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DMST 285 OBGYN 2 > Doppler In Gynecology > Flashcards

Doppler In Gynecology Flashcards

1
Q

Doppler is performed with what kind of scan?

A

EV scan

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2
Q

What do we look for with doppler in gynecology? 7

A
  1. Endometrial flow
  2. Ovarian torsion
  3. Solid masses
  4. Pelvic congestion
  5. Pelvic inflammatory disease
  6. Molar pregnancy
  7. AVM’s
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3
Q

What is a molar pregnancy?

A

Persistent trophoblastic disease

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4
Q

What does a moderate uterine artery doppler look like?

A

High velocity and high resistance wave form

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5
Q

In terms of uterine artery doppler velocities vary through cycle to do what?

A

Match need for vascular supply

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6
Q

Uterine abnormalities can cause what to happen with flow?

A

Resistance to flow to decrease

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7
Q

What are two types of uterine abnormalities?

A
  1. Endometrial carcinoma
  2. Uterine Leiomyoma
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8
Q

What is the RI for the proliferative phase?

A

0.88 (+/- 0.05)

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9
Q

What is the RI for the ovulation to lateral phase?

A

+/- 0.85 (+/- 0.06)

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10
Q

Label the image

A
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11
Q

Label the image

A
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12
Q

Label the two images 2

A
  1. Sagittal endovaginal image of a uterus with calcified arcuate vessels
  2. Transverse image of the same uterus
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13
Q

In terms of endometrial doppler it is routine to do what?

A

Observe flow

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14
Q

Where do we put the colour doppler for endometrial doppler?

A

Over the endometrium on TA and EV

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15
Q

What are some pathologies seen in the endometrium with abnormal colour flows and doppler? 3

A
  1. Endometrial carcinoma
  2. Endometrial polyps
  3. Submucosal fibroids
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16
Q

What are endometrial carcinomas?

A

Endometrial hyperplasia or thickened endometrium

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17
Q

What are endometrial polyps? If we see them what do we do?

A
  1. Colour doppler, looking for feeding stalk artery
  2. If seen spectral tracing to prove arterial flow
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18
Q

When would we do Ovarian doppler?

A

Ovarian torsion

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19
Q

If we see ovarian torsion what do we do? 3

A
  1. A DDX for acute localized pain in the pelvis
  2. Look for colour flow
  3. Spectral doppler must be performed
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20
Q

What do we look for in terms of ovarian torsion?

A

Look for colour flow first

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21
Q

What does positive and negative colour flow mean in terms of Ovarian torsion?

A
  1. Positive colour doesn’t mean NO torsion
  2. Negative colour flow doesn’t mean torsion either
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22
Q

Typical torsion is the absence of flow, but what are some things to note? 2

A
  1. Arterial flow can still be seen in some torsion
  2. Venous flow is first to disappear
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23
Q

What must we always do with ovarian doppler?

A

Correlate with the other side to ensure settings are correct

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24
Q

How is ovarian doppler best seen?

A

On endovaginal scan

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25
Q

How does ovarian doppler vary with menstrual cycle? Think RI

A
  1. Proliferative phase RI = 0.88 to 0.84
  2. Follicular phase RI rises to 0.92
  3. Ovulation RI decreases to 0.44
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26
Q

What does the ovarian doppler look like on the dominant follicle?

A
  1. PI and RI reflect decreased vascular impedance and an increase in flow in ovary with the dominant follicle
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27
Q

In terms of ovarian doppler, Inactive ovary has what?

A

Low or absent end-diastolic flow

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28
Q

In terms of ovarian masses Malignant lesions tend to have what type of flow?

A

More central flow

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29
Q

In terms of ovarian masses, benign lesions tend to have what type of flow?

A

Peripheral flow

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30
Q

What do we have between benign and malignant processes in the ovarian mass?

A

Considerable overlap

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31
Q

What are the RI for Ovarian Neoplasms?

A

RI < 0.4

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32
Q

What is the P1 for ovarian neoplasm?

A

PI <1

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33
Q

In terms of ovarian doppler, what is the diastolic flow?

A

It is increased

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34
Q

Doppler is non-specific for what?

A

Malignancy

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35
Q

What does this image demonstrate?

A

Ovarian doppler of the corpus luteum

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36
Q

What is this an image of?

A

Cyst with a solid component

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37
Q

What are clinical S/S of acute salpingitis? 3

A

Acute signs and symptoms
1. Fever
2. High white count
3. Extreme motion tenderness

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38
Q

What does AVM stand for?

A

Arteriovenous malformation

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39
Q

What is Arteriovenous malformations?

