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Modalities > US gynae & obstetrics > Flashcards

US gynae & obstetrics Flashcards

1
Q

what is included in the gynae US

A
  • uterus
  • ovaries
  • fallopian tube
  • bladder
  • adnexa
  • pouch of douglas
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2
Q

anatomy of uterus

A
  • pear-shaped organ
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3
Q

function of uterus

A
  • provides mechanical protection, nutritional support and waste removal for pregnancy
  • contractions of muscular walls during labour is responsible for pushing out fetus
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4
Q

variations in uterine positions

A
  • anteverted
  • midposition/ axial
  • retroverted
  • anteflexed
  • retroflexed
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5
Q

location of ovaries

A
  • varies due to laxity of ligamentous attachments
  • ovaries usually seen lateral to the uterus
  • internal iliac vessels are found at the posterolateral border of the ovaries
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6
Q

what is menstrual and ovarian cycle

A
  • repeating series of changes in the endometrium
  • avg of 28 days
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7
Q

3 phases of menstrual cycle

A
  • menstrual phase
  • proliferative phase
  • secretory phase
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8
Q

2 phases of ovarian cycle

A
  • follicular phase
  • luteal phase
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9
Q

describe what happens during the menstrual phase

A
  • functional layer of endometrial lining of the uterus is shed and exits through vagina
  • slowly rising levels of FSH and LH secreted by pituitary gland –> cause development of ~20 primary follicles
  • pri follicles grow and develop into secondary follicles –> release estrogen and low level of progesterone
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10
Q

describe what happens during the proliferative phase

A
  • after ~5 days, estrogen levels rise and enters proliferative phase
  • endometrium begins to regenerate, blood vessels and glands begin to regrow
  • ~ day 9, only one healthy secondary follicle becomes dominant while other follicles become antretic
  • dominant follicle continues to grow in size and is responsible for producing large amounts of estrogen during late follicular phase
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11
Q

describe what happens during ovulation

A

~ day 14, high levels of estrogen causes FSH and LH to rise rapidly
- spike in LH cause ovulation –> mature dominant follicle ruptures and release egg
- follicles that did not rupture degenerate and their eggs are lost
- level of estrogen decreases when extra follicles degenerate

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12
Q

describe what happens during secretory phase

A
  • after ovulation, menstrual cycle enters the secretory phase
  • ovarian cycle enters the luteal phase
  • cells in the follicle that ruptured during ovulation undergoes changes and form the corpus luteum –> produces significant amount of progesterone and smaller amount of estrogren
  • progesterone facilitates the regrowth of the uterine lining to prepare for implantation
  • progesterone also inhibits release of further FSH and LH –> prevents any further egg and follicles from developing
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13
Q

what happens if no egg is fertilised

A
  • corpus luteum degenerates and levels of estrogen and progesterone decreases, initiating the next menstrual cycle
  • decrease in progesterone also allows hypothalamus to send GnRH to anterior pituitary, releasing FSH and LH and starting cycle again
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14
Q

possible causes for abnormal PV bleed

A
  • irregular menstrual cycle
  • menorrhagia
  • dysmenorrhea
  • postmenopausal bleeding
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15
Q

possible causes of pelvic pain

A
  • torsion
  • pelvic inflammatory disease
  • ruptured cyst
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16
Q

common clinical indications that warrants a gynae scan

A
  • abnormal vaginal discharge
  • amenorrhea
  • pelvic mass
  • infertility
  • follicle monitoring
  • locate intrauterine contraceptive device (IUCD)
  • developmental abnormality
  • postpartum complications (RPC)
  • abnormal PV
  • pelvic pain
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17
Q

2 types of sonographic methods performed in gyane

A

transabdominal (TA)
- transducer placed on lower abdomen to acquire images of the female pelvis

transvaginal (TV)
- transducer placed within the vaginal cavity

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18
Q

advantages of TA approach

A
  • non-invasive (for female who has never had sexual intercourse before, whose hymen remains unbroken: virgo intacta)
  • visualises the entire pelvis
  • gives a global overview
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19
Q

limitations of TA apporach

A
  • patients unable to fill the bladder will result in poor quality image
  • patient unable to hold bladder for duration of scan - feel uncomfortable
  • obese patients (fats attenuate signals)
  • retroverted uterus
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20
Q

advantages of a TV approach

A
  • examinations of patients who are unable to fill up bladder
  • examinations of obese patients
  • examinations of retroverted uterus
  • allows use of higher-frequency transducers –> better resolution, better image quality & better anatomic detail
  • better detail and characterisation of the internal characteristics of the internal characteristics of a pelvic mass
  • better detail of the endometrium
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21
Q

