Medical Specialty:
Obstetrics / Gynecology

Sample Name: Ultrasound OB - 3


Description: A 37 year-old female with twin pregnancy with threatened premature labor.
(Medical Transcription Sample Report)


This is a 37 year-old female with twin pregnancy with threatened premature labor.

GENERAL EVALUATION: Twin B

Fetal Cardiac Activity: Normal at 166 BPM

Fetal Lie: Longitudinal, to the maternal right.

Fetal Presentation: Cephalic.

Placenta: Fused, posterior placenta, Grade I to II.

Uterus: Normal

Cervix: Closed.

Adnexa: Not seen

Amniotic Fluid: AFI 5.5cm in a single AP pocket.

BIOMETRY:
BPD: 7.9cm consistent with 31weeks, 5 days gestation

HC: 31.1cm consistent with 33 weeks, 3 days gestation

AC: 30.0cm consistent with 34 weeks, 0 days gestation

FL: 6.4cm consistent with 33 weeks, 1 day gestation

CI (BPD/OFD): 77 (70-86)

FL/BPD: 81 (71-87)

FL/HC: 21.3 (19.9-21.5)

FL/AC 21 (20-24)

HC/AC: 1.00 (0.96-1.11)

GESTATIONAL AGE BY CURRENT ULTRASOUND: 33 weeks, 0 days +/- 2 weeks, 2 days FETAL WEIGHT BY CURRENT ULTRASOUND: 2194 gms (4 lbs 13 oz) = 6th percentile EDD BY CURRENT ULTRASOUND: 07/30/07

GESTATIONAL AGE BY DATES: 35 weeks, 5 days

L M P: Not given.

EDD BY DATES: 07/11/07

GESTATIONAL AGE BY PREVIOUS ULTRASOUND: 35 weeks, 2 days DATE OF PREVIOUS ULTRASOUND: 04/20/07 EDD BY PREVIOUS ULTRASOUND: 07/13/07

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 B is small for gestational age and equivalent to twin A (size and dates as detailed above).

Nuchal cord.

Low amniotic fluid volume.



Keywords: obstetrics / gynecology, normal fetal, premature labor, amniotic fluid, nuchal cord, twin pregnancy, gestational age, fetal, pregnancy, gestation, gestational, cord, twin, ultrasound,