Diagnostic Radiology Notes

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER TWO Ultrasound Artifacts CRT04210 · Ultrasound Imaging START READING NOTES Study Ultrasound Artifacts using the sections below. Use the topic navigation to continue through Ultrasound Imaging. Contents of This Topic ULTRASOUND PHYSICS LECTURE 4 DEFINITION COMMON ARTIFACTS REVERBERATION ACOUSTIC SHADOWING ACOUSTIC ENHANCEMENT EDGE SHADOWING BEAM WIDTH ARTIFACT SLICE THICKNESS ARTIFACT SIDE LOBE ARTIFACT MIRROR IMAGE ARTIFACT DOUBLE IMAGE ARTIFACT EQUIPMENT GENERATED ARTIFACTS ULTRASOUND ARTIFACT ULTRASOUND PHYSICS LECTURE 4 ARTIFACTS DEFINITION In ultrasound imaging, an artifact is an appearance on the image which does not faithfully represent the structures present in the subject being scanned. Therefore the echoes are a false or misleading image which need to be properly understood and interpreted. Artifacts may appear as structures seen in the image which do not exist in the subject, or structures which should be seen in the image but are not. Structures may also be represented in the wrong location in the image ( mis -registration ). Artifacts may be caused by improper function or use of equipment, or they may simply be a characteristic of the physical properties of ultrasound waves and their interaction with tissues. COMMON ARTIFACTS Reverberation Acoustic shadowing Acoustic enhancement Edge shadowing Beam width artifact Slice thickness artifact Side lobe artifacts Mirror image artifacts Double image Equipment generated artifacts REVERBERATION Reverberation is the production of false echoes due to repeated reflections back and forth between the transducer face and a strong reflector in the subject. The first returning echo is displayed correctly, but some of the returning sound bounces off the face of the transducer back into the subject like a weak transmitted pulse. This returning pulse meets the strong reflector again causing another returning echo from the same interface. As the time taken for the second echo to arrive is twice that taken by the first echo, the image will display it at twice the depth. This results in a series of equally spaced false echoes to be displayed on the ultrasound image. REVERBERRATION REVERBERATION The bouncing of the sound back and forth (reverberation) often occurs between the transducer face and the subcutaneous fat / muscle layer. It also commonly occurs when the sound waves reverberate between two anatomic reflecting surfaces in the subject, such as between the near and far surface of an area of gas. In this case the echoes are placed much closer together in the image, and the appearance is termed comet tail. Small gas bubbles create an almost continuous band of reverberation called Ring down FORMATION OF COMET TAIL ARTIFACT COMET TAIL ARTIFACT RING DOWN ARTIFACT ACOUSTIC SHADOWING Acoustic shadowing appears as an area of low level echoes or no echoes at all distal to an interface with a large acoustic mismatch. It is caused by severe attenuation of the beam at the interface. This will occur where the beam passes from soft tissue to gas (99.9 % of the beam is reflected) It also occurs where the beam passes from soft tissue to bone (40% reflection and 60% absorption by the bone) ACOUSTIC SHADOWING GAS OR STONES? ACOUSTIC ENHANCEMENT This artifact appears as an area of increased echo brightness distal to an area of low attenuation. Enhancement is normally seen distal to structures containing fluid such as the urinary bladder, gall bladder, or cyst. Time –gain compensation is applied equally to areas of the subject with minimal attenuation such as a cyst, and to adjacent areas of tissue. Therefore echoes from within the cyst are increased by the TGC unnecessarily resulting in a distal brightness. ACOUSTIC ENHANCEMENT EDGE SHADOWING When the sound beam meets a curved interface both refraction and reflection occur which results in an edge shadowing artifact. As the ultrasound beam meets the curved surface, some is reflected away from its true course and some continues into the second medium, but is refracted or bent from its original course This results in an acoustic shadow distal to the curved edges of the mass. EDGE SHADOWING BEAM WIDTH ARTIFACT The beam width can vary depending upon focusing, divergence etc. Since the width of the beam is not always as small as the objects being imaged, echoes arising from the edge of the beam will be displayed as having arisen from the beam centre. A small reflector will generate an echo for as long as it remains in the beam and so will be represented as a line in the display rather than a dot. Some echoes from outside the assumed plane will be displayed as if from within the plane. We may for example, see some echoes arising from outside the bladder but displayed within the bladder BEAM WIDTH ARTIFACT SLICE THICKNESS ARTIFACT This is similar because it is related to the size of the ultrasound bream, and creates false echoes in areas that should be echo free. The ultrasound machine assumes the echoes received by the transducer are from a very thin slice of tissue. However, an image is actually composed from several slices, and therefore echoes from slices either side of the intended slice may be displayed in the image. This is often seen in transverse views of the urinary bladder. Structures adjacent to the slice through the bladder will be included within the bladder. SLICE THICKNESS ARTIFACT SIDE LOBE ARTIFACT As well as the main beam used to form the ultrasound image, the transducer also produces many smaller and weaker side lobes. These are not normally used to form the primary image, but they can cause artifacts These also cause echoes to be displayed in areas which should be echo free. This is more apparent when there are very strong reflectors , such as gas, adjacent to an echo free area. This can give a false impression of a septation within the urinary bladder or gall bladder. SIDE LOBE ARTIFACT MIRROR IMAGE ARTIFACT Some large smooth reflectors, such as the diaphragm, return such a strong echo to the transducer that they are read by the machine as part

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER TWO Ultrasound Safety and Biological Effects CRT04210 · Ultrasound Imaging START READING NOTES Study Ultrasound Safety and Biological Effects using the sections below. Use the topic navigation to continue through Ultrasound Imaging. Contents of This Topic ULTRASOUND SAFETY IS ULTRASOUND SAFE? OPERATING MODES AND THEIR RISKS PULSED DOPPLER AND POWER DOPPLER BIOLOGICAL EFFECTS SAFE USE SOME GUIDELINES CONCLUSION ULTRASOUND SAFETY ULTRASOUND SAFETY BASIC RULES AND PRINCIPLES IS ULTRASOUND SAFE? So far ultrasound has not been proven to be unsafe in humans. However, ultrasound is now being very widely used and advances in technology are leading to increasing power levels being used to obtain diagnostic information. This can lead to measurable biological effects The interaction of ultrasound with biological tissue can result in effects which may cause heating, interfere with normal functioning of cells, and cause structural damage. It is important for people using ultrasound to do all they can to minimize the exposure of the patient to ultrasound to reduce these risks. OPERATING MODES AND THEIR RISKS B Mode ultrasound imaging records returning echoes strength as a brightness display on the screen. This is the normal grey scale imaging used for real time ultrasound. This uses the lowest output power