RD obstetrics Flashcards
- Adnexal mass (? Ill-defined), heterogenous echogenicity on US (? Has echoes), isointense on T1 and homogenously dark on T2. Which of the following is most likely:
a. Hemorrhagic cyst
b. Simple cyst
c. Endometrioma
d. Mature teratoma
c. Endometrioma T at US contains uniform low-level echoes (ground glass); at MRI high T1 signal that persists with FS; T2 signal varies, but characteristic is low T2 signal (T2 shading)
- Adnexal mass (? Ill-defined), heterogenous echogenicity on US (? Has echoes), isointense on T1 and homogenously dark on T2. Which of the following is most likely:
a. Hemorrhagic cyst F = may have intermediate-high T1 signal secondary to haemorrhage, without loss of signal on fat sat images; usually high T2 signal however, as opposed to endometriomas which often have T2 low signal (“shading”)
b. Simple cyst F not ill-defined, no echoes if simple
c. Endometrioma T at US contains uniform low-level echoes (ground glass); at MRI high T1 signal that persists with FS; T2 signal varies, but characteristic is low T2 signal (T2 shading)
d. Mature teratoma F unlikely to be of homogeneous low T2 signal – exception would be fibroma/fibrothecoma
- Young woman (20 something), 6 weeks after last period, pelvic pain for several hours. Presents to ED. β-hcg pending. US shows (hyperechoic) fluid in pelvis and blurred uterine outline with hyperechoic adnexa. Most likely?
a. Appendicitis
b. Ruptured ectopic
c. Endometrioma
d. Ovarian torsion
e. Tubo-ovarian abscess
f. Mucinous tumour
*LW:
According to statDx and Promethius: “indefinite” uterus sign = PID.
“Indefinite” uterus sign
Inflammation and echogenic fluid in the cul-de-sac obscure uterine margins, especially along posterior border (also seen on CT).
Thus favoured option is tubo ovarian abscess.
Previous answer:
Ruptured ectopic
- Young woman (20 something), 6 weeks after last period, pelvic pain for several hours. Presents to ED. β-hcg pending. US shows (hyperechoic) fluid in pelvis and blurred uterine outline with hyperechoic adnexa. Most likely?
a. Appendicitis F
b. Ruptured ectopic F = uterus usually normal appearance, adnexal mass but ovary often seen as separate 6 weeks post period with hyperechoic fluid – she pregnant dawg
c. Endometrioma F
d. Ovarian torsion F
e. Tubo-ovarian abscess T cystic/solid/heterogenous adnexal mass, normal ovarian morphology not recognisable (Zagoria p274); uterus enlarged, ill-defined Again, pregnant.
f. Mucinous tumour F
- Antenatal scan shows anterior abdominal wall mass with cord inserted into side.
a. Omphalocele
b. Pseudo-omphalocele
c. Gastroschisis
d. Cord AVM
c. Gastroschisis T if cord inserts into abdominal wall adjacent to mass (Callen p627, Pocket p131)
- Antenatal scan shows anterior abdominal wall mass with cord inserted into side (LAS – cord inserts into abdo adjacent to mass).
a. Omphalocele T if cord inserts onto mass
b. Pseudo-omphalocele F = deformation of the fetal abdomen by transducer pressure coupled with an oblique scan orientation
c. Gastroschisis T if cord inserts into abdominal wall adjacent to mass (Callen p627, Pocket p131)
d. Cord AVM F mass will be within cord
- Antenatal scan at 20 weeks shows placenta over os. Technician asks you to check, and placenta is now clear of os. Which is most likely?
a. Braxton Hicks contraction
b. Overfilled bladder
c. Low lying placenta
d. Placenta previa
a. Braxton Hicks contraction T transient myometrial contractions can simulate placenta previa; note thick myometrium; resolves with time. Can be seen at US from 8 weeks on (Obstetrics & the Newborn).b. Overfilled bladder T overly distended maternal bladder can mimic true placenta previa. BEST OPTION?
- Antenatal scan at 20 weeks shows placenta over os. Technician asks you to check, and placenta is now clear of os. Which is most likely?
a. Braxton Hicks contraction T transient myometrial contractions can simulate placenta previa; note thick myometrium; resolves with time. Can be seen at US from 8 weeks on (Obstetrics & the Newborn).
b. Overfilled bladder T overly distended maternal bladder can mimic true placenta previa. BEST OPTION?
c. Low lying placenta F
d. Placenta previa F if true PP would stay over os (not transient).
