Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a prev
CPT4 code
Name of the Procedure:
Ultrasound, Pregnant Uterus, Real-Time with Image Documentation, Follow-Up (e.g., Re-evaluation of Fetal Size, Amniotic Fluid Volume, and Organ Systems Suspected or Confirmed to be Abnormal)
Summary
This ultrasound procedure is a non-invasive imaging test performed on pregnant women to evaluate the growth and development of the fetus. It uses real-time imaging to document fetal size, amniotic fluid volume, and to re-assess any previously identified or suspected abnormalities in the fetal organs.
Purpose
The primary goal of this procedure is to monitor the fetus's growth and development, ensuring that the baby is growing appropriately for its gestational age and identifying any potential issues. This follow-up scan is crucial for re-evaluating previously noted concerns.
Indications
- Abnormal findings in a prior ultrasound.
- Suspicion of fetal growth restriction or macrosomia.
- Concerns regarding amniotic fluid levels.
- Monitoring of previously identified organ anomalies.
- High-risk pregnancies warranting close monitoring.
Preparation
- No specific preparation is usually required, but it is recommended to wear comfortable, loose-fitting clothing.
- Patients may need to have a full bladder depending on the stage of pregnancy.
- Previous ultrasound reports should be brought to the appointment.
Procedure Description
- The patient lies on an examination table, typically on her back.
- A clear, water-based gel is applied to the abdomen to help the transducer make secure contact with the skin.
- The sonographer moves the transducer over the abdomen to capture real-time images of the uterus and fetus.
- Standard fetal growth parameters are measured, including head circumference, abdominal circumference, and femur length.
- Amniotic fluid volume is assessed using the amniotic fluid index or single deepest vertical pocket method.
- Detailed images of the fetal organs are captured to re-evaluate suspected abnormalities.
- Findings are documented and reviewed by a radiologist or obstetrician.
Duration
The procedure typically lasts between 20 to 40 minutes, depending on the complexity of the case and the cooperation of the fetus.
Setting
Ultrasounds are usually performed in an outpatient setting, such as a hospital's radiology department, a specialized ultrasound clinic, or an obstetrician’s office.
Personnel
- Sonographer (ultrasound technician)
- Radiologist or obstetrician (for interpretation of results)
Risks and Complications
- Ultrasound is extremely safe with no known risks or complications for the mother or fetus.
- Rarely, discomfort from the pressure of the transducer or coldness of the gel might be experienced.
Benefits
- Non-invasive and provides critical information on fetal well-being and development.
- Helps in early detection and management of potential issues.
- Immediate real-time imaging results are available.
Recovery
- No recovery period is required as this is a non-invasive procedure.
- Normal activities can be resumed immediately after the ultrasound.
- Follow-up appointments or additional ultrasounds may be scheduled based on the results.
Alternatives
- Magnetic Resonance Imaging (MRI) may be used in certain cases but is less commonly employed due to cost and limited availability.
- Routine physical examinations and non-stress tests can complement ultrasounds but do not provide the same level of detailed imaging.
Patient Experience
During the ultrasound, patients generally feel minimal to no discomfort. They may feel slight pressure from the transducer or coolness from the gel. The procedure is painless, and any anxiety or stress can be alleviated by knowing the purpose and steps of the procedure. After the scan, patients can immediately return to their daily activities.