28 Ultrasound Evaluation of the Uterus Liina Péder SUMMARY OF KEY POINTS + Sonography is the imaging modality of choice for evaluation of the myometrium, with magnetic resonance imaging (MRI) reserved as a problem-solving technique. “Many mliesian dct anomalies can be accurately diagnosed with sonography, and three-imensional (3D) imaging ofthe fundal ‘contour is diagnostic in differentiating thebicormuateuteres (1 em fundal cleft between the two horns) and the septate uterus ‘Adenomyosis presents most commonly in middle-aged ‘multiparous women with uterine tenderness, ysmenorthea, and ‘menorthagia and most commonly appears on ultrasound images san ill-defined or poorly manginsted area within the ryometrium of thickening of the hypoechoic subendometrial halo, The most specific findings are myometrial eysts and echogenic linear or nodular extension of the endometrium into the subjacent myometrium, + Leiomyoma isthe most common uterine neoplasm. Symptoms are primarily related to location and size. Although most leiomyomas are sharply marginated, well-circumscribed. hypoechoic masse, leiomyomas may be ixoechoic or echogenic relative to the myometrium, + There i overlap inthe sonographic and MRI appearance of leiomyomas and adenomyosisi2denomyomas, andthe entities may coexist ‘+ Lipoleiomyomas are typically extremely echogenic and sharply marginated with posterior attenuation, + Leiomyosarcomas may be difficult to differentiate ‘rom degenerating leiomyomas on both sonography and MRI + Patients with gestational trophoblastic disease (GID) ‘most commonly present with an echogenic endometrial ‘mass contnining numerous «mall cyte and demonctrating ‘increased vascularity. Fetal parts may be seen in partial moles or ‘coexistent tin pregnancy. Myometral invasion can be seen with persistent disease or choriocarcinomas, but on imaging may be dlfcult to diferentiate ftom increased vascularity snd ‘pseudoinvasion’ from the placental bed, arteriovenous malformations (AVMs), or retained products of conception (POO), + Uterine AVMs are most often traumatic in origin but may also be ‘congenital or disgnosed inthe setting of persistent GTD and RPOC. + Sonography may be helpil in the diggnoss of endocervical polyps. However, the sonographic appearances of cervical leiomyoma and carcinoma overlap. OUTLINE Imaging, #47 ‘Malignant Conditions, 866, Guidelines, 847 Gestational Trophoblastic Disease, 865, Techniques, 847 ‘Uterine Sarcomas, 858 Anatomy, 848 Iatrogenic Processes, 871 Congenital Malformations, 852 Arteriovenous Malformations, 871 Benign Uterine Conditions, 857, Intrauterine Contraceptive Devices, 72 Adenomyasis, 857 ‘The Postpartum and Postabortive Uterus, 872 Leiomyomas, 858 Cervical Cysts and Polyps, 878 Lipomatous Uterine Tumors, 866 Conclusions, 878 Sonography is clearly the modality of choice for imaging the female pelvis, including the werus and adnexal structures. In our clinical Inboratory, 2 combination of transabdominal pelvic scanning as well 4¢ teansvaginal examination ie performed in most patients, Thi approach allows the examiner to evaluate the true pelvis in is entirety ‘with a wide field of view on transabdominal imaging, as well as to 846 assess specific structures using high-resolution images obtained on ‘ansvaginal scanning, Primary evaluation with ultasound in conjunc ‘ion with clinical information ie often sufficient for diagnosis and patient management and will help optimize recommendations for further imaging as necessary. When ultrasound evaluation fails to provide adequate information or does not answer the clinical question, Ob/Gyne Books FullCHAPTER 28 Ultrasound Evaluation of the Uterus further evaluation with MRE, computed tomography (CT) sanning, Iysterography 0” saline infesion sonography (SI) ean be performed IMIR of the uterus i discussed in detail n Chapter 36 1 this chapter, we discus uluasound evaluation of the normal unerus, anatomic variants, and benign and malignant conditions. is cussion ofthe normal and sbacrml endometriam in the patent who presente with abnormal uterine bleeding ie presented in Chapter 27. IMAGING Guidelines ‘The American Insite of Ultrasound in Medicine (ATUM) guidelines {or imaging of the uterus have been developed to assist physicians in performing sonographic studies of the female pelvis.’ Knowing the ‘potential, but also the imitations, of wlirazound helps us to maximize the probability of detecting most significant abnormalities, As with any linial test, ultrasound examination ofthe pelvis should be performed ‘only if there is a valid clinical reason, Following the AIUM guidelines, the indications for pelvic sonography includ, but are not limited to, the following: 1, Braluation of pelvic pain 2, valuation of pelvic masses 3, Evaluation of endocrine abnormalities, incleding polycystic 4, Evaluation of dysmenorthes (painful menses) 5. Evaluation of amenorrhea 6, Evaluation of abnormal bleeding 7, Evaluation of delayed menses 8 9. 0 Follow-up of a previously detected abnormality valvation, monitoring, and/or treatment of infertility patents [valuation in the presence ofa limited clinical exemination of the pelvis 11, valuation for signs or symptoms of pelvic infection 12, Further characterization of pelvic abnormality noted on another imaging study 13, Byaluation of congenital uterine and lower genital act snomalies 14, Evaluation of excessive bleeding, pain, oF signs of infection after pelvic surgery delivery, or abortion Fig 2e-1 indentation below she lower uterine segrer 2ppearance of the vagina (short arrows ciceting the level ot ne linear homogeneously echogenic ender 15, Localization ofan intrauterine conteaceptve device 16, Scecening for malignancy in high-risk patients 17, Evaluation of incontinence or pelvic organ prolapse 18, Guidance for interventional or surgical procedures; and 19, Preoperative and postoperative evaluation af pelvic structures! Techniques All relevant anatomic structures inthe pelvis should be identified frst, by transabdominal technique, and then more detailed evaluation of the deep pelvic structures showld be performed using the transvaginal nique. In specific situations when transvaginal evaluation cannot be performed or tolerated, ransrectal or ransperineal evaluation can be very useful ‘The transducer should be selected to operate atthe highest clin- cally appropriate frequency that will allow adequate visualization of deep pelvic structures. For transabdominal evaluation, a 3.5-MHz higher transducer is employed, Curved linear array ansducers, as wel as sector transducers with smaller footprint, are most often employed, or transsbdominal evaluation, the bladder should be adequately distended to displace bowel superiorly ovt of the true pelvis and to provide an acoustic window to visualize the uterus and adnexa ig. 28-1) or transvaginal evaluation, the urinary bladder should be emptied and the patient placed in a comfortable position but with her pelvis tilted either with the use of stieups of by the placement of padding under the patient to elevate the hips. The patent or the sonographer, depending upon the patient's preference, may introduce the vaginal insducer wit real-time monitoring, For transvaginal evaluation, the TUM recommends using probe frequencies of 5 MH2 ot higher (Fig, 28-2). Ifa male sonologist is performing the examination, a female rember of the salf should be present se a chaperone. However, in some clinical situations, a chaperone is helpful and recommended even, for 3 female sonologis., “The vagina, uterus, and the urinary bladder are used as reference points for identification ofthe remsining normal and abnormal pelvic structures. The ulerine size, shape, and orientation should be assessed and documented ia bath sagital (long-axis) and transverse (axial oF short-axis) planes. The endometrium, myometrium, and cervix should be carefully evaluated, and their appearance documented. The werine s.A, Sagital maging plane. Noe rrernal 0s (long arrow, the stated surrounding hyaoecho'e subendemetal helo larrowheods. Nove the acoustic window oroviced by the cis: tended urinary bacer (2. B, ond viens ( ransverse imaging plane. Note the Had (2), rght and let overs (arrows Ob/Gyne Books FullSECTION II_ Gynecology FIG 28-2 Transvaginal gray-scale uk ‘hin brightly eenogen foi visualized halo (arrows) can be a tothe love Feld of view, length is measured in long axis from the fundus tothe external os of the cervix, and the anteroposterior dimension is measured on the same image perpendicular tothe lng axis. The with is measuzed an ether 4 trancaxial or coronal imaging plane. Ifthe volume of the uterine corpus is assessed, the cervical component should be excluded.’ Myo- smelsil masses and contour abnormalities should be recorded in two ferent planes and thet locations recorded. Assessment of the endo- ‘metrium is performed primarily inthe sagittal (or sometimes coronal) plane, Variations of the normal appearance of the endometrium ring different phases of the menstrual cyele and with hermonal supplementation should be considered (Fig, 28-8) and have been {escrined in detail in preceding chapters. Doppler evaluation of the sterus and endometrium can be of added value. 