Henry Ford Hospital Medical Journal

Volume 25 | Number 2 Article 4

6-1977

Diagnostic ultrasound in gynecologyManojkumar H. Shah

Chang Y. Lee

James J. Karo

Bruce H. Drukker

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Recommended CitationShah, Manojkumar H.; Lee, Chang Y.; Karo, James J.; and Drukker, Bruce H. (1977) "Diagnostic ultrasound in gynecology," HenryFord Hospital Medical Journal : Vol. 25 : No. 2 , 75-84.Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol25/iss2/4

Henry Ford hlosp Med Journal

Vol 25, No 2, 1977

Diagnostic ultrasound in gynecology

Manojkumar H. Shah, M D ; * Chang Y. Lee, M D ; * * James J. Karo, M D , * * * and Bruce H. Drukker, M D * *

The accuracy of diagnostic ultrasound in 484 gynecologic patients was evaluated. In 97% of them, the ultrasonic findings were either diagnostic or confirmatory of the final clinical condition. The ultrasonic procedure was useful in the evaluation of pelvic or adnexal masses, confirmation and assess­ment of early pregnancy, location of lost Intrauterine contraceptive devices, diag­nosis of tubo-ovarian abscess and hydati-diform mole. The ultrasonic study aided in developing a precise surgical approach as well as reducing the number of operative procedures performed only for diagnosis. In 3%, the ultrasonic studies were misleading, indicating the limitations of the procedure and reinforcing the need to use this pro­cedure in conjunction with other accepted modalities of examination.

U LTRASONIC diagnostic techniques have been a major contribution to the practice of clinical obstetrics since Donald and his co­workers in 1958 reported their application in normal pregnancies.'' In 1961, Donald and Brown successfully measured the biparietal diameter of the fetal head for the evaluation of fetal maturity.^ The characteristic ultra­sonic pattern of hydatidiform mole was de­scribed by Willocks et al in 1964.^ Ultra­sound has also been used forthe recordingof fetal heart rate, fetal breathing movements, observation of fetal activity, and detection of congenital fetal anomalies.

Ultrasound is also suited for gynecologic evaluation since this noninvasive diagnostic modality produces images of the soft tissues in the abdomen and pelvis ithout radiation exposure. Employment of ultrasound as a diagnostic aid in gynecology has been in­creasing steadily in the United States." This study was undertaken to assess the clinical value of ultrasound as a diagnostic and management aid in gynecologic problems.

*Now at Trover Clinic, Madisonville, KY

** Department of Gynecology — Obstetrics

***Formerly, Department of Radiology

Address reprint requests to Dr. Chang Y. Lee at Henry Ford Hospital, 2799 W. Grand Boulevard, Detroit Ml 48202

Materials and methods

During a five-year period, from January 1, 1971, through December 31, 1976, ultra­sonograms were performed on 1,369 pa­tients for the evaluat ion of gynecologic problems. All studies were completed in the Diagnostic Ultrasound Laboratory of Henry Ford Hospital. We have excluded 860 pa­tients referred by private physicians in the present study because of difficulties in fol-

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low-up. A total of 509 patients was referred bythe medical staff of Henry Ford Hospital and ultrasonograms of 484 patients were evaluated. The other 25 patients were ex­cluded becauseof insufficient medical infor­mation or unavailability of medical records.

In the early part of this study, ultrasound procedures were performed with a Picker bistable B-Scanner. However, inthe last one and a half years of study, Cray Scale Scan­ning was employed using a Picker EDC Gray Scale B with a 2.25 MHZ 19 mm diameter long Internal Focus Transducer. The abdo­men and pelvis were systemically scanned at 1 to 2 cm intervals in longitudinal and transverse planes. Ten to 12 Polaroid photos were made at each examination as a perma­nent record. All patients were scanned using the full bladder technique.

