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ULTRASONOGRAPHY
OF PELVIC MASS IN
FIRST TRIMESTER
Prof. Aboubakr Elnashar
Benha university
Hospital, Egypt
ABOUBAKR ELNASH...
CONTENTS
I. INTRODUCTION
1. CLINICAL IMPLICATIONS
2. INCIDENCE
3. TECHNIQUE
II. CAUSES
 UTERINE
 ADENXAL
 Incidence
 C...
ABOUBAKR ELNASHAT
I. INTRODUCTION
1. CLINICAL IMPLICATIONS
 American College of Radiology:
a comprehensive 1st T US:
 Important
 includes
 uterus,
 cer...
1. Allows for visualization of pelvic anatomy before the
 Expanding uterus:
shifts and conceals neighboring structures.
...
2. Differentiate between
benign and malignant masses
ABOUBAKR ELNASHAT
3. Early identification of abnormalities in 1st T:
 Plan for management
 Observation:
 smaller masses with benign featu...
2. INCIDENCE
 Increase detection rate
 Routine U/S in early pregnancy:
 4%
 At CS: 0.5%
ABOUBAKR ELNASHAT
3. TECHNIQUES
1. TV approach
 Indications
1. Identification of incidental findings on TAS
2. Inability to visualize the a...
2. Three-dimensional sonography
 Beneficial in imaging of the uterus and adnexa.
 creates a user-independent
 lifelike ...
3. Color Doppler sonography.
 Hemodynamic changes of pregnancy can complicate
analysis.
 Ominous diagnoses
 disorganize...
ABOUBAKR ELNASHAT
II. CAUSES
I. UTERINE
II. ADENEXAL
1. Ovarian
1. Simple cyst
2. Haemorrhagic cyst
3. OHSS
4. Endometrioma
5. Luteoma
6. Cancer
ABOUBA...
2. Tubal
Hydrosalpinx
Heterotopic pregnancy
3. Paratubal cyst
III. NON-GYNAECOLOGICAL
1. Mesenteric cyst
2. Appendix mass
...
 Tumors Unique to Pregnancy
1. Luteomas:
may be virilizing
2. Theca-lutein cysts:
can be large and appear complex.
seen...
A. UTERINE MASSES
ABOUBAKR ELNASHAT
Fibroids
 The most prevalent gynecologic disorder of the gravid
and non-gravid female.
 Characters:
 persistent, round,...
Subserosal fibroid. TV transverse:
 a round heterogeneous mass, measuring 0.51 cm wide (+),
projecting beyond the contour...
 Effect of pregnancy on fibroid
 {highly sensitive to estrogen}: growth and
maturation in 1st T.
 grow so large ≥ blood...
 Red, or carneous, degeneration
 hemorrhagic infarction
 {Venous thrombosis within the periphery of the tumor or
ruptur...
 Challenges for imaging during pregnancy
1. Subserosal-type fibroids pushed close to an ovary
by the gravid uterus
±diffi...
TVS of uterine myoma and gestational sac (GS) at 8 w.
ABOUBAKR ELNASHAT
TAS of uterine myoma and fetal head at 39 ws gestation.
ABOUBAKR ELNASHAT
ABOUBAKR ELNASHAT
ABOUBAKR ELNASHAT
ABOUBAKR ELNASHAT
ABOUBAKR ELNASHAT
ABOUBAKR ELNASHAT
Uterine contraction and fibroid in the same patient
ABOUBAKR ELNASHAT
Anterior lower uterine segment fibroid compressing the cervix
ABOUBAKR ELNASHAT
ABOUBAKR ELNASHAT
B. ADNEXAL MASSES
Adnexa: appendages of an organ
Adnexal mass:
lump in tissue near the uterus,
usually in the ovary or fal...
Prevalence
 2.3 %
ABOUBAKR ELNASHAT
Characters
1. Nearly all are benign
 Majority
<5 cm
simple cysts
without complication
majority of these cysts likely begi...
2. High possibility of regression
-Ovarian cysts:
Most are undetectable at 14 w (mostly C.Luteum)
Simple (<5 cm), hemorrha...
3. Complications
 Depend on
 Size
 Gest age
 Rupture
 Haemorrhage
 Torsion (up to 5%)
 Obstructed labour
 Fetal ma...
US
• Abd & TV
• Diagnostic in most cases (> 90%)
• Types:
I. SIMPLE CYST
II. LOW LEVEL ECHO CYST
III. COMPLEX CYST
IV. SOL...
ovary
uteru
s
Unilocular, thin-walled, anechoic
I. SIMPLE OVARIAN CYST
ABOUBAKR ELNASHAT
Unilocular
 Thin-walled
 Anechoic
Follicular cyst ABOUBAKR ELNASHAT
Simple cysts
Corpus luteal or follicular cyst
Haemorrhagic cysts ABOUBAKR ELNASHAT
 Massively enlarged ovaries
 Thin-walled septation
 Ascites may be present
OHSS
ABOUBAKR ELNASHAT
Hydrosalpinx
 Tubular-shaped structure
 Anechoic content
 Incomplete septum
ABOUBAKR ELNASHAT
 Corpus Luteum cyst
 The most commonly encountered cystic adnexal
mass during pregnancy.
 form after fertilization of a...
 Characteristics
 Fluid-filled
 Smooth, thick walls
 Grow to a maximum diameter at the end of 1st T
 The decreasing f...
Corpus luteum. TVS
( a ) transverse and
( b ) sagittal images of the ovary demonstrate a predominately
anechoic cyst conta...
 Complications in pregnancy
 The lifetime of the corpus luteum in a pregnant woman is much longer
than during a normal m...
 Persistent corpus luteum in 2nd trimester
can seal externally within the ovary and continue to collect fluid within:
uni...
 Society of Radiologists in Ultrasound
 non pregnant
 do not recommend follow-up sonography for simple cysts smaller
th...
 Both the corpus luteum and corpus luteum cyst
 Dense peripheral “ring of fire” vascularity on color
Doppler imaging.
 ...
