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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

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

II

Dedication

To my mother

To my father

To my sisters

To my brothers

To my friends

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.

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.

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.

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

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

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

IX

35-36 References

Appendices

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

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

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

Chapter one

Introduction

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

2

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

3

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.

4

Chapter Two

Literature Review and Background Studies

4

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

5

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

6

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

7

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)

8

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)

9

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

10

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

11

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)

12

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

13

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

14

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)

15

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

16

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

17

chorionic hematoma and abnormal size and shape of yolk sac, follow up should be

closely done. (17)

18

Chapter Three

Materials and methods

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.

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)

20

Figure (3.2): Mindary DP 10 portable ultrasound machine (19)

Figure (3.3) LOGIQ 100 PRO portable ultrasound machine (19)

21

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.

22

Chapter Four

Results

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

23

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

24

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

25

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

26

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

27

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

28

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

29

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

30

Chapter Five

Discussion, Conclusion and recommendations

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.

31

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

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.

33

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).

34

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.

35

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).

http://www.american/

http://www.isuog.org/nr/rdonlyres/9225e408-c904-4a7f-84ae-812e456f%20bddd%20/0/isuog

36

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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http://www.used/

37

Appendices

38

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 ( )

39

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 ( )

40

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

41

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.

42

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.

43

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.

44

Image (9) Transverse US image of gravid uterus, CRL: .87cm and GA:

6weeks and 6 days.


8weeks and 3 days.

45


11weeks and 3 days.


11weeks and 2 days.

46


12weeks and 2 days.


12weeks and 4 days.

47


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.

48

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.

49

Image (19) Transverse US image of gravid uterus (blighted ovum), GS:

4.99cm and GA: 10weeks and 2days.


10weeks.

50


8weeks and 4 days.


7weeks and 2 days.

51

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.

52


10weeks and 6 days.

Image (26) Transverse US image of gravid uterus, CRL: .78 cm and GA: 6

weeks and 5 days.

53

Image (27) Transverse US image of gravid uterus, CRL: 1.45 cm and GA: 7

weeks and 5 days.


weeks and 5 days.

54


weeks.


weeks and 2 days.

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