산과 USG4
- 복부
- Stomach : 9주부터 보여 14주면 무조건 보여야 됨. Midline 절대 안넘음
- Large stomach bubble : AFI 유지 잘되면 크게 의미 없음 초) pyolic atresia : 위크고 양수과다, rare
- Small stomach bubble : 최근 비워짐, esophageal atresia, hernia(chest, abd. wall), aneuploidy, anhydroamnios, microgastria à reassessment!
- Respiratory anomaly, CNS, karyotype…
- Small & Large intestine
- Idiopathic transient early intestinal fluid dilatation : 14~17주 발생 18~22주 소실 : 예후좋음
- Term Colon 18mm이상, rectum 13mm 이상 시 주의
- Small bowel dilatation : transiently은 normal fetal outcome / progressive : intestinal abnormality 발생 가능성 à serial 하게 관찰
- 7.6mm at term
- ü Echogenic Bowel
- iliac wing 정도로 echogenicity 증가
- low frequency transducer (<5mHz)로 하지않으면 진단 과잉진단
- Adverse outcome : aneuploidy(3%, 주로 trisomy21), cystic fibrosis, IUGR, IUFD, infection (1.9% CMV), gestointestinal obstruction à % 높지 않으니 isolated 면 산모와 상의
- Jejuno-ileal junction atresia : 3 삼분기 발견
- Liver & GB
- Infection, ischemic insult, thromboemboli, tumor, sludge & lithiasis in GB à USG 로 찾기 힘듬
- Isolated liver calcification: good prognosis / non-isolated : chromosome abnormality, CMV infection
- GB : teardrop-shape at RUQ, 30주 까지 커지다 크기 유지됨
- Isolated non visualization of fetal GB : persistent à agenesis, biliary atresia 가능성 à detailed USG
- 복강 내 종괴
- DDX 방법 : kidney, bladder 등 잘 있나? 성별, 도플러, 성상, 연동운동, 언제부터, 크기변화…
- Lower abdominal cyst
- Ovary cyst (남녀 합쳐 54%) > duplication cyst > mesenteric cyst > meconium pseudocyst
- Ovarian cyst : 제3삼분기에 보임(엄마 H 영향), simple or complicated, 자연호전, >4cm, complex 면 수술해야 할 수
- Duplication cyst : 남아 m/c, 여아 2nd m/c, intestine의 extra-portion at 식도~장 à 3 layer cyst wall, 연동운동
- Meconium pseudocyst : well defined hypoechoic heterogenous mass with calcified echogenic wall
- GI abnormality (small bowel stresia, volvulus, microcolon, intussusception, Meckel’s diverticulum, imperforate anus) 동반
- Ascites, polyhydroamnios, dilated bowel
- Volvulus : whirlpool sign, sup. mesenteric a 막혀 necrosis 오면 연동운동 소실 à 조속한 분만, 조속한 외과수술
- Duodenal atreasia : double bubble sign (duodenum, stomach) 두 bubble 연결되어 있으며, fluid 이동 봐야
- late 2nd trimester or early 3rd trimester 에 발견할 수 있어 poly 시 주의
- Trisomy 21 있을 수 있으니 karyotype
- Choledochal cyst : biliary tract dilatation
- liver 의 inf. Margin에, 도플러 (-), duct 와 연결, 연동운동 없음
- 21.5% congenital anomaly, 50퍼 이상이 산후 간 이상
- DDx biliary atresia : 약간 작은데 초음파로 구분 어려움
- Upper abdominal mass
- Neuroblastoma : nerve tissue malig.
- 90% 가 Rt. Adrenal gl.
