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ISUOG 2nd trimester guidelines - Dr.Ashok Khurana
 

ISUOG 2nd trimester guidelines - Dr.Ashok Khurana

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    ISUOG 2nd trimester guidelines - Dr.Ashok Khurana ISUOG 2nd trimester guidelines - Dr.Ashok Khurana Presentation Transcript

    • ISUOG Mid-Trimester Guidelines Ashok Khurana The Ultrasound Lab, C-584, Defence Colony, New Delhi - 110024. INDIAScientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Routine mid-trimester fetal ultrasound ISUOG GuidelinesUltrasound Obstet Gynecol (2010)Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.8831(Ultrasound Obstet Gynecol 2011; 37: 116-126) GUIDELINESPractice guidelines for performance of the routine mid-trimester fetalultrasound scanL. J. SALOMON, Z. ALFIREVIC, V. BERGHELLA, C. BILARDO, E.HERNANDEZ-ANDRADE, S. L. JOHNSEN, K. KALACHE, K.-Y. LEUNG, G.MALINGER, H. MUNOZ, F. PREFUMO, A. TOI and W. LEE on behalf of theISUOG Clinical Standards Committee Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Routine mid-trimester fetal ultrasound At the outset! Not just an anatomic surveyScientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Routine mid-trimester fetal ultrasound Lecture outline• Introductory fluff• Who needs one• When• Who should do it• Equipment & Documentation• Safety• Logistics Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Routine mid-trimester fetal ultrasound Lecture outline• Fetal biometry and well being• The fetal anatomic survey• The echo and neurosono documents• The maternal anatomy survey• Critique: Have we set the bar too high?!• An overview of other society guidelines Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • “The wisdom of experience” Supplementary information / remarks!• Illustrations from the original document• Supplemented where necessary Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • And just in case you still do not know… ISUOGThe International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) is a scientific organization that encourages sound clinical practices, teaching, and research for diagnostic imaging in womens health care Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • ISUOG Clinical Standards Committee PurposeThe ISUOG Clinical Standards Committee (CSC) has a remit to develop Practice Guidelines and Consensus Statements as educational recommendations that provide health care practitioners with a consensus-based approach for diagnostic imaging. They are intended to reflect what is considered by ISUOG to be currently the best practices at the time they were issued Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • The mid-trimester fetal ultrasound scan Purpose & OverviewThe main objective of fetal ultrasound is to provideaccurate diagnostic information for the delivery ofoptimized antenatal care with the best possible outcomesfor mother and fetus.The technique is used to determine gestationalage, perform fetal measurements, detect congenitalmalformations and identify multiple pregnancies.Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • The mid-trimester fetal ultrasound scanThe Guidelines document specifically states:Although many malformations can be identified, it is acknowledged that some elude detection even with sonographic equipment in the best of hands or they may develop later in pregnancy.A healthcare practitioner should counsel the woman/couple regarding the potential benefits and limitations of the procedure Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • The mid-trimester fetal ultrasound scan Who should have one: everyone ……all pregnant women should be offered an ultrasound scan for the detection of fetal anomalies and pregnancy complications…….Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • The mid-trimester fetal ultrasound scan When should the scan be performed?• “18-22 weeks”• Earlier scans date better• Earlier scans require equipment, expertise and time• Later scans see better• Later scans see more• Local legislation Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • The mid-trimester fetal ultrasound scan When? 100 90 80 70 Anomalies (%) 60 50 40 30 20 10 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 Weeks of PregnancyScientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • The mid-trimester fetal ultrasound scan Who should perform this scan?• Individuals who have “specialised training”• Local legal requirements Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • The mid-trimester fetal ultrasound scan What equipment?• real time, grey scale ultrasound capabilities• transabdominal ultrasound transducers (3 – 5 MHz range)• adjustable acoustic power output controls with output display standards• freeze frame capabilities• electronic calipers• capacity to print/store images• regular maintenance and servicing Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • The mid-trimester fetal ultrasound scan What equipment?Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • The mid-trimester fetal ultrasound scan Documentation & Reporting• Electronic and/or paper document sent to the referring care provider in reasonable time• Sample reporting form• Images of standard views (stored either electronically or as printed copies) should also be produced and stored• Motion videoclips for the fetal heart• Many jurisdictions require image storage for a defined period of time Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • The mid-trimester fetal ultrasound scan Reporting Form Copies of this document are available at: http://www.isuog.orgScientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • The mid-trimester fetal ultrasound scan Safety• Prenatal ultrasonography appears to be safe for clinical practice• To date, there has been no independently confirmed study to suggest otherwise.• Fetal exposure times should be minimized, using the lowest possible power output needed to obtain diagnostic information, following the ALARA principle (As Low As Reasonably Achievable).• More details are available from the ISUOG Safety Statement Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • The mid-trimester fetal ultrasound scan What if an exam does not match up?• Recommendations represent minimum practice guidelines• Reasons for deviations from these recommendations should be documented• If the examination cannot be performed completely in accordance with adopted guidelines, the scan should be repeated, at least in part, at a later time• the patient can be referred to another practitioner. This should be done as soon as possible, to minimize unnecessary patient anxiety and unnecessary delay in the potential diagnosis of congenital anomalies Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited. Scientific content is the copyright of the speaker. or growth disturbances.
