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
Adnexa: Not seen
Amniotic Fluid: There is a single 3.9cm anterior pocket.
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 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
Monochorionic diamniotic twin pregnancy.
Twin A is small for gestational age but equal to twin B (size and dates is detailed above).
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: radiology, consistent with weeks, normal fetal, preterm labor, nuchal cord, twin pregnancy, current ultrasound, amniotic fluid, gestational age, fetal, fluid, ultrasound, weeks, twin,