1

Normal Uterine Size: By ultrasound, the normal postmenarchal nulliparous uterus is 5-8 cm in length, 1.5-3 cm thick, 2.5-5 cm. wide. Myometrium: The normal myometrium is hypoechoic, homogeneous, and reasonably well demarcated from the endometrial echos. Endometrial Structure: The endometrium consists of a constant basal layer (basalis), and a cycling functional layer (functionalis). The Functional layer includes a thin compactum layer and a thick spongiosum layer. Name of phase menstrual phase follicular phase (also known as proliferative phase) ovulation (not a phase, but an event dividing phases) luteal phase (also known as secretory phase) Days 1-4 4-14 14 15-26 Gestational Sac first appears in the substance of the decidua (intradecidual) at 4.5 weeks, and should be seen in virtually all normal 5 week intrauterine pregnancies. The yolk sac is a definite evidence of a true gestational sac, first seen at 5 weeks. It is a landmark to the early embryo, which develops along it's outer margin . Yolk sac should be seen when sac is 8-10mm. MSD by vaginal probe, or 20 mm. MSD by abdominal probe. By vaginal probe high resolution scanning the embryo is first seen between 5.7-6.1 weeks, with heartbeat appearing at 6.2 weeks. Small normal embryos may not have a heartbeat. Embryo should be seen by High resolution scan at 18mm MSD, or 25 mm MSD by abdominal scan. Anembryonic Gestation (Blighted Ovum) By High Resolution Vaginal Scanning a sac >13 mm MSD (Mean Sac Diameter) with no yolk sac is often considered abnormal, but occasional normal pregnancies do not show yolk sac up to 20mm. By Lower Resolution Abdominal Scanning a sac >20 mm. MSD with no yolk sac is abnormal. Vaginal Scanning to improve certainty should then be done. By High Resolution Vaginal Scanning a sac >18 mm. MSD without an embryo is often considered abnormal, however normal sacs up to 20 mm. may show no embryo. By Lower Resolution Abdominal Scanning a sac >25 mm. MSD without an embryo is abnormal. At this sac size, if subsequent Vaginal Scan also negative, anembryonic nature is virtually assured.

ischemic phase (some sources group this 27-28 with secretory phase) Phase menstrual phase proliferative phase secretory phase Days 1-4 4-14 Thickness thin Trilaminar

15-28 thick

2
Associated Findings in threatened Abortion Subchorionic Bleeding : Often visible as endometrial fluid surrounding the external (Decidua Capsularis) aspect of the gestational sac. As long as the placental (Decidua Vera) interface of the gestational sac and decidua remain intact, the pregnancy often continues. From the standpoint of Hemorrhage volume (Estimated from formula Length (cm) X Height (cm) X Depth (cm) X 0.52 = Volume ml), less then 75-200 ml. is often associated with continued development. Slow Heartbeat: Embryonic heart rate < 85 BPM is a negative prognostic sign, but is less reliable in small embryos. Small Sac: When the mean sac diameter (MSD) exceeds Crown Rump Length (CRL) by less then 5 mm., loss rate is 80%, however this "small sac" sign occurs only 2% of the time. Threatened Abortion: Bleeding in the First Trimester. Vaginal bleeding occurs during the first 20 weeks in nearly 25% of clinical pregnancies. Since almost half of these pregnancies will be lost, it is a source of great concern, and a major indication for ultrasound examination. Incomplete Spontaneous Abortion (Embryo Dead): In many cases, the embryo will have already died, persistent chorionic function maintains a positive HCG assay. Expulsion of the sac is often delayed several days, though it may be seen to slowly migrate from the initial fundal location toward the uterine cervix

Obstetrical Ultrasound Measurements Gestational Sac: The first element to be measurable is the gestation sac of the early pregnancy. The gestational sac is measured in three dimensions, and the average, the Mean Sac Diameter (MSD) used for estimating gestational age.It is useful between 5 and 8 menstrual weeks with accuracy of +/- 0.5 week (95% CI). As a rough rule of thumb, the MSD + 30 = Menstrual Age in days. Embryonic Crown-Rump Length The length of the embryo on the longest axis (excluding the yolk sac) constitutes the crown-rump length. This is among the best documented parameters to date the embryo, with accuracy of +/- 3-5 days. As a rough rule of thumb, the CRL + 6.5 = Menstrual Age in Weeks. Biparietal diameter (BPD): The transverse width of the head at it's widest, usually recognized by a symmetric demonstration of the fetal thalmus. We measure from the the leading edge to leading edge of the bones, because this leading interface is most distinct. The BPD best used after 12 weeks. Accuracy is +/- 1.1 week 14-20 weeks, +/- 1.6 weeks 20-26 weeks, +/- 2.4 week 26-30 weeks, and +/- 3-4 weeks after 30 weeks.

