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IIIIII
Doppler Ultrasound in Gynecology
and Obstetrics
Christof Sohn, M.D.
Professor Department of Obstetrics/Gynecology Hanover University Clinic Hanover, Germany
Hans-Joachim Voigt, M.D.
Professor Director Gynecological Hospital
Westpfalz Klinikum GmbH
Kaiserslautern, Germany
Klaus Vetter, M.D.
Professor Obstetric Clinic
Vivantes Medical Center Neukoelln
Berlin, Germany
Translated by Oliver French, M.D.
With contributions by
P.M. Baier, A. Baudendistel, H. Frey, F. Geka, M. Gonser, C. Hofstaetter, Ö. Kilavuz,
A. Scharf, C. Sohn, K. Vetter, H.-J. Voigt
466 illustrations
32 tables
Thieme
Stuttgart · New York
Library of Congress Cataloging-in-Publication Data
is available from the publisher.
This book is an authorized translation of the German edition published and copyrighted 1999 by Georg Thieme Verlag, Stuttgart, Germany.Title of the German edition: Kursbuch Dopplersonographie in Gynäkologie und Geburtshilfe
Translator: Oliver French M.D., Ithaca NY, USA
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 re- quested to examine carefully 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.
IV
© 2004 Georg Thieme Verlag, Rüdigerstrasse 14, D-70469 Stuttgart, Germany http://www.thieme.de Thieme New York, 333 Seventh Avenue, New York, NY 10001, USA http:///www.thieme.com
Cover design: Martina Berge, Erbach-Ernsbach Typesetting by primustype R. Hurler GmbH, D-73274 Notzingen, Typeset on Textline/HerculesPro Printed in Germany by Grammlich, Pliezhausen
ISBN 3-13-135591-3 (GTV) ISBN 1-58890-261-7 (TNY) 12345
Some of the product names, patents, and registeredde­signs 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 be 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

Doppler ultrasound is the most successful clinical in­novation introduced into obstetrics and gynecology in the last few years. This functional biophysical tech­nique has extended the limits of the specialty. It is now possible to record and analyze the hemodynam­ics of the blood supply of individual organs in gyne­cology and the fetoplacental unit in obstetrics. Thanks to cardiotocography and Doppler ultrasound, the black box of pregnancy now presents some quite size­able illuminated peepholes. They are the basis for part of the considerable progress in prenatal and peri­natal medicine.
In contrast to other methods the diagnostic and clinical value of Doppler ultrasound was demonstrated before its widespread acceptance. It is the method of choice for determining the sufficiency of the utero­placental and fetoplacental circulations and for an­swering questions regarding the fetal response to
various changes in its environment, such as the blood supply. In most cases differential analysis of the state of both arterial and venous circulation, combined with echocardiography, provides a reasonably accurate real­time image of the condition of the fetus, and allows
suitable specific therapeutic measures to be under­taken.
Each of the editors has been repeatedly asked to pro­vide an up-to-date book on Doppler ultrasound. In view of the increasingly complex nature of the subject they focused on Doppler ultrasound in obstetrics and gynecology, and in collaboration with other authors wrote this book to assist readers in their everyday practice.
It is inevitable that in such a dynamic field the new matter presented here will be called into question or overtaken within a short time by new research. We would like to encourage our readers not to spare us from constructive criticism, for only in that waycan we make progress in caring for the women and children entrusted to us.
We would like to thank Thieme Verlag, especially Dr. M. Becker, for their productive collaboration, and our co-workers and families for their patience.
Hanover/Kaiserslautern/Berlin Christof Sohn Autumn 2003 Hans-Joachim Voigt
Klaus Vetter
V

Contributors’ Addresses

Peter M. Baier, M.D. Center for Gynecology and Obstetrics University Medical Center Hanover, Germany
Anja Baudendistel, M.D. Center for Gynecology and Obstetrics University Medical Center Frankfurt, Germany
Holger Frey ECOSCAN GmbH Wiesbaden, Germany
Fani Geka, M.D. Center for Gynecology and Obstetrics University Medical Center Frankfurt, Germany
Markus Gonser, M.D. University Gynecology and Obstetrics Medical Center Tübingen, Germany
C. Hofstaetter, M.D. Department of Prenatal Diagnostics and Therapy Center for Gynecology and Obstetrics Bonn University Hospital Bonn, Germany
O. A. Oemer Kilavuz Department of Obstetrics Berlin, Germany
A. Scharf, M.D. Center for Gynecology and Obstetrics University Medical Center Hanover, Germany
VI

