Step by Step Interventional Ultrasound in Obstetrics and Gynaecology

Step by Step
INTERVENTIONAL
Ultrasound
in Obstetrics &
Gynaecology
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ANESTHESIA IN OBST. & GYN.
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PREGNANCY GUIDE
Step by Step
INTERVENTIONAL
Ultrasound
in Obstetrics & Gynaecology
Kuldeep Singh
MBBS FAUI FICMCH
Consultant Ultrasonologist
Special Interest in Obstetric Sonology
in Detailed Anomaly Scanning and
Color Doppler for Management and Gynecological Scanning
Conducts FOGSI recognised ultrasound training courses in
Obstetrics, Gynecology and Infertility
(Basics and Color Doppler)
Ultrasound training division: 011-56117174
Dr Kuldeep’s Ultrasound and Color Doppler Clinic
D-115, East of Kailash, New Delhi 110065 (India)
Phones: 011-26441720, 26233342 Mobile: 98111 96613
singhdrkuldeep@rediffmail.com
Narendra Malhotra
MD FICOG FICMCH Ian Donald Diploma
Practising Obstetrician & Gynecologist
Special Interest in High-Risk Obstetrics, Ultrasound,
Laparoscopy and Infertility, ART and Genetics
Malhotra Nursing and Maternity Home Pvt Ltd (India)
84, MG Road, Agra 282010
Phones: 0562-2260275/2260276/2260277 Mobile: 98370 33335
mnmhagra@sancharnet.in
www.mnmhagra.com, www.mttbc.com
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Step by Step Interventional Ultrasound in Obstetrics & Gynaecology
© 2004, Kuldeep Singh, Narendra Malhotra

All rights reserved. No part of this publication should be reproduced,
stored in a retrieval system, or transmitted in any form or by any means:
electronic, mechanical, photocopying, recording, or otherwise, without
the prior written permission of the authors and the publisher.
This book has been published in good faith that the material provided
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matters are to be settled under Delhi jurisdiction only.
First Edition : 2004

ISBN 81-8061-367-4
Typeset at JPBMP typesetting unit
Printed at Replika Press Pvt. Ltd.
Preface
Ultrasound today is the mainstay investigation in the field

of obstetrics and gynaecology. It is now quick, easy,
reproducible and inexpensive to make an anatomical
diagnosis in obstetrics and gynaecology. The addition of
color gives us an insight to the physiology of the area/
organ/fetus being scanned and 3D and 4D have added a
new anatomical plane and dimension.
Introduction of interventional procedures to obstetrics
and gynaecological ultrasound has now made it possible
for us to help in making a histopathological diagnosis.
This step by step book aims at introducing the reader
and familiarising the reader to interventional sonography
in Obstetrics and Gynaecology.
It is mandatory by the Indian PNDT law to register your
machine and clinic to perform interventional genetic
diagnostic procedures.
Kuldeep Singh
Narendra Malhotra
Acknowledgements
Our heartiest thanks to our parents, elders, teachers,

spouses, siblings, our sons, daughters and our friends who
have helped us step by step at every step of our ambitious
project of step by step series.
We were introduced to interventional sonography by
Ananda Kumar (Singapore), Rajat Goswamy (UK), Asim
Kurjack and Sanja Kupesic (Croatia), Prof Kratrochwil
(Austria), Ambarish Dalal, Pratap Kumar, Bhupendra Ahuja,
Dr PK Shah, Jatin P Shah and Pranay Shah and many many
others who taught us small tricks of the trade at each step of
our life.
We are extremely grateful to our wives Nishu K Singh
an expert housewife and supporter and Dr Jaideep Malhotra
an expert infertility specialist.
Our children who are studying Jaanvi, Ramanjeet,
Neharika Malhotra (Medical Student) and Keshav. Thank
you children for letting us do what we want from your time:
God bless you four and grow up and do well.
Contents
1. Introduction ............................................................. 1
2. Training .................................................................... 8
3. Obstetric Procedures ............................................ 16
4. Gynaecology Procedures ..................................... 41
5. Infertility Procedures ........................................... 58
APPENDICES
Appendix 1: Ectopic Pregnancy Pretreatment Scores ... 71
Appendix 2: High Risk Pregnancy Evaluation Form .. 73
Appendix 3: Consent Form for IVF-ET ........................ 79
Appendix 4: Fetal Abnormalities ................................. 99
Index .......................................................................... 105

One Introduction
1.1 Filling forms
1.2 Relevant history
1.3 Machine and equipment
1.4 Patient preparations
1.5 Counselling and legal aspects
1.6 Documentation and reporting
1.7 Analgesia and anaesthesia
1.1 FILLING FORMS

Maintain a form for further follow up in your clinic. One
never knows when the information is required.
The routine information required in these forms is:
a. Name
b. Age
c. Address
d. Telephone Number
e. Referred by
f. PNDT Act Form ‘F’ as required by Government of
India law
g. Undertaking by patient and doctor for obstetric
ultrasound with Form ‘F’ and Form ‘G’.
h. For genetic defects in for ventional procedures the
clinic/Nace has to be specially registered and
licenced by Govt. under the PNDT act as a genetic
Lab.
2 Interventional Ultrasound in Obs & Gynae
1.2 RELEVANT HISTORY
Always spend few minutes with your patient to take the
details of the history. It gives confidence to the patient and
you get your perspective of what all to expect.
The history to be taken routinely is :
a. Previous obstetric history consisting of details of
any abortions (spontaneous or missed), any second
or third trimester losses (possible reasons), any
previous deliveries (vaginal or caesarian). Try and
look into the previous records which can throw any
light.
b. Any symptoms in this pregnancy.
c. Any ultrasound done so far in this pregnancy. Check
the records carefully.
d. Last menstrual period and regularity of menstrual
cycles.
e. Any tests done and their reports.
f. Referring doctors requisition slip (This is now a legal
requirement with Form ‘F’).
1.3 MACHINE AND EQUIPMENT (FIGS 1.1 TO 1.5)

Any good resolution scanner is a requisite for interventional
procedures and should have both probes (transabdominal
and transvaginal) all standard accessories, biopsy guides
for both probes, recording and documenting facility and
different types of needles, etc.
1. Machine with transabdominal and transvaginal probes.
2. Minor operation theatre.
3. Biopsy guides for transabdominal and transvaginal
probes.
Introduction 3
Fig. 1.1: Machine with probes and

biopsy guide
Fig. 1.2: Abdominal probes with biopsy guide and needle

Fig. 1.3: Vaginal probes and biopsy guides with needles
Fig. 1.4: Various biopsy guides
4. Biopsy needles of all sizes and lumen for abdominal

and vaginal routes.
5. Standard accessories.
6. Standard equipment for minor O.T. procedure.
7. Consent form.
Introduction 5
Fig. 1.5: Ovum pick up set
1.4 PATIENT PREPARATIONS

Patient is prepared for as any other minor operative
procedures.
1. Admission charts and proper consent.
2. Preoperative antibiotic and Tetvac injection.
3. Preoperative part preparation, bowel and bladder
evacuation.
4. Supine/lithotomy position.
5. Sterilized probe (Dipping in Cidex solution).
6. Aspetic measures.
7. Analgesia/anaesthesia.
1.5 COUNSELLING AND LEGAL ASPECTS

1. Proper genetic registered centre (PNDT Act).
2. Genetic counselling for chromosomal defects.
3. Counselling for procedure and side effects.
4. Legal consent.
5. Counselling for acceptable procedure related risks and
abortions.
6. Legal malpractices issues may be different in different
countries.
A plaintiff must demonstrate that the physician breached
the standard care and his action/inaction caused injury, since
the standard care is so rapidly changing the physician must
be alert to new developments and must inform these to the
patient.
1.6 DOCUMENTATION AND REPORTING

1. Proper hard copy/soft copy documentation.
2. Detailed step wise procedure reporting.
3. Report complications.
4. Clear follow up of instructions.
1.7 ANALGESIA AND ANAESTHESIA

Usually these procedures are quick and relatively painless
and require only reassurance, mild analgesia and local
anaesthesia.
1. Local anaesthesia.
2. Analgesic injections.
3. Short general anaesthesia with propofol, pentothal or
ketamine.
4. All standard resuscitation equipment.
5. Trained anaesthetist.
Introduction 7
H/o Anomalies/Suspected Defect
9-11 weeks 16 weeks 18 weeks +

↓ ↓ ↓
USG USG USG
Nuchal translucency Morphology Fetal morphology
Nasal bone ↓ ↓
Ductus venosus Amniocentesis Fetal blood
Umbilical artery ↓ ↓
Iliac bone angle Karyotype Karyotype
DNA culture Enzyme
L/S ratio DNA, IgM
CVS Early Amnio Surfactant Blood gases
↓ Culture
Karyotype Haematology
DNA culture
Enzyme assay
Flow Chart 1.1: Showing approach to a pregnant patient for
anomaly detection and confirmation
Two Training
2.1 Guidelines
2.2 Theoretical aspects
2.3 Training parameters
2.4 Suggested training schedule
2.5 Prerequisite criteria for a trained
ultrasonologist
2.6 Mandatory proposed certification for
an ultrasonologist (Obs and Gyn)
2.7 Gynaecological ultrasound
2.8 Training
A proper training in obstetric and gynaecological ultrasound

is a must and a postgraduate degree/diploma in obstetric
and gynaecology/surgery/ Interventional Radiology/
Radiology/MBBS with one year training under a Radiologist.
2.1 GUIDELINES
The practice of ultrasound and the use of diagnostic and
interventional ultrasound is now a necessary tool rather
than a luxury. It is impossible to even conceive an Obstetric
Care Unit and Fetal Medicine Unit or even Gynaecology
and Infertility Diagnostic Unit without ultrasound.
To practise ultrasound in India it is mandatory to be
trained in ultrasonography under proper guides and to do
100 cases minimum of Obs. and Gyn. Ultrasound and 6
months to 1 year of observership under a Radiologist or an
approved centre.
Training 9
2.2 THEORETICAL ASPECTS

