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12/2/2014

SYMPOSIUM
EQUIPMENTS

 Purpose (s)
 Indications
 Safety
 Budgeting
 After sales service
 Education and training
program

DR. Dr. WIKU ANDONOTOPO, SpOG (K)

DEPT. OB/GYN, Sub-


Sub-Divisi Fetomaternal
FK-
FK-UI/ RSUD TANGERANG, BANTEN
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THE ULTRASOUND EQUIPMENT : COMPONENTS


AND THEIR USES Ultrasound Frequency
1. The probe, in which the transducer is  Transvaginal probe : 5 – 10 MHz
housed
2. The control panel  ↑ Frequency → ↑ image resolution → ↓
3. The freeze frame penetration of the sound beam
4. Measuring facilities
5. A means of storing images
 Safety concern
 2D, 3D, 4D, and Doppler

3 4

Probe (s)

 Consist of a head, shaft, and a grip


 Types : straight, and bending
 Convex probes
 Mechanical sector probes
 3D TV probes
 Accessories of a TV probe

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MEASURING FACILITIES :
The monitor

 Ideally : 2 monitors (operator and


patient/parents)

 View the examination comfortably

 Reduces considerably the risk to the operator of


ergonomic-related repetitive strain injury

ONSCREEN MEASUREMENT
ONSCREEN MEASUREMENT

POSITION
BASIC OF TV SCANNING

 Clearer images : no tissue causing distortion &


reverberation
 High frequency
 Preparing the patient and the probe
 Probe insertion and rotation
 Basic techniques in TV scanning
Cease to be operational DEPENDENT

the acquisition of images


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Probe Insertion and Rotation


1. Wet the tip of condom with clean water or jelly

2. Insert into the vagina slowly and obtain a sagittal


(longitudinal) section of the uterus. Come back when
the orientation is lost.

(Left) Transabdominal sonography requires a full-bladder to see a


3. Make sure that the direction of the image is always
normal size uterus and ovaries (Right). An empty-bladder is preferable fixed
for TVS

Anteversion
Probe insertion & Rotation
 The abdominal side of the patient is displayed on the left side of
the image
Retroversion
 The back side of the patient is displayed on the right side of the
image

 Transverse image : the right side of the patient is displayed on


the left side of the image

 IMPORTANT : Rotate the the probe always from 12 o’clock to 9


o’clock to go from a sagittal section to a transverse section of the
uterus and vice versa
A display of a sagittal section of an anteverted uterus by the TVS approach

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Basic Techniques in TV Scanning

1. Bring the probe head as close as possible to the


object

2. Select the ultrasound frequency appropriately

3. Adjust the depth of the focal zone properly.


Reduce the number of focal zones when seeing
fetal cardiac activity

Basic Techniques in TV Scanning Basic Techniques in TV Scanning


4. Consider the pressure to the object by the probe 6. Use a negative contrast medium (saline) for
head. The probe head should be maintained in a outlining the uterine cavity clearly :
short but adequate distance from soft objects sonohysterography
being viewed
When a clear image cannot be obtained :
5. Palpate the uterus or ovaries with the probe  Put your hand on the abdomen and push the
head, when the patient complains of a lower object toward the vaginal fornix
abdominal pain  TAS, CT, or MRI

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ULTRASONOGRAPHIC EVALUATION OF
Scanning Technique PELVIC BLOOD FLOW

1. Sliding

2. Rotating

3. Rocking
PELVIC BLOOD FLOW
• iliac arteries and veins
4. Panning • extrinsic ovarian vascular system ovarian arteries
• intrinsic ovarian vascular system intraovarian arteries

EXTRINSIC
OVARIAN
VASCULAR SYSTEM

VENOUS
OVARIAN DRAINAGE
HILUS

INTRINSIC OVARIAN
SYSTEM

OVARIAN
HILUS

ARCADE

CENTRAL
MEDULLARY
PART OF THE
STROMA
OVARIAN CORTEX

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• UKURAN FOLIKEL & PERTUMBUHAN


• ARUS DARAH PERIFOLIKULER Day 3 Day 12

• KETEBALAN ENDOMETRIUM & EKHOGENISITAS


• ARUS DARAH SUBENDOMETRIAL

• FOLLICULAR SIZE AND GROWTH


• PERIFOLLICULAR BLOOD FLOW

FOLLICULAR GROWTH DAY 10th

Ovarian US multimodalic view showing a dominant follicle in a regular menstruating


22-year-old woman (7th day of cycle).

