I.8 OB-GYN Examples
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## I.8 OB-GYN Examples

The following are simple, non-comprehensive illustrations of report sections.

### I.8.1 Example 1: OB-GYN Root with Observation Context

The following example shows the highest level of content items for a second or third trimester OB exam. Subsequent examples show details of section content,

Nest | Code Meaning of Concept Name | Code Meaning or Example Value | TID
--- | --- | --- | ---
1 | OB-GYN Ultrasound Procedure Report |  | TID 5000
1.1 | Language of Content Item and Descendants | English | TID 1204
1.2 | Subject Name | Jane Doe | TID 1007
1.3 | Subject ID | 123-45-6789 | TID 1007
1.4 | Procedure Study Instance UID | 1.2.842.111724.7678.32.34 | TID 1005
1.5 | Procedure Study Component UID | 1.2.842.111724.7678.55.34 | TID 1005
1.6 | Procedure Accession Number | 20011007-21 | TID 1005
1.7 | Image Library |  | TID 5000
1.7.1 |  | IMAGE 1 | TID 5000
1.7.2 |  | IMAGE 2 | TID 5000
1.7.n |  | IMAGE N | TID 5000
1.8 | Patient Characteristics |  | TID 5001
1.8.n |  |  | TID 5001
1.9 | Summary |  | TID 5002
1.9.n |  |  | TID 5002
1.10 | Fetal Biometry Ratios |  | TID 5004
1.10.n |  |  | TID 5004
1.11 | Long Bones |  | TID 5006
1.11.n |  |  | TID 5006
1.12 | Fetal Cranium |  | TID 5007
1.12.n |  |  | TID 5007
1.13 | Biophysical Profile |  | TID 5009
1.13.n |  |  | TID 5009
1.14 | Amniotic Sac |  | TID 5010
1.14.n |  |  | TID 5010

The following example shows the highest level of content items for a GYN exam. Subsequent examples show details of section content.

Nest | Code Meaning of Concept Name | Code Meaning or Example Value | TID
--- | --- | --- | ---
1 | OB-GYN Ultrasound Procedure Report |  | TID 5000
1.1 | Subject Name | Jane Doe | TID 1007
1.2 | Subject ID | 123-45-6789 | TID 1007
1.3 | Image Library |  | TID 5000
1.3.1 |  | IMAGE 1 | TID 5000
1.3.2 |  | IMAGE 2 | TID 5000
1.3.n |  | IMAGE N | TID 5000
1.4 | Patient Characteristics |  | TID 5001
1.4.n |  |  | TID 5001
1.5 | Findings |  | TID 5012
1.5.1 | Findings Site | Ovary | TID 5012
1.5.n |  |  | TID 5012
1.6 | Findings |  | TID 5013
1.6.1 | Findings Site | Ovarian Follicle | TID 5013
1.6.2 | Laterality | Left | TID 5013
1.6.n |  |  | TID 5013
1.7 | Findings |  | TID 5013
1.7.1 | Findings Site | Ovarian Follicle | TID 5013
1.7.2 | Laterality | Right | TID 5013
1.7.n |  |  | TID 5013
1.8 | Pelvis and Uterus |  | TID 5015
1.8.n |  |  | TID 5015

### I.8.2 Example 2: OB-GYN Patient Characteristics and Procedure Summary

Nest | Code Meaning of Concept Name | Code Meaning or Example Value | TID
--- | --- | --- | ---
1 | OB-GYN Ultrasound Procedure Report |  | TID 5000
| …. |  | TID 5000
1.8 | Patient Characteristics |  | TID 5001
1.8.1 | Gravida | 5 | TID 5001
1.8.2 | Para | 3 | TID 5001
1.8.3 | Aborta | 2 | TID 5001
1.8.4 | Ectopic Pregnancies | 1 | TID 5001
1.9 | Summary |  | TID 5002
1.9.1 | LMP | 20010101 | TID 5002
1.9.2 | EDD | 20010914 | TID 5002
1.9.3 | EDD from LMP | 20010914 | TID 5002
1.9.4 | EDD from average ultrasound age | 20010907 | TID 5002
1.9.5 | Gestational age by ovulation date | 185 d | TID 5002
1.9.6 | Fetus Summary |  | TID 5003
1.9.6.1 | EFW | 2222 g | TID 300
1.9.6.1.1 | +/-, range of measurement uncertainty | 200 g | TID 310
1.9.6.1.2 | Equation | EFW by AC, BPD, Hadlock 1984 | TID 315
1.9.6.2 | Comment | Enlarged cisterna magna | TID 5003
1.9.6.3 | Comment | Choroid plexus cyst | TID 5003

