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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5841_Библиотеки_им_академика_М_И_Перельмана
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Training 9
threatened abortion, ectopic pregnancy , biometery, anomaly
scanning, IUGR, placental evaluation, amniotic fluid
evaluation, color doppler uses and 3D and 4D ultrasound.
Complete gynecological ultrasound aspects include use
of
TVS, color and 3D in evaluating female pelvis and
evaluating infertility and complete interventional
procedures.
2.2 TRAINING PARAMETERS
FIRST LEVEL
(At least 30 hours a week for two months)
These are aimed at:-
1.
Confirm intrauterine pregnancy.
2. Confirm viability.
3. Determine number of gestations.
4. Fetal biometry.
5. Assessment of growth.
6. Presentation.
7. Amniotic fluid assessment.
8. Placental assessment.
9. Cervix measurement.
10. Suspect abnormalities.
SECOND LEVEL
(About 100 sessions and 300 hours)
These are aimed at:-
1.
Detect and specify early pregnancy problems.
2. Detect and specify abnormalities.
3. Assessment of growth restriction.
4. Fetal biophysical profiling.
10 Step by Step Ultrasound in Obstetrics
5. Understanding Color Doppler.
6. Accurately sampling various blood vessels by
Doppler and analysing them.
7. Knowledge of interventional procedure.
8. Knowledge of 3-D and 4-D.
9. Analysis of malignancies.
THIRD LEVEL (3 years)
These are aimed at:
1.
Acquiring 3-D and 4-D image.
2. Perform interventional procedures.
3. Research and development.
4. Ability to teach basic stalls.
2.3 SUGGESTED TRAINING SCHEDULE
Viable pregnancies 10
Nonviable pregnancies
10
Normal biometry 10
Growth restrictions 10
Abnormal pregnancy 10
(Ectopic/Multiple etc.)
Color Doppler studies obstetric 10
Gynaec 10
IUCD’s 5
Fibroids 10
Ovarian cysts 10
Gynaec disorders 10
Transvaginal scan 10
These are minimum number of scans for Level-I training.
Another 100 cases of detailed Obstetric and Gynecolo-
gical cases for various indications including color and 3-D
should be logged for Level-II training.
Training 11
A standard reporting format for gynecology and
Obstetrics should be adhered to with details of dif
ferent
descriptive terminology.
2.4 PREREQUISITE CRITERIA FOR A
TRAINED UL
TRASONOLOGIST
1. The ultrasonologist should be able to identify early
pregnancy and emer
gency gynecological problems by
transvaginal and transabdominal ultrasound.
a. Early pregnancy:
• Fetal viability;
• Description of the gestational sac, embryo, yolk
sac;
• Single and multiple gestation (chorionicity).
b. Pathology:
• Early pregnancy failure;
• Ectopic pregnancy;
• Gross fetal abnormalities such as nuchal trans-
lucency, hydropic abnormalities;
• Hydatidiform mole;
• Associated pelvic tumors.
c. Gynecology:
• Normal pelvic anatomy;
• Uterine size and endometrial thickness;
• Measurement of ovaries;
• Pelvic tumors, e.g., fibroids, cysts hydrosalpinx;
• Peritoneal fluid;
• Intrauterine contraceptive devices.
2. The ultrasonologist should be able to recognise the
following normal fetal anatomical features from 18
weeks onwards by abdominal ultrasound.
12 Step by Step Ultrasound in Obstetrics
a. Shape of the skull: nuchal skinfold;
b. Brain: ventricles and cerebellum, choroid plexus;
c. Facial profile;
d. Spine: both longitudinally and transversely;
e. Heart rate and rhythm, size and position, four-
chamber view;
f. Size and morphology of the lungs;
g. Shape of the thorax and abdomen;
h. Abdomen: diaphragm, stomach, liver and umbilical
vein, kidneys, abdominal wall and umbilicus;
i. Limbs: femur, tibia and fibula, humerus, radius and
ulna, feet and hands—these to include shape,
echogenicity and movement;
j. Multiple pregnancy: monochorionic and
dischorionic, twin-twin transfusion syndrome;
k. Amount of amniotic fluid;
l. Placental location;
m. Cord and number of vessels.
