Prof Soha Talaat Cairo university :obstetric US


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Prof Soha Talaat Cairo university :obstetric US

  1. 1. Sonographic diagnosis of pregnancy • First sonographic evidence: 24 days postfertilization = intrauterine gestational sac (5th week gestation sac visualized within the uterine corpus as an echogenic ring with a hypoechoic interior)
  2. 2. The sac is measured inside the hyperechoic rim, including only the echo- free space. • The GS is imaged first in the longitudinal plane, obtaining long axis and AP measurements perpendicular to each other. Then, in the transverse plane at the level of the anteroposterior measurement, the width measurement is obtained. • Measurements are averaged to obtain the GS mean diameter.
  3. 3. Development in the 1st trimester Embryo: • 6 to 8 weeks embryo appears as a uniform echogenic structure within the gestational sac. • 8th week: A head and trunk can be identified. (Head/Trunk ratio : 50%) • The physiological umbilical hernia may be seen in few cases. • 9th week: Evidence of limbs. • 11th week: Increased differentiation of the skull, trunk, limbs and of the organ systems established during the embryonic period, with progressive ossification the skull is recognized as consisting of a frontal bone, orbits, maxilla and mandible. • by the 12th week, the fetal spine
  4. 4. CROWN RUMP LENGTH(CRL) • Accurate date pregnancy between 7 and 13 weeks' gestation. • Measurement of the fetal length from the tip of the cephalic pole to the tip of the caudal pole. • The fetus should be at rest and assuming its natural curvature.
  5. 5. Technical factors can lead to errors in CRL measurements. • Limbs in the CRL measurement, • Excessive curling or extension of the fetus, • Tangential incorporation of the yolk sac .
  6. 6. CRL
  7. 7. Yolk Sac: • Appears by the 6th or 7th week as an echogenic sac like structure located close to the embryo within the gestational sac. • Its diameter increases from 3 mm in the 7th week to 6 mm in the 11th. Corpus Luteum of Pregnancy: • Can be seen in the early pregnancy as a smooth bordered hypoechoic cystic mass next to the uterus. • It usually disappears by the 16th week.
  8. 8. Cervicometry
  9. 9. Funneling & short cervix
  10. 10. Funneling
  11. 11. Nuchal translucency
  12. 12. Abnormal nuchal translucency
  13. 13. FIRST TRIMESTER BLEEDING 3-4 weeks Implantation bleeding Perhaps some fluid in endometrial cavity. Gestational sac not visible at this stage 5-20 weeks Missed abortion Visible embryo. No embryonic activity. Perhaps disorganization of gestational sac and embryo 5-20 weeks Incomplete abortion Some retained products of conception are nonspecific disorganized material 10-20 weeks Early subchorionic hematoma; placental abruption A fairly common occurrence. Usually echo-poor crescentic fluid collection beside gestational sac. Embryo usually alive 5-20 weeks Other Ectopic pregnancy Hydatidiform mole Cervical lesions (not usually detected with ultrasound)
  14. 14. Poor Outcome gestational sac criteria • Abnormal gestational sac size . • Distorted sac shape . • Thin weakly echogenic decidual reaction . • Low position in endometrial cavity .
  15. 15. Unhealthy GS
  16. 16. Unhealthy sac
  17. 17. Is the gestational sac normally located in the endometrial cavity near the fundus•?
  18. 18. Blighted ovum • A better term for blighted ovum is anembryonic gestation. The very early embryo succumbs for some reason (at 4-5 weeks). • Where the diagnosis is not certain (the size of the sac is at a borderline size for identification of the embryo), a repeat scan should be performed in approximately one week
  19. 19. Blighted ovum
  20. 20. Missed abortion
  21. 21. Gestational trophoblastic disease (GTD) • A spectrum of disorders that can develop in subsequent pregnancy. • Hydatidiform mole is the most common manifestation, representing 85% of cases. Hydatidiform mole is noninvasive and remains confined to the endometrium. • Choriadenoma destruens is a locally invasive (myometrium) manifestation that represents 13% of cases of GTD. • Two percent of cases are described as choriocarcinoma, which is locally invasive (myometrium and parametrium). Choriocarcinoma is also highly malignant, spreading hematogenously to the lungs, brain, liver, kidneys, bones, and GI tract
  22. 22. Vesicular mole • The uterus may appear enlarged and filled with a hyperechoic mass with many cystic structures. • The cysts measure 1 - 2 mm. and may not be seen sonographically. During the 2nd trimester, the cysts enlarge to approximately 2 cm. in diameter
  23. 23. TVS
  24. 24. Suspected Ectopic gestation • Specific feature: living embryo in adnexa . • Non specific (correlate with b-HCG) :  Empty uterus .  Pseudo-gestational sac of ectopic pregnancy .  Particulate ascites .  Adnexal mass .  Ectopic tubal ring .
