OBGYN NOTES_ EXAM ONE.pdf

OBGYN EXAM ONE Powerpoint One: Pelvic Anatomy Pelvic Anatomy - Uterus - Three Tissue Layers Serosa (Perimetrium) - outermost Myometrium - middle layer (muscle) Endometrium - innermost functional layer - Internal & External Os of Cervix Internal Os: opening in cervix that...

OBGYN EXAM ONE Powerpoint One: Pelvic Anatomy Pelvic Anatomy - Uterus - Three Tissue Layers Serosa (Perimetrium) - outermost Myometrium - middle layer (muscle) Endometrium - innermost functional layer - Internal & External Os of Cervix Internal Os: opening in cervix that leads to the uterine cavity External Os: opening between cervix & vagina - Shape & Size (varies w/ age & obstetric history (hx) ) Prior to Menarche (has never had a menstrual cycle): cylindrical & narrow Prepuberal: cervix longer than the body/fundus Mature uterus: corpus & fundus enlarge After menopause: regresses in size (due to no estrogen being produced) Nulliparous female (never given birth vaginally) ↓ SAG: less than or equal to 8 cm TRV: up to 5 cm  AP = 3 cm 3+5=8 - Variants in Uterine Position Anteflexed & Antervered: most common Anteverted: normal; uterine body tilts forward, forms 90 degrees angle or less within cervix  Anteflexed: uterine corpus tilts forward & comes in contact with cervix forming acute angle between body & cervix Retroverted: corpus, fundus & cervix displaced posteriorly; most common type of displacement Retroflexed: only fundus is displaced posteriorly Dextroposed: uterine body angled to the right of the cervix - US Appearance of Uterus Uterus Myometrium: mid gray or medium level echoes, homogeneous, smooth contour Cervix of Uterus appears as a donut in TRV Endometrial Cavity: thin echogenic line, varies in thickness in relation to menstrual phase (if they are on their period, or just had it, no line will be seen; fluid can be normal) Vagina: mid gray to medium level echoes, vaginal canal is hyperechoic line - Have patient drink 32 oz of water an hour before prior to exam - Fallopian Tube (four parts) Interstitial: narrowest part, nearest cornu Isthmus: slightly wavy & longer Ampulla: tortuous & longest part (most common place for an ectopic pregnancy to occur) Infundibulum: lateral, trumpet shaped fimbriae; widest - Adjacent Spaces Anterior Cul de Sac (vesicouterine pouch): reflection of peritoneum over anterior surface of uterus & bladder Posterior Cul de Sac (rectouterine pouch, pouch of douglas): reflection of peritoneum over posterior surface of uterus & rectum Space of Retzius (prevesical or retropubic): area lying between bladder & symphysis pubis - Ligaments Cardinal Ligament: anchor uterine corpus (body) & cervix to lateral pelvic wall (contains uterine artery & vein) Uterosacral Ligament: anchor uterine cervix to sacrum Round Ligament: anchor uterine fundus anteriorly Broad Ligament: part of peritoneum that divides true pelvis into anterior & posterior portions (seen well on US when fluid is present; bat wing) - Pelvic Girdle Four Bones: Sacrum, Coccyx, 2 Innominate Bones (Ilium, Ischium & Pubis) - Division of True & False Pelvis  Linea Termnialis (conjugate vera) True Pelvis: all reproductive organs are here False Pelvis (greater pelvis): bladder - Muscles of the Pelvis Rectus abdominis: most anterior muscle; form anterior abdomino-pelvic wall; behind this is TRV abdominis Psoas & Iliacus: large muscles laterally, located in false pelvis Iliopsoas muscle: seen laterally in TRV Obturator Internus: laterally in true pelvis Piriformis: posterior in true pelvis Muscles of Pelvic Floor: levator ani & coccygeus - Ovaries Location most common: lateral to uterus in the adnexa (internal iliac is in this region) in posterior fold of broad ligament may be superior or posterior to uterine fundus may be posterior cul de sac Size SAG 2.5 - 5 cm TRV 1.5 - 3 cm AP.60 - 2.2 cm 2+3=5 