Introduction and Basic Obsterics Ultrasound

► Ultrasound

imaging, also called ultrasound scanning or sonography, is a method of obtaining images from inside the human body through the use of high frequency sound waves

► Ultrasound

20,000 Hz ► Medical ultrasound generally uses frequencies between one and 10 million hertz (1-10 MHz). ► Higher frequency ultrasound waves produce more detailed images, but are also more readily absorbed and so cannot penetrate as deeply into the body.

= sound with a frequency over

► An

ultrasound machine consists of two parts: the transducer and the analyzer. ► The transducer both produces the sound waves that penetrate the body and receives the reflected echoes

► transducer

then receives the returning echoes, translates them back into electric pulses and sends them to the analyzer--a computer that organizes the data into an image on a television screen





► Four

different modes of ultrasound are used in medical imaging
 A-mode

single transducer scans a line through the body with the echoes plotted on screen as a function of depth

 B-mode

linear array of transducers simultaneously scans a plane through the body that can be viewed as a twodimensional image on screen

 M-Mode

stands for motion

 Doppler mode

of accurately measuring velocities of moving material, such as blood in arteries and veins ►most often combined with B-mode scanning to produce images of blood vessels from which blood flow can be directly measured

Obstetric Ultrasound
► Obstetrics

USG provide enough benefits, in enough pregnancies to support its widespread use ► USG has different role in different stages of pregnancies

► Prerequisites

 Details of history, examination and investigations  Relevant risk factors identified  Relevant serology and genetic concerns

► Preparation

 High resolution real time gray-scale USG machine  Experienced sonographer  Comfortable mother  Screen visible to mother (optional) and sonographer

First Trimester Scan
► Comment

 Complimentary to mid trimester scan
► Content

   

Establishing date (CRL) Number of fetuses and chorionicity Establish viability Evaluate gross fetal anatomy

 Examine uterus and adnexal structures  Specific examinations with indications  Nuchal translucency *

18-22 week scan
► Content

   

Confirm viability Check dating/gestational age Confirm fetal number Examine fetal anatomy

& neck ►Thorax ►Abdomen ►Axial skelelton

 Amniotic fluid  Placenta  Uterus & adnexal structures

Third Trimester Scan
► Comment

 Generally targeted scan
► Content

 Depend on indication





& adnexa

► Know

what’s the reason ► Know the machine capability and limitation

► Comfortable

position for both sonographer and patient

•Adequate exposure

► Orientation

 Screen menu  Image orientation

scan: as if from the left side of patient ►Transverse scan: as if from the foot of the patient

agreed orientation for the display of TVS

►General overview  Number of fetus  Presentation & lie  Attitude  Liquor  Placenta

of the fetus

► Show

to the patient (esp the viability)

► Gestational

Sac (GS)

 May require full bladder (displace bowel, providing acoustic window, place the axis of uterus parallel to the anterior abdominal wall)  But may distort the GS and push the uterus away  Retroverted uterus may require TVS  Uterus and adnexal overview : longitudinal sweep then transverse

    Visible from 5 to 6 weeks POA Shape: uniform round or oval Rim of chorionic decidual reaction Measurements:
Diameter 2. Volume

- Accuracy of sac vol: + 1 week

Volume : GSV (ml3) = L (cm) X AP (cm) X T (cm) X 0.5

► GS

 Shape distortion, angulation and irregular margin may indicate missed abortion  Abortion may show choriodecidual haemorrhage


 First described by Robinson in 1975  Most accurate mean of estimating gest age  But depends on the ability to obtain a treu longitudinal section of unflexed embryo with end points clearly seen

► Spine

can be visualised from 9 weeks onward; a guide to obtain the true longitudinal view ► Maybe difficult to obtain after 10 weeks – fetus often curved


 The maximum diameter of the skull at the level of parietal eminences.  Correct section:

shape head ►Short midline in the anterior half of the head ►Cavum septum pellucidum

 Measurement: from the outer table of the proximal surface of the skull to the inner table of the distal surface

 Problems:

: may lead to underestimation (in dolicocephalic shape); due to maternal breathing movements and pressure from transducer ►OP/OA : landmarks may not be visualised clearly - press to rotate the fetal head or tilt the patient head down

► HC

 Not a routine  Same plane as BPD  Measure the outer circumference of the skull

• AC •The best parameter reflecting fetal size and growth • Taken at the level of liver; 4% of body weight and increases steadily with gest age
 Content:
►Liver ►Stomach ►Intrahepatic


potion of umbilical vein (anterior third of the AC)

► FL

 Highly reproducible because of the precisely defined end points  Both ends should be visualised  Measurements made from the centre o the Ushape at the ends of the bone (length of diaphysis)

1. Amniotic fluid index 2. Single quadrant measurement


    

Measurements of 4 quadrants Pools of free liquor Perpendicular to maternal sagital plane Normal range = depend on gestational age At term

olighydramnios ►> 20 polyhydramnios

► Single

pocket measurement

   

Largest pocket of liquor Measurements of 2 perpendicular plane Oligohydramnios = <2 cm Polyhydramnios = > 8 cm

► Anatomy


 Detailed morphology scan is best done 18-22 weeks gestation  Screening or confirmatory  Case selected on risk factors (age, previous history, teratogen exposure etc)

► Systematic


     

Number of fetus Presentation Fetal activity liquor volume Placental site Number of cord vessels

► Begin

with the head, progressing caudally to the thorax, abdomen, urogenital system and spino-skeletal system ► A checklist may be required ► Examination in 3 basic planes
 Coronal  Sagital  Axial

► Head

 Cranial vault  Intracranial contents  Soft tissue of the face

► Thorax

 Heart

chamber view ►A third of thorax ►Both chambers of equal sizes

 Lungs

lobe bigger than the left ►Left lobe behind the heart

► Abdomen

 Liver occupies the upper third  Prior to the junction with the portal vein, umbilical vein will take a J-shaped turn (AC measurement)

► Genitourinary

 Kidneys

lateral to the spine ►Below the level of AC

 Bladder

mass at the centre of pelvis ►Umbilical artery on both side

► Spine

 Observed in 3 basic planes  Completeness should be examined
► Limbs

and digit

► Placenta

 Low lying placenta detected in second trimester should have a repeat scan at 32-34 weeks gestation  Marginal placenta may require TVS  Lower segment = 5 cm from internal os

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