Sonographic Evaluation of the Female Pelvis Ch 42 Flashcards
Patient Prep & History
- Date of LMP
- Gravidity & Parity
- Symptoms
- Family History
- Past Surgeries/Biopsies
- Lab Tests
- Hormone Regimen
Transabdominal
transducer placed at lower abdomen/pelvic area, full bladder
Transvaginal
an internal pelvic
exam, empty bladder
documentation uterine shape, size, orientation
- Length measured in long axis
from fundus to cervix - AP depth in long axis from
anterior to posterior walls
(perpendicular to length) - Width measured from transverse
approach
documentation endometrium
Thickness of endo measured, analyze echogenicity
documentation cervix
Diameter measured with pregnancy
documentation myometrium (fibroids, irregularities)
Evaluated for contour changes,
echogenicity, masses
Adnexa- Ovaries & Fallopian
Tubes
- Evaluate ovaries- size & shape
- Position relative to uterus (Left?
Right?) - Fallopian tubes not always seen
sonographically, document if seen
Cul-De-Sac
- Evaluate for free fluid or mass
- Differentiate normal bowel loops from
mass
If a mass is detected anywhere in
pelvis, document size, location, echogenicity related to uterus and ovaries
Evaluation of a Mass
- Location- intrauterine or extrauterine
- Size- length, AP, width
- External Contour- smooth or irregular borders? well-defined margins or ill-defined?
- Internal Consistency- cystic, complex, solid
Transabdominal Scanning Protocol Sagittal plane:
- cervix, endocervical canal
- posterior cul-de-sac
- uterus (midline, right, and left)
- endometrium
- right ovary and adnexa
- left ovary and adnexa
Transvaginal Scanning Protocol Sagittal: Uterus
- Image from cervix to fundus, endometrial cavity: measure long axis
- Angle slowly to right of uterus
- Angle slowly to left of uterus
- Pull probe out slightly to image cervix
Transabdominal Scanning Protocol Transverse plane:
- vagina, cervix and posterior cul-de-sac
- uterine corpus/body and endometrium
- uterine fundus and endometrium
- right ovary and adnexa
- left ovary and adnexa
Transvaginal Scanning Protocol Coronal: Uterus
- Rotate transducer 90 degrees; image
uterine fundus, body, and cervix with
endometrial canal - Look for free fluid surrounding
uterine cavity.
Inner layer of uterus is
endometrium.
Endo layer is
thin, compact,
relatively hypovascular.
Thin outer layer separated from
intermediate layer by arcuate
vessels.
Normal arcuate vessels often seen
in
periphery of uterus and should not be mistaken for pathology.
Radial arteries arise as multiple
branches from
arcuate arteries and travel centrally to supply rich capillary network in deeper layers of
myometrium and endometrium.
ovaries are
mobile and can move considerably
in pelvis, depending on bladder volume
and whether woman has had previous
pregnancy.
Uterine location influences
position of ovaries.
ovaries are in shape
elliptical, with long axis usually oriented vertically.
Transvaginal scanning is superior for
characterizing texture of ovary.
Ovary is located just
lateral to uterus and
anteromedial to internal iliac vessel,
which can be used as landmark to
localize the ovary.
Transvaginally, the ovaries are easiest to
locate in
transverse plane lateral to the
cornua.
Not uncommon to find ovaries located
above uterus or posterior in rectouterine
cul-de-sac area
ovary appearance changes with
age and menstrual cycle
ovaries are measured in
sagittal or longitudinal plane at longest length and anteroposterior dimension
ovaries in transverse or coronal scans,
width is measured at widest point.
Volume of ovary calculated using formula for prolate ellipse:
0.523 = length× thickness × width
uterus body separated from
cervix by isthmus at level of internal os and identified by narrowing of canal.
Uterus is usually
anteverted and anteflexed.
Uterus may also be
retroflexed when body tilted posteriorly or retroverted when entire uterus tilted backward.
Cervical canal extends from
internal os, where it joins uterine cavity, to external os, which projects into vaginal vault.
imaging the cervix the transducer inserted into
vagina with patient supine, knees gently flexed, hips elevated on pillow.
After uterine cavity examined,
probe should be slowly pulled back slightly to
image internal and external cervical os.
imaging the cervix in sagittal view,
handle of transducer slowly moved upward and/or back to better
image cervix.
imaging the cervix with gentle rotation and angulation of
transducer, coronal images also obtained.
cervix can frequently visualize
cervical inclusion cysts (nabothian cysts) near
endocervical canal.
These cysts are generally
<1–2 cm wide; are anechoic smooth-walled
structures with acoustic enhancement posteriorly.
Of no clinical significance and generally not
measured.
Sonographic appearance of
endometrial canal seen as thin
echogenic line
endometrium consists of
superficial functional layer
and deep basal layer
During menstruation (days 1 to 4),
endometrial canal appears as
hypoechoic central line representing
blood and tissue and reaching 4 to 8
mm, including basal layer.
During this phase of early menses,
acoustic enhancement posterior to
endometrium may appear.
As menses progress (days 3 to 7),
hypoechoic echo that represented
blood disappears and endometrial
stripe is discrete thin hyperechoic line,
usually only 2 to 3 mm.
Early proliferative phase (days 5 to
9)-endometrial canal appears as
single thin stripe- measuring 4-8mm
Functionalis layer seen as
hyperechoic halo encompassing it
Basalis layer of endometrium represents the
thin surrounding
hyperechoic outermost echo.
Later proliferative phase (days 10 to
14)- endo becomes
thicker- measuring
6-10mm
Ovulation occurs toward the end of
proliferative phase.
During secretory (luteal) phase (days 15 to 28), endometrium at
greatest thickness and echogenicity, with posterior enhancement
Functionalis layer becomes
isoechoic with basalis layer.
Endometrial complex measures 7 to 14 mm during
secretory phase.
Endometrial thickness measured from
highly reflective interface of basalis
layer of endometrium and myometrium in sagittal view
Rectouterine recess (posterior cul-de-sac) is most
posterior and inferior
reflection of peritoneal cavity.
Located between rectum and vagina; also known as
pouch of Douglas
Posterior cul-de-sac frequently initial site for
intraperitoneal fluid collection
Gas and fluid-filled bowel loops are
poorly defined, echo-free mobile structures
that usually demonstrate peristalsis under observation.
Solid material in bowel
hyperechoic and may produce shadowing, as does gas.
Sonohysterography also known as
saline infused sonography (SIS) or hysterosonography.
Sonohysterography involves .
instillation of sterile saline solution into endometrial cavity
Sonohysterography is used to
further evaluate endometrium when it exceeds normal thickness or shows focal areas of thickening and polyps suspected.
In premenopausal women, procedure is performed in
mid-menstrual cycle, usually between days 6 and 10.
Sonohysterography will prevent
possibility of disrupting early pregnancy and prevent blood clots artifactually filling some of endometrial cavity