and intensities and is generally considered safe in all applications, PULSED DOPPLER AND POWER DOPPLER Pulsed Doppler uses higher intensity of ultrasound than B Mode, and is therefore more likely to cause biological effects, particularly from heating. Pulsed Doppler ultrasound focuses the beam in a small area for longer periods increasing the dose to those tissues. Power Doppler also uses intensities higher than B Mode, but less than pulsed Doppler BIOLOGICAL EFFECTS There are two important effects which can be caused by ultrasound: 1/ Thermal (heating) 2/ Non thermal effects (cavitation) 1/ As the ultrasound beam travels through the tissue some of its energy is lost through absorption. This absorbed energy is converted into heat which causes a temperature rise of the tissues. The heat rise will depend upon: * the attenuation coefficient of the tissue * the operating frequency of the transducer * power/ intensity of the ultrasound beam * the length of operating exposure time BIOLOGICAL EFFECTS 2/ Non thermal effects ( cavitation ) The oscillating pressure wave caused by an ultrasound beam creates areas of compression and rarefaction. This can cause small bubbles to form in tissues. These can grow, oscillate in size, an at high intensity and pressure these can collapse. This causes high pressures and temperatures in the localized area with the potential to cause biological damage. While this risk is very small in general ultrasound, it is wise to be careful in early pregnancy where the tissues are more vulnerable. CAVITATION SAFE USE Changes in power output and increased use of Doppler ultrasound have led to awareness of the need to take every measure to ensure safe practice. The accepted guideline for safe use is known as the ALARA principle ( “As Low As Reasonably Achievable” ) This is a guide to minimizing exposure times and exposure intensity. ALARA SOME GUIDELINES 1/ Examinations should use B mode real-time in the first instance and employ color and spectral Doppler only when and if required. 2/ The overall examination should be kept as short as possible to minimize exposure times. 3/ The transducer should not be held in a fixed position any longer than necessary. 4/ The transducer should never be left resting on the patients body when not in use. 5/ The output power setting should be as low as possible consistent with obtaining a satisfactory image. 6/ Ultrasound examinations should only be performed for a specific medical indication to obtain useful diagnostic information. 7/ Only suitably trained people should be allowed to operate ultrasound machines. CONCLUSION Although harmful effects have not been shown to result from the use of ultrasound at normal diagnostic levels, the potential for harm does exist. More research still needs to be done. For example, we do not know if the effects from ultrasound exposure are cumulative. As in the use of x-rays, a very small risk is justified when the risk is minimal and the benefit high. ← PREVIOUS TOPICNEXT TOPIC →VIEW ALL MODULE NOTESVIEW SEMESTER NOTESVIEW ALL LEVEL NOTESALL DIAGNOSTIC RADIOLOGY NOTES Need These Notes as PDF? Need a clean, well-formatted PDF copy for offline study, revision or printing? Request the complete notes directly through WhatsApp. GET WELL-FORMATTED PDF NOTES

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER TWO Quality Control and Care of Ultrasound Equipment CRT04210 · Ultrasound Imaging START READING NOTES Study Quality Control and Care of Ultrasound Equipment using the sections below. Use the topic navigation to continue through Ultrasound Imaging. Contents of This Topic QUALITY CONTROL AND CARE OF EQUIPMENT THE COMPETENCE OF THE OPERATOR QUALITY ASSURANCE SERVICE TO THE PATIENT QUALITY OF IMAGE PRODUCTION PERFORMANCE TESTING TISSUE EQUIVALENT PHANTOMS TEST PHANTOMS Maintenance and care of equipment QUALITY CONTROL AND CARE OF EQUIPMENT Getting the best from your machine THE COMPETENCE OF THE OPERATOR Because of the difficulty of interpreting ultrasound images, ultrasound examinations should only be performed by trained and competent personnel. It is better not to do an examination at all than to provide incorrect or misleading diagnostic information. Operators should not only be trained according to acceptable international standards, but they should continue to improve their knowledge and skills throughout their working life. People in training should be supervised by trained and experienced personnel. QUALITY ASSURANCE Quality assurance (QA) is the process of ensuring that all aspects of an ultrasound service meet accepted international standards. A quality assurance program should consider: The competence of the operator The quality of service to the patient The quality of the image production The maintenance and care of equipment SERVICE TO THE PATIENT Patient care should consider the following matters: Careful appointment system to guarantee correct patient preparation, and minimal inconvenience. Careful consideration of patient safety, privacy and confidentiality. A well organized system of reporting procedures, including storage and delivery of results. Patient consent should always be obtained for invasive ultrasound procedures QUALITY OF IMAGE PRODUCTION Performance testing of ultrasound equipment is controversial for the following reasons: Ultrasound is considered a safe modality Modern ultrasound machines are considered stable and reliable Ultrasound QA testing is often considered to be rather subjective There are presently no regulations requiring a QA program PERFORMANCE TESTING Although testing of equipment is not essential, there are some applications, such as breast ultrasound, where it is very advisable. There are also some situations, where trained personnel are available to perform the task, and for those situations, there is special testing equipment available. TISSUE EQUIVALENT PHANTOMS The accuracy with which the ultrasound image represents an anatomical area depends on the correct functioning of the many components of the ultrasound machine. Occasional testing can ensure the machine is performing according to acceptable standards, and is accurate and consistent. Special test phantoms are available which enable people to make these checks TEST PHANTOMS Test phantoms are made of materials which are similar to tissue in their acoustic characteristics. They contain various targets and structures designed for testing a number of parameters such as image resolution and measurement accuracy. TEST PHANTOMS Maintenance and care of equipment Great care must be taken to keep an ultrasound machine in good working order and safe from hazards. 1/ The transducer If piezo electric elements are heated they lose their piezo electric properties because they become depolarized. Therefore the transducer should never be heat sterilized. They are also sensitive to mechanical shock and should never be dropped. MAINTENANCE AND CARE OF EQUIPMENT After use, always leave the transducer clean and dry. Wipe it with warm soapy water and dry. Never used oil based coupling gels. They will perish the rubber casing covering the transducer and allow oil to enter the inside which will cause damage. Use good quality, aqueous based gels only. The transducer should occasionally be sterilized by wiping with aqueous chlorhexidine solution or similar. Don’t leave the transducer to soak. MAINTENANCE AND CARE OF EQUIPMENT 2/ The control desk Remove any dirt or coupling gel by wiping with a soft cloth dampened with warm soapy water. NEVER sit liquids, such as cups of coffee on the control desk, or use the surface to hold other items. 3/ The main console Use the ultrasound machine in a cool dust free environment. Keep the air vents on the side of the machine clear of obstruction and clean. Clean any air filters present. Operate the machine with a voltage stabilizer to protect it from damage by voltage surges. MAINTENANCE AND CARE OF EQUIPMENT 4/ Electrical safety Inspect the transducer closely for any cracks or damage to the plastic housing. Inspect cables for any wear or damage to the insulation. Inspect any plugs, adapters or connector assemblies for any electrical dangers. Connect the machine directly to mains power and not to a multi outlet power board. ← PREVIOUS TOPICNEXT TOPIC →VIEW ALL MODULE NOTESVIEW SEMESTER NOTESVIEW ALL LEVEL NOTESALL DIAGNOSTIC RADIOLOGY NOTES Need These Notes as PDF? Need a clean, well-formatted PDF copy for offline study, revision or printing? Request the complete notes directly through WhatsApp. GET WELL-FORMATTED PDF NOTES

