Doppler Ultrasound in Gynecology and Obstetrics

Bearbeitet vonPeter M. Baier, Holger Frey, Christof Sohn, Klaus Vetter, Hans-Joachim Voigt

1. Auflage 2003. Buch. 232 S.ISBN 978 3 13 135591 1

Format (B x L): 19,5 x 27 cm

Weitere Fachgebiete > Medizin > Sonstige Medizinische Fachgebiete > Radiologie,Bildgebende Verfahren

Zu Leseprobe

schnell und portofrei erhältlich bei

Die Online-Fachbuchhandlung beck-shop.de ist spezialisiert auf Fachbücher, insbesondere Recht, Steuern und Wirtschaft.Im Sortiment finden Sie alle Medien (Bücher, Zeitschriften, CDs, eBooks, etc.) aller Verlage. Ergänzt wird das Programmdurch Services wie Neuerscheinungsdienst oder Zusammenstellungen von Büchern zu Sonderpreisen. Der Shop führt mehr

als 8 Millionen Produkte.

VII

Contents

Basic Concepts

1 Physical and Technical Fundamentals of Ultrasound and Doppler UltrasoundH. Frey

History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Oscillation, Sound Wave . . . . . . . . . . . . . . . . . . . . . . 3

The Generation of Ultrasound . . . . . . . . . . . . . . . . 4

Physical Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Reflection and Refraction . . . . . . . . . . . . . . . . . . . . . . 5Scattering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Interference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Diffraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Absorption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Generating the Image . . . . . . . . . . . . . . . . . . . . . . . . 7Pulse-Echo Procedure . . . . . . . . . . . . . . . . . . . . . . . . . 7Time Gain Compensation . . . . . . . . . . . . . . . . . . . . . . 7A-Mode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7B-Mode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8M-Mode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

The Sound Field . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Resolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Focusing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Scanning Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 10Principle of Operation . . . . . . . . . . . . . . . . . . . . . . . . . 10Linear Array Scanner . . . . . . . . . . . . . . . . . . . . . . . . . . 11Curved or Convex Array Scanner . . . . . . . . . . . . . . . 11Sector Scanner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Phased Array Scanner . . . . . . . . . . . . . . . . . . . . . . . . . 11Mechanical Sector Scanners . . . . . . . . . . . . . . . . . . . . 12

Rotary Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Wobbler Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Annular Phased Array Transducer . . . . . . . . . . . . 13

Ultrasound Artifacts . . . . . . . . . . . . . . . . . . . . . . . . . . 13Distal Acoustic Shadowing . . . . . . . . . . . . . . . . . . . . . 13Dorsal Sound Amplification . . . . . . . . . . . . . . . . . . . . 13

Disadvantages of Mechanical Scanners . . . . . . . 13Margin Shadow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Side Lobe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Slice Thickness Artifact . . . . . . . . . . . . . . . . . . . . . . . . 14Repetition Artifact . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Doppler Sonography . . . . . . . . . . . . . . . . . . . . . . . . . . 15Fundamentals of Doppler Sonography . . . . . . . . . 15

Geometrical Distortion . . . . . . . . . . . . . . . . . . . . . . . . 15Continuous Wave Doppler Systems . . . . . . . . . . . . 17Pulsed Wave Doppler systems . . . . . . . . . . . . . . . . . 17Alias Phenomenon in Pulsed Doppler . . . . . . . . . . . 18Baseline Shift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Wall Filter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Color-Coded Doppler Sonography . . . . . . . . . . . . . . 19Amplitude-Coded Flow Display . . . . . . . . . . . . . . . . 19

Safety Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Thermal Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Mechanical Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Important Definitions . . . . . . . . . . . . . . . . . . . . . . . . . 21

Acoustic Output . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Acoustic Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Intensity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Intensity Special Peak Time Average . . . . . . . . . 21

Risks of Individual Ultrasound Procedures . . . . . 21B-Mode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21M-Mode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21CW Doppler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21PW Doppler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Color-Coded Doppler Sonography . . . . . . . . . . . . 21

