Topic Review

Practical ultrasonography
in obstetrics and gynecology

2010-03-30
R3

Introduction
I. Methodofpelvicultrasonography
I. Transvaginal and transabdominal method
II. Practice Guideline for Pelvic US

II. Ultrasonographyinobsterics
I.
II.
III.
IV .

Emergency sonography
Early pregnancy
Biometry; CRL, BPD, FL, AC
Nuchal translucency

III. Ultrasonographyingynecology
I. Emergency sonography
II. Pathology
- Uterus
- Ovary

I.Methodofpelvicultrasonography
I. Transvaginal and transabdominal method
II.Practice Guideline for Pelvic US

I.Pelvicultrasonography
Method

Transabdominal(TA)

Transvaginal(TV)

Field size

Large
-Relationship of ovaries
to uterus
-Large masses

Limited
-Large masses may be
beyond focal zone
-No entire uterine

Flexibility

-Upper abdomen with

same transducer
-Bladder, distal ureters

Must use TA transducer for

upper abdomen
Bladder not well seen

Invasive nature

Non-invasive
Technique of choice
for paediatrics & others

Invasive
Pt/sonographercommunication
Privacy essential

Preparation

Full bladder

Empty bladder

Resolution

Limited resolution especially

in far field

Superior to TA

TApelvicultrasound

Transverse

TApelvicultrasound

Saggital

TVpelvicultrasound

Coronal or
transverse
Probe marker towards
patients RIGHT

TVpelvicultrasound

Saggital
Probe marker towards
ceiling

OrganAnatomy
Vagina
Mid-line, thin walled, muscular structure
8-9 cm in length
From uterus to vestibule

OrganAnatomy

Uterus
Midline
Pear-shaped muscular hol
low organ
Anterior to rectum poste
rior to bladder
Adult uterus
Length 7cm, wide 4 cm
and AP diameter 3 cm

OrganAnatomy

Uterus

Version: axis of cervix to vagina

Flexion: axis of uterus to cervix

OrganAnatomy

Uterus
Endometrium

Menstruation

Regenerative/ early proliferative

proliferative

Peri-ovulatory

Secretory

OrganAnatomy

Ovary
Posterior and lateral to either side of uterus
Central medulla & outer stroma(follicles)

II.PracticeGuidelineforPelvicUS
The American Institute of Ultrasound in Medicine, 2009

Indications
1. Pelvic pain
2. Dysmenorrhea
3. Amenorrhea
4. Menorrhagia
5. Metrorrhagia
6. Menometrorrhagia
7. F/up of a previously abnormality
8. Evaluation, monitoring, and/or
treatment of infertility patients
9. Delayed menses, precocious puberty,
or vaginal bleeding in prepubertal chil
d
10. Postmenopausal bleeding

11. Abnormal or technically limited pelvic

examination
12. Signs or symptoms of pelvic infection
13. Further characterization of a pelvic
abnormality noted on another imaging
14. Evaluation of congenital anomalies
15. Excessive bleeding, pain, or signs of
infection after pelvic surgery, delivery,
or abortion
16. Localization of IUD
17. Screening for malignancy in patients at
increased risk
18. Urinary incontinence or pelvic organ
prolapse
19. Guidance for interventional or surgical
procedures

PracticeGuidelineforPelvicUS

Uterus
Reference points for other pelvic structures
(1) Uterine size, shape, and orientation
(2) Endometrium
(3) Myometrium
(4) Cervix
(5) IUD: location
(6) Vagina: landmark for cx & lower uterine segment

PracticeGuidelineforPelvicUS

Adnexa(OvariesandFallopianTubes)
First! Identify ovaries
Major point of reference for assessing patholog
y
Size, 2 orthogonal planes
Not identifiable in some females
Prior to puberty, after menopause, large myomatous uteru
s

Normal fallopian tubes: not commonly identified

Adnexal abnormality
Relationship to ovaries and uterus

PracticeGuidelineforPelvicUS

Cul-de-sac
Presence of free fluid or mass
Mass: size, position, shape, characteristics, &
relationship to ov. and uterus

Differentiation of normal bowel from mass

: Transvaginal exam. may be helpful

II.Ultrasonographyinobsterics

I. Emergency sonography
II. Early pregnancy
III. Biometry; CRL, BPD, FL, AC
IV . Nuchal translucency

I. Emergency sonography
EctopicPregnancy
Common cause of morbidity & mortality in childbearin
g age
Positive findings on pregnancy test
Particularly, HCG < behind the estimated GA
Common sonographic findings
Cystic or solid adnexal mass
Dilated & thick-walled fallopian tube
Low echogenic or lucent intraperitoneal fluid
Hematosalpinx & extrauterine G-sac containing yolk sa
c +/- an embryo

