OBS US and GYN IMAGING.pptx redae malday

Presentations

1. OBSTETRIC ULTRASOUND TIFITU NEGA (MD) RADIOLOGIST 2/16/2023 1

2. Course Outline Introduction Basics of ultrasound Indications for obstetric ultrasound 1 st trimester US 2 nd and 3 rd trimester US Complications of early pregnancy Fetal Biometry Placenta Fetal anatomy Fetal anomalies Gynecologic emergencies 2/16/2023 2

3. Introduction Diagnostic ultrasound has been used in obstetrics for more than 50 years . It is very important technique for examining pregnant women and can be used when clinically indicated at any time during pregnancy I t is non invasive and generally considered safe imaging modality . * 2/16/2023 3

4. Cont… Guidelines –delineated by ACR-ACOG-AIUM Scopes of obstetrics Ultrasound: Limited/Basic Specialized Specifications based on Trimester 2/16/2023 4

5. Basics of ultrasound Uses high frequency sound waves (>20KHz) …. 2-20MHz Properties of sound waves Reflection Refraction Transmission 2/16/2023 5

6. Cont… Modes of Ultrasound (Image display) A-mode B-mode M-mode Doppler U/S 3D and 4D U/S Artifacts 2/16/2023 6

7. Roll of Ultrasound Diagnostic Intervention /Treatment 2/16/2023 7

8. Sonographic terminologies Anechoic - without echoes/ echo free . It appears dark on the monitor. E.g. normal urine and bile Hypoechoic – dimmer echoes than adjacent tissue. E.g. lymph nodes and some tumors Hyperechoic – brighter echoes than adjacent tissues. E.g. bone, cirrhotic liver Isoechoic – same echo as adjacent tissues. E.g. some metastatic tumors 2/16/2023 8

9. Fig. echogenicity 2/16/2023 9

10. Homogenous: uniform tissue echo pattern. E.g. normal liver parenchyma, spleen, myometrium Heterogeneous : E cho level is different through out the tissue. E.g. Tumors having both solid and cystic(complex composition). 2/16/2023 10

11. Fig. echopattern 2/16/2023 11

12. Acoustic enhancement – increased echogenicity of tissues that lie behind a structure that causes little or no attenuation. E. g. fluid filed cyst Acoustic shadowing – decreased echogenicity of tissues that lie behind a structure that causes marked attenuation of u/s waves. E.g. stones 2/16/2023 12

13. Cyst – rounded structure with smooth borders having good through transmission and distal acoustic enhancement with no internal echoes. Solid – a structure without cystic components. Complex – both cystic and solid components 2/16/2023 13

14. Fig. characteristics(tissue composition) 2/16/2023 14

15. TECHNIQUES Transabdominal Vs Transvaginal sonography Client preparation Let the bladder be full/empty Position the client supine/ Lithotomy Choose transducer 2/16/2023 15

16. Indications for obstetric u/s Estimation of GA Evaluation of fetal growth in suspected IUGR or macrosomia Vaginal bleeding Determination of fetal presentation during labor Suspected multiple gestation Adjunct to amniocentesis Clinically detectable pelvic mass 2/16/2023 16

17. Suspected molar pregnancy Suspected fetal death Suspected uterine anomaly BPP after 28 weeks of gestation Observation of intrapartum events Suspected oligo- or polyhydramnios Abnormal AFP level Follow up for an identified fetal anomaly 2/16/2023 17

18. Ultrasound signs of early pregnancy Early pregnancy  roughly spans the first 10 weeks of the  first trimester I ntrauterine Gestational sac…. Earliest definitive sign Yolk sac within the GS Fetal pole/Embryonic disc IDSS DDSS Double bleb sign 2/16/2023 18

19. Cont… Gestational sac Is the first definitive sonographic finding to suggest early pregnancy Seen as a small fluid collection Surrounded by echogenic Rim of tissue TAS -at 5 th wk TV-at 4wk 2/16/2023 19

20. INTRADECIDUAL SIGN Early gestational sac or intrauterine fluid collection or Echogenic area in markedly thickened decidua on one side of the endometrial cavity. TVS = 3.5- 4.5wks 2/16/2023 20

21. DOUBLE DECIUDAL SIGN As the sac enlarges it gradually impresses on and deforms the Central cavity echo complex giving rise to double decidual sign Decidual paritalis Decidual capsularis Decidua basalis Uterine cavity 2/16/2023 21

