Ultrasonography in Gynaecology

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Ultrasonography in Gynaecology:

Ultrasonography in Gynaecology Prepared by: Rifsa Naheem Group 6; 5 th Year Faculty of General Medicine.

Introduction:

Introduction Ultrasound was first introduced by Ian Donald (Glasgow 1950) in the field of medicine Sonography is widely used in Gynaecology either with the transabdominal (TAS) or with the transvaginal (TVS) probe Because of the safety, high patient acceptance and relatively low cost, ultrasonography has become a common diagnostic modality in gynaecology these days.

Use of Ultrasound in Gynaecology:

Use of Ultrasound in Gynaecology Use of infertility workup Serial measurement of ovarian follicular diameter ( folliculometry ) and endometrial thickness are done using TVS. Ultrasound can provide presumptive evidence of ovulation. Following ovulation, internal echoes appear and free fluid is observed in pouch of Douglas. To detect correcting time of ovulation by folliculometry in conjuction with plasma oestradiol . Sonographic guided oocyte retrieval in IVF and GIFT programmes .

Use of ultrasound in Gynaecology:

Use of ultrasound in Gynaecology Ectopic pregnancy can be detected on TVS as a “tubal ring” separate from the ovary in a patient with empty uterine cavity. Pelvic mass can be evaluated as regard to its location and consistency. Uterine fibroid, ovarian mass, endometrioma , tubo -ovarian mass, etc. can be delineated when there is confusion in clinical diagnosis. Oncology: TV-CDS can assess the vascularity of the mass. Low flow impedance with a high flow velocity raises the suspicion of a malignant tumor.

Use of Ultrasound in Gynaecology:

Use of Ultrasound in Gynaecology Endometrial disease: Women with unexplained uterine bleeding, or postmenopausal bleeding .

Transabdominal sonography:

Transabdominal sonography

Transabdominal sonography:

Transabdominal sonography Is done with a linear or curvilinear array transducer operating at 2.5-3.5 MHz. TAS requires full bladder to displace the bowel out of pelvis. Other wise gas in the bowel acts as a complete barrier to ultrasound waves.

Transabdominal sonography:

Transabdominal sonography TAS is best used for large masses like fibroid or ovarian tumor Higher is the frequency of ultrasound wave, better is the image resolution but lesser is the depth of tissue penetration

Transvaginal Sonography (TVS):

Transvaginal Sonography (TVS) It is done with a probe which is placed close to the targt organ. Preparing patient There is no need of a full bladder It also avoids the difficulties due to obesity, faced in TAS

Transvaginal Sonography:

Transvaginal Sonography Transvaginal ultrasound may be done for the following problems: Abnormal findings on a physical exam, such as cysts, fibroid tumors, or other growths Abnormal vaginal bleeding and menstrual problems Certain types of infertility Ectopic pregnancy Pelvic pain

Transvaginal sonography:

Transvaginal sonography TVS operates at a high frequency (5-8 MHz). Therefore, detailed evaluation of the pelvic organs (within 10 cm of the field) is possible with TVS. But the drawbacks of TVS are mainly due to narrow vagina as in virgins, postmenopausal women or post radiation vaginal stenosis .

Transvaginal sonography:

Transvaginal sonography

Ultrasound of Normal ovary:

Ultrasound of Normal ovary

Normal Ovary:

Normal Ovary Normal ovary during a natural menstrual cycle demonstrating normal follicle population and distribution on day 12 postmenstruation . A dominant follicle is visualized in the central portion of the image and several subordinate follicles from the wave (2–5 mm) are observed in the left lateral aspect of the ovary.

Sequence of images recorded during ovulation in situ:

Sequence of images recorded during ovulation in situ The images in the sequence were taken to represent the times at which 90%, 80%, 70%, and so on of the follicle fluid was extruded from the follicle. Time code markers are displayed in the lower left portion of the images.

Atretic follicle of preovulatory diameter:

Atretic follicle of preovulatory diameter Note the thin follicle walls and sharp transition at the fluid-follicle wall interface. The shape of the large atretic follicle is compromised by small peripheral follicles.

