1st Trimester Anatomy & Pathology 12%

Question 1

What is the minimum international reference preparation value for bHCG that indicates a gestational sac should definitely be visualized by transabdominal ultrasound?

a. 1000 units/ml
b. 1500 units/ml
c. 2000 units/ml
d. 4000 units/ml

Answer 1

D
IRP levels for transabdominal ultrasound = 4000 units/ml is the minimum bHCG level for identifying an intrauterine pregnancy.

Question 2

Which of the following is most suggestive of an inevitable abortion?

a. cervical dilatation over 3cm
b. spotting for 2 days
c. cervical length over 3cm
d. presence of vernix in the amniotic fluid

Answer 2

A

Inevitable abortion = bleeding more than 1 week, cramping, PROM, cervical shortening <3cm, dilatation > 2cm.

Question 3

When evaluating the ductus venosus with spectral Doppler:

a. color Doppler is used to demonstrate the umbilical vein, ductus venosus and heart in the same image
b. high filter settings and slow sweep speed are preferred
c. a left parasagittal view of the fetal trunk is obtained
d. a 2-3mm sample is used

Answer 3

A
To evaluate the DV, obtain a right parasagittal view of the fetal trunk and apply color Doppler to demonstrate the umbilical vein, ductus venosus and heart. A 1mm or less sample volume is used to avoid sampling adjacent vessels. A cursor angle of less than 30 degrees should be used for the sample. Low filter settings and fast sweep speed will best display the A-wave. A normal ductus venosus waveform is biphasic with a positive A-wave. An abnormal ductus venosus waveform demonstrates a negative or reversed A-wave.

Question 4

Fetal cardiac activity can first be visualized with transvaginal sonography at approximately what gestational age?

a. 5 weeks
b. 6 weeks
c. 6.5 weeks
d. 7 weeks

Answer 4

B
Transvaginal approach:
gestational sac @ 4 wks
yolk sac @ 5.5 wks
heart @ 6 wks

Question 5

What abnormality occurs when two sperm fertilize the same egg?

a. trisomy 18
b. trisomy 21
c. triploidy
d. autosomal dominant x-linked disorder

Answer 5

C

An egg that is fertilized by two sperm will have an extra full set of chromosomes = triploidy

Question 6

Which of the following is a sonographic sign of an abnormal 8 week intrauterine pregnancy?

a. yolk sac diameter 5mm
b. double bleb sign
c. gestational sac located in the lower uterine segment
d. fetal heart rate of 120bpm

Answer 6

C
If the gestational sac implants in the lower uterine segment, the risk of spontaneous abortion is increased significantly. The yolk sac is not abnormal until the diameter exceeds 6mm.

Question 7

The AIUM defines a late 1st trimester ultrasound evaluation as an exam performed on a fetus that is between:

a. 9 and 11 weeks
b. 10 and 12 weeks 6 days
c. 12 and 13 weeks 6 days
d. 11 and 13 weeks

Answer 7

C
The AIUM defines a late 1st trimester ultrasound evaluation as an exam performed on a fetus that is between 12 weeks and 13 weeks 6 days.

Question 8

Which of the following is a sign of impending fetal demise?

a. Robert sign
b. Deuel sign
c. irregular gestational sac shape
d. Spalding sign

Answer 8

C
Expected poor outcomes include: irregular sac shape, low sac position, thin trophoblastic reaction, weakly echogenic trophoblastic reaction, heart rate <100bpm, abnormal yolk sac size and shape, and calcified yolk sac. The other three choices are sonographic signs of demise that are seen several days after demise occurs.

Question 9

Which of the following is NOT commonly associated with anencephaly?

a. oligohydramnios
b. exophthalmos
c. macroglossia
d. increased MSAFP

Answer 9

A
Anencephaly is seen with other spinal defects, exophthalmos (bulging eyes), macroglossia and polyhydramnios. Increased MSAFP is a clinical sign of anencephaly.

Question 10

A patient presets for a fetal viability scan with an LMP 10 weeks ago. She has been experiencing light vaginal spotting for the last week. The transvaginal exam demonstrates a 2 cm cresent shaped hypoechoic area between the chorion and right uterine wall. These findings are most suggestive of:

a. partial molar pregnancy
b. subchorionic hemorrhage
c. placental abruption
d. normal first trimester pregnancy

Answer 10

B
A subchorionic hemorrhage causes vaginal spotting in the first trimester. Bleeding occurs between the uterine wall and the chorion. The fluid accumulations are typically cresent shaped. Most resolve spontaneously, but can lead to spontaneous abortion.

Question 11

During fetal development, which of the following describes the maternal component of the placenta?

a. chorion frondosum
b. amniotic membrane
c. decidua basalis
d. decidua capsularis

Answer 11

C
The chorion frondosum refers to the fetal portion of the placenta located within the gestational sac. The decidua basalis refers to the placental tissue attached to the uterine wall.

Question 12

Crown rump length (CRL) measures 7mm. What is the estimated gestational age of the pregnancy?

a. 7 weeks
b. 10 weeks
c. 5 weeks
d. 8 weeks

Answer 12

A
Gestational age (days) = CRL + 42
GA = 7mm + 42 = 49 days
49 days = 7 weeks

Question 13

Visualization of which of the following can help differentiate a normal intrauterine pregnancy (IUP) from a pseudo-gestational sac associated with an ectopic pregnancy?

a. corpus luteal cyst
b. increased blood flow velocity in the uterine arteries
c. decreased resistance to flow in the uterine arteries
d. yolk sac

Answer 13

D
A gestational sac in the uterus with a yolk sac indicates an IUP is present. A pseudo-sac seen in the uterus with an ectopic pregnancy would not contain a yolk sac. Both an ectopic and normal IUP can demonstrate a corpus luteal cyst and decreased resistance in the uterine arteries because these changes occur due to hormone stimulation that occurs with both types of pregnancy.

