Ambo university college of health Ultrasound for midwifery students (1).pdf

Ambo university college of health and referral hospital Department of midwifery 3rd year by maru

1. Obstetric ultrasound for midwifery
students
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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2. Objectives
Attheendofthissessionstudentsshouldbeableto:
Defineultrasound
Describehowultrasoundimageisformed
DescribetheInteractionsofultrasoundwithtissue
Identifyorientationofultrasoundscanning
Identifybasiccomponentsofultrasoundmachine
DescribeKnobs(MachineControls)inultrasound
machine
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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3. Introduction
Soundis mechanical vibrations travelling in a physical
medium
Such as air, water, metal or even human tissue.
Soundmay be categorized according to various
frequency levels:
1.Infrasound (0–20 Hz)
2.Audible sound (20–20 kHz)
3.Ultrasound (>20 kHz)
4.Diagnostic ultrasound (1–20 MHz).
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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4. Ultrasound
Ultrasound-referstosoundwave
whosefrequencyisgreaterthan
perceivablebyhumanears(i.e
>2okHz).
Ultrasonographyiscommonlyused
diagnostictestdueto:
Highsafety
Noninvasive
Accurate
Lowcost.
Therangenormallyusedisfrom3to
15MHz.
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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5. Diagnostic ultrasound…
Thereal-timeimageonu/sscreenis
producedbysoundwavesreflected
backfrom:
Organs
Fluidsand
Tissueinterfaceofthefetus
withintheuterus.
Transducersconvertelectrical
energyintosoundwavesthatare
emittedinsynchronizedpulses.
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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6. Diagnostic ultrasound…
Soundwavespassthroughlayersof
tissues,encounteraninterfaceb/n
tissuesofdifferentdensities.
Whenthesewavemeetthetissue
interface.
Reflectedbacktothetransducerand
convertedtoanelectricsignal.
Processedanddisplayedasthe
ultrasoundimageonthemonitor.
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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7. Diagnostic ultrasound…
Theamountofbeamreflected
backisproportionateto:
Theacousticdensitiesof
thetissues.
Whentheacousticdensities
arehigh
Suchaswhenstriking
calcification,bone,stones
andair,nearlythewhole
beamisreflectedbackand
theimageisecho-rich.
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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8. Diagnostic ultrasound…
Iftheacousticdensityaresmall
Lowlevelechoesresult
Iftheacousticdensitiesare
identicalasinhomogeneous
fluidslikeblood,amnioticfluid
andurine
Theentirewaveistransmitted
andnoneisreflected
resultinginanecho-free
image.
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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9. Diagnostic ultrasound…..
Lowerfrequencieswillgivegreater
penetration
Youcanseefurther.
lessimageresolution
Higherfrequenciesallowyoutosee
moredetail
Yieldbetterimageresolution,but
Thepenetrationisless.
Veryhighfrequencieshavethe
potentialforadversebiological
effects.
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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10. Gray scale: Echogenicity
Echogenicityis the ability
to bounce an echo.
1.Hyper echoic:
Bright/white, strong
intensity
2.Hypo echoic:
Dark, low intensity
3.Anechoic:
Black, no intensity
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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11. Whathappenwhensoundwavepassthrough
layersoftissues??
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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12. INTERACTIONS OF ULTRASOUND WITH TISSUE
Whentheultrasoundpulse
travelsthroughtissue,
Itissubjecttoanumberof
interactions.
Themostimportantof
theseinteractionsare:
1.Reflection
2.Scatter
3.Absorption
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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13. INTERACTIONS OF ULTRASOUND …
Reflection
Inultrasoundisverysimilar
toopticalreflection.
Thestrengthofthe
reflectionfromanobstacle
isvariableanddependson:
Thenatureofboththe
obstacleand
Thebackgroundmaterial.
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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14. INTERACTIONS OF ULTRASOUND ….
Scattering
Occursattheopposite
endofthesizescale.
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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15. INTERACTIONS OF ULTRASOUND….
Absorption
Itisdefinedasthedirect
conversionofthesoundenergy
intoheat.
Theamountofabsorption
dependon
Thetypeofthetissueand
Thefrequencyofthetransducer.
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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16. Attenuation
Theprogressiveweakeningof
asoundwaveasittravels
throughamedia/tissue.
Becauseairisapoor
transmitterofu/swaves,
Solublegelisusually
appliedtoactasacoupling
agent.
Solublegelalsopermitsthe
u/sprobetogentlyslide
alongabdomen/vagina.
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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17. Resolution
Machine’s abilityto
discriminatebetweentwo
imagesspacedclosetogether.
Axial:imageslieinplane
paralleltosoundwave.
Increasefrequencytoincreaseresolution.
Lateral: images lie
perpendiculartosoundwave
Adjustfocalzoneordepthtoincrease
resolution.
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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18. Basic components of ultrasound
Real-timeequipmentcurrently
availablevariesgreatlyin
Size,
Shapeand
Complexity,
Butcontainfivebasiccomponents:
1.Probe, in which the transducer is
housed
2.Control panel
3.Freeze frame
4.Measuring facilities
5.A means of storing images. 5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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19. Probe
Referstothepieceofequipmentinwhichthetransducer
(ortransducers)ismounted.
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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20. Transducer
Houses the piezoelectric
crystals
Converts electrical energy
into sound and back into
electrical energy.
Differentprobeshave
differentfrequencies
Higher frequency =
greater resolution
Lower frequency = greater
penetration
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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21. Types Transducer…
Choose transducer
based on imaging goal
Types:
1.Convex
2.Phased Array
3.Linear
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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22. 1. Convex Probe
Pie shaped image
May be high or low
frequency
1.Sector:3-5MHz:
abdominal scanning
2.TVS: 5-7MHz: trans
vaginal scanning
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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23. 2. Linear Probe
Piezoelectric crystal
arrangementisliner.
Theshapeofthebeamis
rectangular.
Rectangular shaped image
on screen
High frequency, limited
depth
5-10 MHz: vascular or
small parts.
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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24. Orientation in ultrasound
Which way is up?
Knowwhereprobeandscreen
indicatorsare.
Knowyourorientationonyour
patient.
Realizethatyoucanimagethe
sameorganfromdifferent
directionsandseecompletely
differentimageonscreen.
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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25. Orientation…
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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26. Longitudinal View
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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27. Longitudinal View…
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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28. Transverse View
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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29. Transverse View…
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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30. Modality
BMode:“brightness”
mode
Grayscaleusedto
imageorgansin2
dimensions.
Mostlyusedmode.
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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31. Modality…
M Mode: “motion” mode
Graphically plots
returningechoesalong1
lineofB-modeimageover
time
Yaxis=imageplane
Xaxis=time
Example:
FHB
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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32. Modality…
Doppler:
Examinescharacteristicsof
Directionand
Speedoftissuemotionand
Bloodflow.
Usedtodeterminethe
volumeandtherateof
bloodflowthrough
maternalandfetalvessels.
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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33. Knobs (Machine Controls)
Aynalem Y (BSc, MSc, Ass.t professor)
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5/15/2023

