MCU 2018 Workbook For Diagnostic Medical Sonography A Guide To Clinical

i
WORKBOOK FOR DIAGNOSTIC MEDICAL

SONOGRAPHY
A Guide to Clinical Practice, Obstetrics
and Gynecology
ii
iii

SONOGRAPHY
A Guide to Clinical Practice, Obstetrics and

Gynecology
FOURTH EDITION
Barbara Hall-Terracciano, BS, RDMS (OB)(AB)(BR), RT(R)

Sonographer
St. George, Utah
Susan R. Stephenson, MS, MAEd, RDMS, RVT, CIIP

Siemens Medical Solutions USA, Inc.
Salt Lake City, Utah
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Fourth Edition
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987654321
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v
CONTENTS
PART ONE | GYNECOLOGIC SONOGRAPHY

1 Principles of Scanning Technique in Gynecologic Ultrasound
2 Embryonic Development of the Female Genital System
3 Congenital Anomalies of the Female Genital System
4 The Female Cycle
5 Normal Anatomy of the Female Pelvis
6 Doppler Evaluation of the Pelvis
7 Pediatric Pelvis
8 Benign Disease of the Female Pelvis
9 Malignant Disease of the Uterus and Cervix
10 Malignant Diseases of the Ovary
11 Pelvic Inflammatory Disease and Endometriosis
12 Assisted Reproductive Technologies (ARTs), Contraception, and Elective Abortion
13 Complementary Imaging of the Female Reproductive System
PART TWO | OBSTETRIC SONOGRAPHY

14 Principles of Scanning Technique in Obstetric Ultrasound
15 The Use of Ultrasound in the First Trimester
16 Sonographic Evaluation of First-Trimester Complications
17 Sonographic Assessment of the Ectopic Pregnancy
18 Assessment of Fetal Age and Size in the Second and Third Trimesters
19 Normal Placenta and Umbilical Cord
20 Abnormalities of the Placenta and Umbilical Cord
21 Sonographic Assessment of the Fetal Head
22 Sonographic Assessment of the Fetal Neck and Spine
23 Fetal Echocardiography
vi
24 Sonographic Assessment of the Fetal Chest
25 Sonographic Assessment of the Fetal Abdomen (Includes Abdominal Wall)
26 Sonographic Assessment of the Fetal Genitourinary System
27 Normal and Abnormal Fetal Limbs
28 The Biophysical Profile
29 Multiple Gestations
30 Intrauterine Growth Restriction
31 Patterns of Fetal Anomalies
32 Effects of Maternal Disease on Pregnancy
33 The Postpartum Uterus
34 Interventional Ultrasound
35 3D/4D Imaging in Obstetrics and Gynecology
vii

SONOGRAPHY
A Guide to Clinical Practice, Obstetrics
and Gynecology
viii
1
PART ONE
GYNECOLOGIC SONOGRAPHY
Principles of Scanning Technique in

Gynecologic Ultrasound
CHAPTER 1
For additional ancillary materials related to this chapter, please

visit the point.
REVIEW OF GLOSSARY TERMS

Matching
Match the key terms with their definitions.
KEY TERMS DEFINITION

a. Area around an organ
b. Fluid within the abdominal or pelvic
cavity
c. Biophysical results of the interaction of
1. _________ fundus sound waves and tissue
2. _________ transabdominal d. Electronic database containing all the
patient information
3. _________ electronic medical record
(EMR) e. Inside a cavity such as the abdomen or
pelvis
4. _________ picture archiving and
communication system (PACS) f. Top portion of the uterus
g. Paper-based or computerized system
5. _________ transvaginal/endovaginal designed to manage hospital data, such
6. _________ scanning protocol as billing and patient records
7. _________ bioeffects h. Position of the patient with the feet in
stirrups often used during delivery
8. _________ perivascular
i. Electronic list of patients entered into a
9. _________ ascites modality, such as ultrasound, which
10. _________ transducer footprint helps reduce data-entry errors
11. _________ adnexa j. Nonpregnant
12. _________ modality worklist (MWL) k. Around the vessels
13. _________ lithotomy position l. Database that stores radiologic images
14. _________ endocavity m. Physical or electronic system designed
15. _________ radiology information to manage radiology data, such as
system (RIS) billing, reports, and images
16. _________ nongravid n. List of images required for a complete
examination
17. _________ hospital information system
(HIS) o. Imaging through the abdomen
p. Area of the transducer that comes in
contact with the patient and emits
ultrasound
q. Within the vagina
CHAPTER REVIEW
Multiple Choice
Complete each question by circling the best answer.
1. What hospital electronic system would a sonographer use to locate a list of patients on
the ultrasound machine?
a. HIS
b. MWL
c. RIS
d. EMR
2. Pertinent clinical information for a pelvic sonographic examination may include:
a. surgical history, patient age, last menstrual period (LMP), human chorionic
gonadotropin (hCG) levels, prior delivery dates, gravidity, and parity
b. prior delivery dates, patient age, surgical history, gravidity, and history of pelvic
procedures
c. parity, gravidity, symptoms, and pelvic history to include pelvic procedures and
surgical history
d. LMP, symptoms, history of pelvic procedures, patient age, hCG levels, and
accession number
3. Parity is:
a. the number of pregnancies a patient has had
b. the total number of spontaneous and induced abortions a patient has had
c. the number of pregnancies a patient carried to term
d. the total number of pregnancies a patient has had
4. A G4P3A1T3 female is explained as having:
a. four total pregnancies, three pregnancies to term, and one induced abortion
b. four total pregnancies, three pregnancies to term, and one spontaneous abortion
c. three total pregnancies, one full-term pregnancy, one abortion, and currently
pregnant with twins
d. four total pregnancies, three full-term pregnancies, and one abortion
5. Every sonographer should be familiar with ultrasound-related organizations and
suggested scanning protocols for their profession. Choose the group that will not
provide reliable pelvic sonographic scanning information.
a. AIUM
b. ACR
c. SDMS
d. ASE
6. An adequately filled bladder usually extends ____________ the fundus of a nongravid
uterus.
a. slightly below
b. at the same level of
c. slightly beyond
d. approximately 4 cm superior to
7. Select the correct optimization technique.
a. Use a lower-frequency transducer for penetration.
b. Angle the sonographic beam parallel to the structure of interest.
c. Set focal zones 1 cm inferior to the structure of interest.
d. Choose a low-frequency transducer for superficial structures.
8. If a premenopausal female should prepare for a gynecologic ultrasound by drinking 32
ounces of water 1 hour before the examination, what preparation would be
suggested for a 70-year old with vaginal bleeding?
a. No water preparation is needed
b. 10 ounces
c. 25 ounces
d. 50 ounces
9. A 5.0-MHz transducer may not produce a diagnostic image on ______ patient.
a. a large habitus
b. an elderly
c. a thin
d. a young
10. Endovaginal optimal focal range is from:
a. 1 to 5 cm
b. 2 to 7 cm
c. the internal os to the uterine fundus
d. the fornices to the uterine fundus
11. The most appropriate transducer for an obese patient having a gynecologic
examination would be:
a. 2.5 MHz
b. 5.0 MHz
c. 7.5 MHz
d. 15 MHz
12. Endovaginal transducers cannot be inserted past the area of the:

a. external os
b. vaginal fornices
c. internal os
d. labia minora
13. Endovaginal ultrasound may not produce a diagnostic image in a patient:
a. suspected of suffering with ovarian torsion
b. that is being monitored for follicle size/ovulation
c. scheduled for ova aspiration
d. with an enlarged leiomyomatous uterus
14. Select the incorrect statement. Transperineal scanning:
a. is a safe option to replace endovaginal imaging in the case of pregnancy with
ruptured membranes
b. is performed between the labia on the perineum
c. may be performed if a patient declines endovaginal scanning
d. images inferior to bowel gas, therefore, avoiding obstructive shadows
15. Prior to an endovaginal ultrasound, the transducer should be lubricated. Which
lubricant is best for a patient being treated for infertility?
a. saline
b. none
c. K-Y jelly
d. coupling gel
16. The sonographer can adjust power levels and scan efficiently to minimize patient
exposure levels. This is known as:
a. AIUM
b. ARALA
c. ALARA
d. National Institute of Health (NIH) guidelines
17. Saline is often used as a sonographic contrast agent in gynecologic scanning to
visualize the:
a. uterine fundus and adnexas
b. fallopian tubes and endometrial cavity
c. fallopian tubes and adnexas
d. uterus and ovaries
18. Individuals choosing sonography as a profession should become certified. The gold
standard certifying body is:
a. ARRT
b. ARDMS
c. AIUM
d. RDMS
19. Higher frequency transducers provide:
a. greater depth of penetration
b. greater width assessment in transverse
c. better resolution
d. inferior resolution
20. 4D imaging uses:
a. dynamic static sections
b. STIC
c. X, Y, and Z planes
d. X, Y, and Z planes with the dimension of time
Fill-in-the-Blank
1. Optimization of an examination reduces costs and adheres to the _________ principle
in reducing exposure to ultrasound energy and decreasing patient discomfort.
2. Prior to starting a patient sonographic examination, the sonographer should use
_________ facility accepted identifiers to confirm the patient’s identification.
3. A connected hospital can offer electronic systems such as HIS (_________
_________), RIS (_________), EMR (_________), and MWL (_________), which
will make a sonographer’s job easier through the elimination of errors.
4. A full urinary bladder is necessary for a(n) _________ diagnostic pelvic examination,
and an empty urinary bladder is necessary for a(n) _________ diagnostic pelvic
examination.
5. Gel may be prepped for the patient gynecologic examination by placing the bottle in a
_________ or a sink of _________. Do not use a microwave to heat gel because it
may heat unevenly and explode.
4
6. _________ refers to the number of previous pregnancies and includes the current
gestation.
7. Parity of 3 (P3) refers to the number of pregnancies a woman has carried to
_________.
8. Overdistention of the bladder _________ and displaces the pelvic viscera.
9. The best resolution occurs within the _________ zone of the transducer.
10. Base your transducer choice on patient _________ and examination objectives.
11. _________ array transducers combine the wider field of view of sector transducers
with greater near-field visualization and increased linear measurement accuracy.
12. If endovaginal scanning is contraindicated, the _________ approach may enable the
sonographer to obtain images of the _________ and lower uterine segment.
13. A 3D imaging method to image the fetal heart and display it in _________
orthogonal planes is called _________.
14. Imaging with 2D, color, and spectral Doppler is called _________ imaging.
15. Positioning the patient in a left or right _________ may be helpful in the case of a
less than optimally filled bladder when examining the female pelvis.
16. The _________ accredits practices that image obstetric, gynecologic, abdominal,
and breast ultrasound. The _________ also accredits imaging laboratories.
17. A hysterosalpingogram (HSG) uses _________ as a contrast agent.
18. When imaging a solid ovarian mass, careful examination of the liver edge, flanks for
_________, cul-de-sac, and _________ pouch is necessary.
19. _________-filled structures enhance the transmission of sound.
20. A _________ is required on the endovaginal transducer to protect the patient.
Short Answer
1. State pertinent clinical information that should be included in an ultrasound report.
2. Explain how a mass should be imaged, measured, and characterized.
3. Why is a filled bladder necessary for a transabdominal pelvic ultrasound, and an

empty bladder crucial to an endovaginal pelvic ultrasound?
IMAGE EVALUATION/PATHOLOGY
Review the images and answer the following questions.
Patient data entry document
1. Review the patient data-entry document.
a. State the patient’s LMP.
b. Name the type of examination performed on the patient.
c. How many pregnancies has the patient had?

6
Female pelvis
2. What type of imaging is seen in A–C? (Notice varying bladder appearances)
7
Report
3. Review the gynecologic report.
a. What is the endometrial thickness in centimeters?
b. State indication for report.

c. State uterine dimensions.
CASE STUDY
Review the cases and answer the following questions.
1. A 72-year-old patient visited her gynecologist complaining of bleeding from the
vagina for approximately 1 week. A urine test was performed for possible infection
and hematuria. The test was negative for both. A gynecologic examination was
attempted but not completed because of the severe pain it caused the patient due to a
stricture in the vagina. She was then scheduled for a pelvic ultrasound. Describe
what can be done to obtain optimal pelvic images.
2. A 22-year-old G3P2A0 was admitted to ultrasound for a 7-week obstetric ultrasound

for low pelvic pain. She consumed 32 ounces of water prior to the examination, but
had nausea followed by vomiting, and was therefore not able to fill her bladder.
Will the sonographer be able to produce diagnostic images?
9
Embryonic Development of the Female

Genital System
CHAPTER 2

visit the point.

Matching

a. Large, sometimes tortuous ureter due to
distal blockage
b. Second stage of kidney development (aka
wolffian body)
c. Connection between the mesonephros and
the cloaca
d. Structure that appears at approximately 5
1. _________ mesonephros weeks’ gestation that becomes either
2. _________ hydronephrosis ovaries or testes
3. _________ oogonia e. Blockage or absence of a structure
4. _________ urogenital f. Immature oocytes
5. _________ gonadal ridges g. Pertaining to the urinary and genital
system
6. _________ müllerian ducts h. Sac-like vascular structure that lies
(paramesonephric ducts)
below the chorion and develops from the
7. _________ broad ligament hindgut
8. _________ pronephros i. Accumulation of secreted fluid resulting
9. _________ allantois in distention of the uterus and vagina due
10. _________ embryogenesis to obstruction
11. _________ hydroureter j. Fold of peritoneum that connects the
uterus to the pelvis
12. _________ mesonephric ducts
k. Cavity that is part of the development of
13. _________ primordial germ cells the digestive and reproductive organs
14. _________ atretic l. Paired ducts that become the oviducts,
15. _________ oocytes uterus, cervix, and upper vagina
16. _________ diploid m. Section of the uterine broad ligament that
17. _________ hydrometrocolpos covers the ovary
18. _________ mesovarium n. Formation of an embryo
19. _________ cloaca o. Primary or first kidney that develops in
the embryo
p. Precursor of germ cells, become oocytes
or spermatozoa in the adult
q. Urine collection in the kidneys due to
distal obstruction
r. Female germ cells
s. Normal number of paired chromosomes
10
ANATOMY AND PHYSIOLOGY REVIEW

Image Labeling
Complete the labels in the images that follow.
11
CHAPTER REVIEW
Multiple Choice
1. Complete gonadal development requires primordial germ cell migration from the yolk
sac along the dorsal mesentery, where it invades the:
a. Rete primitive sex cords
b. gonadal ridge
c. mesonephric duct
d. proliferative primordial mesentery
2. A method used to classify the embryo that places the embryo into categories
depending on age, size, and morphologic characteristics is called:
a. embryologic staging
b. synoptic tabling
c. Carnegie stages
d. human development staging
3. Cloacal anomalies can result in:
a. bicornuate uterus
b. renal cysts
c. intra-abdominal lesions
d. hydrometrocolpos
4. An ultrasound examination of a patient with hematocolpos should include imaging of
the:
a. kidneys
b. liver
c. spleen
d. pancreas
5. The most common mass lesions in neonates are of:
a. renal origin
b. intestinal origin
c. pulmonary origin
d. peritoneal origin
6. Often, development abnormalities in the female pelvis become apparent:
a. when primigravida
b. during the standard level 2 obstetrical ultrasound
c. at the onset of puberty
d. at the onset of a urinary tract infection
7. The pre-embryonic phase, also known as the first Carnegie stage, lasts into the:
a. third trimester
b. first week
c. first trimester
d. third week
8. If the male gamete (the spermatozoon) that is capable of contributing either an X or Y
chromosome contributes an X chromosome to the ovum, the result is:
a. a male zygote
b. a female zygote
c. twin female zygotes
d. twin male zygotes
9. The embryonic phase begins in the fourth week and extends into the:
a. fifth week
b. sixth week
c. seventh week
d. eighth week
10. Diploid chromosomes are a result of fertilization and result in a count of:
a. 23 chromosomes
b. 13 chromosomes
c. 46 chromosomes
d. 18 chromosomes
11. What cells produce a gender appearance?
a. primordial germ cells
b. ectoderm cells
c. gonadal germ cells
d. mesoderm cells
12. The genital or gonadal ridges are a forerunner of the:
a. female ovaries and male testes
b. female fallopian tubes and male epididymis
c. mesonephros
d. allantois
13. The vaginal fornices surround the end of the:
a. distal vaginal canal
b. labia
c. hymen
d. cervix
14. Which would be an inaccurate diagnosis for a finding of a hypoechoic structure in
the fetal pelvis:
a. ovarian cyst
b. hematocolpos
c. hemangioma
d. distended bladder
12
15. Gender (sex) is determined at approximately days:

a. 28 to 32
b. 44 to 48
c. 54 to 58
d. 66 to 70
16. Müllerian ducts fuse to develop the uterus and:
a. fallopian tubes
b. suspensory ligament
c. genitalia
d. second stage kidneys
17. The normal male chromosomal configuration is:
a. 46XX
b. 46XY
c. 23XX
d. 23XY
18. What hormone is absent in the female fetus that causes regression of the mesonephric
ducts?
a. maternal estrogen
b. male inducer substance
c. placental estrogen
d. circulating testicular hormone
19. What systems develop in tandem in the embryo and are still closely associated in the
adult?
a. pulmonary and circulatory
b. urinary and musculoskeletal
c. reproductive and urinary
d. respiratory and digestive
20. Hydronephrosis and hydroureter can display as a mass in the fetal:
a. cervix
b. chest
c. ovary
d. pelvis
Fill-in-the-Blank
1. In the first few months of early development, the _________ are undifferentiated.
2. External development of genitalia is similar in both sexes until approximately the
_________ week.
3. The promoting factor in the development of female external genitalia is maternal
_________.
4. Bartholin and Skene glans, the clitoris, _________ minora and _________, vestibule,
vagina, and mons _________ make up the external genitalia.
5. The _________ becomes the genital tubercle in both genders.
6. Gonadal gender can be determined in the _________ embryo at approximately the
_________ day of gestation, which correlates with Carnegie stage 18.
7. Carnegie stage 20 correlates with day 49 for gonadal gender in the _________
embryo.
8. _________ folds grow, forming the labia minora through fusion of the posterior
portion, resulting in the frenulum.
9. Carnegie stages classify the embryo by age, _________, and appearance of structures
in the first _________ weeks of development.
10. The _________ and _________ systems develop simultaneously, resulting in
coexisting malformations.
13
11. Determination of chromosomal gender or sex occurs at the time of _________.

12. The fully developed fallopian tube lies _________ in the abdominal cavity.
13. The ovary is suspended by the _________, the _________ ligament of the ovary, and
the _________ ligament.
14. Most congenital anomalies in fetuses in utero occur in the genitourinary system, with
urinary tract abnormalities accounting for about _________ of the total.
15. The female gamete, known as the ovum, contributes to the _________ chromosome.
16. Embryonic kidneys develop in the stages: _________, mesonephros, and
metanephros.
17. Between puberty and menopause, approximately _________ to _________ fertile
ova are produced.
18. If an abnormal fluid collection is suspected in utero in the midline female pelvis,
_________ outflow may be obstructed.
19. A female gonad is a(n) _________.
20. Prenatal ultrasound may also detect congenital anomalies in the ovaries, uterus, and
vagina, especially when they enlarge and produce a pelvic _________.
Short Answer
1. Describe how hydrometrocolpos would appear on fetal ultrasound.
2. Name and briefly describe the four ligaments of the female pelvis.
3. Excited first-time parents (primigravida) are presenting for an ultrasound for unsure
dates. The mother has a large body habitus and a history of irregular cycles, of
which she does not record dates. They are thrilled to view the pregnancy images and
are hoping to learn the fetal gender. Endovaginal ultrasound was performed because
of maternal body habitus, and calculations date the fetus at 9w2d (9 weeks 2 days).
Can gender information be provided to the parents and why?
14
CASE STUDY
Review the cases and answer the following questions.
1. An ultrasound was performed on a 30-week female fetus. It demonstrated bilateral
well-circumscribed fluid collections in the fetal pelvis positioned in the right
adnexa and left adnexa adjacent to the urinary bladder. The right hypoechoic
collection measured 0.9 × 0.8 cm, and the left measured 0.7 × 0.8 cm. A follow-up
ultrasound examination at 36 weeks again demonstrated a right and left adnexal
hypoechoic collection, both measuring 1.0 × 0.9 cm.
a. Discuss the finding.
b. Would a follow-up fetal ultrasound be beneficial?
c. What should the plan of care be for this fetus?
2. A 37-year-old was sent to the ultrasound department with the diagnosis of small for
dates. The female fetus measured within normal parameters, but oligohydramnios
(low amniotic fluid volume) was noted. A thorough examination of the amniotic
fluid and fetal urinary system detected a hypoechoic mass posterior to the fetal
urinary bladder. Explain what this formation may be and provide an explanation.
15
Congenital Anomalies of the Female

Genital System
CHAPTER 3

visit the point.

Matching

a. Anomaly that results in one vagina, two
cervices, and two uterine horns
b. Mechanism by which the uterine septum
regresses
c. Accumulation of watery fluid in the
uterine cavity
d. Uterus didelphys with obstructed
unilateral vagina and associated
ipsilateral renal and ureter agenesis
e. Retention of blood in the uterine cavity
f. Paired embryonic tubes roughly parallel
with the mesonephric ducts that empty
into the urogenital sinus. In the female,
the upper part of these ducts form the
fallopian tubes, and the lower parts fuse
to form the uterus
g. Mental or physical traits, anomalies,
malformations, or diseases present at
birth
h. A small opening, especially one of
entrance into a hollow organ or canal
i. Complete failure of resorption of the
uterovaginal septum
j. Medical condition in which a pregnant
woman’s cervix begins to dilate and
1. _________ metroplasty efface before her pregnancy has reached
2. _________ uterine aplasia term. This may cause miscarriage or
3. _________ ostium (pl. ostia) preterm birth during the second and third
trimesters.
4. _________ hematocolpos
k. Characterized by congenital fusion of the
5. _________ imperforate hymen cervical spine, a short neck, a low
6. _________ apoptosis posterior hairline, and limited range of
7. _________ renal agenesis cervical spine motion. Associated with
Mayer–Rokitansky–Kuster–Hauser
8. _________ hydrometra
syndrome.
9. _________ Klippel–Feil syndrome
l. Anomaly that results in one cervix and
10. _________ uterus unicornis unicollis one uterine horn
11. _________ Diethylstilbesterol (DES) m. Nonsteroidal drug administered between
12. _________ hymen the late 1940s to early 1970s to pregnant
13. _________ cervical incompetence women. This drug was first
demonstrated as a transplacental
14. _________ hematometra carcinogen responsible for clear-cell
15. _________ congenital vaginal carcinoma in girls born to
16. _________ uterine didelphys mothers who took the drug during
pregnancy to prevent miscarriage.
17. _________ Wunderlich–Herlyn– Uterine malformations associated with
Werner_________ Syndrome this drug’s exposure include uterine
18. _________ hematometrocolpos hypoplasia and a T-shaped endometrium
n. Reconstructive surgery on the uterus for
16 women with reproductive failure
19. _________ uterus arcuatus o. Accumulation of menstrual blood in the
20. _________ sinovaginal bulb uterus and vagina caused by either an
imperforate hymen or other obstruction
21. _________ paramesonephric
(müllerian) ducts p. The mildest fusion anomaly, resulting in
a partial indentation of the uterine fundus
22. _________ uterus bicornis bicollis with a normal endometrial cavity;
23. _________ septate uterus considered a normal variant
24. _________ hysterosalpingography q. Anomaly that results in two vaginae, two
25. _________ uterine bicornis unicollis cervices, and two uteri
26. _________ subseptate uterus r. Absence of one or both kidneys
s. Complete absence of the uterus
t. Radiographic imaging of the uterus and
fallopian tubes after injection of
radiopaque material
u. Partial failure of the medial septum to be
reabsorbed
v. Anomaly that results in one vagina, one
cervix, and two uterine horns
w.Part of the vaginal plate of the urogenital
sinus, which forms the lower 20% of the
vagina
x. Usually congenital because of failure of
degeneration of central epithelial cells
of the hymenal membrane. An
imperforate hymen is visible upon
examination as a translucent thin
membrane just inferior to the urethral
meatus that bulges with the Valsalva
maneuver and completely covers the
vagina; it must be surgically corrected
y. Ring-like area of tissue that represents
the opening to the vagina
z. Accumulation of menstrual blood in the
vagina resulting from a lower vaginal
obstruction or imperforate hymen
17

Image Labeling
Name the type of uterus.
18
CHAPTER REVIEW
Multiple Choice
1. Complications from uterine and vaginal malformations do not occur from:
a. failure of resorption of median septum
b. paramesonephric (müllerian) duct arrested development
c. müllerian ducts failure to fuse
d. distal ductal regression
2. Germ cells that migrate from the yolk sac to the gonadal region form the:
a. genital ridges becoming sex cords
b. mesonephric ducts
c. female embryos
d. fallopian tubes
3. Apoptosis is related to:
a. DES
b. regression of the septum
c. a short neck
d. paired embryonic tubes
4. Anomalies related to abnormal differentiation of the wolffian and müllerian ducts are
of:
a. ovarian origin
b. septal regression
c. renal origin
d. peritoneal origin
19
5. Ductal segments that create the uterovaginal canal, forming the uterus, cervix, and
majority of the vagina, originate as:
a. wolffian ducts
b. oviducts
c. müllerian ducts
d. gonadal ducts
6. Uterine septal anomalies such as complete septum are a result of:
a. Bc12 gene absence
b. regression syndrome
c. BBS10
d. uterus arcuatus
7. A thickened sinusal tubercle develops into a sinovaginal bulb that becomes:
a. hymen
b. lower one-fifth of the vagina
c. complete vagina
d. urogenital sinus
8. Müllerian duct anomalies are not associated with the:
a. vagina
b. uterus and cervix
c. fallopian tubes
d. ovaries
9. Unilateral arrested müllerian ducts cause:
a. uterine aplasia
b. uterus unicornis unicollis
c. uterus bicornis bicollis
d. uterus arcuatus
10. Hypoplastic uterus produces:
a. a small endometrium and myometrium
b. dysplasia
c. hypoplasia
d. uterine agenesis
11. The most frequent location of the transverse vaginal septum is the:
a. uterine corpus
b. lower one-third of the endometrial canal
c. junction of the upper and middle third of the vaginal canal
d. longitudinal septa
12. Which ultrasound scanning plane is most helpful in diagnosing vaginal
malformations, such as atresia?
a. coronal
b. transverse
c. Y
d. longitudinal
13. Sonohysterography is also known as:
a. saline sonography
b. 3D hysterography
c. static hysterography
d. saline infusion sonography
14. Uterus bicornis bicollis and uterus bicornis unicollis (to include uterus arcuatus)
result from:
a. complete fusion failure
b. partial fusion failure
c. septal union failure
d. septal resorption failure
15. Cervical incompetence is reported in 38% of ____ uterus anomalies:
a. arcuate
b. unicornate
c. bicornate
d. didelphic
16. What müllerian anomaly is most associated with renal agenesis?
a. uterine didelphys
b. arcuate uterus
c. bicornuate uterus
d. uterine aplasia
17. Failure of uterine median septum resorption results in:
a. uterine didelphyis
b. septate uterus
c. bicornuate uterus
d. unicornuate uterus
18. The uterine septum consists of:
a. poorly vascularized fibromuscular tissue
b. highly vascularized fibromuscular tissue
c. nonvascular fibromuscular tissue
d. muscular and connective tissue
19. DES, an estrogen used from 1948 to 1971, is related to all of the following
anomalies except:
a. uterine corpus
b. ovarian
c. cervix
d. vaginal
20. Anomalies of the fallopian tubes include:
a. tube duplication, accessory ostia, and hypoplasia
b. ectopic location and hyperplasia
c. luminal atresia, absent muscular layer, and absent ampulla
d. accessory ostia, patency, and double tube
20
Fill-in-the-Blank
1. Most congenital anomalies are diagnosed in the _________ or recurrent _________
loss populations.
2. The American Fertility Society has adapted a müllerian duct anomaly classification
system based on configuration of _________, its clinical symptoms, the _________
options, and prognosis.
3. The ducts that are paired in both female and male embryos are _________ and
_________.
4. Female fetuses lack _________, which causes wolffian duct degeneration.
5. Müllerian ducts fuse by _________ to form the unified body of the _________ and
cervix.
6. A double cervix (cervical duplication), in rare cases, develops with a complete
_________ and _________ septa.
7. Pelvic ultrasound can help to diagnose _________, menstrual blood, fluid, and
secretions in the uterus and vagina.
8. A tense, bulging membrane would be diagnosed as _________.
9. The method used to create a vagina if vaginal agenesis is diagnosed is _________.
10. Treatment of a transverse vaginal septum would include drainage of _________ and
the preservation of a space of adequate size to function as a normal vagina.
11. In the case of atretic or absent vagina, the _________ scanning approach is helpful.
12. Complete or incomplete failure of one müllerian duct to form results in _________.
13. Sonographic _________ imaging of the unicornis uterus is most sensitive,
demonstrating myometrial and _________ structures, as well as cervical canal,
uterine external contours, and cornual angles.
14. A bicornuate uterus has increased _________ distance (usually greater than
_________ cm) and concave cleft in the external fundal uterine contour measuring
deeper than _________ cm.
15. A septate uterus has a _________ fundal contour on magnetic resonance imaging.
16. Uterine didelphys presents as _________ hemi-uteri with their own endometrium
and vagina.
17. Narrowing of the uterine cavity by the septum is a condition suggesting poor
_________ outcome.
18. An arcuate uterus results in a _________ indentation of the uterine fundus.
19. DES is known to cause a _________-shaped uterine endometrium.
20. Supernumerary ovaries can develop masses, such as benign _________ and
_________.
21
Short Answer
1. A 16-year-old female complains of monthly pelvic pain. The physician learns that the
patient has not begun menstruating. Upon physical examination, the physician notes
fullness in her inferior midpelvis. What is the most likely diagnosis? Describe what
ultrasound would demonstrate.
2. A pelvic ultrasound examination performed on a 33-year-old for pelvic pain

demonstrated a normal appearing anteverted uterus, normal right and left ovary with
positive blood flow, and a superior adnexal heterogenous mass measuring 3.8 × 3.1
× 3.4 cm. Provide a gynecological explanation.
3. A 23-year-old with a bicornuate uterus miscarried her first pregnancy in the 18th
week. She is currently 13 weeks pregnant. Discuss what can be done to increase the
ability to continue this pregnancy to term. Explain why intervention may be
necessary.
4. A 32-year-old DES-exposed woman was undergoing a hysterosalpingogram (HSG)

because she had spontaneously aborted two times and had one ectopic pregnancy
that resulted in the surgical loss of her right fallopian tube. Describe possible
uterine findings the HSG will demonstrate.
5. A HSG is performed on a 26-year-old female who is diagnosed with infertility. She

has been unable to conceive for 2 years. Previous 2D transabdominal and
transvaginal ultrasound and laboratory results were normal. A left fallopian tube
was not noted on the HSG. Give reasons for nonvisualization of the tube.
22
1. Name the view. What is the likely diagnosis?
2. What portion of the uterus is the open white arrow pointing to? Describe the
endometrium.
3. Name the imaging technique used to acquire these images? Describe the uterus.
4. What is the likely diagnosis of these images? Name the pelvic structure that is
affected.
23
5. Name the uterine type.
24
CASE STUDY
1. A healthy 24-year-old gravid 1 patient delivered prematurely at 29 weeks. The
pregnancy was considered normal until the premature delivery. The patient became
pregnant twice, both ending in miscarriage. An HSG was ordered through the
imaging department. Describe the image.
2. A 40-year-old that was exposed to DES in the womb was found to have clear cell
adenocarcinoma (CCA), a rare vaginal and cervical cancer. DES females are at
increased risk of acquiring CCA. The physician determined that a complete workup
would benefit this patient, so a pelvic ultrasound was ordered. Explain the uterine
images.
25
The Female Cycle
CHAPTER 4

visit the point.

Matching

a. The absence of menstruation
b. Male hormones produced in small
quantities by the female ovaries and
adrenal glands, with the greatest
quantities occurring at the midpoint of a
woman’s menstrual cycle
c. An ovarian layer containing spindle-
shaped cells incapable of hormone
production
d. Uterus angled forward toward the cervix
e. Forward-tipped uterus with the cervix
and vaginal canal forming a 90-degree
angle or less
f. The portion of an ovarian follicle filled
with liquor folliculi. Spaces formed by
the confluence of small lakes of
follicular liquid in the ovary.
g. Formed in the ovary when a follicle has
matured and released its egg (ovum)
after ovulation. The follicle becomes the
corpus luteum that produces
progesterone. Progesterone causes the
lining of the uterus to thicken for egg
1. _________ antrum (follicular) implantation.
2. _________ theca interna h. Painful menstruation
3. _________ positive feedback loop i. A system of glands and cells that produce
4. _________ luteinization hormones released directly in the
5. _________ corpus luteum (Latin for circulatory system
“yellow body”) j. A general term for female steroid sex
6. _________ progesterone hormones secreted by the ovary and
responsible for female sexual
7. _________ amenorrhea characteristics
8. _________ gonadotropins k. Hormone produced by the anterior
9. _________ retroverted pituitary, which simulates ovarian
10. _________ estrogen follicle production in females and sperm
production in males
11. _________ menorrhagia
l. Hormones produced by the anterior
12. _________ negative feedback pituitary that affect the female and male
13. _________ dysmenorrhea gonads
14. _________ oligomenorrhea m. Protein hormones secreted by
15. _________ suspensory gonadotropic cells of the pituitary gland
(infundibulopelvic) ligament n. A mature, fully developed ovarian cyst
16. _________ theca externa containing the ripe ovum
17. _________ androgens o. The transformation of the mature ovarian
follicle into a corpus luteum
26 p. When concentration of a hormone rises
above a certain level, a series of actions
18. _________ endocrine system take place within a system to cause the
19. _________ anteverted concentration to fall. Conversely, steps
are taken to increase concentration when
20. _________ mesometrium the level is too low.
21. _________ gonadotropic q. Abnormally heavy or prolonged
22. _________ rectouterine recess (pouch) menstruation
23. _________ anteflexed r. The mesentery of the uterus. It constitutes
the majority of the broad ligament of the
24. _________ follicle-stimulating
uterus, excluding only the portions
hormone (FSH)
adjacent to the uterine tube and ovary.
25. _________ retroflexed
s. Abnormally light or infrequent
26. _________ Graafian follicle menstruation. Opposite of menorrhagia.
27. _________ perimetrium t. The outer serosa layer of the uterus,
28. _________ polymenorrhea (poly = equivalent to the peritoneum
many, menorrhea = bleeding) u. Steps taken to increase concentration
when a level is too low
v. Frequent irregular periods
w.A steroid hormone produced by the
corpus luteum, whose function is to
prepare and maintain the endometrium
for the reception and development of the
fertilized ovum
x. Area in the pelvic cavity between the
rectum and the uterus that is likely to
accumulate free fluid; also known as the
posterior cul-de-sac and the pouch of
Douglas
y. A backward angle of the uterine fundus in
relation to the cervix
z. A uterus tilted posterior toward the
rectum
aa.A peritoneum ligament extending
upward from the upper pole of the ovary
bb.An ovarian layer characterized by
polyhedral cells and numerous blood
vessels that secrete estrogen. The cells
develop from stromal cells that produce
steroid hormones.
27

Image Labeling
Anatomy of the female reproductive system
Ovarian and endometrial cycle association
28
Female reproductive organs and their related ligaments
29
Menstrual cycle phases
Uterine layers
30
CHAPTER REVIEW
Multiple Choice
1. Changes in the endometrium, which constitutes the menstrual cycle, are preparation
for:
a. fertilization of the oocyte
b. arrival of the fertilized ovum
c. luteinizing phase
d. secretory phase
2. Female reproductive cycle is defined as:
a. span from menarche (beginning of menstrual function) to menopause (cessation of
menstrual function)
b. span beginning with the fertilized ovum through birth
c. the ovarian and uterine cycles, the hormonal changes that regulate them, and
related cyclical changes in the breasts and cervix
d. premenses and postmenopause
3. Which is not a layer of the uterus?
a. serometrium
b. perimetrium
c. myometrium
d. endometrium
4. Endometrial sloughing occurs during what phase?
a. early follicular, menses
b. proliferative
c. luteal
d. secretory
5. Which statement correctly describes fallopian tube anatomy?
a. The widest portion of the fallopian tube is the isthmus.
b. The fimbriae connect to the uterine cornua.
c. The infundibulum is the distal funnel-shaped portion of the fallopian tube.
d. The isthmus contains finger projections called fimbriae.
6. Normal ovaries are oval shaped and measure approximately:
a. 5 × 3 × 15 mm
b. 5 × 5 × 3 mm
c. 2 × 3 × 4 in
d. 5 × 3 × 1.5 cm
7. The lowest portion of the uterus is the:
a. vagina
b. cervix
c. internal os
d. external os
8. The hormone not secreted by the hypothalamus and controlling reproductive events is:
a. gonadotropin-releasing hormone (GnRH)
b. luteinizing hormone (LH)
c. FSH
d. sex hormone-binding globulin
9. Choose the area of the hypothalamus that stimulates and regulates the menstrual cycle.
a. preoptic
b. lateral
c. posterior
d. anterior
10. Secondary amenorrhea is described as:
a. women who have started menstruation, then had an absence of their menses for
three cycles or 6 months
b. infrequent or light menstruation
c. failure of menstruation to begin
d. transient, intermittent, or permanent cessation of menstruation
11. Osteoporosis, Addison disease, and low thyroid function are related to:
a. small ovaries
b. luteal cysts
c. polycystic ovarian syndrome
d. the secretory phase
12. The main source of female hormones is (are) the:
a. hypothalamus
b. pituitary gland
c. gonadotropin
d. ovaries
31
13. Ovarian endocrine functions do not control:

a. menstrual cycle
b. TSH
c. body shape
d. female characteristics
14. Select the hormone that is transported in a “pulsatile” manner with varying frequency
and amplitude depending on physiologic conditions.
a. LH
b. GnRH
c. FSH
d. TSH
15. Choose the function that FSH is not involved with:
a. progression of the menstrual cycle
b. spermatogenesis in men
c. ovarian follicle development
d. ova maturation
16. Choose the female chemical responsible for maturation of the endometrium:
a. estrogen
b. FSH
c. TSH
d. progesterone
17. A sharp rise in LH, known as “LH surge,” is responsible for:
a. endometrial sloughing
b. corpus luteal progression
c. ripening of the Graafian follicle
d. embryo maturation
18. Which is not a natural occurring estrogen?
a. estribe
b. estrone
c. estriol
d. estradiol
19. What can stimulate progesterone?
a. follicular cysts
b. implantation
c. a corpus luteum
d. oxytocin
20. polymenorrhea is:
a. a menstrual cycle length that is less than 21 days
b. menstrual cycle length that is longer than 35 days
c. heavy menstrual bleeding
d. painful menstruation
21. Changes in endometrial thickness are not associated with:
a. hyperplasia
b. endometrial polyps
c. carcinoma
d. homogeneous echotexture
22. Ovarian measurements are determined:
a. on views in one plane and three dimensions: length, width, and depth
b. on views in two orthogonal planes and three dimensions: length, width, and depth
c. on views in one plane and two dimensions: length and depth
d. on views in two orthogonal planes and two dimensions: length and width
23. During what phase of the menstrual cycle do follicles become dominant?
a. luteal
b. early follicular
c. mid to late proliferative
d. late follicular
24. During the late proliferative phase, the endometrium thickens to approximately:
a. 3 to 5 mm
b. 9 to 12 mm
c. 5 to 11 mm
d. 7 to 9 mm
25. The triple line (three-line sign) indicates the ______________ stage.
a. late proliferative
b. late luteal
c. early secretory
d. midfollicular
26. Amenorrhea is:
a. heavy menstruation
b. light menstruation
c. painful menstruation
d. menstrual cessation
27. Ultrasound is ordered in the postmenopausal patient most often for:
a. pelvic pain
b. vaginal bleeding
c. abnormal lab values
d. vaginal mucosal wrinkles
32
Fill-in-the-Blank
1. A female baby is born with approximately _________ oocytes in each ovary.
2. The uterus, fallopian tubes, two _________, cervix, _________, and the mammary
glands make up the female reproductive internal organs.
3. The three uterine anatomical sections are _________, _________, and _________.
4. The two fallopian tubes are also known as _________ or _________.
5. Fimbriae sweep the _________ into the lumen of the fallopian tube.
6. The _________ ligament attaches to the pelvic wall, as well as to the ovaries.
7. Located in the diencephalon is the hypothalamus, which is positioned in the human
_________.
8. The hypothalamus secretes hormones that stimulate and suppress the release of
hormones in the _________ gland.
9. The anterior pituitary receives _________ hormones in concentrated form because of
the unique vascular system of the hypophyseal portal system.
10. Anterior pituitary tissue produces _________ hormone for protein production,
_________ for milk production, adrenocorticotropic hormone to stimulate the
_________ glands, and thyroid-stimulating hormone, which stimulates the
production and secretion of thyroid hormones, as well as FSH and LH.
11. Ovaries function as _________ and endocrine glands.
12. Also known as luteinizing-hormone-releasing hormone, GnRH is secreted by the
hypothalamus and stimulates the release of _________ and _________ from the
anterior pituitary gland.
13. FSH causes cells in follicles to produce increasing amounts of estrogen, which
stimulates the _________ to thicken before _________ occurs.
14. LH is necessary for growth of _________ follicles and ovulation of the dominant
follicle.
15. Endometrial maturation is caused by _________.
16. If fertilized egg implantation does not occur, _________ and _________ decrease,
causing sloughing of the endometrium.
17. Two layers surround a developing follicle: _________ and _________.
18. With implantation, the _________ secretes estrogen along with the corpus luteum.
19. The three phases of the ovarian cycle are _________, _________, and _________.
20. Meiotic arrest of primary oocytes occurs until _________.
21. The endometrium should be measured on the _________ image, to include the
anterior and posterior portions of the _________ endometrium.
33
22. Two layers of endometrium are shed during menses, _________ and _________.
23. When menstrual bleeding stops, the _________ phase begins.
24. Ultrasound imaging during the secretory phase demonstrates a uniformly _________
endometrium.
25. The most common hormonal disorder among reproductive age women is _________.
26. HRT is _________.
Short Answer
1. A 72-year-old patient presented to her doctor complaining of one episode of
spotting (light vaginal bleeding). Her physical examination was normal. Laboratory
tests were ordered, as was a pelvic ultrasound. Explain how to perform a thorough
sonogram and expected findings.
2. What are the expected endometrial measurements of a uterus in the menstrual phase,
proliferative phase, and secretory phase?
3. Name a structure that releases progesterone during pregnancy. Explain the function of
progesterone during pregnancy.
4. Explain the function of LH.
34
1. Identify the structure in image A. What phase is it? Was the image acquired
abdominally or using an endovaginal technique? Image B was collected using what
technique?
2. What is the large hypoechoic structure in the image of a nongravid 25-year-old?
35
CASE STUDY
1. A 27-year-old nulligravida (never been pregnant) visited her gynecologist to discuss
her inability to become pregnant. She stated her menstrual cycles were irregular and
infrequent. The doctor noted that the patient displayed excess hair growth and
obesity. Laboratory tests were ordered along with a pelvic ultrasound. Explain what
the patient’s physical appearance and cycle irregularity may suggest. What findings
may be displayed on the images?
2. This 68-year-old postmenopausal woman is complaining of bloody vaginal discharge

and mild pelvic pain. Explain the image considering normal versus abnormal
findings.
36
37
Normal Anatomy of the Female Pelvis
CHAPTER 5

visit the point.

