Advanced Gynaecological Ultrasound Masterclass

(Infancy to postmenopausal female)

Day  1 

1 Approach and methodology of pelvic ultrasound and normal findings

1. Performed transabdominally, when the urinary bladder is optimally full.
2. In consenting sexually active youth, endovaginal us in performed
3. When endovaginal imaging is not feasible, transperineal US can be used.

Overview of this Gynaecology Ultrasound Course, basics of ultrasound anatomy, types of ultrasound, patient preparation, patient positioning, transducer selection and preparation, Modes of scanning, transvaginal scanning protocol, common artefacts and image optimization, international guidelines of probe preparation for genital tract and disinfection, normal ultrasound appearances from infancy to post-menopausal age group.

2. Congenital abnormalities of the female genital tract

Basic embryology of the genital tract, Role of ultrasound in suspecting and diagnosing congenital abnormalities on B mode ultrasound, and further evaluation with 3D ultrasound imaging. Differential diagnosis, clinical implications: impact on fertility and current management options. Challenging cases. Paediatric female pelvis and Gonadal dysgenesis.

3. Abnormalities of the uterine myometrium (MUSA Protocol: Morphological uterus sonographic assessment)

A. Uterine and cervical fibroids and other cervical lesions…….40 minutes

Fibroid Mapping (submucosal, intramural, subserosal, pedunculated) and FIGO classification. Clinical Impact of fibroids on fertility, menstruation and diagnostic relevance. Role of 3D ultrasound. Role of interventional radiology in the management of fibroids.

International practice guidelines AIUM

• Indications
• Qualifications and responsibilities of personnel
• Documentation
• Equipment specifications
• ALARA (as low as reasonably achievable) principle

Common artifacts and image optimization

• Transabdominal
• Reverberation artefact
• Mirror artefact
• Bowel–ring shadows
• Transvaginal – air bubble in sheath – ring down artefact
• Equipment optimization

Day  2 

A. Uterine adenomyosis

Ultrasound findings in adenomyosis and recognition of early subtle features on B mode ultrasound. Common differential diagnosis. Role of color Doppler and 3D ultrasound in diagnosis and management. How to detect adenomyosis evaluate the extent of the disease, describe the ultrasound findings using standardized terminology, evaluation of disseminated peritoneal endometriosis with Gyn Ultrasound Course Online.

B. Ovarian Endometriotic cysts

Terminology, pathophysiology, clinical presentation and ultrasound features of typical and atypical endometriotic cysts. Uniloculated and multiloculated cysts. Endometriomas with hyperechoic walls, cystic-solid lesions, purely solid lesipn, anechoic cysts, fluid-fluid levels. How to identify pelvic adhesions. Differential diagnosis and complications of endometriomas.

C. Deep Endometriosis: IDEA Protocol

So the most important terminology you have known is MUSA protocol 
MUSA guidelines for uniform terminology and definition-myometrial spectrum- reduce variations
Fibroid, adenomyosis, ACUM and special masses
We will discuss all these details.
A.    Asymmetric myometrial thickening.
B.    Focal lesion with cysts
C.    Translesional vascularity 
D.    interrupted junctional zone focal and diffuse    

Terms, definitions and measurements to describe sonographic features of the myometrium and uterine masses: a consensus opinion from the morphological uterus sonographic assessment (MUSA) group.

Aim of MUSA

• terms, definitions and measurements
• grey scale, Colour Doppler and 3D
• Fibroid versus adenomyosis and smooth muscle tumors 

Uterine adenomyosis

• Ultrasound findings in adenomyosis and recognition of early subtle features on B mode ultrasound.
• Common differential diagnosis.
• Role of color Doppler and 3D ultrasound in diagnosis and management.
• Evaluation of disseminated peritoneal endometriosis.

Adenomyosis histology

• Presence of ectopic endometrial mucosa within the myometrium.
• Invagination of the endometrium in the myometrium at a depth of at least 2.5mm below the basal layer of the endometrium (direct sign)
• Leads to hypertrophy of smooth muscle, heterogenous Echotexture and coarse parenchyma.

