1 Introduction ................................................. 1
2 General Techniques in Gynecological Ultrasound ............... 3
2.1 Transabdominal Scan ..................................... 4
2.2 Transvaginal Scan ....................................... 8
2.3 Three-Dimensional Ultrasound ........................... 13
2.4 Doppler ................................................ 25
2.5 Tips and Tricks of Pelvic Ultrasound ................... 34
2.6 Sonohysterography (SHG) ................................ 47
2.7 Gel Sonovaginography (GSV) ............................. 51
Suggested Reading ........................................... 54
3 Ultrasound Evaluation of Myometrium ......................... 55
3.1 Evaluation of Myometrium ............................... 55
3.2 Normal Myometrium ...................................... 61
3.3 Fibroids (Leiomyoma or Myoma) .......................... 64
3.3.1 Fibroid Mapping ................................. 68
3.3.2 Red Degeneration ................................ 76
3.3.3 Fibroid Embolization ............................ 77
3.3.4 Diffuse Uterine Leiomyomatosis .................. 78
3.3.5 Disseminated Peritoneal Leiomyomatosis (DPL) .... 79
3.4 Adenomyosis and Adenomyomas ............................ 81
3.4.1 Adenomyoma ...................................... 90
3.5 Sarcoma ................................................ 93
Suggested Reading ........................................... 95
4 Ultrasound Evaluation of Endometrium ........................ 97
4.1 Evaluation of Endometrium .............................. 97
4.2 Normal Endometrium .................................... 105
4.2.1 Endometrium in Paediatric Age Group ............ 105
4.2.2 Endometrium in Reproductive Age Group .......... 105
4.2.3 Endometrium in Postmenopausal Women ............ 105
4.3 Endometrial Polyps .................................... 108
4.4 Endometrial Hyperplasia ............................... 121
4.4.1 Tamoxifen-Associated Endometrial Changes ....... 121
4.5 Endometrial Malignancy ................................ 130
4.6 Differential Diagnosis of Thickened Endometrium ....... 143
4.7 Asherman's Syndrome or Intrauterine Adhesions ......... 145
4.8 Subendometrial Fibrosis ............................... 150
4.9 Endometritis .......................................... 152
4.10 Intracavitary Fluid in the Uterus ..................... 157
Suggested Reading .......................................... 161
5 Ultrasound Evaluation of the Cervix ........................ 163
5.1 Evaluation of the Cervix and Its Normal Appearance .... 163
5.2 Nabothian Cysts ....................................... 165
5.3 Cervical Polyps ....................................... 167
5.4 Cervical Fibroids ..................................... 175
5.5 Cervical Carcinoma .................................... 177
Suggested Reading .......................................... 186
6 Ultrasound Evaluation of the Vagina ........................ 187
6.1 Normal Vagina ......................................... 187
6.2 Congenital Vaginal Anomalies .......................... 189
6.3 Vaginal Cysts ......................................... 189
6.3.1 Gartner Duct Cysts and Mullerian Cysts ......... 189
6.3.2 Bartholin Gland Cysts .......................... 189
6.3.3 Skene Gland Cysts .............................. 189
6.4 Vaginal Masses and Vaginal Cancer ..................... 194
6.5 Other Vaginal Pathologies ............................. 199
6.5.1 Vaginal DIE .................................... 199
6.5.2 Foreign Body in the Vagina ..................... 199
6.6 Vulval Carcinoma ...................................... 200
Suggested Reading .......................................... 201
7 Ultrasound Evaluation of Ovaries ........................... 203
7.1 Evaluation of Ovaries and Persistent Adnexal Masses ... 203
7.1.1 Morphology, Measurement and Doppler
Evaluation of the Ovary and Ovarian Masses
(Including Persistent Adnexal Masses) .......... 203
7.1.2 Morphological Classification of Ovarian/
Adnexal Masses ................................. 215
7.2 Normal Ovaries ........................................ 217
7.3 Polycystic Ovaries (PCO) .............................. 222
7.3.1 PCO in the Absence of PCOS ..................... 222
7.4 Ovarian Masses ........................................ 225
7.4.1 Functional or Physiological Cysts .............. 225
7.4.2 Endometriotic Cysts (Endometriomas) ............ 228
7.4.3 Ovarian Neoplasms .............................. 238
Suggested Reading .......................................... 294
8 Endometriosis .............................................. 295
8.1 Deep Infiltrating Endometriosis (DIE) ................. 295
8.1.1 DIE of Large Bowel (Rectosigmoid) .............. 297
8.1.2 DIE of the Vaginal Wall ........................ 300
8.1.3 Cervical DIE ................................... 303
8.1.4 Uterosacral DIE ................................ 305
8.1.5 Bladder DIE .................................... 307
8.1.6 DIE Involving the Ureters ...................... 309
8.1.7 Uterus in Cases with DIE ....................... 311
8.2 Extra-Pelvic Endometriosis ............................ 313
8.2.1 Abdominal Wall Endometriosis ................... 313
8.2.2 Abdominal and Thoracic Endometriosis ........... 315
