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The National Ribat University
Faculty of Graduate Studies and Scientific Research
Ultrasonograpic Criteria for First Trimester by Transabdominal
Scanning
A Thesis Submitted for Partial Fulfillment of the Requirements of
the MS.c Degree in Medical Diagnostic Ultrasound
By: Marwa Ibrahim Yousif Nogod
Supervisor: Dr.Ahmed Abdelrahim Mohammed
1439-2018
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I
األيت
: تعالي قال
﴿ ا ر ٳف ف ط ي ه ا ق ل ا خ ٲ اى ض ل ٱ ش ن ل أ
﴾ ﴾۷۷﴿ يث ه نص خ
العظيم هللا صدق
۷۷األيت يس سورة
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II
Dedication
To my mother
To my father
To my sisters
To my brothers
To my friends
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III
Acknowledgement
First great thanks to Allah almighty who made all
things possible and gave me power success of this
research. I would like to present heart felt gratitude to my
supervisor Dr. Ahmed Abdelrahim Mohammed for his
guide and support.
Thank full to my colleges whom I appreciate their
help, good dealing and support.
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IV
Abstract
This was across sectional descriptive study carried out in order to evaluate
ultrasonographic criteria for first trimester of pregnancy by transabdominal
scanning, the study was conducted from June 2017 to October 2017 in ultrasound
departments the different hospitals and clinics in Khartoum state. Using Mindary
DP 20 portable ultrasound machine, Mindary DP 10 portable ultrasound machine
and LOGIQ 100 PRO portable ultrasound.
The study was conducted from 100 pregnant women in the first trimester. It was
analyzed using Statistical package for Science program system social .78% normal
pregnancy with cardic activity, 17% intact fetal but no cardic activity because they
were early weeks and 5% pregnancy failure. There was 2% pregnant with corpus
lueteal cyst, 1% pregnant with pelvic inflammatory disease and 1% pregnant with
fibroid. The result shows the ultrasound in the first trimester is visualize and
localize the gestational sac, assess the gestational sac in size and shape, determine
the gestational age, determine chronicity and amnionicity, determine the
gestational age and expected date of delivery when the last menstrual period
unknown and assess the adnexa.
The study recommended that all pregnant women should do ultrasound scan in
every pregnancy, and should be advised to do regular scanning to improve
pregnancy outcome and ultrasound should be viable in all hospitals and centers to
facilitate the diagnosis of pregnancy and follow up.
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V
ملخص البحث
لتقن ظس الحول ف الثالث اشش االل تاصتخذام الوجات ز الذساص صف هقطع اجشت
ف هضتشفات 7102حت اكتتش 7102ف الفتش هي فق الصت للثطي, قذ اجشت الذساص
ذ اصتخذاهت االجز التال :عادات الخشغم الوختلف ق
Mindary DP 20) Mindary DP 10, LOGIQ 100 PRO (
االحصائ للعلم تن تحلل التائج تاصتخذام ظام تشاهج الحزم حال 011اجشت الذساص ف
% هي االج لن تن 02% هي االج تثعات قلة غثع, 27االجتواع )اس ت اس اس(. حج جذ
%حول هع جد 7% فشل ف الحول. 5تحذذ ثعات القلة للجي الن ف االصاتع الوثكش هي الحول
% حول هع التاب ف الحض. قذ ظحت 0% حول هع جد سم لف ف الشحن 0كش ف الوثط,
شكل حجن كش الذساص اى عول الوجات فق الصت ف الثالث شس االل هي الحول تحذد هقع
كزلك تحذد عوش الجي عذها تكى .الحول, الضائل االه, عوش الجي هاعذ الالد الوتقع
اخشدس شش غش هعشف لذ الضذ الحاهل.
اصت ز الذساص جوع الضاء الحاهل تاجشاء الوجات فق الصت ف كل حول اى تكى تشكل
س لتحضي تائج احول جة اى تكى الوجات فق الصت هتفش ف جوع الوضتشفات هتظن د
الوشاكز لتضل هعشف هتاتع الحول.
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VI
List of content
Page No Content
I االيه
II Dedication
III Acknowledgement
IV Abstract {English}
V Abstract {Arabic}
VI List of contents
X List of tables
XI List of Figures
XII List of abbreviations
Chapter one: Introduction
1-3 1.1 Introduction
3 1-2 Objectives
3 1-2-1 General Objective
3 1-2-2 Specific Objective
3 1-3 Over view of the study
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VII
Chapter two: Literature Review and Background Studies
4-5 2-1 Normal conception
5 2-2 Normal sonographic appearance of early pregnancy
5-6 2-2-1 Gestational sac
6-7 2-2-2 Double decidual sign (DDSS)
7-8 2-2-3 Yolk sac
9 2-2-4 The embryo
9-10 2-3 Indications for first trimester
10 2-4 First trimester protocol
10 2-5 Guidelines for examination
10 2-5-1 Assessment of viability/early pregnancy
10-12 2-5-2 First trimester measurements
12 2-6 Problems of early pregnancy
12 2-6-1 Miscarriage or Abortion
12-13 2-6-1-1 Missed abortion
13 2-6-1-2 Threatened abortion
13 2-6-1-3 Complete abortion
13 2-6-1-4 Incomplete abortion
13-14 2-6-2 Ectopic pregnancy
14 2-6-3 Trophoblastic disease
14 2-6-3-1 Hydatidiform mole
14 2-6-3-1-1 Complete hydatidiform
14 2-6-3-1-2 Incomplete or partial mole
14 2-6-3-2 Choriocarcinoma
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VIII
15 2-6-4 First trimester masses
15 2-6-4-1 Ovarian masses
15-16 2-6-4-2 Uterine masses
16-17 2-7 Previous studies
Chapter three: Methodology
18 3.1 Study design
18 3.2 Duration and area of the study
18 3.3 Study population
18 3.4 Sample size
18 3.5 Data collection and instrumentation
18 3.5.1 Patient preparation
18 3.5.2 Patients position
19 3.5.3 Data collection
19-20 3.5. 4 Equipment used
21 3.5.5 Technique
21 3.6 Methods of data analysis
21 3.7 Ethical consideration
Chapter four : The Results
22-29 Results
Chapter Five: Discussion, Conclusion and Recommendations
30-32 5.1 Discussion
33 5.2Conclusion
34 5.3 Recommendations
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IX
35-36 References
Appendices
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X
List of tables
Page Title Table No
22
descriptive statistic, minimum, means, maximum, and
STD for age, GS diameter cm, CRL cm and GA per
weeks
4.1
22 The number of GS 4.2
23 Sonographic feature of GS (the shape) 4-3
24 Sonographic feature of GS (the size) 4-4
25 The features of yolk sac 4-5
26 The presence of cardiac activity 4-6
27 The feature of early pregnancy associated finding and
abnormalities seen
4-7
28 Correlation between age, GS diameter, CRL diameter and
GA per weeks
4-8
