The document provides guidelines from the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) for performing routine mid-trimester fetal ultrasound scans between 18-22 weeks of pregnancy. It recommends that all pregnant women should be offered the scan to detect fetal anomalies and complications. The scan should assess fetal growth and anatomy, and be performed by an individual with specialized training using standardized ultrasound equipment and documentation. While many malformations can be identified, some may be missed even with best practices.
Obstetrical Ultrasound• Introduced in the late 1950’s ultrasonography is a safe, non- invasive, accurate and cost-effective means to investigate the fetus• Computer generated system that uses sound waves integrated through real time scanners placed in contact with a gel medium to the maternal abdomen• The information from different reflections are reconstructed to provide a continuous picture of the moving fetus on the monitor screen
Obstetrical Ultrasound• Introduced in the late 1950’s ultrasonography is a safe, non- invasive, accurate and cost-effective means to investigate the fetus• Computer generated system that uses sound waves integrated through real time scanners placed in contact with a gel medium to the maternal abdomen• The information from different reflections are reconstructed to provide a continuous picture of the moving fetus on the monitor screen
In this presentation we will discuss
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Introduction
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Transition to Acting
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1. ISUOG Mid-Trimester
Guidelines
Ashok Khurana
The Ultrasound Lab,
C-584, Defence Colony,
New Delhi - 110024. INDIA
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2. Routine mid-trimester fetal ultrasound
ISUOG Guidelines
Ultrasound Obstet Gynecol (2010)
Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.8831
(Ultrasound Obstet Gynecol 2011; 37: 116-126)
GUIDELINES
Practice guidelines for performance of the routine mid-trimester fetal
ultrasound scan
L. 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 the
ISUOG Clinical Standards Committee
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3. Routine mid-trimester fetal ultrasound
At the outset!
Not just an anatomic survey
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4. Routine mid-trimester fetal ultrasound
Lecture outline
• Introductory fluff
• Who needs one
• When
• Who should do it
• Equipment & Documentation
• Safety
• Logistics
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5. 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
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6. “The wisdom of experience”
Supplementary information / remarks!
• Illustrations from the original document
• Supplemented where necessary
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7. And just in case you still do not know…
ISUOG
The 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 women's health care
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8. ISUOG Clinical Standards Committee
Purpose
The 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
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9. The mid-trimester fetal ultrasound scan
Purpose & Overview
The main objective of fetal ultrasound is to provide
accurate diagnostic information for the delivery of
optimized antenatal care with the best possible outcomes
for mother and fetus.
The technique is used to determine gestational
age, perform fetal measurements, detect congenital
malformations and identify multiple pregnancies.
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10. The mid-trimester fetal ultrasound scan
The 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
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11. 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…….
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12. 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
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13. 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 Pregnancy
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14. The mid-trimester fetal ultrasound scan
Who should perform this scan?
• Individuals who have “specialised training”
• Local legal requirements
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15. 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
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16. The mid-trimester fetal ultrasound scan
What equipment?
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17. 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
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18. The mid-trimester fetal ultrasound scan
Reporting Form
Copies of this document are available at:
http://www.isuog.org
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19. 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
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20. 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.
21. The mid-trimester fetal ultrasound scan
And now coming to the core stuff!
• Fetal biometry and well being
• Anatomical survey
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22. The mid-trimester fetal ultrasound scan
Fetal biometry and well being
• Fetal biometry
• Amniotic fluid assessment
• Fetal movement
• Doppler ultrasonography
• Multiple gestation
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23. Fetal biometry
Parameters
• Biparietal diameter (BPD)
• Head circumference (HC)
• Abdominal circumference (AC)
• Femur diaphysis length (FDL)
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24. Fetal biometry
Parameters
• Standardised manner and strict quality criteria
• Audit of results
• Still images to document the measurements
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25. 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
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26. 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.
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27. 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
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28. 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)
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29. 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
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30. 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)
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31. 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
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32. 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
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33. 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
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34. 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
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35. 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
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36. 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
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37. 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!
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38. 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
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39. 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).
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40. 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 Placenta
Neck Absence of masses (e.g. cystic hygroma) Position
Chest/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
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41. Head
Skull
• Size: measurements
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42. 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
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43. Head
Skull
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44. 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
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45. Head
Skull: density
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46. Head
Brain
• lateral ventricles (including choroid plexi)
• cavum septi pellucidi
• midline falx
• thalami
• cerebellum
• cisterna magna
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47. Head
Brain
• lateral ventricles (including choroid plexi)
• cavum septi pellucidi
• midline falx
• thalami
• cerebellum
• cisterna magna
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48. Head
Brain: The neurosonogram
Sonographic examination of the fetal central nervous system:
guidelines for performing the „basic examination‟ and the „fetal
neurosonogram‟
Ultrasound Obstet Gynecol 2007; 29; 109–116
Copies of this document are available at:
http://www.isuog.org
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49. Head
Brain: The neurosonogram
Sonographic examination of the fetal central nervous system:
guidelines for performing the „basic examination‟ and the „fetal
neurosonogram‟
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50. Head
Lateral ventricle measurements
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51. 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.
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52. Head
Face
• Going beyond the “Minimum evaluation”
• Additional views and techniques in specific situations
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53. 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
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54. 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)
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55. Thorax
Guidelines
• Shape/Ribs/Lungs/Diaphragm/Cardiac evaluation
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56. 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
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57. Cardiac evaluation
Some really important stuff!
• Basic cardiac examination: 4 chamber view
• Extended basic cardiac examination: 4C + outflows
• Three vessel and three vessel trachea views
Ultrasound Obstet Gynecol 2008; 32: 239 – 242
ISUOG 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 the
ISUOG Fetal Echocardiography Task Force
Copies of this document are available at:
http://www.isuog.org
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58. 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.
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59. 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°
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60. Basic Extended Cardiac evaluation
The outflows and three vessel views
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61. 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
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Scientific content
component of the routine anatomical survey
62. 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
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63. 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.
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64. Abdomen
Guidelines
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65. 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
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66. 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; 109–116
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67. 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.
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68. 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
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69. 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
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70. Placenta
Guidelines
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71. 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
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Scientific content
72. 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
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73. 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
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74. 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.
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75. THANK YOU FOR YOUR ATTENTION
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