Imaging in 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

Imaging

Ultrasonography X-Rays, CT Scan, MRI Electronic Fetal Monitoring (EFM) Cardiotocography (CTG) Amniosintesis

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)

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)

TM 1 Examination

Decidualisation, Gestational sac (GS), Yolk sac, Blighted ovum ? 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

Decidualisation

Evaluation: 1-2 weeks Normal : 3 mm, if less, progesteron < Prognosis

Gestational sac

Intrauterine ?/ at adnexa Attention : pseudogestasional sac Normal

NORMAL YOLK SAC

TAUS
GS is 20 mm

TVUS
GS is10 mm 5 - 5.5 weeks

7 weeks

Yolk sac must be visible

Abnormal : Irregular > 6,5 mm : thalassemia < 3, mm : Growth hormon

Normal : 3 - 6 mm ( 3,5 6,6 mm )

Yolk sac

Blighted ovum (BO)

Diameter 10 mm without yolk sac Diameter 15 mm without fetal echo Wait dan see ?

CROWN RUMP LENGTH (CRL)

Head extension Appropriate gain/ zoom Head to buttock/rump, exclude extremities and yolk sac

CRL : Accurate for 6-10 weeks

Biometry

< 5 weeks

5 weeks

6-10 weeks

10-12 weeks

> 12 weeks

GS

GS and Yolk sac

CRL

CRL BPD

BPD, Femur , etc.

Subchorionic Bleeding

Prognosis

Hematoma > 50% GS floating intra uterin GS in lower segment Bradycardia < 90 bpm

Evaluation 5-7 days

Fetal anomalies

Anencephalus

Hygroma colli

Susp of chromosomal abnormalities

NB : T-1 : Absent/exist? T-2 : Hypoplastic/ absent ? NT : < 3 mm

Gemellus : Chronionisitys and amnionisity

Twin peak sign:

Triplet

Conjoint twin

Suspect thalassemia

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

Hydrops Fetalis

Meningocele, omphalocele

Ectopic Pregnancy

Pseudogestasional Early diagnosis , early management : better outcome

Mola hydatidiform

TM 2-3 US EXAMINATION

Sign of life, number of fetus, presentation, and fetal movement 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

Fetal Biometry
BPD, HC, AC, FL, EFW HL, Cerebellum, OFD, OOD, IOD

Amniotic Fluid

Single pocket : 2-8 cm AFI : 4 quadrant : 5-25 cm

Polyhydramnion

Oligohydramnuion

PLACENTA

Plasenta previa trimester I

Bladder effect

Plasenta previa - inkreta

Contraction effect

Umbilical Cord

Fetal Heart

Fetal Abdomen

Extremities and Spine

FETAL SEX

Fetal Growth Chart

Documentation
Date,

identity, picture orientation Permanent record : photo, CD, video Description : location, size, types of abnormalities

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

GYNECOLOGICAL US

Proliferation phase

Secretion phase

Imaging

Ultrasonography X-Rays, CT Scan, MRI Electronic Fetal Monitoring (EFM) Cardiotocography (CTG) Amniosintesis

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

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 and midpelvis in the case of breech presentation 2. Maternal disorder - brain tumor, spinal trauma - adrenal tumor (pheochromocytoma) - uterine and ovarian mass

Magnetic Resonance Imaging

Fetal indications -Central nervous system and thoracic abnormalities -observation of lecithin peak (used MRspectroscopy--in vivo analysis of lung maturity

Guidelines for Diagnostic Imaging during Pregnancy

1.Woman should be counseled that X-ray exposure from a single diagnostic procedure dose not result in harmful fetal effects. Specifically, exposure to less than 5rad has not been associated with an increase in fetal anomalies or pregnancy loss

Guidelines for Diagnostic Imaging during Pregnancy

2. Concern about possible effects of high-

dose ionizing radiation exposure should not prevent medically indicated diagnostic Xray procedure from being performed on the mother. During pregnancy, other imaging procedures not associated with ionizing radiation, such as ultrasonography and magnetic resonance imaging, should be considered instead of X-rays when possible

Guidelines for Diagnostic Imaging during Pregnancy

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 the 1st trimester

Guidelines for Diagnostic Imaging during Pregnancy

4. Consultation with a radiologist may be helpful in calculating estimated fetal dose when multiple diagnostic X-rays are performed on a pregnant woman

Guidelines for Diagnostic Imaging during Pregnancy

5. The use of radioactive isotope of iodine is contraindicated for therapeutic use during pregnancy

1.

2.

3.

Plain Ray a. Chest X-Ray * Respiratory disorders * Choriocarcinoma b. Abdominal X-Ray * Dermoid Cyst / Teratomas * Fetal presentations and congenital malformations * Pelvimetry Intravenous Pyelography (IVP) * Ureteric obstructive lesions e.g Calculi, uterine fibroids * Congenital anomalies of the Urinary bladder, ureters and Kidney A Videocystourethrogram * Stress incontinence * Bladder diverticula

Hemorrhagic Cyst

Coronal SSFSE T2W image

Axial SSFSE T2W image

Leiomyoma
Axial T2W SSFSE image

Benign Mucinous Cystadenoma

Axial FSE T2W image

Imaging

Ultrasonography X-Rays, CT Scan, MRI Electronic Fetal Monitoring (EFM) Cardiotocography (CTG) Amniosintesis

ELECTRONIC FETAL MONITORING AND CARDIOTOCOGRAPHY

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

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Reactive Pattern
Baseline FHR 120-160 bpm

2 accelerations in 20 minutes Acceleration amplitude > 15 beats lasting > 15 seconds 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 fetal response to hypoxia. In most situations, decelerations of the FHR will precede the loss of variability, indicating the cause of neurologic depression.
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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.

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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
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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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Variable Decelerations

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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Variable Decelerations

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 the contraction. A result of CNS hypoxia; in more severe cases, it may be the result of direct myocardial depression.
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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 X-Rays, CT Scan, MRI Electronic Fetal Monitoring (EFM) Cardiotocography (CTG) Amniosintesis

AMNIOSINTESIS
A PROCEDURE TO OBTAIN THE AMNIOTIC FLUID BY INSERT THE NEEDLE THROUGH MATERNAL ABDOMEN GUIDED BY THE ULTRASOUND UNDERTAKEN AT 16 20 WEEKS OF PREGNANCY

EARLY DIAGNOSIS OF CHROMOSOMAL ABNORMALITIES, THALASSEMIA, ANOTHER GENETIC DISEASES

AMNIOSINTESIS

THANK YOU