Ultrasound Obstet Gynecol 2011; 37: 116–126

Published online 7 December 2010 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.8831

GUIDELINES

Practice guidelines for performance of the routine

mid-trimester fetal ultrasound scan
L. J. SALOMON, Z. ALFIREVIC, V. BERGHELLA, C. BILARDO, E. HERNANDEZ-ANDRADE,
S. L. JOHNSEN, K. KALACHE, K.-Y. LEUNG, G. MALINGER, H. MUNOZ, F. PREFUMO, A. TOI
and W. LEE on behalf of the ISUOG Clinical Standards Committee

Clinical Standards Committee serves as an important baseline against which later scans
may be compared for the evaluation of growth and health.
The International Society of Ultrasound in Obstetrics Ultrasonography can also be used to detect congeni-
and Gynecology (ISUOG) is a scientific organization tal anomalies3 – 6 . The Eurofetus study7 , a multicenter
that encourages sound clinical practice, teaching and project involving 61 obstetric ultrasound units from 14
research for diagnostic imaging in women’s healthcare. European countries, examined the accuracy of routine
The ISUOG Clinical Standards Committee (CSC) has mid-trimester ultrasonographic examination in unselected
a remit to develop Practice Guidelines and Consensus populations. Over one half (56%) of 4615 malformations
Statements as educational recommendations that provide were detected and 55% of major anomalies were identified
healthcare practitioners with a consensus-based approach before 24 weeks of gestation.
for diagnostic imaging. They are intended to reflect what is Although many countries have developed local guide-
considered by ISUOG to be the best practices at the time at lines for the practice of fetal ultrasonography, there
which they were issued. Although ISUOG has made every are still many areas of the world where they have not
effort to ensure that guidelines are accurate when issued,
been implemented. Most countries offer at least one
neither the Society nor any of its employees or members
mid-trimester scan as part of standard prenatal care,
accepts any liability for the consequences of any inac-
although obstetric practice varies widely around the
curate or misleading data, opinions or statements issued
world. This can be related to the availability of qualified
by the CSC. They are not intended to establish a legal
practitioners and equipment, local medical practice and
standard of care because interpretation of the evidence
legal considerations; in some countries, insurance-related
that underpins the guidelines may be influenced by indi-
cost reimbursements strongly influence how routine mid-
vidual circumstances and available resources. Approved
trimester scans are implemented. Nonetheless, a WHO
guidelines can be distributed freely with the permission of
Study Group stated: ‘Worldwide, it is likely that much
ISUOG ([email protected]).
of the ultrasonography currently performed is carried out
by individuals with in fact little or no formal training.’8 .
INTRODUCTION The intent of this document is to provide further guid-
ance for healthcare practitioners in the performance of
Ultrasonography is widely used for the prenatal evalua- the mid-trimester fetal ultrasound scan.
tion of growth and anatomy as well as for the management
of multiple gestations. The procedure provides diagnostic
findings that often facilitate the management of problems GENERAL CONSIDERATIONS
arising in later pregnancy. For example, abnormal fetal What is the purpose of a mid-trimester fetal ultrasound
growth is a leading cause of perinatal morbidity and mor- scan?
tality in both industrialized and developing countries. In
2005, the World Health Organization (WHO) concluded The main objective of a routine mid-trimester fetal
that impaired fetal growth had many causes related to: ultrasound scan is to provide accurate diagnostic
genetic factors, maternal characteristics such as nutrition, information for the delivery of optimized antenatal care
lifestyle including smoking, age and disease; complica- with the best possible outcomes for mother and fetus.
tions of pregnancy; and the physical, social and economic The procedure is used to determine gestational age and
environment1,2 . A mid-trimester fetal ultrasound scan to perform fetal measurements for the timely detection of

