Ultrasound in Gynecology and Obstetrics

ultrasound in
gynecology
ord obstetrics
Sam N. Hassani
ultrasound in
gyrecology
and obstetrics
(in collaboration with R. L. Bard)
includes 337 illustrations
I Springer-Verlag
New York Heidelberg Berlin
S. N. Hassani, M.D.
Assistant Professor of Radiology
State University of New York at Stony Brook and
Physician in Charge, Ultrasound Division, Department of Radiology
Queens Hospital Center
Jamaica, New York 11432
R. L. Bard, M.D.
New York City
Library of Congress Cataloging in Publication Data
Hassani, N., 1938-

Ultrasound in gynecology and obstetrics.
Includes bibliographies and index.
1. Diagnosis, Ultrasonic. 2. Generative organs, Female-Diseases---
Diagnosis. 3. Ultrasonics in obstetrics. 1. Bard, Robert Laurence. II. Title.
RG1075.U4H37 618.2'07'54 77-28316
All rights reserved.

No part ofthis book may be translated or reproduced in any form without written
permission from Springer-Verlag.
© 1978 by Springer-Verlag New York Inc.
Softcover reprint of the hardcover 1st edition 1978
987654321
ISBN-13: 978-1-4612-6256-5 e-ISBN-13: 978-1-4612-6254-1

DOl: 10.1007/978-1-4612-6254-1
To Our Families
foreword
by Dr. Donald L. King
The past decade has seen the ascent of ultrasonography to a

preeminent position as a diagnostic imaging modality for obstetrics
and gynecology. It can be stated without qualification that modern
obstetrics and gynecology cannot be practiced without the use of
diagnostic ultrasound, and in particular, the use of ultrasonogra-
phy. Ultrasonography quickly and safely provides detailed, high-
resolution images of the pelvic organs and gravid uterus. The
quality and quantity of diagnostic information obtained by ultra-
sonography far exceeds anything previously available and has had
a revolutionary impact on the management of patients. High-
resolution static images permit the intrauterine diagnosis of fetal
growth retardation and fetal abnormalities. In addition to tradi-
tional images, newer dynamic imaging techniques allow observa-
tion of fetal motion, cardiac pulsation, and respiratory efforts. The
use of ultrasonography for guidance has greatly augmented the
safety and utility of amniocentesis.
One of the great virtues of diagnostic ultrasound has been its

apparent safety. At present energy levels, diagnostic ultrasound
appears to be without any injurious effect. Although all the availa-
ble evidence suggests that it is a very safe modality and that the
benefit to risk ratio is very high, the actual safety margin for its use
Vll
as yet remains unknown. As a consequence,
practitioners are urged to limit its use only to
those situations in which genuine clinical indica-
tions exist and real benefit to the patient is likely
to result.
The future will bring with it greater understand-

ing not only of the biologic effects of ultrasound
but many new techniques for its application in
diagnosis and therapy. One of these, the use of
pulse-Doppler ultrasound, will almost certainly
be valuable to assess and eventually measure
blood flow in the uterine arteries, placenta, and
within the fetus itself. The vast potential of diag-
nostic ultrasound as yet has hardly been ex-
ploited. The great growth of the past decade will
eventually be overshadowed by even greater
progress in the future.
Donald L. King, M.D.

Associate Professor of Radiology
Columbia University
New York, New York
FOREWORD
Vlll
foreword
by Dr. Jan J. Smulewicz
In his recent book, Dr. Hassani did a very thorough exploration

and an excellent explanation of the wide variety of examinations in
the field of obstetrics and gynecology with the ultrasonography
method. I found the book very easy to read, the interpretation very
clear, and the large volume of material excellently chosen. I am
sure that the book will be of great interest to practitioners, espe-
cially obstetricians and gynecologists. This method being noninva-
sive and eliminating the danger of ionizing radiation, should find its
way into every hospital or center where good medical care is
provided.
Jan J. Smulewicz, M.D.

Professor of Radiology
Mount Sinai School of Medicine
Director of Radiology
Beth Israel Medical Center
New York, New York
ix
preface
Ultrasound imaging has reached a stage of sophistication whereby

diagnostic information can be gained without discomfort to the
patient and with complete absence of morbidity and mortality. The
procedure is quick, safe, noninvasive, and, in many instances,
supercedes and obviates more time-consuming procedures requir-
ing catheterization, injection of a contrast material, and radio-
graphic imaging. In obstetric problems, the danger of ionizing
radiation to the fetus is eliminated. In debilitated and very ill
patients this simple and painless method becomes the procedure of
choice.
Unique features of ultrasound equipment allow for pinpoint locali-

zation of lesions and direct visual guidance of percutaneous punc-
ture techniques for aspiration and biopsy. The accuracy of ultra-
sound-guided cystic punctures and the absence of side effects
make this modality far superior to percutaneous invasive tech-
niques performed with other imaging systems. Renal cyst puncture
and amniocentesis are but two of the procedures in which ultra-
sonic guidance is the method of choice. Since this modality is
noninvasive, it may be performed serially and at any given time.
xi
This sequential observation of pathophysiology The comprehensive scope serves as a general
in the fetus and the mother provides important reference for both the family practitioner and the
data on the progression of acute and chronic student in training.
diseases and their response to treatment. The
In the sections on physical and practical applica-
unusual accuracy of ultrasound in differentiating
tions, precise directions for examination are
cystic from solid masses and its ability to local-
given and scanning pitfalls with the production
ize the lesion in a three-dimensional representa-
of artifacts have been underscored. The evolu-
tion have rendered other diagnostic procedures
tion of scanning systems has been traced so that
unnecessary for the practicing obstetrician and
the potential features and limitations of each
gynecologist. The standard radiologic evaluation
imaging unit are recognized. Representations of
for abdominal masses has generally included the
each type of scanning device are illustrated and
plain x-ray film of the abdomen, intravenous
their inherent advantages discussed.
urography, barium enema, gastrointestinal se-
ries, cholecystography, and radioisotopic proce- Examination of each area has been arranged so
dures. Invasive and time-consuming studies that the reader may review the pertinent regional
such as lymphangiography and arteriography anatomy before studying the ultrasonic presenta-
have also been used, sometimes without adding tion of normal structures. The pathology of each
further diagnostic information. Sonography is organ is presented as a disease spectrum and the
safe and relatively inexpensive and should be evolution of the disorder is discussed. Correla-
included in the workup of a mass lesion. Since tion between sonographic findings and the histo-
ultrasound may give a specific diagnosis, its ap- pathologic changes is emphasized. The combina-
plication should follow the plain x-ray film. This tion of real-time and gray-scale scanning offers
simple and rapid study may eliminate the need the reader a comprehensive understanding of
for a prolonged hospital stay and the discomfort ultrasonic pathology.
of further examinations. Diagnostic ultrasound
Where controversy exists, the opinions ofvar-
has greatly reduced the patient time spent in the
ious authorities are cited and compared with our
x-ray department, giving the obstetrician and
experience. The diagnostic versatility of the var-
gynecologist faster and more reliable diagnostic
ious imaging systems are evaluated for each or-
information, and generally speeding up the pa-
gan complex and the investigative method of
tient turnover at the hospital. With the economic
choice is suggested for each disorder.
emphasis on the cost reduction of medical ser-
vices and hospitalization expense, the ultra- Considerable attention has been given to clinical
sound department serves a vital function in facil- and pathologic aspects. The practice of ultra-
itating diagnostic services. sonic scanning requires a thorough knowledge of
The purpose of this book is to introduce the the diagnostic problems of obstetrics and gyne-
physician to the essential principles of ultra- cology and their related specialties. The text is
sound physics and the practical aspects of scan- designed as a bridge between sonographic imag-
ning procedures. Important concepts are clearly ing and general obstetric and gynecologic
and thoroughly presented. Mathematical formu- principles.
las and advanced physics principles beyond the
scope of the clinician have been omitted. The
text is limited to the pelvis and medically related
areas in order to concentrate on each area in
sufficient depth so as to be valuable to the spe-
cialist who must be familiar with the diagnostic
capabilities of atraumatic scanners in his field.
The methods of examination and diagnostic find-
ings are detailed to be useful to the obstetrician,
gynecologist, radiologist, and general surgeon.
PREFACE
XlI
ocknovvledgrnents
I wish to express my deep appreciation to Drs. Hugh Barber, Fred

Benjamine, George Blinick, Philip Bresnick, Alfred Brockunier,
Bernard Diamond, Hilliard Dubrow, Fritz Fuchs, Martin Kurman,
James Nelson, Seymour Sussman, Martin Stone, Michael Tafreshi,
and Maurice Abitbol for their support of our academic efforts
in the application of ultrasonography to the field of obstetrics and
gynecology.
We are also very grateful to Akram Hassani, Nat Lewis, John H.
Grant, Marie Snailer, Judy Sharpe, Lee Weingarten, R.D.M.S.,
and Sonia Suga for their technical assistance.
The investigative efforts of our many colleagues in the field of
ultrasonography have greatly facilitated the evolution of this text-
book. The support of the publishers and the collaboration of the
Editorial Staff are warmly acknowledged.
XIIl
contents
Introduction XVll
1 principles of ultrasonography
CHARACTERISTICS OF ULTRASOUND
EQUIPMENT AND PRACTICAL ASPECTS OF USE 16
REFERENCES 38
2 gynecologic ultrasound 40
GENERAL INTRODUCTION 40
ANATOMY 41
SONOLAPAROTOMY 47
ULTRASONIC CHARACTERIZATION OF GYNECOLOGIC TUMOR
MASSES 52
UL TRASONIC DIFFERENTIAL DIAGNOSES OF OVARIAN MASSES 67
CONGENITAL ANOMALIES 68
INFLAMMATORY PELVIC LESIONS 69
REFERENCES 70
3 ultrasonography in obstetrics 71
GENERAL INTRODUCTION 71
PATIENT HISTORY 72
XV
PALPATION OF THE ABDOMEN BEFORE EXAMINATION 73
CHANGES IN UTERINE SIZE DURING PREGNANCY 73
SONOANATOMY 74
SONOLAPAROTOMY 74
SONOFLUOROSCOPY OF THE PREGNANT UTERUS 75
SONOPHYSIOLOGY OF PREGNANCY 80
PRESENTATION AND POSITION 103
DIFFERENTIAL DIAGNOSIS 106
MULTIPLE PREGNANCY 108
SPURIOUS PREGNANCY OR PSEUDOCYESIS 108
THE PLACENTA 108
FETAL EVALUATION 119
ANOMALIES OF PREGNANCY 121
ABNORMAL FETUSES 126
ASSOCIATED ABNORMALITIES IN PREGNANCY 126
REFERENCES 130
4 ultrasonography of gynecologically and obstetrically

related medical and surgical disorders 33
ULTRASONOGRAPHY OF THE URINARY TRACT IN GYNECOLOGIC
DISORDERS 133
ULTRASONOGRAPHY OF THE LIVER IN GYNECOLOGIC
DISORDERS 137
ULTRASONOGRAPHY OF ASCITES IN GYNECOLOGIC DISORDERS 139
ULTRASONOGRAPHY OF THE RETROPERITONEAL AREA IN
GYNECOLOGIC DISORDERS 143
ULTRASONOGRAPHY OF RENAL DISORDERS IN OBSTETRICS 147
UL TRASONOGRAPHY OF CARDIAC DISORDERS IN OBSTETRICS 152
UL TRASONOGRAPHY OF GASTROENTERIC DISORDERS IN
OBSTETRICS 161
ULTRASONOGRAPHY OF HEPATIC DISORDERS IN OBSTETRICS 162
ULTRASONOGRAPHY OF GALLBLADDER AND BILLIARY TRACT
DISORDERS IN OBSTETRICS 164
ULTRASONOGRAPHY OF PANCREATIC DISORDERS IN
OBSTETRICS 167
ULTRASONOGRAPHY OF SPLENIC DISORDERS IN OBSTETRICS 168
ULTRASONOGRAPHY OF THYROID DISORDERS IN OBSTETRICS 171
REFERENCES 174
index 177
CONTENTS
xvi
introduction
Diagnoses are missed not because of lack of knowledge on the part of

the examiner, but rather because of lack of examination.
Sir William Osler
The field of diagnostic ultrasound has expanded in applica-

tion so rapidly over the past few years that it has become
part of the routine diagnostic workup. The history of ultra-
sonography is vastly different from the evolution of X rays.
After the discovery of the X ray in 1885, it was rapidly
accepted by the medical community and many radiologic
societies soon appeared. The imaging potential of X rays was
so exciting that many patients and their physicians received
massive exposure to this form of highly penetrating electro-
magnetic energy. The dreadful sequelae of radiation-induced
injuries and malignancies subsequently appeared.
The development of ultrasonography is quite different. In

spite of the absence of demonstrable side effects and the
xvii
ease and accuracy of the study, its use did not new horizons in the study of tissue signatures.
become fashionable until very recently. The Soon we were imaging the medium-sized arteries
nature of the sound beam is that of mechanical and veins in the upper abdomen and, comparing
energy and its possible long-term biologic effects these with our anteroposterior (AP) and cross-
still remain unclear. However, it is known that table lateral angiograms, we were able to
the ionizing effects of X rays make even small sonographically map the organs in relation to the
doses potentially harmful. Sonar mechanical vascular anatomy.
vibrations are such that energy below the level
that breaks tissue bonds will not produce any The fundamentals of ultrasound, like those of
tissue damage. Our experience to date with low any other branch of medicine, require the user to
intensity ultrasound suggests that no hazardous be familiar with the effects and limitations of the
effects will occur in the short or long term in method. By this technique we are able to locate
patients. different organs and tissues and measure the
interfaces between them, and to cut in cross
The field of ultrasonography has assumed such
sections through different structures. In contrast
importance primarily as a result of the harmless
to other eXaIninations which yield indirect infor-
nature of the modality. Also, the tireless efforts
mation, ultrasound enables us to outline the le-
of a large number of investigators from varied
sion directly and to investigate its relationship
medical fields and allied services have developed
with neighboring structures. There is no need for
sonography into one ofthe best diagnostic tools.
the adIninistration of any radiologic contrast,
The pioneers in ultrasound, using only A-mode
possibly harmful to the function of the impaired
to combat the skepticism of their colleagues,
organ. Ultrasound, both as a screening and diag-
must have been exceptionally dedicated and pa-
nostic modality, is a noninvasive and atraumatic
tient. Scanning the abdomen and mentally inte-
procedure and is complimentary to angiography
grating thousands of A-mode spikes to give an
in many cases. The unique feature of ultrasound
answer to the clinician in need of a firm diagnosis
is the ability to recognize and differentiate deep
must have produced great frustration. This prob-
body organs and lesions having similar density
lem was alleviated by the introduction of B-
on conventional X-ray studies.
mode scanning units. Soon this technique was
followed by the time-motion- or M-mode.
The information gained through ultrasound, as in
My personal experience with ultrasonography other imaging procedures, is optimized when
began with the late Dr. Lajos von Micsky and his coupled with the patient's clinical picture. At
experiments conducted in a water tank. This present, parenchymal lesions of the lung cannot
type of study was mainly intended to produce be evaluated by ultrasound since the air-
higher quality pictures in order to improve diag- containing lung will not transInit sound waves.
nostic accuracy. The introduction of Doppler
ultrasound proved to be an instant success with The history of Ultrasonography is a long one and
clinicians in the evaluation of the fetal heart. The the procedure has suffered from many setbacks
idea of scanning the pelvis with a full bladder in its attempt for acceptance by the medical
opened the ultrasonic door to the visualization of profession. Its inherently harmless nature has
the deep pelvic organs and dramatically im- accounted for a significant portion of its
proved diagnostic accuracy in this region. popularity in modem medical practice. Whether
the sophisticated electronic technology that
The true revolution in Ultrasonography began spawned high resolution ultrasound will cause
with the development of the scan converter with the growing field of ultrasound to supersede
its sophisticated logarithmic compression other diagnostic modalities, or create
amplifiers. This presentation of a scan in various non ultrasonic imaging systems that will phase
shades of gray related to echo amplitude opened out ultrasonography, remains to be determined.
INTRODUCTION
xviii
The pioneers of ultrasonography had much diffi- of the first medical sonar units in the late 1940s
culty in applying sonar to diagnosis since they and early 1950s.
were using first generation scanners based on
ultrasonic technology used in industry and mili- Continuing new developments in ultrasound
tary pursuits. In later years newer ultrasonic were spurred on by dedicated researchers. The
units designed to meet specific clinical purposes application of new electronic circuitry and rapid
have been constructed. Cooperation of physi- reporting data retrieval systems changed the use
cists, engineers, and physicians dedicated to ul- of ultrasound from that of a research tool to an
trasonic imaging has led to development of diag- essential diagnostic modality. The fields of
nostic systems of considerable practical value. echoencephalography and then of M-Mode
Since the early days of the application of sonar echocardiography were developed. Next,
principles in medicine, there have been continual unidimensional and two-dimensional ultrasonic
new innovations in this field. The progress of scanning were combined.
acoustic waves in diagnostic imaging has been
aided by the development of special ultrasonic As various medical teams cooperated in the de-
transducers, sophisticated amplifiers, and sensi- velopment of ultrasonic scanners, smaller and
tive electronic displays. The introduction of re- more practical ultrasonographic units became
cently perfected scan converter systems adds a available. Pioneer work in the use of ultrasonog-
new dimension to the field of ultrasonography. raphy in obstetrics and gynecology was done by
Thompson (5) and Gottesfeld (6). W. L. Wright
The word sonar is an acronym of sound naviga- designed a hand-operated ultrasonic unit. Subse-
tion and ranging. Historically, ultrasound was quently many compact commercial ultrasono-
developed during World War I. Langevin (1) graphic units became available. J. J. Wild made
used the principle of sonar to detect and locate great contributions to the field ofultrasonogra-
submarines. Sounding of the ocean floor to pro- phy. In particular, he devoted his work to the
vide depth measurements was employed in 1918 differentiation of benign and malignant tumors
to aid in shipping and navigation (1). Further (7).
improvement in technology created more exten-
sive usage of sonar in industry and military situa- When the prototype of the contact ultrasonic
tions. Military sonar used by the navy could scanner became more popular, since the
measure the depth of a reflecting surface and transducer could now be placed on the patient's
also track an object in motion. In 1930 ultra- skin with direct contact, many further advances
sound was used in industry to detect flaws in iron in equipment design became possible. Water
castings. Prior to World War II, Dussik (2) used bath scanning of the eye (8) was another
ultrasound in the field of medicine. His attempt technical development, and was soon followed
to visualize the ventricular system of the brain by the application of time-motion displays (9).
was unsuccessful. However, in 1937, he de- By using two-dimensional real-time scanning
signed an ultrasonic device for application to the systems respiratory and vascular motion can be
brain (3). The first ultrasonic instrument, called detected and pathological conditions evaluated,
the supersonic reflectoscope, was introduced in in addition to detection and evaluation of their
1940 (4). This practical instrument, based on the three-dimensional images.
pulse-echo technique, measured distance on the
principle of transmission of very short pulses of At present, use of ultrasonography is spreading
sonic energy. During World War II the applica- into many branches of medicine. It has become
tion of radar principles in military imaging fur- an integral part of many subspecialties, such as
ther helped to develop the sonar technique. The obstetrics and gynecology and urology, since it
conjoint use of both imaging systems speeded is one of the most accurate diagnostic tools in
progress in each field and led to the availability many disorders involving soft tissue pathology.
INTRODUCTION
xix
Modern electronics has given the medical
sonographer high-resolution equipment which is
relatively simple to use. The application of ultra-
sonography has been so rapid that it is now the
preferred diagnostic test in many clinical prob-
lems. In certain disorders, such as placenta
previa, it is virtually the only diagnostic tool that
is available.
INTRODUCTION
XX
principles of
ultrasonography
.....
CHARACTERISTICS OF ULTRASOUND
NATURE OF ULTRASONIC WAVES
Sound is a mechanical vibration of particles in a medium

around an equilibrium position. Sonic waves require a me-
dium of a molecular nature in order to propagate. The highest
frequency audible to the human ear is 20,000 cycles per
second or 20 kiloHertz (KHz). Sound waves above this
frequency are described as ultrasound. Unlike electromag-
netic waves, sound cannot travel across a vacuum (10).
The wavelength of audible sound in air varies from a few

inches to a few feet. Ultrasonic waves are usually produced
by a continuous series of contractions and relaxations of
substances that have piezoelectric properties. The waves
generated are carried as condensations and rarefactions in the
transmitting medium. The frequency range used in diagnostic
medicine is approximately 1 million cycles per second, with a
wavelength of about 1.5 millimeters (mm) in water.
PIEZOELECTRIC PRINCIPLE SOUND WAVES
The piezoelectric effect is fundamental to the Sonic waves travel through a medium as
development of ultrasound. "Piezo" is derived alternate condensations and rarefactions. The
from the Greek word piesis, ie, to press. following practical definitions are commonly
Piezoelectric actually means' 'pressure used (Fig. l.1c).
electric." Quartz has piezoelectric qualities,
since its size and shape change under the
influence of an electric field. When an electric 1. Cycle. One cycle is the entire
current is passed through quartz, the crystal condensation and rarefaction phase.
expands and contracts according to the polarity 2. Wavelength. The length of one cycle is
of the current. Sound waves are generated as a a wavelength, or, a complete
result of these compressions and rarefactions. condensation and rarefaction zone is a
On the other hand, mechanical energy, in the wavelength.
form of sound waves applied to the crystal,
produces an electric current. This is known as 3. Frequency. The number of cycles per
the piezoelectric principle (Fig. 1.1a and b). unit time. The frequency of sound
Several other substances are known to have waves is described in terms of hertz
piezoelectric properties, such as barium titanate, (cycles per second).
lithium sulfate, and lead zirconate (11). The 4. Velocity . Velocity is the speed of sound
titanates are the more commonly used crystal in the medium through which sound is
(10) for sonography. propagated.
FIGURE 1.1
Piezoelectric effect. (a) Mechanical
stress deforming crystal and
producing current. (b) Expansion of
crystal as current is applied and
contraction of crystal as current
polarity is reversed. (c) Wave pattern
produced by alternate compressions
and rarefactions. A, spatial pulse
length; B, full cycle; C, wavelength;
D, amplitude.
(el
CHAPTER 1: PRINCIPLES OF ULTRASONOGRAPHY

2
The relationship between velocity, wavelength, energies. The formula for the ratio of echo
and frequency is as follows: amplitude in terms of decibels is as follows:
V = Ax F db = 20 log All A2
Velocity = Wavelength x Frequency where Al is the echo amplitude and A2 the inci-
dent sound amplitude.
EFFECT OF MEDIUM
BEAM WIDTH AND ECHO PATTERN
In any given medium the velocity of sound
remains constant, but its frequency varies The beam width is related to the diameter of the
inversely with wavelength. The higher the crystal. Ultrasonic waves transmitted from the
frequency, the smaller the wavelength. High- transducer have a diverging beam width. In this
frequency sound waves are more directional path, any echo received is registered as if it were
than low-frequency sound. However, the in the central beam axis (12). A target on the
attenuation of high-frequency waves is greater edge of the beam is recorded in the same way as
than that of low-frequency waves, since the a target in the middle.
absorption of sound is greater at high frequency
(10). In medical work, frequencies above 1 MHz The appearance of the displayed point is
are employed. At a frequency of 2 MHz, the important. The echo is registered as a dot or line.
wavelength of sound in water is approximately The dots lie in the center of the beam and the
0.75 mm. lines are perpendicular to the beam axis of the
Velocity depends on the density and elasticity of transducer. The length of each line is
the medium. The elasticity of the medium is proportional to the width of the beam. The
significant, since the velocity of sound changes apparent beam width is wider if the target is
in media of different inherent elastic properties. located obliquely to the incident beam. The
In a homogeneous medium, ultrasound travels in effective beam width changes with the
a straight line at a velocity dependent on the sensitivity of the ultrasound machine. By
properties of the medium but independent of increasing the sensitivity of the machine, low-
wavelength. amplitude echoes from the edge of the beam are
registered. However, the target is displayed as
lines instead of dots and resolution is decreased.
INTENSITY Also, the geometry of the target is extremely
important (Fig. 1.2a,b, and c). If the transmitted
The intensity of the ultrasound beam is a beam is stationary and at right angles to the
measure of the strength of its energy and is target, the shape ofthe returned echo is specified
defined as power per unit area. The intensities by the electric characteristics of the transducer
used in commercially available medical units (12). If the transmitted beam is not stationary or
usually are between 1 and 40 milliwatts per strikes the target obliquely, the shape of the
square centimeter (mW/cm2). Tissue damage returned echo is elongated due to a greater
may occur at 4 W/cm 2 (11,18); thus, currently effective beam width with respect to the target.
used intensity levels are roughly 100 to 1000 Thus, the echoes appear as small lines instead of
times lower in energy than the potentially dots (Fig. 1.3a,b, and c).
damaging level. The safety margin is much
greater, since the acoustic pulse is active less ATTENUATION
than 1 percent of the scanning time.
The decibel (db) is the practical unit for the When a sonic beam is passed through a medium,
measurement of sound intensity. The ratio of a decrease in the intensity of the sound, ie,
signal amplitUdes must be expressed attenuation, may be expressed as a half-value
logarithmically due to the wide range of echo layer. The half-value layer is the distance the

3
~,{
A B C
---4 T
~I--'!--I\
/1
I
ill A NN\ (a)
--- ·--- --- -- ---

~ T
--- --- --- --- ---
A
•
--- .--- --- -- ---

•
!La
=0 (b)
-- -- -- --
~
I
T
-- . -- -- --
/\
•
-- -- -- -- =1
~ (c)
FIGURE 1.2 tissue and the square of the frequency of sound.

Reflection processes. (a) Strong echo generated by Attenuation of the sonic beam has many
perpendicular interface (A). Weaker echoes due to sound
reflected away from receiving transducer (B,C). Diffuse low- practical applications. For example, cystic and
level echoes from irregular reflecting interface (D). (b) No solid masses can be differentiated since cystic
echoes produced as sound beam passes through masses have a much greater half-value layer than
homogeneous medium of cystic structure. Note high through
transmission represented as multiple echoes distal to the do solid structures. In general, soft tissue
posterior wall. (c) Echo production by solid, attenuation is 1 db/MHz/cm. Attenuation of
nonhomogeneous medium. Note poor through transmission bony structures is about 20 times greater than
with no echoes distal to the posterior wall. T, transducer.
that of soft tissue. For this reason, a low-
frequency transducer must be used when
scanning through bony structures such as the ribs.
transmitted sound must travel before its initial
intensity is reduced by one-half. For example,
bone has a smaller half-value layer than does soft ACOUSTIC IMPEDANCE
tissue (10). However, energy loss is also caused
by beam divergence, scattering, and absorption The transmissivity of the ultrasonic beam
of sound by tissue. The amount of sound depends upon sound velocity (V) and the density
absorbed is proportional to the depth of the (D) of the medium. The overall transmission is

4
defined as acoustic impedance (Z). the closer the two objects may be and still be
Consequently, acoustic impedance is directly individually recognized. The resolution of any
related to the product of the speed of sound in a wave form is directly related to the frequency of
given medium and the tissue density (11). Thus, oscillation. Higher frequency sound usually has
better resolution but its intensity falls off rapidly
Z =DV
as it passes through a given medium (11). Lower
where Z is the impedance, D the density, and V frequency sound usually has excellent transmis-
the sound velocity. If the interface between two sion but poor resolution characteristics. The fre-
media is a region of acoustic impedance mis- quency range between 2 and 3.5 MHz has the
match, a reflection will take place proportional best balance between resolution and transmis-
to the impedance differential. Each tissue has a sion for abdominal scanning. However, equip-
characteristic acoustic impedance. ment available at present does not allow identifi-
RESOLUTION
FIGURE 1.3
Resolution is the minimum distance between two Echo shape and beam path. (a) Narrow beam. Point target
displayed as sharp dot. (b) Wide beam. Point target displayed
point targets required to register each point as a as short line perpendicular to beam. (c) Narrow beam.
distinct entity. The greater the resolving power, Oblique linear target displayed as short line. T, transducer.
T • •
la)
Ib)
T /
Ie)

5
cation of very deep-seated abdominal structures distinguish two points located perpendicular to
below a certain size. Recognition of a smaller the beam axis (Fig. 1.5a,b, and c). The minimum
lesion depends on the overall resolution of the resolvable side-by-side distance between two
equipment. objects is measured as the lateral resolution.
This distance is inversely proportional to the
In ultrasound we are concerned with axial and width of the beam and depends on the diameter
lateral resolution. Axial or depth resolution is the of the crystal, the wavelength, and the degree of
ability to distinguish two points along the beam beam divergence with distance.
axis (Fig. 1.4a,b, and c). The minimum resolva-
ble distance is measured as the axial resolution REPETITION RATE
and depends on wavelength, since objects sepa-
rated by less than one wavelength cannot be The rate at which bursts of ultrasonic energy are
resolved. Although the wavelengths of current emitted is called the repetition rate. Most
transducers vary from 0.1 to 1.5 mm, the resolu- commercially available instruments emit 200 to
tion ofthe oscilloscope, or scan converter tube, 2000 repetitions per second. This high repetition
may not be sufficient to separate very closely rate requires extremely sensitive receivers
spaced echoes. The display system must be sen- capable of detecting a signal that has less than 1
sitive enough to match the transducer frequency. percent ofthe incident ultrasonic beam energy
Lateral or azimuthal resolution is the ability to reflected back to the transducer.
(a)
FIGURE 1.4
Axial resolution. (a) Two point targets
displayed as one echo. (b) Two point
T
• • targets partially resolved. (c) Two point
targets resolved as two distinct
structures. T, transducer.
(b)
T
• •
(c)
CHAPTER 1: PRlNCIPLES OF ULTRASONOGRAPHY

6
T
(a)
• FIGURE 1.5
Lateral resolution. (a) Three point
ro-
• targets displayed as one point. (b)
T
• Two point targets shown as one
---
"'- point with better azimuthal resolution
due to narrower beam width. (c)
Optimal resolution distinguishing two
(b) closely spaced targets. T, transducer.
1 T
F-==~ (e)
REVERBERAnON
The face of the transducer may act as a reflecting

surface to returning sound waves.
Consequently, the sound beam may bounce
back from the surface of the transducer, follow
its original course , and, in return, hit the
FIGURE 1.6 transducer a second time to be displayed on the
Reverberation phenomenon. The face of the transducer acts
as a reflecting surface to the returning sound beam. The echo oscilloscope at a distance twice as far from the
bounced back appears on the oscilloscope as a series of transducer as the original echo. This pattern may
progressively weaker echoes. Note the reverberation artifact be repeated with progressively weaker echoes.
in abdominal scanning.
This phenomenon is called reverberation and
may produce confusing and troublesome
artifacts (Fig. 1.6).
DISTANCE MEASUREMENT OF
REFLECTING INTERFACE
By knowing the velocity of sound in the medium

being examined and the time it takes for the
sonic pulse to strike an interface and return as a
reconverted echo, it is possible to measure the
distance between the reflecting interface and the
transducer. Mter the sonograph is calibrated for

7
the velocity of sound in the medium examined, are specular reflectors (12), and the reconverted
time is converted to distance automatically. waves return as a narrow beam. Proper angular
relationships between transmitted waves and the
reflected beam are required to receive echoes of
DIRECTIVITY, REFLECTIVITY, AND maximum intensity from this narrow beam. For
TRANSMISSIVITY example, heart valves and posterior cyst walls
act as specular reflectors. Structures that scatter
Ultrasonography is based on the pulse-echo rela- the reconverted sound waves in a diffuse pattern
tionship. Short electric pulses produced by a are called diffuse reflectors. The parenchyma of
generator are converted by a transducer into the liver is a typical diffuse reflector; the echoes
bursts of acoustic energy. The sound beam emit- produced do not depend on angulation and are
ted proceeds in a typical divergent path and usually of low amplitude (13). Adequate exami-
produces different echoes, depending upon the nation of diffuse reflectors requires a variety of
interacting media. transducer positions and angles.
High-frequency ultrasound has many similarities Fluid-filled structures in the body cavity transmit
to light energy. In its course of travel, ultrasound sound well and are detectable by the fact that
will be reflected and refracted when it strikes an reflection occurs at the boundaries of the cavity,
interface between two acoustically different me- which are areas of differential impedance. The
dia. If physiologic and geom(!tric conditions are interface between a fluid-filled cavity and
suitable, diffraction also occurs. bordering tissue yields a large impedance change
and strong echoes are returned. Acoustic
Reflection of ultrasound depends on the acoustic mismatch is much greater between tissue and
impedance mismatch of two media. The greater bone. For example, at the interface between soft
the difference in impedance, the greater the tissue and bone, more than 50 percent of the
reflection. That portion of the sound wave not transmitted sound waves will be reflected. At an
reflected is transmitted through the medium. If air-soft tissue interface, 100 percent reflection
the incident beam is not perpendicular to the occurs.
interface, sound will be reflected and refracted,
Different organs in the body have different
depending on the angle of incidence (11). The
acoustic impedances. Therefore, the
incident beam should be normal to the interface
transmissivity of sound will change as it travels
studied to achieve maximum reflection back to
through various tissues. Every time the
the transducer. Snell's law of optical refraction
transmitted beam of ultrasound strikes an
applies to the refraction effect of the incident
interface, an ultrasonic wave (echo) is reflected
beam and Huygen's principle of optical
back and displayed on an oscilloscope. The
diffraction applies to diffraction of the sonic
greater the acoustic impedance mismatch at the
beam.
interface between two media, the greater the
The principal advantage of high-frequency sound reflection. Consequently, in heterogeneous
is that it can be aimed toward specific organs. media, many echoes are produced; in
Study by ultrasound is optimal when the beam homogeneous media there are few or no echoes.
strikes at an angle perpendicular to the reflecting Therefore, heterogeneous structures are said to
interface. If the beam is not quite perpendicular be echogenic, whereas homogeneous regions are
to the object of interest, a portion of reflected echo-free or anechoic. A fluid-filled cavity is
sound will not return to the crystal. Therefore, homogeneous and thus echo-free. Fluid-filled
correlation between directivity and reflectivity is cysts and solid masses are differentiated by the
necessary for a good examination. absence or presence of echo~producing
interfaces within the lesions. This principle is
Certain structures have high reflecting qualities used to diagnose pericardial effusions, ascites,
for ultrasound waves. Flat and concave surfaces and normal blood pools, such as the aorta.

8
The acoustic impedance of bone and high-
atomic number elements is very great, while that A-MODE (AMPLITUDE MODE)
of air is low. Therefore, the incident beam at a The A-mode ultrasound system displays the
soft tissue-air interface is totally reflected. Since electrically converted echo pattern as a vertical
there is no penetration, lung scanning with deflection (Fig. 1.7a). The amplitUde of each
ultrasound is impossible at present. At soft deflection is proportional to the reflected energy
tissue-bone interfaces, significant quantities of received by the transducer. The deflections
ultrasound are absorbed. Thus, the ribs may occur at different points on a calibrated tracing,
produce some difficulty when the liver or spleen corresponding to the distance of the reflecting
is scanned. The bony structures of children, surface from the face of the transducer. The
however, cause fewer problems because these
structures are smaller and contain less calcium.
FIGURE 1.7
Display modes. (a) A-mode. Echo-producing inteIfaces
produce vertical deflections proportional to echo amplitude.
DISPLAY MODES (b) B-mode. Vertical deflections converted into dots of
brightness may be used for scanning. Brightness of dots is
proportional to echo amplitude. (c) M-mode. Motion of
The reflected echoes may be displayed by A- objects recorded by moving the B-mode tracing along the
mode, B-mode, or M-mode presentations. time axis. T, transducer.
I 1
(al
(bl
(cl

9
number, shape, location, and amplitude of the as a black-and-white or a gray scale by using a
echo spikes furnish detailed information of the scan converter.
structure examined. The horizontal distance
between registered echoes is proportional to the The M-mode presentation may be recorded on
depth of the tissue which produced reflection. Polaroid film or on a cathode-ray tube. A strip
chart recorder affords better detail.
B-MODE (BRIGHTNESS MODE)
MECHANISM OF CROSS-SECTIONAL
With B-mode, echoes are displayed on the
IMAGE PRODUCTION
oscilloscope as a series of dots and lines, the
brightness of which varies with the intensity of
As the transducer moves over stationary
the reflected waves, since the echoes are
structures a cross-sectional image will be built
projected as a linear series of bright dots (Fig.
up from the organ of interest. The scanning is
1. 7b). The second dimension of the oscilloscope
performed through a specially designed arm
can be used for acoustic section or
which holds the ultrasonic transducer. The arm
sonolaparotomy of an organ by moving the
motion is followed by a computer which spatially
transducer in the desired planes. This technique
orients the transducer position and echo pattern
is called B-mode. Consequently, a single
on the monitor screen. As the transducer moves
sonolaparotomy produces a two-dimensional
the returned echo signals will appear on the
representation. In B-mode, a great deal of
oscilloscope (Fig. 1.8). The final image is the
information is lost during the study of a specific
representation of the outline of the scanned area.
area as a result of attempting better visualization
of the topographic anatomy. On the other hand,
With low sensitivity only the outline of the
this technique permits cross-sectional study of
organs is visualized. At high sensitivity the
the body and also allows sonolaparotomy to be
internal texture is registered. With modern gray
performed in any direction and plane (Fig. 1.8).
scale, different shades of gray are seen clearly
without changing the sensitivity setting during
M-MODE (MOTION MODE)
the study.
In M-mode, the motion of a pulsatile structure is
recorded by moving the B-mode tracing across GRAY-SCALE IMAGING
the oscilloscope at preselected speeds. Actually, Conventional B-mode systems use threshold
the display of the amplitude of the echoes is detection to register echoes on a phosphor
changed to dots. The dots of moving organs on storage oscilloscope screen. These echoes are
B-mode are swept across the oscilloscope in a recorded as dots of light and a large number of
vertical direction and registered. This motion these dots are used to form an image on the
can also be demonstrated in the horizontal screen. Echoes above a certain amplitude are
direction by time exposure photography while displayed as dots with constant intensity, while
the transducer is held stationary (Fig. 1.7c). echoes of a lesser amplitude below the detection
Modification of the amplitude of echoes to dots threshold are not displayed. Most of the earlier
is called intensity modulation. When the echo abdominal scans* were performed with a storage
has been changed to a dot and the amplitude oscilloscope for echo registration. A final
converted to intensity, the time factor may be photographic record was taken in the form of a
introduced into the oscilloscope tracing. In most Polaroid picture of the storage screen. The
echograms the oscilloscope sweeps from bottom resultant image showed dots of constant
to top or from left to right on the display tube. intensity although many echoes came from
When the M-mode sweeping has a vertical and interfaces with varying echogenicity. The final
horizontal motion, one dimension can be used
for time and the other for distance. The tracing *Hassani, Ultrasonography of the Abdomen. New York,
can be displayed on a regular television monitor Springer-Verlag, 1976.

10
sonogram with the storage or bistable unit
consisted of a black-and-white photograph
without information regarding echo amplitude.
There is good representation of the size, shape,
t and position of the lesion and also whether it is

cystic or solid. However, the internal echo
pattern may only be evaluated in a qualitative
manner since it involves manipUlation of the
sensitivity settings.
Gray scale displays a dynamic range of echo
amplitudes simultaneously as varying shades of
gray. High-intensity echoes appear dark gray
and low-intensity echoes light gray. Anechoic
areas are colorless with current registration
methods. Usually, the sensitivity setting need
not be adjusted to evaluate tissue echo
characteristics. For example, echoes from the
renal collecting system appear dark gray while
those from the surrounding parenchyma are light
gray.
Early gray-scale techniques used photographic

film to record scans. Film was exposed to a scan
pattern composed of amplitude-modulated
echoes presented to a short-persistence oscillo-
scope. Usually four shades of gray were ob-
tained with this method. Disadvantages included
a complicated area scanning technique to pre-
vent overwriting echoes, and a longer scanning
time inherent with this maneuver. In addition,
the camera F-stop setting, oscilloscope intensity,
and film speed influenced the gray-scale effect
(14). After the scan was completed, the film had
to be developed before the picture could be in-
terpreted. Current commercial systems in which
a scan converter is used offer eight to ten shades
of gray displayed on a television tube (Fig. 1.9).
The scan converter tube detects all echo intensi-
ties and is connected to a closed circuit televi-
sion system providing an instant visual display of
the area scanned. The technique is the same as
for conventional B-scanning methods. Scanning
time is reduced due to better resolution and
FIGURE 1.8
Spatial orientation of the scan. As the transducer traverses simultaneous display of weak and strong echoes,
the body contour, the echoes returning from the region being eliminating the need to vary sensitivity settings
scanned are aligned on the oscilloscope in exact depth with
during sectioning. The image developed on the
respect to the sound beam. The series of echoes returned are
oriented in a two-dimensional arrangement over a 1800 scan monitor tube may then be recorded with Pola-
arc. roid, 35 mm film, or multiformat imaging using a

11
microprocessor. Moderate differentiation of sig-
nal processing enhances contrast at tissue inter-
faces (14). Most scan converter systems offer
information processing techniques for postscan
image optimization (Fig. 1.10).
REAL-TIME SCANNING
The real-time scanner has greatly increased the
scope of information available from ultrasonic
exmnination. This modality has been applied to
numerous areas of the body (15-17). The two
main advantages of real-time scanning are the
rapidity with which the examination can be
FIGURE 1.9 completed and the ability to observe motion.
Demonstration of multiple shades of gray. Real-time scanners usually employ either a
rotating transducer or a linear array of
transducers.
There are several commercially available real-

time scanners. One of the earliest real time scan-
ners (Fig. 1.11) uses two 2.5-MHz transducers
that elnit ultrasonic beams toward a parabolic
acoustic mirror (Fig. 1. 12a) . The reflector sends
a parallel set of sound waves through a water-
containing bag applied to the body surface. A gel
is used as a coupling agent. The scanning field is
covered 15 times per second and the sectional
view studied is about 14 cm in length and 20 cm
in depth. This field is built up to approximately
120 lines within 70 lnilliseconds (msec). The
width of the section is a few millimeters. The
unit produces instantaneous sectional images
and displays them simultaneously on an oscillo-
scope and television monitor. This immediate
and continuous presentation makes it possible to
visually record movement of a desired structure.
Without shifting the applicator head, parallel
sectional scans can be taken up to 3.5 cm lat-
erally by remote control of the motion of the
transducer mounted within the applicator head.
The linear array scanner, in which the applicator

has a linear array of 64 transducers, firing four at
a time, to produce approximately 60 lines of
information (Fig. 1.12b), has been available com-
mercially for a few years. Presently, many types
of real-time units have been developed.
Most machines are equipped with depth com-

pensation controls which amplify the near, far,

12
FIGURE 1.10
Contact diagnostic ultrasound scanner.
Courtesy of Picker Corporation.

13
FIGURE 1.11 of up to 90°. The wave front may also be focused
Real-time scanner.
Courtesy of Siemens Company. to different depths. Resolution with current
systems varies (Fig. 1.12c).
or overall field. Another device adjusts the
shades of gray on the monitor. We use the commercially available Bronson-
Turner unit in combination with the gray-scale
Linear transducer arrays may be electronically unit in the study of the breast. The scanning part
phased by pulsing each of the multiple of the Bronson-Turner consists of a handpiece
transducer crystals as a separate unit. The wave and a small chamber which contains the
front formed follows the pattern of transducer transducer and acts as a water bag. The
excitation. The wave pattern may be made to transducer has a 10 MHz frequency and is
produce a sector scan with a variable scan angle enclosed in a housing that is held against the area

14
of interest. The transducer of the Bronson-
Turner unit is about 0.25 inch in diameter and 1.5
inches long. This unit has a rapid scanning rate
of 11 sweeps per second. It produces a dynamic
display of successive cross sections that appear
on a television monitor. The transducer moves in
a sector and the image appears linearly. The
(a) scanning part is coupled through a flexible cable
to the cathode-ray tube.
~ The cathode-ray tube resembles a 12-inch

~~----------------.
television set. The section of the tissue being
T~ studied appears on the monitor and is
~------------------
~ represented in dark and light areas which
~------------------
~ directly correspond to the amount of reflected
(b)
sound beam. There are two controls: One selects
the depth of field and covers the ranges of 0 to 3
cm, 1.5 to 4.5 cm, and 3 to 6 cm. The second
varies the sensitivity setting of the unit (gain
setting) and can be manipulated from 40 to 80 db
(standarized with reference to an echo returned
from a plain glass plate); it is calibrated in IO-db
steps.
(c)
DOPPLER EFFECT
FIGURE 1.12
Real-time scanning systems. (a) Rotating transducer reflects The frequency change of mechanical waves due
sound waves from parabolic surface to generate parallel to the relative motion of either sound source or
beam. (b) Linear transducer array. Multiple transducers
being pulsed in sequence to produce parallel beam. (c) observer is called the Doppler effect. It is named
Phased linear array. Variable wavefront generated by after Christian Doppler who first described this
coordinated pulsing of each transducer element. T, phenomenon. The measurement of sound
transducer.
frequency is obtained by computing the pressure
peaks that cross an observer in a unit of time or
in I second. If the sound source moves toward
the observer during measurement a greater
number of peaks will be counted and the
calculated frequency will be greater than the
"true" frequency. On the other hand, if the
sound source moves away from the observer the
calculated frequency will be lower than the
"true" frequency. This phenomenon also occurs
if the observer moves toward or away from the
3Ource. The Doppler effect can be used in the
detection of the moving organ by using two
crystals, one crystal generating a continuous
ultrasonic beam emitted toward the organ of
interest and second receiving the reflected echo.
The stationary organ does not change the

15
frequency of the reflected sound, while the the location or depth of an interface as well as
moving organ does change the frequency of the the velocity of the flow.
reflected ultrasonic beam.
EQUIPMENT AND PRACTICAL ASPECTS

DOPPLER TECHNIQUE OF USE
The operation of Doppler instruments is based The essential part of a sonographic unit consists
on transmitting and receiving an ultrasonic beam of the following elements.
that hits moving structures or fluids, such as
blood in the cardiovascular system. The simplest 1. Transducer. The transducer acts as a
Doppler has a transducer with two crystal ele- sender and receiver of sonic waves. It
ments. One crystal transmits a continuous sonic functions as a receiver 99.9 percent of
beam and the second receives the reflected the time.
waves. The transmitting crystal is excited 2. Transmitter. The transmitter regulates
through a low-power oscillator which operates in the sonic waves through the transducer.
the range of 3 to 8 MHz. The sound intensities A timer in the transmitter controls the
are usually under 50 mW/cm2 • frequency and duration of ultrasonic
pulses emitted by the transducer.
The transmitted and received signals occur at the
3. Receiver. Returning echoes reconverted
surface of the transducer and the returned
through the transducer to electric
information appears in electronic form at the
impulses are picked up by the receiver
receiving amplifier. The end result is called
and signal amplifier.
amplitude-modulated or AM waves. These AM
waves are sinlilar to radiowaves in that the 4. Signal amplifier. The signal amplifier,
amplitude of the modulation is proportional to located between the receiver and
the amplitude of the returned signal. A radio cathode-ray tube, increases the voltage
frequency amplifier with a special detector may of the signal.
be used to clarify the returning Doppler signal. 5. Cathode-ray tube. The cathode-ray tube
receives the amplified impulses of the
With modem Doppler instruments we are able to
returning echo. The processed impulses
listen to the Doppler signal range for almost all
are displayed on the cathode-ray tube or
physiologic flow patterns. As we gain more oscilloscope.
experience, a great deal of information can be
obtained regarding the blood flow. For example, The transducer is the only element discussed in
areas of stenosis in a blood vessel produce a this section.
high-velocity-type jet flow which yields a high-
frequency Doppler signal. These signals are
clearly differentiated from those either distal to TRANSDUCER
or proximal to the stenotic signal. As previously
COMPONENTS
described, structures in motion can easily be
detected. For example, fetal heart motion can be The transducer has a lead zirconate crystal with
identified as early as 8 to 10 weeks after piezoelectric properties, which can expand and
conception. contract in response to electric pulses (Fig. 1.1).
The piezoelectric crystal has a small cylindrical
The most modem Doppler equipment shape and is generally 1 to 2 cm wide and 1 mm
incorporates features of continuous-wave thick. The electrodes providing the electric po-
Doppler combined with pulse-echo type tential are connected to both sides of the crystal.
ultrasound, and has the capability to determine The vibrating crystal causes compressions and

16
rarefactions in all directions. To provIde a unidi- NEAR FIELD AND FAR FIELD
rectional ultrasonic beam, a backing material is Divergence of the beam from the transducer is of
used to absorb the waves in unwanted direc- extreme importance. In a circular transducer,
tions. The backing material acts as an acoustic as the beam emitted from the face is cylindrical.
well as a mechanical damper for the crystal. During the course of propagation, the sound
waves run parallel for a certain distance and then
The frequency of oscillation controls the gradually begin to d:verge. That portion of the
resolution capability of the system. After beam close to and parallel with the transducer is
transmission, the acoustic energy of reflected called the near field and that extending from the
sound is reconverted into electric impulses for divergent point is called the far field (Fig.
data analysis, since the same crystal generates 1.13a,b, and c). At the end of the near field, the
electric currents when exposed to returning intensity of sound is maximal in the axis of the
high-frequency waves. The transducers usually beam. Thus, maximum information is obtained
used in clinical work have different frequency when the object is located in the near field be-
ranges, from 1 to 15 MHz. Approximately 99.9 cause the sound beam is parallel to the trans-
percent of the time the transducer acts as a ducer and more perpendicular to the target. Con-
receiver. sequently, the intensity of the reconverted echo
is greater.
To vary the frequency of the sound, the trans-
ducer must be changed. For example, a fre- OPTIMAL CRYSTAL SIZE
quency of 2.25 MHz is used in abdominal stud- To increase the resolution ofthe ultrasonic beam
ies. For echocardiography, a transducer (12), its width should be as small as possible. To
frequency of 3.5 MHz is utilized (18). The char- enlarge the near field and obtain better informa-
acteristics of the system depend on the fre- tion, the size of the crystal is increased or wave-
quency of the transducer and the choice of fre- length decreased. Reducing the diameter of the
quency depends on the region to be studied (18). crystal narrows the width of the beam but de-
Transducers oflow frequency have longer wave- creases the length of the near field and increases
lengths, resulting in greater beam penetration the divergent angle of the far field (12).
and better depth of study. However, increasing
the wavelength decreases the resolution of the To obtain the optimum size of the transducer
system. High frequency offers high resolution. crystal, the beam width should be constructed in
In ophthalmology, the transducer frequency var- such a way that the near field is half the desired
ies from 7.5 to 20 MHz. As a result, the higher operating range of the transducer. To obtain
frequency provides optimal definition of small higher resolution, frequency should be in-
objects but the depth of penetration is limited. creased. In practice, the highest frequency con-
sistent with maximum penetration for the re-
quired study is utilized (Fig. 1.14a,b, and c).
MOUNTING
The disc of piezoelectric crystal in the FOCUS
transducer has a suitable mounting arrangement Resolution can also be improved by using
for optimal resolution (19-21). To produce focused or collimated transducer to reduce beam
continuous waves a thin layer of a matching width within the focal zone. By applying a
wave is used to improve the sensitivity (18). In focusing lens with a concave surface, the focus
the back of the transducer is a loading or backing of the ultrasonic beam will be narrowed to a
material, which absorbs sound energy directed predetermined distance from the face of the
or transmitted backward. Consequently, the transducer (Fig. 1.13). The focused transducer
quality and shape of forward energy, especially has helped to improve resolution of deep
of short pulses, are improved. abdominal structures.

