3D-4D ULTRASOUND IN UTERINE SEPTUM EVALUATION

3D-4D ULTRASOUND IN UTERINE SEPTUM EVALUATION

1. PROF.NARENDRA MALHOTRA M.D., F.I.C.O.G., F.I.C.M.C.H, F.R.C.O.G.,F.I.C.S.,F.M.A.S.,F.I.A.P. Prof. Dubrovnick International University V.P. WAPM(world association of prenatal medicinne ) Imm Past President ISAR Presiddent ISPAT Sec Gen SAFOG Member FIGO guidelines committee President FOGSI (2008-2009) Dean I.C.M.U. (2008) Director Ian Donald School of Ultrasound National Tech. Advisor for FOGSI-G.O.I.—Mc Arthur Foundation EOC Course Managing Director GLOBAL RAINBOW HEALTH CARE Director ART-RAINBOW –IVF Practicing Obstetrician Gynecologist at Agra. Special Interest in High Risk Obs., Ultrasound, Laparoscopy and Infertility, ART & Genetics Member and Fellow of many Indian and international organisations Awarded best paper and best poster at FOGSI : 5 times, Ethicon fellowship, AOFOG young gyn. award, Corion award, Man of the year award, Best Citizens of India award Over 50 published and 200 presented papers Over 100 guest lectures given in India & Abroad and 24 ORATIONS Organised many workshops, training programmes , travel seminars and conferences Editor 18 books, many chapters, on editorial board of many journals Editor of series of STEP by STEP books Revising editor for Jeatcoate’s Textbook of Gynaecology 7 th and 8 th edition (2015) Very active Sports man, Rotarian and Social worker MALHOTRA NURSING & MATERNITY HOME PVT. LTD. GLOBAL RAINBOW HEALTH CARE,AGRA 84, M.G. Road, Agra-282 010 Phone : (O) 0562-2260275/2260276/2260277, (R) 0562-2260279, (M) 98370-33335; Fax : [phone] www.malhotrahospitals.com,www.rainbow hospitals.org

2. OBSTETRICS GYNECOLOGY 3D-4D ULTRASOUND IN UTERINE SEPTUM EVALUATION

3. 3 D ULTRASOUND Role in uterine cavity evaluation narendra malhotra www.rainbowhospitals.org [email protected] thnx to sonal panchal , ashok khurana,asim kurjack , jaideep malhotra for their inputs on 3d and 4 d

4. This is because.. Introduction of volume ultrasound has significantly increased the information available through imaging, especially in reproductive medicine. 3D gives idea about the global structure and morphology. 3D power doppler assesses global vascularity Thus both are believed to be more accurate in assessment of ovary-follicle, uterus- endometrium .

5. OBSTETRICS GYNECOLOGY

6. OBSTETRICS GYNECOLOGY The image in 2D is the bisectrix of the sweep angle Combination of transvaginal scanning and volume ultrasound has significantly increased the information available through imaging, especially for uterus, ovaries and fallopian tubes .

7. OBSTETRICS GYNECOLOGY RIC5-9-D Volume Endocavity Probe Helping you see more anatomical information displayed in a single image

8. OBSTETRICS GYNECOLOGY Advantages of 3D ultrasound 1. Surface rendering 2. Multi-planar imaging 3. Exact volume measurement 4. Power Doppler quantification 5. Inversion mode 6. Automation 7. Virtual scan

9. OBSTETRICS GYNECOLOGY This is because.. 3D gives idea about the structure and morphology of the whole volume, instead of a plane. It explains the anatomy better. 3D power Doppler assesses global vascularity . Can calculate volumes more accurately.

10. OBSTETRICS GYNECOLOGY 3D 4 D Approach cervix Uterus Ovary Fallopian tubes Others

11. OBSTETRICS GYNECOLOGY Uterus… Shape of uterine (endometrial) cavity Mullerian Anomalies Health of the uterus Endometrial lesions Myometrial lesions Receptivity of endometrium

12. OBSTETRICS GYNECOLOGY Shape of the endometrial cavity Normal shape of the endometrial cavity is triangular anteroposteriorly and pear shaped in sagittal section and it is a potential cavity.

13. OBSTETRICS GYNECOLOGY Shape of the endometrial cavity is distorted by... Congenital uterine abnormalities: These can diagnosed based on external fundal contour and endometrial contour . Acquired lesions distorting or invading endometrium.

14. OBSTETRICS GYNECOLOGY Greatest advantage of 3D is the coronal plane.

15. OBSTETRICS GYNECOLOGY Unicornuate uterus: 3D is the modality for diagnosis

16. OBSTETRICS GYNECOLOGY And 3D US has an advantage of assessing both these contours at a time. Differential diagnosis of congenital duplication abnormalities of uterus like bicornuate, septate and arcuate is based on external fundal contour and contour of the endometrial cavity.