- 출생 후 호전 많으나, 간전이시 항함 필요할 수
- Complex cystic, uniformly echogenic, calcified mass, single feeding artery (-)
- 3rd trimester
- DDx bronchopulmonary sequestration : nonfunctional lung tissue, 90% Lt., aorta blood supply, 50~75% 자궁내 호전, 85~90% 횡격막 위, extrapulmonary sequestration CDH 가능성
- 1st trimester abdominal mass
- 다른 기형 동반(1/3)
- isolated à 지속 (choledochal cyst, ileal duplication cyst, hepatic cyst) / 소실( normal, anorectal malformation)
- 신장 – renal agenesis, hydronephrosis, re
- 갯수, duplication, 위치, 크기, urinary tract dilatation, cystic renal disease
- Obstruction, non-obstruction, dysplastic, cystic renal disorder
- 1삼분기 간이랑 비슷, 2,3 분기 가면 간보다 까망
- Renal Agenesis : 남아
- Unilateral : adrenal gl. Lying down(sagittal view), 반대 kidney 커짐 à abscent, ectopic, 못찾음… à 32% uro기형 (Vesico Ureteral reflux, megaureter, duplex kidney), renal dysfunction risk, HTN, 30% genetic abnormalies(청력검사), Mullerian anomaly
- Bilateral : rare, anhydroamnios, lying down adrenal sign, 도플러(-), 방광 안보임, 폐 발달 저하
- Hydronephrosis (=urinary tract dilatation) : male>female
- Renal pelvis AP diameter 2nd ~4mm, / 3rd ~7mm
- Transient, Congenital anomalies of the kidney and urinary tract (CAKUT)
- Serial, uni or bilateral, ureter dilatation 동반여부, renal parenchyma, 방광, 양수양, 60% genetic or other malformation
- Renal duplication
- Upper pole moiety : ectopic ureter insertion, ureterocele
- Lower pole ureter dilatation – reflux
- Renal cystic anomalies
- Genetic disease : ARPKD, ADPKD, GCD(glomerulocystic kidney dz), MCD(medullary cystic dysplasia)
- Non genetic : MCDK(multicystic dysplastic kidney), obstructive renal dysplasia, renal cyst
- MCDK(multicystic dysplastic kidney)
- non-communicating cyst(크기 다양, 그 사이는 하양), dysplastic renal tissue(cortex, medulla 구분 안됨), non-functioning kidney, collecting system 안보임
- Unilateral 80%, Lt. à 반대 보상적 비대 : 좋은 예후인자
- Bilateral 20% : severe oligo, bladder (-) à 바터신드롬, 예후 안좋음
- 5~40% other renal anomaly ex) UPJ obst.(calyx 와 연결) Renal agenesis(lethal), 반대 hypoplasia(예후나쁨), VUR
- Isolated 아니면 genetic test: Meckel-Grube syndrome(encephalocele, polydactyly), trisomy13, 18
- DDx UPK obst, obst cystic dysplasia(cortex 에 cyst, hyperechoic), ARPKD(cyst 크기 작음), dilated ureter
- Obstructive renal dysplasia (=obstructive cystic dysplasia)
- Echogenic kidneys + cortical cyst + urinary tract dilatation
- Post. Urethral valve in male, cloaca or urogenital sinus in female, UPJ obst., VUJ obst.
- DDx MCDK(UT dil (-), 모양 불규칙), non-obst. renal dysplasia(다른 기형), ARPKD(작음)
- Renal cyst
- Unilocular, non-communicating, upper pole
- DDx duplication, calyx communicating
- ARPKD (autosomal recessive polycystic kidney dz)
- PHKD1 mutation
- Bilateral, symmetric, cystic renal dz + hepatic fibrosis, male=female
- Microcystic -->하얗고, 커짐, oligo, bladder(-), pul. hypoplasia
- DDx trisomy13(enlarged, echogenic cyst, visible cyst), Meckel-Gruber synd.(다른기형), ADPKD(비대칭, 양수량 정상)
- ADPKD (autosomal dominant polycystic kidney dz)
- PKD1, PKD2, PKD3 gene mutation, sporadic
- Moderated enlarged, 하양cortex, 어두운 medullaà corticomedullary differenciated 과장, bladder정상, AFI 정상, cortex에 cyst(+)
- 진단시 부모 유전검사, 다음 임심시 PGD
- Neuroblastoma
- Adrenal gl. Rt>Lt, 3분기, 25% cystic change, liver meta 가능, 다양한 예후
- Adrenal hemorrhage
- 시기에 따라 다양한 echo
- DDx neuloblastoma(변화 거의없음), BPS (feeding vessel from Ao.),
- Avoid adrenalectomy
- Fetal skeletal Dysplasia
- GA, all long bone length & shape & contour, foot length(femur/foot <0.9 이상), mineralization, lethality (폐의 모양, 크기, rib이 70%두름, CC/AC<0.6)
- Thanatophoric dysplasia : Rhizomelic, micromelic
- m/c lethal skeletal dysplasia
- FGFR3 mutation
