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6 Ultrasonography inFemale Infertility andContraceptive Operation
285
• Complete ectopic is characterized as the IUD is completely inserted into the myometrium and cannot be
found inside the cavity. Both partial ectopic and complete ectopic all belong to IUD incarceration.
• Extrauterine ectopic
• Extrauterine ectopic is dened as the IUD is completely outside the uterus.
• Ultrasonography is utilized to identify the existence
and type of IUD, as well as the location and form of
IUD. The displacement, incarceration, perforation,
and pregnancy with IUD can be found by
ultrasonography.
2. Ultrasonic diagnosis
• Intrauterine device
– Different kinds of IUD with different materials
show different sonographic characteristics
Fig. 6.14 Various kind of IUD.Ectopia of IUD includes partial ectopic, complete ectopic, extrauterine ectopic
(Figs.6.15, 6.16, 6.17, 6.18, 6.19, and 6.20). Most
tail wire of the IUD shows a hyperechoic line under
ultrasonography (Fig.6.21).
– There are two common methods to judge whether
the IUD is in the right location. (1) On the longitudinal section of uterus, the top of IUD is less than
2cm away from the exterior periphery of uterine
serosal layer. (2) On the longitudinal section of
uterus, the superior extremity location of IUD is
above the bisector point of the line between the
uterine fundus and internal cervical os.
• Downward IUD.The criteria stated above is used to
measure whether the IUD is downward. Signicant
downward IUD can be totally located in the cervical
canal (Figs.6.22 and 6.23).
• Ectopic IUD
– Partial ectopic: IUD is not located in the center of
uterine cavity, partially inserted into muscular layer
or close to serosal layer, partially in the uterine
cavity.
– Complete ectopic: ultrasound examination shows
the depth of IUD inserted into muscular layer and
no IUD in the uterine cavity (Fig.6.24).
– Extrauterine IUD
– Ultrasound shows that IUD is in the para-uterine
organs, Douglas pouch, or vesicouterine pouch. If
the ectopic IUD is far from uterus and covered by
the surrounding intestine or above the pelvic cavity,
ultrasound examination cannot accurately locate its
position, and further examinations such as X-ray,
CT, or MRI are necessary.
• Pregnancy with IUD
• Pregnancy with IUD mostly happens with ectopic
IUD.Both the IUD and gestational sac are shown in
Fig. 6.15 Metal IUD. (a) Retroverted uterus. The longitudinal view of the uterus shows two parallel hyperechoic lines in the shape of the Chinese
character “二”, with posterior comet tail sign. (b) The transverse view shows a circle IUD
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Fig. 6.16 Intrauterine device. Sonogram shows an “I”-shaped hyperechoic IUD in the uterine cavity on the longitudinal view, which shows
a hyperechoic triangle on the transverse view
H. Luo and H. Pang
the uterine cavity at the same time. In some conditions, IUD in the normal location could also be combined with pregnancy (Fig.6.25).
3. Special tips
• Ultrasound examination is the preferred method to
detect the IUD, replacing the X-ray which is commonly used in the past.
• When sonographer judging the location of the IUD
pays attention to the thickness of muscular layer of
fundus. If the myometrium is signicantly thickened,
notice the location relation between the top of IUD
and the fundus of the uterus.
Fig. 6.17 T-shaped IUD. (a) Sagittal view shows s beading-shaped hyperechoic IUD. (b) Coronal section shows the IUD in a “T” shape
Fig. 6.18 IUD
Fig. 6.19 Gyne Fix IUD
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6 Ultrasonography inFemale Infertility andContraceptive Operation
Fig. 6.20 Mirena
Fig. 6.21 The tail ber of the IUD shows a bright line
287
6.3 Ultrasound Diagnosis
ofComplications ofContraceptive
Operation
I. Penetration of uterine
• Basic conception
Penetration of uterine is the common complication
happening during the contraceptive operation. Severe
complication is vascular injury, abdominal organs
absorbed into the uterine cavity, such as epiploic
appendices, omentum, and intestine, resulting in
internal hemorrhage, bowel necrosis, inammation,
and even death.
Common reasons are soft uterus of breastfeeding
women, scarred uterus, excessive retroverted or retroexed uterus, uterine malformation, and unskilled
operations.
