Atlas of Fetal Ultrasound: Normal

Imaging and Malformations 1st Edition

Victor Bunduki
Visit to download the full and correct content document:
https://textbookfull.com/product/atlas-of-fetal-ultrasound-normal-imaging-and-malform
ations-1st-edition-victor-bunduki/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Atlas of Normal Imaging Variations of the Brain Skull

and Craniocervical Vasculature 1st Edition Alexander M.
Mckinney (Auth.)

https://textbookfull.com/product/atlas-of-normal-imaging-
variations-of-the-brain-skull-and-craniocervical-vasculature-1st-
edition-alexander-m-mckinney-auth/

Atlas of Dermatologic Ultrasound Ximena Wortsman

https://textbookfull.com/product/atlas-of-dermatologic-
ultrasound-ximena-wortsman/

Essentials of Ultrasound Imaging Thomas L. Szabo

https://textbookfull.com/product/essentials-of-ultrasound-
imaging-thomas-l-szabo/

Pocket Atlas Of Emergency Ultrasound Robert F. Reardon

https://textbookfull.com/product/pocket-atlas-of-emergency-
ultrasound-robert-f-reardon/
Atlas of Ultrasound-Guided Regional Anesthesia 3rd
Edition Andrew Gray

https://textbookfull.com/product/atlas-of-ultrasound-guided-
regional-anesthesia-3rd-edition-andrew-gray/

Ultrasound in Gynecology An Atlas and Guide 1st Edition

Mala Sibal (Auth.)

https://textbookfull.com/product/ultrasound-in-gynecology-an-
atlas-and-guide-1st-edition-mala-sibal-auth/

Obstetric Imaging: Fetal Diagnosis and Care Joshua A.

Copel Et Al.

https://textbookfull.com/product/obstetric-imaging-fetal-
diagnosis-and-care-joshua-a-copel-et-al/

Atlas of Wide Field Retinal Angiography and Imaging 1st

Edition Igor Kozak

https://textbookfull.com/product/atlas-of-wide-field-retinal-
angiography-and-imaging-1st-edition-igor-kozak/

Atlas of Chest Imaging in COVID 19 Patients

https://textbookfull.com/product/atlas-of-chest-imaging-in-
covid-19-patients/
 Victor Bunduki
Marcelo Zugaib

Atlas of
Fetal Ultrasound

Normal Imaging and Malformations

123
Atlas of Fetal Ultrasound
Victor Bunduki • Marcelo Zugaib

Atlas of Fetal Ultrasound

Normal Imaging and Malformations
Victor Bunduki, M.D., Ph.D. Marcelo Zugaib, M.D., Ph.D.
Associate Professor Professor
São Paulo University Obstetrics
Brazil University of São Paulo
Brazil
Foreign Assistant
Parisian University
France

Member of International Fetal Medicine and

Surgery Society

Translated and adapted from the Portuguese language edition: Atlas de Ultrassom Fetal Normal e
Malformações 2nd edition, by Victor Bunduki and Marcelo Zugaib, ©Editora Atheneu, 2011. All rights
reserved.
ISBN 978-3-319-54797-8    ISBN 978-3-319-54798-5 (eBook)
https://doi.org/10.1007/978-3-319-54798-5

Library of Congress Control Number: 2017959639

© Springer International Publishing AG 2018

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed
to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty,
express or implied, with respect to the material contained herein or for any errors or omissions that may have been
made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Printed on acid-free paper

This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Preface

It is with great pleasure that we present this English edition of Atlas of Fetal Ultrasound:
Normal Imaging and Malformations. The original is in its second edition in Brazil, as the first
edition sold out and was reprinted over the years. It is one of the reference books for Medical
Schools and Specialist Title Examinations in our country.
The authors are very experienced in fetal structural ultrasound and there is a lack of pub-
lished fetal ultrasound images organized as an atlas in the medical literature. In the present
volume, emphasis was placed on the image captions and short introductory texts to the chap-
ters. Readers will notice that the captions present concepts and advice in a coherent and didac-
tic way. Fetal structural ultrasound must be performed in a systematic manner from the fetal
head to the feet. Every sonographer should find his own methods, making sure that the fetal
scan is carried out using a uniform technique that is repeated from patient to patient. We
believe that this is the best way to avoid diagnostic mistakes.
Some might say that publishing a paper edition of a book of fetal images would be obsolete,
as digitalization is the most important method for sharing knowledge. In our opinion, an orga-
nized and complete printed edition of fetal images is of great interest. Obtaining information
only from digitalized media can lead to a focal and thus incomplete approach to fetal patho-
logical conditions. This volume helps practitioners to organize ideas and offers a complete
overview of the fetus, as it covers most fetal malformations. In addition, this atlas is presented
in both a printed and a digitalized form, offering students and professionals the complete range
of options.
This atlas was conceived to be easily handled and it can be used as a handbook; therefore,
professionals can bring it to their daily practice and check for images and pathological condi-
tions that occasionally appear during their routine work.

São Paulo, Brazil Victor Bunduki, M.D., Ph.D.

São Paulo, Brazil Marcelo Zugaib, M.D., Ph.D.
1 September 2017

v
Contents

1 Normal Fetal Structural Ultrasound�������������������������������������������������������������������������   1

1.1 Head and Neck�����������������������������������������������������������������������������������������������������   1
1.2 Face ���������������������������������������������������������������������������������������������������������������������   1
1.3 Spine �������������������������������������������������������������������������������������������������������������������   1
1.4 Chest �������������������������������������������������������������������������������������������������������������������   2
1.5 Heart���������������������������������������������������������������������������������������������������������������������   2
1.6 Abdomen�������������������������������������������������������������������������������������������������������������   2
1.7 Kidneys ���������������������������������������������������������������������������������������������������������������   2
1.8 External Genitals�������������������������������������������������������������������������������������������������   2
1.9 Extremities�����������������������������������������������������������������������������������������������������������   2
1.10 The Umbilical Cord���������������������������������������������������������������������������������������������   2
1.11 Amniotic Fluid�����������������������������������������������������������������������������������������������������   2
1.12 Placenta and Membranes�������������������������������������������������������������������������������������   2
2 The Fetus at the First Trimester ������������������������������������������������������������������������������� 15
3 Central Nervous System Abnormalities������������������������������������������������������������������� 29
3.1 Anomalies of the Cerebral Midline/Anomalies of Ventral Induction
of the Fetal Brain: Holoprosencephaly ��������������������������������������������������������������� 29
3.2 Agenesis of the Corpus Callosum����������������������������������������������������������������������� 29
3.3 Ventriculomegaly (Hydrocephalus)��������������������������������������������������������������������� 30
3.4 Abnormalities of the Posterior Fossa: Dandy–Walker Malformation����������������� 30
3.5 Cerebellar Abnormalities������������������������������������������������������������������������������������� 30
3.6 Destructive Anomalies����������������������������������������������������������������������������������������� 30
3.7 Additional Anomalies ����������������������������������������������������������������������������������������� 31
3.8 Contour Anomalies: Encephaloceles������������������������������������������������������������������� 31
3.9 Other Anomalies ������������������������������������������������������������������������������������������������� 31
4 Neural Tube Defects��������������������������������������������������������������������������������������������������� 49
4.1 Anencephaly ������������������������������������������������������������������������������������������������������� 49
4.2 Open Spina Bifida ����������������������������������������������������������������������������������������������� 49
4.3 Hidden Spina Bifida (Spina Bifida Oculta)��������������������������������������������������������� 50
5 Ultrasound Evaluation of the Fetal Face ����������������������������������������������������������������� 61
6 The Fetal Heart: Standpoint of the General Sonographer������������������������������������� 71
7 Fetal Echocardiography��������������������������������������������������������������������������������������������� 83
7.1 Fetal Echocardiography: Level 1�������������������������������������������������������������������������   83
7.2 Fetal Echocardiography: Level 2�������������������������������������������������������������������������   83
7.3 Indications for Fetal Echocardiography��������������������������������������������������������������� 83
7.4 Timing of Fetal Echocardiography ��������������������������������������������������������������������� 84
8 Noncardiac Thoracic Malformations ����������������������������������������������������������������������� 91

vii
viii Contents

9 The Fetal Abdomen����������������������������������������������������������������������������������������������������� 101

