BASIC OBSTETRIC

ULTRASOUND
SARAH B. PINGOL, MD, FPOGS, FPSUOG
Department of Obstetrics & Gynecology
Northern Mindanao Medical Center

Ultrasound Technology
l Ultrasound

waves: high frequency

sound waves vibrating > 20,000
cycles per second
l Diagnostic ultrasound: 2-7.5 MHz

Ultrasound Technology
Electrical pulses/Alternating current
Vibration of piezoelectric crystals
(transducer)
Sound waves
Object/Tissues
Echoes
Image

TAS vs TVS
l ADVANTAGES

OF TVS

Patient discomfort less: empty bladder

Clearer images
Earlier diagnosis of normal or abnormal
pregnancy
Earlier diagnosis of pelvic pathology
Eliciting pain and tenderness
A modified bimanual exam

TVS vs TAS
l DISADVANTAGES

OF TVS

Children, postmenopausal, and

nonsexually active women
Large pelvic masses not fully visualized
Variations in pelvic structures
Patient s refusal to undergo the
examination

First Trimester Scan

l GOALS

Establish an intrauterine pregnancy

Identification of number of gestations
Detection of embryonic and fetal
viability
Evaluation of complicated early
pregnancy
Early dating of pregnancy
Evaluation of the uterus and adnexae

First Trimester Scan

l Gestational

sac (GS)

Earliest ultrasonic confirmation of an

intrauterine pregnancy
Double decidual sac sign: GS
surrounded by an echogenic ring
(chorionic villi + decidua parietalis)

First Trimester Scan

l

SONOGRAPHIC FEATURES OF A
NORMAL GS (Nyberg, 1991)
External appearance

Shape: round or oval

Position: fundal or middle portion of uterus
Contour: smooth
Wall: echogenic, 3 mm in thickness

Internal landmarks
Yolk sac present when GS > 13 mm
Embryo present when GS > 18 mm; growth: 1 mm/d

DOUBLE DECIDUAL SAC SIGN

DC: decidua capsacularis; DP: decidua parietalis

First Trimester Scan

TVS
2-3 mm

TAS
5 mm

LMP

4 wks, 3 days

5 wks

Serum -hCG

2000 mIU/ml

6500 mIU/ml

Mean sac
diameter

First Trimester Scan

l Yolk

Sac

A circular echo-free mass

Marker of a viable pregnancy: confirms
presence of pregnancy even before an
embryo is present
TAS: 6 menstrual wks
TVS: 5 menstrual wks

First Trimester Scan

l Amnion:

double bleb sign

l Placenta

and umbilical cord

Placenta: asymmetrical thickening of

decidual and trophoblast layers
surrounding GS; 6 menstrual wks
Umbilical cord: 9 menstrual wks

First Trimester Scan

l Embryo

Fetal pole
TVS: 6 menstrual wks
TAS: 7 menstrual wks

Cardiac activity
6 wks by TVS
May be absent for embryos < 4 mm
Always present for embryos 5 mm

Rate of growth: 1 mm/day

First Trimester Scan

Sonographic
landmark
Gestational sac
Yolk sac
Embryo
Embryonic heart
beat

Age at detection (wks)

TVS
TAS
4.5
5
5
6
6
7
6
7

First Trimester Scan

l Biometry:

Prediction of menstrual

age
GS, using MSD: 5-6.5 wks
Crown-rump length
7 wks
Variability: 4-5 days (increases to 7-10 days
after 12 wks)
Menstrual age = CRL + 6.5

CROWN-RUMP LENGTH

Early Pregnancy Failure

l

Indications for early pregnancy UTZ

monitoring
1st trimester vaginal bleeding
Pregnancy following infertility tx
History of recurrent/habitual abortion or pregnancy
losses
Previous spontaneous abortion or ectopic
pregnancy
Presence of structural uterine anomalies
Unreliable menstrual dates
Lower abdominal pain

PREDICTORS OF EARLY PREGNANCY FAILURE (Filly, 1993)

Criteria

Sensitivity Specificity

PPV

Major Criteria
25 mm MSD w/o embryo
(TVS: 18 mm)

29

100

100

20 mm MSD w/o yolk sac

(TVS: 13 mm)

41

100

100

Thin decidual reaction

28

99

96

Weak decidual amplitude

53

99

98

Irregular contour

37

99

97

Absent double decidual sign

37

98

94

Low position

20

99

94

Minor Criteria

PPV: positive predictive value. Presence of 3 criteria increases PPV to 100%.