A

A plexus of arteries and veins without a capillary bed

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40
Q

Where can Arteriovenous malformations occur? 2

A

In the pelvis
1. Typically involve the myometrium
2. Can involve the endometrium

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41
Q

How is Arteriovenous malformation usually acquired 3

A
  1. Trauma
  2. Surgery
  3. Can be associated with gestational trophoblastic disease
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42
Q

What is the resistance of AVMs? 2

A
  1. Extremely low resistance
  2. Coupled with low resistance venous flow on spectral
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43
Q

In terms of arterio malformation colour doppler shows what?

A

Abundance of aliasing

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44
Q

What does this image demonstrate?

A

Arteriovenous maformation

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45
Q

In terms of Ovarian vein thrombophlebitis, which side is typically affected?

A

Right side 80-90% of the time

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46
Q

What modalities are used to diagnose AVMs? 3

A
  1. CT
  2. MRI
  3. Sonography
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47
Q

What would we use to scan Ovarian vein thrombophlebitis? (Structure)

A

IVC

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48
Q

What is the DDX for Ovarian vein thrombelitis? 5 (what is linked/ causes it)

A
  1. Appendicitis
  2. Fibroids
  3. Nephrolotihiasis
  4. Ovarian torsion
  5. Two-ovarian abscesses
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49
Q

What does this image demonstrate?

A
  1. Norma Ovarian vein on the left
  2. Thrombophlebitis normal
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50
Q

What is ovarian vein thrombophlebitis?

A

Inflammation of the vein caused by a clot

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51
Q

How common is ovarian vein thrombophlebitis?

A

Rare condition

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52
Q

What is associated with ovarian vein thrombophlebitis? 3

A
  1. Postpartum
  2. Malignancies
  3. PID
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53
Q

What is pelvic congestion?

A

chronic pelvic pain lasting for more than. 6 months

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54
Q

What is the cause of pelvic possible due to?

A

Chronic dull ache

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55
Q

What are symptoms of chronic dull ache? 4

A
  1. Premenstral
  2. Menstrual
  3. Postcorital
  4. Perirenal
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56
Q

What is pelvic congestion associated with? What is the gold standard? 3

A
  1. Varicose veins in legs
  2. Multi parity
  3. Venography is the diagnostic gold standard
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57
Q

What does this image demonstrate?

A

Pelvic congestion

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58
Q

What is the cause of pelvic congestion? 2

A
  1. Unknown
  2. Possibly due to incompetent ovarian veins
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59
Q

How is doppler useful?

A

It is a relatively safe non-invasive method to asses maternal and fetal circulation

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60
Q

What does doppler assist us in doing?

A

Identifying fetuses at risk for poor fetal outcome by quantitative and qualitative factors

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61
Q

What are some qualitative benefits of doppler?

A

It allows us to assess flow patterns

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62
Q

How does doppler allow us to identify quantitative functions?

A

It allows us to obtain flow measurements

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63
Q

Why is it important not to abuse doppler?

A

There is a theoretical danger of increased exposure causing bio effects due to the increased energy (power) required for doppler

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64
Q

Which Doppler methodology adds little extra energy? And which one adds a lot of extra energy?

A
  1. Colour doppler
  2. Pulsed doppler
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65
Q

There are how many ways to assess with doppler? 3

A
  1. Colour
  2. Spectral
  3. Continuous wave
66
Q

Most fetal blood flow investigated is how fast? (speed)

67
Q

What is colour doppler used to do? 2

A
  1. Used to located vessel
  2. Used for vessels difficult to see on gray scale imaging (circle of Willis)
68
Q

What is the benefit of power doppler? 2

A
  1. Direction of flow is not needed
  2. We can see smaller vessels with slower flow
69
Q

What are qualitative analysis?

A

Observed changes that do need to be measured

70
Q

What are some examples of qualitative analysis variables? 3

A
  1. Loss of diastolic flow
  2. Reversal of diastolic flow
  3. Notching of the venous flow
71
Q

Diastolic velocities increase as term approaches, why?

A

Decreased placental resistance (larger placental vessel)

72
Q

Why is semiquantitative analysis difficult to use?

A

Used because of the difficulty to control the angle of incidence

73
Q

What ratios does semiquantitative analysis include? 3

A
  1. Pulsatility index (PI)
  2. Resistance index RI
  3. Systole/ Diastole Ratio
74
Q

How do we calculate Pulsatility Index?

A

(Peak systolic velocity - End diastolic velocity)/ Mean velocity

75
Q

How do we calculate resistance index?

A

(Peak velocity - end diastolic velocity) / Peak systolic velocity

76
Q

How do we calculate systole/ diastole ratio?

A

Peak systolic velocity/ End diastolic velocity

77
Q

Semiquantitative analysis equations are dependant on what?

78
Q

All semiquantitative analysis equations are thought to reflect how?

