My Lecture On Ultrasound Imaging

Ultrasound Diagnostics
December 25, 2011
Ultrasound diagnostics - V.Mythily,JCE
Ultrasound Imaging
Introduction
Ultrasound imaging involves exposing part of the body to high-frequency sound waves to produce pictures of the inside of the body. Ultrasound exams do not use ionizing radiation (as used in x-rays). Because ultrasound images are captured in real-time, they can show the structure and movement of the body's internal organs, as well as blood flowing through blood vessels.
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Ultrasound
Sound waves travelling and being reflected from surfaces at different scale
calcification will reflect waves Fluid will conduct A picture is produced Can apply SONAR principles to determine flow
EXCELLENT for liver, gallbladder, ovaries Cheap and accessible
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Advantages of ultrasound
Measure the reflectivity of tissue to sound waves Can also measure velocity of moving objects, e.g. blood flow (Doppler imaging) No radiation exposure, completely non-invasive and safe Fast Inexpensive Low resolution Medical applications: imaging fetus, heart, and many others
Ultrasound in Imaging
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Physics of Ultrasound
What is Acoustic Wave

Pressure waves that propagate through matter via compression and expansion of the material Generated by compressing and releasing a small volume of tissue Longitudinal wave Particles in the medium move back and force in the same direction that the wave is traveling Shear Wave Particles move at right angles to the direction of the wave
Not used for medical ultrasound imaging

Longitudinal Waves
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Temporal and Length Characteristics of an Ultrasound Pulse
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Dependence of Pulse Length on Wavelength and Frequency
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ENERGY & AMPLITUDE
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Ultrasound Pulse Amplitude, Intensity, and Energy
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The Production of an Echo and Penetrating Pulse at a Tissue Interface
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Acoustic Wave Range
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Velocity of ultrasound
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Attenuation Coefficient
Some typical values of 0 for different substances
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Scattered Signal
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Axial and lateral resolution
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Beam Width and Pulse Diameter Characteristics of Both Unfocused and Focused Transducers
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Schematic of an Ultrasound Imaging System
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Functions of Transducer
Used both as Transmitter And Receiver Transmission mode: converts an oscillating voltage into mechanical vibrations, which causes a series of pressure waves into the body Receiving mode: converts backscattered pressure waves into electrical signals
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Single Crystal Transducer (Probe)
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Single Crystal probe
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Shapes of transducer
Transducers available on a modern imaging system are designed for a wide variety of clinical applications. Transducer groups: bottom right: linear and curved linear arrays; top right:phased arrays; left side: specialty probes including intraoperative, transesophageal, and transvaginalarrays
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The shape of the transducer is adapted to the application: (1) abdominal transducers general purpose; (2) intraoperative transducers; (3) small parts transducers (muscles,tendons, skin, thyroid, breast, scrotum); (4) intrarectal transducer(rectal wall, prostate); (5) intravaginal transducer (uterus, ovaries, pregnancy); (6) infants (abdominal, brain).
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Matching Layer
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Continuous Wave vs Pulsed

Continuous wave (CW) Ultrasound The voltage signal applied to the transducer is a continuous sinusoid signal Pulsed Ultrasound A pulsed signal is introduced (more common), allowing to separate reflected signal from targets at different distances based on time delay
Transducer Array
With a single crystal, manual or mechanical steering of the beam is needed to produce a two-dimensional image Practical systems today use an array of small piezoelectric crystals Allow electronic steering of the beam to optimize the lateral resolution
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Transducer Array
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Transducer Arrays
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Array types
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Pulse Echo Imaging

Transducer is excited for a short period, generating a narrowband short pulse Detects backscattered wave (echo) generated by objects Repeat the above process, with the interval between two input pulses greater than the time for the receiver to receive the echo from the deepest object (2 d_max/c)
Typical Transmit Pulse
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What is the Reflected signal?
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Fresnel & Fraunhofer Zone
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Doppler Imaging
Principles Velocity vs. frequency shift (Doppler Freq) Used for blood flow velocity measurement Stenosis or narrowing of the arteries causes blood flow velocity change Children at risk of stroke have cerebral blood velocities 3-4 times of normal Imaging methods:
Continuous wave (CW) Doppler measurement

