Contrast Contrast mediamedia

Radiographic contrast media are substance whose 1o purpose is to enhance diagnostic information of medical system

contrast in an x-ray film is caused by the varying absorption of x-ray by the material being irradiated.

Absorption --> dependent on atomic number of atoms present in the include , on the concentration of these molecule and on the thickness of the irradiated slices

Substances of very low density --> Negative CM.Substances of with high x-ray density

CLASSIFICATION OF X-RAY CLASSIFICATION OF X-RAY CONTRAST MEDIUM (CM)CONTRAST MEDIUM (CM)

Negative CM Positive CmGases-air BaSO4 Iodinated CM-CO2

- Triiodobenzoic acid Water insoluble CM OilyCM

derivertives- aqueous suspensions

-diiodopyridine

Monomeric ionic cM Dimeric ionic CM

Monomeric nonionic Cm Dimeric nonionic CM

• Main CM use today are --> Insoluble BaSO4 --> diagnosed GI tract

--> Water soluble CM --> Vascular system

--> Body cavity

and organs

-- Barium sulfate > ใน GI tract

-- > Peritonium ไม่� สาม่ารถ Absorpt ได้

Development of CMDevelopment of CM• Water solubel CM Water solubel CM เร��ม่ เร��ม่ 1925/1926 by Arthur Bing 1925/1926 by Arthur Bing

synthesized organic iodine preparations of synthesized organic iodine preparations of pyridinepyridine

- - -- 5 iodo 2 pyridone acetic acid.- - -- 5 iodo 2 pyridone acetic acid. Uroselectan (Bing and Rath) Uroselectan (Bing and Rath)

Monoiodinated pyridine Monoiodinated pyridine compound use for IV compound use for IV urography by Moses Swick urography by Moses Swick

-- > Improving solubility-- > Improving solubility-- > Increasing iodine content-- > Increasing iodine content-- > toxicity-- > toxicity

N

I

O

CH2 -OOO Na+

-- Uroselectan > two product -- Uroselectan > two product โด้ย โด้ย Solubility by Solubility by

changing side chain ; adding changing side chain ; adding methylglucamine methylglucamine

(Far next 20 (Far next 20++ Years) Years)

-- > Iodine-- > Iodine เป็�น เป็�น 2 2 atomsatoms

DIODONDIODONEE

NEOIPAXNEOIPAX

N

I I

O

CH2

COO (Methylglucamine)+

Diiodinated pyridine co Diiodinated pyridine co -19301950mpoundsfrom -19301950mpoundsfrom

N

O

CH3

COO-Na+Na+COO-

I I

•

•Benzene ring is the precursor of the MODERN”, Water soluble contrast agent

12

34

5

6

COOH

I

R1

I

R2

I“1950” “ Triiodinated CM”

- - COOH Salt/amide binding, water solubility- R

1/R2

- toxicity and lipophillia- R

2 - elimitation pathway

• Carboxyl group -- > อาจอยู่��ในรู�ปของ Na+ / Meglumine salt ซึ่��งทำ�าให้�แตกต�วเป�น cation,

anion ซึ่��งเรู�ยู่กว�า Ionic contrast

media ซึ่��งจะเก�ด adverse reaction และทำ�� สำ�าคั�ญคั%อ osmolality

12

34

5

6

COO-

I

NHCOCH3

I

CH3COHN

I“1955”

““ Diatrizoic acid” Diatrizoic acid”AngiographinAngiographinurografinurografinUrorisonUrorisonHypaqueHypaqueRenografinRenografin

12

34

5

6

COO-

I

CONHCH2CH2OH

I

CH3COHN

I

IoxithalamateIoxithalamateTelebrixTelebrix

สารป็ระกอบด้�งกล่�าวจะอย��ใน สารป็ระกอบด้�งกล่�าวจะอย��ในSolution of salt Solution of salt ได้ แก� ได้ แก�sodium sodium แล่ะแล่ะ// หร!อ หร!อmeglumine saltmeglumine salt

-- - 1968 > Non ionic contrast -- - 1968 > Non ionic contrast โด้ยการเพิ่��ม่ โด้ยการเพิ่��ม่ Non-ionizing Non-ionizing

glucose glucose ที่$� ที่$� carboxyl group carboxyl group ----> > non-ionizing non-ionizing compoundcompound

