doppler gynecology pdf doppler en gynécologie

Doppler en gynécologie

1. DOPPLER
IN GYNECOLOGY
DR MERIEM BEHIDJI
M.D. Gynecologist & obstetrician specialist
ALGERIA
Email :[email protected]

2. DOPPLER EFFECT
The doppler effect

3. Whatisthe doppler phenomenon?
Doppler shift frequency (fd): ft - fr

4. Goals of doppler •Detectionflow in a vessel
•Detectiondirection of flow
•Detectionof type of flow : normal /abnormal
•arterialvenous
•Measurementsthe velocityof flow

5. The doppler equation

6. Using Doppler depends on the Doppler shift principl e, which measures the change in US frequency
following its scatter by a moving object, when recei ved back by the transducer.
The moving object in this case is blood within bloo d vessels, plus the movement of the vessel wall
itself.

7. Types of doppler

8. There are different transvaginal techniques for exa mining
vascularity in the female genital tract.
•PW: Pulsed Wave
•CFM:Colorflow mapping
•PDI: Power Doppler
•HD flow: HIGH DEFINITION FLOW

9. 1.
Pulsed
wave
spectral Doppler mode
The pulse wave image above shows all the measuremen t indices
written electronically below the tracing:
PEAK SYSTOLIC VELOCITY (PSV)
END DIASTOLIC VELOCITY (EDV)
MEAN VELOCITY (MNV)
RESISTIVE INDEX (RI)
SYSTOLIC / DIASTOLIC RATIO (S/D), PULSATILITY INDEX (PI), HEART
RATE (HR)

11. Measurement indices: 1. Pulsatilityindex is the term used to represent th e ratio of peak
systolic velocity –end diastolic velocity divided b y time averaged
velocity [(PSV+EDV) / 2].
2. Resistive index is the ratio of peak systolic ve locity -end diastolic
velocity divided by peak systolic velocity. Accordi ngly, the maximum
reading should be one.
3. Velocity is the maximum shift over one cycle.
4. Flow is the average velocity times the lumen area of the vessel.

12. PsV EdV
ACCel (Acceleration Index)
RI (Resistance Index):
PsV-EdV/PsV
PI (Pulsatility Index):
PsV-EdV/TAMAX
Time Average MAX curve

13. Spectral doppler
PSV
Baseline
EDV
BEAM PATH
Angle
correction
cursor
Sample
volume

14. FACTORS THAT INFLUENCE THE DOPPLER SPECTRUM Blood flow direction
(A, D) Velocity profiles for blunt flow and parabolic flow, respectively.
(B, E) If a wide ultrasound beam is used to insonate th e vessel, all the velocities present will be detecte d.
(C, F) Idealized Doppler spectra that would be obtaine d from complete insonation of blunt flow and parabol ic flow.

15. Nonuniforminsonationof the vessel
Incomplete insonation of the vessel will occur when a narrow beam
is used. The area within the vessel where flow is d etected is shown
when a large sample volume length (A and B) and a sma ll sample
volume length are used (D, E) along with typical Doppl er spectra that
may be obtained (C and F). Note the absence of low-ve locity flow in
(F) compared with (C) creating a window under the spect rum.

16. ANGLE OF INSONATION

17. High
-
pass
filter
•The shape of the Doppler spectrum can also be alter ed if the high-
pass filter is set too high, removing important inf ormation from the
spectrum, such as the presence of low -velocity diastolic flow.

18. Gain The
gain is used to amplify the Doppler signal may also alter the appeara nce of the
spectrum. If the gain is set too low, flow may not be dete cted. Increasing the gain
can increase the appearance of spectral broadening, and may also lead to errors in
velocity measurements.
An inappropriately high gain can also lead to overloading of the instrument, causing
poor direction discrimination, and this may result in a mirror image of the spectrum
appearing in the reverse direction on the display
Doppler spectrum demonstrating the appearance of a
mirror image below the baseline that may occur when
the scanner’s Doppler gain control is set too high.

19. Spectral baseline
DROPPING BASELINE
Normal baselineInverted baseline

20. Sample volume size

21. Optimizinggatesize and position
Gate shouldbe over a central part of the studiedvesse l
Wide gate including 2 vessels with 2 waveforms below and above the baseline

22. Angles of insonationand errorin velocity
measurements
•Angles of insonation> 60 °
shouldn’tbeusedto minimize
thiserror

23. 2.Color doppler The primary purposes for using color Doppler during ultrasound imaging are:
•It is used to document the presence and direction o f blood flow within the
tissue, but does not show flow velocity
•Identifies the specific vessels of interest before being examined
•Differentiating between vascular and non-vascular s tructures
•Identifies gross circulation anomalies in the exami ned area
•Helps in correcting the beam/vessel angle for veloc ity measurement
•Shows alterations of blood flow in certain organs, which may indicate
change in physiological function, or presence of di sease.

