceptive pills
• COP Cardiac output
• CP Circumvallate placenta
• CRL Crown rump length
• CS Cesarean section
• DA Duodenal atresia
• DC Dichorionic
• DD Differential diagnosis
XIV
Abbreviations Habashy Sono-Tricks Vol.II
• EA Esophageal atresia
• EB Echogenic bowel
• ECS Elective cesarean section
• END Early neonatal death
• EP Ectopic pregnancy
• ET Endometrial thickness
• FADS Fetal akinesia deformation sequence
• FGR Fetal growth restriction
• FP Fetal pole
• FT Full term
• FTS First trimester scanning
• G6PD Glucose 6 phosphate dehydrogenase
• GA Gestational age
• GB Gall bladder
• GIT Gastrointestinal tract
• GSD Gestational sac diameter
• GTD Gestational trophoplastic disease
• GTN Gestational trophoplastic neoplasia
• HCG Human chorionic gonadotropin
• HTN Hypertension
XX
• IABD Intrabdominal bowel dilatation

• IAI Intra-amniotic infection
• IOL Induction of labor
• IUFD Intrauterine fetal death
• IUGR Intrauterine growth restriction
• IUI Intrauterine infection
• IUP Intrauterine pregnancy
• IVC Inferior vena cava
• IVT Intervillous thrombus
• LBWC Limb-body wall complex
• LUS Lower uterine segment
• LUTO Lower urinary tract obstruction
• MCA Middle cerebral artery
• MCDK Multicystic dysplastic kidney
Megacystis microcolon intestinal hypoperistalsis
• MMIHS
syndrome
• MOM Multiple of median
• MPCI Marginal placental cord insertion
• MSD Mean sac diameter
• MSH Massive subchorionic hematoma
• NEC Necrotizing enterocolitis
XXI
• NST Non-stress test

• NT Nuchal translucency
Omphalocele, imperforate anus, exstrophy of UB,
• OIES
spine deformity
• P19 Parvovirus
• p95 95th percentile

• PA Placental abruption
• PAPP-A Placenta associated plasma protein –A
• PBS Prune belly syndrome
• PCA Posterior cervical angle
• PET Pre-eclampsia
• PGH Perigestational hemorrhage
• PHM Partial hydatiform mole
• PL Placental lake
• PMD Placental mesenchymal dysplasia
• PP Placenta previa
• PPH Postpartum hemorrhage
• pPROM Preterm premature rupture of membranes
• PROM Premature rupture of membranes
• PSV Peak systolic velocity
XXII
• PTB Preterm birth

• PTL Preterm labor
• PUJO Pelvi-ureteric junction obstruction
• PUL Pregnancy of unknown location
• PUV Posterior urethral valve
• RBCs Reb blood cells
• RCOG Royal College of Obstetricians and Gynaecologists
• RFM Reduced fetal movements
• ROC Remnant of conception
• SL Succenturiate placenta
• SMF Submucous fibroid
• SUA Single umbilical artery
• T1 First trimester
• T13 Trisomy 13
• T18 Trisomy 18
• T21 Trisomy 21
• T3 Third trimester
• TAUS Trans-abdominal ultrasound
• TEF Tracheo-esophageal fistula
XXIII
• TFP Trans-fundal pressure

• TMD Transient myeloproliferative disorder
• TOP Termination of pregnancy
Toxoplasmosis, rubella, cytomegalovirus, herpes
• TORCH
simplex virus
• TPUS Trans-perineal ultrasound

• TRAP Twin reversed arterial perfusion
• TTTS Twin to twin transfusion syndrome
• TUI Tomographic ultrasound imaging
• TVUS Trans-vaginal ultrasound
• UB Urinary bladder
• UCI Umbilical cord insertion
• US Ultrasound
Vertebral, anal atresia, cloaca, tracheoesophageal
• VACTERL
fistula, renal anomaly, limb anomaly
• VCI Velamentous cord insertion
• VM Ventriculomegaly
• VP Vasa previa
•w Week
• YS Yolk sac
• Yst Yolk stalk
XXIV
Failed Pregnancy
Figures 1 - 43
References
1 - 17
• Early 1st trimester milestones - TVUS

• Pseudogestational sac
• TVUS criteria of failed pregnancy
• Perigestational hemorrhage (PGH)
• Chorionic bump (CB)
• Impending pregnancy failure
• HCG calculator
Habashy Sono-Tricks Vol.II Trick: 1 Failed Preg.
TVUS Early 1st trimester milestones

GA(±0.5w) Structure 1st appears on TVUS MSD CRL
5w Gestational sac (GS) 2mm --
5½w Yolk sac (YS) 6mm --
6w Embryo (featureless) + heartbeat 10mm 3mm
7w Amnion 18mm 10mm
8w Head-trunk-limb buds 26mm 16mm
• Sonographic signs of intrauterine pregnancy (IUP) before yolk

sac & embryo appear  Fluid collection in the uterus = the
gestational sac: this fluid has the following sonographic
features:
oIntradecidual sign: intrauterine fluid collection, eccentrically
located in the decidua, anterior or posterior to a thin white line
(the endometrial interface)
oDouble sac sign : 2 concentric echogenic rings surrounding
an echolucent area (represent decidua capsularis & parietalis)
oNonspecific sac-like appearance ; oval or rounded, with no
double sac sign or intradecidual sign  this is present in
≥50% of early IUP
• Although the double sac & intradecidual signs are more

specific (reassuring) for IUP, they are not present in all cases.
• Although the intrauterine sac like fluid is nonspecific for IUP,
its incidence is more (& may be present earlier than the 1st 2
signs). So its presence in absence of adnexal mass or
significant free pelvic fluid  the likelihood is at least 99%
that it is a gestational sac (simply because the incidence of
IUP [98%] >>>>>>EP[2%])
2
Failed Preg. Trick: 1 Habashy Sono-Tricks Vol.II
• The problem in the intrauterine sac like fluid is that it may be

mistaken with the pseudogestational sac that is present in 3% of
EP.
Uterine Fluid Gestational Sac Pseudogestational sac

Shape Regular Irregular(pointed
edges)
Contents Clear Debris

Yolk sac or fetal ± X
pole
Site Decidua (ET) Cavity

Probe pressure Change shape Stable
Power Doppler Flow in periphery (Chorion) Cold
Adnexa Usually normal or corpus Bagel sign or blob
luteum sign
• GS without contents  GA=5w. If with YS  GA=5.5w.

• GSD: widest, inner to inner , i.e. does not include the chorion
• MSD : average of the A-P, transverse & sagittal GSD
• MSD is more accurate than GSD
• CRL:longest, make sure not to include the YS
• Once embryo is present  GA by CRL not GS
3
Criteria of Failed Pregnancy(Missed Abortion)-TVUS

Diagnostic (Definite) Suspicious (Uncertain) 
Wait 7-10 days
CRL≥7mm with no pulsation CRL<7mm with no pulsation
MSD≥25mm with no fetal pole MSD:16-24 mm with no FP
(FP)
No pulsating FP ≥14d after No pulsating FP 7-13d after detection of
detection of gestational sac without gestational sac without YS or embryo
YS or embryo
No pulsating FP ≥11d after No pulsating FP 7-10 d after detection
detection of gestational sac with YS of gestational sac with YS
Cessation of a previously Absent FP ≥ 6wks after LMP
documented cardiac activity
Empty amnion sign: amnion is visible
regardless of CRL
beside the yolk sac with no visible
embryo (i.e. GS has 2 adjacent circles :
YS & amnion, with no FP). 
suspicious not definitive because 2 YS
• CRL cut-off was 5mm of MCDA twin could be mistaken for it.
in the 90s  become Expanded amnion sign: embryo with no
7mm due to 15% CRL cardiac activity with amnion visible
interobserver variability around it (normal cardiac activity is
• MSD cut-off was 16mm seen before the amnion is identified)
in the 90s  become Yalk stalk sign: if CRL≤5mm without
25mm due to 19% heartbeat & embryo is not immediately
interobserver variability adjacent to the yolk sac (i.e. separated
by the yalk stalk [YSt] ± YSt seen)  it
is probably dead (as the YSt should be
present with CRL>5mm)
Large Yolk sac > 7mm (outer-to-outer)
4
Perigestational Hemorrhage Chorionic Bump

(PGH) (CB)
= Subchorionic Hematoma
Incidence •2% of pregnancies <10 wks 1% of pregnancies
•20% of those have vaginal <10wks
bleeding <10 wks
Pathology Venous bleeding from the Arterial hematoma

chorionic plate in the chorionic
plate
US Morphology •Irregular or crescentric (oval) •Focal rounded
fluid collection between the GS protrusion of the
& uterine wall chorion into GS
•Acute: isoechoic to GS  •Isoechoic to
hypoechoic / anechoic with time chorion
Doppler Avascular on Doppler mapping
DD •Yolk Sac
•Twinning
•Vesicular Mole
Prognosis •>90% pregnancy success rate if •Overall live birth:
living embryo + Small PGH 65%
(<20% of GS circumference) •CB+ live embryo:
•Large PGH (>50% of GS 85% live birth rate
circumference) : 25% Loss rate •All pregnancies
even if living embryo with multiple CB
•PGH+ Embryonic bradycardia are not-viable
≤90bpm: 80% loss rate
Although both PGH & CB are weak suggestives for failing pregnancy ,
neither of them are definitive for missed abortion so when detected 
follow up 2 wks later is mandatory
5
Risk factors for impending pregnancy failure

when embryonic heartbeat is seen
Slow embryonic heart Slow Borderline
rate
GA:6-6.w <90bpm 90-99bpm
CRL:1-4mm
GA:6.3-7w <110bpm 110-119bpm
CRL:5-9mm
Large subchorionic
hematoma Surrounds ≥ 2/3 of the gestational sac
Small GS size in relation MSD-CRL<5mm

to the embryo Or subjectively : too little fluid around the embryo
Β-hCG Calculator
Initial β-hCG level Expected rate of ↑ after 48h in normal IUP

<1500mIU/ml 50%
1500-300mIU/ml 40%
>3000mIU/ml 30%
•Measurements of serum β-hCG / 48 hours may be used to help

determine viability of early intrauterine pregnancies (IUP) and
to help management in pregnancies of unknown location (PUL)
in hemodynamically stable patients.
•β-hCG level for a successful IUP should be expected to ↑ by
≥35% in 2 days. A slower rate of ↑ suggests a possible
miscarriage or ectopic pregnancy (EP).
6
•For women who are having a miscarriage the β-hCG should be

expected to ↓ 35-45% over 2 days. A fall that is slower than this
is suggestive of EP.
•About 15-20% of ectopic pregnancies have ↑ in β-hCG similar to
IUP & about 10% of EP have a ↓ in β-hCG similar to a
miscarriage.
•To calculate the % of ↓ or ↑ in β-hCG over 48 hours  put the 2

levels in the “Beta hCG Doubling Time Calculator” at
www.perinatology.com.
•Diagnosis of failed IUP is mainly a sonographic diagnosis and

use of β-hCG ↓ is only prognostic.
•Diagnosis of EP should combine data from clinical picture,
TVUS and β-hCG values. i.e. avoid rushing to EP using β-
hCG only  treat the patient not a blood test.
7
Gestational sac
Endometrium
Figure (1); [a&b]: The intradecidual sign. TVUS at 5th week of gestation
shows the sagittal plane of the uterus with an intrauterine fluid collection,
eccentrically located in the decidua beside the endometrial interface.
Figure (2) : The double sac sign. TVUS at 5th week of gestation shows the
sagittal plane of the uterus with 2 concentric echogenic rings surrounding an
echolucent area. They represent the decidua capsularis and paritalis.
8
IDDS
Endometrial Fluid
Figure (3); [a&b]: The intradecidual sac sign (IDSS). [a] the gestational sac
(GS) burrows itself into the endometrium  an asymmetrically placed
echogenic ring with an echolucent center. The intradecidual gestational
sac is an echogenic ring eccentric to the line created by apposition of the
endometrial surfaces. Recent terms for the IDSS are intrauterine sac-like
structure or probable intrauterine pregnancy. [b] IDSS with blood in the
endometrial cavity.
9
Figure (4): The double sac sign. TVUS at 5th week of gestation shows 2
concentric echogenic rings within the endometrial interface. They represent
the decidua capsularis and paritalis.
10
Obstetric Sono-Tricks Missed Abortion Trick: 21 Habashy Sono-Tricks Vol.II
3 decidua Parietalis Capsularis Basalis
YS
Figure (5); [a&b]: The double decidual sac sign (DDSS). [a] When the
enlarging gestational sac protrudes from the site of implantation and
expands into the uterine cavity  mass effect on the opposite uterine wall.
This process produces 3 types of decidua; namely: the decidua basalis is
where the sac is attached to the uterine wall and marks the site where the
placenta will develop, the decidua capsularis which is the endometrium that
covers the expanding sac and the decidua parietalis which is the
endometrium that is being pushed by the expanding sac. The concentric
rings created by the decidua capsularis and parietalis create the DDSS. This
finding is characterized as a probable intrauterine pregnancy. [b] DDSS +
yolk sac (YS)  definite intrauterine pregnancy (IUP).
11
Figure (6); [a–c]: The intradecidual sign. [a] 2D-TVUS shows the sagittal
uterine plane where there is an intrauterine fluid collection, eccentrically
located in the decidua beside the endometrial interface. [b&c] 3D-TVUS
coronal plane of the same case.
12
Obstetric Sono-Tricks Failed Preg. Trick: 1 Habashy Sono-Tricks Vol.II
Figure (7): The 3 types of decidua; namely: the decidua basalis is where the
sac is attached to the uterine wall and marks the site where the placenta will
develop, the decidua capsularis which is the endometrium that covers the
expanding sac and the decidua parietalis which is the endometrium that is
being pushed by the expanding sac.
13
Figure (8): The double sac sign.
[a] TVUS at 5th week of
gestation shows the sagittal
plane of the uterus with 2
concentric echogenic rings
surrounding an echolucent area.
They represent the decidua
capsularis and paritalis. Note
the associated left broad
ligament myoma that displace
the corpus to the right side. [b]
3D-TVUS of the same case
shows the coronal plane of the
uterus with the intrauterine
gestational sac (IUGS).
14
Figure (9): Zoomed TVUS image at the at 7th week of gestation shows fetal
pole (embryo), amnion and yolk sac. Remember that the yolk sac will
always be outside the amnion; the embryo lies inside the amniotic sac.
15
YS Embryo
Amnion
Amniotic Chorionic
cavity cavity
Figure (10); [a&b]: TVUS shows intrauterine pregnancy at the 7th week of
gestation. [a] 1-gestational sac (GS), 2- yolk sac (YS), 3-featureless embryo
(fetal pole FP), 4- amnion (amniotic membrane), 5- amniotic cavity, 6- extra-
embryonic coelom (chorionic cavity). [b] embryonic cardiac activity
detected by pulsed by Doppler.
Figure (11); [a&b]: TVUS early 1st trimester milestones. [a] head-trunk-limb
buds at the 8th week of gestation. [b] cord insertion: 2 ends can be seen
simultaneously early in the 1st trimester at about the 8th week of gestation;
one in the placenta and the other in the embryo’s abdomen.
16
Figure (12); [a&b]: Early 1st

trimester biometry and
viability. 2D-TVUS at the
6th week of gestation
shows: [a] gestational sac
diameter (GSD): widest,
inner-to-inner diameter of
the gestational sac (does not
include the chorion). Crown
rump length (CRL): longest
fetal pole length. Yolk sac
diameter (YS): widest ,
outer-to-outer. [b] Regular
embryonic heart rate using
the spectral Doppler.
17
Figure (13): Normal embryo at the 9th week of gestation.
18
Amnion Chorionic cavity

(extra-embryonic coelom)
Amniotic cavity YS
Figure (14): Normal embryo at 10 weeks, the yolk sac will start to be
obliterated as the amnion apposes to the chorion.
19
Figure (15); [a&b]: Rhombencephalon is a normal hypoechoic area near the
cranial end of the embryo 8-10 w.
Figure (16); [a&b]: TVUS of a 9 weeks embryo shows: [a] limb buds and [b]
notochord.
20
Figure (17); [a–d]: 3D-TVUS surface rendering of an embryo at the 8th week
of gestation.
21
Figure (18); [a–d]: Failed pregnancy. Though the GSD is 22.6mm (i.e. <
25mm which is the cut-off for failed pregnancy diagnosis), this pregnancy is
considered failed as contour of the sac is irregular and the coelom is
echogenic (blood debris).
22
Figure (19); [a–c]: Failed pregnancy. CRL is 22.66 mm without embryonic

cardiac pulsation. If CRL ≥ 7 mm without pulsation  definite failed
pregnancy.
23
Figure (20); [a&b]: Failed
pregnancy. CRL is 15.79
mm without embryonic
cardiac pulsation. If CRL ≥
7 mm without pulsation 
definite failed pregnancy.
24
Figure (21); [a–c]: Failed pregnancy. CRL is 10.11 mm without embryonic

cardiac pulsation. If CRL ≥ 7 mm without pulsation  definite failed
pregnancy.
25
Figure (22); [a–c]: Failed pregnancy. Sac diameter is 33.15mm with no fetal
pole (FP). If mean sac diameter is ≥ 25 mm without FP  definite failed
pregnancy.
26
Amnion
Embryo
YS
Figure (23): The expanded amnion sign: “Case No-1”. TVUS shows the
amnion surrounds an embryo with no cardiac activity. Embryologically, if
the amnion has expanded enough to be visible around the embryo, there
should be cardiac activity. A collapsed yolk sac was noted beside the
amnion. Remember that the embryo is inside the amnion and the yolk sac
is outside.
27
Amnion YS
Embryo
Amnion
Embryo
Figure (24); [a&b]: The expanded amnion sign: “Case No-2”. TVUS shows
the amnion surrounds an embryo with no cardiac activity. This is a
suspicious sign for failed pregnancy.
28
Embryo
Amnion
YS
Figure (25): The expanded amnion sign: “Case No-3”. TVUS shows the
amnion surrounds an embryo with no cardiac activity. Normally embryonic
cardiac activity should be seen before the amnion is identified. Beside the
amnion an abnormally large yolk sac (8 mm) had been noted. The normal
yolk sac diameter (outer-to-outer) is < 6 mm. Both the expanded amnion
sign and the large yolk sac are suggestive for failed pregnancy.
29
Figure (26): The expanded

amnion sign: “Case No-4”.
Embryo US image shows the amnion
surrounds an embryo with no
cardiac activity. Normally
embryonic cardiac activity
should be seen before the
amnion is identified. Beside
the amnion an abnormally
YS large yolk sac (9 mm) had
been noted. Both the
expanded amnion sign and
the large yolk sac are
suggestive for failed
pregnancy.
Figure (27) : The empty

amnion sign: “Case No-1”.
TVUS shows that the amnion
is visible inside the
gestational sac without an
embryo inside the amnion.
May be confused with the
finding of a sac with a yolk
sac. This sign is suggestive Amnion
for failed pregnancy.
30
Amnion
YS
Figure (28); [a&b]: The empty amnion sign : “Case No-2”. TVUS shows
that the amnion is visible inside the gestational sac without an embryo
inside the amnion. May be confused with the finding of a sac with a yolk
sac.
31
Figure (29); [a-d]: Perigestational hemorrhage (PGH) or subchorionic

hematoma. “Case No-1”. Irregular avascular fluid collection between the
gestational sac & the uterine wall. [a&b] PGH. [c&d] normal chorion. It
represents a venous bleeding from the chorionic plate.
32
*

hematoma. “Case No-2” Crescentric heterogeneous fluid collection between
the gestational sac & the uterine wall. It has a reticular pattern simulating the
hemorrhagic ovarian cyst. [a] PGH by 2D-US. [b&c] PGH by 3D-US. [d] the
embryo is still alive even in presence of the PGH.
33
*
Figure (31): Large perigestational hemorrhage: “Case No-3”. TVUS

shows a hypoechoic fluid collection between the gestational sac and the
uterine wall at the 8th week of gestation. This embryo shows bradycardia
at the time of the scan (83bpm) and eventually demised on follow up scan
1 week later.
34
*
*
*
Figure (32); [a-c]: Perigestational hemorrhage (PGH) or subchorionic

hematoma. “Case No-4”.
35
*
*
*

hematoma . “Case No-5”.
36
*

hematoma. “Case No-6”.
37
*
Figure (35): Perigestational hemorrhage (PGH) or subchorionic hematoma.

