Ultrasound Examination in Obstetrics and Gynecology

6/11/2015
Ultrasoundexaminationinobstetricsandgynecology
OfficialreprintfromUpToDate
www.uptodate.com2015UpToDate
Author
ThomasDShipp,MD,
RDMS
SectionEditors
CharlesJLockwood,MD,
MHCM
DeborahLevine,MD
DeputyEditor
VanessaABarss,MD,
FACOG
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:May2015.|Thistopiclastupdated:Apr24,2015.
INTRODUCTIONTheterm"ultrasound"referstosoundwavesofafrequencygreaterthanthatwhichthe
humanearcanappreciate,namelyfrequenciesgreaterthan20,000cyclespersecondorHertz(Hz).Toobtain
imagesofthepregnantornonpregnantpelvis,frequenciesof2to10millionHertz(2to10megahertz[MHz])
aretypicallyrequired.
Realtimeimagingisthemostcommonsonographictechniqueusedinobstetricsandgynecology.Multiple
individualBmodegrayscaleimagesareobtainedandrapidlydisplayedinsuccession,therebycreatingavideo
oftheareaofinterestovertimethatcanbeusedtoevaluateitsstructureandsomeaspectsofitsfunction.
Realtimeultrasoundisespeciallyusefulforimagingmobilesubjects,suchasthefetusorheart,andfor
quicklyviewinganorganfromdifferentorientations.
Thephysicalprinciplesofultrasoundimagingarediscussedseparately.(See"Basicprinciplesandsafetyof
diagnosticultrasoundinobstetricsandgynecology".)
BASICPROCEDUREANDEQUIPMENTSonography,likesurgery,isanoperatordependenttechnology.
Ahighlevelofcompetencecanonlybeachievedbysupervisedexperiencewithalargevarietyofnormaland
abnormalexaminations.
PreprocedureissuesThesonographershouldknowthereasonfortheultrasoundexaminationandresults
ofotherevaluationsrelatedtothepatient'sproblem.Allofthisinformationiscriticalfortargetingspecific
structures,choosingwhethertouseatransvaginaland/ortransabdominaltechnique,anddecidingwhether
additionalstudiesmaybehelpful(eg,salineinfusionsonohysterography,Dopplervelocimetry).
Inthepast,patientswereroutinelyaskedtofilltheirbladderspriortotheultrasoundexamination.With
improvementsinultrasoundtechnologyanduseofthevaginalprobe,thishasbecomeunnecessary[1].There
islittlebenefittohavingafullbladderforobstetricalexamsanditisoftenveryuncomfortableforthepatient.
Furthermore,afullbladdercandistortanatomy(eg,falsediagnosisofplacentapreviaorfalselyelongated
cervix).Thecervixcanusuallybeseentransabdominallywithoutafullbladder.Ifitcannotbeseen
transabdominally,transvaginalsonographyalmostalwaysprovidessatisfactoryimages.Similarly,if
transabdominalvisualizationofthepregnancyisinadequateinthefirsttrimester,transvaginalsonographywill
almostalwaysshowmoredetailandisoptimallyperformedwithanemptybladder.
Ingynecologicpatients,notallowingthepatienttoemptywhateverurineisinherbladderjustpriortoa
transabdominalultrasoundexaminationgenerallypermitssufficientinitialvisualizationofthepelvis.As
discussedabove,transvaginalsonographyshouldbeperformedwithanemptybladder.
ObesityAbdominalobesitylimitsthetechnicalqualityoftheultrasoundexamination.Imagingmaybe
improvedbyhavingthepatientlieonhersideandplacingthetransduceratthesideofthematernalabdomen
ratherthaninthemidlinewherethereisgreaterthicknessofabdominaladiposetissueand/orbyuseof
transvaginalultrasound.Althoughfetalanatomicsurveysformalformationsaretypicallyperformedat18to20
weeks,performingtransabdominalexaminationlateringestation(20to22weeks)intheobesegravidamay
improvevisualizationofanatomy[2].However,transvaginalultrasoundoffetalanatomymaybemoreeffective
earlier.
PatientpositionInobstetricsandgynecology,mostexamsareperformedwiththewomaninasemi
recumbentposition.Apaddedtableandpillowsprovidereasonablecomfort.Itisdesirabletobeabletoelevate
http://www.uptodate.com.ezproxy.ugm.ac.id/contents/ultrasoundexaminationinobstetricsandgynecology?topicKey=OBGYN%2F5388&elapsedTimeM
1/15
6/11/2015
theheadofthebedbecausemanypregnantwomenareunabletolieflat,especiallylaterinpregnancy.Others
willrequirepillowsunderneaththeirkneesorbehindtheirbacktoachieveacomfortableposition.
Transvaginalultrasoundexaminationsaredonewiththewomaninalithotomyposition.Alternatively,acushion
canbeplacedunderthebuttockstoraisethepelvis,whilethelowerextremitiesarefroglegged.
GelUltrasoundwavesdonotpassthroughairwelltherefore,couplinggelisnecessary.Thegel,whichis
placedonthepatient'sskinfortransabdominalscansandonthecoveredprobefortransvaginalscans,
preventsairfromcomingbetweenthetransducerandthepatient.Thegelalsopermitstheultrasoundprobeto
gentlyslideovertheabdomenoralongthevagina.Warmingthegelinacommercialwarmingdeviceimproves
patientcomfort.
TransducersandprobesThetransducerislocatedinsidetheultrasoundprobe.Themostcommon
transducersusedfortransabdominalscanningaresectororcurvilineartransducersthathavefrequenciesupto
7.0or8.0MHz[3].Transducersusedfortransvaginalscanningtypicallyhavefrequenciesupto9.0MHz.Itis
importanttokeepinmindthathigherfrequencytransducersprovidesuperiorresolution,buthavelesstissue
penetration.Thistradeoffisimportantforachievingimagesofdiagnosticquality.
