DIANA, PRINCESS OF WALES HOSPITAL, GRIMSBY

BASIC TRANSVAGINAL ULTRASOUND WORKSHOP

COURSE HANDBOOK

This guide is for personal use only and its contents remain the property of the author. It may not be reproduced in any form without permission. Mr I I Bolaji 2003 Basic Grimsby Transvaginal Ultrasound Workshop

Grimsby Basic Transvaginal Ultrasound Workshop

INTRODUCTION I am pleased to welcome you to the 11th Grimsby Basic Transvaginal Ultrasound Workshop at Diana, Princess of Wales Hospital, Grimsby. The first workshop was enthusiastically received in July 1997 and the faculty has thoroughly enjoyed the participation and enthusiasm of delegates. The Royal College of Obstetricians and Gynaecologists has granted seventeen CME points with equivalent accreditation from the Royal College of Radiologists. Transvaginal sonography is one of the few very important and useful developments in Obstetrics and Gynaecology in the past decade. The first invention was attributed to an Austrian called Kratochwill in 1969. However, from the early eighties, its use began to spread very rapidly. The reason for the improved diagnostic power and added therapeutic possibilities of the Transvaginal probe arise from the proximity of the probe to the pelvic target organs, and the relatively thin vagina, which enable the use of higher sound frequencies. Vaginosonography is less angle-dependent than abdominal and because there is minimal fat in the vaginal, the vaginal scan does not discriminate between the very thin and the morbidly obese patients. The Clinical Directorates of both Radiology and Obstetrics recommend that ultrasound training should be a component for the MRCOG. This training at all stages must include the technique of transvaginal ultrasound for the examinations of the first trimester pregnancies. The topics covered in this Course include theoretical and practical basis of transvaginal ultrasound sonography and broad clinical application. The primary objective is to teach every delegate a simple, safe, step-by-step technique of transvaginal scanning, as applied to obstetrics and gynaecology, and safe interpretation of the various findings. New topics have been introduced this time to include Teleradiology/ Telemedicine/TeleObstetrics and Screening for malignancy using DNA Analysis. I hope, at the end of the Course, all participants will have gained sufficient knowledge and experience in this new, exciting imaging technique and confidence in the interpretation of findings. I sincerely hope that you will find your stay in Grimsby for this workshop a worthwhile venture. May I take this opportunity to thank all those who have assisted me in the organisation of this course. This includes the secretarial and administrative support of Ms Lynn Young, PGMC Co-ordinator, Brenda Hartill, Lesley Tilbury (my secretary) and most importantly the dedicated women who kindly agreed to participate in the Hands-onSession of the workshop. MR IBRAHIM I BOLAJI
[MBBS FRCPI MD FRCOG] COURSE DIRECTOR 2003

2
Grimsby Basic Transvaginal Ultrasound Workshop

TRANSVAGINAL SCANNING TECHNIQUE STEP- BY- STEP APPROACH

3
Grimsby Basic Transvaginal Ultrasound Workshop

EQUIPMENT 1 FAMILIARITY WITH YOUR EQUIPMENT Scan machines do vary considerably in their technical details and it is important to familiarise yourself with the control panel (remember cock-pit drill). It is of paramount importance to be able to perform focusing and contrast controls at different depths, controlling of image depth of field, cursor movement and measurement of different dimensions and determination of the position of the orientation mark on the screen. 2 PREPARATION OF THE PATIENT i) Patient Information Patient information is important regardless of the gynaecologic or obstetric procedure plan. Informing the patient about transvaginal sonography is especially important. A brochure should be available in all units in several languages to explain what this involves when appointments are sent to patients. At the beginning, patients should be reassured and offered a simple but thorough explanation about the procedure again and should be shown the approximate distance the probe will be introduced into the vagina. ii) Approach And Respect For Privacy Bimanual examination is embarrassing and transvaginal scanning (TVS) is very embarrassing to the patients. Every effort should be made to respect patients' privacy whilst undressing or at the end of the scanning procedure. The patient should be covered appropriately throughout the procedure and permission should be obtained if there are observers in the room. 3 THE EXAMINATION TABLE There are 3 possible positions that can be adopted in transvaginal scanning: 1 Special gynaecological Table Special gynaecological examination tables, equipped with thigh/leg rest which allow the patient to assume the lithotomy position for convenient transvaginal scanning. They are similar to couches used for Colposcopy.

Grimsby Basic Transvaginal Ultrasound Workshop

Buttocks - on - Pillow Flat, cushioned examination tables with a pillow under the buttocks to elevate to pelvis

Buttocks -on -Edge, Feet on- Stool Flat, cushioned examination tables but with the patients' buttocks brought to the edge of the table while the feet are resting on a high stool.

PROBE INTRODUCTION Non-sterile condoms that do not have a reservoir tip are ideal as probe covers and keep the transducer free from cross contamination among patients. Three to 5 mls of transducer gel is placed inside the sheath. Gel is also placed on the outside tip of the condom-covered probe to facilitate ease of vaginal insertion. The probe having been gelled and covered with the appropriate sheath, condom or glove and then introduced very gently through the introitus with care taken not to cause undue pain.

CONCLUSION OF THE EXAMINATION At the end of the procedure the probe should be withdrawn very gently and the patient be allowed to dress in privacy. The probe should be wiped with appropriate medium, usually a virucidal and bactericidal towlette or spray disinfectant must be used to clean probe head and shaft between examinations for hygiene and safely stored in its socket. These probes are very expensive and should be treated with "TLC".

