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Imaging in obstetrics & gynaecology (part 1- Gynaecological scans in benign conditions)
MBBS;MS. FICOG. MICOG.
Founder Principal & Controller,
Jhalawar Medical college , Jalawar.
Mahatma Gandhi Medical College,sitapura ,
DR. RIDHI KATHURIA
PG 2ND year
DEPTT OF OBS & GYN
NIMS MEDICAL COLLEGE & HOSPITAL
WHAT IS MEDICAL IMAGING?
MEDICAL IMAGING is the technique and process
used to create images of the human body (or parts and
function thereof) for clinical purposes (medical
procedures seeking to reveal, diagnose, or
examine disease) or medical science (including the
study of normal anatomy and physiology).
Uses High-frequency broadband sound
>20,000 Hz, i.e. 2 KHz.
Reflected by tissues upto varying degrees
depending on the tissue content, type,
Converting the echoes into electric signals.
Interpreting and displaying those signals
Can be snapshot or in real time.
Can be directed in a beam
Obeys the laws of reflection and refraction
Reflected by objects of quite small size
Can be converted to analogue or digital signals for image production
No radiation exposure
o Travels poorly through gas
o The amount reflected depends on the
degree of acoustic mismatch
o The piezoelectric crystals are quite delicate
The ultrasound beam & the receipt of echoes is achieved by
Mounted in an array on a probe.
The probe can be fixed or oscillating.
The wave of sound can be focused to a point of interest.
The image is displayed on an oscilloscope or TV
The image will be formed by-
1) Direction of echo.
2) Strength of echo.
3) Time taken for the echo to return.
These 3 characteristics determine which pixels on the
screen will light up & with what intensity.
DIAGNOSTICULTRASOUND a. Typically involves frequencies of 2 – 15
b. Lower frequencies will give greater
c. And thereby one can see further
d. Higher frequencies allow to see more
e. But the penetration is less
f. And very high frequencies have the
potential for adverse biological effects
Hand held Probes.
Contain the Piezoelectrical
Of varying types depending
on shape, usage, desired
structure/area to be
A Linear Array of Crystals
Produces parallel sound waves
And a rectangular image
Good for surface structures
A Curved Array of Crystals
Will fit curved surfaces of the body
The density of scan decreases
proportionally to the distance from the
Produces a fan-like image
Can fit into narrow spaces
Has poor near-field resolution
A Sector Array of Crystals
Used to scan by placing it within the
More detailed view of the structures.
Special emphasis for follicular monitering.
Ultrasound is no substitute for a good history & a thorough
clinical (general & specific systemic) examination .
ALWAYS do an abdominal scan before using the vaginal
The trick is to build up a 3-dimensional picture in your
mind using real-time imaging
For large masses
In gynecology diseases
Uterus , ovaries, follicles
Pouch of Douglas
Pelvic floor muscles
TRANSVERSE SECTION OF
THE STRUCTURES, JUST
ABOVE THE PUBIC
(OVARIES SEEN CLEARLY
AS HERE, MAY NOT BE
POSSIBLE IN ALL CASES)
TRANS VAGINAL SCANNING
ANTEVERTED UTERUS:- Fundus
faces the same direction as bladder
RETROVERTED UTERUS:- Fundus faces
the opposite direction as bladder
Size - 7.5 x 5.0 x 2.5cm
Length - Fundus to Cervix(7.5-8.0cm)
Depth - Antero-posterior(4.5-5.0cm)
Width - Coronal view (2.5-3.0cm)
Changes during menstrual cycle
1-4 mm after menses
8-10 mm at ovulation(tri laminar)
When evaluating a suspected uterine mass, the practitioner
should identify the appropriate anatomical structures.
The initial step is to identify the bladder anteriorly and the
The position of the uterus depends on the distension of the
bladder and rectosigmoid.
The normal uterus appears sonographically as a uniform
With pregnancy a myoma can be seen
better as the anechoic amniotic fluid
provides a good window.
