GYN
Ovaries
Polycystic Ovaries
Stein-Leventhal
Hemorrhagic Cysts
fine reticular septations or heterogeneous mass w/ multiple echoes
high on T1 and homogeneously bright on T2
resolves spontaneously (f/u 6-8 wks)
ddx: endometrioma, hemorrhagic corpus luteum cyst, dermoid, follicular cyst
Ovarian Teratomas
most common benign ovarian neoplasm
classic mimicker
rarely malignant
at risk for torsion
complex, partially cystic, w/ echogenic areas that may shadow
dermoid plug = Rokitansky nodule
presence of struma ovarii can (rarely) cause thyrotoxicosis
Benign Ovarian Neoplasms
mucinous or serous cystadenomas, Brenner tumors
granulosa cell tumors, fibromas, thecomas (secrete estrogens –> endometrial hyperplasia)
Sertoli-Leydig cell tumors (secrete androgens –> virilization)
cannot differentiate from malignant neoplasms
complex lesions with septations and solid tumor nodules
RI > 0.4 (not reliable)
Adnexa
ovary, fallopian tube, and broad ligament(contains fallopian tube and uterine artery)
fallopian tube segments – intramural, isthmus, ampulla, and infundibulum
Adnexal Mass
Cystic Adnexal Mass
Ovarian Malignancy
Guidelines
Premenopausal:
<2.5cm and simple – Physiologic follicle. No follow up
2.5cm to 10cm (simple or complex) – Follow up in 6 weeks x 2
>10cm – Laparoscopy and resection
Postmenopausal:
<5.0cm and simple – Follow up in 3 months, then 6 months x 2, then 1 year
>5.0cm or complex at any size – Laparoscopy and resection
Uterus
Congenital Anomalies
Endometrium
two layers – basal layer and functional layer(shed during menstruation)
atrophies after menopause, which may lead to bleeding
Endometrial thickness
Premenopausal
menstrual: 2-4 mm
proliferative: 5-11 mm
secretory: 7-16 mm
Postmenopausal
Will depend on the whether or not there is a history of vaginal bleeding, and on the use of hormonal therapy / tamoxifen.
Vaginal bleeding (and not on tamoxifen):
No history of vaginal bleeding:
If on tamoxifen: <6 mm (although ~50% of those receiving tamoxifen have been reported to have a thickness of >8 mm)
After D&C or spontaneous abortion, endometrium should be no thicker than 5 mm or suspect retained POC
Endometritis
ultrasound is nonspecific
may see endometrial fluid, debris, gas
caused by PID, postpartum, postinstrumentation, IUD
Endometrioma / Endometriosis
adnexal cyst filled with homogeneous low-level echoes (“ground glass” appearance) or reticular septations, similar to hemorrhagic cyst
bright on T1 w/ low signal areas on T2 (shading) due to iron
may be multilocular with areas of anechoic fluid or may have fluid-fluid levels
often multiple
associated w/ metrorragia, dysmenorrhea, infertility
cyclic Δ
Endometrial Polyps
can cause intermenstrual beeding, menorrhagia, or infertility
saline infusion sonohysterography is useful
homogeneously hyperechoic or complex with cysts
single feeding vessel on color doppler
treated hysteroscopically
Endometrial Hyperplasia
present w/ vaginal bleeding
diffuse process, w/ or w/o cellular atypia
if atypia present, there is a substantial risk of progression to endometrial CA
Endometrial Carcinoma
endometrial thickening (>8-10 mm) with an ill-defined endometrial-myometrial interface
SIS: poorly distensible uterine cavity lined by a diffusely irregular and thickened endometrium or focal area of endometrial thickening
Myometrium
Fibroids
three types: intramural (confined to myometrium), submucosal (projecting into endometrium), and subserosal (projecting from serosal surface)
color doppler will identify vessels
have increased risk of pregnancy loss
may cause pain during pregnancy
may obstruct vaginal delivery
may cause placental abruption or IUGR
leiomyosarcomas enlarge over time
dx of submucosal fibroid may be aided w/ sonohysterogram
heterogeneous appearance due to:
necrosis
calcification
cystic degeneration
hyalinization
Adenomyosis
Form of endometriosis where there is aberrant endometrial tissue in the myometrium
Diffuse or focal
US - Sonographic appearance overlaps w/ fibroids, but presence of small cysts or hypoechoic areas or variation during menstrual cycle is suggestive of adenomyosis.
