FIRST TRIMESTER ULTRASOUND REPORT

SAMPLE ULTRASOUND REPORT TO LMC

(if different reports are sent to the Laboratory and the LMC)

Hospital No:

Exam Date:

9 August 2010

Dear ……………….

Thank you for referring your patient ………………………………………………………

…………………………………………………………………………………………………

INDICATION:

Nuchal translucency scan. For first trimester combined screening.

History:

Maternal age:

31 years

Last period:

15 May 2010

EDD by ultrasound: 13 February 2011 EDD by dates: 19 February 2010

Gestational age: 13 weeks + 1 day

Gestational age by dates

12 W+ 2 D*

First Trimester Ultrasound:

Transabdominal US with Voluson E8

Ultrasound view:

Good

Fetal heart action present

Frequency

150 bpm

Crown-rump length (CRL) 73.4 mm

Biparietal diameter (BPD) 23.5 mm

Nuchal translucency (NT) 1.90 mm

Not looked for

Present

Absent

Nasal bone (tick one or leave blank)

Not able to be visualised for

technical reasons

Fetal anatomy:

Skull/brain appears normal, heart not examined, spine appears normal, abdomen appears

normal, stomach visible, bladder visible, hands both visible, feet both visible.

Placenta: Anterior

Amniotic fluid: Normal

Maternal Structures:

Right ovary:

normal morphology

Left ovary:

normal morphology

Summary:

Normal first trimester scan. NT=1.9 mm. First trimester combined screening is planned,

therefore risk assessment has not been performed.

13 weeks 1 day +/- 7 days by scan today.