IMAGING IN FIRST TRIMESTER

Presenter: Dr. QURESHI

Facilitator: Dr. MUTALA

OUTLINE
• 1.Introduction
• 2.Embryology
• 3.Formation of organs/systems
• 4.Role of first trimester sonography
• 5.Sonographic evaluation in 1st trimester
• 6.Anomalies in 1st trimester
• 7.Multiple gestation
1.INTRODUCTION
• Pregnancy is divided into three trimesters The first trimester of
pregnancy is the first 12 weeks after the first day of the last
menstrual period.

• The first trimester of pregnancy is a period of rapid growth and

change that spans
Fertilization, blastocyst formation, implantation, gastrulation,
neurulation, the embryonic period and early fetal life.

• The imaging method of choice is ultrasound .

TVS (8-12Mhz) demonstrates superior resolution in comparison
to TAS (3-5Mhz) in earlier visualization of the gestational sac ,
its contents and embryonic cardiac activity.
 2.EMBRYOLOGY
Pre-ovulation 1-2 wks Follicular maturation & Ovulation

Conceptus 3-5 wks Fertilization/zygot

Morula
Blastocyte
Implantation
Flat embryo

Embryonic 6-10 wks C-shaped embryo

Major organs develop

Fetal 11-12 wks Growth

 Follicular maturation & ovulations

• The pituitary gland secretes

-Follicle stimulating hormone (FSH)
-Luteinizing hormone (LH)

• Enlargement and proliferation of multiple

primary ovarian follicles

• The dominant follicle produces an estrogen

surge 4 days before ovulation
• Ovulation occurs at approximately day 14 of the menstrual cycle
with expulsion of a secondary oocyte

• Corpus luteum secretes progesterone and to a lesser

degree estrogen.

• If no pregnancy- corpus luteum involutes

• In Pregnancy- luteal involution prevented by HCG secreted by

the syncytiotrophoblast
(the outer layer of cells of the gestational sac)
• Day 14 –fertilization &
formation of zygot(union
of mature ovum & sperm).

• Day 18-morula (16 cell

stage) enters into uterus

• Day 20-blastocyst implants

• Implantation site
uterine fundus
most often on the
ipsilateral side of
ovulating ovary.
Decidual reaction
In pregnancy,production of progesterone results in
hypertrophic changes in the endometrial cells & glands to
provide nourishment to the Blastocyst.

Occurs as a hormonal response regardless the pregnancy

is intrauterine or ectopic
• Day 23-implantation completes
• B-hCG becomes positive shortly after implantation

Primary yolk sac forms

The conceptus cannot be imaged Transabdominally or

Transvaginally ,the entire conceptus size 0.1 mm.

• Day 27-28
Secondary yolk sac forms (GSD is 3mm)

& it’s the secondary yolk sac that is visualized by ultrasound

• Vascularization of placenta begins from 5th wks

• Gastrulation during 5th wks.(formation of 3 germ layers).

• Neurulation begins in 5th wks.(formaiom of neural plate & its closure to form
neural tube)
• Embryonic period(6-10 wks, essentialy all internal & external structres are
present in the adult form). Nearly all congenital malformations occur before or
during the embryonic period.

• Fetal period(wks 11-12) early in the fetal period body growth is rapid and head
growth is relatively slower .
Crown rump length doubles between week 11 -14.
3.Formation of organs/systems
• Cardiovascular

week 5 paired cardiac tubes form and begin

pumping by the end of the week

week 8 heart has a definite form

week 10 the peripheral vascular system is

complete
• GIT
week 6 primitive gut forms
week 8-12 midgut herniation into the base of
the umbilical cord
week 8 rectum separates from the urogenital
sinus
week 10 anal membrane perforates

• Kidneys
week 8 primitive kidneys ascend from the pelvis
week 11 kidneys in adult position
• Genitalia
week 10 external genitalia sexless
week 14 external genitalia mature fetal form

• CNS
week 6 primary brain vesicles form
week 9 third and lateral ventricles identified

