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2nd and 3rd Trimester OB Protocol Protocol Protocol will vary with patient age and fetal position The goal of the exam is to image each structure in the protocol The protocol is divided up into sections o It is highly recommend that you complete each image in the applicable section before moving to the next section when possible Placenta Comp Images- Heart Rate, Uterine Cervix , Ovaries, Adnexa, Placenta, and Fluid Structure/ Order Scan Plane Label Landmarks Identified Uterus/ Fetus Uterine Cervix Adnexa TX NO IMAGE-SCAN THROUGH TX HEART RATE TX HEART RATE Sagittal CERVIX ML Sagittal CERVIX ML Sagittal FETAL LIE Sagittal Sagittal ADNEXA SAG RT ADNEXA SAG LT PLACENTA SAG INF PLACENTA SAG MID PLACENTA SAG SUP Q1 Q2 Q3 Sagittal Placenta Sagittal Sagittal Amniotic Fluid Index (volume) Q1+Q2+Q3 +Q4= AFI *Structures seen in each pocket will vary Sagittal Sagittal Sagittal Sagittal Q4 Begin at cervix, move superiorly out of uterine fundus o Identify the fetus within the uterus o Identify number of fetuses o Identify fetal lie o Determine the right and left sides of the fetus Fetal heart and chest o Enlarge image of heart and document heart rate with M-mode or Spectral Doppler Fetal heart and chest o Enlarge image of heart and document heart rate with a cine-loop Vaginal Canal Cervix Amniotic Sac Vaginal Canal Cervix Amniotic Sac Measure Cervical Length o External os to internal os Document presenting fetal structure Cervix o Indicate Breech or Vertex in annotation RT Adnexa include ovary if possible LT Adnexa include ovary if possible Placenta closest to Cervix Retroplacental complex Placenta Mid- include cord insertion Retroplacental complex Placenta- superior portion Retroplacental complex Measure largest vertical pocket clear of fetal components from Anterior to Posterior Measure largest vertical pocket clear of fetal components from Anterior to Posterior Measure largest vertical pocket clear of fetal components from Anterior to Posterior Measure largest vertical pocket clear of fetal components from Anterior to Posterior Pocket Protocol Reference Page 423 423 550 549 548 596 2nd and 3rd Trimester OB Protocol Fetal Measurements Structure/ Order Scan Plane Label Landmarks Identified Fetal Measurements BPD HC Trans Axial CEREBELLUM CISTERNA MAGNA NUCHAL FOLD Abdomen TX Long Bone AC FL Long Bone HL Cavum septum pellucidum, IHF, Thalami and Parietal bones Measurement technique Place calipers on the outside of the closet parietal bone to the inside of the farthest parietal bone Cavum septum pellucidum, IHF, Thalami and Parietal bones Measurement technique o Place calipers outside to outside of the parietal bones o Open the calipers with an ellipse that surrounds the fetal skull IHF, Cerebral Peduncles, Cerebellum, Cisterna Magna, and Nuchal Fold Measurement technique o Place calipers on the outside of the lateral wall to the outside of the opposite lateral wall IHF, Cerebral Peduncles, Cerebellum, Cisterna Magna, and Nuchal Fold Measurement technique o Place calipers at the level of the mid posterior wall of the cerebellum to the inside of occipital bone IHF, Cerebral Peduncles, Cerebellum, Cisterna Magna, and Nuchal Fold Measurement technique o Place calipers at the level of the mid posterior wall of the cerebellum from the outside of occiptal bone to outside skin line Umbilical vein/portal vein junction 3 points of the spine Symmetrical ribs Measurement technique o Place calipers on outside of skin line directly behind spine and in front of abdomen. o Open calipers to form an ellipse around abdomen including the skin line Femur bone with distal or end shadowing Measurement technique o Place calipers from end to end on the femur Do not include epiphysis point o Calipers should dissect the middle of the bone Humerus bone with distal or end shadowing Measurement technique o Place calipers from end to end on the humerus-Do not include epiphysis point o Calipers should dissect the middle of the bone Pocket Protocol Ref. Page 575 579 576 576 & 577 578 582 583 584 2nd and 3rd Trimester OB Protocol Fetal Head and Face Structures Organ/ Order Scan Plane Label Landmarks Identified Fetal Head Coronal CHP IHF Choroid Plexus within ventricle o Try to get both in one