Sonography of the Female Pelvis

What is the appearance of the endometrium during the menstrual, early proliferative, late proliferative & secretory phases? What is the endometrial thickness during the proliferative & secretory phase?

-Menstrual (day 1-4): thin, broken echogenic line, hypoechoic thickening. 4-8 mm -Early proliferative phase (day 5-9): single thin stripe. 6 mm. "Three-line sign". -Late proliferative phase (day 10-14): trilaminar appearance. Endometrium thickens to 10 mm. Ovulation occurs here. -Secretory phase (day 15-28): uniformly echogenic, there is through transmission and posterior acoustic enhancement, hyperechoic thickening. 7-14 mm

What tissue does the Fallopian tubes & uterus arise from? How does the uterus form from this tissue?

-The body of the uterus is mostly muscle while the cervix is collagenous and elastic, with slight smooth muscle. -Fallopian tubes are situated in the superior free margin of the broad ligament and is covered by peritoneum. -The uterus is derived from the embryonic mullerian ducts as they elongate and form a lumen between the 7th and 12th weeks of embryonic development.

What vessel provides the main blood supply to the uterus? Where does this artery arise from? What arteries penetrate the myometrium & supply the deep layers of the myometrium & the endometrium?

-The uterine arteries are the main arterial supply to the uterus. It arise from the anterior division of the internal iliac artery and ascends lateral to uterus in the broad ligament and multiple branches pierce the uterine wall dividing anterior and posterior arcuate arteries. -From the arcuate arteries comes the radial arteries that give rise to straight and spiral arteries which supply the deep layers of the myometrium and endometrium. -Arcuate supply myometrium -Radial supply endometrium

What 3 factors affect the size of the uterus?

Age, parity, hormonal status

Be able to discuss the ovarian cycle, its phases & development of the follicle. What size is the graafian follicle prior to ovulation? What is the cumulus oophorus, corpus luteum? What is Mittelschmerz?

Ovulation normally occurs mid cycle on about day 14 of a 28 day cycle. Ovarian follicles develop during first half of the menstrual cycle, known as follicular phase which starts the first day of menstrual bleeding and continues until ovulation on day 14. As ovarian follicles grow, the fill with fluid and secrete increasing amounts of estrogen. -graafian follicle: mature follicle w/mature egg 18-25 mm or 1.8 cm -cumulus oophorus: solid mass of follicular/granulosa cells that surround maturing ovum -corpus luteus cyst (CLS): single cyst with one ovary which develops after mature follicle ruptures -mittleschmerz: pain during menstruation

What is the relative size of the neonatal, prepubertal, pubertal, & postmenopausal uterus? What is the prepubertal & nulliparous cervix to uterine body ratio?

Uterine size: -Neonatal: 2-2.5 cm long (appears large due to maternal/placental hormones) -Prepubertal: 1-3 cm long -Pubertal: 6-8 cm long -Postmenopausal: 3-5 cm long Uterine body ratio: -Prepubertal 2:3 (⅔ length of uterus) -Nulliparous 1:3 (⅓ length of uterus)

Describe the attachments of the broad, round, & suspensory ligaments

-Broad ligaments: a peritoneal fold that attaches the uterus, fallopian tubes, and ovaries to the pelvis. -Round ligaments: fibrous cords that occur in front of and below the fallopian tubes between the layers of broad ligament. Supports uterus by connecting the front of the uterus to the groin region. -Suspensory ligaments: one continuous tissue that connects the ovary to the wall of the pelvis.

Where are the anterior cul-de-sac, posterior cul-de-sac, & space of Retzius located?

-Cul-de-sac is a potential space -anterior cul-de-sac is located anterior to the fundus of the uterus between the urinary bladder and the uterus. -posterior cul-de-sac is located posterior to the uterus between the uterus and the rectum AKA pouch of Douglas. -space of retzius is located between the anterior bladder wall and the pubis symphysis.

What is the normal appearance & thickness of the post-menopausal endometrium?

-Decreases in size due to lack of hormones. Endometrial appears as a thin echogenic line with a measurement of 4 mm or less or 5 mm or less can be considered normal.

