2.1 Guidelines Relevant To Breast Examinations

All breast ultrasound examinations should be carried out systematically using a combination of longitudinal, transverse, radial, anti-radial and coronal scan planes in order to demonstrate the contours, architecture and ultrasound characteristics of the following:

• skin, nipple and areola
• subcutaneous fat
• superficial and deep layers of the superficial fascia
• lactiferous ducts and sinuses
• fibro-glandular breast and interspersed fatty tissues
• Cooper’s ligaments
• retro-mammary space
• pectoralis major, pectoralis minor and serratus anterior muscles
• axilla:
  • lymph nodes
  • axillary vessels
  • muscles and fatty tissues.

The sonographer should be able to:

• communicate the relevant information sensitively, recognising the patient’s fears and anxieties
• ensure privacy and modesty
• position the patient in a standardised way to ensure reproducibility of technique and lesion localisation
• carry out a comprehensive extended ultrasound examination of the whole breast(s) +/- axilla(e) or a localised examination targeted to a specific area of the breast according to the individual clinical presentation
• demonstrate the normal anatomy of the breast, axilla and chest wall and associated vascular supply and perfusion using a combination of B-mode and Doppler techniques
• recognise the spectrum of normal ultrasound appearances of breast tissue resulting from physiological variations due to aging or pregnancy
• carry out a simple clinical examination in order to correlate the underlying sonographic appearances of a palpable abnormality
• locate the sonographic position of a mammographically detected abnormality
• recognise and demonstrate abnormal ultrasound appearances resulting from disease
• assess the need to extend the examination to include additional areas of the ipsi-lateral breast and/ or the contra-lateral breast in view of sonographic and/or mammographic findings

Observations

Examination of focal lesions or pathological findings should involve the assessment of:

• size (maximum diameter)
• shape (depth:width ratio)
• outline including margin definition and regularity
• internal echo-texture
• posterior and edge through transmission
• mobility and compressibility
• adjacent tissues

In the case of the use of Doppler, examinations should include the assessment of:

• number, alignment and configuration of vessels
• orientation and relationship of vessels to any lesion
• velocity and resistance of arterial blood flow

Care must be taken to use minimal transducer pressure and to use high frequency (>5MHz), low PRF (~1000Hz), minimal wall filter (50-100Hz) and a colour gain level just above noise level to demonstrate low amplitude low velocity signals.Where malignancy is suspected the examination should be extended to include the axilla and internal mammary lymph node areas.

Additional Reading

• AIUM. (2002) Standard for the Carry outance of Breast Ultrasound Examination (online) Maryland USA, American Institute of
• Ultrasound in Medicine. Available at: http://www.aium.org/publications/clinical/breast.pdf [2]
• Dixon AM (2007) Breast Ultrasound: How, Why & When? Edinburgh, Elsevier
• Hagen-Ansert S. (2007) Sonographic evaluation of the breast (online) General Medical Systems, Ultrasound Online CME Courses.
  Available at http://www.gehealthcare.com/usen/education/proff_leadership/products/msu... [3]
• RCR. (2003) Guidance on Screening and Symptomatic Breast Imaging. BFCR(03)2, London, Royal College of Radiologists.

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2.2 Guidelines Relevant To General Medical Examinations

During an abdominal ultrasound examination, the anatomical structures which the sonographer should normally examine must be in accordance with the clinical information given and are shown in Table 2.

The sonographer should demonstrate:

• normal anatomy/variants of abdominal organs and structures including age related appearances of the each organ in at least two planes. (This should include assessment of size, outline and ultrasound characteristics)
• pathological findings including focal and diffuse processes and associated haemodynamic findings (pre- and post-operative assessments) • the presence of any abnormal intra-abdominal fluid collections or masses
• when clinically relevant: vascular anatomy including position, course and lumen of relevant vessels (Haemodynamic observations including the presence/absence of flow, its direction, velocity and variance)
• The emphasis of the examination of the above structures will be altered according to clinical presentation

