MCQ Flashcards
Cholestasis of pregnancy
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Breast MRI enhancment patterns
Rapid early enhancement with washout suspicious for malignancy
If intermediate early enhancement, may be type 1 (persistant, most benign but could still be malignant) type 3 (plateau - suspicious), or type 3 (washout - highly suspicious)
Peripheral enhancement first is suspicious for malignancy
Central more benign
Benign breast ultrasound features
Marked hyperechogenicity Thin echogenic pseudocapsule Wider than tall / parallel Circumscribed Ellipsoid Gentle lobulations
Malignant breast ultrasound features
Spiculate - most specific Taller than wide Angular or microlobulated Shadowing Markedly hypoechoic Calcs Poorly defined margin
Linguine sign
Hypoinense lines on MR
Intracapsular silicone implant rupture
Tomosynthesis radiation dose
Single DBT images has dose similar to single FFDM image
Atypical ductal hyperplasia on biopsy
Spectrum of change from normal, to flat epithelial atypia, to atypical ductal hyperplasia, to DCIS
If core biopsy shows ADH, treat with open biopsy - 18% are upstaged to DCIS or invasive carcinoma
Cleopatra view
AKA axillary view
A supplementary exaggerated CC to see the axillary tail, performed if a lesion is only seen in the axilla on MLO
Failed pregnancy
CRL >/= 7mm with no heartbeat MSD >/= 25mm with no embryo Absence of embryo with heartbeat: 2 weeks after GS without yolk sac 11 days after GS with yolk sac
Cervical carcinoma
High T2 signal compared with background low signal Cervix
T2 to assess parametrial invasion to see if surgical candidate - if T2 hypointense cervical ring intact, parametrial infasion unlikely.
CT is primarily for assessing adenopathy (although MR can do similar?)
Most are squamous - HPV 16 and 18
Several adenocarcinoma types- clear cell, endometrioid, mucinous, serous
Also neuroendocrine (small) and adenosquamous) - small cell have a poor outcome
Adenos generally though to give higher rates of mets - thoracic and adrenal
Ovarian cycle
Proliferative - becomes trilaminar Secretory - uniformly hyperechogenic Imaging best performed in early proliferative Proliferative = follicular Secretory = luteal
Twin demise
Flatenned remnant known as fetus papyraceus
Surviving co-twin at risk of growth restriction, encephalomalacia and microcephaly
Twin embolisation syndrome a rare complication - multi-organ ischaemia, usually antecedent twin-twin transfusion syndrome
Fitz-Hugh-Curtis syndrome
Perihepatitis from peritoneal spread of infection in PID
Molar pregnancy
Complete, 90% diploid 46XX (less commonly XY) - single sperm or less likely two sperm
Partial, triploid 69XXY, normally from two separate sperm, one X and one Y (other triploid combos possible)
Complete - multiple intrauterine cystic space - bunch of grapes or snow storm
Partial - large cystic placenta and growth retarded fetus
Increased incidence in Asia
Physiological gut herniation of fetus
Should not be seen after 12 weeks
Ultrasound screening
Unacceptably high rates of biopsy of benign lesions
How many Ca does screening miss
1 in 8 pre-menopausal, 1 in 10 post
Clinical exam breast sensitivity
Detects 50% of cancers, including 5% of cancers not visible on mammography. May modestly improve early detection
Mammogram timing
Early follicular phase, as breasts are less dense
Fibroadenoma, epi
Commonest breast lesion in <40
Stellate
93% are malignant.
Most invasive breast cancers are stellate (2:1 stellate:circular)
Radial scar
Must have no skin thickening or retraction
Long spicules with intervening lucencies, different on different projections
AKA complex sclerosing lesion
Removed as can have associated carcinoma which is not distinguished on core biopsy
Black star - lucent centre (different from carcinoma)
Single reader v double reader v CAD
Routine use of CAD significantly increases recall rates. No significant effect on positive predictive value for biopsy – can increase detection rate by 4.7%, sensitivity by 4%.
CADET II study showed cancer detection rates attained with single reading with CAD were equivalent to those attained with double reading.
Performed equally well at recalling patients with cancer in whom the predominant radiologic feature was either a mass or a microcalcification.
Double reading showed superior performance for parenchymal deformities and in women with denser background pattern – i.e. CAD poor at detecting architectural distortion.
Single reader with CAD was better than double reading for asymmetric densities, but the number of these is small and accounted for only 35 of cancers.
