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Transvaginal ultrasound presentation by Dr. Taila Amber

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Transvaginal Ultrasound; TVS; presentation on TVS, Heavy menstrual bleeding, Fibroid uterus, Congenital uterine anomalies, Uterine scar, Pelvic pain, Pelvic mass,

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Transvaginal ultrasound presentation by Dr. Taila Amber

  1. 1. TRAN SVAGINAL U LTRASOU N D DR. TAILA AMBER
  2. 2. PELVIC ULTRASOUND ° Noninvasive procedure used to assess organs and structures within the female pelvis. ° Allows quick visualization of the female pelvic organs and structures including the uterus, cervix, vagina, fallopian tubes, and ovaries. - Doppler ultrasound may also show blood flow in certain pelvic organs. Dr, Talia Amber
  3. 3. PELVIC ULTRASOUND > TRANSABDOMINAL ULTRASOUND > TRANSVAGINAL ULTRASOUND With Or Without ° SALINE INFUSION SONOGRAPHY ° COLOUR DOPPLER Dr, Talia Amber
  4. 4. 1 Ilyll M 3. zip ‘ . ... .-. .&‘ Dr. Talia Amber , I I - 1‘ x’ r‘ - . ‘ / ¢'—. '='. ‘ / /’/ L/11$ . ». .. -- Ill! /I/ :_4_: _ . , ___-' 'M/ '/'. r'/ ’. “ - . Lllfi"/ I‘i‘I"l/ /4"‘. ' J‘ . ‘ ; r. * L’. i . ,‘<; {'_. '.‘r, ’;:7i‘7" ~. "-. ‘. . . , . . .3 , , ~'’T-'&_g/ ‘- “ § ‘ ‘~ ‘x-" 3‘ -C‘~§: °]' . . _.‘>
  5. 5. Saline-Infused Ultrasound
  6. 6. lUlll’l. ./lEllT
  7. 7. Trtmsabrlomimrl and Transvaginal Ultrasound TRAN SABDOMINAL TRAN SVAGINAL o "Panoramic" pelvic view o More-limited pelvic view o Noninvasive o Invasive - Distended bladder needed for 0 Empty bladder necessary optimal visualization o Expense of examination - Expense of examination a Dlfficult to detect pregnancies under6 weeks‘ gestation o Detects earlier pregnancies . Easy to team . Easy to leam - Readily combined with pelvic exam o Readily combined with pelvic exam - 3-5 MHz - 5-8 MHz
  8. 8. TVS : ASSESSMENT - Size, shape, and position of the uterus and ovaries - Thickness, echogenicity and presence of fluids or masses in the endometrium, myometrium, fallopian tubes, or in or near the bladder - Length and thickness of the cervix ° Changes in bladder shape - Blood flow through pelvic organs Dr, Taiia Amber
  9. 9. INDICATIONS - Abnormalities in the anatomic structure of the uterus ° Fibroid tumors (benign growths), masses, cysts within the pelvis ° Intrauterine contraceptive device (IUCD) - Pelvic inflammatory disease (PID) ° Postmenopausal bleeding ° Monitoring of ovarian follicle size for infertility evaluation ° Aspiration of follicle fluid and eggs from ovaries for in vitro fertilization ° Ectopic pregnancy (pregnancy occurring outside of the uterus, usually in the fallopian tube) ° Monitoring fetal development during pregnancy Dr, Talia Amber
  10. 10. CONTRAINDICATIONS >ABSOLUTE: ° Paediatric age group ° Premature rupture of the membranes ° Bleeding associated with known placenta praevia > RELATIVE: ° Refusal of the patient Dr, Talia Amber
