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A. FirstTrim ISUOG Guidelines
A. FirstTrim ISUOG Guidelines
Laurent J Salomon
Laurent J Salomon
Why ?
The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) is a scientific organization that encourages sound clinical practice, teaching and research for diagnostic imaging in womens healthcare. Practice Guidelines and Consensus are intended to reflect what is considered by ISUOG to be the best practices at the time at which they were issued. Guidelines are not intended to establish a legal standard of care because interpretation of the evidence that underpins the guidelines may be influenced by individual circumstances and available resources.
Approved guidelines can be distributed freely with the permission of ISUOG (info@isuog.org).
Laurent J Salomon
Laurent J Salomon
Laurent J Salomon
What equipment ?
For routine screening, equipment should have at least the following:
real time, gray-scale ultrasound capabilities; transabdominal and transvaginal ultrasound transducers adjustable acoustic power output controls with output display standards; freeze frame capabilities; electronic calipers; capacity to print/store images; regular maintenance and servicing.
Laurent J Salomon
What document?
An examination report should be produced as an electronic and/or a paper document, to be sent to the referring care provider in reasonable time. A sample reporting form is available at the end of this guidelines. Images of standard views (stored either electronically or as printed copies) should also be produced and stored. Motion videoclips are recommended for the fetal heart. Local laws should be followed. Many jurisdictions require image storage for a defined period of time.
Laurent J Salomon
Fetal exposure times should be minimized, using the lowest possible power output needed to obtain diagnostic information,following the ALARA principle (As Low As Reasonably Achievable).
Doppler ultrasound is associated with greater energy output and may have more potential for bioeffects.. Doppler examinations should only be used in the first trimester if clinically indicated. More details are available from the ISUOG Safety Statement.
Laurent J Salomon
Laurent J Salomon
Defining viability:
Strictly speaking, viability implies the ability to live independently outside the uterus and cannot be applied to embryonic and early fetal life. Fetal viability, from an ultrasound perspective, is therefore the term used to confirm the presence of an embryo with cardiac activity at the time of the examination. Typically embryos become detectable by ultrasound at a length of 1-2 mm and then grow by approximately 1 mm per day. The cephalic and caudal ends are indistinguishable until 53 days (around 12 mm) when the diamond-shaped rhombencephalic cavity (future 4th ventricle) becomes visible Cardiac activity is often evident when the embryo measures 2 mm or more but is not evident in around 5-10% of viable embryos measuring between 2 and 4 mm. Heart activity generally becomes visible in all normal embryos with CRL over 5 mm. If there is doubt about heart activity, then a repeat scan should be considered after a few days
Laurent J Salomon
The use of terms such as an apparently empty sac, the double-decidual ring or even pseudosac do not accurately confirm or refute the presence of an intrauterine pregnancy.
Ultimately, the decision is a subjective one and is, therefore, influenced by the experience of the person performing the ultrasound examination.
In an asymptomatic patient, it is advisable to wait until the embryo becomes visible within the intrauterine sac as this confirms that the sac is indeed a gestational sac..
Laurent J Salomon
Accurate dating of pregnancy is essential for appropriate follow up of pregnancies and has been the primary indication for routine ultrasound in the first trimester. It provides valuable information for the assessment of fetal growth later in pregnancy, appropriate obstetric care, and the management of preterm or post term pregnancies in particular.
Laurent J Salomon
The optimal time for assessment appears, therefore, to be somewhere between 8 and 13+6 weeks.
Laurent J Salomon
Singleton nomograms remain valid and can be applied in the presence of multiple pregnancy It is recommended, that these and any other nomograms be locally validated before they are adopted into use because geographic and ethnic variations may occur. It is recommended that the CRL measurements should be used to determine gestational age unless it is above 84 mm, when HC can be used, as it becomes slightly more precise than BPD.
Laurent J Salomon
Fetal biometry ?
The mean gestational sac diameter (MSD) has been described in the first-trimester from 35 days from the last menstrual period (LMP) onwards. CRL measurements can be carried out transabdominally or transvaginally. Bi-parietal diameter (BPD) and head circumference (HC).
Nomograms are also available for abdominal circumference (AC), femur length and most fetal organs, but there is no reason to measure these structures as the part of routine first trimester scan. For all measurements, calliper placement should follow the technique in the selected nomogram. Strict quality criteria should be applied.
Laurent J Salomon
Fetal biometry ?
Laurent J Salomon
Laurent J Salomon
Fetal anatomy ?
The introduction of nuchal translucency (NT) aneuploidy screening in the 11 13+6 week window has rekindled an interest in early anatomy scanning. Stated advantages include early detection and exclusion of many major anomalies, early reassurance to at risk mothers, earlier genetic diagnosis, and easier pregnancy termination if appropriate. Limitations include need for trained and experienced personnel, uncertain cost/benefit ratio, late development of some anatomical structures and pathologies (e.g. corpus callosum, hypoplastic left heart) which make early detection impossible and can lead to difficulties in counselling due to the uncertain clinical significance of some findings
Laurent J Salomon
Laurent J Salomon
Laurent J Salomon
Laurent J Salomon
Laurent J Salomon
Laurent J Salomon
Laurent J Salomon
Laurent J Salomon
Laurent J Salomon
Placenta, cord ?
The echostructure of placenta should be evaluated. Frankly abnormal findings should be noted and followed up. Position of placenta in relation to the cervix is of less importance at this stage of pregnancy age since most migrate away from the internal cervical os. Placenta praevia should not be reported at this stage. Special attention should be given to patients with prior caesarian section who may be predisposed to scar pregnancy or placenta accreta with significant complications. Gynaecological pathology, both benign and malignant, may be detected during any first trimester scan. The number of cord vessels, cord insertion at the umbilicus and presence of cord cysts should be noted.
Laurent J Salomon
Placenta, cord ?
Laurent J Salomon
Most experts recommend that NT should be measured between 11 and 13 weeks + 6 days, corresponding to a measurement of crown-rump length (CRL) between 45 and 84 mm.
Laurent J Salomon
NT measurement
NT implementation requires several elements to be in place including suitable equipment, counseling and management, and operators with specialized training and continuing certification. However, even in absence of NT based screening programs, qualitative evaluation of the nuchal region of any fetus is recommended and if it appears thickened, then expert referral should be considered.
NT measurements used for screening should only be done by trained and certified operators.
Laurent J Salomon
NT measurement
NT can be measured by the transabdominal or transvaginal route. Quality criteria:
neutral position, sagittal section image should be magnified The amniotic membrane should be identified separately from the fetus. The US machine should allow measurements precision of 0.1 mm. Calipers should be placed correctly (on-on) to measure NT.
The maximum measurement meeting all the criteria should be recorded and used for risk assessment. Multiple pregnancy requires special considerations /chorionicity. A rigorous audit of operator performance and constructive feedback from assessors has been established in many countries and should be considered essential for all practitioners who participate in NT based screening programs
Laurent J Salomon
Laurent J Salomon
USE THE
FORM !!
Laurent J Salomon
Laurent J Salomon
Acknowledgements:
Writting Committee: Salomon LJ and Alfirevic Z (Chairs), Timor-Tritsch I, Seshadri S, Papageorghiou A, Tabor A, Chalouhi G, Toi A, Yeo, G, Bilardo C, Raine-Fenning N.
Special appreciation to Jacques Abramowicz (USA), MD, PhD for his contribution to the Safety section and to Jean-Philippe Bault (France), MD for providing some of the images.
Laurent J Salomon