24. However, many factors affect color Doppler scanning , and these must be
considered before using the technique for diagnost ic purposes. The list
includes:
•The US power transmitted into the tissue
•The overall sensitivity is affected by the colourga in used
•Sensitivity and resolution are related to probe fre quency
•Pulse repetition frequency PRF
(scale) is important, as lower frequency is
more effective to examine low velocities, and high pulse repetition frequency
reduces aliasing,
•Using color Doppler to examine large areas reduces the frame rate,
•Proper focusing of the ultrasound beam is important , as color flow image is
optimized at the focal zone.

25. For optimal doppler examination

26. COLOR DOPPLER SPECIFIC PARAMETERS •Colorbox steeringby changingangle of insonation(a s mallangle for a
good image)
•Inversion of spectral flow and colorflow
•Adjustingcolor wall filter filter setting displayed on color scale
(horizontal arrow )
•Adjustingcolorgain

27. Colormap
The direction of the blood is
depicted by colour on the monitor. -
-Red colour depicts blood flow
towards the probe
-Blue colour shows blood direction
away from the probe.

28. Aliasing •Aliasing is a undersamplingerror
•Aliasing accureswhen the PRF (sampling rate) is inf erior to 2 x the
Doppler frequenceshift
•Prevention of aliasing during colourDoppler mapping , to have pure
red and blue hues can done by increasing the pulse repetition
frequency / the scale.
•However, over correction of the scale may lead to l oss of colour
especially, in vessels with slow flow like the corp us luteum.

29. ALIASING •The most common artefact in colourand PWD imaging i s aliasing.
•It occurs when the upper limit of the displayable D oppler shift is
exceeded. This is known as Nyquistlimit.
•It is calculated as the pulse repetition frequency PRF / 2.
•Aliasing takes place when the high velocity blood flow generates
Doppler shift exceeding half the PRF

30. Aliasing in colordoppler •Lighter hues of both coloursmay indicate
aliasing,
and the scale
should be increased as first attempt to correct it.
•It can also be seen in turbulent flow, irrespective of machine
adjustments. This may be seen in cases with arterio venous shunts.

31. ADJUSTEMENTS TO CORRECT ALIASING :
•Use a shallow depth of imaging to increase the puls e repetition
frequency, which is reciprocally related to the pul se repetition period.
Shallow imaging decreases the last parameter, hence increases the PRF,
and reduces the Nyquistlimit,
•Adjust the colourgain properly to avoid causing aliasing,
•Increase the pulse repetition frequency (the scale),
•Change the angle of insonation
•Use a high frequency probe
•Adjust the baseline up or down, according to the di rection of the tracing.
This does not really correct the aliasing, but may affect the way it is
displayed.

32. Aliasing in doppler of uterin artery
The colourDoppler shows aliasing of
myometrialblood vessels, with
different hues of blue, red and
yellow in the same area.
Before switching the pulse wave, the
colourscale should be increased to
obtain uniform coloursof red and
blue.
PEAKS CROSS BASELINE
DROPPING BASELINE
INCREASING SCALE

33. PRF
Pulse repetition frequency
The high frequencies present in the Doppler
signal will be incorrectly displayed on the
Doppler spectrum if aliasing has occurred as
a result of a low pulse repetition frequency
(PRF). This results in misleading waveform
shapes and errors in velocity measurement.
The effect of aliasing is easily visualized, as
the Doppler waveform appears to ‘wrap
around’ from the top of the spectrum to
the bottom. Aliasing can be corrected by
increasing the PRF.

34. Duplex and Triplex Doppler techniques: •In this case, pulsed wave Doppler can be used direc tly, with
real time imaging over the well-visualisedvessel Duplex
Doppler imaging.
•the Triplex technique using the three modes of real time
imaging, colourand pulsed wave Doppler techniques 
increase the liability aliasing

36. Magnified view (right) of the color Doppler interro gation region shows the components used to acquire the waveform
:
Doppler beam path (green
)
angle indicator (blue), which is oriented parallel to the long axis of the
vessel
Doppler angle (Θ), which should be less than
60
°
sample
volume or “gate” (yellow).
Gray
arrows = flow
direction

37. 3. Power Doppler •Power Doppler is a technique where the color flow o utput magnitude
is displayed, rather than Doppler frequency signals . It does not show
the direction of flow or blood velocity.
•low flow velocities++

38. Techniques and principlesof power doppler
•The ultrasonographicexamination provided data relat ed to lesion size, lesion
volume, vascular location (location), vascular inde x (VI), flow index (FI), and
vascular-flow index (VFI).
•The region of interest:expthe uterine mass.
1. Evaluating the total
color percentage
and
flow amplitude
for the volume of
interest
2. The virtual organ computer aided analysis (VOCAL) software for the analysis
of 3D power Doppler histograms used with computer a lgorithms to form
indices of blood flow andvascularization.