### I.8.3 Example 3: OB-GYN Multiple Fetus

Nest | Code Meaning of Concept Name | Code Meaning or Example Value | TID
--- | --- | --- | ---
1 | OB-GYN Ultrasound Procedure Report |  | TID 5000
1.n | …. |  | TID 5000
1.5 | Summary |  | TID 5002
1.5.1 | EDD from LMP | 20020325 | TID 5002
1.5.2 | Fetus Summary |  | TID 5003
1.5.2.1 | Fetus ID | A | TID 1008
1.5.2.2 | EFW | 1.6 Kg | TID 300
1.5.2.2.1 | Equation | EFW by AC, BPD, Hadlock 1984 | TID 315
1.5.2.2.2 | +/-, range of measurement uncertainty | 160g | TID 310
1.5.2.3 | Fetal Heart Rate | 120 {H.B.}/min | TID 300
1.5.3 | Fetus Summary |  | TID 5003
1.5.3.1 | Fetus ID | B | TID 1008
1.5.3.2 | Comment | Choroid plexus cyst | TID 5003
1.5.3.3 | EFW | 1.4 kg | TID 300
1.5.3.3.1 | Equation | EFW by AC, BPD, Hadlock 1984 | TID 315
1.5.3.3.2 | +/-, range of measurement uncertainty | 140 g | TID 310
1.5.3.4 | Fetal Heart Rate | 135 {H.B.}/min | TID 300
1.6 | Biophysical Profile |  | TID 5009
1.6.1 | Fetus ID | A | TID 1008
1.6.n | … |  |
1.7 | Biophysical Profile |  | TID 5009
1.7.1 | Fetus ID | B | TID 1008
1.7.n | … |  |

### I.8.4 Example 4: Biophysical Profile

Nest | Code Meaning of Concept Name | Code Meaning or Example Value | TID
--- | --- | --- | ---
1 | OB-GYN Ultrasound Procedure Report |  | TID 5000
1.n | …. |  | TID 5000
1.9 | Biophysical Profile |  | TID 5009
1.9.1 | Gross Body Movement | 2 {0:2} | TID 5009
1.9.2 | Fetal Breathing | 2 {0:2} | TID 5009
1.9.3 | Fetal Tone | 2 {0:2} | TID 5009
1.9.4 | Fetal Heart Reactivity | 2 {0:2} | TID 5009
1.9.5 | Amniotic Fluid Volume | 2 {0:2} | TID 5009
1.9.6 | Biophysical Profile Sum Score | 10 {0:10} | TID 5009

### I.8.5 Example 5: Biometry Ratios

Optionally, but not shown, the ratios may have by-reference, inferred-from relationships to the content items holding the numerator and denominator values.

Nest | Code Meaning of Concept Name | Code Meaning or Example Value | TID
--- | --- | --- | ---
1 | OB-GYN Ultrasound Procedure Report |  | TID 5000
1.n | …. |  | TID 5000
1.9 | Fetal Biometry Ratios |  | TID 5004
1.9.1 | HC/AC | 77% | TID 5004
1.9.2 | FL/AC | 22 % | TID 5004
1.9.2.1 | Normal Range Lower Limit | 20 % | TID 312
1.9.2.2 | Normal Range Upper Limit | 24 % | TID 312
1.9.2.3 | Normal Range Authority | Hadlock, AJR 1983 | TID 312
1.9.3 | FL/BPD | 79 % | TID 5004
1.9.3.1 | Normal Range Lower Limit | 71 % | TID 312
1.9.3.2 | Normal Range Upper Limit | 81 % | TID 312
1.9.3.3 | Normal Range Authority | Hohler, Am J of Ob and Gyn 1981 | TID 312
1.9.4 | Cephalic Index | 82 % | TID 5004
1.9.4.1 | Normal Range Lower Limit | 70 % | TID 312
1.9.4.2 | Normal Range Upper Limit | 86 % | TID 312
1.9.4.3 | Normal Range Authority | Hadlock, AJR 1981 | TID 312

### I.8.6 Example 6: Biometry

This example shows measurements and estimated gestational age.