34. TIME GAIN COMPENSATION(TGC)
Amachinecontrolused
toamplifyorgain
giventotheincoming
signals.
Usedcompensatesfor
absorptionandscatter.
Canadjustnearorfar
fieldforbestimage
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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35. Knobs (Machine Controls)…
Freeze:
Freezes image on the
screen
For measurements (or
stored image).
Cine:
Allowsyoutomove
backwardorforwardin
timeamongstillimages
Depth:
Changes the field of view
to allow visualization of
deeper or more superficial
structures
Text:
Allows for labeling of
images
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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36. Knobs (machine Controls)…
Gain
Controls brightness or
“contrast”
Use maximum gain
and minimum power
Tracker Ball
This is the “mouse” for
your computer, usually
with right and left
click buttons to
execute functions
Used to superimpose
things on the screen
May have several
functions
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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37. Knobs (Machine Controls)…
Zoom
To enlarge your view
Calipers
To measure
distance
between 2
points
Ellipse
To measure area
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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38. Questions?
5/15/2023Aynalem Y (BSc, MSc, Ass.t professor)
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39. References
5/15/2023Aynalem Y .
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1.Problem-basedobstetricultrasoundfirstedition
2.Ultrasound:TheRequisitesThirdEdition
3.WilliamsOBSTETRICS,27thedition
4.StevenG.Gabbe.Obstetricsnormalandproblemsin
pregnancy2007,fifthedition.