Ligaments Mesovarian: anchors ovary to posterior surface of broad ligament Ovarian ligament: anchors ovary to uterine Infundibulopelvic ligament: anchors ovary to pelvic brim Facts Only abdominal organs not covered by peritoneum (nude ovary) Produces hormones (estrogen) & gametes (sex cell)  Composed of 2 parts: cortex (outer) - contains primordial follicles & medulla (inner) - contains CT, nerves, blood supply, lymphatics & smooth muscle tissue - Ovarian Follicles Born w/ million of primordial follicles Graafian Follicle: most dominant/largest follicle that matures each month Graafian Follicle ruptures w/ ovulation at appx 1.8 to 2.5 cm (25 mm) After rupture, a secondary oocyte ruptures from the Graafian follicle and heads towards the uterine cavity, where it implants on the wall. The body of the graafian will become the corpus luteum of menstruation. If fertilized, corpus luteum remains & maintains pregnancy by producing hormones, if not it dissolves If not pregnant, it sheds & becomes corpus albicans, it shrivels up and goes away Follicles are sometimes often referred as cyst, but they are not a true cyst unless it’s bigger than 2.5 cm - US Appearance of Ovaries Similar to myometrium in echogenicity Follicles give “swiss cheese or chocolate chip” appearance Post menopausal ovaries difficult to visualize Tips for visualization: turn down gains, ovary may be anterior to internal iliac vessel - Pelvic Vascular Supply Hypogastric artery (internal iliac) Uterine artery Ovarian Artery Veins has similar pattern; distensible & vary in size w/ certain conditions Ring of fire will show around ovary Ovarian Torsion (similar to testicular torsion): lack of flow, inflammation, hypoechoic Powerpoint Two: Pelvic Exam - What can be visualized? Uterus, Ovaries, Fallopian Tubes (dilated; only seen if filled w/ fluid), Vagina & Gravid Uterus (pregnant) - Transabdominal Pelvic Exam (external) 32 oz of water finished 1 hour prior to exam Postmenopausal patient is 24 oz Transducer: 3.5 to 5 MHz, curvilinear Patient Position: supine - Reasons for Bladder Filling 1. Pushes Uterus superiorly & posteriorly 2. Decreases angle of incidence 3. Pushes loops of bowel out of view 4. Provides acoustic window for uterus & adnexa 5. Provides anatomic reference point 6. Provides for assessment of mass mobility 7. Provides for mass companion - Scanning Tips You can push harder than you think Perform the exam as quickly as possible w/o missing anything The Uterus ML is not always ML of the Pelvis Ovaries can be recognized by follicles, posterior enhancement, & internal iliac vessels - Transvaginal (TV) / Endovaginal (EV) Pelvic Exam (internal) Empty Urinary Bladder Disrobe from waist down Elevated hips, if gynecology table not available Position: Lithotomy Prepare the probe, insert probe or ask patient to insert probe like a tampon Male sonographers must have a female chaperone present during the exam  Advantage: better resolution, can measure & analyze smaller structures, no need for bladder filling, preferred method for visualizing the ovaries Disadvantage: smaller more limited field of view due to frequency & limitation in prove movements - Transvaginal Orientation Anterior - screen left Posterior - screen right Inferior - top of screen Superior - bottom of screen 90 degree counterclockwise rotation from transabdominal orientation*** - Transperineal Exam Scanning between labia & perineum Patient Position: Lithotomy Useful when transvaginal US is contraindicated (you do not want to do it) Newer developments in OB/GYN scanning - Sonohysterography 25 - 30 ML of sterile saline in endometrial (uterine) cavity Delineates endometrial cavity  Used in evaluation of endometrial polyps, fibroids, endometrial hyperplasia, & patency of fallopian tubes - Contrast Agents Contrast agent that gets injected via catheter