Demodulation Time correlation Pulse mode Doppler measurement
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Display Modes
Application of A-Mode
Applications: ophthalmology (eye length, tumors),localization of brain midline, liver cirrhosis, myocardium infarction Frequencies: 2-5 MHz for abdominal, cardiac, brain;515 MHz for ophthalmology, pediatrics, peripheral blood vessels Used in ophthalmology to determine the relative distances between different regions of the eye and can be used to detect corneal detachment High freq is used to produce very high axial resolution Attenuation due to high freq is not a problem as the desired imaging depth is small
M-Mode Display
Display the A-mode signal corresponding to repeated input pulses in separate column of a 2D image, for a fixed transducer position Motion of an object point along the transducer axis (z) is revealed by a bright trace moving up and down across the image Often used to image motion of the heart valves, in conjunction with the ECG
M Mode
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B-Mode Display
Move the transducer in x-direction while its beam is aimed down the z-axis, firing a new pulse after each movement Received signal in each x is displayed in a column Unlike M-mode, different columns corresponding to different lateral position (x) Directly obtain reflectivity distribution of a slice! (blurred though!)
B MODE DISPLAY
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Application of B-Mode
Can be used to study both stationary and moving structures High frame rate is needed to study motion (more later) Directly obtain reflectivity distribution of a slice! (blurred though!) No tomographic measurement and reconstruction is necessary!
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Instrumentation for demodulation based method
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Continuous Doppler method
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Blood velocity measurement
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Normal PW Doppler spectrogram of blood flow through the aortic valve
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(a) Using color Doppler techniques, blood flow within the ventricles can be visualized. This image shows the flow in a normal left ventricle at the beginning of diastole. Red colors represent flow toward the transducer, coming from the left atrium through the mitral valve and into the left ventricle. Blue colors show the blood within the left ventricle flowing away from the transducer toward the aorta. (b) Doppler techniques can be used to acquire the slower, regional velocities of the heart muscle itself. Local velocities in the direction of the transducer are represented in red, and velocities away from the transducer are in blue.
Pulse Mode Doppler Measurement

Use only one transducer Transmits short pulses and receives backscattered signals a number of times Can measure Doppler shifts in a specific depth
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Colour doppler image
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Sample image of pulsed wave Doppler showing arterial flow
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Applications of Ultrasound
Ultrasound Imaging involves exposing part of the body to high-frequency sound waves to produce pictures of the inside of the body. Ultrasound exams do not use ionizing radiation (as used in xrays). Because ultrasound images are captured in real-time, they can show the structure and movement of the body's internal organs, as well as blood flowing through blood vessels.
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Digital Ultrasound Imaging
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There are two basic equations used in ultrasonic imaging. One relates the (one-way) distance d of an object that caused an echo from the transducer to the (round-trip) time delay t and speed of sound in the medium
The other equation relates the received signal strength S(t) to the transmitted signal T(t), the transducers properties B(t), the attenuation of the signal path to and from the scatterer A(t), and the strength of the scatterer (t): S(t )=T(t )B(t )A(t )(t )
Example of M-mode imaging of a heart at two points during the cardiac cycle. Upper panel shows heart during diastole (relaxation) with a line of sight through it and the corresponding A-line converted to an M-line.
The lower panel shows the same heart during systole (contraction) and the A- and M-lines. Note the thicker walls and smaller ventricular cross-section during systole.
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Transesophageal transducer for cardiac imaging. This transducer is swallowed by the patient and makes ultrasound images of the heart from within the esophagus.
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Concentric Left ventricle hypertrophy
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Doppler color flow image of a patient with mitral regurgitation in the left atrium. The bright green color corresponds to high velocities in mixed directions because of very turbulent flow leaking through a small hole in the mitral valve.
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Transesophageal echocardiographic (TEE) image showing an atrial septal defect (ASD)
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EchoEncephalography
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(a) Normal cranial ultrasound (b) Fluidfilled cerebral cavities on both sides as a result of an intraventricular hemorrhage.
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Abdominal ultrasound Imaging
Abdominal ultrasound is a scanning technique used to image the interior of the abdomen
Ultrasound
Sound waves travelling and being reflected from surfaces at diffirent scale
calcification will reflect waves Fluid will conduct A picture is produced Can apply SONAR principles to determine flow
EXCELLENT for liver, gallbladder, ovaries Cheap and accessible

