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OB/GYN Board Exam - Ultrasound (Basics)

STUDY
PLAY
What does the vagina measure?
7-10 cm
The thickness of the enometrium varies. It measures ---- immediately following menses and ---- just prior to the beginning of menses.
1mm
8mm
What is the premenopausal ovarian size and volume?
3.5 x 2.0 x 1.5
9.8 cm3
What is the postmenopausal ovarian size and volume?
2.0 x 1.0 x 0.5
5.8 cm3
What is the uterine size from 2-8 years old?
3.3 cm
0.75 AP
What is the uterine size from 9-menarche?
4.3 cm
1.3 AP
What is the uterine size for nullparous?
8.0 cm
3.0 AP
What is the uterine size for multiparous?
9.0 cm
4.0 AP
What is the uterine size for postmenopausal women?
Varies, based on parity
What do the fallopian tubes measure?
7-14 cm
The space of Retzius is also called?
Retropubic space
Prevesical space
The Vesicouterine Space is also called?
Anterior cul-de-sac
The Rectouterine space is also called?
Pouch of Douglas
Posterior cul-de-sac
The anterior trunk vessels give rise to which arteries? OII SUUV
O - obturator
I - inferior vesicle
I - inferior gluteal

S - superior vesicle
U - umbilical
U - uterine
V - vaginal
The ovarian arteries are also known as:
Gonadal Arteries
Dilated tortuous veins near the uterus and/or in the adnexa (varicose veins) are a significant finding and may be associated with what?
Pelvic Congestion Syndrome
Doppler Characteristics - What are the uterine arteries?
Moderate to high velocity
High resistance
The Uterine arteries have higher resistance in which phase?
Proliferative (postmeno)
Radial arteries have higher resistance in which phase?
Proliferative (postmeno)
Doppler characteristics - What are the ovarian arteries in follicular phase?
Low velocity
High Resistance
In the periovulatory period and luteal phase, impedance ---- dramatically on the side of the ------- -------.
Drops
Dominant follicle
(lower PI & RI)
In postmenopausal women, the resistive index approaches ----- with increasing age.
1.0
Menarche is the onset of menses and usually occurs between what age?
11 and 14
Menopause occurs between what age?
44 and 55
Premature menopause occurs prior to what age?
40
When will the dominant follicle usually be identified? And how much will it measure?
Day 8
10 mm
Any follicle measuring greater than what will most likely ovulate?
>11 mm
Follicles grow linearly at a rate of what?
2-3 mm per day
The maximum measurement of a follicle varies between what?
15-30 mm
What suggests ovulation will occur within 24 hours?
Line of decreased reflectivity around the follicle.
What suggests ovulation will occur within 36 hours?
Presence of cumulus oophorus (mural nodule within the follicle).
A surge of LH causes rupture of the dominant follicle within:
24-36 hours
What is the maximum post menses AP diameter?
2 mm
How long does the proliferative phase last?
About 10 days
What is the maximum AP diameter of the endometrium in the secretory phase?
14-16 mm
Most patients on OCP's will not develop a dominant follicle but will have smaller ones measuring what in size?
5-19 mm
Female factors of infertility include: AT PEUC
A - anovulation/abnormal ovulation
T - Tubal/transport factors (adhesions, hydrosalpinx)