3D imaging is incress- ingly available and can also provide valuable additional information, particularly by providing cozonal image ofthe fundal contour ofthe sterus in women with suspected wterine congenital malformations and to localize leiomyomas. SIS, ora it is often referred to, conobysterography isan innovative technique used to evaluate a variety of endometrial and myometrial processes that involve the endometrial canal, The most common indi= cations for SIS inchade, but are not limited to, evaluation of the followin: 1. Abnormal uterine bleeding 2. Ucerine cavity, especially with regard to uterine leomyomas, polyps, and synechiae 3. Abnormalities detected on transvaginal sonography. including focal (or éiffuse endometrial or intracavitary abnormalities Congenital abnormalities of the uterus Inferlity 6. Recurrent pregnancy loss SIS is contraindicated in women who could be pregnant ot have an active infection, Because the normal secretory endometrium may be thick and simulate endometrial disease, the examination should be scheduled in premenopausal women during the follicular phase of the smensttual cyl, after mensteval flow has ceased but prior o ovulation, no later than the 10ch day ofthe menstrual cycle. Active vaginal bleed sng isnot generally a contraindication but can make imaging calleng- ing or even nondiagnostic” [AC ou institution, we perform a preliminary transabdominal and transvaginal sonogram before SIS, After the procedure is explained to sound images of Ine long arowt representing atact ov mucus between the echo posters layers of the endometrium and the subjacent hypoecne fanechoe tubular etove'e vessels separeing the outer ftom the ier 0 normal vious. A, Sagittal imeging plane. Note subencometral halo (short arrows iste layer of tae myomettum a oked arrow). B, ladder. B, Tansverse imaging alare. The hycoechoie subendometial mn surrounding tne eehogene encornetr um, Nove sgnifeanty maroved resolution {and visvalation of the normel zorel aretomy in these nigh sguerey vansvaginal images in comparison recuancy vansebdorsinal images (Fg. 28-1). However, the transsocorninal mages heve « ger ‘ovding 9 deter overview o! pelvic stuctures, the patient, the external ois cleansed before catheterization of the ‘cervical canal using aseptic technique. A sonobysterography catheter (shed with saline to remove any aie bubbles) is then advanced into the endometrial canal, Once in the endometrial canal, the balloon is inflated (preferably with alin rather than air to avoid shadowing) so that the catheter does not become dislodged. However, some clinicians prefer to usea catheter without a balloon. The speculum is removed, and the transvaginal probe is teinserted adjacent tothe catheter. Under ‘ultrasound guidance, the balloon is gently retracted to occlude the internal os. Sterile saline should be administered under reali sonography. The amount of saline introduced s variable, often between Sand 30 mL. Normal anatomy and abnormal findings should be doce: ‘mented in two separate imaging planes using a high-frequency trans vaginal probe, and the endometrium should be fully evaluated from ‘one corava to the other (Fig 28-4), Additional techniques such as color Doppler and 5D imaging may be helpfl in evaluating both normal and abnormal findings ‘Anatomy The ters isa hollow oganin which the myometrium ie iemly adhe. ‘nt to thin internal layer of endometrium. Externally the uterus is embedded between the two lyes ofthe broad ligament Anatomical, the uterus lies between the bladder anteriorly and the rectosigmoid «colon poseriony. The uterus is divided into two major pat, the body for corpus and the cervix. The most superior aspect of the uterus is refered (o asthe fundus andthe area where the fallopian tubes enter {nto the uterus is referred to a8 the cornu. Anteriat co the fallopian tubes ae the ound ligaments, one on each side, which extend antro Intrlly coursing through the inguinal canals and inserting onto the fascia ofthe labia majora. The uterus has a dual arterial blood supa ‘The majority of the blood supply comes from the uterine arteries, which arse from the internal iiae arteries, anda minor soure of blood supply is the ovarian arteries. ‘The were most often anteverted and antelexed (Fig. 28-5), but itmay alo be retzoilexed (Fig, 28-6) orreroverted (Fg, 28-7). Deseip tions of flexion refer to the tlationeip of the body ofthe wtervs to the cervc atthe evel ofthe internal os (usualy the ange is about 270 degrees, whereas version reles lo the cervical eelationship to the vagina. The cervix ofthe uterus is fixed in the midline. However, the body af the uterus canbe mobile and uterine pestion and orientation Ob/Gyne Books FullCHAPTER 28 Ultrasound Evaluation of the Uterus Menstrual _-Basall ands FIG 28-3 A, Disgram deviting normal develoarvent ofthe endomettium during the mensirval, pl feratve, tnd secretory chases, Inthe "nansttal ahase, he endometrium eppears a3_8 thn, imegular rteraoe, The enrol echagenie'ty arobebl aes ftom slough issue ana blo, In the pralfesive prose, he endome. ‘rum ig reli vely hypoechae, Ikely@ raiectan of the stright anc orderly arrangement of ine glandular elements. The conial thn, echogenic Ine is Ikely 8 soecula” reflection rom the endometrial surfaces. In ‘he sscratary ahase, the ancoretrum achieves ts maximum inckness anc eovegene'. Th’ spaeerence is trom the distended and torivous glonds, wien conten secrevons. B, Pasimensitvel vensvaginel sagitl image of the utoru tng the normal thn homogeneously echegen'c early proliferate endome: om (calipers ©, Transvaginal sagival moge of the perovlatory endometium, A tiveelovered endome: rrumis S00, ging the endometrium a stated gnpearance: th sd endome:ril lumen sdemonstrateg by the ory thn central eerogenic Ine {thin arrow, The surtounding hypoeeroie lier rooresening the fdematous ‘unctionals andematrum (thick arrow and an outer nyperecnoie lar ng the basal endometrium larowheads are seen. D, Transvaginal seital image of the secretory endorsetism. In the tary stage othe manstrul * 25 thick and mare horrageneausly fecnogerie, (A rom Flesener AC. Kolemers GC, Eniman 85: Sonograahe gepicion of the endometr urs Sung normal cycles, Ultrasound Med Bil 12:27', 1886, Pergamon Jourral Lia, Reonntec by permiss of Elsevier Seionce. Copyright 1886 by Weld Federation of Utasourd in Medicine and Biology:SECTION II_ Gynecology FIG 28-4 Sal catheter balloon ed sonanystercgram. A, ransvaginal sagital image row positioned inthe favor endocervical canal, Anecho¢fud 'in Canal anc wer encomettal cavity (e) B, Transvaginal epttal image star aalne infusion. The nerral thn fechoger © endom Note several smal round anechowe s ‘Yum, These ote the arcuate vessels ard we rium ig wel seen cvcumterentaly, The endomerrel cay is flee with enechoie fu, sina linear configuration in Ie filin wi 2 posteror wall of the myame- ‘olor Doppler. €, A coronal three.d mensional constuction ater salne infusion, emonstrating the normal regular thin, echogerie endometrium wi'nou any iniecevicary abnormaltes. Dy Ie compar so infusion revealag @ 100% nt fendometum, say change with varying degrees of bladder and rectal distention, Retroversion and retroflexion are not infrequent in the nongravid state In such cases the fundus ofthe uterus is positioned in the sacral hollow. During pregnancy the uterus enlarges and physiologically undergoes reduction by the 14th to 16th weeks of gestation. The fundus of the uterus then rises into the false pelvis, If this fils to happen, the uterus becomes “trapped” in the sacral hollow, often referred to as “incarcerated In czes of incarceration of the uterus, the cervix is drawn upward either against or above the symphysis pubis, resulting in distortion of the bladder and urethra as the gestation progresses. The posteriorly positioned fundus can cause pressure on the rectum. Typically patients present between the 13th to 17th weeks of pregnancy with symptoms of bladder outlet obstruction. A history ‘of multiple rps tothe emergency 100m for bladder outlet absteuction should raise suspicion A constellation of thee findings on sonography is diagnostic of an incarcerated ler: e pregnancy is deep within the cul-de-sac, .e maternal urinary bladder lies anterior rather than inferior to the uterine corpus and marked bladder distention is noted. 3. A sofl tissue structure (the cervix) is seen Betveen the bladder and pregnancy: This appearance can be misconstrued 36 an empty sterus associated with an ectopic or abdominal pregnancy, coronal th ‘vtary leiomyoma larraws), separate trom e-dimensionslreconsttucton ever salne nin, regular echogenic Failure (o recognize an incarcerated uterus can result in compromise ‘of the uterine cteulation, leading to spontaneous abortion ot even Uterine rupture. If recognized early, manval uterine repositioning is ‘usually possible ( ) ‘The shape and size of the uterus vary throughout lle, affected ‘mostly by hormonal status. The mean measurement of the prepubertal ‘uterus is 2.8 cm in length and 0.8 cm in maximum anteroposterior simension, with the cervix accounting fortwo thirds of the total ength and contributing to the pear-shaped appearance ( ) Weis important to remember that ia the immediate postdelivery state, the ‘neonatal uterus can be slightly larger owing tothe effects of residual ‘maternal hormones, For the same reason, the echogenic endometrium is well seen and a small amount of fluid can be present in the endo: retrial cavity From birth until 4 years of age, the uterus decreases in size, At approximately & years of age, the werus starts to grow preferentially in the fundus. The uterus continues to grow for several years after menarche until it reaches the mean dimensions of a reproductive age ‘uterus, which are approximately 7 cm long and 4 cm wide. Parity increates the size ofthe uterss, with a mltipsrous uterus measuring approximately 85 cm by 55 em, Following menopause, the uterus decreases in size, The decrease in, sine is related to the number of years since menopause, although the Ob/Gyne Books FullCHAPTER 28 Ultrasound Evaluation of the Uterus FIG 28-5 A, Illustrator demon sniover normal virus. The ceri is pointing slaty more aosterior i rela Ship to the vagie, ana the funous is flexed anteror in relation cervix, B, Mal ne sagitel sonagrar demonstrating enreversion of she laces tne fundus vating a1 anteloxed, from James 8. Cooner, M2, Sen Diego, CA reduction in sie is believed to be most rapid during the first decade following menopause, The length of the normal postmenopausal uterus has been reported to range from 3.5 to 6.5 em and the antero posterior dimension from 1.2 to 1.8 cm. ‘The normal myometrium is composed of three layers. The inner most layer, immediately subjacent to the endometrium, isthe