The theoretical aspects one should know, should cover topics
on Physics of ultrasound, ultrasound machines and probes,
how to use an ultrasound machine, PNDT Act, laws of
ultrasound, medicolegal aspects, methodology, patient
preparations, complete obstetric ultrasound uses including
use in first, second and third trimesters, diagnosis of
threatened abortion, ectopic pregnancy, biometery, anomaly
scanning, IUGR, placental evaluation, amniotic fluid
evaluation, colour Doppler uses and 3D and 4D ultrasound.
Complete gynaecological ultrasound aspects include use
of TVS, colour Doppler and 3D in evaluating female pelvis
and evaluating infertility and complete interventional proce-
dures.
2.3 TRAINING PARAMETERS
FIRST LEVEL
(At least 30 hours a week for two months)
These are aimed at to:-
1. Confirm intrauterine pregnancy.
2. Confirm viability.
3. Determine number of gestations.
4. Fetal biometry.
5. Assessment of growth.
6. Presentation.
7. Amniotic fluid assessment.
8. Placental assessment.
9. Cervix measurement.
10. Suspect abnormalities.
SECOND LEVEL
(About 100 sessions and 300 hours)
1. Detect and specify early pregnancy problems.
2. Detect and specify abnormalities.
3. Assessment of growth restriction.
4. Fetal biophysical profiling.
5. Understanding Colour Doppler.
6. Accurately sampling various blood vessels by
Doppler and analysing them.
7. Knowledge of interventional procedure.
8. Knowledge of 3-D and 4-D.
9. Analysis of malignancies.
THIRD LEVEL (3 years)

1. Acquire 3-D and 4-D image.
2. Perform interventional procedures.
3. Research and development.
4. Acquire ability to teach basic skills.
2.4 SUGGESTED TRAINING SCHEDULE

Viable pregnancies 10
Nonviable pregnancies 10
Normal biometry 10
Growth restrictions 10
Abnormal pregnancy 10
(Ectopic/Multiple etc.)
Colour Doppler Studies Obstetric 10
Colour Doppler Studies Gynaec 10
Training 11
IUCD’s 5
Fibroids 10
Ovarian cysts 10
Gynaec disorders 10
Transvaginal scan 10
These are minimum number of scans for Level-I training.
Another 100 cases of detailed Obstetric and
Gynaecological cases for various indications including colour
and 3-D should be logged for Level-II training.
A standard reporting format for gynaecology and
Obstetrics should be adhered to with details of different
descriptive terminology.
2.5 PREREQUISITE CRITERIA FOR A

TRAINED ULTRASONOLOGIST
1. The ultrasonologist should be able to identify early
pregnancy and emergency gynaecological problems by
transvaginal and transabdominal ultrasound.
a. Early pregnancy:
• Fetal viability
• Description of the gestational sac, embryo, yolk
sac
• Single and multiple gestation (chorionicity).
b. Pathology:
• Early pregnancy failure
• Ectopic pregnancy
• Gross fetal abnormalities such as nuchal trans-
lucency, hydropic abnormalities
• Hydatidiform mole
• Associated pelvic tumors.
• First trimester markers of chromosomal
anomalies
c. Gynaecology:
• Normal pelvic anatomy
• Uterine size and endometrial thickness
• Measurement of ovaries
• Pelvic tumors, e.g., fibroids, cysts hydrosalpinx
• Peritoneal fluid
• Intrauterine contraceptive devices.
2. The ultrasonologist should be able to recognise the
following normal fetal anatomical features from 18
weeks onwards by abdominal ultrasound.
a. Shape of the skull: nuchal skinfold
b. Brain: ventricles, cerebellum, choroid plexus
c. Facial profile
d. Spine: both longitudinally and transversely
e. Heart rate and rhythm, size and position, four-
chamber view
f. Size and morphology of the lungs
g. Shape of the thorax and abdomen
h. Abdomen: diaphragm, stomach, liver and umbilical
vein, kidneys, abdominal wall and umbilicus
i. Limbs: femur, tibia and fibula, humerus, radius and
ulna, feet and hands—these to include shape,
echogenicity and movement
j. Multiple pregnancy: monochorionic and dichorionic,
twin-twin transfusion syndrome
k. Amount of amniotic fluid
l. Placental location
m. Cord and number of vessels.
3. Fetal biometry
a. Crown-rump length, biparietal diameter, femur length,
head circumference, abdominal circumference,
interpretation of growth charts.
Training 13
4. Activity: recognise and quantify

a. Fetal movements
b. Breathing movements
c. Eye movements.
5. Second trimester markers of chromosomal anomalies
and their scoring
2.6 MANDATORY PROPOSED CERTIFICATION
FOR AN ULTRASONOLOGIST (OBS AND GYN)
1. One hundred hours in 6 months, of supervised scanning
to include (one year observership):
a. 100 gynaecological examinations and early
pregnancy problems (principally by transvaginal
sonography but transabdominal experience also
required).
b. 200 obstetric scans covering the full spectrum of
obstetric conditions.
2. Logbooks:
30 cases on one A4 page with ultrasound picture, at
least 15 anomalies should be included.
These are suggested training hours and comply with
the Indian Government’s requirement under the modified
PNDT Act.
2.7 GYNAECOLOGICAL ULTRASOUND

1. Normal pelvic anatomy
a. Uterus
• Uterine size, position, shape and movement
• Cyclical morphological changes in the endomet-
rium
• Measurement of endometrial thickness
b. Ovaries
• Size, position, shape and measurement
• Cyclical morphological changes
• Measurement of follicles and corpus luteum
• Assessment of peritoneal fluid
2. Gynaecological complications:
a. Uterus
• Fibroids
• Adenomyosis
• Endometrial hyperplasia
• Endometrial cancer
• Polyps
• Location of intrauterine contraceptive device
b. Tubes
• Hydrosalpinx and other abnormalities of the
fallopian tubes
c. Ovaries
• Cysts; benign and malignant, morphological
scoring systems
• Endometriosis
• Ovarian carcinoma
• Differential diagnosis of pelvic masses
3. Infertility:
a. Monitoring of follicular development in sponta-
neous and stimulated cycles
• Diagnosis of hyperstimulation syndrome
• Diagnosis of polycystic ovaries
• Sonosalpinography
4. Invasive procedures:
a. Oocyte retrieval
Training 15
b. Injection of ovarian cysts

c. Aspiration of ovarian cysts
d. Drainage of pelvic abscesses
e. Extraction of intrauterine contraceptive device.
5. Doppler in gynaecology
6. Infertility and oncology.
2.8 TRAINING
Training certification as accepted by PNDT law should be
taken before attempting any interventional procedure.
Proper training and experience can be gained by regular
practise on Phantoms. Operator must be well familiar with
all probes and needles.
Three Obstetric
Procedures
3.1 Counselling and patient
preparations
3.2 Tricks and traps of interventional
ultrasound
3.3 Procedures
3.4 Anaesthesia and place
3.5 Chorionic villous sampling
3.6 Amniocentesis and coelocentesis
3.7 Cord blood sampling and
umbilical cord catheterisation
3.8 Fetal blood evaluation and
transfusion
3.9 Fetal shunts
3.10 Intrauterine pressure assessment
3.11 Diagnostic and therapeutic
procedures in twins
3.12 Fetal reduction in high order multiple
pregnancy
3.1 COUNSELLING AND PATIENT

PREPARATIONS
• Obstetric interventional procedures are usually per-
formed for diagnosis and therapy.
Obstetric Procedures 17
• Diagnostic obstetric procedures are for prenatal diag-

nosis in patients identified to be at a risk of birth defects
or genetic defects.
• Therapeutic obstetric procedures are an attempt to give
some palliative treatment intrauterine so as to save the
fetus from damage/death until a gestation of viability.
For counselling one needs to observe the following points:
1. Communication with the patient and family.
2. Explain medical facts, diagnosis, probable cause
of disorder and options of management.
3. Heredity.
4. Risk of recurrence.
5. Course of action and options.
6. Ethical, religious and social counselling.
7. Explain procedural risks and side effects and
complications.
8. Discussion of ethical dilemmas of procedure benefit
and balance of procedure related risks.
9. Choice of abortion.
10. Choice of fetal reduction in high order multiple
gestations.
11. Misdiagnosis and limitations (Not all misdiagnosis
are due to negligence).
3.2 TRICKS AND TRAPS OF

INTERVENTIONAL ULTRASOUND
A sound knowledge of the following:
a. Physics of ultrasound: It is essential for the sonologist
to be aware of the working of ultrasound machines and
the way images are generated and how the resolution
can be improved.
b. Artefact: It is essential to understand reverberation
artefacts and comet tail artefacts, mirror image artifacts,
chinese hat artifact, etc otherwise many procedures will
be not done or done incorrectly.
c. Invasive procedures: To do invasive procedures the
operator must be well versed with using correct
transducer, correct instruments, proper gain controls.
The common obstetric procedures will be:
i. CVS
ii. Amniocentesis
iii. Cord blood sampling
iv. Fetal biopsy (Figs 3.1 to 3.4)
v. Fetal blood transfusion
vi. Fetal shunts
vii. Twin gestation for (TRAP syndrome)
d. Technical aspects: Freehand or biopsy guide technique.
Angle of needle in freehand technique should be 90° to
the beam. Single operator or two operator technique.
Use of sono enhanced needles.
3.3 PROCEDURES
All invasive obstetric procedures are aimed at making a
prenatal diagnosis in patients at risk of congenital genetic
malformations, a few of these procedures are also aimed at
therapeutically saving the fetus in utero till the time of
viability when they can be delivered for further paediatric
surgical management.
3.4 ANAESTHESIA AND PLACE

As discussed earlier all obstetric interventional procedures
should be done in:-
Fig. 3.1: Biopsy of the fetal muscle
Fig. 3.2: Biopsy of the fetal skin

Fig. 3.3: Needles for biopsy of the fetal skin
Fig. 3.4: Instruments for biopsy of the fetal skin

1. Hospital OT.
2. Minor OT set-up.
3. Under analgesia, local anaesthesia.
4. Short general anaesthesia.
3.5 CHORIONIC VILLOUS SAMPLING

(FIGS 3.5 TO 3.10)
1. First trimester modality.
2. Aims to retrieve adequate trophoblastic tissue.
3. USG guided procedure.
4. TAS and transcervical CVS.
5. TVS and transmyometrial CVS.
6. TAS and free hand/biopsy abdominal CVS.
7. CVS needle (maleable).
8. TAS with partially full bladder to identify chorionic
tissue.
9. Lithotomy position.
Fig. 3.5: Syringe used for an abdominal CVS

Fig. 3.6: An outline of the chorion to delineate the site for CVS
Fig. 3.7: Outline diagram to show a CVS being done

transabdominally
Fig. 3.8: Outline diagram to show a CVS being done

transvaginally
Fig. 3.9: Villi as seen in the Petri dish after the procedure
Fig. 3.10: Villi as seen through a microscope
10. Asepsis and vaginal cleaning.

