Surprise Adnexal Finding

About a week ago, I scanned a 40 year old female patient complaining of pelvic pain.  I performed a transvaginal sonogram and found this right adnexal mass:

The above is in sagital and here it is in transverse:

I was unable to determine its origin so I described it as a complex tubular mass in the right adx and stated I was unable to clearly see a right ovary. The doctor sent the patient on for a CT scan, which basically repeated what I said: right adnexal mass, unable to determine origin.  The patient was scheduled for surgery, which was performed yesterday, and the doctor was shocked to find that is was a cancerous appendix! Apparently very rare. 

Lower uterine contraction

Ob scan today, patient is 20 weeks. We always do a transabdominal cervical length at this exam. When I first looked at the cervix, the patient appeared to have placenta previa and I was thinking I'd do a transvaginal at the end of the anatomy scan to confirm it.  Here is the first image:

At the end of the exam I took another look:

The placenta was completely away from the cervix and the patient avoided a transvaginal exam.  It's always good to get another look after 10-15 minutes to see if the patient was just having a contraction.

Great review of adnexal masses

I came across this Power Point presentation on adnexal masses this morning. It really gives a great explanation of the different types of masses and their characteristics.

http://radiology.bidmc.harvard.edu/learninglab/genito/kong.pdf

Interesting Ectopic

I scanned a young lady this week who presented with mild pain, no bleeding, positive hcg. Transvaginal ultrasound was performed; the uterus was empty and I noted moderate anterior and posterior cul-de-sac fluid. 

The right adnexa was very heterogeneous with masses of different textures and free fluid. I also noted a two centimeter cyst on the right ovary, which I thought was probably the corpus luteum. Transabdominally, I could see a large mass in the right adnexa slightly anterior to the uterus.

After informing the doctor, we performed a colpocentesis (which was the first time I had seen this done). Sure enough, the pelvis was full of blood. We sent her to the ER where surgery confirmed the ectopic, however it was on the left side! I was very surprised since I had seen a 4 cm mass in the right adnexa.  This area turned out to be a large blood clot. My mistake here was seeing the mass on the right and only briefly exploring the left, assuming the right would be the side of the ectopic. In the future I will be sure to adequately explore both adnexas!

Placenta Accreta

Dr. David Toms, a contributor to my ultrasound book, sent me this link to a video he produced on placenta accreta. Really helpful for understanding how it occurs and how we as sonographers can detect it!    http://youtu.be/1N0kDsq8TeI                     

Ovarian masses vs. fibroids

A couple of weeks ago, I scanned a 60 year old patient for an annual follow up of her fibroids.  I observed large bilateral masses in the adnexas, which appeared to be ovarian in origin, but with her history of fibroids, I couldn't be sure.  I had the physician come in the room to view the masses live with me; he agreed with my suspicion and informed the patient that she may have ovarian masses, but we needed to do a CT scan.  After he left the room, as I led the patient to the restroom where she could get dressed, she turned around and hugged me.  She was very frightened and I felt horrible about what must be going through her mind.  It was the first time I had to console a patient on my own; the patients are usually given the results of the ultrasound in the doctor's office, not in my scan room.

She had a CA-125 drawn, which came back abnormal at 223.  The CT results were inconclusive, stating that the radiologist was also not able to determine the origin of the masses, ovarian or uterine.  She is being seen at MD Anderson currently and will have surgery within the next two weeks.  I will post an update.

Fetal Practice Breathing

I received a question from a reader yesterday: "When I'm doing a biophysical profile, does seeing the fetus hiccup count as the breathing motions?"

The physicians at my office do not consider hiccups counting as breathing movements, however, I did some research and found that this opinion varies from doctor to doctor.  The Institute for Advanced Medical Education believes that hiccups do count (see this link for more info: https://iame.com/online/bio/bio.html)  so the answer to this question would be to find out what your facility counts as breathing and abide by their policies.  During my research, I also came across some other interesting information on PrenatalAnswers.com:

Believe it or not, your baby has been practicing its breathing since the end of the first trimester!  Of course the baby is not really breathing yet, it is surrounded by fluid and does not ‘breathe’ the fluid—it is only pushing the fluid in and out of its mouth and throat. The baby gets its oxygen from the mother who supplies fully oxygenated blood to the baby via the placenta and the umbilical cord.  Read the full article here: http://www.prenatalanswers.com/fetal-respirationspractice-breathing/