thinnest and is relatively compact histologically. This layer is ako both hypo: vascular and bypoechoic when compared to the echogenic endome ‘sium and surrounding middle layer of the myometsium. This layer is often refered to as the subendametrial halo and may not always be visualized sonogeaphically. Sometimes, small extremely echogenic foci, uevaly less than a few millimeters in size and without posterior shadowing, ae seen in the inner myometrium at the endomé ryometril interface, These foci ate thowght to represent dystrophic calcifications due to previous intrauterine instrumentation and have FIG 28-6 A, llustraton demonstrating 2 srerus. The cervix 's in conventonsl aesiian * felatonsha to the vagina, However, tho Uterine fundus is lexed aostorcly at the lavel of :re internal os in ‘lation to the corvx, B, Wiclne sagt transvaginal sonogram cemon= ‘stating uterine revvatiexon. Uterine fundus (F) 1s positaned posterior ‘etotlexed 9 ‘elton 70 she cervix (Cx), Note enguleton setvaen canal ard thin echogenic encometr um iowing tothe exon. UA om James A, Covper, MD, San Dego, CA) ‘no clinical significance. The middle or intermediate layer lies between the subendometrial halo and the arcuate vesels, Thit isthe thickest myometrial layer and is normally uniform and intermediate in echo- enicty. The outer layer les peripheral to or above the arcuate vessels, This layer is relatively thin and slightly less echogenic compared tothe intermediate layer in most patients. The cervix is measured from the internal os, identified by narrowing or “waisting” of the uterus at he junction ofthe ower verine segment with the cervix tothe lps of the external os, which can be seen to project into the lumen of the vagina, The central endocervical canal is echogenic and continuous with the endometsium. The surrounding fibrous cervical stroma is quite hypaechoie and is continuous with the subendomettal halo, if present. The outer cervical muscular layer is continuous with and simular in echogenicity to the intermediate layer of the myometrium ig. 28-10), ‘The arcuate veses separate the outer layer feom the intermediate layer of the myometrium, The arcuste veins ae larger than the arcuate arteries and are potentially compressible with excessive probe of manual pressure, The arcuate vessels (particularly the veins) can be prominent and mimic cystic changes, This potential misinterpretation ‘an easily be clarified by using color Doppler imaging (Fig. 24-11,SECTION II_ Gynecology FIG 28-7 A, lsiration demonstotng uterus the cers ' angles slghtly posteriori reletion ta the vegine, end the funcus is bent slghily easter orn relation to the cers, ndicatng reloflex on a8 inal sonagram demonstrating posterior rié posteior angular of the cervix ‘oper, MD, San Diego, CA ‘The arcuate arteries branch into radial srteries that penetrate the {intermediate layer and reach the level of the inner layer. The ateuate arteries may calefy in postmenopausal women, and this process can bee seen earlier in diabetie patients, This change is considered part of the normal aging process (Fig. 28-12), CONGENITAL MALFORMATIONS ‘The incidence of congenital millerian duct anomalies is estimated to be approximately 0.5% in the general population, However, they are more often diagnosed during workup for infertility, fequent misear- Flages, or menstrual disorders. Pmbryologically, the two paired mil Jerian ducts ultimately develop into the fallopian tubes, lerus, cervix, and the upper two thirds to four fifths of the vagina. The lower one fifth to one third ofthe vagina and the ovaries have a separate embryo= logic origin. Uterine malformations arize from three different causes failure of development of the millerian ducts, failure of fasion af the llerian ducts, of filuse of resorption of the median septum (Fig, 26-13). There isa strong association of upper urinary tract anomalies ‘with congenital uterine malformations. These anomalies have been reported to be most common in patients with hypoplasia or agenesis, occuring in a8 many a¢ 30% to 40% of pasients, Isplateral renal agenesis and ectopic pelvic kidney are most common, Ob/Gyne ly developmental fluze of the mlilerian ducts can gesult in agenesis or hypoplasia ofthe proximal two thitds ofthe vagina cervix, and uterus, being part of the Mayer-Rokitansky-Kister Hauser (MRKH) syndrome. This syndrome is an extreme form of millerian ‘duet anomaly with complete agenesis of the proximal vagina and anomalous cervix and uterus and patients stally present in early puberty with primary amenorrhea. The ovaries are normal but the fallopian tubes may be closed and the uters ie often anomalous, The vaginal aplasia can vary from complete absence to a blind-ending ‘pouch. Associated renal anomalies ate common, in particular absence for ectopia of the kidney. Because there can be subtypes of MRKH, symdrome as well as overlap with other rare millerian duct hypoplasia! aplasia syndzomes, itis important to describe findings rather than ‘ying to fi them into a strict category, MRI is wally the most helpful imaging modality for diagnose of thie enty given the complex spec tum of findings. Most important is communication with the clinical ‘team regarding the elevance af findings and preoperative planning ‘Arcested development ofthe millerian ducts can aso cause terine agenesis or hypoplasia. This abnormality may present a vaginal, ervi ‘al, fundal, tubal, or combined agenesis or hypoplasia, ‘Complete or partial agenesis of a unilateral millerian duet leads to development of a unicornuate uterus witha single fallopian tube (Fig 28-13). The unicomnuate uterus accounts for approximately 20% of all millerian duct anomalies, In some cate, rudimentary horn on the opposite side can be seen, This rudimentary horn may or may not communicate with the endometrial cavity in the normal side. I there is no communication between the endometrial cavities of the rudi ‘mentary and normal horns, retrograde menstruation may occur, leading tothe development of endometriosis. Ectopic pregnancies may also rarely occur in the rudimentary horn, Such ectopic pregnancies ‘an lead to massive hemorthage as they can grow to relatively large size before rupturing. Therefore ifa rudimentary hora is documented, surgical resection is usually ecommended. The poorest fetal survival among all mallerian duct anomalies has been reported with the uni ‘comuate uterus. Spontaneous abortion has been reported to occur in 3496, preterm labor in 20%, and intrauterine demise in 10%."* The live beth rate is estimated to be only 50%.’ The unicoravate wterus seems to be the most dificult mullerian duct anomaly to confidently diagnose on sonography because it can be confused and misdiagnosed asa small uterus. Looking for the contralateral rudimentary horn, ‘whieh can be filed with blood, may sometimes help. The rudimentary hhorn may have a distended and dystrophic appearance and should not ‘be mistaken for an adnexal mace. MRI is considered the study of choice {in resolving these complicated situations, Recently 3D vltrasound has ‘been reported to be useful in diagnosis, allowing visualization on the ‘coronal imaging plane of a single asymmetric endometrial cavity that ‘slaterally deviated, with or without a rudimentary horn. Forty percent ‘of cases are reported to have renal anomalies, typically ipsilateral tothe rudimentary hor, most often renal agenesis or pelvic kidney:* ‘Complete failure of fasion of che mollerin ducts leads to develop ‘ment of two separate uteri, each with its own cervix, termed uterus 60%), making accurate and specific diag oie of the cause of symptoms more dificult. ‘The imaging features of adenomyosis derive from the presence of, the ectopic endometrial glands within the myometrium, a5 well astheSECTION II_ Gynecology surrounding stromal reaction of densely packed smooth muscle ells “This process often results in globular enlargement of the uterus without 2 discrete mase or contour deformity Although focal deno- siyomas caa develop, they are rare and ate walikely to cause a contour abnormality as leiomyomas often do. The previously described sono- graphic zonal anatomy of the uterus is altered inpatients with adeno- siyosis, The eubendometral halo hecomes thicker and more irregular, either diffusely or focally Poor definition of the endometrial myome- ‘vial junetion with pseudo-widening of the endometrial echo complex {caused by heterotopic endometrial issue extending from the stratum buasale. The subjacent myometrium may become heterogencous with areas of increased or decreased echogenicity. Tiny punctate echogenic foci may be noted in the involved atea, Hypoechoic striations may radiate throughout the involved patenchyma and extend posteriorly, believed to be edge shadowing due to the extensive smooth muscle Laypertrophy. Although this shadowing is very similar to shadowing ‘cased by leiomyoma, areas of adenomyosis lack distinet margins and ‘mass effect and are more irregular and less rounded, as opposed (0 leiomyomas, which ae typically round and sharply marginated. Small anechoic cysts, which on pathologie examination correspond to dilated endometrial glands, are often observed inthe subendomettil myome= trium, particularly during the secretory stage of the menstrual cycle. Hyperechoie foci, either linear or nodular, may extend dizectly from the endometrium into the myometrium and are believed to represent foci of ectopic endometrial tisve (Fig. 28-18)-Color Doppler ‘examination can also be helpful in differentiating adenomyosis from leiomyomas, Areas of adenomyosis often demonstrate diffuse hyper: vascularity throughout the lesion, whereas peripheral rather than, internal blood flow is most commonly observed on color Doppler interrogation of leiomyoras, ocal adenomyosis, or adenomyoma, presents with a more atypical appearance (see Fig. 28-18) and is visualized as a focal mass with poorly defined margins, in contrast to leomyomas, which have distinct ‘margins. Occasionally 2 focal adenomyoma is primarily cystic in appearance and may sometimes be found on MR to be filled with blood products. 