  25. 25. Empty uterus
  26. 26. Ectopic
  27. 27. Non disrupted ectopic
  28. 28. Ovarian ectopic
  29. 29. Retained products of conception
  30. 30. Subchorionic haematoma
  31. 31. Abdominal pregnancy • In an ectopic pregnancy, the fertilized egg may implant in: – One of the fallopian tubes. About 99% of ectopic pregnancies occur in a fallopian tube.2 – One of the ovaries (very rare). – The cervix (very rare). • The abdomen. This occurs in just over 1% of ectopic pregnancies.2 Although extremely rare, there are reports of women developing abdominal ectopic pregnancies after having a hysterectomy.5
  32. 32. Rare types Interstitial pregnancy Hetertropic pregnancy
  33. 33. Twins • May arise from fertilization of: Two separate ova (Dizygotic (DZ), fraternal ) Single fertilized ovum (Monozygotic(MZ),i dentical Twins)
  34. 34. Twins • Assessment of viability. • Chorionicity and amnionicity. (DZ)>Dichorionic Diamniotic (MZ)> depend on stage of division: DC/DA MC/DA > most common(70%). MC/MA > incidence of conjoined twins.
  35. 35. Chorionicity and amnionicity Delta or lumda sign in DCDA T sign in MCDA
  36. 36. Multiple gestation • Transvaginal view of an 8 week twin intrauterine pregnancy. • There is a normal fetal pole in each sac, and each sac has a normal echogenic trophoblastic rim.
  37. 37. 2D US
  38. 38. Monoamniotic
  39. 39. Conjoined twins
  40. 40. 3D US
  41. 41. Twin Gestation • Incidence of congenital anomalies appears to be twice as common than in singleton pregnancy. • Major malformation 2.1% in twins, 1.05% in single fetus. • Increased rate of anomalies in monozygotic twins .
  42. 42. Multiple pregnancy
  43. 43. From the 2nd trimester on, routine examination should begin with a longitudinal survey scan for general orientation before proceeding to more selective and detailed views.
  44. 44. Symmetrical growth curve
  45. 45. Cranial structures to note • Head shape. • Bone density . • Ventricular system size and appearance. • Cavum septum pellucidum . • Thalami • Cerebellum and vermis • Cysterna magna • Nuchal fold .
  46. 46. 12 weeks GA
  47. 47. Brain anatomy • The transventricular view is used for measurement of the biparietal diameter (BPD), head circumference (HC), and width of the ventricles. • The transcerebellar (or suboccipitobregmatic) view allows examination of the mid-brain and posterior fossa; this view is used for measurement of the transverse cerebellar diameter (TCD) and cisterna magna (CM).
  48. 48. Trans ventricular
  49. 49. Ventriculomegaly • Measurement is obtained at the level of the glomus of the choroid plexus, perpendicular to the ventricular cavity with the calipers inside the echoes generated by the lateral walls . • The measurement is stable in the second and early third trimesters, with a mean diameter of 6–8 mm and is considered normal when less than 10 mm .. At mid gestation a value of 10.0 mm or greater should be considered suspicious
  50. 50. 15 weeks GA
  51. 51. The depth of the cisterna magna • measured between the cerebellar vermis and the internal side of the occipital bone is usually 2–10 mm (Mahony, 1988). With dolicocephaly, measurements slightly larger than 10 mm may be encountered
  52. 52. Acrania- Anencephaly- exencephaly • Incidence :1/1000 • Errors of dorsal induction • Failure of closure of neural tube at cranial end. • Absence of brain and vault : frog like appearance
  53. 53. Meckel Gruber syndrome
  54. 54. Exencephaly : • Amorphus mass resembling brain structures uncovered by bone . • Facial structures and orbits are present • Spinal and CNS abnormalities . • Polyhydramnious
  55. 55. Exencephaly 12 weeks
  56. 56. Exencephaly 20 weeks
  57. 57. Encepalocele • 1in 2000 • cranial defect with varying degrees of brain herniation. • most cases occurring in the occipital and (less commonly) frontal regions. • The mass may be purely cystic, or it can contain echoes from brain tissue.