Copyright  2010 ISUOG. Published by John Wiley & Sons, Ltd. ISUOG GUIDELINES
Routine mid-trimester fetal ultrasound scan 117

growth abnormalities later in pregnancy. Other goals requirements for this activity may vary depending on the
are to detect congenital malformations and multiple country.
pregnancies. In order to achieve optimal results from routine
Prenatal screening examination includes an evaluation screening examinations, it is suggested that scans should
of the following: be performed by individuals who fulfil the following
criteria10 :
- cardiac activity;
- fetal number (and chorionicity if multiple pregnancy); - trained in the use of diagnostic ultrasonography and
- fetal age/size; related safety issues;
- basic fetal anatomy; - regularly perform fetal ultrasound scans;
- placental appearance and location. - participate in continuing medical education activities;
- have established appropriate referral patterns for
Although many malformations can be identified, it suspicious or abnormal findings;
is acknowledged that some may be missed, even with - routinely undertake quality assurance and control
sonographic equipment in the best of hands, or that measures.
they may develop later in pregnancy. Before starting the
examination, a healthcare practitioner should counsel the What ultrasonographic equipment should be used?
woman/couple regarding the potential benefits and limi-
tations of a routine mid-trimester fetal ultrasound scan. For routine screening, equipment should have at least the
following:
Who should have a mid-trimester fetal ultrasound scan? - real time, gray-scale ultrasound capabilities;
- transabdominal transducers (3–5-MHz range);
Many countries offer at least one routine mid-trimester
- adjustable acoustic power output controls with output
fetal ultrasound scan. As one example, an imaging work-
display standards;
shop organized by the Eunice Kennedy Shriver National
- freeze frame capabilities;
Institute of Child Health and Human Development in
- electronic calipers;
the United States9 reached a consensus that all preg-
- capacity to print/store images;
nant women should be offered an ultrasound scan for the
- regular maintenance and servicing, important for
detection of fetal anomalies and pregnancy complications.
optimal equipment performance.
Serial scans may be helpful for some mothers with risk
factors for adverse pregnancy outcome (e.g. hypertension
or diabetes) and others may benefit from more detailed What document should be produced/stored/printed
scans that are targeted to their specific situation. Repeated or sent to the referring healthcare provider?
or detailed examinations, however, are not considered to
An examination report should be produced as an
be routine scans.
electronic and/or a paper document, to be sent to the
referring care provider in reasonable time. A sample
When should the mid-trimester fetal ultrasound scan be
reporting form is available at the end of this article.
performed?
Images of standard views (stored either electronically or
A routine mid-trimester ultrasound scan is often per- as printed copies) should also be produced and stored.
formed between 18 and 22 weeks of gestation. This Motion videoclips are recommended for the fetal heart.
period represents a compromise between dating the preg- Local laws should be followed. Many jurisdictions require
nancy (more accurate if established earlier) and the image storage for a defined period of time.
timely detection of major congenital anomalies. Countries
where pregnancy termination is restricted should balance Is prenatal ultrasonography safe?
detection rates against the time needed for counseling
and additional investigation. Some centers perform the Prenatal ultrasonography appears to be safe for clinical
anatomical survey using transvaginal scanning at approx- practice. To date, there has been no independently
imately 13–16 weeks’ gestation. This earlier approach confirmed study to suggest otherwise. Fetal exposure
can provide useful information about gestational age as a times should be minimized, using the lowest possible
baseline for growth assessment or determination of chori- power output needed to obtain diagnostic information,
onicity for twins, but may require special training for the following the ALARA principle (As Low As Reasonably
early interpretation of anatomical structures. Achievable). More details are available from the ISUOG
Safety Statement11 .
Who should perform the mid-trimester fetal ultrasound
scan? What if the examination cannot be performed
in accordance with these guidelines?
Individuals who routinely perform obstetric scans should
have specialized training for the practice of diagnos- These recommendations represent minimum practice
tic ultrasonography in pregnant women. However, the guidelines for the mid-trimester fetal ultrasound scan.

Copyright  2010 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2011; 37: 116–126.
118 Guidelines