Question 14

The gestational sac with __________ are the first signs of an intrauterine pregnancy seen with ultrasound.

a. fluid in the endometrial canal
b. decidual reaction of the endometrium
c. a corpus luteal cyst
d. fluid in the posterior cul-de-sac

Answer 14

B
The first sign of an IUP seen on ultrasound is the gestational sac with decidual reaction in implantation. Double decidual sac sign or intradecidual sign due to implantation seen at 5.5-6 weeks. If a patient with suspected pregnancy demonstrates a fluid filled structure in the endometrial canal, but no decidual reaction, the patient should be thoroughly evaluated for ectopic pregnancy.

Question 15

During fetal development, which of the following describes the fetal component of the placenta?

a. chorion frondosum
b. decidua basalis
c. amniotic membrane
d. decidua capsularis

Answer 15

A
The chorion frondosum refers to the fetal portion of the placenta located within the gestational sac. The decidua basalis refers to the placental tissue attached to the uterine wall.

Question 16

Megacystitis in a first trimester is diagnosed when the bladder length is greater than or equal to:

a. 5mm
b. 10mm
c. 7mm
d. 3mm

Answer 16

C
Megacystitis in a first trimester is dignosed when the bladder length is greater than or equal to 7mm. It can be associated with aneuploidy.

Question 17

The yolk sac is considered normal in size when the inner diameter is less than ________.

a. 3mm
b. 5mm
c. 6mm
d. 8mm

Answer 17

C

A yolk sac > 6mm usually indicates a blighted ovum or fetal abnormalities if a fetal pole is detected.

Question 18

When is PW Doppler appropriate to evaluate the first trimester fetus?

a. when IUGR is suspected
b. PW Doppler should never be used to evaluate a first trimester
c. when aneuploidy is suspected
d. when fetal anemia is suspected

Answer 18

C
PW Doppler should not be used on the standard first trimester exam. If aneuploidy, skeletal dysplasia or congenital heart disease is suspected, then it is appropriate to evaluate the ductus venosus and the tricuspid valve. Care must be taken to keep the Thermal Index at or below 0.7. IUGR and anemia are not typically diagnosed until the 2nd trimester or later.

Question 19

The most common location of an ectopic pregnancy is:

a. cervical
b. ampulla
c. isthmus
d. interstitial

Answer 19

B

The most common location for ectopic pregnancy is in the ampullary portion of the fallopian tube.

Question 20

Which of the following is responsible for the symptoms of early pregnancy, such as nausea and vomiting?

a. bHCG
b. AFP
c. progesterone
d. estrogen

Answer 20

C
Progesterone:
Responsible for premenstrual symptoms and symptoms of pregnancy (N/V)
Responsible for endometrial proliferation AFTER ovulation to prepare for implantation
Blocks the development of new follicles
Stimulates uterine blood supply for pregnancy
Causes breasts to prepare for lactation but inhibits lactation during pregnancy
Causes formation of cervical mucus plug in pregnancy

Question 21

All of the following are signs of embryonic demise, except:

a. double bleb sign
b. 7mm yolk sac
c. distorted gestational sac
d. calcified yolk sac

Answer 21

A
The double bleb sign is a sign of an early intrauterine pregnancy. An enlarged or calcified yolk sac is a sign of embryonic demise. A distorted or irregular gestational sac is also indicative of demise.

Question 22

A 26 year old patient presents with a positive pregnancy test and an approximate age of 7 weeks 3 days from her LMP. Beta hCG levels are significantly higher than a 7 week gestation. The exam shows a large heterogeneous solid mass measuring 6 x 4 x 3 cm within the endometrial cavity. The uterus measures 10 x 6 x 5cm. What is the most likely explanation for the sonographic findings described?

a. heterotopic pregnancy
b. leiomyosarcoma
c. hydatidiform mole
d. Chorioadenoma destruens

Answer 22

C
A hydatidiform molar pregnancy is an abnormality of the placenta and rarely involves the formation of a fetus. It is marked by high levels of Human Chorionic Gonadotropin (hCG). Molar pregnancies grow much more rapidly, compared to normal fetal growth. It has the appearance of a large and random collection of grape-like cell clusters. In some cases it can be malignant and requires chemotherapy or radiation treatment after surgical removal.

Question 23

Which of the following carries the lowest risk of spontaneous abortion?

a. cervical os dilated to 4cm
b. gestational sac implanted in the endometrial cavity near the uterine cornua
c. vaginal spotting for the last ten days
d. significant leakage of amniotic fluid

Answer 23

B
If the gestational sac implants in the lower uterine segment, the risk of spontaneous abortion is increased significantly. Other causes for increased risk of spontaneous abortion include cervical dilation > 3cm, PROM, extended period of bleeding (1 wk +).

Question 24

Which of the following is the recommended method to document fetal number in an early pregnancy?

a. count the number of amniotic sacs, with or without an embryo
b. count the number of visible embryos
c. count the number of areas with early placental formation
d. count the number of yolk sacs present in the gestational sac(s)

Answer 24

B
When documenting fetal number, only count embryos. Incomplete fusion of the amnion and chorion or elevation of the chorionic membrane by intrauterine hemorrhage can mimic the appearance of a second sac.

Question 25

Which of the following early embryologic structures procedure progesterone? a. morula b. blastocyst c. trophoblastic cells d. zygote

Answer 25

C Trophoblastic cells produce progesterone and bhCG in very early pregnancy. These cells develop into the chorionic villi of the placenta.

Question 26

Which of the following types of twin gestation will have the highest risk for conjoined twins? a. monochorionic/monoamniotic b. monochorionic/diamniotic c. dichorionic/diamniotic d. dizygotic

Answer 26

A A diamniotic twin gestation will produce two separate amniotic sacs. A membrane will be identified that separates the fetuses. A monoamniotic twin gestation will have no membrane to separate the fetuses. The absence of this membrane leads to increased risk for cord entanglement, nuchal cord and conjoined twins.

Question 27

Which of the following types of twin gestation will have the thickest membrane between the fetuses? a. conjoined twins b. monochorionic/monoamniotic c. dichorionic/diamniotic d. monochorionic/diamniotic

Answer 27

C A dichorionic diamniotic twin gestation will produce two separate placentas and two amniotic sacs. A membrane will be identified that separates the fetuses. The membrane will be greater than 2mm in thickness.

