09妇产科疾病的超声诊断2011-ENGLISH

nullnullUltrasonography on Gynecology and ObstetricsLiu LipingSangreal--------uterusSangreal--------uterusTHE DAWINCI CODENORMAL ANATOMYNORMAL ANATOMY Pelvic Cavity Posterior : Occupied by rectum, colon, and ileum Anterior: bladder, ureters, ovaries, fallopian tubes, uterus, and vaginaPre-inspection :Pre-inspection :Moderate bladder filling UterusUterusHollow, pear-shaped organ Divided into fundus, body, and cervix Usually anteflexed and anteverted Covered with peritoneum except anteriorly below the os where peritoneum is reflected onto bladder Supported by levator ani muscles and pelvic fascia Round ligament keeps uterus in positionUterine sizeUterine sizePrepubertal : 3 cm long by 0.5 to 1.0 cm wide Menarcheal: 8 cm long by 4 cm wide Postmenopausal: 3.5 to 5.5 cm long by 1 to 2 cm wide Normal size : 2~3(thick)×4~5(width)×7~8 cm(length)nullUterine longitudinal diameter Uterine wide diameter Uterus before and after the Trail nulllength 7~8cmbefore and after the Trail 2~3cmwidth 4~5cmUterine PositionUterine PositionMidline anteversion: most common; degree of anteversion is bladder distention dependent Right or left: normal variant in absence of pelvic masses Retroverted: entire organ displaced posteriorly Retroflexed: body displaced with respect to cervixUltrasonography of normal uterusUltrasonography of normal uterusUterine serosa layer: Linear high-echo ;clear, smooth; Myometrium: Homogeneous middle-echo ; Endometria: The middle line of high echo , around the weak echo . It is well known that the endometrium changes dynamically in response to cyclic hormonal flux. nullUterine serosa layer Myometrium Endometria Normal uterus transabdominal ultrasonographynullTransvaginal sagittal view of the uterus. The rounded fundus is shown toward the left of the image with the endometrial stripe rumming through the middle of the uterine cavity.MyometriumEndometriaUterine serosa layerFallopian Tube（输卵管）Fallopian Tube（输卵管）Infundibulum: funnel-shaped lateral tube that projects beyond the broad ligament to overlie the ovaries Ampulla: sidest part of the tube where fertilization occurs Isthmus: hardest part; lies just lateral to the uterus Length: 12 cm; supplied by ovarion arteries and veinsOvary（卵 巢）Ovary（卵 巢） Almond shaped Attached to back of the broad ligament by mesovarium; sometimes called suspensory ligament of the ovary Lies in ovarian fossa Fossa is bounded by external iliac vessels, ureter, and obturator nerve Receives blood from ovarian artery Blood drained by ovarian vein into inferior vena cava on right; on left by ovarian vein into lert renal veinSonography of the normal ovarySonography of the normal ovaryAn ovoid homogeneous echodensity; follicular cysts are often present. The best sonographic marker for the ovary is identification of a follicular cyst, which has the classic appearance of being thin walled and anechoic with through-transmission posteriorly.nullTransabdominal sagittal image shows the left ovary posterior to the urinary bladdernullTransvaginal sagittal image of the ovaryovarian folliclenullFollicular wall flowCommon Diseases of Obstetrics and GynecologyCommon Diseases of Obstetrics and GynecologyGynecology ：Leiomyoma ；Carcinoma ;；Ovarian Tumors; Inflammatory mass ;etc. Obstetrics： Natural pregnancy ； Abnormal pregnancy; etc.The uterus Leiomyoma /HysteromyomaThe uterus Leiomyoma /HysteromyomaCharacteristics of LeiomyomasCharacteristics of LeiomyomasMost common pelvic tumor Smooth muscle cell composition Fibrosis occurs after atrophic of degenerative changes Degeneration occurs when fibroids outstrip their blood supply; calcification May be pedunculated Clinical: enlarged uterus, profuse and prolonged bleeding, painUterine Locations of leiomyomasUterine Locations of leiomyomasSubmucosal Erode into endomertial cavity – heavy bleeding; infertility Intramural May enlarge to cause pressure on adjacent organs; infertility Subserosal May enlarge to cause pressure on adjacent organs nullSubserous myomaBroad ligament myomaCervical myomaintramurous myomaSubmucous myomaUltrasonic performanceUltrasonic performanceTwo-dimensional：①Increased uterine body or Form disorders； ②Spherical hypoechoic area in the uterine body ，Rear echo attenuation； ③With calcification or Cystic change, etc；④Signs of oppression； Color Doppler：Tumor around with the blood flow signal in the shape of ring or semi-circular ring ； Doppler spectrum：Medium resistance index，RI 0.6±0.1。