usg obstetri
DESCRIPTION
ObgynTRANSCRIPT
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ULTRASOUND IN OBSTETRICS
PELATIHAN ASUHAN PERSALINAN NORMAL (APN) KEPANITERAAN KLINIK DISIPLIN ILMU OBGIN FK UMI / UNISMUH 2015
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OBSTETRICS ULTRASOUND
Anatomi normal kehamilan trimester I
Anatomi normal fetus trimester II dan III
Komponen non-fetal trimester II dan III
Abnormalitas Fetus
Abnormalitas komponen non-fetal
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Tujuan USG pada kehamilan dini :
–Untuk mengetahui hamil/tidak.
–Untuk menentukan kehamilan intra
atau ekstrauterin.
–Bila intrauterin : Lokasi GS ?
–Jumlah kehamilan
–Usia kehamilan
–Kelainan kehamilan
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Pemeriksaan USG obstetri dapat dilakukan melalui 2 cara :
1. TVUS (transvaginal US)
* Lebih superior
* Penderita tdk perlu menahan kencing
2. TAUS (transabdominal US)
* Perlu buli-buli yg penuh
Pemeriksaan USG Obstetri
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TRIMESTER PERTAMA
– Gestational Age secara klinis dihitung
dari hari pertama haid terakhir (HPHT)
sebelum terjadinya konsepsi.
– Konsepsi biasanya terjadi antara hari ke
13 sampai hari ke 17 dari siklus haid.
– Usia kehamilan (Gestational Age)
secara klinis adalah 2 minggu lebih tua
dari tanggal terjadinya konsepsi
(Embryonic Age).
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Garis echogenic menunjukkan cav.uteri (panah)
* = GS struktur anechoic tanpa struktur apapun didalamnya
Gbr.1
Kehamilan Normal Trimester I
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Khas dikelilingi 2 lapisan cincin echogenic double desidual sign – Inner ( panah pendek)
– Outer (panah panjang)
Gbr.2
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USG TVUS kehamilan pada usia
4,5 minggu
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Double decidual sign pada usia kehamilan 5 minggu
dc = decidua capsularis
dv = decidua vera (parietalis)
* = hematoma subchorionic kecil
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Diagram anatomi dari double decidual sign
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Kantong gestasi usia kehamilan 5 minggu dimana telah terlihat
Yolk sac ukuran 3 mm. fetal node belum terlihat
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GS pada usia kehamilan 5,5 mgg
GS ( kepala panah) yang berisi yolk sac ( panah ),
tetapi belum tampak embrio didalamnya
Gbr 3
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Embrio 6,5 mgg
p = 5 mm
Berdekatan dgn YS
Masih tampak sbg struktur yg menyatu
Gbr. 4
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Gambaran corpus
luteum secara USG :
– Kista dengan dinding
tipis (a)
– Kista berdinding tebal (b)
(a)
(b)
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- Kista dengan internal echo ( c )
- Kista dengan diffuse
internal echo (d)
(c)
(d)
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6 mgg :
– Heartbeats dapat terdeteksi pertama kali
(TVUS) gerakan kerlap-kerlip
berdekatan dgn YS
- 2-3 hari kemudian, HB terlihat
didalam embrio yang tampak lebih
jelas
Heart rate normal:
Usia kehamilan < 6,3 mgg : 100x/mnt
Usia kehamilan 6,3-7 mgg : 120x/mnt
Usia kehamilan > 9 mgg : 140x/mnt
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TVUS sagital yg memperlihatkan aktifitas jantung embrionic
pada usia kehamilan 6 minggu. CRL terukur 2,4 mm
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TVUS sagital (M-mode) yg memperlihatkan aktifitas
jantung embrionic pada usia kehamilan 6 minggu.
