viii Contents Physical and Technical Principles 1 Physical and Technical Principles of Color Doppler Sonography R. Kubale and G. Hetzel Historical Development... 2 B-Mode Sonography... 2 Physical Principles of Echo Production... 2 Principles of Ultrasound Instrumentation... 3 Analysis of B-Mode Information and Artifacts... 7 Duplex and Color Doppler Sonography... 9 Physical Principles of Motion Detection... 9 Technical Principles and Equipment Settings... 9 Technical Aspects of the Examination and Equipment Settings... 16 Analysis of Doppler Information and Artifacts... 18 New Technical Processes and Approaches... 23 New Developments in Transducer Technology... 23 New Techniques of Signal Acquisition and Processing... 24 2 Safety Aspects of Doppler and Color Doppler Sonography H.-D. Rott Mechanisms oftissue Effects... 29 Heating... 29 Cavitation... 29 Risk Assessment ofvarious Ultrasound Techniques... 30 Duplex Sonography... 30 Color Doppler... 31 Power Doppler... 31 Color Velocity Imaging (CVI)... 31 Transvaginal Scanning... 31 Ultrasound Contrast Agents... 31 Exposure of Gas-Containing Tissues... 32 Measures to Limit Risk... 32 Recommendations... 32 General Recommendations... 32 Pulsed Doppler... 32 Appendix: Statements on the Biological Safety of Diagnostic Ultrasound Fields... 33 EFSUMB Statement on the Clinical Safety of Diagnostic Ultrasound 10... 33 WFUMB Statement on Thermal Effects in Clinical Applications 25... 33 Infertility Evaluation and Assisted Reproduction 3 Uterine Blood Flow in Fertile and Infertile Women S. Kupesic and A. Kurjak Uterine Blood Supply... 36 Changes in Uterine Blood Flow during the Menstrual Cycle... 36 Blood Flow Parameters in the Uterine Arteries... 36 Blood Flow Parameters in the Radial and Spiral Arteries. 37 Uterine Blood Flow in Infertile Women... 38 Uterine Blood Flow and Fertilization Rate... 39 Uterine Blood Flow in the Normal Cycle and during Ovarian Stimulation with Confirmed Ovulation... 39 Endometrial Imaging... 39 Conclusions... 39
Contents ix 4 Uterine Causes of Infertility S. Kupesic and A. Kurjak Ultrasound Detection ofuterine Abnormalities... 41 Congenital Anomalies... 41 Endometrial Polyps... 41 Submucous Leiomyomas... 42 Adenomyosis... 44 Endometritis... 44 AshermanSyndrome... 44 Ultrasound Detection ofendometrial Causes of Infertility... 45 Effect of Endometrial Thickness and Morphology on Fertility... 45 Effect of Age on Endometrial Function... 47 Endometrial Peristalsis... 47 Cervical Factor... 47 5 Changes in Uterine and Ovarian Perfusion with the Onset of Menopause A. Kurjak and S. Kupesic Decline offertility in the Perimenopausal Period... 50 Uterine Receptivity... 50 Oocyte Quality... 50 Ovarian Function... 51 Effects of Estradiol and Progesterone on Vascular Resistance... 51 Sympathetic Innervation of the Uterus... 51 EstrogenEffect... 51 ProgesteroneEffect... 52 Effect of Age on Ovarian and Uterine Perfusion... 52 Authors Study... 52 Interpretation of the Results... 54 6 Color Doppler Sonography for the Optimization of Assisted Reproduction D. Grab and K. Sterzik Functional Evaluation ofthe Endometrium... 57 Authors Studies... 58 Patients and Methods... 58 Examination Procedures... 58 Results... 61 Discussion of the Role of Doppler Examinations... 64 Summary... 66 7 Pulsed Doppler and Color Duplex Sonography in the Assessment of Tubal Patency B. Hüneke, A. Kleinkauf-Houcken, C. Lindner, and W. Braendle Applications ofdoppler Sonography in Reproductive Medicine... 69 Assessment oftubal Patency... 69 Patients and Method... 69 Examination Technique... 70 Results... 73 Discussion of the Value of the Test Procedures... 74 Summary... 75 8 Abnormalities of Corpus luteum Function S. Kupesic, A. Kurjak, and T. Zodan Morphology and Biochemistry ofthe Corpus luteum. 77 Conventional Methods in the Diagnosis and Treatment ofluteal Phase Defect... 78 Possible Causes of Luteal Phase Defect... 78 DiagnosisofLutealPhaseDefect... 78 Treatment of Luteal Phase Defect... 79 Ultrasound and Doppler Sonography in the Detection ofluteal Phase Defect... 79 LUF Syndrome... 79 Blood Flow in the Corpus luteum during Early Pregnancy... 81
