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DMST 244 Obstetrics and Gyn Sonography 1 > Mod 7 2nd Trimester Detailed Anatomy Ultrasound > Flashcards

Mod 7 2nd Trimester Detailed Anatomy Ultrasound Flashcards

1
Q

When would a detailed anatomy scan be performed?

A

18-20 weeks gestation.

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2
Q

Why would we do a detailed anatomy scan at 18-20 weeks?

A
  1. All organs are demonstrated to assess for anatomic defects.
  2. Biometry is also performed
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3
Q

The detailed 2nd trimester exam is how long?

A

45-60 minutes let your patient know at the beginning of the exam

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4
Q

When doing the detailed Anatomy example we should always be aware of the patients what?

A

Possible discomfort of things like
1. Full bladder
2. Backache
3. Supine hypotension

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5
Q

What should we do to make the patient more comfortable?

A
  1. Reassure patient if bladder is uncomfortably full that you will take a few images and then have a pee break
  2. Offer a extra pillow or raise the head of the bed slightly
  3. Cushions can be placed under the knees or have your patient bend their left knee
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6
Q

What is supine hypotension?

A

Caused by pregnancy putting pressure on the IVC and lower aorta, reducing venous return.

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7
Q

What are signs and symptoms of supine hypotension?

A
  1. Fidgeting patient
  2. feeling hot
  3. Light headed
  4. Nauseous
  5. Faint
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8
Q

If the patient starts to exhibit signs of supine hypotension what should we do?

A
  1. Immediately roll her on her side (left side is best)
  2. Patient may need to sit up for a brief time
  3. Can turn on a fan or offer a glass of water
  4. Can scan with patient tilted to the left
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9
Q

What do we look for in a sagittal sweep in the detailed anatomy scan?

A
  1. The position of the fetus
  2. Check for fetal heart motion
  3. Check for the number of fetuses
  4. Assess for the presence of amniotic fluid
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10
Q

What is the Sagittal sweep process for the detailed anatomy scan?

A

Sweep in sagittal from midline through uterus laterally to each adnexa and back

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11
Q

What do we look for on a transverse sweep of the detailed anatomy scan?

A
  1. Assess for fibroids on the uterus
  2. Assess for adnexal masses usually arising from the ovary
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12
Q

What is the process for the transverse sweep of the detailed anatomy scan?

A

Sweep through midline uterus and along the lateral aspect of the uterus to include adnexa, all the way up to umbilicus

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13
Q

If we find fibroids on the uterus during the detailed anatomy scan what should we do?

A

Document these findings in two planes and measure in three

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14
Q

What are some adnexal masses we might see in a transverse detailed anatomy scan? and what should we do?

A
  1. Corpus luteal cysts
  2. Dermoid cysts
    document these findings in two planes and measure in three dimensions
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15
Q

When documenting the cervix during second trimester what should we do?

A
  1. Document the length of the cervix
  2. Normal is >3cm
  3. Measure from Inner OS to External OS
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16
Q

What are these images representing?

A

A contraction happening during the ultrasound. This is called the 9 cm cervix

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17
Q

What is the pitfall here for the scan? And what are the negatives

A

Overall distended bladder can also cause the bladder measure to be overestimated. Can also falsely make a shortened cervix look long. Come back to it later after voiding. This kind of full bladder can potentially hide pathology

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18
Q

What is the red arrow pointing to?

A

Anterior placenta

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19
Q

What is the red arrow pointing towards?

A

Posterior fundal placenta

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20
Q

Why do we document the placenta? and what do we assess?

A
  1. Document the placental position in transverse and sagittal
  2. Assess the placental texture and thickness
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21
Q

The placenta grows how much per week?

A

1mm/wk

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22
Q

What is this a picture of?

A

SAG placenta

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23
Q

What is this a image of?

A

TRX placenta

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24
Q

When measuring the placenta how should it be done?

A
  1. Measure from the placental edge to the Internal OS of the cervix
  2. Placenta should be a minimum of 2 cm away from the internal OS of the cervix
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25
Q

What planes should we document the placenta in?

A

SAG and TRX

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26
Q

The placenta cord insertion should be how far form the placental edge?

A

> 2cm in both planes

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27
Q

After a brief survey of the uterus you should have established what?

