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• ULTRASOUND • RANSVAGINAL • RANSABDOMINAL • MRI • CT • FLUOROSCOPY • NTERVENTIONAL RADIOLOGY Case courtesy of Craig Hacking, Radiopaedia.org, rID: 43471 Case courtesy of Bruno Di Muzio, Radiopaedia.org, rID: 31750• • • ‘Justification of Ultrasound Requests: CURRENT VERSION V4’ (2021) JUSTIFICATION OF ULTRASOUND REQUESTS, 4, pp. 15–21. Available at: https://www.glowm.com/section- view/heading/Magnetic%20Resonance%20Imaging%20in%20Gynecology/item/67#.• IMAGING REQUESTS MUST BE SPECIFIC AND SUPPORTED BY CLINICAL HISTORY , PHYSICAL EXAMINATION ,AND RELEVANT LAB FINDINGS . • U LTRASOUND MAY NOT BE SUITABLE FOR ALL ABDOMINAL CONDITIONS ,SUCH AS SUSPECTED OCCULT MALIGNANCIES . • W ITH ENOUGH CLINICAL INFORMATION ,REQUESTS MAY BE REDIRECTED TO CT OR MRI WITH THE REFERRER NOTIFIED • INAPPROPRIATE REQUESTS WILL BE RETURNED WITH GUIDANCE . view/heading/Magnetic%20Resonance%20Imaging%20in%20Gynecology/item/67#.FICATION OF ULTRASOUND REQUESTS, 4, pp. 15–21. Available at: https://www.glowm.com/section- • • • • • • • • • • • • • • • • • • • • • • • ‘Justification of Ultrasound Requests: CURRENT VERSION V4’ (2021) JUSTIFICATION OF ULTRASOUND REQUESTS, 4, pp. 15–21. Available at: https://www.glowm.com/section- view/heading/Magnetic%20Resonance%20Imaging%20in%20Gynecology/item/67#.• • • • • • • PERFORMED BETWEEN 11+2AND 14+1 WEEKS – WHEN THE CROWN -RUMP LENGTH (CRL) IS BETWEEN45 MM AND 84 MM • DETERMINES: • LOCATION OF PREGNANCY • N UMBER OF FOETUSES • C HORIONICITY - ARE TWINS SHARING SAME PLACENTA ? • G ESTATIONAL AGE (CRL MEASUREMENT ) • A SSESS FOR MAJOR STRUCTURAL ABNORMALITIES E .G. ACRANIA /EXENCEPHALY • C HECK UTERUS FOR FIBROIDS OVARIAN MASSES https://www.bmus.org/static/uploads/resources/2021_SoR_and_BMUS_guidelines_v1.0_.pdf.R) AND BRITISH MEDICAL ULTRASOUND SOCIETY (BMUS). Available at:S ECOND RIMESTER ULTRASOUND (“20- WEEK SCAN ”) • OFFERED BETWEEN 18 AND 20+1WEEKS • ENABLES MEASUREMENT AND PLOTTING OF FOETAL GROWTH AGAINST GESTATIONAL AGE ,AMNIOTIC FLUID LEVEL AND PLACENTAL POSITION • AIMS TO DETECT11 CONDITIONS Congenital Congenital heart Anencephaly Spina bifida Cleft lip diaphragmatic hernia disease Bilateral renal Lethal skeletal Exomphalos Gastroschisis agenesis dysplasia Edwards’ syndrome Patau’s syndrome https://www.bmus.org/static/uploads/resources/2021_SoR_and_BMUS_guidelines_v1.0_.pdf.R) AND BRITISH MEDICAL ULTRASOUND SOCIETY (BMUS). Available at:THIRD TRIMESTER ULTRASOUND • A SSESS GROWTH • A SSESS PLACENTAL POSITION • A SSESS AMNIOTIC FLUID • F OLLOW UP ANY PREVIOUSLY DIAGNOSED ABNORMALITIES • M UST BE CLINICALLY INDICATED– NO EVIDENCE SUPPORTING ROUTINE THIRD TRIMESTER SCANNING Important to note, most foetal USS is carried out by sonographers and obstetric consultants, not radiology consultants. https://www.bmus.org/static/uploads/resources/2021_SoR_and_BMUS_guidelines_v1.0_.pdf.R) AND BRITISH MEDICAL ULTRASOUND SOCIETY (BMUS). Available at:• T O DATE ,NO EVIDENCE , THAT SUGGESTS ULTRASOUND POSES HARM TO HUMANS (INCLUDING THE DEVELOPING FOETUS ) • D ESPITE THIS – INVOLVES DEPOSITION OF ENERGY INTO THE BODY • S