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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5782_Библиотеки_им_академика_М_И_Перельмана.pdf
CHAPTER 13 Obstetrical Scanning Protocol for First, Second, and Third Trimesters 329
e
cerebrei
n
Aorta
ebra
Stomach
Umbilical portion
Bladder
32. LATERAL VENTRICLE with measurement.
Calipers for
measurement
of lateral
ventricle
Occipital
bone
Amniotic
fluid
Falx
33. ABDOMINAL CIRCUMFERENCE image at the level of the junction of the umbilical vein and portal vein sinus. Measurement is
around the outline of the abdomen. The abdomen should appear round.
of portal vein
(left portal vein)
Portion of
uncoiled
umbilical
cord
Femur
Right portal
vein
Medial wall of
the lateral
ventricle
(near the atrium)
Thalamus
Choroid
plexus
Lateral wall of th
lateral ventricle
Cross-section
fetal abdome
Inferior
vena cava
Vert
34. LONG AXIS image of the femur with measurement from one ossified end of the femur to the other ossified end.
Femur
Placenta
330 PART IV Pelvic Scanning Protocols
Amniotic
Soft tissue and muscle
and spinal canal
NOTE: For long bone measurements, cursors are placed at the bonecartilage interface. The cartilaginous ends of the bones are not included
in the measurement.
35. LONG AXIS image of the humerus with measurement from one
ossified end of the humerus to the other ossified end.
cross-section
Extremity
surrounding humerus
Humerus
Placenta
Rib portions/
shadow
fluid
Portion of spine
36. Image of the lower portion of the LEG.
Portion
of foot
Lower
leg
Tibia
Blood vessel
Amniotic fluid
Myometrium
Placenta
Fibula
Patella
CHAPTER 13 Obstetrical Scanning Protocol for First, Second, and Third Trimesters 331
Placenta
Elbow
Hand
Open fetal
(out of plane)
37. Image of the RADIUS and ULNA.
Radius
38. Image of a HAND.
Ulna
Other arm
Amniotic
fluid
Hand
Lower
arm
Placenta
Limb
39. Another image of the HAND.
Small
(fifth) finger
Ulna
Radius
Wrist
hand
Bent finger
Thumb
332 PART IV Pelvic Scanning Protocols
and below nostrils)
40. Image of FACIAL PROFILE.
41. CORONAL image of the nostrils and lips.
Amniotic
fluid
Chin
Limb
Lips
Amniotic
fluid
Acoustic
shadow
Filtrum (between
Nostrils
Placenta
NOTE: Most physicians only require images of 1 hand, foot, arm, and leg
based on the assumption that both were evaluated during the survey.
CHAPTER 13 Obstetrical Scanning Protocol for First, Second, and Third Trimesters 333
Cord B
Head B
Multiple Gestations
Additional Required Images
Each fetus of a multiple gestation should be imaged as previously
described for singleton pregnancies plus the following additional
views as they apply:
1. Image of a twin pregnancy demonstrating separate sacs.
Sac B with embryo
Placenta B
Placenta A
B
B
A
Sac A with embryo
A
Labeled: TWINS / SEP SACS
2. Image of second trimester twins demonstrating the presence of a
separating membrane.
Sac A
Sac B
Uterus
Placenta
Cord A
Thin membrane
Labeled: TWINS / MEMBRANE
334 PART IV Pelvic Scanning Protocols
3. Image of triplets.
Uterus
Sac C
Embryo C
Sac B
(embryo not in
the scanning plane)
Thick
membranes
Sac A
Embryo A
Labeled: TRIPLETS
NOTE: It is important to demonstrate the position of the presenting
fetus. This is the fetus that is lower in the uterus, closer to the cervix,
and will be delivered first. This fetus is labeled “A” and the other fetus is
labeled “B.” If there are more than 2 (as in Number 3) then “C,” “D,” etc.,
will be used. This labeling allows individual growth rates to be determined. If possible, determine the gender of each fetus. This information
may help determine whether they are fraternal or identical.