Adenomyosis background
Presence of islands of ectopic endometrial tissue within the myometrium
Types 

• Focal/diffuse
• Superficial / deep (> one third  myometrium depth)
• Adenomyoma 

Adenomyosis background

• On per vaginal examination, usually there is a globular uterus, which is painfun on mobilization
• Abnormal uterine bleeding
• Dysmenorrhea
• Pelvic pain

Adenomyosis imaging
TRANSVAGINAL ULTRASOUND 
Included 14 trials with 1895 aggregate participants 

• Sensitivity of TVS for adenomyosis is 82.5% (95% CI: 77.5-87.9)
• Compared to MRI 
• Sensitivity – 77.5%
• Specificity of 92.5%
• Pelvic MRI is used in cases of diagnostic dilemma (myoma / endometrial lining) and for associated endometriosis

Sonography technique 

• Transadominal sonograophy
• Transvaginal sonography
• Other techniques – research level as of now
• Sonohysterography
• Sonoelastography

Ultrasound findings in adenomyosis 

• Globular enlargement of the uterus.
• Anechoic spaces in the myometrium.
• Asymmetric anterior and posterior uterine wall thickening.
• Subendometrial echogenic linear striations
• Heterogeneous Echotexture
• Obscure endometrial-myometrial border
• Thickening of the transition zone 
• Compared to MRI 
• Sensitivity – 77.5%
• Specificity of 92.5%
• Pelvic MRI is used in cases of diagnostic dilemma (myoma / endometrial lining) and for associated endometriosis

Day  3 

• PCOD: Always a dilemma: How to resolve
• Rotterdam consensus and androgen excess and PCOS society guidelines for ultrasound diagnosis. Antral follicle count, the definition of PCOD (polycystic ovarian disease) and PCOS (polycystic ovarian syndrome) Role of TVS and advanced imaging techniques SONO AVC Gynecology Course.
• Follicular monitoring
• Normal ultrasound appearances of ovaries and variation with the age and hormonal status of the patient. Ovarian reserve.  Evaluation of uterine endometrium, Correlation with the menstrual cycle, Antral Follicular count and follicular monitoring, Role of doppler in endometrial receptivity.
• ART (Assisted Reproductive techniques)
• Overview of common ART. Role of ultrasound in ART (Assisted Reproductive techniques).
• Timing of oocyte retrieval and embryo transfer. Complications of ART.

Before we know abnormal ovary we must know normal ovary 

• Normal ovaries are the ones that have the largest diameter of 2 to 3cm, 
• The ovarian volume of 3 to 6.6cc,
• Antral follicle count (AFC) per ovary of 5 to 12,
• Isoechoic stroma,
• Stromal RI of 0.6 to 0.7,
• Stromal PSV 5 to 10 cm / sec,
• Stromal FI 11 to 14.

Ovaries with these features are categorized as normal ovaries because they respond to standard stimulation protocols and produce adequate follicles for the concerned assisted reproduction technology.

These standard protocols are 75 IU for intrauterine insemination (IUI) cycles and 150 to 225 IU for in vitro fertilization (IVF) cycles.

What are low-reserve ovaries?

• Low-reserve ovaries are the ones, that have low reserve, and reserve in ovaries means number of reserve follicles in the ovary.
• Therefore, these are the ovaries that have less number of antral follicles, less than 5 per ovary.
• As they have less number of antral follicles they are also small in size.
• They have a largest diameter of less than 2 cm and a volume less then 3cc. 
• As the reserve of AFC is low, these ovaries produce less number of follicles at the end of stimulation.

Poorly responding ovaries

• Poorly responding ovaries are the ones that respond poorly to any stimulation.
• This means that these ovaries require larger doses of gonagotropins for stimulation
• This poor response can be attributed to the poor blood flow to these ovaries.
• Measurement of ovarian stromal flow in early follicular phase is related to subsequent ovarian response in IVF treatment.
• Ovarian stromal PSV after pituitary suppression is predictive of ovarian responsiveness and the outcome of IVF treatment.
• These ovaries show high resistant (RI>0.7), low velocity (PSV<5cm/sec) flow.

