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to hundreds of case-based micro learning courses

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across all key Radiology. So Specialties learn

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more at MRI online.com today. We're

0:43

honored to welcome Dr. Alka Singh hall for a lecture

0:46

on transvaginal ultrasound evaluation of non-gravity cervix

0:49

and uterus.

0:50

Dr. Singhal is a radiology postgraduate. She

0:53

has over 28 years of global Radiology experience

0:56

and has worked and trained in Sydney Australia and in the

0:59

US she is currently associate director of radiology at

1:02

madanta hospital Deli India. She has

1:05

authored several chapters on thyroid and parathyroid and

1:08

leading textbooks of indoctrine surgery and is

1:11

the associate editor of the ijri Indian

1:14

Journal of radiology and imaging

1:17

at the end of the lecture, please join Dr. Singhal and otna

1:20

session where she will address any questions you may have on

1:23

today's topic, please use the Q&A feature to submit your

1:26

question at any time during the lecture with that

1:29

being said we are ready to begin today's lecture Dr. Singh

1:32

Hall. Please take it from here.

1:35

Okay, great. So, I'm visible. I'm audible in

1:38

my screen shares with both, too. Thank you.

1:41

Thank you so much for the warm introduction and invite

1:44

MRI online indeed. It

1:47

is really exciting to share my experiences with

1:50

all of you here and I'm really looking forward

1:53

to all your questions and make decision as in direct

1:56

as you would like. It could be thank you very much. So

1:59

I got a call for covering plants

2:02

the mainly the non gravit service

2:05

and the uterus. So let's see and the top

2:08

is that I gave her comprehensive along this stuff.

2:11

It's topics approach and methodology of PBS consultant

2:14

normally is in the

2:17

service the fibroids adenomyces and endometrial evaluation

2:20

cover them all.

2:23

Approach and patient preparation and positioning

2:26

transduced selection and be preparation and normal

2:29

in profound appearances. Now, we've all

2:32

grown up doing at radial ultrasound. Imaging we

2:35

know the basics. Of course, we are going to and do

2:39

the trans abdominal ultrasound before we

2:42

proceed to the plants vaginal ultrasound. We

2:45

want to create such beautiful images on

2:48

transmitter ultrasound, but how do these come

2:51

up?

2:52

It is a lot that's gone between them.

2:55

A patient preparation patient positioning equipment selection appropriate

2:58

transducer sanitization and

3:02

sterilization practices and for all these

3:05

we look forward to the AIU guidelines. That's

3:08

the

3:09

Which illustrates and the indications the

3:12

qualifications responsibility of the transcript of

3:15

personal so the most important factor

3:18

while we are doing the transfer Channel ultrasound is read the

3:21

history to the indications.

3:24

And the patient preparation it also

3:27

apart from the physical preparation. It

3:30

also involves counseling the

3:33

patient and explaining the procedure that what you're going

3:36

to do So the patient's not taking passive prize in

3:39

shock when you actually do the scam. So that is very

3:42

important. So that way you actually get supported the

3:45

patient in doing the scan so this and it

3:48

really makes us can so easy. There are many Maneuvers

3:51

which require your patients cooperation. We need

3:54

to Sliding test and various other Maneuvers so

3:57

that way making the patient comfortable is very important before

4:00

we proceed and of course documentation as

4:03

for the guidelines and Equipment settings,

4:06

avoiding artifacts and image optimization is

4:09

very important following the Elara principle.

4:13

Okay, the transit terminal y it's it's

4:16

a preferred modality in young children. And of

4:19

course people, you know

4:22

females however today we

4:25

are going to focus on mainly transfer Channel, which is

4:28

the investigation that we use for

4:31

most

4:33

females

4:34

now as you all know that the size of

4:37

the uterus goes on increase in the uterus in

4:40

the service ratio in preparator the

4:43

services prominent and bigger but as the

4:46

minaki said in the uterus

4:50

Corpus the body grows and release your

4:53

switches to twist to one for the uterus body

4:56

and serve it smaller again in postmenopausal Period

4:59

the uterus body strings and

5:02

their Vision again goes back. So that's important to remember

5:05

and if you feel any change in

5:08

the pattern or behavior over a period

5:11

of time, that's when you also suspect and diagnose

5:14

and normalities.

5:16

Now how does a typical normal uterus look for look

5:19

like we have to understand the normal before we actually

5:22

begin to diagnose the abnormal as we

5:25

insert the probe. We see a very nice beautifully looking

5:28

Salvage and endometrium lining we will

5:31

discuss that in detail and see what it looks

5:34

like.

5:37

Then what you have to remember your probe orientation the

5:40

right and the left that is a challenge for beginners.

5:43

So have a properly sterilized

5:46

and covered with a sheet and you have your latest sweet

5:49

gloves or whatever. You have taken the history of the patient. You've got

5:52

the patient and hypotany position. If a table has

5:55

got a little trending book kind of a tilt or anything, but

5:58

if you require for any questions like this those situations

6:01

are very helpful or you put a pillow

6:04

under the patients button. So that gives

6:07

a little bit of a tilt and elevation and gives you

6:10

better alignment to scan the uterus.

6:12

and the unitary region

6:14

so with all these practices and the guidelines

6:17

in mind and sterilization when you've got a probe

6:20

ready and appropriate equipment settings you insert the

6:23

flow or do you see you see the service the external

6:26

as these surveys and then the internal loss?

6:30

And then you see that you're trying body the endometrial lining.

6:34

Okay now here I want to stress because

6:37

examination I've been requested the

6:40

stress in the service. Now what happens is most of

6:43

the time we actually beginning to look at the

6:47

Upper part our eyes are looking at the

6:50

front desk first and we actually don't tend to

6:53

find blind spot this area or not.

6:56

Even look at this service area, right?

