Normal Pelvic Ultrasound

Nazari L,

Assistant professor OB/GYN

Shahid Beheshti University of Medical Sciences

Spring 2016

Introduction

Chief complaint

Symptoms

Check duration of symptoms

Any ultrasound done previously. Check the records carefully

LMP

Any tests done and their reports

Referring doctors requisition slip

Female Anatomy Review

Uterus: Size, shape, mobility and probe

tenderness

Endometrium: Thickness and morphology.

Any focal abnormality

Myometrium : Echo pattern and presence of

fibroids and their location

Ovaries: Size and echo pattern. Any abnormality to be mentioned in terms of size, echo pattern, walls and focal abnormalities within it

Extra-ovarian adnexal

areas: Report whether

any mass is delineated

or not

Free fluid or fluid in the

pouch of Douglas or adnexa

Transabdominal approach :

•Lower frequency

•Lower resolution image

•Better visualized with full bladder

Transvaginal approach:

•Higher frequency

•higher resolution image

•Better visualized with empty bladder

Indications of TVS

Gynecologic sonography

Early first trimester obstetric

Later OB: Cervix, placenta previa and

evaluation of fetus before 14 weeks’

Suspected EP

Suspected lower abdominal disease in whom

a diagnosis has not been made with TAS

Follicle monitoring

Monitoring for ART

Preparation for TVS

Empty bladder

Explain to the patient

Consent ( Verbal / written)

Be sure about virginity!

Chaperone

Privacy ; Cover the Patient with a sheet

Supine position , bending knees

Anterior limitation : Flex her hips and bring

her knees up toward her chest

Sagittal

Coronal

Uterus

Is a reliable landmark because of its

central location, relatively large size

and the well-known pear-shape

The cervix is less mobile than the

uterine body due to uterosacral

ligaments that position the cervix in

the midline of the pelvis

Uterus

Size: varies with age:

Neonate: Relatively Large, Body> cervix

Childhood: Tubular, Body< cervix

Menarche: Large, Body> Cervix

Post menarche: Body = 2x Cervix

Reproductive age: 80x40x40 mm

Multiparous : +10 mm in each dimension

Version : Angle of the cervix to the vaginal

Flexion: Angle of body of the uterus at the

isthmus

Cysts within the cervix, termed nabothian

cysts, occur frequently

Result from the retention of mucus within

obstructed endocervical glands

Myometrium

•Myometrium is moderately hypoechoic,

especially in relation to the more echogenic

endometrium

•Normal myometrium is homogeneous in

echotexture

Endometrium

Endometrium is the innermost layer of the

uterus that lines the uterine cavity

There is often blood and shed tissue in the

uterine cavity during mensturation

During the late proliferative phase, the

endometrium (calipers) has a multilayered

appearance: echogenic around its periphery

and in the midline, and hypoechoic in between

During the secretory phase, the endometrium

is thick and echogenic

Measurement of the endometrial thickness is

useful in a number of clinical settings

This measurement is best obtained from a

sagittal transvaginal sonographic image,

after sweeping through the uterus to find the

site of maximal thickness

Excluding any fluid that may be present in

the endometrial cavity

Fallopian tubesInterstitial portion :

seen as a hyperechoic line

extending from the

lateral uterine angle to

the origin of the broad ligament

Isthmus and ampulla : rarely seen without the use of contrast media

Infundibulum can be seen if it is floating in peritoneal fluid

Interestitial portion of tube

Fimbria of the tube surrounded by fluid

Ovaries

Iliac vessels are a reliable landmark for

their visualization

Due to mobility of the ovaries and

transducer pressure, position of the ovaries

is often varying for example:

• Cul-de-sac

• In front of the uterus

• Above the uterus

• In the abdominal cavity

Ovaries

Ovaries are imaged as homogeneous,

hypoechogenic ovoid structures with

slightly echogenic central part

Antral follicles 5-12 per ovary

The pouch of douglas

In women of fertile age, fluid is almost

always seen in the pouch of douglas, at least

in the late follicular phase and in the

secretory phase of the menstrual cycle

In the early luteal phase , the pouch of

douglas normally contains 15-25ml fluid

Fluid outside the pouch of douglas in the

space between the uterus and the bladder is

abnormal

An ultrasound finding of even a small

amount of fluid in the pouch of douglas in a

postmenopausal woman is unusual, a follow

up scan is advisable to exclude that the fluid

is a first sign of ascites