insertion Enhance color & pulse wave characteristics in small vessels - Three Dimensional Imaging Current development & investigation on-going Beneficial for service detail, non-diagnostic Provides topographical imaging info Useful in evaluation of face, digits, limbs & neural tube defects (spinal cord) - Sonographer’s Responsibilities Proper Equipment Reduce patient discomfort Minimize exposure to US Provide through & systematic examination Adhere to code of conduct Achieve registration through ARDMS Stay current on emerging trends w/ continuing medical education Powerpoint Three: Menstrual Cycle Menstrual Cycles - Menstruation A cyclic process whereby the endometrial lining is shed if implantation of a conceptus has not occurred Starts @ Menarche (first period) 10 - 14 years old Ends @ Menopause 45 - 55 years old - 3 Phases of Menstrual Cycle Menstrual Phase - bleeding - days 1 - 5 Proliferative Phase - endometrium gets thicker - pro-life - preparing for life - days 6 -14  Secretory Phase (luteal phase) - endometrium is the thickest in this phase, eggs is secreted from the graafian follicle - once ovulation occurs - days 15 - 28 - Menstrual Phase Endometrium degenerates - shedding of the lining Sloughs off the myometrium Expelled as menses (blood) Typically 12 - 24 hours of heavy flow, with less flow for the next 4 - 7 days - Proliferative Phase Regrowth of endometrium Mainly under influence of estrogen Estrogen released by ovarian follicles**** Ends @ ovulation - ovulation is appx day 14 of 28 day cycle - Secretory (Luteal) Phase Begins @ ovulation (ovulation occurs due to luteinizing hormone (lh) ) The rise in LH will cause the graafian follicle to release a secondary oocyte which leads to ovulate Ends when menstruation starts Glandular & Vascular changes in endometrium Primarily under influence of progesterone Absence of fertilization results in fall in estrogen & progesterone; start of menstruation Endometrium is the thickest during this phase - Endometrial Thickness In premenopausal patients, there’s significant variation at different stages of the menstrual cycle Menstruation: 2 - 4 mm Early Proliferative Phase (day 6-14): 5 - 7 mm Late Proliferative / Preovulatory Phase: up to 11 mm Secretory Phase: 7 - 16 mm  S/P D&C or Spontaneous Abortion: < 5 mm (if thicker) consider RPOC (retained products of conception - still some body parts in there) Postmenopausal endometrial thickness is typically < 5 mm, but this will vary * - ANYTHING HRT FOR POSTMENOPAUSAL SYMPTOMS, YOU HAVE TO TAKE ESTROGEN & PROGESTERONE AT THE SAME TIME - Hormonal Regulation Endometrium responds to estrogen & progesterone levels in the blood Levels controlled by feedback system between: ovaries, hypothalamus, anterior hypophysis of pituitary Chain of Events - Hypothalamus Secretes Gonad Releasing Hormone (GnH) Rise in GnH causes Pituitary Gland to released Follicle Stimulating Hormone (FSH) - allows follicles to grow eggs - Pituitary Gland Releases FSH FSH causes numerous follicles in ovary to grow Rising estrogen levels trigger Pituitary to release Luteinizing Hormone (LH) Rise in LH causes ovulation to occur - Things to Remember Proliferative Phase - Estrogen Secretory phase - Progesterone LH causes ovulation to occur Hypothalamus - GnH Pituitary - FSH, LH Ovaries - Estrogen, Progesterone - Follicular Development  5 - 7 follicles stimulated each month by FSH Ovarian follicles grow @ a rate or 2 - 3 mm per day, prior to ovulation Non-dominant follicles normally do not exceed 11 mm Dominant follicle is Graafian follicle Ruptures through tunica albuginea @ ovulation Other follicles undergo atresia & form scar tissue (corpus albicans) - Follicular Development Blood and/or fluid drain to posterior cul de sac @ ovulation Follicles are measure if large or in patient undergoing ovulation induction