6:59

However, there is a great wealth of information here and

7:02

a lot of diagnostic abnormalities that

7:05

can be diagnosed and ultrasound. If you really pay attention to

7:08

this area as well when we are doing our TPS.

7:11

So like we learned in Radiology, we have

7:14

to look at an image from corner corner and we

7:17

must include anatomical organ that we

7:20

are Envision in total. That's very very important. So how

7:23

do we image service actually insert

7:26

the pro and you might have to actually pull the probe a

7:29

little bit out again so that we can actually see

7:32

the margin of the service and very

7:35

well see the interior of all the posterior wall and

7:38

see nice in the normal pattern. Now, if

7:41

you see the nice and the normal straight line

7:44

nice opposition of both the

7:47

lips of this nice echogenic and do cervical

7:50

mucosa and nice the seven.

7:54

A southern Zone that's

7:57

kind of reaffirms and research

8:00

that all is well, right. However, this

8:03

pattern is hardly seen most the females that we

8:06

see today have Napoleon says that's the only thing we kind

8:09

of think we can diagnose with this ultrasound in

8:12

this area. However, if we actually

8:15

pay attention, there's a lot more than we can.

8:18

Evaluate of course avoid pressure because it

8:21

will distort the image.

8:23

So that's about the normal appearances and we always have

8:26

to scan in both two orthogonal

8:29

planes at least and go in

8:32

the oblique planes as in when required for

8:35

the relevant pathology.

8:38

okay measurements, of course, we know the

8:41

orthogonal planes and the guidelines

8:44

have been issued by this yoga and various and body

8:48

so we know that we can do

8:51

a straight line measurement or a

8:54

appropriately adjusted measurement as well.

8:57

Now various terminologies have come there

9:00

is a new circumstances. There's free code

9:03

there is Cohen this Palm there is a idea

9:06

there is aita there

9:09

is foreheads. Now, there's a lot going on now for

9:12

a beginner. It gets very challenging to

9:15

figure out as to what to do. However, aim

9:18

of all these various and

9:21

consensus is to standardize and

9:24

merge the different reporting patterns into

9:27

one. So I'm going to try and

9:30

keep to the means of protocol and the terminology so

9:33

that we are all on the same page and of

9:36

course following the figure for classification for the

9:39

fibroid mapping as well.

9:41

The mucopan consensus has got various terminologies

9:44

and lexicon that have been described. These

9:47

should be adopted for reporting practices and

9:50

keeps us like Pirates by

9:53

Reds Pirates all these practices. So it just

9:56

keeps us all in the same page.

9:59

So like I said intermittent thickness, where do we measure we

10:02

measure it the widest part? So that's the widest part

10:05

the intermittent thickness and that we are going to mention not here not

10:08

here not anyway else. That's how we

10:11

will measure that's a transverse pain, which is the pain of

10:14

the widest time either that we is going to measure and document

10:17

as well.

10:19

Now we also have

10:22

to make an observation of the Interior

10:25

part of the uterus and the posterior

10:28

part of the uterus.

10:30

Do not think that this is a power area and ultrasound

10:33

cannot see this if I take a

10:36

class on E deep intimate deep

10:39

pelvic endometriosis, you will know if we

10:42

try and pay attention to this area. There is

10:45

a lot that you can diagnose an ultrasound. It's

10:47

inflammation extension of endometriosis

10:50

into the posterior and into the

10:53

interior pondices both can be diagnosed by

10:56

ultrasound. So always pay attention to the area beyond

10:59

the uterus. Look at the margin the

11:02

line. Is it smooth or is it there is any

11:05

irregularity or anything that can be the earliest

11:08

feature that can give your clue to what could

11:11

be the cause of the non-specific pain that the

11:14

patients changing and ecologists and trying

11:17

to figure out what's bothering. Okay. So do

11:20

evaluate not just let's understand alignments

11:23

the words that we use very commonly incubated

11:26

straight through what you didn't replace so

11:31

the commonly the interface

11:34

uterus and tiruplets futurist.

11:37

So basically you got when

11:40

you've got the normal orientation that is you've got

11:43

the orientation map your thumb interiorly on

11:46

the group and

11:47

So did it's a necklace to the left and the right

11:50

is to the right patient right now the service

11:53

and the uterine body if they added an

11:56

angle to one another and if that angle is obtuse.

11:59

This angle that is an in-key of

12:02

its uterus.

12:03

Between the angle between the lower you're trying and this now

12:06

what's important in this position is the

12:09

funders is close to the urinary bladder here

12:12

and the service here is closer to the

12:15

richesticide region, okay.

12:17

Let's look at another single where we

12:20

have a we have a very true it's

12:23

uterus. So what is happening here? We again

12:26

we have the service closer to

12:29

the bladder and we have the fontest.

12:34

interiorly and the electricid mode is of course

12:37

posteriorly is to the

12:39

service

12:41

So in this case again the angle.

12:44

Between the service and

12:47

the body is a reflex angle more than 180 degrees.

12:50

So this angle is

12:52

over 180 degrees

12:54

coming to the next video when we do

12:57

not have an angle between the service and you're

13:00

trying body. So that's like as if you could put them

13:03

both in a street line. And in this case

13:06

when you can have it any word it when you

13:09

have a straight line and the fundus is

13:13

closer to the urinary bladder and the little

13:16

sigmoid is of course behind.

13:18

Or you could have a retro. Let's do

13:21

you test when you have

13:23

so it's closer to the bladder and the fundus away

13:26

from the bladder.

13:28

Understanding these four scenarios helps you in correcting your

13:31

reporting documentation, which is

13:34

very important another three layers of the myometrium. So

13:37

we know we've seen the vehicle which

13:40

suppose you have an equagenic line in the endometrium. Then

13:43

you have the endometrium. This is an equation and then

13:46

you have the first layer which is the inner thin

13:49

Highway going that just about the endometrium and

13:52

you have the middle layer that is thick and homogenous and

13:55

that's the one and then you have an outer

13:58

layer which is like yes, because Janet in the middle

14:01

lay and arcade versus separate middle

14:04

and out the lights and that's

14:07

where you see the awkward calcifications in the postmenopausal

14:10

Premier commonly normally see

14:13

Another area to observe is the junctional Zone.

