TEST 3 STUDY GUIDE EMBRYOLOGY, INFERTILITY, US IN OB Flashcards
____ are derived from primordial germ cells , multiply quickly and w/ degeneration at birth there are 1-2 million.
oogonium
oogonia differentiate into primary oocytes w/ a single layer of granulosa cells from the cortical cord forming the _____ _____; this process remains arrested untill puberty.
primordial Follicles (ovaries)
true or false?the ductus venosus shunts oxygenated blood past the liver into the IVC
true
what is the first system to become functional in the embryo?
cardiovascular
the celiac artery, SMA, and IMA develop from the ______ _____ _____
vitelline artey complex
gestational (postovulatory) age is considered from:
2 weeks from the first day of the LMP
What caries oxygenated blood from the embryonic portion of the placenta to the embryonic tubular heart?
umbilical veins
the pancreas is formed from the ___
foregut
during embryonic life, what is the spleen responsible for?
producing RBC and WBC
the external genitals of male and femaly embryos are undifferentiated until the 8th week of gestation; before that all embryos have a region known as the _____ _____.
genital tubercle
when does neural tube formation take place?
3 to 4 weeks gestation
the liver and pancreas originate in the embryonic ____
duodenum
the _____ & ____ systems develop simultaneously arising from mesoderm on common ridge.
urinary and reproductive
congenital anomalies of the ___ system is highly associated with the ____ system.
urinary; reproductive
the _____ ____ (Woofian duct) develops into the urinary system.
Mesonephric duct (Woofian duct)
true or false? gonadal ridges are formed before the ovaries or testies
true
the ______ _____ (Mullerian duct) developos into the female reproductive system
paramesonephric ducts (Mullerian duct)
The mesonephric ducts (Wolffian ducts) and paramesonephric ducts (Mullerian duct) arise from mesoderm on ____ _____.
common ridges
the female reproductive system development is linked to ___ ___
renal system
what is the formula to calculate pediatric ovarian size?
prolate ellipse formula
L x H x W x 0.523= ___cm3
what is the prolate elipse formula?
measure pediatric ovarian size
prolate elips formula: L x H x W x 0.523= ___ cm3
when do the external genitalia develop by?
12 weeks
no morphologic indication of sex until __ weeks. until this point male and female embryos appear identical
9
what type o sonography outlines vagina to see pelvic mass or complex congenital abnormality?
hydrosonovaginography
what is the measurement of the bladders smooth thin wall when full or partial full?
< 3 mm if full or <5 mm if partial full
what should we look for when imaging the bladder and how do we angle the transducer?
look for bilateral ureteral jets
angle transducer cauded to view bladder neck and urethra
what do we look for post void of urinary bladder?
check for urinary residual, or to seperate cyst from bladder
what is the newborn uterus measurements and what does it look like?
- prominent 3.5 cm thickened, bright echogenic endometrial lining
- teardrop shape (inverse pear) shape until 2-3 months old
what is the measurement of the prepubertal uterus and what shape is it?
prepubertal uterus:
- 2.5-3 cm length
- fundus to cx ratio decreases to 1:1
- inverse pear shape
- endometrial stripe not visualized (because endometrium doesnt thicken until period starts)
what supples the uterus with blood?
uterine arteries branch off internal iliac arteries
true or false? it is possible to see flow in myometrial tissue w/ no flow in endometrium
true
how is the vagina best visualized?
on midline longitudinal image TA
what does the vagina look like sonographically?
- tubular structure behind bladder continuous with cervix
- mucosal wall cause bright echo within tubular structure
what is the best way to measure ovarian size?
ovarian volume using the prolate-ellipse formula:
L x H x W x 0.523 = ___ cm3
what supplies the ovaries w/ blood
blood supply from the ovarian artery originating from aorta and uterine artery
approximately 0.5% of femal patients have ____ uternine anomalies. ___ ____ abnormalites are about 50% of the total number.
congenital
urinary tract
what are some congenital anomalies associated with?
spontaneous abortion, and obstetric complications
what is the most comon genital anomaly detected in utero?
hydrometrocolpos (fluid filled vagina and uterus)
true or false? hydrometrocolpos can sometimes compress urinary tract to cause hydronephrosis or hydroureter
true
hydrometrocolpos
fluid filled uterus (metro) and vagina (colpos)
what are the 6 types of Mullerian anomalies?
