FIRST TRIMESTER FIRST TRIMESTER SONOGRAPHYSONOGRAPHY

Judi Januadi EndjunSanny SantanaNovi ResistantieFebriansyah DarusFinekri

FETOMATERNAL DIVISIONDepartment of Obstetrics and GynecologyGatot Soebroto Central Army HospitalSchool of Medicine, University of Indonesia

2005

AM I PREGNANT ?AM I PREGNANT ?

AGENDA AGENDA Introduction. Introduction. Patient position.Patient position. Normal early Normal early

pregnancy.pregnancy. Abnormal early Abnormal early

pregnancy. pregnancy. Diagnostic procedures Diagnostic procedures Conclusions.Conclusions. References. References.

JJE/RSPAD/INTIUM/2005

INTRODUCTIONINTRODUCTION

ALARA ALARA (as low as reasonably (as low as reasonably acceptable) principle in determining acceptable) principle in determining intensities and time of exposureintensities and time of exposure

AIUM : AIUM : intensities < 94 mW/cmintensities < 94 mW/cm2 2 are are below the acceptable threshold. Do not below the acceptable threshold. Do not hold the transducer to interrogate a hold the transducer to interrogate a certain area any longer than neededcertain area any longer than needed

INTRODUCTION

± 30% of fertilized eggs develop into a fetus

Many of the defects occur during embryogenesis (0 – 8 weeks)

Fetal development : > 8 weeks

TVS is vital in the evaluation of complicated 1st trimester pregnancy (0 – 13 weeks)

INTRODUCTIONINTRODUCTION

The terms incomplete abortions, missed abortion, failed IUP, and embryonic demise are used interchangeably, which can contribute to confusion.

It is best to most accurately describe TVS features (i.e., presence or absence of embryo / YS, fetus, heart motion, and retrochorionic hemorrhage

PATIENT POSITIONPATIENT POSITION

TRANSDUCERS

Bambang Karsono

curvilinear

Transvaginal / rectal

DEFINITIONS DEFINITIONS

Menstrual age (postmenstrual)Menstrual age (postmenstrual)~ from LMP~ from LMP

Conceptual ageConceptual age~ from ovulation date (IVF)~ from ovulation date (IVF)

Gestational ageGestational age~ ovulation date + 2 weeks~ ovulation date + 2 weeks

(Merz E. Ultrasound in Gynecology & Obstetrics, 1991)(Merz E. Ultrasound in Gynecology & Obstetrics, 1991) Bambang Karsono

DEFINITIONS

Kehamilan minggu ke-6Kehamilan minggu ke-6

~ kehamilan 5 minggu + 0 hari ~ kehamilan 5 minggu + 0 hari

sampai dengan 5 minggu + 6 harisampai dengan 5 minggu + 6 hari

Kehamilan 6 mingguKehamilan 6 minggu

~ kehamilan 6 minggu + 0 hari ~ kehamilan 6 minggu + 0 hari

sampai dengan 6 minggu + 6 harisampai dengan 6 minggu + 6 hari

Bambang Karsono

Objectives of 1st Trimester US Examinations

Location and gestational age determination.

Detection of embryo and or fetal life Evaluation of pregnancy

complications Detection of anomalies Detection of multiple pregnancy Evaluation of pelvic mass, IUD, etc

DECIDUALIZATION

Normal Early Normal Early PregnancyPregnancy

Physical and physiological changes.

Embryo and fetal development. Technique : transabdominal,

transvaginal (the method of choice), transrectal, or transperineal.

Transducer selection Informed consent : very important

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

Normal early Normal early pregnancypregnancy

TVS can detect GS within the thickened choriodecidua at 5-6 W

Decidua capsularis : forms most of the GS

Decidua vera : the true decidua that surrounds the GS

Decidua basalis : and chorion frondosum form the placenta

Normal early pregnancyNormal early pregnancy

-hCG > 2000 mIU/ml + GS should be sees on TVS in an IUP. -hCG doubles every 48 hours in a normal IUP

YS should be visible in a GS that is ± 10 mm

The embryo should be visible in a 16 – 20 mm GS

Normal early pregnancyNormal early pregnancy

Heart motion should be visible in an embryo ≥ 3 mm.

