RADIOLOGY IN OBGYN�

DR A.E. EDUGBE

OUTLINE

• Introduction
• Ultrasound
• History of ultrasound
• Biologic effect of ultrasound
• Indications of ultrasound
• sonoHSG
• Magnetic Resonance-guided Focused Ultrasound (MRgFUS)
• Doppler ultrasound
• Plain xray
• HSG
• Intervention radiology
• Bone densitometry
• CT scan
• MRI
• Societies involved in imaging
• Conclusion

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INTRODUCTION

• The new millennium saw a proliferation of imaging techniques used in medical practice.

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• Research into the development, refinement, and application of imaging in gynecology is apparent in the literature.

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• Recent advances in fetal imaging have been the result of technological achievements in sonography and magnetic resonance imaging, with dramatic improvements in resolution and image display.

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• Both 3- and 4-dimensional ultrasound imaging have continued to evolve, and Doppler applications have expanded.

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INTRODUCTION

• Radiography and contrast hysterosalpingography (HSG) have all but been replaced by computed-tomographic (CT) scanning with its excellent pelvic organ resolution.

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• In addition, magnetic resonance imaging (MRI) is now readily available in most centers and has literally added new dimensions to pelvic imaging.

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• Magnetic resonance imaging has added immensely to the already profound impact of sonography on obstetrics

ULTRASOUND

• BRIEF HISTORY

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• Remember Titanic
• In 1912, the passenger ship Titanic hit an iceberg on it maiden trip crossing the Atlanic from Southampton to New York

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• In that time physicists took interest in using sound to detect large objects submerged in water
• During WWI French physicist Paul Langevin was responsible for developing hydrophone that detected submarine which resulted in sinking the German in 1916

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• In 1917, Langevin invented the quart sandwish transducer which serve as the basis for modern ultrasound

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ULTRASOUND

• Following this technology

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• Ultrasound was used for Navigation

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• Detect flaws in metal

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• Cardiac valve movement

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• Scottish physician Ian Donald conducted a research for development of a clinical use employing ultrasound in the 1958

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• Since 1950s the development of ultrasound in medicine in general and particularly in the field of obgyn has continued exponentially

PHYSICS OF ULTRASOUND

• Sound is a mechanical vibration travelling in a physical medium such as air, water, metal or even human tissue
• Sound may be categorized as
• Infrasound (0-20Hz)
• Audible sound (20Hz -20kHz)
• Ultrasound (> 20KHz)
• Diagnostic ultrasound (1-20 MHz)

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USS

• Ultrasound is the term used to describe sound of frequencies above 20 000 Hertz (Hz), beyond the range of human hearing.

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• Frequencies of 1–30 megahertz (MHz) are typical for diagnostic ultrasound.
• 3–5 MHz for abdominal areas
• 5-7 MHz transvaginal
• 5–10 MHz for small and superficial parts and
• 10–30 MHz for the skin or the eyes.

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USS

• The real-time image on the ultrasound screen is produced by sound waves reflected back from organs, fluids, and tissue interfaces

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• Transducers made of piezoelectric crystals

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• crystals convert electrical energy into sound waves that are emitted in synchronized pulses, then “listen” for the returning echoes.

USS

• Because air is a poor transmitter of high-frequency sound waves, soluble gel is applied to the skin to act as a coupling agent.

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• Sound waves pass through layers of tissue, encounter an interface between tissues of different densities, and are reflected back to the transducer

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• Dense tissue such as bone produces high-velocity reflected waves, which are displayed brightly on the screen.

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• Conversely, fluid generates few reflected waves and appears dark or anechoic on the screen.

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• these digital images can be generated at 50 to greater than 100 frames/second

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• Higher-frequency transducers yield better image resolution, whereas lower frequencies penetrate tissue more effectively.

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• Route of ultraound
• Transabdominal
• Transvaginal
• Trans rectal
• Trans perineal

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BIOLOGICAL EFFECTS OF ULTRASOUND

• Sonography should be performed only with a valid medical indication and with the lowest possible exposure setting to gain necessary information

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• the ALARA principle—As Low As Reasonably Achievable (American Institute of Ultrasound in Medicine, 2007, 2008).