39. ADVANTAGES OF POWER DOPPLER

40. DISADVANTAGES OF POWER DOPPLER

41. Evaluation of the vascularity of the
endometrial cavity using 3D power Doppler. (A) The uterus displayed first using two-
dimensional gray-scale ultrasound.
(B and C) Power Doppler activated to
assess endometrial vascularity.
(D and E) The 3D volume activated to
obtain the entire endometrial volume.
(F) VOCAL software used to calculate the
vascularisation index, flow index and
vascularization flow index.

42. .
Evaluation of ovarian vascularity using 3D
Power Doppler.
(A) The ovary displayed first in gray-scale
and 3D power Doppler activated to
assess ovarian vasculature. (B and C)
(B) The entire ovarian volume was
calculated.
(C) (D) VOCAL software used to calculate
vascularisation index, flow index and
vascularization flow index.

43. Doppler US TECHNIQUE …. •To have successful Doppler examination, the operator should have good knowledge of the
following points about the examined vessel, which are collectively known as the vessel Doppler
signature:
•The location of the blood vessel to be examined,
•The pulse sound wave characteristic,
•The pulse wave appearance.
•Before switching the Doppler on, a real time image of the i dentified artery must be obtained, and
verified with colour flow imaging.
•Always attempt to orient the beam parrell to the flow, t o have the best quantitative estimates of
flow.
•Place the gate to cover the entire cross sectional area of the vessel. Switch pulsed Doppler on, to
get good flow waveforms, based on sound and visual recogn ition of the right signal.
•Freeze the machine, and take note of the measurement indi ces. Take a record of the result.
•Repeat the examination if ever in doubt, or for confirma tion.

44. Practical IMPLICATIONS IN
GYNECOLOGY

45. HORMONAL EFFECT The effect of estrogen and progesterone on the bloo d flow velocity
waveform.
•The periovulatoryand luteal phases increasing diast olic velocity
(reduced S/D ratio, pulsatilityindex, or resistance index).
•Generally the uterine arteries have high resistance and systolic flow,
with a diastolic notch during the follicular phase.
•There is further increase in velocity during the lu teal phase, together
with increased diastolic flow .
Doppler (color, pulsed) in women: A REAL Marker OF hormonal impregnation in
women.

46. Subendometrialvascularisation changes with
cycle

48. Anatomy of uterine and ovarian vessels
The uterine arteries: The uterine artery joins the uterus at the level of the endocervix.
The curved up vessels can be detected with colourma pping.
It is important to know if one is examining the maj or trunk, or one of
its ascending branches.
It is usually easy, except when large uterine fibro ids or ovarian cysts are
occupying the area.

49. Vascularisation of uterusand ovary
(From Thierry Van den Bosch et al.

50. DOPPLER UTERIN

51. Frontal and sagittal view

52. Uterine artery
Doppler
Techniques:
US assessment of UAD velocimetry using CD in the 2D
mode, and flow velocity waveforms are obtained from
the
ascending main branch of the uterine artery
on the right
and left sides of the cervix in a longitudinal plane be fore
they enter the uterus.
The gate of the Doppler is positioned when the vessel wi th
good color signals was identified on the screen.
PI and RI of the uterine arteries is calculated automa tically
Both uterine artery Doppler indices are taken and the
average is calculated.

54. CHILDHOOD

55. •This image shows good uterine
artery blood flow, during both
systole and diastole.
•The PI was 1.77 and RI 0.8.
•This pattern usually represents
good ovulation.
SOURCE :

56. •Doppler image, but with absent
uterine artery late
diastolic flow
.
This pattern has been reported to
be associated with infertility.
•the PI and RI were 3.7 and 1.0
respectively, indicating less
adequate ovulation.

57. (a) Colour Doppler image of vessels coursing
through the myometrium towards the
endometrium. Subendometrial vessels
(probably corresponding to spiral arteries and
veins) are seen as well (cycle day 11).
(b) (b) Doppler shift spectra obtained from a
subendometrial artery (cycle day 4).