Early Pregnancy Failure

l Yolk

sac > 5 mm (5 mm at 6-7 wks)

l Small gestational sac, small GS-CRL
difference, early oligohydramnios
l Fetal cardiac activity
Absent cardiac activity when CRL 5 mm
Fetal bradycardia (< 85 bpm)
l Intrauterine

hematomas (subplacental
> subchorionic)

Ectopic Pregnancy
Absence of an intrauterine yolk sac or
embryo
l Absence of double decidual sign (DDS): 2
rings surrounding the gestational sac
l

Pseudogestational sac: single echogenic ring

surrounding an intraendometrial fluid
collection
l

Pseudogestational sac located w/in the

endometrial cavity
Normal GS eccentrically located

Ectopic Pregnancy
l Presence

of gestational structures
within fallopian tube
l Fallopian tube with amorphous
content (e.g. blood clots)
l Indirect signs: empty uterus +
positive pregnancy test blood clots
in cul-de-sac

Ectopic Pregnancy
ULTRASOUND AND SERUM -hCG ASSAY
Intrauterine
pregnancy

Serum
-hCG

Outcome

Normal uterine pregnancy

Ectopic pregnancy
Abnormal uterine pregnancy
Recently aborted, abnormal or
early intrauterine pregnancy
Ectopic pregnancy

Gestational Trophoblastic Diseases

Complete mole: globular moderately
echogenic or homogenous mass filling the
uterine cavity, with varying degrees of
cystic degeneration (snowstorm pattern/
honeycomb appearance)
l Partial mole: placenta with numerous
cystic spaces, fetus abnormal or growth
retarded
l Theca lutein cysts: 20-50%
l

Gestational Trophoblastic Diseases

l Invasive

mole and Choriocarcinoma

Focal irregular echogenic regions in the

myometrium
l Use

of pulsed or color Doppler

Low pulsatility index within uterine

arteries (0.4-1.0)
Increased systolic and diastolic flow,
low resistance (0.4-0.5)
Neovascularization

HYDATIDIFORM MOLE

Normal & Abnormal Fetal

Anatomy
l Fetal

skull: egg-shaped/ovoid and

smooth, ossified by 12 wks
Lemon-shaped: spina bifida
Strawberry skull: Trisomy 18
Cloverleaf skull: craniosynostosis
Absence of midline echo:
holoprosencephaly/hydranencephaly
Absence of skull: anencephaly

TRANSTHALAMIC PLANE

CSP: Cavum septum

pellucidum
T: Thalami
TV: Third ventricle
SF: Sylvian fissure

TRANVENTRICULAR PLANE

C: Choroid plexus
VA: Ventricular
atrium
MW & LW: Medial &
lateral walls of
lateral ventricle

TRANSCEREBELLAR
PLANE

CH: Cerebral
hemispheres
CV: Cerebellar vermis
CM: Cisterna magna
CSP: Cavum septum
pellucidum

SPINA BIFIDA:
Lemon sign

TRISOMY 18:
Strawberry sign

ANENCEPHALY

CRANIOSYNOSTOSIS:
Clover-leaf skull

Normal & Abnormal Fetal

Anatomy
l Ventricles:

Anterior and posterior horns 1 cm

Increased ventricular/hemispheric ratio or gross
ventricular dilatation: hydrocephaly,
ventriculomegaly

Cavum septum pellucidum: small

midline rectangle shaped cavity one
third of the way from front of skull
Agenesis of corpus callosum, alobar
holoprosencephaly

AGENESIS of CORPUS
CALLOSUM: Teardrop sign

HOLOPROSCENCEPHALY

Normal & Abnormal Fetal

Anatomy
l Posterior

fossa

Transverse cerebellar diameter (TCD)

Numerically equal to AOG at 13-24 wks

Cerebellar hemispheres: eyeglass,

number 8, or dumbell appearance
Banana-shaped cerebellum: spina bifida

Cisterna magna: 1 cm
Increased: Dandy-Walker syndrome

Nuchal fold: 0.6 mm

Increased: Down syndrome

SPINA BIFIDA:
Banana sign

DOWN SYNDROME:
Nuchal fold thickness

Normal & Abnormal Fetal

Anatomy
l Face

Internal and external orbital diameters

should be equal: hypo- or hypertelorism, microphthalmia
Lenses: cataracts, anophthalamia
Nose
Cleft lip and palate
Mandible and maxilla: micrognathia,
maxillary hypoplasia in Down syndrome

Normal & Abnormal Fetal

Anatomy
l

Fetal spine: vertebra with closed

horseshoe or U appearance
Open defect/V shaped: spina bifida
Sac protruding from open defect:
menigomyelocoele

