Radiology of Obstetrics and

Gynaecology

Dr Iga Kirabo
PG3 MMED RADIOLOGY
 Modalities for imaging the pelvis
• Plain x-ray
• Ultrasound scan
• Sono-hysterography
• HSG
• CT
• MRI
• Angio/CTA/MRA
 Gynecological –US Scan indications
(non pregnant female pelvis)
• Pelvic pain including dysmenorrhea
• Pelvic mass
• Abnormal PV bleeding
• Abnormal PV discharge
• Amenorrhea
• Check for position of IUCD
• Infertility
• Genital tract developmental anomalies
• Urinary or bladder symptoms
• Diffuse abdominal pain
• Follicular monitoring in fertility treatment
 Obstetric ultrasound indication
• in the report of the Royal College of
Obstetricians and Gynaecologists on the use
of the ultrasound examination in pregnancy
(1984),
• benefits of a routine examination significantly
outweighed any potential adverse effect from
the dangers of the examination itself.
 Indications for an obstetric ultrasound
• Estimation of gestation age
• Evaluation of pattern of fetal growth
• PV bleeding of undetermined etiology
• Fetal presentation before onset of labour
• Suspected multiple gestation
• Adjunct to amniocentesis
• Significant uterine size/clinical discrepancy
• Pelvic mass detected clinically
• Suspected hydatidiform mole
• Cervical cerclage
• Special procedures
• Suspected IUFD
• Suspected uterine abnormalities
• Localization of IUCD
• Follicular follow-up
• Biophysical profile after 28wks GA
• Monitoring of intrapartum events
• Evaluation of AFI in suspected oligo/poly
hydraminous
• Suspected abruptio placenta
• EFW
• Abnormal serum alpha fetoprotein for GA
• Followup of identified fetal anomalies
• History of previous congenital anomaly
• Serial evaluation of fetal growth in multiple
gestations
First trimester scan (commonly performed at
9-12WOA)
• Identifying the gestation sac in vitro
• Viability
• Number of fetii
• Uterine anatomy and adnexial region
• Nuchal translucency
Second trimester (perfomed at 18-20WOA)

• Viability
• AFI
• Location of placenta
• Gestational age
 obstetrics
• Recommendations for obstetric USS
• 18-22wks from LNMP
• 32-36wks from LNMP
• There is no indication for scan in the first
trimester of pregnancy unless there is clinical
abnormality
Why ultrasound scan in normal pregnancy?

• 90% fetal anomalies occur without family

history
• Few mothers show obvious risk factors
• There can be significant fetal anomalies in a
clinically normal pregnancy
• Neither clinical exam nor family history is an
entirely reliable way to detect multiple
pregnancy
 Cont…
• Mothers with placenta previa may show no
evidence until bleeding starts at onset of
labour.
• Up to 50% of mothers who claim to know
their obstetric dates with certainity are infact
more than two weeks in error when GA is
calculated on scan
 Objections to scanning during normal
pregnancy.
• Cost implication not justified relative to
benefit to patient.
• NB: the decision to scan or not to scan a
normal pregnancy must be made by the
physician and each patient
• There are no universally accepted guidelines.
 Fetal sex determination
• Fetal sex determination is not a valid medical
indication for scan except when there is a
strong familial risk of sex linked genetic
disorder.
 Importance of obstetric scan at 18-22wks
GA
• Establish GA
• Establish multiplicity
• Diagnose fetal anomalies
• Locate placenta
• Recognize uterine leiomyomas
 Importance of obstetric scan at 32-36wks
GA
• Recognize IUGR
• Recognize fetal anomalies missed in 1st scan
• Confirm presentation and lie
• Placental position
• Amniotic fluid index (AFI)
• Exclude possible complications e.g
leiomyomas, tumours etc.
 Indications for obstetric scan before 18wks
GA
• When there is evidence of clinical abnormality
• Doubt about GA
 Information got from an earl scan before
18wks GA
• Confirm pregnancy
• Accurate GA estimation
• Locate pregnancy i.e. intrauterine Vs extra-uterine
• Multiplicity
• Exclude molar pregnancy/blighted ovum
• Exclude pseudopregnancy due to pelvic mass or
hormone secreting ovarian tumours
• Diagnose leiomyomas or ovarian mass
 Indication for scan in post partum pelvis

