Advanced Ultrasound Gynae Techniques
Transcript of Advanced Ultrasound Gynae Techniques
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Advanced Ultrasound Gynae Techniques
Contrast Studies and Recurrent Miscarriage / Fertility Issues
Bill Smith
Clinical Diagnostic Services (Educational)
London
BMUS : Gynaecological Ultrasound Imaging and Management
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• Comprehensive approach to gynaecological scanning
techniques
• Colour Doppler imaging techniques in gynaecology and
reproductive medicine
• Ultrasound contrast imaging of the uterine cavity and
Fallopian tubes
• Increasing impact of ultrasound imaging techniques in the
investigation of recurrent pregnancy loss
Advances in Gynaecological Ultrasound
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• Comprehensive approach to gynaecological scanning
techniques
• Colour Doppler imaging techniques in gynaecology and
reproductive medicine
• Ultrasound contrast imaging of the uterine cavity and
Fallopian tubes
• Increasing impact of ultrasound imaging techniques in the
investigation of recurrent pregnancy loss
Advances in Gynaecological Ultrasound
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ULTRASOUND IN GYNAECOLOGY
Imaging Modalities and Formats
2D
Transvaginal
Grey Scale
2D
Transabdominal
Grey Scale
2D
Transrectal
Grey Scale
Colour Doppler
Imaging
3D
Transvaginal
Imaging
Contrast Imaging
SIS / HSS
3D Virtual
Imaging
(FlyThru)
Real Time
Elastography
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2D
Transvaginal
Grey Scale
Colour Doppler
Imaging
Real Time
Elastography
TRS TVS TAS
3D TVS
SMI RTE
3D F/T 3D SIS
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ULTRASOUND IN GYNAECOLOGY
Scanning Applications
Pelvis
Transabdominal
Pelvis
Transvaginal
Pelvis
Transrectal
General
Abdominal
Thyroid Breast
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ULTRASOUND IN GYNAECOLOGY
Scanning Applications
Pelvis
Transabdominal
Pelvis
Transvaginal
Pelvis
Transrectal
General
Abdominal
Thyroid
TRS
TVS
TAS
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ULTRASOUND IN GYNAECOLOGY
Imaging Modalities and Formats
2D
Transvaginal
Grey Scale
2D
Transabdominal
Grey Scale
2D
Transrectal
Grey Scale
Colour Doppler
Imaging
3D
Transvaginal
Imaging
Contrast Imaging
SIS / HSS
3D Virtual
Imaging
(FlyThru)
Real Time
Elastography
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2D Transabdominal Grey Scale
TAS remains of significant benefit as part of pelvic ultrasound due to the following factors :
• Increased expansive field of
view
• Reduced transmission
frequencies associated with TAS
• Total patient acceptability
• Convenience of use
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2D Transabdominal Grey Scale
TAS complements or provides an
appropriate alternative to TVS re :
• Anatomical studies – congenital malformations
• Delineation of large pelvic lesions
• Fibroids
• Pelvic pain
• Pelvic malignancy
• Renal tract examination
• Interventional / Theatre procedures
• TVS contraindicated
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ULTRASOUND IN GYNAECOLOGY
Imaging Modalities and Formats
2D
Transvaginal
Grey Scale
2D
Transabdominal
Grey Scale
2D
Transrectal
Grey Scale
Colour Doppler
Imaging
3D
Transvaginal
Imaging
Contrast Imaging
SIS / HSS
3D Virtual
Imaging
(FlyThru)
Real Time
Elastography
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2D Transrectal Grey Scale
TRS is of value in gynaecological terms re:
• Imaging of the deep pelvic structures and pelvic floor
• Imaging of the cervix
• Staging of pelvic ( cervical ) malignancy
• Assessment of endometriosis
• Imaging of the rectum
• Urinary / Faecal incontinence
• Interventional / Theatre procedures
• TVS contraindicated
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ULTRASOUND IN GYNAECOLOGY
Imaging Modalities and Formats
2D
Transvaginal
Grey Scale
2D
Transabdominal
Grey Scale
2D
Transrectal
Grey Scale
Colour Doppler
Imaging
3D
Transvaginal
Imaging
Contrast Imaging
SIS / HSS
3D Virtual
Imaging
(FlyThru)
Real Time
Elastography
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Colour Doppler Imaging
Spectral Doppler remains very
limited in the assessment of
gynaecological disorders and pelvic
lesions. High definition Colour Flow
Mapping and Power Doppler imaging
technologies have had a major impact
in diagnostic terms as well as their
effects on clinical management.