29 Cross tabulation features of pregnancy and Yolk sac features 4-9
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XI
List of figures
Page Figure name Figure No
6 Intradecidual gestational sac 2-1
8 The gestational sac (GS), demonstrating the yolk sac (YS) 2-2
8 Normal yolk sac. A/ Nine weeks B/ Eight weeks 2-3
9 An embryo. Nine weeks 2 Days 2-4
12 Crown–rump length (CRL) measurement technique in a fetus
with CRL 60 mm (12+3 weeks)
2-5
19 Mindary DP 20 portable ultrasound machine 3-1
20 Mindary DP 10 portable ultrasound machine 3-2
20 LOGIQ 100 PRO portable ultrasound machine 3-3
22 Number of GS 4-1
23 Shape of GS 4-2
24 Size of GS 4-3
25 Features of yolk sac 4-4
26 Presence of cardiac activity 4-5
27
Feature of early pregnancy associated finding and
abnormalities seen
4-6
28 Scatterplot shows linear relationship between CRL
cm and GA weeks
4-7
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XII
List of Abbreviations
Abbreviation
Meaning
CLC Corpus luteal cyst
CRL Crown rump length
EDD Expected date of delivery
GA Gestational age
GS Gestational sac
HSG Human chorionic gonadotropin
IUP Intrauterine pregnancy
LMP last menstrual period
MSD Mean gestational sac diameter
NT Nuchal translucency
PID Pelvic inflammatory disease
TAS Trans abdominal scanning
TAV Trans vaginal scanning
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Chapter one
Introduction
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1
Chapter one
Introduction
1-1 Introduction:
The mean duration of a term pregnancy is 40 weeks based on menstrual dating,
with the first day of the last menstrual period (LMP) representing the clinical
reference point. If divided into three equal trimesters, each trimester of pregnancy
is technically 13.33 weeks or 13 weeks when rounded off to the nearest tenth.
Some authors may refer to the first trimester as 12 weeks or 14 weeks. (1)
The first trimester of pregnancy is characterized by amenorrhea, morning
sickness, enlargement of the breast, increased urinary frequency, disturbed
appetite, sleep disturbance, increase pigmentation in skin and breast such as
cluasma, primary and secondary areolae, also uterine enlargement, softening and
moisture and hyperplasia of the cervix and vagina with acidity of the vagina. The
primary laboratory test for the diagnosis of pregnancy is the serum detection and
measurement of human chorionic gonadotropin (HCG). (2)
A standard obstetric sonogram in the first trimester includes evaluation of the
presence, size, location, and number of gestational sac(s). The gestational sac is
examined for the presence of a yolk sac and embryo/fetus. When an embryo/fetus
is detected, it should be measured and cardiac activity should be detected. (3)
The uterus, cervix, adnexa, and cul-de-sac region should be examined. Each
ovary should be examined. The corpus luteum can vary greatly in appearance
during the first (and early second) trimesters of pregnancy. Sonographic
appearances include a solid, rounded target like lesion or a predominately cystic
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structure. The size of a corpus luteum is also variable, commonly measuring up to
3cm. (4)
The sonographic features of normal early intrauterine pregnancy (IUP) can be
divided into two categories: prior to visualization of a gestational sac, and after
visualization of a gestational sac. Gestational sac (GS) is a sonographic term (not
an embryonic one) used by sonographers to describe the sonographic appearance
of an early IUP. The GS represents the chorionic sac and its contents including the
yolk sac, embryo, and amnion. (2,5)
Prior to visualization of gestational sac we had seen decidual reaction which is
the thickening of the endometium. After approximately 4.5 weeks (LMP-based), a
tiny gestational sac (diameter 2 mm) becomes visible within the decidua
surrounded by the echogenic trophoblastic ring. The GS grows approximately 1
mm in diameter per day. It is usually visualized from (5wks +5days) of gestation
using the TAS. (1, 5)
The first structure in the gestational sac to be sonographically visualized is the
yolk sac. The yolk sac is seen as a relatively thick walled ring in the chorionic
cavity. The yolk sac is appearing by TAS by 7 weeks GA when the MSD is 20
mm. The yolk sac will be the earliest source of nutrients for the developing the
fetus. The yolk sac diameter increases steadily (0.1 mm per day) until 10 weeks
GA to a max of 5 to 6 mm. (1, 5)
The embryo is initially seen on the wall of the yolk sac at about 7-7.5 weeks
LMP with TVS.. This pole structure actually has some actually has some curve to
it with the embryo head at one end and what looks like a tail at the other end. (2, 5)
The first trimester fetal measurements are the mean gestational sac diameter
(MSD) and crown–rump length (CRL). The MSD has been described in the first
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trimester from 35 days from the LMP onwards. The MSD is the average of the
three orthogonal measurements of the fluid-filled space within the gestational sac.
In the presence of the embryo, the CRL provides a more accurate estimation of
gestational age because MSD values show greater variability of age prediction. (6)
1-2 Objectives:
1-2-1 General Objective:
To evaluate ultrasonographic criteria for first trimester of pregnancy by Trans
abdominal scanning.
1-2-2 Specific Objective:
1. To visualize and localize the gestational sac.
2. To assess the gestational sac.
3. To determine the gestational age.
4. To determine chronicity and amnionicity.
5. To correlate the expected date of delivery between the last menstrual period
and the gestational age.
6. To assess the adnexa.
1-3 Over view of the study:-
This study consists of five chapters. Chapter one contains introduction,
problem, objectives and over view of the study. Chapter two deal with literature
review which include anatomy, physiology, ultrasound appearance, investigations
which usually done and previous studies. Chapter three contains methodology of
the study. Chapter four contains results. Finally chapter five contains discussion
results, conclusion and recommendations followed by references and appendices
which include ultrasound image.