14:16

We have very high end ultrasound equipment

14:20

these days and even on 2D you

14:23

can observe but of course 3D is very gives great

14:26

classic with volume contrast or PCI and

14:29

all these modes you can actually see

14:32

the dimensional Zone and it's like a very

14:35

close to MRI the images the quality that you can

14:38

create just with ultrasound. So observe this

14:41

for interruptions or irregularity or any

14:44

other feature because these are very important.

14:47

In diagnosing abnormalities and as

14:50

better user protocol as well. So that's

14:53

what Musa says if the Dig said the

14:56

junctional zone is irregular interrupted and focally

14:59

or diffusely all those findings be document

15:02

and that's the acromatic representation of

15:05

the same feature. Okay. All right.

15:09

So moving on.

15:11

What about the menstrual cycle correlation and understanding

15:14

of the endometri lining

15:17

the menstrual cycle is very important. So let's

15:20

begin from the T1 of menstrual period

15:23

or just immediately one or two days after this. The

15:26

intimate training has just been shared. So

15:29

it's a pain echogenic endometrium, which is about maybe three

15:32

four millimeters or something like that. And

15:35

then as the stimulation goes,

15:38

oh as the cycle progresses towards

15:41

the ovulation the endometri lining pigments

15:44

and it becomes trial Amina and this is

15:47

on the ovulation praise. You will see

15:50

a nice trial and endometrium. You can see Sutton hypo

15:53

hyper egoic areas,

15:56

which are normal findings.

15:58

And of course for if you are doing follicular monitoring or

16:01

any other study, you will be assessing the vascularity as

16:04

well. And even otherwise colors are

16:07

being part of gyne examination and must be used

16:10

in every area of the pelvic scan.

16:13

for every patient

16:16

coming to the late phase the post ovulatory phase

16:19

the endometrium lining becomes homogenously Highbury

16:22

boy and with the

16:25

loss of trial laminar appearance.

16:27

So British knowledge, we finished the

16:30

first part the normal findings and now

16:33

we move on to the part two, which is the Continental anomalies

16:36

that we can diagnose on transfer channels.

16:40

now

16:41

maybe earlier a few years ago. We would have an

16:44

MRI to diagnose these but now with the

16:47

high-end equipment and very freely available

16:50

3D ultrasound modalities. We

16:53

can diagnose all of them with the

16:56

3D ultrasound technique.

16:58

So of course 3D is very helpful in.

17:01

Assessing and labeling them.

17:04

When does the patient come to us? The patients

17:07

come to us with primary infertility or

17:10

yeah of an incidental diagnosis. Of

17:13

course, the common abnormalities that we keep on

17:16

seeing is the bike on weight the commonest and

17:19

then of course 78 and died Elvis and all these abnormalities that

17:22

we see but let's understanding people as

17:25

to what do we mean by them?

17:27

Across a knowledge of embryology origin

17:30

and the way the

17:33

malarian track embryology goes

17:36

is very helpful to understand the

17:39

future normalities and let's look

17:42

at the classification. The class one

17:45

is eight Genesis of hyperplasia where

17:48

this segmental or complete the

17:51

uterus itself is absent. So basically what happens

17:54

we know there's a fusion so we can have a septum partial

17:57

acceptance It's all the side support the

18:00

corner to infuse or you can have a single Corner which

18:03

is not communicating.

18:05

Accordingly can have class 1 which is a Genesis

18:08

or hypoglassia Class 2, which is a unicorn weight

18:11

uterus, but without a rudimentary

18:14

horn and last three the diet else is uterus

18:17

also called the uterusal because of the

18:20

double interest a class for the pipeline materials complete

18:23

a passion the uterus with two horns

18:26

plus I is accepted uterus complete a

18:29

partial and plus it's the archery

18:32

uterus and it is a concave impeller in the

18:35

you try and find us we've been together. Yes. Next last

18:38

one is due to still be strong. You have a t-shaped

18:42

That let's understand them Percy aim

18:45

guidelines. Let's understand the abnormalities.

18:50

So we we are basically doing a 3D sweep

18:53

and we are getting a meat coronal limit and that

18:56

one image is really really helpful in gathering the

18:59

diagnosis. So we are looking the mid coronal

19:02

images of the uterus of teen period to some volumes in

19:05

the eater. So what happens is we get

19:08

a clear depiction of the circles and the

19:11

endometrial Funtime and the lower uterine segments

19:14

and these three areas that you will focus your

19:17

attention on will help you elucidate and

19:21

be various abnormalities.

19:24

Now let's understand. What do we mean by 0 self?

19:27

Understood? What do we mean by endometrial Founders and

19:30

the angles?

19:32

So observe the solution funders, which

19:35

is the Contour of the urine of the

19:38

uterus, right the cirrhosal surface of the

19:41

uterus, right endometrial fundus is this

19:44

is the endometrial fundus. This is the endometrial

19:47

lining at the top and the location of the

19:50

two tube will ostia we observe these two ostia and

19:53

if he's draw a line drawing joining the

19:56

two and if we draw a line

19:59

from the center point

20:01

Connecting to the endometrial funders and

20:04

this distance called a is called

20:07

indentation of the intermittent this

20:10

distance and this is measured

20:13

as a distance from a line connecting the two tube

20:16

will ostea.

