Mid trimester sonography

Dr. Sushila Gyawali

MDRD, 3rd year resident
PAHS
Code :802
 Introduction
• Second trimester targeted scan done between 18 and 22 weeks.
• Systematic method of ultrasound scanning of the fetus will ensure that
a reasonably complete examination of the fetus is accomplished.
• Anatomical survey of fetus with baseline for growth assessment for
future.
Objectives

• To predict with confidence, the structural normalcy of the baby

within reasonable limits of expectation.
• To identify severe and lethal abnormalities.
• To raise the suspicion of an abnormality, which would warrant
further testing or serial scans.
 GENERAL CONSIDERATIONS
• Before beginning counsel the woman/couple regarding the
potential benefits and limitations of a routine mid-trimester
fetal ultrasound scan.
• A routine mid-trimester fetal ultrasound examination includes
an evaluation of the following: -
1. Cardiac activity;
2. Fetal number (and chorionicity and amnionicity in cases of multiple
pregnancy);
3. Gestational age/fetal size;
4. Basic fetal anatomy;
5. Placental appearance and location;
6. Amniotic fluid volume.
7. Measurement of cervical length (CL)-in some settings,TVS preferred.
• All pregnant women should be offered a mid-trimester scan
as part of routine pregnancy care.
• A routine mid-trimester ultrasound scan can be performed
between about 18 and 24 weeks of gestation.
• Should follow the ALARA principle and not be performed
solely for parental entertainment purposes.
• Results of the scan should be documented and
communicated appropriately, and copies of the reports and
images should be stored for future reference.
• At the end of the examination, one must be able to declare with confidence the
following three aspects:
1. The fetus is structurally normal for this period of gestation.
2. Major abnormalities have been detected or excluded.
3. A suspicion of anomaly is raised.

• If the examination cannot be performed completely in accordance with adopted

guidelines
• The scan should be repeated to ensure a complete examination, or
• The patient should be referred to another examiner
 The Second Trimester Targeted Scan
The second trimester ultrasound scan involves a seven step process as
listed:
• History
• Survey
• Biometry: BPD,HC,FL,EFW
• Targeted Imaging
• Fetal activity/movement
• Fetal environment: Placenta , Amniotic fluid, Cervix,
• Reporting
Anatomical planes and structures to be examined

#HEAD:
1. Transthalamic plane
2. Ventricular plane
3. Transcerebellar plane
 Transthalamic plane

• It is the plane which has been traditionally

used to measure BPD and HC .
• Three structures to be looked for in this plane
are:
 Falx which is interrupted by
 Cavum septum pellucidum
 Thalami, forming an arrow
pointing to the occiput

CSP can be seen in transthalamic and lateral

ventricular plane.
 Ventricular plane
The three structure to be identified in this plane are:
– The lateral ventricles.
– Choroid plexuses
– Cavum septum pellucidum
• Atrial width:
• Distal ventricle is measured on true axial views
(closer ventricle obscured by artifact).
• Calipers : inner walls of the ventricles opposite
the deepest part of the parieto-occipital fissure;
• A normal value is taken as below 10 mm
• Ventricles : mild asymmetry is common.
• Choroid fills more than 60% of atrium width.
• Medial ventricle wall and the choroid: less than 3 mm
• 88% of fetuses with cerebral abnormalities ass with
ventricular abnormality.
 Transcerebellar plane
• It is imaged by rotating the probe posteriorly
from the BPD plane till clear view of the
posterior fossa and occipital bone is obtained.
• The three structures to be identified in
posterior fossa are:
• Rounded cerebellar hemisphere
• Vermis of cerebellum
• Cisterna magna
• Transverse cerebellar diameter: Up to about
24 weeks, TCD corresponds to gestational
weeks.
• Cisterna magna:
• Measured between the cerebellar vermis
and inner occipital bone on an axial plane.
• Normally 2 to 10 mm
Normal
variants

Blake Pouch cyst

Choroid plexus cysts

Cavum velum interpositi

periventricular calciication (arrow) in fetus with
pseudo-TORCH

Agenesis of Corpus Callosum

 POSTERIOR FOSSA AND CEREBELLUM

MEGA CISTERNA MAGNA

Dandy Walker Malformation:

• Classic DWM is a triad of partial or
complete vermian agenesis.
• Cystic enlargement of fourth ventricle and
• Elevated tentorium.
 FACE
The three planes of examination of fetal face : Axial, Sagittal, and
Coronal

The three major structures to be visualized are:

• Orbits
• Nose and mouth
• Lips, palate and mandible
• Orbits :
• Axial or coronal view.
• Confirm the presence of both
orbits
• Evaluating their sizes and
shapes
• Orbits should be symmetrical in
size
• The outer and inner interorbital
distances within a normal
range.
Microphthalmia Hypertelorism
protuberant maxilla

coloboma
• Nose and nasal bone
• Sagittal view.
• Nasal bone hypoplasia
• BPD/NASAL BONE ratio >11 sensitivity and specificity of 49% and 92%,
• A single cut-off of 2.5mm
• NBL of less than 0.75 MoM provided the best definition of nasal
bone hypoplasia sensitivity and specificity of 49% and 92%,
• Prenasal thickness : increases with gestation(2.4mm at 16 weeks to
4.6mm at 24 weeks)

• PT/NBL ratio= 0.35-0.8

• Chromosomal
anomalies= >0.8

• Increase in prenasal thickness • Absent nasal bone or shortened nasal

bone : marker of trisomy 21.
 LIPS AND NOSE
• Anterior coronal view
• Nose and lips .
• Mid-coronal view
• Premaxillary triangle formed by two
nasal bones as the two sides of the
triangle and the premaxilla as the base of
the triangle.
• Completion of the triangle ensures that
there is no cleft hard palate.
• Posterior coronal view
• Orbits.
• Palate can be examined in the axial plane
• unremarkable uvula( +nce of equal sign)
implies the presence of an intact palate.
• In –nce of = sign:CP could not be
r/o,Targeted 3D imaging helpful
• In general, an upper lip defect may be seen and is best appreciated on
angled coronal scanning.
• A vertical hypoechogenic region through the fetal upper lip usually
represent the defect in lip (cleft lip).
• It is a good practice to comment on fetal swallowing in real time at the
time the scan is performed
 NUCHAL FOLD THICKNESS

• In 2nd trimester, nuchal fold

thickness is measured in
suboccipital bregmatic plane.
• One caliper should placed on the
outer edge of skin and other against
outer edge of occipital bone.
• The ideal angle of insonation is
approximately 30 degree to the
horizontal.
• A measurement of 6mm or greater
between 14-22 weeks is a/w
increased risk of Trisomy 21
Neck:
• Normally appears as cylindrical,
with no protuberances, masses
or fluid collections.
• Obvious neck masses, such as
cystic hygromas, goiter or
teratomas, should be
documented.

CYSTIC HYGROMA: often a/w chromosomal

aneuploidies, hydrops fetalis and IUFD
 THORAX
• Shape and transition to the abdomen.
• Texture of the lungs
• Homogeneously echogenic tissue
surrounding the heart, separated by the
hypoechoic, dome-shaped diaphragm from
the abdominal organs.
• Both lungs should be homogeneous without
mediastinal shift or masses.
• Asses thoracic circumference, lung area
• Normal cardiothoracic ratio remains constant.
• Heart should occupy one-third to one-half the sonographic diameter of the thorax.
• Cardiac position and axis are constant.
• Ribs: number or appearance, normally encircle at least 70% of the thoracic
circumference
 Congenital
Pulmonary Airway
Malformation
Bronchopulmonary Sequestration

Congenital Diaphragmatic
Hernia
 HEART

• Maximum frame rate with single

acoustic focal zone and relatively
narrow field of view .
• Images should be magnified until the
heart fills at least one-third to one-half
of the ultrasound display screen.
• Start with assessment of its situs, axis,
and rhythm.
• 3 views
• Four-chamber view
• Outflow tract views and
• Three-vessel view , three-vessels-
and-trachea view.

The four-chamber view is important because 10% to 96% of structural anomalies

are detectable on this view.(source Rumack 6E)
Four chamber view :
• Basic screening :
• A normal regular rate ranges
from 120-160 bpm.
• The heart should be located in
the left chest (same side as the
fetal stomach) if the situs is
normal.
• A normal heart is usually no
larger than one third of the area
of chest and is without
pericardial effusion.
• The heart is normally deviated
by about 45+/-20 degree
towards the left side of the fetus.
• The crux of heart formed by IVS,
atrioventricular septum and
Interatrial septum
• Chamber symmetry
• Movements of mitral and tricuspid
valves in real time
OUTFLOW TRACTS

• At the origin, the outflow tracts are seen crossing each other with pulmonary artery
anteriorly and aorta posteriorly.
• The anterior aortic root should be continuous with the IVS and posterior aortic root
with mitral valve.
• Bifurcation of pulmonary artery must be documented.
• The crossing of outflow tract can be appreciated in transverse view which shows
cross section of aorta and long section of pulmonary artery.
 THREE VESSEL VIEW

• Cephalad tilt from the four

chamber view at a plane superior to @ PAS
cardiac chambers.
• The three vessels seen from left to
right are the pulmonary artery,
aorta, and superior vena cava (svc)
• Pulmonary artery : the largest in
diameter
• SVC : smallest.
• Number, alignment/arrangement,
and size of three vessels with
determination of blood flow
direction with CDI can be
accomplished at this level.
Three vessels and trachea view (3VT), Doppler
assessment. The correct direction of flow (away from
the heart) is demonstrated in both the aorta and
ductus Arteriosus.
 Other views

Aortic arch view.