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Colour Doppler Imaging
Visualisation of tissue vascularity
allows detailed evaluation of diffuse
disease processes as well as the
nature of gynaecological masses.
Neovascularity associated with high
risk changes can be identified at a
relatively early stage.
Modern colour Doppler imaging
provides the basis for ultrasound
(“subjective”) investigation of
functional as well as anatomical
features.
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ULTRASOUND IN GYNAECOLOGY
Imaging Modalities and Formats
2D
Transvaginal
Grey Scale
2D
Transabdominal
Grey Scale
2D
Transrectal
Grey Scale
Colour Doppler
Imaging
3D
Transvaginal
Imaging
Contrast Imaging
SIS / HSS
3D Virtual
Imaging
(FlyThru)
Real Time
Elastography
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Real Time Elastography
The technique compares the
compressibility or “hardness” /
“softness” of structures with that of
surrounding tissue. Colour mapping
of the relative compressibility of
tissues is superimposed onto the TVS
2D image.
RTE differentiates between normal
myometrial and endometrial tissue
and recognises tissue changes
associated with pathology or
functional (ovarian) activity.
Recent developments involve
utilisation of “shear wave
technology”.
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ULTRASOUND IN GYNAECOLOGY
Imaging Modalities and Formats
2D
Transvaginal
Grey Scale
2D
Transabdominal
Grey Scale
2D
Transrectal
Grey Scale
Colour Doppler
Imaging
3D
Transvaginal
Imaging
Contrast Imaging
SIS / HSS
3D Virtual
Imaging
(FlyThru)
Real Time
Elastography
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3D Transvaginal Imaging
In leading units, 3D (volumetric) ultrasound
is now established as an integral part of
transvaginal (TVS) ultrasound scanning.
The technology offers significant clinical and
practical benefits and enhances clinical
communication.
Modern systems are very easy to use and
utilisation of advanced 3D TVS technology
significantly shortens examination times for
gynaecological ultrasound scans. It provides
the basis for post-scan evaluation and
reporting.
Despite the practical and clinical value,
benefit to the patient and positive financial
implications, the role of 3D (volumetric)
ultrasound technology in gynaecology has yet
to be fully realised.
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3D Transvaginal Imaging
A single, automated (5-8 second) sweep, i.e.
“Survey Sweep”, of the ultrasound beam
through a selected volume of body tissues or
specific organ creates a wealth of anatomical
or clinical information.
This can be rapidly stored and easily retrieved
for manipulation of ultrasound data to create
omnidirectional anatomical planes. 3D
ultrasound information can be displayed in a
variety of imaging formats
The combination of 3D technology and TVS
ultrasound provides high resolution imaging
in all anatomical planes.
3D ultrasound imaging of the female pelvis is
easy, very straightforward from a technical
point of view.
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3D Transvaginal Imaging
Reduces scanning times
Post-scan reporting
More effective management of busy
scan lists
Image recording and archiving
Clinical communication
PRACTICAL ADVANTAGES
Reduced scanning times
Reduced exposure to ultrasound
energies
Reduced transducer movements
Increased diagnostic effectiveness and
improved clinical communication
PATIENT BENEFITS
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3D Transvaginal Imaging
• Uterine studies
• Ovarian studies
• Complex pelvic disease
• SIS + 3D virtual imaging
(“Ultrasound Hysteroscopy” )
CLINICAL APPLICATION
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3D Transvaginal Imaging
• General anatomy
• Anatomical malformations
• Myometrial / Endometrial
pathology
• IUD
• Uterine / Cervical malignancy
spread
• Fertility + ART management
• SIS
UTERUS
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3D Transvaginal Imaging
• General anatomy
• Anatomical malformations
• Myometrial / Endometrial
pathology
• IUD
• Uterine / Cervical malignancy
spread
• Fertility + ART management
• SIS
UTERUS
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3D Transvaginal Imaging
• General anatomy
• Anatomical malformations
• Myometrial / Endometrial
pathology
• IUD
• Uterine / Cervical malignancy
spread
• Fertility + ART management
• SIS
UTERUS
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3D Transvaginal Imaging
• General anatomy
• Anatomical malformations
• Myometrial / Endometrial
pathology
• IUD
• Uterine / Cervical malignancy
spread
• Fertility + ART management
• SIS
UTERUS