  58. 58. Occipital encephalocele
  59. 59. Holoprosencephaly • Holoprosencephaly is a complex abnormality of the forebrain resulted from failure in the diverticulation of the prosencephalon. It is classified in three major varieties: • Alobar: single primitive ventricle; fused thalami; absence of the third ventricle, neurohypophysis, olfatory bulbs and the head is generally small; • Semilobar: the two cerebral hemispheres are partially separated; • Lobar: the interhemispheric fissure is well developed posteriorly and anteriorly, but there is still a variable degree of fusion of the cyngulate gyrus and the lateral ventricles and absence of the septum pellucidum. • Chromosomal abnormality has been associated, specially trisomy 13, but maternal infections and paternal toxic exposures also can be implicated. All kinds of holoprosencephaly can be diagnosed by ultrasound.
  60. 60. Holoprosencephaly • Associated anomalies: Holo-pros-encephaly, cephalocele, disgenesis of corpus callosum, cerebellar hypoplasia, atresia of third ven-tricle, midline proboscis, hypoplastic tongue, tracheoesophageal fis-tula, cardiac anomalies, and adrenal hypoplasia.
  61. 61. F, 24 y, 0000, negative consanguinity, no general disease, discovered at 27weeks GA
  62. 62. Fetal brain
  63. 63. Fetal brain 3D
  64. 64. Fetal face
  65. 65. Associated anomalies
  66. 66. F, 28Y, 0000, negative consanguinity ,No general disease ,discovered to have poly hydraminos at 36 weeks , 2D &4D US
  67. 67. MRI fetal brain
  68. 68. Differential diagnosis • The most common diagnostic problem is differentiation among : • Hydranencephaly. • Schizencephaly . • Extreme hydrocephalus. • Alobar holoprosencephaly • Porencephaly. • Some spared cortical mantle should still be seen with porencephaly and alobar holoprosencephaly.
  69. 69. Hydrocephalus
  70. 70. Hydrocephalus
  71. 71. Hydranencephaly. • 1-2.5:10,000 births • Absence of the cerebral hemispheres with an incomplete or absent falx and a sac-like structure containing cerebral spinal fluid surrounding the brainstem and basal ganglia.
  72. 72. Schizencephaly • Clefts in the cerebral mantle (usually bilateral), lined by pia- ependyma, with communication between the ventricles and subarachnoid space.
  73. 73. Choroid plexus cyst • 0.4-3.6% , usually isolated finding . • Resolve by 22—26 GA. • May be associated with aneuploidy, trisomy 18&21. • Size 0.3– 2cm • Unilateral bilateral solitary or multiple
  74. 74. Arnold chiari
  75. 75. Vermian agenesis
  76. 76. use of three-dimensional (3D) ultrasound • Evaluation of the fetal face is well established. The advantages over standard 2D ultrasound include the visualization of scanning planes that are physically impossible or very difficult to obtain, the demonstration of the surface of the face, and the possibility of having panoramic views. • The limitations of the technique are the same as for 2D sonograms. If the fetal face is not accessible or there is not a pocket of amniotic fluid separating the face from the surrounding structures, 3D willbe of little help
  77. 77. 3D face US
  78. 78. Cleft lip
  79. 79. Skeleton mode to see palate
  80. 80. Micrognathia • Referred to as the Robin anomalad, which may be a sporadic isolated finding (in about 40% of cases) or may be associated with other anomalies or with recognized genetic and non-genetic syndromes including Treacher Collins, Robin and Robert syndromes, Cornelia de Lange syndrome, chromosomal abnormalities (mainly trisomy 18 and triploidy) and teratogen exposure
  81. 81. Craniosynostosis • Suspected in the presence of an abnormal skull shape Failure to visualize the sutures that are normally seen as linear interruptions of the echogenic calvarium increases the index of suspicion. • Recent reports on 3D ultrasound suggest that this technique may be valuable in the diagnosis of craniosynostosis.