Corpus hemorrhagicum:

Corpus hemorrhagicum When blood fills the corpus luteum lumen, the cystic corpus luteum is regarded as a corpus hemorrhagicum . Corpus hemorrhagicum demonstrating thick walls of peripheral luteal tissue and a central hemorrhagic clot with an interspersed fibrin network.

Corpus albicans :

Corpus albicans Corpus albicans resulting from regression of a luteal structure from a previous cycle. Corpus albicans are typically visualized as hyperechoic structures within the ovary and they may occasionally appear to be more pronounced owing to the presence of surrounding follicles.

Functional cysts of the ovary - Follicular cysts: :

Functional cysts of the ovary - Follicular cysts: This young female patient underwent sonography for non-specific pain in the lower abdomen. Ultrasound images of the pelvis show bilateral ovarian cysts which show absence of internal nodules, septae or debris. These findings are typical of follicular cysts of the ovaries. Follicular cysts are functional cysts and are enlarged ovarian follicles that have not ruptured (ovulated). They are usually unilateral.

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Functional cysts of the ovary – Corpus Luteum cysts Lt. adnexal cystic mass- Luteal cyst (Lt. ovary):

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Functional cysts of the ovary – Corpus Luteum cysts Rt. ovarian simple cyst:

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Hemorrhagic ovarian cysts: Hemorrhagic cyst of ovary resulting from Ovulation induction This young nulliparous female patient undwerwent ultrasonography following ovulation induction. The right ovary shows a typical hemorrhagic cyst formed from the corpus luteum . The first image (top row- left) is a transabdominal ultrasound image showing fine fibrinous strands within the cystic mass in the right ovary. Transvaginal ultrasound and color Doppler images confirm these findings. The uterus shows typical secretory changes in the endometrium suggesting post ovulatory phase.

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Hemorrhagic ovarian cysts: Hemorrhagic cyst of ovary resulting from Ovulation induction This young nulliparous female patient undwerwent ultrasonography following ovulation induction. The right ovary shows a typical hemorrhagic cyst formed from the corpus luteum . The first image (top row- left) is a transabdominal ultrasound image showing fine fibrinous strands within the cystic mass in the right ovary. Transvaginal ultrasound and color Doppler images confirm these findings. The uterus shows typical secretory changes in the endometrium suggesting post ovulatory phase.

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Hemorrhagic ovarian cysts: Hemorrhagic cyst of ovary with co-existing chocolate cyst/ endometrioma : This patient has a co-existing chocolate cyst with a hemorrhagic cyst in the same (right) ovary. The cyst on the left half of the ultrasound image is a hemorrhagic cyst. Note the fine fibrinous strands within the cyst suggesting clot formation. The cyst on the right half of the image is homogenous with fine echoes throughout the ovarian cyst. This is a typical appearance of an endometrioma (chocolate cyst)

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Hemorrhagic ovarian cysts: Hemorrhagic cyst of ovary with ruptured ectopic pregnancy: This female patient has a left ovarian hemorrhagic cyst (see ultrasound image above-left). In addition, there is a large collection of free fluid with particulate matter in the pelvis. The right fallopian tube is thickened with a ring shaped mass. This suggests that there is significant hemorrhage into the pelvis due to a ruptured ectopic pregnancy (right tubal ectopic gestation). The left ovarian hemorrhagic cyst appears intact, ruling out ruptured hemorrhagic cyst.

PowerPoint Presentation:

Hemorrhagic ovarian cysts: Hemorrhagic cyst of ovary with ruptured ectopic pregnancy: This female patient has a left ovarian hemorrhagic cyst (see ultrasound image above-left). In addition, there is a large collection of free fluid with particulate matter in the pelvis. The right fallopian tube is thickened with a ring shaped mass. This suggests that there is significant hemorrhage into the pelvis due to a ruptured ectopic pregnancy (right tubal ectopic gestation). The left ovarian hemorrhagic cyst appears intact, ruling out ruptured hemorrhagic cyst.