- incomplete vaginal canalization (segmental mullerian agenesis)
- unicornuate uterus
- uterus didelphys
- bicornuate uterus (best trans)
- septate uterus
- DES exposure in utero
the ___ portion of the paramesonephric (Mullerian) duct fuses and develops into the uterus and part of the vagina
caudal
what forms most of the female genital tract?
paramesonephric (Mullerian duct)
what causes the newborn female uterus to appear prominent with thickened hyperechooic endometrial lining?
hormonal stimulation received in utero
prepubertal size of the uterus demonstrates a fundus:cx ratio of what?
1:1
congenital anomalies of the uterus have a high association with ___ anomalies
renal
hydrocolpos
fluid filled vagina
bicornuate uterus
duplication of the uterus w/ a common cervix
- low incidence of infertility
- best seen in trans
- rudimentary horn may cause complications
unicornuate uterus demonstrates:
uterus is small and laterally positioned
- infertility and pregnmancy loss
- renal agenesis contralateral side
- uterus long and slender
- difficult to differentiate from normal
- deviated long, slender (ex cigar) uterine shape
didelphys uterus demonstrates:
complete duplication of the uterus, cervix, and vagina
- complete duplication
- does not usually require tmt
- 2 endometrial complexes
what causes vaginal atresia and how is it diagnosed?
- cause: segmental agenesis or incomplete canalization of the vagina.
- Diagnosed by: development of fluid or blood in the uterus and cervix (hydrocolpos, hydrometrocolpos, or hematometrocolpos)
septate uterus demonstrates:
2 closely spaced uterine cavities w/ 1 fundus and 2 cervical canals or vaginal septum
- high incidence of fertility problems
- septum can be removed by hysteroscope
____ _____ has the highest incidence of fertility problems; the septum may be removed hysteroscopically
septate uterus
segmental mullerian agenesis ( incomplete vaginal canalization) appearance:
- produces transverse vaginal septum or vaginal atresia
- Dx by dev of hydrocolpos, hydrometrocolpos or hematometrocolpos
- Cx may by absent w/ or w/o blood in uterus or cx
- in neonatal -large cystic pelvic/abd mass bec. maternal sim or it is sen at puberty
- may also be caused by imperforate hymen
unicornuate uterus appears:
- renal agenisis on contralateral side
- uteus long & slender (ex cigar), small and positioned laterally
- hard to tell from normal
infertility and pregnancy loss
uterus didelphys appears:
complete duplication w/ 2 endometrial compleses
(doesnt urually require treatment
bicornuate uterus appears:
duplication w/ common cervix
best seen in trans
low incidence of infertility
rudimentary horn may cause problems
septate uterus appears:
(we dont usually see this because it is very thin)
2 uterine cavities closely spaced w/ 1 fundus and 2 cervical canals or vaginal septum
**highest incidence of infertility**
septum can be removed w/ hysteroscope
DES exposure in utero appearance:
normal uterus w/ t-shaped endometrial cavity
causes vag malignancies-
their mothers took DES in 70s due to risk of abortion
difficult to diagnose w/ US
the most common cause of female pseudohermaphroditism is:
a congenital virilizing adrenal hyperplasia.
an increase in androgens leads to masculinization
true or false? Mullerian abnormalities include improper fusion, incomplete development of one side, and incomplete vaginal canalization.
true
what is percocious puberty?
onset of normal physiologic and endocrine processes of puberty in girls before age 8.