PP is common in T2, with only a small minority persisting into late T3. Pics Callen p736
Full maternal bladder
• Approximates anterior and posterior uterine wallo Normally implanted placenta appears low
• Falsely elongates cervix
• Have patient void and repeat examFocal myometrial contraction
• Contraction can cause approximation of uterine wallso Similar to maternal full bladder
• May mimic placentao Can appear mass-like and echogenic
• Resolves with time
• TVUS can often differentiate cervix from contraction
o Slip of fluid seen at IO
- Fetal hydrops, normal stomach bubble and heterogenous echogenic mass in chest (also recalled as cystic-solid mass on prenatal US). Which is most likely
a. CPAM
b. Cystic hygroma
c. Bronchogenic cyst
d. CDH
e. BPS
a. CCAM T echogenic +/- cystic mass, mediastinal shift, hydrops (caval compression), polyhydramnios (oesophageal compression). StatDx says hydrops in < 10%.
- Fetal hydrops, normal stomach bubble and heterogenous echogenic mass in chest. Which is most likely
a. CPAM T echogenic +/- cystic mass, mediastinal shift, hydrops (caval compression), polyhydramnios (oesophageal compression). StatDx says hydrops in < 10%.
b. Cystic hygroma
c. Bronchogenic cyst
d. CDH *AJL - false - there is a normal stomch bubble so CDH is unlikely.
(Previous answer: less T Hydrops uncommon unless associated malformations present)
e. BPS less T hydrops may occur from cardiovascular compression(Added D&E)
- Postmenopausal woman (55 year old) with hirsutism. Ovarian mass. Most likely:
a. Sertoli-leydig
b. Leydig
c. Thecoma
d. Granulosa cell tumor
e. Mucinous cystadenoma
a. Sertoli-leydig can produce testosterone & virilise
- Postmenopausal woman (55 year old) with hirsutism. Ovarian mass. Most likely:
a. Sertoli-leydig can produce testosterone & virilise
b. Leydig – as above, but pure Leydig cell tumour (Hilus cell tumours) are rare
c. Thecoma – produce oestrogen; results in precocious puberty, endometrial hyperplasia/carcinoma
STAT DX-Thecoma may be associated with endometrial thickening if it secretes estrogen
Thecoma may be associated with hirsutism and amenorrhea if it secretes androgen
d. Granulosa cell tumor– as above
e. Mucinous cystadenoma – non-functional
Woman on IVF. U/S shows multiple cysts in left adnexa. U/S is routine.
a. normal stimulation.
b. hyperstimulation.
c. mucinous tumour
d. hydrosalpinx
• A = stimulation = normal to see multiple follicles/cysts while receiving stimulating hormones
Note:
• B = OHSS
signs:
o Bilateral ovarian enlargement (≥ 5cm, often > 10cm)
o Numerous large follicular cysts with dramatically increased local blood flow (some cysts may contain haemorrhage)
o Echogenic stromal tissue
o Ascites & effusions
MRI features of endocervical canal.
a. high T1.
b. central low T2 with peripheral high T2
c. parametrical extension is equivalent to 3b
d. cervical cancer is lower T2 than the rest of the normal cervix.
D = Kind-of T = high-signal intensity mass within low-signal intensity cervical stroma on T2WI; Roth – the tumour is intermediate in T2 signal – brighter than the inner fibromuscular stroma & darker than normal cervical mucosa
A = F on T1WI’s the whole uterus exhibits intermediate signal
B = F endocervical canal hyperintense, mid layer hypointense, outer layer intermediate T2 signal
C = F parametrial extension is FIGO stage II (but not to pelvic wall)
D = Kind-of T = high-signal intensity mass within low-signal intensity cervical stroma on T2WI; Roth – the tumour is intermediate in T2 signal – brighter than the inner fibromuscular stroma & darker than normal cervical mucosaEndocervical canal- mucosa : high- muscle : low- outer layer : intermediate
with regards to mri
Cervix on T2W images shows the following distinct zones from within outside [ Fig. 2 ]:
Zone 1: central hyperintense mucous in cervical canal.
Zone 2: high-signal intensity endocervical mucosa and glands (contains numerous folds and clefts as the plicae palmate). Combined thickness of zones 1 and 2 is 2 to 3 mm.
Zone 3: hypointense fibrous stroma is 3- to 8-mm thick.
Zone 4: outer intermediate signal intensity of loose stroma.
On T1W images, cervix appears as intermediate signal intensity structure without clear visualization of its zonal anatomy.