Irregular, myometrial, cystic spaces predominantly involving the posterior uterine wall, an enlarged uterus with a widened posterior wall (see Image 1), an eccentric endometrial cavity, and decreased uterine echogenicity without lobulations, contour abnormality, or mass effects (which is more commonly seen with leiomyomas). Sonograms may also show an ill-defined margin between the normal myometrium and the abnormal myometrium, as well as an elliptically shaped myometrial abnormality.
MRI - Junctional zone thickness was 12 mm or greater. A maximum thickness of 8 mm or less usually excludes the disease. When the maximum junctional zone diameter is 8-12 mm, secondary findings such as high–signal-intensity foci on T1- or T2-weighted images, are necessary to make the diagnosis.
Nabothian Cyst
Cervical Cancer
Cervical Cancer Staging
Stage 1 - confined to cervix
Stage 2 - beyond cervix, but not to pelvic sidewall or lower 1/3 of vagina
Stage 3 - extends to lower 1/3 of vagina
3A - lower 1/3 of vagina
3B - pelvic sidewall
Stage 4 - see below
Hydrosalpinx
caused by PID, endometriosis, prior instrumentation, leading to adhesions that obstruct the peritoneal opening of the tube
infected = pyosalpinx
Tubo-Ovarian Abscess
severe form of PID, usually bilateral
complex, multiloculated adnexal mass w/ echoes from debris/pus
may have thick septations, ovary may be encased
Ectopic pregnancy
tubal, cornual, cervical, and intraperitoneal
increased peripheral blood flow
“tubal ring” = echogenic ring
cornual = intramural portion of fallopian tube
blood or secretions in uterus = pseudogestational sac
heterotopic = coexistence of ectopic and intrauterine pregnancies
beta levels should double every 2 days
Gestational Trophoblastic Disease
complete hydatidiform mole – large amount of trophoblastic tissue w/ absence of fetal tissue – 46XX, both sets from father
appears as large complex mass with cystic spaces surrounded by echogenic tissue
partial mole – both fetal (usually dead or abnormal) and abnormal placental tissue are present – typically triploid (69 XXY)
appears as gestational sac containing abnormal fetus and markedly thickened placenta w/ focal cystic areas, may mimic hydropic placenta w/ fetal demise
trophoblastic tumor – rare, develops in placental bed following normal pregnancy, appears similar to recurrent or persistent complete moles (poorly defined mass or masses in the uterus, with hypoechoic areas that represent vessels)
choriocarcinoma – develops infrequently after molar evacuation
DIFFERENTIALS
Cystic Abdominal Mass (fetus)
IUGR (dates mismatch = IUGR)
maternal – deficient supply of nutrients: smoking, malnutrition, multiple gestations, anemia, high altitude, maternal vascular disease, severe diabetes
placental – extensive placental infarctions, chronic partial separation, placenta previa
fetal – decreased intrinsic growth, congenital heart disease, genitourinary anomalies, CNS anomalies, chromosomal abnormalities (trisomy 13, 18, 21), viral infection (rubella, CMV)
symmetric = severe, early onset, fetal causes such as chromosomal abnormalities
Endometrial Mass & Positive ß-hCG
retained POC
endometritis
Endometrial Fluid
cervical stenosis
cervical CA
hydrometrocolpos
endometritis
Pelvic Free Fluid
Placental Lesions
infarct (maternal side)
intervillous thrombus
fibrin deposition
First Trimester Vaginal Bleeding
spontaneous abortion
ectopic pregnancy
anembryonic pregnancy
molar pregnancy
subchorionic hemorrhage
OB - General
Follicle ruptures at 20-24mm
Sac diameter grows 1.13mm/day
Normal gestational sac ~2x length of embryo
Yolk sac should be seen w/ 8-10mm gestational sac or at 5-6 wks (transvaginal)
Fetal pole should be seen w/ 18mm gestational sac (25mm is diagnostic)
Fetal heart activity seen at 6w2-3d (CRL ≥ 5mm)
Cervical length should be >3cm