“Case No-7”. 3D-TVUS at 6th week of gestation shows a crescentric
heterogeneous fluid collection between the gestational sac & the uterine wall.
It has a reticular pattern simulating the hemorrhagic ovarian cyst. This case
was referred for suspecting partial molar pregnancy. The reticular patterns of
PGH differs from the snow stormy appearance of molar pregnancy in 2
aspects; 1st: the hypoechoic areas in PGH are of different sizes, 2nd: they are
communicating (unlike molar pregnancy).
38
*

hematoma in an early twin pregnancy. “Case No-8”.
39
*

hematoma in an early twin pregnancy. “Case No-9”.
40
*

hematoma in an early twin pregnancy. “Case No-10”
41
*
*
* *
Figure (39); [a-d]: Chorionic bump (CB). “Case No-1”. Focal rounded
echogenic protrusion of the chorion into the gestational sac. It represents an
arterial hematoma in the chorionic plate.
42
*
*
* *
*
avascular echogenic protrusion of the chorion into the gestational sac.
43
* *
*
*
*
*
echogenic protrusion of the chorion into the gestational sac. [a] 2D-TVUS.
[b-d] 3D-TVUS  not add benefit to 2D in CB diagnosis.
44
Chorionic
Bump (CB)
*
* *
Viable Embryo *
(Color Doppler)
*
Viable Embryo
(Spectral Doppler)
Figure (42); [a-c]: +ve embryonic cardiac activity  is a good omen in

chorionic bump (CB); this signifies that this pregnancy mostly will not fail.
45
2 Chorionic bumps (CB)
*
*
IUGS
No Yolk Sac (YS)

No Fetal Pole (FP)
Figure (43): >1 Chorionic bump is a poor omen  this signifies that this
pregnancy mostly will fail: TVUS shows an intrauterine gestation sac
(IUGS) where its amniotic cavity is distorted by 2 focal echogenic
projections arising from the chorion (i.e., 2 chorionic bumps). Note that
there is no yolk sac nor fetal pole. This pregnancy was failed on follow up
scan 2 weeks later. IUGS: intra-uterine gestational sac.
46
Gestational Trophoblastic
Disease
(GTD)
Figures 44 - 72
References
18 - 33
• Molar sonographic pattern

• Types of molar pregnancies
• DD
• Phantom HCG
• Post-partum GTD
• Non-GTD moles
• Triploidy
GTD Trick: 2 Habashy Sono-Tricks Vol.II
• Molar sonographic pattern: echogenic intrauterine tissue sheets

that are interspersed with numerous punctuate regular
sonolucencies (small anechoic cysts= vesicles) that give a snow
storm (Swiss-cheese = bunch of grapes = honey-comb)
echotexture .
• Irregular sonolucent areas may occur 2ry to internal hemorrhage
or an area of unoccupied uterine lumen.
• Ovaries may harbor multiple bilateral theca lutein cysts

(30%).
No GS (Nor fetus) =Complete hydatiform mole CHM

=Partial hydatiform Mole PHM
Swiss-Cheese GS (or Fetus)
(Triploidy)
Placenta
(Chorion) =Complete hydatiform mole with
GS(or Fetus)
+ coexisting fetus =CHMF Dichorionic
With Normal
twin ; 1 of them is normal and the other
placenta
is complete mole.
• Theca lutein cysts (30%)  resolve spontaneously within

few months after evacuation. Their presence does not suggest
malignancy.
• Although low resistant uterine artery flow, vascular
trophoblasts, and/or thin vascular myometrium are suggestive
sonographic signs of aggressive neoplastic potentials of the
GTD, the presence of myometrial invasion (Invasive
mole=Chorioadenoma destruens) or choriocarcinoma is only
based on pathological examination
49
Habashy Sono-Tricks Vol.II Trick: 2 GTD
Age:
• Commonly in the reproductive age
• Rarely perimenopausal
• Extremely rare postmenopausal  PMB
• GTD >50y  ↑ risk of malignancy (but benign cases also rarely
reported postmenopausally)
DD
Hydropic Degeneration of Missed Abortion Molar Pregnancy
Irregular anechoic areas Regular

HCG ↓ HCG ↑
Mostly focal Mostly diffuse (fill the uterus)
Avascular May be Vascular
No bilateral theca lutien cysts May have bilateral theca lutein
cysts (in 30% of cases)
• Post-Evacuation Follow up of β-HCG is recommended weekly

till 3 consecutive normal levels then monthly for 6 months. If
elevated (or plateaued)  Post-molar syndrome= Persistent
GTD = GTN (neoplasia)
• Phantom HCG: False +ve HCG: due to human heterophilic

antibodies (that can bind to animal IG in commercial HCG
assays), It has the following features:
 Stationary
 Low (<1000 mIU/ml)
 Urine pregnancy test –ve.
50
• Other causes of +ve Serum Quantitative HCG in absence of

US signs of pregnancy (whether intra-or-extrauterine or
GTD):
 Biochemical pregnancy (pregnancy failure before US
detection),
 Ovarian germ cell tumors
 Paraneoplastic syndrome (GI, breast)

 Pitutary HCG in perimenopause or with ovarian
failure (decrease with COCs).
Postpartum GTD
• GTD that develop after full term delivery

• They are usually more aggressive than those diagnosed early in
pregnancy
• Rare (<<< Molar pregnancy )
• 2w-6m interval from antecedent pregnancy
• Delayed diagnosis as it is usually considered as pregnancy
related 2ry PPH (remnant or infection)
• Poor prognosis. Most of the reported postpartum GTD are
malignant
• Suspect when :
 Vaginal bleeding, High hCG (>3w postpartum)
 Thick ET, hetrogenous myometrium , Bulky uterus
 +ve Power Doppler flow.
 Adnexa: usually free
51
Non-GTD Moles
Carneous A uterine mass that consists of clotted blood, remnants of the

Mole = placenta and fetal membranes (ROC) ± fetus. It may be retained
Fleshy Mole in the uterus for many months after a miscarriage or missed
abortion.
Breus’ Mole Massive Subchorionic Hematoma (MSH)  Refer to “Placental
Abruption” chapter
Pseudo- Placental Mesenchymal Dysplasia (PMD)  Refer to “Placental

Mole Tumors” ; chapter number 5.
Triploidy
• 69 Chromosomes
• Partial molar pregnancy that escape detection (& termination) in
the early 1st trimester (6-9w) and continues farther.
• Once detected : TOP
Large cystic placenta + Early FGR + Fetal anomaly
• 85% have anomalies: commonest are ventriculomegaly,

syndactyly, posterior fossa abnormalities
• Possible maternal complications : PET (early), placental
abruption (PA), retained placenta (PPH).
• 10% of spontaneous abortions are triploidy
52
Types Diandric Digynic

Incidence 85% 15%
Extra set is Paternal Maternal
Pathogenesis Dispermy >> Diploid Sperm Diploid egg
Placenta Large Small
Cystic (Hydropic) Normal
FGR Symmetric Asymmetric

Theca lutein cysts ± X
NT Mild ↑ NT Normal
Double markers ↑hCG, ↓PAPP-A  screen ↓hCG, ↓PAPP-A  screen
(T1) +ve results for T21 +ve results for T18 or 13
PET ± X
DD
Like triploidy in: But in PMD:
Placental • Early large cystic • Usually structurally
Mesenchymal placenta normal fetus
Dysplasia (Pseudo- • FGR(50%), IUFD(30%) • Possible BWS(20%)
mole) • ↑ hCG(40%) • ± hepatic hamartoma
• 80% female fetus
2 placentas normal placenta with normal fetus &
CHMF
cystic placenta without fetus
• No placentomegaly
• Usually focal
Placental lakes
• Commonly >20w
• Normal fetal growth & anatomy
Chorioangiomatosis Chorioangiomas are May undergo hemorrhage
vascular solid masses or infarction  cystic
53
• Thickened cystic placenta is present in both partial mole & PMD

(& FGR is present in both). ↑β-hCG is also in both .
• If the fetus is structurally abnormal  Partial mole. If not 
karyotyping is recommended to exclude triploidy (partial mole)
54
Obstetric Sono-Tricks GTD Trick: 2 Habashy Sono-Tricks Vol.II
Figure (44); [a-c]: Complete hydatiform mole (CHM). “Case No-1”

Echogenic intrauterine tissue sheets that are interspersed with numerous
punctate regular sonolucencies  snow storm= Swiss-cheese = bunch of
grapes = honey-comb appearance.
55
Hemorage
Snow storm
Figure (45); [a&b]: Complete hydatiform mole (CHM). “Case No-2”.

Echogenic intrauterine tissue sheets that have a snow storm appearance with
areas of hemorrhage in-between.
56
Snow storm
Figure (46): Complete hydatiform mole (CHM): “Case No-3”. TAUS

shows a sagittal plane of the uterus with multiple small cystic areas (the
snowstorm appearance) that represents the hydropic villi. No fetal parts
are seen
57
Snow storm Obstetric Sono-Tricks
Figure (47): Complete hydatiform mole (CHM). “Case No-4”. Echogenic

intrauterine tissue sheets that are interspersed with numerous punctate
regular sonolucencies  snow storm appearance with areas of hemorrhage
inbetween. [a] 3D-US using the ovix mode (omniview), [b] 3D-US using the
multislice mood. 3D-US has no benefit over the 2D-US in GTD diagnosis.
58
Hemorage
Snow storm

intrauterine tissue sheets that are interspersed with numerous punctate
regular sonolucencies  snow storm appearance with areas of hemorrhage
in-between.
59
Snow storm

intrauterine tissue sheets that have a snow storm appearance with areas of
hemorrhage in-between.
60
Snow storm
Figure (50); [a-c]: Complete hydatiform mole (CHM). “Case No-7”.

Echogenic intrauterine tissue sheets with numerous punctate regular
sonolucencies  snow storm appearance with areas of hemorrhage in-
between. Sometimes focal area of hemorrhage simulating a gestational sac
lead to misdiagnosis a s a partial mole.
61
Snow storm
Figure (51); [a&b]: Complete hydatiform mole (CHM). “Case No-8”.
sonolucencies  snow storm appearance with areas of hemorrhage in-
between. Sometimes focal area of hemorrhage simulating a gestational
sac lead to misdiagnosis as a partial mole.
62
Snow storm
Snow storm Embryo

Embryo
Figure (52); [a-d]: Partial hydatiform mole (PHM). “Case No-1”.

sonolucencies  snow storm appearance with a dead embryo beside it.
63
Snow storm Embryo
Embryo
Snow storm
Figure (53); [a-c]: Partial hydatiform mole (PHM). “Case No-2”. Echogenic
intrauterine tissue sheets with numerous punctate regular sonolucencies 
snow storm appearance with an embryo beside it.
64
Snow storm
Snow storm
Gestational
sac
Figure (54); [a-d]: Partial hydatiform mole (PHM). “Case No-3”.

sonolucencies  snow storm appearance with an intrauterine gestational sac
(IUGS). All these images are for the same case.
65
Gestational
sac
Snow storm
Figure (55); [a-c]: Partial hydatiform mole (PHM). “Case No-4”.

Intrauterine gestational sac (with a double decidual sign) surrounded by
chorion that has numerous punctate regular sonolucencies  snow storm
appearance. All these images are for the same case.
66
Gestational Snow storm

sac
Figure (56); [a&b]: “Case

No-5”. Partial hydatiform
mole (PHM). Intrauterine
gestational sac (with a
double decidual sign)
surrounded by chorion that
has numerous punctate
regular sonolucencies 
snow storm appearance. All
these images are for the
same case.
67
Snow storm
Embryo
Figure (57); [a&b]: Partial hydatiform mole (PHM). “Case No-6”.

Intrauterine gestational sac (with a fetal pole) surrounded by chorion that has
numerous punctate regular sonolucencies  snow storm appearance.
68
Normal Figure (58): Triploidy =

myometrium partial molar pregnancy:
only one cystic placenta plus
fetal parts.
Snow storm
Fetus
Triploidy
Figure (59): Complete

hydatiform mole with CHMF
coexisting fetus (CHMF) =
normal fetus with coexisting Fetus
mole. “Case No-1”. 2
placentas; one of them is a
normal placenta with a cord Normal Snow storm
attached to a normal fetus placenta
and the other placenta is
cystic without a fetus.
Fetus
69
CHMF
Normal placenta
Fetus
Snow storm
Figure (60): Complete hydatiform mole with coexisting fetus (CHMF) =

normal fetus with coexisting mole. “Case No-2”. 2 placentas; one of them
is a normal placenta with a cord attached to a normal fetus and the other
placenta is cystic without a fetus.
70
Fetus
Fetus
Snow storm
CHMF Normal placenta
Normal myometrium
Snow storm
Fetus
Normal placenta Normal placenta
Figure (61); [a&b]: Complete hydatiform mole with coexisting fetus

(CHMF): “Case No-3”. Dichorionic twin; 1 of them is complete mole and
the other is normal fetus with normal placenta. All these images are for the
same case.
71
Fetus
Normal
placenta Snow storm
CHMF
Snow storm
Normal
placenta
Figure (62); [a&b]: Complete hydatiform mole with coexisting fetus

(CHMF): “Case No-4”. Dichorionic twin; 1 of them is complete mole and
the other is normal fetus with normal placenta. All these images are for the
same case.
72
Normal
placenta
Fetus Snow storm
Normal
placenta Snow storm
Figure (63): “Case No-5”. Complete hydatiform mole with coexisting fetus
(CHMF): dichorionic twin; 1 of them is complete mole and the other is
normal fetus with normal placenta.
73
Theca lutein cysts
Normal ovaries
Figure (64): Theca lutein cysts. [a] Multiple bilaterally enlarged ovaries that
harbour multiple clear cysts. They are present in about 30% of GTD cases.
They result from ↑hCG level. Their presence does not suggest malignancy.
They resolve spontaneously post-evacuation. [b] normal ovaries seen in a
case of CHM that was proved to be choriocarcinoma post-evacuation.
74
Figure (65); [a&b]: Theca lutein cysts. Multiple bilaterally enlarged ovaries
that harbour multiple clear cysts. They are present in about 30% of GTD
cases. They result from ↑hCG level.
75
Figure (66): Theca lutein cysts. Transabdominal ultrasound shows an
enlarged ovary with a multiseptated appearance. They are present in
about 30% of GTD cases.
76
Figure (67): Uterine artery

Doppler waveform and
indices are not prognostic
about the neoplastic
potentials of molar
pregnancy, though it is
mostly low resistant in most
cases of choriocarcinoma.
[a] low resistance noted in
spectral Doppler
assessment of the uterine
artery in a case of vesicular
mole [b] high resistance
noted in uterine artery
Doppler in another case of
vesicular mole. Both a & b
were benign on
pathological assessment.
77
Indistinct
EMJ
Figure (68): Post-partum gestational trophoplastic disease (PP-GTD): “Case

No-1”. This case presented with 2ry postpartum hemorrhage (PPH) 3 weeks
after a spontanous vaginal birth (SVB). This TAUS image shows a bulky
uterus (sub-involuted) with indistinct endomyometrial junction (EMJ).
Heterogeneous ill defined myometrial lesion that displayed signal on power
Doppler mapping. Picture suggestive for choriocarcinoma on sonobasis;
that was proved pathologically.
78
Indistinct
EMJ
Figure (69); [a-c]: Post-partum gestational trophoplastic disease (PP-GTD):

Bulky uterus (sub-involuted) with indistinct endomyometrial junction (EMJ).
Heterogeneous ill defined myometrial lesion that displayed signal on power
Doppler mapping. Picture suggestive for choriocarcinoma on sonobasis ; that
was proved pathologically. These are ultrasound images of the same case in
figure 68.
79
“Case No-2”. This case was presented with 2ry PPH. TVUS Bulky uterus
(subinvoluted) with indistinct endomyometrial junction. Hetrogenous ill
defined myometrial lesion that displayed signal on power Doppler mapping.
These sonographic findings were suggestive for choriocarcinoma; that was
proved pathologically.
80
Theca lutein cysts

Choriocarcinoma

Bulky uterus (subinvoluted) with indistinct endomyometrial junction.
Hetrogenous ill defined myometrial lesion that displayed signal on power
was proved pathologically. These US images are for the same case in figure
70.
81
Figure (72); [a-d]: Post-partum gestational trophoplastic disease (PP-GTD):

Bulky uterus (subinvoluted) with indistinct endomyometrial junction.
Hetrogenous ill defined myometrial lesion that displayed signal on power
was proved pathologically. These US images are for the same case in figure
No 70.
82
Placental Abruption (PA) =
Accidental Hemorrhage
Figures 73 - 92
References
34 - 42
• Clinical picture & risk factors

• Site of abruption
• Age of abruption
• DD
• Chronic abruption oligohydramnios sequence (CAOS)
• Massive subchorionic Hematoma MSH (Breus’ mole)
Placental Abruption Trick: 3 Habashy Sono-Tricks Vol.II
•PA is “a clinical diagnosis”. US shows clot only in 30%

•In cases of antepartum hemorrhage APH  1st do US to rule out
placenta previa; preferably TVUS (i.e. PP is a sonographic
diagnosis but PA is a clinical one)
•PA C/O: vaginal bleeding, pain, uterine contractions , fetal

distress
•PA risk factors: prior PA, HTN, trauma
•80% of PA are revealed & 20% are concealed (retroplacental)
•Amount of vaginal bleeding usually doesn’t correlate with the
clot size
•Subjectively: Clot <30% of placenta size  good prognosis
Site of Abruption
• Placental edge hematoma: raised (lifted)
placental edge (most cases)
Commonest
hemorrhage
Marginal
• Hematoma adjacent to placenta: curvilinear

from
clot near placenta
placental
• Remote hematoma: blood dissect under
edge
membranes clot distant from placenta (e.g.
near the internal os)
hematoma
• Usually large & acute  placentomegaly
placental
common
2nd most
Retro-
between
(hemorrhage into placenta)
placenta &
• Worst
uterus
hematoma • Subchorionic (retrochorionic) or subamniotic
placental
Rare
on the fetal (retroamniotic ) clot (hematoma)

Pre-
surface of • May simulate placental mass

placenta (chorioamngioma) or large venous lake
85
Habashy Sono-Tricks Vol.II Trick: 3 Placental Abruption
Age of Abruption
• Echogenic blood
Acute hematoma Rare
• Isoechoic to placenta
• Clot is hetrogenous or hypoechoic
Subacute hematoma Commonest • ± Septations
• ± fluid-fluid level (if large)
Chronic (resolving) 2nd most
Sonolucent
hematoma common
•Doppler (color/power)  differentiate clot from placenta & uterus.