Corpus luteum cyst of pregnancy. TVS
( a ) sagittal and
( b ) TS: an anechoic round structure with thin walls.
( c ) Sagit...
1. Borderline mucinous tumor of the ovary. TAS
( a ) sagittal and
( b ) TS: a predominately cystic mass with thick septati...
2. Ectopic or heterotopic pregnancies in the adnexa
 fed by a peripheral ring of vessels and can be
seen directly adjacen...
Ectopic pregnancy.
( a ) TS: a thick, echogenic ring
( b ) peripheral vascularity on sagittal color Doppler
ABOUBAKR ELNAS...
II. LOW-LEVEL ECHO CYSTS
1. Endometrioma 95%
2. Hemorrhagic cyst 50%
3. Teratoma 18%
4. Malignant Neoplasm 12%
Patel et al...
Low-level echo cysts + Characteristic
Features
Endometrioma
Hyperechoic wall foci (in 35%)
Hemorrhagic cyst :
Lacelike int...
1. Hemorrhagic corpus luteum cyst
 As the blood settles, the cyst appears
 more heterogeneous
 thin, fibrinous septatio...
 Follow-up
 Recommended
{lack of specificity}
1. Growth requires continued follow up
2. The presence of
 thick septatio...
Hemorrhagic corpus luteum cyst of pregnancy. TVS
( a ) transverse and
( b ) sagittal images of the ovary show heterogeneou...
Anechoic with lacelike internal echoes
within cyst
Hemorrhagic C.
Corpus Luteum
ABOUBAKR ELNASHAT
2. Decidualized Endometriomas
 Ovarian endometrioma
 US:
 high diagnostic sensitivity and specificity
 round, hypoecho...
Diffuse „ground glass‟ pattern due to presence of old blood
Endometrioma
ABOUBAKR ELNASHAT
 Decidualized Endometriomas
 As the endometrium of the uterus decidualizes
under the influence of progesterone during
pr...
Endometrioma. TVS coronal image of the right adnexa
a large, thick-walled hypoechoic mass with homogeneous internal
echoes...
Decidualized ovarian endometrioma mimicking a borderline
tumor.
( a ) Sagittal image of the right adnexa
 cystic mass wit...
 Decidualized endometriomas
 become slightly smaller or remain stable in size
throughout pregnancy
 (Cancerous masses e...
1-Dermoid Cyst
The commonest 36%
2-Endometriotic cyst 5%
3-Malignant Cyst 1-3%
III. COMPLEX CYST
ABOUBAKR ELNASHAT
Dermoid
Complex mass solid
and cystic ( fat, bone)
Fill in Pattern
ABOUBAKR ELNASHAT
1. Dermoid Cysts=Mature teratoma
 US:
 correctly identified dermoid cysts 86 %
 never misdiagnosed them as malignant
 ...
William et al, 2011
ABOUBAKR ELNASHAT
 Characters
 Well- circumscribed complex
 Heterogeneous masses arising from the ovary.
 Consist of well- dd tissues fr...
fat fluid level (A)
tip of the iceberg sign (B). ABOUBAKR ELNASHAT
Dermoid mesh (A)
dermoid plug (B). ABOUBAKR ELNASHAT
(a–c) Dermoid plug/Rokitansky nodule.
A rounded hyperechoic focus casting a dense acoustic
shadow, typical of a Rokitansky...
(a–d) Diffuse high echogenicity.
High level echoes throughout a left adnexal mass, with associated
posterior acoustic shad...
(a–c) Peripheral nodular bright echoes with little acoustic
shadowing (a), T1 (b) and FS (c) magnetic resonance sequences
...
 Fat–fluid levels. Hyperechoic and cystic components within
masses, separated by a linear interface, are in keeping with ...
Tip of the iceberg.
Two examples (a, b) where posterior acoustic attenuation from a
hyperechoic mass makes the deep aspect...
Dermoid mesh. High reflectivity lines and dots thought to be due
to the presence of hair floating within the cyst
ABOUBAKR...
Intracystic floating balls. Uncommon but pathognomonic sign.
Multiple hyperechoic balls float within the cyst cavity:
(a) ...
Multiple features:
dermoid mesh,
shadowing echodensity and
linear interface
ABOUBAKR ELNASHAT
Multiple features:
regional high echogenicity,
dermoid mesh and
shadowing Rokitansky noduleABOUBAKR ELNASHAT
Hyperechoic mural nodularity. Borderline tumour was suspected
but MRI demonstrated
 the cystic component to be fatty sebu...
Ultrasound (a) demonstrates mass with multiple linear high
reflectivity echoes.
This could be misinterpreted as dermoid me...
TAS: complex heterogenous cyst posterior to the uterus and
contains turbid and echogenic contents. The right ovary is
visu...
homogeneous hyperechoic right ovarian lesion with hypoechoic
distal shadowing
Plane Transverse
ABOUBAKR ELNASHAT
ABOUBAKR ELNASHAT
Dermoid cyst may have
hyperechoic elements with
acoustic shadowing and
no internal Doppler flow.
Can have a complex appear...
Dermoid. TVS. transverse images of the ovary
heterogeneous round mass with punctate and linear
echogenic foci representing...
 Benign cystic teratomas torsion
 well-known cause of ovarian torsion
 1. limited venous outflow on color Doppler
 The...
C.P:
 repeated episodes of clinical improvement
followed by pain
 {torsion temporarily resolves and resumes}
 the torsi...
Dermoid cyst.
( a ) Sagittal and
( b ) transverse grayscale images of the ovary demonstrate a
predominately homogenous mas...
Mature cystic teratoma and Brenner tumor. TVS
( a ) sagittal and
( b ) transverse image of the ovary demonstrates a
hetero...
3. Malignant cyst=Ovarian Cancer
 3.6–6.8 % of all persistent adnexal masses.
 US:
 1st T: early detection of a cancer
...
 If findings are indeterminant,
 MRI
 may add specificity
 may also be limited by the restricted use of
gadolinium con...