Standardorientationwhenperforminganultrasoundexaminationallowsaconsistentoptimalinterpretationof
theultrasoundfindings.Thetransabdominalultrasoundprobeisheldintherighthandwiththemark(ie,a
grooveorridgeononesideoftheultrasoundtransducer)onthethumbside.Withthisorientation,therightside
ofthepatientisdisplayedontheleftsideoftheultrasoundimagingscreen.Thetopoftheimage(thesmall
angledportion)representsstructuresthatareclosertothetransabdominalultrasoundtransducer,andthe
bottomoftheimage(thewidepieshapedperimeter)representsstructuresfurtherawayfromthetransducer.
Becausetheultrasoundprobecanbemaneuveredfrommanydifferentvantagepoints,theimageorientationis
onlylimitedbytheflexibilityofthehandholdingtheultrasoundprobe.
Transvaginalultrasoundprobesdifferfromtransabdominalprobes.Withatransvaginalprobe,theultrasound
beamcanprojectatananglefromtheaxisoftheprobe.Themarkontheproberepresentstheleftsideofthe
screen.Therefore,iftheprobeisinsertedintothevaginaandthemarkisheldat12:00,theleftsideofthe
imagedisplayrepresentstheanterioraspectofthepelvis,andtherightsiderepresentstheposterioraspectof
thepelvis.Thetopoftheimage(thesmallangledportion)representsstructuresthatareclosertothe
transvaginalultrasoundtransducer,andthebottomoftheimage(thewidepieshapedperimeter)represents
pelvicstructuresfurtherawayfromthetransducer.Whentheprobeisrotatedwiththemarkat9:00,the
orientationisquitedifferent.Theinferiorandsuperiorportionsareunchanged,buttheleftandrightsidesofthe
screennowrepresenttherightandleftaspectsofthepelvis,respectively.Thetransvaginalprobecanbeboth
rotatedandangledtobothsidesofthepelvis.Thismaneuveringcanbedisorientingtoinexperienced
examiners,yetisessentialforacompleteexaminationofthefemalepelvis.
Itmaybemorecomfortableforthepatientifsheinsertsthetransvaginalprobeintohervaginaherself.A
disposableprobecover(eg,malecondom)isusedtokeepthetransvaginalprobecleanduringexaminations
[4].Aftereachuse,transvaginalprobesarecleanedanddisinfectedaccordingtothemanufacturer
recommendations.Thegoalofpreparingtransvaginalultrasoundtransducersforpatientuseistoachievea
highlevelofdisinfection.Thisisaccomplishedbyremovingthedisposableprobecoverandusingrunning
watertoremoveanydebris.Aclothorsimilarpadcanbeusedtocleananddrythetransvaginalprobe.The
probeisthendisinfectedwithahighleveldisinfectanttoprovidemaximumsafetyforreuseinthenextpatient.
Therearemanysuchdisinfectants,including2.4to3.2percentglutaraldehydeproducts,suchas"Cidex,"
"Metricide,"and"Procide,"nonglutaraldehydeproducts,suchas"CidexOPA"and"CidexPA,"and7.5
percenthydrogenperoxidesolution[4].
ManualsettingsSeveralparametersrequiremanualadjustmenttoobtainoptimalimagesbecausepatients
differinbodyshapeandintheareatargetedforexamination(eg,culdesac,upperabdomen,kidney).
Thesizeoftheimagefieldshouldbeadjustedtoobtainthebestvisualization.Theareaofinterestshould
beenlargedtoallowforcriticalevaluation.
Thedepthofpenetrationshouldbeadjustedforthoroughassessmentofthestructureofinterestandits
environment.Ifsethigh,abroadanatomicareacanbeseen,butindividualstructureswillbesmall,
2/15
6/11/2015
indistinct,and'faraway,'whileatlowsettings,theimagewillbeseen'closeup'anddetailed,but
surroundingstructureswillnotbevisualized.Dependingontheareaofinterest,thedepthofpenetration
willtypicallybeadjustedmanytimesduringanultrasoundexaminationtobothobtainabroadviewandto
honeinonspecificstructures.
Thefocalzoneshouldbeelectronicallyadjustedtoenhancevisualizationofstructuresatthedepthbeing
evaluated.Thetransmitzonefocusshouldbemanuallyplacedat,orjustbelow,thelevelofthestructure
ofinterest.
Thegainshouldbeadjustedtoachieveanappropriatelevelofbrightness.Turningthegainuptoohigh
willmaketheimagetoobright,andturningitdowntoolowwillmaketheimagetoodark.Thereis
progressivelossofamplitudeandintensityofreturningsoundwaveswhenimagingstructuresthatareat
greaterdistancesfromtheprobe.Thislossvarieswiththeparticulartissuebeinginsonated.Echoesfrom
deeperstructurescanbeamplifiedorenhancedtoimprovevisualization.Similarly,excessivereverberant
echoescanbedecreasedbyturningdownthegain,thusraisingthethresholdforechodetectionata
particularlevel.Thisisaccomplishedbyusingthetimegaincompensation(TGC)knobs,whichare
adjustedtochangethebrightnessatvariouslevelsoftheimage[3,5].Somenewerultrasoundmachines
haveanautomaticallyadjustinggainfeature.Thismaybeespeciallyhelpfulforthosewithless
experience,andforthosepatientswhoaremoredifficulttoinsonate,suchasobesewomenorthosewith
priorabdominalsurgery.
Tissueharmonicimagingisanultrasoundtechniquethatenhancesvisualizationofstructuresthatmay
nothavebeenvisualizedclearlywithstandardgrayscaleimaging[6].Standardtwodimensionalgray
scaleultrasoundusesacertainfundamentalfrequency,specifictothetransducer.Thereturningechoes
aredetectedatthisfrequency.Harmonicfrequenciesoccurasthesoundwavemovesthroughtissues
andareformedinmultiplesofthefundamentalfrequency.Thefirstharmonic,whichistwicethe
fundamentalfrequency,isusedfortissueharmonicimaging.Theseharmonicfrequenciesincreasewith
morepenetrationoftheultrasoundbeam,andtheyareatloweramplitudethanthefundamental
frequency.Theinclusionoftheseharmonicfrequenciesresultsinanimagewithbettercontrast.Tissue
harmonicimagingisespeciallyhelpfulinobstetricsandgynecologyintheobesepatientwhen
visualizationislimited[5,7].
