FIRST TRIMESTER SONOGRAPHY

Judi Januadi Endjun

Sanny Santana Novi Resistantie Febriansyah Darus Finekri

FETOMATERNAL DIVISION Department of Obstetrics and Gynecology Gatot Soebroto Central Army Hospital School of Medicine, University of Indonesia 2005

AM I PREGNANT ?

AGENDA

Introduction. Patient position. Normal early pregnancy. Abnormal early pregnancy. Diagnostic procedures Conclusions. References.
JJE/RSPAD/INTIUM/2005

INTRODUCTION

ALARA (as low as reasonably acceptable) principle in determining intensities and time of exposure
AIUM : intensities < 94 mW/cm2 are below
the acceptable threshold. Do not hold the transducer to interrogate a certain area any longer than needed

INTRODUCTION

30% of fertilized eggs develop into a fetus

Many of the defects occur during embryogenesis (0 8 weeks) Fetal development : > 8 weeks TVS is vital in the evaluation of complicated 1st trimester pregnancy (0 13 weeks)

INTRODUCTION

The terms incomplete abortions, missed abortion, failed IUP, and embryonic demise are used interchangeably, which can contribute to confusion.
It is best to most accurately describe TVS features (i.e., presence or absence of embryo / YS, fetus, heart motion, and retrochorionic hemorrhage

PATIENT POSITION

TRANSDUCERS

curvilinear Transvaginal / rectal Bambang Karsono

DEFINITIONS

Menstrual age (postmenstrual) ~ from LMP

Conceptual age ~ from ovulation date (IVF) Gestational age ~ ovulation date + 2 weeks
(Merz E. Ultrasound in Gynecology & Obstetrics, 1991)

Bambang Karsono

DEFINITIONS

Kehamilan minggu ke-6 ~ kehamilan 5 minggu + 0 hari sampai dengan 5 minggu + 6 hari
Kehamilan 6 minggu ~ kehamilan 6 minggu + 0 hari sampai dengan 6 minggu + 6 hari
Bambang Karsono

Objectives of 1st Trimester US Examinations

Location and gestational age determination. Detection of embryo and or fetal life Evaluation of pregnancy complications Detection of anomalies Detection of multiple pregnancy Evaluation of pelvic mass, IUD, etc

DECIDUALIZATION

Normal Early Pregnancy

Physical and physiological changes. Embryo and fetal development. Technique : transabdominal, transvaginal
(the method of choice), transrectal, or transperineal.

Transducer selection Informed consent : very important

14-15

19

22

25

29

32

35

LMP

OvulationFertilization

Uterine cavity

HCG (+) USG (+) Implant >10 mIU/ml >400 mIU/ml ation

> 1800 mIU/ml

Normal early pregnancy

TVS can detect GS within the thickened choriodecidua at 5-6 W Decidua capsularis : forms most of the GS
Decidua vera : the true decidua that surrounds the GS Decidua basalis : and chorion frondosum form the
placenta

Normal early pregnancy

-hCG > 2000 mIU/ml + GS should be sees on TVS in an IUP. -hCG doubles every 48 hours in a normal IUP
YS should be visible in a GS that is 10 mm

The embryo should be visible in a 16 20 mm GS

Normal early pregnancy

Heart motion should be visible in an embryo 3 mm. - Normal embryos : HR > 85 bpm at 6 7 weeks - HR < 85 bpm can indicate impending failed pregnancy, re-scan in 1 week or so - TV-CDS can be used to detect heart motion

Normal early pregnancy

Certain fetal structures seen on TVS are specific to the early developing fetus : Rhombencephalon : seen at 6 W, is a cystic area in the

brain that eventually forms the 4th ventricle (cisterna magna) Bowel herniation : into base of umbilical cord is seen between 8 12 W

Chorio-amnion is unfused until 18-20 W IUP in one horn of bicornuate uterus Corpus luteum cyst of pregnancy : usually regresses by 14 to 16 W

PROBLEMS
Incorrect gestational age estimation, increase perinatal morbidity and mortality; also medicolegal problems

Case : CS due to post term preterm baby

AIUM Guidelines for 1st Trimester Ultrasound

1.

The uterus and adnexa should be evaluated for the presence of a gestational sac (GS). If GS is seen, its location should be documented. The presence or absence of an embryo should be noted and CRL recorded

AIUM Guidelines 1 :

CRL is a more accurate indicator of GA than GS diameter. Identification of a YS or an embryo is definitive evidence of a GS. Intrauterine fluid collection can sometimes represent pseudogestational sac associated with ectopic pregnancy

AIUM Guidelines 1 :
During the late 1st trimester, BPD and other fetal measurements also may be used to establish fetal age

AIUM Guidelines :
2.