20:18

to the mid endometrial fundus

20:21

okay, so observe this area observe the

20:25

cereal Contour observe the endometrial control

20:28

and

20:30

This area will give you diagnosis. And of course

20:33

you will be observed in the cavity for how how far the

20:36

split is going on. Right? So

20:39

let's look at that. So what does a normal

20:42

ultrasound look like? We all know that this is a very

20:45

nice globular shape uterus that we can see. This is

20:48

the normal. This is the cirrusion fundus. This is

20:51

the endometrial fundus. These are the statial part

20:54

of the Fallopian tubes and these other

20:57

These are the two or

21:00

Austria, right?

21:02

Okay, right. Now let's look at that when the

21:05

normal the uterine morphology. What is the endometrial fundus

21:08

looks like it's normally it's straight

21:11

or conveys. It's either straight

21:14

or conveys here. It's marginally convert. It's

21:17

or it's straight. That's normal. What is

21:20

a serial fundus look like in a normal cereal fantas is

21:23

normally convicts with less than

21:26

10 millimeter in damage.

21:28

The fitness normal picture in mind let's look

21:31

at the abnormal situations now in

21:34

the abnormal situations first and almost Vietnam

21:37

and aqued uterus now in

21:40

an art way to dress what happens to the

21:43

fundal indentation the funding the

21:46

endometrial fundal indication, so it

21:49

is concave.

21:51

Visibus this was straight or conveyed

21:54

here. We have the fundal indentation endometrial indentation

21:57

is concave with the central point of the

22:00

indentation. He said use Angle now,

22:03

how do we meet angles if this is the ostead I

22:06

draw upon line here. This is the Osteo and I draw a line

22:09

here that angle appears to me to be more than

22:12

90 degrees.

22:13

So this is an obtuse angle and

22:16

indentation is less than 10 millimeter.

22:19

That means it's not going to deep into the

22:22

Endometrial cavity it is less than 10 millimeters.

22:25

If I draw a line from here to here, that's the

22:28

a line, right?

22:33

Now what about the social funders in this case? The social fundus is

22:36

all right normal, uniformly conflicts or with

22:39

an invitation of less than 10 millimeters right now moving

22:42

on. Let's look at a case.

22:45

So here we've taken as 3D sweep. So that's so sad

22:48

transfers. That's a coronary reconstruction. And

22:51

we see this beautifully we see that

22:54

you ostia we try and make a line like this a

22:57

line like this and we obviously see that the

23:00

angle is more than 90 degrees, right? And then

23:03

we see the a line is less

23:06

than 10 millimeters. That's a typical uterus come

23:09

into the midst of normality the septic.

23:13

Now what happens in a set we are doing the subset did

23:16

uterus right now?

23:17

So what happens in this is the play there's

23:20

a presence of a septum which does not extend entirely up

23:23

to the service and the central point of the septim is

23:26

at a huge angle. So this line that's

23:29

drawing. The two is an acute angles obviously less than

23:32

90 degrees and the indentation this indentation

23:35

this distance that we are trying to measure is more than

23:38

10 millimeters. And of course the social

23:41

pandas is normal our normal uniformly

23:44

convex within a nutrition of this then can we

23:47

just

23:48

I mean your case. So again, we have a

23:51

tick and a sweep and that's a case which is showing that angle

23:54

is an acute angle and this distance

23:57

is more than 10 million.

23:59

Right and the pseudosal surface is all right

24:02

normal.

24:03

Moving on to the next the another case

24:06

of subcepted uterus again. We have a acute angle

24:09

and we have this lesson 10 millimeter

24:12

as a distance here and at the case, okay coming

24:15

to the next substitute uterus. What

24:18

happens here is there's a September completely divides

24:21

the cavity from the one this up to the

24:24

service. So of course the results is,

24:27

okay and normal, so we clearly see that there

24:30

is a

24:31

to separate

24:33

it's extending up to the surface rights update

24:36

uterus coming to the next step icon review.

24:39

This is interesting. You notice now here

24:42

the serosal service at the observe this indentation

24:45

here. So there are two well deformed

24:48

forms, you're trying on and be communicate in

24:51

this survival region and if there

24:54

is a fundal indentation, which is more than 10 millimeters

24:57

and it is dividing the two

25:00

pawns. This is very classic of pi-corn mature

25:03

example here we can faintly appreciate

25:06

is a fundal indentation. So we've labeled

25:09

as a spike on which you press in this case or it

25:12

could be subject as well.

25:15

And of course, how do you suspect on trans abdominal ultrasound

25:18

when you see this is

25:21

incidentally with a pregnancy a gsac here,

25:24

but if you see two ecogenic of endometri lining

25:27

separated by a highway Point myometrium, and

25:30

that's when you begin to suspect and of course, however 3D

25:33

is a routine and that's when you have must always the

25:36

sweet.

25:37

Come into titles. This is too

25:40

well defined Cornwall that the wide apart

25:43

and do not communicate. And of course

25:46

there is a fundal indentation more than 10mm divisions

25:49

to Corner.

25:51

That's a case of futurist title who's

25:54

just going all the way.

25:58

Up unicorn which uterus so basically there's a

26:01

unicorn weight without a rudimentary on that's what

26:04

you see this and make sure fundus so they're too well

26:07

defined design. So the instead

26:10

of two, we just have one corner and that's what

26:13

you see and if the other one is there, it's separate.

26:16

It's not communicating then of

26:19

course Wonderland condition is more than 10mm and separating the

26:24

It's just a case taken a sweep. And that's the

26:27

Unicorn which uterus very classically. You can

26:30

see that another case of a classic unicorn.

26:34

right

26:36

this is a teacherbutrons just

26:40

Right coming to the service like

26:43

we discussed so we are going to be well, we utiline

26:46

Services very important area to begin

26:49

up. So evaluate before observing the upper part before you

26:52

move there you please concentrate on this area.

26:55

What all can you find diagnose and ultrasound chronic

26:58

cell cycles so I can call it so I can

27:01

fibroid low length iuc c a

27:04

service. So I collect job it gestation and DD with

27:07

opportunity progress. There's a lot

27:10

you can see.