ScanninganddocumentationThepatient'sname,medicalrecordnumber,dateofexam,referring
clinician,andreasonforreferralshouldbedocumented.Itisbesttostarttheexaminationbygettinganoverall
viewoftheuterusinanobstetricalultrasoundexaminationorthepelvisinagynecologicexamination.Afterthis
globalview,theexamcanfocusonspecificaspectsofanatomy.Toaccomplishthisoverallview,thedepthof
penetrationshouldbegreatenoughtoallowforabroadviewoftheuterusandpelvis.Withoutthisglobalview,
importantaspectsoftheexaminationcouldbemissed(eg,largepedunculatedfibroidsorlargeovarian
dermoids).
Almostallobstetricalandgynecologicsonographyisdoneinrealtime,freelymovingtheprobetovieweach
structurefrommultipleorientationsandthenfreezingandstoringthedesiredimages.Mostultrasoundsystems
canreevaluatethelastfewsecondsofimagesbyscrollingthroughthemasslowasframebyframeinacine
loop.Shortclipsofmobilestructures,suchasthefetalheart,arealsocommonlykeptaspartofthepatient's
record.Imagesofbothnormalandabnormalanatomy,includingsizemeasurementswhereappropriate,should
bestored.Biometricmeasurementsaretypicallyperformedonthedisplaymonitorfromafrozenimage.(See
"Prenatalassessmentofgestationalageandestimateddateofdelivery".)Theultrasoundimagesshouldbe
retainedaslongasclinicallyusefulandconsistentwithlocallegalrequirements.
Awrittenultrasoundreportshouldbeincludedinthepatient'smedicalrecord,andsenttothereferringclinician
inatimelyfashion[810].Clinicallysignificantfindingsshouldbecalledtothereferringcliniciantoensureand
facilitateappropriatefollowup.Emergentfindingsshouldbecalledtothereferringclinicianwhilethepatientis
stillintheultrasoundfacilityorenroutetothephysician'sofficeorhospital.
ADVANCEDTECHNIQUESAdditionalclinicaltechniquesareusedselectivelytoprovidefurtherevaluation
ofuncertainfindingsonrealtimegreyscaletwodimensionalsonography[6].
ThreedimensionalsonographyThreedimensionalsonographyreferstoatwodimensionalstaticdisplay
3/15
6/11/2015
ofthreedimensionaldata.Specialprobesandsoftwareareneededtoacquireandrendertheimages.Although
notanewtechnique,theindicationsforitsusehavenotbeenwelldefined[5].Theuseofthreedimensional
technologycanreducescanningtimewhilemaintainingadequatevisualizationofthefetusinobstetrical
ultrasoundandthepelvisingynecologicultrasound[1113].Surfacerenderingofthefetuswiththree
dimensionalsonographycanbetterdemonstrateabnormalitiespreviouslydetectedwithtwodimensional
sonography,especiallyfacialabnormalitiesandneuraltubedefects.Fetalcentralnervoussystemthree
dimensionaldatasetscanbeexaminedremotelytodiagnosefetalbrainmalformations[14].
Ingynecology,thecoronalplaneoftheuterusiseasilyobtainedwiththreedimensionalbutnottwodimensional
sonography,thusenhancingvisualizationoftheuterus,especiallytheuterinecavity.Thishasimprovedthe
capabilitiesforthesonographicdiagnosisofuterineanomalies[15].
Threedimensionalsonographyhasbeenusedtoidentifymalpositionofanintrauterinedevice(IUD),especially
amongsymptomaticpatients[16].
FourdimensionalsonographyFourdimensionalsonographyreferstothreedimensionalimagesthatcan
beviewedinrealtime.Itisalsocalleddynamicthreedimensionalsonography.Ithasbeenusedtostudythe
fetalheart,fetalmovement,andfetalbehavioralstates.
SonohysterographySalineinfusionsonohysterographyreferstoaprocedureinwhichfluidisinstilledinto
theuterinecavitytranscervicallytoprovideenhancedendometrialvisualizationduringtransvaginalultrasound
examination.(See"Salineinfusionsonohysterography".)
DopplerultrasoundRealtimeultrasoundisprimarilyusedtoevaluatemorphology,andisespeciallyuseful
forstudyingtheanatomyofmovingobjects,suchasthefetus.Bycomparison,Dopplerultrasoundisusedto
studybloodflowandisparticularlyhelpfulinevaluatingthefunctionalstateofthefetalcardiovascularsystem,
fetoplacentalanduteroplacentalbloodflow,andpelvictumors.SpecificusesofDopplersonographyarefor
evaluationoffetalanemiabyassessingpeaksystolicflowinthemiddlecerebralartery,forevaluationof
uteroplacentalinsufficiencyinfetuseswithgrowthrestriction,andforassessingbloodflowtosuspected
ovariantumorsamongmenopausalwomen.Dopplercolorflowmappingusesdifferentcolorstodepictthe
directionofflowonarealtimeultrasoundimage.PowerDopplerenablesvisualizationofslowerflowinsmall
vesselswithoutdifferentiatingthedirectionofbloodflow.
DopplerultrasoundandspecificusesofDopplerultrasoundarediscussedindetailseparately:
(See"Dopplerultrasoundoftheumbilicalarteryforfetalsurveillance".)
(See"VenousDopplerforfetalassessment".)
(See"Sonographicdifferentiationofbenignversusmalignantadnexalmasses".)
(See"ManagementofpregnancycomplicatedbyRhesus(Rh)alloimmunization",sectionon'Middle
cerebralarterypeaksystolicvelocity'.)
TELEMEDICINEBothtwodimensionalultrasoundimagesandthreedimensionaldatasetscanbesent
electronicallyforevaluationbyexperts[1113]ortofacilitateconsultationbetweenapatientorreferring
physicianandaspecialist[17].Thetransmissionandsharingofultrasoundimagesandvolumescanbeeasily
accomplishedusingtheDigitalImagingandCommunicationsinMedicine(DICOM)protocol[17].Theprovision
ofsuchconsultativeservicestoresourcepoororremoteareasallowspatientcaretooccurthatmaynothave
happened,exceptundermoredifficultcircumstances.
