![Page 1: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/1.jpg)
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
![Page 2: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/2.jpg)
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
![Page 3: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/3.jpg)
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 4: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/4.jpg)
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
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 5: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/5.jpg)
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
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 6: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/6.jpg)
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
![Page 7: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/7.jpg)
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
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 8: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/8.jpg)
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
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 9: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/9.jpg)
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
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 10: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/10.jpg)
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.
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 11: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/11.jpg)
AIUM Guidelines 3 :AIUM Guidelines 3 :
• 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
Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan
![Page 12: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/12.jpg)
AIUM Guidelines 4 :AIUM Guidelines 4 :
• 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
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 13: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/13.jpg)
< 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
Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan
![Page 14: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/14.jpg)
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
Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan
![Page 15: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/15.jpg)
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
Trish Chudleigh, 2004JJE-13/07/2009JJE-13/07/2009
Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan
![Page 16: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/16.jpg)
JJE-20071022
Y S1
2
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 17: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/17.jpg)
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.
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 18: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/18.jpg)
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
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 19: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/19.jpg)
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
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 20: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/20.jpg)
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 21: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/21.jpg)
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
Trish Chudleigh, 2004
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 22: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/22.jpg)
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
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 23: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/23.jpg)
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
Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan
![Page 24: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/24.jpg)
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
Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan
![Page 25: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/25.jpg)
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 ?
Trish Chudleigh, 2004
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 26: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/26.jpg)
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
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 27: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/27.jpg)
77thth Week of Menstrual Age Week of Menstrual Age(Day 22 – 28 Postconception)(Day 22 – 28 Postconception)
• 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
Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan
![Page 28: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/28.jpg)
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 29: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/29.jpg)
88thth Week of Menstrual Age Week of Menstrual Age(Day 36 – 42 Postconception)(Day 36 – 42 Postconception)
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
Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan
![Page 30: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/30.jpg)
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 31: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/31.jpg)
99thth Week of Menstrual Age Week of Menstrual Age(Day 43 – 49 Postconception)(Day 43 – 49 Postconception)
• 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
Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan
![Page 32: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/32.jpg)
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 33: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/33.jpg)
10 – 12 WEEKS PREGNANCY10 – 12 WEEKS PREGNANCY
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 34: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/34.jpg)
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 35: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/35.jpg)
12 WEEKS12 WEEKS
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 36: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/36.jpg)
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
Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan
![Page 37: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/37.jpg)
• 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
![Page 38: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/38.jpg)
11stst Trimester screening Trimester screening• Yolk sac (shape, size, and number)
• Nuchal translucency (NT)
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 39: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/39.jpg)
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
![Page 40: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/40.jpg)
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatanSumber; ISUOG, 2002
![Page 41: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/41.jpg)
Sumber : ISUOG, 2002JJE-20071022JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 42: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/42.jpg)
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
Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan
![Page 43: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/43.jpg)
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
Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan
![Page 44: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/44.jpg)
Fetal medicine
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
Sumber: ISUOG
![Page 45: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/45.jpg)
hypoplasia absent
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan Sumber: ISUOG
![Page 46: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/46.jpg)
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
Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan
![Page 47: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/47.jpg)
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)
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 48: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/48.jpg)
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
Trish Chudleigh, 2004JJE-13/07/2009JJE-13/07/2009
Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan
![Page 49: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/49.jpg)
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
Trish Chudleigh, 2004JJE-13/07/2009JJE-13/07/2009
Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan
![Page 50: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/50.jpg)
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)
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 51: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/51.jpg)
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
Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan
![Page 52: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/52.jpg)
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
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 53: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/53.jpg)
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
Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan
![Page 54: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/54.jpg)
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 55: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/55.jpg)
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
Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan
![Page 56: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/56.jpg)
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 57: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/57.jpg)
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)
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 58: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/58.jpg)
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
Trish Chudleigh, 2004JJE-13/07/2009JJE-13/07/2009
Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan
![Page 59: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/59.jpg)
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 60: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/60.jpg)
ChoriocarcinomaChoriocarcinoma
• Highly malignant
• Multiple metastases
• The primary tumor is often very small
Trish Chudleigh, 2004JJE-13/07/2009JJE-13/07/2009
Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan
![Page 61: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/61.jpg)
Pregnancy and Endometrial CystPregnancy and Endometrial Cyst
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 62: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/62.jpg)
Pregnancy and IUDPregnancy and IUD
2002-07-10-08 Pregnancy and IUD © Sosa www.TheFetus.net
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 63: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/63.jpg)
Down SyndromeDown Syndrome
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 64: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/64.jpg)
Echogenic bowelsEchogenic bowels
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 65: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/65.jpg)
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
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 66: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/66.jpg)
Doppler studyDoppler study
• Uterine artery Doppler : notching → IUGR, preeclampsia, IUFD
• Only for HRP
• Detection of heart beat
• Blood flow study
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 67: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/67.jpg)
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)
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 68: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/68.jpg)
CVS and Early AmniocentesisCVS and Early Amniocentesis
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 69: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/69.jpg)
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
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 70: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/70.jpg)
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
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan
![Page 71: USG Intensif 6. Screening 10 - 14 Weeks JJE 20090416](https://reader033.vdokumen.com/reader033/viewer/2022061118/5469f83daf7959285a8b497a/html5/thumbnails/71.jpg)
THANK YOUTHANK YOU
JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan
KesehatanKesehatan