Digital mammography
40% more sensitive with no change in recall rate
MRI indications
Lump with normal mammogram and USS Young with BRCA (annual from 30) Dense breast and LCIS Staging multicentric multifocal disease Positive node with negative uss and mammo Post surgical review of lumpectomy
Maternal AFP
Elevated in 80% of cases with open spina bifida
Normal in most fetuses with closed spina bifida
Also elevated in omphalocele, multiple fetuses
And liver tumours and germ cell tumours (esp. yolk sac tumour)
Elevated in placental chorioangioma (the most common placental tumour)
Reduced in Trisomies and Turners
Spina bifida
Associated with trisomy 18, 13
Limb anomalies - DDH, talipes, rockerbottom feet
Neurenteric cysts
Lemon skull, banana cerebellum/Chiari
Pregnancy screening
1st trimester:
Nuchal translucency, PAPP-A, HCG
1:300 or less is increased risk - offer diagnostic testing
<3mm is normal nuchal translucency 11.3-13.6 weeks, manigified, neutral neck, midline, fluid behind neck (CRL 45-84mm)
2nd trimester:
AFP, HCG, oestriol and inhibin A
In Downs, HCG up and PAPP-A down. AFP would also be down. Inhibin A higher, oestriol lower
Ovarian tumour markers
CA125
AFP - teratomas and yolk sac tumours (esp)
bHCG - small number of dysgerminomas
(AFP positive in mothers with fetuses with neural cord defects)
Endodermal sinus tumour
Is a synonym for yolk sac tumour
Ovarian cystadenoma
Serous unilocular
Serous more commonly bilateral (15% v 5%) (65% of malignant serous bilateral, 15% benign - 60% are benign, 25% malignant)
Serous more common
Mucinous multiloculated thin septations, and more commonly calcify (mural), and tend to be larger. 80% of mucinous are benign
Serous have papillary projections, psammoma bodies
Serous associated with BRCA1
Serous 60% benign, 25% malignant, rest boderline
Mucinous 80% benign 10% malignant, rest boderline
Mucinous associated with KRAS mutation
CMV
Necrotising inflammation
90% asymptomatic (in utero infection)
Prominent cytomegalic cells with intranuclear and intracytoplasmic inclusions
Tendendy to localise in ependymal and subependymal regions of brain.
Duodenal atresia
30% have Downs
Present in 3-5% of Downs
Meckel Gruber syndrome
Triad
Renal cystic dysplasia
Occipital encephalocele / holoprosencephaly
Post axial polydactyl (post axial is ulnar side)
AR
AKA pseudotrisomy 13
Cleft palate
Approximately 1:1000 Amniocentesis as high rate of chromosomal abnormality 1-4 classification 1 lip 2 palate 3 bilateral lip 4 lip and palate 50% 4, 25% 1 and 25% 2
Hydrops
Immune - rhesus Non-immune - heart failure, infection, Parvovirus is the most common infection to cause hydrops TORCH Aneuploidy Turners - lymphatic failure
Any cause of failure - shunts from tumours, vascular malformations,
Fetal anaemia - beta thalassamia not til 6-9 months. Homozygous alpha may be commonest cause of fetal hydrops in some parts of world
Errors of metabolism
CPAM could cause caval compression
CPAM
Can cause caval compression and hydrops (33-80%), (although another source said 10%, and false when asked if most cases have an effusion)
polyhydramnios from oesophageal compression (25-75%)
Single umbilical artery
IUGR Velamentous cord Trisomy (if other abnormalities) Renal agenesis same side Sirenomelia / mermaid syndrome
Ovarian sex-cord stromal
Granulosa (5% bilateral - most common oestrogenic tumour of ovary, 50% post-menopause, 45% pre)
Thecoma
The above two produce oestrogen, cause precocious puberty or endometrial hyperplasia / carcinoma
Sertoli-Leydig - rare, virilisation (testosterone)
Fibroma - most common one to cause Meigs (90% of M if fibroma. 40% of F causes Meigs)
Physiologic bowel herniation
Should not be seen after 12-13 weeks
Polycystic ovary syndrome
Clinical and biochemical diagnosis Peripheral cysts - 12 or more follicles in each ovary (Rotterdam - new study says 25) "String of pearls" 2-9mm Volume of ovary > 10mL
2 out of 3 of Oligomenorrhoea Clinical and biochemical hyperandrogenism Polycystic ovaries on ultrasound AND Exclusion of other causes
Can cause endometrial hyperplasia / cancer / polyps
20% of reproductive age women