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3D Transvaginal Imaging
• Ovarian morphology
• Ovarian lesions
• Ovarian malignancy spread
• Adnexal (para-ovarian) lesions
• Fertility + ART management
OVARY
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<18 yrs >18 yrs Gravida
Peri-menopausal Post-menopausal
Ovarian Follicle Stromal Patterns
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3D Transvaginal Imaging
• Ovarian morphology
• Ovarian lesions
• Ovarian malignancy spread
• Adnexal (para-ovarian) lesions
• Fertility + ART management
OVARY
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3D Transvaginal Imaging
• Ovarian morphology
• Ovarian lesions
• Ovarian malignancy spread
• Adnexal (para-ovarian) lesions
• Fertility + ART management
OVARY
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3D Transvaginal Imaging
• Ovarian morphology
• Ovarian lesions
• Ovarian malignancy spread
• Adnexal (para-ovarian) lesions
• Fertility + ART management
OVARY
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• Grade 3 - 4 Endometriosis
• Pelvic Malignancy
• Chronic / Acute PID
• Tubulo-Ovarian Masses
“ Complex ” Gynaecological Disease
3D Transvaginal Imaging
3D volumetric TVS promotes the concept of post-scan
evaluation and reporting
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Adhesions Adhesions Adhesions
Adhesions
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ULTRASOUND IN GYNAECOLOGY
Imaging Modalities and Formats
2D
Transvaginal
Grey Scale
2D
Transabdominal
Grey Scale
2D
Transrectal
Grey Scale
Colour Doppler
Imaging
3D
Transvaginal
Imaging
Contrast Imaging
SIS / HSS
3D Virtual
Imaging
(FlyThru)
Real Time
Elastography
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Contrast Imaging : Uterine Cavity
SIS + 3D Virtual Imaging
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Contrast Imaging : Fallopian Tubes
HSS
HSS.avi video
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A flexible approach to pelvic scanning and developments in
ultrasound imaging technology provide a more effective
assessment of major organs and associated gynaecological
disorders. Comprehensive examination of the pelvis involves
any combination of the following:
• Scanning techniques - Transvaginal
• Imaging modalities - 2D - 3D - 4D
- Grey Scale
- Colour Doppler
- Elastography
• Ultrasound procedures - HSS (hysterosonosalpingiography)
- SIS (saline infusion sonohysterography)
- Ultrasound Hysteroscopy (FlyThru)
Advances in Gynaecological Ultrasound
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• Comprehensive approach to gynaecological scanning
techniques
• Colour Doppler imaging techniques in gynaecology and
reproductive medicine
• Ultrasound contrast imaging of the uterine cavity and
Fallopian tubes
• Increasing impact of ultrasound imaging techniques in the
investigation of recurrent pregnancy loss
Advances in Gynaecological Ultrasound
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Colour Doppler Imaging in Gynaecology and Reproductive Medicine
Clinical Applications of CFM
• Ovulation Monitoring and ART
• Uterus : Myometrium
Endometrium
Endocervix
• Ovaries : Functional
Neoplasms
• Complications of Pregnancy
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Pre-ovulatory
Luteal Phase
Conception Cycle
Luteal Phase
Non- Conception Cycle
Ovarian
Dysfunction
CFM : Ovulation Monitoring and ART
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Luteal Phase Assessment N = 100
• Natural cycle
Ovulation confirmed by U/S +/-
Urinary LH
• Single scan – ovulation + 7 days
(+/- 1 day)
Assessment of Corpus Luteum
Endometrium
• Serum Progesterone (P4)
Assay – Scan +/- 24 hrs
Follicular / Periovulatory Phase
Appearances
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1 2 3 4
110
0
100
90
60
70
50
40
30
80
20
10
1 2 3 4
20
0
18
12
14
10
8
6
16
4
2
Corpus Luteum (Grade)
N=100
Corpus Luteum (Grade)
N=100
Non-conception Endom Grade A-
Non-conception Endom Grade A+
Conception Cycle Endom Grade A+
Non-conception Conception Cycle
End
om
etri
al T
hic
knes
s (m
m)
P4
(n
mo
l/l)
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CFM : Early Pregnancy
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CFM : Uterus
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CFM : Endometrium
Endom.
Ca.
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CFM : Endometrium
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CFM : Endocervix
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CFM : Ovaries
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• Very often co-existing clinical issues. Significant overlap in
terms of clinical causes and ultrasound features associated
with both conditions.
