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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5786_Библиотеки_им_академика_М_И_Перельмана.pdf
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It is important to realize that there is no true gold standard for methods used
to assess tubal patency. The only thing one can do is to compare the results of
various methods, none of which can provide us with the truth, e.g. compare the
results of HyCoSy with those of hysterosalpingography or with laparoscopy
with chromopertubation. Overall, agreement between these methods has been
reported to be good.
20–23
ACKNOWLEDGEMENTS
This work was supported by the Swedish Medical Research Council (grants nos
K2001-72X-11605-06A, K2002-72X-11605-07B and K2004-73X-11605-09A),
two governmental grants (Landstingsfinansierad regional forskning, Region Skåne
and ALF-medel), and funds administered by Malmö University Hospital.
References
1. Sladkevicius P, Valentin L, Marsal K.
Ultrasound in obstetrics and gynaecology
296
Endometrial thickness and Doppler
velocimetry of the uterine arteries as
discriminators of endometrial status in
women with postmenopausal bleeding: a
comparative study. Am J Obstet Gynecol
1994;171(3):722–728
2. Forrest TS, Elyaderani MK, Muilenburg MI,
Bewtra C, Kable WT, Sullivan P. Cyclic
endometrial changes: US assessment
with histologic correlation. Radiology
1988;167(1):233–237
3. Ritchie WG. Sonographic evaluation of
normal and induced ovulation. Radiology
1986;161(1):1–10
4. Merz E, Miric-Tesanic D, Bahlmann F,
Weber G, Wellek S. Sonographic size
of uterus and ovaries in pre- and
postmenopausal women. Ultrasound Obstet
Gynecol 1996;7(1):38–42
5. Raine-Fenning NJ, Campbell BK, Clewes JS,
Kendall NR, Johnson IR. Defining
endometrial growth during the menstrual
cycle with three-dimensional ultrasound.
Br J Obstet Gynaecol 2004;111(9):944–949
6. Pache TD, Wladimiroff JW, de Jong FH,
Hop WC, Fauser BC. Growth patterns
of nondominant ovarian follicles during
the normal menstrual cycle. Fertil Steril
1990;54(4):638–642
7. Sladkevicius P, Valentin L, Marsal K. Blood
flow velocity in the uterine and ovarian
arteries during the normal menstrual cycle.
Ultrasound Obstet Gynecol 1993;3(3):
199–208
8. Jokubkiene L, Sladkevicius P, Rovas L,
Valentin L. Assessment of changes in
volume and vascularity of the ovaries during
the normal menstrual cycle using threedimensional power Doppler ultrasound.
Hum Reprod 2006;21(10):2661–2668
9. Sladkevicius P, Valentin L, Marsal K. Blood
flow velocity in the uterine and ovarian
arteries during menstruation. Ultrasound
Obstet Gynecol 1994;4(5):421–427
10. Sladkevicius P, Valentin L, Marsal K.
Transvaginal gray-scale and Doppler
ultrasound examinations of the uterus and
ovaries in healthy postmenopausal women.
Ultrasound Obstet Gynecol 1995;6(2):81–90
11. Valentin L, Akrawi D. The natural history
of adnexal cysts incidentally detected at
transvaginal ultrasound examination in
postmenopausal women. Ultrasound Obstet
Gynecol 2002;20(2):174–180
12. Landgren BM, Collins A, Csemiczky G,
Burger HG, Baksheev L, Robertson DM.
Menopause transition: annual changes
in serum hormonal patterns over the
menstrual cycle in women during a nineyear period prior to menopause. J Clin
Endocrinol Metab 2004;89(6):2763–2769
13. Jokubkiene L, Sladkevicius P, Rovas L,
Valentin L. Assessment of changes in
endometrial and subendometrial volume
and vascularity during the normal menstrual
cycle using three-dimensional power
Doppler ultrasound. Ultrasound Obstet
Gynecol 2006;27(6):672–679
14. Parsons AK, Lense JJ. Sonohysterography
for endometrial abnormalities: preliminary
results. J Clin Ultrasound 1993;21(2):87–95
15. Exalto N, Stappers C, van Raamsdonk LA,
Emanuel MH. Gel instillation sonohysterography: first experience with a new
technique. Fertil Steril 2007;87(1):152–155
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16. Campbell S, Bourne TH, Tan SL, Collins WP.