Penetration of uterine is divided into incomplete and
complete penetration of uterus.
• Ultrasound diagnosis
– Incomplete penetration of uterus
Incomplete penetration of uterus refers to the
penetration is limited to the myometrium, not
involving the serosal layer. The outline of uterus
is clearly shown and the echo of serosa is continual. There is no abnormal echo in uterine cavity and only one hyperechoic string is detected in
the injured myometrium (Fig.6.26).
– Complete penetration of uterus
Complete penetration of uterine is characterized
by the penetration break through the serosal
layer, resulting in discontinued serosal layer. The
Fig. 6.22 IUD move down to the internal cervical os. (a) Transabdominal ultrasound shows that the bottom of IUD reach to the internal os of the
cervix. (b) Transvaginal ultrasound shows that the bottom of IUD reach to the internal os of the cervix
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H. Luo and H. Pang
wide and hyperechoic string echo is visible in the
injury with irregular shape. The lesion always
protrudes outwards. Intestinal echo can be
scanned in the uterine cavity in some cases.
Heterogeneous echo is visible around or far from
the uterus, and free liquid area is visible in the
pelvic cavity (Fig.6.27).
Fig. 6.23 IUD moves down to the cervical canal
• Special tips
– Pay attention to the continuity of the serosal layer
and the completion of the uterine outline in suspected uterine penetration cases.
– Observe the echo of myometrium and the relation-
ship between the myometrium and the uterine
cavity line.
– Sonographer should be cautious about the abnormal
echo in the uterine cavity, parametrial uid dark
area, and masses.
• Typical case
A 32-year-old patient received uterine curettage
because of intrauterine death after 4-month menolipsis and received dilation and curettage three times.
She comes to the hospital with the chief complaint of
vaginal bleeding. The ultrasonography reports: The
size of uterus is larger than normal. The echo of serosal layer is discontinuous. Irregular hyperechoic
mass in the size of 20mm×16mm×23mm is visible closed to the fundus, partially penetrate through
the myometrium and into uterine cavity. The depth of
uid in the Douglas pouch is about 10mm. The ultrasound manifestation shows suspected penetration of
uterus. In the exploratory laparotomy, uterus is found,
Fig. 6.24 IUD incarceration. (a–d) IUD inserted into muscular layer partially or completely, representing enhanced echo in the muscular layer
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6 Ultrasonography inFemale Infertility andContraceptive Operation
Fig. 6.25 Pregnancy with IUD. (a) pregnancy with downward IUD; (b) pregnancy with IUD in normal location
289
Fig. 6.28 Penetration of uterus. M indicates the mass in the fundus
Fig. 6.26 Incomplete penetration of anterior uterine wall, without
breaking through to the serosal layer
surrounded with omentum and sigmoid. The mass of
70mm in size is included with sigmoid, uterine fundus, left ovary fallopian tube, and left pelvic wall,
containing fetal scapula and necrotic tissue. The
injury is found in the left corner of corpus, which is
penetrated with omentum (Fig.6.28).
II. Intrauterine adhesions and cervical adhesion.
• Basic conception
Intrauterine adhesions, also known as Asherman syndrome, is caused by any kind of endometrial injury.
The injured endometrium necroses, inammatory
cells inltrate, and villus or decidual tissue degrades,
resulting in brous connective tissue and muscular
tissue hyperplasia. Even worse, the endometrium is
totally injured and brous connective tissue or even
muscular tissue under it gets exposed and then
adheres together. This situation mostly happens after
contraceptive operation, curettage, and other intra-
Fig. 6.27 Complete penetration of anterior uterine wall, breaking
through the serosal layer
uterine operation.
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H. Luo and H. Pang
The manifestations of Asherman syndrome include:
oligomenorrhea, amenorrhea, periodic abdominalgia, infertility, and recurrent abortion. Resistance can
be felt during cervical dilatation. In severe cases, the
probe fails to go through the cervix to the uterine cavity. After going through the adhered cervix, some
dark-red bleed shed out.
According to the location, range, and severity of
intrauterine adhesion, the Asherman syndrome is
classied as adhesion of internal cervical os, adhesion of uterine cavity, and complex adhesions
(Fig.6.29).
