7/19/2011

Ultrasound Evaluation
Of the Fetal Abdomen
Mani Montazemi, RDMS
Director of Ultrasound Research & Education
Geisinger Medical Center
Danville, Pennsylvania
Fetal Abdomen

Current Official Practice Guideline

Abdomen
Anterior abdominal wall
Cord insertion
Stomach
Presence, size, situs

Kidneys
Bladder
Number of umbilical cord vessels
Fetal Abdomen

Scanning Tips

Fetal Abdomen

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Fetal Stomach
Wide range of shapes
Round to oval to kidney-shaped

Wide range of sizes

4mm to 4cm

Variable filling and emptying

Based on fetal swallowing and peristalsis

Fetal Abdomen

Non-visualization of the Stomach

< 19 wks, 50% ABNL
> 19 wks, 100% ABNL

Fetal Abdomen

Esophageal Atresia

Fetal Abdomen

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Esophageal Atresia
Incidence 1 in 2500 to 4000 live births
Overall detection rate only 50%
Most of the polyhydramnios occur after 24 weeks
Small
S ll stomachh bubble
b bbl could
ld be
b dismissed
di i d as being
b i
normal

Fetal Abdomen

Esophageal Atresia
Small stomach depend on the type of
esophageal atresia
5 types
yp - most common with
tracheoesophageal fistula
Fluid may cross the fistula
Gastric secretions may accumulate

Fetal Abdomen

Esophageal Atresia
High incidence of additional
anomalies > 50%
Cardiac, other GI, GU track,
CNS, Facial, skeletal, T18/21

40 % have IUGR
Incidence three times higher
in twins
Classic findings
Polyhydramnios
Absent or small stomach
bubble

Fetal Abdomen

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Non-visualization or
Always Small Stomach (< 1cm)
Causes:
High Gastrointestinal obstruction
Mouth to esophagus
Narrow/compressed chest
Thoracic or neck mass
Swallowing disorders
Defect or mass in the fetal mouth (clefts)
Severe neurologic or muscular abnormalities
Fetal Abdomen

What do you see?

Fetal Abdomen

Duodenal Obstruction

Large, obstructed stomach and a distended proximal duodenum

Fetal Abdomen

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Duodenal Obstruction
Two cystic structures in the abdomen that
communicate with each other
Classic double bubble

Fetal Abdomen

Duodenal Obstruction
Can be seen as early as 22 weeks, usually its
not apparent up until 29-32 weeks
Polyhydramnios after 24 weeks
Detection rate = only 50%

Associated with a 30% incidence of trisomy 21

Associated with VACTERL complex

Fetal Abdomen

VACTERL Complex
Vertebral defects
Anal atresia
Cardiac defects

Tracheoesophageal fistula
Esophageal atresia
Renal anomalies
Limb defects
Fetal Abdomen

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Duodenal Obstruction
Majority of cases are due to mechanical problems
Intrinsic causes structural abnormalities
Atresia (42%)
half of all duodenal atresias occur with Down syndrome, although
conversely, few cases of Down syndrome have duodenal atresia

Diaphragmatic web (10%)

Stenosis (38%)

Extrinsic causes external cause

Annular pancreas
Malrotation
Ladds bands
Fetal Abdomen

Duodenal Obstruction
Prognosis is dependent
upon whether other
anomalies are present
and their severity

Fetal Abdomen

Polyhydramnios is a constant
feature in all intestinal atresia

Fetal Abdomen

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Ventral Wall Defects

Omphalocele

Gastroschisis

Central defect
Associated anomalies are common
High risk of aneuploidy

Periumbilical defect
Associated anomalies are uncommon
Little to no risk of aneuploidy
High rate of bowel related
complications
Associated with substance abuse &
medications

Fetal Abdomen

Omphalocele

Herniation of intraabdominal contents

into the base of the cord
ALWAYS covered by a membrane
Fetal Abdomen

Omphalocele
Umbilical cord inserts onto membrane
In large defects may be displaced eccentrically

The herniated bowel is NOT directly exposed to

amniotic fluid
Bowel usually does not thicken or dilate

Fetal Abdomen

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Is This an Omphalocele?