• Immediate
• Severe bleeding
• Retained placenta
• Undelivered twin
• Six weeks post partum
• Continued bleeding
• Persistent pain
• Failure of uterus to return to normal
size(involute)
• Continuous abnormal PV discharge
• Palpable mass in the pelvis
Interventional ultrasound applications in obs
& gyn.
• Ultrasound guided needle puncture or
aspiration
• Follicular harvest/ oocyte retrieval in ART.
• Embryo transfer
• Hysterosonography
• Chorionic villus sampling
• Amniocentesis
• Multi-fetal pregnancy reduction
• Percutaneous umbilical blood sampling
• Fetal skin biopsy
• Fetal muscle biopsy
• Fetal liver biopsy
• Fetal amniotic shunting
• Intra-operative ultrasound guidance
 Plain x ray imaging
• Evaluation of pelvic masses
• IUCD
• Calcified pelvic tumors
• Pelvimetry (measuring the size of the pelvis)
 X Ray in obstetrics
• A radiation physicist can calculate the estimated dose of radiation to the
fetus to assist in patient counseling.
• No single diagnostic procedure should results in a radiation dose that
threatens the well-being of the developing embryo and fetus.
• It is essential when you counsel your patient not to promise her a perfect
baby to avoid parenteral disappointments and lawsuits.
• As part of counseling, you should inform mother that the actual risk
depends on gestational age and that spontaneous birth anomalies occur in 4
to 6 percent of all deliveries exposed to the radiations.
• It is also important to clarify that x-rays affect only body tissues which

come into direct contact with the beam .

• NB:the advent of other imaging modalities have rendered this
method obsolete because of it potential risks associated to
developing embryo
 X Ray
Uses:
• Diagnose Intrauterine fetal death, fetal presentation
and position
• Diagnose congenital malformations. e.g.
hydrocephalus
• Pelvimetry
• Placental localization
• Exclude vesicular mole: no boney skeleton at 15
weeks or more
 Fetography
• Demonstrates fetus in utero

– To detect suspected
abnormalities of
development or death

– To determine presentation
and position of fetus

– To determine number of
fetuses

 KUB and lateral

Twins
 What is “breach presentation”?

• Baby enters
birth canal
with buttocks
or feet first as
opposed to
normal head
first
presentation
Breach Normal
 Placentography

• Radiography of placenta following

injection of a radiopaque substance

• Shows walls of uterus to locate

placenta in cases of placenta
previa

– (In most pregnancies, the placenta is

located at the top or side of the uterus. In
placenta previa, the placenta is located
low in the uterus)

• Sonography is now preferred

imaging modality!
 Pelvic Pneumonography
Study of female
reproductive
organs by
injection of gas in
peritoneal cavity

Virtually replaced
by sonography
 X Ray

Risks:
• Congenital fetal malformations. In early pregnancy, A single
abdominal exposure exposes the abdomen for 0.5 rads while
pelvimetry exposes the abdomen for 1.1 rads. Microcephaly
and mental retardation occurs at a dose of 100-200 rads.
• Abortion and Intrauterine fetal death
• In late pregnancy, cleft palate and cataract
• Fetal gene mutation and infertility
• Fetal neoplasms especially leukaemia.
 HSG(hystereo-salpingography)
• Radiological investigation of the uterus and
fallopian tubes by administration of water
soluble contrast medium under flouroscopy
Indications Contra-indications
• Infertility • Pregnancy
• salpingitis • During or immediately
• Congenital anomalies after menses 10 days
• Recurrent abortions after menses first date
• Recurrent PV bleeding • TAH
• Monitor tubal patency • Recent D&C
after operation • Recent abortion
• Uterine tumors • PID with PV discharge
 Pt preparation
• 10 day rule be observed
• Abstain from sexual intercourse from booking day
to day of examination
• General hygiene observed by pt
• Hydrocortisone given to those who are
hypersensitive to contrast medium
• Analgesic given 1hour prior to examination
• Buscopan may be administered 1hr prior
• Physical and psychological preparation
 CT OF THE PELVIS

