Prof. M.C.Bansal.

MBBS;MS. FICOG. MICOG.

Founder Principal & Controller,
Jhalawar Medical college , Jalawar.
Ex.Principal&Controller;
Mahatma Gandhi Medical
College,sitapura , Jaipur.

IMAGING IN OBSTETRICS &

GYNAECOLOGY
DR. RIDHI KATHURIA
PG 2ND year
DEPTT OF OBS & GYN
NIMS MEDICAL COLLEGE & HOSPITAL
JAIPUR

WHAT IS MEDICAL IMAGING?

MEDICAL IMAGINGis the technique and
process used to createimagesof
thehuman body(or parts and function
thereof) for clinical purposes (medical
proceduresseeking to reveal,diagnose, or
examinedisease) or medical science
(including the study of normal
anatomyandphysiology).

M
O
D
A
L
I
T
I
E
S

1.
Ultrasonography.
2. X-Ray.
3. Hysterography.
4. Hysteroscopy.
5. CT Scan
6. MRI.
7. PET.

ULTRASONOGRAP
HY
Uses High-frequency broadband sound
waves.
>20,000 Hz, i.e. 2 KHz.
Reflected by tissues upto varying degrees
depending on the tissue content, type,
consistency.
Receiving echoes.
Converting the echoes into electric
signals.
Interpreting and displaying those signals
Can be snapshot or in real time.

ADVANTAGES
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
Non Invasive
Fast
Relatively inexpensive.

DISADVANTAGES
Ultrasound waves;
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 PIEZOELECTRIC CRYSTALS
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 screen.

The image will be formed by1) 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.

DIAGNOSTIC
ULTRASOUND

a. Typically involves frequencies of 2 15

mHz
b. Lower frequencies will give greater
penetration
c. And thereby one can see further
d. Higher frequencies allow to see more
detail
e. But the penetration is less
f. And very high frequencies have the
potential for adverse biological effects

Hand held Probes.

Contain the
Piezoelectrical
Crystals.

PROBES

Of varying types
depending on
shape, usage,
desired
structure/area to be
visualised.

A Linear Array of
Crystals
LINEAR
PROBE

Produces parallel sound

waves
And a rectangular image
Good for surface
structures

A Curved Array of Crystals

Will fit curved surfaces of the body
CURVED
PROBE

The density of scan decreases

proportionally to the distance from
the transducer

A Sector Scanning
Probe
SECTOR
PROBE

Produces a fan-like image

Can fit into narrow spaces
Has poor near-field
resolution

A Sector Array of Crystals

TRANS
VAGINAL
PROBE

Used to scan by placing it within the

vaginal opening.
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 probe.

The trick is to build up a 3-dimensional picture

in your mind using real-time imaging

TRANS ABDOMINAL

Full bladder
Panaromic view
For large masses
Abdominal organs
Lymphnodes

TRANS VAGINAL
Empty bladder
In gynecology
diseases
Uterus , ovaries,
follicles
Pouch of Douglas

TRANS PERINEAL
Pelvic floor muscles

TRANS RECTAL
Pubo-Rectalis Muscle
Anal Sphincter

TYPES OF
TECHNIQ
UES &
PRE
REQUISIT
ES

NORMAL APPEARANCES

TRANSVERSE
SECTION OF THE
STRUCTURES, JUST
ABOVE THE PUBIC
SYMPHYSIS.
(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

ULTRASOUND
IN GYNAECOLOGY

THE UTERUS
Normal Appearance

NORMAL MEASUREMENTS
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)
Myometrium
Homogenous
Hypoechogenic
EndometriumChanges 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 rectosigmoid posteriorly.
The position of the uterus depends on the distension of
the bladder and rectosigmoid.
The normal uterus appears sonographically as a
uniform structure.

I
N
D
I
MYOMAS
C
Irregular uterine contour
Hypo/iso/hyper echoic masses
A
Size, number, location
T
ADENOMYOSIS
I
Enlarged uterus
Asymmetric thickening ofO
myometrium
N
Heterogeneous echotexture
S

CONGENITAL ANOMALIES
Bicornuate uterus
Sepatate uterus
Didelphous uterus

ABNORMAL UTERINE BLEEDING

Polyps
Submucosal fibroid

POSTMENOPAUSAL BLEEDING

ENDOMETRIAL
ABNORMALITIES

Endo thickness- >5mm needs evaluation

ENDOMETRIAL CANCER
Myometrial invasion

TAMOXIFEN THERAPY
Thick endometrium
Subendometrial stromal
vacuolation

MISSING IUCD
Bright echogenic
Penetration to myometrium

ANOMALIES OF THE UTERUS

BICORNUATE UTERUS

DIDELPHUS UTERUS

S
E
P
T
A
T
E

U
T
E
R
U
S

F < 2cm
Incomplet
e/Partial
Septum

F > 2cm
Complete
Septum

FIBROID UTERUS

Calcific changes may also

be seen as RING
CALCIFICATIONS seen as
bright line encircling the
mass

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

POOR VASCULARITY OF THE MASS FURTHER

CONFIRMS THE DIAGNOSIS OF A FIBROID.

