超音波教學 Schedules Section 1 First Trimester Section 2 Fetal Brain Develop (2) Section 3 Fetal Spine Section 4 Face and Neck Section 5 Chest Section 6 Fetal Heart (2) Section 7 Abdominal Wall & GI Section 8 GU system Section 9 Muscular System & U.C. Section 10 Placenta

超音波教學 Section I Speaker 陳志堯醫師 Director 趙灌中主任 洪正修主任 August 25, 2006

Normal Early Pregnancy Topic 1 Normal Early Pregnancy

Day 22

Day 23

Day 26

Day 13 Day 21 Day 28

AL, allantois; CF, chorion frondosum; CL, chorion laeve; CS, connecting stalk; DV, decidua vera (along endometrium; E, embryo; ECS, extrachorionic space (endometrial cavity); EEC, extraembryonic coelom; EEM, extraembryonic mesoderm; OM, omphalomesenteric duct; PG, primary gut, Y1 primary yolk sac; Y2, secondary yolk sac.

Blastocyst implantation site in spontaneous pregnancies 89.1% had E-GSs detected in the upper region, which was found to be the most frequent region. Minami S, J Nippon Med Sch. 2003 Jun;70(3):250-4.

Anembryonic Pregnancy Mean sac diameter > 10mm with no Y.S. Mean sac diameter > 18mm with no Emb. Empty amnion. Poor color signal around sac.

Potential Pitfalls

Potential Pitfalls Mistaking yolk sac for embryo

Potential Pitfalls Mistaking Y.S. for embryo Mistaking sub-chorionic hemorrhage for G.S.

Potential Pitfalls Mistaking Y.S. for embryo Mistaking sub-chorionic hemorrhage for G.S. Missing multiple G.S.

IUP Lt adnexal ectopic sac

Potential Pitfalls Mistaking Y.S. for embryo Mistaking sub-chorionic hemorrhage for G.S. Missing multiple G.S. Pseudo-sac of E.P.

Potential Pitfalls Mistaking Y.S. for embryo Mistaking sub-chorionic hemorrhage for G.S. Missing multiple G.S. Pseudo-sac of E.P. Normal rhombencephalon for cystic brain mass

Potential Pitfalls Mistaking Y.S. for embryo Mistaking sub-chorionic hemorrhage for G.S. Missing multiple G.S. Pseudo-sac of E.P. Normal rhombencephalon for cystic brain mass Physiological bowel herniation for omphalocele.

MGH mid-gut herniation

Topic 2: 1st Trimester Ultrasound Screening 11~13+6 weeks scan

NT

隋·巢原方在《诸病源候论》 “妊娠三月名始胎，当此之时，血不流行，形象始化，未有定仪，因感而变。”

妇女怀孕3个月时，胚胎已渐次发育成胎儿，这时虽然已从形体上初步成形。但是还没有定型，即所谓“未有定仪”，其可塑性很大，当孕妇见到带有什么特征的东西，她所怀胎儿的形象，包括胎儿的形体和精神，也就会随之产生变化，这就是“见物而变”的本意。故此给那些想生一个长相漂亮、体力过人、才华出众的孩子的孕妇提出了要求，在孕期内要多想好事，多多行善，多看美好的事物，以期感化腹内的胎儿。通过母亲美与善的良好“见物”刺激，而使胎儿向更加聪明、善良、健康、漂亮的方面“变化”。

五帝时帝妃子姜源氏妊娠期间性情清静，喜好稼樯，经常随夫郊祭。观察植物生长，所以她的儿子后稷能种五谷，成为我国农业的第二始祖。这里边即寓有“见物而变”的含义。古人“见物而变”胎教理论的提出，当然受当时文化背景的影响，有时代的局限性，但还是有一定的实际指导意义。

Maternal Age (MA) 30 MA + 15~18 weeks 母親血清生化測試 50-70 Screening Methods 偵測率 % Maternal Age (MA) 30 MA + 15~18 weeks 母親血清生化測試 50-70 MA + 11~13+6 weeks NT 70-80 MA + 11~13+6 weeks NT +母親血清游離-hCG & PAPP-A 85-90 MA + 11~13+6 weeks NT & NB 90 MA + 11~13+6 weeks NT & NB + 母親血清游離-hCG & PAPP-A 95 Fetal Medicine Foundation, London 2006

胎兒NT增厚之病理生理學 心臟功能失調 頭部及頸部靜脈充血 細胞外間質成分轉變 淋巴管排泄失能 貧血 低蛋白血症 先天性感染

R. BECKER Ultrasound Obstet Gynecol 2006; 27: 613–618

R. BECKER Ultrasound Obstet Gynecol 2006; 27: 613–618

Karl Oliver Kagan,Obstet Gynecol. 2006 Jan;107(1):6-10. 叫我第一名 6.5~7.4 Karl Oliver Kagan,Obstet Gynecol. 2006 Jan;107(1):6-10.

WHY AND FOR WHOM IN THE FIRST TRIMESTER? Previous family history of cardiac defects The finding of an increased NT at 11 to 14 weeks.

Nasal Bone

The gestation should be 11-13+6 weeks and the fetal CRL should be 45-84 mm. In chromosomally normal fetuses the incidence of absent nasal bone is < 1% in Caucasian populations and about 10% in Afro-Caribbeans. The nasal bone is absent in 65-70% of trisomy 21 fetuses and in > 50% of trisomy 18 and 30% of trisomy 13 fetuses. For a false positive rate of 5%, screening by a combination of sonography for fetal NT and nasal bone and maternal serum free β-hCG and PAPP-A can potentially identify more than 95% of trisomy 21 pregnancies. Fetal Medicine Foundation, London 2006

Ductus Venosus At 11-13+6 weeks abnormal ductal flow is observed in 5% chromosomally normal fetuses, in about 80% with trisomy 21 and 75% with all chromosomal abnormalities. Assessment of the ductus venosus can be combined with measurement of fetal NT to improve the effectiveness of early sonographic screening for trisomy 21

Reversed A-wave

Tricuspid Valve Regurgitation Large Facial Angle

Other Easily Identified Anomalies Single Umbilical Artery Exomphalos Megacystis

Take Home Message Intradecidual sac sign (IDSS): 4-4.5 wks Yolk sac: 5-5.5 wks Embryo > 5mm: cardiac activity must be seen. Embryo with heart beat: 6-6.5 wks (TVS) Double belb sign: Y.S + amniotic sac Embryo forms within amnion Determine chorionicity/amnionicity in multiple gestations by No. YS = No. amnions

Special Concern Ectopic pregnancy (EP) 1.4% No IUP + tubal mass + CDS fluid (best clues) Pseudogestational sac sign Adnexal abnormalities (80-95%) Tubal hematoma (40-60%) Tubal ring (50%) Ring of fire 85% of EP on the same side of corpus luteum Sonar (-) in 5-10% Suspect EP if no IUP and hCG > 2000

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