Table 2. Structures for Abdominal Ultrasound Examination

Structures	Evaluation
Liver	size, shape, contour and ultrasound characteristics of all segments appearance of intrahepatic vessels and ducts porta hepatis and adjacent area portal venous, hepatic venous and arterial systems
Diaphragm	contour, movement, presence of adjacent fluid, masses, lobulations
Ligaments	appearance of falciform, ligamentum teres and venosum
Gallbladder	size, shape, contour and surrounding area ultrasound characteristics of the wall and the nature of any contents
Common Duct	maximum diameter and contents; optimally it should be visualised to the head of pancreas
Pancreas	size, shape, contour and ultrasound characteristics of head, body, tail and uncinate process; diameter of main duct
Spleen	size, shape, contour and ultrasound characteristics including the hilum assessment of splenic vein blood flow and presence/absence of collaterals
Aorta	diameter, course and branches including the bifurcation appearance of its walls, lumen and para-aortic regions
Ivc	patency, diameter, appearance of its lumen and para-caval regions
Adrenals	not routinely viewed but any apparent abnormality of size and ultrasound characteristics should be noted
Kidneys	size, shape, position and orientation, outline and ultrasound characteristics of cortex, medulla, collecting system, main and intra-renal arteries and veins
Ureters	assessment of the presence/absence of dilatation/reflux
Urinary Bladder	appearance of wall and contents assessment of volume pre- and post-micturition
Prostate	size and shape
Gastro-Intestinal Tract	wall thickness, contents, diameter of lumen, motility, presence/absence of masses
Other Structures	where relevant include: omentum, muscles, abdominal wall, possible hernias, lymph nodes sites for potential fluid collection (including upper/ lower abdomen and the thorax)
Proceed to examination of the pelvis where necessary (Refer to Section 2.3)

Contrast Enhanced Ultrasound (CEUS)

A contrast enhanced ultrasound (CEUS) examination is the utilisation of a specialised microbubble ultrasound contrast agent combined with dedicated contrast hardware of the ultrasound system in order to evaluate suspected pathologies in specific organs of the body. This is done by observing the enhancement pattern of the lesion during the arterial, portal and late vascular phases (see below). It is increasingly in clinical use for diagnostic imaging and post-interventional procedures e.g. radiofrequency ablation (RFA) for several organs.

CEUS Imaging Post Injection:

Arterial Phase	starts at 10-20 seconds, ends at 25-35 seconds
Portal Phase	starts at 30-45 seconds, ends at 120 seconds/td>
Late Phase	120 seconds
Bubble Disappearance	240-360 seconds(1)

Individual cases should always be managed on the basis of the clinical information available for that particular patient.

It is preferable that the examination is carried out by two sonographers, one to complete the ultrasound examination and the other to administer the contrast agent.

Refer to Section 2.2 in addition to the following:

The sonographer should:

• review previous images/reports prior to the procedure to confirm the region(s) of interest
• review the clinical history for factors, which might contraindicate the procedure (e.g. allergy to sulphur hexaflouride, uncontrolled systemic hypertension and adult respiratory distress syndrome)
• prepare the contrast agent according to the manufacturer’s directions and 5mls of saline prepared in a separate syringe to be used as a flush post injection
• insert venflon according to local protocols, ensuring a strict aseptic technique is used in preparing and giving the I.V. injection
• ensure the appropriate contrast preset is set on the ultrasound system
• inject 2.4mls of contrast agent (using a needle diameter not less than 20G to avoid loss of bubbles due to mechanical impact during injection), to be given initially as a bolus followed by a 5ml saline flush
• ensure that if characterisation of the lesion is unsuccessful or additional lesions are found in the late phase a further 1ml of contrast agent is given focusing on the lesion of interest
• ensure that the examination time is continuous for a period of 5 minutes, but longer if necessary, timed by a stop-clock from the beginning of the examination
• remove the venflon and ensure bleeding has stopped before the patient leaves the department.

In relation to associated knowledge, the sonographer should be aware of:

• local guidelines for acceptance of requests
• the behaviour of benign and malignant lesions
• limitations of CEUS and of the sonographer’s own limits of experience and understanding
• the range of diagnostic options available following CEUS and the importance of other imaging techniques
• contra-indications

In relation to departmental procedures, the sonographer should:

• ensure that a protocol is in place for the delegation and injection of the ultrasound contrast agent
• ensure that a protocol is in place for carrying out and reporting of CEUS
• ensure that a programme of annual basic life support training is in place for all staff

References

1. Guidelines for Good Clinical Practice Recommendations for Contrast Enhanced Ultrasound (CEUS) - Update 2008. EFSUMB study group et al. Ultraschall in Med 2008: 29:28-44. 

Additional Reading

• Albrecht, T., Blomley, MJK., Bolondi, L., et al. (2004). Guidelines for the use of contrast agents in ultrasound. Ultraschall Med 25: 249-256.