Grimsby Basic Transvaginal Ultrasound Workshop

SCANNING TECHNIQUE BASIC PRINCIPLES 1 Regardless of the route selected to perform the scan, a methodical and systematic scanning routine should be followed at all times. At the end of the procedure clean the probe with a damp soft cloth or rinse in water and wipe it clean with Chlorhexidene wipes or spray. Very often the manufacturer will provide you with special instructions to ensure continued cleanliness of the probe.

ALWAYS RETURN THE PROBE TO ITS CASE AS BREAKAGES ARE COSTLY. ORIENTATION Orientation of the image depends on the characteristics of the ultrasound probe in use. The plane of insonation may be originating from an end transducer, side transducer or a combination of both. These differences will determine the appearance of the images on the screen. It is important that you always remember the following anatomic landmarks in the pelvis which will help you during the scanning procedure. 1 The bladder is probably the most important as it is easily identified and is present in all patients, unless it has been removed or bypassed by previous surgery. A full bladder may affect the ability to demonstrate the ovaries and may distort the image, however, a small amount of urine in the bladder is useful as it helps its identification. The uterus is the second most important landmark and, unless removed by previous hysterectomy, should enable you to establish your orientation in the sagittal or coronal planes. The internal iliac vessels. These are located on the side walls of the pelvis and their identification outlines the boundaries of the lateral pelvic wall. The ovaries are normally anterior and medial to the structures.

Grimsby Basic Transvaginal Ultrasound Workshop

Figure 1. Relationship of the pelvic vasculature and ureter to the adnexa, uterus, and vagina.The iliac vessels are positioned adjacent to the ovary .

Figure 2.

An AP -view of the uterus showing a late follicular endometrium. The endometrial thickness = 15mm. The basalis-myometrium interface is seen (short solid arrow) and some shadowing caused by a small intramural fibroid also is shown (open arrow)

SCANNING PLANES The two scanning planes that one should concentrate on are the sagittal (also known as vertical, longitudinal or antero-posterior) and coronal (also known as horizontal, crosssectional or trans-pelvic) planes. It is important that, while scanning in the coronal plane, you should keep the right and left orientations correct at all times.

7
Grimsby Basic Transvaginal Ultrasound Workshop

STEP-BY-STEP APPROACH TO VAGINAL SCANNING IThe Uterus 1 Introduce the ultrasound probe with the insonation plane in the sagittal position and the tip of the probe pointing downward and posteriorly. This is to follow the natural curve of the vaginal cavity.

Figure 3. Introduction of transvaginal probe

Observe the monitor screen during the introduction so as to determine the presence or absence of any pathology in the vaginal wall or rectovaginal septum and to see the cervix as you approach the anterior fornix. The urethra and the bladder base should be to one side of the screen. Align the ultrasound probe with the longitudinal axis of the uterus so that the whole uterus, from the fundal region to the cervix, is visible. The entire uterine contour should be examined from the right side to the left and from the anterior surface to the posterior.

Figure 4. Alignment of the probe with the longitudinal axis of the uterus

Grimsby Basic Transvaginal Ultrasound Workshop

Observe the appearance of the cervical canal and endocervical region, the regularity of the uterus and the thickness of the endometrium in the sagittal plane. If the uterine contour is irregular determine whether there are fibroids or not. By altering the direction of the tip of the probe anteriorly more of the bladder will be seen, whilst tilting it posteriorly more of the Pouch of Douglas will be seen

Figure 5. Anterior tilting of the probe to see more of the bladder.

Figure 6. Posterior tilting of the probe to see more of the Pouch of Douglas.

After examination of the uterus in the longitudinal plane, rotate the probe 90 degrees around its axis and make sure that the orientation is correct to give you the correct anatomical positions on the screen. Again examine the cervical and uterine contours, the outline of the uterine cavity, the appearance of the uterine wall and endometrial thickness.

Grimsby Basic Transvaginal Ultrasound Workshop

Figure 7.

Coronal or cross section view of the uterus and adnexa.

II -

The Adnexa 1 From the sagittal view of the uterus, rotate the probe 90 degrees into the coronal plane. It is often easier to identify the ovaries in the coronal or oblique sagittal than the sagittal plane.

Figure 8.

Illustration of the area being examined in the central "semi-coronal" plane.

10
Grimsby Basic Transvaginal Ultrasound Workshop

Figure 9 . A cross section view of the area examined above (fig 8) as it appears on the monitor.

When viewing either the right or left ovary it is important to maintain their anatomical relation with the internal iliac vessels. In this workshop you will be taught to rotate the probe 90 degrees clockwise to align the marker spot on the probe handle with the direction of the arrow. Point the tip to the right adnexa to identify and examine the right tubes and ovaries. The ovary will appear medial and anterior to the internal iliac vessels. Its position in the pelvis, however, may be variable from being high and near the pelvic brim, or very low and behind the uterus depending on whether there are any adhesions, history of previous surgery or adnexal pathology. Then point the tip of the probe to the left, without rotating the probe , to examine the left tube and ovary. This will maintain the anatomical relationship of the ovary with the internal iliac vessels.

Figure 10. Examination of right and left adnexae

The ovaries are identified with ease in young and premenopausal women and appear as ellipsoid, uniformly hypoechoic structures with a regular outline.

Grimsby Basic Transvaginal Ultrasound Workshop

11

If examined in the early follicular phase, the ovary contains a number of small follicles. In the normal luteal phase, the corpus luteum is the hallmark of this phase. A small amount of fluid is seen in approximately a quarter of women after ovulation. The surrounding bowel is usually more echogenic and peristaltic movement is easily seen. 4 The peri- or postmenopausal ovaries are more difficult to identify as they become smaller with age and do not show the follicular structures of the reproductive years.

