The "Need to know" of Maternal Fetal Ultrasound

"Need to know" of Maternal fetal Medicine & Gyn Ultrasound Written by: Kristen Coco-Hemmerle RDMS

This book is made by a Sonographer for Sonographers who are in the Ob-Gyn Field.

This is a quick reference guide to most common things you will come across on a day to day basis whether you are working with an Ob-Gyn Physician or a department of Maternal fetal Medicine.

I have been very fortunate in my career to work with some of the best doctors who were willing to teach me and I always willing to learn. I have been very successful in my career and continue to move up in this field. Those who are happy with where they are at in their career great. But those who want to move up and really truly want to know what it takes to become the best of the best then you "Need to Know". This book was made to help with little pointers. It will give you the knowledge and better understanding of why taking that extra step brings you further in your career and gives you a better understanding of why the care of these patients and their unborn baby is more than just taking an image. It’s about really understanding and getting all the history of these patients to better prepare you for what to do next. So when you are asked a question by the provider you will already have the answer for them. It will keep you one foot ahead of everyone else in your field. And it is all because you took the time to take the extra step in getting the information. You have to prove you want to be here and that you are willing to put in the time to get where you want to go. If you don't, then maybe this is not the book for you or the field for you. You can't expect a big paycheck without the work.

I paid my dues of over 17 years of scanning Ob, Gyn and general and continue to do so everyday. I have taken many nights of on call, overnight shifts, sleeping in the hospital when there was a snow storm because no one else would and working weekends. All with raising two kids and a few of those years as a single mom. So don’t think that it is impossible. Anything is possible, you just have to want it. You have to be determined and don’t let anyone say you can’t or your not good enough. You are, you just need the right tools to get there. You need to have an understanding of what things are and when we do them, why we do them. This book is a tool to help you. This is not everything OB and GYN. There are multiple books online you can purchase with what is normal and not normal. This is a great guide for everyday things you will come across when scanning and this is great for new sonographers that are just graduating.

Need to know protocols of Ob and Gyn Scanning.

OB protocols for a viability/dating scan.

Transabdominal may be done if over 10 weeks but always transvaginal before 10 weeks. This give you a better look at the uterus, gestational sac, yolk sac and cervix.

Images: Sagittal Uterus, Transverse Uterus, Cervical length, CRL x 3 (this allows you to get an average for dating). Fetal Heart Rate in M-Mode (ALARA). Ovaries is visualized, if unable to be obtained then document adnexa.

OB Protocol for first Trimester Nuchal Scans.

The Uterus ,Cervix and Adnexa (Ovaries) should be documented, Cardiac motion in M-Mode, Chorionicity and Amnionicity, calvarium, fetal abdominal cord insertion, presence of both limbs upper and lower and NT measurement. NT measurements must be magnified to fill the fetal head, neck and upper thorax and amnion separate from NT line. (See image examples on next page).

OB Protocol for 2nd trimester Anatomy Scans.

Head, Face, Neck , Lateral Ventricles, Choroid Plexus, Midline Falx, Cavum Septi Pellucidi, cerebellum, Cisterna Magna, Upper Lip, Nuchal Fold ( only between 16-20 weeks) Chest, Heart : 4 Chamber view, Situs, LVOT, RVOT, 3 Vessel Trachea view, Abdomen, Stomach, Kidneys, Bladder, Umbilical cord insertion into fetal abdomen, Umbilical cord vessel number, Spine: Long Cervical, Thoracic, Lumbar and Sacral.

Extremities: Presence of legs, arms, hand, feet, fingers (5th digit) and toes. External genitalia. Placenta location and Placental cord insertion.

The following is a list of common questions or situations you may come across with on a daily basis when seeing Obstetrical and GYN patients. Now keep in mind, alot of times the patients may ask us the questions; because they feel like they are with us for more time than the doctor or provider and that we have more time to talk to them. Don't get annoyed we are here to make the experience easy for them but stay within our limits. If you don't know simply say " I am unsure, but you can ask the provider when you see them". They will respect you more for your honesty.

What does NIPT/ NIPS stand for ?

NIPT​ - Non Invasive prenatal testing NIPS​ - Non Invasive prenatal screening Every lab calls it something different but these are the different names (all are NIPT) Harmony, informaSeq, MaterniT21 PLUS, Panorama, and verifi. (Screening is 95.4%-98.6% accurate).

How do they get the gender from the mom’s blood ?

