Rewording 3 Papers

Menstrual Cycle

● A female reproductive years begin around 11 to 13 years of age at the onset of menses

and end around age 50, when menses ceases.

● The average menstrual cycle is approximately 28 years in length, beginning with the first

day of menstrual bleeding.

● Premenarche is the physiological status of pre puberty , the time before the onset of

menses.

● Menarche is the state after reaching puberty in which menses occur normally every 28

days.

● Menopause refers to the cessation of menses.

Follicular Development and Ovulation

● During the menarcheal years, an ovum is released once a month once a month by one of

the two ovaries.

● All ova begin development during embryonic life and remain in suspended animation

within pre-antral follicle as an immune oocyte until the onset of menarche.

● Each ovary contains approximately 200,000 oocytes at the time of birth.

● When a young girl reaches puberty, the hypothalamus begins the pulsatile release of

gonadotropin releasing hormones.

● Which stimulates the anterior pituitary gland to secrete varying levels of gonadotropin(

primarily follicle-stimulating hormone and luteinizing hormone).

● The luteinizing hormone level will typically increase rapidly 24 to 36 hours before

ovulation in a process known as LH surge.

● It is the LH surge, accompanied by a smaller FSH surge that triggers ovulation in day 14.

● After ovulation, the ovary enters the luteal phase. This phase begins with ovulation and is

14 days in length.

● During Luteal Phase, the cells in the lining of the rupture ovarian follicle begin to

multiply and create corpus luteum or yellow body.

● The corpus luteum immediately begins secreting progesterone.

● As progesterone levels decline, menstruation occurs and the cycle begins.

Anatomy and physiology of female pelvis

● Two approaches are used to sonographically evaluate the female pelvis: transabdominal

and endovaginal(transabdominal).

● Transabdominal requires a full bladder for acoustic windows.

● Requires the 3.5 to 5 MHz transducer for adequate penetration.

● An edovaginal examination is performed with empty bladder and uses a 7.5 to 10 MHz

transducer.

● The transabdominal scan offers wider field view for general screening of pelvic anatomy.

Pelvic Landmarks:

● The Mons Pubis, Labia Majora, Labia Menora, Clitoris, Urethra, Vagina, and Anus.

● The external genitalia is called vulva or pudendum.

Bony Pelvic:

● Composed of four bones: two innominate bones, the sacrum and the coccyx.

● Anatomically, the pelvis divided into two continuous compartments the true and false

pelvis.

● False pelvis known as greater or major pelvis.

● The true pelvis known as the lesser or minor pelvis.

Muscles of the pelvis:

● Psoas muscle

● Iliacus

● Iliopsoas

Muscles of true pelvis:

● Rectus abdominis- lies anteriorly.

● Obturator internus- lies on the lateral side of the bladder and gives the bladder its square

shape.

● Piriformis- lies at the level of the body of the uterus and is often confused with ovaries.

● Levator ani- lies at the level of the cervix and vagina forms the floor of the pelvis.

Bladder and Uterus:

● Located in the anterior segment of the pelvic cavity, posterior to the pubic symphysis.

● Not seen graphically but is identified by the visualization of “ ureteral jets” in the

posterior inferior portion of the urinary bladder as it fills.

● Identified as “swirling of urine” identified with color doppler.

Pelvic organs:

● Internal organs, two ovaries and fallopian tubes, a uterus and vagina.

● External organs are mons pubis, labia majora, labia minora, clitoris, bulb of two

vestibules, greater vestibular glands and the vestibule of vagina.

Vagina:

● Collapsed muscular tubes extend from the external genitalia to the cervix of the uterus.

● Lies posterior to the urinary bladder and anterior to the rectum and anus.

Pathology of Uterus

Gartner’s Duct Cyst:

● Most common cystic lesions of the vagina.

● Obstruction of the uterus and/ or vagina may result in accumulation of fluid hydrometra,

hematometra, or pyometra.

● S/A- Anechoic, posterior enhancement, well defined borders, and edge shadowing.

Pathology of the Cervix

Nabothian Cyst:

● Results from chronic cervicitis or obstructed and dilated endocervical glands.

● S/A-- round anechoic , usually measures less than 2cm, along the cervical canal.

● They may be multiple.

● Symptoms-- Asymptomatic

Cervical Polyps:

● Benign condition arises from hyperplastic protrusion of epithelium of the cervix.

