76802 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure)

Name of the Procedure:

Ultrasound, Pregnant Uterus, Real Time with Image Documentation, Fetal and Maternal Evaluation, First Trimester (< 14 weeks 0 days), Transabdominal Approach; Each Additional Gestation

Summary

This procedure involves using an ultrasound machine to capture real-time images of the uterus during the first trimester of pregnancy. It's done using a transabdominal approach and is enhanced further by separate imaging for each additional gestation (if there are twins, triplets, etc.).

Purpose

The procedure aims to evaluate the health and development of the fetus, as well as detect any abnormalities in the mother’s uterus during the first trimester of pregnancy. It helps to provide critical information about fetal growth and well-being, confirm gestational age, and identify multiple pregnancies.

Indications

• Confirmed early pregnancy
• Suspected multiple gestations
• Monitoring of fetal development in the first trimester
• Investigating unexplained bleeding
• Assessing for potential pregnancy complications such as ectopic pregnancy or miscarriage

Preparation

• The patient may be asked to drink water and have a full bladder to improve image quality.
• No special fasting or medication adjustments are typically required.
• The healthcare provider may review the patient's medical history and perform a physical examination.

Procedure Description

1. The patient lies on an examination table.
2. A clear gel is applied to the abdomen to help transmit sound waves.
3. The technician or radiologist uses a transducer (a handheld device) to send sound waves into the body.
4. The sound waves create real-time images of the uterus and fetus, which are viewed on a monitor.
5. For multiple gestations, separate imaging is performed for each fetus.
6. The procedure typically involves no anesthesia.

Duration

The procedure typically takes about 20 to 30 minutes.

Setting

The procedure is usually performed in a hospital's radiology department, an outpatient imaging center, or a prenatal clinic.

Personnel

• Radiologist or ultrasound technician
• Obstetrician (sometimes present for interpretation)
• Nurse or medical assistant

Risks and Complications

• Minimal risks are associated with this non-invasive procedure.
• There is a rare possibility of discomfort due to the pressure of the transducer.

Benefits

• Provides essential information about fetal development and maternal health.
• Helps in early detection of potential issues like multiple pregnancies or ectopic pregnancy.
• Non-invasive and painless, with immediate imaging results.

Recovery

• No recovery time is required.
• The patient can resume normal activities immediately after the procedure.

Alternatives

• Transvaginal ultrasound: Provides more detailed images during early pregnancy but is more invasive.
• MRI: Not typically used in the first trimester for fetal imaging.

Patient Experience

• The patient may feel slight pressure from the transducer but no pain.
• The gel applied may feel cold but is easily wiped off afterward.
• Instructions and communication from the healthcare team help ensure comfort and understanding throughout the procedure.