Ovarian dermoid cyst or Cystic teratomas: :

Ovarian dermoid cyst or Cystic teratomas : These ultrasound images reveal bilateral ovarian complex masses that contain both solid and cystic components. The right ovary shows a cystic mass with a solid, highly echogenic " dermoid plug". This is a solid nodule containing fat and various tissues including hair. Posterior acoustic shadowing is seen. The left ovary shows a dermoid plug and, in addition, a " dermoid mesh" is also seen, an irregular echogenic solid mass within the cyst. Echogenic debris is seen floating within the fluid

PowerPoint Presentation:

Ovarian dermoid cyst or Cystic teratomas : These ultrasound images reveal bilateral ovarian complex masses that contain both solid and cystic components. The right ovary shows a cystic mass with a solid, highly echogenic " dermoid plug". This is a solid nodule containing fat and various tissues including hair. Posterior acoustic shadowing is seen. The left ovary shows a dermoid plug and, in addition, a " dermoid mesh" is also seen, an irregular echogenic solid mass within the cyst. Echogenic debris is seen floating within the fluid

PowerPoint Presentation:

Ovarian dermoid cyst or Cystic teratomas : These ultrasound images reveal bilateral ovarian complex masses that contain both solid and cystic components. The right ovary shows a cystic mass with a solid, highly echogenic " dermoid plug". This is a solid nodule containing fat and various tissues including hair. Posterior acoustic shadowing is seen. The left ovary shows a dermoid plug and, in addition, a " dermoid mesh" is also seen, an irregular echogenic solid mass within the cyst. Echogenic debris is seen floating within the fluid

PowerPoint Presentation:

Ovarian dermoid cyst or Cystic teratomas : These ultrasound images reveal bilateral ovarian complex masses that contain both solid and cystic components. The right ovary shows a cystic mass with a solid, highly echogenic " dermoid plug". This is a solid nodule containing fat and various tissues including hair. Posterior acoustic shadowing is seen. The left ovary shows a dermoid plug and, in addition, a " dermoid mesh" is also seen, an irregular echogenic solid mass within the cyst. Echogenic debris is seen floating within the fluid

LUTEINIZED UNRUPTURED FOLLICLE:

LUTEINIZED UNRUPTURED FOLLICLE Images from a woman who developed hemorrhagic anovulatory follicles during a study of natural cycle folliculogenesis and ovulation (A, B). There is evidence of extravasated blood in the lumen of the structures and the walls are thin did not develop any visual evidence of luteinization . Progesterone levels were below those accepted as clinically normal.

Rupture of hemorrhagic ovarian cyst: :

Rupture of hemorrhagic ovarian cyst: Transabdominal scanned image

PowerPoint Presentation:

Rupture of hemorrhagic ovarian cyst: Transvaginal scanned image

Ovarian hyperstimulation syndrome (OHSS): :

Ovarian hyperstimulation syndrome (OHSS): This young adult female patient was examined to evaluate the uterus and ovaries. She was under treatment for infertility and was using gonadotropins . Ultrasound images of the ovaries show grossly enlarged ovaries with large cysts (measuring 2.6 to 3 cms .) in both ovaries. These ultrasound findings are diagnostic of OHSS or ovarian hyperstimulation syndrome.

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Ovarian hyperstimulation syndrome (OHSS): The ultrasound image again show hyperstimulated ovaries. Both ovaries are grossly enlarged and cystic.

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Ovarian hyperstimulation syndrome (OHSS): Transvaginal ultrasound images of ovarian hyperstimulation syndrome: This young adult female patient showed multiple large theca lutein cysts of both ovaries, arranged in spoke-wheel pattern (ultrasound images above) which were the result of use of gonadotropins in the management of infertility. The cysts vary in size from 2 to 4 cms . with the ovaries massively enlarged (each ovary measures up to 7 cms . in size). This can be classified as grade-2 hyperstimulation of the ovaries (ovarian diameter from 5 to 10 cms .). There is not evidence of ascites . The color Doppler image of the ovaries shows vessels passing along the margins of the cysts. One of the complications of such enlarged ovaries in OHSS is torsion and in certain cases rupture of the ovaries, both of which are medical emergencies. Ovarian hyperstimulation syndrome is known to occur more frequently in patients of pre-existing Polycystic ovaries (PCO).

