| Patient Name | Age / Sex | ||
|---|---|---|---|
| Referring Doctor | Date |
Indication: Early pregnancy assessment. LMP and menstrual dating should be confirmed from the clinical record. Gestational age is correlated with measured sonographic parameters. Relevant symptoms and serum β-hCG are reviewed when available.
Technique: Real-time transabdominal and/or transvaginal pelvic ultrasonography as performed; targeted color Doppler where indicated.
Gestational Findings:
Uterus / Endometrium: Uterus is anteverted and of normal contour, measuring approximately 80 × 45 × 40 mm (illustrative values). Myometrium is homogeneous. Endometrial / decidual reaction is assessed. Relationship of the gestational structure to the uterine cavity, cervix and any cesarean scar must be confirmed on actual images.
Right Adnexa / Ovary: Right ovary measures approximately 30 × 20 × 18 mm (illustrative values), with preserved morphology. No separate adnexal lesion is demonstrated in this example; verify against the examination.
Left Adnexa / Ovary: Left ovary measures approximately 31 × 21 × 19 mm (illustrative values), with preserved morphology. No separate adnexal lesion is demonstrated in this example; verify against the examination.
Pouch of Douglas / Free Fluid: No free fluid is seen in the pouch of Douglas in this illustrative example. Confirm the presence, location and volume of fluid on the actual study.
Cervix: Cervical canal is closed. Cervical length measures approximately 35 mm (illustrative reference measurement). No focal cervical mass is demonstrated in this example.
Myometrium: Uterine myometrium demonstrates homogeneous echotexture, without a discrete fibroid or focal collection in this example.
Adnexal Survey: Both adnexal regions are surveyed for a separate gestational structure or suspicious mass. Findings must be confirmed on the actual scan, particularly when ectopic or heterotopic pregnancy is suspected.
Additional Findings: No additional sonographic abnormality is demonstrated in this illustrative example; replace with the observed findings.
Ultrasound findings are operator-dependent. Early gestation, bowel gas, body habitus and imaging route may limit visualization. Absence of an embryo or cardiac activity is not diagnostic of pregnancy failure unless validated size and/or follow-up interval criteria are satisfied. Confirm all findings and measurements against the actual examination.
ILLUSTRATIVE TEMPLATE ONLY: Normal example measurements are not patient measurements. Replace all example findings with actual sonographic observations and verify diagnosis, dating, clinical context and recommendations before signing.
MBBS MD (Consultant Radiologist)