USG ACADEMY

WHAT, WHEN & HOW OF SONOGRAPHY IN

OBSTETRICS & GYNAECOLOGY
(A PROCEDURE GUIDE)

COMPILED BY
DR.DIPALI KADAM
MR.ABHAY SANTOSHWAR

USG ACADEMY PAGE # 1 / 59

 TABLE OF CONTENTS

01 The Physics of Ultrasound……………………………………….. 05

02 Guidelines for the performance of ultrasound
examination in obstetrics & gynaecology………….……………06
03 The Static & Dynamic Parameters……………………………….11
04 Ultrasound findings in Normal Pregnancy……………………… 12
05 Hallmarks of Normal IUP…………………………………………..13
06 Biometrics in First Term……………………………………………14
07 Biophysical Profile Scoring (BPP)………………………………...15
08 Obstetric Doppler………………………………………………….. 17
09 Foetal Echo………………………………………………………….18
10 MARKERS OF IUFD……………………………………………….20
11 IUGR Summary………………………………………………… 21
12 Fetal Abnormalities diagnosable by Ultrasound…………….. 22
13 Skeletal Dysplasia……………………………………………….. 24
14 Pelvic Scanning & difficulties…………………………………… 27
15 Advantages of TVS………………………………………………... 35
16 SONOHYSTEROGRAPHY……………………………………… 36
17 Growth Graphs…………………………………………………… 42
18 Growth Charts…………………………………………………… 44
19 Glossary……………………………………………………………. 54

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 PREFACE

The following pages of this handbook are meant to serve you as a reference to the
procedures & techniques used for diagnosis in Obstetrics & Gynaecology. It is by
any chance not a final word or a commandment. We request you to kindly do all the
needful reading to make optimum use of this handbook.
We would appreciate your inputs for the betterment of this handbook.

“Sonography is a diagnostic art and CORRECT METHOD takes it to perfection”

Happy Scanning!

“PRACTICE DOES NOT MAKE PERFECT, ONLY PERFECT PRACTICE MAKES

PERFECT.”
- SHIV KHERA

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 ACKNOWLEDGEMENT
The publication of this guide is incomplete without the mention of following supporters of
the Academy.

Dr.Satish Kadam, MBBS, MD (Anaesthesia), BA, LLB.

Consultant Anaesthesiologist.

Dr.Atul Dakhole, MBBS, DMRD, DNB.

Consultant Radiologist, Rainbow Medinova Diagnostic Centre, Nagpur.
Ex. Lecturer, Dept. Of Radiology, Lata Mangeshkar Hospital, Nagpur.

Dr.Vivek Patil, MBBS, MD (Radiology)

Associate Professor, Dept. Of Radiology, Govt. Medical College, Nagpur.

Dr.Sulabha Joshi, MBBS, MD (Obs / Gyn)

Head of the Department, Dept. of Obstetrics & Gynaecology, Lata Mangeshkar Hospital &
N K P Salve Institute of Medical science & research centre, Nagpur

Dr.Mrs.Pratibha Baheti, MBBS, MD (Obs/Gyn)

Consultant Gynaecologist

Dr.Mrs.Sunita Mahatme, MBBS, MD (Obs/Gyn)

Associate Professor, Dept. of Obstetrics & Gynaecology, Govt. Medical College, Nagpur.

Dr. Vikram Alsi, MBBS, DA

Consultant Anaesthesiologist, TEEM Anaesthesia

The complete staff of USG Academy & Shushrusha Sonography Clinic.

Mr.Rajesh Neware, M-Com.

Miss.Mangala Warke, Bsc, LLB.
Miss.Sheetal Wasnik, MA.
Miss.Shalini Tirpude, Bsc.
Miss.Jyoti Raut, BA.
Mrs.Chandrakala Admane.

Friends & Family members are not the last, nor the least.

Dedicated to the Participants.

USG ACADEMY PAGE # 4 / 59

 CHAPTER-I

THE PHYSICS OF ULTRASOUND

The following are considered to be the major components of an Ultrasound

machine
1) The Transducer (Probe)
2) The Processor (Computer)
3) The Display Unit (Monitor)
An Ultrasound machine works on the principle of transmitting & receiving sound
waves. The sound waves collected are processed by a computer to give them a
format which can be displayed on the monitor. The job of producing the sound
waves & again collecting the reflections is done by a piezo electric transducer.

How to choose an Ultrasound Scanner

1) The most important thing that decides the choice of the machine & the
configuration is the application, i.e. the anatomy to be visualized.
2) The second thing would be the depth of scan.
3) The resolution is a deciding factor in applications which need a great degree
of clarity in image quality.
4) The availability of a specific transducer frequency. The choice of transducers
again is application dependent.
5) Proper software for measurements & reporting.
6) User friendly interface. (Saves a lot of time while scanning)
7) Portability, if required.
8) Post sales support.

TERMINOLOGY
The following terms are of great importance to adjust an image to its optimum
quality.
1) Gain: - It increases the brightness of low intensity echoes. You can gain
brightness with Gain.
2) Dynamic Range: - It is a boon to real time scanners & facilitates movement
of probe or the anatomy while scanning & still transmits a live image.
3) TGC: - Time Gain Compensation is used to increase the brightness at
specific depths.
4) Frame Rate: - It is the number of frames a machine can display on the
monitor per second. Higher frame rates replenish the data on the screen
faster & thus more fresh data is available at any point of time.
5) Brightness & Contrast: - These knobs are situated normally on the monitor
& can be used to fine tune the image quality. Once adjusted it hardly needs
further improvement.

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 CHAPTER-II

THE WHAT, WHEN & HOW OF ULTRASOUND EXAMINATION IN

OBSTETRICS AND GYNAECOLOGY

[A] Gynecological Examination

[B] Routine Ultrasound in Obstetrics
[C] Guidelines for Screening Mid trimester Obstetrical Scan

[A] GYNAECOLOGICAL EXAMINATION

These guidelines are developed to provide standards for practitioners performing
ultrasound studies of the female pelvis. The transvaginal approach may complement or
replace the abdominal examination. However, patient’s consent should always be
obtained.
1. lmages to be recorded:
o Uterus with measurements in three dimensions.
o Endometrial thickness.
o Ovaries with measurement in three dimensions and should include the
measurement of the dominant follicle in each ovary, when indicated.
o Adnexal masses with measurements and characteristics (i.e. solid, cystic,
mixed etc.)
o Cul-de-sac should be viewed to detect free fluid.
o Any abnormality should be documented.

2. Documentation:
It is essential to make adequate records of the study. Permanent images of all the
appropriate areas, both normal and abnormal, should be included in the record. Labeling
with the patient’s name, the examination date, measurements and where important
orientation should be included. A written report including a description of normal, abnormal
findings and measurements should be included for the medical record.

3. Preparation:
The patients’ urinary bladder should be full for transabdominal / transvesical ultrasound.
This is not necessary for transvaginal examinations. It may be prudent to offer a third party
presence during a transvaginal examination.

4. Equipment:
Abdominal Ultrasound examinations should be conducted with a real-time scanner,
preferably using sector or curved linear transducers using frequencies of 3.5 MHz or
higher. Transvaginal scans should be done with frequencies of 5 MHz or higher.

5. Care of the equipment:

Equipment should be serviced and calibrated at least once in a year. Vaginal probes
should be covered with a disposal sheath and following the examination, the sheath
should be discarded and the probe cleaned.

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[B] ROUTINE U L T R A S O U N D I N O B S T E T R I C S

1. Routine Ultrasound
o The first term scan can be performed for viability, gestational age & no. of
foetus.
o The second term scan (18-22 wks) can be performed to rule out congenital
anomalies. It is the optimal time for evaluation of dating, biometry and
malformation.
o The third term scan is meant for growth, maturity & presentation.

Earlier or subsequent ultrasound examinations can be offered only when medically

indicated.

[C] GUIDELINES FOR SCREENING MIDTRIMESTER OBSTETRICAL SCAN

These guidelines have been developed for use by all practitioners performing obstetrical
screening studies in hospitals and private facilities. In some cases, a limited examination
may be performed in emergencies and for follow up of a complete examination.
Specialized ultrasound examination may be necessary in certain circumstances. Not all
structural anomalies may be detected with an ultrasound scan; however the following
guidelines may increase the detection rates of many major fetal abnormalities.

1. EQUIPMENT:
Real time scanners using abdominal transducers of 3.5 MHz or higher are generally used
Instruments should be serviced and calibrated at least once a year.

2. DOCUMENTATION:
It is essential to keep adequate records of the study. A permanent record of the images
should incorporate, where ever possible, measurements and anatomical findings specified
later in this document. Proper labeling should include the examination date and patient
identification. A written report should be produced for inclusion in the patient’s medical
record.

