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i

Color Doppler Sonography in Gynecology and Obstetrics

iii
Werner O. Schmidt, M.D.
Professor and Chairman Department of Gynecology and Obstetrics
The Saarland University Hospital
With contributions by:
F. Bahlmann G. Bernaschek
W. Braendle B. Breyer J. Deutinger
A. K. Ert an M. Friedrich
A. Funk U. Gembruch
T. Golaszewski D. Grab H.-J. Hendrik G. Hetzel
T. Hitschold M. Holländer B. Hüneke
A. Kleinkauf-Houcken J. König
Asim Kurjak, M.D., Ph.D.
Professor Department of Gynecology and Obstetrics Sveti Duh Hospital University of Zagreb Zagreb, Croatia
R. Kubale S. Kupesic
A. Kurjak
A. Lindinger C. Lindner H. Madjar D. Mink K. R. Reitnauer H.-D. Rott
W. Schmidt K. Sterzik I. Tossounidis K. Vetter C. Villena-Heinsen H.-J. Voigt E. Weiss
T. Zodan
579 illustrations 90 tables
Thieme
Stuttgart · New York
iv
Library of Congress Cataloging-in-Publication Data
Farbdopplersonographie in Gynäkologie und Geburtshilfe. English.
Color Doppler Sonography in gynecology and obstetrics / [edited by] Werner O. Schmidt, Asim Kurjak ; with contributions by F. Bahl­mann ... [et al.] ; [translator, Terry Telger].
p. ; cm. Includes index. ISBN 3-13-130131-7 (GTV : alk. paper) -- ISBN 1-58890-179-3 (TNY : alk. paper)
1. Color Doppler ultrasonography. 2. Duplex ultrasonography.
3. Generative organs, Female--Ultrasonic imaging. 4. Breast--Can­cer--Ultrasonic imaging. 5. Fetus--Ultrasonic imaging. 6. Ultrasonics in obstetrics.
[DNLM: 1. Genital Diseases, Female--ultrasonography--Atlases.
2. Pregnancy Complications--ultrasonography--Atlases. 3. Ultra­sonography, Doppler, Color--methods--Atlases. 4. Ultrasonography, Prenatal--methods--Atlases. WP 17 F219 2005a] I. Schmidt, Werner, Prof. Dr. II. Kurjak, Asim. III. Bahlmann, F. IV. Title.
RG107.5.U4F3713 2005
618’.047543--dc22
2004022003
This book is an authorized and updated translation of the German edition published and copyrighted 2000 by Georg Thieme Verlag, Stuttgart, Germany. Title of the German edition: Farbdopplersono­graphie in Gynäkologie und Geburtshilfe.
Important note: Medicine is an ever-changing science under­going continual development. Research and clinical experi­ence are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have ma­de every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book. Nevertheless, this does not involve, imply,or express any guarantee or responsibility on the part of the publishers in re­spect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine care- fully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or spe­cialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is par­ticularly important with drugs that are either rarely used or have been newly released on the market. Every dosage sched­ule or every form of application used is entirely at the user’s own risk and responsibility. The authors and publishers re­quest every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at
www.thieme.com
on the
product description page.
Translator: Terry Telger, Fort Worth, Texas, USA
Illustrator: Angelika Kramer, Stuttgart, Germany
2005 Georg Thieme Verlag Rüdigerstraße 14 70469 Stuttgart, Germany http://www.thieme.de Thieme New York, 333 Seventh Avenue, New York, NY 10001 USA http://www.thieme.com
Cover design: Angelika Kramer, Stuttgart, Germany Typesetting by Druckhaus Götz GmbH, D-71636 Ludwigsburg, gesetzt auf CCS Textline (Linotronic 630) Printed in Germany by Grammlich, Pliezhausen
ISBN 3-13-130131-7 (GTV) ISBN 1-58890-179-3 (TNY) 12345
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 b e construed as a representation by the publisher that it is in the public domain.
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. This applies in particular to photostat reproduction, copying, mimeogra­phing, preparation of microfilms, and electronic data proces­sing and storage.

Preface

v
Color Doppler sonography has opened new scopes for our specialty not just in perinatology but also in gynecology and oncology. This new technology has enabled the precise visuali­zation and detailed examination of highly complex vascular structures.
The present book, which contains over 40 contributions from leading experts, is intended to present relevant informa­tion in an easy-to-read format that will be an authoritative guide in both routine and specialized diagnostic situations. Practical tips and guidelines will help the reader to use color Doppler ultrasound appropriately and effectively. Reference curves and documentation guidelines are integrated into the
various chapters.
This book is being published at a time when the clinical relevance of color Doppler sonography has become an ex­tremely topical issue. By providing a comprehensive review of the literature and a detailed subject index, the editors and con­tributing authors have tried to bring newcomers up to date on
the research aspects and clinical applications of color Doppler imaging.
This book can also provide a valuable reference for inter­ested colleagues who are preparing for national registry ex­aminations.
The editors wish to thank their coauthors for their eager
willingness to collaborate on this project. We also acknowl­edge the consistently prudent and constructive help of Dr. A. K. Ertan from our center, who coordinated the contributions, and of the staff of Thieme Medical Publishers. Their efforts helped to speed the book to its completion.
It was the explicit goal of the editors and contributors to provide the interested reader and ultrasound user with a refer­ence that would be of substantial value for everyday clinical
work.
Homburg, Saar and
Zagreb, Kroatien
Werner Schmidt
Asim Kurjak
vi