A

Downstream flow impedance

79
Q

As impedance increased what happens to pulsatility waveform?

A

It decreases

80
Q

RI and S/D ratios can’t be calculated when what happens?

A

The diastolic velocity reaches zero

81
Q

PI will continue to change in what conditions?

A

Even when diastolic flow is zero

82
Q

S/D ratios are the most commonly used for what?

A

Analysis but when EDV is zero reversed, PI is more favourable

83
Q

For accuracy what must we do?

A

Three or more waveforms should be measured and averaged to reduce operator error and to account for external variables

84
Q

What cardiac signs help a role in the accuracy of the heart? 2

A
  1. Tachycardia
  2. Bradycardia
85
Q

What can the fetus do to affect accuracy?

A

Fetal breathing and motion

86
Q

During the embryonic period it is is normal that have what type of pattern?

A

High resistance pattern with absent end diastolic flow

87
Q

Toward of the end of the first trimester what happens?

A

End diastolic flow appears

88
Q

As pregnancy progresses what should increase?

A

End diastolic velocity

89
Q

Label the waveforms?

A
  1. 1st trimester
  2. 2nd trimester
  3. Third trimester
90
Q

What fetal vessels are routinely assessed? 6

A
  1. Umbilical artery
  2. Fetal cerebral vessels (MCA)
  3. Ductus venosus
  4. Umbilical vein
  5. Fetal aorta
  6. Fetal IVC
91
Q

Doppler of uterine arteries is used to detect markers for what? 3

A
  1. Placental insufficiency
  2. IUGR
  3. Suspected pre-eclampsia
92
Q

In the presence of IUGR, scans are performed how?

A

Weekly if the results are normal

93
Q

Abnormal results require what frequency of scans?

94
Q

What are indications for Umbilical artery doppler? 5

A
  1. Small for gestation age
  2. Hypertension in pregnancy
  3. Diabetes type 1
  4. Discordant growth in TTTS
  5. Poor growth twins due to placental insufficiency
95
Q

The PI, RI, and S/D ratios do what with gestational age?

96
Q

Umbilical artery ratios are higher where?

A

If measured at fetal end of the cord

97
Q

Where should we try to measure in the umbilical arteries?

98
Q

How should we scan the umbilical arteries in the situation of twins?

A

Just outside of the fetal abdomen

99
Q

Reversed diastolic flow indicate what?

A

Severe fetal distress and may lead to intrauterine death

100
Q

RI of what is abnormal from 26 weeks onward

101
Q

Fetal doppler values must be referenced with what?

102
Q

What kind of flow is seen in the umbilical arteries?

A

Monophasic and low resistance

103
Q

What does abnormal flow patterns look like for umbilical arteries?

A

Absent or reversed diastolic flow

104
Q

What is abnormal umbilical artery flow referred to?

A

AEDF and REDF

105
Q

In terms of umbilical arteries here, what is affecting them?

A

Fetal breathing

106
Q

Why is the importance of MCA doppler?

A

Assessing fetal cardiovascular distress

107
Q

What does MCA stand for?

A

Mid cerebral arteries

108
Q

Where is MCA found?

A

Just inferior to the BPD

109
Q

What does MCA flow look like normally? (During brain development and increasing gestational age) 2

A

Monophasic
1. High resistance as the brain develops
2. Lower with increasing gestational age

110
Q

In terms of the MCA, accuracy requires what?

A

Scanning parallel to the course of the MCA with an angle of <15 degrees

111
Q

Where should we sample in terms of MCA doppler?:

A

Near the origin as PSV decrease laterally

112
Q

In terms of MCA doppler, with IUGR there can be what?

A

Brain sparing

113
Q

What is brain sparing referred to?

A

Asymmetrical IUGR

114
Q

Preferential flow to the brain results in what?

A

Increased diastolic flow to compensate for fetal asphyxia

115
Q

The PI of the MCA can be compared to what?

A

The UA in a cerebral- placental ratio (CPR)

116
Q

What is the CPR formula?

A

CPR = MCA PI/ UA PI

Or

(Mid cerebral artery pulsatility index)/ (umbilical pulsatility index)

117
Q

What does cerebral placental ratio describe?

A

The relative impediments to blood flow between maternal and fetal circulation

118
Q

What is the normal CPR and Abnormal CPR values?

A
  1. Normal and >1:1
  2. Abnormal is <1:1
119
Q

What is an ominous sign for hypoxia in the fetus? 2

A
  1. Increased diastolic flow in the MCA
  2. Absent or reversed diastolic flow in the UA
120
Q

In terms of these waveforms. What is happening to the placental resistance? What does this resistance do to the placenta? What can we see with the umbilical venous flow? What does the brain do to compensate?