Fetal Abdomen

Pseudo-Omphalocele

Caused by scanning oblique or

by excessive transducer pressure
Fetal Abdomen

Omphalocele
Can be a small or large wall defect

Fetal Abdomen

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Omphalocele
Small

Failure of normal midgut rotation

Cord midpositioned
Us all contains only
Usually
onl bowel
bo el
Associated with chromosomal
anomalies

Fetal Abdomen

Omphalocele
Large
Failure of anterior abdominal
wall closure
Cord eccentric
May contain organs
Scoliosis
Associated with structural
anomalies

Fetal Abdomen

Omphalocele

Measurements of AC
inaccurate and should
be excluded from
biometric calculations

Fetal Abdomen

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Omphalocele

IUGR has been reported in 20% of patients

50% have associated anomalies (20% cardiac)
30% are associated with trisomy 13 & 18
Elevated maternal serum alpha-fetoprotein (70%)

Fetal Abdomen

Omphalocele
Omphalocele and cord cyst may co-exist
Whartons jelly cyst mucoid degeneration of Wharton Jelly
Allantoic cyst always near insertion site
Omphalomesenteric duct cyst associated with intraabdominal
mesenteric cysts

Jane J.K. Burns, RDMS

Fetal Abdomen

Diagnostic Challenge
Separate from but contiguous with the bladder

Fetal Abdomen

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Patent Urachus With Allantoic Cyst

Urachus is an embryological remnant of the
allantois which runs from the apex of the bladder
through the umbilical ring to terminate in the
proximal umbilical cord

Yolk Stalk
Allantoic Stalk

Umbilical Cord

Cloaca

Fetal Abdomen

A Ruptured Omphalocele
Can Resemble Gastroschisis

Fetal Abdomen

Omphalocele @11 Weeks ?

Potential Pitfall
Fetal Abdomen

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Normal Midgut Herniation

Fetal bowel normally herniates into the base
of the umbilical cord at approx. the 7-8 weeks
MA
Detected sonographically from 9-11
9 11 wks
Should not be visible by 12 week
Possible Anomaly
CRL > 44mm with persistent herniation
Maximum dimension of abdominal mass > 7mm

Fetal Abdomen

Normal Midgut Herniation

This appearance should not be mistaken for a
ventral wall defect

Fetal Abdomen

Midgut (umbilical) herniation

beyond the 12th week of gestation
has to be considered pathological

Fetal Abdomen

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Gastroschisis

Small defect to right of cord insertion

No membrane over bowel

Fetal Abdomen

Gastroschisis
Incidence is 1 in 3000 births
Varies considerably with
maternal age
Strong association reported
among younger patients

Less likely for organ

herniation
Variable amounts of bowel
herniated
Bowel floats within
amniotic fluid
Fetal Abdomen

Gastroschisis
Hepatic herniation is less frequent with
gastroschisis than with omphaloceles

Fetal Abdomen

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Gastroschisis
Small defect (2-4cm)

Fetal Abdomen

Gastroschisis

Associated anomalies in about < 10% of fetuses

IUGR in up to 50%
No chromosomal abnormalities
Elevated maternal serum alpha-fetoprotein
alpha fetoprotein (70%)

Fetal Abdomen

Gastroschisis
Oligohydramnios
More common than polyhydramnios
Suggest fetal distress

Polyhydramnios
Suggest bowel obstruction or atresia

Fetal Abdomen

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Gastroschisis
Marked bowel dilatation, which may be either
external or internal to the abdominal cavity, suggests
bowel obstruction and/or ischemia

Fetal Abdomen

Gastroschisis
Bowel can twist and cut off blood supply

Fetal Abdomen

Gastroschisis

Fetal Abdomen

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Gastroschisis

Fetal Abdomen

Gastroschisis

Fetal Abdomen

Ectopic Cordis
Large omphalocele coming all the way to heart

Rare malformation
Protrusion of heart through chest wall
Association - Pentalogy of Cantrell

Fetal Abdomen

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Pentalogy of Cantrell
A term used to describe the association of 5 anomalies:
1. Midline supraumbilical abdominal defect
2. Defect of the lower sternum
3 Defect of the diaphragmatic pericardium
3.
4. Anterior diaphragmatic hernia
5. Intracardiac abnormalities

Fetal Abdomen

Pentalogy of Cantrell US Findings

Midline anterior wall defect
usually upper abdomen
Ectopic heart
Pericardial or pleural effusion
Craniofacial anomalies
Ascites
Two vessel cord