Presence or absence of cardiac activity should be reported Fetal number should be documented
Evaluation of the uterus, adnexal structures, and cul-de-sac should be performed

3.

4.

AIUM Guidelines 2 :

Real time observation is critical for this diagnosis. With vaginal scan, cardiac motion should be appreciated by a CRL of 5 mm. If an embryo < 5 mm is seen with no cardiac activity, a follow-up scan may be needed to evaluate for fetal life.

AIUM Guidelines 3 :

Multiple pregnancies Pseudo GS : incomplete fusion between the

amnion and chorion, or elevation of the chorionic membrane by intrauterine hemorrhage

JJE/RSPAD/INTIUM/2005

AIUM Guidelines 4 :

Recognition of incidental findings : myomas, adnexal

mass, fluid in the cul-de-sac or the flanks and subhepatic space

Correlation of serum hormonal levels with US findings often is helpful for diagnosis of EP or normal pregnancy

EMBRYO and FETUS DEVELOPMENT

BIOMETRICS PARAMETER
< 5 weeks 5 weeks 6-10 weeks 10-12 weeks > 12 weeks

GS

GS (Yolk sac)

CRL

CRL BPD

BPD FL etc

Bambang Karsono

Gestational age estimation

GS YS CRL BPD HC FL HL
JJE/RSPAD/INTIUM/2004

Gestational Sac

Normal : cincin ekoik regular dgn bagian

sonolusen ditengahnya

Yolk Sac

Size, shape, and location Normal : rounded,

diameter 3 6 mm, fixed

Abnormal : not

rounded, diameter < 3 mm or 8 mm, and floating inside GS.

CRL

CROWN-RUMP LENGTH (CRL)

4+ WEEKS PREGNANCY

5 WEEKS PREGNANCY

6 WEEKS PREGNANCY

CARDIAC ACTIVITY AT 6 WEEKS

7 WEEKS PREGNANCY

8 WEEKS PREGNANCY

9 WEEKS PREGNANCY

10 12 WEEKS PREGNANCY

12 WEEKS

st 1

Trimester screening

Soft markers chromosomal anomalies : golf ball (echogenic

foci intra cardiac), NT, echogenic bowels Anensefalus Hidrosefalus

1st Trimester screening

Yolk sac (shape, size, and number) Nuchal translucency (NT)

Nuchal Translucency (NT)

Enlargement (> 3 mm) is associated with chromosomal abnormalities Different from cystic hygroma associated with Turners syndrome; cystic hygromas usually have septations The membrane represents skin elevated from the nuchal area, possibly related to a cardiac malformation or edema If present, there is high association with chromosomal abnormality. Detection and evaluation of NT require meticulous scanning, usually using a transabdominal approach
(Arthur C. Fleischer, 2004)

PREGNANCY FAILURE

Pre-embryonic : > 50% Embryonic : 28% Fetus : 10% 7-9 weeks : 5% 10-12 weeks : 1 2%

GS (+) : 11,5% YS (+) : 8,8% Embryo 5 mm : 7,1% Embryo 5-10% : 3,3% Embryo 10 mm : 0,5%

ETIOLOGY

Pre-embryonic : 70% chromosomal abnormalities Embryonic : 56% chromosomal abnormality

Fetus : placentation abnormality, perfusion

disturbances, uterine defect : uterus subseptus ( 4,7 x) , uterus arcuatus ( 5,8 x), uterus septus, maternal disease(s), cervical incompetent. Antibody antinuclear : Uterine artery Pulsatility Index
Progesterone

Abnormal Early Pregnancy

Blighted ovum
Molar pregnancy, trophoblastic disease Subchorionic bleeding IUFD Multiple pregnancy Ectopic pregnancy, combine pregnancy Screening fetal anomaly

Blighted Ovum

Dinding KG tipis dan iregular Tidak tampak ekho janin pada diameter KG 25 mm Dapat disertai perdarahan sub korionik Bl perlu : USG serial Bandingkan dengan kadar HCG darah

Molar pregnancy

Early in trophoblastic disease, may appear as thickened, irregular tissue within uterus. (Arthur C. Fleischer, 2004)
After 12 W, hydropic villi can be recognized as punctate cystic areas.
(Arthur C. Fleischer, 2004)

May be associated with theca lutein cysts (septated cystic adnexal masses).
(Arthur C. Fleischer, 2004)

Subchorionic bleeding

Daerah hipoekoik iregular subkorion

Perhatikan regularitas dinding korion, letak janin dan tanda kehidupan, anomali uterus