To look for abnormalities that may be present in the abdominal organs, such as masses or enlargements in the spleen or liver To evaluate the nature of a mass that may have been felt by the examining doctor or seen on other radiologic exams To evaluate for enlargement of the liver or spleen To determine the cause of kidney failure, such as kidney disease, obstruction of the kidneys or blockage of the kidneys' blood vessels . To evaluate for the cause of jaundice or abnormal liver enzymes To look for enlargements (aneurysms) of the abdominal aorta To evaluate problems with blood flow in the vessels of the various abdominal organs
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Ultrasound liver images
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Ultrasound is used to help diagnose a variety of conditions, such as:

abdominal pain or distention. abnormal liver function. enlarged abdominal organ. stones in the gallbladder or kidney. an aneurysm in the aorta.
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Abdominal ultrasound imaging is performed to evaluate the:

kidneys liver gallbladder pancreas spleen abdominal aorta and other blood vessels of the abdomen
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Diagnostic examination of the liver

Normal liver
liver parenchyma is visualised as a uniform pattern of a medium-strength echoes, stronger than spleen and renal, but weaker than pancreas parenchyma
liver size - enlarged ,shrinking diffuse liver diseases

more echogenic
cirrhosis, fatty infiltration
not specific - biopsy needed!

Diagnostic examination of the liver

focal liver diseases
benign / malignant cystic, solid, mixed focal lesions primary / secondary not specific - ultrasonically guided percutaneous puncture/biopsy
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Ultrasound image of thoracic base: (a) normal lung, (b) pleural effusion.
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Abnormal Axillary Lymph Nodes
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Pancreas
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Ultrasound liver image
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Liver
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Gall Bladder
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Gall bladder images
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Ultrasound imaging
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The above ultrasound images show the normal anatomy of the gall bladder taken from different angles of the transducer during sonography. The parts seen here are the fundus, body, neck and the cystic duct. Note the close relation of the cystic duct to the portal vein.
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Gall bladder carcinoma

This a middle aged male patient who presented with constipation. Ultrasound images of the liver and gall bladder reveal an ominous mass infiltrating the gall bladder wall with invasion of the right lobe of liver. There is also a large calculus seen in the gall bladder. These ultrasound images are diagnostic of gall bladder carcinoma
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Ultrasound image of a double gall bladder
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IHBR-intrahepatic biliary tree dilatation due to gall bladder stone

Mirizzi syndrome - Stone at the neck of the gall bladder
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Ultrasound imaging of gall bladder calculi
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Liver image with nodules showing liver carcinoma
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Ultrasound images of kidney
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Anatomy of kidney
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Longitudinal image of normal Right Kidney
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Ultrasound Imaging of Kidney
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Transverse image of Normal Right Kidney