Matching

a. Aka vesicouterine recess. Potential space
between the uterus and the urinary
bladder
b. On the opposite side
c. Fibrous tissue that replaces the corpus
luteum
d. Aka greater or major pelvis. Area
superior to and anterior to the pelvic
brim
e. Hormone that stimulates growth and
1. _________ pouch of Douglas maturation of the ovarian Graafian
2. _________ corpora albicantia follicle. The anterior pituitary gland
secretes the hormone
3. _________ true pelvis
4. _________ follicular atresia f. Degeneration and reabsorption of the
5. _________ serosa follicle before maturity
6. _________ iliospoas muscle g. Latin anatomical term referring to the
7. _________ linea terminalis portion of an organ opposite from its
opening
8. _________ anterior cul-de-sac
h. Aka pelvic brim or linea terminalis. Inner
9. _________ hypertrophy surface of the pubic and ilium bones
10. _________ fundus contains a bony ridge that serves as the
11. _________ space of Retzius line dividing the true and false pelvis
12. _________ contralateral i. Increase in size
13. _________ orthogonal j. On the same side
14. _________ iliopectinal line k. Aka innominate line. Line drawn from the
pubic crest to the arcuate line dividing
15. _________ false pelvis the true and false pelvis
16. _________ ipsilateral l. At right angles (perpendicular)
17. _________ follicle-stimulating m. Aka posterior cul-de-sac or the
hormone (FSH) rectouterine recess. Potential space
between the rectum and the uterus
n. Serous membrane enclosing an organ that
often excretes lubricating serous fluid
o. Aka properitoneal space. Space between
pubic symphysis and urinary bladder
p. Aka lesser or minor pelvis. Portion of the
pelvic cavity inferior and posterior to
the pelvic brim
q. Combination of the psoas major, psoas
minor, and iliacus muscles
38

Image Labeling
Pelvis anatomy
39
Low anterior muscle descending lower abdomen visualized on transverse pelvic ultrasound
40
Midline sagittal female pelvis
Uterus and cervix
41
Uterine divisions
Uterine positions
42
Fallopian tube regions

Ovary/fallopian tube, cross-section ovary
43
CHAPTER REVIEW
Multiple Choice
1. Choose the sonographic method that uses lower-frequency transducers?
a. endovaginal EVS
b. complementary
c. transvaginal TVS
d. transabdominal TAS
2. During an EV ultrasound, slight residual urine in the bladder will help identify the:
a. vaginal fornices
b. fallopian tube
c. internal os of the cervix
d. uterine myometrium
3. What bones comprise the pelvic skeleton:
a. coccyx, sacrum, two innominate bones
b. sacrum, ischium, coccyx, ilium
c. pubic symphysis, sacrum, coccyx
d. two innominate bones, ilium, ischium
4. An imaginary line between the true and false pelvis is:
a. linea alba
b. promontory
c. elinea terminalis
d. symphysis pubis
5. The cross-sectional shape of the iliospoas muscle appears on ultrasound as:
a. ovoid
b. hook with bulbous medial limb
c. long and dark coursing forward
d. cylindrical
6. The space of Retzius (preperitoneal space) is located:
a. in the superior pelvis
b. in the rectouterine recess
c. fundally on the myometrium
d. between the urinary bladder and the symphysis pubis
7. It is not uncommon to see anterior echoes (artifact) in the urinary bladder. They are:
a. uric acid crystals
b. wall reverberation
c. imaged detrusor muscle
d. urea and creatinine
8. The technique offering the most direct assessment of pelvic anatomy is:
a. endovaginal EVS
b. transabdominal TAS, transvaginal TVS
c. transabdominal TAS
d. global
9. The vagina is:
a. muscular, stratified, and attaches to the bladder wall
b. nonfibrous, 6 to 8 cm long, and measures 1 to 2 cm transabdominally
c. thin-walled, 7 to 10 cm long, and produces a moderately hypoechoic pattern
d. tubular, nonmuscular, and follows the cervix
10. What is the largest portion of the uterus?
a. fundus
b. corpus
c. isthmus
d. cervix
11. The uterine layers are:
a. serosal (perimetrium), continuous with fascia; myometrium, smooth muscle and
connective tissue; endometrium, mucosal
b. serosal, muscular tissue; myometrial, muscular and connective tissue; endometrial,
muscular
c. perimetrium, mucosal; myometrium, muscular, endometrium, mucosal
d. serosal (perimetrium), mucosal; myometrium, muscular; endometrium, mucosal
12. A uterus in a young girl would:
a. appear cylindrical
b. appear inverted pear shape
c. appear globular
d. nonvisualize
13. Cysts of the cervix are caused by occluded cervical glands and known as:
a. Gartner’s duct cyst
b. dermoid cysts
c. Nabothian cysts
d. corpus luteum cysts
44
14. A uterus lying in a plane perpendicular to the ultrasound beam entering through a full
bladder is labeled:
a. sagittal
b. retroflexed
c. longitudinal
d. anteflexed
15. Ovaries should be measured using a:
a. volume calculation (length × width × height / 2 = volume in cm3)
b. volume calculation (length × width) / 2
c. linear calculation (length × width × height)
d. linear calculation (length × width)
16. Mittelschmerz is:
a. pain associated with menstruation
b. midcycle pain often associated with ovulation
c. pain associated with rupture of the dominant follicle
d. a term for cramping
17. One branch of the internal iliac artery is of importance to sonographers because it is
accessible to Doppler evaluation using an endovaginal approach. It is the:
a. vaginal branch of the uterine artery
b. hypogastric artery
c. uterine artery
d. cervicouterine artery
18. What is not a benefit of endovaginal ultrasound?
a. ability to move the tranducer cephalad and anteriorly
b. lateral rotation
c. depth of penetration
d. high frequency
19. To obtain standard pelvic sonogram guidelines for sonographers, contact the website
for the:
a. American College Testing (ACT) or American Institute of Ultrasound in Medicine
(AIUM)
b. American Institute of Ultrasound in Medicine (AIUM) or American College of
Radiology (ACR)
c. American Registry of Diagnostic Medical Sonographers (ARDMS) or American
College Testing (ACT)
d. American Registry of Diagnostic Medical Sonographers (ARDMS) or American
Institute of Ultrasound in Medicine (AIUM)
20. Fat or smooth muscles are more _________ than the skeletal muscles.
a. superior
b. linear
c. hypoechoic
d. echogenic
Fill-in-the-Blank
1. A hydrated patient usually drinks _________ ounces of fluid to fill the urinary
bladder, whereas a dehydrated patient may require more fluid to fill the bladder.
2. Contraindication of TVS includes _________ and prepubertal virgins.
3. Three functions of the female bony pelvis are: _________, _________, and
_________.
4. A transverse pelvic ultrasound demonstrates two abdominal and pelvic muscles:
_________ and _________.
5. The _________ muscle is often obscured by bowel gas, but most likely to be seen
with a very full urinary bladder.
6. External genitalia, urinary bladder, urethra, uterus, fallopian tubes, vagina, ovaries,
colon, and rectum are classified as _________.
7. A partially filled bladder demonstrates its walls as _________, whereas a distended
bladder demonstrates _________ walls.
8. _________ can be seen with color Doppler or high gain in gray-scale imaging when
the ureteral valve opens with a bolus of urine to the bladder.
45
9. Gassy bowel can be _________ away from the field of view by filling the urinary
bladder, which provides an _________ window into pelvic structures.
10. _________ and _________ make up the external genitalia.
11. A _________ that seals the uterus from bacteria during pregnancy is generated in the
glands of the mucosa of the _________ canal.
12. The posterior wall of the vagina is _________ than the anterior wall. The upper end
of the vagina attaches to the _________.
13. The fallopian tube is divided into three sections, called _________, _________,
_________.
14. The ultrasound imaging method of choice for ovarian assessment is _________.
15. Echogenic ovarian foci, with or without shadowing, noted on an ovary may indicate
the presence of _________.
16. Bowel can mimic a _________ mass, especially in the absence of _________.
17. In the case of venous congestion, veins may form pelvic _________, which are
readily identifiable by ultrasound.
18. List three imaging techniques that may help diagnose ovarian torsion: _________,
_________, and _________.
19. On both transabdominal and endovaginal ultrasound, the ovary may be identified by
its characteristic “Swiss cheese” pattern of _________ follicles against the low-
amplitude gray of the ovarian cortex.
20. Visualization of the coronal plane in 3D imaging enables the uterine _________,
_________, and _________ to be viewed for an accurate diagnosis.
Short Answer
1. During pregnancy, the cervix provides a method of preventing bacteria from entering
the uterus. Explain the process.
2. Explain the difference between the false pelvis and the true pelvis.
3. Which area, the space of Retzius or the pouch of Douglas, is more likely to collect
free fluid?
46
4. A pelvic sonogram is revealing a solid hook-shaped mass on a thin

posthysterectomy/oophorectomy (surgical removal of the uterus and ovaries)
patient. Discuss the finding.
5. Discuss filling methods for the urinary bladder.
1. Label the structure the dashed white arrow is pointing at.
2. Label the structure positioned between the two thin arrows.

3. Name the structure the three white arrows are positioned around.
4. Name the structure the open arrow is pointing at.
47
5. Name the artifact depicted by the open arrow
6. Name the structure depicted by the white arrow

7. What is the thin arrow pointing at?
8. What is the thick arrow pointing at?
9. Name the structure indicated by the arrow.

48
CASE STUDY
1. A 14-year-old complained of severe inferior midline pelvic pain. Diagnose the single
image.
2. A woman brought her 15-year-old daughter to their gynecologist’s office because she
was concerned about the latter’s monthly adnexal pain and lack of menses.
Incidentally, the mother mentioned that the daughter had difficulty losing weight and
had recently developed dark, thick facial hair near the chin. Suggest a diagnosis
based on clinical findings and ultrasound imaging.
49
Doppler Evaluation of the Pelvis
CHAPTER 6

visit the point.

Matching

a. Anatomical parts added, attached, or
adjunct to another or others
b. Physiological process involving the
growth of new blood cells from
preexisting vessels
c. Small vascular structures found along the
periphery of the uterus
1. _________ pulsatility index (PI) d. Measurements used to compare the
resistance of a medium to the
2. _________ ovarian vessels
propagation of flow
3. _________ arteriovenous malformation
e. Blood vessels that supply oxygenated
4. _________ impedance indices blood to and drain deoxygenated blood
5. _________ uterine artery away from the ovaries
6. _________ S/D ratio f. Doppler measurement that takes the
7. _________ Pourcelot resistive index highest systolic peak minus the highest
8. _________ adnexa diastolic peak divided by the highest
systolic peak
9. _________ secretory phase
g. Days 5 to 9 of the menstrual cycle
10. _________ proliferative phase early
h. Days 10 to 14 of the menstrual cycle
11. _________ arcuate vessels
i. Doppler measurement that uses peak
12. _________ angiogenesis systole minus peak diastole divided by
13. _________ proliferative phase late the mean
j. Difference between peak systole and end
diastole
k. Days 15 to 28 of the menstrual cycle
l. Main vessel carrying oxygenated blood
toward the uterus
m. Abnormal connection between veins and
arteries
50

Image Labeling
Pelvic structures and vessels
Diagram of arteries on a transverse uterus
51
Uterine, vaginal, and ovarian blood supply

Diagram of uterine and ovarian arteries
52
CHAPTER REVIEW
Multiple Choice
1. Malignant tumors, benign tumors, and inflammatory conditions are not related to:
a. angiogenesis
b. normal physiologic blood flow
c. abnormal blood flow
d. hypoxia
2. Select the true statement regarding American College of Radiology practice
guidelines for an ultrasound examination of the female pelvis:
a. Use the lowest possible sonographic exposure settings to gain the necessary
diagnostic information.
b. Identify all relevant structures through transabdominal or transvaginal imaging,
knowing that in few cases both will be needed.
c. High-quality patient care requires no demographic documentation.
d. Conduct the sonographic examination of the female pelvis with a real-time scanner
without transducer frequency adjustment.
3. Choose the most appropriate transducer frequency for a transabdominal pelvic
sonogram on a patient with a large body habitus.
a. 2.5 MHz
b. 5.0 MHz
c. 7.5 MHz
d. 12 MHz
4. A full urinary bladder enhances uterine visualization, but frequently causes a
suboptimal ____________ Doppler exam because of the angle of incidence.
a. arcuate artery
b. spiral artery
c. radial artery
d. uterine artery
5. If a cystic mass is suspected during a full bladder pelvic ultrasound examination, the
patient should:
a. partially void the urinary bladder and further investigate the pelvis
b. completely void the urinary bladder and further investigate the pelvis
c. fully distend the urinary bladder and further investigate the pelvis
d. complete the examination under the current conditions
6. Which position provides the best visualization of free fluid in the pouch of Douglas
during an endovaginal ultrasound examination?
a. prone
b. supine with vertical tilt
c. lithotomy with a slight reverse Trendelenberg
d. Trendelenberg
7. Quantitative measurements of Doppler studies include:
a. systolic/diastolic (S/D) ratios
b. measurements of estimating absolute blood velocities, assessment of vascular
impedances, and quantifying flow disturbances
c. resistance index (RI) interrogation
d. PI flow resistance
8. With constant perfusion pressure, the flow _______ as the impendance to flow
_________.
a. increases, decreases
b. increases, increases
c. remains constant, increases
d. decreases, increases
9. Resistive index (RI) calculates:
a. the ratio of the peak systolic velocity to the end-diastolic velocity
b. the mean systolic and diastolic ratio
c. vascular impedance
d. angle of insonation
10. Suspicion for vascular occlusion occurs when a:
a. low-resistance pattern is detected in a normally high-resistance region
b. waveform is erratic
c. biphasic waveform is detected
d. high-resistance pattern is detected where low resistance is normally seen
11. A correct angle of _______ is required when analyzing vascular flow to determine
its velocity by a Doppler shift:
a. less than 60 degrees
b. less than 45 degrees
c. exactly 60 degrees
d. more than 90 degrees
53
12. Normal arterial flow is seen as:

a. recurring laminar flow with minimal sidewall turbulence
b. alternating diastolic and systolic uptake
c. alternating quick uptake systolic peak followed by a lower diastolic flow
d. reduced peak systolic over diastolic
13. What is laminar flow?
a. blood velocity traveling the highest near the tunica intima (internal vessel wall)
b. uniform velocity through the vessel lumen
c. irregular flow because of vessel stricture
d. blood velocity traveling highest in the midvessel
14. Name the vessel (appearing as a tubular structure) often seen sonographically in the
uterine myometrium.
a. radial artery
b. arcuate artery
c. uterine artery
d. spiral artery
15. The functional layer of the endometrium is supplied by the:
a. radial artery
b. radial and spiral artery
c. arcuate and spiral artery
d. spiral artery
16. An arteriovenous malformation (AVM):
a. is commonly seen in the cervix
b. mostly involves the uterine endometrium
c. is typically acquired through surgery or trauma
d. is hyperechoic and well circumscribed
17. Choose a statement that is not related to pelvic congestion:
a. frequently diagnosed in nulliparous women
b. vulvar, perineal, and lower extremity varices
c. chronic dull pelvic ache
d. worsens with prolonged standing or walking
18. The best description of classic ovarian torsion is:
a. free pelvic fluid
b. an oval structure with peripheral cysts measuring approximately 7 mm
c. an ovary with hypervascular patterns
d. an enlarged, edematous ovary with multiple small peripheral follicles and little or
no vascular flow
19. Complex masses of the pelvis are:
a. malignant if seen with papillary cystic projections and free fluid
b. benign if void of a thick septa and thick walls
c. difficult to discriminate because benign and malignant characteristics can be
similar
d. diagnosed only with Doppler evaluation
20. Which statement is correct?
a. Low-resistance flow has a low end-diastolic and peak-systolic velocity.
b. High-resistance flow has a low end-diastolic value with a high peak-systolic
value.
c. High-resistance flow has a high end-diastolic and low peak-systolic velocity.
d. Arteries always demonstrate high-resistance flow, whereas veins always
demonstrate low-resistance flow.
Fill-in-the-Blank
1. _________ ultrasound is a vital component in the evaluation of pelvic pathology and
physiology.
2. Following a transvaginal examination, clean the transducer with a(n) _________
solution.
3. Two ultrasound examinations that complement each other are _________ and
_________.
4. A sonographer must question every patient about _________ allergies.
5. Endovaginal sonography is superior to the transabdominal approach when imaging the
_________ artery.
6. Dilated venous structures larger than _________ mm raise suspicion for pelvic
congestion.
7. High and low _________ are the two categories of Doppler flow analysis.
8. The presence of blood flow in a select area or vessel, at a known depth, with a
sample volume describes _________.
54
9. Unless the scale has been inverted, flow moving toward the transducer will be plotted
_________ the Doppler baseline, whereas flow traveling away from the transducer
will be displayed _________ the baseline scale.
10. Spectral waveform velocity is displayed in what two measurements: _________ or
_________.
11. Color Doppler, which is a color _________, is based on the amount of the frequency
shift and the _________ they are moving in relation to the transducer.
12. Modern ultrasound color Doppler _________ maps are not standardized, which
allows for a variation of colors, hues, and intensities in _________ structures.
13. Low-velocity flow regions are best analyzed with _________ Doppler to determine
the presence and _________ of flow.
14. The ovarian artery anastomoses with the _________ artery at the uterine cornua.
15. Midluteal phase uterine arterial flow mean values in premenopausal patients are
similar to those of _________ patients.
16. The ureters and _________ arteries follow an inferior track over the _________
muscle. The artery then crosses the common iliac artery, enters the
infundibulopelvic _________ , and progresses to the ovary.
17. The ovarian veins travel differently in the left pelvis than in the right pelvis. The left
ovarian vein courses _________ and drains into the left _________ vein. The
_________ receives the right ovarian vein.
18. Although the gold standard for diagnosing pelvic congestion is _________,
ultrasound is helpful because of its ability to diagnose multicystic ovaries in these
patients and multiple _________ venous structures adjacent to the uterus.
19. During pregnancy, veins _________ to accommodate increased blood _________.
20. The early proliferative phase is day _________ of the menstrual cycle.
Short Answer
1. Although the uterine artery can be imaged along the lateral uterine body, in what
location is it visualized the best and using what ultrasound method?
2. Discuss a finding of periuterine vein measuring greater than 5mm in a nongravid

uterus.
55
3. An infertility patient being sonographically examined in the early follicular phase of
her cycle demonstrates limited color and power Doppler flow of her ovaries.
Explain this finding.
4. Describe the appearance of arterial and venous waveforms. List benefits of knowing
arterial versus venous flow within or external to a structure.
5. Identify arteries of the uterus, from the perimetrium to the endometrium.
1. Identify structure “1” and describe the pathology.
2. Identify structure “2” and explain its normal relation to structure “1”.
56
3. This image was performed transabdominally, demonstrating the uterine cornua. Name
the arteries that are anastamosing at the arrow.
4. Name the view.
5. Name the imaging method, view, and uterine position for image A. Name the view for
image B.
57
6. Name the flow pattern seen in the images.
58
CASE STUDY
1. A 33-year-old complaining of heavy menstrual bleeding for 8 days followed the
advice of her doctor and presented to the ultrasound department for a pelvic
ultrasound. She was gravida 2, para 0. The first pregnancy spontaneously aborted
during week 8. The event occurred naturally and without a need for medical
assistance. The second pregnancy spontaneously aborted at 14 weeks and did
require dilation and curettage (D and C). The procedure caused a perforation into
her uterine endometrium. Describe image A pathology, and then make a diagnosis
based on images A–C.
59
2. A 44-year-old gravida 6, para 6 woman returned to her gynecologist complaining of

constant pelvic pain. She has a family history of ovarian cancer and therefore has
routine ultrasounds for peace of mind. Her most recent ultrasound was 18 months
ago, and her diagnosis was normal for the uterus, vagina, ovaries, and adnexal
regions. Her gynecologist recommended a pelvic transabdominal and transvaginal
ultrasound. Incidentally, this patient is known to have varicose veins that appeared
after her third pregnancy. Create a diagnosis based on patient history and the
images.
60
61
Pediatric Pelvis
CHAPTER 7

visit the point.

Matching
KEY TERMS DEFINITIONS

a. Increase in adrenal gland activity seen at
the onset of puberty
b. Synthetic estrogen used from 1940 to
1971 to aid in pregnancy maintenance
that resulted in T-shaped uterus in
female children
c. Class of tumors that originate in either the
1. _________ diethylstilbestrol egg or the sperm
2. _________ Turner syndrome d. Loss of primordial germ cells in the
3. _________ gonadal dysgenesis gonads of an embryo
4. _________ adrenarche e. Having both male and female sexual
5. _________ rhabdomyosarcoma characteristics
f. Vascular tumor of the adrenal gland
6. _________ hermaphrodite g. Early onset of puberty usually before 8
7. _________ pseudohermaphrodite years of age
8. _________ thelarche h. Individual with external genitalia of one
sex and the internal organs of another
9. _________ precocious puberty sex
10. _________ germ cell tumors i. Malignancy derived from striated or
11. _________ Rokitansky nodule, aka skeletal muscle
dermoid plug j. Nodule projecting from a thickened cyst
12. _________ pheochromocytoma wall, usually ovarian in origin
13. _________ Café au lait skin k. Start of breast development at the onset
pigmentation of puberty
14. _________ ambiguous genitalia l. Genetic syndrome characterized by an X
and O chromosome combination
resulting in a female with premature
ovarian failure and lack of puberty
m. Intersexual genitalia
n. Irregular flat spots of increased skin
pigmentation
62

Image Labeling
Urothelial neoplasms
Classification of germ cell tumors of the ovary
63
Effects of GnRH on the hypothalamic–pituitary and reproductive axis
CHAPTER REVIEW
Multiple Choice
1. An ineffective method of reducing adolescent anxiety prior to and during an ultrasound
examination would be:
a. singing songs and reciting nursery rhymes for younger adolescents
b. allowing a bottle or pacifier for an infant
c. providing a chaperone
d. permitting parents or loved ones to stay during the examination
2. When examining the pelvis of an infant or small child with ultrasound, which
transducer is recommended?
a. phased array or curved linear in the range of 4 to 10 MHz
b. curved linear 5 MHz
c. linear 12 MHz
d. phased array or curved linear in the range of 1 to 5 MHz
3. Motion reduction on still images while imaging children can be attained by:
a. giving instructions to hold their breath
b. singing songs
c. using a higher frame rate
d. using slightly more transducer pressure
4. Bladder filling for infants can usually be accomplished by bottle feeding for:
a. 10 minutes prior to the sonographic examination
b. 30 minutes prior to the sonographic examination
c. 45 minutes prior to the sonographic examination
d. 1 hour minutes prior to the sonographic examination
64
5. A newborn female uterus is typically ______ shaped, while a 3-month-old uterus is

usually ______ shaped.
a. pear, cylindrical
b. spade, pear
c. pear, spade
d. spade, tube
6. The best method to visualize an adolescent vagina is by:
a. visual examination
b. endovaginal sonography (EVS)
c. transabdominal sonography (TAS)
d. perineal imaging
7. Ovarian volume of a female under 5 years old is _____________.
a. 1 cm3
b. 1 cm3 or less
c. between 2 cm3 and 3cm3
d. 5cm3
8. Ovarian cysts measuring over 9 mm in the first year of life are known as:
a. microcysts
b. macrocysts
c. simple cysts
d. well-circumscribed cysts
9. The most common lower urinary tract tumor discovered in the pediatric community is:
a. rhabdomyosarcoma
b. medullary sarcoma
c. chondrosarcoma
d. fibrosarcoma
10. In the pediatric population, benign lesions of the lower urinary tract such as
leiomyoma, fibroma, and hemangioma:
a. occur in older adolescents more often than in infants and young children
b. occur in children associated with fetal alcohol syndrome
c. are very uncommon
d. may transition into cancer if untreated
11. Choose the structure in the female pediatric pelvis most affected by both malignant
and benign tumors:
a. uterus
b. ovaries
c. cervix
d. vagina
12. An infection that can potentially affect the ovaries, uterus, and fallopian tubes and
can cause tubo-ovarian abscess, endometritis, salpingitis, oophoritis, and/or pelvic
peritonitis:
a. hydrosalpinx
b. pelvic inflammatory disease (PID)
c. endometriosis
d. urinary tract infection (UTI)
13. The most common site of pediatric female genital tract tumors is the:
a. urinary bladder
b. cervix/vagina
c. fallopian tube
d. ovary
14. Precocious puberty is:
a. related to sexually active adolescents
b. a secretion of the lining of ovarian cysts in adolescence
c. the onset of puberty usually before 8 years of age
d. is related to sexually abused pediatric patients
15. A unilateral tumor that can cause precocious puberty and highly malignant is:
a. embryonal carcinoma
b. choriocarcinoma
c. arrhenoblastoma
d. granulosa-theca
16. Select Turner syndrome characteristics:
a. stocky arms and legs, wide neck, and genital underdevelopment
b. polydactyly, abnormal genitalia, and omphalocele
c. deficient ovaries, dwarfism, amenorrhea, and webbed neck
d. choroid plexus cyst, polyhydramnios, and esophageal atresia
17. Ambiguous genitalia in neonates warrants sonography to exclude anomalies
associated with:
a. gonads, adrenal glands, and kidneys
b. internal and external genitalia, spleen, kidneys
c. breast lumps and internal genitalia
d. gonads, liver, pancreas, and spleen
18. The most common ultrasound appearance of a rhabdomyosarcoma is described as:
a. heterogeneous with 2 to 4 mm calculi and irregular borders
b. hypoechoic with well-defined walls measuring 1 mm
c. homogeneous with sharp thin borders
d. homogeneous with a muscle-like appearance
65
19. Gartner’s duct cysts:

a. are located within the uterine myometrium and are complex in appearance
b. are located within the vaginal wall, have a simple cystic appearance, and are both
single or multiple in number
c. are located cervically and are hypoechoic solid structures
d. are located vaginally and are heterogeneous
20. Hematometrocolpos is:
a. blood in the vagina
b. blood in the cervix
c. blood in the uterus
d. blood in both the uterus and the vagina
Fill-in-the-Blank
1. The method of ultrasound imaging that is close to the vagina and does not require
introduction of a transducer into the vagina is called _________.
2. High-resolution, real-time, and _________ are important imaging techniques for the
lower abdominal and pelvic structures of infants, children, and adolescents.
3. In adolescent pelvic sonography, _________ may be required if bladder filling cannot
be achieved by p.o. (by mouth) fluid intake.
4. Adult and pediatric ultrasound examinations are similar in scanning _________ and
exam _________.
5. Transperineal ultrasound imaging delineates _________ pathology and imperforate
_________.
6. The prepubertal uterus measures _________ cm long.
7. Ovarian cysts in birth to two-year-olds usually relate to a higher level of _________
in the neonate.
8. When a tumor, such as a rhabdomyosarcoma, originates from the bladder or
prostate, pediatric patients have symptoms of _________ and _________.
9. In the pediatric pelvis, pheochromocytoma is usually detected in the submucosal layer
of the _________ wall of the bladder near the _________ or in the _________ of
the bladder.
10. Ovarian tumors present with a variety of symptoms, including _________,
_________, and _________.
11. A _________ is common during reproductive years, occurs mostly on the right, and
presents with pain.
12. Meigs syndrome is the triad of _________, _________, and _________.
13. Dysgerminoma is the most common malignant pediatric _________ mass.
14. Serous tumor usually demonstrates _________ septa, solid elements, and are
_________.
15. Ovarian cysts may cause ovarian _________ if they become large.
16. “Streak” gonads, which are related to gonadal dysgenesis, resemble _________ but
contain no _________ cells or follicles.
17. Fluid in the vagina is _________ and blood in the vagina is _________.
66
18. Fluid in both the uterus and vagina is _________.

19. During hormone replacement therapy for precocious puberty, sonography is used to
monitor _________ and volume changes of the uterus and _________.
20. Clinical symptoms of ovarian torsion are _________, _________, _________,
_________, and _________.
Short Answer
1. Internal gynecology examinations are usually not possible or desirable in young girls.
Ultrasound can provide a painless and unobtrusive method to examine pelvic
organs. List indications for a gynecologic ultrasound examination in a young female.
2. Name anatomy that is generally visualized with pelvic ultrasound in an adolescent

with a full urinary bladder.
3. Explain where rhabdomyosarcoma is usually discovered in the pediatric population.
Describe the typical sonographic appearance.
4. A 14-year-old girl complaining of a “lump” in her midpelvis and mild sporadic

pelvic pain for 2 weeks was presented to her doctor and was found to have a
midline low pelvic mass measuring approximately 12 cm long and 6 cm wide.
There was no visualized indication of vaginal bleeding. Her menses had been
irregular since onset. State a possible diagnosis.
5. Explain the difference between hydrocolpos, hydrometra, hematometra, hematocolpos,

hydrometrocolpos, and hematometrocolpos.
67
1. Identify the organ in image A and discuss the pathology. Identify the organ in image B
and discuss the pathology. What pelvic malignant processes can be related to the
findings in images A and B?
68
2. Name the structure seen in images A and C with arrows pointing toward it. It is also
visualized in image B, but without arrows directed at it. Describe the appearance of
the structure and suggest a probable diagnosis.
69
3. Name the organ in images A–D and related pathology. Explain a nonmalignant
pediatric pelvic process that may produce this condition.
70
4. Label the image. Identify the structure depicted by the long arrow, short arrow, and
open arrow in image A. Identify the view of image B. State the structure that the
short arrow and long arrow point to.
71
CASE STUDY
1. A young teenage girl complained of dull low pelvic pain for approximately 1 day. She
reported severe pain for the last 2 hours. Her low abdomen and pelvis were tender
upon examination. A pelvic ultrasound followed by a CT was ordered. Image A,
which is a contrast-enhanced CT, demonstrates a transverse image showing the
uterus adjacent to a mass (depicted by arrows). Both structures are superior to the
urinary bladder (inferior white structure). View the images and discuss anatomy
portrayed by the arrows, then suggest a diagnosis.
72
2. A 10-month-old baby was reported by her mother to have had bulging at her vagina.
Within a short time frame, the bulging developed into an outgrowth from the vaginal
introitus. Describe the most likely diagnosis based on patient history and image
appearance.
73
Benign Disease of the Female Pelvis
CHAPTER 8

visit the point.

Matching

a. Surgical removal of adhesions (scar
tissue)
b. Failure to ovulate
c. Inflammation of the bowel
d. Surgery performed with an electrical
device such as an electrocautery
e. Blood-filled ovarian cyst resultant from
endometriosis implants
1. _________ adhesiolysis f. Hormone produced by the anterior
2. _________ psammoma bodies pituitary gland that stimulates growth of
the Graafian follicle
3. _________ endometrioma
g. Form of carcinoma that grows into the
4. _________ lysis
uterine musculature
5. _________ hysteroscope
6. _________ uterine dehiscence h. Genetically abnormal pregnancy that
7. _________ electrosurgery develops into a grape-like mass within
the uterus
8. _________ oligomenorrhea
i. Increased testosterone levels associated
9. _________ hirsutism with polycystic ovary syndrome (PCOS)
10. _________ red degeneration j. Excessive production/secretion of
11. _________ hyperandrogenism androgens
12. _________ omentum k. Reconstructive surgery of the uterus
13. _________ tamoxifen l. Instrument allowing visualization of the
14. _________ follicular-stimulating uterus
hormone (FSH) m. Collapsing and rolling inward
15. _________ involute n. Hormone produced by the anterior
16. _________ anovulation pituitary gland that stimulates ovulation
17. _________ placenta previa o. Breaking up of tissue
18. _________ hyperandrogenemia p. Abnormally heavy or prolonged menses
19. _________ radiodense (radiopaque) q. Infrequent menses
r. Infrequent ovulation
74 s. Peritoneal fold supporting the abdominal
viscera
20. _________ hysteroplasty
t. Growth of the placenta into the
21. _________ luteinizing hormone (LH)
myometrium
22. _________ Crohn disease
u. Implantation of the placenta in the lower
23. _________ placenta accrete uterine segment or on the cervix
24. _________ hydatidiform mole v. Microscopic collection of calcium
25. _________ menorrhagia associated with specific tumor types
26. _________ oligoanovulation w.Tissue that absorbs x-rays appearing
27. _________ chorioadenoma destruens white on the resulting radiograph
x. Hemorrhage into a leiomyoma that has
outgrown its blood supply
y. Antiestrogenic drug used to decrease the
occurrence of certain estrogen-sensitive
breast cancers
z. Partial separation of the myometrium at
the location of uterine scar
aa.Excessive hair on a woman

Image Labeling
Cervical cyst
Cervical neoplasm
75
Pathogenesis of the polycystic ovary syndrome
(LH, progesterone, and estrone levels increase or decrease with PCOS, indicate whether these hormone levels raise or
lower)
Leiomyoma locations
76
CHAPTER REVIEW
Multiple Choice
1. Select the cervical anomaly that does not cause bleeding:
a. leiomyoma
b. polyp
c. Nabothian cyst
d. hyperplasia
2. HSG is:
a. hysterosalpingography
b. hysteroscopic guidance
c. hystersonography
d. hysteroplastic service guide
3. Uterine dehiscence is caused by:
a. subserosal and intramural fibromas
b. endometrial and cervical polyps
c. multiparity
d. uterine surgeries, such as cesarean section (C/S)
4. Leiomyomas:
a. occur in 50%–60% of women of reproductive age
b. are the most common tumor of the female pelvis
c. usually occur after menopause
d. are also known as myometra
5. Degenerative changes occur when myomas:
a. become larger than 3 cm
b. become painful
c. outgrow their blood supply
d. fibrotic menorrhagia occurs
6. Sonohysterography:
a. produces radiation to the patient
b. may cause bleeding, intense pain, and provide ovarian contour information
c. is performed in place of a myomectomy
d. demonstrates myomatous extension onto the endometrium through visualizing
filling defects
7. Imaging identification of a previous cesarean section (C/S) scar can be performed
most effectively by:
a. endovaginal sonography
b. transabdominal sonography
c. transperineal sonography
d. hysteroscopy
8. Differentiating a pelvic mass from bowel may be done by:
a. monitoring the suspect area for peristalsis
b. noting fluid levels
c. demonstrating gas bubble formation
d. measurements
9. Lymphoceles, uromas, hematomas, and abscesses:
a. are easily differentiated because each has unique attributes
b. share sonographic characteristics
c. display similar laboratory results
d. cause distinct symptoms
10. A fibromyoma located within the myometrium is labeled:
a. subserosal/serosal
b. pedunculated
c. intramural
d. submucosal
11. Anechoic or complex lesions of the superior anterolateral vagina wall (adjacent to
the cervix) are:
a. Nabothian cysts
b. fibroid cysts
c. Bartholin’s gland cyst
d. Gartner’s duct cyst
12. Select the sonographic criteria most likely not related to benign ovarian cysts:
a. absence of internal echoes
b. increased posterior enhancement
c. homogeneously increased echogenicity
d. smooth, well-defined borders
13. The “ring of fire” demonstrated peripherally when imaging a cyst with color or
power Doppler is related to:
a. theca lutein cysts
b. corpus luteum cysts
c. surface epithelial inclusion cysts
d. hemorrhagic cysts
77
14. Sonographic findings in serous cystadenoma compared to mucinous cystadenoma

are:
a. generally similar and may therefore be difficult to diagnose from imaging
b. serous displays cystic fluid-fluid levels, mucinous appears cystic with projections
from the cyst wall
c. serous shows simple pinpoint echoes, mucinous shows thick walls
d. serous demonstrates a hemorrhagic appearance, mucinous demonstrates
multilocularity
15. Gonadoblastoma tumors may cause all of the following except:
a. primary amenorrhea
b. abscess
c. abnormal genitalia
d. virilization
16. Meigs syndrome presents as:
a. enlarged ovaries demonstrating a “string of pearls” sign
b. simple cysts usually measuring 7 to 10 cm
c. triad of ascites, pleural effusion, and an ovarian neoplasm
d. thick-walled, irregular contoured cysts
17. Select the description for ovarian remnant syndrome:
a. severe adhesions and endometriosis
b. FSH/LH hyperstimulation
c. unilateral oophorectomy
d. bilateral salpingo-oophorectomy followed by restored functionality of remnant
ovarian tissue
18. A posthysterectomy AP vaginal cuff should measure:
a. 2.0 × 3.5 cm
b. greater than 3.1 cm
c. 4.2 × 2.0 cm
d. less than 2.2 cm
19. Brenner tumors:
a. are related to the cervix
b. are usually detected in the fifth decade of life
c. are cystic
d. are known as cystadenomas
20. Paraovarian cysts arise from the:
a. adnexa
b. ovarian epithelium
c. ovarian stroma
d. cervix
Fill-in-the-Blank
1. An accurate way to diagnose endometrial hyperplasia is performing a _________.
2. ACOG recommended treatments for endometrial hyperplasia include _________,
_________, and _________.
3. Asherman syndrome, which is _________ of the endometrium, is also known as
_________.
4. A condition in which the uterine myometrium separates leaving an intact peritoneum is
_________.
5. Leiomyomas occur in approximately _________% to _________% of women of
reproductive age.
6. Techniques that may help demonstrate myomas include _________, _________, and
increasing the output power because myomas tend to attenuate the sound beam.
7. Chills, general malaise, and weakness may describe a postoperative _________.
8. A collection of blood, due to trauma or a disease process, within an organ or potential
space is a _________.
9. Leiomyomas are also called _________, _________, and _________.
10. Red degeneration is _________ into a leiomyoma that has outgrown its blood
supply.
11. The normal appendix measures less than _________ from outer edge to outer edge.
12. If fallopian tubes are detected sonographically as tubular, tortuous, and fluid-filled, a
diagnosis may be _________ or _________.
78
13. A myoma that receives its blood supply from other organs is a _________.
14. Theca lutein cysts, luteum cysts, and follicular cysts are classified as _________ or
functional cysts.
15. Ovarian torsion presents mostly on the ___________ side and demonstrates
_________ of blood flow.
16. Fibrothecomas arise from the _________.
17. _________ are fluid-filled masses caused by serous fluid collections between layers
of peritoneum or adhesions.
18. Benign myomas develop from _________ and fibrous _________ tissue.
19. Cysts measuring less than _________ cm in greatest diameter usually regress
spontaneously.
20. Teratomas commonly appear as _________ masses. They are mostly _________ and
contain echogenic foci or fat.
Short Answer
1. Define endometrial hyperplasia and explain its appearance on a sonographic image.
List common reasons women develop endometrial hyperplasia.
2. Explain hysterosalpingography and the safest time to perform the examination.
3. A 48-year-old patient with known myomas has recently suffered increased vaginal
bleeding during her menses. Why is it important to measure the myomas and detect
their location?
4. A 33-year-old G3 P3 delivered by C/S one month ago. Previous to the scheduled

delivery, she had requested and consented to a tubal ligation, which was performed
immediately following the birth of her child. Over the last month, she has
complained of tenderness in the left low pelvis. Ultrasound demonstrated a 3.8 × 4.3
× 3.8 cm hypoechoic left adnexal mass with internal debris adjacent to the uterus.
CT followed and demonstrated a 4.0-cm loculated fluid collection in the same
location. State a probable diagnosis. Describe symptoms that the patient may have
5. Compare benign cystic teratoma to dermoid tumor.
79
1. Identify structures depicted by open arrow. Identify structures between two thin
arrows. Name the method used to obtain the image.
2. How was this image collected? What is the structure demonstrated? Label the views
adjacent to 1, 2, and 3.
3. A saline infusion sonohysterography was performed on this uterus. Label the structure
the arrow points to.
80
4. Define the structure the open arrow points to. Define the structure the thin arrow
points to.
5. What is depicted by the black arrow on the radiograph (image A)? Explain the
structure next to the arrow in image B.
81
6. Identify the anatomy in images A, B, and C.
82
CASE STUDY
1. Patient E, a 23-year-old, presented to the emergency department with severe pain in

the right low abdomen. He stated the pain started this morning and increased so that
currently if he walks or coughs, he gets nauseated. The patient had a tender right
abdomen and elevated white blood cell (WBC) count. Make a diagnosis based on
the clinical history, laboratory result, and ultrasound images.
2. After suffering several months of bilateral adnexal pain, a 26-year-old woman went to
her gynecologist for assessment. The doctor noted a mass in each adnexa and
therefore requested a pelvic ultrasound. Since the patient also complained of
irregular menses and an inability to become pregnant after 10 months, the physician
also ordered FSH and LH blood serum levels. Explain a possible diagnosis for
bilateral adnexal masses after viewing the image and the reason for FSH and LH
testing.
83
Malignant Disease of the Uterus and

Cervix
CHAPTER 9

visit the point.