P - polycystic ovarian disease
E - endometriosis
U - uterine factors (fibroids, congenital)
C - cervical factors
What 4 things does sonography do for a baseline evaluation for IVF?
1. Establish
2. Monitor
3. Confirm
4. Guide
What are the types of Clomiphene Citrate?
Clomid
Serophene
What are the types of Gonadotropins?
Repronex
Follistim
Pergonal
Bravelle
Gonal-F
What is the type of Glucophage?
Metaformin
What do follicles typically measure when they are aspirated for IVF?
18-24 mm
What do ZIFT & GIFT stand for?
Zygote intrafallopian tube transfer
Gamete intrafallopian tube transfer
What does IUI stand for?
Intrauterine Insemination
In ZIFT, where is the zygote placed?
Fallopian tube
In GIFT, what is placed into the fallopian tube?
Sperm and Ova
In IUI, where is the sperm placed?
Uterine fundus
In IVF, where are the embryos placed?
Uterus
In OHSS, you find large simple with what ovarian diameter?
>5 cm
What do you call a small amount of fluid in the endometrial cavity?
Hydrometra
Postmenopause - The normal endometrial strip is less than what in a asymptomatic patient?
<8 mm
Postmenopause - What is considered a normal endometrial measurement if there is a history of bleeding?
4-5 mm
Postmenopause - what does the endometrium measure on a patient receiving unopposed estrogen only?
Up to 8 mm
Postmenopause - the endometrial strip measures up to --------- in estrogen phase, then ------- during progesterone phase.
10-12 mm
decreases
Postmenopause - What does the EC measure with continuous combined hormones?
<8 mm
What is the most common cause of postmeno bleeding?
Exogenous estrogen administration
What is the most common cause of postmeno bleeding in non HRT patients?
Endometrial atrophy
What are some causes of postmeno bleeding?
Endometrial carcinoma
Cervical carcinoma
Estrogen producing functional tumor of the OV (rare)
What is the most common congenital uterine anomaly with Failure of Formation?
Unicornuate uterus (partial agenesis)
What is the most common congenital uterine anomaly with Failure of Fusion?
Bicornuate Uterus
What is the most common congenital uterine anomaly with Failure of Dissolution?
Septate Uterus
Arcuate Uterus
What is the most common congenital uterine anomaly with Failure of Disappearance?
Gartner's Duct Cyst
What is associated with DES? VIP TIC
V - vaginal epithelial changes
I - intrauterine wall defects
P - poor pregnancy outcome

T - t-shaped UT
I - increased risk of CX carcinoma
C - constricting bands in the uterus
What are the 3 types of Vaginal Anomalies?
1. Vaginal Atresia
2. Vaginal Septa
3. Vaginal Duplication
What should you always evaluate in patients with congenital malformations?
The Urinary Tract
What is the most common tumor of the female pelvis?
Leiomyomas
Lieomyoma clinical signs include: I A IF HE
I - Infertility

A - alteration in NML menstrual flow

I - increasing pain with degenerative changes.
F - frequent urination

H - heavy periods (menometorrhagia)
E - enlarged UT
Lieomyoma - sono - SWWELPD
S - shadowing
W - well circumscribed
W - whirled interior architexture
E - extrinsic compression of post bladder wall
L - lobulated UT contour
P - pedunculated may appear as hypo adnexal mass.
D - displacement of endo echoes
Adenomyosis
Benign invasion of endometrial glands and stoma into the myometrium.
Adenomyosis occurs in ------- year old women with ------ and ------.
40-50
dysmenorrhea
irregular bleeding
Adenomyosis can produce myometrial cysts measuring what?
2-6 mm
"venetian blind" type shadowing is associated with what?
Adenomyosis
What is the most common encountered gynecologic malignancy?
Endometrial Carcinoma
Endometrial Carcinoma has a relationship with what?
Increased Estrogen
Endometrial Carcinoma - risk factors - OHH PS
O - obesity
H - history of atypical hyperplasia of endo
H - history of tamoxifen

P - postmeno, wtih increased risk if on ERT
S - strong family history of UT cancer
Endometrial Carcinoma - sono - II FAT
I - increased UT size
I - inhomogenicity

F - fluid in EC
A - alteration in size, shape, & sono texture of UT.
T - thickened endo (4-5 mm) esp in postmeno women
Endometrial Hyperplasia
Proliferation of endometrial glandular tissue.
What may Endometrial Hyperplasia be caused by?
Unopposed Estrogen Hormone Replacement Therapy
Endometrial Hyperplasia is a common cause of what?
UT bleeding
Endometrial Hyperplasia may be caused by: U POPE
U - unopposed EHRT