9.1 Pathological Conditions��������������������������������������������������������������������������������������� 101
10 Urinary Tract�������������������������������������������������������������������������������������������������������������� 117
10.1 Urinary Tract Malformations����������������������������������������������������������������������������� 117
10.2 Other Urinary Tract Malformations������������������������������������������������������������������� 118
10.3 Urinary Tract Dilatations����������������������������������������������������������������������������������� 119
11 Genitals ����������������������������������������������������������������������������������������������������������������������� 137
12 Skeleton and Limbs����������������������������������������������������������������������������������������������������� 145
13 Soft Tissues ����������������������������������������������������������������������������������������������������������������� 167
14 Umbilical Cord and Placenta������������������������������������������������������������������������������������� 183
15 Ultrasound in Fetal Infections����������������������������������������������������������������������������������� 193
15.1 Ultrasound Findings Associated with Prenatal Infections��������������������������������� 193
16 Multiple Gestation ����������������������������������������������������������������������������������������������������� 201
16.1 Introduction������������������������������������������������������������������������������������������������������� 201
16.2 Ultrasound View������������������������������������������������������������������������������������������������� 201
16.3 Complications That Can Be Diagnosed by Ultrasound������������������������������������� 201
17 Fetal Aneuploidies������������������������������������������������������������������������������������������������������� 211
17.1 Trisomy 13��������������������������������������������������������������������������������������������������������� 211
17.2 Trisomy 18��������������������������������������������������������������������������������������������������������� 211
17.3 Trisomy 21��������������������������������������������������������������������������������������������������������� 211
17.4 Turner Syndrome����������������������������������������������������������������������������������������������� 212
17.5 Other Aneuploidies ������������������������������������������������������������������������������������������� 212
18 Invasive Procedures in Fetal Medicine��������������������������������������������������������������������� 237
18.1 Chorionic Villus Sampling��������������������������������������������������������������������������������� 237
18.2 Amniocentesis��������������������������������������������������������������������������������������������������� 237
18.3 Cordocentesis����������������������������������������������������������������������������������������������������� 238
18.4 Others����������������������������������������������������������������������������������������������������������������� 238
19 “Three-Dimensional Ultrasound”����������������������������������������������������������������������������� 245
20 Doppler Ultrasound in Obstetrics����������������������������������������������������������������������������� 255
20.1 Physical Basis of Doppler Velocimetry������������������������������������������������������������� 255
20.2 Sonogram Analysis ������������������������������������������������������������������������������������������� 255
20.3 Uterine Artery Doppler Velocimetry����������������������������������������������������������������� 255
20.4 Diagnosis of Fetal Distress ������������������������������������������������������������������������������� 256
20.5 Tracking Aneuploidies��������������������������������������������������������������������������������������� 256
Contributors

Joelma Queiroz Andrade, M.D., Ph.D. Obstetrics Division, Faculdade de Medicina,

Hospital das Clinicas, Universidade de São Paulo, São Paulo, Brazil
Lisandra Stein Bernardes, M.D., Ph.D. Obstetrics Division, Faculdade de Medicina,
Hospital das Clinicas, Universidade de São Paulo, São Paulo, Brazil
Fabricio Marcondes Camargo, M.D. Echocardiography Department, Faculdade de
Medicina, Hospital das Clinicas, Universidade de São Paulo, São Paulo, Brazil
Mario Henrique Burlacchini de Carvalho, M.D., Ph.D. Department of Obstetrics and
Gynecology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
Harris Birthright Centre for Fetal Medicine, King´s College Hospital and School of Medicine,
London, UK
Rossana Pulcinelli Vieira Francisco, M.D., Ph.D. Department of Obstetrics and Gynecology,
Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
Eliane Azeka Hase, M.D., Ph.D. Obstetrics Division, Faculdade de Medicina, Hospital das
Clinicas, Universidade de São Paulo, São Paulo, Brazil
Marco Antonio Borges Lopes, M.D., Ph.D. Department of Obstetrics and Gynecology,
Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
Maria de Lourdes Brizot, M.D., Ph.D. Department of Obstetrics and Gynecology, Faculdade
de Medicina, Universidade de São Paulo, São Paulo, Brazil
Fetal Medicine Foundation, London, UK
Fernando Andrade Maistro, M.D. Obstetrics Division, Faculdade de Medicina, Hospital
das Clinicas, Universidade de São Paulo, São Paulo, Brazil
Seizo Miyadahira, M.D., Ph.D. Obstetrics Division, Faculdade de Medicina, Hospital das
Clinicas, Universidade de São Paulo, São Paulo, Brazil
Roseli Mieko Yamamoto Nomura, M.D., Ph.D. Department of Obstetrics and Gynecology,
Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
Maria Okumura, M.D., Ph.D. Obstetrics Division, Faculdade de Medicina, Hospital das
Clinicas, Universidade de São Paulo, São Paulo, Brazil
Gustavo de Paula Pereira, M.D. Department of Obstetrics and Gynecology, Faculdade de
Medicina, Universidade de Campinas, São Paulo, Brazil
Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
Marcio Jose Rosa Requeijo, M.D., Ph.D. Department of Obstetrics and Gynecology,
Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
Faculdade de Medicina de Itajubá, Minas Gerais, Brazil
Regina Schultz, M.D., Ph.D. Department of Pathology, Faculdade de Medicina, Hospital das
Clinicas, Universidade de São Paulo, São Paulo, Brazil
ix
 Normal Fetal Structural Ultrasound
1

Morphological ultrasound includes a systematic and orga- 1.1 Head and Neck
nized study of each fetal segment to make a detailed descrip-
tion of most of the fetal anatomy and attachments (amniotic –– CENTRAL NERVOUS SYSTEM:
fluid, cord, and placenta). Cranial shape: regularity, sutures, echogenicity, propor-
The fetal morphological examination should be per- tion BPD/OFD.
formed in a systematic manner, as if it were anatomical –– BRAIN:
expertise on the fetus, intending to ensure its structural nor- Medium line.
mality or diagnose malformations. Each operator should Cross section.
have his/her own routine and carry out the examination in the Midbrain, thalami, cavum septi pellucidi, falx cerebri.
same sequence, facilitating the work, and helping with the Lateral ventricles: walls, dimensions, choroid plexus,
diagnosis of structural abnormalities. width, and/or relationship between the left ventricle
The identification of fetal abnormalities allows conduct to (VE) and the head circunference (HC).
be established in relation to pregnancy continuation. In addi- Posterior fossa: cerebellar hemispheres, cerebellar ver-
tion, it indicates possible intrauterine treatment, helps to mis, cisterna magna, and fourth ventricle.
choose the place, time, and mode of delivery, prepares the Sagittal view.
postnatal treatment strategy, and guides parents with regard Corpus callosum.
to prognosis and risk of recurrence.
For effective detection of fetal malformations, it is benefi-
cial to carry out morphological ultrasound in all pregnant 1.2 Face
women. It is known that the selection of only patients who are
acknowledged to be at risk allows a detection rate of 10–15% Profile (sagittal view): forehead, nose, lips position, tongue
of fetal anomalies, because 85–90% of fetal malformations position, longitudinal bone palate, jaw position, size and
occur in pregnancies with no identifiable risk factors. position of the eye sockets, and the relationship between
When fetal abnormality or increased risk of its occurrence them and the biparietal diameter.
is suspected, patients should be referred to tertiary centers Coronal section.
with a fetal medicine service. Mouth: upper lip integrity.
A brief anamnesis precedes the morphological examina- Cross-section: upper dental arch, hard palate.
tion, avoiding inappropriate questions during the examination. Neck: neck position and identification of possible neck
The report preparation is a critical stage of morphological tumors.
examination. The text should contain, in addition to biomet-
ric data, a description of all the structures seen, including
attachments. The absence of diagnosable fetal abnormalities 1.3 Spine
on examination should be reported once completed.
Any defects should be described in the body of the report Cross section: the anterior vertebral body’s ossification cen-
and should appear in the conclusion. Plausible differential ter and the two centers of the side blades, which should form
diagnosis should be suggested if there is any doubt about the a triangle.
diagnosis. Coronal longitudinal section: ossification centers of lat-
The following described structures should always be eral blades that line in parallel. In our view, this section
­analyzed to exclude fetal malformation. shows spina bifida better.

© Springer International Publishing AG 2018 1

V. Bunduki, M. Zugaib, Atlas of Fetal Ultrasound, https://doi.org/10.1007/978-3-319-54798-5_1
2 1
Median sagittal section: visualization of the spinous pro-
cess, vertebral body ossification centers, and the skin integ-
rity immediately above the spinous process.
1.4 Chest
Several cutting plans.
Size and shape of the rib cage.
Echogenicity of the lungs.
Location, size, shape, and echogenicity of masses or fluid
collections.
1.5 Heart
Cross section.
Heart position and relative position of the heart
chambers.
Four-chamber view: ratio between the chambers, inter-
ventricular and interatrial septum, valves. and myocardial
echotexture.
Oblique cross-section.
Left and right ventricular outflow tract: crossing of the
great vessels.
Diaphragmatic cupula.
1.6 Abdomen
Stomach: presence of gastric bubbles, volume, and location.
Liver and gallbladder: location, volume, and echogenicity.
Bowel: caliber and echogenicity.
Location, shape, volume, and echogenicity of intraperito-
neal collections and masses.
Location, size, and content of abdominal wall masses.
Confirmation of the normal insertion of the umbilical
cord (in median sagittal section and cross-section).
1.7 Kidneys
Kidneys: location, number, volume and echogenicity, pres-
ence of cysts, and pyelocaliceal and ureteral ectasia.
Bladder: volume and wall thickness.
Normal Fetal Morphological Ultrasound
Measurement of renal pelvis when visible and always in
the posterior–anterior direction in the cross-section of the
kidney stores.
1.8 External Genitals
Female gender: large and small labia, clitoris.
Male gender: scrotum, testicles, penis.
The identification of sex is of great value in twin pregnan-
cies and in diseases linked to sex.
1.9 Extremities
Length of long bones.
Check the presence of all long bones.
Check abnormal curvatures of the same.
Number and position of the fingers.
Contractures and postural deformities.
1.10 The Umbilical Cord
Volume, location, and echogenicity of abnormal masses.
Number of vessels: a higher incidence of malformations
in fetuses with a single umbilical artery.
Check abdominal and placental insertion of the umbilical
cord.
1.11 Amniotic Fluid
Volume analysis and echogenicity.
The abnormal volume of amniotic fluid has greater value
when it is associated with fetal malformations. An excess of
this fluid is more significant than oligoamnios.
1.12 Placenta and Membranes
Location.
Thickness, echogenicity, and texture.
Presence of membranes, septations, and their relationship
with the fetus.
1.12 Placenta and Membranes 3

