Doppler In Gynecology Flashcards
(160 cards)
1
Q
Doppler is performed with what kind of scan?
A
EV scan
2
Q
What do we look for with doppler in gynecology? 7
A
- Endometrial flow
- Ovarian torsion
- Solid masses
- Pelvic congestion
- Pelvic inflammatory disease
- Molar pregnancy
- AVM’s
3
Q
What is a molar pregnancy?
A
Persistent trophoblastic disease
4
Q
What does a moderate uterine artery doppler look like?
A
High velocity and high resistance wave form
5
Q
In terms of uterine artery doppler velocities vary through cycle to do what?
A
Match need for vascular supply
6
Q
Uterine abnormalities can cause what to happen with flow?
A
Resistance to flow to decrease
7
Q
What are two types of uterine abnormalities?
A
- Endometrial carcinoma
- Uterine Leiomyoma
8
Q
What is the RI for the proliferative phase?
A
0.88 (+/- 0.05)
9
Q
What is the RI for the ovulation to lateral phase?
A
+/- 0.85 (+/- 0.06)
10
Q
Label the image
A
11
Q
Label the image
A
12
Q
Label the two images 2
A
- Sagittal endovaginal image of a uterus with calcified arcuate vessels
- Transverse image of the same uterus
13
Q
In terms of endometrial doppler it is routine to do what?
A
Observe flow
14
Q
Where do we put the colour doppler for endometrial doppler?
A
Over the endometrium on TA and EV
15
Q
What are some pathologies seen in the endometrium with abnormal colour flows and doppler? 3
A
- Endometrial carcinoma
- Endometrial polyps
- Submucosal fibroids
16
Q
What are endometrial carcinomas?
A
Endometrial hyperplasia or thickened endometrium
17
Q
What are endometrial polyps? If we see them what do we do?
A
- Colour doppler, looking for feeding stalk artery
- If seen spectral tracing to prove arterial flow
18
Q
When would we do Ovarian doppler?
A
Ovarian torsion
19
Q
If we see ovarian torsion what do we do? 3
A
- A DDX for acute localized pain in the pelvis
- Look for colour flow
- Spectral doppler must be performed
20
Q
What do we look for in terms of ovarian torsion?
A
Look for colour flow first
21
Q
What does positive and negative colour flow mean in terms of Ovarian torsion?
A
- Positive colour doesn’t mean NO torsion
- Negative colour flow doesn’t mean torsion either
22
Q
Typical torsion is the absence of flow, but what are some things to note? 2
A
- Arterial flow can still be seen in some torsion
- Venous flow is first to disappear
23
Q
What must we always do with ovarian doppler?
A
Correlate with the other side to ensure settings are correct
24
Q
How is ovarian doppler best seen?
A
On endovaginal scan
25
How does ovarian doppler vary with menstrual cycle? *Think RI*
1. Proliferative phase RI = 0.88 to 0.84
2. Follicular phase RI rises to 0.92
3. Ovulation RI decreases to 0.44
26
What does the ovarian doppler look like on the dominant follicle?
1. PI and RI reflect decreased vascular impedance and an increase in flow in ovary with the dominant follicle
27
In terms of ovarian doppler, Inactive ovary has what?
Low or absent end-diastolic flow
28
In terms of ovarian masses Malignant lesions tend to have what type of flow?
More central flow
29
In terms of ovarian masses, benign lesions tend to have what type of flow?
Peripheral flow
30
What do we have between benign and malignant processes in the ovarian mass?
Considerable overlap
31
What are the RI for Ovarian Neoplasms?
RI < 0.4
32
What is the P1 for ovarian neoplasm?
PI <1
33
In terms of ovarian doppler, what is the diastolic flow?
It is increased
34
Doppler is non-specific for what?
Malignancy
35
What does this image demonstrate?
Ovarian doppler of the corpus luteum
36
What is this an image of?
Cyst with a solid component
37
What are clinical S/S of acute salpingitis? 3
Acute signs and symptoms
1. Fever
2. High white count
3. Extreme motion tenderness
38
What does AVM stand for?
Arteriovenous malformation
39
What is Arteriovenous malformations?