22. YOLK SAC Yolk sac is the first anatomic structure identified within the GS Seen withTVS -5.5WKand TAS 6-7 WKS Well defined thin walled , maximum diameter of 6mm with sonolucent center Embryo is seen as subtle area of focal thickening along the periphery of yolk sac=Diamond Ring sign Confirms that intrauterine fluid collection represent an early IUP 2/16/2023 22

23. Functions of yolk sac Nutrient for embryo Site for initial hematopoiesis Contributing for the developing of gut and reproductive system Providing endocrine, metabolic and i mmunological function 2/16/2023 23

24. Cont,d Time of formation at around 28 days menstrual age Mean Size: 1.0 mm - 4.7 weeks 2.0 mm - 5.6 weeks 3.0 mm - 7.1 weeks 4.0 mm - 10 weeks Finally disappears - around 12 weeks At 10 weeks of gestation—if yolk sac diameter is < 3 mm or > 7 mm, it implies an increased risk for developmental anomalies. 2/16/2023 24

25. DOUBLE BLEB SIGN Describes the relation between the amniotic and yolk sac. < 7wk Helps to identify the amniotic membrane 2/16/2023 25

26. 1 st Trimester Ultrasound May be performed either trans -abdominally or trans-vaginally 2/16/2023 26

27. Components First trimester GS location GA-GS and CRL Identification of embryo Fetal heart motion Fetal number Ux and adenxa Nuchal translucency 2 nd and3 rd trimester fetal number Position Fetal heart motion Placental location Amniotic fluid volume GA Survey of fetal anatomy Evaluation of maternal pelvic mass 2/16/2023 27

28. DETERMINING GESTATIONAL AGE FIRIST TRIMESTER First trimester is the most accurate time to date pregnancy ,when biologic variation is minimal Gestational sac 5wk-6wk inside of border of hypoechoic sac MSD = L+W+H 3 One diameter in perfectly round sac 2/16/2023 28

29. Crown rump length Accurate 6wk -12wk Longest longitudinal diameter of fetal axis excluding yolk sac and the extremities Embryo shouldn’t be flexed After 13wks it is not reliable because of fetal flexion 2/16/2023 29

30. Nuchal translucency : May be assessed towards the end of the first trimester. Increased values may be related to chromosomal disorders and cardiac abnormalities. 2/16/2023 30

31. 2/16/2023 31

32. 2 nd AND 3 rd TRIMESTER GA DETERMINATION BPD Can be measured from around 9 wks until the end of pregnancy. Accurate predictor of GA 12-26 wks Outer to inner wall measurement Plane of section is through thalami , CSP and third ventricle The calvaria should be symmetric and smooth Influenced by fetal head shape 2/16/2023 32

33. Fig. BPD 2/16/2023 33

34. HEAD CIRCUMFERENCE Same accuracy BPD measurement More accurate predictor of GA when the skull shape is abnormal Plane of section 3 rd ventricle Thalami cavum septum pellucdi Outer to outer OR HC too small—Commonly seen in synostosis, cerebral infarction HC too large—Commonly seen in hydrocephalus, intracranial hemorrhage, Tumor 2/16/2023 34

35. ABDOMINAL CIRCUMFRENCE Intra hepatic umblical veins serves as a landmark (hockey stick appearance) It is measured from outer edge to outer edge of soft tissues. It allows evaluation of head-to-body disproportion, i.e. detects IUGR. Variability is high. It is a good predictor of fetal weight. 2/16/2023 35

36. Cont. Fetal kidneys ,urinary bladder and cord insertion shouldn’t be included AC too small (less than 5th percentile)—Commonly seen in diaphragmatic hernia, Gastroschisis, renal agenesis, Omphalocele AC too large (more than 95th percentile)—Commonly seen in hepatosplenomegaly, abdominal tumor, GIT obstructions, obstructive uropathy, ascites. 2/16/2023 36

37. FEMURE LENGTH Accurate during early second trimester Easiest due to one dimensional Measure only the ossified Portion Proper alignment is ensured by demonstrating both femoral head or greater trochanter and the femoral condyle simultaneously 2/16/2023 37