Matching

a. Malignant tumor arising from any
glandular organ
b. Any disease of a gland or of glandular
tissue
c. Pivotal adrenal steroid that is a precursor
to testosterone and other androgens
d. Any substance that blocks or modifies the
action of estrogen
e. Prevents the development, growth, or
proliferation of malignant cells
f. Hyperplastic growth that protrudes from
the epithelium of the cervix; may be
broad-based or pedunculated
g. Narrowing or obstruction of the cervical
canal caused by an acquired condition
h. Metastatic type of persistent
trophoblastic neoplasia that can result
from any type of pregnancy but most
often occurs with molar pregnancy
i. Malignant condition that presents with
abnormal thickening of the endometrial
cavity and irregular bleeding in
perimenopausal and postmenopausal
women
j. Condition that results from estrogen
stimulation to the endometrium without
the influence of progestin; frequent cause
of bleeding, especially in
postmenopausal women
k. Pedunculated or sessile mass attached to
the endometrial cavity
l. Presence of endometrial tissue of varying
differentiation
m. Variant of placental site trophoblastic
tumor
n. Gynecologic malignancy occurring
between the fourth and sixth decades and
linked to BRCA-1 and BRCA-2;
adenocarcinoma is the most common
histologic type
o. Rare earth metallic element possessing
paramagnetic properties that are used in
1. _________ pelvic inflammatory disease contrast media for magnetic resonance
imaging (MRI)
2. _________ resistive index (RI)
p. Trophoblastic tissue that has overtaken
3. _________ epithelioid trophoblastic the pregnancy and has propagated
tumor throughout the uterine cavity; these
4. _________ adenosis tumors arise from the placental
5. _________ cervical stenosis chorionic villi
6. _________ leiomyosarcoma
7. _________ tamoxifen q. A fleshy ovarian tumor with yellow
streaks that originates in cells of the
8. _________ endometrial hyperplasia primordial membrana granulosa and may
9. _________ antineoplastic grow to an extremely large size
10. _________ human papilloma virus r. A hormone secreted by the placental
(HPV) trophoblastic cells, it is found in the
11. _________ teratogenic urine and blood of pregnant women.
Elevated levels are found with
12. _________ polycystic ovarian gestational trophoblastic neoplasia
syndrome (GTN)
13. _________ methotrexate s. A virus that is transmitted through sexual
14. _________ granulosa cell tumor contact and produces lesions on the
15. _________ androstenedione mucous membranes. It is considered to
be a causative factor in cervical
16. _________ squamous cell carcinoma carcinoma.
17. _________ persistent trophoblastic t. Watery discharge sometimes present with
neoplasia (PTN) fallopian tube carcinoma
18. _________ human chorionic u. Tumor penetrating into and possibly
gonadotropin (hCG) through the uterine wall
84 v. Benign tumor composed of smooth
muscle cells and fibrous connective
19. _________ choriocarcinoma tissue that occurs in the uterus
20. _________ hydrops tubae profluens w.Malignant uterine tumor that is
21. _________ gadolinium composed of smooth muscle cells and
fibrous connective tissue;
22. _________ endometrial carcinoma sonographically appears like benign
23. _________ cervical polyp leiomyomas
24. _________ placental-site trophoblastic x. Spread of bacteria or body cells,
tumor (PSTT) especially of cancer cells, from one part
25. _________ leiomyoma of the body to another
26. _________ Peutz–Jeghers syndrome y. Drug prescribed in the treatment of
severe psoriasis and a variety of
27. _________ salpingo-oophorectomy malignant neoplastic disease
28. _________ pulsatility index (PI) z. Cytological study (developed by George
29. _________ endometrial polyp Nicholas Papanicolaou) used to detect
30. _________ Papanicolaou (pap) smear cancer in cells that an organ has shed;
31. _________ gestational trophoblastic used most often in the diagnosis and
neoplasia (GTN) prevention of cervical cancer and also
valuable in the detection of pleural or
32. _________ submucosal leiomyoma peritoneal malignancies
33. _________ adenocarcinoma aa.Infection of the uterus, fallopian tubes,
34. _________ endometrioid and adjacent pelvic structures; usually
35. _________ fallopian tube carcinoma caused by an ascending infection in
which disease-producing germs spread
36. _________ sonohysterography from the vagina and cervix to the upper
37. _________ metastases portions of the female reproductive tract
38. _________ antiestrogen bb.Malignant end of the GTN spectrum.
39. _________ invasive mole This group of life-threatening diseases
persists most often from a molar
40. _________ radiation therapy
pregnancy.
41. _________ polypoid
cc.Inherited disorder characterized by the
presence of polyps of the small intestine
and melanin pigmentation of the lips,
mucosa, fingers, and toes; anemia from
the intestinal polyp is common
dd.Type of PTN that usually occurs several
years after a normal term pregnancy
ee.Endocrine disorder associated with
chorionic anovulation and Stein–
Leventhal syndrome
ff. Containing more than two normal sets of
chromosomes
gg.Doppler measurement that uses peak
systole minus peak diastole divided by
the mean
hh.The treatment of neoplastic disease by
using x-rays or gamma rays; deters the
proliferation of malignant cells by
decreasing mitosis or by impairing DNA
synthesis
ii. Peak systole minus peak diastole divided
by peak systole. An RI of 0.7 or less
indicated good perfusion of an organ,
whereas an RI of greater than 0.7
indicates decreased perfusion
jj. Surgical removal of the fallopian tubes
and ovaries
kk.Injection of sterile saline into the
endometrial canal under ultrasound
guidance. This procedure allows for
good visualization of the endometrial
borders to rule out pathology.
ll. Slow-growing malignant tumor
composed of squamous epithelium. This
is the most common type of cervical
cancer.
mm.Type of leiomyoma that deforms the
endometrial cavity and can cause heavy
or irregular menses
nn.Nonsteroidal antiestrogen compound
that is currently the most widely
prescribed drug for the treatment of
breast cancer
oo.Causing congenital anomalies or birth
85 defects
CHAPTER REVIEW
Multiple Choice
1. Select the factor most unlikely to contribute to endometrial cancer.
a. obesity, particularly those more than 50 pounds overweight
b. nulliparous females
c. female having multiple sex partners
d. female encountering menopause after 52 years of age
2. Tamoxifen may cause estrogenic effects in:
a. premenopausal women
b. multiparous women
c. postmenopausal women
d. women diagnosed with menorrhagia
3. Endometrial cancer typically presents as:
a. uterine bleeding
b. bloating
c. urinary frequency
d. persistent indigestion and constipation
4. Select an imaging method that can provide accurate diagnostic tumor angiogenesis
information.
a. EV
b. TA
c. 3D
d. color and pulsed Doppler
5. Which condition will not cause the endometrium to appear thickened?
a. myomas
b. menstrual cycle follicular phase
c. endometrial hyperplasia
d. cervical carcinoma
6. Leiomyosarcomas:
a. have well-circumscribed borders
b. have infiltrative borders and are misdiagnosed frequently in early stages
c. have a whorl-like appearance
d. mostly reside in the cervix
7. Fallopian tube carcinoma is an aggressive tumor that occurs in the patient’s:
a. fourth decade
b. fifth decade
c. sixth decade
d. seventh decade
8. Myomas, endometriosis, adenomyosis, pregnancy, pelvic inflammatory disease, and
adenocarcinoma can cause an elevated:
a. CA-125
b. hCG
c. testosterone
d. HGB
9. Ninety percent of fallopian tube carcinoma is:
a. visualized transabdominally
b. causes hepatomegaly
c. metastatic
d. treated exclusively with radiation therapy
10. Infection by HPV is the largest cause of:
a. fallopian tube carcinoma
b. ovarian adenocarcinoma
c. primary uterine carcinoma
d. cervical carcinoma
86
11. Exposure to diethylstilbestrol in utero causes an increased incidence of

adenocarcinoma of the:
a. cervix and ovary
b. cervix and vagina
c. uterus and fallopian tube
d. fallopian tube and ovary
12. Peutz–Jeghers syndrome consists of:
a. multiple cystic areas within a solid cervical mass and copious watery vaginal
discharge
b. yellow, odorous vaginal discharge and pain
c. hydronephrosis and urinary retention related to uterine carcinoma
d. carcinoma of the cervix that responds easily to aggressive therapy
13. The International Federation of Gynecology and Obstetrics (FIGO) classification
system for staging cervical cancer:
a. is extremely accurate and therefore well utilized in the gynecological community
b. limited due to inaccuracies of estimated tumor size and bladder wall and rectal
wall invasion
c. reports stage I tumors at 50% and stage II at 75%
d. concludes cervical stenosis is common
14. Select the modality that can most accurately stage cervical cancer:
a. ultrasound
b. choriocarcinoma tumors (CT)
c. MRI
d. radiography
15. Select the phrase used to describe a group of uterine neoplasms that occur as a
complication of pregnancy.
a. GTN
b. pregnancy-related life-threatening tumors
c. CT
d. malignant gestational neoplasia
16. Trophoblastic disease may affect the ovary with:
a. hemorrhagic cysts
b. Graafian cysts
c. endometrial cysts
d. theca-lutien cysts
17. The frequently used laboratory test ordered to determine pregnancy is:
a. hCG
b. HPG
c. betaCG
d. chorion gonadotropin
18. Although clinical signs for endometrial cancer and leiomyosarcomas are
nonspecific, most present with:
a. significant amounts of free fluid
b. uterine bleeding and pain
c. irregular bowel habits
d. hydronephrosis
19. Fertilization by more than one sperm creates:
a. twins
b. polypoid karyotype
c. triploid karyotype
d. diploid karyotype
20. A drug prescribed for treatment of severe psoriasis and a variety of malignant
neoplastic disease:
a. methimazole
b. metaxalone
c. methoxy
d. methotrexate
Fill-in-the-Blank
1. _________ is a nonsteroidal antiestrogen compound and the most widely prescribed
drug in the world for the treatment of _________ cancer.
2. Patients displaying uterine lesions, even if asymptomatic, appear to have an
_________-fold risk of endometrial cancer if on tamoxifen therapy.
3. Endometrioid type cancer is divided into Type 1, _________ grade, and Type 2,
_________ grade.
4. 3D ultrasound is used to diagnose cancer. It can detect the infiltration of cancer into
the _________ or _________.
87
5. Overall, _________ is more accurate than ultrasound in determining deep myometrial

invasion of endometrial carcinoma.
6. A rare (3%), fast-growing malignancy derived from smooth muscle in the uterine wall
is _________.
7. Tumors of the fallopian tube that cause profuse watery discharge are known as
_________.
8. The differential diagnosis for carcinoma of the fallopian tube is _________
carcinoma, pelvic _________, and myomas.
9. Cervical cancer is usually asymptomatic and best detected by _________.
10. The junction between the two types of epithelium of the cervix is called _________.
11. Cervical cancer prognosis depends on _________ size, _________, and patient
_________.
12. Along with the EV approach, _________ and _________ are used to define the
cervix.
13. The appearance of a bulky cervix on ultrasound may be a _________ involving the
lower uterine segment, benign endometrial _________, and, occasionally,
endometrial _________.
14. Persistent trophoblastic neoplasia occurs most often with _________ pregnancies.
15. _________ chromosomes with _________ autosomes and _________ sex
chromosomes complete the normal genetic makeup of a fertilized ovum.
16. The most common form of PTN is _________, accounting for 80% to 95% of cases.
17. Choriocarcinoma has an absence of _________, while invasive mole contains it.
18. Most PTN cases are managed by chemotherapy. _________ and _________ are very
chemoresistant and therefore require surgical intervention.
19. Treatment for endometrial cancer, leiomyosarcoma, or fallopian tube carcinoma is
_________.
20. The endocrine disorder associated with chronic anovulation and Stein–Leventhal
syndrome is _________.
Short Answer
1. Margaret, an overweight, polycystic ovarian syndrome (PCOS), 64-year-old, who has
never married or given birth, started bleeding vaginally after being menopausal
eight years. An EV ultrasound diagnosed with a 3.3 × 2.8 × 3.1 cm heterogeneous
mass in the endometrium. Provide a possible diagnosis and explain factors that led
to the diagnosis.
2. Discuss the most accurate way to measure an endometrium with and without fluid.
88
3. Why are accurate measurements imperative regarding intracavitary radiotherapy?
4. Compare and contrast forms of PTN: Invasive mole, choriocarcinoma, placental-site

trophoblastic tumor, and epithelioid trophoblastic tumor.
5. Discuss the five stages of cervical cancer.
1. Identify the transducer and the ultrasound imaging method used to obtain the image.
What is the structure? State a differential diagnosis.
89
2. Describe what is depicted by the thick arrow, open arrow, thin short arrow, and thin
long arrow. Explain the view.
3. Explain image A, and define the anatomy. What is the mechanical index (MI) and
thermal index (TI) value stated on the image? Describe image B and anatomy seen.
4. What is the image view? State the anatomy and pathology.
90
5. Define the view of images A and B. Make a diagnosis.
CASE STUDY
1. This patient is a 65-year-old diabetic who had sporadic menstrual cycles prior to
menopause. She presented to her family practice physician several years ago,
complaining of “hot flashes.” The doctor prescribed estrogen for her to relieve the
symptoms of “hot flashes.” The patient took the unopposed estrogen for 2 years
when she started bleeding vaginally. She explained her history to her new
gynecologist, who immediately withdrew the progesterone and ordered a pelvic
ultrasound. Correlate the patient’s history with the images, discuss anatomy and
pathology, and make a diagnosis.
91
2. A 59-year-old patient being treated with tamoxifen for breast cancer complained of
constant dull pelvic pressure. View the images and offer an explanation.
92
93
Malignant Diseases of the Ovary
CHAPTER 10

visit the point.

Matching

a. Used as a tumor marker for carcinomas
of embryonic origin
b. Inherited gene mutation associated with a
significant increase of breast and
ovarian cancer risk
c. Protein found in tumor cells that results in
an elevation of blood levels
d. Tumor marker for colon, stomach, breast,
lung, some thyroid, and ovarian cancers
e. Neoplasm originating in the germ cells
(ovum)
f. Neoplasm involving the surface
epithelium of the female reproductive
organs (ovary), which involves cells
with a clear appearance on microscopic
examination
g. Malignant tumor of the ovary arising from
undifferentiated germ cells of the
1. _________ mucinous embryonic gonad. The tumor is
cystadenocarcinoma histologically identical to seminoma
found in the testicle.
2. _________ Sertoli–Leydig cell
tumors/androblastoma h. Tumor of the ovary containing epithelial
or stromal elements resembling
3. _________ Krukenberg tumor endometrial tissue. Typically arises
4. _________ endometrioid tumor from endometriosis, and a large
5. _________ pseudomyxoma peritonei percentage are malignant.
6. _________ alpha fetoprotein (AFP) i. Neoplasm involving the surface
epithelium of the ovary
7. _________ clear-cell adenocarcinoma
j. Gene that produces a protein, which
8. _________ HER2/neu regulates normal cell growth found in
9. _________ yolk cell tumor/endodermal breast and ovarian cancer cells. The
sinus tumor identification of this protein enables
10. _________ salpingo-oophorectomy determination of treatment options.
11. _________ lactate dehydrogenase k. Carcinoma of the ovary, usually
(LDH) metastatic from gastrointestinal cancer,
marked by areas of mucoid degeneration
12. _________ BRCA1/BRCA2
and by the presence of signet-ring cells
13. _________ dysgerminoma
l. Enzyme involved in production of energy
14. _________ epithelial ovarian cancer of the cells. Elevated levels in the blood
15. _________ serous carcinoma indicate tissue damage, cancers, or other
16. _________ laparotomy diseases.
17. _________ struma ovarii m. Surgical incision in the abdomen usually
performed to evaluate the organs
18. _________ Meigs syndrome
n. The finding of pleural effusion, ascites,
19. _________ CA 125 and an ovarian mass
94 o. Cystic mass filled the thick gelatinous
cystic fluid
20. _________ mucinous cystadenoma p. Large cystic ovarian mass with thick-
21. _________ carcinoembryonic antigen walled septations; may have internal
(CEA) debris layering components.
22. _________ serous cystadenocarcinoma q. Accumulation of mucinous material in
23. _________ teratoma/teratocarcinoma the peritoneal cavity
24. _________ sex cord stromal tumors r. Surgical removal of the ovary and
fallopian tube
s. Type of epithelial ovarian cancer, which
presents as a partially cystic mass with
solid components
t. Large multilocular ovarian neoplasm with
papillary projections
u. Related to the sex-cord (cord-like masses
of gonadal epithelial tissue) stromal
tumors seen in ovaries, mostly in young
adults
v. Solid ovarian mass originating from the
embryonic gonadal ridges and Sertoli
cells
w.Extremely rare neoplasm of the ovary
containing thyroid tissue
x. A rare malignant form of a common germ
cell tumor found in young adults
containing fat, bone, hair, skin, and/or
teeth

Image Labeling
Typical metastatic sites for ovarian cancer
95
Common sites of ascites fluid collection in the peritoneum
CHAPTER REVIEW
Multiple Choice
1. Select the false statement:
a. Ovarian cancer has a strong family history, making genetic screening important.
b. Studies show that women who used oral contraceptives are at the greatest risk for
developing epithelial ovarian cancer.
c. Ovarian malignancy is a disease of low prevalence, accounting for only 5% of all
female cancers.
d. Over 90% of sporadic ovarian cancer cases occur in women over 50 years of age.
2. Which technique is not directed at improving detection and outcome of ovarian
cancer:
a. epidemiologic studies
b. immunologic studies
c. improved imaging techniques
d. endocrine studies
3. Choose the most unlikely risk factor for developing ovarian cancer.
a. living in a developing country
b. late menopause
c. nulliparity
d. menses with early onset
4. Extended ovulatory activity, over 40 years, places women in what risk category for
developing ovarian cancer:
a. low risk
b. medium risk
c. high risk
d. ovulatory activity is not a factor
5. The gene that is related to errors in the replication process resulting in
overexpression:
a. thymine
b. HER2/neu
c. BRCA1
d. BRCA1
6. A characteristic of most epithelial cancers is the tendency to:
a. display irregular borders with heterogeneous contents
b. cause extreme, continuous pain
c. form cystic masses with multiple septa
d. demonstrate well-circumscribed borders
96
7. If positive vaginal cytology is noted in association with ovarian cancer, it is most

likely due to:
a. proximal migration of tumor cells
b. drainage to mediastinal nodes
c. liver metastases
d. antegrade spread
8. Frequently, the only symptom of ovarian cancer is:
a. right upper quadrant pain caused by ascites accumulation
b. pelvic pressure and bloating
c. bilateral leg discomfort due to mass encroachment of the femoral nerve
d. urinary tract infection and vaginal bleeding
9. To increase specificity in diagnosing ovarian malignancy, laboratory values such as
_____ are tested.
a. CA 125, AFP, hCG, CEA
b. CA 125, LDH, PET, BPT
c. LDH, CEA, CA 51.3, APF
d. CA 152, LDH, CD, 3D
10. What imaging method provides diagnostic value by presenting calcifications,
sometimes in a curvilinear fashion, soft tissue masses, and patterns suggesting
abdominal distention?
a. hysterography
b. fluoroscopy
c. CT
d. plain film radiography
11. The imaging modality providing the most accurate tissue characterization regarding
adnexal masses is:
a. ultrasound, including 3D multiplanar technology
b. CT
c. MRI
d. PET
12. Menopausal females utilizing hormone replacement therapy (HRT) will demonstrate:
a. a wrinkled ovarian surface and a change in texture
b. normal-sized ovaries
c. ovarian regression
d. diminished ovarian blood supply
13. Malignancy suspicion increases with the amount of solid tissue in a complex mass
and if the volume exceeds __________ in postmenopausal women and __________
in premenopausal women.
a. 10 cm3, 20 cm3
b. 5 cm, 10 cm
c. 5 to 7 cm3, 1 to 15 cm3
d. 10 cm2, 25 cm2
14. Metastasis to the ovary:
a. is rare
b. is common
c. occurs most commonly from primary brain carcinoma
d. causes bladder frequency
15. Compressibility of a mass while scanning can assist in differentiating bowel from
malignancy and is performed by:
a. EV ultrasound
b. valsalva technique
c. “hands-on” maneuver
d. positioning the patient in Trendelenburg
16. Nonneoplastic cystic foci of the ovary are commonly seen in ______________
females and are difficult to differentiate from malignant lesions, so should be
considered when determining the diagnosis.
a. premenstrual
b. menstruating
c. perimenopausal
d. menopausal
17. Epithelial ovarian cancers typically form cystic masses and:
a. solid papillary growths
b. reduction of ovarian volume
c. tissue specificity used to determine benign vs. malignant lesions
d. decreased laboratory enzyme levels
18. Pseudomyxoma peritonei is defined as:
a. illusive peritoneal ascites, which is difficult to image
b. a type of ovarian cancer presenting as a partially cystic mass with solid
components
c. pleural effusion, ascites, and an ovarian mass
d. the accumulation of gelatinous material in the peritoneal cavity
19. Ovarian malignancy is often associated with ascites, which first accumulates in the:
a. right upper quadrant
b. bilateral paracolic gutters
c. dependent portion of the peritoneal cavity
d. splenic flexure
20. Color Doppler of malignant lesions frequently demonstrates:
a. reduced vascular patterns
b. disorganized vascular patterns
c. peripheral vascular patterns
d. no vascular patterns
97
Fill-in-the-Blank
1. Late stage diagnosis of ovarian malignancy leads to a _________ prognosis.
2. A large number of patients with ovarian malignancy present with or develop
_________ bleeding.
3. Two inherited gene mutations related to an increase of breast and ovarian cancer are
_________ and _________.
4. A Krukenberg tumor is a cancerous tumor of the _________, and usually metastasizes
from _________ cancer.
5. The effect of ovulation is known to cause increased inflammation and wound healing
because of repeated trauma to the ovarian _________.
6. Ascites associated with ovarian malignancy collects in the _________ and
_________, mostly on the _________ side.
7. Ovarian cancer is mostly a disease of _________ menopausal and _________
menopausal women.
8. Ovarian cancer is the most common tumor responsible for _________ malignancy in
women.
9. The stage I ovarian cancer detection rate is _________%. If early detection occurs,
the cure rate is _________%.
10. Benign processes, such as endometriosis, fibroids, and even pancreatitis, result in an
increased CA 125, as does _________.
11. AFP is alpha fetoprotien; LDH is _________; CEA is _________; and hCG is
_________.
12. A CT examination can demonstrate pelvic sidewall masses, lymph node enlargement
in the retroperitoneum, liver metastases, and calcifications, especially when
_________ and _________ contrast is given.
13. Although it cannot always distinguish a malignant process from benign, _________
remains the diagnostic method of choice as a screening technique for adnexal
processes.
14. The effective method to investigate for ovarian cancer includes _________
ultrasound, _________ examination, and the tumor marker _________.
15. To determine pelvic mass from possible bowel, _________ must be identified.
16. Ovarian metastatic masses are usually bilateral and more common on the _________
side.
17. Fallopian tube neoplasms are rare and frequently malignant and often confused with
_________ malignancies.
18. One of the most lethal forms of cancer is ovarian because it is frequently diagnosed
in _________ stages of the condition.
19. Exploratory _________ remains the gold standard in visualization of adnexal
malignancy. _________ is helpful in staging ovarian cancer.
20. Eighty percent of ovarian malignancies originate from the ________ covering the
ovaries.
98
Short Answer
1. Discuss factors that determine the prognosis of ovarian cancer.
2. In what way is breast cancer related to ovarian cancer?

3. A 54-year-old gynecological patient complaining of bloating and increasing
abdominal girth and whose laboratory values for proteins and hormones is
increased may be suspicious for _______. What are the three substances cancer
cells produce that laboratory testing searches for? What term is given to these
substances?
4. Discuss laboratory assays utilized in the detection of ovarian cancer. Consider

increased levels as well as declines.
5. A 62-year-old menopausal woman complains to her gynecologist of dull pain in her

inferior pelvis. State current diagnostic tools available to investigate and determine
her condition.
99
1. Name the structure visualized in images A and B. Identify the structure the open arrow
is pointing to in image A and B. Describe what the long arrows are pointing to in
image B. What transducer was used to obtain these images?
2. Name the view and organs imaged. Describe what the small open arrow, thin arrow,
thick arrow, and large open arrow are depicting.
100
3. A patient with known ovarian cancer complained of abdominal pressure and

submitted to an abdominal ultrasound. View the four images. A and B demonstrate
the right upper quadrant in transverse and longitudinal views. C displays the inferior
abdomen/superior pelvis. D shows pleural space superior to the liver. Name a
likely diagnosis.
4. Describe the appearance of this case of ovarian cancer.
101
5. Name the imaging technique used in these images. Describe image A and compare to
image B.
CASE STUDY
1. A 48-year-old smoker of 30 years presented to her doctor with the complaint of

incessant coughing. An AP/Lateral chest radiograph was ordered. View the image,
noting the mass (arrowhead). A biopsy diagnosed the mass as lung carcinoma. The
patient had additional testing that included a brain, chest, abdomen, and pelvic CT
for staging, pelvic ultrasound, and laboratory values. Explain where metastases may
occur in the female pelvis and a likely cancer type in this region.
102
2. A 14-year-old presented to her gynecologist stating that she had been suffering right
side pelvic pain. Also noted was a history of menarche at the age of 12 that ceased
after 1 year. The physical exam discovered a right pelvic mass. Ultrasound of the
pelvis was requested. Review image A, the surgical depiction, and image B, the
ultrasound counterpart. Describe the appearance of the structure in image B. Make a
diagnosis.
103
Pelvic Inflammatory Disease and

Endometriosis
CHAPTER 11

visit the point.

Matching

a. Presence of endometrial glands and
tissue found in the uterine wall
b. Painful menstruation
c. Painful intercourse
1. _________ pyosalpinx d. Implants of endometrial tissue outside the
uterus
2. _________ oophoritis
e. Blood-filled cyst located on the ovary
3. _________ tuboovarian abscess (TOA)
f. Bacterial infection of the endometrium
4. _________ tuboovarian complex with potential extension into the
5. _________ adenomyosis surrounding (parametrial) tissues
6. _________ Fitz-Hugh-Curtis syndrome g. Rare complication of PID resulting in the
7. _________ dysmenorrhea development of liver adhesions due to
the inflammatory exudates. aka
8. _________ salpingitis perihepatitis
9. _________ endometriosis h. Myometrial inflammation
10. _________ myometritis i. Infection of the ovaries
11. _________ pelvic inflammatory diseasej. Infection of the connective tissue
(PID) surrounding the uterus
12. _________ dyspareunia k. Infection of the female reproductive tract
13. _________ endometritis l. Pus within the fallopian tube
14. _________ endometrioma m. Infection of the peritoneum
15. _________ parametritis n. Infection of the fallopian tube
16. _________ peritonitis o. Infection found in the late stages of PID,
resulting in inability to differentiate
tubal and ovarian structures
p. The ability to identify the ovary and tube
in the presence of adhesions or infection
104

Image Labeling
Microorganisms and pathways of pelvic infections

Common sites for endometriosis
Process involving endometrial cell growth into the myometrium
105
CHAPTER REVIEW
Multiple Choice
1. Pelvic inflammatory disease is:
a. scarring of the fallopian tube epithelium due to injury
b. thickening and redistribution of endometrium due to injury or infection
c. a process of heavy, painful bleeding caused by inflammation
d. infection of the female genital tract causing diffuse inflammation
2. One incident of PID can increase the risk of tubal factor infertility and ectopic
pregnancy:
a. two times
b. four times
c. six times
d. ten times
3. BV is:
a. bacterial vaginosis
b. basal vein
c. bleeding vaginally
d. bacteria vaginismus
4. Pelvic inflammatory disease is mostly caused by:
a. sputum transmission
b. blood transmission
c. airborne transmission
d. sexual transmission
5. Select the “gold standard” imaging method for diagnosing PID:
a. MRI
b. ultrasound
c. CT
d. PET
6. Fitz-Hugh-Curtis syndrome is caused the peritonitis and includes what organ:
a. pancreas
b. spleen
c. liver
d. ovaries
7. Early PID sonographic findings are:
a. edematous fallopian tube wall, large amount of pelvic free fluid
b. enlarged ovaries, hydrosalpinx
c. TOA
d. mild uterine enlargement, indistinct margins of pelvic structures, and a
heterogenous, thickened endometrium
8. Most PID patients are:
a. adolescent/early teen years
b. young women of reproductive years
c. premenopausal age 35 to 50
d. postmenopausal
9. Define tubo-ovarian complex:
a. tuboovarian complex refers to the affected ovary and tube that are adherent to one
another, but their individual architecture is still identifiable on ultrasound
b. ovarian and tubal structures cannot be seen separately on ultrasound evaluation
c. pus within the fallopian tube and infection of the peritoneal covering of the ovary
d. infection of the female reproductive tract
10. Chronic progression of endometriosis can lead to all but the following:
a. severe cyclic pelvic pain
b. infertility
c. simple cysts
d. invasion of organs
11. Endometriosis is known to affect:
a. all menstruating females
b. reproductive age females
c. perimenopausal females
d. postmenopausal females
12. Endometriosis _________ transforms into malignancy.
a. rarely
b. never
c. usually
d. always
106
13. Introduction of an intrauterine device may elevate the risk for PID following
insertion for:
a. 1 to 3 days
b. 3 weeks
c. 5 to 10 days
d. 1 month
14. Endometriomas appear sonographically thick-walled, spherical masses, and
frequently (95% of the time) displaying:
a. low-level internal echoes (“ground glass” appearance)
b. a singular simple cystic appearance
c. hypoechoic “bubble” appearance
d. internal finger-like projections
15. Hydrosalpinx develops when:
a. ovaries enlarge and blockage of the fallopian tube occurs distally
b. pelvic infection migrates through the uterus
c. fluid accumulates within a scarred, obstructed fallopian tube
d. pus develops within the infected fallopian tube
16. Ultrasound is the imaging modality of choice for viewing pelvic structures. When
findings are equivocal, what other imaging method is preferable for viewing and
accurate diagnosis?
a. CT
b. PET
c. MRI
d. laparoscopy
17. Select the least likely method of treatment used for chronic pain caused by
endometriosis:
a. NSAIDs
b. narcotic analgesics
c. oral contraception
d. continuous progestins
18. Laparoscopy is a tool used in diagnosing endometriosis. It can also:
a. treat the condition
b. suggest the best curative method
c. administer direct palliative medications
d. worsen the condition
19. The most effective treatment for patients suffering from severe endometriosis who do
not respond to conservative surgical management and medical therapies is:
a. narcotic analgesics
b. aromatase inhibitors, selective progesterone receptors modulators, and TNF-α
inhibitors
c. angiogenic ablation
d. oophorectomy with or without uterine conservation
20. The common symptoms of adenomyosis are:
a. sporadic intense pelvic pain
b. abnormal bleeding, secondary dysmenorrhea, enlarged, tender uterus
c. foul vaginal odor, vaginal discharge
d. diarrhea, constipation, lower back pain
Fill-in-the-Blank
1. The most likely area for PID to develop is _________, also known as _________.
2. The three major sequelae of PID are _________, _________, and _________.
3. Endometriosis implants are located in the _________, usually involving the
_________ and posterior cul-de-sac.
4. The two most common polymicrobes related to PID are _________ and _________.
5. Frequent symptoms of PID are _________ and _________; more specifically,
constant dull pain and _________ tenderness.
6. PID patients in acute pain may not be able to tolerate a full bladder; therefore,
_________ scanning with Doppler capability is necessary for a quick and accurate
diagnosis.
7. The presence of endometrial glands and tissues in the uterine wall is _________.
8. The most common infection of the lower genital tract in women of reproductive age is
_________.
107
9. Some patients with PID exhibit _________ fluid; although, _________ fluid or fluid
with dependent low-level echogenicity is indicative of _________ accumulation.
10. Focal-cystic implants of endometriosis are known as _________ or _________ and
usually measure _________ cm.
11. Endometriomas display _________ flow around and not within when viewed using
color Doppler.
12. A conservative treatment method for endometriosis includes _________ and
_________.
13. Endometriosis is a _________ condition. The intent of therapeutic intervention is to
decrease pain and _________ and elimination of disease recurrence.
14. A uterine condition in which endometrial _________ and _________ are located
within the uterine myometrium proximal to the basalis layer of the endometrium is
adenomyosis.
15. Tubo-ovarian complex results from the escape of _________ beyond the tube.
16. Adenomyosis is generally considered a variant of _________.
17. A highly sensitive and specific imaging method for diagnosing adenomyosis is
_________.
18. Pelvic inflammatory disease is most prevalent in _________ adolescents.
19. If color Doppler flow is visualized within an endometrioma, _________ must be
suspected.
20. A tube affected by PID is more likely to be found within the _________ aspect of the
pelvis in contrast to enlarged ovarian structures that are often found _________ to
the normal uterus.
Short Answer
1. Discuss the migration and stages of PID.
2. A 19-year old presents to her gynecologist with an off-white discharge and 1 week of
low pelvic pain following spring break from college. She admits to being sexually
active. What additional symptoms would be helpful to diagnose PID?
3. A strong family history of endometriosis existed in a 28-year old with constant dull
pelvic pain that worsened during menstruation. Explain endometriosis, symptoms,
and its stages.
108
4. A G3 P3 40-year-old married female, who is faithful to her husband, with complaints

of continual tenderness in the pelvis and erratic bleeding. Her physician reports
guarding and uterine enlargement upon physical examination. Based on symptoms
and examination observation, is PID, endometriosis, or adenomyosis a more
accurate pre-imaging diagnosis?
1. Label the structure depicted by the open arrow. What is the long arrow pointing to?
What type of Doppler was used to collect the image?
2. State the measured structured and view. If the radiologist desires measurements to be
hand recorded as tenths following the decimal, how should the measurements be
written?
109
3. Identify the measured structure and the structure depicted by the arrow.
4. View the image and identify the process by its “typical” appearance.
5. Identify the process in the image.

110
CASE STUDY
1. A 34-year old with known endometriosis has returned to her gynecologist for
evaluation of increasing pelvic pain. Over several years, she has tried conservative
treatment as well as surgery. Pain decreased following surgical excision 2 years
ago, but is now unbearable. An ultrasound was ordered. View the study and
diagnose the patient’s condition.
2. This G3 P3, 38-year-old patient was diagnosed with endometriosis 5 years ago. She
recently suffered painful menstruation and irregular bleeding for 18 months before
scheduling an appointment with her gynecologist. After physical exam, the doctor
requested EV ultrasound because of the patient’s complaints and a finding of
enlarged uterus. Review the images and identify anatomy that explains the diagnosis
of adenomyosis that this patient received. State other imaging modalities that can
ensure an accurate diagnosis.
111
Assisted Reproductive Technologies

(ARTs), Contraception, and Elective
Abortion
CHAPTER 12

visit the point.