x Contents 9 Interventional Ultrasound in Reproductive Medicine S. Kupesic, A. Kurjak, and A. K. Ertan Follicular Aspiration in Assisted Reproduction... 83 Transabdominal Follicular Aspiration... 83 Transurethral Follicular Aspiration... 84 Transvaginal Follicular Aspiration... 84 GIFT(Gamete Intrafallopian Transfer) and ZIFT (ZygoteIntrafallopianTransfer)... 85 Embryo Transfer... 85 Fallopian Tube Catheterization... 85 Aspiration ofovarian Cysts... 86 Drainage ofcul-de-sac Abscesses... 86 Selective Reduction ofmultiple Pregnancies... 86 Techniques ofultrasound Tubal Imaging... 87 Hysterosonosalpingography... 88 Obstetric Ultrasound 10 Doppler Ultrasound Examinations from Folliculogenesis to Early Pregnancy S. Kupesic, A. Kurjak, and W. Schmidt Overview... 96 Monitoring Folliculogenesis... 96 Development ofthe Corpus luteum... 97 Changes in Endometrial Blood Flow... 98 Luteal Blood Flow in Normal and Abnormal Pregnancies...100 Trophoblastic Invasion and Development ofthe Placenta...101 11 Evaluation of Early Placentation and the Embryonic Circulation with Doppler Ultrasound A. Kurjak and S. Kupesic Implantation...103 Development ofthe Intervillous Circulation...103 Classic Theory...103 Objections and Alternative Theories...104 Color Doppler Studies...104 Vascularization ofthe Yolk Sac and Vitelline Duct...106 Changes in Uterine Perfusion after Placentation...107 Uterine Arteries and Spiral Arteries...107 Embryonic and Fetal Circulation...107 Fetal Vessels...108 Summary...109 12 Color Doppler Sonography in Ectopic Pregnancy H. J. Voigt Importance oftransvaginal Sonography and Serum hcg...111 Transvaginal Color Doppler Sonography...112 Typical Findings in Normal and Ectopic Pregnancy...112 Diagnostic Efficiency...112 Author sstudies...112 Assessment of the Method...115 Summary...115 13 Physiology of Doppler Flow in Maternal Vessels during Pregnancy T. Golaszewski, J. Deutinger, and G. Bernaschek Conditions ofintrauterine Life...116 Physical Principles...116 Anatomical and Physiological Principles...116 Adaptive Processes during Pregnancy...117 Technique oftransvaginal Pulsed Doppler Flowmetry...117 Authors Studies...118 Uterine Perfusion in a Normal Pregnancy...118 Uterine Perfusion in an Abnormal Pregnancy...119 Uterine Perfusion on Medication or following Uterine Manipulation...120
Contents xi Discussion...121 Uterine Perfusion in a Normal Pregnancy...121 Uterine Perfusion in an Abnormal Pregnancy...121 Uterine Perfusion on Medication or after Uterine Manipulation...122 Summary...122 Doppler Flowmetry of Maternal Vessels as a Screening Test?...122 14 Color Doppler Sonography of the Uterine Arteries in Early Pregnancy to Screen for Preeclampsia and Uteroplacental Insufficiency A. Funk Applications ofcolor Doppler Sonography during Pregnancy...124 Technique oftransvaginal Doppler Sonography...124 Normal Development ofuterine Artery Doppler Spectra...125 NormalValuesinEarlyPregnancy...125 Early Doppler Examination ofuteroplacental Blood Flow in Abnormal Pregnancy...126 Patients...126 Results...127 Discussion...127 Summary...128 15 Normal Fetomaternal Doppler Indices in the Second and Third Trimesters of Pregnancy A. K. Ertan, H. J. Hendrik, I. Tossounidis, and W. Schmidt Establishing Normal Curves...129 Methodology...129 Defining the Normal Population...129 Plotting Quantile Curves...129 Results...130 Discussion...133 Progression of Doppler Indices during the Course of Pregnancy...133 16 Venous Doppler Sonography F. Bahlmann Historical Development...135 Physiology...135 Umbilical Vein...135 Ductusvenosus...136 Inferior Vena Cava...139 Hepatic Veins...139 Clinical Applications...140 Intrauterine Growth Retardation Due to Chronic Placental Insufficiency...140 Growth Discordance in Multiple Pregnancy...141 Hydrops fetalis...141 Conclusion...143 Other Diseases...143 Specific Obstetric Problems 17 Color Doppler Sonography in the Diagnosis of Nuchal Cord A. K. Ertan, H. J. Hendrik, and W. Schmidt Importance ofnuchal Cord...148 Color Doppler Study on the Diagnosis ofnuchal Cord.148 Examination Technique...148 Results...149 Importance of Nuchal Cord Diagnosis in the Biophysical (ABCD) Profile...150 Role ofdoppler Sonography in NC...151 Summary...153