  11. 11. HOW IT IS PERFORMED lut. ttnt | ‘ltt. t. »-. ttl. : ll. llltItlt. _. Transducer
  12. 12. DEMERITS ° Slight DISCOMFORT with the insertion of the transvaginal transducer into the vagina ° Ultrasound transducer covered in a plastic or latex sheath fl LATEX ALLERGY Dr, Talia Amber
  13. 13. NORMAL FINDINGS ON TVS
  14. 14. Fallopian tube Fundus of uterus ‘R ‘ Uterine cavity Penmetnum A _ TX Body of uterus Myometnum Endometnurn Cervical canal k Cervix Vagina
  15. 15. Uterus ‘ , Endometriurn Lqngigcudinal view of uterus K K. . during transvaginal ultrasound PREMENOPAUSAL ET: FOLLICULAR PHASE = 4-8mm SECRETORY PHASE = 7-14mm POSTMENOPAUSALET: <5mm
  16. 16. II . u K S: ‘D-cQO4“II (D ugu be-Do‘-C Pr». --we unny-no K--urn. 1 )1 Ioootn not to “OK opkgand iv-cu-4 0- In. -.4 u I; u, -Ir‘ UIIOUO I’ Itlltléll ‘I Q ‘It. )1.-
  17. 17. .: o a 1 acre .1 . Enl- . . .2». .. t rt .7». (J. - o . .l- as. I 3. at. (J 95. .4 «Os at pl. -4 9!. run . rno. ..s. I -u. . - wt . . . .. . . - p luOO
  18. 18. NORMAL FOLLICLES
  19. 19. Normal Size of the Ovaries Upper Limit of Normal Phase of Life Mean Volume (cc) ‘ Volume (cc) 0-3 months 1 4 3 months-2 years 1 3 Premenarchal (3-15 3 9 years) Menstrual female 10 22 Postmenopausal 6 14 >15 years after 2 4 menopause [tr l? xlIC<. Amzsw
  20. 20. ROLE OF TVS lllla G)i’l. lAECOl. OG‘ti’
  21. 21. STRUCTURAL ABNORMALITIES
  22. 22. NORMAL SEPTATEI ARCUATE , I T .3'. C°RI‘IUAT. Ei
  23. 23. li’il': '%i‘Il'ffl. iI: 'Il= ififit-£3. - 1* UTERINE 8 LE E DI N G TA I TV SCAN __, _,f""7Te_‘v’ ‘—’_ . PELVIC PELVIC MAss PAIN / . ‘ ENLARGED UTERUS ‘ Large mass ‘ OVARIAWCVST OVARIAN CYST Relationship with other ENDOMETRIOSIS organs PID Ascites I Detailed morphology
  24. 24. ' PRINCIPAL 1ST LINE INVE. STlC. ATlON ° UTERINE PATHOLOGY: — FIBROIDS ° SUBMUCOSAL ° INTRAMURAL ° SUBSEROSAL ° BROAD LIGAMENT - ADENOMYOSIS - SARCOMAS ° OVARIAN MASSES: — OVARIAN CYST ' SIMPLE ' HEMORRHAGIC ° MATURE CYSTIC TERATOMA ' OTHER CYSTS - ENDOMETRIOMAS
  25. 25. UTERINE PATI-IOLOGY: TIBROIS ** WELL-CIRCUMSCRIBED LESIONS * FOCI OF CALCIFICATION WITH ACOUSTIC SHADOWING '’ BLOOD VESSELS PASSING AROUND THE LESION CINUMBER I: IS| ZE CILOCATION
  26. 26. Pcdunculatcd Cervix S jOvary Intramural S. .. / I» » ST Submucosal / I A Uterus Subscrosal A I _ g I an}
  27. 27. SUB-MLICOSAIL FIBROID Uterine cavity L Submu'Eosal fibroid FR Uterine wall
  28. 28. INTRA-I). /I U RAI. FIBROD UTERINE FIBROID POSTERIOR WALL / NORMAL MYOMETRIUM ENDOMETRIAL STRIPE HYPOECHOIC MASS-FIBROID
  29. 29. SUBSEROSAL FIBROID , 1 ‘-. ’ , ‘ ' / '~. , . - v t 1- K ' " l J33 ’ K I 4, . , , ._ - I_, ./ V i l‘. . . I " tr _J l ‘ . '. ’ ; ‘ ‘s " t . ~ xx». .- v « I ‘. : }'~“. - I A}
  30. 30. AERIOMYOSIS HETEROGENOUS LOOKING JUNCTIONAL ZONE MYOMETRIUM MYOMETRIAL ASYMMETRY CYSTIC AREAS WITHIN MYOMETRIUM BLOOD VESSELS PASSING THROUGH ABNORMAL LOOKING AREA