• The major cause of both conditions is “ ovarian dysfunction ”
– very often associated with persistent, active follicular /
luteal cysts.
• “ Breakthrough ” ovarian follicular activity remains the chief
cause of PMB. “ Unopposed oestrogens ” associated with
active follicular cysts remains the major underlying cause of
perimenopausal disorders.
• “ Ovarian dysfunction ” is associated with atypical
endometrial proliferation as well as the formation and growth
of endometrial polyps and uterine fibroids.
Pelvic Pain / Abnormal Uterine Bleeding
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Clinical symptoms and features associated with persistent
functional ( luteal and follicular ) cysts :
• Pelvic / abdominal pain
• Abnormal uterine ( menstrual ) bleeding
• Bloatedness and IBS type symptoms
• Breast symptoms
• Urinary tract symptoms
• Tiredness, headaches, PMS etc
• Endometriosis
• Pelvic hyperaemia
Pelvic Pain / Abnormal Uterine Bleeding
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CFM : Ovaries
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CFM : Ovaries
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CFM : Ovaries
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CFM : Ovaries
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CFM : Ovaries
TVS – CFM
Serial Scanning
August
October
November
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CFM : Complications of Pregnancy
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CFM : Complications of Pregnancy
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• Comprehensive approach to gynaecological scanning
techniques
• Colour Doppler imaging techniques in gynaecology and
reproductive medicine
• Ultrasound contrast imaging of the uterine cavity and
Fallopian tubes
• Increasing impact of ultrasound imaging techniques in the
investigation of recurrent pregnancy loss
Advances in Gynaecological Ultrasound
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SIS is now established as a routine ultrasound investigation in many
leading units. The procedure involves gradual distension of the
uterine cavity by transcervical instillation of normal saline solution.
3D TVS imaging provides detailed anatomical studies of the uterine
cavity and clearly delineates structural abnormalities or the presence of intracavital pathologies.
Contrast Imaging in Gynaecology and Reproductive Medicine
Saline Infusion Sonohysterography (SIS)
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3D TVS imaging of the distended cavity demonstrates
• Intracavital / submucosal fibroids
• Endometrial polyps
• Intracavital adhesions
• Detailed endometrial examination
• Cavity wall contour
Contrast Imaging in Gynaecology and Reproductive Medicine
Saline Infusion Sonohysterography (SIS)
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Contrast Imaging in Gynaecology and Reproductive Medicine
Saline Infusion Sonohysterography (SIS)
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SIS is routinely used in leading units as part of the investigation and
clinical management of abnormal uterine bleeding as well as
recurrent miscarriage and female infertility.
Advanced 3D (FlyThru) imaging technology has created the concept
of “Ultrasound Hysteroscopy”
Contrast Imaging in Gynaecology and Reproductive Medicine
Saline Infusion Sonohysterography (SIS)
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“Ultrasound Hysteroscopy”
FlyThru 3D Imaging of the Uterine Cavity
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High Resolution
TVS
Advanced 3D
Technology
Saline Infusion
Sonohysterography
FlyThru Virtual
Imaging
Advanced 3D Ultrasound in Gynaecology
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Advanced 3D Ultrasound in Gynaecology
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HSS is now established as the routine procedure for examining the
patency and general healthiness of the Fallopian tubes. It has been
shown to be an effective alternative to X-ray HSG.
HSS combined with SIS as part of the same procedure demonstrates
internal features of the uterine cavity as well as the Fallopian tubes. Ultrasound imaging of the myometrium also demonstrates
associated myometrial disease or lesions involving the cavity.
TVS ultrasound is regarded as safe without risks associated with
ionising radiation.
Patients appear to tolerate HSS contrast media better and experience
less general discomfort compared to X-ray HSG. Instillation of
contrast media with HSS is much more gentle compared with that required as part of X-ray HSG.
