PRETES 1 SYAH RINI WISDAYANTI DR, SP.OG,M.KES

PRETES 1

SYAH RINI WISDAYANTI DR, SP.OG,M.KES

• Tujuan USG pada awal kehamilan :

• Untuk mengetahui hamil/tidak.

• Untuk menentukan kehamilan intra atau ekstrauterin.

• Bila intrauterin : Lokasi GS ?

• Jumlah kehamilan

• Usia kehamilan

• Kelainan kehamilan

TRIMESTER PERTAMA

• Tanggalan kehamilan secara klinis didasarkan pada hari pertama haid terakhir sebelum

terjadinya konsepsi.

• Konsepsi biasanya terjadi antara hari ke 13 sampai hari ke 17 dari siklus haid.

• Buku-buku embriologi biasanya menggunakan gambaran berdasarkan tanggal konsepsi, yang mana gambaran tersebut lebih muda 2 minggu dari tanggalan secara klinis.

• Dua struktur embriologik yg terlihat pada trim.I, dpt digunakan untuk tanggalan kehamilan :

• 1. Gestational sac (chorionic sac), terlihat

pertama kali sekitar minggu ke 5 menstruasi.

• 2. Embrio, terlihat pertama kali sktr mgg ke 6 menst.

• Struktur ini dapat terlihat dengan baik jika menggunakan transvaginal ultrasound.

• Struktur pertama yang terlihat pada trim I, adalah GS yang dikelilingi oleh membran chorionic dan vili chorionic.

• GS ini terlihat sebagai daerah sonolusen (struktur hitam) bulat di dalam cavum uteri.

• Cairan dalam GS bukanlah cairan amnion, karena

kantong amnion belum berkembang. Tp cairan tsb kita kenal dengan nama “extraembryonic coelom”.

• GS dan Yolk Sac:

• GS bertumbuh cepat, rata-rata pertumbuhan dalam diameter, 1 mm/hari.

• Dalam minggu ke 5-6 yolk sac akan terlihat.

• Krn yolk sac adalah asal embrionik, maka dengan terlihatnya yolk sac di dalam uterus membuktikan adanya kehamilan intrauterin.

KOMPLIKASI KEHAMILAN DINI

PERDARAHAN VAGINAL TRIMESTER I

• Abortus spontan (komplit/inkomplit)

• Blighted ovum

• Missed abortion

• Molahydatidosa

• Kehamilan ektopik

• Abortus spontan :

• Komplit :

• Uterus kosong, hanya terlihat penebalan echo central.

• Inkomplit :

• Selain echo central masih tampak retained product of conception.

• Blighted ovum = anembryonic gestation

• Terdapat gestational sac yg kosong di dalam cavum uteri

• Gambaran USG :

• Small for dates

• Deformed (tennis racquet), dinding tidak jelas

• Tebal gestational sac tidak merata

• Echo bakal placenta tidak nampak

Jika ragu BO pd usia 6-7 minggu : scan ulang 1 minggu

Bila besar GS tidak bertambah > 75% atau bila tetap

tidak terlihat fetal nodes : 100% BO.

• Missed abortion :

• Masih nampak echo fetus dalam gestational sac tetapi sudah deformed/misshapened dan immobile karena sudah mati.

• Uterus : small for dates

• Echo placenta masih tampak (kadang2 menebal karena perubahan hidropik)

• Molahydatidosa :

• Uterus large for dates

• Vesicular pattern dalam uterus. Ukuran vesikula : 3-5 mm, bisa lebih besar lagi.

• Snowstorm appearance

• 30% kasus : terdapat pula theca lutein cyst, bilateral, multilocular cyst.

• Kehamilan Ektopik :

• 1 dalam 400 kehamilan. 95% di daerah tuba

• Diagnostik USG : Accuracy : 80- 90% saja.

• Gambaran USG :

• Uterus membesar, tetapi tidak ada gestational sac/kadang-kadang terdapat echo dari decidual cast (pseudogestational sac).

• Adanya massa bulat/irreguler

dengan gestational sac di dalamnya di daerah adnexa (cul-de-sac).

Kadang-kadang terlihat heartbeat/gerakan.