- must have all 3 signs (breast dev., pubic and axillary hair, menstruation)
causes of precocious puberty
- idiopathic 80% secondary to eary activation of hypothalmic-pituitary-gonadal axis
- may be related to CNS lesion tht effects hypothalmus
- 20% 2o to causes other than pit axis= pseudoprecocious
precocious puberty sonographic appearance:
- adult configured uterus
- symetric ovarian enlargement *VERIFIES true precocious puberty
precocious puberty treatment
hormone replacement therapy w/ US follow ups to monitor size and volume changes
pseudoprecocious puberty definition and causes
- incomplete precocious puberty
- do not have all 3 signs
- **breast development, axillary and pubic hair, menstruation**
- do not have all 3 signs
- hormone secretion from pathology other than hypothalmic-pituitary-axis
- CAUSES: enchphalitis; hypothyroidism, mccune albright syndrome, ovarian neoplasm , brain tumor
pseudoprecocious puberty sonographic findings:
- infantile uterus and ovaries
- if infantile uterus and asymetrical enlarged ovaries, suggest ovarian pathology
- usually CT or MRI of adrenal and hypothalmic region
Neonatal Cysts appearance
typical ovary heterogeneous & cystic
Most cysts < 9mm resolve spontaneously
Cysts >2 cm; pathology
true or false? neonatal cysts have a higher incidence w/ babies whos mothers had toxemia, diabetes, and Rh isoimmunization, hypothyroidism
true
appearance & complications of neonatal cysts
- complications: hemorrhage, salpingotorsion
- appearance
- various size
- simple
- or hemorrhagic w/ internal exhoes
- may be caued by torsion
- may see hemorrhagic ascites and/or peritonitis (free fluid)
- may compress other organs
ovarian torsion facts
- usually occur w/in first 2 decades of life
- rt side 3x more likely to torse than left (less space on left due to gut)
- s/s: severe onset abd pain
- Sonographic: enlarged ovary, fluid in cul de sac, or tumor
- Color doppler: variable
Ovarian teratomas are uncomon in neonate and adolescents
- ___ ____ tumors 60% of ovarian neoplams in pt < age 20
germ cell
what is the most common benign pediatric germ cell tumor?
benign mature teratoma or dermoid cyst
benign mature teratoma or dermoid cyst appearance & complication:
- size: 5-15 cm
- multiple appearance
- most common complication: torsion (16-40%)
true hermaphroditism have both ___ and ____ tissue
ovarian and testicular
errors in sexual development result in ____ ____(hermaphroditism)
ambiguous genitalia (hermaphroditism)
**dermoid cyst
dermoid cyst
showing tip of the iceburg
shadowing makes it hard to see boundaries
scrotum appearance
scrotum appearance
2 testes
low level echogenicity
7-10mm diameter
mediastinum teste and epididymus not seen until after puberty
cryptorchidism
undescended teste, location important, associated w/ increased risk of malignancy, infertility, torsion
anorchidism
monorchidism
ano- absence of both testes
mono- absence of 1 teste (usually left)
acute scrotal pain common causes:
testicular torsion and epidymitis is most common
torsion of apendages, trauma, acute hydrocele and incarcerated hernia
dermoid tumor appearance:
- complex mass- heterogenous
- mural nodules and echogenic foci w/ acoustic shadowing
- neonatal period –> less shadowing seen than in adolescent
Image: classic dermoid mesh (screen door)
ovarian cystic teratoma: most common germ cell tumor
tip of iceburg –> makes it hard to see boundaries
ovarian cystic teratoma: most common germ cell tumor
tip of iceburg –> makes it hard to see boundaries
dermoid cyst
dermoid cyst
epididymititis
infection of epidydymis, common in men all ages
increased flow to epididymis w/ extension into teste ( when infection spreads)
infertility affects 1 in __ couples in the US. 40% male, 40% femalw, 20% combined or unknown
7
when evaluating infertile pt, what are the sonograpohers 2 main objective?
- access the structural anatomy
- assess the endometrium
a ____ uterus is associated with a high incidence of inferility because of an inadequate blood supply from the septum
septate
__ of fallopian tubes is evaluated by sonographic and saline exam
patency
the clinical triad of a polycystic ovarian syndrome includes:
oligomenorrhea, hirtsutism, and obesity
female factors of infertility:
- cervical
- endometrial/uterine
- tubal
- ovulatory
- peritoneal
male factors of infertility:
- not enough sperm
- decreased sperm motility
- obstruction of spermatic ducts or vas deferens
- scrotal varicolceles
role of the cervix
provide nonhostile environment for sperm
glands secrete mucus
crypts hold sperm
most common cause of hostile cervical mucus?