xii Contents 18 Chronic Placental Insufficiency H. J. Hendrik, A. K. Ertan, and W. Schmidt Definitions...155 Definition and Incidence of Chronic Placental Insufficiency...155 Intrauterine Growth Retardation...156 Diagnosis ofchronic Placental Insufficiency...158 Diagnostic Systems...158 Indications for Doppler Sonography...159 Clinical Management ofchronic Placental Insufficiency Suspected from Doppler Findings...160 Antenatal Fetal Heart Rate Monitoring...160 Pathological Changes in Organ Systems...160 Biophysical Profile...161 Summary...162 Identifying Cases with IUGR...162 Obstetric Management...163 19 Severely Abnormal Doppler Findings and Perinatal Abnormalities A. K. Ertan, H. J. Hendrik, and W. Schmidt Surveillance ofcompromised Fetuses...166 Absent End-Diastolic Flow (AEDF) and Reverse Flow.. 166 Technical Aspects in the Diagnosis of Absent End- Diastolic Flow and Reverse Flow...166 Absent End-Diastolic Flow in the Umbilical Artery and/or FetalAorta...168 Reverse Flow in the Umbilical Artery and/or Fetal Aorta. 168 Clinical Results of AEDF or Reverse Flow in the Umbilical Arteryand/orFetalAorta...168 Significance of Severely Abnormal Doppler Findings..170 Summary...173 20 Fetal Doppler Findings in Late Pregnancy K. Vetter Physiological Findings in Late Pregnancy...176 Aorta:QuantitativeAnalysis...176 Aorta: Qualitative Analysis...176 Cerebral Arteries...177 Renal Arteries...177 Femoral Arteries...177 Changes in Findings at Term and in Postterm Pregnancies...178 TermEffect...178 Circulatory Balance...179 Summary...180 21 Intrapartum Fetal Heart Rate Changes and Doppler Sonography E. Weiss Pathophysiology and Technical Problems...182 Changes in Uterine Artery Waveforms during Labor.. 183 OurResults...183 Discussion of Uterine Doppler Changes during Labor...185 Intrapartum Waveform Changes in Umbilical and Intrafetal Vessels...187 Umbilical Cord Doppler during Labor...187 Effect of Intrapartum FHR Decelerations on Quantitative Parameters of Umbilical Blood Flow...192 Direct Effect of Intrapartum Fetal Hypoxia or Hypoxemia on Blood Flow Patterns in the Umbilical Arteries and Vein...193 Intrapartum Blood Flow Patterns in the Fetal Aorta...194 Intrapartum Blood Flow Patterns in Fetal Cerebral Vessels...195 Summary...196
Contents xiii 22 Color Doppler Ultrasound in Fetal Echocardiography A. Lindinger Congenital Heart Disease Incidence and Risk Factors...198 General Introductory Remarks on Color Doppler Sonography ofthe Fetal Heart...199 Indications for Color Doppler Sonography Advantages andlimitations...199 Special Features of Fetal Echocardiography...199 Ultrasound Examination ofthe Fetal Heart...200 NormalFindings...200 Color Doppler in the Diagnosis of Congenital Heart Disease...205 Management of Suspected Congenital Heart Disease...218 23 Use of Color Doppler in Echocardiography U. Gembruch Importance ofcolor Doppler Echocardiography in Prenatal Diagnosis...219 Examination ofthe Normal Heart...219 Equipment Settings...219 Examination Technique...220 Cardiac Valve Regurgitation...221 Functional Physiological Tricuspid Regurgitation...221 Pathological Tricuspid Regurgitation...221 Tricuspid and Mitral Valve Regurgitation...221 Semiquantification of AV Valve Regurgitation...222 Anomalies ofvisceroatrial Blood Flow...222 Anomalies ofatrioventricular Blood Flow...223 Anomalies ofventriculoarterial Blood Flow...224 Anomalies ofblood Flow through the Cardiac Septa.. 