•No flow in hematoma (clot)
±Blood diffuses through the amnion Echogenic liquor, ingested
 echogenic stomach contents, echogenic bowel
•Rarely in twin PA  hematoma may dissect between membranes

 cyst between membranes
•If PA is suspected on clinical or US basis

Check signs of fetal distress (bradycardia, abnormal BPP or
Doppler
Check cervical changes (PTL): shortening/funneling
DD
• Rounded uterine wall mass , iso-
Myoma or-hypoechoic to myometrium
≈ Retro-placental • Myoma has blood flow (≠ clot)
PA • Transient myometrial thickening
Focal myometrial
 mass like (ill-defined)
contraction
• Shows flow (≠clot)
Chorioangioma ≈ Pre-placental PA Vascular placental mass
86
Chronic Abruption Oligohydramnios Sequence (CAOS)
PA Outcomes
Severe + IUFD 10%
>37w 40%
50%
30% 20%
Deliver Not deliver within 7d of PA
<37w within 7d
40% 60%
of PA
Will not develop Will develop
oligohydramnios oligohydramnios (CAOS)
•Criteria for diagnosis
 Clinically significant vaginal bleeding (>7 days before
delivery)
 Early normal liquor
Oligohydramnios eventually develops without concurrent
evidence of pPROM
•US detection rate: 75%
•Eventually 65% of them  pPROM
Chronic Abruption Oligohydramnios Sequence (CAOS) ≠

Congenital High Airway Obstructive Sequence (CHAOS)
Massive Subchorionic Hematoma MSH (Breus’ Mole)
• Intraplacental hematoma
• Maternal hematoma near the fetal surface of the placenta
• Considered as a form of Chronic Abruption Oligohydramnios
Sequence (CAOS)
87
Placentomegaly (>5cm)+ FGR
• Large hematoma  variable US appearance: isoechoic to the

placenta , hypoechoic or heterogeneous (heteroechoic)
• ± Fluid-fluid level
• Avascular
Worse prognosis  usually ends by IUFD (especially if large and
near the cord insertion)
DD: other causes of placentomegaly:

•Hydrops
•Intrauterine infection (IUI)
•Placental mesenchymal dysplasia (PMD)
•Macrosomia
88
Acute
Retroplacental
abruption
Figure (73): Acute retroplacental hematoma. This case was complaining of

an antepartum hemorrhage (APH) at 33 w of gestation. TAUS shows an ill
defined echogenic area seen on the maternal surface of the placenta near to
uterine wall associated with oligohydramnios. This echogenic area did not
show flow on power Doppler mapping. This area was tender on targeted
probing.
89
Figure (74): Large marginal

Placenta acute PA: located adjacent to
an otherwise well-attached
anterior placenta. PA is acute
so the clot is isoechoic to the
placenta.
Marginal acute abruption
Figure (75): Acute retroplacental

& intra-placental hemorrhage.
Acute clot is isoechoic to the Normal Acute
placenta, making it appear thick placenta AP
and heterogeneous.
Doppler shows no flow (normal
flow in the remaining attached
placenta).
90
Obstetric Sono-Tricks Placental Abruption Trick: 3 Habashy Sono-Tricks Vol.II
Figure (76); [a-b]: Small marginal Placental abruption (PA): a small

marginal PA, the edge of the placenta has been lifted off the uterine wall. A
small sonolucent hematoma is seen, suggesting the abruption is old. Color
Doppler shows flow in the placenta and uterus but not in the clot. [a] TAUS
shows upper placental edge abruption in a fundal placenta. [b] TVUS shows
lower (leading) placental edge abruption in a placenta previa.
Myometrium
Placenta
Abruption
Abruption
Placenta
Figure (77): Old retroplacental Figure (78): Preplacental abruption:

abruption. A hypoechoic area hypoechoic and avascular area on
beneath the placenta between it and the fetal surface of the placenta .
the uterus. Its hypoechogenicity Color Doppler shows retroplacental
signifies that it is not recent. flow behind the otherwise well
Chronic abruption may mimic a attached anterior placenta.
retroplacental myoma.
91
Figure (79): Retro-amniotic hematoma; a type of preplacental abruption. Obstetric Sono-Tricks

Note the separation between the amnion and the maternal wuterine wall
with fluid in between that has a reticular pattern characteristic for
organizing blood.
92
Normal placenta Oligohydramnios

Acute
Retroplacental
abruption
Myometrium
Figure (80): Acute retroplacenta hematoma. This case was complaining of

an antepartum hemorrhage (APH) at 36 w of gestation. TAUS shows an ill
defined echogenic area seen on the maternal surface of the placenta near to
uterine wall associated with oligohydramnios. This area was tender on
targeted probing.
93
Oligohydramnios Acute
Retroplacental
PA
Myometrium
Fetal surface
of the placenta
Figure (81): Acute retroplacenta hematoma. This case was complaining of

an antepartum hemorrhage (APH) at 34w of gestation. TAUS shows an ill
defined echogenic tender area between the maternal and fetal surfaces of
the placenta. Oligohydramnios was also present.
94
Sub-Acute
Retroplacental
abruption
Figure (82): Sub-acute retroplacental hematoma. This case was complaining

of an antepartum hemorrhage (APH) at 29w of gestation. TAUS shows an ill
defined hetrogenous tender area between the maternal and fetal surfaces of
the placenta with few septations. Oligohydramnios was also present.
Echogenic bowel
Sagittal plane
Normal kidneys
Axial plane
Fig. (83): Same case in figure 82. Figure (84): Same case in figure
Checking kidneys in such cases is 82. Associated echogenic bowel
important to exclude any anomaly (EB) may be noted from the
causing oligohydramnios. ingested blood.
95
Chronic Placenta
Retroplacental
Abruption
Figure (85): Chronic abruption oligohydramnios sequence (CAOS): this

case was 29w on 1st presentation where biophysical profile & Doppler
interrogation were normal. 2 weeks later her condition changed to the
following images: [a] chronic placental abruption, [b] oligohydramnios,
though she denied any pPROM, [c] absent end diastolic flow in the
umbilical artery.
96
Abruption
Placenta
Figure (86): Placental abruption can jeopardize the fetal well being. [a]
subacute retroplacental abruption  [b] high resistant umbilical artery flow
.
Figure (87); [a-b]: The echogenicities associated with grade III placenta can
mimic that with PA, but here it is diffuse, uniform and mostly associated
with normal fetal well being (BPP & Doppler), hence Grade III placenta is
considered as an almost a normal variant.
97
Oligo
Placenta MSH
Figure (88); [a-c]: Massive subchorionic hematoma MSH (Breus’ mole):

large intraplacental hematoma (11.4x7.9 cm) with oligohydramnios. =
chronic abruption oligohydramnios sequence (CAOS)
98
Obstetric Sono-Tricks Placental Abruption Trick: 3 Habashy Sono-Tricks Vol.II
Placenta MSH
Figure (89):Massive subchorionic hematoma MSH (Breus’ mole): large

intraplacental hematoma (11.4x7.9 cm) with oligohydramnios. = chronic
abruption oligohydramnios sequence (CAOS). [b] absent end diastolic flow
in the umbilical artery (AEDF). [c] reversed “a” wave in the ductus venosus
Doppler tracing. [b&c] are consequences of CAOS.
99
Figure (90): Old placental abruption in the inter-twin membrane:
dichorionic gestation with placental abruption of 1 placenta  a complex
fluid collection (hematoma) has dissected between the twin membranes.
Twin membrane cysts may be secondary to old blood or un-fused
membranes.
100
Figure (91): Focal transient

myometrial contraction (FMC)
Outer myometrium is present behind the placenta.
The inner contour of the
myometrium is affected more
FMC than the outer one. FMC is
isoechoic to the myometrium.
Placenta
Figure (92): Preplacental

abruption: Focal
Hematoma on the placental retroplacental
surface (preplacental) & focal hematomas
retro-placental hematomas are
present. Pre-placental abruption is
rare and often presents in
conjunction with marginal &
retroplacental PA.
Preplacental
abruption
101
Placental Lakes (PL) ,
Intervillous Thrombus (IVT) &
Placental Calcification
Figures 93 - 113
References
43 - 50
PL & IVT Placental Calcification

• Lakes VS Infarcts • Classification
• Significance
• Significance
• DD
Habashy Sono-Tricks Vol.II Trick: 4 Placental lakes
• Multiple homogenous regular (oval) sonolucencies in placenta

(hypoechoic foci)
• Occasional fluid-fluid level (maternal RBCs settled in serum)
Sites:
• Central PL = basal (Commonest): surrounded by otherwise
normal placenta
• Sub-chorionic PL: along the fetal surface of placenta  may
bulge in the amniotic cavity
• Rarely: retroplacental, full-thickness or lake-previa (PL in low-
lying placenta with lake near the cervix)
• Etiology: ? Avillous vascular space ↑ intervillous space
regulate placental pressure
• PL thrombosis  infarct IVT
• Placental lakes (PL ) & intervillous thrombus/infarcts (IVT)
often co-exist
PL IVT
Echogenicity Sonolucent Hypoechoic
Slow swirling turbulent flow by real-time gray X

Flow
scale US & power Doppler (not color)
Shape & size may change during scanning : X
Dynamic with maternal re-positioning or uterine
contractions
• Often an incidental finding with excellent prognosis
• Rarely  FGR (especially if ≥3 [PL number], ≥3 cm[largest size]
&/or ≤ 23w [GA])
• Placental mesenchymal dysplasia (PMD) may be considered as

a rare subset of PL  innumerable sonolucencies in a thick
placenta  severe FGR
104
Placental Lakes Trick: 4 Habashy Sono-Tricks Vol.II
DD
Chorioangioma Solitary circumscribed solid mass Doppler  Flow easily
Often near the cord insertion seen
CHMF: 2 placentas
Partial GTN: thick cystic normal placenta with
GTD
placenta + FGR ± anomalies normal fetus & cystic
placenta without fetus
Usually Marginal
PA Usually symptomatic (bleeding, No flow
pain, PTL)
Lacunae NEXT TABLE
Lakes Lacunae
Fundal Previa
Regular Irregular
Difficult flow detection (Doppler) Easier
T2 or T3 onwards T1 onwards
Dynamic Static
Usually good prognosis Usually bad prognosis
Rarely FGR APH (Accreta)
105
Placental Calcification (Grading - Maturity)
Grannum Classification
Grade GA Calcification Chorionic plate
0 <18w No Smooth
1 18-29w Occasional scattered tiny Subtle indentations
parenchymal calcifications
2 30-38 Larger basal calcifications with Deeper (does not
comma like echodensities at the reach the basal plate)
chorionic plate
3 ≥39w Significant basal plate Complete indentations
calcifications with echodensities that reach up to the
outlining the cotyledons basal plate
• Punctate echogenic foci that don't produce 0

significant acoustic shadows
• Mainly in the basal plate and intercotyledonary 1
septa
• Indented chorionic late  as if the placenta
2
is divided into compartments (cotyledons)
• Its central portion is usually echo-spared
(fall-out areas). 3
• Placental calcium deposition is common and is a normal

physiologic process that occurs throughout pregnancy
• Incidence of placental calcification increases with increasing
GA, mostly 3rd trimester
• 15-50% of placentas show some degree of calcification after 33
wks
106
• Probably related to maternal serum calcium level:

 More common in low parity
 More common in young maternal age
 More common in late summer and early fall (when maternal
serum calcium levels are highest)
• More common in Caucasian
• When 1st proposed in 1979, it was studied to correlate with fetal

lung maturity  proved inconclusive for that thereafter
• Then studied extensively for correlation with adverse perinatal
outcomes in late pregnancy; e.g. IUGR, low birth weight, fetal
distress, meconium stained liquor
• Although premature placental aging = early progression to

grade III placenta (<34w) is sometimes associated with
placental insufficiency (e.g. HTN, SLE, DM & smoking), Its
presence does not change the diagnosis nor the prognosis in
such cases
• Presence of grade III placenta in fetuses with FGR who had
normal biophysical profile (BPP) and fetoplacental Doppler
interrogation should not change the decision in their
management
107
• Presence of early grade III placenta in otherwise normal mother

and fetus is of no clinical significance
• There is no increased calcification in postdate placentas:
• Delayed placental maturity (i.e. grade 0 >34w) was thought to be
associated with gestational DM  this proved thereafter to be
clinically insignificant
• Placenta grading is a subjective assessment and has poor inter-
observer agreement (especially for grade III placenta)  low
reproducibility
• There is no proof that placental calcification has any pathologic
or clinical significance no evidence to support routine
reporting of Grannum grades in clinical practice due to its
limited effectiveness .
• The echogenicities associated with grade III placenta can

mimic that with placental abruption PA, but here it is diffuse,
uniform and mostly associated with normal fetal well being
(BPP & Doppler).
108
Obstetric Sono-Tricks Placental Lakes Trick: 4 Habashy Sono-Tricks Vol.II
Figure (93): Placental lake (PL). [a] fundal placenta. Calipres measure the
placental thickness. [b] deepest vertical amniotic pocket (DVP). [c&d]
Small sonolucent area in the placenta. Note that the shape and size of the
sonolucent area change with maternal repositioning (compare c & d) 
dynamic placental sonolucency.
109
Retroplacental PL
Subchorionic PL
Central PL
PL bulge
Figure (94); [a-c]: Various locations of placental lakes. [a&b] Central,

retroplacental, subchorionic (along the fetal surface of the placenta) or [c]
bulge in the amniotic cavity.
110
* *
Figure (95): Placental Lake (PL) : Central intra-placental lake with fluid-
fluid level. The lake contour had been changed after changing the maternal
position  dynamic nature.
111
*
*
Figure (96); [a&b]: Placental Lake (PL) : [a] single large subchorionic
placental lake that bulges into the amniotic cavity. [b] later on after changing
the maternal position, the lake contour had been changed and contains a
fluid-fluid level dynamic nature.
*
*
Figure (97): Placental lakes (PL): 2 placental sonolucencies with fluid fluid
in one of them .
112
Figure (98): Intervillous thrombus (IVT) = placental infarcts: multiple small

homogenous regular anechoic intraplacental lesions.
113
*
Figure (99): [a] An intervillous thrombus (IVT) or infarct with a retracting

blood clot and surrounded by an otherwise normal placenta. [b] A large IVT
With multiple older infarcts which are mostly focal areas of fibrosis.
114
Figure (100); [a&b]: Placental

lakes (PL) and placental
infarcts (intervillous thrombus
– IVT) are coexisting.
115
* *
Figure (101): Intervillous thrombus (IVT) = placental infarcts: multiple

small homogenous regular anechoic avascular intraplacental lesions.
116
Figure (102): Placental Lake (PL) : Central intra-placental lake in a fundally

located placenta. It has a fluid-fluid level. The lake contour had been
changed after changing the maternal position  dynamic nature.
* *
Figure (103): Placental lacunae in placenta accreta: multiple irregular

anechoic avascular areas in placenta previa. They were static during
scanning ; i.e. no change in shape or size with change of the probe pressure
or maternal posture.
117
*
Figure (104); [a-d]: Placental lacunae in placenta accreta: multiple irregular

anechoic avascular areas in placenta previa. The presence of placental
lacunae in a placenta previa increases the likelihood of being accreta.
118
Figure (105); [a-d]: Placental lacunae in placenta accreta: multiple irregular

anechoic vascular spaces in placenta previa. N.B. Placental lacunae could be
vascular or not.
119
Figure (106): Myometrial

veins not accreta: right lateral
placenta and uterine wall
shows large myometrial veins
located behind the placenta.
Prominent myometrial veins
are seen more often with
posterior placentas and are
considered a normal finding.
**
Figure (107):
Posterior placenta accreta: right
lateral placenta with history of
myomectomy, there is loss of
the normal hypoechoic zone
behind the placenta due to of
focal placental invasion. Rarely
posterior placentae invade the
myo-metrium.
120
Figure (108): Grannum placental grading. [a] grade 0. [b] grade 1. [c] grade
2. [d] grade 3. The greater the placental calcification &/or the chorionic plate
indentation , the higher will be the placental grade. Premature placental
aging (i.e. Grade III placenta < 34w) is of no clinical value with normal
biophysical profile & Doppler
121
Figure (109); [a-d]: Grade II placenta. Occasional scattered tiny parenchymal

calcifications. This is the commonest placental grade in the 3rd trimester.
122
Figure (110): Placental lake and

thrombus (PL-IVT): Color
Doppler ultrasound of a placental
sonolucency demonstrates lack of
flow within the structure. A subtle
intraluminal echogenicity without
* flow, is probably a small thrombus
in this placental lake.
Figure (111): Placenta grade

