Repro

Question 1

The uterus

neonate

Answer 1

Uterus is larger than you would think for a baby (maternal / placental hormones
are still working). If you look close, the shape is a little weird with the cervix often larger than the fundus.

Question 2

The uterus

prepuberty

Answer 2

The shape of the uterus changes - becoming more tube-like, with the cervix and uterus the same size.

Question 3

The uterus

puberty

Answer 3

The shape o f the uterus changes again, now looking more like an adult (pear-like)
- with the fundus larger than the cervix. In puberty, the uterus starts to have a visible endometrium - with phases that vary during the cycle.

Question 4

The Ovaries - Changes During Life

Answer 4

Just like with the uterus, infants tend to have larger ovaries (volume around 1 cc), which then
decrease and remain around or less than 1 cc until about age 6. The ovaries then gradually
increase to normal adult size as puberty approaches and occurs.

Question 5

Turner Syndrome

Answer 5

The XO kids. Besides often having aortic coarctations, and

horseshoe kidneys they will have a pre-puberty uterus and streaky ovaries.

Question 6

Embryology

Answer 6

The quick and dirty of it is that the mullerian ducts make the uterus and upper 2/3 of the vagina.

The urogenital sinus grows up to meet the mullerian ducts and makes the bottom 1/3 o f the vagina.

Wolffian ducts are the boy parts, and
should regress completely in girls.

Question 7

Mullerian Ducts

Answer 7

Uterus
Fallopian Tubes
Upper 2/3 o f the Vagina

Question 8

Wolffian ducts

Answer 8

Vas Deferens
Seminal Vesicles
Epididymis

Question 9

Urogenital Sinus

Answer 9

Prostate

Lower 1/3 o f the Vagina

Question 10

Embryology

step 1

Answer 10

Imagine that the stuff that makes the kidneys and the uterus is all the sam soup

you have two bowls of this stuff - half on the left, and half on the right

Question 11

Embryology

step 2

Answer 11

as development occurs, this soup gets poured down the back of the belly

the upper part making the kiendy and the bottom part making hte uterus

Question 12

Embryology

step 3

Answer 12

now the bottom two puddles of spilled/poured soup begin to fuse forming one puddle (uterus)

Question 13

Embryology

step 4

Answer 13

but because they are just mashed together they dont have a central cavity necessary to carry a baby

so there is a clean - up operation (cleavage), and this occurs from bottom to top - like zipping up a jacket.

Question 14

Embryology ways to screw up

1

Answer 14

You can only have soup on one side. This is a “failure to form” As you can imagine,
if you don’t have the soup on one side you don’t have a kidney on that side. You also
don’t have half o f your uterus. This is why a unilateral absent kidney is associated with
Unicomuate Uterus (+/- rudimentary horn).

Question 15

Embryology ways to screw up

2

Answer 15

As the soup gets poured down it can fail to fuse completely. This can be on the
spectrum o f mostly not fused - basically separate (Uterus Didelphys) or mostly fused
except the top part - so it looks like a heart (Bicomuate). Because the Bicomuate and
Didelphys are related pathologies - they both get vaginal septa (Didelphys more often
than Bicomuate - easily remembered because it’s a more severe fusion anomaly).

Question 16

Embryology ways to screw up

3

Answer 16

The clean up operation can be done sloppy (“failure to cleave”). The classic example
of this is a “Septate uterus,” where a septum remains between the two uterine cavities.

Question 17

Mullerian Agenesis

Answer 17

(Mayer-Rokitansky-Kuster-Hauser
syndrome): Has three features: (1) vaginal atresia, (2) absent or
rudimentary uterus (unicomuate or bicomuate) and (3) normal
ovaries. The key piece of trivia is that the kidneys have issues
(agenesis, ectopia) in about half the cases.

Question 18

Unicornuate Uterus

4 variants

Answer 18

unicornuate +Communicating Cavitary Rudimentary Horn

U nicornuate + Non Communicating
Cavitary Horn

Unicornuate + Noncavitary Rudimentary Horn

Isolated unicornuate. Most Common Subtype (35%)

Question 19

Unicornuate Uterus

overview

Answer 19

If you see a unicomuate uterus the classic teaching is to look for a rudimentary horn. The reason is the
rudimentary horns can have endometrium - and if present can cause lots of phantom female belly pain
problems (dysmenorrhea, hematometra, hematosalpinx, etc…, etc…, so on a so forth). Endometrial tissue
in a rudimentary hom (communicating or not) - increases the risk of miscarriage. An additional problem
could be a pregnancy in the rudimentary hom - in both the communicating and noncommunicating typesalthough
especially bad in the non-communicating sub-type because it nearly always results in
rudimentary hom rupture (life-threatening bleeding).
Renal agenesis contralateral to the main uterine hom (ipsilateral to the rudimentary horn) is the most
common abnonnality.

Question 20

Uterus Didelphys

Answer 20

This is a complete uterine duplication (two cervices, two uteri, and two upper 1/3 vagina).

A vaginal septum is present 75% of the time. If the patient does not have vaginal obstruction this is usually asymptomatic.

Question 21

Bicornuate uterus

Answer 21

This comes in two flavors (one cervix “unicollis”, or two cervix “bicollis”). There will be separation of the uterus by a deep myometrial cleft - makes it look “heart shaped”. Vaginal septum is seen around 25% of the time (less than didelphys). Although they can have an increased risk of fetal loss, it’s much less of an issue compared to Septate.
Fertility isn’t as much of a “size thing” as it is a blood supply thing. Remember you can have 8 babies in your belly at once and have them live… live long enough to take part in your reality show.

Question 22

T-shaped uterus

Answer 22

This is the DES related anomaly. It is historical trivia, and therefore extremely high yield for the “exam of the future.” DES was a synthetic estrogen given to prevent miscarriage in the 1940s. The daughters of patients who took this
dmg ended up with vaginal clear cell carcinoma, and uterine anomalies
classically “T-Shaped.”

Question 23

Septate uterus

Answer 23

This one has two endometrial canals separated
by a fibrous (or muscular) septum. Fibrous vs Muscular can
be determined with MRI and this distinction changes surgical
management (different approaches). There is an increased risk
o f infertility and recurrent spontaneous abortion. The septum
has a shitty blood supply, and if there is implantation on it - it
will fail early. They can resect the septum - which improves
outcomes.

This is the most common Mullerian duct anomaly associated
with miscarriage. This is improved with resection o f the
septum.

Question 24

A rc u a te U te ru s

Answer 24

Mild smooth concavity o f the uterine
fundus (instead o f normal straight or convex) This is not really
a malformation, but more o f a normal variant. It is NOT
associated with infertility or obstetric complications.

Question 25

Bicornuate quick

Answer 25

• “H e a rt S h a p e d ’’ - Fundal co n to u r is less than 5 mm above the tuba l ostia • No s ig n ifica n t infertility issues • Resection of the “s e p tum ” results in poo r o u tcom e s

Question 26

Septate quick

Answer 26

* Fundal co n to u r is Normal; more than 5 mm abo ve the tubal ostia * L e g it infertility issues - impla ntation fails on the se ptum (it’s a b lo od s u p p ly th in g ) * Resection of the septum can help

Question 27

Hysterosalpingogram (HSG) overview

Answer 27

If you haven’t seen (or done one) before - this is a procedure that involves cannulation of the cervix and injecting contrast under fluoro to evaluate the cavity of the uterus.

Question 28

Hysterosalpingogram (HSG) trivia

Answer 28

' HSGs are performed on days 7-10 of menstrual cycle, (after menstrual bleeding complete - i.e. “off the rag”) “ Contraindications: infection (PID), active bleeding (“rag week’’), pregnancy, and contrast allergy. ■ Bicornuate vs Septate is tough on HSG - you need MRI or 3D Ultrasound to evaluate the outer fundal contour.

Question 29

Cycle days

Answer 29

0-7 “Rag Week,” 7-14 Proliferative, 14-28 Secretory | *Day 14 Ovulation

Question 30

Salpingitis Isthmica Nodosa (SIN)

Answer 30

This is a nodular scarring o f the fallopian tubes that produces an Aunt Minnie Appearance. As trivia, it usually involves the proximal 2/3 o f the tube. This is of unknown etiology, but likely post inflammatory / infectious (i.e. being a woman of questionable moral standard / “free spirit”). It’s strongly associated with infertility and ectopic pregnancy and that is likely the question.

Question 31

Salpingitis Isthmica Nodosa (SIN) aunt minnie

Answer 31

Nodular diverticula of the fallopian tubes No dominant channel

Question 32

Uterine AVM

Answer 32

These can be congenital or acquired, with acquired types being way more common. They can be serious business and you can totally bleed to death from them. The typical ways to acquire them include: previous dilation and curettage, therapeutic abortion, caesarean section, or just multiple pregnancies. Doppler ultrasound is going to show: serpiginous and/or tubular anechoic structures within the myometrium with high velocity color Doppler flow.

Question 33

Intrauterine Adhesions (Ashermans) -

Answer 33

This is scarring in the uterus, that occurs secondary to injury: prior dilation and curettage, surgery, pregnancy, or infection (classic GU TB). This is typically shown on HSG, with either (a) non filling o f the uterus, or (b) multiple irregular linear filling defects (lacunar pattern), with inability to appropriately distend the endometrial canal. MRI would show a bunch of T2 dark bands. Clinically, this results in infertility.

Question 34

Endometritis

Answer 34

This is in the spectrum o f P1D. You often see it 2-5 days after delivery, especially in women with prolonged labor or premature rupture. You are going to have fluid and a thickened endometrial cavity. You can have gas in the cavity (not specific in a postpartum women). It can progress to pyometrium, which is when you have expansion with pus.

Question 35

Pelvic Floor overview

Answer 35

Getting old and having a bunch o f kids can sometimes make stuff hang out o f your vagina and cause you to pee your pants (when you don’t actually want to pee your pants). It is important to make that distinction between “prolapse” (stuff hanging out o f your vagina), and “relaxation” (peeing and/or pooping your pants when you sneeze). Both are b a d ... although one is worse — I ’ll let you decide which one that is.

Question 36

Pelvic Floor anatomy

Answer 36

This anatomy is complicated - buncha facial bands “ligaments” muscles etc... created a “sling” which keeps all this stuff from falling out the bottom. The best way to think about the pelvic sling o f a female is to group it into 3 functional compartments: Anterior compartment (bladder and urethra), Middle compartment (vagina, cervix, uterus, and adnexa), and Posterior compartment (anus and rectum). This anatomy is incredibly complex - but a few o f these vocab terms could make easy questions:

Question 37

Pelvic Floor endopelvic fascia

Answer 37

Buncha ligaments / fascia (pubocervical fascia, rectovaginal fascia, cardinal ligaments, etc..) most o f which have vaginal or cervix in the name. Main support for the anterior & middle compartments.

Question 38

Pelvic Floor levator ani

Answer 38

This is the main muscular component o f the pelvic floor composed o f the puborectalis, pubococcygeus, and iliococcygeus. This muscle groups constant contraction maintains the pelvic floor height.

Question 39

Pelvic Floor Relaxation

Answer 39

``` Pelvic floor relaxation has two components (pelvic floor descent and widening) that can be graded during maximal strain on sag MR1: • Hiatal enlargement (H line) — less than 6cm - measurement o f widening • Pelvic floor descent (M line) - less than 2cm - measurement o f descent Wider H or longer M = Worse. Organs hanging out = worse. ```

Question 40

Pelvic Floor MRI protocol

Answer 40

``` Steady State - T2 - 3 planes Dynamic State - Rapid T2 with Fat Sat, Sag Plane Only —performed during Valsalva, Kegel, and/or taking a shit (seriously) ```

Question 41

Pelvic Floor PCL

Answer 41

(pubococcygeal line) = drawn from inferior margin o f the symphysis pubis to the junction between the first and second coccygeal elements.

Question 42

Pelvic Floor H line

Answer 42

drawn from the inferior margin o f the symphysis pubis to the posterior aspect o f the puborectalis muscle sling.

Question 43

Pelvic Floor m line

Answer 43

shortest distance between the posterior aspect o f the puborectalis muscle sling and the PCL

Question 44

Pelvic Floor Axial image through the Ischioanal space

Answer 44

(Triangular o f fat lateral and caudally to the levator ani - could show a loss o f the normal “H shaped” vagina or direct defects / asymmetric thinning in the muscular sling. Having said that - for the purpose o f multiple choice - this anatomy is usually demonstrating an anal fistula in the setting o f Crohns

Question 45

Pelvic floor urogenital diaphragm

Answer 45

This is the most caudal or superficial musculofascial structure. It does not have a marketable sex toy name (unlike Levator Ani). This thing usually finds it way into multiple choice exams as the anatomic landmark used in the classification o f urethral injury - as discussed in the GU chapter.

Question 46

Cystocele overview

Answer 46

Bladder Descent > 1 cm | below the pubococcygeal line.