SVC & IVC view .

Ductal arch view

 Echogenic Intracardiac focus (EIF)
• Small bright echogenic focus (as bright as bone ) within the fetal heart on a four chamber view .
• Present in ~ 4-5% of karyotypically normal fetuses.
• When seen in isolation with no maternal risk factors : benign course
• Represent mineralization of papillary muscles.
• Majority are unilateral ,< 3mm. Left ventricle is the most frequent in terms of location.
• Associations :
– Downs syndrome: Upto 12% association

Turn off tissue harmonic imaging and

decrease gain : to visualize EIF.
 ABDOMEN
• The abdomen is divided into three
levels for convenience – Upper
/Mid/Lower
• Upper abdomen: Three structures to be
identified are – Stomach, Portal vein
and Liver
• Abdominal organ situs should be
determined.
• The fetal stomach should be identified
in its normal position on left side.
• Bowel should be contained within the
abdomen and umbilical cord should
insert into intact abdominal wall.
• Abnormal fluid collections of the bowel
(e.g. Enteric cysts , obvious bowel
dilatation) should be documented.
Esophageal Atresia:. no visible stomach distended esophageal pouch, distended
oropharynx
 Double bubble sign
• Another bubble adjacent to stomach bubble other than
gastric bubble.
– D/D : Duodenal atresia, Choledochal cyst, Duplication cyst

Two fluid filled

structures in the
fetal abdomen: a
‘double bubble’
sign.
 ABDOMINAL WALL
• The most common types of abdominal wall
defects are:
– Gastroschisis and Omphalocele
– Bladder exstrophy, Cloacal exstrophy
– Pentalogy of Cantrell (severe ventral body wall
defects)
– Abdominoschisis in amniotic band syndrome
Gastroschisis
• Small (<4 cm in most cases), full-
thickness paraumbilical defect of
the abdominal wall, most often
located to the right of the
umbilicus.
• Herniation of free-floating loops in
amniotic fluid.
• Umbilical cord inserts normally into
the abdomen, adjacent to but
separate from the defect
• No increased risk of ass
aneupleoidies.
Omphalocele:
• Herniation into base of the umbilical
cord with umbilical cord apex of the
herniated sac, covered by the amnion
• Often associated with aneuploidies are
trisomies 13 and 18, Beckwith-
Weidemann syndrome.
• Detailed evaluation for the presence of
associated structural anomalies and
genetic testing to be done.
• Fetal weight estimation: formulas that
are based on indices of fetal head and
femur length but not abdominal
circumference
• Vaginal delivery following spontaneous
onset of labor should be preferred unless
other indications
Amniotic Band Syndrome: anterior abdominal wall defect,
lower extremity shows constriction ring caused by amniotic Bladder Exstrophy: wall defect (arrows), located low in the
bands. abdomen. inability to visualize the bladder, caudal
D/D Body stalk anomaly:umbilical cord is very short or absent displacement of the umbilical cord insertion site
 MID-ABDOMEN

• In the mid-abdomen, three structures to be identified are – Right

kidney, Left kidney and Small bowel
• The kidneys should be visualized in the transverse and coronal axis.
• The AP diameter of renal pelvis is done in transverse section.
• The small bowel is identified by its peristalsis

DILATED BOWEL
Structural- Ileal/jejunal atresia, ARM
Functional: Meconium plug,
Hirschprung disease
 LOWER ABDOMEN

• Three structures to be identified

are – Bladder, Two umbilical
arteries and Genitalia
• The parabladder location is the
best site for the identification of
single umbilical artery and is done
using color Doppler.
 Evaluation of fetal Urinary Tract
• Kidneys
– Presence Collecting System
– Number • Dilatation
• Level of obstruction
– Position • Cause of obstruction
– Appearance (echogenicity, • Unilateral/Bilateral
cysts)
– Unilateral/Bilateral
• Bladder Fetal gender
– Presence
– Appearance and size
• In the second trimester , kidneys
often appear as isoechoic structures
adjacent to fetal spine on
transabdominal ultrasonography.
• As the fetus matures,
corticomedullary differentiation
becomes more obvious, especially in
third trimester.
• Normal RPD are less than 4 mm at 16
to 27 weeks and less than 7 mm at
28 weeks or more.
• Calyceal dilation: always pathological.
 Horseshoe Kidney

M/C fusion anomaly of the kidney.