Note the position of the gallbladder (GB) next to the liver and inferior vena cava (IVC).
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Transverse view of renal blood supply of the Right Kidney (Color Doppler shows hilum vessels in red and blue).
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Dilated ureter seen below bladder (transverse view )
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Hydronephrosis
Hydronephrosis is distension and dilation of the renal pelvis calyces, usually caused by obstruction of the free flow of urine from the kidney, leading to progressive atrophy of the kidney.
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Overview of degrees of hydronephrosis
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Kidney with Mild Hydronephrosis
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Kidney with Moderate Hydronephrosis
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Kidney with severe hydronephrosis Note that the shape of the kidney is completely obliterated by the severe hydronephrosis
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Kidney Stone
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Kidney stones
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US image with kidney cyst
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Renal cysts
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Polycystic kidney
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Image taken after renal transplantation
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Renal transplant in longitudinal view located in the pelvic fossa. Figure shows a small intra-parenchymal bleed after a biopsy (blue area).
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US image with renal stent
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Information of foley(flexible catheter)
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Fungating bladder mass
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Other organs
Fluid surrounding the spleen can be investigated
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Attenuation caused by Gall stones
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Ultrasound in Gynecology
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3-D imaging of Fetal face
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A cross section through the fetal head at 12 weeks
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Ultrasound has uses in many areas of gynecology to assess the pelvic organs. Sound is easily transmitted through water. For this reason a full bladder can help with visualization of the pelvic organs when looking through the abdominal wall. Often a more accurate image can be obtained by placing the ultrasound transducer into the vagina - an empty bladder is better for this type of examination. Transducer in the vagina will also give closer proximity to the pelvic organs and give clearer and more detailed images.
Reasons why a gynecological scan may be requested include:

Abnormal bleeding Abdominal pain To Assess a lump that has been found Exclude ovarian cancer Infertility Sonohysterography HyCoSy
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Abnormal bleeding
Menstrual bleeding usually occurs each 28 days. Sometimes the cycle may be longer or shorter than 28 days. At times the cycle may be very irregular, or bleeding may become very heavy. This may just be due to a temporary hormonal imbalance, but it can be due to problems in the uterus or the ovaries.
Endometrial polyp
A small growth of the tissue of the lining of the uterus (endometrial polyp) can occur. These can cause periods to be heavier or to have bleeding at unusual times. Mostly these are not cancerous, but occasionally if left alone for a long time they can become cancerous. Polyps can usually be seen on transvaginal ultrasound, but a technique called sonohysterography can be used to make them easier to see.
Endometrium polyp
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Endometrium polyp
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Fibroids
Fibroids are a growth arising from the muscle of the uterus. They can press on the lining of the uterus (endometrium) and cause irregular bleeding or heavy periods. It is very rare for a fibroid to become cancerous
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Fibroids in the uterus
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Photography of huge fibroid
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A fibroid in the uterus
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Ultrasound image of a fibroid
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Image of a fibroid
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Image of fibroid distorting the endometrium
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Polycystic ovarian syndrome

The ovaries produce hormones which control the uterus. Some conditions can alter the hormonal production and stop the ovaries producing an egg (ovulation) each month. An example of this is polycystic ovarian syndrome
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Image of the polycystic ovarian syndrome
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Image of the polycystic ovary
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Assessment of pelvic lumps