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER TWO Biological Effects of Diagnostic Ultrasound CRT04210 · Ultrasound Imaging START READING NOTES Study Biological Effects of Diagnostic Ultrasound using the sections below. Use the topic navigation to continue through Ultrasound Imaging. Contents of This Topic GROUP NO.9 Ultrasound energy, is type of mechanical energy called sound characterized by vibrating or moving particles within a medium. It is true that ultrasound energy can cause adverse effects in human body but diagnostic ultrasound is safe. CAVITATION B.HEAT FORMATION C. FETAL EFFECTS Group Members; GROUP NO.9 ASSIGNMENT Ultrasound energy can cause adverse effects in human body, but diagnostic ultrasound is safe discuss. Ultrasound energy, is type of mechanical energy called sound characterized by vibrating or moving particles within a medium. Diagnostic ultrasound, is the sound of frequency between 1MHz to 20MHz. It is true that ultrasound energy can cause adverse effects in human body but diagnostic ultrasound is safe. The following are the effects of ultrasound energy in the human body,. Cavitation Heat formation Fetal effects CAVITATION any cavity contains fluid or gas. when there is exposure of ultrasound beam there is formation of bubbles within the cavity during compression bubbles burst result in formation of free radical which combine with chemical components in the cavity lead to the formation of chemical compound.E.g toxins which can cause death of body cells. NB. but this phenomena is very rare. B.HEAT FORMATION When ultrasound waves pass through a tissue they tend to heat it up due to the collision of medium particles. This tissue can be easily warmed to 40 degree celsius but in diagnostic ultrasound the rise in temperature is just a small fraction of 1 degree celsius. Although in normal circumstance the heat is usually easily carried away by blood circulation or simply dissipated into surrounding tissues. C. FETAL EFFECTS The ultrasound technology have effects on fetal bodies. Due to frequent scanning of pregnant women, gave birth to lower weight babies, the newborn babies also seems to have delayed speech disorder and most of the babies who were frequently exposed to ultrasound are left handed. Despite of all those above effects, the growth and development of child will proceed as normal. Group Members; 1.SAID RAMADHAN 2.FELIX DEUS 3.FRANCISCO F SUKA ← PREVIOUS TOPICNEXT TOPIC →VIEW ALL MODULE NOTESVIEW SEMESTER NOTESVIEW ALL LEVEL NOTESALL DIAGNOSTIC RADIOLOGY NOTES Need These Notes as PDF? Need a clean, well-formatted PDF copy for offline study, revision or printing? Request the complete notes directly through WhatsApp. GET WELL-FORMATTED PDF NOTES

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER TWO Common Gynecological Anomalies – Part 1 CRT04210 · Ultrasound Imaging START READING NOTES Study Common Gynecological Anomalies – Part 1 using the sections below. Use the topic navigation to continue through Ultrasound Imaging. Contents of This Topic Common Gynaecological Anomalies- Part 1 UTERUS TECHNIQUE CONGENITAL ANOMALIES Septate/arcuate uterus Bicornuate uterus Uterine didelphys Differentiation requires visualization of Less divergence of endometrial stripes SEPTATE UTERUS Endocrine causes Primary amenorrhea 3.Pelvic inflammatory disease (PID) A.Pelvic Inflammatory Disease: US Findings B.Endometritis Indistinct, thickened endometrial stripe, +/- fluid, air C.Pelvic Inflammatory Disease (PID) Hydrosalpinx (Hydrosalpingitis) US Findings :Complex, multicystic, thick walled mass, internal echoes TOA: US Findings Complex, multicystic, thick walled mass, internal echoes 4.Uterine Fibroids Uterine Fibroids Risk factors: the following factors are predisposing Fibroids (Leiomyomas) Types of Fibroids TYPES(LOCATION) OF LEIOMYOMAS (FIBROIDS) Location of Fibroids Fibroids: US Findings Fibroid Pedunculated LEIOMYOMA- Calcifications in Pedunculated subserosal leiomyoma Complications of Fibroids: Benign neoplasm Hormonally responsive 7.Uterine Sarcoma Ectopic endometrium located within the myometrium Adenomyosis Pt presentation: Adenomyosis: US Findings Think adenomyosis: Think leiomyoma (Fibroid): 8.Endometrial Hyperplasia, and Polyps 10.Abnormal bleeding in postmenopausal women 11.Endometrial carcinoma 12.Cervical Mass 12.Abnormal Vagina 12.Intrauterine Device (IUD) Intrauterine Device (IUD) Echogenic, shadowing, linear structure in endometrial cavity Common Gynaecological Anomalies- Part 1 MDU,BMI,ECHO&ECG,DDR UTERUS Outline- Uterine Pathologies Technique Normal anatomy Congenital anomalies Leiomyoma/Fibroids Pelvic Inflamatory Disease Adenomyosis Endometrial Hyperplasia and polyps. Postmenopausal uterus- Endometrial Ca TECHNIQUE Endovaginal improved spatial resolution smaller field of view Transabdominal imaging complementary enlarged uterus congenital anomalies evaluation of the kidneys MRI/HSG may provide more specific information in selected cases Review of normal Anatomy 1.CONGENITAL ANOMALIES CONGENITAL ANOMALIES Incidence 0.1% to 0.5% all women 9% in women with infertility or fetal loss Associated with renal anomalies Defects include: Septate/arcuate uterus Unicornuate uterus Bicornuate uterus Uterine didelphys Septate/arcuate uterus Has a normal external surface but two endometrial cavities Degree of septation varies from a small midline septum to total septate uterus with longitudinal vaginal septum Arcuate has slight midline septum with minimal fundal cavity indentation Unicornuate uterus Bicornuate uterus Uterus in which the fundus is indented (≥1 cm) and the vagina is generally normal. Results from only partial fusion of the müllerian ducts Leads to a variable degree of separation of the uterine horns that can be complete, partial, or minimal. Uterine didelphys “double uterus” duplication is limited to the uterus (didelphys) and cervix (bicollis) although other structures (vagina, bladder, etc may be involved) Differentiation requires visualization of endometrial stripes fundal contour Visualization of fundal contour may require Transabdominal Ultrasound or 3 dimensional ultrasound SEPTATE VS. BICORNUATE UTERUS BICORNUATE UTERUS Divergent endometrial stripes > 1.0 to 1.5 cm cleft between horns BICORNUATE UTERUS Divergent endometrial stripes > 1.0 to 1.5 cm cleft between horns X > 1.5 cm Bicornuate uterus ( Double Endometrium) Less divergence of endometrial stripes