Question 47

Cystocele urethral hypermobility

Answer 47

``` what you say if the urethra is rotated horizontally. This changes the treatment f rom , retropubic urethropexy (for normal stress incontinence) to a pubovaginal sling. ```

Question 48

Cystocele risk factors

Answer 48

Squeezing a bunch of kids out o f your vagina - can rupture o f the pubocervical fascia

Question 49

Cystocele risk factors

Answer 49

Squeezing a bunch of kids out o f your vagina - can rupture o f the pubocervical fascia

Question 50

Uterine prolapse overview

Answer 50

Decent o f the cervix or posterior vaginal fornix < 1 cm above the pubococcygeal line. A big turd can prop up the uterus - so it is best to measure them with an empty rectum (post defecation phase).

Question 51

Uterine prolapse risk factor

Answer 51

hysterectomy

Question 52

Uterine prolapse axial imag

Answer 52

Axial images could show the vagina lose its normal "H" shape - hanging low like the sleeve o f a w izard (or the tongue o f a tired dog).

Question 53

Rectocele overview

Answer 53

Abnormal rectal bulging (typically anteriorly). Due to weakening o f the rectovaginal fascia. The describe them by how far they bulge relative to the anal canal.

Question 54

Rectocele risk factors

Answer 54

Vaginal surgery. Hysterectomy, Chronic Constipation, Being Old as Dirt.

Question 55

Fibroids (Uterine Leiomyoma) hyaline (classic)

Answer 55

Most common type T1 dark T2 dark Tl+C homogenous

Question 56

Fibroids (Uterine Leiomyoma) hypercellular

Answer 56

Densely packed smooth muscle (without much connective tissue). Respond well to embolization T1 dark T2 bright Tl+C homogenous

Question 57

Fibroids (Uterine Leiomyoma) lipoleiomyoma

Answer 57

Rare fat containing subtype (maybe the result of degeneration!. This thing will be hvperechoic on ultrasound. Will look like a fattv uterine mass on CT. Will drop signal on fat saturation sequences. T1 Bright (dark if fat sat) T2 bright Tl+C maybe rim enhancement

Question 58

Fibroids (Uterine Leiomyoma) degeneration

Answer 58

4 types of degeneration are generally described. What they have in common is a lack of / paucity of enhancement (fibroids normally enhance avidly). The process of degeneration (basically a fibroid stroke) can cause severe pain as well as fever and/or leukocytosis.

Question 59

Fibroid Degeneration | Hyaline Classic Degeneration

Answer 59

``` Most common type. The fibroid outgrows its blood supply, and you end up getting the accumulation o f proteinaceous tissue. ``` T1 variable (usually dark) T2 heterogenous ( usually dark) Tl+C none

Question 60

Fibroid Degeneration | Red Carneous

Answer 60

``` This one occurs during pregnancy - caused by venous thrombosis. The classic imaging finding is a peripheral rim o fT l high signal. ``` T1 peripheral rim ov bright T1 T2 variable Tl+C none

Question 61

Fibroid Degeneration Myxoid Degeneration

Answer 61

uncommon T1 dark T2 bright Tl+C minimal

Question 62

Fibroid Degeneration Cystic Degeneration

Answer 62

uncommon T1 dark T2 bright Tl+C none

Question 63

Uterine Leiomyosarcoma

Answer 63

The risk o f malignant transformation to a leiomyosarcoma is super low (0.1%). These look like a fibroid, but rapidly enlarge. Areas of necrosis are often seen.

Question 64

Adenomyosis overview

Answer 64

This is endometrial tissue that has migrated into the myometrium. You see it most commonly in multiparous women of reproductive age, especially if they’ve had a history of uterine procedures (Caesarian section, dilatation and curettage).

Question 65

Adenomyosis types

Answer 65

Although there are several types, adenomyosis is usually generalized, favoring large portions of the uterus (especially the posterior wall), but sparing the cervix. It classically causes marked enlargement o f the uterus, with preservation o f the overall contour.

Question 66

Adenomyosis imaging

Answer 66

They can show it with Ultrasound or MRI. Ultrasound is less specific with findings including a heterogeneous uterus (hyperechoic adenomyosis, with hypoechoic muscular hypertrophy), or just enlargement of the posterior wall. MRI is the way better test with the most classic feature being thickening of the junctional zone of the uterus to more than 12 mm (normal is < 5 mm). The thickening can be either focal or diffuse. Additionally, the findings o f small high T2 signal regions corresponding to regions o f cystic change is a classic finding.

Question 67

Adenomyosis of the Uterus

Answer 67

T2 Bright Cystic Foci and thick junctional zone

Question 68

Adenomyosis of the Uterus

Answer 68

T2 Bright Cystic Foci and thick junctional zone

Question 69

Thick Endometrium overview

Answer 69

Remember the stripe is measured without including any fluid in the canal. Focal or generalized thickening in post menopausal women greater than 5mm should get sampled. Premenopausal endometriums can get very thick - up to 20mm can be normal.

Question 70

Thick Endometrium trivia

Answer 70

• Estrogen secreting tumors - Granulosa Cell tumors o f the ovary will thicken the endometrium. • Hereditary Non-Polyposis Colon Cancer (HNPCC) - have a 30-50x increased risk of endometrial cancer

Question 71

Postmenopausal Bleeding: | Is it from atrophy or cancer?

Answer 71

•Endometrium less than 5 mm = Probably Atrophy •Endometrium > 4-5 mm = Maybe cancer and gets a biopsy

Question 72

Tamoxifen Changes

Answer 72

This is a SERM (acts like estrogen in the pelvis, blocks the estrogen effects on the breast). It’s used for breast cancer, but increases the risk of endometrial cancer. It will cause subendometrial cysts, and the development of endometrial polyps (30%). Normally, post menopausal endometrial tissue shouldn’t be thicker than 4mm, but on Tamoxifen the endometrium is often thick (some papers say the mean is 12 mm at 5 years). When do you biopsy? Clear guidelines on this are illusive (if forced to guess I’d pick 8 or 10 mm). The only thing that seems consistent is that routine screening is NOT advised. If you are wondering if a polyp is hiding you can get a sonohysterogram (ultrasound after instillation o f saline).

Question 73

Endometrial Fluid

Answer 73

In premenopausal women this is a common finding. In postmenopausal women it means either cervical stenosis or an obstructing mass (usually cervical stenosis).

Question 74

Endometrial Fluid

Answer 74

In premenopausal women this is a common finding. In postmenopausal women it means either cervical stenosis or an obstructing mass (usually cervical stenosis).

Question 75

Endometrial Cancer overview

Answer 75

Basically all uterine cancers are adenocarcinoma (90%+). The only possible exception for the purpose o f multiple choice would be the rare “leiomyosarcoma” - which looks like a giant fucking fibroid.

Question 76

Endometrial Cancer typical scenario

Answer 76

A postmenopausal patient (60s) with bleeding.

Question 77

Endometrial Cancer work up

Answer 77

First step is going to be an ultrasound. If the endometrium is too thick (most people say 4- 5mm) then it gets a biopsy. Almost always this will be stage 1 disease, and no further imaging will be done. If there is concern that it’s more than stage 1 - that is when you would get MRI (CT is shit for the uterus and would never be the right answer). • First Step Postmenopausal Bleeder = Ultrasound • Too Thick ? = Biopsy • Extent of Disease = MRI

Question 78

Endometrial Cancer appearance on MRI

Answer 78

* T1 Iso * T2 Mildly Hyper * Tl+C Homogenous, but less enhancement compared to adjacent myometrium ( it’s dark). * DWI Will show restricted dijfusion. This sequence is good fo r "Drop mets ” into the vagina, and fo r lymph node detection.

Question 79

Endometrial Cancer critical stage

Answer 79

• Stage 2 disease is defined as cervical stroma invasion. This is supposedly high risk for lymph node mets. • The diagnostic key is the post contrast imaging (obtained 2-3 mins after injection). If the cervical mucosa enhances normally, you have excluded stromal invasion. • Stage 2 is probably going to change management by adding pre-op radiation to the cervix, plus a change from TAH to radical hysterectomy (obviously this varies from center to center).

Question 80

Endometrial Cancer stage 1 imaging

Answer 80

T1+C: Normal Dark Cervical Stroma (star). Enhancement of the Cervical Mucosa (arrows) Excludes Invasion.

Question 81

Endometrial Cancer stage 2 imaging

Answer 81

T1+C: Tumor Invasion o f the Cervix

Question 82

Endometrial Cancer other possible trivia

Answer 82

• Moving from stage 1A (<50% myometrium) to stage 1B (>50% o f the myometrium) also increases the risk o f lymph node disease. • Some sites will do lymph node sample at stage 1 A, and radical lymph node dissection at stage IB.

Question 83

Cervical Cancer overview

Answer 83

It’s usually squamous cell, related to HPV (like 90%). The big thing to know is parametrial invasion (stage lib). Stage Ila or below is treated with surgery. Once you have parametrial invasion (stage lib), or involvement o f the lower 1/3 o f the vagina it’s gonna get chemo/ radiation. In other words, management changes so that is the most likely test question.

Question 84

Cervical Cancer stage IIA

Answer 84

Spread beyond the cervix, but NO parametrial invasion Surgery

Question 85

Cervical Cancer Stage IIB

Answer 85

Parametrial involvement but NOT extension to pelvic side wall. Chemo/ Radiation

Question 86

Cervical Cancer what is the parametrium

Answer 86

The p aram etrium is a fib ro u s b an d that separates the supravaginal cervix from the bladder. It e x te n d s between the layers of the bro ad ligament.

Question 87

Cervical Cancer why is the parametrium important

Answer 87

The uterine artery runs inside the parametrium, hence the need for chemo - o n ce in va de d .

Question 88

Cervical Cancer how do you tell if the parametrium is invaded

Answer 88

Normally the ce rv ix has a T2 d a rk ring. That thing should be intact. If the tum o r goes throug h th a t thing, you g otta call it invaded.

Question 89

Solid Vaginal Masses

Answer 89

An uninvited solid vaginal mass is usually a bad thing. It can be secondary (cervical or uterine carcinoma protruding into the vagina), or primary such as a clear cell adenocarcinoma or rhabdomyosarcoma. leiomyoma squamos cell carcinoma clear cell adenocarcinoma vaginal rhabdomyosarcoma

Question 90

Solid Vaginal Masses Leiomyoma

Answer 90

Rare in the vagina, but can occur (most commonly in the anterior wall).

Question 91

Solid Vaginal Masses Squamous Cell Carcinoma

Answer 91

The most common cancer of the vagina (85%). This is associated with HPV. This is just like the cervix.

Question 92

Solid Vaginal Masses Clear Cell Adenocarcinoma

Answer 92

This is the zebra cancer seen in women whose mothers took DES (a synthetic estrogen thought to prevent miscarriage). That plus “T-Shaped Uterus” is probably all you need to know.

Question 93

Solid Vaginal Masses Vaginal Rhabdomyosarcoma

Answer 93

This is the most common tumor o f the vagina in children. There is a bimodal age distribution in ages (2-6, and 14-18). They usually come off the anterior wall near the cervix. It can occur in the uterus, but typically invades it secondarily. Think about this when you see a solid T2 bright enhancing mass in the vagina / lower uterus in a child.

Question 94

Solid Vaginal Masses mets trivia

Answer 94

* A met to the vagina in the anterior wall upper 1/3 is “always ” (90%) upper genital tract. * A met to the vagina in the posterior wall tower 1/3 is "always ” (90%) from the Gl tract.

Question 95

Cystic Vaginal I Cervical Masses Nabothian Cysts

Answer 95

These are usually on the cervix and you see them all the time. They are the result o f inflammation causing epithelium plugging o f mucous glands.

Question 96

Cystic Vaginal I Cervical Masses Gartner Ducts Cysts

Answer 96

These are the result o f incomplete regression of the Wolffian ducts. They are classically located along the anterior lateral wall of the upper vagina. If they are located at the level o f the urethra, that can cause mass effect on the urethra (and symptoms).

Question 97

Cystic Vaginal I Cervical Masses Bartholin Cysts

Answer 97

These are the result o f obstruction o f the Bartholin glands (mucinsecreting glands from the urogenital sinus). They are found below the pubic symphysis (helps distinguish them from Gartner duct).

Question 98

Cystic Vaginal I Cervical Masses Skene Gland Cysts

Answer 98

Cysts in these periurethral glands, can cause recurrent UTIs and urethral obstruction.

Question 99

Gartner duct cyst quick

Answer 99

anterior lateral upper vagina

Question 100

Bartholin gland cyst quick

Answer 100

— “Ba rth o lin is B e low ” the p u b ic s ymphysis | — “B a rth o lin is n e a r the Butthole.

Question 101

O V A R Y / A D N E X A ovulation

Answer 101

Follicles seen during the early menstrual cycle are typically small (< 5 mm in diameter). By day 10 of the cycle, there is usually one follicle that has emerged as the dominant follicle. By mid cycle, this dominant follicle has gotten pretty big (around 20 mm). The size isn’t surprising because it contains a mature ovum. The LH surge causes the dominant follicle to rupture, releasing the egg. The follicle then regresses in size, forming a Corpus Luteum. A small amount of fluid can be seen in the cul-de-sac. Occasionally, a follicle bleeds and re-expands (hemorrhagic cyst) - more on this later.

Question 102

O V A R Y / A D N E X A ovulation quick

Answer 102

LH durring faollicular phase with dominant follicle right before ovulation then LH surge with ovulation then luteal phase with corpus luteum

Question 103

O V A R Y / A D N E X A meaningless vocab premenopausal ovarian cyst

Answer 103

< 1 cm = Follicle 1-2 cm = Dominant Follicle > 3 cm = Cyst

Question 104

Cumulus Oophorus

Answer 104

This is a piece of anatomy trivia. It is a collection of cells in a mature dominant follicle that protrudes into the follicular cavity, and signals imminent ovulation (its absence means nothing).

Question 105

Fertility Meds

Answer 105

Medications such as a Clomiphene Citrate (Clomid), force the maturation of multiple bilateral ovarian cysts. It is not uncommon for the ovaries of women taking this drug to have multiple follicles measuring more than 20 mm in diameter by mid cycle.

Question 106

Theca Lutein Cysts

Answer 106

this is a type of functional cyst (more on that below), related to overstimulation from b-HCG. What you see are large cysts (~ 2-3 cm) and the ovary has a typical multilocular cystic “spokewheel” appearance.

Question 107

Theca Lutein Cysts think about 3 things

Answer 107

* Multifetal pregnancy, * Gestational trophoblastic disease (moles), * Ovarian Hyperstimulation syndrome.

Question 108

Ovarian Hyperstimulation Syndrome

Answer 108

This is a complication associated with fertility therapy (occurs in like 5%). They will show you the ovaries with theca lutein cysts, then ascites, and pleural effusions. They may also have pericardial effusions. Complications include increased risk for ovarian torsion (big ovaries) and hypovolemic shock.

Question 109

Paraovarian (Paratubal) Cyst

Answer 109

Cyst that is in the adnexa but not within the ovary. Instead these things are located adjacent to the ovary or tube. If the cyst is simple (not septated or nodular) and clearly not ovarian they will not need followup — is doesn't matter how big it is, as they have incredibly low rate of malignancy.

Question 110

TLDR

Answer 110

Simple paraovarian cysts do not require follow up.

Question 111

TLDR

Answer 111

Simple paraovarian cysts do not require follow up.

Question 112

Premenstrual ovaries

Answer 112

* The ovaries o f a pediatric patient stay small until around age 8-9. * Ovaries may contain small follicles.

Question 113

premenopausal ovaries

Answer 113

* A piece o f trivia; premenopausal ovaries may be HOT on PET (depending on the menstrual cycle). * This is why you do a PET in the first week o f the menstrual cycle.

Question 114

``` postmenopausal ovaries ( > one year after menses stops): ```

Answer 114

* Considered abnormal if it exceeds the upper limit of normal, or is twice the size of the other ovary (even if no mass is present). * Small cysts (< 3 cm) are seen in around 20% o f post menopausal women. * In general, postmenopausal ovaries are atrophic, lack follicles, and can be difficult to find with ultrasound. * The ovarian volume will decrease from around 8cc at age 40, to around 1 cc at age 70. * The maximum ovarian volume in a post menopausal woman is 6 ml. * Unlike premenopausal ovaries, post menopausal ovaries should NOT be hot on PET.