image, if not do separately (in axial plane) Fetal Head Transaxial VENTRICLES (indicate RT & LT) IHF Ventricles IHF Ventricle Measurement Technique o Posterior ventricle o Measure internally lateral to medial at glomus FACE Orbits Mandible LENS Orbits Echogenic lens (can be in transaxial plane) NOSE AND LIPS Nostrils Upper lip 590 PROFILE Forehead, nose, extended chin and neck 589 Fetal Head VENTRICLES (indicate RT & LT) Fetal Face Face Coronal Face Midline Sagittal Pocket Protocol Reference Page 580 581 w/o measurement 581 2nd and 3rd Trimester OB Protocol Fetal Thorax, Abdomen and Pelvis Structures Organ/ Order Scan Plane Sagittal Label Stomach Kidneys Transverse RT lung Diaphragm Liver LT lung Diaphragm Stomach 574 DIAPHRAGM LT STOMACH Stomach Transverse spine 571 Transverse spine Right kidney Left kidney 565 Left Sagittal Kidney (can be taken in coronal) Measurement technique o Superior to inferior border Left Sagittal Kidney (can be taken in coronal) Measurement technique o Superior to inferior border Transverse spine Umbilical cord insertion into abdomen Abdominal skin line Umbilical cord projecting from abdomen 566 Free floating loop of umbilical cord demonstrating 3VC 570 Iliac wings Bladder Color Doppler around bladder 568 DIAPHRAGM RT Transverse KIDNEYS Sagittal RK SAG LK SAG Sagittal Transverse CI Umbilical Cord Transverse CORD Bladder/ Cord Transverse 3VC Bladder Transverse BLADDER Iliac wings Bladder GENDER (identify male or female) Male o Scrotum and penis Female o Labia Gender Transverse Pocket Protocol Reference Page Thorax/ Abdomen Sagittal Landmarks Identified 567 569 572 & 573 2nd and 3rd Trimester OB Protocol Fetal Spine and Extremities Organ/ Order Scan Plane Label Landmarks Identified CSP SAG Skull, cervical spine, and upper thorax o Sagittal view not available coronal is acceptable, label accordingly 555 Sagittal TSP SAG Distal neck, thorax, and upper abdomen o Sagittal view not available coronal is acceptable, label accordingly 556 Sagittal LSP SAG Lower abdomen to lower point of LSP o Sagittal view not available coronal is acceptable, label accordingly 557 Transverse CSP TX Spine up-just below skull, skin line 559 Transverse TSP TX Spine up-mid thorax, rib, skin line 560 LS-SP TX Spine up-iliac wings, skin line Longitudinal RT HUMERUS Shoulder, humerus and elbow Longitudinal Elbow, ulna, radius and wrist Longitudinal RT ULNA/RADIUS RT HAND Wrist and fingers (open and closed) Longitudinal LT HUMERUS Shoulder, humerus and elbow Longitudinal LT ULNA/RADIUS Elbow, ulna, radius and wrist connections Longitudinal LT HAND Wrist and fingers (open and closed) Longitudinal RT FEMUR Femur and knee Longitudinal RT TIB/FIB Knee, tibia, fibula and ankle o FRONTAL View Coronal RT FOOT Foot Toes Longitudinal LT FEMUR Femur and knee LT TIB/FIB Knee, tibia, fibula and ankle o FRONTAL View LT FOOT Foot Toes Sagittal Spine Transverse Upper Extremity Lower Extremity Pocket Protocol Reference Page Longitudinal Coronal 584 w/o measurement 586 587 & 588 584 w/o measurement 586 587 & 588 583 w/o measurement 585 583 w/o measurement 585 2nd and 3rd Trimester OB Protocol Fetal Heart Fetal heart images will vary from site to site, all students are responsible for completing a sweep through the heart to determine situs and connection and recognize views Organ/Order Scan Plane Label Landmarks Identified Right and left atrium Foramen Ovale Right and left ventricle Tricuspid and Mitral Valves Spine (IVS Vertical) Right and left atrium Foramen Ovale Right and left ventricle Tricuspid and Mitral Valves Spine Superior Vena Cava & Inferior Vena Cava Long axis Sagittal fetal chest Inferior vena cava Right atrium Superior vena cava Left Ventricular Outflow Tract Long Axis Transverse fetal chest Left ventricle Aortic valve Aortic root Proximal aorta 3 branches-innominate, left common carotid artery & left subclavian Thoracic aorta Right ventricle Pulmonary valve Pulmonary trunk RT ventricle Pulmonary valve RT pulmonary artery LT pulmonary artery Aorta Aortic valve Pulmonary trunk Ductus arteriosus Thoracic aorta AO SVC DA Subcostal 4 Chamber View Apical 4 Chamber View Aortic Arch Right Ventricular Outflow Tract Right Ventricular Outflow Tract Ductus Arteriosus Arch 3 Vessel View Transverse fetal chest (IVS