38. Complications of early pregnancy Bleeding Possible explanations are: Intact uterine pregnancy (50%)-Threatened Abortion or implantation site bleeding Missed abortion(25-30%) Incomplete abortion Inevitable abortion Complete abortion Blighted ovum(20-25%) Ectopic pregnancy Hydatiform mole. 2/16/2023 38

39. Missed abortion N on viable fetus within the uterus There may not be symptoms of abortion Absence of cardiac activity in embryos >5mm on TVS is considered diagnostic Absence of cardiac activity in fetal pole CRL > 7mm on TAS 2/16/2023 39

40. Fig. missed abortion 2/16/2023 40

41. Inevitable Abortion ( Abortion in Progress ) Detached GS with embryo from implantation site which leads to spontaneous abortion within next few hours. Common USG findings are—cervix is dilated and measures >3 cm , gestational sac is located low within uterus with progressive migration of sac toward/into cervical canal on serial scan 2/16/2023 41

42. Inevitable Abortion ( Abortion in Progress ) Clinical Triad Persistent painful uterine contractions Bleeding >7 days Rupture of membranes but no passage of tissue 2/16/2023 42

43. Incomplete Abortion (Retained Products of Conception) Portion of placental or fetal tissue remains within uterus. Common USG findings are: • Endometrium thickness is >5 mm • Gestational sac shows dead fetus / collection • Gestational sac is irregular/angulated, small in size, contains amorphous echogenic material 2/16/2023 43

44. Choriodecidual reaction is ragged disrupted Sub chorionic fluid ± haemorrhage Clinically present as—continued vaginal bleeding , patulous cervix . 2/16/2023 44

45. 2/16/2023 45

46. Blighted ovum/ Anembryonic pregnancy Absent yolk sac when MSD>8mm on TVS >20mm on TAS Absent embryo when MSD >16mm on TVS; >25mm on TAS Poor decidual reaction <2mm Irregular gestational sac shape Abnormally low sac position 2/16/2023 46

47. US characteristics of abnormal gestational sac Major criteria Absence of yolk sac: Absence of embryo: Distorted sac shape Growth <1mmMSD/day Minor criteria Irregular sac contour Thin decidual reaction<2mm Weak decidual echo amplitude Absent decidual sac sign Sac positioned low in uterus 2/16/2023 47

48. Ectopic pregnancy 1% 0f all pregnancies The coexistent intra and extrauterine gestations occur ~1:30000 pregnancies. Clinical trades Patients at risk Previous ectopic pregnancy Hx. of PID Pregnant women with IUCD in situ Previous tubal microsurgery or in vitro fertilization Previous laparoscopic tubal ligation 2/16/2023 48

49. Tubal ectopic: 93-97% Ovarian ectopic: 0.5-1% Cervical ectopic: <1% Abdominal ectopic: 1.4% Scar ectopic 2/16/2023 49

50. Uterus : empty uterine cavity, psuedogestational sac in 20% Tube & ovary: simple adnexal cyst, complex adnexal cyst/mass, tubal ring sign and ring of fire sign Peritoneal cavity -free fluid in cul de sac Live pregnancy in ectopic position 2/16/2023 50

51. Correlation with serum B- hCG is necessary where there is persisting doubt weather the uterine contents represent true or psuedogestational sac In the absence of intrauterine gestational sac, B-hCG level exceeding 1800 miu/ml is evidence for an ectopic pregnancy. With TVS, a live embryo may be seen in the adnexa in up to a quarter of patients, significantly more than with TAS. 2/16/2023 51

52. 2/16/2023 52

53. 2/16/2023 53

54. Hydatiform mole Most common gestational trophoblastic disease(80%) Clinical feature Complete mole(classic mole) (70%) I nvolves the whole placenta No fetal part/fetus and diploid in karyotype. 2.Partial mole(30%) I nvolves only a portion of the placenta . Abnormal fetus and triploid in karyotype (owing to fertilization of an ovum by two sperm cells) Rarely a normal fetus may coexist with a complete mole 2/16/2023 54

55. u/s : complete mole shows the uterus is filled with multiple tiny cysts often described as snowstorm (bunch of grapes) appearance. Partial mole shows vesicular changes in only a portion of the placenta. The associated triploid fetus has multiple anomalies. Theca lutein cysts (50%) 2/16/2023 55