Matching

a. Clinical treatments and laboratory
procedures used to establish a
pregnancy. This includes treatments in
which both eggs and sperm are handled
but, in general, would exclude the
treatment if eggs are only stimulated and
not retrieved, or if only the sperm are
handled
b. Transfer of embryo 5 to 6 days after
fertilization
c. Transfer of embryo 2 to 3 days after
fertilization
d. Fertility medication used for controlled
ovarian hyperstimulation of a single or
multiple follicles
e. Process that promotes the development of
single or multiple follicles in the ovary
using clomiphene citrate, letrozole, or
gonadotropins
f. Process, usually using liquid nitrogen, to
freeze embryos or gametes
g. In vitro fertilized embryo transfer into the
uterine cavity at the cleavage (2 to 3
days after fertilization) or blastocyst (5
to 6 days after fertilization) stage
h. Primary hormone produced by ovarian
follicles in women of childbearing age
i. Period during which the viability and
survivability of both oocytes and sperm
1. _________ blastocyst transfer
are maximum; refers to the 4- to 5-day
2. _________ intrauterine contraceptive interval ending on the day after ovulation
device (IUD or IUCD)
j. The capacity to produce offspring
3. _________ periovulatory period
k. First half of the ovarian cycle
4. _________ clomiphene citrate characterized by high levels of
5. _________ in vivo fertilization circulating follicle-stimulating hormone
6. _________ theca lutein cysts (FSH), which result in ovarian follicle
maturation
7. _________ cryopreservation
l. An ART option rarely used, where the
8. _________ infertility sperm and ova (i.e., gametes) are placed
9. _________ secretory phase directly in the ampullary portion of the
10. _________ estradiol fallopian tube for in vivo fertilization
11. _________ intracytoplasmic sperm m. Hormone produced by the trophoblastic
injection (ICSI) cells of the normal developing placenta
or by abnormal germ cell tumors, molar
12. _________ subfertility pregnancies, and choriocarcinoma
13. _________ controlled ovarian n. Product inserted into the uterine cavity as
hyperstimulation (COH) a mechanism to prevent pregnancy
14. _________ in vitro fertilization (IVF) o. Process whereby ova and sperm come
15. _________ proliferative phase into contact outside the body and fuse to
form a zygote from extracted ova and
_________ assisted reproductive sperm in a laboratory setting
16. technologies (ART)
p. Process whereby ova and sperm come
17. _________ human chorionic into contact within the body and fuse to
gonadotropin (hCG) form a zygote
18. _________ ovarian reserve q. Failure to achieve a pregnancy after 12
months or more of regular unprotected
112 intercourse
r. Injection of a single sperm into an ovum
19. _________ cleavage-stage embryo
s. Placement of seminal fluid-free sperm
20. _________ intrauterine insemination
through the cervix directly into the
(IUI)
uterine cavity
21. _________ ovulation induction
t. Second half of the ovarian cycle, when
22. _________ fertility the corpus luteum secretes high levels of
23. _________ menstrual phase progesterone that acts on the
24. _________ fertile window endometrium
25. _________ luteal phase u. First 5 days of the menstrual cycle,
characterized by endometrial shedding
26. _________ follicular phase
v. Coil placed in the fallopian tube,
27. _________ microinsert resulting in tissue growth and
28. _________ gamete intrafallopian obliteration of the lumen and thereby
transfer (GIFT) providing a means of contraception
29. _________ ovarian hyperstimulation w.Excessively severe response to
syndrome (OHSS) ovulation induction therapy, requiring
30. _________ embryo transfer (ET) hospitalization
x. Begins with the administration of fertility
medications that induce the development
of one or multiple follicles. When
follicles reach an optimal size, a trigger
such as hCG is administered to induce
the follicle to mature further to release
its ovum.
y. Estimation of a woman’s remaining
follicles
z. Time just before and after midcycle
during which the endometrium may
demonstrate a range of appearances
spanning across both the proliferative
and secretory phases
aa.Portion of the menstrual cycle during
which endometrial tissue proliferates. It
overlaps the menstrual phase and
extends through midcycle
bb.Enlarged ovaries with multiple cysts
due to abnormally high levels of hCG
cc.Portion of the menstrual cycle
characterized by an increase in
circulating progesterone and during
which endometrial tissue is thickest and
prepared for embryo implantation
dd.Condition of being less than normally
fertile, though still capable of achieving
pregnancy
113

Image Labeling
Infertility etiologies that may be overcome through assisted reproductive technologies
114
Process of conception
115
Menstrual cycle phases
116
Birth control method
U.S. intrauterine devices
117
CHAPTER REVIEW
Multiple Choice
1. Infertility is the failure to produce a pregnancy with unprotected intercourse after:
a. 4 months
b. 8 months
c. 12 months
d. 2 years
2. Sonographic assessment of the male _______________ may help to assess and
diagnose infertility in a couple.
a. scrotum
b. epididymis
c. vas deferens
d. accessory glands
3. Administration of clomiphene citrate is monitored by ______________________ to
observe ovarian response.
a. laboratory levels and basal temperatures
b. ovulation test results
c. ova and semen analysis
d. EV sonograms and serum hormone levels
4. A fertilized egg is initially known as a:
a. blastocyst
b. gamete
c. zygote
d. trophoblast
5. What is the fluid-filled cavity that develops within primary follicles and is
sonographically visible?
a. cumulus oophorus
b. antrum
c. Graafian follicle
d. granulosa cells
6. The second half of the ovarian cycle is the:
a. follicular phase
b. luteal phase
c. ovulatory phase
d. luteum phase
7. The endometrium is thinnest during the:
a. menstrual phase
b. proliferative phase
c. periovulatory phase
d. secretory phase
8. The dominant follicle grows approximately _______ daily, in the 4 to 5 days
preceding ovulation.
a. 9 to 10 mm
b. 6 to 7 mm
c. 3 to 4 mm
d. 1 to 2 mm
9. When determining the antral follicle count (AFC) for an infertility patient, only
follicles between _____________ are tallied.
a. 1 to 2 cm
b. 0.5 to 1 cm
c. 4 to 8 mm
d. 20 to 100 mm
10. The syndrome associated with irregularly timed menstrual cycles, elevated androgen
levels, often manifested by increased hair growth, hair loss, and acne is:
a. Ovarian Entrapment Syndrome (OES)
b. Polycystic Ovary Syndrome (PCOS)
c. Luteinized Unruptured Follicle Syndrome (LUF)
d. Female Reproductive Syndrome (FRS)
11. Normal endometrial thickness varies from _________ through the menstrual cycle
during the reproductive years.
a. 0.5 to 1.5 cm
b. 1 to 15 mm
c. 1 to 2 cm
d. 3 to 14 mm
12. Polyps, myomas, synechiae, retained products of conception, endometrial
hyperplasia, and carcinoma can best be viewed using:
a. saline infusion sonohysterography
b. EV sonography
c. TV sonography
d. TA sonography
13. Distortion of the uterine cavity, interference of uterine/endometrial blood flow, tubal
ostia occlusion are mostly related to:
a. an abnormal septum
b. mucus collection
c. submucosal fibroids
d. adenomyosis
118
14. The preferred imaging method to ensure fallopian tube patency is:
a. MRI
b. SIS
c. laparoscopy
d. HSG
15. The prevailing reason for male infertility is:
a. varicoceles
b. testicular failure
c. idiopathic causes
d. vasoepididymal obstruction
16. The most common current in vitro fertility method is:
a. ZIFT
b. allowing the embryo to develop for several days after ovum extraction and
fertilization, then transferring transcervically to the uterus
c. GIFT
d. ET
17. Intracytoplasmic sperm injection (ICSI) is:
a. the injection of one sperm into the cytoplasm of one egg
b. in vivo method of inseminating a single ovum via fallopian tube
c. a technique that treats immobile sperm intratesticular to increase progressive
motility
d. extraction of ova cytoplasm followed by sperm injection and replacement
18. Choose the sonographic stage related to ovarian follicular monitoring:
a. baseline
b. follicular phase
c. periovulatory period
d. OHSS
19. Which statement is not a complication of clomiphene of gonadotropin usage?
a. OHSS
b. multifetal gestation
c. singleton gestation
d. electrolyte imbalance
20. The stage of an embryo at 2 or 3 days after fertilization is known as:
a. gamete
b. zygote
c. blastocyst
d. cleavage
21. A reproductive endocrinologist uses a container responsible for moving embryos
into the uterine cavity. The container is a:
a. speculum
b. TV biopsy guide
c. indwelling catheter
d. transfer catheter
22. EV sonography is utilized to detect a gestational sac:
a. 3 weeks after fertilization
b. at 6.5 weeks from LMP
c. 5.5 weeks after egg retrieval/fertilization
d. post LMP 4 weeks
23. Prior to sonographic visualization of IUDs, what imaging method was utilized to
check placement?
a. MRI
b. CT
c. radiography
d. SIS
24. Essure is a permanent birth control. Where is it inserted?
a. fallopian tube
b. ovarian artery
c. cervix
d. fornix
25. Select the IUD that releases synthetic hormones to prevent pregnancy:
a. ParaGard
b. Lippes Loop
c. Essure
d. Mirena
Fill-in-the-Blank
1. Couples who have etiologies of infertility that may in fact produce a pregnancy with
assistance are known as _________ or _________.
2. Diagnosing _________ anomalies and _________ of the uterus, tubes, and ovaries
that lead to infertility is frequently performed by sonography.
3. COH is frequently linked with timed _________, _________, or _________ to
achieve pregnancy.
119
4. The normal ovarian/menstrual cycle lasts _________ days, beginning on the first day
of a woman’s menses and extending to the _________ day of her next menses
5. Day 14 of the menstrual cycle is usually when _________ occurs.
6. The corpus luteum begins to degenerate about _________ days after ovulation if
fertilization does not occur.
7. A surge in _________ causes the dominant follicle to rupture, at which time the
_________ will erupt from the ovary.
8. The mean diameter of a dominant follicle, at the time of ovulation, is _________.
9. _________ acquisition can provide automated counting of follicles.
10. A “string of pearls” is associated with _________ and increased surface area.
11. The endometrium consists of a _________ layer and a _________ layer.
12. The process of developing intrauterine adhesions resulting from postpartum or
postabortal surgical curettage, pelvic inflammatory disease (PID), uterine surgery
(cesarean section or myomectomy), or tuberculosis is called _________.
13. Sonography of the endometrium is able to assess _________, _________ flow,
_________ movements, and presence of intracavitary lesions and of intracavitary
fluid.
14. Adenomyosis is the presence of endometrial tissue within the _________.
15. Semen analysis includes sperm _________, _________, and _________.
16. The classic appearance of multiple tubular veins superior to the testes that can
contribute to infertility is described as _________.
17. Once follicles are considered to be mature, _________ is administered to induce
ovulation.
18. An endometrial thickness of more than _________ millimeters (mm) results in
improved pregnancy outcomes.
19. Varicocele is determined by _________ or more veins measuring _________ mm or
greater with or without the Valsalva technique.
20. The process by which a physician injects saline into one or more of the gestational
sacs, selectively aborting particular sacs yet preserving the rest of the gestation, is
_________.
21. The two IUD types marketed in the United States that are well known and provide
reversible contraception are _________ and _________.
22. An IUD that moves from the uterine endometrium is known as _________.
23. The Essure microinsert is _________-shaped and once inserted, requires
_________ months to completely block the fallopian tube.
24. If pelvic infection occurs with implantation or long-term use of an IUD, immediate
_________ is suggested.
120
Short Answer
1. A female fertility patient presents for ovarian reserve assessment. Explain what she
should expect.
2. Discuss the EV appearance of the normal uterine endometrium during the three phases
of the menstrual cycle.
3. A couple who has been infertile for 2 years is seeking medical help. Testing has
determined the sperm concentration to be slightly low. Explain the most likely and
probably least costly process to assist with their infertility.
4. A patient who had an IUD placed 2 years ago is now unable to locate the string during
her monthly string check. What may cause the inability to detect the string, and what
is the best method to reveal the IUD position?
5. A female complaining of severe abdomen pain presents to the emergency room.

Laboratory tests and routine abdomen/pelvis radiographs are ordered to assist with
diagnosis. The inferior midpelvis radiograph demonstrates a “bright” circular
artifact in the inferior midpelvis. Provide a likely explanation for the artifact.
1. Identify the image depicted by the arrow and anatomy with a star. Is blood flow
documented? What imaging method was used to collect this image?
121
2. State the anatomy, laterality, and view of this image. What are the structural
dimensions? State what the stars are identifying.
3. Analyze the image of a sagittal lower uterine segment and cervix.

4. Identify the pathology seen surrounding the star. What are the arrows pointing to?
122
5. Define the images. What is an abnormal measurement for the structure depicted by the
arrow?
CASE STUDY
1. A G2 P2 patient who is now caring for her 2-year-old daughter and 6-month-old son
had a Mirena placed 6 weeks postpartum. Her gynecologist advised a monthly check
for strings. Just recently, she was unable to locate the string. The gynecologist was
unable to see the string. An ultrasound was ordered to identify the IUD position.
Offer a diagnosis based on the image.
123
2. This 33-year-old G4 P3 patient committed to irreversible contraception by utilizing an
Essure microinsert contraceptive device. Six months after the devices were
inserted, a typical ultrasound was ordered to document normalcy. Develop an
ultrasound report for the patient’s gynecologic surgeon after viewing the image.
124
125
Complementary Imaging of the Female

Reproductive System
CHAPTER 13

visit the point.

Matching

a. Commonly used MRI contrast agent
b. Utilizing mixed imaging parameters (T2
and T1) to create an optimal image
c. Having an intensity or brightness greater
than surrounding structures
d. Set of parameters used to create a
1. _________ high signal intensity specific type of image (T1, T2, T2 FS)
2. _________ time to repetition (TR) e. Time between the application of the 90
3. _________ hypointense degree pulse and the peak of the echo
signal
4. _________ sequence(s)
f. Commonly used MRI technique to
5. _________ graded compression
suppress signal from fat tissue
6. _________ hyperintense
g. Signal that depicts brightness on the MRI
7. _________ fat saturation (FS) image
8. _________ isointense h. Time between pulses in a series of pulses
9. _________ gadolinium for a single image
10. _________ Magnetic resonance i. Technique of applying pressure
imaging (MRI) weightings (weighted (compression) to displace structures
image) such as bowel to bring intra-abdominal
structures within the focal zone
11. _________ hybrid imaging
j. Having an intensity or brightness less than
12. _________ time to echo (TE) that of surrounding structures
k. Having the same image intensity as that of
surrounding structures
l. Arrangement of radio frequency pulses
and gradients that combine to create an
image
126

Image Labeling
MRI unit
CHAPTER REVIEW
Multiple Choice
1. Choose the imaging modality with the largest field of view.
a. MRI
b. CT
c. US
d. both MRI and CT
2. MRI is based on the ability to manipulate _____ ions.
a. cation
b. hydrogen
c. negative
d. chromium
3. Name the device responsible for transmitting radiofrequency within the MRI unit.
a. NMV
b. gradient coil
c. antenna
d. magnetic field
4. T2 and T1 are types of MRI:
a. weighting
b. images
c. values
d. displays
5. The MRI technique to selectively remove signal from adipose protons is:
a. TE
b. TR
c. FS
d. NMV
6. Recently, research has shown that gadolinium can accumulate in the human:
a. liver
b. spleen
c. brain
d. kidneys
127
7. CT attenuation is the _____ of intensity as radiation passes through a patient.

a. gradual loss
b. gradual increase
c. coefficient
d. value
8. What are the measurement units, from white to black, that CT uses to display images?
a. Duplex
b. Range
c. Monochrome
d. Hounsfield
9. Select the modality that offers the best tissue differentiation:
a. US
b. CT
c. MRI
d. CT and MRI
10. Vaginal agenesis can be responsible for:
a. septa
b. hematometrocolpos
c. Gartner’s duct cysts
d. a homogeneous MRI image
11. A malignant multilocular cervical cyst is known as:
a. adenoma malignum
b. cervicitis
c. tunnel cluster
d. endocervical hyperplasia
12. Name the imaging modality initially used to locate uterine fibroids:
a. US
b. CT
c. MRI
d. CT and MRI
13. ________ is used most often to predict the response of fibroids to uterine artery
embolization.
a. US
b. CT
c. MRI
d. CT and MRI
14. MRI adds extensive diagnostic data to uterine studies by displaying how many
distinct soft tissue zones?
a. two
b. three
c. four
d. five
15. MRI T2 imaging displays simple ovarian cysts and simple paraovarian cysts as:
a. high signal
b. intermediate signal
c. low signal
d. fat saturation signal
16. Select an advantage that CT imaging has over MRI imaging as a complementary
modality to ultrasound.
a. no radiation exposure
b. faster image acquisition
c. extensive multiplanar positioning
d. superior tissue differentiation
17. Dehiscence is seen:
a. within the fundal endometrium
b. within the fundal myometrium
c. at the level of the external os
d. lower uterine segment
18. The two most likely modalities to demonstrate cervical competence are:
a. CT, MRI
b. CT, US
c. US, MRI
d. MRI, CT
19. Graded compression is a(n) _______ technique and that is helpful in locating the
_______ :
a. US, appendix
b. CT, fallopian tubes
c. CT, adnexal fibroids
d. MRI, pelvic hernia
20. Choose the reason why uterine müllerian duct errors are imaged with MRI.
a. It displays related anomalies such as kidney and vertebral body involvement
b. Its strength in evaluating soft tissue uterine configurations
c. Its ability to image the difficult body habitus
d. The cost factor
128
Fill-in-the-Blank
1. Unlike radiation-based imaging techniques such as CT and X-ray, MRI has presented
no _________.
2. A group of parameters used to create a specific type of image is known as MRI
_________.
3. MRI is an ever-evolving imaging modality that continues to prove itself as a
_________ imaging tool to evaluate the fetus, obstetric, and gynecologic patient.
4. MRI imaging relies on the ability to manipulate _________ protons contained in
water within the body tissues.
5. MRI contrast administration of _________ during pregnancy is controversial.
6. CT imaging risks decrease into the _________ trimesters; however, research has
shown that a slightly increased risk of childhood cancer is associated with radiation
in utero.
7. An MRI exam is _________ compared to CT and US.
8. Appendicitis on MRI shows an appendiceal diameter greater than _________ mm,
wall thickness greater than _________ mm, high signal intensity contents on T2-
weighted images, and surrounding _________.
9. MRI cannot visualize nonhydrogen structures in the pelvis such as _________ or
_________ devices.
10. Although the contribution of MRI in the evaluation of fetal abnormalities adds details
that US was unable to resolve, it is only used in _________ to _________% of the
uncertain cases.
11. Incomplete _________ of the endometrium and myometrium with an intact serosal
layer characterizes uterine dehiscence.
12. The diagnosis of cystic teratoma is reasonably unequivocal because of the
_________ within the mass, which MRI detects with specific FS sequences.
13. MRI diagnosis of endometrioma is based on the detection of _________ products of
different ages within a unilateral or bilateral adnexal mass.
14. Fallopian tube fibroids are best characterized with MRI because this complementary
modality can define the _________ location because of its exceptional tissue
differentiation ability.
15. MRI is capable of defining a polyp from a _________ mass. CT demonstrates
endometrial cavity masses as _________ findings.
16. An advantage of MRI as compared to US of the uterine myometrium and
endometrium is MRI’s ability to depict defined _________.
17. Ultrasound is an excellent imaging modality for evaluating the uterine endometrium,
especially the _________ approach.
18. Lesions related to adenomyosis appear as poorly defined hypointense regions
involving the endometrium and continuing to the _________ on MRI.
129
19. The modalities _________, and _________ are capable of viewing anatomy in many
planes, which include orthogonal and oblique.
20. Both _________ and _________ are widely utilized for cancer staging.
Short Answer
1. Compare US, MRI, and CT imaging of the uterine endometrium.
2. Consider US and MRI in the pregnant female when appendicitis is suspected.
1. Is image A T2 or T1? Is image B T2 or T1? What structure is the left arrow pointing
toward in both images? What structure is the right arrow pointing toward in both
images?
130
2. Name the structure the arrows are directed toward in both images.
3. What is the uterine position?
131
4. Name the uterine position. What is the anatomic region depicted by the arrows? What
is a likely diagnosis?
5. Name the uterine position.
132
6. Is image A T2 or T1? Is image B T2 or T1?

Name the imaged structure.
What is seen within (arrow)?
7. What are the arrows directed toward in the image?
133
CASE STUDY
1. A 27-year-old G3P0 woman is investigating the reasons for repeated miscarriage. Her
physician offered MRI after a transabdominal ultrasound was performed. Describe
the uterus and explain why the patient may have suffered three miscarriages.
2. After viewing the cervix (black double arrow) displaying as dilated near the internal
os with a closed inferior portion (dashed line), diagnose the situation. Note the
image shows a twin pregnancy.
134
135
PART TWO
OBSTETRIC SONOGRAPHY
Principles of Scanning Technique in

Obstetric Ultrasound
CHAPTER 14

visit the point.

Matching

a. The amount of transmitted energy by the
ultrasound beam. The higher the
frequency, the lower the mechanical
index or MI; thus, the lower the
frequency, the higher the MI.
1. _________ Aortocaval compression b. Pregnancy outside of the uterus
syndrome (supine hypotensive c. Entrapment of the umbilical cord
syndrome) between the presenting fetal part and the
2. _________ ectopic pregnancy cervix
3. _________ mechanical indices d. Compression of the aorta and inferior
vena cava (IVC) by the gravid uterus,
4. _________ thermal indices resulting in symptoms of nausea,
5. _________ vasa previa hypotension, lightheadedness, and
6. _________ placenta previa syncope
e. Condition where the placenta
implantation is low in the uterus and
will deliver before the fetus
f. The output power indication of the
amount of acoustic power it takes to
raise the temperature of tissue by 1 °C
136

Image Labeling
Obstetric examination report pages
137
1. State the reported BPD length.
2. State the reported EFW.

3. State the FL SD.
4. State the time the page 1/2 was printed.
5. State the biophysical profile total.
6. State the cervical length.
Obstetric EFW report pages
7. State the ultrasound MA.
8. State the approximate fetal weight at 34 weeks.
138
CHAPTER REVIEW
Multiple Choice
1. Select the incorrect statement. A moderately filled bladder is useful:
a. when assessing competency of the internal os
b. in determining placental position relative to the os when there is a low-lying
placenta
c. in displacing a low fetal head upward into a position where the BPD can be
measured
d. in determining cervical dilation
2. Aortocaval compression syndrome results in all except:
a. nausea
b. teary eyes
c. feeling faint
d. fidgeting
3. The cause of aortocaval compression syndrome is:
a. drinking cold water before an ultrasound examination
b. moving from the erect to the supine position too quickly
c. compression of the great vessels
d. lying supine with a pillow under one or the other side
4. Aortocaval syndrome usually occurs after:
a. 12 weeks’ gestation
b. 15 weeks’ gestation
c. 17 weeks’ gestation
d. 20 weeks’ gestation
5. Endovaginal examinations may be necessary in all except:
a. situs
b. a 12-week pregnancy
c. evaluation of presenting fetal parts
d. vasa previa
Fill-in-the-Blank
1. A moderately filled bladder enhances visualization of the internal os by providing
an _________ view of that area.
2. The umbilical cord presenting between a fetal part and the cervix is _________.
3. The sonographer should establish an _________ routine for scanning.
4. If a patient is obese, and therefore the fetus is far from the transducer face, a
_________-frequency transducer will optimize imaging.
5. It is the consensus of the Consensus Development Conference on Diagnostic
Ultrasound Imaging in Pregnancy panel that ultrasound examination in pregnancy
should be performed for a specific _________ indication.
6. It is the conclusion of NIH that no deleterious effects have been demonstrated as
resulting from the use of _________ ultrasound, either 2D or 3D, but that it should
continue to be used _________.
7. An adequately filled bladder allows for imaging of the _________ and the lower
_________ edge.
8. _________ ultrasound in the first trimester should be used only when medically
indicated.
139
9. High _________ and _________ increase potential bioeffects to the embryo and fetus.
10. A spatial-peak-temporal-average (SPTA) below _________ for an unfocused beam
decreases the possibility of bioeffects.
Short Answer
1. Discuss the effect of 3D ultrasound on expectant parents.
2. Name reasons endovaginal ultrasound in pregnancy and postpartum patients is

recommended.
1. Explain the left and right images.
140
2. Label the four long thin arrows, short thick arrow, short thin arrow, and long thick
arrow.
CASE STUDY
1. A G3P3 patient who is 7 weeks postpartum telephones her obstetrician stating that she
is discharging clots vaginally. An ultrasound of the uterus was ordered. Diagnose
the image.
141
The Use of Ultrasound in the First

Trimester
CHAPTER 15

visit the point.

Matching

a. Area located in the head of the sperm
containing enzymes to aid in penetration
of the oocyte
b. Membrane enclosing the amniotic cavity
and embryo or fetus
c. Abnormal number of chromosomes
d. Early gestation consisting of a thin outer
layer of cells (trophoblast), a fluid-filled
cavity, and an inner cell mass
(embryoblast)
e. Membrane around the chorionic cavity,
made up of trophoblast cells and
extraembryonic mesoderm
f. Bud-like outward growths from the
trophoblast, some of which will give
rise to the fetal portion of the placenta
g. Duration of pregnancy counted from
fertilization (conception) expressed in
hours or days. Also called embryonic
age or postovulatory age
h. Product of fertilization including all
stages from zygote to fetus
i. Progesterone-secreting structure formed
by a follicle after releasing its oocyte
j. Measurement of longest axis of an embryo
determines gestational age
k. Due date, calculated by adding 280 days
to the first day of the last menstrual
period, also called estimated date of
confinement (EDC)
l. Changes in the endometrium to allow
implantation of a blastocyst
m. Group of hormones, primarily produced
in the ovaries, which affect secondary
sex characteristics and the menstrual
1. _________ estrogen cycle
2. _________ mean sac diameter (MSD) n. Penetration of an oocyte by a sperm to
3. _________ yolk sac (synonym: umbilical form a diploid zygote
vesicle) o. Hormone produced in the anterior
4. _________ decidualization pituitary, which stimulates the
maturation of ovarian follicles
5. _________ luteinizing hormone
p. Haploid cell that when merged with a
6. _________ umbilical vesicle (synonym:
gamete from the opposite sex creates a
yolk sac)
diploid zygote
7. _________ estimated date of delivery
q. Duration of pregnancy counted from the
(EDD)
first day of the last menstrual period,
8. _________ LMP expressed in weeks and days or
9. _________ spermatozoon (plural: fractions of weeks. A pregnancy
spermatozoa) typically lasts about 280 days or 40
10. _________ crown-rump length (CRL) weeks, counted from the first day of the
11. _________ human chorionic last menstrual period, and is commonly
gonadotropin (hCG) divided into three trimesters:
1st trimester—0 days (first day of last
12. _________ progesterone menstrual period) to end of the 13th
13. _________ corpus luteum week
14. _________ gravidity 2nd trimester—14 weeks to the end of
the 27th week
15. _________ parity
3rd trimester—28 weeks to delivery
16. _________ conceptus
r. First sonographic evidence of an
17. _________ gestational sac intrauterine pregnancy, the fluid-filled
18. _________ morula blastocyst
s. Number of times a woman has been
142 pregnant
19. _________ conceptual age t. Hormone produced by trophoblast cells
of the blastocyst that extends the life of
20. _________ gestational age (GA, the corpus luteum in the ovary. Most
synonym: menstrual age) pregnancy tests are based on detection of
21. _________ pregnancy associated hCG
plasma protein A (PAPP-A) u. First day of last menstrual period
22. _________ chorionic villi v. A hormone produced in the anterior
23. _________ amnion pituitary that triggers ovulation in
24. _________ gamete females
25. _________ oocyte w.Average mean diameter of the
gestational sac used to determine
26. _________ chorion
gestational age
27. _________ follicle stimulating hormone
x. Solid cluster of undifferentiated cells
(FSH)
formed by repeated cleavage of the
28. _________ nuchal transluceny (NT) single cell that resulted from the fusion
29. _________ blastocyst of two gametes
30. _________ acrosome y. Subcutaneous fluid in the posterior region
31. _________ fertilization of the neck of embryos and fetuses up to
14 weeks’ gestational age. Abnormally
32. _________ aneuploidy large nuchal translucencies have been
33. _________ zygote associated with a higher risk of
chromosomal and structural
abnormalities
z. Female gamete, aka ovum or egg
aa.Protein produced by the trophoblasts.
Abnormal levels of PAPP-A may be
associated with an increased risk of
chromosomal abnormalities
bb.Hormone produced by the corpus
luteum and the placenta
cc.Male gamete
dd.A structure within the cavity of the
blastocyst that provides nourishment to
the embryo and produces its first blood
cells. The secondary umbilical vesicle
(yolk sac) is the first structure to be
sonographically identified within the
gestational sac
ee.A structure within the cavity of the
blastocyst that provides nourishment to
the embryo and produces its first blood
cells. The secondary umbilical vesicle
(yolk sac) is the first structure to be
sonographically identified within the
gestational sac
ff. Single cell resulting from the fusion of
two gametes
gg.Summary of a woman’s pregnancy
outcomes. The most common description
of parity is expressed in four numbers.
The first is the number of term
deliveries; the second is the number of
preterm deliveries (usually after 24
weeks of gestational age); the third is the
number of other pregnancies and
includes both spontaneous and
therapeutic abortions; and the fourth
number is the woman’s living children
143
Image Labeling
Fertilization and cell division – Label each box insert and state hours or days of development
Nine-day human blastocyst

144
Uterine embryo implantation
145
End of third week trophoblast and embryo
Five-week embryo
Nuchal translucency measurement – Select letter depicting correct measurement method
146
CHAPTER REVIEW
Multiple Choice
1. A normal gestation lasts approximately:
a. 200 days
b. 280 days
c. 9 months
d. 9.5 months
2. Ultrasound in the first trimester is mostly performed to demonstrate:
a. GA and likelihood of continuing to term
b. EDD and FSH
c. EDD and GA
d. to evaluate a corpus luteum and EDD
3. The head of the sperm cells contains ___________ which house enzymes allowing for
penetration of the outer layer of the ovum.
a. mitochondria
b. nucleus
c. acrosome
d. seminiferous fluid
4. The ______________ hormone triggers ovulation.
a. luteinizing
b. hCG
c. follicle-stimulating
d. estrogen
5. What does not assist the ova to move into and through the fallopian tube?
a. fimbriae
b. contractile walls
c. cilia
d. infundibulum
6. Fertilization generally occurs in the ____________ portion of the fallopian tube:
a. ampullary
b. isthmic
c. fimbriated
d. interstitial
7. What prevents more than one sperm entering an ovum?
a. cytotrophoblast shell
b. zona pellucida
c. exocoelomic
d. mitochondria
8. A cluster or ball of forming cells is a:
a. zygote
b. conceptus
c. morula
d. trophoblast
9. A blastocyst consists of all except:
a. blastocele
b. trophoblast
c. embryoblast
d. blastocyte
10. Preparatory changes in the endometrium allowing for implantation are:
a. decidualization
b. basal reaction
c. implantation window
d. trophoblastic
11. The portion of the endometrium that surrounds the blastocyst:
a. decidua parietalis
b. decidua capsularis
c. decidua basalis
d. decidua vera
12. The yolk sac becomes part of the embryonic gut and contributes to:
a. digestive, respiratory, and urogenital development
b. primitive colon and neurologic development
c. genital and cardiac development
d. amnion and fluid development
13. The first structure seen sonographically within the uterus in early pregnancy is the:
a. yolk sac
b. blastocyst
c. amniotic cavity
d. chorionic sac
14. At what age have the rudimentary forms of all embryonic organs and structures
developed:
a. 8 weeks’ GA
b. almost 11 weeks’ menstrual/gestational age
c. 10 weeks postconception
d. 5 weeks from the LMP
147
15. The placenta will mature from early pregnancy to release all but the following:
a. estrogen
b. hCG
c. luteinizing hormone
d. progesterone
16. Sonography may detect a blastocyst embedded in the decidua as early as ________
after conception:
a. 11 days
b. 21 days
c. 2 weeks + 4 days
d. 2 weeks
17. Choose the correct statement:
a. The primitive heart begins to beat about 27 days after conception.
b. One hundred twenty beats per minute (bpm) is average at 5 weeks.
c. The normal resting heart rate of a third trimester fetus is 110 to 160 beats per
minute (bpm).
d. Cardiac pulsations should be documented in all normal embryos 8 mm or larger.
18. The five brain vesicles, which will become the lateral ventricles, third ventricle, and
the upper and lower parts of the fourth ventricle, and the connections between them
develop from the:
a. prosencephalon and rhombencephalon
b. telencephalon
c. diencephalon
d. mesencephalon and midbrain
19. The most accurate measurement for dating in early pregnancy is the:
a. mean sac diameter
b. maximal sac diameter
c. LMP
d. CRL
20. When the nuchal translucency (NT) measurement is combined with ___________,
the detection rate for trisomy 21 increases to 86%.
a. EDC
b. PAPP-A and free β-hCG
c. biochemical markers
d. human chorionic gonadotropin
Fill-in-the-Blank
1. Spontaneous pregnancy loss usually happens in the _________.
2. Gametes are _________ cells with _________ chromosomes.
3. The whip-like tails of sperm contain _________.
4. The pituitary produces _________, which stimulates the maturation of _________.
5. A ruptured follicle, or corpus luteum, releases _________.
6. Once the ovum is fertilized, the structure is called a single diploid cell, _________,
or _________.
7. _________ hours after fertilization, rapid cell division occurs. It is known as
_________.
8. The developing cluster of cells travels through the fallopian tube and reaches the
uterus about _________ days after fertilization.
9. The two endometrial layers are a thin _________ layer adjacent to the myometrium
and a functional layer of _________.
10. The implantation window begins _________ days after ovulation and lasts
approximately _________ days.
11. Nourishment from the endometrial glands cross the _________ and enter the
_________.
12. A blastocyst’s inner cell mass differentiates into two layers: thick _________
adjacent to the trophoblast, and thin _________ facing the blastocele.
13. The first visualized structure within the gestational sac is the _________.
148
14. First blood cells to the embryo are produced by the _________ and are transferred
to and fro through the _________ veins and arteries.
15. The embryonic disc contains _________ germ cell layers from which all future
organs and _________ is derived.
16. Fetal stage begins following the _________ period after about _________.
17. Fetal placenta occupies the _________ portion of the endometrium, leaving the basal
layer intact.
18. The double sac sign is developed by two layers of deciduas, _________ and
_________.
19. A 5-week yolk sac measures about _________ mm in diameter and enlarges to
_________ mm at 11 weeks, then disappears by _________ weeks’ gestational age.
20. The primitive fetal heart begins beating about _________ after conception.
Short Answer
1. Explain the role of the uterine endometrium at implantation.
2. Discuss and describe quantitative and qualitative pregnancy test results.
3. Explain early sonographic intrauterine pregnancy findings and correlate with dates.
4. Define the necessary components of a first trimester sonogram based on the AIUM
Practice Guideline for the Performance of Obstetric Ultrasound Examinations.
5. An early G1 obstetric patient is confused about information from her doctor stating
how far she has progressed into the pregnancy. Explain the duration of pregnancy
and its divisions to her.
149
1. Name the anatomy in A to G.
2. Name the anatomy the thin and thick arrows are directed toward.
150
3. Describe this image using the correct ultrasound technical terminology.
4. Explain the image that is positioned between braces.

5. Identify the image and labels.
151
CASE STUDY
1. A G1 23-year-old reported to her doctor for vaginal spotting. She was distraught and
wanted to know the condition of her pregnancy. No reason was determined for
bleeding vaginally, although the inexperienced sonographer noted a “bulge” on the
2D profile image. This prompted the sonographer to obtain cross-sectional and 3D
images of the region in question. Diagnose the images.
152
2. A 41-year-old G1 patient was aware of trisomy risks involved with her age. She
plans on taking advantage of all testing options to determine the health of her
pregnancy. Explain images A and B to her.
153
Sonographic Evaluation of First-Trimester

Complications
CHAPTER 16

visit the point.

Matching
KEY TERMS Definitions

a. Spontaneous or induced termination of an
early pregnancy and expulsion of fetal
and placental tissues
b. Invasive procedure in which a quantity of
amniotic fluid is removed from the
amniotic sac for analysis of the fetal
cells or for the presence of certain
chemicals in the fluid itself. This
procedure may be performed as a
palliative measure in patients with
severe polyhydramnios.
c. Pregnancy that has failed prior to the
development of an identifiable embryo,
or in which embryonic tissue has been
resorbed after early embryonic demise
d. Deficiency of red blood cells
e. Empty gestational sac seen in an
anembryonic pregnancy
f. Abnormally slow heart rate
g. Invasive procedure in which the
chorionic villi of an early pregnancy are
removed for analysis
h. Abnormal fertilization of an oocyte that
1. _________ anemia contains no maternal chromosomes,
2. _________ inevitable abortion resulting in the proliferation of swollen
chorionic villi and the absence of
3. _________ complete hydatidiform mole
identifiable embryonic structures
4. _________ toxemia of pregnancy
i. Spectrum of disorders that begin at
5. _________ abortion fertilization and involve abnormal
6. _________ gestational trophoblastic proliferation of the trophoblasts that in a
neoplasia normal pregnancy would have gone on to
7. _________ tachycardia form the placenta. Gestational
trophoblastic disease may become
8. _________ anembryonic pregnancy invasive and become malignant and
9. _________ hyperthyroidism metastasize.
10. _________ triploid, triploidy j. Invasive or metastatic form of gestational
11. _________ chorionic villus sampling trophoblastic disease
12. _________ missed abortion k. Form of gestational trophoblastic disease
resulting from abnormal fertilization, in
13. _________ partial hydatidiform mole which there is proliferation of swollen
14. _________ gestational trophoblastic chorionic villi, also called a molar
disease pregnancy
15. _________ respiratory insufficiency l. Excessive vomiting. It is called
16. _________ amniocentesis hyperemesis gravidarum during
pregnancy
17. _________ hydatidiform mole
m. Excessive activity of the thyroid
18. _________ threatened abortion,
threatened miscarriage n. Spontaneous abortion in which some
products of conception remain in the
19. _________ subchorionic hemorrhage
uterus
154 o. Failed early pregnancy that is in the
20. _________ hyperemesis process of being expelled from the
21. _________ theca lutein cysts uterus
22. _________ bradycardia p. Spontaneous failure and expulsion of an
early pregnancy
23. _________ miscarriage
q. Early failed pregnancy that remains in the
24. _________ subchorionic hematoma uterus
25. _________ blighted ovum r. Hydatidiform mole
26. _________ incomplete abortion s. Abnormal fertilization resulting in one
27. _________ molar pregnancy maternal and two paternal sets of
chromosomes (triploidy), leading to the
development of an abnormal fetus and
placenta
t. Inadequate absorption of oxygen and/or
inadequate expulsion of carbon dioxide
u. Crescent-shaped sonolucent collection of
blood between the gestational sac and
the uterine wall
v. Subchorionic hematoma
w.Abnormally rapid heart rate
x. Vaginal bleeding in a pregnancy of less
than 20 weeks; may be accompanied by
pain or cramping
y. Large, often bilateral ovarian cysts, the
formation of which is usually stimulated
by excessive levels of circulating hCG
z. Pregnancy-induced hypertension,
proteinurea, edema, and headache
(preeclampsia), which may progress to
the development of seizures (eclampsia)
aa.Having three copies of each
chromosome
CHAPTER REVIEW
Multiple Choice
1. Uterine size estimation by physical examination, to determine pregnancy age, may be
inaccurate because of all except:
a. uterine fibroids
b. maternal obesity
c. surgical scars
d. parity
2. What laboratory value is useful when a smaller-than-expected gestational sac is seen
with ultrasound?
a. PAPP-A
b. hCG
c. progesterone
d. estrogen
3. Early-onset intrauterine growth restriction is defined as crown-rump length at least
____ standard deviations below the mean for the expected gestational age.
a. one
b. two
c. three
d. four
4. Spontaneous pregnancy loss before 20 weeks (of clinically recognized gestations) is
as high as:
a. 30%
b. 20%
c. 10% to 20%
d. 5%
5. A pregnancy less than 20 weeks with vaginal bleeding is termed:
a. threatened abortion
b. inevitable abortion
c. miscarriage
d. hemorrhagic conceptus
6. A gestational sac without an embryo or yolk scan with a mean sac diameter greater
than ____________ (EV) generally predicts pregnancy failure.
a. 10 mm
b. 1.5 cm
c. 2.0 cm
d. 25 mm
155
7. Select the yolk sac with the healthiest characteristics:

a. oblong
b. round
c. less than two standard deviations below the mean yolk sac diameter for
gestational age
d. more than two standard deviations above the mean yolk sac diameter for a given
gestational age
8. Pregnancy failure is most likely to occur when the fetal heart rate is:
a. 150 bpm at 8 weeks
b. ≥155 bpm at 6.3 to 7 weeks
c. 120 to 130 bpm at 9 weeks
d. <110 bpm at 6.3 to 7 weeks
9. Select the statement that does not indicate probable embryonic demise:
a. 6 mm embryo without cardiac activity
b. no double bleb sign with a <5 mm embryo
c. no cardiac activity with a <5mm embryo and a double bleb sign
d. enlarged amniotic sac with <5 mm embryo
10. The risk of spontaneous miscarriage, preeclampsia, placental abnormalities, or
preterm delivery is increased by crescent-shaped sonolucent fluid between the
gestational sac and the uterine wall, which is called:
a. chorionic hemorrhage
b. subchorionic hematoma
c. retroplacental bleed
d. subamniotic hemorrhage
11. A complete hydatidiform mole usually results in:
a. large-for-dates uterus and vaginal bleeding
b. a triploid pregnancy with 69 chromosomes
c. vaginal bleeding and a small-for-dates or normal-sized uterus
d. a thick, hydropic placenta
12. Select the measurement not usually included in a first-trimester screening for
assessing risk in a chromosomally abnormal fetus:
a. CRL
b. NT
c. MSD
d. ductus venosus Doppler velocimetry
13. Hydatidiform moles are caused by:
a. preeclampsia
b. abnormal fertilization
c. malignant neoplasms
d. papillomavirus infection prior to pregnancy
14. Select the correct sonographic appearance for inevitable abortion:
a. early empty gestational sac
b. crescent-shaped fluid collection between the gestational sac and the uterus
c. oval-shaped gestational sac
d. empty low-lying gestational sac, open cervix
15. Theca lutein cysts are usually stimulated by excessive levels of hCG and related to:
a. blighted ovum
b. fetal aneuploidy
c. complete molar pregnancy
d. neoplasia
Fill-in-the-Blank
1. A sonogram is ordered to date a pregnancy if _________ and if _________.
2. If the crown-rump length is more than two standard deviations below the mean for the
expected gestational age, _________ may be suspected.
3. Genetic abnormalities cause _________ of pregnancy failure.
4. A patient with an anembryonic pregnancy or embryo demise that has not yet been
expelled from the uterus is labeled as a _________ or _________.
5. A blighted ovum is also called an _________.
6. The “empty amnion sign” is _________.
7. Routine obstetric ultrasound done between approximately 6 and 12 weeks divulging a
normal singleton fetus demonstrates a miscarriage rate of _________.
156
8. An embryo measuring _________ or greater should demonstrate cardiac activity.

9. Ultrasound views an incomplete abortion as a _________ endometrium or _________
within the uterus.
10. The diagnosis of molar pregnancy is critical, and _________ blood tests to
determine _________ levels are normal for three consecutive weeks following
suction and curettage of the uterine cavity.
11. Enlarged ovaries are frequently seen during complete molar pregnancy as a result of
elevated _________ levels.
12. Molar pregnancy has the ability to develop into _________.
13. An intrauterine mass over 3.45 cm in largest diameter, and a _________
endometrium, and _________ resistance arterial Doppler flow is likely a form of
gestational trophoblastic disease.
14. First-trimester sonography can detect _________ abnormalities, such as
acrania/anencephaly, spina bifida, encephalocele, holoprosencephaly, and Dandy–
Walker malformation.
15. Toxemia of pregnancy presents as pregnancy-induced hypertension, proteinuria,
edema, and headache (preeclampsia) and may progress to _________ (_________).
Short Answer
1. Explain how fibroids affect a pregnancy.
2. Discuss the importance of diagnosing molar pregnancy as early as possible. Explain

effective treatment protocols for the condition.
3. Compare and explain the difference between first-trimester hydatidiform mole and a
second trimester hydatidiform mole.
4. Define incomplete abortion, missed abortion, inevitable abortion, and threatened

abortion. Describe their ultrasound appearance.
157
1. Explain this image of uterine contents in a 10-week gestation with reported bleeding.
2. Discuss image A and compare it to image B. What is the arrow pointing at in image
B?
158
3. Identify what the arrows are depicting in the images.