Contents

Basic Concepts
1 Physical and Technical Fundamentals of Ultrasound and Doppler Ultrasound
H. Frey
History ....................................... 3
Oscillation, Sound Wave ...................... 3
The Generation of Ultrasound ................ 4
Physical Effects ............................... 5
Reflection and Refraction ...................... 5
Scattering .................................... 6
Interference .................................. 6
Diffraction .................................... 6
Absorption .................................... 6
Generating the Image ........................ 7
Pulse-Echo Procedure ......................... 7
Time Gain Compensation ...................... 7
A-Mode ...................................... 7
B-Mode ....................................... 8
M-Mode ...................................... 8
The Sound Field .............................. 9
Resolution .................................... 9
Focusing ...................................... 9
Scanning Procedures ......................... 10
Principle of Operation ......................... 10
Linear Array Scanner .......................... 11
Curved or Convex Array Scanner ............... 11
Sector Scanner ................................ 11
Phased Array Scanner ......................... 11
Mechanical Sector Scanners .................... 12
Rotary Principle ............................. 12
Wobbler Principle ........................... 13
Annular Phased Array Transducer ............ 13
Ultrasound Artifacts .......................... 13
Distal Acoustic Shadowing ..................... 13
Dorsal Sound Amplification .................... 13
Disadvantages of Mechanical Scanners ....... 13
Margin Shadow ............................... 14
Side Lobe ..................................... 14
Slice Thickness Artifact ........................ 14
Repetition Artifact ............................ 14
Doppler Sonography .......................... 15
Fundamentals of Doppler Sonography ......... 15
Geometrical Distortion ........................ 15
Continuous Wave Doppler Systems ............ 17
Pulsed Wave Doppler systems ................. 17
Alias Phenomenon in Pulsed Doppler ........... 18
Baseline Shift ................................. 18
Wall Filter .................................... 19
Color-Coded Doppler Sonography .............. 19
Amplitude-Coded Flow Display ................ 19
Safety Aspects ................................ 20
Thermal Effects ............................... 20
Mechanical Effects ............................ 20
Important Definitions ......................... 21
Acoustic Output ............................. 21
Acoustic Power ............................. 21
Intensity .................................... 21
Intensity Special Peak Time Average ......... 21
Risks of Individual Ultrasound Procedures ..... 21
B-Mode ..................................... 21
M-Mode .................................... 21
CW Doppler ................................ 21
PW Doppler ................................ 21
Color-Coded Doppler Sonography ............ 21
Summary ..................................... 21
Important Instrument Settings ............... 22
Selecting the Most Suitable Transducer ......... 22
B-Mode Settings .............................. 22
Depth of Penetration ....................... 22
Gain ........................................ 22
Focusing .................................... 22
Setting the Doppler Parameters ................ 22
Sample Volume ............................. 22
PRF and Baseline Shift ....................... 22
Scaling the Time Axis ....................... 22
Wall Filter .................................. 22
Orientation of the Tracings of Spectra ........ 22
Color-Coded Doppler .......................... 23
Size of the Color Window .................... 23
PRF......................................... 23
Color Gain .................................. 23
VII
Contents
2 Indices for the Evaluation of Doppler Sonograms
K. Vetter, M. Gonser, H.-J. Voigt
Introduction ................................. 25
Quantitative Measurements .................... 25
Qualitative Measurements ..................... 25
Angle Problems ............................... 25
Wall Filter .................................... 26
Indices Used to Evaluate Two-Dimensional
Doppler Sonograms .......................... 26
Indices of Velocity ............................. 26
Indices of Acceleration ........................ 28
Path Length Index ............................. 29
Temporal Indices ............................. 29
Relative Flow Index ........................... 30
Optical Classification ......................... 32
Clinical Procedure ............................ 33
Reference Curves ............................. 34
Index Quotients .............................. 37
Summary .................................... 39
Suggestions for Obstetric Practice .............. 39
3 Vascular Supply of the Uteroplacentofetal Unit and Techniques
for the Examination of Individual Vessels
C. Sohn
Vascular Supply of the Uteroplacentofetal
Unit .......................................... 41
Uteroplacental Blood Supply ................... 41
Fetoplacental Blood Supply .................... 42
Fetal Blood Supply ............................ 42