• Pada KET : disamping gbran

tersebut di atas, terlihat pula tanda- tanda perdarahan berupa massa kistik yang berbatas iregular di daerah cul-de-sac

TRIMESTER II DAN III

• Biometri fetus trim II dan III :

• BPD (Biparietal diameter)

• HC (Head circumference)

• AC (Abdominal circumference)

• FL (Femur Length)

• Bentuk kepala :

• Kepala fetus normalnya berbentuk oval, dengan

rasio BPD dan OFD berkisar antara 0,7-0,87.

• Rasio ini disebut juga cephalic index

• Bentuk kepala yg lebih bulat  brachycephaly (Cephalic index > 0,87)

• Bentuk yang lebih

memanjang ke belakang  dolicocephaly (Cephalic index < 0,7)

TRIM. II DAN III : MS dan CARDIA

TRIM.II DAN III : ABDOMEN

• Biometri abdomen :

• Sgt kompleks karena :

• Level potongan bervariasi.

• Gerakan fetus

termasuk bernafas dapat merubah

tidak hanya lokasi tapi juga bentuk dari abdomen.

• Acoustic shadow dari tulang belakang dan anggota gerak dapat menyulitkan

identifikasi garis kulit.

Components of the second and third trimester fetal anatomic survey :

• Head, including cerebral ventricles and posterior fossa

• Spine

• Stomach

• Urinary bladder

• Renal region

• Heart with four-chamber view

• Abdominal wall at cord insertion site

• Uterus, adnexae

• Placenta location

• Amniotic fluid assessment

• KELAMIN FETUS (GENDER):

• Menentukan kelamin fetus dapat dilakukan sejak kehamilan 14 minggu ke atas  tergantung apakah fetus membuka paha atau tidak.

• Tidak boleh membuat diagnosis kecuali sudah yakin benar.

• Disarankan u/ tidak pernah menanyakan orangtua, kecuali jk mereka ingin mengetahuinya, anda hrs berusaha memberitahu.

ANOMALI FETUS LAINNYA

• Hydrops fetalis :

• Isoimmune Hydrops dan Nonimmune Hydrops.

• Gambaran USG Hydrops fetalis :

* Penebalan kulit sec.menyeluruh > 5 mm dan atau 2 atau lebih keadaan di bawah ini:

- Pericardial effusion - Pleural Effusion

- Ascites

- Placental Enlargement

PLACENTA

• Penilaian akurat posisi placenta biasanya dilakukan pertama kali pada scan rutin kehamilan 16-20

minggu.

• Echo level placenta lebih tinggi dari echo dinding myometrium. Chorionic plate terlihat sebagai garis terang di antara cairan amnion dan echo homogen placenta.

• 95% wanita implantasi placenta di fundus uteri. 5%

 placenta letak rendah pd minggu ke 16-20, hrs scan kembali pd trimester III (1 dari 5  placenta previa)

• Gambaran sonografik placenta :

• Daerah implantasi placenta sec sonografik dpt terlihat sekitar minggu ke 8 kehamilan.

• Krn merupakan struktur yg kaya akan vaskular, mk placenta lebih echogenic dibanding myometrium tempat placenta melekat, dan jauh lebih echogenic dibanding cairan amnion.

• Lokasi placenta dpt berubah :

• Placenta dpt implantasi di mana saja di dalam uterus, dan lokasi ini dpt berubah sesuai kemajuan usia kehamilan.

- 95% wanita implantasi placenta di fundus uteri.

5%  placenta letak rendah pd minggu ke 16- 20, hrs scan kembali pd trimester III (1 dari 5  placenta previa⁾ .

• Perpindahan lokasi placenta : migrasi. Akibat 2 proses :

• Segmen bawah uterus mengalami peregangan.

• Krn supply darah segmen atas uterus lebih banyak dibanding segmen bawah uterus (trophotropism)

• GRADING PLACENTA (GRANNUM) :

• Merupakan klasifikasi perubahan normal dari placenta selama

kehamilan.

• Grade 0  Homogeneous placental substance, smooth chorionic plate.

• Grade 1  Random echogenic areas

• Grade 2  Basal echogenic areas, comma-like indentations in the chorionic plate.

• Grade 3  Echo-poor areas, deep indentations in the chorionic plate, and irregular echogenic areas

PENILAIAN CAIRAN AMNION

• Volume cairan amnion : sec. kualitatif

• Sbg panduan : jika tepi dari fetus sulit dipisahkan (sangat

berdekatan) dengan dinding uterus  oligohydramnion (cairan terlalu sedikit)

• Sebaliknya jk fetus bebas mengapung dan sdkt sekali menyentuh dinding uterus  polyhydramnion (terlalu banyak cairan).