CRL terukur 2,4 mm
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Gambaran USG dari kehamilan normal pada
(berdasar CRL) :
A. 6 minggu 5 hari
B. 9 minggu 2 hari
A B
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Rhombencephalon tampak pada
mgg ke 8
Mgg ke-10 :
-Struktur anatomi (termasuk
rhombencephalon) dgn
kepala dan badan terlihat jelas
-Limb buds :
-Extr. atas (panah pendek)
-Extr. bawah ( kepala
panah )
Gbr 6
Gbr 7
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TVUS kehamilan trichorionic triplet dengan 3 kantong
gestasi usia kehamilan 10 minggu
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TVUS usia kehamilan 11 – 12 minggu
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Akhir trimester I beberapa struktur
fetal sudah teridentifikasi jelas : (Gbr 7)
– Jantung dengan 4 ruang
–Lambung
–Vesica urinaria
–Extremitas
–Wajah
–Skeleton
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Anatomi fetus pada akhir trimester I
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USG dari janin dgn letak sungsang
C=bladder
D=fetal skull
E=fetal leg
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USG janin dengan letak kepala
C=bladder
D=fetal skull
E=fetal leg
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USG dari janin yang sementara
melambaikan tangan
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USG janin yang sementara
berdoa
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Gambaran USG janin yang
sementara bernyanyi
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Gambaran USG janin yang
sementara mengisap ibu jarinya
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USG yg memperlihatkan
jari tangan janin
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USG janin dengan
kelamin lelaki
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Penentuan usia kehamilan Trimester I
Penentuan usia kehamilan dpt dilakukan
melalui :
1. Riwayat menstruasi HPHT*
2. Pemeriksaan fisis
3. Kadar -hCG kwantitatif
4. USG (TVUS/TAUS)*
* Lebih akurat
USG lebih akurat dibanding HPHT
HPHT hanya mendukung hasil USG
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Extraembryonic
coelom
Uterine cavity
Yolk Sac
Embryo Amniotic
Membrane
Chorionic
villi
Kehamilan 6 – 7 minggu
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Embryo is
between
calipers
Yolk Sac
Yolk Sac
Extraembryonic
coelom
Uterine cavity
Embryo
Amniotic
membrane Chorionic
villi
Kehamilan 7 minggu
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Embryo
Chorionic Sac
Yolk Sac
Kehamilan 8 minggu
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Crown-Rump Length
- Greatest length of embryo
- Exclude yolk sac
Yolk Sac
CRL
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QT4
Crown-Rump Length
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PENENTUAN USIA KEHAMILAN
TRIMESTER II DAN III
Biometri janin trimester II dan III :
– BPD (Biparietal diameter)
– HC (Head circumference)
– AC (Abdominal circumference)
– FL (Femur Length)
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Biparietal Diameter (BPD)
Abdominal Circumference (AC)
Head Circumference (HC)
Femur Length (FL)
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Cavum Septum
Pellucidum
Falx
Sinciput Occiput
Thalamus
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QT7
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Circumference measurement
C=(D1+D2) X 1,57
Where C=circumference and D1 & D2 are diameters
D1
D2
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PENGUKURAN USIA KEHAMILAN
TRIMESTER II & III MELALUI PANJANG
FEMUR (FL)
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QT9
PENENTUAN USIA KEHAMILAN MELALUI
PENGUKURAN AC :
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Abortus spontan :
– Komplit :
• Uterus kosong, hanya terlihat
penebalan echo central.
– Inkomplit :
• Selain echo central masih tampak
echo dari sisa-sisa jaringan
kehamilan (retained products of
conception).
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Complete abortion. Note thinness and
regularity of endometrial interfaces (arrow)
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TVUS abortus incompletus
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Incomplete abortion with irregular
choriodecidua and deflated sac
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Missed Abortion/Blighted Ovum
Diagnosis pasti kegagalan kehamilan
trimester I, dengan TVUS, apabila tdk
terdeteksi heart beat pada :
1. Embrio dengan panjang ≥ 5 mm
2. Usia kehamilan berdasarkan GS ≥ 6,5 mgg
Suspek :
1. Diameter rata2 GS > 8mm tanpa Yolk sac
2. Diameter rata2 GS > 16 mm tanpa embrio
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Anembryonic Gestation = Blighted ovum
– Terdapat kantong gestasi yg kosong di dalam cavum uteri
– Gambaran USG :
–Small for dates
–Deformed (tennis racquet), dinding tidak jelas
– Tebal kantong gestasi tidak merata
–Echo bakal placenta tidak nampak
Jika ragu BO pd usia 6-7 minggu : scan ulang 1 minggu
Bila besar GS tidak bertambah > 75% atau bila tetap tidak terlihat fetal nodes : 100% BO.