3. KEY IMAGES:
Key images of obstetrical examination that should be studied, whenever possible, and
recorded.

Intracranial anatomy

- BPD plane with BPD, HC or/and OFD measurements

- Ventricular plane
- Transcerebellar plane with measurements of the transcerebellar diameter (TcD)

Fetal spine

Transverse, Coronal & longitudinal plane of spine.

Note the curvature.
Note: does not exclude all possible anomalies

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Heart
Four-chamber view
Outlets of heart
Note: it will not exclude some septal defects

Abdomen
Stomach
Kidneys (renal area)
Abdominal wall at cord insertion
Abdominal Circumference
Bladder

Femur (length) FL

Placenta and cervix

Amniotic fluid
- Polyhydramnous - Fluid pocket greater than eight cms
or amniotic fluid
index > 25

- Oligohydramnous - Fluid Pocket less than two cms or

Amniotic fluid index < 8
Note: There is some variation with gestational age.
GLOSSARY
BPD = Biparietal diameter
OFD or HC = Occipitofrontal diameter/ Head circumference
TcD = Transcerebellar diameter
AC = Abdominal circumference
FL = Femur length

4. SPECIFIC CONSIDERATIONS:
a) Fetal viability and number should be documented.
b) An estimate of the amount of amniotic fluid should be reported.
c) Placental location, appearance and its relationship to the internal OS should be recorded.
If possible, the number of vessels in the cord is noted.
Comment: The placental position in early pregnancy may not reflect the position at the
time of delivery.
d) Evaluation of the uterus and adnexal structures should be performed to allow
recognition of clinically relevant myomas and adnexal masses.
e) Cervix: length measurement, when relationship of placenta to internal OS indicated
clinically.

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5. MEASUREMENTS.
[I] HEAD

(i) Biparietal diameter (BPD) should be measured and

recorded at standard reference level which should include the
cavum pellucidum and the thalami.
Abnormalities in the shape of the fetal skull (e.g. lemon shape)
can be demonstrated at that examination.

(ii) Head circumference (HC), measured directly at the same

level as the biparietal diameter or calculated from the BPD and Occipitofrontal diameter
(OFD).

(iii) Transcerebellar diameter (TcD), taken at the axial plane of the posterior fossa. This
permits assessment of the cisterna magna (normal 4 to 11 mm) and the nuchal skin fold
(normal = less than 6 mm). A six mm or more measurement is considered suspicious for
Down’s syndrome.

(iv) Ventricular plane (VP) located slightly cephalad to the BPD plane permits
assessment of the size of the posterior horn of the cerebral lateral ventricle and the
appearance of the choroid plexus (normal = less than or equal to 10 mm).

[II] Abdominal circumference (AC) should be

determined at the level of the junction of the umbilical vein
and portal sinus. This view only allows measurement of
abdominal circumference.
All of the measurements that are obtained should be
measured at least twice because of the problems in
measurements and this repeated measurement should not
only be reserved for abdominal circumference (AC).
Comment: AC requires more than one measurement since
the measurement error is larger.

[III] LIMBS

(i) Femur length (FL)

is the largest longitudinal
measurement of the
femur not including the
femoral head.

(ii) Limbs - visualization of four limbs should be recorded.

6. FETAL ANATOMY

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To rule out most fetal anomalies, the study should include three views of the intracranial
anatomy (BPD, OFD, transcerebellar area) and a careful study of the entire spine view. A
four chamber view of the heart, the location and presence of stomach cavity, urinary
bladder, kidney (renal area), umbilical cord insertion site on the anterior abdominal wall.

7. ASSESSMENT OF GESTATIONAL AGE:

Assessment of gestational age is usually based on ultrasound parameters of BPD, AC and
FL and compared with other clinical information. The current measurements should be
compared with normal ranges for the gestational age and only if ultrasound measurements
are outside the normal range for menstrual dates (i.e.10-90%), is pregnancy redated and
these measurements used for subsequent evaluation – for example a pregnancy of 18
weeks is redated with a measurement less than 17 weeks or greater than 19 weeks. If so,
a new date for delivery is determined. Subsequent ultrasound will not change the due date
and this information needs to be incorporated in repeated scans in second and third
trimester of a given pregnancy.

8. MULTIPLE PREGNANCIES:
Multiple pregnancies require documentation of number of fetus, placental site and
number, comparison of size, presence and nature of the separating membrane.

Disclaimer
This text refers to the guidelines for standard screening second trimester scan and
is not meant to be all inclusive. Some anomalies may remain undetected.

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 CHAPTER-III

THE STATIC & DYNAMIC PARAMETERS

THE STATIC VARIABLES & THEIR TIMING OF THE SCAN ARE AS FOLLOWS:-

SR. PARAMETER WKS OF

PREGNANCY
(CLINICALLY)
1 Gestation Sac 5 – 7 weeks
2 CRL 7-12 weeks
3 BPD 13 wks +
4 Head Circumference 18 wks +
5 Abdominal Circumference 20 wks +

THE DYNAMIC VARIABLES

SR. PARAMETER WKS OF PREGNANCY

(CLINICALLY)
1 Rapid Vermilion Movement 7-10 wks
2 Rapid movement with extension & flexion 9-20 wks
3 Extension Movement of Head 10-20 wks
4 Extension Movement of Trunk & Limbs 11-40 wks
5 Changes in Posture : Creeping 11-40 wks
6 Rotation of Head 12-40 wks
7 Isolated Limb Movements 11-40 wks
8 Fetus pushes against uterine wall 14-40 wks
9 Hands touching Face, Head 12-40 wks
10 Total Body Movement of mechanical Stimuli 12-40 wks
11 Motor Response of only concerned part to stimuli 20-40 wks
12 Mouth opening and tongue protrusion 14-40 wks
13 Extension & crossing of legs 14-26 wks
14 Sucking, Swallowing & Breathing 14-20 wks
15 Hiccups 24-40 wks
16 Breathing more frequent after meals 26-40 wks
17 Hand Grasp 22-40 wks
18 Motor stimuli to sound stimuli 28–40 wks

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 CHAPTER-IV

ULTRASOUND FINDINGS IN NORMAL PREGNANCY

SR. WEEKSOF GESTATION ULTRASOUND FINDINGS

1 2 Weeks OVULATION

2 3 Weeks IMPLANTATION (DIFFICULT TO VISUALIZE)

3 4-5 Weeks GESTATIONAL SAC

4 6-7 Weeks Embryo & its heart movements

5 8 Weeks Embryo can be differentiated into head & body

6 10 Weeks Distinction between the head, thorax and abdomen

becomes possible
7 11-12 Weeks The measurement of BPD becomes possible

8 14-16 Weeks Limb measurements can be done with ease

9 16-18 Weeks Time to look for congenital foetal anomalies and

collect baseline for growth parameter, time for
amniocentesis
10 20-28 Weeks Establish growth pattern BPD, AC, HC, FL, I.U.

blood transfusion easy

11 >28 Weeks Do not rely on BPD alone , Multiple foetal growth

parameters (MFGP)

12 > 36 Weeks Time to accurately diagnose placenta previa

13 Third Stage Labour Placental separation and expulsion

14 Post Partum Involution of Uterus. Exclusion of retained

placenta/ membrane / puerperal sepsis and pelvic

mass.

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 CHAPTER-V

HALLMARKS OF NORMAL IUP

DOUBLE DECIDUAL
SAC

YOLK SAC

CARDIAC ACTIVITY

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 CHAPTER-VI

BIOMETRICS IN FIRST TERM

1) GS – GESTATION SAC

2) CRL – CROWN TO RUMP LENGTH

3) BPD – BI-PARIETAL DIAMETER

4) FL – FEMUR LENGTH

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 CHAPTER-VII

BIOPHYSICAL PROFILE SCORING

(B P P)

 DYNAMIC FETAL ASSESMENT.

 FETUS WITH ITS ENVIRONMENT.
 MONITOR FETAL ACTIVITY.
 RESPONSE TO INTRINSIC AND EXTRINSIC FACTORS.
 FETAL RESPONSE TO POTENTIALLY DETRIMENTAL MATERNAL DISEASE
STATE e.g. PIH.

PATHOPHYSIOLOGY
 MORBID FETAL CONDITIONS-

 FETAL ASPHYXIA- AC V/S CHR. 50- 60 %

 DEVELOPMENTAL OR FUNCTIONAL
 ANOMALY OR BOTH 25- 30 %.
 ACQUIRED DISEASE- 15- 20 % INF, Anti Body.