17
T
(a)
(b)
(c)
FIGURE 1.13 the cycle repeated. There are different types of

Transducer beam patterns. (a) Nonfocused transducer. transducers.
Parallel wavefront forms the near field. Divergent beam in far
field. (b) Focused transducer. Narrowest beam width at focal
zone. (c) Collimated transducer. Elongated near field and less
far field beam divergence. T, transducer. PULSE CHARACTERISTICS AND THE
DAMPING SYSTEM
The optimal spatial pulse length is between 1 and

2.5 cycles. The excited crystal has a tendency to
FUNCTION oscillate for a long time, producing a prolonged
As previously described, piezoelectric crystals spatial pulse length too long to provide adequate
emit ultrasound pulses as short as 1 second in axial resolution. The damping system controls
duration. After the sonic burst has been emitted, crystal oscillation by mechanical and electronic
the transducer then acts as a receiver, picking up means (Fig. 1.15a,b, and c). Damping may be
the reflected sonic waves. After this period of adjusted manually or built into the electronic
time, another burst of ultrasound is emitted and circuity. Overdamping produces a short spatial

18
pulse length and the pulse may lack sufficient the information and is manually adjustable (gain
energy to be useful. Thus, a properly spaced control). Further modification depends on spe-
pulse depends on a well-adjusted damping cific clinical use. Generally, after amplification,
system. the waveform is rectified to remove all negative
components so that only the upper half of the
signal is presented. Further modification can be
SIGNAL PROCESSING accomplished so that only the outline or bound-
ary of the upper half of the electric signal is
Reconverted ultrasonic echoes produce an elec- presented as an envelope detection (Fig. 1. 16c).
tric impulse when they reach the transducer
crystal. This impulse is transmitted as an ampli-
fied radio frequency (RF) (18,21) signal into the
system. The RF mode appears as a series of FIGURE 1.14
signals above and below the baseline ofthe oscil- Beam width and crystal size. (a) Wide crystal with long near
field. tb) Medium crystal with shorter near field. (c) Narrow
loscope (Fig. 1.16a and b). Amplification in- crystal with short near field and great beam divergence in the
creases the size of the signal without changing far field. T, transducer.
la)
Ib)
Ie)

19
-4 T
~)))))))) 11I111111I
(a)
FIGURE 1.15
Damping effect. (a) Underdamping
resulting in multiple oscillations of
-4 ))))))111 11
T transducer crystal. (b) Proper damping
producing optimal spatial pulse length.
(c) Overdamping with insufficient pulse
cycles. T. transducer.
(b)
-4 T )) )1
(e)
(a)
FIGURE 1.16
Signal processing. (a) RF signal
produced by incoming echo on
T transducer crystal. (b) Amplification RF
signal. (c) Rectification of RF signal and
envelope detection. T. transducer.
(b)
(e)
20
T
(al
FIGURE 1.17
Signal processing. (a) Envelope
T detection of rectified RF signal. (b)
Leading edge display or differentiation of
signal. (c) Rectification and amplification
of signal for oscilloscope display. T.
(bl transducer.
(el
This presentation is called video display. Enve- adjust the rejection level, as needed, for proper
lope detection or video display with its multiple ultrasonic examination.
peaks can be converted into a smooth, single,
large peak called the video signal (Fig. 1.17a).
MAIN SYSTEM CONTROL
This signal may be further amplified or .modified
by accentuating the leading edge of the signal POWER SWITCH
(Fig. 1.17b) by taking the first derivative of the An on-off switch is connected to a standard 110-
video signal that produces a thin echo. The small volt outlet. The line is grounded to prevent an
negative phase (Fig. 1.17b and c) following the electric hazard.
initial signal further accentuates the leading edge
of the echo by rectification, giving finer echoes REJECT
and enhancing the resolution of the system. An- The reject control varies the amplitude threshold
other step in processing the video is to add a required to record an echo. It discriminates
reject level so that only large-amplitude echoes against low-level echoes and is used to remove
above a certain threshold will be detected (Fig. "grass"-like interference at higher gain settings.
1. 18a,b, and c). Rejection is very important to
GAIN
eliminate unnecessary echoes (Fig. 1.18b) and
electric noise or "grass" (Fig. 1.18b and c). The gain control amplifies the electronic signal of
However, certain low-level echoes are required the received echo. Some units employ an
for optimal information. The sonographer should attenuation system to achieve this effect. Two

21
T
(a)
FIGURE 1.18
Rejection. (a) RF signal. (b) Amplified
T signal with unwanted echoes and
electric noise. (c) Elevation of
baseline echo threshold displaying
only amplified signal. T, transducer.
(b)
(e)
types of gain are available: near gain and total adjusts the cycles of sound available from each
gain. Near gain increases the amplitude of pulse. A shorter pulse increases resolution;
echoes in the near field. Total or coarse gain however, a beam too highly damped lacks
produces a uniform increase in size of all sufficient penetrating ability and sensitivity.
displayed signals, and sets the overall gain of the Increasing the damping decreases the amplitude
receiver, which is independent of range. of all recorded echoes and is similar to
decreasing the total gain.
TGC
Time gain compensation (TGC) or depth DELAY
compensation control is an adjustable amplitude Delay adjusts the starting point of the
correction to increase or decrease the echo oscilloscope display, and the crystal artifact as
intensity in any given region of the field. It was well as other near field echoes can be moved out
originally designed to compensate for the loss of of the visual display. Selected segments of tissue
sound energy with increasing distance due to may be displayed in the far field. Delay actually
tissue attenuation. Newer systems make it helps to determine where the TGC curve
possible to selectively enhance or depress any starts.
part of the field.
DEPTH
DAMPING The amount of tissue or field represented on the
The damping control regulates the oscillation of oscilloscope or television face can be varied
the transducer. By reducing or damping from 5 to 40 cm in most commercially available
transducer ringing from the excitation pulse, it systems.

22
INTENSITY DIGITAL READ-OUT
Brightness of the trace for all display modes may A computer types patient information and scan
be adjusted manually. identification which can be introduced directly
onto the television display, and may then be
FOCUS photographed. Electronic calipers measure di-
The beam can be focused for optimal display. mensions instantaneously on the monitor.
Focusing should be performed after intensity is RECORDING
adjusted.
A permanent record can be obtained on photo-
graphic film of the 35-mm, 70-mm, or Polaroid
ASTIGMA TISM
type. X-ray film can also be used. Videotape
Astigmatism may be incorporated into the focus systems and multi-imagers may be adapted for
system so that the focusing process can be permanent displays.
refined further.
ARTIFACTS IN ULTRASONOGRAPHY
GRATICULE
A reference scale for measurements, the grati- Difficulties in scanning due to bone, gas, and
cule's illumination can be adjusted. Parallel radiographic contrast will be discussed in this
transverse and longitudinal lines form a pattern section. Echoes from internal structures vary
of squares. according to acoustic impedance, organ size and
shape, tissue attenuation from overlying
SCALE structures, and organ depth. Artifacts may result
The field may be varied in increments of 0.5 to 3 when the ultrasound beam is not perpendicular
cm per square, which is valuable for examining to the skin surface, and from organ contour and
smaller organs. image distortion due to beam width. Echoes in
the near field, close to the transducer, may be
MAGNIFICA TION lost in the "dead zone" of the beam due to
continued oscillation of the crystal during the
The echoes displayed can be magnified by either
receiving phase. Newly designed low-pulse-
rescanning on a smaller scale per unit square or
voltage units with effective damping systems
by electronically "zooming" the image
compensate for this problem.
presented on the television monitor.
Reverberation artifacts are recognized by their
CONTRAST ENHANCEMENT
periodicity and decreasing echo amplitude on the
Newer gray-scale units offer scan converter A-mode and B-mode. These occur when sound
tubes that make it possible to emphasize various encounters a highly reflecting interface, such as
shades of gray to maximize the information bone or air. The loud-echo artifact, distal to a
display. strongly reflecting surface and appearing as an
echo-free region immediately following the
ERASE strong echo, is due to crystal reverberation. It is
An erase switch clears the oscilloscope or noted on the A-mode as echoes elevated from
television tube so that a new scan can be started. the baseline (22). This artifact is frequently noted
when the gallbladder and edematous renal
CENTER transplants are scanned. Lowering the
sensitivity permits the echoes to return to the
The scanning beam must be centered over the
baseline and the echo-free artifact disappears.
oscilloscope field, either manually or
automatically. Distortion caused by misalignment of

23
potentiometers in the scanning arm and changes used in therapeutic ultrasound as compared with
in the preset determination of acoustic velocity diagnostic insonation. In diagnostic work, the
may be detected by frequent calibration with an power of ultrasound is on the order of mW/cm 2 •
acoustic phantom. The energy levels used in physiotherapy are
thousands of times greater and are sufficient to
BIOPHYSICAL EFFECTS OF produce measurable heat in biologic tissues (28).
ULTRASOUND Still greater power is used in such surgical
applications as ablation of nerve endings and
The unexpected and tragic experiences resulting destruction of normal and abnormal areas of the
from the early applications of diagnostic brain for neurosurgical therapy (29).
radiology and the great physical and psychologic Tissue damage may occur at ultrasonic power
trauma produced by uncontrolled use of X rays levels many thousands of times greater than cur-
have alerted the ultrasonographer to extreme rently used diagnostic beam intensities. Simple
caution in the use of ultrasonic investigation in agitation may cause cellular membranes to rup-
human beings. Ultrasonographers have carefully ture at high frequency. Elevation of tissue tem-
attempted to maximize their efforts to obtain perature and cavitation occur during prolonged
diagnostic interpretations with minimal exposure to high-energy sonic waves. Chemical
ultrasonic energy input into the adult and fetal changes include a change in pH caused by the
organ systems. release of radicals and increased tissue oxidation
rates. Also noted are increased membrane
During clinical applications, the possible genetic permeability and greater enzymatic activity.
and somatic changes have been constantly moni- Since ultrasound is nonionizing, cumulative ef-
tored throughout the short- and long-term pe- fects are not to be expected (30).
riods. Many carefully controlled experimental
studies have been performed to determine the Ultrasonic waves with very high energy levels
various parameters of safe ultrasonic exposure. are used in cleaning mechanical devices,
Even at this stage ofthe development of ultra- polishing metals, and drilling.
sound, we have had limited experience with the
As mentioned, the damaging effect of ultrasound
long-range effects. Whether the ultrasonogra-
depends upon the energy range and physical
pher's fingers will fall off in 20 years from exces-
characteristics of the sonic beam. The ultrasonic
sive handling of ultrasonic equipment or whether
energy is the product of the measured radiation
he will show no detectable physical damage or
and the sonic beam velocity, which is translated
definite chromosomal changes is totally unpre-
into watts. The intensity of the beam is the
dictable at present. However, according to the
power per unit of specific cross-sectional area
latest experimental reports and worldwide corre-
or, actually, watts per square centimeter (W/
lation of data on ultrasonic side effects, there is
cm 2). The intensity of power of an ultrasonic
no substantiation of any harmful effects due to
beam usually is calculated from the electric input
use of ultrasound at the energy levels encoun-
to the corresponding transducer. This
tered in current diagnostic scanning units. The
measurement is an estimated value because the
collected data of many investigators have re-
sound intensity suffers from complex variations
vealed that there is an extremely large margin of
of the pulse shape and spatial distribution of the
safety at acoustic energy levels used in diagnos-
beam energy.
tic ultrasound. Numerous publications based on
clinical and laboratory findings have docu- There are many reports regarding the biologic
mented that to date there is no evidence that this effects of ultrasound in clinical application (31-
level of ultrasonic energy has any deleterious 33). The work of Hellman et al (34) has revealed
effects, whether genetic or physical (23-27). no evidence of fetal or maternal damage. In our
experience over the past five years with a large
Widely differing energy and power outputs are number of patients who have undergone a

24
variety of ultrasonic examinations involving with ultrasonic sectional anatomy and a knowl-
such areas as eye, thyroid, heart, brain, edge of anatomic pathology and surface topogra-
abdominal organs, and pregnant uterus, we have phy are extremely important. Comprehension of
not found any deleterious effects thus far. organ relationships and their normal ultrasonic
However, we are still following our data. patterns is necessary to evaluate the extent of
disease and the involvement of adjacent struc-
Macintosh and Davey (35), in 1970, reported an tures by pathologic processes. Two-dimensional
increased number of chromosomal aberrations ultrasonic imaging uses pulses which have a fre-
after exposing human leukocyte cultures to low- quency of2 to 3.5 MHz. At this frequency the
level diagnostic ultrasound; but in their second beam has physical characteristics which allow
study (36) they reported that chromosomal the sound to be concentrated into a narrow beam
aberrations did not occur below the level of 8.2 and easily manipulated in a directed column of
mW!cm2 intensity. waves capable of penetrating the body to a depth
of approximately of 20 to 30 cm of soft tissue.
At present we conclude, on the basis of all
existing evidence, that there are most likely no
significant somatic changes produced by the PATIENT PREPARATION
energy level of the diagnostic range of
ultrasound. The possibility of delayed genetic In most instances there is no need for patient
effects remains questionable. preparation. In obstetric and gynecologic
examinations the bladder should be distended to
delineate pelvic organs and to increase the
GENETIC EFFECTS OF ULTRASOUND penetration of the ultrasonic beam. To study the
pancreas, it is preferable that the patient be NPO
The increased use of ultrasound in fetal and (nothing per mouth, or fasting state) since it may
maternal disorders and its recent application to be necessary to insert a nasogastric tube to
the male testis requires investigation into the suction out gastric air or instill gasless water to
potential genetic hazards of clinical distend the stomach and outline the duodenal
ultrasonography. An excellent in vivo study (30) contour.
of mouse gonads insonated at levels up to 20
times the intensity of currently used ultrasound Scanning causes no discomfort for the patient
energy revealed no evidence that dominant and in many situations is similar to fluoroscopy,
lethal mutations or sterility are induced in male in that the patient must be positioned properly
mice. Follow-up for 8 weeks demonstrated no and the image on the screen monitored
drop in testis weight or sperm count and no constantly. After the area to be scanned is
induction of translocations or chromosome exposed, mineral oil is usually applied to the skin
fragments in spermatocytes (30). Altqough the surface to prevent an air gap, which would
risk of genetic derangement from ultrasound markedly reflect sound between the transducer
appears to be slight, its carcinogenic effect may and the area involved. Complete contact
not have been fully evaluated in humans at this between the surface of the applicator of the real-
early stage in the widespread application of time scanner and the skin surface is obtained by
ultrasonography to the general population. using an ultrasonic gel.
PRACTICAL ASPECTS OF DUTIES OF THE TECHNOLOGIST

SONOLAPAROTOMY
The ultrasonographer should clearly understand
In sonolaparotomy proper direction of the beam the various methods of examination and proper
toward a specific organ is essential. Familiarity control settings of the scanning machine used.

25
Patience and search are basic to good manding. The examiner must make a final inter-
ultrasonography. The method of study changes pretation before the procedure is terminated. A
the quality of echo display. Each type of specifically trained nurse-technician can perform
commercially available instrument has its the study; however, the physician-in-charge
characteristic image production. For this reason, should be in constant attendance for consulta-
each unit functions with its own criteria, and the tion and interpretation of specific findings shown
art of ultrasonography is to extract maximum on the Polaroid. For example, during a routine
information from a specific unit. study of the liver for metastases from an un-
known source, a hypernephroma of the upper
However, certain techniques and criteria are
pole of the right kidney may be incidentally
essential for basic studies. These include the
discovered.
ultrasonographer's familiarity with the following
technical considerations.
1. Arrangement of a proper TGC curve
POSITIONING THE TRANSDUCER
on the oscilloscope for the study of a
specific organ
2. Selection of the proper transducer The transducer acts as a transmitter and receiver
and the time between sonic emission and
3. Familiarity with a system of returned echo is a measure of the depth of the
identification reflecting surface. Maximum reflection is
4. Changing the gain setting as needed achieved when the organ of interest lies
5. Selection of the rate of sectoring perpendicularly to the sonic beam. Any degree
of tilt of the transducer or reflector diminishes
6. Knowledge of the types of scanning
the intensity of the echo, and the signal may
(eg, linear, compound, arc, or sector)
even be lost. In certain cases, difficulty in
7. Study of the patient in mUltiple positioning the transducer and factors such as
positions obesity can attenuate the returned ultrasound.
8. Maintenance of a minimum of eight
shades of gray in gray-scale units One aspect of the art of ultrasonography is to be
aware of target displacement from the trans-
9. Familiarity with the use of real-time ducer and make corrections. Selection of a
scanning proper scanning speed is important if every echo
10. Knowledge of the ultrasonic produced is to be recorded (37). If the scanning
limitations of sonography speed is too fast, many reflected echoes will be
11. Detection of through transmission missed by the receiving transducer. If the speed
pattern in combined A-mode and B- is too slow, artifactual echoes may be produced
mode for better evaluation of because the reflected sound will have a higher
pathology signal concentration in specific areas at a given
period of time. The rate of transducer motion
should be constant regardless of the scanning
speed. When a normal technique is not applica-
PHYSICIAN PARTICIPATION ble, other variations must be devised. Changes
may be made in the transducer, patient position,
Ultrasonography is similar to creating a painting . scanning plane, or scanning mode. For example,
The task of the operator is to display the echoes a I-MHz transducer may salvage a study in
from a lesion and demonstrate its shape, loca- which a 2.25-MHz transducer cannot penetrate
tion, and texture. Ultrasonography is far more excess subcutaneous fat; in renal scanning hy-
delicate than fluoroscopy in that pathology de- perextension of the patient may permit better
tection and physician performance are more de- delineation of the kidney; multiple scanning

26
planes are generally necessary to visualize the
entire placenta; and minimal ascites may not be
T detected on routine supine B-scanning but appli-
cation of the A-mode transducer to the depen-
dent anterior abdominal wall will demonstrate as
little as 100 ml of free fluid. M-mode and real-
(a) time scanners may be used to verify the pulsa-
tion of a vascular structure.
TYPES OF SCANNING
/ \ There are several types of scanning, as follows.

/ \ (b) 1. Manual B-scanning
a. Linear scan (Fig. 1.19a)
b. Sector scan (Fig. 1.19b)
c. Compound scan (Fig. 1.19c)
d. Arc scan
2. Automated B-scanning
3. Real-time scanning
(e)
FIGURE 1.19
Types of scanning. (a) Linear scan. Sound beam THREE-DIMENSIONAL
perpendicular to the skin surface. (b) Sector scan. CONCEPTUALIZATION
Transducer rotated about a fixed axis. (c) Compound scan.
Combination of linear and sector scan. T, transducer.
In ultrasonography the examination of the organ
is performed in various specific planes. These
include the transverse and longitudinal planes,
but may also include oblique and decubitus or
erect scanning positions. The area of pathology
must be confirmed in at least two planes. The
shape, location, and configuration of the lesion
should be evaluated by right-angle scanning to
produce a three-dimensional representation of
the region of pathologic interest. In order to
produce complete mental integration of the scan
data, the examiner should continually
concentrate on the images appearing upon the
oscilloscope and link them together in his mind
as they are produced and erased. In this way, the
ultrasonographer has a mental image of the area
scanned which is formed from two right-angle
scan planes to produce a total three-dimensional
summation of the two-dimensional pictures.
Thus, two Polaroids at perpendicular scan
planes can document the lesion which is
extrapolated to a three-dimensional

27
conceptualization by the sonographer's
understanding of the scan data.
For example, if a right lateral placenta is scanned

in the longitudinal midline plane, the anterior
and posterior extensions of the placenta may
simulate twin placentas (Fig. 1.20a). This situa-
tion is resolved by right-angle scanning or simply
following the images produced as the scan pro-
ceeds toward the right side and the leaves of the
placenta fuse to form the lateral-type placenta
(Fig. 1.20b). Similarly, a fundal placenta extend-
FIGURE 1.20(a) ing anteriorly, posteriorly (Fig. 1.21), and to the
Supine longitudinal scan. Finely stippled echo patterns of
both an anterior and a posterior segment of the placenta is
right and left walls of the uterus may appear as a
demonstrated. The anterior and posterior extensions of the placenta which completely rings the uterus on a
placenta may simulate twin gestation. To avoid this problem transverse scan (Fig. 1.22). This problem is cor-
mUltiple sectional studies are needed.
rected when the mental image of complete trans-
verse scans shows the placental echoes to fuse
toward the fundus and fade toward the cervix
(Fig. 1.23a and b). A longitudinal midline scan
would serve the same purpose to demonstrate
the nature of the basically fundal-type placenta.
A similar problem exists when the echogenic

wall of the gestational sac is sectioned
tangentially, producing a dense area of echoes
within the uterine cavity . Confusion is generally
quickly resolved when more information is
obtained by mUltiple sequential scans in
combination with right-angle sectioning for
FIGURE 1.20(b)
Supine transverse scan. Gray scale. The right and left leaves further clarification.
of the placenta fuse to form the lateral-type placenta.
It is important in ultrasonic scanning that areas
of abnormal echoes must be reproducible in
mUltiple scan planes. This double check
FIGURE 1.21
Supine longitudinal scan. Gray scale. A midline scan shows prevents the diagnosis of pathologic conditions
the placenta covering practically the entire uterine cavity . A when confusing echo patterns are produced as
smaU portion of the uterus near the internal os is free of either normal variants or artifacts due to motion
placental echoes.
(Fig. 1.24).
ULTRASONIC IDENTIFICATION:
PRINCIPLE OF SECTIONAL SCANNING
Evaluation of ultrasonic studies requires a

complete three-dimensional representation of
organs and areas of pathologic significance. As
the application of ultrasound in medicine
increases, more information can be obtained. A
CHAYI'ER 1: PRINCIPLES OF ULTRASONOGRAPHY

28
Irecise and accurate identification system makes
: easier to interpret an echogram. For this
eason special scanning planes are needed to
lerlorm the study and to obtain a corresponding
onie pattern to compare with routine
adiographs. The system of identification in
orne ultrasound departments uses the umbilicus
.s a reference point. In supine positions
ectional scanning (transverse and longitudinal)
1IGURE 1.22
FIGURE \-22 :upine transverse scan in case shown in Fig. 1.21. Gray
cale. Scan in this plane shows the placenta to completely
ne the visualized uterine cavity.
l!GURE 1.23(a)
FIGURE 1-23a .upine transverse scan. A serial complete transverse scan
hows the placental echoes to fuse toward the fundus.
'IGURE 1.23(b)
.upine longitudinal scan. A serial complete longitudinal scan
hows the placental echoes to fuse toward the fundus.

29
planes are obtained by considering the umbilicus
as the zero point. Sections above and to the right
of the umbilicus are designated as plus cuts and
sections below and to the left are called minus
sections. We have been using a different
identification system for upper abdominal and
pelvic ultrasonography to avoid disadvantages of
the above system, which are as follows.
1. It is necessary in many instances

(especially in studies of the upper
abdomen) to compare ultrasonic
photographs with corresponding
FIGURE 1.24 radiographs. When the umbilicus is
Supine longitudinal scan. A longitudinal midline scan used as a topographic reference point,
demonstrates the motion artifacts in the chorionic plate, fetal information which can be used to
head, and posterior wall of the bladder.
compare radiographic studies with
ultrasonic sectoral scanning is not
obtained, unless a lead marker is
attached to the umbilicus before the
patient is exposed to X rays. The
position of the umbilicus varies in many
pathologic conditions and even among
normal young and old individuals.
Indeed, it may be surgically absent.
Since it is not a fixed reference point,
the exact echogram cannot be
reproduced on repeat examination in
many pathologic conditions (eg, ascites,
abdominal mass) after a lapse of time.
2. Absence of use of prone, decubitus,
angled, and oblique scanning planes.
REFERENCE POINTS
Experience has shown that many obstacles
present in previous studies would be avoided if a
fixed structure in the body was used as a
reference point (38). We use the xiphoid process
of the sternum, symphysis pubis, and crest of the
ilium as reference points.
ANTERIOR PROJECTION
ATC series
In the anterior projection, if a line is drawn
between the two iliac crests, it will pass approxi-
mately through the plane of the umbilicus. This
line or plane represents the zero point and is
,:alled the ATe (anterior transcrestal) plane. All
sections above this plane are known as A TC-

30
plus (eg, ATC+I, +2, +3), and all sections be- ultrasound refers to the side of the examination
low this plane are called ATC-minus (eg, closest to the sonic beam. Sections above the
ATC-I, -2, - 3), Each number corresponds to iliac crest are called RDC- LDC-plus.
the distance in centimeters from the ATC plane.
Longitudinal decubitus
In scanning the pancreas, the hilum of the right
In longitudinal sections the axillary line becomes
kidney is localized and oblique sections are
the reference point. Therefore, all sections
made between the hilum of the right kidney and anterior to the right (RDA) or left (LDA)
the spleen. These slices are called KP (kidney- decubitus axillary line are plus sections, and all
pancreas) sections. sections posterior to the axillary lines are minus
LXP series sections.
The line or plane between the xiphoid process
and symphysis pubis in normal individuals also ERECT PROJECTION
crosses the umbilicus and is called the LXP line If the patient is sitting, instead of the term
or plane. The LXP plane transecting the decubitus (D) we use the term erect (E), and
midportion of the body is designated as LXP-O abbreviations such as REC or LEC and REA or
and all the sections toward the patient's right LEA are used.
side are known as LXP-plus (eg, LXP+ 1, +2,
These views are specifically used to study the
+ 3), while sections toward the patient's left side
chest wall, as for pleural effusion, and to
are called LXP-minus (eg, LXP-l, -2, -3).
evaluate the effect of gravity on abdominal
POSTERIOR PROJECTION structures, ptotic organs, or positional changes
of organ relationships in normal and abnormal
PTC series
conditions in the supine, semierect, and erect
In the posterior projection the transcrestalline or
positions.
plane represents the zero point and is called the
PTC (posterior transcrestal) plane. The ANGULATION
transcrestal plane is PTC-O and all sections
If the transducer is pointing toward the head or
above this plane are known as PTC-plus (eg,
the right side, the degree of angulation relative to
PTC+ 1, +2, +3).
the perpendicular body section is designated as
PLS series plus. If the transducer is pointing toward the feet
The spine is also used as a reference point for or the left side it is designated as minus. For
posterior views and sections, and is called the example, A TC + 2 + 15° is the section 2 cm above
PLS (posterior longitudinal spine) line or plane. the transcrestalline in anterior projection with a
PLS-O indicates a midline scan. Sections toward 15° angulation toward the head.
the right side of the spine are called PLS-plus
sections (eg, PLS+ 1, +2, +3), and those toward SUBCOSTAL AND INTERCOSTAL SECTIONS
the left are called PLS-minus sections (eg, Subcostal sectional study starts at the xiphoid
PLS-l, -2, -3). process and runs parallel to the ribs from the
xiphoid. Intercostal section is similar to
DECUBITUS PROJECTION subcostal section. On the right side it is called
Transverse decubitus right subcostal (RSC) section, and on the left
In the lateral projection, with the patient lying on side it is called left subcostal (LSC) section. The
his side, the crest of the ilium is the zero point rib itself is the zero point. Thus, RSC-O is
and all planes above it are plus cuts. If the meaningless because the rib produces a sonic
patient's right side is up he is said to be lying in shadow. The sections below the pertinent rib are
the right lateral decubitus (RDC) position, and if numbered accordingly. For example, RSC-ll is
his left side is up he is in the left lateral decubitus a section below the lIth rib on the right side, and
(LDC) position (right decubitus crest or left LSC-l1 is the section below the II th rib on the
decubitus crest). The term decubitus in left side.
CHAPTER 1: PRlNCIPLES OF ULTRASONOGRAPHY

31
TRANSDUCER CONTACT
Various scanning planes are utilized during a

routine study. If the plane of interest does not lie
perpendicularly to the body surface, acoustic
contact may be impaired. As a result a large
number of echoes are lost during scanning if
sectional planes are perpendicular to the table
rather than to the patient. To prevent loss of
contact at curved areas of the body, the
Sonic examiner must direct the transducer
shadow perpendicularly to the body contour to achieve
maximum beam intensity.
FIGURE 1.25
Supine longitudinal scan. Gray scale. Scan shows an echo- In scanning over scar tissue sonic shadow (Fig.
dence linear structure in the deep subcutaneous tissues which 1.25) may prevent the obtaining of adequate in-
casts a sonic shadow. Calcified scar due to 20-year-old formation, and the best maneuver would be to
incision.
scan obliquely at the edge of the scar tissue. This
may occur after scarring of C-section (Cesarean
section).
SENSITIVITY SETTING OR
ATTENUATION STUDIES
As in routine EKG tracings, the

ultrasonographer should establish a standard
baseline sensitivity setting for each organ to
avoid confusion in interpretation. After each
study or section, the attenuation may be changed
to differentiate various components of an organ,
or cystic from solid masses.
The frequency of ultrasound determines the
average attenuation beam pattern (12). Using a
higher frequency and a shorter sonic pulse a
narrower beam may be obtained, which
increases resolution. By lowering the frequency,
however, deep structures can be visualized
better. At higher frequency, deep structures
reflect weak echoes (12). These produce serious
problems in diagnosis, and can be corrected by
adjusting the time gain compensation (TGC)
control. The TGC corrects for higher average
absorption (39). This adjustment must be made
when an organ returns echoes at a certain
frequency but does not return them at another
frequency. In this case the pattern of the beam

32
from the transducer has changed or the receiver over the pelvic region with the bladder as a
is not properly compensating for average baseline, and then moved over the area of
attenuation loss. pathologic interest for further evaluation. In this
fashion, confirmation of a cystic lesion is readily
made and the nature of the mass can be
determined. In addition to its use in pelvic
GAIN SETTING OR TGC CHANGE DURING disorders, this method may be used in many
STUDY other areas of the body. The differential
diagnosis of a thyroid cyst from a solid tumor is
Opinions vary regarding changing TGC settings made with certainty when the cystic lesion is
during scanning. One group is in favor of compared to the cystic cavity of the globe of the
changing the TGC during the study if it is eye as the transducer is shifted over the closed
necessary (40), because the attenuation of sonic eyelid. Similarly, the gallbladder is used as a
waves varies in different organs. Consequently, cystic reference point in upper abdominal
it is difficult to outline the entire organ in one scanning if it is distended.
plane with a fixed attenuation. On the other
hand, changing the attenuation control during
the examination may produce artifacts. These
problems are avoided with gray-scale systems. FACTORS ALTERING NORMAL
ACOUSTIC IMAGE
There are certain limitations to, and problems

COMPARATIVE STUDIES AND SHIFTING
METHOD inherent in, each study. Some can easily be
avoided; others, which are extremely difficult to
When difficulties exist in distinguishing a purely prevent, include the following.
cystic lesion from a complex mass or solid mass 1. Respiratory motion.
with few internal echoes, comparative studies
2. Marked dehydration, which can be
with the contact scanner or use of the shifting
avoided by proper hydration.
method with the real-time scanner may help to
eliminate the uncertainty. A known fluid-filled 3. Gas in the bowel. Gas interferes with
body cavity such as the distended bladder may sound transmission and the deep
be taken as a cystic reference standard during abdominal and retroperitoneal regions
scanning. The gray-scale unit or real-time cannot be properly evaluated.
scanner is adjusted for the known cystic Therefore, the study should be repeated
structure so that it is displayed on the after the patient has been given a
oscilloscope as an echo-free area with distinct laxative and a cleansing enema. When
borders. Comparison between the bladder and excessive gas is present in the stomach,
the suspected mass lesion is then made while the semierect position allows the gas to
scanning to obtain both in the same slice. This is rise to the fundus where it will not
most easily performed with the contact scanner interfere with the scan of abdominal
when using a real-time scanner. The comparison organs. As previously described, bone
method may not be easily done if the suspected effectively blocks the ultrasonic beam
cystic pathology is at a great distance from the and no information is gained distal to a
bladder, since many real-time transducer heads bony structure.
or applicators are of limited length.
4. Presence of radiographic contrast
The shifting method is a form of sonofluoroscopy material in the gastrointestinal tract.
where the applicator of the unit is first placed Water-soluble contrast in the

33
gastrointestinal tract does not alter scanning in this plane. Three-dimensional
gross anatomy nor the transmission of visualization is obtained when the area
ultrasonic waves through the abdomen. perpendicular to the markings is scanned.
With barium in the gastrointestinal
tract, however, even with a high-gain MARKING THE BODY WITH THE TRANSDUCER
setting, only the anterior aspect of the By convention, the symphysis pubis is marked
bowel is detectable for imaging (41). with an angle and the umbilicus or transcrestal
Barium blocks the passage of plane is designated by a perpendicular line.
ultrasound to organs located behind
barium-filled bowel loops. This problem
MARKING THE POLAROID PICTURE
can be detected by a plain film of the
abdomen and a history of contrast For complete information (as in X-ray
examination. techniques) each Polaroid should have at least
two figures on the front. The first figure
S. Deep mediastinal area and lung represents distance from reference points (either
pathology cannot be evaluated by transversely or longitudinally) in centimeters.
ultrasonography because the air- The second figure is used to show the gain
containing lung transmits ultrasound setting, sensitivity setting, or attenuation. A
poorly. third number may be used to designate the angle
6. The pelvic bone prevents evaluation of of tilt. The name, date, age, and sex of the
structures deep in the pelvic cavity. patient will appear on the back of the Polaroid,
Evaluation of this area can be improved or these data may be digitized onto the scan by a
by using an internal transducer. computer. After each Polaroid is labeled, it is
7. Resolution of systems. At present, good practice to string each in sequence on a
commercially available strip of masking tape.
ultrasonographic units have limited
resolution, and deep intraabdominal VISUAL ORIENTATION OF POLAROID PRINTS
structures, smaller than 1 cm in Anterior abdominal transverse scans are viewed

diameter, cannot be evaluated by from below. Longitudinal scans are viewed from
conventional presentation or gray scale. the left side of the patient in the supine, and from
the right side of the patient in the prone position.
ORIENTATION
TOPOGRAPHIC MARKING OF SUSPICIOUS AREA SIMULTANEOUS DISPLAY OF A-MODE

In any ultrasound department, a water-soluble WITH B-SCAN
dye or grease pencil should be available so that
an organ or area of interest can be marked upon During the course of B-scanning, any anechoic
the skin. Multiple markings of suspected pathol- or echo-free area can be verified by A-mode. For
ogy will allow this area to be scanned in the example, the aorta is detected and identified by a
plane delineated on the skin. If the area is con- narrow, echo-free area between two high spikes
stant in this plane and also demonstrated in a that exhibit a characteristic "to-and-fro" motion
perpendicular plane, then it is a true area of on the A-scope.
disease as opposed to artifact (37).
Because of the nature ofthe electronic threshold
ORIENTATION OF SCAN of the B-scan, an echo oflow intensity will not
The ultrasonographer can find the true be registered; hence, a mass with few internal
orientation of an organ or area of pathology by echoes may be considered cystic in the B-mode.
making appropriate markings on the skin and On the other hand, the small internal echoes

34
displayed on the A-scope greatly add to
diagnostic accuracy. Also, echo artifacts of gas
and bone as well as the "loud echo" artifact
from a relatively sonolucent area can be
observed on the A-scope and corrected.
TISSUE ECHO PATTERN
We use the following definitions for the

evaluation and differentiation of echoes from
different biologic tissues.
rlUUKC 1 . ~O
Supine longitudinal scan. Gray scale , bladder moderately ECHOGENIC

distended . Uterus is well seen posterior to the bladder; an
ovarian cyst is demonstrated cephalad to the bladder. This is The term echogenic is used to denote the
an example of an echo-free lesion. There are no internal presence of internal echoes within organs with
echoes; the distal boundary is well identified. complex interfaces of various anatomic,
heterogeneous structures.
ECHO-FREE
Echo-free areas have no internal echoes at

maximum gain settings of the ultrasonic unit.
The borders of the echo-free zone may be sharp
or irregular. The distal boundary of the echo-free
region must always be identified. Cysts are
examples of echo-free structures. (Fig. 1.26).
ECHO-POOR
FIGURE 1.27
The term echo-poor signifies the presence of
Supine longitudinal scan. Note dumbbell-shaped uterus with scattered, homogeneous, or nonhomogeneous
caudal bowing of the bladder wall. Sharply outlined distal low-amplitude internal echoes within a range of
wall of the fundal portion of the fibroid uterus indicates
moderate degree of cystic degeneration. Note low-amplitude interest. The borders may be well defined or
internal echoes. This is an example of an echo-poor region indistinct. This echo pattern is often seen in
leiomyomata (Fig. 1.27).
ECHO-RICH
The term echo-rich implies the presence of high-
amplitude echoes occurring at medium
sensitivity settings. The outlines of the echo-rich
area may be intact or interrupted. Echo-rich
areas are found in many solid tumors (Fig. 1.28).
,
ECHO-DENSE
'/ Echo-dense zones are filled with high-amplitude

echoes at low sensitivity. This is most commonly
noted in areas distal to cystic lesions (Fig. 1.29).

35
SONIC SHADOW SIGN
Ultrasonic waves are mechanical entities, and

will propagate at a rate depending upon the
elasticity and density of the medium (38). The
acoustic impedance and the velocity of
propagation are two main factors in determining
the nature or density of the medium. Water, soft
tissue, and blood have similar velocities of
propagation for sonic waves and similar acoustic
impedances (38). Grossly, these media are
homogeneous and practically no refraction of the
beam will occur during passage through these
FIGURE 1.28 media.
Supine longitudinal scan. Gray scale. This fibroid uterus is
rounded with a low- and high-level internal echo pattern. The velocity of ultrasonic waves in bone and
Compare the area of poor echoes with the area of rich their acoustic impedance therein is high. Thus, a
echoes. Echo-rich areas are found in many solid tumors.
large amount of refraction of the beam in a new
direction will occur. There is a high absorption
of sonic waves in bone. Similar conditions are
also noticeable in heavily calcified organs or
organs containing calculus. As a result of high
absorption of the ultrasonic beam in bone,
heavily calcified organs, or calculus, there are no
sonic waves beyond these structures. The
acoustic impedance of air is low and as a result
there is no propagation of ultrasonic waves in an
air-fluid interface. This dominant interface
causes complete reflection, or bounces back all
ultrasonic waves. Thus, air, bone, heavily
calcified organs, and calculus are barriers to
FIGURE 1.29 ultrasound.
Supine transverse scan. Gray scale. The echo-free ovarian
cyst is well circumscribed and the posterior wall is sharp with The absorption of osseous structures, calculus,
high through transmission. Adjacent to it is an irregular
fibroid uterus, where the sonic beam is attenuated. Areas of and heavily calcified organs, or the complete
high through transmission are echo dense. reflection of sonic waves at an air-fluid interface,
causes a sonolucent area which is called a sonic
shadow. The sonic shadow should not be mis-
taken for sonolucent structures. It is usually a
tubular area beyond the calculus or air-filled
loops of the intestine, for example, and extends
downward, if the transducer is perpendicular to
the area. However, by changing the position of
the transducer, the echo itself can be produced
beyond the calculus or air-fluid loops of the in-
testine. This should not be mistaken for sonolu-
cent structures or pathologic conditions. The
through transmission should always be carefully
investigated to avoid a false impression of sonic
CHAPfER 1: PRINCIPLES OF ULTRASONOGRAPHY

36
shadow, especially during angulation of the
transducer.
In summary, the sonic shadow will occur when
the ultrasonic beam hits bone, calculus, heavily
calcified organs, or an air-fluid interface (Fig.
1.30a and b), thus causing a sonolucent area
behind these structures. It should not be
mistaken for a pathologic condition. For better
evaluation of this false impression, the
transducer should be moved perpendicularly to
the area of interest to investigate the through
transmission.
FiGURE l.30(a)
Supine transverse scan. Gray scale. Below the echoes of the DETECTION OF THROUGH
distal bladder wall-uterus interface is a total sonic shadow.
Air or calcium will produce a total acoustic shadow. Gas TRANSMISSION PATTERN
gangrene of the uterus is demonstrated.
Through transmission is the sound energy that
passes through a structure and is then recorded
by the receiving transducer. It is inversely
proportional to the attenuating properties of the
medium and is registered on the oscilloscope as
the number of echoes and their amplitudes at the
distal interface of the region insonated.
We designate through transmission for me pur-

poses of abdominal scanning to mean the echo
density of the reflections distal to the organ or
region under ultrasonic investigation. Character-
istically, cysts have posterior multiple echoes of
FIGURE l.30(b)
Prone longitudinal scan. Gray scale. Scan over the spine in high amplitude. We term this high through trans-
the midline shows the vertebral spinous processes and parts mission. Large, solid tumors such as fibroids
of the dural covering of the spinal canal. This is a PLS-O tend to absorb significant sound energy, and
section.
have few posterior echoes which are generally of
low amplitude. This phenomenon is called low
through transmission. In between these ex-
tremes, other levels of echo density will be ap-
propriately defined as moderate through trans-
mission. The echo density noted is related to the
effect of the TGC and reverberation characteris-
tics of the medium. Since the sound is not atten-
uated by a cyst, the TGC is overcompensating
when echoes are produced at the distal interface.
These high-amplitude echoes are associated with
significant reverberation effects. The combina-
Disos
tion produces the flood of echoes which we refer
to as through transmission.