40. Ultrasound
in
obstetrics
Aynalem Y (BSc, MSc, Ass.t professor)
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41. Objectives
Attheendofthissessionstudentsshouldbeableto
Describethebenefitsofultrasoundinobstetrics
Identifyindicationsofultrasoundinfirsttrimester
pregnancy
Describehowtoidentifyintrauterinepregnancy
DescribehowtodetermineGAandEFW
Identifyindicationsofultrasoundin2
ND
AND3
RD
trimesterpregnancy
Aynalem Y (BSc, MSc, Ass.t professor)
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42. Potential uses of ultrasound in obstetrics
Locate the pregnancy –
exclude ectopic.
Assessment of viability.
Diagnosis of molar
pregnancy
Determining gestational age
Diagnosis of multiple
pregnancy.
Assessment of pelvic masses.
Screening for fetal
abnormalities
Assisting amniocentesis.
Screening for placenta previa
Cervical length monitoring.
Assessment of fetalgrowth.
Evaluation of polyhydramnios
Diagnosis and management of
malpresentation.
Assessment of fetalwelfare.
Assessment of postpartum
uterus.
Directing intrauterine
interventionsAynalem Y (BSc, MSc, Ass.t professor)
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43. FIRST TRIMESTERULTRASOUND
Mostcriticalandtenuous
periodofhumandvpt.
Till12weeks
The optimal time to
estimate GA is during
1st TM
Biologic variations in the
size from fetus to fetus
is minimal.
Aynalem Y (BSc, MSc, Ass.t professor)
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44. 1st TM u/s…cont’d
Route:-TVUS>TAUS
WithTVUS
Gestationalsacisseen
by4-5wksand
Fetalpoleswith
cardiacactivitiesby
6wks.
CRListhemostaccurate
biometricpredictionof
GA.
Aynalem Y (BSc, MSc, Ass.t professor)
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45. Components of 1st TM u/s examination
GSlocation
Embryoandyolksacidentification
CRL
Cardiacactivity
Fetalnumber
Assessmentofembryonic/fetalanatomy.
EvaluationofUx,adnexae,culde-sac
Assessmentoffetalnuchalregionifpossible
Aynalem Y (BSc, MSc, Ass.t professor)
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46. First trimester pregnancy…
Gestational Sac
isthefirststructure
identifiedintheuterusof
anearlypregnancy.
Isgenerallyvisibleat≈5
weeksgestation
AnormalGSgrow1mm
perday
Canbeusedfordating.
Aynalem Y (BSc, MSc, Ass.t professor)
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47. First trimester pregnancy…
Aynalem Y (BSc, MSc, Ass.t professor)
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Yolk Sac
•The next structure
visualizedistheyolksac.
•Identifiedatapproximately
5½weeks
•Seenat20mm sac
diameterabdominallyand
8mm sacdiameter
vaginally.
•Differentiatestruefrom
pseudogestationalsac.

