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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5775_Библиотеки_им_академика_М_И_Перельмана
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B.Uterinearteriovenousmalformation
C.Retainedproductsofconception
D.Endometritis
5.Basedupontheimage,whatisthechorionicityandamnionicityofthispregnancy?
A.Monochorionic,monoamniotic
B.Monochorionic,diamniotic
C.Dichorionic,monoamniotic
D.Dichorionic,diamniotic
6. In the setting of a positive pregnancy test, the presence of an intrauterine fluid collection with a
smooth,roundedorovalcontourmostlikelyrepresentswhichofthefollowing?
A.Ectopicpregnancy
B.Intrauterinepregnancy
C.Adenomyosis
D.Spontaneousabortion
7. What is the crown rump length established by the Society ofRadiologists in Ultrasound at which
cardiacactivityshouldbepresent?
A.3mm
B.5mm
C.7mm
D.9mm
8.Ananechoicroundstructurewithintheheadat8to10weeksofgestationmostlikelyrepresentswhich
ofthefollowing?
A.Normalventricles
B.Ventriculomegaly
C.Rhombencephalon
D.Anencephaly
9.A26-year-oldfemalepresentswithpelviccrampinginthefirsttrimester.Theclinicalsignificanceof
theabnormalityshowndependsonwhichofthefollowingcriteria?
A.Lengthoftime
B.Size
C.Gestationalage
D.Patient’sage
10.Whichofthefollowingisthemostaccuratemethodtoestablishgestationalage?
A.Meangestationalsacdiameter
B.Dateoflastmenstrualperiod
C.Crown-rumplength
D.Biometricvariablesfromsecondtrimesterultrasound
11.Howmanyyolksacswillbepresentinamonochorionicmonoamnioticpregnancy?
A.0
B.1
C.2
D.3
12.Afemalepresentswithcontractionsandapelvicultrasoundwasperformed.Whichofthefollowing
isshownintheultrasoundimage?
A.Placentaprevia
B.Cervicalfunneling
C.Normalcervix
D.Artifactualshorteningofthecervix
13. Which ofthefollowing should be used for a first trimester ultrasound performed earlier than 10
weeks’gestation?
A.Tis
B.Tib
C.Tix
D.Tim
14.Obstetricultrasoundimageoftheumbilicalcordisprovided.Themostlikelydiagnosisis:
Image courtesy of Donna Justis, RDMS, and Fidelma B. Rigby, MD, Virginia Commonwealth
UniversityHealthSystem,Richmond,VA.
A.Centralinsertion
B.Velamentousinsertion
C.Eccentricinsertion
D.Vasaprevia
15.Whichofthefollowingshouldbeusedtodocumentembryonicheartrate?
A.SpectralDoppler
B.M-mode
C.ColorDoppler
D.B-mode
16.Whichofthefollowingisseeninanormalumbilicalcord?
A.Twoarteriesandonevein
B.Onearteryandtwoveins
C.Twoarteriesandtwoveins
D.Onearteryandonevein
17.Whatisthenormalplacentalthickness?
A.<2cm
B.2to4cm
C.>4cm
D.Variablebasedonpatient’sage
18.Whatisthesignificanceofthefindingshowninthisfirsttrimesterultrasound?
ImagecourtesyofHazemHawasli,MD,HenryFordHospital,Detroit,MI.
A.Theyaredetectedin80%offirsttrimesterpregnancies.
B.Theyaremoreoftenlocatedtowardtheplacentalinsertionsite.
C.Theyusuallyhavenoclinicalsignificance.
D.Themajoritypersistuntildelivery.
19.Whichofthefollowingactionswouldbeexpectedtodecreasethemechanicalindex?
A.Increasethecenterfrequencyoftheultrasoundbeam
B.Movefocalzoneclosertothetransducer
C.Increasetheultrasoundpoweroutput
D.Decreasethegain
20.Thethermalindex(TI)is:
A.Adirectmeasurementofthetemperatureincreaseasaresultoftissueabsorptionofultrasound
B.Anestimateoftheincreaseintemperatureofinsonatedtissues
C.Calculationbasedontheenergylostwithintissuesbecauseofscatter
D.NotapplicablewhenfollowingtheALARA(aslowasreasonablyachievable)principle
21. The following image is from thepelvic ultrasound ofa patient in thefirst trimester. Which ofthe
followingisthemostappropriatenextstepinmanagementofthispatient?
ImagecourtesyofHazemHawasli,MD,HenryFordHospital,Detroit,MI.
A.Reassurepatientofnormalpregnancy
B.Shortintervalfollow-upultrasound
C.SerialbetahCGmeasurements
D.Counselpatientonembryonicdemise
22.Withregardtothepotentialadversebioeffectsofdiagnosticultrasoundonhumans:
A.Dose–effectstudieshavenotshownanyultrasound-inducedbiologicaleffects.
B. The potential for adverse bioeffects is likely to decrease with more recent advances in
ultrasoundequipment.
C. Recent discussions ofultrasound safety arethe resultof bioeffects having beendetected in
humanpatients.
D. The potential for adverse biological effects exists and may increase with technological
advances.