The clinical course of each patient, in­cluding operative findings and pathology reports, was obtained from hospital records. In each case the reason for the ultrasound study was analyzed. The ultrasonic finding was classified as diagnostic if the scan dem­onstrated characteristics of a lesion which led to a specific diagnosis. When the scans confirmed the clinical diagnosis and gave additional information concerning size, shape, and location, the scan was consid­ered conf i rmatory. When there was dis­crepancy between ultrasonic findings and clinical and/or operative findings, the scans were classified as misleading. Inthe present study, we did not choose to separate diag­nostic and confirmatory findings. In our opinion, there is no clear-cut difference between these two groups as far as gynecologic ultrasound evaluation is con­cerned. The influence of ultrasonic findings on the clinical management of gynecologic problems was also assessed to determine the clinical value of ultrasound as a diagnostic aid in gynecologic practice.

Results

The most common reason for referral of the 484 gynecologic patients for the ultra­

sonic scan was evaluation of early preg­nancy (200 patients). Ofthese, 107 patients were referred for evaluation of gestational age and placental location pr iorto amnio­centesis to obtain fluid and cells to be used for genetic counseling.

In 185 patients, ultrasonic scans were performed for the evaluation of pelvic and adnexal masses. In 180 cases, the ultrasonic studies were either diagnostic or confirma­tory In this group the ultrasonic diagnosis or impressions were confirmed by the opera­tive findings and subsequentclinical evalua­tion. In five cases (2.7%), ultrasonic findings were different from the findings at operation and/or clinical follow-up (Table I).

In the evaluation of early pregnancy, the ultrasonic scan was either diagnostic or con­firmatory in 170 and misleading in five cases. In one case, the patient was referred for ultrasonic scan with the clinical impression of intrauterine pregnancy with leiomyoma. Surprisingly, intra-abdominal pregnancy of 16 weeks' gestation was detected by ultra­sound and later confirmed by surgery (Figure 1) (Table II).

Location of intrauterine contraceptive de­vice (lUCD) was attempted in 50 patients (Table 111). In 40 nonpregnant patients lUCD was located in uterine cavity by ultrasound which was confirmed later by dilatation and curettage or clinical follow-up. In one pa­tient intraperitoneal location of lUCD was diagnosed with the aid of pelvic x-ray. In seven pregnant patients, ultrasound re­vealed lUCD in four patients which was conf i rmed on d i la ta t ion and curettage. However, in one of the patients, an extra­uterine pregnancy was misdiagnosed as in­trauterine on ultrasound. In two pregnant patients with lUCD in situ, lUCD was not detected by ultrasound (Table 111).

Six patients were referred for ultrasonic study w i th the c l in ica l impression of hydatidiform mole. Hydatidiform mole was diagnosed in two patients (Figure 2). In one patient, hydatidiform mole was evacuated

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by suction curettage. The other patient had large uterine leiomyoma which had an ultra­sound appearance (diffuseechoes) similar to thatof amole (Figure 3). Three patients were found to have normal intrauterine pregnan­cies and one patient had a missed abortion.

Ultrasound was accurate in 19 patients who were referred to rule out ectopic gesta­tion (Table IV). Only one patient demon­strated ectopic pregnancy by ultrasound. This was confirmed later at the time of operation. In the 15 patients, intrauterine pregnancies were demonstrated by ultra­sound (Table VI).

Discussion

In 1967, Thompson and his associates^ reported their assessment of the diagnostic accuracy of diagnostic ultrasound in 100 patients w i t h gynecologic problems. In 1974, Cochrane and Thomas^ reported the results of diagnostic ultrasound in the eval­uation of gynecologic problems in 201 pa­tients. The ultrasound f indings were diagnostic and confirmatory in 82% ofthese patients. In 1975, Queenan and co-workers" evaluated ultrasound as a diagnostic aid in gynecologic problems in 300 patients. In 21%, the ultrasound was diagnostic and in 74% it was confirmatory. The ultrasonic studies were misleading in 5% of their cases.