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2.3 Guidelines Relevant To Gynaecological Examinations

The type of examination carried out, i.e. using vaginal (EV) and/or trans-abdominal (TA) techniques should be directed by the clinical presentation of the patient. As discussed in Section 1.5 a full explanation of the techniques should be given to the patient and appropriate consent sought. The need for a chaperone should also be considered. (Refer to Section 1.6).

The sonographer should consider the following:

• obtaining information regarding the patient’s previous medical and menstrual history including stage and cycle
• establishing information relating to any medication e.g. oral contraceptive pill, hormone replacement therapy, Tamoxifenthat EV ultrasound is the recommended technique for detailed assessment of the endometrium (e.g. referral for post menopausal bleeding) and ovaries (e.g. referral for polycystic ovaries)
• using colour flow mapping and/or power Doppler in appropriate clinical presentations e.g. the assessment of myometrial vascularity, ovarian angiogenesis, endometrial vascularity
• using 3D ultrasound in the assessment of pathology and congenital malformations of the uterus and ovaries Observations The anatomical structures which the sonographer should normally examine during a gynaecological examination should be in accordance with the clinical information given and are shown in Table 3. This should include assessment of size, outline and ultrasound characteristics.

Table 3: Structures for Gynaecological Ultrasound Examination

Structure	Evaluation
Uterus	position, size, shape appearance of the myometrium
Endometrium	appearance and thickness
Ovaries	position, size, shape, appearance number, size and internal echo pattern of follicles when present
Adnexae	presence or absence of mass(es). appearance and size when present
Fallopian Tubes	assessment where visible
Pouch Of Douglas	presence or absence of fluid and/or masses

 The sonographer should:

• demonstrate the normal anatomy/variants of the female pelvic organs and structures including age related appearances of each organ in at least two planes
• relate the ultrasound appearances to the relevant menstrual or menopausal status with particular attention to any patient drug regime
• demonstrate pathological findings and associated haemodynamic findings
• demonstrate the presence of any abnormal intra-abdominal fluid collections or masses
• review the urinary tract when a pelvic mass is identified

Assisted Reproductive Techniques

The sonographer should be competent to carry out the following:

• serial examinations to monitor the effect of hormone therapy
• serial examinations to assess timing of ovulation in spontaneous and stimulated cycles
• monitoring for evidence of ovarian hyper-stimulation and ovarian hyper-stimulation syndrome
• serial examinations for monitoring endometrial receptivity in embryo replacement cycles
• confirmation of conception in successful treatment cycles
• confirmation of the presence and site of single/multiple gestation(s)
• assessment for ectopic pregnancy

The sonographer should understand the role of hystero-contrast-sonography (HyCoSy) in the diagnosis oftubal patency and saline installation sono-hysterography (SIS) for the diagnosis of intra-uterine pathology affecting the endometrium.

The sonographer should be aware of:

• the role of the Human Fertilisation + Embryology Agency (HFEA) in assisted conception techniques
• current advice on the requirement for pre-examination analgesia, to include non-steroidal inflammatory drugs (NSAIDs)
• the recommendations of prophylactic antibiotic prescription in accordance with local protocols or guidelines.
• This guidance should be read in conjunction with Section 2.5

Hystero-Contrast-Sonography (HyCoSy)

The sonographer should refer to Section 1.6 for guidelines on intimate examinations.

The following recommendations are for guidelines to practise and local variations may apply.

The examination should be booked up to Day 14 last menstrual period (LMP). If the patient has a longer cycle than 28 days this can be extended. The patient must be informed of the procedural risk to an early pregnancy.

Before the procedure the sonographer should:

• check LMP, recording the day of cycle and whether regular or irregular
• record any history of infections
• check that the patient’s cervical smear checks are current
• give a full explanation of the procedure and gain informed consent before continuing

For a baseline scan the sonographer should:

• image the uterus in the midline longitudinal section and record the endometrial measurement
• image the uterus in transverse section recording the endometrial measurement
• note the position of the cornua
• image and measure both ovaries in 3 planes
• note and record any pathology present, stating its position
• if there are uterine fibroids present state their relationship to the endometrial cavity
• once the catheter is in situ, image its position in the cavity

During the procedure:

• 1 to 2 mls of contrast agent is injected into the cavity
• do not over fill the cavity; not only will this cause unnecessary discomfort, it could induce spasm in the fallopian tubes leading to a false negative result (tubes appear blocked)
• further contrast is introduced only as required
• both tubes should be imaged from the cornua to the ovary and spill demonstrated
• if the contrast is not seen to flow immediately both tubes should be observed for a minimum of 5 minutes to exclude spasm
• ideally the procedure should be video recorded where possible

Safety

Any procedure that involves the cervix may lead to shock. Prior to the procedure, it is the responsibility of the sonographer undertaking the examination to ensure that a medical practitioner is available to attend to the patient at immediate notice when contacted.

