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

screen

transducer

console

printer

 Four

different modes of ultrasound are used in medical imaging

A-mode
a

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

B-mode
a

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

 M-Mode
M

stands for motion

 Doppler mode
capability

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
Head

& neck Thorax Abdomen Axial skelelton

 Amniotic fluid Placenta Uterus & adnexal structures

Third Trimester Scan

Comment

Generally targeted scan

Content

Depend on indication
Anatomy

Growth/Doppler/BPP
Amniotic

fluid

Presentation

Placenta
Uterus

& adnexa

Technique
Know

whats the reason Know the machine capability and limitation

 Comfortable

position for both sonographer and patient

Adequate exposure

Technique
Orientation

Screen menu Image orientation

Longitudinal

scan: as if from the left side of patient Transverse scan: as if from the foot of the patient
No

agreed orientation for the display of TVS

General overview Number of fetus Presentation & lie Attitude Liquor Placenta

of the fetus

Technique
Show

to the patient (esp the viability)

Measurements
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

GS
Visible from 5 to 6 weeks POA Shape: uniform round or oval Rim of chorionic decidual reaction Measurements:
Diameter 2. Volume
1.

- 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

Measurements
CRL

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

 BPD

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

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:
Breech/transverse

: 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

bubble

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)

Liquor
1. Amniotic fluid index 2. Single quadrant measurement

 AFI

Measurements of 4 quadrants Pools of free liquor Perpendicular to maternal sagital plane Normal range = depend on gestational age At term
<8

olighydramnios > 20 polyhydramnios

 Single

pocket measurement

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

 Anatomy

scan

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

appropach

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
4

chamber view A third of thorax Both chambers of equal sizes

 Lungs
Right

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
Seen

lateral to the spine Below the level of AC

Bladder
Cyctic

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