ที่$�สาม่ารถล่ะล่ายน%&าได้ ที่$�สาม่ารถล่ะล่ายน%&าได้ ---- o>---- o>oo ooooooo oo ooooooo

C

I

O NH

NHCOCH3

I

NCH3CO

CH3

I

CONHCHCH2OH

CH2OH

I

I

I

CONHCHCH2OH

CH2OHCH3CHCONH

OH

OH OH

OH OCH2OH

MetrizamideMetrizamide IopamidolIopamidol

I

II

I

R3 COO-

R2R1

I I

Ionic monoacid dimeric compound Ionic monoacid dimeric compound Ioxalic acid Ioxalic acid

Osmolality of ionic and Osmolality of ionic and nonionic CM nonionic CM

mgI/ml Osmolality mosm/kg water

BloodBlood290

Ionic monomeric CM Ionic monomeric CM Urografin - 30% (sod meg diatrizoate)

146 710

45 219

1050

60 292

1500

76 370

2100

AAAAAAAAAAA AAAA AAAAAAAAAAAA 306 1530

- 38Telebrix (sod meg ioxithalamate) 380 2100

Ionic dimeric CM Ionic dimeric CM - 320Hexabrix (sod meg

ioxaglate) 320 600

Nonionic monomeric CM Nonionic monomeric CM () 300 480

370Ultravist370 770

Iopamiro 370370 800

350Omnipaque350 820

Nonionic dimeric CM Nonionic dimeric CM Isovist 300

300 320

Physicochemical Physicochemical properties of properties of water soluble water soluble

contrast mediumcontrast medium• WATER SOLUBILITY ;– MEGLUMINE SALT > sodium salt .– --- High temp increase , COOH group in ionic CM , hydrop

hillic group in– - non ionic CM.

• VISCOSITY ~ iodine content , molecule size ,low temperature meglumine salt >sodium salt.

• OSMOLALITY = C x N (C =conc. In gm/ L , N =num -ber of particles

M M= molecular weight of total molecule )

• Low osmolality contrast medium ; -ionic monoacid dimeric CM, non ion

ic CM.• Chemical stability ; no toxic

degradation product.• Biochemical safty ; inertcompound

• - conclusion of water soluble CM ; - - high iodine conc , good water solubility - -minimum viscosity ,lower /iso

osmolarity - heat and chemical stability

- biologic inertness - selective excretion

- safety and reasonable cost

CONTRAST MEDIUM CONTRAST MEDIUM TOXICITY TOXICITY

Osmotoxi ci tyOsmotoxi ci ty• Hemodynamic Effects Hemodynamic Effects

– Vasodilatation (local and general) Vasodilatation (local and general)– HemodilutionHemodilution– HypervolemiaHypervolemia– Changes in pulmonary artery Changes in pulmonary artery

pressure, cardiac output and pul pressure, cardiac output and pul monary and systemic resistance monary and systemic resistance

• Adverse Effects Upon Erythrocytes Adverse Effects Upon Erythrocytes– Crenation, rigidity Crenation, rigidity– Mobility resulting in tissue anoxia and incresed pe Mobility resulting in tissue anoxia and incresed pe

ripheral resistance in microciculation ripheral resistance in microciculation• Adverse Effects Upon Capillary Endothelium Resulti Adverse Effects Upon Capillary Endothelium Resulti

ng in ng in – Tissue anoxia– Increased capillary permeability–Vasodilatation– Systemic hypotension– Osmotic hypervolemia

CHEMOTOXICITY : ION CHEMOTOXICITY : ION AND MOLECULAR AND MOLECULAR

EFFFECTSEFFFECTS Molecular Toxicity Molecular Toxicity– Detrimental effects on Detrimental effects onerythrocyteserythrocytes

– Prolongation of thrombin time Prolongation of thrombin time– Increased coagulation time Increased coagulation time– Inhibition of normal platelet Inhibition of normal plateletaggregationaggregation

– Histamine release Histamine release– Increased cholinergic activity Increased cholinergic activity