Prevention of Shock

The risk of cervical shock is reduced if the following are observed:

• inform and reassure the patient throughout the procedure
• avoid the use of tenaculum forceps
• avoid unnecessary manipulation of the cervix
• do not over inflate the catheter balloon, approximately 0.5 - 1.0 ml is sufficient; it should not be inflated in the cervical canal
• contrast agent should be used sparingly
• if carry outing a S.I.S., ensure saline can flow out of the cavity; do not use excessive pressure
• ensure that the patient is aware of the signs and symptoms of infection and the necessary action to take

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2.4 Guidelines relevant to Musculo-skeletal examinations

As the field of musculo-skeletal (MSK) ultrasound imaging is extensive, the following section covers the most widely used applications in sonographic practice. The anatomical structures which the sonographer should normally examine during a musculo-skeletal ultrasound examination will be variable and dependent on the signs and symptoms with which the patient is presenting (see Tables 4 + 5 as examples). A clinical history should be taken prior to any examination.

 

Table 4: Structures for the Achilles Tendon Examination

Structures	Evaluation
The Achilles Tendon (Inflammation)	assessed in both transverse and longitudinal planes from its insertion point into the posterior aspect of the calcanium to the myotendenous junction special attention should be given to evidence of inflammatory changes as focal spindle thickening hypoechoic regions within the tendon detectable blood flow within the tendon when using power Doppler thickening of the paratendon bursitis
The Achilles Tendon (Rupture)	assessed with the patient sitting with the foot in a neutral position to allow accurate assessment of width of any tear

 

 

Table 5: Structures for the Shoulder Examination

Structures	Evaluation
General	evidence of free fluid/bursitis within the shoulder region should be excluded
Long Head Of Biceps (LHB) Tendon	examined in longitudinal and transverse sections from its insertion point within the shoulder to the myotendonous junction assessment should be made of the following: - the LHB AP diameter evidence of calcification within the tendon evidence of complete or partial tear of the bicep tendon its position within the bicipital groove evidence of subluxation out of the bicipital groove increased fluid within the tendon sheath
Subscapularis Tendon	assessed in both longitudinal and transverse planes from its insertion point into the shoulder to the myotendinous junction tendon should be evaluated for thickening associated with inflammation calcification partial or complete tears fluid collections
Infraspinatous Tendon	assessed in both longitudinal and transverse planes from its insertion point into the shoulder to the myotendinous junction tendon should be evaluated for thickening associated with inflammation calcification partial or complete tears fluid collections
Superspinatous Tendon	in both longitudinal and transverse planes from its insertion point into the shoulder to the myotendinous junction tendon should be evaluated for thickening associated with inflammation calcification partial or complete tears fluid collections also be evaluated for impingement by dynamic assessment
Acromio-Clavicular Joint	assessed for any evidence of inflammation that may instigate impingement

 

Table 6: Pathologies

Examination	Pathologies
Elbow	tendinosis of common flexor/extensor origins tendinosis and rupture of triceps and distal biceps tendons effusion loose bodies bursae
Wrist/Hand	tendon tears and tenosynovitis carpal tunnel syndrome space occupying lesions pulley injuries arthropathy
Knee	effusion bursae (including ruptured Baker’s cyst) meniscal cysts collateral ligament sprains patellar tendon tendinosis and rupture
Hip	developmental dysplasia of the hip (DDH) effusion (children, adults, prosthetic joints) bursae tendinosis and tendon tears
Lower Limb	muscle contusion and tears tendinosis and tendon tears
Soft Tissue	lipomas sarcomas

 
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2.5 Guidelines relevant to obstetric examinations

The nature of examination carried out, i.e. using vaginal (EV) and/or transabdominal (TA) techniques should be directed by the gestational age of the pregnancy and/or the clinical presentation of the woman. As discussed in Section 1.5 a full explanation of the relevant technique(s) should be given to the woman and appropriate consent sought. The need for a chaperone should also be considered. (Refer to Section 1.6).

