Color Doppler imaging of the uterine artery

Color Doppler ultrasound and spectral Doppler imaging of the uterine artery is an important part of any obstetric Doppler imaging. The uterine arteries of both sides must be visualized first on color flow imaging, by tracing these vessels as they cross the external iliac artery and vein of each side. The uterine artery can sometimes be elusive for the novice; the trick I use, is to trace the full length of the external iliac vessels from the inguinal region upwards in long axes. This leads to a strange, but prominent artery crossing the iliac artery and vein in an oblique X manner- this is the uterine artery. Spectral Doppler trace will confirm the nature of the uterine artery. (The color Doppler video clip above shows the Right uterine artery in a 14 week old gestation).
When should the uterine artery be imaged? The uterine artery must be imaged from as early as 11- 14 weeks onwards to rule out/ predict a high risk pregnancy. 
Normal PI values at 11 to 13 weeks are usually greater than 2.5. However, lower PI and RI values may be seen on the ipsilateral side as the placenta (ie: if the placenta is located to the right lateral region of the uterus, the right uterine artery would have far lower PI and RI values than the left uterine artery).
The spectral Doppler trace below shows normal values in a 24 week old pregnancy:

With values of PI= 0.76 and RI of 0.5, this uterine artery is normal for 24 weeks.











Bifurcation of the uterine artery (normal anatomical variants of the uterine artery):

 

This patient showed a division (bifurcation) of the right uterine artery (see color Doppler video above), with both vessels seen crossing over the external iliac vessels of that side. The uterine artery is known to divide or in some cases to be duplicated on one or both sides. Both branches of the uterine artery on the right side are seen to lead to the parent vessel in the video above.  

References:
                 1) Uterine artery Doppler study in ICSI (intra-cytoplasmic sperm injection) pregnancies (free article)
                 2)  Doppler Study uterine artery of 17 to 24 weeks gestation in advanced maternal age
                 3)  Role of uterine artery Doppler in determining those women at risk of placental insufficiency -   this is an excellent article from centrus.com
                4) http://www.ultrasound-images.com/fetus-general.htm#Color_Doppler_imaging_of_the_uterine_artery

Retained placenta- Ultrasound video

  

This ultrasound video clip shows a echogenic, heterogenous endometrial mass in the uterus after delivery a few days ago. The patient had a history of inability to deliver the placenta. In view of such a history, and the large size of the mass in the endometrial cavity, this is a clear evidence of retained placenta.

For more details of this case of retained placenta visit:
http://www.ultrasound-images.com/placenta.htm#Retained_products_of_conception/_retained_placenta
References: http://www.jultrasoundmed.org/content/19/1/7.full.pdf

Ultrasound imaging of normal deep veins

 
The normal deep veins of the lower limb- the femoral and popliteal veins are usually studied to rule out deep venous thrombosis. One of the various methods of ruling out clot formation (thrombosis) in the deep veins is the application of mild pressure with the ultrasound probe on the deep vein. This method is called compression and the method is called testing the compressibility of the deep vein.
This ultrasound video clip (above) shows the femoral vein (FEM V.) and the popliteal vein (POPL V.), after probe pressure is applied to determine whether complete collapse of the veins is possible. The end stage shows total apposition of the walls of the vein as pressure is applied. This confirms the absence of thrombus (clot) within the vein. This testing of the normal compressibility of the femoral and popliteal veins must be done along the full extent of the deep veins. As one goes downwards along the course of the femoral vein to the mid thigh, this may be difficult due to the femoral vein entering the adductor canal.
   At this stage the sonologist may try looking for normal augmentation of flow by pressure on the calf muscles. A sharp augmentation spike on spectral doppler trace means there is no thrombus along the course of the deep veins till the calf.
For more on this topic visit: color Doppler and ultrasound study of the deep veins of lower limb.

Subendometrial or junctional zone contractions (endometrial peristalsis):

  
This transvaginal ultrasound video clip shows the changes that take place in the endometrium of the uterus, in the immediate post-ovulatory phase or days immediately after ovulation. This patient underwent medication for induction of ovulation. The first part of the ultrasound video clip shows the endometrium on day 1 after ovulation- the endometrial stripe shows early secretory changes. But this ultrasound video shows another more striking feature- slow but definite waves of peristalsis (contractions) in the endometrium  proceeding from the cervix of the uterus upwards to the fundus. These waves of contraction are called junctional zone contractions or subendometrial contractions. It is believed that these contractions help propel the sperms upwards in the uterine cavity to enable fertilization of the ovum.
  Junctional zone contractions or endometrial peristalsis is most obvious in the immediate post-ovulatory period and decrease after that. During menstruation too, subendometrial and uterine contractions help propel the blood and endometrial tissue downwards; here the peristalsis is from the fundus downwards.
References: 1) Google books description of endometrial peristalsis
2) Textbook of ultrasound (google books)- subendometrial contractions
3) article on junctional zone peristalsis- Ultrasound imaging

Cystitis cystica- transrectal Ultrasound video

I uploaded this excellent demonstration of a small 5 mm. cyst in the submucosal region of the urinary bladder on youtube. I was intrigued by the appearance of this small bubble close to the upper surface of the prostate and was confused if this was a prostatic lesion or a bladder pathology. Much research on the net confirmed that this was indeed cystitis cystica. See: Ultrasound images and case study of cystitis cystica
Some studies suggest that cystitis cystica or cystitis of the bladder with cyst formation, may not be as rare as one thinks. But I disagree, this being the first case I have come across after many years of urinary bladder and TRUS/ transrectal ultrasound imaging.

Puzzling case of parotid tumor:

This ultrasound and Color Doppler video clip of a right parotid tumor in a middle aged male patient shows the diagnostic dilemma in arriving at an exact pathological diagnosis. This tumor shows characteristics of both Warthin's tumor as well as pleomorphic adenoma. Sometimes, only the pathologist can make the "final diagnosis". What is apparent is that this is a benign mass of the parotid, with a higher likelihood of it being a Warthin's tumor.
See: Warthin's tumor of parotid

Dermoid cyst of ovary:

Dermoid cysts of ovary are also known as mature cystic teratoma or benign teratomas of the ovary. This young lady in her early twenties was found to have bilateral dermoid cysts of the ovaries, although small ones at 2 to 3 cms. size.

The above ultrasound video clip shows one such case with dermoid cysts in both ovaries.
The mature cystic teratoma or dermoid cysts are seen as hyperechoic masses in the ovaries.
See: http://www.ultrasound-images.com/ovaries.htm#Ovarian_dermoid_cyst_or_Cystic_teratomas