• Amniotic Fluid Index (AFI) : Teknik mengukur

• Transduser diletakkan tegak lurus dgn lantai (pasien supine), jk sdh ditemukan kantong terdalam cairan amnion dari satu

kuadran di antara 4 kuadran uterus, mk gambar tsb difreeze, lalu diukur kedalamannya.

• Bgn terdalam sec.vertikal dari kantong yang difreeze ini, tidak boleh berisi ekstremitas fetus atau umbilical cord.

• Proses tsb diulang masing-masing untuk tiga kuadran lainnya.

• Tidak semua kuadran berisi cairan.

• AFI : nilai normal

• Pd trimester III : AFI 8 cm - 20 cm  normal

• 5 cm – 8 cm : equivocal

• < 5 cm : oligohydramnion

• > 20 cm : polihydramnion (bbrp studi melaporkan polyhydramnion jika

> 25 cm)

• Kondisi abnormal yg berhubungan dengan polyhydramnion, antara lain :

• Diabetes pada ibu

• Anomali fetus : obstruksi gastrointestinal, kelainan kepala dan leher yg mengganggu fetus menelan.

• Kelainan cardiovascular dan skeletal.

• Dampak polyhydramnion intrapartum :

• fetus terus mengapung  kepala sulit “engaged”

malpresentasi.

• Prolaps corda

• Kondisi abnormal yg berhubungan dengan oligohydramnion antara lain :

• Renal agenesis

• Anomali yg mengobstruksi aliran urine.

• Growth retardation

• Preeclampsia

• Serotinitas

1. The thermal index, the temperature elevation that potentially can induce fetal injury, is increased in which of the following?

• a. Pulsed Doppler imaging

• b. Longer examination time

• c. Locations near fetal bone

• d. All of the above

• 2. Sonographic evaluation of all except which of the following are best achieved in the first trimester?

• a. Adnexa

• b. Cervical length

• c. Ectopic pregnancy

• d. Chorionicity of twins

3. A 42-year-old woman presents with vaginal spotting. She has not had a period for 2 months and believes she is perimenopausal. A transvaginal ultrasound is performed in her gynecologist’s office. What is the minimum mean sac diameter measurement necessary to diagnose an anembryonic pregnancy with certainty?

• a. 7 mm

• b. 10 mm

• c. 20 mm

• d. 25 mm

• 4. What is the upper limit of normal after 15 weeks’ gestation for the lateral ventricle?

• a. 5 mm

• b. 10 mm

• c. 15 mm

• d. 20 mm

• 5. What condition should be suspected when a “tear drop”

shaped lateral ventricle is seen on prenatal sonography?

• a. Holoprosencephaly

• b. Arnold-Chiari malformation

• c. Dandy-Walker malformation

• d. Agenesis of the corpus callosum

• 6. Caudal regression sequence /CRS is increased in what maternal medical complication?

• a. Seizure disorder

• b. Diabetes mellitus

• c. Advanced maternal age

• d. Systemic lupus erythematosus

7. Which of the following is not of prognostic significance in the

evaluation of congenital diaphragmatic hernias?

• a. Presence of fetal swallowing

• b. Degree of liver herniation in the chest

• c. Sonographic lung-to-head measurement

• d. Magnetic resonance imaging of lung volumes

• 8. What is the most common class of congenital anomalies?

• a. Spine

• b. Renal

• c. Cardiac

• d. Gastrointestina

• 9. Which of the following is not associated with impaired fetal swallowing and non- visualization of the fetal stomach?

• a. Hydrops fetalis

• b. Duodenal atresia

• c. Esophageal atresia

• d. Craniofacial abnormalities

• 10. What is the primary source of amnionic fluid in the late second trimester?

• a. Fetal urine production

• b. Fetal pulmonary exudates

• c. Secretions from syncytiotrophoblast

• d. Transudate across the amnion mesenchym

• 11. Which of the following is correct regarding contribution to amnionic fluid volume in the second and third trimesters?

• a. Highest production is from fetal urination

• b. Highest resorption is into fetal respiratory tract

• c. Least resorption is across fetal vessels on placental surface

• d. All of the above are correct

• 12 What is the normal amnionic fluid volume at term?

• a. 300–500 mL

• b. 750–800 mL

• c. 1200–1500 mL

• d. 1800–2000 mL

• 13. Which of the following is not a significant source for fluid in the amnionic cavity in the first trimester?