The sonographer should consider the following:

• using the most appropriate scanning technique(s) for the gestational age of the pregnancy
• awareness of the safety issues relevant to the type of examination required and the gestational age of the pregnancy examined
• confirmation (or otherwise) of the presence of embryonic/fetal heart pulsations at the start of the examination
• taking correctly the measurements which date the pregnancy or assess fetal growth most accurately, in accordance with national guidelines
• assessing the gestational age or growth velocity of the fetus using such measurements and appropriate, referenced biometry charts
• evaluating whether the embryonic/fetal, placental and other uterine appearances are normal for the gestational age of the pregnancy in accordance with current best clinical practice
• discussing the findings with the woman in accordance with locally agreed practice
• reporting the findings to the referring health care professional in accordance with locally agreed practice
• assessing the relevance and completeness of the ultrasound findings obtained and their association with various clinical conditions amenable to detection by ultrasound

Image Acquisition

It is recommended that a set of standard images is taken and stored for every obstetric examination carried out. For dating examinations the images displaying the measured embryonic or fetal sections referred to in the written report should be taken and stored. Representative images of any abnormal or unusual findings referred to in the written report should be imaged and stored. (Refer to Sections 1.9 and 4.2).

Terminology

The correct terminology should always be used, for example:

• ‘embryo’ describes a conceptus of <10 weeks (menstrual age) while ‘fetus’ describes a conceptus of >10 weeks (menstrual age)
• ‘live’ should be used to describe an embryo or fetus in which fetal heart pulsations can be seen. As ‘viable’ means capable of sustaining independent life, it should be used with caution before 24 weeks of gestation
• potentially ambiguous phraseology such as ‘the fetus appears normal’ should be avoided
• where the routine anomaly examination demonstrates normal findings the following phrases are recommended:

‘The ultrasound appearances are normal’
or
‘No abnormalities were detected’


•  ‘cannot be excluded’ is not clinically helpful and therefore should not be used. The following is recommended:

’Ultrasound findings do not indicate an ectopic pregnancy’

Maternal Obesity

In order to reduce the likelihood of a sonographer developing work-related musculo-skeletal disorders (WRMSD) and/or exacerbate the condition when present, multiple repeat examinations of clinically obese women should be avoided. Clinical obesity is defined as a body mass index (BMI) >35. (Refer to Section 1.7)

Where inadequate visualisation within the allocated appointment time at the routine anomaly scan undertaken between 18(0) and 20(6) weeks is due to clinical obesity of the mother, one repeat examination only should be offered, at a gestational age of 22-23 weeks. Should the anomaly scan remain incomplete at the second examination, the sonographer should record in the report that the routine anomaly scan could not be completed, due to increased maternal BMI and that no further appointment has been given.

Similarly serial scans to assess fetal growth in the well but obese mother should be refused. A scan at 36 weeks only, to assess presentation and growth in the multiparous mother, preceded by a growth scan at 32 weeks in the nulliparous mother, is recommended.

Ultrasound examinations should not normally be extended beyond the allocated appointment time.

Establishing Gestational Age (GA)

Gestational age should be assessed and established in accordance with NICE guidelines(1) and using nationally recommended dating charts(2)

10 weeks - 13(6) weeks	CRL(1)
CRL >84mm	HC(1)

Prior to visualisation of a live embryo, the gestational age may be assessed from the measurement of the mean gestation sac diameter (MSD). This should be calculated using the two maximum diameters of the sac from the longitudinal, sagittal view using the vaginal route3. Where a vaginal examination is declined, the full bladder technique should be used and the gestation sac volume calculated(4). It is recommended that the expected date of delivery (EDD) is only assigned once a live embryo or fetus has been identified.

Assigning Gestational Age after 12 Weeks 6 Days

As the accuracy of GA assessment declines with increasing crown rump length (CRL), it is recommended that assigning an expected date of delivery between 13(0) and 14(0) weeks is undertaken with caution. Similarly assigning the EDD using head circumference (HC) measurements between 80mm and 120mm (equivalent to 12(4)-15(6) weeks) should also be undertaken with caution. Ultrasound biometry carried out between 16(0)-26(0) weeks should be used. After this gestation biometry should only be used to evaluate fetal growth velocity.