ORGAN SPECIFIC ORGAN SPECIFIC TOXIC EFFECTSTOXIC EFFECTS

• Contrast media can produce a combination of e Contrast media can produce a combination of e xcitatory effects associated with their chemica xcitatory effects associated with their chemica

l molecular structure and inhibitory effects ass l molecular structure and inhibitory effects ass ociated with their hypertonicity. These effects ociated with their hypertonicity. These effects include seizures, clonic spasms, mental distur include seizures, clonic spasms, mental distur bances, and occasionally more serious complic bances, and occasionally more serious complic

ations such as aphasia, cortical blindness, and ations such as aphasia, cortical blindness, andencephalopathy.encephalopathy.

• Nonionic media are significantly better tolerat Nonionic media are significantly better tolerat ed by the central nervous system. The use of i ed by the central nervous system. The use of i

onic products has beeen abandoned completel onic products has beeen abandoned completel y in myelography. y in myelography.

Adverse Effects Upon the Cardiovascular System• Electrophysiologic effects Electrophysiologic effects

– Heart rate alterations Heart rate alterations– Atrioventricular conduction delay Atrioventricular conduction delay–ArrhythmiasArrhythmias

• Hemodynamic Effects Hemodynamic Effects–HypotensionHypotension– Inhibition of LV contraction Inhibition of LV contraction– Alterations in coronary blood flow Alterations in coronary blood flow

• Metabolic Effects Metabolic Effects– Alterations in myocardial Alterations in myocardialmetabolismmetabolism

– Hypocalcemia (calcium chelation) Hypocalcemia (calcium chelation)

Contrast Contrast NephropathyNephropathy

Acute renal failure Acute renal failure - Acute renal failu - Acute renal failu re may occur with or without oliguri re may occur with or without oliguri

-a (less than 400 ml urine per twenty -a (less than 400 ml urine per twenty four hours). four hours).

Serum creatinine Serum creatinine is a slow reactor is a slow reactor to nephrotoxicity and usually peaks to nephrotoxicity and usually peaks

after two to seven days. More precis after two to seven days. More precis e clearance measurement are, howe e clearance measurement are, howe

ver, seldom available. ver, seldom available.

Functional. Effects Functional. Effects - - Functional effects on rena Functional effects on rena

l glomeruli and tubules of l glomeruli and tubules of mild to moderate degree mild to moderate degree

may be seen but the effe may be seen but the effe ct on the glomerular filtr ct on the glomerular filtr

ation rate is minor. ation rate is minor.

Possible Mechanisms in Possible Mechanisms in the Development the Development

of Acute Renal Failureof Acute Renal Failure Hemodynamic Changes Hemodynamic Changes

Reduced renal blood flow Reduced renal blood flow Increased blood viscosity Increased blood viscosity

Erythrocyte alterations, Erythrocyte alterations, Endothelial damage Endothelial damage

Platelet aggregation, Thrombus formati Platelet aggregation, Thrombus formationon

Increased intratubular pressure caused Increased intratubular pressure caused by intratubular obstruction by intratubular obstruction

Reduced filtration fraction Reduced filtration fraction

Intratubular Obstruction Intratubular Obstruction Gel formation from mucoproteins

Albuminuria Increased excretion of uric acid Increased excretion of oxalate

Reduced glomerular filtration rate

Tubular Cell Damage Tubular Cell Damage Acute tubular necrosis

Medullary necrosis Vacuolization (*osmotic nephrosis *)

Tubular functional disturbances . Immunologic Mechanisms Immunologic Mechanisms

Proliferative glomerulonephritis Antibody formation Allograft rejection , Complement activation

.

RISK FACTORS AND RISK FACTORS AND PREDISPOSING FACTORS PREDISPOSING FACTORS

FOR NEPHROTOXICITY FOR NEPHROTOXICITY• Chronic renal insufficiency• Diabetes (and reduced renal

function)•Dehydration• Contrast dose and time

relationships of contrast injections.• --- Obstructive uropathy myeloma .• Advanced age.• surgery and vascular interventional p

rocedures.