- Normal embryos : HR > 85 bpm at 6 – 7 weeks - HR < 85 bpm can indicate impending failed pregnancy, re-scan in 1 week or so - TV-CDS can be used to detect heart

motion

Normal early Normal early pregnancypregnancyCertain fetal structures seen on TVS are

specific to the early developing fetus : Rhombencephalon : seen at 6 W, is a cystic area

in the brain that eventually forms the 4th ventricle (cisterna magna)

Bowel herniation : into base of umbilical cord is seen between 8 – 12 W

Chorio-amnion is unfused until 18-20 W IUP in one horn of bicornuate uterus Corpus luteum cyst of pregnancy : usually

regresses by 14 to 16 W

PROBLEMS PROBLEMS

Incorrect gestational age Incorrect gestational age estimation, increase perinatal estimation, increase perinatal morbidity and mortality; also morbidity and mortality; also

medicolegal problemsmedicolegal problems

Case : CS due to post term Case : CS due to post term → → preterm babypreterm baby

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

AIUM Guidelines AIUM Guidelines 1 :1 : CRL is a more accurate indicator of CRL is a more accurate indicator of

GA than GS diameter.GA than GS diameter.

Identification of a YS or an embryo Identification of a YS or an embryo is definitive evidence of a GS. is definitive evidence of a GS. Intrauterine fluid collection can Intrauterine fluid collection can sometimes represent sometimes represent pseudogestational sac associated pseudogestational sac associated with ectopic pregnancywith ectopic pregnancy

AIUM Guidelines 1 :AIUM Guidelines 1 :

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

AIUM Guidelines :AIUM Guidelines :

2.2. Presence or absence of cardiac Presence or absence of cardiac activity should be reportedactivity should be reported

3.3. Fetal number should be Fetal number should be documenteddocumented

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

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.

AIUM Guidelines 3 :AIUM Guidelines 3 :

Multiple pregnanciesMultiple pregnancies Pseudo GS : Pseudo GS : incomplete fusion between the incomplete fusion between the

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

JJE/RSPAD/INTIUM/2005

AIUM Guidelines 4 :AIUM Guidelines 4 :

Recognition of Recognition of incidental findings : incidental findings : myomas, adnexal mass, myomas, adnexal mass, fluid in the cul-de-sac or fluid in the cul-de-sac or the flanks and subhepatic the flanks and subhepatic spacespace

Correlation of serum Correlation of serum hormonal levels with hormonal levels with US findings often is US findings often is helpful for diagnosis of helpful for diagnosis of EP or normal pregnancyEP or normal pregnancy

EMBRYO and FETUS EMBRYO and FETUS DEVELOPMENTDEVELOPMENT

< 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

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Gestational age Gestational age estimationestimation

GSGS YSYS CRLCRL BPDBPD HCHC FLFL HLHL

JJE/RSPAD/INTIUM/2004

Gestational Gestational SacSac

Normal : Normal : cincin ekoik regular dgn cincin ekoik regular dgn bagian sonolusen ditengahnyabagian sonolusen ditengahnya

Yolk Sac

Size, shape, and Size, shape, and location location

Normal : Normal : rounded, rounded, diameter 3 – 6 mm, diameter 3 – 6 mm, fixedfixed

Abnormal : Abnormal : not rounded, diameter < 3 mm or ≥ 8 mm, and floating inside GS.

CRLCRL

CROWN-RUMP LENGTH (CRL)

44++ WEEKS PREGNANCY WEEKS PREGNANCY

5 WEEKS PREGNANCY5 WEEKS PREGNANCY

6 WEEKS PREGNANCY6 WEEKS PREGNANCY

CARDIAC ACTIVITY AT 6 WEEKS

7 WEEKS PREGNANCY

8 WEEKS 8 WEEKS PREGNANCYPREGNANCY

9 WEEKS PREGNANCY

10 – 12 WEEKS PREGNANCY

12 WEEKS

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

11stst Trimester screening Trimester screening

11stst Trimester Trimester screeningscreening

Yolk sac (shape, size, and number)Yolk sac (shape, size, and number) Nuchal translucency (NT)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)

PREGNANCY FAILURE

Pre-embryonic : Pre-embryonic : > 50%> 50%

Embryonic : 28%Embryonic : 28% Fetus : 10%Fetus : 10% 7-9 weeks : 5%7-9 weeks : 5% 10-12 weeks : 1 – 10-12 weeks : 1 –

2%2%

GS (+) : 11,5%GS (+) : 11,5% YS (+) : 8,8%YS (+) : 8,8% Embryo Embryo 5 mm : 5 mm :

7,1%7,1% Embryo 5-10% : Embryo 5-10% :