TECHNIQUES - SCORING.
 FETAL BREATHING- At least 1 episode of FMB, 30 sec in 30 min. = 2 score.
 GROSS BODY MOVEMENTS – at least 3 discrete bodies /limb movement in 30
min, continuous movement. =Score 2
 FETAL TONE- At least 1 episode of ext à flexes. Of trunk/limb, Hand-O/C =Score
2.
 Cardiac Acceleration -1 episode of Cardiac Acceleration. Bt 15bpm for 15 sec, in 30
min.= Score 2
 Qualitative Amniotic Fluid Volume – 2x2 cm at least one pocket. =Score 2

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INTERPRETATION
o ALWAYS ALONG WITH OBST. FACTORS e.g. cervical condition, fetal anomaly,
PIH.
o 10/10, 8/10 with Normal Liquor - Foetal Asphyxia. Less, No Induction for fetal
disease.
o 8/10 with Abnormal Liquor – Chronic Foetal Asphyxia - 89/1000- May deliver if
Membrane -Intact, Lung-renal Maturity Nor.
o 6/10 with Normal Liquor - Possible F. Asphyxia - F. Mature ->Deliver, Not->Repeat
in 24 hr < 6/10 delivers.
o 6/10 with abnormal liquor - Deliver Fetus.
o 4/10, 2/10, 0/10- almost Asphyxia -91/125/600-1000, Deliver the Fetus.

Fetal Hypoxia

CNS Cellular Dysfunction Ao.Body Chem. Receptor

Reflux Redistribution of
Cardiac Output.

Hypotonia. Less Bld –Kid- Oligo.

Absent F,Breathing.
Less. Bld Lung- RDS.
Absent F.Movment.
Less Bld- GIT- Necro.EC.
Less Bld –Plac- IUGR>

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 CHAPTER-VIII

OBSTETRICS DOPPLER

 ASSESS-PHYSIOLOGY-PATHOPHYSIOLOGY-OF-MATERNAL-FETAL CIRCULATION.
 COLOR-AUDIO-SPECTRAL. DOPPLER.
CIRCULATION
1. UTERO-PLACENTAL – Uterine Artery.
2. FETO-PLACENTAL –Umbilical Artery.
3. FETAL – MCA ,AO,RENAL, DV,IVC
1) UTERO-PLACENTAL CIRCULATION
o UTERINE ARTERY DOPPLER (BOTH SIDES)
o IMPORTANCE OF DIASTOLIC NOTCH
o ABSCENCE / REVERSAL OF DIASTOLIC FLOW
o RI-- < 0.54
o IMPORTANCE- PLACENTAL INSUFFICIENCY DUE TO RAISED PLACENTAL RESISTENCE –
PIH, ECLAPSIA, HYPOXIA, IUGR.
2) FETO-PLACENTAL CIRCULATION
o UMBILICAL ARTERY FLOW- PATTERN
o S/D RATIO < 3
o FACTOR OF FETAL INSUFFICIENCY
o INDICATOR OF PROBABLE F.ASPYXIA.
o REVERSAL /ABSCENCE.
o TO BE VIEWED WITH OTHER PARAMETERS.

3) FETAL CIRCULATION.
o F.MCA- ASYM-IUGR,
o AORTIC- PERIPHERAL VASOCONSTRICTION IN INSUFFICIENCY.
o DUCTUS- RT. SIDED DECOPRESION.
o RENAL –RAISED RESISTENCE.
o IVC.
INTERPRETETION
o Nor.Ut. + Nor. Um => Healthy
o Ab.Ut. + Nor. Um. => Premature.
o Nor. Ut. + Ab.Um. = > Hypoxia.

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o Ab. Ut. + Ab. Um. = > Worst.
o OMNIOUS SIGNS- REVERSAL OF DIASTOLIC FLOW ASSOCIATED OLIGO, PIH.
o REVERSAL IN IVC- ACIDOSIS/HYPOXIA.

CHAPTER-IX

I - FETAL ECHO

 20-24 WK
 OPERATOR DEPENDENT-METICULOUS.
 4C HRT-OUT TRACTS- (95% anomalies detected)
 NOT FOR ALL ROUTINE PATIENTS
 ASD,VSD,PS - COMMON

I- INDICATIONS FOR FETAL ECHO

1) MATERNAL AND FAMILIAL:-

o Family h/o CHD.

o Maternal DM.
o Maternal drug exposure
o Infections.
o Maternal Alcoholism.
o Maternal Connective Tissue Disorder.
o Maternal Phenylketonuria

2) FETAL INDICATION:-

o Polyhydramnous.
o Non-immune hydrops.
o Dysrhythmias.
o Extra-cardiac Anomalies.
o Chromosomal Aberration.

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o Sym. IUGR.

III - TECHNIQUE

o FETAL RT- LT ASSESMENT.

o AC SECTIONà CRANIAL ANGULATION à 4C HRT à CLOCK-ANTICLOCK
ANGULATION à OUT-TRACTS.
o CHAMBER IDENTIFICATION.
o AO-PA CRISS CROSS PATERN.
o SERIAL SCANS.
o M-MODE.
o DOPPLER

IV – PATHOLOGY

o HYPOPLASTIC LV- 4C.

o VSD- 4C, MUSCULAR- MEMBRANOUS.
Muscular- r/o trisomy 13, 18.
Membranous- 90 % close by 8th TR.
o ASD – PRIMUM - Single Atrium.
SECUNDUM - Difficult to Diag F.Ovale.
o A-V ENDOCARDIAL CUSHION DEFECT.
o TOF- VSD ,Ao-overide,PS,Hyper RV
o TRANSPOSITIONS.
o COARCTATION OF AORTA.

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 CHAPTER-X

INTRAUTERINE DEMISE

SONOGRAPHIC FEATURES OF
EMBRYONIC / FETAL DEMISES

a) No cardiac activity

b) No fetal movement

c) Passive motion of fetus seen with change of position.

d) Spalding sign positive (i.e. overlapping of skull bones)

e) Echogenic bowel

f) Oligohydramnios

* Fetal age at the time of fetal death can be established by FL / limb measurements

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 CHAPTER-XI

IUGR Summary Table:

Hypoplastic IUGR Hypotrophic IUGR Small for Gestational
 Manifestation
(intrinsic IUGR) (Nutritional IUGR) Age

< 10%ile estimated.  < 10%ile estimated.  < 10%ile estimated.

 Size
fetal weight fetal weight fetal weight
1)Symmetric 1)Asymmetric 1)Symmetric
Biometrics  2) HC & AC<GA 2) HC & FL=GA 2) all measurements
3)FL=GA or FL<GA 3)AC<GA (HC,AC,FL) small
1) Increased
1) Increased umbilical
umbilical SD ratio if
SD ratio if fetal
fetal distress,  Normal umbilical and
 Doppler distress.
uterine Doppler
2)Uterine SD may
2) uterine SD normal 
be abnormal
 May be predictive of Usually reassuring,
Reliable prediction
 NST/BPP fetal distress, but not may need to repeat in
of fetal distress 
reliable 1-2 hours
Early fetal exposure, Utero-placental  Normal, just a
 Cause infection, genetic insufficiency, mostly constitutionally small
abnormality maternal  baby
Fetal distress  Fetal distress
Fetal distress
 Course common, NST/BPP common, NST/BPP
uncommon 
may not predict usually predictive
Survivors bear Survivors may suffer
 Prognosis stigmata of causative from prematurity,  Essentially normal
process  otherwise normal.

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 CHAPTER-XII

FOETAL ABNORMALITIES DIAGNOSABLE BY ULTRASOUND

1A1V (single umbilical artery)

Achondroplasia
Acondrogenesis
Agenesis of the Corpus Callosum
Agenesis of the Cerebellar Vermis
Amniotic band syndrome
Anencephaly
Asphyxiating thoracic dystrophy
Atrial septal defect
Beckwith-Weidemann syndrome
Bronchogenic cyst
Cardiac anomalies
Choledochal cyst
Choroid Plexus cyst
Cleft lip and palate
Club foot
Coarctation of Aorta
Congenital pulmonary lymphangiectasis
Congenital kidney diseases
Conjoint twins
Craniofacial anomalies
Cystic adenomatoid malformation
Cystic Hygroma
Dandy Walker malformation
Diaphramatic hernia
Duodenal atresia
Ectopia Cordis
Encephalocele
Fetal alcohol syndrome
Gastroschisis
Holoprosencephaly
Hydrocephalus (1)
Hydrocephalus (2)
Hydrocoele
Hydronephrosis

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Hydrops fetalis due to Rh incompatibility
Meckel-Gruber syndrome
Megaureter
Microcephaly
Multicystic kidneys (1)
Multicystic dysplastic kidneys (2)
Myelomeningocele
Omphalocele (1)
Osteogenesis imperfecta (1)
Porencephaly
Prune Belly syndrome
Pulmonary hypoplasia
Renal agenesis
Spina bifida(1). See Myelomeningocele
Spina Bifida(2)
Thanatophoric dwarfism
Tetrology of Fallot
Thalassaemia major
Total anomalous pulmonary venous drainage
Truncus Arteriosus
Transposition of great vessels
Tricuspid atresia
Patent Ductus Arteriosus
Trisomy 13 (Patau syndrome)
Trisomy 18 (Edward syndrome)
Trisomy 21 (Down syndrome)
Turner syndrome
Twin-to-twin transfusion
Vacterl associations
Ventricular septal defect

NOTE: - PLEASE REFER TO THE TEXT BOOKS FOR DETAILS

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 CHAPTER-XIII

ULTRASONOGRAPHY IN SKELETAL DYSPLASIA

OSSIFICATION
The process of bone formation is called as ossification which continues through out the
pregnancy and even after birth. It is most rapid during the first trimester of pregnancy.
The process of ossification starts at the center of diaphysis and is called as primary center
of ossification.Secondary centers of ossification for the ends of the long bones appear
before and after birth.

