Top Tips for Gynaecological Ultrasound. Catherine Kirkpatrick Consultant Sonographer Dublin Oct 2018

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1 Top Tips for Gynaecological Ultrasound Catherine Kirkpatrick Consultant Sonographer Dublin Oct 2018

2 We can all scan a pelvis so what can we do to improve? Uterus, endometrium and ovaries, got it covered! Or have we?? Tricky to cover everything thought provoking and signposting!

3 History of the female condition

4 Start at the very beginning.. The patient history is essential Return poor requests and ask for more clinical history Ask your own clinical history whilst the patient is in front of you Know your anatomy and physiology Patient Prep

5 The Ovaries Scanning the ovaries easy? How could we improve what information we provide the clinician?

6 What would we say about this? Simple Complex

7 Could we use a scoring system to assess?

8 Could we use a scoring system to assess?

9 IOTA Classification system for ovarian masses Simple descriptors Prediction of malignancy Standardisation of terminology Becomes more useful in pathway management for clinicians

10 Benign Malignant Functional Cysts Endometrioma Serous Cystadenoma Serous cystadenocarcinoma Mucinous Cystadenocarcinoma Mucinous Cystadenoma Mature teratoma/dermoids Endometrioid Carcinoma Clear Cell Carcinoma Malignant Teratoma Fibroma Thecoma Granulosa Cell Tumour Secondary Cancers (Breast & GI)

11 IOTA Normal Normal functional Indeterminate /borderline Malignant

12 IOTA definitions >3mm

13 Simple Descriptors Case courtesy of Dr Maulik S Patel, <a href=" From the case <a href=" </a> Johnson, S 2017

14 No Simple Descriptors Apply? Use the IOTA rules Taken from: Johnson, S. 2017

15 No Simple Descriptors Apply? Use the IOTA rules Taken from: Johnson, S. 2017

16 Rules Benign unilocular, smooth mulilocular tumour < 100 mm, largest solid component diameter < 7mm, acoustic shadows, no blood flow (colour score 1) Malignant Irregular solid tumor, Irregular mulglocular-solid tumor 100 mm, 4 papillary structures, ascites, very strong blood flow (color score 4) Indeterminate

17 Rules Rule 1 Rule 2 Rule 3 If one or more M features are present in the absence of B features, the ovarian mass can be classified as malignant If one or more B features are present in the absence of M features, the ovarian mass can be classified as benign If both M features and B Features are present, or there are no M or B Features, the ovarian mass can be classified as indeterminate (second stage investigations recommended)

18 The uterus All fibroids and not much else?

19 The Uterus

20 I m sorry ultrasound can Or not can diagnose it? endometriosis

21

22 Adenomyosis Presence of ectopic nests of endometrial glands and stroma within the myometrium, surrounded by reactive smooth muscle hyperplasia Tiny myometrial cysts give rise to the classic venetian blind appearance

23

24 Deep Infiltrating Endometriosis rectosigmoid utero-sacral ligaments recto-vaginal septum vagina bladder

25 Deep Infiltrating Endometriosis ources/files/alison_smith.pdf

26 Lumps and Bumps

27 Don t forget my vagina! or cervix for that matter! he_vagina_and_cervix_-_anne_marie_coady.pdf

28 Don t forget my vagina! or cervix for that matter!

29 Can t find what you re looking for? Back to the clinical history? Is it only gynae pathology that could be causing the patient symptoms?? Consider not all pelvic pain is ovary or uterus related Explore some possible non gynae causes of pelvic pain Ultrasound assessment Consideration of inclusion into a standard pelvic assessment?

30 USS Pelvis: Pelvic Pain? Ovarian? Cause Put the curvy down and back away!!!! We need to examine the bowel!

31

32 Appendicitis Accuracy of clinical evaluation of acute appendicitis is low especially in the young female (Üeberrüeck et al. 2004) Incredibly variable appearances of the normal appendix leads to false positives Operator dependant

33 Appendicitis High frequency linear probe Compressible thin walled Compared with the terminal ileum, there is no peristalsis Can be seen in up to 70% of patients (according to the literature..).. Purposely excluded and normal measurement of an appendix although some literature use 4mm

34 Appendicitis Non- compressible Appendicoliths Creeping fat/echogenic inflamed mesenteric fat which may be hyperaemic Localised effusion/free fluid Enlarged/reactive lymphadenopathy

35

36

37 Crohn s

38 Other pathologies and conditions which can cause pelvic pain? Epiploic appenagitis Omental infarction Rectus sheath Haematoma Hernia Chronic Nerve Damage Psychosocial Issues

39 That s not what they asked for!! 18 y/o female Dec 16 :RIF pain 2/12? Tubo-ovarian cause Ultrasound: The uterus, endometrium and both ovaries appear normal. The urinary bladder was empty therefore could not be assessed. No adnexal mass or free fluid seen. Nov 17: Significant W/L and continued RIF pain. Ultrasound for SB US? SB Crohn s No Significant abnormal results in all blood tests or urinalysis performed between Dec 16 & Dec 17

40

41

42 Conclusions.. & Thoughts Gynae Ultrasound isn t always simple, in fact its complex! Look beyond the usual to improve We need to be able to provide meaningful, useful Radiology reports for clinicians Wider reading and understanding of symptoms can help with our thought process when scanning Is it always a gynae problem? TOP TIP: There is so much to think about! Why not have a study group session?????? Thinking: the process of considering or reasoning about something using thought or rational judgement; intelligent.

43 References Dr Maulik S Patel, <ahref=" From the case <a href=" </a> x_-_anne_marie_coady.pdf S Guerrieroet al Ultrasound ObstetGynecol2016; 48:

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