Question 28

When evaluating a first trimester fetus, the reported crown rump length should be: a. the largest of at least 3 measurements b. the average of at least 3 measurements c. the largest of at least 5 measurements d. the smallest of at least 3 measurements

Answer 28

B When evaluating a first trimester fetus, the reported crown rump length should be the average of at least 3 measurements.

Question 29

Which of the following statements regarding twins is true? a. conjoined twins are caused by cleavage of the morula within the first 4 days of pregnancy b. identical twins are always dizygotic c. dizygous twins are always the same gender d. most monozygous pregnancies are diamniotic

Answer 29

D Identical twins are always monozygotic. Monozygous twins are always the same gender. Conjoined twins are caused by cleavage of the morula after the 13th day of pregnancy. Most monozygous pregnancies are diamniotic.

Question 30

What is the most common cause of demise in the first trimester? a. chromosomal abnormalities b. prior history of abortion c. maternal smoking d. uterine trauma

Answer 30

A | The most common cause of demise in the first trimester is due to chromosomal abnormalities.

Question 31

Which of the following describes the sonographic appearance of a normal nasal bone in a 1st trimester fetus? a. three parallel lines that are perpendicular to the frontal brone b. two parallel lines, resembles an equals sign (=) c. single linear reflection that is parallel to the maxilla d. an echogenic foci at the tip of the nose

Answer 31

B The normal nasal bone in a fetus is identified as a hyperechoic line that is posterior to the echogenic skin line. The nasal bone should be greater echogenicity to the skin reflection. The two echogenic lines are parallel and said to resemble an = sign.

Question 32

Which of the following demonstrates the lowest risk of embryonic demise? a. thin, mildly echogenic trophoblastic reaction b. multiple lobulations of the gestational sac c. TV ultrasound identifies a gestational sac with MSD 12mm and 5mm yolk sac but no embryo d. implantation in the lower uterine segment

Answer 32

C Indications for embryonic demise include distorted sac shape, thin and weakly echogenic trophoblastic reaction, low implantation site. On TV ultrasound, an embryo should be identified with a 16mm or greater MSD. A yolk sac less than 5.6mm in diameter is normal. The yolk sac should be identified with a 8mm or greater MSD.

Question 33

A normal ductus venosus waveform in the first trimester fetus demonstrates: a. a biphasic pattern with antegrade A-wave b. a continuous antegrade flow pattern with limited pulsatility c. a biphasic pattern with retrograde A-wave d. a triphasic flow pattern with 2 phases moving in the retrograde direction

Answer 33

A In the 1st trimester, a normal ductus venosus waveform is biphasic with a positive A-wave. An abnormal ductus venosus waveform demonstrates a negative or reversed A-wave, which suggests aneuploidy may be present.

Question 34

The _______ forms the outer layer of the placenta that is in contact with the endometrium. a. yolk sac b. blastocyst c. chorion d. amnion

Answer 34

C | The chorion forms the outer layer of the placenta that is in contact with the endometrium.

Question 35

The chorionic villi and membrane are formed from the: a. yolk sac b. trophoblastic cells c. blastocyst d. amnion

Answer 35

B Trophoblastic Cells: produce progesterone and hCG, involved with implantation, develop into chorionic villi then into placenta.

Question 36

The discriminatory bhCG level refers to: a. bhCG levels associated with ectopic pregnancy b. bhCG levels associated with molar pregnancy c. bhCG levels in blood that correspond with the first possible sonographic visualization of the gestational sac d. bhCG levels in blood that MUST correspond with the sonographic visualization of the gestational sac

Answer 36

D The discriminatory bhCG levels refers to bhCG levels in blood that MUST correspond with the sonographic visualization of the gestational sac, (5w2d). The threshold levels refers to bhCG levels in blood that correspond with the first possible sonographic visualization of the gestational sac, (4w3d).

Question 37

All of the following are layers of the endometrium that form with pregnancy, except: a. decidua capsularis b. decidua parietalis c. decidua basalis d. decidua accreta

Answer 37

D Decidua Capsularis: tissue that envelops the blastocyst after implantation Decidua Basalis: becomes maternal placenta, blastocyst attaches to this layer Decidua Parietalis: other tissue not involved in the implantation process

Question 38

The number of yolk sac: a. can be used to determine the amnionicity of the mutlifetal pregnancy b. is irrelevant in first trimester ultrasound evaluation c. can be used to determine the chorionicity of the multifetal pregnancy d. can only be assessed with transvaginal ultrasound

Answer 38

A The number of the yolk sacs can be used to determine the amnionicity of the multifetal pregnancy. 2 embryos + 2 yolk sacs = diamniotic pregnancy; 2 embryos + 1 yolk sac = monoamniotic pregnancy

Question 39

A patient presents for a pelvic ultrasound due to pain and bloating. Her LMP was 5 weeks ago and and bhCG levels are at 10unit/ml. A mild amount of anechoic fluid is noted in the posterior cul de sac. All of the following are a potential cause for the fluid accumulation, except: a. ovulation b. ruptured appendix c. endometriosis d. ectopic

Answer 39

D The bhCG levels indicate there is no pregnancy present. An ectopic pregnancy would cause bhCG levels of 1000units/ml plus in a 5 week gestation.

Question 40

Using transvaginal sonography, the yolk sac can be identified as early as week ____ of the pregnancy. a. 3 b. 4 c. 5 d. 6

Answer 40

C Using transvaginal sonography, the yolk sac can be identified as early as week 5 of the pregnancy. Using transabdominal sonography, the yolk sac can be identified as early as week 7 of the pregnancy.

Question 41

Which of the following signs indicates an abnormal early pregnancy? a. Chadwick sign b. Murphy sign c. Cullen sign d. Hegar sign

Answer 41

C The Cullen sign indicates the presence of bluish discoloration around the maternal umbilicus. The discoloration is associated with an intraperitoneal hemorrhage. A ruptured ectopic could cause the bleed. Pain, bleeding and a positive pregnancy test accompanied by the Cullen sign is highly suspicious for a ruptured ectopic. Hegar sign refers to the softening of the lower uterine segment with pregnancy. The OB physician will palpate the uterus during the pelvic exam. Chadwick sign refers to the bluish discoloration of the vaginal walls due to engorgement of the veins. This is a normal finding in early pregnancy. The OB physician will visualize this sign of the pelvic exam.

