FETAL IMAGING

ISUOG
• The International Society of Ultrasound in
Obstetric and Gynecology
SECOND TRIMESTER ULTRASOUND
Mid trimester fetal ultrasound scan

• Determine gestational age

• perform fetal measurements
• detect congenital malformations
• Identify multiple pregnancies
 Who should have one:
• Everyone!
When should the scan be performed?
• 18-22 weeks
• EARLIER??
• LATER??
 Who should perform this scan?
• Individuals who have specialized training
• Local legal requirements
 Safety
The ALARA principle or ”As Low As Reasonably
Achievable”

• no confirmed damaging biological effects in

mammalian tissue
• no fetal harm has been demonstrated in more
than 30 years of use
 Components of Standard Ultrasound Examination by Trimester

FIRST TRIMESTER SECOND AND THIRD TRIMESTER

Gestational sac location
Embryo or yolk sac identification
Crown-rump length
Cardiac activity
Fetal number, including number of Amnionic fluid volume
amnions and chorions of multiples
when possible
Uterus, adnexal, and cul-de-sac
evaluation
Fetal number
Presentation
Fetal heart motion
Placental location
Gestational age assessment
Fetal weight estimation
Evaluation for maternal pelvic
masses
Fetal anatomic survey
Some Indications for Second- or Third-Trimester Ultrasound
Examination
Estimation of gestational age
Evaluation of fetal growth
Vaginal bleeding
Abdominal or pelvic pain
Incompetent cervix
Determination of fetal presentation
Suspected multiple gestation
Adjunct to amniocentesis
Significant uterine size or clinical dates discrepancy
Pelvic mass
Suspected molar pregnancy
Adjunct to cervical cerclage
Some Indications for Second- or Third-Trimester Ultrasound Exam
Suspected ectopic pregnancy
Suspected fetal death
Suspected uterine abnormality
Evaluation of fetal well-being
Suspected hydramnios or oligohydramnios
Suspected abruptio placentae
Adjunct to external cephalic version
Preterm prematurely ruptured membranes or preterm labor
Abnormal biochemical markers
Follow-up observation of identified fetal anomaly
Follow-up evaluation of placental location for suspected placenta previa
History of previous congenital anomaly
Serial evaluation of fetal growth in multifetal gestation
Evaluation of fetal condition in late registrants for prenatal care
 Fetal Measurements:
1. Fetal biometry
2. Amniotic fluid assessment
3. Fetal movement
4. Doppler ultrasonography
5. Multiple gestation
 1. FETAL BIOMETRY
PARAMETERS:
A. Biparietal diameter (BPD)
B. Head circumference (HC)
C. Abdominal circumference (AC)
D. Femur Diaphysis length (FDL)
 1. Fetal Biometry
A. Biparietal Diameter (BPD)
– at 14- 26 weeks, is usually the most accurate parameter
 ULTRASOUND 18-20 WEEKS - Normal
ULTRASOUND 18-20 WEEKS - Normal (MORPHOLOGY SCAN)
ULTRASOUND (MORPHOLOGY
HEAD ULTRASOUND
18-20 WEEKS - Normal SCAN)
(MORPHOLOGY SCAN)
HEAD ULTRASOUND

• HEAD ULTRASOUND
The correct plane for the measurement of
thecorrect
The head circumference (HC) and bi-parietal
plane for the measurement of BPD: Measure outer table of the
diameter
the (BPD)must include
head circumference thebi-parietal
(HC) and cavum skullMeasure
BPD: to the inner table.
outer table of the
septum (BPD)must
diameter pellucidum,include
thalamus
the and choroid
cavum HC:to
skull Measure around
the inner table.the outer
 BPD
• Estimating GA from
BPD
B. Head Circumference
 B. Head Circumference
• Same view as BPD
• Outer to outer
• Superior to BPD for dating
HC = 1.62 × (BPD + OFD)
Fetal Measurements:
B. Head Circumference

DOLICHOcephaly BRACHYcephaly
– If the head shape is flattened – Head shape if rounded
 Fetal Measurements
C. Abdominal circumference (AC)