 Sonographic images of benign and malignant ovarian
morphology. Numeric representation of increasing morphologic
complexi...
Morphologic scoring
Each of 4 parameters as assessed
Malignancies tended to have high scores (over 9).
ABOUBAKR ELNASHAT
 IOTA
International Ovarian Tumor Analysis 2012
5 ultrasonic features to predict a malignant tumour
(M features):
Irreg...
5 ultrasonic features to predict a benign tumour (B
features):
Unilocular cyst (B1),
Presence of solid components for w...
ABOUBAKR ELNASHAT
ABOUBAKR ELNASHAT
 Tumor markers
 physiologically elevated during pregnancy.
 imaging remains the best diagnostic tool for
ovarian cancer...
 Serous cystadenocarcinoma
 More anechoic areas than the mucinous type
 Never exists as a unilocular cyst .
 careful e...
Serous borderline tumor. TVS
( a ) sagittal and
( b ) transverse images of the ovary demonstrate a large hypoechoic cystic...
U/S echogenic mural nodule in
cystic mass.
Papillary serous
Cystadenom
Few small
papillae
ABOUBAKR ELNASHAT
Mucinous Cystadenocarcinoma
Solid areas Many papillary. P
ABOUBAKR ELNASHAT
IV. SOLID ADNEXAL MASSES
1. Benign:
1. Subserous Fibroid
2. Luteoma of pregnancy
3. Ovarian Fibroma
2. Malignant:
 Metast...
At 16 weeks' gestation with R adnexal solid mass Leiomyoma or
ovarian mass.
A
B
ABOUBAKR ELNASHAT
using the IOTA criteria: tumor was malignant:
1) M.1 - Irregular solid tumor
2) M.2 - Presence of ascites - around 1500 ml...
 Doppler is applied to solid components of malignant
neoplasms,
 increased disorganized vascularity
 low resistive and ...
4. MANAGEMENT OF OVARIAN MASS
 During pregnancy
 Risk of obsrvation
 torsion
 rupture
 bleeding,
 obstruction, or
 ...
< 5 cm
 Observation
 cystic benign-appearing
{Early in pregnancy, this is likely a corpus
luteum cyst, which typically r...
 Unilocular
 Thin-walled
 Anechoic
Follicular cyst ABOUBAKR ELNASHAT
5 - 10 cm
 color Doppler and possibly MRI
 Observation
 simple cystic appearance
(Schmeler, 2005; Zan etta, 2003) .
 E...
 Resection
 When
 at 14 to 20 w
 {most masses that will regress will have done
so by this time}.
 If the corpus luteu...
C. Non gynecological
ABOUBAKR ELNASHAT
Non gynecological
1. Appendicitis
 can present similarly to complicated right-sided
adnexal masses
{its location near the...
 During pregnancy,
 the enlarging uterus forces the appendix slightly
higher than McBurney’s Point (normally located
one...
 CT
 is often utilized for diagnosis of acute appendicitis
in nonpregnant women.
 However, in those who are pregnant an...
 The inflamed appendix appears as
 large (greater than 6 mm),
 fusiform, blind-ending structure
 thick, hyperemic wall...
 Effect on pregnancy
 If it does not remain localized, the noxious fluid
can irritate the uterus, resulting in higher ra...
 DD:
 ectopic/heterotopic pregnancies
 ovarian torsion if the patient presents in the first
trimester
 abruption in th...
2. Ectopic kidneys
 lying low in the pelvis
 can cause displaced flank” pain from vesicoureteral
reflux and ascending ur...
Summary
 A comprehensive sonographic examination of the
pelvis in the first trimester can reveal a spectrum
of incidental...
 A comprehensive Sonography remains the best
modality for examination of the adnexa and for
distinguishing malignant from...
 Sonography is also superior for determining the
hazards of uterine fibroids, a potentially serious
barrier to implantati...
Teaching Points
• First-trimester sonography leads to earlier detection of
small masses that would otherwise go undiagnose...
• Though most pelvic masses identified in the first
trimester are benign, malignancy is occasionally
seen.
 Sonography in...
• Sonography has high accuracy in the characterization
of adnexal masses and determining their potential to
undergo torsio...
Thanks
ABOUBAKR ELNASHAT
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Ultrasonography of pelvic mass in early pregnancy

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Ultrasonography of pelvic mass in early pregnancy

  1. 1. ULTRASONOGRAPHY OF PELVIC MASS IN FIRST TRIMESTER Prof. Aboubakr Elnashar Benha university Hospital, Egypt ABOUBAKR ELNASHAT
  2. 2. CONTENTS I. INTRODUCTION 1. CLINICAL IMPLICATIONS 2. INCIDENCE 3. TECHNIQUE II. CAUSES  UTERINE  ADENXAL  Incidence  Causes  Characters  US  Management  NON GYNECOLOGICAL ABOUBAKR ELNASHAT
  3. 3. ABOUBAKR ELNASHAT I. INTRODUCTION
  4. 4. 1. CLINICAL IMPLICATIONS  American College of Radiology: a comprehensive 1st T US:  Important  includes  uterus,  cervix  adnexa  cul-de-sac region” along with  gestational contents ABOUBAKR ELNASHAT
  5. 5. 1. Allows for visualization of pelvic anatomy before the  Expanding uterus: shifts and conceals neighboring structures.  Hormonal effects of pregnancy  leiomyoma to enlarge  cysts to rupture  adnexal masses to undergo torsion  cancers to grow. ABOUBAKR ELNASHAT
  6. 6. 2. Differentiate between benign and malignant masses ABOUBAKR ELNASHAT
  7. 7. 3. Early identification of abnormalities in 1st T:  Plan for management  Observation:  smaller masses with benign features  Surgery:  larger (≥7 cm)  suspicious for malignancy.  undergoing torsion  if necessary, during 2nd T. {At that time, risks of spontaneous abortion and preterm labor are lowest}. ABOUBAKR ELNASHAT
  8. 8. 2. INCIDENCE  Increase detection rate  Routine U/S in early pregnancy:  4%  At CS: 0.5% ABOUBAKR ELNASHAT