Consideration must be given to local circumstances and at the mid-trimester scan on the basis of fetal head size
medical practices. Reasons for deviations from these (BPD and/or HC) or FDL. The chosen reference standards
recommendations should be documented. If the exam- should be indicated in the report16 . Subsequent scans
ination cannot be performed completely in accordance should not be used to calculate a new estimated date of
with adopted guidelines, the scan should be repeated, at confinement if age has already been established by a high-
least in part, at a later time, or the patient can be referred quality scan earlier in the pregnancy. Additional measure-
to another practitioner. This should be done as soon as ments, optimally at least 3 weeks from a preceding scan,
possible, to minimize unnecessary patient anxiety and are usually reported as deviations from mean values with
unnecessary delay in the potential diagnosis of congenital their expected ranges for a given age. This information
anomalies or growth disturbances. can be expressed as Z-scores, percentile reference ranges
or on a graph, although the degree of deviation from
What is the role of a more detailed ultrasonographic normal at this early stage of pregnancy that would justify
examination? action (e.g. a follow-up scan to assess fetal growth or fetal
chromosomal analysis) has not been firmly established.
Individuals who perform ultrasonographic scans during Combining measurements significantly improves accu-
pregnancy should have referral mechanisms in place racy compared with prediction based on HC alone17 .
to manage suspected or detected abnormalities. A However, the clinical significance of this improvement is
minimum examination, following the guidelines presented marginal because the improved accuracy represents less
herein, should be performed before referring the patient, than 1 day18 .
unless technical factors prevent completion of the initial
evaluation. Biparietal diameter (BPD)
Anatomy.
GUIDELINES FOR EXAMINATION - Cross-sectional view of the fetal head at the level of the
thalami;
Fetal biometry and wellbeing - ideal angle of insonation is 90◦ to the midline echoes;
- symmetrical appearance of both hemispheres;
The following sonographic parameters can be used to - continuous midline echo (falx cerebri) broken in middle
estimate gestational age and for fetal size assessment12 – 14 : by the cavum septi pellucidi and thalamus;
- no cerebellum visualized.
- biparietal diameter (BPD);
- head circumference (HC); Caliper placement. Both calipers should be placed
- abdominal circumference (AC) or diameter; according to a specific methodology, because more than
- femur diaphysis length (FDL). one technique has been described (e.g. outer edge to inner
edge or ‘leading edge’ technique vs. outer edge to outer
Measurements should be performed in a standardized edge), at the widest part of the skull, using an angle
manner on the basis of strict quality criteria15 . An audit that is perpendicular to the midline falx (Figure 1)19 . The
of results can help to ensure accuracy of techniques with same technique as that used to establish the reference
regard to specific reference tables. An image(s) should be chart should be used. The cephalic index is a ratio
taken to document the measurement(s). Examples of still of the maximum head width to its maximum length
images appropriate for fetal biometry are demonstrated and this value can be used to characterize fetal head
in Figure 1. shape. Abnormal head shape (e.g. brachycephaly and
If gestational age has not already been established at dolichocephaly) can be associated with syndromes. This
a dating or first-trimester scan, it should be determined finding can also lead to inaccurate estimates of fetal age

Figure 1 Standard fetal biometry: sonographic measurements of the biparietal diameter and head circumference (a), the abdominal
circumference (b) and the femur diaphysis length (c). In this example, calipers are placed on the outer and inner edges of the skull for BPD
measurement (large white dots in (a)); some reference charts have been developed using different caliper placement for this measurement
(e.g. outer edge to outer edge of the skull).

Copyright  2010 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2011; 37: 116–126.
Routine mid-trimester fetal ultrasound scan 119