in accurate timing in relation to ovulation- too late or too early
_____ test evaluates cervical mucus w/in 24 hours of intercourse to look for # and motility of sperm
postcoital
nongravid uterus cervical length and opening is hard to assess, hysterosalpingogram can be used to ev. internal os diameter. diameter < __ mm may indicate cervical stenosis
< 1 mm
true or false? congenital uterine anomalies make up 1% and includes defects in mullerian duct dev, fusion , or reabsorbtion, and are associated w/ renal anomalies
true
____ and ___ uterus are most easily seen in trans; look for 2 cervix and vagina
bicornate and didelphys
___ uterus has high incidenence of infertility; 2 uterine cavities and a single fundus; septum causes problem for implantation (important diagnosis)
septate
___ daughters presents w/ T-shaped uterus and has an increased risk of cervial incompetence
DES
to become pregnant, endometrial thickness of __ mm is needed
6 mm
Luteal phase deficiency:
lack of progesterone production
after ovulation, ___ is secreted by the corpus luteum; secretion of ___ begins in secretory phase of the endometrial cycle
progesterone
progesterone
when is the 3 line sign seen and what does it consist of?
seen during the endometrial phase ; consists of hypoechoic mucosa and the echogenic interface where they meet
true or false? MRI and HSG beter to image uterine anomalies
true
true or false? 3D US is the best (2nd best=trans. TV) to see bicornate uterus
true
__ and __ uteruses are not assosicated w/ infertility
bicornate didelphys
tshaped uterus is a congenital anomaly caused by exposure to ___; if the level of progeterone produced in the luteal phase is inadequate, then the endometrial lining may be thinner than normal.
DES
Endometrial ____ usually have a narrow base attachment w/ vascular pedicle feeding it.
polyps
how does uterine synechiae (scars) appear on US?
hyperechoic linear strands (adhesions) extending from one wall of uterine cavity to the other.
cause: multiple biopsies, D&E, (wont allow uterus to expand)
what causes polycystic ovarian syndrome?
pituitary gland producing more LH than FSH
What is given to trigger ovulation as a substitute for LH ?
hCG
severe ovarian hyperstimulation syndrome appears:
enlarged ovaries w/ multiple cysts, ascites, and pleural effusion
image bicornate uterus
image bicornate uterus
what 4 conditions of the endometrium can all lead to unsuccessful pregnancy?
- Luteal Phase deficiency-(lack of progesterone production)
- submucosal fibroids (broad base circumf flow)
- polyps (narrow base stalk - vascular pedicle)
- synechiae {scars} linear strands adhesions (dont let the uterus expand)
___ and ____ must have 2 endometriums going to each horn to be bicornate or didelphys
bicornate; didelphys
____ are estrogen dependant, and usually have rounded borders
fibroids
submucosal fibroids
submucosal fibroids
saline infused sonography of submucosal fibroid with SIS and color Doppler showing circumferential flow
saline infused sonography of submucosal fibroid with SIS and color Doppler showing circumferential flow
SIS & Polyp
SIS & Polyp
uterine synechia w/ SIS
uterine synechia w/ SIS
image (catheter going into cervix w/ balloon on the end ot hold it in place)
what two things do we evaluate the fallopian tubes for?
hydrosalpinx and patency
How do we evaluate the fallopian tubes for patency?
- injecting saline and looking for spillage in cul-de-sac-
- (can also be done w/ air)
- HCG hysterosalpingogram (fluoroscopy w/ x ray imaging)
- Rubins test- (CO2 in fallopian tube)
- sugically laparoscopy (chromopertubation)
Robins Test facts:
- (No longer used)
- simplest and oldest test for tubal patency using CO2 under pressure
- very unreliable
___phase- several follicles <5mm
follicular
Best predictor of ovulation that rises after ovulation?
basal body temp
___ rises just before ovulation and found in urine?
LH
_____ can inhibit release of FSH and LH
polycystic ovarian syndrome (PCOS)
**common w/ infertility**
an ovarian cyst > ___ could interfere w/ the response of ovarian stimulation and may represent a persistent follicle.
