OBGYN Ultrasound Interesting Case Conference

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OB/GYN Ultrasound Interesting Case Conference

• Ana Lourenco MD
• August 27, 2007

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40FFollow-up Fetal Growth
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Pericardial Effusion, 2 V cord, SltD, AMA

• 2V Cord ? Increased risk trisomies, structural
  anomalies
• Pericardial Effusion
• Normal variant lt2mm
• 2-7mm and NO other anomalies ? normal outcome
• Can be associated with hydrops, structural
  anomalies

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Follow-Up

• Fetal cardiac echo ? Normal anatomy pericardial
  effusion resolved.

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47 F Spotting between periods
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Pelvic US
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Endometrial Polyp
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Polyps

• Most often 40-50 yr old women
• Hyperplastic overgrowth of endometrial lining
• Vast majority benign
• Excised to evaluate for possible underlying
  malignancy and for symptoms of bleeding
• Can be asymptomatic
• Can regress
• Removed in infertility patients, even if
  incidental

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26F Size lt Dates
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Echogenic Fluid Vernix vs Meconium

• Size lt Dates
• Growth 3wks less than expected from prior US
• Calcified placenta
• S/D BPP Normal
• Plan ? Delivery induced next day
• No meconium

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37 F High Risk Survey for AMA
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Right 5th middle phalanx not seen
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Hypoplastic Middle Phalanx 5th finger

• Downs marker, but remainder of survey WNL
• Can be isolated anomaly
• Amnio ? Normal

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44 F Heavy menses
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Prior h/o 3 C-sections
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29F OB FUplacental location
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Fetal Pelvis
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• Insert cine of pelvis.

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Fetal Cystic Masses

• Ovarian cyst in female
• Duplication cyst Mesenteric cyst
• Urinary tract obstruction
• Choledochal cyst (Right side)
• Meconium pseudocyst
• Cystic teratoma
• Lymphangioma

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2 Weeks Later
Increased Size from 2.5 to 3.5 cm
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Septation or Debris?
Layering Debris!
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35F for 1st trimester screen
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Thickened NT, diffuse skin thickening,
omphalocele ? Trisomy 18 at CVS
Doppler 1ST Trimester?
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Same patientNew pregnancy July 2007
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Abnormally Large YS

• Associated with aneuploidy and embryonic demise
• Close interval F/U needed given h/o prior Trisomy
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40F ?viability
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25F with spotting, BHCG
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Calcified YS Embryonic demise
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26 F for evaluation of CDH seen on outside US
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Cephalic Presentation
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Right CDH

• Rare
• 1 in 2000-4000 live births
• Liver nearly always in chest
• Associated pleural effusion and ascites often
• Worse prognosis if stomach in chest

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CDH Hernia Types

• 90 Bochdalek posterior
• B for back
• 5-10 Morgagni anterior midline, more often
  right sided
• Very rare - Hiatus hernia

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22F no menses x 3 yrs?premature ovarian failure
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Right ovary SAG
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• PCOS
• Overweight
• Hirsutism
• Endocrine dysfunction
• Insulin resistance
• Lipid abnormalities
• Reduced fertility
• Irregular menses
• Rx variable

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30F with bleeding HCG
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Left Adnexa, Separate from ovary
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• Left ectopic
• Size lt 3.5cm ? treated with MTX
• Intrauterine fluid collection.
• No YS, EP, EHR

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24F HCG Bleeding
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Left adnexa, separate from ovary
Left ovary
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Another Left Ectopic!

• Treated medically with methotrexate.
• Methotrexate cytotoxic to dividing cells.
  Stops cell growth within the ectopic.
• Patients often experience pain post-Rx.
• Need f/u BHCG to verify Rx success. Adnexal mass
  persists for some time at US.

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37F High Risk Fetal for AMA
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1 month later
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Duplicated Collecting System with Upper Pole
obstruction and Ureterocele

• Weigert Meyer rule Upper pole obstructs Lower
  pole refluxes

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29F outside US showed right hydrothorax and
nuchal thickening

• Amnio normal chromosomes

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Nuchal Thickening

• Associated with Tri 13, 18, 21, Turners,
  nonimmune hydrops
• Chromosomal abnormalities 20
• gt 6mm Nuchal Thickening at 2nd Trimester
• Pleural effusion ? ? unrelated. ?thoracic duct
  obstruction

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40F for HSG s/p Essure tubal microinserts
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Essure Tubal Microinserts

• Permanent Birth Control
• Alternate birth control required for 3 months
  after placement
• HSG to confirm tubal occlusion at 3 months
• Hysteroscopic placement

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Essure Microinserts
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33F 1st Trimester Screening
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5mm NT
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Nuchal Translucency

• Many pitfalls!
• Sonographer certification required
• Strict guidelines CRL 45-84mm GA 11.1-13.6
• Amnion can be fake-out, though usually does not
  appear abnormally thickened
• Patient declined CVS. To have amnio later.