  31. 31. Ct’ Talia . ~1.iT1I)r= ’
  32. 32. ONIARIALNI IVIASSES * BEST IMAGING TECHNIQUE FOR THE ASSESMENT OF OVARIAN PATHOLOGY ° IOTA GROUP: 10 SIMPLE RULES TO IDENTIFY A BENIGN OR MALIGNANT TUMOUR
  33. 33. RULES FOR PREDICTING A MALIGNANT TUMOUR (M - RULES) I M1 I IRREGULAR souo TUMOUR I M2 I PRESENCE or ASCITES I M3 I AT LEAST4 PAPILLARY STRUCTURES M4 IRREGULAR MULTILOCULAR SOLID TUMOUR WITH LARGEST DIAMETER 2 100mm MS I VERY STRONG BLOOD FLOW (COLOUR SCORE 4) RULES FOR PREDICTING A BENIGN TUMOUR ( 3 - RULES) I B1 I UNILOCULAR I 82 I PRESENCE or souo COMPONENT, LARGEST DIAMETER <7mm I 83 I PRESENCE OF ACOUSTIC SHADOWS I 34 I SMOOTH MULTILOCULAR TUMOUR WITH LARGEST DIAMETER <100mm I as I NO BLOOD FLOW (COLOUR SCORE o) ‘D lat '—. -1r'ri: ‘~‘
  34. 34. OVARIAN CYSTS 1* ' Simple cyst step 1 Ovarian c' Non-ovarian *— HOmo, ,mg(C Cy“ step 2 US pattern recognition "' , En. ;3omc(r(Qm, ~, Mature cystic step 3 Low Risk or High Risk tcraiofflil ff‘-K Any other cyst pox x : I" yrul-gr nf ignore Evaluation with MR or Surgery Follow up with US
  35. 35. ULTRASOUND PATTERN RECOGNITION U Any other ‘cyst Simple cyst ' J ' 3. my’ "''I""'"' W? Hemormagic cyst Mature cystic teratoma ® Endotretrioma ‘ I
  36. 36. SIVIPLE OVARIAN CYST ° Anechoic lesion with posterior acoustic enhancement ° Unilocular e Thin, smooth walls * No solid or well-vascularized components RT RDNEXR 'L. ‘II 5‘ - if” - I
  37. 37. , . .(l. l;‘. _ . — V‘. 7L; ii* Simple cyst diagnostic approach Done No FU _7: not "t‘l€'V‘-I on Done No FU ‘. ’Ir. *l'. I ‘5.; 'i i"- i1'i‘f; -If a‘v"-': '~; t '§1t3II{i ll -, LJ{"'lI"_]I‘. Yearly FU wit‘ t, uni I IC‘$QIv‘. "d ‘. "It, ‘l". '—’. r"l in lt'pLI"7 arrvzst ierta '1 v, Itenigr Further evaluation 1. II1 URI or surgery High Risk Done. No FU Llci r 1:? rnent: an Yearly FU witri US _mt. l res: -i. e:J Ii. Iet". tti: -r‘ n report a 'nr; »:‘. t : :er'. a:r‘I. I: -en 5'1 Further evaluation ' L‘. Iti ‘NR1 or SL-tt]rEt', ‘
  38. 38. HEMORRHAGIC CYST * Low risk patient Cystic mass < 5 cm with a reticular pattern due to fibrin strands or with diffuse low-level echoes e The cyst may contain a solid-appearing area with good through-transmission, without internal flow at color Doppler, and typically with concave margins, consistent with a blood clot it initially contents appear " Ground G| ass”. ° Later as "Spiders web” or ”wobble like jelly” II Iai —. -rr’ri: ‘~‘
  39. 39. I? -IEII. /IORRI-IAGIC OVARIAINI CYST
  40. 40. HEMORRHAGIC OVARIAN CYST HEMORRHAGIC OVARIAN CYST MIMICKING A CARCINOMA. NO FLOW THROUGH IT Dr. Talia Amber
  41. 41. HEMORRHAGIC CYST Hemorrhagic cyst diagnostic approach In early nieitopause 0°“ "° F” 6—12 WOOII FU III? ‘ as Not mentioning 'esol~ed . Gone in report is o N I I Jncnanged- . M-"ti Done No FU in early menopause Mention in resort Further evaluation airncist Ceftainly benign with ‘. ‘Rl or surgery 6-12 week FU with US in late mertooause re: -solved . . done Further evaluation unchanged - l. ‘Rl w in ". ‘Rl or surgery
