LIMITED OBSTETRIC ULTRASOUND
JANUARY 14-16, 2016
Course Director: Oksana H. Baltarowich, MD
THURSDAY, JANUARY 14, 2016
9:00
-
10:30
Introduction to Ultrasound Principles
Mani Montazemi, RDMS
10:30
-
10:45
Break
10:45
-
12:00
Ultrasound Imaging of the Normal Female Pelvis
12:00
-
1:30
Lunch on Your Own
12:30
-
1:30
Principles of Ultrasound Physics
Nathan Pinkney, BS, CDOS
1:30
-
2:15
Transvaginal Scanning Techniques
Mani Montazemi, RDMS
2:15
-
3:15
Introduction to Ultrasound Evaluation of the Cervix
Mani Montazemi, RDMS
3:15
-
3:30
Break
3:30
-
4:45
Demonstration of GYN Ultrasound
Mani Montazemi, RDMS
4:45
-
5:00
Questions and Answers
Mani Montazemi, RDMS
Mani Montazemi, RDMS
FRIDAY, JANUARY 15, 2016
9:00
-
10:30
1st Trimester Pregnancy
10:30
-
10:45
Break
10:45
-
12:00
Basic Fetal Anatomy
12:00
-
1:30
Lunch on Your Own
1:30
-
2:15
Measurements for Limited Obstetric Ultrasound
G. William Shepherd, PhD,
RDMS, RVT
2:15
-
2:45
Amniotic Fluid Assessment
G. William Shepherd, PhD,
RDMS, RVT
2:45
-
3:30
Biophysical Profile
G. William Shepherd, PhD,
RDMS, RVT
3:30
-
3:45
Break
3:45
-
5:00
Demonstration of Limited Obstetrical Ultrasound
SATURDAY, JANUARY 16, 2016
9:00
-
12:00
Optional Hands-On Scanning
G. William Shepherd, PhD,
RDMS, RVT
G. William Shepherd, PhD,
RDMS, RVT
G. William Shepherd, PhD,
RDMS, RVT
1/6/2014
US Principles Image Orientation
Introduction to
Ultrasound Principles
US Principles Image Orientation
Artifacts
Masses Instrumentation
Basic Principles of Ultrasound
• Ultrasound diagnostically is used in 2 ways
Mani Montazemi, RDMS
Baylor College of Medicine
Division of Maternal-Fetal Medicine
Department of Obstetrics and Gynecology
Manager, Maternal Fetal Center Imaging
Texas Children’s Hospital, Pavilion for Women
Houston Texas
&
Clinical Instructor
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania
Artifacts
B
A D
Masses Instrumentation
US Principles Image Orientation
Artifacts
Masses Instrumentation
Basic Principles of Ultrasound
Basic Principles of Ultrasound
• Ultrasound diagnostically is used in 2 ways
• Ultrasound diagnostically is used in 2 ways
– Anatomic information
US Principles Image Orientation
Artifacts
Masses Instrumentation
What is
Ultrasound?
– Anatomic information
– Blood flow information
US Principles Image Orientation
Artifacts
Masses Instrumentation
What is
Ultrasound?
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US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Artifacts
Masses Instrumentation
Basic Principles of Ultrasound
Basic Principles of Ultrasound
• What is “sound”
• What is “sound”
– Sound is a form of energy
– Sound is a form of energy
• What is “energy”
– Energy is the capacity to do work
• Moving an object, heating the room, lighting
electricity
US Principles Image Orientation
Artifacts
Masses Instrumentation
Basic Principles of Ultrasound
• Sound is mechanical energy
transmitted by pressure waves in a
material medium
– Sound is not electromagnetic
– Matter must be present for sound to travel
US Principles Image Orientation
Artifacts
Masses Instrumentation
Pulsed-echo Principle
• The energy within a pulsed-echo system is
electrical, but the energy in the patient’s
body is sound, which is mechanical
US Principles Image Orientation
Artifacts
Masses Instrumentation
How Does an
Ultrasound
Instrument
Work?
US Principles Image Orientation
Artifacts
Masses Instrumentation
What is a Transducer?
• Converts one form
of energy into
another form
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US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Video Clip - Transducer
Artifacts
Masses Instrumentation
Transducer Frequency
5.0
3.5
2.25
US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Transducer Configurations
• Curved linear
• Straight linear
• Conventional
sector
• Microsector
• Endocavity
• Intraoperative
US Principles Image Orientation
Artifacts
Masses Instrumentation
Transducer Configurations
• Mechanical
• Phased array
Artifacts
– 2.25 MHz
– 3.5 MHz
– 5 - 6 MHz
– 7.5 -10 MHz
– 9.0 MHz
– 12 -17 MHz
Masses Instrumentation
Image Configurations
Linear
Curved
US Principles Image Orientation
Artifacts
Sector
Masses Instrumentation
Transducer Configurations
• Mechanical – moving parts
–
–
–
–
–
–
Wobbler or rotating
Single or multi-element
Mechanical beam steering & focusing
Motor driven/fluid filled scan head
FOV is sector
Single or multi-frequency
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US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Transducer Configurations
• Phased array – no moving parts
– Flat linear
– Curved linear
– Sector
Artifacts
Masses Instrumentation
Curved Linear Array Transducer
•
•
•
•
•
Multi-element
Elements arranged in an arc and are sequentially pulsed
FOV is trapezoidal-sector
Produce larger FOV
Benefits:
– High quality imaging
– Faster frame rate
– Electronic focusing
US Principles Image Orientation
Artifacts
Masses Instrumentation
Video Clip - Transducer
US Principles Image Orientation
Artifacts
Masses Instrumentation
Categories of Sound
Infra Sound
below 20 Hz
Audible Sound
20-20,000 Hz
Ultrasound
Above 20,000 Hz
Sound is categorized according
to the frequency of vibration per seconds
US Principles Image Orientation
Artifacts
Masses Instrumentation
Frequencies Used For
Medical Diagnostic Ultrasound
Are Normally Above 1 MHz
One cycle / second = one Hertz (Hz)
US Principles Image Orientation
Artifacts
Masses Instrumentation
Resolution: What is it?
• Clarity & sharpness of an ultrasound image
• The capability of clearly distinguishing two
points located close to each other on the
sonogram
One thousand cycles / second = one Kilohertz (kHz)
One Million cycles / second = one Megahertz
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US Principles Image Orientation
Artifacts
Masses Instrumentation
Video Clip – Safety
US Principles Image Orientation
Artifacts
Masses Instrumentation
Safety - Prudent Use
Minimize risk
Minimize exposure
Medical indication only 
Minimize exposure time 
Minimize exposure output 
US Principles Image Orientation
Artifacts
Masses Instrumentation
Ultrasound Safety
• Prudent use dictates that the principle of
ALARA be observed and the ultrasound
power levels be maintained As Low As
Reasonably Achievable, in order to provide
the maximum benefit / risk ratio
US Principles Image Orientation
Artifacts
Masses Instrumentation
Output Display Values
• Power
• Thermal Index – heat
– Ratio of the in-situ power to the acoustic power
required to raise tissue temprature by 1o C
• Mechanical Index – cavitation
– Acoustic output in terms of the likelihood of
tissue cavitation
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US Principles Image Orientation
Artifacts
Masses Instrumentation
Image Orientation &
Scanning Planes
Caution
US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Scanning Planes
• Longitudinal
• Transverse
• Oblique
US Principles Image Orientation
Artifacts
Artifacts
Masses Instrumentation
Sagittal Scan
• Longitudinal, vertical planes
• Divide the body into left & right
Masses Instrumentation
US Principles Image Orientation
Sagittal Scan
Artifacts
Masses Instrumentation
Sagittal Scan
H
A
F
P
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US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Sagittal Scan
US Principles Image Orientation
Artifacts
Masses Instrumentation
Artifacts
Masses Instrumentation
Sagittal Scan
US Principles Image Orientation
Sagittal Scan
Artifacts
Masses Instrumentation
Sagittal Scan
Anterior
Maternal Head
Maternal Feed
Posterior
US Principles Image Orientation
Artifacts
Masses Instrumentation
Sagittal Scan
US Principles Image Orientation
Artifacts
Masses Instrumentation
Sagittal Scan
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US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Masses Instrumentation
Sagittal Scan
Anterior
H
Artifacts
F
Posterior
US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Artifacts
Masses Instrumentation
Anterior
H
F
Posterior
US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Artifacts
Masses Instrumentation
Transverse Scan
• Horizontal, transaxial planes
• Divide the body into superior & inferior
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US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Transverse Scan
Artifacts
Masses Instrumentation
Transverse Scan
R
A
L
P
US Principles Image Orientation
Artifacts
Masses Instrumentation
Transverse Scan
US Principles Image Orientation
Artifacts
Masses Instrumentation
Transverse Scan
US Principles Image Orientation
Artifacts
Masses Instrumentation
Transabdominal Transverse
US Principles Image Orientation
Artifacts
Masses Instrumentation
Transverse Scan
Twin Pregnancy
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US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Oblique Scan
Artifacts
Masses Instrumentation
Oblique Scan
• Oblique planes
• Inclined from the standard planes
• In any direction
US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Artifacts
•
•
•
•
•
Artifacts
Masses Instrumentation
Posterior Enhancement
Posterior Enhancement
Acoustical Shadowing
Attenuation
Reverberations
Refraction
US Principles Image Orientation
Artifacts
• Increased intensity in echoes from
reflectors behind a structure that
weakly attenuates sound
• Classical feature of fluid
Masses Instrumentation
US Principles Image Orientation
Posterior Enhancement
Artifacts
Masses Instrumentation
Posterior Enhancement
UT
OV
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US Principles Image Orientation
Artifacts
Masses Instrumentation
Acoustical Shadowing
US Principles Image Orientation
Artifacts
Masses Instrumentation
Acoustical Shadowing
• Marked decrease in intensity of echoes from
reflectors that lie behind a structure that is
strongly reflecting or attenuating sound
• Complete lack of acoustical & anatomical
information in the area of shadowing
US Principles Image Orientation
Artifacts
Masses Instrumentation
Acoustical Shadowing
US Principles Image Orientation
Artifacts
Masses Instrumentation
Acoustical Shadowing
Head
US Principles Image Orientation
Artifacts
Masses Instrumentation
Acoustical Shadowing
US Principles Image Orientation
Artifacts
Masses Instrumentation
Acoustical Shadowing
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US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Acoustical Shadowing
Artifacts
Masses Instrumentation
Attenuation
• Reduction of the sound beam’s
amplitude and intensity as it travels
through a medium
US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Attenuation
Artifacts
Masses Instrumentation
Attenuation
Normal
US Principles Image Orientation
Artifacts
Masses Instrumentation
Attenuation
US Principles Image Orientation
Artifacts
Masses Instrumentation
Reverberations
• When 2 or more reflectors in the sound
path cause multiple, repetitive
artifactual echoes
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US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Reverberations
US Principles Image Orientation
Artifacts
Masses Instrumentation
Video Clip – Artifacts
•
•
•
•
•
Posterior Enhancement
Acoustical Shadowing
Attenuation
Reverberations
Refraction
Masses Instrumentation
Reverberations
US Principles Image Orientation
Artifacts
Masses Instrumentation
Cervix – US Appearance
US Principles Image Orientation
Artifacts
Artifacts
Artifacts
Masses Instrumentation
Echogenicity
• Intensity of echoes reflected by tissues
or structures from inside the body
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US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Artifacts
Masses Instrumentation
