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ProtocolDetermine the 1st day of the last normal menstrual period, if unknown determine if a previous OB examination has been performed that identified an estimated date of delivery for the patient (due date)Protocol will vary with patient age and fetal position. Therefore the protocol will need to be adjusted appropriately.Protocol is broken into 3 segments—uterus and ovary images, gestational sac images& measurementsUterus and Ovary ImagesStructureScan PlaneLabelLandmarks IdentifiedUterus/FetusTXNo Image-Scan ThroughBegin at cervix, move superiorly out of uterine fundusIdentify the fetus within the uterusIdentify number of fetusesVaryHeart RateFetal heart and chestEnlarge image of heart and document heart rate with M-modeVaryHeart RateFetal heart and chestEnlarge image of heart and document heart rate with a cine-loop UterusTransverseUT TX bodyUterus BodyGestational sac (if no gestation sac, an empty endometrium is seen)SagittalUT SAG MLVaginal Canal Uterus (Cervix, Body, and fundus)Gestational SacUT SAG RTRight lateral uterus Portion of gestational sacAdnexa SAG RTLateral to the uterus in the right adnexa regionUT SAG LTLeft lateral uterus Portion of the gestational sacadnexa SAG LTLateral to the uterus in the left adnexa regionRT OvarySagittalRO SagRight ovary RO SAGRight ovary enlargedRO SAGRight ovary enlarged with AP and Length measurementsTransverseRO TXRight ovaryRO TXRight ovary enlargedRO TXRight ovary enlarged with width measurementsLT OvarySagittalLO SagLeft ovary LO SAGLeft ovary enlargedLO SAGLeft ovary enlarged with AP and Length measurementsTransverseLO TXLeft ovaryLO TXLeft ovary enlargedLO TXLeft ovary enlarged with width measurementsGestational Sac ImagesDocument and measure in 3 planes any anechoic areas around sac, these most likely represent hemorrhagesYolk Sac may or may not be seen (if seen measure internal diameter)Utilize GS measurement only if no fetal pole is seen or the sac appears abnormalUtilize CRL measurement as primary measurement technique (once head, abdomen and femur measurements can be taken-do not take CRL any longer)StructureScan PlaneLabelLandmarks IdentifiedGestational SacSagittalGS SAG MIDLongest axis of gestational sac enlargedTrophoblastic ring or decidua basalis or placentaLongest axis of gestational sac enlargedWith length and AP measurements Trophoblastic ring or decidua basalis or placentaGS SAC RTRight lateral gestational sac and uterusAmnion when applicable GS SAC LTLeft lateral gestational sac and uterusAmnion when applicableTransverseGS TX MIDGestational sac enlarged Round and largest areaTrophoblastic ring or decidua basalis or placentaGS TX MIDGestational sac enlarged Round and largest areameasurement of the width include anechoic area only Trophoblastic ring or decidua basalis or placentaPlacenta*this may be taken in less than 3 imagesSagittalPlacenta SAG INFPlacenta closest to cervixRetroplacental complexPlacenta SAG MIDPlacenta Mid- include cord insertionRetroplacental complexPlacenta SAG SupPlacenta- superior portionRetroplacental complexYolk SacSagittalYolk Sac SagYolk sac Fetal poleYolk Sac SagYolk sac enlargedYolk Sac SagYolk sac enlargedMeasure AP internal diameter of yolk sacTransverseYolk Sac TXYolk sacFetal Measurement ImagesWill vary based on gestational ageNote if fetus appears curled, wait until fetus is lengthened out before obtaining a CRLStructureScan PlaneLabelLandmarks IdentifiedFetal PoleCrown Rump Length (CRL)Scan plane varies:Longest Axis of fetal bodyCRLFetal Pole- crown to rump enlargedMeasure longest axis of fetus from crown to rumpFetus-After 12 weeksCoronal HeadBPDCavum septum pellucidumIHFThalamiParietal bonesMeasurement techniquePlace calipers on the outside of the closet parietal bone to the inside of the farthest parietal bone Coronal HeadHCCavum septum pellucidumIHFThalamiParietal bonesMeasurement techniquePlace calipers outside to outside of the parietal bonesOpen the calipers with an ellipse that surrounds the fetal skullTransverse AbdomenACUmbilical vein/portal vein junction 3 points of the spineSymmetrical ribsMeasurement techniquePlace calipers on outside of skin line directly behind spine and in front of abdomen. Open calipers to form an ellipse around abdomen including the skin lineLongest Axis of BoneFLFemur bone with distal or end shadowingMeasurement techniquePlace calipers from end to end on the Femur Calipers should dissect the middle of the bone Do not include epiphysis pointAdditional InformationNuchal Translucency Measurement o f the width of the nuchal lucencyPerformed between 10-14 weeks gestation (CRL=36-84mm)Greater than 3mm is abnormal (associated with Down Syndrome & other abnormalities)Taken in conjunction with PAPP-A lab test24288751855470Images retrieved from 00Images retrieved from Laboratory ValuesQualitative HCG-urine pregnancy test, results positive or negativeQuantitative HCG- blood pregnancy test, results indicate age or age range of pregnancyHematocrit-indicates possible internal bleeding (typically related to ectopic pregnancy)Twins or Multiple FetusesDocument each fetus and sac separatelyIdentify each fetus as “Fetus A, Fetus B, etc.” Fetus A is determined by the its proximity to the cervixIt is extremely important to document number of sacs and placentasFetal Heart RateDocumented using m-mode1st Detected with a CRL of 4-5mmBefore 6 weeks low= 100-115bpm8 weeks=144-159 bpm After 9 weeks=137-144 bpm If no heart rate is detected, evaluate the heart for 2 minutes (heart rate may slow down and pick back up) and get a second observer to validate absence of heart ratePathology Document the pathology it in its entirety (this includes hemorrhages adjacent to sac), images should includeGray scale sagittal and transverse images including images with 3 measurements (length, width and height)Color Doppler image document the presence of blood flowSpectral Doppler image document type and velocity of blood flow ................
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