HOULD ONLY BE USED IN MEDICAL DIAGNOSIS AND MONITORING • O NLY BY PEOPLE WHO ARE FULLY TRAINED TO SAFELY AND PROPERLY UNDERTAKE THE SCAN • U TILIZING THE THERMAL INDEX (TI)AND MECHANICAL INDEX (MI) PROVIDES OPERATORS WITH INDICATIONS OF POTENTIAL ULTRASOUND BIO -EFFECTS . • TI –INDICATION OF RELEVANT POTENTIAL FOR TISSUE TEMPERATURE RISE • MI - INDICATION OF THE ULTRASOUND'S POTENTIAL TO CAUSE ADVERSE BIOLOGICAL EFFECTS THROUGH NON - THERMAL MECHANISMS ,LIKE CAVITATION. https://www.bmus.org/static/uploads/resources/BMUS-Safety-Guidelines-2009-revision-FINAL-Nov-2009.pdf. Society. Available at:Sagittal/longitudinal view of Transverse view of uterus the uterus Dinh, V. (no date) Transverse Imaging of uterus, POCUS 101. Available at: Dinh, V. (no date) Sagittal/Longitudinal Imaging od uterus, POCUS https://www.pocus101.com/gynecology-pelvic- 101. Available at: https://www.pocus101.com/gynecology-pelvic- 19 February 2024).sy-step-by-step-guide/ (Accessed: 2024).ound-made-easy-step-by-step-guide/ (Accessed: 19 February Dinh, V. (no date) Transabdominal Pelvic Ultrasound Transverse View, POCUS 101. Available at: https://www.pocus101.com/gynecology-pelvic-ultrasound-made-easy-step-by-step- Available at: https://www.pocus101.com/gynecology-pelvic-ultrasound-made-easy-step-by-step- guide/ (Accessed: 19 February 2024). guide/ (Accessed: 19 February 2024). Dinh, V. (no date) Transabdominal imaging, POCUS 101. Available at: https://www.pocus101.com/gynecology-pelvic-ultrasound-made-easy- step-by-step-guide/ (Accessed: 19 February 2024). Obtaining a sagittal/longitudinal Transverse view of the uterus view of the uterus Dinh, V. (nodate) Transvaginal Probe Insertion in Blue PhantomModel, POCUS 101. Availableat: Dinh, V. (nodate)Probeindicator at 9o’clock; Transversetransvaginal scanposition, POCUS101. https://www.pocus101.com/gynecology-pelvic-ultrasound-made-easy-step-by-step-guide/ (Accessed: 19February2024).cus101.com/gynecology-pelvic-ultrasound-made-easy-step-by-step-guide/ (Accessed: 19February 2024). Dinh, V. (nodate)CompleteTransvaginal ExamSetupusingBluePhantomModel, POCUS101. Availableat: https://www.pocus101.com/gynecology-pelvic-ultrasound-made-easy-step-by-step-guide/(Accessed: 19February 2024). Dinh, V. (no date) Normal Uterus; Transverse transvaginal ultrasound, POCUS 101. Dinh, V. (no date) Sagittal transvaginal Ultrasound with free fluid in pouch of Douglas, POCUS 101. Available at: https://www.pocus101.com/gynecology-pelvic-ultrasound- Available at: https://www.pocus101.com/gynecology-pelvic-ultrasound-made-easy-step- made-easy-step-by-step-guide/ (Accessed: 19 February 2024). by-step-guide/ (Accessed: 19 February 2024). First Trimester Ultrasound Second Trimester Ultrasound Third Trimester Ultrasound Case courtesy of Dennis Odhiambo Agolah, Radiopaedia.org, rID: 156888 Case courtesy of Alexandra Stanislavsky, Radiopaedia.org, rID: 44795 Case courtesy of RMH Core Conditions, Radiopaedia.org, rID: 26154 Case courtesy of Dennis Odhiambo Agolah, Radiopaedia.org, rID: 156888 Case courtesy of RMH Core Conditions, Radiopaedia.org, rID: 26154 Case courtesy of Alexandra