Clinical Indications:
• Masses
• Lesions
• Vascular abnormalities
• Trauma
• Abscess
• CT pelvimetry

CECT imaging performed 36

 Role of CT and MRI
• Pelvimetry This is more reliable and accurate
in defining the margins of the bony pelvis
than clinical examination.
• ultrasound has led to a decline in the use of
pelvimetry
 CLASSIFICATION OF INTERVENTIONAL
RADIOLOGY

INTERVENTIONAL RADIOLOGY

VASCULAR NON VASCULAR

DIAGNOSTIC THERAPEUTIC PERCUTANEOUS BIOPSY

ABSCESS DRAINAGE

PERCUTANEOUS NEPHROSTOMY

PERCUTANEOUS BILIARY DRAINAGE

RADIOFREQUENCY ABLATION
38
 Angiography/CTA/MRA-indications

• Vascular anomalies
• Identification of vascularity of tumors
• Tumor embolization
 NON-VASCULAR TECHNIQUES

• Interventional radiology
operating theater.
40
 PERCUTANEOUS BIOPSY

Fine Needle Aspiration Cytology

(FNAC)
True Cut Core Biopsy

41
 FNAC and True Cut Core Biopsy
Indications
• Presence or absence of disease.
• Nature of disease (neoplastic, inflammatory,
infectious).
• Extent of disease.

42
 FNAC and True Cut Core Biopsy
Contraindications

• Abnormal coagulation profile

---Elevated prothrombin time (PT).
---Elevated partial thromboplastin time (PTT).
---Depressed platelet counts.
---Low prothrombin concentration (PC).

43
 FNAC and True Cut Core Biopsy
Patient preparation
• Informed consent.
• Normal bleeding profile.
• Start clear liquid diet, the night before the
procedure.
• Anxiolytic agents (anxious patients, severely
painful biopsies like bone, infants).
• Sterilize the puncture site, drape the
surrounding area.

44
 FNAC and True Cut Core Biopsy
Equipment
• FNAC ----- spinal needles (20 – 22 Gauge)
• True Cut Core Biopsy ----- true cut biopsy
needle (unicut 16G 15cm), gun biopsy needle
(speedybell 18G 20cm).

1 2 3

45
 FNAC and True Cut Core Biopsy
Technique
• Ultrasound or CT guided.
• Precise lesion site.
• Apply local anaesthetic (1 % lidocaine)
subcutaneous (True Cut Biopsy).
• Insert needle under guidance.
• Cytopathologist at biopsy procedure can
minimize number of passes.

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 FNAC and True Cut Core Biopsy
Complications
• Pain and discomfort.
• Hemorrhage (heamatoma).
• Pneumothorax (lung biopsy).

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PERCUTANEOUS ABSCESS DRAINAGE

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 Percutaneous Abscess Drainage
Patient preparation
• Normal bleeding profile.
• Fasting for at least 6 hours.
• Sterilize the puncture site, drape the
surrounding area.

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 Percutaneous Abscess Drainage
Technique

• Subcutaneous lidocaine 1 % injection.

• Image guided needle placement.
• After taking some amount of fluid out, wire may
be introduced and exchanged with a catheter
• Guide wire introduced through sheathed needle.
• Catheter (pigtail) advanced over guide wire.
• Catheter fixed in place.
50
 Piriformis. Sciatic Nerve Sacrospinous ligament.