11. Hold anterior lip of cervix.
12. Guide the CVS needle gently towards lower end of
implantation site under direct vision.
13. Suction with a 5 cc syringe and very gentle curetting
movements.
14. Tissue retrived and send in culture media for
karyotyping and culture.
15. Transabdominal sampling done by single or double
needle technique.
16. Ideal time 9-12 weeks.
17. Counselling of patient for pregnancy loss and
genetic disorders
18. Side effects: pregnancy loss, bleeding, failure to
retrive tissue, rupture of membranes, infection,
elevated MSAFP, Rh isoimmunisation, limb body
anomalies.
3.6 AMNIOCENTESIS AND COELOCENTESIS

(FIGS 3.11 TO 3.14)
Coelocentesis
1. Coelomic aspiration under USG guidance.
2. TVS scan to locate anatomy.
3. No anaesthesia or only mild sedation.
4. 20 gauge needle through a biopsy guide/transmyo-
metrial.
5. Needle placed in coelomic cavity.
6. Fluid is aspirated (0.5 – 2.5 ml).
Fig. 3.11: Line diagram showing a coelocentesis
Amniocentesis
1. Indications
• Cytogenetic diagnosis.
Fig. 3.12: Picture showing the placement of the needle

(coeleocentesis)
Fig. 3.13: Freehand technique for amniocentesis (I)

Fig. 3.14: Freehand technique for amniocentesis (II)
• NTD: Late first or early second trimester.

• Metabolic defects.
• Isoimmunisation.
• Fetal lung maturity.
• Late second or early third trimester.
• Intra amniotic infection.
• PROM.
• Drainage of Polyhydramnios.
• Medical treatment of fetus.
• Therapeutic.
2. Selection of a needle (18-22 gauge spinal needle).
3. USG scan to identify pocket free of placenta and cord
and fetal parts.
4. Ultrasonographically guided amniocentesis.
5. Ultrasonographically monitored amniocentesis.
6. Convex probe or sector probe or even linear probe is
TAS (Figs 3.13 and 3.14).
7. Needle with stylet introduced by freehand technique or
fixed biopsy guide technique.
8. Stylet removed and amniotic fluid aspirated.
9. 0.5 ml first fluid is discarded to avoid maternal cell
contamination.
10. 5-15 ml fluid is aspirated and sent for karyotyping
of fetal cells and for genetic culture.
Early Amniocentesis
1. Procedure before 15 weeks gestation.
2. Equal diagnostic potential as a mid-trimester amnio-
centesis with added advantage of a easier termination
if required.
3. Can be done TVS guided also.
Complications
1. Fetal loss.
2. Fetal injury.
3. Fetal respiratory complication (Macaca fasicularis).
4. Amniotic fluid leakage.
5. Bloody taps.
6. Fetomaternal transfusion.
7. Infection.
8. Meconium staining.
9. Rh isoimmunisation.
3.7 CORD BLOOD SAMPLING

(CORDOCENTESIS) (FIGS 3.15 TO 3.21)
With the development of interventional ultrasound in
obstetrics an access to fetal circulation was discovered.

Access to fetal blood and fetal circulation has led to our
improvement of many fetal diseases, diagnosis and
diagnosis of fetal acidemia and event therapy. Fetal blood
Fig. 3.15: Free loop of umbilical cord seen on a 2D scan
Fig. 3.16: Definitely see that you look for a free loop of
umbilical cord
Fig. 3.17: Arrow showing the placement of the needle
Fig. 3.18: Routes for cordocentesis depending on the free loop

and the site of the placenta
Fig. 3.19: Catheterisation of the umbilical cord
Fig. 3.20: Transducer position, fetal position and the technique

for cordocentesis as shown in the line diagram
Fig. 3.21: Proper technique and route for cordocentesis
sample provides fetal lymphocytes through which faster

and more accurate genetic diagnosis can be made.
Indications
• Cytogenetics.
• Viral and parasitic infections.
• Red blood cell alloimmunisation.
• Fetal thrombocytopenia.
• Nonimmune hydrops evaluation.
• Perinatal fetal assessment.
• Twin-twin transfusion and TRAP evaluation.
Sites
1. Free loop of umbilical cord (Loop).
2. Umblical fetal abdomen attachment (Fetal abdomen).
3. Umblical placental attachment (Placenta).
4. Fetal portal vein (intrahepatic) (Portal vein).
Technique
1. Free hand (Fig. 3.13).
2. Fixed biopsy guide.
3. 20-22 gauge needle (spinal).
4. Local anaesthesia and strict asepsis.
5. 2-5 ml blood in dry heparinised syringes.
Complications
1. Failure to obtain blood or contaminated blood
(maternal).
2. Fetal loss.
3. Infection.
4. Amniotic fluid loss.
3.8 INTRAUTERINE FETAL TRANSFUSION

Indications
1. Fetal anemia.
2. Fetal thrombocytopenia.
3. Correction of immunodeficiencies.
Technique
1. Intravascular (in umbilical vein).
2. Intraperitoneally (in fetus).
Intravascular transfusion can be given in the umbilical
vein free loop, intrahepatic portion or even exceptionally
in left cardiac ventricle. Interperitoneal transfusion may
be performed from 14 weeks gestation.
• 20 gauge spinal needle.
• Bolus transfusion or an intrauterine exchange can be
given via a 3 way value.
Risks and Complications
• Procedure related risk
• Transfusion risk
• Alloimmunisation risk
3.9 FETAL SHUNTS (FIG. 3.22)

Fetal shunting should be contemplated for conditions
frequently associated with significant neonatal mortality
and morbidity.
Indications
1. Obstructive uropathy.
2. Pleural effusion.
3. Pulmonary cysts.
Fig. 3.22: Hydrocephalus puncture for termination

4. Ventriculomegaly.
5. Fetal ascites.
Fetal Invasive Therapy

1. Natural history of condition should be known.
2. Condition severe enough to interfere with normal
development and cause death or disability.
3. Treatment should be capable of improving the
natural history of the condition.
4. Evidence from animal models should support this.
5. Exclude all other fetal anomalies.
6. Reliable prognostic tests.
7. Immature fetus for delivery.
8. Benefits to fetus must outweigh risks.
9. Counselling and informed consent.
10. Proper ANC and follow-up.
11. Postnatal corrective methods.
12. Scientifically evaluated treatment.
Types of Shunt
1. Vesico-amniotic : Obstructive uropathy
Posterior urethral valve
2. Pyleo-amniotic : Hydronephrosis
3. Pleuro-amniotic : Hydrothorax/chylothorax
4. Cysto-amniotic : Pulmonary cyst
5. Peritoneo-amniotic : Ascites
6. Ventriculo-amniotic : Cerebral ventriculomegaly
Technique
• Skilled personnel
• Genetic treatment centres (quartenary referral)
• Written consent
• Counselling
• OPD procedure
• Mild analgesia/anaesthesia
• Fetal injection pancuronium (to paralyse fetus: tempo-
rary)
• Prophylactic antibiotics.
Types of Shunts
Rocket fetal catheter : a double pigtail silastic catheter
(external and internal diam 2.1 and 5.1 mm)
• High resolution scan to identify target
• Asepsis
• 20 gauge spinal needle in amnotic cavity and amnio
infusion with 150-200 ml warm saline.
• Introduction of metal trocar in target site and drainage
of target fluid
• Fetal catheter is straightened and introduced
• Withdrawal of cannula
The procedure of shunts is not without risks and
maternal and fetal complications.
Today great advances have taken place in form of
microendoscope and laser techniques to deal with such
cases.
3.10 INTRAUTERINE PRESSURE
ASSESSMENT (FIG. 3.23)
Intra-amniotic pressures are studied in labour and in condi-
tions of poly and oligohydramnios and in fetal body
cavities.
Pressure changes equipments are available, a needle is
passed into the cavity of whose pressure has to be evaluated
and connected to the pressure detection system.

