A Comparison of Transvaginql 1nd
Abdominai Ultrasound in Vílualizing the
First Trimester Conceptus
Mark T. Cullen, MD,lacqueline f. Green¡ RDMS, E. Albert Reece, MD, Iohn C. Hobbins, MD
Ultrasound visuallzation of the Êrst trlmester embryo
was compared usíng aMominal and transvaginal so-
nography. The parameters evaluated included the ability
to õbtairi biometry the ability to visualize detailed inler-
nal anatomy and a subiective assessment of the overall
image clariiy. In 120 patients studied, transvaginal so*
nognphy wãs superiol to abdomlnal sonography in ob-
taiñinþ tiometrið measurements in 51 cases (49%) ryd
fur vis-i¡alizíng internal anatomy in 45 cases (¡8%); also
the image claiity of transvaginal sonography was sub-
jectiveþ better in 75 cases (637d. Vaginal sonography
T^orou"d resolution in reaþtime uttrasound now
I' alío*s scrutiny of the ñrst trimester conceptus.r Vi-
Isuallzation ,íd appreciation of normal embry-
dnlc development ag"ndemonÉtrâted by ultrasonography
may allow structural anomatieg to be detected in the ñrst
trimester of pregnanc¡À
Recent enthuslasm for transvaginal sonography in the
diagnosis of ectopic pregnancyË and oócyte retrieval,"
and preliminary experience during the ñrst trimester of
pregnancyó'prompted an evaluation of the comparabíl-
ity of transrraginal ultrasound ve¡çus the abdomlnal ul'
trasound examination for visualizÍng the embryo. Theo'
retical advantages of the vaginal approach indude the
lack of requirement for bladder distentiorL closer prox-
imity of the embryo to the transducer (thus allowing the
Rec¡lved Mav 16, 1988, from the 9ection of Matam¡l'Fetal Medi'
clne, Departmånt of Obstetrics rnd Gynecologg Yale Univerrity
School oi Mediclno, New Haven Connecticut' Revised manucript
accepled fot publlcatlon M¡rch 23, 1989"
Aädre¡¡ cdrrecpondence and rcprint requests to Dr. Cullen: Deprrt'
ment of Obstetriir and Gynecology Yale Univenity School of Medi'
clne,3Tl Cedar 9treel, New Ll¡ven, CT 06n0.
@ 1989 by the American Institute of Ul¡asound ln Medicine o I Ultrasound Med 8:565*569, 1989
was superior to abdominal sonography in gestations
g10 weeks, in obese patients, and in patientsrlrith r€tro'
verted uteri. The rñajor difficulty encountered with
transvaginal sonography was the límited manewerabil'
-tool views. Vaginal so'
ity of tñ'e probe tõ générate speciñc
nögraphy can be J valuable in imaging the ñrst
trimeitei fetus, complementing, not replacing, abdomi-
nal sonography, xEi wönDsi transvaginal sonography
ßrst trimester of pregnancy. (l lJltmsoand Med 8:565,
1989)
use of higher frequenry probea), and fewer tissue lnter-
faces to tranwers€,
MATERIAI.S AND METHODS
ln our ó month study ending February 1988, 120 ñrst
trimester ultrasound examinations were performed on
105 consecutive patients in the Perinaial Unit of Yale.
New Haven Hospital. Ninety patients were referred fur
pregnancy dating, six for an anomaþ in a previous
pregnancy and nine for maternal diabetes mellitus.
Each patient underwent an abdominal ultnsound ex-
amination with a full bladder using a S-MHz sector
transducer (Alok¿ 280 SL Denver, CO) and a transvâ'
ginal examin¡tion wlth bladder emptied using a 7'Mllz
vaginal transducer (Bruel and Kjaer, Matborough, MA).
All ulhasounds were performed by at leaet two of the
authors.
An anatomical survey was performed and included
visualízation of the heart, bladder, kldney+ and adrenal
glands. The biometric parameters obtained included the
r 0Tl8-4297ß9/$X50
566 TRANWAGINAL AND ABDOMII{ÀI UITRASOUND I Ultrasound Med 8565-569, 1989

bþrietal dirmeter, crown-rump and femur lengths, detailed anatomy For ffnal anaþsis, gestatlonal lges
rrylnre approprlate fur gestational age'F A aubjectlve were subdivided into three groups: s8 wee&a;9 ts 10
opinion wâs made as to the preÉned tedlniquÊ at the weelç; and 1l through 13 week+ inclusive,
time of the scan by two observers based on theanatomic
vlsualizalion and the overall lmage clarity- Uterlne posi* RESUËrS
tion and the mate¡nal weight were recorded in all cases.
If one modality appeared superior, the reason wâ9 In all an emþryo
12O cases, observed. Of these, 33
lfq
noted, {27?6} were 58
weeks, 49 (4196) fell into the 9 to 10 week
Anaþsls was performed usÍng cro;¡ tabulatlon at spe: group and 3S (327o) were in the 1l through 13 week
ciñc gestational ages plotted aginst subiective daríty group The abiltty to obÉain bíometry and visualize anaþ
the ab,flity to obtain biometry and the ability to visuallze ómy and the subiectlve assessment in each g¡otlP are

Ftgurc 1Graphlc regesentalion of the ablsty to obtrin B¡orn?ry WüålLsd $ ;þd¡llly

biometry by modality at grouped gestatlonal age.