  9. 9. 3. TECHNIQUES 1. TV approach  Indications 1. Identification of incidental findings on TAS 2. Inability to visualize the adnexa or cervix 3. Examination of an obese patient.  Benefits  tolerable for the patient  avoids  fetal radiation  signal attenuation by SC tissues.  higher resolution views of pelvic pathology {higher frequency that contain anatomy of interest within a shallower focal length} ABOUBAKR ELNASHAT
  10. 10. 2. Three-dimensional sonography  Beneficial in imaging of the uterus and adnexa.  creates a user-independent  lifelike volume that can be manipulated and reconstructed in the coronal plane:  cannot usually be obtained by 2DUS:  additional information that is essential when evaluating uterine anomalies. ABOUBAKR ELNASHAT
  11. 11. 3. Color Doppler sonography.  Hemodynamic changes of pregnancy can complicate analysis.  Ominous diagnoses  disorganized vasculature with  low resistance  high flow is characteristic  Early in 1st T, embryos  most susceptible to thermal and mechanical energy generated by pulsed spectral Doppler  Doppler studies  only when there is clear diagnostic benefit  minimizing embryonic exposure time and intensity ABOUBAKR ELNASHAT
  12. 12. ABOUBAKR ELNASHAT II. CAUSES
  13. 13. I. UTERINE II. ADENEXAL 1. Ovarian 1. Simple cyst 2. Haemorrhagic cyst 3. OHSS 4. Endometrioma 5. Luteoma 6. Cancer ABOUBAKR ELNASHAT
  14. 14. 2. Tubal Hydrosalpinx Heterotopic pregnancy 3. Paratubal cyst III. NON-GYNAECOLOGICAL 1. Mesenteric cyst 2. Appendix mass 3. Diverticular disease 4. Pelvic kidney 5. Urachal cyst ABOUBAKR ELNASHAT
  15. 15.  Tumors Unique to Pregnancy 1. Luteomas: may be virilizing 2. Theca-lutein cysts: can be large and appear complex. seen in: pregnancies with inordinately high hCG secretion e.g.  gestational trophoblastic disease  Twins  other situations with increased placental mass. 3. OHSS:  caused by: ovulation-induction therapy spontaneously {mutation in the FSH receptor} ABOUBAKR ELNASHAT
  16. 16. A. UTERINE MASSES ABOUBAKR ELNASHAT
  17. 17. Fibroids  The most prevalent gynecologic disorder of the gravid and non-gravid female.  Characters:  persistent, round, well-defined masses  iso- or slightly hypoechoic compared to the surrounding myometrium  Peripheral vascularity by color Doppler  ±shadowing calcifications  areas of cystic change when undergoing degeneration ABOUBAKR ELNASHAT
  18. 18. Subserosal fibroid. TV transverse:  a round heterogeneous mass, measuring 0.51 cm wide (+), projecting beyond the contour of the uterus.  The gestational sac with embryo is noted ABOUBAKR ELNASHAT
  19. 19.  Effect of pregnancy on fibroid  {highly sensitive to estrogen}: growth and maturation in 1st T.  grow so large ≥ blood supply: painful degenerative changes:  changing echogenicity  loss of clear circumferential vascularity.  various types of degeneration:  hyaline or myxoid degeneration  calcification  cystic degeneration, or  red (hemorrhagic) degeneration. ABOUBAKR ELNASHAT
  20. 20.  Red, or carneous, degeneration  hemorrhagic infarction  {Venous thrombosis within the periphery of the tumor or rupture of intratumoral arteries}. ABOUBAKR ELNASHAT
  21. 21.  Challenges for imaging during pregnancy 1. Subserosal-type fibroids pushed close to an ovary by the gravid uterus ±difficult to dd from a solid ovarian mass. 2. Degenerative changes ± complicate diagnosis.  3 DUS: better dd an ovarian mass.  Color Doppler: delineating blood flow  MRI: If US is inconclusive ABOUBAKR ELNASHAT
  22. 22. TVS of uterine myoma and gestational sac (GS) at 8 w. ABOUBAKR ELNASHAT
  23. 23. TAS of uterine myoma and fetal head at 39 ws gestation. ABOUBAKR ELNASHAT
  24. 24. ABOUBAKR ELNASHAT
  25. 25. ABOUBAKR ELNASHAT
  26. 26. ABOUBAKR ELNASHAT
  27. 27. ABOUBAKR ELNASHAT
  28. 28. ABOUBAKR ELNASHAT
  29. 29. Uterine contraction and fibroid in the same patient ABOUBAKR ELNASHAT
  30. 30. Anterior lower uterine segment fibroid compressing the cervix ABOUBAKR ELNASHAT
  31. 31. ABOUBAKR ELNASHAT
  32. 32. B. ADNEXAL MASSES Adnexa: appendages of an organ Adnexal mass: lump in tissue near the uterus, usually in the ovary or fallopian tube ABOUBAKR ELNASHAT
  33. 33. Prevalence  2.3 % ABOUBAKR ELNASHAT
  34. 34. Characters 1. Nearly all are benign  Majority <5 cm simple cysts without complication majority of these cysts likely begin as corpora lutea  Ovarian cancer: 0.004–0.04%. Most are borderline with a low malignant potential ABOUBAKR ELNASHAT
  35. 35. 2. High possibility of regression -Ovarian cysts: Most are undetectable at 14 w (mostly C.Luteum) Simple (<5 cm), hemorrhagic, OHSS: 90-100% -Ovarian mass: < 6cm: 95% >6cm: 60% -Persistent: 75% are complex ABOUBAKR ELNASHAT
  36. 36. 3. Complications  Depend on  Size  Gest age  Rupture  Haemorrhage  Torsion (up to 5%)  Obstructed labour  Fetal malpresentation ABOUBAKR ELNASHAT
  37. 37. US • Abd & TV • Diagnostic in most cases (> 90%) • Types: I. SIMPLE CYST II. LOW LEVEL ECHO CYST III. COMPLEX CYST IV. SOLID • Complex (Solid–cystic): more likely to be malignant. • Purely solid or purely cystic: more likely to be benign. ABOUBAKR ELNASHAT
  38. 38. ovary uteru s Unilocular, thin-walled, anechoic I. SIMPLE OVARIAN CYST ABOUBAKR ELNASHAT
  39. 39. Unilocular  Thin-walled  Anechoic Follicular cyst ABOUBAKR ELNASHAT
  40. 40. Simple cysts Corpus luteal or follicular cyst Haemorrhagic cysts ABOUBAKR ELNASHAT
  41. 41.  Massively enlarged ovaries  Thin-walled septation  Ascites may be present OHSS ABOUBAKR ELNASHAT
  42. 42. Hydrosalpinx  Tubular-shaped structure  Anechoic content  Incomplete septum ABOUBAKR ELNASHAT