Flat, convex, or minimally indented fundal contour (< 1 cm) SEPTATE UTERUS SEPTATE UTERUS SEPTATE UTERUS X < 1.0 – 1.5 cm Endocrine causes Absence, atresia or obstruction of vagina, cervix, or uterus +/- Pelvic mass Role of imaging confirm level of abnormality extent of vagina presence / absence of uterus and cervix 2.Primary amenorrhea Primary amenorrhea Uterine Agenesis Note: No Uterus posterior to UBL Primary amenorrhea Haematocolpos in imperforate Hymen Note: Blood collection in Uterine cavity(HAEMATOMETRA) 3.Pelvic inflammatory disease (PID) Ascending infection that may involve the uterus(endometrium), fallopian tubes, ovaries, and pelvic cavity, and may produce tubo-ovarian abscesses(TOA) Presents with LAP, Fever, PV discharge, Cervical motion tenderness A.Pelvic Inflammatory Disease: US Findings Endometritis (Endometrial fluid) Hydrosalpinx: Dilated fallopian tube Thickened, inflamed fallopian tube +/- internal echoes (pyosalpinx)- Pus fillled Tubo – Ovarian Abscess Fluid in cul-de-sac (Pouch of Douglas) B.Endometritis Sx: fever, leukocytosis, tenderness, foul smelling discharge Occurs post partum, following D&C, PID Indistinct, thickened endometrial stripe, +/- fluid, air post partum findings RPOC Endometritis: US Findings Endometritis (Fluid in Endometrium) C.Pelvic Inflammatory Disease (PID) Fluid in pouch of Douglas Significant Fluid > 1cm deepest pool D.Hydrosalpinx (salpingitis) Hydrosalpinx (Hydrosalpingitis) Infection of fallopian tubes Dilated, tubular, anechoic structure between uterus and ovary E.PYOSALPINX US Findings :Complex, multicystic, thick walled mass, internal echoes F.(Tubo-ovarian cyst)-TOA: TOA: US Findings Often bilateral Ovarian margins may be indistinct ovary relatively spared Complex, multicystic, thick walled mass, internal echoes TOA: US Findings 4.Uterine Fibroids Definition Are benign monoclonal tumors arising from the smooth muscle cells of the myometrium, termed leiomyoma. They contain a large amount of extracellular matrix (collagen, proteoglycan, fibronectin) and are surrounded by a thin pseudocapsule of areolar tissue and compressed muscle fibers. Synonyms: fibroid or fibromyoma. Incidence: The most common gynecological tumors in about 30% of women of reproductive age. 20% of women after 30 years develop uterine fibroid. More prevalent in black African women Uterine Fibroids Etiology: The possible etiology is hyperestrinism (estrogen-dependent tumor). The evidences supporting this include: Associated with exposure to circulating estrogen (arise during adulthood) Shrink following menopause Maximum growth when estrogen secretion is maximal, spurt in growth in the decade before menopause (an ovulatory cycles with unopposed estrogen) Increased growth during pregnancy (caused by estrogen) Estrogen receptors are more in leiomyoma compared to the rest of myometrium N.B. Growth factors may act synergistically with estrogen to induce growth of myoma Risk factors: the following factors are predisposing Age: common between 35 & 45 years. Parity: common in nulliparous or low porous & relatively infertile women. Race: common in black women Family history : +ve. Obesity Early menarche (<10 years old) A longer interval since last birth increases risk Consumption of alcohol, especially beer, appears to increase the risk of developing fibroids however smoking decreases the risk of having fibroids. Significant consumption of beef, ham, or other red meats is associated with an increased relative risk of fibroids Protective factors Early age at first birth decreases risk consumption of green vegetables with a decreased risk Fibroids (Leiomyomas) Fibroids are benign tumors of the uterus arising from the Myometrium Smooth muscle neoplasms Patients Presentation Asymptomatic Abnormal Uterine bleeding- Menorrhagia Pelvic pain Infertility Abortions ( Submucosal and Intramural

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER TWO Common Gynecological Anomalies – Part 2 CRT04210 · Ultrasound Imaging START READING NOTES Study Common Gynecological Anomalies – Part 2 using the sections below. Use the topic navigation to continue through Ultrasound Imaging. Contents of This Topic Common Gynaecological Anomalies- Part 2 ADNEXAL MASSES: NORMAL ANATOMY Us evaluation of adnexal masses Morphologic features suggestive of benignity 1.Simple ovarian cysts Simple ovarian cysts: US Findings Simple ovarian cysts 2.Paraovarian cyst PARAOVARIAN CYST 3.Complex cysts Complex Cyst 4.Endometriosis Endometriosis- Endometrioma ENDOMETRIOMAS: Endometriosis- Sonographic pitfall Clot/Debris Clear Cell Carcinoma ENDOMETRIOSIS 5.HEMORRHAGIC CYST HEMORRHAGIC CYSTS: 6.Dermoid 7.CYSTIC TERATOMA DERMOID CYSTS: CFI may be helpful 9.Polycystic ovary disease PCOD: US Findings Morphologic features suggestive of malignancy B.SOLID ADNEXIAL MASSES Kruckenberg Tumor SOLID OVARIAN MASSES: Fibromas Fibrothecoma Be careful to differentiate from: Dermoid- Benign masses Common Gynaecological Anomalies- Part 2 MDU,BMI,ECHO&ECG,DDR ADNEXAL MASSES: Role of Ultrasound Dx of benign disease may result in less invasive or elective surgery may eliminate need for surgery altogether Dx of malignancy allows prompt referral to experienced gyn-oncologic surgeon Indeterminate US consider MRI NORMAL ANATOMY Oval Echogenic central stroma Small anechoic cysts 3 x 2 x 1 to 2 cm inpremenopausal women NORMAL ANATOMY Normal Ovaries Us evaluation of adnexal masses Location Morphology pattern recognition for benign pathology Size Echotexture:cystic, complex (mixed cystic and solid), or solid. Vascularity Associated findings A.CYSTIC ADNEXIAL MASSES Morphologic features suggestive of benignity Smooth walls No septations Thin septations that are avascular Absence of solid components or mural nodularity 1.Simple ovarian cysts Size Likely benign if: < 6 cm in premenopausal < 5 cm in postmenopausal > 3 cm get follow up to ensure regression or stability More common than originally thought Postmenopausal follicular cysts > 5 cm increased likelihood of malignancy less likely to resolve > 3 cm get follow-up Simple ovarian cysts: US Findings Anechoic Well defined Thin wall Posterior enhancement Sharp Back wall Simple ovarian cysts Follicular cysts- Functional cysts Anechoic cysts have a thin wall, are completely anechoic, and are enhanced through transmission. Regardless of their size, they are unlikely to be malignant In women of menstrual age, the most common anechoic cyst is the functional cyst These usually are small < 2 cm in diameter; however, they may enlarge up to 10 cm. Simple ovarian cysts They typically regress spontaneously. At times, birth control pills are necessary to suppress their growth. When an anechoic cyst is seen that is larger than 6 cm, the likelihood of neoplasm is high. If there are no wall irregularities or septations, the cyst is most likely secondary to a benign neoplasm such as a cystadenoma 2.Paraovarian cyst 10% of all adnexal masses Adjacent to ovary Less likely to resolve If > 6 cm may lead to torsion Rarely malignant They arise from the broad ligament. Their size does not change during the menstrual cycle. PARAOVARIAN CYST Clear plane between cyst and ovary 3.Complex cysts Seen in Malignant/Infected cysts/ Haemorrhagic cysts Features Thick walled Septated Echocomplex; Mixed echogenicity Mural Nodularity Complex Cyst Note the Thick walls and Mural Nodularity 4.Endometriosis Ectopic location of endometrial tissue outside uterus. Location varies: peritoneal cavity, pelvic organs, ligaments