A
  1. Placental resistance is rising
  2. Causes loss of perfusion in the placenta
  3. Umbilical venous flow decreases causing hypoxia
  4. The brain compensates and increases diastolic flow in the MCA
121
Q

Immune hydrops can lead to what?

122
Q

What is anemia in terms of doppler?

A

Increased systolic velocity due to decreased viscosity of the blood

123
Q

Peak systolic velocity increase with what?

124
Q

Values are always correlated with what?

125
Q

What value indicates a amniocentesis is required? And if so what else is possibly needed?

A
  1. > 1m/sec
  2. Possible fetal blood transfusion
126
Q

What does this sample demonstrate?

A

MCA sample for immune hydrops

127
Q

What do these images demonstrate?

A

Corrrect angle vs incorrect angle

128
Q

In terms of MCA doppler, fetal position is of importance how?

A

Fetal position is dependent, which means this can be difficult

129
Q

In terms of MCA doppler, for an accurate measurement, what should we do? 2

A
  1. The fetal head should be in the transverse plane
  2. An axial section of the brain, including the thalami and the sphenoid bone wings, should be obtained and magnified
130
Q

In terms of MCA doppler, constant probe pressure can cause what type of reaction? Why?

A
  1. Reaction similar to fetal distress
  2. Fetus will shunt more blood to the brain
131
Q

What is the ductus venosus?

A

A shunt that allows oxygenated blood in umbilical vein to bypass the liver and go directly to the right atrium

132
Q

What does the ductus venosus do?

A

Regulator of oxygen to the fetus

133
Q

How much of the umbilical vein blood is dependent on the ductus venosus?

134
Q

Where is the ductus venosus located?

A

In the fetal liver between LT portal vein and IVC

135
Q

How should we obtain the ductus flow? 4

A
  1. Level of the AC
  2. Colour doppler of the UV
  3. Sweep towards fetal heart
  4. Look for aliasing (due to narrow lumen)
136
Q

Label the image

137
Q

What does this image demonstrate?

A

Ductus venosus in trans and sagittal

138
Q

What does this image demonstrate?

A

Ductus venosus in trans and sag

139
Q

Label the image

140
Q

In terms of the ductus venosus, it is abnormal to see flow go where?

A

Below the baseline

141
Q

In TTTS, the recipient twin may demonstrate what? Why?

A
  1. Flow below the base line with tricuspid regurgitation.
  2. Volume overload - getting to much blood
142
Q

Assessments of the DV can be used for what? 2

A
  1. First trimester screening for aneuplody
  2. Second and third trimester scanning when there are concerns regarding IUGR and Fetal cardiac compromise
143
Q

What does these images demonstrate?

A

Normal Ductus venosus

144
Q

What does these images demonstrate?

A

Abnormal Ductus venosus

145
Q

There is continuous flow of oxygenated blood where?

A

To the fetal liver and, via the ductus venous, the heart

146
Q

What is the continuous flow of oxygenated blood flow affected by?

A

Fetal breathing or movements, which means we need to be careful when sampling

147
Q

Where can the umbilical vein be sampled?

A

In the cord of fetal abdomen

148
Q

The umbilical cord can pulsated until when? (weeks)

A

Up to 13 weeks

149
Q

In terms of the umbilical vein, the presence of pulsatility can be be higher when?

A

In chromosomal abnormal fetuses

150
Q

Pulsatility in the UV coupled with AEDF or REDF in the umbilical artery indicates what?

A

Poor outcome

151
Q

Label the umbilical vein spectral doppler waveforms

A
  1. Normal
  2. Breathing movements
  3. Single pulsations
  4. Double pulsations
152
Q

How often is the fetal aorta used now?

A

Not as frequently

153
Q

Where do we sample the fetal aorta?

A

In descending aorta just above the diaphragm

154
Q

What is the appearance of the fetal aorta?

A

Similar to umbilical artery

155
Q

Changes in aorta are noticed how?

A

Before they appear in the umbilical artery

156
Q

In the fetal aorta decreased, absent or reversed diastolic flow indications compare how to the umbilical artery

157
Q

What is the IVC waveform near the heart?

158
Q

What does the IVC look like spectrally near the heart in the presence of IUGR? 3

A
  1. A wave will increase
  2. S wave and D wave will decrease
  3. The D wave may also be absent or reversed
159
Q

Uterine artery doppler is used for the prediction of what?

A

Placenta insufficiency

160
Q

What factors in the uterine artery doppler waveform would indicate placental insufficiency? 4

A
  1. Low PAPP-A (pregnancy associated plasma protein)
  2. PI >1.45 (1.2 is normal)
  3. Notching
  4. Blood test performed for the1st trimester screen

DMST 285 OBGYN 2 (15 decks)

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