They use the fetal DNA that passes through the mom's blood from the placenta and looks for the detection of the Y chromosome. If a Y chromosome is detect it is consistent with a Male fetus. If a Y chromosome in NOT detected then is may be consistent with a female fetus.

What is the difference between a Sequential 1 and NIPT ?

Sequential 1 is a first trimester screening for chromosomal abnormalities. It will NOT tell you the gender but does give you the PAPP-A Mom Level. Sequential 1 is done between 11 weeks and 13 weeks (Most labs use a CRL of 45mm- 84mm, but this may differ from lab to lab).

Ultrasound is done along with the Sequential 1 to obtain a CRL (crown rump length) and a NT (Nuchal Translucency). *Note* In order for a sonographer to do this exam you MUST be certified in NTQR or FMF. This is a seperate certification aside from your ARDMS. (You do NOT have to have your ARDMS to get NT certified). The PAPP-A Mom is a screening within the Sequential 1 that measures the pregnancy associated plasma protein. If this level is low, there is a greater chance of a risk of ONTD (open neural tube defect). This is 90 % accurate for Down Syndrome and 80% accurate for ONTD. This is covered by most insurances regardless of age.

NIPT - is more accurate , gives you fetal gender early in the first trimester. BUT, without an indication or the patient being advanced maternal age ( 35 years old or older at delivery) this is NOT covered by most insurances.

Sequential 2 Sequential 2 is done between 15 weeks gestation and 18 weeks gestation (but can be test up to 21 weeks gestation) This can ONLY be done if a sequential 1 was already drawn. This will check for ONTD and combine the blood result with the sequential one for a risk factor of ONTD. MSAPF Maternal Alpha-Fetoprotein Test , this is a blood test and can be done from 14 weeks gestation to 22 weeks gestation (most commonly drawn between the 16th and 18th week of pregnancy).

AFP measures in low and high levels, these results are combined with the mother age, ethnicity and weight in order to assess the probabilities of potential genetic disorders.

High level AFP​ - may suggest the baby has a neural tube defect such as spina bifida or anencephaly, this may also suggest defects with the esophagus.

Low Level AFP​ - indicate abnormal levels of hCG and estriol with may indicate T21 (Trisomy 21), T 18 ( Trisomy 18 / Edwards Syndrome) or another type of abnormality. *(Most common false reading is inaccurate dating. Please ensure all dating is accurate and that the correct assigned EDD is documented and matches the patient's chart by their provider.

Another common false reading is Multiples (Twins, Triplets, etc.)

A MSAFP are normally done when a doctors office does an NIPT. If a Sequential 1 and Sequential 2 is done then a MASAP will NOT be done.

If a patient has missed the opportunity for a Sequential 1 between 11-13 weeks and does NOT have an indication for an NIPT. A Quad screen can be drawn.

Quad Screening: ​also called a triple screen which is a screening for abnormalities. It can be done from 15 weeks to 21 weeks and is 80% accurate for women over the age of 35 and 75% for when younger than 35 years of age. It also has a greater chance of false positive and false negatives.

Scanning patients that are IVF. What are the questions you should ask and why this matters.

1. Ask the patient…”Are these your eggs or donor eggs ?” (If a patient froze their eggs at age 28 but is now 42 and pregnant they are NOT Advanced Maternal Age or AMA) (This is also important if they used a donor what age was the donor egg) 2. If they are the patients eggs were they frozen or a fresh transfer ? (If it was a fresh transfer and it is the patients eggs you would use the current age they are and if their age falls into the guideline of being 35 at the time of delivery then the correct indication would be AMA) 3. You ask the patient ..(If frozen) “How old were you when you froze your eggs ?”

4. How many did they implant and how many took ? (This is important because it must be documented if two embryos were implanted and on ultrasound you see a single fetus with fetal cardiac activity demonstrated early in the pregnancy and the other fetus did not make it you must accurately document these findings on all of the lab paperwork. For

5.

6.

7.

this screening you would mark other and document Twin pregnancy reduced to a singleton.) (We want to try to elevate any false positives or false negatives).

If twins I always ask- Did they implant two and you got two or did they implant one.

(There is always a possibility the one will split).

