Download - USG Trimester 1 21-11-05
FIRST TRIMESTER FIRST TRIMESTER SONOGRAPHYSONOGRAPHY
Judi Januadi EndjunSanny SantanaNovi ResistantieFebriansyah DarusFinekri
FETOMATERNAL DIVISIONDepartment of Obstetrics and GynecologyGatot Soebroto Central Army HospitalSchool of Medicine, University of Indonesia
2005
AM I PREGNANT ?AM I PREGNANT ?
AGENDA AGENDA Introduction. Introduction. Patient position.Patient position. Normal early Normal early
pregnancy.pregnancy. Abnormal early Abnormal early
pregnancy. pregnancy. Diagnostic procedures Diagnostic procedures Conclusions.Conclusions. References. References.
JJE/RSPAD/INTIUM/2005
INTRODUCTIONINTRODUCTION
ALARA ALARA (as low as reasonably (as low as reasonably acceptable) principle in determining acceptable) principle in determining intensities and time of exposureintensities and time of exposure
AIUM : AIUM : intensities < 94 mW/cmintensities < 94 mW/cm2 2 are are below the acceptable threshold. Do not below the acceptable threshold. Do not hold the transducer to interrogate a hold the transducer to interrogate a certain area any longer than neededcertain area any longer than needed
INTRODUCTION
± 30% of fertilized eggs develop into a fetus
Many of the defects occur during embryogenesis (0 – 8 weeks)
Fetal development : > 8 weeks
TVS is vital in the evaluation of complicated 1st trimester pregnancy (0 – 13 weeks)
INTRODUCTIONINTRODUCTION
The terms incomplete abortions, missed abortion, failed IUP, and embryonic demise are used interchangeably, which can contribute to confusion.
It is best to most accurately describe TVS features (i.e., presence or absence of embryo / YS, fetus, heart motion, and retrochorionic hemorrhage
PATIENT POSITIONPATIENT POSITION
TRANSDUCERS
Bambang Karsono
curvilinear
Transvaginal / rectal
DEFINITIONS DEFINITIONS
Menstrual age (postmenstrual)Menstrual age (postmenstrual)~ from LMP~ from LMP
Conceptual ageConceptual age~ from ovulation date (IVF)~ from ovulation date (IVF)
Gestational ageGestational age~ ovulation date + 2 weeks~ ovulation date + 2 weeks
(Merz E. Ultrasound in Gynecology & Obstetrics, 1991)(Merz E. Ultrasound in Gynecology & Obstetrics, 1991) Bambang Karsono
DEFINITIONS
Kehamilan minggu ke-6Kehamilan minggu ke-6
~ kehamilan 5 minggu + 0 hari ~ kehamilan 5 minggu + 0 hari
sampai dengan 5 minggu + 6 harisampai dengan 5 minggu + 6 hari
Kehamilan 6 mingguKehamilan 6 minggu
~ kehamilan 6 minggu + 0 hari ~ kehamilan 6 minggu + 0 hari
sampai dengan 6 minggu + 6 harisampai dengan 6 minggu + 6 hari
Bambang Karsono
Objectives of 1st Trimester US Examinations
Location and gestational age determination.
Detection of embryo and or fetal life Evaluation of pregnancy
complications Detection of anomalies Detection of multiple pregnancy Evaluation of pelvic mass, IUD, etc
DECIDUALIZATION
Normal Early Normal Early PregnancyPregnancy
Physical and physiological changes.
Embryo and fetal development. Technique : transabdominal,
transvaginal (the method of choice), transrectal, or transperineal.
Transducer selection Informed consent : very important
11 14-14-1515
1919 2222 2525 2929 3232
LMPLMP OvulationOvulation- -
FertilizatiFertilizationon
Uterine Uterine cavitycavity ImplanImplan
tationtation
HCG (+) HCG (+) >10 >10
mIU/mlmIU/ml
USG (+) USG (+) >400 >400
mIU/mlmIU/ml
3535
> 1800 > 1800 mIU/mlmIU/ml
Normal early Normal early pregnancypregnancy
TVS can detect GS within the thickened choriodecidua at 5-6 W
Decidua capsularis : forms most of the GS
Decidua vera : the true decidua that surrounds the GS
Decidua basalis : and chorion frondosum form the placenta
Normal early pregnancyNormal early pregnancy
-hCG > 2000 mIU/ml + GS should be sees on TVS in an IUP. -hCG doubles every 48 hours in a normal IUP
YS should be visible in a GS that is ± 10 mm
The embryo should be visible in a 16 – 20 mm GS
Normal early pregnancyNormal early pregnancy
Heart motion should be visible in an embryo ≥ 3 mm.
