0:32

Well, it's great to be here.

0:33

Um, as she said in the intro,

0:36

I am a community radiologist.

0:40

I do have a specialty training in fetal ultrasound.

0:43

Um, but I do practice as a general radiologist

0:47

on my day-to-day world for the most part.

0:49

So my goal tonight is not to put in, you know,

0:55

general Show you a bunch of super esoteric cases

0:58

of things that you will never see to wow, you know,

1:02

the viewer or something like that. Um, really what

1:05

I'm going to show you are things that I actually

1:08

have seen people—my own partners in my own practice—

1:11

miss. Fortunately, we caught them before things went

1:14

south, but these are things that, um, things that

1:18

people do miss not infrequently and can, you know,

1:21

for lack of a better way of saying it, land in a courtroom

1:23

with a malpractice suit.

1:27

So my title is basically, how do

1:29

you stay out of trouble if you're, um,

1:32

interpreting obstetrical ultrasound?

1:34

Um, hold off on this for a second.

1:37

This is just a standard OB report.

1:39

I did do a noon conference, um, through this website

1:44

where I really just covered how to interpret a general

1:49

obstetrical ultrasound.

1:50

I went through sort of image by image, why we

1:53

take what we take and how to interpret it.

1:57

So I'm not going to get into all that again,

1:59

because that's an entire lecture, but I am just

2:02

going to do, um, a quick—this is supposed

2:06

to be, um, you know, a case-based review.

2:08

So we're looking at cases and, you know, if you're

2:10

reviewing a CT of the chest doing an interstitial lung

2:13

disease lecture, you'd go through a whole chest

2:16

CT, but with fetal ultrasound, you know, you're

2:18

basically scanning this baby from head to toe, and a

2:20

lot of times you're just focused on a couple areas.

2:22

So it's not that useful to do an entire scan

2:25

on every patient, but I am going to start by

2:28

just going through one scan that's normal-ish

2:33

and just kind of go through how I interpret it.

2:36

Um, this is the report that we use,

2:40

and you just want to, you know, go through quickly.

2:42

You're going to make sure there's one baby.

2:44

You're going to talk about whether it's

2:45

breech or cephalic or vertex, um, where the

2:48

placenta is, and make sure there's no previa.

2:51

You're going to look at the quantity

2:52

of amniotic fluid, measure the cervix,

2:54

make sure the uterus and ovaries are okay.

2:56

You're going to measure pretty much these

2:58

four biometric measurements: the

3:03

BPD, the head circumference, the abdominal

3:04

circumference, and femur length, which will

3:06

generate an estimated age based on ultrasound.

3:09

And you want to compare that to your clinical dates

3:12

in order to generate, um, a weight percentile.

3:17

Um, obviously there's a whole lot of, uh,

3:20

anatomic things that you want to look at.

3:22

And the impression is generally going to be, unless

3:24

there's something abnormal here, your assessment

3:27

of whether or not these sizes and dates are okay.

3:31

So let's pull up just this routine scan.

3:35

And I literally did just, I picked,

3:37

I think this is from, it's from 2017.

3:40

I picked it because we used to not, these

3:42

were all de-identified back in those days.

3:44

So this isn't by any means the perfect scan.

3:48

I didn't want to show you something perfect.

3:49

I just picked something that was

3:51

basically at random.

3:52

So this is how we scan it, how I go through it.

3:56

So, um, we typically take a picture of

3:59

the cervix first; you measure it, it's

4:01

over three centimeters, which is normal.

4:04

Um, this tech actually, which I like, decided to do a

4:08

color box over the internal cervical os,

4:12

which shows that there's no significant flow there.

4:15

That's looking for something called a

4:17

vasoprevia, or at least you're screening for that.

4:21

Um, then we're going to start taking pictures of the

4:26

one thing I think is incredibly important is to just

4:28

do a general overview of the uterus and fetus first.

4:34

So this is a long midline.

4:36

So we see that this is the

4:38

mom's head and the mom's foot.

4:39

So this baby is cephalic in presentation.

4:43

The placenta is posterior.

4:47

If you see the abdominal cavity and thorax filling.

4:52

the amniotic cavity and that there is fluid

4:57

surrounding the smaller parts, then you

5:00

know that the amniotic fluid is normal.

5:02

You do not need to measure an AFI in every case.

5:05

This is the gestalt way that you may not

5:09

realize why your eye might tell you that

5:11

fluid is normal, but that's what it is.

5:13

The body fills the cavity, and there's fluid

5:16

interspersed between the smaller parts.

5:19

Um, this is just transverse.

5:22

Some screening images.

5:26

Uh, we like to look at the cord insertion,

5:30

um, and whether it's really peripheral or

5:32

marginally located, or even a velamentous cord

5:35

where it comes in here and then, uh, moves over.

5:38

This is a nice central cord insertion.

5:42

Um, we measure the lateral ventricle.

5:45

Um, this is probably the most important

5:47

measurement in the entire study.

5:51

Um, it's going to be, well, as far as the brain goes,

5:54

um, I actually like to measure it kind of right across.

5:59

Sorry, where the choroid curves.

6:02

But the reality is if the, if the,

6:05

if the choroid is filling the lateral

6:07

ventricle here, it's going to be normal.

6:08

So this is a normal size ventricle.

6:10

Anything under 10 millimeters is normal.

6:12

She got five.

6:13

I just got about 6.5

6:15

6:15

Either way, it doesn't matter.

6:17

Um, this is a picture of the cavum septi pellucidi.

6:21

This is really important.

6:22

You want to see a nice, clear fluid

6:24

filled box here, and you want to make

6:29

sure the frontal horns of the lateral ventricles are

6:30

touching that the, uh, posterior fossa is here.

6:35

We're looking at the cerebellum.

6:37

Um, you want to make sure that the central

6:39

portion of the cerebellum, the vermis, is intact.

6:42

We'll add a Dandy-Walker malformation.

6:45

The, um, cisterna magna back here.

6:48

We don't routinely measure it.

6:50

The abnormal measurement is, is 10; 10 is gigantic.

6:55

So if, unless it looks incredibly large to you,

7:00

I don't really think it's necessary to measure it,

7:02

but a lot of people do. This is also a time you

7:04

might want to look at the nuchal thickness.

7:07

To measure the nuchal thickness, you have the cavum,

7:10

the thalamus, and the cerebellum.

