BASIC PRINCIPLES OF

ULTRASOUND AND OTHER

IMAGING TECHNIQUES
DR. N. I. ILOANUSI
LECTURER/CONSULTANT RADIOLOGIST
DEPARTMENT OF RADIATION MEDICINE
FACULTY OF MEDICAL SCIENCES
COLLEGE OF MEDICINE
UNIVERSITY OF NIGERIA, ITUKU-OZALLA CAMPUS, ENUGU

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 OUTLINE
• The role of women’s imaging in the field of obstetrics and gynaecology
• Ultrasound:
• Definition
• History
• Basic physics of ultrasound
• Benefits and risks
• Limitations
• Clinical applications
• Fluoroscopic studies
• Magnetic Resonance Imaging
• Interventional Radiology
• Computed Tomography
• Nuclear Medicine

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 THE ROLE OF IMAGING IN THE FIELD OF
OBSTETRICS AND GYNAECOLOGY
• To display female pelvic anatomy for the purpose of early detection,
diagnosis and treatment of various pathologies
• Historically, pelvic imaging began with techniques involving ionizing
radiation- x-rays, fluoroscopic exams like hysterosalpingography (HSG)
and vaginography, pelvic arteriograms
• A lot changed with the advent of medical ultrasound. For the first time,
the gravid uterus could be visualized and monitored. Ultrasound is the
first line imaging modality in Ob/Gyn
• CT is primarily used for staging of gynaecological malignancies and for CT
pelvimetry
• MRI which has an added advantage of exquisite soft tissue resolution and
has largely replaced CT (in more advanced economies)
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 ULTRASOUND DEFINITION
• Ultrasound imaging (sonography) entails using high
frequency sound waves (usually in the range of MHz) to
produce images of sections of the body
• Sound waves are produced by the ultrasound transducer
which travel into tissues. Echoes generated at tissue
interfaces return to the transducer and are organized into
images
• Sound waves are not ionizing- a great advantage
• They show the organs in real-time which assists in accurate
diagnosis
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 *History
• Lord Raleigh, 1877: ‘Theory of Sound’
• Pierre & Jacques Curie, 1880- Piezoelectric (PZ) effect
• Langevin, 1914: 1st ultrasound generator using the PZ effect
• Solokov, 1928: Ultrasound for material testing
• Dussik, 1942: 1st application of ultrasound in medicine
• After WWII, Japanese researchers explored medical ultrasound further and
developed different applications

*A short History of the development of Ultrasound in Obstetrics and Gynecology

Copyright 1998-2002 Joseph SK Woo MBBS, FRCOG. http://www.ob-ultrasound.net/history1.html
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*History continued
• Professor Ian Donald (in 1959) was the 1st to use medical ultrasound
for observing the pregnant uterus and did a lot of work on foetal
cephalometry in the Royal Maternity Hospital, Rottenrow, Glasgow
• By the end of the 1960’s, there was a boom in the use of medical
ultrasound
• Early 1970’s: Ultrasound images were static and in greyscale
• Mid 1970’s: Real-time imaging
• Early 1980’s: Spectral Doppler (waveforms), Colour Doppler
• Now: 3-D, 4-D, Handheld devices, Harmonic imaging, Elastography,
etc
*A short History of the development of Ultrasound in Obstetrics and Gynecology
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Copyright 1998-2002 Joseph SK Woo MBBS, FRCOG. http://www.ob-ultrasound.net/history1.html
BASIC PRINCIPLES OF ULTRASOUND

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COMMON SOUND FREQUENCIES

Culled from Slideshare®฀

Assoc Prof Sreedhar Rao
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AAMC Moodabidri, India
BASIC ULTRASOUND PHYSICS
• Sound waves are longitudinal mechanical waves
• They need an elastic medium for propagation
• Sound wave velocity through soft tissues is about 1500m/s
• V= f
• Increased f---- reduced ---- reduced tissue penetration