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Important Instrument Settings . . . . . . . . . . . . . . . 22Selecting the Most Suitable Transducer . . . . . . . . . 22B-Mode Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Depth of Penetration . . . . . . . . . . . . . . . . . . . . . . . 22Gain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Focusing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Setting the Doppler Parameters . . . . . . . . . . . . . . . . 22Sample Volume . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22PRF and Baseline Shift . . . . . . . . . . . . . . . . . . . . . . . 22Scaling the Time Axis . . . . . . . . . . . . . . . . . . . . . . . 22Wall Filter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Orientation of the Tracings of Spectra . . . . . . . . 22

Color-Coded Doppler . . . . . . . . . . . . . . . . . . . . . . . . . . 23Size of the Color Window . . . . . . . . . . . . . . . . . . . . 23PRF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Color Gain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

VIII

4 Blood Flow Analysis During PregnancyK. Vetter, M. Gonser

Uteroplacental Vessels . . . . . . . . . . . . . . . . . . . . . . . . 53Reference Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Physiological Flow Changes . . . . . . . . . . . . . . . . . . 54

Fetoplacental Vessels . . . . . . . . . . . . . . . . . . . . . . . . . 55Umbilical Vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Reference Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Abnormal Flow Changes . . . . . . . . . . . . . . . . . . . . . 55Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Physiological Flow Changes . . . . . . . . . . . . . . . . . . 56Pathological Flow Changes . . . . . . . . . . . . . . . . . . . 56Morphological Changes . . . . . . . . . . . . . . . . . . . . . . 56

Umbilical Vein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58Reference Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58Physiological and PathologicalFlow Alterations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Fetal Vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59Aorta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Evaluation Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . 59Reference Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59Physiological Flow Changes . . . . . . . . . . . . . . . . . . 60

2 Indices for the Evaluation of Doppler SonogramsK. Vetter, M. Gonser, H.-J. Voigt

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Quantitative Measurements . . . . . . . . . . . . . . . . . . . . 25Qualitative Measurements . . . . . . . . . . . . . . . . . . . . . 25Angle Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Wall Filter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Indices Used to Evaluate Two-DimensionalDoppler Sonograms . . . . . . . . . . . . . . . . . . . . . . . . . . 26Indices of Velocity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Indices of Acceleration . . . . . . . . . . . . . . . . . . . . . . . . 28Path Length Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Temporal Indices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Relative Flow Index . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Optical Classification . . . . . . . . . . . . . . . . . . . . . . . . . 32

Clinical Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Reference Curves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Index Quotients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Suggestions for Obstetric Practice . . . . . . . . . . . . . . 39

3 Vascular Supply of the Uteroplacentofetal Unit and Techniquesfor the Examination of Individual VesselsC. Sohn

Vascular Supply of the UteroplacentofetalUnit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Uteroplacental Blood Supply . . . . . . . . . . . . . . . . . . . 41Fetoplacental Blood Supply . . . . . . . . . . . . . . . . . . . . 42Fetal Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Methods of Examining Specific Vessels . . . . . . . 44Displaying the Maternal Vessels . . . . . . . . . . . . . . . . 44

Examining the Uterine Arteries in theSecond Trimester . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Examining the Uterine Arteries in theThird Trimester . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Displaying the Peripheral Fetal Vessels . . . . . . . . . 47Examining the Umbilical Artery . . . . . . . . . . . . . . 47Examining the Aorta in the Secondand Third Trimesters . . . . . . . . . . . . . . . . . . . . . . . . 48

Examining the Central Fetal Vessels . . . . . . . . . . . . 50Examining the MCA . . . . . . . . . . . . . . . . . . . . . . . . . 50Examining the Carotid Artery . . . . . . . . . . . . . . . . 51

Arteries Supplying the Brain . . . . . . . . . . . . . . . . . . . 60Reference Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Physiological Flow Changes . . . . . . . . . . . . . . . . . . 61

Renal Arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Evaluation Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . 62Reference Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Ductus Arteriosus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Inferior Vena Cava . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Evaluation Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . 62Reference Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Physiological Flow Changes . . . . . . . . . . . . . . . . . . 62Pathological Flow Changes . . . . . . . . . . . . . . . . . . . 62

Ductus Venosus Arantii . . . . . . . . . . . . . . . . . . . . . . . . 62Hepatic Veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Effect of Therapeutic Measures . . . . . . . . . . . . . . . 63Prostaglandins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Antihypertensives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

�-blockers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64Calcium Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . 64