Stanislavsky, Radiopaedia.org, rID: 44795 Extrauterine migration Anteverted uterus with uterus Adenomyosis didelphys of Mirena IUD Case courtesy of Craig Hacking, Radiopaedia.org, rID: 174626 Case courtesy of Henry Knipe, Radiopaedia.Case courtesy of Alexandra Stanislavsky, Radiopaedia.org, rID: 13726 Spina Bifida Foetal Hydrocephalus Myelomeningocele Foetal Cleft Lip Case courtesy of Alexandra Stanislavsky◉ rID: 48403 Case courtesy of Maulik S Patel rIDCase courtesy of Maulik S Patel rID: 23105Figure: Sagittal MRI scan of a normal female pelvis (2024) Pelvic Pain Support Network. Available at: https://www.pelvicpain.org.uk/diagnosis/imaging/mri/ (Accessed: 17 February 2024). Figure: Foetal MRI image (2012) Aunt Minnie Europe. Available at: https://www.auntminnieeurope.com/clinical-news/article/15644194/fetal-mri-can-complement-prenatal-ultrasound (Accessed: 17 February 2024).• • • • • • • • • • • •• P ELVIC PAIN OR SWELLING • ENDOMETRIOSIS Problems urinating or defecating Pelvic floor disorders • V AGINAL BLEEDING •Functional disorder of the pelvic floor associated • ADENOMYOSIS with urinary or bowel incontinence •Chronic constipation, when anorectal • LUMPS OR MASSES manometry or balloon expulsion tests are nondiagnostic • ADNEXAL M ASS •Ovarian cysts •Fallopian tube abnormalities • U TERINE LEIOMYOMATA (FIBROIDS ) •Cancer •Ovarian, endometrial, cervical & bladder • cancer •Germ cell tumours, squamous cell carcinoma •Any lymph node involvement • •Metastasis to ovaries - Krukenberg's tumours •Investigate anatomical/congenital abnormalities • when-should-mri-be-considered (Accessed: 01 March 2024). should MRI be considered?, APPLIED RADIOLOGY. Available at: https://appliedradiology.com/articles/imaging-the-female-pelvis- Appropriate Use Criteria: Imaging of the Abdomen and Pelvis (2023) Carelon Clinical Guidelines and Pathways. Available at: https://guidelines.carelonmedicalbenefitsmanagement.com/abdomen-and-pelvis-imaging-2023-04-09/ (Accessed: 01 March 2024).• • • • • • • • • • doi:10.53347/rid-17179.dy, Y. (2012) ‘Junctional zone’, Radiopaedia.org [Preprint]. of Women’s Medicine [Preprint]. doi:10.3843/glowm.10067.Imaging in Gynecology’, The Global Library A – T1-weighted sagittal image of uterus B – T2-weighted sagittal image of the uterus C – T1-weighted coronal image of uterus and adjacent structures (adnexa) D – T2 -weighted coronal image of uterus and adjacent structures (adnexa) Magnetic Resonance Imaging in Gynecology. Global Library of Women's Medicine, (ISSN: 1756-2228), DOI:hotograph]. In: 10.3843/GLOWM.10067. Women’s Medicine [Preprint]. doi:10.3843/glowm.10067.ce Imaging in Gynecology’, The Global Library of Deep infiltrating endometriosis - rectovaginal Axial T1 fat sat Sagittal T2 weighted Case courtesy of Michael P Hartung◉ rID: 77328 Mature cystic Oblique T2 weighted teratoma of the ovary Sagittal T2 weighted Case courtesy of Alexandra Stanislavsky◉ rID: 148932 Axial T1 fat sat Uterine Leiomyoma Axial T1 weighted Coronal T2 weighted Sagittal T2 weighted Coronal T1 C+ fat sat Case courtesy of Abbas M. Mahmood rID: 90580 Axial T1 C+ fat sat Sagittal T2 weighted Ovarian