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Ultrasound and Cervical Ultrasound and Cervical IncompetenceIncompetence
Tara BenjaminTara BenjaminHarvard Medical School, Year IIIHarvard Medical School, Year III
Gillian Lieberman, MDGillian Lieberman, MD
September 2003
Tara Benjamin, HMS IIIGillian Lieberman, MD
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Tara Benjamin, HMS IIIGillian Lieberman, MD
AgendaAgenda
I. UltrasoundI. UltrasoundII. Patient PresentationII. Patient PresentationIII. Cervical IncompetenceIII. Cervical IncompetenceIV. Supplemental Patient PresentationIV. Supplemental Patient Presentation
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Tara Benjamin, HMS IIIGillian Lieberman, MD
UltrasoundUltrasound-- OverviewOverview
Electricity within a transducer produces Electricity within a transducer produces sound waves.sound waves.Tissues receive the waves and either Tissues receive the waves and either attenuate, transmit, or reflect them to attenuate, transmit, or reflect them to different degrees.different degrees.Reflected wavesReflected waves--ECHOESECHOES-- are received by are received by the transducer at interfaces and combine the transducer at interfaces and combine to create an image of the scanned sector.to create an image of the scanned sector.
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Tara Benjamin, HMS IIIGillian Lieberman, MD
UltrasoundUltrasound-- OverviewOverview
Echoes from tissues of high Echoes from tissues of high acoustic acoustic impedanceimpedance mismatch are stronger.mismatch are stronger.EchogenicEchogenic-- has internal echoes, appears has internal echoes, appears white (bone, air).white (bone, air).AnechogenicAnechogenic-- lacking internal echoes, lacking internal echoes, appears lucent (clear fluid).appears lucent (clear fluid).
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Tara Benjamin, HMS IIIGillian Lieberman, MD
UltrasoundUltrasound-- IndicationsIndications
Throughout pregnancy:Throughout pregnancy:~ Gestational Age ~ IUP/Viability~ Gestational Age ~ IUP/Viability~ Placental Evaluation ~ Fetal Survey~ Placental Evaluation ~ Fetal Survey
Complications by trimesterComplications by trimesterMaternal DisordersMaternal Disorders
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Tara Benjamin, HMS IIIGillian Lieberman, MD
UltrasoundUltrasound-- Indications (Cont.)Indications (Cont.)
Guidance for amniocentesis and chorionic Guidance for amniocentesis and chorionic villusvillus samplingsamplingPregnant women who develop:Pregnant women who develop:
~ Vaginal Bleeding ~ Pelvic Pain~ Vaginal Bleeding ~ Pelvic Pain~ Premature labor ~ Trauma ~ Premature labor ~ Trauma
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Tara Benjamin, HMS IIIGillian Lieberman, MD
UltrasoundUltrasound-- AdvantagesAdvantages
No ionizing radiationNo ionizing radiationTransaxialTransaxial, , sagittalsagittal, and oblique planes, and oblique planesCheaper than CT and MRICheaper than CT and MRIPortablePortable“Real time”“Real time”
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Tara Benjamin, HMS IIIGillian Lieberman, MD
UltrasoundUltrasound--Female Reproductive Female Reproductive AnatomyAnatomy
Source: www.ynhh.org/pat_edu/hysterectomy/ why.html
External os
Internal os
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Tara Benjamin, HMS IIIGillian Lieberman, MD
Ultrasound Techniques Ultrasound Techniques TransvaginalTransvaginal
Transducer is Transducer is introduced to the introduced to the midvaginamidvagina
Uterus
Endometrium
Endocervical Canal
Cervix
Source: BIDMC PACS
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Tara Benjamin, HMS IIIGillian Lieberman, MD
Ultrasound Techniques Ultrasound Techniques TransvaginalTransvaginal (Cont.)(Cont.)
Advantages:Advantages:~Earlier detection of pregnancy~Earlier detection of pregnancy~Earlier evaluation of fetal milestones~Earlier evaluation of fetal milestones~Distended bladder not required~Distended bladder not required~Better evaluation of cervix~Better evaluation of cervix~Higher resolution of images~Higher resolution of images
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Tara Benjamin, HMS IIIGillian Lieberman, MD
Ultrasound Techniques Ultrasound Techniques TransabdominalTransabdominal
Transducer sends Transducer sends signals through signals through abdomenabdomen
Uterus
Endometrium
Cervix
Urinary bladder
Endocervical canal External Os
Source: BIDMC PACS
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Tara Benjamin, HMS IIIGillian Lieberman, MD
Ultrasound Techniques Ultrasound Techniques TransabdominalTransabdominal (Cont.)(Cont.)