There are many different causes for a lump that has been found. The uterus can be enlarged by a pregnancy that has not yet been diagnosed. The uterine wall can contain fibroids, which are growths of the muscular tissue. They can be single or multiple and the sizes can vary enormously.
During the reproductive years, the ovaries are continually going through the cycle of egg production. This involves the formation and resolution of a cyst. Sometimes this process does not function perfectly and the cyst may become very large. Ovarian cancer can also produce a lump. Ultrasound can help to find it at an early stage, when treatment may be able to get a good long term result
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Image of an ovarian cyst
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Abdominal pain
Pain can be caused by any organ in the abdomen and it may be difficult without tests like ultrasound to establish the exact cause. Discomfort with the onset of a period is common. Sometimes a problem like endometriosis can cause severe pain and cysts can be seen. These cysts are often on or near the ovary. The ovaries produce a cyst each month. These usually resolve around the time of the next period, but sometimes they can become larger and tender. They can also cause abdominal pain
Endometriosis
Endometrial-like cells appear and flourish in areas outside the uterine cavity
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US of ovary
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Infertility
Ultrasound of the pelvis is important to analyze the cause of infertility. Ovarian follicles are the basic units of female reproductive biology, each of which is composed of roughly spherical aggregations of cells found in the ovary. They contain single immature egg.
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The development of the follicles in the ovary can be seen and give information about egg production. The lining of the uterus will respond to the hormones and will have a specific appearance at different stages of the menstrual cycle. The internal structure of the uterus (endometrial cavity) can be better assessed by sonohysterography and the fallopian tubes can be better assessed by hy-co-sy .
Sonohysterography
Sonohysterography is a new technique developed to better image the uterine cavity. It uses an infusion of sterile saline through a soft plastic catheter placed in the cervix in conjunction with transvaginal ultrasound. The saline infusion distends the uterine cavity and provides an excellent contrast to the lining, giving improved visualization of uterine and endometrial pathology.
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Sonohysterography
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Why is it performed? The main indications for this procedure include: Abnormal uterine bleeding both pre and post menopausal Investigation of infertility and recurrent miscarriage Suggestion of a mass in the endometrial cavity on ultrasound
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Uterine Abnormalities Examples of this include endometrial polyps (a growth of the lining of the uterus), uterine fibroids (a growth of the muscular tissue of the uterus), blockage of the fallopian tubes and polycystic changes in the ovary. Congenital uterine abnormalities such as a bicornuate uterus (shown here) can interfere with the implantation of embryos and so reduce the chance of pregnancy.
A bicornuate uterus or bicornate uterus, commonly referred to as a "heart-shaped" uterus, is a type of uterine malformation where two "horns" form at the upper part of the uterus.
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Bicarnote uterus
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Cancer screening
The ovary is one of many organs in the body that can develop a cancer. This usually occurs after the menopause and is more likely if there is a history of ovarian cancer.
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Symptoms from ovarian cancer tend to occur quite late in the disease when it is difficult to treat. Ultrasound has been able to detect early cancers, while they are still small and have not caused any symptoms. Growth of a tumour requires the formation of new blood vessels. Colour doppler ultrasound can show these vessels and the blood flowing within them.
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Ovarian Cancer Screening

This examination helps identify if the ovaries are enlarged or if new blood vessels have appeared to supply a growing tumour. Regular screening is recommended for those at increased risk (e.g. over 50 years of age) as ovarian cancer is the fourth most common cause of death from cancer in women.
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HyCoSy
Hysterosalpingo-contrast-sonography (HyCoSy) is a transvaginal ultrasound technique in which a solution of galactose and 1% palmitic acid (Levovist) - or a mixture of air and saline - is infused into the uterine cavity and observed to flow along the Fallopian tubes to assess tubal patency. The bright echoes generated by the Levovist makes tubal visualization easier, which is further improved by the addition of colour Doppler imaging
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Obstetrical ultrasound
Obstetrical ultrasound
A Doppler ultrasound study may be part of an obstetrical ultrasound examination Obstetrical ultrasound provides pictures of an embryo or fetus within a woman's uterus, as well as the mother's uterus and ovaries.
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Doppler ultrasound is a special ultrasound technique that evaluates blood flow through a blood vessel, including the body's major arteries and veins in the abdomen, arms, legs and neck. During an obstetrical ultrasound the examiner may evaluate blood flow in the umbilical cord or may in some cases assess blood flow in the fetus or placenta.
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Obstetrical ultrasound is a useful clinical test to:

establish the presence of a living embryo/fetus estimate the age of the pregnancy. diagnose congenital abnormalities of the fetus. evaluate the position of the fetus. evaluate the position of the placenta. determine if there are multiple pregnancies. determine the amount of amniotic fluid around the baby. check for opening or shortening of the cervix or mouth of the womb. assess fetal growth. assess fetal well-being
Why and when?