III: 3rd trimester placenta
shows extensive basal and
cotyledon calcifications ; i.e.
grade III placenta. In presence
of normal amniotic fluid,
normal fetal growth &
normal Doppler; the finding
of grade III placenta is
considered as a normal variant
and should not change the
clinical decision.
*
123
Echogenicities
Sonolucencies
Figure (112); [a&b]: Grade III placenta. Multiple placental punctate
echogenicities with multiple placental sonolucencies.
Normal umbilical
Artery Doppler
Figure (113): Grade III placenta: multiple punctate placental echogenicities

seen at the periphery of each placental cotelydon. Most cases with grade III
placentae has an associated with normal fetal well being (BPP & Doppler)
 i.e. considered as an almost a normal variant. DVP: deepest vertical
pocket (liquor).
124
Placental Tumors
Figures 114 - 123
References
51 - 65
• Chorioangioma
• Placental teratoma
• Placental mesenchymal dysplasia (PMD)
Placental Tumors Trick: 5 Habashy Sono-Tricks Vol.II
Chorioangioma
• Well defined hypoechoic vascular placental mass (Doppler is

essential for diagnosis) ,usually T3
• Mostly on the fetal surface of placenta near the cord insertion
• Rarely heterogeneous : if hemorrhage, infarction or hyaline
degeneration
• Chorioangiomatosis (rare variant): multiple chorioangiomas 
diffusely heterogeneous placenta (more prone to complications)
• Most cases are small (<5cm) & single with excellent prognosis
• Possible associations:
Hydrops caused by either A-V shunting or fetal anemia
(hemolysis)
o Vascularity is more predictor for complications (hydrops)
than size
o Vascularity may be ↓ or ↑ as pregnancy advances
IUGR (FGR)/ preeclampsia PET
Rare associated anomalies: hepatic & cutaneous
hemangiomas, Beckwith–Wiedemann syndrome BWS,
single umbilical artery (SUA).
• Etiology:?, placental hypoxia angiogenesis; i.e. reactive

proliferation , not a true neoplasm
• Often female fetuses
127
Habashy Sono-Tricks Vol.II Trick: 5 Placental Tumors
DD
Placental lakes (PL) Too slow flow (Doppler) Dynamic
Intervillous thrombus Does not change the
(IVT) placental contour
No flow
Placental hematoma Appearance evolves
(PA) over time
Submucous fibroid Separable from
Uterine wall mass
(SMF) placenta
Partial mole (PHM) Large cystic placenta FGR ± anomalies
Placental teratoma Heterogeneous mass with
± calcification
cystic & solid components
Placental metastases Maternal: Melanoma (±  Fetal: Neuroblastoma
fetus), lymphoma, breast (adrenal)
Placental Teratoma
• Regular soft tissue mass with variable echogenicity
(heterogeneous: solid & cystic), usually on the fetal surface of
the placenta (rarely pedunculated)
• Common calcification but never organized skeletal structure (no
clear cranial & caudal end ≠ twin reversed arterial perfusion
sequence TRAP)
• Blood supply from placental arteries (Not umbilical cord ≠
TRAP)
• Little or no flow on Doppler mapping (≠ Chorioangioma)
DD:
• Acardiac twin in twin reversed arterial perfusion (TRAP): fetus
like appearance (axial skeleton without head) ,has a separate
umbilical cord and located in the amniotic cavity
• Chorioangioma: Vascular , uncommon calcification
128
• Extremely rare benign non-trophoblastic tumor originating

between amnion & chorion
• Pathology: ? True neoplasm or extreme form of acardiac twin
• Prognosis : Incidental finding with no adverse effects (neither
fetal nor maternal)
Placental Mesenchymal Dysplasia (PMD) – Pseudo-mole
• Thickened multicystic placenta (seen as early as 13w) with a

structurally normal fetus
• ±enlarged vessels along the fetal surface of the placenta
• Etiology : ? Placental mosaicism or subtype of PL

• Placental developmental pathology rather than neoplasia
• Rare placental pathology, under-recognized
• 50% FGR
• 20% BWS
• 30% IUFD or early neonatal death (END)
• 40% has ↑ β-hCG
• 60% PTL
• May  PET
• Rarely: associated hepatic hamartoma , gastroschisis
• 10% (only) normal outcome
• 80% female fetus
129
DD
Thick cystic placenta FGR
Partial mole
(Like PMD) Anomalies (usually)
2 placentas normal placenta with normal fetus &
CHMF
cystic placenta without fetus
Chorioangiomas are May undergo hemorrhage
Chorioangiomatosis
vascular solid masses or infarction  cystic
• Thickened cystic placenta is present in both partial mole & PMD

(& FGR is present in both). ↑β-hCG is also in both .
• If the fetus is structurally abnormal  Partial mole. If not 
karyotyping is recommended to exclude triploidy (partial mole)
130
Cord insertion
Chorioangioma
*
Placenta
Chorioangioma
Placenta
Figure (114); [a&b]: Chrioangioma: “Case No-1”. Well defined

hypoechoic placental mass on the fetal surface of the placenta near the cord
insertion.
131
Chorioangioma
Placenta
Cord insertion
Chorioangioma
*
Placenta
Figure (115); [a&b]: Chrioangioma: “Case No-2”. Hypoechoic placental

mass on the fetal surface of the placenta near the cord insertion.
132
* *
Figure (116); [a-c]: Chrioangioma: “Case No-3”. Well defined hypoechoic

placental mass on the fetal surface of the placenta near the cord insertion.
133
* *
Figure (117); [a-c]: Chorioangioma: “Case No-4”. A well-defined

hypoechoic vascular placental mass on the fetal surface of the placenta,
bulging into the amniotic cavity. Intra-lesional flow was seen on color
Doppler.
134
* *
* *
Figure (118); [a-d]: Chrioangioma: “Case No-5”. Well defined

heterogeneous placental mass on the fetal surface of the placenta near the
cord insertion and bulge into the amniotic cavity.
135
*
Figure (119); [a&b]: Chrioangioma: “Case No-6”. Well defined

heterogeneous placental mass on the fetal surface of the placenta near the
cord insertion and bulge into the amniotic cavity.
136
*
*
Cord
Teratoma Insertion
feeder
Figure (120): Placental teratoma : [a&b] an exophytic placental mass that is

contiguous with the anterior margin of the placenta. This placental mass is
complex with cystic components (i.e. heterogeneous: solid & cystic) and
shadowing (calcifications). The mass was not free floating and the
calcifications does not look like an organized skeleton (≠ twin reversed
arterial perfusion sequence TRAP). [c] Color Doppler of the mass shows
direct blood supply to the teratoma from the placenta, not through an
umbilical cord. A normal cord insertion of the cord into the placenta is seen
beside the mass.
137
*
Figure (121): Fetus-in-fetu (FIF): :Axial US of the fetal abdomen shows a

cystic mass with a large, central, solid component. Calcifications are also
present inside the mass This calcifications are not related to the placenta
(≠ placental teratoma). The mass is not connected to a separate cord (≠
twin reversed arterial perfusion sequence TRAP). The mass is inside the
maternal uterus (≠ lithopodion, abdominal pregnancy).
138
*
Kidneys
Figure (122); [a&b]: Fetus-in-fetu (FIF): Axial ultrasound through the fetal
abdomen during the mid-trimester shows a heterogeneous abdominal mass
(i.e. partly cystic and partly solid mass). This mass is separable from the
urinary tract and was not related to the fetal bowel. The echogenic parts
within the solid element of the mass represent a skeletal remnants.
139
* *
*
*
*
Figure (123); [a&b]: Placental mesenchymal dysplasia (PMD): Color

Doppler images through the placenta show placental thickening and several
cystic spaces. The fetus had fetal growth restriction (FGR). Amniocentesis
results were normal. Postnatal placental pathology showed mesenchymal
dysplasia. Sonographic features are identical to a thick cystic placenta in
triploidy and genetic testing is recommended. Both carry a dismal
prognosis.
140
Succenturiate Lobe &
Circumvallate placenta
Figures 124 - 144
References
66 - 74
Succenturiate lobe Circumvallate placenta
• US features • US features
• Significance • Significance
• DD • DD
Succenturiate-Circumvallate Trick: 6 Habashy Sono-Tricks Vol.II
Succenturiate Lobe = Accessory Placenta = Bilobed Placenta
• ≥1 accessory lobes apart from the main placenta (gray-scale) with

submembranous communicating vessels in-between (Doppler)
• i.e. 2 separate placental masses, cord inserted on the main (larger,

1ry) placental lobe (usually marginal or velamentous)
• Bilobed placenta is a SL variant (less common) where there are 2
equal placental masses with central thinning & the cord inserted
on the thinned area (usually velmentous)
If the main lobe &/or SL are low-lying  communicating vessels

can cross the internal os  vasa previa VP type 2 (TVUS Doppler)
• 5% of all pregnancies, usually under-recognized

• Excellent prognosis if isolated
• If associated with :
VCI FGR, cord trauma
VP: APH (Fetal)
•May be missed during delivery  retained placenta  PPH.
DD
Acute placental Blood is isoechoic to Doppler  No flow in
abruption the placenta hematoma
Focal myometrial No submembranous Distort the inner myometrium
contractions connecting vessels (more than the outer myometrium)
Transient (resolves with time)
143
Habashy Sono-Tricks Vol.II Trick: 6 Succenturiate-Circumvallate
Circumvallate placenta (CP) = Placenta extracorialis

= Placental band or shelf
• Elevated placental margin = placental edge lift (thickened) =

margin infolding (rolling up) towards the cord insertion site=
placental edge protrudes into the uterine cavity
• Marginal placental shelf (band): short band of tissue attaches on
placenta only (not the uterine wall nor the fetus); i.e.. placenta-
to-placenta band. Within 3 cm of the placental margin
• Center of the placenta may bulge towards the amniotic cavity
(best seen by 3D surface rendering)
3D-US  Surface rendering mode  Tire Sign
•Marginal fold of the chorion  Circumferential depression

with thick peripheral ring on the chorionic plate  appearance
of a “tire mounted on a wheel”.
For this sign to appear:
•3D box include the entire placenta (including the cord

insertion & margins) with amniotic fluid pocket.
•Large acquisition angle : 850.
•Maximum quality  slow acquisition of a non-moving
structure (the placenta)
•Green line is directed toward the chorionic plate (preferably
curved to fit the placental surface)
144
Etiology: ? Early marginal placental infarct (marginal membranes

tethering) Chorionic plate is smaller than the basal plate 
chorionic membrane does not insert at the placental edge but
somewhat inwards.
•Excellent prognosis
•↑ PTL, placental abruption (PA) & FGR
DD (other causes of intrauterine membranes/bands)

Synechiae Uterine scar  membrane • Membranes attached to
(Amniotic infolding around adhesions the uterine wall
sheets) 2-3mm bands , ±flow • Often triangular (∆)
attachment point
Amniotic band Thin avascular bands Membranes attach to fetus
syndrome (ABS) (±amputation)
Uterine Only at the fundus • Usually septum

duplication • Smooth indentation
anomaly
Another DD is the accessory lobe: The rolled-in edge of the

placenta sometimes mistaken as SL. The differentiation between
CP & SL is by carefully examining the area between the 2 masses
(by grayscale & Doppler US) : if it is placental tissue  CP, if it
is vessels  SL
145
*
Accessory
Lobe
Accessory
Lobe Main
* Placenta
Junction between
The 1ry & 2ry placentae
Figure (124); [a-c]: Succenturiate lobe (SL): “Case No-1”. Accessory

placental lobe is seen apart from the main placenta.
146
* *
* *
Figure (125); [a&b]:

Succenturiate lobe (SL):
“Case No-2”. Accessory
placental lobe is seen apart
from the primary placenta.
Note the thin area between
the 2 lobes of the placenta *
simulating the hourglass
with unequal halves.
147
SL
*
1ry
Placenta
* SL
1ry
Placenta
Figure (126): Accessory placenta (succenturiate placenta SL): “Case No-

3”. [a] 2 separate placentae; one is larger posterior and the other is smaller
anterior. The main placental lobe in this case is posterior, and the anterior
lobe is considered accessory. [b] An anterior and posterior placenta are
connected via submembranous communicating vessels (arrow).
148
SL
1ry
Placenta
SL
1ry
Placenta
Figure (127); [a&b]: Succenturiate lobe (SL): “Case No-4”. 3D-US using
the multislice mode shows an accessory placental lobe beside the main
placenta. Note the thin area between the 2 lobes of the placenta.
149
1ry
Placenta
*
SL
Figure (128): Succenturiate lobe (SL): “Case No-5”. 2D US accessory

placental lobe is seen apart from the main placenta.
Figure (129); [a&b]: Succenturiate lobe (SL): 3D-US using the multi-slice
mode accessory placental lobe is seen apart from the main placenta.
Note the membranous communication in-between. These US images are
for the same case in figure 128.
150
1ry
Placenta
SL
Figure (130): Succenturiate lobe (SL): “Case No-6”. Accessory placental

lobe is seen near the main placenta. [a-c] 2D-US. [d] 3D-US using the
multi-slice mode.
151
Same
Placenta
Figure (131): Pseudo-Succenturiate Lobe: [a] Sagittal view shows an
anterior smaller placenta and a posterior larger placenta. Initial impression
suspect an anterior succenturiate anterior lobe. [b] Axial ultrasound of the
same case shows a connection between the anterior and posterior placenta.
Therefore, this placenta is normal without a succenturiate lobe. Whole
uterine scanning is necessary to accurately determine placental morphology.
152
Figure (132): Circumvallate

placenta (placenta extra-corialis):
elevated placental margins 
rolled-up placental edges; i.e.
placental margins protrude into
the amniotic cavity.
Fig. (133): Circumvallate placenta:

same case using the 3D-Multislice
mode (= tomographic US imaging
TUI).
153
Figure (134); [a&b]: Circumvallate placenta: elevated placental margin

placental margins protrude into the amniotic cavity and not attached to the
fetal surface (unlike the amniotic band syndrome ABS ).
154
Obstetric Sono-Tricks Succenturiate-Circumvallate Trick: 6 Habashy Sono-Tricks Vol.II
Figure (135): Circumvallate placenta: Marginal placental shelf (band):

band attaches the 2 placental edges together passing parallel to the fetal
surface of the placenta and not attached to the fetus nor the maternal
uterine wall (unlike amniotic band syndrome and uterine synichiea
respectively).
155
Figure (136); [a&b]: Circumvallate
placenta: Marginal placental shelf
(band): placenta-to-placenta band.
156
Figure (137): Circumvallate placenta. The placental edge lift with an

associated placenta-to-placenta band (that attaches to the margins of the
placenta) are the hallmarks of circumvallate placenta.
157
Figure (138): Circumvallate placenta: the placental shelf (band): A thick
membrane extends from one placental edge to the other. It represents the
lifted membranes. It is placenta-to-placenta band that attaches on placenta
only ; not the uterine wall (≠ synechiae) nor the fundus (≠ uterine septum).
158
Figure (139); [a&b]: Uterine

Synechiae (amniotic sheets):
TAUS shows a thick linear
echo (fibrous band) crossing
the uterine cavity between
the anterior and the posterior
uterine walls. The amnion
drapes over the synechia
which is clearly separate
from the placental margins
(≠circumvallate placenta). In
this case the echogenic band
was in the lower uterine
segment LUS (i.e. away
from the fundus (≠ uterine
septum) and the fetus moved
freely around it (i.e. the band
was not attached to the fetus
≠ amniotic band syndrome
ABS)
159
Figure (140); [a&b]: Uterine
Synechiae (amniotic sheets):
2-3mm avascular membranous
adhesions between uterine
walls and not attached to the
fetus (unlike the amniotic
band syndrome). They are the
result of uterine adhesions
where the amniotic membrane
enfold around them.
160

placenta : TAUS shows
rolled-up placental edges
with central placental bulge.

placenta: 3D-US using the
multi-slice mode shows that
the center of the placenta
bulges towards the amniotic
cavity.
161
Circumvallate placenta: 3D-
US using the multi-slice
mode shows that the center
of the placenta bulges
towards the amniotic cavity
and the margins are
infolded.
162
Figure (144); [a&b]: Tire

sign in circumvallate
placenta: 3D-US using the
surface mode where the 3D
box includes the entire
placenta  circumferential
depression with thick
peripheral ring on the
chorionic plate 
appearance of a “tire
mounted on a wheel”.
163
Marginal /Velamentous Cord
Insertion &
Vasa Previa
Figures 145 - 154
References
75 - 81
Marginal & Velamentous Cord Insertion
• US features
• Significance
Vasa Previa
• US features
• Types
• DD
• Significance
Habashy Sono-Tricks Vol.II Trick: 7 MPCI - VC I - VP
Marginal Placental Cord Insertion (MPCI)

Velamentous Cord Insertion (VCI)
• Marginal placental cord insertion (MPCI): Umbilical cord

insertion (UCI) within 2 cm of the placental edge with all
branching vessels on the fetal surface of the placenta
• Velamentous cord insertion (VCI): UC inserts on membranes
(not placenta), at variable distance from the placenta . Vessels
then diverge & travel beneath membranes towards placenta
(Mangrove tree sign)
• If VCI is in lower uterine segment (LUS)  risk for vasa previa

(VP)
• MPCI, VCI & VP  combined grayscale & Doppler (color &
pulsed) is essential for diagnosis
• Submembranous vessels are not protected by Wharton jelly 
susceptible to trauma
• Etiology: ? Trophotropism of placenta: early central cord

insertion but later part of the placenta resorb (placenta often
small & thick) MPCI  may progress to VCI
• VCI incidence: 1% of singleton, 7% of DC twins, 40& of MC
twins
• Adverse outcomes with MPCI is < VCI

• Associated abnormalities:
FGR/PTL
Single umbilical artery (SUA): 15% of MPCI & 10% of VCI
Manual placental extraction at labor
166
MPCI – VCI - VP Trick: 7 Habashy Sono-Tricks Vol.II
Vasa Previa (VP)
•Umbilical vessels cover or within 2 cm of internal os

•Submembranous (i.e. fixed ≠ free loop near the cervix)
•TVUS with Doppler (color & pulsed)  is essential for diagnosis
Types
VP Type1 Vasa previa with velamentous Low-lying vessels from

cord insertion (VP+VCI) low cord insertion
VP type 2 Vasa previa with succenturiate Low-lying vessels between
lobe (VP+SL) the 2 placental lobes
•90% of VP is associated with low lying placenta