OBSTETRICALSONOGRAPHYObstetricalultrasoundprovidesinformationaboutthepregnancythatis
essentialforprovidingoptimalprenatalcare:accuratedeterminationofgestationalage,fetalnumber,cardiac
activity,placentallocalization,anddiagnosisofmajorfetalanomalies[18].Inthesecondtrimester,fetal
anomalydetectionratesrangefrom16to44percent,withdetectionratesupto84percentforlethalanomalies
[18].Ultrasoundexaminationalsoimprovesthedetectionoffetalgrowthdisturbancesandabnormalitiesin
amnioticfluidvolumehowever,abeneficialimpactonpregnancyoutcomehasnotbeenproven.
IndicationsSpecificobstetricalindicationsforultrasoundexaminationarelistedinthetable(table1).More
thanoneexaminationisindicatedforpatientswithongoingriskfactorsforadversepregnancyoutcome.
TheAmericanCollegeofObstetriciansandGynecologists(ACOG)alsostatesthatthebenefitsandlimitations
4/15
6/11/2015
ofultrasonographyshouldbediscussedwithallpatients,afterwhichperformanceofascreeningprocedureis
reasonableinpatientswhorequestit[19].Aneuploidyscreeningexaminationscanbeperformedinthefirst
and/orsecondtrimester.Afetalstructurescreeningexaminationistypicallyperformedinthesecondtrimester.
Ifasinglescreeningexaminationisperformed,theoptimaltimeisat18to20weeksofgestation[18].This
representsabalancebetweenaccuratedatingofgestationalageanddetectionoffetalanomalies.(See
"Routineprenatalultrasonographyasascreeningtool".)
BasicexaminationAbasicobstetricalultrasoundexaminationprovidesthefollowinginformation[1921]:
Fetalnumber(chorionicityifmultiplegestation)
Fetalbiometry
Fetalpresentation
Documentationoffetalcardiacactivity
Placentalappearanceandlocation
Assessmentofamnioticfluidvolume
Surveyoffetalanatomy(lateralventricles,choroidplexus,falx,cavumseptipellucidi,cerebellum,
cisternamagna,upperlip,4chambercardiacviewandventricularoutflowtracks,stomach,kidneys,
bladder,cordinsertionsiteandvesselnumber,spine,limbs,genitaliainmultiplegestations)
Maternalanatomy(cervix,uterus,adnexa)
Fetalbiometryisusedtoestimategestationalageandfetalweight,asappropriateforthestageofpregnancy.
(See"Prenatalassessmentofgestationalageandestimateddateofdelivery"and"Prenatalsonographic
assessmentoffetalweight".)
ACOGrecommendsthatthecervixandadnexabeexaminedwhenclinicallyappropriateandtechnically
feasible[19].TheAmericanInstituteofUltrasoundinMedicine(AIUM)andtheAmericanCollegeofRadiology
(ACR)echothisposition,andfurtherstatethat"atransperinealortransvaginalscanmaybeconsideredwhen
evaluationofthecervixisneeded"[9,22,23].(See"Secondtrimesterevaluationofcervicallengthforprediction
ofspontaneouspretermbirth".)
Fetalmovementshouldbeassessed,althoughtemporaryabsenceorreductionoffetalmovementduringan
examinationisnotnecessarilyworrisomeasitcanbeduetoanormalfetalsleepcycle.(See"Decreasedfetal
movement:Diagnosis,evaluation,andmanagement",sectionon'Normalfetalmovement'.)Abnormal
positioningorunusuallyrestrictedorpersistentlyabsentfetalmovementsmaysuggestanabnormality,suchas
arthrogryposis.
Thespecificcomponentsoffirstversussecondandthirdtrimesterexaminationsarelistedinthetables(table2
andtable3).Ifacomponentisnotvisualizedadequately,apanelofexpertsopinedthatafollowup
examinationintwotofourweeksmaybereasonable,dependingonthelimitationsandfindingsoftheinitial
examination[18].
Indepthdiscussionsofsonographicexaminationofcongenitalanomalies,theplacenta,amnioticfluid,andfetal
growthabnormalitiescanbefoundseparately:
(See"Clinicalfeatures,diagnosis,andcourseofplacentaprevia".)
(See"Clinicalfeaturesanddiagnosisofthemorbidlyadherentplacenta(placentaaccreta,increta,and
percreta)".)
(See"Assessmentofamnioticfluidvolume".)
(See"Fetalgrowthrestriction:Diagnosis".)
(See"Fetalmacrosomia".)
(See"Sonographicfindingsassociatedwithfetalaneuploidy".)
(See"Secondtrimesterevaluationofcervicallengthforpredictionofspontaneouspretermbirth".)
Seeindividualtopicreviewsonspecificcongenitalanomalies
LimitedexaminationLimitedultrasoundexaminationscanbeperformedtoaddressspecificfocused
questions,ideallyinpatientswhohavebeenpreviouslyevaluatedbyacompleteexamination.Examplesof
5/15
6/11/2015
appropriateuseoflimitedstudiesincludeconfirmationofthepresenceorabsenceoffetalcardiacactivity,
checkingfetalpresentation,andassessmentofamnioticfluidvolumeinconjunctionwithnonstresstesting[9].