Suggested Reading .......................................... 317
9 Ultrasound Evaluation of Adnexal Pathology ................. 319
9.1 Fallopian Tube ........................................ 319
9.2 Pelvic Inflammatory Disease (PID) ..................... 319
9.3 Chronic PID ........................................... 337
9.4 Hydrosalpinx .......................................... 340
9.5 Tubal Malignancy ...................................... 346
9.6 Paraovarian and Paratubal Cysts ....................... 349
9.7 Peritoneal Inclusion Cysts ............................ 356
Suggested Reading .......................................... 361
10 Ultrasound Evaluation of Pregnancy-Related Conditions ...... 363
10.1 Ectopic Pregnancy ..................................... 363
10.1.1 Tubal Ectopic Pregnancy ........................ 365
10.1.2 Interstitial Ectopic Pregnancy ................. 373
10.1.3 Cornual Ectopic Pregnancy ...................... 376
10.1.4 Ovarian Ectopic Pregnancy ...................... 379
10.1.5 Cervical Ectopic Pregnancy ..................... 381
10.1.6 Scar Ectopic Pregnancy ......................... 385
10.1.7 Intra-abdominal Pregnancy ...................... 387
10.1.8 Heterotopic Pregnancy .......................... 388
10.1.9 Intra-myometrial Ectopic Pregnancy ............. 390
10.2 Retained Products of Conception (RPOC) ................ 391
10.3 Gestational Trophoblastic Disease (GTD) ............... 401
10.3.1 Molar Pregnancy ................................ 401
10.3.2 Gestational Trophoblastic Neoplasia (GTN) ...... 406
Suggested Reading .......................................... 411
11 Torsion .................................................... 413
11.1 Ovarian Torsion ....................................... 413
11.2 Non-ovarian Torsion ................................... 429
Suggested Reading .......................................... 433
12 Ultrasound Evaluation of Congenital Uterine Anomalies ...... 435
12.1 Embryopathogenesis .................................... 435
12.2 AFS Classification of Uterine Anomalies ............... 438
12.3 Approach to Diagnosing a Uterine Anomaly .............. 439
12.4 Types of Uterine Anomalies ............................ 444
12.4.1 Arcuate Uterus ................................. 444
12.4.2 Subseptate Uterus .............................. 446
12.4.3 Septate Uterus ................................. 447
12.4.4 Bicornuate Uterus .............................. 448
12.4.5 Uterus Didelphys ............................... 450
12.4.6 Unicornuate Uterus ............................. 451
12.4.7 Absent/Hypoplastic Uterus ...................... 453
12.4.8 'T-Shaped' Uterus .............................. 454
12.5 Cervical and Vaginal Anomalies ........................ 455
12.6 ESHRE/ESGE Classification of Congenital Uterine
Anomalies ............................................. 464
12.7 Reporting Uterine Anomalies ........................... 466
Suggested Reading ............................................. 467
13 Ultrasound in Other Miscellaneous Conditions ............... 469
13.1 Uterine Vascular Abnormalities (Arteriovenous
Malformations) ........................................ 469
13.2 Perforation of the Uterus ............................. 475
13.3 Vesicouterine Fistula ................................. 478
13.4 Retroflexed Uterus .................................... 480
13.5 Caesarean Scar Defect (LSCS Scar Defect) .............. 482
13.6 Intrauterine Contraceptive Device (IUCD) .............. 489
13.7 Follicular Monitoring and Ultrasonography in
Patients with Infertility ............................. 498
13.7.1 Cyclical Changes During Menstrual Cycle
(Both Natural and Induced) .................... 498
13.7.2 Types of Scans Done in Patients Presenting
or on Treatment for Infertility ............... 498
13.7.3 Luteinised Unruptured Follicle ................. 499
13.8 Ovarian Hyperstimulation Syndrome (OHSS) ............. 503
Suggested Reading ............................................. 507
14 Exploring Pathologies Based on Clinical Presentation ....... 509
14.1 Abnormal Uterine Bleeding ............................. 509
14.1.1 Common Forms of Abnormal Uterine Bleeding ...... 509
14.1.2 Abnormal Uterine Bleeding in the Reproductive
Age Group ...................................... 509
14.2 Pelvic and Adnexal Masses ............................. 512
14.2.1 Ovarian Masses ................................. 514
14.2.2 Uterine Masses ................................. 515
14.2.3 Tubal Masses ................................... 515
14.2.4 Tubo-ovarian Masses ............................ 515
14.2.5 Paraovarian Masses ............................. 515
14.2.6 Pseudoperitoneal or Peritoneal Inclusion
Cysts .......................................... 515
14.2.7 Pelvic Hematomas and Pelvic Abscess ............ 515
14.2.8 Non-gynecological Masses ....................... 515
14.2.9 IOTA Recommendation for Evaluation of
Persistent Adnexal Masses ...................... 519
14.3 Acute Pelvic Pain ..................................... 526
14.4 Locating the Pregnancy and Pregnancy of Unknown
Location (PUL) ........................................ 532
Suggested Reading ............................................. 535
Index ......................................................... 537
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