USEFUL MANOEUVRES 1 Tilting/Angling the shaft The plane of insonation is tilted or angled to any direction in the pelvis. This is achieved by tilting the ultrasound transducer by its handle so as to point the tip of the probe in the desired direction.

Figure 11. Tilting of the tip of the probe

Pushing and pulling the probe This manoeuvre brings the tip of the probe closer to the region of interest, thereby bringing the structure in question into the focal length of the probe (focal zone).

Grimsby Basic Transvaginal Ultrasound Workshop

12

Figure 12. Pushing /pulling manoeuvre

Rotating the probe The handle is slowly rotated along the longitudinal axis of the probe to change the plane of insonation. This manoeuvre helps to build a three dimensional image in the sonographer's mind to assist the diagnosis. It is also used when measurement of follicular diameter in two different planes is required.

Figure 13. Rotational movement

Pressure on right or left iliac fossa Applying pressure on the right or left iliac fossa, usually by the patient, will bring ovaries which are high in the pelvis down and closer to the probe thus facilitating their visualisation.

Steering If the facility is available in the machine, electronic steering of the beam in either direction allows visualisation of the areas outside the field of view without the need to move the probe. This is useful if the ovaries or adnexal masses are displaced laterally or if the patient is in pain and minimal movement of the probe is desired.

Grimsby Basic Transvaginal Ultrasound Workshop

13

Figure 14. Electronic steering

6.

Testing for pain The probe can reach and touch any pelvic organ seen on the monitor and test for pain by watching the organ on the screen and localizing it.

REPORTING OF FINDINGS Schematic Reporting System 1 The uterus and cervix. Anteverted/retroverted uterus. Endometrial thickness. Decidual reaction, gestation sac (true or pseudosac). Uterine cavity abnormality, fibroids, polyps, etc. Cervical state (closed, dilated). The adnexa (tubes and ovaries). Hydrosalpinx Ovarian cysts (solid/cystic i.e. complex). Polycystic ovary (PCO). Macrocystic ovary (MCO). Pouch of Douglas (cul-de-sac). Free fluid/clots. Solid masses. Other pathology (bladder, pelvic kidney, etc.).

14
Grimsby Basic Transvaginal Ultrasound Workshop

INTERPRETATION OF THE IMAGES 1 The Cervix The cervix undergoes changes during the menstrual cycle and sometimes echogenic shadows are seen along the cervical canal. Endocervical glands may also form cystic structures along the cervical canal either because of an inflammatory process or as a result of squamous metaplasia. These cystic structures may vary in size during the menstrual cycle and are simple cysts.

The Uterus The uterus is usually anteverted and, in the sagittal plane, the appearance would be of the bladder and the anterior wall of the uterus next to each other with minimal separation. If the uterus is retroverted then its anterior wall will be far away from the bladder and usually loops of bowel fill the space between then. This is an important point in the differentiation between an anteverted and retroverted uterus.

The Endometrium Endometrial appearance and thickness vary with the stage of the menstrual cycle. In the early menstrual phase an anechoic collection of blood may be seen within the endometrial cavity and the endometrial interphase appears as a very thin, echogenic line.

Figure 15. A T-pelvic view of the pelvis showing the bladder (white arrow) and the uterus. The
endometrial stripe (small black arrow) and the edge of the uterus (arrowhead) are clearly seen. The ureter is asterisked.

15
Grimsby Basic Transvaginal Ultrasound Workshop

Figure 16. An AP view of the uterus showing a late follicular endometium. The basalis layers (arrow) and an the endometrial stripe clearly visible. The endometrium is hypoechoic, which is characteritic of the follicular phase.

Phases of Endometrium As the follicular phase progresses the endometrium thickens and, in the immediate preovulatory phase, it is between eight and ten millimetres thick. Three separate lines should be seen with the middle representing the endometrial cavity. An anechoic halo 1-2mm. thick separates the endometrium from the myometrium. The outline of the endometrial cavity should be regular, however, on occasions there are endometrial polyps or submucous fibroids that distort the outline. In the luteal phase the endometrium appears more echogenic and less thick. In women with amenorrhoea or infrequent periods (oligomenorrhoea) the endometrium may be extremely thickened to over 1.5cm. and vary in echogenicity. This is due to prolonged unopposed oestrogen effect. Similarly thickened endometrium with small cystic lesions may be seen in women who are postmenopausal and an Tamoxifen therapy for previous breast surgery. The postmenopausal endometrium is atrophic and appears as a thin, echogenic line measuring no more than 5mm. The surrounding subendometrial halo should be symmetrical and intact. 4 Early Pregnancy Choriodecidual thickening is seen at about 4 weeks and a gestational sac may be seen as early as 4-5 weeks from the last menstrual period. The double ring "decidual" sign is an important feature of normal intrauterine pregnancy. The inner ring sign represents the chorionic sac and the outer ring is the decidualised endometrium. By the end of the fifth week the gestational sac and possibly fetal heart beats may be demonstrable without difficulty. Fetal movement is noted at seven weeks or later.

Grimsby Basic Transvaginal Ultrasound Workshop

16

Figure 17. An AP view of a singleton gestation in a woman presenting with vaginal bleeding. An area of subchorionic haemorrhage is seen (black arrowhead). The fetal pole (black arrow) and amnion (white arrowhead) are also seen.

Figure 18. A T-Pelvic view showing an ectopic pregnancy coexistent with an intrauterine pregnancy.