Echogenicity
Liquids
Solids
Vessels & Ducts
Soft Tissue
Bone
Gallbladder
Urinary Bladder
Fibrous Cysts
Tumors
Gall Stone
Kidney Stone
Cysts
Polyps & Lesions
Calcific Plaque
US Principles Image Orientation
Artifacts
Masses Instrumentation
• Echogenicity of a structure is described
relative to surrounding or adjacent
tissue
US Principles Image Orientation
Echogenicity
• Anechoic
• Hypoechoic
• Hyperechoic
US Principles Image Orientation
Artifacts
Artifacts
Masses Instrumentation
Anechoic
• Sonolucent
• No internal echoes
Masses Instrumentation
Anechoic
US Principles Image Orientation
Artifacts
Masses Instrumentation
Anechoic
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US Principles Image Orientation
Artifacts
Masses Instrumentation
Anechoic
US Principles Image Orientation
Artifacts
Masses Instrumentation
Hyperechoic
Anechoic
US Principles Image Orientation
Artifacts
Masses Instrumentation
Hyperechoic
• High intensity echoes
• Increased echogenicity
• Echogenic
US Principles Image Orientation
Artifacts
Masses Instrumentation
Hyperechoic
Hyperechoic
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US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Hypoechoic
Artifacts
Masses Instrumentation
Hypoechoic
• Low intensity echoes
• Decreased echogenicity
US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Clotted Blood
Hemoperitoneum
Artifacts
Masses Instrumentation
Echotexture
• Homogeneous
• Heterogeneous
US Principles Image Orientation
Artifacts
Masses Instrumentation
Homogeneous
US Principles Image Orientation
Artifacts
Masses Instrumentation
Homogeneous
• Uniform echoes
• Fine, smooth texture
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US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Homogeneous
Artifacts
Masses Instrumentation
Heterogeneous
• Non-uniform echoes
• Irregular texture
US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Heterogeneous
Normal
Artifacts
Masses Instrumentation
Heterogeneous
Normal
US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Types of Masses
• Cystic
• Solid
• Complex
Artifacts
Masses Instrumentation
Cystic Masses
•
•
•
•
Anechoic
Fluid filled
Smooth, well defined margins
Posterior enhancement
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US Principles Image Orientation
Artifacts
Masses Instrumentation
Cystic Masses
US Principles Image Orientation
Artifacts
Masses Instrumentation
Cystic Masses
Cephalocele
US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Solid Masses
•
•
•
•
•
Artifacts
Masses Instrumentation
Solid Masses
Contains varying amounts of internal echoes
Regular or irregular margins
Poorly defined back wall
Posterior attenuation of sound
Distal acoustic shadow
US Principles Image Orientation
Artifacts
Masses Instrumentation
Uterine Leiomyoma – US Findings
• Discrete solid mass
– single or multiple
US Principles Image Orientation
Artifacts
Masses Instrumentation
Uterine Leiomyoma – US Findings
• Variable echogenecity
– hypoechoic, hyperechoic
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US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Solid Masses
Artifacts
Masses Instrumentation
Hemorrhagic Cyst
Artifacts
Masses Instrumentation
Complex Masses
•
•
•
•
•
•
US Principles Image Orientation
Masses Instrumentation
Diagnostic Challenge
Uterine Leiomyoma – US Findings
US Principles Image Orientation
Artifacts
Predominantly Cystic
Mostly cystic
Posterior enhancement
Internal echoes
Thin or thick septations
Thin or thick walls
US Principles Image Orientation
Artifacts
Masses Instrumentation
Mural Nodule vs. Clot
• Lace-like pattern of internal echoes
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US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Artifacts
Masses Instrumentation
Complex Masses
Mural Nodule vs. Clot
Normal
Sacrococcygeal Teratoma
US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Complex Masses
Artifacts
Masses Instrumentation
Complex Masses
Cervical Teratoma
US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Complex Masses
Artifacts
Masses Instrumentation
Complex Masses
•
•
•
•
Predominantly Solid
Mostly echogenic
Internal cystic changes
Posterior attenuation
Cystic Lymphangioma
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US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Complex Masses
Artifacts
Masses Instrumentation
Describing A Mass
•
•
•
•
•
Size
Shape, borders, wall
Acoustic properties (cystic, solid, complex)
Posterior enhancement or attenuation
Location
Normal
Hepatoblastoma
US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
How Would You
Describe This Mass?
Artifacts
Masses Instrumentation
How Would You
Describe This Mass?
In the right adnexa
TRV Pelvis
US Principles Image Orientation
Artifacts
Masses Instrumentation
How Would You
Describe This Mass?
In the right adnexa there is a round, well marginated
thin walled mass with a sharply defined back wall,
US Principles Image Orientation
Artifacts
Masses Instrumentation
How Would You
Describe This Mass?
In the right adnexa there is a round, well marginated
thin walled mass with a sharply defined back wall,
thin internal septations,
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US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
How Would You
Describe This Mass?
In the right adnexa there is a round, well marginated
thin walled mass with a sharply defined back wall,
thin internal septations, low intensity echoes,
US Principles Image Orientation
Artifacts
Masses Instrumentation
How Would You
Describe This Mass?
Artifacts
Masses Instrumentation
How Would You
Describe This Mass?
In the right adnexa there is a round, well marginated
thin walled mass with a sharply defined back wall,
thin internal septations, low intensity echoes,
and excellent posterior enhancement.
US Principles Image Orientation
Artifacts
Masses Instrumentation
Basic System Overview
In the right adnexa there is a round, well marginated
thin walled mass with a sharply defined back wall,
thin internal septations, low intensity echoes,
and excellent posterior enhancement.
The features are those of a
complex, predominantly
cystic mass.
US Principles Image Orientation
Artifacts
Masses Instrumentation
Patient Data Entry
US Principles Image Orientation
Artifacts
Masses Instrumentation
Patient Data Entry
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US Principles Image Orientation
Artifacts
Masses Instrumentation
Transducer / Exam Selection
US Principles Image Orientation
Masses Instrumentation
Transducer / Exam Selection
US Principles Image Orientation
Transducer Selection
Artifacts
Artifacts
Masses Instrumentation
Probe Handling
Resolution vs. Penetration
• Right frequency for penetration
• Highest frequency for resolution
US Principles Image Orientation
Artifacts
Masses Instrumentation
?
US Principles Image Orientation
Artifacts
Masses Instrumentation
Probe Handling – “Sagittal”
Probe Handling – “Sagittal”
Incorrect
Incorrect
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US Principles Image Orientation
Artifacts
Masses Instrumentation
Probe Handling – “Sagittal”
Artifacts
Masses Instrumentation
Probe Handling – “Sagittal”
Correct
Incorrect
US Principles Image Orientation
US Principles Image Orientation
Artifacts
Masses Instrumentation
Probe Handling – “Sagittal”
US Principles Image Orientation
Artifacts
Masses Instrumentation
Probe Handling – “Transverse”
Incorrect
US Principles Image Orientation
Artifacts
Masses Instrumentation
Probe Handling – “Transverse”
Incorrect
US Principles Image Orientation
Artifacts
Masses Instrumentation
Probe Handling – “Transverse”
Correct
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US Principles Image Orientation
Artifacts
Masses Instrumentation
Probe Handling – “Don’t”
US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Artifacts
Masses Instrumentation
Probe Handling
US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Artifacts
Masses Instrumentation
Basic Controls
•
•
•
•
•
Freeze
Overall Gain
TGC
Depth
Focus
US Principles Image Orientation
Artifacts
Masses Instrumentation
Overall Gain
Overall Gain - Increase
• An increase or decrease of
the gain will change the
brightness of the image
• Affects entire field of view
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US Principles Image Orientation
Artifacts
Masses Instrumentation
Overall Gain - Increase
US Principles Image Orientation
Artifacts
Masses Instrumentation
Overall Gain - Decrease
US Principles Image Orientation
Artifacts
Masses Instrumentation
Overall Gain - Decrease
US Principles Image Orientation
Artifacts
Masses Instrumentation
Overall Gain - Increase
US Principles Image Orientation
Artifacts
Masses Instrumentation
Overall Gain - Decrease
US Principles Image Orientation
Artifacts
Masses Instrumentation
Overall Gain
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US Principles Image Orientation
Artifacts
Masses Instrumentation
Time Gain Compensation
US Principles Image Orientation
Artifacts
Masses Instrumentation
Time Gain Compensation
• These slide pots controls
amplification of returning
echo signals at specific
depths
Near Field
• The TGC compensates for
loss in signal strength as
the ultrasound beam
passes through an organ
Mid Field
Far Field
• Affects specific portions
of the field of view
US Principles Image Orientation
Artifacts
Masses Instrumentation
Time Gain Compensation
US Principles Image Orientation
Artifacts
Masses Instrumentation
Time Gain Compensation
Brighter
Darker
US Principles Image Orientation
Artifacts
Masses Instrumentation
Time Gain Compensation
US Principles Image Orientation
Artifacts
Masses Instrumentation
Time Gain Compensation
Brighter
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US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Time Gain Compensation
Artifacts
Masses Instrumentation
Time Gain Compensation
Darker
US Principles Image Orientation
Artifacts
The diagnosis is only As good as
the information your image provides
Masses Instrumentation
Time Gain Compensation
US Principles Image Orientation
Artifacts
Masses Instrumentation
What Constitute a Good Image?
US Principles Image Orientation
Artifacts
Masses Instrumentation
What Constitute a Good Image?
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US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Artifacts
Depth
Masses Instrumentation
Depth
• Controls the depth of
field of view
• When the image depth is
changed, the field of
view increases or
decreases
US Principles Image Orientation
Artifacts
Masses Instrumentation
Too Small
Depth
Just Right
Too Big
US Principles Image Orientation
Artifacts
Masses Instrumentation
Focus
• Transmit Zone
US Principles Image Orientation
Artifacts
Masses Instrumentation
Focus
Region of minimum beam width in a focused ultrasound beam
– Highlights area of interest
– Place at or slightly below
area of interest
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US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
Artifacts
Focus
US Principles Image Orientation
Artifacts
Masses Instrumentation
Focus
Masses Instrumentation
Don’t Get Fooled By Poor Technique
Pay Attention to Focal Zone
US Principles Image Orientation
Artifacts
Masses Instrumentation
Cine Loop
• Stores and displays images with no loss of
quality
Ancillary Functions
US Principles Image Orientation
Artifacts
Masses Instrumentation
M-Mode
• Useful in evaluating motion and velocity of
moving structures
– Fetal Heart Motion
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US Principles Image Orientation
Artifacts
Masses Instrumentation
OB Calculations
Sac Diameter
• Highlight and Select OB Calc