• Reduced f---- increased ---- enhanced tissue penetration

• When sound gets to a tissue interface a combination of three phenomena
occur- reflection, refraction, absorption and the ratio depends on the tissue
characteristics.
• Reflection is what produces the ultrasound image
• Refraction produces artefacts
• Absorption causes wave attenuation (Energy loss)
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ULTRASOUND CONTD

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• Transmitter / Receiver mechanism

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ULTRASOUND (COUPLING) GEL
• Known as a coupling agent
• Allows ultrasound signals to
penetrate into the body and
return to the transducer
producing an image
• Sound waves move very well
through fluid and solids but are
impeded by the air
• So the ultrasound gel
eliminates the layer of air
between the probe and the
skin
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ULTRASOUND MODES
• A- mode (Amplitude mode):
• Ultrasound signals from tissue
interfaces are displayed as spikes on a
graph
• The Y-axis represents the amplitude of A- mode
the signal while the X-axis represents tracing
the distance of the tissue interface
from the transducer
• This was the 1st type of ultrasound
mode
• Used mainly for ophthalmic
ultrasound
• M- mode (Motion mode):
• Used for imaging moving tissue
• Signals from moving structures are
displayed as waves in a continuous B- mode
manner on a graph tracing
• Used mainly for assessing foetal heart
rate and for cardiac imaging
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• B- mode (Brightness mode): Fig A
• The most common mode (Fig A)
• Ultrasound signals from tissues are displayed as
multiple dots of varying degrees of brightness
which appear as images in a 2-dimensional manner
on the monitor
• The brightness displayed is directly proportional to
the intensity of the echo generated
• D- mode (Doppler mode):
• Detects and measures blood flow. It is based on the
Doppler effect
• A series of ultrasound pulses are sent into the
blood vessel from the transducer and the returning
echoes are either processed as colour flow images
(colour Doppler) or spectral (waveform) images
(spectral Doppler)
• Spectral Doppler is widely used in faeto-maternal
medicine for investigation of IUGR. Umbilical artery
Doppler or even Doppler of the foetal intracranial Fig B
arteries can be done to identify foetuses at risk
• Colour Doppler and Power Doppler are used often
in evaluating the placenta, umbilical cord and also
abnormal masses
• Most machines combine B and D mode (Fig B)
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ULTRASOUND CONTD

• Terminologies describe
echogenicity (ability to generate
echoes):
- Hyperechoic: placenta
- Hypoechoic: myometrium
- Anechoic (echo-free): amniotic
fluid
- Isoechoic

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 BENEFITS AND RISKS
BENEFITS RISKS
• Non-invasive. No ionizing radiation • Misdiagnosis
• Widely available, cheap, portable • *Thermal effect. Pulsed ultrasound can
• Gives a clear picture of soft tissues, produce elevations of temperature and
which usually do not show up well damage in biological tissues in vivo,
in plain radiographs particularly in the presence of bone
(intracranial temperature elevation).
• Real time imaging & therefore This can cause cavitation but the body
useful for guided procedures such part has to be exposed to ultrasound for
as needle aspirations and biopsies a very long time for this hazard to occur.

*Abramowicz, Jacques & B Barnett, Stanley & A Duck, Francis & D Edmonds, Peter & H Hynynen, Kullervo & C Ziskin, Marvin.
(2008). Fetal Thermal Effects of Diagnostic Ultrasound. Journal of ultrasound in medicine : official journal of the American Institute
of Ultrasound in Medicine. 27. 541-59; quiz 560. 10.7863/jum.2008.27.4.541. 16
 LIMITATIONS OF ULTRASOUND IMAGING
• Ultrasound waves cannot be transmitted through air. Therefore a gas-
filled viscus will not image optimally with ultrasound
• Obese subjects severely limit the resolution of ultrasound images.
Remember that sound waves get attenuated as they travel deeper
through tissues
• Ultrasound cannot penetrate bone and limits is usability for bone
imaging (remember, bone isn’t elastic)