Head Circumference a measurement which considers both transverse (BPD) and front to back (APD) will be more accurate. This combined measurement is called the head circumference. A true circumference is not actually measured though. The BPD and APD (anterior/posterior diameter) are measured and the circumference of the resulting oval calculated.

3
If the machine does not calculate Head Circumference, you can do it easily with the formula (APD + BPD)/2 X 3.14 = Head Circumference Femur Length The femur length is a repeatable measurement with accuracy similar to the BPD. It is affected by skeletal dysplasias, but since these are rare, it is a reliable measurement which confirms measurements of the head. It is best measured after 14 weeks. Abdominal circumference The abdominal circumference is another circumference estimate made by averaging the anterior-posterior and transverse diameters times 3.14. It is made at the widest point in the abdomen, through the liver at the level of the left portal vein or stomach. Biophysical Profile Fetal Breathing Movements: Complex Reflex, Sensitive but not Specific, False + in Sleep Fetal Trunk and Extremities Movements: Moderate Complexity, less Sensitive, more specific All pregnancies 26 weeks or more must show motion during routine ultrasound, if not, further evaluation is done, first Acoustic stimulation, and if negative, Formal Biophysical Profile. Fetal Tone: Simple maintenance of flexion "Fetal Position" posture. Relatively insensitive, but ominously specific often for more advanced distress. Amniotic Fluid Volume: Not neural reflex, but a physiologic reflection of urine production and uterine retention. Adenexal Mass Sonographic Findings: 1) Functional cyst smooth, round, anechoic, thin-walled ovarian cyst larger than 2.5 cm. 2) Hemorrhagic cyst - homogeneous internal echoes, fishnet appearance, retracting clots and fibrous strands, and fluid-fluid levels. 3) Cystic teratoma tip of iceberg sign, hyperechoic mass with dark acoustic shadow, and heterogeneous tissues. 4) Endometrioma adnexal cystic mass with diffuse, low-level internal echoes and hyperechoic foci in the wall. 5) Ovarian Torsion - diagnosis rests on ovarian enlargement with normal ovarian volume being up to approximately 15 cc. Other suggestive findings are multiple peripherally based follicles. 6) Ovarian malignancy a solid component to an ovarian lesion is the most significant predictor of malignancy; irregular thick wall and septa > 3mm; Doppler demonstration of central blood flow within a solid component. PID Pelvic inflammatory disease (PID) is caused by sexually transmitted infection, most commonly chlamydia or gonorrhea or both. PID also occurs as a complication of appendicitis, diverticulitis, pelvic abscess, and post-abortion or post-delivery infection. Acutely, patients present with fever, pelvic tenderness, and vaginal discharge. The inflammation commonly becomes chronic and patients present with pelvic mass and dyspareunia. Most cases occur in young, sexually active women, although 1-2% of tubo-ovarian abscesses are reported in postmenopausal women. Sonographic Findings: 1) Pyosalpinx pus-filled, dilated fallopian tube is recognized by the echogenic particulate matter that fills or layers within the tube. 2) Tubo-ovarian complex dilated fallopian tube and inflamed ovary within a mass formed by adhesions. Pus appears as layering echogenic fluid and gas within mass.

Ectopic Pregnancy An ectopic pregnancy is implantation of a fertilized ovum outside of the fundus or body of the uterine cavity. Usually bleeding or pain in a patient with a positive BHCG is the common presentation. Ectopic pregnancy can never be excluded. We can confirm an intrauterine pregnancy (IUP) by documenting a yolk sac or a live embryo with a heartbeat. Ectopic pregnancy is much less likley if an IUP is found. Ultrasound Landmarks in Normal Pregnancy Finding Expected Visualization Approximate Weeks 4.5 - 5 5.5 - 6 6 - 6.5 6 - 6.5

Gestational sac BHCG > 1000 by EV; BHCG > 1800 by TA Yolk sac Mean sac diameter > 8 EV, > 18 TA Embryo Mean sac diameter > 16 EV, > 25 TA Fetal heartbeat Embryo > 5mm EV, any size TA Sonographic Findings:

1) Any abnormality outside the uterus significantly increases the risk of ectopic pregnancy. 2) Signs of an ectopic include adnexal masses, complex fluid, a ring of echogenic decidualized tissue involving the fallopian tube (tubal ring sign) or fluid in the cul-de-sac or Morrison's pouch. 3) An acute bleed may be very echogenic and blend in with the pelvic fat in the cul-de-sac and be missed unless you're specifically looking for it. Acute blood can also be anechoic. 4) An ectopic will often be on the side of the corpus luteum cyst but does not have to be. Beware of calling an ovarian follicle an ectopic; an ectopic always has an echogenic ring.