Question 42

A patient presents with an LMP of 7 weeks 4 days. The script states the fundal height is large for gestational age and acute onset of systemic HTN. These clinical findings are most suggestive of: a. multiple pregnancy b. heterotopic pregnancy c. ectopic pregnancy d. molar pregnancy

Answer 42

D | Acute onset of Maternal HTN in the first trimester is a strong indicator of a molar pregnancy.

Question 43

The embryo and yolk sac can be seen with TV ultrasound as early as: a. 4 weeks b. 5.5 weeks c. 4.5 weeks d. 6.5 weeks

Answer 43

B | The embryo and yolk sac can be seen with TV ultrasound as early as 5.5 weeks.

Question 44

Which of the following describes the function of the chorionic villi? a. to produce white blood cells b. to produce red blood cells c. to provide nourishment to the fetal blood d. to maintain intraplacental pressure

Answer 44

C Maternal blood enters the intervillous spaces to deliver nutrients and oxygen to the fetus through the chorionic villi of the placenta. Waste products are excreted into the blood before it exits the spaces to return to the maternal circulatory system.

Question 45

A 25 year old patient presents for a first trimester scan with uterine size consistent with a 12 week fetus but the LMP indicates a 7 week pregnancy. You identify a mass of mottled tissue with cystic components and internal blood flow that occupies the fundus of the uterine cavity. There is also a gestational sac with a 4mm embryo identified in the inferior portion of the endometrial canal. Which of the following best describes these findings? a. fundal uterine contraction with an impending abortion b. lower uterine segment ectopic c. adenomyosis with an impending abortion d. partial molar pregnancy

Answer 45

D A partial molar pregnancy will demonstrate a molar pregnancy that coexists with an IUP. The IUP can be normal or abnormal. If it is abnormal, triploidy is a common finding. Larger than dates is a common symptom of molar pregnancy due to the excessive overgrowth of the trophoblastic tissues.

Question 46

What cardiac view is used to document proper fetal heart position on a first trimester exam? a. left ventricular outflow tract view b. aortic arch view c. 4 chamber view d. 3 vessel trachea view

Answer 46

C Color Doppler can be used to demonstrate the fetal heart structure when screening for suspected defects. The 4 chamber view and 3 vessel trachea view can be documented later in the first trimester. The 4 chamber view is used to document chamber size, heart position, cardiac axis. The cardiac axis can more easily displayed using the 4 chamber view and color Doppler.

Question 47

Which of the following is associated with an inevitable abortion, but is not present with a threatened abortion? a. dilated cervix b. low implantation site c. bleeding d. cramping

Answer 47

A Threatened abortion: cramping, bleeding, closed cervix Inevitable abortion: bleeding more than one week, cramping, cervical dilation A low implantation site can be associated with both types of abortions.

Question 48

Which of the following is/are a sign of spina bifida in a 13 week fetus? a. narrow brainstem and dilated cisterna magna b. obliterated cisterna magna and intracranial translucency c. lemon sign d. banana sign

Answer 48

B In early pregnancy, the signs of spina bifida include compression of the choroid, intracranial translucency, and obliterated cisterna magna with an enlarged brainstem. These changes occur due to the posterior shift of the cranial contents. The typical banana and lemon sign are not well demonstrated in the first trimester because the cerebellum is not fully formed and the cranium is not fully ossified. Evaluation of the skin line can demonstrate the open defect, but vertebral evaluation is limited at this age.

Question 49

Which of the following is a characteristic of an incomplete abortion? a. slower than expected increase in hCG b. 1-2mm endometrial stripe c. amenorrhea d. slower than expected decrease in hCG levels

Answer 49

D Incomplete abortion occurs when only a portion of the products of conception expelled from uterus. Sonographic findings include thick, irregular endometrium with fluid in canal. Symptoms include cramping, bleeding, decreasing hCG, but slower than expected if a complete abortion has occurred.

Question 50

The embryo is most sensitive to teratogenic effects between _________ gestation. a. 4 and 7 weeks b. 2 and 4 weeks c. 3 and 8 weeks d. 6 and 10 weeks

Answer 50

C | The embryo is most sensitive to teratogenic effects between 3 and 8 weeks.

Question 51

One yolk sac with two embryos indicates: a. impending fetal demise b. monoamniotic twins c. diamniotic twins d. dichorionic twins

Answer 51

B | One yolk sac with two embryos indicates monoamniotic twins.

Question 52

On transvaginal ultrasound, the minimum mean sac diameter that should always demonstrate a yolk sac in a normal IUP is: a. 20cm b. 10mm c. 5mm d. 8mm

Answer 52

D On transvaginal ultrasound, a mean sac diameter > 8mm should demonstrate a yolk sac in a normal IUP and on transabdominal ultrasound a mean sac diameter >20mm should demonstrate a fetal pole in a normal IUP.

Question 53

Which of the following statements is correct regarding multifetal pregnancy? a. fetus A is always the fetus closest to the uterine fundus b. fetus B is always the fetus closest to the internal os c. easiest to determine amnionicity/chorionicity in the first trimester, around 8 weeks gestation d. multifetal pregnancies have a reduced risk of complications compared to a singleton pregnancy

Answer 53

C When scanning multiple gestations, it is easiest to determine amnionicity/chorionicity in the first trimester, around 8 weeks gestation. It is also important to document fetal number, placental location and number and look for a separating membrane. Fetus A is always the fetus closest to the internal os. If more than 2 fetuses present, document the other fetal locations relative to Fetus A and location in uterus.