● Causes chronic inflammation.

● Polyps may be pedunculated, projecting out of the cervix, or broad based.

● Symptoms-- Irregular bleeding.

Leiomyomas/myomas/fibroids:

● Not common in cervix

● When fibroids are small the patient is asymptomatic.

● If mass enlarges the bladder or bowel obstruction may result.

● Fibroids may be prenduclated and prolapse into the vaginal canal.

Cervical Stenosis:

● Obstruction of the cervical canal at the internal or external os.

● Causes radiation therapy , previous biopsy, post menopausal cervical atrophy, chronic

infections or cervical carcinomas.

● The stenosis can cause the accumulation of uterine secretion.

Cervical Carcinoma:

● Squamous cell carcinoma is the most common type of cervical cancer cancer.

● Detected by PAP smear

● Ultrasound plays a secondary role in detecting cervical cancer.

● Symptoms are vaginal discharge or bleeding.

● Risk factors are multiple sexual partners, HPV, Young first pregnancy.

Pathology of the Uterus

Congenital Anomalies:

● Gynastresia-- Absence of vagina and uterus.

● S/S--Patient presents in teens with secondary sex characters and amenorrrhea.

● S/A--Poorly defined mass of tissue and no endometrial echoes.

Bicornuate Uterus:

● Duplication of the uterus and one vagina.

● S/S-- No problem if non gravid , Associated infertility and abortion.

● S/A-- Transverse plane shows two endometrial echoes.

Uterus Didelphys:

● Double uterus and double vagina.

● S/S and S/The same as a bicornuate uterus.

Unicornuate Uterus:

● Single uterine tube and horn but two ovaries are present.

● S/S-- Risk infertility and abortion

● S/A-- Not seen on U/S but the uterus may appear thin.

Subseptate Uterus:

● Uterus contains a division between two horns.

● S/S and S/A same as a bicornuate uterus.

Pathology of endometrium

Endometrial Hyperplasia:

● Most common cause of abnormal uterine bleeding.

● Appearings as thickening of endometrium.

● In premenopausal women endometrium measures more than 15mm, it suggests

hyperplasia.

● In asymptomatic postmenopausal patient 8mm is the upper limit of normal .

● A woman on HRT may have endometrial thickness up to 15mm.

● Endometrial thickness of kess than 5mm in postmenopausal patient excludes endometrial

abnormalities.

Endometrial Polyps:

● Cause uterine bleeding or can be asymptomatic.

● Diffuse or focal endometrial thickening.

● Associated with infertility and irregular heavy bleeding.

● S/A-- Hypoechoic or Hyperechoic

Endometritis:

● Inflammation and present as endometrial thickening or fluid in the endometrium.

● Risk factors-- PID, Postpartum state, any instrumental invasion.

Endometrial Changes

● During menses it is not uncommon to see varying levels of fluid debris within the uterine

cavity.

● During the proliferative phase the endometrium thickens to an average of 4 to 8mm.

● When measured as a double-layer from anterior to posterior.

● After ovulation during secretion phase endometrium reaches its thickest dimension

averaging 7 to 14mm and becomes echogenic, blurring the three line appearance.

● Postmnopausal patients on HRI or taking tamoxifen may demonstrate normal endometrial

thickness of up to 8mm.

Abnormal Menstrual Cycle

● Menorrhagia abnormal heavy or long periods are associated with uterine fibroids,

intrauterine devices or hormonal imbalances.

● Oligomenorrhea abnormal short or light periods often associated with polycystic ovarian

syndrome.

● Dysmenorrhea is described as a painful period which is associated with endometriosis.

● Amenorrhea absence of menstruation which may result from congenital vaginal or

cervical stenosis or an infection, trauma, ovarian dysfunction or other endocrine

disturbances that affect ovarian function such as pituitary disease.

Pelvic Recesses and Bowl

● Vesicouterine Pouch or anterior cul-de-sac, is located anterior to the fundus of the uterus

between the urinary bladder and the uterus.

● Recto Utérine Pouch or posterior cul-de-sac, is located posterior to the uterus between

the uterus and the rectum.

● Retropubic space also known as space of Retzuis can be identified between the anterior

bladder wall and pubic symphysis.

● A small amount of fluid in the posterior cul-de-sac is considered normal.