Poorly responding ovaries with little stromal flow: these ovaries show high resistance (RI>0.7), low velocity (PSV<5cm / sec) flow 

Low reserve and poorly responding ovaries

• Low reserve and poorly responding ovaries are often used as synonyms, but these are different entities.
• This is so because the reserve is related to antral follicle count or ultimate yield of follicles/ova at the end of stimulation, whereas response relates to the sensitivity of the ovary to ovulation-stimulating agents to produce those follicles.

Each ovary is a combination of the above characteristics

• This means that any ovary would be a permutation combination of one of the characteristics from each of these two groups.
• One group has a normal response, poor response and hyper response and the other group has normal reserve, low reserve and high reserve or polycystic ovaries.
• It is, therefore, a combination of findings like AFC and stomal flow: RI, PSV and FI that would ultimately decide to optimum stimulation protocol.

Day  4 

• Ectopic Gestation
• Pathophysiology, risk factor, detailed ultrasound features of various locations of pregnancy, differential diagnosis, case-based review, correlation with serum Beta HCG, [tubal, ecopic, ampullary isthmal, fimbrial, intestinal ectopic/corneal ectopic, ovarian ectopic, cervical ectopic, scar ectopic, abdominal ectopic]. Diagnostic clues to ectopic pregnancy. Complications, how to diagnose ruptured ectopic pregnancy, expectations of the gynecologist from ultrasound imaging.
• Molar pregnancy
• Molar pregnancy or hydatidiform mole ultrasound diagnosis of complete and partial molar pregnancy. Bio c, clinical presentation and types- complete versus partial molar pregnancy, clinical correlation and management perspectives.
• Retained products of conception and uterine AVM formation - role of ultrasound in evaluation of persistent hypervascular postpartum findings, differential diagnosis and management perspectives, mimics of RPOC, differentiation from endometrial polyp and submucosal fibroid.
• Management options and role of interventional radiology in uterine AVM emobilization and expectations from ultrasound reporting 

Early pregnancy ultrasound 

• Structure
• Viability
• Dating
• Number
• Assessment of other pelvic masses?
• Screening for fetal abnormalities?
• Assisting CVS and amniocentesis?

Gestational sac

• Visible at 4-5 wks GA with TVUS & at 6 wks GA with TAUS.
• Eccentric echogenic ring with anechoic center
• Measures by mean sac diameter
• GA size increased by about 1mm/day in early pregnancy
• Discriminatory zone: serum hCG level in which GS is expected to be visible by US: hCG> 2000 mIU/ml by TVUS / hCG> 6000 mIU/ml

Gestational sac

• Yolk sac: : bright ring with anechoic center located inside GS seen at 5 wk GA& persists to 11-22 weeks.
• Embryo/fetus: seen by TVUS as thickening of yolk at 6 wks GA
• Presence of cardiac activity: usually seen around the time fetal pole is present, further confirming viability (6th wks)

Confirming intrauterine gestational 

• Double decidual sac sign 
• Intradecidual sign
• Double bleb sign

Double decidual sac sign (DDSS)

• The double decidual sac sign (DDSS) in this Gynaecology Ultrasound Course is a useful feature on early pregnancy ultrasound to confirm an early intrauterine pregnancy (IUP) when the yold sac or embryo is still not visualized.
• It consists of the deciduas parietalis (lining the uterine cavity) and deciduas capsularis (lining the gestational sac) and is seen as two concentric rings sourroundign an anechoic gestional sac.
• Where the two adhere in the deciduas basalis, ans is the site of future placentral formation.
• Present in 53% of IUP
• With modern high-resolution TVS, presence of the DDSS can be used to confirm accurately iUP location prior to sonographic visualization of embryonic contents, and therefore to exclude effectively ectopic pregnancy
• Absence of the DDSS, however, does not preclude an IUP

Intradecidual sac sign (IDSS)

• As per this sign, site of implantation is seen as
• As early gestational sac or
• An intrauterine fluid collection or 
• An echogenic area
• In a markedly thickened deciduas on one side of the uterine cavity.
• Useful feature in indentifying and early intrauterine pregnancy (IUP) as early as 25 days of gestation.
• The threshold level (earliest one ca seen the sign) is 24 days of gestation and the discriminatory level (one should always see the sac) is 47 days.
• Although useful if seen, its presence has been reported in fewer cases of IUP than originally thought (60%), and its absence does not exclude an IUP.   