Nest | Code Meaning of Concept Name | Code Meaning or Example Value | TID
--- | --- | --- | ---
1 | OB-GYN Ultrasound Procedure Report |  | TID 5000
1.n | …. |  | TID 5000
1.8 | Fetal Biometry |  | TID 5005
1.8.1 | Biometry Group |  | TID 5008
1.8.1.1 | Biparietal Diameter | 5.5 cm | TID 300
1.8.1.2 | Biparietal Diameter | 5.3 cm | TID 300
1.8.1.3 | Biparietal Diameter | 5.4 cm | TID 300
1.8.1.3.1 | Derivation | Mean | TID 300
1.8.1.4 | Gestational Age | 190 d | TID 5008
1.8.1.4.1 | Equation | Jeanty, 1982 | TID 5008
1.8.1.4.2 | 5th Percentile Value of population | 131 d | TID 5008
1.8.1.4.3 | 95th Percentile Value of population | 173 d | TID 5008
1.8.2 | Biometry Group |  | TID 5008
1.8.2.1 | Occipital-Frontal Diameter | 18.1 cm | TID 300
1.8.3 | Biometry Group |  | TID 5008
1.8.3.1 | Head Circumference | 34.3 cm | TID 300
1.8.3.1.1 | Derivation | Estimated | TID 300
1.8.4 | Biometry Group |  | TID 5008
1.8.4.1 | Abdominal Circumference | 34.9 cm | TID 300
1.8.4.2 | Abdominal Circumference | 34.3 cm | TID 300
1.8.4.3 | Abdominal Circumference | 34.3 cm | TID 300
1.8.4.4 | Abdominal Circumference | 34.5 cm | TID 300
1.8.4.4.1 | Derivation | Mean | TID 300
1.8.4.5 | Gestational Age | 190 d | TID 5008
1.8.4.5.1 | Equation | Hadlock, 1984 | TID 5008
1.8.4.5.2 | 2 Sigma Lower Value of population | 184 d | TID 5008
1.8.4.5.3 | 2 Sigma Upper Value of population | 196 d | TID 5008
1.8.5 | Biometry Group |  | TID 5008
1.8.5.1 | Femur Length | 4.5 cm | TID 300
1.8.5.n | … |  | TID 300

This example shows measurements and with percentile ranking.

Nest | Code Meaning of Concept Name | Code Meaning or Example Value | TID
--- | --- | --- | ---
1 | OB-GYN Ultrasound Procedure Report |  | TID 5000
1.n | …. |  | TID 5000
1.8 | Fetal Biometry |  | TID 5005
1.8.1 | Biometry Group |  | TID 5008
1.8.1.1 | Biparietal Diameter | 5.5 cm | TID 300
1.8.1.2 | Biparietal Diameter | 5.3 cm | TID 300
1.8.1.3 | Biparietal Diameter | 5.4 cm | TID 300
1.8.1.3.1 | Derivation | Mean | TID 300
1.8.1.4 | Growth Percentile Rank | 63 % | TID 5008
1.8.1.4.1 | Equation | BPD, Jeanty 1982 | TID 5008
1.8.2 | Biometry Group |  | TID 5008
1.8.2.n | … |  | TID 300

### I.8.7 Example 7: Amniotic Sac

Nest | Code Meaning of Concept Name | Code Meaning or Example Value | TID
--- | --- | --- | ---
1 | OB-GYN Ultrasound Procedure Report |  | TID 5000
1.n | …. |  | TID 5000
1.6 | Findings |  | TID 5010
1.6.1 | Finding Site | Amniotic Sac | TID 5010
1.6.2 | Amniotic Fluid Index | 11 cm | TID 300
1.6.3 | First Quadrant Diameter | 10 cm | TID 300
1.6.4 | Second Quadrant Diameter | 12 cm | TID 300
1.6.5 | Third Quadrant Diameter | 11 cm | TID 300
1.6.6 | Fourth Quadrant Diameter | 12 cm | TID 300

### I.8.8 Example 8: OB-GYN Ovaries

The content structure in the example below conforms to TID 5012 “Ovaries Section”. The example shows the volume derived from three perpendicular diameters.

