Menstrual Ultrasound

Hi,
I'm very happy to have started a column about ultrasound that appears at AuntMinnie.com. If you bop over there, peruse the selections and sometime type Birnholz into the search list and links to the articles will appear.

The term 'Aunt Minnie' is attributed to Ben Felson, who was an excellent plane film radiologist, and very likely the very best radiology educator  in the history of the specialty. I had the pleasure of meeting him personally  a few times when I was a resident. He was very fond of jokes and humor, and his lectures sparkled with wit. He used the term Aunt Minnie for something you recognize almost instantly on an X-ray film without necessarily having to think  about how you know it - just like knowing that it is your Aunt Minnie when she visits.

The latest article at Aunt Minnie is entitled menstrual ultrasound and it is about the ultrasound exploration of  the dynamics of menstruation and of pathological vaginal bleeding. There is a lot of discussion of the 'hypervascular' myometrium, which is equivalent to diffuse adenomyosis clinically. These images are baseline and energy Doppler views  of the uterus in a woman with vaginal bleeding and pelvic pain. The top image is a shear wave elastogram showing that the myometrium is quite hard with diffuse adenomyosis. A blog treat, since I'm reserving elastography for a future article there. 

 

 Long axis, through a thin endometrium with some liquid blood in the endometrial cavity.  Energy Doppler is monocolor. directional Energy Doppler is multicolored

  transverse views
 

All Images are made with a Supersonic Imagine Aixplorer.

back to blogging

I was very disappointed at the lack of comments about the mystery case. I don't think there are many followers for this blog, but I did e-mail a lot of the so called movers and shakers in OB ultrasound about this case, but as expected, no one seemed willing to make a public mistake, even in an out of the way place like this. Really, guys, when you get to the point where protecting your fragile reputations is more important than learning, you might as well give up.

To be honest, I really didn't expect a lot of correct answers. Most places that do obstetrical ultrasound are mired in a limited set of anatomic issues and act as if a check list a items constitutes a medically acceptable  exam. Consider the issue of selection of major congenital anomalies, where any number of large controlled studies have shown that average performance is really bad. Even if detection rates were very much better, anatomic findings would be relevant in perhaps 5 % of cases. What about the 95% majority of patients? How are they best served? What about the factors that can injure an anatomically "normal" fetus with life long behavioral, intellectual, or motor problems.

The idea is to go beyond an anatomic checklist and a few body measurements to  examining a fetus ultrasonically in exactly the same way that a Pediatrician or, better yet, a Neonatologist would examine a newborn infant. Therein lies the strength and potential of ultrasound.

The challenge case is still open.

Fetal Challange Case

This fetus was seen at 26 weeks GA and again at 28 weeks for a size and dates discrepancy.There was a mild but definite decrease in amniotic fluid volume in both exams. There were no anatomic malformations, growth is normal. The 3D image at 28 weeks was essentially identical to another face view in the earlier exam.

What is the diagnosis?


There is enough information for a relatively specific diagnosis, which will be revealed and discussed after those of you who do OB ultrasound exams make your comments.

Ultrasound Reporting & Photography

Let's link two separate factors: medical imaging is photography and the imaging report is the main marketing tool of the free standing imaging facility.


The first proposition is pretty direct for image forming rather than its inseparable companion,  image interpretation. I'm never surprised at how many of the people I know in the various disciplines of medical imaging  identify their hobby as photography. And, to be sure, the mandatory exposure of residents in Diagnostic Radiology exposes them to a graduate level education in the tech of photography that goes far beyond what the vast majority of professional photographers see or get. Is there really a difference between sunlight or gamma ray photon and  phonon photography at a conceptual level?

I hope you will all visit my light photography website and enjoy the various topic galleries at Visual Jason Photography.

 I believe the second notion was one that my good friend Dr George Flinn in Tennessee expressed when I started in private practice at the end of 1988 after 20 years in big hospital/academia, where, also, patients tend to have no (or not offered any alternatives) in where they have their imaging studies.The main Harvard associated hospitals never send patients for imaging studies to each other, and there is no phrase in the local language for even expressing the idea of having imaging studies at any of the Tufts or Boston University locations. Perhaps that failure to share resources has something to do local pride of excellence. The situation is much worse in Chicago, where for many years the larger hospitals have formed hospital networks that don't recognize each other's existence, which, from my personal opinion is motivated by economic factors primarily.

From the standpoint of the free standing clinic, what the referring physician gets is a report of the patient's visit. That needs to be coherent, complete, and accurate as well as prepared and sent promptly. We can assume that when there is an urgent issue, the physician involved with an individual exam will contact the referring physician directly. Most of the time the report is e-mailed, faxed, or sent by conventional mail. The referring physician typically has none of the options for reviewing images directly with a Radiologist when everyone is rounding in the same location. For the time being, we will concentrate on the way things have been done for the last 50 years and reserve discussion of some of the free web based PACS systems that are available to private practice Radiologists for a later posting.

What George realized and had been doing in his own practice was a novel way of placing images directly on the reports. What the referring physician needs is to know the interpretation of the Radiologist for the exam, does it answer the clinical question, if not, what should be done next. Placing images on the report is a way of validating the interpretation and expressing visually how an interpretation was made. It also illustrates that the interpretation was made from technically satisfactory images (which has always been a major issue in ultrasound). It is not the images themselves that are important, but what they represent. A report with great images conveys the professionalism of the center doing the study, which is a marketing function when there are multiple locations that appear to provide the same service for patients.

Our own little contribution to this was the thought that when a referring physician sits down to go through all the reports filtering in for their patients, especially those with lesser problems, it may be a little tricky to remember who's who. So, what we do and have done for most of the time we have been in private practice is to photo-identify all of our reports with a closeup of the patient in the upper right hand corner of the report, near the patient's name and identifiers.