Ovarian hyperstimulation syndrome
Bilateral ovaries > 5mL
Numerous large follicular cysts, with increased blood flow
Echogenic stromal tissue
Ascites and effusions
Ectopic pregnancy
2% of all pregnancies
Clinodactyly
Angulation at interphalangeal joint, typically 5th finger
Associated with aneuploidy - Down (60%), 18, Klinefelter, Turner
(In Downs often also have hypoplasia of middle phalanx of 5th)
Uterine malformations, outcomes
Bicornuate similar to general population
Didelphus and septate have increased miscarriage rates- 30% and 60%
Twin peak sign / lambda sign
Sign of dichorionicity - placental tissue on separating membrane
Tuberculous salpingitis
Thickwalled, cystic masses
Painful, afebrile
Molar pregnancy
Complete mole haploid - 2 sperm empty egg or duplicated single sperm
Partial mole - two sperm in an egg with chromosomes - triploid
Bilateral theca lutein cysts from high HCG - upto 50%, more common in complete
Invasiv mole 5-10%
Choriocarcinoma 1-5%
Echogenic bowel
Soft marker of T21 CF Intra-amniotic haemorrhage with swallowed blood products CMV IUGR Fetal hypoxia Hydrops
Placental praevia
Low lying <2cm
Marginal covers part of cervix but not os
Partial - partially covers os
Complete
Omphalocele
Associated with trisomies - 18 most common, also 13 and 21. And Turners, Klinefelters
Beckwith Weidemann
Bladder exstrophy and cloacal exstrophy
Raised maternal AFP (along with neural cord defects more commonly, and tumours)
Toxoplasmosis
Calc in thalamus, basal ganglia, choroid plexus. If just periventricular think CMV or TS
Microcephaly and mental retardation
Or macrocephaly from aqueduct stenosis
Head size may return to normal
Fetal heart rate
100bpm 5-6 weeks
140-160 at 8 weeks
Monozygotic twins
MCDA 60%, DCDA 30%, MCMA 10%
Number of yolk sacs
Is equal to the number of amnions
Fused placentas, twins
Dichorionic can fuse, giving appearance of monochorionicitiy
DCDA twins
2/3 dizygotic, 1/3 monozygotic
FIGO cervical cancer staging
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Cervical MR appearance
T1 uniform intermediate
High T2 mucosa
Low T2 fibrous inner zone
Intermediate T2 outerzone continuous with myometrium
Fetal enteric duplication cyst
80% cystic, 20% tubular - more likely to communicate with GI tract
Located in the mesentery
30% will have associated abnormalities - GI for hindgut and spine for foregut
Urinary tract
In the fetus, ureteric dilatation more significant than renal pelvis dilatation, which may be normal
Fetal pleural effusion
Most commonly chylo Associated with Aneuploidy Hydrops (and pulmonary masses e.g CPAM, sequestration, cardiac disease) May get secondary polyhydramnios
10% resolve spontaneously
May require thoracocentesis or thoracoamniotic shunting if large or recurrent
Karyotyping advised -6% abnormal
Normal placenta
> 2cm thick
Thinned in diabetes, HTN. Puts fetus at risk of growth restriction
Abruption
Clinical diagnosis. Ultrasound may be negative.
Marginal most common
Separation of chorionic plate and placenta (pre-placental collection)
Raised placental edge in 50%
Pseudoomphalocele
Deformation of abdomen from transducer pressure, and oblique scan angle. More common in oligohydramnios
Also physiological gut herniation at early gestation
Twins
80% Didi, monodi 30%, mm 1% 5x risk of preterm delivery MCMA 54% perinatal mortality Didi 10% md 20%
TTTS
10-20% of monochorionic pregnancies
More common if diamniotic
Maternal diabetes
Associated with:
Heart - VSD, truncus transposition
Lung - RDS, TTN
GI - situs, meconium plug
CNS - lots - neural tube, holoprosencephaly, caudal regression, sirenomelia
Renal - agenesis, hydronephrosis, ureteric duplication
Skeletal - polydactyly, syndactyly
Other - poly, macrosomia, IUGR, single UA
Fetal intracranial calc
Toxoplasmosis and CMV - toxo random, CMV periventricular
Tumours
Sturge Weber and TS
Mega cisterna magna
> 10mm antenatally
Trisomy 18, CMV, infarction
2,59,uterine cancer staging (endometrial), ovarian, others?
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Chorioangioma
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