Also as seen, cystic ill defined areas are
suggesting ‘Red Degeneration Of
Calcific changes may also be seen as
‘RING CALCIFICATIONS’ seen
as bright line encircling the mass
POOR VASCULARITY OF THE MASS FURTHER
CONFIRMS THE DIAGNOSIS OF A FIBROID.
The fibroid impinges
within the uterine
The fibroid stalk may
twist on itself.
Get detached from
the original area of
Hence, becoming a
Brightness is due the fat (fatty
degeneration) content of the mass.
A common benign condition
that often co-exists with
endometriosis and fibroids,
often described as endometriosis
within the uterus itself .
Endometrial tissue exists within
the muscle of the uterus. During
menstruation this degenerates
and the blood cannot escape the
uterine muscle causing pain;
some blood may finally escape
resulting in abnormal p.v.
• MAY BE NORMAL
• Diffuse uterine enlargement with no alteration in echo-
texture or uterine contour, often reported as a “bulky
• Asymmetrically thickened uterus, usually posteriorly
• Poorly defined focal area of hypoechoic or hyperechoic
texture within the myometrium, representing a focal
adenomyoma (can be multiple)
• Cystic hyperplasia of the endometrium
• Myometrial cysts
The loss of endometrial myometrial
junction when seen on images is
Cystic appearance with
• Deposition of calcium in
abnormal tissues, without
abnormal blood calcium levels.
• It may occur as a part of ageing
process, or may follow an
instrumentation or procedure like
• Bright echogenic lesion with
posterior shadowing is suggestive
• The shadowing is due to complete
reflection of the waves when they strike the
Normal fallopian tubes
not seen, in a routine
Pathological tubes seen
as dilated, truncated
• Ectopic Pregnancy
• Tubal Carcinoma
Ciliae of the inner lining (endosalpinx) of the fallopian tube
beat towards the uterus, tubal fluid is normally discharged
via the fimbriated end into the peritoneal cavity from
where it is cleared.
If the fimbriated end of the tube becomes agglutinated, the
resulting obstruction does not allow the tubal fluid to pass;
it accumulates and reverts its flow downstream, into the
uterus, or production is curtailed by damage to the
TUBAL PHIMOSIS refers to a
situation where the tubal end is
partially occluded, in this case
fertility is impeded, and the risk
of an ectopic pregnancy is
lumen is s/o
Echogenic debris seen within the lumen is s/o pus.
The normal ovary in the resting (menstrual) phase is moderately
echogenic, well marginated and located at the lateral edge of the
Because it is mobile, it may be found from the pelvic cul-de-sac to
the lower abdomen ( often displaced superiorly by distended
urinary bladder, coming to lie anterior and lateral to the iliac
Despite this variability, it is typically found lateral to the fundus of
PREMENARCHAL (Vol. = 0-8 ml)
Ovaries are small, and often show a uniform moderately echogenic solid structure.
It is typical to note scattered antral follicles (small 3-6 mm cysts) during the years 9-13
Follicles in younger patients however are not necessarily evidence of endocrine
Size of premenarchal ovaries is quite variable, making conclusions based on size
PUBERTY THROUGH MIDDLE AGE (Vol. = 0-18 ml)
Solid background with scattered antral follicles (3-6 mm cysts).
This pattern is punctuated by the regular cyclic development of graafian follicles.
POST-MENOPAUSAL (Vol. = 0-8 ml)
Solid background, antral follicles may persist 4 -5 years following clinical menopause.
Ovarian size is smaller.
1. Because of the ovary has a variable, usually oval shape,
size is best expressed as an estimated volume.
Volume (ml.) = Length (cm) x Width (cm) x Depth (cm) x 0.52
2. The Ratio of larger to smaller ovary should normally be
less then 2:1.
Age (yrs) Volume (ml) Mean (ml)
0-10 0.2 - 4.9 1.7
11-20 1.7 - 18.5 7.8
21-30 2.6 - 23.0 10.2
31-40 2.6 - 20.7 9.5
41-50 2.1 - 20.9 9.0
51-60 1.6 - 14.2 6.2
61-70 1.0 - 15.0 6.0
Values ; 95% confidence level
• Although the hormonal background of follicular development is among the
more complex endocrine events, the resulting sequence of gross
morphologic changes visualized by ultrasound is a simple sequence of
• Using measures of size, number, and temporal progression, ultrasound can
verify normal sequences, or in many cases, diagnose ovulation failure by
recording at what point follicular development is arrested.