extra pelvic. Functionalis layer, Repetitive cycles of hemorrhage Begins 2 – 7 days before menses but sever during Menses. Similar repeated period related pains. Past uterine surgery may implant endometrial cells along incision. Endometriosis- Endometrioma In most cases, sonography cannot demonstrate the tiny ectopicimplant Difficult to see by US especially if lesions small. Cystic or complex lesions may be seen (endometriomas). The localized form of the disease creates an endometrioma. This is seen as a cyst on transabdominal scanning Ultrasound shows a diffuse low-level echoes are seen: the “chocolate” cyst echoes due to blood ENDOMETRIOMAS: US Findings Homogeneous, low-level echoes ENDOMETRIOMAS: US Findings Low- lovel internal echoes Endometriosis- Sonographic pitfall Masses may give septations and nodularity. DD cancer. MRI helps to confirm presence of blood. Laparatomy is gold standard. Rx may be surgical but Hormonal suppression may be done. Oophrectomy and Hysterectomy for severe cases. Clot/Debris : ENDOETRIOMA Mural Nodularity Clear Cell Carcinoma ENDOMETRIOMA: Mural Nodules ENDOMETRIOSIS Beware mural irregularities or nodules increased incidence of clear cell and endometroid Ca. May have vascular wall Adhesions If US features suggestive but non-specific confirm with MRI CAs rarely contain hemorrhage laparoscopy 5.HEMORRHAGIC CYST Hemorrhagic cysts more often present with acute pain contain clot solitary HEMORRHAGIC CYSTS: US Findings Pattern of internal echoes variable but changes over time Ultimately resolves Thin, regular wall Increased through transmission No internal vascularity HEMORRHAGIC CYSTS: US Findings Diffuse homogeneous, low level echoes HEMORRHAGIC CYSTS: US Findings Lace-like or spider web pattern of internal echoes/septations HEMORRHAGIC CYSTS: US Findings Dependent debris HEMORRHAGIC CYSTS: US Findings Echogenic clot HEMORRHAGIC CYSTS: Evolving Appearance HEMORRHAGIC CYSTS: US Findings No internal vascularity HEMORRHAGIC CYSTS For questionable clot versus mural nodule check vascularity roll patient HEMORRHAGIC CYSTS If solid appearing focus adherent and avascular, obtain f in 6 weeks (esp. if clinical presentation is atypical) clot should change 6.Dermoid Dermoids are the most common ovarian neoplasm. Rare forms of dermoids include the specialized tumors of struma ovarii (with thyroid tissue) and carcinoid tumors. Malignant degeneration (into squamous cell carcinoma) of dermoids is rare. This typically occurs in older women. Immature teratomas occur in young women 10 to 20 years of age. 7.CYSTIC TERATOMA Most common ovarian neoplasm Most common in the reproductive years Contains txs from all 3 germ cell layers Typically assx, found incidentally Complications: torsion, rupture Malignant transformation < 2% DERMOID CYSTS: US Findings Echogenic mass Posterior sound attenuation DERMOID CYSTS: US Findings Fat/fluid level Floating debris (hairball) DERMOID CYSTS: US Findings Mural nodules, +/- Ca++ DERMOID CYSTS: US Findings Echogenic linear speckles CFI may be helpful pedunculated leiomyoma 9.Polycystic ovary disease Polycystic ovary disease, which includes Stein-Leventhal syndrome (infertility, hirsutism, and oligomenorrhea), is one of the most common endocrine disorders. The diagnosis is made on the basis of clinical, sonographic, and biochemical criteria. Luteinizing hormone is elevated and follicle-stimulating hormone levels are

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER TWO Gynecology Uss CRT04210 · Ultrasound Imaging START READING NOTES Study Gynecology Uss using the sections below. Use the topic navigation to continue through Ultrasound Imaging. Contents of This Topic INTRODUCTION Gynecology Uss Uterus parts LAYERS The thickness of the basal layer is typically consistent, although minimal changes may occur throughout the menstrual cycle. The endometrial cavity, also referred to as the uterine cavity, is located between the two functional layers of the endometrium. Uterine Size and Shape Uterine Positions Uterus position Congenital anomalies UTERINE PATHOLOGY This lack of blood supply results in necrosis and clinically the patient will present with acute, localized pelvic pain. Fibroids may also affect the contractile motion of the uterus, thus leading to interference with sperm migration. Leiomyosarcoma Nabothian Cyst VAGINAL PATHOLOGY Cervical Carcinoma GYNOCOLOGY – ULTRASOUND INTRODUCTION The uterus is a pear-shaped, retroperitoneal organ that lies anterior to the rectum, posterior to the urinary bladder, and is bounded laterally by the broad ligaments . Its primary function is to provide a place for the products of conception to implant and develop. The uterus can be divided into four major divisions: fundus, corpus, isthmus, and cervix. Gynecology Uss The largest part of the uterus is the corpus, or body. The corpus is located inferior to the fundus. The isthmus is the area located between the corpus and the cervix. During pregnancy, the isthmus may be referred to as the lower uterine segment. Gynecology Uss The cervix is the rigid component of the uterus that is located inferior to the isthmus, and it is the portion of the uterus that projects into the vagina. The cervix is marked superiorly by the internal os, which is in contact with the isthmus, and inferiorly by the external os, which is in close contact with the vagina. Uterus parts Fundus. The uppermost and widest part of your uterus. It connects fallopian tubes. Corpus. The main body of uterus. This is where a fertilized egg implants during pregnancy. Isthmus. The part of uterus between corpus and cervix. It’s where uterus starts to narrow or thin. Cervix. The lowest part of uterus. cervix opens to vagina. LAYERS The uterine wall consists of three layers . The outermost layer is referred to as the serosal layer or perimetrium, which is continuous with the fascia of the pelvis. The middle layer is the myometrium or muscular layer, which constitutes the bulk of the uterine tissue, providing the area where contractile motion occurs. The inner mucosal layer of the uterus is referred to as the endometrium. The endometrium can be further divided into a deep or basal layer and a superficial or functional layer The thickness of the basal layer is typically consistent, although minimal changes may occur throughout the menstrual cycle. The functional layer of the endometrium is the component that is shed during menstruation; thus, the thickness of the functional layer of endometrium will vary during the menstrual cycle as a result of hormonal stimulation The endometrial cavity, also referred to as the uterine cavity, is located between the two functional layers of the endometrium. This cavity is contiguous with the lumen of the fallopian tubes laterally, and the cervix inferiorly. Uterine Size and Shape The size and shape of the uterus depends on the age of the patient, parity, and the presence of pathology or congenital anomalies that may alter its contour. The normal neonatal uterus is tubular in appearance and may exhibit distinct endometrial echoes in the first week of life as a result of maternal hormone stimulation. Following the neonatal period, the cervical anteroposterior 579 diameter is equal to or slightly greater than that of the uterine fundus Gynecology Uss The uterus grows minimally during prepubertal years, whereas after puberty, the uterine fundus becomes much larger than the cervix, consequently providing the pear-shaped appearance of the normal adult