HC

HC

Fig. 1.4 In the same section as in the previous figure, we proceed to

Fig. 1.1 Transverse view of the fetal head, showing the midline struc- the visualization of the cerebellar hemispheres (CH) and the cerebellar
tures. The section also shows the normal brain in the cerebral hemi- vermis in its entirety (arrow)
spheres and vermis (VER) and hippocampus spins (HS). The arrow
indicates the Sylvian fissure lateral to the cephalic pole. FC falx cerebri,
TL thalami, M midbrain, PF posterior fossa

SISTEMA NERVOSO CENTRAL NORMAL

CER

TL PC FP
P
SB

F CSP HC

FS
Fig. 1.5 Cross-section, laterally oblique (lateral tilting), shows the
posterior horn of the lateral ventricle (arrow). WM white matter, P cho-
roid plexus
Fig. 1.2 Same section as in the previous figure: largest increase show-
ing a normal central nervous system; the structures listed must be seen
constantly and systematically. PF posterior fossa, CSP cavum septum
pellucidum, TL thalami, CP cerebellar peduncle, FC falx cerebri, HS
hippocampus region, FS Sylvian fissure or cerebral large groove, CER
cerebellum

Fig. 1.6 Same section as in the preceding figure showing where to

measure the posterior horn of the lateral ventricle (arrow and calipers).
The atrioventricular width is measured where the choroid plexus ends
(P) and corresponds to the transition of the body with the posterior horn
of the lateral ventricle

Fig. 1.3 Also in a cross-section of the cephalic pole, slightly oblique

caudally, the thickness of the nuchal fold can be measured (arrow)
4 1
Fig. 1.7 Median sagittal section of the fetal head showing the corpus
callosum (CC) in the anterior portion, medially above the cavum septi
pellucidi (CSP)
Fig. 1.8 Same section as in the previous figure, but with the fetal body
showing in the cephalic pole the corpus callosum completely (arrows).
Notice in particular the posterior-most portion of the corpus callosum.
This should be observed because it is absent in partial agenesis of the
corpus callosum
Normal Fetal Morphological Ultrasound
Fig. 1.9 Cross-section in the base of the brain showing the arterial
circle (circle of Willis) and indicating the power doppler with the mid-
dle cerebral artery in the topographies of smaller wings of the sphenoid
(arrows)
Fig. 1.10 Median sagittal section of the face showing the usual profile.
Normal alignment is observed between the forehead and the chin
(absence of retrognathism or undershot)
1.12 Placenta and Membranes 5

C N
M

Fig. 1.11 Same view as in the previous figure used to measure nasal
bones (calipers)
Fig. 1.14 Coronal section of the fetal face through the chin (M) and tip
of the nose (N), showing an intact upper lip (arrows). Note that this cut,
which is due to fetal bending, can pass transversely through the chest
and fetal heart (C)

Fig. 1.12 Same section as in the previous figure at the dynamic time of
fetal yawning
Fig. 1.15 Same section as in the preceding figure, with the fetal mouth
open, facilitating the observation of the upper lip integrity (arrows).
Also, the fetal nostrils are observed. N nose, M chin

Fig. 1.13 Still in the sagittal face section, the tongue (arrow) is
observed in the normal position inside the mouth. LL lower lip, UL
upper lip
Fig. 1.16 Cross-section complementing the analysis of facial clefts
where the superior alveolar arch integrity is observed (–arrows dental
arch)
6 1 Normal Fetal Morphological Ultrasound

Fig. 1.17 Coronal section of the face, which is more posterior than the Fig. 1.20 Cross-sections of the fetal chest showing normal four cham-
lips, passing through the eyeball and showing the fetal lens bers, an intact ventricular septum and foramen ovale (arrow)

Fig. 1.21 Cross-sections of the fetal chest showing four normal cham-
Fig. 1.18 Complementary element in the cephalic pole analysis is the bers, an intact ventricular septum and foramen ovale (arrow)
paramedian sagittal section for tangenting lateral surface to observe the
outer ear (arrow)

AD
VD

VE AE VD

AD

Fig. 1.22 Cross-section of the chest showing four cardiac chambers

Fig. 1.19 Cross section of the fetal chest through the heart and show- with a normal appearance. Right atrioventricular valve (arrow)
ing four chambers with normal appearance. VE left ventricle, VD right implanted slightly lower than the left
ventricle, LA left atrium, RA right atrium
1.12 Placenta and Membranes 7

AE

Fig. 1.23 Same section as in the previous figure showing the foramen Fig. 1.26 Slightly oblique sections of the chest showing the left and
ovale with its valve (arrow) opened to the left atrium (LA) right ventricular outflow tract. VE left ventricle, AO aorta, VD right ven-
tricle, PA pulmonary artery

Fig. 1.24 View of the four chambers, out of the foramen ovale’s plan, Fig. 1.27 Slightly oblique section of the chest showing the beginning
to show the foramen ovale (arrow). The integrity of the rest of the atrial of the aortic arch (arrows) and its main branches
septum is seen to the left and to the right of the arrow

Fig. 1.28 Slightly oblique sagittal section showing the continuation of

Fig. 1.25 Slightly oblique sections of the chest showing the left and
the aortic arch with the descending thoracic aorta (arrows)
right ventricular outflow tract. VE left ventricle, AO aorta, VD right ven-
tricle, PA pulmonary artery
8 1 Normal Fetal Morphological Ultrasound

VB
E VB

Fig. 1.29 Paramedian sagittal section in the left side of the fetal chest
and abdomen in which we can see the heart (COR) and lung (PUL) Fig. 1.32 Cross-section with a slight caudal inclination of the front
separated from the left hepatic lobe by the intact diaphragm (arrow) portion showing the gallbladder (VB) and the stomach (E). Observe the
cord insertion medially (arrow)

COR
V
A
E
E

Fig. 1.30 Slightly oblique sagittal section to the left of the fetus show- Fig. 1.33 Cross-section of the fetal abdomen used for the measure-
ing the intrahepatic portion of the umbilical vein (arrow) and the stom- ment of waist circumference. The repair points are the stomach (S),
ach (S). Again, we see the heart (HEA) and the left lung separated from aortic cross-section (A) and intrahepatic path of the umbilical vein (V)
the abdomen by the intact diaphragm

VB
E

E R
VB
VB

Fig. 1.34 In a section slightly caudal in relation to the previous figure,

note the presence of the normal left kidney (K), stomach (S), and gall-
Fig. 1.31 Cross-section with a slight caudal inclination of the front bladder (GB)
portion showing the gallbladder (GB) and the stomach (S). Observe the
cord insertion medially (arrow)
1.12 Placenta and Membranes 9

RINS
NORMAIS

RD RE

Fig. 1.38 Coronal view of the chest (on the left) and abdomen (on the
right) with Power Doppler showing descending aorta giving rise to fetal
renal arteries. This technique is useful in cases of doubt with regard to
unilateral or bilateral renal agenesis
Fig. 1.35 Cross-section of the fetal abdomen at the level of the kidney
stores (arrows). RK right kidney, LK left kidney, S stomach

Fig. 1.36 Median sagittal section of the fetal pole showing the corpus
callosum in full (arrows), just above the cavum septi pellucidi (CSP)
Fig. 1.39 Paramedian sagittal section (on the left) showing the fetal
kidney in longitudinal section. On the right, cross-section of the fetal
abdomen at the level of the renal stores in a fetus with an anterior back,
showing the kidneys in cross-section. VER = vertebra in cross-section

AO

Fig. 1.37 Ideal cross-section of the abdomen to visualize the renal Fig. 1.40 Coronal section of the lumbar region of the fetus showing a
stores. Notice the left kidney, right kidney, and aorta (AO) normal kidney (left kidney). Arrows indicate the left adrenal gland,
which is quite visible in the early gestational ages, and should not be
confused with renal stores
10 1 Normal Fetal Morphological Ultrasound