ADVERSE ADVERSE REACTIONREACTION

แบ�ง ตาม่สาเหต)ได้ เป็�น แบ�ง ตาม่สาเหต)ได้ เป็�น 2 2 กล่)�ม่กล่)�ม่ 1. General or largely dose-

independent contrast media reactions (anaphylaxis)

2. Chemotoxic, local and cardiovascular effects, side effects dependent on the dose

General reactions General reactions (anaphylactoid (anaphylactoid

reactions)reactions) -- Mild > urticaria, nausea, retching, feeling hot, sneezing yawning, ticklish feeling in the thorax, buzzing in the ears

-- Moderate > bronchospasm, -- Severe > respiratory dyspnea, tachycardia,

bradycardia, shock / cardiac arrest / fatal

Severe, fatal reaction --> 1:10,000 - 50,000 ไม่�ขึ้+&นก�บ osmolality

Risk factorRisk factor• ผู้��ป(วยู่อายู่)น�อยู่กว�า 1 ป* , ผู้��สำ�งอายู่)มากกว�า 50 ป* , ผู้��

ป(วยู่ม�โรูคัปรูะจ�า ต�วอยู่��ก�อน เช่�น โรูคัห้�วใจ , DM• ม�ปรูะว�ต�แพ้�อาห้ารูทำะเล , ยู่า , เป�น asthma and

eczema , ม� reaction ได�สำ�งข�0นถึ�ง - 45 เทำ�า• ม�ปรูะว�ต�แพ้� CM, เก�ด reaction ได�สำ�งข�0นถึ�ง 11 เทำ�า

แต�อยู่�างไรูก2ด�ในพ้วก mild และ moderate reaction ยู่�งไม�ถึ%อว�าเป�น absolute contraindication

• การูตรูวจ พ้บว�าการูฉี�ด I.V. ทำ�าให้�เก�ด reaction ได� มากกว�าการูฉี�ด I.A., dose ของ CM พ้บว�าไม�เก��ยู่วข�อง

ก�บการูเก�ด general reactions แต�อาจจะม�ผู้ลต�อรูะบบ ต�าง ๆ ของรู�างกายู่ได�

ProphylaxisProphylaxis• ซั�กป็ระว�ต� allergy, หล่�งจากฉี$ด้ยาแล่ วให คาเขึ้/ม่ไว อย�างน อย

10 นาที่$• ส%าหร�บผู้� ป็1วยที่$�ม่$ risk ส�ง ควรจะให steroid เพิ่!�อ

prophylaxis อย�างน อย 12 ชั่��วโม่ง

• 32 12Methylprednisolone ( mg) แล่ะ 2 ชั่��วโม่งก�อนตรวจ

• Prednisone (20 mg) ที่)ก 6 ชั่��วโม่ง จ%านวน 3 คร�&ง ก�อนตรวจ

• Hydrocortisone (100 mg) ที่)ก 6 ชั่��วโม่ง จ%านวน 2 คร�&ง ก�อนตรวจ แล่ะอาจจะให histamine receptor

blocker ร�วม่ด้ วย

TreatmentTreatment• ถ าเก�ด้ ถ าเก�ด้ mild reaction mild reaction ไม่�ต องให ยาใด้ ๆ แต�ถ าผู้� ป็1วย ไม่�ต องให ยาใด้ ๆ แต�ถ าผู้� ป็1วย

anxiety anxiety ม่าก อาจจะให ม่าก อาจจะให valium I.V> 5-10 mg valium I.V> 5-10 mg ถ าม่$ ถ าม่$cutaneous reaction cutaneous reaction ม่าก อาจให ม่าก อาจให antihistamine I.V. antihistamine I.V. 2 mg 2 mg แล่ะอาจจะร�วม่ก�บ แล่ะอาจจะร�วม่ก�บ hydrocortisone 100-250 mg hydrocortisone 100-250 mg

แล่ะ แล่ะ HH22 receptor antagonist receptor antagonist200 mg.200 mg.

