{"id":"69a23715efd4f1d917504564","name":"Obstetrical Ultrasound - Second/Third Trimester","slug":"obstetrical-ultrasound-second-third-trimester-2","description":"Structured template for obstetrical ultrasound evaluating gestational age, fetal growth, and anatomical survey in pregnancy.","category":{"modality":"Ultrasound","system":"Genitourinary"},"tags":["obstetrics","pregnancy","fetal biometry","gestational age","fetal growth","anatomical survey","second trimester","third trimester"],"sections":{"title":{"defaultText":"Obstetrical Ultrasound","aiInstructions":"Use the standard title 'Obstetrical Ultrasound' or modify based on specific indication (e.g., 'Obstetrical Ultrasound - Growth Assessment', 'Obstetrical Ultrasound - Anatomy Survey'). Do not add clinical details to the title."},"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 studies available for comparison.","aiInstructions":"If prior obstetrical ultrasound(s) are mentioned, document the date(s) and findings. If no prior studies are available, use the default text. If comparison is made to prior studies, note interval changes in fetal growth and development."},"technique":{"defaultText":"Multiple sonographic images of the pregnant uterus were obtained. Selected static images were reviewed and interpreted.","aiInstructions":"Document the imaging technique used (transabdominal, transvaginal, or both). Include any specific views or measurements obtained. Describe the quality of the study if relevant to interpretation."},"findings":{"defaultText":"Single live intrauterine pregnancy identified.","aiInstructions":"Begin with confirmation of pregnancy viability and number of fetuses. Document fetal presentation, placental location, and amniotic fluid volume. Present biometric measurements with corresponding gestational ages. Include anatomical survey findings. Organize findings systematically by anatomical region.","fields":[{"name":"Pregnancy Viability and Number","defaultText":"Single live intrauterine pregnancy identified.","aiInstructions":"State whether pregnancy is single or multiple. Confirm fetal cardiac activity and heart rate. Document any evidence of fetal demise if present."},{"name":"Fetal Presentation","defaultText":"Fetal presentation noted.","aiInstructions":"Document fetal presentation (cephalic, breech, transverse, or variable). Include position if clinically relevant."},{"name":"Placenta","defaultText":"Placenta is normally located and free of the cervical os.","aiInstructions":"Document placental location (anterior, posterior, fundal, lateral). Specify if placenta is free of cervical os (rule out previa). Note placental echotexture, thickness, and any abnormalities (infarction, calcification, masses). Document if placenta is singleton or multiple."},{"name":"Cervical Length","defaultText":"Cervical length is within normal limits.","aiInstructions":"Measure and document cervical length in centimeters. Include measurement technique (transvaginal preferred). Note if cervix appears shortened or incompetent. Document cervical funneling if present."},{"name":"Biparietal Diameter","defaultText":"Biparietal diameter measured.","aiInstructions":"Document biparietal diameter (BPD) measurement in centimeters and corresponding gestational age in weeks and days. Note if measurement is consistent with clinical dates or if there is discrepancy."},{"name":"Head Circumference","defaultText":"Head circumference measured.","aiInstructions":"Document head circumference (HC) measurement in centimeters and corresponding gestational age in weeks and days. Compare to BPD-derived age and note any discrepancy."},{"name":"Abdominal Circumference","defaultText":"Abdominal circumference measured.","aiInstructions":"Document abdominal circumference (AC) measurement in centimeters and corresponding gestational age in weeks and days. AC is most sensitive for growth assessment. Note if measurement suggests growth restriction or macrosomia."},{"name":"Femoral Length","defaultText":"Femoral length measured.","aiInstructions":"Document femoral length (FL) measurement in centimeters and corresponding gestational age in weeks and days. Include both lower extremity measurements if obtained. Note any discrepancy with other biometric parameters."},{"name":"Estimated Fetal Weight","defaultText":"Estimated fetal weight calculated.","aiInstructions":"Document estimated fetal weight (EFW) in grams with confidence interval (±) and percentile for gestational age. Assess weight percentile relative to appropriate-for-gestational-age (AGA), small-for-gestational-age (SGA), or large-for-gestational-age (LGA) categories."},{"name":"Amniotic Fluid Volume","defaultText":"Amniotic fluid volume is normal.","aiInstructions":"Document amniotic fluid volume as normal, oligohydramnios, or polyhydramnios. If measured, include deepest vertical pocket (DVP) in centimeters or amniotic fluid index (AFI). Note any areas of decreased fluid or abnormal distribution."