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 APPLICATION OF ULTRASOUND
IN
OBSTETRICS AND GYNAECOLOGY

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 Ultrasound Applications in Obstetrics & Gynaecology
• Assessment of pelvic pain- acute (e.g. ectopic pregnancy) or
chronic
• The commonest cause of acute pelvic pain in the setting of a positive pregnancy test is ectopic
pregnancy
• Other causes of *acute pelvic pain: Large ovarian cyst, rupture of an ovarian cyst, ovarian torsion,
degenerating leiomyoma, acute PID
• The commonest cause of chronic pelvic pain is **chronic PID and possibly, endometriosis.
• Assessment of a pelvic mass- e.g. leiomyomata
• Abnormal vaginal bleeding- in the non-pregnant or pregnant
woman
• Search for a ‘lost IUCD’
* Choudhary, V., Somani, S., Somani, S., & Kaul, R. (2017). Evaluation of series of 177 cases of acute gynaecological emergencies in tertiary care hospital. International Journal of
Reproduction, Contraception, Obstetrics and Gynecology, 5(6), 1700-1704.
**Luntsi G. Pattern of Gynaecological Pelvic Ultrasound Findings among Women with Pelvic Pain in a Tertiary Hospital
In Kano, North Western Nigeria. IOSR-JDMS, AUGUST 2015: (14), 7: 79-82. 19
Ultrasound Applications in Obstetrics & Gynaecology
• Pregnancy:
• Assessment for foetal well-being
• Assessment of other parts of the pregnant uterus- placenta,
uterine wall, cervical canal, adnexa
• Ruling out foetal anomalies
• Emergencies- acute pain or bleeding per vaginam
• Confirming foetal demise
• Workup for infertility: TVUS, follicle tracking,
sonohysterography
• Intervention: Drainage of cysts, abscess collections, etc.

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IMAGING THE UTERUS AND ITS ADNEXA
• The pelvic organs-
uterus, ovaries (& at
times, the fallopian
tubes) are imaged
by two routes:
• Trans-abdominal
(TA), with the TA axial scan of the pelvis showing TA sagittal scan of the uterus
curvilinear the uterus and ovaries on either side
transducer
• Trans-vaginal (TV),
with the endo-
cavitary transducer

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TV sagittal scan of the uterus
 ULTRASOUND OF THE ENDOMETRIAL CYCLE

• Ultrasound can also detect the

menstrual cycle phase
• During the early proliferative phase ES- DAY 10
the endometrial stripe is thin and
unilaminar (a)
• In the late proliferative phase it (a) (b)
adopts a trilaminar appearance (basal
& functional layers) (b)
• In the immediate pre-ovulatory phase,
the basal endometrial layer thickens,
as a result of the pre-ovulatory
progesterone spike (c)
• After ovulation, the stripe is in the
secretory phase; echoes begin filling
in between the basal and functional
endometrial layers and the stripe
gradually becomes thick and
echogenic (d) (c) (d) 22
ULTRASOUND OF THE OVARIAN CYCLE
( FOLLICLE TRACKING)
• Follicle achieves dominant size (1.5cm MFD)
in the mid- proliferative phase; mature size
(1.9cm MFD) in the late proliferative phase,
and proceeds to rupture thereafter
• Features suggestive of imminent rupture
may be seen- presence of Cumulus
oophorus, formation of stigma, sonolucent
rim surrounding a serrated follicular wall,
peri-follicular colour signal on Doppler. At
this time, the endometrial stripe has a
characteristic trilaminar configuration
• The follicle ruptures and either completely Cumulus Oophorus
disappears or reduces significantly in size by
more than 7.5mm from the previous
diameter Corpus luteum
• Formation of corpus luteum- cystic or solid 23
DETECTION OF ABNORMAL FOLLICULAR DEVELOPMENT