Examinations in the First Trimester

• First trimester confirmation of pregnancy, dating or growth It is recommended that requests for early pregnancy ultrasound examinations are only carried out on women with a recent positive pregnancy test, and after 5 weeks and 3 days of gestation i.e. after the yolk sac is normally identified(5). The conclusion from examinations carried out before this gestation will frequently be of a pregnancy of unknown location(3). This diagnosis is of limited clinical value and will merely necessitate a repeat ultrasound examination in 7-10 days.

The optimal gestational age range over which to assess gestational age by ultrasound biometry is 7(0)-12(6) weeks. It is recommended that ultrasound assignment of the EDD is best carried out within this gestational range.

• Nuchal translucency screening

The nuchal translucency screening examination, either as part of a programme combined with serum screening, or as a stand-alone screening option for Down’s screening of twins or higher multiple pregnancies, should follow nationally agreed guidelines.(1)(6)

The structures which the sonographer should normally examine, and measure correctly according to referenced charts where appropriate, during a first trimester examination are shown in Table 7.

 

Table 7. Structures Examined in a First Trimester Ultrasound Examination

Structure	Evaluation	Measurements
Uterus	position, appearance
Gestation Sac	position, appearance, contents	Mean gestation sac diameter
Embryo	heart pulsations present/absent	Crown rump length
Fetus	heart pulsations, present/absent anatomical assessment	Crown rump length Nuchal Translucency
Placenta	position, appearance
Multiple Pregnancy	the above + chorionicity
Both Adnexae	appearance

Examinations in the Second Trimester

The structures which the sonographer should normally examine appropriately and measure correctly according to referenced charts during a second trimester dating examination are shown in Table 8.

 

Table 8. Structures examined in a second trimester ultrasound dating examination

Structure	Evaluation	Measurements
Skull And Intracranial Anatomy At Level Of Lateral Ventricles	appearance	Head Circumference (Biparietal diameter)
Intracranial Anatomy At The Sub-Occipito-Bregmatic Level	appearance	Transcerebellar diameter
Abdomen At Level Of Stomach And Umbilical Vein	appearance	Abdominal circumference
Femur	appearance	Femur length
Fetal Movements	observed
Placenta	position relative to the cervical os
Amniotic Fluid	volume

• Fetal Anomaly Screening

In keeping with nationally agreed guidelines, it is recommended that the optimal gestational age range over which routine fetal anomaly screening is carried out is 18(0)-20(6) weeks.(1)(6) (Refer to Section 1.10) The structures which the sonographer should be able to examine during a routine fetal anomaly screening examination are shown in Table 9. Similarly the measurements that the sonographer should be able to make correctly according to referenced charts during the same examination are also shown in Table 9. It is anticipated that the majority of these measurements will only be taken in cases where abnormal findings are identified or suspected. The range of structures and measurements included in such an examination will normally be determined by local guidelines.

In addition to the assessment of the fetal anatomy as indicated in Table 9, the sonographer should also be able to take the fetal measurements according to referenced charts and make the assessments shown in Table 10.

Examinations in the Third Trimester

• Fetal Growth, Fetal Well Being or Placental Localisation

These examinations may be requested and undertaken in the Second Trimester where appropriate.

Fetal growth should be assessed and represented using nationally recommended size charts.(2)

The structures which the sonographer should normally be able to examine appropriately and to measure correctly according to referenced charts during an examination to assess fetal growth, fetal well being or placental position are shown in Table 11.

Table 9. Structures examined in Fetal Anomaly Ultrasound Screening

Structure	Evaluation	Measurement
Skull	bones, shape
Brain	cavum septum pellucidum both lateral ventricles, including choroid plexus cerebellum cerebellar vermis cisterna magna	atrial width transcerebellar diameter cisterna magna width
Face	mid-sagittal profile coronal view of lips alveolar ridge both orbits and lenses	inter-orbital diameters
Neck	nuchal skin	nuchal skin fold thickness
Chest	size
Heart	position, size, appearance, 4 chamber view, left and right ventricular outflow tracts
Lungs	appearance
Diaphragm	appearance
Stomach	position, appearance
Bowel	appearance
Kidney Left And Right		AP, transverse and longitudinal diameters
Renal Pelvis Left And Right		AP diameter
Bladder	size, appearance	AP, transverse and longitudinal diameters
Abdominal Wall	appearance, cord insertion
Umbilical Cord	number of vessels
Spine And Skin Covering	appearance in longitudinal, transverse and coronal planes
Twelve Long Bones	appearance
Hand Left And Right	carrying angle, fingers
Foot Left And Right	carrying angle, toes
Genitalia (Where Clinically Relevant)