Follicle ruptures between 1.8 - 2.5 cm (2.0 average) Mittelschmerz is mid cycle pain associated w/ ovulation Depo provera birth control prevents dominant follicle formation and ovulation - Abnormal Menstrual Patterns Dysfunctional Uterine Bleeding (DUB) = vaginal bleeding not related to menstrual cycle - random spotting Hypermenorrhea = excessive volume during cyclic menstrual bleeding Hypomenorrhea = abnormally small amount of menstrual bleeding Polymenorrhea = frequent menstrual bleeding less than 21 days apart Oligomenorrhea = menstrual bleeding greater than 35 days apart Menorrhagia = excessive bleeding in time and/or volume Dysmenorrhea = painful uterine bleeding Dyspareunia = painful intercourse Amenorrhea = absence of menstrual flow // primary - patient never menstruated // secondary - patient had menstrual periods but stopped - Oral Contraceptives Combined estrogen-progestin BC & progestin-only pills or implants prevent the pituitary gland’s release of hormones that stimulate ovulation - Hormone Replacement Therapy (HRT)  Used to treat the symptoms of menopause: hot flashes, mood swings, sleep disorders, vaginal dryness Pros: decreases menopausal symptoms Cons: increased risk of breast cancer, uterine cancer, ovarian cancer Powerpoint Four: Congenital Anomalies - Congenital Anomalies Rare; Incidence.10 -.50% Usually w/o symptoms Can mimic other pathologies 50% of time occur w/ malformations of Urinary System - Causes Most anomalies are the result of: Total or partial atresia of the Mullerian Ducts Failure of Mullerian Ducts to fuse Failure of uterovaginal septum to disappear - Anomalies of the Vagina Symptoms begin @ puberty Signs & Symptoms: pelvic pain, dysmenorrhea, dyspareunia, delayed onset of menses Cause: obstruction at some level of uterus, cervix or vagina - COLPOS = VAGINA // METRA = UTERUS - Blood in Uterus will hypoechoic - Look for body of endometrium to find retention of menstrual blood in uterus - Conditions Associated w/ Vaginal Anomalies Hematocolpos - retention of blood in vagina Hematometra - retention of menstrual blood in uterus Hematometrocolpos - retention of menstrual blood in uterus & vagina Vaginal Agenesis - absent vagina  Vaginal Atresia - lack of vaginal development - Uterine Anomalies Most common are septate uterus, bicornuate uterus & didelphic uterus May be found w/ vaginal anomalies Cause: failure of septum to disappear, failure of ducts to fuse, partial fusion of ducts Arcuate Uterus - slight indentation of fundus Uterus Subseptus - failure of septum to reabsorb completely; separation of uterine corpus Uterus bicornis - uterus has two horns (bicervical or unicervical) Uterus didelphys - two uteri, two cervices & vaginas - More than 1 Uterus = Uteri // More than 1 Cervix = Cervices - Coronal (side) will be the best cut to see urine anomalies - Diethylstilbestrol (DES) Syndrome Drug given pregnant mothers to prevent miscarriage Causes reproductive tract anomalies in the fetus Most common anomalies are bands in uterus, uterine wall defects & T shaped uterus - Fallopian Tube Anomalies Rare Absent Doubling on one side Atresia of a portion (infertility or ectopic pregnancy) - Ovarian Anomalies Absence of ovaries rare Fallopian tubes also absent Supernumerary ovaries Accessory Ovarian Tissue - Paraovarian Cyst Found in broad ligament or in the fallopian tubes near the ovaries Arise from rosenmuller’s organ AKA: paratubal cyst or hydatid cyst of morgagni - type of paraovarian cyst (pedunculated) These don’t usually cause symptoms & are incidental findings - Gartner’s Duct Cyst Cyst in anterolateral portion of vagina Remnant of Mullerian Duct System Appears as anechoic mass in Vagina Prone to infection - Congenital Anomalies in Pregnancy Anomalies tend to be obliterated on US after 22 weeks gestation Pregnancy may occur in one or both