Double bleb sign

• Visualization of a gestational sac containing a yolk sac and amniotic sac giving an appearance of two small bubbles.
• The embryonic disc is located between the two bubbles.

What do you mean by pregnancy of unknown location?
What are the possibilities?

• Early IUP
• Early EUP
• Early failed pregnancy

Pregnancy of unknown location (PUL)
PUL = +ve pregnancy test + no IU or ext.U pregnancy in US scan
Differential diagnosis is:

1. Very early pregnancy, not detected with ultrasound
2. Complete miscarriage 
3. Unidentified ectopic pregnancy

Ectopic pregnancy:

• When the gestational sac is implanted anywhere else but the fundal endometrium iof normal uterus, by definition it is an ectopic pregnancy.
• These locations may be

Why is the diagnosis important:

• Abnormal pregnancy outcome
• Pregnancy complications
• Risks to mother

Clinical presentation:

• Period of amenorrhea and positive bcHG
• Vaginal spotting and irregular vaginal bleeding
• Abdominal pain
• Vasomotor shock and fainting 
   

Day  5 

Ultrasound evaluation of ovarian masses (60 minutes)

• International ovarian tumour analysis (IOTA) and Ovarian-Adnexal Reporting & Data System (O-RADS ultrasound 1-5 Risk stratification and Management System). Efficacy of IOTA simple rules, O-RADS, and CA 125 to distinguish benign and malignant adnexal masses.
• Common Benign ovarian cysts: Case based Review (60 minutes)
• Follicular cyst, theca leutin cysts, corpus luteum cyst, Haemorrhagic cysts, ovarian endometriotic cysts and dermoid cysts, and ovarian teratomas. Paraovarian cysts. Clinical presentation and ultrasound diagnosis. Clinical relevance, complications, impact on fertility, follow up and management. 

Normal ovaries premenopausal

• The normal ovary contains over two million primary oocytes at birth, about 10 of which mature each menstrual cycle.
• Out of the 10 Graafian follicles that begin to mature, only one becomes the dominant follicle and grows to size of 18-20mm by mid-cycle, when it ruptures to release to oocyte.
• The other nine follicles become atretic and fibrous.
• After release of the oocyte. The other nine follicles become atretic and fibrous
• After release of the oocyte, the dominant follicle collapses, and the granulosa cells in the inner lining proliferate and swell to form and corpus luteum of menstruation.
• Over the course of 14 days the corpus luteum degenerates, leaving the small scarred corpus.

Scanning of adnexal pathologies

• USG should be almost always the 1st line of imaging before CT & MRI 
• You must arrive at a conclusion!
• Therefore use all available US tools:
• - Primary transvaginal sonography (TVS), combine it with
• - Transabdominal sonography (TAS)
• - Use a Variety of transducers for frequency, depth, color and power Doppler, employ 3D as needed….
• Most of the time the question is: is it malignant or is it benign?
• Remember: not all masses are ovarian.
• - take a good history
• - talk to the patient! She may be your best source of information
• - :Do a bimanual pelvic exam before as well as after the scan to confirm US findings
• - Ask for a menstrual history

Menstrual History: Important

• In the reproductive years, physiologic as well as pathologic processes are driven by the menstrual cycle or by (therapeutic or pathologic) hormonal stimulation.
• Know your patient’s first day of her cycle.
• In the secretory phase of the cycle do not attempt to make a diagnosis of ovarian pathology in a new patient. Rather look for the corpus luteum using the color Doppler 
• Be careful, reschedule the patient in the follicular phase of one of her next cycles.
• If she has irregular cycles, ask her to call for an appointment to suit her based on her time of bleeding.