1 is important to dlferentiate Between adenomyomas and leiomyomas. At surgery, lefomyomas can often be easily separated and removed from the adjacent myometrium, whereas adenomyomas are not easily separated from the surrounding myometrium because of the surrounding smooth mule hypertrophy. Therefore, adeno- yosis or adenomyomas cannot be focally excised for cure Sonography has a reported sensitivity of 8096 to 87% and aspecifc- fty of 94% to 989 in diferentisting between adenomyosis and Ieio- syomas. The most specific ultrasound findings ae the small anechoie myometrial cysts (seen best in the second half ofthe menstrual cycle) and the echogenic linear striations oF nodules extending from the endometrium into the subjacent myometrium. Myometrial contrac tions can cause heterogeneity ofthe myometrium and apparent thick ening of the subendometrial halo on ultrasound images and the junctional zone on MRI, thereby mimicking adenomyosis. When dif- ficulties arise in sonographic diagnosis, MRI can be helpful in achiev- ing a more definitive diagnosis. However, focal adenomyomas may be ficult to differentiate from leiomyomas with both imaging madal ties." Im particular, on the rare occasions when an adenomyoma protrudes into the endometrial cavity it will appear identical to 2 intracavitary polyp or pedunculated submucosal or intracavtary Ieio- rnyoma, Some authors consider polypoid adenomyomas a separate entity fom adenomyosis.” Endometrial abnormalities, euch se hyperplasia and carcinoma, are reported to occur more often in patents with adenomyosis.” Rarely, an adenocarcinoma has been reported to arise from within a focus fof adenomyosis. Adenocarcinoma would be very difficult to distin= guich on any imaging modality tom «ypieal adenomyosis without PGmaees) tie Diffsely lobular uterus with smooth extemal vetine contour Asymmetric olobularty yore cysts areasechogeie fs Peoudosrickerng ofthe enometum Dis increase internal vascularity Siated edge shadows/"venetian Bind” shadowing without a escrete Fecal ill defined mass Features that help to detente from liomyomas Smooth extemal contour of ters Minimal mass effect on serosaerdomoviun relative tothe sie ofthe besion Leck of cleifeton defined mains Contal versus porigheralvascuaity malignancy (see Fig 28-18). A more common scenario would be an ‘endometrial carcinoma extending into foci of adenomyosis, I cases in ‘which adenomyosis coexists with endometrial cancer itis very dificult to determine whether the cancer is insinuating into preexisting areas ‘of adenomyosis oi there aze areas of tee myometsial invasion, This dlstinetion is erucal because myometrial invasion is an important prognostic indicator. However, it cannot ahsays be achieved on imaging land can even be very dificult to determine on histopathologic exami nation (Table 28-1). Loiomyomas {eiomyomas (Shrods or myomas) are benign smooth masde neo sms with varying amounts of fibrous Ussue and are the mest common vteine neoplasm, reported it 20% 10 30% of women over 30 years of ag. Leionnyomas ate more common in Affcan-American ‘women. Othe rik ators include obesity, ery age of onset of men struation, and a diet rich in red meat. There may bea genie pedi position, These tumors ae usally make, causing enlargement of the uterus with 3 lobular seal contour unlike adenomyosis, which results i globular but smooth-contoured uterine enlargement. eiomyomas most commonly present wih palpable pelvic mass, uterine enlargement, pelvic pain, anemia, and dysfunctional uterine bleeding. Symptoms ate largely rated to location and size. The vast, rsjrity of leiomyomas are intramural, submucosal including inte ‘autty), or subsea in location. SubserosalIkiomjomas may be ‘exophytic or peduncuated (Fig. 28-19), Intemural leionyomas ae most common butarleastkely tobe symptomatic. On rare ocasions, ancxaphytc leiomyoma wil projectnte the broad igament (italia rmentous) In thes instances, the leiomyoma may diniallyand radio logical simulate an ovarian mass (Fg 28-20) leiomyoma can also arse inthe cervix (sce later). An unusual form of leiomyoma isthe parasitic leiomyoma, a pedunculated suhierosl miyoma that, ifn close ‘contact with an adjacent structure can parasitze the blood supply and ‘even become detached fom the uterus This asitcation of liom: smasistelevanthecause symptoms and eatmentaryacordingto their location and subtype.” However, when leomyamas ac lage, they may ‘be diicul wo das acording to this scheme (Fig, 28-21), Growth of leiomyomas is dependent on estrogen level, Rapid rowan pregnancy is reported in about 50% of patients (Fi. 28-22) ‘When rapidly growing, somyomas cen outgrow their blood ssp resuling in degeneration oF infarction.” Leiomyomas ate sesocited ‘with increased risk early pregnancy aire, especially in women with ‘multiple gestation.” Leiomyomas located in the cervix and lower ‘lerine segment con interfere with vaginal delivery and should be Ob/Gyne Books Fullium. Altrough a simi 0 ‘he increased theokness of of several smal subordom transvagral sonograch image Gorronstrsting heterogensiy of the myemevrum and two acace rmyometraleysislarow with increased through transmission, Such myomerral very specite nding for adenomyosis. 9,6 CHAPTER 28 Ultrasound Evaluation of the Uterus pieal features of adenomyor B, Sagitel sonogram of the uterus venetian Bina” or "eomblice” sviations inthe posterior myer n of stratons may ae seen with kiomyomas, the absence ofa focal mass, 9 posterior wal of the uterus compared io. rial myometrial eysts rake this more character wal and the presence 1 of adenomyosis. BY, Sagal ato deleves ‘0 be 8 rating hterogene y of the myarverrum, which ' also relstvoly hypoeeho c. Nove several ecrogenic Heat ions extencing from shea rm can be sat finding for sdonomyos's "mm inta the myometrium (arrows) and one nedlar ech ‘80, A simi pattern of excometral tissu extending inte he myo resonance maging {VA Ob/Gyne Books FullSECTION I|_ Gynecology FIG 28-18, cont'd C, Trensvagiral sonogram in wth a toval hypoechoic ad On grayscole imeging it een be very d'feuk to dite I edenomyama from en intarurel li yor. D, Color Dapoler image ef the same patent n C, demonstrating increased vascalarty within acenomyoms, Such increased vaseularty woula be atypical or a learyome, E, Another patient with en faceromyor, In his case tne adenamyema is hyperachac lara, indenting aut separte om the endo metrum. F, ensvaginal color Dopoler mege of a aster fof adenomyosis with 5 mass nought to rearesent an edenomsyarna arising in he 3 citfuse adenomyas's. A lege cystic. "ass (asteris!'s seen on the igh, whicn WasCHAPTER 28 Ultrasound Evaluation of the Uterus FIG 28-18, contd G, Axial 12 weigrted MBI mage better demon sttses the extent of the acenomyosisIdfuse low signal intensity of ‘the myomet um) as Wales the mare focal adencmyoma white arrows) with numerous small hyperintense foe. A srmall subtle area of serosal Dreckinrough se noted [nlck arraw, when represants“expaling” of the aderosarcoma depicted as» large high T2W signal heterogeneous ass noted anteriorly lastensi H, Segital posccontrast TIW mage demarsirates tumor extending ftom the vierine wall though she serosal surface ino the anterior pebis larrowsl. The fnal pathologic image demonstratea endometral somal sarcoma with heterogeeous differentiation, FIGO stege Ill International Federation of Gynecology and Obstertst monitored during pregnancy. Conversely, eiomyomas may precipi= ously decrease in size and even infact folowing delivery as estrogen levels drop. As estrogen levels decline in older women, leiomyomas pically regress and thus are rarely symptomatic in postmenopausal patients Leiomyomas are readily recognized on sonography, although the sonographic appearance ie variable. Inthe pas, the diagnosis of leio- rmyomas was often suggested on ultrasound images if the uterus was heterogeneously enlarged, especially if the contour was lobular However, in today’s ultrasound practice, most leiomyomas are readily sdentified as focal, sharply marginated myometrial masses, and a dif- fusely heterogeneous enlarged uterus is more likely to indicate adeno- yosis, Leiomyomas may be hypoechoic, ioechoie, or echogenic relative to the myometrium, although the majority ate hypoechoic. ‘The surrounding myometrium can become compressed snd form 2 pseudocapsule, which can be readily identified on ultrasound images 48 well as MRI ( ). Oceasionally compressed Iympbatics and vessels can create a thin hypoechoic rim around intramural lio myomas ( ). Although small leiomyomas are typically hhomogencous, liomyomas larger than 3 cm in diameter are often heterogeneous (1 ). As leomsyomas increase in siz, they tend to outgrow their blood supply, which leade to degeneration: hyaline, synod, cystic, oF hemorrhagic ( 5). Degenerated leiomyoma: have a more atypical appearance on sonography and MRI ( 5) Degeneration may result in edema with cystic spaces, echo- genic hemorrhagic areas, and dystrophic calcification. Dystrophic cal~ ‘ification occurs predominantly in postmenopausal patients. The cakifiations ean be curvilinear and peripheral or clump-like and will demonstrate dense posterior shadowing. Many leiomyomss demon- strate areas of acoustic attenuation even if they do not contain obvious calefestions. The posterior shadowing may be dense or striated like), This ttenvation is believed to be caused by the ional zone between apposed tissues of different acoustic properties such as fibrous tissue and smooth muscle, as well a refraction from the edges of whorls and bundles of smooth muscle.” This character- istic shadowing is very helpful in differentiating an exophytic leo syoma from an adnexal or ovarian mass. However, the smooth muscle hypertrophy associated with adenomyosis may also cause a striated pattern of posterior shadowing and a similar appearance ( face of the leiomyoma with the ‘normal