Problem Solving with 3D Sonography of the Uterus & Adnexa - HD

Introduction to 3D Sonography of the Uterus and Adnexa

Hi, I'm Rochelle Andretti from Vanderbilt University
and I'm going to be speaking about 3D sonography of the
uterus and a nexa problem solving.

In the next 30 minutes, I'd like to have some fun
with a series of patient cases demonstrating problem solving
techniques using 3D sonography of the uterus and adnexa.

I have no relevant financial relations to disclose,
so as an artist has carved a work of art from a dead tree.
In this park in Bordeaux, France, we will slice
through 3D volumes to obtain our work of art,
which is a final product that answers a clinical question.

Problem solving surrounds the use
of the reconstructed coronal plane.
The coronal plane of the uterus
and ad nexa usually can't be visualized using traditional 3D
imaging, but it answers important questions
that could not be previously addressed
with traditional 2D imaging.

And the majority of these applications will
involve the uterus.
And as you can see here we have a surface rendered 3D
coronal image of the uterus, which
of course is a normal.

So I'd like to show examples
that illustrate practical applications
of 3D sonography of the pelvis.
This will include assessing uterine shape anomalies,
improving visualization of the entire IUD delineating
and locating abnormalities associated with the endometrium
and reconstructing the fallopian tube when adjacent cystic
structures are demonstrated.

Manipulations for Image Reconstruction

First, what are the manipulations that we need to use
in order to reconstruct the image?
First there's a manual or automatic
or automated sweep which is performed to obtain a volume
through the acquisition plane,
which is usually the sagittal plane of the uterus.

Then a multiplanar format
or display will appear on the screen,
which are three orthogonal planes with
or without a surface rendered image.
And the surface rendered image is a thicker slice
through the volume, with depth perception that it's improved
by different computer generated
shading and lighting effects.

And then of course we'll slice
or rotate using a marker dotter line
to select scan the scan plane from the volume.

So here we have an example of the multiplanar display.
First you can see that we have the acquisition plane,
the sagittal plane, and we have these lines, the blue line
representing the coronal plane, the green line,
the transverse plane.

So first our first quadrant is the transverse view
of this sagittal acquisition plane.
And our third quadrant would be the coronal view sliced
through the midline of the endometrium.
And then we have our surface rendered image
in the fourth quadrant.

So here is an enlarged view
of the surface rendered image where we've rotated it.
So the fundus is on top the way we usually like
to view the coronal view of the uterus.

So let's go through how we might,
actually perform this manipulation.
So here we go. So its lineup,
the endometrium
with the horizontal line, the Z plane,
which is our coronal plane.
So right here we'll be lining it up
and we'll have to rotate the uterus a bit so that
we are in perfect alignment.

Then we also wanna line up the endometrium
and the transverse plane as well.
And then we'll come over to the coronal plane
where we can first rotate it so that the fundus
is on the top and we can view it in a
plane that we're more used to seeing.

And then we can enlarge it
and we can manipulate the image by rotating
in both the X and Y planes so
that we can see this entire IUD on one image,
which we will see in just a second here.
Voila.

Uterine Shape Anomalies

So first let's
look at some uterine shape anomalies.

So why is it important that we determine what type
of uterine shape anomaly the patient has?
First uterine anomalies are associated
with an increased risk of infertility
and obstetrical complications.
The correct diagnosis helps to minimize complications
and manage infertility.

So the need for intervention
and the type of intervention is determined
by the proper classification of the anomaly.

So one of the most useful applications in anomaly evaluation
is determined is to determine the etiology
for two cavities seen by 2D imaging.
So each of these images represents a different anomaly
and there are different managements for each.

So before we look at each particular
anomaly,
I'd like to just show you the classification
of uterine malformations according
to the American Fertility Society.
And as you can see, the coronal plane
best delineates these anomalies.

And what we're going
to be talking about mainly are the most common anomalies,
which are on the spectrum of the arcuate
and septate uterus, as you can see here,
and the bor delphis uterus.
These two images here.

Subseptate Uterus

So let's first look at this patient,
a 24-year-old gravita four para ofor
with recurrent pregnancy loss at
11
to 15 weeks gestational age.

So we can see our first patient with two cavities.
We do our reconstructed coronal plane
and we have what we call the sub septate uterus
where we have a partial septum and a smooth fundus.

So the septate uterus is an A FS class five.
It's the result of lack of resorption of the uterine septum
after complete fusion of the malian ducts,
it may be partial or complete.

As I mentioned, there's always a,
a smooth fundal contour
or occasionally it might be slightly undulated,
but very, very small.
It's associated with early pregnancy loss
and the management of infertility includes a procedure,
a hysteroscopic metro plasty removal of the septum.