P - PCOD
O - obesity
P - persistent anovulatory cycles
E - estrogen producing tumors of the OV
Estrogen producing tumors of the ovaries include which 2 types?
Granulosa cell tumors
Thecomas
What is the endo measurement for Endometrial Hyperplasia in premeno women?
>14 mm
What is the endo measurement for Endometrial Hyperplasia in postmeno women on estrogen only?
>5 mm
What is the endo measurement for Endometrial Hyperplasia in postmen in estrogen phase?
up to 8 mm, decreases in progest. phase
Endometrial Polyps
Localized overgrowths of endo tissue.
What does SIS stand for?
Saline Infusion Sonohysterography
What is SIS also called?
Hystersonography
Follicular cysts usually measure:
3-8 cm
What is the maximum measurement of a normal dominant follicle?
3 cm
Corpus luteal cysts rarely exceed what size?
4 cm
Corpus luteal cysts can be seen with pregnancy but usually resolve by how many weeks?
16 weeks
What are the largest of the functional cysts?
Theca lutein cysts
Polycystic Ovarian Syndrome is also called:
Stein-Leventhal Syndrome
Multiple bilateral cysts are seen with PCOS, measuring:
<1 cm
How many follicles are seen per ovary with PCOS?
12-19 per ovary
PCOS can also have what kind of appearance?
"string of pearls" (peripheral cysts 2-6mm)
What are the 5 types of Epithelial Tumors?
1. Serous
2. Mucinous
3. Endometroid
4. Clear Cell
5. Transitional Cell (Brenner)
Pseudomyxoma Peritonei occurs with which type of tumors?
Mucinous
Sertoli-Leydig Tumor is also called:
Arrhenoblastoma / Androblastoma
How do Metastatic tumors spread?
1. Direct Invasion
2. Peritoneal fluid
3. Blood vessels and Lymphatics
Where does the Krukenberg Tumor arise from?
GI tract
PID is what kind of infection?
Ascending infection
Benign Serous Tumors - sono - LAPS
L - large, unilocular
A - anechoic
P - possibly internal thin-walled septations
S - sharply marginated
Malignant Serous Tumors - sono - MOM AP
M - multilocular
O - occasional echogenic material within
M - multiple papillary projections/septations