Fig. 1.41 Cross-section of the fetal abdomen at the level of the navel, Fig. 1.44 Same section as in the previous figure, but without the amni-
showing the regular insertion of the umbilical cord (arrows). C column otic fluid interface, which worsens the visualization of the skin integrity

C
C

Fig. 1.45 Transversal section of fetal abdomen showing fetal vertebra

Fig. 1.42 Same section as in the previous figure, with the help of color (arrows) and ribs (C)
Doppler, it identifies the normal insertion of the umbilical cord (IUC;
arrows)

Fig. 1.46 Longitudinal section of the fetal arm showing the humerus
(arrows). This is the ideal section for measurement of the bone
Fig. 1.43 Median sagittal section of the fetal spine showing the nor-
mal appearance of the column. It is important, in this section, to also
observe the integrity of the skin (arrows). The visible elements of the
column in this section are: the anterior arches of the vertebrae or the
vertebral bodies (AA) and the spinous processes (SP)
1.12 Placenta and Membranes 11

5 4 3
2
R U 1

Fig. 1.47 Same longitudinal section of the fetal arm. Note the humeral
insertion of the deltoid (arrow), the biceps (B) and further distally, we Fig. 1.50 Section tangential to the fingertips (1, 2, 3, 4, 5) in a semi-­
see the radial portion (R) and ulna (U) inflected position

Fig. 1.48 Longitudinal section of the fetal forearm showing the ulnar Fig. 1.51 Longitudinal section of the fetal thigh showing the femur
free edge (arrows). This observation practically excludes post-axial (arrows). This is the ideal section for the measurement of bone
polydactyly

TI

45
23 P

1
FI

Fig. 1.52 On the left, normal position of the feet; on the right, evi-
dence of the presence of tibia (TI) and fibula (FI, arrow)
Fig. 1.49 The same view of the previous figure in a lower magnifica-
tion, showing the free edge of the ulna (arrows) and the individual
fingers
12
Fig. 1.53 Section of the sole the foot in a 16-week fetus. Failure to
display no long bone in the same section shows an angle of 90° between
the foot and the leg, which characterizes the absence of equinovarus
foot
Fig. 1.54 Longitudinal section of the leg in the coronal position show-
ing the tibia (TI) and fibula (FI)
Fig. 1.55 Cross-section of the fetal perineum showing the large labia
(LL) in the female fetus. Fetus at 30 weeks
1 Normal Fetal Morphological Ultrasound
GL
GL
Fig. 1.56 Same section as in the previous figure at a lower
magnification
GL
GL
Fig. 1.57 Cross-section of the fetal perineum showing female genital
type. Observe the parallel small lips and hyperechoic line that corre-
spond to the vaginal opening. This triad decides the female sex at
18 weeks or even earlier. K = fetal knees
Fig. 1.58 Longitudinal section of the fetus in the late first trimester
showing normal male genitals. BLA = fetal bladder. Same section as in
the previous image in a male fetus at 16 weeks. Note the presence of the
penis (arrow)
1.12 Placenta and Membranes 13

PLAC
PLAC

Fig. 1.59 Longitudinal section of the male external genitalia in a

31-week fetus. P penis, S scrotum

Fig. 1.62 Anterior placenta of grade I (PLAC). Note small chambers

(arrows) in the fetal placental board featuring grade I

B
P

PLAC

Fig. 1.60 Longitudinal view of normal fetal male genitals at 31 weeks

gestation. P = penis, B = scrotum
Fig. 1.63 Placenta grade II (PLAC). Chambers are noted to be more
pronounced (arrows) and more echogenic and of heterogeneous texture
than in the previous figure

LV LV
PLAC
PLAC

Fig. 1.61 Anterior placenta view of grade 0 (PLAC) and normal amni- Fig. 1.64 Placenta grade III. Placental calcifications are noted (arrows)
otic fluid (NL). F = fibula and the presence of venous lakes (VL). We can already distinguish the
placental buds
14 1 Normal Fetal Morphological Ultrasound

Fig. 1.65 Cross-section of the cord showing the presence of three ves- Fig. 1.66 Longitudinal section of the umbilical vein (V), but with the
sels. A = umbilical arteries, V = umbilical vein umbilical artery (A) in cross-section
 The Fetus at the First Trimester
The first trimester ultrasound scan is one of the main exami-
nations to be performed in prenatal care. With the increase in
technology and the development of modern scans it is pos-
sible to make diagnoses earlier than before.
The main goals of this particular ultrasound scan are:
ascertaining an ongoing intrauterine pregnancy, gestational
age evaluation, pregnancy viability analysis, diagnosis of
twin pregnancy and its eventual chorionicity, early detection
of some gross fetal abnormalities, and early screening for
fetal aneuploidies, using nuchal translucency (NT) measure-
ment and other markers.
The gestational sac can be seen using a transvaginal trans-
ducer after the 4th week of pregnancy and after 5 weeks,
when an abdominal transducer is used. A small anechoic
round structure is observed, in the endometrial cavity. At
5 weeks, using the endovaginal transducer, the yolk sac can
be observed, which appears before the embryo. The embryo
begins to be seen after 5 weeks through a transvaginal scan
and 1 week later through the abdominal transducer. When
the mean gestational sac diameter measures ≥2.5 cm, it is
mandatory to visualize the embryo in a normal ongoing
pregnancy. When this does not occur, it is characterized as an
anembryonic gestation. The fetal heartbeat can be observed
when the crown–rump length (CRL) of the embryo is >4 mm.
The presence of the intrauterine gestational sac practically
excludes the possibility of ectopic pregnancy, at least for
spontaneous pregnancies.
Until embryo visualization is obtained, the gestational
age could be calculated using the mean diameter of the ges-
tational sac, although it is not an accurate method of gesta-
tional age estimation. The best measure for gestational age
calculation, during this period, is the crown–rump length
(CRL), which can be measured after 5 or 6 weeks of preg-
nancy, i.e., as soon as the embryo is seen. This method pres-
ents a mean variation of about 5 days (between the 7th and
9th weeks) and 7 days between the 10th and 13th weeks. It is
very important to estimate the correct gestational age at this
time, as approximately 30% of pregnant women do not
remember their last menstrual period correctly or the gesta-
© Springer International Publishing AG 2018
V. Bunduki, M. Zugaib, Atlas of Fetal Ultrasound, https://doi.org/10.1007/978-3-319-54798-5_2
2
tional age is not consistent because of irregular menstrual
periods or because of oral contraceptive use, or even because
of short inter-pregnancy intervals.
Fetal viability can be ascertained after 6 weeks of preg-
nancy (CRL = 5 mm) when it is possible to see the embry-
onic heartbeat. The absence of a fetal heartbeat after this
period characterizes a non-evolutive pregnancy, known as
abortion. Other ultrasound signs can suggest a bad prognosis
for the pregnancy; however, these markers should be care-
fully analyzed.
The bad prognosis factors related to the gestational sac
are the irregularity of the sac, its size in relation to the
embryo’s size and a gestational sac measuring over 20 mm
without the presence of the yolk sac. When the yolk sac is
too big, an association with embryo death is reported. An
irregular-shaped yolk sac is also associated with abortion.
When the yolk sac is seen, the possibility of anembryonic
pregnancy can be excluded.
First-trimester ultrasound can also diagnose multiple
pregnancies and their chorionicity. It is important do make a
diagnosis of chorionicity because of the increased risk asso-
ciated with monochorionic pregnancies such as fetal death,
twin-to-twin growth discrepancies, and twin-to-twin transfu-
sion syndrome. Before 10 weeks, this diagnosis is carried out
by the visualization of the number of sacs. Each gestational
sac with its embryo has its own independent placenta. When
there is a unique gestational sac with two embryos inside it,
a monochorionic pregnancy is diagnosed. After the 11th
week, chorionicity is defined by the shape and thickness of
the amniotic membrane at the placental insertion. In a mono-
chorionic–diamniotic pregnancy, the amniotic membranes
form a T shape at its insertion and two thin layers can be
noticed between membranes that separate twins. In a dicho-
rionic pregnancy, the chorion forms the Greek letter lambda
(λ).
Diagnosis of first-trimester fetal malformations is also
possible, especially using the endovaginal probe. The skull
integrity and cranial calcification can be examined after
12 weeks. At the brain, the interhemispheric line and choroid
15
16
plexuses can be seen. With the normal visualization of these
structures, fetal pathological conditions such as anencephaly,
acrania, and alobar holoprosencephaly can be ruled out. The
diagnosis of encephalocele and ventricular dilatation is
sometimes possible.
Heart position can be observed in the fetal thorax.
Sometimes it is possible to see the four chambers of the
heart. On a transverse image at the fetal abdomen, the stom-
ach and bladder can be evaluated after 11 weeks. In some
cases, at the end of the first trimester, both fetal kidneys can
be seen. When the stomach is absent, we should repeat the
examination and if it persists a diaphragmatic hernia should
be hypothesized.
Bladders with significant dilatation should be re-­
evaluated. Most of the time, spontaneous resolution occurs;
however, cases of low urinary obstruction should be sus-
pected when the dilatation becomes worse in the next evalu-
ation. The abdominal circumference can be measured after
12 weeks or when CRL is ≥45 mm. The presence of herni-
ated bowels through the cord insertion leads us to a diagnosis
of omphalocele after 12 weeks. The diagnosis of gastroschi-
sis is also possible during this period. The vertebral spine can
also be better evaluated after 12 weeks and fetal movements
aid a better examination quality.
Spina bifida and rachischisis had been already reported
during this period of pregnancy. The superior and inferior
limbs can also be examined during the first trimester. In gen-
eral, arms and hands are settled laterally to the cephalic pole;
its visualization can be obtained in a transverse section of the
fetus. Hands are usually open and fingers can be counted.
Legs and feet can also be seen in a transverse section image.
The absence of a limb should be diagnosed during the first
trimester of pregnancy. In spite of several reports of bad for-
mation during the first trimester, ultrasound sensitivity is still
2 The Fetus at the First Trimester
insufficient to diagnose many malformations and this tech-
nique is not a substitute for the second-trimester morpho-
logical examination.
The search for ultrasound markers of fetal aneuploidy is a
crucial part of the first-trimester ultrasound scan between 11
and 13 weeks and 6 days. Measurement of nuchal translu-
cency (NT) is the most important marker. To achieve the cor-
rect measurement of this marker, fetal CRL must be between
45 and 84 mm (11–13 weeks and 6 days). The fetus should
be in a neutral position at the sagittal section (the same tech-
nique as that used to achieve CRL measurement). The maxi-
mum thickness of the hypoechogenic area between the skin
and subcutaneous tissue from which the fetal spine evolves
(hyperechogenic lines) is measured. It is important to care-
fully distinguish fetal skin from amniotic membrane, once
both have the same image of a thin hyperechogenic mem-
brane. Therefore, we should wait for fetal movements that
separate the fetus from the membranes. The image should be
zoomed until it takes at least 75% of the frame. The caliper
movement should make a change of 0.1 mm at the measure-
ment. At least three different measurements of NT should be
made and the biggest one considered. These are the criteria
approved by the Fetal Medicine Foundation. The combina-
tion of mother's age, previous history of chromosomopathy,
and the NT measurements has a sensitivity of 85% for detect-
ing Down’s Syndrome cases with a 5% false-positive rate.
When the software used to calculate the risks is not available,
values up to 2.5 mm should be considered normal.
The placenta can also be evaluated at the beginning of the
pregnancy with regard to its position and aspect. The pres-
ence of a heterogeneous image with many anechoic vesicles
of different sizes should be lead to the suspicion of tropho-
blastic disease. Diagnosis can be made earlier through the
endovaginal examination.
2 The Fetus at the First Trimester 17

