sonographic eval of female pelvis Flashcards by Gina VanSteenacker

Why do we need a full bladder to scan transabdominally?

Displaces Bowel/colon out of true pelvis

acoustic “window”

anatomic and “cystic” reference point

mobility of organs/masses (full decreases the mobility of organs)

contour reflects size/shape of surrounding organs

causes physiologic retroversion of uterus (enables you to see the full uterus better)

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How do you prep a patient for a transvaginal scan?

No prep

Have patient urinate prior to exam

have them wait and go again

bladder should be as empty as possible

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why is a bladder thats too full a problem? (over distended)

It compresses the uterus

pushes the ovaries far out of the picture

measurements are askew

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What is an adequate history for a transabdominal scan?

First day of LMP

Gravid (no. of pregnancies G)

Parity (no. of live births P)

abortions (how many…miscarriages too A)

menstrual status

patients symptoms

Personal/family history of cancer

pelvic surgieris

previous pap/biopsy results

lab tests

findings on pelvic exam

previous US or other imaging tests

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what is Peri/premenopausal?

2-10 years prior to cessation of menses

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Explain the trans abdominal scan (TA)

are you allergic to latex!!!

gel

where the transducer goes

pictures

can go to bathroom

transvaginal/endovag scan next…explain (TV or EV)

2 part exam

insert just the tip with the patient

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What four major organization cover the performance standards for transvaginal exams?

SDMS - society of diagnostic medical sonography

AIUM - american institute of ultrasound in medicine

ACOG - american college of obstetrics and gynecology

ACR* - american college of radiology

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What are the guidelines from the ACR to do pelvic exams?

Must have a valid medical reason

lowest possible dose (100mW/cm squared)

All anatomy and pathology MUST BE DOCUMENTED and IDENTIFIED if it’s not documented it doesn’t exist (TA and TV)

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When would you do a transperineal scan done?

prolapse uterus

PROM (premature rupture of membranes) pregnancy)

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Guidelines from the ACR about pelvic exams are what?

Personal (registered)

documentation (if it’s not documented it didn’t happen)

protocols (for billing)

equipment (safe and up to date)

QA (quality assurance must be done)

quality improvement ( ways to fix problems)

must prove this process is done for accreditation for that facility

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What is the technique for a TA pelvic exam?

TA - full bladder “Overview” of the entire pelvis

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What transducer do you use for a TA exam?

Curvilinear or sector/vector up to 5 mHz

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What is the technique for a TV exam?

Empty bladder

detail and characterization

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What transducer do you use for a TV exam?

TV transducer - 7.5 MHz or higher

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How must you identify anatomy and pathology?

In two planes

proves the existance

measure in three diameters

document in two planes

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What help does the equipment have to help us get good pelvic images?

Built in presents (vascular, abdominal etc)

should “tweak” to improve (gain, focus, etc)

harmonics (takes away low level junk, delineates walls)

highest frequency to penetrate

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What do we identify when we look at anatomy and pathology?

identify sonographic characteristics (hetero, cystic etc)

location (where the heck is it?)

size (measure it!! volume or cm or mm) Pay attention to what units the paper work requires

external contours (circumscribed, irregular etc)

internal consistency (solid, anechoic etc)

see slide 15 for pictures

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What must you see if you call a mass a cyst?

Through transmission

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When is a transabdominal scan very limited?

obese patients

patients unable to fill their bladder

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What does a transabdominal scan give us?

Global view

done in long and transverse

very methodical and routine

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What is uterus midline?

When you can see the canal all the way through from the fundus through to the vagina

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how do you measure length of the uterus?

fundus to cervix

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Where do you zoom and measure the endometrium?

at it’s thickest point

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IF there is fluid in the endometrium do you include it in the measurement?

no…only the endometrium, not the fluid

outside wall to endo wall on each side

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after midline uterus what do you scan next?

uterus -->lateral uterus --> **adnexa long**

How do you scan adnexa?

