Diagnostic Ultrasound

for Postgraduates in
Obstetrics and
Gynaecology
Max Brinsmead MB BS PhD
May 2015
Potential uses for ultrasound in the 1st
trimester of pregnancy:
 Locate the pregnancy – exclude ectopic
 Assessment of viability
 Diagnosis of molar pregnancy
 Determining gestational age
 Diagnosis of multiple pregnancy
 Assessment of other pelvic masses
 Screening for fetal abnormalities
 Assisting CVS and amniocentesis
 Other uses for ultrasound in obstetrics:

 Screening for placenta previa

 Assessment of APH
 Cervical length monitoring
 Assessment of fetal growth
 Evaluation of polyhydramnios and hydrops
 Diagnosis and management of malpresentation
 Assessment of fetal welfare
 Assessment of the postpartum uterus
 Directing intrauterine interventions
Potential uses for ultrasound in
gynaecology:
 Assessment of adnexal pelvic masses
 IUCD and Implanon location
 Treatment of ovarian cysts (aspiration) and ectopic
pregnancy (methotrexate)
 Investigation of postmenopausal bleeding
 Evaluation of pelvic pain
 Investigation of menorrhagia
 Diagnosis of polycystic ovaries
 Tubal patency studies in infertility
 Evaluation of primary amenorrhoea
 Screening for ovarian cancer
 Monitoring of follicle number and growth for IVF
 Egg recovery for IVF and ICSI
But before you can
do all this…
You must know how to drive an
ultrasound machine
 What is Medical Ultrasound?

 Sound waves whose frequency is beyond the

human ear
 That is >20 kHz
Advantages of Ultrasound:

 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
An ultrasound image is produced by:

 Producing a beam of sound waves

 Transmitting this through the object of interest
 Receiving echoes
 Converting the echoes into electric signals
 Interpreting and displaying those signals
 Can be snapshot or in real time
The ultrasound beam AND 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 is formed by:

 The direction of the echo

 The strength of the echo
 The time taken for the echo to return
 These 3 characteristics determine which pixels on
the screen will light up
 And with what intensity
So the ultrasound image will be:

 White = Area of high acoustic impedance e.g. bone

 Black = Areas of low acoustic impedance e.g fluid
 All shades of grey in between
 Shadowed by area of non penetration or areas
behind those of high acoustic impedance e.g.
behind bone
Disadvantages of Ultrasound:

 Travels poorly through gas

 The amount reflected depends on the degree of

acoustic mismatch

 The piezoelectric crystals are quite delicate

Diagnostic ultrasound:

 Typically involves frequencies of 2 – 15 mHz

 Lower frequencies will give greater penetration
 And thereby you can see further
 Higher frequencies allow you to see more detail
 But the penetration is less
 And very high frequencies have the potential for
adverse biological effects
Types of Probes:
 A linear array of crystals
 Produces parallel sound waves
 And a rectangular image
 Good for surface structures
 A sector scanning probe
 Produces a fan-like image
 Can fit ito narrow spaces
 Has poor near-field resolution
 A curved array of crystals
 Will fit curved surfaces of the body
 The density of scan decreases proportionally to the distance
from the transducer
Probe Types
Machine Controls
Max’s Maxim Number 17

 Using an ultrasound machine without using

a few of its knobs is like driving a car only
in the first gear

 It’s a safe to go…

 But you don’t get very far

Some tips:
 Don’t be intimidated by all the knobs
 Just like driving a car, You only need to know a few
basic controls
 Practice and play!
 The first challenge is to find the switch to turn it on
 There may be more than one
 Next find the machine pre set for the exam you are
about to do
 And do all this before you get to the patient
Some more tips:
 Ultrasound is no substitute for a good history
 ALWAYS do an abdominal scan before using the
vaginal probe
 Know how to switch probes
 Is it safe to “hot wire”?
 The trick is to build up a 3-dimensional picture in your
mind using real-time imaging
 You will always be better than sonographers because
you know the anatomy and pathology
 Or you will get to see it!
 So beware of premature conclusions
Machine Controls:

 Gain
 Controls brightness or “contrast”
 Also in a array of sliding levers
 Use maximum gain and minimum power
 Depth
 Reach to the area of interest then…
 Zoom
 To enlarge your view then…
 Freeze
 For measurements (or stored image)
Machine Controls
Machine Controls 2:

 Tracker Ball
 This is the “mouse” for your computer, usually with right
and left click buttons to execute functions
 Used to superimpose things on the screen
 May have several functions
 Calipers
 To measure distance between 2 points
 Ellipse
 To measure area
Machine Controls
Some more tips:
 Use a low light but make sure you can see all the
controls
 Adjust contrast on your screen before you start
 Make yourself and the patient comfortable
 Use a good quality transducer gel - SPARINGLY
 Remember the prime purpose of the exam
 Make sure that always follow a routine and do it all
 Scroll-back and cine re-loop can be very useful
 Look for acoustic enhancement on the other side of
fluid
 Look for shadowing on the other side of bone
Some traps:
 Doing patients in succession when data from one is
carried forward onto the next
 When you find a fetal heart make sure that it inside a
uterus
 Pseudo sac within the uterus with an ectopic
 Measuring the yolk sac as a part of the CRL
 Image duplication resulting in the false diagnosis of
twin sacs
 A small amount of free fluid in the pelvis can be
normal
 Know the many variations of a corpus luteum
 Using a too-narrow field of view
 Proven uses for ultrasound in pregnancy:
 Dating the gestation
 Many women cannot provide a reliable LMP
 Should be +/- 7 days based on CRL in the 1st trimester
 Can be +/- 10 days based on HC, AC and FL in 2nd trimester
 Becomes increasingly unreliable after 22w
 Identification of multiple pregnancy
 Twins have a perinatal mortality that is 2-4x singletons
 Monitoring for discordant growth with Doppler reduces risk
 Important to diagnose zygosity
 Identification of breech in the third trimester
 ECV reduces the rate of Caesarean section
 Few RCTs of routine ultrasound have shown any
effect on overall perinatal mortality and morbidity
Unproven uses for ultrasound in pregnancy:
 Screening for Aneuploidy
 Cost effectiveness of universal screening debated
 Ethical issues and patient choice involved
 Screening for structural malformations
 Sensitivity is 13 – 50% depending on expertise & equipment
 And only half of these before 20 w gestation
 False positives occur
 Screening for IUGR in the 3rd trimester
 Sensitivity is 80-90%
 But the positive predictive value of neonatal morbidity is only 25-
50%
 The rest have constitutional smallness
Harmful Effects of ultrasound in pregnancy:
 It is not ionising radiation
 However, thermal effects and cavitation can occur
in tissues exposed to high power ultrasound
 One RCT of repeated routine ultrasound with
Dopplers in the 3rd trimester found a small but
significant decrease in birth weight in the exposed
cohort
 A meta analysis showed males exposed to
ultrasound in uterus are more likely to be left-
handed
Caring for your ultrasound machine:
 Treat your probes as if they were made of glass
 Wash, clean and dry probes
 Sterilisation options
 Don’t use oil or alcohol
 Transport probes safely stowed
 If you changed the machine defaults set them back
to the original
Ultrasound in the first trimester of
pregnancy:
 Start with the abdominal probe
 Counsel the patient about your expected findings
and expertise
 First find the cervix and/or uterine body
 It’s not as far in as you think
 Look for embryo at the edges of a sac <7w
 FH should be demonstrable when sac size is >2 cm
 Measure CRL up to 12w, thereafter BPD, HC, AC
and FL
 Remember ectopic and multiple pregnancy
 If you are not sure say so…
 Exclude ectopic and recheck in 7 – 14 days
 Check the POD and ovaries before you finish
 Pain & Bleeding in Pregnancy

Emergency Management

Inconclusive Vaginal Scan = Empty uterus

Quantified beta HCG

<500 iu/L 500 - 1000 iu/L >1000 iu/L

Observe Diagnostic laparoscopy if clinically Assume ectopic & proceed accordingly

suspicious
Repeat HCG in 24 - 48 hrs
Rescan when >1000 iu/L
or follow to <10 iu/L if EP possible
Ultrasound in the third trimester of
pregnancy:
 Start with abdominal palpation
 Tell patient purpose of examination
 Quick scan for presentation and lie
 Measure BPD, HC, AC and FL
 Remember that this does not predict dates
 Liquor volume
 Find placenta and examine lower edge in
relationship to the presenting part
 Suspected placenta previa best evaluated by PV or
TV scan
 Ovaries virtually never seen
Ultrasound for the non pregnant woman:
 Start with abdominal probe
 Preferably with a full bladder
 I measure uterine dimensions in two planes
 Then send patient to empty bladder…
 And switch to vaginal probe
 First find the cervix
 Acutely anteverted/flexed uterus is tricky
 Find and measure endometrium
 Then evaluate myometrium
 Ovaries can be anywhere
 And cannot be found 25 – 30% of the time
 I measure ovaries in two dimensions
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