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1、Ultrasonography on Gynecology and ObstetricsSangreal-uterusTHE DAWINCI CODE Pelvic CavitylPosterior:Occupied by rectum,colon,and ileumlAnterior:bladder,ureters,ovaries,fallopian tubes,uterus,and vaginaNORMAL ANATOMYPre-inspection:Moderate bladder filling UteruslHollow,pear-shaped organlDivided into
2、fundus,body,and cervixlUsually anteflexed and antevertedlCovered with peritoneum except anteriorly below the os where peritoneum is reflected onto bladderlSupported by levator ani muscles and pelvic fascialRound ligament keeps uterus in positionUterine sizelPrepubertal:3 cm long by 0.5 to 1.0 cm wid
3、elMenarcheal:8 cm long by 4 cm widelPostmenopausal:3.5 to 5.5 cm long by 1 to 2 cm wideNormal size:23(thick)45(width)78 cm(length)Uterine longitudinal diameter Uterine wide diameter Uterus before and after the Trail length 78cmbefore and after the Trail 23cmwidth 45cmUterine PositionlMidline antever
4、sion:most common;degree of anteversion is bladder distention dependentlRight or left:normal variant in absence of pelvic masseslRetroverted:entire organ displaced posteriorlylRetroflexed:body displaced with respect to cervixUltrasonography of normal uteruslUterine serosa layer:Linear high-echo;clear
5、,smooth;l Myometrium:Homogeneous middle-echo;lEndometria:The middle line of high echo,around the weak echo.It is well known that the endometrium changes dynamically in response to cyclic hormonal flux.Uterine serosa layer Myometrium Endometria Normal uterusNormal uterustransabdominal ultrasonography
6、transabdominal ultrasonographyTransvaginal sagittal view of the uterus.The Transvaginal sagittal view of the uterus.The rounded fundus is shown toward the left of the rounded fundus is shown toward the left of the image with the endometrial stripe rumming through image with the endometrial stripe ru
7、mming through the middle of the uterine cavity.the middle of the uterine cavity.MyometriumEndometriaUterine serosa layerFallopian Tube（输卵管）lInfundibulum:funnel-shaped lateral tube that projects beyond the broad ligament to overlie the ovarieslAmpulla:sidest part of the tube where fertilization occur
8、slIsthmus:hardest part;lies just lateral to the uteruslLength:12 cm;supplied by ovarion arteries and veinsOvary（卵 巢）l Almond shapedlAttached to back of the broad ligament by mesovarium;sometimes called suspensory ligament of the ovarylLies in ovarian fossalFossa is bounded by external iliac vessels,
9、ureter,and obturator nervelReceives blood from ovarian arterylBlood drained by ovarian vein into inferior vena cava on right;on left by ovarian vein into lert renal veinSonography of the normal ovarylAn ovoid homogeneous echodensity;follicular cysts are often present.lThe best sonographic marker for
10、 the ovary is identification of a follicular cyst,which has the classic appearance of being thin walled and anechoic with through-transmission posteriorly.Transabdominal sagittal image shows the Transabdominal sagittal image shows the left ovary posterior to the urinary bladderleft ovary posterior t
11、o the urinary bladderTransvaginal sagittal image of the ovaryTransvaginal sagittal image of the ovaryovarian follicleFollicular wall flowCommon Diseases of Obstetrics and GynecologyGynecology：Leiomyoma；Carcinoma;；Ovarian Tumors;Inflammatory mass;etc.Obstetrics：NaturalNatural pregnancy；Abnormal pregn
12、ancy;etc.The uterus Leiomyoma/HysteromyomaCharacteristics of LeiomyomaslMost common pelvic tumorlSmooth muscle cell compositionlFibrosis occurs after atrophic of degenerative changeslDegeneration occurs when fibroids outstrip their blood supply;calcificationlMay be pedunculatedlClinical:enlarged ute
13、rus,profuse and prolonged bleeding,painUterine Locations of leiomyomasSubmucosal Erode into endomertial cavity heavy bleeding;infertilityIntramuralMay enlarge to cause pressure on adjacent organs;infertilitySubserosalMay enlarge to cause pressure on adjacent organs Subserous myomaBroad ligamentmyoma
