USG Intensif 8. Fetal Biometry Based on ISUOG JJE 20080901

FETAL BIOMETRYFETAL BIOMETRYBASIC COURSE OF O&G ULTRASOUND FOR RESIDENTSBASIC COURSE OF O&G ULTRASOUND FOR RESIDENTS

( ( ISUOG CURRICULUMISUOG CURRICULUM ) )

Judi Januadi EndjunJudi Januadi Endjun

Intensive Ultrasound CourseIntensive Ultrasound Course

DIVISION OF MATERNAL AND FETAL MEDICINEDIVISION OF MATERNAL AND FETAL MEDICINEDepartment of Obstetrics and GynecologyDepartment of Obstetrics and Gynecology

Gatot Soebroto Army Central Hospital / School of Medicine Veteran University– JakartaGatot Soebroto Army Central Hospital / School of Medicine Veteran University– Jakarta

20082008

JJE-13/07/2009JJE-13/07/2009Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan

KesehatanKesehatan

MATERI AJAR INI HANYA MATERI AJAR INI HANYA UNTUK DIPERGUNAKAN UNTUK DIPERGUNAKAN

DALAM KEGIATAN DALAM KEGIATAN PENDIDIKAN DAN PENDIDIKAN DAN

KESEHATANKESEHATAN


KesehatanKesehatan

RSPAD GATOT SOEBROTODITKESAD


KesehatanKesehatan

Motto :

• Jalani hidup ini dengan sabar, jujur dan ikhlas,

• Mau mengerti dan melaksanakan tatacara (adab) yang benar, dan

• Mempunyai kemauan untuk selalu berbuat baik memperbaiki diri dan

lingkungan, serta membuat orang lain lebih baik


KesehatanKesehatan

KEUTAMAAN ILMU

Barang siapa mengamalkan apa-apa yang ia ketahui, maka Allah SWT akan mewariskan kepadanya ilmu yang belum diketahuinya, dan Allah SWT akan menolong dia dalam amalannya sehingga ia mendapatkan surga. Dan barang siapa yang tidak mengamalkan ilmunya, maka ia

tersesat oleh ilmunya itu, dan Allah SWT tidak menolong dia dalam amalannya sehingga ia akan mendapatkan neraka (sabda Rasulullah Muhammad SAW)

Ilmu lebih utama dari harta, ilmu adalah pusaka para Nabi, sedangkan harta adalah pusaka Karun atau Fir’aun.

Ilmu lebih utama dari harta, karena ilmu akan menjagamu sementara harta malah engkau yang harus menjaganya.

Ilmu lebih utama dari harta karena di akherat nanti pemilik harta akan dihisab, sedangkan orang berilmu akan memperoleh syafaat.

Ilmu lebih utama dari harta karena pemilik harta bisa mengaku menjadi Tuhan akibat harta yang dimilikinya, sedangkan orang berilmu justru mengaku sebagai hamba Tuhan karena

ilmunya.Harta itu jika engkau berikan menjadi berkurang, sebaliknya ilmu jika engkau berikan malahan

semakin bertambah.

Pemilik harta disebut dengan nama kikir dan buruk, tetapi pemilik ilmu disebut dengan nama keagungan dan kemuliaan.

Pemilik harta itu musuhnya banyak, sedangkan pemilik ilmu temannya banyak.Harta akan hancur berantakan karena lama ditimbun zaman, tetapi ilmu tidak akan rusak dan

musnah walau ditimbun zaman.

Harta membuat hati seseorang menjadi keras, sedangkan ilmu malah membuat hati menjadi bercahaya.

(hamba Allah)

JJE-13/07/2009JJE-13/07/2009 Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan

FETAL BIOMETRYFETAL BIOMETRY

• 1st Trimester

• 2nd Trimester

• 3rd Trimester

JJE-20090526JJE-13/07/2009JJE-13/07/2009

Hanya untuk Pendidikan dan Hanya untuk Pendidikan dan KesehatanKesehatan

< 5 weeks< 5 weeks 5 weeks 6-10 weeks 10-12 weeks

GS GS

(Yolk sac)

CRLCRL CRLBPD

> 12 weeks> 12 weeks

BPD BPD

FLFL

etcetc

BIOMETRICS PARAMETERBIOMETRICS PARAMETER

Bambang KarsonoJJE-13/07/2009JJE-13/07/2009


Gestational age estimationGestational age estimation

• GS• YS• CRL• BPD• HC• FL• HL


KesehatanKesehatan

Gestational Sac DiameterGestational Sac Diameter


KesehatanKesehatan

Yolk Sac DiameterYolk Sac Diameter


KesehatanKesehatan

CRLCRL


KesehatanKesehatan

Applications of Fetal Biometry in Applications of Fetal Biometry in the 2the 2ndnd and 3 and 3rdrd Trimesters Trimesters