Diaphragm: echogenic line arching

upward, separating the heart and lungs in
the chest from the stomach and liver in
the abdomen
Defect: diaphragmatic hernia

NORMAL FETAL
SPINE

SPINA BIFIDA

Normal & Abnormal Fetal

Anatomy
l Fetal heart: four-chamber view
Located midline, with apex pointing left or to
the same side of the stomach
Occupies 1/3 of chest, cardio-thoracic ratio
50%
2 atria of approximately the same size
2 ventricles of approximately the same size
and thickness, contract simultaneously
Atrial and ventricular septae meet the 2 AV
vales at the center of the heart
2 AV valves open and close simultaneously

Normal & Abnormal Fetal

Anatomy
l Fetal

heart: outflow tracts

2 arterial valves
Aorta rises wholly from the left ventricle
Pulmonary trunk slightly larger than the
aorta
Pulmonary valve anterior and cranial to
the aortic valve
At their origins the great arteries lie at
right angles and cross over each other

FETAL HEART , Four-Chamber View

DAO: descending aorta; LA: left atrium; LV: left
ventricle; RA: right atrium; RV: right ventricle

Normal & Abnormal Fetal

Anatomy
l Fetal

lungs: seen on each side of the

heart, with low to medium
echogenicity (more echogenic than
the liver)
Increased echogenicity: diaphragmatic
hernia, cystic adenomatoid
malformation, sequestration
Anechoic space at the periphery, with
displacement or collapse: hydrothorax

Normal & Abnormal Fetal

Anatomy
l Fetal

gastrointestinal tract: each

plane should show stomach bubble,
umbilical vein, liver, and spine
Double bubble sign: duodenal atresia
Absence of stomach bubble:
esophageal atresia

DUODENAL ATRESIA:
Double bubble sign

Normal & Abnormal Fetal

Anatomy
l Fetal

kidneys: hypoechoic structures

on both sides of the spine
Absence of renal perenchyma: renal
agenesis
Increased echogenicity: polycystic
kidneys
Large multicystic spaces: multicystic
dysplasia

POLYCYSTIC
KIDNEYS

MULTICYSTIC
DYSPLASIA

Normal & Abnormal Fetal

Anatomy
l Umbilical

cord & insertion: 2 arteries,

1 vein
Dilatation of cord, with echogenic
structure within: omphalocoele
Loops of bowel extruded out through
the abdominal wall: gastroschisis

OMPHALOCOELE

GASTROSCHISIS
bowel

umbilical cord

Normal & Abnormal Fetal

Anatomy
l Fetal

gender

Hamburger sign: female

Turtle sign: male

MALE

FEMALE

Estimation of Gestational Age

l

FIRST TRIMESTER
Mean Sac Diameter (MSD)
TAS: 5 mm ~ 5 wks and 5 days
TVS: 2-3 mm ~ 4 wks and 3 days

Crown Rump Length (CRL): 7-9 wks

Margin of error: 3-5 days

When gestational age is determined by

1ST TRIMESTER parameters it is considered
ESTABLISHED.

Estimation of Gestational Age

l BIPARIETAL

DIAMETER (BPD)

Widest transverse diameter between

two fetal parietal bones
Transverse axial plane: rugby football
shaped, falx cerebri divides cerebral
hemispheres, parietal bone outline 3
mm, calipers passing through thalamus
Most accurate at 14-20 wks ( 1 wk)

Estimation of Gestational Age

l CEPHALIC

INDEX (CI)

Recognition of head shape change

CI = BPD/ Occipitofrontal diameter
(OFD) x 100
Normal: 74-83
< 71: Dolichocephaly (flattened, long)
> 87: Brachycephaly (round)

Estimation of Gestational Age

l HEAD

CIRCUMFERENCE (HC)

Independent of head shape change

HC = (BPD + OFD) x 1.57

FETAL HEAD MEASUREMENTS

Estimation of Gestational Age

l ABDOMINAL

CIRCUMFERENCE (AC)

At the widest diameter of the liver

Landmarks: left portal vein, fetal
stomach, vertebral body
ANTEROPOSTERIOR DIAMETER (APD)
TRANSVERSE DIAMETER (TAD)
Least reliable parameter for fetal aging
Predictor of growth disturbance; EFW

Estimation of Gestational Age

l

FEMORAL LENGTH
Measured from blunt ends (greater trochanter
to lateral epicondyle)

Other parameters:

Fetal humerus and tibia (Jeanty et al, 1984)

Fetal radius and ulna (Hill, 1985)
Transcerebellar diameter (Hill, 1990)
Binocular distance (Jeanty, 1994)
Interorbital and intraorbital diameters
(Mayden, 1982)

