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Atypical Appearance of a Molar Pregnancy

Posted by Julie Gaston

Aug 3, 2015 8:26:07 AM

Hydatidiform Molar Pregnancy occurs when the cells that are supposed to form the placenta grow abnormally. In a “complete mole” or CHM no normal fetal tissue is present. In a “partial mole” or PHM fetal tissue is identified. There is also an invasive mole, a coexistent live fetal pole with mole and a malignant form, coriocarcinoma. This blog will focus on a case that was diagnosed as a CHM. Routinely, these patients will present with abnormally high serum hCG levels and an enlarged uterus. A recent study suggests that only 60% of patients will have vaginal bleeding. They can also present with anemia, hyperemesis, hypertension, and ovarian theca-lutein cysts.

Most sonographers are aware of the classic “cluster of grapes” appearance of the uterus with a molar pregnancy. Like these 2 images from the web:molar_pic_1

Here is a case with an atypical ultrasound appearance. A 25 year old female came in for a routine early ultrasound exam to establish dating and viability. She presented with no symptoms. By her last menstrual period she should have been around 8 weeks 6 days along. She had no blood work yet, only a positive urine test.

Upon evaluating the pelvis transabdominally the uterus measured large, greater than 15 cm. Transvaginally, multiple large cysts were identified. A large hyperechoic solid mass was seen encompassing the endometrium. No fetal pole, yolk sac or true gestation sac was identified. The ovaries appeared normal without evidence of a theca-lutein cyst.molar_pic_2

 

An immediate serum hCG was ordered and was 160,252. Two days later a D & C was performed with suction. Serial serum hCG labs where performed and dropped each week (4660, 1655, 135, 10) until they reached 0 which took about 6 weeks. The patient has recovered and is planning on conceiving again this summer. molar_pic_3

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Topics: OB Gyn Ultrasound

Nuchal Translucency

Posted by Julie Gaston

Jun 15, 2015 4:04:48 PM

I am in the process of turning in images to the Fetal Medical Foundation and thought it was an appropriate time to write a blog on NT’s. As a reminder for those that already do them and a resource for those that are looking to become certified. Remember that the gestational period must be between 11 and 13 weeks 6 days. This equates to a crown rump of between 45 and 84 mm. Patients may be off on dates and referring physicians may have incorrectly measured the crown rump length in the original exam- so I have found that measuring the CRL first will save you a lot of time and frustration. If you do find the patient is too far along for the NT screening, move forward with biometry and limited anatomy including arms, legs, hands, feet, stomach, bladder, cord insertion, and choroids. These patients will then be counseled on their options regarding further testing.

Once you establish that the fetus is within the appropriate gestational age for a nuchal translucency screening, try to image the fetus in a supine position. NT_blog_pic_1-1This may require a steep angle and creative maneuvering but it will be worth it. You can image the fetus prone and then invert the image. I just find that it is more difficult to image the face in a true midline position this way. Now that you have the fetus in the correct plane to measure, you want to magnify, magnify, magnify! The fetal head and thorax should occupy the whole screen. This can be tricky as the fetus may bounce around in and out of your box, be patient! Eventually he or she will settle.

You must visualize the echogenic tip of the nose, the palate, and the translucent diencephalon. You do not want to see the zygomatic process of the maxilla. Your eye will move back and forth from the profile to the back of the neck. Try to move the fetus perpendicular with your probe so the NT will be crisp and clear. Remember that the head should be in a neutral position. If the baby extends the neck back it may falsely elevate the NT measurement. If the chin is down and the neck is flexed it can be falsely decreased. Always measure the largest part and make sure that the inner border of the horizontal line of the calipers is placed on the echogenic line that defines the NT thickness not in the fluid. Keep the gain down and the dynamic range high to image a crisp line for measuring. Most systems have a setting for NT measurements so try and start there.NT_blog_pic_2

This image shows the amnion separate from the NT. Take great care to distinguish between the two so you do not measure the amnion by mistake. Always take 3 or more measurements because they can vary from position to location. Good luck and may all your babies cooperate!