A - ascites
P - possible multiple echogenic foci
Endometriod Tumors - sono - MAP
M - mixed cystic & solid mass
A - associated enometrial abnormality
P - possibly areas of hemorrhage or necrosis
Fibroma - sono - PRASHH
P - posterior acoustic shadowing
R - rarely focal or diffuse calcifications
A - associated with ascites
S - similar to pedunculated fibroid or Brenner Tumor
H - homogeneous
H - hypoechoic
Thecoma - sono - HAPS
H - hypoechoic ovarian mass
A - abnormally thick endometrium
P - posterior acoustic shadowing
S - solid
Benign Mucinous Tumor - sono - M50FT
M - multiloculated
50 - 50cm (measures up to)
F - fine, gravity dependent echoes
T - thicker and more numerous septations
Malignant Mucinous Tumor - sono - MEM
M - multiloculated cystic lesion
E - echogenic material
M - measures 15-30 cm
Transitional/ Brenner - sono - HSMCM
H - hypoechoic
S - solid mass
M - may have small cystic spaces
C - calcifications
M - may mimic an ovarian fibroma
Dysgerminoma - sono - MSM
M - multiloculated solid mass
S - size variable
M - may be bilateral
BCT - sono - DFCP
D - diffusely echogenic
F - fat fluid level (change patient posistion)
C - complex with calcifications
P - predominantly cystic adnexal mass
Sertoli-Leydig - sono - SES
S - solid
E - echogenic mass
S - similar appearance to granulosa cell tumor
Krukenberg Tumor - sono - BASH
B - bilateral
A - ascites
S - solid
H - hypoechoic or complex
PID
Inflammation of pelvic and adnexal structures.
Hydrosalpinx
Collection of fluid within a scarred or obstructed fallopian tube.
What do you see with Stage I (early) PID?
Endometritis
What do you see with Stage II (subacute or acute) PID?
May produce pyosalpinx.
What do you see with Stage III (severe) PID?
May see TOA if purulent material leaks from the fimbriae.
May see Fritz-Hugh Curtis Syndrome.
What is Fritz-Hugh Curtis Syndrome?
Development of peritonitis and acute perihepatitis.
Which stage of PID do you have broad ligament and ovarian involvement?
Stage III
What stage do you see the "indefinite uterus sign"?
Chronic PID
What is it called when you have adhesions that may cause the pelvic organs to merge centrally?
"indefinite uterus sign"
What are the clinical signs of PID? FLLPPCC
F - fever
L - leukocytosis
L - lower abdominal pain
P - purulent vaginal discharge
P - pelvic tenderness
C - cervical motion tenderness
C - constant dull pain worsened by sex
What do you call painful intercourse?
Dyspareunia
PID - stage I - sono - TIFFD
T - thickening/irregularity of the endometrium
I - indistinct borders of pelvic structures
F - fluid, debris, or gas w/in EC
F - fluid in Posterior CDS
D - diffuse hypoechogenicity of uterus
PID - stage II - sono - PUST
P - pyosalpinx
U - unilateral but may be bilateral
S - shaggy tubal walls
T - tubular adnexal cystic masses
PID - stage III - sono - TIT
T - TOA (unilateral or bilateral w/ hyperemic flow)
I - indistinct walls surrounding the mass
T - TOC
What is TOC?
Tubo-ovarian complex
(Tube & ovary inflammed, no abscess)
PID - Chronic - sono
Hydrosalpinx
Indefinite uterus or lobster claw sign
Endometriosis
Functional endometrial tissue outside of the endometrium and myometrium.
Where can Endometriosis occur?
Anywhere in the pelvis
Ovaries (most common)
Fallopian Tubes
Broad Ligament
Posterior CDS
Pelvic peritoneum
Endometriosis is most common in what type of patients?
White
Reproductive age
Higher Socioeconomic status
Postponed having children till later in life
What are the 2 types of Endometriosis?
Diffuse (scattered minute implants)
Localized (Endometrioma)
What is Endometrioma referred to as?
Chocolate Cyst
How many stages are there with Endometriosis?
4
Endometriosis - Describe Stage I :
Minimal
Few or superficial implants
Endometriosis - Describe Stage II:
Mild
More implants and deeper involvement
Endometriosis - Describe Stage III:
Moderate
More implants
Ovaries affected
Adhesions
Endometriosis - Describe Stage IV:
Severe
Like stage III but with:
Multiple, more dense adhesions
What are the clinical signs of Endometriosis?
Chronic Pain
Infertility
4 D's
Endometriosis - What are the 4 D's?
Dysmenorrhea - painful period
Dyspareunia - painful sex
Dysuria - difficult urination
Dyschezia - difficult defecation
What is the measurement for an appendicitis?
> 6mm
What 3 things is bowel wall thickening associated with?
Diverticulitis
Gastroenteristis
Bowel-related abscesses
What is interstitial cystitis?
Bladder wall thickening (focal or diffuse)
History of UTI's
How can you confirm a bladder wall neoplasm?
By demonstrating vascular flow to the mass
Bladder Diverticulum
Urine filled outpouching of the bladder wall.
A Bladder Diverticulum may -------- on post-void scan.
Enlarge
Neurogenic Bladder
Urinary bladder malfunction due to neurologic deficit.
(lacks bladder control due to brain/nerve condition)
Neurogenic Bladder can result in
Urinary bladder stasis
(patients might have to self catheterize)
Hyperthermia
>38.9 degrees
Heat exposure to infants between ----- and --- weeks is not good.
4 and 14 weeks
Autosomal Dominant
One parent is affected
Evident in each generation
Rarely skips a generation
Autosomal Dominant - What is the probability of transmitting the trait to an offspring with each pregnancy?
50%
Autosomal Recessive
Parents are usually unaffected
May skip a generation
What is the probability of transmitting the trait to an offspring with each pregnancy?
25%
Karyotype
The complete chromosomes in a cell
Euploid
A normal, balanced set of chromosomes (23 pairs)
Aneuploid
An unbalanced set of chromosomes (too many/too few)
Trisomy
Presence of an extra chromosome
Triploidy
Presence of additional set of chromosomes (69)
Genotype
The genetic makeup of an individual
Phenotype
The expression of the genetic makeup of an individual. (physical & physiologic)
When is first trimester scanning performed?
Between 11.5 and 13.5 weeks
What are the 2 parts of first trimester scanning?
1. Nuchal Translucency scan
2. Maternal Blood Test (HcG & PAPP-A)
What does PAPP-A stand for?
Pregnancy associated plasma protein A
Both of these test help diagnose what?
Trisomy 21
Trisomy 18
What is the CRL when doing a Nuchal Translucency scan?
45-84 mm
What do some centers consider an abnormal NT measurement to be?
>3 mm
How is NT measured?
Inner to Inner
What should the NT not be mistaken for?
Adjacent amnion
What are PAPP-A and HcG produced by?
Trophoblastic tissue
What can low levels of PAPP-A and HcG mean?
Abnormal implantation
Poor placentation
Trisomy 21
When is a CVS typically performed?
Between 9-12 weeks
What are obtained with the CVS and karyotyped?
Trophoblastic cells
What 4 things are in the Multiple Marker (Quad) Screen?
1. MSAFP
2. hCG
3. uE3 (unconjugated estriol)
4. Inhibin-A
What does the Quad screen test help detect?
ONTD's
Trisomy 21
Trisomy 18
What is considered elevated MSAFP?
>/= 2.0 - 2.5 MoM
Elevated MSAFP is associated with - I MOOM MAP
I - incorrect dates