First, we have to be familiar with the appearance of ovarian masses 

• Appearance:
• “Bizarre shapes”
• Mixed components
• Size
• Is it uni- or bilateral?
• Ascites
• Motion tenderness 
• Vessels
• Mobility” sliding/fixed?
• When there are documented, the next step is: LOOK AT THE VASCULARITY

Spectrum of appearances of ovarian tumors is very wide

• A thin walled unilocular cyst has a very low risk of malignancy of 0.96%
• A large cyst (> 10 cm) with a large solid component and vascularity has a high risk of malignancy.

IOTA

• The international ovarian tumor analysis (IOTA) ground was founded in 1999
• By the dirk timmerman, Lil Valentinan Tom bourne.
• Its first aim was to develop standardized terminology
• In 2000 IOTA published a consensus statement on terms, definitions, and measurements to describe the sonographic features of adnexal masses, which is now widely used.
   

Day 6 

Malignant ovarian masses (40 minutes)

• Ultrasound features of malignant ovarian masses: pattern of recognition and case-based review, with further imaging and Histopathological correlation of confirmed cases. Relevance of size and CA 125 levels, role of ultrasound as an early diagnostic tool in the silent killer neoplasm
• Malignant Ovarian masses subtypes: pathology of ovarian tumors, Classification, Imaging features and understanding the differential diagnosis (40 minutes). 
• Metastatic ovarian malignancy: Role of ultrasound in evaluation of complications (40 minutes)

Abbreviations 

• ADNEX= assessment of different Neoplasias in the Adnexa, CA-125= cancer antigen 125, 
• (IOTA) International Ovarian Tumour Analysis,  
• O-RADS = Ovarian-Adnexal Reporting and Data System

Ca ovary The challenging spectrum 

• Ovarian cancer is the second most lethal gynecological malignancy.
• Only 25% of patients present with stage I disease
• More than 70% of patients with ovarian cancer seek treatment after there has been the regional or distant spread of the disease  
• The 5-year survival rate among women with advanced-stage disease is less than 30 %

Morphologic Scoring System for adnexal masses based on US features

Ca ovary biochemical markers

• Ca 125 has been found to be extremely useful in following the response to chemotherap
• Detecting subclinical recurrence
• CA 125 is the fold standard tumor marker in ovarian cancer.
• A serum level of CA 125 is used to monitor response to chemotherapy, relapse, and disease progression in ovarian cancer patients.

Ovarian cancer incidence and risk factors

• Ovarian cancer is the leading cause of mortality form gynecologic cancers
• The overall lifetime risk of developing ovarian cancer for women in the US is 1.4% to 1.8%
• This risk varies from 0.6% for women with no family history, at least three-term pregnancies, and four or more years of oral contraceptive use, to 3.4% for nulliparous women with no oral contraceptive use. 

Ovarian cancer the challenge

• Ovarian cancer is often asymptomatic in its early stages and thus most patients have widespread disease at the time of diagnosis.
• Unfortunately, the majority of epithelial ovarian cancers remain clinically undetected until patients have developed late-stage disease and only a mere 25% of cancers are detected as stage I disease.
• When diagnosed in stage I, however, the cure rate can approach 90% with currently available cytoreductive surgery and combination chemotherapy.

CA125

• CA 125 levels of less than 35 U/ml are now accepted as normal
• When stratified by disease stage, elevated levels were found in more than 90% of patients with advanced-stage ovarian cancer but in only 50% of patients with stage I disease
• Elevated levels of CA125 are more strongly associated with serous, rather than mucinous tumors

Disease recurrence based on serum CA125 levels

•  Doubling of this tumor marker level, either from the upper limit of normal (35 U/mL) in patients with normalization of this marker after primary treatment 

Or

• From the nadir levels in the patients with an elevated serum marker value that never normalizes after primary treatment

