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Ob/Gyn Sonography An Illustrated Review 2nd Edition Jim Baun, BS, RDMS, RVT, FSDMS Professional Ultrasound Services San Francisco, California SPECIALISTS IN ULTRASOUND EDUCATION, TEST PREPARATION, AND CONTINUING MEDICAL EDUCATION iv SPECIALISTSCopyright IN ULTRASOUND © 2016, EDUCATION, 2004 by Davies Publishing, Inc. TEST PREPARATION, AND CONTINUINGAll rights MEDICAL reserved. EDUCATION No part of this work may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic or mechanical, including photocopying, scanning, and recording, without prior written permission from the publisher. Davies Publishing, Inc. Michael Davies, Publisher Specialists in Ultrasound Education, Christina J. Moose, Editorial Director Test Preparation, and Continuing Charlene Locke, Production Manager Medical Education Janet Heard, Operations Manager 32 South Raymond Avenue Pasadena, California 91105-1961 Jim Baun, Illustration Phone 626-792-3046 Stephen Beebe, Illustration Facsimile 626-792-5308 Satori Design Group, Inc., Design Email [email protected] www.daviespublishing.com Notice to Users of This Publication: In the field of ultrasonography, knowledge, technique, and best practices are continually evolving. With new research and developing technologies, changes in methodologies, professional prac- tices, and medical treatment may become necessary. Sonography practitioners and other medi- cal professionals and researchers must rely on their experience and knowledge when evaluating and using information, methods, technologies, experiments, and medications described herein, always remaining mindful of their own, their patients’, their coworkers’, and others’ safety and well-being. Regarding any treatments, procedures, technologies, and/or pharmaceutical products identified, users of this publication are advised to check the most current information provided by product manufacturers and professional societies to verify their latest recommendations regarding methodologies, dosages, timing of administration, practice guidelines, standards of care, and contraindications. It is the responsibility of practitioners, relying on their own experi- ence and knowledge of their patients, to report, make recommendations, and work within these standards, in consultation with other clinicians such as referring and supervisory physicians, to determine to take all appropriate safety procedures and to determine the best treatment of each individual patient. To the fullest extent of the law, neither Davies Publishing, Inc., nor the authors, contributors, reviewers, or editors assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence, or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Library of Congress Cataloging-in-Publication Data Names: Baun, Jim, author. | De Lange, Marie. Ob/Gyn sonography. Preceded by (work): Title: Ob/Gyn sonography : an illustrated review / Jim Baun. Description: 2nd edition. | Pasadena, California : Davies Publishing, Inc., [2016] | Preceded by Ob/Gyn sonography : an illustrated review / Marie De Lange, Glenn A. Rouse. 2004. | Includes bibliographical references and index. Identifiers: LCCN 2015042279 | ISBN 9780941022873 (alk. paper) Subjects: | MESH: Obstetrics--Atlases. | Obstetrics—Examination Questions. | Genital Diseases, Female—ultrasonography—Atlases. | Genital Diseases, Female--ultrasonography--Examination Questions. | Pregnancy Complications—ultrasonography—Atlases. | Pregnancy Complications—ultrasonography—Examination Questions. Classification: LCC RG107.5.U4 | NLM WQ 18.2 | DDC 618.107/543--dc23 LC record available at http://lccn.loc.gov/2015042279 Printed and bound in China ISBN 978-0-941022-87-3 vii Reviewers Marveen Craig Traci B. Fox, EdD, RT(R), RDMS, RVT Vice President, International Foundation for Assistant Professor, Department of Radiologic Sciences Sonography Education and Research (Retired) Jefferson College of Health Professions Founder, International Ultrasound Institute Assistant Research Professor, Department of Radiology Tucson, Arizona Sidney Kimmel Medical College at Nirvikar Dahiya, MD Thomas Jefferson University Assistant Professor of Radiology Philadelphia, Pennsylvania Department of Radiology Diane Kawamura, PhD, RT(R), RDMS, FAIUM, FSDMS Mayo Clinic College of Medicine Brady Presidential Distinguished Professor Phoenix, Arizona Department of Radiologic Sciences Marianna Desmond, EdM, RDMS, RT(R) Weber State University Clinical Coordinator, Diagnostic Medical Sonography Ogden, Utah Triton College Frederick W. Kremkau, PhD, FACR, FAIMBE, FAIUM, River Grove, Illinois FASA Julia A. Drose, BA, RDMS, RDCS, RVT Professor of Radiologic Sciences Manager, Divisions of Ultrasound and