limitations of TV approach

A
  • because of higher frequencies, FOV is limited
  • orientation difficult for larger masses (extend if out FOV)
  • limited depth (superiorly or laterally placed ovaries or masses may not be visualised)
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22
Q

contraindications of TV

A

patient:
- is a virgin
- is an elderly
- refuses

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23
Q

what transducer is used for TA scan

A
  • low frequency (1-5MHz) curvilinear probe
  • provides adequate penetration and large footprint to image the reproductive organs and surroundings
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24
Q

why is full bladder required for a TA scan

A
  • bladder located anterior to the uterus
  • full bladder provides an acoustic window for the US waves to pass through
  • also displaces small bowels from FOV - bowel gas obscures visualisation of uterus and ovaries and any pelvic mass
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25
Q

what if patient has overdistention of bladder

A
  • compromised evaluation
  • ask patient to partially empty bladder
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26
Q

how to scan bilateral adnexal regions to include both ovaries and surrounding

A

angle to probe, using the bladder as an acoustic window, to image ROI

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27
Q

what does full bladder cause on a TV scan

A
  • uncomfortable during scan
  • cause artifact on TV scan image
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28
Q

in TV scan, what axis correlates to the sagittal plane

A
  • long axis = sagittal plane
  • plane perpendicular to sagittal = coronal plane
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29
Q

ovaries are most easily located in which plane

A

coronal

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30
Q

describe an anterverted uterus

A

uterus tilted forward, towards bladder

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31
Q

describe a retroverted uterus

A
  • uterus tilted backward, away from bladder
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32
Q

normal sonographic appearance of the female pelvis

A
  • pear-shaped
  • diameter and length of body double that of the cervix
  • outline of uterus should be smooth
  • normal adult uterus varies in size:
    *parity increases the size in uterus
    *after menopause, uterus atrophies
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33
Q

normal measurements of nulliparous uterus

A
  • L: 8cm
  • W: 5cm
  • AP diameter: 4cm
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34
Q

normal measurements of primiparas

A

1cm increase in each dimension of a nulliparous uterus
- L: 9cm
- W: 6cm
- AP diameter: 5cm

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35
Q

normal measurements of multiparas

A

2cm increase in each diameter of a nulliparous uterus
- L: 10cm
- W: 7cm
- AP diameter: 6cm

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36
Q

thickest portion of the uterus

A

myometrium

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37
Q

what is myometrium made up of

A

muscle tissue

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38
Q

what are the 3 layers of myometrium

A
  • inner layer
  • intermediate later
  • outer layer
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39
Q

describe the inner layer of the myometrium

A
  • just adjacent to and surrounds the endometrium
  • hypoechoic and thin
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40
Q

describe the intermediate layer

A
  • thickest, homogeneous, and show low to moderate echogenicity
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41
Q

describe the outer layer of the myometrium

A
  • thin layer separated from the intermediate layer by the arcuate vessels
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42
Q

what is the 2 layers of endometrium

A

functional layer - thickens during menstrual cycle and sheds during menses

basal layer - remains intact throughout the cycle and contains the arteries which supply the functional layer as it thickens

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43
Q

sonographic appearance of endometrium

A

varies throughout the menstrual cycle

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44
Q

endometrial cavity

A
  • is a thin echogenic line
  • result of specular reflection from the interface between the opposing surfaces of the endometrium
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45
Q

describe the sonographic appearance during menstrual phase

A
  • endometrium is a thin echogenic line
  • there can be clots and fluid present within the uterine cavity
46
Q

describe the sonographic appearance during the early proliferative phase

A
  • thin echogenic line
  • normal endometrial thickness: 4-8mm
47
Q

describe the sonographic appearance during the late proliferative phase (periovulatory)

