Ultrasound

in
Obstetrics
Ramon M. Gonzalez MD FPOGS
Professor
UST Faculty of Medicine and Surgery
Indications of Ultrasound in the First Trimester

Intrauterine
Confirmation of Confirm cardiac
localization of
pregnancy activity
gestational sac

Assessment of
Diagnose or
Assessment of normal embyro
evaluate multifetal
gestational age and gestational sac
pregnancy
before 10 weeks
Indications for First-Trimester Ultrasound Examination

Assess certain fetal Evaluate maternal

anomalies such as pelvic masses
anencephaly in and/or uterine
high risk patients abnormalities

Evaluate suspected
Measure nuchal
gestational
translucency for
trophoblastic
fetal aneuploidy
disease
Components of Standard Ultrasound
Examination of the First Trimester

Gestational sac size, location, and number

Embryo and/or yolk sac identification

Crown-rump length
Fetal number including amnionicity and chorionicity
of mutifetal gestations
Embryonic/fetal cardiac activity
Evaluation of the maternal uterus, adnexa and
cul-de-sac
Mean Sac Diameter

• Gestational sac
• Small anechoic
fluid collection
• Measured as the
mean of three
dimensions
• 4-5 weeks AOG
 Mean Sac Diameter
• MSD of 25mm
• (+) Embryo (+) YS

• MSD of 25mm
• (-) Embryo (-) YS
• Anembryonic
pregnancy
 Yolk Sac
• 1st anatomic structure
identified w/in the GS
• A brightly echogenic ring
with an anechoic center
• Seen at 5 ½ weeks
• Confirms an intrauterine
pregnancy
• Large or mega yolk sac
• >5 mm
• Poor prognosis
• May indicate failing
pregnancy
A 26y/o primi 8 weeks by LMP CC: hypogastric
pain + spotting. Pregnancy test (+). TVS-
Intrauterine pregnancy CRL- 6mm, no cardiac
activity. What is the management?

A. Request for serum β hCG

B. Repeat scan after 1 or 2 weeks
C. Evacuation of products of conception
D. Observe and repeat scan after 1 month
A 26y/o primi 8 weeks by LMP CC: hypogastric
pain + spotting. Pregnancy test (+). TVS-
Intrauterine pregnancy CRL- 16mm, no cardiac
activity. What is the management?

A. Request for serum β hCG

B. Repeat scan after 1 or 2 weeks
C. Evacuation of products of conception
D. Observe and repeat scan after 1 month
 What is the most accurate structure to
measure to of determining gestational age?

A. MSD
B. CRL
C. BPD
D. FL
 Crown Rump Length
• 6 weeks – (+) embryo;
(+) cardiac activity
• Embryo = 5mm ( TVS)
• (+) cardiac motion
• Embryo < 7mm with no
cardiac activity
• Repeat TVS after 1
week
• Embryo : 10mm and
(-) cardiac activity
→1st trimester demise
 • Embryo
• Embryonic period :
3rd-8th weeks from
LMP
• Fetal period : 9th
week from LMP
• CRL
• Most accurate
sonographic method
of determining
gestational dates
• Until 13 wks and 6
days gestation
Crown Rump Length • Accurate to 5-7
days
 A 26y/o primi 9 weeks by LMP. She is
regularly menstruating. TVS- Intrauterine
pregnancy , 8 weeks 5 day by CRL w/ good
cardiac activity. What gestational age should
we use?

A. 8 weeks and 5 days

B. 9 weeks
C. Repeat TVS after 1 week
D. Repeat TVS after 2 weeks
Sonographic Gestational Age Assessment
 Findings Diagnostic of Pregnancy Failure

Crown–rump length of ≥7 mm and no heartbeat

Mean sac diameter of ≥25 mm and no embryo

Absence of embryo with heartbeat ≥2 weeks after a scan

that showed a gestational sac without a yolk sac

Absence of embryo with heartbeat ≥11 days after a scan

that showed a gestational sac with a yolk sac
Nuchal Transluscency

• Component of first-trimester aneuploidy

screening
• Represents the maximum thickness of the
subcutaneous translucent area between
the skin and soft tissue overlying fetal
spine at the back of the neck
• Measured in sagittal plane between
11 and 14 weeks
• NT thickness - >/=3 mm
• Fetal aneuploidy
• Structural anomalies –heart defects
• Targeted sonography
• Fetal karyotyping
Williams Obstetrics 26th Edition
 Ectopic Pregnancy

TVS - adnexa

TVS - adnexa TVS - adnexa

Ectopic Pregnancy
Adnexal findings
• Confirmed diagnosis
• Fallopian tubes and ovaries
visualized and an extrauterine
yolk sac, embryo, or fetus