7:13

Um, sometimes it's hard to see exactly

7:15

where the skull is and the skin.

7:17

Um, it's probably from about here to here,

7:20

but sometimes you have to get different

7:22

angles on there to really measure it properly.

7:25

Um, biparietal diameter, um, is just bone to bone here.

7:30

Uh, and it's at the level of the cereb,

7:32

I mean, sorry, the level of the thalamus.

7:34

And you just want to make sure it looks symmetric.

7:37

The head circumference

7:39

can be measured on the same image.

7:42

Uh, basically, um, you have the

7:45

cavum, the thalamus, and

7:47

the tentorium of the cerebellum.

7:49

The big mistake people make is including

7:52

the cerebellum, which is too, I think you

7:54

can see me on the video, is too angled this

7:57

way, so it would tend to over-measure it.

8:00

Um, this is the nose and lips, so this is the nostrils.

8:04

You're looking at a sort of a

8:05

coronal view, cut like this.

8:08

Um, the upper lip, you're just basically

8:10

looking to rule out a cleft here.

8:12

Another nice picture of the face.

8:16

Um, uh, the profile view, this is of course the one

8:20

that all the, uh, parents want, um, and we want it too.

8:25

But what I'm looking at on this is the nasal bone.

8:29

I want to make sure it's not really short looking.

8:32

I don't measure it in any

8:33

case, by any means.

8:35

Um, something like this is about normal.

8:39

Um, if it's half that, it's looking pretty short.

8:41

And you also want to make sure that the

8:43

nose is lining up with the chin here,

8:45

so there's no micrognathia, for example. In this

8:49

image, the sonographer was off axis a little bit, and

8:52

now it makes it look like the chin is really small.

8:55

Now we all know that can happen.

8:57

But if this was your only picture and the baby did

9:01

have a problem, you could get in trouble because you

9:04

didn't take this picture showing that it was normal.

9:07

So you just want to make sure while your

9:09

sonographer is taking these cute little

9:10

pictures for the parents that you're not

9:14

getting some abnormal, making it look abnormal.

9:17

So she did it again here and

9:19

even here to a certain degree.

9:20

Notice how the nasal bone is nice and long there.

9:24

Uh, the spine, look at the cervical, the

9:27

thoracic, they're going trans on the spine,

9:30

thoracic, and the lumbar spine, really not a lot

9:34

bad happens in the thoracic and cervical spine.

9:37

Um, what we want to spend most of our time in

9:39

is the lumbar spine, and you're looking for this

9:42

nice turn into the sacrum here, and there's skin

9:46

covering it, and you can see that point down there.

9:49

If you can see that, you know you're happy.

9:52

Um, you got to look at the kidneys,

9:53

which are always hard to see.

9:55

Some of the newer scanners are a little better.

9:57

You know, oftentimes this is about all you're

9:59

seeing is this kind of structure here that looks

10:02

a little round, a little, you know, different

10:04

from the surrounding bowel over here. To be

10:05

honest, I don't really see a kidney, but that's

10:09

why I like this picture, and this shows that

10:11

there are two renal arteries, and if there are two

10:13

renal arteries, there's going to be two kidneys.

10:17

An abdominal circumference.

10:18

You want to make sure you have the stomach.

10:20

This is the umbilical segment of the portal vein.

10:22

You really should have this curving here like this.

10:26

Not all your measurements are going to

10:28

be perfect, and that's okay, but you just

10:29

want to know that you tried your best.

10:32

This also should be fit to the skin.

10:34

So it's not fit here, and it's not fit there.

10:37

So it's not perfect, but it's pretty close.

10:40

And you know, it's reasonable.

10:43

Um, if there was a problem with the measurements later

10:47

on, um, you know, you might want to come back and look

10:50

at these, but you're basically, you're trying to fit.

10:53

Around structure to some around a circle

10:56

to something that's not entirely round.

10:58

So it's not always possible to get it perfect.

11:01

Uh, we look at the cord insertion to make

11:02

sure there's no gastroschisis or

11:05

omphalocele, and we don't see anything here.

11:08

A lot of times the legs get in

11:09

the way, so that's just normal.

11:11

The bladder is present.

11:13

We see a three-vessel umbilical cord.

11:16

So the key thing here is that you want to see

11:19

the vessels touching both sides of the urinary bladder.

11:23

If it's not touching the urinary bladder on both sides,

11:26

it's not a three-vessel cord. Here's a femur length.

11:30

They've done a nice job.

11:32

This is actually the femoral head that's cartilaginous

11:34

and the femoral condyles, which are cartilaginous.

11:37

You want to make sure that you measure just from the

11:40

end of the bone here to the end of the bone here.

11:41

Sometimes you'll get a fake-out little, what we

11:44

call a femoral point, which is a specular reflection

11:48

off of this cartilage, and people will over

11:50

measure that, and that causes, uh, over-measuring.

11:56

The lower extremities.

11:58

Um, I like to see a picture of the tibia and

12:01

fibula together with the ankle in cross-section.

12:05

You don't want to see a foot coming

12:06

off to the side here like this.

12:08

That would be a club foot.

12:09

So this looks pretty good.

12:11

That's probably okay.

12:13

I don't love it, but I don't

12:15

see anything horrible there.

12:17

So it's, you know, again, I'm not

12:18

showing you the most perfect case.

12:20

I want to show you something that's realistic.

12:23

Um, I prefer when the sonographers

12:26

actually label which feet and which leg it

12:29

is, 'cause this could just be any foot, but

12:31

you see sort of one there and one there.

12:34

So the feet are present, um, which

12:36

is really the most important thing.

12:38

There's one arm and hand that's present.

12:40

I like to just make sure I see the forearm and hand,

12:43

so there's not some sort of limb reduction abnormality.

12:48

Here's the other hand kind of tucked behind the

12:50

head here, which is also not that infrequent.

12:53

Um, but you see two bones in

12:55

the forearm, so I'm happy there.

12:57

Um, this baby is flipped over, so we're

12:59

not getting a great view of the heart,

13:02

but what we do see is four chambers.

13:06

So here's the spine.

13:08

Which means this is posterior.

13:09

This is anterior.

13:11

I'm going to draw a little line on here.

13:13

If you draw a line from the spine through the sternum,

13:19

sorry, just move this over a little bit, the mid-spine

13:24

through the sternum, which is going to be somewhere

13:28

in here, you can't see it that well, and then draw

13:31

an angle down along the, um, interventricular septum.