Fetal Abdomen

Limb-Body Wall Complex

Also known as body stalk anomaly
Failure of ventral abdominal wall to close
Often left sided

Jane J.K. Burns, RDMS

Fetal Abdomen

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Limb-Body Wall Complex

Abdominal organs lie in a sac outside the abdominal cavity

Short or absent umbilical cord
Fetus lies directly on placenta*
Universally fatal

Fetal Abdomen

Limb-Body Wall Complex

Amniotic bands attached broadly to the fetus &
placenta
Large thoraco-abdominal wall defect
no covering membrane

Distorted body axis

Jane J.K. Burns, RDMS

Fetal Abdomen

Limb-Body Wall Complex

Severe scoliosis prominent feature
Limb defects common
Complex array of multiple malformations
Craniofacial & Internal organ anomalies

Fetal Abdomen

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Bladder & Cloacal Exstrophy

Failure of closure of lower
abdominal wall resulting in
exposed bladder
Omphalocele
Absent bladder
Imperforate anus
Spinal abnormalities
Malformation of the
genitalia
Single umbilical artery

Fetal Abdomen

Bladder Exstrophy
2o to abnormal development of
the cloacal membrane
Incidence is 1:30,000 births
Eversion & exteriorization of
the pelvic viscera on the
abdominal surface
Inferiorly displaced umbilicus
Widely separared pubic bones

Reports of T21 & 13

Fetal Abdomen

Bladder Exstrophy US Findings

Non-visible bladder
Normal kidneys
Normal amniotic fluid
volume
Low CI
Bulging mass
protruding from the
lower abdominal wall
Small penis
Splayed iliac bones
Fetal Abdomen

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Cloacal Exstrophy
Omphalocele & bladder extrophy with prolapsed ileum between the two bladder halves

Fetal Abdomen

Ventral Wall Defects

Relation to Umbilicus
Above umbilicus
Consider pentalogy of cantrell

At umbilicus
Consider
C id gastroschisis
hi i or omphalocele
h l l

Below umbilicus
Consider exstrophy of bladder or cloaca

Difficult to tell because of size

Consider body stalk anomaly
Fetal Abdomen

Normal Appearance of Bowel

Amniotic fluid is swallowed & as it gets to the small
bowel it mixes with bowel mucopolysaccharide
Moves to the large bowel water is resorbed, leaving
meconium
Meconium is expelled at birth
If there is obstruction or if meconium is abnormally
thick that wouldnt pass it causes obstruction in the
bowel meconium ileus
Fetal Abdomen

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Normal Appearance of Bowel

Meconium
Variable in echogenicity (hypo to hyperechoic), can be
seen throughout the later part of pregnancy, particularly in
late 3rd trimester

Fetal Abdomen

Hyperechoic Bowel
What Does
That Mean?
Fetal Abdomen

Hyperechoic Bowel
Increased echogenicity of the mesentery and small
bowel walls

The bowel itself is not echogenic

Fetal Abdomen

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Hyperechoic Bowel
Often normal variant
Related to higher
frequency transducers
and to images with
greater contrast

Fetal Abdomen

Fetal Abdomen

Echogenic Fetal Bowel

Abnormal if

> 4 cm in size
May have mass effect
Homogeneo s or heterogeneous
Homogeneous
heterogeneo s
Brightness > bone (femur, spine, iliacs)

Fetal Abdomen

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Echogenic Fetal Bowel

Seen in association with:
Cystic fibrosis, trisomy 21, cytomegalovirus
(CMV), parvo virus (5th disease), GI obstruction
and IUGR

Fetal Abdomen

Echogenic Bowel
Swallowed blood (intra-amniotic hemorrhage)

4 days post-amniocentesis
Fetal Abdomen

Meconium Peritonitis
Leaking of bowel contents leading to an
intense peritoneal reaction

Fetal Abdomen

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Meconium Peritonitis
50% have underlying bowel pathology

Fetal Abdomen

Meconium Peritonitis
Calcifications 85%
Usually punctate, linear or clumped foci

Fetal Abdomen

Meconium Peritonitis
Calcifications 85%
Usually punctate, linear or clumped foci

Ascities 54%
Usually
U ll complex
l

Fetal Abdomen

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Meconium Peritonitis
Calcifications 85%
Usually punctate, linear or clumped foci