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Chapter Two
Literature Review and Background Studies
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Chapter Two
Literature Review and Background Studies
2-1 Normal conception:
A mature ovum is released through ovulation at around day 14 of the menstrual
cycle, as the graafian follicle ruptures and liberates the ovum into the peritoneal
cavity. The fimbria of the fallopian tube transports the ovum into the distal portion
of the tube, the infundibulum. Conception, also referred to as fertilization, is the
union of an ovum with a sperm. A sperm, which can live up to 72 hours, unites
with the egg in the distal one third of the fallopian tube, most likely in the ampulla.
Conception usually occurs within 24 hours after ovulation. The combination of the
sperm and ovum produces a structure referred to as the zygote. The zygote
undergoes rapid cellular division and eventually forms into a cluster of cells called
the morula. The morula continues to differentiate and form a structure referred to
as the blastocyst. (7)
The preimplantation blastocyst has three components an outer zone of yet un
differentiated cells called trophoblast an inner cell mass, and a fluid space or
antrum called the blastocyst cavity or blastocele. The inner cell mass is destined to
form the embryo whereas the trophoblast evolves into the chorion from which
forms the fetal component of the placenta. The trophoblast serves as a source of
nutrition for the rapidly developing blastocyst and also secretes hCG. Adequate
amounts of hCG is essential at this stage to maintain the activity of the corpus
luteum. The corpus luteum secretes estrogen and progesterone during the first
trimester of pregnancy which is essential for normal uterine and decidua
(endometrium) function. The end of the blastocyst with the inner cell mass attaches
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to the endometrium to begin the process of implantation about 6 days following
formation of the zygote (day 19 to 20 of the menstrual cycle). (8)
The trophoblast mysteriously starts to invade the endometrium with digestive
action. This invading mass of trophoblast is known as the syncytiotrophoblast. The
blastocyst embeds completely in the functional layer of the thickened endometrium
by about day 24 LMP. A new layer of endometrium forms over the burrowed
blastocyst which results in the blastocyst being completely surrounded by
endometrium. The covering endometrium is referred to as the decidua capsularis
whereas the deeper zone of endometrium which is the site of the future placenta is
called the decidua basalis. There is a thin, transparent membrane known as the
zona pellucida which surrounds the conceptus including the primitive
preimplantation blastocyst. On days 20 or 21 of the menstrual cycle, the blastocyst
begins to implant into the decidualized endometrium at the level of the uterine
fundus. By 28 days, complete implantation has occurred and all early connections
have been established between the gestation and the mother. The blastocyst makes
these links with the maternal endometrium via small projections of tissue called
chorionic villi. The implantation of the blastocyst within the endometrium may
cause some women to experience a small amount of vaginal bleeding. This is
referred to as implantation bleeding. The fourth week of gestation is an extremely
dynamic stage in the pregnancy. (7, 8)
2-2 Normal sonographic appearance of early pregnancy:
2-2-1 Gestational sac:
Implantation usually occurs in the fundal region of the uterus between day 20
and day 23. The earliest sonographic sign of an IUP was described by focal
echogenic zone of decidual thickening at the site of implantation at about 3 and
half to 4 weeks of gestational age. The first reliable gray-scale evidence of an IUP
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is visualization of the gestational sac within the thickened decidua this sign
referred to as the intradecidual sign and should be eccentrically. (9)
It appears as a small fluid collection surrounded completely by an echogenic
rim. The central fluid collection corresponds to the chorionic cavity and the
surrounding echoes are due to the chorionic decidual complex. Normalcy is
indicated with the following:
• The echogenicity of the rim should exceed the level of myometrial echoes
• The position of a normal gestational sac should be found in the fundus or in the
mid to upper uterus and is always abutting the endometrial canal. (10)
Figure 2-1: Intradecidual gestational sac (10)
Gestational sacs are usually round, but as they grow they frequently become
elliptic and they may get irregular in shape as a result of uterine myoma, uterine
contraction, bleeding surrounding the implantation site or distended maternal
bladder. (10)
2-2-2 Double decidual sign (DDSS):
The double decidual sign which describes the sonographic visualization of two
distinct layers of decidua associated with a true intrauterine pregnancy. The two
layers of decidua represent the decidua capsularis and decidua vera separated
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by a variable layer of fluid in the endometrial cavity (fluid may represent mucous,
blood, or a mixture of these two). Visualization of the DDSS is helpful to
distinguish between a true gestational sac and a pseudogestational sac which
represents fluid in the endometrial cavity in the absence of an intrauterine
pregnancy. This distinction between a true gestational sac and a pseudogestational
sac is important for the diagnosis of ectopic pregnancy since a pseudogestational
sac is present in about 15% of ectopic pregnancies. (8, 10)
2-2-3 Yolk sac:
The first structure in the gestational sac to be sonographically visualized is the
yolk sac. The yolk sac is seen as a relatively thick walled ring in the chorionic
cavity. The yolk sac is spherical in shape, with a well defined echogenic rim and
sonolucent center. The yolk sac can be seen in the chorionic cavity from about 5 to
12 weeks of gestation. It will be demonstrated by 7 weeks GA when the MSD is
20 mm. The yolk sac diameter increases steadily (0.1 mm per day) until 10 weeks
GA to a maximum of 5 to 6 mm . After 10 weeks LMP, the yolk sac is more
difficult to visualize as it is compressed by the expanding amnion and amniotic
cavity. After about 8 weeks LMP, the yolk stalk (sometimes labelled the vitelline
duct) may be seen in the gestational sac as a separate cord-like structure connecting
with the yolk sac. The thickness of the yolk stalk is similar to the thickness of the
wall of the yolk sac. The yolk stalk appears much thinner than the umbilical cord
and much thicker than the amnion. (8, 10)
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Figure 2-2: The gestational sac (GS), demonstrating the yolk sac (YS) which is the
first intragestational structure (11)
Figure 2-3: Normal yolk sac. A, Nine weeks. B, Eight weeks. (11)
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2-2-4 The embryo:
The period from conception to the end of the ninth postmenstrual week is known
as the embryonic period. The remaining 30 weeks of pregnancy comprise the fetal
period. The correct terminology for the conceptus is embryo and after 10 weeks is
fetus. (11)
Figure 2-4: An embryo. Nine weeks 2 Days. (12)
2-3 Indications for first trimester:
Indications for first-trimester sonography include but are not limited to:
a. Confirmation of the presence of an intrauterine pregnancy.
