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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5817_Библиотеки_им_академика_М_И_Перельмана-1.pdf
Contents
Reasonable Suspicion of Fetal Anomalies or
Fetal Disease ................................. 97
Multiple Pregnancy with Discordant Growth .. 97
Suspicion of Cardiac Anomaly or
Heart Disease ................................ 98
Other Indications ............................. 98
Summary
Indications for Doppler Ultrasound in the
First, Second, and Third Trimesters ........... 98
First Trimester .............................. 98
Second Trimester ........................... 98
Third Trimester ............................. 98
9 Doppler Sonography in Obstetrics—Screening At-Risk Populations
H.-J. Voigt
Validity of a Test ............................. 99
Validation of Indices ......................... 100
Screening Population ......................... 101
Screening in Cases of Suspected Uteroplacental Perfusion Disorders and/or Pregnancy-
Induced Hypertension ........................ 101
Screening for Suspected Fetoplacental
Perfusion Disorders and/or IUGR ............. 102
Summary .................................... 102
10 Doppler Ultrasound Diagnosis in Preeclampsia, Eclampsia,
and HELLP Syndrome
C. Sohn
Pathological Changes in Preeclampsia ........ 103
Evaluating the Risk of Preeclampsia in the
First and Second Trimesters—Examining the
Uteroplacental Arteries ....................... 105
Doppler Ultrasound Findings ................... 105
Confirming a Diagnosis of Preeclampsia in the
Second Half of Pregnancy—Demonstrating
Characteristic Doppler Sonographic Changes
of Preeclampsia in the Uteroplacental Vessels . 106
Evidence for or Exclusion of Fetal Risk—Eval-
uating the Fetal or Fetoplacental Vessels ...... 106
Doppler Sonographic Findings ................. 106
Doppler Sonographic Findings ................. 106
Redistribution of Blood (Brain Sparing) ......... 107
Summary .................................... 109
11 Doppler Ultrasound in the Diagnosis of Fetal Anomalies
K. Vetter, Ö. Kilavuz, H.-J. Voigt
Anomalies in the Region of the Head and
Neck ......................................... 111
Anomalies of the Lung and Diaphragm ....... 113
Fetal Cardiac Malformations .................. 114
Malformations of the Gastrointestinal Tract
and the Abdominal Wall ...................... 114
X
Anomalies of the Urogenital System .......... 116
Placenta ...................................... 119
Hydrops Fetalis ............................... 119
Anhydramnios ............................... 119
Malformations of the Umbilical Cord ......... 119
Doppler Ultrasound Diagnosis of
Malformations in Early Pregnancy ............ 121
Coccygeal Teratomata ........................ 118
12 Multiple Pregnancy and Doppler Ultrasound
C. Sohn, A. Scharf
Contents
Studies Using Doppler Ultrasound
for Multiple Pregnancies ..................... 124
Theoretical Considerations Related to the Above
Studies ....................................... 125
Special Considerations for the Use of Doppler
Ultrasound in Twin Pregnancies ............. 126
Acardius Acranius, TRAP ....................... 126
Crossed Cord Around the Neck ................. 126
Velamentous Insertion and Vasa Previa ......... 126
Monochorionic Multiple Fetuses with
Circulatory Communication Disorders ......... 127
Twin-to-Twin (Feto−Fetal) Transfusion
Syndrome (TTTS, FFTS) ........................ 127
Hydramnios-Oligohydramnios ................. 127
Summary .................................... 128
13 Possible Applications of Doppler Ultrasound in Fetal Anemia
K. Vetter, Ö. Kilavuz
Noninvasive Procedures for Suspected Fetal
Anemia ...................................... 129
Ultrasonic Imaging ............................ 129
Doppler Ultrasound ........................... 130
14 Umbilical Cord Complications and Doppler Ultrasound
K. Vetter, Ö. Kilavuz
Doppler Ultrasound Findings when Umbilical
Cord Complications Affect Hemodynamics .... 133
Obstetric Applications of Doppler Ultrasound:
References ................................... 135
Diagnostic Doppler Ultrasound in