• Ultrasonic diagnosis
– Simple internal cervical os adhesion: The uterine
cavity is separated and uid dark area is visible in
the cavity, with some spotty slight echo. The adhesion lesion of the endometrium is
inhomogeneous.
– Intrauterine adhesion: Adhesion is mostly located
in the isthmus uteri. In moderate cases, the uterine
cavity is slightly separate, with some scattered
echo and hyperechoic line in it. In severe cases,
the uterine cavity is obstructed, the cavity line is
disappeared, and the endometrium is hypoechoic
or anechoic.
– Complex adhesion
– Adhesion occurred both in the internal cervical os
and uterine cavity. The endometrium is hypoechoic
or anechoic, and not clearly identied. The dis-
continuous endometrium is no more than 2mm in
thickness, and its boundary is not clearly sepa-
rated from the myometrium.
• Special tips
– The ultrasonographic feature of intrauterine adhe-
sion is complex. Transvaginal sonohysterography
can help to visually show the intrauterine
adhesion.
– Hysteroscopy can evaluate the severity and range of
the intrauterine adhesion.
III. Intrauterine pregnancy residual
• Basic conception
– Intrauterine pregnancy residue is the most common
complication of abortion, which could lead to
hemorrhage, even hemorrhagic shock.
– The manifestation of pregnancy residue is vaginal
bleeding for more than 10 days after abortion,
excessive bleeding, or recurrent bleeding after the
bleeding stopped.
• Ultrasonic diagnosis
– Small amount of intrauterine residue shows a small
patchy enhanced echo. Large amount of intrauterine residue shows aky strong echoes or inhomogeneous echoes, with irregular shapes.
– Abnormal uid dark area can be detected in the
uterine cavity in patients with bleeding. If
observed carefully, owing slight spotty echo can
be captured.
– If the vaginal bleeding lasts for a long time, the
sonogram shows scattered hyperechoic mass in
the dark area of separate uterine cavity. Tissue
necrosis present as enhanced and disordered echo
in the uterine cavity (Fig.6.30).
– In some cases, unilateral or bilateral ovarian preg-
nancy corpus luteum cysts do not disappear.
Fig. 6.29 Intrauterine adhesion. (a) A 30-year-old patient, amenorrhea
3months after contraceptive operation. Adhesion is found both in the
cervix and uterine cavity. The echo of endometrium is not clear and the
mid-down part of uterine cavity is separated by dark area of uid and
slight spot echo. (b) Sonogram shows intrauterine adhesion, thin and
discontinuous endometrium, and some uid dark area in the internal
cervical os
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6 Ultrasonography inFemale Infertility andContraceptive Operation
291
Fig. 6.30 Intrauterine residue. (a–d) Images show the intrauterine space-occupying lesions after abortion or induced labor. The curettage was
conrmed as residue
– Color Doppler ow image shows the blood ow in
the intrauterine occupation, indicating the residue
is viable tissue.
IV. Abortion failure
• Basic conception
Abortion failure is dened as the residual fetus or
placental villus in the uterine cavity after
abortion.
The cause of abortion failure includes that the size of
embryo sac is too small or too large, excessive uterine exion, uterine malformation, and operative fault.
• Ultrasonic diagnosis
– Pregnancy sac is still in the uterine cavity and grows
up. Even the embryo and heartbeat are visible
(Fig.6.31).
– Pay attention to the malformation and abnormal
location of the uterus.
V. Pelvic inammatory disease
• Basic conception
Pelvic inammatory disease (PID) refers to the
inammation of female internal genitalia, surrounding connective tissue, and pelvic peritoneum.
PID caused by contraceptive operation is mostly the
result of incomplete suction evacuation and infected
operation.
Fever, abdominal pain, abnormal leukorrhea, and
abnormal vaginal bleeding are the main manifestation of PID.
• Ultrasonic diagnosis
– In mild cases, there are no obvious sonographic
features.
– In severe cases, a sonogram shows the enlarged
uterus, thickened and hypoechoic myometrium,
and heterogeneous hypoechoic tissue or uids in
the uterine cavity (Fig.6.32).