PCOS

LUF

Ovarian
failure Partial follicular
rupture

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THE OBSTETRIC ULTRASOUND
• Confirmation of pregnancy and assessment foetal development
• Foetal biometry and dating (dating is better done before 28 weeks of GA. Best
time is the 1st trimester)
• 1st trimester Ultrasound:
• Confirmation of pregnancy
• Anomaly scans
• 2nd trimester ultrasound:
• Detect other foetal abnormalities
• Confirm normal growth
• 3rd trimester ultrasound:
• Confirm normal growth and rule out IUGR (Intra- Uterine Growth Restriction)

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 FOETAL BIOMETRY Tips for early cyesis imaging
• If you see:
• Measurement of parameters to • A gestational sac, pregnancy is up to 5
assess gestational age and growth weeks
• A gestational sac + yolk sac,
• Parameters deployed: pregnancy is approximately 5.5 weeks
• Mean Gestational Sac Diameter • A gestational sac + yolk sac + embryo,
(GSD): used before the embryo the pregnancy is at least 6 weeks
becomes visible
• If you CRL is >5mm, there should be
• Crown Rump Length (CRL): Used once discernible foetal cardiac activity
the embryo is up to 7mm in length
• Head Circumference (HC) or Bi-
Parietal Diameter (BPD): Used by the
end of the 1st trimester- 13+ weeks
(HC and BPD are most accurate for
dating between weeks 13-23)
• Femur length (FL): Used as from 13+
weeks (After week 23, only FL is most
accurate for dating)
• Abdominal Circumference (AC): For
foetal weight estimation
• Others- humeral, tibial, fibular length,
cerebellar width, thoracic
circumference, etc. Assessment of CRL 26 Health
Woodland Women’s
Plane for BPD & HC measurement Plane for AC measurement

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Plane for FL measurement Measurement of Amniotic Fluid Index (AFI)
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SONOHYSTEROGRAPHY
• Also called ‘saline-induced
sonohysterography’ (SIS)
• It evaluates the endometrial lining
and cavity
• Particularly useful for visualizing
endometrial polyps Uterus before saline infusion Normal SIS

• Other indications: fertility workup

to rule out intrauterine adhesions,
endometrial hyperplasia, suspected
endometrial cancer, post-
menopausal bleeding, submucous
leiomyoma, retained products of
conception, etc
• Contraindications: Active PID,
pregnancy, IUCD in utero 29
Endometrial polyps seen on SIS
HYSTEROSALPINGOGRAPHY (HSG)
• A x-ray- based exam done (ideally) with the
fluoroscopy machine
• An iodine-based, water-soluble contrast
agent is injected through the cervical canal
and images taken of the progress of the
contrast through the reproductive tract
• After a decline, this exam is gaining Normal HSG
popularity again, due to advances in
reproductive technology
• Indications: Congenital anomalies, uterine
synechiae, adenomyosis, masses like Septate uterus
polyps, leiomyomas, tubal abnormalities
like salpingitis isthmica nodosum,
hydrosalpinx & peritubal adhesions
• Contraindications: active pelvic infection,
pregnancy
• HSG should be done any day between days
7 to 12 of the menstrual cycle
• Protocol: Scout film, contrast images, +/-
‘withdrawal’ film
Hydrosalpinges 30
MAGNETIC RESONANCE IMAGING (MRI)
• An excellent tool for imaging the uterus and adnexa because of
superior soft tissue resolution
• It is indicated when ultrasound is not helpful or is equivocal- not a
first line imaging modality. It’s the best tool for staging of
malignancies
• Images of the pelvic organs are acquired in axial, sagittal and coronal
planes thereby improving the chances of a definitive diagnosis
• The T2-weighted sequence is preferred to T1. The latter has poor
tissue contrast

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UTERINE ZONAL ANATOMY ON MRI
• Endometrium- High signal (black
arrow)
• Junctional zone- Low signal sub-
endometrial layer of the
myometrium (also called the
‘inner’ myometrium) (short
white arrow)
• Myometrium- Intermediate
signal intensity (long white
arrow)