Preeclampsia, Eclampsia, and HELLP
Syndrome .................................. 135
Multiple Pregnancy and Doppler Ultrasound . . 135
Advanced Topics in Obstetrics and Gynecological Doppler Ultrasound
15 Doppler Ultrasound and the Cardiotocogram
H.-J. Voigt
Comparing Tests ............................. 139
Comparing Tests to Predict Neonatal Asphyxia . . 139
Comparing Tests to Predict Neonatal Acidosis . . . 140
Information Lead Time Using Doppler
Ultrasound ................................... 140
Clinical Significance of Doppler Ultrasound ... 141
16 Doppler Ultrasound Findings Near Term
K. Vetter
Physiological Findings in the Late Stages of
Pregnancy .................................... 143
Aorta: Quantitative Analysis ................... 143
Aorta: Qualitative Analysis ..................... 144
Cerebral Arteries .............................. 144
Common Carotid Artery ..................... 144
Middle Cerebral Artery ...................... 144
Renal Arteries ................................. 145
XI
Contents
Changes at Term and Postterm ............... 145
Femoral Arteries .............................. 145
The “Term Effect” ............................. 146
The Circulatory Balance........................ 146
Clinical Conclusions .......................... 147
Doppler Ultrasound during Labor? ........... 148
Summary .................................... 149
17 Diagnostic and Clinical Significance of Doppler Ultrasound in Obstetrics
M. Gonser, K. Vetter
Studies of Diagnostic Significance ............ 151
Uteroplacental Arteries ........................ 152
Umbilical Arteries and Other Fetal Vessels ...... 152
Umbilical Arteries and Fetal Aorta ............ 152
The Umbilical Vein in Arterial Diastolic Block
or Reverse Flow ............................. 152
Cerebral Arteries and Redistribution of
the Circulation .............................. 153
Studies of Clinical Significance ............... 153
Uteroplacental Arteries ........................ 154
Umbilical Arteries ............................. 154
Analysis of Individual Clinical Doppler
Studies ..................................... 154
Cumulative Metaanalysis .................... 155
Conclusions .................................. 156
Diastolic Reverse Flow ....................... 156
Multiple Pregnancy ......................... 156
Summary .................................... 158
18 Doppler Sonography of the Fetal Venous Circulation
C. Hofstaetter
XII
Anatomy ..................................... 159
Physiology ................................... 160
The Left Path from the Ductus Venosus
to the Foramen Ovale ....................... 160
The Right Path from the Inferior Vena Cava
to the Right Atrium ......................... 160
Ultrasound Display and Doppler Sonography
of the Venous System ........................ 161
Results of the Doppler Studies ................ 162
Summary .................................... 165
19 Seven Cases Illustrating the Use of Doppler Ultrasound in Obstetrics
K. Vetter, H.-J. Voigt
1—Fetal Growth Restriction .................. 167
2—Extreme Fetal Growth Restriction Due to
Endarteritis Obliterans .................... 168
3—Exclusion of Potter Syndrome ............. 169
4—Closely Coordinated Preventive Care for
High-Risk Patients ........................ 171
5—Patient with Antiphospholipid-Antibody
Syndrome ................................. 172
6—Marked Fetal Growth Restriction .......... 177
7—Twin Pregnancy with Twin-to-Twin
Transfusion Syndrome .................... 178
20 Doppler Ultrasound in Gynecology
P.M. Baier
Tumor Angiogenesis .......................... 184
Essential Considerations for Clinical Practice . . 185
Examination Procedure and Instrumentation
for Ultrasound Diagnosis of the Pelvis ........ 185
Evaluation .................................. 186
Ovarian Diagnosis ............................ 187
Conventional Ultrasound Examination of the
Ovary: Procedure and Results .................. 187
Normal Findings in the Doppler Ultrasound Ex-
amination of the Ovaries ...................... 188
Contents
Significance of Color-Coded Doppler Ultra-