A
  • classic triple line appearance is seen in an endometrium
  • endometrium appears echogenic around its periphery and in the midline, and hypoechoic in between
  • hypoechoic areas are the functional layer while the peripheral echogenic layers are the basal layers
  • normal endometriual thickness: 6-10mm
48
Q

describe the sonographic appearance in the secretory phase

A
  • functional layer become increasingly echogenic until it merges with the equally echogenic basal layer to appear as a thick echogenic secretory-phase-endometrium
  • endometrium appears thick and echogenic
  • normal thickness: 7-14mm
49
Q

how is the endometrium measured

A
  • measure on the longitudinal or sagittal image of the midline uterus, showing entire endometrium in continuity to the cervical canal
  • measure at the thickest portion
  • ensure the calipers are placed on the outer echogenic border
50
Q

normal sonographic appearance of ovary

A
  • ellipsoidal in shape
  • homogenous echotexture
  • central slightly more echogenic medulla
  • usually has multiple well-defined anechoic cystic follicles within
  • appearance changes with phase of the menstrual cycle
51
Q

normal sonographic appearance of ovary during early proliferative phase

A
  • many anechoic, well-defined, small cystic follicles stimulated by FSH and LH develop and grow in size
52
Q

normal sonographic appearance of ovary during ovulation

A
  • dominant anechoic cystic follicle with well defined borders seen within ovary (around day 9)
53
Q

normal sonographic appearance of ovary after ovulation

A

corpus luteum has variable appearances:
- hypoechoic/ isoechoic
- thin or thick walls
- presence or absence of cystic centre
- cystic centre which may or may not contain internal echoes
- on colour doppler, shows a “ring of fire” due to peripheral vascularity

54
Q

appearance of cervix

A
  • cervical canal is a thin echogenic line
  • outline of cervix should be smooth and the cervical wall of homogenous echotexture
55
Q

appearance of the vagina

A
  • hypoechoic tubular structure with a
  • central echogenic linear line representing the apposed surfaces of the vaginal mucosa
56
Q

types of uterine malformations

A
  • arrested development of the Mullerian ducts
  • failure of fusion of the Mullerian ducts
  • failure of resorption of the median septum
57
Q

possible sites of fibroid/ leiomyoma/ myoma

A
  • intramural
  • submucosal
  • subserosal
  • pedunculated
58
Q

endometrium thickness

A

1-14mm

59
Q

what is endometrium thickness affected by

A
  • stimulated by estrogen
  • involuted by progesterone
60
Q

possible causes of endometrial thickening

A
  • dysfunctional uterine bleeding
  • endometrial hyperplasia
  • hormonal replacement therapy (HRT)
  • tamoxifen treatment
  • endometrial carcinoma
  • endometrial polyps
  • endometritis
61
Q

types of obstruction in the genital tract

A

part
- colpos = vaginal distention
- metrocolpos = uterine cavity and vaginal distention

content
- blood = haemato
- fluid = hydro
- pus = pyo

62
Q

features of PCOS

A
  • chronic anovulation
  • sub-fertility
  • irregular menstrual cycles
  • oligo or amenorrhea with occasional heavy bleeding
  • usually presents from menarche (puberty)
63
Q

PCOS is a syndrome consisting of

A
  • amenorrhea
  • hirsutism
  • obesity
  • enlarged, polycystic ovaries
64
Q

advantages of using a TA approach on fetus

A
  • pushes uterus up out of pelvis and into a horizontal position
  • displaces gas-filled bowel loops
  • provide visualisation of the cervical os
  • acts as a landmark
  • enables visualisation of the adnexa
65
Q

limitations of a full bladder in obstetric TA scan

A
  • painful for patient
  • may distort gestation sac/ uterus
  • may deviate uterus
  • may push uterine walls together so a normal placenta looks low
  • may push uterus deep into the pelvis
66
Q

display function for a first trimester fetus

A

B-mode
M-mode

67
Q

display function for a second trimester fetus

A

B-mode
Colour doppler

68
Q

display function of a third trimester fetus

A

B-mode
Colour doppler
Pulsed doppler
3D/4D

69
Q

ultrasound intensity of the display functions from least to most intense

A

B-mode < M-mode < colour doppler < pulse doppler

70
Q

when is the first trimester scan done

A

11-14 weeks

71
Q

what is gravidity/ gravida

A
  • refers to total number of conceptions
  • nulligravid - no pregnancy
  • primigravida - first pregnancy
  • gravida 4 - fourth pregnancy
72
Q

what does the 4 digit numbers in gravida represent

A
  • full term births
  • premature births
  • abortions
  • live children
73
Q

what is parity/ para

A
  • refers to total number of births that weighed more than 500g
  • twins counted as 1 pregnancy
  • primipara - delivered 1 preg
  • multipara - delivered 2+ preg
74
Q

