USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416

OBSTETRIC ULTRASOUND: OBSTETRIC ULTRASOUND: SCREENING AT 10 – 14 WEEKSSCREENING AT 10 – 14 WEEKS

Judi Januadi EndjunJudi Januadi Endjun

DIVISION OF MATERNAL AND FETAL MEDICINEDIVISION OF MATERNAL AND FETAL MEDICINE

Department of Obstetrics and GynecologyDepartment of Obstetrics and GynecologyGatot Soebroto Army Central Hospital Gatot Soebroto Army Central Hospital

School of Medicine Veteran University– JakartaSchool of Medicine Veteran University– Jakarta

20092009

MATERI AJAR INI HANYA MATERI AJAR INI HANYA UNTUK DIPERGUNAKAN UNTUK DIPERGUNAKAN

DALAM KEGIATAN DALAM KEGIATAN PENDIDIKAN DAN PENDIDIKAN DAN

KESEHATANKESEHATAN

JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan

KesehatanKesehatan


KesehatanKesehatan

Motto :

• Jalani hidup ini dengan sabar, jujur dan ikhlas,

• Mau mengerti dan melaksanakan tatacara (adab) yang benar, dan

• Mempunyai kemauan untuk selalu berbuat baik memperbaiki diri dan

lingkungan, serta membuat orang lain lebih baik


KesehatanKesehatan

Objectives of 1Objectives of 1stst Trimester US Trimester US ExaminationsExaminations

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

J. Wisser, 2005


KesehatanKesehatan

Normal Early PregnancyNormal 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 importantJJE-13/07/2009JJE-13/07/2009

Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan

11 14-14-1515

1919 2222 2525 2929 3232

LMPLMP OvulationOvulation- -

FertilizatiFertilizationon

Uterine Uterine cavitycavity ImplanImplan

tationtation

HCG (+) HCG (+) >10 >10

mIU/mlmIU/ml

USG (+) USG (+) >400 >400

mIU/mlmIU/ml

3535

> 1800 > 1800 mIU/mlmIU/ml


KesehatanKesehatan

AIUM Guidelines for 1AIUM Guidelines for 1stst Trimester UltrasoundTrimester 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

2. Presence or absence of cardiac activity should be reported

3. Fetal number should be documented

4. Evaluation of the uterus, adnexal structures, and cul-de-sac should be performed


KesehatanKesehatan

AIUM Guidelines 1 :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

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


KesehatanKesehatan

AIUM Guidelines 2 :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.


KesehatanKesehatan


• Multiple pregnancies• Pseudo GS : incomplete fusion between the

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

JJE-13/07/2009JJE-13/07/2009



• 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


KesehatanKesehatan

< 5 weeks< 5 weeks 5 weeks 6-10 weeks 10-12 weeks

GS GS

(Yolk sac)

CRLCRL CRLBPD

> 12 weeks> 12 weeks

BPD BPD

FLFL

etcetc

BIOMETRICS PARAMETERBIOMETRICS PARAMETER

Bambang KarsonoJJE-13/07/2009JJE-13/07/2009


Gestational SacGestational Sac

• The earliest ultrasonic confirmation of an intrauterine pregnancy

• Usually visualized from 31 days or 4+3 weeks, 2 – 3 mm in diameter

• Circular transonic area surrounded by a thick bright ring, usually lies at uterine fundus, and eccentrically placed (important markers for confirming an intrauterine pregnancy)

Trish Chudleigh, 2004JJE-13/07/2009JJE-13/07/2009


Yolk SacYolk Sac

• Circular transonic mass within the GS• Measurement from mid to mid (Blaas, 2008)

• First be identified transvaginally at about 35 days (3 – 4 mm in diameter)

• Grows slowly, maximum diameter of 6 mm at 10 weeks

• Identification of the YS difficult after about 12 weeks

• Correlation between YS morphology and the outcome of pregnancy is not clear



JJE-20071022

Y S1

2


KesehatanKesehatan

Yolk SacYolk 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.