nullintramurous myoma nullSubserous myomaintramurous myoma nullSubserous myomanullCervical myomanullAbundant tumor blood flowMUTnullRI 0.61nullSubmucous myoma with calcificationTeratoma Dermoid Tummors （卵巢良性囊性畸胎瘤/皮样囊肿)Teratoma Dermoid Tummors （卵巢良性囊性畸胎瘤/皮样囊肿)Pathology ：derives from germ cell，the most common ovarian neoplasm, constituting 20% of ovarian tumors. up to 20% are bilateral. About 80% occur in women of childbearing age. nullSize ranges from small to 40 cm Unliateral,round to oval mass Contains faty,sebaceous material, hair, cartilage, bone, teeth Clinical: asymptomatic to abdominal pain, enlargement and pressure; pedunculated, subject to torsion Sonography: Cystic/ complex/solid mass, echogenic components; acoustic shadowing Special Ultrasound Findings:Special Ultrasound Findings:1. A cystic mass: with an echogenic mural nodule 2. A paste sign：particulate liptinite 3. A fluff of hair sign 4. A fat-fluid level sign：with fluid level in the cyst, fat above, fluid below. 5. A complex massnullcystic teratoma of ovaryA cystic massPaste signFluff of hair signnullPaste signFat-fluid level signA complex massnullA 8 years old girl, cutting off a three kilograms benign teratomaThe role of Ultrasound in ObstetricsThe role of Ultrasound in ObstetricsTRIMESTERSTRIMESTERSFirst trimester = 0 to 12 weeks of gestation Second trimester = 13 to 26 weeks of gestation Third trimester = 27 to 42 weeks of getsation Postterm pregnancy = >42 weeks of gestationIndications for First-Trimester SonographyIndications for First-Trimester SonographyConfirm presence of intrauterine pregnancy Evaluate for suspected ectopic pregnancy Define cause of vaginal bleeding Determine gestational age Confirm suspected multiple gestations Aid in invasive procedures Evaluate pelvic masses Detect uterine abnormalitiesNatural pregnancyNatural pregnancyNonage pregnancy (First-Trimester) Nonage pregnancy (First-Trimester) Definition ：Pregnancy before 12 weekend.The Normal First TrimesterThe Normal First Trimester5 weeks pregnant— Gestational sac； 6-7 weeks pregnant— Germ; 7-8 Weeks —Primitive heart tube pulse； 8-11 weeks — Yolk sac; 9 weeks — Embryonic, placenta.Sonographic Features of a Normal Gestational SacSonographic Features of a Normal Gestational SacShape: round of oval Position: fundal or middle portion of uterus; a center position relative to endometrium Contour: smooth Wall: echogenic; 3 mm of more in thicknessnullInternal landmarks: yalk sac present when gestational sac is larger than 10 mm; embryo present when gestational sac is larger than 18 mm Growth: 1 mm per day (range: 0.7 mm to 1.5 mm per day) null4-5 weeks pregnant In the gestational sac we can see a embryo point, the earliest embryo. null7 weeks pregnant Fetus was about 4 mm，we can see apparent heart throb, and small limb bud .null8 weeks pregnant Three-dimensional ultrasound show its beginning of the shape of a human.nullUmbilical bordEmbryonic headEmbryonic abdomennullYolk sacEmbronic headAmniotic sacnull9 weeks pregnant Known as a fetal，Development of the various parts of the fetus, tends to improve.null12 weeks pregnant The spine is identifiable , as the two bead-like high echo. Ears, limbs, bones can be shown and measurement. Ultrasound of the Second and Third TrimestersUltrasound of the Second and Third TrimestersIndications for Second- and Third-TrimesterIndications for Second- and