27:11

We begin to observe. So we are concentrating on

27:14

this area between the external laws and the internal laws.

27:17

And of course, we're going to look at the area around as

27:20

well and area outside our area

27:23

outside as well.

27:26

So what do we see? So we have to like we

27:29

discussed in the technique we have to use the full pullback technique

27:32

to we view it

27:35

carefully. And of course, we always observe the

27:38

adjacent areas as well. Like we discussed this

27:41

normal appearances take abnormalities can

27:44

be very subtle. So there's a case of a polyp

27:47

so which is very subtle almost isoy. So only

27:50

when we put color on we can demonstrate them

27:53

if there is if it's in the both insist, they

27:56

are often any boy can we can clearly see them and that's

27:59

that's why that's the commonest technology we diagnosed

28:02

but this is not ISO equal normalities. We

28:05

have to be alert in a way to diagnose that

28:08

so that's the same case when you put the color doctor

28:11

on it just give a flow and there was an endometrial polyp

28:14

in that case. So there was a

28:17

cycle polyp in that case. So that's an abnormality that you

28:20

can diagnose. What do we see commonly just a

28:23

case. So of course we see Michael

28:26

Nepot insist but like you say we do not get

28:29

lost in them. You can often see

28:32

other abnormalities which could be masses which

28:35

could be ca which could be fibroid observe those

28:38

with equals and check for vascularity. You

28:41

could be looking at lesions as well. So that is

28:44

very important to concentrate and evaluate any

28:47

abnormal areas.

28:49

Right and always suggest further Imaging if you need to you

28:52

could have a iecd trade that is lying

28:55

here Marina. That's the you could diagnose that

28:58

this also patient had you know my changes right,

29:01

of course chronic service ideas. Like

29:04

you saw the normal appearance. This is an old image.

29:07

So basically you can see hit Regina's appearances and

29:11

heterogeneous calcific areas or maybe

29:14

fluid or thickening of the mucosal surface

29:17

and all these suggests some kind of an inflammatory

29:20

pathology going on you could have

29:24

Heterogeneous irregularity and altered vascularity

29:27

and that's when you begin to suspect

29:30

that. I'll be looking at maybe see your service of course

29:33

pap. Smear is the first test but many times

29:36

the lesions are often so large and so obvious that

29:39

I mean people have not consulted

29:42

and not caught in the routine. Yes, so

29:47

We have to look at those as well.

29:50

So of course with the risk factors

29:53

and clinical symptomatology of CSL

29:56

bits, I'm going to skip the staging. Of

29:59

course we know.

30:00

We'll skip so let's look at the ultrasound appearance

30:03

is what do we see?

30:06

The UBC hypochoic heterogeneous Mass. Involving the

30:09

service we can see increase vascularity and

30:12

we can try and make up the size and document

30:15

any parametric Invasion. If you

30:18

are able to identify extension to vagina. It's just

30:21

an organs or into the bladder or

30:24

the procedure parameterial area.

30:28

so ultrasound is very helpful in evaluating the

30:31

extent and also we can look for eyelet lymph

30:34

nodes and

30:36

response to therapy as well. Okay. Now this

30:39

is the literature reference for

30:42

a

30:44

Hippopot, so let's look at

30:47

the legion. So now here we see the services bulky. We

30:50

have the compiling contour and it's got

30:53

a very heterogeneous. It's a it's a biopsy proven

30:56

case of see so it's we have got a heterogeneous hyperque

30:59

mass and which is quite distort in the

31:02

outline.

31:03

So it's again, we have a heterogeneous isolipoate partly

31:07

appreciated. But if you put colored up

31:10

with it is an abnormal focus of blood flow.

31:13

That's when you suspect abnormality. Of

31:16

course, you would suggest an MRI or further Imaging to

31:19

take it further again.

31:22

You may just miss this tumor area here,

31:25

but if you just see this probably it's extending

31:28

on the other side that just look like probably a lesion

31:31

there. So be observant and use color

31:34

doctor. It's a great tool and of course always you

31:37

when you have an image like this that means you have actually

31:40

scanned the whole service. But if I see the

31:43

image which is cut here then I do not know if the holes

31:46

of it has been scanned or not. You can see lesions

31:49

and again, which you have to I can

31:52

see large Legions look at the irregular margins

31:55

and solid Mass lesion there you

31:58

can see the lesions extending beyond

32:01

our generates and look at

32:04

both. Now. This is a transverse image see their margins

32:07

and parameterial invasion. You can also predict that

32:10

on ultrasound because if you don't see the nice and the round

32:13

Contour as we saw in the normal skin and the beginning

32:16

anything deviating from that normal

32:19

pattern would suggest that you're probably looking at

32:22

Some abnormality, right? So that's

32:25

the thing.

32:27

So moving on of course, you see

32:30

a heterogeneous kind of an area you kind

32:33

of maybe just now look at this as a postmenopausal uterusal

32:36

that you that's the you try in body

32:39

and look at the amount of enlargement of

32:42

the service interior almost kind of invading the urinary platter

32:45

as well. And it's great vascularity another

32:48

heterogeneous Mass station. So looking

32:51

and this is one which is involving proceededly,

32:54

so develop the practice of looking beyond the

32:57

uterus and you can pick up at normality straight

33:00

there.

33:01

Okay, so, of course, I'll Recreation we

33:04

look at the ovaries. Yes, but if you see any

33:07

solid hyper equality area between the valid vessels,

33:10

you may suspect I like lymph nodes and ultrasound

33:13

as well and that can be very helpful.

33:16

Again a case of a large mass region just the schematic

33:19

tracing for appreciation.

33:22

Large mass extending Beyond again. So there

33:25

are many areas way ultrasound can

33:28

be helpful in giving you an extension

33:31

of

33:34

Disease and diagnosis now literature also

33:37

says that he can actually measure a

33:40

lot and document as well. So what all can

33:43

you measure you can measure the maximum tumor Lane,

33:46

but it's maybe diameter medicine depth of invasion and

33:49

the tumor free margin interiorly posteriorly.