A plexus of arteries and veins without a capillary bed
40
Where can Arteriovenous malformations occur? 2
In the pelvis
1. Typically involve the myometrium
2. Can involve the endometrium
41
How is Arteriovenous malformation usually acquired 3
1. Trauma
2. Surgery
3. Can be associated with gestational trophoblastic disease
42
What is the resistance of AVMs? 2
1. Extremely low resistance
2. Coupled with low resistance venous flow on spectral
43
In terms of arterio malformation colour doppler shows what?
Abundance of aliasing
44
What does this image demonstrate?
Arteriovenous maformation
45
In terms of Ovarian vein thrombophlebitis, which side is typically affected?
Right side 80-90% of the time
46
What modalities are used to diagnose AVMs? 3
1. CT
2. MRI
3. Sonography
47
What would we use to scan Ovarian vein thrombophlebitis? (Structure)
IVC
48
What is the DDX for Ovarian vein thrombelitis? 5 (what is linked/ causes it)
1. Appendicitis
2. Fibroids
3. Nephrolotihiasis
4. Ovarian torsion
5. Two-ovarian abscesses
49
What does this image demonstrate?
1. Norma Ovarian vein on the left
2. Thrombophlebitis normal
50
What is ovarian vein thrombophlebitis?
Inflammation of the vein caused by a clot
51
How common is ovarian vein thrombophlebitis?
Rare condition
52
What is associated with ovarian vein thrombophlebitis? 3
1. Postpartum
2. Malignancies
3. PID
53
What is pelvic congestion?
chronic pelvic pain lasting for more than. 6 months
54
What is the cause of pelvic possible due to?
Chronic dull ache
55
What are symptoms of chronic dull ache? 4
1. Premenstral
2. Menstrual
3. Postcorital
4. Perirenal
56
What is pelvic congestion associated with? What is the gold standard? 3
1. Varicose veins in legs
2. Multi parity
3. Venography is the diagnostic gold standard
57
What does this image demonstrate?
Pelvic congestion
58
What is the cause of pelvic congestion? 2
1. Unknown
2. Possibly due to incompetent ovarian veins
59
How is doppler useful?
It is a relatively safe non-invasive method to asses maternal and fetal circulation
60
What does doppler assist us in doing?
Identifying fetuses at risk for poor fetal outcome by quantitative and qualitative factors
61
What are some qualitative benefits of doppler?
It allows us to assess flow patterns
62
How does doppler allow us to identify quantitative functions?
It allows us to obtain flow measurements
63
Why is it important not to abuse doppler?
There is a theoretical danger of increased exposure causing bio effects due to the increased energy (power) required for doppler
64
Which Doppler methodology adds little extra energy? And which one adds a lot of extra energy?
1. Colour doppler
2. Pulsed doppler
65
There are how many ways to assess with doppler? 3
1. Colour
2. Spectral
3. Continuous wave
66
Most fetal blood flow investigated is how fast? (speed)
<1 m/s
67
What is colour doppler used to do? 2
1. Used to located vessel
2. Used for vessels difficult to see on gray scale imaging (circle of Willis)
68
What is the benefit of power doppler? 2
1. Direction of flow is not needed
2. We can see smaller vessels with slower flow
69
What are qualitative analysis?
Observed changes that do need to be measured
70
What are some examples of qualitative analysis variables? 3
1. Loss of diastolic flow
2. Reversal of diastolic flow
3. Notching of the venous flow
71
Diastolic velocities increase as term approaches, why?
Decreased placental resistance (larger placental vessel)
72
Why is semiquantitative analysis difficult to use?
Used because of the difficulty to control the angle of incidence
73
What ratios does semiquantitative analysis include? 3
1. Pulsatility index (PI)
2. Resistance index RI
3. Systole/ Diastole Ratio
74
How do we calculate Pulsatility Index?
(Peak systolic velocity - End diastolic velocity)/ Mean velocity
75
How do we calculate resistance index?
(Peak velocity - end diastolic velocity) / Peak systolic velocity
76
How do we calculate systole/ diastole ratio?
Peak systolic velocity/ End diastolic velocity
77
Semiquantitative analysis equations are dependant on what?
Angle
78
All semiquantitative analysis equations are thought to reflect how?