Out from uterus to the iliac vessels

What is the routine for transverse TA?

Vagina --> Cervix --> uterine body -->w and w/o measurement -->fundus -->adnexa -->ovaries double check lecture to make sure all steps are here

How do you measure an ovary?

long and AP

Document in 2 plans, measure it in ____?

Three

What are the steps for TA scanning longitudinal?

Uterus midline - measure RT uterus Rt edge of uterus RT adnexa - btw uterine edge and iliac vessels Uterus Midline (no pic just for bearings) Lt uterus Lt edge of uterus Lt adnexa Endometrium

What is the pre exam protocol for TV scan?

explain proceedure prep probe have patient empty bladder pt remove clothes from waist down position patient have patient guide probe...DONT LET GO!

What is the orientation for TV scanning?

LT side of screen: crainial / rt side of patient (Fundus of uterus) RT side of screen: caudal/ LT side of patient (close to transducer)

What is the scanning plane for TV?

Top - caudal Bottom - Crainal RT - anterior LT- posterior

to see the fundus of the uterus in TV, which direction does the handle go?

handle goes down so the face of the transducer goes up

How do you do a translabial scan?

use a 3.5 - 5 MHz or TV probe cover with probe cover place in perineal area oriented toward the vagina

what do muscles look like on US?

Hypoechoic structures with echogenic striations

What muscles will you see on TA and TV images?

obturator internus muscle pelvic floor muscles illiopsoas muscles

WHat is TV scanning considered?

Coronal Imaging

How do you tilt the transducer to visualize fundus?

How do you tilt the tv probe to visualize the cul-de-sac?

posterior

How do you distinguish vessels vs cyts?

Doppler...color or power doppler

When would you use doppler on an ovary?

if you suspect torsion

What would an ovary/testical with torsion look like?

larger edematous

What are the different doppler ratios?

S/D ratio (peak systole/end diastole) Resistive index (A-B/A) Pulsatility Index (A-D/mean)

Are the arteries usually anterior or posterior to the veins in the pelvis?

Where do you find the iliac vessels?

lateral pelvis

Where are the uterine vessels when not pregnant?

RI 0.88 assess lateral to cervix/LUS at level of internal os

Where do you find the vascularity for the vagina?

2 sources of blood anterior surface of finish slide 37

When does ovarian doppler vary?

Throughout the menstrual cycle

In the follicular phase what does ovarian doppler look like?

high resistance/low velocity (diastolic)

When will you have the highest velocity in the ovaries?

during ovulation

What happens to the diastolic flow in post menopausal ovaries?

no diastolic flow evident after 5 yrs into menopause RI 1.0

What does impedance mean?

resistance and visa versa

how many layers does the uterus have?

three

What is the serosa?

it is the outer layer of the uterus...not visualized

what is the myometrium?

Middle muscle layer break up slide 40

What are the outer vessels you can see in the uterus?

arcuate arteries

Which arteries come right up into the endometrium?

spiral arteries and radial arteries

What is vascular congestion in the pelvis?

big hypoechoic circles around the outside of the uterus larger iliac vessels veins are dilated

What is the body of the cervix separated from the cervix by?

the ithmus level of the internal os

What is the consistency of the cervical canal?

homogeneous

What is a nebothian cysts?

a normal cyst 1-2 cm found in the cervical canal

How does the cervical canal appear?

homogeneous echogenic central line

how do we visualize the true lie of the uterus?

endovaginally

with an anteverted uterus, which side of the screen is the fundus on?

to the left of the screen Cervix to the right of the screen

how is the endometrium best visualized?

endovaginally

During menstruation, what days do you see a hypechoic line and what is it's normal measurement?

days: 1-4 4-8mm

Do we see normal Fallopian tubes?

What do abnormal Fallopian tubes look like?

tortuous tubular structure 8-10mm wide

What is PID?

Pelvic Inflammatory Disease

What is hydrosalpinx?

Fluid in the Fallopian tubes.