Question 115

Ovarian cyst If the cyst is simple, regardless o f age it’s almost certainly benign.

Answer 115

What if they don’t tell you if the patient is pre or post menopausal ? You can use 50 years old as a cut off. Under 50 Pre, 50 & up Post.

Question 116

Incidental Simple Appearing Ovarian Cyst -Shown on CT

Answer 116

PreMenopausal:< 3 cm = Call it Normal Follicle PreMenopausal: > 3 cm = Get an US PostMenopausal: < 1cm = Call it Normal Cyst PostMenopausal: > 1cm = Get an US

Question 117

Incidental Simple Appearing Ovarian Cyst | -Shown on US

Answer 117

PrcMenopausal:< 7 cm = No Follow Up PreMenopausal: > 7 cm = Follow Up (3 months) PostMenopausal: < 5 cm = No Follow Up PostMenopausal: > 5 cm = Follow Up (3 months)

Question 118

Ovarian cyst that is not simple

Answer 118

Cyst is not simple (irregular septations, papillary proiections. or solid elements) = GYN consult.

Question 119

Sinister six ovraian masses

Answer 119

``` In most clinical practices, the overwhelming majority o f ovarian masses are benign (don't worry, I’ll talk about cancer, too). Physiologic and functioning follicles Corpora lutea Hemorrhagic cysts Endometriomas Benign cystic teratomas (dermoids) Polycystic ovaries ```

Question 120

Functioning Ovarian Cysts

Answer 120

Functioning cysts (follicles) are affected by the menstrual cycle (as I detailed eloquently above). These cysts are benign and usually 25 mm or less in diameter. They will usually change / disappear in 6 weeks. If a cyst persists and either does not change or increases in size, it is considered a nonfunctioning cyst (not under hormonal control). Simple cysts that are > 7 cm in size may need further evaluation with MR (or surgical evaluation). Just because it’s hard to evaluate them completely on US when they are that big, and you risk torsion with a cyst that size.

Question 121

Corpus Luteum

Answer 121

The normal corpus luteum arises from a dominant follicle (as I detailed eloquently above). These things can be large (up to 5-6 cm) with a variable appearance (solid hypoechoic, anechoic, thin-walled, thick-walled, cyst with debris). The most common appearance is solid and hypoechoic with a “ring of fire” (intense peripheral blood flow).

Question 122

THIS v.v THAT: Corpus Luteum VS Ectopic Pregnancy

Answer 122

They both can have that “ring of fire” appearance, but please don’t be an idiot about this. Most ectopic pregnancies occur in the tube (the corpus luteum is an ovarian structure). If you are really lucky, a “hint” is that the corpus luteum should move with the ovary, where an ectopic will move separate from the ovary (you can push the ectopic away from it). Also, the tubal ring of an ectopic pregnancy is usually more echogenic when compared to the ovarian parenchyma. Whereas, the wall of the corpus luteum is usually less echogenic. A specific (but not sensitive) finding in ectopic pregnancy is a RI of <0.4 or >0.7.

Question 123

Ectopic quick

Answer 123

RI <0.4, or >0.7 Thick echogenic rim Ring of fire moves separate from the ovary

Question 124

Corpus luteum quick

Answer 124

RI 0 .4 -0 .7 thin echogenic rim ring of fire moves with the ovary

Question 125

Endometrioma epidemiology

Answer 125

This targets young women during their reproductive years and can cause chronic pelvic pain associated with menstruation. The traditional clinical history of endometriosis is the triad of infertility, dysmenorrhea, and dyspareunia.

Question 126

Endometrioma classic appearance

Answer 126

The classic appearance is rounded mass with homogeneous low level internal echoes and increased through transmission (seen in 95% of cases). Fluid-fluid levels and internal septations can also be seen. It can look a lot like a hemorrhagic cyst (sometimes).

Question 127

Endometrioma imaging findings

Answer 127

As a general rule, the more unusual or varied the echogenicity and the more ovoid or irregular the shape, the more likely the mass is an endometrioma. Additionally, and of more practical value, they are not going to change on follow up (hemorrhagic cysts are). In about 30% of cases you can get small echogenic foci adhering to the walls (this helps make the endometrioma diagnosis more likely). Obviously, you want to differentiate this from a true wall nodule.

Question 128

Endometriosis complications

Answer 128

The complications of endometriosis (bowel obstruction, infertility, etc...) are due to a fibrotic reaction associated with the implant. The most common location for solid endometriosis is the uterosacral ligaments.

Question 129

Endometrioma becoming cancer

Answer 129

About 1% of endometriomas undergo malignant transformation (usually endometrioid or clear cell carcinoma). How do you tell which one is which??? Malignancy is very rare in endometriomas smaller than 6 cm. They usually have to be bigger than 9 cm. Additionally, the majority of women with carcinoma in an endometrioma are older than 45 years. So risk factors for turning into cancer: (a) older than 45, (b) bigger than 6-9 cm.

Question 130

Endometrioma pregnancy trivia

Answer 130

There is a thing called a “decidualized endometrioma. ” This is a vocab word used to describe a solid nodule with blood flow in an endometrioma of a pregnant girl. Obviously this is still gonna get followed up - but is a mimic of malignancy. The thing never to forget is that if the patient is NOT pregnant and you see a solid nodule with blood flow - that is malignant degeneration - period - no hesitation, next question.

Question 131

Endometrioma on MRI

Answer 131

Will be T1 bright (from the blood). Fat saturation will not suppress the signal (showing you it’s not a teratoma). Will be T2 dark! (from iron in the endometrioma). The shading sign is a buzzword for endometriomas on MR imaging. On T2 you should look for “shading.” The shading sign describes T2 shortening (getting dark) of a lesion that is T1 bright.

Question 132

Endometrioma What is the most sensitive imaging feature on MR1 for the diagnosis of malignancy in an endometrioma ?

Answer 132

an enhancing mural nodule

Question 133

Endometrioma mri findings quick

Answer 133

T1 bright T2 shaded

Question 134

Hemorrhagic Cysts overview

Answer 134

As mentioned on prior pages, sometimes a ruptured follicle bleeds internally and reexpands. The result is a homogenous mass with enhanced through transmission (tumor w o n ’t do that) with a very similar look to an endometrioma. A lacy “fishnet appearance” is sometimes seen and is considered classic. Doppler flow will be absent. The traditional way to tell the difference between a hemorrhagic cyst vs endometrioma, is that the hemorrhagic cyst will go away in 1-2 menstrual cycles (so repeat in 6-12 weeks).

Question 135

Hemorrhagic Cysts MRI

Answer 135

Will be T1 bright (from the blood). Fat saturation will not | suppress the signal (showing you it’s not a teratoma). The lesion should NOT enhance.

Question 136

Hemorrhagic Cysts old ladies

Answer 136

Postmenopausal women may occasionally ovulate, so you don’t necessarily need to freak out (follow up in 6-12 weeks). Now, late postmenopausal women should NEVER have a hemorrhagic cyst and if you are shown something that looks like a hemorrhagic cyst in a 70 year old - it’s cancer till proven otherwise.

Question 137

THIS vs THAT: E n d om e triom a vs H em o r rh a g ic C ys t us

Answer 137

Endometrioma - Homogeneous with Low Level Echoes Hemorrhagic Cyst - Lacy fishnet appearance

Question 138

Dermoid overview

Answer 138

These things typically occur in young women (20s-30s), and are the most common ovarian neoplasm in patients younger than 20. The “Tip of the Iceberg Sign” is a classic buzzword and refers to absorption of most of the US beam at the top of the mass. The typical ultrasound appearance is that of a cystic mass, with a hyperechoic solid mural nodule, (Rokitansky nodule or dermoid plug). Septations arc seen in about 10%.

Question 139

Dermoid MRI

Answer 139

Will be bright on T1 (from the fat). There will be fat suppression (not true of hemorrhagic cysts, and endometriomas).

Question 140

Dermoid do they ever become cancer

Answer 140

About l% of dermoids can undergo malignant transformation (almost always to squamous cell CA). Again, risk factors are size (usually larger than 10cm), and age (usually older than 50).

Question 141

Dermoid gamesmanship 1

Answer 141

Gross Fat containing ovarian mass on CT

Question 142

Dermoid gamesmanship 2

Answer 142

The Old Tooth Trick - shown on plain film, CT, or even as susceptibility (dark stuff) on MR. Remember Dermoids are basically teratomas, and teratomas grow all kinds of gross shit including teeth, hair, finger nails etc... The tooth is obviously the classic one.

Question 143

Dermoid gamesmanship 3

Answer 143

“Dot -dash” pattern has been described for hair within a cyst.

Question 144

Rare Cancer Transformation Subtypes

Answer 144

Endometrioma > Clear Cell | Dermoid > Squamous

Question 145

Endometrioma quick MRI

Answer 145

T2 mild hyperintense

Question 146

Dermoid quick MRI

Answer 146

T1FS hypointense

Question 147

Hemorrhagic cyst quick MRI

Answer 147

T1, T1FS, T2 hyperintense

Question 148

Polycystic Ovarian Syndrome overview

Answer 148

Typically an overweight girl with infertility, acne, and a pencil mustache (not a full Ron Swanson)

Question 149

Polycystic Ovarian Syndrome imaging

Answer 149

Ten or more peripheral simple cysts (typically small < 5 mm) Usually Characteristic 'string-of-pearls' appearance. Ovaries are typically enlarged (> 10 cc), although in 30% of patients the ovaries have a normal volume

Question 150

Ovarian Cancer overview

Answer 150

Ovarian cancers often present as complex cystic and solid masses. They are typically intraovarian (most extra-ovarian masses are benign). The role o f imaging is not to come down hard on histology (although the exam may ask this of you), but instead to distinguish benign from malignant and let the surgeon handle it from there.

Question 151

Ovarian Cancer think cancer if

Answer 151

Unilateral (or bilateral) complex cystic adnexal masses with thick ( > 3 mm) septations, and papillary projections (nodule with blood flow). Solid adnexal masses with variable necrosis

Question 152

Ovarian Cancer knee jerks

Answer 152

Multiple thin or thick septations = Call the Surgeon Nodule with Flow = Call the Surgeon Solid Nodules Without Flow = o Get an MR to make sure it’s not a dermoid plug, o If it’s not a dermoid, then call the surgeon

Question 153

Mucinous O v a rian C y s tad e n o c a rc in om a

Answer 153

Often a large mass. They are typically multi-loculated (although septa are often thin). Papillary projections are less common than with serous tumors. You can see low level echos (from mucin). These dudes can get Pseudomyxoma peritonei with scalloping along solid organs. Smoking is a known risk factor (especially for mucinous types).

Question 154

THIS vs THAT: Serous vs Mucinous

Answer 154

Serous: Unilocular (fewer septations) Papillary Projections Common Mucinous: Multi-locular (more septations) Papillary Projections Less Common

Question 155

E n dome trio id O v a rian C an c e r: overview

Answer 155

This is the second most common ovarian cancer (serous number one, mucinous number three). These things are bilateral about 15% o f the time.

Question 156

E n dome trio id O v a rian C an c e r: thigns to know

Answer 156

• 25% o f women will have concomitant endometrial cancer, with the endometrial cancer as the primary (ovary is met). • Endometriomas can turn into endometrioid cancer • 15% are bilateral

Question 157

Gamesmanship: Ovarian Mass + Endometrial Thickening

Answer 157

``` This is a way to show both Endometrioid CA (which often has both ovarian and endometrial CA), and Granulosa-Theca Cell Tumor (which produce estrogen - and cause endometrial hyperplasia) ```

Question 158

B.F.M’s - for Adults

Answer 158

It’s useful to have a differential for a B.F.M. (Big Fucking Mass) in an adult and a child. I discuss the child version o f this on page 58. For adults think about 3 main things: (1) Ovarian Masses - Mucinous and Serous (2) Desmoids - Remember Gardner Syndrome (3) Sarcomas

Question 159

Fibroma I Fibrothecoma

Answer 159

The ovarian fibroma is a benign ovarian tumor, most commonly seen in middle aged women. The fibrothecoma / thecoma spectrum has similar histology. It’s very similar to a fibroid. On ultrasound it’s going to be hypoechoic and solid. On MRI it’s going to be T1 and T2 dark, with a band of T2 dark signal around the tumor on all planes. Calcifications are rare.

Question 160

Meigs syndrome

Answer 160

This is the triad of ascites, pleural effusion, and a benign ovarian tumor (most commonly fibroma).

Question 161

Fibromatosis

Answer 161

This is a zebra. You have tumor-like enlargement of the ovaries due to ovarian fibrosis. It typically hits girls around the age of 25. It’s associated with omental fibrosis and sclerosing peritonitis. You are going to get dark T1 and T2 signal. The buzzword for that T2 signal is “black garland sign. ” The condition is benign, and sometimes managed with surgical removal of the ovaries.

Question 162

brenner tumor

Answer 162

Epithelial tumor of the ovary seen in women in their 50s-70s. It’s fibrous and T2 dark. Unlike Fibromas, calcifications are common (80%). They are also sometimes referred to as “Ovarian Transitional Cell Carcinoma ” for the purpose of fucking with you.

Question 163

Struma Ovarii:

Answer 163

These things are actually a subtype of ovarian teratoma. On imaging you are looking for a multilocular, predominantly cystic mass with an INTENSELY enhancing solid component. On MRI - the give away is very low T2 signal in the “cystic” areas which is actually the thick colloid. These tumors contain THYROID TISSUE, and even though it’s very rare (like 5%), I would expect that the question stem will lead you to this diagnosis by telling you the patient is hyperthyroid or in a thyroid storm.

Question 164

Metastatic Disease to the Ovary

Answer 164

Around 10% of malignant ovarian tumors are mets. The primary is most commonly from colon, gastric, breast, lung, and contralateral ovary. The most common look is bilateral solidtumors.

Question 165

Krukenburg Tumor

Answer 165

This is a metastatic tumor to the ovaries from the GI tract (usually stomach).

Question 166

Ovarian Torsion overview

Answer 166

Rotation of the ovarian vascular pedicle (partial or complete) can result in obstruction to venous outflow and arterial inflow. Torsion is typically associated with a cyst or tumor (anything that makes it heavy, so it flops over on itself).

Question 167

Ovarian Torsion critical point

Answer 167

The most constant finding in ovarian torsion is a large ovary.