DetailedexaminationAdetailedfetalstructuralsurveyshouldonlybeundertakenbythosewiththe
necessarytrainingandskillsrequiredfortheseadvancedexaminations.Indicationsforadetailedfetal
examinationinclude,butarenotlimitedto,apreviouspregnancyaffectedbyafetalanatomicor
genetic/chromosomalabnormality,suspectedorknownfetalanatomicorgenetic/chromosomalabnormalityin
thecurrentpregnancy,knownfetalgrowthdisorder,andcurrentpregnancycomplicationspossiblyaffectingthe
fetus(eg,congenitalinfection,abnormalamnioticfluidvolume,alloimmunization)[21].Fetalevaluationinthese
settingsrequiresamoredetailedexaminationoffetalanatomythanabasicfetalsurveyandrequiresmore
advancedskillsandknowledge.In2013,ataskforcecomposedofparticipantsfromseveralmajornational
obstetricalandradiologicalorganizationsintheUnitedStatesdevelopedaconsensusreportwithguidelinesfor
performanceofthisexamination[21].Thedetailedexaminationincludesalloftheelementsofthebasic
examinationandalsomayinclude:
Evaluationofthebrain,includingallventricles,parenchyma,vermis,cisternamagna,cerebellum,and
corpuscallosum
Neckincludingnuchalthickness
Innerandouterfacialstructures(eg,palate,orbits,lens,lips,nose/nasalbone,jaw)
Ears
Detailedexaminationofcardiopulmonaryanatomy
Diaphragm
Ribs
Smallandlargebowel
Adrenalglands
Gallbladder,liver
Spleen
Renalarteries
Abdominalwall
Spine
Limbs,includinghands,feet,digits(numberandposition),humerus,femur,ulna,radius,tibia,fibula
Sex
Umbilicalcord(vessels,placentalinsertion,structure)
Placenta(lobes)
Neoplasms
TransabdominalexaminationThepatient'sabdomenisexposedfromthepubicbonetotheumbilicusor
xiphoid(dependinguponstageofpregnancy)anddrapedtopreventgelfromsoilingclothing.Itisprudentto
documentfetalcardiacactivityastheinitialstep,asadiagnosisoffetaldemisedeterminesthecontextforthe
remainderoftheexamination.Usingrealtimescanning,thetransabdominalultrasoundprobeismaneuvered
intodifferentpositionstoallowvisualizationofmultiplestructures,toviewasinglestructurefrommany
differentvantagepoints,andtoavoidinterferencefromimpedimentssuchasboneandintestinalair.Other
maneuversthatmayimprovethequalityoftheimageinclude:
Adjustingthefrequencyoftheultrasoundwave:higherfrequenciesresultinlowerpenetrationand
improvedresolution.Multipletransducersofdifferentfrequenciesmaybenecessaryduringan
examinationtobalanceresolutionandneedfortissuepenetration.Asanexample,ifoneoftheareasto
beexaminedisclosetotheultrasoundprobe,ahigherfrequencyprobewouldgivethebestresolution,but
maynotgiveanadequateimageofanotherstructuredeepinthepelvis.
Usingtheprobetoapplypressure.Thiscanbeparticularlyhelpfulwhenassessingtherelationship
betweentwoormorecontiguousstructures.
Havingthepatientrollfromsidetoside.Scanningfromthesideofthematernalabdomencansometimes
greatlyimprovevisualizationofthefetusinpregnantwomenwithtruncalobesity.
6/15
6/11/2015
Ifthefetalpresentingpartislowinthepelvis,elevatingthematernalhipsmayhelpmovethepresenting
partcephalad,makingiteasiertovisualize.
TransvaginalexaminationAtransvaginalultrasoundexaminationisindicatedforevaluatinganearly
pregnancy,assessingthecervixtoevaluatebleeding(eg,length,proximitytoplacenta),orimproving
visualizationoffetalpartslowinthepelvis.(See"Prenatalassessmentofgestationalageandestimateddate
ofdelivery"and"Secondtrimesterevaluationofcervicallengthforpredictionofspontaneouspretermbirth".)
Transvaginalprobesaremanipulatedbothbyrotationandanglingfromthemidline.Properorientationis
essentialasthefieldofviewismuchsmallerwiththetransvaginalprobeascomparedtotransabdominal
probes(see'Transducersandprobes'above).
Nonmedicaluse(See"Basicprinciplesandsafetyofdiagnosticultrasoundinobstetricsandgynecology",
sectionon'Nonmedicaluse'.)
GYNECOLOGICSONOGRAPHY
IndicationsGynecologicultrasoundexaminationhasmultipleuses,includingbutnotlimitedto[24]:
Evaluationofthemenstrualcycle(endometrialthickness,folliculardevelopment)
Monitoringnaturalorstimulatedfolliculardevelopmentduringinfertilitytherapy
Localizationofanintrauterinedevice
Evaluationofabnormaluterinebleeding
Assessmentofapelvicmass(eg,adenomyosis,fibroid,cancer,cysts)
Evaluationforsequelaeofpelvicinfection(eg,abscess,hydrosalpinx)
Evaluationofcongenitaluterineanomalies
Screeningformalignancy
ComponentsThecomponentsofatypicalgynecologicsonographicexaminationinclude[24]:
Uterinesize,shape,andorientation
Evaluationofendometrium,myometrium,andcervix
Identificationandmorphologyofovaries,ifpossible
Assessmentoftheuterusandadnexaformasses,cysts,hydrosalpinges,fluidcollections
Evaluationoftheculdesacforfreefluidormasses
Normalfallopiantubesusuallycannotbeseenduringpelvicsonography.
ExaminationTheultrasoundexaminationisusuallyinitiatedtransabdominally.Thebladderdoesnothaveto
befullhowever,ifthepelviscannotbeseenwell,itmaybenecessarytohavethepatientfillherbladdertoa
comfortablecapacity.Thismaybeespeciallyimportantforthosewomenwhoareunabletotolerateplacement
ofatransvaginalultrasoundprobe.Ofteninthesecases,theentireexaminationcanbeperformed
transabdominally.Ifaspecificquestionremainsunanswered,orifanabnormalityissuspected,other
approaches,suchasatransrectalexaminationorevenatransperinealexamination,maybeconsidered.Other
techniquesforimprovingvisualizationaredescribedabove(see'Transabdominalexamination'above).
Transabdominalscanningisimportantforevaluatingtheupperpelvisandabdomen,suchaswithlargefibroids,
ovarianneoplasmsthatextendintotheupperabdomen,orovarieslyinghighinthepelvis.Imagesonly
obtainedbytransvaginalscanningmaynotbeadequate,ormaymisspathology,asdistancebetweenthearea
underinvestigationandthevaginaincreases.