- Cervical cancer staging
a. Stage I invades the parametrium but not the lower third of vagina
b. Stage IIIB involves the bladder mucosa
c. Stage IVA involves rectal mucosa
d. Stage IIIA extends beyond the true pelvis
e. Stage II involves the lower third of the vagina
c. Stage IVA involves rectal mucosa
1 a - microscopic
1 b - macroscopic
2 a - upper 2/3 vagina
2 b - parametrium
3 a - low 1/3 vagina
3 b - obstructive uropathy
4 a - bowel bladder invasion
4 b - met
- Incidence of ectopic pregnancy (not assisted reproduction):
a. 1:50
b. 1: 150
c. 1: 500
d. 1: 1500
a. 1:50
Dahnert/Robbins: 2% of all pregnancies.
- A 60 year old female presents to the emergency department with RIF pain. Ultrasound demonstrated a hyperechoic rounded lesion in the right adnexa with cystic areas and no shadowing. This is most in keeping with:
a. Ovarian torsion
b. Ovarian metastasis
c. Acute appendicitis
d. Ovarian dermoid
e. Haemorrhagic cyst
c. Acute appendicitis T possible if perforated with abscess (thick echogenic fluid +/- gas bubbles), can occur at any age
- A 60 year old female presents to the emergency department with RIF pain. Ultrasound demonstrated a hyperechoic rounded lesion in the right adnexa with cystic areas and no shadowing. This is most in keeping with:
a. Ovarian torsion F usually occur in reproductive age & 1st three decades of life
b. Ovarian metastasis ?F ovary mets more common in premenopausal women due to vascularity of ovaries. However a possibility, typically from endometrium, breast, GIT or fallopian tube.
c. Acute appendicitis T possible if perforated with abscess (thick echogenic fluid +/- gas bubbles), can occur at any age
d. Ovarian dermoid F unlikely without any shadowing; typically stop growing at menopause & are most common in women < 45 years
STAT Dx
Multiple sonographic appearances, all of which are almost pathognomonic
including : “Echogenic mass without significant shadowing”
e. Haemorrhagic cyst F wrong age group
ADB–>not sure about this one, don’t favour appendicitis.The description sounds like a dermoid (though more commonly dx in younger) but the presentation would want you to rule out torsion because of a mass. Flip a coin 50:50.
In summary: Dont know
RP–>Ovarian torsion has a bimodal age distribution occurring mainly in young women (15-30 years) and post-menopausal women. Approximately 20% of the cases occur during pregnancy 1.
- 36 female for first trimester screening ultrasound. Which does NOT affect risk of aneuploidy?
a. Maternal age
b. Nuchal translucency
c. Ossification of nasal bones (or “unossified nasal bones”)
d. Length of middle phalanx of the little finger
e. Twin pregnancy
d. Length of middle phalanx of the little finger ?F this is a sign in the 2nd trimester = clinodactyly (hypoplasia of middle phalanx of 5th finger). Nomograms for 17-26 weeks. Seen in 2-4% of normal hands and 60% of fetuses with T21.
e. Twin pregnancy F In dizygotic pregnancies, the maternal age-related risk for chromosomal abnormalities for each twin is the same as in singleton pregnancies and therefore the chance that at least one fetus is affected by a chromosomal defect is twice as high as in singleton pregnancies. In monozygotic twins, the risk for chromosomal abnormalities is the same as in singleton pregnancies and in the vast majority of cases both fetuses are affected. Correct response is referring to aneuploidy risk for individual twin, but overall for the pregnancy the risk of aneuploidy (of either twin) is doubled)
- 36 female for first trimester screening ultrasound. Which does NOT affect risk of aneuploidy? (source FMF UK / StatDx)
a. Maternal age T
b. Nuchal translucency T
c. Ossification of nasal bones (or “unossified nasal bones”) T nasal bones not visible in T1 in 60-70% of fetuses with T21 & 2% of chromosomally-normal fetuses. At 15-20 weeks the nasal bones should both be > 2.5mm in length.
d. Length of middle phalanx of the little finger ?F this is a sign in the 2nd trimester = clinodactyly (hypoplasia of middle phalanx of 5th finger). Nomograms for 17-26 weeks. Seen in 2-4% of normal hands and 60% of fetuses with T21.