In the last 10 years many studies have been reported of
intrauterine and intrafetal pressures and their importance
in antenatal surveillance. These help in understanding fetal
pathophysiology but at the current status are a research
tool.
Fig. 3.23: Intra-amniotic pressure assessment
3.11 DIAGNOSTIC AND THERAPEUTIC

MEASURES IN TWINS (FIGS 3.24 TO 3.26)
All procedures done in singleton pregnancies for prenatal
diagnosis can be done in twins also (amniocentesis, CVS,
cord blood sampling, etc). In monochorionic twins special
procedures can be done to improve outcome.
1. Twin to twin transfusion syndrome
a. Amniodrainage by a 18 gauge needle.
b. Laser coagulation of placental anastomosis.
c. Selective feticide of acardiac twin in TRAP
syndrome.
3.12 FETAL REDUCTION IN HIGH ORDER

MULTIPLE PREGNANCY
Today due to the rampant use of ovulation inducing drugs
and increase in ART procedures there is an increase in the
incidence of HOMP’s. This carries a very high incidence
of preterm and LBW births with a very high neonatal
mortality and morbidity.
A safe option is fetal reduction
• Counselling
Fig. 3.24: Multifetal pregnancy for reduction

Fig. 3.25: Equipments for fetal reduction
Fig. 3.26: Stepwise reduction of two fetuses in a

quadruplet pregnancy
• Written consent
• Reduction to twins/rarely to singleton
• Ideal timing 7-9 wk or >10 weeks (spontaneous
reduction)
• TVS or TAS
• Mild anaesthesia
• Identify nearest to probe fetus
• Double bore needle technique (Dalal) or single bore
no 26 gauge needle (Malhotra and Shah 2000)
• Needle introduced in fetal thorax under USG
guidance through a biopsy guide
• Injection of 0.5 – 1 ml of KCl
• Confirm fetal demise
• Prophylactic antibiotics and tocolytics.
Complications
• Fetal loss
• Bleeding
• Infection
Generally a safe procedure and a safe option of reducing
neonatal morbidity and mortality and improving outcomes
of HOMP’s.
Four Gynaecology
Procedures
4.1 Introduction
4.2 Adnexal cystic masses
4.3 Pelvic masses
4.4 Ectopic pregnancy management
4.5 Transcervical metroplasly
4.6 Urogynaecology
4.1 INTRODUCTION (FIGS 4.1 AND 4.2)

A p/s and p/v is still the mainstay of any gynaecological
examination, however the results are subjective, addition
of TVS has given an objective component and is a marriage
of palpation and imaging, addition of colour gives physio-
logical information and 3D has added a new dimension to
examining the pelvis, however all these are anatomical and
physiological diagnosis and to get a histopathological
diagnosis, the needle has to be introduced in the target organ
to obtain a sample for HPE–Interventional gynaecological
sonography.
• Counselling
• Written consent
• Minor OT set-up
• Anaesthesia
• Proper needles
Fig. 4.1: Transvaginal probe with biopsy guide and needle
Fig. 4.2: Transvaginal probe with biopsy guide and needle
• Biopsy guide
• Prophylactic antibiotics
• Pre and post-procedure TVS and colour Doppler scan.
Gynaecology Procedures 43
4.2 ADNEXAL CYSTIC MASSES (FIGS 4.3 TO

4.10)
Adnexal cystic mass
↓
TVS
↓
Size/shape/morphology
Benign non Suspicion Ectopic

resolving cyst of
↓ malignancy Unruptured Ruptured
USG guided ↓
Laparo-
aspiration and USG guided ↓
scopy
injection of FNAC
sclerosing agents Benign Malignant < 2.5 cm >2.5
↓ |
Laparoscopy bHCG
Cure Reccurs surgery with <10000
↓ radiotherapy ↓ Laparo-
Laparoscopy TVS scopy
guided
injection
of MTX
Indications for ultrasound guided puncture of adnexal

cysts.
1. Is it necessary?
2. Is it possible?
3. Is it acceptable?
4. Is it enough?
Technique
Fig. 4.3: Drainage of a hydrosalpinx
Fig. 4.4: 3D ultrasound evaluation of the tube

(Hydro and pyosalpinx)
Fig. 4.5: Cyst puncture under ultrasound guidance
Fig. 4.6: Cyst puncture under ultrasound guidance
• Counselling
• Written consent
• USG evaluation
• Minor OT procedure
• Anaesthesia
Fig. 4.7: Ovarian cyst puncture with a 28-week pregnancy
Fig. 4.8: Needle seen in ovarian cyst

Fig. 4.9: Abnormal ovaries as seen on a laparoscope

(laparoscopic ovarian cystectomy)
Fig. 4.10: Ovarian cyst with multiple coarse internal echoes

(endometrioma)
• TAS or TVS
• Needles 17 gauge—20 gauge
• Aspiration pump
• Injection of sclerosing agents (Terramycin or athoxy-
sclerol)
• Cytological examination of cyst aspirated material
• Antibiotics
• Follow-up
4.3 PELVIC MASSES

Pelvic masses may arise from the genital tract or may be
non-gynaecological. They may be cystic, solid or mixed
Pelvic mass
↓
TVS
↓
Try to confirm
Origin
Gynaecological Abscess Non-gynaecological

↓
↓ Bowel
Drainage
Uterine Tubal Ovarian ↓ Urinary tract
Wash Mesentery
↓
Drainage Other
Cystic Mixed Solid ↓
↓ ↓ ↓ Local USG guided
Aspirate Aspirate FNAC antibiotic FNAC
then Laparoscopic
decide removal
and may be infective or neoplastic.
4.4 ECTOPIC PREGNANCY MANAGEMENT

(FIGS 4.11 TO 4.14)
There is today a non-surgical method for treating ectopic
Suspected ectopic
↓
TVS and colour Doppler
↓
βhCG
Heterotrophic Ruptured
Adnexal mass
↓ Tubal ectopic
Ruptured abortion
↓ <3 cm >3 cm ↓
Laparoscopic ↓ MTX Hae- Shock
surgery inj of Local Laparoscopy systemic mody-
KCl in ectopic MTX in namics
Live ectopic mass stable
↓
Conservative Salpingectomy
TVS guided
Laparotomy
KCl
in fetal heart Laparoscopy
and 50-75 mg
MTX in sac
pregnancies which have not ruptured and where patients

are haemodynamically stable.
Technique
• Diagnosis
• Counselling
Fig. 4.11: Ectopic pregnancy as evaluated

by a TVS and colour Doppler
Fig. 4.12: Tecnique for management of an ectopic pregnancy
Fig. 4.13: Laparoscopic management of an ectopic pregnancy

Fig. 4.14: Local injection in an ectopic pregnancy
• Written consent
• Anaesthesia
• TVS guided needle 17-20 gauge put in sac
• Salpingocentesis
• Injection of 50-75 mg of MTX or RU486 or others
• Prophylactic antibiotic
• Baseline blood tests and βhCG levels
• Monitoring treatment by serial TVS colour Doppler and
βhCG.
• > 80 percent success
• > 70 percent spontaneous tube recanalisation.
• A very good, safe and effective treatment for early
unruptured ectopic pregnancy.
4.5 TRANSCERVICAL METROPLASTY

Congenital anomalies of the uterus are a major cause of
recurrent pregnancy loss and even infertility.

A hysteroscopic correction of septa and lateral metro-
plasty is the gold standard treatment modality.
The same treatment can be carried out under ultrasound
guidance.
Improved resolution of machines have opened up new
exciting possibility of septum resection as an OPD procedure
under ultrasound guidance.
Fig. 4.15: Urinary bladder study in a normal female

Fig. 4.16: Urinary bladder study in a female

with incontinence (I)
Fig. 4.17: Urinary bladder study in a female

with incontinence (II)
4.6 UROGYNAECOLOGY (FIGS 4.15 TO 4.17)
• Post-voiding residual volume
• Descent of bladder neck
Urodynamic Sonography
Lithotomy position
(transperineal, translabial, transrectal, transvaginal,
introital and intraurethral)
↓
Visualisation of
sphincteral zone
↓
Lower part of bladder
↓
Pubic symphysis and
arcuate ligaments
↓
Prepubic structure
Urodynamic Exploration
↓
Urethrocystometry
↓
Urethral pressure
profile at rest
↓
Urethral pressure profile
(Valsalva)
Coughing and holding
↓
Uroflowmetry
↓
Electromyography
Stress Incontinence Surgery and Ultrasound

Preoperative assessment
Stress incontinence diagnosis
↓
Evaluation of prolapse
↓
Detection of surgical contraindications
↓
Operative prognosis
Peroperative
• Control of suspension position
• Tension of suspension
• Passage of instrument in Retzius space
• Urinary stress in continence evaluation
• Suprapubic vesical catheter
Postoperative
• Anatomical modifications
• Visualisation of exogenous tissues
Urodynamic ultrasound today can offer a reliable and
safe and nonsatiation method to morphologically evaluate
the female urinary tract.
Five Infertility
Procedures
5.1 Uterine cavity evaluation (Hycosy)
5.2 Tubal evaluation
(Sonosalpingography)
5.3 Ovarian cyst punctures
5.4 Ovum pickup or ovum retrieval
5.5 Tubal cannulation
5.6 TVS guided SIFT/DIPI/IOI
5.7 USG guided embryo transfer
5.8 USG guided PCO puncture
Today transvaginal ultrasound is indispensible tool for the

diagnose infertility specialist. Treating infertility without
a transvaginal scan is like walking in the dark without a
torch. A lot of infertility diagnosis and therapy is based on
interventional ultrasound used in daily practise. These
simple, reproducible, noninvasive methods help the
infertility specialist to reach a diagnosis at the first sitting
and counsel the patient. Interventional ultrasound has led
to a one step infertility diagnosis protocol.
Infertility Procedures 59
5.1 UTERINE CAVITY EVALUATION