A
  1. Viable fetus
  2. Fetal lie
  3. Fetal number
  4. Placental localization
  5. Uterine or adnexal pathology
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28
Q

After sweeps and documental of maternal structures what do we do next?

A

Image fetal anatomy in groupings based on fetal position

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29
Q

What is opportunistic scanning?

A

Take what the fetus is showing you, we do this because sometimes it can be difficult or sometimes impossible to image some fetal anatomy if the fetus is not in an optimal position.

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30
Q

Where do we start with the fetal anatomy scans?

A
  1. After your sweep, decide which fetal anatomy is in the best position to image or document
  2. Start with whatever is “up”
    If the heart is visible, do that first because it is harder to get
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31
Q

What are the fetal anatomy groupings?

A
  1. Head
  2. Spine
  3. Abdomen
  4. Heart
  5. Limbs (upper and lower)
  6. Gender
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32
Q

What are some fetal head images?

A
  1. BPD, HC
  2. Ventricles
  3. Bilateral choroid image
  4. Cerebellar image/ posterior fossa
  5. Orbital image
  6. Nose lip image
  7. Face image
  8. Profile
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33
Q

When imaging the fetal head what should we look for?

A
  1. Asses the head shape
  2. High on the fetal head or cephalic on the fetus the head shape is round
  3. At the BPD level the fetal head is more oval
  4. Does the Calvarium have a smooth appearance?
  5. Is the head Dolichocephalic (narrow), Normal, Brachycephalic (wide)
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34
Q

Label the fetal head

A
  1. Transventricular plane
  2. BPD
  3. Transcerebelar
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35
Q

What is the BPD measurement criteria?

A
  1. Perpendicular to the Falx
  2. Symmetric hemispheres
  3. Measure the widest point across the skull
  4. Calipers placed from leading edge to leading edge
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36
Q

During the BPD image what do we assess?

A
  1. Cavum septi pellucidi
  2. The third ventricle
  3. Ambient cistern
  4. The falx cerbri
  5. Shape of the cranium
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37
Q

What does the ventricular image assess?

A
  1. The dependent ventricle (the ventricle farthest from the transducer)
  2. Echotexture of depended choroid
  3. Measurement of atrium size
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38
Q

What does the bilateral choroid image do?

A

Assess the echotexture of both choroid together

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39
Q

What is the Cerebellar image/ posterior fossa used for?

A
  1. Used to assess the cerebellar shape and size
  2. Presence and size of the cisterna magna
  3. Nuchal fold thickness
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40
Q

A large cisterna is a marker for what?

A

Aneuploidy

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41
Q

What is this an image of?

A

Dandy walker malformation. Cerebellar vermis is absent, cyst in cisterna magna

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42
Q

What is the orbital image used to assess?

A
  1. Hypertelorism (eyes too far apart)
  2. Hypotelorism (eyes too close together)
  3. Size of the orbits (micropthalmia = small eyes)
  4. Anopthalima (no eyes)
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43
Q

If we see lens during the orbital image what does this mean?

A

anopthalima

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44
Q

What is this an image of?

A

Orbital image

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45
Q

What is this an image of?

A

Fetal face image

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46
Q

What is this an image of?

A

Fetal face image

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47
Q

What is the nose lip image? and what is it used for?

A
  1. This image skims the nose and lip
  2. Tangential plane
  3. Taken to rule out Cleft lip and abnormal nostrils
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48
Q

What are these images of?

A

Nose lip image

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49
Q

How do we get a profile image?

A

Line up the forehead, nose and chin on this image

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50
Q

What is this an image of?

A

Profile shot

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51
Q

What do we assess in a profile image?

A
  1. Chin
  2. Nasal bone
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52
Q

What do we assess in the chin for the profile shot?

A
  1. Micrognathia: Small mandible
  2. Retrognathia: Receding Chin
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53
Q

What do we assess in the nasal bone for the profile image?

A
  1. If it presents >2.5mm
  2. Absent or hypoplastic
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54
Q

What is this an image of?

A

BPD (transthalamic view)

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55
Q

What is this an image of?

A

Posterior Fossa

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56
Q

What is this an image of?

A

Choroid

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57
Q

What are the fetal spine images taken in the 2nd trimester?

A
  1. Sagittal upper, mid, and lower spine
  2. TRX at the level of sacrum
  3. TRX kidneys with renal pelvisies
  4. Sagittal kidneys if possible
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58
Q

What area already assessed will help validate a normal spine?