when the BPD is used; in these cases, HC measurements Estimated fetal weight (EFW)
are more reliable20 .
Mid-trimester sonographic measurements can be used to
identify abnormalities of fetal size23,24 . Some countries
Head circumference (HC)
also use this information to estimate fetal weight as
Anatomy. As described for the BPD, ensuring that a baseline parameter for the detection of subsequent
the circumference placement markers correspond to the growth problems. Many ‘size discrepancies’ are explained
technique described on the reference chart. by incorrect menstrual age estimates, even in women
with ‘certain dates’25,26 . If gestational age is determined
Caliper placement. If the ultrasound equipment has ellipse at an earlier scan, EFW can be compared to dedicated
measurement capacity, then the HC can be measured normal, preferably local, reference ranges for this
directly by placing the ellipse around the outside of parameter14,27,28 . However, the degree of deviation from
the skull bone echoes (Figure 1). Alternatively, the HC normal at this early stage of pregnancy that would justify
can be calculated from the BPD and occipitofrontal action (e.g. follow-up scan to assess fetal growth or fetal
diameter (OFD) as follows: the BPD is measured using a chromosomal analysis) has not been firmly established.
leading edge technique as described in the previous section Amniotic fluid assessment
whereas the OFD is obtained by placing the calipers in the
middle of the bone echo at both the frontal and occipital Amniotic fluid volume can be estimated subjectively or
skull bones. HC is then calculated using the equation: HC using sonographic measurements. Subjective estimation is
= 1.62 × (BPD + OFD). not inferior to the quantitative measurement techniques
(e.g. deepest pocket, amniotic fluid index) when per-
Abdominal circumference (AC) formed by experienced examiners29,30 . Patients with devi-
ations from normal should have more detailed anatomical
Anatomy. evaluation and clinical follow-up.
- Transverse section of the fetal abdomen (as circular as
possible); Fetal movement
- umbilical vein at the level of the portal sinus;
Normal fetuses typically have a relaxed position and
- stomach bubble visualized;
show regular movements. There are no specific movement
- kidneys should not be visible.
patterns at this stage of pregnancy. Temporary absence
or reduction of fetal movements during the scan
Caliper placement. The AC is measured at the outer
should not be considered as a risk factor31 . Abnormal
surface of the skin line, either directly with ellipse
positioning or unusually restricted or persistently absent
calipers or calculated from linear measurements made
fetal movements may suggest abnormal fetal conditions
perpendicular to each other, usually the anteroposterior
such as arthrogryposis32 . The biophysical profile is not
abdominal diameter (APAD) and transverse abdominal
considered part of a routine mid-trimester scan33 .
diameter (TAD) (Figure 1). To measure the APAD, the
calipers are placed on the outer borders of the body Doppler ultrasonography
outline, from the posterior aspect (skin covering the spine)
to the anterior abdominal wall. To measure the TAD, the The application of Doppler techniques is not currently
calipers are placed on the outer borders of the body recommended as part of the routine second-trimester
outline, across the abdomen at the widest point. The AC ultrasound examination. There is insufficient evidence
is then calculated using the formula: AC = π (APAD + to support universal use of uterine or umbilical
TAD)/2 = 1.57 (APAD + TAD). artery Doppler evaluation for the screening of low-risk
pregnancies34 – 36 .
Femur diaphysis length (FDL)
Multiple gestation
Anatomy. The FDL is imaged optimally with both ends of The evaluation of multiple pregnancies should include the
the ossified metaphysis clearly visible21,22 . The longest following additional elements:
axis of the ossified diaphysis is measured. The same
technique as that used to establish the reference chart - visualization of the placental cord insertion;
should be used with regard to the angle between the - distinguishing features (gender, unique markers, posi-
femur and the insonating ultrasound beams. An angle of tion in uterus);
insonation between 45◦ and 90◦ is typical. - determination of chorionicity is sometimes feasible in
the second trimester if there are clearly two separate
Caliper placement. Each caliper is placed at the ends of placental masses and discordant genders. Chorionicity
the ossified diaphysis without including the distal femoral is much better evaluated before 14–15 weeks (lambda
epiphysis if it is visible (Figure 1). This measurement sign or T-sign).
should exclude triangular spur artifacts that can falsely Abnormalities of umbilical cord insertion into the
extend the diaphysis length. placenta, such as velamentous cord insertion, are more

Copyright  2010 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2011; 37: 116–126.
120 Guidelines