Corpus luteum regresses by 16-18 wks
Need to be 14wks GA to dx oligo in setting of renal agenesis (Potter syndrome)
Ventricular atria should be < 10mm
Should see gestational sac by:
1000 IU (transvag)
1800 IU (transabdominal)
Fetal Heart Rate
5-6 wks → 100-110
8-9 wks → 150-170
Fetal Demise
Amniotic fluid measurements
Subjective
Single-deepest pocket measurement - measured vertically, normally between 3-8cm
Four quadrant AFI - sum of deepest vertical pocket in each quadrant, normally 5-20cm
Fetal measurements
Macrosomy
First Trimester Pregnancy Failure
No heartbeat on TVS (w/ embryo >5mm in length or GA at least 6.5 weeks)
Suspicious, but not diagnostic:
Mean sac diameter of more than 8 mm and no visible yolk sac
Mean sac diameter of more than 16 mm and no visible embryo
ß-HCG above 1,000 mIU/ml and no gestational sac seen
ß-HCG above 10,000 mIU/ml and no embryo identified
Normal Yolk Sac (5-6 wks)
Round
<5-6 mm
anechoic
thin wall
no calcifications
Slow Embryonic Heart Rate
At 6-6.3 wks (CRL<5mm), <100bpm assoc with increased risk of fetal demise; if <90, rec f/u in 1-2 wks
At 6.3-7 wks (CRL 5-9mm), <120bpm assoc with increased risk of fetal demise; of <110, rec f/u in 1-2 wks
Subchorionic Hematoma
blood coll b/w chorion and uterine wall
thick irregular membrane, may track beneath placenta, may have internal echoes
prognosis related to size of hematoma
differentiate b/w normal fluid b/w chorion and amnion
tx is bedrest
Marginal Cord Insertion
Velamentous Cord Insertion
aberrant vessels traveling between chorion and amnion
risk of bleeding during labor, preterm labor, fetal anomalies
Placenta Previa
placenta covering the internal cervical os
complete, partial, or marginal
can resolve
necessitates C-section
Vasa Previa
Placental Abruption
premature detachment of placenta from uterine wall
retroplacental or subchorionic hematoma
normal u/s does not r/o abruption
Placenta Accreta, Increta, Percreta
accreta: attachment of the placenta directly to the myometrium, without invasion of chorionic villi into the myometrium
increta: invasion of chorionic villi into the myometrium
percreta: penetration of villi through the myometrium, to or through the serosa of the uterus
frequently occur @ site of prior C-sect
raise possibility when 1) anterior previa seen w/ prior c-section and 2) u/s shows thinning of myometrium overlying placenta (1-2 mm or less)
Succenturiate Lobe
accessory placental lobe
failure of placental villi to atrophy
can lead to hemorrhage prenatally or during labor
can lead to postpartum hemorrhage if not delivered
Chorioangioma
benign placental tumor
cause fetal growth restriction & hydrops
solid mass within or projecting from placenta
may cause high-output heart failure (distended umbilical vein) and hydrops
Cervical Incompetence
early dilitation of cervix
shortening and funneling of cervix
length: 3cm normal, 2.5-3cm borderline, <2.5cm incompetent
complication is pre-term labor
treatment is cerclage
Uterine Synechia and Amniotic Sheet
uterine synechia result in amniotic sheets, smooth thick projections of tissue into the gestational sac
broad based attachment to uterine wall
does not adhere to fetus, therefore no fetal abnormalities
increased incidence of fetal malpositioning
Oligohydramnios (DRIPPC)
Demise of fetus, Drugs
Renal anomalies, bilateral (agenesis, PCKD, obstruction)
IUGR (decreased renal perfusion)
PROM
Post-dates, 40 wks or greater
Chromosomal abnormalities
Polyhydramnios (TARDI)
Twins
Anomalies, fetal (esophageal, duodenal, small bowel obstruction, anencephaly, facial clefts/tumors, intrathoracic masses, mesoblastic nephroma)
Rh incompatibility
Diabetes
Idiopathic
associated with chromosomal abnormalities
causes maternal symptoms (pain, premature contractions, LE edema, hydronephrosis)
Intra-amniotic Hemorrhage