50

pallailr Uoüff obìÂln¡d

VAGNÂILY
Â8001,{NÂtlY
ÐtHlEO{¡¡rOU€s

0
5,0 wl¡ g-10

gtshlümslqo

Figure 2 Graphïc representâtlon of the ability t'o vi; Analoûy VlsuÉlþed by Modaily
cuallze detailed internal ânatomy by modality at rc
grouped gertatlonal age"
þ
6t
pallðnlt
n
I
smlorìy rh¡dlred

40
tl
I VAGII¡ALIY
{ì¡ YT
E¡ ABOÔMIIIÀLLY
a 9' E ÐfiæO{NEUãS
20
(\¡
I ø f.¡gr}Efr
o it

0
5.8 wk¡ 9"10 vrt{$ ryks tottl
ge$lâtlonattgs

Flgure 3Graphic representatlon of the subiectlve prefi subþcllrc ßs9sÍrfii* ol ünrga Clatlly
erence by modality at gmuped gestational a6e'
ìn
80

Ëô
rnodðlll! preler|d
p8lþl{$ I v¡ctt¡¡L
40 (t¿
E ÂgÞOlvÍ¡lÄt
Ng I EouAtcLAårY
ð
?o

ô
wl(s 1 Ë1(!
Gt3lallon¡lAgr
J Ultnsound Med 8¡565*569, 1989
Figute 4 Transvaginal ¡can of a 55 week embryo (8, embryo)'
depicted in Figures 1 to 3. Transvaginal scanning was
exclusively successful in obtaining biometry in 51 cases
({3j6) and for visualizing internal ånatomy in 45 cases
(38%) the image clarity of transvaginal scanning was
subiectiveþ superior in 75 cases (ó3?6). Wtth abdominal
scanning, biometry was obtained in 35 cases (29%),
CULLEN ETAL 56î
anatomy visualized in 7 cases (67o), and the image ap*
peared subiectively superior in 30 patients (2596). Bio-
metr¡r was obtained by both mod¡llties ln 34 cases (28%),
ânilomy was visualized by both techniques in 64 cases
(53flo), and subjective equlvalence occurred in 15 in-
stances (12%).
Ftgurr 5 Abdominal ultrasound of
the ¡¡¡tre 5.5 week embryo as in Fig.
ure 4 (8, embryo).
568 TI,ANSVAGINALAND ABBOMINALULÍR¡,SOUND I Ultnround Med 8:5ó5*569¿ 1989

Fþure 6 Abdomlnal ulh¡eound of a 105 week

embryo with qntic hygromu Ç cystlc hygroma;
cp droroid plexus)-

ln ó3 examinations {53?o), a leason r^tås offered br the ÐTSCUSSION

superiority of one modality over the other. Vaglnal so"
nognphy was preferred in cases of måternal obesity (17
casesf oi a retroverted uterua (16 cases). Abdomlnal
scannlng was citd äs the better modality ln ?il cases ín
which fõtal position made vaginal ecannlng dlfficult,
and 7 other cases ïnvohing a ñbroid uterus, pelvlc mass'
or an anteverted uteruso ln no case was discgmfort re'
ported by elther procedure.
The utility ând ådvantâge of tnnsvaginal sonography
were examined in this study. thrlike previous reports on
vaginal sonognphy which have been descriptive ln na-
ture. this evaluation was based on two obþctlve crlteria
as well as a subiective assessment. The objective criterla
lncluded the ability to obtain biometry and to visualize
anatomy. The¡e are dependent not only on ¡tsolutlon,

Ftgurc 7 Transvaginal ultrasound of same

ernbryo as in Flgure 6 NotTce the loer of de'
taíl (C, cystic hygroma).
I Ultrasound Med 8¡565-569, 1989
but also on the ability to generate speciÊc views. In this
seriee, although the vâSinal route was subiectively supe-
rior in 639o of all patients, traditionat abdominal scan- á"
ning was sufficient in obtaining biometry and for ana-
tomlc vlsualization in ó9Yo and 60S of all patienþ
respectively. As illushated in Figures 4 and 5, trans- '4,
vaginal sonognphy was superior in visualizing the con'
ceptus through the 10th week, in obese Patients, and in
caies in which the bladder was not full. These advan-
l"
tages were less pronouncedln advanclnggesÞdon (Figs.
6 and 7\, especialþ in obtaining biometric measure- Ê Fossum
ments, because of the limited maneuverability of the
-
probe.
Ultrasound visualization of the embryo in the ñrst '7.
trimester allows documentat¡on of normal embryonic
development,rl Case reportst-ü illustrate the ability of
ultrasound to diagnose structural anomalíes during this 8.
gestâtional period. We foresee an increasing tole for ul'
trasound diagnosis of congenital anomalies in the ñrst
trimester of pregnancy. Vaginal sonography will com- 9.
plement, not replace, the t¡aditional abdominal ex¡mi-
nation, 10.
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