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Colour Doppler hardly identifies any blood vessels within the tumour, as most
of the inhomogeneous areas are composed of tissue oedema, necrosis and pus.
Note
Further images relating to this chapter are found on the CD accompanying this
book.
References
Gynaecological pathology: tubes and ovaries
1. Baltarowich OH, Kurtz AB, Pasto ME et al.
The spectrum of sonographic findings in
hemorrhagic ovarian cysts. Am J Roentgenol
1987;148:901–905
2. Bourne TH, Campbell S, Reynolds KM
et al. Screening for early familial ovarian
cancer with transvaginal ultrasonography
and colour blood flow imaging. BMJ
1993;306:1025–1029
3. Demopoulos RI, Bigelow B, Vasa U. Infarcted
uterine adnexa: associated pathology. NY
State J Med 1978;78:2027–2029
4. Granberg S, Norstrom A, Wikland M.
Tumors in the lower pelvis as imaged
by vaginal sonography. Gynecol Oncol
1990;37:224–229
5. Granberg S, Wikland M, Jansson I.
Macroscopic characterization of ovarian
tumors and the relation to the histological
diagnosis: criteria to be used for ultrasound
evaluation. Gynecol Oncol 1989;35:139–144
6. Granberg S, Wikland M. Endovaginal
ultrasound in the diagnosis of unilocular
ovarian cysts in postmenopausal women.
Ultrasound Q 1992;10:1–13
7. Isager-Sally L, Weber T. Torsion of the
fallopian tube during pregnancy. Acta
Obstet Gynecol Scand 1985;64:349–351
8. Kupfer MC, Schwimer SR, Lebovic J.
Transvaginal sonographic appearance of
endometriomata: spectrum of findings.
J Ultrasound Med 1992;11:129–133
9. Lerner JP, Timor-Tritsch IE, Federman A,
Abramovich G. Transvaginal ultrasonographic
characterization of ovarian masses with an
improved, weighted scoring system. Am J
Obstet Gynecol 1994;170:81–85
10. Meire HB, Farrant P, Guha T. Distinction
of benign from malignant ovarian cysts
by ultrasound. Br J Obstet Gynaecol
1978;85:893–899
11. Montz FJ, Schlaerth JB, Morrow CP.
The natural history of theca lutein cysts.
Obstet Gynecol 1988;72:247–251
12. Morley P, Barnett E. The use of ultrasound
in the diagnosis of pelvic masses. Br J Radiol
1970;43:602–616
13. Moyle JW, Rochester D, Sider L et al.
Sonography of ovarian tumors:
predictability of tumor type. Am J
Roentgenol 1983;141:985–991
14. Van Nagell, JR van, DePriest PD et al.
Early diagnosis of epithelial ovarian cancer.
In: Markman M, Hoskins WJ (eds) Cancer
of the ovary. Raven Press, New York,
1993: 128
15. Nogales F. Germ cell tumours of the ovary.
In: Fox H (ed) Obstetrical and gynecological
pathology. Churchill Livingstone, New York,
1987: 637
16. Osmers RGW, Osmers M, von Maydell B,
Wagner B, Kuhn W. Preoperative evaluation
of ovarian tumors in the pre-menopause
by transvaginosonography. Am J Obstet
Gynecol 1996;175:428–434
17. Russell P, Bannatyne P. Surgical pathology
of the ovaries. Churchill Livingstone,
Edinburgh, 1989
18. Sassone AM, Timor-Tritsch IE, Artner A
et al. Transvaginal sonographic
characterization of ovarian disease:
evaluation of a new scoring system to
predict ovarian malignancy. Obstet Gynecol
1991;78:70–76
19. Serov SS, Scully RE, Sobin LH. Histological
classification of ovarian tumors. In: International classification of tumors, vol 9. WHO,