Decidual thickening in the absence of the double ring sign, and if associated with fluid accumulation within the uterine lumen, is generally termed "pseudosac" and should raise the suspicion of an ectopic pregnancy. Full details of normal and abnormal pregnancy appearances are discussed in the lecture session. 5 Ovarian and Adnexal Appearance Different ovarian pathologies present with varied appearances. Simple functional cysts are solitary and measure 4-7cm. in diameter. Dermoid cysts usually have smooth external surfaces and thin walls. The contents vary from low to high level echogenicity creating acoustic shadows in some areas. Endometriomas appear as motley echogenic and spherical lesions. More echogenic areas may appear in the centre of the cyst. In all ovarian lesions attention should be paid to the presence of septa, the number of loculi, presence of intracystic lesions, presence of solid areas and the appearance of

Grimsby Basic Transvaginal Ultrasound Workshop

17

fluid collection in the Pouch of Douglas. Persistence of any ovarian lesion for over 6-12 weeks requires further investigation.

Figure 18. The left adnexal showing a 48mm x 41mm hypoechoic left ovarian cyst.

Figure 19. The right ovary showing a complex, hypoechoic mass (black arrowhead). Note the internal septations. Cul de sac fluid (white arrowhead) is also seen. Endometrioma was revealed at surgery.

Measurement of the ovary and estimating its volume Measure the largest diameter (in centimetres) in the parasagittal plane (D1) and the antero-posterior diameter (D2). In the transverse plane measure the largest diameter in the transverse section (D3). There is no need to measure an anteroposterior diameter in this plane. The volume is calculated from the formula of an ellipsoid (D1 X D2 X D3 X 0.5231). Measurement of the mean follicular diameter during superovulation is determined by calculating the average of three or four diameters in two planes (two perpendicular measurements in the sagittal plane and either the largest or two diameters in the coronal plane).

Grimsby Basic Transvaginal Ultrasound Workshop

18

Adnexae Abnormal and distended Fallopian tubes appear as irregular, tortuous cystic structures with thickened walls and incomplete septa. Often they are very close to the respective ovary. They should be differentiated from free fluid collections in pelvic pockets of adhesions.

Figure 21. The left adnexal showing a 48mm x 41mm hypoechoic left ovarian cyst. No internal echoes are seen and the mass represents a benign corpus liteum cyst. Note the iliac vein (arrow) lying adjacent to the ovary. Normal compressed ovarian tissue cannot be found easily.Follow up TV scan after menses was normal.

Figure 22. The left adnexal showing the classic string of pearls of a polycystic ovary. The edge of the ovary (arrow) and multiple small ovarian follicles in the cortex are seen easily.

Grimsby Basic Transvaginal Ultrasound Workshop

19

Figure 23. A T-pelvic view showing an enlarged , multicystic ovary secondary to hyperstimulation. The entire ovary measured 11.2 X 7.2cm , and there are multiple cysts present within the ovary.

Grimsby Basic Transvaginal Ultrasound Workshop

20

Grimsby Basic Transvaginal Ultrasound Workshop

CLINICAL APPLICATION EARLY PREGNANCY SCANNING Technique 1 2 Patient Preparation Equipment Full bladder for transabdominal scan. Empty for transvaginal. Static scan more difficult to use but resolution and access to pelvic organs good. Real-time easy to use and orientate. Sector more versatile but image often inferior to good linear array. Gain and depth of focus (if present). Set to give least reverberation without loss of image clarity. Obtain uterine axis with midline scan. Rotate 90 to obtain transverse uterine scan. Bladder. Vagina. Cervix. Endometrial cavity. Ovaries. Empty bladder. Scars. Malposition of uterus.

Controls

4 5

Scan Sequence Landmarks

Difficulties Encountered

Changes in Early Pregnancy Endometrium shows CYCLICAL CHANGES during ovarian cycle. First signs of pregnancy are thickening and fluffiness of endometrium: RING SIGN at 5/40. GESTATION SAC grows rapidly. FETAL ECHO Appears between 6 and 7/40. YOLK SAC Also seen. FETAL HEART Seen to move 7-8/40. FETAL MOVEMENTSeen 9-10/40. BY 12 WEEKS GESTATION THE FOLLOWING SHOULD BE EVIDENT: Position and shape of uterus. No. of gestation sacs. No. of fetuses. Size of sacs and fetuses. Presence of fetal heart movement (FHM) and fetal movement (FM). Presence of fetal poles. Placentation site. Hidden extras.

Grimsby Basic Transvaginal Ultrasound Workshop

21

DEVELOPMENTAL MILESTONE GESTATIONAL SAC YOLK SAC EMBRYONIC HEARTBEAT CROWN-RUMP LENGTH AMNIOTIC SAC GESTATIONAL SAC The chorionic sac is usually referred to in the imaging literature as the gestational sac, which is not an anatomic term. The sac is the first reliable indicator of an intrauterine gestation (IUG), by the time of first missed period (15 days post fertilization, 4 weeks LMP). It is fluid filled containing the embryonic disc, amnion, yolk sac and extraembryonic coelom. The early sac visualize before yolk sac becomes evident will measure 3-5mm (inner wall/inner wall) and will grow by 1-2mm/day until yolk sac, embryonic heart beat and fetal pole become apparent. Visualization of the chorionic sac rules out ectopic pregnancy, except in patients who conceive after ovulation induction or assisted reproductive technology. The normal incidence of heterotopic pregnancy (1:30,000 pregnancies) may be 5-10 fold increased in such patients. A normal chorionic sac carries with it a miscarriage rate of 11.5%. YOLK SAC The next structure visible after the gestational sac and the first reliable indication of a healthy pregnancy is the yolk sac. This is generally imaged at day 20-24 (5-51/2 weeks LMP) as a pair of parenthesis located on the decidual basalis aspect of the chorionic sac, perpendicular to the beam of the transducer. With time , magnification or