common in multiple gestations and can be associated with Table 1 Recommended minimum requirements for basic
several pregnancy complications, such as fetal growth mid-trimester fetal anatomical survey
restriction, vasa previa and abnormal fetal heart rate
patterns37,38 . Unfortunately, many cases of vasa previa Head Intact cranium
Cavum septi pellucidi
may not be recognized during pregnancy39 .
Midline falx
Thalami
Follow-up of multiple pregnancies should be arranged Cerebral ventricles
in accordance with local guidelines and clinical practices. Cerebellum
Cisterna magna
Face Both orbits present
Anatomical survey Median facial profile*
Mouth present
Recommended minimum requirements for a basic fetal Upper lip intact
anatomical survey during the mid-trimester of pregnancy Neck Absence of masses (e.g. cystic hygroma)
are summarized in Table 1. Chest/Heart Normal appearing shape/size of chest and lungs
Heart activity present
Four-chamber view of heart in normal position
Head Aortic and pulmonary outflow tracts*
No evidence of diaphragmatic hernia
Skull. Four areas of the fetal skull should be evaluated Abdomen Stomach in normal position
Bowel not dilated
routinely: size, shape, integrity and bone density. All
Both kidneys present
these characteristics can be visualized at the time of the Cord insertion site
head measurements and when the brain is evaluated for Skeletal No spinal defects or masses (transverse and
anatomical integrity (Figure 2)40 . sagittal views)
Arms and hands present, normal relationships
- Size: measurements are performed as mentioned in the Legs and feet present, normal relationships
biometry section. Placenta Position
- Shape: the skull normally has an oval shape without No masses present
Accessory lobe
focal protrusions or defects and is interrupted only by
narrow echolucent sutures. Alterations of shape (e.g. Umbilical cord Three-vessel cord*
lemon, strawberry, cloverleaf) should be documented Genitalia Male or female*
and investigated41 .
*Optional component of checklist: can be evaluated if technically
- Integrity: no bony defects should be present. Rarely, feasible.
brain tissue can extrude through defects of the frontal
or occipital bones, although cephaloceles may occur at
other sites as well. Brain. Standard scanning planes for the basic examina-
- Density: normal skull density is manifested as a contin- tion of the fetal brain have already been described in an
uous echogenic structure that is interrupted only by cra- ISUOG guideline document19 which can be downloaded
nial sutures in specific anatomical locations. The absence from the Society’s website (http://www.isuog.org). Two
of this whiteness or extreme visibility of the fetal brain axial planes permit visualization of the cerebral structures
should raise suspicion of poor mineralization (e.g. osteo- relevant to the anatomical integrity of the brain. These
genesis imperfecta, hypophosphatasia)42 . Poor mineral- planes are commonly referred to as the transventricu-
ization is also suggested when the skull becomes easily lar and transthalamic planes (Figure 2). Imaging artifacts
depressed as a result of manual pressure from transducer may obscure the hemisphere closest to the transducer. A
placement against the maternal abdominal wall. third axial transcerebellar plane can be added to evaluate

Figure 2 Transverse views of the fetal head demonstrating standard transventricular (a), transthalamic (b) and transcerebellar (c) scanning
planes. The first two planes allow assessment of the anatomical integrity of the brain. The third permits evaluation of the cerebellum and
cisterna magna in the posterior fossa.

Copyright  2010 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2011; 37: 116–126.
Routine mid-trimester fetal ultrasound scan 121

the posterior fossa. The following brain structures should narrow field of view can help to maximize frame rates.
be evaluated: Images should be magnified until the heart fills at least a
third to half of the display screen.
- lateral ventricles (including choroid plexi);
- cavum septi pellucidi; Basic cardiac examination. The basic cardiac screening
- midline falx; examination is interpreted from a four-chamber view of
- thalami; the fetal heart. A normal regular rate ranges from 120
- cerebellum; to 160 beats per min. The heart should be located in the
- cisterna magna. left chest (same side as the fetal stomach) if the situs is
normal. A normal heart is usually no larger than one-third
Face of the area of the chest and is without pericardial effusion.
The heart is normally deviated by about 45 ± 20◦ (2 SD)
Minimum evaluation of the fetal face should include an towards the left side of the fetus49 .
attempt to visualize the upper lip for possible cleft lip
anomaly43 (Figure 3a). If technically feasible, other facial Extended basic cardiac examination. An extended basic
features that can be assessed include the median facial cardiac evaluation, which includes the aortic and
profile (Figure 3b), orbits (Figure 3c), nose and nostrils. pulmonary outflow tracts, can increase the detection rates
for major cardiac malformations above those achievable
by the four-chamber view alone. Views additional to
Neck those of the basic examination are more likely to
The neck normally appears as cylindrical with no identify conotruncal anomalies such as tetralogy of Fallot,
protuberances, masses or fluid collections44 . Obvious neck transposition of the great arteries, double outlet right
masses such as cystic hygromas or teratomas should be ventricle and truncus arteriosus. Normal great vessels
documented. are approximately equal in size and should cross each
other as they exit from their respective ventricular
chambers.
Thorax Some investigators have described an optional ‘three-
vessels and trachea view’ that may also be useful for
The shape should be regular with a smooth transition
evaluating the pulmonary artery, ascending aorta and
to the abdomen45 . The ribs should have normal
right superior vena cava, in terms of their relative sizes
curvature without deformities. Both lungs should appear
and anatomical relationships50 . For a more detailed
homogeneous and without evidence of mediastinal
description of fetal cardiac screening, the reader is referred
shift or masses. The diaphragmatic interface can often
to the ISUOG guidelines for the fetal cardiac examination.
be visualized as a hypoechoic dividing line between
This document can be downloaded from the Society’s
the thoracic and abdominal content (e.g. liver and
website48 (http://www.isuog.org).
stomach)46,47 .
Abdomen
Heart
Abdominal organ situs should be determined51 . The fetal
General considerations for cardiac examination. The stomach should be identified in its normal position on
basic and extended basic cardiac ultrasonographic the left side. Bowel should be contained within the
examinations are designed to maximize the detection of abdomen and the umbilical cord should insert into an
congenital heart disease during a second-trimester scan intact abdominal wall. Abnormal fluid collections of the
(Figure 4)48 . A single acoustic focal zone and relatively bowel (e.g. enteric cysts, obvious bowel dilatation) should

