GYNA and OBS

DR/ AMR SALAH

ultrasound

Dr /Amr Salah
1
 Collection 2

Dr /Amr Salah
 folliculometry 3

Dr /Amr Salah
Cyclical Changes During Menstrual Cycle 4

Dr /Amr Salah
Cyclical Changes During Menstrual Cycle 5

Dr /Amr Salah
 6

Dr /Amr Salah
 7

Dr /Amr Salah
 8

Dr /Amr Salah
 9

Dr /Amr Salah
 10

Dr /Amr Salah
 11

Dr /Amr Salah
 How to do
folliculometry 13

Follicular
count Is there Is there Ovulation
dominant
Corpus
mature happened
Previous Follicles ?? luteum
cyst
Follicles
Timing 14

1. Scan just at the end of menstruation>> base line exam

2. Scan at 10 to 12 day
3. Serial exam to maturity
4. Ovulation
5. At secretory phase of cycle

Dr /Amr Salah
1-Importance of D5/6 scan 15
• Follicle count
• To R/O cyst
• Endometrial shedding
• Rule out any other pelvic pathology
• Follicles ~ 3 to 5 mm
• Stromal blood flow

Features that suggest low ovarian reserve are as follows:

• (1) an ovarian volume of less than 3 mL,
• (2) fewer than 3-6 antral follicles (between two ovaries)
• (3) PSV of ovarian stromal vessels being less than 6 cm/sec.
Dr /Amr Salah
 16

Dr /Amr Salah
3 types of ovaries 17

1. Normal ovary : 5 / 15 follicle

2. Polycystic ovary : more than 15
3. Low reserve ovary : less than 5 ( inactive less than 3)

Dr /Amr Salah
 18

Dr /Amr Salah
 19

Dr /Amr Salah
Step1 just post menstruation 20

Ovary
Endometrium
Follicles count
to R\O
Any cyst
Any pathology
Size of ovary Dr /Amr Salah
2- Day 10-12 exam :
Dominant follicle more than 10- 12 mm 21

Dr /Amr Salah
Follicular monitoring 22

• we should start guessing the ovulatory dominant follicle i.e. dominant follicle
which is destined to ovulate.
• Basically, there are three varieties of eligible follicles:

1. Atretic dominant follicle: follicle on day 3, but it is not destined to ovulate. It

has an irregular shape, rough edges, and may be little echogenic.
2. Ovulatory dominant follicle: This follicle is typically round, with smooth
borders, and usually hypoechoic.
3. Anovulatory-luteinizing dominant follicle: fails to ovulate, and later becomes a
cyst or luteinizes. These are also round and smooth, however anechoic.

Dr /Amr Salah
 23

Dr /Amr Salah
 24

Dr /Amr Salah
 Importance of D10/12 scan 25

• At this time, one expects to see in one of

the ovaries a dominant follicle of about
16–18 mm, with Doppler flow around more
than 50 % of its circumference with a PSV
of about 10 cm/sec.

• The presence of Doppler signals around

more than 50 % of the dominant follicle is
generally associated with a good-quality
oocyte

Dr /Amr Salah
 26

Dr /Amr Salah
 27

Dr /Amr Salah
Doppler of dominant and non dominant ovary 28

Dr /Amr Salah
Importance of D10/ 12 scan 29

• and a uterine artery of PI less

than 3 are considered as reliable
markers for good endometrial
receptivity.

• The visualization of spiral arteries

into the endometrium has also
been seen to correlate well with
good receptivity

Dr /Amr Salah
 Step2 at day 10 to 12 30

Ovary
Endometrium
Any follicles more
Just measuring
than 10 mm Dr /Amr Salah
3- Serial exam to maturity 31

Dr /Amr Salah
3- Serial exam to maturity 32
• The patient is generally scanned on alternate days, and
the size of each follicle and endometrium is noted.