4. State the correct diagnosis for this pregnancy. There is no identifiable cardiac
activity.
5. State the correct diagnosis for this pregnancy.

159
6. What is the arrow pointing toward?

7. State a diagnosis for this pregnancy. There is no fetal cardiac activity.
160
8. Diagnose the image using the arrow as a hint.
CASE STUDY
1. A primigravida patient began spotting and within 12 hours started heavy bleeding. She
was noted on ultrasound to have miscarried. She chose to allow the process to
continue naturally. One week later, when she began having severe cramping, she
returned to her doctor. An ultrasound was ordered. Describe and diagnose the two
images.
2. A 17-year-old G1 patient reported to ultrasound with a family history of “babies
being born with bone problems.” She was unable to provide a clear description.
Review the image, describe the anatomy, and attempt a diagnosis.
161
Sonographic Assessment of the Ectopic

Pregnancy
CHAPTER 17

visit the point.

Matching

a. Gestation located within the
intraperitoneal cavity, apart from tubal,
ovarian, or intralegamentous sites
b. Number of techniques used to aid
fertilization, including in vitro
fertilization (IVF), intracytoplasmic
sperm insertion (ICSI); follicle
aspiration, sperm injection, assisted
follicular rupture (FASIAR).
c. Glycoprotein hormone produced in
pregnancy that is made by the
developing embryo soon after
conception and later by the placenta
d. Gestation located within the
endocervical canal
e. Gestation located within a rudimentary
uterine horn or one horn of a bicornuate
1. _________ intramural pregnancy or septated uterus
2. _________ double decidual sac sign f. Two concentric hyperechoic rings
3. _________ pregnancy of unknown (representing the echogenic base of the
location (PUL) endometrium and the decidua
capsularis/chorion levae) surrounding
4. _________ abdominal pregnancy
the anechoic gestational sac in a normal
5. _________ intrauterine contraceptive intrauterine pregnancy
device (IUD)
g. Implantation of a fertilized ovum in any
6. _________ sliding sac sign area outside the endometrial cavity
7. _________ heterotopic pregnancy h. Concomitant intrauterine pregnancy and
8. _________ beta human chorionic ectopic pregnancy
gonadotropin (β-hCG) i. Shock due to a decrease in blood volume
9. _________ hypovolemic shock j. Gestation located in the intramyometrial
10. _________ tubal ring sign segment of the fallopian tube
11. _________ cervical pregnancy k. Gestation located within the myometrium
12. _________ Morison’s pouch of the uterus
13. _________ pelvic inflammatory diseasel. Form of birth control: small, plastic or
(PID) copper, usually T-shaped device with a
string attached to the end that is inserted
14. _________ assisted reproductive into the uterus
techniques (ART)
m. Laboratory procedure in which sperm
15. _________ ovarian pregnancy are placed with an unfertilized egg in a
16. _________ in vitro fertilization (IVF) Petri dish to achieve fertilization; the
17. _________ interstitial pregnancy embryo is then transferred into the uterus
to begin a pregnancy or cryopreserved
18. _________ ectopic pregnancy for future use
162 n. Level of β-hCG at which a normal
intrauterine pregnancy can be seen with
19. _________ cornual pregnancy sonography
20. _________ discriminatory cutoff o. Gestation located within the ovary
p. Infection of the female reproductive tract
that results from microorganisms
transmitted especially during sexual
intercourse or by other means such as
during surgery, abortion, or parturition
q. Pregnancy in which no signs of an
intrauterine pregnancy or ectopic
pregnancy are seen by sonography
r. When gentle pressure from the transducer
moves the gestational sac
s. Hyperechoic ring of trophoblastic tissue
that surrounds an extrauterine gestational
sac
t. Hepatorenal recess; deep recess of the
peritoneal cavity on the right side
extending upward between the liver and
the kidney; gravity-dependent portion of
the peritoneal cavity when in the supine
position
Image Labeling
Ectopic pregnancy implantation sites
CHAPTER REVIEW
Multiple Choice
1. Ectopic pregnancy can be caused by:
a. elevated β-hCG
b. hypovolemic shock
c. oviduct surgical history
d. irregular sperm motility
2. Signs of tubal rupture may include all but:
a. hypotension
b. rebound tenderness
c. tachycardia
d. UTI
3. When are ectopic pregnancies usually diagnosed?
a. 2 to 4 weeks
b. 4 to 8 weeks
c. 6 to 10 weeks
d. 8 to 12 weeks
4. β-hCG levels should approximately double every _________ hours:
a. 48
b. 36
c. 24
d. 12
163
5. At what level of β-hCG concentration should a normal intrauterine pregnancy be seen?

a. 3.000 to 10,000 U/mL
b. 1,500 to 2,500 mIU/mL
c. 500 to1,000 mIU/L
d. 2,000 to 3,000 mIU/mL
6. Interstitial pregnancy occurs in the:
a. rudimentary uterine horn
b. cervix
c. cornua
d. intramyometrial segment of the fallopian tube
7. Ectopic pregnancy most often implants in the:
a. fallopian tube
b. ovary
c. cornua
d. cervix
8. ___________ percent of patients with an ectopic pregnancy have no symptoms.
a. 30
b. 40
c. 50
d. 60
9. Cervical pregnancy is rare and linked to all of the following except:
a. previous curettage
b. ovulation induction techniques
c. endometriosis
d. IUD use
10. Procedures that cause an injury to the myometrium, including curettage,
hysteroscopy, myomectomy, metroplasty, and cesarean section, can be the cause of
_____________ pregnancy:
a. infundibular
b. interstitial
c. heterotopic
d. intramural
11. Heterotopic pregnancy means pregnancy:
a. outside the uterus
b. eccentric in the uterus
c. intrauterine and extrauterine, simultaneous
d. with bleeding
12. What β-hCG levels are necessary to visualize an IUP using the transabdominal
approach?
a. 2,500 mIU/L
b. 4,000 IU/m
c. 6,500 mIu/mL
d. 8,500 mIU/mL
13. Which ectopic pregnancy location can support a pregnancy the longest before
detection?
a. abdominal
b. ovarian
c. cervical
d. intramural
14. A pseudosac:
a. is a true gestational sac positioned low in the uterine cavity
b. is a fluid collection caused by bleeding from the decidualized endometrium
c. abuts the endometrial canal
d. has a double decidual sac sign
15. Cervical pregnancy frequently presents on ultrasound as a(n) _________ shaped
uterus:
a. oval
b. cylindrical
c. “T”
d. hourglass
16. A sonographic technique that can assist in determining a pseudosac from an early
viable gestation is:
a. graded compression
b. the abdominal approach
c. color Doppler
d. low resistive index
17. A ruptured tubal pregnancy presents as a:
a. complex mass-like area representing hemorrhage and free fluid
b. circumscribed mass
c. solid heterogeneous mass with irregular borders
d. hypoechoic cyst with nodular internal foci
18. An aborting gestational sac will appear ___________ with color Doppler.
a. poorly perfused
b. avascular
c. well perfused
d. as a pseudosac
19. If ultrasound is equivocal in the diagnosis of ectopic pregnancy, _____________
may be used for diagnosis:
a. laparoscopy
b. laparotomy
c. culdocentesis
d. curettage
20. What imaging method is considered the “gold standard” for diagnosing and locating
an abdominal ectopic pregnancy?
a. TV ultrasound
b. TA ultrasound
c. CT
d. MRI
164
Fill-in-the-Blank
1. About _________ of all pregnancies in the United States are ectopic.
2. The pathway from the uterine cavity to the peritoneal cavity is through the _________.
3. β-hCG levels increase and then plateau at approximately _________ weeks.
4. Repeated or _________ β-hCG levels are necessary to detect an increase, decrease,
or leveling of the hormone.
5. When the β-hCG level is below the discriminatory cutoff and an IUP is not visualized,
this could indicate an early _________, a spontaneous abortion, or an _________
pregnancy.
6. Ectopic pregnancy symptoms usually present as vaginal _________, pelvic
_________, and palpable _________.
7. Heterotopic pregnancy occurs when two or more fertilized ova implant, usually an
_________ pregnancy and an _________ pregnancy.
8. The increase in C-section scar pregnancies is probably because of the _________.
9. Symptoms of general malaise, nausea, vomiting, vaginal bleeding, and painful fetal
movements are associated with _________ ectopic pregnancy.
10. Transvaginal sonography should demonstrate a fetal pole with cardiac motion at
_________ weeks of gestation.
11. Sonographic evaluation of ectopic pregnancy should include the _________ recess
and paracolic _________ to evaluate for the extent of free fluid.
12. An endometrial stripe thickness less than 8 mm suggests an _________ or ectopic
pregnancy.
13. Three criteria for interstitial pregnancy are: _________ uterine cavity, gestational
sac greater than _________ cm from the most lateral point of the endometrial cavity,
and gestational sac surrounded by a thin _________ layer.
14. The sliding sac sign suggests an _________ in progress.
15. The yolk sac should be visualized by _________ weeks’ gestation.
16. The area most likely to collect fluid in the right abdomen between the liver and the
kidney is called _________.
17. Color Doppler presents as a _________ around a viable ectopic pregnancy.
18. In the setting of an ectopic pregnancy, the uterus may appear _________.
19. MTX, known as _________, interferes with cell _________, and is used to manage
ectopic pregnancy in a _________ manner.
20. Findings on physical exam of a pregnant female vary with the hemodynamic
condition of the patient; hypotension, tachycardia, shoulder pain from diaphragmatic
irritation, significant abdominal pain, rebound tenderness and guarding,
hypovolemic shock, or even diminished pain may all be signs of _________ and/or
_________.
165
Short Answer
1. List reasons that a fertilized ovum may have difficulty transporting to the endometrial
cavity.
2. Describe the expected appearance of an extrauterine pregnancy.
3. A 23-year-old G2 P1 presents to the emergency room with right adnexal pain. Routine
laboratory testing documented pregnancy and a normal WBC. Ultrasound was
ordered and demonstrated a normal, empty uterine cavity and the right ovary to have
what appeared to be an echogenic corpus luteum cyst with a wide echogenic ring
demonstrating color flow. Make a diagnosis.
4. Explain the time frame for visualization of the yolk sac, cardiac activity, and double
decidual sac sign.
1. State the structure and anatomy at thick and thin arrows.
166
2. Diagnose the location of this ectopic pregnancy.

3. Label the structure the arrow is pointing to. What ultrasound imaging method collected
the image. State the location of the ectopic pregnancy.
4. Explain a probable reason for free fluid in this patient with a known ectopic ruptured
tubal pregnancy. Name the region of the fluid collection.
167
5. Label the structure depicted by the arrow in this transverse transvaginal image.
CASE STUDY
1. A positive home pregnancy text, missed menses, and positive qualitative hCG
determined a 22-year-old woman to be pregnant at approximately 4.5 weeks. She
became nervous about the pregnancy when she saw slight bloody discharge from the
vagina and felt pelvic pressure. An ultrasound was ordered by her obstetrician.
Describe the image.
2. Study the image and diagnose the viability of this cervical pregnancy.
168
169
Assessment of Fetal Age and Size in the

Second and Third Trimesters
CHAPTER 18

visit the point.

Matching

a. Minimum distance between two bright
echoes along the path of the ultrasound
beam that is half the spatial pulse length
b. Ratio of the BPD to the OFD
1. _________ macrosomia
c. Precision rate of the probability of
2. _________ cephalic index (CI) disease
3. _________ occipitofrontal diameter d. Minimum distance between two bright
(OFD) echoes at right angles (perpendicular) to
4. _________ predictive value the ultrasound beam path directly related
5. _________ axial resolution to the beam width and focal zone
6. _________ lateral resolution e. Fetus over 4,000 g (8 pounds 13 ounces)
f. Measurement from the frontal to the
occipital obtained at the same level as
the BPD
CHAPTER REVIEW
Multiple Choice
1. The fetal expected birth date is known as the EDC or:
a. GA
b. EDD
c. GA
d. LMP
2. The most accurate fetal measurement can be obtained from:
a. the BPD
b. the AC and FL
c. the HC
d. multiple parameters
3. Which phase of pregnancy provides the most accurate dating?
a. early embryo measurements
b. early second trimester, 16 to 18 weeks
c. late second trimester, 25 to 26 weeks
d. early third trimester, 28 to 29 weeks
4. The preferred measurement method for fetal growth is:
a. single “correct”
b. BPD, FL, AC, HL, HC
c. average of multiple measurements within a “cluster”
d. HC, AC, FL
170
5. The normal duration of pregnancy is:

a. 40 weeks from ovulation
b. 40 weeks from the LMP (38-week gestation ± 2 to 3 weeks)
c. conception date plus 40 weeks
d. GA plus 4 weeks
6. Lateral resolution is:
a. measurements along the path of the beam, parallel to the ultrasound beam direction
b. the depth at which sound beam is narrowest (focused)
c. across the path of the beam
d. related to the frequency of sound and pulse length
7. The most accurate fetal measurements are taken:
a. along the beam axis using axial resolution
b. along the beam axis using lateral resolution
c. transversely to the beam using axial resolution
d. transversely to the beam using lateral resolution
8. Ultrasound measurement errors due to beam width and machine calibration of
____________ are acceptable.
a. 3% to 4%
b. 1 or 2 mm/10 cm
c. 1 to 2 cm
d. 2%/10 cm
9. The most common and routine measurements to assess the fetal growth and well-being
are:
a. HL, FL, HC, AC
b. FL, HC, AC, OD
c. BPD, HC, AC, FL
d. BPD, AC, HC, MFP
10. Select a fetal characteristic that is not a third trimester individuation:
a. long fetus
b. dolichocephaly
c. thin fetus
d. bradycardia
11. What structures are seen in an accurate BPD measurement?
a. complete oval calvarium slightly superior to the parietal, sphenoid, petrous ridge
structures
b. thalamus, cavum magnum
c. complete oval calvarium with the cerebellum demonstrated
d. orbital, base X, occipital
12. To estimate an accurate fetal age, the BPD measurement should be obtained before:
a. 29 weeks
b. 31 weeks
c. 33 weeks
d. 35 weeks
13. An HC measurement should be obtained:
a. using the inner edge of the calvarium at the level of the BPD
b. using the outer edge of the calvarium at the level of the BPD
c. using the outer edge of the calvarium at the level of the cerebellum
d. at the level of the occipito circumference
14. Select the correct CI formula:
a. (D1 + D2) × 1.57
b. BPD/FOD × 100
c. 89%/OD × (d1 − d2)
d. FOD/BPD × 100
15. Platycephaly is:
a. premature closure of the cranial sutures
b. flattening of the forehead, causing skull widening
c. a type of coneheadedness
d. shortening of the vertical dimension of the skull and widening of both diameters of
the transverse plane
16. The most exact of the orbit measurements is the:
a. BOD
b. OOD
c. IOD
d. IGE
17. All of the following are fetal long bones except:
a. tibia
b. humerus
c. metacarpal
d. ulna
18. Fetal weight by ultrasound is frequently requested to rule out all except:
a. macrosomia
b. BPP
c. IUGR
d. possible low birth weight
171
19. If the umbilical/portal junction is not visualized while attempting an AC

measurement, use the level of the fetal:
a. stomach
b. kidneys
c. adrenals
d. cord insertion
20. Preferred technique for measuring the fetal abdomen and head circumference is:
a. outer boundary
b. ellipse
c. trace
d. two-point
Fill-in-the-Blank
1. Two purposes of second and third trimester measurements of a fetus are estimating
_________ and determining the size and development.
2. Differences in fetal growth parameters can be caused by maternal _________,
_________, and genetics.
3. Normally, conception takes place about _________ weeks after the LMP.
4. Accurate measurements are partially determined by _________ and _________ image
resolution.
5. Short and frequent pulses yield the greatest _________ resolution.
6. Higher frequency transducers provide the best _________ resolution.
7. Macrosomia equates to a fetus over _________ grams.
8. Determining sonographic dates for a fetus using a single parameter is not desirable,
especially in _________ pregnancy.
9. Measurement errors occur in as many as 45% of fetuses in the circumstance of
external uterine pressure with the _________ measurement.
10. The more measurements obtained and averaged during a fetal ultrasound, the more
_________ the fetal age estimate.
11. MFP (_________) is the average gestational age determined by four common
measurements of the fetus.
12. If the fetal head is very low in the pelvis, a(n) _________ transducer may allow
BPD measurements.
13. A fetus with a long and narrow head is called _________.
14. Cerebellar size is generally unaffected by fetal _________ disturbances and is
independent of the shape of the _________.
15. A correct AC measurement demonstrates the _________ vein junction with the
_________ vein perpendicular to the _________.
16. A structure within the cranium that maintains a relationship to fetal growth throughout
pregnancy is the _________.
172
17. Common fetal body ratios are _________, _________, and _________.
18. The recommended technique for obtaining an accurate AC is to first locate the long
axis of the _________.
19. Tall parents tend to have _________ babies.
20. The femur measurement can be reliably used after _________ weeks’ gestation.
Short Answer
1. Ann has a history of oligomenorrhea. She is G3 P2. Her first pregnancy delivered
close to her EDD and the second delivered 3 weeks early owing to incompetent
cervix. Explain reasons why accurate fetal dating is important for this pregnancy as
well as all pregnancies.
2. Discuss reasons why BPD measurement can be inaccurate.
3. Explain dolichocephaly and brachycephaly and their relationship to CI.
4. A student sonographer continually obtained FL measurements 6 to 11 days longer than

the other fetal parameters on the second and third trimester fetal examinations. What
is a probable explanation? Discuss the correct femur measurement technique.
173
1. What type of resolution is point A to B? What type of resolution is B to C and D to E?
What part of the beam is the arrow pointing to?
2. Label the structures associated with numbers 1 (thick arrows), 2, and 3 (thin arrow).
174
3. Label the bones associated with numbers 1 and 2.
4. Identify the distance labeled 1 and the distance labeled 2.
175
5. Identify the circled labels, O1 and L.
6. Label structures 1 and 2. What are the “X’s” measuring? Explain a reason for this
measurement.
176
7. Name the measured lower extremity bone in image A, then the measured bone in
image B.
Hint: Note the thickness of each bone.
177
CASE STUDY
1. A G3 P2 patient’s second child was noted in utero to have dysplasia, which was seen
in the femur at 22 weeks. She was understandably concerned about the bony
structure of the fetus in her third pregnancy. Assess the images and state if there is
suspicion of bony abnormality.
Name the two bones in the forearm.
Discuss the typical length differences of the bones.
Which bone was measured in the image?
Make a comment regarding distal and proximal bone termination within the forearm.
178
2. Name the structure in images A and B. Describe the type of measurement used in the
images. What are the three types of measurement used for accurate abdomen
assessment? State the anatomy seen when this structure is properly measured.
179
Normal Placenta and Umbilical Cord
CHAPTER 19

visit the point.

Matching

a. The functional layer of the endometrium
in the gravid woman
b. Uterine contractions that do not lead to
labor
c. Inhalation and suspension of breath
1. _________ bilobed placenta
coupled with abdominal muscle
(succenturiate lobe)
contraction to increase abdominal
2. _________ Braxton Hicks pressure
3. _________ cotyledons d. White, cheese-like coating of fetal skin
4. _________ deciduas e. Extra placental lobe smaller than the
5. _________ retroplacental placenta
6. _________ valsalva f. Area between the myometrium and
placenta
7. _________ vernix caseosum g. Mucous tissue surrounding the umbilical
8. _________ Wharton’s jelly cord
h. Lobule or subdivision of the maternal
placenta containing fetal vessels,
chorionic villi, and the intervillous
space
180

Image Labeling
Fetal circulation
181
Umbilical cord insertions
CHAPTER REVIEW
Multiple Choice
1. The placenta is responsible for all but:
a. hormonal functions
b. nutritive functions
c. respiratory functions
d. excretory functions
2. Vascular resistance changes in the umbilical cord can be caused by all except:
a. umbilical cord compression
b. maternal hypotension
c. placental tumor
d. maternal diabetes
3. The umbilical cord originates from fusion of the yolk sac stalk and the
omphalomesenteric duct at approximately:
4. The maternal side of the placenta:
a. is homogeneous
b. is made of approximately 20 cotyledons
c. is bordered by amnion
d. attaches to the chorionic plate
182
5. The umbilical cord consists of:

a. two veins, an artery, and a layer of amnion
b. two veins, an artery, and surrounding mucoid epithelial tissue
c. two arteries, a vein, and a layer of chorion
d. two arteries, a vein, and Wharton’s jelly
6. The normal at term umbilical cord length is approximately:
a. 40 to 45 cm
b. 44 to 52 cm
c. 52 to 61 cm
d. 75 cm
7. The normal term placenta weighs between:
a. 250 and 320 g
b. 330 and 450 g
c. 480 and 600 g
d. 570 and 660 g
8. A normal placental thickness at 24 weeks’ gestation is less than:
a. 2 cm
b. 3 cm
c. 4 cm
d. 5 cm
9. Placental calcification may be caused by all except:
a. lung maturity
b. maternal smoking
c. parity
d. season of the year
10. A normal mean circumference of the term umbilical cord is:
a. 3.8 cm
b. 2.8 cm
c. 4.0 cm
d. 2.5 cm
Fill-in-the-Blank
1. More than _________ of placentas show macroscopic calcification after _________
weeks.
2. Umbilical arteries carry _________ blood from the fetus to the placenta. The
umbilical vein returns _________ back from the placenta.
3. The umbilical _________ are longer than the _________ and wind around it.
4. The use of _________ should make visualization of the umbilical cord insertion into
the placenta easily identifiable.
5. The placenta has metabolic functions such as _________, _________, and
_________.
6. Maternal _________ can affect the size, vascularization, and function of the
placenta.
7. The maternal and fetal circulations within the placenta are _________. The vascular
channels within the placenta are part of a _________-impedance system.
8. The _________ approach is ideal for imaging questionable previas late in pregnancy.
9. An _________ bladder can cause a false-positive appearance of placenta previa.
10. When scanning the placenta, the beam should be _________ to the chorionic plate,
especially when measuring thickness.
11. A low-lying placenta or placenta previa may mimic a uterine _________ or
_________.
12. Complete evaluation of the placenta includes structural _________, _________,
retroplacental appearance, and _________ of the cord.
183
13. The umbilical artery has a _________-resistance, and _________ diastolic blood
flow characteristic in the normal placenta.
14. A late third-trimester placenta may exhibit cystic areas located centrally within
clearly delineated lobes which may represent areas of _________.
15. The cross-sectional area of the cord has been found to correlate with gestational age,
up until it reaches a plateau at _________ weeks.
Short Answer
1. A G2 P1 obstetric patient with history of a previous anomalous umbilical cord was
anxious about her current pregnancy, especially the cord. Describe methods to best
visualize the umbilical cord.
2. Suggest techniques that can be used to clearly interrogate the placenta.
1. State the anatomy the arrows are directed at in images A and B.
184
2. Explain the bright patterns in the image. Grade the placenta.

3. Does the placental thickness measurement in the image include the retroplacental
thickness? Should it? Does the thickness appear normal?
CASE STUDY
1. A student sonographer imaged a 9-week pregnancy. She had a concern about a
“mass” at the anterior gestational sac (arrow). What is the “mass”?
185
Abnormalities of the Placenta and

Umbilical Cord
CHAPTER 20

visit the point.

Matching

a. Focal dilatation of an artery
b. Placenta where the lobes are nearly
equal in size and the cord inserts into the
chorionic bridge of tissue that connects
the two lobes
c. Fatal condition associated with multiple
congenital anomalies and absence of the
umbilical cord
d. Very rare condition where there is
massive subchorionic thrombosis of the
placenta secondary to extreme venous
obstruction
e. Attachment of the placental membranes to
the fetal surface of the placenta rather
than to the underlying villous placental
margin
f. Bending, twisting, and bulging of the
umbilical cord vessels mimicking a knot
1. _________ marginal insertion in the umbilical cord
2. _________ umbilical coiling index g. Periumbilical abdominal wall defect,
(UCI) typically to the right of normal cord
insertion that allows for free-floating
3. _________ gastroschisis bowel in the amniotic fluid
4. _________ umbilical hernia h. Condition characterized by multiple
5. _________ extrachorial placenta complex fetal anomalies and a short
6. _________ thrombosis umbilical cord
7. _________ body stalk anomaly i. Also known as battledore placenta,
occurs when the umbilical cord inserts
8. _________ synechiae (Asherman at the placental margin instead of
syndrome) centrally
9. _________ Mickey Mouse sign j. A term used to describe the cross section
10. _________ venous lakes of the three-vessel umbilical cord or the
11. _________ limb-body wall complex portal triad (portal vein, hepatic artery,
common bile duct)
12. _________ umbilical cord
k. Central anterior abdominal wall defect of
13. _________ false knot
the umbilicus
14. _________ true knot
l. A term that refers to a thickened placenta
15. _________ Breus’ mole
m. Linear, extra amniotic tissue that
16. _________ bilobed placenta projects into the amniotic cavity with no
17. _________ omphalocele restriction of fetal movement
18. _________ aneurysm n. Intraplacental area of hemorrhage
19. _________ placentomegaly o. Result of fetus passing through a loop or
loops of umbilical cord, creating a
knot(s) in the cord
p. Failure of the normal physiologic gut
herniation to regress into the abdomen,
resulting in a small amount of bowel
protruding into the base of the umbilical
cord
q. Vascular structure connecting the fetus
and placenta that normally contains two
arteries and one vein surrounded by
Wharton’s jelly
r. Method of assessing the degree of
umbilical cord coiling, defined as the
number of complete coils per centimeter
length of cord
s. Tubular, anechoic structures found
beneath the chorionic plate that
correspond to blood-filled spaces found
at delivery
186

Image Labeling
Label placenta type

Abnormalities of umbilical cord or membrane insertion into the placenta
187
Label placentation type
Extrachorial placentation
Label type of accreta

Placenta accreta spectrum classification
188
Label type of abruptio

Abruptio placentae
Label type of cord insertion

Placental cord insertion
189
Label the cord type type
Vasa previa
Label the cord type
Umbilical cord
190
Label the cord type
Umbilical cord
Label the cord type
Umbilical cord
191
CHAPTER REVIEW
Multiple Choice
1. Placental hydrops produces a:
a. thin placenta with venous lakes
b. thick placenta with a “ground-glass appearance”
c. annular placenta with irregular contour
d. membranacea placenta with low-resistance blood flow
2. A “jelly-like placenta” is associated with:
a. venous lakes
b. IUGR
c. adjacent fibroids
d. degeneration
3. A succenturiate placenta:
a. has increased frequency in primigravidas
b. is ring-shaped
c. most often has velamentous umbilical cord insertion
d. is edematous
4. Circumvallate placental tissue is:
a. flat and noted on approximately 20% of placentas
b. associated with a rolled edge
c. extremely rare, 1:20,000 to 40,000 pregnancies
d. prone to fetal macrosomia
5. Risk factors for placenta previa include all except:
a. previous cesarean section
b. multiple gestations
c. previous elective abortions
d. hypertension
6. A placenta is considered low-lying if the inferior margin is:
a. 0.5 cm from the internal os
b. adjacent to the internal os
c. within 2 cm of the internal os
d. posterior
7. The most infiltrative form of placenta accreta is:
a. percreta
b. accreta
c. increta
d. invasive
8. Attachment problems of the placenta are known as all except:
a. morbidly adherent placenta
b. placental attachment disorder
c. abnormally invasive placenta
d. infiltrative myometrial placenta
9. Placental infarction is:
a. visualized at the fetal placental surface
b. caused by obstructed spiral arteries
c. multiple hemorrhages into placental lakes
d. a factor in macrosomia
10. A benign vascular malformation of the placenta is a:
a. teratoma
b. septal cyst
c. lacunae
d. chorioangioma
11. Premature separation of all or part of the placenta from the myometrium is:
a. hemorrhage
b. subchorionic
c. abruption
d. subdural
12. Linear, extra amniotic tissue projecting into the amniotic cavity is noted often in
pregnant women with a history of:
a. uterine curettage
b. cervical dilation
c. multiples
d. STDs
13. Amniotic band syndrome is a condition that:
a. involves free-floating membrane
b. is a result of rupture of the amnion without rupture of the chorion
c. is not revealed in the third trimester
d. involves the uterine septum
14. A condition of pregnancy where the trophoblastic cells produce excessive amounts
of β-human chorionic gonadotropin is:
a. multiparity
b. fetal entrapment
c. molar pregnancy (hydatidiform mole)
d. compression syndrome
192
15. SUA is associated with all except:

a. cardiovascular malformations
b. central nervous system defects
c. musculoskeletal abnormalities
d. skeletal dysplasia
16. PRUV, a common vascular variant, describes:
a. a strictured right portal vein
b. a duplicated right portal vein
c. pancreatic right portal vein
d. open right portal vein
17. TTTS is caused by:
a. battledore umbilical insertion
b. monochorionic twin pregnancies sharing a placenta with anastomoses between the
umbilical vessels
c. oligohydramnios
d. discordant fetal size and polyhydramnios
18. Prenatal management of known umbilical pseudo and true cysts:
a. is not necessary since resolution is imminent
b. typically refers to MRI for evaluation
c. involves serial ultrasound examinations
d. displays echogenic characteristics near the placental insertion
19. Cord prolapse is defined as:
a. a compressed umbilical cord
b. presentation of the umbilical cord in advance of the fetal presenting part during
labor and delivery
c. excessive bending and twisting of the umbilical cord
d. focal bulge or vascular protuberance of the umbilical cord
Fill-in-the-Blank
1. Subamniotic cysts or subamniotic hematomas result from rupture of _________ close
to the umbilical cord insertion into the placenta.
2. Selective loss of placental parts and growth of other parts is known as _________.
3. The ring-shaped annular placenta is related to postpartum _________ mostly due to
poor separation.
4. Acute placental abruption hemorrhage appears highly _________ on ultrasound.
5. Choriocarcinomas appear _________, echogenic, and _________ masses.
6. Placenta accreta is mostly located in the _________, _________ uterine segment.
7. Visualization of multiple _________ is highly suggestive of placenta accreta.
8. Multiple chorioangiomas or those larger than _________ cm are related to maternal
and fetal complications.
9. Early detection of fetal anemia is possible where chorioangioma is suspected, through
Doppler measurements of the _________.
10. Extremely hydropic and swollen chorionic villi are frequently related to _________.
11. Molar pregnancies have a characteristic _________ appearance with uterine cavity
_________.
12. The most common reason for emergency postpartum hysterectomy is a _________.
13. A coexisting fetus with an enlarged thickened placenta revealing multiple small
cystic spaces is a _________.
14. The placenta may sonographically appear thickened in some cases of IUGR, with
patchy areas of _________ and abnormal texture.
193
15. A two-vessel umbilical cord reveals the presence of a single umbilical _________
and is sometimes associated with congenital anomalies such as cardiovascular
malformations, central nervous system defects, _________ or genitourinary defects,
and _________ malformations.
16. The umbilical vessel abnormality seen with conjoined twins is _________ vessels.
17. Maternal cocaine abuse leads to the fatal condition _________.
18. Velamentous insertion is more frequent in _________ gestations.
19. Compressed umbilical cords place the fetus at risk for _________ or _________
compromise.
20. A successful method of identifying a nuchal cord is imaging using _________
technology.
Short Answer
1. An obstetrical patient in her 32nd week of pregnancy presents to ultrasound for
transient anterior pelvic pain. Ultrasound revealed unusual Doppler patterns at the
anterior inferior uterine wall adjacent to the anterior midlevel placenta and
hypoechoic regions. Discuss a diagnosis and other sonographic signs that may be
demonstrated.
2. Compare placenta accreta to increta and percreta. State risk factors.
3. A 34-week G2 patient presents to the emergency room complaining of 3 hours of

intense pain near her belly button. Ultrasound noted a viable fetus with no
appearance of obvious distress and a normal appearing fundal anterior placenta.
Suggest a diagnosis and a course of action.
4. Explain the reason scanning for and reporting nuchal cord is controversial.
5. Discuss a cause of facial cleft.
194
1. Describe the type of umbilical cord insertion in the image.
2. Identify the condition demonstrated in the images.
195
3. Identify the anatomy in images A, B, and C.
196
4. Image A reveals a large ovoid mass in 2D. Image B reveals the same mass with color
Doppler sonography demonstrating vascularity within. Diagnose the anatomy.
CASE STUDY
1. The images are of different pregnancies. Both pregnancies suffered sporadic spotting.
View the images and explain why spotting and bleeding has occurred.
197
2. This static image was collected during a routine anatomy check ultrasound that was
performed at 21 weeks. Diagnose the finding.
198
199
Sonographic Assessment of the Fetal Head
CHAPTER 21

visit the point.

Matching

a. Congenital brain anomaly resulting from
a migrational defect of the occipital
horns of the lateral ventricles, leading to
ventricular enlargement
b. Long narrow head
c. Graph
1. _________ anophthalmia
d. Dilatation or distention of a hollow
2. _________ brachycephaly
structure
3. _________ cebocephaly
e. Posterior displacement of the maxilla and
4. _________ colpocephaly mandible
5. _________ dysgenesis f. Congenital absence of one or both eyes
6. _________ dysmorphic g. Either the rostral or caudal end of the
neural tube
7. _________ dolichocephaly h. Toward the cephalic or head end
8. _________ ectasia i. Congenital anomalies of the head due to
9. _________ nares teratogens or development disruptions of
10. _________ neuropore the nervous system
11. _________ nomogram j. Ability of embryonic cells to differentiate
into any type of cell
12. _________ pathognomonic
k. Abnormally formed organs
13. _________ pluripotent
l. Central portion of the cerebellum
14. _________ retrognathia between the hemispheres
15. _________ rostral m. Short broad head due to premature suture
16. _________ teratogen fusion
17. _________ vermis n. Nostrils
o. Disease characteristic
p. Malformation of an organ or structure
q. Substance that interferes with embryonic
development
200

Image Labeling
Three primary brain vesicles.
Drawing of ventricles and intracranial anatomy.
201
Classification of common facial clefts.
CHAPTER REVIEW
Multiple Choice
1. The choroid plexus:
a. invaginates into the ventricles
b. is hyperechoic
c. is positioned in the anterior ventricle
d. initially takes up approximately 1/3 of the cerebral hemisphere
2. The metencephalon and myelencephalon are part of the:
a. myelencephalon
b. prosencephalon
c. rhombencephalon
d. mesencephalon
3. The corpus callosum, cerebellar vermis, sulci, gyri, migration of the germinal matrix,
and myelination develop after
4. BPD is measured at the level of the _______ and septum pellucidum or columns of the
fornix.
a. cistern magna
b. third ventricle
c. septum pellucidum
d. parietal sutures
202
5. What is the alternative measurement to the BDP?

a. FL
b. HL
c. AC
d. HC
6. The most studied artery in the fetal brain is the:
a. circle of Willis
b. MCA
c. ICA
d. anterior communicating
7. A normal cistern magna measurement is less than:
a. 4 mm
b. 1 cm
c. 8 mm
d. 1.5 cm
8. The most frequent anomaly noted with cleft palate or cleft lip is:
a. club foot
b. enlarged forehead
c. anophthalmia
d. retrognathia
9. Fetuses with mandible anomalies are at risk of acute neonatal:
a. skeletal dysplasia
b. respiratory distress
c. cognitive deficits
d. chin prominence
10. Sonographic features of meroanencephaly include:
a. a frog-like appearance
b. polydactyly
c. CP
d. oligohydramnios
11. A fetal brain with no recognizable cerebral cortex and defined thalami and
cerebellum is:
a. holoprosencephaly
b. CL
c. hydranencephaly
d. acrania
12. Agenesis of the corpus callosum reveals all except:
a. wide high third ventricle
b. laterally displaced ventricles
c. absent cavum septum pellucid
d. hypertelorism
13. Dandy–Walker malformation consists of:
a. hypertrophy of the third ventricle
b. marked cystic dilation of the fourth ventricle
c. marked cystic dilation of the lateral ventricles
d. enlargement of the anterior horns
14. Lissencephaly is an absence or paucity of gyri resulting in the characteristic
appearance of:
a. a smooth cerebral surface after 20 weeks
b. absent sulci after 20 weeks
c. an enlarged CM
d. a decreased lateral ventricular measurement
15. A markedly retroflexed neck is an indication of:
a. Chiari malformations
b. Dandy–Walker complex
c. schizencephaly
d. iniencephaly
16. A correct measurement of the BPD involves placing two cursors at the:
a. inner margins of the cranium
b. outer margins of the cranium
c. outer edge of the proximal skull to the inner edge of the distal skull
d. inner edge of the parietal bones
17. A long narrow head is:
a. related to brain sparing
b. brachycephaly
c. ectasia
d. dolichocephaly
18. Enlargement of the ventricles and cerebrospinal fluid displacement of the choroid
plexus results in a condition called:
a. dangling choroid plexus
b. teardrop ventricle
c. cebocephalic
d. cephalic pole
19. Bleeding anywhere in the fetal cranium is known as all except:
a. intraparenchymal hemorrhage
b. subdural hematoma
c. germinal matrix hemorrhage
d. petechial hemorrhage
20. A measurement of the lateral ventricular atrium should not exceed:
a. 1 cm
b. 1 mm
c. 8 mm
d. 2 cm
203
Fill-in-the-Blank
1. The forebrain is also known as the _________.
2. Many brain structures develop between weeks _________, resulting in this time frame
being identified as the critical period of brain development.
3. The great cerebral vein is also called _________.
4. The third ventricle is positioned between the _________ and the frontal horns of the
lateral ventricles.
5. A microcephalic fetus may demonstrate _________ ventricles.
6. The best angle of insonation to obtain peak velocity of the MCA is less than
_________ degrees.
7. A decreased interorbital distance is _________.
8. Between _________ weeks of gestation, the transverse cerebellar diameter measured
in millimeters correlates 1:1 with the gestational age.
9. Holoprosencephaly is divided into _________, _________, and _________ varieties,
defined by the degree of separation of the cerebral hemispheres.
10. There is a strong association between absence of the cavum septum pellucidum and
absence of the corpus callosum with _________.
11. Protrusions of the meninges and frequently of brain substance through a defect in the
cranium are termed _________.
12. The term for small head is _________.
13. To obtain the MCA peak velocity, image the fetal head in a _________ plane.
14. The presence of a single median bony orbit with a fleshy proboscis above it is
_________.
15. Arnold–Chiari malformations often have accompanying _________.
16. The BPD maintains its closest correlation with gestational age in the _________
trimesters.
17. Facial clefts are the most frequent craniofacial anomalies and the _________ most
common congenital malformation.
18. A sonolucent area in the choroid plexus is known as _________.
19. Macrocephaly is defined as a head circumference _________ standard deviations
_________ the mean for gestational age and sex.
20. The tongue extending beyond the teeth or alveolar ridge is _________.
204
Short Answer
1. Explain microcephaly.
2. What are cranial structure alternative methods of determining the age of a fetus other
than BPD, HC, AC, and FL?
3. Discuss cephalocele and encephalocele and cranial myomeningocele.
1. Name the structure the arrow is directed toward.
205
2. Name the structures the open arrow and long arrow point at.
3. Name the structures. Which is normal? Name the anomaly.

4. Offer a diagnosis.
206
CASE STUDY
1. A 30-year-old G3P2 was told that her fetus had a cranial anomaly and was referred to
a perinatologist for a level II ultrasound. View the image and suggest a diagnosis.
2. A fetus was noted to have an irregular cranial image. What is the finding? What is the
projected outcome?
207
Sonographic Assessment of the Fetal Neck

and Spine
CHAPTER 22

visit the point.