Prenatal sonographic findings
1. A bridge of renal tissue
connecting the lower poles
2. Abnormal longitudinal axis of
both kidneys and

“Lying Down” Adrenal

Signindication of renal Absent Renal Arteries
agenesis or ectopia
 • Fetal Hydronephrosis
• Associated with : aneuploidy and postnatal uropathy
• Risk of any postnatal pathology
• 12% for mild,
• 45% for moderate, and
• 88% for severe hydronephrosis.
• 96% of the fetuses with mild hydronephrosis (RPD > 4 mm and < 7 mm at 18-23 weeks)
midtrimester : resolved in F/u.

• Increased risk for postnatal

uropathy
• UT dilation (RPD ≥ 7 mm at
<28 weeks and ≥ 10 mm at ≥28
weeks)
• Peripheral calyceal dilation
• Dilated ureter,
• Abnormal renal parenchymal
thickness or appearance
Abnormal bladder
• Oligohydramnios
 Autosomal Recessive Polycystic Kidney
Multicystic Dysplastic Kidney Obstructive Cystic Dysplasia
Disease
 Megacystis : Enlarged bladder
that fails to empty over 45
minutes of observation.
Severe megacystis, defined as
bladder length greater than 15
mm

Posterior Urethral Valves

• Keyhole appearance of Dilated urinary
bladder (B) and proximal urethra (*) and
dilated tortuous ureters.
• exclusively in males
 Genitalia
• Their normal appearance should be
checked.
• Gender determination can rely on
visualization of the penis and scrotum
themselves in males and on the two or four
parallel labial lines in the female.
• Fetal rectovesical interspace : F>M
• Ambiguous genitalia :
• Abnormal phallic structure (absent, short
or abnormal shape) and/or scrotum
(absent or bifid)
• Masculinization of female external
genitalia:enlarged phallic structure and
abnormal/fused labia instead of a scrotum,
with identifiable uterus or a relatively large
rectovesical distance.
• Three structures create the ‘tulip’ sign, with the short penile shaft nestled between the bifid scrotum.
• Short rectovesical distance
• Urethra is visualized as an echogenic line (arrow) ending along the base/shaft of the short penis,
consistent with hypospadias
 SPINE
• Spine is imaged in three axes (Sagittal, Transverse and Coronal)
• S4 is the most caudal vertebral body ossification center in the second trimester(S5 in 3 rd
trimester.
• In the sagittal axis we look for :
- Cervical widening
- Parallel thoracic and lumbar spine
- Sacral tapering
• In sagittal section of the spine , the typical “three line appearance” is identified
which consists of (Skin line, lamina and body of vertebra in the order)
• In transverse axis, three ossification centres forming a triangular shape is
identified.
Open spina bifida (Myeloschisis) : splaying of the laminae , progressive increase
interpedicular distance with abrupt tructaion of soft tissues at site of open
neural tube defect.

Close spina bifida (Skin-Covered

Myelomeningocele ): small
posterior cyst containing neural
elements (calipers) covered by skin
protruding through the splayed
laminae
 Sacrococcygeal
Teratoma.

single lower
extremity;
Sirenomelia
Caudal Regression.
Sagittal sonogram of spine at 21 weeks shows
abrupt termination of ossiied vertebral bodies
Transverse color Doppler image at level of
bladder shows lack of ossiied pelvic bones
 THE EXTREMITIES
• All the four extremities must be identified.
• In each extremity we look for:
• The three segments – proximal, mid and distal
• The three features – length ,echogenicity and shape
• Subjective assessment of muscle mass
• Bone scanned throughout long section
• Upper limb
• Humera, including humeral length(not routine )
• Radius/Ulna of both sides
• Fingers and thumbs including hand opening

• Lower limb
• Both femora, including femur length (FL) as a part of biometric
assessment
• Both tibia and fibula, sagittal views to demonstrate orientation
of the ankles to screen for talipes.
• Both feet
• It is important to note that foot and leg are at right angles to each other.
• In a low risk patient, counting of fingers is not essential but it would be wise
to look for opening and closing of hands.
PATTERN OF LIMB SHORTENING
Thanatophoric Dysplasia at 22 Weeks
M/c lethal cause of skeletal dysplasia.
Achondrogenesis:
Osteogenesis Imperfecta Type II:
FL greater than 3 SD below the mean, demineralization of the
calvarium, and multiple fractures within a single bone:
Cervix

90% of preterm birth no prior history of

PTB, that is, the “low-risk” population.
ISUOG FORMAT FOR Mid-trimester fetal ultrasound scan report for
singleton pregnancy
References:
• Diagnostic Ultrasound, Rumack - 6th edition
• ISUOG Practice Guidelines (updated): performance of the routine mid-trimester
fetal ultrasound scan,2022.
• The Second Trimester Obstetric Scan: A rational approach (Including rule of three),
Seshadri Suresh, Indrani Suresh,2014