Epidural Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Contents

IX

5 DocumentationC. Sohn

Sample Documentation Records . . . . . . . . . . . . . . 66

6 Common Errors in the Doppler Ultrasound Display of Uterine Blood Flowand Fetal VesselsF. Geka, C. Sohn

Correct Display of Vessels with NormalInstrument Settings . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Role of the Angle in the Doppler Examination . 69

Possible Sources of Error in DopplerUltrasound Examinations of Maternaland Fetal Vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71Displaying the Uterine Artery . . . . . . . . . . . . . . . . . . 71Displaying the Umbilical Artery . . . . . . . . . . . . . . . . 73Displaying the Fetal Aorta . . . . . . . . . . . . . . . . . . . . . 74Displaying the Middle Cerebral Artery . . . . . . . . . . 76

Complete Series of Doppler UltrasoundExaminations, Including Displays of MaternalUterine and Fetal Peripheral and CentralVessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Basic Concepts: References . . . . . . . . . . . . . . . . . . . 80Physical and Technical Fundamentalsof Ultrasound and Doppler Ultrasound . . . . . . . 80Indices for the Evaluation of DopplerSonograms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80Blood Flow Analysis During Pregnancy . . . . . . . 80

Obstetric Applications of Doppler Ultrasound

7 The Role of Doppler Ultrasound in the Diagnosis of Ectopic PregnancyH.-J. Voigt

The Significance of Transvaginal Sonographyand Serum hCG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Characteristic Sonographic Findings inEctopic Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . 85

Transvaginal Color Doppler Ultrasound . . . . . . . 86Diagnostic Validity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86Effectiveness of the Procedure . . . . . . . . . . . . . . . . . 86Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87Critical Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

8 Indications for Obstetric UltrasoundC. Sohn

IUGR and Biological Measurement . . . . . . . . . . . . 92Basic Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92Some Specific Measurements . . . . . . . . . . . . . . . . . . 92

Skull . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92Extremities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93Cerebellum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

Procedure when Biological Measurements areAbnormal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93Growth Restriction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Suspected IUGR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

PIH/Preeclampsia/Eclampsia . . . . . . . . . . . . . . . . . . 96

Status Post Dysmature Delivery/IntrauterineDeath . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

Status Post Preeclampsia/Eclampsia . . . . . . . . . . 97

Abnormalities in the Recorded Fetal HeartRate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Contents

X

Reasonable Suspicion of Fetal Anomalies orFetal Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Multiple Pregnancy with Discordant Growth . . 97

Suspicion of Cardiac Anomaly orHeart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

Other Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

SummaryIndications for Doppler Ultrasound in theFirst, Second, and Third Trimesters . . . . . . . . . . . 98

First Trimester . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98Second Trimester . . . . . . . . . . . . . . . . . . . . . . . . . . . 98Third Trimester . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

9 Doppler Sonography in Obstetrics—Screening At-Risk PopulationsH.-J. Voigt

Validity of a Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

Validation of Indices . . . . . . . . . . . . . . . . . . . . . . . . . 100

Screening Population . . . . . . . . . . . . . . . . . . . . . . . . . 101

Screening in Cases of Suspected Uteroplacen-tal Perfusion Disorders and/or Pregnancy-Induced Hypertension . . . . . . . . . . . . . . . . . . . . . . . . 101

Screening for Suspected FetoplacentalPerfusion Disorders and/or IUGR . . . . . . . . . . . . . 102

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

10 Doppler Ultrasound Diagnosis in Preeclampsia, Eclampsia,and HELLP SyndromeC. Sohn

Pathological Changes in Preeclampsia . . . . . . . . 103

Evaluating the Risk of Preeclampsia in theFirst and Second Trimesters—Examining theUteroplacental Arteries . . . . . . . . . . . . . . . . . . . . . . . 105Doppler Ultrasound Findings . . . . . . . . . . . . . . . . . . . 105

Confirming a Diagnosis of Preeclampsia in theSecond Half of Pregnancy—DemonstratingCharacteristic Doppler Sonographic Changesof Preeclampsia in the Uteroplacental Vessels . 106

Evidence for or Exclusion of Fetal Risk—Eval-uating the Fetal or Fetoplacental Vessels . . . . . . 106Doppler Sonographic Findings . . . . . . . . . . . . . . . . . 106Doppler Sonographic Findings . . . . . . . . . . . . . . . . . 106Redistribution of Blood (Brain Sparing) . . . . . . . . . 107