48. First trimester…
Embryo
Is visualized after the yolk sac is seen at ≈6 wks
Should be seen at 18mm sac diameter vaginally
and 25 mm sac diameter abdominally.
Aynalem Y (BSc, MSc, Ass.t professor)
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49. Gestational Age determinations
1. Early : MSD
Shouldbemeasuredin3dimensions
MSD(cm)=[L(cm)+AP(cm)+T(cm)]/3correlatewith
giventable
Aynalem Y (BSc, MSc, Ass.t professor)
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50. Early : MSD…
Gestational Age…
Aynalem Y (BSc, MSc, Ass.t professor)
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51. Gestational Age…
2. CRL
Once the embryo is seen, the CRL should be used.
The most accuratemethod in estimating GA in 1st
TM.
CRL is more accurate than MSD.
Only the CRL and not a combination of MSD and
CRL should be used to assign gestational age.
Aynalem Y (BSc, MSc, Ass.t professor)
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52. Gestational Age…
2. CRL……
TheCRLismeasuredalong
thelongaxisoftheembryo
fromthetopofthehead
(crown)tothebottomofthe
body(rump).
Accuracy:3daysif
measuredb/n7-10wks
5daysifCRLismeasured
b/n10-14wks
Aynalem Y (BSc, MSc, Ass.t professor)
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53. Aynalem Y (BSc, MSc, Ass.t professor)
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54. First trimester pregnancy…
A non viable pregnancy
can beconfirmed when
The CRL is ≥7mm and no
cardiac activity is seen.
MSD ≥25 mm with non
visualization of embryo
Aynalem Y (BSc, MSc, Ass.t professor)
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55. Blighted ovum(anembryonicsac)
Aynalem Y (BSc, MSc, Ass.t professor)
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56. Documentation in 1
st
TM pregnancy
Thefollowinginformationshouldbe
obtainedanddocumented:
1.PresenceorabsenceofIUgestationalsac
2.Identificationofanembryoifpossible.
3.Fetalnumber
4.Presenceorabsenceoffetalcardiacactivity
5.Crown-rumplength
6.Evaluationofuterus,adnexalstructuresand
presenceoffreefluid.
Aynalem Y (BSc, MSc, Ass.t professor)
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57. Second and
third TM u/s
examination
???
Aynalem Y (BSc, MSc, Ass.t professor)
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58. 2
nd
and 3
rd
TM u/s examination
Singlemostimportantscanduringpregnancyisthe
secondtrimestertargetedscan.
Primarilymeantforexclusionordiagnosisoffetal
anomalies.
Themajorityofthesestudiesareperformed
between18and23weeks.
Aynalem Y (BSc, MSc, Ass.t professor)
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59. 2
ND
and 3
RD
TM u/s examination ….
Indications
Estimation of GA
EFW
Fetal number
Amnionicity, chorionicity
Presentation
Fetal cardiac activity
Placental location
AFV
Evaluation of Ux, adnexa, Cx
Fetal anatomy survey
Evaluation of vaginal bleeding
Pelvic/abd., Pain
BPP
Amniocentesis, etc
Aynalem Y (BSc, MSc, Ass.t professor)
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60. Types of examinations
Standard u/s exam
Includesanevaluationof
Fetalpresentation
AFV
Cardiacactivity
Placentallocation
Fetalbiometry
Fetalnumber
Anatomicsurvey.
Whentechnicallyfeasiblematernalcervixandadnexa
shouldbeexamined
Aynalem Y (BSc, MSc, Ass.t professor)
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61. Types of examinations….
Limited examination
Goaldirectedsearchforasuspectedproblemor
findinge.g.
Toconfirmfetalcardiacactivityinableeding
patient
Toverifyfetalpresentationinlaboringmother.
Canalsobeusedasguidance.
Aynalem Y (BSc, MSc, Ass.t professor)
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62. Types of examinations…
Specializedexamination
Adetailedanatomicexaminationisperformed
whenanomalyissuspectedon
ThebasisofHx
Biochemicalabnormalities,or
Theresultofeitherlimited/standardscan.
Aynalem Y (BSc, MSc, Ass.t professor)
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63. Types of examinations…
Otherspecializedexamination
Dopplersonography
BPP
Fetalecho.oradditionalbiometricmeasurements.
Aynalem Y (BSc, MSc, Ass.t professor)
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64. Fetal Life
Positivecardiacactivity.
Fetaldeath
Absenceofcardiac
activityforatleast2-3
minutes.
Ideallyconfirmedby
twoormoreexaminers.
Aynalem Y (BSc, MSc, Ass.t professor)
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65. Fetal Lie and Presentation
Lie-relationshipoflong
axisoffetustothelongaxis
ofthemother
Longitudinal
Transverse
Oblique
Presentation–partofthe
fetusclosesttomaternal
pelvicinletorcervix
Cephalic(vertex,brow,face)
Breech
Shoulder
Compound
Aynalem Y (BSc, MSc, Ass.t professor)
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66. GA assessment in 2nd and 3rd TM
The4standardbiometricparameterscommonly
usedtoestimateGAandfetalweightin2ndand
3rdTM:
1.Biparitial diameter (BPD)