Ukur luas daerah perdarahan

Bila perlu evaluasi USG serial

IUFD

Diagnosa : B-mode atau doppler Tidak tampak pulsasi jantung atau tali pusat Bila ragu, ulangi USG 1 minggu Cari kausa : perdarahan, anomali uterus,
kelainan yolk sac, anomali janin, dll
Beri informed consent dengan baik, hati-hati pasien rujukan konsultasi USG

Multiple pregnancy

The numbers of GS Amniotic band Thickness of amniotic band Fetal echo : be careful vanishing twin Fetal live and gestational age Anomaly Adnexal mass

Triplets

Quadruplet

Ectopic pregnancy (EP)

Clinical conditions which increase risk of EP include the presence of a scarred tube from salpingitis/PID and/or previous tubal surgery TVS : no GS within uterus. Uterus size is normal or slightly enlarged Extrauterine extraovarian adnexal mass, pseudogestational sac, and hemoperitoneum The EP is usually on the side of the CL. Living embryo outside of the uterus
(Arthur C. Fleischer, 2004)

Ectopic pregnancy

EP may also contain a rim of increased vascularity, although this is variable, depending on the extent of trophoblastic invasion into the tubal wall TV-CDS can distinguish distended paraovarian/uterine veins from the vascular rim of an EP EP have variable wall vascularity and pain A ruptured EP can be implied if there is a complex solid tubal mass, hematosalpinx, or hemoperitoneum

(Arthur C. Fleischer, 2004)

Rare types of ectopic pregnancy

Cornual EP : can occur within one uterine

cornua, it can enlarge because it is surrounded by myometrium. If it ruptures, catastrophic bleeding can occur Abdominal EP : can be diagnosed by the presence of fetus, choriodecidua, or placenta separate from uterus Cervical EP : GS inside the cervical area Ovarian EP : virtually impossible to distinguish from CL if the embryo is not seen
(Arthur C. Fleischer, 2004)

Down Syndrom

Echogenic bowels

Anencephaly

TVS can be used to detect anencephaly as early as 7-8 W

(Arthur C. Fleischer, 2004)

TAS : 12 14 W

PREGNANCY + ENDOMETRIOSIS CYST

Doppler study

Uterine artery Doppler : notching

IUGR, preeclampsia, IUFD

Only for HRP

Detection of heart beat

Blood flow study

Doppler study

Ductus venosus

Vitelline duct blood flow

Uterine artery

Uterine artery

Notching

Diagnostic Procedures in the 1st Trimester

CVS : under continuous sonographic visualization of the

catheter in which chorionic villi are aspirated from the developing placenta.

Early Amniocentesis : an aspiration needle is guided

into the amniotic fluid under continuous sonographic guidance. It is sometimes difficult to puncture both chorion and amnion in 13 16 W pregnancies

Retrieval of tissue for karyotyping

(Arthur C. Fleischer, 2004)

CVS and Early Amniocentesis

CONCLUSIONS

TVS has a vital role in the evaluation of patients presenting with hemorrhage, distinguishing a pregnancy with subchorionic hemorrhage from an ectopic pregnancy or failed IUP. (Arthur C.
Fleischer, 2004)

TVS can accurately detect ectopic gestational sacs in most cases. (Arthur C. Fleischer, 2004) Determine the objectives of 1st trimester ultrasound. Use the appropriate transducer and the route of examination. Minimize side effects. CPD very important for maintaining personal competence 3D and Doppler examinations should be performed if there indicated.

REFERENCES
1.

Fleischer AC. Sonography in gynecology and obstetrics : just the facts. McGraw Hill, Singapore, 2004.
Fleischer AC, Kepple DM. Transvaginal sonography of early intrauterine pregnancy. In: Fleischer AC, Manning F, Jeanty P, Romero R, eds. Sonography in Obstetrics and Gynecology : Principles and Practice, ed6. New York: McGraw-Hill,2001:62. Fleischer AC, Diamond MP, Cartwright PS. Transvaginal sonography of ectopic pregnancy. In: Fleischer AC, Manning F, Jeanty P, Romero R, eds. Sonography in Obstetrics and Gynecology : Principles and Practice, ed6. New York: McGraw-Hill,2001:113. Sherer DM, Manning FA. First trimester nuchal translucency screening for fetal aneuploidy. In: Fleischer AC, Manning F, Jeanty P, Romero R, eds. Sonography in Obstetrics and Gynecology : Principles and Practice, ed6. New York: McGraw-Hill,2001:89.

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THANK YOU