Ultrasound scan is currently considered to be a safe, non-invasive, accurate and cost-effective investigation in the fetus. It has progressively become an indispensible obstetric tool and plays an important role in the care of every pregnant woman.
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Day 1: Fertilisation Day 2: Cleavage Day 3: Compaction Day 4: Differentiation Day 5: Cavitation Day 12: Bilaminardisc formation Day 9: cell massdifferentiation Day 7: Implantation Day 6: Zona hatching Day 12: Mesoderm formation Day 18: Mesoderm spreading Day 23: Amniotic sac enlargement
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Use of ultrasound in obstetrics

1. Diagnosis and confirmation of early pregnancy.
The gestational sac can be visualized as early as four and a half weeks of gestation and the yolk sac at about five weeks. The embryo can be observed and measured by about five and a half weeks. Ultrasound can also very importantly confirm the site of the pregnancy is within the cavity of the uterus.
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2.Vaginal bleeding in early pregnancy.

The viability of the fetus can be documented in the presence of vaginal bleeding in early pregnancy. A visible heartbeat could be seen and detectable by pulsed doppler ultrasound by about 6 weeks and is usually clearly depictable by 7 weeks.
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If this is observed, the probability of a continued pregnancy is better than 95 percent. Missed abortions and blighted ovum will usually give typical pictures of a deformed gestational sac and absence of fetal poles or heart beat. Fetal heart rate tends to vary with gestational age in the very early parts of pregnancy. Normal heart rate at 6 weeks is around 90-110 beats per minute (bpm) and at 9 weeks is 140-170 bpm. At 5-8 weeks a bradycardia (less than 90 bpm) is associated with a high risk of miscarriage.
Many women do not ovulate at around day 14, so findings after a single scan should always be interpreted with caution. The diagnosis of missed abortion is usually made by serial ultrasound scans demonstrating lack of gestational development. For example, if ultrasound scan demonstrates a 7mm embryo but cannot demonstrable a clearcut heartbeat, a missed abortion may be diagnosed. In such cases, it is reasonable to repeat the ultrasound scan in 7-10 days to avoid any error.
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The timing of a positive pregnancy test may also be helpful in this regard to assess the possible dates of conception. A positive pregnancy test 3 weeks previously for example, would indicate a gestational age of at least 7 weeks. Such information would be useful against the interpretation of the scans. In the presence of first trimester bleeding, ultrasonography is also indispensible in the early diagnosis of ectopic pregnancies and molar pregnancies.
3. Determination of gestational age and assessment of fetal size.

Fetal body measurements reflect the gestational age of the fetus. This is particularly true in early gestation. In patients with uncertain last menstrual periods, such measurements must be made as early as possible in pregnancy to arrive at a correct dating for the patient. In the latter part of pregnancy measuring body parameters will allow assessment of the size and growth of the fetus and will greatly assist in the diagnosis and management of intrauterine growth retardation (IUGR).
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4. The Crown-rump length (CRL)

This measurement can be made between 7 to 13 weeks and gives very accurate estimation of the gestational age. Dating with the CRL can be within 3-4 days of the last menstrual period. (Table) An important point to note is that when the due date has been set by an accurately measured CRL, it should not be changed by a subsequent scan. For example, if another scan done 6 or 8 weeks later says that one should have a new due date which is further away, one should not normally change the date but should rather interpret the finding as that the baby is not growing at the expected rate.
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The Biparietal diameter (BPD)

The diameter between the 2 sides of the head. This is measured after 13 weeks. It increases from about 2.4 cm at 13 weeks to about 9.5 cm at term. Different babies of the same weight can have different head size, therefore dating in the later part of pregnancy is generally considered unreliableDating using the BPD should be done as early as is feasible.
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The Femur length (FL)

Measures the longest bone in the body and reflects the longitudinal growth of the fetus. Its usefulness is similar to the BPD. It increases from about 1.5 cm at 14 weeks to about 7.8 cm at term. Similar to the BPD, dating using the FL should be done as early as is feasible.
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The Abdominal circumference (AC)

The single most important measurement to make in late pregnancy. It reflects more of fetal size and weight rather than age. Serial measurements are useful in monitoring growth of the fetus. AC measurements should not be used for dating a fetus.
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4. Diagnosis of fetal malformation.