uteri  Associated w/ higher rate of premature labor & labor complications - US Appearance Wide variety of appearances Coronal (EV) / Transverse (TA) images more diagnostic Sagittal images may no show duplication Fundus wider than 5 cm Two separate endometrial echoes - Incompetent Cervix is a cervix that is opened. For it to be competent, it needs to be 2.5cm in length. If it’s smaller than than the cervix is opening and it’s incompetent. - Pitfalls of Imaging Sonographer misinterpretation: pedunculate or subserosal fibroid, ovarian mass Powerpoint Five: Benign Pathology - Cervix & Uterus - Leiomyomas, Myoma, Fibroid, Fibroma & Fibromyoma are all the same thing - Indications for US exam Uterine enlargement Pelvic Pain Irregular or Post Menopausal Bleeding Palpable Pelvic mass Amenorrhea or Dysmenorrhea Infertility Recurrent UTI Dyspareunia Benign Conditions of the Cervix - Nabothian Cyst “Inclusion cyst”  Forms in the response to inflammation of endocervical gland Common Incidental Finding - serendipitous Size: 3 mm to 3cm Anechoic w/ enhance sound transmission in cervix - Cervical Polyps More common in multigravidas More common in patients 40 - 50s Asymptomatic Most common benign cervical neoplasm May appear on US as small echogenic areas in cervix Pain during intercourse & menstruation - Cervical Myoma (Fibroid) Occur in cervix 3 to 8% of time May be asymptomatic May cause dyspareunia, dysuria, cervical obstruction, prolapse, bleeding, obstructed labor Treatment: resection or hysterectomy if warranted Cervix may appear bulky or distorted - Endometrial Polyps Most common in patients 40 - 49 years of age Etiology unknown (Idiopathic) Localized growths of endometrial tissue Most often found in cornual region of fundus May be asymptomatic or cause bleeding May appear on US as hyperechoic areas within endometrium - Tamoxifen Effects Non-steroidal anti-estrogen drug Given to patients w/ breast cancer Associated w/ endometrial changes  May lead to development of polyps, endometrial cancer, myoma growth If endometrium is greater than 5 mm, sonohysterography indicated - Adenomyosis (adeno - gland, myo - mass, osis - abnormal condition) Endometrial glands & stroma grow into the myometrium More common in women over 50 years Can be definitely diagnose surgically or with MRI Seen in association w/ leiomyoma in over ½ of cases US appearance: enlarged uterus of normal or decreased echogenicity Can be mistaken for a fibroid (if it’s a focal region) Venetian Lamp shade appearance - Leiomyoma (fibroid, myoma, fibromyoma, fibroma) Benign muscle tumors Most common tumor of female pelvis Consist of lobulation of myometrial tissue which can distort the uterine contour & endometrial stripe Found in 20% of women greater than 35 years Braxton hicks can look like a fibroid, but it’s just a contraction Much more common in African American populations Size: 1 mm to 20 cm Signs & Symptoms: pelvic pain, menorrhagia, asymptomatic, bladder or rectum pressure, infertility, spontaneous abortion - Myoma Classifications Classified in relation to position to uterine wall: Intramural (Interstitial) - in the myometrium (inter - inside) Subserosal - outer region - found in serosa (peritoneum) - body is looking distorted / lobulated Submucosal - inner region - distorting endometrium Pedunculated (has a tail, stalk, pedicle) - Estrogen & Fibroids During pregnancy, fibroids may grow due to increase in estrogen  After menopause with decrease in estrogen, fibroid tend to shrink Fibroid & Endometrial stripe should shrink after menopause if not, most likely cancer. Uterus & Ovaries should also get small. - US Appearance of Fibroids Varies Degenerative changes: cystic degeneration, calcific, hyaline degeneration Subtle changes in echogenicity of myometrium Well defined masses* Whorled appearance* Hypoechoic to Anechoic