Question 168

Ovarian Torsion features

Answer 168

``` Unilateral enlarged ovary (greater than 4 cm) Mass on the ovary Peripheral Cysts Free Fluid Lack of arterial or venous flow ```

Question 169

Ovarian Torsion the ovary is not a testicle

Answer 169

The ovary has a dual blood supply. Just because you have flow, does NOT mean there isn’t a torsion. You can torse and de-torse. In other words, big ovary + pain = torsion. Clinical correlation recommended.

Question 170

Hydrosalpinx overview

Answer 170

There are a variety of causes, the most common is being a skank, infidel, or free spirit (PID). Additional causes include endometriosis, tubal cancer, post hysterectomy (without salpingectomy / oophorectomy), and tubal ligation. Rare and late complication is tubal torsion.

Question 171

Hydrosalpinx buzz 1

Answer 171

Thin (or thick in chronic states) elongated tubular structure in the pelvis.

Question 172

Hydrosalpinx buzz 2

Answer 172

The buzzword is “cogwheel appearance,” referring to the normal longitudinal folds of a fallopian tube becoming thickened. Another buzzword is “string sign” referring to the incomplete septae. The “waist sign” describes a tubular mass with indentations of its opposing walls (this is suppose to help differentiate hydrosalpinx from an ovarian mass).

Question 173

Pelvic Inflammatory Disease (PID) overview

Answer 173

Infection or inflammation of the upper female genital tract. It’s usually secondary to the cultural behaviors of trollops and strumpets (collectors of Gonorrhea / Chlamydia). As a hint, the question writer could describe the patient as “sexually disreputable. ” The question could also describe the patient as recently appearing as a guest on the Maury Show (the "Not the Father!” show — google if unfamiliar, it could be on the exam).

Question 174

Pelvic Inflammatory Disease (PID) us findings

Answer 174

On ultrasound you are gonna see a Hydrosalpinx. The margin of the uterus may become ill defined (“indefinite uterus” - is a buzzword). Later on you can end up with tubo-ovarian abscess or pelvic abscess. You can even get bowel or urinary tract inflammatory changes.

Question 175

Paraovarian Cyst

Answer 175

This is a congenital remnant that arises from the Wolffian duct. They are more common than you think with some texts claiming these account for 10-20% of adnexal masses. They are classically round or oval, simple in appearance, and do NOT distort the adjacent ovary (key finding). They can indent the ovary and mimic an exophytic cyst, but a good sonographer can use the transducer to separate the two structures.

Question 176

Ovarian Vein Thrombophlebitis

Answer 176

This is seen most commonly in postpartum women, often presenting with acute pelvic pain and fever. For whatever reason, 80% of the time it’s on the right. It’s most likely to be shown on CT (could be ultrasound) with a tubular structure with an enhancing wall and low-attenuation thrombus in the expected location of the ovarian vein. A dreaded sequela is pulmonary embolus.

Question 177

Peritoneal Inclusion Cyst

Answer 177

This is an inflammatory cyst of the peritoneal cavity that occurs when adhesions envelop an ovary. Adhesions can be thought of as diseased peritoneum. Whereas the normal peritoneum can absorb fluid, adhesions cannot. So, you end up with normal secretions from an active ovary confined by adhesions and resulting in an expanding pelvic mass. The classic history is patient with prior pelvic surgery (they have to tell you that, to clue you in on the presence of adhesions), now with pain. They could get tricky and say history of PID or endometriosis (some kind of inflammatory process to piss off the peritoneum). In that case, it is likely they would show an ultrasound (or MR) with a complex fluid collection occupying pelvic recesses and containing the ovary. It’s not uncommon to have septations, loculations, and particulate matter within the contained fluid.

Question 178

Peritoneal Inclusion Cyst key features

Answer 178

* Lack of walls. “Passive shape” that conforms to and is defined by surrounding structures. * Entrapment of an ovary. Ovary will be either in the collection, or at the periphery.

Question 179

Peritoneal Inclusion Cyst classic vignette

Answer 179

A woman of reproductive age with a history of endometriosis, pelvic surgery, and pelvic inflammatory disease. Accompanied by images (most likely ultrasound, less likely CT or MR) or a fluid-filled mass that conforms to the shape of the pelvis and surrounds an ovary.

Question 180

Gestational Trophoblastic Disease

Answer 180

Think about this with marked elevation of B-hCG. They will actually trend betas for tumor activity. Apparently, elevated B-hCG makes you vomit - so hyperemesis is often part of the given history. Other pieces of trivia is that moles are more common in ages over 40, and prior moles makes you more likely to get another mole.

Question 181

Hydatidiform Mole overview

Answer 181

This is the most common form, and the benign form of the disease. There are two subtypes

Question 182

Hydatidiform Mole Complete Mole overview

Answer 182

(classic mole) (70%): This one involves the entire placenta. There will be no fetus. The worthless trivia is that the karyotype is diploid. A total zebra scenario is that you have a normal fetus, with a complete mole twin pregnancy (if you see that in the wild, write it up). The pathogenesis is fertilization of an egg that has lost its chromosomes (46XX).

Question 183

Hydatidiform Mole Complete Mole first trimester us

Answer 183

Classically shows the uterus to be filled with an echogenic, solid, highly vascular mass, often described as “snowstorm” in appearance.

Question 184

Hydatidiform Mole Complete Mole second trimester us

Answer 184

Vesicles that make up the mole enlarge into individual cysts (2-30 mm) and produce your “bunch of grapes” appearance.

Question 185

Hydatidiform Mole Partial mole overview

Answer 185

(30%): This one involves only a portion of the placenta. You do have a fetus, but it’s all jacked up (triploid in karyotype). The pathogenesis is fertilization of an ovum by two sperm (69XXY). Mercifully, it’s lethal to the fetus.

Question 186

Hydatidiform Mole partial mole us

Answer 186

The placenta will be enlarged, and have areas of multiple, diffuse anechoic lesions. You may see fetal parts.

Question 187

Hydatidiform mole theca lutein cyst

Answer 187

Remember I mentioned that Theca Lutein cysts are seen in molar pregnancies. Theca Lutein Cyst Trivia: Most commonly bilateral and seen in the second trimester

Question 188

Invasive Mole

Answer 188

This refers to invasion of molar tissue into the myometrium. You typically see it after the treatment of a hydatidiform mole (about 10% of cases). US may show echogenic tissue in the myometrium. However, MRI is way better at demonstrating muscle invasive. MRI is going to demonstrate focal myometrial masses, dilated vessels, and areas of hemorrhage and necrosis.

Question 189

Choriocarcinoma | the guacamole has gone bad

Answer 189

This is a very aggressive malignancy that forms only trophoblasts (no villous structure). The typical attacking pattern of choriocarcinoma is to spread locally (into the myometrium and parametrium) then to spread hematogenous to any site in the body. It’s very vascular and bleeds like stink. The classic clinical scenario is serum p-hCG levels that rise in the 8 to 10 weeks following evacuation of molar pregnancy. On ultrasound, choriocarcinoma (at any site) results in a highly echogenic solid mass. Treatment = methotrexate.

Question 190

Fractured Penis overview

Answer 190

This is one of the most tragic situations that can occur in medicine. There are several potential mechanisms of injury. Anecdotally, it seems to be most common in older men participating in extra-marital relations with strippers named “Whisper.” There is at least one article stating “impotence” is protective - which makes sense if you think about the pathophysiology. They can show it on ultrasound (look for hematoma) or MRI.

Question 191

Fractured Penis key trivia

Answer 191

Defined by fracture of the corpus cavernosum and its surrounding sheath, the tunica albuginea (black line outlining the dong bone).

Question 192

Fractured Penis cartooned t1 axial through the dong bone

Answer 192

Interruption of the black line (tunica albuginea) - arrow. It’s helpful to look for hemorrhage (Tl bright) in the corpus cavernosum (the primary stabilizing stmt of this battering ram).

Question 193

Fractured Penis stigmata

Answer 193

Stigmata of this injury can include a sub optimal angulation (Peyronie disease) from fibrous scar formation.

Question 194

Prostate cancer overview

Answer 194

Biopsy of the prostate is a terrible terrible situation, worse than anything you can imagine in 1000 years of hell. MR1 of the prostate (instead of biopsy) is probably a little better although many sites use an endorectal coil.. .my God this endorectal coil! You can use prostate MRI for high risk screening (high or rising PSA with negative biopsy), or to stage (look for extracapsular extension).

Question 195

Prostate anatomy

Answer 195

Anatomists like to use “zones” to describe locations, and it actually helps with pathology. The anterior fibromuscular gland is dark on T1 and T2. The central and transitional zones (together called the "centralgland”) are brighter than the anterior muscular zone, but less bright than the peripheral zone on T2. In other words the peripheral zone is the most T2 bright.

Question 196

Prostate adenocarcinoma zone breakdown

Answer 196

Peripheral Zone: 70% Transition Zone: 20% Central Zone: 10%

Question 197

Prostate base zones

Answer 197

transitional zone - inner cetnral zone - middle peripheral zone - outer

Question 198

Prostate midgland zones

Answer 198

central zone - inner | peripheral zone- outer

Question 199

Prostate apex zones

Answer 199

just peripheral zone

Question 200

Prostate done confuse

Answer 200

zones and glands

Question 201

Prostate dark stuff

Answer 201

central gland | where bph nodules live

Question 202

Prostate bright stuff

Answer 202

peripheral zone | where cancer lives

Question 203

MRI finding for Prostate CA

Answer 203

Cance r is d a rk on T2 (background is h ig h ), restricts on diffusion (low on ADC), and enhances early and washes out (type 3 curve - just like a breast cancer).

Question 204

Prostate bone mets

Answer 204

bone scan

Question 205

prostate cancer trivia

Answer 205

PSA can be useful when considering risk of bone mets. There is at least 1 paper that says a PSA < 20 has a high predictive value in mling OUT skeletal mets. In other words, PSA tends to be high when disease is aggressive enough to go to the bones.

Question 206

prostate cncer staging

Answer 206

``` The main thing to know is stage II vs stage III, as extra capsular extension is the most important factor governing treatment. ```

Question 207

Prostate cancer stage II

Answer 207

Confined by capsule (T2) Abutment o f the capsule without bulging

Question 208

Prostate cancer stage III

Answer 208

Extension through capsule (T3a) Bulging o f the capsule, or frank extension through it