(FIGS 5.1 AND 5.2)
Day 2 of MC
↓
TVS
↓
Complete shedding of
Endometrium
↓
Bright line of cavity
↓
day 5/6-10
↓
Sonohysterography
↓
Infant feeding tube
in uterus
↓
TVS
↓
Instill saline
gently under asepsis
↓
Deliniation of cavity
↓
Diagnosis of polyps, Asherman’s, septum, arcuate,
bicornuate, submucous fibroids and foreign body
Fig. 5.1: Cavity evaluation by sonohysterography
Fig. 5.2: Sonohysterography showing Asherman’s syndrome

and a polyp in the uterine cavity
5.2 TUBAL EVALUATION

(SONOSALPINGOGRAPHY) (FIGS 5.3 TO 5.5)
Day 6-10 of MC
↓
TVS
↓
Clean vagina and introduce a No 8 Fr Foley’s
catheter and inflate bulb with 2 cc fluid
↓
TVS to identify bulb
↓
Image the adnexa
↓
Colour flow imaging
↓
Inject mixture of saline and air
↓
Look for colour bruit
↓
Look for fluid in POD
↓
Deflate bulb
↓
Do sonohysterography
↓
Document spill on both sides, fluid in POD and
sonohysterography pictures.
Fig. 5.3: Sonohysterosalpingography
Fig. 5.4: Positive contrast with Echovist
Fig. 5.5: 3D Power Doppler sonosalpingography

5.3 OVARIAN CYST PUNCTURES

Ovarian cyst punctures: Many a times follicular cyst or
CL cysts persist for many cycles and delay the ovulation
induction protocols such cysts can be easily punctured
under TVS guidance and the cyst wall sclerosed. (Techni-
que described in Adnexal cyst aspiration).
5.4 OVUM PICKUP OR OVUM RETRIEVAL

(FIGS 5.6 AND 5.7)
It is today unthinkable to retrieve oocytes by any other
method than TVS guidance puncture for ART procedures.
Patient on stimulation protocol for ART
↓
Follicle growth monitoring
↓
When follicle/follicles are > 18 mm
↓
HCG 5000-10,000 units
Intramuscular injection
↓
33-35 hrs later
↓
Ovum pick-up is scheduled
↓
IVF OT
↓
Anaesthesia
↓
Clean vagina with saline
↓
TVS localisation of ovary
↓
Biopsy guide
↓
17 gauge OPU needles
↓
Follicular aspiration by foot guided controlled
suction in IVF test tubes
5.5 TUBAL CANNULATION (FIGS 5.8A TO C)

Tubal cannulation from the cornual end is best done by
hysteroscopic guidance or fluoroscopic guidance. With
ultrasound, using a Jansen Anderson cannula, cornual
cannulation can be done
Day 6-10 of MC
↓
TVS
↓
Uterine sounding under asepsis
(No anaesthesia, no analgesia)
↓
Introduction of JA cannula with stylet
↓
TVS
↓
Rotate cannula
↓
Inject saline slowly
↓
Check spill by TVS (colour flow imaging)
↓
Use glide wire to cannulate if cornual block
↓
Rept procedure on other side
5.6 TVS GUIDED SIFT/DIPI/IOI

1. Using the JA cannula a transcervical TVS guided semen
intrafallopian tube insemination (SIFT) can be done in
cases of single tubal patency.
2. Using a TVS guided puncture of pouch of Douglas a
deep intraperitoneal insemination can also be attempted
for repeated IUI failures with patent tubes (DIPI).
3. Intra ovarian insemination (IOI) into the dominant
follicle 35 hours after HCG injection has also been tried
as a insemination technique and is done by a 17 gauge
needle through a biopsy guide attached on the TV probe.
5.7 USG GUIDED EMBRYO TRANSFER

(FIGS 5.9 AND 5.10)
In acutely displaced uteri and in difficult to negotiate
cervical canal and internal os TAS is used at the time of
Embryo transfer to facilitate correct placements. A direct
needle can also be introduced transmyometrial in cases
when cervix is non-negotiable.
The needle is introduce from the fornix, into the uterus
and the tip is advanced under TVS guidance to reach the
endometrial cavity. The embryo transfer cannula loaded
with embryos is then threaded in this needle and the
embryos directly deposited in the endometrial cavity under
vision.
Fig. 5.6: Oocyte pickup
Fig. 5.7: Oocyte retrieval

C
Figs 5.8A to C: Ultrasound guided cannulation
5.8 USG GUIDED PCO PUNCTURE
(FIGS 5.11A TO D)
Resistant polycystic ovaries, not responding to medical
treatment are treated by LEOS (Laparoscopic electro
ovarian surface cauterisation).
Making multiple punctures on ovarian surface restores
the endocrinology of PCO. The same has been attempted
by ultrasound guidance multiple puncture technique after
injection of some saline.
Also attempts are being made to retrieve immature
oocytes from PCO patients and to mature these oocytes in
vitro culture systems. This will save the patient from
receiving injections of gonadotrophins and will also save
patient from potential OHSS risk.
Fig. 5.9: Embryo transfer by the transmyometrial route

Fig. 5.10: Preferred routes to go via the myometrium in the

uterine cavity (to avoid vascular injury)
Fig. 5.11A: Laparoscopic puncture

Fig. 5.11B: PCO punc-

ture by TVS guidance
Fig. 5.11C: Polycystic

ovarian drilling by lapa-
roscope
Fig. 5.11D: TVS gui-

ded immature oocyte
retrieval in PCO
One Appendix
ECTOPIC PREGNANCY
PRETREATMENT SCORES
Variable Score
1 2 3
Gastational age (days) > 49 ≤ 49 ≤ 42
β-hCG (MIU/ml) ≤ 1000 ≤ 5000 ≤ 5000
Progesterone (ng/ml) ≤5 ≤ 10 > 10
Abdominal pain None Induced Spontaneous
Hydrosalpinx (cm) ≤1 ≤3 ≤3
Haemoperitoneum (cm) ≤ 10 ≤ 100 ≤ 100
For score 12 or less → Medical treatment 90% success.
Preoperative Preparations for International

Procedures
1. All interventional USG guided needle procedures
should be treated as minor gynaecological
operations.
2. Proper consent and patient counselling is a must
for use of anaesthesia and for the procedure itself.
3. Shouild be done by a framed sonologist
(Gynaecologist or a radiologist) who is well versed
with the procedure and its limitations and
complications.
4. Preoperative preparation includes tetanus toxoid
injection, one dose of broad spectrum antibiotic
(omnatax, supacef or magnatam or augmentin).
5. Proper disinfection of the part and site of puncture
(vaginal or abdominal wall).
6. Pre and postoperative monitoring of vitals of the
patient.
7. Postoperative antibiotic cover is usually not needed.
Unruptured ectopic management

βhCG + USG + Serum P
P ≥ 25 mg/ml P > 5 but < 25 P>5

βhCG 100000 mu/ml phCG ≥ 1000
↓ ↓
↓
Viable pregnancy TVS D&C
(usually intrauterine)
↓
TVS Novilli Villi
↓ Ectopic
Conservative Tt
↓ βhCG → Curetlay
Sac > 4 cm Sac < 4
↓ hCG or some
Surgery ↓
MTX Ectopic
Laparo- Laparo
scopy scopy IMI Intra sac
Indications for IVF and OPU

1. Blocked tubes.
2. Failed repeated IUIs.
3. Endometriosis.
4. Oligoasthenospermia (Borderline male factor)
5. Immunological infertility.
6. Long standing unexplained infertility.
7. Anti sperm antibodies
Two Appendix
HIGH RISK PREGNANCY

EVALUATION FORM
Name
Age Gravida Para
Aborta LMP EDC
EDC by ultrasound
Medical or surgical
Reproductive associated Present pregnancy
history conditions
Age: < 16 = 1 Previous gynaeco- Bleeding

logic surgery = 1__ <20 weeks = 1__
16-35 = 0 Chronic renal = 1__ <20 weeks = 3__
> 35 = 2 __ disease Anaemia
Parity: 0=1 Gestational = 1__ (<10 g%) = 1__
1-4 = 0 diabetes (A) Postmaturity = 1__
>5 = 2 Class B or = 3__ Hypertension = 2__
Two or more =1 __ greater diabetes Premature = 2__
abortions or Cardiac disease= 3__ rupture of
history of Other signifi- = ___ membranes
infertility cant medical Polyhydra-
Postpartum =1 __ disorders mnios = 2__
bleeding or (score 1 to 3 IUGR = 3__
manual removal according to Multiple = 3__
Child > 9 lb = 1 __ severity) pregnancy
Child <5 lb 8 oz = 1 __ Breech or = 3__
Contd...
Contd...
Medical or surgical
Reproductive associated Present pregnancy
history conditions
Toxaemia or =2 __ malpresentation
hypertension Rh isoimmuni- = 3__
Previous =2 __ sation
caesarean section
Abnormal or =2 __
difficult labor
Column Totals __
Total Score __ __ __
(Sum of the three
columns)
Appendix Two 75
GENETIC SCREENING QUESTIONNAIRE
Name ___________________________________________
Patient # _________________ Date ___________________
1. Will you be 35 years or older when the baby is due?

