Fourth Edition
Editors Narendra Malhotra MD FICMCH FICOG MAIUM MISUOG FIAJAGO
Professor, Dubrovnik International University, Croatia Director, Global Rainbow Health Care
Agra, Uttar Pradesh, India
PK Shah MD FCPS FICOG FICMU FICMCH DGO DFP
Professor, Department of Obstetrics and Gynecology Seth GS Medical College and King Edward VII Memorial Hospital
Mumbai, Maharashtra, India
Pratap Kumar MD DGO FICS FICOG FICMCH
Professor, Department of Obstetrics and Gynecology Kasturba Medical College and Hospital
Manipal, Karnataka, India
FOGSI Chairman of Imaging Science Committee (1991–95)
Prashant Acharya MD FICOG
Consultant in Fetal Medicine and High-risk Obstetric Care Vice-President, FOGSI 2012 Paras Advanced Center for Fetal Medicine
Ahmedabad, Gujarat, India
Sonal Panchal MD
Professor, Dubrovnik International University, Croatia Consultant Sonography Specialist Dr Nagori's Institute for Infertility and IVF Ahmedabad Advisory Board International Journal of Infertility and Fetal Medicine
Ahmedabad, Gujarat, India
Jaideep Malhotra MD FICOG FICMCH
Professor, Dubrovnik International University, Croatia Director, Rainbow IVF
Agra, Uttar Pradesh, India
Foreword WW Sumpaico
KY Leung
Headquarters
Jaypee Brothers Medical Publishers (P) Ltd
4838/24, Ansari Road, Daryaganj
New Delhi 110 002, India
Phone: +91-11-43574357
Fax: +91-11-43574314
Email: jaypee@jaypeebrothers.com
Overseas Offices
J.P. Medical Ltd
83 Victoria Street, London
SW1H 0HW (UK)
Phone: +44-2031708910
Fax: +02-03-0086180
Email: info@jpmedpub.com
Jaypee-Highlights Medical Publishers Inc
City of Knowledge, Bld. 237, Clayton
Panama City, Panama
Phone: +1 507-301-0496
Fax: +1 507-301-0499
Email: cservice@jphmedical.com
Jaypee Medical Inc
The Bourse
111 South Independence Mall East
Suite 835, Philadelphia, PA 19106, USA
Phone: +1 267-519-9789
Email: jpmed.us@gmail.com
Jaypee Brothers Medical Publishers (P) Ltd
17/1-B Babar Road, Block-B, Shaymali
Mohammadpur, Dhaka-1207
Bangladesh
Mobile: +08801912003485
Email: jaypeedhaka@gmail.com
Jaypee Brothers Medical Publishers (P) Ltd
Bhotahity, Kathmandu, Nepal
Phone: +977-9741283608
Email: kathmandu@jaypeebrothers.com
Website: www.jaypeebrothers.com
Website: www.jaypeedigital.com
© 2014, Jaypee Brothers Medical Publishers
The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book.
All rights reserved. No part of this publication and may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers.
All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book.
Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.
This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought.
Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity.
Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com
Ultrasound in Obstetrics and Gynecology
Fourth Edition : 2014
9789351521587
Printed at
5Contributors
- AK Debdas
- Jamshedpur, Jharkhand, India
- Aida Salihagic Kadic
- Zagreb, Croatia
- Ajay S Dhawle
- Akshatha Prabhu Sharma
- New Delhi, India
- Alaa Ebrashy
- Cairo, Egypt
- Alok Sharma
- Himachal Pradesh, India
- Amar R
- Manipal, Karnataka, India
- Amreen Singh
- Anita Kaul
- New Delhi, India
- Ankesh R Sahetya
- Mumbai, Maharashtra, India
- Anu Vij
- Mumbai, Maharashtra, India
- Ashini Acharya
- Ahmedabad, Gujarat, India
- Ashok Khurana
- New Delhi, India
- Ashwini V
- Mumbai, Maharashtra, India
- Asim Kurjak
- Zagreb, Croatia
- Babu S Patel
- Ahmedabad, Gujarat, India
- Badreldeen Ahmed
- Doha, State of Qatar
- Berivoj Miskovic
- Zagreb, Croatia
- Betty Lau
- Hong Kong
- BI Patel
- Ahmedabad, Gujarat, India
- Biserka Funduk Kurjak
- Zagreb, Croatia
- Boris Ujevic
- Zagreb, Croatia
- Branko M Plavsic
- Texas, USA
- Chaitanya Nagori
- Ahmedabad, Gujarat, India
- Chander Lulla
- Mumbai, Maharashtra, India
- Christine M Dudiak
- Baltimore, USA
- Clare M Tempany
- Baltimore, USA
- Deepika Deka
- New Delhi, India
- Fang Yang
- Hong Kong
- Geeta Kolar
- Hyderabad, Andhra Pradesh, India
- Gino Varga
- Zagreb, Croatia
- Gokul Das
- Guwahati, Assam, India
- Harold V Posniak
- Baltimore, USA
- Hema Divakar
- Bengaluru, Karnataka, India
- Hriday Acharya
- Ahmedabad, Gujarat, India
- Ichiro Kawabata
- Nagara Gifu, Japan
- Indrani Suresh
- Chennai, Tamil Nadu, India
- Jaideep Malhotra
- Agra, Uttar Pradesh, India
- JP Rao
- Agra, Uttar Pradesh, India
- Juan Luis Alcázar
- Pamplona, Spain
- Kazuo Maeda
- Yonago, Japan
- Keshav Malhotra
- Agra, Uttar Pradesh, India
- Kuldeep Singh
- New Delhi, India
- KY Leung
- Hong Kong
- Larry Waldroup
- Philadelphia, USA
- Maja Predojevic
- Zagreb, Croatia
- Mandakini Pradhan
- Lucknow, Uttar Pradesh, India
- Martina Ujevic
- Zagreb, Croatia
- Mary C Olson
- Baltimore, USA
- Meeta Kulshreshtha
- Agra, Uttar Pradesh, India
- Milan Kos
- Mrinalini
- New Delhi, India
- Mukta Jain
- Indore, Madhya Pradesh, India
- Nadah Zafar
- Texas, USA
- Narendra Malhotra
- Agra, Uttar Pradesh, India
- Neelima Y Mantri
- Mumbai, Maharashtra, India
- Neharika Malhotra
- Agra, Uttar Pradesh, India
- Nika Kalogjera
- Niraj Mahajan
- Mumbai, Maharashtra, India
- Nitin P Ghonge
- New Delhi, India
- Nozer K Sheriar
- Mumbai, Maharashtra, India
- PK Shah
- Mumbai, Maharashtra, India
- Pooja Lodha
- Pradeep Kumar Gupta
- Jaipur, Rajasthan, India
- Pranay R Shah
- Mumbai, Maharashtra, India
- Prashant Acharya
- Ahmedabad, Gujarat, India
- Prashanth Adiga
- Manipal, Karnataka, India
- Pratap Kumar
- Manipal, Karnataka, India
- Prathima Radhakirshnan
- R Rajan
- Kerala, India
- Rajat Ray
- Raju R Sahetya
- Mumbai, Maharashtra, India
- Ranjit Akolekar
- London, UK
- Reena J Wani
- Mumbai, Maharashtra, India
- Rich Feld
- Philadelphia, USA
- Rishabh Bora
- Agra, Uttar Pradesh, India
- RN Goel
- Agra, Uttar Pradesh, India
- Rohit Jain
- Agra, Uttar Pradesh, India
- S Suresh
- Chennai, Tamil Nadu, India
- Sakshi Mittal
- Agra, Uttar Pradesh, India
- Sakshi Tomar
- Agra, Uttar Pradesh, India
- Samiksha Gupta
- Agra, Uttar Pradesh, India
- Sanchita Dube Ghonge
- New Delhi, India
- Sanja Kupesic Plavsic
- Texas, USA
- Satish K Bhargava
- Shantala Vadhiyar
- Shanthi Sairam
- Chennai, Tamil Nadu, India
- Shashi Gupta
- Jaipur, Rajasthan, India
- Shifali Gupta
- Shigenori Iwagaki
- Nagara Gifu, Japan
- Sonal Panchal
- Ahmedabad, Gujarat, India
- Sudhanshu Bankata
- Sudheer Gokhale
- Sumit Gupta
- Leicester, UK
- Suseela Vavilala
- Hyderabad, Andhra Pradesh, India
- Teresa Ma
- Hong Kong
- TLN Praveen
- Ulrich Honemeyer
- Dubai, UAE
- Uma Ram
- Chennai, Tamil Nadu, India
- Vanaj Mathur
- Agra, Uttar Pradesh, India
- Vikas Kohli
- New Delhi, India
- Yuichiro Takahashi
- Nagara Gifu, Japan
The development of ultrasonography in Obstetrics and Gynecology is fascinating. The improvement in the resolution of two-dimensional sonography allows detailed examination of the fetal structures even in the first trimester. The use of high frequency endovaginal transducer gives fine details of the uterine cavity and adnexa allowing the detection of variety of female genital tract abnormalities and early pregnancy complications. Nowadays, three- and four-dimensional ultrasound machines are more widely available than previously.