 

Table 10. Additional Structures Examined in Fetal Anomaly Ultrasound Screening

Structure	Evaluation	Measurements
Skull And Intracranial Anatomy At Level Of Lateral Ventricles		Head circumference (Biparietal diameter)
Intracranial Anatomy At The Sub-Occipito-Bregmatic Level		Transcerebellar diameter
Abdomen At Level Of Stomach And Umbilical Vein		Abdominal circumference
Femur		femur length
Fetal Movements	observed
Placenta a) Low Lying b) IVF Pregnancy c) Succenturate/Multilobate d) Velamentous Insertion e) Multifetal	position relative to the cervical os If a),b),c) d) and/or e) apply, trans-abdominal scan of cervix with colour Doppler to exclude vasa praevia(7)	Heart rate
Amniotic Fluid	volume

 

Table 11. Structural Evaluation in a Third Trimester Ultrasound Examination

Structure	Evaluation	Measurements
Fetal Lie	presentation
Skull And Intracranial Anatomy At Level Of Lateral Ventricles		Head circumference (HC) (Biparietal diameter) (BPD)
Abdomen At Level Of Stomach And Umbilical Vein		Abdominal circumference
Femur		Femur length (FL)
From The Above Information	estimation of fetal weight	(BPD), HC, AC, FL
Umbilical Artery	end diastolic flow	pulsatility index
Middle Cerebral Artery		pulsatility index, velocity
Ductus Venosus	forward flow	pulsatility index
Fetal Movements	assessed for frequency during examination
Amniotic Fluid - Singleton Pregnancy - Multiple Pregnancy	volume volume	amniotic fluid index deepest pool
Placenta a) At Risk Of Vasa Praevia(7) b) Low Lying c) Placenta Praevia	position relative to the cervical os colour Doppler across cervix assess vaginally assess vaginally	heart rate distance of placental leading edge to internal os

References

1. http://www.bmus.org [4] (Charts recommended for clinical obstetric practice - February 2007)
2. http://nice.org.uk [5] (Antenatal care - routine care for the healthy pregnant women- March 2008)
3. Royal College of Obstetricians and Gynaecologists. The Management of Early Pregnancy Loss Guideline No.25. London RCOG 2006.
4. Robinson HP & Fleming JEE (1975). ‘Gestation Sac’ Volumes as Determined by Sonar in the First Trimester of Pregnancy. BJOG 82: 100-107
5. Grisolia G, Milano V, Pilu G et al (1993). Biometry of early pregnancy with vaginal sonography. Ultrasound Obstet Gynecol 3:403-411
6. http://www.screening.nhs.uk/downs [6] (Antenatal Screening - Working Standards for Down’s Syndrome Screening 2007 - April 2007)
7. Daly-Jones E, John A, Leahy A, McKenna C & Sepulveda W (2008). Vasa Praevia; a Preventable Tragedy. Ultrasound 16(1): 8-14.

Additional Reading

• http://www.vasapraevia.co.uk [7]

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2.6 Guidelines Relevant To Paediatric And Neonatal Ultrasound Examinations

Before undertaking any paediatric ultrasound examination the sonographer should:

• be aware of the content and implications of The Children’s Act(1)
• be aware of the issues surrounding consent by patients to examinations, with particular reference to consent by, or on behalf of, children(2)
• be aware of the implications and issues surrounding ‘Gillick competence’(3)

During the examination the sonographer should:

• consider the special needs and care of the patient, including the presence of the parent/guardian/ accompanying person during the examination where appropriate
• use appropriate communication*
• make use of immobilisation and other techniques where relevant; sedation should only be used in extenuating circumstances such as when complex pathology is evident
• demonstrate normal anatomy/variants, including age related appearances of the whole organs and structures examined in at least two planes including size, shape, outline and ultrasound characteristics+
• make the relevant measurements and relate to the normal range for age
• understand the role of ultrasound in prenatally diagnosed conditions and its role in the management of the neonate

* Refer to Section 1.4
+ Refer to Section 2.2

The paediatric anatomical structures which the sonographer would normally examine will depend upon the request and should be in accordance with the clinical information but may include any of the following identified in Table 12.