KesehatanKesehatan

THE EMBRYOTHE EMBRYO• Embryonic period : from

conception to the end of the 9th postmenstrual week

• Fetal period : from 10th weeks

• TVS : 37 days, bright linear echo, adjacent to the YS, close to the connecting stalk, and the CRL 2 mm

• Grows at around 1 mm per dayTrish Chudleigh, 2004


KesehatanKesehatan

CROWN-RUMP LENGTH (CRL)CROWN-RUMP LENGTH (CRL)

• < 50% of women are certain about their menstrual dates

• IVF : the most accurate method• CRL : as soon as the embryo can be

seen → unflexed, and longitudinal section

• A discrepancy between certain menstrual dates and CRL might indicate an early IUGR

• CRL taken between 5 – 7 weeks or > 12 weeks are inaccurate

Trish Chudleigh, 2004


KesehatanKesehatan


KesehatanKesehatan

44++ WEEKS PREGNANCY WEEKS PREGNANCY• GS 2 – 5 mm is seen within the

endometrium

• Spherical, regular in outline, and eccentrically situated towards the fundus

• Implanted just below the surface of the endometrium (midline echo), and is surrounded by echogenic trophoblast

• If YS not visible → repeated in 1 week



KesehatanKesehatan

55thth Week of Menstrual Age Week of Menstrual Age(Day 15 – 21 Postconception)(Day 15 – 21 Postconception)

Observed under microscope : IVF/ET, ICSI

Chorionic sac : 16 day post conception, 2 mm. Day 18 : 4 mm, YS can be seen

The chorion : circular echogenic structure bordering directly on the decidua

HRCD imaging can define maternal blood vessels between the decidua and chorion

J. Wisser, 2005


KesehatanKesehatan

55thth Week of Menstrual Age Week of Menstrual Age(Day 15 – 21 Postconception)

• A hypoechoic structure in the uterine cavity can be identified as a chorionic sac only if it is surrounded by hyperplastic endometrium and displays an echogenic border, the chorion frondosum

• If these signs are disregarded, a fluid collection in the uterine cavity (= pseudogestational sac) in an ectopic pregnancy may be misinterpreted as an intrauterine pregnancy

• If mean GS diameter > 12 mm and YS can’t be seen → suspect anembryonic pregnancy → repeated in 1 week (Chudleigh T, 2004)

J. Wisser, 2005JJE-13/07/2009JJE-13/07/2009


66thth Week of Menstrual Age Week of Menstrual Age(Day 22 – 28 Postconceptional)(Day 22 – 28 Postconceptional)

• Fetal pole : can usually be seen adjacent to the YS, echogenic structure about 1 mm long on the surface of the YS

• Notochord : pear shaped appearance in coronal section and contains a central notochord. The neural tube begins to close from the rostral direction. These process concludes on day 38 of menstrual age with closure of the inferior neuropore

• Heart activity : 23rd day post conception, consistently after 26th day. The development of the cardiac pump and vascular system are parallel

J. Wisser, 2005JJE-13/07/2009JJE-13/07/2009


66thth Week of Menstrual Age Week of Menstrual Age(Day 22 – 28 Postconceptional)

• The embryo changes from being straight line at the top of YS to being kidney-bean-shaped, with the YS separated from the embryo by the vitelline duct

• CRL : 4 – 10 mm

• IF FHR is not detectable → miscarriage ?



KesehatanKesehatan

CARDIAC ACTIVITYCARDIAC ACTIVITY

• CRL ≥ 7 mm should visible FHR

• Rapid of the mean FHR between 6-9 W followed by a slight decline after 10 W

• Late onset and FHR in the 1st trimester → higher rate of spontaneous abortion


KesehatanKesehatan


• Separation from the YS : 4 mm embryo, rostral pole begins to fold away from the YS, still broadly adherent to the YS.

• After development of the connecting stalk, the embryo increasingly separates, the YS is extruded into the extra-amniotic coelom.

• Only the vitelline duct connecting it to the embryonic vascular system

J. Wisser, 2005JJE-13/07/2009JJE-13/07/2009



KesehatanKesehatan


Brain : rapid development and comprises ± 50% of the total body length, body length 9 mm, two cardiac chamber separated by a distinct IVS. At 36 day CA, body movement can be detected (reflect the CNS function).