e. Twin pregnancy F In dizygotic pregnancies, the maternal age-related risk for chromosomal abnormalities for each twin is the same as in singleton pregnancies and therefore the chance that at least one fetus is affected by a chromosomal defect is twice as high as in singleton pregnancies. In monozygotic twins, the risk for chromosomal abnormalities is the same as in singleton pregnancies and in the vast majority of cases both fetuses are affected. Correct response is referring to aneuploidy risk for individual twin, but overall for the pregnancy the risk of aneuploidy (of either twin) is doubled)
- 28 female with repeated spontaneous abortions occurring in the second trimester. HSG demonstrates a Y shaped uterus with both Fallopian tubes present and patent. Which is MOST correct?
a. Arcuate uterus
b. Bicornuate uterus
c. Uterus didelphysis
d. Septate uterus
e. Unicornuate uterus
d. Septate uterus T there is significant overlap with the appearances of bicornuate uterus on HSG and need US or MRI to accurately delineate, thus given additional Hx, septate is favoured given Associated with recurrent spontaneous abortions (32-94%, 65% pooled spontaneous abortion rate).
- 28 female with repeated spontaneous abortions occurring in the second trimester. HSG demonstrates a Y shaped uterus with both Fallopian tubes present and patent. Which is MOST correct?
a. Arcuate uterus F
b. Bicornuate uterus F Pregnancy outcomes have been reported to be close to those of the general population. However, some women do develop complications, such as pregnancy loss, preterm labor, or malpresentations. [UTD].
c. Uterus didelphysis F have 2 separate cervices & uterine cornua that are widely divergent. Spontaneous abortion rate 30%. Often the horns are more widely divergent c.f. septate uteri.
d. Septate uterus T there is significant overlap with the appearances of bicornuate uterus. Associated with recurrent spontaneous abortions (32-94%, 65% pooled spontaneous abortion rate).
e. Unicornuate uterus F
- 22 female approximately 8-10 weeks pregnant by dates presents with pelvic pain. Ultrasound confirms a live intrauterine gestation of 10 weeks gestation. A left adnexal 6 cm cyst is shown with peripheral vascularity and heterogenous internal echoes. Which is the MOST likely cause?
a. Corpus luteum
b. Corpus luteum with haemorrhage
c. Torted ovary
d. Heterotopic pregnancy
e. Dermoid cyst
b. Corpus luteum with haemorrhage T4.
22 female approximately 8-10 weeks pregnant by dates presents with pelvic pain. Ultrasound confirms a live intrauterine gestation of 10 weeks gestation. A left adnexal 6 cm cyst is shown with peripheral vascularity and heterogenous internal echoes. Which is the MOST likely cause?
a. Corpus luteum F
b. Corpus luteum with haemorrhage T
c. Torted ovary F increased risk during pregnancy, however atypical
d. Heterotopic pregnancy F possible , but risk 1:7,000 with spontaneous pregnancies, being much higher in IVF (affects 1-2% of IVF pregnancies)
e. Dermoid cyst F? possible. Look for echogenic Rokitansky nodule etc.US Req p309 – the most common adnexal mass, the CL cyst, is usually < 3cm (but can rarely reach 8cm), peak size at 7 weeks & resolves sonographically by mid 2nd trimester.US Req p366 – the appearance of a CL cyst, if complex & esp, with a thick rim, can overlap with adnexal ectopic pregnancy – key feature is can it be separated from the ovary (if not CL cyst, if can separate ectopic likely)
- 25 year old female has a second trimester ultrasound which demonstrates an echogenic mass within thorax on the left with a small systemic artery. Associated hydrops. (VIC – stomach normal place)
a. CCAM
b. Extralobar pulmonary sequestration
c. Congenital diaphragmatic hernia
d. Neuroblastoma
e. Rhabdomyosarcoma
b. Extralobar pulmonary sequestration T hydrops may occur from cardiovascular compression
- 25 year old female has a second trimester ultrasound which demonstrates an echogenic mass within thorax on the left with a small systemic artery. Associated hydrops. (VIC – stomach normal place)
a. CCAM F no systemic supply; hydrops more common
b. Extralobar pulmonary sequestration T hydrops may occur from cardiovascular compression
c. Congenital diaphragmatic hernia F Hydrops uncommon unless associated malformations present
d. Neuroblastoma
e. Rhabdomyosarcoma
- Morphology scan at 20 weeks. Placenta is anterior and measures 1 cm from the cervix. The cervix is nodular and bulky. Which is the MOST likely explanation?
a. Braxton Hicks contraction.
b. Full bladder.
c. Low lying placenta.
d. Placenta praevia.
e. Lower uterine segment leiomyoma.