b. Evaluation of a suspected ectopic pregnancy.
c. Defining the cause of vaginal bleeding.
d. Evaluation of pelvic pain.
e. Estimation of gestational (menstrual) age.
f. Diagnosis or evaluation of multiple gestations.
g. Confirmation of cardiac activity.
h. Imaging as an adjunct to chorionic villus sampling, embryo transfer, and
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localization and removal of an intrauterine device.
i. Assessing for certain fetal anomalies, such as anencephaly, in high-risk
patients.
j. Evaluation of maternal pelvic masses and/or uterine abnormalities.
k. Measuring the nuchal translucency (NT) when part of a screening
program for fetal aneuploidy.
l. Evaluation of a suspected hydatidiform mole. (3, 12)
2-4 First trimester protocol:
Evaluate and Document the Following:
a. Location and gestational age of pregnancy.
b. Presence or absence of viability.
c. Fetal number.
d. Evaluation of the uterus and adnexal structures. (13)
2-5 Guidelines for examination:
2-5-1 Assessment of viability/early pregnancy:
Fetal viability, from an ultrasound perspective, is therefore the term used to
confirm the presence of an embryo with cardiac activity at the time of examination,
embryonic cardiac activity has been documented in normal pregnancies at as early
as 37 days of gestation29, which is when the embryonic heart tube starts to
beat30.Cardiac activity is often evident when the embryo measures 2 mm or
more31, but is not evident in around 5–10% of viable embryos measuring between
2 and 4 mm. (6,14 )
2-5-2 First trimester measurements:
Mean internal gestational sac diameter (MGSD) has evolved as the most
popular method of quantifying gestational sac size because it is a relatively simple
technique. MGSD is measured using the sum of three orthogonal dimensions of the
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fluid-sac wall interface divided by three. The chorionic wall of the sac is not
included in MGSD measurement. Gestational sac measurement is accurate to
within approximately 1 week of menstrual age. MGSD increases about 1 mm per
day in early gestation. The gestational has a sac diameter of about 5 mm at 5
weeks LMP (35 days). Gestational age in days can be calculated by adding 30 to
the MGSD in mm. e.g. MGSD is 22 mm. Add 30. Gestational age is 52 days or 7
weeks 3 days LMP. This technique is accurate up to a MGSD of 25 mm. The
MGSD becomes progressively less reliable for predicting gestational age as the
first trimester of pregnancy advances. Once the embryo can be seen, the
measurement of choice for estimation of gestational age becomes the CRL. (8, 14)
CRL measurements can be carried out transabdominally or transvaginally. A
midline sagittal section of the whole embryo or fetus should be obtained, ideally
with the embryo or fetus oriented horizontally on the screen. An image should be
magnified sufficiently to fill most of the width of the ultrasound screen, so that the
measurement line between crown and rump is at about 90◦ to the ultrasound beam.
Care must be taken to avoid inclusion of structures such as the yolk sac. In order
to ensure that the fetus is not flexed, amniotic fluid should be visible between the
fetal chin and chest (Figure 1). However, this may be difficult to achieve at earlier
gestations (around 6–9 weeks) when the embryo is typically hyperflexed. (6, 14)
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Figure 2-5: Crown–rump length (CRL) measurement technique in a fetus with
CRL 60 mm (12+3 weeks). (14)
2-6 Problems of early pregnancy:
2-6-1 Miscarriage or Abortion:
Refer to the termination of pregnancy before the fetus is viable.
2-6-1-1 Missed abortion:
Is fetal demise for a period of more than 8 weeks without the onset of labor or
the expulsion of products of conception. The diagnosis is usually based on the
absence of cardiac activity within the fetal pole. The terms blighted ovum and an
embryonic pregnancy have been used to describe a gestational sac without a
detectable fetal pole. The Royal College of Obstetricians and Gynecologists
(RCOG) have proposed a set of guidelines to establish embryonic death by
ultrasound. According to these guidelines, the absence of cardiac activity in an
embryo of crown–rump length (CRL) > 6 mm, or the absence of a yolk sac or
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embryo in a gestation sac of mean diameter > 20 mm, enables conclusive diagnosis
of a missed miscarriage. (11. 14)
2-6-1-2 Threatened abortion:
Is usually diagnosed in women with a history of vaginal bleeding and in whom
a live embryo can be visualized on the scan. Threatened abortion is the most
common clinical indication for ultrasound evaluation of an early pregnancy. (11, 15)
2-6-1-3 Complete abortion:
Refers to complete passage of the products of conception associated with
spontaneous or inducted abortion. Uterine bleeding diminishes gradually and
ceases in about 10 days. During that time, the decidua is shed and the uterus begins
to return to normal size. The pregnancy test becomes negative in relatively rapid
time. (8, 15)
Complete miscarriage is usually diagnosed when the endometrium is very thin
and regular. The ultrasound appearances are therefore comparable to those of the
non-pregnant uterus in the early proliferative phase. (11, 15)
2-6-1-4 Incomplete abortion:
Refers to retention of products of conception (referred to as retained products),
typically residual trophoblastic tissue (placenta). In most cases, the embryo or fetus
is passed and there is retention of chorio decidual tissues. Retained products appear
on ultrasound as echogenic tissues in the uterus without a recognizable gestational
sac or embryonic structures. In most cases, the echogenic tissue is irregular. (8, 15)
2-6-2 Ectopic pregnancy:
An ectopic pregnancy is defined as implantation of the blastocyst anywhere
outside of the uterine cavity. Up to 97% of ectopic pregnancies occur in the
fallopian tube with the majority of these being located in the ampulla of the tube,
which is the normal site of fertilization and zygote formation. Ectopic pregnancies
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may also occur in the cervix, ovary, and abdomen (peritoneal cavity). Unless
otherwise indicated, reference to ectopic pregnancy usually implies tubal
pregnancy. Heterotopic pregnancy refers to coexisting ectopic and intrauterine
pregnancy. (8, 15)
2-6-3 Trophoblastic disease:
2-6-3-1 Hydatidiform mole:
2-6-3-1-1 Complete hydatidiform:
Complete hydatidiform moles are characterized by generalized swelling of the
villous tissue and diffuse trophoblastic hyperplasia in the absence of embryonic or
fetal tissue. The ultrasound appearance used to be described as a snowstorm. This
description was homogenous distribution of cystic areas within the uterus to be
identified. Other common findings were one or several areas of fluid collections,
with irregular contours and thin walls. Serum hCG will be high in these women. (11,
15)
2-6-3-1-2 Incomplete or partial mole:
Is typically characterized by marked focal swelling of the villi with focal
trophoblastic hyperplasia, presence of normal villi, presence of fetus, cord, and
amniotic membrane, abnormal karyotype, the chromosomes are derived from a
duplicated paternal set and a haploid ovum. The classic presentation described is
late first trimester or early second trimester bleeding, large-for-dates uterus, and
abnormally elevated serum $-hCG levels. (8, 15)
2-6-3-2 Choriocarcinoma:
Choriocarcinomas are highly malignant and the woman usually presents with
multiple metastases. The primary tumor is often very small and an extensive search
of the placenta is frequently required to find the lesion. (11.15)
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2-6-4 First trimester masses:
2-6-4-1 Ovarian masses:
The most common mass seen in the first trimester of pregnancy is the corpus
luteum cyst. The corpus luteum cyst secretes progesterone to support the
pregnancy until the placenta can take over its hormonal function. It forms in the
secretory phase of the menstrual cycle and increases in size if a pregnancy occurs.