• a. Fetal skin

• b. Fetal urine

• c. Flow across amnion

• d. Flow across fetal vessels

• 14. Which of the following is not true regarding osmolality of fetal urine?

• a. Fetal urine is isotonic to amnionic fluid.

• b. Fetal urine is hypertonic to fetal plasma.

• c. Fetal urine is hypotonic to maternal plasma.

• d. All of the above are true

• 15. In a healthy pregnancy at term, which of the following is the best estimation of daily fetal urine volume?

• a. 250 mL

• b. 500 mL

• c. 750 mL

• d. 1000 mL

16. Which of the following is not an acceptable way to document amnionic fluid when reporting ultrasound findings?

• a. Amnionic fluid index of 12.2 cm

• b. Deepest vertical pocket of 4.1 cm

• c. Maximal vertical pocket of 5.2 cm

• d. Subjectively normal amnionic fluid volume

• 17. Fetal growth

restriction with

polyhydramnios is most classically associated with which of the following chromosomal

abnormalities?

• a. 45,XO

• b. 47,XXY

• c. Trisomy 21

• d. Trisomy 18

• 18. Maternal intake of which of the following is

associated with

oligohydramnios from direct fetal renal effect?

• a. Angiotensin-receptor blockers

• b. Nonsteroidal

antiinflammatory drugs

• c. Angiotensin-converting enzyme inhibitors

• d. All of the above can be

associated with

oligohydramnios

• 19. A 35-year-old presents at 18 weeks’

gestation for fetal anatomical survey. She has no pertinent medical, obstetric, or family history, and she takes only prenatal vitamins. She had low-risk cell-free DNA result around 12 weeks. Anhydramnios is readily apparent upon starting her ultrasound. She has not observed any leakage of fluid. What considerations do you have as you move through the ultrasound?

• a. Identification of the bladder and external genitalia to rule out posterior urethral valve

• b. Identification of fetal kidneys to rule out bilateral renal agenesis or bilateral multicystic dysplastic kidneys

• c. Ensuring appropriate fetal growth and normal umbilical artery Doppler studies to rule out placental insufficiency

• d. All of the above should be carefully assessed

• 20. A 24-year-old G1 at 35 weeks’ gestation presents to labor and delivery with complaints of decreased fetal movement. She consistently drinks 2 liters of water per day. A variable deceleration is noted on her non-stress test, which was reactive. An ultrasound is performed, and an amnionic fluid index of 4.1 cm is found. What is the most appropriate next step?

• a. Assessment of maternal blood pressure

• b. Detailed patient history and sterile speculum exam

• c. Umbilical artery Doppler study if fetal growth restriction is suspected

• d. All of the above should be completed

• 21. In the lower genital tract, the term intraepithelial neoplasia refers to squamous epithelial lesions that are potential precursors of invasive cancer. In the case of cervical intraepithelial neoplasia (CIN), what term applies when abnormal cells involve the full thickness of the squamous epithelium?

• a. CIN 1

• b. CIN 2

• c. CIN 3

• d. Carcinoma in situ (CIS)

• 22. All of the following are true statements regarding the cervix transformation zone ( Z) EXCEPT:

• a. Nearly all cervical neoplasia develops within the Z.

• b. Squamous metaplasia occurring within the Z is abnormal.

• c. The Z lies between the original squamous epithelium and columnar epithelium.

• d. The location and size of the Z change through the process of squamous metaplasia

• 23. Clinically, human papillomavirus (HPV) types are classified as high risk (HR) or low risk (LR) based upon their oncogenic potential.

Which two HR HPV types together account or approximately 70 percent of cervical cancers worldwide?

• a. 6 and 11

• b. 11 and 45

• c. 16 and 18

• d. 18 and 31

• 24. A 20-year-old nulligravida complains of occasional pelvic pain and intermittent vaginal discharge. She is also concerned about possible exposure to sexually transmitted infections.

Which of the following is the most common sexually transmitted disease?

• a. Chlamydial infection

• b. Gonorrhea

• c. Trichomoniasis

• d. Genital human papillomavirus infection

• 25. Which of the following is the LEAST common outcome of cervical human papillomavirus infection?

• a. Latent infection

• b. Subclinical infection

• c. High-grade dysplasia or cancer

• d. Cervical intraepithelial neoplasia (CIN) 1