58. MENOPAUSE

59. MENOPAUSE withoutHormone replacement therapy •DOPPLER HypovascularisationDECREASE UTERIN BLOOD FLOW
•Art. uterineNO diastolicflow
•Lowresidualdiastole ≤ 2-3 years
•Uterus: rare signals(myometrium)
•Ovary: littleor no flow detectable
•DECREASE OF UTERIN VASCULARIZATION
•NO DIASTOLE ,IP>3. IR >0.9
•ENDOMETRIAL ATROPHY

60. HRT adapted
–Flux IP : 1, 5 -2,80
HRT upper dose
– Flux : IP < 1,5
HRT low dose
Flux : IP > 3

61. DOPPLER OVARIEN

62. VASCULAR OVARIAN ANATOMY

63. Vx intra-ovarianarteries
Vx foll. (résistances
stables, Velocityhigh)

64. Ovarianarteries:
•The ovarian vessels enter the ovaries at the upper outer corner, are difficult to
sample, due to the suboptimal angle of insonation.
•During the follicular phase , ovarian arteries have
low velocity
with
low diastolic flow.
Resistance
to flow is 40% lower in vessels inside the ovary, c ompared to the main
artery itself.
•During the luteal phase there is increased blood velocity and reduced resis tance, in
the ovarian vessels. the pulsatilityindex is lower in the artery on the same side as the
dominant follicle and corpus luteum, than in the co ntralateral vessel.
•Progressive neovascularisationand increased vascula rity of the dominant follicle
occurs by the time of LH surge, up to follicular ru pture, and formation of the corpus
luteum.
•There is no more neovascularisationof the corpus lu teum after ovulation, when the
blood vessels are usually dilated to their maximum, and blood flow does not increase
even after exogenous oestrogenmedication.

66. Specificitiesof ovarian doppler
•Ovarian vascular variations related to ovulation ha ve been
demonstrated and related to
hormonal changes
.
•Two exploration sites are possible: the ovarian str oma
the ovarian artery
•Ovarian flows in Doppler energy have the appearance of a vascular
crown surrounding the follicle dominant (when it re aches 10-15 mm)
•the corpus luteum, allows easy identification of th e functional ovary
•the calculation of the indexes of resistance and pu lsatilityshows a
marked increase in vascularity 48 hours before ovulation a nd then in
the luteal phase .

67. Doppler measurements
in arteries in the ovarian stroma

68. (a) Colour Doppler image of the vessels
in the ovarian stroma (cycle day 4).
(b) Typical Doppler shift spectrum
obtained from an artery in the ovarian
stroma (cycle day 14).

69. (a) Colour Doppler image of the dominant follicle (cycl e day
13).
(b) Typical Doppler shift spectrum obtained from an a rtery in
the wall of the dominant follicle some neovasucalis ation of
a mature follicle (cycle day 13).

70. (c) Colour Doppler image of the corpus luteum in the
midluteal phase. Note the good stromal vascularisatio n
(d) Typical Doppler shift spectrum obtained from an artery
in the wall of the corpus luteum.

71. Menopause
(a) Colour Doppler image of the vessels in the
ovarian stroma of a post-menopausal woman.
(b) Typical Doppler shift spectrum obtained from an
artery in the ovarian stroma of a post-menopausal
woman

72. The assessment of flow at the level of the ovarian artery elicits more divergences as to the results o btained.
This is probably related to the greatest difficulty in anatomically identifying the vessel concerned,
like that of the uterine artery, the landmarks of wh ich are more easily reproducible. It was clearly di splayed the possibility
of confusion with the tubal artery following an int raoperative study with a
precise view of the site to be studied .
The staSsScally different values found thus show m ean pulsatility index of 1.11 and 1.53 for
the tubal artery
and
artery
ovarian
respectively; the same is true for resistance index es.
The authors conclude that there is a possibility of confusion between the signals of
two arteries, which once again encourages us to take into account the intra-ovarian vessels, the anatomi cal origin of
which is irrefutable.

73. PROLIFERATIVE
PERIOVULATORY

74. CORPUS LUTEUM

75. P. Sladkevicius... Ultrasound in Obstetrics and
Gynecology, 3, (1993) PI OF ARTERY OVARIAN STROMA ARTERIES PER CYCLEVELOCITY OF JUXTA FOLLICLAR ARTERIES PER CYCLE

76. Practical pathological implications

77. Endometrium

78. Utility of three dimensional (3-D) ultrasound and pow er Doppler in
identification of high risk endometrial cancer at a tertiary care hospital in
southern India: A preliminary study.
Taiwanese Journal of Obstetrics & Gynecology 57 (201 8) 522-527
Conclusions :3D ultrasound and power Doppler are re liable tools for differentiating benign and maligna nt endometrial
lesions, with VFI being the single most effective m easure. However, utility of 3-D tool for differentia tion between tumour
characteristics needs further validation