Hysterosalpingo contrast sonography
(HyCoSy) and its future role within the
investigation of infertility in Europe. Ultrasound Obstet Gynecol 1994;4(3):245–253
17. Chenia F, Hofmeyr GJ, Moolla S, Oratis P.
Sonographic hydrotubation using agitated
saline: a new technique for improving
fallopian tube visualization. Br J Radiol
1997;70(836):833–836
18. Heikkinen H, Tekay A, Volpi E,
Martikainen H, Jouppila P. Transvaginal
salpingosonography for the assessment
of tubal patency in infertile women:
methodological and clinical experiences.
Fertil Steril 1995;64(2):293–298
19. Ayida G, Harris P, Kennedy S, Seif M,
Barlow D, Chamberlain P. Hysterosalpingocontrast sonography (HyCoSy) using
Echovist-200 in the outpatient investigation
of infertility patients. Br J Radiol
1996;69(826):910–913
20. Shahid N, Ahluwalia A, Briggs S, Gupta S.
An audit of patients investigated by
hysterosalpingo-contrast-sonography
(HyCoSy) for infertility. J Obstet Gynaecol
2005;25(3):275–278
21. Cimen G, Trak B, Elpek G, Simsek T,
Erman O. The efficiency of hysterosalpingocontrast sonography (HyCoSy) in the
evaluation of tubal patency. J Obstet
Gynaecol 1999;19(5):516–518
22. Dijkman AB, Mol BW, van der Veen F,
Bossuyt PM, Hogerzeil HV. Can
hysterosalpingocontrast-sonography replace
hysterosalpingography in the assessment
of tubal subfertility? Eur J Radiol
2000;35(1):44–48
23. Holz K, Becker R, Schurmann R.
Ultrasound in the investigation of
tubal patency. A meta-analysis of three
comparative studies of Echovist-200
including 1007 women. Zentralbl Gynakol
1997;119(8):366–373
24. Sokalska A, Valentin L. Changes in
ultrasound morphology of the uterus and
ovaries during the menopausal transition
and early postmenopause: a 4-year
longitudinal ultrasound study. Ultrasound
Obstet Gynecol 2008;31:210–217
Normal gynaecological anatomy (uterus, tubes, ovaries)
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Gynaecological pathology: the uterus
Rehan Salim Davor Jurkovic
ABSTRACT
Uterine pathology includes congenital uterine anomalies, uterine fibroids,
uterine sarcoma, adenomyosis, endometrial polyps, endometrial hyperplasia and
malignancy.
The impact of two-dimensional and three-dimensional ultrasound on the clinical
management of uterine pathology is discussed.
KEYWORDS
Adenomyosis, fibroids, hyperplasia, malignancy, polyps, sarcoma, uterine anomalies.
INTRODUCTION
The use of ultrasound in the examination of the uterus has evolved over the last
few decades. Initially, ultrasound was mostly used to raise a suspicion of a possible uterine abnormality, whilst more invasive techniques, such as laparoscopy
or hysteroscopy, were used to establish the final diagnosis of uterine lesions.
Improvements in ultrasound technology, and in particular the use of high-frequency transvaginal probes, have helped to transform the role of ultrasound from
a general screening tool to a definitive diagnostic test for most pathological conditions affecting the uterus. In this chapter we will review the use of ultrasound in
the diagnosis of uterine pathology.
CONGENITAL UTERINE ANOMALIES
These morphological anomalies of the uterus, which arise during organogenesis,
have been a source of much debate regarding their significance. Traditionally,
they have been associated with poor reproductive outcomes, specifically
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recurrent early pregnancy loss and preterm labour. However, clear evidence
regarding their prevalence and benefit of treatment has always been lacking.