Monitoring fetal growth

Detection of fetal anomalies

Late gestational age assignment

Fetal weight estimation

Merz E, 2005JJE-13/07/2009JJE-13/07/2009


PRE-REQUISITESPRE-REQUISITES

• Gestational age : CRL, redating should be done only once

• Equipment settings : velocity calibration, gain setting, scale calibration

• Defining the reference plane : use standard reference

• Defining the biometry points : outer to inner and outer to outer ; measurement in late pregancy

• Use of growth charts : upper and lower limits

• DocumentationMerz E, 2005


KesehatanKesehatan

BASIC BIOMETRYBASIC BIOMETRY

A. Cephalometry

B. Abdominometry

C. Measuring the long tubular bones

D. Extended biometry

A. Head : BPD , OFD, HC

B. Abdomen : ATD, ASD, AC

C. Limbs : FL, HL

Merz E, 2005JJE-13/07/2009JJE-13/07/2009


A. CEPHALOMETRYA. CEPHALOMETRY

• Parameters : BPD, OFD, HC

• Reference plane : transverse occipito-frontal plane

• Technique : outer to outer (BPD, OFD), outer to inner (BPD)

• Dolicho-cephalic head shape : HC

• Growth curves : Indonesia

Merz E, 2005JJE-13/07/2009JJE-13/07/2009


Sumber: AIUM

HEAD AND NECKHEAD AND NECK


KesehatanKesehatanSumber: AIUM

Assessment of Gestational AgeAssessment of Gestational Age

• Should be accomplished at the time of the initial scan using a combination of a cranial measurement (BPD, HC) and limb measurement (FL).

• 3rd trimester measurement may not accurately reflect gestational age.

Merz E, 2005JJE-13/07/2009JJE-13/07/2009


Assessment of Gestational AgeAssessment of Gestational Age

• Should be based on the earliest examination : current fetal age = estimated age at time of initial study – number of weeks elapsed since first study

• Measurement of structurally abnormal fetal body parts (head in hydrocephalus or limbs in skeletal dysplasia) should not be used in the calculation of estimated gestational age

Merz E, 2005


KesehatanKesehatan

The standard reference level for The standard reference level for measurement of the BPD is an axial image measurement of the BPD is an axial image

that includes the thalamusthat includes the thalamus

• Dolichocephalic or brachycephalic : the BPD measurement may be misleading → use CI or HC

• Cephalic index (CI) : ratio of BPD to FOD (NORMAL : 75 – 85%)

• Linear relationship BPD and GA between 20 – 30 W : ± 9 days in 95% of pregnancies (Campbell, J Obstet Gynecol Br Cwlth, 1969)

• Hadlock et al (1982) : 36 – 42 W → 3.6 W

• Best : 12 – 18 W → GA : 89.4% (LMP : 69.7%)


KesehatanKesehatan

BIPARIETAL DIAMETERBIPARIETAL DIAMETER

• Most popular and problematic• Entire calvarium and appears ellipsoidlike

• Falx cerebri, anterior and posterior fossae• Thalami : two triangular echo-free areas in the

midportion

• Septum cavi pellucidi : two short parallel lines• 3rd ventricle : between the thalami, by a slitlike

appearance


KesehatanKesehatan


• Frontal horn of the lateral ventricles, which is separated by the septum cavum pellucidum

• Outer to outer margin of the parallel parietal bone (RSPAD Gatot Soebroto Hospital)


KesehatanKesehatan


• Linear relationship BPD and GA between 20 – 30 W : ± 9 days in 95% of pregnancies (Campbell, J Obstet Gynecol Br Cwlth, 1969)

• Hadlock et al (1982) : 36 – 42 W → 3.6 W

• Best : 12 – 18 W → GA : 89.4% (LMP : 69.7%)


KesehatanKesehatan

OCCIPITO-FRONTAL OCCIPITO-FRONTAL DIAMETER (OFD)DIAMETER (OFD)

• Same plane used for BPD• Distance from the

midechogenic plane of the occipital bone to the midechogenic plane of the frontal bone

• Anteroposterior resolution : < 2 mm

• Lateral resolution : 3 – 5 mm


KesehatanKesehatan

HCHC

• HC is measured at the same level as the BPD, around the outer perimeter of the calvarium