Figure 3 Ultrasound imaging of the fetal face. The mouth, lips and nose are typically evaluated in a coronal view (a). If technically feasible, a
median facial profile provides important diagnostic clues for cleft lip, frontal bossing, micrognathia and nasal bone anomalies (b). Both fetal
orbits should appear symmetrical and intact (c).

Copyright  2010 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2011; 37: 116–126.
122 Guidelines

Figure 4 Basic and extended basic views of the fetal heart. The basic cardiac scan is obtained from a four-chamber view (a) when both
ventricles are seen during end diastole (calipers). An extended basic scan of the great arteries demonstrates the left (b) and right (c)
ventricular outflow tracts. Separate arterial outflow tracts (calipers), approximately equal in size, exit their respective ventricles by crossing
over each other in normal fetuses.

Figure 5 Ultrasound imaging of the fetal cord insertion site, bladder with umbilical arteries, kidneys and spine. The umbilical cord insertion
site into the fetal abdomen (a, arrow) provides information about the presence of ventral wall defects such as omphalocele or gastroschisis.
The fetal bladder (b, *) and both kidneys (c, arrowheads) should be identified. Axial and longitudinal views of the spine provide effective
screening for spina bifida, especially when these scanning planes are abnormal in the presence of frontal skull deformation and an obliterated
cisterna magna (c,d).

be documented. Aside from the left-sided stomach, a fetal Cord vessels may also be counted using gray-scale imaging
gallbladder may be seen in the right upper quadrant next as an optional component of the routine anatomical
to the liver, although this latter finding is not a min- survey.
imum requirement of the basic scan. Any other cystic
Kidneys and bladder
structures seen in the abdomen should prompt referral for
a more detailed scan. The fetal umbilical cord insertion The fetal bladder and both kidneys should be identified
(Figure 5a) site should be examined for evidence of a (Figures 5b and 5c). If either bladder or renal pelves
ventral wall defect such as omphalocele or gastroschisis. appears enlarged, a measurement should be documented.

Copyright  2010 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2011; 37: 116–126.
Routine mid-trimester fetal ultrasound scan 123

Figure 6 Sonography of the fetal upper extremities, lower extremities and placenta. The presence or absence of the upper and lower limbs
should be documented routinely unless they are poorly visualized due to technical factors (a, b). Placental position should be determined in
relation to the maternal cervix (c).

Persistent failure to visualize the bladder should prompt cases. Loss of the echolucent space between an anterior
referral for a more detailed assessment. placenta and the uterine wall is neither a sensitive nor a
specific marker for placenta accreta. Although placenta
Spine accreta may be suspected during a routine mid-trimester
scan, a more detailed evaluation is usually required to
A satisfactory examination of the fetal spine requires
further examine this possibility.
expertise and meticulous scanning, and the results are
heavily dependent upon fetal position (Figures 5c and 5d).
Complete evaluation of the fetal spine from every pro- Genitalia
jection is not part of the basic examination, although
transverse and sagittal views are usually informative. The Characterization of external genitalia to determine fetal
most frequent of the severe spinal abnormalities, open gender is not considered mandatory in the context of a
spina bifida, is usually associated with abnormal intracra- mid-trimester routine scan. Reporting of gender should be
nial anatomy such as a characteristic cerebellar deformity considered only with parental consent and in the context
(banana sign) and obliterated cisterna magna. Other views of local practices.
of the fetal spine may identify other spinal malformations,
including vertebral abnormalities and sacral agenesis19 . Cervix, uterine morphology and adnexa