79. •49 years, presented with
postmenopausal bleeding.
•2D ultrasound showed thickened
endometrium (A).
•3D ultrasound showed significantly
increased endometrial volume
(B) and multiple global vascular
pattern on power Doppler (C).
•All vascular indices were elevated
consistent with malignant
pathology (D).
•Histopathology revealed
endometrial carcinoma.
Source PR AGADI

80. Doppler and endometrium: No normal endometrialflow
• No flow in hyperplasia (exceptif pyometry)
• Thickenedendometrium+ flow evokespolypor cancer
• Lessthan2 vesselsorientedtowardsbenignpolyp
• 2 or more vesselsorientedtowardscancer
• Tamoxifenand pregnancy= exception
The color Doppler is useful:
•In the detection of organic lesions
•In benign / malignant orientation but insufficientl y reliable
Color doppler
Fleischer AC, Shappell HW… JUM, 21, 2002

81. THE DIAGNOSTIC VALUE OF THE DOPPLER ULTRASONOGRAPHY IN
DISTINGUISHING THE ENDOMETRIAL MALIGNANCIES IN WOMEN WITH
POSTMENOPAUSAL BLEEDING.
Arch GynecolObstet. 2011 Dec 8
•
106 women who presented with postmenopausal bleeding w ere enrolled in a prospective cohort
study
• Endometrial malignancy was diagnosed in 24 of the pati ents (22.7%)
• According to ROC curve analysis the endometrial thick ness of 5 mm, uterine artery PI of 1.450,
uterine artery RI of 0.715, radial artery PI of 1.060, an d radial artery RI of 0.645 were defined as the
cut-off points.
• In multivariate regression model,
only uterine artery PI was identified as independent
determinant of malignant endometrium.
• CONCLUSIONS: Blood flow of uterine artery and also myometrialand
endometrial vasculature displayed lower impedance i n patients with
malignant endometrium, but these lower indices are not already adequate
for using as diagnostic tests.

83. Vessel
pattern
IETA-TERMINOLOGY ENDOMETRIAL VASCULARITY
A. SINGLE
B. SINGLE BRANCHING
C. MULTIPLE FOCAL
D. MULTIPLE
MULTIFOCALE
E. SCATTERED
F. CIRCULAR

84. IETA EVALUATION :VASCULARISATION OF
ENDOMETRIUM

85. VESSEL TYPE

87. ADENOCARCINOMA

88. ENDOMETROIDE CARCINOMA

90. MALFORMATIONS

91. UTERIN PATHOLOGY

92. Malformations uterines

93. POLYP/MYOMA

94. POLYP

95. CERVICAL POLYP

96. HSN

97. FIBROMA AND DOPPLER

98. The Use of Doppler to Diagnose Myometrial
Masses
uterine artery pulsed spectral waves from a uterus with
multiple fibroids. Note the high systolic and diast olic flow,
indicating increased vascularity of the uterus, whic h is common
with fibroids.

99. Myometriallesions:vascularpattern

100. POST MYOMA 2-5

101. PEDICULE MYOMA
VASCULARISATION ++++
MYOMA NECROBIOSIS
WITH INTRALESIONAL
VASCULARISATION

102. MYOMA AFTER 3 MONTHS OF AGONIST

103. Necrobiosisin myomawithCD

104. SARCOMA Doppler sonography of perifibroid and intrafibroid ar teries of uterine leiomyomas
Bukunmi Michael Idowucorresponding author and Bolanle Olubunmi Ibitoye

105. SARCOMA

106. ADENOMYOSIS
Adenomyosisgives rise to ill-defined lesions of mix ed
echogenicity:
•Myometrialcysts
•Fan shaped shadowing
•Hyperechogenicislands
•Irregular junctional zone with subendometriallinesa nd buds.
•At color dopplerimaging, translesionalvascularizati on is
seen

107. ADENOMYOSIS

108. Color imaging: circumferential (a), intralesional (b), and
translesional (c) vascularization
(adapted from Van den Bosch et al

109. Adenomyomafrom leiomyoma

110. Using the 3D power Doppler, there was a significant difference
in the vascular location of the Doppler flow betwee n thefibroidsand
adenomyomasbeing more scattered in adenomyomaand more
peripheral in fibroids (P < 0.00).
There were higher 3D power Doppler vascular indices in the group with
fibroids than adenomyomas(VI, FI, VFI) .
The uterine artery Doppler indices (RI, PI) showed no significant
difference between fibroids and adenomyomas.

