uterine pathology

King’s Gynaecology Ultrasound

Uterine Pathology

Rehan Salim MD MRCOG

King’s Gynaecology Ultrasound

Congenital uterine anomalies

• Associated with poor reproductive histories– Recurrent first trimester miscarriage

• Relatively rare– 3% in “normal” women– 3% infertile women– 6-24% in recurrent miscarriage

• Several types – most common “duplication anomalies”– Arcuate, subseptate, bicornuate

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Congenital uterine anomalies• Ultrasound first line screening tool• Accurate in screening for duplication anomalies

– Split in endometrial echo by “septum”– Conventional ultrasound not able to differentiate

further• Accurate in detecting more severe anomalies

– Unicornuate- single interstitial portion of Fallopian tube

– Rudimentary cornu may be present +/- functioning endometrium

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Duplication anomalies

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Duplication anomalies

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Congenital uterine anomalies

• Three-dimensional ultrasound– Non-invasive accurate method for evaluation of

uterine morphology– Examination of organ from all aspects– Measurements of organs’ volume regardless of their

shape– 3-D reconstruction of pelvic anatomy

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Three-dimensional ultrasound

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Diagnosis of uterine anomalies

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Fibroids

• Focal proliferation of uterine smooth muscle• Benign • Associated with menstrual disorders, subfertility, pain,

pressure symptoms• Common

– 40% of women aged 40 will have at least one fibroid

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Uterine fibroids

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Fibroids• Size• Number• Location

– Submucous– Intramural– Subserous– Pedunculated

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Mapping of fibroids

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Assessment of submucous fibroids

• Proportion of submucous uterine fibroid protruding into the uterine cavity is critical for successful surgical removal

• Classification of submucous fibroids prior to surgery is difficult• 3-D SIS is a novel technique for assessing the uterine cavity, which

has potential advantages over 2-D SIS and diagnostic hysteroscopy

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Classification of submucous fibroids

• Type 0 - pedunculated fibroid without intramural extension

• Type I - sessile fibroid with intramural extension <50%

• Type II - sessile with an intramural extension >50%

The European Society of Hysteroscopy, 1993

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Submucous fibroid

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Submucous fibroid

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Submucous fibroid

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Submucous fibroid

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Adenomyosis

• Endometrial glands within myometrium• Benign• Associated with pain and menorrhagia• Present in 20% of hysterectomy specimens

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Adenomyosis

• Asymmetrical thickening of myometrium• Hyperechogenic• Cystic• Acoustic shadowing• Diffuse branching vessels

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Adenomyosis

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Intrauterine adhesions

• The uterine cavity is irregular and hyperechogenic. • Calcifications are often present causing shadowing on

the scan.• Areas of normal endometrium may be preserved.• Echogenic intrauterine fluid accumulation may be

present suggestive of haematometra.

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Intrauterine adhesions

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Osseous metaplasia

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Caesarean section scars

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Ultrasound of the uterus

• Sensitive method to diagnose a variety of uterine abnormalities

• Saline infusion sonohysterography improves sensitivity and specificity of the diagnosis of intracavitary lesions

• 3-D ultrasound is the method of choice for the diagnosis of congenital uterine anomalies

• 3-D SIS has a potential to become a standard technique for pre-operative assessment of submucous fibroids