- Normal embryos : HR > 85 bpm at 6 – 7 weeks - HR < 85 bpm can indicate impending failed pregnancy, re-scan in 1 week or so - TV-CDS can be used to detect heart
motion
Normal early Normal early pregnancypregnancyCertain fetal structures seen on TVS are
specific to the early developing fetus : Rhombencephalon : seen at 6 W, is a cystic area
in the brain that eventually forms the 4th ventricle (cisterna magna)
Bowel herniation : into base of umbilical cord is seen between 8 – 12 W
Chorio-amnion is unfused until 18-20 W IUP in one horn of bicornuate uterus Corpus luteum cyst of pregnancy : usually
regresses by 14 to 16 W
PROBLEMS PROBLEMS
Incorrect gestational age Incorrect gestational age estimation, increase perinatal estimation, increase perinatal morbidity and mortality; also morbidity and mortality; also
medicolegal problemsmedicolegal problems
Case : CS due to post term Case : CS due to post term → → preterm babypreterm baby
AIUM Guidelines for 1AIUM Guidelines for 1stst Trimester UltrasoundTrimester Ultrasound
1. The uterus and adnexa should be evaluated for the presence of a gestational sac (GS). If GS is seen, its location should be documented. The presence or absence of an embryo should be noted and CRL recorded
AIUM Guidelines AIUM Guidelines 1 :1 : CRL is a more accurate indicator of CRL is a more accurate indicator of
GA than GS diameter.GA than GS diameter.
Identification of a YS or an embryo Identification of a YS or an embryo is definitive evidence of a GS. is definitive evidence of a GS. Intrauterine fluid collection can Intrauterine fluid collection can sometimes represent sometimes represent pseudogestational sac associated pseudogestational sac associated with ectopic pregnancywith ectopic pregnancy
AIUM Guidelines 1 :AIUM Guidelines 1 :
During the late 1During the late 1stst trimester, BPD and trimester, BPD and other fetal other fetal measurements also measurements also may be used to may be used to establish fetal age establish fetal age
AIUM Guidelines :AIUM Guidelines :
2.2. Presence or absence of cardiac Presence or absence of cardiac activity should be reportedactivity should be reported
3.3. Fetal number should be Fetal number should be documenteddocumented
4.4. Evaluation of the uterus, adnexal Evaluation of the uterus, adnexal structures, and cul-de-sac should structures, and cul-de-sac should be performed be performed
AIUM Guidelines 2 AIUM Guidelines 2 :: Real time observation is critical for
this diagnosis.
With vaginal scan, cardiac motion should be appreciated by a CRL of ≥ 5 mm. If an embryo < 5 mm is seen with no cardiac activity, a follow-up scan may be needed to evaluate for fetal life.
AIUM Guidelines 3 :AIUM Guidelines 3 :
Multiple pregnanciesMultiple pregnancies Pseudo GS : Pseudo GS : incomplete fusion between the incomplete fusion between the
amnion and chorion, or elevation of the chorionic amnion and chorion, or elevation of the chorionic membrane by intrauterine hemorrhagemembrane by intrauterine hemorrhage
JJE/RSPAD/INTIUM/2005
AIUM Guidelines 4 :AIUM Guidelines 4 :
Recognition of Recognition of incidental findings : incidental findings : myomas, adnexal mass, myomas, adnexal mass, fluid in the cul-de-sac or fluid in the cul-de-sac or the flanks and subhepatic the flanks and subhepatic spacespace
Correlation of serum Correlation of serum hormonal levels with hormonal levels with US findings often is US findings often is helpful for diagnosis of helpful for diagnosis of EP or normal pregnancyEP or normal pregnancy
EMBRYO and FETUS EMBRYO and FETUS DEVELOPMENTDEVELOPMENT
< 5 weeks< 5 weeks 5 weeks 6-10 weeks 10-12 weeks
GS GS
(Yolk sac)
CRLCRL CRLBPD
> 12 weeks> 12 weeks
BPD BPD
FLFL
etcetc
BIOMETRICS PARAMETERBIOMETRICS PARAMETER
Bambang Karsono
Gestational age Gestational age estimationestimation
GSGS YSYS CRLCRL BPDBPD HCHC FLFL HLHL
JJE/RSPAD/INTIUM/2004
Gestational Gestational SacSac
Normal : Normal : cincin ekoik regular dgn cincin ekoik regular dgn bagian sonolusen ditengahnyabagian sonolusen ditengahnya
Yolk Sac
Size, shape, and Size, shape, and location location
Normal : Normal : rounded, rounded, diameter 3 – 6 mm, diameter 3 – 6 mm, fixedfixed
Abnormal : Abnormal : not rounded, diameter < 3 mm or ≥ 8 mm, and floating inside GS.