225 Color Doppler Sonography in Fetal Arrhythmias...226 Summary...227 24 Structure of the Human Placenta and Pathomorphological Changes in Placental Insufficiency K. R. Reitnauer Structure ofthe Human Placenta...230 Weight and Dimensions...230 Early Development of the Human Placenta...230 Structure of the Villous Tree...232 Microstructure of the Terminal Villus...234 Maturation of the Placenta...235 Vascular Architecture of the Villous Tree...235 Regulation of Villous Blood Flow...235 Concept of the Placentone...236 Morphology and Physiological Transformation of the Maternal Basal-Plate Vessels...236 Placental Insufficiency...237 Definition and Etiology of Placental Insufficiency...237 Placental Compensatory Mechanisms...237 Classification of Placental Insufficiency by its Progression...238 Morphological Counterparts of Latent or Overt Placental Insufficiency...238 25 Morphological and Morphometric Studies of the Placenta with Doppler Abnormalities of the Fetal Umbilical Arteries* T. Hitschold Clinical Aspects ofplacental Insufficiency...249 Pathophysiological Aspects ofplacental Insufficiency.249 Pathomorphological Aspects ofplacental Insufficiency...250 Validation ofdoppler Findings by Placental Histology...251 Resistance Index of the Umbilical Arteries...251 End-Diastolic Blood Flow Velocities in the Umbilical Arteries...252 Clinical and Diagnostic Value of Doppler Sonography of the Umbilical Arteries...254
xiv Contents Gynecological Ultrasound 26 Sonographic and Doppler Sonographic Examination of Uterine Anomalies S. Kupesic and A. Kurjak Classification of Uterine Anomalies...260 Diagnosis and Complications ofseptate Uterus...261 Ultrasound in the Diagnosis and Treatment ofseptate Uterus Authors Results...261 Patients and Methods...261 Results...262 New Thoughts on Old Problems...264 27 Doppler Examination of the Normal Endometrium and Benign Endometrial Changes S. Kupesic and A. Kurjak Changes in the Normal Endometrium during the Menstrual Cycle...266 Changes in Endometrial Blood Flow during the Menstrual Cycle...266 Submucous Leiomyomas...268 Endometrial Polyps...269 Endometrial Hyperplasia...270 Adenomyosis...271 Endometritis...272 Incomplete Abortion...272 Decidua...272 28 Transvaginal Color Doppler and Pulsed Doppler Diagnosis of Benign Changes in the Uterine Myometrium A. Kurjak and S. Kupesic Examination Technique, Anatomy, and Physiology...274 Leiomyomas (Fibroids)...274 Vascularization of Leiomyomas...275 Management ofuterine Leiomyomas and the Importance ofcolor Doppler Sonography...277 Medical Treatment with GnRH Agonists...277 Surgical Treatment...277 Vascular Diseases in the Lesser Pelvis (Varicose Veins or Arteriovenous Malformations)...278 29 Use of Color Doppler in the Evaluation of Suspicious Endometrial Findings M. Holländer, C. Villena-Heinsen, A. K. Ertan, and W. Schmidt Incidence ofendometrial Carcinoma...280 Diagnostic Investigation ofsuspicious Endometrial Findings...280 Color Doppler Sonography...280 Examination ofthe Uterine Artery...281 Experience at the Department ofobstetrics and Gynecology, Homburg University Hospital, Saar...281 Patients and Methods...281 Visualization and Morphology of the Vessels...282 Resistance Indices of Endometrial Vessels...284 Effect of Menopausal Status and Hormone Use...284 Effect of Histopathological Parameters, with Reference toprognosticfactors...285 Subendometrial and Myometrial Vessels...286 Summary...286
Contents xv 30 Malignant Uterine Tumors A. Kurjak and S. Kupesic Endometrial Carcinoma...288 Incidence...288 RiskFactors...288 TargetGroupforScreening...288 Screening: Dream or Reality?...288 Authors Experience...292 ReviewoftheLiterature...293 Uterine Sarcoma...296 Authors Experience...296 Cervical Carcinoma...297 Conclusion...297 31 Blood Flow Changes in Cervical Carcinoma Treated by Primary Chemotherapy C. Villena-Heinsen, A. K. Ertan, M. Holländer, and W. Schmidt Treatment ofcervical Carcinoma...299 Assessing Treatment Response with Pulsed Color Doppler Sonography...299 Authors Studies...299 Discussion...301 Summary...302 32 Color Doppler Imaging of Benign Adnexal Masses A Spectrum of Findings A. Kurjak, S. Kupesic, and A. K. Ertan Appearance ofnormal Ovaries by B-Mode and Color Doppler Ultrasound...304 Specific Adnexal Masses...304 Cystic and Cystic-Solid Ovarian Masses...304 Solid Ovarian Masses...307 Conclusions...308 33 Malignant Adnexal Tumors A. Kurjak, S. Kupesic, and A. K. Ertan Color Doppler Sonography ofadnexal Malignancies.. 