Geneva, 1973
20. Strickler RC, Kelly RW, Askin FB.
Postmenopausal ovarian follicle cyst: an
unusual cause of estrogen excess. Int J
Gynecol Pathol 1984;3:318–322
21. Valentin L, Sladkevicius P, Marsal
K. Limited contribution of Doppler
velocimetry to the differential diagnosis of
extrauterine pelvic tumors. Obstet Gynecol
1994;83:425–433
22. Garner EI. Advances in the early detection
of ovarian carcinoma. J Reprod Med
2005;50:447–453
23. Exacoustos C, Romanini ME, Rinaldo D
et al. Preoperative sonographic features of
borderline ovarian tumours. Ultrasound
Obstet Gynecol 2005;25:50–59
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24. Togashi. Ovarian cancer: the clinical role of US,
CT, and MRI. Eur Radiol 2003;13:L87–104
25. Kinkel K, Frei KA, Balleyguier C, Chapron
C. Diagnosis of endometriosis with
imaging: a review. Eur Radiol 2006;16:
285–298
26. Fruscella E, Testa AC, Ferrandina G
et al. Ultrasound features of different
histopathological subtypes of borderline
Ultrasound in obstetrics and gynaecology
ovarian tumors.Ultrasound Obstet Gynecol
2005;26:644–650
27. Valentin L, Ameye L, Testa A et al.
Ultrasound characteristics of different types
of adnexal malignancies. Gynecol Oncol
2006;102(1):41–48
28. Ko ML, Jeng CJ, Chen SC et al. Sonographic
appearance of fallopian tube carcinoma.
J Clin Ultrasound 2005;33:372–374
328
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Doppler ultrasonography in gynaecology
Bruno Cacciatore Rüdiger Osmers
Juriy W Wladimiroff
ABSTRACT
Two-dimensional colour-coded Doppler, two-dimensional power Doppler and
three-dimensional power Doppler techniques are used for determining the
location, nature and quantity of vascularization in adnexal masses. Malignancy
is associated with reduced arterial downstream impedance in the presence of
neo-angiogenesis. Doppler techniques have been used for identifying pelvic
inflammatory disease, cystic endometriosis and adnexal torsion.
Variable reports have appeared on Doppler utero-ovarian blood flow as a
predictor of pregnancy in assisted reproduction.
KEYWORDS
Adnexal tumour, colour-coded Doppler, in vitro fertilization, pelvic inflammatory
disease, resistance index, three-dimensional power Doppler, two-dimensional
power Doppler.
INTRODUCTION
There are different transvaginal techniques for examining vascularity in the
female genital tract. They include colour-coded Doppler, two-dimensional (2D)
and three-dimensional (3D) power Doppler ultrasonography.
ADNEXAL MASSES
Most Doppler studies are focused on preoperative differentiation between benign
and malignant tumours. Normal cell growth depends on adequate blood supply.
Tumour growth is characterized by neo-angiogenesis. The vascular architecture
is altered. Malignant tumours appear to produce substances that promote the
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formation of new blood vessels, making their growth, invasion and spread possible. These newly formed vessels often lack a complete muscular layer. Vascular
tone and flow impedance are therefore lower than in benign masses. Furthermore,
these vessels generate arteriovenous anastomoses that may cause major pressure
gradients and high-velocity flow patterns. These altered flow patterns can be visualized by means of colour-coded Doppler ultrasonography. High diastolic flow
velocities have been established in malignant lesions. Different indices such as the
resistance index (RI) and pulsatility index (PI) have been introduced to establish
downstream impedance in tumour vessels.
Assessment of the vascularity of a tumour starts off with the exact location and
distribution of vessels in relation to the tumour, followed by Doppler ultrasonography. Colour-coded Doppler allows qualification of resistance to flow as well as
location and intensity of vascularization of adnexal masses. With respect to the RI,
a lowest value of ≤0.45–0.50 has been suggested as a sign of potential malignancy.1
Others found the time-averaged maximum velocity to be a useful parameter.2
Colour-coded Doppler ultrasonography has been reported as a means of increasing
the diagnostic accuracy of adnexal malignancies.