CRLCRL
CROWN-RUMP LENGTH (CRL)
44++ WEEKS PREGNANCY WEEKS PREGNANCY
5 WEEKS PREGNANCY5 WEEKS PREGNANCY
6 WEEKS PREGNANCY6 WEEKS PREGNANCY
CARDIAC ACTIVITY AT 6 WEEKS
7 WEEKS PREGNANCY
8 WEEKS 8 WEEKS PREGNANCYPREGNANCY
9 WEEKS PREGNANCY
10 – 12 WEEKS PREGNANCY
12 WEEKS
• Soft markers chromosomal anomalies : golf ball (echogenic foci intra cardiac), NT, echogenic bowels•Anensefalus•Hidrosefalus
11stst Trimester screening Trimester screening
11stst Trimester Trimester screeningscreening
Yolk sac (shape, size, and number)Yolk sac (shape, size, and number) Nuchal translucency (NT)Nuchal translucency (NT)
Nuchal Translucency (NT)
Enlargement (> 3 mm) is associated with chromosomal abnormalities
Different from cystic hygroma associated with Turner’s syndrome; cystic hygromas usually have septations
The membrane represents skin elevated from the nuchal area, possibly related to a cardiac malformation or edema
If present, there is high association with chromosomal abnormality.
Detection and evaluation of NT require meticulous scanning, usually using a transabdominal approach (Arthur C. Fleischer, 2004)
PREGNANCY FAILURE
Pre-embryonic : Pre-embryonic : > 50%> 50%
Embryonic : 28%Embryonic : 28% Fetus : 10%Fetus : 10% 7-9 weeks : 5%7-9 weeks : 5% 10-12 weeks : 1 – 10-12 weeks : 1 –
2%2%
GS (+) : 11,5%GS (+) : 11,5% YS (+) : 8,8%YS (+) : 8,8% Embryo Embryo 5 mm : 5 mm :
7,1%7,1% Embryo 5-10% : Embryo 5-10% :
3,3%3,3% Embryo Embryo 10 mm 10 mm
: 0,5%: 0,5%
ETIOLOGYETIOLOGY Pre-embryonic : 70% chromosomal
abnormalities
Embryonic : 56% chromosomal abnormality
Fetus : placentation abnormality, perfusion disturbances, uterine defect : uterus subseptus ( 4,7 x) , uterus arcuatus ( 5,8 x), uterus septus, maternal disease(s), cervical incompetent.
Antibody antinuclear : Uterine artery Pulsatility Index
Progesterone
Blighted ovum Molar pregnancy, trophoblastic
disease Subchorionic bleeding IUFD Multiple pregnancy Ectopic pregnancy, combine pregnancy Screening fetal anomaly
Abnormal Early PregnancyAbnormal Early Pregnancy
Blighted Ovum
Dinding KG tipis dan iregular
Tidak tampak ekho janin pada diameter KG 25 mm
Dapat disertai perdarahan sub korionik
Bl perlu : USG serial Bandingkan dengan
kadar HCG darah
Molar pregnancy Molar pregnancy Early in trophoblastic disease, may
appear as thickened, irregular tissue within uterus. (Arthur C. Fleischer, 2004)
After ± 12 W, hydropic villi can be recognized as punctate cystic areas. (Arthur C. Fleischer, 2004)
May be associated with theca lutein cysts (septated cystic adnexal masses). (Arthur C. Fleischer, 2004)
Subchorionic bleeding
Daerah hipoekoik iregular subkorion
Perhatikan regularitas dinding korion, letak janin dan tanda kehidupan, anomali uterus
Ukur luas daerah perdarahan
Bila perlu evaluasi USG serial
IUFD
Diagnosa : B-mode atau doppler Tidak tampak pulsasi jantung atau
tali pusat Bila ragu, ulangi USG 1 minggu Cari kausa : perdarahan, anomali uterus,
kelainan yolk sac, anomali janin, dll Beri informed consent dengan baik, hati-
hati pasien rujukan konsultasi USG
Multiple Multiple pregnancypregnancy
The numbers of GS Amniotic band Thickness of amniotic band Fetal echo : be careful vanishing twin Fetal live and gestational age Anomaly Adnexal mass
Triplets
QuadrupletQuadruplet
Ectopic pregnancy (EP)Ectopic pregnancy (EP) Clinical conditions which increase risk of EP include the
presence of a scarred tube from salpingitis/PID and/or previous tubal surgery
TVS : no GS within uterus. Uterus size is normal or slightly enlarged
Extrauterine extraovarian adnexal mass, pseudogestational sac, and hemoperitoneum
The EP is usually on the side of the CL.