Day 7 

• Ovarian torsion: ultrasound diagnosis and Doppler findings (40 minutes) pelvic Doppler and ultrasound examination
• Fallopian tube ultrasound and adnexal lesions, pelvic inflammatory disease, genital tuberculosis (40 minutes)
• Evaluation of acute lower abdominal pain: differential diagnosis: case based review (40 min)

Ovarian torsion incidence

• Ovarian torsion is the fifth most common gynecologic surgical emergency
• Ovarian torsion has bimodal age distribution occurring mainly in young women (15-30 years)  and post-menopausal women.
• Approximately 20% of the cases occur during pregnancy 

What is the ovarian torsion 

• Ovarian torsion (also known as adnexal torsion) is considered a surgical emergency.
• It occurs when there is rotation of the adnexal supporting structures around the vascular axis
• During the event, an impairment of blood flow may occur and lead to adnexal damage.
• Ovary and fallopian tube may be involved separately or together.
• Ovarian torsion is the twisting of an ovary on its ligamentous supports and can result in a compromised blood supply.
• Adnexal torsion is a term that is inclusive of either the ovary, fallopian tube, or both.
• Concomitant ovarian and tubal torsion has been shown to occur in up to 67% of cases of adnexal torsion.
• Ovarian torsion is defined as
• Partial or complete rotation of the ovarian vascular pedicle
• And causes obstruction to venous outflow and arterial inflow
• Also terms adnexal torsion 
• Or tubo-ovarian torsion,
• Refers to rotation of the ovary and portion of the fallopian tube supplying the vascular pedicle.

What are the risk factors for adnexal torsion?

• Adnexal torsion is more common in women of reproductive age.
• Previous adnexal torsion is an important risk factor. Conditions associated to enlarged ovaries are considered risk factors: adnexal mass, polycystic ovarian, ovarian hyperstimulation after infertility treatment 

Ovarian torsion challenge in diagnosis

• It can be intermittent or sustained and results in venous, arterial, and lymphatic stasis.
• It is a gynecological emergency and requires urgent surgical intervention to prevent ovarian necrosis.

Can ovarian torsion occur during pregnancy?

• Yes, adnexal torsion can occur more frequently during the first trimester and an enlarged corpus luteum is usually detected.
• 17%-20% of cases occurring in pregnant women
• This is probably due to the increased occurrence of physiologic and pathologic ovarian masses, therapy for infertility, and pregnancy compared with that in females at the extremes of age.

Ovarian torsion Key ultrasound features

• Unilateral enlarged ovary,
• Uniform peripheral cystic structures, 
• A coexistent mass within the affected ovary,
• Free pelvic fluid,
• Lack of arterial or venous flow, and a twisted vascular pedicle.

Ovarian torsion Key ultrasound features: Remember 

• The presence of flow at Color Doppler imaging does not allow exclusion of torsion but instead suggests that the ovary may be viable, especially if flow is present centrally
• Absence of flow in the twisted vascular pedicle may indicate that the ovary is not viable.

Ovarian torsion Key ultrasound features CT: Remember 

• Enlarged ovary,
• Uterine deviation to the twisted side,
• Smooth wall thickening of the twisted adnexal cystic mass, 
• Fallopian tube thickening,
• Peripheral cystic structures in ovary, and ascites.

Delay in diagnosis, misdiagnosis

• Due to nonspecific symptoms 
• Varied imaging findings
• Early recognition and restoration of blood flow are important to avoid irreversible ovarian damage

What is a normal ovary and its cyclical variations?

• The premenopausal adult ovary is a highly dynamic structure that changes in size, morphology, and blood flow with the menstrual cycle
• Premenopausal: ovary is normally an ellipsoid structure with a volume of less than 6cm3
• During menopause, ovaries decrease in size, each with a volume of less than 2.5cm3

Day 8 

Ultrasound evaluation of Endometrium (60 minutes)

Evaluation of endometrial pathologies and IETA classification. Endometrial polyps, endometrial carcinoma, cystic endometrium, Localization of IUCD

Trans perineal ultrasound, Pelvic floor ultrasound (30 minutes)

Advanced Gynae Applications : 3D 4D ultrasound : Tips and tricks for image optimization (30 min)