a. Braxton Hicks contraction. T can appear mass-like & echogenic
- Morphology scan at 20 weeks. Placenta is anterior and measures 1 cm from the cervix. The cervix is nodular and bulky. Which is the MOST likely explanation?
a. Braxton Hicks contraction. T can appear mass-like & echogenic
b. Full bladder. F check again with bladder empty, but wouldn’t account for nodularity
c. Low lying placenta. T < 2cm from internal os
d. Placenta praevia. F not covering os
e. Lower uterine segment leiomyoma. T fibroids can affect cervix
- You go on a relief trip to the Phillipines after a massive earthquake. A 19 year old girl presents to the clinic with pelvic pain. She is afebrile. Ultrasound reveals bilateral thick walled cystic adnexal masses. Which is MOST likely?
a. Bilateral ovarian cysts.
b. Endometriosis.
c. Tuberculous salpingitis.
d. Polycystic ovarian syndrome.
e. Hydrosalpinx.
c. Tuberculous salpingitis. T Bilateral complex cystic and solid adnexal masses ± calcification (TB TOAs)8.
You go on a relief trip to the Phillipines after a massive earthquake. A 19 year old girl presents to the clinic with pelvic pain. She is afebrile. Ultrasound reveals bilateral thick walled cystic adnexal masses. Which is MOST likely?
a. Bilateral ovarian cysts. F
b. Endometriosis. F usually diffuse low-level internal echoes
c. Tuberculous salpingitis. T Bilateral complex cystic and solid adnexal masses ± calcification (TB TOAs)
d. Polycystic ovarian syndrome. F
e. Hydrosalpinx. ?F usually tortuous/serpiginous, “beads on a string”
- During a routine 20 week morphology scan, a small mass is identified at the junction of the umbilical cord and anterior abdominal wall. The cord insert in the centre of the mass. Which is MOST likely?
a. AVM of the cord
b. Gastroschisis
c. Normal physiologic herniation
d. Omphalocoele
e. Pseudo-omphalocoele
d. Omphalocoele T cord inserts onto mass
- During a rountine 20 week morphology scan, a small mass is identified at the junction of the umbilical cord and anterior abdominal wall. The cord insert in the centre of the mass. Which is MOST likely?
a. AVM of the cord F can’t find in Req, Callen or StatDx!
b. Gastroschisis F beside cord insertion
c. Normal physiologic herniation F must be < 12 weeks & < 7mm diameter
d. Omphalocoele T cord inserts onto mass
e. Pseudo-omphalocoele F = Deformation of the fetal abdomen by transducer pressure coupled with an oblique scan orientation
- 35 year old woman. Combined risk screening plus NT of 2.5 says risk 1:280 with background risk of 1:280. What do you do?
a. Talk to referrer
b. Report & get clerical staff to make sure referrer gets it
c. Borderline normal risk in report
d. Note normal in report
a. Talk to referrer TFMF UK say “screen-positive group cut-off of 1 in 300”
– this cut-off is also used in Queensland.
This will detect 80% of T21 fetuses & have a false positive rate of 5%. The estimated risk for trisomy 21 was 1 in 300 or more in 8% of the normal pregnancies, in 82% of those with trisomy 21 and in 78% with other chromosomal defects. For a screen-positive rate of 5%, the detection rate was 77% (95% confidence interval 72–82%).
⇨ Patient high-risk, need to discuss with patient & be offered invasive testing
.“… those preparing the report have obligations to report unusual, urgent or significant unexpected findings to the referrer in a timely manner. The timeliness is determined by the severity of the finding in the clinical context.” (RANZCR Standards of Practice for Diagnostic and Interventional Radiology Version 9.1, (2009) 33)
- 20 week US shows hydrops. Rounded homogenously echogenic mass in left thorax. Stomach bubble not identified. Most likely:
i) CCAM
ii) CDH
iii) Myocardial issue
CDH or CCAMI would prefer CDH1)
20 week US shows hydrops. Rounded homogenously echogenic mass in left thorax. Stomach bubble not identified. Most likely:
i) CCAM T microcystic form uniformly echogenic, well defined, hydrops occurs not uncommonly. If large a potential cause of absent stomach bubble by compression of oesophagus.