  42. 42. ENDOMETMOMAS Homogeneous and hypoechoic mass Diffuse low-level echoes (ground-glass) No internal flow at color Doppler No enhancing nodules or solid masses In 30% echogenic foci are seen within cyst wall
  43. 43. ENDOMETRIOMAS Dr, Talla Amber
  44. 44. Endometrioma dtagnost ic approach wlthou! echogenac foc. may be hemorrhagzc cyst 6-12 week FU with US to rule out hemorrh cyst -mrh echogemc: IOCK Ixkeiy endomernoma Yearly FU with US or surgical removal High Risk nrthouf echogerrrc focv nvay be henworrhagx: cyst 6-12 week FU with US " e to rule out hcmorrh cyst mrhout cchogcnrc foci may be hen1orr+: ag. <: cyst Late , _ i _ ‘_m_‘, _f. _,A, M: Further evaluation with -‘V ' MRI or surgical removal with echogemc foc: /lke/ y endomernoma ' Late I KN-l . -(‘ad *8 Yearly FU lhlth US or surgcal rernoval
  45. 45. MATURE CYSTW TERATOMA * Hypoechoic mass with hyperechoic nodule (Rokitansky nodule or dermoid plug OR White ball) ** Usually unilocular (90%) * May contain calcifications (30%) * May contain hyperechoic lines caused by floating hair it May contain a fat-fluid level, i. e. fat floating on aqueous fluid
  46. 46. MATURE CYSTIC TERATOMA ARROW POINTING ROKITANSKY NODULE Dr, Talia Amber
  47. 47. MATURE CYSTW TERATOMA The ‘tip-of-the-iceberg‘ sign: acoustic shadowing from the hyperechoic part of the dermoidrcyst (arrow)
  48. 48. MATURE CYSTIC TERATOMA Mature cystic teratoma diagnostic approach U"llll resecled If not resected, continue FU (yearly? )
  49. 49. ANY OTHER CYST - Possibly NEOPLASM Large size Vascularized septations *9 Vascularized solid components Vascularized thick, irregular wall * Secondary findings associated with malignant lesions: Large quantities of ascites, lymphadenopathy and peritoneal deposits are strongly associated with an increased likelihood of malignancy. ii‘ Li 3 ~<l7l. "“'
  50. 50. MALIGNANT L Dr, Talia Amber
  51. 51. MALIGNANT CYST Any Othfif cyst DOSSID/ y malignant “ace multiple focal wall solid compo- septations septations thickening men‘. 2 flow. -.' Low Risk and High Risk Surgical resection by oncologic gynaecologist who may request prior imagingebased staging
  52. 52. A- OVARIAN CYST: 1. HEMORRHAGIC CYST 2. TORSION OF ADNEXA: Dermoid cyst (congested, enlarged, edematous, multiple small cysts, ghost-like ovaries, free fluid in 1/3) 8- ENDOMETRIOSIS C- PELVIC INFLAMMAROTY DISEASE Dr, Talla Amber
  53. 53. 'r PYOSALPINX: ° SAUSAGE SHAPED STRUCTURE ° THICKER WALLS ° ECHOGENIC FLUID WITHIN THE TUBE ° INCOMPLETE SEPTA ° ON CROSS SECTION : RETORT-SHAPED / COG- WHEEL/ BEADS ON A STRING Dr, Talla Amber
  54. 54. PYOSALPINX ir'i’i’—
  55. 55. ROSALPINX ‘- »‘~‘}‘-‘:2, 1 ‘ ’ 1 7 -1‘ _ *_. . —; :'. ::. —9¢- ~42- __' - J - ‘_—. /_— qzx -, .. .1 -‘. .: -’ "f, ‘ - T *4 — _ - I . . —— “ _ ~ "“' ’ - _A . —_-A -, ... . :9 —‘ . . . ‘:a. ‘‘ . . . - S *-—_. ‘_‘: _ ' DILATED TUBE ENVE= I.OPS THE OVARY