Adnexal cystic masses less than 5 cm in diameter in the first trimester are usually
follicular or corpus luteum cysts and almost always resolve spontaneously. In an
A symptomatic patient with a simple or benign appearing adnexal cyst measuring
less than 5 cm, no further follow up of the cyst is necessary. Other cystic masses
may present in the first trimester of pregnancy because of displacement by the
enlarged uterus. Torsion, rupture, and dystocia have all been described as
complications of ovarian cystic masses associated with pregnancy. (9, 15)
Although the risk of malignancy in women of reproductive age is low, any
adnexal mass seen on routine sonography must be evaluated fully to exclude
malignancy. The most common persistent ovarian masses seen in pregnancy are
dermoid cysts, benign cystadenomas and endometriomas. (11, 15)
2-6-4-2 Uterine masses:
Uterine fibroids are a common pelvic mass often identified during pregnancy
and often associated with localized pain and tenderness. Most fibroids do not
change in size during pregnancy, although some may enlarge rapidly as a result of
estrogenic stimulation. Infarction and necrosis may occur because of rapid growth.
These patients often experience pain. Sonographically, uterine fibroids appear as
solid, often hypoechoic uterine masses. They may have areas of calcification and
infrequently have cystic, avascular areas related to necrosis. Fibroids may be
differentiated from focal myometrial contractions by the transient nature of
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myometrial contractions. A repeat examination 20 to 30 minutes after the initial
examination reveals disappearance of a focal myometrial contraction, whereas a
fibroid will still be present. Fibroids also may distort the uterine contour (serosal
surface), whereas focal myometrial contractions usually bulge into the amniotic
cavity. (9, 15)
2-7 Previous studies:
Michiel C.Van den Hof and Nestor N. Demianczuk in October 2003 made
study about the use of first trimester ultrasound. They found the first trimester
ultrasound is recommended: for suspected multiple gestation to allow for reliable
determination of chorionicity or amnionicity, for suspected ectopic pregnancy,
molar pregnancy and suspected pelvic masses, for early assessment of anatomic
development in situations of increased risk for major fetal congenital
malformations, for assessment of threatened abortion to document fetal viability
or for incomplete abortion to identify retained products of conception, to date when
last menstrual period date is uncertain, and recommend prior to pregnancy
termination. (16)
Mohamed Nur Osman Mohamed Adam in 2006, in Sudan – Pakistan, made
study about ultrasonographic criteria for fetal screening in first trimester, the study
showed that in first trimester of pregnancy, ultrasound should be performed
routinely not only to asses gestational age, also to evaluate the conception, which
helps in management of pregnancy and improve the outcome. A great minority of
pregnancy women were uncertain of their LMP, in this cases ultrasound is a single
most important modality to estimate the gestational age. In case of absence of
cardiac activity, rescanning should be performed and in confirmed cases of dead
embryo, uterus should be evacuated. In case of ectopic pregnancy, determination
of pregnancy should be carried out, to save the life of mother. In case of sub
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17
chorionic hematoma and abnormal size and shape of yolk sac, follow up should be
closely done. (17)
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18
Chapter Three
Materials and methods
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18
Chapter three
Materials and methods
3.1 Study design:
This was a descriptive cross sectional study deal with ultrasonograpic criteria
for first trimester by trans abdominal scanning where the data were randomly
collected.
3.2 Duration and area of the study:
The study was conducted from June 2017 to October 2017 in ultrasound
departments the different hospitals and clinics in Khartoum state.
3.3 Study population:
Pregnant women in the first trimester at Khartoum state.
3.4 Sample size:
The sample of this study is hundred pregnant women in the first trimester
presented to ultrasound departments
3.5 Data collection and instrumentation:
3.5.1 Patient preparation:
The woman attending for a transabdominal gynecological or early pregnancy
examination should be asked to drink two pints of water to fill her bladder. When
the bladder is overfull and the woman is in obvious discomfort, partial bladder
emptying is the best solution. Sufficient urine will usually be retained to make a
successful examination possible.
3.5.2 Patients position:
Transabdominal scans are performed with the woman supine or with her head
slightly raised.
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19
3.5.3 Data collection:
The data was collected using data collecting sheet design especially for the
study which includes the following variables: ultrasound findings visibility of
gestational sac, location of gestational sac, number of gestational sac, size of
gestational sac, shape of gestational sac, the yolk sac, the cardiac activity, the
measurements by MGD or CRL, also features of early pregnancy failure, and
others us finding such as subchorionic hematoma, uterine fibroid, corpus luteal
cyst, dermoid cyst and PID), age and clinical features.
3.5. 4 Equipment used:
1. Ultrasound machines with curvilinear array 3.5- 5 MHz, and coupling gel was
used for scanning.
2. The Sonographic examination was performed with a high resolution real time
scanners using ( Mindary portable ultrasound machines and LOGIQ 100 PRO
machine).
