Obstetric and Gynecologic Ultrasound: Case Review Series

265 Pages·2006·9.439 MB·English

by  Karen L. Reuter MD FACR, T. Kemi Babagbemi MD

Series Editor
David M. Yousem, MD, MBA
Professor of Radiology
Director of Neuroradiology
Russell H. Morgan Department of Radiology and Radiological Science
The Johns Hopkins Medical Institutions
Baltimore, Maryland
Other Volumes in the CASE REVIEW Series
Brain Imaging
Breast Imaging
Cardiac Imaging
Gastrointestinal Imaging
General and Vascular Ultrasound
Genitourinary Imaging
Head and Neck Imaging
Musculoskeletal Imaging
Nuclear Medicine
Pediatric Imaging
Spine Imaging
Thoracic Imaging
Vascular and Interventional Imaging
1600 John F. Kennedy Blvd.
Suite 1800
Philadelphia, PA 19103-2899
OBSTETRIC AND GYNECOLOGIC ULTRASOUND ISBN-13: 178-0-323-03976-5
Copyright © 2007, 2001 by Mosby, Inc., an affiliate of Elsevier Inc. ISBN-10: 0-323-03976-6
All rights reserved.No part of this publication may be reproduced or transmitted in any form or by
any means, electronic or mechanical, including photocopying, recording, or any information storage
and retrieval system, without permission in writing from the publisher. Permissions may be
sought directly from Elsevier’s Health Sciences Rights Department in Philadelphia, PA, USA:
phone: [phone], fax: [phone], e-mail: [email protected].
You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com),
by selecting “Customer Support” and then “Obtaining Permissions.”
NOTICE
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our knowledge, changes in practice, treatment and drug therapy may
become necessary or appropriate. Readers are advised to check the most current information
provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of the practitioner, relying on their
own experience and knowledge of the patient, to make diagnoses, to determine dosages and
the best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the Editors assume any liability for
any injury and/or damage to persons or property arising out or related to any use of the
material contained in this book.
Library of Congress Cataloging-in-Publication Data
Reuter, Karen L.
Obstetric and gynecologic ultrasound / Karen L. Reuter, T. Kemi Babagbemi.—2nd ed.
p. cm -- (Case review series)
Rev. ed. of: Obstetric and gynecologic ultrasound / Pamela T. Johnson, Alfred B. Kurtz. c2001.
Includes bibliographical references and index.
ISBN 0-323-03976-6
1. Generative organs, Female—Ultrasonic imaging. 2. Fetus—Diseases—Diagnosis. I. Babagbemi,
T. Kemi. II. Johnson, Pamela T. (Pamela Teecc) Obstetric and gynecologic ultrasound. III. Title.
IV. Series.
RG107.5.U4J647 2007
618′.047543—dc22
2006044958
Acquisitions Editor: Meghan McAteer
Developmental Editor: Ryan Creed
Project Manager: Bryan Hayward
Printed in Hong Kong.
Last digit is the print number: 9 8 7 6 5 4 3 2 1
To the radiology residents and all those who
participate in the obstetrical and gynecological
care of women
SERIES FOREWORD
I have been very gratified by the popularity and positive feedback that the authors
of the Case Review Series have received upon the publication of the first editions
of their volumes. Reviews in journals and word of mouth have been uniformly
favorable. The authors have done an outstanding job in filling the niche of an afford-
able, easy-reading, case-based learning tool that supplements the material in THE
REQUISITES series.
It was recognized that while some students learn best in a noninteractive study-
book mode, others needed the anxiety or excitement of being quizzed, i.e., being
put on the hot seat. The format that was selected for the Case Review Series—
showing a limited number of images needed to construct a differential diagnosis and
asking a few clinical and imaging questions—was designed to simulate the Boards
experience (The only difference is that the Case Review books give you the correct
answer and immediate feedback.) Cases are scaled from relatively easy to very hard
to test the limit of the reader's knowledge. In addition, a brief authors’ commentary,
a link back to THE REQUISITES volume, and an up-to-date reference in the literature
are provided.