ii) CDH ?T usually not uniformly echogenic (unless maybe contains only liver); absence of stomach bubble raises suspicion though; hydrops uncommon unless associated malformations present (Statdx)
iii) Myocardial issue F
Causes of absent stomach bubble ⇒ always do follow-up US
• Physiologic (< 30min)
• Oligohydramnios
• Swallowing abnormality
o CNS defect
o Neck/chest mass
• Esophageal atresia
• Congenital diaphragmatic hernia (CDH)
• Situs abnormality
Causes of hydrops fetalis
• Immune hydrops (Rh-mediated)
• Non-immune hydrops:
o Cardiac (25-30%)
• Structural CHD
• Arrhythmia
• High-output failure (teratoma, AVM, anaemia)
o Chromosomal (15%)
• Trisomy 21/18/13
• Turner syndrome
o Infection (parvovirus B19, TORCH)
o Chest anomalies (CCAM → mass effect)
o Urinary tract obstruction (uncommon cause)
o ↓ oncotic pressure (nephrotic syndrome, hepatitis)
o TTTS
o α-thalassaemia (homozygous form)
- Echogenic bowel on 20 week scan. Most correct:
i) Unlikely T21
ii) As isolated finding suggests aneuploidy
iii) Likely T13/18
iv) CF
iv) CF T
2) Echogenic bowel on 20 week scan. Most correct:
i) Unlikely T21 F isolated echogenic bowel = 7x’s increased risk of T21 (FMF)
ii) As isolated finding suggests aneuploidy F soft marker – seen in 0.5-1% of normal US; more likely T21 if other markers seen
iii) Likely T13/18 F
iv) CF T
Echogenic bowel causes
• Normal variant during 2nd trimester (transient inspissation; 0.5-1% of normal fetuses)
• Genetic/syndromic causes
o Cystic fibrosis
o Down syndrome (rare but has been reported)
• Systemic causes
o IUGR
o CMV infection
o Fetal hypoxia
o Hydrops
• Local factors
o Intra-amniotic haemorrhage (ingested blood)
o Early ascites
o Meconium peritonitis
- 38yo female 11/40. NT scan shows 2.4mm nuchal thickness. With BHCG and PAPP-A gives risk of Aneuploidy of 1/281. Age related risk assessed at 1/281 as well. Advice for patient:
i) NT risk same as age related risk – no further tests
ii) High risk – advise CVS/amnio
iii) Low risk - advise CVS/amnio
iv) High risk - terminate
ii) High risk – advise CVS/amnio Patient high-risk, need to discuss with patient/O&G & be offered invasive testing
FMF UK say “screen-positive group cut-off of 1 in 300” – this cut-off is also used in Queensland. This will detect 80% of T21 fetuses & have a false positive rate of 5%. The estimated risk for trisomy 21 was 1 in 300 or more in 8% of the normal pregnancies, in 82% of those with trisomy 21 and in 78% with other chromosomal defects. For a screen-positive rate of 5%, the detection rate was 77% (95% confidence interval 72–82%).
- 25 yo obese female. No luck getting pregnant over 15months (probably can’t get a root). Findings on ultrasound (? Most likely or least likely ?):
a. Both ovaries demonstrate 20 follicles all less than 5mm
b. Collapsed ovarian cyst and fluid in POD
c. Simple (anechoic) 4cm cyst left ovary
d. Adnexal cyst
e. Cyst with low-level echoes measuring 4cm in diameter
f. POD cystic lesion
a. Both ovaries demonstrate 20 follicles all less than 5mm PCOS = 2003
*AJL - I have updated the question to reflect the more up to date criteria as outlined below (from radiopaedia)
The updated diagnostic criteria are based on a 2018 international consensus guideline: In patients >8 years post menarche, and using a high-frequency endovaginal probe:
- Follicle number per ovary (FNPO) ≥ 20,
and/or
- Ovarian volume ≥10 mL, ensuring no corpora lutea, cysts or dominant follicles are present
4) 25 yo obese female. No luck getting pregnant over 15months (Most likely) findings on ultrasound:
a. Both ovaries demonstrate 20 follicles all less than 5mm PCOS
(See above). (Previous answer discussed Rotterdam criteria which has been superseeded)
b. Collapsed ovarian cyst and fluid in POD F this would suggest ovulation
c. Simple (anechoic) 4cm cyst left ovary F would suggest persisting dominant follicle or benign neoplasm
d. Adnexal cyst ?T possible
e. Cyst with low-level echoes measuring 4cm in diameter T endometrioma possible, and could explain infertility
f. POD cystic lesion ?T possible
- Molar pregnancy (which is true?)
a. Never see fetal part in complete mole
b. Partial mole diploid
c. Association with bilateral theca lutein cysts
d. 30% invasive or malignant
e. Partial moles are at increased risk of malignant transformation.