56. Fig. complete mole 2/16/2023 56

57. 2/16/2023 57

58. Multiple pregnancy A. Dichorinic-Diamniotic Two placentas, Two GS ,two yolk sac & two separate amniotic sacs May result from a fertilization of a single or two ovum Relatively fewer complications On US-Thick inter twin membrane-Lambda sign>2mm B.Monochorionic Diamniotic One GS and one placenta two yolk sac Two amniotic sac Thin inter twin membrane(T-Sign)<2m in thickness Chronicity is best assessed by US from 9-10wk 2/16/2023 58

59. Cont. C.Monochorionic- monoamniotic One placenta, one GS ,one amniotic sac and one yolk sac Always result from fertilization of a single ovum No inter twin membrane Cxn : 40% survival rate, may be conjoined twins. In general 3-7x of fetal anomalies 2/16/2023 59

60. Dichorionic diamniotic twins 2/16/2023 60

61. 2/16/2023 61

62. DISCUSS COMPONENTS OF BIOPHYSICAL PROFILE SCORE ASSIGNMENT 2/16/2023 62

63. Amniotic fluid Increases in volume up to 34wk of GA Decreases after 34wk Amniotic fluid index (AFI) Used to assess amniotic fluid volume. It refers to the sum of vertical depths of largest clear amniotic fluid pockets (free of umbilical cord and fetal parts) in 4 uterine quadrants. Method—Patient lies supine, uterus viewed as 4 equal quadrants, transducer should be perpendicular to plane of floor and aligned longitudinally with patient’s spine. Twin AFI calculated by same procedure as in single pregnancy. Normal values are 5-25 cm. 2/16/2023 63

64. Polyhydramnios:AFI>25cm Cause: Fetal —High intestinal/Esophageal/tracheal atresia's /obstruction of bowel hydranencephaly, anencephaly, encephalocele, agenesis of corpus callosum, microcephaly – Trisomy 13, 18, 21 Maternal— Rh -incompatibility, diabetes Idiopathic Is suggested by large pockets of fluid. An AFI > 25cm or a single fluid pocket greater than 8cm deep is s suggestive of Polyhydraminos. 2/16/2023 64

65. 2/16/2023 65

66. Oligohydramnios : Refers to an abnormally low amniotic fluid volume(<500ml). Fluid pockets are small; fetal parts are crowded. Fetal surface features such as the face are difficult to visualize The AFI< 5 cm or Single largest pocket ≤ 2 cm Measurement of the largest fluid pocket in the vertical direction of < 1cm is indicative of severe Oligohydramnios. 2/16/2023 66

67. Cont. Cause: Premature rupture of membranes (most common ) Post maturity Renal agenesis / dysgenesis Prune belly syndrome Infantile polycystic kidney disease Urethral atresia IUGR/ fetus demise. 2/16/2023 67

68. Intrauterine Growth Retardation-IUGR Types—symmetric/asymmetric/mixed A. Symmetric IUGR Early-insult occurs before 26 wks GA There is proportionate decrease in HC and AC, maintaining normal HC ÷ AC ratios 2/16/2023 68

69. Cont.. Asymmetric IUGR late-onset IUGR occurs after 26 weeks GA There is disproportionate decrease in fetal measurements due to uteroplacental insufficiency with preferential shunting of blood to fetal brain occurring. HC ÷AC and FL ÷ AC ratios are high Amniotic fluid volume is decreased. 2/16/2023 69

70. Sonographic parameters AC and/or EFW <10 th  percentile with deranged Doppler parameters presence of  oligohydramnios  without ruptured membranes increased head circumference (HC) to abdominal circumference (AC) ratio (in asymmetrical type 2/16/2023 70

71. Cont.…. Doppler features:  will require a chart to calculate absolute values U U mbilical artery Doppler Assessment increased PI above 95 th  percentile A bsent/reversed diastolic flow umbilical venous Doppler assessment presence of pulsatility uterine arterial Doppler assessment increased mean uterine artery PI above 95 th  percentile presence of  notching  in mid to late pregnancy 2/16/2023 71

72. The placenta L ocalization of the placenta is an essential part of routine ultrasound examination. It can be distinguished from surrounding portions of the chorion and underlying myometrium from 12 wks gestation onward. Features of placenta Vascular supplies Grades-Currently not applicable ( No significant clinical correlation with the GA) 2/16/2023 72