Question 209

Prostate urologists

Answer 209

``` Seminal vesicles (T3b) and the nerve bundle are also right behind the prostate and can get invaded (urologists love to hear about that). ```

Question 210

Prostate cancer key concept

Answer 210

Prostate Cancer is a lot like Breast Cancer - in that it is very common and often a “benign” entity (1 in 6 men will be diagnosed with prostate cancer , 3% will die o f it). There are tons and tons of elderly people with low grade prostate CA and breast cancers (DCIS) that will never even know they have it unless somebody does a biopsy on them... or worse performs screening on them. Which brings us to the PSA. When family medicine doctors starting doing PSA checks on everybody suddenly there was this enormous spike in the incidence o f prostate cancer. Suddenly everyone has cancer (I blame the liberal media).

Question 211

Prostate cancer Clinically Significant Cancer:

Answer 211

Gleason Score > 7 Cancer Volume > 0.5cc ``` Extension through the Capsule (loss o f normal T2 signal in the seminal vesicle, bulging of the capsule / frank invasion through it, loss o f fat between prostate and rectum, neurovascular bundle asymmetry). ```

Question 212

Prostate cancer Who Dies of Prostate Cancer ?

Answer 212

There are 3 factors - Gleason Scores 8-10, Advanced Clinical Stage (mets), and PSA > 20. People with Gleason scores less than 6, PSA < 10, and staging < 2a (less than half the lobe) are unlikely to die o f the prostate cancer.

Question 213

Prostate cancer management

Answer 213

It is gonna depend a lot on who you ask. Most people will add hormone therapy around stage 2B (more than half the lobe) but it is complicated.

Question 214

Prostate cancer PSA

Answer 214

This is an antigen produced by the normal prostate and incorporated into the ejaculate (from the window to the wall), for the purpose of dissolving cervical mucus e tc ... It also leaks out into the blood in small amounts in normal men and in larger amounts when the prostate is abnormal (cancer, infected, riding a bicycle, sticking stuff up your ass that don’t belong up your ass, and benign hypertrophy). Family Medicine docs will screen people starting at 50. Some numbers to have a vague familiarity with include: Normal < 4. Low Risk Category < 10. High Risk Category > 20. After prostatectomy normal is zero, if it rises to 0.2 think recurrence. After radiation anything over 2.0 is concerning for recurrence (although it’s a little more complicated than that). PSA < 20 = bone mets unlikely.

Question 215

Prostate cancer Gleason

Answer 215

There is a “grade” a “ score” and a “group” - you better fucking believe the distinction is fair game.. • Gleason Grade: This refers to the histological patterns in the sample “ 1” is normal, “5” is very very not normal. 2-4 are in the middle. • Gleason Score: This is the sum of the two most common “grades.” The more common pattern is always first. So “A” 3+5 = 8, and “B” 5+3 = 8. “B” has more of 5 than “A” and is therefore worse off. Total scores less than 6 aren’t usually reported. • Gleason Group: This uses pattern scores to reflect the actual risk. This removes the confusion over one 7 being worse than another 7. For example 3+4 is grade 2, and 4+3 is grade 3. Grade is 1-5

Question 216

PI-RADS overview

Answer 216

Scores are calculated by using data from DWI, T 2, and Enhancement. Tumor in the Transition zone is determined primarily from T2 (t for t). Peripheral zone is determined primarily from DWI.

Question 217

PI-RADS PZ-DWI

Answer 217

1-Normal 2-Linear / Wedge 3-Vague Patchy (goes to 4 with enhancement) 4-Focal < 1.5 cm 5-Focal > 1.5 cm or with extracapsular ext

Question 218

PI-RADS TZ-T2

Answer 218

1-Normal Nodules - full capsule 2-Atypical Nodule - no capsule (goes to 3 with coal restricted DWI) 3-Heterogenous, blurry margins (goes to 4 with restricted DWI > cm)4-Low Signal < 1,5 cm 5-Low Signal > I.5 cm or with extracapsular ext

Question 219

Benign prostatic hyperplasia (BPH): overview

Answer 219

Obviously this is super common, and makes old men pee a lot. Volume o f 30cc is one definition. Most commonly involves the transitional zone (cancer is rare in the transitional zone - 10%). The central gland enlarges with age. The median lobe component is the one that hypertrophies and sticks up into the bladder. It can cause outlet obstruction, bladder wall thickening (detrusor hypertrophy), and development of bladder diverticulum.

Question 220

Benign prostatic hyperplasia (BPH): ivp buzzword

Answer 220

The IVP buzzword is “J shaped”, “Fishhook”, or “Hockey stick” shaped ureter - as the distal ureter curves around the enlarged prostate.

Question 221

Benign prostatic hyperplasia (BPH): nodules on mri

Answer 221

In the Transitional Zone (Central Gland) T2 Heterogenous Can Restrict Diffusion May enhance and washout

Question 222

Post Biopsy Changes PROSTATE

Answer 222

Classically T1 bright stuff in the gland. It’s subacute blood.

Question 223

prostate peripheral zone tumor quick

Answer 223

T2 - dark ADC - dark Enhancement - early enhancement, eraly washout

Question 224

prostate peripheral zone hemorrhage quick

Answer 224

T2 - dark (soetomes T1 bright) ADC - dark (less dark) Enhancement - none

Question 225

prostate central/transitional zone tumor quick

Answer 225

T2 - dark 'charcoal' ADC - dark Enhancement - early enhancement, early washout

Question 226

BPH quick

Answer 226

T2 - dark ' well efined' ADC - less dark Enhancement - can enhance

Question 227

Male pelvic cysts lateral

Answer 227

seminal vesicle cyst diverticulosis of the ampulla of vas deferens

Question 228

male pelvic midline cysts

Answer 228

prostaticu utricle mullerian duct cyst ejaculatory duct cysts

Question 229

Seminal Vesicle Cyst overview

Answer 229

The classic look is a unilateral cyst that is lateral to the prostate. If they get large they can look midline, but if they show you a large one you won’t be able to tell it from a utricle cyst. They can be congenital or acquired.

Question 230

Seminal Vesicle Cyst congenital trivia

Answer 230

* Associated with renal agenesis * Associated with vas deferens agenesis * Associated with ectopic ureter insertion * Associated with polycystic kidney disease

Question 231

Seminal Vesicle Cyst acquired trivia

Answer 231

* Obstruction often from prostatic hypertrophy, or chronic infection/scarring * Classic history is prior prostate surgery

Question 232

Prostatic Utricle Cyst: things to know

Answer 232

• This represents a focal dilation in the prostatic urethra (remnant of the Mullerian duct) - as such they communicate with the urethra and can cause “dribbling” (both on and off of the basketball court). • Hvpospadias is the most common associated condition which makes sense given the relationship with the urethra. • Other Associations: Prune Belly Syndrome, Downs, Unilateral Renal Agenesis. and my personal favorite - the Imperforate Anus. • The tendency towards superinfection is also explained by the communication with the urethra. • A sneaky trick would be to show it on a RUG, where a prostate utricle cyst would look like a focal out-pouching from the prostatic urethra.

Question 233

Mullerian Duct Cyst things to know

Answer 233

* This represents a failed regression of the caudal ends of the Mullerian ducts (male equivalent of the vagina /cervix). * Does not communicate with the urethra and does not have the same associations as utricle cyst.

Question 234

This vs That utricle cyst and mullerian cyst

Answer 234

utricle cyst: Pear Shaped and Usually Smaller Will NOT extend above the base o f the prostate Communicates with the Urethra (JJtricle), therefore could opacify on a RUG mullerian cyst: Tear Drop Shaped Will extend above the base o f the prostate Does NOT communicate with the Urethra, should not opacify on a RUG Both have a tiny risk (mostly case reports) o f malignancy (various types: endometrial, clear cell, squamous).

Question 235

Prostate Abscess

Answer 235

This can cause a thick walled, scptated, heterogenous, cystic lesion anywhere in the prostate. It is usually bacterial (E. coli). When chronic it can have a more “swiss cheese” appearance referred to as “cavitary prostatitis.” Usually this is imaged via transrectal ultrasound - because it gives you (the urologist) the option to do an image guided drain.

Question 236

Torsion of the Testicle overview

Answer 236

Results from the testis and spermatic cord twisting within the serosal space leading to ischemia. If it was 1950 you’d call in your nuclear medicine tech for scintigraphy. Now you just get a Doppler ultrasound.

Question 237

Torsion of the Testicle greyscale

Answer 237

The grey scale findings are fairly straight forward. The testicle is going to be darker (hypo-echoic) and asymmetrically enlarged - at least in the chronic setting. If it’s chronic then it will shrink up.

Question 238

Torsion of the Testicle doppler

Answer 238

The doppler findings are somewhat complex. The most obviously / basic look would be to show you absent arterial flow. This would be the equivalent of an underhand slow pitch. The curve ball would be to show you preserved arterial flow BUT with increased resistance and a decreased diastolic flow (or reversed diastolic flow). That is correct my friends. Arterial flow does NOT need not be absent for torsion to be present (depending on the duration and severity). This leads the way for some seriously fuckery if the test writer wants to be an asshole. The best way to think about it is like this: Testicle = Brain. Just like the brain requires continuous diastolic flow (the thing is never off), so does the testicle.

Question 239

Torsion of the Testicle three possible patterns

Answer 239

1 - Classic Absence of Arterial Flow 2 - High resistance Arterial Flow (with decreased or reversed diastolic flow) 3 - Monophasic Arterial Waveform (loss of the normal dicrotic notch)

Question 240

Torsion of the Testicle stuffery

Answer 240

We are talking about testicular artery wave forms here. The normal cremasteric artery will not have diastolic flow (think about that think as the artery to a muscle) - it’s normally high resistance.

Question 241

Torsion of the Testicle cause

Answer 241

The “bell-clapper deformity,” which describes an abnormal high attachment of the tunical vaginalis, increases mobility and predisposes to torsion. It is usually a bilateral finding, so the contralateral side also gets an orchiopexy.

Question 242

Torsion of the Testicle viability

Answer 242

The viability is related to the degree of torsion (how many spins), and how long it has been spun. As a general rule, the surgeons try and get them in the OR before 6 hours.

Question 243

testicular High Flow States I Hyperemia

Answer 243

If torsion demonstrates decreased flow, it is useful to have an idea about what can demonstrate increased flow (decreased R.I. or increased diastolic flow) Two things worth thinking about in this scenario: (1) Epididymo-orchitis (2) Detorsion. The distinction between these two will be the clinical scenario. Orchitis is painful. Detorsion is pain free.

Question 244

Epididymitis overview

Answer 244

Inflammation o f the epididymis, and the most common cause of acute onset scrotal pain in adults. In high-school / college age men (likely sexually active men) the typical cause is chlamydia or gonorrhea. In married men (not likely to be sexually active) it is more likely to be e-coli, due to a urinary tract source. The epididymal head is the most affected. Increased size and hyperemia are your ultrasound findings. You can have infection o f the epididymis alone or infection o f the epididymis and testicle (isolated orchitis is rare).

Question 245

Epididymitis: typical spread

Answer 245

Tail ► Body ► Head

Question 246

Epididymitis: gamesmanship

Answer 246

Could be asked as “where is the most common location” ? = Tail (because in most cases it starts there).

Question 247

Orchitis overview

Answer 247

Typically progresses from epididymitis (isolated basically only occurs from mumps). It looks like asymmetric hyperemia.

Question 248

Orchitis typical

Answer 248

(1) Epididymitis ► (2) Epididymitis + Orchitis

Question 249

Orchitis mumps

Answer 249

Straight to Orchitis

Question 250

Orchitis impending infarct

Answer 250

The swelling o f the testicle can become so severe that it compromises venous flow. In this case you will see loss of diastolic flow (or reversal) - similar to the atypical torsion patterns. This is reported as a sign of “impending infarct.”

Question 251

Testicular Trauma overview

Answer 251

The big distinction is rupture vs fracture. Surgical intervention is required if there is testicular rupture. Intratesticular fracture, and hematomas (small) do not get surgery.

Question 252

Testicular Trauma rupture

Answer 252

Disrupted tunica albuginea, heterogenous testicle, poorly defined testicular outline

Question 253

Testicular Trauma fracture

Answer 253

Intact tunica albuginea, linear hypoechoic band across the parenchyma o f the testicle, well defined testicular outline.

Question 254

testicle Epidermoid Cyst

Answer 254

This is a benign mass of the testicle (no malignant potential), with an Aunt Minnie “onion skin” look, - alternating hypoechoic and hyperechoic rings. It’s relatively non-vascular relative to the rest of the testicle.

Question 255

Tubular Ectasia of the Rete Testis

Answer 255

This is a common benign finding, resulting from obliteration (complete or partial) o f the efferent ducts. It’s usually bilateral - and in older men. The location of the cystic dilation is next to the mediastinum testis. Think about this as a normal variant. It requires no follow up or further evaluation.

Question 256

Calcified Vas Deferens

Answer 256

You see this all the time in bad diabetics. This can be shown on plain film or CT.

Question 257

Testicular cancer overview

Answer 257

In general, hypoechoic solid intratesticular masses should be thought of as cancer until proven otherwise. Doppler flow can be helpful only when it is absent (can suggest hematoma - in the right clinical setting). If it’s extratesticular and cystic, it’s probably benign. The step 1 trivia is that cryptorchidism increases the risk of cancer (in both testicles), and is not reduced by orchiopexy. Most testicular tumors met via the lymphatics (retroperitoneal nodes at the level o f the renal hilum). The testable exception is choriocarcinoma, which mets via the blood. Most testicular cancers are germ cell subtypes (95%) - with seminomas making up about half o f those.

Question 258

Testicular cancer risk factors

Answer 258

Cryptorchidism (for both testicles), Gonadal Dysgenesis, Klinefelters, Trauma, Orchitis, and testicular microlithiasis (maybe).

Question 259

Testicular Microlithiasis

Answer 259

This appears as multiple small echogenic foci within thetestes. Testicular microlithiasis is usually an incidental finding in scrotal US examinations performed for unrelated reasons. It might have a relationship with Germ Cell Tumors (controversial). Follow-up in 6 months, then yearly is probably the recommendation - although this recommendation is controversial.

Question 260

Testicular Seminoma

Answer 260

This is the most common testicular tumor, and has the best prognosis as they are very radiosensitive. They are much more common (9x) in white people. The classic age is around 25. It usually looks like a homogenous hypoechoic round mass, which classically replaces the entire testicle. On MR1 they are usually homogeneously T2 dark (nonseminomatous GCTs are often higher in signal).

Question 261

Testicular Non-Seminomatous Germ Cell Tumors

Answer 261

Basically this is not a seminoma. We are talking about mixed germ cell tumors, teratomas, yolk sac tumors, and choriocarcinoma. They typically occur at a young age relative to seminomas (think teenager). They are more heterogeneous and have larger calcifications.

Question 262

Testicular Lymphoma overview

Answer 262

Just be aware that lymphoma can “hide” in the testes because of the blood testes barrier. Immunosuppressed patients are at increased risk for developing extranodal/ testicular lymphoma. Almost all testicular lymphomas are non-hodgkin B-cell subtypes. On US, the normal homogeneous echogenic testicular tissue is replaced focally or diffusely with hypoechoic vascular lymphomatous tissue.

Question 263

Testicular Lymphoma buzzword

Answer 263

multiple hypoechoic masses o f the testicle.

Question 264

Burned-Out Testicular Tumor

Answer 264

If you see large, dense calcifications with shadowing in the testicle of an old man this is probably what you should be thinking. The idea is that you’ve had spontaneous regression of a germ cell testicular neoplasm, that is now calcified. An important pearl is that there can still be viable tumor in there. Management is somewhat controversial and unlikely to be asked (most people pull them out).

Question 265

Testicular cancer staging pearl

Answer 265

Testicular mets should spread to the para-aortic, aortic, caval region (N1-N3). It’s an embryology thing. If you have mets to the pelvic, external iliac, and inguinal nodes - this is considered “nonregional” i.e. Ml disease. The exception is some kind of inguinal or scrotum surgery was done before the cancer manifested - but I wouldn’t expect them to get that fancy on the test. Just remember inguinal / pelvic nodes are non-regional and a higher stage (Ml).

Question 266

High Yield Tes ticle Tumor Trivia Seminoma

Answer 266

the most common and has the best prognosis (it melts with radiation)

Question 267

High Yield Tes ticle Tumor Trivia Multiple hypoechoic masses

Answer 267

lymphoma

Question 268

High Yield Tes ticle Tumor Trivia Homogenous and Microcalcifications

Answer 268

seminoma

Question 269

High Yield Tes ticle Tumor Trivia Cystic Elements and Macrocalcifications

Answer 269

Mixed Germ Cell Tumor / Teratoma

Question 270

High Yield Tes ticle Tumor Trivia METS

Answer 270

Most testicular tumors met via the lymphatics (choriocarcinoma mets via the blood - and tends to bleed like stink)

Question 271

High Yield Tes ticle Tumor Trivia gynecomastia

Answer 271

can be seen with Sertoli Leydig Tumors

Question 272

High Yield Tes ticle Tumor Trivia peutz jeghers

Answer 272

Sertoli Cell Tumors are also seen with Peutz-Jeghers

Question 273

Testicular cancer Elevated Beta hCG

Answer 273

Seminoma Choriocarcinoma (Non-S)

Question 274

testicular cancer Elevated AFP

Answer 274

Mixed Germ Cell (Non-S) Yolk Sac (Non-S)

Question 275

Male infertility Obstructive

Answer 275

``` Congenital bilateral absence o f the vas deferens (seen in Cystic Fibrosis), ejaculatory duct obstruction, prostatic cysts. Think about associated renal anomalies (Zinner Syndrome). ```

Question 276

Male infertility Non-Obstructive

Answer 276

Varicocele, Cryptorchidism, Anabolic Steroid Use, Erectile Dysfunction and “The Liberal Media.”

Question 277

Varicocele

Answer 277

This is the most common correctable cause of infertility. They can be unilateral or bilateral. Unilateral is much more common on the left. Isolated right sided should make you think retroperitoneal process compressing the right gonadal vein.

Question 278

Cryptorchidism

Answer 278

Undescended testes. The testicle is usually found in the inguinal canal. The testicle has an increased risk o f cancer (actually they both will - which is weird). It’s most commonly seen in premature kids (20%).

Question 279

Major complication association fo r cryptorchidism

Answer 279

* Malignant degeneration - o f both the undescended and contralateral testicle * Infertility * Torsion * Bowel Incarceration - related to the association o f indirect inguinal hernia

Question 280

Cryptorchidism gamesmanship

Answer 280

A good distractor would be “orchitis.” It’s a pathology that involves the balls, so it’s not totally far fetched. Obviously they can get IV orchitis... but not at a higher rate. It’s not a reported association - so don’t fall for that.