Afterevaluationofthepelvistransabdominally,thepatientisaskedtovoidbecausetransvaginalsonographyis
bestperformedwithanemptybladder.Guidingtheprobetowardtheareaofinterest,suchasanovary,and
watchinghowthisareamovesinrelationtotheotherpelvicorgansishelpfulforevaluationofcomplicatedor
unclearpelvicanatomy,especiallyinthesettingofabnormalities.Asanexample,apelvicmass(pedunculated
fibroidorsolidovarianmass)mayliebetweentheuterusandnormalappearingovariantissue.Onastillimage,
theuterus,mass,andnormalovarymayappearcontiguous.Withmovementoftheprobe,thespecificoriginof
themasscanusuallybedetermined.
7/15
6/11/2015
Visualizationofpelvicstructureswiththetransvaginalprobeislimitedbytherelativepositionsofthepelvic
organsandthepresenceofanypelvicmasses.Theresolutionofhighfrequencyvaginalprobesisgooduptoa
depthof6to8cm.Transvaginalsonographycanbeperformedconcurrentlywithanabdominalexaminationto
betterdefinenormalandabnormalanatomy[25].Asanexample,byapplyingpressureabdominally,theuterus
withanyassociatedfibroids,andeventheintestines,canbemovedawayfromtheovaries,allowingbetter
visualization.
Uterineweightcorrelateswithuterinevolume,whichcanbecalculatedusingtheprolateellipsoidmethod
wherevolume=4/3(pi)(uterinelength/2)(anteroposteriordiameter/2)(transversediameter/2)[26,27].Uterine
measurementsaremostaccuratelyobtainedbytransvaginalsonography[28].Themeanouterdimensionsof
theuterusamong263premenopausalwomen(nulliparas,primiparas,multiparas)andmenopausalwomen(less
thanorequaltofiveyearsofmenopause,andgreaterthanfiveyearsofmenopause)withnouterineorovarian
pathologicalfindingsareshowninthetable(table4).Theaveragetransversewidthoftheendometrialcavity
(ie,insidedimensionoftheuterus)is2.7cmamongnulliparas,3.0cmamongprimiparas,and3.2cmamong
multiparas[29].
Thetypicalmeasurementofendometrialthicknessincludesboththeanteriorandposteriorendometrialwalls.If
fluidispresentwithintheendometrialcavity,theanteriorandposteriorendometrialechoescanbemeasured
independentlyandsummed.Immediatelyaftermenses,theendometriumis1to4mmthickastheestrogen
concentrationrises,thethicknessincreasesto7to10mm.Afterovulation,echogenicityincreasesstartingin
thebasalareabythelutealphase,theentireendometriumishyperechogenicwithathicknessof8to16mm.
Inpostmenopausalwomen,athickendometriallining(definedas>4mm)canbeamarkerofendometrial
hyperplasiaormalignancy[30].
Multiple2to5mmfolliclesmaybeseenintheovaries.Aleadingfollicleofabout10mmcanbeidentifiedat
the9thor10thcycledayitgrowsrapidlyandis20to24mmindiameterjustbeforeovulation.Afterovulation,
thecorpusluteumdevelopsandmayhaveaslightlyheterogeneousconsistency.Thewalltypicallyappearsto
bethickwithlowlevelinternalechoesandcircumferentialbloodflow.Thediameterofanormalfollicleor
corpusluteumdoesnotusuallyexceed30mm.Acorpusluteumcystappearsasahomogeneous
hypoechogenicthinwalledstructure.
Anyabnormalitynotedshouldbedescribed,asappropriate:size,shape,location,echogenicity,echopattern
(cystic,solid,complex,septations),andadifferentialdiagnosisofthemostlikelycausesoftheabnormality
shouldbeprovided.Additionalstudies,suchasDopplervelocimetryorsalineinfusionsonohysterography,may
beusefulindefiningsuspectedlesions,orthreedimensionalsonography,whichmaybehelpfulforevaluating
theuterineshapeinthosepatientswithinfertility.
Theuseofultrasoundingynecologyandultrasoundimagesofgynecologicdisorderscanbefoundseparately:
(See"Sonographicdifferentiationofbenignversusmalignantadnexalmasses".)
(See"Ultrasonographyofpregnancyofunknownlocation".)
(See"Ultrasoundevaluationofthenormalmenstrualcycle".)
(See"Evaluationoftheendometriumformalignantorpremalignantdisease".)
PelvicfloorsonographyTranslabialortransperinealultrasoundisbeingusedincreasinglytoevaluatethe
pelvicfloorintheworkupofwomenwithpelvicorganprolapseandurinaryoranalincontinence.Otherusesof
pelvicfloorsonographyincludeevaluationofurethraldiverticula,rectalintussusception,meshlocation,and
residualurinevolume[31].Theroleofpelvicfloorsonographyintheevaluationofwomenwithpelvicfloor
symptomsisstillunderinvestigation.(See"Endorectalendoscopicultrasoundintheevaluationoffecal
incontinence".)
CREDENTIALSSonographyisanoperatordependenttechnology:ahighlevelofcompetencecanonlybe
achievedbysupervisedexperiencewithalargevarietyofnormalandabnormalexaminations.
IntheUnitedStates,ultrasoundexaminationsinobstetricsandgynecologyaretypicallyperformedby
diagnosticmedicalsonographers.AlmostallofthesehealthprofessionalsarecredentialedbytheAmerican
RegistryofDiagnosticMedicalSonography(ARDMS)andreceivethecredentialsRDMSuponcompletionof
extensiveeducation,training,andtesting.SomesonographersarealsocredentialedbytheAmericanRegistry
8/15
6/11/2015
ofRadiologicTechnologists.
Theexaminationsaresupervisedandinterpretedbyasonologist,whoisaphysicianwithtrainingand
experienceinthisarea.Itisuptothephysiciantoprovideareportbaseduponthedataprovidedbythe
sonographer,and,ifindicated,bypersonallyscanningthepatienttoconfirmormodifythedifferentialdiagnosis.
IntheUnitedStates,theAmericanInstituteofUltrasoundinMedicineandtheAmericanCollegeofRadiology
(ACR)haveformulatedguidelinesfortraining,credentialing,continuingeducation,andultrasoundlaboratory
accreditation(availableontheInternetatwww.aium.organdwww.acr.org)[8,32].