What it the length of the Fallopian tubes? What are the 4 sections of the Fallopian tube? What is the narrowest section? Where does fertilization occur?

-Fallopian tubes are 10-12 cm in length. -4 sections: infundibulum (lateral segment), ampulla (middle segment), isthmus (medial segment), interstitial portion (segment that passes through the uterine cornua -The interstitial portion is the narrowest segment of the fallopian tube. -Fertilization occurs in the ampulla.

Be able to describe the location, course & appearance on sonography of the muscles of the false pelvis.

-Iliacus -Psoas To determine separation of iliacus and psoas muscles, the bright echogenic line representing the interposed fascial sheath can be used. The iliopsoas is hypoechoic and marginated. Both transverse and longitudinal images can be obtained through urinary bladder midline with lateral angulation

Be able to classify leiomyomas based on their location. Which one may be pedunculated? Which one is the most symptomatic?

-Leiomyomas (fibroids) are the most common neoplasms of the uterus. -Classifications: -intramural: confined to the myometrium (most common) -submucosal: projecting into the uterine cavity and displacing or distorting the endometrium -subserosal: projecting from the peritoneal surface of the uterus -Subserosal fibroids may be pedunculated and may present as adnexal mass. -Submucosal fibroids although are less common, produce the most symptoms and may be associated w/infertility.

What bones form the anterior, posterior & lateral borders of the female pelvis?

-Sacrum and coccyx form posterior pelvis -Ilium, ischium, and pubis (innominate bones) form anterior and lateral borders

Know & be able to identify the muscles located in the true pelvis & those that make up the pelvic floor.

-piriformis -obturator internus -levator ani

What are the 3 main part to the uterus? Where does the Fallopian tube enter the uterus & which portion of the Fallopian tube enters the uterus?

fundus, body and cervix. The fallopian tube enters the uterus at the fundus at the cornua. The innermost region of the fallopian tube, mucosal layer, runs directly into the mucosal layer of the uterus (endometrium).

What portion of the vagina is highly echogenic on sonography?

Inner layer of mucosa.

What are the maximum dimensions of the nulliparous, multiparous, & postmenopausal (> 65yrs old) uterus?

Nulliparous: 8x5x5 cm. Multiparous: 10x7x7 cm. Postmenopausal: 5x3x3 cm

What is the sonographic appearance of the ovary? Where is the ovary positioned? Where is the ovary located in relation to the internal iliac vessels & ureter?

Ovaries are almond shaped measuring approximately 3 cm and lie posterior to the uterus at the level of the cornua. Ovaries are usually located medial to the external iliac vessels and anterior to the internal iliac vessels and ureter. Follicles are anechoic, sharply marginated cysts.

What divides the true pelvis from the false pelvis? What are the landmarks of this division?

Pelvic brim. Sacrum to the pubic symphysis. The true pelvis is lesser and like a small bowl shape it contains the urinary bladder and sexual organs, while the false is the greater and lies superior to arcuate line and is not relevant to child birth.

What are the 3 layers of the uterus? Which layer is affected by hormones & what hormones affect it? What hormone influences what phase?

The 3 layers of the uterus consists of perimetrium (outer), endometrium (inner) and myometrium (middle). Perimetrium is the external layer and reflects on the anterior surface of the uterus at the isthmus. The myometrium is the thickest layer and is made of smooth muscle. Endometrium is the mucous membrane lining the uterine cavity, and is affected by hormones including estrogen and progesterone. Estrogen influences proliferative phase, while progesterone influences secretory phase

What are the muscles that make up the anterior abdominal wall?

The anterior part of the abdominal wall contains the rectus abdominis and pyramidalis muscles. The external and internal oblique muscles and the transversus abdominis muscle are lateral.

What structure connects the ovary to the uterine cornua? What structure connects the ovary & Fallopian tube to the pelvic sidewall?

The ovarian ligament connects ovary to uterine cornua. The suspensory ligament connects ovary and Fallopian tube to pelvic sidewall.

What is the sonographic appearance of skeletal muscle?

They appear as hypoechoic structures w/echogenic striations. -The rectus sheath separates the sonographic appearance of the rectus abdominis muscle from surrounding fat and bowel as a bright linear echogenic reflector