• Moderate --> severe reaction Moderate --> severe reaction – Hypotension, bronchospasm, angioneurotic Hypotension, bronchospasm, angioneurotic

edema edema ให ให adrenaline 1:1,000 subcu. 0.2-0.3 ml adrenaline 1:1,000 subcu. 0.2-0.3 ml หร!อ หร!อdilute dilute เป็�น เป็�น 1:10,000 I.V. 1 ml 1:10,000 I.V. 1 ml ให ให high dose steroid high dose steroid

ค!อ ค!อ hydrocortisone 500-1,500 mghydrocortisone 500-1,500 mg– Bradycardia --> atropine I.V. 0.5-2 mgBradycardia --> atropine I.V. 0.5-2 mg– Hypovolumic shock --> Hypovolumic shock --> ให ให fluidfluid

IMAGING IN IMAGING IN OB / GYNOB / GYNPLAIN FILM .

CONTRAST STUDY .

ULTRASONOGRAPHY .

CT SCAN .MRI .

RADIOGRAPHIC EXAMINATION IN THE

OBSTETRICS.• Radiography ใชั่ ล่ด้ล่งเน!�องจากม่$

ร�งส$•Radiographic signs fetal maturity . Fetal position. Lie . Presentation.•Fetal death and anomalies.

Plain Plain abdomenabdomen

•Confirm pelvic mass; particularly in obese patient

•often possible to see a translucent fat-line between bladder and uterus (Uterine mass tend to lie in the midline, ovarian; tend to remain on their own side)

•Calcification– Uterine fibroid (patchy calcification)– ovarian dermoid ( teeth like

calcification ), high fat content.– Ovarian fibroma– Ovarian carcinoma– -- Tuberculous pyosalpinx > Amorphouscalcification

– ICUD, Intravaginal tampon

•Chest– infertile may be toxic effect from pulmonary i

nfection ห้รู%อเก�ดรู�วมก�บ endometritis /salpingitis–in case of ovarian and uterine carcinoma --> pulmonary metastases and pleural effusion

–Trophoblastic tumour 3 main type of chest metastases

•Skull–sellar turcica

IVPIVP• Demonstrated

distorsion, deviation or obstruction of the urina

ry tract in the pelvis• Ureteric obstruction

• complication ofhysterectomy

- Partial, complete ureteric occlusion by a suture

- --Hydronephrosis > incomplete occlusion

- Extravasation of CM from the ureter into

pelvic fasia- Vesicovaginal fistula- Pelvic accumulation of

blood (hematoma) or lymph (lymphocyst)

•Cystography– Used to investigate stress incontinence an

d demonstrated vesicoureteric reflux• Barium enema

– Bowel involvement by spreading of pelviccarcinoma

•Hysterosalpingography– -- Indication/contraindication > slide เด�ม–Any water-soluble contrast medium can use.

HYSTEROSALPINGOGRAPHY

1. Infertility 2. Recurrent abortion3. To monitor the effects of tubal surgery

The contraindicatio

ns are:•Active pelvic sepsis•Severe renal or cardiac disease•Sensitivity to contrast media•Recent dilatation and curettage•Pregnancy•The week prior to and the week following menstruation.

•The examination is best performed at about the middle of the menstrual cycle.

Complication• -- Pain > Hypogastric colic; probably

related to distension of the uterus

-- > lower abdominal pain due to peritoneal irritation

• -- Venous intravasatio > excessic injection pressure

• Exacerbation of pelvic infection

Normal Normalhysterosalpingoghysterosalpingog

ramram Normal uterine cavity is approximately triangular, wi th sides of 3 .7 cm. The cervical canal has a length

about 2 .5 cm or less. Thecor nua of t he ut er us ar e of t en seen.

-- Isthmicpar t of t he Fol l opi an t ube >di ffi cul t t o i dent f y

-- Broaderampul l ar y and i nf undi bul ar >usual l y dear l y seen.

-- Spillage >Amor phous st ape ar ound t he end of t he t ube

The abnormal The abnormalhysterosalpingoghysterosalpingog

ramram• Conginital anomaly of the

-- uterus > Varying degree of failure of fusion of the

Mullerian ducts

Abnormality of Abnormality of the fallopian the fallopian

tubestubes• -- Salpingitis/Hydrosalpinx > Result in b lockage of the tube ; complication from previous infection

• -- Tuberculous salpingitis > Tuberculosis usually result in obstructi

on of their distal ends, irregular caliber of the tube with small filling defect and

some dilatation of their peripheral part

• --Salpingitis isthmica nodosu > tiny fragments of contrast

medium are seen apparentty lying outside the main lumen

of the isthmic part of the tub es., may be related to endom

etriosis

• -- Tubal blockage > commonest abnormality

-- > no contrast medium being split on the peritonium

สาเหต ) 1 Poor operative technique 2. Tubal spasm 3. Obstruction following tubal infection or operation 4. Fimbrial adhesions 5. Tubal pregnancy 6. Sterilization procedure

Indication of -ultrasound in OB G

YN• Gestational age .• Growth of fetus .• Multiple gestation .• Fetal death .• Location of placenta .• Fetal anomaly.• Adnexal mass .