• The resting ovary contain a women's full complement of potential follicles.
• The resting primordial follicles are too small to be seen grossly or on a scan.
Initial follicular development occurs
during the proliferative (follicular)
phase of the menstrual cycle,
approximately days 1-14 counting from
the first day of menstrual flow, and
ends with ovulation.
During the follicular phase, a small
subset of the primordial follicles are
stimulated to develop, and
accumulate follicular fluid, with
enlargement ultimately visible by
Developing Follicles are
first seen by ultrasound
as a group of 4-8 antral
follicles 3-5mm size by
day 6-7 .
By Ultrasound, early antral follicles are 2-4mm in size. Developing
follicles range between 5-10 mm.
The dominant (selected) follicle will continue to grow, reaching
10mm on day 8-9 and reaching final mature size of 18-24 mm, on day
14 prior to ovulation.
Typically subordinate (non-dominant follicles) reach 10 mm and then
Follicles 11 mm or larger are
usually dominate follicles.
Secretory (Luteal) Phase
On about day 14, the mature follicle expels
In most cases, loss of fluid associated with
expulsion of the oocyte results in
disappearance or substantial decrease in
size of the mature follicle.
This abrupt change in size represents the
Ultrasound sign of ovulation.
Free Fluid seen in POD, is also arbitrarily
taken as a sign of ovulation
In the 1st scan, the star marked follicle is the selected
It is seen approaching the margin of the ovarian cortex
& also is the largest of all others.
The defect in the follicle heals in 2-5 days.
The wall thickens as cells are "luteinized"( lining cells enlarge and fill with lipid),
and in most cases, the antrum fills with blood to form a "Corpus Hemorrhagicum”.
The follicle becomes a "Corpus Luteum", contributing hormone secretion,
particularly progesterone to support the Secretory Phase.
On ultrasound, the corpus luteum reappears in in several forms.
• 1/3 are a typical cyst of similar size to the mature follicle or larger.
• 1/3 are more echogenic, forming a nearly "solid" ultrasound appearance.
• 1/3 are not apparent at ultrasound examination.
If pregnancy occurs, HCG secreted by the trophoblast maintains the
corpus luteum through the 10 week of gestation.
If pregnancy does not occur, the Corpus Luteum usually disappears
within a day or two of the onset of menses.
Because almost all functional ovarian cysts disappear by
the 5th day of the subsequent cycle, concerns regarding
neoplastic origin of unusually large functional of cysts
can usually be dispelled by demonstrating their
disappearance by 3-5 days into the next cycle.
For the same reason, screening for early
ovarian tumors must be done during the first 5
days of the cycle to avoid needless confusion
with physiologic cysts.
In these cycles, the proliferative
maturing effects of E2 (estrogen)
are not properly synchronized
with the the LH (luteinizing
The resulting follicle does not
reach full size or ovulate.
Ultrasound shows a dominate
follicle which does not reach full
mature size (16-24mm.) and
atresic. This is the morphologic
pattern most frequently observed
in patients taking oral
Follicular development is
grossly normal, but aspiration
or natural ovulation does not
produce an oocyte.
Failure to demonstrate a
cumulus oophorus with a
mature follicle on very high
resolution ultrasound may be
However visualization of the
cumulus is difficult under
optimal conditions, the
accuracy of ultrasound
in demonstrating the
syndrome in probably low.
Under routine study, these
cycles are likely to appear
In this syndrome, an
apparently normal mature
luteinized follicle fails to
rupture and ovulate. It
goes on to behave as a
The syndrome can be
recognized as a follicle
which fails to collapse in
association with the
expected LH peak.
Ultrasound findings cant
be taken as conclusive.
Primary ovarian failure leads to small
ovaries and low secretion of estrogen.
The anestrogenic state leads
to lack of feedback on gonadotrophin
secretion and Hypergonadotropism.