4 methods to calculate GA

A
  1. LMP
  2. fundal height
  3. b hCG
  4. US measurements - most accurate during first trimester (8-10 weeks)
75
Q

how LMP calculates GA

A

date of LMP +7days, -3months, +1year

76
Q

how is fundal height done to determine GA

A

felt by doc’s hand; in cm; topmost portion of uterus to SP

77
Q

when does GA start its calculation from

A
  • first day of LMP
  • ovulation normally occurs ~14 days before onset of next period
  • for the first 2 weeks of a 40-week pregnancy, mother is not pregnant, but the 2 weeks is included in the GA
78
Q

when is the average EDD

A

40 weeks after LMP

79
Q

normal sonographic appearance in early pregnancy

A
  • endometrium appears thickened with decidual reaction noted
  • early GS appears as a round anechoic area surrounded by hyperechoic ring = “double decidual sign”
  • yolk sac and embryo/fetal pole must be visualised when GS diameter >25mm
  • fetal heartbeat can be confidently observed when CRL >7mm
  • GS in normal position
80
Q

how to determine GA with US

A

1st tri, done by either:
- crown-rump-length
- measuring GS

81
Q

how is measurement of GS done

A

can do either:
- avg diameter
- volume estimation (AxBxCx0.523)

82
Q

how is measurement of CRL done

A
  • longest measurement of the fetus (from crown to rump)
  • care taken to exclude sac
83
Q

4 different types of multiple gestation pregnancies

A
  • monochrionic
  • dichorionic
  • monoamniotic
  • diamniotic
84
Q

how can fetal heartrate be measured

A
  • M-mode
  • pulsed doppler
85
Q

US of fetal death

A
  • no FH
  • pointing of GS
  • low position of GS
  • large GS with small or absent embryo
  • abnormal size and shape of YS
  • appearances do not match dates
  • no fetal movement
  • spalding sign of fetal head
  • diffused oedema of entire fetus
86
Q

types of abortion

A
  • complete
  • incomplete
  • inevitable
  • missed
  • threatened
87
Q

sonographic indication of an ectopic pregnancy

A
  • b hCG >1800mlU/ml and
  • intrauterine GS not identified
  • live fetus seen outside of uterus
  • tubal echogenic ring may be seen
  • echogenic rim surrounding a hypoechoic center
  • colour doppler may show peripheral vascularity
  • possible hemoperitoneum or free fluid in POD
88
Q

sonographic appearance of a tubal pregnancy

A
  • tubal echogenic ring may be seen
  • echogenic rim surrounding a hypoechoic center
  • colour doppler may show a peripheral vascularity
  • possible hemoperitoneum or free fluid
89
Q

normal nuchal translucency measurement

A

< 2.5mm

should be measured with fetus in supine position

90
Q

what is acrania/ anencephaly

A

absence of a fetal skull with freely exposed brain tissue to amniotic fluid

91
Q

what is thickened nuchal translucency

A

associated with chromosomal abnormality

92
Q

what is cystic hygroma

A
  • fluid-filled sac that results from a blockage in the lymphatic system
  • can progress to hydrops and eventually fetal death
93
Q

2 types of abdominal wall defect

A
  • omphalocele
  • gastroschisis
94
Q

what are the 3 views done to view fetal head/brain

A
  • ventricular
  • thalamic
  • cerebellar
95
Q

how is BPD measured

A

from outer table of skull to inner table

96
Q

how is HC measured

A

perimeter around the outer skull border

97
Q

when can HC be used for dating

A
  1. unsure of LMP
  2. irregular LMP cycles
  3. no previous dating
98
Q

what is the cerebellar view for

A

to evaluate the shape and size of the cerebellum

99
Q

how does the cerebellum look like

A

seen as a ‘dumbbell’ shape in the posterior fossa

100
Q

what can TCD equates to

A

gestational age

101
Q

normal occipital horn measurement

A

< 10mm

102
Q

combined anterior horn normal measurement

A

<20mm when BPD is <6.5cm

103
Q

normal binocular distance

A

space between orbits = width of one eye

104
Q

when leiomyoma turns cancerous, it is known as

A

leiosarcoma

105
Q

what type of leiomyoma is missed on what type of US scan

A

TA - small fibroids
TV - pedunculated

106
Q

what is the GA of a fetus of first trimester

A

4-14 weeks

107
Q

what is the GA of a fetus of second trimester

A

14-28 weeks

108
Q

what is the GA of a fetus of third trimester

A

28 weeks onwards

109
Q

normal NT measurement

A

< 2.5mm

110
Q

what does abnormal NT measurement indicate

A

associated with chromosomal abnormality

111
Q

what are the 3 vessels present in the umbilical cord

A

2 arteries + 1 vessel

Modalities (5 decks)

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