Obstetric ultrasound .

• Normality and abnormality of the1 st trimester.

• Assessementof the gestati onal age an dfetal number.

• Structural abnormal i ty.• Growthand fetal wel l bei ng thro

ughoutpregnancy .

FIRST TRIMESTER SONOGRAPHY .

•Localization of gestational sac at 4weeks.

•Fetal node at 6 weeks.•Cardiac activity at 7weeks.•Number of fetus.•Fetal age ----CRL ,femur,BPD.

Ultrasound Features of Normal Intrauterine

Pregnancy• Ear l i est si gn i s f undal endomet r i al t hickeni ng

• At5wks, gest at i onal sac shoul d be vi si bl e– The gest at i onal sac i s sur r ounded by an ec

ho dense r i ng– - Normal sac grows at a rate 0.7 1.75mm/day fro

- m 5 1 1 wks• 6At wks, embryonic structures appearanc

A• 65At . wks, positive cardiac movement

– 5Crownrumpl engt h appr oxi mat el y mm.

Transvaginal Ultrasound in Intrauteri

ne Pregnancy• - 3Gestational sac seen as early as

oo o o o o2 1 0 0 0/.

• - ooooo oo oooo ooooooo100%7 200/.– - 3640Firstseenbetween daysandwhen gest at i onal sac bet ween

- o o o69

•oooooo oooo o ooooo oooo - oo ooo ooooooooooo oooooo o o oooo ooo o ooo ooo ooooo4 0

9tionalsacdi ameter i s greater than mm.

Fetal Cardiac Dysrhythmias

• normal heart rate : - 120 160 bp

m

Fetal position•Lie

–Longitudinal - normal–Transverse oblique - abnormal

•Presentation–Normal - vertex–Abnormal - face

Fetal position,cont•Position

–Fixed–Hyperflexion

• Fetal death• - Spalding’s sign 2 3 days to appear• unreliable if head engaged after 3

6wks• - 4 4Gas in heart or SVC Hrs dayA

•AAAAAAAAAAAA

Fetal ageassesment

• LMP = uncertain-2040%

•Obj ect i ve– Antinatal Manage

• Fetal Well Being• Decision for fetalmaturity

Fetal age assesment by radio

graphy• 1052/ just be visible• 1452/ definite fetus visible• 2452/ calcaneus• 2652/ talus• AAA AA AAA AAAA AAAAAAAAA36 /52• 3852/ upper t i bi a

AAAAAAAAA•AAAAAAAA

Fetal Age Assessment by

US•Definition– - CR = crown to rump distant (cm)– Biparietal diameter = head diamete

r across the thalami– Fetal age = number of wks since fertilization

– Gestational age = no. wks since last menstrual period

– GA = FA + 2 wks

Fetal Crown - Rump Length

• Real time machine

•CRL 8-13 weeks• Length of pregnancy +/- 5 days

Fetal Femur• - 1Length of femur +/ week• - oooo14 23•oooo oo oooo oooo ooooooooo•ooooo oo o oooooooooo ooooooooo oooo

o ooo23

Fetal AgeAssessment

, cont• Calculation of Gestational Age ()– 6CR(cm) +– oooo oo ooo() 4+ 2 , 15– -4 1 152BPD (cm) x + , if bet.

0 wks– 4 20BPD (cm) x , if older thanooo

Ectopic Pregnancy

• Endometrial thickening.• Adnexal mass.• Fluid in the Pouch of Douglas.• Demonstrated of a living fetus outsid

e the uterus 10%• HCG level > 1800 mIU/ml with no evi

dence of an intrauterine pregnancy.