increase in the gain, the circular nature of the structure becomes apparent. Visualization of the yolk sac precedes that of the embryo and its heartbeat by 3-7 days. The yolk sac allows more certain diagnosis of the chorionic sac to inexperienced sonographers and rules out a pseudosac, thus effectively ruling out ectopic pregnancy. EMBRYONIC HEARTBEAT After the appearance of the yolk sac, the next reliable sign for most observers is the pulsation of EHR. The embryo is generally obscured by the yolk sac and invisible as a distinct structure until around day 30 (61/2 weeks LMP). However, between days 25 and 28 [(51/2)-6 weeks LMP)] the pulsation of EHR are visible to the careful observer, using magnification and perhaps M mode. The HR is initially in the range of 80-100 bpm below day 30 (61/2 weeks LMP), probably represent impulse generation in the sinus venosus. HR increases rapidly to 160-190 bpm by day 47-50 (9 weeks), reflecting the growing competency of the sinoatrial node. This HR continues in this range into the second trimester, slowing then to the 120-160 bpm range considered normal in obstetrics.This slowing is thought to represent early parasympathetic innervation of the sinoatrial node. CROWN-RUMP LENGTH This is also known as the embryonic pole, early embryonic size, and (most correctly) as the greatest embryonic length, the crown-rump length (CRL), is first noted as a small echogenic focus between the yolk sac and decidual basalis aspect of the chorionic sac, 3-7 days after the yolk sac is noted.

Grimsby Basic Transvaginal Ultrasound Workshop

22

TYPES OF ABORTION (MISCARRIAGE) Threatened. Inevitable: Complete. Incomplete. Missed. Threatened Abortion (Miscarriage) Incidence - at least 1:5 pregnancies. Timing - 4, 8, 12, 16/weeks. 75% of threats with live fetus do well. 65% of abortions are due to chromosomal abnormalities. Scanning these has altered management because it introduces precision into the diagnosis by confirming or excluding the presence of a viable pregnancy in utero, thus reducing hospitalisation time and waiting "to see what happens". LOOK FOR: Presence of gestation sac. No. of sacs. Presence of fetus. No. of fetuses. Size of fetus. Movement of fetus. Fetal heart movement (FHM). Evidence of clots. BEWARE Apparently empty gestation sac need not exclude viable pregnancy. Often useful to repeat scan in one or two weeks. Fetus in utero does not exclude ectopic pregnancy. CLINICAL PICTURE OVERRIDES ULTRASOUND FINDINGS.

Blighted Ovum Fertilization occurs but only placental tissue develops. No fetus present. Ultrasound Findings: UTERUS Enlarged. SAC Empty - NO FETUS. Irregular in shape, often collapsed fluid levels if bleeding. Fails to grow on repeat scans.

Grimsby Basic Transvaginal Ultrasound Workshop

23

Missed Abortion (Early Fetal Demise) Fetus dead in utero. Ultrasound findings depend on gestation of pregnancy. EARLY Called missed abortion. SFD. Collapsed irregular sac. Crumpled fetus - Apple bobbing sign. No FHM. LATE Called INTRAUTERINE DEATH. SFD. Reduced liquor. Disorganised fetal echo. No FHM. Spaldings sign. Ectopic Potentially FATAL. Incidence: 0.3-1% of all pregnancies. Classically 8-10/40 with PAIN but varies, especially with COILS and previous ectopic. Ultrasound CANNOT CONFIRM ectopic unless fetus seen alive outside uterus (rare) but can usually EXCLUDE ectopic if fetus seen inside uterus (exceptions exist). Ultrasound Findings: Uterus bulky. No gestation sac in uterus. Thick decidua ? Pseudo sac. Fluid in POD. Fetus alive elsewhere (rare). Amorphous unilateral pelvic mass. BEWARE Other pelvic pathology can present as CLASSICAL ectopic, e.g.: Dermoid cyst. Bleeding corpus luteum. Twisted ovary. Do not be put off by STERILIZATION. (Even hysterectomised patients have had ectopics.) CLINICAL PICTURE OVERRIDES ULTRASOUND FINDINGS. Mole No fetus. PLACENTA degenerates. HYPERPREGNANCY STATE due to excessive HCG production. LFD BOGGY uterus. Ultrasound Findings: SNOWSTORM/Uterine contents FULL OF HOLES. Easily confused with DEGENERATING FIBROID. Twins Twin gestation sacs COMMONLY result in ABSORPTION of one with delivery of SINGLETON FETUS. MUST:See twins in 2 PLANES - some equipment can fool you.

24
Grimsby Basic Transvaginal Ultrasound Workshop

GUIDANCE ON ULTRASOUND PROCEDURES IN EARLY PREGNANCY

(Report by Joint Royal Colleges of Radiologists RCR Obstetricians and Gynaecologists RCOG)

Grimsby Basic Transvaginal Ultrasound Workshop

25

GUIDANCE ON ULTRASOUND PROCEDURES IN EARLY PREGNANCY

1 POLICY 1.1 There should be a written policy as to the procedure to be adopted when early intrauterine death is suspected to minimize the chances of evacuating the uterus in error. Such a policy must be brought to the attention of all staff joining the unit. The written policy should state that if there is any doubt about pregnancy viability then delay in arranging evacuation of the uterus is essential. At the ultrasound examination the following should be recorded: 1.3.1 1.3.2 1.3.3 1.3.4 1.3.5 1.3.6 1.3.7 1.4 The number of sacs and mean gestation sac diameter. The regularity of the outline of the sac. The presence of any haematoma. The presence of a yolk sac. The presence of a fetal pole. The crown rump length measurement. The presence or absence of fetal heart movements.