Question 54

An asymptomatic patient presents for a viability scan in the first trimester. The ultrasound exam demonstrates a fetal pole that measures at 7 weeks 2 days. A 7mm yolk sac is identified. The fetal HR is evaluated by m-mode and is estimated at 79bpm. There is no evidence of subchorionic hemorrhage. Which of the following statements is true? a. a blighted ovum is present b. the yolk sac is abnormally enlarged but the fetal heart rate is normal c. the fetal heart rate indicates potential demise but the yolk sac is normal d. the yolk sac is abnormally enlarged and the fetal heart rate is lower than normal

Answer 54

D There is not a fetal pole present in a blighted ovum. The normal yolk sac measures less than 5.6mm in internal diameter. A fetus 6-9 weeks should have a heart rate over 100bpm. After 9 weeks the heart rate should stay above 140bpm. The average heart rate in the second trimester is 120-160bpm.

Question 55

Mild tricuspid regurgitation in a first trimester fetus is suggestive of: a. maternal diabetes b. normal fetus c. aneuploidy d. IUGR

Answer 55

C Tricuspid regurgitation of any level is suggestive of aneuploidy. Trisomy 13, 18 and 21 have been associated with tricuspid regurgitation in the 1st trimester.

Question 56

Average normal heart rate in an early first trimester pregnancy is _________. a. 100-115bpm b. <137bpm c. 120-160bpm d. <100bpm

Answer 56

A | Average normal heart rate in an early first trimester pregnancy is 100-115bpm.

Question 57

The first trimester of pregnancy is defined as: a. weeks 4-13 b. weeks 1-13 c. weeks 6-14 d. weeks 6-12