13:37

This should be about a 45-degree angle, which it is.

13:42

The most anterior chamber in the

13:44

heart is the right ventricle.

13:45

So we know this is the right ventricle, the

13:47

right atrium, the left atrium, which should

13:50

touch the aorta, and the left ventricle.

13:53

There's a little bright dot in the heart

13:55

here, so we'll keep an eye on that.

13:58

Here's an even worse picture of the heart, so

14:01

that doesn't really help us, but I feel like

14:03

we've confirmed that our axis is pretty good.

14:06

The heart isn't shifted one way or another,

14:08

and we see four chambers, so I would

14:10

pass this four-chamber view of the heart.

14:15

This is the three-vessel view, which is not very good.

14:19

In this case, um, this should look like a, this

14:23

is the pulmonary artery going into the ductus.

14:26

So it's a longer sort of, some

14:28

people call it the dot-dot-dash.

14:30

So it's, it's a longer dash.

14:32

And then this dot would be the aorta, and

14:34

this dot would be the superior vena cava.

14:37

This is not the greatest one in the world.

14:40

Um, they're trying to do it again here.

14:43

It's not great.

14:45

Would I pass it?

14:46

Probably knowing that, you know, this tech is

14:49

really good and she knows what she's doing.

14:51

But if you didn't pass this image, um, and wanted them

14:56

to repeat it, then I wouldn't fault someone for that.

15:00

Here's the right ventricular outflow tract.

15:02

So this is more of a sagittal view.

15:04

So here's the sternum over here.

15:06

This would be the right ventricle

15:07

and the right ventricular.

15:08

So right ventricle is most anterior.

15:10

So that's the RVOT coming out.

15:12

Sagittal view.

15:13

That looks good.

15:15

And it's wrapping around the aorta in

15:17

cross-section, which is what you want.

15:20

That's supposedly the LVOT.

15:22

I would not pass that, but however, this is good.

15:26

This is the aorta coming out.

15:28

Here's the anterior wall of the aorta.

15:30

And the criteria is that the anterior wall of the

15:32

aorta has to line up with the interventricular septum.

15:35

So this line should go into this line, and you're happy.

15:40

So this is a passable LVOT.

15:44

It's a boy, and that's the end.

15:47

But now this is fairly critical.

15:50

A lot of people, and I see, um, legal cases where people

15:54

don't do any cine clips, and I'm telling you cine clips,

15:59

people think, oh well, if I take a cine clip I'm gonna,

16:02

you know, miss something that would be documented.

16:07

I will tell you, for the vast majority of cases, the

16:10

CineClip often saves people because they ended up

16:12

seeing something, or it saves them because they, um,

16:19

because there was something that wasn't taken a still

16:22

picture of, but it's in the CineClip and it's normal.

16:25

So I'm going to show you what I look for in the heart.

16:27

Again, this isn't the greatest heart picture.

16:30

Maybe we have another one, but I will

16:32

show you something as we go through here.

16:34

We scan back up.

16:36

And we're going to scan from, sorry, from the

16:41

four chamber view up towards the head into

16:43

this three vessel view that we saw before.

16:46

And there's that pulmonary outflow tract going into

16:50

the ductus with the aorta and the superior vena cava.

16:54

So I'm looking at that here.

16:56

It's actually a little better here.

16:57

You see it here, here, and here.

16:59

So at that point, I would feel okay about passing it.

17:02

We talked about earlier before

17:03

that it didn't look so hot.

17:06

Here's another four chamber view of the heart.

17:08

Okay.

17:09

So this is better.

17:10

So.

17:10

What I mainly do when I'm looking at the four

17:13

chamber cine is I'm looking at these valves.

17:16

I'm looking at, so this is the

17:17

right ventricle and right atrium.

17:19

So that's the tricuspid valve.

17:21

And I want to make sure that I see the

17:24

valve opening and closing here, that

17:27

there's basically, you know, two leaflets.

17:29

There's a, you can kind of see

17:30

them as they go back and forth.

17:32

The left ventricle, it's a little harder to see.

17:36

Let me see if we kind of scroll back through it.

17:39

I don't see a great.

17:40

I don't see a great mitral valve here.

17:45

But I do see a tricuspid valve.

17:47

So, you know, that's not required.

17:49

So I'd probably be okay with this, but I am seeing

17:53

a couple of times this little echogenic structure.

17:55

So that's probably an echogenic intracardiac

17:57

focus, which is a soft marker for Down syndrome.

18:01

We'll talk about that a little later.

18:02

Actually.

18:03

I like to do a nice cine through the whole body.

18:06

So it goes bladder, bowel, you're into the,

18:10

that's actually the gallbladder right there.

18:13

You're into the stomach right here.

18:18

And from there you go into the heart and you see that

18:23

the heart is pointed to the same side as the stomach.

18:25

So that's always a critical thing to see.

18:29

It doesn't really show us much more than that.

18:33

And then here's a cine clip of the head.

18:35

Um, so again, we see the lateral ventricle, this

18:38

choroid filling it, so we know it's normal.

18:40

We see the cavum with the frontal horn

18:43

touching it, so we know that's normal.

18:45

Here's the cerebellum with an intact

18:48

vermis, so we know that's normal.

18:50

So in this one little cine clip here, we've

18:53

cleared the entire head, which is nice.

18:56

And so that's.

18:57

I know I went through that pretty fast,

18:59

but I just wanted to go through one scan to

19:02

kind of show you how I would just approach it.

19:06

Um, and again, if you really need to, you

19:08

can go back and review that other lecture

19:10

I did for, um, for the noon conference one.

19:15

Uh, so this is case one, I just grabbed obviously

19:18

the salient images, which are going to be the

19:20

things with the abnormality, but threw in some

19:22

other ones to do it as sort of a case review.

19:25

So you're not just shown the

19:27

abnormality and know what it is.

19:28

So I'm going to go through these, and I'll ask

19:30

you to just look at them and make a decision

19:33

as to what you think the abnormality is and

19:36

then we'll go do a little quiz at the end.

19:39

So I'll just hold a few seconds on each one.

19:41

These are pictures of the head.

19:47

decide if you see anything abnormal.

19:54

And there's usually going to be

19:55

a label, so spine, profile, CSP.

19:59

We did just talk about a

20:00

little bit of what these should

20:01

show.

