Carney - 1st Trimester Ultrasound USAFP PPTminimizer

8/6/2019 Carney - 1st Trimester Ultrasound USAFP PPTminimizer

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First Trimester First Trimester

Ultrasound Ultrasound Leo A. Carney, III DOLeo A. Carney, III DO

LCDR, MC, USNLCDR, MC, USN

Family Medicine Staff Family Medicine Staff

Naval Hospital Pensacola Naval Hospital Pensacola


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QuestionsQuestions

What Measurement is the most accurate for What Measurement is the most accurate for ultrasound dating?ultrasound dating?

In what order do fetal structures appear?In what order do fetal structures appear?

What are the 7 items to document in 1What are the 7 items to document in 1 stst trimester trimester ultrasounds?ultrasounds?


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Obj ectivesObj ectives

R eview the indications for first trimester R eview the indications for first trimester ultrasoundultrasound

Discuss utilization of ultrasound andDiscuss utilization of ultrasound andlaboratory data in the evaluation of firstlaboratory data in the evaluation of firsttrimester bleedingtrimester bleedingR

eview measurements and how theyR

eview measurements and how theyapply to dating criteriaapply to dating criteriaDiscuss how to document a first trimester Discuss how to document a first trimester ultrasound inultrasound in the medical recordthe medical record


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IndicationsIndications

Dating of pregnancyDating of pregnancySize vs dates discrepancy; multipleSize vs dates discrepancy; multiplegestation determinationgestation determination **(1(1 stst Trimester)*Trimester)*

Vaginal bleedingVaginal bleeding Abdominal or pelvic pain: rule out ectopic Abdominal or pelvic pain: rule out ectopicpregnancy/ torsion/ heterotopicpregnancy/ torsion/ heterotopic

pregnancy/ ovarian cystpregnancy/ ovarian cyst ***Not credentialed to***Not credentialed todo***do***

To confirm viabilityTo confirm viability


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Pr egnancy Dating with 1 Pr egnancy Dating with 1 stst

t r imeste r ult r asound t r imeste r ult r asoundThe only utility for routine ultrasound asThe only utility for routine ultrasound asdetermined by the R ADIUS studydetermined by the R ADIUS study

Early dating is the most accurate (+/Early dating is the most accurate (+/- - 55--7d or 7d or 8%)8%)Better defines timing for later testing andBetter defines timing for later testing andinterventionsinterventions

Triple/Quad testTriple/Quad test Tocolysis/SteroidsTocolysis/Steroids

R educes the incidence of induction for R educes the incidence of induction for

postdatespostdates


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M easu r ementsM easu r ements

Mean Sac Diameter Mean Sac Diameter Should be measured in 3 dimensionsShould be measured in 3 dimensions May be all that is visible at the discriminatoryMay be all that is visible at the discriminatory

zone; IUP best confirmed with some fetalzone; IUP best confirmed with some fetalelement, such as a yolk sacelement, such as a yolk sac

Embryonic CrownEmbryonic Crown- -R ump Length (C R L)R ump Length (C R L) Measurement of a C R L with fetal cardiacMeasurement of a C R L with fetal cardiac

activity is theactivity is the b estb est measurement for datingmeasurement for datingpurposespurposes


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T ypical M easu r ements T ypical M easu r ements

There are tables for determiningThere are tables for determininggestational age based on:gestational age based on:

Gestational Sac MeasurementGestational Sac Measurement CrownCrown--R ump LengthR ump Length

All of the U/S machines at NHP contain All of the U/S machines at NHP contain

software which perform these calculations.software which perform these calculations.The measurements will trigger theThe measurements will trigger thegestational age determination.gestational age determination.


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Dete r mination of Gestational AgeDete r mination of Gestational Age

G estational Age (weeks)

Sac Size(mm)

CRL(mm)

4 3

5 6 6 147 27 8 8 29 15 9 33 2110 3111 4112 5113 71


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Ea r ly Emb r yoEa r ly Emb r yo


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T he C r own T he C r own--Rump Length Rump Length


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Late 1 Late 1 stst T r imeste r T r imeste r 10 week10 week


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Ea r ly Pr egnancy Failu r eEa r ly Pr egnancy Failu r e

F ailure of appropriate interval growth byF ailure of appropriate interval growth byu/s of embryou/s of embryoF etal pole/yolk sac should be seen by theF etal pole/yolk sac should be seen by thetime the MSD is 20 mm (not as accuratetime the MSD is 20 mm (not as accurateas F CA though)as F CA though)F etal Cardiac Activity should be seen byF etal Cardiac Activity should be seen bythe time the C R L is 4mm (5mm per AIUM)the time the C R L is 4mm (5mm per AIUM)

If not, may repeat the u/s in one weekIf not, may repeat the u/s in one week


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Rule out ectopic Rule out ectopic