14、Cervical myomaintramurous myomaSubmucous myomaUltrasonic performancelTwo-dimensional：Increased uterine body or Form disorders；Spherical hypoechoic area in the uterine body，Rear echo attenuation；With calcification or Cystic change,etc；Signs of oppression；lColor Doppler：Tumor around with the blood flo
15、w signal in the shape of ring or semi-circular ring；lDoppler spectrum：Medium resistance index，RI 0.60.1。intramurous myomaSubserous myomaintramurous myomaSubserous myomaCervical myomaAbundant tumor blood flowAbundant tumor blood flowMUTUTRI 0.61Submucous myoma with calcificationTeratoma Dermoid Tummo
16、rs（卵巢良性囊性畸胎瘤/皮样囊肿)lPathology：derives from germ cell，the most common ovarian neoplasm,constituting 20%of ovarian tumors.up to 20%are bilateral.About 80%occur in women of childbearing age.lSize ranges from small to 40 cmlUnliateral,round to oval masslContains faty,sebaceous material,hair,cartilage,bon
17、e,teethlClinical:asymptomatic to abdominal pain,enlargement and pressure;pedunculated,subject to torsionlSonography:Cystic/complex/solid mass,echogenic components;acoustic shadowingSpecial Ultrasound Findings:1.A cystic mass:with an echogenic mural nodule2.A paste sign：particulate liptinite3.A fluff
18、 of hair sign4.A fat-fluid level sign：with fluid level in the cyst,fat above,fluid below.5.A complex masscystic teratoma cystic teratoma of ovaryof ovaryA cystic massPaste signFluff of hair signPaste signFat-fluid level signA complex massA 8 years old girl,cutting off a three kilograms benign terato
19、maThe role of Ultrasound in ObstetricsTRIMESTERSlFirst trimester =0 to 12 weeks of gestationlSecond trimester =13 to 26 weeks of gestationlThird trimester =27 to 42 weeks of getsationlPostterm pregnancy=42 weeks of gestationIndications for First-Trimester SonographylConfirm presence of intrauterine
20、pregnancylEvaluate for suspected ectopic pregnancylDefine cause of vaginal bleedinglDetermine gestational agelConfirm suspected multiple gestationslAid in invasive procedureslEvaluate pelvic masseslDetect uterine abnormalitiesNatural pregnancyNatural pregnancyNonage pregnancy(First-Trimester)Definit
21、ion：Pregnancy before 12 weekend.5 weeks pregnant Gestational sac；6-7 weeks pregnant Germ;7-8 Weeks Primitive heart tube pulse；8-11 weeks Yolk sac;9 weeks Embryonic,placenta.The Normal First TrimesterSonographic Features of a Normal Gestational SaclShape:round of ovallPosition:fundal or middle portio
22、n of uterus;a center position relative to endometriumlContour:smoothlWall:echogenic;3 mm of more in thicknesslInternal landmarks:yalk sac present when gestational sac is larger than 10 mm;embryo present when gestational sac is larger than 18 mmlGrowth:1 mm per day(range:0.7 mm to 1.5 mm per day)4-5
23、weeks pregnant4-5 weeks pregnant In the g In the gestational sac we can see a estational sac we can see a embryo point,the earliest embryo.embryo point,the earliest embryo.7 weeks pregnant7 weeks pregnant Fetus was about 4 mmFetus was about 4 mm，we can see we can see apparent heart throb,and sappare
24、nt heart throb,and small limb bud.mall limb bud.8 weeks pregnant8 weeks pregnant Three-dimensional ultrasound show its beginning Three-dimensional ultrasound show its beginning of the shape of a humanof the shape of a human.Umbilical bordEmbryonic headEmbryonic abdomenYolk sacEmbronic headAmniotic s
25、ac9 weeks pregnant9 weeks pregnant Known as a fetalKnown as a fetal，Development of the Development of the various parts of the fetus,tends to improvevarious parts of the fetus,tends to improve.12 weeks pregnant12 weeks pregnantThe spine is identifiable,as the two bead-like high The spine is identifi
26、able,as the two bead-like high echo.Ears,limbs,bones can be shown and echo.Ears,limbs,bones can be shown and measurement.measurement.Ultrasound of the Second and Third TrimestersIndications for Second-and Third-Trimesterl Estimate gestational age for patients with uncertain dateslEvaluate uterine si