Ultrasonography becomes an integral part of the clinical practice in managing pregnancy, gynecological problems, infertility and even asymptomatic pregnancy. Apart from the diagnosis or exclusion of an abnormality, ultrasonography can be used to assist intervention or even for direct intervention.
Knowing the limitation of ultrasonography, we sometimes need to order “big gun” modalities like computed tomography or magnetic resonance imaging to make a definitive diagnosis.
To optimize the usefulness of ultrasonography and to avoid missing an important lesion or abuse of the ultrasonography, training is very important. An error in scanning may end up into a medicolegal case.
The editors Narendra Malhotra, PK Shah, Pratap Kumar, Prashant Acharya, Sonal Panchal, Jaideep Malhotra and various authors have made a lot of contribution to this FOGSI publication “Ultrasound in Obstetrics and Gynecology”, covering many important topics from basic physics through clinical practice to legal and ethical issues. Congratulations to their success. I hope the readers will find this comprehensive FOGSI textbook useful. Continuous medical education can improve the standard of clinical practice and hence the health of the women and their babies.
WW Sumpaico
Secretary General
AOFOG
KY Leung
mbbs, md, frcog, fkham (obs and gyn)
Dip Epidem and Appl Stat President
11Preface to the Fourth Edition
Ultrasound has been the find of the century and the biggest invention of medical history. No single investigative tool has had so much influence on all fields of medicine as ultrasound. In Obstetrics and Gynecology, when Professor Ian Donald in 1957–58 first demonstrated fetal measurements and ovarian cyst, and later fetal movements (1960) by real time he said, “This is it! We have come to an end of an era of diagnosis”. What Professor Ian Donald said was partially right because he never predicted the development of computers and image managements.
The advancement in computer technology has today made ultrasound a virtual look into the “Pandora box”. Today, with high resolution (HD), and three- and four-dimensions, we are able to study not only fetal and pelvic anatomy but also physiology, pathology, and behaviors (fetal).
Technology is advancing every day and new softwares are now making scanning simpler and accurate. With the light steering mechanisms, it is now possible to do noninvasive fetoscopy. With HD 3D, it is now possible to replace hysteroscopy as gold standards of cavity evaluation. With interventional techniques, it is now possible to treat many conditions of fetus intrauterine and many gynecological conditions, and assisted-reproductive technology (ART).
This textbook is being revised after a very long gap, and we hope our gynecologists, obstetricians, ART specialists, and fetal medicine experts find this book useful.
“See better with sound”
“Turn on the color to improve your image”
“Switch to a new dimension 3rd and 4th”
“Practice better medicine with ultrasound”
Note: In India, the PCPNDT law mandates all practicing ultrasound to be registered and to fulfill all criteria and conditions of the law.
Narendra Malhotra
PK Shah
Pratap Kumar
Prashant Acharya
Sonal Panchal
13Preface to the First Edition
The development of high technology like ultrasound has literally produced a diagnostic revolution in Obstetrics and Gynecology. In the past, ultrasound had a minimal impact on the day-to-day practice of Obstetrics and Gynecology. However, in the present day, ultrasound is part and parcel of routine work for diagnostic as well as therapeutic value. This allows the obstetrician and gynecologist to look into the problems more precisely for better management. Ultrasound has brought in a new revolution in diagnosis and management. Those who think this is an overstatement have either not used the technique or have not invested the time to become proficient enough with the technique to appreciate its real potential. Once a person becomes familiar with its potential, he may not be able to practice without it.
