76811 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation

Name of the Procedure:

Ultrasound, pregnant uterus, real-time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation

Summary

This procedure is a non-invasive imaging technique where an ultrasound probe is used to examine a pregnant woman’s uterus and developing fetus in real time. It includes image documentation and an evaluation of both maternal and fetal health, focusing on detailed fetal anatomy. The procedure is performed via the transabdominal approach, typically during the first gestation.

Purpose

This ultrasound is designed to:

• Assess the health and development of the fetus.
• Evaluate the anatomical structure of the fetus.
• Monitor the maternal uterus and surrounding structures to ensure a healthy pregnancy.
• Detect abnormalities early in the pregnancy.

Indications

The procedure is indicated for:

• Routine prenatal care.
• Monitoring fetal growth and development.
• Assessment of fetal anatomy to check for congenital abnormalities.
• Verification of the number of fetuses (for single or first gestation).
• Investigating complications such as bleeding, pain, or suspected miscarriage.

Preparation

Patients should:

• Drink plenty of water about an hour before the procedure to ensure a full bladder, which helps improve the quality of images.
• Wear loose, comfortable clothing for easy access to the abdomen.
• No specific fasting or medication adjustments are typically required unless directed by the healthcare provider.

Procedure Description

1. Initial Setup:
   • The patient lies on an examination table, typically on their back.
   • A clear gel is applied to the abdomen to facilitate sound wave transmission.
2. Execution:
   • The technician or sonographer moves the ultrasound probe across the abdomen to capture images of the uterus and fetus.
   • Real-time images are displayed on a monitor and recorded for documentation.
3. Evaluation:
   • The healthcare provider assesses these images to evaluate the health and anatomy of the fetus and maternal structures.
4. Completion:
   • The gel is wiped off, and the patient can resume normal activities immediately.

Duration

The procedure typically takes about 20 to 45 minutes, depending on the clarity of images and the specific assessment needs.

Setting

It is usually performed in an outpatient clinic, hospital, or specialized imaging center.

Personnel

• Sonographer or ultrasound technician
• Radiologist or obstetrician for image interpretation and consultation

Risks and Complications

Ultrasound is extremely safe with:

• No known risks or complications.
• Non-ionizing radiation ensures it is safe for both mother and fetus.

Benefits

• Provides crucial information about fetal and maternal health.
• Non-invasive and painless.
• Immediate preliminary results can often reassure or inform further medical decisions.
• Helps in early detection of potential abnormalities or complications.

Recovery

• No recovery time is required.
• Patients can resume daily activities immediately after the procedure.
• Follow-up appointments are scheduled as part of routine prenatal care.

Alternatives

• Other imaging methods (e.g., MRI) may be used for specific diagnostic needs but are generally less common during pregnancy.
• Individual alternatives should be discussed with the healthcare provider, considering their pros and cons.

Patient Experience

• The procedure is typically comfortable; the main sensation is the cool gel and slight pressure from the probe.
• Some patients may experience minor discomfort from a full bladder.
• Anxiety can be alleviated by discussing concerns with the healthcare provider before the procedure.