• Once the follicle reaches an average diameter of 16

mm, a daily monitoring of the follicle is
recommended

• Once the average diameter is 18 mm, with an

endometrial thickness of at least 6 mm (ideally 7 mm),
the referring clinician may choose to give the patient
an HCG injection to induce ovulation (likely to occur
36–40 hours after the injection is administered), and
intercourse or insemination is timed accordingly Dr /Amr Salah
Cumulus oophrous 24 to 36 hours before ovulation 33

Dr /Amr Salah
 34

Dr /Amr Salah
Step3 serial exam to maturity 35

Endometrium Ovary
Reach more than Follicle more
7mm than17mm Dr /Amr Salah
4 signs of ovulation 36

Dr /Amr Salah
 Step4 ?? ovulation 37

Endometrium
Ovary
Reach more than
Ovulation sign
7mm Dr /Amr Salah
secretory phase 38

Dr /Amr Salah
Luteal phase defect 39

Dr /Amr Salah
Assessment of corpus luteum gives idea about
luteal phase of cycle 40

Dr /Amr Salah
Corpus luteum wave form 41

Dr /Amr Salah
 Step5 luteal phase 42

Ovary
Endometrium
Corpus luteum with
Secretory phase
psv more than 10Dr /Amr Salah
 Recap 43

Dr /Amr Salah
Step1 just post menstruation 44

Ovary
Endometrium
Follicles count
to R\O
Any cyst
Any pathology
Size of ovary Dr /Amr Salah
 Step2 at day 10 to 12 45

Ovary
Endometrium
Any follicles more
Just measuring
than 10 mm Dr /Amr Salah
Step3 serial exam to maturity 46

Endometrium Ovary
Reach more than Follicle more
7mm than17mm Dr /Amr Salah
 Step4 ?? ovulation 47

Endometrium
Ovary
Reach more than
Ovulation sign
7mm Dr /Amr Salah
 Step5 luteal phase 48

Ovary
Endometrium
Corpus luteum with
Secretory phase
psv more than 10Dr /Amr Salah
 49
Tubal lesions

Dr /Amr Salah
 50

Dr /Amr Salah
 Hydrosalpnix 51

Dr /Amr Salah
Hydrosalpnix 52

• Fluid filled dilatation of the fallopian tube

Clinical presentation
• Patients may be asymptomatic or may
present with pelvic pain or infertility.

Ultrasound
• thin- or thick-walled (in chronic cases)
• elongated or folded, tubular, C-shaped, or
S-shaped fluid-filled structure
• distinct from the uterus and ovary.

Dr /Amr Salah
Hydrosalpnix 53

Dr /Amr Salah
Hydrosalpinx 54

Dr /Amr Salah
How to diagnose ?? 55

1 para-ovarian 2 incomplete
Adjacent to ovary septations
Dr /Amr Salah
How to diagnose 56

3 tubular shape
Dr /Amr Salah
 57

Dr /Amr Salah
Incomplete septation 58

Dr /Amr Salah
 59

Dr /Amr Salah
?? 60

Dr /Amr Salah
Complete vs incomplete septations 61

Dr /Amr Salah
 62

Dr /Amr Salah
Para ovarian lesion 63

Dr /Amr Salah
Waist sign 64

Dr /Amr Salah
 65

Dr /Amr Salah
 66

Dr /Amr Salah
 67

Dr /Amr Salah
 68

Dr /Amr Salah
MRI 69

Dr /Amr Salah
 70

Dr /Amr Salah
 71

Dr /Amr Salah
 Hemato / pyo salpnix 72

Dr /Amr Salah
Pyosalpnix 73

• Fallopian tube that is filled, and often distended, with pus.

• A pyosalpinx may be seen as a thickened fallopian tube and may or may not
be associated with debris.
• The Fallopian tube may be distended.

Dr /Amr Salah
Hematosalpnix 74

Ultrasound
May demonstrate a dilated fallopian tube where altered blood products within the tube
are often demonstrated as homogeneous low-level echoes

Causes include
• tubal ectopic pregnancy: common cause
• endometriosis: common cause
• tubal carcinoma
• pelvic inflammatory disease
• fallopian tube torsion
• retrograde menstruation : uterine cervical stenosis
• pelvic trauma
Dr /Amr Salah
Hemato / pyo salpnix 75

Dr /Amr Salah
 76

Dr /Amr Salah
 77

Dr /Amr Salah
 78

Dr /Amr Salah
DD 79

Hydrosalpinx Pyo-hemato
Dr /Amr Salah
Hydro vs. pyosalpinx 80

Dr /Amr Salah
 81

Dr /Amr Salah
 Cervical and vaginal
82
lesions

Dr /Amr Salah
 83

Dr /Amr Salah
 84

Dr /Amr Salah
Mucosal folds in the cervix, termed plicae palmatae 85

Dr /Amr Salah
Nabothian (inclusion) cysts 86
• They may vary in size from a
few millimeters to 4 cm

• may be single or multiple

• usually diagnosed incidentally,

although they may be
associated with healing
chronic cervicitis.