PowerPoint Presentation:

LUTEINIZED UNRUPTURED FOLLICLE Images from a woman who developed hemorrhagic anovulatory follicles during a study of natural cycle folliculogenesis and ovulation (A, B). There is evidence of extravasated blood in the lumen of the structures and the walls are thin did not develop any visual evidence of luteinization . Progesterone levels were below those accepted as clinically normal.

PERSISTENT ANOVULATORY FOLLICLE :

PERSISTENT ANOVULATORY FOLLICLE Failure of ovulation and development of “cystic” follicle. The follicle typically grows larger than the mean preovulatory follicle diameter of 23 mm, thin atretic follicle walls are observed and small flecks of particulate matter are frequently seen in the lumen or aggregated at the side of the structure.

PowerPoint Presentation:

PERSISTENT ANOVULATORY FOLLICLE Image of a hemorrhagic anovulatory follicle. Extravasated blood and an interspersed fibrin network are observed within the lumen. The walls of this structure are thin, echoic, and do not have the appearance of luteal tissue.

BENIGN OVARIAN NEOPLASIA:

BENIGN OVARIAN NEOPLASIA Images of a small intraovarian dermoid cyst (A, B). The cyst is completely embedded in the ovary and is surrounded by focal areas of hyperechoicity . Small follicles are observed in the surrounding stroma . Folliculogenesis and ovulation were impaired in this ovary. The contralateral ovary demonstrated compensatory hypertrophy.

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BENIGN OVARIAN NEOPLASIA Images of a small intraovarian dermoid cyst

OVARIAN ENDOMETRIOMA :

OVARIAN ENDOMETRIOMA Images of ovarian endometrioma (A, B). The structure is hypoechoic and exhibits low amplitude uniformly distributed echotexture in the cavities of the cysts.

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OVARIAN ENDOMETRIOMA Images of ovarian endometrioma

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OVARIAN ENDOMETRIOMA Ultrasound images of chocolate cysts of ovary

Premature ovarian failure.:

Premature ovarian failure. Image from a woman in premature ovarian failure. Only the stroma of the ovary is identified. A very few follicles of less than 1 mm diameter can be observed on the inferior aspect of the ovary.

POLYCYSTIC OVARY SYNDROME :

POLYCYSTIC OVARY SYNDROME Images from women with differing expressions of the four major subtypes of the metabolic syndrome associated with polycystic ovary syndrome (A–D). The images exhibit quite differing ultrasonographic appearances in the size and distribution of follicles within PCOS ovaries. A recent corpus luteum is clearly visible in the ovary in panel (D).

PowerPoint Presentation:

POLYCYSTIC OVARY SYNDROME Images from women with differing expressions of the four major subtypes of the metabolic syndrome associated with polycystic ovary syndrome (A–D). The images exhibit quite differing ultrasonographic appearances in the size and distribution of follicles within PCOS ovaries. A recent corpus luteum is clearly visible in the ovary in panel (D).

PowerPoint Presentation:

POLYCYSTIC OVARY SYNDROME Images from women with differing expressions of the four major subtypes of the metabolic syndrome associated with polycystic ovary syndrome (A–D). The images exhibit quite differing ultrasonographic appearances in the size and distribution of follicles within PCOS ovaries. A recent corpus luteum is clearly visible in the ovary in panel (D).

PowerPoint Presentation:

POLYCYSTIC OVARY SYNDROME Images from women with differing expressions of the four major subtypes of the metabolic syndrome associated with polycystic ovary syndrome (A–D). The images exhibit quite differing ultrasonographic appearances in the size and distribution of follicles within PCOS ovaries. A recent corpus luteum is clearly visible in the ovary in panel (D).

The Oviduct (Fallopian Tube):

The Oviduct (Fallopian Tube)

Normal Oviduct:

Normal Oviduct An image of an oviduct visualized from the uterine cornu to the fimbria . The ampulla , infundibulum and very fine interfaces representing the fimbria may be appreciated on the superior aspects of the ovaries.