37
To evaluate transmission characteristics of a presence of fluid-filled necrotic spaces within a
structure, the posterior border of that structure tumor increases beam transmission and the
must be identified. The distal border is visualized tumor appears on the oscilloscope as a lesion
at low-sensitivity settings when the medium is with multiple posterior echoes. At low
highly transonic, as in fluid structures and sensitivity, anterior and posterior borders of a
parenchymatous glands, such as the liver and degenerating tumor may be outlined and the high
spleen. When the medium is poorly transonic, posterior echo density may simulate a simple
the sound beam is attenuated significantly and cyst. This error is avoided by sensitivity studies
sensitivity must be increased to amplify distal in which a characteristic echogenic mass is
echoes. This is particularly true for solid, revealed as gain is increased. Indeed, certain
acoustically homogeneous tumors such as tumors have a biologic tendency to degenerate
leiomyomata and lymphomas. Indeed, (eg, leiomyomas, liposarcomas, renal cell
maximum gain settings may be necessary to carcinomas), and by demonstrating increased
faintly image the distal wall. These masses may through transmission in a previously poorly
not contain sufficient internal interfaces to transmitting tumor internal degeneration can be
produce echoes and may appear as sonolucent documented, which may aid in histosonographic
lesions. In these cases, the echo-free region is tissue typing.
differentiated from a cyst by a poorly delineated
posterior wall, indicating poor through A highly transonic structure may exhibit a low
transmission. posterior echo density when the distal interface
Through transmission does not occur when lies adjacent to bone or air. Known as a reverse
scanning over bone, barium, or air. Air sonic shadow, this occurs when a lesion's distal
interfaces reflect, bony interfaces absorb, and wall lies next to a gas-containing viscus (eg, a
heavy metals tend to scatter sound. The net renal cyst whose posterior wall lies over the air-
effect is a lack of penetration of the ultrasonic filled colon) or bony surface (eg, an ovarian
beam. During the scan, a sonic shadow is noted cyst lying over the spine). The presence
when the transducer is passed over bone, of a sharply outlined distal wall will alert the
barium, or air. If the incident sonic energy is ultrasonographer to the possibility of such
sufficient, reflection artifacts may be noted over acoustic damping, and the area should be
air and bone. The artifacts appear as a series of rescanned in mUltiple projections to demonstrate
echoes spaced at equal intervals, gradually the intrinsic, high through transmission of the
diminishing in amplitude. These electronic transonic structure.
artifacts must not be confused with echoes from
deep interfaces.
REFERENCES
Sonic shadowing is best appreciated during
linear scanning with B-mode and by
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simultaneously noting the abrupt termination of
Elect 23:626, 1928
A-scope echoes in a single high-amplitude echo. 2. Dussik KT: Uber die moglichkeit hochfrequente
During compound scanning the posterior border mechanische schwingungen als diagnostisches
of an ultrasonically shadowed region may be hilfsmittel zu verwerten. Z Neurol Psychiat
filled in with echoes, spuriously creating a distal 174:153, 1942
3. Dussik KT, Dussik F, Wyt L: Aufdem Wege zur
interface. The examiner must exercise great
hyperphonographie des Gehirnes. Wien Med
caution when scanning over bone or bowel so as Wochenschr 97:425, 1947
not to "create" an echo-free lesion. 4. Firestone FA: The supersonic refiectoscope for
interior inspection. Metal Prog 48:505, 1945
Tumors with internal degeneration permit better 5. Thompson HE, et al: Ultrasound as a diagnostic
through transmission than do architecturally aid in diseases of the pelvis. Am J Obstet Gynecol
intact masses of the same histologic type. The 98:472, 1967

38
6. Gottesfeld KR, et al: Ultrasonic placentography. 26. Mannor S, Serr D, lsaschar T, et al: The safety of
A new method for placental localization. Am J ultrasound in fetal monitoring. Am J Obstet Gyne-
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waves for detecting changes in texture in living mosome damage. Br J Radiol 45:335, 1972
tissue. Lancet 1:655, 1951 28. Lehmann JF, and Guy AW: Ultrasound therapy.
8. Baum G, Greenwood 1: The application of ultra- In Reid JM, Sikov MR (eds): Interaction of Ultra-
sonic locating techniques to ophthalmology. Arch sound and Biological Tissues. Workshop Pro-
Ophthalmal 60:263, 1958 ceedings. US Department of Health, Education,
9. Hertz CH, Edler I: Die regrstrierung von her- and Welfare Publication FDA 73-8008, BRHIDBE
zwanbewegungen mit hilfe des ultraschallimpuls- 73-1. Washington, DC, USGPO, 1973, pp 121-128
verfahrens. Acustica 6:361, 1956 29. Pennington CL, Stevens EL, Griffin WL: The use
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cian. A brief review. J Clin Ultrasound 3:69,1975 ease. Laryngoscope 80:578, 1970
11. Wells PNT: Physical Principles of Ultrasonic Di- 30. Lyon MF, Simpson GM: An investigation into the
agnosis. New York, Academic Press, 1969 possible genetic hazards of ultrasound. Br J Ra-
12. Garrett WJ, Robinson DE: Ultrasound in Clinical diol 47:712, 1974
Obstetrics. Springfield, Ill, Thomas, 1970 31. Wells PNT: Physical principles of ultrasonic diag-
13. Kossoff G: Display techniques in ultrasound pulse nosis. London, Academic Press, 1969, pp. 53-72
echo investigation. A review. J Clin Ultrasound 32. Hill CR: The possibility of hazard in medical and
1:61, 1974 industrial applications of ultrasound. Br J Radiol
14. Carlsen EN: Gray scale ultrasound. J Clin Ultra- 41:561,1968
sound 1:190, 1973 33. Freimanis AK: The biological effects of medically
15. Marich KW, Zatz LM, Green PS, et al: Real time applied ultrasound and their causes. CRC Crit
imaging with a new ultrasonic camera. 1. In vitro Rev Radiol Sci 1:639, 1970
experimental studies on transmission imaging of 34. Hellman LM, et al: Safety of diagnostic ultra-
biological structures. J Clin Ultrasound 3:5, 1975 sound in obstetrics. Lancet 1: 1133, 1970
16. Weill F, Elsenschar A, Aucent D, et al: Ultra- 35. Macintosh nc, Davey DA: Chromosome aberra-
sonic study of venous patterns in the right hypo- tions inducted by an ultrasonic fetal pulse detec-
chondrium. An anatomical approach to differen- tor. Br Med J 4:92, 1970
tial diagnosis of obstructive jaundice. J Clin 36. Macintosh nc, Davey DA: Relationship between
Ultrasound 3:23, 1975 intensity of ultrasound and induction of chromo·
17. Zatz LM, Marich KW, Green PS, et al: Real time some aberrations. Br J Radiol 45:320, 1972
imaging with a new ultrasonic camera. II. Prelimi- 37. Hassani N: Method and usage of ultrasound in
nary studies in normal adults. J Clin Ultrasound clinical medicine. J Nat! Med Assoc 67:41,1974
3:17,1975 38. Hassani N: Ultrasonic appearance of peduncu-
18. Goldberg BB: Diagnostic Ultrasound in Clinical lated uterine fibroids and ovarian cysts. J Nat!
Medicine. New York, Grune & Stratton, 1975 Med Assoc 66:432, 1974
19. Ballantine HT, Bolt RH, Hueter TF, et al: On the 39. Holm HH: Ultrasonic scanning in the diagnosis of
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Science 112:525, 1950 Br J Radiol 44:24, 1971
20. Ballantine HT, Hueter TF, Nauta WJH, et al: 40. Holm HH, Rasmussen SN, Kristensen JK: Errors
Focal destruction of nervous tissue by focused and pitfalls in ultrasonic scanning of the abdomen.
ultrasound. Biophysical factors influencing its ap- Br J Radiol 45:835, 1972
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7: 1133, 1970

39
gynecologic
ultrasound
GENERAL INTRODUCTION
Evaluation of gynecologic disease by pelvic scanning has

proven to be highly rewarding with the new high-resolution
gray-scale units and real-time scanners. However, adequate
scanning of pelvic organs in the nonpregnant female can only
be accomplished with adequate distension of the bladder,
because the sound-reflecting bowel loops of the colon and
small intestine produce a barrier to proper examination of the
pelvic organs. The bowel loops must be displaced out of the
pelvic area by the distended urinary bladder. Failure to pro-
duce this sonic window results in incomplete demonstration
of pathology and the creation of artifacts.
The pelvic structures are physiologically related organs in
close physical proximity. Because of this anatomic arrange-
ment, there may be difficulty in distinguishing ovarian from
uterine masses, since these organs generally approximate one
another. Also, completely different pathologic entities may
have similar ultrasonic appearances.
40
Analysis of altered morphology must be
modified by the internal echo pattern of the
lesion, through transmission characteristics,
and clinical and palpatory findings. A thorough
appreciation of the gross pathology of the
ovaries and uterus is necessary to fully assess
B ladde r --'&,:,.....:lL..- ... the restructured anatomy and variable echo
pattern of pelvic diseases.
Using this multifaceted approach, a nonspecific

pelvic mass may be reliably given a histologic
FIGURE 2.1(a) diagnosis. Although it may be impossible with
Supine transverse scan. Gray scale. An echo-free cystic mass
present equipment to differentiate a solid ovar-
with irregular posterior borders is distal to the bladder. This
midline mass simulates a degenerating fibroid. However, in ian tumor plastered to the uterus from a myoma-
this patient the uterus was totally removed. This illustrates tous fibroid nodule, or a focal area of marked
the importance of considering history in ultrasonographic cystic internal degeneration of a fibroid uterus
diagnosis. Irregular outline in this ovarian cyst is due to
pericystic fibrosis. from an adjacent ovarian cyst, many specific
diagnoses are now available to the clinician. De-
generative changes and inflammatory conditions
may be evaluated and the relationship of the
mass to the regional organs and its effect on the
surrounding structures may be studied.
It must be emphasized that accurate history is

essential for proper ultrasonic diagnosis. If a
complete history is not available, or if the person
performing the examination is not present during
final analysis of the scans, gross errors may be
made (Fig. 2.la and b). Also, the examiner must
be familiar with the limitations of ultrasound
described in Chapter 1.
ANATOMY
FIGURE 2.1(b)
Supine transverse scan. Gray scale. An echo-free cystic mass
with irregular posterior borders is distal to the bladder. This VAGINA
midline cystic structure developed following hysterosalpingo-
oophorectomy. Diagnosis was localized hematoma.
The vagina is a musculomembranous structure
arising from the vulva and extending to the
uterus, and is located between the bladder and
rectum.
Anteriorly, the vagina is in contact with the
bladder wall and urethra, this portion being
called the vesicovaginal septum. Approximately
one-fourth of the vagina is separated from the
rectum, which is called the cul-de-sac of Douglas
or rectouterine pouch. The anterior and poste-
rior walls of the vagina lie in close apposition
CHAPTER 2: GYNECOLOGIC ULTRASOUND

41
with potential space which lies transversely,
and , as a result, in cross-section, the canal has
an H-shape. The vagina is capable of marked
distension, such as occurs with an accumulation
of blood behind an imperforate hymen. This pa-
thology may easily be detected ultrasonically.
The upper end of the vagina is a blind space into
which is projected the lower portion of the uter-
ine cervix. The blind space or vaginal vault is
subdivided into anterior, posterior, and lateral
fornices. The posterior fornix is longer than the
FIGURE 2.2(a)
Supine longitudinal scan. Real-time scanner. In the nongravid anterior one . The vagina joins the uterus at an
state, the uterus is located between the bladder and rectum. acute angle; as a result its anterior wall is shorter
The uterus has a flattened pear-shaped configuration. than its posterior wall.
UTERUS
The uterus is a muscular organ partially covered

by peritoneum. In the nongravid state, the uterus
is located between the bladder and rectum. It has
a flattened, pear-shaped configuration (Fig. 2.2a)
and consists of two parts, eg, an upper triangular
part or corpus, and a lower cylindrical part or
cervix. The posterior surface of the corpus is
slightly convex, while the anterior surface of the
corpus is flat. The fallopian tubes originate from
FIGURE 2.2(b) the cornua at the junction of the superior and
Supine longitudinal scan. Gray scale. Bladder artifact is lateral margins. The upper segment of the
common and appears as a multilayered linear echo pattern
interspersed with amorphous dots. This disappears with uterus, having a convex configuration, is called
reduced gain settings. the fundus. From the lateral margins on either
side are attached the broad ligaments. In the
adult the uterus measures grossly 6 x 4 x 3 em,
FIGURE 2.2(c)
Supine longitudinal scan. Gray scale. The cephalic portion of in greatest dimension longitudinally , trans-
the bladder may produce echogenic artifacts when scanned versely, and anteroposterioriy, respectively. It is
while incompletely filled . Further distension generally clears slightly larger in mUltiparous women. The rela-
these artifacts.
tion between the lengths of the corpus and cervix
varies. In nulliparas, the two are of about equal
length. In multiparas, the cervix represents ap-
proximately one-third of the total length of the
organ. The bulk of the uterus consists of muscle,
and the anteroposterior walls lie almost in con-
tact. The cavity between them then appears as a
narrow slit. The cervix has an internal and an
external os. The ligaments of the uterus are the
broad ligaments, which are two winglike struc-
tures extending from the lateral margins ofthe
uterus to the pelvic wall. This divides the pelvic
CHAPTER 2: GYNECOWGIC ULTRASOUND

42
cavity into anterior and posterior compartments. SONOANATOMY
A fallopian tube is attached to the inner two-
thirds of the superior margin from the mesosal- Detection of gynecologic pathology necessitates
pinx. The other ligaments are the round and a thorough knowledge of the normal pelvic
uterosacral ligaments. ultrasonic anatomy as well as the age- and
hormone-dependent physiologic normal
The usual position of the uterus is slightly variants. The size of the uterus and ovaries
anteflexed. In examining the patient in the varies with the patient's age, menstrual cycle,
upright position ultrasonically, the uterus is and hormonal therapy.
almost horizontal and somewhat flexed
anteriorly, the fundus resting upon the bladder. The normal distended bladder is echo free,
The cervix is directed backward toward the sharply outlined, and smoothly contoured, with
sacrum. The uterine artery, which is a main high through transmission characteristics. It is
branch of the hypogastric artery, can be easily situated immediately below the anterior abdomi-
detected by the real-time scanner. nal musculature. Linear artifacts are commonly
noted along the ventral portion of the bladder
The fallopian tubes extend from the uterine paralleling the muscle planes of the abdominal
cornua toward the ovaries. They measure ap- wall (Fig. 2.2b). When the bladder is incom-
proximately 8 to 14 cm in length. Each tube has pletely filled, the cephalic border will be sliced
an interstitial portion, isthmus, ampulla, and in- tangential to the ultrasonic beam and may simu-
fundibulum. The infundibulum or fimbriated ex- late a solid echogenic lesion (Fig. 2.2c). Further
tremity is the funnel-shaped opening of the distal filling of the bladder will produce an echo-free
end of the tube, which opens into the abdominal center in this area as the bladder distends cephal-
cavity. Diverticula may sometimes extend from ically. The vagina and uterus form the dorsal
the lumen of the tube for a variable distance into boundaries of the bladder (Fig. 2.3). Superiorly
its muscular wall and reach almost to its serosa. and cranially, reflections of the small bowel are
These may playa role in the development of noted. The acoustic configuration of the bladder
ectopic pregnancy. varies according to the degree of distention of
the bladder as well as the size and position of the
normal and pathologic pelvic structures. The ov-
OVARIES erdistended bladder may produce difficulties in
the proper examination of the pelvic organs. For
The ovaries are almond-shaped and, in the adult, example, an ovarian cyst may not be ultrasoni-
they measure 2.5 to 5 cm in thickness. After cally separable from the bladder (Fig. 2.4). For
menopause they diminish markedly in size. The this reason, we study the pelvis with the bladder
ovaries are situated in the upper part of the initially greatly distended to search as much of
pelvic cavity, located in the slight depression on the lower abdomen as possible. The bladder is
the lateral wall of the pelvis between the diver- then partly emptied to a moderate size to visual-
gent external iliac and hypogastric vessels ize the pelvic organs without the mass effect of
known as the ovarian fossa of Waldeyer. The the full bladder or to separate the bladder from
ovary is attached to the broad ligament by the surrounding cystic structures (Fig. 2.5),
mesovarium. The ovarian ligament extends from
the lateral and posterior portion of the uterus to The bladder is finally emptied to distinguished
beneath the insertion of the fallopian tube at the this echo-free structure from any other adjacent
uterus. The major part of the ovary is located in echo-free zone such as an ovarian cyst or
the abdominal cavity and is free of a peritoneal bladder diverticulum.
covering except near the hilum, where there is a
narrow band toward the peritoneum covering the The vagina presents as a set of parallel lines
mesosalpinx. dorsal to the lower bladder wall. This double line

43
represents the ventral and dorsal walls of the
vagina, which diverge as the region ofthe cervix
is encountered. A bulge in the dorsal vaginal wall
is the posterior fornix (Fig. 2.6). Sufficient fluid
may accumulate in this potential space to simu-
late an echo-free cyst. Aspiration of the secre-
tions in this area will remove the cystic space.
The uterus appears on B-scan systems as an

echo-free, pear-shaped organ at low sensitivity.
Gray-scale imaging shows the tissue of the
normal uterus as a low-amplitude, diffuse
FIGURE 2·3 reflector contained within the dark gray echoes
of the outer margins. The fundus of the uterus
FIGURE 2.3
Supine longitudinal scan. Gray scale. The normal uterus may
produce a slight impression against the bladder wall. Note the
typical echo pattern of the vagina projecting from the region
of the fornix.
FIGURE 2.4
Supine longitudinal scan. Gray scale. The presence of an
overdistended bladder may produce difficulty in the imaging
of a distinct interface between the bladder and a cephalically
located ovarian cyst.
FIGURE 2.5
Supine longitudinal scan. Gray scale. Same patient as in Fig.
2.4. The bladder is now partially emptied. Note the echogenic
area separating the ovarian cyst from the bladder. We
routinely empty the bladder in all patients with pelvic cystic
FIGURE 2·4 lesions.
FIGURE 2.6
Supine longitudinal scan. Gray scale. The normal uterus may
produce a slight impression against the bladder wall. The
posterior fornix appears as an echo-free area when fluid
filled. Note the typical echo pattern of the vagina projecting
from the region of the fornix.

44
will normally produce only a slight impression
on the dorsal bladder wall (Fig. 2.6). The uterus
usually forms a variable angle with the vagina
since it assumes an anteverted position in most
women. The endometrial cavity is frequently
seen as a central, linear echo, running along the
craniocaudal axis of the uterus (Fig. 2.7a), and it
is heavier in postpartum patients (Fig. 2.7b).
This linear type of echo should not be confused
with the echo of an intrauterine contraceptive
device (IUCD) (Fig. 2.8). These echoes
disappear at low sensitivities and thus are
distinguished from an IUCD echo which may
appear identical in shape (Fig. 2.9a,b, and c).
Since the uterus has moderate through
transmission characteristics, structures such as
FIG RE 2·7 (a)
FIGURE 2.7(a)
Supine longitudinal scan. Gray scale. The endometrial cavity
is frequently seen as a central linear echo running along the
craniocaudal axis of the uterus. Note ovarian cyst.
FIGURE 2.7(b)
Supine longitudinal scan. Gray scale. The echo pattern of the
endometrial cavity is heavier during menstruation.
FIGURE 2.7(c)
Supine longitudinal scan. Gray scale. Scattered low-
amplitude echoes may be noted within the uterus
corresponding to the endometrial canal. These frequently
disappear at low gain settings, which distinguishes this entity
from an IUCD of similar ultrasonographic appearance. The
echo pattern of the endometrial cavity is heavier in
postpartum patients.
FIGURE 2-7 (b)
FIGURE 2.8
Supine longitudinal scan. Gray scale. The echo pattern of an
FIGURE 2-7 (c) IUCD is usually stepladder-shaped and does not disappear by
changing the sensitivity setting.

45
FIGURE 2.9(a)
Supine longitudinal scan. B-mode. This is a scan through four
segments of the Lippes loop.
FIGURE 2.9(b)
Supine longitudinal scan. Gray scale. The linear stepladder-
type echoes of Lippes loop are seen in the uterine cavity. A
number of echo-reflecting portions of an IUeD related to the
beam axis during the study.
FIGURE 2.9(c)
Supine longitudinal scan. Gray scale. A halo of echo-poor
tissue surrounds the centrally located IUeD. Through
transmission is increased. Localized bulging of the uterus at
this site is due to acute endometritis secondary to the IUeD.
Incidentally noted is the echo-poor outline of the rectum.
FIGURE 2-9 (a)
the rectum and the sacral curvature are generally

observed. The size, shape, and position of the
uterus depend on the age of the patient,
hormonal status, and the number of previous
pregnancies. The fundus ofthe uterus is smaller
in premenarchal and postmenopausal patients
than in patients in the child-bearing years. The
uterus generally enlarges with increasing parity.
We have noted that the through transmission of
the uterus of early pregnancy increased
compared with the nonpregnant uterus. This is
presumably due to vascular enlargement which
is noted clinically at this time. The uterine
arteries may be imaged if a high-frequency
transducer is used with the real-time scanning
system. These vessels may be seen as paired
FIGURE 2-9 (b) pulsatile structures lateral to the body of the
uterus.
The normal ovary varies in size, shape, and
position. It may vary from 2.5 to 5 cm in length
FIG RE 2-9 (e) (1). The normal ovary may be demonstrated as a
relatively sonolucent area if its size approaches
the upper limits of normal. When visible, the
ovaries appear as bilateral ovoid masses
dorsolateral to the uterus.
The parapelvic musculature is frequently
displayed in routine pelvic scanning. The
iliopsoas is shown as a broad echo-free band
noted alongside the pelvic sidewalls (Fig.
2.lOa,b, and c). In transverse scans it appears as
IUCD an elliptical, bilateral, anechoic area. This may
simulate a renal outline; however, there are no
echoes corresponding to the renal pelvic

46
FIGURE 2.10(a)
Supine transverse scan. B-mode. The echo-free. winglike
iliopsoas is symmetrically located at the pelvic sidewalls.
FIGURE 2.10(b}
Supine transverse scan. Gray scale. The iliopsoas lines the
ventral sidewalls of the pelvis with a winglike pattern.
FIGURE 2. I O(c)
Supine longitudinal scan. Gray scale. A triangle of echo-free
fluid is noted during scanning over the pelvic sidewalls.
Beneath the ascitic fluid is the bandlike configuration of the
iliopsoas.
collecting system. The muscle will fill in with

echoes at high sensitivity, distinguishing this
FIGURE 2-10 (a) structure from a cystic lesion. In longitudinal
scans a parallel set of interfaces demarcates this
muscle as it passes anteriorly upon entering the
pelvis. This is generally seen between 5 and 8 cm
lateral to the midline longitudinal scan plane.
Further caudally in the pelvis the iliacus lines the
lateral pelvic walls as a saucer-shaped, echo-free
band beyond which no sound passes due to the
attenuation of the pelvis. Laterally and
anteriorly, the external iliac artery and vein are
often noted as echo-free, tubular or rounded
structures, depending upon the scan plane. They
dre easily distinguished as to the artery or vein
by the distinctive pulsations shown with the real-
time scanner.
FIGURE 2-10 (b) Scanning of the anterior abdominal wall is very
rewarding in evaluating diseases of the
subcutaneous tissues and ventral musculature.
Areas of fibrosis due to scarring will distort the
ultrasonic beam while the presence of calcified
scar tissue produces a sonic shadow (Fig. 2.11).
FIGURE 2-10 (c)
An abdominal wall hematoma may be noted as
an echo-free area within the muscle echoes, and
is most often due to violent coughing or trauma
(Fig. 2.12). Abscess formation in the abdominal
wall may be noted in diabetic patients or patients
with regional enteritis (Fig. 2.13).
SONOLAPAROTOMY
The full bladder as described is essential to

pelvic ultrasonography. Gynecologic
examination of a patient without a distended
bladder does not yield information for diagnosis.

47
On the other hand, a distended bladder has
several advantages.
1. The distended bladder is a good
transmitting medium, and as a result the
examination of deep-seated pelvic
lesions is easier.
2. The distended bladder displaces the
bowel loops upward, which otherwise
would prevent proper ultrasonic
examination.
3. The distended bladder can be used as a
reference standard for "cystic" and
other areas, which are compared with
FIGURE 2.11 the bladder for tissue signature. For
Supine longitudinal scan. Gray scale. Scan shows an echo-
dense linear structure in the deep subcutaneous tissues which example, echogenic masses at standard
casts a sonic shadow. Calcified scar due to 20-year-old sensitivity fill in with echoes as the
incision. sensitivity is increased, while cystic
structures appear to be similar to the
bladder on the oscilloscope screen.
Other criteria described in Chapter 1
should also be considered.
The examination starts with the patient in the

supine position. Basically, the bony pelvis
prevents visualization of pelvic structure from
behind in the supine position; occasionally, a
pillow is needed under the hips to elevate the
pelvis so that the area of pathology remains
perpendicular to the sonic beam. On other
occasions, it may be necessary to elevate the
table top so that an abdominal mass descends
FIGURE 2.12 and its relationship with the pelvic organs can be
Supine transverse scan. B-mode. Abdominal wall hematoma evaluated.
may be noted as an echo-free area within the muscle. Note a
few scattered echos within the echo-free zone. Other positions, such as the oblique, are of great
value, especially for detection and evaluation of
peritoneal fluid and adhesions; confirmation or
exclusion of adhesions could alter the entire
prognosis.
Examination usually starts in the midsagittal
plane. We use LXP (longitudinal, xiphoid, pubic
symphysis) as a midline reference. Sectioning in
every centimeter yields excellent results. The
study should continue longitudinally until the
iliopsoas is clearly seen, since this structure is a
good landmark for the border of the true pelvis.
The transverse section follows the sagittal
examination. We use the transcrestalline as a

48
reference point (ATC-O). Usually it is a matter of
choice as to whether the scan is performed in an
ascending maneuver from the pubic bone or in a
descending maneuver from the transcrestalline
(the line passing through both iliac crests usually
traversing the umbilicus in a normal individual).
Additional examination may include oblique and
angled scanning.
LOCALIZATION OF IUCDs
Most of the commonly used intrauterine

contraceptive devices (IUCD) are strongly
FIGURE 2.13 echogenic and have a characteristic
Supine transverse scan. Gray scale. The patient is obese and configuration. They are readily identified in both
diabetic. Beneath the thick subcutaneous fat layer is an echo-
free zone with a few internal echoes. The margins are slightly cross-sectional and longitudinal scans at low
irregular. Abdominal wall abscess. sensitivity by their specific shapes. The linear
echoes of the endometrial cavity may simulate
an IUCD (Fig. 2.14) but disappear at low
sensitivity. In our experience, the small Dalkin
shield may be more difficult to image at present
due to its size and shape; however, this device
may be better imaged with the higher resolution
of gray-scale units. The IUCO is optimally
located when it lies centrally within the uterine
cavity near the fundus. It has proven valuable to
study the position of the IUCD immediately after
insertion rather than at a later date, since an
abnormally placed device may be replaced at
once.
When the string of the IUCD cannot be identi-
fied by vaginal examination, uterine perforation
FIGURE 2.14 of the device must be ruled out. Our experience
Supine longitudinal scan. Gray scale. At moderate gain the shows that ultrasonography is sufficiently sensi-
IUCD stands out in sharp contrast to the normally echo-poor
uterus.
tive for intrauterine detection of IUCDs (Fig.
2.15a). It has been stated that in the case of a
Lippe's loop, if the plain film reveals the loop to
be closed the IUCD is located inside the uterus,
and if the loop is open the IUCD is in an extrau-
terine location. Ultrasonographically, if the
strong echoes of the IUCD are not demonstrated
within the uterus, then the IUCD is located out-
side the uterus. The extrauterine IUCD is diffi-
cult to image since it is masked by the surround-
ing bowel echoes. The appearance of the
radiographic image of the IUCD on plain X-ray
film with evidence that no intrauterine echoes
were observed during ultrasonic scanning indi-

49
cates that the device has petforated the uterus.
In this situation, hysterography is not necessary
for diagnostic confirmation. However, to obtain
the relationship of the perforated IUCD to the
uterine cavity, hysterography with contrast is
useful (Fig. 2.15b). In spite of an optimally lo-
cated IUCD, however, intrauterine pregnancy
may still occur (Fig. 2.16).
PELVIC MASSES
The most frequent request in the ultrasound

FIGURE 2.1S(a) laboratory is to evaluate a clinically evident
Supine longitudinal scan. Gray scale. Intraluminal echoes of pelvic mass or confirm the existence of such a
strong amplitude within the uterus are aligned with regularity.
IUCD in position. mass in patients who are difficult to examine.
Frequently, due to excess obesity, poor patient
cooperation during pelvic examination, or reflex
guarding due to pelvic disease, ultrasound is the
only method of establishing the diagnosis of a
pelvic tumor of inflammatory process.
Ultrasonography may not only document the
presence of questionable palpatory findings, but
may also offer the clinician a differential
FIGURE 2.lS(b) diagnosis of the most likely possibilities.
Hysterosalpingogram. When the IUCD is located within the
uterus it is easily imaged by ultrasound. When it is outside
Ultrasonography provides an undistorted, three-
the uterus, as in this case, no intrauteri ne echoes will be dimensional spatial representation of the pelvic
noted and X rays must be taken to demonstrate the IUCD mass under study. The biologic history of the
within the pelvis. This hysterosalpingogram shows the IUCD
in relation to the uterine cavity.
pathology may be studied by evaluating the
changing ultrasonic appearance of the lesion
with serial sonograms. Such findings as increase
in tumor size, appearance of lymph node
masses, and cystic internal necrosis may be
documented. These further data sharply narrow
the differential diagnostic possibilities to that of a
malignant process. Satisfactory sequential
decrease in size of a suspected inflammatory
lesion on antibiotic therapy may obviate the
need for surgical intervention.
CYSTIC AND SOLID PELVIC LESIONS
The ultrasonic criteria for differentiation of cys-

tic and solid lesions have been presented earlier.
A brief review is useful to classify the gynecol-
ogic tumors in a practical manner. Typically,
cysts have a lack of internal echoes at low and
high sensitivity and remain the same size as the

50
\ FIGURE 2.16
Supine longitudinal scan. Gray scale. The bulbous uterine
fundus contains a gestational sac with medium-amplitude
echoes characteristic of the pregnancy ring. Within the sac
are stepladder-shaped high-amplitude echoes typical of a
Lippes loop. Coexistent intrauterine pregnancy with IUCD.
FIGURE 2.17
Supine transverse scan. Patient with epigastric mass. Liver
and kidney noted on right. Echo-free area extended from
pelvis to xiphoid process. Paraovarian cyst at surgery.
FIGURE 2.18
tational sac Supine longitudinal scan. Gray scale. The uterus is enlarged
with an irregular outline. It is generally echo poor. Areas of
high and low through transmission are noted, consistent with
FIGURE 2·16 the diagnosis of a fibroid uterus.
sensitivity is increased. The procedure by which

the sensitivity is increased, wherein cysts are
noted to remain echo free while solid lesions fill
in echoes, is known as an attenuation study. The
attenuation study is used to differentiate cystic
from solid masses and aid in the detection of
cystic internal degeneration in solid masses. It
may also be termed a sensitivity study. The
principle of measuring the sonic through trans-
mission or sonic attenuation of a lesion is ex-
tremely useful in the differential diagnosis of
pelvic tumors.
Echoes are usually obtained from the anterior

and posterior walls of cystic, complex, or solid
lesions. As the attenuation is decreased or the
sensitivity increased, the cystic lesion remains
FIGURE 2·17 echo free. This is because the ultrasonic beam is
minimally attenuated by the homogeneous fluid
(Fig. 2.17). Due to this lack of attenuation, an
echo-dense area occurs behind the distal wall of
FIGURE 2·18 the cyst which is due to reverberation-type
echoes and is amplified by the effect of the TOe
curve upon the amplitude of the received
echoes.
Lymphomas and certain lymph node masses
may simulate a cystic lesion. Solid tumors fill in
with echoes at high sensitivity. At low gain set-
tings the distal border is imaged when the sub-
stance of the mass is highly transonic or poorly
attenuating. If the tumor is highly attenuating,
the distal border may not be imaged even at
maximum gain setting. This is especially true of
Fibroid solid, acoustically homogeneous masses such as
lymphomas and leiomyomas (Fig. 2.18). Tumors

51
with internal degeneration permit better through
transmission than do architecturally intact mas-
· II ses of the same histologic type. Production of
fluid-filled necrotic spaces within a tumor in-
II
I<I/, creases beam transmission and the tumor ap-
.. - , , - C.\"sli(' an'a pears on the oscilloscope as a lesion with multi-
ple posterior echoes (Fig. 2.19). At low
,\ \, It!' I'
sensitivity, anterior and posterior borders of a
'Iii ' ~I "1' •
degenerating tumor may be outlined and the high
'" l id,: :
:1' 1 ,~ I' lL 1", ' 1 I rtf~._.L. posterior echo density may simulate a simple
cyst (Fig. 2.20). This error is avoided by sensitiv-
" T'P'
~....~,....,. .....,.........
Illaddl'J" ity studies in which a characteristic echogenic
mass is revealed as gain is increased. Indeed,
FIGURE 2.19 certain tumors have a biologic tendency to de-
A-mode confirmation of cystic structure with echo-free space generate (leiomyomas,) and by demonstrating
followed by high-amplitude echoes of distal wall.
increased through transmission in a previously
poorly transmitting tumor internal degeneration
can be documented, which may aid in histosono-
graphic tissue typing. A tumor with a necrotic
center will show the size of the echo-free space
to visibly decrease as the gain setting is
increased.
Through transmission is lower in a degenerating
solid tumor than in a simple cystic lesion.
Optimal ultrasonic analysis of the cystic or solid
nature of a lesion is obtained with the combined
use of A-mode, B-mode, and gray-scale imaging
and the application of the attenuation study as
FIGURE 2.20
Supine longitudinal scan. Degenerating fibroid uterus
previously described. With this technique, we
simulating ovarian cyst. Solid portion of fibroid uterus seen in have achieved over 96 percent accuracy in
video-display (not included in this book). evaluating cystic and solid lesions. Other solid
tumors of the pelvis which may appear echo free
FIGURE 2.21 are seen with the frozen pelvis of advanced
Supine longitudinal scan. Gray scale. Complete separation of ovarian or cervical carcinoma. In this case, the
a cyst from the uterus is documented when no part of the internal texture of the lesion remains echo free,
lesion is noted to be in continuity with the uterus or vagina.
Diagnosis of ovarian cyst. but the distal border has a lower through
transmission pattern than does a simple cystic
lesion.
ULTRASONIC CHARACTERIZATION OF
GYNECOLOGIC TUMOR MASSES
Knowledge of the gross pathology of the uterus

and ovaries allows the ultrasonographer to easily
interpret these entities as they appear in cross-
sectional and longitudinal studies during
scanning. After determining the size and shape
of the mass, the position of the tumor in

52
FIGURE 2.22(a)
Supine transverse scan. Gray scale. There is an echo-free
space with high through transmission. The anterior margin of
this zone is irregular and is in connection with the uterine
cavity. Fibroid with massive cystic degeneration.
FIGURE 2.22(b)
Supine longitudinal scan. Gray scale. The echoes of the
outline of the tumor are quite useful to the ultrasonographer.
Cystic structures have a sharp anterior and posterior
interface. Diagnosis in the cystic lesion shown in Fig. 2.22a
using multiple sectional studies was compatible with ovarian
cyst, which was later proven at surgery.
FIGURE 2.22(c)
Supine longitudinal scan. B-mode. Same case as in Fig. 2.22a
FIGURE 2-22 (a) and b. Demonstration of well-defined ovarian cyst.
topographic relation to the uterus is evaluated.

Complete separation of a mass from the uterus is
documented when no part of the mass is noted to
be in continuity with the uterus or vagina (Fig.
2.21). Thus, the lack of a separating interface
between a tumor and the uterus implies that it is
in continuity with and may be part of the uterus
(Fig. 2.20). This necessitates that the normal
uterus be positively identified in all scans and
that the absence of a separating interface be
inferred only after mUltiple cuts in many
different scan planes are performed.
The echoes of the outlines ofthe tumor are quite
useful to the ultrasonographer. Cystic structures
have a sharp anterior and posterior interface.
The amplitude of the distal wall echoes is
stronger than that of the anterior wall echoes due
in part to the concave reflecting surface of the
FIGURE 2-22 (c) distal wall returning a large portion of the
transmitted sound energy (Fig. 2.22a,b, and c).
Solid lesions tend to have poorly defined
margins. The anterior wall echo amplitude is
generally higher than that of the distal wall due
to the attenuation properties of the solid tumor
tissue (Fig. 2.23a). These characteristics of the
margins of cystic and solid tumors must be
demonstrated by scanning the lesion in many
planes for total evaluation. Similarly, the wall-
contents interface of the tumor is smooth and
sharp in cystic lesions while, in contrast, it is
poorly demarcated in solid tumors. Echoes from
the borders are best imaged by linear or sector
scannmg maneuvers.

53
FIGURE 2.23(a)
Supine longitudinal scan. Gray scale. The vaginal walls
appear echo poor. At the point of contact between the
anterior and posterior aspect is an echogenic interface. The
cervix is enlarged; the huge mas s that represents the enlarged
uterus is due to fibroid uterus.
FIGURE 2.23(c)
Supine transverse scan. Real-time scanner. The body of the
uterus is enlarged with a diffuse low-level echo pattern.
Through transmission is high in this example of a fibroid
uterus.
FIGURE 2.23(b)
Supine longitudinal scan. Gray scale. The bladder is
incompletely filled. The uterus is massively enlarged with an
echo-poor pattern. High through transmission is noted in the
degenerating portion of the superior fibroid uterus. The poor
through transmission of the lower fibroid portion signifies FIGURE 2.23(d)
lack of cystic changes. Supine longitudinal scan. Gray scale. The uterus is enlarged
with a distinctly nodular outline. An irregular echo pattern
and the presence of a variable through transmission pattern
confirm the diagnosis of fibroid uterus.
Nodular

54
The internal texture of the mass is best studied
with compound scanning techniques, since the
parenchyma of tumors are diffuse reflectors.
Cysts are echo free except for occasional linear
echoes due to clearly delineated septa. Anterior
compartment echo artifacts may be noted in
cysts at higher gain settings. Through
transmission is high in cysts except when the
mass sits adjacent to a highly attenuating
surface. In this case a very high amplitude echo
marks the distal wall. Solid tumors have poor
through transmission except when there is cystic
internal degeneration. It is not uncommon to find
a massively degenerated fibroid nodule
FIGURE 2.24 appearing as an ovarian cyst.
Supine transverse scan. Real-time scanner. The echo-free
bladder is above a diffusely enlarged smooth uterine outline.
Centrally located echoes are noted. This pattern is typical of
adenomyosis, although it may occur in fibroids of the small UTERUS
intramural type.
ENLARGED UTERUS
The commonest finding in the field of obstetrics

and gynecology is an enlarged uterus. Pregnancy
is the most probable common cause, because the
fluid content of the pregnant uterus is high at 5
weeks. Posterior echo-rich areas may be demon-
strated ultrasonically, along with the presence of
a gestational sac. After delivery the uterus re-
mains enlarged for a period of time. Ultrasono-
graphic findings related to threatened and missed
abortions will be described in detail.
Inflammatory conditions are allUlIier l:ause of

FIGURE 2.25 enlarged uterus. A hematometra may present a
Supine transverse scan. Gray scale. Uterine enlargement
with a nonhomogeneous echo-poor internal texture.
cystic appearance in an enlarged uterus. Uterine
Endometrial carcinoma. Note lateral echo-free iliopsoas. tumors are an additional cause of uterine en-
largement and will be discussed in detail.
UTERINE MASSES
The most common pathologic cause for an
enlarged uterus is leiomyoma uteri (Fig.
2.23a,b,c, and d). Other conditions enlarging the
uterus include polyps, endometriosis,
endometrial hyperplasia, adenomyosis (Fig.
2.24), idiopathic uterine enlargement, and
malignant tumors of the uterus (Fig. 2.25).
The majority of uterine fibroids occur in the
myometrium as intramural fibroids. The submu-
cus variety tend to bulge into the endometrial

55
cavity and produce spontaneous abortion (Fig.
2.26). The subserous type distorts the outer sur-
face creating a markedly irregular outline (Fig.
2.27). The cervical fibroid is generally solitary in
this site and may easily complicate labor if en-
larged (Fig. 2.28). Intraligamentous (Fig. 2.29)
and pedunculated fibroids are rare.
I
Degenerative changes are more common in the
submucous, subserous types (Fig. 2.30a,b, and
Cervical fibroid c), ligamentous and pedunculated fibroids due to
the poorer blood supply. Various degrees ofhya-
FIGURE 2-26 line degeneration are noted in all types of fi-
broids. Cystic degeneration is a sequel to hyaline
changes and increases with the size of the tumor
and the age ofthe growth (Fig. 2.30d). Torsion is
FIGURE 2.26
Supine transverse scan. Gray scale. Massive elongation of
the cervix which is also echo-free due to fibroid tumor. The
gestational sac is eccentric with opening of the caudal sac and
multiple irregular echoes. Spontaneous abortion soon
followed.
FIGURE 2.27
Supine longitudinal scan. Gray scale. Massive protrusion of
myoma from the dorsal uterine outline characteristic of
subserous myoma.
FIGURE 2-27 FIGURE 2.28

Supine transverse scan. Real-time scanner. A moderately
echogenic mass with variable through transmission patterns
is noted adjacent to the uterine cervix. Patient is 4 months
pregnant and the amniotic fluid ofthe uterus is noted as an
echo-free area. Pedunculated cervix fibroid.
FIGURE 2-28
FIGURE 2.29
Supine transverse scan. Gray scale. Solid tumor mass
extends laterally from the uterus into the broad ligament with
an echo-poor internal echo pattern. Intraligamentous fibroid.
In tral igamen tous

fibroid

56
common in pedunculated fibroids (Fig. 2.30e).
Calcification often occurs, but is rare in the sub-
mucous growths. Occasionally, frank bone for-
mation may be noted. Infection and suppuration
are most common in the submucous type due to
the effects of local ulceration and its relation to
the uterine cavity. Sarcomatous changes occur
in less than 1 percent of cases.
The ultrasonic appearance offibroids varies with

the gross pathologic process. The usual
presentation is that of a large, irregular uterine
outline, with a nodular architecture and poor
FIG URE 2·30 (a) margin properties. The solid and undegenerated
fibroid markedly attenuates the sound so that the
distal margin is poorly imaged. The coarseness
of the echo pattern is related to the cellularity of
FIGURE 2.30(a)
Supine longitudinal scan. Rounded lesion with sharp
septations simulates ovarian cyst of multilocular type. This is
a degenerating portion of a large fibroid uterus.
FIGURE 2.30(b)
Supine longitudinal scan. Gray scale. Inferior portion of
fibroid uterus produces sonic shadow due to great attenuation
of sonic beam. Superior myoma has completely degenerated
with cystic changes and high through transmission.
FIGURE 2.30(c)
Supine longitudinal scan. Gray scale. Bulbous, irregular
outline to this fibroid uterus. Note that internal degeneration
FIGURE 2·30 (b) is best demonstrated by observing areas of high through
transmission.
FIGURE 2.30(d)
Supine longitudinal scan. Gray scale. Cystic degeneration is a
sequel to hyaline changes and increases with the size ofthe
FIGURE 2·30 (c)
tumor and the age of the growth. Note focal area of cystic
degeneration.

57
the tumor parenchyma. Very cellular leiomyomas
may show a snowflake pattern due to wide
separation of the fibrous supporting framework,
and may mimic hydatidiform mole, in which case
ultrasonography should be coupled with clinical
data and laboratory findings (Fig. 2.30f).
Cystic degeneration may be microsopic or gross.
The tiny cystic transformations in the fibroid
appear as areas of greater echogenicity and
increased through transmission. The presence of
echoes in a fibroid previously not noted to have
FIGURE 2.30(e) echoes signifies internal necrosis. Large echo-
Supine longitudinal scan. Gray scale. Cystic degeneration of free spaces may occur when cystic changes are
the pedunculated fibroid uterus due to torsion
massive and confluent. Calcification may be
amorphous or ring shaped (Fig. 2.31a and b).
Amorphous calcium deposits produce high-
amplitude echoes and attenuate the sound beam
(Fig. 2.32a and b). Ring-shaped calcification may
simulate a fetal head. In spite of all diagnostic
studies, the origin of the mass may never be
determined and laparotomy may be necessary
for definitive diagnosis (Fig. 2.33a).
Endometritis occurs following pregnancy and is
secondary to retained fetal contents or placental
tissue. The uterus is typically involuted at this
time and is enlarged. The inflammation may
FIGURE 2.30(0
Supine longitudinal scan. Gray scale. Very cellular FIGURE 2.3J(a)
leiomyomas may show a snowflake pattern due to wide Supine transverse scan. Gray scale. A rounded echogenic
separation of the fibroid supporting framework, and may structure is seen in the echo-poor uterus. This calcific fibroid
mimic hydatidiform mole. Note the echo pattern of the mimics a fetal head outline. Another calcific fibroid might
uterus. Compact fibroid tissue in the cervix and snowflake mimic the body. Absence offetal motion and fetal heartbeat
pattern in the fundus are observed. signifies the presence of a uterine fibroid.

58
extend to the myometrium and is depicted by the pear-shaped appearance (Fig. 2.33b). These
sonogram as generalized anechoic areas in the endometrial inroads have a tendency to be echo
affected portions of the uterus. If severe, poor and located near the endometrial canal, in
associated changes of salpingitis and pelvic our experience. Others have described an
abscess formation may be observed (2). echogenic pattern (3).
Small intramural fibroids may simulate Uterine polyps or endometrial polypoid hyper-
adenomyosis of the uterus. However, in plasia may simulate adenomyosis, since the
adenomyosis, due to endometrial tissue of the uterus may be diffusely enlarged with echoes in
uterine cavity projecting into the myometrium, the region of the endometrial cavity. A widened
the uterine enlargement is generally symmetric endometrial cavity with internal echoes is more
and smooth with little gross distortion of the characteristic of polypoid disease .
FIGURE 2.31(b)
Supine film from IVP (Intervenous
Pyelogram). Double ringlike shadows (
calcific fibroids are noted in the
pelvis. These films are useful in
evaluating a heavily calcified pelvic
mass when sonic shadowing prevents
optimal ultrasonic imaging.

59
Endometriosis is caused by ectopic endome-
trium in various locations in the pelvis and abdo-
Foley catheter men. Cystic or solid lesions may be noted in
various combinations. The cystic lesions contain
dark, unclotted blood surrounded by a thick cyst
wall due to the marked fibrotic reaction in this
disease process. The solid lesions cause irregu-
V
larity of the uterine echo pattern and the fre-
quent intense desmoplastic changes tend to fuse
the neighboring organs together.
Sonic shadow
Our experience with uterine cancer or sarcoma
has shown an enlarged uterus that could not be
definitively distinguished from other causes of
FIGURE 2.32(a)
Supine longitudinal scan. Gray scale. Foley catheter in uteromegaly.
bladder. High-amplitude echoes anteriorly with sonic shadow
represent clusters of amorphous calcification.
OVARY
In our experience, with the application of

various ultrasonic techniques, positional
maneuvers, and multiple frequency scanning, we
have been unable to visualize the normal-sized
ovary within the pelvis. In most instances the
ovaries are hidden in the soft tissues of the pelvis
and the resulting returned echoes must merge
and interphase with the echoes of the
surrounding soft tissues and bony pelvic walls.
Occasionally, in routine study normal ovaries
can be seen (Fig 2.34a). As the ovaries enlarge
FIGURE 2.32(b) there is a better chance of recording the image of
Supine longitudinal scan. Gray scale. An irregularly outlined this structure by scanning since it occupies more
mass in the pelvis is noted with multiple sonic shadows.
Distal wall reverberation artifacts are noted. Sonic space within the pelvic cavity (Fig. 2.34b).
shadowing may prevent effective imaging of the distal
boundaries of the mass. Roentgen analysis is necessary for The detection of early enlargement of the ovaries
certain calcific masses. depends upon the nature of the expansile
process. A simple cystic lesion projecting from
the ovary rather than being within the stroma of
the ovarian tissue may be detected easily at a
rather small size. Small cysts within the ovarian
structure, such as the multiple cysts of the Stein-
Leventhal syndrome with surrounding thick
fibrous septa, are detectable when of moderate
size and appear as a complex mass on the
oscilloscope. Complex masses that are more
solid than cystic, such as the dermoid cyst, may
be extremely large and still be very difficult to
detect ultrasonically. Thus, the nature of the
lesion and its geometry with respect to the

60
FIGURE 2.33(a)
Air contrast gynecogram. Pelvic mass with multiple discrete
nodules projecting from the tumor. With this complicated
lesion it is virtually impossible to distinguish the boundaries
between the uterus and the ovaries. Similarly, ultrasound
may not be able to separate adherent ovarian and uterine
masses.
FIGURE 2.33(b)
Supine transverse scan. Gray scale. Adenomyosis simulates
fibroid uterus. Adenomyosis was demonstrated at operation.
Adenomyosis
perpendicularity of the scanning beam are

extremely important in the imaging of ovarian
lesions. A simple ovarian cyst has an echo-free
lumen with a sharp posterior wall, and an echo-
rich reverberation pattern is noted distal to the
posterior interface at high sensitivity settings.
Ovarian cysts with internal septations may be
easily demonstrated if the walls of the septa are
perpendicular to the interrogating ultrasonic
beam. Internal septa may also be visualized by
compound scanning techniques with high gain

61
settings to image the diffuse reflections of the
portions of the septa that are nonperpendicular
to the sound beam.
OVARIAN MASS
The gross morphology, internal architecture,

and consistency of ovarian tumors are subject to
wide variation. Follicular cysts and serous
cystadenomas present as unilocular echo-free
Ovaries lesions. Mucinous cystadenomas are
multilocular, so that the echo-free picture is
FIGURE 2-34 (a) broken by mUltiple septa usually with thin walls
(Fig. 2.35a and b). Ovarian cysts may present
with various shapes, positions, and contours and
may be located anywhere in the pelvic cavity
(Fig. 2.36a and b) or may occupy the entire
abdomen (Fig. 2.36c). Ovarian cysts may regress
and completely disappear. This is the usual
biologic history of thecal lutein cysts associated
with pregnancy.
FIGURE 2.34(a)
Supine transverse scan. Gray scale. Occasionally, in routine
study normal ovaries can be seen.
FIGURE 2.34(b)
Supine transverse scan. Gray scale. As the ovaries enlarge
there is a better chance of recording their image by scanning
Ovaries since they occupy more space within the pelvic cavity.
FIGURE 2-34 (b) FIGURE 2.35(a)

Supine transverse scan. B-mode. Large echo-free area with
sharp boundaries and high through transmission. Simple
ovarian cyst.
FIGURE 2.35(b)
Supine transverse scan. B-mode. Large echo-free area with
sharp boundaries and high through transmission.
FIGURE 2-35 (a) Multiloculated ovarian cyst.

62
Teratomas comprise roughly 10 percent of ovar-
ian cystic tumors. They may be cystic or solid
(Fig. 2.37a and b). If the fatty contents of the
tumor are in one position for a sufficient time, a
fluid level may be seen in the fat interface during
scanning. Cystic dermoids may present as echo-
free areas of varying size at high gain. As the
sensitivity is decreased, the solid portion of the
tumor may be identified. Due to the irregular
outline of the tumor and the multiplicity of its
internal contents, the teratoma is frequently dif-
ficult to image. Often only the cystic zone can be
FIGURE 2.36(a) delineated. The physical finding of a large tumor
Supine longitudinal scan. Gray scale. Small echo-free cystic
mass with the ultrasonic demonstration of a
space is typical of ovarian cyst.
small cystic space suggest the possibility of a
dermoid tumor. Areas of calcification appear as
highly echogenic zones. If the calcification or
ossification is sufficient, a sonic shadow will be
cast.
A second pattern of the benign ovarian teratoma

has been demonstrated with gray-scale units.
The solid contents of the tumor may show dis-
tinctive ultrasonic findings. The most frequent
sign is the presence of a highly reflecting irregu-
lar region in the vicinity of an echo-free cystic
cavity. This is presumed to be related to the
presence of hair and sebum which are highly
FIGURE 2.36(b)
Supine transverse scan. Gray scale. The echo-free ovarian echogenic (4), but not as reflective as calcium or
cyst is seen in sharp contrast to the echogenic uterus. Note bone. When the tumor has a predominance of
high through transmission pattern. hair, sebum, or calcium as opposed to the cystic
components, the sonic shadow may be pro-
duced. This sonic shadowing often obscures the
FIGURE 2.36(c)
Supine longitudinal scan. Gray scale. Ovarian cyst occupying remainder of the mass and may simulate colonic
the entire abdomen. gas or feces. When this is encountered, a flat
plate of the abdomen may be performed to rule
out the presence of feces or to demonstrate the
suspected fat lucency or dental structure of a
dermoid cyst. Alternatively, a cleansing enema
may be given and the patient rescanned.
Ovarian fibromas cannot be differentiated from

pedunculated fibroids. Indeed, they may show
areas of focal cystic degeneration typical of
longstanding fibroid tumors (Fig. 2.37c). There is
no way to differentiate a solid ovarian carcinoma
from a fibroma at this time (Fig. 2.38a and b).
Papillary cystadenomas appear as cystic spaces
with the small papillary excrescences showing as

63
FIGURE 2.37(a)
Supine longitudinal scan. B-mode. Echo-free space with
occasional septations noted. Predominantly cystic teratoma.
FIGURE 2.37(b)
Supine transverse scan. Gray scale. Cystic teratoma with
heterogeneous echo pattern. Note cystic and solid
components.
FIGURE 2.37(c)
Supine longitudinal scan. Gray scale. Huge mass posterior to
the bladder is noted with cystic degeneration. Diagnosis at
surgery was ovarian fibroma. Ovarian fibromas cannot be
differentiated from pedunculated fibroids by
ultrasonography.
FIGURE 2-37 (a)
FIGURE 2.38(a)
Supine transverse scan. Gray scale. Small, sharply
circumscribed lesion with scattered central echo pattern and
high through transmission represents degenerating ovarian
fibroma. This tumor cannot be differentiated from a
pedunculated uterine fibroid.
FIGURE 2.38(b)
Supine transverse scan. An irregular solid mass with a large
FIGURE 2-37 (b) cystic component is fused to the uterus. Surgery showed
ovarian carcinoma infiltrating the uterus and local structures.
FIGURE 2-37 (e)

64
fine echoes projecting into the lumen. If papilla-
tions are noted outside the lumen of the cystic
areas, the presence of ascites must be inferred.
The fluid surrounding the outer projections per-
mits them to be imaged as separate interfaces.
The presence of loculated ascites in conjunction
with a cystic papillary lesion implies malignancy
(Fig. 2.39a,b,c, and d). Indeed, the serous cys-
tadenocarcinoma is the most common type of
ovarian cancer. Early in its course, this tumor
may be well defined with echo-free spaces asso-
ciated with fine echo speckling peripherally.
However, as the tumor spreads to the omentum
FIGURE 2-39 (a) and peritoneum, loculated ascites develop and
the pelvic organs become fixed by malignant
FIGURE 2.39(a)
Supine transverse scan. Gray scale. Area ofloculated ascites
may simulate an ovarian cystic tumor. Motion of bowel loops
noted with real-time scanner and presence of other areas of
ascites confirm the diagnosis.
FIGURE 2.39(b)
Supine longitudinal scan. Gray scale. The bladder is empty.
There is an echogenic mass with irregular contours superiorly
representing bowel and omentum adhesion. Anteriorly, a
single bowel loop apparently "standing erect" in the ascites
is noted. This is connected to the anterior abdominal wall by
an adhesion which is cut by the ultrasound beam at an angle
too oblique to permit registration on the oscilloscope.
FIGURE 2.39(c)
Supine transverse scan. Gray scale. The "erect" bowel loop
is connected to the anterior abdominal wall by an adhesion.
Adhesions are characteristic of malignant ascites. Patient had
FIGURE 2-39 (b) ovarian carcinoma.
FIGURE 2.39(d)
Supine transverse scan. Gray scale. The bladder has been
emptied. Echo-free areas with scattered internal echoes and
irregular margins were fixed and did not change position with
motion. Malignant ascites from ovarian carcinoma.
FIGURE 2-39 (e)

65
FIGURE 2.4O(a)
Supine transverse scan. Gray scale. Echo-free ovarian
carcinoma with septation.
FIGURE 2.40(b)
Supine transverse scan. Gray scale. Echo-free ovarian
carcinoma with a few internal echoes. Note absence of
through transmission.
FIGURE 2.4O(c)
Supine longitudinal scan. Gray scale. Echo-free ovarian
carcinoma. Again absence of through transmission is noted.
FIGURE 2-40 (a) loculated ascites develop and the pelvic organs
become fixed by malignant adhesions or frozen
pelvis (Fig. 2.40a,b, and c).
Inflammatory lesions of the tubes and ovaries

may produce a wide variety of ultrasonic pat-
terns. Salpingitis is the most common pathologic
condition of the tube. This infection may follow
abortion, childbirth, cervicitis, surgical proce-
dures such as dilatation and curettage or IUCD
insertion, and radiation therapy. The ascending
inflammation from the uterus usually involves
both tubes. In acute salpingitis the tube is red
and distended with purulent exudate. Chronic
salpingitis shows variable enlargements of the
tube associated with dense local adhesions.
Complications of salpingitis include pyosalpinx
with retention of pus in the blocked tube, and
FIGURE 2-40 (b) hydrosalpinx with the distended tube having a
sausage or distorted shape and thin walls. Pelvic
abscess and oophoritis are also associated with
the sequelae of salpingitis.
FIGURE 2-40 (c) Acute pelvic tubal inflammation generally has
the appearance of a small rounded adnexal or
cul-de-sac cystic mass with regular borders, and
is frequently bilateral. As the infection produces
a much larger mass or is complicated by
oophoritis or pelvic abscess formation (Fig.
2.41a), a larger, multilocular mass with irregular
borders frequently obscuring the outline of the
uterus is apparent (5). Simple pelvic abscesses
frequently are found in the midline in the cuI de
sac, while uncomplicated tuboovarian abscesses
tend to have an adnexal location or may develop
during pregnancy (Fig. 2.41b).