KesehatanKesehatan

HC / AC RatioHC / AC Ratio


KesehatanKesehatan

B. ABDOMINOMETRYB. ABDOMINOMETRY

• Parameters : ATD, ASD, and AC (outer-to-outer)

• Growth curve : Indonesia

• Head/trunk ratio : IUGR; micro or macrocephaly → BPD/ATD or HC/AC


KesehatanKesehatan

ABDOMINOMETRYABDOMINOMETRY

• Reference plane : umbilical vein (UV) enters the portal sinus

• Locating the reference plane : fetal trunk in a transverse scan perpendicular to the long axis; the liver, stomach, and UV are identified; approximately circular; and the UV appears only as a short vascular segment within the liver

• Pitfalls : full length of the UC,and pressing too hard


KesehatanKesehatan

Abdominal CircumferenceAbdominal Circumference


KesehatanKesehatan

AC chartAC chart


KesehatanKesehatan

ACAC


KesehatanKesehatan

5. Fetal weight should be estimated in the 5. Fetal weight should be estimated in the late 2late 2ndnd and in the 3 and in the 3rdrd trimesters and trimesters and requires the measurement of AD or ACrequires the measurement of AD or AC


KesehatanKesehatan

5A. AC should be determined on a true 5A. AC should be determined on a true transverse view, preferably at the level of transverse view, preferably at the level of the junction of the left and right portal the junction of the left and right portal veinsveins

• EFW : IUGR or Macrosomia


KesehatanKesehatan

5B. If previous fetal biometric studies have been performed, an estimate of 5B. If previous fetal biometric studies have been performed, an estimate of

the appropriateness of interval growth should be giventhe appropriateness of interval growth should be given

JJE-20071022JJE-13/07/2009JJE-13/07/2009


Estimation Of Fetal WeightEstimation Of Fetal Weight

• BPD

• AC

• FL

• Volumetry


KesehatanKesehatan

Fetal weight should be estimated in the Fetal weight should be estimated in the late 2late 2ndnd and in the 3 and in the 3rdrd trimesters and trimesters and

requires the measurement of AD or ACrequires the measurement of AD or AC


KesehatanKesehatan

EFW chartEFW chart


KesehatanKesehatan


KesehatanKesehatan

Bambang Karsono, 1988JJE-13/07/2009JJE-13/07/2009


C. MEASURING THE LONG C. MEASURING THE LONG TUBULAR BONESTUBULAR BONES

• Indications : Early detection or exclusion of skeletal dysplasias; Gestational age : microcephaly, IUFD

• Parameters : ossified shaft, consisting of the diaphysis and metaphysis; the epiphyses are ignored; the curvature is also ignored

• Technique : sound beam perpendicular to the long axis of the bone (if possible), the ends of the bones are sharply defined


KesehatanKesehatan

MEASURING THE LONG TUBULAR MEASURING THE LONG TUBULAR BONESBONES

• Growth Curves : the majority of growth curve have been plotted to the femur; the other long bones is still reserved for extended biometry; and almost linear growth rate in the 2nd trimester, followed by a declining rate in the third trimester.

• Bone disorders : high degree of confidence


KesehatanKesehatan

4C. FL should be routinely measured and 4C. FL should be routinely measured and

recorded after the 14recorded after the 14thth weeks weeks

• There is considerable biological variation in normal FL late in pregnancy


KesehatanKesehatan

Femur Length measurementFemur Length measurement


KesehatanKesehatan


KesehatanKesehatan

FL curveFL curve


KesehatanKesehatan


KesehatanKesehatan

D. EXTENDED BIOMETRY D. EXTENDED BIOMETRY (ORGAN BIOMETRY)(ORGAN BIOMETRY)

For the purpose of addressing a specific issue :

1. Head and Neck

2. Thorax

3. Abdomen and Pelvis

4. Specific Bone Measurement

5. Other Measurement


KesehatanKesehatan

D.1. HEAD and NECK : D.1. HEAD and NECK : Cerebral VentriclesCerebral Ventricles

• Biometry points : hydrocephalus, measurements of the lateral ventricles can be taken at the level of the frontal horns, pars centralis, or occipital horns; the frontal measurements are the easiest to perform

• Technique : the lateral ventricles measured directly

• Normal values : pars centralis < 13 mm; bifrontal ventricular width 11 mm at 13 W and 24 mm at term; the ratio of bifrontal ventricular width to BPD was 0.48 at 13 W and 0.25 by term


