Sibal - Ultrasound in Gynecology: an Atlas and Guide

Springer Nature Singapore Pte Ltd. 2017

Mala Sibal 1

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Before the advent of ultrasound, diagnosis in gynecology was difficult and inaccurate, since it had to be made with the use of bimanual vaginal examination, wherein one would physically feel various pelvic structures and make an attempt to diagnose the pathology. Ultrasound, specifically transabdominal ultrasound (TAS), revolutionised gynecology and for the first time allowed the clinical practitioner to visualise the structures in the pelvis in addition to feeling them bimanually. Today, with the advent of transvaginal ultrasound (TVS), we can not only see the pathology at close range with better resolution, but also simultaneously touch the various structures with the probe and identify whether they are tender, fixed, etc. This interactive component of TVS has further increased the accuracy of diagnosis, giving it in many cases an edge over CT or MRI. Ultrasound for evaluation is also easily available and more affordable. Since TVS accesses many of the pelvic structures at closer range, it also enhances tissue resolution and Doppler evaluation. The addition of Doppler to ultrasound examination, and in particular Power Doppler that studies low-velocity flows, helps visualise the presence of flow within tissues and vascular patterns that further enhances the accuracy of diagnosis and also helps in differentiating between pathologies. Images generated by using all these three techniques have been extensively used in the chapters that follow.

In addition to 2D ultrasound (TAS and TVS) and Doppler, 3D ultrasound is also a useful adjunct and is indispensable in the diagnosis of certain conditions like uterine anomalies or the location of intrauterine contraceptive devices (IUCDs). 3D ultrasound has also contributed to accurate volume estimations, as well as reproducibility and storage of data, which is important in the research and study of pathologies. There has also been further progress in ultrasound diagnosis with sonohysterogram (SHG) and gel sonovaginography (GSV), which is resorted to in special cases. All of the above techniques of gynecological ultrasound have been described and employed to identify features and gynecological pathologies in the chapters ahead, and accordingly, images generated using these techniques can be found across various chapters of this book.

There are13 chapters that follow. Chapter explores pathologies based on four common clinical situations: abnormal uterine bleeding, pelvic/adnexal masses, acute pelvic pain and scans to locate the pregnancy including pregnancies of unknown location (PUL).

In most of the chapters, the first subsection typically discusses how to evaluate and report on the region of interest using ultrasound. These are based primarily on the consensus statement of the International Ovarian Tumour Analysis (IOTA), International Endometrial Tumor Analysis (IETA) and Morphological Uterus Sonographic Assessment (MUSA) groups. This subsection is usually followed by normal findings in that region, including variations with age and variations across phases of the menstrual cycle. This is followed by subsections of the chapter that are devoted to various pathologies. Each of the pathologies has some basic information on the pathology, along with the classification and clinical presentations mentioned briefly upfront. This is followed by ultrasound features that are captured in succinct itemised points. This, in turn, is followed by a large number of images many of which are composite images of a single case showing various aspects of ultrasound imaging that aid in the diagnosis. These figures have legends below that highlight the ultrasound findings and, in some cases, additional clinical information of the patient that is relevant.

All the images shown in the chapters are of patients that the author has personally scanned using multiple ultrasound techniques that were curated over a period of 14 years. Further, most of the patients have been followed up clinically, with operation notes, discharge summaries and histopathology reports. This is particularly important so that the reader sees ultrasound images of cases with confirmed pathologies, as opposed to images where the diagnosis of the pathology has been presumed but not confirmed.

Springer Nature Singapore Pte Ltd. 2017

Mala Sibal 1

(1)

Today, with ultrasound, we can actually see pathology, and with a transvaginal ultrasound (TVS), one can not only see the pathology at close range, but also simultaneously touch the various structures that are seen, making it a dynamic and interactive examination (Fig. ). This is a distinct advantage of TVS over CT and MRI. Presently, ultrasound technology has advanced to such an extent that one can see on ultrasound almost as much as a pathologist can see on gross examination of a specimen (both the external surface and cut sections). Not only that, one can in addition see flow patterns within the mass which cannot be ascertained by gross examination of the specimen.

Ideally a transabdominal scan (TAS) is done first with a full bladder, followed by a transvaginal scan (TVS) after having emptied the bladder. It is important that the technique is standardised, fixed and predetermined.