Advantages:Advantages:~ Images available in ~ Images available in transaxialtransaxial, , sagittalsagittal, , and oblique planes of viewand oblique planes of view~ Noninvasive~ Noninvasive~ Better 3~ Better 3rdrd trimester visualizationtrimester visualization
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Tara Benjamin, HMS IIIGillian Lieberman, MD
Patient L.S.Patient L.S. 2/25/022/25/02
40 year old woman with a twin pregnancy 40 year old woman with a twin pregnancy comes to BIDMC for a well being check.comes to BIDMC for a well being check.HPIHPI-- gestational age 33 weeks.gestational age 33 weeks.PMHPMH-- positive for DES exposure.positive for DES exposure.
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Tara Benjamin, HMS IIIGillian Lieberman, MD
Patient L.S.Patient L.S.-- TransabdominalTransabdominal UltrasoundUltrasound
Normal L.S.
UterusUrinary Bladder
Endometrium
Cervix
CervixEndocervical canal External os
Sources: BIDMC PACS
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Tara Benjamin, HMS IIIGillian Lieberman, MD
Patient L.S.Patient L.S.-- TransvaginalTransvaginal UltrasoundUltrasound
Normal L.S.
Sources: BIDMC PACS
EndometriumUterus
Endocervical canal
CervixCervix
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Tara Benjamin, HMS IIIGillian Lieberman, MD
Patient L.S. Patient L.S. --Ultrasound FindingsUltrasound Findings
Ballooning of cervixBallooning of cervixOpening of internal and external Opening of internal and external osos1cm 1cm echogenicechogenic focus focus posteriorlyposteriorly at level of at level of external external ososNo measurable closed cervixNo measurable closed cervix
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Tara Benjamin, HMS IIIGillian Lieberman, MD
Patient L.S.Patient L.S.-- Ultrasound Ultrasound DDxDDx
Mucus plug Mucus plug PolypPolypCervical IncompetenceCervical Incompetence
Diagnosis: Cervical IncompetenceDiagnosis: Cervical Incompetence
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Tara Benjamin, HMS IIIGillian Lieberman, MD
Cervical IncompetenceCervical Incompetence
DefinitionDefinition-- passive and painless dilatation of the passive and painless dilatation of the cervix in the 2cervix in the 2ndnd trimestertrimesterIncidenceIncidence-- 0.20.2--2 of every 1000 pregnancies2 of every 1000 pregnanciesEtiologyEtiology-- Congenital (DES exposure) or Acquired Congenital (DES exposure) or Acquired (trauma)(trauma)11stst presentationpresentation-- pelvic pain, low backache, pelvic pain, low backache, vaginal discharge (w/ or w/o blood)vaginal discharge (w/ or w/o blood)
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Tara Benjamin, HMS IIIGillian Lieberman, MD
Cervical Incompetence (Cont.)Cervical Incompetence (Cont.)
US findingsUS findings-- shortened cervix, funneled internal shortened cervix, funneled internal osos from inside out, from inside out, endocervicalendocervical ballooningballooningDiagnosisDiagnosis-- established by an obstetric history of established by an obstetric history of cervical dilation in the 2cervical dilation in the 2ndnd trimestertrimesterComplicationsComplications-- membrane rupture, delivery of membrane rupture, delivery of immature fetus, pregnancy lossimmature fetus, pregnancy lossTreatmentTreatment-- cerclagecerclage (if possible) and (if possible) and prophylactic prophylactic cerclagecerclage in subsequent pregnanciesin subsequent pregnancies
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Tara Benjamin, HMS IIIGillian Lieberman, MD
Cervical IncompetenceCervical Incompetence-- Treated Treated by by CerclageCerclage
Cerclage sutures
Funneling endocervical canal
Source: BIDMC PACS
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Tara Benjamin, HMS IIIGillian Lieberman, MD
Prophylactic Prophylactic CerclageCerclage
Placement of sutures for McDonald cervical cerclage. A, We use a double-headed Mersilene band with four "bites" in the cervix, avoiding the vessels. B, The suture is placed high upon the cervix close to the cervical-vaginal junction, at the level of the internal os.