uterus. Following menopause, the uterus typically becomes much smaller than the premenopausal uterus Uterine Positions The uterine position within the pelvis is variable The normal position of the uterus is considered to be anteversion or anteflexion. Anteversion describes the uterine position in which the body tilts forward or anteriorly, forming a 90-degree angle with the vagina. Gynecology Uss Anteflexion of the uterus denotes the position in which the uterine body folds forward, possibly coming in contact with the cervix. Retroversion of the uterus is the position in which the uterine body tilts backward or posteriorly, without a bend where the cervix and body meet. Retroflexion is the uterine position that results in the uterine body tilting backward and actually coming in contact with the cervix Gynecology Uss The uterus may also be oriented more to the left or right of the midline, resulting in a variation between anatomic midline and functional midline. The uterus that is located more on the left is referred to as a levoverted uterus, whereas the uterus that is located on the right is referred to as dextroverted uterus Uterus position Retroverted uterus. Commonly called a tipped or tilted uterus. This is when your uterus is tilted or tipped backward so it curves toward your spine instead of forward toward your abdomen. Anteflexed uterus. Your uterus is anteflexed when it’s bent forward. The tilt is severe and can put pressure on your abdomen or bladder and cause painful symptoms. Retroflexed uterus. Your uterus is retroflexed when it’s bent backward. The tilt puts pressure on your lower back Congenital anomalies Bicornuate uterus. A heart-shaped uterus. Arcuate uterus. Similar to a bicornuate uterus but with less of a dip or heart shape. Septate uterus. When uterus is divided into two parts by a membrane. Unicornuate uterus. When have one fallopian tube and an irregularly shaped uterus. Didelphys uterus. When you’re born with two uteruses Gynecology Uss Bicornuate uterus (Fig. 17-8). A bicornuate uterus, also referred to as bicornis unicollis, is present when the endometrium divides into two endometrial cavities, with a prominent concavity noted in the outline of the uterine

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER TWO Image characteristics and Optimization CRT04210 · Ultrasound Imaging START READING NOTES Study Image characteristics and Optimization using the sections below. Use the topic navigation to continue through Ultrasound Imaging. Contents of This Topic IMAGE CHARACTERISTICS IN ULTRASONOGRAPHY AND OPTIMIZATION Ultrasound Image Image characteristics and Optimization Echogenicity L R Echotexture Homogeneous Image Optimization in ultrasonoghaphy Introduction Resolution Spatial resolution Axial resolution Lateral resolution Factors Affecting Lateral Resolution Effect of Beam width Effect of beam frequency Effect of scan line density Line Density Spatial resolution versus tissue depth Use of Multifrequency Transducers Broad Band Transducers Multiple centre-frequency transducers Frame rates, Scan line density, and Tissue Depth For high lateral resolution: For large tissue depths: For very high framing rates (rapid motion) Contrast resolution Temporal resolution IMAGE CHARACTERISTICS IN ULTRASONOGRAPHY AND OPTIMIZATION J. J. John (DDR-CUHAS) Ultrasound Image In B-mode, it composed of a variety of bright dots that vary in intensity. Intensity vary according to the strength of electricals signals hence, returning echoes from tissues or structures in the body. The location of each dot corresponds to the anatomic location of each echo-generating organ or structure Provides anatomic and non-anatomic information (artifacts) An ultrasound image is composed of a variety of bright dots that vary in intensity according to the strength of the returning echoes from internal tissues and/or structures in the body. The location of each dot corresponds to the anatomic location of each echo-generating organ or structure. Each image provides a dot-for-dot correct anatomic representation of organs and structures in the body. On the image there is also non-anatomic information, which is the result of things happening to the ultrasound beam before, during or after it strikes a reflecting surface. These phenomena, which are the result of the imaging technique itself, are called artifacts and are discussed elsewhere. Image characteristics and Optimization An ultrasound image is composed of a variety of bright dots that vary in intensity according to the strength of the returning echoes from internal tissues and/or structures in the body. Some of the returning echoes are strong and register as bright white dots on the image. The brightest areas with the highest intensity echoes are called hyperechoic. Areas with echoes of lesser strength are hypoechoic. There is no specific name for echoes of moderate strength. Areas with no echoes are anechoic and therefore black on the images. When two structures generate the same kind of echoes, they are isoechoic. Echogenicity We are considering intensity of echoes and image apperance ECHOGENICITY Focus on the intensity of echoes reflected by tissues or structures from inside the body. Brightness of the dots generated by returning echoes from the body. Echogenicity is the intensity of echoes reflected by tissues or structures from inside the body. Literally and simplistically, it means the ability of something to generate echoes. ECHOGENICITY Intensity of dots forming the image vary according to the strength of electricals signals processed and hence the returning echoes from tissues or structures in the body. Some of the returning echoes are strong and register as bright white dots on the image. Some are weak and register as less bright dots on the image. ECHOGENICITY The brightest areas with the highest intensity echoes are called hyperechoic. Areas with echoes of lesser strength are hypoechoic. There is no specific name for echoes of moderate strength. Areas with no echoes are anechoic and therefore black on the images. When two structures generate the same kind of echoes, they are isoechoic. ECHOGENICITY Hyperechoic High intensity echoes Hypoechoic Low intensity echoes Anaechoic No internal echoes Isoechoic Same intensity echoes Word slide Summary of previous page ECHOGENICITY Echogenicity of a structure is described relative to surrounding or adjacent tissue When we describe echogenicity of a structure, we describe it in relative terms comparing the echogenicity of the structure to that of surrounding or adjacent echoes. QUESTION: True or false? Echogenicity is an inherent property of a specific tissue. ANSWER: False. Echogenicity of a structure is an not absolute property. It is a relative thing, relative to the surrounding tissue. ECHOGENICITY Hyper echoic:- High intensity or bright echoes, which are more echogenic than the standard to which comparison is made, usually the surrounding tissue. Hyperechoic means high intensity or bright echoes, which are more echogenic than the standard to which comparison is made, usually the surrounding tissue. Image characteristics and Optimization The round hyperechoic solid mass (arrow) under the capsule of this moderately echogenic liver is a hemangioma. The normal liver is the standard for comparison in this case. The hyperechoic solid mass within this spleen represents a focal deposit of lymphoma. Image characteristics and Optimization Due to sickle cell nephropathy, the cortex