What was the date of the transfer ? Was it a 3 day or 5 day ? (This is important when calculating the due date) Did you do PGD or CCS (​Preimplantation genetic diagnosis (PGD) is a genetic test on cells removed from embryos, to help select the best embryo(s) to achieve pregnancy or to avoid a genetic disease (CCS Comprehensive Chromosome screening) ​The purpose of CCS is to analyze, select and transfer only embryos that do not have abnormalities in their number of chromosomes. Screening embryos in advance can help achieve higher implantation rates and fewer pregnancy losses. (This is not covered by insurances so patient have to pay out of pocket or some offices may allow them to be part of a research study but there are guideline to which the patient has to meet.) (This also allows the patient to know the gender of the embryos before they are implanted so they will know what they are having before you even scan them).

What are some findings you would see under ultrasound when scanning a patient that is either a Gestational diabetic or Pre-existing diabetic ?

Some patients may ask how does this happen ? I didn’t have it with my last pregnancy.

The placenta is designed to share & capture glucose to the fetal side. However, excessive maternal glucose allows free transfer to the fetus and stimulates the fetal pancreas, this may trigger fetal hyperinsulinemia and caused the following complications that we can see under ultrasound. polyhydramnios large for dates fetus fetal macrosomia Some cases you also can see a thickened placenta (IUGR)​ intrauterine growth restriction: when the maternal diabetes severe there can be a paradoxical IUGR as opposed to fetal macrosomia single umbilical artery Multiple fetal abnormalities are associated with patient who are pre-existing diabetic.

Cardiac abnormalities & Renal abnormalities are just a few.

(To find out more about what abnormalities to look for go to ​Radiopaedia.org​ ) IUGR Intrauterine growth restriction IUGR is caused by abnormalities in the placenta. The placenta is an organ that delivers oxygen and nutrients to the baby.

IUGR can be caused by multiple different reasons: Hypertension (Hypertension may lead to preeclampsia)

Smoking Drinking Placental insufficiency All of these indications will demonstrate an elevated umbilical Doppler wave formation.

If a patient tells you they are G3P1 what are some questions you should ask and are important to know ?

1. Did you have a Miscarriage ?

2. Did you have a TOP (Termination of pregnancy / Abortion) If it is either a TOP or a miscarriage I always like to ask if they bleed or did they have a D&C. Sometimes patients do not have D&C they are give a medication like ​Methotrexate,​ it stops embryonic cells from dividing and multiplying and is a non-surgical method of ending pregnancy in its early stages. ​RU486​ is a pill that has been safely used, It is also FDA-approved as a medical abortion option but can only be taken up to 10 weeks gestation. If a patient had a D&C ​Dilation and curettage​ (D&C) is a brief surgical procedure where the cervix is dilated and a catheter is inserted into the endometrial lining and is cleaned out of all remaining products of conception or tissue. (D&C are not only done for miscarriages or abortions there are multiple reasons that we will cover later in GYN).

I also like to ask my patients if it was a TOP was it for Chromosomal reason that they terminated ? Was something wrong with the baby that they terminated and also how many weeks were they when they terminated ?

If they had a D&C I always like to ask if Chromosomes were done. Did the doctor send the tissue out to be evaluated for a chromosomal abnormality? This is important because when doing your nuchal or even if they are doing an NIPT, it asks on the lab form if there is a history of chromosomal abnormalities. This may affect the results so you want to make sure you get the most accurate information.

Another thing to keep in mind about a D&C is that they can cause scar tissue inside the cavity which is known as ​Asherman Syndrome​. (Ashermans Syndrome occurs in women who have had several dilatation and curettage (D&C) procedures. Another way is from a severe pelvic infection unrelated to surgery may also lead to ​Asherman syndrome​. (Which are adhesions (another word for scar tissue) in the uterine cavity).

The following are different medical terms and their definitions and what the differences are.

Remember you want the patient's history and also the indications to be accurate. You have to prove you know what your doing and also show that you are willing to take the extra step and help the providers give the best care to the patient. So the providers in turn can manage the patients pregnancy in the best way.

Habitual aborter :​ This is a person who has had greater than 3 miscarriages , abortion , terminations in total.

Spontaneous ​Abortion​: Death of the fetus or passage of products of conception (fetus and placenta) ​before 20​ wk gestation they miscarried on their own.

Incomplete Abortion​: Death of a fetus before 20 weeks and the fetal pole is still seen under ultrasound with NO cardiac activity and patient has not bleeding.

Threatened Abortion:​ Is when the patient has a Positive Beta HCG and we don’t see the gestational sac, yolk sac or fetal pole growing as usual.