• Musculoskeletal
week 5 limb buds form
week 9 upper limbs are bent at the elbow
& fingers are distinct
4.Role of 1st trimaster pregnancy
The role of imaging in first trimester is to

 Confirm an intrauterine pregnancy

 Date the pregnancy
 Determine fetal number
 Evaluate for ectopic pregnancy
 Assess viability
 Evaluate for and answer the clinical indication.
Indications of u/s in first trimaster

ACR GUIDELINES
5.Sonographic evaluation in first trimester
• GESTATIONAL SAC

• YOLK SAC

• EMBRYO

• AMNION

• MENSTRUAL AGE
 Gestational sac
1.Presence of GS
Approach
TVS detection - 4.5 - 5 weeks menstrual age
TAS detection - 5 weeks
SITES
UTERUS,CERVIX,ADNEXAE

GS should be identified at HCG level >1000-2000 mIU/ml.

Located mid to upper uterus
Regular shape
round to oval
Echogenic rim > 2 mm
Grows approx 1.1 mm / day
-
Intradecidual sac sign.

• Visualization of the gestational sac within the

thickened decidua.

• It is the first sonographic evidence of pregnancy

seen.

• Focal echogenic thickening at the site of

implantation within the decidua may also be seen.
Intradecidual sac sign

Gestaional sac at 4wks 5 days MA 6 days later….. Normal sac growth

Focal endometrial thickening at implantation site – 4 weeks MA
 Double decidual sac sign
 Based on visualization of GS as an echogenic ring formed by the decidua
capsularis and chorion leave eccentrically located within the dcidua vera,
forming two echogenic ring.

• Inner ring

Chorion frondosum(future placenta)

decidua basalis
chorion laeve
decidua capsularis

• Outer ring

decidua vera.
 Double decidual sac sign
dv

Double
decidual ring
should always
be present
when MSD is
>10mm

TVS at 8
weeks MA

DDSS differentiates the decidual cast of an ectopic

pregnancy from an intrauterine pregnancy
Pseudogestational sac

• The DDS must be distinguished from PGS of

ectopic pregnancy.

• PGS an intrauterine fluid collection surrounded

by single decidual layer.

A large pseudogestational sac of an

ectopic pregnancy
Endometrial Trophoblastic flow
-Low resistance waveform
 2.Size of GS TVS . LARGE EMPTY SAC

• Accuracy 1 week of menstrual

age

• Mean sac diameter (MSD)

Three orthogonal dimensions of the

fluid sac wall interface.
CORONAL

Most acccurate by TVS in the sagittal

and transverse planes at right angles
to one another.

• Abnormal GS size is the most

reliable indicator of
abnormal outcome based on
GS characteristics.

SAG
3.Other gestational sac criteria
for poor outcome.

• shape
distorted sac shape

• position
abnormally low position
within the endometrial
cavity.

• trophoblast-
thin weakly echogenic,
trophoblastic reaction.
(<2mm)
 YOLK SAC
• The first structure to be detected within the gestational sac.

• Its identification is diagnostic of an intrauterine pregnancy

• Help in the diagnosis of embryonic demise & increased risk

of fetal abnormality

• YS grows at a rate of 0.1mm per milimeter of GSD when MSD is

<15mm, then slows to 0.03mm per mm.

• Yolk sac maximum diameter is 5.6 mm between 5-10 weeks

menstrual age.
 Role:
1.Transfer of nutrients to the embryo while placental circulation forms.

2.Angiogenesis occurs in the wall of YS in 5th wks.The vascular network

eventually joins fetal circulation via vitelline arteries & veins

3.Haematopoiesis occurs in the wall of the YS in the 5th week before the liver
takes over in the 8th week & later in spleen,bone marrow,lymph nodes.

4. The dorsal part of the yolk sac is incorporated into the embryo as primitive gut
in the 6th week and remains connected to the midgut by a stalk called the
vitelline duct

•
 1.Presence of YS

• TAS detection – at GSD 16mm

should always be visualized at GSD 20mm.

• TVS detection- allows earlier visualization

-at GSD of 8mm
-B-HCG > 7,200
• Nonvisualization of the yolk sac is abnormal.

