ULTRASONOGRAPHY AND DOPPLER

Far Eastern University

Dr. Nicanor Reyes Medical Foundation Department of Obstetrics and Gynecology

ULTRASONOGRAPHY IN OBSTETRICS

Technology
picture displayed is produced by SOUND WAVES reflected back from the imaged structure a transducer containing piezoelectric crystals converts electrical energy to high-frequency sound waves water-soluble gel- as a coupling agent Dense tissue (bone) produces high-velocity reflected waves- WHITE Fluid- generates few reflected waves- BLACK

Technology
Images are generated quickly (> 40 frames/sec) picture appear real-time. Higher-frequency transducers- better image resolution Lower- frequencies penetrate tissue more effectively but resolution is poor

Safety
only for valid medical indication no confirmed damaging biological effects in mammalian tissue no fetal harm has been demonstrated in more than 30 years of use

Clinical Applications
ACCURATE ASSESSMENT OF: GESTATIONAL AGE FETAL GROWTH FETAL AND PLACENTAL ANOMALIES AOG based on ultrasound - more accurate than the LMP reduction in the number of labor inductions for postterm pregnancy AND avoidance of delivering a premature baby

Table 162. Components of Standard Ultrasound Examination by Trimester

FIRST TRIMESTER Gestational sac location Embryo or yolk sac identification Crown-rump length SECOND AND THIRD TRIMESTER Fetal number Presentation Fetal heart motion

Cardiac activity
Fetal number, including number of amnions and chorions of multiples when possible

Placental location
Amnionic fluid volume

Gestational age assessment

Fetal weight estimation

Uterus, adnexal, and cul-de-sac evaluation Evaluation for maternal pelvic masses Fetal anatomic survey

Some Indications for First-Trimester Ultrasound Examination

Confirm intrauterine pregnancy Evaluate suspected ectopic pregnancy Estimate gestational age (most accurate) Diagnose or evaluate multiple gestations Confirm cardiac activity Assist to chorionic villus sampling, embryo transfer, and localization and removal of intrauterine device Evaluate suspected gestational trophoblastic disease Define cause of vaginal bleeding Evaluate pelvic pain Evaluate maternal pelvic masses or uterine abnormalities

First Trimester
Transabdominal Scan Gestational sac 6 weeks Fetal echoes & cardiac activity 7 weeks Transvaginal Scan Gestational sac 5 weeks Fetal echoes & cardiac activity 6 weeks

First Trimester
Diagnosis of pregnancy viability TVS: cardiac motion usually is observed when the embryo is 5 mm in length (CRL) valuable in diagnosing abnormalities such as embryonic demise as well as anembryonic gestation Multifetal gestation can be identified- OPTIMAL TIME to determine chorionicity BEST TIME to evaluate the uterus, adnexal structures, and cul-de-sac Between 11-14 weeks- fetal nuchal translucency can be accurately- often in conjunction with maternal serum markers, in the detection of aneuploidy

Table 163. Some Indications for Second- or Third-Trimester Ultrasound Examination Estimation of gestational age Evaluation of fetal growth Vaginal bleeding Abdominal or pelvic pain Incompetent cervix Determination of fetal presentation Suspected multiple gestation Adjunct to amniocentesis Significant uterine size or clinical dates discrepancy Pelvic mass Suspected molar pregnancy Adjunct to cervical cerclage

Table 163. Some Indications for Second- or Third-Trimester Ultrasound Examination Suspected ectopic pregnancy Suspected fetal death Suspected uterine abnormality Evaluation of fetal well-being Suspected hydramnios or oligohydramnios Suspected abruptio placentae Adjunct to external cephalic version Preterm prematurely ruptured membranes or preterm labor Abnormal biochemical markers Follow-up observation of identified fetal anomaly Follow-up evaluation of placental location for suspected placenta previa History of previous congenital anomaly Serial evaluation of fetal growth in multifetal gestation Evaluation of fetal condition in late registrants for prenatal care

Table 164. Essential Elements of a Standard Examination of Fetal Anatomy

Head and Neck Cerebellum Choroid plexus Cisterna magna Lateral cerebral ventricles Midline falx Cavum septi pellucid Chest Four-chamber view of heart Evaluation of both outflow tracts if technically feasible Abdomen Stomachpresence, size, and location Kidneys

Bladder
Umbilical cord insertion into fetal abdomen Umbilical cord vessel number Spine Cervical, thoracic, lumbar, and sacral spine Extremities

Legs and armspresence or absence

Gender Indicated in low-risk pregnancies only for evaluation of multiple gestations

Fetal Biometry
formulas and nomograms allow accurate assessment of gestational age describe normal growth of fetal structures provides an estimated gestational age from the crown-rump length measurement in the first trimester estimates both gestational age and fetal weight in the second and third trimester using measurements of the biparietal diameter, head circumference, abdominal circumference, and femur length.