  43. 43.  Corpus Luteum cyst  The most commonly encountered cystic adnexal mass during pregnancy.  form after fertilization of an expulsed ovum from an ovarian follicle.  They sustain to produce progesterone and maintain the early pregnancy. ABOUBAKR ELNASHAT
  44. 44.  Characteristics  Fluid-filled  Smooth, thick walls  Grow to a maximum diameter at the end of 1st T  The decreasing function as the placenta assumes that an endocrinologic role: serially shrinking size by 2nd T. ABOUBAKR ELNASHAT
  45. 45. Corpus luteum. TVS ( a ) transverse and ( b ) sagittal images of the ovary demonstrate a predominately anechoic cyst containing hypoechoic dependent debris representing old blood products ABOUBAKR ELNASHAT
  46. 46.  Complications in pregnancy  The lifetime of the corpus luteum in a pregnant woman is much longer than during a normal menstrual cycle  it has more opportunity to grow:  rupture  torsion  hemorrhage  intervention and further imaging:  unnecessary  should not be followed during 1st T when progesterone production is essential. ABOUBAKR ELNASHAT
  47. 47.  Persistent corpus luteum in 2nd trimester can seal externally within the ovary and continue to collect fluid within: unilocular corpus luteum cyst.  {cyst contains fluid}, it is anechoic with enhanced through- transmission  thin lacelike echogenic septae if it is filled with blood.  The size of the cyst is a strong predictor of its ability to spontaneously regress,  all cysts ≤5 cm resolving completely without intervention ABOUBAKR ELNASHAT
  48. 48.  Society of Radiologists in Ultrasound  non pregnant  do not recommend follow-up sonography for simple cysts smaller than 5 cm,  yearly sonography of larger cysts should be considered, despite low malignant potential.  Pregnant  Standard scheduling of obstetric ultrasounds ABOUBAKR ELNASHAT
  49. 49.  Both the corpus luteum and corpus luteum cyst  Dense peripheral “ring of fire” vascularity on color Doppler imaging.  These vessels exhibit low resistance and high diastolic flow on spectral Doppler.  There are typically little or no internal solid components. ABOUBAKR ELNASHAT
  50. 50. Corpus luteum cyst of pregnancy. TVS ( a ) sagittal and ( b ) TS: an anechoic round structure with thin walls. ( c ) Sagittal color Doppler: peripheral vascularity representing the “ring of fire ABOUBAKR ELNASHAT
  51. 51. 1. Borderline mucinous tumor of the ovary. TAS ( a ) sagittal and ( b ) TS: a predominately cystic mass with thick septations. ( c ) Color Doppler: blood flow within a septation ABOUBAKR ELNASHAT  DD:
  52. 52. 2. Ectopic or heterotopic pregnancies in the adnexa  fed by a peripheral ring of vessels and can be seen directly adjacent to a cyst  move independently from the ovary with pressure applied by the examiner.  more complex and echogenic than luteal cysts when compared to the ovarian parenchyma.  will invariably become symptomatic  Corpus luteum cysts  Sliding sign” is not visualized`  Usually asymptomatic, especially when they are relatively small in size  However, large cysts can rupture, undergo torsion, and bleed. ABOUBAKR ELNASHAT
  53. 53. Ectopic pregnancy. ( a ) TS: a thick, echogenic ring ( b ) peripheral vascularity on sagittal color Doppler ABOUBAKR ELNASHAT
  54. 54. II. LOW-LEVEL ECHO CYSTS 1. Endometrioma 95% 2. Hemorrhagic cyst 50% 3. Teratoma 18% 4. Malignant Neoplasm 12% Patel et al (Radiology. 1999;210:739-745.) ABOUBAKR ELNASHAT
  55. 55. Low-level echo cysts + Characteristic Features Endometrioma Hyperechoic wall foci (in 35%) Hemorrhagic cyst : Lacelike internal echoes (in 40%) Teratoma Regional bright echoes ( in 97% ) ABOUBAKR ELNASHAT
  56. 56. 1. Hemorrhagic corpus luteum cyst  As the blood settles, the cyst appears  more heterogeneous  thin, fibrinous septations that are without color Doppler flow.  The clot retracts to the walls of the cyst:  solid or reticular hyperechoic structure.  Cyst:  well defined with  enhanced through transmission {predominant presence of non-bloody cystic fluid}.  Rupture of cyst: free pelvic fluid. ABOUBAKR ELNASHAT
  57. 57.  Follow-up  Recommended {lack of specificity} 1. Growth requires continued follow up 2. The presence of  thick septations  nodular walls  vascularity:  suspicious for neoplasia  surgery must be considered.  MRI 3. By 2nd T: true functional hgic cysts should have involuted. ABOUBAKR ELNASHAT
  58. 58. Hemorrhagic corpus luteum cyst of pregnancy. TVS ( a ) transverse and ( b ) sagittal images of the ovary show heterogeneous echogenic material within an anechoic cyst representing hemorrhagic blood products in a corpus luteum cyst ABOUBAKR ELNASHAT
  59. 59. Anechoic with lacelike internal echoes within cyst Hemorrhagic C. Corpus Luteum ABOUBAKR ELNASHAT
  60. 60. 2. Decidualized Endometriomas  Ovarian endometrioma  US:  high diagnostic sensitivity and specificity  round, hypoechoic cystic masses  regular thick walls  possibly small echogenic foci along the inner rim.  DD:  Hgic corpus luteum cyst  involute by 2nd T  Endometrioma will not. ABOUBAKR ELNASHAT
  61. 61. Diffuse „ground glass‟ pattern due to presence of old blood Endometrioma ABOUBAKR ELNASHAT
  62. 62.  Decidualized Endometriomas  As the endometrium of the uterus decidualizes under the influence of progesterone during pregnancy: 12 % of ovarian endometriomas undergo decidualization  Their benign appearance transforms to closely mimic borderline ovarian tumors  Solid intracystic papillary excrescences  Irregular walls.  The projections may be quite vascular and can exhibit low resistance flow. ABOUBAKR ELNASHAT