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Gambaran TVUS dari blighted ovum dgn kantong gestasi
yg berbentuk irreguler
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Blighted ovum
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Gambaran TVUS dari blighted ovum dgn MSD kantong gestasi
berukuran 3 cm namun tidak tampak yolk sac maupun fetal node
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Gambaran TVUS coronal dari blighted ovum
dgn MSD = 18 mm
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Gambaran TVUS dari kantong gestasi dengan
yolk sac yg sangat kecil pada border line case
yg memerlukan scan ulangan untuk follow up
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Blighted Ovum
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Blighted Ovum
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TVUS sagital dari penderita dengan perdarahan
pervaginam dimana terlihat adanya kantong amnion
didalam kantong gestasi namun tdk terlihat fetal node
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Missed abortion :
– Masih nampak echo fetus dalam
kantong gestasi tetapi sudah
deformed/misshapened dan immobile
karena sudah mati.
– Fetal heart beat tidak tampak
– Uterus : small for dates
– Echo placenta masih tampak (kadang2
menebal karena perubahan hidropik)
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Missed Abortion
Suatu GS intrauterine dgn CRL embrio 5,38 mm, tanpa heart beat dalam embrio
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Gambaran TVUS janin yg telah meninggal
Fetal heartbeats (-)
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Gambaran TVUS M-mode yg merekam denyut jantung
janin yg telah (-) pertanda janin telah meninggal
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Missed abortion. No
heart motion was detected.
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Missed Abortion
( denyut jantung janin (-) )
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Kehamilan Ektopik
Terjadi bila blastocyst terimplantasi
di tempat lain selain endometrium
Seringkali terjadi antara usia
kehamilan 5 dan 6 mgg
Gambaran klinis :
– perdarahan pevaginal
– nyeri rongga pelvis
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Kemungkinan lokasi KE
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Kehamilan ektopik di daerah serviks
GS yang berisi embrio tampak berada di daerah serviks
Heart beat (+)
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Kehamilan Ektopik
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Gambaran TVUS kehamilan ektopik dengan janin
yg masih hidup didalam kantong gestasi
yg berada didaerah cul-de-sac
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Gambaran USG dari kehamilan ektopik
dgn kantong gestasi berada di tuba
Fallopii kiri
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TVUS kehamilan ektopik dengan tubal ring di luar uterus
serta adanya bayangan bekuan darah di belakang uterus
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Gambaran TVUS Kehamilan Ektopik Terganggu (KET)
dgn kumpulan cairan didaerah adneksa dan
terlihat pula kista adneksa kiri
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TVUS potongan coronal kehamilan ektopik dengan kantong gestasi
Berada dalam tuba kiri disertai perdarahan disekeliling tuba
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Ring of fire
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Kehamilan heterotopik
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Gestational Trophoblastic Disease
Molahydatidosa :
– Uterus large for dates
– Vesicular pattern dalam uterus. Ukuran
vesikula : 3-5 mm, bisa lebih besar lagi.
– Snowstorm appearance
– 30% kasus : terdapat pula theca lutein
cyst, bilateral, multilocular cyst.
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First trimester hydatidiform mole
![Page 87: Usg Obstetri](https://reader031.vdocuments.site/reader031/viewer/2022012303/56d6beae1a28ab3016932453/html5/thumbnails/87.jpg)
Jaringan mola dengan kantong gestasi
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Gambar USG mola
![Page 89: Usg Obstetri](https://reader031.vdocuments.site/reader031/viewer/2022012303/56d6beae1a28ab3016932453/html5/thumbnails/89.jpg)
Gambar USG dgn dopler
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Molahidatidosa dengan
kista thecalutein
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Hydatidiform mole and theca lutein cysts
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PLACENTA
Penilaian akurat posisi placenta biasanya dilakukan pertama kali pada scan rutin kehamilan 16-20 minggu.