c. Association with bilateral theca lutein cysts T – more common in complete mole – 25-60%
5) Molar pregnancy
a. Never see fetal part in complete mole F True if singleton pregnancy complete mole no fetal tissue present; False if coexist with a normal pregnancy (rare)
*LW think is also true, and would ignore the above dual pregnancy rarity.
b. Partial mole diploid F triploid (see below)
c. Association with bilateral theca lutein cysts T – more common in complete mole – 25-60%
d. 30% invasive or malignant F
**SCS: Robbins. Big 9th Ed. “Continuous elevation of HCG may be indicative of persistent or invasive mole which develops in 15% of molar pregnancies, and is seen more frequently in complete moles. In addition 2.5% of complete moles give rise to gestational choriocarcinoma”.
e. Partial moles are at increased risk of malignant transformation. F (complete 20% risk of transformation into invasive mole or choriocarcinoma; although partial moles have an increased risk of persistent molar disease, they are not considered to have an increased risk for choriocarcinoma.)
- Pt presents for nuchal translucency scan. Bowel between abdo wall and cord insertion.
a. Normal bowel herniation
b. Omphalocele
c. Gastroschisis
d. Pseudo-omphalocele
b. Omphalocele T if scanned ≥ 12 weeks
6) Pt presents for nuchal translucency scan. Bowel between abdo wall and cord insertion.
a. Normal bowel herniation T if scanned < 12 weeks (11 weeks 5 days by FMF)
b. Omphalocele T if scanned ≥ 12 weeks
c. Gastroschisis F
d. Pseudo-omphalocele F technical due to probe or other pressure creating impression of omphalocele
Bowerman and associates – normal must be <7mm at any age. Any cord mass when CRL >44mm (11.1 weeks) is presumed abnormalNuchal scan performed 11+1 and 13+6.Thus the answer here is likely omphalocele.
- 20wk gestation. Placenta 1cm from internal os. Cervix 4cm long.
a) Low lying placenta
b) Extremely full bladder
c) Placenta praevia
d) Circumvellate placenta
a) Low lying placenta T
7) 20wk gestation. Placenta 1cm from internal os. Cervix 4cm long.
a) Low lying placenta T
b) Extremely full bladder ?T;
*LW: felt less likely as although can cause “abnormal placental location”, it can also cause apparent lengthening of the cervix, and is listed at 4cm - normal, so would assume this is why cervical length listed in question stem, to help exclude it from more correct option of A).
c) Placenta praevia F does not cover any part of os
d) Circumvellate placenta F placenta margin elevated along with membranes
Abnormal placental location
• Technical/mimic
o Full maternal bladder
o Uterine contractions (transient)
o Placental abruption
• Placenta previa spectrum
o Low-lying placenta: ≤ 2cm from internal os, but does not cover or reach it
o Marginal placenta: covers part of cervix but not internal os
o Partial previa: partially covers internal os
o Complete previa: total coverage of internal os (almost never resolves)
- Pregnant woman with painless bleeding
a) Placental abruption
b) Placenta praevia
c) Placenta percreta
d) Placenta accrete
b) Placenta praevia T most commonly presents as painless bleeding in T
38) Pregnant woman with painless bleeding
a) Placental abruption F usually painful – StatDx says 80% present with vaginal bleeding +/- pain, while 20% present with pain & no bleeding
b) Placenta praevia T most commonly presents as painless bleeding in T3
c) Placenta percreta F classic presentation is uncontrollable hemorrhage in 3rd stage of labor
d) Placenta accrete F classic presentation is uncontrollable hemorrhage in 3rd stage of labor
- Obstetric measurements
a) 1st trimester CRL more accurate dating than biometry in T2
a) 1st trimester CRL more accurate dating than biometry in T2 T Although MFMs at Mater use the nuchal scan for dating (more accurate measurements, standardized).
- Woman undergoing infertility work up. US showed normal size uterus. HSG shows banana shaped uterus with a single fallopian tube.
a) unicornuate uterus
b) septate uterus
c) bicornuate uterus
d) didelphyis
a) unicornuate uterus ?T At USS, often difficult to detect, esp. if not suspected. Findings are a small, elliptical uterus deviated to one side at US; HSG findings fit though. High rate of obstetric complications.
