Chan Pei Pei Carman

Principal Sonographer, Department of Diagnostic & Interventional Imaging

6 Dec 2014

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Doppler application in

pelvic ultrasound

Anatomy

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http://en.wikipedia.org/wiki/Arcuate_vessels_of_uterus#mediaviewer/File:Uterine_arterial_vasculature.svg

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http://www.dartmouth.edu/~humananatomy/figures/chapter_35/35-9.HTM

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Ovarian Vessels

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https://www.google.com.sg/search?q=ovarian+artery&biw=1229&bih=688&source=lnms&tbm=isch&sa=X&ei=0EhwVJ3iA46CuwSgu4KQCw&sqi=2&ved=0CAYQ_AUoAQ#facrc=_&imgdii=_&imgrc=14VzcIdJJNIGbM%253A%3BrG6UQygjgFWRWM%3Bhttp%253A%252F%252Fnaffaausa.org%252Fwp-content%252Fthemes%252Fmobile_pack_base%252Fgroups%252Fnokia_high%252Ftemplates%252Fgonadal-vein-i8.JPG%3Bhttp%253A%252F%252Fimages.frompo.com%252F7def3442e1707482c4a9d61a6dc2b827%3B672%3B712

• Pelvic arteries <10 – 50cm/s

• Pelvic veins <10cm/s

• Preg RI decreases with gestation

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Resistive

index (RI)

Reproductive Menopause

Uterine artery

branches

0.80 0.84 - 1

Ovary 0.37- 0.67

lowest at late

follicular/early

secretory

0.60 -1

Technical Aspect

Optimized for low flow:

• Power Doppler – more sensitive

• Low pulse repetition frequency: 300 - 600Hz

• Low wall filter

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Technical Aspect

Basic Doppler techniques:

• Appropriate color box size

• Correct Doppler gain

• Not excessive 2D gain – color write priority

• Adequate penetration for Doppler

• Appropriate Spectral Doppler gate size

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LO

Applications

• Cervix

• Endometrium

• Myometrium

• Adnexa

• Pregnancy

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Cervix

Dilatation of endocervical canal with prominent endocervical glands

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Cervical Polyp

Prolapsed Fibropolyp

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Cervix CA

Cervix

• Nabothian cyst – usually do not need Doppler

• Cervical polyp – feeding artery

• Prolapsed fibropolyp – long pedicle

• Carcinoma - hypervascular

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Endometrium

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Polyp vs Submucosal Fibroid

Single primary feeding artery

Periphery vascularity

CA

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CA with 40% invasion into myometrium

Endometrium CA

• More advanced tumour, greater vascularities,

lower resistance

• Wide RI range: < 0.4 - < 0.7

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Myometrium

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Fibroid vs Adenomyoma / Adenomyosis

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Diffuse vascularities

straight through myometrium

Periphery

Leiomyoma vs Leiomyosarcoma

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Leiomyoma

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Leiomyoma

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Leiomyosarcoma

Literature on Leiomyosarcoma

• Literature in 90’s, PSV > 41cm/s, RI < 0.40

• Hypervascular

• Literature since 2007: no reliable Doppler criteria

• >8cm; 50% of cases has cystic degeneration8

• Single uterine tumour, rapid growth

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Adnexa

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Pedunculated Fibroid

Bridging vessel

Bridging Vessel?

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Ovarian CA

Bridging Vessel

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Uterus X

Paraovarian Cyst vs Blood Vessel

Dilated Fallopian Tube vs Blood Vessel

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Tubo-ovarian Abscess

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Torsion

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Big teratoma

Whirlpool Sign

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• Enlarged ovary (+/- ovarian lesion) /

Normal ovary + adnexal lesion

• Raised echogenicity of ovary

• Follicles displaced to periphery

• Whirlpool sign adds specificity: – target with concentric hypoechoic/ hyperechoic strips