},{"name":"Fetal Head and Brain","defaultText":"Cranium and brain are normal in appearance. Posterior fossa structures are visualized and normal.","aiInstructions":"Document cranial vault symmetry, bone integrity, and intracranial structures. Describe ventricular system, cerebellum, and posterior fossa. Note any abnormalities such as ventriculomegaly, hydrocephalus, or structural malformations."},{"name":"Fetal Spine","defaultText":"Spine is intact with normal vertebral alignment and ossification.","aiInstructions":"Document spine visualized in longitudinal and transverse planes. Assess vertebral bodies, posterior elements, and skin coverage. Note any abnormalities such as open neural tube defects, scoliosis, or hemivertebrae."},{"name":"Fetal Face, Lips, and Nose","defaultText":"Face, lips, and nose are normal in appearance.","aiInstructions":"Document facial profile, nasal bone, upper lip, and palate assessment. Note any cleft lip or palate, facial abnormalities, or structural defects. Include nasal bone length if first or early second trimester."},{"name":"Fetal Heart","defaultText":"Four-chamber heart view is normal with regular cardiac activity and normal heart rate.","aiInstructions":"Document four-chamber heart view, cardiac axis, and chamber sizes. Include fetal heart rate (FHR) in beats per minute (bpm) measured by M-mode. Assess for any structural cardiac abnormalities, septal defects, or valve abnormalities if cardiac views are adequate. Note if detailed cardiac assessment is limited."},{"name":"Fetal Lungs and Thorax","defaultText":"Lungs and thorax are normal in appearance.","aiInstructions":"Document lung echogenicity and thoracic cavity size. Note any abnormalities such as pleural effusion, masses, or structural defects. Assess diaphragm integrity."},{"name":"Fetal Abdomen and Stomach","defaultText":"Abdomen is normal. Stomach is visualized and normal in size.","aiInstructions":"Document abdominal wall integrity and absence of gastroschisis or omphalocele. Visualize stomach bubble and assess size. Document liver echotexture. Note any abdominal masses, ascites, or bowel dilatation."},{"name":"Fetal Kidneys and Bladder","defaultText":"Kidneys are bilateral and normal in size and echotexture. Bladder is visualized and normal.","aiInstructions":"Document bilateral kidneys with normal size, echotexture, and amount of renal pelvis dilatation. Include renal pelvic anteroposterior (AP) diameter in millimeters if measured. Visualize bladder and assess size. Note any hydronephrosis, renal agenesis, or abnormal echotexture."},{"name":"Fetal Extremities","defaultText":"Extremities are normal with appropriate number of digits and normal alignment.","aiInstructions":"Document bilateral upper and lower extremities visualized with normal number of digits and normal alignment. Assess for clubfoot, limb defects, or abnormal positioning. Note if views are limited."},{"name":"Umbilical Cord Insertion","defaultText":"Umbilical cord insertion is normal at the fetal abdomen.","aiInstructions":"Document cord insertion site as normal (abdomen) or abnormal (velamentous, etc.). Assess number of umbilical vessels (should be 3: 2 arteries, 1 vein). Note any cord abnormalities such as knots, strictures, or excessive length."},{"name":"Maternal Uterus and Adnexa","defaultText":"Maternal uterus and adnexal structures are normal.","aiInstructions":"Document uterine size, contour, and echotexture. Assess for uterine fibroids or abnormalities. Evaluate adnexal structures for masses or abnormalities. Note any findings that may impact pregnancy."}]},"impression":{"defaultText":"Single intrauterine pregnancy with composite fetal age and normal interval growth. Estimated delivery date provided.","aiInstructions":"Summarize key findings including: (1) number of fetuses and viability, (2) composite gestational age in weeks and days with consistency of biometric parameters, (3) assessment of fetal growth (AGA, SGA, or LGA), (4) interval growth assessment if prior studies available, (5) estimated delivery date (EDD), (6) placental location, (7) amniotic fluid volume, (8) any abnormalities identified in anatomical survey with specific findings and recommendations for follow-up. Use clear, concise language appropriate for clinical communication. If abnormalities are identified, provide specific anatomical descriptions and clinical significance."}},"aiUsageInstructions":{"summary":"Use this template to generate a complete Obstetrical Ultrasound - Second/Third Trimester 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-second-third-trimester-2","claudeApiUrl":"https://radiluxreports.com/templates/api/claude/obstetrical-ultrasound-second-third-trimester-2","useInDashboardUrl":"https://radiluxreports.com/?templateId=69a23715efd4f1d917504564","apiUrl":"https://radiluxreports.com/templates/api/obstetrical-ultrasound-second-third-trimester-2","updatedAt":"2026-03-01T00:12:23.220Z","license":"Free for clinical and educational use. Attribution appreciated."}}