66
ULTRASONIC DIFFERENTIAL DIAGNOSES
OF OVARIAN MASSES
The following differential diagnoses of ovarian

masses may be inferred by Ultrasonography.
1. Distended cecum. The cecum lies in

the right iliac fossa and extends over
the iliopsoas. Occasionally, the cecum
hangs over the pelvic brim or lies
further down in the pelvic cavity.
When filled with gas, there is a sonic
FIGURE 2.41(a)
shadow; when filled with fluid, the
Supine longitudinal scan. Gray scale. The pelvic tubal cecum may simulate an ovarian cyst.
inflammation generally has the appearance of a small rounded
adnexal or cul-de-sac cystic mass with regular borders. 2. Redundant sigmoid colon. The sigmoid
lies within the true pelvis. When a loop
is filled with fluid and, especially, is
redundant, it may mimic ovarian cyst
or ovarian mass.
3. Appendicular abscess. When the
appendix is long, it may extend into
the right pelvis. If this type of
appendix develops infection and finally
ruptures, with or without adhesions, it
may simulate ovarian mass.
4. Paraovarian cyst. Paraovarian cysts
originate from the vestigial remnants
of the wolffian body and are located
within the broad ligament.
Ultrasonographic ally , they cannot be
distinguished from other cysts. They
FIGURE 2.41(b)
Supine longitudinal scan. Gray scale. Simple pelvic abscesses may bleed into the peritoneal cavity.
frequently are found in the midline in the cuI de sac. This
abscess developed during pregnancy.
5. Hematocele. If hematocele is a result
of ruptured ectopic pregnancy at the
time of ultrasonographic examination,
the following conditions should be
considered.
a. Torsion of an ovarian cyst
b. Enlarged cystic corpus luteum
c. Hemorrhagic corpus luteum
d. Appendicular abscess
6. Distended bladder. Unusually
distended bladder or bladder
diverticulum ultrasonographically may
simulate an ovarian cyst or ovarian
mass most of the time. An insertion of
a Foley catheter is of great assistance.

67
7. Hematometra. Complete obstruction VAGINAL ANOMALIES
below or at the level of the cervix
during menstrual life can cause Absence of the vagina is a severe congenital
detectable mass. As previously anomaly due to complete lack of union of the
described, an imperforate hymen may miillerian ducts. The vagina is derived from
cause hematocolpos, hematotrachelos, different tissues. The lower one-third of the
hematometra, and hematosalpinx. vagina is usually unaffected and may appear
8. Cystic degeneration of fibroid uterus. externally intact and anatomically correct. The
diagnosis may not be made until adolescence
9. Mesenteric cyst. when the symptoms of amenorrhea,
10. Polycystic kidney disease. dyspareunia, or hematocolpos present. Other
11. Pelvic kidney. failures of miillerian duct fusion result in double
vagina, with a complete longitudinal'septum, or
12. Retroperitoneal pelvic neoplasia. a partial septate vagina with an incomplete
13. Hematoma of the rectus. septum. A rudimentary second vagina may fill
14. Adherence of omentum. with secretions and produce a cystic lesion
bulging into the vaginal canal.
15. Carcinoma of sigmoid.
The imperforate hymen is due to developmental
16. Tuboovarian masses.
error of the urogenital sinus and is the most
17. Ascites. frequent genital anomaly. The hymen is located
at the junction of the vagina and the vestibule.
This membrane is usually thin and sheetlike,
CONGENITAL ANOMALIES although it may be thick and fibrous. The
application of ultrasonic diagnosis in this area is
Congenital anomalies of the genital tract are extremely important, and may show the echo-
related to maldevelopment of the embryonic free appearance of retained secretions or old
miillerian ducts and urogenital sinus. The blood behind the hymen. The vagina and uterus
majority of congenital anomalies of the vagina may be sufficiently distended with blood to
and uterus are caused by failure of the miillerian produce hematocolpos and hematometrium.
ducts to fuse completely. The miillerian ducts in This may present as amenorrhea, an abdominal
the embryo migrate caudally and midlioe to fuse mass, or the area may become secondarily
in the formation of the rudimentary uterus, infected. Ultrasonography in this case will show
cervix, and upper vagina. Abnormalities in the the fluid-filled vagina as tubular in shape and
development of the miillerian ducts lead to echo free. The posterior fornix will also bulge
congenital absence or atresia of the vagina, while the uterus is engorged with blood and
double or septate vagina, double uterus, absent appears as an enlarged structure with an echo-
uterus, and uterus unicornis. These anomalies free lumen of variable size. The presence of
are frequently accompanied by congenital hematosalpinx and hemoperitoneum should be
defects of the urinary tract such as absent or carefully investigated by the ultrasonographer.
ectopic kidneys. Developmental defects of the
urogenital sinus create the imperforate hymen
and persistent urogenital sinus membrane.
UTERINE ANOMALIES
The ultrasonographer must be aware of the gross
pathologic changes of the internal genitalia and Disorders of the miillerian ducts result either
urinary tract associated with external anomalies from failure of formation of these embryonic
of the genital organs for effective pelvic structures or from failure of their fusion. The
scanning. anomalies may be unilateral or bilateral.

68
Unilateral absence ofthe duct results in uterus ultrasonography is technically a laparotomy with
unicornis with a normal vagina and cervix. The sound waves, septations of the uterus are best
uterus possesses only one cornu and fallopian revealed with scanning in mUltiple planes. This
tube. Bilateral absence of the ducts is associated diagnostic ability depends upon the examiner's
with congenital absence of the uterus and experience and his previous exposure to similar
vagma. cases. In our experience, the transverse lie is the
most common malpresentation. Our customary
Imperfection of fusion causes duplication anom- method is to evaluate all transverse lies, in which
alies of the uterus. The double uterus may be external version attempts have failed, by
externally intact with two internal cavities ultrasound with the specific intention of
formed by a longitudinal ridge of tissue. This demonstrating a uterine anomaly as one of the
septation may be complete, producing two uter- causes of malpresentation. We find that
ine cavities, or incomplete, giving partial separa- Trendelenburg's position is often a useful
tion of the uterine cavity. This latter is called a maneuver in addition to routine scanning planes.
subseptate uterus. The uterus may be divided
externally in the more severe forms of fusion Although contrast hysterosalpingography best
defects, producing two uteri. Uterus arcuatus is shows the internal uterine cavity, it does not
a heart-shaped uterus with minimal external divi- show the external configuration of the uterus.
sion. A partial fusion defect produces the bicorn- This test also cannot safely be performed during
uate uterus. The resultant two uteri are associ- early pregnancy and allow continuation of
ated with a single common cervix. The most gestation. Hysterography is limited in that it will
extreme variety offusion failure results in uterus not show a rudimentary hom that does not
didelphys with two completely independent communicate with the uterine cavity.
uteri, each capable of sustaining normal preg- Ultrasound may show the gross extent of the
nancy. This is often accompanied by a double intrauterine septation as well as the outer shape
vagina deformity. of the uterus. The site of gestation may be
evaluated and the growth and the relative
Asymmetric duplication anomalies produce position of each uterine cavity may be assessed.
rudimentary horns which mayor may not Serial ultrasonography may allow preliminary
communicate with the remaining uterine cavity. diagnosis of a genital tract anomaly and still
Clinical problems arise when gestational permit the patient with a miscarriage history to
implantation occurs in this type of hom or safely deliver a viable fetus due to proper
retained menstrual flow dilates the obstetric management.
noncommunicating rudimentary hom, producing
mass effect or rupture of this structure.
Septation defects may be clinically silent and INFLAMMATORY PEL VIC LESIONS
never diagnosed in the preconception state or
during the normal course of pregnancy. They Ultrasound is not only extremely valuable in the
may be incidentally detected at cesarean section detection of inflammatory diseases of certain
after removal of the fetus and manual size such as tuboovarian abscesses,
exploration of the uterine cavity. The most hydrosalpinx, and pelvic abscesses, but is the
common symptoms of uterine duplication are only tool able to aid in follow-up of these
repeated abortion, premature delivery, and conditions, ie, final surgical intervention or
difficult labor with malposition and dystocia. medical treatment. In addition, serial studies can
Ultrasonography of the uterus must be give excellent information regarding pelvic mass
accompanied by renal ultrasonography to associated with inflammatory disease. With this
evaluate the presence of the frequently tool, subsidance or exacerbation of disease
associated urinary tract abnormalities. Since process can easily be recorded (5).

69
ENDOMETRIOSIS
Endometriosis with chocolate cyst produces

different echo patterns relating to the size and
duration of the process. It usually is of a
complex nature.
METASTATIC LESION TO PELVIS
Metastatic lesion to the pelvis may produce any

pattern and should be differentiated from pelvic
masses by detecting the source of metastasis.
APPENDICEAL ABSCESS
Appendiceal abscess in our experience produces

an echo-free area in the right lower quadrant
with irregular borders. With interval serial
studies, the course of the disease can be
predicted.
FREE FLUID COLLECTION
Free fluid collection in the pelvic region can be

detected ultrasonically and, by changing the pa-
tient's position, can be differentiated from locu-
lated fluid. In free fluid, ascites, or loculated
fluid, if the source is unknown, special attention
should be directed toward the ovary.
REFERENCES
1. Von Micsky: Gynecologic Ultrasound. In King,

DL (ed.): Diagnostic Ultrasound. St. Louis, CV
Mosby, 1974, pp. 204-240
2. Haines M, Taylor CW: Gynecologic Pathology.
Edinburgh, Churchill Livingstone,'1975, p 161
3. Kobagashi S, Sekiba K, Niwa K, et al: Ultrasonic
classification of uterine myomas. Presented at 1st
World Federation Ultrasound in Medicine and Bi-
ology, San Francisco, 1976
4. Guttman PH: Benign ovarian teratoma. Tip of the
iceberg sign. Presented at 1st World Federation
Ultrasound in Medicine and Biology, San Fran-
cisco, 1976
5. Uhrich PC, Sanders RC: Ultrasonic characteristics
of pelvic inflammatory masses. J Clin Ultrasound
4: 199, 1976

70
ultrasonography
in obstetrics
GENERAL INTRODUCTION
The application of ultrasound in obstetrics and gynecology

was first described by Donald et al in Europe in 1958 (1). In
America it was described by Taylor et al in 1964 (2). Today,
ultrasound is rapidly replacing the use of X-ray studies in the
field of obstetrics and gynecology. Since ultrasound study is
safe, atraumatic, and noninvasive, it is thus an ideal scanning
procedure for the abdominal and pelvic regions. At present it
is essential to the practice of modern obstetrics and
gynecology.
Exploration with ultrasound proceeds with the patient placed
in the supine position. Mter examining the abdomen, a
coupling agent such as mineral oil is applied to the skin. As
previously described, the umbilicus or the symphysis pubis is
used as a reference point. In obstetric studies, it is better to
choose the transcrestal plane and puboxiphoid line as
reference points. This is of particular importance in the case
of the pregnant woman with progression of conception and
increasing fetal size. In pregnancy the umbilicus moves
71
upward and comparison of earlier with later for the first time to an infant alive or dead with a
pictures is difficult. Transverse, longitudinal, minimal weight of 500 g. A multipara is a female
and oblique scans with varying angulation are who has given birth two or more times to infants
used to produce a diagnostic set of data suitable weighing 500 g or more, alive or dead. The term
for comparison. grand mUltipara is applied to a female who has
given birth seven or more times to infants
In obstetrics, B-mode or gray-scale two-
weighing 500 g or more. In our history taking, we
dimensional ultrasound in combination with a
follow a scheme of recording obstetric data using
real-time scanner yields the greatest diagnostic
four digits. The first number refers to the number
information. In scanning certain areas, such as
of pregnancies, the second number refers to the
the fetal head, the usage of A-mode adds more
number of premature deliveries, the third
information and improves accuracy.
number refers to the number of abortions, and
the fourth number refers to the number of living
PATIENT HISTORY children. For example, 4-2-1-1 would mean four
pregnancies, two premature deliveries, one
The examiner's first procedure in using abortion, and one living child.
ultrasound is to take a proper history from the
patient. All information should be recorded. PARTURIENT
PATIENT'S AGE A parturient is a female in the process of giving

birth.
The patient's age is critical in evaluating the
history. For example, in the childbearing years,
PUERPERA
patients with bleeding most likely have
reproductive disorders; while in adolescent
A puerperal female is one who has given birth
females, the cause of bleeding with a normal
during the past 42 days.
utlrasonographic appearance has an endocrine
basis. In postmenopausal females, the
ultrasonographic examination of a patient with MENSTRUATION
bleeding usually reveals a pelvic mass, and
carcinoma of the genital tract is high in the list of The date of the last normal menstrual period
differential diagnoses. (LNMP) should be thoroughly investigated.
In primary dysmenorrhea, there is usually no
GRAVIDITY ultrasonographic demonstrable pelvic mass at
the condition's inception. In secondary
Gravidity is synonymous with pregnancy. A dysmenorrhea, usually there is a demonstrable
primigravida is a female who is pregnant for the pelvic disease which mayor may not be detected
first time. A multigravida is a female with several ultrasonographically.
previous pregnancies.
Changes in menstrual patterns should be
carefully evaluated and differentiated from
PARITY uterine bleeding unrelated to menses.
Menorrhagia or hypermenorrhea involves
The term parity is used when a female has given prolonged menstrual bleeding. Metrorrhagia is
birth to an infant weighing 500 grams (g) or more, irregular or actually acyclic bleeding.
alive or dead. When the weight is not known, Menometrorrhagia is excessive or irregular
ultrasonography helps to estimate gestational uterine bleeding between as well as during
age. A primipara is a female who has given birth menstruations. Oligo menorrhagia is a reduction
CHAPTER 3: ULTRASONOGRAPHY IN OBSTETRICS

72
of the menstrual frequency. As a result, the TABLE 3.1 History Profile
interval between the cycles is longer than 28 1. BLEEDING
days, but usually less than 3 months. Normal menstruation yes no
Polymenorrhea is abnormally frequent Intermenstrual bleeding yes no
menstruation. Abnormalities of bleeding during Contact bleeding yes no
2. PAIN
menstruation usually have an endocrine origin.
Is pain related to menstruation? yes no
Intermenstrual bleeding usually has Does pain radiate? yes no
" p:lin localized? yes no
ultrasonographically demonstrable benign or
3. VAGINAL DISCHARGE
malignant causes. Bleeding after intercourse or Is discharge accumpanied by pain? yes no
douching may have malignant causes. Is discharge heavy'! yes no
Is discharge more than two weeks? yes no
Does discharge have color or odor~ yes no
4. HISTORY OF CONTRACEPTIVE
PAIN
USE
Do you have IUCD? yes no
The ultrasonographic importance of the history Duration of use
of pain is related to the fact that certain masses Is this type of IUCD effective? yes no
can produce special types of pain. For example, Do you discharge with IUCD? yes no
5. HISTORY OF INTERCOURSE
localized pain in the lower abdomen may arise
Do you have regular intercourse? yes no
from the uterus or vagina. Do you have painful intercourse? yes no
6. HISTORY OF MEDICAL
Adnexal pain is usually referable to the lower
PROBLEMS
abdomen and often radiates to the medial aspect Do you have diabetes? yes no
of the thigh. Sharp pain with sudden onset may Do you have hypertension? yes no
be due to torsion of pedunculated fibroid. Do you have cardiac disease~ yes no
Do you have renal disease? yes no
We have a special history sheet, shown in Table Do you have history of syphilis? yes no
3.1, which may be completed by either the Do you have history of TBC? yes no
nurse, technician, examiner, or even the patient Do you have epilepsy? yes no
Do you have allergies? yes no
in a short period of time. The physician can thus
Do you take any medication yes no
get enough information to collate with the 7. SURGICAL HISTORY
ultrasonographic findings for final interpretation. Did you have any operations? yes no
Date of operation
Place of operation
Diagnosis
PALPATION OF THE ABDOMEN BEFORE Result
EXAMINATION 8. FAMILY HISTORY
Do you have twinning? yes no
In the twelfth week of pregnancy, the uterus Do you have hereditary disease? yes no
9. SOCIAL HISTORY
usually can be felt by manual abdominal Do you use tobacco? yes no
examination just above the symphysis pubis. Do you use alcohol? yes no
The abdominal enlargement is less pronounced What is your occupation?
in nulliparas than in multiparas. 10. BREAST HISTORY
Do you have any breast disease? yes no
Do you have any discharge from
nipples? yes no
CHANGES IN UTERINE SIZE DURING Do you have any tenderness? yes no
PREGNANCY Did you have any operations on the
breasts? yes no
In the first few weeks of gestation, the increase

in size of the uterus is in the anteroposterior
direction. As time passes, the uterus becomes

73
I globular and by 10 to 12 weeks it measures an
average diameter of 8 cm.
In pregnancy associated with inflammatory
process or carcinoma of the cervix, the cervix
from the early phase of gestation may remain
enlarged.
SONOANATOMY
FIGURE 3.l(a) The detailed sonoanatomy of the female pelvis

Supine longitudinal scan . Gray scale. The distended bladder has been described in Chapter 2. However, a
noted anteriorly . The echogenic uterus is seen posterior to
the bladder. Central echoes represent uterine cavity.
few additions deserve to be mentioned here. The
skin, adipose tissue, muscular layers, and planes
of the abdominal wall can be delineated by
proper gain setting. The omentum and bowel
have irregular, disorganized groups of echoes
(3). The spine is easily identified as a posterior
structure stopping sound transmission. The nor-
mal uterus is easily identified (Fig. 3.1a) .
..- .---1Foley
- I catheter
SONOLAPAROTOMY
In the nonpregnant female the symphysis pubis

and small intestine shield the pelvic organs.
Ultrasound consequently cannot penetrate the
FIGURE 3.I(b)
Supine longitudinal scan. Gray scale . The rounded echoes of pelvic organs to delineate the anatomy of the
the Foley catheter balloon are noted in the bladder. The uterus and adnexal structures.
enlarged uterus is seen posterior to the bladder.
Before examination, the bladder should be
distended for better penetration of the ultrasonic
FIGURE 3.I(c) beam. Bladder distention is accomplished by
Supine longitudinal scan. Gray scale. The rounded echogenic having the patient drink a large amount of fluid
Foley catheter balloon is noted in the distended bladder.
and instructing her not to void before
examination. A filled bladder displaces the
uterus posteriorly while it displaces the small
intestine superiorly. Consequently, a
transmitting window is created through which
the beam can be more effectively angled, thus
permitting better delineation of the pelvic
organs. By directing the beam at various angles,
Foley the characteristic echoes of the pel vic organs can
catheter be registered with as little attenuation as
possible.
In some patients it is necessary to fill the bladder
with a Foley catheter in order to distend the

74
bladder in various stages for proper evaluation of longitudinal pictures (from left to right) are
the uterus and pelvic region. The bladder may attached in sequence.
need to be filled and then emptied by degrees
and then refilled for optimal diagnosis. The use The screen of the oscilloscope is divided into
of a catheter is necessary for quantitative filling centimeter equivalents. Therefore, the centime-
of the bladder and for the patient who arrives for ter is used as a reference for measurement of the
an ultrasonographic procedure with an incom- sonogram. The oscilloscope screen may be cali-
pletely filled bladder (Fig. 3.1b and c). brated into 1-, 2-, or 3-cm divisions. Using need-
lepoint calipers, the biparietal diameter of the
The distended bladder is echo free. This cystic-
head or the anterioposterior diameter of the fetal
type structure is located below the symphysis
chest can be measured. Direct digital read-out
pUbis. In nonpregnant women the uterus also
systems are commercially available with elec-
appears echo poor behind the bladder at low
tronic calipers.
sensitivity. The size of the normal uterus varies
with age, menstrual function, and parity. Clear
delineation of the normal ovaries and other
adnexal structures is extremely difficult. These SONOFLUOROSCOPY OF THE PREGNANT
organs may be mistaken for one another. UTERUS
Pathologic changes of these organs may make
the recognition of individual structures easier. The uterus is initially examined by rapid
scanning to familiarize the ultrasonographer with
Our application of the anterior transcrestal plane the location of the fetus, its lie and presentation,
(ATC) and longitudinal xiphoid pubis (LXP) sys- and site of the placenta. This screening may be
tems of identification over a period of four years performed with either the real-time scanner (Fig.
has proven to be of great practical value. This 3.2), bistable unit (Fig. 3.3), or gray-scale
appears, in our opinion, to be the most useful machine (Fig. 3.4). The presence of a variable
method of marking the skin in relation to the persistence oscilloscope with a rapidly fading
bony structures for amniocentesis and other pro- scan image as the transducer is quickly
cedures where the patient may need to be re- traversing the uterus is of added value.
moved from the ultrasound department and have Maximum information is obtained in the
a subsequent procedure performed by other longitudinal scanning planes. Further data are
physicians. acquired in the transverse plane.
In early pregnancy or in the case of small pelvic The position of the fetus is first identified. The
lesions, the interval between sections is location of the head in either the breech (Fig.
approximately 1 cm. In later pregnancy or with 3.5a) or vertex (Fig. 3.5b) presentation is stud-
large pelvic masses, sections at 2- to 4-cm ied. The cranial vault is echogenic and appears
intervals may be used. However, the type of as a circle of high-amplitude echoes. The circle
sectioning and the intervals used are up to the of echoes produced by the body is oflower echo
examiner. Permanent records can be obtained amplitUde. The fetal thorax is found and the
through the use of a Polaroid or 9O-mm filming relationship of the fetal head to the fetal body
from the oscilloscope. Gray-scale images are and thorax is noted (Fig. 3.6a). This is important
usually obtained from the screen of a scan in abnormal fetal lie where intrauterine rotational
converter. A series of pictures is then taken to maneuvers are considered. The fetal respiratory
complete the study. These include the transverse excursions are monitored either with A-mode,
sections, ATC series, and the longitudinal M-mode, or the real-time scanner. The fetal
sections, LXP series, which are attached in aorta is followed from the heart as it descends
order so they may be displayed for final into the fetal abdomen (Fig. 3.6b). The relation
interpretation. The transverse pictures are of the aorta to the spine is noted with the real-
arranged in an ascending manner and the time scanner. The echogenic liver and spleen in

75
the abdomen are found as are the echo-free
stomach, gallbladder, and umbilical vein. The
kidneys (Fig. 3.7) are studied for possible hydro-
nephrosis from obstructive uropathy or other
renal anomaly. The bladder is identified in the
pelvis (Fig. 3.8a). The fetal genitalia are searched
for at the region of the perineum. The fetal scro-
tum and penis may be evaluated if they are not
obscured by overlying fetal structures (Fig.
3.8b). The number and motion of the extremities
are observed for possible fetal anomaly or ner-
vous system disorder.
The umbilical cord is followed from the placenta

(Fig. 3.9) to the insertion into the fetal umbilicus
FIGURE 3.2 (Fig. 3.10). The position of the placenta is
Supine transverse scan. Real-time scanner. The fetal head is located (Fig. 3.1l). The presence of physiologic
scanned in the vertex position. The typical ovoid shape and
midline echo complex are obtained by manipulation of the placental degeneration is studied and pathologic
scanning head. placental echo patterns may be demonstrated.
Shadowing of fetal parts by the posterior
placenta is commonly encountered (Fig. 3.8a).
The relationship ofthe placenta to the internal
FIGURE 3.3 cervical os is identified.
Supine transverse scan. B-mode. To obtain the optimal
biparietal diameter, A-mode and B-mode are used. The In obese or large-for-date patients, the
sensitivity is decreased so that only the calvarial echoes and
midline echoes are imaged. Care must be taken to position
ultrasonographer looks for mUltiple gestation
the falx echoes exactly in the middle of the cranial cavity . (Fig. 3.12), polyhydramnios, and other
disorders. We find that the fetal head is best
studied for twin gestation with the real-time
scanner. Rapid scanning with the gray-scale unit
FIGURE 3.4
Supine transverse scan. Demonstration of fetal head with
gray scale. Note midline echo pattern and anterior
reverberation artifacts. Measurement ofbiparietaI diameter is
performed from the darkest anterior to the darkest distal
echoes of the bony calvarium .

76
FIGURE 3.5(a)
Supine longitudinal scan. Gray scale. The fetus is in the
breech presentation. The middle portion of the posterior
placenta is indented by the fetal head and body.
FIGURE 3.5(b)
Supine longitudinal scan. Gray scale . The fetus is in the
vertex presentation. The middle portion of the anterior
placenta is indented by the flexed fetal knee which extends
from the fetal hip and returns from the placenta as the fetal
leg which tapers appropriately.
FIGURE 3.6(a)
Supine longitudinal scan. Gray scale. The fetal aorta appears
as a parallel series oflines passing from the thorax into the
abdomen. The pulsatile nature of this structure is best shown
with M-mode or real-time scanning.
IGURE 3-6(a)
FIGURE 3.6(b)
Supine transverse scan. The fetal aorta appears as a parallel
series of lines passing from the thorax into the abdomen.
FIGURE 3.7
Supine cross-sectional scan . Gray scale. On either side of the
echogenic fetal spine are the kidney outlines. One kidney is
echo-free since the cut is above the level of the calyceal
system. The central echo pattern is clearly visible in the other
kidney.
FIGURE Hi(b)
FIGURE 3-5(a)
FIGURE 3-7
FIGURE 3-5(b) ~

77
FIG RE - (3)
FIGURE 3-10
FIGURE 3.8(a)
Supine longitudinal scan. Gray scale. The fetal body is seen
in longitudinal scan and the echo-free region in the fetal pelvis
represents the fetal bladder. Note posterior placenta.
FIGURE 3.8(b)
Supine longitudinal scan. Gray scale. The fetus is in the
vertex presentation. The fetal buttocks are noted facing
ventrally. There is no evidence of a penis or scrotum. A
female was delivered.
FIGURE 3.9
Supine longitudinal scan. Gray scale. The umbilical cord is
imaged as a stepladder-type of echo passing between the
placenta and the umbilicus.
FIGURE 3.10
Supine longitudinal scan. Gray scale. The fetus lies in the
vertex presentation. Extending from the anterior placenta is
the fragmented echo pattern of the umbilical cord which
FIGURE 3-8 (b) enters the fetal abdomen.
FIGURE 3.11
Supine longitudinal scan. Gray scale. Anterior placenta. The
fetal parts are scanned in a perpendicular manner and
produce a sonic shadow so that distal structures may not be
adequately imaged.
FIGURE 3-9

78
will also provide satisfactory information. If
there is difficulty in observing the head, the
presence of two placentas is proof of twin
gestation. Care must be taken not to mistake a
right or left lateral placenta with its anterior and
posterior extensions as a double placenta (Figs.
3.13-3.15). The presence of two umbilical cords
and two fetal heartbeats with M-mode are
confirmatory findings. Three fetal heads may be
observed but are difficult to image together in
one plane. The appearance of more than three
FIGURE 3.12 heads is uitrasonographically confusing at times
Supine longitudinal scan. Gray scale. Rounded high- and accurate counting may not be possible.
amplitude structures appear at both poles of the uterus and
represent fetal heads. Twin gestation is identified when two The small-for-date patient is studied for possible
fetal heads and two placentas are noted. The fetal head is
distinguished from the fetal thorax by the absence of fetal fetal anomaly, such as anencephaly or
heart motion. microcephaly, and the relationship of the size of
the fetal head to the body is noted. The
transmission of aortic pulsation can be detected
by the real-time scanner or gray scale (Fig. 3.16).
When sonofluoroscopy is completed, special
attention may be given to each fetal structure
with appropriate measurements.
FIGURE 3.\3
Supine transverse scan. Gray scale. Tn multiple sections, a
fundal placenta with anterior, posterior, and both lateral FIGURE 3.14
extensions is seen. Supine transverse scan. Gray scale. In multiple sections a
fundal placenta with anterior and posterior extensions is
seen.

79
SONOPHYSIOLOGY OF PREGNANCY
DIAGNOSIS OF EARLY PREGNANCY
Ultrasonography makes it possible for the

obstetrician to determine early pregnancy. In the
uterine cavity there is a group of dense echoes
arranged in a circular pattern. This is the
gestational sac or pregnancy ring (Fig. 3.17). The
gestational sac is usually located in the upper
half of the uterus (Fig. 3.18). A low-lying
gestational sac may signify an impending
FIGURE 3.15
Supine longitudinal scan. Gray scale. Care must be taken not spontaneous abortion (4). Our experience has
to mistake a right or left lateral placenta with its anterior and shown that the gestational sac may be found in
posterior extensions as a double placenta. any portion of the uterine cavity and still follow
its normal course of development. The
gestational sac should not be mistaken with a
small cystic lesion of the endometrium (Fig.
3.19). Before examination the bladder should be
distended. An overdistended bladder or the
presence of a pelvic mass may flatten the
gestational sac (Figs. 3.20 and 3.2\). Optimally,
the pregnancy ring or gestational sac can be
recognized at 5 weeks gestation, which
corresponds to 7 weeks from the last normal
menstrual period. The identifying echoes should
be regular in shape and centrally located within
the uterine cavity (Fig. 3.22). From the sixth to
Aorta the tenth week of fetal development the
gestational sac enlarges until its edges fuse with
FIGURE 3.16 the wall of the uterus.
Supine transverse scan . Gray scale. The transmission of
aortic pulsation can be detected by real-time scanner or gray As mentioned, pregnancy can be diagnosed
scale. ultrasonographically from the fifth week of
FIGURE 3.17
Supine longitudinal scan. Gray scale. The gestational sac or FIGURE 3.18
pregnancy ring seen in the fundus of the uterus. Supine longitudinal scan. Gray scale. The usual location of
the gestational sac is in the upper half of the uterus.

80
gestation. Considering the 15 percent incidence
offalse positive and false negative results with
immunologic pregnancy tests, ultrasonography
not only adds information but is a confirmatory
test.
The gestational sac is usually noted as a circular
configuration of echoes within the enlarged
uterus. It is extremely important to obtain
echoes from the entire margin of the gestational
Endometrial cyst sac to evaluate the architecture of the pregnancy
ring as a three-dimensional structure and to
FIGURE 3-19
determine whether it is intact or broken and
where such interruption in the wall may occur.
The initial examination is performed in the
sagittal plane with sections taken in the LXP
system along the plane between the pubis and
umbilicus. The sectioning interval must be small
FIGURE 3.19
Supine longitudinal scan. Gray scale. The gestational sac-
like structure is seen within the uterine fundus and in the
midline. No echogenic boundary is noted. This differentiates
this cystic structure from the gestational sac. Diagnosis,
endometrial cyst.
FIGURE 3.20
Supine longitudinal scan. Gray scale. Gestational sac of early
pregnancy. Flat echogenic outline may be a normal variant of
the usually rounded gestational sac, and may be due to an
overdistended bladder.
FIGURE 3-20
FIGURE 3.21
Supine longitudinal scan. Gray scale. Note flattening of the
gestational sac by a posteriorly located fibroid uterus with
echogenic internal echo pattern.
FIGURE 3.22
Supine longitudinal scan. Gray scale. Echo pattern of a
FIGURE 3-21
centrally located ring is noted in the uterine fundus. This is
the ideal location for the gestational sac.

81
FIGURE 3.23
Supine longitudinal scan. Gray scale. Two gestational sacs
noted inside the uterine cavity.
FIGURE 3.24(a)
Supine longitudinal scan. Gray scale. The thin echogenic rim
of the gestational sac is noted with increased thickness of
echoes along the periphery of the sac denoting the early
placenta. Within the gestational sac scattered echoes identify
the developing fetus.
FIGURE 3.24(b)
Supine transverse scan. Gray scale. Thickening of the
gestational sac denotes formation of the early placenta. Fetal
FIGURE 3·23 echoes are not yet noted.
since the uterus and the contained pregnancy

ring generally measure no more than 8 to 10 cm.
We have found slices taken at 0.5-cm intervals
satisfactory for the purpose of completely
demonstrating the gestational sac. Occasionally,
variations in the angulation of the transducer are
needed to avoid any misinterpretation of
gestational sac pathology. This is especially true
if detection of more than one gestational sac is to
be confirmed. The relationship of the gestational
sac to the uterus is studied next in the sagittal
plane to detect the shape, position, and number
(Fig. 3.23). The study is then continued in the
transverse plane or ATC system and the
geometry of the gestational sac and uterus are
FIGURE 3·24 (a)
corroborated to complete the three-dimensional
sonolaparotomy of the uterus and the developing
pregnancy. Serial examinations are added as
necessary to follow the growth of the gestational
sac.
FIGURE 3·24 (b) A thickening of a portion of the pregnancy ring is
generally noted at the eighth to ninth week which
represents the developing placenta (Fig. 3.24a
and b). After 9 weeks, localized internal echoes
appear within the gestational sac and are due to
the enlarging fetal outline (Fig. 3.25), and usually
at this time the Doppler study is positive for the
fetal heartbeat. At 10 to 13 weeks the gestational
sac has been obliterated and is no longer
identifiable by ultrasound. At about 10 weeks of
gestation the border of the gestational sac
approximates the wall of the uterus. As the
pregnancy ring disappears gradually the placenta
and fetal head will appear (Fig. 3.26).

82
FIGURE 3.25
Supine longitudinal scan. Gray scale. Within the gestational
sac is the amorphous echo pattern of the developing fetus.
Motion is demonstrable with the real-time scanner. Nine
weeks gestation.
FIGURE 3.26
Supine longitudinal scan. Gray scale. Thirteen weeks'
gestation shows a placenta occupying 60 percent of the
uterus. Within the echo-free amniotic fluid the early outline of
the fetal head and body is demonstrable.
FIGURE 3.27
Supine transverse scan. Gray scale. The uterine outline is
minimally enlarged. Scattered internal echoes are noted.
Patient was in the fourth month of gestation. Incomplete
abortion.
FIGURE 3-25
Abnormality of the gestational sac and a dilated

cervix are indicative of an impending abortion. If
the fetal structures do not appear within 9 to 10
weeks, a blighted ovum is suspected. When the
borders of the gestational sac are ill-defined and
irregular, pregnancy loss should be considered
(Fig. 3.27).
As previously mentioned, the period of gestation
from the tenth to the thirteenth week is the" gray
zone" of ultrasonic diagnosis, since neither the
gestational sac nor the fetal head can be imaged.
Ultrasonography usually shows scattered
formless internal echoes within the fluid-filled
center of the uterus. If the initial examination is
FIGURE 3-26
performed at this time, there may be diagnostic
difficulty in distinguishing between normal
pregnancy, hydatidiform mole, missed abortion,
or fibroid uterus with cystic transformation (6).
FIGURE 3-27
This problem may be ameliorated with the
application of Doppler ultrasound, since the fetal
heart is often detected at 12 weeks' gestation.
The real-time scanner may also be used to detect
intrauterine fetal motion which verifies a normal
early pregnancy. The use of either Doppler
ultrasound or real-time scanning during the
"gray zone" of pregnancy may provide relief
both to the worried patient and the
ultrasonographer. Serial demonstration of fetal
echoes differentiates the normal pregnancy from
all conditions which cause dirty uterus when
coupled with a pregnancy test when the uterus is
enlarged. Development of choriocarcinoma after
evacuation of hydatidiform mole, or recurrence

83
of choriocarcinoma following treatment with an
I increase in the uterine size and elevation of
gonadotrophic titer, can be accurately
evaluated.
Frequently, the corpus luteum of pregnancy is
seen in either ovary and appears as a cystic mass
approximately 2 to 4 cm in diameter (Fig.
3.28a,b,c, and d). With progression of
Lutein --"10-.....;.:;;;;. . ... pregnancy, the luteal cyst will spontaneously
cyst regress. Occasionally a luteal cyst may be large
(simple or septate), and in rare instances may be
F FIGURE 3-2 (a) hemorrhagic and cause complications of
pregnancy, such as an abortion (Fig. 3.29a and
b).
Evaluation of gestational age is accomplished by
measuring the gestational sac. The diameter of
the pregnancy ring is applied to a standard graph
to obtain the gestational age. As the gestational
Lutein FIGURE 3.28(a)

cyst Supine longitudinal scan. Gray scale. Cystic cul-de-sac mass
measures 4 cm. This cyst regressed spontaneously with serial
scans until complete disappearance. Asymptomatic theca
lutein cyst.
I FIGURE 3-2 (b)
FIGURE 3.28(b)
Supine transverse scan. Gray scale. Cystic mass lesion seen
I FIGURE 3-28 (e) in the left adnexal region. This cyst regressed spontaneously
with serial scans until complete disappearance.
Asymptomatic theca lutein cyst.
FIGURE 3.28(c)
Supine transverse and longitudinal scan. Gray scale. The
bladder is optimally distended. Gestational sac is well seen in
the uterine cavity. A 3 x 3 cm lutein cyst in the left adnexal
region is noted.
FIGURE 3.28(d)
Supine transverse scan. Gray scale. Simple lutein cyst in the
right adnexal region.

84
, sac disappears, the head of the fetus becomes
manifest. By the thirteenth week of pregnancy,
the fetal skull is visible in about 75 percent of
cases. In subsequent weeks, the correlation
reaches 95 percent (Fig. 3.30a and b).
Gestational age is most accurately determined
by measuring the biparietal diameter of the fetal
head and comparing the results with the standard
charts.
In early pregnancy the fetal head outline is
rounded and circular in shape. This is contrasted
with the configuration of the head in later months
FIGURE 3.29(a)
Supine longitudinal scan. Gray scale. Large multiseptate when an elliptic appearance is the rule.
cystic lesion in the cuI de sac is noted. Patient admitted to the
hospital with a diagnosis of threatened abortion. Patient The fetal thorax is seen at about 15 to 17 weeks'
underwent surgery because of enlarging cystic lesion. At gestation. Better estimation of fetal age and
operation, hemorrhagic lutein cyst was found. weight may be obtained by the combined use of
the biparietal diameter with the fetal thoracic
measurement.
In scanning the fetal head, care should be taken
to identify the central linear echo pattern of the
midline structures for accurate measurement of
the biparietal diameter. The source of the
midline echoes is considered to be from the falx
cerebri or interhemispheric fissure.
By using the biparietal diameter and
anteroposterior diameter of the fetal thorax with
a reliable nomogram, the estimated fetal weight
may be ascertained. The biparietal diameter
alone may be used to estimate fetal weight, but it
is not accurate. However, the biparietal
diameter is highly accurate for fetal age
determination (Fig. 3.31).
FIGURE 3.29(b) The fetal head is first visible at 12 to 13 weeks'
Supine transverse scan. Gray scale. Same case as in Fig. gestation. This figure is important since many
3.29a. Multiseptate hemorrhagic lutein cyst again is noted.
elective abortions by the suction technique must
be carried out before 14 weeks' gestation ifthey
are going to be performed in the first trimester.
Second trimester abortions have a higher
morbidity and mortality. The absence of a fetal
head during scanning implies that a suction
curettage is safe at this time.
To evaluate the gestational age optimally, it is
best to wait until approximately the seventeeth
week of gestation (Fig. 3.32a and b). If a patient
is unsure of her dates, serial measurements at 3-
week intervals will show the rate of growth on

85
FIGURE 3.30(a)
Supine longitudinal scan. Gray scale. The crescent-shaped
echoes of the placenta are best visualized when the fetal head
is separated from the placenta by some distance, so that the
amniotic fluid provides a good interface with the placenta.
FIGURE 3.30(b)
Supine longitudinal and transverse scan. Gray scale .
Demonstration of the fetal head, fetal body , and placenta in
the early second trimester.
,.

86
FIGURE 3.31
Supine longitudinal scan. B-mode. The biparietal diameter is
highly accurate for fetal age determination. The midline
echoes are demonstrated for accurate location and
measurement.
FIGURE 3.32(a)
Supine longitudinal scan. B-mode. For accurate evaluation of
gestational age it is best to wait approximately 17 weeks of
gestation.
FIGURE 3.32(b)
Supine longitudinal scan. Gray scale. The fine echo pattern of
the placenta is noted between the echo-poor space of the
uterine wall and the echo-free zone of the amniotic fluid. At
17 weeks' gestation the fetal head may be clearly imaged.
FIGURE 3-3 1
the standard tables. It has been noted that fetal
head sizes may be placed into one of three
percentile ranks. Large is denoted as being
greater than the 75th percentile, average as
between the 25th and 75th, and small as less than
the 25th. Under normal conditions fetuses falling
within one group will remain at the same
cephalic level during growth until birth. One
group studying fetal development for
intrauterine growth retardation found it optimal
to take a first measurement at 22 weeks'
gestation and again at 32 weeks' gestation (7).
We make multiple serial measurements between
20 and 36 weeks for the most accurate
assessment of fetal growth and development. It
must be noted that, late in pregnancy, the
diabetic fetus will have a larger biparietal
diameter due to the macrosomic condition. Fetal
FIGURE 3-32 (a) well-being may not be established by measuring
the biparietal diameter in this group. A mature
fetus with weight greater than 2500 g may be
diagnosed when the biparietal measurement is at
least 8.7 cm.
FIGURE 3-32 (b)
MEASUREMENT OF THE BIPARIETAL

DIAMETER
Prior to the evolution of the ultrasonic method,

the physician had to rely on roentgenographic
studies to measure the size of the fetus and
biparietal diameter. X-ray studies allow a
reliable and accurate measurement of the fetal
skull in relation to the bony pelvis (Fig. 3.33), if
the head is located in the pelvis and lies in

87
FIGURE 3.33
Flat plate of the abdomen. Single fetus in the
vertex presentation. The small fetal parts are
on the left. Ribs and spine are noted. The
bony structures are well visualized by X-ray.
The soft tissues are optimally imaged by
ultrasound. Relationship of calvarium to the
bony pelvis for cephalopelvic disproportion
determination can be optimally evaluated by
using X-ray pelvimetry.
certain particular planes, eg, the lateral or sections to localize the fetal head and fetal
anteroposterior planes. If conditions do not meet thorax. The real-time scanner permits the
the optimal pelvimetry criteria and the amount of ultrasonographer to detect immediate changes in
magnification cannot be estimated precisely, the fetal head position or motion of the individual
reliable dimensions of the fetal head cannot be fetal parts.
ascertained. Using ultrasound, the most
Exact measurement of the biparietal diameter
accurate measurements may be obtained
(BPD) depends upon precise localization of the
disregarding the fetal position and lie.
fetal lie and the angle of the fetal head with
The majority of fetuses are in the cephalic respect to the investigating sound waves. The
presentation. The discernment of another biparietal diameter is defined as the maximum
orientation is extremely important in obstetric reproducible distance between the fetal temporal
management. Information regarding fetal or parietal bones. The midline echo of the falx
presentation is best obtained with longitudinal must be centered between the strong echoes of

88
the cranium. A-mode and B-mode
measurements are made directl y from the screen
(Fig. 3.34).
Gray-scale scanners produce a thicker skull out-
line and the output must be reduced to depict the
calvarium as a single line (Fig. 3.35a). Electronic
calipers may be used to measure the biparietal
diameter. Digital read-out or a permanent record
on a Polaroid print will provide the measuring
landmarks, or simultaneous comparisons can be
made between bistable and gray scale (Fig.
3.35b). Using black and white, or leading edge
for BPD, simultaneous A-mode and B-mode dis-
play can be superimposed in some units (Fig.
FIGURE 3.34
Supine transverse scan. B-mode. The maximum biparietal 3.36a).
diameter is best obtained when the sensitivity is lowered to
most clearly delineate the cranial outlines. Note the In scanning the vertex presentation, with the
exquisitely sharp skull contour. head on the side, a longitudinal scan will
determine the plane of the dorsal flexure of the
head within the maternal pelvis. This angle of
flexure is corrected by proper angulation of the
transducer in the transverse scanning plane.
FIGURE 3.35(b)
Supine longitudinal scan. Simultaneous comparison between
bistable and gray scale for the measurement of the biparietal
diameter.
FIGURE 3.35(a)
Supine transverse scan. Gray scale. Gray-scale scanners
produce a thicker skull outline and the output must be
reduced to depict the calvarium as a single line.

89
Appropriate transverse scans are made until the
maximum intracranial distance is located_ This is
most easily accomplished with the real-time
scanner since any change in the fetal skull
position due to inherent fetal movements may be
immediately noted and corrected by the
ultrasonographer _
FIGURE 3.36(a)
Supine transverse scan. Gray scale. Measurement of the
BPO. After detection of the calvarium and midline echo with
leading edge, A-mode translation may be performed and
superimposed over the scan.
FIGURE 3-36 (a)
FIGURE 3.36(b)
Supine transverse scan. Gray scale. Nonperpendicular
studies produce false echo pattern which is not valid for the
measurement of the biparietal diameter.
FIGURE 3.36(c)
Supine transverse scan. Gray scale. Another diameter that
presents perpendicular surfaces is that of the occipitofrontal
plane. The occipitofrontal diameter is much larger than the
biparietal diameter. This also is not a valid measurement.
FIGURE 3.36(d)
Supine transverse scan. Occasionally, midline echoes appear
as a curve . This is still a valid reading.
FIGURE 3-36 (b)
FIGURE 3-36 (c)

90
The examiner should move the transducer over
TABLE 3.2 Approximation of Gestational
the abdomen until strong and equal-amplitude Age From Biparietal Diameter (BPD)
echoes are received from the near and far sides
of the skull with A-mode. Since the abdomen of BPD (em) GESTATIONAL AGE
the pregnant subject is round in late gestation, 2.5 14.0
the transducer can move in various angulations 2.6 14.0
up to 90° from the vertical plane. This maneuver 2.7 14.5
2.8 14.5
facilitates accurate measurement of the BPD.
2.9 15.0
StUdying the patient with A-mode and B-mode in 3.0 15.5
3.1 16.0
combination with gray scale yields the maximum
3.2 16.5
information. In A-mode study, the echoes from 3.3 16.5
the fetal skull usually are equal when both sides 3.4 17.0
of the skull are perpendicular to the sonic beam. 3.5 17.5
In the vast majority of cases, the distance 3.6 17.5
3.7 18.0
between the equal-amplitude echoes signifies the
3.8 18.5
BPD. It should also be kept in mind that the only 3.9 18.5
other diameter that occasionally presents 4.0 19.0
perpendicularly is that of the occipitofrontal 4.1 19.5
plane. Using the knowledge that the 4.2 19.5
4.3 20.0
occipitofrontal diameter is much larger than the
4.4 20.5
BPD (Fig. 3.36b and c), these two diameters may 4.5 20.5
be differentiated. Also, if two nonperpendicular 4.6 21.0
surfaces are measured, the vertical deflections 4.7 21.5
are not equal in height. Again, it should be 4.8 21.5
4.9 22.0
emphasized that the absence of midline echoes
5.0 22.5
invalidates the reading. 5.1 22.5
5.2 23.0
As described above, the widest diameter of the
5.3 23.5
fetal skull that is perpendicular to the midline 5.4 23.5
echoes is considered to be the maximum 5.5 24.0
biparietal diameter. Occasionally, midline 5.6 24.5
echoes appear as a curved line; this still implies a 5.7 24.5
5.8 25.0
valid reading (Fig. 3 .36d). There are a number of
5.9 25.0
charts and tables available for fetal age 6.0 25.5
evaluation from the biparietal diameter. 6.1 26.0
Unfortunately, large variations in gestational age 6.2 26.0
determination exist between these tables (8-10). 6.3 26.5
6.4 27.0
Most of these differences may be explained on
6.5 27.5
the basis of geographic locality, socioeconomic 6.6 27.5
status, or racial differences. 6.7 28.0
6.8 28.5
We use the placental appearance and the data 6.9 28.5
listed in Table 3.2 for our determinations. These 7.0 29.0
data are comparable with those in the literature. 7.1 29.5
If the BPD is calculated to be more than 105 mm, 7.2 29.5
7.3 30.0
the study should be repeated and, if the reading
7.4 30.0
is constant, hydrocephalus should be 7.5 30.5
considered. To avoid any confusion, accurate 7.6 30.6
measurements should be obtained. 7.7 31.0

91
TABLE 3.2 (Continued) obtained when the degree of asynclitism of the
BPD (em) GESTATIONAL AGE fetal head is determined from the sagittal scan
and the ultrasonographer adjusts the transverse
7.8 31.5
7.9 31.9
scan plane angle in an appropriate manner to
8.0 32.6 register the biparietal diameter in the plane
8.1 33.0 perpendicular to the midline structures.
8.2 33.5
8.3 34.1
8.4 34.7
8.5 35.0
8.6 35.4
MATERNAL PELVIS
8.7 36.0
8.8 36.4 Although pelvimetry may be performed with
8.9 37.0 ultrasound, X-ray pelvimetry is still considered
9.0 37. I
the best method for examination of the bony
9.1 38.0
9.2 38.5
pelvis. Indications for X-ray pelvimetry include
9.3 39.0 the following.
9.4 39.2
9.5 39.8 I. If the diagonal conjugate is less than
9.6 40.0 11.5 cm
9.7 40.5
9.8 41.0
2. Presence of diseases which already
9.9 41.8 affect the bony pelvis
10.0 41.9
3. Very prominent ischial spines with
flattened sacrum
For the measurement of BPD, our experience 4. Failure of progression of labor
shows that usage of the A-mode or simple 5. Breech, face, and other abnormal
bistable mode is still superior. If the single spike presentations
is seen for the measurement in the trace, the two
points of the takeofffrom the baseline become 6. Narrowed intertuberous diameter
the actual measurement. The confusing factor is accompanied by narrow sub pelvic angle
the presence of multiple spikes. To overcome
this obstacle, the simplest method is to decrease
the gain setting and slightly change the
HEAD
angulation of the transducer until three clear
spikes are seen. In some commercially available
The calvarium produces a strong echo to the
units, the study can be done simultaneously with
interrogating ultrasound and appears as a
the leading edge or black-and-white pattern on
regular, circular, or elliptic outline on the
the television screen and with special maneuvers
bistable oscilloscope. The increased sensitivity
the two studies can be superimposed. This is
of gray-scale equipment reveals not only the
important because the errors can be minimized
bony structures but also the pericranial soft
to less than 2 mm.
tissues such as fat, muscle, and hair. These are
In measuring the biparietal diameter, the displayed as a region of low-amplitude echoes
ultrasonographer must be aware of the tilting of adjacent to the high-amplitude calvarial echoes.
the fetal skull as it enters the pelvic inlet. In this The exact shape of the fetal head is best
situation, the biparietal diameter may be delineated without the peripheral echoes (which
obtained in an oblique plane relative to the true increase the thickness of the bony outline for
transverse plane. In these cases, the midline measurement purposes) by decreasing the gain
echoes will not lie in the exact midline or may be of the unit. The optimal outline of the head can
completely absent. The optimal study is be obtained through bistable study (Fig. 3.37a).