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BIOLOGICAL EFFECTS OF ULTRASOUND

• Heating
• Thermal index of soft tissue (TIS)
• Thermal index of bone (TIB)
• Thermal index of cranium (TIC)

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• Cavitation

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OBSTETRIC SCANNING

• 1^st trimester scan (11-14 postmenstrual week)
• Presence or absence of intrauterine gestation
• Identification of embryo or fetus
• Yolk sac
• Fetal number
• Presence or absence of fetal activity
• CRL
• Pregnancy location
• Evaluation of uterus and adnexal structure
• Evaluation and measurement of nuchal translucency
• Fetal nasal bone

NUCHAL TRANSLUCENCY

TRANS THALAMIC VIEW FOR BPD AND HC

ABDOMINAL CIRCUMFRENCE

FEMUR LENGTH

BIOLOGICAL EFFECTS OF ULTRASOUND

• 2^nd trimester
• Fetal number
• Chorionicity and amnionicity
• Fetal presentation
• Fetal lie
• Placental location
• Placenta attachment disorders
• Assessment of amniotic fluid volume
• Gestational age
• Fetal genitalia
• Survey of fetal anatomy for gross malformation
• Evaluation of the ovaries and possible maternal pelvic masses

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AFI

TRANS-CEREBELLAR VIEW

4 CARDIAC CAMBER

BIOLOGICAL EFFECTS OF ULTRASOUND

• AFI,
• BPP
• Ultrasound guided amniocentesis, CVS
• Perumbilical blood sampling
• External cephalic version

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GYNAECOLOGICAL SCANNING

• Uterus
• Cervix
• Myometrium
• The endometrium
• Adnexal masses

SONOHSG

• Hysterosalpingosonography (sono-HSG) Hysterosalpingo-Contrast Sonography (HyCoSy) , an ultrasound-based technique, has been proposed as an alternative to hysterosalpingography (HSG) to assess tubal patency in the initial workup of subfertile couples

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• Sono-HSG and HSG are both short, well-tolerated outpatient procedures

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• However, sono-HSG has the advantage of obviating ionizing radiation and the risk of iodine allergy associated with HSG

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• Compared with HSG, sono-HSG also has greater sensitivity and specificity in detecting anomalies of the uterine cavity and permits concomitant visualization of the ovaries and myometrium

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MRGFUS

Magnetic Resonance-guided Focused Ultrasound (MRgFUS) is a noninvasive, incision-less technique used to treat fibroids.

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MRgFUS works by delivering a series of targeted ultrasonic pulses, or sonication to heat up and destroy the fibroids. 

DOPPLER ULTRASOUND

• The Doppler effect was originally postulated by the Austrian scientist Christian Doppler in relation to the colours of double stars.

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• The effect is responsible for changes in the frequency of waves emitted by moving objects as detected by a stationary observer

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• The perceived frequency is higher if the object is moving towards the observer and lower if it is moving away

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• This modality can be performed with either transabdominal or transvaginal sonography to determine blood flow through organs.

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• The doppler principle describes the apparent variation in frequency of a sound as the wave approaches or departs relatives to an observer

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• Doppler ultrasonography has proven to be an invaluable obstetric tool for over 30 years.

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• It can be used to assess both the fetal and placental circulation,

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• Doppler ultrasound of fetal vessels
• Umbilical artery
• Middle cerebral artery
• Ductus venosus

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• Uterine artery Doppler

CLINICAL APPLICATIONS

• Preeclampsia
• IUGR
• Twin twin transfusion syndrome
• Fetal anaemia (RH)

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• Ultrasound for gynaecologic oncology
• Ultrasound in ART

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• Note 3D and 4D ultrasound

PLAIN X-RAY

• Uses
• Diagnosis of pregnancy after 16 weeks (formation of the skeleton).
• Multiple pregnancy.
• Presentation and position.
• Vesicular mole (no foetal shadow).
• Gross congenital anomalies as hydrocephalus and anencephaly.
• Localisation of placental site (the old methods of head displacement from the symphysis pubis or placentography).

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PLAIN X-RAY

• Intrauterine foetal death.
• Pelvimetry and cephalometry.
• Diagnosis of maturity:
• Distal femoral epiphysis appears at 36 weeks.
• Upper tibial epiphysis appears at 38 weeks.
• Measurement of foetal lumbar vertebrae.

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All these indications are now covered by ultrasound and radiodiagnosis is nearly out of modern obstetrics due to its hazards.

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PLAIN X-RAY

• Hazards
• Death of the embryo or teratogenicity particularly if used in the first trimester.
• Gene mutation of the foetus or mother.
• Leukaemia of the newborn.