20:11

So again, the labels, three vessel view, heart.

20:20

And I will, on occasion, throw in

20:21

some of these biometric tables.

20:24

They tend to have a lot of information in them.

20:29

But for the most part, they're all relatively similar.

20:32

So, you know, sometimes there's, you know, a little

20:37

bit of an adaptation to a new one, but for the most

20:39

part, they kind of have, they all look fairly similar.

20:50

Okay.

20:50

So here's the first poll.

20:52

I think Ashley's going to put one up.

20:55

So what else would you like to see?

20:57

Um, a cine clip of the heart, a cine clip of the

21:00

brain, Doppler of the middle cerebral artery, or

21:04

would you like me to get an amniotic fluid index?

21:07

And there's going to be at least one best answer.

21:11

All right.

21:12

So half of you said cine clip of the heart.

21:14

That is the correct answer, which

21:16

I assume is why it's in red.

21:18

Oh no, it's red because it was the

21:19

most, uh, cine clip of the brain.

21:21

No one wanted Doppler of the MCA, which is good.

21:23

And someone wanted an AFI.

21:26

So why in the heck do we want a cine clip of the heart?

21:30

I'm going to show you the cine clip now, and let's see

21:35

what you think.

21:44

So what this

21:46

shows, and I'll try and freeze it.

21:50

So if you look at, let's go back for

21:52

a second to that picture of the heart.

21:55

So this was that three vessel view.

21:58

This is actually better than the

21:59

one we saw on the study I reviewed.

22:01

So here's a nice long ductus arch, the

22:06

aorta in cross section, and the SVC.

22:08

These should go progressively backwards.

22:11

And these two should be about the same

22:13

size, but if anything, this would be a

22:14

little bigger, but what do we see here?

22:18

Um, this is supposed to be a

22:20

four chamber view of the heart.

22:22

Uh, I see what's probably the

22:24

left ventricle and a left atrium.

22:27

I'm not really seeing.

22:29

Much here and much here.

22:31

So there's nothing here.

22:32

I could definitively call a four chamber view.

22:36

When we look at this,

22:42

what you see here is that there's basically

22:45

one giant valve leaflet, a giant mono valve.

22:53

And you can see it right there.

22:57

Here's one leaflet and the other leaflet.

23:00

And as it opens, it's basically this giant

23:03

gaping hole in the middle of the heart.

23:05

So this is an AV canal defect,

23:07

highly associated with Down syndrome.

23:10

Um, and this is, um, a very severe abnormality, which

23:16

shockingly, as bad as it is, is not that hard to miss.

23:20

Fortunately, they're not super common, but

23:22

they're common enough that they happen.

23:25

And I'm going to show you again, this is

23:27

a better four chamber view of the heart.

23:28

It happens to have an echogenic

23:30

intracardiac focus like this.

23:31

That other one we looked at.

23:33

But if you see here, and it's going a

23:35

little fast, but, so again, and spine.

23:39

So this is anterior.

23:40

So you have the right ventricle, right

23:42

atrium, left atrium, left ventricle.

23:45

And you see, I hope you can see that with

23:47

each of these, you see two valve leaflets here

23:50

and you see two valve leaflets there opening.

23:53

And that's really, I spend literally five

23:55

seconds on each cine clip of the heart,

23:57

just making sure I can see those valves.

24:00

Um, just as an aside on this case, the other

24:03

thing we saw here was, remember, we like to

24:06

see the nasal bone coming down to probably

24:08

about here, so it's a short nasal bone.

24:11

And also the femur length here as well as the

24:13

head, but the femur length was kind of small.

24:16

You said cine clip of the head because of

24:17

this, that's not unreasonable, but the pictures

24:20

we showed were pretty normal, but this short

24:23

femur goes along with Down syndrome as well.

24:26

So this is the problem here.

24:28

So here's another example.

24:29

This was actually the case I mentioned that one of

24:32

my partners and our tech missed and called normal.

24:37

Um, so this...

24:39

It shows this big monoventricle again.

24:43

Here's that same picture showing

24:45

the valves opening normally.

24:47

But here's the problem.

24:49

If the tech is always going to try and take a

24:51

picture that looks normal, they're not going

24:54

to want to take a picture that looks like this.

24:56

This is a four chamber view of

24:57

the heart that I froze in here.

25:00

It looks horrendous.

25:01

I mean, it doesn't look like anything that

25:02

resembles four chambers, but look at where

25:06

to go, look at how you can freeze this.

25:10

Sorry.

25:10

Okay.

25:11

Look how you can freeze this image.

25:13

This

25:15

actually looks pretty good.

25:16

Now, I don't really see a good, um,

25:20

interatrial septum, but I see a pretty

25:23

good interventricular septum-looking thing.

25:26

This could pretty much be passed pretty easily.

25:29

So this is the main thing I want to show you is that,

25:32

um, cine clips are so important and you can make

25:39

an abnormality as bad as this look as normal as that.

25:43

So that's why I'm just a plug to make

25:45

sure you take cine clips of the heart.

25:49

Um, this kind of goes back to what I was

25:51

showing you before, how we look at the heart.

25:54

Um, I'm not going to go into this all right

25:57

now, to be honest, we talked about the axis.

26:02

If you actually go back here on this

26:04

one, this could have been one way you

26:06

might not have gone down the tubes.

26:08

If you look at this line here and here, that axis

26:13

is probably a little bigger than 45 degrees, but

26:17

it'd be pretty hard to, you know, pick that

26:21

up necessarily unless you were really clued in.

26:27

This was just a quick companion

26:29

case talking about soft markers.

26:32

Um, EIFs or echogenic intracardiac

26:34

foci have come up a few times.

26:36

They tend to be a very benign finding.

26:40

Um, we see them not infrequently, and

26:43

I'll show you how I dictate them.

26:45

But if you see one, you have to make

26:47

sure there are no other soft markers.

26:50

So there cannot be any mild fetal pelvic ectasia.

26:54

There cannot be echogenic bowel.

26:57

The nuchal thickness cannot be too much, and

27:01

too much would be, um, six millimeters.

27:07

But the problem is in this

27:08

case, this fetus is 28 weeks.

27:11

So it's a week past.

27:13

Um, I mean, it's eight weeks past

27:15

when we should be measuring it.

27:16

So it really doesn't count anymore.