Uterus Didelphys

So here's a second patient two cavities.
This is a 27-year-old gravita one para one with a history
of a spontaneous vaginal delivery
of 34 weeks gestational age.

We do our reconstructed coronal plane
and we have two separate uterine horns, the uterus delphis.

So this is a complete duplication anomaly an A FS class
three where we have lack of malaria
and duct fusion forming two separate uterine horns,
two endometrial cavities and two services.

And it also may be accompanied by two hemi vaginas separated
by a longitudinal or transverse septum.

This is associated with miscarriage
and premature delivery as was the case in this patient.
And it is not a minimal to surgical management
as the septate uterus would be.

Arcuate Uterus

So here we have our third example of two cavities,
a 25-year-old gravity zero
with the incidental finding on a pelvic ultrasound performed
for abnormal bleeding.

So this is the arcuate uterus an A FS class six,
which is the mildest form of a septate uterus
where we have a minimal septum as we can see here,
which is somewhere between five
and 10 millimeters in denting the the uterine fundus.

And I say five to 10 millimeters
because if it's under five millimeters,
it's not really even considered an anomaly.
This is commonly considered a normal variant.
No intervention is necessary,
although there are some reports
of increased second trimester loss in pre uh, preterm labor.

Bicornuate Uterus

So here we have another patient, a 3-year-old gravitate two,
para two with a history
of premature delivery at 28 and 32 weeks.

And as we can see, very widely placed uterine horns.

So is this a uterus delphis
or is it a bicornuate configuration?
And I'm showing you this sweep
through the uterus in the transverse plane just to show you
how difficult it is by 2D imaging,
in this transverse plane to really determine which it is.
Are there really two separate horns here
or is this a bicornuate uterus?
We really can't tell,
although we do know that there is some separation of horns.

So, this is a bicornuate uterus.
As we can see there are two uterine horns,
but they do join immediately above the cervix.

So a bico root uterus is a class four, which is the result
of incomplete fusion of mullerian ducts.
It consists of two uterine horns
with two endometrial cavities that join
above the internal OSS of the cervix.

Like I already mentioned, no intervention is necessary,
but this pregnancy would be managed as high risk
and we would also know that a complication such
as a vaginal septum that we would see
with a uterus delphis would not be into anticipated.

So just as a review, a review, we can see the difference
between the spectrum of the septate
uterus,
and the fusion anomaly
where we see pretty much smooth contour,
although we do in this case have a little bit
of an undulation with a septum as opposed
to two separate uterine horns in the fusion anomaly.

Unicornuate Uterus

So next we have a 29-year-old gravita one para one
with a history of premature delivery at 29 weeks.

Now is this a uterine anomaly?
Actually, this is kind of a trick question
because I don't think you would actually think
that I would be showing you a normal uterus when I'm talking
about fetal anomalies.

So, but actually when we do our
reconstruction in the coronal plane, this is a unicorn
with uterus and this is the only type of
uterine shape anomaly
where we would have absolutely no suspicion
of an anomaly on 2D imaging.

But on our 3D reconstruction,
this would be the only method
to actually make this diagnosis.

So theoral uterus class two a FS
is a result of failure of development
or incomplete development of one of two mullerian tubercle.
We have the presence of only one urine horn
or there is a difference in size of one horn when compared
to the other and usually it's a significant difference
and this is associated with miscarriage
and premature delivery.

So, so much for uterine shape anomalies.
Let's move on to some cases demonstrating IUD malposition.

IUD Malposition

First we have a 26-year-old gravita one para one presenting
to pain clinic and as we can see here,
there is at least a portion
of IUD within the endometrial cavity on this
2D sagittal view.

When we do our reconstruction,
we can see our multiplanar display here
and we can see
on this thin slice coronal view that the arms do appear
to be very low within the endometrial cavity
embedded in the myometrium.

And on our surface rendered view we can see even better
where the shaft of the uterus is
and can see very nicely that this
IUD is actually upside down
with the arms embedded in the myometrium.

Another patient, a 29-year-old gravita one para zero
presenting with pelvic pain.
Once again, we see
that there is some IUD within the endometrial cavity,
but we do our 3D reconstruction in the coronal plane
and we actually can see that there is some sort
of peculiar position of this IUD.

When we rotate the uterus
and enlarge the surface rendered view,
we can actually see that
what we were seeing in the main cavity was actually the arms
of the IUD and the shaft projects into the corneal region
and is somewhat embedded within the myometrium.

So IUD visualization,
we can see here that 2D transvaginal sonography can confirm
the position of at least part of the IUD in the uterus
as we saw on these patients.

But when abnormally located 2D may show that part
of the IUD is embedded in the myometrium
but usually cannot demonstrate the entire IUD
on a single image.
But the 3D coronal view has been used successfully
to improve visualization of the entire IUD in arms
all on the same image.