of this kidney is hyperechoic relative to the adjacent liver parenchyma, which, due to its size, becomes the standard of comparison for most adjacent parenchymal organs. Image characteristics and Optimization The round mass (arrow) in this kidney is relatively hyperechoic when compared to the adjacent renal cortex (arrowheads). The echogenicity of a mass is compared to its organ of origin. Although the tumor itself is not very bright in echogenicity, it contains tiny hyperechoic foci due to microcalcifications scattered throughout the mass, which is a renal cell carcinoma (hypernephroma). ECHOGENICITY Hypoechoic:- Means low intensity echoes or less echogenic than the surrounding tissue. Image characteristics and Optimization This is an image the spleen, which is of moderate echogenicity, and contains several hypoechoic masses (arrows) representing deposits of lymphoma. The masses are hypoechoic relative to surrounding normal splenic parenchyma. The relative echogenicity of a mass is compared to the echogenicity of the organ to which it relates. L In this case the large lobulated hypoechoic masses (arrows) of low echogenicity represent metastatic deposits within the liver (L). The masses are hypoechoic relative to adjacent normal liver parenchyma. R L In this transverse scan of the scrotum, the normal right (R) testis is moderately echogenic, while the left (L) is enlarged and hypoechoic due to testicular cancer. The

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER TWO Interaction of Ultrasound With Matter CRT04210 · Ultrasound Imaging START READING NOTES Study Interaction of Ultrasound With Matter using the sections below. Use the topic navigation to continue through Ultrasound Imaging. Contents of This Topic INTERACTION OF ULTRASOUND WITH MATTER Objectives Introduction Terminologies Acoustic impedance (z) Acoustic boundaries Acoustic mismatch The Interaction Processes Reflection of ultrasound Specular reflections Diffuse/Non-specular Reflections (Scattering) Non-specular Reflections (Scattering) The intensity of an echo Angle of incidence and Echo intensity Reflections Acoustic mismatch and Echo intensity Acoustically homogeneous media Negative role of gas Coupling gel Transducer matching layer Refraction of ultrasound Significance of Refraction in ultrasonography Absorption Effect of Viscosity on ultrasound absorption Effect of Relaxation time on ultrasound absorption Effect of Relaxation time on ultrasound absorption cont.. Effect of beam frequency on ultrasound absorption Significance of absorption in ultrasonography Attenuation of ultrasound in tissue Ultrasonic half value thickness (HVT) ULTRASONIC HALF VALUE THICKNESSES FOR DIFFERENT MATERIALS AT Acoustic windows Acoustic barriers INTERACTION OF ULTRASOUND WITH MATTER J.J. John Objectives At the end of this lecture, students should be able to Describe : How an ultrasound beam propagates through tissues Attenuation of ultrasound beam The interactions processes Practical implications of each interaction process Introduction In ultrasonography, a beam of ultrasound must be directed into the tissues of the subject over a selected area of interest. The ultrasonic energy will then interact with the tissues along its path. The interaction processes are influenced by the characteristics of the ultrasound wave, as well as the physical properties of the tissues through which the beam passes. So different types of tissues will respond differently to an ultrasound beam. Terminologies Acoustic impendance Acoustic mismatch Acoustic boundary/interface Attenuation Acoustic impedance (z) Acoustic impedance is a measure of the resistance of the particles of the medium to mechanical vibrations. This resistance increases in proportion to the density of the medium, and the velocity of ultrasound in the medium. Mathematically: Also known as the characteristic acoustic impedance of a medium. It differ from one medium to the other. Acoustic impedance (z) Acoustic boundaries Positions within tissue where the values of acoustic impedance change are very important in ultrasound interactions. These positions are called acoustic boundaries, or tissue interfaces. For example, urine in the bladder will have an acoustic impedance value which differs from that of the bladder wall, hence their common interface constitutes an acoustic boundary. URINE Acoustic boundaries The unique features of diagnostic ultrasound as an imaging modality are determined by the nature and distribution of the multitude of acoustic boundaries within the tissues of the body. And the extent to which an acoustic boundary affects a beam of ultrasound incident upon it will depend on the magnitude of the difference between the acoustic impedance values of the two structures on either side of the boundary. Acoustic mismatch Acoustic mismatch can be defined as the difference in acoustic impedance (Z) values of the two media forming the boundary. For example an acoustic mismatch for: Muscle/fat boundary= (1.7-1.38)= 0.32 Bone/fat boundary= (7.80-1.38)= 6.42 Soft tissue/air = (1.63-0.0004)= 1.6296 Soft tissue/water = (1.63-1.48)= 0.15 The Interaction Processes Reflection Specular reflection Non specuar reflection (Scattering) Refraction Absorption Reflection of ultrasound This is the most important single interaction process in ultrasound image formation. When a beam of ultrasound strikes an acoustic boundary, some of the beam energy is transmitted across the boundary, while some is redirected backwards(reflected). Depending on the size of the boundary relative to that of the ultrasound beam, or on irregularities of shape on the surface of the reflector. Two types of reflection can occur, these are: Specular reflections Non-specular/Diffuse reflections (Scattering) Specular reflections Specular reflections occur when the boundary is smooth and larger than the beam dimensions. For this type of reflection, a simple law similar to that governing the reflection of light is obeyed Angle of incidence (i) = angle of reflection (r) The reflected beam is referred to as the echo and the probability that an echo will go back to the transducer and be detected increases as the angles i and r decrease. Diffuse/Non-specular Reflections (Scattering) This is the reflection of ultrasound in many direction Occurs when the reflecting interface is irregular in shape, and its dimensions are smaller than the diameter of the ultrasound beam The direction of scatter does not obey the simple law of reflection, but depends on the relative sizes of the scattering target and the ultrasound beam diameter The dimensions of the interface should be about one wavelength of the ultrasound beam or less for scattering to occur Non-specular Reflections (Scattering) Since the wavelengths for typical diagnostic beams are 1 mm or less. and Within the organs, there are many structures which have dimensions of less than 1 mm, so scattered ultrasound provides much useful information about the internal texture of organs. Scattered echoes are much weaker than specularly reflected echo but the high sensitivity of modern ultrasound equipment makes it possible to utilize information from scattered ultrasound for imaging Scattering shows very strong frequency dependence, increasing rapidly as the frequency of ultrasound is increased. The intensity of an echo The intensity of an echo due to specular reflection depends on the Angle of incidence Acoustic mismatch The proportion of beam intensity that is reflected from the interface represented by the reflection coefficient which is given as ratio of the intensity of a reflected beam to that of incidence beam (Ir/Ii) For a given intensity at the source, echo sizes will vary in proportion to this ratio Angle of incidence and Echo intensity The most useful specular reflection takes place when the ultrasound beam strikes a reflector at 90° to the surface of the boundary. This is referred to as normal incidence. On the Normal incidence, angles i and r are equal to zero, and the echo goes straight back with a high probability of being picked up by the transducer Reflections IMAGE A The diaphragm is a large and relatively smooth surface

