Obstetrical ultrasound -It is used to confirm gestational age and viability; to detect and characterize

abnormalities on the fetus, amnionic fuid, and placenta; and to assist with diagnostic and therapeutic
procedures.

Ultrasound - sound waves traveling at a frequency above 20,000 hertz (Hz [cycles per second]).

Transducers use wide-bandwidth technology to perform within a range of frequencies. Higher-frequency

transducers yield better image resolution, whereas lower frequencies penetrate tissue more effectively.

In early pregnancy,
5- to 12-megahertz (MHz) transvaginal transducer usually provides excellent resolution, because the early fetus
lies close to the transducer.

In the first and second trimesters,

a 4- to 6-MHz transabdominal transducer is similarly sufficiently close to the fetus to yield precise images.

Third trimester,
a lower-frequency 2- to 5-MHz transducer may be needed for tissue penetration— particularly in obese patients
which could lead to compromised image resolution.

Sonography should be performed only for a valid medical indication and use the lowest possible exposure setting
to gain necessary information. ALARA principle—as low as reasonably achievable.
 TRANSVAGINAL ULTRASOUND TRANSABDOMINAL ULTRASOUND
(Endovaginal ultrasound)
Indications transvaginal ultrasound offers an invaluable used for a general overview of the pelvis and may be
avenue for imaging the female pelvic anatomy. necessary in some situations in order to image the entirety
of some pelvic pathologies
It augments transabdominal ultrasound for a
more complete evaluation of the ovaries, Transabdominal ultrasound can be applied to visualize the
adnexa, uterus, cervix, and surrounding pelvic liver, gallbladder kidneys, pancreas, small and large
regions intestine, appendix, bladder, uterus, adnexa, spleen,
stomach, aorta, and IVC.
Adnexal/ovarian masses and cysts, endometrial
pathologies, fibroids, and pregnancy (ectopic In the setting of obstetrics and gynecology (OBGYN), the
and intrauterine), as well as evaluation of transabdominal approach is usually performed to evaluate
developmental anomalies, are a non-exhaustive for possible pelvic pathology or pregnancy in a less invasive
list of indications that are commonly evaluated manner.
with this imaging modality.
commonly utilized to evaluate for intrauterine pregnancy,
cholelithiasis, intraabdominal free fluid, abdominal aortic
aneurysm, and hydronephrosis.

Frequency mid-high frequency probe (e.g. >7 MHz) is mid-low frequency transducer (e.g. up to 5 MHz) is usually
usually used used

Bladder The bladder is emptied before the exam A full bladder is used as an acoustic window to achieve
better imaging of the uterus and adnexa

Risk There are no known harmful effects of Transabdominal ultrasound, like most diagnostic
transvaginal ultrasound on humans. ultrasound applications, is associated with little if any risk.
There may be some associated discomfort when pressure
is applied.
Procedure Patient should be supine in lithotomy position.
transabdominal view in pregnancy is obtained using the
curvilinear probe with the patient in a supine position. The
Use a 5-9 MHz endocavitary or transvaginal probe is placed with the indicator to the head of the
probe with a water based/non-irritating patient above the pubis symphysis in the midline.
lubricant and probe cover.
An adequate view of the uterus includes having the length
of the uterus in addition to the cervix and part of the vagina
visualized.

It is important to distinguish the endometrial stripe in the

The transvaginal transducer is inserted, with
transverse view as a dot or oval and the vaginal as a stripe
special attention being made to the orientation
going across the screen. For transabdominal assessment, it
of the image.
is best to obtain imagining in both longitudinal and
transverse views.
A marker on the screen may be used to indicate
• Patient should be supine.
cephalad from caudad on sagittal imaging or
• Use of a 3.5-5 MHz curvilinear probe or phased
right from left on transverse imaging, though
array probe.
various protocols are institution-specific.
• In thin patients a high frequency linear probe can
be used and is helpful for identifying early
pregnancies.4
The probe is placed in the distal vagina or against
• It is best to have a full bladder for the
the external cervical os.
transabdominal approach.
A transvaginal ultrasound probe may be placed • Start just above the pubic symphysis in the
anteriorly, posteriorly, or on either side of the transverse (probe indicator to the patient’s
cervix by placement within the fornix. The right).
posterior fornix creates the inferior border of the • In the transverse plane use the bladder as an
Pouch of Douglas, while the anterior fornix acoustic window to identify the uterus. Fan all
borders the vesicouterine pouch inferiorly. the way through by angling the beam towards
 then head and fan towards the feet. The
Changing the depth of the ultrasound probe will
endometrial stripe should be a hyperechoic line
create a different focal point and thus bring
in the middle of the uterus.
different areas within view. Sagittal imaging is
obtained with side-to-side movements of the
probe, from one adnexa to the other. Turning
the probe to 90° will give us a transverse/semi-
coronal orientation.

The transverse on endovaginal imaging is more

of a coronal plane, while the true transverse
image is done transabdominally.

Subsequent imaging is performed by moving the

probe anterior to posterior. A general survey is
first performed as an initial evaluation by
sweeping the probe from the midline to the
lateral margins at the bilateral adnexa. The
probe is then rotated 90° and swept in the
anterior-posterior direction.

The cervix, internal os, endocervical canal, and

occasionally the external os is imaged in both
sagittal (long-axis) and transverse (short-axis)
orientations.
The cervix is normally 2.5 to 3 cm and may be
measured if there is an indication for it, such as
 recurrent second-trimester miscarriages in the
setting of an incompetent cervix.

Contraindications Rupture of membranes in a pregnant patient, as No absolute contraindications

they are at an increased risk of chorioamnionitis
Imperforated hymen
Vaginal obstruction
Recent vaginal surgery
Lack of patient's consent

Transvaginal approach should not be performed

on an unemancipated minor without verbal
consent from a parent/legal guardian, on a
patient who is virginal, and/or has refused the
exam.

Imaging
LONGITUDINAL VIEW SAGITTAL VIEW
TRANSVERSE VIEW TRANSVERSE VIEW
References:
Williams Obstetrics 26th ed – Obstetrical Imaging
Transabdominal vs. Transvaginal Pelvic Ultrasound Scans (privatesono.com)
Pelvis Ultrasound (radiologyinfo.org)
https://www.ncbi.nlm.nih.gov/books/NBK572084/#:~:text=Circumferentially%20to%20the%20cervix%2C%20the,by%20place
ment%20within%20the%20fornix.
https://www.slideshare.net/thegenuinegenius/obstetrical-ultrasound-167816400

Pregnancy Ultrasound Evaluation - StatPearls - NCBI Bookshelf (nih.gov)

https://www.ncbi.nlm.nih.gov/books/NBK572084/