Where do we find ovaries?

normally lateral to uterus anteromedial to iliac vessels follow the ligaments from the cornea out to the ovaries

What do normal ovaries look like?

ovoid or almond shaped medium level echogenic structure with follicles

what are normal volumes

make these flash cards again

What is the scanning technique for TA transverse?

Vagina cervix LUS Uterus body x2 - measure at body Uterus fundus TRV RT Adnexa TRV LT adnexa

How do you scan the ovaries?

Find ovaries TRV - follow ligament Multiple images of ovary Measure Ovary turn 90 degrees to elongate ovary scan ovary completely measure ovary - long and AP evaluate pelvis for mass/cyst

Where is the notch on the transducer for a long picture?

facing up

Where is the notch of the transducer for TRV scanning for TV?

Towards the sonographer

What is the TV scanning protocol for sagittal images?

in this order: cervix cul-de-sac uterus endometrium uterus RT/LT adnexa ovaries

What is the TV scanning protocol for transverse?

in this order: vagina cervix cul - de - sac uterus adnexa ovaries

What is the name of the posterior cul-de-sac?

pouch of douglas

What does abnormal fluid look like in the pouch of douglas

large amount of fluid or debris septated fluid is abnormal

What does bowel look like?

may be seen with "dirty" shadow or fluid filled with peristalsis if unsure put color on it

What is sonohysterograpy?

saline infused sonography evaluate thickened endometrium to r/o polyp or mass

how is a sonohysterography performed?

physician insert sterile speculum then the catheter is inserted speculum removed tv probe inserted 10-15 cc sterile saline inserted

What is 3-D imaging?

Volume imaging

What do you need in order to see the muscles with ultrasound in the pelvis?

usually a full bladder sector or curved transducer

Where would you see the obturator internus muscle on ultrasound?

posterior lateral corners of the bladder at the vag/cervix level

Where would you see the pelvic floor muscles on US?

transverse inferior aspect of the bladder

Where would you see the Piriformis muscles on US?

posterior lateral to upper half of uterine body/fundus

What type of muscles can you see using the linear transducer?

rectus abdominus muscles - ant abd wall illopsoas muscles

With a retroverted uterus what side of the screen is the cervix/uterus on?

Cervix: left side Uterus: right side

During menstruation, on days 3-7 what does the endometrium look like and what is it's measurement?

thin echogenic line 2-3mm

What days are the early proliferative phase and what is the endometrium measurement?

days: 5-9 6mm

During what phase is the endometrium 10mm and on what number days?

Late proliferative phase days: 10-14 ovualtion is occuring

During the menstrual cycle, what is the phase occurring during days 15-28?

Secretory (luteal) phase endo measures: 7-14mm

If you find fluid in the endometrium, do you measure it?

No, measure each side of the endo around the fluid.

What is the normal size of a postmenopausal endometrium?

<8mm

When is an endometrium that is up to 14mm still considered normal?

when the woman is postmenopausal and on HRT

What is the size of a Graafian follicle?

2-2.5cm day 14 dominant follicle

When does the corpus luteum develop?

after ovualtion

If the ovary volume is 3-8cm cubed, what stage of life is the female in?

premenarchal

What is the volume of menarchal ovaries?

9.8-21.9cm cubed

a postmenopausal ovary volume is 5-7cm cubed...true or false?

false....5.8-8 cm cubed

What size to ovarian follicles need to be in order to be considered normal?

<3 cm

When should postmenopausal cysts be removed?

>5cm with septations or nodules

What are inclusion cysts in the ovaries?

echogenic nonshadowing foci 1-3mm normal

What are focal calcifications?

stromal reaction previous hemmorrhage or infection need f/u to r/o early neoplasm

When is fluid in the pouch of douglas abnormal?

when it is a large amount has debris/septated fluid

What would you use to evaluate the endometrium better?

3D/4D provides a coronal image

sonographic eval of female pelvis Flashcards

(110 cards)