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

11 Doppler Ultrasound in the Diagnosis of Fetal AnomaliesK. Vetter, Ö. Kilavuz, H.-J. Voigt

Anomalies in the Region of the Head andNeck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

Anomalies of the Lung and Diaphragm . . . . . . . 113

Fetal Cardiac Malformations . . . . . . . . . . . . . . . . . . 114

Malformations of the Gastrointestinal Tractand the Abdominal Wall . . . . . . . . . . . . . . . . . . . . . . 114

Anomalies of the Urogenital System . . . . . . . . . . 116

Coccygeal Teratomata . . . . . . . . . . . . . . . . . . . . . . . . 118

Contents

Placenta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Hydrops Fetalis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Anhydramnios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Malformations of the Umbilical Cord . . . . . . . . . 119

Doppler Ultrasound Diagnosis ofMalformations in Early Pregnancy . . . . . . . . . . . . 121

XI

12 Multiple Pregnancy and Doppler UltrasoundC. Sohn, A. Scharf

Studies Using Doppler Ultrasoundfor Multiple Pregnancies . . . . . . . . . . . . . . . . . . . . . 124Theoretical Considerations Related to the AboveStudies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

Special Considerations for the Use of DopplerUltrasound in Twin Pregnancies . . . . . . . . . . . . . 126Acardius Acranius, TRAP . . . . . . . . . . . . . . . . . . . . . . . 126Crossed Cord Around the Neck . . . . . . . . . . . . . . . . . 126

Velamentous Insertion and Vasa Previa . . . . . . . . . 126Monochorionic Multiple Fetuses withCirculatory Communication Disorders . . . . . . . . . 127Twin-to-Twin (Feto−Fetal) TransfusionSyndrome (TTTS, FFTS) . . . . . . . . . . . . . . . . . . . . . . . . 127Hydramnios-Oligohydramnios . . . . . . . . . . . . . . . . . 127

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128

13 Possible Applications of Doppler Ultrasound in Fetal AnemiaK. Vetter, Ö. Kilavuz

Noninvasive Procedures for Suspected FetalAnemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

Ultrasonic Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129Doppler Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . 130

14 Umbilical Cord Complications and Doppler UltrasoundK. Vetter, Ö. Kilavuz

Doppler Ultrasound Findings when UmbilicalCord Complications Affect Hemodynamics . . . . 133

Obstetric Applications of Doppler Ultrasound:References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

Diagnostic Doppler Ultrasound inPreeclampsia, Eclampsia, and HELLPSyndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135Multiple Pregnancy and Doppler Ultrasound . . 135

Advanced Topics in Obstetrics and Gynecological Doppler Ultrasound

15 Doppler Ultrasound and the CardiotocogramH.-J. Voigt

Comparing Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139Comparing Tests to Predict Neonatal Asphyxia . . 139Comparing Tests to Predict Neonatal Acidosis . . . 140

Information Lead Time Using DopplerUltrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140

Clinical Significance of Doppler Ultrasound . . . 141

16 Doppler Ultrasound Findings Near TermK. Vetter

Physiological Findings in the Late Stages ofPregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143Aorta: Quantitative Analysis . . . . . . . . . . . . . . . . . . . 143Aorta: Qualitative Analysis . . . . . . . . . . . . . . . . . . . . . 144Cerebral Arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144

Common Carotid Artery . . . . . . . . . . . . . . . . . . . . . 144Middle Cerebral Artery . . . . . . . . . . . . . . . . . . . . . . 144

Renal Arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

Contents

XII

Changes at Term and Postterm . . . . . . . . . . . . . . . 145Femoral Arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145The “Term Effect” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146The Circulatory Balance . . . . . . . . . . . . . . . . . . . . . . . . 146

Clinical Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . 147

Doppler Ultrasound during Labor? . . . . . . . . . . . 148

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

17 Diagnostic and Clinical Significance of Doppler Ultrasound in ObstetricsM. Gonser, K. Vetter

Studies of Diagnostic Significance . . . . . . . . . . . . 151Uteroplacental Arteries . . . . . . . . . . . . . . . . . . . . . . . . 152Umbilical Arteries and Other Fetal Vessels . . . . . . 152

Umbilical Arteries and Fetal Aorta . . . . . . . . . . . . 152The Umbilical Vein in Arterial Diastolic Blockor Reverse Flow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152Cerebral Arteries and Redistribution ofthe Circulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

