76812 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, 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, plus detailed fetal anatomic examination, transabdominal approach; each additional gestation

Summary

This is a specialized ultrasound procedure for pregnant women that involves a comprehensive evaluation of the fetus and mother. It includes real-time imaging and detailed anatomical examination of the fetus. The transabdominal approach is used, and it can be applied to each additional fetus in a multiple gestation pregnancy.

Purpose

• Medical Condition or Problem: Assessing the health and development of the fetus and the well-being of the mother.
• Goals: To ensure the proper development of the fetus, identify any potential complications early, and monitor the health of the mother and additional fetuses in multiple gestations.

Indications

• Symptoms such as abnormal fetal development indicators or pregnancy complications.
• Factors like multiple pregnancies or a history of complications in previous pregnancies.

Preparation

• Pre-Procedure Instructions: Generally, no special preparation is needed, but the patient may be advised to drink water to ensure a full bladder for a clearer ultrasound image.
• Diagnostic Tests: Previous ultrasound results and maternal health records may be reviewed.

Procedure Description

1. The patient lies on an examination table.
2. A gel is applied to the abdomen to facilitate better ultrasound transmission.
3. A transducer (a handheld device) is moved over the abdomen to capture real-time images.
4. Fetal and maternal evaluations are conducted, including anatomical examination.
5. Images are documented for further analysis.
6. For multiple gestations, the process is repeated for each additional fetus.

• Tools and Equipment: Ultrasound machine with a transabdominal transducer.
• Anesthesia: None required.

Duration

Typically takes around 30 to 60 minutes, depending on the number of fetuses and the complexity of the examination.

Setting

Performed in a hospital radiology department, outpatient clinic, or a specialized prenatal care center.

Personnel

• Radiologist or Obstetrician specialized in ultrasound.
• Sonographer (a technician trained in performing ultrasound exams).
• Occasionally, an obstetric nurse may assist.

Risks and Complications

• Common Risks: Minimal, as ultrasound is a safe and non-invasive procedure.
• Rare Complications: There are no known risks of harm to the mother or fetus from a standard ultrasound procedure.
• Management: Any discomfort can be managed on-site.

Benefits

• Detailed insight into fetal development and maternal health.
• Early detection of potential complications.
• Ability to monitor multiple fetuses effectively.
• Expected outcomes can usually be realized immediately after the examination.

Recovery

• Post-Procedure Care: No special care is needed.
• Recovery Time: Immediate, with no downtime.
• Follow-up: Additional appointments as recommended based on findings.

Alternatives

• Other Options: Limited due to the non-invasive and comprehensive nature of ultrasound.
• Pros and Cons: MRI may offer alternative imaging but is used less frequently due to cost and availability.

Patient Experience

• During the Procedure: Patients may feel some pressure from the transducer but should not experience pain.
• After the Procedure: Usually no discomfort.
• Pain Management: Not typically necessary, but comfort measures include a warm gel and a comfortable examination setting.