17. OBSTETRICS GYNECOLOGY Duplication abnormalities … Ultrasound sensitivity specificity TVS 95.21 % 92.21% TVCD PD 99.29% 97. 23% Volume USG 98.38% 100% Sonohysterography 98.18% 100% (Richman TS et al. 1984) Sonohysterography is therefore not an investigation required for congenital uterine abnormalities,if u have 3D

18. OBSTETRICS GYNECOLOGY Two cervical canals Uterus didelphys : two uterine horns

19. OBSTETRICS GYNECOLOGY Differential diagnosis between septate and bicornuate uterus is the most important as it is the septate uterus that has highest negative impact on fertility outcome.

20. OBSTETRICS GYNECOLOGY

21. OBSTETRICS GYNECOLOGY D/D of bicornuate from septate uterus… Bicornuate uterus Septate uterus

22. OBSTETRICS GYNECOLOGY Bicornuate Septate Dimple on the fundus in bicornuate uterus(red line), Convex or flat fundus in septate uterus ( white line).

23. OBSTETRICS GYNECOLOGY < 5mm > 5mm If a line is drawn touching the tips of both endometrial leaves, the distance between this line and the deepest point in the fundus in the centre is < 5mm in bicornuate uterus and is > 5mm in Septate uterus. Bicornuate Septate

24. OBSTETRICS GYNECOLOGY Medial margins of endometrial leaves is usually convex medially in bicornuate uterus, where as these are straight medially in septate uterus. Barbot J et al. 1995. Bicornuate Septate

25. OBSTETRICS GYNECOLOGY Angle between two leaves of endometrial cavity is obtuse in bicornuate uterus and is acute in septate uterus. Bicornuate Septate

26. OBSTETRICS GYNECOLOGY Bicornuate uterus shows infolding of the endometrium as sublte hypoechoic curved lined parallel to the medial endometrial margin (dotted black line). Bicornuate Septate

27. OBSTETRICS GYNECOLOGY 3D US can show the length, thickness and depth of the septum and can guide the surgical plan.

28. OBSTETRICS GYNECOLOGY It is a complete septum if it extends upto the internal os

29. OBSTETRICS GYNECOLOGY Differentiating Subseptate from arcuate uterus Subseptate uterus Arcuate uterus

30. OBSTETRICS GYNECOLOGY Subseptate Arcuate Acute Obtuse Angle between two endometrial leaves is acute in subseptate uterus but is obtuse in arcuate uterus, though in both the fundal contour is convex or flat.

31. OBSTETRICS GYNECOLOGY > 10 mm < 10 mm A line is drawn touching the tips of both endometrial leaves and distance of this line to the deepest point between the endometrial leaves is > 10mm in subseptate uterus and is > 10mm in arcuate uterus. Subseptate Arcuate

32. OBSTETRICS GYNECOLOGY T shaped uterus It is when the angle between the horizontal part and vertical part of the uterus is almost 90°. The two commonest etiologies for this is DES exposure and tuberculosis. .

33. OBSTETRICS GYNECOLOGY But even on 3D US there is a possibility of misinterpreting an arcuate uterus for normal, or a bicornuate for a septate.. This is because of erroneous rendering .

34. OBSTETRICS GYNECOLOGY To prevent this and to standardize the results, guidelines are developed for rendering the uterus By aligning the sectional planes in true orthogonal planes

35. OBSTETRICS GYNECOLOGY Rendering is difficult when the uterus is curved.. Curved rendering line may help, but when the curve is acute

36. OBSTETRICS GYNECOLOGY Omniview is the answer…

37. OBSTETRICS GYNECOLOGY This case of an arcuate uterus is the best demonstration that a straight section may not be the best way to analyze a curvilinear organ like the uterus. The straight coronal section demonstrated in is clearly inadequate to describe the shape fo the uterine cavity. When a curvilinear section is employed the entire cavity is displayed demonstrating that the dome of the cavity is bending low suggesting an uterine malformation that has clinical implication. This is confirmed by the axial section Advanced VCI in arcuate uterus Straight section Curvilinear section

38. OBSTETRICS GYNECOLOGY 3D US is an excellent tool for differential diagnosis of endometrial lesions and lesions invading/distorting the endometrium ……

39. OBSTETRICS GYNECOLOGY Health of the uterine cavity … Evaluation of junctional zone is much more accurate on 3D US than on 2D US and hysteroscopy

40. OBSTETRICS GYNECOLOGY Junctional zone is damaged in Endometritis : acute or chronic Adenomyosis Malignancy

41. OBSTETRICS GYNECOLOGY Endometritis Acute endometritis shows obliteration of endometrio-myometrial junction and increased vascularity of the endometrium in early proliferative phase. Chronic endometritis shows obliterated junctional zone and absent vascularity in proliferative and secretory phase .

42. OBSTETRICS GYNECOLOGY Another lesion that would lead alteration in junctional zone is adenomyosis …

43. Septal resorption Septal resorption involves subsequent resorption of the central septum once the ducts have fused. Defects in this stage result in a septate or arcuate uterus.