In our study, ultrasonic findings were ei-therdiagnostic or confirmatory in 97% of the cases. In 3% of patients, the ultrasonic stud­ies were misleading, indicating the limita­tions of the procedure, and reinforcing the need to use this procedure in conjunction w i t h o t h e r a c c e p t e d m o d a l i t i e s of examination.

avoiding unnecessary surgery as well as in deciding when surgery was appropriate. Ul­trasonograms were also helpful in convinc­ing the patient that a tumor or cyst was present and required appropriate surgical in tervent ion. In nine instances, cystic teratoma was diagnosed by ultrasonic scan (Figure 4), and confirmed during laparotomy in eight patients. In the other patient, pedun­culated leiomyoma was found at explora­t ion . Ul t rasound was also useful in the differential diagnosis of adnexal mass and cornual, intraligamentary or pedunculated leiomyoma. In two patients, however, possi­ble solid ovarian tumors on ultrasonic scan proved to be intraligamentary leiomyomas. The ultrasound scan was most informative in pelvic examination which were difficult due to obesity, poor patient cooperation, tender­ness or intact hymen. It e l iminated un­necessary invasive diagnostic modalities.

For genetic amniocentesis, ultrasonic scan was essential forthe location of the placenta and estimation of gestational age. In two cases, twin gestation was identified by ultra­sound in early pregnancy.

The usefulness of ultrasound for locating the lUCD when the string has disappeared was demonstrated in 47 patients. The pres­ence or absence of lUCD in the uterine cavity was accurately demonstrated with ultrasound in the nongravid uterus (Figure 5). Where no lUCD is revealed in the uterine cavity, pelvic x-rays are indicated to exclude intraperitoneal location of lUCD. For preg­nancy with lUCD, the diagnostic ability of ultrasound in locating lUCD drops to ap­proximately 70%.

In the evaluation of pelvic and adnexal masses, the lesions were palpated by the physician in the majority of the cases. The ultrasound study offered additional valuable information regarding size, consistency, and whether cystic masses were unilocular or multilocular. Ultrasonic scan was helpful in

In the case of pelvic inflammatory disease, pelvic ultrasound is useful forthe determina­tion of the presence and size of tubo-ovarian abscesses. It is also useful forthe follow-up of patients with extensive gynecologic neo­plasms and evaluation of pelvic, retropubic, and retroperitoneal hematoma formation.

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Shah, Lee, Karo and Drukker

TABLE I EVALUATION OF PELVIC AND ADNEXAL MASSES

WITH ULTRASOUND

A. Diagnostic and Confirmative Findings

Ultrasound Findings Cases Clinical Course and lor Operative Findings

No pelvic mass 50 No pelvic mass Ovarian cyst <5 cm 32 Operation performed (5)

Cystic teratoma (3) Endometrioma (2)

Ovarian cyst >5 cm 63 Operations performed (63) Tubo-ovarian abscess 20 Operations performed (19)

Appendical abscess (1) Leiomyoma 15 Clinically followed (13)

Operations performed (2) Pedunculated (1) Intraligamentory (1)

Total 180

B. Misleading Findings in Ultrasound Study

Ultrasound Findings Cases Clinical Course and Operative Findings

Cystic mass >5 cm 2 No pelvic mass (1) Pelvic adhesions (1)

Adnexal mass possible Solid ovarian tumor 2 Intraligamentory leiomyoma (2)

Dermoid cyst 1 Pedunculated leiomyoma (1) Total 5

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Diagnostic ultrasound in gynecology

TABLE II

EVALUATION OF EARLY PREGNANCY WITH ULTRASOUND

A. Diagnostic and Confirmative Findings Ultrasound Findings Cases Clinical Course or Operative Findings

Intrauterine Pregnancy 13-18 weeks 107 Amniocentesis per formed (103)

Intrauterine pregnancy < 1 2 weeks 25

Non-pregnant 17

Missed abort ion 8 Dilatat ion and curettage per formed (8)

Incomplete abor t ion 4 Di latat ion and curet tage performed (4)

Le iomyoma wi th intrauter ine pregnancy 6

Hydat id i form mole 1 Suct ion curet tage performed (1)