Many structural abnormalities in the fetus can be reliably diagnosed by an ultrasound scan, and these can usually be made before 20 weeks. Common examples include hydrocephalus, anencephaly, myelomeningocoele, achondroplasia and other dwarfism, spina bifida, exomphalos, Gastroschisis, duodenal atresia and fetal hydrops. With more recent equipment, conditions such as cleft lips/ palate and congenital cardiac abnormalities are more readily diagnosed and at an earlier gestational age.
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First trimester ultrasonic 'soft' markers for chromosomal abnormalities such as the absence of fetal nasal bone, an increased fetal nuchal translucency (the area at the back of the neck) are now in common use to enable detection of Down syndrome fetuses
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5. Placental localization.
Ultrasonography has become indispensible in the localization of the site of the placenta and determining its lower edges, thus making a diagnosis or an exclusion of placenta previa. Other placental abnormalities in conditions such as diabetes, fetal hydrops, Rh isoimmunization and severe intrauterine growth retardation can also be assessed.
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6. Multiple pregnancies.
In this situation, ultrasonography is invaluable in determining the number of fetuses, the chorionicity, fetal presentations, evidence of growth retardation and fetal anomaly, the presence of placenta previa, and any suggestion of twin-to-twin transfusion.
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Indications
Dating of pregnancy Size vs dates discrepancy; multiple gestation determination *(1 Trimester)* Vaginal bleeding Abdominal or pelvic pain: rule out ectopic pregnancy/ torsion/ heterotopic pregnancy/ ovarian cyst ***Not credentialed to
st
do***
To confirm viability
Pregnancy Dating with 1st trimester ultrasound

The only utility for routine ultrasound as determined by the RADIUS study Early dating is the most accurate (+/- 5-7d or 8%) Better defines timing for later testing and interventions
Triple/Quad test Tocolysis/Steroids
Reduces the postdates

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Measurements
Mean Sac Diameter
Should be measured in 3 dimensions May be all that is visible at the discriminatory zone; IUP best confirmed with some fetal element, such as a yolk sac
Embryonic Crown-Rump Length (CRL)

Measurement of a CRL with fetal cardiac activity is the best measurement for dating purposes
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Typical Measurements
There are tables for gestational age based on:
Gestational Sac Measurement Crown-Rump Length
determining
All of the U/S machines at NHP contain software which perform these calculations. The measurements will trigger the gestational age determination.
Determination of Gestational Age

Gestational Age (weeks) Sac Size (mm) 3 6 14 27 29 8 15 CRL (mm)
4 5 6 7 8
9
10 11 12 13
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31 41 51 71
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The Early Gestational Sac
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Early Embryo
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The Crown-Rump Length
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Late 1st Trimester10 week
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Early Pregnancy Failure

Failure of appropriate interval growth by u/s of embryo Fetal pole/yolk sac should be seen by the time the MSD is 20 mm (not as accurate as FCA though) Fetal Cardiac Activity should be seen by the time the CRL is 4mm (5mm per AIUM)
If not, may repeat the u/s in one week
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Lab and Ultrasound

Discriminatory Zonethe quant -hCG level at which one would expect to be able to identify an intrauterine pregnancy For vaginal sonography1200-1500 (1000-2000 per ACOG) For abdominal sonography3000-4000 If the quant -hCG is at or above the discriminatory zone, AND no IUP can be identified, the pregnancy may be ectopic
Rapidly Rising Quant HCG

Identifying multifetal gestation Identifying gestational trophoblastic disease
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Multifetal Gestation
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Other applications
Evaluation of gynecologic Uterusposition, fibroids
Adnexaemasses, corpus luteum
structures
Early screen for chromosomal anomalies

Nuchal translucency measurements
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What Measurement is the most accurate for ultrasound dating?

Crown Rump Length Up to the 12th week of life.
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In what order do fetal structures appear?