Echo level placenta lebih tinggi dari echo dinding myometrium. Chorionic plate terlihat sebagai garis terang di antara cairan amnion dan echo homogen placenta.
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Plasenta
Dengan mudah ditentukan pada usia
14 mgg
Lokasi : diuraikan terhadap dinding
uterus dan ostium servisis
Plasenta tampak homogen, atau
memiliki lekuk atau ada fokus echoic
di sepanjang basal plate
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Plasenta
Plasenta pd usia kehamilan 22 mgg – Struktur echogenic homogen yg menutupi aspek anterior dari GS
Doppler : Lebih jelas menunjukkan insersi umb.cord pd
plasenta ()
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Bintik-bintik kalsifikasi di sepanjang tepi kotiledon plasenta – Usia kehamilan 32 mgg
– Usia kehamilan 40 mgg
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Placenta
Myometrium
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Placenta letak rendah dan placenta
previa :
– Perdarahan selama kehamilan : suspek
placenta letak rendah, placenta previa,
atau abrupsi placenta.
– Placenta previa dapat komplit atau
marginal, didiagnosis dgn terlihatnya
jaringan placenta yg menutupi ostium
cervical internum.
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Plasenta previa
Tipe-tipe
plasenta previa : A. Low-lying placenta
B. Partial PP
C. Marginal PP
D. Total/Completely PP
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Klasifikasi plasenta previa
berdasarkan grading : Grade I - plasenta meluas sampai
segmen bawah uterus namun
tidak mencapai ostium uteri
internum
Grade II - plasenta mencapai ostium uteri
internum namun tidak menutupi
Grade III - plasenta menutup ostium uteri
internum secara eksentris
Grade IV - plasenta menutup ostium uteri
secara sentral
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Internal os
External cervical os
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Plasenta previa total
Plasenta previa marginal TVUS (A) dan TAUS(B)
A B
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Pseudoprevia akibat overdistended buli-buli (A)
Setelah pengosongan buli-buli, ternyata plasenta tdk memanjang sampai ke serviks. Gbran seperti serviks ternyata merupakan ddg anterior dan posterior segmen bawah uterus yg tertekan buli-buli
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Anterior plesenta previa
dimana plasenta mencapai
ostium uteri internum
Anterior plesenta previa
dimana plasenta menutup
ostium uteri internum
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Abrupsi / Solusio placenta :
– Abrupsi placenta adalah pelepasan
plasenta sebelum janin dilahirkan
– Perdarahan antepartum yg biasanya
disertai rasa nyeri yg sangat.
(Perdarahan placenta previa tidak
disertai rasa nyeri)
– Secara sonografik mungkin bisa
terdiagnosis. Namun banyak kasus
abrupsi yg tidak terlihat.
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Abrupsi / Solusio Plasenta
Pelepasan prematur sebagian atau seluruh plasenta dari ddg uterus sebelum kelahiran janin
Ultrasound tidak mendeteksi pemisahan plasenta dari dinding, tetapi mengidentifikasi adanya hematoma retroplasental
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Daerah hematoma (HE) yg hipoechoic →
terangkatnya tepi plasenta dan membran
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Placenta
Abruption
Fetal Head
Abrupsi Placenta
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PENILAIAN CAIRAN AMNION
Patokan volume cairan amnion secara kualitatif :
– Jika tepi dari fetus sulit dipisahkan (sangat berdekatan) dengan dinding uterus oligohydramnion (cairan terlalu sedikit)
– Sebaliknya jika fetus bebas mengapung dan sdkt sekali menyentuh dinding uterus polyhydramnion (terlalu banyak cairan).
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Penilaian volume cairan amnion secara kuantitatif :
– 2 metode yg sering digunakan :
• Pengukuran jumlah cairan amnion di kantong (pocket) terdalam secara vertikal (deepest single pocket).
• Total jumlah dari jumlah cairan amnion secara vertikal pada kantong terdalam di empat kuadran uterus (Amniotic Fluid Index / AFI).
