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KEY TERMS

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Key Terms

  1. Simple ovarian cyst: ovarian cyst that is anechoic, thin, and smooth walled, without septa or wall irregularities.

  2. Complex ovarian cyst: any ovarian cyst with morphology other than simple.

  3. Ectopic pregnancy: pregnancy located anywhere outside the normal endometrial location.

  4. Multifetal pregnancy reduction: procedure utilized to reduce the number of fetuses in a given pregnancy to a lower, more desirable number.

  5. Peritoneal inclusion cyst: multiloculated peritoneal fluid collection with pelvic adhesions.

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INTRODUCTION

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The abdominally guided puncture has been largely replaced by the transvaginal puncture given the improved imaging quality for gynecologic organs achieved with transvaginal ultrasound and the proximity of this probe to the targeted lesions. Procedures such as amniocentesis will always be performed abdominally, but marked changes in assisted reproductive technologies, specifically in vitro fertilization (IVF) and human egg retrieval, have paved the way for vaginally guided techniques. The aim of this chapter is to describe the various transvaginally guided puncture procedures, both those being presently performed and innovative procedures being studied experimentally, and the experience gained thus far.

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GENERAL CONCEPTS

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Ever since Smith and Bartrum performed percutaneous aspiration of intraabdominal abscesses in 1974 and Gerzof et al used an abdominal catheter placed sonographically to drain purulent pelvic collections, ultrasound-guided puncture procedures have been used to achieve diagnostic and therapeutic goals.1-3 The advantages of these procedures over traditional surgical means are multiple: ease of technical mastery with accurate needle or catheter placement, diminished invasiveness, avoidance of injury to adjacent organs, portability, low cost, speed of administration, and above all, patient satisfaction and comfort. Possible risks, although quite rare, include bleeding, infection, inadvertent puncture of organs, tumor seeding, and in the case of multifetal reductions, miscarriage.

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Puncture procedures necessarily traverse three-dimensional(3D) space, not only the two-dimensional(2D) view of an ultrasound machine screen. This third dimension, because of the properties of ultrasound, is thinnest at the focal range of the probe and is inversely proportional to the operating frequency of the transducer crystal. This concept is called the slice thickness artifact and means that the operator must take the third dimension of the image into account: At times the tip of the needle used for puncture procedures appears to be within the structure at which it is aimed, but is actually in front of or behind the target structure.

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BACKGROUND

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When puncture procedures are performed abdominally, one of two techniques is employed: needle guide or free hand. Less experienced operators are more comfortable using a needle guide attached to the transabdominal ultrasound transducer to assist needle placement. With increasing experience, the free-hand approach has been successfully practiced, with greater ease of handling the needle, shorter procedure time, and better alignment of the needle within the scanning plane. The limitation of this technique is that occasionally the transverse section of the needle, excluding the tip, is imaged and ...

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