The appearance of primary centre of ossification with corresponding gestational

age (embryologic week)

Clavicle 7th week

Maxilla 9th week
Mandible 9th week
Ribs 8-9 week
Scapula 8th week
Skull 7-12week
Long bones 7-12week
Metacarpals 9th week
Metatarsals 10-12week
Ischium 16week
Pubis 16-20week
Cacaneum & Talus 20-24week
Upper limbs phalanges 8-11week
Lower limb phalanges 9-15week

Secondary centers of ossification

Distal end of femur 32-33week

Proximal end of Tibia 35week
Proximal end of Humerus 38week

USG ACADEMY PAGE # 24 / 59

 SKELETAL DYSPLASIA
(MARKERS OF LETHALITY ON USG):

Biometric parameters for diagnosis

of skeletal dysplasia

Degree of limb shortening

Below 2 SD to 4 SD = Lethal or non- lethal
4 SD = Lethal

Femur / foot length

1 = Normal
0.9 to 1 = IUGR, familial, normal variant
< 0.8 = Skeletal dysplasia

FL / AC ratio (0.16)
Less than 0.16 = Lethal

TC / AC ratio (0.89)
Less than 0.89 = lethal

CC / TC ratio (0.6)
More than 60% indicates narrow thorax

Absolute thoracic measurements below 5th % tile of mean for gestational age.

USG ACADEMY PAGE # 25 / 59

 TERMINOLOGY

Adactyly absence of fingers

Amelia absence of limbs

Brachydactyly short phalanges
Brachymesophalangy short middle phalanges
Clinodactyly incurving of a finger, usually the fifth, in the coronal plane

Hemimelia absence of part of a hand

Hyper- or hypophalangism the presence of a greater or
lesser number of phalanges
Longitudinal defect Absence of part of the limb along its longitudinal axis. This
may be pre-axial (radial), post axial (ulnar) or central

Macrodactyly enlargement of a digit

Oligodactyly absence of fingers
Phocomelia absence of the proximal parts of a limb
Polydactyly Increased number of digits. May be pre- or postaxial

Symphalangism fusion of phalanges in one digit

Syndactyly Fusion of adjacent digits. May involve soft tissues and/or
bone, (after Poznanski)

CHAPTER-XIV

PELVIC SONOGRAPHY IN A FEMALE

Difficulties Inherent in Pelvic Scanning:

1. Similar acoustic properties – (Whereas in the gravid patient the fetus, amniotic
fluid, and placenta have distinctly different acoustic properties) In the non-pregnant
patient muscle, bowel, uterus and ovaries have similar acoustic properties and
produce echoes of similar amplitude and appearance.
2. In the pelvis, although we are dealing with only a few organs of interest, some
such as the ovaries, tubes, and ureters are small, mobile, and variable in location.
3. Surrounding bowel may contain gas which may obscure visualization.

4. Artifacts:
a. Reverberations
b. Beam width - low level echoes in cystic structures

USG ACADEMY PAGE # 26 / 59

 c. Ghost image in central pelvis d/t midline rectum muscles
d. Mirror image duplication of the bladder
e. Edge shadow from bladder

5. Mimics:
a. Dermoid mimics’ bowel and vice-versa
b. Liquified fibroid mimics ovarian mass
c. Pelvic kidney mimics lymphoma
d. TO mass mimics ectopic
e. Large cyst mimics bladder

6. Transvaginal sonography orientation is challenging due to limited field of view.

 

INSTRUMENT SETTINGS:
Transabdominal:
Broad Dynamic Range – (reduce only when trying to clarify cystic structures )
Careful attention to focal zone
Limit the field of view to area of interest (except when trying to clarify location
relative to normal anatomy )
Transvaginal:
Instrument Pre-sets to transvaginal

Pelvic Musculature:

Iliacus/Psoas complex -
Piriformis -
Coccygeus -
Obturator Internus -
Levator Ani -

Echogenicity of Pelvic Anatomy:

Muscles:
Uniform grey tone with more echogenic striations
Symmetrical size varies upon athletic experience of patient
May appear bulbous, enlarged in athletes

USG ACADEMY PAGE # 27 / 59

Bowel:
Brightly echogenic fecal contents
May contain fluid
If empty seen as ovoid muscular cross-sections with echogenic lumen
( pseudokidney sign)
Uterus:
Myometrium medium to low echogenicity
Endometrium brightly echogenic (Depends on menstrual cycle)
Ovaries:
Lower echogenicity than uterus. Follicles are seen.
May have stronger echoes in center
May have multiple small cysts around periphery
Fallopian Tubes:
Not usually seen unless they contain fluid
More echogenic than ovaries
May be apparent with transvaginal scanning
Fascia:
Provides brightly echogenic borders - contains fat, lymphatics, blood vessels
Urinary Bladder:
Thick-walled muscular organ,
Full bladder preparation

Full Bladder Preparation: (Required for transabdominal pelvic exams)

Pushes pelvic organs out of bony pelvis

Provides a non-attenuating acoustic pathway
Pushes bowel away from organs of interest
Provides an anatomical and acoustical reference
Can be used to assess mobility of a mass

Optimal Fullness:
Extends over fundus of uterus
Anterior curve of uterine wall maintained

Pelvic Spaces:

Posterior cul-de-sac (Pouch of Douglas)

Anterior cul-de-sac (Vesicouterine pouch)

Retro-pubic space (Space of Retzius) anterior

peritoneal space

Vaginal fornix : site of culdocentesis and

culdoscopy

USG ACADEMY PAGE # 28 / 59

Causes of Fluid:

Normal cycle– small amounts

Ectopic - amount mild to moderate
PID - amount increases with severity
Cirrhosis, Ovarian Ca. Tuberculin PID - Abdominal and Pelvic Ascites

PelvicBlood Supply:
To Uterus:

Aorta - common iliac artery - uterine artery -arcuate artery - radial artery - straight
artery - spiral artery
To Ovaries:
Ovarian artery leaves aorta above iliac split .
Also fed by branches off the uterine artery medially - anastomosis within broad
ligament .
Infundibulopelvic plexus
Pampiniform Plexus

Ovarian Artery and Vein:

Ovarian artery arises from the aorta slightly inferior to the renal arteries. After giving
off branches to the ovary it continues within the broad ligament and anastomoses
with the uterine artery. The right ovarian vein drains directly into the IVC, whereas
the left ovarian vein drains into the renal vein.

Uterine Artery:
Courses medially on levator ani muscles -- anterior to lower ureter
Ascends within broad ligament along lateral margins of uterus giving off arcuate
branches that penetrate myometrium
Runs along lateral margin of the uterus in the broad ligament and at the level of the
uterine cornua (in fundus) travels laterally to anastomose with the ovarian artery

Internal Iliac Artery:

Descends into the pelvis posterior and lateral to the ovaries and ureter branches to
vagina, uterus, rectum, and Obturator, gluteal, ilio-lumbar, and sacral muscles.

External Iliac Artery:

Located between the bladder and the ilio-psoas muscle - imaged in groin area .

Pelvic organs:-
Ureters:
Enter trigone of bladder
Anterior and medial to IIA and IIV
May be imaged proximally at renal pelvis and distally in bladder wall if enlarged .
Vagina:
Length: 6-8 cm. front, 7-10 cm. posterior
Anchored in pelvis at trigone.