Transgluteal Percutaneous Abscess Drainage:

Stay medial and inferior to avoid neuro-vascular structures
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 Abscess and Fluid Drainage

• Drainage catheters range from 6 F to 20 F.

• Viscous fluid require larger catheters (>10 F)
• Once Catheter is in place, it is secured and
attached to gravity drain or low suction.
• The catheter should be irrigated at least once a
day.
• The catheter may be removed with output less
than 10-20 cc per 24 hour period.
52
 Oocyte harvest
• Ultrasound guided
• Suitable follicle identified
• Subcutaneous lidocaine 1 % injection
• Image guided needle placement.
• Guide wire introduced through sheathed
needle
• Catheter introduced with a guide wire
• Harvested oocyte taken to IVF lab
 Other image guided proceedures
• Ultrasound guided ZIFT
• Ultrasound guided GIFT
Advantages & Disadvantages of image guided
Interventions

• Advantages • Disadvantages
• Less invasive than surgery • Bleeding
• Help prevent unnecessary surgery
• Pain
• Only need for local anesthesia
• Useful tool in sick patients who • Other complications depend
may not be candidates for surgery on where the biopsy is
• Can access sites which may be performed
difficult with surgery
• Much cheaper than surgery

55
 Limitations of Interventional radiology

• Very small lesions, the needle may not be able

to obtain a decent sample size.
• Needle biopsy is not cost effective when the
lesions are less than 1-2 mm
• Individuals with blood disorders, CT guided
biopsy may be very risky.
• Individuals with congestive heart failure, CT
needle biopsy is not recommended. 56
 Criteria for Evaluating Interventional
Radiology Procedures

• Time it takes for the procedure to be

executed
• Complication rates involved in procedure
• Frequency of procedures
• Current standard of care for procedure
• Reimbursement landscape
• Other relevant factors
57
 MRI
• MRI is an important technique in the evaluation
of pelvic pathology
• due to its ability to obtain images with a high
soft-tissue contrast resolution and discrimination
in multiple planes.
• primary technique of choice in the staging of
pelvic malignancy,
• with the exception of staging ovarian malignancy,
where CT is the preferred technique.
 MRI-Safety during pregnancy

• During pregnancy, it should only be performed for maternal

rather than fetal reasons.
• It should be reserved for pregnant patients with suspected
serious problems.
• MRI is better avoided during the first trimester and more
specifically during the period of organogenesis.
• Hazards that may affect the fetus include heating, noise (which
theoretically may cause acoustic damage) and the use of the
contrast agents; gadolinium compounds, which cross the
placenta and enter the fetal bloodstream,
• Evidence for teratogenic effects was shown in animal studies.
 MRI-Safety during pregnancy (Cont.)
• A reduction in crown-rump length was seen in mice exposed
to MRI in mid-gestation.
• Exposure to the electromagnetic fields caused eye
malformations in a mouse strain
• several hours of exposure of chick embryos in the first 48
hours of life to a strong static magnetic field resulted in an
excess number of dead or abnormal chick embryos when
examined at day 5.
• If you are going to scan a breast feeding mother receiving a
contrast agent, advise patient to pump breast milk before the
study, to be used until injected contrast material has cleared
from the body, which typically takes about 24 hours.
 Magnetic Resonance Imaging (MRI) (Cont.)
Uses of MRI:

• Evaluate medical emergencies during pregnancy. e.g.

appendicitis during pregnancy:
• ultrasound is the preferred method for imaging the appendix
in pregnant women, but the enlarged uterus and other
physiologic changes--particularly during the third trimester--
may prevent proper visualization of the appendix, rendering
the exam inconclusive.
• Diagnoses of congenital fetal malformations and fetal tumors
• Facilitating open fetal surgery and other fetal interventions
• Planning for procedures to safely deliver and treat babies

whose defects would otherwise be fatal.