21st March, 2011. T, Moon  (11-2146)

Formatting is trivial with a word processor, but you get the idea. About 1 in 12,500 patients will decline the photo-op, which is their privilege. Everyone else likes it, especially my referring physicians, and I find that it helps me to get back into a case whenever  a patient returns for more scanning. Like most Radiologists, I'm primarily visual. The picture above, was made with the same camera that we use for patient photos with some contrast enhancement for impact. Any digital point and click will work well for this application, especially since there is no need for enlargements.Of course no one gets to see those photos who is not designated to receive the report.

I think I saw a short paper in a recent JACR about some clinic at the Massachusetts General Hospital photo-identifying patient reports. Nice innovation, MGH, although about 20 years behind the curve.

Instructive Case - cont'd

I've always wished that I could produce from memory something pithy and perfect and exactly appropriate from Milton, or Shakespeare, or maybe Pope or Shaw, but I can't. However one thing that I can't seem to get rid of is:  This Case, like first love...very instructive, which is from a Charlei Chan movie. Of course almost no one except for some older cruciverbalists remembers Charle Chan or his three movie portrayers and first love tends to hit at an age when instruction and education are impossible. Now that I've used it up, I hope it will vanish from my memory forever.

The question I asked the patient was - Have any relatives who are anemic?  The answer was, "Why yes, my grand mother had sickle cell disease." No one ever asked me that before."

Now let's get into the case itself. There was early intrauterine pregnancy without any unusual pelvic findings. The two pictures are, obviously, the gall bladder (conventional 2D and  a 3D surface reconstruction, in which the anterior part of the gall bladder has been escised revealing the mucosal floor and stone floating just above it.It has been our practice since we started using phased array imaging in 1976 to do a survey of everything visible transabdominally in everyone referred for any type of abdominal or pelvic ultrasound. In the second or third trimesters of pregnancy, we tend to focus on the fetus, but we will a more extensive maternal exam with even the most minimnal of reasons. We don't charge anything extra for our surveys, they only add a minute or two to the exam, they provide a cache of valuable clinical information, establish a baseline should a question come up in the future, and during the process, patient's often volunteer a lot of relevant history, since they perceive that this is a real medical exam.

Gallstones are highly prevalent, making this one of the commonest intended or unexpected ultrasound imaging findings.In this case we have a young (slender) woman (not a lot of subcutaneous fat to be seen) with a single, larger stone that floats in bile at the distal end of the gall bladder (not the dependent neck region with the patient supine). There is no acoustic shadowing, gall bladder volume is normal, and the wall is thin and delicate.

Typical cholesterol stones are typically preceeded by progressine chronic focal cholecystitis with puntate scarring showing up as reflective patches in the submucosa and as distinct ridging, usually transverse to the axis of the gallbladder) in 3D cutaway views of anterior or posterior lumenal surfaces. The posterior surface, here is absolutely smooth and pristine. All of which suggests that this stone is most likely due to chronic intermittent episodes of hemolysis.  An additional finding was a splenic accessory, next to a slightly rounded tip of a normal sized spleen with a uniform sonic architecture.

The 'incidental' finding now makes us think of Sickle trait or one of the sickle trait variants.Aside from the frequency of renal papillary necrosis and wel described renal concentrating issues in older patients with sickle trait, there is always the worry that episodes of sickling can occur whenever and wherever there may be hypoxia. The prototype and tragic example is sudden death during exercise in black military recruits, which received a lot of attention in the 1980's leading to recognition of this problem and steps for its prevention. Dancers, like this patient, often have workouts that put to shame what a lot of professional athletes can indure. 

There is a really great article about sickle trait by Dr John Kark of the Howard University School of Medicine that you may find really instructive by clicking here.

Interlude: A way to look at the role of ultrasound

John Knowles, presidential adviser and head of Massachusetts General Hospital (when I was a lowly serf there) told me some 30+ years ago that it's a lot easier to prevent disease than to treat it. I treasure the memory of the interaction, although he might have been stingier with his prescient platitudes if he knew that I would soon deviate from my original interest Cardiology.

What I have seen over and over again is that a lot of people are reluctant to have diagnostic exams and how relieved they are when there is a simple, fixable explanation (like pelvic adhesions in a woman afraid of ovarian cancer) or, better, yet, when they exam can show that something really appears to be normal.This is, actually, the main role of ultrasound in obstetrics. There is always maternal anxienty, it gets worse with each pregnancy, typically least first time around and peaking with the third child, eventhough some 90+ % of unselected groups of pregnant women traversing the first trimester in peace, will have 'normal' children close to term.

The great developmental pediatrician HFR Prechtl in a massive body of work, slipped in a paper maybe 15 years ago about  scoring 'wellness' in exams rather than abnormalities.I recall his referring to that as 'optimality testing'. There have been lots of  studies with  'quality of life' as an end point, which is very closely related  and which also provide a set of statistical tools for coping with this type of subjective variable.

I think it is about time that we all got involved in studies which show how a lot of our exams promote patient happiness by eliminating the worries about specific problems. In many ways this is an unique property of ultrasound, which can be used widely, cheaply, and without any compromise in patient safety. In places where ultrasound is trusted, there is also reduced demand upon and improved utilization of CT and MRI, but that is another matter entirely. The tools are there, and after focusing on pathology for so long, a look at the flip side might be refreshing. If you think about it, a negative exam is even better for prevention than finding an early indication of a problem requiring some behavioral modification of pre-emptive drug therapy.

An Instructive Case

The patient is a 21 year old female Afro-American dancer referred with intermittent pelvic pains about 2 weeks after conception.

What should you ask her?