2.Head circumference (HC)
3.Abdominal circumference (AC )
4.Femur length(FL)
Aynalem Y (BSc, MSc, Ass.t professor)
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67. Biparitial diameter (BPD)
Themostaccuratefrom14-
26wks,withavariationof7-
10days
BPDismeasuredfromthe
leadingedge(outermargin)to
theleadingedge(innermargin)
ofthecalvariumonanaxial
imageatthelevelofthe
thalami.
outer-inner
Aynalem Y (BSc, MSc, Ass.t professor)
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68. BPD…
Theimageshould
notincludethe
cerebellar
hemispheres.
Aynalem Y (BSc, MSc, Ass.t professor)
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69. Head circumference (HC)
(HC)ismeasuredatthesame
levelastheBPDaroundthe
outermarginofthecalvarium.
Measurementshouldnotinclude
thesofttissues(e.g.,scalpand
hair)locatedperipheraltothe
calvarium.
Aynalem Y (BSc, MSc, Ass.t professor)
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70. Head circumference…
Aynalem Y (BSc, MSc, Ass.t professor)
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71. Abdominal circumference (AC)
Thefetalabdomenis
measuredinanaxialscan
planeatthelevelofthe
fetalliver.
Optimallytheimageshould
include
Stomachand
Junctionoftheumbilical
portionoftheleftportalvein
withtheportalsinusand
Rightportalvein
Aynalem Y (BSc, MSc, Ass.t professor)
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72. Abdominal circumference….
Should be measured from the outer edge to outer edge of the soft
tissues.
Aynalem Y (BSc, MSc, Ass.t professor)
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73. Femur length (FL)
FLmeasurementcomprises
thelengthofthediaphysis
only,andnottheentire
lengthofthefemur.
Epiphysealcartilages(E)
shouldnotbeincludedinthe
measurement.
Theechogenicfocusalong
themarginoftheepiphysis
shouldnotbeincluded-
Aynalem Y (BSc, MSc, Ass.t professor)
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74. Femur length (FL)….
FLisasaccurateasthe
BPDinthepredictionof
gestationalageinthird
trimester.
Slidetheprobecaudally
fromtheACsectionuntil
theiliacbonesare
visualized.
Aynalem Y (BSc, MSc, Ass.t professor)
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75. FL correct measurement
Aynalem Y (BSc, MSc, Ass.t professor)
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76. Assessment of fetal weight
Monitoringfetalgrowthisastandardcomponent
ofANC.
AcombinationofBPD,HC,ACandFLisused.
Currently,eventhebestfetalweightprediction
methodscanyielderrorsashighas±15percent.
Example,EFW=4kgms
Truewtis4±0.6kgms
Aynalem Y (BSc, MSc, Ass.t professor)
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77. Fetal anatomic
survey
Aynalem Y (BSc, MSc, Ass.t professor)
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78. Fetal anatomic survey
Isevaluationofnormalandabnormalfetal
anatomy.
35-50%ofmajorcongenitalanomalycanbe
detected(sp=90-100%)
Scanningisbestperformedafter16-18wksof
gestation.
Aynalem Y (BSc, MSc, Ass.t professor)
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79. Fetal anatomic survey….
Thesensitivityofu/sfordetectingfetalanomaly
variesaccordingtofactorssuchas:-
GA
Maternal habitus
Position of the fetus
Features of equipment
Skill of the sonographer
Aynalem Y (BSc, MSc, Ass.t professor)
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80. Neural tube defect
The2ndmostcommoncongenitalanomaly,nextto
cardiacanomalies.
Failureofclosureoftheneuraltube(3-4wk)
resultinginexposedneuralplate.
1.Anecephaly
2.Encephalocele
3.Spinalbifida
Aynalem Y (BSc, MSc, Ass.t professor)
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81. Neural tube defect…
1. Anecephaly
Characterizedbyabsence
ofthebrainandcranium
abovethebaseoftheskull
andorbits.
InabilitytoviewBPD
shouldraisesuspicion.
Prominentorbitsand
absentcalvarium—’frog
sign’
Aynalem Y (BSc, MSc, Ass.t professor)
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82. Neural tube defect…
Aynalem Y (BSc, MSc, Ass.t professor)
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83. Neural tube defect…
Aynalem Y (BSc, MSc, Ass.t professor)
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84. Neural tube defects…
2. Spinal bifida
Anopeninginthevertebra
throughwhichameningeal
sacmayprotrude.
1.Meningocele,
2.Meningomyelocele
Associated anomalies
(hydrocephalus-
encephalocele).
Aynalem Y (BSc, MSc, Ass.t professor)
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85. Anterior abdominal wall defects
Omphalocele
Amidlinedefectinthe
abdominalwall.
Aperitonealsaccontainingliver,
smallbowel,stomachand
occasionallycolonprotrudes.
Themassiscoveredbya
protectivelayerofperitoneum
andamnion.
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86. Anterior abdominal wall defects….
Omphalocele….
Diagnosisshouldnotbe
attempteduntilafter11
weeksofgestation.
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86