Induced Abortion: When a patient take therapeutic drugs like ​Methotrexate or RU486 to induce the process of an abortion.

Chemical Pregnancy:​ This is considered a to be a very early miscarriage caused by a chromosomal abnormality. Most women with chemical pregnancies did not even know they were pregnant Ectopic pregnancy:​ happens when a fertilized egg implants someplace other than in the uterus, most of the time it implants in the tubes. A Lot of times patients may have pain may be dizzy but a big important one I have found in all my ectopic patients is they have shoulder pain.

Blighted ovum:​ is a miscarriage in which the baby doesn't develop, but a ​gestational sac continues to grow, and you may continue to experience ​pregnancy symptoms​.

Molar Pregnancy​: ​is a rare condition that causes pregnancy tissue to overgrow and the fetus doesn't develop normally. Molar pregnancies never develop normally. The cause is a chromosomal abnormality.

All of the above is very important to document correctly. Multiple D&C from any of the above can also cause an incompetent cervix or weakening of the cervix. And based on the patient's history the provider may want to have the cervix monitored and measured by ultrasound throughout their pregnancy. (This is most accurately done my transvaginal imaging).

An incompetent cervix​, also called a cervical insufficiency, occurs when weak cervical tissue causes or contributes to premature birth or the loss of an otherwise healthy pregnancy. Uterine abnormalities and genetic disorders affecting a fibrous type of protein that makes up your body's connective tissues (collagen) might cause an incompetent cervix. This can be caused by multiple D&C or the patient having a history of a LEEP procedure. (​LEEP ​stands for ​Loop Electrosurgical Excision​ Procedure. It's a treatment that prevents cervical cancer. A small electrical wire loop is used to remove abnormal cells from your cervix).

If a short cervix is diagnosed early in the pregnancy , a patient may be a candidate for a cervical cerclage. Also known as a cervical stitch, this is a treatment for cervical incompetence or cervical insufficiency, when the cervix starts to shorten and open too early.

A cerclage can only be placed up to 24 weeks gestation. If a short cervix or incompetent cervix is visualized after 24 weeks gestation. The patient may be recommended to be placed on vaginal suppositories called progesterone, crinone or prometrium. Another option is an injection call Makena or 17P. A lot of times while patients are on a treatment plan, they are also placed on bed rest either at home or in the hospital depending on the severity of the cervical shortening and funneling demonstrated on the ultrasound examination. There are some occasions where the cervix is just too short to do either a cerclage or medication and the patient will end up in a delivering prematurely. Doctors always try to get the baby to stay in as long as possible but sometime is out of everyone's control.

What is abnormal and normal ?

Pyelectasis : Dilation of the pelvic kidneys, should always be measured in a transverse view measuring the pelvis in AP diameter.

Fetal Pyelectasis is diagnosed if measurements are: >4-4.5 mm at 18-20 weeks >5 mm at ~20-29 weeks >6 mm at 32 weeks persistent fetal pyelectasis: >7 mm in the 3rd trimester NT 1st trimester.

NT value that exceeds of 3.5 mm are associated with the most common adverse outcomes. NT value of above 2.0mm in thickness is a >95% of adverse outcomes.

Some Maternal fetal Medicine doctors may order NIPT over a Sequential One screen if NT is 2mm or greater.

Nuchal Fold measured up to 20 weeks 6 days.

The measurement is considered abnormal if it is 6 mm or greater.

Lateral Ventricles.

Fetal ventriculomegaly is defined as: >10 mm across the atria of the posterior or anterior horn of lateral ventricles at any point in the gestation.

Pyelectasis is a dilation of the renal pelvis. It is a relatively common ultrasound finding in fetuses and is three times more common in male fetuses. In most cases pyelectasis resolves normally, having no ill effects on the baby.

>4-4.5 mm at 18-20 weeks >5 mm at ~20-29 weeks >6 mm at 32 weeks persistent fetal pyelectasis: >7 mm in the 3rd trimester

This is the correct location of Calipers for a 1st Trimester Nuchal Measurement

Correct location and meaurement for Nuchal Fold 2nd Trimester.

The nuchal fold is a normal fold of skin seen at the back of the fetal neck during the second trimester of pregnancy. Increased thickness of the nuchal fold is a soft marker associated with multiple fetal anomalies, and is measured on a routine second trimester ultrasound.