111. •Fibroidsare typically well-defined round lesions w ith
circumferential vascularity . The echogenicity of fibroids
varies from hypoechogenicto highly hyperechogenic
with a strong retrolesionalshadowing.
•Adenomyosisgives rise to ill-defined lesions of mix ed
echogenicity, myometrialcysts, fanshaped shadowing,
hyperechogenicislands, and irregular junctional zon e
with subendometriallines and buds.
At color Doppler imaging, translesionalvascularization is
seen

112. ADENOMYOSIS :INT THIRD OF THE UTERINE
WALL

113. TO NOT CONFUSE ADENOMYOSIS WITH
VENOUS MYOMETRIUM
EXTERNAL THIRD VASCULARISATION

114. ADENOMYOMA
vascularisation is arranged in a comb-shape

116. To detect vessels of lower velocity, the pulse
rate frequency (PRF) should be set low enough
Ultrasound image of a fibroid with circumferential flow (a) and adenomyosis with
translesional flow (b)
SOURCE Uterine Evaluation Using a Diagnostic Protoc ol Based on MUSA

117. Uterinearterydoppler in adenomyosis

118. Uterine arteriovenous malformation
A UAVM consists of a proliferation of vascular chan nels with fistula formation and an
admixture of small, capillary-like channels. The si ze of these vessels can vary considerably.
They are classified as congenital or acquired. The latter is more common and is often
described as a uterine arteriovenous fistula.

119. AVM
. The lesion showed a florid mosaic pattern with co lor aliasing
Pulsed Doppler showed rapid and turbulent systolic blood flow with increased diastolic flow
suggestive of arteriovenous fistula

121. AVM
Acquired UAVMs disease is
associated with conditions such as :
multiple pregnancies
miscarriage
previous surgery
-dilation and curettage
-termination of pregnancy
-cesarean section

122. AVM
Color Doppler
Typically shows serpiginous/tubular anechoic struct ures within the
myometrium with low resistance (RI ~0.2-0.5), high-vel ocity flow pattern on
color Doppler interrogation.

123. Doppler et Cervical cancer

124. Role of Doppler ultrasound in cervical cancer The transvaginal ultrasound examination is not a
recognisedmethod for cervical cancer screening.
However, the presence of a cervical mass, with
bizarre colourDoppler mapping, should raise this
suspicion.

126. This study assessed women with both
precancerous lesions and cervical cancer and found
significant differences in all 3D-PDU indices studie d (VI,
FI and VFI). More studies, with a larger number of
participants, could help in establishing reference v alues
for 3D-PDU indices in cervical lesions, as it appear s that
3D-PDU could be a promising tool for the assessment of
the vascularity of cervical lesions and their respo nse to
treatment

127. Some reports have appeared on the possible use of
3D power Doppler ultrasonography in the
investigation of intratumoral vascularization and
volume of cervical cancer
This second image shows a glass body power
Doppler coronal section of the cervix, with bizzare
intense peripheral vascularity, fading inwards,
towards the central necrotic area.

128. This ultrasound image shows a sagittal view of a
cervix, with a large necrotic mass occupying most of
the cervix. A narrow stripe of intact tissue can be
seen posteriorly.
The lower part of the uterus is also visible, with a
clear thin endometrial echo.
The cervical canal is no longer identifiable, which is
a characteristic ultrasound finding in most cases w ith
advanced cervical carcinomas.

129. Color Doppler flow evaluation of RI in
cervix vessels may aid in the early
diagnosis and management of
cervical carcinoma and in
differentiating benign from malignant
tumors. The validity of this technique
as a screening program for diagnosis
is limited.
Color and pulsed Doppler
ultrasonography is a noninvasive
technique, which allows in vivo
assessment of tumor vascularity.
6 Several studies applying color Doppler
ultrasound for assessing intratumoral
blood flow in cervical cancer have been
published with controversial results

130. DOPPLER & OvarianPathologies

131. OVARIAN CYST

132. Role of Doppler ultrasound in ovarian cancer
•With ovarian masses, penetrating vessels with anarc hic arrangements into the
mass, along the septae, or into papillary excrescen ces are more suggestive of
malignancy. This is contrary to the peripheral arra ngement of blood vessels seen
around benign tumours.
•Diagnostic accuracy for ovarian malignancy is not e ssentially different between
colour-coded Doppler and power Doppler ultrasonogra phy
Sonographic analysis of adnexal masses including po wer Doppler ultrasonography
appears to improve preoperative diagnosis of malign ancy.
In the case of power Doppler ultrasonography
•the pulse repetition frequency (PRF) should be set at 500Hz
•the gain kept high.
•The colourbox must be small to have a high frame ra te

133. COLOR DOPPLER AND MALIGNICANT
OVARIAN TUMOR

134. Tumourgrowth is characterized by neo -
angiogenesis.
The vascular architecture
is altered.

135. Comparaison Echo / IRM
Good MRI value, but no difference significant with
ultrasound
• YamashitaY. Radiology1995
• Reuter M. EurRadiol1998
• Salmon R. in TDM et IRM en cancérologie de l ’adu lte.
Vigot, Paris 1997

136. Ultrasound and Doppler in the diagnosis of
suspected benign ovarian tumors
H. Marret, M. Cayrol
J. Obstetrics and Reproductive Biology 2013 42, 730 -743
• It is possible to differentiate ultrasound most ben ign cysts
with good sensitivity and specificity.
• The models have for many of them shown their
effectiveness in discriminating tumors
•Benign and malignant nevertheless their evaluation outlook
is regularly worse.