Downstream flow impedance
79
As impedance increased what happens to pulsatility waveform?
It decreases
80
RI and S/D ratios can’t be calculated when what happens?
The diastolic velocity reaches zero
81
PI will continue to change in what conditions?
Even when diastolic flow is zero
82
S/D ratios are the most commonly used for what?
Analysis but when EDV is zero reversed, PI is more favourable
83
For accuracy what must we do?
Three or more waveforms should be measured and averaged to reduce operator error and to account for external variables
84
What cardiac signs help a role in the accuracy of the heart? 2
1. Tachycardia
2. Bradycardia
85
What can the fetus do to affect accuracy?
Fetal breathing and motion
86
During the embryonic period it is is normal that have what type of pattern?
High resistance pattern with absent end diastolic flow
87
Toward of the end of the first trimester what happens?
End diastolic flow appears
88
As pregnancy progresses what should increase?
End diastolic velocity
89
Label the waveforms?
1. 1st trimester
2. 2nd trimester
3. Third trimester
90
What fetal vessels are routinely assessed? 6
1. Umbilical artery
2. Fetal cerebral vessels (MCA)
3. Ductus venosus
4. Umbilical vein
5. Fetal aorta
6. Fetal IVC
91
Doppler of uterine arteries is used to detect markers for what? 3
1. Placental insufficiency
2. IUGR
3. Suspected pre-eclampsia
92
In the presence of IUGR, scans are performed how?
Weekly if the results are normal
93
Abnormal results require what frequency of scans?
Increased
94
What are indications for Umbilical artery doppler? 5
1. Small for gestation age
2. Hypertension in pregnancy
3. Diabetes type 1
4. Discordant growth in TTTS
5. Poor growth twins due to placental insufficiency
95
The PI, RI, and S/D ratios do what with gestational age?
Decrease
96
Umbilical artery ratios are higher where?
If measured at fetal end of the cord
97
Where should we try to measure in the umbilical arteries?
Mid level
98
How should we scan the umbilical arteries in the situation of twins?
Just outside of the fetal abdomen
99
Reversed diastolic flow indicate what?
Severe fetal distress and may lead to intrauterine death
100
RI of what is abnormal from 26 weeks onward
> 0.72
101
Fetal doppler values must be referenced with what?
Fetal age
102
What kind of flow is seen in the umbilical arteries?
Monophasic and low resistance
103
What does abnormal flow patterns look like for umbilical arteries?
Absent or reversed diastolic flow
104
What is abnormal umbilical artery flow referred to?
AEDF and REDF
105
In terms of umbilical arteries here, what is affecting them?
Fetal breathing
106
Why is the importance of MCA doppler?
Assessing fetal cardiovascular distress
107
What does MCA stand for?
Mid cerebral arteries
108
Where is MCA found?
Just inferior to the BPD
109
What does MCA flow look like normally? (During brain development and increasing gestational age) 2
Monophasic
1. High resistance as the brain develops
2. Lower with increasing gestational age
110
In terms of the MCA, accuracy requires what?
Scanning parallel to the course of the MCA with an angle of <15 degrees
111
Where should we sample in terms of MCA doppler?:
Near the origin as PSV decrease laterally
112
In terms of MCA doppler, with IUGR there can be what?
Brain sparing
113
What is brain sparing referred to?
Asymmetrical IUGR
114
Preferential flow to the brain results in what?
Increased diastolic flow to compensate for fetal asphyxia
115
The PI of the MCA can be compared to what?
The UA in a cerebral- placental ratio (CPR)
116
What is the CPR formula?
CPR = MCA PI/ UA PI
Or
(Mid cerebral artery pulsatility index)/ (umbilical pulsatility index)
117
What does cerebral placental ratio describe?
The relative impediments to blood flow between maternal and fetal circulation
118
What is the normal CPR and Abnormal CPR values?
1. Normal and >1:1
2. Abnormal is <1:1
119
What is an ominous sign for hypoxia in the fetus? 2
1. Increased diastolic flow in the MCA
2. Absent or reversed diastolic flow in the UA
120
In terms of these waveforms. What is happening to the placental resistance? What does this resistance do to the placenta? What can we see with the umbilical venous flow? What does the brain do to compensate?