surrounding myometrium is commen and may help to iden= tty a leiomyoma that ie isechoic to the notmal myometrium, Periph- eral blood flow ie commonly observed on color or power Doppler mages; itis much less common to detect internal vascularity in a benign leiomyoma with color Doppler imaging. ‘Submiacosalleiomyomae may present with menorshagis, meno- smetrorrhagia, and even anemia, requiring definitive treatment with resection, Submucosal leiomyomas can have varying degrees ofinta= cavitary extension. Both size and the degree to which a leiomyoms projects into the endometval cavity will determine the likelihood of successfil hysteroscopic resection. Leiomyomas with 50% or great intracavilary extension are more easily resecled via bysteroscopy. Util recently, sonohysterography was considered the best modality to determine the degree of intracavitary extension of a leiomyoma ( ‘More recently, 5D sonography hae proved to be useful as well ). “Transvaginal imaging may be limited if the leiomyomas ate large for pedunculated. In this situation, transahdominal imaging may improve visualization, MRI is a valuable modality to evaluate lage oF atypical leiomyomas, asthe multiplanar capability and large feld of view ave particularly useful red on p. 866 Ob/Gyne Books FullSECTION II_ Gynecology FIG 28-19 Commen loa as res A. Cooper, MD, San Diogo, CA} FIG 28-20 Trensv mr. A let odnexal sole: mass lasterst and collers)'s seen. Altrough the leation would make one thirk of an ovarian mass, it wes in fect a bread ligament myoma. Us, uterus, Ob/Gyne Books FullFIG 28-21 Classifcation of large lelomyomas. A anc B, When leiomyomas are lage, they may appeet 20 be intramural as wel as ether submucosal or subserosaln locaton. In these twa patients, the lelomyomas {calpers) zpcear:0 heve ther epicenter inthe myometrium, hence they are oredominatelyinvamural in Ioeetion, However, they both extend beyond the ‘OU ofthe uterus, givin as 6 bbuler on‘iguation. Thus, they both eppeer to sal component, These large tr somewhat heterogeneous in eerotoxture, Note the thn peraherel hypoecho'e “1m pertelly encompessing the ery oma nA. leelyrapregen'ing comarasaed rmpnatice or vessels, The lai ens of shadowing, Ikely due to dense forous or colagenous material wi FIG 28-23 Large ute nding compressed ryomerrum lorows| hes crested & psoudocensul, FIG 28-22 A, Longitusinslsonogramin ao 1B weeks! ‘gesteional age. An anterior ower lerne segment le omyare arrows seer, It Goes not absiruet the cervix Idema’ceted by ealioers. Bl ladder. B, Wellcicumser bed, heterogenecus laiomyomas (arrows) in the arava wl of e urs ence 20 28° HG Yne Books Fulla SECTION Il_ Gynecology FIG 28-24 Variable sppearance of uterine biomy nd, welic reumseribed hyooechoic small ier 1 leiomyoma. The ror myometrium is heverogenecus ara more larow eistoring he serosal 2 loomyoma demonstrating pe rayamalarrows with @ near 50% ith retoflexed uterus. B, eral achoganie thin rm eakefiestion, D, Coronal three-car tition after saline infusion comons 12s. A, Sagital transvaginal sonogram demonstrating @ tramaral leiomyoma (arrows) separate (rom the endometrium fongtudial ransaborsinal sonogrars im a patient wh ‘mal morphologic aopearance of the uters is markedly distorted. Tre endometrium could not bs idantfied. An antenor subserceal lei contour projects into the urinary Sacer. G, Transvaginal soregram of sonal recon es.» heterogeneous but predominant echagenie suamueasal Ob/Gyne Books FullCHAPTER 28 Ultrasound Evaluation of the Uterus FIG 28-24, cont'd E, Transvaginal sagitl view of te uterus demonstrating a hyaervascular stalk larows! a's ng trom the posterior mal ofthe uterus ane extending through the encometraleanal ito the endoee'y cal canal "ght side of image). F, Ine nyparvascuar stele (arrowhead i connactea to a wel-cermarcated, h aosteror shedowing ‘mat splays te endocervical conal consistent * the color Dapoler derronstration of the vascular stale hase fines leomyora, G, Irnsvaginalitersverse view of » hypoechoic, slightly lool sh fenexe, Uterus cial "0 the leiomyoma. Tubsler ane ruecutes larrov) be jms and the Uterus cepresort vessels n the bridging lr pedicle sign is often better seen on magnetic resonance imaging (MEll end has be reported toe aresent an 70% of peduneulated biomyoras. H, Axa 7Z-weighies (T2W) MA right pedunculated leiomyoma (F), demensating back (72 dark souigaly flow vows of vessels U, uterus. | Coronal 72W with fet satutaton MAL image demonstacing the nculated ight boom mecialy a splaced uta UJ, and 12 cark FW voids lara mane vascularSECTION IL Gynecology FIG 28-25 Marked cystic parent lesterisk of @ lvoe FIG 28-26 Sogital T2-woighted (T2W) mognetie resonence image onsrating various diferent aut common appearances of kloryo~ ‘mas. small sudmueosel leomyorre impress ng the endomevil canal wth typiea! law T2W signal (small arrows, large anterior ntrammur leiomyars generation Wh areas), an0 3 rak with extremely low T2W signal consistent with internal blood produes in from “red ceganeraton Lipomatous Uterine Tumors Lipomatous tomors of the uterus ae rare benign ncoplasme and ste readily recognized on ultrasound images. The histologic specteurn includes pure lipoma, ligesionyoras, fbrolipomas, and myolipo- 28-30)" A lipaetomyomais characterized histologically by FIG 28-27 Lorge relatively echogenic lomyome demonstrating smal ded areas of cyst rtenory as wel 3s "vs 39, Both of thse features aro quite sim br to ukrasoune the presence of mature lipocytes as well as smooth muscle cells and fibrous tissue. Sonographicaly, these lesions are charactristcally ‘extremely echogenic and l ‘occasionally cellular Ieiomyomat can be extremely echogenic. The rmargins ate typically sharp, but can be lobular, Posterior attenuation may be observed owing to the fat content. Usually there wil be no demonstrable color Doppler flow. Lipomatovs lesione aze usually ced within the myometrium. However, asymptomatic and do not require surgery. Beeause mixed lesions can have a more heterogeneous appearance and les characteristic appear ance on ultrasound images, MRI can be used to confirm the presence ‘of macroscopic fat within the lesion and therefore confirm that they axe benign, MALIGNANT CONDITIONS Gestational Trophoblastic Disease GTD is a spectrum of rate diseases characterized by the presence of abnormal trophoblastic proliferation that includes genetically abaor- ral conceptions with neoplastic potential (i.e, complete hydatiiform, moles [CHMs] and partial hydatidiform moles ‘PHMs] as well a gestational raphoplastic neoplasms [GTNs] or persistent trophoblas tie neoplasia [PTN]) including invasive moles and choriocatcinomas (Wig. 28-514), Rik factors for GID include extremes of maternal age (under the age of 20 and over the age of 35 years, expecially over the ge of 50 years) as wellas history of prior molar pregnancy. Tn addition, {GID is much more comman in women of Asian origin. The presence ‘of a highly sensitive biomarker, betachuman chorionic gonadotropin (hCG), a¢ well as the availability of effective chemotherapeutic rei mens has dramatically improved survival rates. The most common type of GID is the CHM. © 80% of GID, with an incidence of approximately 05 to 1 per 1000.” Ms constitute Patients most commonly present with vaginal bleeding, sometimes with passage of vesicles, and with markedly elevated serum hCG levels, ‘As the diagnosis is now most often made earlier in the fist trimester, hyperemesis and an enlarged uterus for dates are lest commonly ‘observed, The genetic material in a CHM is entirely paternal in origin, ‘Most CHM have a 46.XX diploid karyotype secondary o fertilization of a genetically empty egg by two haploid sperm, At pathologicCHAPTER 28 Ultrasound Evaluation of the Uterus FIG 28-28 Saline infusion sonohysterograohy (SIS| in two patients with submucosal, oredomirantlyintvocavitary lniomyoras. Ay Sa ‘rom 8 sonchysteragrarn demonstrating & myarna that 8 saachove :0 the myometrium projecting nto the uterine cavity that so sienced wih fila, Mere tnan 60% af the susrrucosal ocrmyoma inte vray. Nete ov in layer of endometrium, wrick halos to diferentete 4 susrrucossl leiomyame from a broed-besed endometial polyp. This leomyoma was resected hysteroscopical Sonanysterogram of anorne” patent with @ submucosal lecryome Icalpers)projectng into tre uterine caviy. Note parallel Kypeeerce regular bands extonaing tar the arcerior su‘ece of tne leiomyomns posteriorly, socalloe "'veretan bind” shadowing, The dstenced Daloon files with enachoie fd arrow is seen a8 wll on tha mage, ‘examination, no fetal tissue will be identified, The risk of developing PUN is estimated to be approximately 20% following evacuation, However, itis not possible to predict which CHMs will develop per sistent disease by either imaging or pathologic characteristics although women aver the age of 40 years and with hCG levels greater chan 100,000 mallvimL, excessive uterine enlargement, theca lutein ests larger than 6 cm in diameter, and repetitive molar pregnancies seem to be at higher risk for invasion.” Hence, women with CHMs are ‘counseled not to become pregnant fo fll yea following evacuation and are followed carefully with serum hCG levels. 