sound ........................................ 188
Doppler Ultrasound and Myomas ............ 190
Essential Considerations for Clinical Practice . . 190
Endometrial Diagnosis ....................... 191
Essential Considerations for Clinical Practice . . 191
Essential Considerations for Clinical Practice . . 195
21 Diagnosis of the Uterine Tube by Transvaginal Sonography
F. Geka
Application of Ultrasound in Diagnosis of the
Uterine Tube ................................. 197
Display of the Tube by Contrast Sonography .... 197
Comparison to Other Procedures ............. 198
Supplementation by Doppler .................. 198
22 Diagnostic Sonography of Blood Flow in Breast Tumors
A. Baudendistel
Biological Background ........................ 201
Instrumentation ............................. 201
Continuous Wave Doppler ..................... 201
Pulsed Wave Doppler .......................... 202
Color-Coded PW Doppler ...................... 202
Angio Color, Angio Mode, Power Doppler ....... 203
Introduction of Ultrasound Contrast Media ..... 204
Color-Coded Doppler Ultrasound in the
Differential Diagnosis of Breast Tumors ...... 205
Advanced Topics in Obstetrics and Gyneco-
logical Doppler Ultrasound: References ....... 207
Doppler Ultrasound and the Cardiotocogram . 207
Doppler Ultrasound Findings Near Term ...... 207
Diagnostic and Clinical Significance of
Doppler Ultrasound in Obstetrics ............ 208
Doppler Ultrasound of the Fetal
Venous Circulation .......................... 210
Doppler Ultrasound in Gynecology ........... 210
Diagnosis of the Uterine Tube by
Transvaginal Ultrasound ..................... 211
Diagnostic Ultrasound of Blood Flow in
Breast Tumors .............................. 212
Index 213
XIII
Abbreviations
XIV
a. artery
AA constant flow ratio
aa. arteries
A/B ratio ratio of systolic peak to end-diastole
AD abdominal diameter
AFI amniotic fluid index
AIUM American Institute of Ultrasound in
Medicine
ALARA as low as reasonably achievable
AO aorta
ARED absent or reversed diastolic flow
ARS average rising slope
ASA acetylsalicylic acid
AUC area under the curve
AV atrioventricular
B/A ratio ratio of end-diastole to systolic peak
BE base excess
BFC blood flow classification
BGA blood gas analysis
BI balance index
BP blood pressure
BPD biparietal diameter
CFM color flow mapping
CG center of gravity
CI confidence index
CL center of gravity line
CLASP Collaborative Low-dose Aspirin Study
in Pregnancy
CT computed tomography
CTG cardiotocogram
CW Doppler continuous wave Doppler
DGC depth gain compensation
DI diastolic index
DS descending slope
DTVI diastolic time velocity integral
DV ductus venosus
E/A ratio ratio of V
early diastole to V
max
max
arte-
rial contraction
EDRF endothelium-derived relaxing factor
EFSUMB European Federation of Societies in
Ultrasound in Medicine and Biology
EPH edema, proteinuria, hypertension
ES end-systolic
FFT fast Fourier transform
FFTS feto-fetal transfusion syndrome
FIP frequency index profile
FL femur length
(T) maximal Doppler shift frequency at
F
max
end of cardiac cycle
F
(TA) temporal average of the maximal
max
frequencies
(TM) maximal Doppler shift frequency at
F
max
the temporal minimum
(TP) maximal Doppler shift frequency at
F
max
the temporal peak
FP false positives
FSBA fetal scalp blood analysis
GnRH gonadotropin-releasing hormone
HC head circumference
hCG human chorionic gonadotropin
HELLP hemolysis, elevated liver enzymes, and
low platelet count
HWI height width index
HPF high pass filter
ICA internal carotid arteries
ICP intracranial pressure
ImI impedance index
ISPTA intensity special peak time average
IUD intrauterine device
IUGR intrauterine growth restriction (or re-
tardation)
IVC inferior vena cava
LHV left hepatic vein
LMP last menstrual period
MCA middle cerebral artery
MHV middle hepatic vein
MIT mean inflow time
MRI magnetic resonance imaging
MRT mean residence time
MV
max
peak systolic velocity
NO nitrogen monoxide
NST nonstress test
OCT oxytocin challenge test
OFD occipitofrontal diameter
OR odds ratio
PCR placental-cerebral ratio
PI pulsatility index
PIH pregnancy-induced hypertension