• Nonvisualization of the yolk sac in the presence of an embryo

by TVS is associated with embryonic demise in 100% of
patients .
Normal Yolk sac at 9 weeks
TAS.MSD>16mm-yolk sac present TVS.MSD >8mm-yolk sac present
 2.Size of YS
• An abnormally small or large yolk sac is often the first sonographic indicator of an
abnormal outcome.
(AT 8-12 wks < 2mm , AT 5-10 wks > 5.6mm in singleton pregnancy)

• It is invariably associated with subsequent embryonic demise.

• If the pregnancy survives the 1st trimester , the fetus may still
be abnormal.

• Fetal pathologic states associated with a large yolk sac are

chromosomal abnormalities such as trisomy 21 & partial molar pregnancy.

omphalocele.
TVS
TAS

An abnormally large yolk sac . Max diameter 5.6mm between 5-10 weeks
3. Shape of YS

This is not predictive of outcome!

whereas size is always

predictive.
 4.YOLK SAC CALCIFICATION

• A calcified yolk sac appears as a shadowing echogenic

mass in the absence of any other yolk sac.

• Only seen with a dead embryo and may calcify 36 hrs after
demise.

• Should be differentiated with an echogenic yolk sac which is

associated with a live embryo. TVS SAG
5. Vascularity of YS

The vitelline arteries and or veins are seen on the periphery

of the yolk sac .
7th-8th week.

Spectral doppler confirms color doppler

Typical waveform
low velocity with no diastolic flow.
6.Number of YS
The number of yolk sacs is helpful in determining amnionicity of the pregnancy.

Number of yolk sacs = number of amniotic sacs if the embryos are alive.

Therefore in a dichorionic diamniotic twin gestation there will be 2 embryos 2

amniotic sacs and 2 yolk sac.

Dichorionic diamniotic twin gestation at 5

weeks
The Embryo
Fetal pole
• Focal thickening along yolk sac
• CRL grows approx 1 mm/day
• Should be seen when:
TVS MSD 16 mm
TASMSD 25 mm

B-HCG > 10,800

Cardiac activity
Embryonic cardiac activity is the most important criteria
for the confirmation of embryonic and fetal life

- TVS at 6 weeks
- TAS at 6.5 weeks

TAS - cardiac activity is always present when the embryo is

visualized.

It is abnormal to visualize an embryo without cardiac activity

TVS - a normal embryo can be detected without cardiac activity.

• Cardiac activity seen sometimes before fetal pole

• Absence of cardiac activity may be normal if CRL <3mm

• Should be seen when:

CRL > 5-6 mm
MSD > 18 mm
B-HCG > 12,000

• HR varies with gestational age:

5-6 wks 90 -115 bpm
8 wks 144 -159 bpm
> 9 wks 137 -144 bpm
 Embryonic heartbeat at 6 weeks

Embryonic bradycardia, an abnormally slow heart rate may indicate an

impending demise

Heart rate of <110 bpm indicates poor prognosis

<100 indicates abnormal outcome
Embryonic bradycardia 69 bpm at 6wks
1 week later. . . . . . . . This embryo died
 The Amnion
• Barely visible at 6 weeks. The actual rate of growth is more rapid
after the 9th week when fetal urine is produced

• The amniotic fluid accumulates at a rate of 5cc per day.

• The amniotic cavity expands to fill the chorionic cavity by 14-16th

wks. & fuses with chorion approx 17 weeks

• Occasionally these membranes may fail to fuse.

• Iatrogenic or spontaneous rupture may occur and lead to the

amniotic Band sequence.(retraction of the amnion in part or in
whole ,upto the base of the umblical cord).
The Double Bleb sign is the earliest demonstration of
the amnion.

The two blebs represent the amniotic sac and the yolk sac.

Can be identified as early as by at 5.5 weeks (CRL 2mm).