Question 281

Zebras and Syndromes Associated With Male Infertility

Answer 281

Pituitary adenoma making prolactin kallman sydrome (cant smell and infertile) klinefelter syndrom (tall and gynecomastia and infertile) zinner syndrome (renal agenesis and ipsilateral seminal vesicle cyst)

Question 282

Transgender

Answer 282

Gender self identity does not match their genetic / sex assigned identity at birth. The alternative is a “Cisgender ” - A man who identifies as a man (XY) or a woman who identifies as a woman (XX). Gender and sexual orientation are different things. Sexual Orientation is the emotion / sexual attraction to others. Transgender people are not necessarily homosexual. Gender self identity is different than who you want to fuck.

Question 283

Transgender Man

Answer 283

A female (XX) who identifies as the masculine (male) gender

Question 284

Transgender Woman

Answer 284

A male (XY) who identifies as the feminine (female) gender

Question 285

“Top and Bottom” Surgeries

Answer 285

Slang for breast & genital procedures (gender-affirming surgery)

Question 286

Vaginoplasty

Answer 286

Procedure to create a functional and cosmetically acceptable neovagina

Question 287

Penoscrotal inversion (PIV)

Answer 287

The most common procedure with the lowest complication rate. It involves orchiectomy and “penile disassembly” in a method similar to the induction ceremony of the feared Unsullied Army. The skin from the disassembled parts is inverted / folded back to create a tunnel. The clitoris is constructed using the native penile neurovascular anatomy.

Question 288

Intestinal Interposition

Answer 288

Second line strategy which involves using a segment of bowel (usually rectosigmoid colon) to create a neovagina by coloperineal anastomosis. They do this because there uhhh - how best to say this — is “insufficient tissue” from the penis to make the tunnel.

Question 289

Phalloplasty overview

Answer 289

Procedure to create a functional and cosmetically acceptable neopenis. Standing urination is a typical metric of success. Several months prior to constructing the neopenis - these patients typically undergo hysterectomy (+/- oophorectomy).

Question 290

Phalloplasty surgery

Answer 290

Vaginectomy and urethroplasty are performed using vascularized vaginal mucosa to try and elongate the urethra. Skin flaps often fail - but the “RFFF” or radial flap procedure is probably the most common. Most of these skin grafts use a “tube in tube” strategy. I can’t believe the details would be on the exam - but you can imagine they roll the skin and subcutaneous fat up to make something that looks like a dick. Maybe not the most impressive of dicks - but a dick none the less. Hey... you know what they say, it’s not the size of the dog in the fight - it’s the size of the fight in the dog. Not sure if this expression applies to a surgically created neo-phallus but I’m trying to be positive.

Question 291

Metoidioplasty

Answer 291

An alternate technique to phalloplasty - which has a lower complication rate. The downside is the length of the created neopenis is usually not enough to have sex, but they can still pee standing up (a major metric to success of the procedure). This technique is performed by first using hormones to hypertrophy the clitoris (like a female body builder). Then the urethra is lengthened (by dividing various ligaments) and anastomosed to the clitoris, which serves as the glans. Labia minora is gonna be the source for skin to construct the shaft.

Question 292

Testicular prostheses / Scrotoplasty

Answer 292

Generally made of silicone (high density on CT) and placed around 6 month post phalloplasty. Just like the those dick pumps you sometimes see in diabetics - a hydraulic pump apparatus can be placed - that thing will have tubing and be more water density.

Question 293

transgender complications

Answer 293

Older technique didn’t resect the vagina - these patients were prone to fistula between the neourethra and native vagina. DVT / PE is a post op risk if the patient is taking hormone therapy. Bleeding, infection, urinary complication (urethral stenosis etc) all can occur - as one might expect.

Question 294

transgender other usrgeries

Answer 294

that could come up on the exam include breast implants, and the various neck surgeries to make a dude look less like a dude (thyroid chondroplasty / tracheal shave) and sound less like a dude (glottoplasty, cricothyroid approximation).

Question 295

Menstrual Age:

Answer 295

Embryologic Age + 14 days

Question 296

Embryo

Answer 296

0-10 weeks (menstrual age)

Question 297

Fetus

Answer 297

> 10 weeks (menstrual age)

Question 298

Threatened abortion

Answer 298

Bleeding with closed cervix

Question 299

inevitable abortion

Answer 299

Cervical dilation and/or placental and/or fetal tissue hanging out

Question 300

incomplete abortion

Answer 300

Residual products in the uterus

Question 301

complete abortion

Answer 301

All products out

Question 302

missed abortion

Answer 302

Fetus is dead, but still in the uterus.

Question 303

Intradecidual Sign

Answer 303

This is the early gestational sac. When seen covered by echogenic decidua is very characteristic of early pregnancy. You can see it around 4.5 weeks. You want to see the thin echogenic line of the uterine cavity pass by (not stop at) the sac to avoid calling a little bit o f fluid in the canal a sac.

Question 304

Double Decidual Sac Sign

Answer 304

This is another positive sign of early pregnancy. It’s produced by visualizing the layers of decidua. small amount of fluid between the decidua vera and decidua capsularis

Question 305

Yolk Sac

Answer 305

This is the first structure visible within the GS. The classic teaching was you should always see it when the GS measures 8mm in diameter. The thing should be oval or round, fluid filled, and smaller than 6 mm. The yolk sac is located in the chorionic cavity, and hooked up to the umbilicus o f the embryo by the vitelline duct.

Question 306

Yolk Sac gone bad

Answer 306

``` The yolk sac shouldn’t be too big (> 6 mm), shouldn’t be too small (< 3 mm), and shouldn’t be solid or calcified. ```

Question 307

The Amnion

Answer 307

``` The membranes o f the amniotic sac and chorionic space typically remain separated by a thin layer of fluid, until about 14-16 weeks at which point fusion is normal. If the amnion gets disrupted before 10 weeks the fetus might cross into the chorionic cavity and get tangled up in the fibrous bands. This is the etiology of amniotic band syndrome, which can be terrible (decapitation, limb amputation, etc...). ```

Question 308

Double Bleb Sign

Answer 308

``` This is the earliest visualization o f the embryo. This is two fluid filled sacs (yolk and amniotic) with the flat embryo in the middle. ``` yolk sac early embryo anmiotic sac placenta site

Question 309

Crown Rump Length

Answer 309

This is typically used to estimate gestational age, and is more accurate than menstrual history. * Embryo is normally visible at 6 weeks.

Question 310

Anembryonic Pregnancy

Answer 310

A gestational sac without an embryo. When you see this, the choices are (a) very early pregnancy, or (b) non-viable pregnancy. The classic teaching was you should see the yolk sac at 8 mm (on TV). Just remember that a large sac (>8-10 mm) without a yolk sac, and a distorted contour is pretty reliable for a non-viable pregnancy

Question 311

Pseudogestational Sac

Answer 311

``` This is not the same thing as an anembryonic pregnancy. This is seen in the presence of an ectopic pregnancy. What you are seeing is a little bit of blood in the uterine cavity with surrounding bright decidual endometrium (charged up from the pregnancy hormones). ```

Question 312

Subchorionic Hemorrhage

Answer 312

These are very common. The thing to know is that the percentage o f placental detachment is the prognostic factor most strongly associated with fetal demise; hematoma greater than 2/3 the circumference o f the chorion has a 2x increased risk of abortion. Other trivia: women older than 35 have worse outcomes with these.

Question 313

Implantation Bleeding

Answer 313

This is a nonspecific term referring to a small subchorionic | hemorrhage that occurs at the attachment o f the chorion to the endometrium.

Question 314

Diagnostic of Pregnancy Failure

Answer 314

Crown-rump length of >7 mm and no heartbeat Mean sac diameter of >25 mm and no embryo No embryo with heartbeat >2 wk after a scan that showed a gestational sac without a yolk sac No embryo with heartbeat >11 days after a scan that showed a gestational sac with a yolk sac

Question 315

Suspicious for Pregnancy Failure

Answer 315

No embryo > 6 wk after last menstrual period Mean sac diameter of 16-24 mm and no embryo No embryo with heartbeat 13 days after a scan that showed a gestational sac without a yolk sac No embryo with heartbeat 10 days after a scan that showed a gestational sac with a yolk sac

Question 316

Pregnancy of Unknown Location overview

Answer 316

This is the vocabulary used when neither a normal IUP or ectopic pregnancy is identified in the setting of a positive b-hCG. Typically this just means it is a very very early pregnancy, but you can’t say that with certainty.

Question 317

Pregnancy of Unknown Location possibilities

Answer 317

1 - Normal Early Pregnancy 2 - Occult Ectopic 3 - Complete Miscarriage

Question 318

Pregnancy of Unknown Location

Answer 318

The management is follow up (serial b-hCG) and repeat US — assuming the patient is hemodynamically stable.

Question 319

High Risk for Ectopic

Answer 319

Hx o f PID, Tubal Surgery, Endometriosis, Ovulation Induction, Previous Ectopic, Use o f an IUD.

Question 320

Ectopic pregnancy locations

Answer 320

The majority of ectopic pregnancies (nearly 95%) occur in the fallopian tube (usually the ampulla). A small percentage (around 2%) are “interstitial” developing in the portion o f the tube which passes through the uterine wall. These interstitials are high risk, as they can grow large before rupture and cause a catastrophic hemorrhage. It is also possible (although very rare) to have implantation sites in the abdominal cavity, ovary, and cervix.

Question 321

Ectopic Bhcg

Answer 321

Always start down the ectopic pathway with a positive BhCG. At around 1500-2000 mlU/L you should see a gestational sac. At around 5000 mlU/L you should see a yolk sac. As a general rule, a normal doubling time makes ectopic less likely.

Question 322

Tubal Ring Sign

Answer 322

An echogenic ring, which surrounds an un-ruptured ectopic pregnancy. This is an excellent sign of ectopic pregnancy - and has been described as 95% specific.

Question 323

Heterotopic Pregnancy

Answer 323

This is a baby in the uterus and a baby in the tube (or other ectopic location). This is pretty rare, and typically only seen in women taking ovulation drugs, or with prior bad PID.

Question 324

The Big 3 to Remember with Ectopics (positive B-hCG)

Answer 324

(1) Live Pregnancy / Yolk Sac outside the uterus = Slam Dunk (2) Nothing in the uterus + anything on the adnexa (other than corpus luteum) = 75-85% PPV for ectopic a. A moderate volume o f free fluid increases this to 97% PPV (3) Nothing in the uterus + moderate free fluid = 70% PPV a. More risk if the fluid is echogenic

Question 325

Fetal Biometry and Fetal Growth

Answer 325

In the second and third trimesters, four standard measurements of fetal growth are made (Biparietal, Head Circumference, Abdominal Circumference, and Femur Length). The testable trivia seems to include what level you make the measurement, and what is and is not included (see chart).

Question 326

Fetal Measurement For Growth Biparietal Diameter “BPD”

Answer 326

Recorded at the level of the thalamus from the outermost edge of the near skull to the inner table of the far skull Affected by the shape of the fetal skull (false large from bachycephaly, false small form dolichocephaly

Question 327

Fetal Measurement For Growth Head Circumference

Answer 327

Recorded at the same slice as BPD Does NOT include the skin Affected less by head shape

Question 328

Fetal Measurement For Growth Abdominal Circumference

Answer 328

Recorded at the level o f the junction o f the umbilical vein and left portal vein Does NOT include the subcutaneous soft tissues

Question 329

Fetal Measurement For Growth Femur Length

Answer 329

Longest dimension of the femoral shaft Femoral epiphysis is NOT included

Question 330

Estimated Fetal Weight

Answer 330

This is calculated by the machine based or either (1) BPD and AC, or (2) AC and FL.

Question 331

Gestational Age (GA)

Answer 331

Ultrasound estimates o f gestation age are the most accurate in early pregnancy (and become less precise in the later portions). Age in the first trimester is made from crown rump length. Second and third trimester estimates for age are typically done using BPD, HC, AC, and FL - and referred to as a “composite GA.”

Question 332

Gestation Age (Less Good Later in the Pregnancy) First Trimester - Crown Rump Length

Answer 332

Accurate to 0.5 weeks

Question 333

Gestation Age (Less Good Later in the Pregnancy) 2nd and 3rd Trimester - “Composite GA”

Answer 333

Accurate to 1.2 weeks (between 12 and 18 weeks) Accurate to 3.1 weeks (between 36 and 42 weeks)

Question 334

Readings Suggestive of IUGR

Answer 334

* Estimated Fetal Weights Below 10th percentile * Femur Length / Abdominal Circumference Ratio (F /AC) > 23.5 * Umbilical Artery Systolic / Diastolic Ratio > 4.0

Question 335

Readings Suggestive of IUGR Not A ll is lost

Answer 335

If the kid is measuring small, he might just be a little guy. If he has normal Doppler studies - most of the time they are ok.

Question 336

Readings Suggestive of IUGR Maybe All is lost

Answer 336

If the kid is measuring small, suggesting IUGR, and he has oligohydramnios (AFI < 5) or polyhydramnios, he/she is probably toast.

Question 337

Readings Suggestive of IUGR Trivia

Answer 337

Most common cause for developing oligohydramnios during the 3rd trimester = Fetal Growth Restriction associated with Placental Insufficiency.

Question 338

Intrauterine Growth Restriction Asymmetric overview

Answer 338

Think about this as a restriction o f weight followed by length. It is the more common o f the two types. The head will be normal in size, with the body being small. Some people call this “head sparing,” as the body tries to protect the brain. You see this mainly in the third trimester, as a result o f extrinsic factors.

Question 339

Intrauterine Growth Restriction Asymmetric classic scenario

Answer 339

The classic scenario would be normal growth for the first two trimesters, with a normal head / small body (small abdominal circumference) in the third trimester - with a mom having chronic high BP / pre-eclampsia.

Question 340

Intrauterine Growth Restriction Asymmetric causes

Answer 340

There are a bunch o f causes. I recommend remembering these three: High BP, Severe Malnutrition, Ehler-Danlos.

Question 341

Intrauterine Growth Restriction Symmetric overview

Answer 341

This is a global growth restriction, that does NOT spare the head. This is seen throughout the pregnancy (including the first trimester). The head and body are both small. This has a much worse prognosis, as the brain doesn’t develop normally.

Question 342

Intrauterine Growth Restriction Symmetric causes

Answer 342

There are also a bunch o f causes. I recommend remembering these: TORCH infection, Fetal Alcohol Syndrome / Drug Abuse, Chromosomal Abnormalities, and Anemia.