  63. 63. Endometrioma. TVS coronal image of the right adnexa a large, thick-walled hypoechoic mass with homogeneous internal echoes ABOUBAKR ELNASHAT
  64. 64. Decidualized ovarian endometrioma mimicking a borderline tumor. ( a ) Sagittal image of the right adnexa  cystic mass with internal irregular solid projections.  17W IUP ( b ) Color Doppler: low-resistance vascularity within the excrescences ABOUBAKR ELNASHAT
  65. 65.  Decidualized endometriomas  become slightly smaller or remain stable in size throughout pregnancy  (Cancerous masses enlarge)  revert after delivery  wall is similar to that of uterine endometrium.  MRI  does not add significant diagnostic benefit {Analysis of vascularity has not revealed consistent chronological, morphological, or flow differences.  is limited by avoidance of contrast}  US Follow up: monthly is recommended ABOUBAKR ELNASHAT
  66. 66. 1-Dermoid Cyst The commonest 36% 2-Endometriotic cyst 5% 3-Malignant Cyst 1-3% III. COMPLEX CYST ABOUBAKR ELNASHAT
  67. 67. Dermoid Complex mass solid and cystic ( fat, bone) Fill in Pattern ABOUBAKR ELNASHAT
  68. 68. 1. Dermoid Cysts=Mature teratoma  US:  correctly identified dermoid cysts 86 %  never misdiagnosed them as malignant  The most common complex pelvic mass identified during pregnancy ABOUBAKR ELNASHAT
  69. 69. William et al, 2011 ABOUBAKR ELNASHAT
  70. 70.  Characters  Well- circumscribed complex  Heterogeneous masses arising from the ovary.  Consist of well- dd tissues from multiple germ cell lines:  fat, calcifications, hair, and sebum  distinctive hyperechoic linear markings (lines and dots) within the dermoid  highly echogenic areas that strongly shadow (“tip of the iceberg sign”).  No change in size during pregnancy ABOUBAKR ELNASHAT
  71. 71. fat fluid level (A) tip of the iceberg sign (B). ABOUBAKR ELNASHAT
  72. 72. Dermoid mesh (A) dermoid plug (B). ABOUBAKR ELNASHAT
  73. 73. (a–c) Dermoid plug/Rokitansky nodule. A rounded hyperechoic focus casting a dense acoustic shadow, typical of a Rokitansky nodule, is seen arising from the wall of a dermoid cyst (a). T1 weighted (b) and fat saturation (c) magnetic resonance images confirm the presence of fat ABOUBAKR ELNASHAT
  74. 74. (a–d) Diffuse high echogenicity. High level echoes throughout a left adnexal mass, with associated posterior acoustic shadowing (a). T1 weighted (b), T2 weighted (c) and fat saturation sequences confirm left adnexal dermoid cyst and simple right ovarian cystABOUBAKR ELNASHAT
  75. 75. (a–c) Peripheral nodular bright echoes with little acoustic shadowing (a), T1 (b) and FS (c) magnetic resonance sequences confirm fat within these nodules ABOUBAKR ELNASHAT
  76. 76.  Fat–fluid levels. Hyperechoic and cystic components within masses, separated by a linear interface, are in keeping with a fluid/sebum layer, but in isolation on ultrasound, a layered appearance is not specific for dermoid cyst.  Mass with anterior anechoic component&dependent more hyperechoic component (a). Sagittal T1 weighted (b) and axial fat saturation (c) confirm the fatty sebum floating above more complex fluid. (d) Linear interface within a partly hyperechoic mass, in this case with a hyperechoic superior component, and with focal echogenicity in keeping with hair floating at the interface ABOUBAKR ELNASHAT
  77. 77. Tip of the iceberg. Two examples (a, b) where posterior acoustic attenuation from a hyperechoic mass makes the deep aspect of the mass difficult to appreciate ABOUBAKR ELNASHAT
  78. 78. Dermoid mesh. High reflectivity lines and dots thought to be due to the presence of hair floating within the cyst ABOUBAKR ELNASHAT
  79. 79. Intracystic floating balls. Uncommon but pathognomonic sign. Multiple hyperechoic balls float within the cyst cavity: (a) ultrasound and (b) computed tomography ABOUBAKR ELNASHAT
  80. 80. Multiple features: dermoid mesh, shadowing echodensity and linear interface ABOUBAKR ELNASHAT
  81. 81. Multiple features: regional high echogenicity, dermoid mesh and shadowing Rokitansky noduleABOUBAKR ELNASHAT
  82. 82. Hyperechoic mural nodularity. Borderline tumour was suspected but MRI demonstrated  the cystic component to be fatty sebum and  the mural nodule to be a Rokitansky nodule.  This was confirmed to be a dermoid cyst at histologyABOUBAKR ELNASHAT
  83. 83. Ultrasound (a) demonstrates mass with multiple linear high reflectivity echoes. This could be misinterpreted as dermoid mesh but the patient was unwell and computed tomography (b) confirmed the presence of gas within this pelvic abscess ABOUBAKR ELNASHAT
  84. 84. TAS: complex heterogenous cyst posterior to the uterus and contains turbid and echogenic contents. The right ovary is visualized. ABOUBAKR ELNASHAT
  85. 85. homogeneous hyperechoic right ovarian lesion with hypoechoic distal shadowing Plane Transverse ABOUBAKR ELNASHAT
  86. 86. ABOUBAKR ELNASHAT
  87. 87. Dermoid cyst may have hyperechoic elements with acoustic shadowing and no internal Doppler flow. Can have a complex appearance due to fat, hair, and sebum within the cyst. ABOUBAKR ELNASHAT
  88. 88. Dermoid. TVS. transverse images of the ovary heterogeneous round mass with punctate and linear echogenic foci representing strands of hair ABOUBAKR ELNASHAT