Contributors

Franz Bahlmann, M.D. Supervising Physician Gynecological Clinic University of Mainz Mainz, Germany
Gerhard Bernaschek, M.D. Professor University Hospital of Vienna Department of Prenatal Diagnosis and Therapy Vienna, Austria
Wilhelm Braendle, M.D. Professor University Hospital Eppendorf Department of Gynecological Endocrinology and Reproductive Sciences Hamburg, Germany
Branko Breyer, M.D. Professor Zagreb, Croatia
Josef Deutinger, M.D. Professor Department of Prenatal Diagnosis and Therapy Vienna, Austria
A. Kubilay Ertan, M.D. Supervising Physician The Saarland University Hospital Homburg, Germany
Michael Friedrich, M.D. Supervising Physician The Saarland University Hospital Homburg, Germany
Andreas Funk, M.D. Associate Professor Director Department of Obstetrics and Gynecology District Hospital Nürtingen Nürtingen, Germany
Ulrich Gembruch, M.D. Professor Department of Obstetrics Medical Center of Obstetrics Bonn, Germany
Thomas Golaszewski, M.D. Specialist for Gynecology and Obstetrics Amstetten, Austria
Dieter Grab, M.D. Associate Professor and Supervising Physician Department of Gynecology University of Ulm Ulm, Germany
Hans-Joachim Hendrik, M.D. Supervising Physician The Saarland University Hospital Department of Prenatal Diagnosis Homburg, Germany
Gert Hetzel Siemens AG Sales Dept. Sonography Erlangen, Germany
Thomas Hitschold, M.D. Professor and Director Gynecological Clinic Municipal Hospital Worms Worms, Germany
Martin Holländer, M.D. Department of Gynecology The Saarland University Hospital Homburg, Germany
Bernd Hüneke, M.D. Professor and Head Department of Prenatal Medicine Gynecological Clinic and Polyclinic University Hospital Eppendorf Hamburg, Germany
A. Kleinkauf-Houcken, M.D. Specialist for Gynecology and Obstetrics Hamburg, Germany
Jochem König, M.D.
The Saarland University Hospital Institute for Medical Informatics Homburg, Germany
Reinhard Kubale, M.D.
Associate Professor Institute for Radiology, Sonography, and Nuclear Medicine Pirmasens, Germany
Professor Sanja Kupesic, M.D., Ph.D. Sveti Duh Hospital Department of Obstetrics Zagreb, Croatia
Professor Asim Kurjak, M.D., Ph.D. Sveti Duh Hospital Department of Obstetrics Zagreb, Croatia
Angelika Lindinger, M.D. Professor
The Saarland University Hospital Department of Pediatric Cardiology Homburg, Germany
Christoph Lindner, M.D. Professor Gynecological Hospital Elim-Hamburg Hamburg, Germany
Helmut Madjar
Associate Professor Specialist Gynecology German Clinic for Diagnostics
Wiesbaden, Germany
Dieter Mink, M.D.
Associate Professor
The Saarland University Hospital Department of Gynecology Homburg, Germany
Contributors
vii
Karin Reitnauer, M.D.
The Saarland University Hospital Institute of Pathology Homburg, Germany
Hans-Dieter Rott, M.D. Professor University of Erlangen-Nuremberg Institute of Human Genetics Erlangen, Germany
Werner O. Schmidt, M.D. Professor and Chairman Department of Gynecology and Obstetrics
The Saarland University Hospital Homburg, Germany
Karl Sterzik, M.D. Professor Praxisklinik Frauenstrasse Ulm, Germany
Isaak Tossounidis, M.D. Department of Gynecology The Saarland University Hospital Homburg, Germany
Klaus Vetter, M.D. Professor Department of Obstetrics Neukölln Hospital Berlin, Germany
Carlos Villena-Heinsen, M.D. Associate Professor Municipal Hospital Baden-Baden Gynecological Clinic Baden-Baden, Germany
Hans-Joachim Voigt, M.D. Professor and Director Gynecological Clinic Westpfalz Klinikum GmbH Kaiserslautern, Germany
Erich Weiss, M.D. Associate Professor District Hospital Böblingen Gynecological Clinic Böblingen, Germany
Tina Zodan, M.D. Gynecological Clinic Universitätsspital Zürich Zurich, Switzerland
viii

