Pediatric Conditions & Considerations PDF

Pediatric Conditions & Considerations DMUT 2050 - Topic 15  Outline  Sonographic technique  Review normal anatomy  Ovarian abnormalities  Uterine & vaginal abnormalities  Infection  Sonographic Technique  Sonography is primary modality for...

Pediatric Conditions & Considerations DMUT 2050 - Topic 15  Outline  Sonographic technique  Review normal anatomy  Ovarian abnormalities  Uterine & vaginal abnormalities  Infection  Sonographic Technique  Sonography is primary modality for evaluating the pediatric pelvis  Transabdominal vs. transvaginal  TV if sexually-active, older teens  Often able to use higher frequency transducer (up to 9 MHz for TA)  Linear transducers  Bowel, peritoneum, superficial lesions  Patient prep  Well hydrated  Catheterized – may have to catheterize infants to get full-bladder  Pediatric Anatomy  Uterus  Newborn = 3.5 cm  Prepuberty = 2.5 – 3 cm.  Postpuberty = 5 – 8 cm.  Ovarian volumes  Newborn uterus is prominent,  Neonate – larger volume thickened with distinct  0-5 years old = < 1 mL endometrial lining – maternal hormonal stimulation.  6-8 years old = 1.2 mL  Prepuberty – endometrium if  9-10 years old = 2.1 mL seen will be pencil thin.  11 years old = 2.5 mL Tubular shape.  Menstrual = up to 9.8 mL  Postpuberty – endometrium goes through cyclic changes.  Pediatric Ovaries  Ovaries may not be visualized  Depends on location, size & age of patient  Ovaries located between lower pole of kidneys to true pelvis in neonates  Ovaries often appear heterogeneous  Small cysts  Ovaries have wide variation in location in neonates due to long pedicle and small pelvis. Ovarian Abnormalities  Ovarian Cysts  Ovarian cysts more common than previously thought  Type of cyst  In neonates, large cysts often  Follicular (3-20 cm) intra-abdominal in location  Corpus luteum  Associated with cystic  Hemorrhagic fibrosis and congenital  Parovarian cyst juvenile hypothyroidism  Rare  Abdominal ovarian cyst must be differentiated from  Can be seen prenatally mesenteric or omental cysts during 2nd and 3rd trimester  Ovarian Torsion  Can occur in normal  Symptoms ovaries but more likely in  Acute onset of lower ovaries with a mass abdominal pain  More common in children  Nausea  Relatively longer fallopian  Vomiting tubes  Leukocytosis  Ovaries more mobile  Sonographic Appearance  Acute Torsion  Ovarian enlargement  Fluid in the pelvis  Ovarian mass  Whirlpool sign  Doppler not always reliable  The demonstration of multiple follicles (8-12mm) in the peripheral portion of a unilaterally enlarged ovary (Push follicles to the periphery due to vascular congestion) Ovarian Torsion  Partial / Intermittent Torsion  Massive ovarian edema  Marked enlargement of ovary  Solid, hypoechoic mass  Enhanced through transmission  Enlargement due to compromised venous and lymphatic drainage.  Ovaries can be up to 35 cm  Refer to Chapter 54 Rumack  Ovarian Neoplasms  Account for 1% of childhood tumors  10-30% of all malignant tumors  Frequently occur around puberty  Commonly present with:  Abdominal pain  Palpable mass  May undergo torsion or hemorrhage  Ovarian Neoplasms  Ovarian neoplasms in the pediatric population:  Teratoma  Dysgerminoma  Most common malignant germ cell tumor  Cystadenoma/ cystadenocarcinoma  Granulosa theca cell tumor (precocious puberty)  Arrhenoblastoma (masculanizing effects)  In girls under 10, 84% of germ cell tumors are malignant.  Germ cell tumors account for 60% of ovarian neoplasms in children  75-95% of germ cell tumors in childhood are benign teratomas  Ovarian Neoplasms Benign Teratoma – 12 year old Stomal Cell Carcinoma  Leukemic Infiltration  Ovaries are often a site for acute leukemia  Ovarian involvement in up to 50% of cases  Large hypoechoic pelvic masses with smooth, lobulated margins  The tumor may infiltrate the pelvic organs so uterus and ovaries are not identified Pediatric Cancer Spread to Ovaries  Spread from  Neuroblastoma  Lymphoma  Colon carcinoma  Enlargement of one or both ovaries  Malignant tumors  Central, Low resistance Doppler flow  Benign tumors  Peripheral, High resistance Doppler flow  There are exceptions  Non-neoplastic or malignant lesions also have low resistance flow, such as tubo- ovarian abscess, corpus luteum, ectopic pregnancy etc. Uterine & Vaginal Abnormalities  Congenitial Abnormalities  Any congenital uterine abnormality in an adult can also be seen in the pediatric population  Bicornuate uterus most common  Hydrocolpos or hydrometrocolpos accounts for 15% of abdominal masses in newborn girls  Imperforate hymen  Transverse vaginal septum  Stenotic or atretic vagina  Mayer-Rokitansky-Kuster-Hauser Syndrome  2nd most common cause of primary amenorrhea  Consists of:  Vaginal atresia  Bicornate uterus (rudimentary)  Normal tubes and ovaries  Associated with renal & skeletal anomalies  Usually unilateral renal agenesis or ectopia  Rhabdomyosarcoma  Most common primary malignant tumor of uterus and vagina  Vagina a more common site than uterus arising close to the cervix  6-18 months of age most common  Present with vaginal bleeding  Arises from anterior wall of vagina  Tumor extension into bladder is common  Sonographic appearance:  Solid, homogeneous mass that fills vaginal cavity Rhabdomyosarcoma Other Considerations  Pregnancy  Diagnosis of pregnancy must be considered in children over age 9  Increased risk of pregnancy related complications  Toxemia  Preeclampsia  Placental abruption  Lacerations  C-section  Premature labor/ delivery and perinatal mortality are also higher in this group  Foreign Bodies  Cause 4% of cases of vaginitis  Most common foreign body:  Wad of toilet paper  Common cause of vaginal bleeding/discharge  Sonographic appearance:  Echogenic material with distal acoustic shadowing  May slightly indent posterior bladder wall  Foreign Bodies 7 year old girl with vaginal discharge  References  Rumack, C.M., Wilson, S.R., & Charboneau, M.D. (2016). Diagnostic Medical Ultrasound (5th Ed.). Toronto: Mosby, Inc.