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Imagingin Obstetric and Gynecology

A. Kurdi Syamsuri, Hatta Ansyori, Nuswil Bernolian

Division of Maternal-Fetal Medicine

Department of Obstetric and Gynecology

Dr. Moh. Hoesin General Hospital/

Faculty of Medicine University of Sriwijaya

Palembang, 2013

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Imaging

Ultrasonography

X-Rays, CT Scan, MRI Electronic Fetal Monitoring (EFM)

Cardiotocography (CTG)

Amniosintesis

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ULTRASOUND (US) EQUIPMENT

Types of ultrasound:

- 2-D (real-time)

- Doppler

- Color Doppler- 3-D static

- 3-D real-time (4-D)

Probe (transducer):

- Transabdominal (3

5 MHz)- Transvaginal (5 8 MHz)

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Obstetric US : TM 1

Is there any pregnancy ?

Intra /extra uterine ? Or both ?

Gestational age

Signs of fetal life

Evaluation of pregnancy complication Search for source of vaginal bleeding

Detection of fetal anomalies

Detection of multifetal pregnancy

Suspicious of chromosomal disorder

Evaluation of adnexa, pelvic tumor, location of IUD Prenatal diagnosis : CVS (chorionic villous sampling)

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Decidualisation, Gestational sac (GS), Yolk sac, Blightedovum ?

Crown-Rump Length (CRL), Heart beat

Fetal movement

Multifetal pregnancy, conjoint twin ?

Subchorionik bleeding

Suspi of fetal anomalies ( Anencephalus/ hygroma colli )

Susp of chromosomal disorder ( NT nuchal

translucency, nasal bone) Ectopic pregnancy

Adnexal tumor , uterine myoma

TM 1 Examination

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Evaluation: 1-2 weeks

Normal : 3 mm, if less, progesteron 6,5 mm : thalassemia

< 3, mm : Growth hormon

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Yolk sac
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=%5Cwebsites%5Cemedicine%5Cradio%5Cimages%5CLarge%5C46304630Fig_6_Lg_YSa.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=%5Cwebsites%5Cemedicine%5Cradio%5Cimages%5CLarge%5C4629Fig_5._Nl_YS.JPG&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=%5Cwebsites%5Cemedicine%5Cradio%5Cimages%5CLarge%5C46254625Fig_1._CRL_5.4mma.JPG&template=izoom2

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Diameter 10 mm without yolk sac Diameter 15 mm without fetal echo

Wait dan see ?

Blighted ovum (BO)

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Head extension

Appropriate gain/ zoom

Head to buttock/rump, exclude extremities and yolk sac

CROWN RUMP LENGTH (CRL)

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< 5 weeks 5 weeks 6-10 weeks 10-12 weeks

GS GS andYolk sac

CRL CRLBPD

> 12 weeks

BPD, Femur , etc.

CRL : Accurate for 6-10 weeks

Biometry

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Subchorionic Bleeding

Prognosis

Hematoma > 50%

GS floating intra uterin

GS in lower segment Bradycardia < 90 bpm

Evaluation 5-7 days

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Fetal anomalies

Anencephalus Hygroma colli

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NB : T-1 : Absent/exist?

T-2 : Hypoplastic/ absent ?

NT : < 3 mm

Susp of chromosomal abnormalities

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Gemellus : Chronionisitys and amnionisity

Twin peak sign

:

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Triplet

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Conjoint twin

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Suspect thalassemia

8-9 weeks Screening : Hb, MCV, MCH Hb elektroforesis, DNA

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Hydrops Fetalis

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Meningocele, omphalocele

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Pseudogestasional

Early diagnosis , early management : better outcome

Ectopic Pregnancy

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Mola hydatidiform

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Sign of life, number of fetus, presentation, and fetalmovement activity

Gestational age determination : preterm, term, posdate

Estimated Date of Delivery

Fetal growth and fetal well-being

Amniotic volume

Placenta and umbilical cord

Fetal Anatomy and Fetal functional

Multifetal pregnancy Uterine myoma (position), cervix and adnexa

TM 2-3 US EXAMINATION

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Fetal BiometryBPD, HC, AC, FL, EFW

HL, Cerebellum, OFD, OOD, IOD

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Single pocket: 2-8 cm

AFI : 4 quadrant : 5-25 cm

Amniotic Fluid

Polyhydramnion Oligohydramnuion

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PLACENTA

Bladder effect

Contraction effect

Plasenta previa trimester I

Plasenta previa - inkreta

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Umbilical Cord

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Fetal Heart

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Fetal Abdomen

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Extremities and Spine

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FETAL SEX

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Fetal Growth Chart

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Documentation

Date, identity, picture orientation

Permanent record : photo, CD,

video

Description : location, size, types

of abnormalities

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Conclusion

US examination in obstetric very helpful,

should be serial to assess fetal growth

Use the fetal growth chart Early detection

On indication, nor for massal screening

informed consent/ counselling

Referral system : Level 1, level 2, level 3

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GYNECOLOGICAL US

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Proliferation phase Secretion phase

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Imaging

Ultrasonography



Amniosintesis

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Magnetic Resonance Imaging

MRI useful tool in both OB/GYN imaging

No reported harmful human effects from

its use, including any mutagenic effects /No demonstrable fetal heart pattern

changes during imaging

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MRI Systems

At $2 million, the most expensive equipment in the hospital

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Magnetic Resonance Imaging Indication- Any gestational age if no other

imaging studies can be performed

Maternal indication

1. Measurements of the pelvic inlet andmidpelvis in the case of breech presentation

2. Maternal disorder

- brain tumor, spinal trauma

- adrenal tumor (pheochromocytoma)