Ultrasound in obstetrics and gynaecology
3,4
It is difficult, however, to differ-
entiate between primary ovarian carcinoma and metastatic tumours to the ovary.
When encountering adnexal masses in premenopausal women, there appears to
be no significant difference in sensitivity and specificity of colour-coded Doppler
ultrasonography between the follicular and luteal phase of the menstrual cycle.
Sonographic analysis of adnexal masses including power Doppler ultrasonography appears to improve preoperative diagnosis of malignancy.7 Quantitative
assessment includes calculation of the tumour vascularity index which is
determined by quantification of the number of pixels in a defined region of
interest according to the formula: number of coloured pixels/total number of pixels
minus the number of pixels in the fluid or avascular areas.8 In the case of power
Doppler ultrasonography, the pulse repetition frequency (PRF) should be set at
about 500 Hz and the gain kept high, i.e. just below the level at which background noise appears. The colour box (region of interest) must be kept small to
avoid artificial echoes and to preserve a high frame rate.
Diagnostic accuracy for ovarian malignancy is not essentially different between
colour-coded Doppler and power Doppler ultrasonography.9 Contradictory
reports have appeared on the use of 3D power Doppler imaging; some do not
consider this technique to be superior to 2D power Doppler ultrasonography.10
Others suggest that this modality may further improve early detection of ovarian carcinoma.11 Some reports have appeared on the possible use of 3D power
Doppler ultrasonography in the investigation of intratumoral vascularization and
volume of cervical cancer.
12
5
6
330
OTHER PELVIC PATHOLOGY
Both colour-coded and 2D power Doppler ultrasonography have been reported to
improve the diagnosis of pelvic inflammatory disease.13 The former technique also
appears to assist in the diagnosis of cystic endometriosis14 and adnexal torsion.
15
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IN VITRO FERTILIZATION
The role of Doppler ultrasonography has also been studied in women undergoing
assisted reproduction. Using colour-coded Doppler ultrasonography, different
utero-ovarian blood flow changes during the peri-implantation period have been
established in conception and non-conception cycles. Doppler assessment of uterine arterial resistance may help to determine the time interval within the menstrual cycle that provides the most optimal endometrial receptivity for embryo
implantation.16 In another study uterine and ovarian vascular impedance values
as expressed by a PI in the uterine artery of >3.26 and in perifollicular vessels
of >1.08 were indicative of reduced pregnancy chances.17 Combined colourcoded and 3D power Doppler ultrasonography suggested that follicles containing
oocytes capable of producing a pregnancy have a well-defined and more uniform
perifollicular vascular network.18 At variance with these data are two other studies in which endometrial and subendometrial blood flow measured by 3D power
Doppler ultrasound were not good predictors of pregnancy.
References
19,20
Doppler ultrasonography in gynaecology
1. Alcazar JL, Lopez-Garcia G. Transvaginal
color Doppler assessment of venous flow in
adnexal masses. Ultrasound Obstet Gynecol
2001;17:434–438
2. Valentin L. Comparison of Lerner score,
Doppler ultrasound examination, and their
combination for discrimination between
benign and malignant adnexal masses.
Ultrasound Obstet Gynecol 2000;15:
143–147
3. Guerriero S, Alcazar JL, Coccia ME et al.
Complex pelvic mass as a target of
evaluation of vessel distribution by color
Doppler sonography for the diagnosis
of adnexal malignancies: results of a
multicenter European study. J Ultrasound
Med 2002;21:1105–1111
4. Guerriero S, Ajossa S, Garau N, Piras B,
Paoletti AM, Melis GB. Ultrasonography
and color Doppler-based triage for adnexal
masses to provide the most appropriate
surgical approach. Am J Obstet Gynecol
2005;192:401–406
5. Alcazar JL, Galan MJ, Ceamanos C,
Garcia-Manero M. Transvaginal gray scale
and color Doppler sonography in primary
ovarian cancer and metastatic tumors to the
ovary. J Ultrasound Med 2003;22:243–247
6. Leeners B, Funk A, Rath W. Effect of
menstrual cycle on Doppler measurements
of adnexa tumors. Zentralbl Gynakol
2000;122:203–206
7. Marret H, Ecochard R, Giraudeau B, Golfier F,
Raudrant D, Lansac J. Color Doppler energy
prediction of malignancy in adnexal masses
using logistic regression models. Ultrasound
Obstet Gynecol 2003;22:218–219
8. Marret H, Sauget S, Giraudeau B, Body G,
Tranquart F. Power Doppler vascularity
index for predicting malignancy of adnexal
masses. Ultrasound Obstet Gynecol
2005;25:508–513
9. Taylor A, Jurkovic D, Bourne TH, Natucci M,
Collins WP, Campbell S. Comparison of
transvaginal color Doppler imaging and
color Doppler energy for assessment of
intraovarian blood flow. Obstet Gynecol
1998;91:561–567
10. Alcazar JL, Castillo G. Comparison of
2-dimensional and 3-dimensional powerDoppler imaging in complex adnexal
masses for the prediction of ovarian cancer.
Am J Obstet Gynecol 2005;192:807–812
11. Kupesic S, Plavsic BM. Early ovarian cancer:
3-D power Doppler. Abdom Imaging
2006;31(5):613–619
12. Hsu KF, Su JM, Huang SC et al. Threedimensional power Doppler imaging of
early-stage cervical cancer. Ultrasound
Obstet Gynecol 2004;24:664–671
13. Molander P, Sjoberg J, Paavonen J,
Cacciatore B. Transvaginal power Doppler
findings in laparoscopically proven acute
pelvic inflammatory disease. Ultrasound
Obstet Gynecol 2001;17:233–238
14. Pascual MA, Tresserra F, Lopez-Marin L,
Ubeda A, Grases PJ, Dexeus S. Role of color
Doppler ultrasonography in the diagnosis
of endometriotic cyst. J Ultrasound Med
2000;19:695–699
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15. Pena JE, Ufberg D, Cooney N, Denis AL.
Usefulness of Doppler sonography in the
diagnosis of ovarian torsion. Fertil Steril
2000;73:1047–1050
16. Chien LW, Lee WS, Au HK, Tzeng
CR. Assessment of changes in uteroovarian arterial impedance during the
peri-implantation period by Doppler
sonography in women undergoing assisted
reproduction. Ultrasound Obstet Gynecol
2004;23:496–500
17. Ozturk O, Bhattacharya S, Saridogan E,
Jauniaux E, Templeton A. Role of uteroovarian vascular impedance: predictor
of ongoing pregnancy in an IVF-embryo
transfer programme. Reprod Biomed Online
2004;9:299–305
18. Vlaisavljevic V, Reljic M, Gavric Lovrec
V, Zazula D, Sergent N. Measurement of
Ultrasound in obstetrics and gynaecology
perifollicular blood flow of the dominant
preovulatory follicle using threedimensional power Doppler. Ultrasound
Obstet Gynecol 2003;22:520–526
19. Järvelä IY, Sladkevicius P, Kelly S, Ojha K,
Campbell S, Nargund G. Evaluation of
endometrial receptivity during in-vitro
fertilization using three-dimensional power
Doppler ultrasound. Ultrasound Obstet
Gynecol 2005;26:765–769
20. Ng EH, Chan CC, Tang OS, Yeung WS,
Ho PC. The role of endometrial and
subendometrial blood flows measured
by three-dimensional power Doppler
ultrasound in the prediction of pregnancy
during IVF treatment. Hum Reprod
2006;21:164–170
332
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Medico-legal implications of ultrasound imaging in obstetrics and gynaecology
Hylton B Meire
ABSTRACT
Medical litigation is increasing in frequency throughout the western world and in
a minority of cases, especially in obstetric care, may be settled for huge sums of
money.