- TD type1 (micromelia, prominent bowing, telephone receiver femur, macrocephalic, normal shaped skull, brachydactyly)
- Type2 (cloverleaf skull, femur longer, less curved, platyspondyly(편평한spine) less marked)
- Achondrogenesis: micromelic, spine ossification deficient, short trunk, 큰머리, 팔다리 짧고, 폐작고, 부어있음
- 2nd m/c lethal skeletal dysplasia
- Cartilaginous matrix formation 장애
- Type IA 모름, 머리, 척추 다 저하/ Type IB DTDST mutation, skull ossification, spine은 ↓/ Type II COL2A1 mutation /
- Osteogenesis imperfect: micromelic
- COL1A1, COL1A2 – type I collagen
- Type I : nondeforming OI c blue sclerae
- Type II : perinatally lethal OI, micromellia, multiple Fx c hypomineralization, beaded rib,
- Type III : progressively deforming OI, skull 누르면 눌림
- Type IV : common variable OI c normal sclerae
- Campomelic dysplasia: mesomelic
- Bowed, bent-limb dysplasia
- SOX9 gene : cartilage, early testis 발달 영향 à tracheobronchomalacia
- Ossification 은 괜춘 Fx (-), 휘었지만 부러지진 않음. Hypoplastic scapulae(scapula 위치에 clavicle 같은 뼈)
- 46, XY c female phenotype, uterus 있을 수
- Achondroplasia : non-lethal, Rhizomelia
- m/c 유전, 치명x,
- FGFR3 mutation, AD, 80% sporadic, hetero(non-lethal), hono(lethal)
- ü Proximal femur diaphysis-metaphysis angle 증가, Collar hoop sign (femur 각도 증가, spur), frontal bossing, nasal bridge depressing à frontal bossing 더 강화, 머리큼, brachydactyly
- Craniosynostosis
- Apert synd
- FGFR2 mutation, AD, new mutation, paternal age 증가
- Craniosynostosis, Hand & foot syndactyly
- 척추, 손, 발
- CNS : m/c, incidence 높음
- Spine USG
- ① Axial view : 3 ossification center dots
- ② Coronal : 3 line appearance (body, 2 pedicle): cranio-occipital junction, lumbosacral prior to sacrum 은 정상적으로 넓음
- ③ Sagittal : vertebra body & post center, curvature, cauda 까지 점차 작아짐
- ü NTD d/t Chromosome, DM, valproate, previous sacrococcygeal teratoma
- ① Open NTD : skin 없어 신경조직 노출됨 ex) Chiari II malformation
- w 예후 25% 는 5년 내 사망, 소뇌 hernia(m/i), affected lv, covered memb.
- ② Closed NTD : meningocele, lipomeningocele, lipomyelomenigocele, myelocystoceles
- w 12% of NTD
- w MC, LMMC, MCC : Chiari II malformation (-)
- ü Brain : banana sign (sensitivity 99%), lemon sign, microcephaly, lat. VM
- ü Chiari II malformation : CSF, neural tissue spinal defect 로 빠져나옴
- ü Iniencephaly
- ① Inion : 그리스어 nape of the neck, (occiput 의 prominence)
- ② RF : folic acid 부족
- ③ Deficient occiput, inion / Rachischisis of cervical and thoracic spine / Retroflexion of the head
- ü Diastematomyolia : cord 나뉨 by bone, fibrous tissue
- ü Scoliosis / hemicertegra : vertebra segmentation 이상, 갑자기 척추가 꺽임
- ü Sacral agenesis / Dysgenesis
- ① caudal regression synd.: sacrum 의 caudal cell mass 없음 / hypoplastic 다리2개 / non-lethal / anal atresia / 엄마 DM
- ② Sirenomelia: sacrum 의 caudal cell mass 있는데 damage / 다리1개or fusion / renal agenesis à oligo / anus (-)
- ü Sacrococcygeal teratoma
- ① female많은데 male 이 malig 더
- ② 빨리자라서 close f/u
- ③ Poly, hydrops
- w Limb : absence / abnprmal No. motion, alignment
- ü Amniotic band synd. : 사지 어디든, 말단 edema
- ü Club foot : Talipes equinovarus
- ① isolated (2/3) : aneuplod < 4%
- ② complex with spina bifida(m/c), arthrogryposis, myotonic dystrophy à aneuploidy(10~30%) : Trisomy 18,13, triploid
- ü clinodactyly : 4,5번 손가락이 안쪽으로 굽음. 다른 marker 있으면 genetic synd. Karyotupe
- ü clenched hand : clinodactyly+ 2번이 3덮고 엄지 adductà trisomy 18, karyotype
- ü polydactyly : 새끼 손(R>L)>발가락(L>R) 많음
- ü syndactyly : 손가락 분리 안됨, 3~4번이 붙음(m/c)
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산과 USG4
Zetta
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23.02.09 18:54
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