HUMANFACTORSANDERGONOMICSWorkrelatedmusculoskeletaldisordersareincreasingly
prevalentamongthosewhouseultrasoundtechnology.Someaspectsofthesonographicexaminationthatcan
leadtopainandmusculoskeletaldysfunctionmaynotbemodifiablebytheclinician,eg,therepetitivemotion
associatedwithscanningorpatientobesity.Manyotheraspects,however,canbemodifiedtodecreasethe
riskofmusculoskeletaldisorders.Theseincludeproperpositioningandposture,applyingexcessiveforce,and
overuse.Manyfactorsareimportantforproperpositioning,butthemostimportantarepropertablepositioning
andheight,avoidanceoftwistingoftheneckortrunkand,mostimportantly,positioningthepatientveryclose
totheclinicianandmeticulouslyavoidingabductionofthescanningarm[33].
SAFETYTherearenowelldocumentedharmfuleffectstothefetusfromdiagnosticultrasoundexamination
usedappropriately[18].Nevertheless,examinationsshouldbeperformedonlyforvalidmedicalreasons[19],
fortheshortestamountoftime,andwiththelowestlevelofacousticenergythatallowsdiagnosticevaluation
[18].(See"Basicprinciplesandsafetyofdiagnosticultrasoundinobstetricsandgynecology".)
GUIDELINESFROMNATIONALORGANIZATIONS
AmericanCollegeofObstetriciansandGynecologists(ACOG)practicebulletin:Ultrasonographyin
pregnancy[19]
EuniceKennedyShriverNationalInstituteofChildHealthandHumanDevelopment(NICHD)workshop
consensusstatementonfetalimaging[18],whichincludedparticipantsfromthe:
SocietyforMaternalFetalMedicine(SMFM)
AmericanInstituteofUltrasoundinMedicine(AIUM)
AmericanCollegeofObstetriciansandGynecologists(ACOG)
AmericanCollegeofRadiology(ACR)
SocietyforPediatricRadiology(SPR)
SocietyofRadiologistsinUltrasound(SRU)
AIUMpracticeguidelinefortheperformanceofobstetricultrasound
InternationalSocietyofUltrasoundinObstetricsandGynecology(ISUOG):performanceoffirsttrimester
fetalultrasoundscan[34]
ISUOG:practiceguidelineforperformanceofroutinemidtrimesterfetalultrasoundscan[20]
RoyalCollegeofObstetriciansandGynaecologists(RCOG):Ultrasoundscreening
SocietyofObstetriciansandGynaecologistsofCanada(SOGC)Ultrasoundguidelines
AsiaandOceaniaFederationofObstetricsandGynaecology[35]
SUMMARYANDRECOMMENDATIONS
Sonographyisanoperatordependenttechnology:ahighlevelofcompetencecanonlybeachievedby
supervisedexperiencewithalargevarietyofnormalandabnormalexaminations.(See'Credentials'
above.)
Standardorientationwhenperformedusingatransabdominalultrasoundprobeistoholditintheright
handwiththemarkonthethumbside,whichisthesidedisplayedontheleftsideoftheultrasound
image.Withatransvaginalprobe,themarkontheproberepresentstheleftsideofthescreentherefore,
iftheprobeisinsertedintothevaginaandthemarkisheldat12:00,theleftsideoftheimagedisplay
9/15
6/11/2015
representstheanterioraspectofthepelvis,andtherightsideoftheimagerepresentstheposterior
aspectofthepelvis.(See'Transducersandprobes'above.)
Manualadjustmentofsettings(size,depth,focalzone,gain,tissueharmonicimaging)isimportantto
obtainoptimalimages.(See'Manualsettings'above.)
Informationgainedfromrealtimeultrasoundexaminationcanbeenhanced,whenindicated,byadditional
studiesusingDoppler,sonohysterography,andthreedimensionalimaging.(See'Advancedtechniques'
above.)
Theindicationsforobstetricalultrasoundexaminationarelistedinthetable(table1).(See'Indications'
above.)
Suggestedcomponentsofabasicobstetricalandgynecologicevaluationhavebeenoutlinedbyvarious
groups.(See'Basicexamination'aboveand'Gynecologicsonography'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
Topic5388Version16.0
http://www.uptodate.com.ezproxy.ugm.ac.id/contents/ultrasoundexaminationinobstetricsandgynecology?topicKey=OBGYN%2F5388&elapsedTime
10/15
6/11/2015
GRAPHICS
Indicationsforultrasoundexaminationduringpregnancy
Determinethelocationofpregnancy(intrauterineorextrauterine)
Estimategestationalageanddateofdelivery
Confirmfetalcardiacactivityorfetaldeath
Evaluatevaginalbleedingorpelvicpain
Evaluateasignificantuterinesizeanddatesdiscrepancy
Diagnosesuspectedmultiplegestationanddeterminechorionicity
Evaluatefetusforanomalies
Evaluatefetalweightandgrowthovertime
Asanadjuncttodiagnosticortherapeuticprocedures
Evaluatesuspectedgestationaltrophoblasticdisease
Evaluatecervixforriskofpretermlossorbirth
Evaluateapelvicmass
Followupofapreviouslydetectedabnormality
Aspartoffetalaneuploidyscreening
Evaluateasuspecteduterineabnormality
Aspartoftheevaluationofabnormalmaternalanalytes
Biophysicalfetalevaluation
Evaluatesuspectedabnormalitiesofamnioticfluidvolume(oligohydramnios,polyhydramnios)
Evaluatesuspectedabruptioplacentae
Evaluateandfollowupsuspectedplacentaprevia
Determinefetalpresentation
Aspartofanevaluationforprematureruptureofmembranesorprematurelabor
Asonographicstudyshouldonlybeperformedforavalidmedicalindication.Nonmedical
useofobstetricultrasonographyhasbeendiscouragedbymajorsocities,includingthe
AmericanCollegeofObstetriciansandGynecologists(ACOG),theAmericanInstituteof
UltrasoundinMedicine(AIUM),andtheInternationalSocietyofUltrasoundinObstetrics
andGynecology.