Studies of Clinical Significance . . . . . . . . . . . . . . . 153Uteroplacental Arteries . . . . . . . . . . . . . . . . . . . . . . . . 154

Umbilical Arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154Analysis of Individual Clinical DopplerStudies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154Cumulative Metaanalysis . . . . . . . . . . . . . . . . . . . . 155

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156Diastolic Reverse Flow . . . . . . . . . . . . . . . . . . . . . . . 156Multiple Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . 156

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158

18 Doppler Sonography of the Fetal Venous CirculationC. Hofstaetter

Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160The Left Path from the Ductus Venosusto the Foramen Ovale . . . . . . . . . . . . . . . . . . . . . . . 160The Right Path from the Inferior Vena Cavato the Right Atrium . . . . . . . . . . . . . . . . . . . . . . . . . 160

Ultrasound Display and Doppler Sonographyof the Venous System . . . . . . . . . . . . . . . . . . . . . . . . 161

Results of the Doppler Studies . . . . . . . . . . . . . . . . 162

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

19 Seven Cases Illustrating the Use of Doppler Ultrasound in ObstetricsK. Vetter, H.-J. Voigt

1—Fetal Growth Restriction . . . . . . . . . . . . . . . . . . 167

2—Extreme Fetal Growth Restriction Due toEndarteritis Obliterans . . . . . . . . . . . . . . . . . . . . 168

3—Exclusion of Potter Syndrome . . . . . . . . . . . . . 169

4—Closely Coordinated Preventive Care forHigh-Risk Patients . . . . . . . . . . . . . . . . . . . . . . . . 171

5—Patient with Antiphospholipid-AntibodySyndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172

6—Marked Fetal Growth Restriction . . . . . . . . . . 177

7—Twin Pregnancy with Twin-to-TwinTransfusion Syndrome . . . . . . . . . . . . . . . . . . . . 178

20 Doppler Ultrasound in GynecologyP.M. Baier

Tumor Angiogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . 184Essential Considerations for Clinical Practice . . 185

Examination Procedure and Instrumentationfor Ultrasound Diagnosis of the Pelvis . . . . . . . . 185

Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186

Ovarian Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187Conventional Ultrasound Examination of theOvary: Procedure and Results . . . . . . . . . . . . . . . . . . 187Normal Findings in the Doppler Ultrasound Ex-amination of the Ovaries . . . . . . . . . . . . . . . . . . . . . . 188

Contents

XIII

Significance of Color-Coded Doppler Ultra-sound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188

Doppler Ultrasound and Myomas . . . . . . . . . . . . 190Essential Considerations for Clinical Practice . . 190

Endometrial Diagnosis . . . . . . . . . . . . . . . . . . . . . . . 191Essential Considerations for Clinical Practice . . 191Essential Considerations for Clinical Practice . . 195

21 Diagnosis of the Uterine Tube by Transvaginal SonographyF. Geka

Application of Ultrasound in Diagnosis of theUterine Tube . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197Display of the Tube by Contrast Sonography . . . . 197

Comparison to Other Procedures . . . . . . . . . . . . . 198Supplementation by Doppler . . . . . . . . . . . . . . . . . . 198

22 Diagnostic Sonography of Blood Flow in Breast TumorsA. Baudendistel

Biological Background . . . . . . . . . . . . . . . . . . . . . . . . 201

Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201Continuous Wave Doppler . . . . . . . . . . . . . . . . . . . . . 201Pulsed Wave Doppler . . . . . . . . . . . . . . . . . . . . . . . . . . 202Color-Coded PW Doppler . . . . . . . . . . . . . . . . . . . . . . 202Angio Color, Angio Mode, Power Doppler . . . . . . . 203Introduction of Ultrasound Contrast Media . . . . . 204

Color-Coded Doppler Ultrasound in theDifferential Diagnosis of Breast Tumors . . . . . . 205

Advanced Topics in Obstetrics and Gyneco-logical Doppler Ultrasound: References . . . . . . . 207