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Normal Oviduct The fimbria of the oviduct are clearly visualized in free fluid surrounding the ovary following ovulation or hysterosalpinography .

Hydrosalpinx:

Hydrosalpinx Hydrosalpinx is usually easily diagnosed as well-constrained fluid accumulation in the adnexae . In some cases, adhesions between the oviduct and ovary may be visualized.

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Hydrosalpinx Hydrosalpinx is usually easily diagnosed as well-constrained fluid accumulation in the adnexae . In some cases, adhesions between the oviduct and ovary may be visualized.

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Uterus Reconstructed coronal view of the uterus demonstrating cornuas (arrow) and cervix, with a normal uterine contour

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Normal Uterus Planar views of normal uterus using volume contast imaging

Normal Uterus:

Normal Uterus Normal Uterus in longitudinal view

Uterine Pathology:

Uterine Pathology

Fibroids (leiomyomata) :

Fibroids ( leiomyomata ) Intramural leiomyomata are frequently visualized. Examples of fibroids which compromise the contours of the endometrial cavity are shown (A–D). Refraction artifacts resulting from tissue density interfaces and the texture of the fibroids often aid in their identification.

PowerPoint Presentation:

Fibroids (leiomyomata) Intramural leiomyomata are frequently visualized. Examples of fibroids which compromise the contours of the endometrial cavity are shown (A–D). Refraction artifacts resulting from tissue density interfaces and the texture of the fibroids often aid in their identification.

PowerPoint Presentation:

Fibroids (leiomyomata) Intramural leiomyomata are frequently visualized. Examples of fibroids which compromise the contours of the endometrial cavity are shown (A–D). Refraction artifacts resulting from tissue density interfaces and the texture of the fibroids often aid in their identification.

PowerPoint Presentation:

Fibroids (leiomyomata) Intramural leiomyomata are frequently visualized. Examples of fibroids which compromise the contours of the endometrial cavity are shown (A–D). Refraction artifacts resulting from tissue density interfaces and the texture of the fibroids often aid in their identification.

Congenital anomalies of uterus:

Congenital anomalies of uterus Unicornuate uterus

Congenital anomalies of uterus:

Congenital anomalies of uterus Bicornuate Bicollis Uterus

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Congenital anomalies of uterus Didelphic uterus with Left sided hematometra

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Congenital anomalies of uterus Subseptate Uterus

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Congenital anomalies of uterus Complete Septate

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Congenital anomalies of uterus Arcuate uterus

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Congenital anomalies of uterus DES Uterus (exposure to diethylstilbestrol during embryonic period)

Endometrium:

Endometrium

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Endometrium Post menstruation

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Endometrium Trilaminar appearance during proliferation

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Endometrium Secretory phase

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Endometrium Premenopausal Endometrium Endometrium Sagittal US image of the uterus obtained during the secretory phase of the menstrual cycle shows a thickened, echogenic endometrium (cursors).

Pathology of Endometrium:

Pathology of Endometrium Endometritis . US image demonstrates multiple echogenic foci within the endometrium (arrow) representing gas.

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Pathology of Endometrium Postmenopausal endometrial atrophy. Transvaginal US image demonstrates a postmenopausal endometrium with thin walls and outlined with fluid. .

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Pathology of Endometrium Submucosal fibroid. (a) Transvaginal US image reveals a uterine mass (arrows) with posterior acoustic shadowing.

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Pathology of Endometrium Submucosal fibroid. Sonohysterogram reveals that the mass is submucosal in location, a finding that is consistent with an echogenic fibroid.

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Pathology of Endometrium Endometrial hyperplasia. US image shows an endometrium with diffuse thickening (maximum thickness, 1.74 cm) due to hyperplasia (cursors). This finding was confirmed at biopsy.

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Pathology of Endometrium Endometrial adenocarcinoma . (a) US image reveals a heterogeneous endometrial mass (arrows) that is difficult to distinguish from the myometrium . Cursors indicate the entire transverse width of the uterus.

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IUD IUD. US image shows a hyperechoic linear structure within the endometrial canal (arrow) representing an IUD.