  89. 89.  Benign cystic teratomas torsion  well-known cause of ovarian torsion  1. limited venous outflow on color Doppler  The main ovarian vessels may appear twisted and some flow to the ovary from uterine collaterals can be present. 2. free pelvic fluid from edema and vascular congestion. 3. Ovarian enlargement ABOUBAKR ELNASHAT
  90. 90. C.P:  repeated episodes of clinical improvement followed by pain  {torsion temporarily resolves and resumes}  the torsion may not be captured on a single sonographic study. ABOUBAKR ELNASHAT
  91. 91. Dermoid cyst. ( a ) Sagittal and ( b ) transverse grayscale images of the ovary demonstrate a predominately homogenous mass with echogenic areas and posterior acoustic shadowing from calcifications ABOUBAKR ELNASHAT
  92. 92. Mature cystic teratoma and Brenner tumor. TVS ( a ) sagittal and ( b ) transverse image of the ovary demonstrates a heterogeneous mass with mixed anechoic cystic and solid echogenic components ABOUBAKR ELNASHAT
  93. 93. 3. Malignant cyst=Ovarian Cancer  3.6–6.8 % of all persistent adnexal masses.  US:  1st T: early detection of a cancer  safe  high accuracy for determination of malignant potential  1st: confirm that mass is intraovarian by probing with TV transducer and observing the absence of “sliding.” ABOUBAKR ELNASHAT
  94. 94.  If findings are indeterminant,  MRI  may add specificity  may also be limited by the restricted use of gadolinium contrast in the pregnant patient. ABOUBAKR ELNASHAT
  95. 95.  Sonographic images of benign and malignant ovarian morphology. Numeric representation of increasing morphologic complexity is noted in the first column. ABOUBAKR ELNASHAT
  96. 96. Morphologic scoring Each of 4 parameters as assessed Malignancies tended to have high scores (over 9). ABOUBAKR ELNASHAT
  97. 97.  IOTA International Ovarian Tumor Analysis 2012 5 ultrasonic features to predict a malignant tumour (M features): Irregular solid tumour (M1), Ascites (M2), At least 4 papillary structures (M3), Irregular multilocular solid tumour with a largest diameter of at least 100 mm (M4) Very high colour content on colour Doppler examination (M5). ABOUBAKR ELNASHAT
  98. 98. 5 ultrasonic features to predict a benign tumour (B features): Unilocular cyst (B1), Presence of solid components for which the largest solid component is <7 mm in largest diameter (B2) Acoustic shadows (B3) Smooth multilocular tumour (B4) No detectable blood flow on Doppler examination (B5). ABOUBAKR ELNASHAT
  99. 99. ABOUBAKR ELNASHAT
  100. 100. ABOUBAKR ELNASHAT
  101. 101.  Tumor markers  physiologically elevated during pregnancy.  imaging remains the best diagnostic tool for ovarian cancer in pregnancy.  US by experienced specialists using IOTA criteria superior to  tumor markers and  Mathematical predictive models ABOUBAKR ELNASHAT
  102. 102.  Serous cystadenocarcinoma  More anechoic areas than the mucinous type  Never exists as a unilocular cyst .  careful evaluation of the entire cyst wall is very important  { borderline serous or mucinous cystadenocarcinoma may be  almost completely unilocular,  with the exception of one or more mural nodules that usually demonstrate associated vascularity by color Doppler} ABOUBAKR ELNASHAT
  103. 103. Serous borderline tumor. TVS ( a ) sagittal and ( b ) transverse images of the ovary demonstrate a large hypoechoic cystic mass with hyperechoic papillary projections. Color Doppler images ( c , d ) demonstrate mild vascularity within the papillary projections as well as a second lesion with moderate vascularity ABOUBAKR ELNASHAT
  104. 104. U/S echogenic mural nodule in cystic mass. Papillary serous Cystadenom Few small papillae ABOUBAKR ELNASHAT
  105. 105. Mucinous Cystadenocarcinoma Solid areas Many papillary. P ABOUBAKR ELNASHAT
  106. 106. IV. SOLID ADNEXAL MASSES 1. Benign: 1. Subserous Fibroid 2. Luteoma of pregnancy 3. Ovarian Fibroma 2. Malignant:  Metastasis, commonly from the GI tract ( Krukenberg tumor),or  Primary solid tumors of the ovary ABOUBAKR ELNASHAT
  107. 107. At 16 weeks' gestation with R adnexal solid mass Leiomyoma or ovarian mass. A B ABOUBAKR ELNASHAT
  108. 108. using the IOTA criteria: tumor was malignant: 1) M.1 - Irregular solid tumor 2) M.2 - Presence of ascites - around 1500 ml. 3) M.3 - Very strong blood flow (color score: 4) Initially our diagnosis was malignant germ cells tumor- dysgerminoma ABOUBAKR ELNASHAT
  109. 109.  Doppler is applied to solid components of malignant neoplasms,  increased disorganized vascularity  low resistive and pulsatility indices, representing high blood flow to the tumor.  Free fluid in the abdomen is likely indicative of maternal ascites from tumor spread. ABOUBAKR ELNASHAT
  110. 110. 4. MANAGEMENT OF OVARIAN MASS  During pregnancy  Risk of obsrvation  torsion  rupture  bleeding,  obstruction, or  malignancy.  Risk of Surgery  intraoperative and perioperative risks  fetal loss  preterm contractions  an increased risk of embolic events ABOUBAKR ELNASHAT
  111. 111. < 5 cm  Observation  cystic benign-appearing {Early in pregnancy, this is likely a corpus luteum cyst, which typically resolves by the early second trimester}.  Excision  sonographic characteristics suggest cancer-  thick septa  nodules,  papillary excrescences, or  solid components (William,2018) ABOUBAKR ELNASHAT
  112. 112.  Unilocular  Thin-walled  Anechoic Follicular cyst ABOUBAKR ELNASHAT
  113. 113. 5 - 10 cm  color Doppler and possibly MRI  Observation  simple cystic appearance (Schmeler, 2005; Zan etta, 2003) .  Excision  display malignant qualities  symptomatic  cysts grow 10 cm: Excision {substantial risk of malignancy, torsion, or labor obstruction} ABOUBAKR ELNASHAT