27:18

I think that that's at eight millimeters, and

27:21

the baby's head is, if you can see me flex

27:23

backwards like this, or extended, I should say.

27:25

So it's going to increase it.

27:26

So that's not really

27:28

relevant to this case, but I just showed

27:30

it so that you know if you see an EIF,

27:33

make sure none of these other things exist.

27:36

Um, in this baby, actually, the

27:38

femur length was kind of short again.

27:41

Um, so that could be a soft marker.

27:45

But the main thing is you want

27:47

to measure the nuchal fold.

27:48

This is kind of going to what I showed you before,

27:51

how depending on how you image, it can make it

27:55

hard to know where the bone ends and the skin is.

28:00

You can get varying measurements.

28:01

So it's very easy to overmeasure

28:04

it, but you can't ever really under

28:06

measure it if you're in the right plane.

28:09

So what I like to do a lot of times is go

28:10

to that cervical spine image and measure it

28:12

sagittally right along at the bottom of the

28:15

nuchal bone, sort of perpendicular to it, and

28:18

you can usually get a pretty good estimate.

28:21

Um, so what is an EIF?

28:22

It's an echogenic focus in the papillary muscle.

28:26

They tend to be in the left ventricle.

28:29

There's an association with Down syndrome, but it's not huge.

28:33

Um, what you want to say is to, this is my verbiage.

28:37

Basically, in the absence of other risk

28:40

factors, so the mom isn't 35 or older, there's

28:42

none of these other soft markers, then it's

28:44

basically going to be a normal variant.

28:46

But you just make sure if you're going to use

28:49

a dictation template, something like this, that

28:52

you clear that those other things aren't there.

28:55

There can't be a second soft marker.

28:58

Okay, so case number two.

29:01

This actually, this case happened like three weeks ago.

29:06

And again, I'm not, I don't work at a

29:08

big, you know, tertiary care hospital.

29:11

This is a community hospital.

29:13

So I'm going to walk you through

29:15

exactly how this happened.

29:16

The tech was, and I'm not kidding, was,

29:18

this was literally at 4:55 and I was.

29:22

Heading out at five and the tech comes

29:24

to me and says, "Hey, what's this?

29:26

There's this weird thing in the fetus.

29:29

So I want you to look at that and look at that

29:31

and tell me, and here's a cine clip of it.

29:34

Maybe you can make a decision

29:35

about what you think that is.

29:43

And then

29:45

this was another picture she showed

29:47

me, and it shows something right here.

29:51

This is hard to pick up.

29:52

This is that structure again, but I'll just

29:54

tell you, this is a little bit of ascites.

29:56

She picked that up and she goes, "You

29:58

know, I think this baby's got ascites."

30:03

So the question is, what do

30:06

you think that other thing is?

30:07

And then I want you to look at this picture right here.

30:18

I'm giving you a second.

30:19

So you can just

30:20

kind of look at each number and, and

30:25

see if there's anything that you don't like

30:27

or something else you would want to see.

30:31

Okay, I think this is going to be

30:32

the next, um, poll quiz, Ashley.

30:37

So, the question is, are you happy with this?

30:39

What else do you need?

30:40

Cine clip of the heart again, cine clip of the

30:42

brain, uh, clinical due date, or nuchal thickness?

30:46

So I'll give you a few seconds to answer that.

30:50

Excellent.

30:50

So, clinical due date, which got 50

30:53

percent of the votes, is the right answer.

30:59

So I'm going to tell you exactly how this went down.

31:02

So I didn't quiz you on what this is, but this

31:04

is actually a thickened gallbladder in the fetus.

31:07

So I saw this thickened gallbladder.

31:10

I saw this ascites.

31:13

And, um, oh, to add insult to

31:16

injury, and I'm literally not making

31:18

this up, this patient was, uh, deaf.

31:21

So I'm trying to communicate with her.

31:24

She's trying to read my lips.

31:25

This is, you know, when we're

31:27

supposed to be wearing masks.

31:28

I got someone else on the phone

31:30

who's trying to translate for her.

31:32

It was like FaceTiming her and signing to her.

31:35

It was nuts.

31:37

Um, but I want to go back to something.

31:39

And I, and I hadn't really paid

31:42

that close attention to this yet.

31:44

I was just sort of freaked out by, Whoa,

31:46

why does this baby have a really thick

31:48

gallbladder wall and why does it have ascites?

31:50

So I called the physician who was of course, someone

31:55

covering and doesn't know this person at all.

31:58

Through like our local Medicaid clinic.

32:01

And they said, "Oh, you know, well, I don't

32:04

know what to do about thickened gallbladder

32:06

with ascites, but the baby's 35 weeks.

32:09

So there's really nothing we can do.

32:11

So I'm, you know, you can send her, send

32:15

her home and we'll follow up with her.

32:17

And I said, okay.

32:19

Sounds fine.

32:19

Why don't we do that?

32:21

So then I go back to looking at this biometry

32:25

sheet, and I noticed there's no clinical due date.

32:29

So the clinical due date you have

32:32

to have in order to assess this.

32:37

To compare to for the size.

32:39

So if the clinical due date says this baby's supposed

32:41

to be 32 weeks, then obviously that baby's too big.

32:45

If it's supposed to be 38 weeks,

32:46

then obviously this baby's too small.

32:49

The other thing about this case, just

32:50

again, like this was all, this was

32:52

like the culmination of everything bad.

32:54

The tech was brand new.

32:57

She had been working with us for a couple of months

32:59

and wasn't really familiar with the software.

33:00

So she couldn't really figure

33:02

out how to do the due dates.

33:04

This patient was deaf.

33:05

She wasn't sure, there was some discrepancy.

33:07

So I finally got the due dates.

33:10

Um, and one thing that I mentioned on the first study

33:14

we looked at, this is the femoral condyle cartilage.

33:21

And you see this little.

33:22

Point coming off here.

33:24

That's not what you want to measure.

33:26

You want to measure right to the end here.

33:27

So I remeasured it. You can see it actually

33:32

made a reasonable difference: 35 weeks, three

33:35

days down to 32 weeks, four days. So that can

33:38

make a pretty solid difference. And when we put

33:41

in her clinical due dates, all of a sudden we

33:43

find out that this baby is in the 4.

33:47

5th percentile.

33:49

So less than the 5th percentile

33:51

is intrauterine growth restriction.

33:54

So this is all happening after I've talked

33:56

to the doctor and was about to send her out.