metastasis Coronal T2 fat sat from colorectal adenocarcinoma Case courtesy of Jan Frank Gerstenmaier rID: 35120V ERY SUBSPECIALIS– ONLY DONE IN A FEW CENTRES IN THE COUNTRY (EG . HEFFIELD). N OT NORMALLY DONE IN LEICESTER– ONLY FOR ACUTE GI ISSUES(E.G. APPENDICITI) OR RARELY FOR URGENT PLACENTA COMPLICATIONS O BSTETRIC INDICATIONS A DVANCED IMAGING IS CONSIDERED MEDICALLY NECESSARY FOR DIAGNOSIS AND MANAGEMENT OF ANY OF THE FOLLOWING : • FOETAL ANOMALIES • A SSESSMENT PRIOR TO FOETAL INTERVENTION • PLACENTAL COMPLICATIONS • C OMPLICATIONS RELATED TO MONOCHORIONIC TWINS • PELVIMETRY • O THER OBSTETRICAL COMPLICATIONS IMAGING STUDY • ULTRASOUND IS REQUIRED FOR INITIAL EVALUATION OF FOETAL AND PLACENTAL CONDITIONS • FOETAL MRI FOR INDICATIONS INVOLVING THE FOETUS OR PLACENTA ,FOLLOWING NONDIAGNOSTIC ULTRASOUND • MRI PELVIS FOR PELVIMETRY OR OTHER OBSTETRICAL COMPLICATIONS https://guidelines.carelonmedicalbenefitsmanagement.com/abdomen-and-pelvis-imaging-2023-04-09/ (Accessed: 01 March 2024).• • • • • • • • • • imaging’, Ultrasound in Obstetrics & Gynecology, 49(5), pp. 671–680. doi:10.1002/uog.17412.e Magnetic resonance imaging (MRI) of normal foetal chest (a, b) and abdomen (c,d). (a)Axial T2-weighted MRI in a 34+2-weekfetus, showing normally shaped thorax and lungs with age- matched regular signals; (b) coronal image at 35+3 weeks, showing additionally parts of liver, kidneys and adrenal gland on right side. (c) Coronal T2-weighted MRI in a 32+2-week foetus, displaying fluid-filled stomach and bowel loops; (d)sagittal steady-state free-precession image in a 35+6-week foetus, showing in addition the fluid-filled urinary bladder. Note hyperintensity of the heart in (d), in contrast to T2-weighted image (c) imaging’, Ultrasound in Obstetrics & Gynecology, 49(5), pp. 671–680. doi:10.1002/uog.17412.e Coronal T2 weighted Axial T2 weighted Sagittal T2 weighted Foetal x-linked hydrocephalus Case courtesy of Stacy Goergen rID: 50378 Axial T2 weighting Sagittal T2 weighting Coronal T2 weighting Placenta accreta with placenta praevia Case courtesy of Mohammad A. ElBeialy, Radiopaedia.org, rID: 39015 Sagittal T2 weighted Coronal T2 fat sat Coronal T2 weighted Placenta Praevia Case courtesy of Sachin T, Radiopaedia.org, rID: 75629 Sagittal T2 Coronal T2 Axial T2 Microcephaly Case courtesy of Stacy Goergen rID: 51784 T2 weighted Megaureters due to bilateral Coronal T2 weighted duplex kidneys Case courtesy of Fabien Ho rID: 59096• N OT THE MODALITY OF CHOICE FOR ROUTINE GYNAE ASSESSMENT • POOR SOFT TISSUE RESOLUTION IN THE PELVIS • US AND MRI PROVIDE BETTER DIAGNOSTIC VISUALISATION • O NLY REAL ADVANTAGES OF CT ARE THAT IT IS QUICK AND READILY AVAILABLE IN AN EMERGENCY • E XCEPTIONS FOR USE ARE : • ACUTELY UNWELL PATIENTS (UNSTABLE ) THEY WILL HAVE A CT TO QUICKLY NARROW DOWN THE DIFFERENTIALS . • FOR ACUTELY UNWELL FEMALE PATIENTS IN ED – ASSESS FOR GYNAE PATHOLOGY /APPENDICITIS • WE DO US FIRS- TO LOOK FOR GYNAE PATHOLOGY AND TRY TO LOOK FOR APPENDIX • THEN LOW DOSE CT IFUS WAS NOT DIAGNOSTIC- CAN SEE COLLECTIONS,HAEMOPERITONEUM ,NON GYNAE PATHOLOGY ETC • D ISTANT STAGING /RE-STAGING