Single Umbilical Artery
more common in multiple pregnancies
associated with structural abnormalities (holoprosencephaly, hydrocephalus, cerebellar dysgenesis) and Trisomy 18
Umbilical Cord Cysts
Twin pregnancy
dizygotic = dichorionic (different sexes must be dizygotic)
two placentas = dichorionic
delta sign / twin peak sign (extension of placenta into base of membrane) = likely dichorionic
membrane:
thick membrane (>2mm) = likely dichorionic
thin membrane (1-2mm) = likely monochorionic, diamniotic
really thin membrane (<1mm) = likely monochorionic, monoamniotic
two yolk sacs or two amnionic sacs = diamniotic
intermingling of cords, no membrane = monoamniotic
Twin-Twin Transfusion Syndrome
discrepant amniotic fluid volumes (severe = “stuck twin”)
donor has anemia and IUGR
recipient can have high-output cardiac failure, polycythemia, and hydrops
discordant fetal size
monochorionic placentation
Death of Twin
dichorionic <10wks = vanishing twin
dichorionic >10wks = partially resorbed
monochorionic twin death leads to ischemic damage in co-twin (“twin embolization syndrome”)
OB - Neuro
Normal size of lateral vents
Cisterna magna normally <10mm
S:D ratio
starts <4 @ 26-30 wks
<3.5 @ 30-34 wks
<3 from 34 wks onward
increased risk of perinatal morbidity and mortality
absent or reversed end-diastolic flow is poor prognostic sign
associated with placental insufficiency
Serum AFP measured @ 15-20 wks
Triple/Quadruple Screen
High AFP = neural tube defect or gastroschisis
Low AFP = Down syndrome
High hCG = Down syndrome
Low Estriol = Down syndrome
High Inhibin-A = Down syndrome
Hydrocephalus
width of lat vent @ atrium >10mm
“dangling choroid”
ddx aqueductal stenosis, dandy-walker, myelomeningocele (Chiari), encephalocele, arachnoid cyst, intracranial tumor, intracranial hemorrhage
Choroid Plexus Cysts
associated w/ Trisomy 18 & 21
look for associated abnormalities
correlate with maternal age, triple screen
Anencephaly
absence of fetal cranium
some dystrophic brain tissue may be seen
active fetus w/ polyhydramnios
prominent orbits with “frog-like” appearance
Dandy-Walker
dandy walker cyst with keyhole shape, communicates w/ 4th ventricle
dilated cisterna magna
inverse relationship b/w chromosomal abnormalities and presence of hydrocephalus
Encephalocele
Holoprosencephaly
lobar - incomplete falx, partially fused hemispheres
semilobar - fused hemispheres, partially fused thalami
alobar - worst, large central ventricle, fused thalami
associated with Trisomy 13
Schizencephaly
Agenesis of Corpus Callosum
complete or partial, partial usually affecting posterior aspect
parallel ventricles, colpocephaly
sulci radiate from roof of 3rd vent
cavum septum pellucidum excludes ACC
associated with interhemispheric cyst
Intracranial Hemorrhage
usually occurs post-natally, but can result from maternal drug abuse, thrombocytopenia, anticoagulation, trauma, also twin-twin transfusion, death of co-twin, fetomaternal hemorrhage
may result in porencephaly & parenchymal loss
Hydranencephaly
results from massive vascular accident
absence of cortical tissue, fluid-filled fetal head
falx IS present, differentiating from alobar holoprosencephaly
TORCH Infections
findings include microcephaly, periventricular calcifications, hydrocephalus, cerebellar aplasia, encephalomalacia, porencephaly
Spina Bifida
failure of posterior vertebral arches to close
Chiari II virtually always present
assoc with folic acid deficiency
“lemon sign” – flattening or concavity of frontal bones in second trimester, returning to normal in third trimester
banana sign – curved appearance of cerebellum, pulled into foramen
associated anomalies – clubfoot, scoliosis/kyphosis
Hemivertebrae
Scoliosis
Arthrogryposis
Caudal Regression and Sacral Agenesis
both found in fetuses of diabetic mothers, particularly with poor glucose control