VV

Fig. 2.1 Transverse section of the gestational sac with a trophoblastic

crown (arrows), corresponding to a pregnancy of 4 weeks and 5 days Fig. 2.4 Longitudinal view of the yolk sac and its pedicle (VV) in a
8 weeks gestation obtained by transvaginal scan. P = coeloma

SG

Fig. 2.2 Longitudinal image of the embryo (E) at 6 weeks and 3 days.
The increased size of the gestational sac (SG) does not always mean a Fig. 2.5 Transverse image of the gestational sac in a pregnancy of
non-evolutive pregnancy 7 weeks and 1 day, showing the embryo and vitelline vesicle

CE

VV

Fig. 2.6 Transverse image of a uterus on an endovaginal ultrasound

Fig. 2.3 Transverse image of an extra-embryonic coelom showing the demonstrating the vitelline vesicle at the extra-embryonic coelom and
normal aspect of the vitelline vesicle or yolk sac (VIT VES) embryo (arrow) in a coronal image. vv = yolk sac
18 2 The Fetus at the First Trimester

CE

E
VV

TROF

Fig. 2.7 Longitudinal image of the embryo and yolk sac and its pedi-
cle in a 9-week pregnancy. Notice the identification of the cranial por- Fig. 2.10 Transverse image of the uterus showing a 9-week and 5-day-­
tion of the embryo old embryo; amniotic membrane (white arrow); vitelline vesicle (VV);
extra-embryonic coelom (EC); and posterior trophoblast (TROP)

C VV E

Fig. 2.8 Endovaginal ultrasound of an 8-week embryo (E) in a typical Fig. 2.11 Embryo with cardiac activity identified with the use of color
position of flexion position. Observe the vitelline vesicle (VV) at the Doppler. Notice the umbilical cord trajectory (c), which also appears on
extra-embryonic coelom (C) the color Doppler

Fig. 2.12 Demonstration of legs and feet (arrows) o f a 9 weeks and 4

Fig. 2.9 Transverse image of the gestational sac showing all extra days embryo
embryonic parts. Cel = extra-embryonic coelom, A = amniotic fluid
inside the amniotic membrane, VV = vitelline vesicle
2 The Fetus at the First Trimester 19

Fig. 2.16 Demonstration of arm (B) and fetal hand (M). To notice
amniotic membrane (AMNIO)
Fig. 2.13 Transverse image of the fetal upper body showing superior
limb and its segments (arm) in a 9-week and 5-day-old embryo

Fig. 2.17 Sagittal image of the fetus demonstrating the ideal position
for measuring nuchal translucency (NT) and CRL

Fig. 2.14 Transverse abdominal image of a 9-week and 4-day embryo

showing umbilical hernia, which is physiological at this gestational age

Fig. 2.18 Image of a 9-week embryo showing CRL measurement, not

Fig. 2.15 Coronal image of the embryo showing all segments of the in an adequate position for measuring it; however this could be well
arms. Notice the hands (M) beside the fetus head accepted until 10 weeks
20 2 The Fetus at the First Trimester

Fig. 2.22 Transverse image of fetal thorax at the fetal heart level
Fig. 2.19 Measurement of NT measurement (1) and CRL (2) in a fetus showing the tricuspid valve Doppler (calipers), with a normal flow. No
with a posterior back. Notice the caliper position over the anechoic regurgitation observed
image

E
DC

Fig. 2.23 Transverse image of a bicornuate uterus with an embryo (E)

Fig. 2.20 Image demonstrating the correct size of zoom to achieve NT
occupying one of the uterine cavities and decidual cast (DC) at the left
measurement and nasal bone visualization
cornuate

Fig. 2.21 Venous ductus Doppler on first-trimester ultrasound. In this Fig. 2.24 Sagittal image of a 15-week-old fetus, demonstrating the
picture, a normal measurement is observed normal aspect of a superior limb, with finger count (arrows), and an
inferior limb with normal foot position (F)
2 The Fetus at the First Trimester 21

Fig. 2.28 Sagittal image of an embryo demonstrating an anechoic

image in the back of the cephalic pole, which corresponds to the
Fig. 2.25 Femur length measurements can be made at 13 weeks rhombencephalon (arrow)
(arrow)

h PC

PC

Fig. 2.29 Transverse section of the cephalic pole at 11 weeks, showing

the interhemispheric division and visualization of the choroid plexuses
Fig. 2.26 Paramedian sagittal image showing the fetal hand (h) and (CP)
fingers in a 15-week-old fetus

PC

F
PC

Fig. 2.30 Transverse section of the cephalic pole at the lateral

Fig. 2.27 Plantar image of a fetal foot (F). At this time, the fingers can ventricles in a 12-week-old fetus. Notice the normal calcification of the
be counted and the foot position evaluated skull (arrow), midline and hyperechogenic choroid plexuses with
butterfly wings aspect
Another random document with
no related content on Scribd:
a really first-class highly certificated magician from Cairo, or some
big town, and get him to come out and do the job. In the meantime,
as Qwaytin had told me that there were some mounds in the
Kairowin hattia, that we should go there through the eastern part of
the Farafra depression and see if they did not contain treasure.
Qwaytin had heard that they contained buildings, and so thought that
it would be a likely place for buried riches, though, as he said
lugubriously, he did not expect that we should find anything like what
we might have done if we had discovered the treasure of those three
Sultans. The following morning a rather crestfallen caravan set out
for the eastern side of Farafra.
 CHAPTER XXIII