FETAL FEMUR

Estimation of Gestational Age

l
l
l
l
l
l

1st trimester ultrasound dating should be used as the basis for

fetal age
During the 2nd trimester fetal aging is done by multiple
parameter analysis
When 1 parameter falls out of estimate repeat the measurement
of that parameter.
CI should be computed to determine head shape; with head
shape change BPD should be disregarded in favor of HC
AC is least reliable in predicting gestational age but most
sensitive in predicting disturbances of growth pattern
HC and FL should be correlated
HC and FL measurements agree: equivalent gestational age is
considered
FL:HC ratio computed if measurements do not agree: ratio falls
above mean microcephaly, ratio falls below mean - dwarfism

Estimation of Gestational Age

l NON-BIOMETRIC

PARAMETERS

FETAL EPIPHYSIAL OSSIFICATION

CENTERS
Distal femoral epiphysis: 33 wks; 6 mm by
35 wks
Proximal tibial epiphysis: 35 wks
Proximal humeral epiphysis: 38 wks
(positive predictive value if absent: 24%)

Estimation of Gestational Age

l

NON-BIOMETRIC PARAMETERS
FETAL COLONIC GRADE (Zillanti, 1983)
Grade 1: lumen anechoic, thin hypoechoic
muscular and serosal wall (2nd trimester)
Grade 2: lumen more echoic, muscular wall
hypoechoic, increased fat deposits at serosal
layer (early 3rd trimester)
Grade 3: lumen hyperechoic, w acculumation
of meconium; hypoechoic muscular layer
emphasized by surrounding hyperechoic
structures (term gestation)

Estimation of Gestational Age

l

NON-BIOMETRIC PARAMETERS
PLACENTAL GRADING (Grannum, 1979)
Grade O: smooth chorionic plate on the fetal
surface of the placenta, without calcifications
Grade I: placenta with scattered bright echoes
Grade II: increased basal and comma-like
echogenicities extending into the placenta from
the indentations of the chorionic plate
Grade III: extensive basal, curvilinear
echogenicities extending from the chorionic
plate to the base of the placenta

AMNIOTIC FLUID VOLUME

l AFV

increases throughout gestation,

until 38-40 wks
AOG (wks)
12
16
Term
Postterm

AFV (cc)
60 (35-100)
200 (125-300)
900 (500-1200)
350 (250-500)

AMNIOTIC FLUID VOLUME

l POLYHYDRAMNIOS

AFV > 2 L
AFV > 90th percentile for a given
gestational age
l OLIGOHYDRAMNIOS

AFV < 500 ml

AFV < 10th percentile for a given
gestational age

AMNIOTIC FLUID VOLUME

l

SINGLE POCKET ASSESSMENT

Measurement of maximal depth of any AF
pocket
Normal range: 2-8 cm

AMNIOTIC FLUID INDEX (AFI)

Sum of vertical dimensions of the deepest
pocket in 4 quadrants
Normal range: 5-20 cm;
2.5th-97.5th percentile for a given gestatinal age

BIOPHYSICAL PROFILE
l Antepartum

fetal surveillance
l Based on Manning, 1980
l 5 parameters:
Fetal breathing movements
Gross fetal movements
Fetal tone
Fetal heart reactivity (NST)
Amniotic fluid volume

BIOPHYSICAL PROFILE
l

HYPOXIA CASCADE THEORY

Parameter

Fetal Tone

CNS Center
Cortex-subcortical area

AOG
(wks)
7.5-8.5

Fetal Movement Cortex-nuclei

Fetal Breathing Ventral surface of 4th
ventricle

9
20-21

Fetal Heart
Reactivity

24-26

Medulla & posterior

hypothalamus

FETAL BIOPHYSICAL SCORE

Parameter
Score: 2
Fetal breathing At least 30 sec of sustained breathing
movements
in 30 min observation
Gross fetal
movements

3 gross body movements in 30 min

observation

Fetal tone

At least 1 episode of limb motion from

flexion to extension

Fetal heart
2 FHR accelarations of at least 15
reactivity (NST) bpm at least 15 sec in duration assoc
with fetal movts in 20 min observation
Amniotic fluid
volume

AF pocket measuring at least 2 cm in 2

perpendicular planes

BIOPHYSICAL PROFILE
l

INTERPRETATION
10/10: normal, nonasphyxiated
8/10: normal, nonasphyxiated
(normal fluid)
8/10: chronic fetal asphyxia
(decreased fluid)
6/10: possible fetal asphyxia
4/10: probable fetal asphyxia
0-2/10: almost certain fetal asphyxia