Ascities 54%
Usually
U ll complex
l

Bowel dilatations 27%

Fetal Abdomen

Meconium Peritonitis
Calcifications 85%
Usually punctate, linear or clumped foci

Ascities 54%
Usually
U ll complex
l

Bowel dilatations 27%

Pseudocysts 14%
Polyhydramnios 65%
Fetal Abdomen

Meconium Peritonitis
Calcifications can extend to thorax

Fetal Abdomen

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Meconium Peritonitis
Calcifications can extend to scrotal sac

Fetal Abdomen

Abdominal Calcifications

Infections: herpes, toxoplasmosis, cytomegalovirus

Tumors: teratoma, hepatoblastoma, neuroblastoma
Peritonitis: meconium leak
Infarcted bowel
Gallstones
Idiopathic

Fetal Abdomen

Small & Large

Bowel Obstruction
Obstructions below the duodenum are even harder to diagnose

Fetal Abdomen

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Small Bowel Obstruction

Jejunal & ileal obstruction is more common
than duodenal obstruction!
Vascular injury

Small bowel loops can be seen specially in 3rd

trimester

Fetal Abdomen

Small Bowel Obstruction

They peristalsis and change
in configuration
Do not persist, and should
not be >15 mm in length and
7 mm in diameter
Can rarely present as cyst
like mass
Polyhydramnios
Timing & severity dependent
on site of atresia

Small bowels are

centrally located

Fetal Abdomen

Small Bowel Obstruction

Causes:
Intestinal atresia
Related to an in utero vascular accident

Stenosis
Volvulus
Meconium ileus
In fetuses with cystic fibrosis

Fetal Abdomen

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Pitfalls
Different processes can be mistaken for dilated
small bowel
Cysts in an enlarged multicystic displastic kidney
Dilated tortuous ureter

Fetal Abdomen

Large Bowel Obstruction

Normal large bowel < 20 mm
diameter
Rare - It occurs at the anal-rectal
region
Additional structural &
chromosomal anomalies are very
common (75%)
VACTERL & caudal regression
syndrome

Causes:
Atresia
Stenosis
Fetal Abdomen

Solid Abdominal Masses

Mesoblastic nephroma

Fetal Abdomen

Neuroblastoma

Hepatoblastoma

Subdiaphragmatic extralobar
pulmonary sequestration

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Fetal Abdomen

Abdominal Cysts
Differential Diagnosis
RUQ
Hepatic/choledochal cyst

LUQ
Splenic cyst

Posterior
cyst hydronephrosis
Renal cyst,

Anterior/mid-abdomen
Mesenteric cyst, umbilical vein varix

Lower abdomen

Ovarian cyst (but may migrate to mid-abdomen)

Ureterocele
Urachal cyst
Hydrometrocolpos

Fetal Abdomen

Diagnostic Challenge

Fetal Abdomen

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Diagnostic Challenge

Fetal Abdomen

There is Flow! Is it venous or arterial?

Fetal Abdomen

Umbilical Vein Varix

Focal dilatation of umbilical vein
Usually intraabdominal but extrahepatic may
occur in association with persistent right
umbilical vein
It may also occur in free floating loops of cord
Umbilical vein varix of intra-amniotic segment
is rarer than intra-abdominal

Fetal Abdomen

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Umbilical Vein Varix

Focal dilatation of intra-abdominal portion
Usually near cord insertion
Abnormal if internal diameter > 9 mm or twice size of
intrahepatic portion of vein
Normal size at week 20 is 3-4
3 4 mm with linear increase up
to 8 mm at term

Fetal Abdomen

Umbilical Vein Varix

Fetal Abdomen

Umbilical Vein Varix

Can be associated with:

Chromosome abnl (T-21, 18, 9)

Congenital malformations
Decreased growth
H d
Hydrops
Thrombosis

May be first manifestation of elevated venous

pressure therefore may signify increased risk of
cardiac decompensation
As isolated finding: normal outcome
Fetal Abdomen

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Choledochal Cyst
Cystic dilatation of the CBD
Separate from gallbladder
No communication with stomach

Fetal Abdomen

Abdominal Cysts

Fetal Abdomen

Abdominal Cysts
Lower abdomen
Female: think ovarian: may migrate/auto-amputate
Torsion in ~ 40 % if > 5 cm

Fetal Abdomen

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Thank You
Fetal Abdomen

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