O N leaving the hill we took a road that led us towards the north.
We first rounded the western end of the scarp of the detached
plateau parallel to which we had marched on coming from Bu
Gerara, and, about two hours after our start, ascended a steepish
bank on to the top of the plateau, which here was only about fifty feet
high.
From the summit of a small hill close by, a huge cliff stretching to
the north and south, as far as it was possible to see, was visible, far
off in the east; this was evidently the eastern boundary of the Farafra
depression, and, as I afterwards discovered, the continuation of the
cliff to the north of Bu Gerara.
The scarp was too far for me to be able to see any details of its
surface, with the light behind it, and as the top of it showed as only a
straight line, there were no points on it to which I could take a
bearing.
In these circumstances it was impossible either to fix its position
or to estimate the direction in which it ran. I several times met with
this difficulty, but found that, when a cliff faced towards the south, it
was only necessary for me to wait till the sun came round far enough
to begin to light up its surface, and then a rough estimate of the
direction in which it ran could be obtained by taking a bearing on to
the sun itself. This dodge was especially useful when it was
necessary to map the continuation of a cliff, part of which had
already been surveyed and the remainder of it could only be seen
from one point, such as the top of a high hill.
The part of the Farafra depression in which we found ourselves
was an absolutely featureless plain, of hard level sand, that sloped
slightly towards the foot of the scarp on our east. Here and there we
came across patches of greenish clay, with white lines running
through it, showing above the surface of the sand.
The Persian King, Cambyses, during his occupation of Egypt,
sent a great army across the desert to destroy the oracle of Jupiter
Ammon in Siwa Oasis. The army never reached Siwa; but was lost
in the desert. Its last resting-place is unknown, but, according to
native reports, the whole host perished of thirst in this huge
depression in which the oasis of Farafra lies.
I happened to mention to Qwaytin the subject of singing sands,
and asked him if he had ever heard any. He told me that somewhere
in the north of the Farafra depression there was a rock that was
supposed to be the “church” of the spirits of the lost Persian army. It
was called the “infidel rock,” because it “sang on Sunday.” It
appeared to be some form of musical sands.
It was not until the third day after our start from the treasure hill
that we sighted in the west the field of dunes that occupies the
centre of the Farafra wady. They appeared to be almost white in
colour, and lay a long way off.
Qwaytin told me that we should reach the Kairowin hattia on our
third day after leaving his hill. It will give some idea of his utter
incompetence as a guide when I say that we did not actually get
there until two days later.
He came into my tent on the first evening and began yarning in an
aimless sort of way, as he generally did as a preliminary to serious
business, and I endeavoured to extract some information from him
as to the topography of the Bedayat country, with which he was well
acquainted.
But he at once got impatient and changed the subject to that of
his confounded hill. He ended by asking—almost demanding—that
we should go back there to have another look at it, and to make
certain that there was not another hill in the neighbourhood which
might be the one indicated in his book. On my refusing to do so, he
flounced out of the tent—he was certainly a queer customer to deal
with.
 Whenever I spoke to him the next day he began gassing about his
wretched hill, and saying that he wanted to go back to it; but towards
evening he rather recovered himself, and when he came to my tent I
again threw out feelers about the country of the Bedayat, though he
declined to tell me anything about the district, he started giving me a
lot of information about the Bedayat themselves, which, as they are
an almost unknown race, proved extremely interesting.
They claim to be descended from an afrit, whom, for some crime,
either David or Solomon shut up in a box, till he grew to such an
enormous size that he burst it open. There still exists apparently a
mongrel Bedayat—Tibbu tribe, known as the M’Khiat er Rih, that
possess the miraculous power of being able to walk over sand
without leaving any tracks behind them—a most useful
accomplishment in the desert for a race of born freebooters. This
peculiarity they owe to the fact that wherever they go they are
followed by a wind that immediately obliterates their footprints!
On our fourth day after leaving the treasure hill, our road
converged towards the dunes lying on our west, and, as Qwaytin
seemed to be hopelessly lost, I climbed one of the biggest of them
with him to try and make out our position.
From the top, the east and west scarp, with a break in it leading
up to Baharia Oasis, that lies on the north of Farafra, could be seen
in the far distance, but no sign of the hattia Kairowin was visible. In
front of us, however, was a high three-headed sif, or longitudinal
sand dune, that Qwaytin declared to be the landmark for the hattia
from the south.
As we were getting very short of water, the news that the hattia
was not in sight caused something like consternation among my
men. They all started grumbling at Qwaytin’s ignorance of the road,
and Ibrahim went so far as to ask him point-blank why he called
himself a guide, if he knew so little about the desert.
This coming from a young Sudani, hardly out of his ’teens, to an
elderly Arab guide, who, moreover, was a sheykh of his tribe, was a
great ayb, and Qwaytin was intensely put out. Qway, under the
circumstances, would have retaliated with some stinging remarks on
the inferiority of “slaves” and the respect that was due from a boy to
his elders and superiors in rank; but Qwaytin lacked his ready
powers of vituperation. He was a slow-witted old curmudgeon, and
failed entirely to put Ibrahim in his place. His own men stood up for
him in a feeble sort of way. But they were no match for Ibrahim, and
eventually gave up any attempt to defend their sheykh, probably
feeling themselves that there was not much to be said in his
defence. As I rather wanted to encourage a certain amount of friction
between my men and Qwaytin’s, I left them to settle their differences
as best they could, with the result that Qwaytin and his men got
much the worst of the wrangle.
Kairowin hattia measures some eighteen miles from north to
south, by seven from east to west. It consists of a level scrub-
covered area, in which, here and there, are to be seen a few
neglected-looking palms. A number of wells have been sunk here at
various times; one on the extreme eastern edge of the hattia, where
the road coming from Assiut first enters the scrub, is known as Bir
Murr. This well, which I did not visit, is said to be sanded up. Another
well somewhere to the north, I believe, is known as Bir Abd el Qadr.
There are also several others, all of which seem to be impartially
named Bir Kairowin. Probably water can be found under all the lower
lying parts of the hattia by digging for a few feet into the ground,
which throughout this district consists of chalk.
The wells in every case apparently give water so thick with chalk
particles that when first drawn from them it is almost as milky as
whitewash. Attempts to clear the water by passing it through a
Berkefeld filter failed, as the chalk clogged the filter after a few
strokes. But when it had been allowed to stand for a few hours, most
of the chalk settled down to the bottom, and the water that was
poured off passed quite easily through the filter, after which it proved
to be of quite good quality.
I, unfortunately, forgot to wind my watches the first night in the
hattia, and so allowed the half chronometer I had been using in
taking my observations to run down. As I was depending on it for my
longitudes, this necessitated a stay of two or three days in the camp
in order to ascertain its new rate after it had been rewound.
 These watches are for some reason only made so as to run for
one day. As oversights of this kind must be of common occurrence
with travellers, it would seem to be preferable that they should be
made so as to run for two days, and be furnished with an up and
down indicator to show how long an interval has elapsed since they
were last wound.
I spent a considerable part of the time while in the hattia in trying,
without success, to get a shot at gazelle. There appeared to be very
few in the district, though a considerable number of old tracks were
to be seen where they had been feeding on the scrub.
This scarcity of game may perhaps have been due to the fact that
a few bedawin were at that time living there in charge of some
camels belonging to the Senussi zawia at Qasr Farafra. These men
kept away from the camp, but I saw them and their camels several
times wandering about in the scrub, and twice found small hovels
constructed of brushwood, in which they had been living—they had,
so far as I could see, no tents.
My men spent most of their time in grubbing about in some large
mounds. On the top of one of these, about thirty feet high, Ibrahim
found some burnt bricks. The whole mound was covered by a thick
growth of terfa bushes, among which the sand had collected,
completely hiding any building there might have been beneath it.
It must have been originally a building of some size and of
considerable height, and was perhaps a tower. The men unearthed
part of a small room at the base of the mound. It had been well built,
of the same burnt bricks, and the interior was covered with plaster. A
few pieces of broken pottery were found, one of them covered with a
green glaze. There were four or five other mounds of a similar nature
in the neighbourhood; but we had neither time nor implements
thoroughly to examine them.
As the total result of their treasure hunt in Kairowin the men only
unearthed one corpse and a few bits of broken pottery, without
finding even a single copper coin to gratify their cupidity. They were
consequently considerably disillusioned with their occupation, and I
experienced no difficulty in getting them to start for Qasr Farafra.
 I made first for the main well, that is known as the Bir Kairowin, in
order to close my traverse. The water lay about eight feet below the
surface; access being gained to it by the usual sloping path, cut out
of one of its sides. By the top of the well was a mud-built trough for
watering camels, with an empty paraffin tin lying beside it for use as
a bucket.
Immediately on leaving the hattia we got into the dunes, which
cover a large area in the centre of the Farafra depression. The first
two or three dunes gave a little difficulty, but we found the rest of
them quite easy to cross. They were all, so far as I could see, of a
very elongated whalebacked type, which ran roughly from north to
south, in the direction of the prevailing wind.
Qasr Farafra lay almost due west from our camp. Soon after we
got into the sand it became clear that Qwaytin was again hopelessly
lost, as I found we were marching almost due south. I was obliged to
put it to my guide, as inoffensively as I could, that if he would change
the direction in which he was leading us by a mere right angle, we
might perhaps reach our destination, instead of going on to Dakhla
Oasis as we seemed to be doing. Qwaytin was so hopelessly lost
that he accepted my suggestion without the slightest argument.
Soon after this we got out of the sand on to level desert, where a
large number of black nodules of iron pyrites were to be seen lying
on the surface. Further on some fine specimens of sand erosion
were met with in the shape of chalk “mushrooms” and table rocks.
Otherwise this part of the desert was quite featureless. The road lay
entirely over white chalk, which caused a rather trying glare in the
blazing sunlight.
We sighted Qasr Farafra on the evening of the second day after
leaving Kairowin hattia; but as night fell before we could reach it, we
camped a few miles away from the village. Two hours’ march on the
following morning brought us into the oasis. On the outskirts we
passed a patch of ground on which the sand was encroaching, some
palms lying on the north of it being almost entirely submerged.
We camped on the northern side of the village. A large crowd of
natives came out and stood watching us while the tent was being
pitched. Among them was a sulky-looking fellow whom I was told
was the ’omda; so, as soon as the tent was pitched, I invited him and
some of the other men standing by to come in.
We had foolishly camped too close to the village, with the result
that throughout the greater part of the day the camp was surrounded
by a crowd of men and children watching all our actions, peering into
the tent, thronging round the theodolite, when I began to take
observations, and generally showing an ill-mannerly curiosity that
was in great contrast to the conduct of the natives of the other oases
in which we stayed. Farafra being the least known of the Egyptian
oases, the advent of a European was an event of such rare
occurrence that the natives had evidently decided to make the most
of it.
The natives of Farafra Oasis, who are known as the Farfaroni, or
sometimes as the Farafaroni, are a far more vigorous lot than those
of Kharga and Dakhla. They were a surly unpleasant-looking crowd.
The day after our arrival, I went out with the ’omda and Qwaytin to
see the village and plantations. With the exception of an ezba at ’Ain
Sheykh Murzuk, where there are a few houses, a Senussi zawia and
a family or two continuously resident to tend the cultivation near the
well, Qasr Farafra is the only permanently inhabited spot in the
whole Farafra depression. It is a poor little place with a total
population of about five hundred and fifty inhabitants. The houses
are of the usual mud-built type, and in most cases little better than
huts; almost the only exception being that of a square tower,
showing in places the remains of battlements, attributed, perhaps
rightly, by the natives to the Romans, who are said to have erected it
as a keep to protect the village.
This proved to be rather an interesting place. It is not inhabited,
but the door is kept locked with a watchman perpetually on guard
over it. The building is used solely as a storehouse, each family in
the village having the right to the use of one of the rooms that it
contains—there were said to be no less than one hundred and
twenty-five chambers in the building.
 The ’omda showed us over the tower. The entrance lay through a
strong wooden door, at the top of a flight of steps, in a passage
entered in the middle of one of the outer walls, the walls on either
side of which were pierced with apertures, apparently intended for
use as loop-holes. The passage extended the whole height of the
building and was unroofed, in order that stones might be dropped
from above on to any assailant attempting to attack the door.
 BOY WITH CROSS-BOW, FARAFRA.