33:53

So what do we do? So this is the lesion for example, so

33:56

you can measure the maximum length. We can measure them.

33:59

It's more weight. You can measure the maximum depth

34:02

and you can measure the tumor three margins and

34:05

clearly and the tumor free margins the steer.

34:08

So with these documentation you can do that

34:11

all on ultrasound and of course correlate them

34:14

later with your Mr. As well. Right and these

34:17

can also be done in a transverse plane.

34:20

We can measure the transverse diameter and the margins free

34:23

on both. The sides are right

34:26

in the left margin for you as well.

34:29

These are additional information that you can actually get. What

34:32

else. Can you see in the service? Very commonly.

34:35

Yes, of course, you can see so I

34:38

could pregnancy even though it's for non gravity uterus, but

34:41

be alert it could be scar pregnancy often.

34:44

You see the lscess card there

34:47

and you can see pregnancy trapped in the sky area

34:50

or scar endometriosis in

34:53

that area. So see a g sack in the lower

34:56

you're trying segment, of course an empty uterus and balloons Michael

34:59

Canal or an hour plus so it's and

35:02

close internal loss. And of course

35:05

which may give you flow on color Doppler. That's when you suspect

35:08

this you could be looking at so I

35:12

collect topic and that's another case of I

35:15

get a topic and you

35:18

To the platforms you can have hit true topic where

35:21

you can have we can have co-existent.

35:25

Intra you try and a cervical topic.

35:30

Another case of a cervical ectopic pregnancy. So of

35:33

course you could have heterogeneous equals

35:36

the blood clots due to abortion

35:39

in progress and it's just have

35:42

plots and no and just like in sign will help

35:45

you in making a diagnosis. This is just heterogeneous

35:48

contains up abortion in progress

35:51

internal losses often open external cost may

35:54

be open or closed and the blood

35:56

Perhaps would be coming out. It's very

35:59

important to make an accurate diagnosis.

36:02

So that's the differentiation process coming to the

36:05

next topic that we are going to do is a fibroid

36:08

mapping.

36:10

so

36:12

it's fibroids are so common. Right and

36:15

we have to about their

36:19

present in about 50 to 70% because of

36:22

normal symptoms and they can cause

36:25

obstetric complications. They can cause postmenopause reading

36:28

and infertility really medically.

36:31

Now, let's look at them from a clinical perspective. So

36:34

they may be asymptomatic and maturity 50% and

36:37

of course from the

36:40

treatment point of view because we have medical minimal.

36:43

It says techniques and surgical treatment. So what information

36:46

is required by the previous position, which

36:49

will help them make a decision as to how to manage that

36:52

fibroid with that point of view look

36:55

at our community. So location of

36:58

the fibroid whether it's intramurals or

37:01

mucosal or outside.

37:03

the number the size the morphology is

37:06

impact the decision making process

37:09

in the management and of course clinically the severity

37:12

of symptoms the age and the choice of future fertility is

37:15

also considered

37:18

how to evaluate of course always always

37:21

the first trans abdominal scan must

37:24

be done then only you see with the TVs because

37:27

why because you can have larger regions Which

37:30

Way Beyond you can have fibroids reaching up to the umbrellas

37:33

and Way Beyond potentially fibroids and

37:36

other abnormalities that you will not be able to diagnose if

37:39

you just straight away just to a TVs and send the patient away.

37:43

Okay, and also always scan the kidneys when

37:46

you do with the survey scan, you can take a minute to look

37:49

at both the kidneys hydronephrosis or hydrogurator or

37:52

any other abnormality. You can diagnose right? Of course,

37:55

you'll use all the tools the 3D partopular and

37:58

line.

37:59

Infusion, which is probably not done

38:02

at our Institute these days and

38:05

Mr. Is a tool and

38:08

challenging cases.

38:10

So looking at all these features that we need to so

38:13

again, we're going back to the music consensus. So

38:17

to have a uniform reporting protocol. Typically,

38:20

how does a thyroid look like? Of course?

38:23

It's a solid oxygenic Mass arising from the uterine

38:26

endometrium. It's got a well-defined contour acetops

38:29

you and it's got a world appearance at his

38:32

classic and that doesn't differentiating and you

38:35

know Myoma and of

38:38

course, it causes significant annuation of them Pakistan being

38:41

and the shadowing pattern is Phoenician blind contrast

38:44

to anything, you know, my mom which is a fan

38:47

shape they're doing we will discuss this. And of

38:50

course it is got a mind to moderate past Clarity

38:53

on current Doppler which is usually peripheral or skirting

38:56

pattern in contrast to adenoma meter

38:59

which has inputational respiratory

39:02

as well.

39:04

okay, so they will Define solid happy

39:07

correct lesion and colored officials very that

39:10

we discussed and also assessment of

39:13

the color of the health in the treating physician

39:16

and planning the route for embolization if

39:19

Interventional Radiology is planned for

39:23

Now how could the fibroids be looking on ultrasound? They

39:26

could be uniform or non-uniform and in

39:29

uniformly Highway boy or non-uniformly

39:33

with mixed

39:36

teacher Jenny or ecochenic ideas or cystic

39:39

areas with it. Now, let's look at that. Of course.

39:42

They vascular pattern could be married as well you could have

39:45

and generally they are with a peripheral vessel.