caudal regression - spectrum of abnormalities involving lower spine, pelvis, and lower extremities
sacral agenesis - absence of two or more sacral vertebrae
Sirenomelia
Sacrococcygeal Teratoma
may grow anterior or exophytically posterior
may cause hydronephrosis
may result in neurogenic bladder or lower extremity paralysis
highly vascular → HOCHF → hydrops
Cleft lip
Macroglossia
Micrognathia
Hypotelorism/Cyclopia/Proboscis
OB - Chest
CCAM
pulmonary mass w/ cystic and solid components
can cause polyhydramnios
Type 1: cysts > 2cm
Type 2: cysts ~ 1cm <– associated with renal and GI anomalies
Type 3: microscopic cysts
large ones carry a poor prognosis
ddx - sequestration (has doppler flow), CDH (paradoxical diaphragm motion, location of stomach above diaphragm, extends from below diaphragm)
Pulmonary Sequestration
Diaphragmatic Hernia
Bochdalek vs Morgagni
findings - heterogeneous mass, intrathoracic stomach, opening in diaphragm, peristalsis in thorax, paradoxical motion w/ respiration
poor prognosis if: liver w/i thorax, small size of contralateral lung, hydrops
lung/head ratio <1 = poor prognosis, 1.0-1.4 moderate, >1.4 excellent
Tracheal Atresia
Complex mass, predominantly solid
Grow rapidly, may cause HOCHF/hydrops
Increased Nuchal Translucency
measured at 11-14 weeks sagitally
Associated w/ 45X (Turner), Trisomy 21, 13, 18
should undergo amniocentesis or CVS
upper limit of normal - 2.2mm @ 11wk, 2.8 @ 14wk
Thickened Nuchal Fold
Cystic Hygroma/Lymphangiectasia
Uni/multiloculated SQ mass filled w/ lymph fluid
Posterior neck is common location
Can cover entire body (generalized lymphangiectasia)
Associated w/ 45X (Turner), Trisomy 21, 13, 18
May have oligohydramnios
Pleural Effusion
Isolated or associated w/ hydrops
Isolated are likely chylothorax (thoracic lymphatic dysplasia) - associated skin thickening around thorax
karyotyping is advised (6% anomaly)
may tx w/ thoracentesis or thoracoamniotic shunt
Hydrops
At least two of the following: pleural effusion, pericardial effusion, ascites, SQ edema
Immune hydrops- maternal ab crossing placenta and destroying fetal RBC's
Non-immune- cardiac anomaly, lymphatic dysplasia, CCAM, diaphragmatic hernia, arrhythmia, anemia, chromosome abnormality, TORCH infection, teratomas, chorioangioma (placenta), idiopathic
OB - Cardiac
Focal Intracardiac Echogenic Focus (papillary muscle calcification)
Pericardial Effusion
HLHS & Aortic Stenosis
small or absent L ventricle
caused by limiting flow to L heart (ie. aortic stenosis)
poor prognosis
aortic stenosis may result in myocardial fibroelastosis - poor LV contractility
HRV & Pulmonic Stenosis
small or absent R ventricle
caused by pulmonic or tricuspid stenosis or atresia, tetralogy of fallot
w/ isolated pulm stenosis, RV may be small or large
Ebstein anomaly
malformation/malpositioning of tricuspid valve, displaced into RV
leads to regurg & RA enlargement (large RA, small RV)
poor prognosis - large heart, pulmonary hypoplasia, arrythmias
ASD/VSD/PDA
AV canal/Endocardial Cushion Defect
Tetralogy of Fallot
Transposition of Great Vessels
reversed ventricular outflow tracts
dx best made on long axis LV view, both vessels extending cephalad in parallel, aorta anterior to PA
often accompanied by VSD
good prognosis
Truncus Arteriosis
single large vessel arises from both ventricles giving branches to pulmonary, coronary, and systemic arteries
associated L or R ventricular hypoplasia and a large VSD or AV canal
Cardiac Tumors
Arrhythmias
Ectopia cordis
Pentalogy of Cantrell
ectopia cordis & omphalocele
also congenital cardiac defects, distal sternal cleft, ventral diaphragmatic hernia
OB - GI
Esophageal Atresia
Duodenal Atresia
“double bubble” & polyhydramnios
ddx: annular pancreas, malro w/ Ladd's bands, duodenal web
Small Bowel Obstruction