From left to right: conventional 2D ultrasound, HDlive, automatic volume calculation


view. HDlive allows a clear visualization of the region of interest: dominant follicle, the
antral follicles periferically and also the medullar ovarian zone, whereas surrounding
redundant structures were eliminated

• 8 - 10th DAY OF THE M.C. DIAMETER 10 mm •RI = 0.50-0.55 - parameter hemodinamik pertumbuhan folikel
• MAX. DIAMETER 19 - 23 mm •RI = 0.42-0.48 – reduksi signifikan resistensi vaskuler pada fase
preovulasi
• GROWTH RATE: 2 - 3 mm/DAY

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ARUS DARAH PERIFOLIKULER H-13 PREOVULASI

HDlive imaging of the dominant follicle on the 12th day of


spontaneous menstrual cycle. The magic cut software allows
a detailed exploration of the region of interest, in this case,
clearly observe the growing follicle and also the cumulus
complex can be seen within the follicle (yellow arrows).
Notice the different HDlive virtual light positioning (green
arrows)

1. PEMBENTUKAN & RI = 0.43 ± 0.04


VASKULARISASI
Multimodalic view of a dominant follicle in a 32-year-old woman in spontaneous cycle.
Upper row from left to right: 2D US showing the dominant follicle and an antral follicle.
Automatic volume calculation (AVC) showing the volumetry of the findings. HDlive of the
2. MATURASI RI = 0.46 ± 0.03
dominant follicle.
Bottom row from left to right: the same case under ultrasonographic view of a reticular
corpus luteum on a late luteal phase confirming ovulation seen in conventional 2D US, AVC
3. REGRESI RI = 0.50 ± 0.04
and HDlive.

FORMATION AND VASCULARIZATION OF THE


CORPUS LUTEUM

HDlive view of a corpus luteum. Notice the different positions of the virtual
light that gives different shadows and images. The translucency mode is
showing in the upper right image

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FUNGSI NORMAL OVARIUM BERDASARKAN POLA KHAS ARUS DARAH KISTA KORPUS LUTEUM
SIKLIK

LUTEAL PHASE LUTEAL PHASE


PERIOVULASI MATURASI REGRESI

Comparative ovarian view 2D vs HDlive.


HDlive. The figure shows a basal comparative US (day 3 of menses) of a patient with
polycystic ovarian appearance. From left to right: 2D US, HDlive and HDlive in translucency view

HDlive in ovarian stimulation. Left: Basal US scan immediately before starting FSH for ovarian stimulation (day 2 of menstrual cycle).
Center: US control 6 days after FSH estimulation, notice the multifollicular development in a photo-like image. Right: HDlive view of a stimulated ovary in IVF cycle

Ultrasonographic evaluation of a polycystic ovary. Upper left: 2D ultrasound evaluation depicting antral follicles surrounding a
hyperecogenic ovarian medullar zone. Upper right: HDlive view of the same case showing a natural-resembling ovarian appearance.
Bottom row: the same ovary after the elimination of redundant structures, clearly showing the peripheral distribution of the follicles and a
dense medullar zone. Bottom left: translucency view

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VASKULARISASI UTERUS

USIA REPRODUKTIV – ARUS DARAH


KONTINU ARUS DARAH A. UTERINA PADA SIKLUS
MENSTRUASI

1
0.98
0.96
0.94
0.92
INFERTILE WOMEN
0.9
FERTILE WOMEN
0.88
0.86
0.84
0.82
0.8
5 7 9 11 13 15 17 19 21 23 25 27

Kurjak et al. Fertil Steril 1991

SPIRAL ARTERY BLOOD FLOW Perfusi A. Spiralis

4 TIPE PEMETAAN ARUS DARAH

ZONA 1 ZONA 3

ZONA 2 ZONA 4

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SUBENDOMETRIAL
ZONA
PR = 26.7 %
from
P < 0.05
ZONA THE ONLY PERIOD OF
HIPEREKHOGENIC
LUAR GESTATION NOT DETECTED
PR = 36.4 %
DIRECTLY
ZONA
HIPOEKHOGENIC P > 0.05
DALAM
PR = 37.9 %
to
PR = Pregnancy Rate Zaidi et al., Ultrasound Obstet Gynecol 1995

3D power Doppler hysterosalpingography PREIMPLANTATION DIAGNOSIS


Fimbriated end of the oviduct PRECONCEPTIONAL POSTCONCEPTIONAL

Oocytes FERTILIZATION

First polar Blastocyst


body Morula 50-100 cells
16-32 cells
Sperm 6-8 cells
2-4 cells

0 2 3 4 5 days

Chorionic villi of a 24-day-old embryo


Microscopic section of branching chorionic villi
covered by trophoblast
Microscopic section of the trophoblastic
shell of a 13.5-day-old blastocyst:

Endometrium on 4th and 5th week of the


normal pregnancy, more (A) or less (B)
vascularized by 3D Power Doppler. We
called this phenomenon the "comet sign" Uterochorionic and intrachorionic circulation at 12th week of normal pregnancy
A) Transparent "glass body" mode of 3D power Doppler mapping
and it indicates the implantation site
B) Color mode of 3D power Doppler angiography

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FETOSCOPY
2D ULTRASOUND COLOR DOPPLER
Uterochorionic blood flow (color rendering, top)
and intervillous blood flow (transparent rendering, down)
A) at 6 weeks B) 8 weeks

4D HD LIVE ULTRASOUND
3D ULTRASOUND
3D PD ULTRASOUND

Peripheral portion of early chorion

Color doppler visualisation of circulation

VISUALIZZATION OF
VISUALI
VASCULARIZATION IS
SYNCHRONOUS WITH THE
EARLY SOMATIC DEVELOPMENT Usefull tool in differentiation of morphology

Secondary
yolk sac YOLKSAC

the first visible


structure within STALK

the gestational sac

GESTATIONAL SAC PRIMARY OF SOURCE OF


EXTRAEMBRYONIC DIAMETER › 8 mm EMBRIONIC AND BLOOD CELLS
STRUCTURE

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• 4.0 - 5.0 mm 5-8 WEEKS


• 6.0 - 6.5 mm 9 - 12 WEEKS

•The yolk sac appears sonographically as a round, translucent, cyst-like structure, often located near
the periphery of the gestational sac
•Transitory organ, function limited on the first trimester
Kurjak A, et al., J Perinatal Med 1994

POOR EMBRYONIC DEVELOPMENT


OR
EMBRYONIC DEATH

CHANGES IN
YOLK SAC
CHANGES IN
APPEARANCE
VASCULAR
(SIZE, SHAPE,
ECHOGENICITY) PATTERN Large yolk sac is associated with chromosomal aberration of autosomal trisomy
Kucuk T, et al. Yolk sac size and shape as predictors of poor pregnancy outcome. J. Perinat. Med. 1999;27:316-320

VOLUME (mm3)
Volume Vascularity VASCULARITY (%)
EARLY CIRCULATION
70 100

90
60
80
DEGREE OF VISUALIZATION

50 70

60
40
50
30
40

20 30

20
Visualisation of
10 circulation:
10
• uteroplacental
0 0
• umbilical
5 6 7 8 9 10 11 12 • embrionic / fetal
GESTATIONAL AGE (WEEKS)
Kurjak A, et a., J Perinatal Med 1994

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5 weeks:
- gestational sac:
embryo and yolk sac
not yet visible

5-6 weeks:
•Early trophoblast (Intervillous Space)
•Lacunar flow
•Secondary yolk sac

The first visible structures within


gestational sac

A 24-25-day-old (2.5 mm) embryo with


12-13 paired somites, located within the amniotic
sac on top of a huge yolk sac, attached to the
chorion

A 20-day-old (2 mm) embryo: a chorionic plate with villi 3D surface rendering of an embryo & YS at 5 weeks
The amnion is attached to the chorion by a connecting stalk

3D power Doppler image of gestational sac during 5th


week of pregnancy showing heart beat of the embryo

3D surface rendering of an embryo at 5 weeks

The brain primordium is divided by a deep and narrow axial furrow

6 weeks :
clear distinction
between embryo ,
yolk sac and amniotic
membrane

3D surface rendering demonstrates embryo and yolk sac


structure at the 6 weeks of gestation

Recognition of rhombencephalic bubble A 38-day-old embryo: the yolk sac is


attached to the umbilical cord

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7 weeks (CRL 10mm)

- extrapolation of yolk sac


to the extraamniotic
periphery
- growth of vitelline duct
- detection of different
circulatory levels 3D surface rendering demonstrates embryo
and yolk sac structure at the 7 weeks

Yolk sac and chorion

H M

8-9 weeks:
•CRL 15mm, head and trunk differentiation
•neural tube, intracranial structures, falx cerebri, A 43-day-old (approximately 13 mm) embryo:
3D surface rendering from the fetus at 8 – 9 weeks'
•cerebral bubbles, choroid plexuses fluorescent illumination makes the structures of
gestation
•recognition of extremities the face very distinct.

11-12 weeks:
• CRL 50mm
• BPD 15mm
• cerebral and facial details
• choroid plexus - dominant
intracranial structure

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