Methods of Examining Specific Vessels ....... 44
Displaying the Maternal Vessels ................ 44
Examining the Uterine Arteries in the
Second Trimester ........................... 44
Examining the Uterine Arteries in the
Third Trimester ............................. 47
Displaying the Peripheral Fetal Vessels ......... 47
Examining the Umbilical Artery .............. 47
Examining the Aorta in the Second
and Third Trimesters ........................ 48
Examining the Central Fetal Vessels ............ 50
Examining the MCA ......................... 50
Examining the Carotid Artery ................ 51
VIII
4 Blood Flow Analysis During Pregnancy
K. Vetter, M. Gonser
Uteroplacental Vessels ........................ 53
Reference Values ............................ 54
Physiological Flow Changes .................. 54
Fetoplacental Vessels ......................... 55
Umbilical Vessels ............................. 55
Reference Values ............................ 55
Abnormal Flow Changes ..................... 55
Medications ................................ 55
Physiological Flow Changes .................. 56
Pathological Flow Changes ................... 56
Morphological Changes ...................... 56
Umbilical Vein ................................ 58
Reference Values ............................ 58
Physiological and Pathological
Flow Alterations ............................ 58
Fetal Vessels ................................. 59
Aorta ......................................... 59
Evaluation Criteria .......................... 59
Reference Values ............................ 59
Physiological Flow Changes .................. 60
Arteries Supplying the Brain ................... 60
Reference Values ............................ 61
Physiological Flow Changes .................. 61
Renal Arteries ................................. 61
Evaluation Criteria .......................... 62
Reference Values ............................ 62
Ductus Arteriosus ............................. 62
Inferior Vena Cava ............................ 62
Evaluation Criteria .......................... 62
Reference Values ............................ 62
Physiological Flow Changes .................. 62
Pathological Flow Changes ................... 62
Ductus Venosus Arantii ........................ 62
Hepatic Veins ................................. 63
Effect of Therapeutic Measures ............... 63
Prostaglandins ................................ 63
Antihypertensives ............................. 63
β-blockers .................................. 64
Calcium Antagonists ......................... 64
Epidural Anesthesia ........................... 64
5 Documentation
C. Sohn
Sample Documentation Records .............. 66
6 Common Errors in the Doppler Ultrasound Display of Uterine Blood Flow
and Fetal Vessels
F. Geka, C. Sohn
Contents
Correct Display of Vessels with Normal
Instrument Settings .......................... 69
Role of the Angle in the Doppler Examination .69 Possible Sources of Error in Doppler
Ultrasound Examinations of Maternal
and Fetal Vessels ............................. 71
Displaying the Uterine Artery .................. 71
Displaying the Umbilical Artery ................ 73
Displaying the Fetal Aorta ..................... 74
Displaying the Middle Cerebral Artery .......... 76
Complete Series of Doppler Ultrasound Examinations, Including Displays of Maternal Uterine and Fetal Peripheral and Central
Vessels ....................................... 77
Basic Concepts: References ................... 80
Physical and Technical Fundamentals
of Ultrasound and Doppler Ultrasound ....... 80
Indices for the Evaluation of Doppler
Sonograms ................................. 80
Blood Flow Analysis During Pregnancy ....... 80
Obstetric Applications of Doppler Ultrasound
7 The Role of Doppler Ultrasound in the Diagnosis of Ectopic Pregnancy
H.-J. Voigt
The Significance of Transvaginal Sonography
and Serum hCG ............................... 85
Characteristic Sonographic Findings in
Ectopic Pregnancy ............................ 85
Differential Diagnosis ........................ 85
Transvaginal Color Doppler Ultrasound ....... 86
Diagnostic Validity ............................ 86
Effectiveness of the Procedure ................. 86
Errors ........................................ 87
Critical Evaluation ............................. 89
Summary .................................... 89
8 Indications for Obstetric Ultrasound
C. Sohn
IUGR and Biological Measurement ............ 92
Basic Principles ............................... 92
Some Specific Measurements .................. 92
Skull ....................................... 92
Abdomen ................................... 92
Extremities ................................. 93
Cerebellum ................................. 93
Procedure when Biological Measurements are
Abnormal ..................................... 93
Growth Restriction ............................ 94
Suspected IUGR ............................... 94
PIH/Preeclampsia/Eclampsia .................. 96
Status Post Dysmature Delivery/Intrauterine
Death ........................................ 96
Status Post Preeclampsia/Eclampsia .......... 97
IX
Abnormalities in the Recorded Fetal Heart
Rate .......................................... 97