Ultrasonography in

Pregnancy
Clinical management guidelines for
Obstetrician-Gynecologists
Number 58, December 2004
Background
Instrumentation
: real-time, 2-dimensional image
sector or convex array abdominal transducer
3~7 MHz (vaginal transducer: 5~9 MHz)
linear and circumference measurement
store the images
: thermal index- tissue temperature
mechanical index- microscopic gas bubbles
: 3-dimension advantage
 Type of examinations
; standard
limited
specialized
( during the second & third trimesters)

-first trimester obstetric ultrasonography is

distinct from this
<Standard Examination>
: fetal presentation, amniotic fluid volume
cardiac activity, placental position, fetal biometry
anatomic survey, and uterus & adnexa
: after 16~20 weeks of gestation

: can be difficult to visualize because of fetal size,

position, movement, abdominal scar, increased
maternal wall thickness
 Head and neck Abdomen
cerebellum stomach (presence,size,situs)
choroid plexus kidneys, bladder
cisterna magna umbilical cord vessel number
lateral cerebral ventricles & insertion site into fetal abd.
midline falx Spine
Chest C-,T-,L-,S-spine
cadiac exam: 4-chamber Extremities
if feasible: both outflow tract legs ans arms
Sex
evaluation of multiple gestation
<Limited Examination>
: when a specific question requires investigations
ex) fetal heart activity in a bleeding patient
fetal presentation in a laboring patient
<Specialized Examination>
: anomaly is suspected on the basis of history,
biochemical abnormalities or clinical evaluation,
or suspicious results from standard, limited exam

: fetal Doppler, biophysical profile, fetal echocardio

-graphy, additional biometric studies

: by an operator with experience and expertise

 <First-Trimester Ultrasonography>
Indications

: the presence of IUP

suspected ectopic pregnancy and H-mole
the cause of vaginal bleeding
pelvic pain, estimate gestational age
evaluate multiple gestations
cardiac activity , pelvic mass, uterine abnormality
villus sampling, embryo transfer, IUD remove
 Imaging Parameters
: transvaginal, transperineal > transabdominal
1. presence of a G-sac in uterus or adnexa
evaluates a yolk sac or embryo
CRL check (gestational age, more accurate)

if, without these finding- R/O ectopic pregnancy

2. cardiac activity when embryo > 5 mm

3. fetal number (amnionicity, chorionicity)

4. uterus presence, location, size of leiomyoma

adnexal masses
fluid collection of PCDS
 <Second-Trimester Ultrasonography>
Indication

: estimation of gestational age

evaluation of fetal growth
vaginal bleeding
incompetent cervix
abdominal and pelvic pain
fetal presentation
multiple gestation
amniocentesis
uterine size
pelvic mass
H-mole
cervical cerclage placement
ectopic pregnancy
fetal death
uterine abnormality
biophysical evaluation
polyhydramnios or oligohysramnios
abruptio placentae
fetal weight, presentation in preterm labor
abnormal serum screening value
follow up fetal anomaly
placeta previa
previous congenital anomaly
fetal condition
 Imaging Parameters
1. fetal cardiac activity (abnormal rate or rhythm)
fetal number (chorionicity, amnionicity, size)
AFV (increased, decreased) genitalia

2. qualitative or semiqualitative AFV

(amniotic fluid index, deepest pocket)

3. placenta (location, appearance, relationship to

the internal cervical os)
umbilical cord vessel number
4. assess gestational age by BPD, AC, FL
fetal growth abnormality, IUGR, macrosomia
BPD- thalami and cavum septi pellicidi level
outer edge~ inner edge
head circumference (more reliable)
head circumference- outer margin of calvarium
FL- after 14 weeks
accurately femoral diaphysis length
AC-umbilical vein, portal sinus, stomach level
at the skin line
estimate fetal weight (IUGR, macrosomia)
5. Interval measurement shoud be evaluated
no less than 2 weeks

6. maternal uterus and both adnexa

(leiomyomata, adnexal masses)
not possible to image the ovaries
 Ultrasound Facility accreditation
: physician- familiar with the anatomy, physiology,
and pathophysiology of the pelvis,
the pregnant uterus, and the fetus
: undrego specific training
regularly review, update their expertise

: physician are responsible for the quality and

accuracy of ultrasound examinations performed
in their names
 Documentation
: appropriate documentation of fetal biometry,
maternal and fetal anatomy
clinical assessment & decision making

: use preprinted template (biometry & anatomy)

: image stere- thermal paper

videotape
 Quality control, Performance improvement, safety,
and Patient education
: quality control- careful recordkeeping
reliable archival of report & image
clinical correlation with outcome
: transducer- microbial transmission
(transabdominal- wiping)
(endovaginal- cover)
: practitioner- update and review their skill
counseled the limitation of ultrasound
Clinical Consideration and
Recommendations
How safe is ultrasonography for the fetus?
: safe but, cannot be completely innocuous
: when there is a valid medical indication
the lowest possible ultrasonic exposure setting
casual use should be avoided

: physical effect- mechanical vibration

increased tissue temperature
 Should all patients be offered ultrasonography?
: for example, 90% of fetal anomaly are born to
no risk mother
: detection rate- 16~85%

: not obligated to perform ultrasonography in low

risk or no indication
 What gestational age represents the optimal time
for an obstetric ultrasound examination?
: 16~20 weeks
: if first trimester- ovulation induction
reproductive technology
bleeding, hyperemesis
previous ectopic preg
abdominal pain, aneuploidy
 How may ultrasonography be used to detect
chromosomally abnormal fetuses in the second
trimester in the women at high risk?
: be targeted to detect fetal aneuploidy
(minor anatomic features)
: advanced age, multiple marker screening
: no randomized controlled trial
-evidence is insufficient to support or refute
the general use of a specialized ultrasound
examination to evaluate the entire at risk
obstetric population
 How is ultrasonography used to detect disturbance
in fetal growth?

: intrauterine growth restriction

: macrosomia
<Intrauterine growth restriction>
: multitude of etiologies
depending on the etiology, time of onset,
severity of the growth restriction

: <10th percentile (<5th or <3rd )

10% of infants in any population
not pathologically but familial & ethnic
: abdominal circumference, head circumference,
biparietal diameter, femur length
caculates on the basis of formulas

: IUGR suspected serial measurements of fetal

biometric parameters detailed ultrasound
survey confirm diagnosis & severity

: amniotic fluid volume

-oligohydramnios IURG (77~83%)
: Doppler velocimetry (umbilical arteries)
-not useful as a screening
useful in diagnosis & fetal evaluation

: identification of IUGR
-by recording growth velocity (2~4 weeks apart)
<Macrosomia>
: variability of the estimate (plus/minus 16~20%)
most formulas- greater error
(ex. >4,500g 12.6% , <4,500g 8.4%)
: accuracy of the ultrasound estimation
-sensitivity 22~44%
specificity 99%
positive predictive value 30~44%
negative predictive value 97~99%
Conclusions
Ultrasound examination
: accurate method of gestational age (1st half)
fetal number ,viability, placental location
Diagnose major fetal anomalies
Diagnosis of fetal growth abnormalities
Safe for the fetus when used appropriately
Specific indication are the best basis for the use
of ultrasonography in pregnancy
Optimal timing for single ultrasound examination
: 16~20 weeks
Summary of Recommendations
Serial ultrasonograms to determine the rate of growth
every 2~4weeks
Casual use of ultrasonography should be avoided
Before examination, counseled the limitation of
ultrasonography for diagnosis