USG ACADEMY PAGE # 29 / 59

Uterus:

Adults: 6-8 cm. length, 3-5.5 cm. width, 2-3 cm. height
Childhood development:
Prepubertal
Adult: L-6-8cm
W-3-5cm
H-2-3cm
Post menopausal:
Cervix:
Internal Os
External Os
Effacement
Normal Length (1/3 to ½ of uterus)
Measure on transvaginal exam - full bladder may cause cervix to appear longer

In Pregnancy:
Lengths less than 3.0 cm may indicate incompetent cervix
In pregnancy 2.8 cm during early gestation
5.2 cm at 34 weeks
Decreases in length with effacement

Isthmus: most flexible part of uterus, site of bending

Corpus:
Fundus:
Cornua:
Myometrium:
Endometrium:

Measured in longitudinal scan across widest part of endometrium / 2

Normal width proliferative stage 2-4 mm single layer
Normal width secretory stage 5-7 mm single layer
Normal width postmenopausal 2-3 mm (over 5 mm abnormal) single layer

Double layer measurement:

Less than 4 mm. atrophic endometrium
Typical measurement in reproductive years 8-12 mm.
Parametrium:
Uterine Version:

USG ACADEMY PAGE # 30 / 59

 Anteverted Retroverted

Uterine Flexion:

Anteflexed
Retroflexed

Congenital Anomalies - Uterus:

Arrested development of mullerian ducts

Uterus unicornis, unicollis
Rudimentary uterine horn
Non-connecting
Functional - with or without endometrium
Failure of fusion
Complete: uterine didelphys
Partial: Bicornis uterus
Uterus arcuatus (see Berman text Figure 5.5)
Failure of resorption of the median septum
Uterus Septus
Uterus Subseptus
T-shaped Uterus
Congenital Malformations of uterus associated with miscarriages, premature delivery,
uterine rupture, renal anomalies on the same side.

Diagnosed by abnormal shape of uterus, especially transverse visualization of two

endometriums or two uteri.
 

USG ACADEMY PAGE # 31 / 59

Ovaries:

Adults Normal Size:

2.5-5 cm. length
1.5-3 cm. width
1-1.5 cm. height
Cortex: contains germ cells and cells which produce estrogen and progesterone

Follicles: immature germ cells

Fallopian Tubes:
8-14 cm. in length - curled within adnexal regions
Divisions:
Interstitial (also called intramural)
Isthmus
Ampulla
Infundibulum or fimbriated end
Bowel:
Normal is compressible
Rt. lower quadrant common site of intussusception (ileocecal area) and appendicitis
 Transvaginal Ultrasound:

Transducer Preparation:
Cleanliness
Sheath, glove, or condom (non-talc)
Latex storage - expiration 5 years, do not expose to sunlight or UV light

Patient Preparation:
Bladder empty except in cases of possible placenta previa
Plan ahead to only have to insert once
Elevate hips to allow transducer movements below hips
Patient education and consent important

Image Orientation:

Longitudinal images rotated 90 degrees from transabdominal

Anterior is to the lower left when facing the image; Posterior is to the lower right

USG ACADEMY PAGE # 32 / 59

 Inferior/Posterior portions of the anatomy are closest to the transducer face

Transverse images are semi-coronal and not true transverse

Inferior/Posterior portions of the anatomy are closest to the transducer face
Rt /Left orientation on the images is the same as for transabdominal
90 degree counterclockwise rotation from longitudinal images

Transperineal Scanning:

Patient in same position as for endovaginal

Sector transducer covered with sheath and placed between labia on perineum
Utilized in place of transvaginal
Utilized for visualization of cervix, urethra, lower uterine segment in pregnancy
when transvaginal cannot be utilized (PROM)
Transverse Orientation true coronal directed inferior to superior
Sagital orientation has anterior on left side of image

CHAPTER-XV

TRANSVAGINAL SONOGRAPHY, WHY?

The biggest advantage of TVS scan is the proximity of the probe with the anatomy to be
visualized. The high frequency of the transducer facilitates better near field resolution.

[1] PREPARATION OF PATIENT:-

o Consent
o Short history + LMP
o Empty bladder
o Lithotomy position

USG ACADEMY PAGE # 33 / 59

[2] PREPARATION OF TRANSVAGINAL PROBE:-

The tip should be covered with ultrasound coupling gel and introduce into a protective
rubber sheet.

[3] ADVANTAGES OF TVS:-

o No Full Bladder
o Same high resolution possible in even obese patients.
o Can be performed immediately. ( no waiting)
o Early detection of Foetal Anomalies.
o Early diagnosis of pregnancy.
o Better Diagnosis of quite a few Pelvic diseases due to high resolution.
o Best Tool for sonography in Infertility & Assisted Reproduction.

[4] LIMITATIONS OF TVS

o Finding larger than 7cm to 10cm or those outside the pelvis are difficult to scan with
the vaginal because of its limited focal length
o This procedure cannot be done on patients with intact hymen.
o In elderly patients, the vagina has less elasticity, & this limits the maneuverability of
the probe.

[5] SCANNING TECHNIQUE:-

Basic scanning directions planes and depths are achieved by moving the probe.
Any combination of the following may be used to obtain the best possible images:

USG ACADEMY PAGE # 34 / 59

 (A) Rotating the probe along its longitudinal axis

(B) Angling the shaft, pointing it in any desired direction.

(C) Pushing or pulling the probe,”positioning”deeper or

closer structures within the focal range of the probe.

[6] SCANNING STEPS

SCANNING ROUTINE:-
It is suggested that a relatively strict scanning routine should be followed. The “natural”
plan of scanning we found useful is:
o In beginning, as the probe advances, scan the cervix, at least passingly.

USG ACADEMY PAGE # 35 / 59

 o The uterus should be found and evaluated. At this point the cervix should be
included.
o If the patient is pregnant, study the gestation.
o Go to the adnexia, study the ovaries and tube (if feasible), and look for possible
masses.
o One of the most important places to scrutinize is the cul-de-sac.
o Other places, structures, and additional pathologies can now be addressed.
o It is still important to use the largest possible magnification that still enables
orientation as well as recognition of the organs or pathology. Magnification does not
alter the resolution using high-frequency probes.

[7] EXAMINATION
Cervix:-
Cervix can be scanned as the probe penetrates 2.5-3cm into the vagina, almost 2-
3cm before the tip of the probe reaches the cervix. It may also be examined after locating
the uterus and then pulling the probe slowly outward.
Cervix should be imaged in horizontal and vertical plane along with cervical canal. The
mucus within the endocervical canal usually appears as an echogenic interface. This may
become hypo echoic during the periovulatory period as the cervical mucus has a higher
fluid content. The uterine vessels can be seen as punctate anechoic structures at the level
of the internal cervical os. Cystic structures adjacent to the cervical canal and external os
are frequently seen. They represent endocervical cysts and Nabothian cysts.
Scanning of the cervix during pregnancy is primarily for ruling out cervical
incompetence and placenta previa.

Uterus:-

USG ACADEMY PAGE # 36 / 59

 The transverse or horizontal scan should be followed by the vertical scanning
plane, which will reveal the entire uterus with its endometrial lining. The endometrium has
a variety of appearances depending on its stage of development .

In the proliferative phase the endometrium tends to measure 4-

8 mm in AP dimension. This measurement includes both
endometrial layers combined.

In the periovulatory phase has the thickest endometrium,

usually measuring 7-14 mm.

In post menopause, the uterus becomes gradually smaller. It has a uniform echogenicity
with an extremely thin endometrial lining.
Scanning of lateral uterine margin on either side may reveal the ingoing, outgoing, and
pulsating vascular packets at the level of the junction between the cervix and the body of
uterus. Blood flow is readily seen in these vessels with the high-frequency transducer.
Blood flow measurements of the uterine artery and vein may be done using this site.
A high proportion of woman who have an intrauterine device have various
symptoms attributed to the device. With transvaginal sonography it is possible to locate the
device and indicate whether it is the uterine cavity, it has moved into the region of the
lower uterus and upper cervix or it is embedded in the myometrium.

Fluid in the endometrial canal in a 70-

year-old woman with postmenopausal
bleeding. Sagittal transvaginal US scan
shows a small amount of fluid in the
endometrial canal, which must be
subtracted from the endometrial
measurement (A - b).

USG ACADEMY PAGE # 37 / 59

 In case where it is technically difficult to depict an enlarged uterus, the widest
possible angle should be used. Another possibility is to use the “split-screen” technique,
which consists of subsequent imaging of the sagittal sections of the uterine corpus on the
split screens. The total size of the uterus is obtained by adding up the measurements on
the two screens. However, if the uterus if the uterus seems to be excessively enlarged a
transabdominal scanning should be added to enable a better examination.