Yes___ No___
2. Have you, the baby’s father, or anyone in either of your
families ever had any of the following disorders?
• Down syndrome (mongolism) Yes___ No___
• Other chromosomal abnormality Yes___ No___
• Neural tube defect, i.e. spina bifida Yes___ No___
(meningomyelocoele or open spine), anencephaly
• Hemophilia Yes___ No___
• Muscular dystrophy Yes___ No___
• Cystic fibrosis Yes___ No___
If yes, indicate the relationship of the affected person to
you or to the baby’s father:
3. Do you or the baby’s father have a birth defect?
Yes___ No___
If yes, who has the defect and what is it? ____________
4. In any previous marriages, have you or the baby’s father
had a child, born dead or alive, with a birth defect not
listed in question 2 above? Yes___ No___
If yes, what was the defect and who had it? __________
5. Do you or the baby’s father have any close relatives with
mental retardation? Yes___ No___
If yes, indicate the relationship of the affected person to
you or to the baby’s father: ________________________
Indicate the cause, if known: ________________________
6. Do you, the baby’s father, or a close relative in either of
your families have a birth defect, any familial disorder, or a
chromosomal abnormality not listed above?
Yes___ No___
If yes, indicate the. condition and the relationship of the
affected person to you or to the baby’s father:
______________________________________________
7. In any previous marriages, have you or the baby’s father
had a stillborn child or three or Yes___ No___
more first-trimester spontaneous pregnancy losses?
Have either of you had a chromosomal study?
Yes___ No___
If yes, indicate who and the results: ______________
8. If you or the baby’s father are of Jewish ancestry, have
either of you been screened for
Tay-Sachs disease? Yes___ No___
______________________________________________
If yes, indicate who and the results ______________
9. If you or the baby’s father are black, have either of you
been screened for sickle cell disease?
Yes___ No___
If yes, indicate who and the results:
______________________________________________
10. If you or the baby’s father are of Italian, Greek, or

Mediterranean background, have either of you been
tested for beta-thalassaemia? Yes___ No___
______________________________________________
11. If you or the baby’s father are of Philippine or Southeast
Asian, ancestry, have either of you been tested-for beta-
thalassaemia? Yes___ No___
______________________________________________
12. Excluding iron and vitamins, have you taken any
medications or recreational drugs since
being pregnant or since your last menstrual period?
(include nonprescription drugs.) Yes___ No___
If yes, give name of medication and time taken during
pregnancy:
______________________________________________
Appendix Two 77
CONSENT FOR AMNIOCENTESIS FOR
DIAGNOSIS OF FETAL DISORDER
Amniocentesis is a test which can detect some birth defects
and hereditary disorders. The test is done by withdrawing a
sample of fluid from the bag of water surrounding the
fetus (baby). This fluid is obtained by introducing a needle
through the abdomen and uterus (womb). Some slight
discomfort is experienced when the needle is introduced.
I, _______________________ , have been informed of
the following risks and limitations of amniocentesis for
the diagnosis of fetal disorders, and have had the oppor-
tunity to question and discuss these with my physician and
his or her assistants.
1. When the test is being performed in a stage of pregnancy
when spontaneous miscarriage sometimes occurs,
amniocentesis has not been shown to increase the chance
of miscarriage.
2. The possibility of injuring the fetus or umbilical cord
with the needle exists; however, the chance of this
happening is considered to be very small.
3. As in all surgical procedures, there is a possibility of
infection. If serious enough, this could cause loss of
pregnancy. This risk is very low and every precaution is
taken to maintain a sterile technique.
4. Ultrasound is performed to localise the placenta
(afterbirth), to determine whether HIV: > are present,
and to visually guide the needle into the bag of water. It
is also used to visualise fluid pockets and to evaluate
fetal heart motion before and after the test.
5. In two-thirds of patients, the placenta is located on the
front of the uterus. In these cases it may be necessary to
pass the needle through the placenta in order to obtain
amniotic fluid. This could result in fetal bleeding.
Although fetal bleeding is rare, it has been known to
occur.
6. It is rare that the test cannot be successfully completed
because of an inability to get an adequate sample of fluid.
7. An occasional complication is leakage of either clear or
blood-tinged fluid from the vagina shortly after the tap.
This leakage is not considered to be a serious
complication and it should cease within 24 hours. If
leakage persists beyond 24 hours, it is recommended that
you notify your physician
8. In some cases, the fetal cells do not grow in culture after
an amniocentesis and the procedure may have to be
repeated. This occurs in not more than one in fifty
patients.
9. Since the test screens only for selected birth defects, the
results do not guarantee the birth of a normal child. It is
understood that there is a slight possibility that the
laboratory tests could incorrectly assess the baby’s health.
10. I believe the benefits of my having amniocentesis
outweigh these potential risks associated with the
procedure. I have had the opportunity to discuss any and
all questions about the procedure and give my consent
to have the procedure performed.
Three Appendix
CONSENT FORM FOR IVF-ET
We, ................................................................ (husband) and

(wife), hereby authorise Dr ..................................................
and the team of the hospital and IVF centre to treat us by in
vitro fertilisation and embryo transfer.
We understand that IVF-ET involves:
Administration of drugs/hormones for controlled ovarian
hyperstimulation for obtaining adequate number of eggs.
Daily monitoring of egg development with blood tests and
transvaginal ultrasonography.
Egg retrieval by a minor operative procedure performed
either laparoscopically or under transvaginal ultrasound
guidance.
Fertilisation of the retrieved eggs in vitro, in an incubator,
with the husband’s/donor spermatozoa, transfer of the
fertilised egg/embryo into the uterus.
Further blood tests and hormonal injections to support and
monitor the outcome,
We also hereby give our consent and authorise
Dr .........................................
of the hospital and IVF centre to perform the following
operation or other procedure:
1. Ultrasound guided vaginal oocyte retrieval.
2. Diagnostic/operative laparoscopy and follicular puncture.
3. Intrauterine embryo transfer.
4. Laparoscopic intrafallopian gamete/embryo transfer.
We acknowledge that:
1. The nature and purpose of operation or other procedure
and anaesthesia, the risks involved, alternatives and the
possibility of complications have been explained to us
by Doctor ......................................................................
......................................................................................
and all our questions, if any, have been answered to our
satisfaction. We are aware that the practice of medicine
and surgery is not an exact science, and we acknowledge
that no guarantee has been made as to the results that
may be obtained.
2. We further consent to the administration of such
anaesthetic as may be considered necessary or a advisable
in the judgement of the medical staff of the hospital.
3. We consent to the admittance of observers, in accordance
with ordinary practices of the hospital, to the use of Close-
circuit television, the taking of photographs (including
motion pictures), and the preparation of drawings and
similar illustrative, graphic material, and we also consent
to the use of such photographs and other material for
scientific purposes, provided our identity is not revealed
by the pictures or by the descriptive text accompanying
them.
4. We understand that there is neither guarantee of a
successful outcome nor is there an assurance of a
normal healthy live birth if pregnancy does occur.
5. We understand that failure may be due to a variety of
factors such as failure to respond to the ovulation
inducing drugs, failed retrieval of eggs, inability of the
husband to produce sperm, poor quality of eggs or sperm
on the day of IVF, failed fertilisation or a laboratory
accident resulting in the loss of an egg or embryo.
It is, of course, understood that even after signing this
Appendix Three 81
consent form we may withdraw from the the programme

without prejudicing our future therapy of clinical care.
Patient’s signature ..................... Date : .............................
Husband’s signature ................. Date : .............................
I have explained the above to the subject on the date stated

on this consent form.
Physician’s signature ...........................................................
Date .........................
PRINCIPAL IVF CONSENT FORM
We ........................................................................ (the wife)

and .......................................................................................
(the husband) .......................................................................
of ........................................................................... (address)
.............................................................................................
CONSENT TO TREATMENT FOR IN VITRO FER-

TILISATION AND RELATED PROCEDURES.
1. We have discussed the treatment and procedures with
Dr ..................................................................................
2. The treatment and procedures have been explained to
our satisfaction and we have been given written
information. We have been given the opportunity to ask
questions which have been satisfactorily answered.
3. We understand that treatment may be provided by staff
of the hospital.
4. We acknowledge that while the purpose of the treatment
and procedures is to establish a viable pregnancy a
guarantee of success cannot be and has not been given.
5. We acknowledge that the procedures may be cancelled
prior to completion of a course of treatment.
6. We understand that there are risks associated with the
procedures including but not limited to the risks of
miscarriage, tubal pregnancy and multiple pregnancy.
7. We understand that fetal abnormalities may occur in as-
sociation with the treatment and procedures as may also
occur with natural conception.
8. We are aware that we are free to withdraw from the treat-
ment programmes at any stage.
Appendix Three 83
9. If we have eggs which do not fertilise or are not insemi-

nated, we request that: (circle your choice)
a. They be made available for testing procedures not
involving fertilisation; or
b. They be disposed of immediately.
10. If we have embryos which are not be transferred or
cryopreserved because they are abnormal or of poor
quality or surplus to our needs we request that:
(circle your choice)
a. They be observed until they cease development; or
b. They be disposed of immediately
Signed:
........................................... ........................................
(Wife) (Husband)
........................................... ........................................
(Witness: (Witness:
Medical Practitioner Medical Practitioner or
or Counsellor) Counsellor)
Date ....................... Date ................................

CONSENT FOR OOCYTE DONATION
We ........................................................................ (the wife)

and .......................................................................................
(the husband) .......................................................................
of ........................................................................... (address)
.............................................................................................
CONSENT TO THE DONATION OF OOCYTES, COH

and FOLLICLE PICK UP UNDER GA
We have discussed oocyte donation and stimulation and fol-
licle pick up procedures with Dr ..........................................
1. Procedures have been explained to our satisfaction. We
have been given the opportunity to ask questions, which
have been satisfactorily answered.
2. We understand that drugs will be used to stimulate our
ovary to produce multiple follicles which will be
aspirated under GA by USG guided needle.
3. We shall jointly determine the future management of any
of our follicles.
a. Donation of follicles to a couple selected by the
hospital. If there is no suitable recipient, the follicles
may be left to succumb and used for research.
b. Disposal of the follicles. (circle your choice)
4. In the event that one partner becomes incapable of
making and informed decision, it is our current wish that:
(circle your choice)
a. The other partner be given the opportunity to make
lawful decision.
b. The follicles be dealt with according to para-graph 4.
Appendix Three 85
5. We hereby give consent for use of drugs to stimulate the

ovaries for controlled ovarian hyperstimulation. We
understand the small risk of hyperstimulation syndrome.
6. We hereby give an informed consent for follicle
aspiration under general anaesthesia, we have been
explained the procedures, risks and complications
associated with anaesthesia and the procedure itself.
Signed :
........................................... ........................................
(Wife) (Husband)
........................................... ........................................
(Witness: (Witness:
Medical Practitioner Medical Practitioner or
or Counsellor) Counsellor)
Date........... Date..............
CONSENT FOR ACCEPTANCE OF
DONOR, OOCYTE
We hereby give our free consent for acceptance of donor

oocytes in case of failure to obtain oocytes from (wife’s)
Mrs .. ovaries. We have been explained about the procedure
fully in my own language by Dr ..........................................
.............................................................................................
We will bring the oocyte donor ourselves and would like
to maintain privacy in this matter. All the responsibility of
the donor legal or otherwise is our own. The doctor has
nothing to do in this situation.
Sd. .................................... Sd. ......................................