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MRI- Clinical Diffuse adenomyosis of the uterus

applications
• The junctional zone is lost in
pathologies like diffuse
adenomyosis
• MRI is more sensitive than
ultrasound in diagnosing
malignancies Early stage endometrial cancer

• However, in a resource-
constrained economy like
ours, MRI is not routinely
used for pelvic imaging

Endometrial cancer in a post-

menopausal woman 33
Interventional Radiology in Ob/Gyn
• The aim is to provide image-guided, minimally invasive alternatives to
traditional surgical procedures to suitable patients
• Polyvinylalcohol (PVA) is used for embolotherapy
• Procedures:
• Selective arterial embolization procedures to stem bleeding- from postpartum
haemorrhage, abnormal placentation, cervical cancer, uterine AVMs, etc
• Uterine artery embolization for leiomyomas
• Various arteries can be embolized- uterine artery, hypogastric, inferior epigastric,
depending on the site of extravasation
• A pig-tail catheter is introduced into the aorta percutaneously through the femoral
artery and then threaded down to the anterior division of the internal iliac artery.
Contrast is injected to pick up the site of extravasation and the catheter advanced to
the site
• Placement of IVC filters in postpartum women at risk of DVT

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COMPUTED TOMOGRAPHY
• Simply put, this is a 3-dimensional x-ray machine
• An x-ray tube rotates round the patient positioned
in the gantry, sending x-rays through the area of
interest, which are then picked up by detectors
and displayed as images on the monitor
• CT is not the modality of choice for Ob/Gyn
imaging because of some obvious drawbacks:
• Radiation dose
• Poor soft tissue contrast in the pelvic organs
• However, CT can be used for staging of
malignancies
• Still used for pelvimetry*, especially where there is
insurance coverage. It’s relatively expensive. Its
clinical value is debatable
• CT pelvimetry is a low radiation dose
procedure
• However, some new advances have been
made. There is now CT pelvimetry done with
stereoradiographic imaging (SRI), which *Ben Abdennebi, A. et al. Comparative dose levels between CT-scanner and slot-scanning
further reduces the radiation dose device (EOS system) in pregnant women pelvimetry
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Physica Medica: European Journal of Medical Physics , Volume 33 , 77 - 86
 Transverse diameter/AP diameter pelvic inlet
CT PELVIMETRY
• A small maternal pelvis is a contraindication to
attempting vaginal delivery of a fetus in breech
presentation because of the potential difficulty
in delivering the aftercoming fetal head
• A pelvis too small for safe vaginal delivery has
been defined as measuring less than*:
• either 12 cm in the widest transverse diameter of the
pelvic inlet or
• 11 cm in the anteroposterior diameter of the pelvic
inlet, or
• 10 cm at the mid-pelvis between the ischial spines
• Digital pelvimetry on a CT scanner has been Interspinous diameter
advocated as a replacement for conventional
radiographic pelvimetry to obtain these
measurements because it reduces the absorbed
radiation dose
• The most important distance is the interspinous
distance of the pelvis (on the axial image) *Gimovsky ML, Willard K, Neglio M, Howard T, Zeme S. X-ray pelvimetry in a breech protocol: a comparison
because most cases of obstructed labour occur of digital radiography and conventional methpds. Am J Obstet Gynecol 1985;153:887-888.
**Aronson D, Kier R. CT pelvimetry: the foveae are not an accurate landmark for the level of the ischial
at the level of the ischial spines** spines. American Journal of Roentgenology. 1991;156: 527-530. 10.2214/ajr.156.3.1899750
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NUCLEAR MEDICINE IN
GYNAECOLOGY
• Used mostly in the field of gynae-
oncology
• Tumour staging. Detection of
metastases
• Follow-up imaging in oncology
• The commonly used modality is
Positron Emission Tomography (PET
scan). The radio-pharmaceutical
used is 18-Fluorodeoxyglucose
(FDG)
• PET can be superimposed on a CT
image to create a PET-CT study

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THANKS FOR LISTENING

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