•5% of low-lying placentas have VP
•So any PP  Check cord insertion & internal os (TVUS:
grayscale & Doppler)
DD
Cord presentation Free floating loop near the internal os (not fixed, i.e.
intra-amniotic not submembranous)
Uterine or cervical Maternal venous flow
varicosities
Marginal sinus • PP with one of the placental veins located near the
previa cervix but the cord insertion is normal
• Pulsed Doppler (venous not arterial ≠ VP)
Chorioamniotic Linear sonolucency near the internal cervical os
separation without Doppler flow
Marginal placental • Blood at the internal os ≈ placenta or UC
abruption • No flow in the hematoma (clot)
167
•VP is unprotected by Wharton jelly  susceptible for

compression & tear
•Fetal APH  IUFD associated with minimal vaginal bleeding
•Risk of IUFD: 45% if not diagnosed prenatally, 5% if diagnosed
•If diagnosed antenatally  bed-rest, ECS at 35w
168
Figure (145): Normal

central placental cord
insertion (PCI).
Eccentric is also
normal but >2 cm
from the placental
edges,
Figure (146): 4 types of placental cord centeral

insertion on the fetal surface of the
placenta . The first 2 are normal. The later
2 are pathological and may have
consecutive complications.
eccentric
marginal
velamentous
169
Normal central cord
insertion in the placenta:
170
Obstetric Sono-Tricks MPCI – VCI - VP Trick: 7 Habashy Sono-Tricks Vol.II
Figure (148): Marginal placental cord insertion (MPCI): umbilical cord

insertion (UCI) is seen near the upper edge of the placenta (within 2 cm of
the placental margin). Note that all the branching vessels are on the fetal
surface of the placenta (i.e. not velamentous cord insertion)
171
Figure (149); [a&b]: Marginal placental cord insertion (MPCI): Umbilical
cord insertion (UCI) is near the upper edge of the placenta with all vessels
on the fetal surface of the placenta (i.e. no associated velamentous cord
insertion).
172
Figure (150); [a&b]: Velamentous cord insertion (VCI): “Case No-1”. The
“mangrove tree sign”: the placental end of the umbilical cord (UC) ends
distal to the placenta then cord vessels diverge towards the placenta. This
diversion mimics the root of the mangrove tree.
173
Figure (151); [a&b]: Velamentous cord insertion (VCI): “Case No-2”. The
distal to the placenta then cord vessels diverge towards the placenta.
174
Figure (152); [a-c]: Velamentous cord insertion (VCI): “Case No-3”. The
distal to the placenta then cord vessels diverge towards the placenta.
175
VP
PP
Cervix
Figure (153): Vasa previa : transvaginal color Doppler US shows a low

lying anterior placental lobe and a posterior accessory lobe with
communicating vessels crossing the internal cervical os. These
communicating vessels do not move with fetal nor maternal movements
(≠ free floating umbilical cord loop beside the internal os).
176
VP
Cervix
Figure (154): Vasa previa : transvaginal color Doppler US shows an

umbilical vessel crossing the internal cervical os. This vessel does not
move with fetal nor maternal movements (≠ free floating umbilical cord
loop beside the internal os), and on spectral Doppler tracing it shows fetal
heart rate (not Maternal heart rate ≠ maternal uterine artery).
177
Fetal Abdominal Wall Defects
Figures 155 - 181

References
82 - 97
• Physiological Gut Herniation

• Omphalocele
• Gastroschisis
• Cantrell Pentalogy
• Bladder Exstrophy
• Cloacal Exstrophy
• Body Stalk Anomaly
• DD
Habashy Sono-Tricks Vol.II Trick: 8 Abd. Wall Defects
Physiological gut herniation
• Normal embryologic process in the first trimester (T1) due to

rapid midgut growth > abdominal wall
• Not in all fetuses
• Always midline with UCI at its base
• Within the umbilical cord
• Bowel returns to abdomen by 11-12w
• Should not extend > 1cm
• Bowel only (never liver)
Omphalocele (Exomphalos)
Rounded central midline abdominal wall bulge (defect) at the site

of the cord insertion through which gut is herniated and covered
by membrane (peritoneum & amniotic membrane)
• Commonly liver herniated with the gut.

• Nonliver containing omphaloceles (bowel only) have a higher
rate of associated structural and chromosomal abnormalities
(60% aneuploidy rate)
• Commonly associated polyhydramnios & ascites ; in the third
trimester (T3)
• The covering membrane is mostly thin, but may be
multicystic mucoid degeneration of Wharton jelly that is
sandwiched between the peritoneum & amnion
180
Abd. Wall Defects Trick: 8 Habashy Sono-Tricks Vol.II
Syndromes associated with omphalocele:

• Beckwith-Wiedmann syndrome (BVS): + Macrosomia,
nephromegaly, macroglossia
• Cantrell pentalogy: high omphalocele+ ectopia cordis, cardiac
defect, sternal/pericardial/diaphragmatic defects
• OIES complex: Low omphalocele+ UB exstrophy+imperforate
anus + spine anomaly
Gastroschisis
• Abdominal wall defect beside the cord insertion (mostly Rt

paramedian) through which bowel herniates without peritoneal
cover  irregular surface of the herniated bowel
• Echogenic wall of the extruded bowel (chemical peritonitis
from amniotic fluid exposure
• Extracorporeal bowel dilatation is common (85%)

• Intraabdominal bowel dilatation (IABD) >14 mm 
associated atresia (30%)
• Risk factors: young mothers, drug abuse
• Extruded viscera: small bowel>large bowel> stomach> UB>
liver
• Oligohydramnios is more common than polyhydramnios (due
to IUGR in 25%). Polyhydramnios is suggestive for associated
atresia
181
Exomphalos Gastroscheisis
Peritoneal cover √ X
External surface Smooth (rounded) Irregular
(cauliflower)
Cord insertion At the top of the Beside it
lesion
Extruded liver Common Rare
Associated anomaly/ 30% 10%
Aneuploidy
Prognosis Worse Better
Amniotic Fluid Polyhydramnios is Oligohydramnios is
common common
Cantrell Pentalogy
• 5 classic components of Cantrell pentalogy:

1. Supraumbilical abdominal wall defect (with omphalocele >>
gastroschisis)
2. Sternal defect with ectopia cordis
3. Anterior diaphragmatic defect
4. Diaphragmatic pericardial defect
5. Intracardiac defect
• All 5 anomalies are not always present  incomplete
expression of the syndrome
• Most cases: Omphalocele + Ectopia cordis

• Usually fatal
182
• Mostly sporadic, May be associated with: craniofacial and

vertebral anomalies or T13,18 or Turner syndrome
• Omphalocele:
o Points ventrally  Isolated omphalocele
o Points cranially Cantrell pentalogy
o Points caudally  Coloacal exstrophy
• DD:
o Body stalk anomaly: distorted fetus that is adherent to
placenta with no free-floating cord
o Amniotic band syndrome: slash defects that frequently
involves head, neck & limbs . Bands may be seen
Bladder Exstrophy (BE) =

Ectopia Vesicae
•Absent UB (UB filling :15 min) + lower than normal cord

insertion (at the superior margin of the exstrophic UB). N.B.
Umbilical arteries normally encompass UB as they pass from
internal iliac arteries to the umbilicus
•Soft tissue mass in the lower abdominal wall (midline sagittal)
due to exposed posterior UB wall  inflammatory polyps
creates “lumpy bumpy” surface (i.e. irregular lower abdominal
wall)
•Normal amount of liquor
183
•Male: female = 3:1

•Associations: Genital & spine anomalies, Rarely: T21,13
•DD: Other causes of absent UB:
Normal fetus (that just urinate rescan after 15 min)
Bilateral renal agenesis: anhydramnios & lying down adrenals
ARPCK (autosomal recessive polycystic kidney)
Bilateral MCDK (multicystic dysplatic kidney)
Severe IUGR: oligohydramnios ± abnormal Doppler
Donor twin in twin to twin transfusion syndrome (TTTS)
Cloacal Exstrophy (CE)/ OEIS Complex – Syndrome
• Absent UB = BE
• Abdominal wall defect with elephant trunk sign: bowel
herniation between 2 halves of UB
• Absent anal dimple = anal atresia
OIES Complex : Omphalocele, Imperforate anus, Exstrophy of

UB & Spinal deformities (e.g. spina bifida, hemivertebra)
• Omphalocele (i.e membrane bound) forms the upper part of the

defect in most (65%) CE cases (i.e. not essential for diagnosis)
• 60% have associated genitourinary anomalies (may 
oligohydramnios)
184
Body stalk anomaly (Limb-Body wall complex LBWC)
•Confusing fetal anatomy (gross distortion with complete loss of

anatomical landmarks) . In my opinion  as if the fetus is torn in
pieces
•Short or absent Umbilical cord
•Thoraco/abodominal wall defect(s): (bizarre evisceration) 

viscera attached to the placenta Stuck fetal appearance 
Fixed fetal placental relationship (even with change of the
mother’s position)
•Scoliosis and limb defects
•±Craniofacial defects (< amniotic band syndrome ABS)

•All organs are potentially involved: e.g heart (ectopia cordis,
congenital heart disease: CHD), congenital diaphragmatic hernia:
CDH, renal , bowel atresia
• Oligohydramnios if left till T2&3
•LBWC is a lethal anomaly  TOP
•DD: ABS & Cantrell Pentalogy (Both have normal umbilical

cord)
185
Significant Simple
Abdominal Cloacal Bladder Omphalocele Gastroschisis
wall defects exstrophy (CE) exstrophy
(BE)
On membrane Low on On On
Cord insertion or low on abdominal membrane abdominal
abdominal wall wall wall
In cases with No Present No
Membrane
omphalocele
Free-floating Yes No No Yes
bowel
UB visible No No Yes Yes
Anal dimple No Yes Yes Yes
visible
Normal Cord Defect to the Rt of the CI Gastroschisis

Insertion Low defect below CI & no extruded Bladder
(CI) bowel exstrophy
CI in membrane surrounding defect Omphalocele
Low defect including CI & absent UB Cloacal
exstrophy
High defect above and potentially Cantrell
Abnormal
involving the CI pentalogy
CI
Distorted Absent (or Body stalk
anatomy & Umbilical too short) anomaly
fixed fetal cord Amniotic band
position Present
syndrome
186
Obstetric Sono-Tricks Abd. Wall Defects Trick: 8 Habashy Sono-Tricks Vol.II
Figure (155): Physiologic gut herniation at 10 weeks gestation, seen in

sagittal view. [a&b] axial views using 2D-TVUS. [c&d] sagittal views
using 3D-TVUS.
187
Figure (156): Physiologic gut herniation at 10 weeks gestation, seen in
sagittal view. [a & b] 2D-TVUS. [c] 3D-TVUS using the ovix mode (VCI-C).
[d] 3D-TVUS using the multislice mode (TUI).
188
Figure (157); [a&b]: Physiologic gut herniation at 10 weeks gestation, seen

in sagittal view.
189
Figure (158): Normal umbilical cord insertion in the fetal abdomen as seen
during the mid-trimester ultrasound scan. [a] axial plane. [b] sagittal plane.
190
Figure (159): Omphalocele.

There is a peritoneal cover for
the herniated bowel.
Figure (160): Omphalocele.

The umbilical cord inserted at
the top-center of the lesion.
191
Figure (161): Omphalocele. [a] There is a peritoneal cover for the herniated
bowel. [b] The umbilical cord inserted at the center of the herniated lesion.
192
Figure (162): Omphalocele: [a] There is a peritoneal cover for the herniated
bowel. [b] The umbilical cord inserted at the center of the herniated lesion.
193
Skin Cystic
edema hygroma
Figure (163): Syndromic omphalocele: the association of [a] omphalocele,

[b] cystic hygroma, skin edema, [c] pleural effusion and [d] echogenic
intracardiac focus (EIF) in a case of Down syndrome (trisomy 21: T21).
194
Figure (164): Syndromic omphalocele: the association of [a] omphalocele,

[b] thick nuchal fold (NF in this case is 7.25mm ; it is normal up to 6 mm) in
a case of Down syndrome (trisomy 21: T21).
195
Figure (165): Omphalocele [a&b] with ventricular septal defect (VSD) [c]
in a fetus with trisomy 21 (T21 : Down syndrome).
196
Ant.
Abd.
Wall No
Amniotic
Cover
Spine
Figure (166): Gastroschisis.

[a] The herniated bowel
floats in the amniotic cavity
without a peritoneal cover.
[b] The umbilical cord
inserted beside the
herniated lesion.
UC
Herniated
bowel
197
Figure (167): Gastroschisis. [a] The herniated bowel floats in the amniotic
cavity without a peritoneal cover. [b] The umbilical cord inserted beside
the herniated lesion.
198
No
Amniotic
Cover
Figure (168); [a-c]: Gastroschisis. The herniated bowel floats in the amniotic
cavity without a peritoneal cover.
199

Gastroschisis. The herniated
bowel floats in the amniotic
cavity without a peritoneal
cover.
Gastroschisis. The umbilical
cord inserted beside the
herniated lesion.
200
Figure (171): Omphalocele

VS physiologic mid-gut
herniation: This image
shows a sagittal plane with
an embryonic abdominal
wall defect that contains the
liver at 10 weeks 5 days of
gestation. This is an
omphalocele and waiting

till the end of the 12th
gestational week will not
change the diagnosis to the
physiologic gut hernia as
the later should not contain
liver.
Figure (172): Gastroschisis

VS physiologic mid-gut
herniation: This image
shows an axial plane with
an embryonic extruded
bowel loops adjacent to the
cord insertion at 11 weeks
of gestation. This is a
gastroschisis and waiting
till the end of the 12th
gestational week will not
change the diagnosis to the
physiologic gut hernia as
the later should be within
the cord not beside it.
201
Heart
St.
Supraumbilical
omphalocele
Figure (173): Pentalogy of Cantrell: [a] Ectopia cordis: fetal heart is

outside the fetal chest cage. Note the heart in this case as if protruded from
the plane of the abdominal circumference. [b] Supraumbilical
omphalocele. Note the direction of the omphalocele is towards the fetal
chin (i.e. supraumbilical abdominal wall defect). Ectopia cordis and
omphalocele are the hallmarks of pentalogy of Cantrell.
202
Heart & liver are extruded
Spine defect
omphalocele
Heart outside the chest
Figure (174); [a-c]: Pentalogy of Cantrell: semisagital and axial planes show
the fetal heart located outside the chest cage (ectopia cordis) near the
exomphalos. Ectopia cordis and exomphalos are the hallmarks of Cantrell
pentalogy.
203
Soft
Tissue
Lump
Below
UCI
Low
Cord Absent
insertion UB
Figure (175); [a-c]: Bladder exstrophy (BE) = ectopia vesica: These images
show the 3 characteristic findings of BE: (1) absent UB. (2) low cord
insertion & (3) soft tissue protuberance in the fetal abdomen between the
cord insertion and the genitalia.
204
Umb.
Cord
Insertion
UCI
Soft
Tissue
Lump
Below
UCI
Absent UB
Absent *
UB
*
Figure (176): Bladder exstrophy (BE): [a] Sagittal view of a fetus at 23

weeks gestation shows an irregular contour of the lower anterior abdominal
wall caudal to the cord insertion site (which is lower than normal). The
bladder is not seen as a fluid-filled structure in the expected location. [b]
Axial color Doppler sonography shows the umbilical arteries on either side of
a soft tissue protuberance from the anterior abdominal wall. The bladder is
not seen as a fluid-filled structure between the umbilical arteries. [c] Axial
oblique view shows absent fetal urinary bladder between the umbilical
arteries near the fetal cord insertion site.
205
Soft
Tissue
Lump
Below
UCI
Absent
UB
Figure (177): Bladder exstrophy (BE) = ectopia vesicae: [a] Sagittal view of
a fetus at 23 weeks gestation shows an irregular contour of the lower
anterior abdominal wall caudal to the cord insertion site (which is lower
than normal). The bladder is not seen as a fluid-filled structure in the
expected location. [b] 3D- surface rendering of the lower fetal abdomen
shows a soft tissue protuberance in the anterior abdominal wall above the
gentalia; the exctrophied UB.
206
Figure (178); [a-c]: OEIS complex: Omphalocele & spine deformities are the
hallmarks of OEIS complex or syndrome. OEIS stands for: Omphalocele,
Exstrophy of the urinary bladder, Imperforate anus and Spine deformities. In
this case the spine deformity was sacral agenesis: note that the spine ended
caudally at the lumber region and there is no acoustic shadowing dorsal to the
area between the 2 iliac bones (where the sacrum should be present).
207
Figure (179); [a-b]: OEIS complex: Omphalocele & spine deformities are the
hallmarks of OEIS complex or syndrome. OEIS stands for: Omphalocele,
Exstrophy of the urinary bladder, Imperforate anus and Spine deformities.
208
No umb. Cord
Fetus attached
To placenta
Kyphoscoliosis
Figure (180): Body stalk anomaly (limb-body wall complex LBWC):

confusing fetal anatomy with gross distortion of the anatomical landmarks.
[a&b] bizarre evisceration anterior abdominal wall defect with the viscera
attached to the placenta  absent umbilical cord. [c] kyphoscoliosis (bended
& interrupted spine). [d] limb defect (no identifiable parts distal to the
femur).
209
Exomphalos Fetus attached

to the placenta
Scoliosis
Placenta
Figure (181): Body stalk anomaly (limb-body wall complex LBWC):

Gross fetal anatomical distortion. The fetus is attached to the placenta with
abdominal wall defect and scoliosis. There is no umbilical cord between
the fetus and the placenta.
210
GIT Anomalies
Figures 182 - 241
References
98 - 152
Duplication
Peritoneal
Obstruction Hepatobiliary DD
Meconium peritonitis
Esophageal atresia Hemangioma Absent stomach
Duodenal atresia Hamartoma Echogenic bowel

Enteric Duplication Cyst
Hepatoblastoma
Small bowel atresia Abdominal
calcification
Colonic atresia GB Stone
Choledochal
Mesenteric cyst
Anal atresia Hepatosplenomegaly

cyst
Cloacal malformation
Biliary Atresia Ascites
Volvulus
GIT Trick: 9 Habashy Sono-Tricks Vol.II
Esophageal Artesia (EA)

•90% of EA has associated tracheo-esophageal fistula (TEF)
•40% postnatal mortality rate oVertebral defects
oAnal atresia
•50% US detection sensitivity oCardiac defects,
•40% associated IUGR oTEF
oRenal anomalies
•50% associated anomalies (30% : VACTERL)  oLimb abnormalities
•Absent stomach (for >2 hour) + polyhydramnios (>20w)
•Presence of stomach not exclude EA (as type A,C &D liquor can
pass via the TEF  Small stomach). These types are post-natal
diagnosis.
•Pouch sign: transient filling of proximal esophagus. Not
diagnostic ; as it may be seen in normal fetuses (more suggestive
for EA if extend below the clavicle)
•C-Loop sign: EA with DA  distended distal esophagus ,stomach
& duodenum  Mostly T21
Type Incidence
EA TEF
A 82% Proximal Distal