73. 2/16/2023 73

74. Placenta previa Is attachment of placenta in the lower uterine segment. Low lying L ower margin of the placenta is within 2cm of the Internal cervical os False positive diagnosis may result from: An over filled bladder Myometrial contractions A low position early in pregnancy Repeat scanning, either with an empty bladder or after an interval of 15-30 min, generally resolves the first two problems 2/16/2023 74

75. 2/16/2023 75

76. Fig. Placenta previa 2/16/2023 76

77. Placental abruption : is premature separation of a normally positioned placenta from the myometrium. It can cause sub chorionic(marginal ) or retro placental(central) hemorrhage. Dx is suggested by demonstrating retro placental complex of veins and thickening of the placenta(> 4cm). 2/16/2023 77

78. 2/16/2023 78

79. Placental infarcts : Systemic pathology within the mother, such as vascular disease or hypertension, can lead to uteroplacental insufficiency, the development of large hypoechoic placental infarcts and poor prognosis for the fetus. 2/16/2023 79

80. Placental adherence Placenta acreta Placenta increta Placenta percreta Ultrasound features 2/16/2023 80

81. Placentomegaly It refers to increase in placenta thickness measuring >5 cm , in sections obtained at right angles to long axis of placenta. Common causes are: Fetal — Fetal hydrops, hemolytic disease of the newborn, chromosomal abnormality, umbilical vein obstruction, fetomaternal hemorrhage. Maternal — Anemia , diabetes, syphilis. Placenta —Molar pregnancy, Chorioangioma, Intraplacental hemorrhage. 2/16/2023 81

82. Fetal anatomy Head Intracranial anatomy becomes visible after 12 th wks Lateral ventricles Choroid plexus assessment Cerebellum Cerebrum Cisterna magna Nuchal fold 2/16/2023 82

83. The cerebellar diameter should approximately equal the weeks of gestation. (Ex: 19weeks=19mm) Cisterna magna: < 10mm Nuchal fold: (outer edge of occipital bone to skin surface ) <6mm (between 17-20weeks). The atrium of lateral ventricles should be less than 10mm in diameter (best measured at the occipital horn). The choroid plexus should be homogenous. 2/16/2023 83

84. Face Profile orbits Nasal Lips 2/16/2023 84

85. Thorax Shape & size Heart detected at 7wks bt detailed anatomy can be seen after 16-17wks Alignment, chambers , valves Heart beats 2/16/2023 85

86. Lung Not well developed until late in third trimester, 35-36wks Diaphragm Relatively hypoechogenic Move during respiration Both sides should be identified 2/16/2023 86

87. Fetal aorta & IVC 2/16/2023 87

88. Abdomen Stomach after 14wks of age presence, size, and situs Liver Echogenecity, umbilical veins Cord insertion Insure the abdominal around cord insertion is intact Spleen Gall bladder Can confuse wz umbilical veins Fetal intestine 2/16/2023 88

89. Kidneys Can be imaged 12-14 wks onwards. Confirm the presence and position of both kidneys. Look for pelvis, pyramids, sinuses & capsule The renal pelvis TS diameter should be less than 5mm. 2/16/2023 89

90. Bladder can be recognized as early as 14-15 wks Presence & size urethral atresia: large fetal bladder (bl), urinary ascites (asc), and hydronephrotic kidneys Posterior urethral valves with keyhole bladder 2/16/2023 90

91. Fetal genitalia The scrotum & penis may be seen as early as 18wks bt female genitalia can be reliably identified after 22wks Testis are seen in the third trimester 2/16/2023 91

92. Spine can be seen at 12 th wks but clearly visible after 15 th wks Coronal or Sagital of entire spine: cervical Thoracic Lumbar Sacral 2/16/2023 92

93. Extremities can be seen from 13wk The fingers & toes can be identified after 16wks Position, length, movement 2/16/2023 93

94. Blood flow characteristics in the fetal blood vessels can be assessed with Doppler 'flow velocity waveforms‘ The blood vessels commonly interrogated include the umbilical artery, the aorta, the middle cerebral artery, ductus venosus (DV) and umbilical vein (UV ) Diminished flow, particularly in the diastolic phase of a pulse cycle is associated with compromise in the fetus. Abnormal uterine artery Doppler velocimetry on pre-eclampsia, intra-uterine growth retardation and adverse pregnancy outcomes. Doppler Ultrasound 2/16/2023 94