Source: Obstetrics- Normal and ProblemPregnancies
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Tara Benjamin, HMS IIIGillian Lieberman, MD
Patient K.P.Patient K.P. 6/10/026/10/02
A 33 year old pregnant woman comes to A 33 year old pregnant woman comes to BIDMC for followBIDMC for follow--up ultrasound.up ultrasound.HPIHPI-- at last visit fetal size was less than at last visit fetal size was less than gestational age by ultrasound. gestational age by ultrasound.
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Tara Benjamin, HMS IIIGillian Lieberman, MD
Patient K.P.Patient K.P.--TransvaginalTransvaginal UltrasoundUltrasound
FindingsFindings~ Ballooning of the ~ Ballooning of the
cervixcervix~ Closed cervical length ~ Closed cervical length
of 5 mmof 5 mm~ Size equals dates~ Size equals dates
Source: BIDMC PACS
Cervix
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Tara Benjamin, HMS IIIGillian Lieberman, MD
K.P.K.P.
DiagnosisDiagnosis-- Cervical IncompetenceCervical IncompetenceTreatmentTreatment-- CerclageCerclage
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Tara Benjamin, HMS IIIGillian Lieberman, MD
SummarySummary
I. UltrasoundI. UltrasoundA. OverviewA. OverviewB. IndicationsB. IndicationsC. AdvantagesC. AdvantagesD. AnatomyD. AnatomyE. TechniquesE. Techniques
1. 1. TransvaginalTransvaginal2. 2. TransabdominalTransabdominal
II. Patient L.S.II. Patient L.S.A. HistoryA. HistoryB. US FindingsB. US FindingsC. C. DDxDDx
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Tara Benjamin, HMS IIIGillian Lieberman, MD
Summary (Cont.)Summary (Cont.)
III. Cervical III. Cervical IncompetenceIncompetence
A. DefinitionA. DefinitionB. EtiologyB. EtiologyC. PresentationC. PresentationD. US FindingsD. US FindingsE. DiagnosisE. DiagnosisF. ComplicationsF. ComplicationsG. TreatmentG. Treatment-- CerclageCerclage
IV. Patient K.P.IV. Patient K.P.A. HistoryA. HistoryB. US FindingsB. US Findings
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Tara Benjamin, HMS IIIGillian Lieberman, MD
ReferencesReferences
Fleischer, Arthur and Donna Fleischer, Arthur and Donna KeppleKepple. . Diagnostic Diagnostic SonographySonography: : Principles and Clinical ApplicationsPrinciples and Clinical Applications. 2. 2ndnd ed., 1995. W. B. Saunders ed., 1995. W. B. Saunders Co.Co.GabbeGabbe. . ObstetricsObstetrics--Normal and Problem PregnanciesNormal and Problem Pregnancies. 4. 4thth ed., 2002. ed., 2002. Churchill Livingstone, Inc.Churchill Livingstone, Inc.Gay, Spencer and Richard Woodcock, Jr. Gay, Spencer and Richard Woodcock, Jr. Radiology RecallRadiology Recall. 2000. . 2000. Lippincott Williams and Wilkins.Lippincott Williams and Wilkins.NovellineNovelline, Robert. , Robert. Squire’s Fundamentals of RadiologySquire’s Fundamentals of Radiology. 5. 5thth ed. 1997. ed. 1997. Harvard University Press.Harvard University Press.Reeder, Maurice and William Bradley, Jr. Reeder, Maurice and William Bradley, Jr. Gamut’s in Radiology: Gamut’s in Radiology: Comprehensive Lists of Roentgen Differential DiagnosesComprehensive Lists of Roentgen Differential Diagnoses. 3. 3rdrd ed. ed. 1993. Springer1993. Springer--VerlagVerlag New York, Inc.New York, Inc.www.ynhh.org/pat_edu/hysterectomy/ why.html
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AcknowledgementsAcknowledgements
Michelle Swire, MDMichelle Swire, MDEamonEamon Kato, MDKato, MDPamela Pamela LepkowskiLepkowskiGillian Lieberman, MDGillian Lieberman, MDLarry BarbarasLarry Barbaras
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