Ultrasound

Question 1

First trimester bleeding

Answer 1

Gestational Trophoblastic Neoplasm (Complete Mole)

typical appearance of a cystic endometrial mass w/ “swiss cheese endometrium,” is seen in this case. nce of increased vascularity within and surrounding the mass is also typical of gestational trophoblastic neoplasia (GTN). Complete mole is the most common type of GTN.

—> Pseudomole can look similar with hydropic changes/sonolucencies in the uterus but shouldn’t have internal flow

—> perigestational hemorrhage should also have a normal gestational sac

Question 2

12 weeks pregnant w/bleeding

IUP and this

Answer 2

Perigestational Hemorrhage

internal echoes within the fluid collection seen best on the transvaginal images.

The amnion has not yet fused with the chorion and the fluid collection lies between the chorion and the uterine wall.

PGH often lenticular and extends from the placental edge

—> Chorioamniotic separation appears as anechoic fluid between the amnion and chorion (our case hasn’t fused yet)

—> pseudogestational sac (seen w/ectopic sometimes) is round or tear-drop shaped and is a single fluid collx in the uterus. NO normal IUP/gestational sac

Question 3

at what crown rump length can an embryo without heartbeat be called “not viable”

Answer 3

7mm

if it is smaller, need f/u to determine

Question 4

First trimester bleeding

Answer 4

Cervical Ectopic

Assess for an “hourglass” shape of the uterus (the body of the uterus is the superior bulge; the cervix, distended by the ectopic pregnancy, creates the inferior bulge). The internal os is closed.

W/spontaneous abortion, sac will be central in the cervical canal, not implanted in the wall. W/c sx scar, will be implanted anteriorly in the low uterus and there will be no space between gestational sac and the bladder

Question 5

Answer 5

Tubal Ectopic

echogenic adnexal ring (calipers) is highly suspicious for tubal ectopic pregnancy. A small amount of fluid but no gestational sac is seen within the uterine cavity.

“pregnancy of unknown location” only used when there is a positive pregnancy test but no evidence of an intra- or extrauterine gestation on vaginal ultrasound The right ovary is normal without evidence of a hemorrhagic cyst.

Question 6

first trimester bleeding

Answer 6

Interstitial (cornual) ectopic

On the transvaginal transverse ultrasound of the uterus, the nondistended endometrium can be followed to the gestation in the cornua of the uterus (the interstitial line sign). Very thin, if any, myometrium is present on the other side of this sac .

marked vascularity also

Question 7

Elevated HCG and bleeding

Answer 7

Invasive Mole: GTN

Gestational trophoblastic neoplasms may be 1 of the following subtypes: complete hydatidiform mole, invasive mole, choriocarcinoma, and partial mole. Complete hydatidiform moles may progress to invasive moles where the myometrium is invaded, or to choriocarcinoma, which is a malignant form of molar pregnancies with metastases commonly seen to lung and liver. Patients are treated with suction evacuation of the mass and with methotrexate or other chemotherapy

Complete moles Diploid, partial are Triploïd and have some fetus (all dad, all bad, etc)

Question 8

34F with LLQ pain

Answer 8

Paraovarian Cyst

Simple unilocular cyst adjacent to the ovary which doesn’t change with time

—> can cause torsion of the broad ligament which presents similar to ovarian torsion and is managed surgically

—Serous cystadenoma can look similar but would arise from the ovary/may distort ovary

Question 9

POD 1 with dropping hematocrit

Answer 9

large perinephric hematoma

Question 10

Dilated ureter and finding

what are common artifacts seen with this condition?

Answer 10

Uretovesicular junction stone

—> posterior shadowing is most specific

—> twinkle artifact is also common

—> note absent right jet

Question 11

No vascular flow on Doppler, patient p/w painless jaundice and acholic stool

Answer 11

Biliary Ductal Dilatation

Question 12

US signs in Renal Vein thrombosis?

Answer 12

Enlarged, hypoechoic/edematous kidney

absence of flow in MRV and thrombus in vein are most specific

obstruction of venous outflow can lead to reversal of arterial diastolic flow

^RI

*tardus parvus is seen in renal arterial stenosis, upstream

Question 13

Things that increase RI in kidney?

Decrease?

Answer 13

Increased seen in cases where it is harder for blood to get into the kidney :

ATN/AKI

hypoperfusion

Decreased seen with :

Renal artery stenosis

Question 14

Tardus parvus –

what is each part and what does it tell you

Answer 14

Phenomenon observed downstream to sites of arterial stenosis

Useful for renal artery stenosis (will also get lower RI)

due to reduced magnitude of blood flow through narrowed vessel during systole

tardus: prolonged systolic acceleration (i.e. slow upstroke)
parvus: small systolic amplitude and rounding of systolic peak

Question 15

Normal flow velocity Portal Veins?

Waveforms?

Answer 15

normal 20-40

10 or below PH

Also waveforms:

biphasic (if it dips below baseline, or if it is reversed (hepatofugal flow)

little bit of pulsation is normal

Question 16

What aspects of cysts would make them less likely to show posterior acoustic enhancment?

Answer 16

Small cysts (<5mm)

Deep cysts (>3cm)

Question 17

what determines acoustic impedance in a tissue?

Answer 17

Sound velocity in and density of tissue

defined as the product of the density (in kg/m^3) and speed of sound (in m/s) in the tissue

Question 18

4 yo girl with fever and flank pain

Answer 18

Pyelonephritis

edematous kidney with decreased flow esp at the poles

(DMSA scanning is the classic test used to diagnose pyelonephritis)

imaging usually only done if not responding to tx and concern for complication

Question 19

in the groin

Answer 19

pseudoaneurysm

arising from the common femoral artery, with the classic “yin-yang” sign within. This “yin-yang” appearance indicates that there is bidirectional flow due to swirling of blood within the pseudoaneurysm.

Distance-measurement calipers are seen on the neck of the pseudoaneurysm.

An arteriovenous fistula will have forward flow, not to-and-fro flow, at the site of the fistula

Question 20

38F diabetic

Answer 20

Focal Fatty infiltration

echogenicity, elongated configuration, lack of mass effect, and a characteristic location (posterior aspect of medial segment) are characteristic features of steatosis at ultrasound

Ddx:

Hepatic cavernous hemangioma; also echogenic, but typically round and exert mass effect. Chemical shift MR can help distinguish between this entity and focal fat in problematic cases

Hepatocellular carcinomas may be echogenic (and may mimic hemangiomas), but the normal appearance of background liver, the lack of mass effect, and the linear border seen here argue against it

Hepatic adenomas may be slightly echogenic, but they also exert mass effect and are typically round

Question 21

What is the artifact and what causes it

Answer 21

Reverberation artifact

caused by back and forth reflection of US beam by two closely spaced interfaces

echoes appear as multiple equally spaced lines

often caused by highly reflective interfaces such as calcification or metallic objects