Prof Laurent J SALOMON

Laurent J Salomon

Laurent J Salomon

Why ?
The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) is a scientific organization that encourages sound clinical practice, teaching and research for diagnostic imaging in womens healthcare. Practice Guidelines and Consensus are intended to reflect what is considered by ISUOG to be the best practices at the time at which they were issued. Guidelines are not intended to establish a legal standard of care because interpretation of the evidence that underpins the guidelines may be influenced by individual circumstances and available resources.

Approved guidelines can be distributed freely with the permission of ISUOG (info@isuog.org).
Laurent J Salomon

What is the purpose of a 1st Trimester Fetal Ultrasound Scan ?

Confirm viability, accurately establish GA, determine the number of fetuses, and, in the presence of a multiple pregnancy, assess chorionicity and amnionicity. Towards the end of the first trimester, the scan also offers an opportunity to detect gross fetal abnormalities and, in health systems that offer the first trimester aneuploidy screening, measure the NT. It is acknowledged, however, that many gross malformations may develop later in pregnancy or may not be detected even with appropriate equipment in the most experienced of hands. Before starting the examination, a healthcare practitioner should counsel the woman/couple regarding the potential benefits and limitations of a routine mid-trimester fetal ultrasound scan.
Laurent J Salomon

Who should be offered a scan and when ?

Increasingly offered during the 1st trimester, particularly in high-resource settings. Ongoing technological advancements have allowed the resolution of ultrasound imaging in the first trimester to evolve to the stage where detailed early fetal development can be assessed and monitored. There is no reason to offer routine ultrasound simply to confirm an ongoing early pregnancy in the absence of any clinical concerns or specific indications. It is advisable to offer the first ultrasound scan when gestational age is thought to be between 11 and 13+6 weeks gestation First trimester here refers to a stage of pregnancy starting from the time viability can be confirmed (i.e. presence of a gestational sac in the uterine cavity with an embryo demonstrating a cardiac activity) up to 13+6 weeks of gestation.

Laurent J Salomon

Who should perform the scan ?

In order to achieve optimal results from routine screening examinations, it is suggested that scans should be performed by individuals who fulfill the following criteria: trained in the use of diagnostic ultrasonography and related safety issues; regularly perform fetal ultrasound scans; participate in continuing medical education activities; have established appropriate referral patterns for suspicious or abnormal findings; routinely undertake quality assurance and control measures. Are in training and under supervision in a training program. If the examination cannot be performed completely in accordance with adopted guidelines, the scan should be repeated, at least in part, at a later time, or the patient can be referred to another practitioner. This should be done as soon as possible, to minimize unnecessary patient anxiety and unnecessary delay in the potential diagnosis of congenital anomalies or growth disturbances.
Laurent J Salomon

What should be done in case of multiple pregnancies ?

Determination of chorionicity and amnionicity are important for care, testing and management of multifetal pregnancies. Chorionicity should be determined in early pregnancy when characterization is most reliable. Once this is accomplished, further antenatal care including the timing and frequency of ultrasound examinations should be planned, according to the available health resources and local guidelines.

In QUARELLO Edwin these UNIVERSITE DE MONTPELLIER 1

Laurent J Salomon

What equipment ?
For routine screening, equipment should have at least the following:

real time, gray-scale ultrasound capabilities; transabdominal and transvaginal ultrasound transducers adjustable acoustic power output controls with output display standards; freeze frame capabilities; electronic calipers; capacity to print/store images; regular maintenance and servicing.

Laurent J Salomon

What document?
An examination report should be produced as an electronic and/or a paper document, to be sent to the referring care provider in reasonable time. A sample reporting form is available at the end of this guidelines. Images of standard views (stored either electronically or as printed copies) should also be produced and stored. Motion videoclips are recommended for the fetal heart. Local laws should be followed. Many jurisdictions require image storage for a defined period of time.