• Other US findings
• Inhomogeneous complex mass
adjacent to the ovary ( 60%)
• Hemorrhage w/in the ectopic
sac or by an ectopic pregnancy
that has ruptured into the tube
Williams Obstetrics 25th Edition
Interstitial Ectopic Pregnancy
Ectopic Pregnancy

•Ring of fire
•Placental blood flow
w/in the periphery of
the complex adnexal
mass
•Seen also in corpus
luteum
 Ectopic Pregnancy
• Hemoperitoneum

• Anechoic or hypoechoic fluid

• Blood in the dependent
retro-uterine cul-de-sac Fluid
• Surrounds the uterus as it fills
the pelvis

• Adnexal mass + Peritoneal fluid Fluid

highly predictive of ectopic

pregnancy

Williams Obstetrics 25th Edition

 A 26y/o G2P1 (1001) 6 weeks by LMP CC:
hypogastric pain + spotting. Pregnancy test
(+). TVS- thickened endometrium and no
adnexal masses. What is the diagnosis?

A. Threatened abortion
B. Ectopic pregnancy
C. H-mole
D. PUL
 A 26y/o G2P1 (1001) 6 weeks by LMP CC:
hypogastric pain + spotting. Pregnancy test
(+). TVS- thickened endometrium and no
adnexal masses. What is the management?

A. Pelvic laparoscopy
B. Pelvic laparotomy
C. Serial serum β hCG
D. Repeat TVS after 3 days
•Bleeding or pain and a (+) pregnancy test
TVS
•If yolk sac, embryo or fetus is identified in
the uterus Intrauterine pregnancy
•If yolk sac, embryo or fetus is identified in
the adnexa Ectopic pregnancy
•If TVS is nondiagnostic, in which neither
intrauterine or extrauterine is identified
pregnancy of unknown location (PUL)
How many layers of membrane/s should
be seen on ultrasound in cases of
dichorionic twin?

A. 1
B. 2
C. 3
D. 4
 Ultrasound in Multifetal Pregnancy
Sonographic determination of chorionicity
• Dichorionic
• Twin peak or lambda sign
• Triangular portion of placenta
seen insinuating between the
amniochorion layers.
• Thick dividing membrane :
>/=2mm
• 2 layers of amnion and 2 layers of
chorion
• Different genders of the fetuses
Lambda sign is best visualized in the late 1st and
Early 2nd trimester
Twin Peak
Ultrasound in Multifetal Pregnancy
Sonographic determination of chorionicity

• Monochorionic
• T- sign
• No apparent
extension of
placenta between
dividing membranes
• Thin dividing
membrane: <2mm
• 2 layers of amnion
 A C C A A A

A A

C C

Dichorionic placenta Monochorionic placenta

 Monochorionic diamnionic pregnancy

Hydramnios defined by a largest vertical

Twin to pocket of >8 cm in one sac and
oligohydramnios defined by largest vertical
Twin pocket of < 2cm in the other twin
Transfusion
Syndrome Growth discordancy may be found but is
NOT considered as diagnostic criteria

Stuck twin or polyhydramnios-

oligohydramnios syndrome—“poly- oli.”
Twin to Twin Transfusion
Syndrome
• Anastomoses between twins
may be artery-to-vein (AV), artery-
to-artery (AA), or vein-to-vein
(VV). Schematic representation of
an AV anastomosis in twin-twin
transfusion syndrome that forms a
“common villous district” or “third
circulation” deep within the
villous tissue. Blood from a donor
twin may be transferred to a
recipient twin through this shared
circulation. This transfer leads to a
growth-restricted discordant
donor twin with markedly reduced
amnionic fluid, causing it to be
“stuck.”
 • Stage I—discordant amnionic fluid
volumes but urine is still visible
sonographically within the bladder
of the donor twin
• Stage II—criteria of stage I, but
Quintero urine is not visible within the
donor bladder
Staging • Stage III—criteria of stage II and
System abnormal Doppler studies of the
umbilical artery, ductus venosus,
or umbilical vein
• Stage IV—ascites or frank hydrops
in either twin
• Stage V—demise of either fetus.
 Gestational
Trophoblastic Disease
• Sonographic imaging
• Mainstay of trophoblastic disease
diagnosis
• Complete Mole
• Appears as echogenic uterine
mass with numerous anechoic
cystic spaces but without a fetus
or amnionic sac.
• “Snowstorm”
• Partial Mole
• Thickened, multicystic placenta
along with a fetus or at least fetal
tissue
• Most common misdiagnosis is
incomplete or missed abortion
 Gestational
Trophoblastic Disease