  82. 82. • Fetal yawning and smiling as a marker of fetal neurobehavior or biophysical assessment
  83. 83. Spine
  84. 84. Myelo-meningiocele
  85. 85. Myelo-meningiocele
  86. 86. Female
  87. 87. Female
  88. 88. Male sex
  89. 89. Fetal echocardiography • The five axial views in the normal cardiac examination. • In the lower image the situs is determined. • The plane above is the 4- chamber view (4CV). • More cephalic is the left and right outflow tract. • The highest plane is the arches at the 3-vessel and trachea (3VT) view. (From Yagel S, Cohen SM, Achiron R. Obstet Gynecol 2001;368;
  90. 90. Fetal Heart
  91. 91. PKD
  92. 92. PUV
  93. 93. PUJ
  94. 94. Multi cystic dysplastic
  95. 95. Abdomen
  96. 96. Isolated ascites
  97. 97. Abdominal wall abnormalities omphalocele
  98. 98. Abdominal wall abnormalities Gastroschisis
  99. 99. The following are features of body stalk anomaly • The typical ultrasound features are • major abdominal wall defect. • severe kyphoscoliosis. • neural tube defect. • limb abnormalities. • malformed umbilical cord • Absence of umbilicus and unbilical cord and adherence of the placenta to the herniated viscera through large anterior wall defect and reduced amniotic fluid render foetus immobile
  100. 100. Body stalk anomaly
  101. 101. SKELETON • Limb buds are first seen by ultrasound at about the 8th week of gestation; the femur and humerus are seen from 9 weeks, the tibia/fibula and radius/ulna from 10 weeks and the digits of the hands and the feet from 11 weeks. • Body movements (wiggling) are seen at 9 weeks and, by 11 weeks, limbs move about readily. • . At the 18–23-week scan, the three segments of each extremity should be visualized, but it is only necessary to measure the length of one femur.
  102. 102. Development of upper& lower extremities
  103. 103. Skeletal abnormalities • Asymmetry . • Dysplasias . • Contractures. • Fractures. • Duplications • reductions
  104. 104. Malformation of fetal skeleton can be classified into two major categories: Generalized type : multiple bones are involved . Focal type : a variable pattern both in distribution and extent in involvement.(Bowerman, 1995)
  105. 105. Nonlethal Dwarfism 1. Achondroplasia. 2. Asphyxiating thoracic dysplasia (jeune syndrome). 3. Chondroectodermal dysplasia (Ellis-van Creveld syndrome). 4. chondrodysplasia punctata. 5. Spondyloepiphyseal dysplasia. 6. Diastrophic dwarfism. 7. Metatrophic dwarfism. 8. Hypochondroplasia. Lethal Bone Dysplasia (in order of frequency) 1. Thanatophoric dysplasia 2. Osteogenesis imperfecta, type II. 3. Achondrogenesis type I + II. Jeune syndrome (may be nonlethal). 4. Hypophosphatasia, congenital lethal form.Chondroectodermal dysplasia (usually nonlethal). 5. Chondrodysplasia punctata, rhizomelic type. 6. Camptomelic dysplasia. 7. Short rib polydactylysyndrome 8. Homozygous achondroplasia.
  106. 106. • Routine conventional ultrasound is the main prenatal screening method for skeletal disorders, identifying abnormalities of fetal bones (De Pellegrin et al., 2000). • Detection of a shortended femur is the most common indication that a skeletal dysplasia may be present • Examination of all extremities will confirm generalized involvement and help establish a differential diagnosis.
  107. 107. • The cranium and facies are evaluated subjectively for facial dysmorphism. The limbs are evaluated for rhizomelia, mesomelia and acromelia, bowing and mineralization patterns. Hands and feet are evaluated for relative size, posturing and configuration of the phalanges. The axial skeleton is inspected subjectively for mineralization patterns, platyspondyly and rib shape and length (Krakow et al., 2003).
  108. 108. Club foot
  109. 109. Fractures
  110. 110. Asymmetry
  111. 111. Thantophoric dysplasia
  112. 112. Pregnant female 18 weeks GA
  113. 113. 3D
  114. 114. 4D
  115. 115. Achondogenesis IA
  116. 116. Normal Sonographic Placental Anatomy • Sonographic pattern of the placenta changes from a series of small white specules at around 8weeks gestation to a granular appearance by 10 weeks gestation. • In the second trimester it becomes homogenous with a non calcified texture. • At about 20-24weeks, some echo free spaces within the placental substance develop and enlarge as pregnancy advances. • After 36 weeks, the spaces becomes more apparent and they are separated by wide calcified areas of inter -cotyledons septa.
