{"id":"69a23530efd4f1d9175043ef","name":"Obstetrical Ultrasound - Prenatal Assessment","slug":"obstetrical-ultrasound-prenatal-assessment","description":"Structured template for obstetrical ultrasound reports evaluating gestational age, fetal growth, and anatomical survey during pregnancy.","category":{"modality":"Ultrasound","system":"Genitourinary"},"tags":["obstetrical","prenatal","pregnancy","biometry","fetal growth","gestational age","anatomy survey"],"sections":{"title":{"defaultText":"Obstetrical Ultrasound","aiInstructions":"Use standard title format. May add trimester or indication if specified in report (e.g., 'Obstetrical Ultrasound - Second Trimester', 'Obstetrical Ultrasound - Growth Assessment')."},"clinicalHistory":{"defaultText":"[Patient-specific — populated at report time]","aiInstructions":"Ask the user for: patient age, sex, presenting complaint, relevant clinical history, and reason for the exam. This section contextualizes the entire report. Always include it."},"comparison":{"defaultText":"No prior obstetrical ultrasound studies available for comparison.","aiInstructions":"If prior studies are mentioned, document the date and findings. If no comparison is available, use default text. Note interval changes if prior studies exist."},"technique":{"defaultText":"Multiple sonographic images of the pregnant uterus were obtained. Selected static images were presented for radiologist interpretation.","aiInstructions":"Document the imaging approach (transabdominal, transvaginal, or both). Include any technical limitations or positioning challenges if mentioned."},"findings":{"defaultText":"Single intrauterine pregnancy identified with appropriate biometric parameters.","aiInstructions":"Provide overview of pregnancy viability and fetal number. Then detail each section systematically: biometry with gestational age correlation, placental findings, amniotic fluid assessment, and anatomical survey results.","fields":[{"name":"Fetal Viability and Number","defaultText":"Single live fetus identified with appropriate cardiac activity.","aiInstructions":"Document number of fetuses and confirm fetal cardiac activity. Note heart rate if provided. Specify if multiple gestations and chorionicity/amnionicity if applicable."},{"name":"Fetal Presentation","defaultText":"Fetal presentation noted.","aiInstructions":"Document specific presentation (cephalic, breech, transverse, or variable). Include any positional changes if noted."},{"name":"Biparietal Diameter","defaultText":"Biparietal diameter within normal limits for gestational age.","aiInstructions":"Document exact measurement in centimeters and corresponding gestational age in weeks and days. Compare to reference standards."},{"name":"Head Circumference","defaultText":"Head circumference within normal limits for gestational age.","aiInstructions":"Document exact measurement in centimeters and corresponding gestational age in weeks and days."},{"name":"Abdominal Circumference","defaultText":"Abdominal circumference within normal limits for gestational age.","aiInstructions":"Document exact measurement in centimeters and corresponding gestational age in weeks and days."},{"name":"Femoral Length","defaultText":"Femoral length within normal limits for gestational age.","aiInstructions":"Document exact measurement in centimeters and corresponding gestational age in weeks and days."},{"name":"Composite Gestational Age","defaultText":"Composite gestational age determined from biometric parameters.","aiInstructions":"Calculate or document the composite gestational age in weeks and days based on all biometric measurements. Note if measurements are concordant or discordant."},{"name":"Estimated Fetal Weight","defaultText":"Estimated fetal weight appropriate for gestational age.","aiInstructions":"Document exact weight in grams with margin of error and percentile for gestational age if provided."},{"name":"Placenta","defaultText":"Placenta normally located and free of the cervical os.","aiInstructions":"Document placental location (anterior, posterior, fundal, lateral). Specify relationship to cervical os. Note placental appearance (echogenicity, homogeneity, thickness) and any abnormalities such as previa, abruption, or infarction."},{"name":"Cervical Length","defaultText":"Cervical length within normal limits.","aiInstructions":"Document cervical length measurement in centimeters. Note if cervical insufficiency or shortening is present. Relevant primarily in second and third trimester assessments."},{"name":"Amniotic Fluid Volume","defaultText":"Amniotic fluid volume normal.","aiInstructions":"Document amniotic fluid assessment (normal, polyhydramnios, oligohydramnios). Include deepest pocket or AFI measurement if provided."