• Theca lutein cyst

• Incidence : 20%- 50%
• Regression : 10-12 weeks
after molar evacuation
• Multiple cyst ,
multiseptated
appearance
Second and Third
Trimester
 Fetal presentation and position

Cardiac activity

Fetal number
Indications
of Second Fetal anatomic survey
and Third
Trimester Evaluation of uterine or ovarian masses
Ultrasound
Evaluation of fetal well-being

Placental localization

Amniotic fluid determination

Components
of Standard
Ultrasound
Examination
of the Second
and Third
Trimester
 Biparietal Diameter
In 2nd trimester, BPD most accurately
reflects the gestational age

Variation – 7-10 days

Measured on the transthalamic view

at the level of the thalami, midline
echogenic falx and cavum septum
pellucidum

From outer table to inner table of

bony calvarium
Head Circumference

• Measured in transthalamic view

• Placing an ellipse around the
outer edge of the skull
• Or measuring occipital-frontal
diameter (OFD) and calculating
the circumference from the BPD
and OFD

Williams Obstetrics 25th Edition

Femur Length
•From the greater trochanter to
the lateral epicondyle
•Correlates well with BPD and
GA
• Measured
• Beam perpendicular to long
axis of the shaft, excluding the
epiphysis
• GA estimation
• variation of 7 to 11 days -
second trimester

Williams Obstetrics 25th Edition

Femur Length

Mildly foreshortened femur

• Minor marker for Down syndrome

Dramatically foreshortened femur

• Prompts evaluation for skeletal dysplasia

Normal range for FL to (AC) ratio : 20

to 24%
• FL/AC < 16 percent suggests a lethal skeletal
dysplasia
 Abdominal Circumference
• Greatest variation for AOG –
2 to 3 weeks
• Measured on the TRANSVERSE
VIEW at the level of the :
• Spine
• Stomach
• Confluence of umbilical vein
with portal sinus
• Most affected by fetal growth
• Most sensitive estimate of
fetal growth
Callen’s Ultrasonography in Obstetrics and Gynecology., 6th ed., 2017
Fetal biometry
 Amniotic Fluid Measurement
•
• Measurements
• Single deepest vertical fluid pocket
• • Normal value: 2 and 8cm
• Sum of deepest vertical pockets
from each of four equal uterine
quadrants— AFI
• Normally ranges between 5
and 24 cm.
• “Borderline” oligohydramnios
• AFI between 5-8cm
 • Fetal Anatomical Evaluation
• Goal of 2nd and 3rd trimester
sonography
• Systematic evaluation of fetal
anatomy
• Determine whether specific
Congenital anatomical components
Anomaly appear normal or abnormal
Scan
• American College of Obstetricians
and Gynecologists (2011)
recommends performed at 18 to 20
weeks AOG
 Cisterna
magna /
Cerebellum
Fetal spines
Ventriculomegaly

Mild ventriculomegaly - atrial width measures 10 to 12 mm;

Moderate ventriculomegaly - atrial width measures 13 to15 mm
Severe ventriculomegaly - atrial width measures >15 mm
 Anencephaly

Neural Spina Bifida

Tube
Defects Cephalocoele
Encephalocoele
 Anencephaly
• Failure of closure at the
cranial end of the neural
tube
• Absence of the cranium
and telencephalon
• Hydramnios
• Lethal during the
neonatal period
Acrania Anencephaly
 Failure of distal closure during early
embryogenesis.

Defect in the vertebrae, typically the

dorsal arch, w/ exposure of the
meninges and spinal cord.
Spina
Bifida Associated with various degree of
motor impairment, lower limb
paralysis or dysfunction and
incontinence.
Associated with hydrocephalus – poor
prognostic factor for intellectual
development.
 • Spina bifida occulta –
vertebral schisis covered
Spina Bifida by normal soft tissues.
• Spina bifida aperta – full
thickness defect of the
skin, underlying soft
tissues and vertebral
arches and exposing the
neural canal.
• myelomeningocoele –
herniation of
meningeal sac
containing neural
elements
• meningocoele –
herniation of
meningeal sac only
Meningomyelocoele
 Encephalocoele

Herniation of brain
Associated with
tissue and Most common –
hydrocephalus and
meninges through occipital area
microcephaly
a skull defect.

Intellectual
Neonatal mortality impairment and
rate - 40% neurologic
sequelae – 80%
 • Encephalocele-
Large defect in the
occipital region of
the cranium
(arrows) through
which meninges
and brain tissue
have herniated.

