Second-trimester anatomy ultrasound report template
Between 20 and 24 weeks, the anatomy scan assesses fetal anatomy system by system. A report organized this way makes clear what was seen and what was limited.
SECOND-TRIMESTER ANATOMY ULTRASOUND
FINDINGS:
Single live fetus in [x] presentation. Heart rate of [x] bpm.
Biometry: BPD [x] mm; HC [x] mm; AC [x] mm; FL [x] mm. Estimated weight of [x] g ([x] percentile).
Skull: intact calvarium; lateral ventricles of [x] mm; cerebellum of [x] mm; cisterna magna of [x] mm.
Face: normal profile, intact upper lip, symmetric orbits.
Spine: aligned, with no visible closure defects.
Heart: normal situs, symmetric four chambers, crossing outflow tracts and normal three-vessel view.
Abdomen: stomach, kidneys and bladder in their usual location. Intact abdominal wall.
Limbs: four limbs with visible segments and movement present.
External genitalia of [male/female] appearance.
Placenta [x], [x] mm from the internal os. Normal amniotic fluid. Three-vessel cord.
Cervical length of [x] mm, transvaginal.
IMPRESSION:
Single pregnancy with a live fetus, [x] weeks and [x] days. Fetal anatomy with no abnormalities detectable by this method.
FINDINGS:
Lateral ventricle measuring 11 mm at the atrium, with a dangling choroid plexus. Other cranial structures normal in appearance.
IMPRESSION:
Mild unilateral ventriculomegaly.
RECOMMENDATIONS:
Fetal medicine assessment, neurosonography and follow-up ultrasound.
Fields in brackets are filled in from the exam. The template is a starting point: the report must reflect what was seen and your practice's guidelines.
Frequently asked questions
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