A

Posterior fossa images for banana sign

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59
Q

How many ossification centers are there?

A

three

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60
Q

What are the only things visible on the fetal spine ultrasound?

A

Ossification centers

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61
Q

The anterior ossification center is what?

A

The vertebral body

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62
Q

The posterior ossifications are what?

A

Pedicle laminar junction

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63
Q

As the gestational age increases, the lamina does what?

A

Ossifies into a linear structure rather than circular

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64
Q

Ossification is not complete until which week?

A

18 weeks gestation

65
Q

We must view the spine on how many planes?

A
  1. TRX
  2. SAG
    *if you can not view in a sagittal plane, then a coronal view is acceptable)
66
Q

What images should we have for the fetal spine in sagittal?

A
  1. One image at distal end to include the sacrum
  2. One image at the cephalic end to include cervical spine into cranium
67
Q

What images should we have for the fetal spine in sagittal?

A
  1. One image at distal end to include the sacrum
  2. One image at the cephalic end to include cervical spine into cranium
68
Q

When imaging the spine we should include as many what as possible?

A

Vertebral ossifications in image as possible

69
Q

Most important thing to do for a spine image is to do what?

A

Sweep through spine in transverse

70
Q

How many images are taken for a TRX spine?

A
  1. One image taken at the lumbosacral junction
71
Q

What is this an image of?

A

SAG Cervical Spine

72
Q

What is this an image of?

A

SAG Lumbar and sacral spine

73
Q

When imaging the TRX spine at sacrum it is ideal to image what? and how?

A

Both iliac crests and all three ossification centers in transverse, with the transducer directly over spine “spine up”.

74
Q

When getting a TRX spine image at sacrum we should try to image away from where? what else is seen here?

A
  1. try to image spine away from uterine wall
  2. Fetal bladder is seen as well
75
Q

Where are the kidneys located on 2nd trimester scan?

A
  1. Either side of the spine
  2. Lack distinction during this trimester
76
Q

What is the dimensions of the kidneys during this trimesters?

A

Over 5mm is the upper limit

77
Q

What is the sonographic appearance of the renal pelvises around this trimester?

A

hypoechoic and minimally dilated up to 3mm

78
Q

What should we assess from the images of the kidneys?

A

Compare the size of them to see if they are normal or abnormal

79
Q

How should the kidneys present in this trimester?

A

Spine in middle

80
Q

Longitudinal images of the kidneys are done when?

A

If any abnormality is detected in the kidney such as
1. Hydronephrosis
2. Renal cysts

81
Q

What is this an image of?

A

TRX kidneys

82
Q

What is this an image of?

A

SAG kidneys

83
Q

Where are the adrenals located on the fetus during this trimester?

A

Superior and medial to kidneys

84
Q

What is the sonographic appearance of the adrenals during this trimester?

A

Hypoechoic with echogenic centers

85
Q

What is this an image of?

A

Neonatal adrenal

86
Q

What are the fetal abdomen images we need to take?

A
  1. Abdominal circumference
  2. Stomach
  3. Cord insertion into abdomen
  4. Bladder
  5. Two umbilical arteries
  6. Three vessel cords

+/- SAG diaphragm with stomach and heart (can be imaged with abdomen or with heart)

87
Q

What does Abdominal circumference (AC) assess?

A
  1. Presence of stomach and position of organs
  2. Is the stomach on the left side?
88
Q

What might/might not be seen during the abdominal circumference image?

A
  1. The GB may be seen.
    - Do not confuse it for the stomach
    - IT is ovoid looking and is on the right side
  2. Should only see one stomach bubble
89
Q

What are some landmarks of the AC image?

A
  1. Stomach
  2. Umbilical vein draining into portal sinus
  3. Round shape
  4. Rib symmetry (unbroken ribs)
  5. Adrenal glands
  6. Spine
90
Q

What does the fetal bladder look like during this trimester?

A
  1. Anechoic structure between iliac crests
  2. Should fill and empty every 20 minutes
91
Q

What does the presence of the bladder indicate?

A

At least one functioning kidney

92
Q

What is this an image of?

A

Fetal bladder

93
Q

When we get an image of the cord insertion into fetal abdomen what do we need to do?

A

Ensure clear, unobstructed visualization of cord insertion with no fetal parts in the way

94
Q

What is this an image of?