Figure I.8-1. Ovaries Example

Nest | Code Meaning of Concept Name | Code Meaning or Example Value | TID
--- | --- | --- | ---
1 | OB-GYN Ultrasound Procedure Report |  | TID 5000
1.n | …. |  | TID 5000
1.9 | Findings |  | TID 5012
1.9.1 | Finding Site | Ovary | TID 5012
1.9.2 | Ovary |  | TID 5016
1.9.2.1 | Left Ovary Volume | 6 cm3 | TID 300
1.9.2.2 | Left Ovary Length | 3 cm | TID 300
1.9.2.3 | Left Ovary Length | 3 cm | TID 300
1.9.2.4 | Left Ovary Length | 3 cm | TID 300
1.9.2.4.1 | Derivation | Mean | TID 300
1.9.2.5 | Left Ovary Width | 2 cm | TID 300
1.9.2.5.1 | Derivation | Mean | TID 300
1.9.2.6 | Left Ovary Height | 2 cm | TID 300
1.9.2.6.1 | Derivation | Mean | TID 300
1.9.3 | Ovary |  | TID 5016
1.9.3.1 | Right Ovary Volume | 7 cm3 | TID 300
1.9.3.2 | … |  | TID 300

### I.8.9 Example 9: OB-GYN Follicles

The content structure in the example below conforms to TID 5013 “Follicles Section”. It uses multiple measurements and derived averages for each of the perpendicular diameters.

Figure I.8-2. Follicles Example

Nest | Code Meaning of Concept Name | Code Meaning or Example Value | TID
--- | --- | --- | ---
1 | OB-GYN Ultrasound Procedure Report |  | TID 5000
1.n | …. |  | TID 5000
1.8 | Findings |  | TID 5013
1.8.1 | Finding Site | Ovarian Follicle | TID 5013
1.8.2 | Laterality | Right | TID 5013
1.8.3 | Number of follicles in right ovary | 2 | TID 5013
1.8.4 | Measurement Group |  | TID 5014
1.8.4.1 | Identifier | #1 | TID 5014
1.8.4.2 | Volume | 3 cm3 | TID 300
1.8.4.3 | Follicle Diameter | 15 mm | TID 300
1.8.4.4 | Follicle Diameter | 13 mm | TID 300
1.8.4.5 | Follicle Diameter | 14 mm | TID 300
1.8.4.5.1 | Derivation | Mean | TID 300
1.8.5 | Measurement Group |  | TID 5014
1.8.5.1 | Identifier | #2 | TID 5014
1.8.5.2 | Volume | 4 cm3 | TID 300
1.8.5.3 | Follicle Diameter | 18 mm | TID 300
1.9 | Findings |  | TID 5013
1.9.1 | Finding Site | Ovarian Follicle | TID 5013
1.9.2 | Laterality | Left | TID 5013
1.9.3 | Number of follicles in left ovary | 1 | TID 5013
1.9.4 | Follicle Measurement Group |  | TID 5014
1.9.4.1 | Identifier | #1 | TID 5014
1.9.4.2 | Volume | 3 cm3 | TID 300
1.9.4.3 | Follicle Diameter | 15 mm | TID 300

### I.8.10 Example 10: Pelvis and Uterus

Nest | Code Meaning of Concept Name | Code Meaning or Example Value | TID
--- | --- | --- | ---
1 | OB-GYN Ultrasound Procedure Report |  | TID 5000
1.n | …. |  |
1.9 | Pelvis and Uterus |  | TID 5015
1.9.1 | Uterus |  | TID 5016
1.9.1.1 | Uterus Volume | 136 cm3 | TID 300
1.9.1.2 | Uterus Length | 9.5 cm | TID 300
1.9.1.3 | Uterus Width | 5.9 cm | TID 300
1.9.1.4 | Uterus Height | 4.2 cm | TID 300
1.9.2 | Endometrium Thickness | 4 mm | TID 5015
1.9.3 | Cervix Length | 5.3 cm | TID 5015

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