Because of the success of the series, we have begun to roll out the second
editions of the volumes. The expectation is that the second editions will bring the
material to the state-of-the-art, introduce new modalities and new techniques, and
provide new and even more graphic examples of pathology.
Drs. Reuter and Babagbemi have taken on the task of refreshing the Obstetric
and Gynecologic Ultrasound Case Review, previously authored by Drs. Johnson and
Kurtz. They have breathed new life into the edition and have used new cases that
teach the fundamental principles of this high risk area of the body. Radiologists
are on the hot seat when it comes to OB ultrasound and our tools have really pro-
gressed to the point of acquiring such fine anatomy that we may even be able to
tell the color of a fetus’ eyes in the not too distant future (just joking!). I commend
them for their attention to detail and hard work.
I welcome the Obstetric and Gynecologic Ultrasound Case Review by Drs. Reuter
and Babagbemi to the second edition series, which includes Genitourinary
Imaging second edition by Drs. Zagoria, Mayo-Smith, and Fielding and Head and
Neck Imaging second edition by David M. Yousem and Ana Carolina B. S. da Motta.
First edition volumes include Cardiac Imaging Case Review by Gautham Reddy
and Robert Steiner; Breast Imaging Case Review by Emily Conant and Peggy
Brennecke; Vascular and Interventional Imaging Case Review by Suresh
Vedantham and Jennifer Gould; Pediatric Imaging Case Review by Rob Ward and
Hans Blickman; Nuclear Medicine Case Review by Harvey A. Zeissman and Patrice
Rehm; General and Vascular Ultrasound Case Review by William D. Middleton;
Musculoskeletal Case Review by Joseph Yu; Obstetric and Gynecologic Ultrasound
Case Review by Pamela Johnson and Al Kurtz; Spine Imaging by Brian Bowen;
Thoracic Imaging by Phil Boiselle and Theresa McLoud; Genitourinary Imaging
by Ron Zagoria, William Mayo-Smith, and Glenn Tung; Gastrointestinal Imaging by
Peter Feczko and Robert Halpert; Brain Imaging by Laurie Loevner; and Head and
Neck Imaging by David M. Yousem.
David M. Yousem, MD, MBA
vii
PREFACE
This updated case review series focuses on ultrasound in obstetrics and gynecology,
with a few pertinent comparisons drawing on the role of 3D ultrasound, body
computed tomography and magnetic resonance imaging.
Our goals in making this case review more current were twofold. The first was
to replace images whenever possible with higher resolution ones from more recently
available equipment. We generally did not change the case material selected or
the specific teaching points emphasized by the original authors, Drs. Johnson and
Kurtz. Test questions related to the cases were modified as necessary. The second
goal was to update the literature and cross-references to the new edition of
THE REQUISITES on ultrasound.
Karen L. Reuter, MD, FACR
T. Kemi Babagbemi, MD
ix
ACKNOWLEDGMENTS
We thank all of those who contributed or assisted in obtaining cases, beginning
of course with profound thanks to Drs. Pamela T. Johnson and Alfred B. Kurtz
who wrote the original Obstetric and Gynecologic Ultrasound: Case Review. Much
appreciation to Dr. Carol Benson and Dr. Sara Durfee who provided many of the
obstetrical images and to Dr. Beryl Benacerraf, Dr. Mary Frates, Dr. Faye Laing,
Dr. Don DiSalvo, Dr. George Bega, Dr. Beverly Coleman, Mr. Dennis Woods,
Dr. Alda Cossi, and Dr. Cheryl Sadow, who contributed additional select images.
Much gratitude also goes to the Brigham and Women's Hospital sonographers,
specifically Linda Marquette, Jaclyn Sangco, Kris Ann Botka, Allison Forest,
Denie Bernier, Regina Viner, Youssef Mina, Julie Mombourquette, Cherise Petersen,
and Christine McDonald (Siemens) for their invaluable effort in acquiring top quality
images.
— K. L. R.
— T. K. B.
A special thank you to my husband, Dr. John Krolikowski, for his loving
encouragement and much appreciated technical expertise. — K. L. R.