92
The linear midline structure of moderate echo-
genicity that parallels the posteroanterior axis of
the calvarium is thought to represent the inter-
hemispheric region, including the intracranial
falx cerebri and the third ventricle. There is a
consistent set of symmetric echoes lateral to the
anterior portion of the falx, most likely repre-
senting the lateral portion of the anterior hom of
the lateral ventricle (11). Another pair of ante-
riorly located C-shaped structures appear at the
junction of the frontal bone with the facial bones
and represent the bony orbits. When the correct
plane offetal skull orientation is demonstrated, a
band of reverberation artifacts is often seen
which originates from the near table and should
not be mistaken with any other structures. Occa-
sionally, motion of the fetus may produce some
difficulties in measuring BPD (Fig. 3.37b).
SPINE
Distal to the head, a pair of strongly echogenic

lines connect the thorax with the head. This is
the ultrasonic appearance of the cervical spine in
sagittal section (Fig. 3.38a). This structure
continues with a dorsal curvature into the rest of
the spine, ending at the strong echo complex of
FIGURE 3.37(b)
Supine transverse scan. Occasionally, motion of the fetus
may produce some difficulty in measuring BPD.
FIGURE 3.37(a)
Supine transverse scan. B-mode. The optimal outline of the
head can be obtained through bistable study.

93
the pelvis (Fig. 3.38b). The spine produces a
sonic shadow in later weeks of pregnancy (Fig.
3.38c). Ribs appear as parallel lines projecting
from the spine (Fig. 3.38d). Along the spine-
and of a similar configuration-lies the aorta.
This may be differentiated from the spine by the
sharper appearance of the parallel lines and the
lack of sonic shadowing which may be often
demonstrated when the spine lies ventrally
adjacent to the transducer. The aorta is best
distinguished from the vertebral column by the
typical, synchronous pulsations shown with the
FIGURE 3.38(a) fine real-time scanner.
Supine longitudinal scan. Gray scale. Distal to the head, a
pair of strongly echogenic lines connect the thorax with the
head. This is the ultrasonic appearance of the cervical spine
in sagittal section.
FETAL HEART
The fetal heart becomes a functional pumping

organ at 35 to 45 days' amenorrhea. One
investigator, using A-mode echography, was
able to detect fetal heart motion as early as 45
days' amenorrhea (12). It is possible to observe
fetal heart motion with A-mode or M-mode at 7
to 10 weeks' gestation (13). The application of
M-mode or real-time scanning makes evaluation
of fetal death a straightforward process when
coupled with Doppler studies. The unequivocal
signs of fetal death by radiologic imaging occur
long after fetal demise. The ultrasonic signs by
FIGURE 3.38(b) bistable or gray scale are indirect signs.
Supine longitudinal scan. Gray scale. The cervical spine
continues with a dorsal curvature into the rest of the spine,
ending at the strong echo complex of the pelvis.
FIGURE 3.38(d)
FIGURE 3.38(c) Supine longitudinal scan. Gray scale. The fetus is in the
Supine longitudinal scan. Gray scale. The spine produces a vertex presentation. Linear parallel echoes extend from the
sonic shadow in later weeks of pregnancy. dorsal spine representing the posterior rib cage. A sonic
shadow is produced by the dorsal spine.

94
However, when motion studies are available, the
beating fetal heart is rather easy to image (Fig.
3.39a and b). The absence of a fetal heartbeat
when expected is the most definite sign of
non viability of the fetus.
MONITORING THE FETAL HEART RATE
The fetal heart motion can be easily detected by

the real-time scanner. However, at present, in
our experience, irregularity of the fetal heart
cannot be adequately judged by the real-time
FIGURE 3.39(a)
M-mode scan over the maternal abdomen and fetal thorax. scanner. For precise evaluation the fetal heart
The fetal heart appears as an echo-free area with a clearly signal should be registered through a chart
demonstrated rapid and cyclic echo of the contracting recorder. Doppler ultrasound can be used for
ventricle. The beating heart identifies the fetal thorax.
continous monitoring of the fetal heart rate. The
normal fetal heart rate is 120 to 140 beats per
minute. A unit with a mUltiple transducer array
permits continuous tracking of the fetal heart,
even if the fetus moves. Tracking with this
instrument, the fetal heart signals will be
transmitted to a counting circuit and chart
recorder. The other channel of the unit records a
simultaneous tracing showing uterine
contractions. Any irregularity of the fetal heart
rate can easily be registered during the course of
labor and followed throughout delivery. The unit
can be adjusted so that any decrease or
alteration in the fetal heart motion can be
detected and the physician can thus be alerted to
possible fetal distress.
FIGURE 3.39(b)
M-mode scan over the maternal abdomen and fetal thorax.
Demonstration offetal heart and fetal respiratory motion.
FETAL THORAX
Cross section of the chest reveals the rounded

outline of the vertebral column due to the verte-
bral body and the elements of the neural arch.
The fetal heart has already been discussed; how-
ever, the identification of this structure most
accurately locates the fetal thorax (Fig. 3.40a
and b). Rib detail may often be imaged as a series
of closely parallel echogenic linear structures
(Fig. 3.38d). In late pregnancy, the fetal thorax
produces a sonic shadow over the placenta (Fig.
3.41). The motion of thorax can be demonstrated
by M-mode (Fig. 3.39b).

95
FIGURE 3.4O(a)
Supine transverse scan. Gray scale. The fetal heart with its
internal septum may be localized by gray scale. Verification
of this structure is made with M-mode or the real-time
scanner.
FIGURE 3.40(b)
Supine longitudinal scan. Gray scale. The fetal body is seen
in cross section and an echo-free region with a dividing
septum is noted to represent cardiac chambers. Note sonic
shadowing by fetal parts .
FIGURE 3.41
Supine longitudinal scan. Gray scale. The fetal thorax may
occasionally produce a sonic shadow sign as a normal
variation. Echo-free area represents fetal heart.
FIGURE 3-40 (a)
FIGURE 3.42(a)
Supine longitudinal scan. Gray scale. The flat chorionic plate
of the anterior placenta protrudes into the amniotic cavity
and extrudes the umbilical cord. The cord generally appears
FIGURE 3-40 (b) as an interrupted linear array of parallel echoes due to its
tortuous course and motion.
FIGURE 3.42(b)
Supine longitudinal scan. Gray scale. The cord appears as a
stepladder pattern in this case.
FIGURE 3-41

96
FIGURE 3.43
Supine longitudinal scan. Gray scale. Cross section through
the fetal upper abdomen demonstrating the fetal gallbladder
in the right upper quadrant as a pearshaped echo-free
structure surrounded by echoes of the liver. In the left upper
quadrant is the fluid-filled fetal stomach. The fluid is due to
fetal SWallowing.
FIGURE 3.44
Supine longitudinal scan. Gray scale. The fetal heart is noted
as an echo-free zone within the thoracic cavity divided by a
linear echo representing the interventricular septum.
Immediately cranial and to the left of the cardiac chambers is
noted a rounded echo-free structure in the fetal left upper
quadrant characteristic of the fetal stomach.
FIGURE 3-43
FIGURE 3.45
Supine transverse scan. Gray scale. Cross section through
the fetal abdomen. The placenta is posterior. The fetal back is
ventral to the maternal abdominal wall and the spine casts a
sonic shadow. On either side of the spine are the ovoid renal
outlines.
FETAL ABDOMEN
The fetal abdomen is a rounded image in cross

section and is most easily separated from the
fetal thorax by a lack of cardiac pulsations. The
attachment of the umbilical cord at the fetal
umbilicus (Fig. 3.42a) may be noted as an
interrupted series of linear parallel echoes (Fig.
3.42b) with gray scale, or as a pulsatile structure
with the real-time scanner. The fetal liver is
echogenic. In the right upper quadrant are noted
FIGURE 3-44
two anechoic structures representing the
gallbladder and stomach (Fig. 3.43).
The gallbladder may appear ovoid or linear in
shape and is shorter than the umbilical vein. The
FIGURE 3-45 umbilical vein has an anteroposterior course
from the umbilicus to the region of the venous
union near the dorsal spine. These two
structures are best separated by the pulsations of
the vein with the real-time scanner. In the left
upper quadrant, the fluid-filled fetal stomach is
seen as an echo-free space of variable
appearance (Fig. 3.44).
The fetal kidneys are miniature versions of the
adult organs. They have an echo-free periphery
and an echogenic interior and are lateral to the
dorsal spine (Figs. 3.45 and 3.46). Intrauterine
hydronephrosis may be identified by cystic
transformation of the renal outlines (Fig. 3.47).

97
The urinary bladder is imaged as an ovoid or
rectangular echo-free area in the fetal pelvis.
(Fig. 3.48a and b). This organ varies in size and
fetal urination may be observed by gray scale at
short time intervals, or with the real-time
scanner during micturition after observing
bladder distension. The fetal colon may be
occasionally imaged as an echo-free area in the
abdominal cavity unrelated to other cystic
organs (Fig. 3.49).
FIGURE 3.46
Supine transverse scan. Gray scale. Cross section through
the fetal abdomen. The thorax produces a sonic shadow sign.
The fetal back is ventral to the maternal abdominal wall and FET AL WEIGHT
the spine casts a sonic shadow. On either side of the spine are
the ovoid renal outlines. With optimal calibration of the ultrasonograph
machine, the measurement of the head and
thorax is obtained and used in evaluation offetal
weight. This is accomplished in the third
trimester by measuring the biparietal diameter of
the fetal head and the anteroposterior diameter
of the chest (14). The cross section of the chest is
shown when the circular structure of the thorax
is visible and the vertebral bodies are delineated.
By using the biparietal diameter and
anteroposterior diameter of the fetal chest and
by placing a straightedge across the nomogram,
the estimated age or weight of the fetus can be
evaluated (15).
In 80 percent of our cases, the estimated weight
by using both BPD and anteroposterior diameter
FIGURE 3.47 of the chest is within 0.5 pounds (lb) of the actual
Supine transverse scan. Gray scale. Section through the fetal birth weight. In the remaining 20 percent, there
kidneys shows multiple disorganized echo-free areas instead are a number of reasons to explain these
of the expected renal outline. Fetus born with massive
bilateral hydronephrosis which after autopsy was proven to differences. For instance, in diabetes, the fetal
be due to posterior urethral valves. weight is approximately 1 lb more than that
predicted by the measurements. In malnourished
fetuses due to such causes as placental
insufficiency, the weight of the fetus would be
less than that of the estimated range. In our
series, such fetuses with BPDs of9 cm or greater
had a weight of more than 5.5lb, and 98 percent
of the infants were mature. Normally, the fetus
with a BPD of over 9 cm has a weight of6.7Ib.
By using the clinical data and combined
ultrasonic studies proper decisions regarding
elective cesarean section can be made.

98
SEX DETERMINATION
The higher resolution of gray-scale systems now

permits detailed imaging of the fetal perineum.
The fetal orientation is noted and then the
perineum is localized by finding the landmarks of
the fetal bladder and fetal pelvis. Sections are
made parallel to the long axis of the fetus to
detect the fetal penis or scrotum connected to
the fetal perineum. This physical attachment
must be demonstrated to rule out the possibility
FIGURE 3.48(a)
Supine transverse scan. Gray scale. Rectangular outline of of fetal limbs simulating the rounded appearance
the echo-free fetal bladder. Note echogenic area of the fetal of the scrotum. The penis appears as a short
spine with distal sonic shadowing. linear echo pattern and the scrotum as an echo-
free compartment with a central median septum
(Fig. 3.50a,b,c,d,e, and f). The low-level echoes
of the testes appear as symmetric low-amplitude
echoes within the fetal scrotal compartments.
The female sex is ascertained by exclusion of the
presence of the penis and scrotum by ultrasonic
imaging. The best time for scanning is at 30 to 32
weeks' gestation. The determination offetal sex
is useful for genetic counseling of parents who
may be suspected of having children with sex-
linked disorders, such as hemophilia (16).
FET AL EXTREMITIES
FiGURE 3.48(b)
Supine longitudinal scan. Gray scale. Round echo-free The upper and lower limbs of the fetus are best
bladder in the fetal pelvis is seen. Note posterior placenta.
studied with a combination of high-resolution
gray-scale scanning and real-time scanning. The
real-time scanner is most suitable for observing
FIGURE 3.49 the motion of the arms and legs. The presence of
Supine transverse scan. Gray scale. A small echo-free area is
noted near the echo-free bladder. Multiple scans showed this appropriate fetal movements assures that gross
to have the typical configuration of the fetal colon. neurologic function is intact. Sonofluoroscopy of
the uterus shows the coordinated motion of the
upper and lower limbs with respect to the fetal
trunk. Mental integration of the movement
allows the ultrasonographer to decide which
extremity is part of the upper trunk and which
limb is associated with the lower portion of the
fetus. After real-time scanning has located and
identified the fetal limbs with accuracy, the gray-
scale unit may study these regions with either a
2.25 or a 3.5-MHz transducer to image the bony
structures of the arms and legs as well as the

99
FIGURE 3.50(a)
Supine transverse scan. Gray scale. The echogenic fetal
scrotum appears at the perineum between the fetal buttocks.
Courtesy of D. J. Flanigan, Santa Barbara, California.
FIGURE 3.50(b)
Supine longitudinal scan. Gray scale. Scan taken through
fetal perineum. Search produced no echoes protruding from
the fetal buttock region. Female infant delivered.
FIGURE 3.50(c)
Supine longitudinal scan. Gray scale. Vertex presentation.
The echo-free bladder clearly outlines the fetal pelvis. In the
region of the perineum no projections of a penis or scrotum
are noted. Female infant delivered.
FIGURE 3-50 (a)
digits ofthe developing fetus (Fig. 3.51a,b,c,d,e,

and 0. Although it is difficult to visualize the
phalanges of the hands and feet, effort on the
part of the ultrasonographer may produce a
picture clearly depicting the presence 01 an
adequate number of fingers or toes. This is of
great value in suspected fetal genetic defects or
other anomalies.
FETAL MOTION
Early fetal motion may be detected between 8

and 10 weeks' gestation with a real-time
FIGURE 3-50 (b)
scanning system and consists of changes of
position of the fetus within the uterine cavity and
limb motion without alteration of the fetal
position in the gestational sac (17). In our
,
FIGURE 3-50 (e)
experience with the real-time scanner, fetal heart
motion can be detected at 14 weeks of gestation
in most cases. Later in gestation, movement
patterns of head bobbing and chest wall
excursion become discernable. Each type of
motion provides specific clinical data about the
fetus. Head bobbing implies a certain degree of
neurologic function is present in the fetal
nervous system. The presence of chest wall
motion implies that the fetus may be able to
breathe when born (17). Indeed, fetal motion
sometimes is so vigorous that one may have
great difficulty in obtaining true and accurate

100
FIGURE 3.50(d)
Supine longitudinal scan. Gray scale. The fetal buttocks are
anterior and in the superior part of the uterus.
Ultrasonographic searching could not demonstrate a penis
nor a scrotum. Female infant delivered.
FIGURE 3.50(e)
Supine oblique scan. Gray scale. The fetal penis sppears as a
linear echo extending from the fetal perineum. On either side
are noted shorter and rounder echogenic structures
representing the fetal scrotum with its testicles. Courtesy of
D. J. Flanigan, Santa Barbara, California.
FIGURE 3.50(f)
Supine longitudinal scan. Gray scale. The fetal penis
extending from the fetal perineum . Note both fetal knees.
FIGURE 3-50 (d)
fetal measurements , such as thorax size and

biparietal diameter (Fig. 3.52). Movement may
be so rapid that two fetal heads may be observed
if the scanning speed is slow enough to record a
single fetal head in two different positions. Real-
time scanning affords the best imaging of various
fetal movements.
FETAL GROWTH
FIGURE 3-50 (e) For determination of fetal growth, ultrasonic

cephalometry is one of the most valuable tools
when combined with clinical correlation. At the
FIGURE 3-50 (I)
beginning of gestation, fetal growth can be
followed by measuring the size of the gestational
sac. As growth progresses, the fetal heart may
be detected by the real-time scanner. As time
passes , the BPD can be monitored sequentially.
The average increase in the BPD is
approximately 1 to 2 mm per week. Sudden
changes in the growth rate of the fetal head
suggest certain pathologic conditions; eg, a
sudden decrease in fetal head size may indicate
either placental insufficiency or fetal death. In
cases of twin gestation, the BPD of both fetuses
should be followed. On occasion during
examination, the identification as to which twin
is which may be difficult. In abnormal
pregnancy, such as is associated with
anencephaly or hydrocephalus, the BPD

101
FIGURE 3.51(a)
Supine longitudinal scan. Gray scale. The fetal lower limbs
are seen in cross section. Fetal extremities are seen as
discrete echogenic areas. Sonic shadow is present.
FIGURE 3.51(c)
Supine transverse scan. Gray scale. The fetal thorax is
identified in an oblique plane . The fetal elbow, forearm, and
FIGURE 3.51(b) hand with distinct echoes from the digits are clearly
Supine transverse scan. Gray scale. Anterior placenta. Fetal displayed.
extremities are noted.
Fetal elbow
CHAFfER 3: ULTRASONOGRAPHY IN OBSTETRICS

102
measurement and follow-up is extremely helpful
for final termination of the pregnancy.
PRESENTATION AND POSITION
Ultrasonography is an excellent method for

evaluation of presentation and position.
Ultrasonography is especially valuable when
there is difficulty in palpation. Obesity, muscular
resistance of the abdominal wall, or a very thick
anterior placenta are among the commonest
FIGUR 3-51 (d) obstacles to palpation of the fetus. With
ultrasonic study, the muscles of the anterior
abdominal wall and their fascial attachments can
be seen in detail. If the patient is heavy and
obese, Scarpa's fascia is occasionally outlined
( 18).
FIGURE 3.51(d)
Supine transverse scan . Gray scale . The fetal elbow,
forearm , and hand are clearly displayed.
FIGURE 3.51(e)
Supine transverse scan. Gray scale. Anterior placenta with a
prominent umbilical cord is visualized. The fetal hand with
distinct digits is imaged clearly with high-resolution gray
scale.
FIGURE 3.51(f)
FIGURE 3-51 (e) Supine transverse scan. Gray scale. Clearly displayed fetal
perineum.
FIGURE 3.52
Supine longitudinal scan . Gray scale. Vertex presentation.
FIGURE 3-51 <0 There is a double outline due to the fetal skull. Also noted is a
double outline to the distal bladder wall. Real-time scanner
revealed vigorous fetal movement against the bladder.

103
The fetal head is transonic and can be easily
identified as a round structure on one side of the
uterus or the other.
Since the majority of fetuses are in the cephalic

presentation, the discernment of another
orientation is extremely important in obstetric
management. Information regarding
presentation and position can be obtained in the
longitudinal section. The fetal attitude is easily
determined by localizing fetal parts in both
longitudinal and horizontal ultrasonic studies.
FIGURE 3.53 The longitudinal scan is taken for identification

Supine scan. Demonstration of midline echoes emanating
from such structures as falx cerebri, third ventricle, and of the fetus and its lie. Then horizontal sections
lateral ventricle. are performed at selected levels for verification
of presumptive diagnostic findings. Taking the
total fetus into consideration, stronger echoes
will be returned from the skull than from any
other fetal part (18). The reflecting bony calvar-
ium, including the echoes of the inner and outer
tables, makes the localization easier. However,
demonstration of the midline structures, such as
the falx cerebri or the lateral ventricles, is abso-
lutely diagnostic (Fig. 3.53). Difficulties arise
when the head is engaged and penetration
through the pubic bone is not possible.
The fetal trunk can first be identified by the

detection of the fetal spine and fetal heart with
the real-time scanner. For further evaluation,
FIGURE 3.54 different sections at different levels, including
Supine longitudinal scan. Gray scale. In the cephalic
presentation the fetal head can be localized in the lower part oblique projections, are necessary.
of the uterus. Subsequently, the fetal heart and kidneys can be
displayed by bistable or gray-scale units.
Difficulties arise in distinguishing the fetal heart
from the fetal bladder when the interventricular
septum cannot be identified. By slicing at
various levels, the position of the bladder with
respect to the rest of the trunk can be
ascertained. Cardiac contractility can be
evaluated and the pulsations of the fetal heart
(120 to 140 beats per minute) can be captured by
M-mode. Grossly, fetal heart motion can be
monitored by the real-time scanner, whereas the
bladder echo has no motion. Identification of
fetal anatomy has been described in detail.

104
CEPHALIC PRESENTATION
The fetal head can be localized in the lower part

ofthe uterus (Fig. 3.54). Detection of the head
and its display echo does not present any
difficulty. The only problem, as previously
described, arises when the head is engaged and
thus difficult to image.
The shape of the returned echo is extremely

important for assessing fetal head position.
FIGURE 3.55 When the head is well flexed, the plane of
Supine longitudinal scan. Gray scale. In the breech section goes through both the parietal and
presentation the fetal head can be localized in the upper part
of the uterus. suboccipitobregmatic diameters. Consequently,
the displayed echo appears perfectly circular in
shape. With further extension of the head, other
diameters can be identified and the head loses its
circular shape.
BREECH PRESENTATION
In breech presentation, the head can be localized

in the upper part of the uterus (Fig. 3.55). In
contrast to the cephalic presentation, detection
of the head and its display echoes may present
some difficulties, especially when there is
excessive movement of the fetus. The problem
arises in distinguishing the fetal head from the
fetal trunk; but the best landmarks for
differentiation of these two structures are the
fetal spine and fetal heart. Longitudinal sections
are of great value for detection of the breech
(18).
FIGURE 3.56
Supine scan. Gray scale. In the transverse lie the fetal head
and trunk are located in the transverse position.
TRANSVERSE LIE
In transverse lie, the head and trunk are ususally

located at the same level and fetal parts (eg,
hands, feet) are generally located above or below
the trunk (Fig. 3.56). The main difficulty in
detecting transverse lie is that its appearance
must be differentiated from that of twins. The
only way to achieve absolute certainty is tu
obtain multiple sections at different times. The
cause of the malpresentation must be further

105
FIGURE 3.57
Supine longitudinal scan. Gray scale. The uterus is enlarged
with extrinsic pressure over the posterior border of the
bladder. Note echogenicity of the fibroid uterus.
FIGURE 3.58(a)
Supine longitudinal scan. Real-time scanner. The uterus is
enlarged. The gestational sac is flattened in the
anteroposterior diameter by a fibroid tumor of irregular
outline and patchy echo pattern. Spontaneous abortion
followed.
FIGURE 3.58(b)
Supine longitudinal scan. Gray scale. The uterus is enlarged.
Infarcted fibroid nodule with internal echoes is seen in the
FIG URE 3-57 uterine fundus. Clear, well-defined gestational sac is located
in lower portion of the uterus.
investigated (19). If the real-time scanner is

available, the diagnostic workup is made more
simple.
DIFFERENTIAL DIAGNOSIS
Any pelvic mass of sufficient size or any

enlarged uterus should be investigated for
possible pregnancy. The following conditions
require full investigation.
1. In a simple, uncomplicated fibroid, the

uterus demonstrates as an echo-free
space (20), but in pregnancy, fetal parts
have their own echo patterns. On the
other hand, in myomatous degeneration
(21), the fibroid usually has some
IFIGURE 3-58 (a) internal echoes (Fig. 3.57). Another
valuable criterion is the fact that the
fibroid is much firmer than the pregnant
uterus, and, as a result, this usually
. FIGURE 3-5 (b produces an indentation on the
posterior surface of the bladder. Fibroid
uterus may be accompanied by
pregnancy (Fig. 3.58a and b). Headlike
calcified fibroid uterus (Fig. 3.59a and b)
should not be mistaken for the fetal
head and will be discussed in detail.
2. The distinction of a bladder
diverticulum from a pregnant uterus is
easily made.
3. Recognition of a nonpregnant uterus in
an abnormal position relative to other

106
organs automatically excludes
pregnancy (22).
4. Ovarian cysts usually are echo free
(Fig. 3.60) unless the cysts are
loculated.
5. Carcinoma of the ovary does not have a
specific echographic pattern and only
the mass can be outlined (23).
6. Ectopic pregnancy may be suggested by

confirmation of the pregnancy ring
outside of the uterus, fetal parts seen
outside the uterus, or enlargement of the
FIGURE 3-59 (a) uterus with diffuse amorphous internal
echoes and no fetal parts. (Fig. 3.61) The
clinical correlation is of extreme help.
FIGURE 3.S9(a)
Supine transverse scan. Gray scale. Rounded incomplete ring
of echoes is noted within a large fibroid uterus. Distal to the
posterior wall of the calcific mass is an artifactual
reverberation echo simulating the distal boundary of the
fibroid. This may be confused with a fetal head. Ring-shaped
calcified fibroid.
FIGURE 3.S9(b)
Supine transverse scan. Real-time scanner demonstrates
calcified fibroid simulating a fetal head. Note the sonic
shadowing distal to the calcific interface. Sonic shadowing is
generally better appreciated with the real-time scanner due to
it~ linear beam path.
FIGURE 3.60
Supine transverse scan. Gray scale. Ovarian cyst in the right
side is seen. Ovarian cysts are usually echo-free unless the
cyst is loculated.
FIGURE 3-59 (b) FIGURE 3.61

Supine transverse scan. Gray scale. Rounded adnexal mass
with scattered internal echoes represents ectopic gestational
sac.
FIGURE 3-60

107
7. Hydatidiform mole usually produces
symmetric uterine enlargement and has
a specific echo pattern which is
described in detail (Fig. 3.62).
MULTIPLE PREGNANCY
The early state of multiple gestation may be

recognized before fetal structure is observed.
There is more than one gestational sac and as the
pregnancy progresses more than one fetal head,
FIGURE 3.62 thorax, and placenta may be demonstrated (Fig.
Supine longitudinal scan. Gray scale. The uterus is diffusely 3.63a,b, and c). Separate gestational sacs may be
enlarged and indents the bladder. Through transmission is
high. Fine echoes fill the uterine cavity. Hydatidiform mole. identified at as early as 6 weeks' gestation (Fig.
3.63d). The problem of the round fetal body
simulating a second head is easily resolved with
demonstration of the beating fetal heart with the
real-time scanner.
SPURIOUS PREGNANCY OR
PSEUDOCYESIS
Pseudocyesis usually occurs near menopause or

in women with an intense desire for a child.
These patients may have increased abdominal
size with usually normal menstruation. Morning
sickness may exist. Ultrasonography is one of
the best tests for these patients since it can
FIGURE 3.63(a) automatically exclude pregnancy. The patient
Supine longitudinal scan. B-mode. Two fetal heads are noted will usually be convinced of the actual situation.
at opposite ends of the uterus in the vertex and breech
presentations. This is the usual appearance of twin gestation.
A posterior placenta is noted.
THE PLACENTA
Determination of the placental position in the

uterus with respect to the cervix has been a
major achievement of ultrasound. The normal
placenta may be followed from its earliest phase
to the various physiologic degenerative changes
that occur near term. Abnormalities of position
and internal structure may now be studied with
an accuracy never possible before the advent of
ultrasound. Precise placental localization is
necessary for the evaluation of bleeding in
pregnancy or for the insertion of a needle for
atraumatic amniocentesis. Ultrasonographic

108
placental localization has completely replaced
the procedure of radioisotopic scanning, which
was the preferred method of localization before
the development of 8-scan ultrasound (24-30).
NORMAL PLACENTA
The placenta is first seen at about 10 weeks'

gestation and at this time it may occupy between
one-half and three-fourths of the uterine cavity.
FIGURE 3.63(b) The placental tissue at this time is moderately
Supine longitudinal scan. Gray scale. Anterior and posterior echogenic. Several weeks later it assumes the
placentas are noted. Fetal heads appear at both poles of the
uterine cavity. A linear echogenic septum marks the low-amplitude homogeneous echo pattern that
separation of the twin pregnancy. will characterize this organ for the majority of
the pregnancy (Fig. 3.64a) (31).
Routine study with B-mode or gray scale
demonstrates the placenta as a thick speckled
band of echoes in the echo-free background of
the amniotic fluid (Fig. 3.64b and c). This
homogeneous band is surrounded by a thin
echogenic boundary facing the intrauterine
cavity and represents the chorionic plate of the
placenta (Fig. 3.65a and b). At low sensitivity the
placenta is echo free, while at high gain settings
it completely fills in with echoes. The margins of
the placenta may be determined with great
FIGURE 3.63(c)
accuracy and correlated with external physical
Supine oblique scan. Gray scale. Two rounded fetal heads landmarks.
are adjacent to each other. Optimal documentation oftwins is
provided when both heads are shown in the same plane; Echoes inside the placenta arise from the
oblique sections may be necessary. The real-time scanner internal texture of the placenta, the chorionic
will show twins easily with sonofiuoroscopy.
villi, and are easily recorded with high
amplification (Fig. 3.66). Between the echoes of
FIGURE 3.63(d) the chorionic villi, which are a diffuse reflector
Supine longitudinal scan. Gray scale. Two gestational sacs of ultrasound, and the fetus is an echo-free zone
may be identified as early as 6 weeks' gestation. Note two
gestational sacs inside the enlarged uterus. corresponding to the amniotic fluid.
If the position of the placenta is difficult to

determine, the transverse scan is very helpful in
establishing the primary site of this structure.
This is particularly important in amniocentesis
where, for instance, an anterior placenta may
not entirely cover the anterior wall, and the
ultrasonographer may be able to localize an area
for puncture of the uterus through the anterior
abdominal wall under which no placental tissue
is present.

109
FIGURE 3.64(a)
Supine longitudinal scan. Gray scale. After 12 to 13 weeks of
1
gestation a distinct placenta can be identified in the majority
of cases. Fundus posterior placenta of early pregnancy.
FIGURE 3.64(b)
Supine longitudinal scan. Fine placental echoes are noted
anteriorly which cross over the fetal body. The distal border
of the placenta is bounded by the dark echoes of the
chorionic plate. Note echo-free area of amniotic fluid .
J
FIGURE 3.64(c)
Supine longitudinal scan. Anterior placenta demonstrating
homogenous low-amplitude echo pattern bounded by high-
amplitude echoes of the chorionic plate.
FIG RE 3-64 (a) FIGURE 3.65(a)
Supine longitudinal scan. Gray scale . The fetal head is in the
vertex presentation. The anterior placenta shows the
echogenic margin of the chorionic plate. Sonic shadow is cast
by fetal parts in a normal fetus.
FIGURE 3.65(b)
Supine longitudinal scan. Gray scale. The fetal head is in the
Amniotio fluid vertex presentation. The echogenic margin of the chorionic
plate against the amniotic fluid is well outlined.
FIGURE 3-64 (b)
FIG RE 3-65 (a)
FIGURE 3-64 (e) FIGURE 3-65 (b)

110
Gray-scale imaging reveals new dimensions in
placental growth and pathology . Between 13 and
28 weeks, the internal echoes of the placenta lie
within the chorionic plate and the uterine wall
echoes are low amplitude in intensity (Fig. 3.67).
Since the placenta is a diffuse reflector,
compound scanning techniques generally
produce the best imaging of this structure.
Difficulties arise in the diagnosis of the posterior
placenta. The overlying fetus generally
attenuates much of the sound beam so that the
weak echoes of the posterior placenta may not
be of sufficient intensity to register on the
oscilloscope (Fig. 3.68a and b). This sonic
FIGURE 3.66
Supine longitudinal scan . Gray scale. Echoes inside the
placenta arise from the internal texture of the placenta, the
chorionic villi, and are easily recorded with high
amplification. The placenta is anterior. There is an
indentation in the mid portion of the placenta due to pressure
by a fetal extre mity.
FIGURE 3.67
Supine longitudinal scan. Gray scale. Between 13 and 28
weeks, the internal echoes of the placenta lie within the
chorionic plate and the echoes of the uterine walls are low
amplitude in intensity.
FIGURE 3.68(a)
Supine longitudinal scan. Gray scale. The posterior placenta
is echo free and poorly imaged. Posterior placenta should
always be suspected when the fetal body and head are
FIGURE 3-67 anterior and separated from the posterior uterine wall by any
significant distance.
FIGURE 3.68(b)
Supine longitudinal scan. Gray scale. The overlying fetus
generally attenuates much of the sound beam. so that the
weak echoes of the posterior placenta may not be of sufficient
intensity to register on the oscilloscope.
FIGURE 3-68 (a)
Posterior Posterior
placenta placenta
CHAYfER 3: ULTRASONOGRAPHY IN OBSTETRICS

111
FIGURE 3.69(a)
Supine longitudinal scan. Gray scale. The fetal head is in the
vertex presentation. The anterior placenta shows the
interrupted echogenic margin of the chorionic plate. Sonic
shadow is cast by fetal parts in a normal fetus.
FIGURE 3.69(b)
Supine transverse scan. Gray scale. The placenta may
enlarge markedly in the presence of edema. This is seen in
erythroblastosis fetalis. Posterior placenta.
FIGURE 3.70
Supine longitudinal scan. Gray scale. The uterus is markedly
distended with a large echo-free area due to polyhydramnios.
Note the thin rim of placental tissue from rapid uterine
expansion.
FIG RE 3-69 (a)
shadowing effect is common and its very

presence is one of the diagnostic criteria of a
posterior placenta. The majority of anterior
placentas tend to be on the right side of the
l
uterus, while the placentas located posteriorly
are frequently left sided. This relationship may
be of value to the ultrasonographer trying to
adjust the scanning technique to confirm the
location of a posterior placenta. One means of
filling the posterior placenta with echoes is to
compound scan from the right and left lateral
walls to the abdomen, using the diffuse reflecting
characteristics to produce the typical low-level
, echoes of the placental tissue.
~
j The placental form is subject to local pressure
changes (Fig. 3.69a). It may enlarge markedly in
the presence of edema. This is seen in
FIGURE 3-69 (b)
erythroblastosis fetalis (Fig. 3.69b). The placenta
may be thinned and depressed when adjacent to
some fetal structure or in the distended uterus of
polyhydramnios (Fig. 3.70) (32).
After 28 weeks, small anechoic spaces appear
FIGURE 3-70 within the homogeneous echo pattern and
enlarge as gestation progresses (Fig. 3.71).
These represent blood-filled spaces. As term
approaches, further changes in the homogeneous
echo pattern are noted. By 36 weeks, the
anechoic areas become separated by echogenic
intercotyledonary septa due to calcification of
these septa. Also, poorly margined echogenic
areas may show up in the placenta and are
irregular, amorphous placental calcifications
most likely due to old infarcts (Fig.
3.72a,b,c,d,e, and D.

112
TYPES OF PLACENTA
The anterior placenta is located along the

anterior wall of the uterus. The fundal placenta
lies in the uterine fundus.
A corporeal placenta is adjacent to the body of
the uterus. Thus, an anterior fundocorporeal
placenta extends the entire length of the uterus
in an anterior position. Posterior placentas are
against the posterior uterine wall and the above
classification applies in a similar manner. Lateral
placentas occur on either the right or left lateral
FIGURE 3.71 wall. This type is unusual and may extend
Supine longitudinal scan. Gray scale. Areas of degenerative anteriorly or posteriorly. The tendency for
changes within the placenta may appear as echo-poor regions
with a random distribution. posterior placentas to be left sided and anterior
placentas to be found on the right side may be
due to the rotation of the uterus as it grows out of
the pelvic cavity (33).
The posterior placenta presents unique problems
since it is often shielded from the incident
ultrasound beam by the fetal parts, and the
speckled echoes of the chorionic villi and the
continuous band of the chorionic plate may not
be well visualized. We may be able to appreciate
part of the placenta or observe a separation
between the fetus and the posterior wall of the
uterus that is made from failure to localize any
placental structure inside the uterus (Fig.
2.41B).
PLACENTA PREVIA
The diagnosis of placenta previa is made when

placental tissue overlies the internal cervical os
(Fig. 3.73a,b,c,d,e,f,g,h, and i). A full bladder is
most important to provide a sonic window to
detect low-intensity placental echoes in the
region of the internal os. This is especially true in
the case of posterior placenta previa where the
filled bladder may displace the overlying fetal
structures away from the cervical canal, thus
permitting better imaging. Early detection of
placenta previa is vitally important for patient
care.
The normal placenta will separate the fetal skull
in the vertex presentation from the maternal
sacrum by a distance of less than 1.6 cm.

113
l
FIGURE 3-72 (a) FIGURE 3-72 (d)
FIGURE 3-72 (b) FIGURE 3-72 (e)
FIGURE 3-72 (e) FIGURE 3-72 (0

,
I

114
FIGURE 3.72(a) In the transverse lie or breech presentation,
Supine longitudinal scan. Gray scale. Scan through lateral
placenta showing irregularity of the normally homogeneous
detection of placenta previa is difficult. Placenta
placental tissue with echo-poor and strongly echogenic previa may be marginal, partial, or total, which
regions. Echo-poor areas represent degenerative changes. completely covers the cervical os. To be certain,
Echogenic zones are diffuse calcifications of the placenta.
Normal fetus delivered.
the fornix should be identified. If the longitudinal
section is performed off midline, lateral placenta
FIGURE 3.72(b) may mimic placenta previa. It is thus essential
Supine longitudinal scan. Gray scale. Scan over this posterior that the fornix and the midline be identified for
placenta shows multiple echogenic interfaces with sonic
shadowing, indicative of heavy areas of calcification in detection of placenta previa. If the lower border
regions of previous placental degenerative changes. of the placenta extends to the internal cervical os
the placenta previa is of the marginal type. The
FIGURE 3.72(c)
Supine longitudinal scan. Gray scale. The anterior placenta placental tissue covers the entire cervical os and
has an irregular echo pattern with scattered high-amplitude is of great thickness at this site in total placenta
regions. Placental degeneration changes at 37 weeks' previa. Difficulty often arises in the diagnosis of
gestation.
placenta previa when the placenta is posterior
FIGURE 3.72(d) and the fetus is in the vertex presentation. In this
Supine transverse scan. Gray scale. Same case as in Fig. case, the fetal head produces sonic shadowing of
3.72c. Anterior placenta has an irregular echo pattern with
scattered high-amplitude regions. Placental degenerative the placenta and placental echoes are not
changes at 37 weeks' gestation. visualized. Our experience with the real-time
scanner has shown that under sonofluoroscopy,
FIGURE 3.72(e)
Supine transverse scan. Gray scale. The anterior placenta the fetal head may be pushed into a more
multiple areas of high- and low-amplitude echoes which cephalic position, and the posterior placenta that
represent calcifications and infarctions. had been previously covered by the fetus now
FIGURE 3.72(f) returns many echoes and can be precisely
Supine longitudinal scan. Gray scale. Same case as in Fig. localized. This maneuver may be performed
3.72e. Anterior placenta with multiple areas of high- and low-
amplitude echoes which represent infarctions and
manually or in the Trendelenburg position.
calcifications. Occasionally, nidation may be the predisposing
factor in placenta previa formation. Routine
Ultrasonography during early pregnancy is
recommended to locate the position of the
pregnancy ring to prepare for possible placental
abnormalities (35).
Therefore, any separation less than this makes a
placenta previa unlikely (34). This measurement A large series of placenta previas were followed
may only be applied when the fetal head lies in from midtrimester at 2- to 3-week intervals.
the pelvis. To achieve this position, the mother Serial study showed a significant increase in the
may stand for a time or gentle manual distance between the lower segment of the
maneuvers may be tried if the fetus is in another placenta and the cervix as compared with that
position. To differentiate a floating head from a found upon initial examination. As the end of
placenta previa producing separation of the fetal pregnancy approached, the diagnosis of placenta
skull from the sacrum, manual compression of previa was less justifiable. Of a total of 112
the head in an anteroposterior plane will push patients in the second trimester with ostensible
the freely floating head against the sacrum. If the placenta previa, 102 placental migrations
placenta is between the skull and sacrum, no occurred sufficiently to rule out the diagnosis of
decrease in distance will be noted. If the placenta previa at term (36). Our experience has
amniotic fluid is between the fetal head and the shown that there is little placental migration after
bony pelvis, there will be a notable narrowing of 32 weeks' gestation. Thus, after 32 weeks'
the distance on the precompression and the gestation, the diagnosis of placenta previa may
postcompression scans. be firmly offered.

115
FIGURE 3-73 (a) FIGURE 3-73 (d)
FIGURE 3-73 (c) FIGURE 3-73 (I)

116
FIGURE 3.73(a)
Supine longitudinal scan. Gray scale. Magnified view of total
placenta previa with medium-amplitude echoes covering the
internal os of the uterus. The chorionic plate is difficult to
image in this type of placental position.
FIGURE 3.73(b)
Supine longitudinal scan. Gray scale. The placenta occupies
one-half of the uterus on the posterior wall. There is anterior
extension of the placenta over the internal cervical os
producing placenta previs. Fetal structures are noted within
the amniotic fluid cavity.
FIGURE 3.73(c)
Supine longitudinal scan. Gray scale. The posterior fundal-
corporeal-isthmic placenta extends completely over the
internal cervical os. Note sonic shadowing of the placenta by
the fetal spine.
FIGURE 3-73 (g)
FIGURE 3.75(d)
Supine longitudinal scan. Gray scale. Early detection of
placenta previa. Sixteen weeks' gestation showing placental
echoes completely covering the internal cervical os.
FIGURE 3.75(e)
Supine longitudinal scan. Real-time scanner. The echo-free
bladder is fully distended. The echoes of the placenta extend
from anterior and posterior directions and completely cover
the internal cervical os. The echo-free amniotic fluid
separates the anterior and posterior leaves of the placenta
previa.
FIGURE 3.73(f)
Supine longitudinal scan. Gray scale. The speckled anterior
placental echoe s extend over the internal cervical os in this
placenta previa.
FIGURE 3.73(g)
Supine transverse scan. Scan is taken over the engaged fetal
head. The distance between the sacral wall echoes and the
fetal head is 3 cm. The normal distance is less than 1.6 cm.
FIGURE 3-73 (h) The placenta is posterior and separates the head from the
sacrum by a distance greater than normal in placenta previa.
This distance did not change after pressure was applied.
FIGURE 3.73(h)
FIGURE 3-73 (i) Supine longitudinal scan. Middle pregnancy with placenta
previa. Note cephalic presentation of fetal head. Serial scans
may show migration of placenta upward to a normal position.
FIGURE 3.73(i)
Supine transverse scan. B-mode. The fetal midline and lateral
ventricular walls are demonstrated within the fetal head. The
calvarium is separated from the sacrum by a distance greater
than 1.6 cm due to the presence of a posterior placenta
previa.

117
ABRUPTIO PLACENTAE
Premature separation of the placenta from the

uterus resulting in hemorrhage is the gross
pathologic change in abruptio placentae (Fig.
3.74). The blood hemorrhaging between the
placenta and the maternal uterus generally
appears as an echo-free zone with a crescentic
shape conforming to the anatomic location of the
blood. There may be an associated outward
bulge of the placental contour into the amniotic
cavity. Signs of fetal distress or fetal demise
should be searched for by the ultrasonographer.
Some difficulties may arise in determination of
FIGURE 3.74
Supine longitudinal scan. Gray scale. The placenta is abruptio placentae; however, a combination of
separated from the uterine wall by an echo-free space ultrasonographic information with clinical
representing retroplacental hematoma. This mid-trimester findings greatly facilitates diagnosis. To rule out
bleeding patient had abruptio placentae.
abruptio placentae, ultrasonographic study
reveals the following.
1. Exclusion of placenta previa by prior

ultrasonographic study
2. Presence of numerous echoes making
the placental image thicker, due to
placental separation in abruptio
placentae
3. Detection and/or exclusion of
retroperitoneal hematoma
4. Falsely appearing abruptio placentae
caused by tangential study of normal
placenta; this is clarified by further
sectioning.
PLACENTAL SIZE
The placenta may increase in size in various

physiologic and pathologic states. The placenta
enlarges with multiple gestations deriving their
blood supply from one placental site, and in
diabetes, syphilis, and Rh disorders. The volume
of the placenta decreases in the presence of fetal
demise or organizing infarct. One report stated
that the development of echo-poor spaces within
the near-term placenta is an indication of fetal
maturity (37).

118
FETAL EVALUATION AMNIOCENTESIS
Many antenatal diagnostic studies rely on the

DOPPLER EXAMINATION IN analysis of amniotic fluid components. Chromo-
PREGNANCY some analysis is used in the study of Down's
syndrome in patients with increased maternal
The Doppler principle of change in frequency age or a previous child with a trisomy 21 or other
with motion of a reflector of an ultrasonic signal trisomy disorder. Also, translocations of the 21
has proven to be great use in obstetric chromosome and X-linked disorders such as he-
management. Doppler studies record signals mophilia may be evaluated in this manner. Am-
when motion is present and record no signals niotic fluid is used for enzyme assay in fetuses
when the reflecting surface is motionless. with suspected inherited biochemical disorders.
Doppler ultrasound involves a type of motion Chromosomal linkage analysis is of value in cer-
sensor as contrasted with the imaging sensor of tain autosomal dominant abnormalities. The in-
B-scan ultrasound. It has been used to detect trauterine diagnosis of spina bifida or anence-
early fetal heart motion, locate the placenta, phalic states may be aided by the level of (X-
identify vaginal or pelvic arteries, and study the fetoprotein in the amniotic fluid.
fetal heart rate in late pregnancy stress tests and
labor (38).
Most sampling of amniotic fluid is performed at
The stethoscope has been used for the 16 weeks' gestation, since at this time there is
evaluation offetal heart rate patterns for many adequate amniotic fluid volume and the
years. It has been found that this type of cellularity of the fluid is increased. This early
auscultation can only detect prolonged and tapping allows the performance of a second
severe tachycardia and bradycardia (39). trimester abortion after the biochemical and
Doppler ultrasound permits continuous fetal cytogenetic tests are completed after 2 to 6
heart rate monitoring between uterine weeks. Cells in the amniotic fluid settle rapidly.
contractions as well as during contractions. It is advisable for placental localization to be
Doppler technique may be audible or recorded performed by scanning and then for the patient
on a strip-chart device (40). Doppler ultrasound to be ambulatory until shortly before puncture.
is more sensitive than is phonocardiography Although amniocentesis entails more risk when
since there is less interference with extraneous twins are present, continual visual monitoring
noise. with the real-time scanner will allow for proper
guidance of the needle.
Abnormal fetal heart rate patterns have been
classified into three main categories: (I) early In placental localization prior to amniocentesis,
deceleration due to fetal head compression; (2) it is important to place the needle through the
late deceleration characterizing uteroplacental uterus in an area devoid of placental tissue or
insufficiency; and (3) variable deceleration through the thinnest portion of an anterior
occurring from umbilical cord compression. The placenta as far away from the umbilical artery
continual use offetal heart rate monitoring has and vein as possible (Fig. 3.75). Failure to do this
been found to improve perinatal outcome (41). may result in a bloody tap which can
contaminate the specimen and render it useless
for analysis. The needle may transect the
The observation of the fetal heart rate response
umbilical vessels resulting in fetal demise.
to the stress of uterine contractions has been of
Significant retroplacental bleeding may endanger
use in predicting fetal jeopardy. The oxytocin
the mother.
challenge test (42) using external fetal heart rate
monitoring to show the effect of contractions on The procedure may be performed with the real-
the fetus has also been of value. time scanner or with the puncture transducer.