The major factor underlying this has been the need for invasive diagnostic
methods, such as hysterosalpingography or hysteroscopy and laparoscopy, to
make a diagnosis; these invasive tests are not applicable to all women, thus
making comprehensive screening difficult. The advent of three-dimensional
(3D) ultrasound in gynaecological practice has significantly enhanced our ability to detect uterine abnormalities. This technology collates a set of ultrasound
data, which can then be manipulated and viewed at any arbitrary angle and
plane. In the context of uterine assessment, it allows the operator to view the
coronal plane of the uterus, which is often unobtainable on the conventional
B-mode two-dimensional (2D) transvaginal ultrasound examination, as it is
lying perpendicularly to the ultrasound beam. The importance of this plane
is that it allows for the differentiation between the most common duplication
anomalies including the arcuate, subseptate and bicornuate uterus (Figs 17.1,
17.2). This is important as each of these anomalies carries different reproduc-
tive implications and they have very different management strategies, i.e. an
Ultrasound in obstetrics and gynaecology
attempt to resect a septum in a bicornuate uterus could lead to perforation of
the fundus.
Two early studies examined the diagnostic accuracy of 2D and 3D ultrasonography for the diagnosis of congenital uterine anomalies, using hysterosalpingography as the gold standard.
between 3D ultrasound and hysterosalpingography in classifying the uterus as
abnormal or normal. This result was superior to that of 2D ultrasound, which
did identify all cases of abnormal uterus but also gave a number of false-positive
findings.
The reproducibility of 3D ultrasound diagnosis of uterine anomalies has also
been tested using a modified American Fertility Society classification of congenital uterine anomalies3 (Table 17.1). A good intra- and interobserver agreement
has been reported with only occasional differences between the operators, mainly
in cases of arcuate and subseptate uteri.4 Three-dimensional ultrasound is at present the only imaging technique which has been systematically assessed for the
reproducibility of the diagnosis of congenital uterine anomalies.
Using 3D ultrasound, a large-scale screening study of women at low risk for
the presence of congenital uterine anomalies was done by Jurkovic et al.5 The
reported prevalence of major anomalies was 2.3%, which was similar to the results
of previous studies that used more invasive methods to diagnose uterine defects.6
Subsequently, the reproductive impact of anomalies in the low-risk group was
reported by Woelfer et al, who used 3D ultrasonography to screen 1089 women
who presented for pelvic imaging for indications unrelated to their past reproductive performance.7 The study showed that even in women with an incidental
finding of uterine anomaly, the risk of first-trimester miscarriage was significantly
increased in those diagnosed with a subseptate uterus compared to women with
normal uteri. There was also a slightly higher risk of second-trimester miscarriage
300
and preterm delivery in women with arcuate uteri.
1,2
They both showed a good agreement
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Gynaecological pathology: the uterus
Fig. 17.1 Three-dimensional image of an arcuate uterus in the coronal plane demonstrating
a normal outer contour and a deep fundal indentation of the uterine cavity.
Another comparative study of low-risk women and those with a history of
recurrent miscarriage showed a four times higher prevalence of anomalies in
those who suffered repeated pregnancy losses.8 In addition, the study showed
that uterine anomalies in women with recurrent pregnancy loss tend to be
more severe compared to the anomalies which were diagnosed incidentally on
screening.
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Ultrasound in obstetrics and gynaecology
302
Fig. 17.2 A coronal view of a subseptate uterus showing a deep septum extending down
two-thirds the length of the uterine cavity.
Table 17.1 Three-dimensional ultrasound classification of congenital uterine anomalies
Uterine morphology Fundal contour External contour
Normal Straight or convex Uniformly convex or with
Arcuate Concave fundal indentation with
central point of indentation at obtuse
angle (>90°)
Subseptate Presence of septum, which does not
extend to cervix, with central point
of septum at an acute angle (<90°)
Bicornuate Two well-formed uterine cornua – fundal
contour convex in each
indentation <10 mm
Uniformly convex or with
indentation <10 mm
Uniformly convex or with
indentation <10 mm
Fundal indentation
>10 mm dividing the two
cornua
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These studies provide strong objective evidence to support the widely held
view that congenital uterine anomalies have a significant detrimental effect on
women's reproductive performance. However, it is still not clear what benefits, if
any, surgical correction of uterine anomalies may have on women's future reproductive performance. The ability to perform a detailed non-invasive assessment of
uterine anomalies, including measurement of uterine cavity dimensions before and
after surgery, may help to improve selection of patients and to provide an objective
measure of the success of anatomical reconstruction of the uterine cavity.