1.2

1.3

Extrauterine observations should include the appearance of the ovaries, the presence of any ovarian cyst or any findings suggestive of an ectopic pregnancy, such as tubal mass or fluid in the Pouch of Douglas. This information should be presented in the form of a standardized report clearly signed and dated by the examiner. This is preferable to the common policy of writing emergency scan reports in the clinical records alone. When it is considered that a pregnancy is not viable the decision to perform an evacuation of the uterus should be made by an Obstetrician with appropriate experience and training.

1.5

1.6

Grimsby Basic Transvaginal Ultrasound Workshop

26

GUIDANCE 2.1 An ultrasound scan should be transvaginal if any doubt exists. The following features should be noted: 2.1.1 If the gestation sac has a mean diameter greater than 20mm., with no evidence of an embryo or yolk sac, this is highly suggestive of a blighted ovum. If the embryo has a crown rump length greater than 6mm., with no evidence of heart pulsations, this is highly suggestive of a missed abortion.

2.1.2

2.2

When the mean gestation sac is less than 20mm., or the crown rump length is less than 6mm., a repeat examination should be performed at least one week later both to assess growth of the gestation sac and embryo and to establish whether heart activity exists. If the gestation sac is smaller than expected for gestational age the possibility of incorrect dates should always be considered, especially in the absence of clinical features suggestive of a threatened abortion. Under these circumstances a repeat scan should be arranged after a period of at least 7 days and be performed by experienced personnel.

2.3

Grimsby Basic Transvaginal Ultrasound Workshop

27

TRAINING 3.1 The Clinical Directorates of both Radiology and Obstetrics should maintain, on a continuous basis, a register of those personnel considered to be adequately trained and experienced in obstetric ultrasound. We suggest the following personnel would be appropriate: 3.1.1 3.1.2 3.1.3 Radiographers/midwives with the Diploma in Medical Ultrasound (DMU) or equivalent training/experience. Radiologists with ultrasound training and experience as recommended by The Royal College of Radiologists. Obstetricians and Radiologists who have completed the joint obstetric ultrasound training scheme of The Royal College of Obstetricians and Gynaecologist and The Royal College of Radiologists, or alternatively who have appropriate experience and training in obstetric ultrasound.

3.2

While it is presently stipulated that Radiologists taking their Final Fellowship (FRCR) examination should spend at least 75 hours undergoing practical training in obstetric ultrasound, no such recommendation exists of obstetric trainees, although The Royal College of Obstetricians and Gynaecologists now requires that ultrasound training appears as a component of the training for the MRCOG. Training at all stages must include the technique of transvaginal ultrasound for the examination of first trimester pregnancies and emergency obstetric and gynaecological referrals. Personnel gaining experience in obstetric ultrasound must do so within a structured training scheme and under appropriate supervision. Only trained personnel should report on ultrasound scans. Tutorial instruction in radiology should include theoretical aspects of early pregnancy scanning, including normal physiological changes and appearances. Where the service is provided by the Department of Clinical Radiology, obstetric registrars should be encouraged to attend scanning sessions to observe the practice and learn scanning techniques. Their progress should be carefully monitored and their level of attainment formally assessed. Their attendance must be planned and their training integrated with other personnel in the department. Joint obstetric ultrasound meetings and case conferences should be held regularly and involve appropriate personnel for clinical educational and audit purposes.

3.3

3.4

3.5 3.6

3.7

3.8

Grimsby Basic Transvaginal Ultrasound Workshop

28

3.9

Early intrauterine death should be regarded as of equal significance to fetal death occurring at a later stage. Training in obstetric ultrasound should include consideration of the emotional aspects of early pregnancy loss. Instruction should be given as to how to deal with such a situation in the scanning room in a supportive and sympathetic way and to recognise when more detailed counselling would be appropriate.

3.10

It is important that a robust mechanism exists to deal with women who have suffered early pregnancy loss, and the development of good relationships between all professional groups likely to be involved is essential.

29
Grimsby Basic Transvaginal Ultrasound Workshop

EQUIPMENT 4.1 The hospital should institute a rolling capital equipment replacement programme to ensure that state-of-the-art ultrasound equipment is provided for obstetric examinations in all appropriate locations. The advisability of using equipment more than five years old, unless upgraded, should be carefully considered. All equipment used for early pregnancy scanning should be provided with a transvaginal transducer.

4.2

4.3

Grimsby Basic Transvaginal Ultrasound Workshop

30

ORGANISATION 5.1 Effective communication between the obstetric and radiology departments must be established so that appointments are properly arranged and clinical information reliably transmitted. Patients should not be used as a means of communicating information between departments. A special clinic, usually operating for five days a week, should be established for early pregnancy and gynaecological emergencies. General Practitioners should be able to refer patients to such a clinic directly on a daily basis. The clinic should be staffed appropriately. Facilities for "same day" Beta-human chorionic gonadotrophin ( bhCG) testing should be available in the clinic. Immediate admission for surgery should be possible for patients with unequivocal diagnosis of fetal loss or with acute conditions such as ectopic pregnancy. Protocols should be defined for dealing with emergency cases of complications of early pregnancy which present outside the normal working day, and it is essential that those personnel who provide the "on call" service in obstetric ultrasound are appropriately trained. All personnel must be aware of the serious emotional impact on the patient following the communication that intrauterine death has occurred. Such information should be imparted only when a definite diagnosis has been made by an appropriately trained person. Each obstetric ultrasound facility should have the services of a trained counsellor available for patients with early pregnancy loss. Counselling should take place in a quiet room away from the bustle of the diagnostic department. If possible the partner should be present, as it has been shown that this helps the patient to interpret the information from the doctor and avoid misunderstanding.