27、ze and clinical date discrepancieslEvaluate fetal growthlEstimate fetal weightlDetermine fetal presentationlEvaluate fetal lifel provide adjunct to amniocentesis,percutaneous umbilical blood sampling procedure,or cerclage placementlEvaluate uterine abnormalitylEvaluate abnoumal maternal serum alpha-
28、fetoprotein valueslEvaluate abnormal amniotic fluidlEvaluate placenta Etc.The Second-and Third-Trimester(Metaphase and terminal prengancy)Metaphase and terminal prengancy)Mid-Mid-pregnancy:pregnancy:13-27 13-27 weeks pregnancy.weeks pregnancy.Late-Late-pregnancy:pregnancy:More More than 28 weeks of
29、than 28 weeks of pregnancypregnancy.Scanning TechniqueslSurvey uterus lObserve cardiac activitylDetermine position and number of the fetus and placentalAssess amniotic fluidlLook for uterine of placental masses and fetal anomaliesCheck contentsl1、Fetal head：BPD biparietal diameter;l2、Fetal abdomen:A
30、C abdomen circumference;l3、Fetal limb：FL femur length;l4、Others：Placenta,Fetal heart rate,Amniotic fluid,etc.1、Fetal headMeasuring the Biparietal Diameter(BPD)lObitain biparietal diameter of the fetal head at the transverse level of the midbrain:falx,cavum septi pellucidi,and thalamic nucleilMake su
31、re the head is symmetric and ovallMeasure from outer to inner margins of the skulllIn the third trimester,the BPD is not as accurate in predicting fetal age Fetal head,after 12 weekend Fetal head,after 12 weekend pregnantpregnant Fetal side profile,we Fetal side profile,we can observe its forehead,c
32、an observe its forehead,nose,lip,and chin,etc.nose,lip,and chin,etc.2、Fetal abdomenlThe hepatobiliary system:liver,port venous systerm,hepatic veins and arteries,gallbladder,and bile ductslThe gastrointestinal system:the esophagus,stomach,small and large intestines(colon)lThe urinary system:kidneys,
33、adrenal glands,ureters,bladder.The fetal abdomen circumference（AC)is the most widely measured Measuring the Abdominal Circumference(AC)lThe AC should be taken from a round transverse image with the umbilical portion of the left portal vein midline within the liverlThe outer margin of the abdominal w
34、all should be measuredlThe abdominal wall measurement is the least accurateThe fetal liverThe fetal livergallbladderstomachport venousspinegallbladderstomach3、Fetal limbslThe upper limbs:the ulna the radius the humeruslThe lower limbs:the femur/the thigh bone the fibula the tibia lThe femur is the m
35、ost widely measured long bone（FL femur length ）Femur measurementlHyperechonic linear structure represents the ossified portion of the femoual diaphysis and corresponds to femoral length measurement from the greater trochanter to the femoral condyleslThe mormal femur has a straight laeral border and
36、a curved medial borderlFemur length may be used with the same accuracy as BPD to predict gestational agelFemur length may indicate skeletal dysplasias or intrauterine growth restrictionLong section of the upper limbsThe radiusThe ulnaThe humerus Femur/thigh boneFibula/perone Tibia/shin bone Long sec
37、tion of the lower limbs 4、The placenta（胎盘）lThe major fole of the placenta is to permit the exchange of oxygenated maternal blood(rich in oxgen and nutrients)with deoxygenated fetal blood.lThe thickness of the placenta varies with gestational age,with a minimum diameter of 15 mm in fetuses greater th
38、an 23 weeks.The size of the placenta rarely exceeds 50 mm in the normal fetus.Anterior placenta at 21 weeks of gastationThe placentaUmbilical bordAmniotic fluidThe fetal posterior placenta at 29 weeks of gestationcalcification Anterior placenta at 39 weeks of gastationAnterior placenta at 39 weeks of gastationCalm little faceCalm little faceEating toe Eating toe Eating fingersEating fingersCryingCryingPouttingPouttingFetal with umbilical Fetal with umbilical cord around the neckcord around the neckFetal with cleft lipFetal with cleft lipsmailingsmailing