Color-flow Doppler: trophoblastic Doppler flow

EctopicPregnancy
Decidual cast or pseudogestational sac
Intrauterine fluid collection
Single decidual layer

Cervical pregnancy
-Must distinguish from abortion in progress
Round or oval noncrenated sac
Fetal cardiac activity, constant sac shape & loc.
Closed internal os

36-year-old woman with tubal ectopic

pregnancy after artificial insemination

26-year-old woman with live tubal

ectopic pregnancy :
ring of fire sign of trophoblastic flow

22-year-old woman with

live right-sided tubal ectopic pregnancy

Concomitant intrauterine and ectopic

pregnancy in 32-year-old woman

Right cornual pregnancy

32-year-old woman with
intraabdominal pregnancy

CervicalIncompetence
Common cause of preg. failure in 2nd trimester
Painless dilatation of cervix, preterm labor

Sonographic findings
Bulging of fetal membranes into widened intern
al os & shortening of the cervical canal
Cx length: shortening
(>3cm normally, but temporal change)

provocative measure: helpful tool

Endovaginal sonography: more accurate

34-year-old woman with second trimester cervical

incompetence

RetroplacentalHematoma
&AbruptioPlacentae
Bleeding along basal plate of placenta
due to primary abruptio placentae
or ruptured spiral arteries
Clincal sx
Placental abruption with painful vaginal bleeding
Consumptive coagulopathy
Fetal distress
Sonographic findings:
Crescentic low echoic lesion
Isoechoic to placenta : mimic thickened placenta
low sensitivity

Placental abruption and fetal

demise in 28-year-old woman

32-year-old woman in second trimester

with placental abruption

UterineDehiscenceandRupture
M/C cause of uterine dehiscence: old c/sec scar
Type of rupture
Limited to dehiscence of scar w/ intact serosa
Minimal vaginal bleeding or intraperitoneal hemorrhage

Full-thickness uterine rupture

Massive hemoperitoneum : high fetal & maternal mortality

Sonographic signs of uterine rupture

Protruding portion of amniotic sac
Endometrial or myometrial defect
Extrauterine hematoma & hemoperitoneum

36-year-old woman with uterine rupture after

prolonged induction of vaginal delivery

28-year-old woman with surgically proven

intraabdominal pregnancy resulting
from uterine dehiscence

PuerperalGonadalVeinThrombosis
Uncommon, fatal, postpartum complication
Pathogenesis
Retrograde propagation of thrombosed myometrial
veins draining infected placenta

Sonographic diagnosis
Dilated, noncompressible ovarian v. into IVC

RetainedProductsofConception
Sx: secondary postpartum hemorrhage or infection
Sonographic findings
Endometrial expansion of heterog. echoic material
Focal areas of hyperechogenicity
:Retained placental calcifications

32-year-old woman, 4 days postpartum

Right ovarian vein thrombophlebitis

28-year-old woman with retained products

of conception

Earlypregnancy
G-sac
TV US(useful): 31 days or 4+3 weeks of GA(23mm)
TA US: 5+3 weeks of GA
US finding
At uterine fundus & eccentrically placed

Intradecidual sign
Before visualization of yolk sac or embryo
Two concentric rings

Circular transonic area surrounded by

thick bright ring: double sac sign
Thick, bright ring: invading chorionic villi & decidual reaction

Early pregnancy

Normal intrauterine pregnancy at

4 weeks gestation

Echogenic appearance and

thickness of wall of sac

Early pregnancy

Embryo(fetalpole)
Conceptus before 10 weeks GA
TV US: 37 days GA
US finding
Bright linear echo, adjacent to yolk sac
Close to connecting stalk

Decidual reaction

Yolksac

Early pregnancy

TV US:
About 35 days: first identified
After 12 weeks: Identification is difficult

Membranous sac attached to embryo

providing early nourishment

Amnion

Early pregnancy

Membrane building amniotic sac that surroun

ds and protects embryo
TV US: 6 weeks GA

Chorion
Membranes btwn developing fetus & mother
during pregnancy
Extraembryonic mesoderm
2 layers of trophoblast
Surround embryo &
other membranes