5.2

5.3

5.4

5.5

Grimsby Basic Transvaginal Ultrasound Workshop

31

NOTES ON THE QUESTION OF MEASUREMENTS WITH ULTRASOUND TYPES OF MEASUREMENT Measurements can be made of lengths (straight line or curvilinear), areas and volumes or of times. These measurements can be interpreted in various ways, for example, the age of the pregnancy or the weight of the fetus might be inferred from the measurements. Each step in the process involves some measure of inaccuracy; consideration of the steps involved leads to a better understanding of the limitations in the process. STEPS INVOLVED Consider the example of crown rump length measurement: 1 2 3 4 The probe is positioned to image the CORRECT section of the fetus. Caliper markers are positioned at EACH END of the fetus. The distance between these is READ from the display, and WRITTEN down. Some INTERPRETATION is made: e.g. the CRL is compared with those of a normal population in order to estimate the age of the fetus, assuming that it is a normal fetus.

POSSIBLE SOURCES OF ERROR 1 The correct section might not be obtained through insufficient training, because the fetus is very mobile or because the structures are indistinct because of machine maladjustment. The calipers might be positioned against the wrong part of the image -again operator training. The calipers might not be correctly calibrated (different sound velocity perhaps - or pure misalignment). The measurement is normally taken from a digital display having limited resolution (often to the nearest mm.) The reading of the measurement should provide no problem but a "flashing digit" can occasionally cause problems. Errors in writing down the measurement can occur, especially if the result is not retained on the screen between scans, or is not written down immediately. The measurement now having been made to the best possible accuracy, is now used in some way. The size of the fetus is subject to Natural Biological Variability. This can be physiological or pathological - often the distinction cannot be made on a single measurement but other criteria need to be taken into account or a second measurement made at a subsequent time.

Grimsby Basic Transvaginal Ultrasound Workshop

32

RELATIVE IMPORTANCE OF THESE FACTORS The relative importance of these factors will depend upon the parameter being measured, but usually INTERPRETATION will prove the largest source of error. However, the operator is unable to assess the accuracy of calibration of the machine, unless gross errors exist - routine calibration is most important to avoid this source of error. Robinson and Fleming carried out a critical evaluation of CRL measurement and found, after making three independent readings, that the average standard deviation was 1.2mm. with a mean CRL of approximately 50mm. - a measure of the reproducibility of the technique. They had to take into account factors such as "beam width", photographic scale factors, velocity calibration in determining the mean values but, of course, these did not affect the reproducibility of the technique. STATISTICS It is important to understand the difference between the concepts of Standard Deviation and the Centile. The former is a statistical measure of the spread of values in a "theoretical" population and may not be an appropriate measure for all data. The centile notation represents a division of the actual results obtained. Thus 5% of babies DO have weights below the 5th centile in the sample population.

PLACENTAL IMAGING Ultrasound placentography is: Easy Safe Accurate Repeatable It not only allows LOCALISATION but also CHARACTERISATION and VOLUME assessment in connection with intrauterine FETAL WELFARE. Indications include Bleeding in advanced pregnancy Pain Malpresentation Amniocentesis Fetoscopy IUT Assessment of suspected IUGR

33
Grimsby Basic Transvaginal Ultrasound Workshop

Placental Grading 1st Trimester. Surrounds Gestation Sac Final location depends on implantation site Technique GAIN setting important ENSURE BASAL LAYER is highlighted, otherwise ERRORS created when grade II will look like grade I.

BEAM Perpendicular to GRADE 0 GRADE I GRADE II GRADE III 31/40 36/40 38/40 TERM 5-10% III 50% II 40% I L/S Ratio Mature in 65% 87% 90-100%

PLACENTA never uniformly aged. PREMATURE aging INSUFFICIENT agingPLACENTAL THICKENING

Suspect INSUFFICIENCY Suspect DATES

Thickness Decreases with Advancing Gestation:

Grade I Grade II Grade III immune

3.8cm 3.6cm 3.4cm hydrops, rhesus

Significance doubtful except where diabetes, non isoimmunisation and fetal abnormality suspected. Unusually THIN placenta PLACENTAL AREA Linearly throughout pregnancy in 15%. Growth plateous after 34/40 in 85%. Expect small placenta with IUGR. After 150 days of pregnancy expect placental area to be:

? IUGR or severe juvenile DM.

187cm2 .

Grimsby Basic Transvaginal Ultrasound Workshop

34

PLACENTAL LOCALISATION Technique Bladder full but not too full. Gain settings. Sequence of scan planes. Note: A/P/LAT. Upper/Lower. Relation to Pres. Part. Difficulties Posterior position. Obesity. Advanced pregnancy.

Position of Leading Edge. Distance from Int. OS. ? Succenturate Lobes.

PLACENTA PRAEVIA Grades II III IV I To lower segment. Into lower segment but not down to internal OS. Down to internal OS but not covering it. Covering internal OS totally even at full dilatation.

PLACENTAL MIGRATION makes grading of placenta praevia irrelevant before 32/40 when lower segment of uterus forms. 20% of placentas are praevia 16-20/40 only 0.5% of placentas are praevia at term.

35
Grimsby Basic Transvaginal Ultrasound Workshop

GYNAECOLOGICAL ULTRASOUND Gynaecological ultrasound is perhaps most easily divided into two areas: Problems associated with pregnancy (e.g. infertility, ectopic pregnancy, abortion in its various categories, and those involving masses in the female pelvis. The description of a mass can best be outlined as in the diagram below. It is particularly difficult to put a name to a mass unless other clinical criteria are taken into account.

unilateral I Location and Size or bilateral

adnexal uterine

pelvoabdominal* indeterminate homogeneous septated solid foci multiple cysts multicystic predominately cystic

cystic

II Internal Consistency

complex predominately solid mildly echogenic moderately echogenic markedly echogenic well defined moderately well defined poorly defined absent present suggestive

solid

III Borders

IV Ascites and Other Metastatic Lesions

*Can be uterine or extrauterine.