Question 343

Symmetric IUGR acronym

Answer 343

- Small Head - Skinny Body - Same Throughout Pregnancy - Syphilis (Among other TORCHs) - Scotch Whiskey (Fetal EtOH) - Some Extra Chromosomes

Question 344

Asymmetric IUGR acronym

Answer 344

- Abdomen is small - Aching Belly (Malnutrition) - Abnormally High BP - “Alastic” skin (Ehler Danlos) - Asymmetric Time Interval (primarily seen in 3rd trimester)

Question 345

Umbilical Artery Systolic I Diastolic Ratio overview

Answer 345

The resistance in the umbilical artery should progressively decrease with gestational age. The general rule is 2-3 at 32 weeks. The ratio should not be more than 3 at 34 weeks. An elevated S/D ratio means there is high resistance. High resistance patterns are seen in pre-eclampsia and IUGR. Worse than an elevated ratio, is absent or reversed diastolic flow - this is associated with a very poor prognosis.

Question 346

Umbilical Artery Systolic I Diastolic Ratio the way i remember this

Answer 346

I think about the kid starting out as a clump of cells/mashed up soup. Early on he/she is basically just a “muscle.” Then as he/she gets closer and closer to viable age he/she becomes more like a “brain.” Once you think about it like that - muscle vs brain, it’s much easier to understand why the diastolic flow goes up (S/D ratio goes down).

Question 347

Umbilical Artery Systolic I Diastolic Ratio remember

Answer 347

Remember the brain is always on, so it needs continuous flow. Muscles are only on when you need to perform amazing feats of strength. So more brain = more diastolic flow. This also explains why absent or reversed diastolic flow is so devastatingly bad. In fact, the evil socialist health care systems in Europe use carotid ultrasound as a cheap brain death test (no diastolic flow in the ICA = brain dead). Coincidently, the absence of diastolic flow in the ICA is also used in many American Radiology Departments as hiring criteria for the QA Officer.

Question 348

Biophysical Profile:

Answer 348

This thing was developed to look for acute and chronic hypoxia. Points are assigned (2 for normal, 0 for abnormal). A score of 8-10 is considered normal. To call something abnormal, technically you have to be watching for 30 mins.

Question 349

Components of Biophysical Profile

Answer 349

Amniotic Fluid: At least 1 pocket measuring > 2 cm in a vertical plane: Assess Chronic Hypoxia Fetal Movement: 3 discrete movements: Assess Acute Hypoxia Fetal Tone: 1 episode of fetal extension from flexion: Assess Acute Hypoxia Fetal Breathing: 1 episode of “Breathing motion” lasting 30 sec: Assess Acute Hypoxia Non-stress Test: 2 or more fetal heart rate accelerations of at least 15 beats per minute for 30 seconds or longer: Assess Acute Hypoxia

Question 350

Macrosomia

Answer 350

Babies that are too big (above the 90th percentile). Maternal diabetes (usually gestational, but could be type 2 as well), is the most common cause. As a point of trivia, type 1 diabetic mothers can also have babies that are small secondary to hypoxia from microvascular disease of the placenta. The big issue with being too big is complications during delivery (shoulder dystocia, brachial plexus injury) and after delivery (neonatal hypoglycemia, meconium

Question 351

Erb’s Palsy

Answer 351

Injury to the upper trunk of the brachial plexus (C5-C6), most commonly seen in shoulder dystocia (which kids with macrosomia are at higher risk for aspiration). If you see an aplastic or hypoplastic humeral head / glenoid in a kid, you should immediately think about an Erbs Palsy. Clinical Correlation Recommended.

Question 352

Amniotic Fluid overview

Answer 352

Early on, the fluid in the amnion and chorionic spaces is the result of filtrate from the membranes. After 16 weeks, the fluid is made by the fetus (urine). The balance of too much (polyhydramnios) and too little (oligohydramnios) is maintained by swallowing of the urine and renal function. In other words, if you have too little fluid you should think kidneys aren’t working. If you have too much fluid you should think swallow or other GI problems. Having said that, a common cause of too much fluid is high maternal sugars (gestational diabetes). Fine particulate in the fluid is normal, especially in the third trimester.

Question 353

Amniotic Fluid Index measuremnents

Answer 353

Made by measuring the vertical height of the deepest fluid | pocket in each quadrant of the uterus, then summing the 4 measurements.

Question 354

Amniotic Fluid Index normal

Answer 354

Normal is 5-20.

Question 355

Amniotic Fluid Index oligohydramnios

Answer 355

-AFI < 5 | Not Pee’n Enough-Bad Kidneys

Question 356

Amniotic Fluid Index polyhydramnios

Answer 356

-AFI > 20 or -Single Pocket > 8 cm Not Drinking Enough Pee-Bad Gl

Question 357

Normal Development Brain

Answer 357

Choroid plexus is large and echogenic. There should be less than 3 mm of separation o f the choroid plexus from the medial wall o f the lateral ventricle (if more it’s ventriculomegaly). The cistema magna should be between 2 mm-11 mm (too small think Chiari II, too large think Dandy Walker).

Question 358

Normal Development Face/neck

Answer 358

The “fulcrum” of the upper lip is normal, and should not be called a cleft lip.

Question 359

Normal Development lungs

Answer 359

The lungs are normally homogeneously echogenic, and similar in appearance to the liver.

Question 360

Normal Development heart

Answer 360

The only thing to know is that papillary muscle can calcify “Echogenic Foci in the ventricle,” and although this is common and can mean nothing - it’s also associated with an increased risk o f Downs (look hard for other things).

Question 361

Normal Development abdominal

Answer 361

If you only see one artery adjacent to the bladder, you have yourself a two vessel cord. Bowel should be less than 6mm in diameter. Bowel can be moderately echogenic in the 2nd and 3rd trimester but should never be more than bone. The adrenals are huge in newborns, and are said to be 20 x their relative adult size.

Question 362

Two Vessel Cord - Gamesmanship

Answer 362

There are two main ways to show a two vessel cord. The first one is a single vessel running lateral to the bladder down by the cord insertion. The second is to show the cord in cross section with two vessels.

Question 363

Cystic Rhombencephalon

Answer 363

The normal rhombencephalon is present as a cystic structure in the posterior fossa around 6 - 8 weeks. D o n ’t call it a Dandy-Walker malformation, for sure that will be a distractor.

Question 364

Physiologic Midgut Herniation

Answer 364

The midgut normally herniates into the umbilical cord around 9-11 weeks. Don ’/ call it an omphalocele, for sure that will be a distractor.

Question 365

Placenta and cord normal

Answer 365

You can first start to see the placenta around 8 weeks (focal thickening along the periphery o f the gestational sac). It should be shaped like a disc around 12 weeks. The normal sonographic appearance is “granular” with a smooth cover (the chorion). Underneath the basal surface there is a normal retroplacental complex o f decidual and myometrial veins.

Question 366

Placenta and cord normal

Answer 366

You can first start to see the placenta around 8 weeks (focal thickening along the periphery o f the gestational sac). It should be shaped like a disc around 12 weeks. The normal sonographic appearance is “granular” with a smooth cover (the chorion). Underneath the basal surface there is a normal retroplacental complex o f decidual and myometrial veins.

Question 367

Placenta and cord Normal Placental Aging

Answer 367

As the placenta ages it gets hypoechoic areas, septations, and randomly distributed calcifications.

Question 368

Placenta and cord Venous Lakes

Answer 368

These are an incidental finding o f no significance. They look like focal hypoechoic areas under the chorionic membrane (or within the placenta). You can sometimes see slow flow in them.

Question 369

Variant Placental Morphology

Answer 369

Bilobed placenta Succenturiate lobe Circumvallate placenta

Question 370

Bilobed placenta

Answer 370

Two near equal sized lobes - connected by a thin strip. Increased risk o f type 2 vasa previa (vessel cross the internal os), post partum hemorrhage from retained placental tissue, and velamentous insertion of the cord

Question 371

Succenturiate Lobe

Answer 371

One or more small accessory lobes Increased risk o f type 2 vasa previa, post partum hemorrhage from retained placental tissue

Question 372

Circumvallate Placenta

Answer 372

Rolled placental edges with smaller chorionic plate High risk for placental abruption and IUGR

Question 373

Placental Thickness too thin

Answer 373

<1 cm Placental Insufficiency, Maternal Hypertension, Maternal DM, Trisomy 13, Trisomy 18, Toxemia o f Pregnancy

Question 374

Placental Thickness too thick

Answer 374

>4cm Fetal Hydrops, Maternal DM, Severe Maternal Anemia, Congenital Fetal Cancer, Congenital Infection. Placental Abruption

Question 375

Placental Abruption

Answer 375

Painful

Question 376

Placental Abruption buzzword

Answer 376

Myometrial Contractions / Fibroids will displace the retroplacental complex

Question 377

THIS vs THAT: Placental Abruption vs Myometrial Contraction I Fibroid

Answer 377

Placental Abruption will disrupt the retroplacental complex o f blood vessels

Question 378

Placenta Previa: overview

Answer 378

Painless This is a low implantation of the placenta that covers part of or all of the internal cervical os. A practical pearl is that you need to have an empty bladder when you look for this (full bladder creates a false positive). Several subtypes - as seen in my awesome little chart below.

Question 379

Placenta Previa: buzzword

Answer 379

“painless vaginal bleeding in the third trimester.”

Question 380

Placenta Previa: low lying

Answer 380

Margin is within 2 cm of the internal cervical os

Question 381

Placenta Previa: marginal

Answer 381

Extends to the edge of the internal cervical os (but doesn’t cover it)

Question 382

Placenta Previa: complete

Answer 382

covers the internal os

Question 383

Placenta Previa: central

Answer 383

centered of the internal os

Question 384

Placenta Creta

Answer 384

This is an abnormal insertion of the placenta, which invades the myometrium. The severity is graded with fancy sounding Latin names. The risk factors include prior C-section, placenta previa, and advanced maternal age. The sonographic appearance varies depending on the severity, but generally speaking you are looking for a “moth-eaten” or “Swiss cheese” appearance o f the placenta, with vascular channels extending from the placenta into the myometrium (with turbulent flow on Doppler). Thinning of the myometrium (less than 1mm) is another sign. This can be serious business, with life threatening bleeding sometimes requiring hysterectomy.

Question 385

Placenta Creta Risk factors

Answer 385

Risk factors are prior c-section. and placenta previa

Question 386

Placenta Accreta

Answer 386

Most common (75%) and mildest form. The villi attach to the myometrium, without invading.

Question 387

Placenta Increta

Answer 387

Villi partially invade the myometrium

Question 388

Placenta Percreta

Answer 388

The really bad one. Villi penetrate through the myometrium or beyond the serosa. Sometimes there is invasion of the bladder or bowel.

Question 389

Placenta creta lating

Answer 389

“Ad" = To (accreta) "In " = Into (increta) "Per" = Through (percreta)

Question 390

Placenta Chorioangioma

Answer 390

This is basically a hamartoma of the placenta, and is the most common benign tumor of the placenta. These are usually wellcircumscribed hypoechoic masses near the cord insertion. Flow within the mass pulsating at the fetal heart rate is diagnostic (they arc perfused by the fetal circulation). They almost always mean nothing, but if they are large (> 4 cm) and multiple (“choriangiomatosis”) they can sequester platelets, and cause a high output failure (hydrops).

Question 391

THIS vs THAT: Placental Chorioangioma vs Placental Hematoma

Answer 391

Chrorioangioma has pulsating Doppler flow Hematoma does NOT

Question 392

Normal Cord

Answer 392

Should have 3 vessels (2 arteries, 1 vein).

Question 393

Two Vessel Cord

Answer 393

This is a normal variant - seen in about 1% of pregnancies. Usually the left artery is the one missing. This tends to occur more in twin pregnancies and maternal diabetes. There is an increased association with chromosomal anomalies and various fetal malformations (so look closely). Having said that, in isolation it doesn’t mean much.

Question 394

Velamentous Cord Insertion

Answer 394

This is the term for when the cord inserts into the fetal membranes outside the placental margin, and then has to travel back through the membranes to the placenta (between the amnion and the chorion). It’s more common with twins, and increases the risk of intra-uterinc growth restriction and growth discordance among twins.

Question 395

Marginal Cord Insertion

Answer 395

This is basically almost a velamentous insertion (cord is within 2 cm of the placental margin). It’s also seen more in twin pregnancies.

Question 396

Vasa Previa

Answer 396

Fetal vessels that cross (or almost cross) the internal cervical os. It’s seen more in twin pregnancies, and variant placental morphologies. There arc two types: * Type 1: Fetal vessels connect to a velamentous cord insertion within the main placental body * Type 2: Fetal vessels connect to a bilobcd placenta or succenturiate lobe.

Question 397

Nuchal Cord

Answer 397

This is the term used to describe a cord wrapped around the neck of the fetus. Obviously this can cause problems during delivery

Question 398

Umbilical Cord Cyst

Answer 398

These arc common (seen about 3% of the time) and are usually single (but can be multiple). As a point of completely irrelevant trivia, you can divide these into false and true cysts. True cysts are less common, but have fancy names so they are more likely to be tested. Just know that the omphalomesenteric duct cyst is usually peripheral, and the allantoic cyst is usually central. If the cysts persist into the 2nd or 3rd trimester then they might be associated with trisomy 18 and 13. You should look close for other problems.

Question 399

Down syndrome Congenital Heart Disease

Answer 399

More than half o f fetuses (or feti, if you prefer) with Downs have congenital heart issues, - most commonly AV canal and VSD

Question 400

Down syndrome Duodenal Atresia

Answer 400

Most common intra abdominal pathology associated with Downs (hard to see before 22 weeks)

Question 401

Down syndrome Short Femur Length

Answer 401

Not specific

Question 402

Down syndrome Echogenic Bowel

Answer 402

Not Specific (can be seen with obstruction, infection, CF, ischemia, and lots o f other stuff)

Question 403

Down syndrome Choroid Plexus Cyst

Answer 403

Not Specific, and actually seen more with Trisomy 18. It should prompt a close survey for other findings (normal if in isolation)

Question 404

Down syndrome Nuchal Translucency

Answer 404

Translucency > 3mm in the first trimester,

Question 405

Down syndrome Nuchal Fold Thickness

Answer 405

Thickness > 6mm in the second trimester- nonspecific and can also be seen with Turners

Question 406

Down syndrome Echogenic Focus in Cardiac Ventricle

Answer 406

Not Specific, but increased risk o f Downs x 4

Question 407

Nuchal Lucency:

Answer 407

Measured between 9-12 weeks, this anechoic area between the neck/ occiput and the skin should be less than 3 mm. Measurements > 3 mm are associated with Downs (trisomy 2 1 ) or other chromosomal abnormalities. Positioning of the neck is critical to avoid false positives. The ideal positioning is a neutral neck, with the nasal bone visualized, and the head in the mid-sagittal position. A well delineated skin edge. Maternal blood sample also analyzed for free Beta hCG and pregnancy associated plasma protein-A (PAPP-A).