RT Nuchal Fold Cut Off: 14 weeks - 18 weeks Gestation = 5mm in thickness 18 weeks 1 day - 20 weeks 6 days = 6mm in thickness This has a 77.8% sensitivity rate for a true positive.

2% False positive rate.

The lateral ventricles are paired structures and part of the ventricular system in the brain. They are larger than the third or fourth ventricles.

CSF is produced in the choroid plexus situated within the lateral ventricles.

Fetal ventriculomegaly: When the lateral ventricles at any point in the gestation measures >10mm in A/P diameter. With a separation of more than 3 mm between the anterior wall of the choroid plexus and the anterior wall of the lateral ventricle.(So the black space between the chroid and the wall of the lateral ventricle) Mild/borderline fetal ventriculomegaly: 10-12 mm in A/P diameter Moderate fetal ventriculomegaly: 12.1-15 mm in A/P diameter Severe fetal ventriculomegaly : >15 mm in A/P diameter

The chroid also measures > 3mm from the anterior wall of the chroid to the anterior wall of the lateral ventricle.

Abnormal

Normal

4 chamber view

LVOT

Septum

RVOT

3 Vessel trachea view

AIUM Heart images for anatomy scans

I wanted to add a little information regarding a common finding we see on anatomical surveys and that is an intracardiac echogenic focus and echogenic bowel. .

Echogenic intracardiac focus​ (EIF) is a small bright spot seen in the baby's heart on an ultrasound exam. This is thought to represent mineralization, or small deposits of calcium, in the muscle of the heart. EIFs are found in about 3–5% of normal pregnancies and cause no health problems.

This is commonly seen in Asian and Indian(Asian) in most cases this finding does not appear very significant and may be considered a normal variant.

In addition, the presence of multiple EIF within the same ventricle or on both sides (right and left ventricles) is found to be associated with higher risk of fetal aneuploidy.

(The risk of Trisomy 21 is higher in fetuses with bilateral or multiple foci.)

Most of the time doctors may recommend the patient to have a fetal echo to ensure there are no other cardiac anomalies.

(Be careful that you do NOT mistake a EIF for a moderator bands. Always make sure you see the EIF in two views the 4 chamber heart view and the LVOT and it is always as bright as bone).

Echogenic Bowel ​ is an unusually bright appearance of the baby's bowel on an ultrasound.

Most babies with echogenic bowel are normal.

Causes of echogenic bowel ● ●

● ● ●

Bleeding during the pregnancy Chromosome problems such as Down syndrome. The risk of Down syndrome is thought to be low when there are no additional risk factors, such as abnormal ultrasound or​ ​maternal serum screening results​).

Cystic fibrosis​ (CF). About 3 percent of babie​s with echogenic bowel have cystic fibrosis.

An obstruction in the intestines. An ultrasound may also find extra amniotic fluid around the baby, extra fluid in the baby's belly, or dilated loops of intestine.

Infection such as cytomegalovirus and toxoplasmosis. It is not possible to identify all infections before birth.

Middle Cerebral Artery (MCA) are important to show both in intrauterine growth-restricted (IUGR) and anemic fetuses. The risk of anemia is high in fetuses with a peak systolic velocity (PSV) of 1.50 times the median or higher.

Gestational Age

PSV (Peak Systolic Velocity)

23 Weeks

29.27 - 53.16

24 Weeks

30.66 - 53.22

25 Week

32.12 - 53.72

26 Weeks

33.65 - 54.68

27 Weeks

35.24 - 56.15

28 Weeks

36.92 - 58.15

29 Weeks

38.67 - 60.73

30 Weeks

40.51 - 63.91

31 Weeks

42.43 - 67.74

32 Weeks

44.45 - 72.25

33 Weeks

46.56 - 77.47

34 Weeks

48.77 - 83.44

35 Weeks

51.09 - 90.19

The fetal MCA should be sampled~2 mm ultrasound beam and the direction of blood flow should be 0°. Usually the highest value is taken. This chart is from 1.0 multiples of median to 1.5 multiples of median. Anything above this number is considered abnormal and further evaluation is recommended.

Amniotic Fluid Volume *It helps to protect the fetus from trauma to the maternal abdomen *It cushions the umbilical cord from compression between the fetus and uterus *It has antibacterial properties that provide some protection from infection *It serves as a reservoir of fluid and nutrients for the fetus *Most Diabetics Pregestation or Gestational Diabetics with have a High Level AFI also unknown as Polyhydramnios.