US Principles Image Orientation
Artifacts
Masses Instrumentation
OB Calculations
• Select [Single/A/B] soft key if needed
US Principles Image Orientation
Artifacts
Masses Instrumentation
Measurements
• Calipers, Add Caliper
• Individual measurements
– Trace, Ellipse
• Measures area and
circumference
US Principles Image Orientation
Artifacts
Masses Instrumentation
OB Calculations
• Highlight and select Biometry or AFI
US Principles Image Orientation
Artifacts
Masses Instrumentation
OB Worksheet
• Edit or Delete Measurements
• Enter Previous Exam Data
• Enter Comments
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US Principles Image Orientation
Artifacts
Masses Instrumentation
US Principles Image Orientation
OB Worksheet
US Principles Image Orientation
Artifacts
Masses Instrumentation
Artifacts
Masses Instrumentation
OB Worksheet
US Principles Image Orientation
Artifacts
Masses Instrumentation
OB Worksheet
Thank You
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Normal Anatomy of the
Female Pelvis
Sagittal Scan
• Longitudinal, vertical planes
• Divide the body into left & right
Mani Montazemi, RDMS
Mani Montazemi, RDMS
Female Anatomy
Clinical Instructor – Imaging Manager
Baylor College of Medicine
Division of Maternal-Fetal Medicine
Department of Obstetrics and Gynecology
Texas Children’s Hospital, Pavilion for Women
Houston Texas
Mani Montazemi, RDMS
Female Anatomy
Sagittal Scan
Sagittal Scan
H
A
F
P
Mani Montazemi, RDMS
Female Anatomy
Mani Montazemi, RDMS
Female Anatomy
Sagittal Scan
Mani Montazemi, RDMS
Female Anatomy
Sagittal Scan
Mani Montazemi, RDMS
Female Anatomy
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Sagittal Scan
Transverse Scan
• Horizontal planes
• Divide the body into superior & inferior
Mani Montazemi, RDMS
Female Anatomy
Mani Montazemi, RDMS
Female Anatomy
Transverse Scan
Transverse Scan
R
A
L
P
Mani Montazemi, RDMS
Female Anatomy
Transverse Scan
Mani Montazemi, RDMS
Female Anatomy
Mani Montazemi, RDMS
Female Anatomy
Transabdominal Transverse
Mani Montazemi, RDMS
Female Anatomy
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Uterus
Located in Pelvis Between
Bladder & Rectum
Mani Montazemi, RDMS
Female Anatomy
Vagina
• Lies between the
urinary bladder &
rectum
• The vaginal canal is
indicated by the bright
line separating the
anterior and posterior
walls
BL
Mani Montazemi, RDMS
Female Anatomy
Vagina
Vagina
• The vaginal canal
helps to identify the
midline view of the
uterus
• Helps to distinguish
lateral displacement of
the uterus
Mani Montazemi, RDMS
Female Anatomy
Mani Montazemi, RDMS
Female Anatomy
Vagina
Vagina
• If the hymen is
imperforated at
menarche the vagina
will fill with blood,
forming a
hematocolpos
Mani Montazemi, RDMS
Female Anatomy
Mani Montazemi, RDMS
Female Anatomy
3
1/6/2014
Vagina
Vagina
Mani Montazemi, RDMS
Female Anatomy
Mani Montazemi, RDMS
Female Anatomy
Cervix
Cervix
• Lower cylindrical neck of the uterus which
projects into vagina
• Internal os
– Junction of the uterine
cavity and endocervical
canal
• External os
– Junction of the
endocervical canal and
vagina
Mani Montazemi, RDMS
Female Anatomy
Mani Montazemi, RDMS
Female Anatomy
Cervix
Uterus
*
*
*
Mani Montazemi, RDMS
Female Anatomy
*
*
*
*
*
*
*
*
*
*
• Cervix
• Body
• Fundus
*
*
*
*
*
*
*
*
*
*
Mani Montazemi, RDMS
Female Anatomy
4
1/6/2014
Layers of Uterus
Endometrium
1. Endometrium
– Inner layer which varies in thickness & echo pattern
with stage of the menstrual cycle
2. Myometrium
– Thick, middle muscle layer
3. Serosa
– Thin outer layer
Mani Montazemi, RDMS
Female Anatomy
Mani Montazemi, RDMS
Female Anatomy
Myometrium
inner muscular layer – low echogenicity
Mani Montazemi, RDMS
Female Anatomy
Myometrium
middle muscular layer – moderate echogenicity
Mani Montazemi, RDMS
Female Anatomy
Myometrium
Serosa
arcuate arterial & venous plexus
Mani Montazemi, RDMS
Female Anatomy
Mani Montazemi, RDMS
Female Anatomy
5
1/6/2014
Endometrium
central stripe
Mani Montazemi, RDMS
Female Anatomy
Endometrium
inner functional layer
Mani Montazemi, RDMS
Female Anatomy
Endometrium
outer basal layer
Endometrial Thickness
• Thickness and echotexture depend upon
hormonal status
Mani Montazemi, RDMS
Female Anatomy
Mani Montazemi, RDMS
Female Anatomy
Normal Endometrial Cycle
Early Proliferative Phase
Mani Montazemi, RDMS
Female Anatomy
Linear Echogenic
Normal Endometrial Cycle
Late Proliferative Phase
Mani Montazemi, RDMS
Female Anatomy
Multilayered
6
1/6/2014
Normal Endometrial Cycle
Secretory Phase
Mani Montazemi, RDMS
Female Anatomy
Homogeneously Echogenic
Endometrial Appearance
• Under influence of
estrogen & progestrone
• The glandular epithelium
secrets a glycogen rich
fluid
• Spiral arteries become
tortuous
Mani Montazemi, RDMS
Female Anatomy
Intermenstrual Bleeding
When should the ultrasound examination be performed?
Endometrial Appearance
Mani Montazemi, RDMS
Female Anatomy
Premenopausal Endometrium
Basal layer remains thin & hyperechoic
throughout the menstrual cycle
Mani Montazemi, RDMS
Female Anatomy
Intermenstrual Bleeding
When should the ultrasound examination be performed?
• Immediate
Postmenstrual Phase
• The endometrium is
thin in this phase &
small endometrial
lesions are least likely
to be obscured
Mani Montazemi, RDMS
Female Anatomy
Mani Montazemi, RDMS
Female Anatomy
7
1/6/2014
Endometrial Thickness
1-3 mm
“Early Proliferation Phase”
Endometrial Thickness
4-7 mm
“Late Proliferation Phase”
Mani Montazemi, RDMS
Female Anatomy
Endometrial Thickness
Mani Montazemi, RDMS
Female Anatomy
Endometrial Thickness
8-15mm
“Secretory Phase”
Mani Montazemi, RDMS
Female Anatomy
Endometrial Appearance
Mani Montazemi, RDMS
Female Anatomy
Mani Montazemi, RDMS
Female Anatomy
Endometrial Appearance
Mani Montazemi, RDMS
Female Anatomy
8
1/6/2014
Endometrial Thickness
How to Measure?
SAG
TRV
Postmenopausal < 5mm
Mani Montazemi, RDMS
Female Anatomy
Mani Montazemi, RDMS
Female Anatomy
How to Measure?
SAG
TRV
Mani Montazemi, RDMS
Female Anatomy
Endometrial Measurements
Mani Montazemi, RDMS
Female Anatomy
Endometrial Measurements
• Not included in measurement:
– fluid/debris in canal
– subendometrial halo
Mani Montazemi, RDMS
Female Anatomy
Mani Montazemi, RDMS
Female Anatomy
9
1/6/2014
Endometrial Measurements
*
*
Endometrial Measurements
*
*
Mani Montazemi, RDMS
Female Anatomy
Endometrial Appearance
Mani Montazemi, RDMS
Female Anatomy
Endometrial Appearance
*
*
* *
Mani Montazemi, RDMS
Female Anatomy
Mani Montazemi, RDMS
Female Anatomy
Postmenopausal Endometrium
Postmenopausal Endometrium
• The endometrium
becomes atrophic
• Small amounts are
common, especially in
women receiving HRT
• Appears as a thin
echogenic line 4-5 mm
thick
Mani Montazemi, RDMS
Female Anatomy
• Aids in evaluating the
appearance of the
endometrium
Mani Montazemi, RDMS
Female Anatomy
10
1/6/2014
Uterine Positions
Uterine Positions
• Anteverted
– Tilted forward
• Anteflexed
– Forward fold between the
body & the cervix
• Retroverted
– Tilted backwards
• Retroflexed
– Flexed between body &
cervix
Mani Montazemi, RDMS
Female Anatomy
Tilted Forward
Mani Montazemi, RDMS
Female Anatomy
Uterine Positions
Uterine Positions
Tilted backwards
Mani Montazemi, RDMS
Female Anatomy
Mani Montazemi, RDMS
Female Anatomy
Uterine Size
• Childhood
– 2/3 cervix, 1/3 body &
fundus
• Puberty
– 1 to 1 ratio between
cervix body & fundus
• Adult
– 1/3 cervix, 2/3 body &
fundus
Mani Montazemi, RDMS
Female Anatomy
Uterine Shape
• Childhood
– Cylindrical shape
– Corpus shrinks due to withdrawal of
maternal hormones
– Will not grow until ovaries produce
hormones
• Puberty
– Assumes the pear shape
• Menopausal
– Shrinks & regress to prepubertal state
Mani Montazemi, RDMS
Female Anatomy
11
1/6/2014
Uterine Measurements
Uterine Measurements
SAG
8
Length
TRV
x 5Width x 3AP cm
Length
Mani Montazemi, RDMS
Female Anatomy
Uterine Measurements
SAG
TRV
AP
AP
Mani Montazemi, RDMS
Female Anatomy
Uterine Measurements
Mani Montazemi, RDMS
Female Anatomy
Width
Mani Montazemi, RDMS
Female Anatomy
Uterine Measurements
Mani Montazemi, RDMS
Female Anatomy
Uterine Measurements
Mani Montazemi, RDMS
Female Anatomy
12
1/6/2014
Uterine Measurements
Uterine Measurements
Don’t
Mani Montazemi, RDMS
Female Anatomy
Mani Montazemi, RDMS
Female Anatomy
Ovary
Ovary
• Range in size according to the age
3
Mani Montazemi, RDMS
Female Anatomy
Length
x
2
Width
x
1
AP
cm
Mani Montazemi, RDMS
Female Anatomy
Ovary
Ovarian Volume
• Volume
–
–
–
–
LxWxH/2
Adults – 9.8cm3 (+/-5.8)
Girls until about 5 yrs of age – < 1cm3
Menarche – 4.2cm3 (+/-2.3)
3 x 2 x 2 / 2 = 6cm3
Mani Montazemi, RDMS
Female Anatomy
Mani Montazemi, RDMS
Female Anatomy
13
1/6/2014
Follicular Cysts
Mani Montazemi, RDMS
Female Anatomy
Follicular Cysts
•