'PHIMs are the second most common type of GID.” Patients with, PHMs typically have less trophoblastic proliferation, milder symp: toms, and lower hCG levels. Most PHMS have a 69,XY¥ or 68,XXY triploid karyotype and wil have fetal tissue identified on pathologic FIG 28-29 Three-dimensional mage cf 2 suorucaslintracatarylio- yom (asterst indenting the ecregeric encometrum. (Courtesy of Dr Beryl. Beracerraf, Boston, Mi! ‘examination, These patients are estimated to have a tsk of approxi= nately 5% for developing PIN. Sonography is the primary imaging modality used for diagnosis, and many eases are detected incidentally during first timesterulte- sound examinations, MRI is reserved for problem solving, primazily for assessing the extent of uterine invasion and residual disease belore and after treatment. However, st can be difficult on both MRI and sonography to accurately identify myometrial invasion, Distinction between CHM versus PHM is important, given the higher invasive potential of CHM, The typical ultrasound appearance of CHM in the late first oF second trimester is an enlarged ulerus with the endometrial cavity distended by an echogenic, vaculae mass containing clusters of tiny cysts (bydropic vill), sometimes described as the “snowstorm” of “cluster of grape:” appearance. There are no vile fetal parts, The esence of theca lutein cysts im the ovaries may help confirm the agnosis. However, in today’s practice, theca lutein eysts are intr ‘quently visualized, most likely because patients are imaged and diag~ nosed at an earir gestational age Early in the frst trimester, there i 8 spectrum of sonographic findings ranging from a thickened endo smetrium without a discrete mass oF eytie ateas to the more dase appearance of an echogenic endometrial mass with the so-called “Custer of grapes" multcystic appearance (Pig. 28-31B, C1, and C2). Classically color or power Doppler imaging will reveal increased vas- culaity within the endometsium or mass, However, not all molar pregnancies will demonstrate increased vascularity on Doppler Ob/Gyne Books FullSECTION I Gynecology Ob/Gyne interrogation ( ). Barly in the ist trimester, CHM. ‘may not be distinguishable from a normal ot failed eat'y pregnancy ¢ and ), and corzelation with serum hCG levels is paramount as well a genotyping of the products of conception if ‘evacuated.* Interestingly, detection of CHM at an earlier gestational age does not appear to change the incidence of postmolar GINs.” This supports the concept that the diagnosis should not be reached in haste Dat only after careful correlation with imaging, laboratory, and clinical findings PHM has 2 similar ultrasound appearance to CHM, except that either normal or abnormal appearing fetal pats willbe also identified 0 5). However, there is 2 spectrum of disease, and CHM has ‘been reported to oecus in conjunction with 3 normal live twin fetus f ). The presence of myometrial invasion or retained ‘endometrial tissue on the frst follow-up examination after evacuation hasbeen reported tobe predictive of risk of GIN ox PIN ( ). ‘Dedicated pelvic MRI is superior to sonograply forthe detection ‘of myometrial invasion and is used to assess for myometrial invasion ‘a well ax extrauterine extension. The appearance of CHM on MRI is described a5 Tl-weighted hypointense, T2-weighted hyperintense ‘issue/mass with disruption ofthe junctional zane and enhancing mul ticysti issue within the enlarged uters ( ). However, Ihypervascuavty in the myometzal wall is not predictive of invasive disease and can be seen with normal implantation, RPOC, and AVM, Uterine Sarcomas Although leiomyomas are most often beniga lesions, leiomyossrcomas do rarely occur. The cause of leiomyosarcomas remains uncertain, ‘Although in some cases i is postulated that leiomayassrcomas develop secondary to degeneration ofa preexisting leiomyoma, most liomyo: sarcomas are believed to arise independently rather than fom a pre ‘existing Iciomyoma.” Uterine strcomas ate «ypicallyexteemely aggressive malignancies with poor prognosis, Hoses, early diagnosis ‘an improve survival rates, and therefore, attention to imaging clues is ‘crucial. Clinealy rapid growth of 2 leiomyoma in a perimenopausal ‘or postmenopausal woman raises the possibility of sarcomatous ‘change or degeneration, Ultrasound findings suggestive of malignancy include rapid change i size, indistinct or infiltrative margin, unusually ‘complex echo pattern, and internal vascularity, especially if the distr Dution of the vessels i inregula. However, these findings are neither sensitive nor specific, and there may be no significant sonogeaphie dilference between a rapidly growing or degenerating myoma and a sarcoma, The intemal architectore can change markedly and the Amount of solid Ussue can even increase in degenerating myomas, although such features raise concern for malignancy: MRI ean be ‘obiained to confirm the avid enhancement of solid components “However, MRI Sndinge ate alzo nonspecific, and i there are no prior studies, Lis very difficult to determine if solid components in a degen crated myoma represent residual viable beniga leiomyoma tissue versus newly developing leiomyosarcom, and surgical resection may hoe indicated. Other signe of malignant degeneration include local FIG 28-20 Spectrum ot lpoleiomyomas. A, Sonogrsm dermonstretng 2 wolimarginated 1.5em focal hyserechote anterior myometal mass lerrows) thet was Ipoleiomyoms. B, Transebory al sonogram der ‘onstratng a large Sem Ipoleiarnyor. This mass s loss echogenic anc more neterogeneaus than the [pele.omyoma a A, Out also deman- strates sore pos:erir linear shadowing. €, Transvaginal sonogram of {Tem extremely hyparachoie mass (asters) arsing “ram the lvver tere segment aosteritly wih marcos poster at the fat content. Ths mass was also a Ipoleiomyorns Books FullFig 28-31 A, rating the saecttum of gastationalraphoblestie neoplesa. 8, Trersvagiel long tudinal mage avy is ciscende: echogen's, cystic material lorow, No 9 6, Transvaginal longitucinal rma inractetne pregne 2ovweok twin ge " fn normal twin loo 1gy ara Biomesica! Imaging,SECTION II_ Gynecology FIG 28-31, cont'd E, Three-dimensional sonogram demonstrating normal fetus F]with CHM (arrowheads) ‘win gestaton. F, Axel T2weighted MRI imege demonstrates an enlarged uterus end endometrial cavity ‘led wth hgh signal eysic areas frrow wth centeal low signal more sole-aopeerng ‘sue [arrowhead G. Axial pos:contrastfatsuparessed Ml image confims central more sol ennancing care (arowheaa) anc suirauneing hcelie ennancement of eysic tse (arrow). No exrauterine extension s seen FIG 28-32 Hydropic degeneration of the alacerse. Ths patent presented witn vaginal aleeding inthe late frst timester. Tre placenta is enlarged, echogenic, ané vascular, with numerous anechoic ‘0 hypoechoic cyste reas, wnicn‘a'sea concer for « molerpregnency. However, unon hstolgic ana genesc analysis, findings were consistent with nycropie degeneration of tne alacents with no evigence o! » mola arograney. sresy Deparment of Onsteics ana Gynecology, Yale Universty Sehoal ct Med cine, New Haven, CT) Ob/Gyne Books FullCHAPTER 28 Ultrasound Evaluation of the Uterus FIG 28-33 Partial mol pregnancy. A and B, Gray-seal ester fr gestation dating. There s an ntvauerine ges line Bi, The erawnrum long) reveals a paral hy! ve thekening of numerous small ests. Courtesy Dopartrer roghoblestie issue anterior tothe of Obst invasion and distant metastases, which are more readily detected on (MRI or CT than on sonography ( IATROGENIC PROCESSES Arteriovenous Malformations AVMs consist of multiple communications between the arterial and venous systems without an intervening capillary network. ‘These lesions can be congenital, but are more often iatrogenic as a result of intrauterine instrumentation orate secondary to trauma, malignancy, ‘or infection, Specific causes include miscarriage, therapeutic abortion, dliltation and curettage, cesarean delivery, carcinoma of the cervix ot endometrium, uterine infection, trophoblastic disease, leiomyomas, ‘endometriosis, and uterine surgery” Acquired AVMs consist of mul: tiple small arteriovenous fistulas (AVES) Patents most often present with excessive of dysfunctional uterine bleeding, and sonography is ‘often the first imaging sudy performed, Color and duplex Doppler sonography have very characteristic findings. Serpiginous cystic areas ‘or tangle of tubular anechaic blood vessels can be seen an gray-scale sonography; they fil in with avid flow on color or power Doppler imaging. High-velocity,low-resistance (inereased end-diastolic veloc ity) waveforms inthe feeding artery and pulsatile high-velocity How in the draining vein ate seen on spectral Doppler: These Doppler char acteristics overlap in appearance withthe Doppler findings in patients and Biomedical Imaging, Yale University Senool of Medcne, New Haven, CTs le images {rom 2 woman preserting the f atonal sae containing an embryo (dotted blue-green resoonds fo an estimated gosiatonal age of & weeks & days, Note schagenie apheblaste bssue with numerous eysts lite cel iiform mele. € ard D, Ina second patient wit 3. Histologee and genetic anals's 2 pari hysatisiorm mele, note ree ‘embryo larrowsl. The ebnormel issue also contains res and Gynecology and Department of Radiclogy with GID and RPOC, both of which histologically may also be char acterized by small AVE. Therefore, when these imaging findings are seen, GTD and RPOC should always be excluded By measuring the serum hOG level ( ) Peeudoaneurysms (PSAs) may ako develop as 2 complication of intrauterine procedures. They can be distinguished from AVMs by color and specteal Doppler imaging, A PSA will appear on gray-scale imaging a8 an anechoic cystic steucture. On color Doppler, swirling blood flow with a“yin-yang” pattern will be observed.” A“to-and-fto” pattern with fow heading toward the PSA during systole and away from the PSA during diastole will be noted ia the neck ofthe PSA 09, spectral Doppler interrogation, Knowing that uterine curettage or surgical trauma can cause uterine vascular abnormalities such ar PSAe and APVs ie useful when ‘imaging patients with such clinical history and abnormal vaginal bleeding. Recognizing these lesions on imaging is important because treatment ie quite diferent than for other causes of dysfunctional rine bleeding. These almormahtes can be treated safely with ea catheter arterial embolization and may be worsened by uterine curet= tage. Acquired AVMs are reportedly easier to teat than congenital AVMs because they usually have only one or two feeding arteries. In addition, they are generally not fed by extrauterine vessels and lack 2 ‘dus, unlike congenital lesions." In ous experience, iatrogenic AVES that develop following uterine instrumentation