–parameter with
the widest
variation of 2 to 3
weeks
–parameter most
affected by fetal
growth
• -
 C. Abdominal circumference (AC)
Landmark features:
 Circular section with ribs
 One vertebra -triangle of 3
white spots
 Umbilical vein (short) -
hockey stick
 Stomach left abdomen
• Good for dating of
pregnancy
• Sensitive to growth
aberrations
• Fetal weight assessment
C. Abdominal circumference (AC)
AD and AC measurement
C. Abdominal circumference (AC)
AC = 1.57 × (anteroposterior AD +
transverse AD)
D. Femur Length
 Fetal Measurements:
D. Femur Length
• Correlates well with
both BPD and
gestational age
• Has a variation of 7 to
11 days
• MEASURED WITH THE BEAM
PERPENDICULAR TO THE LONG
AXIS OF THE SHAFT EXCLUDING
THE EPHIPHYSIS
Femur Length
Femur Length
AMNIOTIC FLUID
AMNIOTIC FLUID
AMNIOTIC FLUID MEASUREMENT
LIQUOR
LIQUORand
andAFI
AFI
LIQUOR and AFI

Greater
Greaterthan
thanthe
the95th
95thcentile
centile Amniotic
AmnioticFluid
Fluidindex
index(AFI),
(AFI),Measure
Measurethethe
=Polyhydramnios.
=Polyhydramnios.Less
Lessthan
than deepest
deepestvertical
verticalpocket
pocket(with
(withno
nofetal
fetalcontent)
content)
FETAL ANATOMIC SURVEY
 Craniospinal Abnormality
Craniospinal abnormality
 ULTRASOUND 18-20 WEEKS - Normal
ULTRASOUND 18-20 WEEKS - Normal (MORPHOLOGY SCAN)
ULTRASOUND (MORPHOLOGY
HEAD ULTRASOUND
18-20 WEEKS - Normal SCAN)
(MORPHOLOGY SCAN)
HEAD ULTRASOUND

• HEAD ULTRASOUND
The correct plane for the measurement of
thecorrect
The head circumference (HC) and bi-parietal
plane for the measurement of BPD: Measure outer table of the
diameter
the (BPD)must include
head circumference thebi-parietal
(HC) and cavum skullMeasure
BPD: to the inner table.
outer table of the
septum (BPD)must
diameter pellucidum,include
thalamus
the and choroid
cavum HC:to
skull Measure around
the inner table.the outer
The cerebellar diameter should approximately
The cerebellar
equal the weeksdiameter should
of gestation. approximately
(EG
Transventricular view of the atrium, which is marked by calipers and
contains the echogenic choroid plexus (CH).
Transcerebellar view of the posterior fossa, demonstrating measurement
of the cerebellum (C) and cisterna magna (CM).
The LATERAL VENTRICLES should be less than
The LATERAL
10mm VENTRICLES
in diameter (best measured the than
atless
should be
occipital diameter
10mm inhorn). The CHOROID PLEXII at
(best measured the be
should
homogeneous. The CHOROID
occipital horn).Small, PLEXII should
and sometimes be
multiple,

FACE: Ensure there is symmetry with
NOSE & LIPS: From the 'face' image, rotate the
NOSE & LIPS: From the 'face' image, rotate the
probe to visualize the nose and lips front on.
probe to visualize the nose and lips front on.
2 distinctly separate nodules and in intact
Fetal Anatomy Assessment
Fetal Anatomy Assessment
Fetal abdominal scan
ABDOMINAL ULTRASOUND
ABDOMINAL ULTRASOUND
ABDOMINAL ULTRASOUND

The Abdominal Circumference must include the

The Abdominal
portal Circumference
section from the umbilical include
mustvein, the
the stomach
and asection
portal from
true cross the umbilical
section vein,with
of the spine the stomach
3
First,
First,confirm
confirmthatthatthe
theorgans
organsare
are
correctly
InIna acoronal
coronalplane,
plane,confirm
confirmthe
thepresence
presence
correctlysited
sitedright
rightvsvsleft.
left.
AnAnaxial
axialplane
planethrough
throughthe thechest
chestand
and and
andposition
positionofofheart,
heart,stomach
stomachand
and
 Fetal Abdominal Abnormality
abdominal
• Omphalocoele abnormality
locoele
 Fetal Abdominal Abnormality
• Gastroschisis
al abdominal abnormality
chisis
 FETAL KIDNEYS
FETAL KIDNEYS
FETAL KIDNEYS