KesehatanKesehatan

HEAD and NECK : HEAD and NECK : Cerebral HemispheresCerebral Hemispheres

• Hemispheric width : distance from the midline echo to the inner table of the calvaria

• Ventricle-hemispheric ratio : at the pars centralis; 0.56 at 15 W to 0.28 at term

• Garret (1979) : V/H ratio > 0.5 after 18 W is proof of hydrocephalus

• Evidence for hydrocephalus is not conclusive until 21 WJJE-13/07/2009JJE-13/07/2009


Anterior Cerebral Ventricle Anterior Cerebral Ventricle DiameterDiameter


KesehatanKesehatan

Posterior Cerebral Ventricle Posterior Cerebral Ventricle DiameterDiameter


KesehatanKesehatan

Ratio Va / HRatio Va / H


KesehatanKesehatan

Ratio Vp / HRatio Vp / H


KesehatanKesehatan

HEAD and NECK : HEAD and NECK : Cavum Septi PellucidiCavum Septi Pellucidi

• Slit-like hypoechoic cavity, on the anterior midline, inferior to the corpus callosum

• Uniform increase between 19 – 27 W, followed by a plateau until term

• > 10 mm : cerebral dysfunction, ↑ MR, developmental delay, and neuropsychiatric disorders


KesehatanKesehatan

HEAD and NECK : HEAD and NECK : CerebellumCerebellum

• Transverse cerebellar diameter (TCD)

• Measured by tilting the occipitofrontal plane downward until the cerebellum appears (bilobed structure in the posterior fossa)

• The CSP can still be seen

• Equal to the week 12 – 22 (useful for GA)JJE-13/07/2009JJE-13/07/2009


Transverse Cerebellar DiameterTransverse Cerebellar Diameter


KesehatanKesehatan


KesehatanKesehatan

HEAD and NECK : HEAD and NECK : Cisterna MagnaCisterna Magna

• Measured in the same plane as the cerebellum

• The growth curve is initially linear and declines toward the end of the pregnancy

• Abnormal > 10 mm : trisomy 18 or 13

• DD : Dandy-Walker malformationJJE-13/07/2009JJE-13/07/2009


Cisterna MagnaCisterna Magna


KesehatanKesehatan

HEAD and NECK : HEAD and NECK : Nuchal Fold in the 2Nuchal Fold in the 2ndnd Trimester Trimester

• The skin and subcutaneus tissue in the nuchal area (outer to inner)

• Should not exceed 5 mm in diameter between 15 – 20 W

• ↑ Risk of trisomy 21

• Reference plane : same with cerebellum measurement


KesehatanKesehatan

HEAD and NECK : HEAD and NECK : OrbitaOrbita

• Orbital diameters• Inner inter-orbital distance• Outer inter-orbital distance

• 13 W : coronal scan, angled coronal scan, or transverse scan

• Nonlinear pattern of growth

• Facial dysmorphia, orbital asymmetry, hypo-or-hypertelorismJJE-13/07/2009JJE-13/07/2009


D.2. THORAXD.2. THORAX

Thoracometry : • fetal thoracic measurements on the

cardiac plane;

• bony thorax (initially linear growth) and oblique lung diameter (slight decline by just 12 W);

• detect pulmonary hypoplasia as early as 24 W


KesehatanKesehatan

THORAXTHORAX

Heart : • 4CV;

• ratio of transverse cardiac diameter to transverse thoracic diameter is 0.52 ;

• M-mode and cine-loop : precise evaluation of ventricular width during diastole and systole, a tracing is obtained at the level of the AV-valve, perpendicular to the IVS, and AV-valve are closed at the end of diastolic


KesehatanKesehatan

D.3. ABDOMEN AND PELVISD.3. ABDOMEN AND PELVIS

• Liver

• Gallbladder

• Spleen

• Pancreas

• Stomach

• Bowel

• Kidneys

• Adrenal Glands

• Bladder


KesehatanKesehatan

D.4. SPECIFIC BONE D.4. SPECIFIC BONE MEASUREMENTMEASUREMENT

• Clavicle

• Rib Length

• Vertebral Bodies

• Foot


KesehatanKesehatan

D.5. OTHERS MEASUREMENTSD.5. OTHERS MEASUREMENTS

• Nasal Width

• Bony nasal length

• Tongue circumference

• Shoulder rump length

• The length and circumference of the thigh and lower lrg

• etc


KesehatanKesehatan

THANK YOUTHANK YOU


KesehatanKesehatan

Documents

USG Intensif 8. Fetal Biometry Based on ISUOG JJE 20080901