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Topics: OB Gyn Ultrasound, Nuchal Translucency

Case Study: Ovarian Serous Carcinoma

Posted by Julie Gaston

Mar 27, 2015 11:50:00 AM

High grade ovarian serous carcinoma (HGS-OvCa) accounts for about 70% of ovarian cancer in the United States. Unfortunately, most of these are diagnosed at advanced stages, when the tumors have already metastasized resulting in a 5-year survival rate less than 40%. Therefore, early detection of ovarian serous carcinoma is critical in saving patients.

The following images are from a 41 year old patient that presented to the emergency room for the second time with severe lower abdominal pain. She did not complain of a lack of appetite or bloating. She has no family history or ovarian or uterine cancer.

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An ultrasound was performed and showed a complex right ovarian mass with arterial and venous blood flow. The uterus and left ovary and adnexa were normal. No free fluid was identified in the pelvis or abdominal cavity. 

A CA-125 was ordered before surgery and was elevated at 120. The right ovary and tube were removed with laproscopy. A pelvic washing was performed which was negative for cancer. Pathology was sent and Gynecological Oncologist confirmed the diagnosis of high grade serous carcinoma. The next step was a robotic total laparoscopic hysterectomy with left salpingo oopherectomy, omentectomy and pelvic and paraaortic lymph node dissection.

This case is an example of how pelvic ultrasound is a critical tool for identifying ovarian cancer. As sonographers, it is our job to methodically evaluate the pelvis and use all the tools available to us (color, PW, power Doppler) to investigate lesions. Thankfully, for this patient there was no evidence of metastasis and she is now planning her wedding!

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Topics: OB Gyn Ultrasound

My Patient Has a 2 Vessel Cord... Now What?

Posted by Julie Gaston

Feb 19, 2015 10:20:55 AM

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It’s been a while since I have seen a single umbilical artery (SUA). I came across it the other day and this prompted an investigation. What is the significance? What should I look for next?

Let’s begin with how to best determine a single umbilical artery. Some sonographers like to view the umbilical cord in a transverse plane. Here you can identify the 2 small arteries adjacent to the larger umbilical vein. This can be challenging when there is limited amniotic fluid or you have a suboptimal machine. See the image below, this is a transverse view of the umbilical cord and it is difficult to confirm that there is only one umbilical artery.

This next image was taken at 22 weeks and it is clearer in the transverse plane. Remember that you will most likely be performing your fetal anatomy survey ant 18-19 weeks gestation so you will not have the luxury of this beautiful shot at 22 weeks. cord_2

I feel that imaging the bladder with color Doppler and seeing the umbilical arteries course along each side is the best way to identify a SUA. Remember a few key points here: First, make sure that you are not 90 degrees on the arteries. This may prevent accurate color Doppler fill in. If you only see one artery, tilt your transducer to make sure you are looking from different angles. Secondly, make sure that you are not looking at the iliac arteries. You will see them bifurcate from the aorta. The next 2 images are taken just moments apart. The first you can clearly see one artery from the cord insertion but there is flow identified around the bladder on both sides. As the sonographer steepens her angle you can identify a single umbilical artery and then just a transverse shot of the iliac artery on the other side. This was taken on the same patient as the transverse images at the 18 week fetal anatomy scan and confirmed the suspicion for SUA.

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You have identified a SUA, now what? A single umbilical artery is the most common umbilical anomaly, which occurs in approximately 1% of pregnancies. According to Peter Callen in “Ultrasonography in Obstetrics and Gynecology”, Trisomy 18 is the most common aneuploidy associated with SUA. The next common aneuploidy is Trisomy 13 followed by Turner’s Syndrome then triploidy. SUA is also associated with an increased risk of congenital anomalies, prematurity and intrauterine growth restriction. There is not a consistent pattern of anomalies. Therefore a detailed fetal anatomic survey is critical, paying special attention to the organs, heart and growth. Research suggests that a SUA without any other abnormal findings is benign.

In conclusion, once a SUA is identified we should pay special attention to fetal anatomy and growth. This should not be any different from our routine when performing a fetal anatomy scan. If you do not identify any anomalies, you will likely see this patient back throughout her pregnancy for serial growth scans.  

Below are a few more ultrasound images taken at 22 weeks:

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Topics: OB Gyn Ultrasound