Gestational Age

2.5% cm

5% cm

10% cm

50% cm

90% cm

95% cm

97.5% cm

28 weeks

7.3

7.9

10.1

14.2

20.3

21.3

22.3

29 weeks

7.0

7.6

10.0

14.1

20.3

21.2

22.2

30 weeks

6.4

7.1

9.9

13.8

20.3

21.2

22.2

31 weeks

6.2

6.8

9.8

13.5

20.2

21.2

22.2

32 weeks

5.9

6.5

9.7

13.3

20.2

21.2

22.2

33 weeks

5.6

6.3

9.6

13.2

20.1

21.1

22.1

34 weeks

5.3

6.0

9.5

13.0

20.1

21.1

22.1

35 weeks

5.1

5.7

9.4

12.9

20.0

21.1

22.1

36 weeks

4.8

5.5

9.3

12.7

20.0

21.0

22.0

37 weeks

4.5

5.2

9.2

12.6

20.0

21.0

22.0

38 weeks

4.2

4.9

9.1

12.4

19.9

21.0

22.0

39 weeks

3.9

4.7

9.0

12.3

19.9

20.9

21.9

40 weeks

3.7

4.4

8.9

12.1

19.8

20.9

21.9

41 weeks

3.4

4.1

8.8

11.9

19.8

20.9

21.9

Patients always ask “ What is the length of the baby?”

Well the quick answer is the machine doesn’t calculate the length. BUT, if you want to go above and beyond you can go to a site called: Perinatology.com and find out the length of the baby based on the FL measurement you obtained during that exam.

(Keep in mind it does not do halves so if the baby is 10 ½ inches it will either round up or round down. So please make sure you inform the patient it is not exact).

A quick Guide is listed below. (Side note it will not give you anything under 9 inches FL <30mm) Femur Length

FETAL length

30-31mm

9 inches

32- 34 mm

10 inches

35-39 mm

11 inches

40- 42mm

12 inches

43- 47 mm

13 inches

48- 51mm

14 inches

52- 56mm

15 inches

57- 59mm

16 inches

60- 64mm

17 inches

65- 68mm

18 inches

69- 73mm

19 inches

74- 78mm

20 inches

79- 81mm

21 inches

82- 86mm

22 inches

87- 90mm

23 inches

Gyn Ultrasound Imaging Gyn Protocol :Gyn is done using a curved transducer or endocervical transducer.

Images needed: Uterine size, shape and orientation. Endometrial thickness, myometrium evaluation for evaluation if fibroids or mixed echogenicity, Cervix and ovaries (measured in 3 dimensions LxWxH), Doppler flow of the pelvis may be useful if lesions are visualized. If Fibroids are visualized within the uterine cavity correct documentation of place is very important.

Fibroid placement.

<<<Dermoid

Polycystic Ovary ^

The â&#x20AC;&#x153;Need to knowâ&#x20AC;? Of Gyn ultrasounds.

Let's start with the basics of Phases Day 1 - 5 Menstrual Phase (This is some patients may be longer depending on the number of days in their cycle).

After bleeding STOPS then the Proliferative phase starts and this phase is only for 48 hours and the endometrium should measure between 7-8mm (10-15mm if taking medication for fertility).

(Estrogen thickens the lining and the growth of the graafian follicles start).

Last is the Sâ&#x20AC;&#x2039;ecretory Phase This phase begins soon after ovulation occurs. (This is also known as The luteal phase (or progesterogenic phase) it's always the same duration - 14-16 days. This is because the life of the ovum is only 14 days..

Let's start with the wanting to get pregnant (patient).

A patient comes in said she has been trying to get pregnant with no luck. Before the doctor put them on medication like clomid or femara to stimulate the ovaries we have to do a baseline pelvic sonogram. This is done because we want to make sure that the patient is producing some follicles. (What are we going to stimulate if there is nothing to stimulate). Also, we want to make sure the patient does not have PCOS (Polycystic ovarian syndrome). It is common for women with PCOS to have an inappropriate production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). As a result, they experience limited follicular development (follicles are small sac-like structures within the ovaries, and each follicle contains an egg). With limited follicular development, egg development will not occur. So if PCOS is visualized on a baseline pelvic sonogram there may be some further medications and blood work that needs to be done first before prescribing clomid or femara. Every doctor wants to successfully get their patients pregnant but in the right way and following the steps.