The interior of the tower was a perfect labyrinth of breakneck

stairways and little rooms opening out of narrow dark passages.
After scrambling up several sets of steps and repeatedly banging my
head in the dark against the low roof, we at length emerged into a
sort of courtyard at the top, surrounded by two tiers of small
chambers, each provided with its own locked door. Some further
scrambling landed us on the roof that covered the rooms and formed
a kind of platform surrounding the courtyard. From here a wide view
could be obtained over the oasis and depression.
There was not much of consequence to be seen. Below lay the
village, looking, when viewed from above, even more squalid than
from below. Scattered round it, within a radius of a few miles, lay a
number of small patches of cultivation, showing the positions of the
various wells and springs. Seven or eight miles away to the west
was a cliff of considerable height, forming the scarpment of the Guss
Abu Said—an isolated plateau beyond which, though invisible from
the tower, lay a well, “Bir Labayat,” and the little oases of Iddaila and
Nesla, in another large depression, the dimensions of which were
unknown. Here and there on the floor of the depression a few
isolated hills stood up to break the level monotony, the most
conspicuous amongst them being Jebel Gunna el Bahari, about
fifteen miles to the north-east. Otherwise the view over the
depression was singularly monotonous. The only other noticeable
features being the cliffs in the far distance to the north and east that
marked the limits of the higher plateau.
On descending from the tower the ’omda took me round the
village. Except for its poverty-stricken appearance, it differed little
from those in Dakhla and Kharga Oases. There seemed to be few
houses with a second storey, and the palm leaf hedges, that usually
topped the wall surrounding the flat roofs in the other oases, were
seldom visible.
Having completed our survey of the village, the ’omda took us to
his house. It was a very poor residence for a man of his position in
the village, and was overrun with fowls, goats and filthy little children,
mostly suffering from ringworm. He gave us some dates and very
bad tea, but no cigarettes were produced, probably because, like
most of the inhabitants of the place, he “followed the Sheykh.”
In the afternoon I went with Abd er Rahman and the ’omda to see
the winch of a boring machine that had been given to the zawia by a
wealthy Egyptian in Cairo, in order that they could sink a new well.
They wanted my opinion on it, as two of the cog wheels had been
broken and the work of sinking the well had had to stop in
consequence. It was obvious that there was nothing to be done,
except to replace the wheels. I took measurements of the broken
parts and promised to have duplicates of them made in Cairo, when I
got back, and to have them sent to the oasis.
I was engaged in noting down their dimensions, when Abd er
Rahman informed me that the Senussi sheykhs from the zawia were
coming, and I caught sight of two men, with Qwaytin in their train,
stalking along in my direction.
The zawia was run by three sheykhs who were brothers, the
eldest was, however, at that time away in Cairo. The other two were
not a prepossessing-looking couple. Sheykh Ibn ed Dris, the elder,
was a fine-looking Arab, and would have been even handsome if his
face had not been marred by its dour, truculent expression. His
youngest brother, Sheykh Mohammed, was apparently hardly out of
his ’teens, and seemed to be somewhat of a cipher, being
completely swamped by the aggressive personality of the elder
sheykh. The only impression he made was one of extreme sulkiness.
Qwaytin told me that they had come to take me for a walk round the
plantations that surrounded the village, adding that as I was a
stranger in the oasis they felt that they ought to entertain me.
They did not seem to relish the job very much. Sheykh Ibn ed Dris
was extremely taciturn, and his brother never opened his mouth
during the whole of our tour of inspection.
Compared with the other Egyptian oases, the plantations in
Farafra contained comparatively few palms and a much larger
proportion of other fruit trees—olives, vines, apricots, white
mulberries, figs, pomegranates, limes, sweet lemons, a few orange
trees and a small apple, which, being regarded as a rarity, was very
highly prized. Formerly there used to be a considerable export of
olive oil to the Nile Valley, but for some reason, perhaps because the
trees were getting too old, the crop was said to have diminished
considerably, and barely to suffice for the wants of the oasis.
The fields surrounding the plantations were planted so far as I
saw only with wheat, barley and onions, but durra and rice are also
said to be grown in the oasis. The areas under cultivation seemed
small, but the plants all looked healthy, and even luxuriant. I saw no
patches of salty ground, such as were often to be seen in Dakhla.
 A Bride and her Pottery.
A bride from the poorer classes can only
contribute a small amount of earthenware
towards furnishing her new home. In her wedding
procession she carries this on a chair on her
head. Note the sequins on the front of her dress.
(p. 253).

Farafra is such a small place that administratively it is under

Baharia, the nearest oasis, lying about three days’ journey away to
the north-east. In the whole oasis of Farafra there are only about
twenty wells, the two most important ones were said to be ’Ain
Ebsay, lying four to five miles to the south of the village, which I did
not visit, and ’Ain el Belad (the town well), both of which were said to
be of Roman origin and to resemble those of Dakhla Oasis.
 Some of the wells are said to be connected with long underground
infiltration channels cut horizontally, at some depth below the
surface, similar to those at ’Ain Um Debadib, but I had no opportunity
of examining any of these. The ’Ain el Belad, that supplies the
village, flowed into a large pool covered with green weed and to
some extent surrounded by palm groves, that in the glow of the
setting sun made a most lovely picture.
We ended our promenade at the door of Sheykh Ibn ed Dris’
house in the zawia. It was a gloomy mud-built building, without a
trace of the European furniture that characterised the zawia and
houses of the Mawhub family in Dakhla. Here I took leave of my
unpleasant companions, much, I fancy, to our mutual relief. As the
sheykhs had to a slight extent thawed during our walk, I asked Ibn
ed Dris to let me photograph him, to which, rather to my surprise, he
grudgingly consented. He did not make a pretty picture. He was
wearing his normal expression, a scowl that “never came off,” and
nothing that I said would induce him to look pleasant.
Supplies of all kinds were very scarce in the oasis. No fruit or
vegetables were procurable, and the only eatables to be bought
were fowls, eggs and onions. Owing to nearly the whole of the
inhabitants being members of the Senussia, tobacco was also very
difficult to obtain, as the members of the sect are forbidden to
smoke. The men had all run out of cigarettes, and were much upset
at not being able to renew their supplies.
The morning after my walk with the sheykhs, Ibrahim, who was
always keen on any kind of sport, told me that quail were beginning
to arrive in the oasis, so I went out with him to try and shoot some. I
only, however, saw two—one of which I succeeded in missing twice.
The natives of Qasr Farafra were so unfriendly that I was unable
to see as much of the place as I should have wished, and I was only
able to take a very few photos.
The next morning we packed up and set out to Bu Mungar. After
an uneventful journey of about eight hours to the south-west, over a
featureless level desert, we reached the little oasis of ’Ain Sheykh
Murzuk—the only permanently inhabited spot, besides Qasr Farafra,
in the whole depression.
Three or four men came to meet us as we approached the
plantation, and greeted Qwaytin with enthusiasm. The oasis was a
very small one, extending to only a few acres. The cultivation
consisted of only a few palms and fruit trees and a field or two of
grain. Among the palms were hidden two or three houses, which I,
however, inspected only from a distance. One of them, I was told,
was a Senussi zawia.
 CHAPTER XXIV