95. 3D Ultrasound Display multiple longitudinal, transverse, and coronal images. Images may improve the accuracy of anomaly detection of the fetal face, ears, and distal extremities 2/16/2023 95

96. 4D Ultrasounds adds the element of time to the 3D process. Offers live images Fetal changes like movement, kicking, reach with hands and facial expressions can be seen 2/16/2023 96

97. Fetal congenital Anomalies Fetal hydrops: Pathologic accumulation of fluid in at least two body cavities or fetal components. Immune hydrops Non immune hydrops US demonstrates-fetal Pleural effusion Pericardial effusion Ascites Subcutaneous edema/increased nuchal translucency Dilated umbilical vein Placental enlargement Polyhydraminos Hepatomegaly 2/16/2023 97

98. 2/16/2023 98

99. Trisomy 21 (Down’s sxx ) Most common chromosomal abnormality. Major structural defects CHD ( endocardial cushion defect) Duodenal atresia and Hydrocephalus. Hypoplastic or absent nasal bone ventriculomegaly 2/16/2023 99

100. Increase in nuchal translucency - due to increased lymphatic fluid accumulation under the skin of the fetal neck 1 st TM-> 3mm considered abnormal 6mm in the 2 nd trimester is strongly associated. Measured b/n 11wks - 14wk -detects up to 80% of cases of Down’s sxx with a false positive rate of 5% when combined with maternal age related risk. The detection rate increased to ~90% when combined with biochemical screening. 2/16/2023 100

101. 2/16/2023 101

102. Abnormalities of the CNS occur 1: 1000 live births Ventriculomegaly Dilated cerebral ventricles Ventriculomegaly Vs hydrocephalous Causes can be obstructive hydrocephalus, cerebral atrophy, and maldevelopment. US signs of Ventriculomegaly Diameter of ventricular atrium >10mm, separation of choroid plexus from the medial ventricular wall by >3mm; D angling choroid. M ost common causes of fetal Ventriculomegaly is chiari II malformation and aqueduct stenosis. 2/16/2023 102

103. 2/16/2023 103

104. Anencephaly Is the commonest neural tube defect. US finding Absence of cranial vault and cerebral hemispheres above the level of the orbits»» Frog eye sign / mickey mouse The cerebral hemispheres may be replaced by an amorphous neurovascular mass (area cerebrovasculosa ). The brain stem and cerebellum may be present variably The condition is invariably fatal. Can be detected as early as 11 wk. At 14 wks US has 100% accuracy 2/16/2023 104

105. 2/16/2023 105

106. Encephalocele Fluid filled/ or brain tissue filled sacs that protrude through a defect in the bony calvaria . occipital (75%), frontoethmoid (13%), and parietal (12%) regions. Meningocele contain only CSF, where as encephalocele contain brain tissue. Meningoencephlocele =both CSF & brain tissue If the mass appears cystic, the meningocele component predominates while a solid mass indicates predominately brain tissue Larger encephalocele may show accompanying microcephaly 2/16/2023 106

107. 2/16/2023 107

108. Chiari II malformation : Chiari II malformation : Relatively common congenital malformation of spine & posterior fossa structures. Lumbosacral spina bifida(85%) & descent of the brain stem The 4th ventricle is elongated, the posterior fossa is small, and the cisterna magna is obliterated. Lemon sign = bossing of the frontal bones, causing a lemon shaped appearance in the axial plane. Banana sign is compression of cerebellar hemispheres in to a banana shape 2/16/2023 108

109. 2/16/2023 109

110. Dandy – walker malformation Results from maldevelopment of the roof of the fourth ventricle. Cisterna magna is enlarged and communicates directly with the 4 th ventricle through its absent roof. The posterior fossa is enlarged and the tentorium is elevated. Absent or hypoplastic cerebellar vermis H ydrocephalus is often present 2/16/2023 110

111. 2/16/2023 111

112. Cystic hygroma : Is fluid collection in the fetal neck Caused by failure of the lymphatic system to develop normal connections with the venous system in the neck. US demonstrates Bilateral nuchal cystic mass with a prominent midline septum that represents the nuchal ligament. Up to 70% have abnormal karyotype. 2/16/2023 112