Causes include primary failure,
autoimmune damage, and chromosomal
Ultrasound shows small or absent
ovaries without follicles.
Except in autoimmune causes, this
group of patients do not respond to
FSH and LH levels are found to be low,
and evaluation for pituitary tumor is
Ovarian function is often normal and
may be recovered through correction of
pituitary problems, or exogenous FSH
and HCG (LH replacement).
Due to inadequate stimulation, these
patients also have low
On ultrasound, these patients
ovaries may be "normal", but
are more often enlarged
( > 6ml), and tend to have an
increased number of small
follicles (>11) and no
dominant size follicles.
The stroma in the central part
of the ovary is usually
abundant and hyperechoic.
Doppler blood flow has been
reported to be faster in PCOS.
• May show features of polycystic ovaries
– Bilateral enlarged ovaries with multiple small follicles : 50%
• Increased ovarian size (> 10 cc)
• 12 or more follicles measuring 2 - 9 mm
• Follicles of similar size
• Peripheral location of follicles : which can give a String Of Pearl
• Hyperechoic central stroma
• Ovarian outline may be slightly irregular
• Hypo-echoic ovary without individual cysts : 25%
• Normal ovaries : 25%
• Endometrium – may appear as proliferative
is a complication
from some forms
Ovarian hyperstimulation syndrome is particularly associated with injection of a
hormone called human chorionic gonadotropin (hCG) which is used for inducing
final oocyte maturation and/or triggering oocyte release.
The risk is further increased by multiple doses of hCG after ovulation and if the
procedure results in pregnancy.
Using a GnRH agonist instead of hCG for inducing final oocyte maturation and/or
release results in an elimination of the risk of ovarian hyperstimulation syndrome,
but a slight decrease of the delivery rate of approximately 6%
Based upon the clinical manifestation and imaging findings, OHSS
can be classified into
• Mild OHSS : Characterised by bilateral multicystic ovarian
• Moderate OHSS : If there is associated ascites and abdominal
• Severe OHSS : Characterised by hypovolemia,
haemoconcentration, thrombosis, oliguria, pleural and
Typically shows bilateral
symmetric enlargement of
ovaries (often > 12 cm) with
multiple cysts of varying sizes,
giving the classic
WHEEL - SPOKE
Associated ascites, pleural + /
pericardial effusion (which is
due to capillary leak) may also
• Ultrasound is the preferred imaging
modality. Typically an ovarian dermoid is
seen as a cystic adnexal mass with some
mural components. Most lesions are
• Rokintansky Nodule / Dermoid Plug
• Diffusely or partially echogenic mass with
posterior attenuation owing to sebaceous
material and hair within the cyst cavity : TIP
OF THE ICEBERG Sign
• Echogenic, shadowing calcific or dental
• Presence of fluid-fluid levels
• Multiple thin, echogenic bands caused by
hair in the cyst cavity : DOT & DASH
calcified material within the
Attenuation of the rays
passing through the above
Behind these structures, all
appears dark (sono-opaque)
Rokitansky nodule or Dermoid plug refers to a
solid protuberence projecting from an ovarian
cyst in the context of a mature teratoma.
It often contains calcific, dental, adipose, hair
and / or sebaceous components
• A Theca Lutein Cyst is a type of
bilateral functional ovarian cyst filled
with clear, straw-colored fluid.
• To be classified a functional cyst, the
mass must reach a diameter of at least
• These cysts originate when abnromally
high Beta-HCG are elevated, which can
occur due to multifetal gestations or
CORPUS LUTEAL (CL) cyst is a
type of functional ovarian cyst which
results when a corpus luteum fails to
regress following the release of
Such a cyst is complicated further by
hemorrhage occurring within the cyst.
When associated with pregnancy, it
is the most common pelvic mass
encountered within the
Colour Doppler shows either no vascularity
within the cyst or at times show low resistance
blood flow around the cyst
when present within
the ovaries, proliferates
under the influence of
hormones, during the
Seen here, is the
Transabdominal ultrasound shows a
multiloculated right ovarian endometrioma
with low level echoes