Transvaginal Colour Doppler Sonography (TV-CDS):

Transvaginal Colour Doppler Sonography (TV-CDS) Provides additional information of blood flow to, from or within an organ (uterus of adnexae ). This flow can be measured by analysis of the waveform using the pulsatility index.

PowerPoint Presentation:

Colour flow doppler image Demonstrating perifollicular vascularity around a preovulatory follicle. Visualization of the complete paths of vascular flow around large follicles is challenging owing to the tortuous path of the vascular supply to the dominant follicle.

Power flow Doppler image of a mature, mid-cycle luteal gland demonstrating marked periluteal vascular flow.:

Power flow Doppler image of a mature, mid-cycle luteal gland demonstrating marked periluteal vascular flow.

Power (A) flow Doppler images of recently ovulated follicles/new luteal glands on the day of ovulation.:

Power (A) flow Doppler images of recently ovulated follicles/new luteal glands on the day of ovulation.

Color (B) flow Doppler images of recently ovulated follicles/new luteal glands on the day of ovulation.:

Color (B) flow Doppler images of recently ovulated follicles/new luteal glands on the day of ovulation.

PowerPoint Presentation:

Sonohysterography Sonohysterography is a new technique developed to better image the uterine cavity. It uses an infusion of sterile saline through a soft plastic catheter placed in the cervix in conjunction with transvaginal ultrasound. The saline infusion distends the uterine cavity and provides an excellent contrast to the lining, giving improved visualization of uterine and endometrial pathology.

Sonohysterography:

Sonohysterography Indications Abnormal uterine bleeding both pre and post menopausal Investigation of infertility and recurrent miscarriage Endometrial assessment for patients on Tamoxifen therapy Suggestion of a mass in the endometrial cavity on ultrasound

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Sonohysterography

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Pathology of Endometrium Endometrial polyp. Sonohysterogram reveals a small polyp attached by a stalk to the endometrium (black arrow). An echogenic focus in the endometrial cavity (white arrow) represents injected air.

Sonohysterography:

Sonohysterography Colour doppler imaging of the doppler polyp during sonohysterography

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Sonohysterography Sonohysterography 3D image of endometrial polyp

Sonohysterosalpingography:

Sonohysterosalpingography Normal saline is pushed within the uterine cavity with a paediatric Foley Catheter. The catheter balloon is inflated at the level of the cervix to prevent fluid leak. Ultrasonography of the uterus and fallopian tubes are done. Ultrasound can follow the fluid through the tubes up to the peritoneal cavity and in the pouch of Douglas.

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Pathology of Endometrium Endometrial polyp. Anteroposterior (left) and oblique (right) hysterosalpingograms demonstrate a pedunculated filling defect within the uterine cavity (arrows).

Sonographically guided procedures:

Sonographically guided procedures A needle guide is attached to the shaft of the vaginal probe. With the use of real time, TVS can guide the needle course in safe path. This technique can be utilised for many diagnostic and therapeutic purposes:

PowerPoint Presentation:

Sonographically guided procedures Aspiratio n of cystic masses, e.g – Chocolate cyst Follicular aspiration , e.g - Ovum retreival in IVF Aspiration of tubo -ovarian abscess Biopsies

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Endometrial Adhesions Endometrial adhesions. Hysterosalpingogram reveals irregular filling defects in the endometrium (arrows) representing adhesions.

Transrectal sonography:

Transrectal sonography It can be used where TVS cannot be used due to vaginal narrowing.

Saline Infusion Sonography:

Saline Infusion Sonography Common Indications are: Postmenopausal bleeding Abnormal uterine bleeding Recurrent miscarriage Infertility

Saline Infusion Sonography:

Saline Infusion Sonography Infusion of normal saline into the uterine cavity and doing transvaginal (high resolution) sonography is helpful for the diagnosis of many uterine pathology. SIS catheter is inserted through the cervical os . Normal saline is infused slowly (5-10 ml) when the uterus is imagined with vaginal ultrasound.

THANKS FOR ATTENTION:

THANKS FOR ATTENTION

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