 

Table 12. Structures for Paediatric and Neonatal Ultrasound Examinations

Structure(s)	Evaluation
Abdomen Pelvis	be aware of the paediatric ultrasound characteristics and potential conditions of organs and structures that differ from those of an adult+
Organs + Systems That Might Require Special Attention In The Paediatric Patient
Gastro-Intestinal Tract	particular attention to the pylorus and appendix; assess wall thickness, contents, diameter of lumen, motility, presence/absence of masses; in cases of suspected malrotation assess the relative positions of the SMA and SMV
Neonatal Spine	normal anatomy, congenital defects
Neonatal Hips	normal anatomy, clicking hips,
Neonatal Cranium	ultrasound characteristics of the internal cranial architecture ventricles and choroid plexi subependymal regions head of caudate nucleus thalamus corpus callosum cavum septum pellucidum brain stem posterior fossa contents cerebral gyri and sulci vascular structures

 References

1. Children’s Act 1989 & 2004
2. The Society of Radiographers. (2005). The Child and the Law: The Roles and Responsibilities of the Radiographer. London: The Society of Radiographers.
3. Gillick v West Norfolk and Wisbech Area Health Authority (1985)

Additional Reading

• Royal College of Radiologists’ Guidance on Consent [BFCR (05) 8]
• http://www.bspr.org.uk [8]
• http://www.everychildmatters.gov.uk [9]

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2.7 Guidelines Relevant To The Ultrasound Examination Of Superficial Structures

When undertaking ultrasound examinations of superficial structures, the sonographer should:

• consider the nature of the examination with regard to patient privacy and ascertain the necessity for the presence of a chaperone
• be familiar with the guidelines on intimate examinations*

* Refer to Section 1.6

The anatomical structures which the sonographer should be able to examine correctly are listed in Table 13.

 

Table 13. Structures for Superficial Ultrasound Examinations

Structure(s)	Evaluation
Neck	thyroid gland, parathyroid glands, salivary glands, lymph nodes, trachea, oesophagus, vasculature and muscles
Testes	normal anatomy and vascular supply of the scrotum/penis (proceed to renal assessment when appropriate
Anus	continuity of the internal and external sphincters
Eyes	chambers, lens, retina, retro-orbital structures including the vessels; orbital biometry
Other	the nature of other superficial, palpable masses e.g. lipoma

 For each examination the sonographer should:

• assess the size, shape, contour, ultrasound characteristics of the organ and the relevant vascular structures
• identify normal anatomy/variants and abnormal appearances due to disease processes or trauma

 
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2.8 Guidelines Relevant To Vascular Ultrasound Examinations

The vascular structures which the sonographer should be able to examine are listed below in Table 14.

Table 14. Structures for Vascular Ultrasound Examinations

Structure(s)	Evaluation
Head and Neck	common internal and external carotid arteries; vertebral and subclavian arteries; jugular and subclavian veins; cerebral arteries by transcranial examination
Abdomen	abdominal aorta and main branches; inferior vena cava (IVC) and branches; other visceral arteries and veins as included in general abdominal and gynaecological examinations*
Upper Limb	arteries and veins (deep and superficial) of the upper limb; subclavian, axillary, brachial, radial and ulnar arteries; subclavian, axillary, brachial, radial, ulnar, basilic and cephalic veins
Lower Limb	arteries, veins (deep and superficial) and infra-inguinal grafts of the lower limb aorta, Iliac, femoral, popliteal, peroneal, anterior and posterior tibial arteries; IVC, iliac, femoral, popliteal, gastrocnemius, peroneal, anterior and posterior tibial veins; posterior calf, gastrocnemius and soleal venous sinuses; long and short saphenous veins and their variants
Grafts	inflow vessels, proximal anastomosis, body of graft, distal anastomosis and run-off

* Refer to Sections 2.2 and 2.3

 

The sonographer should be able to:

• demonstrate the vessels relevant to specific clinical criteria in terms of:
  • position and course
  • congenital variations
  • ultrasound characteristics of the lumen and walls including venous compressibility
  • presence/absence of collaterals and/or fistulae
  • ultrasound characteristics of surrounding tissues

• assess by use of pulsed, colour and/or power Doppler the haemodynamics of vessels, including their presence or absence, interruption to flow, flow direction, velocity and resistance measurements. (The angle caliper should be set correctly, with an angle =/<60°, before any velocity measurements are made. The focal zone should include the target of interest when diameter or area measurements are being taken)
• demonstrate and estimate the location and extent of pathological vascular diseases and assess the efficacy of any surgical or other interventional treatment
• demonstrate other pathological processes adjacent to, or involved with, vascular structures and assess their effects on these structures
• assess the relevance of such pathology to the clinical picture

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