119
The placenta is scanned and the transducer is
placed over the largest area of amniotic fluid.
Since a smooth metallic needle will only be
imaged when the beam is perpendicular to the
axis of the needle, a specially grooved needle
with a teflon sheath is used. It is inserted
obliquely through the anesthetized skin to lie
within the amniotic fluid under the transducer
beam. Since the needle is small, if it is not
initially detected, the transducer should be
angled through a gentle arc to pick up the needle
echoes. Sometimes the needle will appear within
the amniotic cavity and no fluid will return. It is
most likely that the membranes have been
displaced by the needle and a brisk push on the
needle may puncture the membranes. This is of
no danger since the real-time scanner monitors
the position of both the needle and the fetus.
(43).
FIGURE 3.75
Supine longitudinal scan. Gray scale. The low-amplitude
echoes of the placenta are contained within the echogenic
boundary of the chorionic plate. Fetal parts are noted.
FIGURE 3.76
Supine transverse scan. Gray scale. The outline of the fetal
skull is irregular with overlapping of the strong cranial
echoes. Fetal demise.
FIGURE 3.77
Supine longitudinal scan. Double-ring contour to the fetal
FIGURE 3-76
head is due to fetal motion during the scanning procedure.
This problem does not occur with real-time scanning.
FIGURE 3.78
Supine transverse scan. Gray scale. Section through distal
part of cranium. Note massive edema of scalp surrounding
FIGURE 3-77 the oval outline of the fetal skull. High through transmission
noted distal to edematous tissues of the pericranium.
Erythroblastosis fetalis.

120
Amniocentesis may also be performed with the gestation, fetal motion may be detected by
puncture transducer with a central bore. The Doppler techniques, M-mode, or the real-time
direction of the probe and the needle site are scanner. These methods are the only means to
marked by the electronic line on the oscilloscope check the fetus during the "gray zone" of
which may be superimposed upon the B-scan. ultrasonic diagnosis occurring between the tenth
This visibly depicts the path of intended punc- and thirteenth week of gestation, when there is
ture. The distal echoes represent the fetus or no clearly defined gestational sac or fetal head.
fetal parts and this distance may be monitored The absence of fetal motion or fetal heart beat
with either the A-mode or M-mode displays. The signifies fetal death. Doppler ultrasound may
area selected is prepared and draped. A steri- accurately record fetal heart motion at 12 weeks'
lized aspiration transducer with a central lumen gestation; in addition, the real-time scanner and
is then attached to the ultrasonic unit. The exact M-mode can detect fetal activity at about 8
depth of the amniotic fluid within the uterus is weeks' gestation. After 13 weeks' gestation, the
determined from the sonogram study, by using characteristic deformities of the nonviable fetus
either digital read-out or A-mode monitoring. are imaged with the gray-scale scanner.
The needle is advanced through the centrallu- Following a given period of time, certain
men of the aspiration transducer into the am- echographic changes are noted on the sonogram.
niotic fluid. The procedure can be continuously A double ringlike contour to the normal single
monitored and the echo from the tip of the ring appearance ofthe fetal skull appears (Fig.
needle will be registered in the same fashion as 3.76). This ultrasonic appearance is equivalent to
echoes from needles directed ultrasonographi- the radiographic "halo" sign, which is noted in a
cally into the uterine cavity for saline abortions. matter of days subsequent to fetal death as a
Ultrasonography has also been utilized in the radiolucency adjacent to the fetal skull, most
placement of endoscopes when direct visual likely representing edema of the fetal scalp or
monitoring of the fetus and placenta is needed. layering out offat within the scalp tissue planes.
The exact depth of the tip of the endoscopic This sign is nonspecific and may be seen in
needle can be evaluated easily (43). fetuses of diabetic mothers (43); in normal
fetuses, either with or without fetal movement
In our experience amniocentesis using ultrasonic
during contact B-scanning (Fig. 3.77); in
guidance is not necessary if a posterior placenta
erythroblastosis fetalis (Fig. 3.78); or when the
has been documented. Sonofluoroscopy is
fetal head deeply indents the bladder wall and
indicated during amniocentesis when the
may produce a double interface echo pattern that
placenta is in the anterior position.
simulates a double skull contour at the point of
contact ofthe fetal head with the bladder. This
pseudo-double ring shape is localized and does
ANOMALIES OF PREGNANCY
not appear to completely encircle the fetal head
(Fig. 3.79).
FETAL DEATH
The chest wall becomes irregular in a similar
The ultrasonic determination of fetal demise manner to the fetal skull after a longer period
depends upon the duration of the pregnancy. In subsequent to fetal demise. This is then followed
early gestation the death of the fetus may be by the appearance of a disorganized echo pattern
represented by fragmentation of the gestational within the fetal head and thoracic cavity (Fig.
sac, which may appear as a circular or triangular 3.80). Subsequently, it is noted that the outlines
echo-free zone interrupted by scattered strong of the head and thorax become grossly distorted
echoes within the uterus. The uterus is generally and that evidence of fetal growth on follow-up
small for the expected dates. Later in pregnancy, sonograms has ceased. Air within the fetus due
Doppler ultrasound and M-mode recording may to internal decomposition may produce a sonic
be used to evaluate fetal viability. Mter Rweeks' shadow (Fig. 3.81). Often it is necessary to wait

121
FIGURE 3.79
Supine transverse scan. Gray scale. The fetal head deeply
indents the bladder. This produces a pseudo-double skull
contour which should not be mistaken for fetal demise. Note
the single layer of the fetal head posteriorly.
FIGURE 3.80
Supine transverse scan. Gray scale. Scan through the fetal
body shows no recognizable anatomic structures. Internal
disorganization is due to fetal demise of several days length.
FIGURE 3.81
Supine longitudinal scan. Gray scale. The distal border of the
fetal body is not imaged due to sonic shadowing. Large
amounts of gas were present intraabdominally due to tissue
decomposition resulting from fetal death.
2 to 6 days to document these changes,

approximately 5 to 7 days after the fetal death
diagnosis can be established. Immediate and
definitive proof is obtained when there is no fetal
heart motion discernable with the real-time
scanner. The optimal determination will be
obtained by usage of the real-time scanner and
Doppler technique. Alternatively, gray scale will
image the cardiac chambers and M-mode may be
used to record the presence or absence of
cardiac contractility.
RADIOLOGIC SIGNS OF FETAL DEATH
· FIGURE 3·80 The following radiologic signs may be observed.

1. Spalding's sign. There is gross
overlapping of skull bones, due to
liquefaction of the brain. This usually
develops several days after fetal death.
2. Exaggerated curvature of the fetal
spine. This situation needs more time to
FIGURE 3· I
develop and depends on maceration of
spinous ligaments.
3. Gas in the fetus. This is the most
I reliable sign.
ABORTION
DIAGNOSIS OF ABORTION
Ultrasonographic findings are extremely useful

in the management of suspected spontaneous
abortion. Ultrasound can determine whether the

122
fetus or gestational sac is within the uterus or has
already passed, and can also evaluate the status
of the products of conception . The decision to
perform surgery on the bleeding pregnant
patient, treat her with bed rest, or send the
patient home without a curettage is assisted by
the ultrasonic findings within the uterine cavity.
The actively bleeding patient with a uterus full of
echoes should have surgery performed; while
the patient with diminishing vaginal hemorrhage
and a uterine cavity without echoes may be
spared an unnecessary dilation and curettage.
The early application of ultrasonography in the
FIGURE 3.S2(a) diagnosis of abortion will save both the patient
Supine longitudinal scan. Gray scale. The uterus is of fibroid and the clinician much valuable time and
type. The pregnancy ring has an irregular shape with an area
of interrupted echo pattern. This configuration when coupled trouble .
with appropriate clinical data represents threatened abortion.
THREATENED ABORTION
In threatened abortion the status of the

gestational sac of the bleeding patient must be
carefully evaluated. The pregnancy ring may be
circular and intact or it may be incomplete or
defective in some areas (Fig. 3.S2a). We have
found that small gaps in the structure of the sac
in the bleeding patient follow a normal course of
events. Similarly, an irregular sac may be
associated with a spontaneous abortion. We
suggest serial evaluation of the gestational sac as
the optimal method of following threatened
abortion (Fig. 3.S2b). A partially open pregnancy
ring may enlarge and close up to form a complete
and intact sac on subsequent scans. The absence
of growth of the uterus is another important
FIGURE 3.S2(b) factor in the analysis of abortion. The normal
Supine longitudinal scan. Gray scale. Large multiseptate
cystic lesion in the cui de sac is noted. Patient admitted to the gestational sac should enlarge within 1 week
hospital with a diagnosis of threatened abortion. Patient while the aborting uterus may show a decrease in
underwent surgery because of enlarged cystic lesion. At size of the pregnancy ring. The ultrasonographic
operation, a hemorrhagic luteal cyst was found.
diagnosis of abortion becomes extremely
complex during the " gray zone" of pregnancy at
10 to 13 weeks' gestation where the pregnancy
ring is no longer present. The ultrasonographer
should not confuse the irregularity of the
gestational sac fusing into the walls of the uterus
with the broken pregnancy ring of the aborting
gestational sac. The use of real-time scanning to
evaluate fetal motion and provide proof of fetal
viability appears to be useful in experienced
hands. We have observed intrauterine echoes
with motion that have still progressed to

123
spontaneous abortion. The application of motion criteria may obviate long hospital stays since the
techniques should be coupled with the clinical various types of abortion may be suggested. An
data and information of the gray scale B-scans. accuracy rate of 97.5 percent was obtained in a
recent series (44).
MISSED ABORTION
As mentioned, threatened abortion may be
The ultrasonographic diagnosis of missed
diagnosed when bleeding occurs with or without
abortion is based on the lack of definite evidence
definite evidence of fetal motion by M-mode or
offetallife. The gestational sac, fetal parts, or
real-time scanning. In missed abortion with
definite fetal movements are not identifiable and
retained fetal tissue, scanning will usually
the uterus is enlarged with only scattered
demonstrate the following:
amorphous echoes in its center. This ultrasonic
appearance is not specific since other conditions
1. Uterus small for date
may mimic a missed abortion (1). Hydatidiform
mole, fibroid uterus, ovarian tumor, and the 2. Failure of uterine growth on repeat
"gray zone" may be confused with a missed serial studies
abortion. Clinical data, laboratory tests, and the 3. Abnormal and amorphous uterine
use of serial sonograms for follow-up are the contents or grossly distorted fetal
optimal tools for determining missed abortion outline
(Fig. 3.83).
4. Absence of fetal motion
SUMMARY Incomplete abortion is suspected when there is

Early bleeding in pregnancy generally occurs at no evidence of normal fetal structure and a series
8 to 11 weeks and is usually due to a blighted of echoes in line with the endometrial cavity is
ovum. The following criteria for the diagnosis of noted.
abortion have been described.
Complete abortion has occurred when there is
1. Loss of definition of the gestational sac only a straight line of echoes in the endometrial
or fragmentation of the pregnancy ring cavity or a complete absence of internal uterine
with a break in its contours echoes. Patients with an ultrasonically "empty"
? Absence of fetal echoes within the uterus may be sent home without routine
gestational sac after 10 weeks' gestation curettage (45).
3. A gestational sac that is small for the
expected date
4. Failure of growth of the pregnancy ring ECTOPIC PREGNANCY
with serial examinations
5. Low position of the gestational sac in Investigation of ectopic pregnancy requires
the uterine cavity with or without an precise history taking and skillful scanning with
open cervix attention to the ultrasonic appearance of the fetal
parts and placenta. A thorough knowledge of the
Real-time scanning combined with Doppler and progressive uterine changes and stages of the
M-mode study yields optimum information in developing fetus is necessary. The best sign of
early pregnancy while the patient is bleeding. No conception is detection of the fetal head. Present
sign offetal movement after 10 weeks' gestation equipment allows differentiation of the fetal head
implies that the pregnancy is in jeopardy (13). from other fetal parts onl y if the head diameter is
The usual outcome of a blighted ovum is a ~reater than 2 cm (Fig. 3.84). Clinical problems
spontaneous abortion. The application of these with ectopic pregnancy usuallv o~cur before this

124
stage of fetal development is reached. Since
investigation ofthe fetal head ofless than 2 cm
diameter is not possible in ectopic pregnancy,
/ other criteria are used.
The uterus in ectopic pregnancy is enlarged to a

moderate size. No definite intrauterine echo
pattern of a gestational sac or fetal head is
demonstrable. If there has been no history of the
passage offetal tissue products, the finding of an
empty uterus with a positive pregnancy test is
strongly suggestive of an ectopic pregnancy.
Various extrauterine signs are noted in the

determination of ectopic gestation. The
identification of a gestational sac or fetal head
outside the uterus is positive proof of ectopic
FIGURE 3.83 pregnancy; however, this finding is rarely
Supine transverse scan. Gray scale. Midline echo-free area observed. More often, a cystic, irregular mass,
within the uterus. The sharp distal wall should be mistaken with or without internal echoes in the adnexal
for part of gestational sac. Retained blood clot from
spontaneous abortion. region or cui de sac is seen.
If the pregnancy sac ruptures, the resulting

hemoperitoneum will produce a cystic pattern in
the cui de sac which will usually change in shape
and position due to gravitational forces. The
chronically ruptured ectopic pregnancy appears
as a complex mass. The uterus often cannot be
separately imaged from the conglomerate pelvic
mass.
FIGURE 3.84
Supine transverse scan. Gray scale. The uterus is normal in
,
size. An echo-free adnexal cyst was noted on serial scans. No
hemoperitoneum was noted. Ectopic pregnancy at surgery. INTRAABDOMINAL PREGNANCY
In intraabdominal pregnancy, there are irregular,

widespread echoes throughout the entire
abdomen, and mUltiple sections must be made to
obtain a recognizable echo pattern. The
ultrasonographer must differentiate the uterus
from the fetal parts, since an enlarged uterus
contains numerous echoes and in longitudinal
scan may have the same ultrasonic appearance
as the fetal body. Extrauterine localization of the
fetal head and intraabdominal extrauterine
position ofthe placenta are important findings;
however, detection of the placenta and chorionic
plate is hindered by the interfacing echo patterns

125
from bowelloops, adhesions, inadequate DISTENSION OF FETAL ABDOMEN
amniotic fluid, and tangential placental slicing.
Distension of the fetal abdomen may be due to
intraabdominal tumor, hydronephrosis, or as-
cites. Hydronephrosis is the most interesting
ABNORMAL FETUSES
cause from an ultrasonographic viewpoint, since
as time passes increased dilation is discernible.
HYDROCEPHALUS
This is usually due to low obstruction of the fetal
urinary tract.
Ultrasound has become a reliable method for the
investigation of hydrocephalus. The biparietal
diameter is greater than 10.5 cm and there is a
relative disproportion between the size of the ASSOCIATED ABNORMALITIES IN
fetal trunk and the enlarged head. The distended PREGNANCY
ventricular system and associated brain atrophy
allow better sonic penetration and increased Ultrasonography is important in detecting or
through transmission is noted. Early in confirming abnormal conditions accompanying
pregnancy, a BPD much larger than the intrauterine pregnancy.
expected size for date associated with a
relatively smaller-than-normal fetal thorax raises
a strong suspicion of hydrocephalus. A dead ASSESSMENT OF AMNIOTIC FLUID
hydrocephalic fetus in utero may be surgically
decompressed allowing for vaginal delivery POL YHYDRAMNIOS
rather than cesarian section. When the diagnosis Polyhydramnios exists when the fluid volume of
of hydrocephalus is made, a cannula may be the amniotic cavity exceeds 2000 ml. This
inserted into the fetal cranium under ultrasonic condition is first clinically detectable when
guidance. Drainage of the dilated ventricles roughly 3000 ml of fluid is present within the
permits serial decrease in cephalic size. Vaginal uterine cavity. Ultrasonographically, a large area
delivery may then be accomplished. of sonolucency inside the uterus is noted with
separation of the limbs from their usual position
closely adjacent to the fetal body. The freely
floating fetal parts are due to the large fluid
ANENCEPHALY
volume in which the fetus lies. The fetal outline
is sharply delineated due to the high through
In normal gestation, the fetal head is usually
transmission of the excess amniotic fluid (Fig.
demonstrable by 12 to 14 weeks' gestation.
3.86a and b).
Anencephaly may be diagnosed after 15 weeks'
gestation when scanning fails to reveal a normal OLIGOHYDRAMNIOS
fetal head despite use of multiple scanning
Oligohydramnios occurs when the fluid volume
planes. When the abnormal skull is definable,
is below the normal range. Hyperflexion of the
poor through transmission is noted due to the
fetal head onto the trunk is observed along with
lack of sonolucent brain tissue and a relative
an associated decrease in size of the expected
overgrowth of the bony craniofacial structures
echo-free zone of amniotic fluid surrounding the
(Fig. 3.85). The fetal outline is generally easily
fetus. This produces poor acoustic visualization
imaged due to the frequently associated
of the external fetal contours and impaired
polyhydramnios. When polyhydramnios is
imaging of the posterior uterine wall and
present the fetus and placenta are more sharply
retrouterine structures.
identifiable, and in many situations the placenta
seems to be compressed by a massive amount of Either polyhydramnios or oligohydramnios may
fluid. reflect fetal abnormality. Anencephaly is

126
FIGURE 3.85
Supine transverse scan. Gray scale. Section through the fetal
head shows total deformity of the usually rounded calvarial
echoes. Paired echogenic oval structures represent the
abnormally enlarged orbits. Through transmission is low due
to the hypertrophy of the facial bones that occurs in
anencephaly.
FIGURE 3.86(a)
Supine longitudinal scan. Gray scale. The uterus is markedly
distended with a large echo-free area due to poly hydranmios.
Note the thin rim of placental tissue from rapid uterine
expansion.
FIGURE 3.86(b)
- .~ Supine longitudinal scan. Gray scale. The freely floating parts
are due to the large fluid volume in which the fetus lies. The
fetal outline is sharply delineated due to the excess amniotic
FIGURE 3-85 fluid.
generally seen with polyhydramnios and renal

agenesis occurs with oligohydramnios.
HYDATIDIFORM MOLE
Hydatidiform mole or molar pregnancy occurs

when the fertilized ovum produces a rapidly
growing mass of grapelike structures instead of a
normal fetus. This creates a uterus larger than
expected for the calculated gestation.
When a patient at 10 to 14 weeks of gestation is

FIGURE 3-86 (a) bleeding and has a larger uterus than that ex-
pected for the date, a mole can easily be sus-
pected; but confirmation needs further investiga-
tion, because in positive cases the uterine cavity
must be evacuated promptly. Before the advent
FIGURE 3-86 (b) of ultrasonography, the diagnosis was based on
clinical data, an enlarged uterus beyond the nor-
mal size for the period of amenorrhea, absence
of fetal parts on X ray, and increased urinary
chorionic gonadotrophin. The first sign was the
passage of vesicles from the vagina, possibly
accompanied by abortion. By the usage of ultra-
sonography, the diagnosis can easily be made.
The ultrasonic appearance of a molar pregnancy

shows no evidence of echoes from a fetus or
placenta. Typically, a snowstorm echo pattern is
noted at high gain settings and is caused by the
numerous tissue interfaces occurring within the

127
FIGURE 3-87 (al FIGURE 3-87 (d)
1 FIGURE 3-87 (e)
FIGURE 3-87 (I)

128
FIGURE 3.87(a) uterine cavity filled with the molar vesicular
Supine longitudinal scan. B-mode. Low-sensitivity scan
shows a few scattered amorphous internal echoes within the
mass. At lower gain settings, the echo pattern
uterus. Hydatidiform mole with low gain setting. from the internal echoes is noted at low sensitiv-
ity (Fig. 3.87a,b,c,d,e, and f). The theca lutein
FIGURE 3.87(b)
Supine longitudinal scan. B-mode. Medium-sensitivity scan
cysts frequently associated with hydatidiform
shows scattered amorphous internal echoes within the mole are readily detected as multilocular or unil-
uterus. Hydatidiform mole with medium gain setting. ocular echo-free masses (Fig. 3.88a and b).
FIGURE 3.87(c)
These decrease in size following evacuation of
Supine longitudinal scan. B-mode. High-sensitivity scan the mole. Echo-free intrauterine spaces are ob-
shows scattered amorphous internal echoes within the served and represent either large cystic areas or
uterus. Hydatidiform mole with high gain setting.
blood clots. Previously, when amniography was
FIGURE 3.87(d) a common method of diagnosing this condition,
Supine longitudinal scan. Gray scale. The uterus is enlarged usually puncture was made into a hematoma and
with an irregular echo pattern. High through transmission is
noted. Snowstorm appearance of hydatidiform mole.
the clinical picture was extremely difficult to
interpret.
FIGURE 3.87(e)
Supine transverse scan. Gray scale. Same case as in Fig. Early diagnosis is imperative due to this
3.87d. The uterus is completely filled with echoes. Scattered condition's potential for malignant
anechoic spaces are noted and represent blood-filled regions.
Hydatidiform mole.
transformation. The question of coexisting
pregnancy is best answered by using gray scale
FIGURE 3.87(f) (Fig. 3.89) or the real-time scanner to
Supine transverse scan. Gray scale. The uterus is completely
filled with echoes. Scattered anechoic spaces are noted and
demonstrate fetal motion. More laboriously, an
represent fluid-filled regions. Hydatidiform mole. attempt may be made to define characteristic
fetal structures.
At 10 to 14 weeks' gestation, difficulties may be
encountered during scanning because neither the
gestational sac nor the fetal head are detectable,
and the only clue to a normal pregnancy may be
FIGURE 3.88(b)
Supine transverse scan. Gray scale. The snowstorm pattern
FIGURE 3.88(a) within the uterus with moderate through transmission is
Supine transverse scan. Gray scale. The enlarged uterus is sometimes noted in recurrent molar pregnancy. The
filled with a snowstorm echo pattern. Bilateral cystic lesions increasing size of the bilateral luteal cysts indicates
with septations are characteristic of the luteal cysts recurrence of this disease.
associated with hydatidiform mole.
Hydatidiform mole •
Lutein
cysts

129
the presence of a placenta. Missed abortion with
retained products of conception may simulate a
mole. In missed abortion that produces molelike
pictures a number of criteria are helpful, eg, the
uterus will be small for date and the pregnancy
test is negative. Other conditions mistaken for a
hydatidiform mole include multiple pregnancy
before appearance of the fetal heads, ovarian
tumors, and degenerating fibroids. In such situa-
tions, clinical data and laboratory tests must be
coupled with ultrasonographic findings.
A condition known as hydropic degeneration of

FIGURE 3.89 pregnancy also exists. This is a proliferative
Supine transverse scan. Gray scale. There is a gestational sac
with a 10-week-old fetus inside to the right of the enlarged
form of fetal demise, in which fetal structure has
uterus. The left part of the massively enlarged uterus is full of disappeared and the placenta has already devel-
low-amplitude snowstorm echoes characteristic of oped hydropic degeneration. This condition also
hydatidiform mole coexistent with pregnancy.
may mimic hydatidiform mole, but the uterus is
small for date. Only 25 percent of moles present
small-for-date uteri. The pregnancy test is not
reliable but chorionic gonadotrophin levels are
usually not as high as in hydatidiform mole. In
both conditions, the uterus should be evacuated.
MASSES IN PREGNANCY
Masses associated with pregnancy can easily be

detected (Fig. 3.90). Masses such as cervical
fibroids may block and interfere with normal
delivery. The usage of ultrasound not only for
detection of these masses but also for determina-
FIGURE 3.90 tion of their relationship to the pregnant uterus
Supine longitudinal scan. Gray scale. The uterus is globular
in shape with an 8-week-old gestational sac in position. An and growing fetus is extremely vital. For exam-
irregularly margined echo-free sac is situated dorsal to the ple, cysts may develop in the ovary following
body of the uterus due to a pelvic abscess. hormone therapy. Ultrasound may be used for
detection and follow-up of such cysts. When
pregnancy exists, the procedure of choice is
ultrasonograp hy .
REFERENCES
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2. Taylor ES, Holmes JH, Thompson HE, et al:
Ultrasound diagnostic techniques in obstetrics
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130
3. Thompson HE: Ultrasonic diagnostic procedures 22. MacVicar J, Donald I: Sonar in diagnosis of early
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13. J~uppila P, Piiroinen 0: Ultrasonic diagnosis of rics. Radiol Clin North Am 13:435, 1975
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46:616, 1975 inal and Pelvic Ultrasonography. Philadelphia,
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37:44, 1971 sound 1:21, 1973
15. Eule J, Bockenstedt F, Salzman E: Diagnostic 35.- Horger EO, Kreuter AK, Underwood PB: Low
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131
with the oxytocin challenge test. Am J Obstet
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43. GoUesfeld K: The ultrasonic diagnosis of intra-
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132
ultrasonography
of gynecologically
and obstetrically
related medical
and surgical
disorders
ULTRASONOGRAPHY OF THE URINARY TRACT IN

GYNECOLOGIC DISORDERS
In pelvic diseases, the urinary tract is the system most

frequently secondarily involved. Both benign and malignant
pelvic tumors may produce hydronephrosis of the
obstructive type (Fig. 4.1a and b). Hydronephrosis may be
readily diagnosed by ultrasound and has been previously
discussed. Cystitis and ureterovesical reflux may cause
hydronephrosis and renal scarring from pyelonephritis.
Additionally, primary diseases of the kidneys often occur in
patients in the older gynecologic age group. Renal tumors are
frequently encountered during routine urography.
Ultrasonography is particularly useful in the diagnosis and
treatment of many genitourinary disorders.
RENAL CYST
The following criteria are used to diagnose a renal cyst (Fig.

4.2a and b).
133
1. Presence of an echo-free zone within
the mass due to a homogeneous
medium.
2. Sharp definition of the distal wall of the
mass with a smooth contour to this
surface, due to the large change in
acoustic impedance at the cyst wall
interface and the parabolic shape
reflecting more sound back to the
transducer.
3. Greater energy of the sound beam due
to minimal attenuation of sound
FIGURE 4-1 (a) traversing the homogeneous fluid-filled
medium, resulting in increased through
transmission and, therefore, increased
echo density distal to the lesion. This
FIGURE 4.l(a)
Supine longitudinal scan. Gray scale. Marked
hydronephrosis thins the renal parenchyma and produces
sacs of fluid with septa radiating centrally.
FIGURE 4.1(b)
Supine transverse scan. Gray scale. Marked hydronephrosis
thins the renal parenchyma and produces sacs of fluid with
multiple septations.
FIGURE 4.2(a)
Prone longitudinal scan. Gray scale. Echo-free lower-pole
renal cyst with sharp demarcation from renal substance.
FIGURE 4-1 (b) FIGURE 4.2(b)

Prone longitudinal scan. Gray scale. Two anechoic areas are
visualized in one slice. The outline of the kidney is severely
distorted. Multiple renal cysts are common in elderly
patients. The opposite kidney should be studied for cystic
FIGURE 4-2 (a) changes.
CHAPTER 4: GYNECOLOGICALLY AND OBSTETRICALLY RELATED MEDICAL AND SURGICAL DISORDERS

134
FIGURE 4.3(a)
Prone longitudinal scan. Gray scale. Space-occupying mass
in upper pole. Solid hypernephroma with high through
transmission, and area of cystic necrosis.
FIGURE 4.3(b)
Erect position. Gray scale. Same case as in Fig. 4.3a. Note
space-occupying mass in upper pole. Solid hypernephroma
with high through transmission, and area of cystic necrosis.
FIGURE 4.3(c)
Prone transverse scan. Gray scale. Irregular mass in upper
pole of kidney. Scattered internal echoes of low amplitude
are noted, and a high through transmission pattern is
observed when compared with the opposite side.
Hypernephroma Degenerating hypernephroma.
FIGURE 4-3 (a)
effect is more pronounced with a larger

cystic mass.
Determination of the precise gain setting that fills

in a cyst with artifactual echoes is a matter of
experience with a specific instrument. A
suspected cyst should be compared with a
known cystic mass standard, such as the
bladder.
SOLID TUMORS
Solid tumors occur with some frequency in older

female patients (Fig. 4.3a and b). The following
FIGURE 4-3 (b) criteria are used to diagnose a solid neoplasm.
1. The distal wall is irregular in contour.

2. The distal wall is not sharply defined
FIGURE 4-3 (c) and has echoes of a lower level than
those of the proximal boundary, due to
small changes in acoustic impedance.
3. Poor through transmission, since a large
amount of sonic energy is attenuated in
passing through the tumor mass.
4. Presence of internal echoes that define
the acoustic nonhomogeneity of the
mass. It may be necessary to increase
the sensitivity setting to demonstrate
internal echoes from an acoustically
heterogeneous lesion. The tumor may
arise in any portion of the kidney.
CHAPTER 4: GYNECOWGICALLY AND OBSTETRICALLY RELATED MEDICAL AND SURGICAL DISORDERS

135
DEGENERATING SOLID TUMORS
As a tumor enlarges it outgrows its blood supply,

producing fluid-filled necrotic spaces that
increase through transmission. At low
sensitivity, the anterior and posterior walls may
be visualized without the appearance of internal
echoes, simulating a cystic structure. At higher
gain settings the tumor will fill in with internal
echoes (Fig. 4.3c) (1). If the tumor has a largely
necrotic center, an echo-free area will remain at
high sensitivity. However, this anechoic region
will be smaller than the tumor outlined at low
sensitivity.
FIGURE 4.4
Supine longitudinal scan. Gray scale. The kidney lies in an Thus, by varying the sensitivity of the receiver,
extremely caudal position in the liver edge. This condition
must be differentiated from a displaced kidney due to a mass ultrasound differentiates a fluid- filled cyst from a
lesion. solid mass with a high degree of accuracy. This
method is reliable for differentiating between the
two lesions when there is continued sonic
homogeneity within the margin of the mass at
different gain settings and no change in the
sharpness of the margins. Electric noise and
reverberation may cause artifacts on the B-scan
in the anterior portion of the cyst. This difficulty
can be resolved by combined usage of A-mode
with the B-scan.
RENAL ECTOPIA
FIGURE 4.5 Renal ectopia may be a surprising finding to the

Erect longitudinal scan. Gray scale. Change in position of a clinician who is evaluating a patient for other
mobile kidney is best demonstrated by scanning in the prone
position and then rescanning in the erect position to disorders such as hepatomegaly, splenomegaly,
document maximum renal excursion. or abdominal or pelvic mass. The displaced
kidney may be located immediately under the
inferior liver edge and be clinically
indistinguishable from true enlargement of the
liver (Fig. 4.4). Horseshoe kidneys may simulate
a variety of abdominal masses. The pelvic
kidney may be normal (Fig. 4.5) or obstructed
and hydronephrotic.
The surgeon must be aware that such a pelvic
mass may be the patient's only functioning renal
tissue. Ultrasonography will delineate the
characteristic renal outline and calyceal echoes.
The expected renal echo pattern in the
retroperitoneum will be absent. Diseases such as
CHAPfER 4: GYNECOLOGICALLY AND OBSTETRICALLY RELATED MEDICAL AND SURGICAL DISORDERS

136
hydronephrosis in the ectopic kidney may also causes of hepatomegaly are metastatic disease,
be diagnosed by ultrasonography. hepatitis, congestive heart failure (2), and biliary
obstruction (2). However, the liver may be
palpable without coexistent hepatomegaly.
BLADDER INVOLVEMENT Emphysema and asthma, with low diaphragms,
or aberrant lobes, such as Riedel's lobe, would
The clinician is frequently concerned with produce such a condition (Fig. 4.7). The liver
bladder function or the effect of pelvic diseases may be enlarged but not palpable in cirrhosis,
upon the bladder. posterior enlargement, and marked obesity.
The distal wall of the fluid-filled bladder is

distinctly outlined by either conventional METASTASES
scanners or real-time units. Volume is readily
assessed with a standard nomogram, and Metastases to the liver have two basic patterns
postvoiding residual urine may be measured (2). At low sensitivity, the presence of a round
without resorting to intravenous urography or collection of echoes or a ring-shaped pattern in a
catheterization techniques. Fluid-filled sonolucent background of normal liver
diverticulae of the bladder may be seen when parenchyma is characteristic. At high sensitivity,
they are about 2 cm in diameter. The evolution areas of sonolucency in diffusely echogenic
of this entity may be followed sequentially and hepatic tissues comprise the second typical
atraumatically. Laterally placed diverticulae are appearance. Any abnormality in echographic
best examined by sector scanning through the anatomy must be documented in both
opposite bladder wall. Large diverticulae must longitudinal and cross section.
not be confused with pelvic cystic lesions.
A different pattern occurs when the liver is
The contour of the bladder is studied for symme- almost completely replaced by metastatic tumor
try, distensibility, and tumor masses. Extravesi- (Fig. 4.6e), or by an infiltrating tumor such as a
cal lesions such as uterine fibroids and ovarian lymphoma. In massive metastases with necrosis
cysts may distort the normal contour of the blad- the liver appears cystic with irregular borders.
der wall. The expected uniform expansion of the Substitution of tumor for liver parenchyma may
bladder is evaluated by monitoring its shape with produce an acoustically homogeneous medium
increasing urine or fluid volumes. Alterations in that strongly attenuates sound energy. The liver
distensibility occur with infiltrating carcinoma appears echo free at medium and high
and chronic inflammatory disease. Masses ad- sensitivities and the posterior wall is poorly
herent to the wall ofthe bladder are most often defined.
malignant.
It has been stated that the most common
Using ultrasonic guidance, percutaneous appearance of metastases on gray scale is that of
puncture of the bladder for diagnostic or low-amplitude echoes within the higher-
therapeutic purposes may be performed quickly amplitude echoes of the normal hepatic
and simply. substance. We have found that high-amplitude
echoes more often represent metastatic disease
(2) or hepatoma. The majority of hepatomas
ULTRASONOGRAPHY OF THE LIVER IN occur in cirrhotic livers. Multiple irregular thick
GYNECOLOGIC DISORDERS echoes represent diffuse liver disease, such as
chronic inflammatory disease or metastases.
The enlarged liver in the gynecologic patient
with a pelvic mass may represent metastatic Liver metastases are a frequent complication of
enlargement (Fig. 4.6a,b,c,d, and e). Common gynecologic malignancies. Metastatic disease

137
FIG RE 4-6 (a) FIGURE 4-6 (d)
FIGURE 4.6(a)
Supine transverse scan. Gray scale. The liver is diffusely
enlarged. Scattered echogenic foci of small to moderate size
are within the liver parenchyma. Liver metastases from
ovarian carcinoma.
FIGURE 4.6(b)
Supine longitudinal scan. Gray scale. Enlarged liver with
multiple echogenic metastases due to ovarian carcinoma.
FIGURE 4.6(c)
Supine longitudinal scan. Gray scale. Large areas of
degenerating metastatic foci are noted within the liver.
FIGURE 4.6(d)
Supine transverse scan. Gray scale. Note mUltiple anechoic
regions within the liver parenchyma at high senstitivity.
Sonolucent areas represent foci of necrotic metastatic
adenocarcinoma.
FIGURE 4-6 (b)
FIGURE 4.6(e)
Supine transverse scan. Gray scale. Huge sonolucent zone
with high through transmission. This cystic-appearing region
represents a massive area of tumor replacement in the liver.
Note the irregular distal wall.
FIGURE 4-6 (e)

138
has a variety of ultrasonic appearances. The
Riedel's obe most common form is that of rounded echogenic
multiple foci within the liver (Fig. 4.6a). The
liver is often enlarged. Large metastatic foci may
have necrotic centers which image as cystic
centers to echogenic lesions (Fig. 4.6d). Another
frequent form is the echo-poor focus within the
echogenic liver parenchyma. Within larger
metastatic zones, an echogenic center may be
noted presumably related to cystic necrosis
within the inner parts of the tumor (Fig. 4.6e).
FIGURE 4.7
Supine longitudinal scan. Gray scale. Riedel's lobe is a ULTRASONOGRAPHY OF ASCITES IN
normal variation of the right lobe of the liver. This right lobe
extends into the right pelvis and may be mistaken for GYNECOLOGIC DISORDERS
hepatomegaly or a mass lesion.
Ascites is a frequent complication of
inflammatory processes and pelvic tumors.
Intraperitoneal fluid assumes the form of either a
transudate (low protein) or exudate (high
protein). A common cause of transudates is
portal obstruction, either intrahepatic or
extrahepatic. Intrahepatic disease usually refers
to cirrhosis of diverse etiology. Extrahepatic
obstruction occurs with portal vein obstruction.
Congestive heart failure, renal disease, and
benign tumors of the ovary also cause ascites.
Exudates usually occur with inflammatory
conditions of the peritoneum. The usual entities
FIGURE 4.8
Supine longitudinal scan. Gray scale. In massive ascites noted are infectious peritonitis and metastatic
without adhesions, the liver floats in the fluid and is lifted off carcinoma, generally from the stomach,
the liver bed. Ascites with adhesions generally holds the liver pancreas, and ovary. The peritoneum reacts to
adjacent to the kidney. The appearance of the thumblike
kidney and the "four finger" shape of the liver produce the inflammation with a fibroblastic exudate that
"mitten sign" characteristic of cirrhotic ascites. causes the peritoneum to adhere to other
peritoneal surfaces, causing adhesions.
Ascites may be free (Fig. 4.8) or loculated (Fig.
4.9a and b). Free ascites is a transudate, except
in the case of chylous ascites resulting from
thoracic duct obstruction. Loculated ascites is
seen with inflammatory conditions in which fluid
is trapped in compartments sealed by peritoneal
adhesions. This may be localized to one area or
diffusely situated throughout the intraabdominal
cavity,
Minimal ascites may be detected with A-mode.
As little as 100 ml offree fluid may be detected
with the patient in the hand-knee position with

139
FIGURE 4.9(a)
Supine longitudinal scan. Gray scale. Moderate amounts of
ascites collect in the pelvis in the supine position. Bowel
loops projecting into the fluid are echogenic and produce a
characteristic irregular outline to the ascitic fluid.
FIGURE 4.9(b)
Supine longitudinal scan. Gray scale. Note small, trapped,
loculated peritoneal effusion. Ovarian carcinoma was the
cause of effusion.
FIGURE 4.10
Supine longitudinal scan. Gray scale. Echo-free triangle of
moderate amount of ascites. As fluid overflows the pelvic
cavity it appears in the flank bordered by the abdominal wall,
FIGURE 4-9 (a) psoas, and displaced bowel loops.
the transducer placed under the anterior

abdominal wall (3). Usually several minutes are
allowed for the fluid to gravitate ventrally before
the area is scanned.
Small amounts of ascites first collect in the pelvis
by gravity. This collection appears as a
sonolucent mass with angular borders
anterosuperiorly due to indentation from
overlying bowel. Larger amounts overflow the
pouch of Douglas and are directed by mesenteric
reflections to specific regions (Fig. 4.10). These
regions include the right paracolic gutter, the
right lower quadrant at the lower end of the small
bowel mesentery, and, with large amounts of
FIGURE 4-9 (b) fluid, the left lower quadrant along the superior
border of the mesocolon (4). Ascites with tumor
seedings or bacteria tends to loculate
preferentially in these areas.
Large amounts of fluid that extend up the
paracolic gutters displace the bowel medially so
that the scan resembles an atomic explosion
FIGURE 4-10 (Fig. 4.11) and can distort the outline of the liver
(Fig. 4.12). The air-containing intestine causes
artifacts in supine scanning over the anterior
abdomen. However, a moderate amount of
ascitic fluid provides an excellent scanning
window. When flank areas are scanned, large
amounts of fluid prevent proper scanning (Fig.
4.13). The lateral border of the medially
displaced liver and spleen can often be clearly
delineated, and elevation of the liver from the
posteriorly located right kidney may be
demonstrated.

140
FIGURE 4.11
Supine transverse scan. Gray scale. Note atomic explosion
configuration of massive ascites. The bowel and
intraabdominal organs are displaced medially . It is difficult to
obtain information of diagnostic value in such a case.
Rescanning when ascites is decreased is useful.
FIGURE 4.12
Supine transverse scan. Gray scale. The liver is shrunken and
floats in an echo-free zone of ascites. Note elevation ofthe
inferior liver edge from the retroperitoneal organs . Cirrhosis
with ascites .
FIGURE 4.13
Supine transverse scan. Gray scale. Massive ascites usually
prevents proper scanning. Echogenic bowel loops project
into the ascitic fluid. The bowel loops usually float freely in
10 RE 4-11 the ascitic fluid and change with position. Fixation of bowel
occurs in malignant and chronic inflammatory processes.
In our experience, it is sometimes possible to

differentiate between benign and malignant as-
cites. Benign fluid usually is free intraperitoneal
fluid and will change position with gravitational
maneuvers . Malignant ascites tends to loculate
and causes adhesions (Fig. 4.14) and will not
alter its location with positioning. When ascites
is in loculated cavities, the walls of the cavities
will be seen as septations, which appear as linear
echo patterns, in the echo-free fluid. Ascites
with underlying carcinomatosis causes adhesion.
As a result, fluid is trapped, loops of bowel are
fixed , and there is no change in the position of
the fluid by changing patient's position. Inflam-
matory changes in the walls or tumor deposits
cause irregularity, so that the posterior wall of
the region scanned will not be smoothly out-
FlOUR 4-13
lined. Appropriate clinical data and ultrasono-
graphic findings almost yield enough information
to differentiate benign from malignant ascites.
Free fluid ascending the paracolic gutters may be

tapped over the lower quadrants without
perforating the medially displaced bowel.
Loculated ascites implies that adhesions are
preventing normal separation of bowel from the
peritoneal surface. Ultrasonic detection of
loculated ascites is very important when
paracentesis is planned, because the risk of
bowel perforation is then increased. Indeed,
since the transducer may be easily placed over

141
the pocket of trapped ascites, ultrasonically
guided paracentesis is the method of choice
when loculated fluid is present (Fig. 4.1Sa).
Excessive ascites prevents proper scanning of

the abdomen. The examination should be
~
repeated after the fluid is aspirated, either blindly
or through ultrasonically guided paracentesis.
Bowel loops The etiologies of ascites are diverse, but when

ascites and pleural effusion coexist this is most
likely due to fibroma with an ovarian origin.
Ovarian fibroma accounts for about S percent of

all ovarian tumors. About 90 percent are
FIGURE 4.14
Supine transverse scan. Gray scale. Note the bowel loop
fixed in peritoneal fluid due to adhesion.
FIGURE 4.15(a)
Supine longitudinal scan. Gray scale. Large amounts of
ascites collect in the pelvis in the supine position. This echo-
free fluid has the same echo pattern as does the urine-filled
bladder. Bowel loops projecting into the fluid are echogenic
and produce a characteristic irregular outline to the ascitic
fluid.
FIGURE 4.l5(b)
Prone posterior longitudinal scan. Gray scale. Echo-free area
above the renal and liver outline is due to a large benign
FIGURE 4-15 (a) pleural effusion secondary to an ovarian tumor. Meigs's
syndrome.
FIGURE 4.l5(c)
Erect posterior longitudinal scan. Gray scale. Echo-free area
above the renal outline is due to a large benign pleural
FIGURE 4-15 (b) effusion secondary to an ovarian tumor. Meigs's syndrome.

142
unilateral, and they occur usually after may retain an echo-free pattern even at high gain
menopause. In 25 percent of cases the tumor is settings (Fig. 4.17a,b, and c) because the
complicated by ascites and hydrothorax diseased lymph nodes are acoustically
(Meigs's syndrome) (Fig. 4.l5b and c). The homogeneous.
effusions regress after removal of the tumor. The
During the scan, every attempt is made to image
cause of the hydrothorax and ascites is not clear.
the spine in order to establish a boundary distal
to the lesion. A lymph node mass adjacent to the
wall of the aorta makes it difficult to verify the
ULTRASONOGRAPHY OF THE position of this vessel within the tumor mass
RETROPERITONEAL AREA IN (Fig. 4.16b). The echo silhouette sign of
GYNECOLOGIC DISORDERS lymphadenopathy adjacent to the aorta, actually
obliterating the anterior aortic wall, has been
The retroperitoneum must often be studied care- noted with B-scan, gray scale, and real-time
fully for any pathology or, mostly, for the staging scanner. Indeed, such a cluster of periaortic
of pelvic tumors. It is difficult to evaluate the lymph nodes may mimic an aortic aneurysm.
retroperitoneal area by ordinary radiographic Generally, these nodal aggregates have an
methods, since space-occupying lesions must be irregular, lobulated outline as compared to an
well advanced in this region before they can be abdominal aortic aneurysm. Scanning other
detected. In addition, despite the standard roent- areas of the abdomen or retroperitoneum may
genographic work-up, which includes intrave- demonstrate other sonolucent lesions distinct
nous urography, barium enema, lymphangiogra- from the abdominal aorta. The presence of other
phy, retroperitoneal air insufflation, and foci of lymphadenopathy rules against the
angiography, the nature of the lesion may remain possibility of an aortic aneurysm. We have noted
unclear. This is especially true of avascular mas- lymphadenopathy appearing as discrete masses,
ses and surgery may be required for definitive sonolucent layers covering the aorta, and
diagnosis. However, sonolaparotomy, as a non- mUltiple tumors that may elevate the aorta and
invasive, safe, and simple technique for detect- inferior vena cava anteriorly (Fig. 4. I 8).
ing, evaluating, and differentiating retroperito-
neal lesions, has been rewarding. Retroperitoneal tumors may be demonstrated
either by prone or supine sonolaparotomy.
These masses may displace the kidneys and
Ultrasonographically, the retroperitoneal space intraabdominal organs by spread into the
is divided into upper and lower sections at the mesentery. Tumors with internal degeneration
plane of the umbilicus or iliac crest (5). The may be observed to have multiple internal
ultrasonographer should identify as many echoes with high through transmission.
structures as possible in the supine, prone, or
Retroperitoneal fluid collections may be noted
lateral projections. The bony pelvis prevents
by an echo-free zone. It may be difficult to
visualization of the lower compartment in
differentiate between hemorrhage, abscess (Fig.
posterior projections. Details of the
4.19), and sterile fluid (5). However, if the
sonoanatomy of each retroperitoneal organ are
patient is symptomatic, collating
described separately.
ultrasonographic information can yield excellent
In the upper abdomen enlarged lymph nodes are results. For example, in a patient with diabetes
usually seen as rounded masses in close and fever, who is nonresponsive to antibiotics,
proximity to the abdominal aorta (Fig. 4.16a,b,c, and who has evidence of a space-occupying
and d). Lymph node masses may be detected in lesion in the retroperitoneum, the usual
any part of the abdomen; lymphadenopathy diagnosis would be an abscess rather than a
generally appears sonolucent. These masses tumor or hematoma.

143
~des
FIGURE 4-16 (d)
FIGURE 4-16 (b)

FIGURE 4.l6(a)
Supine transverse scan. Gray scale. The liver and spleen are
enlargtd. The spleen is echo poor. Multiple matted lymph
nodes are noted in the retroperitoneum and mesenteric lymph
FIGURE 4-16 (c) node chains due to Waldenstrom' s macroglobulinemia.
FIGURE 4.l6(b)
Supine longitudinal scan. Gray scale . The superior
mesenteric artery is markedly displaced anteriorly by a mass
of echo-poor lymph nodes. The celiac axis is also noted
cephalicaly.
FIGURE 4. l6(c)
Supine longitudinal scan. Gray scale. The aortic silhouette is
poorly defined due to the large adjacent lymph nodes in this
advanced case of Waldenstrom's macroglobulinemia. The
real-time scanner is used to locate the aorta in this situation.
FIGURE 4.l6(d)
Supine longitudinal scan. Real-time scanner. The aorta is
displaced dorsally by echo-free matted lymph nodes. Note
the concave shape of the normally straight anterior aortic
wall.

