Laudário Report templates Early obstetric

Early obstetric ultrasound report template (5, 6, 7 and 8 weeks)

The first ultrasound of pregnancy answers three questions: is the pregnancy intrauterine, is it viable and what is the gestational age. The template below covers an intrauterine pregnancy with an embryo and heartbeat; the abnormal example shows how to write the case that does not yet allow a conclusion.

Normal template

TRANSVAGINAL OBSTETRIC ULTRASOUND

TECHNIQUE:

Transvaginal examination.

FINDINGS:

Anteverted, anteflexed uterus with regular contours, containing an intrauterine gestational sac implanted in the uterine body, with a regular decidual reaction.

Mean gestational sac diameter: [x] mm.

Yolk sac present, normal in appearance, measuring [x] mm.

Single embryo, with a crown-rump length (CRL) of [x] mm.

Embryonic cardiac activity present, with a rate of [x] bpm.

No signs of subchorionic hematoma.

Ovaries of normal size and appearance. Corpus luteum in the [right/left] ovary.

No free fluid in the pelvis.

IMPRESSION:

Single intrauterine pregnancy with a live embryo.

Gestational age by CRL: [x] weeks and [x] days.

Estimated due date: [dd/mm/yyyy].

Example: pregnancy of uncertain viability

FINDINGS:

Intrauterine gestational sac with a mean diameter of 18 mm, containing a 4 mm yolk sac.

No embryo is identified at the time of the exam.

IMPRESSION:

Intrauterine pregnancy of uncertain viability. The findings do not meet criteria for pregnancy failure.

RECOMMENDATIONS:

Follow-up ultrasound in 7 to 14 days.

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.

What must not be left out

Mean gestational sac diameter and CRL, with the calculated gestational age.
Yolk sac and cardiac activity, with the rate.
The criterion stated explicitly when there is pregnancy failure (CRL of 7 mm or more without heartbeat; sac of 25 mm or more without an embryo).
Adnexa and free fluid: ectopic pregnancy is also a question for this exam.

In Laudário, this report writes itself while you mark the findings. Automatic measurements, calculations and classifications, with the text in the standard above. Try free for 15 days

Learn moreEarly pregnancy: gestational sac, anembryonic pregnancy and viability criteriaRead on the blog (in Portuguese)

Frequently asked questions

At how many weeks does the embryo appear on ultrasound?

On transvaginal scanning, the gestational sac appears at around 4 to 5 weeks, the yolk sac at around 5 to 5,5 weeks and the embryo with heartbeat at around 6 weeks.

When can the report conclude anembryonic pregnancy?

With a mean gestational sac diameter of 25 mm or more without an embryo. Below that, the finding is suspicious and calls for follow-up.

Other report templates

Obstetric scan at 5, 6 and 7 weeks Obstetric scan at 8, 9 and 10 weeks Obstetric scan at 11 to 14 weeks Obstetric scan at 15 to 20 weeks Obstetric scan at 21 to 27 weeks 1st trimester anatomy scan 2nd and 3rd trimester obstetric 2nd trimester anatomy scan Complete abdomen Transvaginal pelvic Thyroid Breast Kidneys and urinary tract Lower limb venous Doppler

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