• Occasionally, nabothian cysts

have internal echoes, possibly
caused by hemorrhage or
infection.
Dr /Amr Salah
 87

Dr /Amr Salah
 88

Dr /Amr Salah
 89

Dr /Amr Salah
Cervical polyps 90

• sessile or pedunculated well-circumscribed

masses within the endocervical canal

• may be hypoechoic or echogenic

• identifying the stalk attaching to the

cervical wall helps differentiate it from an
endometrial polyp

Dr /Amr Salah
 91

Dr /Amr Salah
 92

Dr /Amr Salah
 93

Dr /Amr Salah
Endometrial polyp ( not cervical) 94

Dr /Amr Salah
Cervical fibroid 95

Dr /Amr Salah
 96

Dr /Amr Salah
 97

Dr /Amr Salah
 98

Dr /Amr Salah
Cervical carcinoma 99

Dr /Amr Salah
 Adenoma malignum 100

• Multiple cystic areas are seen

within a solid cervical mass

• This condition should be easily

differentiated from deep nabothian
cysts because nabothian cysts do
not have an associated mass.

Dr /Amr Salah
 101

Dr /Amr Salah
 102

Dr /Amr Salah
 103

Dr /Amr Salah
Cervical stenosis 104

• Stenosis of the uterine cervix is

the pathologic narrowing of the
uterine cervix.

• The term cervical stenosis is

clinically defined as cervical
narrowing that prevents the
insertion of a 2.5 mm wide
dilator through the cervical os.

Dr /Amr Salah
Hematometra in Patient With Cervical Stenosis 105
Etiology
• chronic infection (chronic cervicitis)
• trauma from previous instrumentation
• cervical polyp
• carcinoma of the cervix
• post radiation therapy
• cervical endometriosis

Dr /Amr Salah
 106

Dr /Amr Salah
Normal vagina 107

Dr /Amr Salah
Vaginal wall cyst 108

Dr /Amr Salah
 109

Dr /Amr Salah
Hematocolpos: vagina filled by blood 110
Hematocolpos 111

Dr /Amr Salah
 112

Dr /Amr Salah
 113

Dr /Amr Salah
hematometrocolpous 114

Dr /Amr Salah
hematometrocolpous 115

Dr /Amr Salah
Labial varices 116

Dr /Amr Salah
 117

Dr /Amr Salah
 118

Dr /Amr Salah
Encysted hydrocele of canal of nuck
Canal of nuck cyst 119

Normal canal Cyst in canal

Dr /Amr Salah
Canal of nuck cyst ultrasound apperance 120

Dr /Amr Salah
Canal of nuck cyst 121

Dr /Amr Salah
Canal of nuck cyst 122

Dr /Amr Salah
Ovarian hernia 123

Dr /Amr Salah
 124

Dr /Amr Salah
 125

Dr /Amr Salah
 126

Canal of nuck
Ovarian hernia
cyst
Dr /Amr Salah
 127
Other pelvic lesions

Dr /Amr Salah
 Pelvic inflammatory
128
disease

Dr /Amr Salah
Pelvic inflammatory disease 129

• Pelvic inflammatory disease (PID) is a broad term that encompasses a spectrum

of infection and inflammation of the upper female genital tract.

Clinical presentation
• More common presentations include acute pelvic pain (of variable intensity),
cervical motion tenderness, vaginal discharge, fever, dyspareunia, and
leucocytosis.

• Right upper quadrant pain from perihepatitis in Fitz-Hugh-Curtis syndrome is

possible.

