2nd and 3rd Trimester

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2nd and 3rd Trimester

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Sono 202 : 

Sono 202 Normal Sonographic Anatomy in the 2nd and 3rd Trimester

Protocol for OB Scan : 

Protocol for OB Scan Fetal viability Fetal lie Number of fetuses AFI (after 28 weeks) Placenta placement Cervical length Fetal age BPD, HC, FL, AC (x 3)

Protocol Continued : 

Protocol Continued Evaluate maternal uterus, ovaries, adnexa Anatomic survey Anatomy to include: head anatomy, spine, stomach, bladder, kidneys, diaphragm, 4 chamber heart, outflow tracts, nose/lips, extremities.

Slide 4: 

The EDC is the due date (estimated date of containment) Remember 40 weeks + 2 weeks The key part to remember is ESTIMATE!

Trimesters : 

Trimesters 1st trimester is 1-12 weeks 2nd trimester is 13- 27 weeks 3rd trimester is 28-40 weeks

Nagele’s Rule : 

Nagele’s Rule EDC= LMP – 3 months + 7 days LMP= EDC + 3 months – 7 days

Gravida/Para : 

Gravida/Para Gravida means- # of pregnancies Para means-viable birth (more than 20wks or over 500 grams at delivery) Often listed as GP0000 Always assess fetal viability first and fetal head then begin the study.

Fetal Presentation : 

Fetal Presentation Fetal lie is in relation to maternal long axis Transverse lie is perpendicular to mother’s long axis Vertex is- head down Breech is- head up

Breech : 

Breech Frank breech means flexion of hips and extension of knees Complete breech means flexion of hips/knees Incomplete breech means intermediate deflexion of one hip and knee (single or double footling)

Fetal Lie : 

Fetal Lie

Fetal Lie : 

Fetal Lie

Fetal Lie : 

Fetal Lie

Fetal Lie : 

Fetal Lie

Fetal Lie : 

Fetal Lie

Maternal Anatomy : 

Maternal Anatomy Check uterus, ovaries, adnexa, and cul-de-sac in longitudinal and transverse planes. Measure cervical length from internal os to external os.

Cervical Length : 

Cervical Length

Uterus : 

Uterus

Ovaries : 

Ovaries

Measurements : 

Measurements

BPD/HC : 

BPD/HC

Humerus Length : 

Humerus Length

AC : 

AC

FL : 

FL

Cranium : 

Cranium May appear cystic or hypoechoic due to high water content. Be sure to check skull contour/shape. The interhemispheric fissure divides the brain in half (also called the falx cerebri or falx line)

Ventricular System : 

Ventricular System Consists of lateral, 3rd and 4th ventricle. Lateral ventricles flow through foramen of Monro into the 3rd ventricle, Fluid then travels through the Aquaduct of Sylvius into the 4th ventricle (foramen of Luschka is in the 4th ventricle). From there it flows through the foramen of Magendie to the spinal canal.

Ventricles : 

Ventricles

Choroid plexus : 

Choroid plexus Glomus should fill the ventricle. Shouldn’t dangle or float. Normal ventricle should be less than 10 mm.

Ventricles/Choroid Plexus : 

Ventricles/Choroid Plexus

Brain : 

Brain

Brain : 

Brain

Lower Brain : 

Lower Brain

Lower Brain : 

Lower Brain

Cisterna Magna : 

Cisterna Magna Normal size is- < 10 mm Measure from the vermis to the inner skull. Nuchal skin fold is measured in the transverse plane at the level of the CSP, cerebellum, cisterna magna Normal values are 5 mm or less, up to 20 weeks Thickened folds are at risk for aneuploidy.

Cerebellum/Cisterna Magna : 

Cerebellum/Cisterna Magna

Nuchal Fold : 

Nuchal Fold

Vertebral Column : 

Vertebral Column Look at it in all 3 planes. Three ossifications points. Only 2 are seen in the sagittal and coronal plane. “Railway sign” *In transverse, all 3 ossifications are seen. (BEST WAY!) Skin should be visualized covering the spine.

Vertebra : 

Vertebra Lamina, posterior ossification Lamina, posterior ossification Body, centrum, anterior ossification

Spine : 

Spine

Spine : 

Spine

Spine : 

Spine

Spine : 

Spine

Spine : 

Spine

Thorax : 

Thorax Lung size, texture, and location should be assessed. Lungs are more echogenic than liver.

Heart : 

Heart Apex is directed to the left anterior chest. Right ventricle is closest to the anterior chest. The chamber closest to the spine is the left atrium. All of the following should be assessed: Position, presence of both ventricles and equal sized, presence of both atria and equal size, normal septum, normally placed valves, normal rhythm.

Heart : 

Heart Outflow tracts should be assessed if possible. The vessels involved in the LVOT and RVOT are the aorta and pulmonary artery.