  117. 117. Placental grading
  118. 118. Grade I 2
  119. 119. Grade III 2
  120. 120. Grade II
  121. 121. Placental Abnormalities  Abnormal Shape or Implantation  Degenerative Placental Lesions  Circulatory Disturbances  Hypertropic Placental Abnormalities  Placental Inflammation  Tumors of the Placenta
  122. 122. Variant placental shapes • include bilobed, • succenturiate, • Circumvallate • placenta membranacea
  123. 123. Placental localization. • US has become indispensable in the localization of the site of the placenta and determining its lower edges, thus making a diagnosis or an exclusion of placenta previa. • Other placental abnormalities in conditions such as diabetes, fetal hydrops, Rh isoimmunization and severe intrauterine growth retardation can also be assessed.
  124. 124. What is the position of the placenta? • At about 7-8 weeks the chorion frondosum begins to thicken and form a recognizable placenta. It covers a large area in the uterus at this stage. For this reason it is best to not try to diagnose placenta previa before10-12 weeks.
  125. 125. Placenta accreta There are multiple variants, defined by the depth of their attachment to uterine wall: • Placenta accreta (75%) :An invasion of the myometrium which does not penetrate the entire thickness of the muscle. • Placenta increta (17%) : Occurs when the placenta further extends into the myometrium, penetrating the muscle. • Placenta percreta 5-7%: The worst form , the placenta penetrates the entire myometrium to the uterine serosa (invades through entire uterine wall). This variant can lead to the placenta attaching to other organs such as the rectum or bladder[David Miller ,2004].
  126. 126. Placenta accreta Risk factors • The condition affects around 10% of cases of placenta praevia. • Increased in incidence by the presence of scar tissue i.e. Asherman's syndrome usually from past uterine surgery, especially from a past Dilation and curettage,[3] (which is used for many indications including miscarriage, termination, and postpartum hemorrhaging), myomectomy,[4] or caesarean section. • A thin decidua can also be a contributing factor to such trophoblastic invasion. Some studies suggest that the rate of incidence is higher when the fetus is female.[5]
  127. 127. PA is a clinical and diagnostic challenge • Ultrasonography (US) remains the diagnostic standard, and routine US examination at 18–20 weeks gestation affords an ideal opportunity to screen for the disorder. Placental lacunae and abnormal color Doppler imaging patterns are the most helpful US markers for PA
  128. 128. Normal placental interface • a) Transverse transabdominal US image shows the hyperechoic placenta (*) surrounded by the hypoechoic myometrium (arrowheads). • (b) Sagittal transabdominal US image shows a thin, hypoechoic line (arrowheads) at the inner aspect of the myometrium representing a subplacental clear space. • (c) Sagittal transabdominal US image shows a normal organized pattern of subplacental blood flow that parallels the myometrium.
  129. 129. US Findings in PA • Placenta previa • Placental lacunae with turbulent flow • Irregular bladder wall with extensive associated • vascularity • Loss of retroplacental clear space • Myometrial thickness <1 mm or loss of visualization • of the myometrium • Gap in the retroplacental blood flow
  130. 130. Placental lacunae. (a) Transverse transvaginal US image shows multiple tortuous hypoechoic structures within the placenta. (b) Transverse transabdominal Doppler US image helps confirm that the hypoechoic spaces are vascular and therefore represent placental lacunae.
  131. 131. Accreta
  132. 132. Colour Doppler Sagittal transabdominal US image shows a gap in the myometrial blood flow in the lower uterine segment.