Several studies have demonstrated a strong correlation

Limbs and extremities between short cervical length on transvaginal scan and
The presence or absence of both arms/hands (Figure 6a) subsequent preterm birth. However, several random-
and both legs/feet (Figure 6b) should be documented using ized controlled trials that examined the combination
a systematic approach52 . Counting fingers or toes is not of routine cervical length measurement and subsequent
required as part of the routine mid-trimester scan. interventions (cerclage, progesterone) failed to demon-
strate conclusively any cost-effectiveness of such screening
programs57,58 . Currently, there is insufficient evidence to
Placenta recommend routine cervical length measurements at the
mid trimester in an unselected population59 .
During ultrasonography, the placental location (Figure
Identification of women with short cervical length may
6c), its relationship with the internal cervical os and its
have significant benefits for research purposes and further
appearance should be described. Examples of abnormal
intervention studies, but this is not a justification for
placental findings include the presence of hemorrhage,
routine cervical scanning. Such a universal screening
multiple cysts with triploidy and placental masses such
program would not only require significant resources and
as chorioangioma. In most cases of the routine second-
quality assurance, but also cause potential disadvantages
trimester examination, transabdominal ultrasonography
by introducing anxiety and unnecessary intervention.
permits clear definition of the relationship between
Uterine fibroids and adnexal masses should be
placenta and internal cervical os. If the lower placental
documented if they are likely to interfere with labor60 .
edge reaches or overlaps the internal os, a follow-up
examination in the third trimester is recommended53,54 .
Women with a history of uterine surgery and low REFERENCES
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124 Guidelines

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ACKNOWLEDGMENTS
Special appreciation to Jacques Abramowicz (USA), MD,
These guidelines were developed by the Prenatal PhD, for his contribution to the Safety section and to
Ultrasound Screening Task Force under the auspices of the Jean-Philippe Bault (France), MD, for providing some of
ISUOG Clinical Standards Committee; Chair, Dr Wesley the images.
Lee, Department of Obstetrics and Gynecology, Oakland
University William Beaumont School of Medicine, Copies of this document are available at:
Rochester, Michigan, USA http://www.isuog.org
Appreciation is particularly extended to specialty consul- ISUOG Secretariat
tants who contributed to this project: Unit 4, Blythe Mews
Blythe Road
Task Force Chair: Laurent J Salomon, MD, PhD
London W14 0HW, UK
Hôpital Necker Enfants Malades, AP-HP, Université
e-mail: [email protected]
Paris Descartes, Paris, France

Copyright  2010 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2011; 37: 116–126.
126 Guidelines

Mid-Trimester Fetal Ultrasound Scan Report Form

Patient: ID number: SONOGRAPHIC N Ab* NV
APPEARANCE OF FETAL
ANATOMY:
Date of birth (DD/MM/YYYY): (N=Normal; Ab=Abnormal*;
NV=Not visualized)
Referring physician: Gray=optional
Head
Date of exam (DD/MM/YYYY):
Sonographer / Supervisor: Shape
Indication for scan and relevant clinical information: Cavum septi pellucidi
Midline falx
Thalami
Gestational age (W + D): Lateral ventricle
Based on: LMP / Previous US / Other : Cerebellum
Cisterna magna
Technical conditions: Good / Limited by:
Singleton / Multiple (use 1 sheet/fetus) Face
=> Chorionicity: Upper lip
Median profile
PLACENTA: Position: Orbits
Relation to cervical os: clear covering mm from os Nose
Appearance Normal Abnormal* Nostrils
Neck
AMNIOTIC FLUID: Normal Abnormal* Thorax
FETAL MOVEMENT: Normal Abnormal*
Shape
No masses
MEASUREMENTS mm Percentile (References) Heart
Biparietal diameter Heart activity
Size
Head circumference Cardiac axis
Abdominal Four-chamber view
circumference Left ventricular outflow
Femur diaphysis Right ventricular outflow
length
Abdomen
Other: Stomach
Other: Bowel
Kidneys
Other: Urinary bladder
*Abnormal findings (please detail): Abdominal cord insertion
Cord vessels (optional)
Spine
Limbs
Right arm (incl. hand)
Right leg (incl. foot)
Left arm (incl. hand)
Left leg (incl. foot)
CONCLUSION: Gender (optional): M F
Other :
Normal and complete examination.
Normal but incomplete examination.
Abnormal examination*
Plans: No further ultrasound scans required.
Follow up planned in ….. weeks.
Referred to ……………
Other:

Produced Printed Stored

No. of images

Copyright  2010 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2011; 37: 116–126.