Ovaries:-
The ovaries have a distinct appearance because of their relatively lower
echogenic texture as well as the different-sized Graaffian follicles. The follicles appear as
echo-free, translucent, rounded structures from several millimeters to 2cm in diameter.
During the reproductive years, these follicles serve as sonographic”markers” of the
ovaries. If there is any uncertainty as to the origin of a round cystic structure, a longitudinal
plane should be imaged.
After menopause it is hard to find the ovaries because the above-described
“markers” (i.e., the follicles) are present, the ovaries themselves atrophy and there is less
pelvic fluid to provide an acoustic interface. With the recent introduction of color coded
Doppler flow imaging, by finding the color coded flow of the ovarian artery or vein one can
better detect the otherwise sonographically “non-detectable” ovaries.

Fallopian tubes:-
The normal fallopian tube is difficult to image because of its small size and
serpiginous course. If found, they are usually lateral to the uterus behind the ovaries or in
the cul-de-sac. They appear as 1cm wide echogenic tortuous structures. Sonographic
delineation of the tube is facilitated by intraperitoneal fluid present in the cul-de-sac.

Cul-de-sac:-
The cul-de-sac or pouches of Douglas may be found by directing the probe
posteriorly. In many cases a small amount of fluid may be present in this space under
normal conditions. Free fluid outlines the posterior wall of the uterus and sometimes even
the ovaries. As mentioned before, it is disadvantageous to place the patients in the

USG ACADEMY PAGE # 38 / 59

Trendelenburg position since some of the fluid will spill from the pouches of Douglas to
other lower-lying spaces. Because of the high resolution of the pictures, even a small
amount of fluid in the cul-de-sac may impress the novice sonographer, leading to false
interpretation, namely “a large fluid collection”.
When a large amount of fluid is present, such as in ascites, the near field findings
are clearly displayed. But the uterus and ovaries may be pushed beyond the focal length
of the probe. Evaluation of the cul-de-sac for presence or absence of fluid, with or without
blood clots, is important in the differential diagnosis of unruptured or ruptured ectopic
pregnancy.

Pregnancy:-
One of the most valuable applications of transvaginal sonography is the early
identification of a normal or abnormal pregnancy. On the average this technique can
detect embryonic or fetal structures one to two weeks earlier than transabdominal
sonography. Warren et al 7 documented the early stages of embryonic development
starting at 4wk of gestation.
The diagnosis of vary early abnormal pregnancy is at times difficult. Keeping in
mind the temporal appearance of embryonic and extra embryonic structures, one could
evaluate the presence or absence of an abnormal pregnancy if the correct dating of
pregnancy itself is known. When any doubt concerning the dating exists, serial ultrasound
scans are appropriate for clinical follow-up.

CHAPTER-XVI

SONOHYSTEROGRAPHY

Saline infusion sonohysterography (SIS) is the term for ultrasound imaging of the uterine
cavity, using sterile saline solution as a negative contrast medium.

SIS is a low-tech, low-cost, painless enhancement of TVS.

INDICATIONS
1. Abnormal uterine bleeding
2. Infertility & Reproductive failure

USG ACADEMY PAGE # 39 / 59

 3. Recurrent abortion
4. Suspected Ashermann’s syndrome
5. Patients receiving tamoxifen therapy
6. Abnormal endometrial images
obtained with any modality

ADVANTAGES OVER HSG

o No radiation exposure
o No iodinated contrast injection Sonohysterography is an excellent procedure for
evaluation of the endometrium and tubal patency
o USG of the uterus, ovaries and pelvis can be performed at the same time & thus
uterine masses & other abnormalities may be picked up which would have been
missed during a conventional HSG.

ADVANTAGES OVER HYSTEROSCOPY

o Hysteroscopy is a more invasive procedure
o Significant financial cost
o Physical discomfort

However Hysteroscopy with biopsy is the "gold standard"

SAFETY
o Symptoms such as discomfort, minor cramping, and mild menstrual-like pain may
be associated with instillation of saline into the uterine cavity.
o Endometritis - 2.5% cases

HOW IT WORKS
With instillation of fluid into the endometrial canal, sonohysterography allows differentiation
between focal and diffuse endometrial or sub endometrial pathologic conditions, which
often lead to a specific diagnosis.

1- Preparation necessary is empty bladder.

2- A speculum is used to expose the cervix, which is cleansed with an iodine swab
3-A sterile 5-F catheter (with or without an occlusive balloon) is flushed with sterile saline
solution before being inserted through the cervical os to prevent the introduction of
echogenic air bubbles, which could obscure the endometrium.

Various catheter types may be used, including pediatric feeding tubes, intrauterine
insemination catheters, and the Goldstein sonohysterography catheter.
A 5-F catheter with a 2-mL balloon may be helpful in patients with
a patulous cervix. However, this device may be uncomfortable
for the patient and may obscure visualization of the lower uterine

USG ACADEMY PAGE # 40 / 59

segment if it is not filled with saline solution and carefully placed in the
endocervical canal. It is also more expensive

4 - Advancement of the catheter is aided by grasping the tip with a ring forceps and
carefully threading it approximately 5–10 cm into the endometrial canal to position the tip
beyond the endocervical canal. The speculum is then carefully removed while the catheter
is left in place.
5 - The covered transvaginal probe is inserted into the vagina, and continuous scanning in
the sagittal and coronal or transverse planes is performed during instillation of sterile
saline solution. Various amounts (5–20 ml or more) of saline solution may be used
depending on how much is retained within the canal; only 2–5 ml are actually needed to
distend the cavity adequately.

Familiarity with uterine physiology is essential

for optimal use in pre-menopausal women.
There is no contraindication to SIS in Non-
pregnant, non-infected women who are
bleeding. Steps should be taken to avoid
uterine lavage propelling cancer cells into the
peritoneal cavity, using low pressure infusion
by avoiding the use of balloons outside
women at risk for cancer.

ADVANTAGES OF SIS
SIS clearly delineates the inner landscape of the endometrial cavity and so fewer
women need be subjected to biopsy, hysteroscopy or even hysterectomy.

A)

TVU showing a submucous myoma.

However, it is not clear how much of
the myoma is intracavitary.

B)

USG ACADEMY PAGE # 41 / 59

 SIS of the myoma shows that half of
the myoma protrudes into the
cavity, forming an acute angle with
the myometrium, and that the
distance from the intramural edge of
the myoma to the serosal surface is
almost 2cm, making this lesion a
candidate for hysteroscopic
resection

C)

A) Sagittal sonohysterogram shows a B) Sagittal transvaginal US scan shows

single polyp (arrowheads) with a the endometrium with a thickness of 15
catheter. The endometrium is normal. mm.

D)

A) Polyps in a 56-year-old woman. (a) B) Sagittal sonohysterogram shows

Sagittal transvaginal US scan shows three polyps (P) with an otherwise thin
the endometrium with a thickness of 12 (1-2mm) endometrium.

USG ACADEMY PAGE # 42 / 59

 mm.
E)

A) B)
Endometrial carcinoma in a 58-year-old woman with substantial postmenopausal bleeding.
(A) Sagittal transvaginal US scan shows the endometrium with a thickness of 44 mm and
a large area of mixed echogenicity suggestive of a mass.
(B) Transverse sonohysterogram shows a 50mm diameter polypoid mass protruding
into the endometrial cavity (calipers indicate the stalk of the mass). Histopathologic
findings indicated poorly differentiated endometrial carcinoma.

A) Endometrial carcinoma in a 51-year-old

woman with a 4-week history of bleeding B)Sagittal sonohysterogram shows diffuse
Sagittal transvaginal US scan shows the thickening secondary to hyperplasia
endometrium with a thickness of 23 m.

USG ACADEMY PAGE # 43 / 59

 A) Secretory endometrium in a 40-year-old B) Sagittal sonohysterogram shows a
woman with diabetes. Sagittal transvaginal diffuse endometrial prominence with a
US scan obtained on day 33 of the thickness of 12 mm (cursors indicate
menstrual cycle suggests a focal diameter of a single wall). Secretory
endometrial bulge with a thickness of 18 endometrium was confirmed at
mm. histopathologic examination.