horizontal) Transverse fetal chest Sagittal Fetal Chest Long Axis Transverse Fetal Chest Short Axis Transverse Fetal Chest 4CH SUBCOSTAL 4CH APICAL SVC/IVC LVOT AA RVOT RVOT SHORT Sagittal Fetal Chest DA Transverse Fetal Chest 3 VESSEL VIEW Pocket Protocol Reference Page 562 564 563 2nd and 3rd Trimester OB Protocol Normal Measurement Ranges Structure Amniotic Fluid Volume Area of Interest Divide the uterus into 4 quadrants and measure the largest vertical pocket of amniotic fluid in each quadrant Plane Sagittal Amniotic Fluid Largest Vertical Pocket Single Sagittal Cerebellum Posterior Fossa of the Brain Sagittal Equal to gestational age Move caudal from BPD, head must be symmetrical Nuchal Fold Skin thickness on the posterior head Coronal Normal -less than 6mm up to 24 weeks gestation Same plane as cerebellum measurement Cisterna Magna Anechoic Space in the Posterior Fossa Longest axis of the kidney Coronal Normal -less than 10 mm Same plane as cerebellum measurement Amount of cerebrospinal fluid in ventricle Coronal Sum of 4 amniotic fluid measurements Kidney Length Lateral Ventricles Measurement Greater than 20cm-abnormal Less than 5cmabnormal *measurement may vary per site Sagittal Greater than 10cm-Abnormal Less than 2cmAbnormal *measurement may vary per site Approximately equal to gestational age through 2nd trimester Comments Patient should be supine With the probe in the sagittal position, locate the largest pocket of amniotic fluid clear of all fetal parts Measure the fluid pocket from anterior to posterior (at least 1cm) Document this measurement for each quadrant of the uterus. Add the measurements for a total Measurement of the largest single vertical pocket of fluid in the uterus Commonly used for twin pregnancies Long axis of the kidney measuring from superior to inferior pole Less than 10 mm Superior to BPD at the level of the ventricles Measure at atrium or the thickest portion of the choroid plexus (CHP) or glomus 2nd and 3rd Trimester OB Protocol Color and Spectral Doppler Analysis Structure Area of Interest Plane Umbilical Artery Document umbilical artery blood flow with Color Doppler and Spectral Analysis in a free loop of the umbilical cord Longitudinal Document umbilical artery blood flow with Color Doppler and Spectral Analysis in a free loop of the umbilical cord Lateral branches of the circle of Willis Longitudinal Umbilical Vein Middle Cerebral Artery Normal Measurement S/D= less than 3 after 30 week PI= less than 1.25 after 30 week Coronal Comments RI-less than .7 after 30 weeks 2nd-3rd trimester= Continuous forward flow with increasing mean velocities until 37 weeks PI= Greater than 1.45 before term Less than 1 by term (Decreases after 32 weeks) Ductus Venosus Shunt between the umbilical vein and inferior vena cava Transverse Abdomen Peak velocity= 50 cm/sec Angle correct is not needed Low resistive wave form High end diastolic flow is normal Absence of diastolic flow indicates fetus is in distress Reversal of diastolic flow is severe and seek immediate help from physician Pulsations can indicate a severe condition Fetal breathing movements will alter continuous forward flow pattern Found slightly caudal to BPD plane Same proximal end Position the head to achieve a Doppler angle of zero or as close as possible High impedance flow with low diastolic flow Abnormal flow will display high diastolic flow Indicate pre-eclampsia, IUGR & anemia High diastolic component Evaluate the “A” waveabnormal if less than 5cm/sec Laboratory Values Qualitative hCG-urine pregnancy test, results positive or negative Quantitative hCG- blood pregnancy test, results indicate possible age of pregnancy Alpha Fetoprotein (AFP)-blood test for detection of certain abnormalities at 15-20 weeks High indicates open neural tube defect Low indicates Down syndrome Abnormal in cases of wrong dates, fetal demise or twins Triple Screen or Quad Screen-combination of blood test including AFP, unconjugated estriol (uE3), hCG, and Inhibin A (Quad screen) Used to detect chromosome abnormalities Pathology Gray scale sagittal and transverse images including images with 3 measurements (length, width and height) Color Doppler image document the presence of blood flow Spectral Doppler image document type and velocity of blood flow