Writing an ultrasound report: Obstetrics

Patient identification and pertinent characteristics:

Patient name.

Identification numbers.

Examination date.

Patient date of birth.

Patient gravidity and parity if clinically relevant.

Pregnancy dating as available.

Indication for ultrasound examination.

Basic information:

Presence or absence of cardiac activity.

Location of gestational sac.

Number of fetuses.

Location of fetuses in multiple pregnancy.

Placental location.

Type of placentation in multiple pregnancy.

Assessment of amniotic fluid.

Fetal lie and presentation.

Fetal biometric measurements:

Mean sac diameter (if no embryo/fetus).

Crown–rump length.

Biparietal diameter.

Head circumference.

Abdominal circumference.

Femur diaphysis length.

Fetal anatomy:

Described appropriate to setting and resources.

Basic anatomy.

Detailed anatomy.

Estimated gestational age based on established guidelines.

Estimated fetal weight (after 24 weeks).

Summary of examination and comments.

Comparison with previous studies.

Limitations of ultrasound examination.

Recommendations for follow-up if necessary

Writing an ultrasound report: Gynecology

Patient identification and pertinent characteristics:

Patient name.

Identification numbers.

Date of examination.

Patient date of birth.

Patient gravidity and parity if clinically relevant.

Mode of previous delivery(ies) if applicable.

Date of last menstrual period.

Indication for ultrasound examination.

Biometric information:

Uterine height, length, and width.

Ovarian measurements in three dimensions are a required part of imaging, but not of written report.

Cul-de-sac: fluid or abnormalities.

Abnormalities:

Uterine.

Adnexal.

Cul-de-sac.

Surrounding pelvic structures.

Final diagnosis and follow-up:

Summary of examination and comments.

Comparison with previous studies.

Limitations of ultrasound examination.

Recommendations for follow-up if necessary

Amniocentesis to assess fetal lung maturity

For obstetric and gynecologic residents only.

Pass grade is assessed subjectively based on review of listed criteria.

        Indication for amniocentesis

Written and oral information provided.

Informed consent signed.

Maternal blood type reviewed.

Procedure

Timeout before procedure.

Fetal viability established before procedure.

Needle insertion performed under ultrasound guidance.

Transplacental puncture avoided if possible.

Needle gauge 22–20.

Maximum of two insertions.

Volume of amniotic fluid retrieved as needed for test.

Fetal wellbeing: assessment of fetal heart rate after procedure.

Rhogam administered if indicated.

Saline contrast sonohysterography

Pass grade: review components with trainee.

Preparation for procedure:

Review indication for procedure.

Ensure no contraindications for procedure exist.

Obtain informed consent.

Evaluate for presence of sexually transmitted diseases and need for antibiotic prophylaxis.

Prepare required equipment.

Ensure timing of procedure is in early proliferative phase and when patient is not actively bleeding.