},{"name":"Fetal Cranium and Brain","defaultText":"Cranium and brain structures normal, including normal posterior fossa.","aiInstructions":"Document appearance of skull, cerebral hemispheres, ventricles, cerebellum, and posterior fossa. Note any abnormalities such as ventriculomegaly, holoprosencephaly, or posterior fossa abnormalities."},{"name":"Fetal Spine","defaultText":"Spine intact with normal vertebral alignment.","aiInstructions":"Document spine continuity and alignment. Note any defects such as spina bifida or scoliosis."},{"name":"Fetal Face","defaultText":"Facial structures normal including lips and nose.","aiInstructions":"Document facial profile, nasal bone presence/absence, lips, and palate. Note any facial clefts or abnormalities."},{"name":"Fetal Heart","defaultText":"Four-chamber heart view normal with regular cardiac activity.","aiInstructions":"Document four-chamber view, cardiac axis, heart rate (specify in beats per minute), and rhythm. Note any cardiac defects or abnormalities. Document outflow tracts if visualized."},{"name":"Fetal Stomach","defaultText":"Stomach visualized and normal in size.","aiInstructions":"Document presence and size of gastric bubble. Note any abnormalities or absence."},{"name":"Fetal Kidneys","defaultText":"Both kidneys visualized with normal appearance.","aiInstructions":"Document presence, size, and echogenicity of both kidneys. Note any hydronephrosis or renal abnormalities."},{"name":"Fetal Bladder","defaultText":"Bladder visualized and normal in size.","aiInstructions":"Document presence and size of bladder. Note any abnormalities such as megacystis."},{"name":"Umbilical Cord Insertion","defaultText":"Umbilical cord insertion normal.","aiInstructions":"Document cord insertion site (central vs marginal). Note number of vessels. Document any abnormalities such as velamentous insertion."},{"name":"Fetal Extremities","defaultText":"Extremities normal with appropriate number of digits.","aiInstructions":"Document presence and appearance of all four limbs and digits. Note any abnormalities such as clubfoot, polydactyly, or limb length discrepancies."}]},"impression":{"defaultText":"Single intrauterine pregnancy with appropriate biometric parameters. Composite fetal age consistent with clinical history. Normal interval growth. Estimated due date provided. Anatomical survey within normal limits.","aiInstructions":"Summarize key findings concisely. State fetal number, composite gestational age (weeks and days), and viability. Document estimated due date. Note if measurements are concordant or discordant with clinical dates. Document any abnormalities identified. Include recommendation for follow-up if indicated (e.g., repeat ultrasound for growth assessment, fetal echocardiography, or specialist consultation)."}},"aiUsageInstructions":{"summary":"Use this template to generate a complete Obstetrical Ultrasound - Prenatal Assessment radiology report.","steps":["1. Collect patient clinical history from the user (age, sex, clinical indication).","2. Confirm whether prior studies are available for comparison.","3. For the Technique section, use defaultText or adapt based on actual acquisition parameters.","4. For each field in sections.findings.fields: ask the user for the finding or infer from clinical context. Use defaultText if the structure is normal.","5. Generate the Impression by summarizing the most significant findings from step 4.","6. Use the aiInstructions for each section to guide the depth and format of the content.","7. Maintain formal radiology report language throughout. Passive voice preferred.","8. If any finding is abnormal, quantify it with measurements and describe its imaging characteristics."],"language":"Formal radiology report language. Passive voice preferred. Avoid first-person pronouns.","format":"Numbered impression list. Prose findings paragraphs or structured field-by-field format both acceptable.","units":"Report measurements in centimeters (cm) for masses, millimeters (mm) for small structures."},"meta":{"canonicalUrl":"https://radiluxreports.com/templates/obstetrical-ultrasound-prenatal-assessment","claudeApiUrl":"https://radiluxreports.com/templates/api/claude/obstetrical-ultrasound-prenatal-assessment","useInDashboardUrl":"https://radiluxreports.com/?templateId=69a23530efd4f1d9175043ef","apiUrl":"https://radiluxreports.com/templates/api/obstetrical-ultrasound-prenatal-assessment","updatedAt":"2026-03-01T00:12:20.210Z","license":"Free for clinical and educational use. Attribution appreciated."}}