Answer 57

``` B Pregnancy consists of 3 trimesters: 1st trimester - week 1 through 13 2nd trimester - week 14 through 28 3rd trimester - week 29 until delivery ```

Question 58

Implantation of the fertilized egg occurs day ________ of the pregnancy. a. 20-23 b. 18-20 c. 15-18 d. 30-33

Answer 58

A | Implantation of the fertilized egg occurs day 20-23 of the pregnancy.

Question 59

How are the long bones of the extremities evaluated in a 13 week fetus with suspected cardiac defects? a. measure the femur length and compare to the humeral length b. document that there are at least two long bones in each extremity c. document 3 long bones are present in each extremity d. the thickness of the femoral diaphyses are documented

Answer 59

C When evaluating a late 1st trimester fetus (12 - 13 weeks 6 days), 3 long bones per extremity should be documented. Long bone length measurements are reserved for cases of suspected skeletal dysplasia. The femur cannot be reliably measured until after 14 weeks gestation.

Question 60

Which of the following correctly describes how to perform a crown rump length on a 13 week fetus? a. fetal neck in neutral position with fluid between the fetal chin and anterior neck b. measurement should demonstrate a straight line, perpendicular to the long axis of the fetus c. calipers placed on the inner edge of the skin of the fetal head and rump d. parasagittal plane with the profile, spine, and rump visible

Answer 60

A Crown Rump Length: Fetus fills 2/3 of the field of view Midsagittal plane with the profile, spine, and rump visible Fetal neck in neutral position with fluid between the fetal chin and anterior neck Calipers placed on the outer edge of the skin of the fetal head and rump Measurement should demonstrate a straight line, parallel to the long axis of the fetus 3 measurements are taken and the average reported

Question 61

The "twin peak" sign is associated with what type of pregnancy? a. diamniotic/monochorionic b. monoamniotic/monochorionic c. diamniotic/dichorionic d. all monozygotic

Answer 61

C The twin peak sign refers to a triangular projection of placental tissue extending from the placental surface at the point where the two gestational sacs touch.

Question 62

With transabdominal ultrasound, a blighted ovum is diagnosed with a mean gestational sac diameter greater than ______ without a fetal pole present. a. 20mm b. 35mm c. 15mm d. 25mm

Answer 62

D A blighted ovum is diagnosed with a mean gestational sac diameter greater than 25mm without a fetal pole present on a transabdominal ultrasound. A mean gestational sac diameter greater than 16mm without a fetal pole present on a transvaginal ultrasound also indicates anembryonic gestation. An enlarged yolk sac is an associated finding.

Question 63

What is the term for the level of bhCG in the blood that corresponds with the first sonographic visualization of the gestational sac? a. discriminatory zone b. proliferative zone c. quantitative zone d. transitional zone

Answer 63

A Discriminatory zone refers to the minimum level of the bhCG in the blood that corresponds with the first sonographic visualization of the gestational sac.

Question 64

What is the minimum international reference preparation value for bhCG that indicates a gestational sac should definitely be visualized by transvaginal ultrasound? a. 1000 units/ml b. 500 units/ml c. 2000 units/ml d. 1500 units/ml

Answer 64

C IRP levels for transvaginal ultrasound = 1000 - 2000 units/ml is the range of bhCG level for identifying an intrauterine pregnancy (IUP); An IUP can be identified if the level exceeds 2000 units/ml; If the level exceeds 2000 units/ml and no IUP is identified, an ectopic pregnancy should be suspected; If the level is between 1000 and 2000 units/ml and no IUP is identified, a follow up exam will most likely be ordered once the level exceeds 2000 units/ml.

Question 65

Diabetes mellitus is associated with: a. fetal weight exceeding 4000 grams b. early lung maturation c. NT defects without other associated defects d. increased risk of embryonic demise and miscarriage in the first trimester

Answer 65

D Diabetes Mellitus is associated with higher incidence of congenital anomalies than gestational diabetes, increased risk of embryonic demise and miscarriage in the first trimester, caudal regression, neural tube defects, anencephaly, microcephaly, duodenal and anal atresia, hydronephrosis, renal agenesis, VSD, ASD, coarctation, transposition, polydactyly and club feet, single umbilical artery, IUGR, and thinned placenta.

Question 66

On transvaginal sonography, cardiac activity must be identified in an embryo with a CRL of _______ or greater to be considered a viable IUP. a. 10mm b. 4mm c. 7mm d. 2mm

Answer 66

C On TV sonography, cardiac activity should first be identified in an embryo with a CRL of 5mm at 6 weeks gestation. Cardiac activity must be seen in embryos with a 7mm and greater CRL or demise is suspected. If the embryo is smaller than 7mm and no cardiac activity is identified, a short follow up exam should be considered to document fetal viability.

Question 67

A patient is admitted to the hospital with pelvic pain, no bleeding and vomiting. An LMP of 6 weeks ago and the pregnancy test that was performed was positive. Serial hCG levels are assessed 36 hours apart. The first reading was 1500/ml and the second reading was 2000/ml. Ultrasound is ordered to assess the pregnancy. What should you expect to find on the exam? a. multiple pregnancy b. molar pregnancy c. ectopic pregnancy d. normal IUP

Answer 67

C An ectopic pregnancy demonstrates a slowly rising hCG level. IRP bhCG levels > 2000ml with empty uterus is a sign of ectopic pregnancy. Normal pregnancy will cause hCG levels to normal IUP should be about 2500-2700ml.

Question 68

What sonographic "sign" refers to the overlapping of the cranial sutures with fetal demise? a. Turner sign b. Spalding sign c. Gartner sign d. Edward sign

Answer 68

B The Spalding sign refers to the overlapping of the cranial sutures with fetal demise. The Deuel sign refers to scalp edema associated with fetal demise. The Robert sign refers to air in the abdominal vasculature that causes echogenic foci on ultrasound exam with fetal demise. These signs are usually identified 1 week or more after the demise occurred.

Question 69

When evaluating the fetal heart in a 13 week 3 day fetus, the 4 chamber view with and without color and the 3 vessel trachea view with color are part of the standard AIUM protocol. What other image must be recorded to demonstrate proper cardiac position and axis? a. aortic arch b. left ventricular out flow tract c. fetal stomach d. sagittal midline thorax

Answer 69

C The AIUM recommends 4 images to document the fetal heart in a late 1st trimester fetus. The 4 chamber view with and without color, the 3 vessel trachea view with color and the fetal stomach. Cardiac position and axis are compared to the position of the stomach. The apex of the heart should point toward the stomach and both structures should be located on the left side of the fetus.

Question 70

The most common place for normal egg fertilization to occur is within which of the following fallopian tube segments? a. ampulla b. infundibulum c. isthmus d. interstitial

Answer 70

A The ampulla segment is the widest and longest portion of the fallopian tube and fertilization most commonly occurs there. For this reason, it is the most common site of ectopic implantation.

Question 71

The chorionicity and amnionicity of a twin pregnancy is determined by: a. paternal genes b. number of chromosomes c. timing of the cell division in the embryo d. timing of the cell division in the zygote

Answer 71

D The timing of the cell division determines the "type" of twins. Monochorionic vs. dichorionic and monoamniotic vs. diamniotic (or conjoined twin).

Question 72

When the cephalic end of the neural tube fails to close, ________ occurs. When the distal end of the neural tube fails to close, _______ occurs. a. trisomy 21, trisomy 18 b. anencephaly, spina bifida c. hydranencephaly, hydrocephalus d. alobar holoprosencephaly, lobar holoprosencephaly

Answer 72

B When the cephalic end of the neural tube fails to close, anencephaly occurs. When the distal end of the neural tube fails to close, spina bifida occurs.

Question 73

The neural tube normally closes by week _______. a. 4 b. 6 c. 8 d. 10

Answer 73

B | The neural tube normally closes by week 6.

Question 74

To obtain a PW Doppler evaluation of the tricuspid valve: a. place the cursor line perpendicular to the interventricular septum b. place the cursor line parallel to the interventricular septum c. a view of the right ventricular outflow tract must be obtained d. at least 5 samples must be recorded

Answer 74

B A 4 chamber heart view is obtained. Imaging the 4 chamber view with the interventricular septum perpendicular to the transducer face will improve the cursor position. A 2-3mm sample volume is placed parallel to the interventricular septum. The regurgitation should also typically be parallel to the septum and an optimal sample is obtained with parallel incidence. At least 3 samples should be obtained. Flow reversal is seen in systole and the velocity is typically over 60cm/s. Tricuspid regurgitation identified in a 1st trimester fetus is suggestive of aneuploidy (Trisomy 13, 18, 21).

Question 75

Preeclampsia in the first trimester of pregnancy is most commonly associated with: a. embryonic demise b. IUGR c. molar pregnancy d. oligohydramnios

Answer 75

C Preeclampsia in the first trimester of pregnancy is most commonly associated with molar pregnancy. If a normal IUP is present when preeclampsia manifests in the 2nd or 3rd trimester, IUGR, oligohydramnios, aged placenta and fetal demise may occur.

Question 76

Which of the following is an expected finding with ectopic pregnancy? a. intrauterine gestational sac surrounded by a single layer of echogenic trophoblastic tissue b. complex intrauterine mass with increased peripheral vascularity c. intrauterine gestational sac surrounded by a double layer of echogenic trophoblastic tissue d. abnormally elevated hCG levels

Answer 76

A The double sac sign or double decidual sign refers to two rings of decidual tissue surrounding the gestational sac. The characteristic is seen in an early IUP at about 5.5 weeks. An ectopic pregnancy would not cause the double decidual sac sign. A gestational sac with a single layer of endometrium surrounding it can be a sign of an ectopic pregnancy. A complex adnexal mass with increased peripheral vascularity is highly suggestive of an ectopic pregnancy.

Question 77

