14495FM-OBGYN.pgs.qxd 8/16/07 2:33 PM Page iii Ultrasonography in Obstetrics and Gynecology A Practical Approach to Clinical Problems Second Edition Carol B. Benson, M.D. Edward I. Bluth, M.D., F.A.C.R. Professor Chairman Emeritus Department of Radiology Department of Radiology Harvard Medical School Ochsner Health System Director of Ultrasound New Orleans, Louisiana Co-Director of High Risk Obstetrical Ultrasound Brigham and Women’s Hospital Boston, Massachusetts Thieme New York • Stuttgart 14495FM-OBGYN.pgs.qxd 8/16/07 2:33 PM Page iv Thieme Medical Publishers, Inc. 333 Seventh Ave. New York, NY 10001 Editor: Timothy Hiscock Editorial Assistant: David Price Vice President, Production and Electronic Publishing: Anne T. Vinnicombe Production Editor: Print Matters, Inc. Vice President, International Marketing: Cornelia Schulze Chief Financial Officer: Peter van Woerden President: Brian D. Scanlan Compositor: Compset, Inc. Printer: Everbest Printing Co. Library of Congress Cataloging-in-Publication Data Ultrasonography in obstetrics and gynecology / [edited by] Carol B. Benson, Edward I. Bluth. — 2nd ed. p.; cm. Includes bibliographical references and index. ISBN-13: 978-1-58890-612-0 (alk. paper) 1. Generative organs, Female—Ultrasonic imaging. 2. Fetus—Diseases—Diagnosis. 3. Ultrasonics in obstetrics. I. Benson, Carol B. II. Bluth, Edward I. [DNLM: 1. Genital Diseases, Female—ultrasonography. 2. Fetal Diseases—ultrasonography. 3. Pregnancy Complications—ultrasonography. 4. Ultrasonography—methods. WP 141 U462 2007] RG107.5.U4U485 2007 618’.047543—dc22 2006051488 Copyright ©2008 by Thieme Medical Publishers, Inc. This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation without the publisher’s consent is illegal and liable to prosecution. 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However, in view of the possibility of human error by the authors, editors, or publisher of the work herein or changes in medical knowledge, neither the authors, editors, or publisher, nor any other party who has been involved in the preparation of this work, warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from use of such information. Readers are encouraged to confirm the information contained herein with other sources. For example, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this publication is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs. Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain. Printed in China 5 4 3 2 1 The Americas ISBN 978-1-58890-612-0 Rest of the World ISBN 978-3-13-125362-0 14495FM-OBGYN.pgs.qxd 8/16/07 2:33 PM Page v We dedicate this book to our families and friends, who supported us in this project: Carol Benson to her husband, Peter, and her children, Nicole and Benjamin. Ed Bluth to Elissa, Rachel, Jonathan, Marjorie, Irene, and Lawry with gratitude and love. 14495FM-OBGYN.pgs.qxd 8/16/07 2:33 PM Page vii Contents Preface . ix Contributors . x 1 Asymptomatic Palpable Adnexal Masses . 1 Jill E. Langer and Peter H. Arger 2 Acute Pelvic Pain. 11 John S. Pellerito 3 Abnormal Premenopausal Vaginal Bleeding. 21 Edward A. Lyons 4 Infertility . 39 Mary C. Frates 5 Amenorrhea in the Adolescent or Young Adult . 50 Anna E. Nidecker, Harris L. Cohen, and Harry L. Zinn 6 Postmenopausal Vaginal Bleeding . 65 Peter M. Doubilet 7 Family History of Ovarian Carcinoma. 76 Andrew M. Fried and Carol B. Benson 8 Tamoxifen . 90 Beverly G. Coleman 9 First-Trimester Pain or Bleeding or Both . 103 Arthur C. Fleischer 10 Second- and Third-Trimester Bleeding . 110 Barbara S. Hertzberg 11 Premature Labor . 121 Geoffrey Wong and Deborah Levine 12 Estimating Fetal Gestational Age . 133 Chaitali Shah and Ashok Bhanushali 13 Uterine Size Greater than Dates . 143 Beryl Benacerraf 14 Uterine Size Less than Dates: A Clinical Dilemma . 156 Alfred Abuhamad 14495FM-OBGYN.pgs.qxd 8/16/07 2:33 PM Page viii viii Contents 15 Ruling Out Fetal Anomalies . 161 Carol B. Benson 16 Family History of Congenital Heart Disease . 174 Douglas L. Brown 17 Pregnant Women with High Maternal Serum–Alpha-Fetoprotein . 187 Andrea L. Fick and Ruth B. Goldstein 18 Maternal Serum Screening Test Positive for Down Syndrome . 199 Thomas D. Shipp 19 Diabetes Mellitus and Pregnancy . 208 Peter W. Callen 20 Teratogen Exposure. 216 Mark A. Kliewer 21 Postpartum Complications . 237 Donald N. Di Salvo Index . 