Contents

Physical and Technical Principles
1 Physical and Technical Principles of Color Doppler Sonography
R. Kubale and G. Hetzel
Historical Development ........................... 2
B-Mode Sonography .............................. 2
Physical Principles of Echo Production ................ 2
Principles of Ultrasound Instrumentation ............. 3
Analysis of B-Mode Information and Artifacts ......... 7
Duplex and Color Doppler Sonography .............. 9
Physical Principles of Motion Detection ............... 9
Technical Principles and Equipment Settings .......... 9
Technical Aspects of the Examination and Equipment
Settings ......................................... 16
Analysis of Doppler Information and Artifacts ......... 18
New Technical Processes and Approaches ........... 23
New Developments in Transducer Technology ......... 23
New Techniques of Signal Acquisition and Processing . . . 24
2 Safety Aspects of Doppler and Color Doppler Sonography
H.-D. Rott
Mechanisms of Tissue Effects ...................... 29
Heating ......................................... 29
Cavitation ....................................... 29
Risk Assessment of Various Ultrasound Techniques ... 30
Duplex Sonography ............................... 30
Color Doppler .................................... 31
Power Doppler ................................... 31
Color Velocity Imaging (CVI) ........................ 31
Transvaginal Scanning ............................. 31
Ultrasound Contrast Agents ........................ 31
Exposure of Gas-Containing Tissues .................. 32
Measures to Limit Risk ............................ 32
Recommendations ............................... 32
General Recommendations ......................... 32
Pulsed Doppler ................................... 32
Appendix: Statements on the Biological Safety of
Diagnostic Ultrasound Fields ...................... 33
EFSUMB Statement on the Clinical Safety of Diagnostic Ultrasound WFUMB Statement on Thermal Effects in Clinical Appli­cations
10
..................................... 33
25
........................................ 33
Infertility Evaluation and Assisted Reproduction
3 Uterine Blood Flow in Fertile and Infertile Women
S. Kupesic and A. Kurjak
Uterine Blood Supply ............................. 36
Changes in Uterine Blood Flow during the Menstrual
Cycle ........................................... 36
Blood Flow Parameters in the Uterine Arteries ......... 36
Blood Flow Parameters in the Radial and Spiral Arteries . 37
Uterine Blood Flow in Infertile Women ............. 38
Uterine Blood Flow and Fertilization Rate ............. 39
Uterine Blood Flow in the Normal Cycle and during
Ovarian Stimulation with Confirmed Ovulation ...... 39
Endometrial Imaging .............................. 39
Conclusions ...................................... 39
4 Uterine Causes of Infertility
S. Kupesic and A. Kurjak
Contents
ix
Ultrasound Detection of Uterine Abnormalities ...... 41
Congenital Anomalies ............................. 41
Endometrial Polyps ............................... 41
Submucous Leiomyomas ........................... 42
Adenomyosis .................................... 44
Endometritis ..................................... 44
Asherman Syndrome .............................. 44
Ultrasound Detection of Endometrial Causes of
Infertility ....................................... 45
Effect of Endometrial Thickness and Morphology on Fertility
Effect of Age on Endometrial Function ................ 47
Endometrial Peristalsis ............................ 47
Cervical Factor ................................... 47
......................................... 45
5 Changes in Uterine and Ovarian Perfusion with the Onset of Menopause
A. Kurjak and S. Kupesic
Decline of Fertility in the Perimenopausal Period .... 50
Uterine Receptivity ................................ 50
Oocyte Quality ................................... 50
Ovarian Function ................................. 51
Effects of Estradiol and Progesterone on Vascular
Resistance ...................................... 51
Sympathetic Innervation of the Uterus ............... 51
EstrogenEffect ................................... 51
ProgesteroneEffect ............................... 52
Effect of Age on Ovarian and Uterine Perfusion ...... 52
Authors’ Study ................................... 52
Interpretation of the Results ........................ 54
6 Color Doppler Sonography for the Optimization of Assisted Reproduction
D. Grab and K. Sterzik
Functional Evaluation of the Endometrium ......... 57
Authors’ Studies ................................. 58
Patients and Methods ............................. 58
Examination Procedures ........................... 58
Results .......................................... 61
Discussion of the Role of Doppler Examinations ........ 64
Summary ....................................... 66
7 Pulsed Doppler and Color Duplex Sonography in the Assessment of Tubal Patency
B. Hüneke, A. Kleinkauf-Houcken, C. Lindner, and W. Braendle
Applications of Doppler Sonography in Reproductive
Medicine ........................................ 69
Assessment of Tubal Patency ...................... 69
Patients and Method .............................. 69
Examination Technique ............................ 70
Results .......................................... 73
Discussion of the Value of the Test Procedures ......... 74
Summary ....................................... 75
8 Abnormalities of Corpus luteum Function
S. Kupesic, A. Kurjak, and T. Zodan
Morphology and Biochemistry of the Corpus luteum .77
Conventional Methods in the Diagnosis and
Treatment of Luteal Phase Defect .................. 78
Possible Causes of Luteal Phase Defect ................ 78
Diagnosis of Luteal Phase Defect ..................... 78
Treatment of Luteal Phase Defect .................... 79
Ultrasound and Doppler Sonography in the Detection
of Luteal Phase Defect ............................ 79
LUF Syndrome .................................... 79
Blood Flow in the Corpus luteum during Early
Pregnancy ...................................... 81