Matching

a. Abnormally formed organs
b. Combination of nonimmune fetal hydrops
and a cystic hygroma
c. Herniation of abdominal contents without
a covering into the amniotic fluid
1. _________ clinodactyly d. Spinal defect where the meninges
2. _________ cryptorchidism protrude
3. _________ dysgenesis e. Protrusion of a sac from a spinal defect
4. _________ dysmorphic that contains spinal cord and meninges
5. _________ gastroschisis f. Abnormal position of the fingers or toes
6. _________ lipoma g. Herniation of the abdominal contents
with a membranous cover
7. _________ lymphangiectasia
8. _________ neuropore
h. Complete exposure of the spinal cord
9. _________ nomogram due to lack of spinal fusion
10. _________ meningocele i. Either the rostral or the caudal end of the
11. _________ myelomeningoceles neural tube
12. _________ myeloschisis j. Ability of embryonic cells to differentiate
13. _________ omphalocele into any type of cell
14. _________ pathognomonic k. Tumor composed of fat
15. _________ pluripotent l. Substance that interferes with embryonic
development
16. _________ rachischisis
m. Failure of one or both testes to descend
17. _________ teratogen from the abdomen into the scrotal sac
n. Incomplete fusion of the neural tube
resulting in a cleft spinal cord
o. Malformation of an organ or structure
p. Disease characteristic
q. Graph
208

Image Labeling
Normal and failed lymph drainage system
Neural tube defect
209
Sacrococcygeal teratomas
CHAPTER REVIEW
Multiple Choice
1. Examination of the anterior neck region is useful in detection of different
abnormalities that may include all except:
a. goiter
b. hemangioma
c. rachischisis
d. teratoma
2. Choose the anatomy that can be detected in the fetal neck.
a. carotid bifurcation
b. anterior communicating artery
c. brachial artery
d. superior vena cava
3. How many ossification centers surround the neural canal?
a. 2
b. 3
c. 5
d. 7
4. Select the fetal position that offers a true sagittal view of the spine.
a. transverse
b. oblique
c. cephalic
d. prone
5. Determination of spinal normalcy is through identification of all except:
a. an intact neural canal
b. divergence of the posterior elements
c. a normal location and shape of spinal ossification centers
d. an intact dorsal skin coutoure
6. Screening for neural tube defects is performed by all except:
a. hCG
b. sonography
c. MSAFP
d. biochemical testing
210
7. The most common location for a cystic hygroma is:

a. in the chest
b. in the axillary region
c. at the neck region
d. at the base of the spine
8. The simplest form of spina bifida is:
a. open spina bifida
b. spina bifida occulta
c. spina bifida aperta
d. spina bifida myomeningocele
9. Anomalies frequently seen in the fetus relating to spina bifida involve the fetal:
a. cranium
b. face
c. anterior neck
d. posterior neck
10. Fetuses affected by spina bifida aperta commonly demonstrate:
a. an enlarged forehead
b. bilateral club feet
c. polydactyly
d. clenched hands
11. Scoliosis is an abnormal:
a. anterior angulation of the spine
b. posterior angulation of the spine
c. lateral curvature of the spine
d. thoracic defect of the spine
12. A term that refers to a heterogeneous group of congenital anomalies affecting the
distal spine and cord, the hindgut, the urogenital system, and the lower limbs is:
a. disruption canalization
b. lumbar/sacral absence
c. sirenomelia
d. caudal regression syndrome
13. A sacrococcygeal teratoma most commonly images as a protrusion:
a. at the umbilical cord insertion
b. at the thoracic region
c. at the lumbar region
d. between the anus and the coccyx
14. The earliest visible indication of caudal regression syndrome is:
a. a short crown-rump length and abnormal yolk sac
b. renal anomalies
c. gastrointestinal anomalies
d. lack of lower extremity movement during an ultrasound examination
15. Suspicion of open neural tube or abdominal wall defect is elevated with a MSAFP
of:
a. 0.10 MoM
b. 0.24 MoM
c. 1.0 MoM
d. 2.4 MoM
Fill-in-the-Blank
1. _________ images are considered best for evaluating structures of the fetal neck.
2. The fetal spine images with three brightly echogenic ossification centers in the
transverse plane by the _________ week of gestation.
3. Three types of scanning planes help with the evaluation of spinal integrity:
_________, _________, and _________.
4. AFP is elevated in NTD, other open fetal defects, such as _________ and _________,
as well as skin disorders that increase diffusion of AFP through fetal skin.
5. Cystic hygromas appear as either _________ or _________ fluid-filled cavities and
are usually located on the _________ neck.
6. The two types of spina bifida lesions are _________ and _________. The most
common form of the process is _________ spina bifida.
211
7. The location and severity of spina bifida has the greatest chance of detection on
_________ views.
8. Fusion of the fetal legs is known as the _________ syndrome.
9. The most common location of a neural tube teratoma is the _________ end.
10. Sagittal and coronal images of _________ anatomy may indicate spinal normalcy or
assist in locating anomalous deviations.
Short Answer
1. A concerned patient has questions about the MSAFP screening. Explain the test and
reasons for performing it, and what can be determined by the results.
2. Two clearly defined legs are not seen in a 21-week fetus during a level I screening
ultrasound. Offer a diagnosis and differential diagnosis.
1. Identify the anatomy displayed. Is it normal or abnormal? State the type of imaging that
produced the image.
212
2. What is the diagnosis? Note *’s.
3. Describe the anatomy depicted by the open arrow. Is it normal? Note: This is an 8-
week fetus.
4. Identify anatomy and the anomaly in the image.
213
CASE STUDY
1. A 23-year-old G1 patient with a family history of congenital “spine problems” was
sent for a level II ultrasound after her level I examination was reported as abnormal.
Explain the fetal spine ultrasound images.
214
2. A pregnant patient with a normal 22-week level I ultrasound complained of decreased
fetal movement and was sent for a nonstress text and AFI ultrasound. The
sonographer noted an anomaly during the ultrasound. View the images or the 30-
week fetus and offer a diagnosis. Explain the condition and likely outcome.
215
Fetal Echocardiography
CHAPTER 23

visit the point.

Matching

a. Abnormal heart rate
b. Without motion
c. Also known as endocardial cushion
defect. Partial: ASD in the lower portion
of the atrial septal defect without a
ventricular defect; Complete: heart with
both an ASD and VSD and a common
valve
d. Abnormal opening between the right and
left atria
e. Slow heart rate
f. Valves located between the atrium and
the ventricles
g. Apex of the heart points to the right
h. narrowing of the aorta
1. _________ double outlet right ventricle i. Connection between the umbilical vein
(DORV) and the inferior vena cava
2. _________ rhabdomyoma j. Both great arteries arise from the right
3. _________ akinetic ventricle with a VSD and pulmonary
stenosis. The same process can occur
4. _________ dextrocardia with the left ventricle with associated
5. _________ right ventricular hypoplasia AV and semilunar valve stenosis
6. _________ ventricular septal defect k. Displacement of the tricuspid valve
(VSD) toward the apex of the heart resulting in
7. _________ ductus venosus tricuspid stenosis and/or regurgitation,
atrialization of the right ventricle
8. _________ premature atrial contractions
(PACs) l. Impaired movement
9. _________ arrhythmia m. Calculation of the heart to chest size
resulting in a ratio
10. _________ truncus arteriosus
n. Opening between the atria allowing for
11. _________ dyskinetic blood flow from the right to the left
12. _________ atrial septal defect (ASD) during fetal life
13. _________ tricuspid atresia o. Subset of cells found in the developing
14. _________ septum primum heart tube that will give rise to the
heart’s valves and septa critical to the
15. _________ Ebstein’s anomaly
proper formation of a four-chambered
16. _________ papillary muscles heart
17. _________ coarctation of the aorta p. Underdevelopment of the left ventricle
18. _________ transposition of the great and aorta, stenosis or atresia of the
arteries (TGA) aortic and/or mitral valves
19. _________ endocardial cushion q. Accumulation of fluid in the chest and
abdomen due to heart failure
216 r. Irregular extra contraction of the atria out
of sync with the ventricles
20. _________ hydrops, nonimmune
s. Muscular projections into the ventricles
21. _________ bradyarrhythmia that anchor the chordae tendinae of the
22. _________ atrioventricular septal AV valves
defects (AVSDs) t. Common benign tumor found in either
23. _________ tetralogy of Fallot ventricle
24. _________ foramen ovale u. Single artery spanning the ventricles
25. _________ atrioventricular valve (AV) v. Single or multiple defect allowing
26. _________ hypoplastic left heart oxygenated blood from the left ventricle
syndrome (HPLHS) to pass into the right ventricle
27. _________ supraventricular w.Congenital heart malformation where the
tachycardia (SVT) aorta arises from the right ventricle and
28. _________ heart/thorax ratio (CTR) the pulmonary artery arises from the left
ventricle
29. _________ arrhythmia
x. Congenital absence of the tricuspid valve
y. Fast irregular heartbeat that is not
ventricular in origin. This may originate
from the atria, AV node, sinoatrial node,
or may be due to a congenital syndrome
such as Wolff–Parkinson–White
syndrome
z. Cyanotic heart malformation with a VSD,
pulmonary stenosis, overriding aorta,
right ventricular hypertrophy, pulmonary
obstruction due to valvular stenosis
aa.First section of the interatrial septum to
form in the embryo
bb.Also known as hypoplastic right heart.
Underdevelopment of the right ventricle
and hypoplasia of the tricuspid valve
cc.abnormal heart rate

Image Labeling
Fetal and newborn circulation
217
Hypoplastic left heart syndrome
Normal heart and heart with tricuspid atresia
218
Normal heart and heart with Ebstein’s anomaly
Normal heart and heart with persistent truncus arteriosus
CHAPTER REVIEW
Multiple Choice
1. The embryonic heart is completely formed at the:
a. beginning of the seventh week
b. beginning of the eighth week
c. end of the seventh week
d. end of the eighth week
2. Fetal blood circulates within the embryo at:
a. 2 weeks’ postconception
b. 6 weeks’ gestational age
c. 3 weeks’ postconception
d. 4 weeks’ gestational age
3. Fetal oxygenated blood circulation from the placenta enters the fetus through the:
a. umbilical vein to the hepatic circulation and left portal vein
b. umbilical vein to the ductus arteriosus and right atrium
c. umbilical artery to the ductus venosus and left portal vein
d. umbilical artery to the left portal vein and IVC
219
4. Fetal blood from the IVC enters the heart:

a. left ventricle
b. right ventricle
c. left atrium
d. right atrium
5. In the fetus, left atrial blood passes through the _________ into the left ventricle.
a. tricuspid valve
b. pulmonary valve
c. semilunar valve
d. mitral valve
6. The greatest concentration of oxygenated fetal blood is to the fetal:
a. abdominal organs
b. retroperitoneal organs
c. cranium
d. distal extremities
7. A normal heart orientation is:
a. levocardia
b. dextrocardia
c. mesocardia
d. dextroposition
8. In the normal fetal heart, which chamber is located closest to the fetal spine?
a. left atrium
b. right atrium
c. left ventricle
d. right ventricle
9. Fetal tachyarrhythmias are heart rates:
a. of more than 180 beats per minute
b. of less than 100 beats per minute
c. best assessed using Doppler
d. usually clinically significant
10. Digoxin, sotalol, and flecainide are most often selected for fetal treatment of:
a. complete heart block
b. SVT
c. PAC
d. VSD
11. A defect of the inlet, outlet, trabecular, or apical portion of the fetal septum involves
the:
a. ventricular septum
b. atrial septum
c. moderator septum
d. endocardial cushion
12. A syndrome that includes aortic atresia, a small left ventricle, and mitral valve
atresia is:
a. pulmonary atresia
b. tricuspid atresia
c. HLHS
d. aortic coarctation
13. Tetralogy of Fallot includes all except:
a. VSD
b. right atrial hypertrophy
c. overriding aorta
d. pulmonary atresia or stenosis
14. An abnormally large right atrium and abnormally small right ventricle is an
indication of:
a. Ebstein’s anomaly
b. TGA
c. overriding aorta
d. DORV
15. What anomaly describes a single vessel overriding a VSD and regurgitant flow?
a. TAPVR
b. valvular atresia
c. truncus arteriosus
d. DORV
16. The most common cardiac tumor is:
a. right ventricular teratoma
b. tuberous sclerosis
c. DiGeorge syndrome
d. rhabdomyoma
17. DORV involves:
a. severe ASD
b. a conotruncal defect with the aorta and pulmonary artery failing to divide
c. parallel aorta and pulmonary artery and VSD
d. premature closure of the foramen ovale
18. Ostium primum and ostium secundum defects involve the:
a. ventricular septum
b. atrial septum
c. moderator septum
d. IVC
19. The pulmonary valve receives blood from the:
a. right atrium
b. left atrium
c. right ventricle
d. left ventricle
20. Ultrasound resolution limits of _______ mm still prevent the identification of small
VSDs.
a. 1 to 2
b. 2 to 3
c. 3 to 4
d. 4 to 5
220
Fill-in-the-Blank
1. Blood begins to circulate in the embryo at _________ weeks’ postconception, which
is _________ weeks’ gestational age.
2. The fetal heart should consume most of the _________ side of the chest and lies at a
normal angle of _________ degrees to the _________ of midline, plus or minus 20
degrees. The normal position of the heart is termed _________.
3. A right-sided heart with the apex pointing left is called _________. A heart
positioned in the right chest with the apex pointing right is labeled _________. A
midline heart is termed _________.
4. The standard first view in an echocardiogram is the _________ view.
5. The subcostal fetal heart view is used for the _________ view, _________ view of
the ventricles, and Doppler interrogation of the _________.
6. A long axis view of the _________ artery demonstrates the RVOT. A long axis view
of the _________ demonstrates the LVOT.
7. The brachiocephalic, left common carotid, and left subclavian artery arise from the
_________ arch, which has a _________ shape or appearance.
8. A fetal sustained heart rate of 100 bpm or less is _________.
9. The most frequent cardiac malformation is _________, occurring in about 30% of live
births.
10. The three bypasses of the fetal heart that close at parturition are _________,
_________, and _________.
11. The 3D imaging mode used specifically for fetal cardiac imaging is _________.
12. Tricuspid atresia results in _________. It appears as a _________ valve.
13. Narrowing of the aorta along the arch is _________ and results in _________
obstruction.
14. Complete TGA demonstrates the great vessels running _________ from the
ventricles.
15. Endocardial cushion defect is also known as _________ or _________. This heart
defect can involve the _________, _________, and _________.
16. The _________ view of the fetal heart is often used for diagnosis of VSD.
17. Tubular structures called _________ are the first development of the fetal heart.
18. _________ atresia, similar to _________ atresia, results in a right ventricular
hypoplasia.
19. The _________ is the most common solid, benign cardiac mass seen in the fetus.
20. The correct flow direction through the foramen ovale is _________ to _________.
221
21. A structure in the right ventricle, the _________, should differentiate the right
ventricle from the left ventricle.
22. The structure that separates the right and left ventricular chambers is the _________.
23. The foraminal flap should be seen opening into the _________ atrium.
24. Tetralogy of Fallot is the result of five defects: a _________, _________,
_________, _________, and _________.
25. _________ is a condition where the aortic root and pulmonary artery arise from the
right ventricle.
26. Failure of the embryonic truncus to separate into the aorta and pulmonary artery is
known as _________.
Short Answer
1. In the case of suspected arrhythmia, where on the fetal heart should M-mode tracings
be performed?
2. Describe the most diagnostic views for diagnosing Ebstein’s anomaly.
3. What two cardiac malformations display parallel great vessels?

4. State where the flap, related to the foramen ovale, is visualized in the normal fetal
heart.
5. What view displays the brachiocephalic, left common carotid, and subclavian artery?
222
1. Diagnose the single image.

2. Describe the view. Explain the anatomy and offer a diagnosis.
223
3. Describe the view and state the name of the structure exiting the left ventricle. Explain
the labels LV, RV, LA, and AoV.
4. What view was used to collect the image? State the anatomy depicted by the long
arrow, short thick arrow, dashed arrow, open arrow, and curved arrow.
5. Describe the defect (see arrow).
224
CASE STUDY
1. A 38-year-old G1 patient elected to have an echocardiogram of her fetus because of

soft markers noted on the midpregnancy anatomy examination. The soft markers
found included a left choroid plexus cyst measuring 0.7 × 0.8 cm and short femurs.
Diagnose the health of the fetal heart.
225
2. This 28-year-old G3 P2 patient complained of not feeling fetal activity for 6 hours.
She had followed her obstetrician’s suggestion of drinking a sweetened beverage
and lying in a quiet room for 1 hour. Since the movement test failed to provide
results, she presented to the doctor’s office where abdominal Doppler testing
suggested an elevated heart rate. She then moved to the ultrasound suite for fetal
imaging. View the image and make a diagnosis.
226
227
Sonographic Assessment of the Fetal Chest
CHAPTER 24

visit the point.

Matching

a. Adds motion to static 3D imaging,
allowing for real-time 3D imaging of
anatomy in motion
b. Toward the back or spine
c. Less echogenic or “darker” on a
sonographic image
d. Accumulation of fluid in the fetal tissues,
peritoneum, and pleural cavities due to
either immune or nonimmune factors
e. From a volume dataset, static 3D images
can display height, width, and depth of
anatomy (three dimensions) from any
orthogonal plane
f. Ability to generate echoes; the
sonographic brightness or darkness
g. Direction you are looking at a patient or
structure, (i.e., anterior to posterior)
h. Half-Fourier acquisition single-shot
turbo spine-echo; a fast spin method to
obtain the MRI dataset
i. Underdevelopment or incomplete
1. _________ anatomic position development of a body part
2. _________ aplasia j. Generalized edema in the subcutaneous
tissue
3. _________ 4D imaging
k. Birth defect of the diaphragm that allows
4. _________ B-mode imaging the abdominal contents to enter the chest
5. _________ bronchogenic cyst l. Areas of low intensity or increased
6. _________ anasarca brightness on the MRI image; equivalent
7. _________ cardiomegaly to hypoechogenic
8. _________ caudal m. Complete absence of a body part
9. _________ 3D imaging n. Genetic disorder causing extremely
fragile bones
10. _________ chorioamnionitis
o. Toward the head or cranium
11. _________ congenital diaphragmatic
hernia (CDH) p. Noncommunicating lung tissue that lacks
pulmonary blood supply
12. _________ congenital multicystic
adenomatoid malformation (CCAM) q. “Brightness-mode” imaging displays
anatomy in two dimensions on the
13. _________ cranial
display screen. The stronger the
14. _________ dorsal returning echo, the brighter the
15. _________ echogenic corresponding dot is on the display.
16. _________ echogenicity Distance from the transducer face is
displayed with the near-field anatomy on
17. _________ echotexture the top of the display and far-field
18. _________ fetal lie anatomy at the bottom of the monitor
display
228 r. Areas of similar intensity or increased
brightness on the MRI image; equivalent
19. _________ fetal presentation
to isoechoic
20. _________ HASTE
s. Term used to describe which portion of
21. _________ hemangioma the fetus will deliver first
22. _________ hydrops t. An enlarged heart
23. _________ hyperintense u. Incomplete development of the lung
24. _________ hypoechoic tissue
25. _________ hypointense v. Relative level of sonographic
echogenicity of a structure
26. _________ isointense
w.Solitary cyst within the lung
27. _________ IUGR
x. This group of findings, also called Potter
28. _________ longitudinal syndrome or oligohydramnios sequence,
29. _________ look direction includes renal conditions such as
30. _________ mediastinum chest agenesis, obstructive processes, and
acquired or inherited cystic disease
31. _________ osteogenesis imperfecta
y. Along the axial cross-section or short
32. _________ Potter sequence
axis of the anatomy being imaged
33. _________ pulmonary hypoplasia
z. Body in the erect position with the palms
34. _________ pulmonary sequestration forward and feet pointed forward
35. _________ real-time imaging aa.Semiautomated process to calculate
36. _________ transverse volume using a 3D dataset
37. _________ ventral bb.An inflammation of the fetal membranes
38. _________ VOCAL (amnion/chorion) due to infection
39. _________ hypoplasia cc.B-mode images are built onto the screen
as the sound beam sweeps through the
tissue
dd.Generates echoes; brighter
sonographically
ee.Toward the belly or front
ff. Benign mass made up of blood vessels
gg.Toward the feet or tail end
hh.Along the length or long axis of the
anatomy being imaged
ii. Replacement of normal lung by
nonfunctioning cystic lung tissue
jj. Area lying between the lungs, which
contains the heart, aorta, esophagus,
trachea, and thymus
kk.Position of the fetus in utero
ll. Areas of high intensity or increased
brightness on the magnetic resonance
imaging (MRI) image; equivalent to
hyperechogenic
mm.Fetal weight below 10th percentile for
gestational age
229

Image Labeling
Anatomical scan planes

Congenital diaphragmatic hernia
Congenital diaphragm deviation
230
CHAPTER REVIEW
Multiple Choice
1. The term describing fetal presentation when the topmost portion of the cranium is
closest to the cervix is:
a. breech
b. cephalic
c. vertex
d. cranial
2. Frank breech means:
a. buttocks are presenting first, and both the hips and knees are flexed.
b. one or both feet are presenting first
c. fetal buttocks present first (toward the cervix) and the hips are flexed so the legs
are straight and completely drawn up toward the fetal chest
d. knees are presenting first
3. The thoracic inlet is at the:
a. level of the mouth
b. base of the neck, level of clavicles
c. base of the lungs
d. level of C1
4. In normal situs, the fetal heart lies with the apex oriented toward the:
a. liver
b. stomach
c. spleen
d. gallbladder
5. A break in the skin surface directly over the spine is associated with:
a. nonossified spinous processes
b. convergence of the paired posterior ossified elements
c. deleted spinous processes
d. myelomeningocele
6. Thoracic chest measurements (outer edge to outer edge) are obtained from a true
transverse view at the level of the:
a. fetal heart
b. three-vessel view
c. cardiac apex
d. widest portion of lung
7. If the fetal heart (in transverse view) occupies more than 1/3 of the thorax, _________
should be considered:
a. pulmonary hypoplasia
b. cardiac hypoplasia
c. pulmonary hyperplasia
d. cardiac hyperplasia
8. Fetal lung development begins in what week?
a. third
b. fourth
c. sixth
d. eighth
9. Respiration becomes possible during the _____ week because of development of
terminal saccules.
a. 20th
b. 24th
c. 26th
d. 28th
10. Fetal lung volume can be estimated by all except:
a. MRI
b. VOCAL
c. 3D data set
d. 2D coronal
11. Successfully locating the oropharynx and laryngeal pharynx is accomplished with a:
a. longitudinal view through the upper neck and an empty pharynx
b. transverse view through the upper neck and an empty pharynx
c. longitudinal view through the upper neck and a fluid-filled pharynx
d. transverse view through the upper neck and a fluid-filled pharynx
12. Lung masses include all except:
a. CCAM
b. aortic aneurysm
c. teratoma
d. pulmonary atresia
231
13. CCAM typically appears as all except:
a. a bilateral large predominantly cystic mass of the lower lobes
b. a unilateral pulmonary mass with one or more large cysts
c. an echogenic mass containing small cysts
d. a homogeneous echogenic mass
14. The presence of abnormal and excessive skin or soft tissue in the nuchal area is a
well-known and common clinical finding in many newborns with Trisomy 21, and is
suspect if the nuchal fold measures:
a. 2 mm or greater in the 8th to 11th week
b. 2 mm or greater in the 11th to 13th week
c. 4 mm or greater in the 19th to 24th week
d. 6 mm or greater in the 19th to 24th week
15. Fetal posterolateral neck thickening may be caused by all except:
a. absent clavicles
b. failure of the lymphatic channels to communicate
c. nuchal skin thickening
d. Turner syndrome
16. The most accurate term for a collection of lymph within the chest is referred to as:
a. hydrothorax
b. chylothorax
c. pleural effusion
d. milky effusion
17. Nonimmune fetal hydrops is related to:
a. erythroblastosis fetalis
b. severe anemia
c. severe fetal disease
d. Rh incompatibility
18. The AC measurement in a fetus with CDH:
a. is smaller than normal
b. is larger than normal
c. is normal
d. displays ascites
Fill-in-the-Blank
1. The dorsoventral axis forms by connecting the _________ to the _________ of the
fetus.
2. _________ and less “invasive” _________ imaging may aid in the evaluation of fetal
structures lying low within the maternal pelvis at the time of the ultrasound
examination.
3. Clavicular growth has a direct relationship to gestational _________.
4. The typical scapula has a sonographic appearance of a _________ or _________
shape, depending on the angle of insonation.
5. The soft tissues may appear thick with generalized fetal _________ or because of
_________ deposits in infants of diabetic mothers.
6. Lung development occurs throughout gestation, resulting in the division of
development into these stages: _________, _________, _________, _________,
and _________.
7. _________ remains the gold standard in accessing lung maturity.
8. The fetal diaphragm is seen as a thin, hypoechoic, dome-shaped muscular band
separating the _________ cavities from _________.
9. Pleural effusions are an accumulation of pleural _________ in the fetal lungs.
10. A pulmonary sequestration is a solid, nonfunctioning mass of lung tissue contained
within the pleural sac that lacks communication with the _________ tree and has a
systemic arterial blood supply.
232
11. Fetal edema may be limited to the neck and is more often associated with fetal
_________ and increased _________ thickness, forming a halo pattern around the
neck, thorax, or abdomen.
12. Cystic hygromas are thought to be a result of a failure in the development of normal
_________ venous communication.
13. Compression on the esophagus by a mass could lead to _________ because of GI
tract obstruction.
14. The heart and mediastinum in a fetus with CDH shift _________ from the side of
herniation.
15. The thymus is located at the level of the great vessel of the heart, _________ to the
aorta and pulmonary artery.
16. The _________ enlarges with immune fetal hydrops and infections.
17. _________ is the most frequently found mass within the fetal chest.
18. To differentiate pulmonary sequestration from CCAM, use _________ to trace the
origin of feeder vessels.
Short Answer
1. Describe the appearance of a normal diaphragm.
2. a. What is the normal presentation for birth?
b. How is a vertex-facing fetus positioned?
c. How is a “transverse-head maternal left” fetus positioned?
3. How is CCAM viewed differently from pulmonary sequestration using ultrasound?

Will MRI, as a complementary imaging modality, be helpful to differentiate the two
processes?
233
4. Explain immune fetal hydrops and compare it with nonimmune fetal hydrops.
1. a. Name the view.
b. Explain why a dotted circular line (arrow) is seen.
c. What is the short arrow pointing to?
2. What are the arrows pointing at?
234
3. Name the structure seen between the arrows.
4. Name the structures at the arrow ends. State the fetal condition.
235
CASE STUDY
1. A screening ultrasound of this fetus reported a possible chest/lung mass. CCAM or

pulmonary sequestration was suspected. An advanced sonogram was performed.
Review the image obtained during the level II examination and offer a diagnosis.
2. A 21-week fetal anatomy scan was performed as a routine to confirm normalcy and
dates. Explain the images and provide a diagnosis.
236
237
Sonographic Assessment of the Fetal

Abdomen (Includes Abdominal Wall)
CHAPTER 25

visit the point.

Matching

a. Congenital disorder where the spinal
cord does not close before birth
b. Congenital blockage or absence of the
bile duct
c. Dilation of the renal pelvises and calices,
usually caused by obstruction
d. Semiautomated process to calculate
volume using a 3D dataset
e. Complete absence of a body part
f. Areas of similar intensity or increased
brightness on the MRI image; equivalent
to isoechoic
g. Accumulation of fluid in the abdominal
cavity
1. _________ VOCAL
2. _________ upper GI h. Reversal of normal organ position
3. _________ trisomy i. Congenital lack of nerves in the colon
resulting in fecal impaction and a
4. _________ situs inversus megacolon
5. _________ parvovirus infection j. Congenital absence or closing of the
6. _________ omphalocele duodenal lumen
7. _________ midgut volvulus k. Membrane-covered ventral wall defect
8. _________ myelomeningocele (spina containing abdominal contents involving
bifida) the umbilical cord
9. _________ meconium ileus l. Adds motion to static 3D imaging,
allowing for real-time 3D imaging of
10. _________ isointense anatomy in motion
11. _________ hypointense m. From a volume dataset, static 3D images
12. _________ hyperintense can display height, width, and depth of
13. _________ hydronephrosis anatomy (three dimensions) from any
orthogonal plane
14. _________ Hirschsprung disease
n. Radiographic study using barium sulfate
15. _________ hematopoiesis as a contrast agent to outline and fill the
16. _________ HASTE gastrointestinal tract
17. _________ gastroschisis o. Areas of low intensity or decreased
18. _________ duodenal atresia brightness on the MRI image; equivalent
to hypoechogenic
238 p. Bowel obstructed by mucus
19. _________ caliectasis q. Congenital disorder caused by
transplacental transmission of the
20. _________ biliary atresia parvovirus to the fetus, characterized by
21. _________ ascites hydrops, ascites, ventriculomegaly, and
22. _________ aplasia other findings
23. _________ 4D imaging r. Areas of high intensity or increased
brightness on the magnetic resonance
24. _________ 3D imaging imaging (MRI) image; equivalent to
hyperechogenic
s. Membrane-free ventral wall defect with
protrusion of abdominal contents lateral
to the umbilical cord
t. Genetic abnormality in which there are
three copies of a particular chromosome
u. Formation of blood cells
v. Bowel obstructed due to bowel twisting
w.Dilation of the renal calices
x. Half-Fourier acquisition single-shot
turbo spin-echo; a fast spin method to

Image Labeling
Fetal circulation
239
Omphalocele
Gastroschisis
240
CHAPTER REVIEW
Multiple Choice
1. The fetal organ that is usually not seen well in the second trimester is the:
a. liver
b. gallbladder
c. pancreas
d. kidneys
2. Left parasagittal views of the fetal abdomen demonstrate the:
a. stomach and left kidney
b. liver and right kidney
c. umbilical entry
d. diaphragm
3. The umbilical vein can be followed in a sagittal view from the anterior abdominal
wall into the:
a. main portal vein
b. inferior vena cava
c. ductus venosus
d. liver’s left portal vein
4. The allantois is:
a. involved in early placental maturation
b. involved in early blood production
c. involved in production of Wharton’s jelly
d. a permanent structure
5. After birth, the ductus venosus closes and becomes the:
a. fissure of ductus
b. ligamentum venosum
c. foramen ovale
d. ligament of Treitz
6. Fetuses of diabetic mothers often display:
a. increased abdominal circumference
b. decreased abdominal circumference
c. increased cranial circumference
d. decreased cranial circumference
7. A correct AC measure includes the:
a. fetal lungs
b. ribs/spine
c. soft tissue surrounding the ribs/spine
d. kidneys
8. The spleen is part of the:
a. digestive system
b. neurologic system
c. respiratory system
d. lymphatic system
9. In a fetus, the spleen is similar in echogenicity to the:
a. kidney
b. liver
c. gut
d. stomach
10. Herniation of the midgut resolves by week:
a. 8
b. 10
c. 12
d. 14
11. Complete situs inversus means the:
a. cardiac apex is on the left and the liver on the right
b. cardiac apex is on the right and the liver on the left
c. cardiac apex is on the left and the liver on the left
d. cardiac apex is on the right and the liver on the right
12. Duodenal atresia involves a fluid-filled stomach and duodenum at the site of
obstruction, which demonstrates a(n):
a. image of a small stomach
b. “double-bubble” image
c. elongated stomach image
d. a long hypoechoic tubular appearance displaying the stomach and intestine without
stricture
13. The descending colon wall-to-wall diameter measurement varies with fetal
gestational age, but should not measure greater than _____ in a preterm fetus.
a. 8 mm
b. 14 mm
c. 1.6 cm
d. 2.0 cm
241
14. Mean fluid volume of amniotic fluid in 20 weeks is:

a. 250 mL
b. 500 mL
c. 750 mL
d. 1,000 mL
15. Oligohydramnios is common with:
a. renal anomalies
b. cardiac anomalies
c. thorax anomalies
d. GI malformations
16. Single umbilical artery is usually insignificant, but has been associated with all
except:
a. gastrointestinal tract abnormalities
b. renal and cardiac abnormalities
c. increased incidence of trisomy
d. pulmonary sequestration
17. Gastroschisis is a wall defect that typically occurs ____ the umbilical cord insertion.
a. superior to
b. inferior to
c. to the left of
d. to the right of
18. Ultrasound displays the fetal liver echotexture as:
a. heterogeneous
b. homogeneous
c. hypointense
d. hyperintense
Fill-in-the-Blank
1. Fetal abdominal organs have attained their normal adult position and structure in the
early _________ trimester.
2. The presence of intact skin surface covering vertebral bodies is helpful to rule out
_________.
3. The fetal abdominal wall displays an outer _________ skin line and a deeper, 1- to 3-
mm _________ muscular layer.
4. A two-vessel cord is most common in a _________ pregnancy.
5. A true transverse AC demonstrates the _________ spine, left-sided stomach, and the
_________ entering into the left portal vein.
6. Absence of the fetal gallbladder may be associated with several conditions, including
biliary _________.
7. Filling and emptying of the fetal stomach occurs, causing absent stomach images,
which requires _________ by a sonographer.
8. Midgut herniation is seen on an early fetus at the _________ portion of the embryo.
9. Duodenal atresia is the failure of the duodenum to change from a solid _________ of
tissue during development to a _________.
10. A volvulus is an obstruction caused by the bowel _________ upon its blood supply.
11. Meconium ileus is most often due to _________.
12. The umbilical cord consists of _________ umbilical vein and _________ umbilical
arteries.
13. Echoes within the stomach can be associated with swallowed _________.
242
14. An omphalocele has a _________, whereas gastroschisis does not.

15. Midgut volvulus is usually diagnosed in the first days of life; the infant typically
presents with _________.
16. The internal structures of the fetal kidneys are not reliably assessed before
_________ weeks.
17. Esophageal maldevelopment is mostly related to the _________ gender.
18. An echogenic mass within the fetal gallbladder may be related to _________ or
_________.
19. Diffuse liver calcifications occur in fetuses with intrauterine _________.
20. The fetal stomach is consistently seen in the _________ trimester.
Short Answer
1. Explain why the distal small bowel does not demonstrate filling until the third
trimester.
2. Duodenal atresia is often related to multiple anomalies. State the associated

anomalies.
3. Echogenic appearing bowel may be caused by a normal fetal abdominal process. It

may also be a cause for concern. Explain.
4. List the three most common fetal bowel obstructions.
243
1. a. Name the view and state what is shown.
b. Name the structures the arrows are directed toward.
c. What is the circular anatomy positioned in between the structures in b.
2. Explain the view of the umbilical cord. What are the arrows directed toward? Is the
cord normal?
244
3. Are the four arrows directed toward ascites?
4. a. The arrow in image A points to the fetal stomach. Name the view.
b. Discuss the appearance of the fetal stomach (arrow) in image B, and offer a
comment.
245
CASE STUDY
1. Diagnose images A and B. Explain the likeness and differences of the young fetuses.
Hint: Image A involves the umbilical cord, whereas image B does not.
2. A screening ultrasound was performed on a 21-week 3-day fetus. The sonogram

reported as normal except for the fetal abdomen, which was somewhat enlarged and
demonstrated hypoechoic regions in the mid-to-inferior abdomen. A follow-up
ultrasound demonstrates abdomen images, oblique view image A, and a transverse
view image B. Describe the images and make a diagnosis.
246
247
Sonographic Assessment of the Fetal

Genitourinary System
CHAPTER 26

visit the point.

Matching

a. Serous fluid accumulation in a body
cavity such as the scrotum
b. Representing two genders
c. Underdevelopment or incomplete
development of a body part
d. This group of findings, also called Potter
syndrome or oligohydramnios sequence,
includes renal conditions such as
agenesis, obstructive processes, and
acquired or inherited cystic disease
1. _________ agenesis
e. Complete absence of a body part
2. _________ aplasia
f. Type of kidney where the upper poles
3. _________ bladder exstrophy fuse, resulting in an appearance similar
4. _________ caliectasis to a horseshoe
5. _________ dysmorphism g. Congenital disorder of the urinary system
6. _________ horseshoe kidney resulting in the absence of the abdominal
muscles, undescended testicles, and
7. _________ hydrocele urinary tract problems
8. _________ HASTE h. Congenital anomaly where the bladder is
9. _________ hypoplasia outside the body through a ventral wall
10. _________ posterior urethral valves defect inferior to the umbilical cord
11. _________ Potter sequence i. Dilation of the renal pelvices and calices,
usually caused by obstruction
12. _________ prune belly syndrome
j. Failure of development
13. _________ 3D imaging
k. Obstructing membrane in the male urethra
14. _________ hydronephrosis
located posteriorly because of abnormal
urethral development
l. Dilation of the renal calices
m. Half-Fourier acquisition single-shot
turbo spin-echo; a fast spin method to
n. From a volume dataset, static 3D images
can display height, width, and depth of
anatomy (three dimensions) from any
orthogonal plane
248
CHAPTER REVIEW
Multiple Choice
1. In the first trimester, fetal kidneys appear __________ to the surrounding anatomy.
a. hypoechoic
b. isoechoic
c. hyperechoic
d. echogenic
2. When the second trimester fetal renals are difficult to visualize, what method will
assist in imaging them?
a. repositioning the mother
b. giving the mother 20 ounces of water to drink
c. color and/or power Doppler
d. reimaging the region after the fetus moves
3. The fetal bladder should be visualized by:
a. 7 to 9 weeks
b. 9 to 11 weeks
c. 11 to 13 weeks
d. 13 to 15 weeks
4. The fetal bladder fills and voids approximately once every:
a. 15 minutes
b. 30 minutes
c. 60 minutes
d. 2 hours
5. Bladder wall thickness cannot be visualized clearly without:
a. a completely voided structure
b. the bladder being distended
c. a transverse approach
d. ascites
6. Oligohydramnios is defined as an amniotic fluid volume of less than ____ cc, as
indicated by a maximum vertical pocket (MVP) of less than 2 cm or an amniotic
fluid index (AFI) of less than ____ cm on ultrasound
a. 500, 5
b. 750, 5
c. 500, 2
d. 750, 2
7. __________ is a condition that a fetus has pulmonary hypoplasia secondary to
oligohydramnios, typically because of renal failure.
a. Prune belly syndrome
b. VUR
c. Hirschprung disease
d. Potter syndrome
8. In the case of the unilateral agenesis, the existing kidney is invariably larger than in a
fetus with two kidneys because of:
a. compensatory hypertrophy
b. anhydramnios
c. double renal artery in the existing kidney
d. UPJ
9. Renal ectopia is a condition:
a. that is incompatible with life
b. where the bilateral kidneys are cystic
c. of aplastic kidneys
d. where a kidney is positioned outside of the renal fossa
10. Horseshoe kidney has the highest prevalence in fetuses with:
a. Turner syndrome
b. Down syndrome
c. Edwards syndrome
d. Patua syndrome
11. Severe fetal hydronephrosis is an APRPD over:
a. 9 mm
b. 11 mm
c. 13 mm
d. 15 mm
12. The prognosis is poor for a fetus with all except:
a. bilateral hydronephrosis
b. pulmonary hypoplasia
c. isoechoic renal echogenicity
d. bladder obstruction
13. In a 30-week fetus, megaureter is diagnosed when the ureter measures greater than:
a. 3 mm
b. 5 mm
c. 6 mm
d. 7 mm
14. A ureterocele is mostly associated with:
a. a duplicated collecting system
b. bilateral ureters
c. a distended bladder
d. males
249
15. Predominantly female renal and/or bladder anomalies include:

a. crossed renal ectopia
b. obstructive uropathy
c. polycystic kidneys
d. Prune belly syndrome
16. Causes of UPJ include all except:
a. ureteral kinks
b. peripelvic adhesions
c. aberrant crossing renal vessels
d. bladder dilation
17. Mesoblastic nephromas are mostly:
a. related to oligohydramnios
b. related to polyhydramnios
c. related to a poor prognosis
d. small
18. The fetal adrenals are best imaged in the:
a. first trimester
b. second trimester
c. third trimester
d. any trimester
19. Labels relating to disorders of sex development include all except:
a. sex chromosome genotype
b. pseudo-hermaphroditism
c. ambiguous genitalia
d. intersex
20. Choose the type of kidney that causes hypertension:
a. echogenic
b. enlarged
c. pelvic
d. horseshoe
Fill-in-the-Blank
1. The most common fetal malformation involves the _________ system.
2. In a transverse plane, fetal kidneys are _________ shaped.
3. The _________ arteries will assist in locating the fetal bladder.
4. The amount of amniotic fluid observed has a direct correlation with the _________ of
the fetus.
5. The presence of _________ after 16 weeks’ gestation raises suspicion for a
malfunctioning GU system.
6. Renal _________ is the congenital absence of one or both kidneys.
7. _________ renal ectopia is a kidney located on the opposite side from which its
ureter inserts into the bladder.
8. A pelvic kidney is located _________ to the renal fossa and _________ to the
bladder.
9. Pelvic dilation in the third trimester means the renal pelvis is dilated over
_________.
10. _________ is the permanent or intermittent retrograde flow of urine from the bladder
into the upper urinary tract.
11. Autosomal recessive polycystic kidney disease (ARPKD) affects both kidneys and is
also known as _________ polycystic kidney disease.
12. A single, nonseptated renal cyst with well-defined borders and no communication
with the renal pelvis describes a _________ renal cyst.
13. The most basic conventional grading system for hydronephrosis characterizes the
kidneys as _________, _________, or _________.
14. Bladder exstrophy demonstrates as a soft tissue mass extending from the _________
wall, with nonvisualization of the normal fetal bladder.
15. _________ kidneys are the most common renal fusion anomaly.
250
16. A posterior urethral valve is an obstructing _________ in the posterior urethra

caused by redundant membranous folds.
17. The most common cause of congenital obstructive hydronephrosis is _________
obstruction.
18. _________ is the failure of the testes to complete the migratory descent into the
scrotum.
19. Megacystitis is _________.
20. Pelviectasis is dilation of the _________ and _________.
Short Answer
1. Explain common ovarian anomalies that can be seen sonographically in the female
fetus.
2. Name and explain the condition demonstrating two commonly seen umbilical arteries
in the fetal pelvis without a cystic structure in between them.
3. Compare and contrast caliectasis, pelviectasis, and pelvicaliectasis.
1. a. What are the arrows directed toward?
b. Are the structures normal?
c. Describe the central portion of the structure.
d. Name the view.
251
2. a. Image A is a transverse demonstrating bilateral kidneys (K); image B is a coronal

view of the same fetus. Both images show an arrow. What structure is the arrow
pointing at?
252
3. Explain the anomaly seen in this 22-week fetal bladder.
253
4. Name the two hypoechoic structures in the sagittal fetus.