33:59

And I'm starting to look at this and I started

34:00

realizing, hey, we don't have dates here.

34:03

So now I'm like, okay, God, now we've gotten

34:05

intrauterine growth restriction and this other thing.

34:07

So let's go to the next poll quiz.

34:13

So what do you want now?

34:15

Now do we want to do a cine of the heart?

34:17

Do we want to make sure there's a three-vessel chord?

34:20

Do we want to Doppler the cord, or do we just

34:23

want to make sure we reiterate to the patient?

34:25

This is super important that you keep

34:27

your follow-up, um, but send her home.

34:31

Excellent.

34:32

So we got a hundred percent on

34:33

Doppler of the umbilical artery.

34:34

So when we have, um, intrauterine growth restriction,

34:41

let's take the gallbladder wall thickening

34:44

and ascites out of the picture for a second.

34:46

Just say you have IUGR,

34:49

you ideally, we want those

34:52

fetuses to go to term.

34:54

So you want to get them to 37, 38 weeks, if you can.

34:58

And you're playing this dance trying to figure

35:00

out, well, how long can we leave this baby in?

35:02

So the obstetrician will do non-stress tests.

35:06

We will check for amniotic fluid volume

35:09

and make sure they're not developing oligohydramnios.

35:11

And the other thing we can do is look at Dopplers.

35:14

And if any of those three things turn bad

35:17

or multiple of them turn bad, then your hand

35:20

is sort of forced to deliver.

35:23

So again, after all this, I go back in and I

35:25

do Dopplers and we see the umbilical artery.

35:29

I use the SD ratio.

35:30

Some people can use resistive index.

35:32

We use the SD ratio.

35:34

It's 5.

35:34

9.

35:36

This should be three or less, which means

35:39

a low, much lower resistant circuit.

35:43

So you can see here, there's

35:44

almost no diastolic flow.

35:47

In fact, here, it almost looks

35:49

slightly reversed, which is pretty bad.

35:52

And then we look at the middle

35:53

cerebral artery Doppler, and it's 2.

35:56

4.

35:58

Um, and this is a much lower resistant waveform,

36:01

where it should be much higher resistant.

36:03

So,

36:06

there's charts and all this kind of stuff,

36:07

you can look up to know what these are, but

36:09

there's a very simple rule you can follow.

36:12

After 30 weeks, which is when we see IUGR, some

36:14

people will say after 28 weeks, the SD ratio in

36:18

the umbilical artery should be less than three.

36:21

Great.

36:22

The middle cerebral artery Doppler should

36:24

just be more than the umbilical artery.

36:26

So in here, this is clearly not less than three.

36:30

This is clearly not greater than the umbilical artery.

36:33

So this is very abnormal.

36:36

So call the doctor back.

36:38

And I said, you know, actually I couldn't

36:41

even get in touch with him again.

36:42

So I just sent her to labor and delivery and I

36:44

called the on-call hospitalist and they called me

36:49

back later and said, you know, this was actually

36:52

the worst strip I've seen in years, meaning like

36:56

the baby's stress, the non-stress test, the, uh,

37:00

decelerations, the heart rate, the, the movement, all this

37:04

stuff, they sent her to a crash C-section.

37:07

So.

37:08

She went from literally like almost going home

37:11

to a crash C-section that saved the baby's life.

37:14

So I think, I just thought this was a very important case

37:18

to illustrate mostly the importance of making sure you

37:21

have accurate clinical dates and how you handle that.

37:26

You never, anytime you identify

37:28

an IUGR fetus, do not send them home.

37:32

Make sure you call the physician first.

37:35

Make sure you check the Dopplers.

37:39

Oh, keep you out of big trouble.

37:41

This is just an example of a normal.

37:43

So your question is the SD ratio in

37:45

the meal of artery less than three.

37:47

It's 2.2

37:48

37:48

Yes.

37:50

Is the SD ratio in the MCA greater than 2.21?

37:53

37:54

Yes, it's normal.

37:57

So that's just an example of a nice normal case.

38:00

Okay.

38:00

Next one.

38:10

This is the measurement of this.

38:11

If you couldn't see it.

38:23

Okay.

38:24

Next poll.

38:26

Um, what else would you like to see?

38:28

Better femur length measurement.

38:30

Next one.

38:31

Cineclip of the brain, a view of the

38:33

distal spine, or an amniotic fluid index.

38:40

Ashley, will you just show the

38:41

answers when I guess they're in?

38:42

Yeah, perfect.

38:43

Thank you.

38:44

So 50 percent of people said cineclip of

38:46

the brain, which is the correct answer.

38:50

Let's talk about why.

38:53

I'll take a look at the cineclip here.

38:57

So again, not an esoteric case.

38:59

This was also a very recent case.

39:02

Um, the person I saw miss this was not a fetal

39:06

person, but he's actually a neuroradiologist.

39:09

So I'm just, I'm showing you

39:11

things that are actually missable.

39:14

And what is the problem here?

39:16

The problem here is that the cavum, as we

39:23

mentioned before, I think I have a better,

39:26

uh, do you get a regular picture of this?

39:30

Yeah.

39:31

So here's this case.

39:33

The cavum.

39:34

Well, here, let me just show you this.

39:37

This is what the cavum should be.

39:38

We talked about it a little bit before.

39:41

It should be, basically, a clear fluid

39:45

filled box with the frontal horns of

39:50

the lateral ventricles touching it.

39:53

These are, you know, why we do it.

39:56

'Cause we want to main thing is to rule

39:58

out agenesis of the corpus callosum.

40:00

Septo-optic dysplasia is also something that

40:03

happens if you're diagnosing holoprosencephaly.

40:05

Based on an absent cavum, you've probably got bigger

40:08

problems than this lecture to deal with.

40:11

Um, so here's that square.

40:13

These are touching it.

40:15

So we know it's normal.

40:17

Look at this case.

40:18

This is clearly not a square.

40:20

It's sort of this abnormally shaped area.

40:24

So we don't like that.

40:25

And then if you look, this

40:27

frontal horn is not touching it.

40:31

So this is just some interhemispheric fluid.

40:34

We don't have this horn

40:37

with closer view; this horn also not touching it.

40:42

And I want to go back to this

40:43

cine clip for one other thing.

40:50

What you also might see is this kind of teardrop

40:54

shaped ventricle, which you can get with.

40:56

Um, agenesis of the corpus callosum.