A)Transverse vaginal scan showing ill

defined thickened endometrium B)SIS demonstrated fundal polyp as well
as cervical inclusion cyst

THE SION TEST OR SONOSALPINGOGRAPHY

The normal fallopian tube is not usually seen by transvaginal sonography unless
some fluid surrounds it. If enough pelvic fluid is present, the fallopian tube and even the fimbrial
end may be detected. It is possible to enhance detection of tube by selecting a mid cycle period for
the scan because of the existence of increased pelvic fluid at that time.
Transvaginal sonography is used to evaluate tubal patency by means of a 5.0 MHz
vaginal transducer.” The Sion Test” or sonosalpingography is done to confirm the tubal patency by
visualizing turbulence near the fimbrial end when a mixture of air and saline is injected through a
Foley catheter placed with in the uterus.
After an informed consent the patient is given Inj. Atropine sulphate (Professor
Gajjar’s Standard chemical Works Ltd., Bombay, India) 0.6mg intramuscularly 10-15 minutes

USG ACADEMY PAGE # 44 / 59

before the test. An 8 F Foley catheter is inserted into the uterine cavity and 2.5-3ml saline is then
injected into the Foley bulb thus stabilizing the catheter with in the uterine cavity. Scanning is now
begun and images of the uterus with the Foley catheter in situ are obtained in a sagittal and coronal
plane. After scanning the uterus, left ovary and right ovary we go back towards the left ovary and
concentrate on an area between the left cornu of the uterus and the left ovary. Approximately 20ml
of saline along with air pushed through the Foley’s catheter. The flow saline and micrometer-sized
air bubbles is observed on transverse section mode and the left tube if patent distends and the
mixture of saline and micro bubbles flows out into the peritoneal cavity with considerable
turbulence on gray scale Ultrasonography.
“The Sion Procedure “effectively solved the entire unanswered question about
sonosalpingography and hysterosalpingo-contrast sonography by sonographic delineation of the
tubes facilitated by instillation of normal saline in the cul-de-sac. Tubal patency was next studied by
us by color Doppler Ultrasonography with local injection of sterile normal saline. The color signal
generated by the air bubbles makes it possible to demonstrate tubal patency on both sides.

CHAPTER-XVII

GRAPHICAL ANALYSIS OF FOETAL GROWTH

When ultrasound measurements of the head, abdomen, and femur. They are plotted on a graph to determine
if they are in the normal range. The graphical display of growth is a useful adjunct to computation of
percentile growth. The following are the most commonly used graphs in the assessment of fetal growth.

USG ACADEMY PAGE # 45 / 59

Biparietal Diameter and Head Circumference: This graph represents growth of the fetal brain.

Femur Length: This represents growth of the leg and skeletal system.

Abdominal Circumference: This represents growth of the liver.

Head/Body Ratio: This compares growth of the head and abdomen. Abnormal growth results in this ratio
being elevated, suggesting Asymmetrical IUGR.

Fetal Weight: This is an estimate of fetal weight derived from the above measurements of the head,
abdomen, and femur.

CHAPTER-XVIII

GROWTH CHART

Embryonic timetable and its appearances on ultrasound

USG ACADEMY PAGE # 46 / 59

Structures visible No. of weeks from
on ultrasound last menstrual period

Gestational sac 4w4d-5w0d

Yolk sac 5w0d-5w3d

Embryonic pole 5w2d

Cardiac pulsations 5w3d

Limb buds 8w0d and >

Fetal movements 8w0d and >

Bowel herniation 9w0d-11w0d

Kidneys 10w0d and >

Choroid Plexus 10w0d and >

Calcification of alvarium 10w0d and >

Orbits 10w4d and >

Stomach bubble 11w0d and >

Cardiac configuration 12w0d and >

Urinary Bladder 12w0d and >

GS MEASUREMENT TABLE

GS(mm) WK GS(mm) WK GS(mm) WK

10 5 28 7.6 46 10.2
11 5.2 29 7.8 47 10.3
12 5.3 30 7.9 48 10.5
13 5.5 31 8 49 10.6

USG ACADEMY PAGE # 47 / 59

14 5.6 32 8.2 50 10.7
15 5.8 33 8.3 51 10.9
16 5.9 34 8.5 52 11
17 6 35 8.6 53 11.2
18 6.2 36 8.8 54 11.3
19 6.3 37 8.9 55 11.5
20 6.5 38 9 56 11.6
21 6.6 39 9.2 57 11.7
22 6.8 40 9.3 58 11.9
23 6.9 41 9.5 59 12
24 7 42 9.6 60 12.2
25 7.2 43 9.7
26 7.3 44 9.9
27 7.45 45 10

GA-Gestational age in week; All values in mm

EXPECTED VALUES FOR FETAL ULNA LENGTH

GA 5 50 95

12 5 8 11
13 8 11 14
14 11 14 17

USG ACADEMY PAGE # 48 / 59

 15 14 17 20
16 16 20 24
17 19 23 27
18 21 25 29
19 24 28 32
20 26 30 34
21 29 33 37
22 31 35 39
23 33 37 41
24 35 39 43
25 38 42 46
26 40 44 48
27 41 45 49
28 43 47 51
29 45 49 53
30 46 51 56
31 47 52 57
32 49 54 59
33 50 55 60
34 52 57 61
35 53 58 62
36 54 59 63
37 55 60 64
38 56 61 65
39 57 62 66
40 58 63 67

GA-Gestational age in week; All values in mm

EXPECTED VALUES FOR FETAL RADIUS LENGTH

GA 5 50 95
12 4 7 10
13 7 10 13
14 9 12 15
15 12 15 18
16 14 18 22

USG ACADEMY PAGE # 49 / 59

 17 16 20 24
18 18 22 26
19 21 25 29
20 23 27 31
21 25 29 33
22 27 31 35
23 29 33 37
24 31 35 39
25 32 36 40
26 34 38 42
27 36 40 44
28 37 41 45
29 39 43 47
30 39 44 49
31 41 46 51
32 42 47 52
33 43 48 53
34 44 49 54
35 45 50 55
36 46 51 56
37 47 52 57
38 47 52 57
39 48 53 58
40 49 54 59

GA-Gestational age in week; All values in mm

EXPECTED VALUES FOR FETAL TIBIA LENGTH

GA 5 50 95
12 4 7 10
13 7 10 13
14 9 13 17
15 12 16 20

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 16 15 19 23
17 18 22 26
18 20 24 28
19 23 27 31
20 26 30 34
21 28 32 36
22 31 35 39
23 33 37 41
24 35 39 43
25 37 41 45
26 40 44 48
27 42 46 50
28 44 48 52
29 44 49 54
30 46 51 56
31 48 53 58
32 50 55 60
33 51 56 61
34 53 58 63
35 54 59 64
36 55 60 65
37 57 62 67
38 58 63 68
39 59 64 69
40 60 65 70

GA-Gestational age in week; All values in mm.

EXPECTED VALUES FOR FETAL FIBULA LENGTH

GA 5 50 95
12 4 7 10
13 7 10 13
14 9 13 17
15 12 16 20

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 16 15 19 23
17 18 22 26
18 20 24 28
19 23 27 31
20 26 30 34
21 28 32 36
22 31 35 39
23 33 37 41
24 35 39 43
25 37 41 45
26 40 44 48
27 42 46 50
28 44 48 52
29 45 49 53
30 46 51 56
31 48 53 58
32 50 55 60
33 51 56 61
34 53 58 63
35 54 59 64
36 55 60 65
37 56 61 66
38 58 63 68
39 59 64 69
40 60 65 70
GA-Gestational age in week; All values in mm.

EXPECTED VALUES FOR FETAL ABDOMINAL CIRCUMFERENCE (AC)

STANDARD STANDARD
GA DEVIATION PERCENTILES DEVIATION
(-4) (-2) 5 10 25 50 75 90 95 (+2) (+4)
12 30 46 49 52 57 62 67 72 75 78 94
13 40 57 60 62 67 73 79 84 86 89 106

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14 50 67 70 73 78 84 90 95 98 101 118
15 60 78 81 84 89 95 101 106 109 112 130
16 70 88 91 95 100 106 112 117 121 124 142
17 80 99 102 105 111 117 123 129 132 135 154
18 90 109 112 116 122 128 134 140 144 147 166
19 100 119 123 126 132 139 146 152 155 159 178
20 108 129 132 136 142 149 156 162 166 169 190
21 118 139 143 146 153 160 167 174 177 181 202
22 126 148 152 156 163 170 177 184 188 192 214
23 134 157 161 165 172 180 188 195 199 203 226
24 142 166 170 175 182 190 198 205 210 214 238
25 150 175 180 184 192 200 208 216 220 225 250
26 158 184 189 193 201 210 219 227 231 236 262
27 165 192 197 202 210 219 228 236 241 246 273
28 173 201 206 211 220 229 238 247 252 257 285
29 179 209 214 219 228 238 248 257 262 267 297
30 186 216 222 227 237 247 257 267 272 278 308
31 193 225 231 237 246 257 268 277 283 289 321
32 199 233 239 245 255 266 277 287 293 299 333
33 205 239 245 252 262 274 286 296 303 309 343
34 211 247 253 260 271 283 295 306 313 319 355
35 216 254 261 268 279 292 305 316 323 330 368
36 221 261 268 275 287 300 313 325 332 339 379
37 227 268 275 283 295 309 323 335 343 350 391
38 232 274 282 290 303 317 331 344 352 360 402
39 236 281 288 296 310 325 340 354 362 369 414
40 240 287 295 303 317 333 349 363 371 379 426

GA-Gestational age; All values in mm.