  133. 133. previavasa
  134. 134. Placenta Previa
  135. 135. Abruption
  136. 136. Subchorionic haematoma
  137. 137. Amniotic fluid index – The volume of the amniotic fluid is evaluated by visually dividing the mother's abdomen into 4 quadrants. The largest vertical pocket of fluid is measured in centimeters. The total volume is calculated by multiplying this value by 4. – Polyhydramnios is usually defined as an amniotic fluid index (AFI) more than 24 cm or a single pocket of fluid at least 8 cm in deep that results in more than 2000 mL of fluid. – Oligohydramnios is sonographically defined as an AFI less than 7 cm or the absence of a fluid pocket 2-3 cm in depth
  138. 138. Hydramnios and Oligohydramnios • Excessive or decreased amount of liquor (amniotic fluid) can be clearly depicted by ultrasound. Both of these conditions can have adverse effects on the fetus. • In both these situations, careful ultrasound examination should be made to exclude intraulterine growth retardation and congenital malformation in the fetus such as intestinal atresia, hydrops fetalis or renal dysplasia
  139. 139. Polyhydramnious
  140. 140. Anhydramnios
  141. 141. Turbid liqour
  142. 142. Bowel • The normal colon is visible in late pregnancy. • Haustrations within the colon can be seen from about 30 weeks, and peristalsis can be frequently observed. • Large bowel obstruction should be suspected if its internal diameter measures 20 mm or more
  143. 143. Lung maturity
  144. 144. Hypolpastic lung
  145. 145. Diagnosis of fetal malformation • Many structural abnormalities in the fetus can be reliably diagnosed by an ultrasound scan, and these can usually be made before 20 weeks. Common examples include hydrocephalus, anencephaly, myelomeningocoele, achondroplasia and other dwarfism, spina bifida, exomphalos, Gastroschisis, duodenal atresia and fetal hydrops. • With more recent equipment, conditions such as cleft lips/ palate and congenital cardiac abnormalities are more readily diagnosed and at an earlier gestational age. • First trimester ultrasonic 'soft' markers for chromosomal abnormalities such as the absence of fetal nasal bone, an increased fetal nuchal translucency (the area at the back of the neck) are now in common use to enable detection of Down syndrome fetuses
  146. 146. Causes of hydrops fetalis • Immune :RH factors • Non immune : • Cardiovascular • Pulmonary :diaphragmatic hernia ,CAM ,chylothorax , pulmonary sequestration . • Chromosomal :trisomy21 ,turner syndrome , triploidy . • Hematologic : thalassemia • Infections :Torch • Neoplastic : neuroblastoma teratoma and congenital leukemia
  147. 147. • Liver :hepatic fibrosis , haemangio- endothelioma , hepatic vascular • Metabolic : Gaucher , gangliosidosis ,hurler syndrome ,mucolipidosis . • Skeletal • Muscular ;e.g arthrogryposis multiplex • Syndomes • Materal :severe anemia , hypoproteinemia
  148. 148. Fetal hydrops
  149. 149. ANTEPARTUM FETAL MONITORING • Biophysical profile (BPP) – Described by Manning (1980) – The number of biophysical activities that could be recorded increased with real time ultrasound: • Fetal movement (FM) • Fetal tone (FT) • Fetal breathing movements (FB) • Amniotic fluid volume (AFV)
  150. 150. ANTEPARTUM FETAL MONITORING • Biophysical profile (BPP) – variables – NST: reactive – as described earlier. – FBM: present - at least 1 episode of at least 30 seconds duration (within a 30 minute period). – FM: present - at least 3 discrete episodes. – FT: normal - at least 1 episode of extension of extremities or spine with return to flexion. – AFV: normal – largest pocket of fluid greater than 1 cm in vertical diameter.