M - multiple gestation
O - ONTD's
O - other fetal anomalies (sacrococcygeal teratoma)
M - maternal/fetal hemorrhage

M - maternal HCC
A - abdominal wall defects
P - placenta chorioangioma
Decreased MSAFP is associated with - FIC
F - fetal demise
I - incorrect dates
C - chromosome abnormalities
Trisomy 18
MS-AFP is -------
hCG is --------
uE3 is --------
Decreased
Decreased
Decreased
Trisomy 21
MS-AFP is -------
hCG is --------
uE3 is --------
Inhibin-A is --------
Decreased
Increased
Decreased
Increased
Amniocentesis
Evaluates fluid levels of amniotic fluid (AFP) (AFAFP) and Acetylcholinesterase
If AFAFP or Acetylcholinesterase levels are elevated, -------------- is most likely.
Occult Neural Tube Defect
Amniocentesis is usually performed around how many weeks?
16 weeks
Amniocentesis - routinely done for women over ---- years of age.
35
What is indigo carmine used for?
To make sure that each sac in a multiple gestation is only tapped once during an Amniocentesis.
Each cell contains how many chromosomes?
46 (23 pairs)
Gamete
Male & female reproductive cell
(ovum/spermatozoa)
Zygote
The single fertilized ovum prior to mitotic division.
Blastomere
Dividing fertilized ovum at 2-cell and 4-cell stages
Located within ampulla of FT
Morula
Mass of dividing cells
Located in isthmus of FT as it enters the Uterus
Blastocyst
Organized collection of cells
The Blastocyst implants into the endo how many days after fertilization?
7 days
What does the outer lining of the Blastocyst consist of?
Trophoblasts (produce hCG to extend life of CL)
Blastocele
The inner fluid filled cavity of the Blastocyst
What does the Blastocele become?
Yolk sac
Amnion
Embryonic Disk
What is hCG produced by?
The trophoblastic cells
Later by the placenta
What forms the basis of a current pregnancy test?
hCG
What does hCG do?
Supports the life of the Corpus Luteum (supplying progesterone)
With an IUP, when does hCG become detectable in the bloodstream?
7-10 days after ovulation
(3 weeks LMP)
hCG doubles every:
And plateaus around:
2-3 days
8-9 weeks, then declines
What are the 2 ways hCG can be measured?
1. Qualitative (urine - positive or negative)
2. Quantitative (blood - specific levels)
What is the most common radioimmunoassay method?
3rd IRP
Greater levels of hCG associated with: MIG
M - multiple gestations
I - incorrect dates
G - gestational trophoblastic disease
Lower levels of hCG associated with: IEE
I - incorrect dates
E - ectopic pregnancy
E - embryonic demise / abnormal IUP
What are the 3 germ layers?
1. Endoderm
2. Mesoderm
3. Ectoderm
What does the endoderm become?
GI & respiratory tracts
What does the Mesoderm become?
Musculoskeletal & Circulatory systems
What does the Ectoderm become?
Brain, Nervous System & Skin
When does the heart begin to beat?
By 6 weeks
Decidua Basalis
Develops where the blastocyst implants.
Maternal contribution to the PL
Decidua Capsularis
Closes over and surrounds the blastocyst
Decidua Parietalis/Vera
Results from hormonal influence on the uninvolved endometrial tissue.
What is the fetal part of the PL?
Chorion Fondosum
When does the trophoblast develop into the chorionic villi?
5 weeks LMP
When do the amnion and chorion begin to fuse?
Mid 1st trimester
When is the fusion of the amnion and chorion completed by?
12-16 weeks
Separation of the 2 membranes before ---- weeks is considered a normal finding.
16 weeks
How would you describe the waveforms of the trophoblastic tissue?
High Velocity, Low Resistance
What is the 1st evidence that a normal IUP is present?
Identification of the gestational sac
A GS should be seen transvaginally with a Serum BhCG level of what?
>1000-2000 mlu/ml (3IRP)
A GS should be seen transabdominally with a Serum BhCG level of what?
>1800 mlu/ml (2IS)
A GS should be seen when a certain LMP is:
>5 weeks
(with a normal 28 day cycle)
The GS grows how many mm per day?
1 mm
The yolk sac should be present when the MSD is >/= to what?
>/= 8mm TV
A nomal GS will appear with what 4 things?
Round, oval or teardrop shaped
Located toward UT fundus or Mid-UT
Double Decidual Sign
Echogenic, intact borders
Mean Sac Diameter (MSD)
MSD = length + height + width / 3

