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Uterine Abnormalities
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Uterine Abnormalities
Leiomyoma (Fibroids) Lipomatous Uterine tumors Leiomyosarcoma Adenomyosis Arteriovenous Malformations
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Leiomyoma or Fibroids Most common neoplasm of uterus
Estrogen dependant Composed of smooth muscle and fibrous connective tissue
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Fibroids- symptoms Frequently asymptomatic Symptoms Pain
Uterine bleeding
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Fibroid Classification
Intramural most common Confined to the myometrium Submucosal Projecting into uterine cavity (distorting or displacing endo) Produce symptoms frequently (less common) Associated with infertility Subserosal Projecting from peritoneal surface
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Fibroids Sonographic Features Figure 15-10
Variable appearance Hypoechoic or heterogeneous mass Distortion of external uterine contour Attenuation of sound beam or shadowing w/o discrete mass Calcification Degeneration or necrosis
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Fibroids
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Lipomatous Uterine Tumors or Lipoleimyomas
Uncommon Benign Consist of Mature lipocytes Smooth muscle Or fibrous tissue
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Sonographically Highly echogenic, attenuating mass within the myometrium Absence of Color Flow within Usually asymptomatic Make sure within uterus (confuse with ovarian dermoid)
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Leiomyosarcoma Rare Malignant (1.3% of uterine cancers)
may arise from a leiomyoma Asymptomatic or uterine bleeding Same symptoms and appearance “Fibroid”
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Sonographically Fig 15-12 Rumack
Similar to a rapidly growing or degenerating Fibroid Rarely diagnosed preoperatively Exception May see local invasion (bladder or rectum) Distant metastases Clue: Rapid growth & post menopausal growth
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Adenomyosis Common condition
Endometrial glands and stroma within myometrium Associated with adjacent smooth muscle hyperplasia Two Forms Diffuse Nodular Can have fibroids present as well Makes severity of adenomyosis difficult to diagnose
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Adenomyosis More common
Diffuse Nodular More common Widely scattered adenomyosis foci within the myometrium Composed of adenomyomas (circumscribed nodules)
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Clinical presentation
Nonspecific Uterine enlargement Pelvic pain Dysmenorrhea Menorrhagia Seen more in women who have had children
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Adenomyosis Not well seen using transabdominal ultrasound
Transvaginal much better
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Sonographic Features of adenomyosis fig.15-13 Rumack
Diffuse ut enlargement Diffusely heterogeneous myometrium Asymmetrical thickening of myometrium Inhomogeneous hypoechoic areas Myometrial cysts Poor delineation of endo-myometrial border Focal tenderness with transvaginal transducer Subendometrial echogenic linear striations Subendometrial echogenic nodules
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LOCALIZED aDENOmyosis
Can be confused with fibroid Inhomogeneous, circumscribed areas within myometrium
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Localized Adenomyomas
Lieomyomas Localized Adenomyomas Usually well defined borders Peripheral vascularity Ill defined borders Internal vascularity
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MRI and ultrasound both good at diagnosing adenomyosis
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Arteriovenous malformations
AVM’S Vascular plexus of arteries and veins with no capillary network Rare lesions Most cases acquired Pelvic trauma Surgery Gestational trophoblastic neoplasia
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AVM’s usually diagnosed
Postabortion and postpartum periods Symptoms Severe vaginal bleeding D&C Could worsen bleeding leading to hemorrhage
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Sonographic appearance of avm’s (Fig 15-14)
Nonspecific 2D ultrasound Multiple tortuous anechoic structures Subtle myometrial heterogeneity Myometrial or endometrial mass Color Doppler Better +++color flow shown, colored mosaic pattern Spectral Doppler High velocity, low resistance arterial flow, high velocity venous flow (more like an artery)
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Differential Diagnosis of avm’s
RPOC GTN (gestational trophoblastic neoplasia) Subinvolution of placental bed ***negative hCG help to distinguishing
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Treatment of avm’s Wait to see if resolve (maybe not AVM)
If severe bleeding immediate treatment emboization
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Abnormalities of Cervix
Nabothian cysts Cervical polyps Leiomyomas Cervical carcinoma
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Nabothian cysts Vary in size mm’s – 4cm Single or multiple Benign
Simple or have internal echoes ?infection or hemorrhage Multiple cysts can result enlargement of cervix
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Cervical polyps Leiomyoma's 8% cx Cause vaginal bleeding
Can be seen U/S usually diagnosed clinically Leiomyoma's 8% cx Pedunculated May prolapse into vagina
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Cervical carcinoma Adenoma Malignum Usually Diagnosed clinically
U/S may show solid retrovesical mass (look like fibroid) MRI best for staging Adenoma Malignum Rare Associated Peutz-Jeghers syndrome (inherited) U/S appears as multiple cystic areas seen within a solid cx mass (nabothian cysts not associated with a mass)
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Pitfall after hysterectomy
Cervical remnant mistaken for Mass Can measure 4.4mm AP AND 4.3 mm Length
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terminology Salpinges- fallopian tubes
Cornua- “Horns” or lateral angle Collis- “neck” Cervix Colpos- Vagina Metra- Endometrial Cavity Hemata- Blood Hydro- Water Pyo- pus
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Short answers Obstruction of the genital tract
1. Congenital causes? 2. Acquired causes? 3. Define Hydrometrocolpos, pyometracolpos,hematometracolpos Hydrocolpos, pyocolpos, hematocolpos Hematometra, pypmetra, hydrometra 4. What are the sonographic appearances of genital tract obstruction? Are there differences before the age of menstruation and after?
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Abnormalities of vagina
Imperforate hymen Most common congenital abn. Female genital tract Gartner’s duct cysts Remnants of caudal end of mesonephric duct Anterolateral or anterior wall of vagina Asymptomatic Usually small Associated with renal and ureteral abnormalities
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Solid masses very rare Pitfalls Neurofibroma
u/s not used for diagnosis (may be used for staging) Pitfalls Vaginal cuff and cervical cuff after hysterectomy Mistaken for mass Vaginal cuff upper limit Transvag- 2.2mm (AP) Transabd- 2.4mm (AP)
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Rectouterine recess or pcds
Fluid within is a normal finding in asymptomatic women Found throughout phases of cycle Possible Sources of fluid Blood or fluid from (follicular rupture, retrograde menses)
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Pcds fluid collections
Pathological Seen with general ascites, blood (ruptured ectopic or hemorrhagic cyst), pus (infection) U/S Used to differentiate type of fluid Anechoic Serous fluid Fluid containing echoes Blood, pus, mucin (clotted blood can look very echogenic)
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PcDS Pelvic abscesses hematomas
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