PIV pulsatility index for veins
PVIV peak velocity index for veins
PLI path length index
PP perfusion pressure
PRF pulse repetition frequency
PRF percentage reverse flow
PV portal vein
PW Doppler pulsed wave Doppler
R relative flow rate index
R reflection gradient
Abbreviations
RAT relative acceleration time
RHV right hepatic vein
RI resistance index
rMIT relative mean inflow time
rMRT relative mean residence time
RF reverse flow
Ro relative flow index
ROC relative (receiver) operating charac-
teristic
ROI region of interest
RR relative risk
RS rising slope
RSA relative spectral area
S/D ratio see A/B ratio
SBI spectrum broadening index
SBR spectrum broadening ratio
SDTI systolic decay index
sens. sensitivity
spec. specificity
STVI systolic time velocity integral
SVES supraventricular extrasystole
SVT supraventricular tachycardia
TA temporal average
TAM time average maximum velocity
TAMV time average maximum velocity
TAMX time average maximum velocity
TASAV temporal average of spatial average
velocity
TAV time average velocity
TC thoracic circumference
TGC time gain compensation
TD thoracic diameter
TM temporal minimum
TP temporal peak
TP true positives
TRAP twin reversed arterial profusion
TTTS twin-to-twin transfusion syndrome
twPI time weighted pulsatility index
UA umbilical artery
ut uteroplacental arteries
UV umbilical vein
v. vein
v.'s veins
VES ventricular extrasystoles
XV
XVI
Basic Concepts
Basic Concepts
1
1
2
1 Physical and Technical Fundamentals of Ultrasound and
Doppler Ultrasound
History
Ultrasound was introduced into medical diagnostic
practice about 50 years ago. It has achieved an outstanding place among diagnostic imaging procedures
by its versatility, the increasingly robust validity of its
imaging results, its economy, and its safety for patients
even with numerous repeated exposures.
In 1942 the Austrian neurologist Dussik was the first
to penetrate the skull with sound to display the ventricles. He called his method hyperphonography. By
the end of the 1940s the reflection of ultrasound was
being used in the United States for the examination of
biological materials. In 1949 Ludwig and Struthers described the use of ultrasound to locate gallstones.
Howry and Bliss in 1950 were able to demonstrate anatomical details, developing B-mode technology. The
Oscillation, Sound Wave
Figure 1.1illustrates the generation and propagation of
a sound wave. When a molecule is made to oscillate
around its resting phase, the oscillation is transmitted
to a neighboring molecule in the medium, from this to
the next molecule and so on. In this way energy of motion, transmitted from molecule to neighboring
molecule, spreads in sinus waves through the medium.
This continuous propagation of the energy of motion is
called a wave or sound wave. It results in alternating
compression and rarefaction in the medium. The
material to be measured was placed in a water bath.
Also in 1950 the Swedish neurosurgeon Lars Leksell
laid the foundation for echoencephalography by recording the middle echo in an intact skull. Edler and
Herz described echocardiography for the first time in
1954.
Satumura was the first to report on ultrasonic Dop-
pler methods for the evaluation of cardiac function.
The introduction of real-time imaging by Krause and
Soldner led to vast advances in the noninvasive examination of the human body.
In what follows we provide an overview of the most
important physical and technical fundamentals of current ultrasonic diagnosis.
atoms and molecules can oscillate along or across the
direction of propagation. Hence we can distinguish between longitudinal waves (in the direction of propagation) and transverse waves (across the direction of
propagation). Only longitudinal waves can be propagated in gases and fluids, because sound waves lack the
shear force necessary for transverse transmission.
Physically, biological tissue can be viewed as a viscid
liquid. The stronger the cohesion between the
molecules, i. e., the denser the material, the greater is
Basic Concepts
Fig. 1.1 Generation and spread of
a sound wave.
Compression
Elongation
Cavitation
3