This chapter outlines the type of cases which may give rise to medical litigation
and emphasizes the need to practise a form of defensive medicine. However, this
should lead to improved standards of patient care, reduce the risk of threatened
litigation and enable a swift and robust defence to be mounted when litigation is
threatened.
KEYWORDS
Claim, claimant, defence, defendant, documentation, expert witness, litigation,
normal practice, protocol.
INTRODUCTION
There has been a rapid and continuing increase in the frequency with which medical personnel are being sued by their patients in recent years. This is fuelled by
increasing media attention and publicity, improved patient education and a consequent increase in patients' expectations.
Regrettably there is now an assumption that if all has not gone well with a
pregnancy or a gynaecological procedure, this is necessarily somebody's fault and
they should be made to pay for their presumed mistake. There can be little doubt
that the upward trend in medical litigation is at least in part fuelled by the legal
profession, who, with very few exceptions, are usually the only real winners in the
majority of cases.
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The objectives of this chapter are to highlight the sort of cases which most
commonly give rise to legal claims and also to make some suggestions which may
reduce the risk of litigation and improve the ability to successfully defend a claim
if and when one is received.
The reader should be reassured by the fact that, in my experience over the last
20 years, only one in 20 claims actually proceeds as far as trial in court. The large
majority are dropped as being unsubstantiated, a smaller proportion are settled
out of court and only if doubt remains does the case come to trial.
THE LEGAL PROCESS
The initial step of the legal process occurs when the potential claimant seeks
advice from a lawyer and asks the question ‘Have I got grounds for a claim?’.
Although it is common for this step to be taken soon after the clinical event has
occurred, it is by no means unusual for claims to be raised several years after the
event. The English legal system is now attempting to limit the delay to no more
than 3 years after the relevant clinical event.
Ultrasound in obstetrics and gynaecology
334
Regrettably the majority of lawyers working in a provincial general practice
environment will not have sufficient knowledge or experience to make a judgement as to whether or not a potential claim is valid. It is therefore almost invariable for the initial lawyer to seek an opinion from a more senior professional
colleague with a specialty interest in medical claims. Thus, it must be remembered that the claimant may rapidly accrue significant legal expenses.
If senior legal opinion suggests that there are possible grounds for a claim it
is then usual for the legal team to request the services of one or more medical
experts who will assess the case and offer a professional opinion on their interpretation of liability. If their advice is that there are grounds for a valid claim,
the claim will then be forwarded to the defendant, the individual or team who
are claimed to be responsible for the adverse clinical event. The defendant may
be a single individual, a clinical team or possibly an entire management board.
The defendant will then appoint legal representatives who will seek additional
expert advice and the merits of the claim will be judged by comparison between
the reports from the claimant's and defendant's experts.
In the UK the legal system has recently been amended to require the two teams
of experts to join together in a secret meeting at which the merits or otherwise of
the claim will be discussed. If all the experts are agreed then the case will either
be settled or dropped according to their recommendations. Only if the experts
cannot agree will the legal teams consider taking the case to trial. Not surprisingly,
the processes outlined above are lengthy and seldom run according to the initial
planned timetable. It is by no means unusual for the entire process to take many
years, usually between two and 10. Clearly, the total cost of the professional legal
fees for this process can be enormous, irrespective of the ultimate outcome.
It is perhaps regrettable that most claimants are unaware of the cost and time
scale involved in making a claim and the majority of claimants regret having initiated the procedure because they find the years of anxiety and uncertainty are
seldom compensated by the ultimate settlement, if any.
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THE TRIAL PROCESS
Unless a medical professional is being accused of a criminal event, all medicolegal cases in the UK are tried in a civil court of law. In a civil court the claimant's case will be presented by the claimant, other witnesses of fact, the medical
expert witnesses and the legal team. The defendant's case will be presented by
the defendant, possibly additional witnesses of fact, the defendant's experts and
legal team. The case is heard by a judge who has to determine whether, ‘on the
balance of probability’, the claimant has a valid case. Needless to say, the judge
will usually have little if any knowledge of medicine or ultrasound and thus he
or she is highly reliant upon the opinion of the expert witnesses. In addition, the
majority of cases are judged on the basis of what was or was not ‘normal practice’
at the time of the relevant clinical incident and whether ‘a responsible body of
medical personnel’ would have acted in the same way as those whose expertise is
being called into question. Legal decisions are also influenced by preceding cases
– ‘precedent’ or ‘case law’.