39:49

Skirting pattern only now traditionally

39:52

we learned three words for

39:55

Five Points intramural sub-zerosol or

39:58

submucose, right? So where intramural significant

40:01

portion is in the mural area significant portion

40:04

is sub-zeroes that are significant ocean is some however,

40:07

the moment nature is now

40:10

being adopted is the Figo classification. So sofiko

40:13

1 2 3. These are

40:16

the most symptomatic fibroids one is intracary two

40:19

is a submucosal with

40:22

more than 50% of Ozil company 3 is

40:25

sub people with less than 50% of me

40:28

personally and four is purely intraven not impacting

40:31

the endometrium not working from Mr. Rosa

40:34

five is a Sub-Zero so fibroids it's

40:37

a bit unclean and seven is for us, right. So

40:40

remembering these let's look at how to

40:43

diagnose fibroids cause spectaculated fibroid.

40:46

You can show the best Solarity and

40:49

if

40:49

Want you may assume that they may be.

40:51

Brought like I'm at five let's look at this. So we have

40:54

an ecogenic endometri lining all around and we

40:57

have a high pay equation. So this probably is

41:00

a hyper egoic intraicavatory fibroid just

41:03

surrounded by the intermittent lining. So it's a

41:06

figure one five point. Okay, that's the

41:09

3D of another case of ego one

41:12

fibroids. It's nicely well really needed

41:15

endometrial lining all around and we

41:18

see the fibroid inside. That's a big

41:21

two or one fibroid

41:24

again there again, we go

41:27

in intracavitry almost into cavity

41:30

fibroid or something because fibroid

41:33

And then we have this fibroid. This fibroid is

41:36

probably a figure.

41:39

If you go three, it's just got a intramural with

41:42

the suddenly proposal but less than 50% endometrial

41:45

component because it's kind of

41:48

easy. It's not your whole and then you have

41:51

internal fibroids which are

41:55

Intermittal fibroids, so which are

41:58

here which are which are impact

42:01

in the intimate lining. So with with

42:04

more than 50% impacting so of

42:07

course, these are FICO type two three fibroids here.

42:11

Okay. So this is clearly a sub zerosal

42:14

fibroid that goes to figure

42:16

Five fibroid well defined

42:19

seated ball and again looking at the

42:22

3D. So again, we have these the fibroids there

42:26

which are impacting the endometrium fibroid, which

42:29

is probably not impact in endometrium. That's

42:32

a lower you try and segment you've got a iecd there

42:35

and that's the nscs card and it's also had some time

42:38

points. So that's another

42:41

in the lower uterine body. There is a cervica region.

42:44

There is a hypoid fibroid. We

42:47

could probably demonstrate a little bit of vascularity. So

42:50

then in that case it's a bit angulated fibroid.

42:54

Okay.

42:56

And it kind of had like a capsule as

42:59

well around it feel that.

43:01

It's what its own capsule kind as well. Okay?

43:04

All right, so

43:07

coming to the next so

43:10

you have the venetian blind shadowing pattern for

43:13

a fibroid. We observe that and how do

43:16

we differentiate these from?

43:20

Endometrial polyps of course are

43:23

hyperic high will show vascularity and typical

43:26

is the polar feeding

43:29

vessel a single vessel sign when you see

43:32

that it's quite suggestible.

43:34

Call it, right so sub mucus

43:37

fibroid is generally hypoicoic and

43:40

it's got a rim pass Clarity polyps generally hyperidicoic and

43:43

as you'll see the single vessel sign.

43:46

So hypericoid and you see the single vessel sign.

43:50

Another sign to observe which is called an equal

43:53

sign which is seen a submuclear Myoma.

43:56

So what happens it is it is growing

43:59

out of the myometrium into the endometrium that

44:02

actually lifts the endometrial lining so

44:05

the endometrial lining up one side and the other

44:08

side in a proximation as people any

44:11

two equationic lines, they make up the equal side that scene

44:14

submucous fibroids.

44:18

So you do aneurysms you can see in commonly imposed

44:21

to mtps or poster

44:24

portions. You see an ill-defined hypochoic

44:27

area. You could think it's a fibroid but you put the

44:30

color. It's a bedroom vascularity. It's an AVM

44:33

there.

44:34

Okay now.

44:37

Epic now what changes can fibroids undergo fibroid

44:40

skin intercoursistic changes calcifications or

44:43

five fatty change

44:46

and let's look at that. So you have a fibroid with

44:49

a sister change, which is called Central cystic area.

44:52

All you could have an hyper equify right?

44:55

That is a like. Oh Leo Myoma, which

44:58

is a well defined hyperequisition that

45:01

you're able to see here.

45:03

Okay, and of course, it's kind of

45:06

an intramural lesion. It's probably some impacting

45:10

the intermetry lining. So

45:13

it's a Figo three kind of fibroid. And

45:16

of course when you see abundant vascularity, very

45:19

heterogeneous vascularity in a fibroid, maybe thinking

45:22

of lines are Leo myosarcoma, and

45:25

that's when you have to really look at that as well

45:28

and such as send the patient for an

45:31

MRI specially when it's large mass and heterogeneous vascularity.

45:34

That's a terribleated differentiation

45:37

between the

45:40

two common entities where

45:43

we often have to use all our various

45:46

parameters to give it diagnosis. And without

45:49

moving to that detail. I'll move

45:52

on to the next topic. That's Idina miles's so of

45:55

course like we discussed it's got the internal and

45:58

vascularity as well.

46:00

No, that's the case adenomyosis. We've

46:03

got some vascularity internally and heterogeneous appearance.

46:06

And of course we have to that's a

46:09

DD of fibroid with an rpoc of

46:12

course rpoc is heterogeneous with many clots.

46:15

And so it's actually a straightforward diagnosis.

46:18

It's not much dilemma DDR POC

46:21

with a polyp policies. Well defined hypery kind

46:24

of Fuller feeding vessels single vessel and

46:27

rpoc will have some kind of a heterogeneous class

46:30

Clarity pattern. That's again, you'll see

46:33

on the 3D.

46:35

So again rpoc with an AVM

46:38

formation also, you can come across if you

46:41

when you put your color Doppler on you see abundant vascularity in

46:44

the rpoc and that's AV information

46:47

that you must remember that I

46:50

just put a spotter for the fibroid that we've already discussed.