– When inammation spread to the ovaries and fal-
lopian tubes and forming inammatory mass, the
sonogram shows a cystic mass or hypoechoic
mass, with unclear boundary. The patients complain about pain when touching the mass. Fluid is
visible around the cyst and in the Douglas pouch.
– If the pelvic inammation is not treated in time, it
may lead to chronic pelvic inammation and pelvic
cavity adhesion, even pelvic abscess (Fig.6.33).
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Fig. 6.31 Abortion failure. (a) Curettage failure of uterus bicornis. (b) After abortion failure, the embryo continues to grow up
H. Luo and H. Pang
Fig. 6.32 Intrauterine inammation. A 25-year-old patient, with the
complaint of abdominal pain, fever for 1week after abortion. Sonogram
shows inhomogeneous echo in the uterine cavity
Suggested Reading
1. Rollason JC, Outtrim JG, Mathur RS.A pilot study comparing the
DuoFertility(®) monitor with ultrasound in infertile women. Int J
Women’s Health. 2014;6:657–62.
Fig. 6.33 Pelvic inammatory mass. Twenty days after an induced
labor, the patient sees a doctor for lower abdominal pain. The sonogram
shows the irregular cystic occupation with septum
2. Su HW, Yi YC, Wei TY, Chang TC, Cheng CM.Detection of ovulation, a review of currently available methods. Bioeng Transl Med.
2017;2(3):238–46.
3. Nowitzki KM, Hoimes ML, Chen B, Zheng LZ, Kim
YH. Ultrasonography of intrauterine devices. Ultrasonography.
2015;34(3):183–94.
Interventional Ultrasound inObstetrics
andGynecology
HongLuo, FanYang, andMinHe
7
7.1 Overview ofInterventional
Ultrasound
Interventional ultrasound, which is characterized by accurately positioning and minimally invasive, is to complete
various biopsies, ultrasonic contrast, aspiration, intubation,
and medical injection under the monitor and guidance of
real-time ultrasonography, so as to achieve the purpose of
diagnosis or treatment.
Interventional ultrasonography has been widely applied
in obstetrics and gynecology. For example, it can be used in
the process of sampling of prenatal diagnoses, such as chorionic villi biopsy, amniotic uid extraction, fetal blood sampling, and tissue sampling for biochemical, enzymology,
cytogenetics examination. Hysterosalpingography is applied
for the diagnosis of the uterine cavity and fallopian tube diseases. Interventional ultrasonography is also used for the
intraoperative monitor. In terms of treatment, it is used for
puncture biopsy, drainage, and injection of pelvic mass, such
as puncture of ovarian endometriotic cyst, encapsulated effusion, and the interventional treatment of ectopic pregnancy.
It is also used for follicle puncture, egg retrieval, and fetal
reduction during the process of assisted reproduction, as well
as intrauterine treatment of fetuses.
At present, three-dimensional ultrasound technology has
been used in obstetrics and gynecology. 3-D images can fully
and vividly display the spatial relationship and 3-D form of
the internal structure of pelvic organs or masses, which helps
to accurately locate the lesion for getting biopsies.
This chapter was translated by Feiran Liu, Department of Obstetrics
and Gynecology, Beijing Shijitan Hospital, Bejing, China
H. Luo (*) · F. Yang · M. He
Department of Ultrasonography, West China Second University
Hospital, Sichuan University, Chengdu, China
7.2 Basic Conditions andOperational
Methods ofInterventional
Ultrasonography
I. Indications and contraindications
• Indications
– In the purpose of diagnosis: Puncture pump, extrac-
tion of umbilical cord blood or amniotic uid,
aspiration cytology, angiography after catheterization, intraoperative monitor, and judgment of
tumor nature.
• In the purpose of treatment: Puncture pump, drain-
age, medical injection (hardeners, antibiotics, hemolytic agents, antitumor drugs and immune
preparations, etc.), and nutrients injections (amino
acids, blood, etc.)
II. Contraindications
• The images displayed by ultrasound are unclear or
unstable or cannot be dened.
• Severe bleeding tendency or impaired coagulation
mechanism.
• The approach of puncture cannot avoid essential
blood vessels or organs.