Prenatal Director, Program for Medical Ultrasound Diagnosis and Genetics Center for Applied Learning Associate Professor of Radiology Wake Forest University School of Medicine University of Colorado School of Medicine Winston-Salem, North Carolina Department of Radiology Annmarie Lobdell, MHS, RDMS, RDCS, RVT Aurora, Colorado Clinical Technology Consultant Terry J. DuBose, MS, RDMS, FSDMS, FAIUM ZONARE Medical Systems, Inc. Associate Professor Emeritus, Diagnostic Medical Mountain View, California Sonography Darla J. Matthew, BAS, RT(R)(S), RDMS College of Health Professions Program Director University of Arkansas for Medical Sciences Diagnostic Medical Sonography Little Rock, Arkansas Doña Ana Community College Las Cruces, New Mexico viii REVIEWERS Cynthia Reber-Bonhall, RDMS, RVT Jill D. Trotter, BS, RT(R), RDMS, RVT Professor and Program Director Director, Diagnostic Medical Sonography Program Diagnostic Medical Sonography Vanderbilt University Medical Center Orange Coast College Nashville, Tennessee School of Allied Health Professions Ellen T. Tuchinsky, BA, RDMS, RDCS Costa Mesa, California Director of Clinical Education (Retired) Janice Hickey Scharf, BSc, RDMS, CRGS, FSC Diagnostic Medical Sonography Clinical Applications Specialist School of Health Professions Ultrasound, Philips Healthcare Canada Long Island University Markham, Ontario, Canada Brooklyn, New York Susan Raatz Stephenson, MS, MA.Ed., BSRT-U, Claudia von Zamory, BA, RDMS(A)(OB/GYN)(B), RVT RDMS, RVT, RT(R)(C), CIIP Ultrasound Program Director Global Training and Education Radiology Project Gurnick Academy of Medical Arts Manager San Mateo, California Siemens Medical Solutions USA, Inc. Kerry E. Weinberg, PhD, RT(R), RDMS, RDCS, FSDMS Sandy, Utah Associate Professor and Director Regina K. Swearengin, BS, RDMS Diagnostic Medical Sonography Program Department Chair, Sonography Long Island University Austin Community College, Eastview Campus Brooklyn, New York Austin, Texas Mark G. Torchia, MSc, PhD Director, Centre for the Advancement of Teaching and Learning Associate Professor of Surgery University of Manitoba Winnipeg, Manitoba, Canada xi Contents Reviewers vii Preface to the 2nd Edition ix PART I OBSTETRICS 1 Chapter 1 The First Trimester 3 Chapter 2 The Placenta 31 Chapter 3 The Umbilical Cord 53 Chapter 4 Fetal Biometry 67 Chapter 5 The Fetal Face and Neck 87 Chapter 6 The Fetal Central Nervous System 111 Chapter 7 The Fetal Chest, Lungs, and Heart 151 Chapter 8 The Fetal Skeleton 197 Chapter 9 The Fetal Abdomen and Pelvis 219 Chapter 10 The Fetal Genitourinary Tract 247 Chapter 11 The Prenatal Genetic Workup 271 Chapter 12 At-Risk and Multiple-Gestation Pregnancies 301 xii CONTENTS PART II GYNECOLOGY 343 Chapter 13 Pelvic Anatomy and Physiology 345 Chapter 14 Pelvic Pathology 371 Chapter 15 Infertility 409 Chapter 16 Pediatric and Postmenopausal Gynecologic Sonography 421 PART III PHYSICAL PRINCIPLES, PROTOCOLS, AND PATIENT CARE 437 Chapter 17 Physical Principles and Instrumentation 439 Chapter 18 Protocols and Patient Care 461 Appendix A Answers to Chapter Review Questions 477 Appendix B Chapters Cross-Referenced to the ARDMS Exam Content Outline 485 Appendix C AIUM Practice Guidelines 491 Appendix D Application for CME Credit 521 Subject Index 539 PART I Obstetrics Chapter 1 | The First Trimester Chapter 2 | The Placenta Chapter 3 | The Umbilical Cord Chapter 4 | Fetal Biometry Chapter 5 | The Fetal Face and Neck Chapter 6 | The Fetal Central Nervous System Chapter 7 | The Fetal Chest, Lungs, and Heart Chapter 8 | The Fetal Skeleton Chapter 9 | The Fetal Abdomen and Pelvis Chapter 10 | The Fetal Genitourinary Tract Chapter 11 | The Prenatal Genetic Workup Chapter 12 | At-Risk and Multiple-Gestation Pregnancies 1 CHAPTER The 1 First Trimester Sonographic Protocols Normal First Trimester Abnormal First Trimester—Failed Pregnancy SONOGRAPHIC PROTOCOLS During the first trimester of pregnancy, the standard sonographic exam is performed to assess the following: • Presence of gestational sac • Size of sac • Location of sac • Number of sacs • Presence of a yolk sac • Presence of an embryo/fetus • Cardiac activity (using a two-dimensional video clip or M-mode imaging) Spectral and color Doppler imaging is avoided whenever possible during the first trimester as it is associated with a higher exposure to acoustic energy. In addition, the examination should assess the following structures: • Uterus • Cervix • Adnexa • Cul-de-sac 3 4 PART I Obstetrics The rest of this chapter rehearses the development of Laboratory Evaluation a pregnancy during the first trimester, including both Laboratory evaluation typically centers on assays for normal and abnormal sonographic findings, targeted the