A special thank you to Sal and Leo for their support, patience, and above all,
love. — T. K. B.
xi
Opening Round
1
C A S E 1
1. A 61-year-old woman on long-term treatment with tamoxifen for breast cancer presents with a
transvaginal sagittal image of the uterus (endometrial thickness of 18 mm). Is this considered normal?
2. What is the effect of tamoxifen on the uterus?
3. What spectrum of endometrial abnormalities does tamoxifen induce?
4. What is the cutoff measurement for abnormal endometrial thickness in a woman taking tamoxifen?
3
A N S W E R S
C A S E 1
Tamoxifen procedure is the most likely to reveal polyps, the most
1. No this is not considered normal; it is diffuse frequent abnormality in tamoxifen-treated women.
endometrial thickening, which may be benign. Furthermore, tamoxifen-related polyps tend to be larger
and have an increased rate of malignant changes com-
2. Estrogenic.
pared to endometrial polyps in the general population.
3. Endometrial hyperplasia, endometrial and endocer- A hyperechoic endometrium with small cystic spaces is
vical polyps, subendometrial cysts, and endometrial the classic finding with tamoxifen therapy (see figure).
cancer. Many of these cystic spaces represent endometrial
polyps; however, cystic hyperplasia may also have
4. The cutoff measurement is 8 mm or greater.
this appearance. Sonohysterograms, 2D or 3D, are often
helpful to elucidate the cause of endometrial stripe
References
thickening.
Cohen I: Endometrial pathologies associated with post-
One study demonstrated that most women on tamox-
menopausal tamoxifen treatment. Gynecol Oncol 96:
ifen do nothave symptoms such as bleeding. Nonetheless,
561, 2005.
almost half of these women had abnormal endometrial
Cohen I, Bernheim J, Azaria R, et al: Malignant thicknesses on ultrasound (defined as >8 mm). Although
endometrial polyps in postmenopausal breast
the risk may be increased as much as sixfold, fewer
cancer tamoxifen-treated patients. Gynecol Oncol
than 1% of the women taking tamoxifen therapy
75:136–141, 1999.
develop endometrial cancer. Most of these women have
DeKroon CD, Louwe LA, Trimbos JB, Jansen FW: The
been receiving the treatment for more than 5 years, and
clinical value of 3-dimensional saline infusion sonog-
most present with postmenopausal bleeding.
raphy in addition to 2-dimensional saline infusion
sonography in women with abnormal uterine bleeding.
Notes
J Ultrasound Med 23:1433–1440, 2004.
Hann LE, Kim CM, Gonen M, et al: Sonohysterography
compared with endometrial biopsy for evaluation
of the endometrium in tamoxifen-treated women.
J Ultrasound Med 22:1173–1179, 2003.
Hulka CA, Hall DA: Endometrial abnormalities associated
with tamoxifen therapy for breast cancer: Sonographic
and pathologic correlation. AJR 160:809–812, 1993.
Ramondetta LM, Sherwood JB, Dunton CJ, Palazzo JP:
Endometrial cancer in polyps associated with tamoxifen
use. Am J Obstet Gynecol 180:340–341, 1999.
Cross-Reference
Ultrasound: THE REQUISITES, 2nd ed, pp 542, 544, 546.
Comment
Tamoxifen is a widely used medication for patients with
breast cancer because of its antiestrogenic effect on breast
tissue. However, the medication can have an estrogenic
effect on the endometrium. Accordingly, these patients are
predisposed to develop a number of different endometrial
abnormalities, including polyps of the endometrium and
endocervix, subendometrial cysts, endometrial hyperpla-
sia, and cancer (endometrial, malignant mixed meso-
dermal tumors, and sarcoma). The risk of developing
one of these pathologic conditions relates to the duration
of tamoxifen therapy; the most common abnormality is
an endometrial polyp.
An endometrial thickness of 8 mm or greater warrants
follow-up. Sonohysterography is an excellent modality to
better delineate the endometrial contents. This imaging
4
C A S E 2
1. In this third-trimester fetus, what is the important finding on this coronal image of the fetal chest?
2. What are the potential complications of this finding?
3. Explain the spectrum of outcomes.
4. What is the treatment if this condition persists or recurs?
5