87. Amniotic Fluid Volume Assessment
1.Subjective Assessment
Fluidvolumesclassifiedas
normal,high,orlowfor
gestationalage
2.Single duplex pocket
measurement
1-2 cm pocket -oligo,
> 8 cm -Polyhydramnios
3.4 Quadrant(Amniotic
fluid index)
Most reproducible/accurate
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88. Subjective Assessment
Normal liquor volume
Aynalem Y (BSc, MSc, Ass.t professor)
88

89. Single Deepest pool
Normal range 2 to 8 cm
Twins vsAFI what do you
know?
Aynalem Y (BSc, MSc, Ass.t professor)
89

90. Amniotic fluid index
TheAFIisobtainedbydividingthegraviduterusintofour
quadrants(i.e.,leftupper,leftlower,rightupper,andright
lower)andperformedwiththepatientinthesupineposition.
Measuringthedeepestfluidpocketthatdoesnotcontain
Fetalpartsor
Umbilicalcordineachquadrant.
Normal AFI
8-24 cm
5-8 borderline
Aynalem Y (BSc, MSc, Ass.t professor)
90

91. Amniotic Fluid Index
Sumofthedeepest
pools
ineachoffour
quadrants
Aynalem Y (BSc, MSc, Ass.t professor)
91

92. PLACENTA
Theplacentais
visualizedbytheend
ofthefirsttrimester.
Bythemidsecond
trimesterawell-
defined,hypoechoic
retroplacentallayeris
seen-myomtrium
Aynalem Y (BSc, MSc, Ass.t professor)
92

93. PLACENTA…
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93

94. Placental Thickness
Placentalthicknessis
assessedsubjectively.
Measurementsofplacental
thicknessareperformedin
themidportionofthe
placenta,perpendicularto
itslongaxis
2-4cmisconsidered
normalduring2
nd
and3
rd
trimestersofpregnancy.
Aynalem Y (BSc, MSc, Ass.t professor)
94

95. Placental Location
Anterior/Posterior/Lateral/Fundal
Placenta Previa
Marginal
Partial
Complete
Low-Lying
95
Aynalem Y (BSc, MSc, Ass.t professor)

96. Placental localisation
Full bladder
Midline sagittal section
Placental position anterior or posterior
Low placenta -measure distance between lower
edge and internal os
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97. Fundal placenta
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98. Major placenta praevia
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98

99. Minor placenta praevia
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100. Adherent placenta
Placenta accrete is abnormal adherence of the
placenta to the uterus
The following three categories in order of
increasing severity:
1.placenta accreta,
2.placenta increta, and
3.placenta percreta.
Aynalem Y (BSc, MSc, Ass.t professor)
100