310 Review ofthe Literature...310 Neoangiogenesis...312 Detecting Blood Vessels and Defining their Location...312 Vascular Patterns...312 Pulsed Doppler Waveforms...313 Vascular Impedance...314 Blood Flow Velocities...315 Stages of Malignant Tumors...315 False-Positive Results...316 Conclusions...317 34 Three-Dimensional Power Doppler Sonography in Evaluating the Angiogenesis of Ovarian Tumors A. Kurjak, S. Kupesic, and B. Breyer Contribution oftransvaginal Color Doppler Sonography...319 Three-Dimensional Imaging...320 Three-Dimensional Imaging of Vascular Patterns...320 Types of Image Acquisition and Equipment for Three- Dimensional Ultrasound...320 Display Modes for Three-Dimensional Vascular Images.. 320 Ultrasound Technology in Tumor Diagnosis...321 Problems in the Interpretation of 3D Power Doppler Data...321 Brief Review of the Mathematical Basis of New Technologies...321 Current Methods for Evaluating Vascular Geometry and Function...322
xvi Contents Technique for Evaluating Vascular Geometry...322 Example of 3D Power-Mode Imaging of Benign and Malignant Gynecological Tumors...322 Advances in Tumor Therapy...326 Summary...326 Future Outlook...326 35 Ovarian Cancer Screening A. Kurjak, W. Schmidt, A. K. Ertan, and S. Kupesic Incidence and Five-Year Survival Rates ofovarian Cancer...330 Requirements ofa Screening Program...330 Definition...330 Screening Methods...331 ScreeningParameters...331 Possible Screening Tests...332 Bimanual Pelvic Examination...332 Cul-de-sac Washings and Radiological Studies...332 TumorMarker...332 Ultrasound...333 Who Should be Screened?...335 Age Distribution...335 FamilyHistory...336 Conclusion...336 OtherRiskFactors...336 36 General Aspects of the Ultrasound Investigation of Blood Flow in Breast Tumors C. Villena-Heinsen, M. Holländer, and W. Schmidt Historical Development...339 Specific Parameters in the Doppler Examination of Breast Tumors...339 Blood Flow Detection...339 Number of Tumor Vessels...341 Resistance Index...342 Absolute Velocities...342 Number and Intensity of Color Pixels and Color Areas... 343 Doppler Waveform...345 Comparison of Mirror Image Areas...345 Conceptual Misunderstandings in the Interpretation ofdoppler Measurements...345 37 Color Doppler Sonography in the Diagnosis of Breast Cancer H. Madjar Evolution ofbreast Cancer Diagnosis...348 Continuous-Wave Doppler...350 Pulsed Doppler Techniques...351 Color Doppler...351 Equipment Settings...352 Examination Technique...353 BloodFlowAnalysis...354 StudyResults...355 Discussion...356 Conclusions...359 38 Usefulness of the Minimum Resistance Index in the Benign Malignant Discrimination of Breast Tumors C. Villena-Heinsen, M. Friedrich, J. König, and W. Schmidt Flow Resistance in Malignant Breast Tumors...360 Authors Studies...360 Patients and Methods...360 Results and Discussion...361 Summary...363
Contents xvii 39 Effect of Menopausal Status and Hormone Replacement on Therapy Resistance Indices and Blood Flow Velocities in Breast Tumors C. Villena-Heinsen, I. Tossounidis, and W. Schmidt Menopausal Status and Benign Malignant Tumor Discrimination...364 Authors Studies...364 Patients and Methods...364 Results...365 Discussion...366 Summary...370 40 Benign Malignant Tumor Discrimination and Prognostic Evaluation of Breast Tumors with Color Doppler Sonography C. Villena-Heinsen, A. K. Ertan, D. Mink, and W. Schmidt Applications ofcolor Doppler Sonography in Breast Cancer...371 Authors Studies...372 Methods...372 Results...372 Discussion...376 Conclusion...377 Index...379