Telencephalon : day 40 CA, rostral, symmetrical outpouching from the prosencephalon & later envelops the diencephalon.

J. Wisser, 2005JJE-13/07/2009JJE-13/07/2009



KesehatanKesehatan


• Limb differentiation : embryo length 16 mm, changes external body shaped, characterized by longitudinal growth & differentiation of the limbs. Differentiation of the upper limbs precedes that of the lower limbs by several days

• Physiologic umbilical hernia : sagittal scan through the UC insertion, hyperechoic structure located in front of the abdominal wall

• Heart : completes its complex structural development. The ostium primum regress & the membranous IVS closes, completely separating the systemic circulation from the pulmonary circulation. Increase epimyocardial mantle, steady rise in HR

• Brain : the head begins more upright position. The midbrain flexure & dominant rhombencephalic fossa are clearly visible in a midsagittal scan

J. Wisser, 2005JJE-13/07/2009JJE-13/07/2009



KesehatanKesehatan

10 – 12 WEEKS PREGNANCY10 – 12 WEEKS PREGNANCY


KesehatanKesehatan


KesehatanKesehatan

12 WEEKS12 WEEKS


KesehatanKesehatan

Clinical Importance of Ultrasound Embryology : Developmental milestones in the 1st trimester

Ultrasound Finding Earliest Visualization Definite Visualization(Menstrual Age) (Menstrual Age)

Chorionic cavity Day 30 Day 32Yolk Sac Day 32 Day 34Fetal pole Day 35 Day 37Heart activity Day 37 Day 40Limbs Day 47 Day 53Telencephalon Day 50 Day 54Movements Day 50 Day 56Stomach Week 10 Week 11Urinary bladder Week 11 Week 12Genitalia Week 12 Week 14

J. Wisser, 2005JJE-13/07/2009JJE-13/07/2009


• Soft markers chromosomal anomalies : golf ball (echogenic foci intra cardiac), NT, echogenic bowels, nasal bone, and TR•Anensefalus•Hidrosefalus

11stst Trimester screening Trimester screening

JJE-20071022JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan

KesehatanKesehatan

11stst Trimester screening Trimester screening• Yolk sac (shape, size, and number)

• Nuchal translucency (NT)


KesehatanKesehatan

Nuchal Translucency (NT)Nuchal Translucency (NT)

• Enlargement (> 3 mm) is associated with chromosomal abnormalities

• Different from cystic hygroma associated with Turner’s 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)JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan

KesehatanKesehatan


KesehatanKesehatanSumber; ISUOG, 2002

Sumber : ISUOG, 2002JJE-20071022JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan

KesehatanKesehatan

Nasal BoneNasal Bone

• Examination of the nasal bone

• The GA should be 11-13+6 weeks and the fetal CRL should be 45 - 84 mm.

• The image should be magnified so that the head and the upper thorax only are included in the screen.

(Arthur C. Fleischer, 2004)JJE-13/07/2009JJE-13/07/2009


Nasal BoneNasal Bone

• A mid-sagital view of the fetal profile should be obtained with the ultrasound transducer held in parallel to the direction of the nose.

• In the image of the nose there should be three distinct lines.

• The top line represents the skin and the bottom one, which is thicker and more echogenic than the overlying skin, represents the nasal bone. A third line, almost in continuity with the skin, but at a higher level, represents the tip of the nose.

(Arthur C. Fleischer, 2004)JJE-13/07/2009JJE-13/07/2009


Fetal medicine


KesehatanKesehatan

Sumber: ISUOG

hypoplasia absent


KesehatanKesehatan Sumber: ISUOG

PREGNANCY FAILUREPREGNANCY 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%

JJE-13/07/2009JJE-13/07/2009


ETIOLOGY OF PREGNANCY FAILUREETIOLOGY OF PREGNANCY FAILURE

• 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

(Arthur C. Fleischer, 2004)


KesehatanKesehatan

Problems of Early PregnancyProblems of Early Pregnancy

1. Hormone measurement : hCG

2. Miscarriage and IUFD3. Ectopic pregnancy4. Cervical pregnancy5. Ovarian pregnancy6. Abdominal pregnancy7. Heterotopic pregnancy