such as dilatation and Ob/Gyne Books FullSECTION IL Gynecology FIG 28-34 Persistent vaphoblstic neoplasia (invasive mole. A, Segittal gray ‘oman prasenting with vaginal be by 2 bbulir echogenic mass Ssurrauneing ty feirum i thinned, there s no avidence of ryometral invasion. Ni se image ofthe vers trom ester. The endomet al eavty s markealy dsterdes its) measuring 6.93 em conlsinng numeraus smal eysts, Amough the gestational sac 8s denied. Findings ate most canssient wh » complete hydatid form mole. B, Coler Dopaler imaging 08 reveal increased vasculerty within ‘xe mole tissu. A 1 mor pregnancies, the a sign ican De 13, Six martns‘olowing treatment, the pa lovin loves. Transverse gray-scale image" €; arrows in D) ‘waveform of gestatonal roprobas Velooty with @ lw resist Uroprabbeste neoplasis, unding myomettses Fe curettage (D&C) rarely equite teatment and most often resolve on their own, I they do not resolve and have developed a nidus, they can bee dificult to treat, even with multiple atempts with UAE. In each instances, the nidus may need to be treated direcly (Fig. 28-35C, and D) Intrauterine Contraceptive Devices Contemporary intrauterine devices (TUDs) for contraception ate eaiy vinsalied with tansabdominal and teanrvaginal sonography at brightly echogenic ructues with dence posterior shadowing located within the endometrial cavity, Transvaginal sonography i commonly edo evalvate placement as well at complications such a migration into the myometrium” 3D sonography has been used with great sucess to improve visti in technically challenging stations, as 7) and is now well as to confirm the specific type of IUD (Fig, considered state ofthe art for evaluating IUD placement at most inti- tions.” Tis important thatthe reconstructed image i of the actual TUD and not from the shadow from the 1UD. If an IUD is not seen on sonography and history confiems place- ment, a pelvic radiograph should be oblained to exclude perforation and expulsion into the peritoneal cavity, Blood products as well as products of conception can obscure visualization of an IUD, st raturnag with slate serum human on ‘oval 9 comalex ryometr al mess (arrows and cal ‘aning numerous eysie speces end clesry separate ‘tom tne enaaret” um endometrium leh appeared normal. E, Saital calor D Spectral Dopalar image demons eaplsia characterized by inreased peak systole and enciastolc index (0.50). Fincings are mast consistent with recuen igh increased vasculety s @ common finding detocine boas ow does not exclude ne sagras§ ‘nie gonadc- lor mage vevesls nereased low within the mass fon che classe a Occasionally, an TUD is seen associated with an intrauterine preg nancy. Although IUDs can be easily identified during the first times tex, they are rarely visualized in the second or third trimester of pregnancy. If removal is under consideration, the relationship of the TUD to the gestational sac, whether superior of inferior to the s3¢, becomes important. tie not often that sonography ie wed to evaluate for Essure device placement, because tubal occlusion i usually cont irmed with hystero solpingography, However, ultrasound findings can comment on the proper anatomic placement in the ostia of the fallopian tubes (Fig 28-57P and G). The Postpartum and Postabortive Uterus Not infrequently, the sonologist i asked to evaluate a woman present ing with bleeding or pain in the first trimester or after delivery of Uherapeutic abortion. The question most commonly asked is whether ‘or not there are RPOC or large hematoma within the uterine cavity ‘A basic knowledge of the normal postpartum uterus is necessary to accurately diagnose pathologic com ‘The normally enlarged gravid several days alter delivery” The uterus rapidly decreases in size dluring the frst 1 to 2 postpartum weeks and is usualy back to itCHAPTER 28 Ultrasound Evaluation of the Uterus FIG 28-35 Leiomyosarcams. Postmenopaussl wome) with nistory of stasle degenersting leiomyoms. A, Transatdominal sonogram damensia: ng eyste degenaration of a lernyoms homogeneous internal echoes and increased shrough transmission. B, Trensabdomiel sonogram 2 yee's Istor demonstrates a new mural nodule lealpersl. C, Adal Ti-weigntes with fet satu magnetic resonance ‘mega caronstretes enhancemast of the murel nodule [arrus. Surgisl removal snc pathologic examination revealed lowegrade sarcoma without myarvetral invasion, Ob/Gyne Books FullSECTION I|_ Gynecology uterine arteriovenous malformations (AVMs| inttavierine devce olacerens with al Dapaler demonstrates a large funda iatrog uv pattern with increosed systale ond diastole clsease was exclided by negative human chorionic gonadotropin levels. B, Exactly similar Dogo apcear ance in differen: pation with etsines produets ot conceot an (RPOC], ©, Trensveginel sanagtars 0 23-76 fle woman wre presented with an AVM from previous DAC with persistent vaginal bleeding folowing Lrerine erery embolastion x 2, Persistent damnant vascular niius Wes noted in the enterior myomer demonsiraing 2 high-velocity Iiwesistence specval Doppler waveform. D, After direct :reatmen nis es we 98 repeat uterine artery embolzatian the AVM is ‘ond the vaginl bleed) ssved. Note ecnagenic emtolzatan rateral nthe anteCHAPTER 28 Ultrasound Evaluation of the UterusSECTION I|_ Gynecology rnongravid size by 6 to 8 weeks postpartum.” The endometrium retums to its pregravid state by 3 to 6 weeks postpartum.” Small amounts of uid and echogenic material (likely representing blood clot) may be seen in the normal postpartum endometrial cavity (Fi, 28.38). Brightly echogenic foc, ikely secondary to air, can also be seen within the endometrial cavity and may persist for several weeks postpartum (Fig. 24-39), particularly following cesarean delivery.” FIG 28-38 Trensadcaminal sagittal sonogram in 2 patient 3 days postosrum preserving with more shan expected residusl posiperum blessing. Flud and tissue larrows| are seen in the endometrial cov onsstent with Hemorrhage. There wes no evidence of releined pro of conception FIG 289 Transsbdor nal sagital caseraan delvery, Linacre focus with diy shadowing arronh tonastent with ars sear within tne endoretial caviy inthe {unc ‘The endaratruo was thi and mormel, Ar in tne endometrial cavty can be » normal finding up to 2 weeks following cesarean delvery and fan also be seen normally after vaginal delvery am ina aatient 1 veek ator “The thickness of the postpartum endometsium is variable, raging in fone study ftom a mean value of 15.8 mm on day I to a mean of 55 mm on day 28." Several studies have evaluated endometzal thickness asa potential sign of RPOC."*" Although there does not appear to be a cutoff value above which RPOC are certain, i the endometrium is extremely ‘thin, tis unlikely that there ze RPOC. One study found that in the absence of an endometsial mass or when the endometrial thickness ‘was les than 10 mm, RPOC were exteemely unlikely” Thus, song. raphy appears to be more useful in excluding the diagnosis than in accurately making the diagnosis. A focal echogenic mast i suggestive ‘of RPOC (Fig. 28-404 and B)."*"* This appearance, however, is not a specific or reliable siga, because hemorthage or blood clat may also bbe echogenic.” Doppler sonography has proved useful in some cases to assist in the diagnosis of RPOC.”” Although flows within 2 focal the cistern same pallent cemonsiates markedly increased vasculariy wthn ine tissue cons stent with APO. fendomerral eeviy (caliper. B, Dopoer imag ng of tneCHAPTER 28 Ultrasound Evaluation of the Uterus FIG 28-41 A, Sagal sonogram ‘ror a patiant presenting with bleed ing 1 week postpartum, Tissue lartons was seen wtrin the endome- tnal cavity, when is dstenced, measuring 15 mm. B, Corresponding coke Dopsle imaging demonstrates no evidence of blood fovt withie the tissue arrows, This representa So intracevtary mass ie suggestive of RPOC in the appropriate clinical sting, the absence of flow does not exclude the dingnosis.”™ Placen tal tissue may persist for months after delivery and be 2 source o persistent hemorrhage (Fig. 28-414. and Bh) If the placental tissue is ‘quite sizeable, there is usually an clement of placenta acces (Pig, 28-42A and 5). In all cases of persistent vaginal Bleding in the postgravid state, when a large amount of tissue is seen within the endometsial cavity, the disgnosis of GID should be considered, although itis much less likely than RPOC (Fig. 28-3A and 5), Clinical correlation as well as correlation with serum hCG levels is often diagnostic in excluding (GYD, ae the hCG level is much higher with GID than with RPOC FIG 28-42 Transvaginal sagt wth continuous vaginal Blea predomnanily hyaer Uterine func. By | sonogram from 2 eationt presenting 2 months ater delivery A, A complex locity lon © sole mass lavrows was se pr evelustion dermonsirates high nis nas retained slacenal tssve, In summary, we have found at our institution that there ie sgnific cant overlp in the gray-scale and Doppler findings of RPOC and AVMs ae well ae GID. MRI is not generally wsefel in differentiating between these entities, Statistically, RPOC is by far the most common, ofthe three. Hence, every case should be addressed individually and coreelated both with the patient’ symptom as well as serum hCG. levelEE SECTION II_ Gynecology CERVICAL CYSTS AND POLYPS ‘The normal zonal anatomy ofthe cervix is well appreciated om trans- vaginal imaging. The endocervieal canal and mucosa typically appear as. canteal echogenic linear stripe that is continuous With the echo= genic endometrium in the body of the uterus, The endocervical canal ts generally thin and homogeneous in appearance without varistion in thickness along its length, although smal eytic areas ae occasionally observed, ikely representing dilated glands, The subjacent fibrous cer vical stroma appears as a markedly hypoechoic band of variable thick ness and is continuous with the subendometrial halo in the body of {he uerus, Hormonal simulation does not appeatt alfect the appear ance of