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Ultrasound milestones
There is a major difference between when a certain finding can appear and when it should be present( the latter having more importance in early pregnancy failure). One can identify structures much earlier with transvaginal ultrasound (TVU), which has a separate timetable (up until the eleventh week there is little reason to view a first trimester pregnancy with TAU other than as an initial quick scouting. The common tomograms (slices) used to assess a portion of the fetal anatomy are the axial slice, the coronal slice, and the sagittal slice, most often midline.
Schematic of the essential planes for ultrasound scanning: axial (a) and coronal planes (b), sagittal (midline) (c) incorporating. T, thalami; C, cavum; CC, corpus callosum; CV, cerebellar vermis. For example, (a) is plane of the biparietal diameter.
Several ultrasound parameters have been used to estimate gestational age. The most commonly used are: mean sac diameter gestation sac volume crownrump length (CRL) biparietal diameter (BPD) femur length
*Recognition of a gestation sac from 4+ weeks and a fetal pole from 6+ weeks will normally be achieved only with a transvaginal probe
Gestational sac
The first ultrasound sign of pregnancy Is generally oblong and has a thick rind Should have a double ring, representing the decidua capsularis and the decidua parietalis Should be seen when the beta human chorionic gonadotropin (hCG) is between 1000 and 2000 mIU/mL. Once seen, the sac diameter should grow by an average of 1 mm a day The mean sac diameter (MSD) can be used as a gauge against which to assess other findings Beware of the pseudosac, which does not have a double ring and is seen in association with ectopic pregnancy
Yolk sac
The second structure to be visible by ultrasound Can be seen when the MSD is 5 mm, but it should be seen by the time the MSD is 8 mm Plays a crucial role in the development of the fetusproviding nourishment and producing the stem cells that develop into red blood cells, white blood cells, and platelets Provides the immunological potential for the fetus until about 7 menstrual weeks, when those functions are taken over by the fetal liver From then on the functionless yolk sac becomes a circular structure without a core, after which it finally disappears by 12 menstrual weeks.
Yolk sac
Embryo
Could be seen by 5 menstrual weeks and a way to determine gestational age is to add 42 days to the crownrump length (CRL) measurement in millimeters. Should increase its CRL by 1mm/d. Not seeing an embryo when the MSD has reached 6 mm is indicative of apregnancy loss The size of the embryo, relative to the MSD, is important if the MSDCRL is <6 mm, the prognosis is very poor. Cardiac activity should be visualized when the embryonic length is greater than or equal to 4 mm not seeing a beating heart at this embryonic size is an ominoussign
Should see on TVS Gestation sac Yolk sac Embryonic pole Fetal heart activity
Time of visualization 5 menstrual weeks when MSD is >7mm 5 weeks or when hCG is>1000 mIU when CRL is >5 mm
In the majority of normal pregnancies, measurement of the biparietal diameter (BPD) and femur length (FL) provide the most accurate assessment of gestational age in the second trimester. It is recommend that measurements of the head circumference (HC), transcerebellar diameter (TCD) and abdominal circumference (AC) are also undertaken. They provide further confirmation of gestational age and aid in the exclusion of growth related abnormalities and spina bifida. In addition, their inclusion encourages a systematic examination of the whole fetus
Measurement of head circumference using the ellipse method (lateral ventricles view)
Measurement of the transcerebellar diameter. The calipers are positioned to obtain an outer to outer measurement of the cerebellum. The cerebellar vermis (CV), cerebellar hemispheres (CB), cisterna magna (CM), nuchal skin fold (NF)
Discordant measurements
BPD and HC For practical purposes, a discrepancy between the fetal head measurements and the patients dates of greater than 2weeks should get the attention of the ultrasound examiner. If the head is bigger, then a quick evaluation of the intracranial anatomy should assure the examiner that this relative macrocephaly is simply a normal variant and,most often, a familial feature If the head circumference is smaller by about 2weeks, this most often is a normal variation, especially in the third trimester. However, the larger the discrepancy, the more one will have to explore the rare condition of pathologic microcephaly
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