Second and Third Trimester• Fetal life / number

• Presentation• Abnormal heart beat• Amniotic fluid

– 05233Total intrauterine volume = . x Lo o o o o

– o o1 2 = 3 5– - 1718 250week = ml– 1100term = ml

• 2000Polyhydramnios > ml• o o< 4 0 0

Fetal abnormalities

•Hydrocephalus– disproportionately

large head

•Anencephaly– no cranial vault visible– dense cranial base

Placenta• 6Normal position cms above internal os.• - 3.4 3 .8 .

– 4DM thicknes > cms.– A AA AA> 7 .

•AAAAAAAA AAAAAAAA–AAAAAAAA AAAAAA–AAAAA AAAAAAAA AAAAA AA AAA AAAAAAA

• Abruptio placenta–A AAAA AAAA AA AAAA AAAA AA AAAAAAAAAAAAA AA

AAAA

Differential diagnosis Differential diagnosis of pelvic massesof pelvic masses

•Size• Pelvic inflammatorydisease

• The internal echopattern

•Ascites

Ovarian tumours Ovarian tumours Benign features Malignant features

size<10cm Size >10 cm Smooth walls

Irregular or poorly defined walls Unilocular cyst Complex cyst with solid component

Multilocular with thin septa Debridinous No debris Ascites

Mass effect only Metastatic nodules or nodes Mass effect only Metastatic nodules or nodes

Mobile - Fixation to pelvic side wall oromentum

The differential The differential diagnosis ofdiagnosis of

pelvic fluid collection pelvic fluid collection includes:includes:• Abscess secondary to PID

• Abscess secondary to sepisi in the abd ominal cavity

•Endometriosis• Physiological fluid, e.g. follicle rupture• Ectopic pregnancy• Dermoid cyst• - Fluid filled bowel loop• Appendix abscess or mucocoele.

EndometriosisEndometriosis Endometriosisistheectopiclocationandfunctioningofendomet r i al gl ands and st r oma and,

- although found in 1 0 2 5 % of laparoto mies, it rarely produces severe symptoms.

The most common si t es, i n descendi ng o r der of f r equency, ar e:

Ovaries Uterine ligaments

Retrovaginal septum Pelvic peritoneum

Rar e si t es - umbi l i cus- abdominal scars- appendix- vagina, vulva, or peritoneum- omentum- lymph nodes.

The differential diagnosis is mainly from ot her haemor r hagi c l esi ons such as ect op

ic pregnancy, ovarian tumours or from der moid cysts with finely echogenic contents.

MRI OF THE FEMALE PELVIS

• Why MRI ?•MRI in Normal Female Pelvis

•Indications for MRI•MRI Techniques•MRI in Female Pelvis Pathology

•MRI in Pregnancy

Why MRI?• Its superior soft tissue contrast.• Multiplanar capabilities.• Pelvis array surface coils allow fo

r increased signal to noise and s uperb spatial resolution.

• Respiratory motion is less of a co nsideration in pelvic than in the

abdomen.

MRI in Normal Female Pelvis

• Uterus consists of a high signal endom etrium surrounded by a thin lowsignal

junctional zone and intermediate signalmyometrium.

• Thej uncti onal zone i s actual l y the i nn er portion of the myometrium.

• The endocervical canal is continou s with the endometrium and has hi

gh signal.• The surrounding stroma is low signal.

Indications for MRI

• Congenital Anomalies• Benign Diseases of the Uterus

–Lei omyoma–Adenomyosis

• MalignantDiseases of the Uterus– Pretreatment evaluation– Cancer of the Endometrium– Cancer of the cervix

MRI Techniques, T1 - weighted image

• -Axial plane from renal hilus symphysi s pubis

• Provide tissue characterization–Hemorrhage–Fluid–Fat

• Identify lymphadenopathy• Glucagon 1 mg IM reduce bowel movement

MRI Techniques, T2-weighted image

• Axial and sagittal planes.• Demonstrate the zonal anatomy an

d sourrounding organs.• - Pelvic coil with a FOV of 20 24 cm.• TR greater than 3500, TE > 100.• 256 195 5Matrix x and a mm slice thickness.

• Coronal view for ovary