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Torsion – 2D features

• Absent venous + enlarged ovary, very suggestive

• Arterial can still be present, ovary has dual supply

• Present of arterial & venous – does not exclude torsion

– viability of ovarian tissue

• Whirlpool sign adds specificity: – Coiling of vessels showing red and blue

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Torsion – Doppler features

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Corpus

Luteum

Mature Follicle

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Clot vs Solid Component

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High grade serous

cystadenocarcinoma

Clot resolve on follow-up

Endometriotic

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vs Tumour

2nd scan

Venous Flow

Doppler artifact

Pregnancy

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Ectopic Pregnancy

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Molar

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Retained Product of Conception (RPOC)

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Arteriovenous Malformation

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Follow-up post embolization

Lack of Typical Doppler Features

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Pedunculated fibroid

Take Home Message

• Apply Power Doppler

• Absent Doppler feature, cannot exclude pathology

• Optimized for low flow

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References

1. Hagen-Ansert SL 2012, ‘The sonography and Doppler evaluation of the female pelvis’, in Textbook of diagnostic Sonography, Mosby.

2. Hagen-Ansert SL 2012, ‘Pathology of the uterus’, in Textbook of diagnostic Sonography, Mosby.

3. Plavsic SK & Larrazaleta M 2013, ‘Use of ultrasound in the field of infertility’, in Kurjak A & Arenas JB, Donald school textbook of transvaginal sonography, 2nd edn, Jaypee Brothers Medical Publishers (P) Ltd.

4. Pozniak MA & Allan PL 2014, ‘Doppler ultrasound of the female pelvis’, in Clinical Doppler ultrasound, 3rd edn, Churchill Livingstone Elsevier.

5. Secil M & Dogra VS 2008, ‘Color flow Doppler evaluation of the uterus and ovaries and its optimization technique’, Ultrasound Clin, 3, pp. 461-482, <10.1016/j.cult.2008.07.004>.

6. Younis JS, Jadaon JE, Haddad S, Izhaki I & Ben-Ami M Apr 2011, ‘Prospective evaluation of basal stromal Doppler studies in women with good ovarian reserve and infertility undergoing in vitro fertilization-embryo transfer treatment: patient with polycystic ovary syndrome versus ovalutory patients’, Fertility and Sterility, vol.95, no.5, <10.1016/j.fertnstert.2011.01.007>.

7. Ahuja AT, Griffith JF, Wong KT, Antonio GE, Chu WCW, Ho SSY, Lolge SJ, Paunipagar BK, Kennedy A, Sohey R, Ho SMS, Woodward PJ & Zwibel WJ 2007, Diagnostic Imaging Ultrasound.

8. Exacoustos C, Romanini ME, Amadio A, Amoroso C, Szabolcs B, Zupi E & Arduini D 2007, Journal of Clinical Ultrasound, vol.35, no.8, <10.1002/jcu>.

9. Hata K, Hata T, Maruyama R, et al. 1997, ‘Uterine sarcoma: can it be differentiated from uterine leiomyoma with Doppler ultrasonography? A preliminary report’, Ultrasound Obstet Gynecol, 9, 101. Exacoustos C, Romanini ME, Amadio A, Amoroso C, Szabolcs B, Zupi E & Arduini D 2007, Journal of Clinical Ultrasound, vol.35, no.8, <10.1002/jcu>.

10. Kurjak A, Kupesic S, Shalan H, et al. 1995, ‘Uterine sarcoma: a report of 10 cases studied by transvaginal color and pulsed Doppler sonography’, Gynecol Oncol, 59(3), 342 – 346. Plavsic SK, Kurjak A & Arenas JB 2013, ‘Uterine lesions’ in Kurjak A & Arenas JB, Donald school textbook of transvaginal sonography, 2nd edn, Jaypee Brothers Medical Publishers (P) Ltd.

11. Auslender R, Shen O, Kaufman Y, Goldberg Y, Bardicef M, Lissak A & Lavie O 2009, ‘Doppler and gray-scale sonographic classification of adnexal torsion’, Ultrasound Obstet Gynaecol, 34, 208-211.

12. Valsky DV, Cohen SM, Hamani Y, Lipschuetz M, Yagel S & Esh-Broder E 2009, ‘Whirlpool sign in the diagnosis of adnexal torsion with typical clinical presentation’, Ultrasound Obstet Gynecol, 34, 239-242, <10.1002/uog.7310>.

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Acknowledgement

Adj A/Prof. Ong Chiou Li

Ms Yang Yin

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