SUBMUCOUS
FIBROID

The fibroid
impinges within
the uterine cavity.

SUB SEROSAL
FIBROID

The fibroid stalk

may twist on
itself.
Get detached
from the original
area of
attachment.

PEDUNCULATED FIBROID

Hence,
becoming a
WANDERING
FIBROID.

LIPOLEIOMYOMA

Brightness is due the fat (fatty

degeneration) content of the

ADENOMYOSIS
A common benign
condition that often coexists 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.
spotting

 MAY BE NORMAL
Diffuse uterine enlargement with no
alteration in echo-texture or uterine contour,
often reported as a bulky uterus

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

DIFFUSE ADENOMYOSIS
The loss of endometrial myometrial
junction when seen on images is
characteristic.

Cystic appearance with

thickened endometrium

DYSTROPHIC CALCIFICATION
OF ENDOMETRIUM

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 curettage

Bright echogenic lesion

with posterior shadowing is
suggestive of calcification.

The shadowing is due to complete

reflection of the waves when they
strike the lesion.

INTRA-UTERINE CONTRACEPTIVE DEVICE

(IN SITU)

IUCD PENETRATING THE

MYOMETRIAL WALL

CERVICA
L
IUCD

IUCD IN BLADDER

PERFORATED IUCD

FALLOPIA
N
TUBES
Normal fallopian
tubes not seen,
in a routine scan.

Pathological
tubes seen as
dilated,
truncated
structures.

HYDROSALPINX HEMATOSALPINX
PID
Tuberculosis
Chlamydia/Gonorr
hoea infection
Ciliaeof 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

Traumatic
Cryptomenorrho
ea
Ectopic
Pregnancy
Tubal Carcinoma
Endometriosis

TUBAL PHIMOSISrefers to a situation where the tubal

end is partially occluded, in this case fertility is impeded,
and the risk of an ectopic pregnancy is increased.

HYDROSALPINX

HEMATOSALPINX
Thick
echogenic
homogen
ous
material
filling the
lumen is
s/o blood

PYOSALPINX
Echogenic debris seen within the lumen is s/o
pus.

OVARIES

NORMAL APPEARANCE

Position
The normal ovary in the resting (menstrual) phase
is moderately echogenic, well marginated and
located at the lateral edge of the broad ligament.
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
vessels).
Despite this variability, it is typically found lateral
to the fundus of the uterus.

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 preceding menarche.
Follicles in younger patients however are not necessarily evidence
of endocrine dysfunction.
Size of premenarchal ovaries is quite variable, making conclusions
based on size alone unreliable.

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.

Uterus

Cervix &
Vagina

Endometrium

PRE- MENARCHAL APPEARANCE

Small Multifollicular
Ovary

Unilocular Ovary

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
Age (yrs)
Volume
Mean (ml)
(ml) 2:1.
should normally be less then
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

Values ; 95% confidence level

51-60

1.6 - 14.2

6.2

61-70

1.0 - 15.0

6.0

Introduction:

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 enlarging
cysts.

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.

Normal Development:

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.

Follicular
Phase
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 ultrasound.

Developing Follicles are

first seen by ultrasound

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 become atretic.
Follicles 11 mm or larger are
usually dominate follicles.

Secretory (Luteal) Phase

On about day 14, the mature
follicle expels the oocyte.
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
sign
of follicle is
st
In the 1taken
scan,as
theastar
marked
ovulationthe selected dominant follicle.
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

CLINICAL
IMPORTANCE

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.

 POLY CYSTIC OVARIAN

DISEASE/SYNDROME

Chronic Ovulation
Failure

HYPO-GONADOTROPISM

HYPER-GONADOTROPISM

LEUTINIZED
UNRUPTURED FOLLICLE
SYNDROME
EMPTY FOLLICLE
SYNDROME
FOLLICULAR ATRESIA

Sporadic Anovulatory
Mechanisms

ABNORMAL FOLLICULAR CYCLES

FOLLICULAR ATRESIA

In these cycles, the

proliferative maturing
effects of E2 (estrogen)
are not properly
synchronized with the the
LH (luteinizing hormone).

EMPTY FOLLICLE
SYNDROME

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
Ultrasound shows a
seen.
dominate follicle which
However visualization
does not reach full mature of the cumulus is
size (16-24mm.) and
difficult under optimal
become rapidly
conditions, the
atresic. This is the
accuracy of ultrasound
morphologic pattern most in demonstrating the
frequently observed in
syndrome in probably
patients taking oral
low. Under routine
contraceptives.
The resulting follicle does
not reach full size or
ovulate.