Gestational sac 4 to 5 weeks Yolk sac 5 to 6 weeks
Fetal pole - 6 to 7 weeks Cardiac Activity - 6 to 7 weeks.
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What is Nuchal Translucency?

Normal fetuses accumulate fluid under the skin behind the head and neck between 9 and 14 weeks of pregnancy. If there is excess fluid it has been associated with chromosome abnormalities such as Down syndrome.
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A simple ultrasound performed between 11 and 13 weeks can measure this fluid (Nuchal Translucency). The gestational age of the fetus can be established by measuring from head to bottom - crown rump length ( CRL ). The NT tends to be larger in a fetus affected by a chromosome abnormality and it can be compared with what is expected for a fetus of the same size.
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Other benefits of an 11 - 13 week scan

Accurate dating of the pregnancy Diagnosis of multiple pregnancy Detection of early pregnancy failure Assessment of early fetal structures (such as the brain, limbs and abdominal wall) and detection of some of the more severe structural abnormalities
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Advantages
Most ultrasound scanning is noninvasive (no needles or injections) and is usually painless. Ultrasound is widely available, easy-to-use and less expensive than other imaging methods. Ultrasound imaging does not use any ionizing radiation. Ultrasound scanning gives a clear picture of soft tissues that do not show up well on x-ray images. Ultrasound is the preferred imaging modality for the diagnosis and monitoring of pregnant women and their unborn babies. Ultrasound has been used to evaluate pregnancy for nearly four decades and there has been no evidence of harm to the patient, embryo or fetus. Nevertheless, ultrasound should be performed only when medically indicated. Ultrasound allows the doctor to see inside the uterus and provides much information about the pregnancy. Risks For standard diagnostic ultrasound there are no known harmful effects on humans.

My Lecture On Ultrasound Imaging

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Ultrasound Diagnostics

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Ultrasound diagnostics - V.Mythily,JCE

EXCELLENT for liver, gallbladder, ovaries Cheap and accessible

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Ultrasound diagnostics - V.Mythily,JCE

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Ultrasound diagnostics - V.Mythily,JCE

What is Acoustic Wave

Not used for medical ultrasound imaging

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Ultrasound diagnostics - V.Mythily,JCE

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Temporal and Length Characteristics of an Ultrasound Pulse

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Ultrasound diagnostics - V.Mythily,JCE

Dependence of Pulse Length on Wavelength and Frequency

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Ultrasound diagnostics - V.Mythily,JCE

ENERGY & AMPLITUDE

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Ultrasound diagnostics - V.Mythily,JCE

Ultrasound Pulse Amplitude, Intensity, and Energy

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Ultrasound diagnostics - V.Mythily,JCE

The Production of an Echo and Penetrating Pulse at a Tissue Interface

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Ultrasound diagnostics - V.Mythily,JCE

Acoustic Wave Range

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Ultrasound diagnostics - V.Mythily,JCE

December 25, 2011

Ultrasound diagnostics - V.Mythily,JCE

December 25, 2011

Ultrasound diagnostics - V.Mythily,JCE

December 25, 2011

Ultrasound diagnostics - V.Mythily,JCE

December 25, 2011

Ultrasound diagnostics - V.Mythily,JCE

December 25, 2011

Ultrasound diagnostics - V.Mythily,JCE

December 25, 2011

Ultrasound diagnostics - V.Mythily,JCE

December 25, 2011

Ultrasound diagnostics - V.Mythily,JCE

Axial and lateral resolution

December 25, 2011

Ultrasound diagnostics - V.Mythily,JCE

December 25, 2011

Ultrasound diagnostics - V.Mythily,JCE

Schematic of an Ultrasound Imaging System

December 25, 2011

Ultrasound diagnostics - V.Mythily,JCE

December 25, 2011

Ultrasound diagnostics - V.Mythily,JCE

Single Crystal Transducer (Probe)

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Ultrasound diagnostics - V.Mythily,JCE

Single Crystal probe

December 25, 2011

Ultrasound diagnostics - V.Mythily,JCE