Le iomyoma and int ra-abdominal pregnancy 16 weeks 1 Operat ion per formed (1)

Ectopic pregnancy 1 Tubal ectopic pregnancy (1)

Total 170

B. M i s l e a d i n g F i n d i n g s

Ultrasound Findings Cases Clinical Course or Operative Findings

Missed abor t ion 3 Endometr ia l hyperplasia (1)

Endometr ia l polyp (1) Prol i ferative endomet r ium (1)

Incomplete abor t ion 1 Hydat id i form mole (1)

Early pregnancy 1 Loop of bowel in repeated scan (1)

Total 5

T A B L E III

E V A L U A T I O N O F L O S T l U C D *

Ultrasonic Findings Cases Clinical Course and Operative Findings

Nongravida uterus

lUCD in uterus 40 Conf i rmed

lUCD not in uterus 3 Intraperi toneal lUCD, d iagnosed wi th x-ray f ind ing (1)

Gravid uterus

Intrauterine pregnancy -->. Dilatat ion and curet tage per formed (3)

wi th lUCD lUCD in uterus wi th ectopic (1)

Intrauterine pregnancy 3 No lUCD, term delivery (1)

no lUCD in uterus lUCD in uterus (2)

Total 50

lUCD: Intrauterine contraceptive device

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i Shah, Lee, Karo and Drukker

TABLE IV

ULTRASONIC SCAN FOR THE DIAGNOSIS OF ECTOPIC PREGNANCY

Clinical Impression Cases Ultrasonic Findings Cases

R/0 Ectopic Pregnancy 19 Intrauterine pregnancy 12 Intrauterine pregnancy 3

with ovarian cyst Ovarian cyst 1 Ectopic tubal pregnancy 1 • Cul-de-sac mass or hematoma Nongravida uterus with intrauterine contraceptive device in situ 1

' Operat ion per formed No cul-de-sac mass

Figure 1 Intra-abdominal location of fetus (approximately 16 weeks of gestation) was clearly apparent on the

ultrasonic scan. The uterus was enlarged wi th leiomyoma. F: Fetus, U: Uterus, B: Bladder.

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Diagnostic ultrasound in gynecology

Figure 2 Typical snow flake echoes of hydatidiform mole were demonstrated. H: Hydatidiform mole

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shah, Lee, Karo and Drukker

Figure 3 Numerous snowflake-like echoes were apparent in the large uterine leiomyoma. Misleading ultrasonic diagnosis of hydatidiform mole was made because of these confusing echoes. M: Leiomyoma, B: Bladder

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Figure 4 Ultrasonic scan of a large benign cystic teratoma. R: Rokitansky's protuberance, F: Level of two different

fluids, D: Benign cystic teratoma.

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shah, Lee, Karo and Drukker

Figure 5 Intrauterine location of intrauterine contraceptive device (lUCD) was demonstrated on the scan.

Ultrasonic scan was taken for lost lUCD string. U: Uterus, I: lUCD, B: Bladder.

References 1. Donald I, MacVicarJ, Brown TC: Investigation

of abdominal masses by pulsed ultrasound. Lancet 1:1188, 1958

2. Donald I, and BrownTG: Ultrasound measure­ment of fetal BPD. Brit / Radiology 34:539, 1961

3. WillocksJ, Duggan, TC, Donald I, D a y N : Fetal cephalometry by ultrasound, j Obst & Cynec 6r ; tComm 71:11-20, 1964

4. Queenan JT, Kubarych SF, Douglas DC: Eval­uation of diagnostic ultrasound in gynecology. Am / Ofastet Gynecol 123:453-464, 1975

5. Thompson HE, HolmesJH, Gottesfeld KR et al: Ultrasound as a diagnostic aid in diseases of the pelvis. Am I Obstet & Cynec 98:472, 1967

6. Cochrane WJ, Thomas MA: Ultrasound diag­nosis of gynecology pelvic masses. Radiology 110:649-654, 1974

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