W E started the next morning at dawn. Soon after leaving ’Ain

Sheykh Murzuk, Qwaytin showed me a pass ascending the
scarp of a small plateau, the Guss abu Said, on our right, over
which, he said, passed a road to Iddaila. From Iddaila, he said, a
road ran direct through Nesla and Bu Mungar to Dakhla Oasis.
Two hours after our start we reached a very small oasis, only an
acre or two in extent, known as ’Ain el Agwa. It contained a few
palms and evidently a well, though the place was so covered with
drifted sand that the palms in some cases were buried nearly to their
crowns, and the well was completely invisible.
About an hour farther on we reached a similar oasis, called ’Ain
Khalif. There were no traces of inhabitants at either of these places;
the dead leaves left hanging on the palms showed that they were
entirely uncultivated, and at ’Ain el Agwa the trees themselves
seemed to be dying.
These little places do not seem to have been previously reported,
though Rohlfs’ route must have passed fairly close to where they
were situated. From the size of the palms they seemed to be only
about twenty years old, so possibly the wells were sunk since the
time of his visit.
Though the sand had to some extent encroached on the oasis at
’Ain el Agwa, it had not done so to anything like the same extent as
at ’Ain Khalif, and the feeble well, discharging into a tiny pool a few
yards across, was still quite clear of sand.
As the water proved to be good, we stopped here for half an hour,
while we refilled the gurba and examined the oasis.
Shortly before sunset we reached a place where the road forked.
A line of small stones had been laid across the right-hand track—a
common sign among the Arabs that the road was not to be followed.
Qwaytin took the left-hand branch and soon afterwards we came to
the top of the descent into Bu Mungar. The path at this point was a
narrow cleft, a few yards long and not more than a foot or two wide,
that proved as difficult to negotiate as the very similar one leading
from the ’Ain Amur plateau down towards Dakhla. Below it lay a
sandy slope that extended to the bottom of the cliff and presented
little difficulty.
On reaching the bottom of the slope we set out for Bu Mungar,
which lay a short distance ahead of us. But on reaching the hattia,
Qwaytin, as usual, got lost, and it was some time before we could
find the well.
It had been a stiflingly hot day and we had marched for over
thirteen hours, with only a short halt at ’Ain Khalif. I had done the
whole distance on foot, so I was dog tired, and extremely thirsty. So,
as the evening of our arrival was cloudy, and as to get in a set of
observations would probably have meant that I should have had to
sit up for several hours for the clouds to clear off, I put off the work
until the following day, meaning to leave the place in the afternoon.
My tent was pitched on the extreme eastern end of the hattia. The
cliff of the plateau formed a huge semicircular bay on our east, the
southern point of which could be seen about twenty-five miles away
to the south-east of the camp. In the middle of this bay lay a second
large detached scrub-covered area.
Bu Mungar contains at least two wells, as in addition to the one
near which we were camped, the men found a second one, about a
quarter of a mile away to the south-west, the position of which was
marked by a group of trees—acacias and palms, so far as I can
remember.
The other well, that lay about two hundred yards to the north-west
of the camp, seemed to be an artesian one, similar to those in the
Egyptian oases. A little stream ran from it for a short distance till it
lost itself in the sandy soil. So far as I was able to see the trees were
larger and the vegetation more luxuriant than in the Kairowin hattia.
 To the south, a huge area covered as far as the horizon with sand
dunes was visible. A large dune overhung the camp on its eastern
side, and drift sand seemed to be encroaching in many places on the
vegetation. In the neighbourhood of the camp was a praying place,
or “desert mosque,” made according to Qwaytin after one of the
Senussi models. This consisted of a line of stones laid out on the
ground much in the shape of a button-hook, the straight portion of
which pointed in the direction of Mecca, to indicate the direction in
which worshippers should face when performing their devotions. It
was the only praying place of the shape that I ever saw.

SENUSSI PRAYING PLACE, BU MUNGAR.

The wells of the hattia perhaps dated from Roman times, as at a

short distance to the south of the camp was a small mud building
(der) which the natives attributed to that period. The remains of the
vaulted roofs and the arched tops of the openings in the walls tended
to confirm this view.
I managed the next day to get the necessary astronomical
observations to fix the position of the place, but was not able to
make a thorough examination of it, as complications with the
Senussia that, from numerous indications I had seen since leaving
Assiut, I had been expecting for some time suddenly came to a
rather unpleasant head.
It was not until I got to Bu Mungar that I discovered that all the
men in my caravan belonged to the Senussia. Qwaytin and his three
men, I knew, had always been of that persuasion, and, while in
Farafra, Abd er Rahman, Ibrahim and Dahab had all been so worked
upon by Sheykh Ibn ed Dris that, just before we left that oasis, they
too had joined the order, and showed all the fanaticism to be
expected from new converts.
A party of thirty Tibbus, sent from Kufara for my entertainment, by
Sheykh Ahmed Esh Sherif, at that time head of the Senussia, were
hanging round somewhere in the neighbourhood of Bu Mungar,
close enough for Qwaytin to start signalling to them by firing shots at
imaginary pigeons and lighting an enormous and quite unnecessary
bonfire at dusk—a well-known Arab signal.
Twenty more men had been sent from Kufara to reinforce the
Mawhubs at their ezba, in the north-west corner of Dakhla, which I
should have to pass in order to enter the oasis on my way to Egypt;
while the inhabitants of Farafra—the only other oasis I could fall back
upon with my small caravan—were members of the order almost to a
man, and were on the look out for me if I returned that way. It was
explained to me that they had allowed me to go to Bu Mungar
instead of to Iddaila—my original intention—in order that I should
leave Egypt, and then, as I had altered my plans, no one would know
“where it happened!”
It was a neat little trap that I had foolishly walked into; but it had its
weak points. It was nearly dusk when Qwaytin fired his signal shots
that led to my enquiries, and, better still, a howling sandstorm was
blowing. If once we got out into the desert in these circumstances, I
felt confident of getting away without difficulty. But the prospect of
having the camp rushed before we could get off gave me such a bad
attack of cold feet that I decided to start running as soon as possible
in order to get them warm.
Qwaytin and his men, however, when told to do so, flatly refused
to leave the hattia. But he and his crowd were such a feeble lot that I
had little difficulty in reducing them to order. We lost so little time that
I got the tanks filled and the caravan off just after sunset.
Before starting it occurred to me that I might borrow a trick from
Abd er Rahman. So finding a sand-free space near the well, I
scratched the Senussi wasm with a stick deeply into the ground, and
then, to mislead the Senussi when they came as to the direction in
which we had gone, drew a line from it pointing towards the west—
the direction in which I knew they feared that I should go—and then
set out towards the south-east to Dakhla.
Almost immediately after leaving the camp we got on to the sand
hills. I then left the road, and, to Qwaytin’s intense disgust, struck out
into the dunes to the south, where the tearing gale that was blowing
very quickly obliterated our tracks.
After marching for two and a half hours, the dunes became
considerably larger, and, as the moon had set, travelling was
attended with such great difficulty that we halted till daylight.
But after leaving Bu Mungar our journey to Mut began to get too
much in the nature of “adventures” to be described in detail. It took
me all that I had learnt, during seven seasons spent in the desert, to
get my caravan into Dakhla, without creating that incident that I had
been warned to avoid, and which might easily have resulted in
something in the nature of a native rising.
No one in the caravan but Qwaytin had been over the road
before, and he, of course, got hopelessly lost, and in any case was
not reliable, so I had to take over his job and do the best I could as
guide.
After leaving Bu Mungar our road for the first day lay all over the
dunes. Late in the afternoon we came across three sifs—dunes with
an A-shaped section running up and down wind—which, since they
stretched across our path, gave us some difficulty. They were all
under twenty feet in height, but their sides were at such a steep
angle that the camels were quite unable to climb them, and the men
had to scoop paths diagonally up the face of the dunes and down
again on the farther side, over which the camels one by one with
difficulty were forced. Small as these sifs were they caused a
considerable delay. But these three ridges proved to be the last of
the dune belt, and the remainder of our road, till we reached the
dunes near Dakhla, we found to be easy going.