- uterine and ovarian mass

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Magnetic Resonance Imaging

Fetal indications

-Central nervous system and thoracic

abnormalities-observation of lecithin peak

(used MRspectroscopy---

in vivo analysis of lung maturity

id li f i i i

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Guidelines for Diagnostic Imagingduring Pregnancy

1.Woman should be counseled that X-ray

exposure from a single diagnostic

procedure dose not result in harmfulfetal effects. Specifically, exposure to lessthan 5rad has not been associated with an

increase in fetal anomalies or pregnancy

loss

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2. Concern about possible effects of high-dose ionizing radiation exposure should notprevent medically indicated diagnostic X-

ray procedure from being performed on themother. During pregnancy, other imagingprocedures not associated with ionizingradiation, such as ultrasonography and

magnetic resonance imaging, should beconsidered instead of X-rays when possible

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3. US and MRI are not associated with

known adverse fetal effects.

However, until more information is available,

MRI is not recommended for use in the1st trimester

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4. Consultation with a radiologist may be

helpful in calculating estimated fetal dosewhen multiple diagnostic X-rays areperformed on a pregnant woman

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5. The use ofradioactive isotope of iodine

is contraindicated for therapeutic useduring pregnancy

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1. Plain Ray

a. Chest X-Ray

* Respiratory disorders

* Choriocarcinoma

b. Abdominal X-Ray

* Dermoid Cyst / Teratomas

* Fetal presentations and congenital malformations

* Pelvimetry2. Intravenous Pyelography (IVP)

* Ureteric obstructive lesions

e.g Calculi, uterine fibroids

* Congenital anomalies of the Urinary bladder,

ureters and Kidney

3. A Videocystourethrogram

* Stress incontinence

* Bladder diverticula

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Axial SSFSE T2W image

Coronal SSFSE T2W image

Hemorrhagic Cyst

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Axial T2W SSFSE

image

Leiomyoma

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Axial FSE T2W image

Benign Mucinous Cystadenoma

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Imaging

Ultrasonography



Amniosintesis

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ELECTRONIC FETALMONITORINGAND

CARDIOTOCOGRAPHY

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Monitoring of FHR & Uterine Contractions(Cardio-toco-graphy)

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Reactive PatternBaseline FHR 120-160 bpm

2 accelerations in 20 minutes

Acceleration amplitude > 15 beats lasting > 15seconds

Variability 15 beats (5-10 beats in premature

fetuses)

No periodic or significant decelerations (>30

beats)

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Non-Reactive Pattern

Lack of reactive criteria over 40 minutes.

Always of concern ante-partum & delivery

is generally indicated.

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Patterns of The FHR

Normal Pattern

Baseline Tachycardia/Bradycardia

Reduced Variability Early Decelerations

Late Decelerations

Variable Decelerations Other Patterns e.g Sinusoidal

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FHR Accelerations

Are common periodic changes in labor and

are nearly always associated with fetal

movement.

Virtually always reassuring and almost

always confirm that the fetus is not acidotic

at that time.

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Variability

A useful indicator of fetal CNS integrity.

May serve as a barometer of the fetalresponse to hypoxia.

In most situations, decelerations of the

FHR will precede the loss of variability,indicating the cause of neurologicdepression.

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Variability

Factors such as a fetal sleep cycle or

medications may decrease the activity of the

CNS and the variability of the FHR.

Decreased variability in the absence of

decelerations is unlikely to be due to hypoxia.

E l D l ti

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Early Decelerations Benign changes caused by fetal head

compression.

Seen in the active phase of labor.

They are usually shallow and symmetrical.

Reach their nadir at the same time as the peak

of the contraction.

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Baseline Tachycardia

Tachycardia may be associated with:

Severe and prolonged fetal hypoxia

maternal fever Fetal anemia

Intraamniotic infection i.e. chorioamnionitis

congenital heart disease

Hyperthyroidism

Prolonged Deceleration

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Prolonged Deceleration

An isolated, abrupt decrease in the FHR to

levels below the baseline that lasts at least

60-90 seconds.

Always of concern and may be caused by

virtually any mechanism that can lead to fetal

hypoxia.

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Variable Decelerations

Umbilical cord compression or, occasionally,

head compression.

Abrupt onset and return

Vary in depth, duration, and shape.

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Frequently preceded and followed by small

accelerations of the FHR.

Coincide in timing and duration with the

compression which coincides with the timing of

the uterine contractions.

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Generally associated with a favorable outcome.

Non-reassuring if:

Persistent.

Progressively deeper to less than 70 bpm

lasting greater than 60 seconds.

Persistently slow return to baseline .

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Late Decelerations

U-shaped, gradual onset and return, usually

shallow 10-30 beats per minute.

Reach their deepest point after the peak of thecontraction.

A result of CNS hypoxia; in more severe cases,

it may be the result of direct myocardialdepression.

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Sinusoidal Heart Rate Pattern

Regular oscillation of the baseline long-term

variability resembling a sine wave, lasting at

least 10 minutes.

Rare and associated with:

Severe chronic fetal anemia

Medications: e.g. pethidine

Severe hypoxia and acidosis.

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Imaging

Ultrasonography



Amniosintesis

AMNIOSINTESIS

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AMNIOSINTESIS

A PROCEDURE TO OBTAIN THE AMNIOTIC FLUID BYINSERT THE NEEDLE THROUGH MATERNAL ABDOMEN

GUIDED BY THE ULTRASOUND

UNDERTAKEN AT 16 20 WEEKS OF PREGNANCY

EARLY DIAGNOSIS OF CHROMOSOMALABNORMALITIES, THALASSEMIA, ANOTHER GENETIC

DISEASES

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AMNIOSINTESIS

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THANK YOU

USG BLOK 17

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