Question 408

Amniotic Band Syndrome overview

Answer 408

The fetus needs to stay in the amniotic cavity, and stay the hell out of the chorionic cavity. If the amnion gets disrupted and the fetus wanders / floats into the chorionic cavity he/she can get caught in the sticky fibrous septa. All kinds of terrible can result ranging from decapitation, to ann/leg amputation.

Question 409

Amniotic Band Syndrome This is most likely to be shown in one of two ways

Answer 409

(1) X-ray of a hand or baby gram showing fingers amputated or a hand/arm amputated - with the remaining exam normal, or (2) Fetal ultrasound with the bands entangling the arms or legs of a fetus.

Question 410

Hydrops overview

Answer 410

Fetal hydrops is bad news. This can be from immune or non-immune causes. The most common cause is probably Rh sensitization from prior pregnancy. Some other causes include; TORCHS, Turners, Twin Related Stuff, and Alpha Thalassemia. Ultrasound diagnosis is made by the presence of two of the following: pleural effusion, ascites, pericardial effusion, and Subcutaneous Edema. A sneaky trick is to instead show you a thickened placenta (> 4-5cm) "placentomegaly” - they call it, although I think it’s much more likely to show a pleural effusion and pericardial effusion.

Question 411

Hydrops quick

Answer 411

Body Wall Edema, Pleural Effusion, Ascites

Question 412

-C h ia r i II / Open N e u ra l T u b e D e fe c t

Answer 412

I think at least some general idea of the mechanism for this pathology is helpful for understanding the ultrasound findings. There are a bunch of purposed mechanisms, and of course they all think they are right. I don’t give a shit which one is the “real mechanism,” I just picked the one that helps me understand the findings. So this is the one I like: You have a hole in your back from a neural tube defect (Step 1 trivia = not enough folate). The hole in your back (“myelomeningocele”) lets CSF drip out. So you end up with a low volume o f CSF. The CSF volume needs to be at a certain pressure to distend the ventricular system. If it’s under distended then the hindbrain structures drop into a caudal position. This caudal herniation of the cerebellar vermis, brainstem, and 4th ventricle is the hallmark o f Chiari II. This caudal herniation o f the cerebellum into the foramen magnum obliterate the normal contour of the vermis, creating the contour o f a banana. If you can think about a normal pressure in the developing ventricular system being necessary for the brain to stretch into a normal shape, then it isn’t a far stretch to think about this normal pressure being needed to shape the skull correctly, too. The low pressure and abnormal distention of the developing brain results in incomplete stretching of the postal (front part) skull. The result is a “lemon shaped” rostral skull. The key point (testable) is that this lemon shape goes away in the 3rd trimester. So it’s only present in the 2nd trimester. The way I remember this is that the problem was from a lack o f volume. Once the brain grows big enough (even if there isn’t enough CSF distention) it still gets big enough to put a normal curve on that rostral skull. So they “grow” out o f it.

Question 413

-C h ia r i II / Open N e u ra l T u b e D e fe c t testable trivia

Answer 413

* Both banana and lemon signs are classic for the Chiari II / Spina Bifida Path * The banana sign is present in both 2nd and 3rd trimesters * The lemon sign is only in the 2nd trimester (you grow out o f it). * The banana sign is more sensitive and specific * The lemon sign is less sensitive and specific; it can also be seen in Dandy Walker, Absent Corpus Callosum, Encephaloceles, etc... Having said that if you see it on the test it’s Chiari 2 + Open NTD. * Hydrocephalus is also seen with Chiari II + Open NTD - but only later in gestation, and only when it’s severe.

Question 414

Banana

Answer 414

-Loss of the normal bilobed shaped of the cerebellum

Question 415

Lemon

Answer 415

-Flat / Concave Frontal Bones

Question 416

Ventriculomegaly overview

Answer 416

There are multiple causes including hydrocephalus (both communicating and non-communicating), and cerebral atrophy. Obviously this is bad, and frequently associated with anomalies.

Question 417

Ventriculomegaly things to know

Answer 417

* Aqueductal Stenosis is the most common cause o f non-communicating hydrocephalus in a neonate * Ventricular atrium diameter > 10 mm = too big * “Dangling choroid” hanging off the wall more than 3 mm = too big

Question 418

V e n tric u lom e g a ly - S h o w s

Answer 418

dangling choroid

Question 419

Choroid Plexus Cyst

Answer 419

This is one o f those incidental findings that in isolation means nothing. Having said that, the incidence o f this finding is increased in trisomy 18. trisomy 2 1 , Turner’s Syndrome, and Klinefelter Syndrome.

Question 420

Facial Clefts

Answer 420

This is the most common fetal facial anomaly. About 30% of the time you are dealing with chromosome anomalies. Around 80% of babies with cleft lips have cerebral palsy. You can see cleft lips, but cleft palate (in isolation) is very hard to see.

Question 421

Cystic Hygroma

Answer 421

If they show you a complex cystic mass in the posterior neck, in the antenatal period, this is the answer. The follow-up is the association with Turners and Downs.

Question 422

Anencephaly

Answer 422

This is the most common neural tube defect. You have total absence of the cranial vault and brain above the level of the orbits. Obviously this is not compatible with life.

Question 423

Anencephaly quick

Answer 423

no brain/vault above the orbits

Question 424

Congenital Diaphragmatic Hernia

Answer 424

Abdominal contents push into the chest. Nearly all are on the left (85%). The things to know is that it (1) causes a high mortality because o f its association with pulmonary hypoplasia, and (2 ) that all the kids are malrotated (it messes with normal gut rotation). If they show this it will either be (a) a newborn chest x-ray, or (b) a 3rd trimester MRI.

Question 425

Echogenic Intracardiac Focus (EIF)

Answer 425

This is a calcification seen in a papillary muscle (usually in the left ventricle). You see them all the time, they don’t mean that much but are seen at a higher rate Trisomy 21 (12%) and Trisomy 13. So you are supposed to look for more features.

Question 426

Echogenic Intracardiac Focus (EIF) highest yield trivia

Answer 426

* It occurs in the normal general population - around 5%, | * It occurs more in Downs patients around 12%.

Question 427

Abnormal Heart Rate

Answer 427

Tachycardia is defined as a rate > 180 bpm. Bradycardia is defined as a rate < 100 bpm.

Question 428

Double Bubble

Answer 428

This is described in detail in the Peds Chapter. Just realize this can be shown with antenatal ultrasound or MRI. It’s still duodenal atresia.

Question 429

Echogenic Bowel

Answer 429

This can be a normal variant but can also be associated with significant badness. Normally bowel is isoechoic to the liver. If it’s equal to the iliac crest bone then it’s too bright. The DDx includes CF, Downs and other Trisomies, Viral Infections, and Bowel Atresia.

Question 430

Sacrococcygeal Teratoma

Answer 430

This is the most common tumor of the fetus or infant. These solid or cystic masses are typically large and found either on prenatal imaging or birth. They can cause mass effect on the GI system, hip dislocation, nerve compression causing incontinence, and high output cardiac failure. Additionally, they may cause issues with premature delivery, dystocia, and hemorrhage o f the tumor. They are usually benign (80%). Those presenting in older infants tend to have a higher malignant potential. The location of the mass is either external to the pelvis (47%), internal to the pelvis (9%), or dumbell’d both inside and outside (34%).

Question 431

Autosomal Recessive Polycystic Kidney Disease

Answer 431

The classic look is massively enlarged bilateral kidneys with oligohydramnios. Additional details in the Peds chapter.

Question 432

Posterior Urethral Valves

Answer 432

The classic look is bilateral hydro on either fetal US or 3rd Trimester MRI.

Question 433

Short Femur

Answer 433

A short femur (below the 5th percentile) can make you think o f a skeletal dysplasia.

Question 434

Incompetent Cervix

Answer 434

When shortened, the cervix is associated with a high risk of premature delivery. You call it short when the endocervical canal is < 2.5 cm in length.

Question 435

Hydronephrosis

Answer 435

occurs in 80% of pregnancies (mechanical compression of the ureters is likely the cause). It tends to affect the right more than the left (dextrorotation of the pregnant uterus).

Question 436

Things That Grow During Pregnancy:

Answer 436

* Babies * Splenic Artery Aneurysms * Renal AMLs * Fibroids

Question 437

Uterine Rupture

Answer 437

You see this most commonly in the 3rd trimester at the site of prior csection. Other risk factors worth knowing are the unicomuate uterus, prior uterine curettage, “trapped uterus’' (persistent retroflexion from adhesions), and interstitial implantation.

Question 438

HELLP Syndrome

Answer 438

Hemolysis, Elevated Liver Enzymes, Low Platelets. This is the most severe form of pre-eclampsia, and favors young primigravid women in their 3rd trimester. It’s bad news and 20-40% end up with DIC. If they are going to show this, it will be as a subcapsular hepatic hematoma in pregnant (or recently pregnant) women.

Question 439

Peripartum Cardiomyopathy

Answer 439

This is a dilated cardiomyopathy that is seen in the last month of pregnancy to 5 months postpartum. The cardiac MRI findings include a global depressed function, and non-vascular territory subepicardial late Gd enhancement - corresponding to cellular lymphocytic infiltration.

Question 440

Sheehan Syndrome

Answer 440

This is pituitary apoplexy seen in postpartum female who suffer from large volume hemorrhage (causing acute hypotension). The pituitary grows during pregnancy, and if you have an acute hypotensive episode you can stroke it out (it bleeds). The look on MR is variable depending on the time period, acute it will probably be T1 bright (if they show a picture). Ring enhancement around an empty sella is a late look.

Question 441

Ovarian Vein Thrombophlebitis

Answer 441

This can be a cause of postpartum fever. Risk factors include C-section and endometritis. The right side is affected five times more often than the left. They could show you an enlarged ovary and a thrombosed adjacent ovarian vein.

Question 442

Retained Products of Conception

Answer 442

The typical clinical story is continued bleeding after delivery (or induced abortion). The most common appearance is an echogenic mass within the uterine cavity. The presence or absence of flow is variable, you can have lots or you can have none. A sneaky way to show this is irregular thickening of the endometrium (> 1 0mm) with some reflective structures and shadowing - representing the fetal parts. You can also think about RPOC when the endometrial thickness is > 5 mm following dilation and curettage. Testable associations include: medical termination of pregnancy (abortion), second trimester miscarriage, and placenta accreta.

Question 443

Endometritis

Answer 443

Broadly speaking, it is an inflammation or infection o f the endometrium. The history will be (if you are given one) fever, and uterine tenderness and recent c-section (or prolonged labor). On ultrasound you will see a thickened, heterogenous endometrium, with or without fluid / air.

Question 444

Placentation Terminology

Answer 444

So you can have monozygotic twins (identical) or dizygotic twins (not-identical). The dizygotics are always dichorionic and diamniotic. The placenta of the monozygotics is more variable and depends on the timing of fertilized ovum splitting (before 8 days = diamniotic, after 8 days = monoamniotic). As a point of trivia, a late splitting (after 13 days) can cause a conjoined twin. As a general rule, the later the split the worse things do (monoamniotics have more bad outcomes - they get all tangled up, and the conjoined ones have even more problems).

Question 445

Membrane Thickness

Answer 445

To differentiate the different types, some people use a method classifying thin and thick membranes. Thick = “easy to see” 1-2 mm, Thin = “hard to see.” Thick is supposed to be 4 layers (dichorionic). Thin is supposed to be 2 layers (monochorionic). Obviously this method is very subjective.

Question 446

Twin-Peak Sign

Answer 446

A beak-like tongue between the two membranes of dichorionic diamniotic fetuses. This excludes a monochorionic pregnancy.

Question 447

T Sign

Answer 447

Think about this as basically the absence of the twin peak sign. You don’t see chorion between membrane layers. T sign = monochorionic pregnancy.

Question 448

Twin peack sing =

Answer 448

dichorionic

Question 449

t sign =

Answer 449

monochorionic

Question 450

Twin Growth

Answer 450

You can use normal growth charts in the first and second trimester (but not the third). The femur length tends to work best for twin age in later pregnancy. More than 15% difference in fetal weight or abdominal circumference between twins is considered significant.

Question 451

Twin- Twin Transfusion

Answer 451

This occurs in monochorionic twins when a vascular communication exists in the placenta. You end up with one greedy fat twin who takes all the blood and nutrients, and one skinny wimpy looking kid who gets the scraps. The somewhat counter intuitive part is that the skinny kid actually does better, and the fat one usually gets hydrops and dies. You are going to have unequal fluid in the amniotic sacs, with the donor (skinny) twin having severe oligohydramnios and is sometimes (*buzzword) “stuck to the wall of the uterus,” or “shrink w rapped.” The fat twin floats freely in his polyhydramniotic sac. The donor (skinny) twin will also have a high resistance umbilical artery.

Question 452

Twin Reversed Arterial Perfusion Syndrome

Answer 452

You can get intraplacental shunting that results in a “pump twin” who will pump blood to the other twin. The other twin will not develop a heart and is typically referred to as an “acardiac twin.” The acardiac twin will be wrecked (totally deformed upper body). The “pump twin” is usually normal, and does ok as long as the strain on his/her heart isn’t too much. If the acardiac twin is really big (> 70% estimated fetal weight o f the co-twin) then the strain will usually kill the pump twin. They could show this as a Doppler ultrasound demonstrating umbilical artery flow toward the acardiac twin, or umbilical vein flow away from the acardiac twin (opposite of normal flow).

Question 453

One Dead Twin

Answer 453

``` At any point during the pregnancy one of the twins can die. It's a bigger problem (for the surviving twin) if it occurs later in the pregnancy. “Fetus Papyraceous” is a fancy sounding Latin word for a pressed flat dead fetus. ```

Question 454

“Twin-Embolization Syndrome”

Answer 454

when you have embolized, necrotic, dead baby being transferred to the living fetus (soylent green is people!). This can result in D1C, tissue ischemia, and infarct. By the way, a testable point is that this transfer can only occur in a monochorionic pregnancy.