Principles and Applications of

Ultrasound to Obstetrics

Honor M. Wolfe

What is the accuracy of

ultrasound in the assessment
of gestational age?

GA Assessment

Accuracy 1/Gestational Age

Gestational age accuracy

1st trimester + 1 week

2nd trimester + 2 weeks
3rd trimester + 3 weeks

First Trimester: CRL

5-12 weeks gestation
< 10 wks + 3-5 days
> 10 wks
less accurate
variable position/flexion
5-7 days
6

2nd and 3rd trimester

Accuracy of GA estimates increases as more
variables are measured.
- Composite estimate of:
Biparietal diameter
Head circumference
Femur length
Abdominal circumference
7

Does maternal BMI impact

ultrasound and if so how and
why?

Physics
High frequency sound waves
> 20,000 cycles/second

Frequency
Number of waves per unit time
Expressed as hertz (Hz)

Diagnostic ultrasound
2-10 million Hz (2-10 MHz)

Physics
Frequency

Inversely proportional to penetration

Directly proportional to resolution

Probes

Transabdominal 3.5, 5, 7 mHz

Transvaginal
8-9 mHz

10

Sound waves
- Transducer both sends and
receives
- Reflected by emitting transducer
- Image displayed as:
1. Brightness - intensity of echo
2. Time lag - distance

11

Ultrasound and BMI

Heavier patients
Need more penetration (lower mHz)
Get less resolution (lower mHz)

12

What are the types of US who

gets what type of scan?

13

Basic Ultrasound
Examination

Fetal number/presentation/life
Placental location
Assessment of AFV
Assessment of gestational age
Survey for gross malformations
Evaluation for maternal pelvic masses

Metric examination
Screening
14

Limited Ultrasound
Assessment of AFV, BPP
Guidance for
Amniocentesis
External cephalic version

Confirmation of fetal death

Placental localization (hemorrhage)
Fetal presentation
15

Comprehensive Ultrasound
Indications
Suspicion of anomalous fetus
History
Clinical evaluation
Previous ultrasound

Detailed assessment of fetal anatomy

Color/power doppler
Arterial/venous doppler
16

What type of anomalies is this

patient at risk for and how good is
ultrasound at finding them?

17

How good is ultrasound at

finding anomalies?
It depends on:
The anomaly
Minor anomalies, heart anomalies hardest
When we look
When apparent, 20 24 wks optimal for most
Who we are looking at
Thinner, normal amniotic fluid volume
And.
Who is looking.
18

Detection
Directly proportional to severity of anomaly
- 89% lethal anomalies
- 77% requiring NICU admission
- 30% minor anomalies

19

Lowest rates
Cardiovascular defects
Cleft up / palate
Microcephalus

20

Types of Ultrasound
what might be missed?

Basic (76805)
Measurements, AFI,
placenta
Head
Heart (not color)
Abdomen

Comprehensi
ve (76811)
Face, profile
Extremities
Heart
Color doppler
Extremities

21

22

23

24

25

26

27

28

What about antenatal testing?

29

Table 43-1. COMPONENTS AND THEIR SCORES OF THE BIOPHYSICAL PROFILE

Variable

Score 2

Score 0

Fetal breathing
movements

The presence of at least 30 sec of sustained fetal

breathing movements in 30 min of observation

Less than 30 sec of fetal breathing

movements in 30 min

Fetal movements

Three or more gross body movements in 30 min of

observation: simultaneous limb and trunk movements

Two or less gross body movement

in 30 min of observation

Fetal tone

At least one episode of motion of a limb from position

Fetus in position of semi- or
of flexion to extension and rapid return to flexion S
full-limb extension with no return
or slow return to flexion with
movement; absence of fetal
movement counted as absent tone.

Fetal reactivity

Two or more fetal heart rate accelerations of least

15 beats/min and lasting at least 15 sec and associated
with fetal movement in 20 min

No acceleration or less than

two accelerations of fetal
heart rate in 20 min of
observation

Pocket of amnionic fluid that measures at least 1 cm

in two perpendicular planes

Largest pocket of amnionic fluid

measures< 1 cm in two
perpendicular planes

Qualitative amnionic
fluid volume

From Manning and colleagues (1985), with permission.

30

31

How well do we estimate fetal

weight?

32

Estimated Fetal Weight

Various formulas
All involve the abdominal circumference
Also Femur length, head circumference and/or
BPD

Less Accurate in bigger babies (> 4000

grams)
Accuracy + 10 15%
Term harder to get measurements
Fetal position AFI
33

 Figure 1 (No legend p 524 OB Gyn 1999:

93: 523-6) put in author and year

34

RED CELL
ALLOIMMUNIZATION
Frequency of Irregular
Antibodies
%

Kell

Duffy

MNS

Kidd

Queenan et al. Obstet Gynecol 1969; 34: 767-70

Geifman-Holtzman et al. Obstet Gynecol 1997; 89: 272-5

Lutheran

35

ACOG recommends
antenatal RHIG

ACOG recommends
antenatal RHIG

36

RED CELL
ALLOIMMUNIZATION
Rhesus Prophylaxis
66% of Rhesus cases
antepartum sensitization
13% of cases inadvertent
omission of RhIG
Hughes et al. Brit J Obstet Gynaecol 1994; 101:297-300
37

RED CELL
ALLOIMMUNIZATION
New Onset RhD Sensitization
Follow maternal titers every 2 - 4
weeks until critical value
reached (32 at UNC)
Determine paternal genotype for
involved antigen
38

RED CELL
ALLOIMMUNIZATION
New Onset RhD Sensitization

Paternal genotype = heterozygous

(55%); do amniocentesis for fetal
blood typing
Paternal genotype = homozygous
(45%) or affected fetus by
amniocentesis DNA testing; begin
serial amniocenteses for OD450
testing

39

RED CELL
ALLOIMMUNIZATION
Previous RhD Sensitization
History of previous IUFD,
intrauterine transfusions or
neonatal exchange
transfusions
Maternal titers not helpful
40