UTERINE FIBROIDS
Uterine fibroids are the most common uterine abnormality encountered in
women of reproductive age, being present in at least 40% of women over the age
of 40. Clinically, they often present with menstrual problems, classically menorrhagia and dysmenorrhoea; however, they may also cause pressure symptoms on
the bladder, leading to urinary frequency. Uterine fibroids can also be found during investigations for infertility, where they are associated with a reduced chance
of successful assisted reproduction treatment.
The ultrasound appearance of fibroids is variable but most commonly they
appear as well-defined, echo-dense single or multiple myometrial tumours (Fig.
17.3). Histologically, fibroids are composed of densely packed whorls of smooth
muscle and connective tissue, which cause reflection of the ultrasound beam and
Gynaecological pathology: the uterus
Fig. 17.3 A transverse view of the uterus showing a large posterior intramural fibroid.
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acoustic shadowing. Occasionally, fibroids may undergo degeneration or they may
contain areas of calcification, which may alter their ultrasound appearance quite
significantly. These changes often occur in pregnancy when the trophic action
of increased circulating oestrogens stimulates fibroids to grow fast. The rapidly
enlarging fibroid may quickly outgrow its blood supply, leading to infarction and
degeneration. Clinically, degeneration of fibroids can be the cause of significant
pain in pregnancy. The degenerated fibroid is located at the site of maximal tenderness and usually has a cystic core, which may be filled with hypoechoic fluid
and septa of the remnants of the necrotic myometrium. These appearances can
be alarming and may be mistaken for more significant pathology, such as a sarcoma or an ovarian mass. The differentiation is generally easy as an ovarian mass
is separate from the uterus and sarcoma is exceedingly rare in premenopausal
women. Similar ultrasound appearances occur in uterine fibroids following embolization. This iatrogenic method of causing vascular occlusion and degeneration
usually results in cystic necrosis similar to that found in pregnancy. However, over
time fibroids that have undergone embolization may become calcified and appear
hyperechoic on ultrasound scan.
Ultrasound in obstetrics and gynaecology
Although uterine fibroids are easily diagnosed on ultrasonography, it is their
location, rather than their presence, which is often the most significant factor
in determining their clinical significance and management options. Intramural
fibroids are predominantly located within the myometrium and they rarely lead
to significant clinical problems unless they are large (i.e. >5 cm), when they may
cause pressure effects on surrounding organs, specifically the urinary bladder, leading to symptoms including urinary frequency. Subserous fibroids project from the
uterine serosa and they too are only problematic when large and indenting surrounding organs. Occasionally, subserous fibroids may be entirely extrauterine and
connected to the uterus by a small pedicle. These are classified as pedunculated
fibroids, which may sometimes undergo torsion and present with an acute abdomen. Occasionally, they may be mistaken for an ovarian tumour; however, this is
overcome by identifying an ipsilateral normal ovary and the stalk connecting the
fibroid to the uterus using Doppler.
Identifying and describing the location of all fibroids on ultrasound examination is of importance as it enables the clinician to make a more complete
assessment regarding the contribution of uterine fibroids to the clinical symptomatology. It also helps to plan further management, selection of the appropriate procedure and the chances of success of removal. Therefore, a small
intramural fibroid on the posterior wall of the uterus is unlikely to be the cause
of any significant menstrual irregularities. However, the knowledge that the uterine cavity is morphologically normal would enable the patient who is suffering
from heavy dysfunctional uterine bleeding to consider either endometrial ablation or an intrauterine progestogen-releasing device to control the symptoms.
Clinically, the most important uterine fibroids are submucous fibroids, which
account for only 5% of all uterine fibroids. These are the cause of the most classic symptoms associated with uterine fibroids – dysmenorrhoea and menorrhagia.
304
Submucous fibroids protrude into the uterine cavity to varying degrees, with
9
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Fig. 17.4 A longitudinal view of the uterus showing a submucous fibroid, which is almost
completely protruding into the uterine cavity.