Echogenic areas w/ distal shadowing Uterine lobulation Endometrial distortion (depends on location & age of fibroid) Uterine enlargement - Pedunculated Fibroid May extend anteriorly, posteriorly, or laterally Differential diagnosis: bicornuate uterus, blind uterine horn, ovarian mass, hydatidiform mole, ectopic pregnancy - Imaging Tips for Myomas 1.Choose lower frequency transducer 2.Increase overall gain 3.TA scanning may be preferable to TV if uterus is enlarged 4.Measure uterus in SAG by taking 2 images 5.It may be impossible to cover the fundus of the uterus w/ the bladder 6.Placing the transducer just superior to pubic bone & angling sharply superior may help in visualization of fundus If uterus is enlarged, evaluation of the patient’s kidneys is warranted to rule out hydronephrosis Powerpoint Six: Malignant Pathologies of the Cervix & Uterus - Endometrial Carcinoma / Cervical Carcinoma  In the US, Endometrial carcinoma is more common than cervical carcinoma Why? Postmenopausal estrogen use (not using progesterone), early diagnosis of Cervical CA w/ PAP smear & cone biopsy, increased patient life span Risk factors for development: obesity, diabetes, high blood pressure, short in height, jewish, age (postmenopausal), estrogen use after menopause Estrogen Relationship: 1. Dysfunctional uterine bleeding w/o ovulation, 2. Hyperplasia of the endometrium, 3. Polycystic ovaries (Stein-Leventhal Syndrome, 4. Theca Granulosa Cell Tumor, 5. Tamoxifen use for breast cancer Pathophysiology: begins in the endometrium, grows toward the myometrium, greater degree of infiltration into myometrium, poorer the prognosis, staging based on degree of tumor spread, grading based on degree of tumor differentiation Signs & Symptoms: bleeding or discharge after menopause & pain Treatment: complete hysterectomy w/ bilateral oophorectomy, lymphadenectomy, pre or post operative radiation therapy US Appearance: uterus may appear normal, uterus may be increased in size, endometrium may be thickened, endometrial cavity may be fluid filled Differential diagnosis: 1. Endometrial Hyperplasia, 2. Endometrial Polyps, 3. Leiomyoma, 4. Cervical Carcinoma (causing hematometra or pyometra) - Leiomyosarcoma Malignant Counterpart of Fibroid Rare (3% of uterine tumors) Suspected when fibroid has a growth spurt Most common in 50s US cannot distinguish from leiomyoma - can only tell by facts (postmenopausal, size increasing) On US, may present as inhomogeneous uterine mass w/ areas of cystic degeneration - Cervical Carcinoma  Risk Factors: 1. Early sexual encounters, 2. Multiple sexual partners, 3. Infection by STD or a sex partner who has an STD, 4. Human Papillomavirus (causes genital warts) Most Common Type - Squamous Cell Prognosis depends on stage @ diagnosis Metastasis via Lymphatic system of Pelvis Staging of Cervical Carcinoma: Stage 1 - confined to cervix, Stage 2 - spread to vagina, upper cervix & parametrium, Stage 3 - spread to lower portion of vagina & to pelvic wall, Stage 3 - extends beyond true pelvis (everything that reproductive) bladder and/or rectal involvement, mets to distant organs (lung, bone & liver) Signs & Symptoms: abnormal pap smear, vaginal discharge, intermittent bleeding (especially after intercourse), more advanced stages: bladder irritability, back pain, ureteral obstruction Treatment: surgical, dependent upon stage of disease: cone biopsy, radical hysterectomy, radiation therapy, chemotherapy EV/TV is the best way to visualize US Appearance: Stage 1 or 2 - may be no charge in cervical appearance, cx may appear bulky or irregular, cx may exhibit changes in echogenicity, hematometra or pyometra may be present due to cervical stenosis Differential Diagnoses: leiomyoma involving the cervix, endometrial carcinoma invoicing the cervix, endometrial polyps prolapsed into the vagina