Husband Wife
Sd ...................................................
Witness Doctor or Counsellor
Appendix Three 87
DONOR SEMEN
We hereby give our free consent for acceptance of donor

semen from cryofreeze sperm bank. We would like to main-
tain privacy in this matter.
Sd. .................................... Sd. ......................................

Husband Wife
Sd ...................................................
CONSENT FOR ACCEPTANCE OF
EMBRYO DONATION
We hereby give our free consent for acceptance of embryo

donation. We have been explained by Dr. ..........................
.............................................................................................
about the procedure fully in our own language. We would
like to maintain privacy in this matter. All the responsibility
legal or otherwise is our own.
Sd. .................................... Sd. ......................................

Husband Wife
Sd ...................................................
Appendix Three 89
ADMISSION—DISCHARGE AND
TREATMENT CHART
No.: ......................
Name: ...................................................................................
Age: ....................... Date of Admission: .............................
Address: ...............................................................................
Date of Discharge: ...............................................................
DIAGNOSIS
CASE PROFORMA SHEET
HUSBAND
Name: .......................................................................................
Age: ......................... Reg. No.: ................................................
Address: ...................................................................................
...................................................................................................
Occupation: ..............................................................................
Semen analysis:
Date Lab Count Motility Morphology Other info.
Wash:
Andrological evaluation:
Treatment: Date: Date: Date:

Appendix Three 91
CASE PROFORMA SHEET

WIFE
Name: ........................................ Age: ..... Reg No. ................

Address ....................................................................................
...................................................................................................
Married since: .......................... years
Present M/C: R/IR ............ S/M/H ....... PL/PF ................
Past M/C: R/IR ................. S/M/H ....... PL/PF ................
LMP: ............................ Dysmenorrhoea ...............................
Galactorrhoea ..................... Thyroid .....................................
Operations .............................................................
Obstetric History: GPALE ....................... Details ................
Contraction:
IUCD ...................... OC ..... Condom ..... Natural ................
Years of use .................
Tuberculosis ........................ Asthma .... Diabetes ................
Hypertension .....................................Drug allergies: ..........
Coital History: ..................... Height: ..... Weight: ................
B.M.I.: .................................. Anemia: .....................................
Pulse .................... B.P.: ............. R.S.: .....................................
C.V.S. ............... Goitre: ..................... Galactorrhoea: ...........
Hirsutism: ............................. Cervix: ...... Mucus: ................
Cervicitis: .................................. Day: ...... Uterus: ................
AV/RV ......................... NS/>N/<N .....................................
S/F/M .......... Fibroids ............ TVS: .....................................
D2FSH: ............. D2LH: ............. PRL .......... TSH: ................
DHEA-S: ................... T ................. E2 ...................... P4 ........................
CMS: ................... PCT: .......................... SCMCT: ................
Laparoscopy: .....................................Endobiopsy: ..............
Histeroscopy: ........................... HSG: .....................................
ASA: ..........................................................................................
Previous ART: .........................................................................
Appendix Three 93
IVF PROFORMA
Name of patient ......................................................................
Age: Wife .......................... Husband .....................................
Address ....................................................................................
...................................................................................................
Phone (Resi) ............................. (Off.) .....................................
History:
Infertility: Primary/Secondary
Duration: Years
Obst. History:
Menstrual History: LMP
Past history/Medical history
History of Surgery:
Past infertility treatment:
IUI: Times Stimulation with
IVF: Cycles at
Protocol used
Eggs recovered = Eggs fertilised = Transferred = Outcome

Contd...
Contd...
Examination:
P: BP: RS/CVS: P/A: PS: P/V:
Investigation:
Male:
1. Semen analysis: No. of reports: Date:
Count: Motility Act. Slugg.: Abnormal
2. Semen Culture:
3. HIV
4. HBsAg
Female:
1. Laparoscopy: date
2. HSG: date
3. Hysteroscopy: date
4. Sonography [base line] date
5. Hormones [base line] FSH LH PRL Prog.
6. E.B.: date
7. Hb Bl Sugar HIV HBsAg Urine
Suitability for IVF: Good: Fair: Poor:

Patient willingness: Good: Fair: Poor:
Appendix Three 95
ANAESTHESIA RECORD
Patient's Name: .......................................................................
Age: ............................ Date: .......................
Operation: ................................ Diagnosis: ...........................
Preoperative: B.P.: ............ Pulse: ............. Hb: ................
C.V.S. ...................
R.S.: ......................
Others: .................
Premedication: ..............................
Anaesthesia: Spinal: ................ Needle No. .........................
General: .............. Intubation: ........... Yes/No
Drugs used: ............. Airway: ........... Yes/No
Pulse oximeter: ............ Yes/No
Cardiac Monitor .......... Yes/No
PREOPERATIVE OBSERVATIONS
Time Pulse B.P. % O2 Sat Medications
Postoperative condition:
Pulse: .................. Level of consciousness: ...........................
B.P.: ............................. General condition: ...........................
Anaesthetist's Name: ............................................................
REQUEST FOR REGISTRATION
Kindly register our names at your clinic for consultation

and advice of treatment for our Infertility. We understand
that treatment may involve any of the Assisted
Reproductive Technologies such as Ovulation Induction
with drugs and Timed Intercourse, Artificial Insemination,
Intrauterine Insemination, in vitro Fertilisation and
Embryo Transfer, Zygote Intrafallopian Transfer.
Cryopreservation of Semen or Embryos, Oocyte Semen
Donation and other forms of Medically Assisted
Reproductive Technologies.
Name of Wife: ....................................... Signature ...............
Date of Birth: .........................................
Occupation: ............................................
Name of Husband: ............................... Signature ...............
Date of Birth: .........................................
Occupation: ............................................
Address: .................................................
.................................................................
.................................................................
Telephone Nos. ..................................... Contact No. ...........
Referred by: ........................................... Reg. No.
.................................................................
Address and Telephone Nos. of the Referring Doctor:
.................................................................
TVF CHART
Patient Name: Date: / 200 SPERM DATA
Chart No.: Aspiration Time: Husband Donor
IVF/ICSI PESA/ICSI TESA/ICSI Thawing ET Count (x106/ml) ( )
ED OD DS Surrogate Motility (Alive)%
Hormone Base line E2: P4 : LH: FSH: Activity Grade I II III IV I II III IV
Profile PRL: β-hCG: E2 pattern: Volume (ml)
Day of MC
Date REMARKS
RO
LO
PIRO
PILO
RIRO
RILO
Hormones E2
P4
LH Age Wife/Hus.
USSR Myom.
Endom (MM) Category
Zone BL.
Vessel Yr. of Inf.
End. Perista-
lsis
Cycle date
UTA PI
UITA RI
Appendix Three 97
Score (UBP) Induction methods

Drugs for
COH
Category Induction Methods
Embryo Freezing
1. Tubal F. 1. Combo
Stage Grade No. 2. Male F. 2. GnRH A. (Short)
3. Endometriosis 3. GnRH A. (Long)
4. Uterine F. 4. GnRH A. Low Dose
5. Cervical F.
5. Low Dose (CC/HMG)
6. Undiagnosed
6. Psure FSH
7. Immunological F.
- 1: Male 7. C.C.
- 3 : Female 8. HMG
Date / 200 8. Anovulation 9. Natural Cycle
Method 9. Others ( ) 10. Others (Anta)
EMBRYOLOGY DATA
#of No. of Deg. Time Day Treat Day Day Embry Transfer Date: / 200 TRANSFER DATA
Dish Eggs of mat- of Ins- 1 NFE 2 3 ZIFT IVF
uration emi. Instrument Rating Complications Catheter
Sound Easy Bleeding Tom cat
Dialator Moderate Leakage OCD
Tenaculum Difficult Pain Wallace
None Failure Others Other

Four Appendix
Fetal abnormalities in Trisomy 21
Organ system Trisomy 21
Head and brain Mild ventriculomegaly

Facial Flat face
Neck Thickened nuchal skin fold
Cystic hygroma
Cardiac Ventricular septal defect
Atrial septal defects
Atrioventricular canal
Echogenic cardiac focus
Gastrointestinal Hyperechoic bowel
Esophageal atresia
Duodenal atresia
Diaphragmatic hernia
Urogenital Renal pyelectasis
Skeletal Short femur and humerus
Clinodactyly of fifth digit
Widely spaced first and second toes
Wide iliac angle
Hydrops/cutaneous Nonimmune hydrops
Liquor amnii ——
Biometry ——
Doppler Abnormal ductus venosus waveform
Head and brain Dolicocephaly

Strawberry-shaped skull 21, 18
and Large cisterna magna
Choroid plexus cysts
Agenesis of corpus callosum
Facial Micrognathia
Microphthalmia
Neck Nuchal thickening
Cardiac —
Gastrointestinal Diaphragmatic hernia
Omphalocoele
Esophageal atresia
Urogenital Hydronephrosis,
Horseshoe kidney
Skeletal Clubfoot deformity
Generalized
arthrogryposis
Clenched hands
Hydrops/cutaneous
Liquor amnii Third trimester polyhydramnios
Biometry Second trimester—
onset intrauterine
growth retardation
Doppler Abnormal ductus
venosus waveform
Appendix Four 101
Head and brain Holoprosencephaly