B 9% Proximal & Distal No
C 6% No H-type
Proximal &
D 2% Any site
Distal
E •Esophagus
1% & trachea
Distal can beProximal
seen (with difficulty) in the Lt
para-sagittal plane of the fetal neck:
o Esophagus: avascular tubular structure with 4 hyperechoic
layers (opposed anterior & posterior walls of the collapsed
esophagus) just ventral (anterior) to the cervical spine.
Esophageal motility can be sometimes observed.
o Trachea: avascular anechoic tubular structure just anterior to
the esophagus.
213
Habashy Sono-Tricks Vol.II Trick: 9 GIT
•Discontinuation (interruption) of the 4 lines of the esophagus 

suggest EA.  not a reproducible sign.
•Esophageal defect  weakness of the posterior tracheal wall
next to the esophageal defect  posterior shift of the posterior
wall of the trachea i.e. loss of the parallel alignment of the
anterior & posterior walls of the trachea  = Tracheal print
sign  though looks helpful in diagnosis of tracheomalacia or
TEF in cases of EA, it is unreliable practically due to:
o Difficult plane acquisition due to the bony shadowing
(clavicles & cervical spine)  ↓ reproducibility.
o Not in all types of EA  ↓ specificity.
Duodenal Atresia (DA)
•Duodenum is the commonest site of intestinal obstruction

•Congenital duodenal obstruction causes: DA, stenosis, web or
annular pancreas
Polyhydramnios (>20w) + Double bubble sign: persistent fluid –

filled stomach & duodenum (that are connected).
•30% of DA  T21
•10% of T21  DA
•50% of DA  Associated anomalies
oCHD in 40%
o20% of Feingold syndrome has DA :
Autosomal dominant (AD) syndrome
Commonest familial syndromic GIT atresias
Associated microcephaly, syndactyly & clinodactyly
214
Small Bowel Atresia

Jejunal Ilial
Dilatation Marked Minor
Loops Multiple Few
Stomach Large Normal
Polyhydramnios Frequent Rare
Earlier Later
PTL More Less
IUGR Frequent Rare
Ascites (perforation) Rare Frequent
Cystic Fibrosis Less More
Associated anomalies Frequent Rare
Prognosis Worse Better
• Normal small bowel diameter : <7mm

• Sausage-shaped bowel : dilated fluid-filled bowel loops
• Triple bubble sign: in jejunal atresia=
stomach+duodenum+jejunum
• T2 echogenic bowel may be the 1st sign
• Peristalsis distinguishes atresia from other abdominal cysts
• Meconium peritonitis (= perforation): ascitis, calcification,
meconium pseudocyst
DD  Congenital chloride loosing diarrhea (CCLD):
• Extremely rare cindition (about 250 cases reported)
• Defective chloride bicorbonate exchange in the intestinal
mucosa  chloride loss
• Same Ultrasound picture of small bowel obstruction
(polyhydramnios and bowel dilatation)
215
CCLD Small bowel Obstruction

They are mostly indistinguishable antenataly  subtle clues for diagnosis
Generalized bowel dilatation Focal
Clear bowel contents Meconium
Normal peristalsis ↑
Frequent streaming motion at the fetal anus by X
color Doppler mapping (=fetal diarreha).
Postnatal Watery diarrhea Constipation
Postnatal↓Serum Cl, ↑Stool Cl Normal
Medical therapy surgical
Apple peel jejunal atresia:

• A rare form of inherited jejunal atresia in which there is
associated shortening of the small bowel distal to the jejunal
atresia (due to absence of the distal superior mesenteric artery).
• Bowel loops distal to the atresia spiral around their vascular
supply  look like an apple peel.
• This condition is highly associated with necrotising enterocolitis
(NEC).
Colonic Atresia (CA)

• The blind-ending loop: Single large dilated bowel loop in
expected peripheral location of colon (±echogenic contents;
meconium)
• Normal colonic diameter: <18mm
• ± small bowel distension
• ± Ascites = Perforation= Meconium peritonitis
• May be associated with Hirschsprung disease
216
Anal Atresia
• Absent target sign (no anal dimple): hyperechoic mucosal strip
within a hypoechoic ring at the perineum (especially in the axial
plane).
• ±Dilated fluid-filled distal bowel (U-or V-shaped bowel in the
presacral space that does not extend to the perineum)
• 3D US may add value (surface mode for the anus and

tomographic ultrasound imaging:TUI mode for the rectum)

• High atresia  associated vesicocolic fistula  calcified
meconium enterocolith (echogenic marbles moving within
bowel)
• Usually missed when isolated (especially if T2 scan is the only
detailed scan underwent in pregnancy , as the associated
dilated bowel is not manifist usually till the 3rd trimester)
• Usually not diagnosed till T3 as bowel dilatation develops late
(if any) & not associated with polyhydramnios
• ≥50% have associated anomalies; e.g. :
VACTERL association: Vertebral, Anal, Cardiac, TEF, Renal,
Limb
OEIS complex: Omphalocele, Exstrophy of UB, Imperforate
anus, Spine
Cloacal Malformation (dysgenesis)
= Urogenital sinus Malformation
• Urethra, vagina & hindgut coalescence  septated conical-
shaped retrovesical cystic pelvic mass that funnels to the
perineum with fluid –fluid level (layering debris from mixing
urine with vaginal secretions ± meconium) = hydrocolpos +
vertical vaginal septum
217
• UB abnormalities:
 Absent or compressed UB: due to preferential decompression
into compliant vagina
Megacystis: urine initially decompressed through fallopian
tubes  chemical irritation may eventually obstruct tubes  ↑
vagina & UB
• ±Ascites: urine backflow through fallopian tubes
• ±Bowel distension: due to hydrocolpos compress bowel,
associated bowel atresia or enterocolith (from mixing urine with
meconium)
• ±hydronephrosis, ±oligohydramnios, ±ambigous genitalia, ±absent
anal dimple
• Commonly has associated anomalies: genitourinary, GIT & spine

• Female >> Male
• Hydrocolpos present in only 50% of cloacal anomalies, and its
absence ↓ antenatal detection
Volvulus
• Coffee bean sign: dilated single kinked bowel loop with
echogenic intraluminal contents (infarction & heamorrhage) ±
ascites (meconium peritonitis)
• Whirlpool sign: swirled mesenteric vessels (often not detected)
• Usually involves small bowel

• Associations: small bowel atresia, congenital diaphragmatic
hernia (CDH), abdominal wall defects & heterotaxy
218
Both are usually T3 Intestinal atresia Volvulus

Incidence More common Rare
Onset Chronic Abrupt
Bowel loop(s) Multiple Single
Intraluminal contents Usually clear Usually
echogenic
Reduced Fetal Movements (RFM) X √

Abnormal NST X √
Hydrops X ±
IUFD X √ (if no TOP)
TOP Not indicated Indicated
Meconium peritonitis (Pseudocyst)
•Fetal bowel perforation (due to obstruction > ischemia) 

chemical peritonitis  peritoneal calcifications : liver capsule
± scrotum (meconium periorchitis).
•Ascites : from spilled meconium or inflammatory response
•Meconium pseudocyst :
 Meconium  inflammation adhesions walled-off area of
perforation
 Irregular thick wall that may calcify
 Contents are variable in echogenicity
 May be large and multiple
219
•Dilated bowel:
 Present if the cause of perforation is bowel obstruction:
oCommonly: atresia or meconium ileus (cystic fibrosis CF)
oRarely: volvulus or intussusception
 Not present if the cause of perforation is bowel ischemia
•Echogenic bowel (EB): due to CF or meconium on serosa
•Polyhydramnios: due to bowel obstruction.
•Meconium peritonitis causes liver calcification on the capsular
surface, but intrauterine infection (IUI) causes intraparenchymal
hepatic calcification. If calcification seen in both locations 
suggest IUI ( ischemia  perforation)
•Spontaneous closure of perforation in utero had been rarely
reported with no long-term postnatal sequelae
Mesenteric Cyst = Mesenteric Lymphangioma=

Omental Cyst =
Mesenteric or abdominal lymphovascular malformation
• Multilocular (>>unilocular) anechoic (>>echogenic)cystic

avascular abdominal mass separable from urinary tract - T2
• Often large  abdominal distension , displacing bowel (but
rarely cause obstruction)
• Rare condition due to proliferation of mesenteric lymphatic

tissue (ectopic lymphatics) that fail to communicate with
central lymphatic system
• Variable intrauterine course: stable, regress or expand &
extend out of the peritoneal cavity (to involve retroperitonium
& lower extremities)
220
DD:
• Bowel atresia: cysts are connecting (contiguous bowel loops),
peristalsis
• Meconium pseudocyst: thick irregular wall, other sequelae of
meconium peritonitis (calcification & bowel dilatation)
• Enteric duplication cyst: often has a thicker wall with no
internal septations, wall has gut signature (hypoechoic
musulosa between the hyperechoic mucosa & serosa), more

common to cause bowel obstruction (dilatation) than
mesenteric cyst
• Ovarian cyst: commonest abdominal cyst in female fetus, T3
• Urachal cyst: midline cyst between UB & cord insertion
• Choledochal cyst: Rt upper quadrant, bile ducts entering it
Enteric Duplication Cyst

• Fetal clear unilocular avascular abdominal cyst separable from
the urinary tract.
• Its wall has a characteristic ringed appearance  “the gut
signature sign”; hypoechoic musculosa between hyperechoic
mucosa & serosa (more apparent with zooming).
• No duct(s) entering it (≠ bile ducts enter the choledochal cyst).
• Rarely cause bowel obstruction
• Commonly in the bowel , rarely : stomach or esophagus.
Hepatic Tumors
• Most hepatic tumors are T3 (third trimester finding)
• All hepatic tumors may lead to abdominal distention ± hydrops
• 5% of fetal tumors are hepatic
• 95% of hepatic tumors are described in the next table
(hemangioma, hamartoma & hebatoblastoma)
221
• The remaining 5% of hepatic tumors are : leukemia and

metastatic neuroblastoma
Hemangioma Hamartoma Hepatoblastoma

Type Benign Malignant
60% of hepatic
% 20% 15%
tumors
Unless hydrops develops, postnatal survival Poor prognosis
Prognosis
is high with >75%

postnatal mortality
• Well defined solid • Predominant cystic or Well defined solid

mass ± central mixed cystic/solid echogenic mass
area of necrosis / mass with multiple with fibrous septa
fibrosis septations  Swiss-  spoke wheel
• Hypoechoic, cheese appearance appearance
Gray scale
hyperechoic or • Cysts are anechoic or

mixed filled with echogenic
echogenicity material
• Mainly intrahepatic
(20% are exophytic=
pedunculated)
• May show rapid
growth
• Vascular (mainly • Disorganized mild
peripheral)+ to moderate
Doppler
significant A-V vascularity

No flow
shunting • No large vessels
• Large draining
vein (&IVC)
222
• Leukemia (transient myeloproliferative disorder: TMD): diffuse

hepatosplenomegaly (without focal lesion), check for T21
markers.
• Metastatic neuroblastoma: 1ry is adrenal. Hepatic metastasis may
be diffusely infiltrating or discrete lesions, placenta may be
involved as well
• Most hepatic hemangiomas (hemangioendotheliomas) resolve

spontaneously by 14m postnatally , only few do not involute and
require resection or embolization
• 15% of hepatic hemangiomas are associated with cutaneous
hemangiomas
• Maternal steroids may be used with rapidly growing hepatic
hemangiomas
• Hepatic mesenchymal hamartoma may be associated with

placental mesenchymal dysplasia or Beckwith-Wiedmann
syndrome (BWS)
Gallstone/sludge
•T3 Echogenic material in the gall bladder (GB): homogenous
echoes or focal echogenicities , ± shadowing
•DD: hepatic echogenicities: infection, meconium peritonitis,
tumor
•Of no clinical significance as they are asymptomatic & almost all

spontaneously resolve by 12 m postnatally
223
•Unknown cause: theories maternal estrogen (↑fetal bile

cholesterol & ↓bile acids), maternal dehydration or placental
abruption (↑indirect bilirubin)
•Normal fetal GB is detected in 60% of fetuses ≥14w as an
anechoic ovoid or tear drop-shaped avascular structure located to
the Rt of the umbilical vein
Choledochal Cyst
• T2 scan  Rt upper quadrant unilocular avascular cyst separate

from the gallbladder (GB) & communicating with bile ducts (2
short tubular ducts entering the cyst)
• If no GB seen  cystic biliary atresia
• Congenital cystic dilatation of the bile ducts (mostly
extrahepatic)
• Lead to: Postnatal jaundice, long-term: biliary cirrhosis &
cholangiocarcinoma
Biliary Atresia (BA)
• T2 persistently Prenatal Non-Visualized fetal GB (PNVGB) or

GB is present but its wall is irregular (crenelated)
• Cystic BA (CBA): Thin-walled small anechoic avascular cyst at
the lower edge of the liver that is not connected to the 2 bile ducts
• Rare anomaly & too difficult antenatal detection (almost only 5%

of cases detected postnatally were suspected antenatally)
• Too poor postnatal prognosis : jaundice, cirrhosis, death in the 1st
2 years of life (unless bypass ± liver transplantation done)
• 10% associated polysplenia, heterotaxy syndrome
224
Nonvisualized (or small) Stomach bubble DD

Persistent (>1 hour); to exclude physiologic emptying
Amniotic Fluid (AF) Cause Explanation
PROM
Severe FGR
Insufficient AF to fill
Absent AF
the stomach
Bilateral Renal Agenesis
(BRA)
No associated If there is no associated

anomaly EA TEF
Stomach in Congenital diaphragmatic Stomach migration

the thorax hernia (CDH) from its normal position
Normal or ↑ AF
Associated anomaly
Fetal akinesia
deformation sequence
masseter muscles &
(FADS)= Arthrogryposis
Contractures pharyngeal muscles
Multiplex Congenita
contracture  prevent
(AMC)
swallowing
Cleftings Palatal anomaly 

Cleft lip/palate ineffective deglutition
225
Echogenic Bowel (EB)
Cause Incidence Clues for Dx

Aneuploidy (T21,18, Other aneuploidy markers (Soft &
2%
13,Turner) Gross)
+microcephaly, Commonest is
FGR, cytomegalo-virus CMV
Intra-Uterine
4% calcification Others: Parvovirus
Infection (IUI)
(peritoneal (P19),
&cerebral) Toxoplasmosis
Cystic Fibrosis (CF) + bowel obstruction (dilatation)
Meconium 4% Peritoneal calcification, pseudocyst,
Peritonitis bowel dilatation
IUGR (FGR) 10% Oligohydramnios , abnormal Doppler
Dependent
History of
layering in
Ingested blood Rare perigestational
stomach
hemorrhage (PGH)
Often transient
From any fetal
Bowel ischemia Rare hypotensive e.g. TTTS, IUI
event
Idiopathic (normal
80% None of the above
variant)
• EB: fetal bowel echogenicity ≥ surrounding bone

• ↓ gain  if bone disappears before bowel  = EB
• Not calcified  does not shadow
• Usually appears as mass-like lesion between stomach and UB
with indistinct border
226
Etiology varies by the cause:

• T21 & CF  thick viscous secretions
• FGR & IUI  bowel hypoperfusion (ischemia)
• Prevalence: 2% of T2 scan
• Focal EB is more likely pathological than diffuse EB
• 10% adverse pregnancy outcome when EB is isolated
• 50% adverse outcome when EB is not isolated
Abdominal Calcification DD
Cause Diagnostic clues
Bowel • Dilated bowel

obstruction  • Enterocoliths (calcified intraluminal meconium)
perforation • ± meconium psuedocyst (irregular thick calcified wall)
• Punctate hepatic parenchymal calcification(usually don’t

shadow)
Intrauterine • e.g. toxoplasma, CMV,P 19, varicella
infection (IUI) • IUI may  bowel ischemia  perforation  capsular
hepatic calcification
• ≥1 echogenic foci in the GB (T3)

GB stone • Shadowing
• Usually resolve in the 1st year of life
• Bowel atresia & IUI  commonly cause calcification

Ascites • Urinoma & hydrops  rarely cause calcification
Usually clear , rarely have internal echoes (= hemorrhage or

Ovarian cyst torsion)  (just mimic calcification) , don’t shadow
227
Hepato-Splenomegaly
Methods for identification of hepatosplenomegaly:

• Subjective (the commonest):
o In the axial plane : ↑AC or abnormal echotexture (hyperechoic
or inhomogenous)
o In sagittal or parasagittal planes dipping at the
thoracoabdominal junction
• Objective : >95th percentile for GA (p95)
Hepatomegaly & splenomegaly may be associated or occur

independently
Rt hepatic lobe length

GA Splenic length (p95)
(p95)
20w 30mm 25mm
25w 40mm 35mm
30w 50mm 45mm
35w 60mm 55mm
40w 65mm 70mm
228
Hepatomegaly
• Intrauterine Infection (IUI): is the commonest cause , CMV
is the commonest of them. Associated: hepatic & cerebral
calcification, ascites, ventriculomegaly (VM), cardiomegaly,
IUGR
• Fetal heart failure (Hydrops fetalis): 2nd common cause.
• Other causes:
 Transient myeloproliferative disorder (TMD) in Down
syndrome : transient leukemia (rare)
 Hepatic tumors :
o Hemangioma (benign)
o Hepatoblastoma (malignant)
 Part of a syndrome:
o Beckwith-Wiedemann syndrome (BWS): macrosomia +
omphalocele+ macroglossia+ nephromegaly+ body
hemihypertrophy
o Zellweger syndrome (cerebrohepatorenal syndrome) :
polycystic kidney (PCKD)+ agenesis of the corpus
callosum (ACC)
Splenomegaly:
• IUI
• Storage diseases (T3) : e.g. Gaucher & Niemann-Pick
syndromes
229
Fetal Ascites
•Fluid within the abdominal cavity around the abdominal organs

