Gynecological Ultrasound

Transcription

1 Gynecological Ultrasound

2 Transabdominal Pelvic Ultrasound: Sagittal Orientation Anterior Head Foot Transvaginal Posterior

3 TA TV

4 Uterus; Sagittal View Abdominal and Transvaginal Pre-menarchal Adult Post-menopausal

5 Endometrium Proliferative Secretory Menstrual Postpartum Post-menopausal Post-menopausal + HRT Normal Sonohysterogram (Hysterosonogram)

6 Ovaries Pre-menarchal Adult Post-menopausal

7 Follicular Development and Ovarian Flow Day 10 Day 12 Early luteal Late luteal

8 Colour doppler Vascular anatomy Confirmation of normal architecture Exploration of unusual or abnormal architecture Patterns of shape and distribution Guide for pulsed doppler Location and identity of vessels Direction of interrogation Non-vascular Fluids in motion Surfaces in motion

9 Doppler Wave Forms and Arterial Structure

10 Sites for Colour and Pulsed Doppler Detection in Normal and Abnormal Ovaries

11 Neovascularization New blood vessel formation Benign conditions Ovulation (follicular development) Corpus luteum Placentation Ectopic pregnancy Wound healing Arthritis Chronic inflammation Benign tumors Endometriomas Occasional fibroids Malignancies

12 Pelvic Tumor Neovascularity

13 Optimizing Low Velocities and Small Vessels Colour doppler Wall filters 0 Persistance 0 Gain, short of widespread artifact Other settings specific to machine e.g. Siemens Versa has a low velocities setting A steady hand (minimize transducer motion) Pulsed doppler All of the above plus; Angle of insonation (parallel vs. perpendicular) Angle adjustment Open gate Multiple small vessels Tortuous vessels Systematic search of multiple vessels Central, perpheral,septal, papillary projections, areas of cyst wall thickening

14 Neoplastic Risk in Adnexal Masses Risk is age and state dependent High Intermediate Low Resistance Index

15 Borderline Serous Cystadenoma

16 Endometriosis, Adenomyosis, Endometriomas Endometriosis no signs Adenomyosis thickened uterine wall Endometrioma ovarian mass

17 An Endometrioma

18 Cervical Cancer Ultrasound useless for either screening or diagnosis

19 Congenital Malformations of Uterus the Reproductive Tract Bicornuate Septate Didelphus Rudementary horn Gartner s duct cysts

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23 Abnormal Endometrium Polyps Submucosal fibroids Synechiae Retained products of conception Tamoxifen Endometrial hyperplasia/cancer Hematocolpos Cervical stenosis IUCDs

24 Small Endometrial Polyp

25 Endometrial Polyp

26 Another Small Endometrial Polyp

27 Endometrial Polyp

28 Endometrial Carcinoma Detectable flow is unusual in Normal endometrium Atrophic endometrium Most endometrial hyperplasias Flow is usually detectable (91%) of endometrial Ca Flow pattern shows low resistance (average RI ~ 0.42)

29 IUCD

30 Abnormal Myometrium Fibroids Leiomyosarcoma

31 Myometrial Tumors Fibroids (Myomas, leiomyomas) peripheral vascularization Leiomyosarcoma thin irregularly spaced vessels some end-diastolic flow (e.g. RI = 0.6) Low velocities (<= 17 cm/sec) necrotic and inflammatory change increases end-diastolic flow - may overlap malignant range high end-diastolic flow(ri < 0.4)

32 Abnormal Cervix Nabothian cysts Incompetent cervix Cervical fibroids Cervical carcinoma Double cervix

33 Nabothian Cysts

34 Fallopian Tubes Hydrosalpynx Pyosalpynx Tubovarian abcess Ectopic pregnancy Fallopian tube carcinoma

35 Hydrosalpynx

36 Ectopic pregnancy Tubal ring (fluid in tube) Gestational sac +/-embryo or yolk sac FHR in real time, M-mode, colour, or pulsed doppler Movement relative to ovary on the same side Free fluid in cul-de-sac +/- behind adnexae Ovary (usually on the same side) with a corpus luteum Increased end-diastolic blood flow in vessels in the mass RI < 6

37 Acute PID Early on, there may be no U/S signs Free fluid in cul-de-sac +/- behind adnexae Fluid in endometrial cavity Fluid in lumen of fallopian tubes No typical changes in doppler patterns or indices Follicles (infected), with fuzzy margins

38 Tubovarian Abcess Complex, hypoechogenic, septated mass Acoustic enhancement Absent colour doppler blood flow in mass Ill-defined margins Fluid in cul-de-sac Loss of anatomical landmarks as disease becomes chronic

39 Chronic PID Hydrosalpynx Tubular anechoic structure Absent colour doppler blood flow i.e. not a vessel Mucosal folds and nodular projections Pyosalpynx Internal echoes Absent colour doppler blood flow Adjacent ovary may indent tube wall

40 Fallopian Tube Carcinoma Rare, <1% of gynecological cancers Average age 52 years (peri- or postmenopausal) Adnexal mass with mixed echogenicity Ovary on same side normal and adjacent May be sausage-shaped As it grows along and within the tube Low RI in supply vessels (one case 0.35)

41 Fallopian Tube Carcinoma

42 Ovaries Cysts Simple Complex PCO Ovarian hyperstimulation Solid and cystic Dermoids Solid Para-ovarian

43 Ovarian Hyperstimulation

44 Ovarian Hyperstimulation

45 Resistance Patterns in Ovarian Masses High resistance (RI 1<>0.6) Cystadenomas, hemorrhagic cysts, dermoid tumors, endometriomas Intermediate resistance (RI 0.6<>0.4) Dermoid tumors, endometriomas Low resistance (RI 0.4<>0) Ovarian cancer, inflammatory masses, endometriomas, dermoids, corpus luteum

46 Simple Thin-walled Anechoic Cyst

47 Septated Ovarian Cyst

48 Suspicious Ovarian Cyst Borderline Serous Cystadenoma

49 Borderline Cystadenoma

50 Ovarian Cancer Issues Normal time of clinical diagnosis is very late Large abdominal mass, ascites, multiple metastases Low cure rate ~30% High mortality 75% High morbidity Early detection (Stage 1) 75-96% survival Current screening tools insensitive and not specific enough Symptoms Bimanual exam Ca-125 Transvaginal ultrasound