Third-Trimester Estimate gestational age for patients with uncertain dates Evaluate uterine size and clinical date discrepancies Evaluate fetal growth Estimate fetal weight Determine fetal presentation Evaluate fetal lifenull provide adjunct to amniocentesis, percutaneous umbilical blood sampling procedure, or cerclage placement Evaluate uterine abnormality Evaluate abnoumal maternal serum alpha-fetoprotein values Evaluate abnormal amniotic fluid Evaluate placenta Etc.The Second- and Third-Trimester ( Metaphase and terminal prengancy)The Second- and Third-Trimester ( Metaphase and terminal prengancy)Mid-pregnancy:13-27 weeks pregnancy. Late-pregnancy:More than 28 weeks of pregnancy.Scanning TechniquesScanning TechniquesSurvey uterus Observe cardiac activity Determine position and number of the fetus and placenta Assess amniotic fluid Look for uterine of placental masses and fetal anomaliesCheck contentsCheck contents 1、Fetal head ：BPD biparietal diameter; 2、Fetal abdomen: AC abdomen circumference; 3、Fetal limb： FL femur length ; 4、Others：Placenta, Fetal heart rate, Amniotic fluid, etc.1 、 Fetal head1 、 Fetal headMeasuring the Biparietal Diameter(BPD) Obitain biparietal diameter of the fetal head at the transverse level of the midbrain: falx, cavum septi pellucidi, and thalamic nuclei Make sure the head is symmetric and oval Measure from outer to inner margins of the skull In the third trimester, the BPD is not as accurate in predicting fetal age null Fetal head, after 12 weekend pregnantnull Fetal side profile, we can observe its forehead, nose ,lip, and chin, etc.2、Fetal abdomen2、Fetal abdomenThe hepatobiliary system: liver, port venous systerm, hepatic veins and arteries, gallbladder, and bile ducts The gastrointestinal system: the esophagus, stomach, small and large intestines(colon)nullThe urinary system: kidneys, adrenal glands, ureters, bladder. The fetal abdomen circumference（AC) is the most widely measured Measuring the Abdominal Circumference(AC)Measuring the Abdominal Circumference(AC)The AC should be taken from a round transverse image with the umbilical portion of the left portal vein midline within the liver The outer margin of the abdominal wall should be measured The abdominal wall measurement is the least accuratenullThe fetal livergallbladderstomachport venousspinegallbladderstomach3、Fetal limbs3、Fetal limbsThe upper limbs: the ulna the radius the humerus The lower limbs: the femur/the thigh bone the fibula the tibia The femur is the most widely measured long bone （FL femur length ）Femur measurementFemur measurementHyperechonic linear structure represents the ossified portion of the femoual diaphysis and corresponds to femoral length measurement from the greater trochanter to the femoral condyles The mormal femur has a straight laeral border and a curved medial border Femur length may be used with the same accuracy as BPD to predict gestational age Femur length may indicate skeletal dysplasias or intrauterine growth restrictionLong section of the upper limbsLong section of the upper limbsThe radiusThe ulnaThe humerus Long section of the lower limbs Long section of the lower limbs Femur/thigh boneFibula /perone Tibia/shin bone 4、 The placenta（胎盘）4、 The placenta（胎盘）The major fole of the placenta is to permit the exchange of oxygenated maternal blood(rich in oxgen and nutrients) with deoxygenated fetal blood. The thickness of the placenta varies with gestational age,with a minimum diameter of 15 mm in fetuses greater than 23 weeks. The size of the placenta rarely exceeds 50 mm in the normal fetus. nullAnterior placenta at 21 weeks of gastationThe placentaUmbilical bordAmniotic fluidThe fetalnull posterior placenta at 29 weeks of gestationcalcification nullAnterior placenta at 39 weeks of gastationnullCalm little faceEating toe Eating fingersnullCryingPouttingnullFetal with umbilical cord around the neckFetal with cleft lipnullsmailingnullnullnull