Laurent J Salomon

Is prenatal ultrasonography safe at 1st trimester ?

Prenatal ultrasonography appears to be safe for clinical practice. To date, there has been no independently confirmed study to suggest otherwise.

Fetal exposure times should be minimized, using the lowest possible power output needed to obtain diagnostic information,following the ALARA principle (As Low As Reasonably Achievable).
Doppler ultrasound is associated with greater energy output and may have more potential for bioeffects.. Doppler examinations should only be used in the first trimester if clinically indicated. More details are available from the ISUOG Safety Statement.
Laurent J Salomon

Laurent J Salomon

Defining viability:
Strictly speaking, viability implies the ability to live independently outside the uterus and cannot be applied to embryonic and early fetal life. Fetal viability, from an ultrasound perspective, is therefore the term used to confirm the presence of an embryo with cardiac activity at the time of the examination. Typically embryos become detectable by ultrasound at a length of 1-2 mm and then grow by approximately 1 mm per day. The cephalic and caudal ends are indistinguishable until 53 days (around 12 mm) when the diamond-shaped rhombencephalic cavity (future 4th ventricle) becomes visible Cardiac activity is often evident when the embryo measures 2 mm or more but is not evident in around 5-10% of viable embryos measuring between 2 and 4 mm. Heart activity generally becomes visible in all normal embryos with CRL over 5 mm. If there is doubt about heart activity, then a repeat scan should be considered after a few days
Laurent J Salomon

Defining an intrauterine pregnancy :

The presence of an intrauterine gestation sac clearly signifies that the pregnancy is intrauterine, but the criteria for the definition of a gestation sac are unclear.

The use of terms such as an apparently empty sac, the double-decidual ring or even pseudosac do not accurately confirm or refute the presence of an intrauterine pregnancy.

Ultimately, the decision is a subjective one and is, therefore, influenced by the experience of the person performing the ultrasound examination.
In an asymptomatic patient, it is advisable to wait until the embryo becomes visible within the intrauterine sac as this confirms that the sac is indeed a gestational sac..
Laurent J Salomon

How should US be used to assess GA?

US assessment of GA (dating) uses the following assumptions:
Gestational (menstrual age) represents post conception age + 14 days. Embryonic and fetal size corresponds to post conception (post fertilization) age. The structures measured are normal Measurement technique conforms to the reference nomogram Measurements are reliable (both within and between observers) The ultrasound equipment is correctly calibrated

Accurate dating of pregnancy is essential for appropriate follow up of pregnancies and has been the primary indication for routine ultrasound in the first trimester. It provides valuable information for the assessment of fetal growth later in pregnancy, appropriate obstetric care, and the management of preterm or post term pregnancies in particular.
Laurent J Salomon

How should US be used to assess GA?

Except in pregnancies arising following assisted reproductive technology (ART), the exact day of conception cannot be reliably determined and, therefore, dating a pregnancy from ultrasound appears to be the most reliable method to establish the true gestational age In the first trimester, many parameters are closely related to GA, but the CRL appears to be the most precise, allowing an accurate determination of the day of conception to within 5 days either way in 95% of cases.

The optimal time for assessment appears, therefore, to be somewhere between 8 and 13+6 weeks.
Laurent J Salomon

How should US be used to assess GA?

At 11-13+6 weeks, the CRL and BPD are the two most commonly measured parameters for pregnancy dating.

Singleton nomograms remain valid and can be applied in the presence of multiple pregnancy It is recommended, that these and any other nomograms be locally validated before they are adopted into use because geographic and ethnic variations may occur. It is recommended that the CRL measurements should be used to determine gestational age unless it is above 84 mm, when HC can be used, as it becomes slightly more precise than BPD.
Laurent J Salomon

Fetal biometry ?
The mean gestational sac diameter (MSD) has been described in the first-trimester from 35 days from the last menstrual period (LMP) onwards. CRL measurements can be carried out transabdominally or transvaginally. Bi-parietal diameter (BPD) and head circumference (HC).