3,3%3,3% Embryo Embryo 10 mm 10 mm

: 0,5%: 0,5%

ETIOLOGYETIOLOGY 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

Blighted ovum Molar pregnancy, trophoblastic

disease Subchorionic bleeding IUFD Multiple pregnancy Ectopic pregnancy, combine pregnancy Screening fetal anomaly

Abnormal Early PregnancyAbnormal Early Pregnancy

Blighted Ovum

Dinding KG tipis dan iregular

Tidak tampak ekho janin pada diameter KG 25 mm

Dapat disertai perdarahan sub korionik

Bl perlu : USG serial Bandingkan dengan

kadar HCG darah

Molar pregnancy Molar 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)

Subchorionic bleeding

Daerah hipoekoik iregular subkorion

Perhatikan regularitas dinding korion, letak janin dan tanda kehidupan, anomali uterus

Ukur luas daerah perdarahan

Bila perlu evaluasi USG serial

IUFD

Diagnosa : B-mode atau doppler Tidak tampak pulsasi jantung atau

tali pusat Bila ragu, ulangi USG 1 minggu Cari kausa : perdarahan, anomali uterus,

kelainan yolk sac, anomali janin, dll Beri informed consent dengan baik, hati-

hati pasien rujukan konsultasi USG

Multiple Multiple pregnancypregnancy

The numbers of GS Amniotic band Thickness of amniotic band Fetal echo : be careful vanishing twin Fetal live and gestational age Anomaly Adnexal mass

Triplets

QuadrupletQuadruplet

Ectopic pregnancy (EP)Ectopic pregnancy (EP) 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

Extrauterine extraovarian adnexal mass, pseudogestational sac, and hemoperitoneum

The EP is usually on the side of the CL.

Living embryo outside of the uterus

(Arthur C. Fleischer, 2004)

Ectopic pregnancy EP may also contain a rim of increased

vascularity, although this is variable, depending on the extent of trophoblastic invasion into the tubal wall

TV-CDS can distinguish distended paraovarian/uterine veins from the vascular rim of an EP

EP have variable wall vascularity and pain A ruptured EP can be implied if there is a

complex solid tubal mass, hematosalpinx, or hemoperitoneum

(Arthur C. Fleischer, 2004)

Rare types of ectopic pregnancy Cornual EP : can occur within one uterine

cornua, it can enlarge because it is surrounded by myometrium. If it ruptures, catastrophic bleeding can occur

Abdominal EP : can be diagnosed by the presence of fetus, choriodecidua, or placenta separate from uterus

Cervical EP : GS inside the cervical area Ovarian EP : virtually impossible to

distinguish from CL if the embryo is not seen

(Arthur C. Fleischer, 2004)

Down Syndrom

Echogenic bowelsEchogenic bowels

AnencephalAnencephalyy

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

TAS : 12 – 14 W

PREGNANCY + ENDOMETRIOSIS PREGNANCY + ENDOMETRIOSIS CYSTCYST

Doppler studyDoppler study

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

Only for HRPOnly for HRP

Detection of heart Detection of heart beatbeat

Blood flow studyBlood flow study

Doppler Doppler studystudy

Vitelline duct blood flow

Ductus venosus

Uterine artery

Uterine artery

Notching

Diagnostic Procedures in the 1st 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)

CVS and Early Amniocentesis

CONCLUSIONS 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.

Use the appropriate transducer and the route of examination.

Minimize side effects.

CPD very important for maintaining personal competence

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

REFERENCES

1. Fleischer AC. Sonography in gynecology and obstetrics : just the facts. McGraw Hill, Singapore, 2004.

2. Fleischer AC, Kepple DM. Transvaginal sonography of early intrauterine pregnancy. In: Fleischer AC, Manning F, Jeanty P, Romero R, eds. Sonography in Obstetrics and Gynecology : Principles and Practice, ed6. New York: McGraw-Hill,2001:62.

3. Fleischer AC, Diamond MP, Cartwright PS. Transvaginal sonography of ectopic pregnancy. In: Fleischer AC, Manning F, Jeanty P, Romero R, eds. Sonography in Obstetrics and Gynecology : Principles and Practice, ed6. New York: McGraw-Hill,2001:113.

4. Sherer DM, Manning FA. First trimester nuchal translucency screening for fetal aneuploidy. In: Fleischer AC, Manning F, Jeanty P, Romero R, eds. Sonography in Obstetrics and Gynecology : Principles and Practice, ed6. New York: McGraw-Hill,2001:89.

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