After the baseline sonogram is done we want to make sure there tubes are open. If the tubes are NOT open there will be no eggs to drop and get fertilized. An HSG is normally done to see if the tubes are open. The doctors I work with do it in the office under ultrasound guidance

using a femvue and a special catheter. This is almost like doing an SIS (Saline Infused sonohysterogram) but instead of just looking at the endometrial lining this put a mixture of air and water into the uterus and in shoulder push out through the tubes if they are open and you would be able to see the bubbles in real time under ultrasound. It is possible for sometimes only 1 yube to be open but the hope it that both are open. An HSG is also done under x-ray in a hospital or imaging center. If done under x-ray instead of using water and air they use a special dye. (This is more painful) But, on rare occasions if we are unsuccessful seeing the tubes open we may refer them for the HGS with the dye at an imaging center. We always like to tell the patient to take 2 motrin about 15-20 mins before her appointment as they may have some cramping but most patient do well with nothing.

<<<​Femvue Once all of this is confirmed then we can start checking and monitoring follicles. No ever Doctor does things a little differently but for the most part every patient who is being prescribed clomid or femara normal takes the medication Day #3 to Day #7 (5 pills) or Day #5 to Day #9.

So the first day of the patients period is Day #1 and then will follow either the 3-7 or 5-9 medication order depending on the doctor. Normally doctors like to do a baseline follicle screen before they start taking the medication so anywhere from day #1 to day #3. Then after they take the medication depending on the doctors office and sometime insurance/out of pocket expenses owed by the patient they may have them come back daily for blood work and ultrasound screening to see how the follicles are responding to the medication or sometimes to make it affordable to the patient they may have them come back on Day #10 or #11 after the medication is finished to see how the follicles respond and then have them time there intercourse with an ovulation predictor or some office offer a (Trigger shot) which is called HCG, Gonal-F or Ovidrel.

All of these are pretty much the same just made by different pharma companies and of course like any other medication they have different pricing. (Some of these are not covered at all so there are some specialty pharmacies that have them cheaper so i always tell the patient take the prescription and shop around). This trigger shot makes the patient ovulate and is normally given in the doctor's office once the ultrasound confirmed that the follicles are a good size. This also makes it easier to time intercourse or if the patient decided is the best time to do IUI (Intrauterine insemination). *​Side Note​: A female ovulates from 10 hours up to 48 hours and sperm​ only live for a maximum of 5 days in the female reproductive tract. The body needs anything between 24-36 hours for creating more sperms so it is a good idea not to do it every day but some doctors may recommend every other day allowing the sperm to build back up.

A ​mature follicle​ that is about to ovulate will measure anywhere between 18 and 25 mm.

“Need to know” Sometimes I am asked what is the difference between a cyst and a follicle ?

On ultrasound, simple cysts and follicles look exactly the same. The difference is that a follicle has a microscopic oocyte (egg) maturing inside of it, a simple cyst does not. For example, follicles are usually small at the beginning of a menstrual cycle and grow as ovulation approaches. If a patient is past the ovulation and a cyst is still there then is was not a follicle and is labeled a cyst. This commonly is considered anything measuring above 2.5cm in diameter.

Let's talk about the endometrium.

For a woman that is menstruating there are different measurements of the endometrium along her cycle. ​During your period: 2 to 4 mm ,Early proliferative phase: 5 to 7 mm, Late proliferative phase: Up to 11 mm, Secretory phase: Up to 16 mm and then it sheds and starts all over again.

For a postmenopausal women normally around the age of 50 there endometrium stabilizes. The endometrium should really not exceed the a thickness of 5mm.

I have come to find that more and more doctors are ordering pelvic ultrasounds on postmenopausal women during their annual pap and exam. I believe the reason behind this is because when a doctor does a pap smear they are only sampling the cervix. They do not stick the brush into the endometrial cavity to check for cancer cells or do an endometrial biopsy. And biopsies need to have an indication or the patient will get stuck with a bill from the office and from the lab.

In the present time the bimanual pelvic exam is no longer the most effective or efficient tool for assessing the female pelvis. Ultrasound is rapidly proving to be a better method of assessment that reliably offers the necessary details and clarity of the reproductive organs with same-day results. Even if the patient presents with no symptoms this does not rule out anything.