•
•
•
•
Follicular Cysts
Mani Montazemi, RDMS
Female Anatomy
Follicular Cysts
< 2.5 cm in diameter
Cysts are usually larger than a mature follicle (3-8cm)
Thin walled and unilocular
Usually unilateral
Can be multiple and bilateral
Mani Montazemi, RDMS
Female Anatomy
Follicular Cysts
Mani Montazemi, RDMS
Female Anatomy
Normal Anatomy of the
Female Pelvis
Thank You
Mani Montazemi, RDMS
Female Anatomy
Mani Montazemi, RDMS
Female Anatomy
14
1/6/2014
Transvaginal Scanning
Techniques
Sagittal Scan
Mani Montazemi, RDMS
Clinical Instructor – Imaging Manager
Baylor College of Medicine
Division of Maternal-Fetal Medicine
Department of Obstetrics and Gynecology
Texas Children’s Hospital, Pavilion for Women
Houston Texas
Mani Montazemi, RDMS
Endovaginal Sonography
Mani Montazemi, RDMS
Endovaginal Sonography
Sagittal Scan
H
A
Sagittal Scan
F
P
Mani Montazemi, RDMS
Endovaginal Sonography
Mani Montazemi, RDMS
Endovaginal Sonography
Sagittal Scan
Mani Montazemi, RDMS
Endovaginal Sonography
Sagittal Scan
Mani Montazemi, RDMS
Endovaginal Sonography
1
1/6/2014
Transverse Scan
Transverse Scan
A
R
L
P
Mani Montazemi, RDMS
Endovaginal Sonography
Mani Montazemi, RDMS
Endovaginal Sonography
Transverse Scan
Mani Montazemi, RDMS
Endovaginal Sonography
Transvaginal – Image Orientation
Transabdominal Transverse
Mani Montazemi, RDMS
Endovaginal Sonography
Transvaginal – Sagittal Plane
• Sagittal plane
• Transverse plane
F
A
F
H
P
A
P
H
Mani Montazemi, RDMS
Endovaginal Sonography
Mani Montazemi, RDMS
Endovaginal Sonography
2
1/6/2014
Transvaginal – Sagittal Plane
Transvaginal – Sagittal Plane
Mani Montazemi, RDMS
Endovaginal Sonography
Mani Montazemi, RDMS
Endovaginal Sonography
Transvaginal – Sagittal Plane
Transvaginal – Sagittal Plane
• Transducer notch is on top
• Thumb on notch
• Urinary bladder is in left
upper corner of sagittal image
• make sure the image is not
reversed
Feet
A
H
Anterior
P
Posterior
F
Head
Mani Montazemi, RDMS
Endovaginal Sonography
Mani Montazemi, RDMS
Endovaginal Sonography
Transvaginal – Sagittal Plane
Anteverted Uterus
F
A
Anteverted Uterus
Mani Montazemi, RDMS
Endovaginal Sonography
P
H
Uterine Fundus
Mani Montazemi, RDMS
Endovaginal Sonography
3
1/6/2014
Transvaginal – Sagittal Plane
Retroverted Uterus
F
A
P
H
Uterine Fundus
Retroverted Uterus
Mani Montazemi, RDMS
Endovaginal Sonography
Transvaginal – Sagittal Plane
Mani Montazemi, RDMS
Endovaginal Sonography
Mani Montazemi, RDMS
Endovaginal Sonography
Transvaginal – Sagittal Plane
Mani Montazemi, RDMS
Endovaginal Sonography
Transvaginal – Sagittal Plane
A
H
F
Transabdominal
P
Mani Montazemi, RDMS
Endovaginal Sonography
Mani Montazemi, RDMS
Endovaginal Sonography
4
1/6/2014
Transverse Scan
F
A
H
A
F
P
Transabdominal
Transvaginal
P
H
Mani Montazemi, RDMS
Endovaginal Sonography
Mani Montazemi, RDMS
Endovaginal Sonography
Transabdominal – Transverse
Mani Montazemi, RDMS
Endovaginal Sonography
Transvaginal – Transverse
Mani Montazemi, RDMS
Endovaginal Sonography
Transvaginal – Transverse
Transvaginal – Transverse
Feet
Right
Left
Head
Anteverted
Mani Montazemi, RDMS
Endovaginal Sonography
Mani Montazemi, RDMS
Endovaginal Sonography
5
1/6/2014
Transvaginal – Transverse
Transvaginal – Transverse Plane
Feet
H
L
R
Right
Left
F
Head
Retroverted
Mani Montazemi, RDMS
Endovaginal Sonography
Mani Montazemi, RDMS
Endovaginal Sonography
Transvaginal – Transverse
F
A
R
Mani Montazemi, RDMS
Endovaginal Sonography
L
R
L
Transabdominal
Transvaginal
P
H
Mani Montazemi, RDMS
Endovaginal Sonography
Transvaginal Scanning Motions
•
•
•
•
Insert & withdraw
Raise and lower
Angulation
Rotation
Mani Montazemi, RDMS
Endovaginal Sonography
Transvaginal Sonography
Thank You
Mani Montazemi, RDMS
Endovaginal Sonography
6
1/6/2014
Evaluation of the Cervix
Predicting Preterm Delivery
Ultrasound Evaluation
Of the Cervix
• Digital
• Fetal Fibronectin
• Ultrasound
Mani Montazemi, RDMS
Mani Montazemi, RDMS
Ultrasound of the Cervix
Clinical Instructor – Imaging Manager
Baylor College of Medicine
Division of Maternal-Fetal Medicine
Department of Obstetrics and Gynecology
Texas Children’s Hospital, Pavilion for Women
Houston Texas
Least accurate method to measure cervical
length & to identify a cervical funnel
Mani Montazemi, RDMS
Ultrasound of the Cervix
Lower Uterine Segment
Mani Montazemi, RDMS
Ultrasound of the Cervix
Transabdominal
Translabial
Transvaginal
Mani Montazemi, RDMS
Ultrasound of the Cervix
J Ultrasound Med 22:239-241, 2003
Filling of the Bladder For Pelvic Sonograms
Beryl R. Benacerraf, MD
Mani Montazemi, RDMS
Ultrasound of the Cervix
Lower Uterine Segment
Mani Montazemi, RDMS
Ultrasound of the Cervix
1
1/6/2014
Transabdominal Examination
Pitfalls
–
–
–
–
–
–
–
Presenting fetal part
Bladder distension
Symphysis pubis cartilage
External os not visible
Critical angle artifact
Large maternal body habitus
Lower uterine contraction
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
Transabdominal Examination
Pitfalls
–
–
–
–
–
–
–
Mani Montazemi, RDMS
Ultrasound of the Cervix
Placenta Previa: False Positives
Over distended bladder can compress the lower
uterine segment to give the appearance of an
anterior previa
Mani Montazemi, RDMS
Ultrasound of the Cervix
Presenting fetal part
Bladder distension
Symphysis pubis cartilage
External os not visible
Critical angle artifact
Large maternal body habitus
Lower uterine contraction
Mani Montazemi, RDMS
Ultrasound of the Cervix
Transabdominal Examination
Pitfalls
–
–
–
–
–
–
–
Presenting fetal part
Bladder distension
Symphysis pubis cartilage
External os not visible
Critical angle artifact
Large maternal body habitus
Lower uterine contraction
Mani Montazemi, RDMS
Ultrasound of the Cervix
2
1/6/2014
Transabdominal Examination
Transabdominal Examination
Pitfalls
Pitfalls
–
–
–
–
–
–
–
–
–
–
–
–
–
–
Presenting fetal part
Bladder distension
Symphysis pubis cartilage
External os not visible
Critical angle artifact
Large maternal body habitus
Lower uterine contraction
Mani Montazemi, RDMS
Ultrasound of the Cervix
Transabdominal Examination
Pitfalls
–
–
–
–
–
–
–
Presenting fetal part
Bladder distension
Symphysis pubis cartilage
External os not visible
Critical angle artifact
Large maternal body habitus
Lower uterine contraction
Mani Montazemi, RDMS
Ultrasound of the Cervix
Placenta Previa: False Positives
Presenting fetal part
Bladder distension
Symphysis pubis cartilage
External os not visible
Critical angle artifact
Large maternal body habitus
Lower uterine contraction
Mani Montazemi, RDMS
Ultrasound of the Cervix
Lower Uterine Segment Contraction
Post Void
• Are common!
• These contractions are very slow & long
Mani Montazemi, RDMS
Ultrasound of the Cervix
“Contractions”
Round myometrium
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
3
1/6/2014
“Contractions”
Thick & asymmetric LUS
Mani Montazemi, RDMS
Ultrasound of the Cervix
“Contractions”
“Contractions”
Thick & asymmetric LUS
Myometrial Thickness ≤ 1.5 cm
Mani Montazemi, RDMS
Ultrasound of the Cervix
Thick & asymmetric LUS
Myometrial Thickness ≤ 1.5 cm
“Contractions”
Cervical length > 5 – 5.5cm
Thick & asymmetric LUS
Myometrial Thickness ≤ 1.5 cm
Cervical length > 5 – 5.5cm
“S” shaped cervical canal
Mani Montazemi, RDMS
Ultrasound of the Cervix
“Contractions”
Mani Montazemi, RDMS
Ultrasound of the Cervix
Thick & asymmetric LUS
Myometrial Thickness ≤ 1.5 cm
“Contractions”
Cervical length > 5 – 5.5cm
Thick & asymmetric LUS
Myometrial Thickness ≤ 1.5 cm
Cervical length > 5 – 5.5cm
“S” shaped cervical canal
“S” shaped cervical canal
Internal os cephalad to
bladder reflection
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
4
1/6/2014
Common Indications
for TV Evaluation of Cervix
If indicated, the cervical length
should ALWAYS be measured
with transvaginal approach
Mani Montazemi, RDMS
Ultrasound of the Cervix
• Evaluating patients with vaginal bleeding to look for placenta
previa
• Fetal parts
• Diagnosing cervical incompetence
• Assessing cervical effacement and dilation in patients with
preterm labor
• Multiple Gestations
• Post cerclage placement
• History of preterm labor
• Succenturiate lobed placentas
• Velamentous cord insertion
Mani Montazemi, RDMS
Ultrasound of the Cervix
Preterm Delivery
Whether that‟s due to incompetent cervix
or preterm labor leading to preterm birth
is the single most common cause
of poor neonatal outcome
Mani Montazemi, RDMS
Ultrasound of the Cervix
Transvaginal Approach
Mani Montazemi, RDMS
Ultrasound of the Cervix
Preterm Delivery
•
•
•
•
Effects 8% of births
Accounts for 15 – 20% of neonatal deaths
75% of non-anomaly deaths
Treatment > $5 billion/yr USA
Mani Montazemi, RDMS
Ultrasound of the Cervix
Transvaginal Approach
Mani Montazemi, RDMS
Ultrasound of the Cervix