3. Fetal biometry
a. Crown rump length, biparietal diameter, femur
length, head circumference, abdominal circum-
ference, interpretation of growth charts.
4. Activity: recognize and quantify
a. Fetal movements;
b. Breathing movements;
c. Eye movements.
2.5 MANDATORY PROPOSED CERTIFICATION
FOR AN
UL TRASONOLOGIST (OBS AND
GYN)
1. One hundred hours in 6 months, of supervised scanning
to include (one year observership):
Training 13
a. 100 gynecological examinations and early
pregnancy problems (principally by transvaginal
sonography but transabdominal experience also
required).
b.
200 obstetric scans covering the full spectrum of
obstetric conditions.
2. Logbooks:
30 cases on one A4 page with ultrasound picture, at
least 15 anomalies should be included.
These are suggested training hours and comply with
the Indian Government’s requirement under the modified
PNDT Act.
Three
First Trimester
3.1 Indications
3.2 Normal first trimester embryonic/fetal
evaluation
3.3 Normal parameter evaluation in the
first trimester
3.4 Abnormal intrauterine pregnancy
3.5 Impending early pregnancy failure
3.6 Ectopic gestation
3.7 Extra fetal evaluation
3.8 Abnormal intrauterine pregnancy
forms
3.9 Complete abortion
3.10 Incomplete abortion
3.11 Molar change
3.12 Sono-embryology chart
3.13 Abnormal fetus
3.14 First trimester scan checklist
3.15 Dilemmas
3.16 First trimester key points
3.17 Transvaginal decision flow charts
3.1 INDICATIONS
1. Confirmation of pregnancy
2.
Vaginal bleeding in pregnancy
(Threatened abortion)
First Trimester 15
3. Estimation of gestational age
4.
Suspected ectopic pregnancy
5. Suspected hydatidiform mole
6. Adjunct to cervical cerclage
7. Suspected multiple gestation
8. Adjunct to chorionic villus sampling
3.2 NORMAL FIRST TRIMESTER
EMBR
YONIC/ FETAL EVALUATION
1. Location of sac
a.
Fundus (Fig. 3.1)
b. Corpus (Fig. 3.2)
c. Cornual (Fig. 3.3)
d. Superior to the cervix
2. Number of sacs
a. Single
b. Multiple (Twin/Triplet/High Order Multiple)
(Fig. 3.4)
3. Size of sac
a. In toto, measure inner to inner diameter of
gestational sac on all three sides and calculate
the size and corresponding gestational age (Fig.
3.5).
b. Size of gestational sac in comparison to the
embryo/fetus size (Fig. 3.6)
4. Embryo/fetal size (Crown rump length) (Figs 3.7
and 3.8)
5. Embryonic cardiac activity. To begin with, the heart
rate is around 85 beats/ minute at 5 to 5½
weeks
(Fig. 3.9) increasing to around 160 beats/minute
(Fig. 3.10) at nine weeks
16 Step by Step Ultrasound in Obstetrics
6. Yolk sac
a. Size
b. Shape
c. Any calcification
Fig. 3.1: Gestational sac located in the uterine fundus
Fig. 3.2: Gestational sac located in the uterine corpus
First Trimester 17
Fig. 3.3: Gestational sac located in the uterine cavity in the cornual
area. Note the amount of myometrium lateral to the gestational
sac differentiating it from a cornual ectopic
Fig. 3.4: Two gestational sacs both located
in the uterine fundus
18 Step by Step Ultrasound in Obstetrics
Fig. 3.5: Gestational sac measurement in all three planes and
calculation of gestational age done by the ultrasound machine
7. Trophoblastic reaction
a. Whether wrapping around and thick reaction
(Fig. 3.11)
b. Locate site (Fig. 3.12)
8. Separation
a. Amnio-decidual separation (Fig. 3.13)
b. Chorio-decidual separation (Fig. 3.14)
Fig. 3.6: Note that the sac is oligoamniotic with the gestational
sac corresponding less than the embryo size
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