Confirm the presence and position of both

Confirm theBepresence
kidneys. cautiousand
notposition of both
to mistake the The kidneys must be measured in a sagittal
kidneys.
adrenalBeglands
cautious notare
which to mistake the Look
quite large. The
orkidneys
coronalmust beUtilize
plane. measured in a sagittal
colour/power
adrenal
for theglands which
anechoic arepelvis.
renal quite The
large. Look
renal orDoppler
coronal to
plane. Utilize
confirm colour/power
renal arteries and help
Fetal Kidneys
spinal abno
FETAL
FETALLIMBS:
LIMBS: FETAL LIMBS:

TheFemur
The Femurlength
lengthshould
shouldonly
onlybebemeasured
measuredwhen
when
Lower limbs
Confirm the presence and equal size The foot should be perpendicular
of the tibia and fibula bilaterally. to the tibia and fibula.
 Fetal Anatomy Assessment
• Fetal sex:
Recognizable from 14 weeks
Placental Localization
The echogenic mucous plug is readily Uterine contraction
visible in the cervix. Measure the length
Beware of uterine contractions
Placenta Localization
PLACENTA
PLACENTA PLACENTA

Placental bed: Locate the placenta (anterior

V's
• posterior
Lower edgeor>5lateral)
cm from internal os
Placental
• <5cm
Ensure therebed:
is a Locate
low lying the placenta
myometrial (anterior
rim of 3mm or
• V'sPlacentae
posterior or
previa lateral)
after 28w(otherwise The placenta tip must be greater
more under the placenta
Ensureplacenta
suspect there is percreta/accreta).
a myometrial rim of 3mm or than 3cm from the internal os.
The placenta tip must be greater
DOPPLER
 DOPPLER VELOCIMETRY
Clinical Applications:
• systolic–diastolic ratio
(S/D ratio) - compares
maximum (peak)
systolic flow with end-
diastolic flow, thereby
evaluating
downstream
impedance to flow
 DOPPLER VELOCIMETRY
Diminished blood flow may be reflected such as
the ff:
1. Diastolic notch
2. Increased SD ratio (Stuart Index)
3. Pulsatility index; Resistance index
4. Absence or reversed end diastolic (ARED)
blood flow
Umbilical artery
Doppler waveforms:

A. Normal diastolic flow.

B. Absence of end-diastolic
flow.

C. Reversed end-diastolic
flow.
 FETAL VESSEL CLINICAL SIGNIFICANCE REMARKS

• Fetal growth Reverse end-diastolic

UMBILICAL restriction flow suggests severe
ARTERY • Not routinely done fetal circulatory
compromise
• Used to monitor Related to
DUCTUS fetuses exposed to pulmonary
ARTERIOSUS indomethacin and hypretension
other NSAIDs
• Increased impedance • Unique for its high
at 16 to 20 weeks is diastolic flow
UTERINE ARTERY predictive of velocities similar
superimposed to those in systole
preeclampsia
 FETAL VESSEL CLINICAL SIGNIFICANCE REMARKS

• Peak systolic The cerebro-

velocity in the placental ratio is an
middle cerebral indicator of brain
artery is increased sparing in fetuses
with fetal anemia with growth
MIDDLE CEREBRAL • detect altered restriction
ARTERY cerebral circulation
before there is
hypoxemia
significant enough
to alter the fetal
heart rate pattern.
 MIDDLE CEREBRAL ARTERY DOPPLER:
MIDDLE CEREBRAL ARTERY DOPPLER:
MIDDLE CEREBRAL ARTERY DOPPLER:

Middle cerebral artery Doppler gives an

indication
Middle of theartery
cerebral "BrainDoppler
sparinggives
effect“.
an
Measure the
indication pulsatility
of the index. Another
"Brain sparing effect“. useful