Sample Type / Medical Specialty: Obstetrics / Gynecology
Sample Name: Ultrasound OB - 4

Description: Twin pregnancy with threatened preterm labor.
(Medical Transcription Sample Report)


Twin pregnancy with threatened preterm labor.

GENERAL EVALUATION: (Twin A)

Fetal Cardiac Activity: Normal at 166 BPM

Fetal Lie: Twin A lies to the maternal left.

Fetal Presentation: Cephalic

Placenta: Posterior fused placenta Grade I-II

Uterus: Normal

Cervix: Closed

Adnexa: Not seen

Amniotic Fluid: There is a single 3.9cm anterior pocket.

BIOMETRY:
BPD: 8.7cm consistent with 35 weeks, 1 day

HC: 30.3cm consistent with 33 weeks, 5 days.

AC: 28.2cm consistent with 32 weeks, 1 day

FL: 6.2cm consistent with 32 weeks 1 day

CI (BPD/OFD): 85 (70-86)

FL/BPD: 71 (71-87)

FL/HC: 20.5 (19.9-21.5)

FL/AC 22 (20-24)

HC/AC: 1.07 (0.96-1.11).

GESTATIONAL AGE BY CURRENT ULTRASOUND: 33 weeks, 2 days, +/- 2 weeks, 2 days. FETAL WEIGHT BY CURRENT ULTRASOUND: 2008 grams (4 pounds 7 ounces)= < 3rd percentile EDD BY CURRENT ULTRASOUND: 7/28/07

GESTATIONAL AGE BY DATES: 35 weeks, 5 days

L M P: not given

EDD BY DATES: 7/11/07

GESTATIONAL AGE BY PREVIOUS ULTRASOUND: 35 weeks, 2 days DATE OF PREVIOUS ULTRASOUND: 4/20/07 EDD BY PREVIOUS ULTRASOUND: 7/13/07

FETAL ANATOMY:
Fetal Ventricles: Normal

Fetal Cerebellum: Normal

Fetal Cranium: Normal

Fetal Face: Normal Nose and Mouth

Fetal Heart (4 Chamber View): Normal

Fetal Diaphragm: Normal

Fetal Stomach: Normal

Fetal Cord: Normal three vessel cord, there is a nuchal cord.

Fetal Abdominal Wall: Normal

Fetal Spine: Normal

Fetal Kidneys: Normal

Fetal Bladder: Normal

Fetal Limbs: Normal

IMPRESSION:
Monochorionic diamniotic twin pregnancy.

Twin A is small for gestational age but equal to twin B (size and dates is detailed above).

Nuchal cord.

Low amniotic fluid volume.

ADDENDUM: TWIN B

After further communication with the ultrasound technologist, the small pocket of anterior fluid is only a small portion of the volume of amniotic fluid for the twin. Although AFI could not be determined, the single pocket meets criteria for normal amniotic fluid.

Keywords: obstetrics / gynecology, consistent with weeks, normal fetal, preterm labor, nuchal cord, twin pregnancy, current ultrasound, amniotic fluid, gestational age, fetal, fluid, ultrasound, weeks, twin,