251 14495FM-OBGYN.pgs.qxd 8/16/07 2:33 PM Page ix Preface We have been pleased by the considerable popularity gynecologist as a sonologist is changing. It is important to achieved by the first edition of Ultrasonography in Obstetrics develop not only accurate diagnostic skills, but also the ap- and Gynecology: A Practical Approach to Clinical Problems. The propriate consultative skills to help direct the workup of clin- second edition builds on the foundation that was originally ical problems. It is hoped that this textbook will assist radi- laid at the Special Course on Ultrasound at the Meeting of ologists, obstetricians, gynecologists, residents, medical the Radiological Society of North America in 1996, and then students and mid-level providers in developing their consul- was further developed in the first edition of this text pub- tative skills regarding the use of ultrasound. lished in 2000. This new edition greatly expands and updates Although some of what is included in this book might be that previous work. considered an opinion, our goal for the second edition of Ul- The overall aim of this textbook is to help the clinician as- trasonography in Obstetrics and Gynecology: A Practical Ap- sess and decide whether sonography or another imaging proach to Clinical Problems is to provide a readable and man- modality is the most appropriate for evaluating a clinical ageable book which will offer guidance for clinicians and problem. In contrast to standard textbooks, our chapters are diagnosticians on the appropriate use of sonography to solve divided according to clinical questions rather than by organ important clinical problems. systems. Our aim is to review the most important clinical is- sues faced by clinicians in their daily practice and to outline approaches for the effective use of sonography and other im- Acknowledgments aging modalities. Most chapters in the second edition have been extensively revised with new illustrations and images The authors would like to thank Drs. Peter Arger, Barbara being added. The authors have attempted to incorporate the Hertzberg, William Middleton, and Carol Stelling for their latest advances in ultrasound as well as to revise earlier rec- help with the conceptual origins for this project. Addition- ommendations based on advances in MRI, CT, and PET. ally, the authors would like to thank Dr. Peter Arger for his Each editor has a special area of interest and all of the au- role as an editor of the first edition. thors are recognized authorities in the fields of ultrasound and radiology. The role of the radiologist, obstetrician, and 14495FM-OBGYN.pgs.qxd 8/16/07 2:33 PM Page x Contributors Alfred Abuhamad, M.D. Peter W. Callen, M.D. Mason C. Andrews Professor and Chairman Professor Department of Obstetrics and Gynecology Department of Radiology Eastern Virginia Medical School University of California—San Francisco Norfolk, Virginia San Francisco, California Peter H. Arger, M.D. Harris L. Cohen, M.D. Professor Professor of Radiology Department of Radiology Division of Body Imaging Hospital of the University of Pennsylvania Department of Radiology Philadelphia, Pennsylvania Stony Brook University Medical Center Visiting Professor of Radiology Beryl Benacerraf, M.D. The Johns Hopkins University School of Medicine Professor Baltimore, Maryland Department of Obstetrics, Gynecology, and Reproductive Biology Beverly G. Coleman, M.D. Harvard Medical School Professor Brigham and Women’s Hospital Radiology Department Boston, Massachusetts University of Pennsylvania School of Medicine Associate Chairman, Abdominal Imaging Carol B. Benson, M.D. Chief of Ultrasound Professor Hospital of the University of Pennsylvania Department of Radiology Philadelphia, Pennsylvania Harvard Medical School Director of Ultrasound Donald N. Di Salvo, M.D. Co-Director of High Risk Obstetrical Ultrasound Assistant Professor Brigham and Women’s Hospital Department of Radiology Boston, Massachusetts Harvard Medical School Director of Ultrasound Services Ashok Bhanushali, M.D. Dana Farber Cancer Institute Department of Radiology Boston, Massachusetts Columbia University College of Physicians and Surgeons New York Presbyterian Hospital Peter M. Doubilet, M.D., Ph.D. New York, New York Professor and Vice Chair Department of Radiology Douglas L. Brown, M.D. Harvard Medical School Professor Brigham and Women’s Hospital Department of Radiology Boston, Massachusetts Mayo Clinic College of Medicine Rochester, Minnesota 14495FM-OBGYN.pgs.qxd 8/16/07 2:33 PM Page xi Contributors xi Andrea L.