Living embryo outside of the uterus
(Arthur C. Fleischer, 2004)
Ectopic pregnancy EP may also contain a rim of increased
vascularity, although this is variable, depending on the extent of trophoblastic invasion into the tubal wall
TV-CDS can distinguish distended paraovarian/uterine veins from the vascular rim of an EP
EP have variable wall vascularity and pain A ruptured EP can be implied if there is a
complex solid tubal mass, hematosalpinx, or hemoperitoneum
(Arthur C. Fleischer, 2004)
Rare types of ectopic pregnancy Cornual EP : can occur within one uterine
cornua, it can enlarge because it is surrounded by myometrium. If it ruptures, catastrophic bleeding can occur
Abdominal EP : can be diagnosed by the presence of fetus, choriodecidua, or placenta separate from uterus
Cervical EP : GS inside the cervical area Ovarian EP : virtually impossible to
distinguish from CL if the embryo is not seen
(Arthur C. Fleischer, 2004)
Down Syndrom
Echogenic bowelsEchogenic bowels
AnencephalAnencephalyy
TVS can be used to detect anencephaly as early as 7-8 W (Arthur C. Fleischer, 2004)
TAS : 12 – 14 W
PREGNANCY + ENDOMETRIOSIS PREGNANCY + ENDOMETRIOSIS CYSTCYST
Doppler studyDoppler study
Uterine artery Uterine artery Doppler : Doppler : notching notching → → IUGR, preeclampsia, IUFDIUGR, preeclampsia, IUFD
Only for HRPOnly for HRP
Detection of heart Detection of heart beatbeat
Blood flow studyBlood flow study
Doppler Doppler studystudy
Vitelline duct blood flow
Ductus venosus
Uterine artery
Uterine artery
Notching
Diagnostic Procedures in the 1st Trimester CVS : under continuous sonographic visualization of
the catheter in which chorionic villi are aspirated from the developing placenta.
Early Amniocentesis : an aspiration needle is guided into the amniotic fluid under continuous sonographic guidance. It is sometimes difficult to puncture both chorion and amnion in 13 – 16 W pregnancies
Retrieval of tissue for karyotyping(Arthur C. Fleischer, 2004)
CVS and Early Amniocentesis
CONCLUSIONS TVS has a vital role in the evaluation of patients
presenting with hemorrhage, distinguishing a pregnancy with subchorionic hemorrhage from an ectopic pregnancy or failed IUP. (Arthur C. Fleischer, 2004)
TVS can accurately detect ectopic gestational sacs in most cases. (Arthur C. Fleischer, 2004)
Determine the objectives of 1st trimester ultrasound.
Use the appropriate transducer and the route of examination.
Minimize side effects.
CPD very important for maintaining personal competence
3D and Doppler examinations should be performed if there indicated.
REFERENCES
1. Fleischer AC. Sonography in gynecology and obstetrics : just the facts. McGraw Hill, Singapore, 2004.
2. Fleischer AC, Kepple DM. Transvaginal sonography of early intrauterine pregnancy. In: Fleischer AC, Manning F, Jeanty P, Romero R, eds. Sonography in Obstetrics and Gynecology : Principles and Practice, ed6. New York: McGraw-Hill,2001:62.
3. Fleischer AC, Diamond MP, Cartwright PS. Transvaginal sonography of ectopic pregnancy. In: Fleischer AC, Manning F, Jeanty P, Romero R, eds. Sonography in Obstetrics and Gynecology : Principles and Practice, ed6. New York: McGraw-Hill,2001:113.
4. Sherer DM, Manning FA. First trimester nuchal translucency screening for fetal aneuploidy. In: Fleischer AC, Manning F, Jeanty P, Romero R, eds. Sonography in Obstetrics and Gynecology : Principles and Practice, ed6. New York: McGraw-Hill,2001:89.
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