MSD (mm) + 30 = gestational age (days)
A MSD >/= ------ is associated with a ----- risk of -------.
>/= 5mm
High
SAB
What is the first structure seen within the GS?
Yolk Sac
With --------- ultrasound, the ------- yolk sac is visible at ------- weeks LMP, and is almost always seen when the MSD reaches ------.
Transvaginal
Secondary
5.5 weeks
8mm
What attaches the YS to the embryo?
Vitelline duct
How do you measure the YS?
Inner to Inner
A YS measuring >------ between --- and --- weeks GA is abnormal.
>5.6 mm
5-10 weeks
The embryo should be seen when the GS measures what TV and what TA?
TV - 16mm
TA - 25mm
How much does the embryo grow per day?
1mm
CRL calculation:
CRL (mm) + 42 = GA
Rhombencephalon
Anechoic structure seen in posterior portion of embryonic/fetal brain.

Part of the normal development of the CNS
When is a Rhombencephalon usually seen?
8-11 weeks
Rhombencephalon should not be mistaken for what?
Dandy-Walker
Ventriculomegaly
When does the midgut herniate into the base of the umbilical cord?
9 weeks
When does the midgut return to the abdominal cavity?
12 weeks
When should you diagnose the herniation as being abnormal?
After 14 weeks
How many weeks after fetal demise does spontaneous abortion occur?
1-3 weeks
Complete Abortion
All products of conception are expelled.
Complete Abortion - How long can the UT remain enlarged after SAB?
Up to 2 weeks
Complete Abortion - How long can the presence of trophoblastic waveforms surrounding the endo remain?
Up to 3 days post SAB
What can you see sonographically with a Complete Abortion?
Emply UT with normal EC
Possibly small amount of fluid in EC
Incomplete Abortion
Part of the products are expelled with portion remaining in the UT.
Incomplete Abortion - How long can the presence of trophoblastic waveforms surrounding the endo remain?
Up to 5 days post event
What can you see sonographically with an Incomplete Abortion?
Thickened/irregular endo echoes
May have fluid in EC
Missed Abortion
Presence of an embryo without cardiac activity.
Missed Abortion - symptoms:
hCG levels less than expected
loss of pregnancy symptoms
decreased UT size
Brownish vaginal discharge
2 observers should watch for how many minutes to confirm absence of cardiac activity?
3 minutes
Threatened Abortion
The future of the pregnancy might be in jeopardy but the pregnancy continues.
What do patients present with in Threatened Abortion?
Vaginal bleeding
Cramping
Closed CX
Inevitable Abortion / Abortion in Progress
SAB is imminent and cannot be halted.
Inevitable Abortion occurs when 2 or more of the following occur:
Effacement of the CX
Cervical dilation > 3cm
ROM
Bleeding more than 7 days
Persistent cramping
Anembryonic Pregnancy is also called:
"Blighted Ovum"
Anembryonic Pregnancy
Embryo does not develop or stops developing early in development and can't be visualized.
Septic Abortion
Results from non-sterile instruments or from infection of retained products of conception.
Ectopic Pregnancy - where is the most common site?
Ampulla of the FT
Ectopic Pregnancy has increased with an increased rate of what?
PID
Name 4 sites of Ectopic Pregnancies?
1. Adnexal
2. Uterine
3. Cervical
4. Abdominal
Abdominal Ectopic Pregnancy - sono - O U APE
O - oligohydramnios