137. Ovariancystand doppler Two main problems need answers:
•discrimination of benign and malignant adnexal mass es
•choice of the appropriate surgical treatment if nec essary

138. IN Doppler studies, the site of tumor vascularity does
not affect the diagnosis in cystic neoplasm, as the tumor
vascularity is encountered almost equally in the wall an d
septae
if the tumor is solid, benign nodules usually have
predominant peripheral vascularity whereas malignant
nodules have predominant central vascularity

141. •Color Doppler study must be done at high-sensitivi ty settings and
lowest PRF possible, without aliasing.
•The vessels detected on color Doppler studies are e valuated further
with
spectral Doppler imaging
.
•When present,
internal vessels
are evaluated in preference to
peripheral vessels.
•The masses are classified as suggestive of malignan cy when the
lowest calculated PI was <1.0 or lowest RI was <0.4
•These indices later correlate with histopathologica l reports.

142. COLOR DOPPLER
Benign ovarian mass with peripheral flow/ Sol id malignant ovarian tumor
with internal blood flow

143. Advanced primary ovarian cancers. (A) Multilocular sol id
ovarian serous adenocarcinoma with increased vascul arity.
Unilocular solid early invasive cancer with increase d vascularity
on color Doppler.

144. PULSED WAVE DOPPLER IN OVARIAN MASSES •Malignant masses have higher peak systolic velocity (PSV) as
compared to benign masses
•Means of quantitative blood flow measurements obtai ned
from tumor vessels. 92% of
malignant tumors show blood
flow
; conversely
the absence of blood flow
is equally
important that suggests benignity of tumor
•The use of spectral analysis indices such as PI and RI, a better
differentiation of ovarian neoplasm can be achieved .

145. •Low impedance to blood flow
with
high velocity
is
suggestive of malignancy, whereas moderate-to-high
impedance to blood flow is correlated to benign tum ors.
•PI of <1
and
RI of <0.4
have been described as cutoff values
for suggesting malignancy
•The new tumor vessels are morphologically abnormal
because they lack intimal smooth muscles, which is
necessary for increasing peripheral vascular resista nce that
reflects in characteristic
absence of diastolic notch in
malignant tumors
and
low impedance to blood flow
velocities

146. Technique
Color Doppler study is
done at high-sensitivity
settings and lowest
pulse repetition
frequency possible,
without aliasing. The
vessels detected on
color Doppler studies
are evaluated further
with spectral Doppler
imaging.

147. In conclusion, the assessment
by transvaginal sonography with color Doppler did
not improve the diagnostic accuracy. Therefore, col orDopplerdoes not
seem to add anything to transvaginal ultrasonograph y in the diagnosis of
endometriomas.

148. GynaecologicalDoppler ultrasound
examination in the diagnosis of adnexal torsion
•Doppler ultrasound examination does not seem to pla y a decisive role
in the diagnosis of adnexal torsion
•Grey-scale sonography appears to be more important (Stark and
Siegel, 1994).
•ColourDoppler signals can be detected either periph erally or centrally
in a substantial proportion of twisted adnexa (Star k and Siegel, 1994).
•Doppler findings probably parallel the vascular cha nges in the adnexa,
persistent arterial flow being expected in less com plete stages of
torsion.
•The detection of flow using the Doppler technique d oes not exclude
adnexal torsion.

149. Coiling of ovarian blood vessels in a case with
preserved arterial and venous blood flow .
https://obgyn.onlinelibrary.wiley.com/doi/full/10.1 002/uog.6369

150. Infertility

151. The use of Doppler in Fertility Ultrasound: •for natural and induced cycles monitoring
•follicular neovascularization
•endometrial bedendometrial receptivity
•uterine artery blood flow .

