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

22

Tara Benjamin, HMS IIIGillian Lieberman, MD

AgendaAgenda

I. UltrasoundI. UltrasoundII. Patient PresentationII. Patient PresentationIII. Cervical IncompetenceIII. Cervical IncompetenceIV. Supplemental Patient PresentationIV. Supplemental Patient Presentation

33

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.

44

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).

55

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

66

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

77

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”

88

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

99

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

1010

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

1111

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

1212

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

1313

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.

1414

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

1515

Tara Benjamin, HMS IIIGillian Lieberman, MD

Patient L.S.Patient L.S.-- TransvaginalTransvaginal UltrasoundUltrasound

Normal L.S.

Sources: BIDMC PACS

EndometriumUterus

Endocervical canal

CervixCervix

1616

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

1717

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

1818

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)

1919

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

2020

Tara Benjamin, HMS IIIGillian Lieberman, MD

Cervical IncompetenceCervical Incompetence-- Treated Treated by by CerclageCerclage

Cerclage sutures

Funneling endocervical canal

Source: BIDMC PACS

2121

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

2222

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.

2323

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

2424

Tara Benjamin, HMS IIIGillian Lieberman, MD

K.P.K.P.

DiagnosisDiagnosis-- Cervical IncompetenceCervical IncompetenceTreatmentTreatment-- CerclageCerclage

2525

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

2626

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

2727

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

2828

Tara Benjamin, HMS IIIGillian Lieberman, MD

AcknowledgementsAcknowledgements

Michelle Swire, MDMichelle Swire, MDEamonEamon Kato, MDKato, MDPamela Pamela LepkowskiLepkowskiGillian Lieberman, MDGillian Lieberman, MDLarry BarbarasLarry Barbaras

2929

Tara Benjamin, HMS IIIGillian Lieberman, MD

DedicationDedication

This talk was inspired by and is dedicated This talk was inspired by and is dedicated to the loving memory of to the loving memory of NylaNyla..