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88F Post-menopausal bleeding
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• Bladder Nodule ? Papillary Urothelial Carcinoma,
  no invasion of lamina propria
• Thickened Endometrium ? Polyp
• Left Adnexal Cystic Mass ? Not yet resected
  likely benign neoplasm

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53F PMB
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Next step?
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Endometrial Carcinoma

• Symptoms PMB most common
• Often diagnosed at earlier stage than other GYN
  CA b/c causes symptoms early
• Risk factors obesity, unopposed estrogen, HTN,
  DM, late menopause, FHx

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34F Polyhydramnios Dilated Bowel on outside US

• Normal Amnio

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AFI 40cm
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Small bowel Atresia

• Distal duodenal vs jejunal
• Intrauterine ischemic insult to bowel
• Surgical repair, usually with good outcomes
• Ddx volvulus in setting of gut malrotation

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28F Polyhydramnios
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AFI 45 cm
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Esophageal Atresia
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Esophageal Atresia

• Associated VACTERL Anomalies, up to 10
• Vertebral
• Anorectal
• Cardiac
• TE fistula
• Renal
• Limb

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28F Fetal cardiac anomaly on outside US
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Hypoplastic Left Heart

• Hypoplastic LV, Mitral Valve, Ascending Aorta
• Fetal Echo CHB ?
• Severely hypoplastic LV
• Severe hypoplasia Aortic Arch
• Large primum ASD

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35F outside US at 36 wk GAshowed brain kidney
abnormalities

• Amnio - Normal

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Agenesis CC Severe Bilateral Hydronephrosis

• ?Syndrome?
• Isolated agenesis CC spectrum of abnormality
  from normal to developmental delay / intellectual
  impairment
• B/L Hydro, most prominent upper poles ? probable
  duplicated system

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24F Abnormal Serum Screen
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• Omphalocele
• Synechiae
• CVS - pending

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Omphalocele

• Failure of fusion abdominal wall
• Bowel /- solid organs covered by membrane
• Cord inserts on center of covering membrane
• Chromosomal anomalies up to 40
• Liver in omphalocele ? lower incidence of
  chromosomal anomalies

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23F for 1st Trimester Screen
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Gastroschisis

• Elevated AFP (more than omphalocele)
• No significant association with syndromes,
  chromosomal anomalies
• Usually right sided, paramedian
• Cord Insertion Normal
• Usually small bowel only, but other organs may
  occasionally herniate thru defect
• No covering membrane

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Complications

• IUGR
• Bowel obstruction
• Perforation, peritonitis
• Hypoperistalsis of bowel
• Bowel ischemia
• Short gut
• Treatment surgical repair after birth, usually
  with resection of segments of stenotic bowel

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Omphalocele
Gastroschisis
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31F with epigastric and back pain
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• Worsening pain ? ER ? US
• Dropping Hemoglobin
• To OR ? Grade 3 Ovarian Endometrioid
  Adenocarcinoma
• ? Arising in background of endometriosis

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35F 1st Trimester Screen
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Encephalocele

• 90 midline
• 75 occipital
• Frontal more common in Asia
• Neural tube defect
• Usually AFP not elevated b/c skin covering
• Chromosomal abnormalities up to 40
• Other anomalies up to 80
• Associated w/ multiple syndromes
• Prognosis poor
• Worse if brain tissue contained in encephalocele
• CVS - pending

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40F Fluid leakage 1 day s/p amnio at outside
office
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Amniocentesis Complications

• Miscarriage 1/250-300
• Amniotic fluid leak 1/100
• Infection very rare
• Fetal injury very rare

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24F RLQ pain fullness on pelvic exam
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Classic Hemorrhagic Cyst

• Lace-like, low level echoes
• No vascular flow
• Retracting clot
• Resolve with time ? 6 wk F/U

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55F Elevated Testosterone
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What next?
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Sertoli-Leydig Cell Tumor

• 1 of ovarian tumors
• Solid, homogeneous mass on US with vascular flow
• May present with virilization

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27F Achondroplastic Dwarffor Fetal Survey
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Genetics Autosomal Dominant

• Homozygous Lethal (25)
• Heterozygous Dwarf (50)
• Normal (25)

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Prenatal US

• Homozygous
• FL lt 3 at 17 wks GA
• Progressive shortening FL at 20 23 wks GA
• FL lt 34mm at 26 wks BPD age
• Heterozygous
• Limb shortening evident late 2nd and 3rd
  trimester
• FL gt 34mm at 26 wks BPD age

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Heterozygous Achondroplasia

• Proximal shortening more pronounced
• Frontal bossing, large head
• Trident Hand
• Spinal stenosis
• Normal intelligence
• 80 of cases due to new mutation
• 20 genetically inherited
• Adult height 4ft

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33F Ovarian mass discovered at 17 wk Fetal Survey
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2 wks later
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Probable Luteoma of Pregnancy

• Often asymptomatic
• Usually discovered at 2nd or 3rd trimester
• Natural history ? Involute after delivery,
  usually in 2-3 wks
• 25 hormonally active
• Can cause virilization of female fetus mother
• DDx other solid ovarian neoplasm

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Cavum Septum Pellucidum

• The Ideal Views!

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The End!