RIU 332 - Sonographic Eval of Pelvis

- Unicornuate uterus: one tube, tilted to side - Related to infertility and pregnancy loss (due to cavity being so small) - Sonography demonstrates long and slender (cigar-shaped) uterus deviated to one side.

Müllerian Anomalies class II: what is the name, how many tubes, what this related to in terms of preg, what does sono represent

- between vagina and rectum - bowel can cause shadowing or gas

Rectouterine Recess and Bowel: location and what can bowels cause on image

retroverted because fundus is on the right side of image - NOT LEFT

orientation of uterus

- Retroverted and retroflexed

orientation?

transvag because no bladder

type of US

refers to axis of cervix relative to vagina

version of uterus: what planes are compared

inner layer of myometrium

what does "i" indicate

- Ovaries identified anterior to internal iliac vessels - Size, shape, contour, echogenicity - Position relative to uterus - Ovarian size determined by measuring length of long axis with AP dimension measured perpendicular to length - Ovarian width measured in transaxial or coronal view - Ovarian volume may be calculated (: 0.523 x length x thickness x width)

adnexa/ovary documentation: what should you measure; where should ovaries be in relation to internal iliacs

- periphery of uterus in arch and should not be mistaken for pathology - located between intermediate and outer layers of myometrium; may look like cystic structures but add color and see they are vessels

arcuate vessels location in uterus

difficult to identify by transabdominal or transvaginal sonography unless surrounded by fluid or filled with fluid (dilated)

are fallopian tubes visualized?

- A and B - bicornuate - C - septate

bicornuate vs septate?

- typically we see in postmenopausal females or diabetic females; not abnormal, just apart of the disease - linear echogenicities with shadowing

calcifications in arcuate arteries: what are the two conditions we would see this is, normal?, sono appearance

- Cannot say diff between Bicornuate and didelphys because this is trans and would need to see cervix

can you differentiate between anomalies?

- Evaluate cul-de-sac for presence of free fluid or mass. - If mass is detected, document size, position, shape, echographic pattern relationship to ovaries, and uterus. - Differentiate normal loops of bowel from mass. - bowel should have peristalsis

cul-de-sac documentation: what are you looking for and what do you do if you see mass; how to tell diff between mass and bowel loops

- hypoechoic thickening with thin echogenic central stripe; 4-8 mm - Increase in number of cells in functional layer

endometrium sono appearance during early proliferative phase + size + what is increasing

- triple layer sign appearance; - central echogenic line surrounded by thicker hypoechoic functional layers bounded by echogenic basil layers - during periovulatory time: should expect to see graafian follicle in ovary with triple layer

endometrium sono appearance during late proliferative phase: name of sign, description, what else should you see at this time

- hyperechoic thickening, posterior enhancement; thickest layer; 7-14 mm - Filled with glands of glycogen, lipids, blood - functional layer is isoechoic with basil layer

endometrium sono appearance during late secretory phase + size

- thin, broken, echogenic line - 4-8mm - If menstrual flow heavy, entire endometrial cavity can appear anechoic

endometrium sono appearance during menstruation

refers to axis of uterine body relative to cervix

flexion of uterus: what planes are compared

number of pregnancies a patient has had

gravidity

- full during TA but not over filled because that will lead to pushing of the uterus and inaccurate measurements - bladder shouldn't pass over fundus too far; need to void urine if it does - empty during TV

how is the bladder during a TA or TV scan

- Body separated from cervix by isthmus at level of internal os and identified by narrowing of canal

how is the body of uterus separated by from cervix

the fundus should be on the left side of image on anterior aspect of body

how to tell if uterus is anteverted on TV

- thin echogenic line; atrophic because we don't need it anymore - Less than 8 mm -- UNLESS female is on hormone replacement therapy ---- Would measure 10 to < 14 mm; don't like 14 mm - If less than 5 mm in female not on HRT no risk for endometrial cancer

menopausal endo: sono appearance, size off and on HRT; what size means female is not at risk of endometrial cancer

cervix due to ligaments

most fixed portion of female anatomy?

- thickest, uniform in echotexture - likely to find lesions here

myometrium: intermediate layer : sono appearance and what are we likely to find here

hematometrocolpos

name of condition

- low vel and high resistive - slight decrease in resistivity prior to ovulation

ovarian art: vel and resistivity + how does resistivity change with ovulation

- cyst: echogenic ovarian foci are common finding: look 1-3 mm, non shadowing foci, usually multiple and on periphery of ovary - cals: echogenic with shadowing; may be sign of cancer

ovaries: unresolved cyst VS calcification sono appearance

number of pregnancies that lead to birth or past 20 weeks of GA with fetus of 500g

parity

- Increases in size after age of 7 years - Greatest size increase occurs after onset of puberty when fundus becomes much larger than cervix. - Uterine length increases to 5 to 7 cm, and fundus-to-cervix ratio becomes 3:1.