101. Placenta Accreta…
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101

102. Multiple Gestations
Monozygotic versus
Dizygotic Pregnancies
Based on days of division
Day0to3-dichorionic
diamniotic;
Day4to8,monochorionic
diamniotic;
Day9to12,monochorionic
monoamniotic;and
Day13to15,conjoined
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102

103. Multiple Gestations…
Which twin A or B ?
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103

104. Documentation of Standard u/s exam in
2
nd
and 3
rd
trimester
1.FetalNumber
2.PresenceofCardiacActivity
3.FetalLie/Presentation
4.PlacentalLocation
5.FluidStatus
6.Estimatedfetalweight
7.EstimatedGA
Ex: Singleton, +CA, Vertex, Ant. Plac., NmlFluid
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105. Questions?
Aynalem Y (BSc, MSc, Ass.t professor)
105

106. Ultrasound
in
Gynaecology
Aynalem Y (BSc, MSc, Ass.t professor)
106

107. Objectives
At the end of this session students should be able
to
Describeimportanceofultrasoundingynecologic
examination
Describenormalanatomyofuterusandovarythrough
ultrasound
Identifyultrasoundfeatureof1
st
trimesterpregnancy
complications
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107

108. Ultrasound indications
Assessmentofadnexalpelvic
masses.
IUCDandImplanonlocation.
Treatmentofovariancysts
(aspiration)andectopic
pregnancy(methotrexate).
Investigation of
postmenopausalbleeding.
Evaluationofpelvicpain
Investigationofmenorrhagia
•Diagnosis of polycystic
ovaries.
•Tubal patency studies in
infertility.
•Evaluation of primary
amenorrhoea
•Screening for ovarian
cancer.
•Monitoring of follicle
number and growth for IVF.
•Egg recovery for IVF and
ICSI
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108

109. Ectopic Pregnancy
HowDxEctopicpregnancy?
Whenawomaninherreproductiveyearspresents
totheemergencyUSroomwithpainandvaginal
bleeding,oneofthefirstquestionstoaskis:
“Isthereanywayyoucouldbepregnant?”
Aynalem Y (BSc, MSc, Ass.t professor)
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110. Aynalem Y (BSc, MSc, Ass.t professor)
110
High risk
PID
Tubal constrictive surgery
tubal stralization
Previous ectopic pregnancy
IUCD
Moderate risk
Infertility
Previous genital infection
Multiple partners
Slight risk
Previous pelvic surgery
Smoking
Douching
Who Is “at Risk” for Ectopic Pregnancy ?

111. Rule out ectopic
Classictriad—
Amenorrhea
Vaginalbleeding
Pain
Musthaveahighindexofsuspicion
Evenmoresointhefaceofriskfactors
Threeprimarytoolsforevaluation
Physicalexam
QuantitativeβHCG
Ultrasound
111
Aynalem Y (BSc, MSc, Ass.t professor)

112. Lab and Ultrasound
DiscriminatoryZone
Thequantβ-hCGlevelatwhichonewouldexpectto
beabletoidentifyanintrauterinepregnancy
Forvaginalsonography—1200-1500(1000-2000
perACOG)
Forabdominalsonography—3000-4000
Ifthequantβ-hCGisatorabovethe
discriminatoryzone,ANDnoIUPcanbeidentified,
thepregnancymaybeectopic!
112
Aynalem Y (BSc, MSc, Ass.t professor)

113. Ectopic Pregnancy…
The DDX in a pregnant patient who presents with
pain and bleeding in the first trimester includes :
1.Normal early pregnancy
2.Spontaneous abortion
3.Ectopic pregnancyand
4.Molar pregnancy.
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113

114. Ectopic Pregnancy…
However,thistriadispresentonlyinabout45%of
patients-Sonographyistheimagingmethodofchoice
inthesepatients.
Oneofthefirstquestionstobeansweredbymeans
ofsonographyis:
“Isthereatruegestationalsac?”
Aynalem Y (BSc, MSc, Ass.t professor)
114