DBS.Normal separation of amnion and chorionic sacs at 9
weeks MA
•Visualization of the amnion
in the absence of an embryo
(after 7 weeks menstrual age)
usually occurs in:
intrauterine embryonic
death with resorption of
the embryo or anembryonic
gestation

•A collapsing irregularly
marginated amnion may be
indicative of embryonic demise.

Abnormal conceptus
 Menstrual age estimation
• Gestational age is defined as the time elapsed since 14 days prior
to conception. This is approximately the duration since the
woman's last menstrual period (LMP) began.

• Menstrual age or Gestational age can be counted as follows.

Gestational age=conceptional age + 2 weeks

• In women with regular 28 day cycles conception occurs 2weeks after the
LMP therefore in such women gestational age and menstrual age are the
same.

• The first trimester is the most accurate time to estimate menstrual age.
• A single first trimester ultrasound solely for menstrual
age estimation is not recommended as there is
inadequate embryonic development to identify
congenital malformations.

• Parameters used

a.Gestational sac size MSD

b.Crown- rump length CRL

c.Biparietal diameter BPD

a.Gestational sac size

This is useful before visualization of the embryo

However, the pregnancy must be followed until the

visualization of the embryonic pole with cardiac activity.

Its accuracy is to within 1 week of menstrual age

Measure Length + width + height divided by 3

Echogenic rim is not included in measurement
b. Crown –Rump length

• If well performed this is

equivalent to BPD
measured in early 2nd
trimester.

by TVS 5th week

TAS 6th week
 c.Biparietal diameter

• By the end of the first trimester the BPD becomes

more accurate than the CRL.

• CRL at this time reflects errors associated with

fetal flexion and extension.

• Late in the 1st trimester the BPD remains highly

accurate when used alone.
6. Anomalies in first trimester
• a. Embryonic demise
• b. Subchorionic haemorrhage
• c. Anembryonic pregnancy
• d. Abortion
• e.Ectopic pregnancy
• f. Congenital anomalies
• g.Gestational Trophoblastic diseases
• h. Masses – Ovarian masses
- Uterine masses
Common causes of early demise / pregnancy failure

• Congenital anomalies

• Luteal phase defect

Failure of the corpus luteum to support the
conceptus once implantation has occurred.

1. shortened luteal phase in ovulation induction

2. luteal dysfunction
obese women or
women over 37 years of age.
Eembryonic demise or a failing pregnancy
1. Definite demise

• TVS-Absence of cardiac activity at gestation of 6.5 weeks or

more
• CRL of 5mm or more

(repeat the scan after 3 days for confirmation)

2.Probably failing pregnancy

• MSD of 8mm or more without a yolk sac

• MSD of 16mm or more without an embryo

3.Moderately high risk of demise

• bradycardia of 80-90 bpm

• large subchorionic haematoma
• yolk sac of >6mm
• Low level of hCG
4.High risk of demise

• Severe bradycardia <80 bpm

• MSD growth rate < 0.7 mm/day fHR

50bpm

• Difference between MSD and

CRL of less than 5mm is
predictive of a miscarriage rate in 94%
(i.e.,MSD-CRL=< 5mm)
b.Subchorionic Haemorrhage
• Separation of the chorionic membrane from the
decidua with accumulation of blood in the subchorionic
space.

• Incidence: 18% of all causes of 1st trimester bleeding

• Prognosis : 9% overall miscarriage rate

prognosis worsens with: -increased maternal age

-earlier gestational age
-size of the haematoma
(most important criterion)
• Acute haemorrhage

hyperechoic or isoechoic

to the placenta

sonoluscent
in 1-2weeks

• Chorionic membrane stripped

from the endometrium
elevated by the haematoma

• Risk of fetal demise doubles once the haematoma reaches 2/3 of the
circumference of the chorion.
c.Anembryonic pregnancy
• Also called blighted ovum.
• It may occur as a blighted twin.

US
• yolk sac identified without an embryo

• empty gestational sac more than 6-8 weeks Menstrual age

• gestational sac small, appropriate or large for dates

• lack of growth or decrease in size on serial scans

Complications:
1st trimester bleeding
GS without an embryo
d.Abortion
Definition:

• A miscarriage, or spontaneous abortion, is a pregnancy loss at less than 20 weeks

of gestational age or less than 500 grams.