113. 2/16/2023 113

114. Congenital diaphragmatic hernia Group of defects in which some parts of the abdominal contents protrude into the chest cavity Most are left side and Posterolateral Polyhydramnios is a common association Postero -lateral defect/ bochdalek hernia Parasternal/ morgagni hernia Septum transversum defect Hiatal hernia Eventration of the diaphragm 2/16/2023 114

115. Ultrasound abdominal organs seen within the thoracic cavity Lt sided hernia may be diagnosed by observing the stomach/bowel to be partially or completely in thorax Shift in position of heart/ mediastinal shift Rt sided by presence of mediastinal shift or hydrothorax Other signs include an abnormal position of GB, HV or UV 2/16/2023 115

116. 2/16/2023 116

117. Anterior abdominal wall defects Gastroschisis Anterior abdominal wall defect invariably to the right side of the umbilicus( Para-umbilical). The defect is usually 2 – 4 cm in size. Content-Bowel and occasionally stomach and / or liver herniates through the defect and floats freely in the amniotic fluid No covering membrane. It is most commonly an isolated defect Postnatal repair is usually successful Prognosis is excellent when no other anomalies are present. 2/16/2023 117

118. 2/16/2023 118

119. Omphalocele More serious abdominal wall defect that is about equal in frequency to Gastroschisis. Midline defect is at the umbilicus with herniation of abdominal contents into the base of the umbilical cord. Both liver and bowel are commonly present in the herniation. A membrane consisting of amnion and peritoneum covers the Omphalocele. Associated anomalies are common (67- 88%) and chromosomal abnormalities are found in up to 40%. 2/16/2023 119

120. 2/16/2023 120

121. Spina bifida Spectrum of spinal abnormalities Failure of the complete closure of the neural tube. It ranges from simple non fusion of the vertebral arches (Spina bifida occulta) to protruding sacs that contain CSF, spinal cord or nerve roots ( myelomeningocele ); to a totally open spinal defect ( myeloschisis ). Most often occurs in the lumbosacral region. 2/16/2023 121

122. US findings Outward splaying of the laminae Defect in the soft tissues overlying the bony abnormality Protruding sac containing fluid and often neural tissues. Ventriculomegaly is present in 75% of cases. Associated Chiari II malformation is common 2/16/2023 122

123. 2/16/2023 123

124. Gynecologic Emergencies Ovarian torsion PID/TOA Massive ovarian Edema 2/16/2023 124

125. Ovarian torsion Partial or complete rotation of the ovary and portions of fallopian tube on the supplying vascular pedicle Needs urgent surgical intervention to prevent ovarian necrosis Occurs more commonly on the right side Common in young age Risk factors – Clinical presentation – 2/16/2023 125

126. Ultrasound findings Edematous and enlarged ovary Variable echogenicity (hypo or hyperechoic) Complex appearance with cystic and or haemorrhagic degeneration Peripherally displaced follicles with hyperechoic central stromal Midline ovarian position Free pelvic fluid in 80% of cases an underlying ovarian lesion may be seen Variable doppler flow abnormality 2/16/2023 126

127. PID Infection and inflammations of the upper female genital tract Highest incidence is in sexually active women 75 % cases being under 25 yrs. Clinical presentation Acute pelvic pain (variable degree of intensity) Vaginal discharge Fever Dyspareunia Leucocytosis RUQ pain from perihepatitis (Fitz –Hugh-Curtis) syndrome 2/16/2023 127

128. ultrasound Pelvic fluid collection Non specific thickening and increased vascurity of the endometrium Adnexal masses with a heterogeneous echo-pattern/Abscess Echogenic fluid in the tube ( pyosalpinx ) Cogwheel sign Thickening loops of the fallopian tube Infolding projections (sometimes looking like nodules) 2/16/2023 128

129. Massive ovarian Edema Rare Tumor like usually unilateral enlargement of the ovary Caused by recurrent intermittent partial torsion of the mesovarium, Resulting venous and lymphatic obstruction Ultrasound Similar to ovarian torsion 2/16/2023 129

130. Maternal hydronephrosis in pregnancy Common(about 90% of mothers have some degree of asymptomatic renal collecting system dilatation) Right side in most cases but can be bilateral Due to ureteral compression via gravid uterus D ilated Ultrasound Feature Dilated renal collecting system and proximal ureter Cause may or may not be identified Follow up US after few wks of deliver is required 2/16/2023 130

131. References 2/16/2023 131