So why is this important?
Embedded IUDs are a major cause of pain
and bleeding in patients and Beryl Serraf
and her group looked at 167 patients with malpositioned IUDs
and found that 75% of these patients presented
with pain or abnormal bleeding.

Intracavitary Abnormalities

So now let's move on to some examples
of intracavitary abnormalities within the uterus.

Post Ablation Tubal Sterilization Syndrome

First we have a 44-year-old female status post roller ball,
endometrial ablation
and bilateral tubal ligation who's
presenting with dysmenorrhea.

And we can see here on the sagittal
and transverse images that we have a fluid collection
that seems to be associated with the endometrial cavity.

Here's another patient, a 34-year-old female status post
thermal endometrial ablation presenting
with right lower quadrant pain.

Hasn't had a menstrual period for about a year.
And this patient also has fluid collections.
On the sagittal view we can see one of them.
And actually on the transverse view we see
that there are two fluid collections associated
with the endometrial cavity.

So where are these fluid collections and why are they there?

So here we can see both patients
with the uterus in the coronal plane.
First patient has this fluid collection over here on the
left and then the second patient has the two fluid
collections, one on either side
and also has these little structures here
and here that appear to be in the interstitial portion
of the fallopian tube.

So what is this diagnosis
before we actually talk about the diagnosis,
let's take a look at each of these patients separately.

First we have a corneal hydrocele pinks within the left
uterine cornew in the first patient.
And in the second patient we have two cornal hydroceles.
And these little structures here are
what we call adana devices.

They're contraceptive devices like Escher coils that many
of you may be familiar with,
that are placed within the interstitial portion
of the fallopian tubes, to cause
granulation granulation tissue to set in,
for tubal occlusion and contraception.

So the diagnosis here is a problem
that has been described
as post ablation tubal sterilization syndrome.

First we have an endometrial ablation in these patients
ablates, the endometrium within the main cavity.
Then we have tubal obstruction
because of the bilateral tubal ligation
and the a Indiana devices, contraceptive occlusion
of the fallopian tubes.

And these patients may still have functioning endometrium
within the uterine corne and
because of that retrograde menstruation into the remaining
proximal tubal segment can cause severe unilateral
or bilateral pain.

And this syndrome was,
first described
by Townsend actually back in 1993.

Endometrial Polyps

So next patient is a 37-year-old gravitated two,
para two presenting with dysmenorrhea
and lengthening menses.

And let's look at a CIC clip
through the endometrium of this patient.
And really it's very difficult just looking
at these 2D images
to determine if there's anything associated
with this endometrial cavity
that's causing this patient's problem.

But when we do our reconstruction, in
the coronal plane, we may have a reason
for the abnormal bleeding.
We have this echogenic structure within the left endometrial
cavity, that is actually an endometrial polyp
and there is absolutely no way we would've been able
to pick out this polyp on our original 2D imaging.

Here's another 55-year-old gravitate two, para two
with postmenopausal bleeding.
We have a thickened kind of globular
and endometrial echo here.
And the endometrial biopsy showed benign pathology.

So what's going on? We can see here on our
color doppler image
that we do have color doppler flow looks like
a feeding vessel maybe associated with the endometrium,
which would be highly suspicious
for an endometrial polyp.

But in our 3D image we can see the shape, origin
and extent of involvement of this polyp, which
gives us even more information than just being suspicious
that there is a polyp
and a hysteroscopic polypectomy was performed,
in this patient.

So a little bit about endometrial polyps.
They're rarely malignant
but associated with abnormal bleeding and cramping.
They're seen as echogenic masses within the endometrial
cavity best demonstrated
with a contrasting proliferative endometrium.

Frequently the location
and number are identified more accurately on the coronal
view as we did in this patient.
And usually they cannot be diagnosed by a securage.

These structures cannot be scraped off or aspirated.
So curate with insufficient tissue
when we see a thickened endometrium
by ultrasound usually means there is a polyp
and the final diagnosis in these patients is made
by a polypectomy, which is performed by hysteroscopy.

Submucosal Fibroids

So now let's move on to another type
of intracavitary abnormality.

A 31-year-old gravita zero presenting with a history
of infertility and menorrhagia.
And as we can see here, we have fibroids associated
with the endometrial cavity on this sagittal
and transverse view of the uterus.

So the relationship of fibroids
to the endometrial cavity is often better evaluated using
sonohysterography, which is installation
of saline within the endometrial cavity.

So here we have the 2D sono histogram in this patient
and we can see that the larger fibroid has at least a
partially submucosal component associated
with the endometrial cavity.