Nomograms are also available for abdominal circumference (AC), femur length and most fetal organs, but there is no reason to measure these structures as the part of routine first trimester scan. For all measurements, calliper placement should follow the technique in the selected nomogram. Strict quality criteria should be applied.
Laurent J Salomon

Fetal biometry ?

Laurent J Salomon

Laurent J Salomon

Fetal anatomy ?
The introduction of nuchal translucency (NT) aneuploidy screening in the 11 13+6 week window has rekindled an interest in early anatomy scanning. Stated advantages include early detection and exclusion of many major anomalies, early reassurance to at risk mothers, earlier genetic diagnosis, and easier pregnancy termination if appropriate. Limitations include need for trained and experienced personnel, uncertain cost/benefit ratio, late development of some anatomical structures and pathologies (e.g. corpus callosum, hypoplastic left heart) which make early detection impossible and can lead to difficulties in counselling due to the uncertain clinical significance of some findings
Laurent J Salomon

Laurent J Salomon

Laurent J Salomon

Laurent J Salomon

Laurent J Salomon

Laurent J Salomon

Laurent J Salomon

Laurent J Salomon

Laurent J Salomon

Placenta, cord ?
The echostructure of placenta should be evaluated. Frankly abnormal findings should be noted and followed up. Position of placenta in relation to the cervix is of less importance at this stage of pregnancy age since most migrate away from the internal cervical os. Placenta praevia should not be reported at this stage. Special attention should be given to patients with prior caesarian section who may be predisposed to scar pregnancy or placenta accreta with significant complications. Gynaecological pathology, both benign and malignant, may be detected during any first trimester scan. The number of cord vessels, cord insertion at the umbilicus and presence of cord cysts should be noted.
Laurent J Salomon

Placenta, cord ?

Laurent J Salomon

Chromosomal anomaly assessment

Ultrasound based screening for chromosomal anomalies in the first trimester may be offered, depending on public health policies, trained personnel and availability of health care resources. The first trimester screening should include the nuchal translucency (NT) measurement. Screening performance is further improved by the addition of other markers including biochemical measurements.

Most experts recommend that NT should be measured between 11 and 13 weeks + 6 days, corresponding to a measurement of crown-rump length (CRL) between 45 and 84 mm.
Laurent J Salomon

NT measurement
NT implementation requires several elements to be in place including suitable equipment, counseling and management, and operators with specialized training and continuing certification. However, even in absence of NT based screening programs, qualitative evaluation of the nuchal region of any fetus is recommended and if it appears thickened, then expert referral should be considered.

NT measurements used for screening should only be done by trained and certified operators.
Laurent J Salomon

NT measurement
NT can be measured by the transabdominal or transvaginal route. Quality criteria:
neutral position, sagittal section image should be magnified The amniotic membrane should be identified separately from the fetus. The US machine should allow measurements precision of 0.1 mm. Calipers should be placed correctly (on-on) to measure NT.

The maximum measurement meeting all the criteria should be recorded and used for risk assessment. Multiple pregnancy requires special considerations /chorionicity. A rigorous audit of operator performance and constructive feedback from assessors has been established in many countries and should be considered essential for all practitioners who participate in NT based screening programs
Laurent J Salomon

Laurent J Salomon

USE THE

FORM !!

Laurent J Salomon

USE THE WEB: www.isuog.org !!

Laurent J Salomon

Acknowledgements:

Writting Committee: Salomon LJ and Alfirevic Z (Chairs), Timor-Tritsch I, Seshadri S, Papageorghiou A, Tabor A, Chalouhi G, Toi A, Yeo, G, Bilardo C, Raine-Fenning N.

Special appreciation to Jacques Abramowicz (USA), MD, PhD for his contribution to the Safety section and to Jean-Philippe Bault (France), MD for providing some of the images.

Laurent J Salomon