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11/26/17 1 Alfred Abuhamad, MD. Eastern Virginia Medical School First Trimester Ultrasound Diagnosis of Fetal Abnormalities: What You Need to Know My Prediction • The first trimester ultrasound will play a major role in clinical management of pregnancy in the next 3-5 years • ( up to 13 6/7 weeks) Current Role of First Trimester Ultrasound • Accurate pregnancy dating • Early diagnosis of multiples • Pregnancy risk assessment • Evaluation of the adnexae Estimation of Gestational Age • If a patient reports no menstrual dates, ultrasound in the first or second trimester should date the pregnancy and establish the EDD • Ultrasound dating of pregnancy is most accurate in the first trimester • Focal zone at appropriate level • Image magnified • Embryo/fetus imaged in neutral position • Maximal length of embryo/fetus shown • Maximal length of embryo/fetus measured in a straight line from cranial to caudal Criteria for CRL Measurement Ultrasound Obstet Gynecol 2014; 44: 649–654 Task Force for Curriculum & Competency Assessment in Ultrasound Training-2017 Estimation of Gestational Age • CRL are most accurate in fetal neutral position and between 11+0 and 13+6 weeks of gestation • Use the mean of three discrete CRL measurements. • Assign EDD by CRL if > 5 days discrepancy at less than 9 weeks of gestation • Assign EDD by CRL if > 7 days discrepancy at 9 - 13 6/7 weeks of gestation BJOG 2014;121:556–565.

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  • 11/26/17

    1

    AlfredAbuhamad,MD.EasternVirginiaMedicalSchool

    FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities:

    WhatYouNeedtoKnow

    MyPrediction

    •  Thefirsttrimesterultrasoundwillplayamajorroleinclinicalmanagementofpregnancyinthenext3-5years

    •  (upto136/7weeks)

    CurrentRoleofFirstTrimesterUltrasound

    • Accuratepregnancydating• Earlydiagnosisofmultiples• Pregnancyriskassessment• Evaluationoftheadnexae

    EstimationofGestationalAge

    • Ifapatientreportsnomenstrualdates,ultrasoundinthefirstorsecondtrimestershoulddatethepregnancyandestablishtheEDD• Ultrasounddatingofpregnancyismostaccurateinthefirsttrimester

    •  Focalzoneatappropriatelevel•  Imagemagnified•  Embryo/fetusimagedinneutralposition•  Maximallengthofembryo/fetusshown•  Maximallengthofembryo/fetusmeasuredinastraightlinefromcranialtocaudal

    CriteriaforCRLMeasurement

    UltrasoundObstetGynecol2014;44:649–654TaskForceforCurriculum&CompetencyAssessmentinUltrasoundTraining-2017

    EstimationofGestationalAge•  CRLaremostaccurateinfetalneutralpositionandbetween11+0and13+6weeksofgestation•  UsethemeanofthreediscreteCRLmeasurements.•  AssignEDDbyCRLif>5daysdiscrepancyatlessthan9weeksofgestation•  AssignEDDbyCRLif>7daysdiscrepancyat9-136/7weeksofgestation

    BJOG2014;121:556–565.

  • 11/26/17

    2

    BJOG2008;115:1273–1278

    SmallCRL

    BiometryinFirstTrimester

    MultiplePregnancy

    AmJObstetGynecol.1994;170(3):824–829.

    Chorionicity:•  100%in1stTrimester•  90%in2ndand3rdTrimesters

    PregnancyRiskAssessment

    HemorrhagicCyst

    CysticTeratoma

    PedunculatedLeiomyoma

    Endometrioma

    EvaluationoftheAdnexae EvolvingRoleofFirstTrimesterUltrasound

    • Imaginginobesepregnantwomen• Screeningforfetalmalformations

  • 11/26/17

    3

    Lettyetal.JUltrasoundMed2017–onlineaccess

    EvolvingRoleofFirstTrimesterUltrasound

    • Screeningforfetalmalformations– ImpactofNIPTscreening– Impactoflimitingaccesstopregnancytermination