5
1/6/2014
Transvaginal Approach
Transvaginal Approach
Feet
Anterior
Posterior
Head
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
Anatomic Landmarks for
Vaginal Sonography
Bladder
External Os
Chorioamnion Membrane
Mani Montazemi, RDMS
Ultrasound of the Cervix
Cervical Length
Internal Os
“Minimizing the effect of excess pressure”
Good midline sagittal view of the cervix
Transvaginal Approach
Mani Montazemi, RDMS
Ultrasound of the Cervix
Transvaginal Approach
Wall of the
vagina
*
Be careful - Excess Pressure
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
6
1/6/2014
Excessive Probe Pressure
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
Excessive Probe Pressure
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
Cervical Length
•
•
•
•
Upper limit of normal
Average
Lower limit of normal
Pathologically decreased
Mani Montazemi, RDMS
Ultrasound of the Cervix
Cervical Length
5.0 cm
4.0 cm
3.0 cm
2.0 cm
Mani Montazemi, RDMS
Ultrasound of the Cervix
7
1/6/2014
“ One step” vs. “Two step” Technique
“ One step” vs. “Two step” Technique
Straight
or
Curved
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
Curved Cervix
Cervical Changes
• Essentially the same in
– Term labor
– Preterm labor
– Cervical incompetence
Mani Montazemi, RDMS
Ultrasound of the Cervix
If height ≥ 5 mm  “two step” technique
Mani Montazemi, RDMS
Ultrasound of the Cervix
Cervical Changes
Cervical Changes
•T
•Y
•V
•U
• Trust
• Your
• Vaginal
• Ultrasound
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
8
1/6/2014
Cervical Changes
Cervical Changes
•
•
•
•
•
T
Y
V
U
Mani Montazemi, RDMS
Ultrasound of the Cervix
Dilation
Effacement
Funneling or Beaking
Posterior – caudal
Bulging membranes
Mani Montazemi, RDMS
Ultrasound of the Cervix
Cervical Changes
• Dilation
– Widening of the endocervical canal from side to
side
Mani Montazemi, RDMS
Ultrasound of the Cervix
Cervical Changes
• Effacement
– Shortening of the cervix
– Reduction of the cervical length from internal end
to external end
Mani Montazemi, RDMS
Ultrasound of the Cervix
Cervical Changes
• Funneling or Beaking
– Extension of amniotic fluid for some variable
distance (≥ 5mm) into the endocervical canal from
internal os toward external os
– „V‟ shape
• More common, triangular “notch” at the internal os
– „U‟ shape
• Uncommon, typically larger than V-shaped variety
• Usually deeper than it is broad and may be dynamic
Mani Montazemi, RDMS
Ultrasound of the Cervix
Cervical Changes
• Funneling or Beaking
– Extension of amniotic fluid for some variable
distance (≥ 5mm) into the endocervical canal from
internal os toward external os
– „V‟ shape
• More common, triangular “notch” at the internal os
– „U‟ shape
• Uncommon, typically larger than V-shaped variety
• Usually deeper than it is broad and may be dynamic
Mani Montazemi, RDMS
Ultrasound of the Cervix
9
1/6/2014
Cervical Changes
• Funneling or Beaking
– Extension of amniotic fluid for some variable
distance (≥ 5mm) into the endocervical canal from
internal os toward external os
– „V‟ shape
• More common, triangular “notch” at the internal os
– „U‟ shape
• Uncommon, typically larger than V-shaped variety
• Usually deeper than it is broad and may be dynamic
Mani Montazemi, RDMS
Ultrasound of the Cervix
Cervical Changes
• Funneling or Beaking
– Extension of amniotic fluid for some variable
distance (≥ 5mm) into the endocervical canal from
internal os toward external os
– „V‟ shape
• More common, triangular “notch” at the internal os
– „U‟ shape
• Uncommon, typically larger than V-shaped variety
• Usually deeper than it is broad and may be dynamic
Mani Montazemi, RDMS
Ultrasound of the Cervix
Cervical Beaking – V Shape
Mani Montazemi, RDMS
Ultrasound of the Cervix
Cervical Funneling – U Shape
Mani Montazemi, RDMS
Ultrasound of the Cervix
Cervical Funneling
Diagnostic Challenge
Funnel Length
> 1.6 cm
Cervical Length
< 2.0 cm
Funnel Width
>1.4 cm
Sonographic Criteria
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
10
1/6/2014
Diagnostic Challenge
Mani Montazemi, RDMS
Ultrasound of the Cervix
Diagnostic Challenge
Mani Montazemi, RDMS
Ultrasound of the Cervix
Diagnostic Challenge
Mani Montazemi, RDMS
Ultrasound of the Cervix
Diagnostic Challenge
Mani Montazemi, RDMS
Ultrasound of the Cervix
Cervical Changes
to
• Posterior  Caudal
– In the early to mid pregnancy the cervix points
posteriorly toward the sacrum
Mani Montazemi, RDMS
Ultrasound of the Cervix
Cervical Changes
to
• Posterior  Caudal
– In the early to mid pregnancy the cervix points
posteriorly toward the sacrum
– As the woman progresses towards labor the cervix
starts to rotate to line up with vagina
Mani Montazemi, RDMS
Ultrasound of the Cervix
Soft
11
1/6/2014
Cervical Changes
Preterm Labor
“to evaluate for cervical dilation”
• Bulging of membranes
– Fluid extends all the way to the external os
– If into vagina, delivery likely unstoppable
BLADDER
AF
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
Preterm Labor
“to evaluate for cervical dilation”
Mani Montazemi, RDMS
Ultrasound of the Cervix
Diagnostic Challenge
Mani Montazemi, RDMS
Ultrasound of the Cervix
Cervix – Dynamic Changes
Remember
Cervical Change
is Dynamic!
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
12
1/6/2014
Cervix – Dynamic Changes
Mani Montazemi, RDMS
Ultrasound of the Cervix
Cervical Stress Test with
Gentle Pressure
Mani Montazemi, RDMS
Ultrasound of the Cervix
Cervix – Dynamic Changes
Mani Montazemi, RDMS
Ultrasound of the Cervix
Cervical Stress Test with
Gentle Pressure
Mani Montazemi, RDMS
Ultrasound of the Cervix
Cervical Stress Test with
Gentle Pressure
Don’t…
• Use cervical ultrasound as a screening test
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
13
1/6/2014
Don’t…
Don’t…
• Rely upon transabdominal ultrasound to
measure length to identify a funnel. It is not
reproducible because of the variable pressure
created by the maternal bladder
• Measure cervical length before16 weeks, too
much variation to be useful
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
Introduction to Ultrasound
Evaluation of the Cervix
Diagnostic Challenge
Thank You
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
Diagnostic Challenge
Vasa Previa
• Partial or complete obstruction of the internal
cervical os by blood vessels
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
14
1/6/2014
Vasa Previa
•
•
•
•
•
Low lying placentas;
Succenturiate lobed placentas;
Velamentous cord insertion;
Multiple pregnancies;
Pregnancies resulting from IVF
Risk Factors
Most Common
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
Placenta Previa – Marginal
Placenta Previa – Partial
Inferior edge of placenta within 2cm of IO
Often resolves with advancing pregnancy
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
Placenta Previa – Complete
Mani Montazemi, RDMS
Ultrasound of the Cervix
Edge of placenta partially covers IO
Difficult to differentiate from marginal previa
Often resolves with advancing pregnancy
Asymmetric complete previa
Small part of placenta crosses IO
May resolve with advancing pregnancy
If > 1.5 cm crosses IO then less likely to resolve
Placenta Previa – Complete
Mani Montazemi, RDMS
Ultrasound of the Cervix
Symmetric complete previa
Placenta centrally implanted on cervix
Will not resolve with advancing pregnancy
15
1/6/2014
3 weeks later
27 weeks
Hospitalized with bleeding
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
• It is recognized that apparent placental position
early in pregnancy may not correlate well with
its location at the time of delivery
• It is recognized that apparent placental position
early in pregnancy may not correlate well with
its location at the time of delivery
• “Trophotropism”
• “Trophotropism”
– The ability or the desire of the placenta to
seek a blood supply
– Proliferation of placental villi in areas of better
blood supply (corpus , fundus)
Kurt Benirschke, MD
– The ability or the desire of the placenta to
seek a blood supply
– Proliferation of placental villi in areas of better
blood supply (corpus , fundus)
Kurt Benirschke, MD
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
16
1/6/2014
Trophotropism
Succenturiate lobe
• May be low-lying or cross internal os
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
Trophotropism
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
17
1/6/2014
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
Mani Montazemi, RDMS
Ultrasound of the Cervix
Introduction to Ultrasound
Evaluation of the Cervix
Thank You
Mani Montazemi, RDMS
Ultrasound of the Cervix
18
12/22/2015
Sonography in the First Trimester
Basic Embryology
1mm
Sac
G. William Shepherd PhD, RDMS, RVT
1
Embryonic Timeline