144
FIGURE 4.17(a)
Supine longitudinal scan. Gray scale. Discrete clusters of
anechoic and echogenic masses above the normal aortic
outline are noted. Hodgkin's disease .
FIGURE 4.17(b)
Supine longitudinal scan. Gray scale. Discrete clusters of
anechoic and echogenic masses obscure the normal aortic
outline. Hodgkin's disease.
FIGURE 4.17(c)
Supine transverse scan. Gray scale. Periaortic
lymphadenopathy presenting as multiple anechoic masses.
Left paraaortic lymph nodes displace the left kidney laterally.
FlGURE 4-17 (a)
FIGURE 4.18
Supine longitudinal scan. Gray scale. The inferior vena cava
is well demarcated from the mass of lymph nodes
immediately adjacent to the vessel.
FIGURE 4-17 (b)
FIGURE 4.19
Prone longitudinal scan. Echo-free retroperitoneal hematoma
displaces the lower pole of the kidney anteriorly. Leaking
aortic aneurysm.
FIGURE 4-17 (e)

145
ULTRASONOGRAPHY IN PLANNING LOCALIZATION OF DEEP LESIONS
RADIATION THERAPY IN GYNECOLOGIC
DISORDERS Sonolaparotomy with different gain settings can
be performed at the same time that the patient's
Radiation therapy planning is an essential aspect anatomic contour is scanned. Thus, the location
of the treatment of certain pelvic malignancies. and size of a space-occupying lesion relative to
In gynecologic malignancy, B-scan or gray scale regional anatomy can be recorded.
ultrasonography is practical and accurate for
demonstrating cross-sectional anatomy and Ultrasonographic study to delineate deep-seated
displaying the morphology of organs altered by lesions and retroperitoneal lymphadenopathy is
pathologic processes. Deep-seated tumors can very useful. Enlarged lymph nodes in this area
be localized and tissue characteristics appear as sonolucent masses, with sharp
determined. Consequently, a plan for radiation margins anterior or anterolateral to the spine.
therapy can be based on recording the patient's This information may be obtained in both
anatomic contours. Ultrasonographic longitudinal and transverse scans.
information can be reliably and precisely
incorporated into the treatment plan to decrease Ultrasonography is also valuable for staging
complications and increase the efficacy of the carcinoma of the cervix, since it detects enlarged
treatment. Ultrasonography permits three- lymph nodes in the pelvis and abdomen.
dimensional therapy analysis by use of the data Similarly, ultrasonography is important in
displayed from perpendicular sonograms. A assessing the extent of Hodgkin's disease and
strong echo will appear at the surface of an organ other lymphomas. Ascites, both free and
or mass lesion because different tissues have loculated, can also be diagnosed.
different acoustic characteristics.
Pelvic malignancy, especially in the uterus and
cervix, can be outlined and tumor size and
contour used to plan treatment. If intracavitary
The patient's anatomic contour can be obtained
applicators are to be used, their position can be
in any desired plane simply and accurately. At a
monitored by ultrasound. The echo from a
very low gain setting, a single sweep of the
radium-loaded tandem is quite strong. To
transducer over the area of interest will give a
calculate dosage, the positon of the applicator
contour tracing (6,7). Ultrasonographic marking
with respect to the bladder as well as the uterine
is more accurate than mechanical jigs, lead
width must be known.
solder, plastic templates, or plaster. The
transducer can be swept over a given region Ultrasonography detects bladder tumors and
repeatedly. If the area of pathology is complex, determines the degree to which the bladder wall
mUltiple sections can be made for additional is involved. Special transurethral and transrectal
information. scanners are available, which may add more
information for staging malignancies of the
Lung lesions, at present, cannot be evaluated by bladder and prostate.
ultrasonography because sound does not
transmit through pulmonary tissue that contains Upper abdominal organs are also outlined and
air. However, the thickness ofthe chest wall can necrotic tumors demonstrated (1). The enlarged
be displayed, so that treatment can be planned spleen in malignant disorders can be mapped
for carcinoma of the breast. This measurement is three dimensionally and irradiated accordingly.
important because it is used to calculate beam The development of radiation fibrosis within
energy and for tangential planning, so that irradiated organs is evidenced by the increased
underlying lung tissue receives minimum echogenicity of the organ parenchyma (8). The
irradiation (6). kidneys can be localized and their size and

146
position determined so that they can be shielded
appropriately during treatment (9).
The portal of treatment can be outlined over the
abdomen, retroperitoneum, or pelvis. Breaking
the contact between transducer and skin surface
produces a mark on the scan. Thus, the
periphery of a specific region can be marked on
the scan and the skin painted with indelible ink.
In every step of marking, the transducer should
be elevated slightly from the skin surface; the
margin is obtained by visual display. A Polaroid
is taken as a baseline and compared with
Polaroids of future examinations. In this manner
FIGURE 4.20 portal margins can be decreased as needed.
Prone longitudinal scan. Gray scale. Minimal
hydronephrosis. Note multiple echo-free sacs. This is
physiologic hydronephrosis of pregnancy.
ULTRASONOGRAPHY OF RENAL
DISORDERS IN OBSTETRICS
RENAL DISEASE IN PREGNANCY
The physiologic hydronephrosis of pregnancy

occurs early in gestation and lasts through the
puerperium. This produces moderate dilatation
ofthe calyces, pelves, and ureters which is more
pronounced on the right side (Fig. 4.20). We note
that this dilatation usually clears in normal
patients within 3 months of delivery. During
pregnancy, radiologic investigation of the
genitourinary tract must of necessity be limited.
Ultrasound is a superb noninvasive means of
assessing the physiologic and pathologic changes
of the kidneys in gravid females. The size,
shape, and position of the kidneys are easily
determined. Ptosis may be simply evaluated with
positional changes. The ratio of the renal
parenchyma to the calyceal complex and the
extent of parenchymal damage may be assessed
in the diagnosis of chronic renal disease.
The kidney has an ovoid configuration in the
transverse plane and is elliptic in the longitudinal
axis. In the normal kidney, the renal
parenchyma appears echo free (colorless or light
gray), and calyceal echoes extend to the ventral
and medial borders of the kidney. The image of
the kidney with the real-time scanner is similar
to that with the conventional B-scan.

147
FIGURE 4.21(a)
Supine longitudinal scan. Gray scale. The edematous kidney
is better delineated. The through transmission is higher than
normal.
FIGURE 4.21(b)
Prone longitudinal scan. Gray scale. Patient with acute
nephritis . Note renal parenchyma produces higher through
transmission.
FIGURE 4.22
Prone longitudinal scan. Gray scale. Splitting of the renal
sinus echoes forming an ovoid echo pattern. Obstructive
hydronephrosis.
lFIGURE 4-21 (a)

Acute nephritis is an uncommon complication of
pregnancy. Often the kidney cannot be satisfac-
torily imaged with routine intravenous pyelogra-
phy. Nephrotomography is often needed to out-
line the kidney satisfactorily and substantially
increases the radiation exposure. We note by
ultrasound that the kidney is swollen and in-
creased in its anteroposterior diameter. The
through transmission pattern is higher than nor-
mal due to the edematous renal parenchyma
(Fig. 4.21a and b). The chronic renal diseases
include chronic glomerulonephritis, chronic in-
terstitial nephritis, chronic pyelonephritis, colla-
gen diseases, and renal tuberculosis. Chronic
renal disease may appreciably increase the risk
of toxemia of pregnancy. Ultrasonography
FIGURE 4-21 (b) shows that chronic renal disease generally pro-
duces a smaller kidney than normal. The kidney
may be affected diffusely or focally. Chronic
pyelonephritis and systemic lupus erythemato-
FIGURE 4-22
sus tend to produce areas offocal scarring patho-
logically, although smooth and contracted renal
outlines may be noted ultrasonographically.
However, at present, in our experience, it is not
possible to demonstrate focal scarring or to dif-
ferentiate medical disorders of renal parenchyma
ultrasonically. The diagnosis of chronic renal
disease is best made by renal biopsy. Upon deep
inspiration, the kidneys are outlined on the skin
with indelible ink or by scratch marks made with
a scalpel or needle tip. Biopsy may be performed
under ultrasonic guidance, since the kidney ap-
pears in the line of sight of the sonic beam from
the transducer and the depth to the renal paren-
CHAPTER 4: GYNECOLOGIC ALLY AND OBSTETRICALLY RELATED MEDICAL AND SURGICAL DISORDERS
148
chyma may be read off the ()scilloscope directly. The size of the obstructed kidney may appear
The ultrasonically guided renal biopsy uses a increased, normal, or decreased. Interstitial
needle which will fit through the center of the edema of acute obstruction tends to enlarge the
puncture transducer. Follow-up examination af- renal parenchyma. Back pressure atrophy of the
ter 24 hours may be added to evaluate the possi- cortex associated with chronic obstruction
bility of local hematoma formation. Basically, produces a small kidney in most cases (11).
renal biopsy with a puncture transducer needs Thus, renal size may only be interpreted
extensive experience and patient cooperation. diagnostically with reference to sequential
studies over a known period of time.
Pathophysiologic changes in the pelvicalyceal
OBSTRUCTIVE UROPATHY system reflect the degree and duration of
increased pressure and damage from
Routine evaluation of obstructive uropathy in- superimposed infection. Dilatation of the
cludes a plain X-ray film of the abdomen and calyces, infundibula, and pelves usually
intravenous urography. Nephrotomography, re- progresses proportionately. However, the
trograde pyelography, arteriography, and renal extrarenal pelvis acts as a hydraulic buffer,
isotope studies are frequently added for further sparing infundibula and calyces as it dilates to
information. The poor function of the obstructed dissipate the increased pressure.
kidney generally necessitates delayed films, mul- The earliest pathologic changes of chronic
tiple injections of contrast medium, significant increased pressure occur in the calyceal system.
radiation exposure, and patient discomfort asso- Blunting of the acute forniceal angle is followed
ciated with long waiting periods on a hard table. by flattening and eventual clubbing of the calyx.
In addition, osmolality of the contrast medium Subtle calyceal alterations often escape
may increase intrapelvic pressure sufficiently to
ultrasonic detection (12) due to the resolution of
produce pyelosinus reflux or even peripelvic ex- the 2.25-MHz transducer routinely used in renal
travasation of urine and contrast medium into scanning. The renal sinus is the invagination of
the retroperitoneum (10). The routine study of the renal hilus and contains the renal pelvis,
the kidney in pregnancy is limited due to expo- major caylces, and main renal vessels. The
sure. Ultrasonography may yield extensive in-
principle ultrasonic observation in early
formation; however, for urinary stasis or deter-
obstruction is dilatation of the renal sinus
mination of the site of obstruction the contrast produced by intrarenal enlargement of the renal
study is necessary. pelvis and adjacent major calyces.
The first ultrasonographic finding in hydrone-

Urinary stasis may have obstructive (Fig. 4.22) phrosis is "splitting" of the renal pelvicalyceal
and nonobstructive mechanisms. Impedance to echoes (13). This corresponds to distension of
urine flow commonly occurs with tumors and the calyces and infundibula, so that distinct
calculi of the kidneys, ureters, and bladder. echoes are reflected by each inner wall surround-
Other ureteral problems include anomalies of ing the anechoic collected urine. As dilatation
insertion, stricture, stenosis, and pregnancy. proceeds, degeneration of renal tissue distorts
Abnormal ureteral compression is associated the calyces into pockets of urine retained within
with retrocaval ureter, lymphadenopathy, compressed atrophic bands of renal tissue. This
abscess, hematoma, or aberrant vessel. produces the picture of thick septa dividing a
Nonobstructive stasis follows neurogenic large cystic collection, with a shell of remaining
dysfunction of the bladder, chronic sonolucent cortex discernable at medium sensi-
inflammatory conditions, atony of the ureters tivity (14). Further destruction of the cortex by
with high urinary output, and vesicoureteral back pressure atrophy and infection may result
reflux (11). in a lobulated renal periphery, simulating a mul-
149
tilocular cyst (15). Eventually, only a fluid-filled distinguishes between the swollen kidney of
sac of variable size can be visualized (13). Differ- acute renal failure and the dilated pelvicalyceal
entiation between hydronephrosis and pyone- system of the obstructed kidney.
phrosis may be suggested by observing irregular-
The high calcium content of the usual
ity of tissue septa dividing cystic collections
radioopaque calculus markedly reflects sound
within the kidney (14). However, in our experi-
waves. The echo from the stone will appear to be
ence, differentiation of these two conditions by
stronger than the surrounding calyceal echoes, if
ultrasonography is extremely difficult, and again
it acts as a specular reflector. An irregular or
appropriate clinical data and laboratory findings
amorphous calculus will act as a diffuse reflector
are more informative.
and will be difficult to image. The lack of through
transmission may cause a sonic shadow (Fig.
Polycystic renal disease is a disorder transmitted 4.24) (16). A secondary observation may be
by an autosomal dominant gene and is frequently splitting of the renal sinus echoes due to
found in many members of an affected family. concurrent hydronephrosis. In the presence of a
Since the clinical manifestations of this disease dilated renal collecting system, renal calculi of
usually appear in the early forties, it is usually lower reflecting qualities may be demonstrated
not a common problem in pregnancy. as low-amplitude echogenic masses lying against
the dependent wall of the dilated collecting
Polycystic disease is generally diagnosed by
system.
observing bilaterally enlarged renal outlines with
a markedly lobulated outer contour, as The advent of renal transplantation techniques
contrasted to the smoother surface produced by now allows previously infertile females with
hydronephrosis. In addition, septa in the chronic renal disease to bear children. As
polycystic kidney have a random distribution, as surgical and immunosuppressive techniques
opposed to the central radiation noted in the improve, some women with renal transplants
obstructed and dilated calyceal system (Fig. will become pregnant. The usual site of
4.23a and b) (15). It is difficult to distinguish a transplantation is in the pelvis. Because of this
hydronephrotic sac from a massive renal cyst location, during delivery, the transplant may be
severely compressing the remaining renal compressed and injured by the fetal head.
parenchyma. Ultrasonography may now replace the previous
combined usage of renal urography and
Ultrasound is an excellent screening procedure
pelvimetry in showing the fetal head in relation
for the diagnosis and follow-up of polycystic
to the transplanted kidney.
disease. Early cystic changes will enlarge the
kidney, but will not distort the calyces If contraceptive devices are not employed, the
sufficiently to be detected on routine intravenous transplanted patient may become pregnant soon
urograms. Gray scale may identify cystic lesions after surgery. Ultrasonography is excellent for
before calyceal changes appear. Other affected monitoring the possible complications of renal
organs may also be studied. Thus, transplants.
ultrasonography is ideal for evaluating
asymptomatic family members.
Serial measurements of the size of renal trans-
Anuria may accompany acute renal failure or plants are useful for detecting acute or interme-
calculous disease with obstructive uropathy. diate rejection and shrinkage secondary to pro-
Both have approximately the same overall low gressive fibrosis of the transplanted kidney.
incidence in pregnancy. Renal failure is often Magnification on X-ray film (approximately 20
due to septic abortion or toxemia. The resultant percent) should be corrected before the film is
nonfunctioning kidney cannot be diagnosed by compared with the undistorted scan. The trans-
routine radiography. Ultrasonography quickly planted kidney is located in the iliac fossa

150
FIGURE 4.23(a)
Prone longitudinal scan. Gray scale. Enlarged and distorted
renal outline. Multiple anechoic regions are noted in a diffuse
arrangement. Septations between anechoic cysts are random
in distribution. Opposite kidney with similar appearance.
Polycystic disease.
FIGURE 4.23(b)
Prone transverse scan. Gray scale. The enlarged renal outline
has sonolucent regions with random septations.
FIGURE 4.24
Prone longitudinal scan. Gray scale. A very dark echo
complex within the gray renal collecting system echoes
represents a calcified renal calculus. The distal wall of the
kidney is not imaged. Sonic shadowing may be produced by
highly reflecting renal stones. Head is toward the right.
I FIGURE 4-23 (a)

obliquely. The A-mode or B-mode may be used.
More accurate measurements are possible when
the A-mode echoes are superimposed on a cali-
brated scale. Newly devised electronic calipers
may also be employed.
Longitudinal and transverse scans are made with
respect to the lie of the transplanted kidney ;
length, width, and volume can be calculated.
When the kidney becomes edematous, the
sonolucency and through transmission are
increased compared with the previous
sonogram; size and volume are also increased.
Asymptomatic infections often appear since the
immune mechanisms of these patients are
altered by steroids, cytotoxic drugs, or radiation
therapy. The infections are commonly perirenal
FIGURE 4-23 (b)
abscesses at the site of renal transplantation.
Scanning may demonstrate collections of serum,
lymph, blood, or pus as sonolucent areas that
may fill in with echoes at high sensitivity,
FIGURE 4-24 depending on the contents of the fluid (17, 18).
Morphologic changes in renal transplants are of
diagnostic value. A sudden increase in renal size
implies acute rejection. Absence of expected
hypertrophy of the transplant after several
months suggests chronic rejection and fibrosis.
".
_.3.., ~Sonic
Dilatation of the calyceal system indicates
ureteral obstruction (2). Renal agenesis may also
shadow be detected ultrasonically (Fig. 4.25). Pelvic
lipomatosis can easily be investigated and serial
studies may be used to follow its course (Fig.
4.26).

151
ULTRASONOGRAPHY OF CARDIAC
CARDIAC DISEASE IN PREGNANCY
Many patients suffering from heart disease

during pregnancy are not aware of preexisting
cardiac problems. During pregnancy the heart
rate, cardiac output, and total blood flow are
increased, so that marginal cardiac function may
become symptomatic due to the greater stress
Renal agenesis placed on the cardiovascular system. Cardiac
/ signs and symptoms which appear during
pregnancy, such as hyperventilation, pedal
FIGURE 4.25
Prone transverse scan. Gray scale. The ovoid outline ofthe edema, and various murmurs and unusual heart
left kidney is clearly imaged. The right renal outline is not sounds, may be associated with normal
visible and the low-level echoes ofthe hepatic parenchyma gestation. The obstetrician is thus faced with a
fill the region normally reserved for the right kidney.
Congenital absence of the right kidney. patient who may have significant cardiac
disability.
The established criteria for evaluating heart
disease in pregnancy include the presence of a
diastolic murmur, clear-cut cardiomegaly on the
chest X ray, a grade 3/6 systolic murmur or
greater, and the existence of a severe arrythmia.
The recent advent of echocardiography has
given the clinician a noninvasive means of
categorizing the anatomic type of cardiac lesion
and its effect on the cardiac chambers and
valves.
The principles of echocardiography have been
well discussed in the literature (19). The unit is
FIGURE 4.26 operated in A-mode and M-mode or gray scale,
Prone longitudinal scan. Gray scale. The echo pattern of the with the specially designed cardiac transducer
renal collecting system is heterogeneous due to accumulation
of fatty substance in the renal tissue. This echo pattern is placed over the precordium. A coupling agent
usually seen in pelvic lipomatosis. consisting of a thick gel is generally applied to
the chest wall. The transducer for the adult heart
is typically a 2.25-MHz, 7.5-cm or lO-cm focused
transducer. The transducer face is placed along
the left cardiac border between the fourth or fifth
intercostal space. The transducer is angled
medially as the A-scope is constantly monitored.
The high-amplitude echo pattern of the aortic
valve with its characteristic to-and-fro structure
is easily found with the A-mode display. This is
then verified by observing the M-mode tracing
which may appear on an oscilloscope face,
television tube, or strip-chart recorder. After
locating this echo pattern the transducer is

152
angled inferolaterally to identify the "jerky" apposition of the anterior and posterior mitral
motion of the anterior mitral valve leaflet. valves are readily documented.
Tracings are then recorded in these positions and
The pathologic changes of mitral stenosis
intermediate angulations are performed to
completely outline the entire cardiac apparatus exacerbated by pregnancy are easily observed
in a one-dimensional read-out. on the echocardiogram. The increased cardiac
output along with the shortened diastolic filling
The cardiac valves and chambers may also be time serve to increase the left atrial pressure and
observed with specially designed real-time chamber size. Not only are the chamber
scanners. These consist of an array of dimensions visible, but the presence or absence
transducers which produce a two-dimensional, of clot is detectable. The right ventricular
real-time image. Sonofluoroscopy of the heart is overload results in an increase in the chamber
proving to be a useful adjunct in cardiac size of the right ventricle. Most important is the
diagnosis. This extra dimension gives the shape of the mitral valve echo pattern. The
ultrasonographer much more data which serve to scarring produced by the rheumatic endocarditis
produce a three-dimensional representation with produces shortening of the chordae tendineae,
greater ease than is possible with the fusion of the fissures, and retraction of the valve
unidimensional mental tracing. Indeed, leaflets. These latter present as a reversal ofthe
ventricular contractility abnormalities, valvular opposite motion of the posterior mitral valve
deformities, and chamber enlargements may be leaflet, so that it now follows the path of the
readily studied. anterior mitral valve leaflet. Also, the normal
diastolic flutter of the mitral valve with
RHEUMATIC HEART DISEASE
fluctuation of pressure changes between the left
Although there has been a continuing decrease in atrium and left ventricle is severely limited,
the incidence of rheumatic fever and its producing flattening of the M-shaped valve
associated short-term and long-term cardiac outline. The presence of calcification of the
disorders, rheumatic heart disease is still the valves due to longstanding fibrosis is also
most common cause of organic heart disease in demonstrable by the echogenic nature of the
pregnant females. Mitral stenosis by itself or calcific valve. The degree of stenosis of the
with associated valvular abnormalities is the mitral valve orifice is not well quantified by
most frequently encountered sequel of previous ultrasound. However, the presence of a normal
rheumatic disease. This abnormality may be echocardiogram rules out the presence of mitral
clinically confused with other disorders such as stenosis.
atrial septal defect, primary pulmonary
hypertension, and left atrial myxoma. These Ultrasound is helpful in detecting aortic stenosis
conditions may be separated by their distinctive of either the congenital bicuspid or rheumatic
appearances on the echocardiogram. type. As with mitral stenosis, rheumatic aortic
stenosis is due to commissural fusion. This
The normal echocardiogram shows an ice-pick presents as poor opening motion of the aortic
slice of the heart. The aortic root appears as a valve leaflets with incomplete excursion to the
series of parallel lines with a to-and-fro motion. walls of the aortic root. The left ventricular
Within the aortic root in its lower portion, the outflow obstruction produces left ventricular
echoes of the opened and closed aortic leaflets hypertrophy and left ventricular chamber
are noted. Distal to the aortic root is the left enlargement, which appear as a widened left
atrial cavity, which may be measured from the ventricular cavity with a thickened left
calibrated tracing. The motion of the ventricular wall dimension.
interventricular septum is readily outlined and its
synchrony with the posterior left ventricular wall Insufficiency of the mitral and aortic valves
is seen. The characteristic M-shaped diastolic scarred by rheumatic endocarditis is due to
motion ofthe mitral valve leaflet and the systolic shortening of the valve cusps and chordae
153
tendineae. Mitral regurgitation is more common
in males than in females, in contrast to mitral
stenosis which is most common in females.
However, the apical systolic murmur associated
with pregnancy may be difficult to distinguish
from the murmur of mitral insufficiency.
Echocardiography in mitral insufficiency shows
dilatation of the left heart, especially of the left
atrium.
Most cases of aortic insufficiency are due to

rheumatic inflammatory disease. Aortic
insufficiency is also seen in ankylosing
FIGURE 4.27 spondylitis, lues, and old bacterial endocarditis.
M-mode. Echocardiogram shows echo-free zone behind the Regurgitation produces dilatation of the left
strong epicardial echo complex. Pericardia! effusion. ventricular chamber associated with left
ventricular hypertrophy. Echocardiography
documents this as a distinctive fluttering of the
anterior mitral valve leaflet, due to the eddy
produced in the left ventricle by the stream of
regurgitant blood.
A significant contribution to cardiac diagnosis is

the ability of echocardiography to detect
pericardial effusions in quantities between 100
and 150 ml of free or loculated pericardial fluid.
It is radiologically difficult to differentiate small
to moderate-sized effusions from other causes of
cardiomegaly. Ultrasound shows the fluid as an
echo-free space between the posterior left
ventricular wall and the pericardium (Fig. 4.27).
Pericardial effusion may be due to rheumatic
carditis, trauma, hypothyroidism, malignant
disorders, tuberculosis, ischemic heart disease,
and metabolic disorders. Pericardial effusion or
cardiac tamponade may be treated by
percutaneous insertion of a special aspiration
needle under ultrasonic visual guidance. The
distance of the beating epicardium to the needle
tip may be continually monitored to prevent
cardiac laceration.
Ultrasound is specific in differentiating between

left atrial myxoma and mitral stenosis, a clini-
cally difficult procedure. The echocardiogram
shows flattening of the M-shaped valve with a
series of echoes projecting distally from the
valve in diastole. This finding is pathognomonic
of a left atrial tumor. Prolapse of the mitral valve
is a common condition due to myxomatous de-

154
generation of the mitral valve apparatus. Clinical VASCULAR DISEASE IN PREGNANCY
variations range from asymptomatic patients to
patients with severe arrythmias. This entity is The diagnosis of vascular disorders in pregnancy
more common in females and the average age of is somewhat different than in the nongravid
onset is 37 years. The prolapse appears on echo- patient, due to the need to avoid the ionizing
cardiograms as a distal swing of the valve in radiation inherent in X-ray and radioisotopic
systole. This may involve the anterior mitral procedures. Use of gray-scale and real-time
valve, posterior mitral valve, or both in various scanning together with Doppler ultrasound may
combinations. add significant contributions to the study of
disease entities with vessel pathology.
Another lesion that is specifically diagnosed by
ultrasound is asymmetric septal hypertrophy, ARTERIAL DISEASES
which is a generalized category that includes The gravid term uterus lies upon the abdominal
idiopathic hypertrophic subaortic stenosis. The aorta when the patient is in the supine position.
pathologic change is that of marked and A series of aortograms performed for the
asymmetric thickening of the interventricular diagnosis of placenta previa before the advent of
septum, which narrows the left ventricular diagnostic ultrasound showed anterior
outflow cavity and simultaneously produces compression by the uterus on the wall of the
abnormal mitral valve motion. The characteristic aorta. Reduced blood flow to the peripheral
echo cardiographic picture is that of a thickened vessels was noted. None of the patients were
interventricular septum larger than the left symptomatic for arterial vascular disease.
ventricular wall thickness by a certain degree, However, it is logical to anticipate that younger
accompanied by a paradoxic systolic anterior patients with collagen disease or other forms of
motion of the mitral valve so that it almost arterial insufficiency may have their symptoms
touches the interventricular septum. aggravated by gestational pressure. The aorta
may be imaged during gestation either with the
CONGENITAL HEART DISEASE real-time scanner or with gray scale instruments.
Due to the effective treatment of streptococcal The degree of compression of the aortic lumen in
infections by antibiotics, the incidence of the anteroposterior diameter may be measured.
rheumatic heart disease is decreasing. The
Aneurysms of the abdominal aorta may be
obstetrician is thus faced with a greater
identified easily. Although the cystic medial
percentage of patients with congenital cardiac
necrosis responsible for dissecting aneurysm
abnormalities. The most common cardiac lesion
most often produces a dissection in the thoracic
in the clinical practice of obstetrics is the atrial
aorta, this may extend into the abdominal aorta.
septal defect. The physiologic right heart
Widening of the anterior aortic root is
overload caused by the lesion produces a large
demonstrable with echocardiography in the
right ventricular cavity with a left ventricular
usual positions. Dissection of blood may be
chamber correspondingly decreased in size. A
noted at higher gain settings. The aneurysm of
paradoxic motion of the interventricular septum
the descending thoracic aorta may be studied if
is often demonstrable.
the aneurysmal dilatation comes into contact
Other common types of congenital heart disease with the posterior pleura-chest wall interface.
include ventricular septal defect, patent ductus This may then be demonstrated with M-mode,
arteriosus, congenital aortic stenosis, and gray scale, or real-time scanning. The
Ebstein's anomaly. In each of these suspected complications of rupture into the pleural space
disorders, echocardiography may either confirm or into the pericardial sac may be easily
the clinical diagnosis or discover another cardiac documented with conventional ultrasonic
disorder simulating the physician's impression. techniques.
155
Ultrasonography of the abdominal aorta is
performed in the transverse and longitudinal
planes. Combined use of the real-time scanner
with gray scale is particularly appropriate in
pUlsating structures. Ultrasonography is not
only an excellent diagnostic modality, but is also
the least invasive for the detection and follow-up
of aortic aneurysms. Indeed, this was one of the
first uses of ultrasound in the upper abdomen.
t
Aorta
Improved diagnostic techniques have revealed a
greater incidence of asymptomatic abdominal
aortic aneurysms in the elderly than was
previously recognized (20, 21).
FIGURE 4.28(a)
Supine longitudinal scan. Gray scale. The aorta appears as a Abdominal aortic ultrasonography assumes
linear echo-free structure that tapers smoothly. It usually
may be imaged from the xiphoid process down to the level of
increased importance since this may be the only
the umbilicus. Generally, the distal wall is more sharply method available for examining the geriatric
outlined than is the proximal wall. patient or the pregnant patient with suspected
dissecting aneurysm.
Blood is a good transonic medium.

Consequently, the aorta can be detected easily
by abdominal sonolaparotomy. The aorta is
FIGURE 4.28(b)
Supine longitudinal scan. Real-time scanner. The aorta may located anterior to the spine, generally slightly to
be studied easily with the real-time scanner. The the left (Fig. 4.28a and b). Its walls reflect strong
characteristic systolic contraction wave may be observed. echoes, with an anechoic region representing the
This verifies the aorta and distinguishes it from other echo-
free regional structures. blood-containing lumen. The diameter of the
normal aorta is approximately 3 cm and tapers
off as the aorta descends. On gray scale, blood
does not have the same homogeneity as does
clear fluid.
There is no magnification, and the size of the

aorta may accurately be determined. Simple
measurement may be accomplished by
calculating the anterior-to-posterior diameter in
the longitudinal or transverse planes.
Traditionally, the aorta has been studied with
contrast angiography by the translumbar
approach or through percutaneous, retrograde,
femoral artery catheterization. However,
serious consequences may result from these
methods. A known incidence of thrombosis and
embolization is associated with arterial
catheterization, especially after a plaque, in
patients with severe atherosclerosis. Since
systemic hypertension is frequently associated
with atherosclerosis, hematomas may form at
the puncture site.

156
the vessel (Fig. 4.30). External rupture may
ANEURYSM occur or the channel may reenter the aortic
lumen. The intima is pushed into the blood-filled
Arteriography can only show the lumen of an true lumen by the intramural hemorrhage, which
aneurysm; the clotted portion obviously cannot appears as a septation in the echo-free aorta,
be seen. The true size of an aneurysm is assessed generally best seen on the longitudinal scan. At
by measuring the width of the lumen on the higher sensitivities, the thrombus in the false
angiogram and adding to it the distance from the channel may fill in with echoes. Thrombus is
lumen to the outer calcified wall. If calcification best demonstrated with gray scale equipment.
cannot be seen radiologically, the true dimen-
sions of the aneurysm cannot be accurately esti- PARAAORTIC LYMPHADENOPATHY
mated. In fact, if there is no wall calcification
Paraaortic lymphadenopathy occurs in benign
and the laminated thrombus completely fills the
and malignant states. Large preaortic masses are
aneurysmal sac, the contrast-opacified lumen of
seen in lymphoma and retroperitoneal lymph
the aortic aneurysm may be mistaken for a nor-
node metastases. These conglomerates of nodal
mal distal aorta and the diagnosis completely
tissue silhouette the normal outer wall of the
missed (22, 23). The outer diameter is an impor-
tant preoperative parameter for the surgeon. aorta, sonographically creating a false outer
wall. Lymphadenopathy is difficult to
Elective operation is considered when this mea-
differentiate from aortic aneurysm. Usually, the
surement exceeds 7 cm (21, 23, 24).
anterior border of the aneurysm is more sharply
Abdominal aortic aneurysms may assume a delineated than is the lobulated anterior border
'variety of forms (Fig. 4.29a,b,c,d, and e). of lymph node masses. To confirm paraaortic
Dilatation may be localized and the aneurysm lymph nodes, other areas oflymphadenopathy
saccularly shaped. It usually has a sharp anterior must be sought.
wall, and may easily be confused with a cystic A confusing artifact frequently occurs when the
lesion. However, the outer wall of a cyst is plane of the scanning beam pas ses through the
generally not as sharply defined as is that of an fibrocartilaginous intervertebral discs of thin
aneurysm. Fusiform aneurysms typically patients. Although the body of the vertebra
originate below the level of the renal arteries in blocks sonic transmission, the disc structure
the region of the inferior border of the liver, but appears echo free at low sensitivities and may be
they may involve the entire abdominal aorta. echogenic at higher gain settings. The neural
Fusiform aneurysms may extend into the iliac arch elements may be partly visualized, forming
arteries and may invol ve long segments of the an outline of the spinal canal. In transverse
aorta, beginning in the thoracic aorta and scanning, the anechoic disc may be mistaken for
extending into the abdominal aorta. This a cystic or vascular structure. This problem can
thoracoabdominal aneurysm appears on the be resolved by sensitivity studies and M-mode or
abdominal scan as dilated lumen that tapers in real-time scanners.
size as it descends into the lower abdomen.
Various layers of the aneurysm can be detected VENOUS DISORDERS
by adjusting the sensitivity of the ultrasonic unit. Venous thrombosis and embolic phenomena are
At low sensitivity, only the outer walls of the among the most common serious vascular
aneurysm are seen. Higher sensitivity will show disorders in pregnancy. The combined use of
echoes from the clot or thrombus. The true gray scale and real-time scanning may be of
lumen, filled with blood, remains echo free. particular value in these situations.
Dissecting aneurysm occurs less often in the A less serious but more common problem is the
abdominal than in the thoracic aorta. Intimal venous insufficiency syndrome in pregnancy due
necrosis permits blood to course in the media of to uterine compression of the inferior vena cava.

157
..
FIGURE 4-29 (a)

-~
Aortic aneurysm
FIGURE 4-29 (d)
FIGURE 4-29 (b) FIGURE 4-29 (el
FIGURE 4-29 (el

FIGURE 4-30

158
FIGURE 4.29(a) distend. The cause of the turgescent vessel, such
Supine longitudinal scan. Gray scale. The abdominal aortic as right heart failure, can be determined by
aneurysm appears as a dilatation of the lumen of the aorta
and tapers to the normal aortic caliber. Note posterior sharp evaluating the dilated inferior vena cava.
border. Hepatomegaly due to right heart failure can also
be diagnosed by scanning the inferior vena cava.
FIGURE 4.29(b)
Supine longitudinal scan. Gray scale. Aneurysm of aorta may The normal vessel collapses during the
be confused with other cystic structures. The entrance of the expiratory phase of respiration, but does not do
aorta into the dilatation and its exit from the aneurysmal sac
so in the patient with heart failure. This
are important in definitively diagnosing a saccular abdominal
aortic aneurysm. phenomenon is best studied with the real-time
scanner. Inferior vena cava imaging can also be
FIGURE 4.29(c)
Supine longitudinal scan. Gray scale. Aneurysm of the aorta
used to detect a thrombus or tumor in this
may be confused with other cystic structures. The entrance structure.
of the aorta into the dilatation and its exit from the
aneurysmal sac are important in definitively diagnosing a The image of the inferior vena cava in
saccular abdominal aortic aneurysm. longitudinal section is usually very difficult to
FIGURE 4.29(d)
visualize when the scan is performed with
Supine longitudinal scan. Gray scale. The thoracoabdominal conventional equipment, but is easily
aortic aneurysm appears as a dilatation of the lumen of the demonstrated by the real-time scanner and gray
aorta at the level of the diaphragm and tapers to the normal
aortic caliber. Head is toward the right.
scale. In a normal subject, during inspiration the
vena cava reaches a maximum diameter after
FIGURE 4.29(e) several seconds. Study performed with the real-
Supine transverse scan. Gray scale. Three anechoic regions
time scanner in the paramedian approach shows
are noted. An aortic aneurysm is seen anteriorly with an
inner layer of thrombus producing an echo-free lumen. Distal the vessel's complex motion, which corresponds
to the aneurysm is the echo-poor intervertebral disc. Distally to the respiratory cycle. The liver and aorta
are noted parts of the arch forming the spinal canal.
transmit systolic pressure to the inferior vena·
FIGURE 4.30 cava, so that the anterior wall of the vein has
Supine longitudinal scan. B-mode. Dissection of the wall of even more intense motion than does the anterior
the aneurysm displaces the intimal wall centrally as blood
wall of the aorta (25). During inspiration, it is
runs in the media of the vessel. This appears as a linear echo
band paralleling the lumen of the aorta. Motion of the intimal well filled and prominent; during expiration it is
wall may be observed with M-mode or the real-time scanner. collapsed and not easily visualized.
Shifting method
Where uncertainty exists in verification of the
Although this may be documented by observing inferior vena cava, the aorta can easily be found
total anteroposterior compression of the walls of with the real-time scanner. The applicator of the
the vena cava, this problem is generally not one machine is then shifted toward the right side to
of clinical difficulty. It is, however, of great locate the inferior vena cava. This maneuver can
importance to the ultrasonographer who may also be done from the location of the inferior
examine a patient for an extended period of time vena cava toward the aorta when this artery is
in the supine position (Fig. 4.31a,b, and c). After difficult to identify.
the study is completed, the patient must be
returned gradually to the sitting position. After
Evaluation of the inferior vena cava
the removal of uterine pressure allows
In right-sided cardiac conditions, the respiratory
restoration of circulating blood volume, the
motion of the vena cava diminishes and, in
patient may assume an erect posture and
severe cases, completely disappears; the vein,
ambulate with an attendant nearby.
however, will be seen clearly, measuring at least
Imaging of the inferior vena cava and 2 cm in anteroposterior diameter. Increased
simultaneous measurement of its diameter are diameter of the inferior vena cava usually
valuable in conditions that cause this vessel to signifies right-sided heart failure.

159
FIGURE 431(a)
Supine longitudinal scan. Gray scale. Fast scanning speed
over the inferior vena cava (IV e) may demonstrate the
changes in the outline of this vessel due to inherent motion.
FIGURE 431(b)
Supine longitudinal scan. Gray scale. The ovoid portal vein
may be distinguished from an enlarged common bile duct by
noting its confluence from the splenic vein and the superior
mesenteric vein. This may be observed with gray scale or the
real-time scanner. Note typical location of the portal vein
anterior to the inferior vena cava.
FIGURE 4.31(c)
Supine longitudinal scan. Gray scale. The echo-free lumen of
the inferior vena cava extends into the right atrium. The vena
cava may be completely surrounded by the substance of the
FIGURE 4-31 (a) liver as a normal variant. The kinking of the midportion of the
inferior vena cava is due to the pressure of the
musculotendinous diaphragm on deep inspiration. This kink
may disappear on expiration.
Tumor or thrombus within the inferior vena cava

may be demonstrated with gray scale or real-
time scanners. Internal echoes and the absence
of normal pulsatile motion indicate invasion by
tumor or areas of clotted blood (26). The inferior
vena cava may be displaced anteriorly by
retroperitoneal tumors, lymphadenopathy, and
adrenal masses. The vena cava or the aorta may
be displaced posteriorly by pancreatic lesions.
Extrinsic obstruction by masses in or near the
pancreas may cause the superior mesenteric vein
to distend. The venous system distends in
pericardial effusion or right heart failure. Study
FIGURE 4-31 (b)
of the venous system may suggest a cardiac or
hepatic etiology for hepatomegaly.
THROMBOEMBOLIC DISEASE
FIGURE 4-31 (e)

Treatment of thromboembolic disease with
anticoagulants is common and the expected
complications are few. However, when a gravid
female suffers from thromboembolic disorders
or other hypercoagulable states and is treated
with standard doses of anticoagulant drugs,
certain problems generally occur at the time of
delivery.
The trauma of birth may precipitate fetal
intracranial hemorrhage with resulting
neurologic sequelae or even death. Optimally,
the fetus should have normal coagulation
mechanisms during delivery while the mother
should remain in a hypocoagulable state.

160
Experimental intrauterine fetal injection of Gastrointestinal complaints in the pregnant
vitamin K (phytomenadione) demonstrated the female may stem from such disorders as
feasibility of this approach (27). Vitamin K was cholecystitis, biliary obstruction, appendicitis
administered to the mother intravenously or and appendiceal abscess, peritonitis, hepatic
intraamniotically, producing a subclinical rise in abscess, perinephric abscess, and subdia-
the prothrombin-proconvertin level. Vitamin K phragmatic abscess. Also, ruptured or twisted
was then injected into the fetus under ultrasonic ovarian tumors may cause nausea and vomit-
guidance (27). (The motion of the fetus may be ing. Diagnosis of the above entities may be
observed with A-mode or rapid B-scanning with either specifically confirmed or substantiated
a variable persistence oscilloscope. The best with ultrasonographic scanning. Disease
imaging occurs with the multielement real-time processes such as ulcers, metabolic disorders,
scanner.) Injections with a fine needle were and gastroenteritis and colitis are not
made into the fetal thigh shortly before delivery. diagnosable with ultrasound.
The injection is performed while the fetal thigh is
Disorders of the bowel occurring during
continually monitored with the real-time
pregnancy, such as peptic ulcer disease, regional
scanner; the needle enters the plane of the sound
enteritis, and ulcerative colitis, are best
beam and fetal limb and produces a high-
diagnosed by radiographic barium examinations.
amplitude echo which is then monitored. Any
Ultrasonography is useful to document and
alteration in fetal position is instantly noted and
locate exacerbations or complications of
adjustments are made in needle insertion as
intestinal diseases.
needed. Postdelivery coagulation values were
within normal limits in the fetuses previously Regional enteritis may involve all parts of the
injected in utero. alimentary tract. It mainly affects the small
bowel and the most frequent complication that is
demonstrable by ultrasound is the tendency for
ULTRASONOGRAPHY OF mass formation with the production of fistulas
GASTROENTERIC DISORDERS IN and the adherent masses of matted small bowel
OBSTETRICS loops. These masses appear as poorly localized
areas which are usually transonically complex
GASTROENTERIC DISEASES due to the presence of edematous bowel wall and
its fluid-filled contents.
The common symptoms of nausea, vomiting,
The development of amyloidosis and chronic
and epigastric pain or burning are frequently
renal failure may show small contracted kidneys
nonspecific for gastrointestinal (GI) disorders
with conventional renal ultrasonography.
and may even be a normal part of gestation, as in
the clinical entity of morning sickness. The large Regional enteritis is not exacerbated by
pregnancy.
variety of serious disorders that may mimic the
simple nausea and vomiting of pregnancy are Ulcerative colitis is primarily an intrinsic colonic
basically divided into two types: those related to lesion and only the secondary complications are
gestation and those unrelated to pregnancy. diagnosable with ultrasound. Colonic cancer
with metastases, fatty liver infiltration and
Aside from the normal variations of morning
hepatitis, renal disease, and ocular compli-
sickness, other GI disorders secondary to
cations may be verified with ultrasonography.
pregnancy may stem from hydatidiform mole,
Colitis may be exacerbated by pregnancy.
mUltiple gestation, and hydramnios. These may
be readily diagnosed by ultrasound. Other
causes of GI disorders as hyperemesis In a similar manner to the nausea and vomiting
gravidarum, preeclampsia, and the onset of labor of pregnancy, constipation may be an associated
are supported by the lack of positive ultrasonic aspect of gestation. However, there may be
evidence of definitive pathologic conditions. serious underlying causes for constipation which

161
may demand further investigation. Internal may produce a localized reflex ileus resulting in
lesions of the colon, either of the intrinsic or the fluid accumulation in regional bowel loops. This
submucosal type, are able to produce complete may appear as a cystic mass with septations.
obstruction of the lumen of the large bowel. Perforation of the appendix may result in
Similarly, inflammatory disorders of the chronic localized abscess formation (Fig. 4.32) which
or acute type may produce spasm of the colon or appears as an echo-free area surrounding the
extracolonic abscesses which will obstruct either appendix. Generally, the walls are somewhat
from extrinsic pressure or reflex atony. irregular due to inflammatory edema and
Neuromuscular problems and systemic diseases necrotic debris. Through transmission is high.
such as scleroderma may be encountered.
Anorectal lesions are painful and may cause
reflex constipation. Such problems as
ULTRASONOGRAPHY OF HEPATIC
thrombosed hemorrhoid and anal fissure are
common causes of fecal disorders.
Ultrasonography of the constipated colon is HEPATIC DISORDERS IN PREGNANCY
difficult since there may be great variety in the
size, shal"e, and localization of the fecal Hepatic disorders are common in pregnancy.
products. If the area of fecal tumor is small and Since the normal liver is positioned almost
in the cuI de sac, its bizarre echo pattern may be entirely beneath the ribs, ultrasonic scanning is
mistaken for a dermoid. Fluid contents backing technically difficult due to sonic attenuation and
up behind an impacted colon may simulate a reverberation artifacts caused by the rib cage.
cyst. In severe cases of fecal impaction, the air-
At low sensitivity, the liver appears as an echo-
containing stool may completely block sonic
free organ with a concave distal border overlying
transmission, producing a characteristic picture.
the gallbladder, inferior vena cava, aorta, and
pancreas. At higher gain settings, the liver fills
Intestinal obstruction may occur during preg- with echoes. These weak echoes, shaped like
nancy. The obstructed small or large bowel en- dots or short lines, are reflections from larger
larges as the intraluminal contents accumulate. biliary radicles and hepatic vessels. Using the
The ultrasonic appearance depends upon the gray scale, the liver is more echogenic than is the
presence of fluid or air within the dilated bowel kidney or spleen and less echogenic than is the
loops. Bowel that is fluid filled will appear as an pancreas.
echo-free region separated by multiple septa-
tions corresponding to the walls of the bowel. The increased resolution noted with scan con-
Bowel filled with air (eg, from gas swallowing) verters shows the normal liver to be homoge-
will produce a sonic shadow. Certain areas of the neously filled with gray echoes, throughout
colon may produce diagnostic difficulty in ab- which are scattered multiple, linear, echo-free
dominal ultrasonography. The fluid-filled cecum areas with dark gray walls projecting toward the
and sigmoid, especially in inflammatory condi- hilum.
tions of the colon or adjacent to the colon, will The most common liver disease in pregnancy is
produce hypotonic segments of bowel which ap- viral hepatitis. The course of hepatitis is similar
pear as cystic lesions. The real-time scanner may in the pregnant and nonpregnant states. We have
be used to document peristaltic activity. Ifun- noted that the liver may be enlarged; however,
certainty exists, a water enema will show no consistent parenchymal echo pattern has
changes in size in bowel loops simulating cystic been noted in our series.
lesions.
Chronic toxic and infectious hepatitis results in
Appendicitis in pregnancy is unique in that the cirrhosis, which is an irreversible alteration of
appendix is usually located in the right upper the normal lobular architecture, with widespread
quadrant. Inflammation limited to the appendix fibrosis replacing atrophic liver parenchyma.

162
Areas of regenerating liver tissue are
interspersed diffusely. The size of the liver
varies; however, there is usually an increased
echo pattern in the liver substance, which may
be demonstrated on B-scan and gray scale
studies. The distinctive echo pattern in cirrhotic
patients is due to the wide spectrum of changes
caused by fatty metamorphosis, connective
tissue proliferation, regenerating nodules, and
necrosis in various combinations. The cirrhotic
liver may be accompanied by detectable ascites
Abscess and has a contracted homogeneous appearance.
Cholestatic jaundice of pregnancy associated
FIGURE 4.32 with pruritis is due to cholestasis with dilatation
Supine transverse scan. Gray scale. Appendicular abscess.
Note echo-free round area with irregular border and high of the canaliculi which may contain bile plugs.
through transmission. Patient had history of appendicitis There is no evidence of distal obstruction and it
which developed appendiceal abscess. is thought that the stasis is hormone induced.
Ultrasonography is nonspecific and shows an
increased echo pattern to the hepatic substance.
A similar echo pattern is seen in the acute fatty
liver of pregnancy which is associated with fatty
changes in the hepatic cells.
Abscess formation accompanying pregnancy
may be pyogenic and may appear as single or
mUltiple irregular echo-free areas within the
hepatic parenchyma. An amebic abscess is
usually located in the posterior portion of the
right lobe of the liver. It appears as a complex
mass with irregular walls and a high degree of
through transmission. Liver abscesses regress
more rapidly by ultrasound than by isotopic
scanning. Perihepatic abscesses are noted as
irregular anechoic regions in the subphrenic and
subhepatic spaces. A subphrenic abscess should
not be confused with subpulmonic effusion.
CYSTS
Hepatic cysts may be congenital and may be

incidentally discovered in females of child-
bearing age. These are usually small and
associated with polycystic changes in other
organs, such as the kidney. If the cysts are larger
than 1.5 cm in diameter, they will be detected as
echo-free areas on gray scale systems.
Hydatid cysts are usually large when detected;
the simple echinococcal cyst appears echo free.