• A miscarriage is a broad term that can refer to a complete abortion, incomplete,

inevitable, or missed. If there are retained products of conception this can refer to
parts of the fetus, the placenta, or the membranes.

Pathogenesis:

• Hemorrhage into the decidua basalis and necrotic changes in the tissues adjacent to
the bleed.

• The conceptus becomes detached stimulates uterine contractions resulting in

expulsion.
 TYPES
1. Threatened abortion
2. Inevitable abortion
3. Incomplete abortion
4. Complete abortion
5. Missed abortion
Threatened abortion

• Is first trimester bleeding with a live fetus

• Incidence: 20-25% of all pregnancies

50% survival.
• Clinically
mild bleeding
cramping
closed cervix
• Differentials
extrauterine pregnancy
torted ovarian cyst
THREATENED ABORTION
Inevitable abortion
• Gestational sac with fetus detached from the implantation site.
Spontaneous abortion occurs in the next few hours.

• Clinically
- Bleeding for >7days
- Dilated cervix
- Rupture of membranes
• US
- GS in cervix or LUS
- Cervical dilatation
- Sonolucent crescent around GS (anechoic blood)
Inevitable abortion
Incomplete abortion
• Retained products of conception
Overall US accuracy is 96%
• Clinically
-Slow fall or plateau of HCG levels
-Moderate cramping
- Persistent, heavy bleeding after event

• US
- Complex echo pattern within endometrial cavity

- Bright echoes = air bubble, bony fragments

- Persistent trophoblastic Doppler after 5 days

Retained products of conception
Complete Abortion
• Complete evacuation of all products of conception

• US
- Cervix closed

- Thin regular endometrium

- Moderate to bright endometrial

echoes.

- Doppler + ve upto 3 days

post event.
Missed Abortion

• Retention of dead products of conception within the

uterine cavity for several weeks

• US

- A well defined embryo with no cardiac or limb activity

- Gestation sac >20mm with no yolk sac, >25mm no
embryo
- Acoustic shadowing from complex endometrium
- Fetal size < expected
- Uterine size < expected
- Closed cervix
Missed abortion

ACOUSTIC SHADOW FROM AN ECHOGENIC ENDOMRTRIUM

e.Ectopic Pregnancy
• Implantation outside the endometrial cavity

• It accounts for 15 % of maternal deaths.

• Presentation
classical clinical triad (45% of patients)
1. pain
2. abnormal vaginal bleeding
3. palpable adnexal mass

other, cervical motion tenderness

Risk factors
• any tubal abnormality that may prevent passaage of zygote.
• previous tubal pregnancy
• previuos C-section
• pelvic inflammatory disease
• intrauterine contraceptive device
• previous tubal reconstructive surgery
• maternal factors: increased age & parity
• endometriosis
• ovulation induction, in vitro fertilization and embryo transfer
(ectopic and heterotopic gestation)
• Site

Tubal (95%)
Ampulla (75-80%)
Isthmus (10-15%)
Fimbrial (5%)
Interstitial (2-4%)

Other (5%)
Ovarian (0.5-1%)
Cervical (0.15%)
Abdominal
Interligamentary
 Sonographic features
Uterus

- Absence of an intrauterine pregnancy >6wks

- Slight thickening of the endometrium

- Hyperechoic endometrial thickening due to hormonal

stimulation(50%)
• Decidual cyst
1-5mm cyst at the junction of the endometrium and
myometrium (14%)

• Pseudogestational sac
a single parietal decidual layer surrounding an
anechoic fluid collection due to bleeding (10-20%)

• Decidual endometrium lacks low impedance flow

Pouch of Douglas

• Free fluid (40-83%)

• echogenic particulate fluid due to haemoperitoneum

• 93%positive predictive value

Ddx

• Anechoic fluid in 10-27% of intrauterine pregnancy

 Adnexal ectopic
• solid complex adnexal mass
extrauterine gestational sac without a live embryo or yolk sac

• Embryonic heartbeat(6-28%) pathognomonic

• Echogenic tubal mass (89-100%)

varying flow pattern depending on viability

• Corpus luteum of the ovary(50%)

on the side of the ectopic pregnancy
Right adnexa with possibly an irregular sac and blood flow- haemorrhagic ectopic mass
Interstitial / Cornual ectopic
• Eccentric location in relation to the endometrium and close to uterine serosa

Interstitial line sign

• ecogenic line extending from endometrial canal up to the center of the
interstitial sac or hemorrhagic mass ,seen in 92% of interstitial ectopic.