Encephalocoele
Encephalocoele
Encephalocoele
Meningomyelocoele
Meningomyelocoele
Sagittal image of a
lumbosacral
myelomeningocele,
the arrowheads
indicate nerve
roots within the
anechoic herniated
sac.
 A. Image at the level of the lateral ventricles
demonstrates inward bowing or scalloping of
Cranial Findings of the frontal bones—the lemon sign.
Meningomyelocoele B. Image at the level of the posterior fossa shows
anterior curvature of the cerebellum with
effacement of the cisterna magna—the
banana sign.
Cystic Hygroma
Fetal Lips
and Nose
Facial Clefts
Esophageal
Atresia
Congenital
Diaphragmatic
Hernia
Gastroschisis Omphalocoele
 Ventral wall defects

• Gastroschisis is a full-thickness abdominal wall

defect located to the right of the umbilical cord
insertion. Bowel herniates through the defect into
the amnionic cavity
• Not associated with aneuploidy

• Omphalocoele the abdominal organs herniate into

the base of the umbilical cord covered only by 2
layered of sac amnion and peritoneum
• Associated with other major anomalies and aneuploidy
• A component of several syndromes, including Beckwith–
Wiedemann, cloacal exstrophy, and pentalogy of Cantrell.
Normal
ventral
wall
Omphalocoele Gastroschisis
Kidneys

The threshold measurement for diagnosis on axial views

of the kidney is 7 mm for mild dilation , between 7 and
15 mm for moderate dilation, and greater than 15 mm
for marked dilation.
Duodenal
atresia

The double-bubble sign represents distension of the

stomach (S) and the first part of the duodenum (D)
Evaluation of Placenta

• Normal placenta
• Normal thickness – 40mm

• Placentomegaly - >40mm
placental thickness
• DM
• CMV infection

Williams Obstetrics 25th Edition

 Placenta Previa
• Classification
Cervix • Placenta previa
• Internal os covered
partially or completely by
placenta
• Low -lying placenta
Placenta • Placental edge does not
cover the internal os but
lies within a 2-cm wide
perimeter

Williams Obstetrics 26th Edition

Placenta
Previa
Low lying
placenta
 • Transabdominal sonography
• is confirmatory, average
accuracy of 96%
• Imprecise results - caused
by bladder distention
Placental
Localization • Transvaginal sonography is
safe, and the results are
superior

• Transperineal sonography is
also accurate to localize
placenta previa
 • Placental lacunae, which are vascular
spaces that may contain prominent
color Doppler flow
• Loss of the retroplacental clear space
• Disruption of the bladder-uterine
Placenta serosal interface, which appears as
an irregular, echogenic boundary
Accreta between the bladder and uterine
Spectrum serosa with gray-scale imaging
• Bridging vessels, which are
(PAS) demonstrated with color Doppler to
course from the placenta to the
bladder-serosal interface
• A placental “bulge” that pushes
outward and distorts the contour of
the uterus or other organs. In some
cases of placenta percreta, a focal
exophytic mass also is seen.
Multiple
placental
lacunae
Thinning of
the
retroplacental
myometrium,
with the
smallest
myometrial
thickness
measuring
less than 1
mm in the
sagittal plane.
Thinning of
Retroplacental
Myometrium
Hypervascularity
of bladder-
serosal interface
Increased
vascularity of the
bladder-serosal
interface, with
bridging vessels that
course from the
placenta to the
region of the
bladder- serosal
interface shown
with color Doppler
imaging
Transvaginal
transverse image
showing a large
bulge (suggesting
placenta percreta)
along the bladder-
uterine serosal
interface
(arrowheads) and
multiple large,
irregular lacunae
(arrows).
Disruption of the
bladder-serosal
interface. The echogenic
interface between
bladder and serosa
appears irregular
(arrowheads). The
smallest myometrial
thickness measures <1
mm, and bridging
vessels are highlighted
by color Doppler. Large
lacu- nae also are
shown (arrows).
 Hypervascularity of
bladder-serosal interface
 Predictors of Preterm Birth

TVS cervical length and Mean CL at 24 weeks –

funneling 35mm

Best time
• High risk for preterm birth:
16-22 wks No hard and fast rules about
• Non high risk: 18-24 wks frequency of testing
• Twin pregnancy: 20-24 wks
Cervical Length Assessment
Funneling -
protrusion of
amnionic
membranes into
a portion of the
endocervical
Cervical length
canal that has
dilated.
Shapes of
cervical
funnels
US images
of cervical
funnel
shapes
Normal versus Abnormal Cervical Length

Normal Cervical Length

25mm to 50mm at 14 weeks to 30 weeks

Cervical Length <25mm

Best prediction for PTB at 16 to 24 weeks

Short Cervical Length

Higher the risk for PTB
Better predictor of early PTB than later PTB
Ramon M. Gonzalez MD
Obstetrics and Gynecology
Maternal - Fetal Medicine

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