Contrast Imaging in Gynaecology and Reproductive Medicine
Hysterosonosalpingiography (HSS)
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Contrast Imaging in Gynaecology and Reproductive Medicine
Video HSS.avi
Saline Infusion Sonohysterography (SIS)
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Contrast Imaging in Gynaecology and Reproductive Medicine
Saline Infusion Sonohysterography (SIS)
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Contrast Imaging in Gynaecology and Reproductive Medicine
Saline Infusion Sonohysterography (SIS)
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Contrast Imaging in Gynaecology and Reproductive Medicine
Saline Infusion Sonohysterography (SIS)
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Contrast Imaging in Gynaecology and Reproductive Medicine
X-ray HSG
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• Comprehensive approach to gynaecological scanning
techniques
• Colour Doppler imaging techniques in gynaecology and
reproductive medicine
• Ultrasound contrast imaging of the uterine cavity and
Fallopian tubes
• Increasing impact of ultrasound imaging techniques in the
investigation of recurrent pregnancy loss
Advances in Gynaecological Ultrasound
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A Review of Ultrasound Scan Findings in Patients
Presenting with a History of Recurrent Miscarriage
B. Smith and N. Stillwell, CDS, London
Mr M. Aziz, Ealing Hospital, London
Mr R. Rai, St Mary’s Hospital / Imperial College London
Mr Y. Gordon, London
WCRPL Cannes 2016
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Causes of Recurrent Pregnancy Loss
Unexplained +
Chromosomal / Genetic
Immunological +
Thrombophilia
Infection + Cervical
Hormonal
Uterine Anomalies
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Causes of Recurrent Pregnancy Loss
Unexplained +
Chromosomal / Genetic
Immunological +
Thrombophilia
Infection + Cervical
Hormonal
Uterine Anomalies
Diagnostic Value of
Ultrasound Examination
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Diagnostic Value of “Advanced” Ultrasound Technology
Unexplained +
Chromosomal / Genetic
Immunological +
Thrombophilia
Infection + Cervical
Hormonal
Uterine Anomalies Definite - “crucial”
Partly - “underutilised”
Undetermined - consider: • multifactorial causes of RPL
• utilisation of u/s imaging modalities
No role
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Diagnostic Value of “Advanced” Ultrasound Technology
Unexplained +
Chromosomal / Genetic
Immunological +
Thrombophilia
Infection + Cervical
Hormonal
Uterine Anomalies
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Diagnostic Value of “Advanced” Ultrasound Technology
Unexplained +
Chromosomal / Genetic
Immunological +
Thrombophilia
Infection + Cervical
Hormonal
Uterine Anomalies
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Diagnostic Value of “Advanced” Ultrasound Technology
Immunological +
Thrombophilia
Infection + Cervical
Hormonal
Uterine Anomalies Unexplained +
Chromosomal / Genetic
Immunological +
Thrombophilia
Infection + Cervical
Hormonal
Uterine Anomalies
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Diagnostic Value of “Advanced” Ultrasound Technology
Unexplained +
Chromosomal / Genetic
Immunological +
Thrombophilia
Infection + Cervical
Hormonal
Uterine Anomalies
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Diagnostic Value of “Advanced” Ultrasound Technology
BMUS 2001 / ESHRE 2002
Unexplained +
Chromosomal / Genetic
Immunological +
Thrombophilia
Infection + Cervical
Hormonal
Uterine Anomalies
N=100
1 2 3 4
20
0
18
12
14
10
8
6
16
4
2
Corpus Luteum (Grade)
Non-conception Endom Grade A-
Non-conception Endom Grade A+
Conception Cycle Endom Grade A+
Endom
etri
al T
hic
knes
s (m
m)
N=100
1 2 3 4
110
0
100
90
60
70
50
40
30
80
20
10
Corpus Luteum (Grade)
Non-conception
Conception Cycle
P4 (
nm
ol/
l)
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Diagnostic Value of “Advanced” Ultrasound Technology
Unexplained +
Chromosomal / Genetic
Immunological +
Thrombophilia
Infection + Cervical
Hormonal
Uterine Anomalies
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Diagnostic Value of “Advanced” Ultrasound Technology
Unexplained +
Chromosomal / Genetic
Immunological +
Thrombophilia
Infection + Cervical
Hormonal
Uterine Anomalies
LH Testing commenced
LH Testing POSITIVE
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Diagnostic Value of “Advanced” Ultrasound Technology
Unexplained +
Chromosomal / Genetic
Immunological +
Thrombophilia
Infection + Cervical
Hormonal
Uterine Anomalies
Cycle no.