EXPECTED VALUES FOR FETAL BIPARIETAL DIAMETER (MM) (BPD)

STANDARD STANDARD
GA DEVIATION PERCENTILES DEVIATION

-4 -2 5 10 25 50 75 90 95 +2 +4
12 12 17 18 19 21 23 25 26 27 28 33

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13 15 21 22 23 24 26 28 29 30 31 37
14 19 24 25 26 27 29 31 33 33 34 40
15 22 27 28 29 31 32 34 36 37 38 43
16 25 30 31 32 34 36 37 39 40 41 46
17 28 33 34 35 37 39 41 42 43 44 50
18 31 36 37 38 40 42 44 46 47 48 53
19 34 39 40 41 43 45 47 49 50 51 57
20 36 42 43 45 46 48 50 52 53 54 61
21 39 45 46 48 49 52 54 56 57 58 64
22 42 48 49 51 52 55 57 59 60 61 68
23 44 51 52 53 55 58 60 62 63 64 71
24 47 54 55 56 58 61 63 65 66 68 75
25 49 56 58 59 61 64 66 68 70 71 78
26 51 59 60 62 64 66 69 71 73 74 81
27 54 61 63 64 67 69 72 74 76 77 85
28 56 64 65 67 69 72 75 77 78 80 88
29 58 66 68 69 72 74 77 80 81 83 91
30 60 68 70 71 74 77 80 82 84 85 93
31 62 70 72 73 76 9
7
82 84 86 87 96
32 64 72 74 75 78 81 84 87 88 90 98
33 65 74 76 77 80 83 86 89 90 92 101
34 67 76 77 79 82 85 88 90 92 94 102
35 68 77 79 81 83 86 89 92 94 95 104
36 70 79 80 82 85 88 91 93 95 96 105
37 71 80 82 83 86 89 92 94 96 98 106
38 73 81 83 84 87 90 93 95 97 98 107
39 74 82 84 85 88 90 93 96 97 99 107
40 75 83 84 86 88 91 94 96 98 99 107
GA-Gestational age; All values in mm.

EXPECTED VALUES FOR FETAL FUMUR LENGTH (FL)

GA STANDARD PERCENTILES STANDARD
DEVIATION DEVIATION

(-4) (-2) 5 10 25 50 75 90 95 (+2) (+4)

12 0 4 5 5 7 8 9 11 11 12 16
13 3 8 8 9 11 12 13 15 16 16 21

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 14 6 11 11 12 14 15 16 18 19 19 24
15 9 13 14 15 16 18 20 21 22 23 27
16 12 16 17 18 19 21 23 24 25 26 30
17 15 19 20 21 22 24 26 27 28 29 33
18 17 22 23 24 25 27 29 30 31 32 37
19 20 25 26 27 28 30 32 33 34 35 40
20 23 28 29 30 31 33 35 36 37 38 43
21 26 31 32 33 34 36 38 39 40 41 46
22 29 34 35 36 37 39 41 42 43 44 49
23 30 36 37 38 39 41 43 44 45 46 52
24 33 39 40 41 42 44 46 47 48 49 55
25 35 41 42 43 44 46 48 49 50 51 57
26 38 43 44 45 47 49 51 53 54 55 60
27 40 45 46 47 49 51 53 55 56 57 62
28 42 47 48 49 51 53 55 57 58 59 64
29 43 49 50 51 53 55 57 59 60 61 67
30 45 51 52 53 55 57 59 61 62 63 69
31 47 53 54 55 57 59 61 63 64 65 71
32 49 55 56 57 59 61 63 65 66 67 73
33 51 57 58 59 61 63 65 67 68 69 75
34 52 59 60 61 63 65 67 69 70 71 78
35 53 60 61 62 64 66 68 70 71 72 79
36 55 62 63 64 66 68 70 72 73 74 81
37 57 63 65 66 68 70 72 74 75 77 83
38 58 64 66 67 69 71 73 75 76 78 84
39 59 65 66 68 70 72 74 76 78 79 85
40 60 67 68 70 72 74 76 78 80 81 88

GA-Gestational age in week; All values in mm

EXPECTED VALUES FOR FETAL HEAD CIRCUMFERENCE (HC)

GA STANDARD PERCENTILES STANDARD

DEVIATION DEVIATION
(-4) (-2) 5 10 25 50 75 90 95 (+2) (+4)
12 39 59 63 66 72 79 85 91 95 98 118
13 52 71 75 78 84 90 97 103 106 110 129

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14 64 83 87 90 96 102 109 115 118 121 141
15 76 95 99 102 108 114 121 126 130 133 152
16 88 107 110 114 120 126 133 138 142 145 165
17 99 119 122 126 132 138 145 151 154 158 177
18 111 130 134 137 143 150 157 163 166 170 190
19 122 142 145 149 155 162 169 175 179 182 202
20 132 153 157 161 167 174 181 187 191 194 215
21 143 164 168 172 178 185 192 199 203 207 228
22 153 175 179 183 189 197 204 211 215 219 240
23 163 185 189 194 200 208 216 222 226 230 253
24 173 196 200 204 211 219 227 234 238 242 265
25 182 206 210 214 221 229 237 245 249 253 277
26 191 215 220 224 231 240 248 255 260 264 289
27 199 224 229 233 241 250 258 266 270 275 300
28 207 233 238 242 250 259 268 275 280 285 311
29 215 242 246 251 259 268 277 285 290 294 321
30 223 250 254 259 267 276 285 294 298 303 330
31 230 257 262 267 275 284 293 302 307 311 339
32 236 264 269 274 282 292 301 309 314 319 347
33 243 270 275 280 289 298 308 316 321 326 354
34 249 276 281 286 295 304 314 322 327 332 360
35 254 282 287 292 300 309 319 327 332 337 365
36 259 287 291 296 305 314 323 332 337 341 369
37 264 291 296 300 309 318 327 335 340 345 372
38 268 294 299 304 312 321 330 338 342 347 374
39 271 297 302 306 314 323 331 339 344 348 374
40 275 299 304 308 316 324 332 340 344 348 373
GA-Gestational age in week; All values in mm

EXPECTED VALUES FOR FETAL TRANSCEREBELLAR LENGTH

GA 5 50 95
14 14 16 18
15 14 16 18
16 14 16 18

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 17 15 17 19
18 17 18 19
19 18 19 20
20 18 20 22
21 19 21 23
22 21 23 25
23 22 24 26
24 23 26 29
25 24 27 30
26 25 29 33
27 27 31 35
28 29 33 37
29 29 34 39
30 31 36 41
31 33 38 43
32 34 40 46
33 35 41 47
34 37 43 49
35 39 45 51
36 40 46 52
37 42 48 54
38 43 49 55
39 44 50 56
40 47 52 57
GA-Gestational age in week; All values in mm.

EXPECTED VALUES FOR FETAL HUMERUS LENGTH

GA 5 50 95
12 6 9 12
13 9 12 15
14 11 15 19

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 15 14 18 22
16 17 21 25
17 20 24 28
18 22 26 30
19 25 29 33
20 27 31 35
21 30 34 38
22 32 36 40
23 34 38 42
24 37 41 45
25 39 43 47
26 41 45 49
27 42 46 50
28 44 48 52
29 46 50 54
30 48 52 56
31 48 53 58
32 50 55 60
33 51 56 61
34 52 57 62
35 54 59 64
36 55 60 65
37 56 61 66
38 57 62 67
39 58 63 68
40 58 63 68

GA-Gestational age in week; All values in mm.

CHAPTER-XIX

GLOSSARY
REFERENCES & SUGGESTED READINGS

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1) DIAGNOSTIC ULTRASOUND (vol 1&2):- CAROL M. RUMACK et al

2) TRANSVAGINAL SONOGRAPHY
(SECOND EDITION):- ILAN E. TIMOR – TRITSCH et al

3) ULTRASOUND OF FETAL ANOMALIES: - DR. KULDEEP SINGH

4) ULTRASOUND DIAGNOSIS IN OBSTETRICS & GYNAECOLOGY: -

PROF. DR. HANSMANN et al

5) EARLY PREGNANCY OR ECTOPIC PREGNANCY:-NYBERG D.A.

6) USG IN OBSTETRICS & GYNAECOLOGY: -PETER W.CALLEN
7) FOETAL GROWTH CHARTS & SKELETAL DYSPLASIA - DR.SURESH
8) BASIC USG TRAINING COURSE IN OBSTETRICS & GYNAECOLOGY: – DR.P.K.SHAH

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