Missedabortion
Retention of G-sac in uterus after embryonic or
early fetal death
Dx on US
Cardiac activity(-) in fetal pole of CRL>6mm
Yolk sac or embryo(-) in G-sac of diameter> 20 mm
Blighted ovum

Biometry
CRL
Most acurate dating of early pregnancy
Long axis of fetus
Top of head(crown) to end of trunk (rump)

BPD

Biometry

2nd trimester
Both thalami & cavum septum pellucidum level

FL
After 14 weeks GA
Ossified diaphysis and metaphysis

AC
Single vertebra, umbilical vein (UV), stomac
h
widest part of abdominal circumference
section

Nuchaltranslucency
At CRL(33-88mm)
Max. thickness of subcutaneus translucent
area btwn skin & soft tissues overlying
post. aspect of cervical spine on sagital plane

A thickness > 3 mm
90% trisomy 18 & 13
80% trisomy 21
5% normal

Gynecologic Emergencies

PelvicInflammatoryDisease
M/C cause of acute pelvic pain
Acute complications of PID
TOA, pyosalpinx & peritonitis

Sonographic finding
Early stages or or uncomplicated: normal
Severe or advanced
Usually bilateral
Endometrial thickening +/- endometrial fluid, gas
Ovarian enlargement w/ indistinct borders
Uterine enlargement w/ indistinct contours
Free intraperitoneal fluid

24-year-old woman with pelvic inflammatory

disease and tuboovarian complex

15-year-old girl with pelvic pain, fever, and

bilateral tuboovarian abscesses.

TuboovarianTorsion
Complete or partial torsion of ov. vascular pedicle
Initially compromises lymphatics & vein drainage
eventual loss of arterial perfusion
Sonographic finding
Enlarged ovary, mimic solid hypoechoic or hyper
echoic adnexal mass
Specific sign: multiple cortical follicles in ovary
Free intraperitoneal fluid in pelvis
Intraovarian artery flow : not exclude torsion
Preservation of central venous flow : viable ovary

30-year-old pregnant woman with

surgically proven ovarian torsion

22-year-old woman with ovarian torsion

HemorrhagicOvarianCysts
From corpus luteal or follicular origin
Sonographic finding
Heterogeneous hypoechoic mass w/ int. echo
Thin and thick septations
Fluiddebris level
Echogenic retracting clot
Irregular nodular wall
Ac. intracystic hemorrhage: isoechoic to ov. stroma
- mimic an enlarged ovary

34-year-old woman with acute pelvic pain

caused by hemorrhagic ovarian cyst.

26-year-old woman with ruptured hemorrhagic

ovarian cyst and hemoperitoneum

Pathologyofuterusandovary

Pathologyofuterus
Uterinemyoma
Commonest gynaecological tumor
50% over 40 years
Majority of cases of uterine enlarg.

US finding
Fibrous tissue : dense concentric rings
Well circumscribed hypoechoic,
Increased echo within mass
Irregular uterine outline: subserosal or multiple
Punctate or circumferential calcification(+/-)

Uterinemyoma
Subserisal myoma vs. ovary fibroma
Bridging vascular sign
: Uterine origin

Adenomyosis
Ectopic endometrial glands & stroma in myomet
rium
US finding
Ill-defined low or heterogeneous echoic lesion
in myometrium
Diffusely heterogeneous and enlarged uterus
: severe form of adenomyosis
Small cystic areas, few mm in myometrium
represent menstrual products

Endometrialpolyp
Common (10% of women)
Often associated with endometrial hyperplasia
US finding
Discrete mass in endometrium w/ vascular stalk
Sonohysterogram: useful

Pathologyofovary
Polycysticovaries
Ovary that contains 10 or more cysts measur
ing 28 mm w/ increase in stroma
Clinical: LH or testosterone
Hirsutism, male-pattern baldness, obesity, a
menorrhea, acne, oligomenorrhea

Physiologicovarycyst
Follicular cyst
Result of mature follicle failing to ovulate
Thin walled, unilocular cyst w/ hypoechoic flui
d

Corpus Luteal Cysts

Rupture of mature follicle, series of changes d
uring luteal phase
Beginng: hypoechoic w/ irregular inner wall
+/- some internal echo

Typicalsonographicfeaturessuggestingmalig
nantovarianmass
Size larger than benign lesions
Complexity of the mass
a) Cyst wall : thickened (greater than 3 mm)
irregular contours
papillary projections into cyst
b) Intra-cystic septation : thickening , irregularity
c) Solid elements: irregular mass from cyst wall
d) Mixed echogenicity cyst fluid
Ascites: peritoneal metastases