1
2
3
4
5
LH +ve cycle day
9
10
10
8
15
Scan Ovul. cycle day
14
16
15
14
16
Outcome
Miscarriage
Miscarriage
Non-pregnant
Miscarriage
Pregnancy
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Diagnostic Value of “Advanced” Ultrasound Technology
“Aberrations” of the Ovulatory Cycle
• Luteal phase issues
• Poor endometrial development
• Receding periovulatory
endometrium
• Retrograde menstruation
• Discrepancy LH vs U/S ovulation
Patient numbers 32/71
Unexplained +
Chromosomal / Genetic
Immunological +
Thrombophilia
Infection + Cervical
Hormonal
Uterine Anomalies
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• The impression persists that ultrasound assessment remains
relatively underused in the investigation of recurrent pregnancy
loss
• A comprehensive approach to ultrasound scanning involving a full
range of imaging modalities increases the diagnostic impact of
ultrasound in the investigation of recurrent pregnancy loss
• The role of ultrasound in the evaluation of ovulatory disorders
associated with recurrent pregnancy loss does not appear to be
fully recognised
• Monitoring of ovulatory cycles provides valuable information
regarding functional, anatomical and pathological causes of
recurrent pregnancy loss. It also supports the concept of “preconception planning”
Conclusions
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The Impact of Advanced 3D Ultrasound Technology in the Investigation and Management of Recurrent Miscarriage
B. Smith and N. Stillwell, CDS, London
Mr M. Aziz, Ealing Hospital, London
Mr R. Rai and Dr S Das, St Mary’s Hospital / Imperial College London
WCRPL Cannes 2016
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ULTRASOUND IN GYNAECOLOGY
Imaging Modalities and Formats
2D
Transvaginal
Grey Scale
2D
Transabdominal
Grey Scale
2D
Transrectal
Grey Scale
Colour Doppler
Imaging
3D
Transvaginal
Imaging
Contrast Imaging
SIS / HSS
3D Virtual
Imaging
(FlyThru)
Real Time
Elastography
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Fly Thru
Virtual 3D Ultrasound Imaging
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• established as an integral
element of SIS procedure
• automatic and manual
navigation through the volume
• hybrid endoscopy with
ultrasound information
• great tool for intervention
planning and follow up
Advanced “FlyThru” technology provides the basis for
ULTRASOUND HYSTEROSCOPY
Virtual 3D Ultrasound Imaging
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High Resolution
TVS
Advanced 3D
Technology
Saline Infusion
Sonohysterography
FlyThru Virtual
Imaging
Advanced 3D Ultrasound in Gynaecology
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Advanced 3D Ultrasound in Gynaecology
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FlyThru virtual 3D imaging promotes the concept of
“Ultrasound Hysteroscopy”. Its major applications in terms of
clinical practice currently include:
• General Gynaecology - assessment of abnormal uterine
bleeding
• Reproductive Medicine - investigation of infertility and
recurrent miscarriage
• Pre-requisite in IVF management
• Increasing use of transcervical ultrasound guided
interventional procedures
• Clinical communication and pre-surgical planning
Advanced 3D Ultrasound in Gynaecology
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Ultrasound Findings at SIS
Normal
Myometrial disease fibroids, adenomyosis etc
Intracavital lesions fibroids, polyps, RPOC etc
Anatomical Malformations
Intracavital adhesions
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Ultrasound Findings at SIS
Clinical trial flawed due to (1) lack of feedback from clinical units
and (2) diagnostic confidence levels resulting in 3D virtual imaging
offering an alternative to diagnostic hysteroscopy
Clinical findings:
Patient follow up data available only 57/723
Ultrasound diagnosis Normal 27 Abnormal 30
Hysteroscopic findings Normal 28 Abnormal 29*
* *
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The value of 3D Virtual Imaging (“Ultrasound Hysteroscopy”) in the
investigation of RPL
• Enhanced ultrasound imaging of the uterine cavity
• Effective in the detection of intrauterine adhesions particularly
following intracavital surgical procedure
• Reliable indicator in selecting patients requiring conventional
hysteroscopy and subsequent endoscopic surgical procedure
• Considerable value in terms of pre-surgical planning and clinical
communication
Conclusions
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Thank you for your attention
and enjoy the rest of the meeting
BMUS Study Day
York 2016
Ultrasound in Gynaecology and
Reproductive Medicine
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The Impact of Advanced 3D Virtual Imaging in the
Investigation of Abnormal Uterine Bleeding
and Reproductive Medicine
Bill Smith
Clinical Diagnostic Services (Educational)
London
BMUS Study Day
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Thank you for your attention
and enjoy the rest of the meeting
BMUS Study Day
London 2016
Advances in Gynaecological
Ultrasound