11) Woman undergoing infertility work up. US showed normal size uterus. HSG shows banana shaped uterus with a single fallopian tube.
a) unicornuate uterus ?T At USS, often difficult to detect, esp. if not suspected. Findings are a small, elliptical uterus deviated to one side at US; HSG findings fit though. High rate of obstetric complications.
b) septate uterus F both cavities should fill at HSG, unless complete septum + vaginal septum
c) bicornuate uterus ? T – can be bicornuate bicollis, having cannulated single cervix; at US widely divergent, symmetric echogenic endometrial complexes
d) didelphys ? T – two distinct cervices, may cannulate only single cervix; however at US would see divergent uterine horns
- What favor mucinous rather than serous cystadenocarcinoma of ovary
a) Another cyst on the contralateral side
b) Stipple calcification
c) Known BRCA1
d) Multiple cysts >20
e) Papillary projections and solid component
d) Multiple cysts >20 T mucinous tumours typically larger with more cysts containing viscous mucin12)
What favor mucinous rather than serous cystadenocarcinoma of ovary
a) Another cyst on the contralateral side F bilaterality uncommon for mucinous, 20-70% (frequent) for serous (two-thirds of serous cystadenocarcinomas are bilateral; 5% of mucinous cystadenocarcinoma bilateral)
b) Stipple calcification F calcification characteristic of serous tumour, not mucinous tumour
c) Known BRCA1 F serous more common
d) Multiple cysts >20 T mucinous tumours typically larger with more cysts containing viscous mucin
e) Papillary projections and solid component F papillary projections more common with serous tumours (StatDx)
ADB
serous
-smaller
-thin walled usually unilocular
-papillary projections
-psammomatous calc
-frequent bilateral
-more common to make carcinomatosis
-BRCA1
Mucinous
-larger
-multilocular
- less likely to be bilateral
-linear calc rare
-pseudomyxoma peritonei
- Which of the following is NOT associated with fetal ascites?
a. Diaphragmatic hernia
b. Parvovirus infection
c. Urinary tract obstruction
d. Multicystic dysplastic kidney
e. Rhesus incompatibility
d. Multicystic dysplastic kidney
- Which of the following is NOT associated with fetal ascites?
a. Diaphragmatic hernia T Hydrops uncommon unless associated malformations present
b. Parvovirus infection T the most common infectious cause of hydrops
c. Urinary tract obstruction T fetal ascites secondary to obstruction
d. Multicystic dysplastic kidney F
e. Rhesus incompatibility T immune hydropsHydrops = excess of total body fluid (2 or more abnormal fetal fluid collections: ascites; pleural effusion; pericardial effusion; skin oedema; polyhydramnios). Immune vs non-immune. 20% cases idiopathic. 40% also have detectable structural anomaly. Prognosis is poor if not treated. 75% survival for immune hydrops if treated with blood transfusion. Near 100% fatal if hydrops + fetal anomaly (excluding tachyarrhythmia).
- Which of the following WILL NOT reduce the fetal radiation dose of a pregnant woman who is undergoing a CTPA for suspected pulmonary embolism?
a. Decreased the mAV (?mAs)
b. Not doing the lateral scout
c. Increase scan pitch
d. Lead shielding to protect the abdomen
e. Stop scan field higher to avoid the upper abdomen
*AJL - I would favour lead shielding to be the most useless of all the methods described below and therefore the answer to this question.
*LW - agree as we no longer do this option here at CDHB given the near minimal effect of prtection / dose reduction offered.
All methods will reduce fetal dose, probably B would reduce fetal dose the least.
b. Not doing the lateral scout T utilize a PA projection where possible, and avoid directly scanning fetus
- Which of the following WILL NOT reduce the fetal radiation dose of a pregnant woman who is undergoing a CTPA for suspected pulmonary embolism?
a. Decreased the mAs T++ reduced quantity of x-rays (also can ↓ kVp)
b. Not doing the lateral scout T utilize a PA projection where possible, and avoid directly scanning fetus
c. Increase scan pitch T increasing pitch reduces scan time & patient dose
d. Lead shielding to protect the abdomen T+ can also use oral barium
e. Stop scan field higher to avoid the upper abdomen T++ shorter scan length, stop before fetus is irradiated
All methods will reduce fetal dose, probably B would reduce fetal dose the least.
- 50yo woman presents to GP, unwell for several months. Reports a change in bowel and bladder habit, Clinical examination revealed abdominal distension. An US demonstrated bilateral complex pelvic masses and ascites. Which of the following is MOST LIKELY Dx?
a. Serous cystadenocarcinoma
b. Mucinous cystadenocarcinoma
c. Germ cell tumour
d. Endometrioma
e. Ovarian fibroma
a. Serous cystadenocarcinoma