OF GYNAE CANCER (LOCAL STAGING IS DONE ON MRI) Busse, R.M. (2010) ‘Imaging modalities in gynecology’, Donald School Journal of Ultrasound in Obstetrics and Gynecology, 4(1), pp. 1–12. doi:10.5005/jp-journals- 10009-1123. zz`• • • Evaluation of pelvic trauma • • Preoperative planning for gynaecology surgery • • Pelvic inflammatory disease (PID) • • • Cystic teratoma • Ovarian vein thrombosis • • Postpartum and post surgical • • complications • • 10009-1123. zz`10) ‘Imaging modalities in gynecology’, Donald School Journal of Ultrasound in Obstetrics and Gynecology, 4(1), pp. 1–12. doi:10.5005/jp-journals-Axial CT images demonstrating normal female gynaecological anatomy (no date) Radiology Key. Available at: https://radiologykey.com/ct-of-the-female- pelvis/ (Accessed: 03 March 2024).Case courtesy of Tariq Walizai, Radiopaedia.org, rID: 169691Kelley, L. and Petersen, C. (2018) Coronal CT reformat of female pelvis with ovaries. 4th edn, Sectional Anatomy for Imaging Professionals. 4th edn. Elsevier Health Sciences. Case courtesy of Tariq Walizai, Radiopaedia.org, rID: 169691 Squamous cell carcinoma of the cervix Uterine fibroids - calcified Case courtesy of David Cuete rID: 22853 Case courtesy of Mohammadtaghi Niknejad◉ rID: 20577Ruptured ectopic pregnancy Case courtesy of Vikas Shah◉ rID: 54993 Pelvic Inflammatory Ovarian vein thrombosis Disease (PID) Ovarian vein thrombosis. (Source: Fielding, J.R., Brown, D.L. and Thurmond, A.S. (2011) Gynecologic imaging. Philadelphia, Pa: Elsevier Saunders.)n, D.L. and Thurmond, A.S. (2011) Gynecologic imaging. Philadelphia, Pa: Elsevier Saunders.)Figure: Fielding, J., Brown, D. and Thurmond, A. (2011) Duplication anomaly, Gynecologic Imaging. Elsevier. Figure: Fielding, J., Brown, D. and Thurmond, A. (2011) Tubal Ligation, Gynecologic Imaging. Elsevier. Figure: Fielding, J., Brown, D. and Thurmond, A. (2011) Intra–fallopian tube device used for sterility, Gynecologic Figure: Fielding, J., Brown, D. and Thurmond, A. (2011) Hydrosalpinx, Gynecologic Imaging. Elsevier. Imaging. Elsevier.• Fluoroscopic examination • Uterus • Fallopian tubes • Commonly used to investigate infertility or recurrent spontaneous abortions • Contraindications • Pregnancy • Active pelvic infection • Recent uterine or fallopian tube surgery • Performed during the proliferative phase of menstrual cycle (days 6-12) when the endometrium is thinnest. • Helps to better visualise the uterine cavity • Catheterisation of cervix with a contrast primed catheter– inserted just beyond internal os • Iodinated contrast introduced into the uterus under fluoroscopic guidance Case courtesy of Mohammadtaghi Niknejad, Radiopaedia.org, rID: 85288 Case courtesy of Yaïr Glick, Radiopaedia.org, rID: 56235 Case courtesy of Mohammadtaghi Niknejad, Radiopaedia.org, rID: 157930 Endometrial Polyp Case courtesy of Bahman Rasuli, Radiopaedia.org, rID: 97424Rasuli, Radiopaedia.org, rID: 156211 Bilateral tubal block Adenomyosis• • • • • • • • Uterine myoma (DSA imaging) Uterine arterio-venous malformations PELVIC CONGESTION SYNDROME MRI, 42(1), pp. 104–112. doi:10.1053/j.sult.2020.09.004.nd, CT andd