pediatric after 7 years uterus size, length, fundus to cervix ratio

- Length measured in long axis from fundus to cervix - AP depth measured in long axis from anterior to posterior walls, perpendicular to length - Width measured from transaxial or coronal view - Cervical diameters (with pregnancy) - Endometrium analyzed for thickness and echogenicity - Myometrium, cervix evaluated for contour changes, echogenicity, and masses - Contour of uterus is examined

pelvic ultrasound exam: what types of measurements are needed of the uterus, endo, cervix; what do you evaluate in the myometrium, cervix and uterus

- uterine enlargement and endometrial cavity less than 2 cm AP

postpartum pelvis: uterus and endometrial cavity size

Radial arteries arise as multiple branches from arcuate arteries and travel centrally to supply rich capillary network in deeper layers of myometrium and endometrium

radial arteries location

- (S-D)/S - low = require constant perfusion - higher = doesn't require constant perfusion

resistive index + what does high and low resistivity

Uterus may also be retroflexed when body tilted posteriorly or retroverted when entire uterus tilted backward.

retroflexed vs retroverted

- left of screen: anterior aspect - right of screen: posterior aspect - top of screen: caudal - bottom of screen: cranial

transvag sagittal: scan orientation on the screen

anteverted and anteflexed

typical orientation of the uterus

- high vel, high resistivity - pattern changes when preg to more low resistive

uterine art: vel and resistivity

- Layer thin, compact, relatively hypovascular - Hypoechoic and surrounds relatively echogenic endometrial stripe, creating subendometrial halo - thin echogenic line is endometrial canal consisting of functional layer and deep basal layer

uterus endometrium sono appearance

- homogeneous echotexture with smooth-walled borders. - Any areas of increased or decreased echotexture should be noted and measured.

uterus myometrium sono appearance

septate uterus because the septum is connective tissue that doesn't have much blood supply; if fertilization takes place the egg attaches to septum and because of lack of vascular supply it will not develop

what Müllerian Anomalies is associated with high level of infertility

Bicornuate uterus (class IV)

what anomaly

Unicornuate uterus (white area is endo and darker area around is myometrium; class II)

what anomaly

fallopian tubes dilated

what is this showing

menstruation; thin echogenic

what phase

secretory (thick and echogenic)

what phase

secretory; echogenic and thick

what phase

secretory; thick, echogenic

what phase

triple layer (central echogenic line, hypoechoic hallow, echogenic thin hallow around that from basil layer)

what phase

anterior angulation of the probe; you move you hand posteriorly and angle the face of probe anteriorly

what type of angulation with TV probe is better to see fundus in normal anteverted uterus

- kidneys should be examined for ipsilateral renal agenesis or morphologic abnormalities, because these conditions are commonly associated with müllerian anomalies. - the processes of development go together during embryologic development

If müllerian anomalies encountered, what should also be examined

- Uterus didelphys - Complete duplication of uterus, cervix, and vagina - Not usually associated with fertility problems; generally does not require treatment; chance of carry preg to term is decreased and many end in miscarriage now research is proving

Müllerian Anomalies class III: name, how many uterus, cervix, and vagina's, fertility

- Bicornuate uterus; heart shaped - Duplication of uterus (2) with common cervix (1) - Bilobed uterine cavity has wide-spaced cavities. - Low incidence of fertility complications; usually not treated

Müllerian Anomalies class IV: name, shape, how many uterus and cervix? fertility

- In neonatal patient, ovary may be found anywhere between lower pole of kidneys and true pelvis - heterogeneous secondary to tiny cysts

Pediatric Ovary: location and sono appearance

- Used to determine volume and size of the ovaries, uterus, and cervix, and to exclude ovarian neoplasm. - Liver and adrenal gland should also be assessed to rule out presence of lesion causing precocious puberty.

Precocious Puberty sonographic findings are trying to rule out what?

- best seen in long - tubular structure posterior to bladder that connects with uterine cervix - mucosal walls cause bright central echo within collapsed tubular structure

Vagina: best seen in what plane, sono appearance

- Location (uterine or extrauterine) - Size - External contour (well-defined, ill-defined, irregular borders) - Internal consistency (cystic, complex, predominantly cystic, complex, predominantly solid, solid)

When mass found on sonography, characterize the following features:

- Difference in size of one ovary greater than twice the volume of contralateral ovarian - Ovarian volume greater than 8

abnormal findings in ovaries size

lateral to uterus where we find ovaries and tubes

adnexa def

- Septate uterus - Two uterine cavities are seen closely spaced, with one fundus and sometimes two cervical canals or a vaginal septum - septum come from failure of duct tissue to dissolve properly during embryologic development - highest percent of infertility

Müllerian Anomalies class V: name and what does it look like, where does it come from, fertility

- Segmental Mullerian Anomalies: Vaginal atresia: no external opening from uterus to vagina - Diagnosed by development of hydrocolpos (fluid-filled vagina), hydrometrocolpos (fluid-filled vagina and uterus), or hematometrocolpos (blood-filled vagina and uterus).

Müllerian Anomalies: class 1: what is the anomaly and what is seen

- T-shape - Related to exposure to drug diethylstilbestrol (DES) in utero - Uterus is normal in size and shape externally; however, cavity is T-shaped with irregular contour.