Features
- Rupture late due to greater myometrial distensibility
- High likelihood of catastrophic hemorrhage due to abundant supply of both
ovarian and uterine arteries.
-Two fold mortality compared with other ectopics
Cornual Ectopic Pregnancy
 Abdominal ectopic

• Incidence 1:6000

• Clinical features
-Bloating
-Abdominal pain(fetal movement, peritoneal
- Irritation due to adhesions)
- Bleeding,hypotension and shock

• Complications
-Bowel obstruction or perforation
- Erosion of the pregnancy through the abdominal wall.
RUQ – Echogenic blood in the hepatorenal space
Heterotopic pregnancy
(Concurrent intrauterine and
ectopic pregnancies)

Suspected in patients
undergoing ovalutary induction
or IVF.
In IVF the rate can be upto 1%

Heterotopic pregnancy
Doppler Ultrasound

• High velocity low impedance flow around extrauterine

gestation (54%)

• Resistive index 0.18-0.58

• Absence of peritrophoblastic flow after 36 days

• Ddx of low impedance flow:-

-Corpus luteum cyst
-Fibroid
-Tubo ovarian abscess
Differential diagnosis of ectopic pregnancy
- Haemorrhagic corpus luteum hematoma
- Adnexal mass- hydrosalpinx, endometrioma,ovarian cyst
- Fluid containing small bowel loop
- Eccentrically placed gestational sac in retroflexed,
bicornuate or fibroid uterus
f.Congenital Anomalies
• Nuchal translucency
- Sonoluscent area in the region of the neck typically

-observed in the first trimester between 10 -14 weeks.

• Mechanism:

-Uncertain, thought to be a variation of the normal

development of the lymphatic system in the fetal
cervical spine.
Associations. . . .

• Normal Variant in 0.06 %

• chromosomal abnormalities
trisomies 21 ,18 and 13.
• 30-40% of fetuses with Downs
syndrome have
nuchal skin thickening

• cardiac septal defects in both

karyotype normal and
abnormal fetuses.

• Septations within nuchal

translucency carry
a 20-200 fold risk of
chromosomal anomalies
Nuchal Translucency
Measurement :

Sagittal plane

increases with gestational

age.

3mm or more is
abnormal
Nuchal thickening
Measurement:

Axial plane

Through the thalami the cerebellum

and the occipital bone

Outer skull table to the skin surface.

It increases with gestational age.

6mm or more is abnormal

g.Gestational Trophoblastic Disease
These are disorders characterised by abnormal proliferation of
pregnancy related trophoblasts with progressive malignant
potential.
1. Molar Pregnancy
- Complete Molar pregnancy
- Partial Molar pregnancy
2. Persistent Trophoblastic Neoplasia
- Invasive mole
- Choriocarcinoma
- Placental-site Trophoblastic tumor
Complete molar pregnancy

• The placenta is entirely replaced by hydropic chorionic

villi with excessive trophoblastic proliferation

• US
Enlarged uterus with echogenic tissue expanding the endometrial
canal with uniformly distributed cystic spaces.
1st trim – solid echogenic mass TVS>TAS due to small villi
2nd trim – TAS enough
TAS.COMPLETE MOLAR PREGNANCY

TVS

COMPLETE MOLE WITH FETUS

 Partial molar pregnancy

• Normal placental villi mixed with focal hydropic degeneration

Mild trophoblastic proliferation
• US
- Large placenta with numerous cystic spaces
- gestational sac present but deformed
- Growth retarded fetus with anomalies of triploidy

• Commonly mistaken for a missed or an incomplete abortion.