Ovulation: Day 14-16
Fertilization: Day 14-16
Zygote to Morula: Day 16-18
Morula to Blastocyst: Day 18-19
Implantation: Day 19-20
2
Embryology Terms
Gamete --------- Before fertilization
Zygote ---------- After fertilization
Morula --------- 16 -32 Cells (18 Days)
Blastocyst ---------- 20 Days
Embryonic Disc --- 28 Days
Ultrasound Detection --- 31 Days
Earliest Heart Beat ------ 36 Days



Week 3




3
Yolk Sac Formation: 4w1d
4
Goals for a 1st Trimester Scan





5
Visualization and localization of the
gestational sac
Determination of viability
Determination of the # of embryos & viability
Estimation of gestational age
Determination of any detectable anomalies
6
1
12/22/2015
Earliest Definite Ultrasound Visualization: 31days
4W6D
7
Is this an IUP?
coronal
Pre-embryonic (embryonic disc stage 4w4d or 32days)
8
“Double Sac” Sign
9
10
“Double Sac” Sign
11
12
2
12/22/2015



Pre-Embryonic Period: 3-5 weeks (by LMP)
zygote, morula, blastocyst, implantation,
embryonic disc, gastrulation (tubular embryo)
Embryonic Period: 6-10 weeks heart beat, and
organ formation
Fetal Period: 11 weeks to term
(all organs are present)
13
14
5 weeks by LMP
Estimation of Gestational Age
from the MSD
(mean sac diameter)
Age in Days (by LMP) = (L+W+H) + 30
3
15
16
5w0d by LMP
Transabdominal scan
with EV probe
1cm
4mm
6mm
Width (from trv image) = 6
6+6+4 divided by 3 = 5.3, +30 = 35.3d or 5w
17
18
3
12/22/2015
EV Coronal (trans)
19
20
5 weeks 6 days by LMP
Human Chorionic Gonadotropin

+
x


x

+


xx 13mm
++ 11mm
Width 15mm MSD 13 = 43d =6w1d

9.25
21
Beta Chorionic Gonadotropin Levels






MSD
2mm
5mm
10mm
15mm
20mm
Age (weeks)
5.0
5.4
6.0
6.6
CRL
7.3
Made by trophoblastic cells
Detectable after implantation
Doubling time every 2-3 days
Correlates well with embryonic and sac size
Level maximizes at about 8 weeks
Max level is about 50,000 -100,000 IU/L
Declines after 10-12 weeks
HCG Level
1,164
1,932
4,478
10,379
24,060
22
4-5mm
x
x
* Filly, in Ultrasonography in Obstetrics and Gynecology, ed Callen,
W.B. Saunders, Philadelphia, 1994.
23
24
4
12/22/2015
“Diamond Ring” Sign
Embryonic Timeline




Week 6: Heartbeat will be detectable during this week.
This is the neural tube stage
Weeks 6-10: Essentially all of the tissues and organs
of the embryo will form during this period.
Week 11: All of the organs are present and all but a
portion of the bowel and the external genitalia are in
their final positions.
Week 12: The bowel will reenter the fetal abdomen.
25
5w5d
6w1d
26
CRL and Gestational Age
CRL
2mm
4
8
10
15
20
25
30
40
50
3 days development and growth
Gest. Age
5.7 weeks
6.1
6.7
7.2
7.9
8.6
9.2
9.9
10.9
11.7
27
CRL
60mm
70
80
90
100
110
130
Gest. Age
12.5 weeks
13.2
14.0
14.9
15.9
16.9
17.9
Hadlock et al
Radiology 18: 501, 1992
28
+ + 5mm
6w1d
“Double Bleb” Sign = Yolk sac and the Early Embryo
29
30
5
12/22/2015
6w1d
6w0d
Day
43
Day
48
Day
55
10w0d
Day
61
Day
66
Day
70
31
32
6w3d
2mm
Early Embryo 5w6d
33
34
CRL = 18mm 8w3d
Embryonic Period 7w3d
Fluid?
Oblique Scanning Plane
Fluid?
35
36
6
12/22/2015
Don’t include the yolk sac in the CRL
13mm
7w2d
37
38
Be aware of fetal position
39
41
40
6w1d
7w4d
8w4d
10w3d
42
7
12/22/2015
Manipulation of Transducer for CRL
After 13 weeks use BPD, HC, AC, and FL
43
Skeletal Development
8w2d
44
10w3d
9w3d
45
Questions?






46
Indications for a First Trimester Scan
Is there a pregnancy?
Where is it?
Is it alive?
How many embryos? Are they all alive? All
IUPs?
How far along is the pregnancy?
Anything wrong with the fetus? Sac? Adnexa?
9.5
47







Vaginal bleeding
Size and date discrepancy
No heart tones
Pelvic pain
Accurate dating for future C-section
History of an anomaly
Trauma
48
8
12/22/2015
7 Week Embryo
Significance of the Yolk Sac






Earliest landmark in the early gestational sac
Identifies an IUP
Helps to locate the embryo and heart beat
Should be round and “cystic” 3-6mm
1 yolk sac per embryo, can help identify
monoamnionic twins
Should disappear by 12 weeks
49
50
7 Week Embryo
Yolk Sac
Yolk Sac
Amnion
Chorionic Fluid
Amniotic Fluid
51
Yolk Sac
Too big
52
Irregular-Shaped Yolk Sac
Amorphous
Embryo
1 cm
1.5 cm
Free Fluid
53
54
9
12/22/2015
Vaginal Bleeding (1st Trimester)






Implantation Bleed
Abortion
Subchorionic Hemorrhage
Placental Previa
Ectopic Pregnancy
Blighted Ovum
Compressed Yolk Sac
55
56
The future Jen Shepherd
Implantation Bleed



Most common cause of 1st trimester
vaginal bleeding
Generally not significant
Sonolucent area between the chorion
and uterus (near the internal os)
57
58
Subchorionic Bleeds
Vaginal Bleeding (1st Trimester)







Implantation Bleed
Subchorionic Hemorrhage
Abortion
Placental Previa
Ectopic Pregnancy
Blighted Ovum



59
Can be behind the placenta
Can be behind the chorion lavae
Can be behind the chorionic plate of the placenta
Prognosis depends upon the cause and how much
of the placenta is involved: >1/3 prognosis worsens
60
10
12/22/2015
61
62
63
64
1/4 of placenta is separated from uterus
Vaginal Bleeding: 1st Trimester



8w2d



65
Implantation Bleed
Subchorionic Hemorrhage
Blighted Ovum
Placental Previa
Ectopic Pregnancy
Abortion
66
11
12/22/2015

Blighted Ovum: Arrested or absent development of
the embryonic pole (trophoblasts develop)
No embryo
or Yolk Sac
67
Growth will fall off
HCG will level off
Sac may move
toward Cx
68
Trophoblastic ring
may become irregular
and thin < 2mm
69
70
71
72
Multiple
Irregularities
12
12/22/2015
About 20% of all eggs are incapable of forming an
embryo and will produce a blighted ovum
or new term an anembryonic pregnancy.
Some pregnancies will form an embryo and it will
die early. This is early embryonic demise.
There is an important, although often overlooked
difference between anembryonic pregnancy and
early embryonic demise.
Anembryonic pregnancies do not increase the
chances of future pregnancy failure. They are due
to some inherently “bad” eggs found in all women.
Early embryonic demise may herald a genetic
defect and thus signify possible future pregnancy
failures. Genetic testing may be desirable for
Patients with multiple early demise pregnancies.
These pregnancies may have a visible yolk sac
but the embryo usually becomes necrotic.
73
Vaginal Bleeding: 1st Trimester
74
Placenta Previa







Implantation Bleed
Abortion
Subchorionic Hemorrhage
Placental Previa
Ectopic Pregnancy
Blighted Ovum




The placenta covers the internal cervical os
Unusual finding during the 1st trimester
Placental “migration” may eliminate the previa
Vaso previa may be present even though the
placenta has “migrated”. Rule out vaso previa
with color Doppler
A partial mole can present with placenta previa
75
76
Vaginal Bleeding: 1st Trimester
Placenta Previa
16w1d






77
Implantation Bleed
Abortion
Subchorionic Hemorrhage
Placental Previa
Ectopic Pregnancy
Blighted Ovum
78
13
12/22/2015
Glossary of 1st Trimester Terms


Inevitable Abortion
Abortion: Premature expulsion of the gestation
from the uterus
Incomplete Abortion: The expulsion of only a
portion of the gestational products from the uterus
79
80
Missed Abortion
Fetal Parts
Abortion
in progress
81
82
Retained Products of Conception
83
84
14
12/22/2015
Findings for Embryonic Demise
Old Criteria






Findings for Embryonic Demise

The Findings Below Depend upon Body Habitus
and Type of Transducer, Endovag or transabd
No Sac Growth on Serial Exams
No Cardiac Pulsations in a 5mm Embryo
No Embryo Seen in a Sac 25mm MSD
No Yolk Sac Seen in a 20mm MSD Sac
Trophoblastic Ring is not Intact




No Sac Growth on Serial Exams
A 7 -10 day interval between scans is
recommended
Give the embryo a chance
EV scanning is always best
Abdallah et al US Obstet & Gynecol 2011
85
The Gestational Sac Grows about 1mm/Day
1 Week Should Give a Statistically Significant Increase in MSD
Jan 4
Jan 11
MSD = 3mm
86
Findings for Embryonic Demise

MSD = 10mm 87
Reading an M-Mode
88
Findings for Embryonic Demise

1 second
Heart rate only 60 bpm
Slow Cardiac Pulsations in a 5 (now 7) mm Embryo in an
endovaginal ultrasound examination
No Cardiac Pulsations in a 9mm Embryo in a
transabdominal ultrasound examination
1 second
M-Mode No Heart-beat
Heart rate 160 bpm
89
90
15
12/22/2015
91
92
93
94
95
96
16
12/22/2015
Findings for Embryonic Demise

No Embryo Seen in a Sac 18 (now 25) mm MSD in an
endovaginal ultrasound examination
97
Findings for Embryonic Demise


98
Findings for Embryonic Demise
No Embryo Seen in a Sac 25mm MSD in an
transabdominal or EV ultrasound examination
Was 20mm

No Yolk Sac Seen in a 10mm MSD Gestational Sac
with endovaginal scanning
99
Findings for Embryonic Demise

100
New Criteria for Embryonic Demise
No Yolk Sac Seen in a 20mm
MSD Gestational Sac with
transabdominal scanning




MSD 25mm



No Sac Growth on Serial Exams
No Cardiac Pulsations in a 7 mm Embryo*
No Cardiac Pulsations in a 9mm Embryo **
No Embryo Seen in a Sac 25 mm MSD*
No Embryo Seen in a Sac 25mm MSD**
No Yolk Sac Seen in a 10mm MSD Sac *
No Yolk Sac Seen in a 20mm MSD Sac**
* endovaginal scanning
** transabdominal scan
10.0
101
102
17
12/22/2015
Anembryonic Pregnancy
Small for Dates






Normal Pregnancy / Wrong Dates
Anembryonic Pregnancy (blighted ovum)
Ectopic Pregnancy
Fetal Demise
Oligohydramnios
Intrauterine Growth Retardation (IUGR)
Embryonic Demise
Oligohydramnios
S<D
Ectopic Pregnancy
103
104
Pseudo-sac
Ectopic Pregnancy





95% occur in the tube
5% are interstitial and
are the most dangerous
Cornual and cervical
ectopics are increasing
In vitro procedures
increase the chance of
ectopic pregnancy
Heterotopic: IUP plus
an ectopic
Transabdominal scans
105
Pseudo-sac
Endovaginal scans
106
Ruptured Ectopic
107
Live Ectopic Pregnancy in Right Fallopian Tube
108
18
12/22/2015
Ectopic Pregnancy in Right Cornu
Cervical Ectopic Pregnancy
109
110
Right & Left Horns of
Bicornuate Uterus
Ectopic?
Uterus?
111
112
Hemorrhagic Corpus Luteum Can Look Like an Ectopic
113
114
19
12/22/2015
Molar Pregnancy