DIAGNOSTIC RADIOGRAPHY · NTA LEVEL 4 · SEMESTER TWO Molar Pregnancy CRT04210 · Ultrasound Imaging START READING NOTES Study Molar Pregnancy using the sections below. Use the topic navigation to continue through Ultrasound Imaging. Contents of This Topic Molar Pregnancy GENERAL CONSIDERATION Molar pregnancy-Types Complete Mole Partial mole Natural history of hydatidiform mole Signs and Symptoms Diagnosis Physical exam demonstrates:- Ultrasound is a reliable and sensitive technique. Molar Pregnancy: US Findings Hydatidiform mole: Partial Mole Theca lutein cysts Malignant Mole Follow-up following molar pregnancy Molar Pregnancy Molar Pregnancy Also known as Gestational Trophoblastic Disease(GTD) Molar pregnancy is a form of abnormal pregnancy Results from a defective fertilization process Characterized by vesicular swelling of placental tissue hence appearing like vesicles. GENERAL CONSIDERATION GTD is a complex condition that results from process of reproduction It is a neoplastic process that span from a locally generative process to a highly malignant neoplasm. It includes a tumor spectrum of :- Hydatidiform mole Invasive mole Choriocarcinoma A unique tumor in that:First and only disseminated solid tumor that has proved to be highly sensitive to chemotherapy. Molar pregnancy-Types Hydatidiform mole (benign) Complete Hydatidiform mole Partial Hydatidiform mole Major difference between the two types is that partial moles contain fetal/embryonic tissue and complete moles do not. Malignant Mole(Choriocarcinoma) Transformation of benign mole into malignant mole- invasive mole Complete Mole Results from fertilization of a blighted (empty) ovum by a paternal chromosome, which then duplicates to reach the haploid compliment of 46 chromosomes Lack fetal tissues Uterus is filled with generalized swelling of trophoblastic (placental) tissue. Homozygous Empty Ovum 23 X 46 XX Partial mole Fertilization of a normal 23X ovum by two independent sperms resulting in 69 chromosomes. Presence of both fetal tissues and abnormal placental tissues 23X 69XXX Natural history of hydatidiform mole 80% of molar gestations will resolve completely after evacuation. The remaining 20% will develop persistent trophoblastic disease being:- 15% invasive mole 5% choriocarcinoma. After an initial molar evacuation the risk for a second mole is increased to between 4 to 5 times. After a single spontaneous resolution following fertility and reproductive function returns to within normal limits. Signs and Symptoms Amenorrhea – b’se it is a pregnancy Vaginal bleeding ( 90%) usually after 12 wks of amenorrhea Passage of vesicles (grape like masses) per vagina Hyper emesis gravidarum ( severe nausea &vomiting) – exaggerated early pregnancy symptoms Size of the uterus is inconsistent with gestational age( with no fetal heart beat and fetal movement) usually soft Preeclampsia in the 1sttrimester or other pregnancy induced hypertension. Signs and Symptoms Ovarian (Theca lutein) cysts Features of hyperthyroidism(Anxiety, restlessness, excessive sweating) etc. Clinically, not possible to determine fetal parts, Fetal heart rate Larger uterus/FH than expected GA. Is due to expansion of endometrial cavity by placental tissues and retained blood. However in some cases, FH may be smaller than expected GA Signs and Symptoms In approximately ½ of patients diagnosis is at the time of spontaneous passage of the characteristic vesicles. Abortion usually occurs at about 16-18 weeks compared to 10-12 weeks in other usual spontaneous abortions. Diagnosis Suspicion: clinical history and physical exam Quantitative beta-HCG Ultrasound is the standard for identifying both complete and partial molar pregnancies. The classic image is of grape appearance Physical exam demonstrates:- – Absence of fetal parts and foetal heart sounds in most cases. – Bilateral ovarian masses (theca- lutein cyst) in 15 – 30% Sometimes features of hyperthyroidism Diagnosis Ultrasound is a reliable and sensitive technique. LAB: Elevated hCG in urine and serum In most instances hCG regress and disappear within 14 weeks of evacuation of molar pregnancy. If hCG persists or stagnates or rises it must be concluded that viable tumor cells still persists and this leads to persistent GTD. Ultrasound is a reliable and sensitive technique. Elevated hCG in urine and serum In most instances hCG regress and disappear within 14 weeks of evacuation of molar pregnancy. If hCG persists or stagnates or rises it must be concluded that viable tumor cells still persists and this leads to persistent GTD. Molar pregnancy Complete mole No gestational sac Uterus filled with hypoechoic and hyperchoic contents. Numerous small cystlike spaces within the mass Check HCG-level (very high usually) Extreme nausea and projectile vomiting Molar Pregnancy: US Findings Complete Mole: Heterogeneous, irregular endometrial mass echogenicity variable “cluster of grapes” relatively late appearance + Myometrial invasion Partial Mole: Fetus w/ a “thick placenta” Theca lutein cysts Molar pregnancy (Complete mole) Complete Mole Molar Pregnancy A 44 year old woman presents with a 2 month history of amenorrhea. She now complains of severe vaginal bleeding and abdominal pain. She has a beta HCG level of approximately 200,000 units. Hydatidiform mole: Partial Mole In a ‘partial mole’, the mass may contain both these abnormal cells and often a fetus that has severe defects. In this case the fetus will be consumed( destroyed) by the growing abnormal mass very quickly. Partial Mole Complete Mole Partial Mole Theca lutein cysts Bilateral, involving both ovaries Thick walled Complex cystic masses: arranged in spoke-wheel pattern Theca Lutein cysts Malignant Mole Malignant Mole most commonly develops after molar pregnancy, but may occur after any gestational experience: abortion, ectopic, preterm or term pregnancy Invades the myometrium or adjacent structures it may totally penetrate the myometrium leading to uterine rupture and haemoperitoreum(Blood in the peritoneum). Follow-up following molar pregnancy Important because of the possibility of persistent molar Following molar evacuation, perform serial hCG determination as follows:- . Weekly to non-detectable levels (ie <5MIu/ml) on 3 consecutive successive assays. . Then monthly for 6 months. . Then bimonthly for 6 months Physical work-up is equally important to rule-out metastatic disease:- . Ask for headache, visual disturbance, cough, difficulty in breathing . Involution of the uterus. . Regression of cystic ovarian enlargement (theca lutein cysts) . Obtain a baseline chest X-Ray. Follow-up following molar pregnancy Place the patient on oral conceptive pills during follow-up. NOTE: Avoid IUCD – Risk of perforation Avoid Depo- provera -Irregular bleeding At completion of follow-up pregnancy