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Amniotic Fluid Index (AFI) :
Teknik mengukur :
– Transduser diletakkan tegak lurus dgn
badan pasien (pasien supine), jk sdh
ditemukan kantong terdalam cairan
amnion dari satu kuadran di antara 4
kuadran uterus, mk gambar tsb
difreeze, lalu diukur kedalamannya.
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K1 K2
K3 K4
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Cairan Amnion
Partikel-partikel
echogenic dalam
cairan amnion
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Pengukuran AFI
menjumlahkan 4 lokasi pengukuran N = 12,4 cm
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Polyhydramnion
Janin dgn polyhydramnion berat; tampak dua loop usus yg dilatasi dlm abd. janin
Diagnosis setelah lahir : Atresia jejnum
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AFI : 9,4 + 10 + 9,6 + 8,5
= 37,3
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Polyhydramnion
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Oligohydramnion
Janin 12 mgg
– Tampak tidak ada
cairan amnion
disekeliling
– Janin meninggal
setelah 1 mgg
setelah di USG
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Kehamilan 32 mgg
Dgn pengukuran
pada 4 daerah
terdalam :
AFI =1,2 + 3 + 0 +
0
= 4,2
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Oligohydramnion
Fetal Head
Placenta Placenta
Fetal Chest
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Insersi tali pusat Ptg.transversal abd.janin pada level insersi funikulus umbilikalis ( ↓ )
dimana menunjukkan dinding abdomen anterior yg intak
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Umbilical cord
Umb.cord : – struktur curvelinear yg
berdinding tipis (kpl panah)
– Insersinya di plasenta
dan janin (panah)
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Komposisi vaskuler Cross-section & colour doppler :
- 2 arteri ( kpl panah dan 2 ttk merah)
- 1 vena ( panah dan ttk biru besar )
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Doppler :
2 arteri
umbilicalis dlm
rongga pelvis
janin, yg
berjalan lateral
ke VU ( )
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Kehamilan dgn Mioma Uteri
Mioma uterus besar di
lateral kanan uterus,
tanpa pendesakkan uterus
Pendesakkan GS dan fetus
akibat mioma
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Abnormalitas Fetus
Central nervous System
Spine
Thorax, Neck
Heart
GI tract and Ventral Wall
Genitourinary tract
Skeletal
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Hidrosefalus
- Peningkatan volume CSF di dlm sistem
ventrikuler, ditandai o/ pelebaran bbrp
atau seluruh sistem ventrikel (paling
sering ventrikel lateralis)
- Dapat dideteksi sejak usia kehamilan 18
mgg
- Kriteria :
- Pelebaran atrium ventr.lateralis ± 10 mm
- Plexus choroideus yg menjuntai dari T4
melekatnya di ddg medial ke ddg lateral
ventr.lateralis
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Ptg axial. Janin 35 mgg – Dilatasi ventr.lateralis
(± 18,9 mm)
Fetus 30 mgg – Dilatasi ventrikel
– Plex.choroideus yg memanjang dari T4 perlekatannya di ddg medial ke ddg lateral ventrikel ()
A
B
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Ptg axial, janin 18 mgg
– Dilatasi ventrikel dan
plx.chr yg berjuntai dari
ddg medial ke lateral
ventr.lateralis
Pelebaran ventrikel 3
pd fetus dengan
congenital
toxoplasmosis
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Anencephaly
Coronal (A) dan sagital (B) :
– Absennya dahi dan cranium di atas orbita ()
– Wajah dan mandibula biasanya Normal
A B
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Anencephaly
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Spina Bifida & Meningomyelocele
Fetus trimester III
Defek spina bifida yg luas
dengan lesi kistik besar
yg menonjol ke posteriorakang
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Spina Bifida
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Omphalocele
Ptg.Transversal – Massa kecil yg menonjol
ke anterior pd T4 insersi funiculus umbilicalis
Doppler – v. umbilicalis () tampak
berjalan melewati satu sisi omphalocele sac
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Ompalocele
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Ompalocele
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Omphalocele besar yg menonjol di ddg anterior abd.
Pemb.darah hepatic tampak dalam omphalocele (doppler)
Pemb.darah umbilicus tampak berinsersi ke omphalocele sac
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Doppler US in Obstetric
4D US Examination in Obstetrics
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