115. Ectopic Pregnancy…
Sonographicdiagnosisofectopicpregnancycanbe
complicatedbyacorpusluteumcystwithacomplex
appearance,similartothatofectopicpregnancy.
Carefulassessmentoftheovaryasseparatefromthe
massofanectopicpregnancyiscrucialinthisassessment.
N.B:Itshouldberecognizedthatanovariancyst,even
whencomplicated,isunlikelytobeanectopic
pregnancysinceovarianectopicpregnanciesare
extremelyrare.
Aynalem Y (BSc, MSc, Ass.t professor)
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116. Aynalem Y (BSc, MSc, Ass.t professor)
116

117. TROPHOBLASTIC DISEASE
Trophoblasticdiseasecoversthespectrum
frombenignhydatidiformmoletomalignant
choriocarcinoma.
Earlydiagnosisenablesappropriate
managementandcounselingtobeplanned.
Aynalem Y (BSc, MSc, Ass.t professor)
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118. Hydatidiformmole
COMPLETE MOLE
Enlargeduterus
Classic sonographic
apperarence-solidcollection
ofechoeswithnumeroussmall
(3-10mm)anechoicspaces
(snowstormorgranular
appearance).
Molartissue-bunchofgrapes
signwhichrepresentshydropic
swellingoftrophoblasticvilli
Variableapperance
Noidentifiablefetaltissue
Aynalem Y (BSc, MSc, Ass.t professor)
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119. Hydatidiformmole…
PARTIAL MOLE
Placentaenlarged&
containsareasof
multiplediffuseanechoic
lesions
Fetuswithsevere
structuralabnormalities
or IUGR,
oligohydramnios, or
deformedgestational
sacmaybenoted
Aynalem Y (BSc, MSc, Ass.t professor)
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120. Radiologic/US anatomy of the UX
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121. Normal US Anatomy of ux
Theuterusinthe
postpubertalwomanis
smoothlycontouredand
pear-shaped.
Themyometrium is
uniformlymidlevelin
echogenicity,withthe
Endometrium distinctly
moreechogenic.
Aynalem Y (BSc, MSc, Ass.t professor)
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122. Normal US Anatomy of ux…
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122

123. Normal US Anatomy of the ovaries &
adnexa
TV-best
US demonstrates the
ovaries as ovalsoft
tissue structures with
multiple small cystic
follicles.
The ovaries average
5x3x2 cm in size, with
a maximum of 5 cm in
any one dimension.
Aynalem Y (BSc, MSc, Ass.t professor)
123

124. Fluid in Anterior or Posterior Cul-de-Sac
Location of the Cul-de-Sac
Therearetwosmallpouchesclosetotheuterus,oneon
eitherside,calledthecul-de-sacs.
Theanteriorcul-de-sacislocatedbetweenthebladderand
theuterus.
Theposteriorcul-de-sacisfoundbetweentheuterusand
therectum.
Aynalem Y (BSc, MSc, Ass.t professor)
124

125. Causes of Fluid in Cul-de-Sac
Retrograde menstruation
Increased ovarian
permeability due to estrogen
influence
Uterine fibroids
Endometriosis
Ectopic pregnancy
Uterinerupture
•Ovarian torsion
•Pelvic inflammatory
disease
•Tubo-ovarian abscess
•Pelvic abscess
orhematoma
•Gross ascites
•Following culdocentesis
•Hydatiformmole
•Fluid in the cul-de-sac can be caused by many different factors.
Aynalem Y (BSc, MSc, Ass.t professor)
125

126. Diagnostic Testing of Fluid in the Cul-de-Sac
Transvaginalultrasound
istheprocedurethatis
usedtoshowwhether
thereisfluidbehindthe
uterus.
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126

127. Free Fluid in the Cul-de-Sac…
Aynalem Y (BSc, MSc, Ass.t professor)
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128. Questions?
Aynalem Y (BSc, MSc, Ass.t professor)
128

129. References
5/15/2023Aynalem Y .
129
1.Problem-basedobstetricultrasoundfirstedition
2.Ultrasound:TheRequisitesThirdEdition
3.WilliamsOBSTETRICS,27thedition
4.StevenG.Gabbe.Obstetricsnormalandproblemsin
pregnancy2007,fifthedition.