In fact we have picked up more then 3 uterine/endometrial cancers in the past year in my office alone just by doing an baseline ultrasound without the patient having any symptoms of spotting or pain. What we did find under ultrasound was a thickened endometrium. This is something that cannot be palpated on a bimanual exam and have no other means to assess the endometrial lining without doing an ultrasound. Once the ultrasound was completed and findings were discussed with the patient. We had scheduled them to return for a SIS (Saline infused Sonohysterogram as explained earlier in this book). At the time of the SIS we also do an endometrial biopsy to ensure we get a sample of cells. (Now a biopsy CAN be done because we have an indication/diagnosis and the insurance will cover it). After the Biopsy we do the SIS under ultrasound guidance to evaluate for any polyps. If a polyp is in the endometrial cavity this alone can cause a thickened lining but sometimes there are other reasons. Sometimes the cervix is stenosed and the blood can not get out.

This is a endometrium with SIS â&#x20AC;&#x2039; â&#x20AC;&#x2039;This is the same endometrium without SIS The endometrium without the use of SIS (Saline) it just appears as a thick endometrial stripe as you can see there is no real focal structure to show that a polyp is in the endometrium without recommending the patient come back for another SIS. (*Note some doctors may do the SIS on the same day but there is a good chance that one ultrasound or procedure will not get paid for so it is always a good idea to bring the patient back on another day to have it covered by insurances).

SIS are a great thing to do not only to check when patients come that are post menopausal but a lot of fertility doctors will do it to check for polyps if a patient has trouble getting pregnant.

(Donâ&#x20AC;&#x2122;t forget HSG is to check the tubes not the lining).

If polyps are seen under they normally schedule a patient for a D&C to remove them completely and send the polyps off for pathology to ensure they are not cancerous.

I hope you enjoyed this book as a quick reference guide to understanding the most common things we come across every day. I am always open to ideas if there is maybe some other topics you would like to read about or need a reference guide. Maybe I can just be of some help to someone just starting out. I will be more than happy to help you and share the opportunities I had along the way.

I set up an email that you can use to send me a message or if you have a question. I will be happy to answer anything you have on your mind. I would love to get some feedback about what you think about the book as well if you have the time.

needtoknowobgyn@gmail.com

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Special Thanks My Parents Denise and Mike Donnelly My Husband Lenny Hemmerle Jr My Wonderful Children Dylan & Brody My One and only Sister Dana My Niece, My Godchild & My Princess Lauren Dr Craig Wiener for always teaching me new things and keeping me on my toes and most of all making it fun.

Dr Paul Matta for being the nicest MFM doctor to work with and gaining so much knowledge everyday.

Dr Denise Netta who helped me along the way when I first started MFM full time.

Dr Carlos Benito one of the first MFM Doctors I worked with and being a great teacher to the beginners and help start the way of being something great.

Last but not least all of my friends and co-workers for always encouraging and supporting me.

I am so blessed for all of you.

Some references to use for everyday perinatology.com https://radiopaedia.org/?lang=us https://sonoworld.com/TheFetus/Home.aspx https://fetalmedicine.org/ https://www.aium.org/

The "Need to know" of Maternal Fetal Ultrasound Copyright Š 2019 by KRISTEN ANN HEMMERLE RDMS I am a sonographer for over 17 years with a specialty in Maternal Fetal Medicine and OB - Gyn. I have always been asked how do you know what you know ? My answer is I just do. It's things I have learned along the way working next to some of the best doctors who were always will to teach me.

All rights reserved. No part of this book may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the author, except in the case of brief quotations embodied in critical reviews and certain other noncommercial uses permitted by copyright law.

Special Thanks My Parents Denise and Mike Donnelly My Husband Lenny Hemmerle Jr My Wonderful Children Dylan & Brody My One and only Sister Dana My Niece, My Godchild & My Princess Lauren Dr Craig Wiener for always teaching me new things and keeping me on my toes and most of all making it fun.

Dr Paul Matta for being the nicest MFM doctor to work with and gaining so much knowledge everyday.

Dr Denise Netta who helped me along the way when I first started MFM full time.

Dr Carlos Benito one of the first MFM Doctors I worked with and being a great teacher to the beginners and help start the way of being something great.

Last but not least all of my friends and co-workers for always encouraging and supporting me.

I am so blessed for all of you.

This book is not intended to be copied without the permission of the Author. Any questions please email the Author directly.

Email Me: needtoknowobgyn@gmail.com Special discounts are available for booksellers or others. Inquire support@bookemon.com Printed in United States of America Bookemon Creative Author Press Publication Publication Date: 2019-02-06 ISBN-13: 9781605007748