15 mm
follicles
follicles
____ ___ ___ often occurs w/ clinical triad (oligomenorrhea, hirsutism, obesity)
polycystic ovarian syndrome
PCOS polycystic ovarian syndrome definition:
(string of pearls)
- 12 or more follicles measuring 2-9mm
- ovarian volume > 10 cm3
(string of pearls)
PCOS causes:
obesity, diabetes, thyroid, adrenal, or pituitary gland dysfunction
Polycystic Ovarian Syndrome (PCOS) presents with:
irregular bleeding, thick endometrium, endometrialCA from chronic elevation of estrogen, hirsutism from chronic androgen level elevation
PCOS sonographic appearance:
normal or round ovary w/multiple small immature follicles on periphery (**string of pearls**)
polycystic ovarian syndrome: mechanism
immature follicles continue to produce estrogen and androgen which inhibit pit gland. pituitary gland produces more LH than FSH causing follicle to remain in arrested state of development –>no marure ova is released with ovulation
____ ____ causes 25% of infertility cases
peritoneal factors
endometriosis and adhesions
when do peritoneal inclusion cysts form?
when fluid collects between adhesions that obstruct the fimbriated end of the fallopian tube
alot of these will reoccur
_____ is ectopic endometrial tissue commonly occuring in bilateral ovaries
endometriosis
( chocolate cyst)
______ is the most common benign gynecologic disease in women. approx 10-25% of women w/ gynecologic disease
40% occur in women w/ infertility
endometriosis
what is a normal endometrial response associated with overstimulation?
increasing thickness from 2-3mm to 12-14 mm
thin endometrium, <8mm is associated with what?
decreased fertility in secretory phase
monitoring the endometrium we assess thickness and echogenicity pattern
- endometrial response - increaed thickness
- from 2-3mm to 12-14mm
- measure long plane
- outer to outer (double layer thickness)
- normal trilaminar pattern
- < 8mm - decreased fertility
uterine artery spectral doppler evaluation:
- PI: 2.00-2.99 (ovulation
- ascending branch lateral to cervix on TV
- use color to help ID vessels
Ovarian Induction therapy
what does US monitor? and what does ovarian induction therapy require?
- US monitors number and size of follicles in days 8-14 (follicular phase)
- document all follicles > 10 mm (1cm) in both long and trans planes
_____ and ___ levels determine the approx time of ovulation
follcile size; estradiol
what do the drugs clomiphene citrat (Clomid) or gonadotropin (Pergonal) day 3-5 in normal cycle do?
- Enlarges multiple follicles instead of single dominant follicle.
then US to monitor # & size of follicles day 8-14 (follicular phase) Count all follicles >1cm long & trans
true or false?with ovarian induction therapy, optimum mean follicle size is 15-20 mm. hCG may be given IM to trigger ovulation; w/ retrieval 30-34 hrs later.
true
Ovarian stimulation
cumulus oophorus will become free floating, right before ovulation
what are the 3 types of assisted reproductive therapy
- IVF
- GIFT & ZIFT
- IUI
what is IVF?
in vitro fertilization - method of fertiliing ova outside the body
treatment plan: ovarian monitoring, needle aspiration of oocytes, incubation of oocytes, fertilization, trnsferring embryos to uterus
IVF, optimal placement of the embryos is within 2 cm or 15 mm from fundus
embryo transfer facts:
- embryo transfer can be done laparoscopically or by US guidance
- uterus length measured TA w/ full bladder
- speculum inserted cervix is cleaned
- catheter inserted through cervix and embryos inserted
true or false? it is estimated that 25-30% of IVF pregnancies result in multiple gestations
true
what pts are GIFT and ZIFT reserved for?
patients with 1 functional fallopian tube, unexplained infertility, or cervical factors
What is GIFT and ZIFT? what is the difference btween the two?
ovarian stimulation, oocyte retrieval, mixed w/ sperm in dish and transferred through catheter into fallopian tube
- GIFT- gamete intrafallopian tube transfer
- fertilization takes place inside body {in vivo}
- ZIFT - zygot intrafallopian tube transfer
- same as GIFT but fertilization takes place outside body {in vitro}
- laparascopically, gamete or zygote in fimbriated end of fallopian tube
- US guided -gamete or zygote in isthmic portion of fallopian tube
what are GIFT and ZIFT success rates?