The Biophysical Profile
An examination that is often performed during the late third trimester is the biophysical profile. This test measures fetal well-being and
consists of 5 parameters. The first part of the test involves a nonstress
test. This test is performed in the delivery room or in an obstetrician’s
office and measures spontaneous heart rate accelerations. This part
of the biophysical profile (BPP) is not performed by the sonographer.
The remaining 4 parameters of the BPP are measured by the sonographer. They are as follows: (1) fluid, (2) fetal respiration, (3) fetal tone,
and (4) gross body motion. These parameters and scoring of this test
are described in Table 13-1.
CHAPTER 13 Obstetrical Scanning Protocol for First, Second, and Third Trimesters 335
Fluid pocket
Table 13-1 Biophysical Profile Scoring
Criterion Score (points)
Part I
Nonstress test 2 accelerations of 15 beats/min in
30-min test
Part II
Ultrasound
Examination:
Gross
Movement
Tone
3 separate flexions and extensions in
30-min examination
1 episode of fetal opening and clos-
ing of hand or clenching of foot in
30-min examination
Respiration
At least 60 sec of fetal breathing in
30-min examination
Fluid
At least 1 pocket of amniotic fluid of
at least 1 cm in 2 dimensions
Unqualified Pass
Maximum Total
2
2
2
2
2
8 or more
10
Data from Manning EA, Platt LD, Sipos L: Antenatal fetal evaluation: Development of a fetal biophysical
profile. Am J Obstet Gynecol. 136:787–795, 1980.
Required Images for a Biophysical Profile
1. Demonstration of a POCKET OF FLUID.
Venous lake
Placenta
Labeled: FLUID
336 PART IV Pelvic Scanning Protocols
Amniotic fluid
Fetal diaphragm
Head
2. Demonstration of FETAL RESPIRATION.
Labeled: DIAPHRAGM / RESP
3. Demonstration of FETAL TONE.
Fetal bladder
Fetal
heart
Respiratory
motion
Labeled: HAND
4. Demonstration of FETAL GROSS BODY MOTION.
Arching of
neck or back
Spine
Open hand
Fetal head
Twisting
of torso
Labeled: MOTION
CHAPTER 13 Obstetrical Scanning Protocol for First, Second, and Third Trimesters 337
Doppler calipers
abdomen
umbilical artery blood flow
NOTE: Occasionally it is necessary to measure the resistance to blood
flow within the umbilical arteries. This measurement is obtained by
examining the umbilical cord artery with low-power Doppler. The ratio
of the peak systolic flow to the end diastolic flow is calculated (SD ratio).
This number varies with the age of the fetus and charts are available to
determine if blood flow through the cord is adequate.
5. Umbilical artery Doppler measurement and determination of the
SD ratio.
Doppler gate
.60
m/s
.60
m/s
.30
.30
.60
m/s
.60
Labeled: DOP / UMB ART
Doppler gate
Fetal limb
.30
m/s
.30
Labeled: DOP / UMB ART
Umbilical
cord
Fetal
Doppler calipers
Spectral Doppler tracing of
338 PART IV Pelvic Scanning Protocols
Placenta
6. Uterine artery Doppler measurement and determination of the SD
ratio.
Amniotic fluid
Fetal abdomen
Uterus
Doppler gate
.60
m/s
.60
.30
m/s
.30
Spectral Doppler tracing of
maternal uterine (arcuate) artery
Labeled: DOP / UT AR
NOTE: In some cases, the physician may also want to determine if the
blood flow to the placenta from the mother’s circulation is adequate,
so another Doppler measurement is made at the interface between the
placenta and uterus or in the uterine artery if possible. The SD ratio for
the Doppler wave-form is calculated and checked against a chart value
for the appropriate GA.
Review Questions
Answers on page 629.
1. Using a 28-day menstrual cycle, most radiologists and obstetricians
define the first trimester as the
a) 12 weeks following the first day of the last normal menstrual
period.
b) 12 weeks beginning with the first day of the last normal men-
strual period.
c) 10 weeks beginning with the first day of the last normal men-
strual period.
d) 12 weeks following the last day of the last normal menstrual
period.
2. The sonographic landmark for locating early cardiac activity is the
a) amniotic membrane.
b) double bleb sign.
c) yolk sac.
d) double sac sign.