Figure (3.1): Mindary DP 20 portable ultrasound machine (19)
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20
Figure (3.2): Mindary DP 10 portable ultrasound machine (19)
Figure (3.3) LOGIQ 100 PRO portable ultrasound machine (19)
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3.5.5 Technique:
First trimester sonograms may require the use of a typically 3- to 5-MHz TA
transducer will allow sufficient penetration in most pregnant patients, while
providing sufficient resolution. These frequency ranges will vary among
ultrasound equipment. Obese patients may require the use of lower frequency
transducers for additional penetration. All transducers and transducer cords should
be cleaned after performing an obstetric sonogram to prevent the spread of disease.
(7, 19)
To visualize the uterus and ovaries transabdominal sonographic imaging of
lesser pelvis requires a distended urinary bladder as acoustic window. The patients
in supine position, and place the probe in suprapubic transverse and sagittal. First
we scan the uterus, we find the gestational sac and take the MGS to know the
gestational age and the date of delivery when no embryonic part seen, and when
the embryo is appearance check the cardiac activity and measure the CRL to know
the gestational age and the date of delivery. Then scan the adnexa to show if there
is any finding. (18, 19)
3.6 Methods of data analysis:
The data collected was designed to meet the purpose of the study, then the
statistical analysis of data was being carried out by using software SPSS version 20
for windows (statistical Package For Social Sciences). Statistical significance was
be determined using chi- square test.
3.7 Ethical consideration:
No identification or individual details will published, the objectives of the study
was explain to all individuals participating in this study, no information or patient
details will be disclosed or used for other reasons than the study.
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Chapter Four
Results
Page 39
22
Chapter four
Results
The results showed that in all pregnancy women the GS was visible and there
locations determined.
Table (4.1) shows descriptive statistic, minimum, means,
maximum, and STD for age, GS diameter cm, CRL cm and
GA per
weeks
Table (4.2) shows the number of GS
Figure (4.1) number of GS
99
1 0
20
40
60
80
100
120
Single Twins
Variable N Minimum Maximum Mean Std. Deviation
Age of mothers 100 15 40 27.05 5.895
GS diameter cm 20 1 5 1.75 .961
CRL cm 80 1 7 3.19 1.779
GA weeks 100 4.14( 4wks1d) 13.00 9.0286 2.47069
Valid N (listwise) 0
Frequenc
y
Percent Valid
Percent
Cumulative
Percent
Single 99 99.0 99.0 99.0
Twins 1 1.0 1.0 100.0
Total 100 100.0 100.0
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Table (4.3) sonographic feature of GS (the shape)
Shape Frequency Percent Valid Percent Cumulative
Percent
abnormal 5 5.0 5.0 5.0
Normal 95 95.0 95.0 100.0
Total 100 100.0 100.0
Figure (4.2) shape of GS
95
5 0
10
20
30
40
50
60
70
80
90
100
Normal abnormal
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Table (4.4) sonographic feature of GS (the size)
Shape Frequency Percent Valid Percent Cumulative
Percent
An embryonic
pregnancy
3 3.0 3.0 3.0
Normal 97 97.0 97.0 100.0
Total 100 100.0 100.0
Figure (4.3) size of GS
97
3 0
20
40
60
80
100
120
Normal An embryonic
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Table (4.5) shows the features of yolk sac
Figure (4.4) features of yolk sac
87
10 3 0
10
20
30
40
50
60
70
80
90
100
Intact Absence( so early ) An embryonic
YS Frequency Percent Valid Percent Cumulative
Percent
Absence( so early ) 10 10.0 10.0 10.0
An embryonic 3 3.0 3.0 13.0
Intact 87 87.0 87.0 100.0
Total 100 100.0 100.0
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Table (4.6) shows the presence of cardiac activity
Frequency Percent Valid Percent Cumulative
Percent
Not Present 5 5.0 5.0 5.0
Not Present (early) 17 17.0 17.0 22.0
Present 78 78.0 78.0 100.0
Total 100 100.0 100.0
Figure (4.5) presence of cardiac activity
78
17
5 0
10
20
30
40
50
60
70
80
90
Present Not Present (early) Not Present
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Table (4.7) shows the feature of early pregnancy associated finding
and abnormalities seen
Figure (4.6) feature of early pregnancy associated finding and
abnormalities seen
95
3 2 0
10
20
30
40
50
60
70
80
90
100
Normal pregnancy An embryonic pregnancy Missed abortion
Frequency Percent Valid Percent Cumulative
Percent
Normal pregnancy 95 95.0 95.0 95.0
Missed abortion 2 2.0 2.0 97.0
An embryonic pregnancy 3 3.0 3.0 100.0
Total 100 100.0 100.0
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Figure (4.7) scatterplot shows linear relationship between CRL cm
and GA weeks
Table (4.8) correlation between mother age, GS diameter, CRL
diameter and GA per weeks
Age GS diameter CRL cm GA \weeks
Mother age Pearson Correlation 1 .080 .027 -.015
Sig. (2-tailed) .737 .810 .882
N 100 20 80 100
GS diameter Pearson Correlation .080 1 .a .955
**
Sig. (2-tailed) .737 . .000
N 20 20 0 20
CRL
diameter
Pearson Correlation .027 .a 1 .985
**
Sig. (2-tailed) .810 . .000
N 80 0 80 80
Gestational
age per
weeks
Pearson Correlation -.015 .955** .985
** 1
Sig. (2-tailed) .882 .000 .000
N 100 20 80 100
a. Cannot be computed because at least one of the variables is constant.
**. Correlation is significant at the 0.01 level (2-tailed).
y = 1.0438x + 6.5389 R² = 0.9697
0
2
4
6
8
10
12
14
16
0 2 4 6 8
GA
we
eks
CRL cm
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Table (4.9) cross tabulation features of pregnancy and presence of
cardiac activity
The variance between US dating and LMP dating was 4.045 and the
STD deviation ± 2.01 days
Cardiac activity Features of early pregnancy Total
normal Fibroid missed anembryonic
pregnancy
CLC PID
Not Present 0 0 2 3 0 0 5
Not Present (early) 15 0 0 0 2 0 17
Present 76 1 0 0 0 1 78
Total 91 1 2 3 2 1 100
P value =0.000
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Chapter Five
Discussion, Conclusion and recommendations
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30
Chapter Five
Discussion, Conclusion and recommendations
5.1 Discussion:
The study done in 100 pregnant women in her first trimester of pregnancy with
age between (15-40) years and mean age 27.07±5.89 years, concerning GS
diameter which should be measure in cm in 20women in study the mean sac
diameter was 1.75 ± .961 cm, the minimum 1 cm and maximum 5cm, the mean
gestational age was 9 weeks ± 2.4days.