8 Pregnancies of unknown location

9 Twins pregnancy10 Trophoblastic disease11 Ovarian problems12 Uterine fibroids13 Pregnancy and IUD14 Screening fetal

anomaly15 Organization of early

pregnancy unit



Miscarriage and IUFDMiscarriage and IUFD

Embryonic death (FHR negative) RCOG guidelines (1995) :

1. CRL > 6 mm

2. YS (-)

3. GS > 20 mm

4. If CRL < 6 mm or GS < 20 mm → rescan in 1 week



IUFDIUFD

• Causes : placental (48.4%), fetal (22%), maternal (2.3%), placental & maternal (1%), placental & fetal (12.8%), and indeterminate (13.7%) (Volker, 1992 ; Merz, 2005)

• Placental causes : chronic insufficiency (54%), abruption (24.5%), chorioamnionitis (24.5%), subclinical intervillositis (2.1%), and other causes & combinations (3.2%) (Merz, 2005)


KesehatanKesehatan

Blighted OvumBlighted Ovum

• Thin and irregular wall

• No fetal echo at 25 mm of GS

• Subchorionic bleeding

• Serial US examination

• Compare with serum HCG

JJE-13/07/2009JJE-13/07/2009


Subchorionic bleedingSubchorionic bleeding

• Hypoechoic and irregular area subchorion

• Regularity of chorion wall, fetal location, fetal life, and uterine anomaly

• Sizing the bleeding area

• Serial US examination


KesehatanKesehatan

Ectopic pregnancy Ectopic pregnancy

• 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 . 85% in initial US scan (Chudleigh T, 2004)

• Extrauterine extraovarian adnexal mass, pseudogestational sac (10 – 29% of EP : Chudleigh T, 2004), and hemoperitoneum

• The EP is usually on the side of the CL : ± 78% (Chudleigh T, 2004)

• Living embryo outside of the uterus

Arthur C. Fleischer, 2004JJE-13/07/2009JJE-13/07/2009



KesehatanKesehatan

Multiple pregnancyMultiple 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

JJE-13/07/2009JJE-13/07/2009



KesehatanKesehatan

Molar pregnancyMolar 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)


KesehatanKesehatan

Partial Hydatidiform MolePartial Hydatidiform Mole

• Focal swelling of the villous tissue

• Focal trophoblastic hyperplasia

• Embryonic or fetal tissue

• Complete mole + fetus → molar placenta will be clearly separated from the normal placenta

• Partial moles → molar structures are dispersed inside the placental mass




KesehatanKesehatan

ChoriocarcinomaChoriocarcinoma

• Highly malignant

• Multiple metastases

• The primary tumor is often very small



Pregnancy and Endometrial CystPregnancy and Endometrial Cyst


KesehatanKesehatan

Down SyndromeDown Syndrome


KesehatanKesehatan

Echogenic bowelsEchogenic bowels


KesehatanKesehatan

AnencephalyAnencephaly

• TVS can be used to detect anencephaly as early as 7-8 W (Arthur C. Fleischer, 2004)

• TAS : 12 – 14 WArthur C. Fleischer, 2004


KesehatanKesehatan

Doppler studyDoppler study

• Uterine artery Doppler : notching → IUGR, preeclampsia, IUFD

• Only for HRP

• Detection of heart beat

• Blood flow study


KesehatanKesehatan

Diagnostic Procedures in the Diagnostic Procedures in the 11stst Trimester 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)


KesehatanKesehatan

CVS and Early AmniocentesisCVS and Early Amniocentesis


KesehatanKesehatan

CONCLUSIONSCONCLUSIONS• 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.

Arthur C. Fleischer, 2004


KesehatanKesehatan

CONCLUSIONSCONCLUSIONS• Use the appropriate transducer and the route of

examination. • Minimize side effects.

• CPD very important for maintaining personal competence

• Good evidence that dating by ultrasound is more accurate than even a reliable menstrual history in the majority of cases (Chudleigh T, et al, 2004)

• 3D and Doppler examinations should be performed if there indicated.

Arthur C. Fleischer, 2004


KesehatanKesehatan

THANK YOUTHANK YOU


KesehatanKesehatan

USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416

Documents

Transcript of USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416