41:00

If we could see this one a little better,

41:02

these would look really parallel, but going

41:04

back to this cine clip, as I scroll through,

41:11

you can see that that structure in

41:14

there is clearly not; it's just kind

41:16

of this irregular fluid-filled space.

41:18

So this is agenesis of the corpus callosum.

41:24

Live and die by this rule right here, and you

41:26

won't miss it if you try and sort of pass it.

41:29

Okay.

41:29

You'll get into big trouble.

41:31

And this is a really big one

41:33

that can take you down the tubes.

41:35

Um, seriously, I see a lot of really poor

41:41

cavum pictures that, um, that people pass.

41:45

And fortunately, most babies come out

41:48

okay.

41:49

Um, I remember doing my fellowship at UCSF.

41:51

I used to think that half of all

41:53

babies had some sort of malformation.

41:55

And then I came to a community hospital

41:57

and realized that 99% of 'em do just fine.

42:00

But, you know, that's the fortunate side.

42:03

But the problem is you get lulled

42:04

into a sense of complacency.

42:06

So in this case, that's actually a

42:08

triangular structure, fluid structure.

42:12

The frontal horn is not touching it.

42:16

Here's another example.

42:17

There's kind of a, maybe a box,

42:19

but the frontal horns way out here.

42:21

And this one's way out there.

42:23

Here's something again, almost more

42:25

like the one we just saw, kind of your

42:27

regular frontal horns way out here.

42:30

So your eye and your tech

42:34

are going to really want to

42:36

invent a normal cavum.

42:39

Techs want nothing more than to

42:41

take pictures that are normal.

42:43

And that's a lot of times how

42:44

you end up getting tripped.

42:48

Okay.

42:49

Next

42:50

case.

42:55

And I don't remember what these are either.

42:57

So I'm looking at them as we do too.

43:06

And Ashley, there's

43:06

going to be a next poll coming up here.

43:13

Okay.

43:15

What else would you like to see?

43:17

Sending clip of the heart or the heat, I guess it

43:19

says, better abdominal circumference image,

43:25

an endovaginal image, or an amniotic fluid index.

43:29

So one person said endovaginal

43:32

image, a bunch of people said heart.

43:34

So actually the answer is endovaginal image.

43:37

Um, so I'm just going to go back to the picture.

43:39

If you see here, the cervix, here's the

43:42

placenta; it's completely covering the cervix.

43:45

I'm just going to go through

43:46

these pictures really fast.

43:48

Um, you may not have liked this cavum picture.

43:51

If that's why you said.

43:54

Well, actually, this one looks pretty good.

43:55

There's a box here.

43:57

It is probably hard to tell that these are touching.

43:59

So I will give you that if you, so I can't remember

44:02

looking at more pictures of that head was part of it.

44:06

Um, this wasn't the best four-chamber view.

44:09

So saying that the four, uh, cine clip

44:12

of the heart would be not unreasonable.

44:15

These look pretty good.

44:17

That looks good.

44:19

So anyway, so we did a Cini, this

44:24

is a Cini clip of the cervix.

44:27

And we see basically that the endocervical canal

44:33

here is completely covered by the placenta.

44:37

So this is a previa.

44:39

We used to call it a complete previa,

44:41

and then we'd have marginal previas.

44:43

Now it's just either a low-lying placenta

44:46

if the placental tip is two centimeters or more away,

44:51

and a previa if it comes within

44:55

two centimeters or even covers it.

44:57

But in this case, I would dictate this

44:59

as complete previa, and I would measure

45:02

probably how much it goes across.

45:05

Um,

45:08

so, uh, here's our next poll question.

45:11

So what is the appropriate

45:12

recommendation when you see a previa?

45:14

Is this person automatically going to C-section?

45:18

Do we just do a follow-up at 32 weeks?

45:21

Do we not need any follow-up, or do we send

45:24

the patient immediately to labor and delivery?

45:31

And just, this should probably be pretty fast.

45:34

So you can throw up the answers.

45:37

Okay.

45:38

I figured that would be a hundred percent.

45:39

That was good.

45:41

And then, so here's our 32-week follow-up.

45:44

We see the endocervical canal

45:49

in the picture.

45:50

And, um, yeah, cause I had another question.

45:54

All right.

45:54

So, so what's our recommendation now?

45:59

Is it still there?

46:00

Does the patient need a C-section?

46:02

Uh, has the previa resolved and we no longer,

46:06

and we don't need to follow it anymore?

46:08

Um, did we need more images, or is there

46:12

a marginal previa still present?

46:13

Recommend repeat in four weeks.

46:16

All right, so we got a previa resolved,

46:18

no further evaluation, we needed additional

46:20

images, or marginal previa is still present.

46:23

So, let's go back to this for a second.

46:27

So here's the endocervical canal.

46:29

The placenta is gone.

46:32

I will give you that.

46:33

This is probably some hair.

46:35

If you thought that was a

46:36

marginal previa, that's fine.

46:38

But there is no placenta previa seen.

46:42

So this is where you get in the trap, though.

46:45

Anytime you've had a complete previa

46:49

like that, there's a really critical

46:51

other image you want to do at the end.

46:54

And that is what I mentioned.

46:55

You probably don't remember, but on the very

46:57

first or second image of the case, we went over,

47:01

the tech had done a color image of the cervix.

47:05

And here they decided to put color on, and we

47:09

see some color, and you always will because

47:12

there are all kinds of maternal vessels here.

47:15

So what do you want to do?

47:15

You want to take a picture of these

47:19

vessels with spectral tracings.

47:23

And we see this spectral tracing

47:25

right here, which is in the cervix.

47:28

And that's a maternal heartbeat,

47:29

probably 60, 70, or 80 beats a minute.

47:32

They didn't measure it, but

47:34

look at this fetal heart.

47:35

I mean, look at the tracing on this vessel.

47:37

It's, I mean, that's a fetal heart rate.

47:41

So what is this?

47:42

This is a vasoprevia.

47:45

So, when you had this, this, um, placenta covering

47:54

right here, remember that, uh, again, I think

47:58

you can see me, but it's always hard to know.

48:01

I'm not sure what you see.

48:03

You can see me.

48:04

Okay.

48:05

Um, when you have the placenta, the cord goes

48:08

into it, and then fetal vessels branch out and

48:12

dive down into the placenta, and that's where

48:14

they get their, um, blood flow to go the blood

48:17

and the nutrients and oxygen, everything to

48:18

go back to the fetus from the mother.