Doppler Ultrasound and the Cardiotocogram . 207Doppler Ultrasound Findings Near Term . . . . . . 207Diagnostic and Clinical Significance ofDoppler Ultrasound in Obstetrics . . . . . . . . . . . . 208Doppler Ultrasound of the FetalVenous Circulation . . . . . . . . . . . . . . . . . . . . . . . . . . 210Doppler Ultrasound in Gynecology . . . . . . . . . . . 210Diagnosis of the Uterine Tube byTransvaginal Ultrasound . . . . . . . . . . . . . . . . . . . . . 211Diagnostic Ultrasound of Blood Flow inBreast Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212

Index 213

Contents

XIV

Abbreviations

a. arteryAA constant flow ratioaa. arteriesA/B ratio ratio of systolic peak to end-diastoleAD abdominal diameterAFI amniotic fluid indexAIUM American Institute of Ultrasound in

MedicineALARA as low as reasonably achievableAO aortaARED absent or reversed diastolic flowARS average rising slopeASA acetylsalicylic acidAUC area under the curveAV atrioventricularB/A ratio ratio of end-diastole to systolic peakBE base excessBFC blood flow classificationBGA blood gas analysisBI balance indexBP blood pressureBPD biparietal diameterCFM color flow mappingCG center of gravityCI confidence indexCL center of gravity lineCLASP Collaborative Low-dose Aspirin Study

in PregnancyCT computed tomographyCTG cardiotocogramCW Doppler continuous wave DopplerDGC depth gain compensationDI diastolic indexDS descending slopeDTVI diastolic time velocity integralDV ductus venosusE/A ratio ratio of Vmax early diastole to Vmax arte-

rial contractionEDRF endothelium-derived relaxing factorEFSUMB European Federation of Societies in

Ultrasound in Medicine and BiologyEPH edema, proteinuria, hypertensionES end-systolicFFT fast Fourier transformFFTS feto-fetal transfusion syndromeFIP frequency index profileFL femur lengthFmax (T) maximal Doppler shift frequency at

end of cardiac cycle

Fmax (TA) temporal average of the maximalfrequencies

Fmax (TM) maximal Doppler shift frequency atthe temporal minimum

Fmax (TP) maximal Doppler shift frequency atthe temporal peak

FP false positivesFSBA fetal scalp blood analysisGnRH gonadotropin-releasing hormoneHC head circumferencehCG human chorionic gonadotropinHELLP hemolysis, elevated liver enzymes, and

low platelet countHWI height width indexHPF high pass filterICA internal carotid arteriesICP intracranial pressureImI impedance indexISPTA intensity special peak time averageIUD intrauterine deviceIUGR intrauterine growth restriction (or re-

tardation)IVC inferior vena cavaLHV left hepatic veinLMP last menstrual periodMCA middle cerebral arteryMHV middle hepatic veinMIT mean inflow timeMRI magnetic resonance imagingMRT mean residence timeMVmax peak systolic velocityNO nitrogen monoxideNST nonstress testOCT oxytocin challenge testOFD occipitofrontal diameterOR odds ratioPCR placental-cerebral ratioPI pulsatility indexPIH pregnancy-induced hypertensionPIV pulsatility index for veinsPVIV peak velocity index for veinsPLI path length indexPP perfusion pressurePRF pulse repetition frequencyPRF percentage reverse flowPV portal veinPW Doppler pulsed wave DopplerR relative flow rate indexR reflection gradient

XV

RAT relative acceleration timeRHV right hepatic veinRI resistance indexrMIT relative mean inflow timerMRT relative mean residence timeRF reverse flowRo relative flow indexROC relative (receiver) operating charac-

teristicROI region of interestRR relative riskRS rising slopeRSA relative spectral areaS/D ratio see A/B ratioSBI spectrum broadening indexSBR spectrum broadening ratioSDTI systolic decay indexsens. sensitivityspec. specificitySTVI systolic time velocity integralSVES supraventricular extrasystoleSVT supraventricular tachycardia

TA temporal averageTAM time average maximum velocityTAMV time average maximum velocityTAMX time average maximum velocityTASAV temporal average of spatial average

velocityTAV time average velocityTC thoracic circumferenceTGC time gain compensationTD thoracic diameterTM temporal minimumTP temporal peakTP true positivesTRAP twin reversed arterial profusionTTTS twin-to-twin transfusion syndrometwPI time weighted pulsatility indexUA umbilical arteryut uteroplacental arteriesUV umbilical veinv. veinv.'s veinsVES ventricular extrasystoles

Abbreviations