A

Cord insertion into fetal abdomen

95
Q

What does the umbilical cord look like in TRX during this trimester? What should we see?

A
  1. Looks like micky mouse ears.
  2. Two arteries and one vein
96
Q

Where and why should we image the umbilical cords

A

Image the cord insertion into fetal abdomen to check for abdominal wall defects

97
Q

Where is the insertion into the placenta?

A

The cord should insert into the placenta more than 2 cm away from the edge of the placenta

98
Q

When we image the Umbilical cord what can be associated with congenital abnormalities?

A

2 VC and 1 UA. Fetal echo is indicated when identified

99
Q

When imaging the 2 umbilical arteries at bladder what should we identify?

A
  1. Right and left umbilical arteries around bladder
  2. Document this view
  3. Add colour doppler or power doppler
100
Q

If we want to image the two umbilical arteries at bladder how should we proceed?

A
  1. Angle obliquely inferior from CI to include bladder
  2. Must see colour fill continuously from CI forking around bladder w/o interruption
  3. If done correctly, this proves 3VC
  4. two UA become hypogastric/ internal iliac arteries
101
Q

Where does the cord insert into?

A
  1. Fetal abdomen
  2. Placenta
    >2cm from placental edge
102
Q

What can be imaged with the longitudinal image of abdomen and chest?

A

Abdomen or with heart

103
Q

Why do we take a longitudinal image of abdomen and chest?

A
  1. Assess location of stomach in relation to diaphragm
  2. Assess echotexture of lungs compared to liver
104
Q

For the longitudinal image of abdomen and chest, how should the echotexture of lungs compare to the liver?

A
  1. Should be isoechoic to lungs in the 2nd trimester
  2. Slightly increased echogenicity to liver in the 3rd trimester
105
Q

What structures should be included in the longitudinal abdomen and chest image?

A
  1. Heart
  2. Diaphragm
  3. Stomach
    these images are relative to position of the baby/ fetal lie
106
Q

How does the bowel appear during the 2nd trimester?

A

Appears as a cluster of rings bordered by large bowel

107
Q

How does the colon (large bowel) appear in the 3rd trimester?

A

May contain meconium particles and appear hypoechoic and prominent

108
Q

How big is the large bowel at term?

A

17mm at term

109
Q

What images do we take of the heart during the 2nd trimester?

A
  1. 4 chamber
  2. IVS (Horizontal 4CH)
  3. M-mode heart tracing
  4. Left outflow tract
  5. Right outflow tract
  6. Three vessel view
  7. Heart axis/ situs
110
Q

How do we locate the 4CH in this trimester?

A

From on- axis fetal abdomen AC view, slide cephalic on baby to find

111
Q

How do we find LVOT, RVOT, three vessel view during this trimester?

A

From 4CH keep tilting superior to locate

112
Q

Why do we take a 4 chamber view of the fetal heart?

A

To assess the size of all chambers and valve placement

113
Q

Why do we take an M-mode image of the fetal heart?

A

To measure fetal heart rate

114
Q

What is the significance of this image?

A

This is the level you would do a chest circumference if needed. Not routinely done

115
Q

What do we look for on a 4CH view for this trimester?

A
  1. Heart position: located left of midline
  2. Heart axis: apex points about 45 degrees to the left
  3. Heart size: occupies about 1/3 of the chest
116
Q

How do we optimize our fetal heart image?

A
  1. Use fetal echo preset
  2. Decrease sector width
  3. Zoom
  4. Increase contrast
117
Q

What is the situs of the organs?

A

Stomach and heart are both on the fetal left

118
Q

Why do we need to know the situs of the organs?

A
  1. Need to know fetal position
  2. Where is the spine
  3. Which side of baby is down/up
119
Q

What is this a image of?

A

Intraventricular septum view of the fetal heart

120
Q

What is this an image of from left to right

A

LVOT and RVOT

121
Q

What are outflow images done for?

A

To rule out vessel abnormalities

122
Q

What is this an image of?

A

Left outflow of the heart

123
Q

What is this an image of?

A

Right outflow

124
Q

What is this an image of ?

A

Three vessel view

125
Q

What structures are primarily focused on for a three vessel view?

A
  1. MPA
  2. AO
  3. SVC
126
Q

What is the size of the structures of the three vessel view from largest to smallest?