A patient is admitted to the hospital with pelvic pain, no bleeding and vomiting. An LMP of 6 weeks ago and the pregnancy test that was performed was positive. Serial hCG levels are assessed 36 hours apart. The first reading was 1500/ml and the second reading was 4500/ml. Ultrasound is ordered to assess the pregnancy. What should you expect to find on the exam? a. normal IUP b. molar pregnancy or normal IUP c. multiple pregnancy or fetus with trisomy d. molar pregnancy or multiple pregnancy

Answer 77

D An ectopic pregnancy demonstrates a slowly rising hCG level. Normal pregnancy will cause hCG levels to double every two days. After 36hrs, the hCG levels of a normal IUP should be about 2500-2700ml. At 4500ml, the hCG has already tripled in 36hrs. Molar pregnancy will cause a rapid increase similar to the increase seen with multiple pregnancies.

Question 78

Which of the following correctly describes the nuchal translucency measurement? a. multiple measurements should be obtained and the smallest one that follows the measurement criteria correctly is reported b. multiple measurements should be obtained and the sum of all measurements is reported c. multiple measurements should be obtained and the average of all measurements is reported d. multiple measurements should be obtained and the largest one that follows the measurement criteria correctly is reported

Answer 78

D Multiple NT measurements should be obtained and the largest one that follows the measurement criteria correctly is reported.

Question 79

The most commonly identified predictor of poor outcome in a first trimester ultrasound is: a. abnormally large yolk sac b. pseudosac in the endometrial canal c. subchorionic hemorrhage d. bradycardia

Answer 79

A An abnormally enlarged yolk sac (>5.6mm diameter) is the most commonly identified predictor of poor outcome in 1st trimester pregnancy ultrasound.

Question 80

The embryo of a normal pregnancy will increase in size approximately _________. a. 1mm every 2 days b. 10mm every week c. 1mm every week d. 1mm every day

Answer 80

D | The embryo of a normal pregnancy will increase in size approximately 1mm per day.

Question 81

The yolk sac can first be visualized with transvaginal sonography at what gestational age? a. 6 weeks b. 5.5 weeks c. 6.5 weeks d. 6.2 weeks

Answer 81

B Transvaginal Approach: gestational sac @ 4 weeks yolk sac @ 5.5 weeks heart @ 6 weeks

Question 82

A fetal heart rate ________ indicates a significant risk for demise in the first trimester. a. greater than 100 bpm b. less than 140 bpm c. less than 80bpm d. less than 160bpm

Answer 82

C A fetal heart rate less than 80bpm indicates a significant risk for demise in the first trimester. The normal heart rate in the early first trimester is 100-115bpm.

Question 83

The double sac sign seen in early pregnancy refers to: a. amniotic sac and yolk sac are both visible with transvaginal sonography b. fluid filled gestational sac and fluid filled uterine cavity are both visible with transvaginal sonography c. the presence of dizygotic twins d. the presence of monozygotic twins

Answer 83

B The double sac sign seen in early pregnancy (about 5.5 weeks) refers to fluid filled gestational sac and fluid filled uterine cavity are both visible with transvaginal sonography. The double bleb sign refers to when the amniotic sac and yolk sac are both visible at about 5.5 weeks with transvaginal sonography.

Question 84

Conception occurs approximately: a. 2 hours after ovulation b. 7 days after ovulation c. 2 weeks after the last menstruation d. 4 weeks after the last menstruation

Answer 84

C Conception occurs approximately 2 weeks after the last menstruation. An embryo that is described as 8 weeks from conception is the same as 10 weeks in gestational age reported on the ultrasound for that pregnancy. Conceptual age: the exact date of conception + 2 weeks = gestational age

Question 85

While scanning an asymptomatic patient with a 10 week gestation, you identify a complex cyst in the right ovary. This finding is most suggestive of: a. dermoid cyst b. theca luteal cyst c. corpus luteal cyst d. dominant follicle

Answer 85

C The corpus luteal cyst produces progesterone in early pregnancy. It normally regresses by the 14th week of pregnancy because the placenta takes over progesterone production.

Question 86

In an early intrauterine pregnancy, the amniotic sac and yolk sac are collectively called: a. the double bubble sign b. the double bleb sign c. the Murphy's sign d. the double sac sign

Answer 86

B At about the 5th week of pregnancy, the amniotic sac and the yolk sac can be visualized adjacent to each other within the uterine cavity. The fetal pole is in between the two sacs. This refers to the double bleb sign and is a confirmation of an intrauterine pregnancy.

Question 87

What are the two most common neural tube defects? a. spina bifida and holoprosencephaly b. anencephaly and spina bifida c. holoprosencephaly and anencephaly d. cystic hygroma and spina bifida

Answer 87

B | Anencephaly and spina bifida are the most common neural tube defects.

Question 88

At what gestational age does the CRL become less accurate for fetal dating? a. at 10th week b. at the 12th week c. at the 14th week d. at the 16th week

Answer 88

B Fetal curling can reduce the accuracy of the CRL measurement after the 11th week. Fetal Biometric measurements are used to determine fetal age after 12 weeks. Biparietal diameter, head circumference, abdominal circumference, and femur length.

Question 89

What type of holoprosencephaly can be identified in a 13 weeks fetus? a. lobar b. septo-optic dysplasia c. alobar d. semilobar

Answer 89

C Alobar holoprosencephaly in a first trimester fetus is defined as a single ventricle, fused thalami, with an absent corpus collosum. It is the most severe form and the only type that can be detected in later 1st trimester. The other forms are best evaluated in the 2nd trimester.

Question 90

A patient with a history of an 8 week pregnancy presents for an ultrasound due to pelvic pain and moderate bleeding for the last 4 days. What is the most likely finding on today's exam? a. missed abortion b. spontaneous abortion c. subchorionic hemorrhage d. blighted ovum

Answer 90

B A spontaneous abortion refers to the uterus emptying itself of all products of conception. There is an increased risk of spontaneous abortion with cervical dilation >3cm, PROM, and extended period of moderate bleeding. Patient symptoms include pelvic pain, cramping, moderate to heavy bleeding.

Question 91

Which of the following adnexal masses is a sign of a normal intrauterine pregnancy? a. theca lutein cyst b. corpus luteum cyst c. chocolate cyst d. dermoid cyst

Answer 91

B The corpus luteal cyst produces progesterone in early pregnancy. It normally regresses by the 14th week of pregnancy because the placenta takes over progesterone production. A theca lutein cyst is usually related to a molar pregnancy or multiple pregnancy due to high hCG levels. A dermoid cyst and endometrioma are abnormalities of the ovary.

Question 92

In the 1st trimester, the 4th ventricle is also called: a. cisterna magna b. nuchal translucency c. diencephalon d. intracranial translucency

Answer 92

D The 4th ventricle is also called the Intracranial Translucency. Compressed or absent 4th ventricle (IT) has been associated with spina bifida. Enlargement of the 4th ventricle (IT) can be associated with Dandy-Walker syndrome.

Question 93

The mean sac diameter in a normal IUP will demonstrate _______ increase in size oer day up until the 10th week of gestation. a. 1mm b. 2mm c. 3mm d. 4mm

Answer 93

A | The mean sac diameter in a normal IUP will demonstrate 1mm increase in size per day up until the 10th week of gestation.

Question 94

A patient who has a history of taking fertility medication presents for a fetal viability scan. The fetus is approximately 6 weeks old by LMP. Serum levels were performed by her doctor 5 days ago and bhCG levels were 4000 units/ml. Today the level of bhCG is 4200 units/ml. What transvaginal US exam? a. blighted ovum b. ectopic pregnancy c. heterotopic pregnancy d. molar pregnancy

Answer 94

A The bhCG levels normally double every 48hrs so in three days this patient's serum levels should be approximately 10,000 bhCG with a normal IUP. An ectopic pregnancy will cause a slower rise in bhCG levels but only a 200 unit change over 5 days is much too small of a change for a live ectopic. The embryonic demise most likely occurred not long after the first serum level was assessed. If another serum level is performed in 24hrs, the bhCG levels should decrease significantly. Molar pregnancy leads to increased bhCG levels.

Question 95

A compressed or absent intracranial translucency in a 13 week fetus is an indicator for: a. holoprosencephaly b. hydrocephalus c. spina bifida d. Dandy-Walker malformation

Answer 95

C The 4th ventricle is also called the Intracranial Translucency. Compressed or absent 4th ventricle (IT) has been associated with spina bifida. Enlargement of the 4th ventricle (IT) can be associated with the Dandy-Walker syndrome.

Question 96

The earliest gestational age the gestational sac can be seen transvaginally is? a. 3 weeks b. 4 weeks c. 5 weeks d. 6 weeks

Answer 96

B Transvaginal Approach: Gestational sac @ 4 wks Yolk sac @ 5.5 wks Heart @ 6 wks

Question 97

Regarding twin pregnancy, if division of the zygote is not complete by day 13 of the gestation it will result in: a. conjoined twins b. monochorionic, monoamniotic twins c. dichorionic, diamniotic twins d. monochorionic, diamniotic twins

Answer 97

A Regarding twin pregnancy, if division of the zygote occurs before day 4 of the gestation, this will result in dichorionic/diamniotic twins. If division of the zygote occurs between day 4 and 8 of the gestation, this will result in monochorionic/diamniotic twins. If division of the zygote occurs between day 8 and 13 of the gestation, this will result in monochorionic/monoamniotic twins. If division of the zygote is not complete by day 13 of the gestation, this will result in conjoined twins.

Question 98

An asymptomatic patient presents for a viability scan. Using the transvaginal approach, a 15mm fetal pole is identified without cardiac activity. The yolk sac is present within the gestational sac. Which of the following best describes these findings? a. blighted ovum b. normal pregnancy too early to see cardiac activity at this size c. embryonic demise d. missed abortion

Answer 98

C A 15mm fetal pole indicates an 8 week 1 day old fetus. A blighted ovum would not have a fetal pole. A missed abortion refers to fetal death without evacuation for several months. The patient is asymptomatic with no bleeding. Embryonic demise refers to death of the embryo.

Question 99

Which of the following is a possible maternal complication of diamniotic twins? a. twin to twin embolization b. cord entanglement c. twin to twin transfusion d. anemia

Answer 99

