童教授
一般卵巢瘤開刀的適應症
:
1.卵巢囊腫大於6公分，且觀察2個月，沒有縮小或消失。
2.任何10公分以上的卵巢腫塊。
3.卵巢囊壁上有乳突狀贅生物。
4.有實心部分的卵巢瘤。
5.有腹水。
6.初經之前或停經之後，出現的卵巢腫瘤。
7.懷疑卵巢腫瘤有扭轉或破裂的狀況。
何時會痛：ovarian torsion
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Dermoid
cyst suction要加水
不然黏黏的
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EM thickening
Endometrial
cancer
Adenosarcoma
Amplification
of MDM2 GENE
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Endometrioma
(chocolate cysts or
endometriotic cysts)
Plain radiograph
Not usually helpful in
diagnosis; ~10% of endometriomas can calcify.
Ultrasound
unilocular cyst with acoustic enhancement with
diffuse homogeneous
ground-glass echoes as a result of the haemorrhagic debris. This appearance occurs in 50%
of cases .
Homogenous Low level internal
echoes
Thick walled
Less typical features
include 7:
- multiple locules (~85% will have <5 locules)
- hyperechoic wall foci (present in 35%)
- cystic-solid lesion (~15%) or purely solid lesion (1%)
- anechoic cysts (rare; 2%)
Differential diagnosis
General imaging
differential considerations include:
- haemorrhagic ovarian cyst
- brighter on T2-weighted images
- absence of the "shading sign"
- ovarian dermoid cyst
- will show fat suppression on fat suppressed sequences on MRI
- cystic neoplasm
- tubo-ovarian abscess
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Imaging Ovarian Ovarian
Endometriomas Endometriomas
Tina Marie George Tina
Marie George
Harvard Medical School
Year III Harvard Medical School Year III
Gillian Lieberman, MD
Gillian Lieberman, MD
Corpus luteum cystw/ Central Blood Clot
Differentiating Features
•Complexity
•Heterogeneity
•Irregular Borders
•Unusual shape
Follicular cyst
Differentiating Features
•Thin walls
•Anechoic echogenicity
•Multiple, separate
lesions
Dermoid cyst
Differentiating
Features:
•Mixed hypoechoic and
hyperechoic
areas
•Irregular Borders
•Unusual Shape
Hoffman, UpToDate
„ Distal shadowing
–– Calcific foci in
endometriomas tend to show distal shadowing
–– Echogenic foci in
dermoids can be composed of calcium or fat.
Calcific foci will demonstrate distal shadowing, but foci of fat will
not.
Hemorrhagic cyst
This lesion shows
low-level
internal echoes, clean
margins,
and rounded shape that
could be
confused with
endometrioma.
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Afternoon Meeting: Cases
Port A
implantation
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Termination
after Aminocentesis
May be due to
infection
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Ovarian
cancer, para-caval lymph node recurrence
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Poor appetite
Abdominal
mass
Clear cell
carcinoma
GS LAR
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IVF, AML,
PCOS,
TAE
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Antiphospholipid
with thrombocytopenia
- D-dimer monitor
50k
PPROM
Bilateral
ovarian tumor
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Gestational thrombocytopenia
5%
Mild ITP
Immune thrombocytopenia purpura
Neonatal thrombocytopenia
10% <50000
5% <20000
Stetoid 3-5 days 才會有效
IVIG 6 Hr response
IV anti D
Contraindication, rituximab, cyclophosphamide…
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Aromatic L amino acid decarboxylase deficiency, AADC
AR, DDC gene
7p12.2
20% in Taiwan
Prevalence
1/60000
Dopamine, serotonin↓
Hypotonia
Athetosis
Lethargy
Droopy
eyelids, HTN, GERD
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ADPKD, AD
Incidence
1/25000-40000
Onset in
middle age
50% ESRD in
the 50s
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Controlled ovarian stimulation COS/COH 李教授
GnRH
agonist, (normal: half hour pulsatile) 只有台大噴鼻的
Ultra
long 壓制力太強，need high level
gonadotropin
Long
synchronization
Short for age
>40
Ultra short
Gonadotropin
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Ovulation
LH surge
10-12hr
Onset 34-36hr
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用GnRH agonist Block premature LH surge
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Ovarian
reserve
Birth
2,000,000
Age 14,
300,000
Ultrasound
Early
follicular phase
AFC; Antral
follicle counts
Bad <6
2-9
Volume>10cc,
PCOS
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AMH; Anti-Müllerian hormone
Day 2-5, 3
Inhibit
recruitment
Decrease the
sensitivity of FSH
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Poor
responder <4顆, AMH<1.1,
AFC<6
Normal
Hyper AMH>3.5,
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74 days primordial
follicle to ovulation
Day 3
recruitment
Day 14? FSH↓
selection
取卵費用 12-15萬
Ultrasound
2顆>18mm
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Good
ovarian reserve 用Short
protocol效果差不多
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GnRH
antagonist competitive inhibition
至少比agonist少兩天
效果比較短
減少FSH用量，減少OHSS
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東方人用single 3 mg抑制太強
所以現在都用multiple
0.25mg
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Oocyte
maturation, meiosis I,
diplotene stage
hCG 破卵針，半衰期較長
Heterodimer,
same alpha chain: TSH, LH, FSH, HCG
(alpha chain
glycosylation 仍有差異)
Beta-hCG驗孕
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Recombinant
FSH
HMG(高倍FSH+LH)第三世界老人蒐集尿液
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Two cell, two
gonadotrophin theory
LH->
Thecal cell, androgen
FSH->
granulosal cell, estradiol
Lutenized
granulosal cell才有LH receptor, cholesterol transport
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Luteal
support，補hCG (LH)
不補的話懷孕率很差
FSH高 造成E2高，負回饋抑制pituitary
一顆卵貢獻200pg/ml E2
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Cases
Common exam
找不到
FSH<10,
AGE<40
都可以用
Day 2 看生理期，E2會不會太高，ovarian cyst
陳教授有全台最多OHSS論文
High Risk
E>3600,
卵子>20要減藥
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Titration
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