153. Pelvic Congestion Syndrome

154. Pelvic Congestion in cases of chronic pelvic pain
CFDS showed similar finding in left
adnexa and left ovary, with further
increase in diameter of veins in valsalva
menouvere
Colourflow dopplerstudy (CFDS)
showed multiple dilated veins in right
adnexa and right ovary average
measuring 5 mm in diameter with slow
venous flow

155. The ultrasound appearances of pelvic varices are of
multiple dilatated vessels lying within the broad li gament
of the uterus, with a venous Doppler signal of varyi ng
amplitude .
The venous Doppler signal is
similar to that seen in other dilatated venous syste ms, e.g.
porta hepatis varices.

157. Infertilitydoppler •Ovarian and uterine artery pulsatilityindex decline after ovulation,
•There is a negative correlation between PI , and th e number of
follicles and aspirated oocytes during IVF cycles,
•PI is lower in women with better endocrine response than poor
response,
•The number and size of stromal blood vessels increa se with follicular
development,
•Better radial and spiral arteries perfusion is seen in natural compared
to stimulated cycles,

158. •Absent uterine artery end diastolic flow was report ed more in infertile
women,
•Studies were disagreeable regarding PI and RI impor tance in
predicting IVF cycles outcome,
•Increased endometrial blood flow is expected with p regnancy and
neoplasia, but not in a pseudosacassociated with ec topic pregnancy,
•Endometrial vasculature, uterine arteries PI, and t he presence or
absence of a diastolic notch in uterine arteries pu lse waves are few
criteria used to monitor early pregnancy.

159. In Vitro Fertilization
•Using CDUS, different utero-ovarian blood flow chan ges during the peri-
implantation period have been established in concep tion and non-conception
cycles.
•Doppler assessment of uterine arterial resistance m ay help to determine the
time interval within the menstrual cycle that provi des the most optimal
endometrial receptivity for embryo implantation
•In another study uterine and ovarian vascular imped ance values as expressed
by a
PI in the uterine artery of >3.26
and in
perifollicular vessels of >1.08
were indicative of reduced pregnancy chances

160. ENDOMETRIAL RECEPTIVITY

161. A maximum score of 20 was
associated with the pregnancy
rate of 97.4 %, whereas scores of
13 or less resulted in no
pregnancies.

164. Uterinearterydoppler in infertility

165. Tekay A, Martikainen H, Jouppila P.
Hum. Reprod. Feb. 1996
“No conception if there is no
circulation at the end of diastole
on the 2 uterine arteries”

166. sub-endometrial and endometrial
vascularization deep color Doppler This image shows a power Doppler sagittal
view of a uterus, at the periovulatorystage,
with a rich endometrial and
subendometrialblood plexus.
These are considered to be signs of good
endometrial receptivity.
Its absence significantly decreases the
chances pregnancy
Endometrial vascularity and ongoing pregnancy after IVF
Maugey-Laulom B, Commenges-Ducos M, Jullien V, Papaxantho s-Roche A, Scotet
V, Commenges D.
Eur J Obstet Gynecol Reprod Biol. 2002

167. OVARIAN DOPPLER
Investigation of ovarian blood flow has proven
disappointing, not allowing the predetermination of which
follicles will produce oocytes capable of fertiliza tion and
implantation, but it may soon help our understandin g of
luteal insufficiency
and the cause of poor oocyte quality in
polycystic ovaries
.

168. Follicle
doppler
a mature follicle shows
vascularity in at least 3/4 thof
the follicular circumference and
PSV is 10 cm /sec at this time LH
surge stratsand this the right
time to give HCG trigger

169. •The top left colour Doppler image shows some neovasucalisation of a mature follicle.
•The second top image shows a very vascular corpus luteum, generated by the same follicle.
Note the good stromal vascularisation, as well.

170. This is a continuous pulse wave flow from a blood
vessel within the thick wall of a corpus luteum.
This possibly represents the maximum vessels
dilatation, and blood flow once a corpus luteum is
formed. This is represented by the very low values
of the measurement indices [RI 0.19, and PI
0.25].

171. Ectopicpregnancy
A pseudosacis never vascular.
Ring of fire sign : can be seen on color Doppler
in a tubal ectopic, but can also be seen in a
corpus luteum
an absence of color Doppler flow does not
exclude an ectopic
To differentiate the two, bimanual examination
can be useful +++

172. tubal ring sign :95% chance of a tubal ectopic if s een described in 49% of ectopics and in 68% of
unruptured ectopics

173. FUTUR…..
the value of ultrasonography and color Doppler imag ing in :
the prediction of fibroid growth
A better understanding of the association between a denomyosisand pain
or bleeding symptoms
the role of adenomyosisin infertility and adverse o bstetrical .
The exact correlation between ultrasonographicfeatu res and histological
findings .
Better understanding in the detection and the exclu sion of sarcomas .

174. Systematicdoppler…..YES IN •Metrorrhagia
•unexplained pain
•adnexal mass