Classic triadClassic triad amenorrhea, vaginalamenorrhea, vaginalbleeding, painbleeding, painMust have a high index of suspicionMust have a high index of suspicion

Even more so in the face of risk factorsEven more so in the face of risk factors

Three primary tools for evaluationThree primary tools for evaluation Physical examPhysical exam QuantitativeQuantitative HCGHCG UltrasoundUltrasound


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La b and Ult r asound La b and Ult r asound

Discriminatory ZoneDiscriminatory Zonethe quantthe quant --hCGhCGlevel at which one would expect to be ablelevel at which one would expect to be ableto identify an intrauterine pregnancyto identify an intrauterine pregnancyF or vaginal sonographyF or vaginal sonography1200 1200--15001500(1000(1000--2000 per ACOG)2000 per ACOG)F or abdominal sonographyF or abdominal sonography3000 3000--40004000If the quantIf the quant --hCG is at or above thehCG is at or above thediscriminatory zone, AND no IUP can bediscriminatory zone, AND no IUP can beidentified, the pregnancy may be ectopicidentified, the pregnancy may be ectopic


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Rapidly Rising Quant Rapidly Rising Quant HCGHCG

Identifying multifetal gestationIdentifying multifetal gestationIdentifying gestational trophoblasticIdentifying gestational trophoblasticdiseasedisease

Dont forget lab error (i.e. normalDont forget lab error (i.e. normalpregnancy in your differential)pregnancy in your differential)


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M ultifetal GestationM ultifetal Gestation


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O the r applicationsO the r applications

***Not credentialed to do******Not credentialed to do***

Evaluation of gynecologicEvaluation of gynecologicstructuresUterusstructuresUterusposition, fibroidsposition, fibroids

Adnexae Adnexae masses, corpus luteummasses, corpus luteum

Early screen for chromosomal anomaliesEarly screen for chromosomal anomalies Nuchal translucency measurementsNuchal translucency measurements


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DocumentationDocumentationWhether obtained abdominally or vaginally, theWhether obtained abdominally or vaginally, thefollowing information should be obtained andfollowing information should be obtained anddocumented:documented:

P resence or a b sence of IU gestational sac andP resence or a b sence of IU gestational sac andidentification of an em b ryo if possi b leidentification of an em b ryo if possi b le

Fetal num b er Fetal num b er P resence or a b sence of fetal cardiac activityP resence or a b sence of fetal cardiac activity CrownCrown- -rump lengthrump length Evaluation of uterus and adnexal structures andEvaluation of uterus and adnexal structures and

presence of free fluid (per AIUM) ***Notpresence of free fluid (per AIUM) ***Notcredentialed to do***credentialed to do***


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Final Pea r ls Final Pea r ls

Do not include the yolk sac with the C R LDo not include the yolk sac with the C R LLearn how to obtain images in threeLearn how to obtain images in threedimensions, and how to translate 2ddimensions, and how to translate 2dimages into a 3d modelimages into a 3d modelPractice, practice, practicePractice, practice, practice

Abdominal and Vaginal Abdominal and Vaginal If you are not sure it is an IUP, get helpIf you are not sure it is an IUP, get help


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W hat M easu r ement is the most accu r ate fo r W hat M easu r ement is the most accu r ate fo r ult r asound dating?ult r asound dating?

Crown R ump LengthCrown R ump Length Up to the 12Up to the 12 thth weekweekof life.of life.


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In what o r de r do fetal st r uctu r esIn what o r de r do fetal st r uctu r esappea r ?appea r ?

Gestational sacGestational sac 4 to 5 weeks4 to 5 weeks

Yolk sacYolk sac 5 to 6 weeks5 to 6 weeks

F etal poleF etal pole - - 6 to 7 weeks6 to 7 weeks

Cardiac ActivityCardiac Activity - - 6 to 7 weeks.6 to 7 weeks.


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W hat o r gan, what anatomic view? No r mal o r W hat o r gan, what anatomic view? No r mal o r ab no r mal?ab no r mal?


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W hat o r gan, what view? No r mal o r ab no r mal? W hat o r gan, what view? No r mal o r ab no r mal?


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W hat a r e the lucky #7 components of a fi r st W hat a r e the lucky #7 components of a fi r st

t r imeste r ult r asound again? t r imeste r ult r asound again?


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Components of documentation of aComponents of documentation of afi r st t r imeste r ult r asound pe r A IUMfi r st t r imeste r ult r asound pe r A IUM

# 1: IUP or no IUP# 1: IUP or no IUP # 2: how many fetuses# 2: how many fetuses # 3: F CA or no F CA# 3: F CA or no F CA # 4: C R L# 4: C R L # 5: uterine masses# 5: uterine masses

# 6: adnexal masses# 6: adnexal masses # 7: free fluid# 7: free fluid

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T he end T he end

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Carney - 1st Trimester Ultrasound USAFP PPTminimizer

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