44. Imaging modalities for diagnosis Hysterosalpingography Ultrasonography Magnetic resonance imaging

45. Hysterosalpingography Hysterosalpingography (HSG) allows for assessment of the uterine cavity and tubal patency but is limited at visualising the external uterine contour.

46. Ultrasound Quick, readily available, economical and lacks radiation. Modality of choice for study of uterine abnormalities. Transvaginal route is the preferred route. During secretory phase the endometrium is echogenic and this is the best time to do the scan to exclude MDAs.

47. Ultrasound - limitation But ultrasound leads to poor quality image with large patients, overlying bowel gas, and the external contour may be difficult to visualise. It is in these cases that MRI is more informative.

48. MRI MRI is radiation free and provides clear delineation of both the internal and the external uterine anatomy. –major advantage over B mode US. MRI has been shown to have excellent agreement with the clinical diagnosis of the subtypes of MDA. Mueller GC, Hussain HK, Smith YR, Quint EH, Carlos RC, Johnson TD, et al. Müllerian duct anomalies: comparison of MRI diagnosis and clinical diagnosis. AJR Am J Roentgenol. 2007;189:1294–302 .

49. MRI Standard pelvic MR imaging protocols include axial T1-weighted and T2-weighted images T2-weighted imaging is essential for evaluation of uterine anatomy.

50. Volume USG, 3D and 4D USG has a major role to play in the diagnosis of uterine anomalies : Virtual hysteroscopy Sensitivity of the Volume USG for the detection of congenital uterine abnormalites is > 98%.

51. MAGIC STICKS FOR UTERINE EVALUATION &TREATMENT

52. HSG advantages/disadvantages outpatient procedure is relatively inexpensive, does not require general anesthesia, and is associated with a therapeutic effect . Speroff L. Clinical Gynecology and Infertility. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005. Using iodinated contrast Exposure to radiation Is extremely painful Needs sedation and sometimes even anesthesia Needs to be done in a radiology set up a dvantages disadvantages

53. Volume USG, 3D and 4D USG has a major role to play in the diagnosis of uterine anomalies : Virtual hysteroscopy Sensitivity of the Volume USG for the detection of congenital uterine abnormalites is > 98%.

54. defects max asso. with RSA Best diagnostic tool :USG-TVS/3 D Best treatment tool endoscopy ANATOMIC FACTOR

55. Abnormal uterine shape is due to congenitaluterine abnormalities

56. Coronal views of uterus Normal uterus Arcuate uterus Septate uterus Bicornis uterus

57. Septate uterus 50 % SYMPTOMATIC SPONTANEOUS ABORTION : 20 - 45 % IN THE 1ST TRIMESTER 5 % IN THE 2ND TRIMESTER Gaucherand et al., Eur J Obstet Gynecol Reprod Biol 1994

58. Septae may be of variable length and thickness .

59. PRIMARY INFERTILITY IN SEPTATE UTERUS SCANTY VASC. ESTROGENS POOR ESTROGENIC MATURATION POOR DECIDUALIZATION & PLACENTATION 1)

60. 2) INFERTILITY IN SEPTATE UTERUS  AMOUNTS OF MUSCLE TISSUE INCOORDINATE CONTRACTILITY SPONTANEOUS ABORTION

61. OUTLINES CONTOUR OF THE UTERUS FRONTAL VIEW ALLOWS DETECTION OF UTERINE ANOMALIES 3-D ULTRASOUND

62. 3-D SEPTATE UTERUS

63. Septate uterus OPERATIVE HYSTEROSCOPY PREGNANCY RATES 75 % TO 88.7 % Cararach et al., Hum Reprod 1994 Goldenberg et al., Hum Reprod 1995 Shawki et al 2006

64. Author N. cases Conclusions Heinonen et al 2000 17 Women with uterine anomalies who underwent ART had low implantation rates Pabuccu et al 2004 61 11% spontaneous misc. after metroplasty (9 cerclage Dendrinos et al. 2005 411 Treatment significantly reduced the miscarrage rate Pace et al.2006 40 75 % spontaneous pregnancy aceived Kormanyos et al. 2006 94 Removal even of small residual septa > 1 cm after metroplasty Ban & Tomaževič et al 2007 31 Resection of small uterine septa, improves implantation rate in IVF cycles.

65. Conclusion Volume ultrasound is the modality of choice for uterincavity assessment & endometrial pathology With 3D contrast even the fallopian tubes can mow we visualised nicely Volume USG – VOCAL and colour histogram –in our experience have proved to be of added value in evaluation of ovarian response, endometrial receptivity and Pre HCG follicular and endometrial evaluation.

66. 4 of our latest books released

67. THANK YOU CONGRATULATIONS TO ALL ON 35YRS OF ART

68. THANKYOU