Large for Dates
Vaginal Bleeding
Very High HCG
May be a live embryo
1 in 1200 pregnancies in the USA
Risk is 20-40 fold higher if patient had a
previous molar pregnancy (1 in 30-60)
115
116
Theca Lutein Cysts
There may or may not be a sac.
117
The arrow heads point to the major portion of the mole.
The white arrows point to echogenic invasive villi that extent
almost to the serosal surface of the uterus (black arrows).
119
118
Partial Mole at 12 weeks -Top, 14 weeks - Bottom
120
20
12/22/2015
Large for Dates




Normal Pregnancy / Wrong Dates
Molar Pregnancy
Gestation with Mass / Masses
Multiple Gestation
10.25
121
Bicornuate Uterus
122
Bicornuate Uterus
IUP
123
124
Early Pregnancy with a Mass
Hydatidiform Mole
Theca Lutien Cysts
125
126
21
12/22/2015
Multiple Gestation
127
128
Triplets
Bleeds
B
A
3
C
1
E
D
2
129
Anomalies: Detectable in the 1st Trimester
(Endovaginal Scanning is Best)




Anencephaly
Acrania
Cystic hygroma
Hydrops




Conjoined twins
Large omphalocele
Severe gastroschisis
Thanatophoric dwarf
130
Normal Head at 12 Weeks
Transverse Head at 12 Weeks
Choriod Plexus
Frontal
Occipital
131
132
22
12/22/2015
Anencephaly at 12w3d
133
134
2mm
Acrania at 10w2d
Normal Nuchal Translucency 10w6d
135
136
Normal Herniation of the Gut
into the Base of the Cord at 11w2d
Bilateral Cystic Hygroma at 9w4d
137
138
23
12/22/2015
Omphalocele
12w4d
Low Beta HCG Levels



Blighted Ovum
Wrong Dates
Ectopic Pregnancy
139
140
141
142
High Beta HCG Levels




Wrong Dates
Multiple Gestation
Molar Pregnancy
Choriocarcinoma
24
12/22/2015
Obstetric Scanning: Normal Anatomy
gshepherd@hvc.rr.com
Bill Shepherd PhD, RDMS, RVT
1
Objectives 2nd and 3rd Trimester (1)
2
Objectives 2nd and 3rd Trimester (2)
Evaluation of basic fetal anatomy
4 chamber Heart, Diaphragm
Stomach
Urinary Bladder & Kidneys
Abdominal Cord & Insertions
Skeleton
Head, Face, Neck
Documentation of fetal life, # & presentation
Documentation of amniotic fluid volume
Documentation of placental location
Documentation of obstetric age
Evaluation of uterus, fluid, cervix & placenta
These are the minimum requirements of a 2nd trimester scan
from the American Institute of Ultrasound in Medicine (1985)
3
Determine Fetal Presentation
4
Sag mll
Show Fetal
Position
SAG ML
Breech or transverse head right
5
6
1
12/22/2015
Drag inferior to superior
Slide Inferior to Superior
7
8
Motion 11 weeks / 24 weeks
Documentation of Life
1. Fetal motion
2. Fetal heart motion
3. Fetal circulation (Doppler)
9
M-Mode of the
Fetal Heart
1
2 3
4
10
M-Mode
5 beats
2 seconds
150 beats /minute
11
12
2
12/22/2015
Number of Fetuses
Amniotic Fluid
1. AFI
2. Largest pocket
3. “Eyeball”
13
14
Lower Uterine
Segment
Posterior
Anterior
?
Placental Location
15
16
Placenta
Translabial or
Transvaginal
Sonography
17
Placental Position
LUS - Rule out previa
18
3
12/22/2015
Placenta Previa?
?
Incompetent Cervix
11.0
19
33 weeks
20
Tropho-tropism:
Sag ml
The preferential proliferation of
trophoblastic villi into regions of better
endometrial blood supply
Atrophy of villi occurs where there is
poorer endometrial blood supply
21
22
Placenta Previa: Risk Factors
Tropho-tropism Explains:
Advance maternal age
High parity
Prior cesarean section*
Prior elective abortion
Multiple fetuses
Smoking
IVF
Resolution of placenta previa
Succenturiate lobes of placentas
Marginal & velamentous cord insertions
Vasoprevia
Prolapsed cord
23
24
4
12/22/2015
Placenta Previa: False Positives
Risk of Placenta Previa
After Caesarian Sections
# of C-Sections
0
1
2
3
4
Overfilling of the bladder
Risk of Previa
.26%
.65%
1.8%
3.0%
10%
Pseudoprevia
25
26
False Positives
Normal
Pseudo-previa
Previa
Contraction
3cm
6cm
27
Placental Abruption
28
Placental Abruption
Placental abruption is premature separation of
the placenta from the uterus.
Approximately 1% of pregnancies.
15-25% of all perinatal mortality.
Usually pain & vaginal bleeding.
A central abruption may present with pain but no
bleeding.
The recurrent risk is about 1 in 8 pregnancies.
29
30
5
12/22/2015
The 2 types of Placental Abruptions
mass effect.
Clinical Findings: Placental Abruption
vaginal bleeding.
Vaginal Bleeding
Uterine tenderness
Tetanic uterine contraction
Rapid labor
Fetal demise or distress
Disseminated intravascular coagulation
31
Fresh Placental Abruption
32
Central Placental
Abruption
Hemorrhage
Placenta
33
Placental Abruption: False Positives
34
Venous lake / gain increased
Fibroids
Marginal Veins
Contractions
Venous Lakes
35
36
6
12/22/2015
Marginal
Veins
37
38
Scanning Planes of the Fetal Head
Normal Fetal Anatomy &
Measurements
Sagittal
Head, Neck Spine
Abdominal/ Abdominal wall
Urological, Genital
Skeletal
Cardio-thoracic
39
11.25
41
Coronal
Axial
40
42
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12/22/2015
Transventricular
Choroid Plexus
In lateral ventricle
43
44
Transcerebellar
Transcerebellar
Thalamus 3rd Vent
Cerebellum Cisterna Magnum
45
46
Transcerebellar View
Cavum Septum
Pellucidi
Transthalamic
Cisterna Magna


Cerebellar
hemisphere

47
Head is ovoid in shape
Symmetrical hemispheres
Sharp edges
**
48
8
12/22/2015
Tilting transducer for head views
Abdominal Views
Abdominal section should be round
Stomach bubble should be seen
Umbilical portion of the PV should be seen
and should be 1/3 of the distance to the
center of the abdomen
A cross-section of the fetal spine showing all
three ossification centers should be seen
49
The Fetal Abdominal Circumference
50
The Fetal Abdominal
1 Stomach
2 Portal vein
3 Spine
4 Aorta
5 Abdominal muscles
6 Spleen
7 Liver
6
4
3
1
2
7
5
51
52
Normal or Abnormal?
Why is the stomach so small?
There is nothing to drink…oligohydramnios
53
54
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12/22/2015
R
2
1
4
3
Subtle Tilting of the Transducer
Abdomen
5
1. Umbilical vein
2. Liver
3. Stomach
4. Aorta / IVC
5. Spine
L
55
56
Femur
Epiphysis
57
58
Short Axis
Long Axis
4 Chamber
4 Chamber Heart
at 14 weeks
59
60
10
12/22/2015
Good view for
Heart rate with
M-Mode
11.5
61
62
Normal Position of the Fetal Heart
Good 4 Chamber Views @
27weeks
20 weeks
45 0
L
Aorta
LV RV
LA
RA
R
63
64
What can be seen in this image?
65
66
11
12/22/2015
Rock, slide & drag to see kidneys free of shadow
placenta
umbilical
cord
aorta
IVC
stm
amniotic
fluid
sp
kidneys
67
68
69
70
Urinary Bladder - don’t confuse it with the stomach
Fetal Spine
 Sagittal
Plane
 Transverse Plane
 Coronal Plane
Sagittal
Coronal
Umbilical Cord Insertion in Fetal Abdomen
71
Transverse
72
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12/22/2015
Anterior
This Sag view is of a fetus
in Breech Position
Posterior Ossification Center
Caudal
Cephalad
Anterior Ossification Center
73
Sagittal image of fetal bladder, diaphragm & heart
Fetus is in a vertex position.
74
What is the placental position?
Diaphragm
Biophysical Profile Image
The “Take home Picture”
Rule/ out:
Bossing
Macroglossia
Micrognathia
Nasal bridge
Other
75
76
Cord
Diaphragm
77
78
13
12/22/2015
?
1
?
2
3
Position?
4
Sag
79
80
?
Legs
81
Which one is normal?
83
Arm
82
Frontal
Bossing
11.75
84
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12/22/2015
Macroglossia?
85
86
Twins at 20 and 28 weeks
?
?
Sag ML
28 weeks
Normal?
87
Pseudo-previa
88
My Strangest Case:
8 years after delivery
89
90
15
12/22/2015
91
16
12/22/2015
Fetal Measurements
Measurements
Biparietal Diameter (BPD)
 Head Circumference (HC)
 Abdominal Circumference (AC)
 Femur Length (FL)

G. W. Shepherd
1
2
Caliper Placement
Markers for the BPD & HC
+
+
+
+
3
4
Finding the CSP
5
6
1
12/22/2015
Almost Coronal
+
7
Head low
in Pelvis
8
OFD
9
10
Dolichocephalic &
Brachiocephalic
Cephalic Index (CI) = BPD/OFD
11
Pair HC with BPD to compensate for shape
12
2
12/22/2015
Abdominal Circumference
13
14
15
16
Markers for AC
 Stomach
 Umbilical
Vein
 Round
17
1.75
18
3
12/22/2015
19
20
21
22
Femur Length
23
24
4
12/22/2015
25
26
Curve is normal
27
28
Other Measurements
Thoracic Circumference (TC/AC)
 Heart Circumference
 Renal Circumference & Diameter
 Foot Length
 Twins: Weight discordance
 Cord Doppler S/D

29
30
5
12/22/2015
Normal
TC /AC 70% or Greater
Cardiomegaly
Short Rib Dysplasia
HC/TC --- 1/3 -1/2
31
32
Renal Diameter
Abdominal Diameter= 1/3
Foot = 0.9 – 1.1 Femur
33
Twins
34
Large for Dates






2.0
35
Normal Pregnancy / Wrong Dates
Multiple Gestation
Gestation with Mass / Masses
Molar Pregnancy
Polyhydramnios
Gestational Diabetes
36
6
12/22/2015
Common Causes of Polyhydramnios
High Beta HCG Levels


Wrong Dates
 Multiple Gestation
 Molar Pregnancy
 Choriocarcinoma







Gestational Diabetes
Rh Incompatibility
Anencephaly (50%)
Esophageal Atresia (without TE Fistula)
Duodenal/Small Bowel Atresia
Non-immune Hydrops
Neural Tube Defect (decreased swallowing)
Multiple Gestation
37
38
Types of Twins
Types of Twins


Dichorionic/ Diamniotic (DC/DA)
Divide before day 19 (morula divides)
 Monochorionic/ Diamniotic (MC/DA)
Divide days 19-21 (early blastocyst divides)
 Monochorionic/ Monoamniotic (MC/MA)
Divide days 21-28 (late blastocyst divides)
 Conjoined Twins: divides after day 28
(disc divides)
Dizygotic: Fraternal Twins:
Two ova were fertilized. This results in a
dichorionic/ diamnionic pregnancy
Monozygotic: Identical twins
Result from the division of a single zygote.