``` D Maternal Complications with Multifetal Pregnancy: Anemia Pre-eclampsia/eclampsia Systemic HTN Placental abruption Pre-term labor Post-partum hemorrhage ``` Fetal Complications with Multifetal Pregnancy: Increased risk of anomalies Umbilical cord knots/entanglement (monoamniotic twins) Cord compression IUGR because placenta cannot meet fetal needs Difficult delivery compared to singleton pregnancy

Question 100

An ectopic pregnancy will almost always be seen on the _________. a. right side b. left side c. opposite side from the corpus luteal cyst d. same side as the corpus luteal cyst

Answer 100

D An ectopic pregnancy will almost always be seen on the same side as the corpus luteal cyst. The egg is released from the dominant follicle and a corpus luteum cyst forms. When the right ovary releases an egg it travels into the right fallopian tube. When the left ovary releases an egg it travels into the left fallopian tube. An ectopic implantation is most likely to occur in the ipsilateral fallopian tube.

Question 101

Using transvaginal ultrasound, the minimum mean sac diameter that should always demonstrate an embryo is: a. 25mm b. 8mm c. 20mm d. 16mm

Answer 101

D >16mm mean sac diameter should always demonstrate a fetal pole (TV) >25mm mean sac diameter should always demonstrate a fetal pole (TA)

Question 102

If fertilization occurs, ______ will stop the regression of corpus luteal cyst so that it can produce progesterone to stimulate the decidual reaction. a. bhCG b. estrogen c. luteinizing hormone d. follicle stimulating hormone

Answer 102

A If fertilization occurs, bhCG will cause the corpus luteal cyst to not regress and produces progesterone to stimulate the decidual reaction.

Question 103

An IRP bhCG level of _________ units/ml should definitely correspond with visualization of an IUP by transvaginal ultrasound. a. 500 b. 2000 c. 1000 d. 1500

Answer 103

B IRP levels for Transvaginal Ultrasound = 1000 - 2000 units/ml is the range of bhCG level for identifying an intrauterine pregnancy (IUP); An IUP can be identified at a minimum level of 1000 units/ml but MUST be identified if the level exceeds 2000 units/ml; If the level exceeds 2000 units/ml and no IUP is identified, an ectopic pregnancy should be suspected; If the level is between 1000 and 2000 units/ml and no IUP is identified, a follow up exam will most likely be ordered once the level exceeds 2000 units/ml.

Question 104

Which biometric measurement is not used to estimate fetal age in a detailed evaluation of a 13 week fetus? a. femur length b. head circumference c. biparietal diameter d. abdomen circumference

Answer 104

A The femur length is not used in the late 1st trimester evaluation for fetal dating, but may be helpful for detection of abnormalities. The femoral diaphysis cannot be reliably measured until after 14 weeks gestation.