The art of effective diagnosis is one that relies to a considerable degree on the recognition of visual signs and manifestations of disease aided by ultrasound. Ultrasound has made it obvious that the fetus is an individual virtually from conception which can be made out from early sonography. Furthermore, technical improvements in ultrasonic instrumentation have opened up new avenues to the visualization and evaluation of normal and abnormal fetal anatomy. Normal anatomy and pathological condition in the pelvic structures can easily be diagnosed by transvaginal sonography. The recent developments like color Doppler provide blood flow information and offer new insights into dynamic studies of blood flow within the female pelvis.
Moreover, technical improvements in ultrasonic instrumentation have opened up new frontiers in fetal therapy as well as gynecological and assisted reproduction by interventional sonography.
It is our intention to share experience of various authors in this book, “Ultrasound in Obstetrics and Gynecology”, and we do hope this will benefit various individuals.
Pratap Kumar
MY Rawal
15Acknowledgments
We are thankful to FOGSI for allowing us to bring out the much-needed revised edition of the FOGSI textbook of Ultrasound in Obstetrics and Gynecology. We are thankful to Professor Ian Donald for inventing Obstetrics and Gynecology ultrasound and all the stalwarts from all over the world for improving and giving us newer indications.
We are thankful to late Professor MY Rawal, our teacher of ultrasound and the first editor of this book. Professor Rawal still lives in our hearts and is very fondly remembered by one and all.
We are also thankful to Professor Pratap Kumar who was the editor of the second edition of this book.
This edition has been re-edited by a team of editors from FOGSI—Professor PK Shah, Professor Pratap Kumar, Dr Prashant Acharya, and Dr Sonal Panchal.
Apart from this, significant contributions have been made by Dr Jaideep Malhotra, Dr Ashok Khurana, Dr Neharika Bora, Dr Kuldeep Singh, Late Dr Sakshi Mittal, Dr JP Rao, Dr Rohit Jain, and many others. We are thankful to all of them. Professor Asim Kurjak and Professor Frank Chervenak from Ian Donald School have let us use a lot of chapters from the Ian Donald Book, we are extremely grateful to them and to all the contributors from Ian Donald School.
We thank all the contributors, authors for updating the chapters and presenting the new edition with lots of images.
27List of Abbreviations Used in Figures
AF
amniotic fluid
AFI
amniotic fluid index
AM/AM MEMB
amniotic membrane
AO
aorta
AS
amniotic sac
AVM
arteriovenous malformation
B/b
bladder
BOD
biorbital diameter
CDI
color Doppler imaging
4 CH Heart
four chamber heart
CM
cisterna magna
CP
choroid plexus
CS
cesarean section
CSF
cerebrospinal fluid
CSP
cavum septum pellucidum
Cx/CX
cervix
DA
ductus arteriosus
DV
ductus venosus
E/Endo
endometrium
F
fundus
Fet
fetus
Fib/FIB/FIBR
fibroid
FL
fluid
GS
gestation sac
IOD
interorbital diameter
IVC
inferior vena cava
L
left
LA
left atrium
LAT
left atrium tachycardia
LHV
left hepatic vein
Liv
liver
LK
left kidney
LLQ
left lower quadrant
LO/LT OV
left ovary
LS
longitudinal section
LT UTR ART
left uterine artery
LUQ
left upper quadrant
LV
left ventricle
LVOT
left ventricular outflow tract
LVT
left ventricular tachycardia
MCA
middle cerebral artery
Nab Cyst
nabothian cyst
NBL
nasal bone length
NF
nuchal fold
NT
nuchal translucency
O
ovary
Ov-H
ovary height
Ov-L
ovary length
Ov-W
ovary width
Pla
placenta
POD
pouch of Douglas
R
rectum
RA
right atrium
RAT
right atrium tachycardia
RHV
right hepatic vein
RK
right kidney
RLQ
right lower quadrant
RO/OV-R
right ovary
RUQ
right upper quadrant
RV
right ventricle
RVOT
right ventricular outflow tract
RVT
right ventricular tachycardia
TEV
talipes equinovarus
TH
thalami
TP
pulmonary trunk
TRV UT
transverse image of uterus
TS
transverse section
U/ut/UT
uterus
UB
urinary bladder
UMB ART
umbilical artery
V mole
vesicular mole
V
vagina
VD
ventricular diastole
VS
ventricular systole
VSD
ventricular septal defect
3VV
three vessel view
YS
yolk sac