254
CASE STUDY
1. Both parents of the fetus in images A to C have family members with renal disorders,
although they are unsure of the exact urinary system family history. The images were
obtained during the 22-week anatomy ultrasound. Diagnose these images.
255
2. A sonographer who just completed training produced the attached images of a 32-
week fetus. The sonographer was unsure of the findings. Review and explain the
images.
256
257
Normal and Abnormal Fetal Limbs
CHAPTER 27

visit the point.

Matching

a. Shortening of the most proximal portion
of a fetal limb
b. Abnormally short limb
1. _________ mesomelia c. Flattened vertebral bodies with a
decreased distance between the
2. _________ syndactyly endplates
3. _________ talipes d. Fusion of soft tissue or body segments of
4. _________ rhizomelia fetal digits
5. _________ acromelia e. Shortening of the most distal portion of a
6. _________ platyspondyly fetal limb
7. _________ polydactyly f. Condition of having more than the normal
number of digits on a hand or foot
8. _________ micromelia
g. Abnormal shortening of the middle
portion of a limb
h. Abnormal position of the fetal foot and
ankle
CHAPTER REVIEW
Multiple Choice
1. Between the 32nd and the 35th weeks, the epiphyseal regions of the ___________ can
be seen sonographically:
a. radius and ulna
b. tibia and fibula
c. femur and humerus
d. femur and tibia
2. The normal fetal hand should be viewed in:
a. a flexed position
b. an extended position
c. both flexion and extension positions
d. fixed position
3. A short limb dysplasia affecting the humerus is:
a. rhizomelia
b. osteogenesis imperfecta
c. camptomelia
d. achondrogenesis
4. Shortening of an entire limb is known as:
a. hypophosphatasia
b. micromelia
c. mesomelia
d. dysplasia
258
5. Micrognathia is:
a. an abnormally small lower jaw
b. abnormally shaped ears
c. frontal bossing
d. a prominent forehead
6. A type of skeletal dysplasia demonstrating sonographically as a narrow bell-shaped
thorax is most likely:
a. pulmonary hypoplasia
b. VACTERL
c. OI Type IV dysplasia
d. short rib syndrome
7. Characteristics of rhizomelic limb bowing, frontal bossing, a low nasal bridge, a
“trident” configuration of the hand, macrocephaly, and hydrocephaly may be noted
with:
a. achondrogenesis
b. achondroplasia
c. sirenomelia
d. phocomelia
8. Select the syndrome with the best prognosis for living into adulthood:
a. asphyxiating thoracic dysplasia
b. short rib-polydactyly syndrome
c. achondrogenesis
d. Ellis–van Creveld Syndrome (EvC)
9. Central polydactyly affects the:
a. radial side of the hand
b. ulnar side of the hand
c. three middle digits of the hand
d. thumb
10. The absence of one or more hands is:
a. phocomelia
b. hemimelia
c. apodia
d. acheiria
11. Holt–Oram syndrome demonstrates abnormalities of the skeletal system and:
a. respiratory system
b. cardiac system
c. cranium
d. urinary system
12. Amniotic band sequence is believed to be related to all except:
a. cleft lip/palate
b. ectopia cordis
c. polydactyly
d. amputation
13. The “mermaid syndrome” is rare and lethal, and also known as:
a. absent radii syndrome
b. sirenomelia
c. mesomelia
d. congenital hypophosphatasia
14. Fetal hands and feet anomalies include all but:
a. extra fingers
b. clubbing
c. ischemia
d. finger reduction
15. Congenital hypophosphatasia is an inherited disease related to:
a. defective bone mineralization
b. maternal cocaine use
c. maternal diabetes
d. amniotic sheeting
16. Maternal hyperthyroidism contributes to:
a. phocomelia
b. craniosynostosis
c. caudal regression
d. limb measurements below the 10th percentile
17. What is the most likely cause of digit and limb amputation?
a. amniotic sheets
b. oligohydramnios
c. amniotic bands
d. dysostosis
18. The most common cause of skeletal deformities is:
a. oligohydramnios
b. uterine tumor
c. müllerian anomalies
d. toxic agents
19. Polyhydramnios is common with all except:
a. camptomelic dysplasia
b. TD
c. short rib-polydactyly syndrome
d. achondroplasia
20. Select the thickest extremity long bone:
a. tibia
b. ulna
c. fibula
d. radius
259
Fill-in-the-Blank
1. Fetal _________ limb buds image prior to _________ limb buds.
2. Primary ossification centers of limbs are visualized at _________ weeks, and from
_________ weeks forward, long bones can be accurately measured.
3. Femoral, _________, and humeral epiphyseal visualization suggests fetal maturity.
4. Bones that are thin or deformed caused by abnormal development of cartilage and
osseous tissue are known as _________.
5. The premature fusion of one or several cranial sutures is _________.
6. _________ is a condition involving abnormal ossification.
7. A dysplasia with an extremely poor prognosis due to respiratory complications from
hypoplastic lungs and micrognathia is _________.
8. OI (osteogenesis imperfecta) is rare, inheritable, and related to defects in _________
quality or quantity.
9. Meromelia is a(n) _________ of part of a limb.
10. A fetal forearm with an absent radius is frequently noted to have a radially deviated
hand, which appears as a _________.
11. VACTERL association is defined as V_________, A_________, C_________,
T_________, R_________, L_________
12. Clubfoot is frequently caused by _________ or other conditions that limit fetal
movement.
13. Amniotic bands, known as _________, are associated with medical procedures
involving the uterine _________ and intrauterine infections.
14. Lower extremity fusion is postulated to be caused by a _________ steal
phenomenon.
15. Skeletal dysplasias are mostly _________ to the fetus.
16. Osteogenesis imperfecta causes prenatal bone _________ and fractures.
17. A fetus with an extremely narrow thorax, rhizomelic limbs, polydactyly, pelvic
anomalies, and renal anomalies describes _________ dysplasia.
18. Achondrogenesis is lethal because of _________.
19. The femur bone may resemble the _________ bone on fetal sonography.
20. The most severe form of OI is Type _________.
260
Short Answer
1. Explain expected femur growth throughout pregnancy.
2. What fetal bony structures can be accurately measured to determine growth and size?
3. List the information that may be gathered from long bone measurements and
evaluation.
4. Explain cranial abnormalities that are visualized with sonography interrogation.
5. Discuss the challenges of detecting and diagnosing skeletal dysplasia.
1. Name the structure in the image. Diagnose the condition.
261
2. What type of imaging produced the image? Describe the visualized structure and
position. State the anomaly.
3. Define the pathology on the ultrasound in image A and the radiograph in image B, and
make a diagnosis.
262
4. Explain the syndrome based on the transverse view of the fetal spine in image A and
the magnified view of the fetal hand in image B.
5. Identify and label the extremity anomaly.
263
CASE STUDY
1. An 18-year-old G1 patient who is a late pregnancy registrant presented to the
obstetrician at approximately 30 weeks. Typical laboratory testing and ultrasound
was ordered. The fetal profile image reveals a face, thorax (T), and abdomen. Offer
a diagnosis and sonographic advice based on the single image.
2. A patient delivered at 39 weeks by cesarean section an infant with known dwarfism
characteristics that were detected sonographically. The fetus was noted to have
frontal bossing, macrocephaly, and rhizomelia with bowing. The radiographs were
obtained because of postnatal unexpected hand configuration. Explain the images.
264
265
The Biophysical Profile
CHAPTER 28

visit the point.

Matching

a. Describes an incorrect negative test
result when the state being tested is
present. Example: The fetus reacts
during a BPP; however, there is fetal
compromise due to acidosis.
b. Low fluid surrounding the fetus
c. Abnormally high level of circulating
carbon dioxide
d. Reduced blood oxygen levels
e. Prenatal testing including only the NST
and AFI
f. Positive result when the state being tested
is absent. Example: Nonreactive BPP
1. _________ hypoxemia due to fetal sleep cycles
2. _________ pH g. Intravenous injection of oxytocin causing
3. _________ amniotic fluid index (AFI) the uterus to contract. Monitoring of the
fetal reaction to uterine contractions
4. _________ asphyxia
aims to determine how the fetus reacts to
5. _________ false negative environmental stress.
6. _________ biophysical profile h. Measure of alkalinity or acidity of the
7. _________ oxytocin challenge test blood with neutral at 7; greater than 7 is
(OCT) alkaline; and less than 7 is acidic
8. _________ nonstress test (NST) i. Amount of fluid within the amniotic sac
9. _________ cardiotocographic (CTG) surrounding the fetus. The AFI is an
estimate of this amount.
10. _________ false positive
j. Rough estimate of the fluid surrounding
11. _________ acidosis the fetus obtained through the
12. _________ amniotic fluid volume measurement of four pockets of amniotic
(AFV) fluid, one from each of the abdominal
13. _________ hypercapnia quadrants
14. _________ modified biophysical k. Monitoring of fetal activity to include
profile breathing movements, discrete
movements, tone, and fluid surrounding
15. _________ oligohydramnios the fetus accompanied by a NST
l. Blood pH below 7 resulting from an
increase in hydrogen concentrations due
to impaired blood supply to the fetus
m. Technique of concurrently recording the
fetal heartbeat and contractions
n. Decrease in oxygen content of the blood
accompanied by an increase in carbon
dioxide
o. Noninvasive screening test monitoring
fetal heart rate, movement, and reactivity
of heart lasting approximately 30
minutes
266

Image Labeling
AFI quadrants
Decelerations
267
CHAPTER REVIEW
Multiple Choice
1. Ultrasound observance of fetal well-being is determined by all of the following
except:
a. body movements
b. urine output
c. breathing
d. cervical dilation
2. Electronic fetal heart rate monitoring is performed by:
a. calculating AFV
b. OCT
c. BPP testing
d. calculating fetal growth ratios
3. A fetal biophysical profile in utero observation includes all except:
a. NST
b. fetal tone
c. fetal breathing
d. gross body movements
4. To pass the fetal breathing portion of a BPP, the fetus must exhibit:
a. breath-to-breath intervals of less than 6 seconds
b. at least one episode of sustained fetal breathing of at least 30 seconds’ duration
within a 30-minute span
c. breathing episodes to include hiccups within a 30-minute interval
d. spontaneous motion to include movement of the chest wall and of the abdominal
wall
5. Fetal movements in pregnancy imply normalcy of the fetal:
a. respiratory system
b. musculoskeletal system
c. CNS
d. cerebrospinal fluid volume
6. Fetal movements of the trunk, large limbs, swallowing, face, and hands are
categorized as:
a. motion mode
b. AFV
c. tone
d. gross body movements
7. AFI is determined by:
a. measuring the deepest pocket of amniotic fluid
b. subjective analysis
c. measuring four quadrants in the deepest vertical pocket and totaling the values
d. four transverse depth measurements of amniotic fluid within the pregnant uterus,
summed and totaled
8. The electronic fetal heart monitoring method that has a low false positive and low
false negative, and that usually requires several hours to complete is:
a. OCT
b. NST
c. BPP
d. AFI
9. Oligohydramnios is diagnosed when the amniotic fluid in four quadrants measures:
a. 5.0 cm or less
b. 19.0 cm or more
c. less than 5.0 cm in a quadrant
d. more than 9.0 cm in a quadrant
10. A normal BPP score is 8 or 10, and fetal compromise is likely with a score of:
a. 6
b. 4 to 6
c. 6 to 8
d. 4 or less
11. A cardiotocometer records:
a. fetal gross movement
b. uterine and cervical contractions
c. patterns of fetal heart rate including baseline and changes
d. blood flow patterns and Doppler assessment of the fetal heart
12. Acceleration is defined as:
a. increased fetal gross body movement and tone involving more than 6 movements
in 15 minutes
b. sustained breathing beyond 60 seconds
c. an AFI over 22 cm
d. increase in the fetal heart rate over the baseline of at least 15 beats per minute,
and lasting at least 15 seconds associated with fetal movement
268
13. Startle means:

a. slow and small shifting of the fetal contour
b. quick, generalized movement always initiated in limbs and sometimes spreading
to neck and trunk
c. regular in rate and amplitude
d. irregular, intermittent, large-amplitude breaths; short duration of individual
breaths
14. Normal fetal tone is:
a. three flexion to extension movements with full return in a 30-minute span
b. seen with movement of the extremities in a longitudinal fashion
c. at least one episode of extension of extremities with return to position of flexion,
or extension of spine with return to position of flexion is visualized in a 30-
minute observation period
d. three rolling movements of the trunk or long bones in a 30-minute observation
period
15. An AFI plus an NST is known as:
a. partial BPP
b. modified BPP
c. BPP–NST
d. BPP
16. Regular patterns of fetal breathing are defined as:
a. crescendo–decrescendo changes in rate and amplitude
b. 40 to 60 breaths per minute
c. intermittent, large-amplitude breaths
d. observed in the 20- to 26-week fetus
17. BPP, AFI, and NST testing typically occurs:
a. daily
b. every other day
c. twice weekly
d. once weekly
18. Independent limb movements occur at:
a. the eighth week
b. the ninth week
c. weeks 10 to 12
d. the fourteenth week
19. Fetal movement is mostly related to:
a. placental location
b. AFV
c. fetal individuality
d. maturation of the CNS
20. Fetal breathing can be gauged with a real-time scanner by viewing the fetal abdomen
in a longitudinal fashion, as well as by observing:
a. abdominal contractions
b. caudal–cephalad kidney movement
c. sustained lower extremity flexion–extension with pressure onto the anterior
abdomen
d. prolonged wide opening of jaws, followed by quick closure
Fill-in-the-Blank
1. Monitoring the fetus in the second and third trimesters can be performed by the mother
in the way of _________.
2. _________, a decrease in oxygen content of the blood accompanied by an increase in
carbon dioxide, can be evaluated by antepartum testing.
3. Two electronic fetal monitoring tests involving heart rate are _________ and
_________.
4. The first maternal perception of fetal movement is known as _________.
5. AFI is determined by measuring depth of fluid of _________ quadrants.
6. Amniotic fluid cannot be measured in a pocket that contains _________.
7. The biophysical profile variables can earn a score of _________ if normal, and a
score of _________ if abnormal or do not meet criteria.
8. If a BPP of 8/10 is awarded with an AFI of 4.8 cm, _________ must be considered.
269
9. Fetal movement is usually noted by the mother at _________ weeks.

10. A fetal reactive NST is defined as ________ accelerations with a _________-
minute span.
11. An increase in the fetal heart rate over the baseline of at least 10 beats per minute
and lasting at least 10 seconds is considered normal for fetuses _________ weeks’
gestation.
12. The term _________ is applied to an NST that did not respond as expected in the
allotted time span.
13. Jerky contractions of the diaphragm or abrupt consistent displacement of diaphragm,
thorax, and abdomen are _________.
14. The _________ plane through the fetal chest best demonstrates fetal breathing.
15. Vibroacoustic stimulation can cause a decrease in _________ movements that can
persist for up to an hour after the stimulus.
16. A nonreactive fetus may respond to maternal _________, _________ stimulation,
_________ manipulation of the maternal abdomen, and ___________ ingestion to
stimulate or awaken them.
17. It has been noted at 20 weeks that the fetal heart rate increases with fetal _________.
18. Hiccough is caused by a _________ contraction and counts as a breathing motion if
sustained for _________ seconds during a BPP assessment.
19. Irregular slow fetal breathing involves _________ breaths per minute.
20. Rhythmic bursts of regular jaw opening and closing at the rate of about one per
second suggest _________ activity.
Short Answer
1. Describe fetal movement and compare with fetal tone. Explain the variable
requirements in order to obtain a score of 2.
2. When is antenatal testing for fetal asphyxia performed and why?

3. In what order do BPP variables usually become abnormal?
270
4. Why is it important to obtain a thorough maternal history prior to diagnosing a BPP,

NST, or OCT?
5. How does pH correlate with BPP?
1. Identify the view and anatomy depicted with a “D,” “H,” and “S.” Correlate the view
with a BPP examination, and state the value of the image when seen in real time.
2. Explain the view, anatomy, and information of both images to include biometrics.
Keep in mind that the fetus rolled clockwise from images A to B and continued the
rolling motions throughout the scan. What BPP knowledge can be derived from this
limited information?
271
3. Discuss the image. What is the significance of color Doppler in the lower left of the
image?
CASE STUDY
1. A 29-year-old G4 P3 patient with a history of cesarean deliveries and current
maternal hypertension is measuring large for dates. The growth ultrasound
performed last week determined fetal growth to be in the range of normal, and an
AFI of 15.8 was recorded. A current modified BPP was performed, 1 week after the
growth scan, resulting in a normal NST. Review and discuss the OB report.
272
273
Multiple Gestations
CHAPTER 29

visit the point.

Matching

a. Surgical incision into the uterus, i.e.,
cesarean section
b. Mixing of the ovum and sperm within the
fallopian tubes allowing for fertilization
within the woman’s body
1. _________ follicle stimulating hormonec. Hormone that induces the growth of
(FSH) Graafian follicles
2. _________ monoamniotic d. Increase in circulating blood volume
3. _________ biometry e. Injection of a sperm into the oocyte
4. _________ nonimmune hydrops f. Two zygotes as a result of the fertilization
5. _________ hypervolemic of two ova or the splitting of one ovum
6. _________ monozygotic into two
g. Determination of number of the fetal
7. _________ amnionicity membranes called the amnion
8. _________ thermocoagulation h. Measurements done on an embryo or
9. _________ gamete intrafallopian transfer fetus such as a crown rump length (CRL)
(GIFT) or biparietal diameter (BPD)
10. _________ in vitro fertilization i. Determination of the number of
membranes adjacent to the uterus
11. _________ anembryonic
j. Lack of an embryo
12. _________ quadruplet
k. Large fetus that falls in the 90th
13. _________ chorionicity percentile for weight
14. _________ oligohydramnios l. One zygote
15. _________ dizygotic m. Death rate due to a specific disease
16. _________ zygote n. Low amniotic fluid levels
17. _________ hysterotomy o. Four
18. _________ mortality p. Too much fluid
19. _________ polyhydramnios q. Use of heat to seal tissue
274 r. Fertilized ovum with 23 pairs of
chromosomes
20. _________ intracytoplasmic sperm s. Fertilization of the ovum outside the
injection (ICSI) uterus
21. _________ macrosomic t. One amnion
22. _________ plethoric u. Incidence of disease
23. _________ morbidity v. Edema, accumulation of fluid in tissues
and in the peritoneal cavity, and chest, in
a fetus not affected by erythroblastosis
fetalis
w.Abundant

Image Labeling
1. Label the type of pregnancy
275
What does the “P” represent? What is the arrow directed toward?
Types of conjoined twins
276
CHAPTER REVIEW
Multiple Choice
1. In the United States, who produces the multiples at the highest rate?
a. African Americans
b. Asians
c. Caucasians
d. Mexican Americans
2. Spontaneously occurring monozygotic twinning is noted to be influenced by:
a. environmental factors
b. economic status
c. genetics
d. social status
3. A large for dates uterus may be a result of all except:
a. macrosomic fetus
b. uterine fibroids
c. oligohydramnios
d. multiple gestation pregnancy
4. Decreased Maternal Serum α-fetoprotein (MSAFP) levels can be the result of:
a. fetal open neural tube defects
b. placental masses
c. fetal abdominal wall defects
d. uterine fibroids during pregnancy
5. What is not a risk factor of a multiple pregnancy?
a. decreased morbidity
b. IUGR
c. TTTS
d. low birth weight
6. A monozygotic pregnancy with two placentas and two amnions is labeled:
a. DC/DA
b. DZ/MA
c. MC/MA
d. MZ/DA
7. A pregnancy consisting of two amnions, one chorion, and one placenta is:
a. DC/DA
b. DC/MA
c. MC/DA
d. MC/MA
8. Preeclampsia, hypertension, placental abruption, placenta previa, and postpartum
hemorrhage are:
a. associated with TTTS
b. maternal complications of a multiple gestation pregnancy
c. risks of TRAP
d. fetal complications of twinning
9. The risk of an adverse outcome or abnormality with multiples is greatest with:
a. dichorionic/diamniotic twins
b. monochorionic/diamniotic twins
c. monochorionic/monoamniotic twins
d. dichorionic/monoamniotic twins
10. Sonographic determination of chorionicity and amnionicity is most accurate in:
a. the first trimester
b. the trimester
c. the third trimester
d. all trimesters
11. To determine chorionicity, search for all except:
a. the T-sign
b. the λ-sign
c. the Y-sign
d. a separating membrane at least 1.5 mm thick
12. An intertwin biometric discrepancy of more than 20% suggests:
a. likelihood of a single fetal loss
b. likelihood of gender difference
c. positional variation
d. TRTS
13. Growth restriction in discordant twins is assessed by evaluating all except:
a. UA with Doppler
b. MVP
c. MCA with Doppler
d. biometry
14. The rate of spontaneous demise of singleton and single twin demise is
approximately:
a. 5%
b. 12%
c. 21%
d. 32%
277
15. The most common maternal age–related risk for twinning involves:
a. a higher rate of cesarean section
b. preterm delivery
c. hypertension
d. placental abruption
16. A primary fetal risk factor for mortality and long-term morbidity with multiple
gestations is:
a. postpartum hemorrhage
b. oligohydramnios
c. discordant fetal position
d. low birth weight
17. An abnormality revealing a normal twin combined with a poorly defined twin
possessing an irregular or no cardiac structure is:
a. TTTS
b. TRAP sequence
c. Recipient syndrome
d. Donor syndrome
18. TRAP sequence is commonly referred to as:
a. acardiac twinning
b. pump twin
c. hemodynamic dependency
d. anastomoses
19. A twin pregnancy with a severe imbalance of amniotic fluid between the two
gestational sacs is caused by:
a. Recipient syndrome
b. Donor syndrome
c. TRAP sequence
d. TTTS
20. Conjoined twins connecting at the thorax are classified as:
a. pygopagus
b. omphalopagus
c. thoracopagus
d. craniopagus
Fill-in-the-Blank
1. _________ % of all live births are multiple births, and the two main reasons are
_________ and _________.
2. _________ twinning rates remain fairly constant throughout the world.
3. Monozygotic twinning is the result of _________ of an ovum.
4. A multiple gestation pregnancy is typically noted because of the _________
measuring larger than expected for gestational age.
5. It is estimated that infertility treatments are responsible for _________% of triplet
pregnancies that occur in the United States
6. Congenital malformations occur _________ times more often in twins than in
singletons.
7. DZ twins result from _________ separate fertilized ova, have _________ placentas,
_________ separate chorions, and _________ separate amnions.
8. Multiple gestations are at risk for _________ birth, intrauterine _________, and fetal
anomalies.
9. Concordant defects in twins are mostly related to _________ twins.
10. Chorionicity and amnionicity determination utilizing ultrasound is most accurate in
the _________ trimester.
11. An accurate and easy method of determining type of twinning involves counting the
number of _________ sacs.
12. The _________ sign refers to the presence of a triangular projection of placental
tissue extending into the base of the junction of two chorionic membranes.
278
13. In a twin pregnancy, fetuses measuring _________ or more days difference by CRL
are considered discordant.
14. Growth rates of normal multiples in the 2nd and 3rd trimesters follow those of
singletons until approximately _________ weeks. Triplets lag biometrically earlier
in the pregnancy except for the _________ measurement.
15. An early twin pregnancy that delivers a singleton fetus is known as a _________
pregnancy.
16. All multiple gestations should be considered _________ pregnancies.
17. Fetal vessels overlying the cervical os due to insertion of the umbilical cord into the
amniotic membrane rather than the placenta is _________, and is documented to
occur more frequently with _________ technology.
18. Periodically removing fluid from a twin polyhydramniotic sac is known as
_________ amniocentesis.
19. The highest risk form of twinning is _________.
20. Selective reduction should never be performed on a _________ pregnancy because
of the risk of passing a _________ substance from demise twin into the surviving
twin.
Short Answer
1. List complications of multiples in a pregnancy.
2. A 24-year-old G1 patient was recently diagnosed as DC/DA. She is excited and

curious about the twins and requests an explanation of her pregnancy.
3. Explain the zygote division timeline associated with monozygotic twinning.
4. Discuss the finding of one gestational sac versus two gestational sacs in a transvaginal
first trimester ultrasound.
279
5. State methods of identifying twins on follow-up ultrasound examinations.
1. What type of “sign” does the amniotic membrane show?

2. Name the type of pregnancy.
280
3. Describe and diagnose this type of pregnancy.

CASE STUDY
1. A 28-year-old G4P3013 pregnant patient diagnosed as MC/DA reported to ultrasound

for a 4-week follow-up ultrasound. The previous examination determined that fetus
A measured 6 days smaller than fetus B. Her obstetrician is concerned about
continued discordant growth. What condition is of utmost concern with this
pregnancy? Offer sonographic options that will assist in monitoring the pregnancy.
2. A 23-year-old G2P1 with hyperemesis reported to ultrasound for determination of
fetal number because of excessive vomiting and remarkably elevated HCG levels.
She is 6w1d by LMP. Discuss the image.
281
Intrauterine Growth Restriction
CHAPTER 30

visit the point.

Matching

a. Estimated fetal weight less than the 10th
percentile for the gestational age
b. Without known cause
c. Having three copies of a specific
chromosome
d. Chemical substance that is the subject of
analysis
e. Abnormal chromosome number
f. Combined observation of four separate
1. _________ polyhydramnios fetal biophysical variables (fetal
2. _________ analyte breathing movements, fetal body
movement, fetal tone, and amniotic fluid
3. _________ sensitivity index) obtained via ultrasound
4. _________ placental mosaicism g. Birth weight below 2,500 grams (g) or 5
5. _________ hypoxemia lb 8 oz
6. _________ low birth weight (LBW) h. Weight greater than 4,200 to 4,500 g
7. _________ nonstress test (NST) i. Incidence of a specific disease in a
population for a set amount of time
8. _________ intrauterine growth
restriction (IUGR) j. Diagnosis used to describe an infant that
is smaller than expected for the
9. _________ macrosomic gestational age
10. _________ idiopathic k. The proportion of people who test
11. _________ morbidity negative for the disease and who do not
12. _________ biophysical profile (BPP) have the disease
13. _________ specificity l. Low amniotic level fluids
14. _________ Doppler m. Low oxygen blood level
15. _________ oligohydramnios n. Condition characterized by the
discrepancy between the chromosomal
16. _________ aneuploidy
makeup of the fetus and placenta
17. _________ mortality
o. Frequency of deaths in a specific
18. _________ preeclampsia population
19. _________ trisomy p. Noninvasive ultrasound test that
20. _________ small for gestational age measures blood flow
(SGA) q. Method of assessing fetal well-being by
21. _________ velocimetry observing the fetal heart rate response to
fetal movement
r. The proportion of people who test
positive for a disease and who actually
have the disease
s. High amniotic fluid levels
t. Noninvasive measurement of volume and
velocity of blood flow
u. Hypertension, and protein in the urine,
occurring during pregnancy
282

Image Labeling
IUGR factors
Nonstress test
CHAPTER REVIEW
Multiple Choice
1. Conditions such as poor maternal weight gain, previous IUGR infant, maternal
complications, and inadequate symphysis to fundal height growth are suggestive of:
a. LBW
b. macrosomic fetus
c. IUGR
d. idiopathic anomalies
2. Select the description that does not characterize IUGR:
a. growth two SD below the mean for gestational age
b. fetal lagging abdominal circumference
c. an EFW <10th percentile
d. macrosomia
283
3. A cause of intrauterine growth restriction is:

a. maternal hypertension
b. incorrect LMP
c. unexpected ovulation date
d. small parents
4. IUGR affects the fetal blood flow by:
a. increasing cardiac output
b. redistributing it to the fetal brain
c. redistributing it to the fetal liver
d. an increase in umbilical vein volume
5. IUGR can cause poor health for the fetus into adulthood. They include all except:
a. hypertension
b. diabetes
c. anorexia
d. atherosclerosis
6. Preeclampsia:
a. is a condition where elevated protein is discovered in the maternal urine
b. is a condition of low blood pressure
c. causes maternal hydronephrosis due to elevated urinary protein
d. causes fetal weight gain
7. A common cause of IUGR is:
a. thyroid insufficiency
b. uterine structure
c. placental abnormalities
d. elevated liver enzymes
8. Herpes simplex virus, cytomegalovirus, rubella, and varicella zoster are
____________, which relate to fetal growth restriction.
a. chromosomal conditions
b. enzymes
c. functional conditions
d. infectious conditions
9. Atypical growth patterns where the fetal AC lags the BPD, HC, and FL is known as:
a. symmetric
b. IUGR
c. asymmetric
d. <10th percentile
10. Infection, congenital malformation, drugs, and chromosomal abnormalities are
usually responsible for:
a. stage II birth defects
b. symmetric IUGR
c. asymmetric IUGR
d. stage I hospital admissions
11. Identification of growth-restricted fetuses is done through sonographic EFW, fundal
height, and:
a. serum analytes
b. fetal urinalysis
c. CMP
d. maternal urinalysis
12. BPP should be performed only when:
a. the fetus is 22 weeks or more
b. the fetus is in a vertex position
c. 30 weeks or more
d. delivery of the fetus would be considered.
13. A fundal height measurement difference of more than __ centimeters less than
expected after 20 weeks’ gestation is cause for suspicion of IUGR.
a. 2
b. 0.5
c. 3
d. 1
14. If IUGR is suspected, the recommended interval between growth evaluations is:
a. weekly
b. not less than 2 weeks
c. not less than 3 weeks
d. not less than 4 weeks
15. The predictive error of ultrasound _______ as the gestation increases.
a. decreases
b. remains the same
c. does not change
d. increases
16. Common maternal treatments to increase growth in an IUGR fetus include all except:
a. nonimpact exercise
b. fish oil
c. aspirin
d. hyperoxygenation
17. A normal nonstress test displays:
a. fetal tone
b. two or more accelerations within 20 minutes
c. fetal breathing
d. amniotic fluid volume
18. Hypothermia, hematologic complications, and hypoglycemia are conditions related
to:
a. preeclampsia
b. IUGR
c. acidemia
d. hypoxemia
284
19. IUGR children, especially preterm, have an elevated risk of all except:
a. low blood pressure
b. behavioral problems
c. inferior school performance
d. neurologic damage
20. Select the correct fetal category for a fetus displaying biometric parameters below
10% without a known cause, possibly relating to parental habitus and family history,
small AC/BPD/HC/FL measurements, normal AFI, normal BPD/AC ratio, and
normal placenta.
a. macrosomia
b. symmetrical IUGR
c. asymmetrical IUGR
d. SGA
Fill-in-the-Blank
1. The fetus with poor intrauterine growth has an _________ risk for perinatal mortality
compared with the fetus of normal size.
2. Cord anomalies that increase the risk of for IUGR are _________ and _________.
3. IUGR infants usually achieve normal growth at the age of _________.
4. Growth restriction can cause adverse effects of _________ and _________ life.
5. Poor intrauterine growth and subsequent LBW are common features of many
_________ abnormalities.
6. The most common chromosomal abnormalities that increase a fetus’ risk for IUGR are
_________ syndrome, _________ syndrome, and _________ syndrome.
7. Birth weight at higher altitudes is _________ than that of infants born at sea level.
8. The cause of IUGR may be idiopathic or _________.
9. The accuracy of measuring all biometric parameters _________ with advancing
gestational age. The measurement of _________ is least affected.
10. Maternal medical conditions that affect blood circulation result in a _________ in
uteroplacental blood flow and can lead to IUGR
11. Maternal _________ in pregnancy is one of the leading causes of IUGR.
12. Multiple measurements in fetal ultrasound have been used to _________ accuracy.
13. In a normal fetus, the MCA is a _________ impedance circulation with continuous
_________ flow.
14. _________ Doppler may help differentiate a constitutionally small fetus and a
pathologic IUGR fetus.
15. Risk factors or etiologies of IUGR can be divided into three groups: _________,
_________, and _________.
16. Estimated fetal _________, sonographic biometry, Doppler flow, and _________
fluid changes assist in identification of growth restricted fetuses.
17. Avoidance and cessation of smoking during pregnancy can increase fetal _________.
18. BPP observations are made within a _________ -minute time frame.
285
19. Advanced acidemia, hypoxemia, and hypercapnia affect fetal _________ and
_________, two of the four biophysical features of a BPP.
20. Antenatal surveillance is done with four fetal growth assessments: _________,
_________, _________, and _________.
Short Answer
1. Name three common sites that Doppler interrogates for anomalies in pregnancy.
2. Discuss an accurate and concise method of gathering and presenting fetal ultrasound
data to a requesting physician.
3. State fetal assessment protocols that are most commonly utilized in gauging fetal well-
being once delivery is being considered.
4. Review and explain the fetal heart rate patterns noted in a nonstress test.
1. Describe the anatomy in this fetal abdomen and relate the significance to IUGR.
286
2. Explain the fetal anatomy under interrogation. Is the waveform normal or abnormal for
this vessel?
3. Discuss image A and B waveforms regarding the fetal umbilical artery.
287
4. Describe the fetal anatomy. What are the arrows directed toward in image A? State
the type of waveform seen in image B.
5. Explain what the arrows are pointing to in umbilical cord waveform of the fetus with
IUGR.
288
6. Name three ways to determine the amount of amniotic fluid. Name the likely
measurement type for the images.
289
CASE STUDY
1. Two fetuses were diagnosed with IUGR. Both were referred for Doppler studies.
a. Explain the role of the ductus venosus.
b. How are the waveforms collected?
c. Explain a normal waveform.
d. Discuss the DV Doppler waveforms.
2. The image is used to gather Doppler information.
a. Describe the image and vessels that offer diagnostic information.
b. Name the purpose of performing Doppler of this anatomy.
290
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Patterns of Fetal Anomalies
CHAPTER 31

visit the point.

Matching

a. Serum protein produced by the fetal yolk
sac and liver that aids in the detection of
neural tube defects, ventral wall defects,
skin disorders, and, in rare cases,
nephrosis
b. Any substance measured in a laboratory
such as AFP, Inhibin A, or human
chorionic gonadotropin
c. Abnormal number of chromosomes
1. _________ triple screen d. Normal number of chromosomes in a cell
2. _________ multifactorial e. Mutations caused by multiple genes
3. _________ analyte f. Hormone secreted by immature placenta
4. _________ heterogeneous disorder g. Protein secreted by the corpus luteum and
5. _________ meiosis placenta
6. _________ soft sonographic marker h. Arrangement of chromosomes by type,
7. _________ Inhibin A size, and morphology to determine
normalcy
8. _________ vertical transmission
i. Presence of two different types of cell
9. _________ human chorionic genotypes (karyotype) in an individual
gonadotropin (hCG)
j. Division of a cell resulting in the normal
10. _________ pregnancy-associated haploid number
plasma protein A (PAPP-A)
k. Division of a cell resulting in a
11. _________ alpha fetoprotein (AFP) reduction, by half, in the normal haploid
12. _________ preeclampsia number of chromosomes
13. _________ aneuploidy l. Triad of hypertension, fluid retention
14. _________ mosaicism (edema), and proteinuria occurring after
20 weeks’ gestation
15. _________ unconjugated estriol (uE3)
m. Placental syncytiotrophoblastic hormone
16. _________ haploid found in maternal blood serum
17. _________ quadruple screen n. Involving several different factors
18. _________ mitosis o. Testing for maternal levels of AFP, uE3,
19. _________ karyotype hCG, and Inhibin A
p. Nonspecific transient markers seen in
normal and aneuploidy fetuses that have
an increased incidence in the
chromosomally abnormal fetus
q. Testing for maternal levels of AFP, uE3,
and hCG
r. Hormone produced by the
syncytiotrophoblast
s. From mother to child
292

Image Labeling
Human chromosome structural abnormalities
Name the abnormalities.
293
Trisomy 13
Name common features of this trisomy.
Trisomy 18
294
Trisomy 21
VACTERL association
Name features of this anomaly.
295
CHAPTER REVIEW
Multiple Choice
1. A pattern of multiple anomalies seen in numerous individuals not related to a single
causative factor or pathology is a(n):
a. syndrome
b. disruption
c. malformation
d. association
2. Structural abnormalities in the chromosomes are most often a result of breakage
resulting from:
a. deletion
b. inversion
c. chemical agents
d. translocation
3. The definition of a part of a chromosome rearranging within itself is:
a. inversion
b. insertion
c. deletion
d. translocation
4. The transmission of the genetic code from parents to offspring is:
a. association
b. insertion
c. inheritance
d. sequence
5. Cardiac defects, neural tube defects, and facial clefting are examples of:
a. autosomal recessive gene association
b. multifactorial inheritance
c. autosomal dominant gene association
d. X-linked gene association
6. Increases in hCG and decreases in PAPP-A, along with increased nuchal translucency
(NT) measurements, have been associated with:
a. Trisomy 13
b. Trisomy 18
c. Trisomy 21
d. VACTERL association
7. Second semester biochemical screening should be performed between:
a. 10 to 13 weeks
b. 20 to 25 weeks
c. 18 to 26 weeks
d. 15 to 20 weeks
8. Select the choice that is not associated with diagnosing aneuploidy:
a. chorionic villus sampling
b. qualitative hCG
c. amniocentesis
d. umbilical blood sampling
9. The most apparent ultrasound finding with Aicardi syndrome is:
a. agenesis of the corpus callosum
b. club feet
c. ectopic cordis
d. short limbs
10. Entanglement of fetal structures or the obvious disruption of a fetal part by amniotic
sheets is:
a. uterine synechiae
b. uterine septations
c. amniotic band sequence
d. amniotic sheets
11. Trisomy 21, the most common pattern of malformation in man, results in intellectual
disabilities, neonatal hypotonia, characteristic facial deformities, and, frequently:
a. polydactyly
b. spina bifida
c. cloverleaf skull
d. heart anomalies
12. Trisomy 13 (Patau syndrome):
a. is frequently related to advanced maternal age
b. demonstrates no cranial anomalies
c. includes a short umbilical cord
d. involves the vertebrae with severe kyphoscoliosis
13. An anomaly, either single or multiple, in which the structure or tissue is abnormal
from the beginning is a(n):
a. association
b. malformation
c. sequence
d. deformation
14. The five findings of macroglossia, anterior wall defects, hypoglycemia at birth,
macrosomia, and hemihyperplasia suggest a diagnosis of:
a. HOS syndrome
b. Trisomy 13
c. Cri-du-chat syndrome
d. Beckwith–Wiedemann syndrome
296
15. VACTERL syndrome:

a. is a collection of fetal anomalies
b. is best diagnosed with inhibin-A
c. is determined with amniocentesis
d. requires all seven of the anomalies to form a definitive diagnosis
16. The characteristics of renal dysplasia, limb anomalies, and encephalocele describe
the rare syndrome:
a. Goldenhar
b. Trisomy 13
c. Meckel–Gruber
d. Monosomy X
17. Turner syndrome relates to:
a. oligohydramnios due to inadequate urine production
b. the absence of a sex chromosome
c. limb amputation
d. hand anomalies
18. An anomaly in which the structure of tissue lacks the normal organization of cells is
a(n):
a. syndrome
b. disruption
c. dysplasia
d. association
19. A syndrome that is separated into two subgroups one of which has craniofacial
defects and the other a short cord, anal atresia, lumbosacral meningocele, and
urogenital malformations is:
a. Patua syndrome
b. Cri-du-chat syndrome
c. Beckwith–Wiedemann syndrome
d. limb–body wall complex
20. A condition that provides no known lab values and is known as the cardiac-limb
syndrome is:
a. Holt–Oran syndrome
b. CHARGE syndrome
c. caudal dysplasia sequence
d. Wilms syndrome
Fill-in-the-Blank
1. Structural anomaly findings noted in groups or patterns may represent a _________,
an _________, or a _________.
2. Turner syndrome results from the absence of one of the two _________ chromosomes.
3. Trisomy 13 is also known as _________; Trisomy 21 is known as _________; and
Trisomy 18 is known as _________.
4. Having one extra chromosome in a set or missing a chromosome from a set are
examples of _________.
5. In a Trisomy 21 fetus, a first trimester ultrasound examination often displays a missing
_________ bone.
6. Two environmental teratogens, which mimic genetic defects, are _________ and
_________.
7. A well-known and reliable screening test that evaluates the risk to the general
population for aneuploidy is _________.
8. _________ is the main characteristic of Apert syndrome, which results in changes of
head and face shape.
9. Trisomy 18 is also known as _________ and occurs mostly in the _________
gender.
10. Caudal defects of the sacrum, lumbar vertebrae, and sacral agenesis are anomalies
related to _________.
11. A collection of ventral wall and limb defects describes _________.
12. The classic sonographic finding of Turner syndrome is a _________.
13. _________ syndrome has webbing in the joints and neck.
297
14. A complete extra set of chromosomes is called _________.