Fetal Measurements
Gestational sac (GS) - 4 6 weeks Crown-Rump Length(CRL) - most accurate at 6-10 weeks CRL- obtained in a sagittal plane and include neither the yolk sac nor a limb bud; variation of only 3 to 5 days

Fetal Measurements
Biparietal Diameter (BPD) - at 14- 26 weeks, is usually the most accurate parameter, with a variation of 7 to 10 days BPD- outer edge of the proximal skull to the inner edge of the distal skull, at the level of the thalami and cavum septum pellucidum Head circumference (HC) - If the head shape is flattened (dolichocephaly) or rounded (brachycephaly), this measurement is more reliable than the BPD

Transthalamic view showing thalami (TH) and cavum septi pellucidi (CSP).

Transventricular view of the atrium, which is marked by calipers and contains the echogenic choroid plexus (CH).

Transcerebellar view of the posterior fossa, demonstrating measurement of the cerebellum (C) and cisterna magna (CM).

Fetal Measurements Femur length (FL) - correlates well with both BPD and gestational age, has a variation of 7 to 11 days in the second trimester

Femur Length

Fetal Measurements
Abdominal circumference (AC) - parameter with the widest variation of 2 to 3 weeks, involves soft tissue rather than bone and is also the parameter most affected by fetal growth AC- skin line in a transverse view of the fetus at the level of the fetal stomach and umbilical vein variability of gestational age estimation increases as pregnancy advances third trimester- all individual measurements become less accurate

Fetal Measurements variability of gestational age estimation increases as pregnancy advances third trimester- all individual measurements become less accurate

Amnionic Fluid
amount of amnionic fluid Oligohydramnios - seen as obvious crowding of the fetus and absence of any significant pockets of fluid Polyhydramnios - an apparent excess of fluid Most widely used is the amnionic fluid index (AFI) AFI- NV: 8 and 24 cm ( > 24 weeks ) Largest vertical pocket- NV: 2 to 8 cm (< 24 weeks)

Amniotic Fluid Index

used to measure amniotic fluid calculated by adding the vertical depths of the largest pocket in each of four equal quadrants

Central Nervous System

Neural-Tube Defects second most common class of congenital anomalies Defects result from incomplete closure of the neural tube by the sixth week, or the embryonic age of 26 to 28 days.

Anencephaly Cephalocele Spina bifida

Anencephaly
A lethal defect characterized by the absence of the brain and cranium above the base of the skull and orbits

Anencephaly
can be diagnosed as early as the first trimester Inability to obtain a view of the biparietal diameter should raise suspicion Polyhydramnios from impaired fetal swallowing is common in the third trimester.

Anencephaly
Ultrasonography

the diagnosis can be made as early as 12 -13 weeks

Anencephaly

(Pregnancy Management)
Prognosis:

* invariably lethal * 50% - stillborn * 50% - neonatal death

Anencephaly

(Pregnancy Management)

Monitoring:

* usual prenatal care

- emotional support for the family - assess for polyhydramnios - tocolysis is NOT indicated

Anencephaly

(Pregnancy Management)

Delivery: Vaginal Special Issues: Termination Induction of labor

Anencephaly

(Neonatology)

Resuscitation: never indicated Nursery management: warmth, hygiene facilitation of parental grief

Cephalocele
herniation of meninges and brain tissue through a defect in the cranium, typically an occipital midline defect

Spina Bifida
- a neural tube defect of the spine in which the dorsal vertebral arches fail to fuse together

Spina Bifida

meningocoele

Spina Bifida

meningomyelocoele

Spina Bifida
Ultrasonography

the diagnosis can be made as early as 16 -18 weeks

Sagittal (LEFT) and transverse (RIGHT) views of the spine in a fetus with a large lumbosacral meningomyelocele

Spina Bifida
Ultrasonography

Transverse

Spina bifida
Five cranial signs: 1. Small biparietal diameter 2. Frontal bone scalloping or the so-called lemon sign 3. Elongation and downward displacement of the cerebellumthe so-called banana sign 4. Effacement or obliteration of the cisterna magna 5. Ventriculomegaly

Frontal scalloping or lemon sign in a fetus with a spinal meningomyelocele

The banana sign, seen in this fetus with a meningomyelocele, develops when the cerebellum is bowed and inferiorly displaced, causing effacement of the cisterna magna