22-28% w/ US guidance
Intrauterine insemination (IUI)
- technique used to treat male infertility or unexplained infertility
- catherter containing sperm is placed into uterine fundus
- sperme prep may be from a donor-AID artificial insemination using donor sperm
- US guidance can be used
the risk of heterotropic pregnancy increases to 1;100 with ___ ___ ____
assisted reproductive technologies.
when does fertilization occur outside the body?
in vitro fertilization, and ZIFT
US is correlated to ___ levels to determine the approx time of ovulation
estradiol
dermoid cyst
tip of the ice burg
dermoid cyst
“classic dermoid mesh”
looks like a screen
what are the 3 complications of assisted reproductive technology?
- Ovarian hyperstimulation syndrome (OHSS)
- Multiple Pregnancies -25%
- Ectopic Pregnancy
what is Ovarian hyperstimulation syndrome (OHSS)
Enlarged ovaries, multiple cysts, abd ascites, pleural effusions
OHSS is more common with ______ and there will be mild ovarian enlargemnt of _-_ cm.
PCOS; 5-10cm
Multiple Pregnancies is:
3 or more increased risk fetal/neonatal morbidity & mortality
pt is counseled about fetal reduction by injectin potassium chloride into chest or fetal heart
2 Peritoneal Factors:
- Adhesions (Bands of scar tissue)
- Can obstruct fimbriated end of fallopian tube
- Peritoneal Inclusions Cysts form when fluid collects between these adhesions
- Endometriosis - ectopic endometrial tissue
- Ovaries are most common site
- Often bilateral
______ is used for evaluating the peritoneal factors, adhesions and endometriosis.
Laparoscopy
true or false? with assisted reproductive technology there is an increase risk for ectopic pregnancy, and heterotopic pregnancy
true
heterotopic pregnancy
ectopic pregnancy coexisting w/ intrauterine pregnancy (adnexa needs to be carefully imaged to r/o heterotopic pregnancy.
true or false? OHSS is exacerbated during pregnancy?
true
treatment of OHSS include
- Serial scans during ovarian stim cycles
- Careful tailoring of dose of gonadotropins helps to limit risk of OHSS
- Abort tmt cycle or coast final days of tmt
- Continue follicular dev but withhold admin of addl gonadotropin
- Preform oocyte aspiration after 1-3 day of unstimulated development
- All embryos may be cryopreserved and single embryo replaced in subsequent cycle
true or false? assisted reproductive technology - due to the risk of multiple pregnancies and fetal/neonatal mobidity and mortality, pt with multiple pregnancies is counseled about fetal reduction by injecting potassium chloride into chest or fetal heart
true
treatment of extreme cases of OHSS
Extreme cases
- Abdominal paracentesis
- Drain several liters of ascitic fluid
- Transvaginal us guided aspiration of ascites
normal uterus
uterus didelphys
complete duplication of the vagina, cervix and uterus,
uterus bicornis bicollis
bicornuate uterus has two uterine horns that are fused at 2 cervixes
uterus bicornis unicollis
bicornuate uterus has two uteine horns that are fuesed at one cervix
uterus subseptus
is a milder anomaly marked by a midline myometrial septum within the endometrial canal
uterus unicornis
1 Mullerian duct develops forming a single uterine horn and a uterine tube continuous with 1 cervix and 1 vagina
**what causes uterine uterine malformations with anatomic variations of the uterus, cervix, and vagina?
the incomplete fusion or agenesis of the Mullerian ducts
**dermoid tumor**
dermoid mesh
multiple linear hyperechoic interfaces floating within cyst (hair)
**dermoid cyst**
tip of the iceburg
tip of the iceburg - shadowing makes it hard to see boundaries
mixture of matted hair and sebum producing ill defined acoustic shadowing that obscures posterior wall of lesion
average size and rate of growth of dominate follicle
1-3mm/day
average 22 mm
complications associated w/ assisted reproduction include:
hyperstimulation, multiple gestations, and ectopic pregnancy
infertility
the inablilty to conceive within 12 months w/ regualr coitus
the ____ parts of the paramesonephric (Mullerian )ducts form the uterine tubees
cranial