Meconium Peritonitis
peritoneal fluid or meconium pseudocyst
may be thick-walled cyst with wall calcification
later stages may have isolated intraperitoneal calcifications – calcifications exclude CF
look for complex scrotal ascites
Omphalocele
contains bowel and sometimes liver
midline, covered by membrane
cord vessels travel through it
assoc w/ chromosomal anomalies
Gastroschisis
paraumbilical, usually on right
free-floating, not contained by membrane
good prognosis
Amniotic Band Syndrome
free edges of amnion adhere to fetus and entrap fetal parts
amputation, abdominal/thoracic wall defects, facial clefts, encephaloceles
OB - GU
Renal Agenesis
often associated GU anomalies, such as bicornuate uterus
bilateral leads to oligohydramnios, causing a number of anomalies including pulmonary hypoplasia, abnormal facies, clubfeet (Potter syndrome)
Hydronephrosis (renal pelvis diameter dilatation)
>4mm is dilated in first 23 wks, >7mm is dilated after 23 wks
obstruction, VUR, prune belly
level of obstruction (UPJ, UVJ, urethra)
think of primary megaureter (aperistaltic distal ureteral segment
posterior urethral valves causes bilateral hydro, large bladder & oligohydramnios; ddx urethral atresia
can have urine ascites
Multicystic Dysplastic Kidney
noncommunicating cysts of different sizes, replacing the parenchyma
40% unilateral; associated with contralateral anomalies
caused by UPJ obstruction
atrophies after birth
ARPKD
enlarged echogenic kidneys (enlargement means > 4cm)
may have hepatic fibrosis
may see oligohydramnios and absent bladder in severe cases
Renal Ectopia
Mesoblastic Nephroma
Duplicated Coll System & Ectopic Ureterocele
Ovarian Cysts
Cloacal and Bladder Exstrophy
OB - MSK
Skleletal Dysplasias
Thanatophoric dysplasia - shortening and bowing of long bones, narrow thorax, cloverleaf skull
OI Type 2 - fractures, deformities of ribs and long bones, small thorax, poor mineralization of cranium and soft skull
Achondrogenesis - extensive lack of ossification except for calvarium
Hypophosphatasia - poor ossification and shortening of long bones
Skeletal Dysostoses
Limb Amputations
Radial Ray Defects
Cornelia de Lange, Fanconi, Holt-Oram, TAR, VATER
associated with congenital heart defects and Trisomy 13 & 18
Polydactyly
associated w/ short-rib polydactyly, chondroectodermal dysplasia, asphyxiating thoracic dystrophy, Meckel-Gruber and trisomy 13
Clinodactyly
OB - Trisomies
Trisomy 13 (Patau)
Holoprosencephaly
Ventriculomegaly
Microcephaly
Agenesis of the corpus callosum
Microphthalmia
Hypotelorism
Radial aplasia
Polydactyly
Flexion deformity of fingers
Diaphragmatic defect (hernia/eventration)
Omphalocele
Cardiac anomalies
Echogenic enlarged kidneys
Trisomy 18 (Edwards)
Agenesis of the corpus callosum
Choroid plexus cysts
Hypoplastic cerebellum with enlarged cisterna magna
Strawberry skull
Two-vessel cord
Micrognathia
Hypotelorism
Microphthalmia
Clenched hand with overlapping index finger
Clubfoot
Rockerbottom foot
Omphalocele
Diaphragmatic hernia
Cardiac anomalies
Renal anomalies
Intrauterine growth restriction
Trisomy 21 (Down)
Cerebral ventriculomegaly
Atrioventricular canal
Ventricular septal defect
Tetralogy of Fallot
Nuchal translucency > 2.2-2.8 mm at 11-14 weeks
Nuchal fold 6 mm or greater at 16-20 weeks
Duodenal atresia
Monosomy X (Turner)
Triploidy
Common sonographic presentations - dead embryo or fetus w/ enlarged cystic placenta, severe early-onset growth restriction w/ enlarged cystic placenta
Holoprosencephaly
Dandy-Walker malformation
Agenesis of the corpus callosum
Micrognathia
Microphthalmia
Syndactyly of the third and forth fingers
Clubfeet
Omphalocele
Cardiac anomalies
Renal anomalies
Meckel-Gruber syndrome
encephalocele
polycystic kidneys
polydactyly
cleft palate
cardiac anomalies
liver cysts
oligohydramnios