● Hemorrhage or infection with fluid may be related to a ruptured cyst, ascites a rupture

corpus luteum cyst, ectopic pregnancy or pelvic inflammatory cyst.

Obstetrics

● First trimester --1 to 12 weeks

● Second trimester--13 to 25 weeks

● Third Trimester-- 26 to 40 weeks

First Trimester Complications

Cranial Abnormalities:

● Acrania absense or cranial bones with presence of complete although abnormal

development brain. Leads t o Anencephaly and it’s a lethal abnormality.

● Anencephaly absence of the brain and carnival vault. It’s a lethal abnormality.

● Cephalocele is a midline cranial defect, herniation and meninges of the brain.

● Ventriculomegaly is dilation of the ventricular system, without enlargement of the

cranium may be seen near the end of the first trimester.

● Holoprosencephaly consists of a range of abnormalities resulting from abnormal cleavage

of forebrain.

Spina Bifida

● Spinal abnormalities or bulging within the posterior contour of the fetal spine.

Abdominal Wall Defects

● Herniation sonographically appears as an echogenic mass at the base of the umbilical

cord between 8 to 12 weeks.

Cystic Hygroma (Turner’s Syndrome)

● Associated with chromosomal abnormalities .

● Results from malformation of the lymphatic system which leads to lymph filled cavities

around the neck.

● S/A-- Bilateral cystic mass at posterior lateral border of the neck that has septations.

Placental Hematomas and Subchorionic Hemorrhage

● Embryonic placenta may become detached, resulting in the formation of a hematoma,

which causes vaginal bleeding.

First Trimester Pelvic Masses

Ovarian masses:

● Corpus Luteum most common ovarian mass.

● Regresses and typically are not seen beyond 16 to 18 weeks gestation.

Uterine masses:

● Leiomyomas or fibroids are common throughout pregnancy.

● Fibroids may increase in size in the first and second trimester due to estrogen stimulation.

● Fibroids also may differentiate from focal myometrial contractions (Braxton Hicks

contractions).

Ectopic Pregnancy :

● Pregnancy outside the normal location of the uterus.

● Risk factors are pelvic infections, IUSD, Fallopian tubes surgeries, Infertility treatments

and history of ectopic pregnancy.

● Ectopic pregnancy occurs 95% of the cases in the fallopian tubes but they can also occur

in the ovaries, broad ligaments, peritoneum and cervix.

Sonographic findings in Ectopic Pregnancy :

● As 20% of patients with ectopic pregnancy demonstrate an intrauterine saclike structure

known as the pseudogestational sac.

● Pseudogestational sac does not contain either living embryos or yolk sac.

● Adnexa and fluid in posterior cul de sac.

Heterotopic Pregnancy :

● Intrauterine and extrauterine pregnancy.

Interstitial Pregnancy:

● Cornual pregnancy, life threatening hemorrhage when rupture occurs.

Cervical Pregnancy :

● Sonographic demonstration of gestational sac within the cervix.

Second and Third Trimester

Obstetric Parameters:

● First Trimester is 0-12 weeks of gestation.

● Second Trimester is 13-26 weeks of gestation.

● Third Trimester is 27-40 weeks of gestation.

● Postterm pregnancy is greater than 40 weeks of gestation.

Fetal Presentation:

● Vertex presentation

● Breech position

1. Frank breech position

2. Complete breech

3. Incomplete breech or a footling breech.

Cranium and fetal brain

Falx Cerebri or Inter Hemispheric Fissure

● Separates the brain into two equal hemispheres.

● Absence of falx indicates holoprosencephaly.

Ventricular system of brain

● Consists of two paired lateral ventricles, a midline third ventricle and fourth ventricle.

● The fetal ventricles are important to assess because of ventriculomegaly or hydrocephalus

which represents one of the most common neural tube defects.

The orbits

● Anophthalmia is the absence of both eyes.

● Cyclopia only one eye.

● Hypertelorism fused or closely spaced eyes.

● Hypertelorism abnormally wide spaced eyes.

The Genitalia

● Bladder is a helpful landmark within the pelvis to identify the genital organs.

● Gender of the fetus may be appreciated 14 to 16 weeks of gestation.

● Female genitalia may be seen in the transverse plane.

● The male genitalia may be differentiated as early as 15th to 16th weeks of gestation.