    • The mid-trimester fetal ultrasound scan And now coming to the core stuff! • Fetal biometry and well being • Anatomical surveyScientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • The mid-trimester fetal ultrasound scan Fetal biometry and well being • Fetal biometry • Amniotic fluid assessment • Fetal movement • Doppler ultrasonography • Multiple gestationScientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Fetal biometry Parameters • Biparietal diameter (BPD) • Head circumference (HC) • Abdominal circumference (AC) • Femur diaphysis length (FDL)Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Fetal biometry Parameters• Standardised manner and strict quality criteria• Audit of results• Still images to document the measurements Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Fetal biometry Gestational age• Should be set at dating scan or NT scan• If not, use BPD and/or HC or FDL• Indicate the chosen reference in the report• Combining measurements improves accuracy• Do not reset if already determined in a high-quality scan earlier in pregnancy Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Fetal biometry Biparietal diameter (BPD): anatomy• cross-sectional view of the fetal head at the level of the thalami• ideal angle of insonation is 90° to the midline echoes• symmetrical appearance of both hemispheres• continuous midline echo (falx cerebri) broken in the middle by the cavum septi pellucidi and thalamus• no cerebellum visualized. Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Fetal biometry Biparietal diameter (BPD): calipers• specific methodology e.g. leading edge/widest part of skull/perpendicular to falx• use a chart that uses the same methodology• use cephalic index to reject BPD for HC Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Fetal biometry Head circumference (HC)• anatomy: same as BPD• measure as ellipse if available on machine; use outer margin of bone• else measure OFD from middle of the bone echoes from frontal to parietal: HC=1.62 x (BPD+OFD) Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Fetal biometry Abdominal circumference (AC): anatomy• transverse section of the fetal abdomen (as circular as possible)• umbilical vein at the level of the portal sinus• stomach bubble visualized• kidneys should not be visible Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Fetal biometry Abdominal circumference (AC): calipers• Outer surface of skin line• Trace with ellipse• Else anteroposterior (APAD) and transverse diameter (TAD) and AC = 1.57 (APAD + TAD) Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Fetal biometry Femur diaphysis length: (FDL)• image with both ends of ossified metaphysis clearly visible• measure longest axis• angle of insonation of 45° - 90°• use a reference chart that uses the same measurement methodology• exclude triangular spur artefacts and the distal femoral epiphysis Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Fetal biometry Additional parameters• The ISUOG document suggests BPD/HC/AC/DFL as a minimal requirement• Additional useful parameters include the cerebellar transverse diameter, orbital diameters, lateral ventricular measurements, humeral length, nasal bone and nuchal skin Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Fetal well being Estimated fetal weight• The degree of deviation from normal at this early stage of pregnancy that would justify action (e.g. follow-up scan to assess fetal growth or fetal chromosomal analysis) has not been firmly established• if gestational age is determined at an earlier scan, EFW can be compared to dedicated normal, preferably local, reference ranges for this parameter Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Fetal well being Amniotic fluid assessment• Amniotic fluid volume can be 270 250 Amniotic Fluid Index 230 210 190 estimated subjectively or by using 170 150 130 110 90 sonographic measurements 70 16 18 20 22 24 26 28 30 32 34 36 38 40• Week Subjective estimation is not inferior to the quantitative measurement techniques (e.g. deepest pocket, amniotic fluid index) when performed by experienced examiners Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Fetal well being Amniotic fluid assessment 270 250 Amniotic Fluid Index 230 210 190 170 150 130 110 90 70 16 18 20 22 24 26 28 30 32 34 36 38 40 Week• Patients with deviations from normal should have more detailed anatomical evaluation and clinical follow-up Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Fetal well being Fetal movement• There are no specific movement patterns at this stage of pregnancy• Temporary absence or reduction of fetal movements during the scan should not be considered as a risk• Abnormal positioning or unusually restricted or persistently absent fetal movements may suggest abnormal fetal conditions such as arthrogryposis Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Fetal well being Fetal movement• The biophysical profile is not considered part of a routine mid-trimester scan!• Fetal brain is not yet mature enough! Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Fetal well being Doppler ultrasonography• The application of Doppler techniques is not currently recommended as part of the routine second-trimester ultrasound examination• There is insufficient evidence to support universal use of uterine or umbilical artery Doppler evaluation for the screening of low-risk pregnancies Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Fetal well being Multiple gestations• visualization of the placental cord insertion• distinguishing features (gender, unique markers, position in uterus)• determination of chorionicity is sometimes feasible in the second trimester if there are clearly two separate placental masses and discordant genders. Chorionicity is much better evaluated before 14–15 weeks (lambda sign or T-sign). Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • The anatomical survey At a glance ( table 1 of the document )Head Intact cranium Abdomen Cavum septi pellucidi Stomach in normal position Midline falx Bowel not dilated Thalami Both kidneys present Cerebral ventricles Cord insertion site Cerebellum Skeletal Cisterna magna No spinal defects or masses (transverse and sagittal)Face Both orbits present Median facial profile Arms and hands present, normal relationships Mouth present Legs and feet present, normal relationships Upper lip intact PlacentaNeck Absence of masses (e.g. cystic hygroma) PositionChest/Heart No masses present Normal shape/size of chest and lungs Accessory lobe Heart activity present Umbilical cord Four-chamber view of heart in normal position Three-vessel cord Genitalia Aortic and pulmonary outflow tracts Male or female Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Head Skull• Size: measurements Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Head Skull• Shape: the skull normally has an oval shape without focal protrusions or defects and is interrupted only by narrow echolucent sutures. Alterations of shape (e.g. lemon, strawberry, cloverleaf) should be documented and investigated Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Head SkullScientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Head Skull• Density: normal skull density is manifested as a continuous echogenic structure that is interrupted only by cranial sutures in specific anatomical locations.• The absence of this whiteness or extreme visibility of the fetal brain should raise suspicion of poor mineralization.• Poor mineralization is also suggested when the skull becomes Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Head Skull: densityScientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Head Brain • lateral ventricles (including choroid plexi) • cavum septi pellucidi • midline falx • thalami • cerebellum • cisterna magnaScientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Head Brain • lateral ventricles (including choroid plexi) • cavum septi pellucidi • midline falx • thalami • cerebellum • cisterna magnaScientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Head Brain: The neurosonogramSonographic examination of the fetal central nervous system:guidelines for performing the „basic examination‟ and the „fetalneurosonogram‟Ultrasound Obstet Gynecol 2007; 29; 109–116 Copies of this document are available at: http://www.isuog.org Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Head Brain: The neurosonogramSonographic examination of the fetal central nervous system:guidelines for performing the „basic examination‟ and the „fetalneurosonogram‟ Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Head Lateral ventricle measurementsScientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Head Face• Minimum evaluation of the fetal face should include an attempt to visualize the upper lip for possible cleft lip anomaly• If technically feasible, other facial features that can be assessed include the median facial profile, orbits, nose and nostrils. Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Head Face• Going beyond the “Minimum evaluation”• Additional views and techniques in specific situationsScientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Neck Guidelines• The neck normally appears as cylindrical with no protuberances, masses or fluid collections• Obvious neck masses such as cystic hygromas or teratomas should be documented Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Thorax Guidelines• The shape should be regular with a smooth transition to the abdomen• The ribs should have normal curvature without deformities• Both lungs should appear homogeneous and without evidence of mediastinal shift or masses• The diaphragmatic interface can often be visualized as a hypoechoic dividing line between the thoracic and abdominal content (e.g. liver and stomach) Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Thorax Guidelines• Shape/Ribs/Lungs/Diaphragm/Cardiac evaluation Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Thorax Ribs: An example of how use “Guidelines”• “The ribs should have normal curvature without deformities”• Maintain minimum standards: look at the ribs• Go beyond or note and refer Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Cardiac evaluation Some really important stuff!• Basic cardiac examination: 4 chamber view• Extended basic cardiac examination: 4C + outflows• Three vessel and three vessel trachea viewsUltrasound Obstet Gynecol 2008; 32: 239 – 242ISUOG consensus statement: what constitutes a fetal echocardiogram?W. LEE, L. ALLAN, J. S. CARVALHO, R. CHAOUI, J. COPEL, G. DEVORE, K. HECHER, H.MUNOZ, T. NELSON, D. PALADINI and S. YAGEL for theISUOG Fetal Echocardiography Task Force Copies of this document are available at: http://www.isuog.org Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Cardiac evaluation Aims and technical considerations• The basic and extended basic cardiac ultrasonographic examinations are designed to maximize the detection of congenital heart disease during a second-trimester scan• A single acoustic focal zone and relatively narrow field of view can help to maximize frame rates• Images should be magnified until the heart fills at least a third to a half of the display screen. Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Cardiac evaluation The four chamber view• The basic cardiac screening examination is interpreted from a four-chamber view of the fetal heart• A normal regular rate ranges from 120 to 160 beats per min• The heart should be located in the left chest (same side as the fetal stomach) if the situs is normal. A normal heart is usually no larger than one-third of the area of the chest and is without pericardial effusion• The heart is normally deviated by about 45 ± 20° (2 Scientific content is the copyright ofleft side ofrecordingfetus SD) towards the the speaker. Video the is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Basic Extended Cardiac evaluation The outflows and three vessel viewsScientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Abdomen Guidelines• Abdominal organ situs should be determined• The fetal stomach should be identified in its normal position on the left side• Bowel should be contained within the abdomen and the umbilical cord should insert into an intact abdominal wall• The fetal umbilical cord insertion site should be examined for evidence of a ventral wall defect such as omphalocele or gastroschisis• Cord vessels may also be counted using gray-scale imaging as an optional is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited. Scientific content component of the routine anatomical survey
    • Abdomen Guidelines• Abnormal fluid collections of the bowel (e.g. enteric cysts, obvious bowel dilatation) should be documented• Aside from the left-sided stomach, a fetal gallbladder may be seen in the right upper quadrant next to the liver, although this latter finding is not a minimum requirement of the basic scan. Any other cystic structures seen in the abdomen should prompt referral for a more detailed scan Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Abdomen: Kidneys and urinary bladder Guidelines• The fetal bladder and both kidneys should be identified• If either bladder or renal pelves appears enlarged, a measurement should be documented• Persistent failure to visualize the bladder should prompt referral for a more detailed assessment. Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Abdomen GuidelinesScientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Spine Guidelines• A satisfactory examination of the fetal spine requires expertise and meticulous scanning, and the results are heavily dependent upon fetal position• Complete evaluation of the fetal spine from every projection is not part of the basic examination, although transverse and sagittal views are usually informative• Other views of the fetal spine may identify other spinal malformations, including vertebral abnormalities and sacral agenesis Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Spine Guidelines Sonographic examination of the fetal central nervous system: guidelines for performing the „basic examination‟ and the „fetal neurosonogram‟ Ultrasound Obstet Gynecol 2007; 29; 109–116Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Limbs and extremities Guidelines• The presence or absence of both arms/hands and both legs/feet should be documented using a systematic approach• Counting fingers or toes is not required as part of the routine mid- trimester scan. Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Genitalia Guidelines• Characterization of external genitalia to determine fetal gender is not considered mandatory in the context of a mid-trimester routine scan• Reporting of gender should be considered only with parental consent and in the context of local practices Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Placenta Guidelines• During ultrasonography, the placental location and its relationship with the internal cervical os and its appearance should be described• Placental texture and size• In most cases of the routine second-trimester examination, transabdominal ultrasonography permits clear definition of the relationship between placenta and internal cervical os• If the lower placental edge reaches or overlaps the internal os, a follow-up the copyright of the speaker. Video recording third trimester is recommended Scientific content is examination in the is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Placenta Guidelines + + + + + +Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Placenta Guidelines• Women with a history of uterine surgery and low anterior placenta or placenta previa are at risk for placental attachment disorders. In these cases, the placenta should be examined for findings of accreta, the most sensitive of which are the presence of multiple irregular placental lacunae that show arterial or mixed flow• Abnormal appearance of the uterine wall–bladder wall interface is quite specific for accreta, but is seen in few cases. Loss of the echolucent space between an anterior placenta and the uterine wall is neither a sensitive nor a specific marker for placenta accreta is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited. Scientific content
    • Maternal anatomy Guidelines• Currently, there is insufficient evidence to recommend routine cervical length measurements at the mid trimester in an unselected population• Uterine fibroids and adnexal masses should be documented if they are likely to interfere with labor Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Maternal anatomy Guidelines• Currently, there is insufficient evidence to recommend routine cervical length measurements at the mid trimester in an unselected population• Uterine fibroids and adnexal masses should be documented if they are likely to interfere with labor Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • Take Home Message• Worldwide, it is likely that much of the ultrasonography currently performed is carried out by individuals with little or no formal training• The intent of this document is to provide further guidance for healthcare practitioners in the performance of the mid-trimester fetal ultrasound scan. http://www.isuog.org Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.
    • THANK YOU FOR YOUR ATTENTION www.ashokkhurana.come mail: ashokkhurana@ashokkhurana.com Scientific content is the copyright of the speaker. Video recording is the copyright of ISUOG and GE. Unauthorized copying is strictly prohibited.