U - unusual fetal presentation

A - absence of myometrium surrounding pregnancy
P - poor visualization of placenta
E - empty uterus separate from the developing fetus
Heterotopic pregnancies can occur in general population but most commonly occur in:
Fertility patients
Undergone Zygote / Gamete Transfer
The risk of Heterotopic pregnancies in reproductive patients is:
1:2000 - 1:4000
Ectopic Pregnancy - clinical - VAAPPS
V - vaginal spotting/bleeding
A - amenorrhea
A - adnexal tenderness/mass
P - pelvic pain
P - positive pregnancy test
S - shoulder pain (referred pain from intraperitoneal bleeding)
What is the definitive finding for an Ectopic Pregnancy?
Live extrauterine embryo
Ectopic Pregnancy - sono - FAPE
F - free fluid in CDS, adnexae, pericolic gutters or Morrison's Pouch
A - adnexal mass
P - presence of endometrial decidual reaction
E - empty uterus
What are 3 pitfalls associated with an Ectopic Pregnancy?
1. Pseudogestational sac within the endo cavity
2. Corpus Luteal cyst is mistaken for ectopic
3. Cornual Ectopic is mistaken for intrauterine pregnancy.
How many mm of myometrium should be surrounding each side of a GS?
5 mm
"Ring of Fire"
Using Doppler to show surrounding flow around the GS representing trophoblastic flow.
What are 4 things used to treat Ectopic Pregnancy?
1. Methotrexate Administration
2. Laparoscopy
3. Exploratory Laparotomy
4. Expectant Management
Gestational Trophoblastic Disease (GTD)
Abnormal proliferation of trophoblastic tissue.
When does GTD most commonly occur?
During or after implantation of a fertilized ovum.
(can occur months to years after preg)
What do paternal genomes control?
Proliferation of trophoblastic tissue.
What do maternal genomes control?
Growth of the embryo
What causes GTD?
Duplication of chromosomes in the sperm
Lack of chromosomes in the ovum
Fertilization of the ovum by 2 sperm
GTD - clinical - HHVE MATE
H - hyperthyroidism
H - hyperemesis gravidarum
V - vaginal bleeding/tissue
E - enlarged UT