• The puncture could lead to the pelvic or abdominal
dissemination of lesion.
• The patient is combined with severe systemic dis-
eases, genital inammation, history of allergy to contrast agents, and related agents.
III. Methods of the operation
• According to the purpose of diagnosis and treatment,
choose the supine position, lateral position, prone
position, or bladder lithotomy position, and maintained stability.
• Puncture point should be determined under the guid-
ance of real-time ultrasound.
• The puncture area is routinely sterilized and draped.
• After focal anesthesia and locating the targeted
lesion, let the patient hold their breath and rapidly
© Chemical Industry Press 2022
T. Yang, H. Luo (eds.), Practical Ultrasonography in Obstetrics and Gynecology,
https://doi.org/10.1007/978-981-16-4477-1_7
293
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puncture the needle into the targeted lesion along the
guideline shown on the ultrasound monitor.
• Complete the diagnostic or therapeutic operations
such as puncture, biopsy, drainage, and drug
injection.
• After the interventional operation, the patients should
be observed for 0.5–2hours, especially paying attention to the vital signs and systemic or local abnormalities such as aggravated abdominal pain, bloody
urine, and internal bleeding.
7.3 Application ofIntervention
Ultrasound inObstetrics
H. Luo et al.
Under the guidance of real-time ultrasound, the cell, blood,
or tissue of the fetus can be obtained accurately for further
DNA detection and enzymology examination, which is utilized to diagnose fetal chromosomal abnormalities, hematologic disorders, hereditary disease, and metabolic disease.
Interventional ultrasonography is widely applied in the process of amniotic cavity aspiration, fetal blood sampling, and
villus sampling. Recently, it is also be used in fetus in utero
treatment, egg retrieval, and multifetal reduction. The application of interventional ultrasonography makes the prenatal
diagnosis step into the new era of cellular and molecular
genetics.
I. Amniotic cavity aspiration.
US-guided amniotic cavity aspiration is to obtain
amniotic uid and gather the cells from the uid under
the guidance of ultrasonography. The analyses of
enzyme, protein, metabolite, and karyotype help to
diagnose metabolic diseases, neural tube defects, and
chromosomal abnormalities. The amniotic injection
can also be conducted by interventional ultrasonography. The best time for amniotic cavity aspiration is
18–22weeks of gestation (Fig.7.1).
• Indications
– Advanced maternal age (>35years).
– In couples with a history of chromosomal disor-
ders and family history, or history of abnormal
pregnancy or childbirth.
– Carriers of X-linked genetic diseases and domi-
nant genetic diseases who require gender
identication.
– Pregnant women with a history of viral infection
or radiation exposure; high-risk pregnancy
screening or fetal abnormalities detected by routine ultrasonography.
– Induction of labor by amniocentesis, and intra-
uterine treatment by injecting drugs and nutrients
into the amniotic cavity.
Fig. 7.1 US-guided amniotic cavity aspiration
– Amniotic uid was taken for fetal maturity test or
bacteriological examination in patients with
third-trimester pregnancy or premature rupture of
membranes.
• Preoperative preparation
– Ultrasound equipment. Real-time ultrasound
machine is needed and the frequency of the probe
is 3.5MHz, preferably equipped with a puncture
guide.
– Puncture needle. The size of 20-23G is prefera-
ble, with a length of 15–18cm.
– Medicine. Get preparation for the medicine,
according to the purpose of treatment.
– Others. Tube or culture tube if needed.
• Methods of operation
– The pregnant woman is placed on the supine
position, and routine obstetric ultrasound examination is performed to choose a proper puncture
point.
– After the puncture point is sterilized and draped,
determine the insertion route and depth by the
ultrasound monitor.
– The puncture needle reaches into the amniotic
cavity, and then removes the needle core. The
syringe with the size of 2ml was used to extract
a small amount of amniotic uid. If blood contamination is excluded, a syringe with the volume
of 20 ml is replaced, and extract about 20 ml
amniotic liquid for further examination.
– Inject the medicine into the amniotic cavity if
needed.
– Insert the needle core and pull out the needle.
– After the operation, check the fetus’s heart, fetal
movement, and conditions like whether there is
active bleeding in the injection point for at least
30minutes.