1. Placental resistance is rising
2. Causes loss of perfusion in the placenta
3. Umbilical venous flow decreases causing hypoxia
4. The brain compensates and increases diastolic flow in the MCA
121
Immune hydrops can lead to what?
Anemia
122
What is anemia in terms of doppler?
Increased systolic velocity due to decreased viscosity of the blood
123
Peak systolic velocity increase with what?
Gestation
124
Values are always correlated with what?
Age
125
What value indicates a amniocentesis is required? And if so what else is possibly needed?
1. >1m/sec
2. Possible fetal blood transfusion
126
What does this sample demonstrate?
MCA sample for immune hydrops
127
What do these images demonstrate?
Corrrect angle vs incorrect angle
128
In terms of MCA doppler, fetal position is of importance how?
Fetal position is dependent, which means this can be difficult
129
In terms of MCA doppler, for an accurate measurement, what should we do? 2
1. The fetal head should be in the transverse plane
2. An axial section of the brain, including the thalami and the sphenoid bone wings, should be obtained and magnified
130
In terms of MCA doppler, constant probe pressure can cause what type of reaction? Why?
1. Reaction similar to fetal distress
2. Fetus will shunt more blood to the brain
131
What is the ductus venosus?
A shunt that allows oxygenated blood in umbilical vein to bypass the liver and go directly to the right atrium
132
What does the ductus venosus do?
Regulator of oxygen to the fetus
133
How much of the umbilical vein blood is dependent on the ductus venosus?
~50%
134
Where is the ductus venosus located?
In the fetal liver between LT portal vein and IVC
135
How should we obtain the ductus flow? 4
1. Level of the AC
2. Colour doppler of the UV
3. Sweep towards fetal heart
4. Look for aliasing (due to narrow lumen)
136
Label the image
137
What does this image demonstrate?
Ductus venosus in trans and sagittal
138
What does this image demonstrate?
Ductus venosus in trans and sag
139
Label the image
140
In terms of the ductus venosus, it is abnormal to see flow go where?
Below the baseline
141
In TTTS, the recipient twin may demonstrate what? Why?
1. Flow below the base line with tricuspid regurgitation.
2. Volume overload - getting to much blood
142
Assessments of the DV can be used for what? 2
1. First trimester screening for aneuplody
2. Second and third trimester scanning when there are concerns regarding IUGR and Fetal cardiac compromise
143
What does these images demonstrate?
Normal Ductus venosus
144
What does these images demonstrate?
Abnormal Ductus venosus
145
There is continuous flow of oxygenated blood where?
To the fetal liver and, via the ductus venous, the heart
146
What is the continuous flow of oxygenated blood flow affected by?
Fetal breathing or movements, which means we need to be careful when sampling
147
Where can the umbilical vein be sampled?
In the cord of fetal abdomen
148
The umbilical cord can pulsated until when? (weeks)
Up to 13 weeks
149
In terms of the umbilical vein, the presence of pulsatility can be be higher when?
In chromosomal abnormal fetuses
150
Pulsatility in the UV coupled with AEDF or REDF in the umbilical artery indicates what?
Poor outcome
151
Label the umbilical vein spectral doppler waveforms
1. Normal
2. Breathing movements
3. Single pulsations
4. Double pulsations
152
How often is the fetal aorta used now?
Not as frequently
153
Where do we sample the fetal aorta?
In descending aorta just above the diaphragm
154
What is the appearance of the fetal aorta?
Similar to umbilical artery
155
Changes in aorta are noticed how?
Before they appear in the umbilical artery
156
In the fetal aorta decreased, absent or reversed diastolic flow indications compare how to the umbilical artery
The same
157
What is the IVC waveform near the heart?
Triphasic
158
What does the IVC look like spectrally near the heart in the presence of IUGR? 3
1. A wave will increase
2. S wave and D wave will decrease
3. The D wave may also be absent or reversed
159
Uterine artery doppler is used for the prediction of what?
Placenta insufficiency
160
What factors in the uterine artery doppler waveform would indicate placental insufficiency? 4
1. Low PAPP-A (pregnancy associated plasma protein)
2. PI >1.45 (1.2 is normal)
3. Notching
4. Blood test performed for the1st trimester screen