163
Often septa, necrotic debris, and internal cysts changes during pregnancy. X rays should be
produce the picture of an echogenic mass. avoided during this time. In any case, radiologic
Locating pathology in the liver by procedures are seldom useful during acute chole-
sonotomograms is relatively easy. However, it cystitis, biliary obstruction, or hepatogenic jaun-
may be quite difficult to determine the nature of dice since radiographic examination depends on
the lesion. Diagnostic criteria aid in the functional status of the hepatobiliary system.
differentiating benign from malignant processes Indeed, since ultrasonic imaging is unrelated to
and cystic from solid lesions. the functional status of the gallbladder, it is the
primary method of investigation for the radi-
Surgery may produce fetal wastage in the ographically nonfunctioning gallbladder or the
attempted diagnosis of focal liver lesions. A less suspected diseased gallbladder in the pregnant
traumatic technique uses the percutaneous woman. Anatomically, the right and left hepatic
puncture transducer which enables the clinician ducts join at the porta hepatis to form the com-
to perforate lesions with great accuracy and to mon hepatic duct, which becomes the common
aspirate their contents. This transducer has a bile duct after giving off the cystic duct to the
special central bore through which puncture gallbladder. The common bile duct passes ante-
needles of various sizes can be passed. A fine- rior to the inferior vena cava and through the
gauge needle produces minimal trauma to superior aspect of the pancreatic head to enter
tissues. the duodenum at the papilla of Vater.
When an echogenic zone, at low sensitivity, or a
sonolucent region, at high sensitivity, is The gallbladder is a distensible sac lying in a
delineated, percutaneous cyst puncture may be fossa on the inferior surface of the right hepatic
performed with minimal patient preparation. lobe. The neck ofthe gallbladder and the cystic
Coagulopathy should be ruled out by history and duct are near the porta hepatis, while the fundus
laboratory determinations. The skin is sterilized projects inferolaterally beyond the liver edge.
and draped. The scanning transducer is then The fundus may contact the anterior abdominal
replaced with a sterile puncture transducer. The wall.
sound beam is directed into the zone of interest,
and the depth of the lesion from the skin surface The fluid-filled gallbladder appears echo free at
is readily measured from the echo pattern on the low and medium sensitivities. The resolution of
calibrated A-mode oscilloscope screen. After gray scale systems permits easier localization of
local anesthesia, the needle is advanced into the the gallbladder, and fluid-filled compartments
lesion to a predetermined depth. The contents of greater than 1.5 cm in width can be imaged. The
the suspected metastases are then aspirated and gallbladder is demonstrated along the inferior
submitted for cytologic examination. surface of the liver as an oval or round echo-free
structure and is roughly elliptic in its longitudinal
Ultrasonography provides a sensitive and axis (Fig. 4.33).
atraumatic method for localizing and diagnosing
suspected metastatic foci. The percutaneous In the filled gallbladder the posterior wall is
puncture technique permits simple histologic sharply demarcated and can be delineated in one
confirmation of suspected lesions. scan sweep. As it extends caudally, the
gallbladder becomes more lateral and superficial.
The nonfilled gallbladder is ill defined and
ULTRASONOGRAPHY OF GALLBLADDER difficult to locate.
AND BILIARY TRACT DISORDERS IN The patient is instructed to fast overnight to
OBSTETRICS di~tend the gallbladder optimally.
Demonstration of contractility distinguishes the
Gallbladder and biliary tract diseases are much duodenal bulb from the gallbladder. This is best
more common in females than in males. Hence, done by A-mode or the real-time scanner (Figs.
this organ system may be a site of pathologic 4.34 and 4.35). The gallbladder must always be

164
imaged in both planes to obtain its characteristic
shape to prevent misdiagnosing this echo-free
area as a cyst of the pancreas (Fig. 4.36) or a
metastatic focus in the liver. The biliary tree is
best appreciated with gray scale or real-time
scanners. The ductal system must be dilated to
1.0 cm to be imaged clearly.
Primary acute cholecystitis is not associated
with gallstones. An enlarged echo-free
gallbladder is seen without internal echoes.
There is no response to a fatty meal. Stones are
present in chronic cholecystitis and vary from
gravel-size to several centimeters in dimension.
FIGURE 4-33
In the supine position, gallstones lie against the
posterior wall and appear as echoes within the
gallbladder. On B-scan, single or mUltiple
echoes, close to the posterior wall, are noted.
FIGURE 4.33
Supine longitudinal scan. Gray scale. The gallbladder usually
lies in an oblique position. The neck of the gallbladder is often
situated over the inferior vena cava.
FIGURE 4.34
A-mode at high sensitivity. High through transmission
demonstrated as multiple echoes distal to the posterior wall
of the anechoic gallbladder. No change in size will be noted
when the transducer is over the gallbladder. A duodenal bul b
filled with fluid will change in size with normal contractions.
FIGURE 4.35
Supine longitudinal scan. Gray scale. Dilated gallbladder
over kidney. Sharply outlined anterior and posterior walls.
FIGURE 4-34 No response to fatty meal. Acute cholecystitis.
FIGURE 4.36
Supine oblique scan. Gray scale. The gallbladder was not
imaged in the routine scanning planes. Partial outline of the
gallbladder appears when the oblique scanning plane is used
to locate this structure.
FIGURE 4-35

165
With gray scale imaging, stones as small as 0.4
Multiple em in diameter may be visualized as dark-gray
calculi
masses of echoes adjacent to the distal wall (Fig.
4.37). With careful linear scanning, a sonic
shadow may be produced as the stone blocks
passage of the ultrasound beam (16). Distal to
the stone is an echo-free space corresponding to
the dimension of the calculus in the scanning
plane. Behind the stone, the posterior
gallbladder wall is either poorly seen or not
visualized at all.
If the gallbladder is completely filled with stones,

there is insufficient fluid to produce an echo-free
FIGURE 4.37 interface in which to detect intraluminal echoes.
Supine transverse scan. Gray scale. The gallbladder is echo
free. On the distal wall, high-amplitude echoes of a gallstone The presence of high-amplitude echoes in the
are noted. A sonic shadow occurs distal to the stone. region of the gallbladder and the appearance of a
sonic shadow (16) suggest a stone-filled lumen.
In chronic cholecystitis, the gallbladder may be
shrunken secondary to fibrosis and may contain
too little fluid to be detected.
In both chronic obstruction and acute

inflammation the gallbladder is dilated and there
is no response to fatty meal stimulus. Although
the clinical setting is usually diagnostic, the
pancreas should be investigated to rule out
tumor mass or acute pancreatitis with reflex
cholecystitis.
Obstruction of the distal common bile duct is

usually caused by impacted gallstones,
FIGURE 4.38 carcinoma of the head of the pancreas, strictures
Supine transverse scan. Gray scale. The normal pancreas is of the common bile duct, lymphadenopathy, and
generally situated beneath the inferior surface of the liver.
The echogenic "cobblestone" appearance of the pancreatic secondary tumor deposits in the porta hepatis.
substance is noted above the aorta and superior mesenteric Carcinoma of the common bile duct is rare.
artery. The pancreas is more echogenic than is the liver. Gradual obstruction causes proximal dilatation
of the gallbladder and the common bile duct. The
intrahepatic bile duct appears as a tubular echo-
free structure on longitudinal section, connecting
with the dilated, branching, echo-free major
biliary radicles located cephalad (28).
The dilated common bile duct must be

differentiated from the portal vein. We identify
the portal vein by observing its formation from
the splenic and superior mesenteric venous
tributaries. The splenic vein posterior to the
pancreas is first demonstrated and then followed
to the right upper quadrant to its confluence with

166
the portal vein. Although this may be done with
gray scale, we and others (29) utilize the real-
time scanner for speed and accuracy.
ULTRASONOGRAPHY OF PANCREATIC
Pancreatitis may complicate pregnancy. Either

the acute or chronic form may occur in the
gravid patient. Pseudocyst formation may result
secondary to this disease process . Ultrasonogra-
phy is now being accepted as the best method for
FIGURE 4.39(a) imaging inflammatory processes of the pancreas.
Supine transverse scan. Gray scale. The acutely inflamed Serial examinations may be performed without
pancreas appears as a sonolucent band above the aorta and
inferior vena cava. The edema of acute inflammation risk to the patient or discomfort, and are useful
produces high through transmission and the margins of the in documenting the size of the pancreas in acute
gland are distinctly outlined . The di stal wall is well seen. pancreatitis. Determination of changes in pan-
creatic volume is helpful in following the course
of chronic pancreatitis.
The pancreas has numerous blood vessels ,

ducts, and a lobular architecture. The many
interfaces in this organ produce internal echoes
at medium sensitivity. Ultrasonographically, it is
usually ill defined due to the normal irregularity
of the gland and the absence of a well-defined
pancreatic capsule. The normal pancreas is more
echogenic than is the liver, spleen or kidney. It
has a "pebbly" gray echo pattern on gray scale
systems (Fig. 4.38). The location and shape of
the pancreas vary considerably. It is positioned
rather anteriorly and may assume a sigmoid , L-
FIGURE 4.39(b) shaped , V-shaped, or horseshoe configuration.
Supine longitudinal scan. Gray scale. Enlarged transonic
pancreas due to pancreatitis.
PANCREATITIS
Enlarged pancreas
Ultrasonography is extremely helpful in the
acute stage of pancreatitis when the gland is
edematous and usually well visualized (30). The
margin of the inflamed pancreas is smooth and
the gland becomes highly transonic (Fig. 4.39a
and b).
We have noted that turgescence of the superior
mesenteric vein frequently accompanies
pancreatic enlargement. Other studies show that
inflammation of the pancreas is accompanied by

167
increased fluid content, which permits better denum has been documented by ultrasonogra-
sound transmission and sharp definition of phy (35). The pseudocyst may resemble ascites
boundaries (31). Solid organs surrounding the in the region of the flank.
pancreas are filled in with echoes and the
Other radiologic methods evaluate pseudocysts
pancreas stands out in contrast. The enlarged
by a process of exclusion. Ultrasonography not
head of the pancreas may be mistaken for a
only directly detects the pseudocyst, but also
pseudocyst; however, it does not have the same
permits temporal evaluation of this disorder.
degree of through transmission nor the sharp
posterior wall of a cyst. Since ultrasound is atraumatic and may safely be
repeated as often as necessary, we feel that
Some authors (32,33) feel that ultrasonography is
sonotomography of the pancreas for pseudocyst
frequently inconclusive in chronic pancreatitis.
determination is the method of choice. In
However, large pancreatic stones may
addition, complications such as infection or
occasionally be demonstrated in the parenchyma
rupture may be documented.
of the gland, appearing as strong echoes within
the organ indicative of chronic calculous
pancreatitis. We have demonstrated the sonic
shadow sign (16) in several patients with this ULTRASONOGRAPHY OF SPLENIC
disorder. In chronic pancreatitis the entire gland DISORDERS IN OBSTETRICS
may appear as an echogenic mass; however,
delineation of the gland deteriorates as fibrosis Ultrasound is useful in outlining the size, shape,
and contraction progress. and position of the spleen when splenectomy is
considered as a treatment for various
hematologic disorders. This is the case in the
PSEUDOCYST coagulation disease of idiopathic
thrombocytopenic purpura when steroid therapy
Pseudocyst formation in acute pancreatitis may has failed. We have noted that the spleen may be
be demonstrated by echography as early as 2 massively enlarged and yet not project under the
weeks after onset (31), although pseudocysts left costal margin. Splenomegaly may be difficult
usually appear 8 weeks after acute inflammation. to evaluate in obese patients. Ultrasonography
Some investigators (30,31) described the may be used in these conditions to estimate the
application of sonotomography in diagnosing volume of the spleen or to verify that the left
pseudocyst of the pancreas. Their studies upper quadrant mass is indeed splenic in origin.
revealed that the pseudocyst presents as a The displacement of the intraabdominal organs
rounded sonolucent or transonic area, with a by the gravid uterus may displace the spleen in
strong posterior wall echo. Our series shows that unexpected directions, and ultrasonography may
these cysts may be located in any part of the be used to outline the position of the spleen and
pancreas and may contain septa, pus, or necrotic its regional anatomy so that the surgeon may
debris. After drainage, the cyst becomes optimize the operative approach. In addition, the
irregular and fills in with echoes at higher ultrasonographic appearance of the pathologic
sensitivity settings. spleen may be highly diagnostic of certain
diseases, and may save the patient from other
It is stated that pseudocysts may be mUltiple or
diagnostic procedures of greater morbidity and
lobulated (31,34). We use A-mode in conjunction
discomfort.
with B-scan to prove total transonicity of the
pseudocyst to differentiate it from solid tumors. The normal spleen appears as a concave
The natural course of pseudocystic development sonolucent structure in the left upper quadrant.
can be followed by sonotomography. Sponta- The splenic pulp is homogeneous and the organ
neous rupture of a pseudocyst into the duo- fills in with echoes at very high sensitivity

168
settings. It is much more sonolucent than is the In leukemia cellular infiltration is diffuse. Small
liver and slightly more sonolucent than is the spleens are generally noted in acute leukemia,
renal parenchyma. while larger spleens occur in chronic leukemia.
Infarction and fibrosis are more common in
While scanning the pregnant female, certain chronic myelogenous leukemia than in chronic
anomalies may be encountered. Congenital lymphatic leukemia. These spleens tend to have
variations of the spleen include asplenia, splenic anechoic or low-level echo-producing
separations, accessory spleens, and polysplenia parenchyma. However. we have observed
with mUltiple small spleens. Rather large spleens echogenic spleens in chronic myelogenous
have been incidentally noted as a normal leukemia (Fig. 4.40).
variation in both adults and children.
Trauma may produce splenic injury in pregnant
True cysts of the spleen are rare and may be due women. The enlarged spleen is more easily
to parasites (Echinococcus) or teratoma. False traumatized. The lacerated spleen will usually
cysts are more common and usually occur in the maintain its size and shape as blood spills
young adult. These may produce splenomegaly intraperitoneally. If the capsule is intact, a
in the pregnant woman. They may be serous or splenic hematoma will result, enlarging and
hemorrhagic and are believed to represent distorting the splenic outline. Following trauma,
organizing hematomas (36,37). The cyst has a ultrasonography is performed, so that use of X
sharp posterior border and high through rays will be avoided. Inspection is made for
transmission. If the cyst is hemorrhagic or intraperitoneal blood. The spleen is examined
septate, internal echoes may be demonstrated. for breaks in the continuity of the cortical
An attempt is made to visualize the remaining outline, or areas of hemorrhage that appear
compressed splenic tissue. At higher sensitivity separated from the normal tissue by a band of
settings, the echogenic spleen will contrast with echoes corresponding to the blood-spleen
the echo-free cyst. interface. At higher sensitivity. the compressed
spleen will fill in with echoes, while the
Hyperplastic splenomegaly occurs in hemolytic subcapsular blood remains echo free (30).
anemias, which are a common problem for the
obstetrician. The size and internal echo pattern
depend on the chronicity of the disorder and the INFLAMMATORY PROCESS
extent of fibrosis or calcification of the
parenchyma. For example, in early sickle cell The spleen may enlarge in the presence of
disease the gland is generally large and anechoic extrasplenic inflammatory disease, such as
but later contracts and becomes echogenic. pelvic inflammatory disease or puerperal sepsis,
or may be the site of septic infarcts resulting in
Primary malignant tumors of the spleen are of abscess formation. Splenic abscesses may
the lymphoma family. The spleen may contain appear as irregular sonolucent foci as the spleen
discrete foci of tumor, with or without necrosis. becomes sonopaque at higher gain settings.
In advanced disease complete replacement of Tuberculosis, brucellosis, sarcoid, and other
the organ may occur. Multiple foci of tumor may chronic infections tend to produce echogenic
appear echogenic. The diffusely infiltrated spleens (8).
spleen is homogeneous and generally anechoic
unless areas of necrosis exist. Most of these
spleens highly attenuate the ultrasound beam so INFILTRATIVE DISORDERS
that the posterior border is poorly demonstrated.
Differentiation of this echo-free tumor from a In benign infiltrative disorders that cause
cyst depends upon the through transmission deposition of metabolic products within the
pattern (I). cells, such as Gaucher's disease, the enlarged

169
FIGURE 4.40
Supine transverse scan. Gray scale. The spleen is enlarged,
Spleen echo poor, and transonic. The spleen crosses the midline of
1
the body. Chronic leukemia.
FIGURE 4.41
Supine longitudinal -can. Gray scale. Echo-free zone above
the right hemidiaphru6m. Note the high through transmission
associated with the pleural fluid. One liter of pleural effusion
was evacuated.
FIGURE 4.42
Supine longitudinal scan. Gray scale. The left hemidiaphragm
is well imaged. The gas-containing organs in the left upper
quadrant are displaced by the enlarged spleen of chronic
leukemia.
~
FI URE 4-40
spleen has an echo pattern consistent with the
degree of internal necrosis and fibrosis. Our case
material showed moderately echo genic
parenchyma in patients with such disorders.
VOLUME DETERMINATION
In general, medical disease of the spleen

diffusely enlarges the organ (36), while space-
occupying lesions distort the splenic outline and
compress normal parenchyma.
The spleen may be enormously enlarged and yet
not project below the left costal margin (38).
FIGURE 4-41 Splenic volume can be determined by analyzing
the scans with a pencil-following device linked to
a computer system (38). Massive splenomegaly
occurs in chronic leukemia, portal hypertension,
Gaucher's disease, Hodgkin's disease,
myelofibrosis, lymphosarcoma, and some
FIGURE 4-42
chronic hemolytic anemias. Accurate
determination of splenic volume is useful in the
diagnosis and management of hematologic
disorders.
ULTRASONOGRAPHY OF
DIAPHRAGMATIC DISORDERS IN
OBSTETRICS
The diaphragm separates the lungs from the

abdomen and is affected in diseases of both
regions. Both diaphragmatic motion and contour
may be demonstrated by ultrasound. Fluid

170
collections above and below this muscular by the hormonal and metabolic changes in
septum are easily identified. pregnancy. During gestation the thyroid gland
has large follicles and actively secretes thyroid
The presence of the liver allows sound to reach
hormone.
the midsagittal plane of the right hemidiaphragm
from the posterior aspect almost to the anterior The occurrence of tumors of the thyroid in the
attachment. The sonogram shows a smooth, pregnant female presents particular problems,
mobile arc of dense echoes at the periphery of since the usual diagnostic modality of
the liver. Normally, the left hemidiaphragm radioactive thyroid uptake is associated with the
cannot be imaged from the anterior aspect, and risk of radiation exposure both to the mother and
the portion that may be visualized by posterior the developing fetus. The fetal thyroid
scanning appears as a short, concave, echo- concentrates iodine much more than does the
dense structure. Basically, in pregnant females, maternal thyroid, and cases of congenital
in the early stage, the diaphragm can be properly hypothyroidism have been documented
evaluated. In later pregnancy, its motion has following exposure to radioactive iodine (40).
been restricted due to the gravid uterus, and
The fetus is more sensiti ve to radiation effects
pathologic conditions are more difficult to
since irradiation has a more marked effect on
evaluate.
rapidly dividing tissue. It is well established that
Supradiaphragmatic fluid appears as an echo- a higher percentage of offspring of mothers
free area above the liver echoes of the exposed to X rays die from leukemia or cancer
diaphragm. This zone ceases at the pleural before the age of 10 years (41). In addition to
interface where another linear arc of echoes is malignancy, microcephaly has been noted with
noted (Fig. 4.41). The echo-free area, or free increased incidence in children irradiated in
pleural fluid, will decrease in size as the patient utero. Retardation in growth and development
is moved from the erect to the recumbent during adolescence has also been noted.
position. Loculated fluid or abscess will not
The superficial position of the thyroid gland in
change in shape as the patient's position is
the neck allows inspection and palpation by the
altered.
clinician and permits soft tissue X-ray
A space-occupying mass in the left upper examination and isotopic imaging by the
quadrant makes the left hemidiaphragm easy to radiologist. Since thyroid accumulation of
image. Indeed, if the left hemidiaphragm is radioactive iodine is histologically specific and
visualized without special effort, a sound- thyroid tissue may be ectopic, radionuclide
transmitting mass in contact with the left imaging is the best screening procedure for the
hemidiaphragm must be suspected (Fig. 4.42). detection of thyroid pathology. (The application
This has also been seen when sonic windows of radioisotopes to the localization of the solitary
were created by marked hepatomegaly, ascites, cold thyroid nodule has greatly aided the
and left subphrenic abscesses (39). physician. However, a poorly functioning area
on the scan may represent primary or secondary
carcinoma, benign adenoma, cyst, thyroiditis,
hyperplasia, or hemorrhage.)
ULTRASONOGRAPHY OF THYROID
Thyroid tumors may be studied with high resolu-
THYROID DISEASES tion ultrasound. Gray scale systems and real-
time scanners permit differentiation between be-
Disorders of the thyroid are more common in nign cysts and solid thyroid tumors. Ultrasound
women than in men. Consequently, thyroid is safe, atraumatic, and may be performed seri-
disease is not uncommon in pregnancy. It is well ally, providing important data on the progression
known that the stroma of the thyroid is altered of the disease or its response to treatment.

171
FIGURE 4.43(a)
Supine transverse scan. Gray scale. The normal thyroid
appears as moderately echogenic tissue bounded by the
trachea, carotid sheath, and anterior strap muscles.
FIGURE 4.43(b)
Supine longitudinal scan. Gray scale. The normal carotid
artery appears as an echo-free structure. It should be
identified to determine the normal position of the thyroid
gland.
FIGURE 4.44
Supine transverse scan. Gray scale. Adenoma of the thyroid
usually presents as a tumor with a core of high-amplitude
echoes surrounded by a periphery of low-amplitude echoes.
FIGURE 4-43 (a)
The small size and subsurface location of the

gland permit the ultrasonographer to use a 5-
MHz transducer of limited range but high
resolution for the examination. Better contour
scanning may be achieved by separating the
transducer from the neck surface with a plastic
bag filled with water or oil. The patient is studied
with the neck hyperextended. The anterior neck
is scanned by moving the transducer across the
neck transversely in I-cm intervals from the
hyoid bone to the thoracic inlet. Our system of
identification uses the thyroid cartilage as a
reference point with all sections above it
indicated as plus (+) and all sections below
indicated as minus ( -). A longitudinal scan is
performed to complete the examination along
FIGURE 4-43 (b) the greatest length of the lobe or area of
pathology. This results in a three-dimensional
representation of the organ.
FIGURE 4-44
NORMAL ANATOMY
The thyroid gland occupies the compartment

bounded by the trachea, carotid sheath, and
neck muscles. The trachea lies posteriorly to the
body of the thyroid and is medial to the lateral
and posterior extensions of the individual lobes.
The air-filled trachea blocks the transmission of
sound waves, creating a sonic shadow distally.
The common carotid artery and distended
jugular vein (due to the gravitational venous
filling of the hyperextended neck) appear as

172
bilaterally symmetric, discrete echo-free adenoma the "halo" sign. At the present time,
structures posterolaterally (Fig. 4.43a and b). this sign should be cautiously interpreted, pend-
Anteriorly is the superficial and lateral cervical ing further evaluation. Adenomas larger than 4
musculature. At a given gain setting the thyroid cm in diameter have a tendency to degenerate.
parenchyma fills in with a characteristic Cystic necrosis produces echo-free, fluid-filled
"pebbly" echo pattern of predominantly low- spaces within the adenoma of varying size and
amplitude gray tones within the above anatomic location. The echo pattern of the thyroid ade-
boundaries. noma and the halo sign is best imaged with gray
scale. The appearance of cystic degeneration is
more easily shown with the real-time scanner.
The higher fluid content ofthe degenerating ade-
THYROID CYSTS noma produces a high through transmission pat-
tern. The tumor tends to displace the carotid
At standard gain settings the cyst of the thyroid artery in various directions. The halo sign most
is echo free with high through transmission, likely represents the capsule of the thyroid ade-
resulting in many echoes distal to the posterior noma (42).
wall of the cyst. The cyst remains echo free at
high gain and the size of the lesion is unchanged.
Cysts are generally rounded lesions with smooth THYROID CARCINOMA
walls.
The infiltrating and homogeneous nature of
A recently designed percutaneous puncture
thyroid malignancies produces the ultrasonic
transducer (2) now enables the clinician to
appearance of a lesion that is echo poor. There is
perforate cysts as the transducer is centered
generally an irregular distribution to the echo
over the echo-free zone and aspirate their
pattern and some echogenic areas may be
contents. This transducer has a central lumen
randomly noted. The outer capsule is frequently
allowing passage of a fine-gauge needle which
irregular and we have not observed the halo sign
produces minimal trauma to the tissues. In our
in any thyroid carcinomas to date.
experience in the past 3 years, there have been
no complications of thyroid cyst puncture (40).
Most benign cysts contain serous fluid. Only a THYROID VOLUME
small percentage of malignant lesions have
enough cystic or hemorrhagic degeneration to be Knowledge of the total volume of the thyroid
confused with a cyst at ultrasonic investigation gland is important due to the increasing
(41). Before cyst puncture, we generally check emphasis on medical therapy of thyroid
the location ofthe carotid artery and jugular vein disorders. Three-dimensional reconstruction of
with the real-time scanner. the thyroid lobes during scanning may be further
refined by computer analysis. Special computer-
linked pencil-following devices are available to
give a digital read-out of the glandular volume.
THYROID ADENOMA
Improved estimation of thyroid mass allows
better 1311 dose calculation for the hyperthyroid
Adenoma of the thyroid usually presents as a patient being considered for radiation therapy.
tumor with a core of high-amplitude echoes sur-
Similarly, the course of suppressive drug
rounded by a periphery of low-amplitude echoes
treatment may be followed more precisely.
(Fig. 4.44). Although the majority of benign sim-
ple adenomas will demonstrate this typical ap- The noninvasive nature of thyroid echography
pearance, other ultrasonic pictures may also oc- makes it an ideal modality for the study of cold
cur. We call this echo-poor rim of the thyroid nodules detected by isotopic imaging.

173
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retroperitoneal space lesions by B-scan ultrason-
1. Hassani N, Bard R, von Micsky LI: Through ography. Radiology 104:133, 1972
transmission patterns in solid tumors. In: Pro- 19. Feigenbaum H, Chang S: Echocardiography.
ceedings of the 20th Annual Meeting of the Ameri- Philadelphia, Lea and Febiger, 1972
can Institute of Ultrasound in Medicine. New 20. Halpert B, Willms RK: Aneurysms of the aorta.
York, Plenum Press, 1975. Arch Pathol 74:163, 1962
2. Hassani N, Bard R: Ultrasonography of the Ab- 21. Steinberg I, Stein HL: Visualization of abdominal
domen. New York, Springer-Verlag, 1976 aortic aneurysms. Am J Roentgenol 95:684, 1965
3. Goldberg BB, Goodman GA, Clearfield HR: 22. Rogoff MS, Lipchick OE: Aneurysms of the ab-
Evaluation of ascites by ultrasound. Radiology dominal aorta. In Abrams LH (ed): Angiography.
96:15, 1970 Boston, Little, Brown, 1971, pp 759-772
4. Meyers MA: Distribution of intra-abdominal ma- 23. Segal LB: Ultrasound diagnosis of an abdominal
lignant seeding. Dependency on dynamics of flow aortic aneurysm. Am J CardioI17:101, 1966
of ascitic fluid. AM J Roentgenol 119: 198, 1973 24. Goldberg BB: Ultrasound aortography. JAMA
5. Leopold GR: A review of retroperitoneal ultra- 119:353, 1966
sonography. J Clin Ultrasound 1:82, 1973 25. Weill F, Maurat P: The sign of the vena cava.
6. Brascho DJ: Diagnostic ultrasound in radiation Echotomographic illustration of right cardiac in-
treatment planning. J Clin Ultrasound 1:320, 1973 sufficiency. J Clin Ultrasound 2:27,1974
7. Brown RE, Sartin M, Bogardus CR: Patient con- 26. Greene D, Steinback HL: Ultrasonic diagnosis of
tours in radiation therapy planning. Presented at hypernephroma extending into the inferior vena
the 17th Annual Meeting of the American Institute cava. Radiology 115:676, 1975
of Ultrasound in Medicine, November 16-20, 27. Jensen Fl, Jacobsen B, Larsen JF, et al: Intra-
1972 fetal Injection of Vitamin K. In: Proceedings of
8. Taylor KJW: Gray scale ultrasonography in the the 20th Annual Meeting of the American Institute
differential diagnosis of chronic splenomegaly. In: of Ultrasound in Medicine. New York, Plenum
Proceedings of the 20th Annual Meeting of the Press, 1975
American Institute of Ultrasound in Medicine. 28. Taylor KJW, Carpenter DA: The anatomy and
New York, Plenum Press. 1975 pathology of the porta hepatis demonstrated by
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ultrasound. In: Proceedings of the 20th Annual 1975
Meeting of the American Institute of Ultrasound 29. Weill F, Elsenschar A, Aucent D, et al: Ultra-
in Medicine. New York, Plenum Press. 1975 sonic study of venous patterns in the right hypo-
10. Rabinowitz JG, Keller RJ, Wolf BS: Benign peri- chondrium. An anatomical approach to differen-
pelvic extraVasation associated with renal colic. tial diagnosis of obstructive jaundice. J Clin
Radiology 86:220, 1966 Ultrasound 3:23, 1975
11. Hodson JC, Craven DJ: The radiology of obstruc- 30. Holm HH: Ultrasonic scanning in the diagnosis of
tive atrophy of the kidney. Clin Radiol 17:305, space-occupying lesions of the upper abdomen.
1966 Br J Radiol 44:24, 1971
12. Goldberg BB, Ostrum BJ, Isard HJ: Nephroson- 31. Leopold GR: Pancreatic echography. A new di-
ography. Ultrasound differentiation of renal mas- mension in the diagnosis of pseudocyst. Radiol-
ses. Radiology 90:1 I 13.1968 ogy 104:365, 1972
13. Sanders RC, Bearman S: B-scan ultrasound in the 32. Kahn PC: Pancreatic echography. In Eaton SB,
diagnosis of hydronephrosis. Radiology 108:375, Ferrucci JT (eds): Radiology of the Pancreas and
1973 Duodenum. Philadelphia, Saunders, 1973
14. Mountford RA, Ross FGM, Burwood RJ: The use 33. Leopold GR: Echographic study of the pancreas.
of ultrasound in the diagnosis of renal disease. Br JAMA 232:287, 1975
J Radiol 44:733, 1971 34. Filly RA, Freimanis AK: Echographic diagnosis
15. Damascelli B, Lattuada A, Musumeci R: Two- of pancreatic lesions. Radiology 96:575, 1972
dimensional ultrasonic investigations of the uri- 35. Leopold GR: Echographic and radiological docu-
nary tract. Br J RadioI41:837, 1968 mentation of spontaneous rupture of a pancreatic
16. Hassani N: Sonic shadow sign. J Natl Med Assoc pseudocyst into the duodenum. Radiology
67:307, 1975 102:699, 1972
17. Ben-ora A: Ultrasound diagnosis of Iymphoceles 36. Lande A, Bard R: Arteriographic diagnosis of
following renal transplantation. In: Proceedings of pedunculated splenic cysts. Angiology 25:617,
the 20th Annual Meeting of the American Institute 1974
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174
38. Rasmussen SN: Spleen volume determination by
ultrasonic scanning. Scand J Haematol 10:298.
1973
39. Haber K. Asher WM. Freimanis AK: Echo-
graphic evaluation of diaphragmatic motion in in-
tra-abdominal diseases. Radiology 114: 141. 1975
40. MlIrray [PC: The CU'Tent status of radioactive
iodine. Practitioner 199:696. 1967
41. Stewart A. Webb J. Hewitt 0: A survey of child-
hood malignancies. Br Med J I: 1495. 1974
42. Hassani N, Bard R: Gray scale and real time
ultrasonic evaluation of thyroid neoplasm. In:
Proceedings of the 1st Meeting of the World Fed-
eration of Ultrasound in Medicine. New York,
Plenum Pre~s, 1976

175
index
A B-mode (brightness mode), in oscilloscope displays,
10,34-35
Abdominal sonolaparotomy, 156 Body organs, acoustic impedance of, 8
Abortions Bone, acoustic impedance of, 9
diagnosis of, 122-124 BPD, see Biparietal diameter
missed, 124, 130 Breech presentation, in obstetrical ultrasonography,
threatened, 123 105
Abruptio placentae, 118
Acoustic image, normal, 32-33
Acoustic impedance c
of body organs, 8
formula for, 4-5 Cardiac disease, see also Congenital heart disease
Adenoma, of thyroid, 173 in pregnancy, 152-155
Adenomyosis, uterus and, 55 ultrasonography in, 152-161
Amniocentesis, fetal evaluation by, 119-121 Cecum, distended, 67
Amniotic fluid, 109 Cholecystitis
assessment of, 126-127 primary acute, 165
A-mode, display of, 34-35 reflex, 166
Amyloidosis, 161 Colitis, 161
Anecephaly, 126 Congenital heart disease, 155
Aneurysms Contact diagnostic ultrasound scanner, 13
aortic, 155-158 Cross-sectional image production, 10-15
in pregnancy, 155-157 real-time scanning in, 12-15
Aortic insufficiency, 154 Cyst(s)
Aortic stenosis, 153 hepatic, 163-164
Aortic ultrasonography, 156 ovarian, see Ovarian cyst
Appendicular abscess, 67 paraovarian, 67
differential diagnosis of, 70 renal, see Renal cyst
Arterial disease, in pregnancy, 155 of spleen, 169
Ascites thyroid, 173
benign vs. malignant, 141 Cystadenomas
in gynecological disorders, 139-141 mucinous, 62
ultrasonographic detection of, 139-141 papillary, 63-64
Asymmetric septal hypertrophy, 155 Cystic degeneration, ultrasonic appearance of, 58
Attenuation studies, 33 Cystic lesions
Axial resolution, defined, 6 endometriosis and, 60
in sonolaparotomy, 50-52
Cystic teratoma, 64
B
Beam width, of ultrasonic waves, 3 D

Bile duct, obstruction of, 166
Biophysical effects, of ultrasound, 24-25 Damping control, in sonographic equipment, 18-
Biparietal diameter 22
gestational age and, 91 Deep lesions, localization of, 146-147
measurement of, 87-92 Diaphragmatic disorders, ultrasonography in, 170-
Birth trauma, fetal hemorrhage in, 160 171
Bladder Directivity, in ultrasonography, 8-9
distended, 67 Dissecting aortic aneurysm, 158
echo-free, 43 Distortion artifacts, 23-24
in pelvic disease, 137 Doppler effect, 15-16
in pelvic ultrasonography, 47 Doppler examination, in pregnancy, 119
177
Doppler instruments, operation of, 16 presentation and position of, 75-76, 103-106
Doppler ultrasound, in early pregnancy, 83-84 sex determination in, 99
upper and lower limbs of, 99-100
Fibroids (fibroid tumors, fibromas), 51, 54
E intramural, 55-56, 59
ovarian, 63-64
Early pregnancy, see also Pregnancy pathological process of, 57-58
diagnosis of, 80-87 pedunculated, 57
Doppler sound in, 83-84
Echo amplitude, reverberation and, 23
Echocardiography, principles of, 152
G
Echoes, from tumors, 53-55
Echogenic pattern, 3, 35
Gallbladder, ultrasonography of, 164-167
Echo-poor vs. echo-rich patterns, 35
Gallstones, 165
Ectopic pregnancy, 124-125
Gastroenteric diseases, ultrasonography of, 161-
ruptured, 67
162
Endometrial cavity, sonoanatomy of, 45
Gaucher's disease, 169
Endometrial cyst, in pregnancy, 81
Genital tract, congenital anomalies of, 68-69
Endopetrial hyperplasia, uterus and, 55
Gestational age, biparietal diameter and, 91
Endometriosis, 55, 58-59
Gestational sac, 80-81
cause of, 60
abnormality of, 83
differential diagnosis of, 70
in obstetrical ultrasonography, 106
Enteritis, regional, 161
GI, see Gastrointestinal diseases
Gray-scale imaging, 10-12
in fetal measurement, 89
F
of placenta, 111-112
Gynecologic disorders
Fallopian tube, inflammation of, 66
ascites in, 139-141
Fetal abdomen
liver metastases in, 137-138
distention of, 126
liver ultrasonography in, 137-139
in obstetrical ultrasonography, 97-98
radiation therapy in, 146
Fetal death, 121-122
renal ectopia in, 136
hydropic degeneration and, 130
retroperitoneal area and, 143-149
radiologic signs of, 122
solid tumors in, 135-136
Fetal extremities, in obstetrical ultrasonography, 99-
ultrasonography and, 133-173
100, 102
Gynecologic pathology, detection of: 43
Fetal growth, in obstetrical ultrasonography, 101-
Gynecologic tumor masses, ultrasomc
103
characterization of, 52-60
Fetal hand, 103, 105 Gynecologic ultrasound, 40-70, see also Obstetrical
Fetal head, 92-93 ultrasonography
Fetal heart, 94-95
anatomy in, 41-47
Fetal heart rate, monitoring of, 95
sonoanatomy in, 43-47
Fetal intracranial hemorrhage, 160
sonolaparotomy in, 47-52
Fetal kidneys, in obstetrical ultrasonography, 97-98
ovaries in, 43
Fetal motion, detection of, 100 uterus in, 42-43
Fetal penis and testicles, in obstetrical vagina in, 41-42
ultrasonography, 101
Fetal size, measurement of, 87-92
Fetal spine, in obstetrical ultrasonography, 93-94
Fetal thorax, 95-97 H
Fetal trunk, 104
Fetal weight, 98 Hemotocele, 67
Fetus, see also Fetal (adj.) Hematoma, in obstructive uropathy, 149
abnormal, 126 Hepatic cysts, 163-164
in early pregnancy, 85-87 Hydatid cysts, 163
evaluation of in obstetrical ultrasonography, 75-77, Hydatidiform mole, 127-130
86-87,92-106, 119-121 Hydrocephalus, 126
INDEX
178
Hydronephrosis, 134, 147-149 o
Hydropic degeneration of pregnancy, 130
Hypernephroma, 135 Obstetrical disorders
Hysterography, 69 cardiac disease and, 152-161
Hysterosalpingography, contrast, 69 ultrasonography of, 133-173
Obstetrical sonography, patient history in, 72-73, see
also Gynecologic ultrasound
I Obstetrical ultrasonography, 71-130
abnormal fetuses in, 126
Image production abortions in, 123-124
gray-scale imaging and, 10-12 biparietal diameter measurement in, 87-92
real-time scanning in, 12-15 differential diagnosis in, 106--107
Inferior vena cava, ultrasonography of, 159-160 early placenta in, 82
Intestinal obstruction, in pregnancy, 162 early pregnancy in, 80-88
Intrauterine contraceptive devices ectopic pregnancy and, 124-125
infection from, 66 fetal death in, 121-122
in sonolaparotomy, 49-50 fetal evaluation in, 119-121
IUCD, see Intrauterine contraceptive devices fetal growth in, 101-103
fetal head in, 92-93, 105
fetal presentation and position in, 103-106
J fetal size in, 87-92
fetal trunk in, 104
Jaundice, cholestatic, 163 fetus in, 75-76, 86-88, 92-103,119-121
gallbladder and biliary tract in, 164-174
gastroenteric disorders in, 161-162
K gestational sac in, 80-82
intraabdominal pregnancy and, 125-126
Kidney last normal menstrual period and, 72
displaced, 136 maternal pelvis in, 92
pathological changes in, 147-148 menstrual pattern changes in, 72-73
pleural effusion and, 142 molar pregnancy in, 127-130
multiple pregnancy in, 108
in obstetrical disorders, 149-151
L obstructive uropathy in, 149-151
pain history in, 73
Lateral resolution, defined, 6 palpation of abdomen in, 73
Leiomyoma icteri, 55, see also Fibroids pancreatic disorders in, 167-168
Liver, ultrasonography of, 137-139 placenta in, 78-80, 108-118
Liver disorders, 162-163 placenta previa in, 113-117
Lymphadenopathy, 149 primigravida in, 72
paraaortic, 157 pseudocyesis in, 108
Lymphoma, cystic lesions and, 51 renal disorders in, 147-151
splenic disorders in, 168-170
Oscilloscope displays, B-mode and M-mode in,
M 10
Ovarian cyst, 53, 60-62
Main system control, of sonographic unit, 21-23 differential diagnosis of, 107
Menstruation, in obstetrical history, 72 echo-free, 61, 107
Mitral stenosis, 153-154 in pregnancy, 130
M-mode (motor mode), in oscilloscope displays, 10 teratomas and, 63
Molar pregnancy, 127-130 Ovarian fibromas, differentiation of, 63-64, see also
Morning sickness, 161 Fibroids
Ovarian mass
ultrasonic appearance of, 62-63
N ultrasonic differential diagnosis of, 67-68
Ovarian sarcoma, 64
Nephritis, in pregnancy, 148, see also Kidney Ovarian teratomas, 63
INDEX
179
Ovaries hydropic degeneration of, 130
anatomy of, 43 intestinal obstruction in, 162
cul-de-sac mass in, 66 intraabdominal, 125-126
enlargement of, 60-61 masses in, 130
molar, 127-130
mUltiple, 108
P nephritis in, 148
patient history in, 72-73
Pain, history of, 73 renal disease in, 147-149
Pancreatic disorders, 167-168 sonoanatomy of, 74
Pancreatitis, 167-168 sonofluoroscopy in, 75-79
pseudocyst formation in, 168 sonolaparotomy in, 74-75
Paraaortic adenopathies, 145 sonophysiology of, 80-103
Paraaortic lymphadenopathy, 157 spurious, 108
Paraovarian cyst, 67 vascular disease in, 155-161
Parity, in obstetrics, 72 venous disorders of, 157-161
Pelvic lesions Pregnancy ring, thickening of, 82
inflammatory, 69-70 Primigravida, defined, 72
in sonolaparotomy, 50-52 Pseudocyesis, 108
Pelvic mass Pseudocyst formation, in acute pancreatitis, 168
differential diagnosis of, 106 Puerperal female, defined, 72
as functional renal tissue, 136 Pulse characteristics, damping system and, 18
in sonolaparotomy, 50 Pulse-echo relationship, 8
Pelvic structures, anatomy of, 40-47 Pulse emission, by piezoelectric crystals, 18
Pelvis Pulse length, optimal, 18
free fluid collection in, 70
metastatic lesions to, 70
in obstetrical ultrasonography, 92 R
fetal, 101
Piezoelectric crystals, pulses emitted by, 18 Radiation therapy, in gynecological disorders, 146
Piezoelectric principle, 2 Real-time scanning, 12-15
Placenta Reflecting interface, distance measurement of, 7-8
corporeal, 113 Reflectivity, in ultrasonography, 8- 9
echoes in side, 109 Renal cyst, diagnosis of, 133-135
form of, 112 Renal disorders, in pregnancy, 147-149
gray-scale imaging of, 151 Renal ectopia, 136
normal, 109-113 Renal transplantation, 150-151
in obstetrical ultrasonography, 78-80, 108-llIl Resolution, in ultrasonography, 5-6
posterior, 113 Retrocaval ureter, 149
premature separation of, 118 Retroperitoneal area, ultrasonography of, 143-145
size of, 118 Retroperitoneal hematoma, 145
types of, 113 Retroperitoneal tumors, 143
Placenta previa, 113-117 Reverberation, 7
Polycystic renal disease, 150 Reverberation artifacts, 23
Polyps, uterine, 55, 59-60 Rheumatic heart disease, ultrasound in, 153-155
Pregnancy, see also Obstetrical ultrasonography
amniocentesis in, 119-121
anomalies of, 121-126 s
associated defects in, 126-130
bleeding in, 123-124 Salpingitis, 66
cardiac disease and, 152-155 Scanning, sectional, 28-31, see also Ultrasonic
characteristic jaundice of, 163 scanning
diagnosis of, 80-88 Sensitivity settings, 32
Doppler examination in, 119 Signal processing, 19-21
early, 80-87 Sigmoid colon, redundant, 67
ectopic, 67, 124-125 Solid tumors
gastrointestinal diseases in, 161-162 degenerating, 136
hepatic disorders in, 162-163 in older female patients, 135-136
INDEX
180
Sonic beam, attenuation of, 3-4, see also Ultrasonic Testicles, fetal, 101
beam TOC curve, in ultrasonography, 26
Sonic shadow sign, 36-37 Three-dimensional conceptualization, 27-28
Sonoanatomy Thromboembolic disease, 160
in gynecologic ultrasound, 40-47 Through transmission, in degenerating solid tumor, 52
in pregnancy, 74 Through transmission pattern, detection of, 37-38
Sonofluoroscopy, of pregnant uterus, 75-79 Thyroid adenoma, 173
Sonographic unit Thyroid carcinoma, 173
astigmatism in, 23 Thyroid cysts, 173
contrast enhancement in, 23 Thyroid disorders, 171-173
damping control in, 22 Thyroid gland
delay feature in, 22 normal anatomy of, 172-173
depth control in, 22 volume of, 173
digital readout in, 23 Thyroid tumors, 171-173
erase switch in, 23 Time gain compensation, 22
essential parts of, 16 Tissue, acoustic impedance of, 9
focus in, 23 Tissue echo patterns, 35, 53-55
gain control in, 21-22 Transducer, 16-18
graticule in, 23 beam patterns for, 18
intensity control in, 23 components of, 16-17
magnification in, 23 focus of, 17
main system control in, 21-23 mounting of, 17
power switch in, 21 near and far fields of, 17
recording feature in, 23 optimal crystal size for, 17
reject control in, 21 Transmissivity, in ultrasonography, 8-9
Sonolaparatomy Transverse lie, in obstetrical ultrasonography, 105-
abdominal, 156 106
in deep-seated lesions, 146-147 Tubal inflammation, 66
examination in, 48 Tumors, see also Fibroids
gynecological ultrasound and, 47-52 echoes from, 53-55
location of IUCDs in, 49-50 retroperitoneal, 143
patient preparation in, 25 solid, in female patients, 135-136
pelvic masses in, 50 through transmission in, 51-52
practical aspects of, 25 thyroid,171-173
of pregnant female, 74-75 ultrasonic characterization of, 52-66
Sonophysiology, of pregnancy, 80-103
Sound, velocity of, 3
Sound waves, see also Sonic beam u
attenuation of, 3-4
characteristics of, 2 Ulcerative colitis, 161
medium and, 3 Ultrasonic beam, see also Sonic beam; Sound waves;
reflection of, 4 Ultrasonography
Spleen acoustic impedance and, 4-5
cysts of, 169 transmissivity of, 4
enlarged, 169-170 Ultrasonic echoes, electrical impulse from, 19,23,53-
volume determination for, 170 55
Splenic disorders, ultrasonography of, 168-170 Ultrasonic energy, repetition rate for, 6
Stein-Leventhal syndrome, 60 Ultrasonic identification, 28-31
Supradiaphragmatic fluid, 171 reference points in, 30
Surgical disorders, ultrasonography of, 133-173, see Ultrasonic scanning
also Obstetrical ultrasonography A-mode with B-scan display in, 34-35
angulation in, 31
T anterior projection in, 30-31
attenuation studies and, 32
Technologist, duties of, 25-26 changes in, 33
Teratomas decubitus projection in, 31
cystic, 64 detection of through transmission pattern in, 57-58
ovarian, 63 erect projection in, 31
INDEX
181
LXP plane in, 31 technologist's role in, 25-26
orientation in, 34 three-dimensional conceptualization in, 27-28
sonic shadow sign in, 36-37 of thyroid diseases, 171-173
subcostal and intercostal sections in, 31 transducer positioning in, 27
transducer contact in, 32 transmissivity in, 8-9
tissue echo pattern in, 35 types of scanning in, 27
types of, 27 of urinary tract, 133-137
Ultrasonic waves, see also Sonic beam Ultrasound
beam width of, 3 biophysical effects of, 24-25
echo pattern of, 3 characteristics of, 1-16
nature of, 1 genetic effects of, 25
Ultrasonography, see also Sonographic unit; gynecological, see Gynecological ultrasonography
Sonolaparotomy intensity of, 3
artifacts in, 23-24 resolution in, 5-6
cross-sectional image production in, 10-15 tissue damage from, 24
of diaphragmatic disorders, 170-171 Ultrasound scanner, contact diagnostic, 13, see also
directivity in, 8-9 Ultrasonic scanning
display mades in, 9-10 Urinary tract, ultrasonography of, 133-137
Doppler effect in, 15-16 Uterine masses, 55-60
equipment used in, 16-38 Uterine polyps, 55, 59
of gallbladder and biliary tract disorders, 164-167 Uterus
gray-scale imaging in, 10-12 abdominal palpatation of, 73
of gynecologic ally and obstetrically related surgical anatomy of, 42-43
disorders, 133-173 congenital anomalies of, 68-69
in obstetrics, see Obstetrical ultrasonography degenerative changes in, 56
patience and search in, 26 in ectopic pregnancy, 125
pelvic, 47 enlarged, 55, 127
physician participation in, 26 in pregnancy, 73-79
polycystic renal disease and, 150 sonoanatomy of, 44-45
principles of, 1-38 tumors of, 53-60
pulse-echo relationship in, 8, 19, 23
in radiation therapy for gynecological disorders, 146
real-time scanning in, 12-15 v
reflection interface measurement in, 7-8
reflectivity in, 8 Vagina
in renal transplantations, 150-151 anatomy of, 41-42
repetition rate in, 6 sonoanatomy of, 43-44
resolution in, 5-6 congenital anomalies of, 68
reverberation in, 7 Vascular disease, in pregnancy, 155-161
safety of, 7 Vena cava, imaging of, 159
sectional scanning in, 28-30 Venous disorders, in pregnancy, 157-161
signal processing in, 19-21 Vitamin K injection, 161
INDEX
182

Ultrasound in Gynecology and Obstetrics

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ultrasound in

includes 337 illustrations

Library of Congress Cataloging in Publication Data

Hassani, N., 1938-

All rights reserved.

ISBN-13: 978-1-4612-6256-5 e-ISBN-13: 978-1-4612-6254-1

by Dr. Donald L. King

The past decade has seen the ascent of ultrasonography to a

One of the great virtues of diagnostic ultrasound has been its

The future will bring with it greater understand-

Donald L. King, M.D.

by Dr. Jan J. Smulewicz

In his recent book, Dr. Hassani did a very thorough exploration

Jan J. Smulewicz, M.D.

Ultrasound imaging has reached a stage of sophistication whereby

Unique features of ultrasound equipment allow for pinpoint locali-

I wish to express my deep appreciation to Drs. Hugh Barber, Fred

4 ultrasonography of gynecologically and obstetrically

Diagnoses are missed not because of lack of knowledge on the part of

The field of diagnostic ultrasound has expanded in applica-

The development of ultrasonography is quite different. In

NATURE OF ULTRASONIC WAVES

Sound is a mechanical vibration of particles in a medium

The wavelength of audible sound in air varies from a few

CHAPTER 1: PRINCIPLES OF ULTRASONOGRAPHY

CHAPTER 1: PRINCIPLES OF ULTRASONOGRAPHY

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FIGURE 1.2 tissue and the square of the frequency of sound.

CHAPTER 1: PRINCIPLES OF ULTRASONOGRAPHY

CHAPTER 1: PRINCIPLES OF ULTRASONOGRAPHY

CHAPTER 1: PRlNCIPLES OF ULTRASONOGRAPHY

The face of the transducer may act as a reflecting

By knowing the velocity of sound in the medium

CHAPTER 1: PRINCIPLES OF ULTRASONOGRAPHY

CHAPTER 1: PRINCIPLES OF ULTRASONOGRAPHY

CHAPTER 1: PRINCIPLES OF ULTRASONOGRAPHY

CHAPTER 1: PRINCIPLES OF ULTRASONOGRAPHY

t and position of the lesion and also whether it is

Early gray-scale techniques used photographic

CHAPTER 1: PRINCIPLES OF ULTRASONOGRAPHY

There are several commercially available real-

The linear array scanner, in which the applicator

Most machines are equipped with depth com-

CHAPTER 1: PRINCIPLES OF ULTRASONOGRAPHY

CHAPTER 1: PRINCIPLES OF ULTRASONOGRAPHY

CHAPTER 1: PRINCIPLES OF ULTRASONOGRAPHY

~ The cathode-ray tube resembles a 12-inch

CHAPTER 1: PRINCIPLES OF ULTRASONOGRAPHY

EQUIPMENT AND PRACTICAL ASPECTS

CHAPTER 1: PRINCIPLES OF ULTRASONOGRAPHY

CHAPTER 1: PRINCIPLES OF ULTRASONOGRAPHY

FIGURE 1.13 the cycle repeated. There are different types of

The optimal spatial pulse length is between 1 and

CHAPTER 1: PRINCIPLES OF ULTRASONOGRAPHY

CHAPTER 1: PRINCIPLES OF ULTRASONOGRAPHY

CHAPTER 1: PRINCIPLES OF ULTRASONOGRAPHY

CHAPTER 1: PRINCIPLES OF ULTRASONOGRAPHY