39
40
Factors Influencing Frequency
of Dizygotic Twins




Frequency increases with age and parity
Maternal history of twins increases frequency
by 2-3X
Termination of oral birth control pills
increases frequency of twins
Assisted reproduction: Increases frequency
41
42
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12/22/2015
Chorionicity and Amnionicity:
How do we tell the type of twins?




Types of Twins: Distribution
Determine the # of placentas: 2 placentas = DC/DA
If there’s only one placenta: Is there a membrane?
Thick membrane = DC/DA-fused placenta
Thin membrane = MC/DA*
No membrane = MC/MA*
Look for “chorionic peak”
Determine the sex, if different then it’s DC/DA



Dizygotic (DZ): 70% of twins in USA (1% births
Monozygotic (MZ): 30% of twins in the USA
Monozygotic subtypes:
DC/DA = 18-30% MZ
DC/MA = 70% MZ
MC/MA = 4% MZ twins
43
44
Twins: Two Placentas
Amnion
Chorion
Monochorionic
Placenta
Dichorionic
45
46
Fused Placenta
Di Di
47
48
8
12/22/2015
?
49
50
Twins: One Placenta
Di Di
51
52
Mono-Amniotic?
Mono Di
2.25
53
54
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12/22/2015
Mono Di
55
56
The difference in estimated fetal weights
shouldn’t be more than 20% between
Discordant
Growth
MC/DA Twins
57
Vanishing Twin
37mm
42mm
58
Monoamniotic Twins: Problems
Cord Accidents
 Transfusions
 Conjoined Twins


59
Division after Disc is formed
60
10
12/22/2015
MC/MA
Monoamniotic Twins
A
B
= ACI’s
Ability to change positions
= cord entanglement
61
62
Monoamniotic Twins
Monoamniotic Twins
Single Yolk Sac
Identify twins by placental cord insertions
63
Anomalies found in Monozygotic Twins
Pre-membrane
Fusion
64
Conjoined Twins (Disc divides)
Conjoined Twins
Neural tube defects
Holoprosencephaly
VACTERL association
Heart defects
Bladder extrophy
Syrenomelia
Gonadal dysgenesis
65
66
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Conjoined Twins
Omphalopagus
Twin to Twin Transfusion
Thoracopagus
67
10 week Twins
Discordant Growth 3D
69
68
Any Questions?
70
12
12/22/2015
Fluid Check
Functions of Amniotic Fluid




G. William Shepherd PhD, RDMS, RVT
Cushion and protect embryo/fetus
Allows symmetrical growth
Allows motion for muscle & joint development
Temperature stabilization
1
2
Production of AF: After 12 Weeks
Functions of Amniotic Fluid




 Helps GI system development
 Helps the lungs to develop
 May play a role in the homeostasis of fetal
electrolyte and fluid levels
Fetal kidneys produce urine as early as 12 weeks.
By 18 week > 50% of AF comes from fetal kidneys.
At 25 weeks 100cc urine are produced each day.
At term 600cc of urine are produced each day.
3
AF Consumption After 12 Weeks
 The fetus swallows AF.
 The swallowed AF is absorbed by the bowel.
 The fetal blood-stream transfers most of this fluid
to the maternal blood-stream in the placenta.
 Metabolism produces fluid
5
4
Measurement of Amniotic Fluid
 Subjective method
 Deepest pocket method
 4-quadrant AFI method
6
1
12/22/2015
Deepest Pocket Assessment of AF
 The entire uterus is examined and the
deepest pocket located.
 The anterior to posterior measurement of the
pocket is obtained.
 A value of < 2cm is considered to indicate a
state of oligohydramnios.
 A value > 8cm is considered to indicate
polyhydramnios.
Advantages of the Deepest Pocket Method
 This method provides a quantitative result that
can be used for comparisons to other scans.
 This is an easy technique to learn.
 This method can be used for assessing the
AF volume in twin gestations.
7
Disadvantages of the Deepest Pocket Method
 A single measurement of a complex shape is
not an accurate indicator of volume.
 The deepest pocket method fails to take
gestational age into account.
AF
Volume
1st
2nd
3rd
Gestational age
8
The 4-quadrant Amniotic Fluid Index
 This is the most widely used method for AF
volume assessment.
 The deepest pocket in each quadrant of the
uterus is measured in the AP dimension.
 The sum of these measurements is called the
amniotic fluid index or AFI.
 The AFI values of thousands of normal
gestations have been determined and have
been correlated with gestational age.
postdates
9
10
95th
50th
RUQ
LUQ
RLQ
LLQ
5th
16 20
11
24
28
32
Weeks Gestation
36
40
12
2
12/22/2015
Disadvantages of the 4-quadrant AFI
Advantages of the 4-quadrant AFI
 The AFI is a reasonable assessment of AF volume.
 The AFI provides a basis for comparison to past or
future exams.
 This is a relatively easy number to obtain.
 The AFI takes gestational age into consideration.
 There is a large body of data about this measurement
and fetal well-being.
13
Pockets must be measured
in an absolute AP direction,
in a sagittal scanning plane
 The measurement must be made quickly before
the position of the fetus changes.
 The AFI cannot be used for multiple gestations.
 Although the AFI is more accurate than the
deepest pocket method, there is still some
inaccuracy for this method.
14
A large curvolinear
or linear transducer
is a good choice
15
16
17
18
Small for Dates






Normal pregnancy / wrong dates
Blighted ovum
Fetal demise
Ectopic pregnancy
IUGR
Oligohydramnios
3
12/22/2015
19
20
21
22
Is this a good pocket?
Large for Dates






Normal pregnancy / wrong dates
Multiple gestation
Gestation with mass / masses
Molar pregnancy
Polyhydramnios
Gestational diabetes
9.5cm
23
24
4
12/22/2015
Vernix in the fluid
of 40 week gestation
25
Vernix
26
Vernix: Use of Gain
27
28
29
30
Vernix
5
12/22/2015
Hydrops
?
31
?
32
Deepest Pocket
Twins
33
34
Assessing Fetal Well-Being
3rd %
63-90mm
35
6
12/22/2015
Biophysical Profile (BPP)
BPP: What is it?
 30 minute test to evaluate fetal well-being
 There are 4 ultrasound parameters
Amniotic fluid
Gross fetal body motion (FM)
Fetal tone
Fetal breathing movement (FBM)
 A non-stress test (NST) is also included in a
complete BPP
 The BPP is often used without the benefit of a NST
37
38
BPP: Why do we do it?






BPP: Why do we do it?
Hypertension
Diabetes mellitus
Multiple gestation
Suspected IUGR or oligohydramnios
Known placental or cord abnormality
Failed NST






Maternal heart or renal disease
Previous unexplained fetal demise
Hemoglobinopathy
Postdated pregnancy
Decrease in fetal motion
Other…...
39
40
BPP: How do we score it?
What Does the BPP Assess?
 The BPP assesses O2 delivery & adaptive
behavior of the fetus
 If the fetus is functioning in a normal
fashion, then systemic hypoxia is unlikely.
 The renal function is also assessed.
Fluid changes occur over longer time
periods (12-24 hours).
41
 2 or 0 points are awarded for each parameter.
 If the fetus meets the criteria for the parameter,
it is give 2 points.
 No partial scoring is done in the standard BPP
 Highest possible score is 10
42
7
12/22/2015
BPP: What are the parameters?
 NST Not Discussed
 Fluid
 Motion
 Breathing
 Tone
43
44
Older versions use 30 sec of resp & 2 episodes of gross motion
Parameters: Fluid
Causes of Oligohydramnios
 Fluid throughout the uterine cavity with the largest
pocket of fluid equal or greater than 2 cm in AP
 Many hospitals will go beyond reporting a 2 or a 0
score for this parameter & additionally report the
AFI along with the BPP score.
 Fluid is the most important parameter.
 It takes 12-24 hours for a significant change in fluid
volume to take place







Renal dysfunction (bilateral)
Renal obstruction (bilateral)
Renal agenesis (bilateral)
Bladder outlet obstruction
PROM
Postdates pregnancy
Hypoxia
45
46
Fetal Motion
Parameters: Gross Fetal Motion
 2 discrete (was 3) episodes of fetal motion
 Simultaneous motion of the trunk and a leg or the
head and an arm etc. counts as one episode.
 Motions can include: twisting or flexion of the trunk
or neck. Movement on the legs or arms and
arching of the spine.
 This parameter tests neurological function. Is the
cerebrum getting enough oxygen?
47
48
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12/22/2015
Parameters: Fetal Breathing
Parameters: Fetal Breathing
 Complex reflex, cerebellar and brainstem function
 2 points are given if at least one episode of fetal
breathing (duration of at least 20 sec.) occurs
during the 30 minute exam.
 Fetal breathing is exhibited by diaphragm motion
or motion of the kidneys, liver or expansion of rib
spaces.
 Fetal breathing is rhythmic
 Fetal breathing is problematic it usually doesn’t
occur during fetal sleep cycles.
49
50
Fetal Respiration
3.00
51
52
53
54
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12/22/2015
Parameters: Fetal Tone
 Fetal tone is controlled by the cerebrum
 The opening of a hand and return to original
position counts as one episode of tone
 Active flexion and extension of a limb.
55
Open
56
Closed
The fetal hands are often
near the face.
Motion (clenching, arching)
of the feet can be used
for assessing tone
57
Fetal Tone
58
Duration of the BPP
Manning has reported that in over 200,000 BPP tests,
the average time was less than 8 minutes for normal
results (8/8)
Of course a score of <8 will take 30 min.
59
60
10
12/22/2015
55%
0/10
Value of the Biophysical Profile:
Outcome Data
17%
11%
61
25%
2/10
4/10
62
Umbilical Artery Doppler as an Addition
to Assessment of Fetal Well-Being
0/10
34w1d
8%
2/10
63
Umbilical Artery Doppler
64
S/D vs. Gestational Age
3.0@30w 2.5@35w 2.0@40w
11
12/22/2015
27w
31w
Some nurse midwives find it useful to obtain a set
of fetal measurements during the BPP for EFW
Deteriorating
Cord Doppler
1. S/D < 3.0 WNL for 27w
33w
35w
2. S/D > 4.5 Abn for 31w
3. No diastolic flow Abn
4. Rev diastolic Abn
68
Any Questions?
69
12