Agenesis of corpus callosum
Ventriculomegaly
Enlarged cisterna
Magna
Microcephaly
Facial Micrognathia
Sloping forehead
Cleft lip and/or palate
Microphthalmia
Hypotelorism
Neck Nuchal thickening
Cardiac Ventricular septal defect
Atrial septal defect
Dextrocardia
Echogenic cardiac focus
Gastrointestinal Omphalocoele
Urogenital Renal cortical cysts
Hydronephrosis
Horseshoe kidney
Skeletal Postaxial polydactyly
Camptodactyly
Overlapping digits
Hydrops/cutaneous
Liquor amnii Third trimester hydramnios
Biometry Second trimester—
onset intrauterine
growth retardation
Doppler Abnormal ductus
venosus waveform
Fetal abnormalities in triploidy
Organ system Triploidy

Head and brain Ventriculomegaly
Agenesis of the corpus
callosum
Dandy-Walker malfor-
mation
Holoprosencephaly
Spine Meningomyelocoele
Facial Hypertelorism
Microphthalmia
Micrognathia
Neck Cystic hygroma
Thorax
Cardiac Septal defects
Gastrointestinal Omphalocoele
Urogenital Hydronephrosis
Skeletal Syndactyly of
the third and
fourth fingers
Clubbed feet
Placenta Enlarged placenta or
small, prematurely
calcified placenta
Liquor amnii Oligohydramnios
Biometry Severe, early-onset,
asymmetric intrauterine
growth restriction
(affecting the skeleton more
than the head)
Doppler Abnormal umbilical artery
Doppler waveform, showing
a high-resistance pattern
Appendix Four 103
Fetal abnormalities in Turner’s syndrome

Organ system Turner’s syndrome (XO)
Neck Large, septate, cystic hygroma
Thorax Pleural effusions
Cardiac Coarctation of the aorta
Gastrointestinal Ascites
Urogenital Horseshoe kidneys
Skeletal Short femur
Hydrops Severe lymphoedema
of all the soft tissues
Index
A Coelocentesis 25, 26
Consent for 84-88
Admission discharge treatment acceptance of donor, oocyte 86
chart 89 amniocentesis 77
Adnexal cystic masses 43 donor semen 87
Adnexal cysts puncture 43 embryo donation 88
3D ultrasound evaluation of oocyte donation 84
tube 44 Consent form for IVF-ET 79
drainage of a hydrosalpinx 44 Cordocentesis 28, 30-32
laparoscopic ovarian Counselling 5, 6, 16, 17
cystectomy 47
ovarian cyst puncture 46
D
ovarian cyst with
endometrioma 47 Diagnostic obstetric procedures
technique 43 17
under ultrasound guidance 45 Documentations and reporting 6
Amniocentesis 25, 26, 27, 28
Anaesthesia record 95 E
Analgesia and anaesthesia 6
Anomalies/suspected defect 7 Ectopic pregnancy 71
preoperative preparations 71
C pretreatment scores 71
unruptured ectopic
Case proforma sheet 90 management 72
Chorionic villous sampling 21 Ectopic pregnancy management
site for CVS in chorion 22 49
syringe for abdominal CVS 21 evaluation by TVS and colour
transabdominal CVS 22 Doppler 50
transvaginal CVS 23 laparoscopic management 51
local injection in 52 H
technique 49, 51
Electromyography 56 High risk pregnancy evaluation
form 73
Hydrocephalus puncture 34
F
Fetal abnormalities in 99-103 I
triplody 102
trisomy 13 101 Infertility 58
trisomy 18 100 Infertility diagnosis protocol 58
trisomy 21 99 Doppler sonosalpinography 62
Turner’s syndrome 103 embryo transfer 68
Fetal acidemia 29 immature oocyte retrieval in
Fetal biopsy 18-20 PCO 70
fetal muscle 19 laparoscopic punture 69
fetal skin 19 oocyte pickup 66
instruments for biopsy 20 oocyte retrieval 66
needles for biopsy 20 ovarian cyst punctures 63
Fetal invasive therapy 35 ovum retrieval 63
Fetal reduction in HOMP 38-40 PCO puncture by TVS guidance
equipments for fetal reduction 70
39 polycystic ovarian drilling 70
multifetal pregnancy for sonohysterosalpingography 62
reduction 38 tubal cannulation 64
tubal evaluation 61
stepwise reduction 39
TVS guided SIFT/DIPI/IOI 65
Fetal shunts 34
ultrasound guided cannulation
indication 34 67
technique 35 USG guided embryo transfer
types of shunt 35, 36 65
Filling forms 1 USG guided PCO puncture 68
uterine cavity evaluation 59
G Asherman’s syndrome 60
Polyp in uterine cavity 60
Genetic counselling 5 Interventional gynaecological
Genetic screening questionnaire sonography 41
75 Interventional ultrasound
Gynaecological examination 41 knowledge 17
Index 107
artefact 18 Prenatal diagnosis in twins 37
invasive obstetric procedures Principal IVF consent form 82
18
physics of ultrasound 17 R
technical aspects 18
Intra-amniotic pressures 36, 37 Relevant history 2
Intrauterine fetal transfusion 33 Request for registration 96
Intrauterine pressure assessment Resuscitation equipment 6
36
IVF proforma 93 S
Stress incontinence surgery 57
L
Legal consent 5 T
Legal malpractices issues 6
Therapeutic obstetric procedures
17
M Training 8-15
Machine and equipment 2-5 guidelines 8
abdominal probes 3 gynaecological ultrasound 13
biopsy guides 2, 4 Doppler in gynaecology 15
biopsy needles 4, 42 gynaecological
consent form 4 complications 14
minor operation theatre 2 infertility 14
ovum pick up set 5 invasive procedures 14
standard accessories 4 normal pelvic anatomy 13
standard equipment for OT 4 mandatory proposed
transabdominal probes 2, 42 certification 13
transvaginal probes 2 prerequisite criteria 11
vaginal probes 4 emergency gynaecological
problems 11
P fetal anatomical features 12
fetal biometry 12
Patient preparations 5, 16 markers of chromosomal
Pelvic masses 48 anomalies 13
PNDT act 5, 9, 13, 15 theorectical aspects 9
PNDT act form 1 training parameters 9
Prenatal diagnosis 17 tranining schedule 10
Transcervical metroplasty 52 Urethrocystometry 56

TRAP syndrome 32, 38 Urinary bladder study 53-55
TVF chart 97 Urodynamic sonography 56
Twin to twin transfusion
Urodynamic ultrasound 57
syndrome 12, 32, 37
Uroflowmetry 56
U Urogynaecology 53
Umbilical cord 29, 31 V

catheterisation of 31
free loop of 29 Villi 23, 24

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Step by Step

Forthcoming Publications in the

Step by Step Interventional Ultrasound in Obstetrics & Gynaecology

© 2004, Kuldeep Singh, Narendra Malhotra

First Edition : 2004

Ultrasound today is the mainstay investigation in the field

Our heartiest thanks to our parents, elders, teachers,

Index .......................................................................... 105

1.1 FILLING FORMS

1.3 MACHINE AND EQUIPMENT (FIGS 1.1 TO 1.5)

Fig. 1.1: Machine with probes and

Fig. 1.2: Abdominal probes with biopsy guide and needle

Fig. 1.3: Vaginal probes and biopsy guides with needles

Fig. 1.4: Various biopsy guides

4. Biopsy needles of all sizes and lumen for abdominal

Fig. 1.5: Ovum pick up set

1.4 PATIENT PREPARATIONS

1.5 COUNSELLING AND LEGAL ASPECTS

1.6 DOCUMENTATION AND REPORTING

1.7 ANALGESIA AND ANAESTHESIA

H/o Anomalies/Suspected Defect

9-11 weeks 16 weeks 18 weeks +

A proper training in obstetric and gynaecological ultrasound

2.2 THEORETICAL ASPECTS

2.3 TRAINING PARAMETERS

THIRD LEVEL (3 years)

2.4 SUGGESTED TRAINING SCHEDULE

2.5 PREREQUISITE CRITERIA FOR A

4. Activity: recognise and quantify

2.7 GYNAECOLOGICAL ULTRASOUND

b. Injection of ovarian cysts

3.1 COUNSELLING AND PATIENT

• Diagnostic obstetric procedures are for prenatal diag-

3.2 TRICKS AND TRAPS OF

3.4 ANAESTHESIA AND PLACE

Fig. 3.1: Biopsy of the fetal muscle

Fig. 3.2: Biopsy of the fetal skin

Fig. 3.3: Needles for biopsy of the fetal skin

Fig. 3.4: Instruments for biopsy of the fetal skin

3.5 CHORIONIC VILLOUS SAMPLING

Fig. 3.5: Syringe used for an abdominal CVS

Fig. 3.7: Outline diagram to show a CVS being done

Fig. 3.8: Outline diagram to show a CVS being done

Fig. 3.10: Villi as seen through a microscope

10. Asepsis and vaginal cleaning.

3.6 AMNIOCENTESIS AND COELOCENTESIS

Fig. 3.11: Line diagram showing a coelocentesis

Fig. 3.12: Picture showing the placement of the needle

Fig. 3.13: Freehand technique for amniocentesis (I)

Fig. 3.14: Freehand technique for amniocentesis (II)

• NTD: Late first or early second trimester.

3.7 CORD BLOOD SAMPLING

obstetrics an access to fetal circulation was discovered.

Fig. 3.15: Free loop of umbilical cord seen on a 2D scan

Fig. 3.17: Arrow showing the placement of the needle

Fig. 3.18: Routes for cordocentesis depending on the free loop

Fig. 3.19: Catheterisation of the umbilical cord

Fig. 3.20: Transducer position, fetal position and the technique

Patient # _ Date ___