Dr /Amr Salah
Radiographic features 130

• Ultrasound often only demonstrates ascitic fluid in the peritoneal cavity

• In the most severe cases, ultrasound may show adnexal masses with a
heterogeneous echo-pattern.

• Some sonographic signs associated with tubal inflammation include:

• thickened/dilated fallopian tubes
• incomplete septa in the tube
• increased vascularity around the tube
• echogenic fluid in the tube (pyosalpinx)

Dr /Amr Salah
 131

Dr /Amr Salah
 132

Dr /Amr Salah
 133

Dr /Amr Salah
 134

Dr /Amr Salah
Pelvic inflammatory disease 135

Echogenic fat

Uterus

Dr /Amr Salah
Fitz-Hugh-Curtis syndrome 136

• Fitz-Hugh-Curtis syndrome (FHCS) refers to the development

of perihepatitis in association with pelvic inflammatory disease (PID).

Clinical presentation
• Patients often present with a new-onset right upper quadrant or pleuritic chest
pain on a background of pelvic inflammatory disease.

Dr /Amr Salah
Radiographic features 137

• Shows inflammatory changes in both pelvic and perihepatic regions.

Pelvic findings:
• may show a tubo-ovarian abscess

Perihepatic findings:
• can show inflammatory stranding and fluid along the right paracolic gutter as
well as the perihepatic region
• gall bladder wall thickening
• pericholecystic inflammatory change

Dr /Amr Salah
Fitz-Hugh-Curtis syndrome 138

Dr /Amr Salah
Young female post partum 139

liver

uterus

Dr /Amr Salah
 Tubo-ovarian abscess 140

Dr /Amr Salah
TOA 141
Risk factors include :
• previous pelvic inflammatory disease
• intrauterine device
• multiple sexual partners
• diabetes mellitus
• immunocompromise
• history of uterine surgery (as a complication of a hysterectomy)

Dr /Amr Salah
 142

Ultrasound
• Transabdominal and endovaginal ultrasound are the preferred initial imaging
investigations. Findings may include:

• multilocular complex retro-uterine/adnexal mass

• debris, septations, and irregular thick walls
• commonly bilateral
• echogenic debris within the pelvis

Dr /Amr Salah
TOA 143

Dr /Amr Salah
TOA 144

Dr /Amr Salah
TOA 145

Dr /Amr Salah
 146

Dr /Amr Salah
 147

Dr /Amr Salah
TOA 148

Dr /Amr Salah
 149

Dr /Amr Salah
 150

Dr /Amr Salah
TOA vs. pyosalpinx 151

Dr /Amr Salah
DD of adnexal cyst with fluid-fluid level 152

Hemorrhagic Dermoid TO Pyo

endometrioma
cyst cyst Abscess salpnix

Dr /Amr Salah
 Quiz 153

Dr /Amr Salah
1 154

Dr /Amr Salah
2 155

Dr /Amr Salah
3 156

Dr /Amr Salah
4 157

Dr /Amr Salah
5 158

Dr /Amr Salah
6 159

Dr /Amr Salah
7 160

DR/ AMR SALAH

8 161

Dr /Amr Salah
9 162

Dr /Amr Salah
10 163

Dr /Amr Salah
11 164

Dr /Amr Salah
12 165

Dr /Amr Salah
13 166

Dr /Amr Salah
14 167

Dr /Amr Salah
15 168

Dr /Amr Salah
16 169

Dr /Amr Salah
17 170

Dr /Amr Salah
18 171

Dr /Amr Salah
19 172

Dr /Amr Salah
20 173

Dr /Amr Salah
21 174

Dr /Amr Salah
22 175

Dr/ Amr Salah

23 176

Dr /Amr Salah
24 177

Dr /Amr Salah
25 178

Dr /Amr Salah
26 179

Dr /Amr Salah
27 180

Dr /Amr Salah
28 181

Dr /Amr Salah
29 182

Dr /Amr Salah
30 183

Dr /Amr Salah
31 184
32 185

Dr /Amr Salah
33 186

Dr /Amr Salah
34 187

Dr /Amr Salah
35 188

Dr /Amr Salah
 189
Thank you

Dr /Amr Salah