AnswersandExplanations
1a.AnswerD..Thefirstimageshowsanenlargeduteruswithanendometrialmass.Themassissolid
with multiple small cystic spaces, the so-called “snowstorm” appearance. The next two images show
bilateralenlargedovaries,eachmeasuringover7cmandcontainingthecaluteincysts.Thefindingsofa
solid/cystic endometrial mass with bilateral enlarged cystic ovaries is most consistent with a molar
pregnancy withbilateral theca lutein cysts in a patient with this history. The beta hCG level in these
patientsisabnormallyhigh,usually>100,000mIU/mL.Thecaluteincystsoccurinapproximately15%to
30%ofcasesofmolarpregnancybecauseofhighhCGlevels.Thisisacaseofacompletehydatidiform
mole,whichisthemostcommonformofgestationaltrophoblasticdisease.Clinicalpresentationincludes
hyperemesis gravidarum,vaginal bleeding, andvaginal passage of vesicles corresponding to hydropic
villi. The uterus istypicallylargefordates. The conceptusisdiploid withthemostcommonkaryotype
being46,XXbecauseoffertilizationofaneggdevoidofgeneticmaterialbytwohaploidspermswithall
geneticmaterialbeingpaternalinorigin(“daddy’slittlegirl”).
Choices A and C are incorrect because of the history—one would not expect a woman with
endometrialcancertopresentwithemesis,norwouldshepassvesicles.Also,the37yearoldisyounger
than the typical patient with endometrial cancer, who is typically postmenopausal. The patient has a
normalWBCcount,soBisnotcorrect.
1b.AnswerC.Persistenttrophoblasticneoplasia(PTN)canoccuraftermolarpregnancy—completeor
partial, normal pregnancy, abortion, or ectopic pregnancy. The mostcommon form of PTNis invasive
mole characterizedby trophoblastictissueinvadingthemyometrium. Other less commonforms include
choriocarcinoma,whichispronetodistantmetastases,andplacentalsitetrophoblasticneoplasia,which
isthemostlethalandrareformofPTN.
Reference:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:349–352.
2a. AnswerC. Pelvic US images show normal uterus and normal bilateral ovaries. No intrauterine
gestationalsacorfluidisshown.Noabnormaladnexalmassesareshowneither.
As per recommendations of the Society of Radiologists in Ultrasound (SRU) Multispecialty
Consensus Conference on “Early first trimester diagnosis of Miscarriage and Exclusion of a Viable
Intrauterinepregnancy”publishedin October 2012, ifa single hCG measurement is ≥3,000mIU/mL,a
viableintrauterinepregnancyispossiblebutunlikely.However,themostlikelydiagnosisisanonviable
intrauterinepregnancy,soitisgenerallyappropriatetogetatleastonefollow-uphCGmeasurementand
follow-upultrasonogrambeforeundertakingtreatmentforectopicpregnancy.
2b.AnswerD.Imagesoftherightadnexashowalivingembryowithcardiacactivity.Inpatientswith
positive pregnancy testand noevidence of intrauterine pregnancy (IUP), the positive predictive value
(PPV)ofthisfindingis100%indiagnosinganectopicpregnancy.ThePPVofanadnexalmasscontaining
eitherayolksacornonlivingembryoalsoapproaches100%.A“Tubal”or“adnexal”ringsurroundinga
fluidcollectionhasPPVof95%andacomplexorsolidadnexalmasswithoutembryo,yolksac,ortubal
ringhasPPVof92%.
References:DoubiletPM,BensonCB,BourneT,etal.Diagnosticcriteriafornonviablepregnancyearlyinthefirsttrimester.UltrasoundQ
2014;30(1):3–9.
HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:333–343.
3.AnswerC.Theyolksacistheprimarymaternal–fetaltransportsystembeforeafunctioningplacental
circulationhasfullydeveloped.Itisaround3to5mmcysticstructure,foundeccentricallylocatedwithin
the gestational sac, and resides within the chorionic cavity. The yolk sac can be visualized by
approximately5.5weeksofgestationalage.
TransvaginalUSimageoftheuterusshowstheyolksac(yellowarrow).
Byapproximately6weeksofgestationalage,theembryocanbeidentifiedasa1to2mmechogenic
focusalongtheperipheryoftheyolksac.Itresideswithintheamnioticcavity.
Theamnioticmembraneisthinnerthantheyolksacandisseenmoreeasilyafter7weeksbutcanbe
seenasearlyas6.5weeksofgestationalage.Theamnionandchorionfuseat14to16weeks.
TransvaginalUSimageoftheuterusshowstheamnion(redarrow)andtheembryo(whitearrow).
References:BreeR,EdwardsM,Bohm-VelezM,etal.Transvaginalsonographyintheevaluationofnormalearlypregnancy:correlationwith
HCGlevel.AJRAmJRoentgenol1989;153(1):75–79.
Lindsay DJ, LovettIS,Lyons EA, et al. Yolk sac diameter and shape at endovaginal US: predictors of pregnancy outcome in the first
trimester.Radiology1992;183(1):115–118.