AdaptedfromAmericanCollegeofObstetriciansandGynecologistsPracticeBulletinNo.98.
Ultrasonographyinpregnancy.ObstetGynecol2008112:951.
Graphic58590Version1.0
11/15
6/11/2015
Componentsofafirsttrimesterultrasoundexamination
Gestationalsaclocationanddiameter(ifnoembryoidentified)
Presenceorabsenceofayolksac(diameter)
Presenceorabsenceofanembryo
Presenceorabsenceofcardiacactivity
Crownrumplength
Numberofembryos
Amnionicityandchorionicityofmultiplegestations
Anatomicsurvey,asappropriateforgestationalage*
Evaluationoftheuterus,adnexa,andculdesac
Anembryoisusuallyvisiblewhenthegestationalsacdiameteris20mm,cardiacmotion
maybedetectedwhenthenembryois2mmandisusuallydetectedwhentheembryois
5mm(transvaginalexamination).
*At11to14weeksofgestation,anatomicalassessmentcaninclude:head(cranialbones,midline
falx,choroidplexus)neck(nuchaltranslucencythickness)face(eyes,nasalbone,mandible,lips)
spine(vertebraeandoverlyingskin)chest(lungfields,effusions,masses)heart(regularactivity,
foursymmetricalchambers)abdomen(stomachinleftupperquadrant)bladderkidneys
abdominalwallcord(insertionsite,numberofvessels)extremities(number,hand/footposition).
Datafrom:
1. ACOGPracticeBulletinNo.98.Ultrasonographyinpregnancy.ObstetGynecol2008112:951.
2. ISUOGpracticeguidelines:performanceoffirsttrimesterfetalultrasoundscan.Ultrasound
ObstetGynecol201341:102.
3. ReddyUM,AbuhamadAZ,LevineD,etal.FetalImaging.ExecutiveSummaryofaJointEunice
KennedyShriverNationalInstituteofChildHealthandHumanDevelopment,Societyfor
MaternalFetalMedicine,AmericanInstituteofUltrasoundinMedicine,AmericanCollegeof
ObstetriciansandGynecologists,AmericanCollegeofRadiology,SocietyforPediatricRadiology,
andSocietyofRadiologistsinUltrasoundFetalImagingWorkshop.ObstetGynecol2014
123:1070.
12/15
6/11/2015
Componentsofsecondandthirdtrimesterultrasound
examinations
Presenceorabsenceoffetalcardiacactivity,fetalheartrateandrhythm
Fetalnumber
Fetalpresentation
Assessmentofamnioticfluidvolume
Placentalappearanceandlocation
Umbilicalcordvesselnumberandplacentalinsertionsite,iftechnicallypossible
Fetalbiometry(biparietaldiameter,headcircumference,femorallength,abdominal
circumference)
Evaluationoftheuterus,cervix,andadnexawhenclinicallyappropriate
Fetalanatomicsurvey*
Presenceorabsenceoffetalmovement
Evaluationofeachfetusofamultiplegestation
Biometrycanbeusedtoestimategestationalage(ifnotpreviouslydetermined),fetal
weight,andfetalgrowth(bycomparingtwoormoreexaminationsoveranappropriatetime
interval).
*Fetalanatomicsurveycanincludethefollowingassessments:head(intactcranium,cavumsepti
pellucidi,midlinefalx,thalami,cerebralventricles,cerebellum,cisternamagna,choroidplexus)face
(orbits,mouth,upperlipintact)neck(absenceofmasses)chest/heart(shape/sizeofchestand
lungs,cardiacactivitypresent,fourchamberviewofheart,aorticandpulmonaryoutflowtracts,
diaphragmatichernia)abdomen(stomachinnormalposition,bowelnotdilated,bothkidneys
present,cordinsertionsite,bladder)skeletal(spine,masses,armsandhands,legsandfeet)
genitalia.
Dataadaptedfrom:
1. ISUOG:practiceguidelineforperformanceoftheroutinemidtrimesterfetalultrasoundscan.
UltrasoundObstetGynecol201137:116.
2. ExecutiveSummaryofaJointEuniceKennedyShriverNationalInstituteofChildHealthand
HumanDevelopment,SocietyforMaternalFetalMedicine,AmericanInstituteofUltrasoundin
Medicine,AmericanCollegeofObstetriciansandGynecologists,AmericanCollegeofRadiology,
SocietyforPediatricRadiology,andSocietyofRadiologistsinUltrasoundFetalImaging
Workshop.ObstetGynecol2014123:1070.
13/15
6/11/2015
Normaluterinedimensionsonultrasoundexamination
Parameter
Nullipara
Primipara
Multipara
Menopausal
5years
Menopausal
>5years
Uterinelength
(cm)
7.3(0.8)
8.3(0.8)
9.2(0.8)
6.7(0.7)
5.6(0.9)
Corpuswidth
(cm)
4.0(0.6)
4.6(0.5)
5.1(0.5)
3.6(0.5)
3.1(0.5)
Corpusheight
3.2(0.5)
3.9(0.5)
4.3(0.6)
3.1(0.4)
2.5(0.4)
(cm)
Themeanandstandarddeviation()foruterinelength,width,andheightinpremenopausal
women(nulliparas,primiparas,multiparas)andmenopausalwomen(lessthanorequalto
fiveyearsofmenopause,andgreaterthanfiveyearsofmenopause)withoututerineor
ovarianpathology.Thesedimensionsrepresenttheouterdimensionsoftheuterus,notthe
innerdimensions(ie,dimensionsoftheendometrialcavity).
Datafrom:MerzE,MiricTesanicD,BahlmannF,WeberG,WellekS.Sonographicsizeofuterusand
ovariesinpreandpostmenopausalwomen.UltrasoundObstetGynecol19967:38.
14/15
6/11/2015
15/15

Ultrasound Examination in Obstetrics and Gynecology

Enviado por

Dados do documento

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

Ultrasound Examination in Obstetrics and Gynecology

Enviado por

Direitos autorais:

Formatos disponíveis

6/11/2015

Você também pode gostar