Müllerian Anomalies: class VI: shaped, related to what

- involves the development of secondary sexual characteristics and an increase in size and activity of gonads before normal age - Uterus has enlarged, postpubertal configuration with echogenic endometrial canal. - Ovarian volume enlarged greater than 1 cm3; functional cysts are often present.

Precocious Puberty: what is it, how is uterus size, ovarian size?

- involves maturation of secondary sexual characteristics, but not the gonad, as there is no activation of hypothalamic-pituitary-gonadal axis. - Excessive exogenous synthesis of gonadal steroids is most common cause of precocious pseudopuberty.

Precocious pseudopuberty: what is it and what is most common cause

an abnormally closed hymen that usually does not allow the exit of menstrual fluid - leads to hydrocolpos, mucocolpos, hematocolpos, or hematoma - symptoms: primary amenorrhea and pelvic cyclic pain, development of secondary sexual characteristics

imperforate hymen: what is it, what conditions can it lead, symptoms at puberty

- vaginal agenesis; congenital absence of vagina - absence or hypoplasia of all or part of cervix, uterus, and fallopian tubes - may have renal abnormalities - normal external genitalia except no hole for vagina or very shallow and doesn't connect - normal secondary sexual characteristics: different tissue

mayer-rokitansky-kuster-hauser syndrome : what is it, what can happen to uterus, cervix, what type of abnormalities can be associated, external genitalia

in females, forms the uterus, uterine tubes, and upper part of the vagina (lower vagina and ovaries are diff tissue

mullerian duct

- RAM: Appear as hypoechoic structures with echogenic striations - Rectus sheath separates sonographic appearance of rectus abdominis muscle from surrounding fat and bowel as a bright linear echogenic reflector.

muscles of pelvis: Rectus abdominis muscles and rectus sheath: sono appearance

- seen at posterior lateral corners of bladder at level of vagina and cervix. - Muscle is hypoechoic, ovoid, surrounded by obturator fascia

muscles of pelvis: obturator internus : where are they seen and sono appearance

- thin, hypoechoic, compared to endo - don't include in measure of endo

myometrium: inner layer: sono appearance

- slightly less echogenic than intermediate

myometrium: outer layer: sono appearance

- frequently see cervical inclusion cysts near endocervical canal (within the cervix) - cysts are generally <1-2 cm wide; anechoic smooth-walled structures with acoustic enhancement posteriorly - Of no clinical significance and generally NOT measured - only measured if they look very abnormal

nabothian cysts: what are they, size, what to do with them

- In newborn female, uterus is prominent and thickened with brightly echogenic endometrial lining caused by hormonal stimulation received in utero. - Uterus: Pear-shaped in configuration with length, approximately 3.5 cm with a fundus-to-cervix ratio of 1:2.

neonatal uterus sono appearance , shape, length, fundus to cervix ratio

- Are very mobile and can move considerably in pelvis, depending on bladder volume and whether woman has had previous pregnancy - Are elliptical in shape, with long axis usually oriented vertically - lateral to uterus and anteromedial to internal iliac vessel - Blood supply is from the ovarian artery, which originates directly from aorta, and from uterine artery, which supplies adnexal branch to each ovary.

ovaries: mobility, typical orientation, relation to uterus and internal iliacs, blood supply

- At 2 to 3 months of age, uterus regresses to prepubertal size and tubular configuration. - At this time, length will measure 2.5 to 3 cm, with fundus-to-cervix ratio of 1:1. - Endometrial stripe echoes not visualized. - May be some endometrial fluid present

pediatric 2-3 months uterus sono appearance , shape, length, fundus to cervix ratio, what else is and isn't present

bicornuate uterus

what anomaly

class one mullerian anomaly of vaginal atresia with blood into endo cavity

what anomaly

septate uterus (fundus is curved on top)

what anomaly

t-shaped related to DES exposure

what anomaly

t-shaped uterus

what anomaly

uterus didelphys (class III)

what anomaly

dilation myometrial veins; add color and they would light up

what are the anechoic areas

arcuate artery calcifications

what are the echogenic foci

- When sequence fails to occur, one of these abnormalities results: -- Improper fusion -- Incomplete development of one side -- Incomplete vaginal/uterine canalization

what can happen if mullerian ducts don't develop properly

- not mullerian ducts; it's a different tissue; this means that ovaries and hormone production might be normal but female could have abnormality with uterus

what develops the ovaries and lower vagina

- develop uterus, upper vagina and cervix - Ducts must elongate, fuse, and form lumens between 7th and 12th weeks of embryonic development.

what do the mullerian ducts develop into and how?

- inner myometrium

what is the hypoechoic area around calipers

sag rt adnx; ovary with large follicle

what is this

- power doppler of the arcuate arteries on the periphery of the uterus

what is this showing

posterior angulation of the probe; you move you hand anteriorly and angle the face of probe posteriorly

what type of angulation with TV probe is better to see cervix and rectouterine recess in normal anteverted uterus