4.AnswerC.Thefirstimageshowsanabnormallythickenedendometriumcontainingasolidmasswith
cysticspaces.ThesecondimageshowsDopplerflowwithinthemass.Basedontheimagesprovided,the
clinical history, and laboratory values, the correct answer choice is C, that is, retained products of
conception. Women with retained products of conception (RPOC) typically present with abnormal
bleedingandismostcommonaftersecondtrimesterspontaneousabortion,extremepretermbirth,medical
termination ofpregnancy, andplacenta accreta.Thediagnosis issuggestedwhenthereisamass inthe
endometrial canal that shows Doppler flow. However, lack of flow does not exclude RPOC.
Calcificationsinthemass,becauseofnormalplacentalmaturation,arehighlysuggestiveofRPOC.
Choice A, endometrial hematoma, is not the correct answer because there is Doppler flow in the
mass,whichwouldnotbepresentinahematoma.ChoiceB,uterinearteriovenousmalformation(AVM),
canoccurinthepostabortionandpostpartumperiodswithseverevaginalbleeding.Sonographically,they
canpresentasmultipleserpiginousstructureswithinthemyometrium,orasamyometrialorendometrial
mass.However,theselesionsarerare,andthebetahCGlevelshouldnotbeelevatedasitisinthiscase.
Choice D, endometritis, may show endometrial thickening and may or may not contain fluid and gas.
However,clinicallythesepatientspresentwithfever andanelevatedWBC count.This patient’sWBC
countisnormal.
Reference: Rumack CM, Wilson SR, Charboneau WJ. Diagnostic ultrasound, 4th ed. Philadelphia, PA: Elsevier Health Sciences,
2011:560–561,1521–1523.
5.AnswerD.Thisisanexampleofadichorionic,diamnioticpregnancy.Athickmembrane separates
the twofetuses.A thin membraneis whatseparatesmonochorionic,diamniotictwinpregnanciesandis
usually barely perceptible on ultrasound. Also, this image is a good example of the “twin peak” or
“lambda”sign,whereatriangular-shapedportionofthechorionextendsbetweenthetwochorionicsacs.
Thissignhelpstoconfirm the presenceoftwochorions.Once twochorionshavebeenestablished,the
pregnancymustbedichorionic,diamnioticasdichorionic,monoamniotictwinpregnanciesdonotexist.
Reference:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:496–497.
6.AnswerB.Althoughthe presenceoftheintradecidualordoublesacsignishighlysuggestiveofan
intrauterine pregnancy (IUP), the absence of these signs does not exclude an IUP. Fluid secretions or
bloodwithintheuterinecavityinthesettingofanectopicpregnancyisreferredtoasapseudogestational
sacordecidualcastbutoccursinonlyapproximately10%ofectopicpregnancies.Thelowincidenceof
pseudogestational sacsin additionto the much greater incidenceof intrauterinepregnancies in general
resultsina>99.5% likelihoodthatasmooth,rounded,oroval intrauterinefluidcollection represents a
gestationalsacinapregnantpatient.Therefore,thesecollectionsshouldbetreatedasIUPsuntilproven
otherwise.
ThetermpregnancyofunknownlocationisusedwhenultrasoundshowsnodefiniteIUPandnormal
adnexa.ThedifferentialdiagnosisincludesaveryearlyIUP,occultectopicpregnancy,andacompleted
spontaneousabortion.
References:BarnhartKT.Ectopicpregnancy.NEnglJMed2009;361(4):379–387.
Campion EW, Doubilet PM, Benson CB, et al. Diagnostic criteria for nonviable pregnancy early in the first trimester. N Engl J Med
2013;369(15):1443–1451.
DoubiletPM,BensonCB.First,donoharm…toearlypregnancies.JUltrasoundMed2010;29(5):685–689.
RodgersSK,ChangC,DeBardelebenJT,etal.Normalandabnormal USfindingsinearlyfirst-trimesterpregnancy: reviewofthesociety of
radiologistsinultrasound2012consensuspanelrecommendations.RadioGraphics2015;35(7):2135–2148.
7. AnswerC. Cardiacactivity maybe detectedinembryos assmall as 1 to2 mm,correspondingto
approximately the 6th week of gestation. However, the absence of cardiac motion may be normal in
embryossmaller than4mm.Inordertoaccountfordifferingequipment types, measurementvariability,
andothervariationsinultrasoundimaging,acrown-rumplengthof7mmorgreaterhasbeenestablished
by theSocietyofRadiologistsinUltrasoundasthesizeat whichcardiac activityshouldbe present.A
definitive diagnosis of failed pregnancy requires that an embryo is at least 7 mm and lacks cardiac
activity.
References:CampionEW,DoubiletPM,BensonCB,etal. Diagnosticcriteriafornonviablepregnancy earlyinthefirst trimester.NEngl J
Med2013;369(15):1443–1451.
RodgersSK,ChangC,DeBardelebenJT,etal.Normalandabnormal USfindingsinearlyfirst-trimesterpregnancy: reviewofthesociety of
radiologistsinultrasound2012consensuspanelrecommendations.RadioGraphics2015;35(7):2135–2148.
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