Ultrasound in Gynecology : An Atlas and Guide

This atlas and guide book is focused on gynecological ultrasound, an area that has remained in the shadow of obstetric ultrasound & fetal medicine. Gynecological ultrasound has seen rapid advances owing to expanding research and improved ultrasound equipment. This book leverages these advances and provides abundant illustrations and practice points of classical and new ultrasound features. It serves as a guide for radiologists, gynecologists and sonologists for the accurate diagnosis of gynecological pathologies. The chapters of this book also serve as a comprehensive resource for various topics with hundreds of images and figures, including basic gray scale images, Doppler studies and three dimensional ultrasound illustrations. In addition, standard terms for the evaluation and reporting of gynecological pathologies are discussed. Emergencies like ovarian torsion, complex adnexal cyst are also covered. Foreword by Suresh Seshadri 6 Foreword by Lil Valentin 7 Preface 8 Acknowledgements 10 Contents 11 List of Abbreviations 15 About the Author 17 1: Introduction 18 2: General Techniques in Gynecological Ultrasound 20 2.1 Transabdominal Scan 21 2.2 Transvaginal Scan 25 2.3 Three-Dimensional Ultrasound (Figs. 2.10, 2.11, 2.12, 2.13, 2.14, 2.15, 2.16, 2.17, 2.18, 2.19, 2.20, 2.21, 2.22, 2.23 and 2.24) 30 2.4 Doppler (Figs. 2.25, 2.26, 2.27, 2.28, 2.29, 2.30, 2.31 and 2.32) 42 2.5 Tips and Tricks of Pelvic Ultrasound 51 2.6 Sonohysterography (SHG) 64 2.7 Gel Sonovaginography (GSV) 68 Suggested Reading 71 3: Ultrasound Evaluation of Myometrium 72 3.1 Evaluation of Myometrium 72 3.2 Normal Myometrium (Figs. 3.8, 3.9 and 3.10) 78 3.3 Fibroids (Leiomyoma or Myoma) 81 3.3.1 Fibroid Mapping 85 3.3.1.1 Basics of Fibroid Mapping (Figs. 3.18, 3.19 and 3.20) 85 3.3.1.2 Site of Origin of a Fibroid (Figs. 3.21, 3.22 and 3.23) 87 3.3.1.3 Role of 3D in Fibroid Mapping (Figs. 3.24, 3.25 and 3.26) 90 3.3.1.4 Reporting of Fibroids/Fibroid Mapping (Figs. 3.27 and 3.28) 92 3.3.2 Red Degeneration (Fig. 3.29) 93 3.3.3 Fibroid Embolization (Figs. 3.30 and 3.31) 94 3.3.4 Diffuse Uterine Leiomyomatosis (Figs. 3.32 and 3.33) 95 3.3.5 Disseminated Peritoneal Leiomyomatosis (DPL) (Fig. 3.34) 96 3.4 Adenomyosis and Adenomyomas 98 3.4.1 Adenomyoma (Figs. 3.47 and 3.48) 107 3.5 Sarcoma 110 Suggested Reading 112 4: Ultrasound Evaluation of Endometrium 113 4.1 Evaluation of Endometrium 113 4.2 Normal Endometrium 121 4.2.1 Endometrium in Paediatric Age Group (Fig. 4.10) 121 4.2.2 Endometrium in Reproductive Age Group (Figs. 4.11 and 4.12) 121 4.2.3 Endometrium in Postmenopausal Women (Fig. 4.13) 121 4.3 Endometrial Polyps 124 4.4 Endometrial Hyperplasia 137 4.4.1 Tamoxifen-Associated Endometrial Changes (Fig. 4.44) 137 4.5 Endometrial Malignancy 146 4.6 Differential Diagnosis of Thickened Endometrium (Fig. 4.56) 159 4.7 Asherman’s Syndrome or Intrauterine Adhesions 161 4.8 Subendometrial Fibrosis (Figs. 4.62 and 4.63) 166 4.9 Endometritis 168 4.10 Intracavitary Fluid in the Uterus (Figs. 4.69, 4.70, 4.71, 4.72, 4.73 and 4.74) 173 Suggested Reading 177 5: Ultrasound Evaluation of the Cervix 178 5.1 Evaluation of the Cervix and Its Normal Appearance 178 5.2 Nabothian Cysts 180 5.3 Cervical Polyps 182 5.4 Cervical Fibroids (Figs. 5.15, 5.16 and 5.17) 190 5.5 Cervical Carcinoma 192 Suggested Reading 201 6: Ultrasound Evaluation of the Vagina 202 6.1 Normal Vagina (Fig. 6.1) 202 6.2 Congenital Vaginal Anomalies 204 6.3 Vaginal Cysts (Figs. 6.2, 6.3, 6.4, 6.5, 6.6, 6.7) 204 6.3.1 Gartner Duct Cysts and Mullerian Cysts 204 6.3.2 Bartholin Gland Cysts 204 6.3.3 Skene Gland Cysts 204 6.4 Vaginal Masses and Vaginal Cancer 209 6.5 Other Vaginal Pathologies 214 6.5.1 Vaginal DIE 214 6.5.2 Foreign Body in the Vagina (Fig. 6.13) 214 6.6 Vulval Carcinoma (Fig. 6.14) 215 Suggested Reading 216 7: Ultrasound Evaluation of Ovaries 217 7.1 Evaluation of Ovaries and Persistent Adnexal Masses 217 7.1.1 Morphology, Measurement and Doppler Evaluation of the Ovary and Ovarian Masses (Including Persistent Adnexal Masses) 217 7.1.2 Morphological Classification of Ovarian/Adnexal Masses (Fig. 7.14) 229 7.2 Normal Ovaries 231 7.3 Polycystic Ovaries (PCO) 236 7.3.1 PCO in the Absence of PCOS 236 7.4 Ovarian Masses 239 7.4.1 Functional or Physiological Cysts (Figs. 7.21, 7.22 and 7.23) 239 7.4.2 Endometriotic Cysts (Endometriomas) 242 7.4.2.1 Decidualised Endometriotic Cysts (Figs. 7.32 and 7.33) 249 7.4.3 Ovarian Neoplasms 252 7.4.3.1 Epithelial Tumours 252 Serous Epithelial Tumours 253 Serous Cystadenoma 254 Borderline Serous Tumours 257 Serous Cystadenocarcinoma 258 Serous Cystadenofibroma (Figs. 7.41 and 7.42) 262 Mucinous Cysts 265 Mucinous Cystadenoma 265 Borderline Mucinous Cysts 269 Mucinous Cystadenocarcinoma 274 7.4.3.2 Germ Cell Tumours 277 Dermoids (Mature Cystic Teratoma) 277 Malignant Germ Cell Tumour 287 Sex Cord–Stromal Tumours 295 Granulosa Cell Tumour 295 Sertoli and Sertoli–Leydig Cell Tumours 295 Leydig Cell Tumours 295 Fibromas and Fibrothecoma 297 7.4.3.3 Metastatic Ovarian Masses 302 Suggested Reading 308 8: Endometriosis 309 8.1 Deep Infiltrating Endometriosis (DIE) 309 Significance of DIE 309 8.1.1 DIE of Large Bowel (Rectosigmoid) 311 8.1.2 DIE of the Vaginal Wall 314 8.1.3 Cervical DIE 317 8.1.4 Uterosacral DIE (Figs. 8.10 and 8.11) 319 8.1.5 Bladder DIE 321 8.1.6 DIE Involving the Ureters (Figs. 8.13 and 8.14) 323 8.1.7 Uterus in Cases with DIE (Figs. 8.15 and 8.16) 325 8.2 Extra-Pelvic Endometriosis 327 8.2.1 Abdominal Wall Endometriosis 327 8.2.2 Abdominal and Thoracic Endometriosis (Fig. 8.20) 329 Suggested Reading 331 9: Ultrasound Evaluation of Adnexal Pathology 332 9.1 Fallopian Tube 332 9.2 Pelvic Inflammatory Disease (PID) 332 9.3 Chronic PID 350 9.4 Hydrosalpinx 353 9.5 Tubal Malignancy 359 9.6 Paraovarian and Paratubal Cysts 362 9.7 Peritoneal Inclusion Cysts 369 Suggested Reading 374 10: Ultrasound Evaluation of Pregnancy-­Related Conditions 375 10.1 Ectopic Pregnancy 375 10.1.1 Tubal Ectopic Pregnancy 377 10.1.2 Interstitial Ectopic Pregnancy 385 10.1.3 Cornual Ectopic Pregnancy 388 10.1.4 Ovarian Ectopic Pregnancy 391 10.1.5 Cervical Ectopic Pregnancy 393 10.1.6 Scar Ectopic Pregnancy 397 10.1.7 Intra-abdominal Pregnancy (Fig. 10.24) 399 10.1.8 Heterotopic Pregnancy (Figs. 10.25 and 10.26) 400 10.1.9 Intra-myometrial Ectopic Pregnancy (Fig. 10.27) 402 10.2 Retained Products of Conception (RPOC) 403 10.3 Gestational Trophoblastic Disease (GTD) 413 10.3.1 Molar Pregnancy 413 10.3.1.1 Molar Pregnancy: Complete Mole 413 10.3.1.2 Molar Pregnancy: Partial Mole 416 10.3.2 Gestational Trophoblastic Neoplasia (GTN) 418 10.3.2.1 Invasive Mole 418 10.3.2.2 Choriocarcinoma 418 10.3.2.3 Placental Site Trophoblastic Tumour (PSTT) and Epithelioid Trophoblastic Tumour (ETT) 418 Suggested Reading 423 11: Torsion 424 11.1 