M - markedly elevated hCG levels
A - absence of fetal heart tones
T - theca lutein cysts
E - early onset of pre-eclampsia
GTD - Complete Hydatidaform Mole
The chorionic villi are hydropic without identifiable embryonic or fetal tissue.
GTD - what is the most common form of trophoblastic disease?
Complete Hydatidaform Mole
GTD - Complete Hydatidaform Mole - sono - HEET
H - hypervascular, low resistance flow
E - enlarged UT filled with echogenic mass
E - EC filled with echogenic material (homogeneous in the 1st trimester, cystic areas in the 2nd trimester)
T - theca lutein cysts
GTD - Partial Mole
Has 1 set of maternal chromosomes and 2 sets of paternal chromosomes.
(Results in triploid karyotype)
GTD - Partial Mole have ---- and ----- villi.
hydropic chorionic villi
relatively normal villi
GTD - Partial Mole - Is fetal tissue frequently identified?
Yes
GTD - Partial Mole - sono
Deformed GS
Growth Restricted Fetus
Triploidy anomalies (syndactyly & hydrocephalus)
Enlarged PL with multiple cystic areas
GTD - Mole with Coexisting Normal Fetus
Two conceptions:
1 develops normally
1 develops into GTD
GTD - Mole with Coexisting Normal Fetus - sono
Similar to Partial mole
Normal PL and membranes can be identified
Fetus usually has normal karyotype
PTN stands for what?
Persistent Trophoblastic Neoplasm
Persistent Trophoblastic Neoplasm
Complication of pregnancy that most commonly follows GTD.
When can PTN occur after, besides GTD?
Normal term delivery
SAB
Ectopic pregnancy
What are at high risk for PTN?
Severe degrees of trophoblastic proliferation
What is at low risk for PTN?
Partial Mole
What are the 2 types of PTN?
1. Invasive Mole
2. Choriocarcinoma
Invasive Mole is also called what?
Chorioadenoma Destruens
What is the most common form of PTN?
Invasive Mole
Invasive Mole
Penetrates the myometrium or adjacent structures.
May cause uterine rupture
Malignant, Non-metastatic GTD
Invasive Mole - sono - FIM
F - focal/diffuse echogenic material in EC
I - irregular, sonolucent areas surrounding trophoblastic tissue.
M - may see extending into the myometrium
What commonly occurs with Choriocarcinoma?
Vascular invasion
Hemorrhage
Necrosis of the myometrium
Choriocarcinoma may metastasize to which structures?
Lung
Liver
Brain
Bone
GI tract
Skin
Choriocarcinoma - sono
Elevated hCG in non-pregnant patient
Enlarge UT
Irregular complex mass w/ marked vascularity
Maternal blood pressure is considered elevated when it measures what?
> 140/90
When is organogenesis completed by?
8 weeks
In which plane is the diagphragm best seen?
Coronal
Where should the thoracic circumference be measured?
True transverse view at the level of the four chamber heart.
Is the umbilical cord high resistance or low resistance flow?
Low resistance
Is the middle cerebral artery high resistance or low resistance flow?
High resistance
What condition is most common among pediatric patients?
PID
What should not be used to clean a vaginal transducer?
Betadine
Which is more accurate: the BPD or HC measurement?
HC
What is the double bleb sign?
The sonographic presentation of the amnion and yolk sac.
Is the left lobe or right lobe of the liver larger in a fetus?
Left lobe
Gastroschisis
Protrusion of the intestines into the amniotic cavity.
Affects all 3 layers of the abdominal wall.
Where does Gastroschisis occur?
Lateral to the umbilical cord insertion.
(Usually to the right)
Gastroschisis - Are the intestines covered with a membranous sac?
No
What does a Omphalocele result from?
Failure of the intestines to return to the abdomen during the second stage of intestinal rotation.
Omphalocele - Are the intestinal contents covered by a membranous sac?
Yes
Omphalocele - What is the membranous sac made of?
Amnion
Peritoneum
where is a Omphalocele seen?
At the level of the umbilical cord insertion.
Omphalocele - What can rupture of the sac during delivery cause?
Sepsis
Are there other anomalies associated with Gastroschisis?
No
What are some of the anomalies associated with Omphalocele?
Cardiac defects
Trisomy 13
Trisomy 18
What can be seen in a Omphalocele?
Liver
Bowel loops
Mesentery
Omentum
Sometimes pancreas and spleen
What kind of Omphaloceles have a greater risk of associated chromosome abnormalities?
Omphalocele's containing bowel only.
Bladder Exstrophy
Exposure and protrusion of the urinary bladder.
Bladder Exstrophy - What does this midline defect usually involve?
Lower Abdominal Wall
Anterior wall of the BL
What can Bladder Exstrophy be associated with?
Genital Anomalies
(cleft clitoris, epispadias, with separation of pelvic bones)
What is ascites in the fetal abdomen most commonly associated with?
Hydrops Fetalis
Persistant Right Umbilical Vein
When the umbilical vein courses toward the left side of the fetal abdomen.
Persistant Right Umbilical Vein - The umbilical vein actually enters the ----------- of the liver rather than the -----------.
Right portal vein
Left portal vein
Persistant Right Umbilical Vein- is there always something pathological with this?
No but followup should be done