  114. 114.  Resection  When  at 14 to 20 w  {most masses that will regress will have done so by this time}.  If the corpus luteum is removed before 10W: 17-OH-progesterone, 250 mg IM/W tell 10W gestation.  Laparoscopic removal is ideal (Naqvi, 2015; Sisodia, 2015 )  If cancer is strongly suspected,  consultation with a gynecologic oncologist. (ACOG, 2017) ABOUBAKR ELNASHAT
  115. 115. C. Non gynecological ABOUBAKR ELNASHAT
  116. 116. Non gynecological 1. Appendicitis  can present similarly to complicated right-sided adnexal masses {its location near the right ovary}.  C.P:  acute epigastric pain shifts to the right lower quadrant  nausea, vomiting, and anorexia. ABOUBAKR ELNASHAT
  117. 117.  During pregnancy,  the enlarging uterus forces the appendix slightly higher than McBurney’s Point (normally located one-third of the distance on an imaginary line from the right anterior superior iliac spine to the umbilicus), but this change is not significant during the first trimester.  Pregnant women are also more likely to present with digestive or urinary complaints than nonpregnant women, which can mimic normal pregnancy symptoms. ABOUBAKR ELNASHAT
  118. 118.  CT  is often utilized for diagnosis of acute appendicitis in nonpregnant women.  However, in those who are pregnant and presenting with right sided pain, sonography is an excellent alternative to avoid radiation  MRI  can also be used as a problem-solving tool when ultrasound is indeterminate. ABOUBAKR ELNASHAT
  119. 119.  The inflamed appendix appears as  large (greater than 6 mm),  fusiform, blind-ending structure  thick, hyperemic walls.  The appendix will be noncompressible and, in cases of rupture, surrounded by a small amount of fluid.  Sometimes, a hyperechoic appendicolith is discovered occluding the appendiceal lumen.  If the appendix has ruptured, the wall will not be intact, allowing fluid (e.g., feces, pus) to collect at the opening. ABOUBAKR ELNASHAT
  120. 120.  Effect on pregnancy  If it does not remain localized, the noxious fluid can irritate the uterus, resulting in higher rates of preterm labor and fetal loss.  This is further exacerbated by delayed operative intervention in pregnant women. ABOUBAKR ELNASHAT
  121. 121.  DD:  ectopic/heterotopic pregnancies  ovarian torsion if the patient presents in the first trimester  abruption in the third trimester.  Pyelonephritis  round ligament pain remain clinical diagnoses. ABOUBAKR ELNASHAT
  122. 122. 2. Ectopic kidneys  lying low in the pelvis  can cause displaced flank” pain from vesicoureteral reflux and ascending urinary tract infections.  The pain can mimic an adnexal origin.  Sonography will likely show hydronephrosis in a pelvic kidney located near an ovary, with infection confirmed by urinalysis. ABOUBAKR ELNASHAT
  123. 123. Summary  A comprehensive sonographic examination of the pelvis in the first trimester can reveal a spectrum of incidental findings that share their space with a growing uterus.  Though most of the pathology is also encountered in non-gravid females, the unique hormonal environment of pregnancy can initiate complications or cause otherwise benign- appearing masses to look suspicious. ABOUBAKR ELNASHAT
  124. 124.  A comprehensive Sonography remains the best modality for examination of the adnexa and for distinguishing malignant from benign masses, thus allowing early intervention when safest during the pregnancy or if complications such as torsion are deemed likely.  Its role during pregnancy exceeds tumor markers and can help clarify the physical exam, which is confounded by shifting anatomy. ABOUBAKR ELNASHAT
  125. 125.  Sonography is also superior for determining the hazards of uterine fibroids, a potentially serious barrier to implantation, fetal growth, and later delivery.  Sonography’s vital role during early pregnancy will continue to grow with increased utilization of three- dimensional images. ABOUBAKR ELNASHAT
  126. 126. Teaching Points • First-trimester sonography leads to earlier detection of small masses that would otherwise go undiagnosed until symptomatic or at an advanced stage.  Early exams should cover a comprehensive inspection of the pelvis. • Regularly scheduled obstetric sonography offers the opportunity to follow up and track first-trimester incidental findings for growth or complications. ABOUBAKR ELNASHAT
  127. 127. • Though most pelvic masses identified in the first trimester are benign, malignancy is occasionally seen.  Sonography in conjunction with color Doppler can help make this distinction. • Fibroids are the most common gynecological masses in gravid and non-gravid women, alike.  Two- and three-dimensional sonography can both be useful for localizing and measuring fibroids to determine if they will present challenges during pregnancy and labor. ABOUBAKR ELNASHAT
  128. 128. • Sonography has high accuracy in the characterization of adnexal masses and determining their potential to undergo torsion. This can be very helpful during pregnancy, a time when cysts are more likely to rupture or hemorrhage and cystic or solid masses have more opportunity to be a fulcrum for ovarian torsion. • Sonography remains superior to tumor markers for ovarian cancer detection during pregnancy. ABOUBAKR ELNASHAT
  129. 129. Thanks ABOUBAKR ELNASHAT
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