All of them had intrauterine GS agree with Mohamed Nur Osman Mohamed
Adam, Sudan – Pakistan in 2006 in all patients all the gestational sac was visible.
99% of the GS were single, disagree with Mohamed Nur Osman Mohamed
Adam, Sudan – Pakistan in 2006 which were 97% singleton pregnancy and 3%
twins pregnancy.
Concerning the shape of GS 95%were normal regular outline fundal and
eccentric, while 5% were abnormal in shape(3 an embryonic 3% and 2 missed
abortion 2%), disagree with Mohamed Nur Osman Mohamed Adam, Sudan –
Pakistan in 2006 which were 94% normal gestational sac shape and 6% abnormal
gestational sac shape.
97% of gestational sac had normal size while 3% abnormal in size (3% an
embryonic pregnancy which were gestational sac diameter more than 2.5 mm
without fetal pole), disagree with Mohamed Nur Osman Mohamed Adam, Sudan –
Pakistan in 2006 which were 93% normal gestational sac size and 7% abnormal
gestational sac size.
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Study found that 87% of cases were intact yolk sac while in 13% not seen (10
early pregnancy 10% and 3 an embryonic pregnancy 3%). 78% had normal cardic
activity, 17% intact fetal but no cardic activity because there were in early weeks(
less than 5 weeks) and 5% no cardic activity (3% an embryonic pregnancy and 2%
missed abortion), disagree with Mohamed Nur Osman Mohamed Adam, Sudan –
Pakistan in 2006 which were 97% presence of cardic activity and 3% absence of
cardic activity.
The study found that the incidence of normal pregnancy in the first trimester
was 95%(91% normal pregnancy without associated finding, 4% normal
pregnancy with associated finding 2% CLC, 1% PID and 1%fibroid) and 5%
pregnancy were abnormal (3% an embryonic and 2% missed abortion), disagree
with Mohamed Nur Osman Mohamed Adam, Sudan – Pakistan in 2006 which
were 94% normal pregnancy and 6% abnormal pregnancy.
This study showed significant linear relationship between CRL in cm and GA in
weeks (R2
=0.9697), the CRL measurement increased 1.0438 cm per week. Also
this study showed significant correlation between GA, GS and CRL
respectively(R=0.955, 0.985) p value=0.000. Also there was significant correlation
between cardic activity and feature of pregnancy(as in an embryonic pregnancy,
missed abortion and very early pregnancy ) there were no cardic activity. P
value=0.000.
My present study in comparing with the study conducted in 2003, Michiel
C.Van den Hof and Nestor N. Demianczuk , both of them they found the first
trimester ultrasound is recommended: for suspected multiple gestation to allow for
reliable determination of chorionicity or amnionicity, for suspected ectopic
pregnancy, molar pregnancy and suspected pelvic masses, for assessment of
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32
threatened abortion to document fetal viability or for incomplete abortion to
identify retained products of conception, to date when last menstrual period date is
uncertain, and recommend prior to pregnancy termination.
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5.2 Conclusion:
The ultrasound in the first trimester of pregnancy is very important. Sonologists
should follow specific protocols and guide lines as recommended by national and
international organizations that have an interest in obstetric ultrasound procedures.
This study showed the ultrasound imaging has an important role in
visualization, localization the gestational sac, assessing fetal viability by detecting
the cardic activity and assess the gestational sac features (size and shape).
This study found ultrasound in the first trimester is an accurate method for
assessment of gestational age by using GS and CRL. It showed significant
correlation between GA, GS and CRL respectively(R=0.955, 0.985) p
value=0.000. The variance between US dating and LMP dating was 4.045 and the
STD deviation ± 2.01 days
In this study singleton pregnancy was more than multiple pregnancy. Finally
this study showed that the ultrasound in the first trimester is an important to detect
the uterine and ovarian masses (fibroid, corpus luteal cyst and PID).
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5.3 Recommendations:
All women whenever miss their cycle, they should do investigations to confirm
the diagnosis of pregnancy, and ultrasound is safe, noninvasive, cheap and accurate
imaging modalities that helps in diagnosis of pregnancy and follow up of
conceptions.
All pregnant women should do ultrasound scan in every pregnancy, and should
be advised to do regular scanning to improve pregnancy outcome.
Ultrasound should be available in all hospitals and centers to facilitate the
diagnosis of pregnancy and follow up.
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References
1.Peter Callen. Ultrasonography in Obstetrics and Gynecology. 4th
ed. W.B.
Saunders Co; Philadelphia: 2000. p.128,149.
2. Peter Callen. Ultrasonography in Obstetrics and Gynecology. 5th
ed. Saunders;
Philadelphia: 2007. P. 95.
3. http://www.aium.org/resources/guigelines/obstetric.accessed on 10 June 2017.
At 8:45 pm.
4. http://www2.asum.com.au/wp-content/uploads/2015/09/D 11-policy.acssessed
on 8 June 2017. At 10:00 am.
5. http://www.american pregnancy.org. accessed on 15 October 2017. At 1:55 pm.
6. http://www.isuog.org/nr/rdonlyres/9225e408-c904-4a7f-84ae-812e456f bddd /0/isuog 1
sttguidelines2013.accessed on 10 June 2017. At 9:45 pm.
7. Steven M. Penny. Examination Review for Ultrasound Abdomen& Obstetrics
and Gynecology. First edition. Lippincott William Wilkins; Philadelphia: 2011. P
(293).
8.Denis Gartton et al. The Berwin Instituate of Diagnostic Medical Ultrasound
Obstetrical Ultrasound; Canda: 2005. P (39-89).
9. Carol M.Rumak, Stephanie R.Wilson, J.William Charboneau, Deborach Levine.
Diagnostic Ultrasound. 4th
ed. Elservier Mosby; Philadelphia: 2011. P (1078-
1114).