Ventriculomegaly
Enlargement of the cerebral ventricles The lateral ventricle is commonly measured at its atrium, which is the confluence of the temporal and occipital horn. the measurement is relatively constant at 7 mm, with standard deviation of 1 mm, from 15 weeks onward Mild ventriculomegaly is diagnosed when the atrial width measures 10 to 15 mm, and overt ventriculomegaly when it exceeds 15 mm A dangling choroid plexus characteristically is found in severe cases prognosis is determined by both etiology and rate of progression

Transventricular view of the atrium, which is marked by calipers and contains the echogenic choroid plexus (CH).

The atria appear unusually prominent in this fetus with mild ventriculomegaly (caliper measurement 12 mm).

Cystic Hygroma
congenital malformation of the lymphatic system in which large, often multiseptated, fluid-filled sacs extend from the posterior neck usually develop as part of lymphatic obstruction sequence, in which lymph from the head fails to drain into the jugular vein and collects instead in jugular lymphatic sacs. Prognosis depends on the karyotype

Large, septated cystic hygromas in a 17-week fetus with Turner syndrome

Thorax
four-chamber view of the heart filling approximately two thirds of the area lungs are best visualized after 20 to 25 weeks appear as homogeneous structures surrounding the heart

Diaphragmatic Hernia
left-sided and posterior displacement of the heart to the middle or right side of the thorax by the stomach and bowel absence of the stomach bubble within the abdomen, small abdominal circumference bowel peristalsis seen in the fetal chest

Heart
cardiac malformations are the most common congenital anomalies Almost 90 percent of cardiac defects are multifactorial As many as 30 to 40 percent of cardiac defects diagnosed prenatally are associated with chromosomal abnormalities recognition of a cardiac malformation should prompt fetal karyotyping. The most frequently encountered aneuploidies are trisomies 21, 18, and 13, and 45, X (Turner syndrome).

Four-chamber view of the fetal heart, showing the location of the left and right atria (LA, RA), left and right ventricles (LV, RV), foramen ovale (FO), and descending thoracic aorta (A).

Gastrointestinal Tract
stomach is visible after 14 weeks the liver, spleen, gallbladder, and bowel can be identified in many second- and third-trimester fetuses Non-visualization of the stomach within the abdomen is associated with a number of abnormalities, such as: diaphragmatic hernia, abdominal wall defects and esophageal atresia

Transverse sonogram of a second-trimester fetus with an intact anterior abdominal wall and normal cord insertion.

Normal Abdominal Wall Development

Physiologic gut herniation:
6th 10th week AOG Complete closure of the abdominal wall: 10th 12th week AOG

Abdominal Wall Defects

Omphalocoele Gastroschisis

Abdominal Wall Defects

Gastroschisis full-thickness defect in the abdominal wall Typically it is located to the right of the umbilical cord insertion bowel herniates into the amnionic cavity survival rate of at least 90 percent result from an early vascular occlusion that leads to localized abdominal wall ischemia. Omphalocele abdominal contents covered only by a two-layered sac of amnion and peritoneum. The umbilical cord inserts into the apex of the sac may occur as part of a genetic syndrome, such as Beckwith Wiedemann or pentalogy of Cantrell

In this fetus with gastroschisis, extruded bowel loops are floating in the amnionic fluid to the right of the normal umbilical cord insertion site (arrow).

Abdominal Wall Defects

Gastroschisis full-thickness defect in the abdominal wall Typically it is located to the right of the umbilical cord insertion bowel herniates into the amnionic cavity survival rate of at least 90 percent result from an early vascular occlusion that leads to localized abdominal wall ischemia. Omphalocele abdominal contents covered only by a two-layered sac of amnion and peritoneum. The umbilical cord inserts into the apex of the sac may occur as part of a genetic syndrome, such as Beckwith Wiedemann or pentalogy of Cantrell

Transverse view of the abdomen showing an omphalocele as a large abdominal wall defect with exteriorized liver covered by a thin membrane.

Gastrointestinal Atresia
Most atresias are characterized by obstruction with proximal bowel dilatation the more proximal the obstruction, the more likely it is to be associated with hydramnios. Esophageal atresia may be suspected when the stomach cannot be visualized and hydramnios is present.

Esophageal Atresia

Duodenal atresia
so-called double-bubble sign, which represents distention of the stomach and the first part of the duodenum

Double-bubble sign of duodenal atresia is seen on this axial abdominal image of the fetus.