48:22

So remember, lying all along here are fetal vessels.

48:27

Okay.

48:27

So what happens is this, this placental tissue,

48:30

either, you know, infarcts, atrophies, or regresses,

48:33

or whatever happens, but the membrane that's right

48:37

here can still be there and end up laying down

48:43

on the cervix, and those vessels that were

48:46

running in that membrane are still there.

48:49

So what can happen then is this is the baby's head.

48:53

So as this baby's head delivers, it

48:58

can tear these vessels, compress these

49:00

vessels, but mostly it's tearing them.

49:03

And when you tear one of those

49:06

vessels, you're talking about, you know,

49:09

let's backtrack for a second.

49:11

You tear one of these maternal vessels, and

49:13

the mother loses 50 cc's of blood, which, you

49:15

know, you see with every delivery; no big deal.

49:18

Mom's got five liters of blood.

49:20

You, the baby, lose 50 cc's of blood.

49:23

That's a huge problem.

49:25

So the teaching point here is particular.

49:30

I just check it like I showed you in that second.

49:34

It's a picture of that study.

49:36

I just get the text in the habit of putting color;

49:39

they see color, do a spectral; if you don't see fetal

49:43

heart rate, you're fine. But if you've, if you've

49:47

had a previa and it goes away, make sure when you

49:52

follow it up, that you check that spectral trace.

49:56

I look for color and look for fetal

49:58

vessels there and rule out a vasoprevia.

50:03

Um, this one's a real quick one, but

50:05

I'm showing it to you for a reason.

50:07

So these are all called

50:12

three-vessel cord pictures.

50:14

I want you to tell me which one,

50:16

I didn't do a poll on this one.

50:17

So this is A, B, C, or D; which

50:22

one? Just think about it.

50:24

'Cause there's not a poll. Which one do you

50:26

like or not like? Um, there's one that's

50:29

wrong and one that, and the rest are not.

50:37

And the answer is this one right here.

50:41

Notice the tech was fooled, and I, um,

50:46

this is how I see this not infrequently.

50:48

So remember what I said was that when you see

50:52

the bladder and the quote three-vessel cord,

50:54

so you're looking for these two vessels of the

50:56

three-vessel cord, the umbilical arteries; they

50:59

should be touching the bladder on both sides.

51:02

So here's the bladder: touching, touching.

51:05

This is not the greatest.

51:07

Um, Doppler, but it's still touching;

51:10

this one: touching, touching, touching,

51:14

not touching, touching, touching.

51:17

So what this is, is a single umbilical artery.

51:21

This is actually the iliac vessel

51:24

going into the femoral vessel.

51:25

So it's a big fake-out; now it's a three—vest or, sorry,

51:29

I should say a two-vessel cord, really a bad anomaly.

51:33

It's not.

51:35

Most of the time, a big deal.

51:37

It is associated with growth abnormalities, but where

51:42

we see it, the big problem is it's often associated

51:47

with other abnormalities.

51:49

So when you see, you know,

51:54

agenesis corpus callosum or a myelomeningocele,

51:58

a lot of times associated with that is a two-vessel cord.

52:01

Um, so what you'll see sometimes is that

52:06

people may have missed the subtle something

52:08

somewhere else, but the two-vessel cord was obvious.

52:13

They missed that, which would have

52:15

elevated the scan to a higher level.

52:18

They would've gone and got some

52:19

additional evaluation

52:21

with a perinatologist or something.

52:23

And because that never happened, they end up in court.

52:27

They missed the subtle abnormality, which

52:31

maybe you could have, like, you know,

52:32

said, "Hey, look, you're not a specialist.

52:34

People miss things.

52:35

It's okay."

52:37

But you should have never missed the two-vessel cord.

52:39

So that's—

52:40

It's important to make sure you get that right,

52:43

because it's a sort of like a gateway

52:46

to knowing that maybe I should be looking at other

52:49

things a lot more closely, even though in and

52:52

of itself, it's not a really bad problem.

52:57

Hopefully, that makes sense.

52:59

Then I think this is the last case

53:01

and again, not esoteric—real case.

53:06

Um, actually, so I want you to look at

53:11

them.

53:27

Okay, I didn't show you that much here,

53:29

but, um, this is, I think, our last quiz.

53:32

What's your diagnosis?

53:34

Myelomeningocele, CCAM, pregnancy in the left

53:39

horn of a bicornuate uterus, or none of the above.

53:43

Great, that's what I wanted you to

53:44

say, and nobody got the right answer.

53:47

So, I want to come back to this; this is what the tech

53:53

said, and I've seen this happen. I've seen this case

53:57

twice, um, and both times, the tech said, "Oh, this is

54:05

really interesting; the pregnancy is in the left

54:09

horn" or the right horn or whatever. I can't remember

54:11

what the other one was, of a bicornuate uterus.

54:15

Well—

54:16

Even if you have a bicornuate uterus, what this is

54:19

is actually an intra-abdominal ectopic.

54:23

Um, so this is an 18-week fetus that's

54:25

intra—it's an intra-abdominal ectopic.

54:28

So, what you see here is a

54:30

cervix and a uterus right here.

54:34

So, unless there is a complete duplication of

54:39

the uterus, you should never see this picture.

54:44

In a bicornuate uterus because the bicornuate

54:47

uterus still, at some point, even if it's a deeply

54:51

septated uterus, at some point, the cavities

54:55

come together and the fluid and the baby, you

54:59

know, has got to be somewhere near the cervix.

55:02

So whenever the point of this case is to say,

55:07

if some tech tells me that there's a pregnancy

55:13

in the one horn of a bicornuate uterus,

55:17

that should just raise your antennas

55:18

and you certainly are going to see that

55:20

not a lot more frequently than this.

55:23

But what I want you to do is go look at a cervical

55:26

picture and make sure you see fluid and baby down

55:30

near that cervix because if you don't, what you're

55:34

really looking at is a completely external pregnancy

55:39

to what looks like the uterus.

55:45

And the tech, again, the tech wants to make

55:47

pictures at least normal or make sense.

55:50

An intra-abdominal ectopic does not

55:53

make sense to them, but this does.

55:57

So I think that is the end.

55:59

Um, I don't know if there's any questions.

56:03

All right.

56:03

Thank you.