•Ascites  Lesser sac become apparent  mis-diagnosed as an
abdominal cyst
•Subjectively classified: mild-moderate-severe
Pseudoascites:
• Hypoechoic fetal abdominal wall muscles (or less commonly the
hypoechoic fetal omentum) can mimic fluid (ascites)
• Especially with oblique view perpendicular insonation
frequently discerns muscle layers
• Stops at cord insertion (anterior midline) & posteriorly at ribs
attachment
Causes of fetal ascites
•Hydrops:
- The commonest cause
- Fluid in ≥2 spaces (skin edema, ascites, pleural effusion ,

pericardial effusion or polyhydramnios) ± Placentomegaly
 Immune : Fetal anemia , ↑MOM of PSV of MCA (multiple
of median of the peak systolic velocity of the middle
cerebral artery)
 Non-immune: many causes e.g. fetal mass that ↑ cardiac
output: COP, CHD, arrhythmia, IUI, chromosomal aberration
230
•IUI: FGR, hydrops, calcification (peritoneal , cerebral),

microcephaly
•Viscous perforation:
oBowel atresia : bowel dilatation, meconium peritonitis
oUrinary ascites: (in descending frequency)
Lower urinary tract obstruction)LUTO :
Posterior urethral valve (PUV) or urethral atresia
Prune belly syndrome (PBS)

Megacystis microcolon intestinal hypoperistalsis syndrome
(MMIHS)
Pelviureteric junction obstruction (PUJO)
oCloacal dysgenesis (urogenital sinus malformation)
Isolated Fetal ascites
•Means ascites without associated other serosal spaces fluid

collection nor subcutanous edema (i.e. ascites without
hydrops).
•May be associated with polyhydramnios (unknown
mechanism)
•Generally has a better prognosis than hydrops and than
ascites with an anomaly
•Poor prognosis if onset <24w
•May resolve spontaneously with follow up (15%)
•20%  the cause could not be determined
•Rarely; isolated ascites (without hydrops)  elevate the
diaphragm  lung compression  pulmonary hypoplasia 
hydrops (2ry)
231
Isolated ascites work-up:
•Exclude associated hydrops (pleural effusion, pericardial

effusion, skin edema),
•Measure the PSV of the MCA (to exclude fetal anemia)
•Through fetal structural anatomical scanning (especially
echocardiography)
•Ask her for re-scanning 7days later  to re-check whether
hydrops develops or not (isolated ascites may be an early
sign of an evolving hydrops)
•During this week (between the 1st scan and the 1st follow up
scan) : request TORCH serology (to exclude IUI as a cause
of the fetal ascites)
•Karyotyping is better offered
Possible causes of isolated fetal ascites

40% urinary tract , GIT obstruction, lymphatic malformation
15% CHD or arrhythmia
10% Chromosomal aberration (e.g. T21, T18, Turner’s syndrome)
5% Congenital infections (TORCH, P19, hepatitis )
5% Hepatic causes (e.g. bile duct perforation), metabolic storage disorders
or thoracic causes
5% Fetal anemia (fetomaternal hemorrhage, G6PD ↓, thalasemia)

20% Idiopathic
232
GIT
Anomalies
Synopsis
GIT Anomaly Diagnostic clues

Esophageal
Persistently absent stomach + polyhydramnios
atresia
Duodenal
Double bubble sign
atresia
Small bowel Dilated small bowel (>7mm), triple bubble sign , sausage
atresia shaped bowel loops
Colonic Dilated colon (>18mm), blind ending loop (single dilated
atresia loop at the periphery of the abdomen)
Anal atresia Absent target sign (No anal dimple)
Cloacal Septated conical retrovesical cyst funneled to the perineum
malformation with fluid-fluid level
Volvulus Coffee bean sign (dilated single kinked bowel loop with
echogenic contents)
Meconium Dilated bowel, peritoneal calcification, abdominal cyst with
peritonitis irregular thick echogenic wall
Mesenteric Multilocular anechoic avascular mass separable from the
cyst urinary tract
Enteric Clear cyst separable from the urinary tract with gut signature
duplication (layered thick wall)
cyst
233
Hepatobiliary
Diagnostic clues
Anomaly
Hepatic Solid hepatic mass, highly vascular
hemangioma
Hepatic Cystic hepatic avascular mass with multiple septations

hamartoma (Swiss-cheese appearance)
Hepatoblastoma Solid hepatic mass with spoke wheel appearance (septae),
mildly vascular
GB stone Echogenic material in the GB
Choledochal Rt upper quadrant unilocular avascular cyst separable from

cyst the GB & communicating with 2 bile ducts
Biliary atresia Persistently absent GB , anechoic small cyst at the porta-

hepatis (not connected to the bile ducts)
234
Tongue Hard palate

Pharynx
Lower jaw
Mastoid bones Larynx Trachea
Figure (182): Normal fetal neck anatomy. [a-c] are axial plane, [d] is sagittal.
Figure (183): Sagittal view of the Figure (184): Sagittal view of the
fetal head shows the pharynx fetal neck shows the trachea.
behind the tongue.
235
Figure (185): Esophageal atresia (EA): [a] persistently absent stomach (≥ 2

hours) with polyhydramnios. [b] Polyhydramnios with persistent
subjectively small stomach is suggestive for EA; i.e. The presence of
stomach can not exclude EA (as in types A,C&D of EA the liquor can
pass via the trache-esophageal fistula (TEF) from the trachea to the
esophagus distal to the site of EA).
236
Obstetric Sono-Tricks GIT Trick: 9 Habashy Sono-Tricks Vol.II
Figure (186); [a&b]: Pouch sign in esophageal atresia. Transient filling of

the proximal esophagus. This sign is not diagnostic for EA, as it may be
seen during swallowing in normal fetuses.
237
*
*
Figure (187); [a&b]: Duodenal atresia (DA). Double bubble sign : persistent
fluid-filled stomach & duodenum (that are connected, note the fluid passes
between the 2 bubbles detected by power Doppler mapping).
Polyhydramnios (deepest vertical pocket DVP >8 cm) with
238
Figure (188) : Duodenal atresia (DA). Polyhydramnios (deepest vertical

pocket DVP >8 cm) with double bubble sign : persistent fluid-filled
stomach & duodenum (that are connected).
239
Duodenal atresia (DA).
Polyhydramnios with
double bubble sign :
persistent fluid-filled
stomach & duodenum (that
are connected).
240
Figure (190) : The double bubble sign duodenal atresia (DA): persistent
fluid-filled stomach & duodenum (that are connected). [a] 2D-TAUS axial
fetal abdomenal plane. [b&c] 3D-TAUS using the tomographic ultrasound
imaging mode TUI (or the multislice mode).
241
* *
Figure (191); [a&b]: Duodenal
atresia (DA). Polyhydramnios
(deepest vertical pocket DVP >8
cm) with double bubble sign :
persistent fluid-filled stomach &
duodenum (that are connected).
242
*
*
VSD
Figure (192) : Duodenal atresia (DA) with atreoventricular septal defect

(AVSD) in a case of Down syndrome (Trisomy T21: T21). [a & b] double
bubble sign in duodenal atresia. [c & d] AVSD.
243
*
Figure (193): C-loop sign: the association of esophageal and duodenal

atresias produces a loop of dilated bowel with increased amount of
amniotic fluid in the stomach (i.e. more than isolated duodenal atresia) i.e.
distended distal esophagus, stomach and duodenum  simulating the letter
“C”.
244
Figure (194): Jejunal obstruction. “Case No=1”. [a] Dilated multiple bowel
loops in the third trimester (>7mm). [b] 3D sonography of the same case
using the tomographic ultrasound imaging mode (TUI) = multi-slice mode
(CT like mode). N.B. Congenital chloride loosing diarrhea (CCLD) should
be put in DD of such cases (refer to page 215).
245
Figure (195): Jejunal obstruction. “Case No-2”. [a] Dilated multiple bowel
loops in the third trimester (>7mm). [b] 3D sonography of the same case
using the tomographic ultrasound imaging mode (TUI) = multi-slice mode
(CT like mode).
246
*
*
Figure (196): Triple bubble sign in jejunal atresia. “Case No-3”. Dilated
stomach, duodenum and blind-ending loop of the proximal jejunum.
Associated polyhydramnios is also noted.
247
Figure (197); [a-c]: Fetal bowel obstruction. Multiple connected cystic intra-
abdominal lesions that are changing in shape (i.e. moving = peristalsis).
Jejunal atresia was proved postnatally (intra-operatively). “Case No-4”.
248
*
Figure (198); [a&b]: Jejunal obstruction. “Case No-5”. [a] Dilated multiple
bowel loops in the third trimester (>7mm). [b] 3D sonography of the same
case using the tomographic ultrasound imaging mode (TUI) = multi-slice
mode (CT like mode).
249
*
Figure (199); [a&b]: This oblique image through the abdomen shows
jejunal atresia “Case No-6” bowel dilatation  perforation  ascites +
perihepatic calcification + echogenic bowel (EB).
250
*
*
Figure (200): Apple peel jejunal atresia: A rare

form of inherited jejunal atresia in which there
is associated shortening of the small bowel
distal to the jejunal atresia (due to absence of
the distal superior mesenteric artery). Bowel
loops distal to the atresia spiral around their
vascular supply  look like an apple peel. This
condition is highly associated with necrotising
enterocolites (NEC). Associated echogenic
bowel (EB) and ascites from peritoneal bowel
perforation is noted also in this case.
251
*
Figure (201): Ileal atresia : Sausage-shaped distended bowel loops at the

mid-portion of the abdomen. Peritoneal calcifications (echogenicities seen
beneath the fetal skin suggest bowel perforation  meconium peritonitis
which is more common with ileal atresia (> jejunal atresia).
252
Figure (202); [a-c]: Colonic atresia in third trimester. “Case No-1”. Closed
loop bowel dilatation (>18 mm) where the colon is distended with
meconium.
253
Figure (203); [a-c]: Colonic atresia in third trimester. “Case No-2”. Closed
loop bowel dilatation (>18 mm) where the colon is distended with
meconium.
254
* *
Figure (204): Colonic atresia in third trimester. “Case No-3”. Closed loop
bowel dilatation (>18 mm) where the colon is distended with meconium.
255
Figure (205): Colonic atresia (CA): “Case No-4”. The blind-ending loop:
Single dilated bowel loop (>18 mm) in the expected peripheral location of
the colon with internal echogenic contents.
256
Figure (206); [a-c]: The normal anal dimple which signifies a patent anus
appears as a ‘target sign’; which is a hyerechoic mucosal strip within a
hypoechoic ring at the perineum in the axial plane below the fetal urinary
bladder.
257
*
Figure (207): Anal atresia: [a] absent target sign (i.e. no anal dimple). [b]
blind-ending distended rectum (u-shaped) with intraluminal echogenic foci
(enterolithiasis = coproliths).
258
*
*
Figure (208): Cloacal malformation: Coronal fetal abdominal sonography

shows fluid-fluid levels that represent layering debris in obstructed,
duplicated vagina (as a result from the mixing of urine with vaginal
secretions ± meconium).
Kidney
UB
Figure (209): Hydrocolpos in a case of cloacal malformation. Semi-sagittal

view of the fetal trunk shows a cyst containing echogenic material between
the bladder caudally and the kidney cranially. It represents a distended
vagina from debris caused by coalescence of the vagina with urethra &/or
hind gut in cases of cloacal malformation.
259
Ascites
Peritoneal
calcification
Figure (210): Meconium peritonitis. [a&b] dilated bowel loops + [c]

polyhydramnios = bowel obstruction. [d] peritoneal calcification + ascites =
perforation .
260
Echogenic Bowel
Figure (211); [a&b]: Meconium pseudocyst. Irregular thick wall fetal

abdominal cyst with contents of mixed echogenicities associated with
echogenic bowel and dilated bowel loops. Not that the cyst is separable
from the UB.
261
Dilated bowel
Calcifications Lung
St.
Liver
Meconium
Pseudo-cyst
Figure (212): Meconium peritonitis in ileal atresia : [a&b] axial planes in

the fetal abdomen show multiple dilated small bowel loops. [b] meconium
psuedocyst [c] a sagittal image through the liver in the same case shows
calcifications along the capsule. This signifies bowel perforation with
meconium peritonitis. Note that the calcifications are on the capsule and not
in the parenchyma as would be seen with infection.
262
*
*
*
* *
*
*
Figure (213); [a&b]: Volvulus: fetal abdomen in the third trimester shows a
single dilated segment of bowel that is filled with echogenic debris 
coffee bean sign.
263
* *
H
K
*
*
Figure (214); [a&b]: Mesenteric cyst (lymphangioma): Semi-sagittal planes

of the fetal abdomen show multilocular anechoic avascular abdominal cystic
lesion displacing the bowel and separable from the urinary tract and the
bowel. Note in [a] that the pelviabdominal mass is mainly retroperitoneal
with ventral displacement of the kidney. K: Kidney, H: Heart.
264
*
Figure (215); [a&b]: Mesenteric cyst (lymphangioma): Axial ultrasound of

the fetal abdomen shows multilocular anechoic avascular abdominal cystic
lesion displacing the bowel and separable from the urinary tract and the
bowel.
265
Heart Iliac bone
GB
St.
Figure (216); [a&b]: Enteric duplication cyst: “Case No-1”. The gut
signature sign: transverse US images through the fetal abdomen shows an
anechoic cyst with a distinct trilaminar wall that represents a hyperechoic
mucosa and serosa with a hypoechoic muscular wall in between  = the gut
signature. St.: stomach. GB: gall bladder.
266
Figure (217); [a&b]: Enteric duplication cyst: “Case No-2”. The gut
signature sign: transverse US images through the fetal abdomen show an
anechoic cyst with a distinct trilaminar wall that represents a hyperechoic
mucosa and serosa with a hypoechoic muscular wall in between  = the gut
signature.
267
Rt renal pelvis
St.
UB GB
Lt renal pelvis
Figure (218): 4 normal hypoechoic

areas in the fetal abdomen; stomach
(st), gall bladder (GB), right renal
pelvis and left renal pelvis. [a]
semiaxial plane. [b] axial plane. [c]
coronal plane.
Renal pelvises
268
St.
St.
Figure (219); [a&b]: Hepatoblastoma. Large well defined solid hepatic mass
with the characteristic spoke wheel appearance (i.e. varying echogenicity).
Ascites
*
*
Hepatic
nodules Suprarenal mass
Figure (220): Hepatic Figure (221): Hepatic metastasis

mesenchymal hamartoma: Axial from neuroblastoma :Transverse
ultrasound shows a mixed abdominal US shows a large, solid,
avascular cystic/solid exophytic suprarenal mass. The liver is
liver mass. heterogeneous with a few discrete
nodules (secondries from the
neuroblastoma). Ascites is also
seen.
269
Feeder
Draining
vein
Figure (222); [a-c]: Hepatic hemangioma: Grayscale imaging shows

hypoechoic hepatic tumor. Directional power Doppler indicating the
presence of large feeding and draining vessels. Hepatic hemangioma:
Sagittal oblique ultrasound of the same fetus shows a hyperechoic mass
with cystic areas within it. A clue to the vascular nature of the mass on
this grayscale image is the large draining vein.
270
Figure (223); [a-c]: Gall bladder stones (sludge): focal echogenicities in the
fetal gall bladder (not in the liver parenchyma (≠ parenchymal hepatic
calcification that is present in cases of intrauterine infection IUI).
271
GB
St.
Figure (224); [a&b]: Choledocal cyst: “Case No-1”. Rt upper quadrant

unilocular avascular cyst separate from the gall bladder and communicating
with bile ducts (2 short tubular hepatic ducts entering the cyst).
272
Figure (225); [a&b]: Choledocal cyst: “Case No-2”. Subhepatic unilocular

avascular cyst separate from the gall bladder and communicating with bile
ducts (2 short tubular hepatic ducts entering the cyst).
273
*
Figure (226): Cystic biliary atresia (CBA). A thin-walled small cystic

avascular structure on the caudal surface of the liver that is not connected
to the 2 bile ducts (≠ choledochal cyst).
274
Figure (227): Echogenic bowel (EB): axial images of the fetal abdomen
between the level of the stomach and the level of the urinary bladder; shows
echogenic lesions with indistinct borders. Their echogenicity looks like that
of the nearby rib and spine. They do not shadow (≠bone).
275
* *
Figure (228): Echogenic bowel in Figure (229): Echogenic bowel in
parvovirus infection (P19). Down syndrome (T21).
* *
Figure (230): Isolated echogenic Figure (231): Echogenic bowel in

bowel (i.e. normal variant). cystic fibrosis (CF).
Echogenic bowel may be caused by varius pathologies or may be even a

normal variant. The clue for diagnosis is to search for other
abnormalities, if any.
276
Intrahepatic
calcifications
Echogenic Intrahepatic
Bowel calcifications
Figure (232): Hepatic and bowel echogenicities in intrauterine infection

(IUI): [a] axial sonographic view of the fetal abdomen shows multiple
parenchymal intrahepatic calcifications. [b] coronal view of the fetal chest
abdomen and pelvis show the liver (and bowel) with parenchymal
intrahepatic calcifications (beside the fetal stomach) and echogenic bowel
(above the fetal iliac bone).
277
* *
Figure (233); [a-c]: Hepatic parenchymal calcification: punctate echogenic

foci within the fetal liver in several cases of intrauterine infection (IUI).
278
Figure (234): Hepatomegaly : [a] sagittal, [b] axial image of the fetal
abdomen shows hepatomegaly in a fetus with metabolic storage disease.
279
Sternal dipping
Figure (235): Hepatomegaly. Sagittal view shows the fetal chest and
abdomen where the abdomen was large in comparison to the normal sized
chest (i.e. sternal dipping). Note small filmy ascites between the anterior
hepatic surface and the fetal anterior abdominal wall.
280
Figure (236): Hepatomegaly. A Sagittal US view shows an increased

hepatic length
281
Pseudo-ascites Muscles
Cord
Rib Insertion
Figure (237); [a-c]: Pseudo-ascites: Hypoechoic fetal abdominal wall

muscles can be mistaken as ascites (a common pitfall) in oblique views of
the fetal abdomen. Note that the hypoechoic area is not present at the cord
insertion anteriorly and at the ribs posteriorly.
282
Minimal Skin Mild

Ascites Ascites
Muscles
Liver Splenomegaly
St.
GB
Figure (238): True minimal ascites Figure (239): Splenomegaly in a

(subtle or trace ascites): fluid case with mild ascites proved to has
within the fetal abdominal cavity an intrauterine infection by serology
around the abdominal organs.  parvovirus.
Minimal ascites is diagnosed when
there is anechoic fluid along the Urine
hepatic margin. This may be the 1st Ascites
sign of impending hydrops. Note
the hypoechoic abdominal wall
musculature that is located outside
the peritoneal cavity. There is also ↑↑ UB St.
subtle skin thickening.
Hydroureter
Figure (240): urinary ascites: posterior urethral valve (PUV) a type of lower
urinary tract obstruction (LUTO)  enlarged urinary bladder: megacystis &
hydroureter – perforation  urinary ascites.
283
Lesser Sac
St.
Falciform
Ligament
Figure (241): Severe fetal ascites: fluid within the fetal abdominal cavity
around the abdominal organs. Note that the lesser sac and the falciform
ligament become apparent.
284
Cervix in Obstetrics
Figures 242 - 268
References
153 - 193
• Preterm birth & the cervix