Grimsby Basic Transvaginal Ultrasound Workshop

36

Criteria for Sonographic categorization of pelvic masses. Sonographic Differential Diagnosis of Cystic Gynaecological Pelvic Masses
I Location II Internal Consistency III Definition of Borders Common adnexal homogenous well defined Physiologic ovarian cyst Serous cystadenoma* Hydrosalpinx Endometrioma (s)| Dermoid cyst Para-ovarian cyst Rare Lymphocele Appendiceal abscess| Mesenteric cyst Peritoneal inclusion cyst Ureterocele| pelvo-abdominal septated well to moderately well defined Mucinous cystadenoma (carcinoma)* adnexal or pelvoabdominal solid foci well to moderately well defined Dermoid cyst Ectopic pregnancy Serous cystadenoma (carcinoma)* Loculated lymphocele Loculated pelvic abscess Tubo-ovarian abscess*

Uncommon

Sonographic Differential Diagnosis of Complex Gynaecological Pelvic Masses

I Location II Internal Consistency III Definition of Borders uterine predominantly cystic variable uterine predominantly solid well to moderately well defined Uterine leiomyoma* extrauterine predominantly cystic moderately well defined Tubo-ovarian abscess* Ectopic pregnancy Ovarian cystadenoma (carcinoma)* Fluid-filled loops of bowel Polycystic ovaries| extrauterine predominantly solid well to moderately well defined Degenerated or partially cystic solid ovarian tumour*

Common

Intrauterine pregnancy

Uncommon

Pyometrium Adenomyosis

Uterine leiomyosarcoma Endometrial carcinoma*

Rare

Invasive trophoblastic tumour

Grimsby Basic Transvaginal Ultrasound Workshop

37

Sonographic Differential Diagnosis of Solid Gynaecological Pelvic Masses

I Location II Internal Consistency III Definition of Borders Common uterine moderately echogenic well defined Uterine leiomyoma* extrauterine mildly to moderately echogenic moderately well defined Solid ovarian tumour* (fibroma, teratoma, adenocarcinoma) Pedunculated leiomyoma Lymphoma* indeterminate variable variable Bowel tumours

Uncommon

Endometrial carcinoma or sarcoma Uterine leiomyosarcoma

Lymphadenopathy| Intraperitoneal fat Retroperitoneal tumour Ectopic pelvic kidney

Rare

Grimsby Basic Transvaginal Ultrasound Workshop

38

ULTRASOUND AND INFERTILITY Transvaginal ultrasound (TVS) has become helpful if not essential for monitoring natural and induced cycles. One can assess the size and number of developing follicles. This knowledge is essential for managing a cycle in the safest manner to maximise pregnancy outcome and minimise complications such as hyperstimulation and multiple pregnancy. It is also helpful in endometrial evaluation. The thickness and the characteristics of the endometrial lining will aid in determining the adequacy of treatment and accurate timing for hCG injection. The possibility of visualising details of ovarian structures by ultrasound was first put forward by Kratochwil and his colleagues in 1972. Since then Hackeler et al have used this technique to monitor ovulation induction and have reported a good correlation between the follicular diameter and oestradiol concentrations. The ideal ultrasound machine for evaluating infertility should have a TV probe with a scan angle of at least 90150 degrees that is steerable. Additional features to aid in the case of the examination would include a static zoom and scan from a live and frozen image. This allows for easier and more accurate counting and measurement of follicles. Ultrasound scanning of ovarian follicles is now an established technique for monitoring ovarian activity in a magnitude of clinical conditions.

window through which the pelvic structure may be visualised. The ovaries may be small and mobile and each patient may require a different sized bladder to visualise them satisfactorily. In 2-5% of women one or the other ovary is difficult to visualise, particularly the left as it is covered by sigmoid colon. Using the uterus as a landmark, longitudinal are performed moving the transducer to the left or right until the ovaries are visualised. The presence or absence of a follicle is then confirmed by a longitudinal scan. Follicles may be visualised from a diameter of 3-5mm. and appear as echo-free areas amidst the more echogenic ovarian tissue. The follicles are usually spherical but may appear oblong due to the pressure from a full bladder. Hackeler found that from then on the follicular growth was linear and the mean follicle diameter was 20mm. (range 18-24). Similar findings have been reported by several other authors. The cumulus oophorus can be visualised. Following ovulation one or more of the following may be visualised: 1 2 3 4 Disappearance of the follicle. Appearance of internal echoes. Collapse of the follicle with crenation of the edges. Appearance of fluid in the Pouch of Douglas.

The changes in endometrium may be easily followed by ultrasound.

TECHNIQUE Initially B scanners were used but high resolution real-time scanning is more commonly used. Sector scanners are superior to linear array as the small port of entry allows better visualisation of the lateral pelvic walls. A full bladder is essential as it acts as an acoustic 39
Grimsby Basic Transvaginal Ultrasound Workshop

APPLICATIONS 1 2 3 4 5 6 7 8 9 10 Follicular tracking in patients with infertility. Diagnosis of luteinised unruptured follicle syndrome. Timing of artificial insemination. Monitoring gonadotrophin treatment. Monitoring Clomiphene citrate treatment. Timing of post-coital tests, etc. Diagnosis of polycystic and multicystic ovary syndrome. Luteal phase defects. Diagnosis of early pregnancy. In-vitro fertilization.

|27} 40
Grimsby Basic Transvaginal Ultrasound