  56. 56. ° HMB: — ENDOMETRIAL POLYPS ° POSTMENOPAUSAL BLEEDING Dr Talia Am‘ni= r
  57. 57. 1:! L11 El [lift , i‘}. flfiiiif{-. i‘. '?13. it'll ‘? ——a-: q-—: .- -1 —: :—: .<j 5. ° HYPERECHOIC ° ECHOGENIC BRIGHT RIM ° MORE EVIDENT ON SIS ° FINDING OF A PEDICLE ARTERY -- DIAGNOSTIC
  58. 58. ° PRESENCE OR ABSENCE OF ENDOMETRIAL, CERVICAL, TUBAL, OVARIAN OR BLADDER PATHOLOGY ° ENDOMETRIAL THICKNESS > 5mm - RISK OF PATHOLOGY Dr Tails Aini)+_= r
  59. 59. ° ASSESMENT OF OVARIAN RESERVE : — number of sma| |(2—6mm) or antral follicles ° ROTTERDAM CRITERIA to diagnose POLYCYSTIC OVARIES: — 12 or more follicles, measuring 2-9mm in one or both ovaries — ovarian volume > 10ml Dr, Taila Amber
  60. 60. PULYEYSTIC OVARIES l'~, i'-.1: Gen r7'i: ‘~‘ or in: ’ '-“"<e- ""i'. ‘ I -; 1 ~ 2.-. ~' . ' . ' ‘("1 W . _ o. ‘_. . ‘. .'. ,,. ' ‘ L‘ <- . ' ' -~ 5;‘? _ / .1‘. ‘ ' -Tr’ . ‘P ‘e‘ : - “ f, < r‘§ _. ' o . : s ' , ‘ u L '3‘ 302cm l.7lcm 4.1
  61. 61. ultrasound Pr°bs<‘l, ovary with x" mulgipie . / folligles , V —z/ ’ A
  62. 62. ROLE OE TVS IN OBSTETRICS
  63. 63. Gestational A A Milestone Visible on Ultrasound Possible endometrial thickening; ultrasound 4 weeks may show no evidence of pregnancy. Gestational sac becomes detectable. S. S-6 weeks Yolk sac appears. Fetal pole appears; possible fetal heart beat 5.5-6.5 weeks by vaginal ultrasound. 6.5-7 weeks Feta heartbeat detectable b ultrasound.
  64. 64. NORMAL PREGNANCY Fetus in gestational sac II) Dr. Tana Amber Crescentlc, hypoechoic . subchorlonlc hemmorhage. Small (<1!3 clrcumference of the sac) < 7 fetal Mean CS-2 Ml L! US 0.4 G 3 Go 55 237¢Q; C6 C135? 5004: I2(m
  65. 65. MISCARRIAGE — INTRAUTERINE SAC (<20mm DIA) WITH NO OBVIOUS YOLK SAC OR FETUS --- BLIGHTED OVUM — INTRAUTERINE SAC (<20mm DIA) , >6mm CRL WITH NO OBVIOUS FETAL HEART ACTIVITY --- MISSED MISCARRIAGE
  66. 66. BLIGHTED OVUM
  67. 67. MISSED MISCARRIAGE Earl Fetal Dr Tails . »'1lT1I)+E~’
  68. 68. ECTOPIC PREGIVARIEY * SENSITIVITY : 90.9% * SPECIFICITY : 99.9% FII'D| I'GS: — INHOMOGENOUS MASS / BLOB ADJACENT TO AND SEPARATE FROM OVARY — HYPERECHOIC RING AROUND THE GESTATION SAC ”Bage| sign” — GESTATIONAL SAC WITH FETAL POLE, WITH OR WITHOUT FCA
  69. 69. ECTOPIC PREGNANCY Adnexal Mass AIL ' ’ I §_m_p_t1 Uterus . , C mm" ' D’ IEIIE. .i. mz)r= ’
  70. 70. ASSESMENT OF UTERINE SCAR L‘ type 1A, thin scar within crvicoisthmic can-al (CIC); J type 1B, thin above the internal os (IO); type 2A, dehiscent within the CIC; type 2B, dehiscent above the in H — urriw
  71. 71. OTHER THAN FEW CONTRAINDICATIONS, TVS IS THE METHOD OF CHOICE IN THE ASSESMENT OF PELVIC PATHOLOGIES in GYNAECOLOGY AND OBSTETRICS, TAS BEING USED AS A CONJUANT TO SEE THE EXTENT OF THE DISEASE.

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