the fibrous cervical stroma, The outer muscular cervical layer fs intermediate in echogenicity and is continuous with the middle and outer layers of the myometrium (see Fig. 28-10). Nabothian cysts, rewention cysts that develop secondary to ebstruction of the cervical glands or erypts, are common incidental findings and are usualy asymptomatic. They can be found anywhere along the length of the endocervical canal and can vary in size and number. On ultrasound images, nabothian cysts are most commonly anechoic, well- circumscribed, and avascular with incteased through ansmission, consistent with the sonographic appearance of simple cysts (Pig 24-43), but internal echoes may be observed oving to mucus, debris, and rarely infection Endocervical polyps are most common in premenopausal women ‘over the age of 20 years who have been pregnant. The exact cause is rot known, but chronic inflammation and elevated estrogen levels have been reported to be predisposing factors. Patients may present ‘with vaginal Dleding, although many are asymptomatic, On ultra sound images, an endoluminal cervical mass will be identified, The presence of varculaity ora vascular stalk vl dffereniate endocervical, polyps fom debris, blood clot, ora mucous pg (Fig. 28-42) I large, an endacerveal polyp may obstruct the endocervial canal, resulting in hydrometrocolpes, or may prolapse into the vagina. Cervical leio- syomas appear on ultrasound images as well-crcumscribed masses of variable echogenicity and are typically relatively avascular. They ‘most commonly ase fom the muscular layer snd, hence, ate most commonly exophytic and separate from the endocervical canal (Pg, FIG 28-43 Nabo numerous enechoio severe demonstrating ineteesed through vansmission 28-45), However, the sonographic appearance of cervical liomyomas is nonspecific and may mimic the sonographie appearance of cervical Ultrasound imaging does not play a significant role inthe sereen- ing, diagnosis, or staging of cervical carcinoma, Sereening and diag nosis are performed effectively with Pap (Papanicolaou) smear and ‘cone biopsy, with subsequent staging performed clinically according to the International Federation of Gynecology and Obstetrics (FIGO) staging system (see Chapter 35), If further imaging is requied, itis usually performed with MRI to astess extent of local disease and. Iymph node involvement, or with CT to astes fr lymphadenopathy. and dist netasases. However, sonography may occasionally be the fist imaging modality performed in a patient who presents with, vaginal bleeding or pelvic pain and can also be used to assess com: pliestions, On ultrasound images, cervical cancer wil appear az a mass of variable echogenicity, Rough tumors may be well defined and sharply marginated, specially if small and early stage, cervical cancers wil often infrate and obliterate the normal zonal snatomy of the cervix, and in particular distort the endocervical canal, which is where cervical cancers originate. Differentiating a small, well circumscribed cervical cancer from a cervical leiomyoma on ultra sound imaging is extremely dificult, although increased vascularity and heterogeneity favor the diagnosis of a cervical cancer. Larger masses may ob: it the endocervical canal, resulting in hydro- or hematometzocolpos, and irregularity of the outer margin suggests parametral invasion (Fig. 28-15). CONCLUSIONS ‘Sonography remains the Srs-line and most valuable imaging modality for the evaluation of uterine anatomy, as well a: most benign and malignant processes of the myometsium., However, imaging findings should always be coerelated with th clinical scenario. Ifthe ultrasound findings remain equivocal, MRI is recommended ae the next imaging modality of choice in most cases. Correlation of imaging findings Detween the two modalities and expertise of the reader remain para mount for achieving an accurate diagnosis, ysts of varying sizes along the length of the carvx Ob/Gyne Books FullCHAPTER 28 Ultrasound Evaluation of the Uterus nied ucous plug, and ral vescularity ane FIG 28-44 Endocorvcal palyos. A, Transvaginal gray-scale image of she corx omen: Icalipers| within the endovervesl Gena. Tae aferentl dlagnasis includes blood clo debris as wel as endocervical nelyp.B, Corresponding color Doppler image reveals in fe feecing vessel, confriming that ths 's# soft taaue Pass, most HkeWy én encocervicel aol rather than blood clo: or mucous alug.€ and D, Sagilal nd iranaverse vansvaginal gray-cale mages o! tne ceri ror> snotner pater: wit «large, slghtl heterogeneous encacervieal op lerows! distending the endocerviel Ob/Gyne Books FullSECTION II_ Gynecology Fic 28-45 posterior wall of cervx aut seastae ror the endocervical coral, which appears normal, suggesting that ths ' no! cereal 2 lesion arising from the ruscular Ia rium (calipers fom the enter but extending into the lower leiomyara, 1 the poste st below the level of te internal 09 lerow at indentation © lower uterine segment and upper carve, endometnum. © and D, Sagittal anc transverse trarsveg nal grayscale images tom a nt patins wich on axopnye ery eal ear from the encocerical canal, when s daterded with arechy fexiends into the lower uterine segment. b, blacder. E, Seg ‘at setuction magnetic nance image of the same patient as C and O cemenstates smlar incngs. Low signal intensity cery= cal leomyore (asterst extends ino the lower uterine segment; encocervieal canel is csterded with nigh ‘signal iniensty fu lar. 6, Sacer. Ob/Gyne Books FullCHAPTER 28 Ultrasound Evaluation of the Uterus FIG 28-46 Cones! cerinoms. Sag ol grayscale IA) and color Doppler (B) images o' heterogeneous wellde‘ined, sharaly marginated vascular cervical mass compressing the llac vessels pos troy. The endocervical cena arrow in Als dsolaced anteriorly ana perelly ablrerated, suggesting thet the mass might have originale from tho endecervcal cana Sr Lrrine segrnent or vagina, sthough he mass i lage. However, noris tre extension fo ether the lo ‘he soregraphe apaearence is nansoecie and could be rimicked ay 2 cerveal lecoryoms, REFERENCES 1. American Istiute of Ultrasound in Medicine (ATUMD; American Collegeof Radiology (ACR); American Collegeof Obstetricians and Gynecologits (ACOG); Society for Pecatvic Radiology (SPR) Society of Radiologie in Ultrasound (SRU); ATUM practice guideline fer the performance of th ultrasound examination of the female pls Fleas Med 33051522130, 2014 American Inttate of Ulteasound in Medicine (ATUM): American Collegeof Obstetricians and Gynecologists; American Callege of Raciology: TUM standatd forthe performance of ean infusion onohysteropraphy J Ulrarud Med 22(1121-126, 2003 4, Sample WE, Lippe BM, Gyepes MT: Grayscale ukraconography of ‘ormal female pels. Railgy 125477, 197 ‘Merz, Mri-Teanic D, Baba Fal Sonographic sie of uterus snd ovis in pre-and postmenopausal women Ulraound Obstet Gynect 738, 1996 Miler, Thomas RH, Lines P'The atrophic portmenopasil utr 1.Gin Utrwourd $261, 1977 eke SC, Courier J, Qayyum A: Imaging of mallertn duct anomalies Rauiogrphis 32(6)233-8250, 201. Reichman D, Laufer MR, Robinson BK: Pregnancy aucomes in unicorauate uteri review, er tr 91:1886-198, 2008. Smith NA, Laufer MR: Obstructed hemivagina and ipelteral ena! anomaly (OHVIRA) synérome: management and follow-up, Fert Steril erases, 2007 Schlome B,RodrguerF, Baskin L: Obstructed hemivagina and pelea renal agenesis COHVIRA) syndrome shouldbe redefined as ‘palserl renal anomalies cases of rmapomtic atrophic and deplastic idney with ectopi reer to obstructed hemvagin, J Pediatr Ura 1177, 1-6, 2015 10. Gell JS: Mseriananomabes. Sein ep 11. Protr JA, Haney AF Recurrent fst weimester pregnancy os i ssvoeated wih eine sept bt not wilh Bieornuate ler. Be ‘Str 01212-1215, 2003, Med 21(4):375-588, 2008 12, Daly DG, Maier D Soto-AlbersC:Hysteroscape metrplaty: six year? experience. lster Gnecol 78201 1988. 15, Saravelos SH, Cocksedge KA Li IC: Provlenee and diagnose of ‘congenital sterine anomie in women wit productive fate: & tel spore Hare Reprod Update 1415~129, 2008, 14, Kubik-Huch RA Female pelvis. Eur Rao! 91715, 1999 15, Andretti RF The sonographic diagnosis of adenomyosis, Ultrasound Q 2567, 20, 16. Chopra, Lev-oalf AS, Or Bergin Ds Adenomyosis commen and uncommon manifestations on sonogeaphy and magnetic resonance imaging, } Uliasound Mad 25:17, 206, Ob/Gyne 3 Kuligowa Pet ain overlooked and underdiagnoeed gyneclogic ondtions Radiographs 253, 2008, Braot M:Ultsronogeaphy compared wth magnetic resonance imaging forthe diagnosis of adenomyosis concation with histopathology. 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Mt Sebte NJ, Psher RA, et a Getsonal rophoblvti irene: ESMO clinical practice guidelines for diagnosis, estment and flow vp. ‘nn Oncol 24(Supp 693-50, 2013, BenischkeK, Burton GJ, Bueigen RN: Puhology ofthe Human Placenta 6 Seti, 2012, Springer Berkowit RS, Goldstein DP; Curent management of gestational teophoblaniedzeve esl Ones 123654662, 2008, Kai KK, Lee JH, Dighe Met a Gestational wophobasic disease rulimodakty imaging secerment with special empase on spectrum of sbnormallties and valle of imaping in sping and management of hseae. Cur Probl Dag Rail :t=10, 2012 Sun SY, Melamed A, Golétein DP, ea: Changing presentation of complete hyatiiform mole tthe New England Trophoblaie Disease Center over the pat tice decades: doe extly gnosis aker rik for _estational trophoblastic neoplaa? Gynecol Once 138(1) 46-4, 2015, Malek Se Moradi 8, Mouse AS, eal Complementary role of uitrvound in management of getatonal rophoblsi diese. Iran 7 aol 121213955, 2018, Pravin RA, Hast WA: Pathologie considerations af serine mooth smc tumors. Obstet Gynecol Clin North 22687, 1995. CastonAsagon I, Aragon I, Ureayo Bea: Conservative management ofa uctine teiovenous malformation diagnoved in pregnancy 7 Uhr Med 23-110, 2006 Kwon JH, Kim GS: Obsteteic iatrogenic ates inune ofthe urerus: Akagnosi with US and sestment wt sanventheter arterial embolization. adgeaphies 235,200 Books Full