  151. 151. ANTEPARTUM FETAL MONITORING • Biophysical profile (BPP) – Each variable • When normal: 2 • When abnormal: 0 – Highest Score: 10, Lowest Score: 0 – Accuracy improved by increasing the number of variables assessed. – Overall false negative rate: 0.6/1000
  152. 152. NON-STRESS TEST • REACTIVE Repeat test weekly • EQUIVOCAL :Stimulate movements with motion, sound, or glucose drink • SUSPICIOUS Repeat : test within 24 hours • NON-REACTIVE : Consider other tests of fetal wellbeing and consider gestation re delivery
  153. 153. Biophysical Variable Normal (Score = 2) Abnormal (Score = 0) Fetal breathing movements 1 or more episodes of >20 s within 30 min Absent or no episode of >20 s within 30 min Gross body movements 2 or more discrete body/ limb movements within 30 min (episodes of active continuous movement considered as a single movement) <2 episodes of body/limb movements within 30 min Fetal tone 1 or more episodes of active extension with return to flexion of fetal limb(s) or trunk (opening and closing of hand considered normal tone) Slow extension with return to partial flexion, movement of limb in full extension, absent fetal movement, or partially open fetal hand Reactive FHR 2 or more episodes of acceleration of >15 bmp* and of >15 s associated with fetal movement within 20 min 1 or more episodes of acceleration of fetal heart rate or acceleration of <15 bmp within 20 min Qualitative AFV 1 or more pockets of fluid measuring >2 cm in vertical axis Either no pockets or largest pocket <2 cm in vertical axis
  154. 154. Fetal Doppler
  155. 155. Fetal arterial Doppler Umbilical arterial circulation • The umbilical arterial circulation is normally a low impedance circulation , with an increase in the amount of end diastolic flow with advancing gestation . • Umbilical arterial Doppler waveforms reflect the status of the placental circulation, and the increase in end diastolic flow that is seen with advancing gestation is a direct result of an increase in the number of tertiary stem villi that takes place with placental maturation. • Diseases that obliterate small muscular arteries in placental tertiary stem villi result in a progressive decrease in end-diastolic flow in the umbilical arterial Doppler waveforms until absent, and then reverse flow during diastole is noted
  156. 156. :Normal umbilical cord in long axis, the cord may be seen as a series of parallel lines short axis the arteries and umbilical vein may be seen as three separately circular lucencies Color Doppler image will demonstrate one color in vein and another in the arteries
  157. 157. Umbilical Cord Abnormalities  Single umbilical artery( SUA): Absence of an umbilical artery is believed to be present in 1% of all live births. This condition is frequently referred to as a two vessel cord.  Origins include: Primary agenesis of one of the arteries Secondary atrophy of a previously present artery Persistence of the original, single embryonic artery
  158. 158. SUA  Is associated with other fetal anomalies 25 -50% of the time. For this reason,prenatal discovery of an absent umbilical artery should prompt a thorough survey of the fetal anatomy.  Commonly associated abnormalities include: Trisomies 13 and 18 GU anomalies CNS anomalies Cardiac anomalies Omphalocele Sirenomelia VATER anomalies (Vertebral, Anal atresia, Tracheo- esophageal fistula, Esophageal atresia, Radial aplasia, Renal anomalies)
  159. 159. Sonographic findings Absence of an umbilical artery Two vessel cord Care should be taken to obtain a true transverse section through the cord. When present, a thorough examination of fetal anatomy should be performed.
  160. 160. Umbilical cord cysts Omphalo-mesenteric duct cyst: A cystic lesion of the umbilical cord due to the persistence and dilatation of the embryonic omphalo-mesenteric duct. The cysts are generally located close to the fetus and vary greatly in size. Allantoic cyst: Cystic dilatation of the primitive embryonic allantois.Usually small and located within the cord away from the fetal abdomen.
  161. 161. Umbilical cord cyst Sonographic findings: Demonstration of an umbilical cord cyst Absence of blood flow demonstrated by Doppler Differentiation between the two types is not usually possible and is of  no clinical significance
  162. 162. Cord loop around neck
  163. 163. Uterine artery 1st trimes terEarly 2nd trimester Late 2nd & 3rd trimester
  164. 164. Uterine artery at 24 weeks Normal Abnormal
  165. 165. Umbilical artery • Doppler waveforms of the umbilical arteries can be obtained from any segment along the umbilical cord. • Waveforms obtained from the placental end of the cord show more end diastolic flow than waveforms obtained from the abdominal cord insertion
  166. 166. IUGR
  167. 167. Fetal MCA
  168. 168. MCA
  169. 169. MCA
  170. 170. IUGR
  171. 171. Oligohydramnious
  172. 172. UA& MCA Doppler
  173. 173. Fibroid with pregnancy
  174. 174. Ov mass with pregnancy
  175. 175. The lower uterine segment • Uterine dehiscence and rupture • Pitfalls in assessing cervical length and funneling • Placental imaging in the lower uterine segment : Placenta previa : Placenta accreta, increta, and percreta • Leiomyomas in the lower uterine segment Ectopic pregnancy in the uterine scar
  176. 176. Uterine scar
  177. 177. Caesarian scar complications
  178. 178. Cervical leimyoma
  179. 179. Conditions Causing Acute Abdomen During Pregnancy