A
  1. MPA
  2. AO
  3. SVC
127
Q

What are the steps to getting a cine clip demonstrating the fetal heart for the 2nd trimester?

A
  1. Beginning at the fetal stomach in transverse plane
  2. Slowly sweep cephalic on the fetus
128
Q

What should be demonstrated on the fetal heart cine clip?

A
  1. Stomach
  2. 4CH
  3. LVOT
  4. RVOT
  5. Three chamber view
129
Q

The fetal heart is in which plane in the fetal chest?

A

Horizontal

130
Q

While performing the cine clip from the four chamber view, the LVOT should appear how? The RVOT?

A

Without any change in the transducer plane just tilting. The RVOT should follow

131
Q

While performing the clip when and where should the three vessel view appear?

A

Left and just superior to the RVOT

132
Q

What are some images we take for the fetal limbs?

A
  1. Femur length
  2. Humerus length
  3. Lower limbs (tib/tib)
  4. Upper limbs (rad/ulna)
  5. Foot/ ankle angles
  6. Feet - palmer view
  7. Hands
133
Q

Can all bones be assessed on ultrasound?

A

Yes

134
Q

Routinely the femur is measured at each visit starting when?

A

> 14 weeks

135
Q

The humerus is measured when?

A

During the 2nd trimester detailed exam

136
Q

What do we do for bone scans?

A

Assess for
1. Size
2. Presence
3. Shape
*To assess for skeletal dysplasia or aneuploidy

137
Q

What are the criteria for measuring Femur length?

A
  1. Must be perpendicular to sound beam and straight
  2. Measure femur closest to transducer (image both left and right)
  3. Both Ends of bone clearly visible
  4. Calipers placed at each end of the bone, bisecting the shaft
  5. Only measure diaphysis
138
Q

When is the epiphysis seen?

A

> 32 weeks

139
Q

How do we make the femur perpendicular?

A

Heal/toe

140
Q

What are some lower limbs bones we scan?

A
  1. Femur
  2. Tibia
  3. Fibula
141
Q

What do we need to remember about the lower limb bones?

A
  1. Tibia is thicker than fibula
  2. Tibia is medial
142
Q

What is this an image of?

A

Rt and Lt ankle

143
Q

What are the upper limb bones we image?

A
  1. Humerus
  2. Forearm (radius and ulna)
144
Q

What is something we need to remember about the radius and the ulna?

A
  1. The ulna is medial and forms elbow joint
  2. The radius is lateral and forms wrist joint
145
Q

In what instances would you be required to measure all long bones?

A

Syndromes and chromosomal abnormalities

146
Q

What are the long bones that we would image?

A

Right and Left
1. Tibia and fibula
2. Femur
3. Radius and Ulna
4. Humerus
5. Clavicles
6. Chest circumference

147
Q

What is this an image of?

A

Clavicles

148
Q

Is the genitalia routinely documented?

A
  1. Yes (site dependent)
  2. Important to document with twins and suspected sex linked syndromes
149
Q

What are the pitfalls of imaging genitalia in the 2nd trimester?

A
  1. The labia can be swollen and be mistaken for a scrotum
  2. Testicles do not descend until 28 weeks gestation
  3. Scrotum can be tucked up between legs
  4. Position dependent - legs need to be open
  5. Breech babies are difficult to see
150
Q

What is the sign we kind use to find out the gender here?

A

This is a female FYI
1. Hamburger sign
2. Female: 3 parallel lines signifying interfaces of the labia

151
Q

What gender is this child? and how do we know?

A

This is a male
1. We use the turtle sign to figure out the gender
2. Turtle = visible penis and scrotum

152
Q

When is amniotic fluid measured?

A

2nd trimester detailed assessment

153
Q

A subjective assessment of amniotic fluid is observed when?

A

When the fluid is
1. Subjectively decreased
2. Subjectively increased

154
Q

What is the DVP?

A

Deepest vertical pocket of fluid and what is measured

155
Q

When is AFI (amniotic fluid index) measured?

A

26-28 weeks

156
Q

Amniotic fluid increase until when?

A

34 weeks then slowly diminishes

157
Q

Amniotic fluid is mostly produced by what?

A

Fetal urinary system.
to lesser extents by the umbilical cord, lungs, and skin in early pregnancy

158
Q

What is the vernix?

A

Skin cells floating in the fluid

DMST 244 Obstetrics and Gyn Sonography 1 (22 decks)

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