TAS. PARTIAL MOLE

TVS.LARGE ABNORMAL PLACENTA

h.Masses-Uterine masses
Fibroids

• Common pelvic masses identified in pregnancy.

• Most do not change in size during the pregnancy,
some may enlarge rapidly due to stimulation by
oestrogen .

• Infarction and necrosis may occur due to this rapid growth

resulting in pain which may be severe.
 Masses-Ovarian masses
• Corpus luteum cyst
is the most common mass seen in the first trimester.
secretes progesterone to maintain the pregnancy until the
placenta takes over

• features in pregnancy:
<5cm in size, thin walled & unilocular
by 16-18 weeks have regress

• Complications of ovarian cystic masses associated with

pregnancy are:
Torsion, Rupture and dystocia.
Complicated luteal cyst with haemorrhage
 7.Multiple Gestation
• Multifetal pregnancies are high risk pregnancies that
require increased surveillance in the ante partum
period.

• They carry a 12% incidence of perinatal deaths.

• Determination of chorionicity and amnionicity in the

first trimester comparatively easier than subsequent
trimester.
1. Dizygotic twins or fraternal twins

• Arise from fertilization of two sperm and two ova

• The two zygotes develop into blastocysts that implant

separately each forming an embryo with its own
amnion, chorion and yolk sac i.e dichorionic diamniotic

• For spontaneous conception,diazogatic twins are more

common than monozygotic twins, at a 70:30 ratio.
Factors increasing frequency of dizygotic twins are:

• maternal age and parity

• ethnicity

• heredity

• ovulation induction agents

• endogenous gonadotrophin

• assisted reproductive technology

• maternal height and weight

2.Monozygotic twins or identical twins

• Arise from fertilization of one sperm and one ovum into one
zygote which then undergoes cleavage to result in twins.

• Chorionicity and amnionicity depends on the stage at which

division occurs

• The placentas in monochorionic twin pregnancies have

vascular anastomoses between the circulation of the two
fetuses in 85-100%. These may be artery-artery, artery-vein or
vein-vein.
Early cleavage
Before 4 day after
fertilization

Late cleavage
b/w 4-8 days after
fertilization

Cleavage after
8 days
Of fertilization
 SONOGRAPHIC FEATURES
1.Intertwin membrane

• Identify a membrane separating the fetuses

• Nonvisualization occurs in 10% of diamniotic twins

• Absence may mean.

monochorionic monoamniotic twins

or

stuck twin syndrome

where the intertwin membrane is closely applied to the

smaller twin which has severe oligohydramnios and
restricted movement.
Monochorionic monoamniotic twin gestation
2. Membrane Thickness

• Useful prior to 22 weeks gestation

• The thickness of 2 opposing amniotic layers in MC/DA is

much less than that of 2 layers of chorion and amnion in the
intertwin membrane of DC/DA twins.
 3. Chorionic or twin peak sign

• Extension of placental villi into the potential interchorionic

space at the site where the placenta abuts the chorion of
its own twin.

• Cannot occur in a monochorionic twin because the single

chorion serves as a barrier to the growth of the placental
villi into the intertwin membrane.

• Diagnostic of a dichorionic diamniotic twin pregnancy

The chorionic peak sign is a projection of tissue of similar appearance or
echogenicity to the placenta extending into the intertwin membrane
4. Umbilical cord

Cords followed to a
common tangle
indicate
monochorionic
monoamniotic
twin pregnancy

5. Fetal sex determination

The identification of
different sexes is a clear
indicator of dizygotic
twinning.
 REFRENCES
1.DIAGNOSTIC ULTASOUND. BY CARLOL M. RUMACK 4TH EDITION.

2.STEP BY STEP. ULTRASOUND IN OBSTETRIC BY KULDEEP SING 2ND EDITION.

3.HUMAN EMBRYOLOGY BY KEITH & MOORE 7TH EDITION

4.IMAGING CONSULT INTERNET SITE.

THANK YOU