View source for Pelvic ultrasound (transvaginal)

==Background==
*Also known as endovaginal ultrasound
*Used to evaluate female reproductive organs including uterus, ovaries, fallopian tubes, cervix, and vagina
 
==Indications==
===General===
*Pelvic pain
*Abnormal pelvic or abdominal exam

===Uterus===
*[[Vaginal bleeding]]
*Fibroids
*IUD placement 

===Ovaries and adnexa===
*[[Ovarian cyst]]
*[[Ovarian torsion]]
*Ovarian masses
*[[Tubo-ovarian abscess]]
*Hydrosalpinx

===Pregnancy===
*Confirm intrauterine pregnancy
*Gestational dating 
*Fetal monitoring and surveillance
*Evaluation of placenta
*[[Spontaneous abortion]]
*[[Intrauterine fetal demise]]
*[[Ectopic pregnancy]]
*Heterotopic pregnancy
*[[Molar pregnancy]]

==Technique==
===General===
*Use 5 MHz endocavitary probe (high frequency, low penetration)
*Apply surgical lubricant inside and outside probe cover
*Place patient in lithotomy position
*Gently advance probe into vaginal canal and position adjacent to cervix
**May be more comfortable for patient to insert probe into vagina herself
*Apply gentle pressure to lower abdominal wall with one hand and manipulate probe with other hand

===Longitudinal scan===
*Probe marker pointing at 12:00
*Shows anterior structures on left side of screen
*Begin midline at endometrial stripe
*Scan from right to left through uterus
*Move probe laterally to view adnexa and ovaries

===Transverse scan===
*Rotate probe 90 degrees counterclockwise so probe marker is pointing at 9:00
*Shows right-sided structures on left side of screen
*Start at endometrial stripe and scan throughout uterus
*Locate cornual flare (junction of uterus and fallopian tubes)
*Move probe laterally along fallopian tube to locate ovary
*Ovaries identified by follicular (anechoic or hypoechoic) structures

==Findings==
===Uterus===
*Anteverted: Fundus pointing to anterior abdominal wall
*Retroverted: Fundus pointing to posterior wall 
*Endometrial stripe: Measured from thickest echogenic area (from one basal endometrial interface to the other, including canal)
**Pre-menopausal:
***During menstruation: 2-4mm
***Early proliferative phase: 5-7mm
***Late proliferative phase: 11mm
***Secretory phase: 7-16mm
***After D&C or SAB: >5mm
****Consider retained POC if thicker
**Post-menopausal: 
***With vaginal bleeding: <5mm
***Without vaginal bleeding: <11mm

===Adnexa===
*Simple ovarian cyst: <2.5-3cm

<gallery mode="packed">
File:simple_cyst.jpg|Simple ovarian cyst
File:hemorrhagic_cyst.jpg|Hemorrhagic cyst with blood clot
</gallery>

===Pregnancy (1st trimester)===

*4-5 weeks
**Gestational sac
***First sign of early pregnancy, usually seen between 3-5 weeks gestation
**Double decidual sac sign
***Two concentric rings (uterine lining and gestation lining) around anechoic gestational sac
***Highly suggestive of intrauterine pregnancy (before yolk sac or embryo embryo visualized

**Intradecidual sign
***Thickened decidua on one side of uterine cavity surrounding anechoeic sac

*5-6 weeks:
**Yolk Sac
***Circular (or sometimes as two parallel lines) echogenic structure with thick walls within gestational sac
***Definitive evidence of intrauterine pregnancy 
***Multiple yolk sacs is earliest sign in multiple gestational pregnancy
**Double bleb sign
***Yolk sac and amniotic cavity that look like two bubbles within gestational sac

*6-7 weeks
**Fetal Pole
***First visual manifestation of fetus (or "embryo")
***Thickening of margin on yolk sac

**Cardiac activity present (FHR ~100-115 bpm)
***Crown rump length: ~5mm
*8-9 weeks
**Limb buds appear
**Head identifiable
*9-10 weeks
**FHR ~170-180 bpm
**Fetal movement visible
**End of embryonic period

<gallery mode="packed">
File:double_decidual_sac_sign.jpg|Double decidual sac sign
File:intradecidual sign.jpg|Intradecidual sign
File:double_bleb_sign.jpg|Double bleb sign (yolk sac and amniotic cavity
File:fetal_pole.jpg|Fetal pole (Thickening of yolk sac on one side)
</gallery>

==Images==
===Normal===
<gallery mode="packed">
File:secretory_endometrium.jpg|Normal thickened endometrial stripe during secretory phase
File:Menstrual_endometrium.JPG|Normal thin endometrial stripe during menses
</gallery>

===Abnormal===


====Abnormal Pregnancy====

*Gestational sac >10mm without visible yolk sac
*Gestational sac >18mm without fetal pole
*Collapsed gestational sac
*Pseudgestational sac
**Endometrial breakdown during ectopic pregnancy
**May be erroneously interpreted as true gestational sac in ectopic pregnancy
**Irregularly shaped
**Located in endometrial cavity, instead of eccentrically within endometrium
**No yolk sac present
**May not have double decidual sac sign
*Absence of fetal heart beat in embryo with CRL >5mm
*FHR <90 bpm
*Molar pregnancy
**Many small, irregular cystic structures in endometrium
**"Snowstorm appearance"

<gallery mode="packed">
File:large gestational sac.jpg|Gestational sac greater than 10mm without yolk sac
File:gestational sac without pole.jpg|Gestational sac greater than 18mm without fetal pole
File:collapsed gestational sac.jpg|Collapsed gestational sac
File:pseudogestational sac.jpg|Pseudogestational sac
File:molar pregnancy.jpg|Molar pregnancy with multiple cystic lesions in endometrium, "sandstorm appearance"
</gallery>

====Ectopic pregnancy====

*Implantation of blastocyst outside of endometrium
*Occur in fallopian tubes, cervix, ovaries, peritoneal cavity, or scar of prior uterine surgery
*Most definitive sonographic sign is gestational sac with yolk sac, embryo, or fetal heart beat outside of the endometrium
*Tubal ring
**Echogenic thick-walled anechoic sac visualized between uterus and ovary (separate from ovary when pressure applied to fallopian tube with probe)
*Interstitial Pregnancy
*Cervical Pregnancy
**Implantation of gestational sac below internal cervical os
**Can cause life-threatening hemorrhage
**Must distinguish between cervical ectopic and spontaneous abortion at level of cervix:

<gallery mode="packed">
File:ectopic pregnancy.jpg|Ectopic pregnancy
File:free_fluid_ectopic.png|Free fluid in cul-de-sac with no gestational sac visualized in uterus, presumed ectopic pregnancy in patient with positive pregnancy test
File:tubal ring.jpg|Ectopic pregnancy between ovary and uterus, suggestive of tubal ectopic
File:cervical ectopic.jpg|Ectopic pregnancy at the cervix
</gallery>


==Pearls and Pitfalls==


==Documentation==
===Normal Exam===

===Abnormal Exam===


==Clips==

==External Links==


==See Also==


==References==
<references/>

[[Category:Ultrasound]]
[[Category:Radiology]]