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10. Asim Kurjak, Frank Achervenak. Donald School Text Book for Ultasound in
Obstetrics and Gynecology. First edition. Parthenon Publishing Group; United
Kingdom: 2004. P (163-166).
11. Trish Chudleigh, Basky Thilaganathan. Obstetrics Ultrasound How&Why and
When. 3rd
edition. Elsevier Churchill Livingstom; Umited Kingdom: 2004. P (38-
76).
12. http://wn.com. accessed on 10 October 2017. At 1:55 pm.
13. Susanna Ovel. Sonography Exam Review: Physics, Abdomen, Obstetrics and
Gynecology. Second edition. Elservier Mosby; Philadelphia: 2014. P (357).
14. http://www.aaep.org. accessed on 14 June 2017. At 9:55 am.
15. http://www.bpas.org. accessed on 3 October 2017. At 9:55 pm.
16.http://www.sogc.org/wp-content/uploads/2013/01/135E-CPG-october2003.
accessed on 10 June 2017. At 9:55 pm.
17. Mohamed Nur Osman Mohamed Adam. Ultrasonographic criteria for fetal
screening in first trimester partial fulfillment thesis; Khartoum. 2005-2006.
18. Matthias Hofer, Tatana Reine. Ultrasound Teashing Manual The Basics of
Performing and Interpreting Ultrasound Scan. First edition. Georg Thieme;
Germany: 1999. P (58).
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The National Ribat University
College of Graduate Studies and Scientific Research
Ultrasonographic Criteria for First Trimester by Transabdominal
Scanning
Data sheet collection
Patient data:
Age:
LMP: / / EDD: / /
Ultrasound finding:
Visible of gestational sac: yes ( ) No ( )
Location of gestational sac: intrauterine ( ) extra uterine (ectopic pregnancy) ( )
Number of gestational sac: Single ( ) Twin ( ) More ( )
Normal gestational sac shape: Yes ( ) No ( )
Normal gestational sac size: Yes ( ) No ( )
Normal yolk sac: Yes ( ) No early ( )
Cardiac activity: present ( ) not present ( )
Specify:
GS: GA: EDD: / /
CRL: GA: EDD: / /
Early pregnancy failure:
Missed miscarriage: Yes ( ) No ( )
Incomplete miscarriage: Yes ( ) No ( )
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Blighted ovum: Yes ( ) No ( )
Molar pregnancy: Yes ( ) No ( )
Others US finding:
Sub chorionic hematoma: Yes ( ) No ( )
Uterine fibroid: Yes ( ) No ( )
Corpus luteal cyst: Yes ( ) No ( )
Dermoid cyst: Yes ( ) No ( )
PID: Yes ( ) No ( )
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Image (1) Longitudinal US image of gravid uterus, CRL: 5.4cm and GA: 12
weeks.
Image (2) Transverse US image of gravid uterus (missed miscarriage), CRL:
1.34cm and GA: 7 weeks and 4 days.GS:3.9 cm and GA: 8 weeks and 6 days
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Image (3) Longitudinal US image of gravid uterus, GS: 1.2cm and GA: 5
weeks.
Image (4) Transverse US image of gravid uterus, CRL: 5.22cm and GA: 11
weeks and 6 days.
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Image (5) Transverse US image of gravid uterus, GS: 1.72cm and GA: 5weeks
and 5 days, with corpus luteal cyst.
Image (6) Longitudinal US image of gravid uterus, CRL: 2.46cm and GA:
9weeks and 2 days.
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Image (7) Transverse US image of gravid uterus, CRL: 2.53cm and GA:
9weeks and 2 days.
Image (8) Longitudinal US image of gravid uterus, CRL: 5.49 cm and GA: 12
weeks and 3 days.
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Image (9) Transverse US image of gravid uterus, CRL: .87cm and GA:
6weeks and 6 days.
Image (10) Longitudinal US image of gravid uterus, CRL: 1.7cm and GA:
8weeks and 3 days.
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Image (11) Transverse US image of gravid uterus, CRL: 4.74cm and GA:
11weeks and 3 days.
Image (12) Longitudinal US image of gravid uterus, CRL: 4.42cm and GA:
11weeks and 2 days.
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Image (13) Longitudinal US image of gravid uterus, CRL: 5.69cm and GA:
12weeks and 2 days.
Image (14) Transverse US image of gravid uterus, CRL: 6.20cm and GA:
12weeks and 4 days.
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Image (15) Longitudinal US image of gravid uterus, CRL: 1.2cm and GA:
7weeks and 5days, with corpus luteal cyst.
Image (16) Transverse US image of gravid uterus, CRL: 4.7cm and GA: 11
weeks and 4 days.
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Image (17) Longitudinal US image of gravid uterus, GS: 1.2cm and GA:
4weeks and 3days.
Image (18) Longitudinal US image of gravid uterus with twins GS, CRL:
1.3cm and GA: 7 weeks and 4 days.
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Image (19) Transverse US image of gravid uterus (blighted ovum), GS:
4.99cm and GA: 10weeks and 2days.
Image (20) Longitudinal US image of gravid uterus, CRL: 3.08cm and GA:
10weeks.
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Image (21) Longitudinal US image of gravid uterus, CRL: 2.01cm and GA:
8weeks and 4 days.
Image (22) Longitudinal US image of gravid uterus, CRL: 1.08cm and GA:
7weeks and 2 days.
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Image (23) Longitudinal US image of gravid uterus, CRL: 3.1cm and GA: 10
weeks and 2 days.
Image (24) Longitudinal US image of gravid uterus, CRL: 2.3 cm and GA:
9weeks and 2 days.
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Image (25) Transverse US image of gravid uterus, CRL: 3.91cm and GA:
10weeks and 6 days.
Image (26) Transverse US image of gravid uterus, CRL: .78 cm and GA: 6
weeks and 5 days.
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Image (27) Transverse US image of gravid uterus, CRL: 1.45 cm and GA: 7
weeks and 5 days.
Image (28) Transverse US image of gravid uterus, CRL: 3.82 cm and GA: 10
weeks and 5 days.
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Image (29) Transverse US image of gravid uterus, CRL: 4.06 cm and GA: 11
weeks.
Image (30) Transverse US image of gravid uterus, CRL: 4.43 cm and GA: 11
weeks and 2 days.