first trimester ultrasound my prediction diagnosis of fetal … · 2017. 11. 26. · evolving role...
TRANSCRIPT
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AlfredAbuhamad,MD.EasternVirginiaMedicalSchool
FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities:
WhatYouNeedtoKnow
MyPrediction
• Thefirsttrimesterultrasoundwillplayamajorroleinclinicalmanagementofpregnancyinthenext3-5years
• (upto136/7weeks)
CurrentRoleofFirstTrimesterUltrasound
• Accuratepregnancydating• Earlydiagnosisofmultiples• Pregnancyriskassessment• Evaluationoftheadnexae
EstimationofGestationalAge
• Ifapatientreportsnomenstrualdates,ultrasoundinthefirstorsecondtrimestershoulddatethepregnancyandestablishtheEDD• Ultrasounddatingofpregnancyismostaccurateinthefirsttrimester
• Focalzoneatappropriatelevel• Imagemagnified• Embryo/fetusimagedinneutralposition• Maximallengthofembryo/fetusshown• Maximallengthofembryo/fetusmeasuredinastraightlinefromcranialtocaudal
CriteriaforCRLMeasurement
UltrasoundObstetGynecol2014;44:649–654TaskForceforCurriculum&CompetencyAssessmentinUltrasoundTraining-2017
EstimationofGestationalAge• CRLaremostaccurateinfetalneutralpositionandbetween11+0and13+6weeksofgestation• UsethemeanofthreediscreteCRLmeasurements.• AssignEDDbyCRLif>5daysdiscrepancyatlessthan9weeksofgestation• AssignEDDbyCRLif>7daysdiscrepancyat9-136/7weeksofgestation
BJOG2014;121:556–565.
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BJOG2008;115:1273–1278
SmallCRL
BiometryinFirstTrimester
MultiplePregnancy
AmJObstetGynecol.1994;170(3):824–829.
Chorionicity:• 100%in1stTrimester• 90%in2ndand3rdTrimesters
PregnancyRiskAssessment
HemorrhagicCyst
CysticTeratoma
PedunculatedLeiomyoma
Endometrioma
EvaluationoftheAdnexae EvolvingRoleofFirstTrimesterUltrasound
• Imaginginobesepregnantwomen• Screeningforfetalmalformations
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Lettyetal.JUltrasoundMed2017–onlineaccess
EvolvingRoleofFirstTrimesterUltrasound
• Screeningforfetalmalformations– ImpactofNIPTscreening– Impactoflimitingaccesstopregnancytermination
UltrasoundObstetGynecol2013;41:102–113
FirstTrimesterUltrasound
FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017
FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017
FirstTrimesterUltrasound
Syngelaki,PrenatDiagn.2011;31:90–102
FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017
FirstTrimesterUltrasound
Syngelaki,PrenatDiagn.2011;31:90–102
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1stTrimesterAnomaliesDetectionRateLow-Risk,n=97,976
32.35%(95%C.I.22.45-43.12)Karimetal–UOG2016E-Pub
1stTrimesterAnomaliesDetectionRate
61.18%(95%C.I.37.71-82.19)Karimetal–UOG2016E-Pub
High-Risk,n=2,841
1stTrimesterAnomaliesDetectionRate
• Useofananatomicalprotocolduringfirsttrimesteranomalyscreening(P
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MidsagittalPlane
NT
NB
MidBrain
MaxillaMandible
Cord
Bladder
NuchalTranslucency NasalBone
• Abnormalif:• Absent• Short• Hypoplastic
AneuploidyScreening
FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017
NasalBone–Trisomy21
FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017
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Maxilla
Face - Basic Face - Basic Face - Basic
Face - Basic
MaxillaryGap Mandible
Face - BasicFace - Basic
MidBrain
T
CPITBS
CMOB
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PosteriorFossa–AxialView13weeks
OccipitalBone
FourthVentricle(IT)
ChoroidPlexus
CisternaMagna
Face - Basic
Face - Basic
Normal
SpinaBifida DandyWalker
SpinaBifida DandyWalker
OtherCNSAnomalies
Ventriculomegaly
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Ventriculomegaly NormalVentricles
Ventriculomegaly• ThinningofCP• CPfillinglessthan½ofLV• CPbordersdonottouchlateralventricularwall• SeparationofCPfromsuperiorbordersofLV• Enlarged3rdVentricle
Ventriculomegaly
Anencephaly/Exencephaly AxialPlanes
Normal Holoprosencephaly
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CordInsertion
Cord
CordInsertion
PhysiologicMidgutHerniation• Noteduntil12weeks• AlmostneverseenatCRL>45mm• Measures<7mminaxialplane
JUM1993;12:251–UOG1995;6:240
Omphalocele Omphalocele
OmphaloceleOmphalocele
Pentalogy
Extroph
y
(OEIS)
Omphalocele(Pentalogy)
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GastroschisisSmoothBordersOmphalocele
IrregularBordersGastroschisis
Bladder
Bladder
FetalBladder
• Seenin88%at12weeks• Seenin92–100%at13weeks• RenalsourceofAFis>16weeks
UltrasoundObstetGynecol2003;21:338–341UltrasoundObstetGynecol1996;7:95–100
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NormalBladderLength<7mm
12weeks
Megacystis(7-15mm)• Chromosomalanomaliesin24%• Withnormalchromosomes:• Resolutionin90%• Renalanomaliesin10%
UltrasoundObstetGynecol2003;21:338
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Megacystis(>15mm)• Chromosomalanomaliesin11%• Withnormalchromosomes:• Renalanomaliesin100%
UltrasoundObstetGynecol2003;21:338
FetalGender
• Inaccuratebefore12weeks• Accuracyincreaseswithadvancinggestationalage• Greaterthan95%at>13weeks
ObstetGynecolSurv2009;64:50–57
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Female
Male
DuctusVenosus
3D-Extremities
AneuploidyScreening
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Trisomy21
FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017
Trisomy18
Trisomy13 MonosomyX
FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017
MonosomyX Triploidy
FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017
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Triploidy MidsagittalPlaneinFirstTrimester• Goodscreeningmodalityforfetalabnormalities• RatherthandoingawaywithNT,weneedtoenhancetrainingandfocusondetectionoffetalabnormalities• Theroleoffirsttrimesterultrasoundwillexpandoverthenextyears