And the smaller fibroid actually looks like it's completely
within the cavity just using 2D sonohysterography,
but with 3D Sonohysterography thin slice
and with surface rendering, we actually see that both
of these fibroids are pretty much completely within the
endometrial cavity, which was really not seen nearly
as well on the 2D sonar histogram.

When it comes to the larger fibroid
and hysteroscopically,
we can see this fibroid within the endometrial cavity.

So let's move on now
to a 30-year-old Gravita three para 3 0 0 3 with history
of menorrhagia and multiple pregnancy losses.

We can see on our sagittal
and transverse views that this is a fibroid uterus has some
more peripheral fibroids that are intramural subserosal.
But the one we're most concerned with is this one right here
that appears to be somewhat associated with the endometrium.

And on our 2D sono histogram, we can see
that the fibroid has at least a small submucosal component
along the left uterine cornew.

But when we do our 3D sono histogram, we can actually see
that most of this fibroid actually projects within the
endometrial cavity.

So let's just take a look at what the advantages
of 3D sonohysterography may be over over
2D sonohysterography.

First fast imaging acquisition
of data would decrease the length
of the time the patient is undergoing discomfort
and potentially decreases the time it
takes to perform the study.

And user using the acquired volume
can retrospectively help us
to reconstruct images in any plane.

And then the 3D shows a more accurate location
and better delineation of intracavitary abnormalities
actually with or even without saline,
although the saline may give additional information due
to enhanced contrast, which was actually shown in a couple
of reports by Lev H and then Kalsi.

So let's just talk a few minutes about the management
of submucosal fibroids
and what the role of 3D reconstructions would be.

The options for management depend on the patient's
symptoms, fibroid location and desire for future pregnancy.

And in a patient with fertility
who desires fertility preservation
and there's a submucosal location,
the fibroid is best treated by myomectomy
and 3D can help us determine the type of myomectomy
that's needed to be performed first.

A hysteroscopic myomectomy could be used for those fibroids
that are submucosal with at least one centimeter
of intracavitary extension.

And then a myomectomy by laparotomy
or laparoscopy would be used of course for those
that are intramural or subserosal,
but also for those
with a very minimal submucosal component which could
actually be visualized with 3D sonography.

3D Imaging in the Adnexa

So just for the last few minutes, let's take a look at
how 3D might help us in the adnexa.

Here we have a postmenopausal female presenting
for follow-up of asymptomatic left adnexal cysts.

So of course we see this cystic
structure within the adnexa on the left
and usually we're gonna knee jerk
and we're gonna say adjacent these adjacent adnexal cystic
structures, we're going to assume that they're ovarian
or adnexal cysts.

But by placing the horizontal line, the Z line
that represents the coronal plane
through these cystic areas, we may be able to find a plane
that elongates into a tubular structure.

So here we go. Here is our horizontal line going
through this cystic structure.
And what we see here in the coronal plane is a tubular
structure is actually formed.
And then we also see it on our 3D surface rendered image.

Here is our surface rendered image once again.
And here we have what,
what's called an inversion mode as well.

So the inverse mode produces an echogenic
cast of the cystic area.
That can be extremely helpful in confirming the,
confirming the configuration of the tube
and using the inverse mode or the surface rendered mode
or even just the thin slice.

Reconstruction may save the patient
a surgical intervention.

Since a complex cystic mass in the ad,
nexa would usually require surgery whereas
a hydro sole pinks would not.

So one more,
example,
a 42-year-old gravita one para one presenting
with left lower quadrant pain for follow up
of left dead NAL cysts.

And once again, we see a complex cystic mass in
the left dead nexa.

We do our sweep sally
through the ad nexa, which then
gives us the multiplanar display.
But we really don't find
a tubular structure when we try to perform,
a reconstruction in the coronal plane.

However, going back through the volume in other planes,
and in this case actually in the initial sagittal view,
we actually can come across
a structure that looks like this.
Tubular looks like a ated end.

And here we have the inverse mode showing once again a
tubular configuration.

This looks like a fallopian tube.

So what we learned from this is
that we should not limit ourselves to slicing only
through the coronal plane.
If we are suspicious for a fallopian tube,
we have the whole volume.
We can slice through the other planes as well, to try
to get the structure that we are suspicious maybe there.

Key Points from 3D Imaging of the Uterus and Adnexa

So some key points from 3D imaging
of the uterus and ad nexa.
This will provide a clinic some clinically useful
information, especially if abnormalities associated
with the endometrium are suspected.

It's the modality of choice in uterine shape anomaly
assessment and there is really no need for MRI.

3D can be used with
or without saline sonohysterography to better delineate
and locate abnormalities associated with the endometrium.

It improves visualization of the entire IUD.
And finally, it can be used
to reconstruct the fallopian tube when adjacent
or septated cystic structures are straighted.

So thank you.