4 Chamber View : 

4 Chamber View Spine Foreman Ovale Left Atrium Left Ventricle Right Ventricle Right Atrium

4 Chamber View of Heart : 

4 Chamber View of Heart

Fetal Heart Rate/Rhythm : 

Fetal Heart Rate/Rhythm

LVOT : 

LVOT

RVOT : 

RVOT

Diaphragm : 

Diaphragm Diaphragm separates the thoracic and abdominal cavity. Appears sonographically sonolucent. Stomach should be below the diaphragm.

Diaphragm : 

Diaphragm

Fetal Circulation : 

Fetal Circulation This site is a great animation of the fetal circulation. http://www.indiana.edu/~anat550/cvanim/fetcirc/fetcirc.html

Fetal Circulation : 

Fetal Circulation

Hepatobiliary system and upper Abdomen : 

Hepatobiliary system and upper Abdomen Left lobe is larger because it receives more blood. Don’t mistake gallbladder for portal vein or stomach. Stomach should be seen at > 16 weeks.

Stomach/Liver : 

Stomach/Liver

Urinary System : 

Urinary System Kidneys are seen by the 15 week (Best visualized in transverse to prove 2) Renal pelvis should not measure more than 10 mm by the 20th week. Adrenals are seen by the 20th week. Don’t confuse adrenals with kidneys. If oligohydramnios is seen, it could mean a renal abnormality or Premature Rupture Of Membranes.

Renals : 

Renals

Renals : 

Renals

Renals : 

Renals

Adrenals : 

Adrenals

Genitalia : 

Genitalia Not medically necessary unless you have multiple gestations or if the fetus is at risk for a gender-linked abnormality. Identify bladder first. May be seen as early as 12-16 weeks, but after 20 is better (DON’T GUESS) Males may have a hydrocele.

Female : 

Female

Male : 

Male

Hydrocele : 

Hydrocele

Extremities : 

Extremities Make sure to document both arms and legs. Both hands and feet. Fingers and Toes Club foot should be ruled out.

Extremities : 

Extremities

Extremities : 

Extremities

Extremities : 

Extremities

Extremities : 

Extremities

Umbilical cord : 

Umbilical cord Three vessels in cord (2 arteries, 1 vein) Identify the placenta insertion and insertion into baby. Should be twisted.

Umbilical Cord Insertion : 

Umbilical Cord Insertion

Cord Insertion of Fetus : 

Cord Insertion of Fetus

3 Vessel Cord : 

3 Vessel Cord

Placenta : 

Placenta The role of the placenta is exchange of oxygenated blood and nutrients. Thickness should not exceed 5 cm. Determine its relationship to the cervix. Can be anterior, posterior or lateral. Grading of 0, 1, 2, or 3.

Placenta Grade 0 : 

Placenta Grade 0

Placenta Grade 1 : 

Placenta Grade 1

Placenta Grade 1 : 

Placenta Grade 1

Placenta Grade 2 : 

Placenta Grade 2

Placenta Grade 2 : 

Placenta Grade 2

Placenta Grade 3 : 

Placenta Grade 3

Amniotic Fluid : 

Amniotic Fluid Role of the fluid is to protects fetus, allow it to move freely, maintain pressure. Produced by the umbilical cord, membranes, lung, skin and kidneys. Quantity is directly related to kidney production especially after the 1st trimester. Lung development depends on fluid.

Amniotic Fluid : 

Amniotic Fluid Volume increases up till 34th week. Measure it by the 4 quadrant method. Keep the transducer as perpendicular to the table as possible. Using the maternal umbilicus as the center, look thoroughly in each quadrant. Measure the largest pocket of fluid in each quadrant that doesn’t contain cord. Add all four quadrants together to obtain an amniotic fluid index (AFI) Normal ranges from 10-25cm. (different in every book)

Amniotic Fluid Index : 

Amniotic Fluid Index

Amniotic Fluid : 

Amniotic Fluid

Amniotic Fluid : 

Amniotic Fluid Vernix caseosa is the fatty material and shed skin in amniotic fluid. Looks like “snow” in the amniotic fluid.

Amniotic Fluid : 

Amniotic Fluid

BPP : 

BPP Bio-Physical Profile The fetus develops the ability to do specific things as it matures. First the fetus is able to perform gross body movements. Second the fetus is able to perform fine motor movement. Third the fetus is able to practice breathing.

BPP : 

BPP The biophysical profile assess fetal well-being by looking at whether the fetus is performing these basic functions in a 30 minute period or less. A fetus in distress will begin to stop performing these functions in the reverse order that it began performing them.

BPP : 

BPP Looking for 4 things on ultrasound with BPP. Amniotic Fluid Index – Should be over 10cm by 4 quadrant method. Fetal Breathing – Practicing breathing motions for 15 -20 seconds. Fine Motor Movement – Moving fingers, toes, lips, bending wrist, etc. Gross Motor Movement – Moving body trunk.

BPP : 

BPP Scored on a 0-2 scale (ranging from 0/10 to 8/10 for ultrasound) 0 - meaning not doing activity in 30 minutes 1 - meaning fetus performed activity only once in 30 minutes 2 - meaning fetus performed activity at least 2 times in 30 minutes. Non-stress Test is other part of BPP and would provide the other possible 2 points for a total of 10.

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