LEUTINIZED
UNRUPTURED FOLLICLE
SYNDROME

In this syndrome, an
apparently normal
mature luteinized
follicle fails to
rupture and ovulate.
It goes on to behave
as a luteinized
follicle.
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.

HYPER-GONADOTROPISM

HYPO-GONADOTROPISM

Primary ovarian failure leads to

small ovaries and low secretion
of estrogen.

FSH and LH levels are found to

be low, and evaluation for
pituitary tumor is indicated.

The anestrogenic state leads

to lack of feedback on
gonadotrophin secretion and
Hypergonadotropism.

Ovarian function is often normal

and may be recovered through
correction of pituitary problems,
or exogenous FSH and HCG (LH
replacement).

Causes include primary failure,

autoimmune damage, and
chromosomal mosaicism.
Ultrasound shows small or
absent ovaries without follicles.
Except in autoimmune causes,
this group of patients do not
respond to treatment.

Due to inadequate stimulation,

these patients also have low
estrogen levels.

POLY CYSTIC OVARIAN

DISEASE / SYNDROME

On ultrasound, these
patients ovaries may
be "normal", but are
more often enlarged
( > 6ml), and
tend to have an
increased number of
small incompletely
developed 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.

STRING OF PEARLS
APPEARANCE

 May show features ofpolycystic ovaries

Bilateral enlargedovarieswith multiple small
follicles :50%

Increased ovarian size (>10cc)

12 or more follicles measuring 2 - 9 mm
Follicles of similar size
Peripheral location of follicles : which can give a
String Of Pearl Appearance
Hyperechoic central stroma
Ovarian outline may be slightly irregular

Hypo-echoic ovary without individual

cysts :25%
Normal ovaries :25%
Endometrium may appear as proliferative

OVARIAN HYPERSTIMULATION
SYNDROME
Ovarian
Hyperstimulation
Syndrome(OHSS)
isacomplication
fromsomeforms
offertility
medication.

Ovarian hyperstimulation syndrome is particularly associated

with injection of a hormone calledhuman chorionic gonadotropin
(hCG) which is used forinducing final oocyte
maturationand/ortriggering oocyte release.

The risk is further increased by multiple doses of hCG after

ovulation and if the procedure results in pregnancy.

Using aGnRH agonistinstead 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%

Classification
Based upon the clinical manifestation and imaging findings,
OHSS can be classified into
Mild OHSS: Characterised by bilateral multicystic
ovarian enlargement;
Moderate OHSS: If there is associated ascites and
abdominal distension;
Severe OHSS: Characterised by hypovolemia,
haemoconcentration, thrombosis, oliguria, pleural
and pericardial effusion.

Typically shows bilateral

symmetric enlargement of
ovaries (often > 12 cm) with
multiple cysts of varying
sizes, giving the classic
WHEEL - SPOKE
APPEARANCE.
Associatedascites, pleural + /
pericardial effusion (which is
due to capillary leak) may
also be present.

DERMOID

Ultrasound is the preferred imaging

modality. Typically an ovarian dermoid is
seen as a cystic adnexal mass with
some mural components. Most lesions
are unilocular.
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
(tooth) components
Presence of fluid-fluid levels
Multiple thin, echogenic bands caused
by hair in the cyst cavity : DOT & DASH
PATTERN.

Sebaceous
material/hair/ calcified
material within the cyst.
Acoustic mismatch
Attenuation of the rays
passing through the
above contents.

TIP OF ICEBERG SIGN

Behind these
structures, all appears
dark (sono-opaque)

CYSTIC

VS

MIXED APPEARANCE

Rokitansky noduleorDermoid
plugrefers to a solid protuberence
projecting from an ovarian cyst in the
context of a mature teratoma.
It often contains calcific, dental,

THECA LUTEIN CYST

ATheca Lutein Cystis a

type of bilateral
functionalovarian cystfilled
with clear, straw-colored fluid.

To be classified a functional
cyst, the mass must reach a
diameter of at least three
centimeters.

These cysts originate when

abnromally high Beta-HCG are
elevated, which can occur due
to multifetal gestations or
molar pregnancies.

B/L THECA CYSTS

CORPUS LUTEAL CYST

CORPUS LUTEAL (CL)
cystis a type offunctional
ovarian cyst which results
when acorpus luteumfails
to regress following the
release of anovum.
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 showseithernovascularity

withinthecystorattimesshowlowresistanceblood
flowaroundthecyst

ENDOMETRIO
Ectopic
Endometrium
MA
when present
within the
ovaries,
proliferates
under the
influence of
hormones,
during the
normal cycles.
Seen here, is
the classical
GROUND GLASS
APPEARANCE

Transabdominal ultrasound shows

a multiloculated right ovarian
endometrioma with low level
echoes