The expert witnesses will themselves require the maximum possible amount
of firm evidence on which to base their opinions and their role will be greatly
facilitated if the claimant or defendant can produce the following items:
a contemporaneous protocol from the institution concerned for the type of
•
scan undertaken in the case in question
a request form indicating the type of scan and reason for the scan
•
recorded images of the investigation
•
a formal report indicating what structures were seen and what conclusions
•
were drawn from the images.
Medico-legal implications of ultrasound imaging in obstetrics and gynaecology
If any or all of this information is unavailable then clearly the experts and the judge
will be greatly impeded in their attempts to achieve an accurate judgement.
REDUCING THE RISK OF LITIGATION
It is unfortunate that one inevitable consequence of the current increase in litigation against the medical profession is that doctors now have to practise ‘defensive
medicine’. However, in ultrasound imaging, this is more likely to lead to improved
clinical practice than is perhaps the case in other specialties such as surgery.
There are a number of simple guidelines which may assist in preventing the
types of event which may lead to litigation. These are all common sense and some
are listed below.
Never undertake a type of scan with which you are not entirely familiar (unless in a learning environment)
This advice is particularly relevant to independent practitioners working on
their own and trying to establish or expand their clinical practice. If doctors
undertake a procedure for which they have not received the appropriate special training, avoidable failures are almost inevitable and successful defence
impossible.
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Record sample images (and be able to retrieve them)
In the narrative above the value of good-quality recorded images and their value
in rapidly refuting a potential claim is emphasized.
Always act professionally and responsibly
Perhaps one of the most common inadvertent faults which gives rise to litigation
stems from inadequate time being allocated for the scan. It is better to postpone
a scan and rebook the patient than to cut corners if time is short. For example, if
the bladder is not adequately filled one should wait for it to fill, do a transvaginal
scan or rebook the patient for an alternative time or date. It is also important to
ensure that the medical professional who will receive the report and may have
to act on its findings is fully aware of the training and expertise of the ultrasound
operator. It is therefore advisable to compile a formal report for every examination and to ensure that one's name, speciality and grade are indicated at some
point on this report.
Ultrasound in obstetrics and gynaecology
Be aware of the common traps (and avoid them!)
There are many well-known pitfalls including difficulties in imaging pelvic structures when the uterus is retroverted, correctly differentiating between a pelvic
cyst and a normal bladder and failing to correctly identify a pseudogestation sac.
An adequately trained operator should be aware of all the common traps and
must be vigilant to avoid them.
336
If the scan is suboptimal, say so and explain why
It is, in fact, unusual for a scan to be entirely satisfactory. There are many factors which may compromise the adequacy of a scan including patient size, fetal
position, inadequate equipment and inappropriate request. There is no shame in
confessing to failure to achieve an entirely adequate scan and if the requesting
medical professional is informed that the scan was in some way suboptimal, he
or she will be better able to place the findings in clinical context and determine
whether or not a repeat examination is advisable.
Ensure the equipment is appropriate
This assumes that the operator has at least some influence over the adequacy
of the equipment. It is therefore important to ensure that the equipment is
maintained and calibrated on a regular basis and that any equipment which is
significantly below the current ‘state of the art’ should be replaced as soon as
possible. For those who are obliged to use inadequate equipment and have no
opportunity to ensure its prompt replacement, it is advisable to write a polite
letter to your manager explaining the situation and emphasizing the potential
financial consequences of litigation in the event that inadequate equipment
were found to be responsible for a failed diagnosis. Make sure you keep a copy
of the letter!