    UltrasoundObstetGynecol2013;41:102–113

    FirstTrimesterUltrasound

    FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017

    FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017

    FirstTrimesterUltrasound

    Syngelaki,PrenatDiagn.2011;31:90–102

    FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017

    FirstTrimesterUltrasound

    Syngelaki,PrenatDiagn.2011;31:90–102

  • 11/26/17

    4

    1stTrimesterAnomaliesDetectionRateLow-Risk,n=97,976

    32.35%(95%C.I.22.45-43.12)Karimetal–UOG2016E-Pub

    1stTrimesterAnomaliesDetectionRate

    61.18%(95%C.I.37.71-82.19)Karimetal–UOG2016E-Pub

    High-Risk,n=2,841

    1stTrimesterAnomaliesDetectionRate

    • Useofananatomicalprotocolduringfirsttrimesteranomalyscreening(P

  • 11/26/17

    5

    MidsagittalPlane

    NT

    NB

    MidBrain

    MaxillaMandible

    Cord

    Bladder

    NuchalTranslucency NasalBone

    •  Abnormalif:•  Absent•  Short•  Hypoplastic

    AneuploidyScreening

    FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017

    NasalBone–Trisomy21

    FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017

  • 11/26/17

    6

    Maxilla

    Face - Basic Face - Basic Face - Basic

    Face - Basic

    MaxillaryGap Mandible

    Face - BasicFace - Basic

    MidBrain

    T

    CPITBS

    CMOB

  • 11/26/17

    7

    PosteriorFossa–AxialView13weeks

    OccipitalBone

    FourthVentricle(IT)

    ChoroidPlexus

    CisternaMagna

    Face - Basic

    Face - Basic

    Normal

    SpinaBifida DandyWalker

    SpinaBifida DandyWalker

    OtherCNSAnomalies

    Ventriculomegaly

  • 11/26/17

    8

    Ventriculomegaly NormalVentricles

    Ventriculomegaly•  ThinningofCP•  CPfillinglessthan½ofLV•  CPbordersdonottouchlateralventricularwall•  SeparationofCPfromsuperiorbordersofLV•  Enlarged3rdVentricle

    Ventriculomegaly

    Anencephaly/Exencephaly AxialPlanes

    Normal Holoprosencephaly

  • 11/26/17

    9

    CordInsertion

    Cord

    CordInsertion

    PhysiologicMidgutHerniation•  Noteduntil12weeks•  AlmostneverseenatCRL>45mm•  Measures<7mminaxialplane

    JUM1993;12:251–UOG1995;6:240

    Omphalocele Omphalocele

    OmphaloceleOmphalocele

    Pentalogy

    Extroph

    y

    (OEIS)

    Omphalocele(Pentalogy)

  • 11/26/17

    10

    GastroschisisSmoothBordersOmphalocele

    IrregularBordersGastroschisis

    Bladder

    Bladder

    FetalBladder

    • Seenin88%at12weeks• Seenin92–100%at13weeks• RenalsourceofAFis>16weeks

    UltrasoundObstetGynecol2003;21:338–341UltrasoundObstetGynecol1996;7:95–100

    59

    NormalBladderLength<7mm

    12weeks

    Megacystis(7-15mm)•  Chromosomalanomaliesin24%•  Withnormalchromosomes:•  Resolutionin90%•  Renalanomaliesin10%

    UltrasoundObstetGynecol2003;21:338

  • 11/26/17

    11

    Megacystis(>15mm)•  Chromosomalanomaliesin11%•  Withnormalchromosomes:•  Renalanomaliesin100%

    UltrasoundObstetGynecol2003;21:338

    FetalGender

    • Inaccuratebefore12weeks• Accuracyincreaseswithadvancinggestationalage• Greaterthan95%at>13weeks

    ObstetGynecolSurv2009;64:50–57

    63

    Female

    Male

    DuctusVenosus

    3D-Extremities

    AneuploidyScreening

  • 11/26/17

    12

    Trisomy21

    FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017

    Trisomy18

    Trisomy13 MonosomyX

    FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017

    MonosomyX Triploidy

    FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017

  • 11/26/17

    13

    Triploidy MidsagittalPlaneinFirstTrimester• Goodscreeningmodalityforfetalabnormalities•  RatherthandoingawaywithNT,weneedtoenhancetrainingandfocusondetectionoffetalabnormalities•  Theroleoffirsttrimesterultrasoundwillexpandoverthenextyears


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