Kidneys and Urinary Tract

paraspinous masses frequently as early as 14 weeks, and routinely by 18 weeks The placenta and membranes produce amniotic fluid early in pregnancy,. but after 18 weeks, most of the fluid is produced by the fetal kidneys Fetal urine production increases from 5 mL/hr at 20 weeks to about 50 mL/hr at term Unexplained oligohydramnios suggests a urinary tract abnormality

Longitudinal sonogram of fetal kidney depicting the hypoechoic medullary pyramids (M).

Renal Agenesis
No kidneys are seen ultrasonographically at any point during gestation. The adrenal glands typically enlarge and occupy the renal fossae Without kidneys, no urine is produced, and the resulting severe oligohydramnios leads to pulmonary hypoplasia, limb contractures, a distinctive compressed face, and death from cord compression or pulmonary hypoplasia. When this combination of abnormalities results from renal agenesis, it is called Potter syndrome When these abnormalities result from scant amnionic fluid of some other etiology, it is called Potter sequence.

Urinary Bladder

Secondary hydronephrosis from bladder outlet obstruction

Three-Dimensional Ultrasonography
superior views of fetal surface anatomy improved visualization of selected structures such as the face, ear, and extremities. to adequately image a fetal structure in three dimensions, the part must be surrounded by amnionic fluid because crowding by adjacent structures obscures the captured image. even under ideal circumstances, image processing may take considerably more time than is typically devoted to two-dimensional (2-D) scanning.

DOPPLER VELOCIMETRY
used to determine the volume and rate of blood flow through maternal and fetal vessels Clinical Applications: systolicdiastolic ratio (S/D ratio) - compares maximum (peak) systolic flow with end-diastolic flow, thereby evaluating downstream impedance to flow

Doppler waveforms from normal pregnancy. Shown clockwise are normal waveforms from the maternal arcuate, uterine, and external iliac arteries, and from the fetal umbilical artery and descending aorta. Reversed end-diastolic flow velocity is apparent in the external iliac artery, whereas continuous diastolic flow characterizes the uterine and arcuate vessels. Finally, note the greatly diminished end-diastolic flow in the fetal descending aorta.

Umbilical Artery
This vessel normally has forward flow throughout the cardiac cycle, and the amount of flow during diastole increases as gestation advances. Thus the S/D ratio decreases, from about 4.0 at 20 weeks to 2.0 at term. The S/D ratio is generally less than 3.0 after 30 weeks Umbilical artery Doppler may be a useful adjunct in the management of pregnancies complicated by fetal growth restriction. Not recommended for screening of low-risk pregnancies or for complications other than growth restriction

Umbilical Artery
ABNORMAL: if the S/D ratio is above the 95th percentile for gestational age. In extreme cases of growth restriction, end-diastolic flow may become absent or even reversed These are ominous findings and should prompt a complete fetal evaluationalmost half of cases are due to fetal aneuploidy or a major anomaly In the absence of a reversible maternal complication or a fetal anomaly, reversed end-diastolic flow suggests severe fetal circulatory compromise and usually prompts immediate delivery

Umbilical artery Doppler waveforms:

A. Normal diastolic flow.

B. Absence of end-diastolic flow.

C. Reversed end-diastolic flow.

DOPPLER VELOCIMETRY
Diminished blood flow may be reflected such as the ff: 1. Diastolic notch 2. Increased SD ratio (Stuart Index) 3. Pulsatility index; Resistance index 4. Absence or reversed end diastolic (ARED) blood flow

Ductus Arteriosus
used primarily to monitor fetuses exposed to indomethacin and other nonsteroidal antiinflammatory agents. Indomethacin, which is used for tocolysis, causes constriction of the ductus in sheep and human fetuses The resulting increased pulmonary flow may cause reactive hypertrophy of the pulmonary arterioles, and eventually pulmonary hypertension develops this complication is largely reversible if medication is discontinued before 32 weeks

Middle Cerebral Artery

Peak systolic velocity in the middle cerebral artery is increased with fetal anemia because of increased cardiac output and decreased blood viscosity The cerebroplacental ratio has been introduced as an indicator of brain sparing in fetuses with growth restriction

Uterine Artery
Uterine blood flow increases from 50 mL/min early in gestation to 500 to 750 mL/min by term Increased resistance to flow and development of a diastolic notch have been associated with pregnancy-induced hypertension increased impedance of uterine artery velocimetry at 16 to 20 weeks was predictive of superimposed preeclampsia developing in women with chronic hypertension.

Normal uterine artery waveform with high-velocity diastolic flow.