15. _________ band sequence, or _________ band syndrome, begins with the rupture of
the amnion and subsequently results in the entrapment of fetal parts.
16. Turner syndrome is also known as _________ and _________.
17. Major characteristics of CHARGE syndrome are _________ and _________.
18. Cystic hygroma is common to Turner syndrome and Noonan syndrome; however, the
identification of _________ genitalia differentiates Noonan syndrome from Turner
syndrome.
19. Blindness, seizures, and high mortality in the first years of life are related to
_________.
20. Most triploidy pregnancies are due to two _________ one egg or from an extra
chromosome set from the _________.
Short Answer
1. Discuss risk factors related to chromosomal abnormalities.
2. List the four biochemical markers that are essential to modern prenatal care. What is
the alternative name for this screening test?
3. Compare and contrast autosomal dominant with autosomal recessive genetic coding.
List the syndromes, sequences, and associations related to autosomal dominant
coding.
4. What syndromes affect fetal kidneys and the genital system?
298
1. Explain the images of the same prenatal and postnatal fetal foot. Offer a diagnosis.
2. View and describe the fetal anatomy. What imaging technique is displayed? Make a
diagnosis.
299
3. Explain the image, make a diagnosis, and explain possible related findings for the
anomaly.
4. What are the arrows pointing to? Explain the structure and offer a diagnosis. List other
possible related ultrasound findings.
5. State the cranial anatomy and condition. What fetal disorders may be related?
300
CASE STUDY
1. A 21-year-old compliant G1 patient presented to the ultrasound department for an

anatomy examination. Describe the abdominal image finding. A facial cleft,
hydrocephalus, small abdominal circumference, and hydrocephalus were also noted.
What condition is related to the findings?
2. This 41-year-old G3 P2 mother was referred to a perinatologist in the eleventh week
of her third pregnancy because of her history of having a child with Down
syndrome. Her first child has no known anomalies, and the second was confirmed to
have Trisomy 21 shortly after delivery. The perinatologist performed a first
trimester (11 weeks) ultrasound, and two findings were revealed as seen in the
image. State the findings, offer a diagnosis with differentials. What options are
available for securing a positive fetal condition identification.
301
Effects of Maternal Disease on Pregnancy
CHAPTER 32

visit the point.

Matching

a. Overactive thyroid gland; pathologically
excessive production of thyroid
hormones or the condition resulting from
excessive production of thyroid
hormones
b. Underactive thyroid gland; a glandular
disorder resulting from insufficient
production of thyroid hormones
c. Excessive secretion of parathyroid
hormone resulting in abnormally high
levels of calcium in the blood; can affect
many systems of the body (especially
causing bone resorption and
osteoporosis)
d. Genetic disorder of metabolism; lack of
the enzyme needed to turn phenylalanine
into tyrosine, which results in an
accumulation of phenylalanine in the
body fluids, causing various degrees of
mental deficiency
e. A mechanism by which cells ingest
extracellular fluid contents
f. Development of immunities to Rh-
positive blood antigens from a fetus by
an Rh-negative woman
g. Accumulation of fluid in fetal tissues in
1. _________ systemic lupus erythematous the form of ascites, pleural fluid, and
2. _________ hyperthyroidism skin edema resulting from factors other
3. _________ pinocytosis than a fetomaternal blood group
incompatibility
4. _________ TORCH
h. Congenital form of anemia occurring
5. _________ thrombophilias
mostly in blacks; characterized by
6. _________ nonimmune hydrops crescent-shaped blood cells
7. _________ cytomegalovirus (CMV) i. Inherited form of anemia caused by faulty
8. _________ hypothyroidism synthesis of hemoglobin
9. _________ varicella-zoster infection j. Abnormal condition of pregnancy
10. _________ thalassemia characterized by hypertension, edema,
and protein in the urine
11. _________ diabetes mellitus
k. Coma and seizures in second and third
12. _________ hyperparathyroidism trimesters following preeclampsia
13. _________ germ line l. Maternal high blood pressure that was
14. _________ eclampsia diagnosed prior to pregnancy
15. _________ gestational diabetes m. Thrombophilia or hypercoagulability is
16. _________ Rh isoimmunization the propensity to develop thrombosis
(blood clots) because of a coagulation
17. _________ rubella (aka German abnormality
measles) n. Inflammatory disease of connective tissue
18. _________ phenylketonuria with variable features including fever,
weakness, fatigability, joint pains, and
302 skin lesions on the face, neck, or arms
o. Estimated fetal weight less than the 10th
19. _________ HIV percentile for the gestational age
20. _________ toxemia (aka p. Chickenpox infection
preeclampsia) q. Herpesvirus that causes infectious
21. _________ parvovirus B19 mononucleosis
22. _________ sickle-cell anemia r. Ovum or sperm (germ cells) that have
23. _________ Epstein–Barr virus genetic material that passes to offspring
24. _________ essential hypertension s. Acute febrile highly contagious viral
disease
25. _________ toxoplasmosis
t. Human immunodeficiency virus that
26. _________ IUGR (intrauterine growth progresses into AIDS (Acquired Immune
restriction) Deficiency Syndrome)
27. _________ influenza u. Parasitic infection transmitted to humans
28. _________ Zika virus from undercooked meat or contact with
cat feces
v. Includes toxoplasmosis, other viruses
(syphilis, varicella-zoster, parvovirus
B19), rubella, cytomegalovirus, and
herpes infections
w.Contagious viral disease that is a milder
form of measles lasting 3 or 4 days
x. Any of a group of herpes viruses that
enlarge epithelial cells and can cause
birth defects; can affect humans with
impaired immunologic systems
y. Erythema infectiosum or fifth disease;
spreads via the upper respiratory tract,
this virus affects children more strongly
than adults
z. Mosquito-borne single-stranded RNA
virus related to the dengue virus
aa.Condition in which women without
previously diagnosed diabetes exhibit
high blood glucose levels during
pregnancy
bb.Diabetes caused by a relative or
absolute deficiency of insulin and
characterized by polyuria
303

Image Labeling
TORCH infections
304
Maternal–fetal Rh incompatibility
305
CHAPTER REVIEW
Multiple Choice
1. Physiologic functions of the placenta include all except:
a. exchange nutrients
b. exchange waste
c. exchange solids
d. exchange gas
2. Select the substance that requires “assistance” to cross the placental membrane:
a. carbohydrates
b. infectious agents
c. drugs
d. antibodies
3. What type of imaging provides fetoplacental circulation information?
a. TV
b. EV
c. TA
d. Doppler
4. PROM, toxemia, IUGR, sickle cell disease, and diabetes mellitus result in a
_________ indicating increased vascular resistance.
a. low S/D ratio
b. high S/D ratio
c. low RI
d. high RI
5. A maternal infection occurring before conception:
a. may adversely affect a fetus
b. always adversely affects a fetus
c. never adversely affects a fetus
d. will only affect a fetus if sulfur-based antibiotics are prescribed
6. Maternal infections passed to the fetus are usually via the:
a. urinary and genital tract
b. circulatory and respiratory systems
c. genital tract and circulatory system
d. urinary and respiratory systems
7. A viral infection that is linked to stillbirth, low infant birth weight, congenital heart
anomalies, and micropthalmia is:
a. HIV
b. IUGR
c. EBV
d. varicella-zoster
8. Choose a bacterial infection that is seen during pregnancy and known to cause fetal
prematurity:
a. Epstein–Barr
b. gonorrhea
c. human immunodeficiency virus
d. malaria
9. Select the infection that represents a very common medical complication of
pregnancy:
a. cholera
b. CMV
c. Staphylococcus
d. UTI
10. Select the type of treatment that effectively treats toxoplasmosis and malaria
infections during pregnancy:
a. antiparasitic
b. antibiotic
c. antiviral
d. antiallergenic
11. What percentage of perinatal infections results in congenital anomalies?
a. 1%
b. 2% to 3%
c. 5%
d. 10% to 15%
12. The placental barrier that usually protects fetuses from toxoplasmosis is most
effective:
a. during early pregnancy
b. midpregnancy
c. late pregnancy
d. throughout the entire pregnancy
13. Fetal malformations occurring in the first trimester that consist of cataracts, cardiac
defects, and deafness are caused by:
a. mumps
b. three-day measles
c. herpes virus
d. pertussis
14. Periventricular echogenic calcifications visualized in the fetal cranium are
commonly related to:
a. hyperthyroidism and parathyroidism
b. Rh isoimmunization
c. chickenpox
d. rubella and parvovirus B19
306
15. Select the type of diabetes that occurs only during pregnancy and affects about 7% of
all pregnant women:
a. type I
b. type II
c. monogenic
d. gestational
16. A glucose tolerance test:
a. is usually performed between weeks 24 and 28
b. checks the glucose level 2 hours after p.o. ingestion of a glucose solution
c. that displays a one-hour elevated level will require a four-hour tolerance test
d. is requested only if there is a family history of diabetes mellitus
17. Isoimmunized pregnancies can result in all except:
a. erythroblastosis fetalis
b. hepatosplenomegaly
c. immune hydrops fetalis
d. low β-globin
18. Maternal edema, hypertension, proteinuria, and nervous system irritability define:
a. thrombophilia symptoms
b. toxemia/hypertension symptoms
c. maternal rubella symptoms
d. maternal viral infection symptoms
19. The safest time for a female diagnosed with systemic lupus erythematosus to start a
pregnancy is:
a. early in the childbearing years
b. when disease activity is controlled by small doses of steroids and aspirin
c. after multiple treatments of clomiphene
d. following blood transfusion
20. Select the maternal disease that is least likely to affect a fetus heart:
a. influenza
b. TORCH
c. thalassemia
d. EBV
Fill-in-the-Blank
1. The _________ plays a role as a barrier in preventing or facilitating the transmission
of maternal disease to the fetus.
2. _________ molecules frequently cannot move across the placenta and enter the fetal
circulation.
3. Maternal hypertension _________ uteroplacental blood flow.
4. Normally, as pregnancy progresses, diastolic flow _________, representing
_________ resistance to flow.
5. Infection after implantation, particularly early during _________, accounts for the
largest number of adverse fetal effects.
6. The transmission of HIV to a fetus is affected by the total number of maternal HIV
_________, the effectiveness of the maternal and fetal _________ response, and the
integrity of the placental barrier.
7. Patients with UTIs during pregnancy should be treated with _________ and monitored
by frequent urine cultures.
8. Maternal malaria promotes placental _________, causing IUGR, low birth weight,
abortion, and stillbirth.
9. Fetal _________, a diagnostic test, helps detect heart abnormalities in patients
exposed to CMV and rubella.
10. If severe toxoplasmosis infection occurs, the outcome presents as central nervous
system anomalies such as _________, _________, _________, _________, and
mental retardation.
307
11. Cyanotic heart disease results in premature birth, IUGR, and miscarriages, possibly
because of the lower _________ content in maternal circulation.
12. If an obstetric patient is infected with parvovirus B19, ultrasound to image anatomy
and measurement of the _________ of the middle cerebral artery are noninvasive
procedures to diagnose fetal anemia and nonimmune hydrops.
13. Cesarean section delivery is indicated in the event of _________ virus in the
maternal genital tract.
14. Congenital malformations seen with diabetes are related to high blood sugar levels
resulting in disruption of embryonic _________.
15. The preferred predictor of neonatal weight in the third trimester is the _________
measurement.
16. Hyperthyroidism produces thyroxine, which causes a significant increase in
_________ -birth-weight infants.
17. Uncontrolled PKU prior to and during pregnancy results in low fetal birth weight,
_________ disease, spontaneous _________, and _________ problems.
18. Rh isoimmunization refers to the development of maternal _________ to the surface
antigens on fetal _________ blood cells.
19. Rigid irregularly shaped blood cells that occur mostly in African Americans in the
United States result in a condition known as _________.
20. Ingestion of raw meat and contaminated water, and contact with feline feces is
advised against for the obstetric patient because of the risk of acquiring _________.
Short Answer
1. Define TORCH.
2. Explain possible fetal outcomes with a woman who shows serologic evidence of
previous varicella-zoster.
3. A primigravida 24-year-old diabetic has concerns about her endocrine/metabolic
disorder in regard to her unborn child. Explain congenital anomalies frequently
noted in infants of diabetic mothers and how to decrease the incidence of congenital
anomalies.
308
4. An inner city hospital was reported to have an abnormally high level of babies born to
mothers known to consume and abuse alcohol during pregnancy. List findings that
ultrasound may discover prior to delivery regarding these fetuses.
1. Review the images and explain the invasive ultrasound procedure that it
documented.
309
2. In images A and B, spectral Doppler was performed. Offer a diagnosis.

3. List processes during pregnancy that can produce microphthalmia.
310
4. Describe the findings that are demonstrated in the chest image (A) and abdominal
image (B) of this fetus diagnosed with hydrops fetalis. What irregularities may be
noted in the fetal cranium and neck with this condition?
CASE STUDY
1. A 22-year-old G2 P1 patient with known Rh negative blood is concerned about a
recommendation her obstetrician made regarding receiving an Rh immune globulin
injection following amniocentesis. Explain why her doctor requested the injections.
Review the images and answer the following question.
2. What should the sonographer consider after obtaining this ultrasound image? Explain
the finding and its importance.
311
The Postpartum Uterus
CHAPTER 33

visit the point.

Matching

a. Radiographic examination of the vein
performed after injection of a
radiopaque contrast medium
b. Formation of a blood clot due to
inflammation
1. _________ hysterectomy
c. Stones within the kidney
2. _________ decidua basalis
d. Radiographic images of the kidneys,
3. _________ atony ureters, and bladder after injection of a
4. _________ nephrolithiasis radiopaque dye
5. _________ involution e. Reduction of an organ to its normal size
6. _________ coagulopathy and appearance
7. _________ venogram f. Removal of the uterus
g. Collection of blood outside the vessels
8. _________ emboli
9. _________ thrombophlebitis h. Moving particle, such as thrombosis or
10. _________ chorioamnionitis air, within the bloodstream
i. Portion of the uterine lining that forms the
11. _________ hematoma
maternal portion of the placenta
12. _________ intravenous pyelogram
(IVP) j. Defect in the body’s clotting mechanism
resulting in bleeding
k. Inflammation of the amnion and chorion
due to a bacterial infection
l. Lack of normal muscle tone
312
CHAPTER REVIEW
Multiple Choice
1. The puerperium:
a. describes the postdelivery condition of the female external genitalia
b. starts immediately postdelivery including the placenta and continues until the
uterus retains its prenatal shape
c. is an infection of the placental site within the uterus
d. extends from placental delivery until the first normal menstruation
2. Lactation termination usually produces:
a. anovulation
b. menstrual resumption
c. breast lumps
d. excessive quantities of breast milk
3. Sonography in the puerperium period is used for all except:
a. excessive bleeding
b. pelvic pain
c. following cesarean delivery
d. to determine whether the uterus has returned to prepregnancy state
4. Select the true statement regarding the postpartum uterus:
a. The internal os will be visualized as closed and well delineated following
placental delivery.
b. The endometrium will measure 3 to 8 mm within 24 hours of delivery.
c. Free fluid in the endometrial cavity indicates intrauterine infection.
d. Longitudinal uterine measurements range from 14 to 25 cm.
5. During pregnancy, ovaries generally:
a. remain the same as in the prepregnancy state except for a few more cysts in the
first trimester
b. involute
c. enlarge because of hormone production
d. develop a thickened outer cortex
6. A placenta that completely invades the uterine myometrium, extending into the serosa
is:
a. placenta abruption
b. placenta percreta
c. placenta accreta
d. placenta increta
7. Select the condition that is not likely to be related to postpartum hemorrhage:
a. decreased hematocrit
b. shock
c. hypertension
d. hysterectomy
8. RPOC has a similar sonographic appearance to:
a. endometritis
b. increta
c. a placental polyp
d. a simple cyst
9. Usually, the first indication of uterine (puerperium) infection is:
a. vaginal bleeding
b. flank pain
c. leg/ankle edema
d. uterine tenderness
10. The only infection that is not typically related to postpartum infection is:
a. UTI
b. salpingitis
c. thrombophlebitis
d. breast infection
11. Which of the following is not identified with uterine atony?
a. chorioamnionitis
b. rapid labor
c. oligohydramnios
d. macrosomy
12. The most common signs of POVT are:
a. fever, right-sided pelvic mass, and pelvic pain
b. nausea and groin pain
c. vomiting and flank pain
d. bowel ileus and hypertension
13. Cesarean section delivery:
a. has decreased in the last decade
b. is mostly performed with a transverse incision
c. frequently causes solid mass visualization at the site
d. accounts for approximately 13.8% of all US deliveries
313
14. The most frequent site of postpartum thrombophlebitis is:

a. left ovarian vein
b. fundal uterine vein
c. deep cervical vein
d. right ovarian vein
15. Endometritis:
occurs more frequently with vaginal delivery following a cesarean section
a. delivery
b. appears as an extremely thin endometrium and irregular walls
c. a distinct heterogeneous mass within a fluid-filled endometrium
d. causes a flaccid uterus postdelivery
Fill-in-the-Blank
1. The postpartum period may also be called the _________.
2. Complications seen most frequently following cesarean section are _________ and
_________ at the incision site.
3. Withdrawal of pregnancy-induced hormones caused by delivery cause _________ and
_________ changes in the postpartum period that return the uterus to the
prepregnancy state.
4. If a post C-section patient cannot tolerate transabdominal or transvaginal imaging, the
_________ or _________ imaging method may visualize the C-section incision.
5. The adnexal ligaments of the postpartum patient are typically _________ immediately
following delivery, usually returning to their pregravid states within _________.
6. Postpartum hemorrhage is considered over _________ ml of blood with a vaginal
delivery and over _________ ml of blood in a cesarean delivery.
7. The cause of placenta accreta, percreta, and increta is complete or partial absence of
the _________.
8. Antepartum rupture of the uterus causes emergency _________ and _________.
9. Puerperal infection is any infection in the postpartum period characterized by a
temperature of over _________ on any _________ successive days after the first 24
hours postpartum.
10. The sonographic appearance of endometritis is that of a _________, irregular
endometrium that may have _________ in the endocervical canal.
11. Retained placental tissue following expulsion of pregnancy is known as _________.
12. Postpartum ovarian vein thrombophlebitis, a potentially life-threatening
complication of pregnancy, relates to Virchow’s triad: 1. _________, 2.
_________, and 3. _________.
13. Treatment of PVOT is usually _________ therapy, IVC _________, and _________.
14. _________ occur when there is bleeding at the C-section site of incision and the
body has not reabsorbed the collected blood.
15. Uterine atony can lead to _________.
314
Short Answer
1. Offer an explanation for the uterus acquiring infection in the postpartum state.
2. Define RPOC and describe the sonographic appearance.
3. Explain complications involved with a cesarean section incision.
4. List imaging methods that may offer diagnostic information following complications of
delivery.
1. Describe the finding in the postpartum uterus (arrows). What factors should be
considered when assessing this patient? Recommend a treatment plan, if any.
315
2. Diagnose the sagittal and transverse views of the transvaginal uterine images.
3. Explain the pathology in the uterine images.
316
4. Discuss the uterine pathology. Explain what the arrows point to. Suggest a care plan.
CASE STUDY
1. A 36-year-old G3 P3 recovering from a cesarean delivery performed 36 hours ago

complained of extreme tenderness at her incision site. The incision appeared red
and warm to the touch. No obvious infection was noted. Her vitals were normal,
including a temperature of 99.1 °F. Ultrasound was ordered. Explain and diagnose
the image.
2. The condition seen in this image developed following a C-section. State the type of
imaging that produced the display. Diagnose the condition and offer suggestions for
imaging that will benefit the patient and provide useful information to the radiologist
and obstetrician.
317
Interventional Ultrasound
CHAPTER 34

visit the point.

Matching

a. Woman aged 35 years or older
1. _________ coelocentesis
b. Sampling of fetal blood via the umbilical
2. _________ petri dish
cord; also known as cordocentesis
3. _________ amniocentesis
c. Through the cervix
4. _________ transcervical
d. Sampling of amniotic fluid
5. _________ multifetal
e. Round dish used to culture fetal tissue or
6. _________ advanced maternal age cells
(AMA)
f. Sampling of chorionic villus of the
7. _________ chorionic villus sampling placenta
(CVS)
g. Early sampling of the exocoelomic cavity
8. _________ percutaneous umbilical fluid via placenta-free areas
blood sampling (PUBS)
h. More than one fetus
318

Image Labeling
1. Pregnancy sampling. Name the procedure.

2. Target area for sampling. Name the procedure.
319
3. Sampling. Name the procedure.
4. Fluid extraction. Name the procedure.
320
5. Name the procedure.
6. Name the pieces of hysteroscopy equipment
321
CHAPTER REVIEW
Multiple Choice
1. A common clinical technique for retrieving living fetal cells/cell products from the
pregnant uterus is:
a. PUBS
b. amniotic villus sampling
c. amniocentesis
d. culdocentesis
2. An ultrasound procedure that obtains fetal blood via a needle inserted into the
maternal abdomen is:
a. fetal transfusion
b. reduction
c. fetal rapid blood culture
d. percutaneous umbilical blood sampling
3. Amniocentesis testing is recommended at:
a. 6 to 8 weeks
b. 8 to 14 weeks
c. 14 to 20 weeks
d. 20 to 30 weeks
4. Fetal blood sampling occurs at the:
a. venous cord insertion site
b. arterial cord insertion site
c. intrahepatic umbilical vein
d. intrahepatic umbilical artery
5. Vaginal coelocentesis can provide a sample of extra-amniotic fluid as early as:
a. 8 weeks
b. 12 weeks
c. 10 weeks
d. 6 weeks
6. Women whose maternal serum alpha-fetoprotein (MSAFP) screening results reveal a
value below the mean levels for a given gestational age have been associated with
an increased risk for:
a. trisomy
b. spina bifida
c. cardiac malformations
d. anencephaly
7. The average waiting period for amniocentesis test results, prior to molecular probe
use, for chromosomal abnormalities was:
a. 2 to 5 days
b. 24 hours
c. 7 to 10 days
d. 48 hours
8. The main purpose of multifetal pregnancy reduction is to:
a. limit the numberof children a couple chooses to produce
b. reduce the number of embryos to improve survival for the remaining ones
c. decrease physician liability in a multiples pregnancy
d. decrease the financial burden of multiples
9. Hysterosonosalpingography should always be performed during the
______________ of the menstrual cycle.
a. early follicular phase
b. late proliferative phase
c. secretory phase
d. menstrual phase
10. Select the most common endovaginal ultrasound puncture procedure.
a. percutaneous pelvic mass
b. embryo transfer
c. radiotherapy planning and monitoring
d. oocyte retrieval
11. Culdocentesis is performed to:
a. collect a sampling of the exocoelomic cavity fluid
b. acquire fluid posterior to the lower uterus
c. place a pelvic drainage catheter
d. diagnose inflammatory intestinal wall
12. Ultrasound is used to guide local treatment of the drug _________ for ectopic
pregnancy resolution.
a. methotrexate
b. reprotox
c. methohexital
d. repronex
13. Which imaging modality is most useful in diagnosing ectopic pregnancy?
a. spectral Doppler ultrasound
b. MRI with contrast
c. color Doppler ultrasound
d. TCD
322
14. The gold standard procedure for establishing tubal condition is:
a. sonohysterosalpingography
b. laparoscopy
c. HSG
d. hysteroscopy
15. 3D endovaginal sonography is useful in the detection of all except:
a. IUCD position
b. IUCD shaft and branch orientation
c. detection of IUCD
d. IUCD hormone level
16. Prior to pelvic radiotherapy, tumor invasion of the _______________ should be
searched for with transabdominal and/or transvaginal ultrasound.
a. groin
b. cul-de-sac
c. urinary bladder
d. psoas muscles
17. The legal limit for elective termination of pregnancy in the United States is
determined by:
a. county guidelines
b. state laws
c. findings/laboratory results and fetal gestational age
d. health and welfare of the pregnant woman
18. Counseling that provides communication regarding the occurrence and risk of
occurrence of a familial disorder is:
a. perinatology counseling
b. genetic counseling
c. obstetric counseling
d. pregnancy counseling
19. Maternal age–related chromosome abnormality risk increases after the age of:
a. 35
b. 32
c. 45
d. 40
20. Hysterosonography and hysterosonosalpingography are frequently preferable to
laparoscopy because:
a. general anesthesia is required
b. the ultrasound procedures are more affordable
c. surgical complications may occur
d. recovery time is longer
Fill-in-the-Blank
1. Cordocentesis is also known as _________.
2. A gestationally adjusted MSAFP value greater than _________ times the normal limit
raises suspicion for birth defects or _________.
3. The optimal timing for a CVS is between the _________ after the last menstrual
period.
4. _________ is a serum protein found normally in the fetal circulatory system and
produced by the fetal _________.
5. The lecithin to sphingomyelin ratio (L/S) revealed by amniocentesis is measured to
determine _________.
6. Typically, _________ ml of fetal blood is adequate when sampling is done for testing.
7. Fetal skin, liver, and muscle sampling procedures are known as fetal _________
sampling.
8. Endovaginal ultrasound guided procedures are mostly performed using a needle
_________ with an _________ puncture device.
9. In patients with cervical abnormalities, ultrasound-guided _________ puncture may
be performed under the ultrasound guidance to enhance a positive outcome.
323
10. Tubal catheterization is a diagnostic and _________ technique in diagnosing tubal

patency via injecting and observing fluid passage into the pelvis.
11. Antibiotic prophylaxis is recommended in patients with a positive history of
_________, prior to hysterosonography or hysterosonosalpingography.
12. The goal of radiotherapy is to deliver the _________ possible radiation dose to the
malignant tissue and _________ the damage to the adjacent normal tissue.
13. Advantages of chorionic villus sampling are _________ and _________.
14. Multifetal reduction procedures have increased because of _________ inducing drug
use.
15. Indigo carmine dye is _________ in color.
16. The most common invasive procedures available for direct _________ are treatment
of fetal anemia, alloimmune thrombocytopenia, and nonimmune hydrops by
cordocentesis.
17. Fetal tissue sampling consists of procedures such as fetal _________ biopsy for
diagnosis of a specific enzyme deficit and fetal _________ biopsy for the diagnosis
of genodermatoses.
18. Removal of a small amount of fluid surrounding the fetus via the maternal abdomen,
for testing, is called _________.
19. Transabdominal multifetal reduction is preferred between _________ weeks’
gestation, and endovaginal reduction is successful between _________ weeks’
gestation.
20. Misdiagnosis of tubal occlusion due to tubal spasm is a disadvantage of the
_________ procedure.
Short Answer
1. Discuss reasons that pregnant women request and/or agree to amniocentesis.
2. State the ultrasound data that should be collected prior to an amniocentesis.
3. Explain how and why indigo carmine dye is used during invasive ultrasound
procedures.
324
4. Why do recommendations suggest discarding the first small amount of amniotic fluid
obtained during an amniocentesis procedure?
5. What are advantages of hysterosonosalpingography over HSG or laparoscopy?

1. What type of ultrasound-guided sampling is intended for this image? See open arrows
for a hint.
2. Name the invasive sampling procedure that this image is used for. Note the
exocoelomic activity. Name reasons this procedure is not favored over
amniocentesis.
325
3. State the likely reason for a quadruplet pregnancy. Name the procedure that may
improve the fetal survival rate for multiples.
CASE STUDY
1. Sally recently completed her 6-week postpartum visit with her
obstetrician/gynecologist. Her doctor requested ultrasound following the visit for
device documentation. Explain the images and suggest a possible reason for
performing the ultrasound.
326
2. A 23-year-old presented as a new patient to the gynecology office, complaining of a
“sore” pelvis. She offered a history that included living in England until 1 week ago,
inability to conceive, and two regimens of the ovulation induction medication,
clomiphene. After obtaining a thorough history, a pelvic exam that was suspect for
ovarian enlargement, and a negative urine pregnancy test, a pelvic ultrasound was
ordered. View the images and determine a diagnosis.
327
3D/4D Imaging in Obstetrics and

Gynecology
CHAPTER 35

visit the point.

Matching

a. Display algorithm for viewing more than
one plane simultaneously. Frequently
sagittal, transverse, and coronal planes
that are 90 degrees to each other. Aka,
sectional planes or orthogonal planes
b. Smallest unit of a 3D volume, consisting
of a length, width, and depth
c. Imaging technology involving the
automatic or manual acquisition and
display of a series of 2D images
d. Coronal plane, also called the Z-plane;
often, 2D imaging does not allow
imaging on this reconstructed plane
1. _________ 4D imaging
e. Term used to describe both 3D and 4D
2. _________ STIC (Spatio-temporal imaging
Image Correlation)
f. Continuously updated display of volume
3. _________ ROI (Region of Interest) information; also known as real-time 3D
4. _________ C-plane ultrasound and live 3D ultrasound
5. _________ transparency g. Collection of acquired 2D images
6. _________ 3D ultrasound h. The smallest unit of a 2D image, has
7. _________ orthogonal planes height and length
8. _________ voxel i. Planes that are always at right angles (90
degrees) to each other; typically sagittal,
9. _________ PACS (Picture Archiving transverse, and coronal
and Communication System)
j. Computer or server used to store,
10. _________ volume ultrasound retrieve, and display digital images and
11. _________ VOCAL (Virtual Organ patient information from a variety of
Computer Aided Analysis) imaging resources
12. _________ reference dot k. Point where all three orthogonal planes
13. _________ 3D volume (volume data intersect within the volume; depicts the
set) same anatomic point in three orthogonal
planes; also called the marker dot
14. _________ threshold
l. Standard file format for handling, storing,
15. _________ pixel printing, and transmitting information in
16. _________ DICOM (Digital Imaging any form of medical imaging (i.e.,
and Communication in Medicine) radiology, pathology, laboratory, etc.)
17. _________ multiplanar reconstruction m. Area of data acquisition for the 3D/4D
(MPR) volume
n. Determines whether the voxels will be
328
more or less see-through
18. _________ tomographic ultrasound o. 3D rendering mode that displays the
imaging (Multislice) surface or skin of the body without
19. _________ surface rendering displaying the underlying anatomy
p. Technique used to acquire and display a
volume data set of the fetal heart; the
volume displays as a 4D cine sequence
of the beating heart
q. Filter used to eliminate low-level echoes
r. Display format in which the data are
viewed as a series of parallel
tomographic images similar to the
display methods traditionally used in
computed tomography and magnetic
resonance imaging
s. Software program used to measure the
volume or an irregular object
Image Labeling
1. Name smallest unit of 2D.

2. Name smallest unit of 3D.
3. Name planes of the ROI box.
329
4–6. Name orthogonal planes from left to right.
CHAPTER REVIEW
Multiple Choice
1. 3D/4D imaging uses reconstruction abilities similar to:
a. nuclear medicine
b. angiography
c. computed tomography
d. digital mammography
2. Pixel is defined as:
a. picture element
b. cube acquisition
c. data set
d. planes Y and Z
3. 2D transducers require _________________ acquisition to produce 3D images.
a. automated
b. concentric
c. freehand
d. annular
4. The ability to “see through” the voxel depends on the:
a. resolution setting
b. gain setting
c. mode setting
d. transparency setting
5. Evaluation of hypoechoic structures is enhanced with the adjustment of the:
a. maximum and skeletal modes
b. minimum and inversion modes
c. surface rendering mode
d. X, Y, and Z planes
6. Anomalies of the fetal heart are best detected using ______________ technology:
a. VOCAL
b. scalpel
c. glass body
d. STIC
7. All of the following are clinical applications for 3D/4D gynecologic ultrasound
except:
a. congenital uterine anomalies
b. fetal lip characteristics
c. IUD location
d. infertility evaluation
8. Select the view required to display diagnostic fetal heart images utilizing STIC
technology:
a. coronal AP heart
b. decubitus heart displaying LVOT
c. AP 4 chamber
d. PA 4 chamber
330
9. What is the initial recommended uterine view necessary to produce a diagnostic

coronal view in 3D imaging?
a. sagittal midline
b. parasagittal
c. transverse midbody
d. oblique
10. Select the clinical application for a 3D obstetric image:
a. adnexal mass origin
b. SIS
c. fibroid position
d. clubfoot
11. Limitations of 3D/4D imaging are all except:
a. poor 2D acquisition reveals subpar 3D imaging
b. surface rendering ability
c. decreased reconstructed planes image resolution
d. low amniotic fluid
12. Protocols that will help with the integration of ultrasound into daily practice are all
except:
a. acquisition
b. display
c. volume manipulation
d. patient position
13. In 3D imaging, a filter used to eliminate low-level echoes is called:
a. threshold
b. scalpel
c. transparency
d. minimum
14. The 3D mode that views hypoechoic structures and displays them as a solid structure
or creates a digital cast of the object is:
a. render mode
b. texture mode
c. inversion mode
d. light mode
15. The rendering mode, glass body or transparency, is used with:
a. basic slicing
b. color Doppler
c. casting
d. orthogonal plane manipulation
16. Planes that are positioned 90 degrees to each other in 3D imaging are called:
a. reference planes
b. multiplanes
c. orthogonal planes
d. tomographic planes
17. Which plane will display a coronal view of the uterus if the initial acquisition was
obtained in a sagittal format?
a. A plane
b. B plane
c. C plane
d. multiplanar
18. The smallest unit of a 3D data set is:
a. picture element
b. voxel
c. sensor
d. X plane
19. 3D acquisition that requires a separate transmitter that creates an electromagnetic
field uses:
a. mechanical transducers
b. freehand acquisition
c. fan sweeps
d. sensor-based techniques
20. The advantage of VOCAL is the ability to:
a. aid in measurement of irregular anatomy or cavities
b. aid in the reconstruction of the coronal plane
c. manipulate the method of acquisition after releasing the patient
d. display surface structure
Fill-in-the-Blank
1. The term used to describe both 3D and 4 D imaging is _________ imaging.
2. _________ ultrasound provides anatomic views that are difficult or even impossible
to obtain with _________ ultrasound.
3. When a sagittal uterus is imaged with 3D, the B plane displays a _________ uterus,
and the C plane image displays a _________ uterus.
331
4. Manipulation of the three orthogonal planes allows for the creation of an _________
number of images.
5. _________ transducers obtain conventional 2D images, as well as 3D images.
6. _________ is a motion-gated scanning mode.
7. The _________ determines the amount of data acquired in the X, Y, and Z axes.
8. 3D rendering mode that displays the surface or skin of the body without displaying
the underlying anatomy is _________.
9. A _________ image of anatomy cannot be obtained with conventional 2D imaging.
10. The A, B, and C planes display in an _________ manner, with a dot indicating the
intersection of the three images.
11. Conventional 2D imaging does not display a _________ view.
12. Tomographic ultrasound imaging is also known as _________ imaging.
13. _________ is a 3D measurement tool that is used to calculate the volume of an
object such as the endometrial cavity, an ovarian cyst, or fetal organs such as the
lateral ventricles, lungs, and bladder.
14. 3D is referred to as static imaging, whereas 4D is called _________ imaging.
15. Sensor-based techniques use separate transmitters to create an electromagnetic field
that records the _________, _________, and _________ of the transducer
throughout the volume acquisition.
16. Acquisition _________ of 3D changes the quality of the resulting data set.
17. 4D imaging is the addition of _________ to the data acquisition, resulting in a real-
time display.
18. Matrix transducers used in cardiac applications use more transducer crystals to
provide greater out of plane focus and _________ resolution.
19. Freehand acquisition requires some practice as a _________, steady sweep is
required and a _________ frame rate must be maintained.
20. Regarding 4D ultrasound, the _________ the volume rate, the closer to real time the
images appear.
Short Answer
1. What 3D method may predict fetal weight more accurately than the typically utilized
HC, BPD, AC, and FL measurements? Why?
332
2. Discuss parental bonding in relation to 2D, 3D, and 4D ultrasound.
3. Explain the benefit of obtaining data sets.

4. Describe DICOM and how it relates to 2D and 3D ultrasound.
5. Give examples of how VOCAL can be used in the fetal ultrasound.
1. Name the type of imaging seen in the image. Explain how the upper left image relates
to the entire study.
333
2. Explain image A. Compare and contrast it with image B. Discuss the reason for the
image difference.
3. Study the images and explain the difference between them. Name the feature that
provides the ability to alter 3D images.
334
4. What 3D feature or mode was engaged to produce the image? Name the anatomy.
5. Explain the image.
335
CASE STUDY
1. Jillian, a mother of two healthy children, was anxious about her current pregnancy.
She recently learned of an uncle that was born with severe spina bifida. Because her
screening ultrasound was unable to clear the fetal spine due to fetal position, her
obstetrician ordered a follow-up study for recheck anatomy, to include 3D spine
images. Explain images A, B, and C.
336
2. A 26-year-old G1 P0 patient with no family history of birth defects or syndromes

presented to a screening ultrasound examination at 18 weeks. Fetal growth, amniotic
fluid, cranium, abdomen, heart, spine, and placenta appeared normal. The report
stated a clubfoot was visualized, therefore, she was advised to have an extensive
ultrasound examination with a perinatologist to thoroughly interrogate the fetus.
Offer a diagnosis. Explain the imaging modes.

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WORKBOOK FOR DIAGNOSTIC MEDICAL

WORKBOOK FOR DIAGNOSTIC MEDICAL

A Guide to Clinical Practice, Obstetrics and

Barbara Hall-Terracciano, BS, RDMS (OB)(AB)(BR), RT(R)

Susan R. Stephenson, MS, MAEd, RDMS, RVT, CIIP

Copyright © 2018 Wolters Kluwer.

eISBN 978-1-4963-8561-1 | VST 978-1-4963-8562-8

PART ONE | GYNECOLOGIC SONOGRAPHY

PART TWO | OBSTETRIC SONOGRAPHY

WORKBOOK FOR DIAGNOSTIC MEDICAL

Principles of Scanning Technique in

For additional ancillary materials related to this chapter, please

REVIEW OF GLOSSARY TERMS

KEY TERMS DEFINITION

12. Endovaginal transducers cannot be inserted past the area of the:

2. Explain how a mass should be imaged, measured, and characterized.

3. Why is a filled bladder necessary for a transabdominal pelvic ultrasound, and an

Patient data entry document

1. Review the patient data-entry document.

a. State the patient’s LMP.

b. Name the type of examination performed on the patient.

c. How many pregnancies has the patient had?

2. What type of imaging is seen in A–C? (Notice varying bladder appearances)

3. Review the gynecologic report.

a. What is the endometrial thickness in centimeters?

b. State indication for report.

2. A 22-year-old G3P2A0 was admitted to ultrasound for a 7-week obstetric ultrasound

Embryonic Development of the Female

For additional ancillary materials related to this chapter, please

REVIEW OF GLOSSARY TERMS

KEY TERMS DEFINITION

ANATOMY AND PHYSIOLOGY REVIEW

15. Gender (sex) is determined at approximately days:

11. Determination of chromosomal gender or sex occurs at the time of _________.

Congenital Anomalies of the Female

For additional ancillary materials related to this chapter, please

REVIEW OF GLOSSARY TERMS

KEY TERMS DEFINITION

ANATOMY AND PHYSIOLOGY REVIEW

2. A pelvic ultrasound examination performed on a 33-year-old for pelvic pain

4. A 32-year-old DES-exposed woman was undergoing a hysterosalpingogram (HSG)

5. A HSG is performed on a 26-year-old female who is diagnosed with infertility. She

5. Name the uterine type.

The Female Cycle

For additional ancillary materials related to this chapter, please

REVIEW OF GLOSSARY TERMS

KEY TERMS DEFINITION

ANATOMY AND PHYSIOLOGY REVIEW

Anatomy of the female reproductive system

Ovarian and endometrial cycle association

13. Ovarian endocrine functions do not control:

4. Explain the function of LH.

2. This 68-year-old postmenopausal woman is complaining of bloody vaginal discharge

Normal Anatomy of the Female Pelvis

For additional ancillary materials related to this chapter, please

REVIEW OF GLOSSARY TERMS

KEY TERMS DEFINITION

ANATOMY AND PHYSIOLOGY REVIEW

Uterus and cervix

Fallopian tube regions

4. A pelvic sonogram is revealing a solid hook-shaped mass on a thin

5. Discuss filling methods for the urinary bladder.