• TVUS cervical assessment technique
• Pitfalls & timing
• Cervical funneling
• Cervical glandular area & amniotic fluid sludge
• 3D-TVUS cervical assessment
• Prophylactic cerclage
• Benefits of TVUS assessment of the gravid cervix
• Uterocervical angles
Cervix in Obst. Trick: 10 Habashy Sono-Tricks Vol.II
•PTB is about 10% of births & considered as the commonest

cause for neonatal morbidity & mortality
•The shorter the cervical length (CL) & the earlier it is
detected, the higher the risk of PTB.
•Interobserver & intraobserver variability in TVUS-CL
measurement is about 10% (in digital examination: PV 
50%)
•TVUS-CL can avoid unnecessary interventions in women with
normal CL measurements.
•PTB prevention strategies that applied in the last 30 years (CL
screening, progesterone, corticosteroids & cerclage)
collectively not significantly ↓PTB rates but ↓ its associated
neonatal morbidity & mortality.
• The best assessment of the cervical length (CL) is by TVUS

(the gold standard for CL)
Probability of PTB
T2 Normal CL T2 Short CL
High risk 50%

10%
Low risk 20%
T1&2 CL identify only approximately 60% of spontaneous PTB

287
Habashy Sono-Tricks Vol.II Trick: 10 Cervix in Obst.
TAUS disadvantages:
• Filled maternal UB  may elongate the cervix  mask
funneling
• Fetal parts or maternal obesity can obscure the cervix (30% of
TAUS CL was not obtainable)
Translabial US (TLUS) or Transperineal US (TPUS):
• Using a covered convex probe with sagittal orientation between
the labia majora.
 Advantages: (1) Not require maternal UB filling (≠TAUS)
. (2) Not exert pressure on the cervix (≠TVUS)
 Disadvantages: (1) Rectal gases may obscure the cervix .
(2) It is more difficult to master than TVUS.
Technical recommendations for TVUS cervical assessment :

• Empty UB
• Zooming: cervix occupies about 75% of the screen
• UB is visible on the screen beside the cervix
• Anterior & posterior cervical lips are symmetrical in thickness
& echogenicity
• Avoid undue pressure by the probe (limited concavity created
by the transducer)
• The endocervical canal is visible from the internal os to the
external os
• Calipers placed between the internal os & the external os.
• If the cervical canal is angled or curved (a reassuring sign):
use sum of 2 lines.
• Take 3 measurements for the CL and record the shortest
• In mm.
• TVUS in pPROM not ↑ risk of maternal nor fetal infection
(i.e. safe)
288
• Internal os landmark  UB neck

• External os:
Avoid air in the probe sheath  may mask the external os
The caudal end of the cervical canal not the outermost edge of
the cervical tissue
If it is difficult to identify the external os  push-withdraw
technique (i.e. push the probe inward to see the internal os &
cervical stroma then withdraw it to make the cervix just

disappear then re-push it again)
• CL Cut-off (10th percentile) is 25 mm (old cut-off is 30mm)
Pitfalls in TVUS-CL:
• Full UB: may elongate the cervix , masks funneling or internal
os
• Excessive probe pressure:
• Lower uterine segment LUS contractions: S-shaped cervical
canal (suspected when CL >50mm); can mimic funneling
• Underdeveloped LUS: i.e. indistinguishable form the
endocervical canal <14wks.
Timing:
•Universal screening (low & high risk women): 18-24wks (with
the T2 anatomical scan)
•High risk women (history of midtrimester loss or early PTB)
better to add CL at 12-14wks (with the T1 scan = first trimester
scanning FTS)
289
Repeat CL:
•Screening:
 Low risk women with normal CL at T2  no need to repeat
CL
 High risk women with normal CL at T1& T2  some reports
advise repeat CL/2-4wks.
•After intervention:
 After successful tocolysis  not as predictive as the 1st
measurement  mainly useless
 After cerclage: CL<25mm & closed cervical portion above
the cerclage <10mm  poor outcome
Funneling:
•Opened internal os with wedging of the upper
part of the cervical canal T
•Funneling is a continuous process  cervical
canal shape progression (T-Y-V-U: Trust Your
Vaginal Ultrasound)
•Record the functional CL: the residual shortest U
cervical length (the closed part of the canal ,
exclude the funnel)
•Funnel measurements:
o Funnel width= internal os diameter
V
o Funnel length= opened portion of the cervical
canal
o Funneling percentage: funnel length/ total CL .
Total CL= funnel + functional CL
 Minimal funneling: <25% no ↑ PTB risk
Y
 Moderate funneling : 25-50%
 Severe funneling: >50%
290
•↓CL + Funneling  PTB is

higher than if short CL alone
•Normal functional CL +
Funneling No ↑PTB risk
Dynamic cervical changes:

•In 5% of pregnancies, spontaneous or induced, transient
•Spontaneous funneling during 5 minutes TVUS cervical
scanning
•Induced funneling by: [1] Valsalva maneuver, [2] 15 seconds
transfundal pressure (TFP).
•Conflicting evidence about the benefits added by the presence
of dynamic cervical changes to the mere CL.
• Presence of cervical glandular area

(CGA), which is the endocervical
mucosa, is a reassuring sign. It appears
as hypoechoic and less commonly
hyperechoic zone peripheral and parallel
to the cervical canal simulating the
endometrial strips.
• Presence of amniotic fluid sludge (free floating echogenic

material [debris] in the liquor near the internal os), which is a
sign of intra-amniotic infection (IAI), is a non-reassuring sign
291
3D-TVUS assessment of the gravid uterus:

•May be helpful when there are technical difficulties encountered
to get the mid-sagittal endocervical canal clearly from the
internal os to the external os.
•Can depict the entire stitch of cerclage (as a circle) in the axial
plane (instead of 2 echogenic dots in the saggital or coronal
planes)  clinically insignificant.
•Generally 3D-TVUS will not add any clinical benefit over 2D-
TVUS in patients with & without cerclage.
• Prophylactic Cerclage (i.e. PTL pains not started) is either US

indicated (short CL) or History Indicated cerclage (history of
midtrimester painless loss). Best is to combine both US &
history indicated cerclage (i.e. do cerclage in those with history
of midtrimester loss in whom the CL<25mm before 24wks)
• Liberal cerclage placement in twin and Mullerian anomalies is
not evidenced
Efficacy of US-indicated cerclage (CL<25mm)
Population Effect of cerclage on PTB <35w
Low risk for PTB No significant difference (or about 20%↓)
High Prior PTB 30% ↓
Risk
Prior midtrimester loss 45% ↓ (RCOG & ACOG recommend US
indicated cerclage for CL<25mm before
24wks in these women)
No significant difference (may be
Twinning harmful) , CL screening is relatively
ineffective in twins
292
PTL Prevention Management

Antibiotics XX If pPROM
Tocolytics XX ??
Corticosteroids XX √√
US + History indicated ??
Cerclage
Prophylactic Rescue
Arabeen Pessary Still under trials
Cervicogram
Summary of Cervical Length
sonographic Internal Os Diameter
assessment of the Internal Os Shape
gravid cervix for Internal Os Funneling
prediction of PTB Dynamic Cervical Changes
“The Cervicogram” Cervical Glandular Area (CGA)
Amniotic fluid Sludge
Benefits of sonographic assessment of the cervix in obstetrics:

•Main benefit  Prediction of PTB
•Other benefits:
 Confirm the diagnosis of PTL: maternal abdominal pain
(regular uterine contractions)
 Prediction of onset of spontaneous labor at full-term
 TVUS-CL prediction of success of labor induction & mode of
delivery
293
Confirm the diagnosis of PTL: maternal abdominal pain

(regular uterine contractions):
•CL≥30mm  low risk for PTB  no need for unnecessary
intervention
•CL<20mm  confirm the PTL diagnosis  admit
Prediction of onset of spontaneous labor at full-term
TVUS-CL at 37w Mean GA at delivery
10mm 38wks
35mm 41wks
40mm >41wks
TVUS-CL prediction of success of labor induction

& mode of delivery:
•TVUS-CL is better predictor than Bishop score for success of
vaginal delivery
•TVUS-CL < 25 mm (or wedging)  shorter 1st stage of labor &
higher incidence of successful SVB
•TVUS-CL<20mm in labor  5% CS, TVUS-
CL>40mm10%CS
294
Uterocervical angles
• Anterior cervical angle (ACA): between the endocervical canal

and the inner surface of the anterior uterine wall of the lower
uterine segment (LUS).
• Posterior cervical angle (PCA): between the endocervical canal
and the inner surface of the posterior uterine wall of the LUS.
• ACA during the second trimester studied as a predictor of PTB

• PCA studied as a predictor of successful induction of labor (IOL)
at full term (FT).
• Obtuse angles (≥1000)  suggest ↑ risk for PTB (in ACA) & ↑
Likelihood of successful IOL (in PCA).
• ACA & PCA are recent cervical sono-markers that are still under
research and their predictivity still not as solid as the cervical
length. Their cut offs are still not well standardized.
295
Figure (242): Measurement of the cervical length (CL). TVUS shows the
cervical canal. For appropriate TVUS-CL; after empty the UB  (1)
zooming. (2) the endocervical canal is visible from the internal os to the
external os. (3) calipes placed between the internal and external os. Normal
cervical length is >25mm. Note the presence of a hypoechoic endocervical
strip; the cervical glandular area CGA (a reassuring sign against imminent
preterm birth).
296
Obstetric Sono-Tricks Cervix in Obst. Trick: 10 Habashy Sono-Tricks Vol.II
Figure (243): Normal cervical length (CL). TVUS shows a closed cervical
internal os with normal cervical length (>25mm). Note the presence of a
hypoechoic endocervical strip; the cervical glandular area CGA (a reassuring
sign against imminent preterm birth).
Figure (244); [a&b]: Short cervical length (↓CL). TVUS shows that the
cervical length is < 25 mm which is considered short. Note the absence of
the cervical glandular area (CGA). Absent CGA in cases who have short CL
is considered as a non-reassuring sign that the PTB is imminent.
297
Figure (245); [a-c]: V-shaped cervical canal funnelling. TVUS shows that the
cervical internal os is opened and almost all the cervical canal is funnelled
with only 11 mm closed caudal part (the residual closed cervix or the
functional cervical length).
298
Figure (246): U-shaped cervical canal funnelling. TVUS shows that the
cervical internal os is opened and almost all the cervical canal is funnelled.
299
Figure (247); [a&b]: U-
shaped cervical canal
funnelling. TVUS shows
that the cervical internal os
is opened and almost all the
cervical canal is funnelled.
300
Figure (248): U-shaped cervical canal funnelling. TVUS shows the funnel
depth.
Figure (249): U-shaped cervical Figure (250): U-shaped cervical

canal funnelling. TVUS shows the canal funnelling. TVUS shows the
funnel width (the internal os external os diameter
diameter).
301
Habashy Sono-Tricks Vol.II Trick: 21 Abdominal defects
Figure (251): Normal

cervical canal. TAUS shows
that the cervical internal os is
closed and the cervical canal
length (CL) between the
internal and the external
cervical oses is normal ( > 25
mm).
Figure (252): Cervical canal
funneling. TAUS shows that
the internal os is opened as
well as the proximal part of
the cervical canal.
302
Figure (253): Cervical canal funnelling. [a] suggested 1st by the TAUS. [b]
then confirmed by the TVUS.
303
* *
Figure (254); [a&b]: The

amniotic fluid sludge. Free
floating echogenic
heterogeneous avascular
material (debris) detected in
the liqour near or within the
cervical canal. It is a sign of
intra-uterine infection (IUI).
304
Figure (255): The amniotic fluid sludge. Free floating echogenic

heterogeneous material (debris) detected within the amniotic cavity in or
near the cervical canal. It is a sign of intra-uterine infection (IUI).
305
Figure (256): Funnelling of

the cervical canal: opened
internal os with wedging of
the upper part of the cervical
canal  U-shaped cervix. [a]
functional cervical length (=
residual closed cervical
length). [b] funnel width (=
internal os diameter). [c]
funnel length (length of the
opened portion of the
cervical canal).
Figure (257): Amniotic fluid

sludge: free floating avascular
echogenic debris in the amniotic
fluid near the internal os. It
represents a sign of an intra-
amniotic infection (IAI).
306
Figure (258): U-shaped cervical canal funnelling. 2D-TVUS shows that the
cervical canal is opened all through from the internal os to the external os.
Note the amniotic membrane beside the external os.
Figure (259): U-shaped cervical canal funnelling. 3D-TVUS of the same

case  it does not add to the diagnosis nor the prognosis of such cases.
307
Figure (260): Cervical canal

funnelling. 2D-TAUS shows that
the amniotic fluid continues
down to the cervical canal that
UB suggest cervical canal funnelling
and warrant TVUS. .
Cervix
Figure (261): U-shaped cervical

canal funnelling. 3D-TVUS of
the same case  confirm the
cervical funnelling . N.B. 3D-
TVUS is not superior to 2D-
TVUS in diagnosis of short
cervical canal or prediction of
preterm birth (PTB).
308
Figure (262); [a&b]: The functional cervical length. 2D-TVUS shows

cervical canal funnelling. The residual closed part of the cervical canal
caudal to the apex of the funnel is the functional cervical length (it is 17.8
mm in “a” and 14.4 mm in “b”).
Figure (263); [a&b]: The functional cervical canal length. 3D-TVUS of the
cervical canal in the coronal plane that shows that the internal os is opened
and the proximal part of the cervical canal is funnelled. The residual closed
cervical canal length is 24.8 mm. 3D-TVUS does not add benefit over 2D-
TVUS in functional cervical length measurement.
309
Figure (264); [a&b]: Cervical canal funnelling in presence of a cerclage.

TAUS shows that the cervical canal is opened proximal to the cerclage
(funnel depth is 18.6 mm) and closed distal to it (residual closed cervical
canal or the functional cervical length is short; 20.6 mm).
310
Figure (265); [a&b]: Post-cerclage sonography. TVUS of the uterine cervix

shows 2 echogenicities on both sides of the cervical canal. The nearer the
cerclage to the internal os is the better. Documentation of total cervical length
and cervical length caudal to the cerclage is important in these cases.
311
Figure (266): Post-cerclage sonography. [a] 2D-TVUS of the uterine cervix

shows 2 echogenicities on both sides of the cervical canal. [b&c] 3D-TVUS
shows the axial plane of the cervical canal where the whole circumference of
the cerclage can be seen  clinically insignificant.
312
Figure (267): The anterior cervical angle (ACA). Between the endocervical
canal and the inner surface of the anterior uterine wall of the lower uterine
segment (LUS). Obtuse ACA (≥ 1000) during the 2nd trimester suggests an
increased risk of preterm birth (PTB). ACA is still under trial.
313
Figure (268): The posterior cervical angle (PCA). Between the endocervical Obstetric Sono-Tricks
canal and the inner surface of the posterior uterine wall of the lower uterine
segment (LUS). Obtuse PCA ( > 1000) at full term is suggested to be a
predictor for successful induction of labor (IOL). PCA is still under trial.
314
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330
•Intense synopsis series of US in Ob/Gyn

•Simple & Illustrative (more than 250 US images)
•Rapid reference in causality
•For Ob/Gyn & Radiologist
Any copy, photocopy or re-publishing of this book

without a written permission from Dr. Ahmed El-Habashy is
considered piracy, and committer shall be accused legally
according to the proper regulations.
Author:
Perfection is not attainable;
but if we chase it we can catch excellence
Copyright © 2020
ISBN: 978-977-6551-69-5
Deposit NO: 2020 / 4814

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Author:

Dr. Ahmed Mahmoud El-Habashy, MD

Lecturer of Obstetrics and Gynecology

who extended their unconditional support

where my sonographic knowledge shaped and improved

It gives me great pleasure to introduce this book

The author of this book; Dr. Ahmed El-Habashy is one

This book will aid obstetricians to reach a proper

Prof. Tarek Abdelzaher Karkour

Head of OB/GYN Department

The tremendous improvement in the field of

In view of the paucity of the simplified books about

This book is the 2nd volume of Habashy’s Sono-

I heartedly thank Prof. Elsayed Elbadawy

No words can express my gratitude towards Asst.

I greatly appreciate the efforts done by the

2- Gestational Trophoplastic Disease 48

4- Placental Lakes, Infarcts & Calcification 103

5- Placental Tumors 126

6- Succenturiate & Circumvallate Placentas 142

Marginal / Velamentous Cord Insertion & Vasa

8- Fetal Abdominal Wall Defects 179

9- Fetal GIT Anomalies 212

10- Cervix in Obstetrics 286

Early 1st trimester milestones - TVUS

TVUS criteria of failed pregnancy

Perigestational hemorrhage (PGH)

Chorionic bump (CB)

Impending pregnancy failure

2- Gestational Trophoblastic Disease 48

Molar sonographic pattern

Types of molar pregnancies

Clinical picture & risk factors

Chronic abruption oligohydramnios sequence (CAOS)

Massive subchorionic Hematoma MSH (Breus’ mole)

4- Placental Lakes, Infarcts & Calcification 103

Lakes and infarcts Placental Calcifications

Lakes VS Infarcts Classification

5- Placental Tumors 126

Placental mesenchymal dysplasia (PMD)

Succenturiate lobe Circumvallate placenta

Marginal /Velamentous Cord Insertion &

Marginal & Velamentous

Physiological Gut Herniation

9- GIT anomalies 212

Esophageal atresia Meconium peritonitis

10- Cervix in Obstetrics 286

Preterm birth & the cervix

American College of Obstetricians and

• IABD Intrabdominal bowel dilatation

• NST Non-stress test

• p95 95th percentile

• PTB Preterm birth

• TFP Trans-fundal pressure

• TPUS Trans-perineal ultrasound

• Early 1st trimester milestones - TVUS

TVUS Early 1st trimester milestones

• Sonographic signs of intrauterine pregnancy (IUP) before yolk

• Although the double sac & intradecidual signs are more

• The problem in the intrauterine sac like fluid is that it may be

Uterine Fluid Gestational Sac Pseudogestational sac

Contents Clear Debris

Site Decidua (ET) Cavity