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AlfredAbuhamad,MD.EasternVirginiaMedicalSchool

FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities:

WhatYouNeedtoKnow

MyPrediction

•  Thefirsttrimesterultrasoundwillplayamajorroleinclinicalmanagementofpregnancyinthenext3-5years

•  (upto136/7weeks)

CurrentRoleofFirstTrimesterUltrasound

• Accuratepregnancydating• Earlydiagnosisofmultiples• Pregnancyriskassessment• Evaluationoftheadnexae

EstimationofGestationalAge

• Ifapatientreportsnomenstrualdates,ultrasoundinthefirstorsecondtrimestershoulddatethepregnancyandestablishtheEDD• Ultrasounddatingofpregnancyismostaccurateinthefirsttrimester

•  Focalzoneatappropriatelevel•  Imagemagnified•  Embryo/fetusimagedinneutralposition•  Maximallengthofembryo/fetusshown•  Maximallengthofembryo/fetusmeasuredinastraightlinefromcranialtocaudal

CriteriaforCRLMeasurement

UltrasoundObstetGynecol2014;44:649–654TaskForceforCurriculum&CompetencyAssessmentinUltrasoundTraining-2017

EstimationofGestationalAge•  CRLaremostaccurateinfetalneutralpositionandbetween11+0and13+6weeksofgestation•  UsethemeanofthreediscreteCRLmeasurements.•  AssignEDDbyCRLif>5daysdiscrepancyatlessthan9weeksofgestation•  AssignEDDbyCRLif>7daysdiscrepancyat9-136/7weeksofgestation

BJOG2014;121:556–565.

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BJOG2008;115:1273–1278

SmallCRL

BiometryinFirstTrimester

MultiplePregnancy

AmJObstetGynecol.1994;170(3):824–829.

Chorionicity:•  100%in1stTrimester•  90%in2ndand3rdTrimesters

PregnancyRiskAssessment

HemorrhagicCyst

CysticTeratoma

PedunculatedLeiomyoma

Endometrioma

EvaluationoftheAdnexae EvolvingRoleofFirstTrimesterUltrasound

• Imaginginobesepregnantwomen• Screeningforfetalmalformations

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Lettyetal.JUltrasoundMed2017–onlineaccess

EvolvingRoleofFirstTrimesterUltrasound

• Screeningforfetalmalformations– ImpactofNIPTscreening– Impactoflimitingaccesstopregnancytermination

UltrasoundObstetGynecol2013;41:102–113

FirstTrimesterUltrasound

FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017

FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017

FirstTrimesterUltrasound

Syngelaki,PrenatDiagn.2011;31:90–102

FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017

FirstTrimesterUltrasound

Syngelaki,PrenatDiagn.2011;31:90–102

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1stTrimesterAnomaliesDetectionRateLow-Risk,n=97,976

32.35%(95%C.I.22.45-43.12)Karimetal–UOG2016E-Pub

1stTrimesterAnomaliesDetectionRate

61.18%(95%C.I.37.71-82.19)Karimetal–UOG2016E-Pub

High-Risk,n=2,841

1stTrimesterAnomaliesDetectionRate

• Useofananatomicalprotocolduringfirsttrimesteranomalyscreening(P

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MidsagittalPlane

NT

NB

MidBrain

MaxillaMandible

Cord

Bladder

NuchalTranslucency NasalBone

•  Abnormalif:•  Absent•  Short•  Hypoplastic

AneuploidyScreening

FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017

NasalBone–Trisomy21

FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017

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Maxilla

Face - Basic Face - Basic Face - Basic

Face - Basic

MaxillaryGap Mandible

Face - BasicFace - Basic

MidBrain

T

CPITBS

CMOB

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PosteriorFossa–AxialView13weeks

OccipitalBone

FourthVentricle(IT)

ChoroidPlexus

CisternaMagna

Face - Basic

Face - Basic

Normal

SpinaBifida DandyWalker

SpinaBifida DandyWalker

OtherCNSAnomalies

Ventriculomegaly

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Ventriculomegaly NormalVentricles

Ventriculomegaly•  ThinningofCP•  CPfillinglessthan½ofLV•  CPbordersdonottouchlateralventricularwall•  SeparationofCPfromsuperiorbordersofLV•  Enlarged3rdVentricle

Ventriculomegaly

Anencephaly/Exencephaly AxialPlanes

Normal Holoprosencephaly

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CordInsertion

Cord

CordInsertion

PhysiologicMidgutHerniation•  Noteduntil12weeks•  AlmostneverseenatCRL>45mm•  Measures<7mminaxialplane

JUM1993;12:251–UOG1995;6:240

Omphalocele Omphalocele

OmphaloceleOmphalocele

Pentalogy

Extroph

y

(OEIS)

Omphalocele(Pentalogy)

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GastroschisisSmoothBordersOmphalocele

IrregularBordersGastroschisis

Bladder

Bladder

FetalBladder

• Seenin88%at12weeks• Seenin92–100%at13weeks• RenalsourceofAFis>16weeks

UltrasoundObstetGynecol2003;21:338–341UltrasoundObstetGynecol1996;7:95–100

59

NormalBladderLength<7mm

12weeks

Megacystis(7-15mm)•  Chromosomalanomaliesin24%•  Withnormalchromosomes:•  Resolutionin90%•  Renalanomaliesin10%

UltrasoundObstetGynecol2003;21:338

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Megacystis(>15mm)•  Chromosomalanomaliesin11%•  Withnormalchromosomes:•  Renalanomaliesin100%

UltrasoundObstetGynecol2003;21:338

FetalGender

• Inaccuratebefore12weeks• Accuracyincreaseswithadvancinggestationalage• Greaterthan95%at>13weeks

ObstetGynecolSurv2009;64:50–57

63

Female

Male

DuctusVenosus

3D-Extremities

AneuploidyScreening

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Trisomy21

FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017

Trisomy18

Trisomy13 MonosomyX

FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017

MonosomyX Triploidy

FirstTrimesterUltrasoundDiagnosisofFetalAbnormalities.Abuhamad-Chaoui.September2017

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Triploidy MidsagittalPlaneinFirstTrimester• Goodscreeningmodalityforfetalabnormalities•  RatherthandoingawaywithNT,weneedtoenhancetrainingandfocusondetectionoffetalabnormalities•  Theroleoffirsttrimesterultrasoundwillexpandoverthenextyears