Gynaecological pathology: the uterus
some causing only a minor indent whilst some are entirely within the endometrial cavity, i.e a fibroid polyp (Fig. 17.4). It is important to attempt to provide an
estimate of the degree of protrusion of a fibroid into the uterine cavity as fibroids
that are predominantly within the cavity may be amenable to hysteroscopic resection. A classification system for this is already in use by hysteroscopic surgeons
who define submucous fibroids as type 0 (polyps), which are entirely within the
cavity, type 1, which have <50% of the total fibroid within the myometrium, and
10
type 2 which have >50% of the total fibroid within the myometrium.
The type
2 fibroid may be unsuitable for hysteroscopic resection or may require a twostage procedure. In either case this classification system is aimed at improved
patient selection for hysteroscopic resection and this is conventionally done by
a diagnostic hysteroscopy. However, it is still uncertain whether hysteroscopy
should be the imaging modality to select those fibroids that are amenable to hysteroscopic resection. Vercellini et al reported that only 69% of submucous fibroids
deemed amenable to hysteroscopic resection were actually successfully removed
at operative hysteroscopy.11 This suggests that preoperative assessment by hysteroscopy may not be accurate in predicting the success of fibroid resection.
Ultrasound has the advantage of being a widely available outpatient imaging modality with the ability to measure and assess the depth of fibroid involvement into the myometrium more accurately than any other imaging technique.
However, conventional B-mode transvaginal ultrasound is not accurate enough for
the detection of intracavitary pathology or for the measurement of extension of
fibroids into the uterine cavity.11 A refinement, saline infusion sonohysterography,
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allows a clearer view of the uterine cavity by providing an acoustic contrast
within the uterine cavity. This enables more accurate detection of focal pathology in the uterine cavity, including submucous fibroids, with results comparable
to diagnostic hysteroscopy.12 Three-dimensional ultrasound may further facilitate
the assessment of the relationship of submucous fibroids and the uterine cavity.
Preliminary data indicate that 3D is a reproducible method for the assessment
of uterine fibroids, which may provide a more effective alternative to diagnostic
hysteroscopy for preoperative assessment of submucous fibroids.
13
Submucous fibroids may be a cause of infertility in some women as conception
rates are improved following fibroid removal. Eldar-Geva et al reported a 33.8% miscarriage rate in women with submucous fibroids compared to 16.8% in controls.14
Bernard et al reported that removal of even solitary submucous fibroids improves
live-birth rates.15 Although these results are encouraging, there are no prospective
randomized controlled studies to assess the true impact of these interventions.
The significance of intramural fibroids in women complaining of infertility
remains uncertain. However, a study by Hart et al investigated the impact of
small (<5 cm) intramural fibroids on conception rates in 112 women, using con-
Ultrasound in obstetrics and gynaecology
ventional B-mode ultrasound.
16
They reported that the presence of small intramural fibroids reduced the chances of conception by 50%. These findings are of
some concern and it remains to be seen whether they will be confirmed in future
studies.
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UTERINE SARCOMA
This rare tumour of the uterine myometrium is usually diagnosed after hysterectomy. The clinical presentation is usually of a rapidly enlarging uterus in a postmenopausal woman. Although pain is generally not a feature, the rapid growth
of the tumour may cause it to outgrow its blood supply, leading to necrosis and
subsequent pain. The condition is rare and thought to complicate around 0.03%
of benign fibroids, although this figure is highly speculative. The natural history
of sarcoma uteri remains unknown and there is no clear evidence to link benign
uterine fibroids with subsequent malignant transformation into sarcoma.
Preoperative detection has been problematic as the rarity of the tumour has
not enabled collation of morphological data from significant numbers of women.
The ultrasound features are non-specific and the most useful finding is the presence of wide areas of tumour necrosis. Only limited data regarding ultrasound features of sarcomata are available. On Doppler examination, sarcomas may display
increased vascularity. Hata et al compared blood flow indices between five uterine
sarcomata and 41 uterine fibroids.
for peak systolic velocity, on colour Doppler, the detection rate for sarcoma was
80% with a false-positive rate of 2.4% with no significant difference in resistance index between the two groups. Szabo et al reported on the comparison of
12 women with sarcomas and 117 women with benign fibroids.
the former study, in this group there was a reduction in the resistance index with
an increase in blood velocity within sarcomas. This study also reported that subjective assessment of vascularity demonstrated irregular blood vessel patterns within
17
They reported that using a cut-off of 41 cm/s
18
In contrast to