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MODERN INDICATIONS

• Calcifications
• IUD detection

HYSTEROSALPINGOGRAPHY (HSG)

• Hysterosalpingography (HSG) remains an important radiologic procedure in the investigation of infertility and has become a commonly performed examination due to recent advances of reproductive

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• SG demonstrates the morphology of the uterine cavity, the lumina, and the patency of the fallopian tubes.

HSG

• HSG) is the radiographic evaluation of the uterine cavity and fallopian tubes after the administration of a radio-opaque medium through the cervical canal.

INDICATIONS

• Evaluation of infertility (image the fallopian tubes)
• congenital or anatomic abnormalities of the uterus(e.g itrauterine synaechia, fibriod, polyps, Hydrosalpinx, Tuberculated Salpingitis, Salpingitis Isthmica Nodosa, External Adhesions)
• preoperative control for uterine or tubal surgery
• Might be helpful in the diagnosis of cervical insufficiency

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CONTRAINDICATIONS

• Pregnancy
• Active intrapelvic inflammation.
• vaginal or uterine bleeding
• severe cardiac or renal deficiency,
• uterine or tubal surgery
• Uterine or cervical malignancy

NORMAL HYSTEROSALPINGOGRAPHY

UNICORNOUS UTERUS.

DIDELPHYS UTERUS.

�INTERVENTIONAL RADIOLOGY IN OBSTETRIC AND GYNAECOLOGY PRACTICE�

• Interventional radiology is continuing to reshape current practice in many specialties of clinical care.

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• It is a relatively new and innovative branch of medicine in which physicians treat diseases non-operatively through small catheters guided to the target by fluoroscopic and other imaging modalities

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• Interventional Radiology (IR) is a minimally invasive alternative to open surgery that uses radiological image guidance (fluoroscopy, ultrasound, computed tomography [CT] or magnetic resonance imaging [MRI]) in conjunction with catheters, guide wires and special devices, such as stents, to deliver a wide range of treatments.

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INDICATIONS FOR INTERVENTION RADIOLOGY IN OBGYN

Emergency intervention

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• Interventional radiology should be considered in the management of postpartum haemorrhage secondary to:
• atonic uterus following normal or prolonged labour, with or without caesarean section
• surgical complications or uterine tears at the time of caesarean section
• bleeding while on the recovery unit or in the postnatal ward following a normal delivery or a caesarean
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• bleeding following hysterectomy.

Elective and prophylactic intervention

• Interventional radiology can also be used as a prophylactic measure where there is a known or suspected
• case of placenta accrete, such as placenta praevia on previous caesarean section scar, or placenta accreta diagnosed by scan/colour Doppler or magnetic resonance imaging

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• Note the role of intervention in gynaecologic malignancy

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BONE DENSITOMETRY�

• Depending on its mineral density, bone absorbs x-rays to different degrees.

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• Although plain radiography is useful in the initial evaluation of osteopenia and osteoporosis, it is not sensitive enough to assess bone density.

• Currently, two methods used commonly are dual-energy x-ray absorptiometry (DEXA) to assess integral bone mineral and quantitative computed tomography (QCT) to evaluate bone mineral in high turnover trabecular bone.

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• It employs two x-ray beams of different energy levels and accurately measures bone density in the hip and spine

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COMPUTED TOMOGRAPHY�

• This procedure involves multiple exposures of thin x-ray beams, which are translated into two-dimensional axial images of the particular area of interest, termed a slice

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• Recent software development enable the reconstruction and display of three dimensional images

• appropriate for detection of ovarian tumors
•  less appropriate for examination of uterus

MAGNETIC RESONANCE IMAGING

• A powerful magnetic field is created to align with hydrogen H+ ions (protons) in tissue water molecules. A radio frequency pulse is then use to disrupt the alignment of these protons with the main magnetic field

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• Following the pulse the protons drifts back into alignment with the magnetic field emitting a detectable radiofrequency signa lM

INDICATIONS

• congenital disorders (in case of unclear US finding)
• examination of mother (instead of X-ray or CT)

SOCIETIES INVOLVED IN IMAGING �

• British Medical Ultrasound Society (BMUS),
• the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB)
• the World Federation for Ultrasound in Medicine and Biology (WFUMB)
• American institute of ultrasound in medicine
• The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG)

CONCLUSION

• The rapid expansion and evolution of imaging has significantly developed the field of obstetrics and gynaecology

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• The benefits has also help in therapeutic intervention in managing to mother and the baby

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• The field of gynaecologic oncollogy has benefited from the adjunctive application of CT and MRI

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• The field of interventional radiology is evolving and opening non surgical options in obgyn

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