Ovarian Torsion 424 11.2 Non-ovarian Torsion 440 Suggested Reading 444 12: Ultrasound Evaluation of Congenital Uterine Anomalies 445 12.1 Embryopathogenesis (Figs. 12.1, 12.2) 445 12.2 AFS Classification of Uterine Anomalies (Figs. 12.2 and 12.3) 448 12.3 Approach to Diagnosing a Uterine Anomaly 449 12.4 Types of Uterine Anomalies 454 12.4.1 Arcuate Uterus (Fig. 12.10) 454 12.4.2 Subseptate Uterus (Fig. 12.13) 456 12.4.3 Septate Uterus (Fig. 12.14) 457 12.4.4 Bicornuate Uterus (Fig. 12.15) 458 12.4.5 Uterus Didelphys (Fig. 12.16) 460 12.4.6 Unicornuate Uterus (Fig. 12.17) 461 12.4.7 Absent/Hypoplastic Uterus (Figs. 12.18 and 12.19) 463 12.4.8 ‘T-Shaped’ Uterus (Fig. 12.20) 464 12.5 Cervical and Vaginal Anomalies (Figs. 12.16e, 12.21, 12.22, 12.23, 12.24, 12.25, 12.26, 12.27, 12.28 and 12.29) 465 12.6 ESHRE/ESGE Classification of Congenital Uterine Anomalies 474 12.7 Reporting Uterine Anomalies (Fig. 12.31) 476 Suggested Reading 477 13: Ultrasound in Other Miscellaneous Conditions 478 13.1 Uterine Vascular Abnormalities (Arteriovenous Malformations) 478 13.2 Perforation of the Uterus 484 13.3 Vesicouterine Fistula 487 13.4 Retroflexed Uterus 489 13.5 Caesarean Scar Defect (LSCS Scar Defect) 491 13.6 Intrauterine Contraceptive Device (IUCD) 498 13.7 Follicular Monitoring and Ultrasonography in Patients with Infertility (Figs. 13.26 and 13.27) 507 13.7.1 Cyclical Changes During Menstrual Cycle (Both Natural and Induced) (Figs. 13.26 and 13.27) 507 13.7.2 Types of Scans Done in Patients Presenting or on Treatment for Infertility 507 13.7.3 Luteinised Unruptured Follicle (Fig. 13.28) 508 13.8 Ovarian Hyperstimulation Syndrome (OHSS) 512 Suggested Reading 516 14: Exploring Pathologies Based on Clinical Presentation 517 14.1 Abnormal Uterine Bleeding 517 14.1.1 Common Forms of Abnormal Uterine Bleeding 517 14.1.2 Abnormal Uterine Bleeding in the Reproductive Age Group 517 14.2 Pelvic and Adnexal Masses 520 14.2.1 Ovarian Masses 522 14.2.2 Uterine Masses 523 14.2.3 Tubal Masses 523 14.2.4 Tubo-ovarian Masses 523 14.2.5 Paraovarian Masses 523 14.2.6 Pseudoperitoneal or Peritoneal Inclusion Cysts 523 14.2.7 Pelvic Hematomas and Pelvic Abscess 523 14.2.8 Non-gynecological Masses (Fig. 14.5) 523 14.2.9 IOTA Recommendation for Evaluation of Persistent Adnexal Masses 527 14.2.9.1 Simple Rules (Figs. 14.6 and 14.7) 527 14.2.9.2 Simple Descriptors (Figs. 14.8 and 14.9) 530 14.2.9.3 Three-Step Strategy for Evaluating the Nature of Persistent Adnexal Masses (Ameye et al. 2012) 533 14.3 Acute Pelvic Pain 534 14.4 Locating the Pregnancy and Pregnancy of Unknown Location (PUL) 540 Suggested Reading 543 Index 544 Front Matter....Pages i-xxi Introduction....Pages 1-2 General Techniques in Gynecological Ultrasound....Pages 3-54 Ultrasound Evaluation of Myometrium....Pages 55-95 Ultrasound Evaluation of Endometrium....Pages 97-161 Ultrasound Evaluation of the Cervix....Pages 163-186 Ultrasound Evaluation of the Vagina....Pages 187-201 Ultrasound Evaluation of Ovaries....Pages 203-294 Endometriosis....Pages 295-317 Ultrasound Evaluation of Adnexal Pathology....Pages 319-361 Ultrasound Evaluation of Pregnancy-Related Conditions....Pages 363-411 Torsion....Pages 413-433 Ultrasound Evaluation of Congenital Uterine Anomalies....Pages 435-467 Ultrasound in Other Miscellaneous Conditions....Pages 469-507 Exploring Pathologies Based on Clinical Presentation....Pages 509-535 Back Matter....Pages 537-543