46:53

So I will move on to the next

46:56

what how do we treat fibroids? Of

46:59

course, the first place becomes like

47:02

If you go type 1 0 1 2

47:05

and 3 usually hysteroscopic resection and three four,

47:08

five six treatment depends upon the

47:11

clinical scenario right coming to

47:14

the next video meiosis. Of course,

47:17

we have to recognize it because it

47:20

is often a misdiagnosis

47:23

and the

47:26

patients got married ultrasound

47:29

reports and it's got very symptomatology.

47:33

It can be focal. It can be diffused and

47:36

it can be simple feature or tea and it could

47:39

spread to ovaries. It could stretch to

47:42

the pelvis and anywhere Beyond so right now what is

47:46

it? Basically it's ectopic endometrial tissue, which

47:49

is beyond the

47:51

And endometrium and so it's

47:54

imaginated but at least 2.5 remember

47:57

the basilarity.

48:00

So you have clinical symptomatology of pain

48:03

abnormal bleeding and you to of course.

48:07

TBS is

48:09

an immortality which has great diagnostic

48:12

yield for retinomyosis provided. It's

48:15

done properly. It can evaluate both in the

48:18

uterus in the ovaries. And in the

48:21

pelvis we can do it. There are different modes and techniques available.

48:24

So basically what are the features the features

48:27

are abnormal enactment probability any

48:30

quick spaces in my mission, asymmetric and

48:33

helium procedure. You try and working what's up into

48:36

material ecogenic striations heterogeneous, equitage

48:39

cure endometri water

48:42

thickening of the transitions.

48:44

So you have direct features and indirect features

48:47

a direct features are persists the

48:50

hypericogenic islands and the ecogen is

48:53

sub endometrial lines in the past and the indirect features

48:56

of asymmetrical thickening the globular uterus and The

48:59

Irregular Junction at all observing these C. We

49:02

have ill defined Elemental Linings says

49:05

and equagenic lines globular shape,

49:08

uterus and asymmetric and keynote.

49:11

And this is like a typical denomyosis. We

49:14

can't even appreciate when this

49:17

endometrial lining.

49:19

So these Indians indistinct creatures

49:22

again, that's another case. We can

49:25

clearly see the cystic space is any quite spaces

49:28

and the typical fan shaped shadowing

49:31

that is the in the

49:35

that we see is the CIS and typical appearance of

49:38

the adenomaesis.

49:40

So all the features are well Illustrated

49:43

in this clip here. Thank you.

49:47

So moving on the vascularity pattern you

49:50

can see vascularity intraditional vascularity

49:53

in the adenoviruses.

49:56

So differentiating features, we've already

49:59

covered. It's Destiny's metric neutrals.

50:03

Now another differential, of course.

50:06

We have in cystic endometrial hyperplasia

50:09

the sister located in the endometrium itself,

50:13

but in case of adenomyosis, they are

50:16

outside the endometrium. They are located in the biometric. So

50:19

we have to remember that as a differential to diagnose that

50:22

abnormality.

50:24

Role of elastography, of course because Neo pymas

50:27

are a little firmer and adenomy has

50:30

spokenamis is a softer lesion. So that's

50:33

another tool that we can talk to support in

50:36

our Imaging right? Of course Associated

50:39

findings in pelvis and ovaries always

50:42

look for that's a total new topic that

50:45

we are not going to touch now, you can

50:48

have various editions and hydros helpings

50:51

and of course you can have various other abnormalities

50:54

to support your diagnosis. It's a patient with

50:57

adenomyosis and iucine inserted

51:00

already there.

51:02

Okay, so

51:05

coming to the next of course, you can see additions which

51:08

can be demonstrated. Well on a 3D ultrasound that

51:11

you can diagnose.

51:14

Coming to the next the endometrium abnormalities. So

51:17

one correlation with menstrual cycle

51:20

is a great big topic and you follicular monitoring

51:23

and the common abnormalities. We will look at so

51:26

again, there is ayata guidelines

51:29

that describe how we need to scan the

51:32

interim and how we need to report their normalities. So

51:35

using their lexicon we go ahead with

51:38

that. How do they say you have to actually have a

51:41

like we have guidelines for NT we have guidelines with

51:44

this we have to have our transducer perpendicular when

51:47

you're trying to measure into thickness and we

51:50

measure the widest part and of course it is

51:53

and throw it in between their separated by fluid. Then

51:56

we minus the fluid and

51:59

take the composite endometrial.

52:01

And we measure both separately. Right? And

52:04

if you can't appreciate you can just say endometri

52:07

lining cannot be appreciated. That is also an

52:10

acceptable answer.

52:12

Right. So we have different kind of layerings of

52:15

endometrial lining and of course the communistic normality

52:18

that we diagnose is an individual quality. We

52:21

can suspect on Transit terminal to sound and then

52:24

of course we can soon images to see them we

52:27

can do translate China to sound and that needs it

52:30

very clear. We can document the pascularity 3D gives

52:33

great images for counseling the patient the

52:36

gynecologist can also tell the patient counsel and

52:39

take the patient up for treatment and

52:42

it's very nice we demonstrated so

52:45

no, it's just not so much required these

52:48

days because we can actually give great images just by

52:52

3D ultrasound itself plastic polyps that

52:55

you can document on 3D ultrasound

53:00

Focal and diffuse intermittent hyperplasia. We need

53:03

to be alert, and we need to be able to

53:06

Think when do we raise an alarm to look

53:09

for endometrial carcinoma? We are

53:12

looking at Absolute measurements volumes can be done theoretically

53:15

but we still look at the thickness. So

53:18

we have cystic endometrial hypoglass. Yeah,

53:21

maybe see cystic changes in endometrium and thicken endometrium,

53:24

but when we see a

53:27

lot of rascularity and Invasion into the Miami trim,

53:30

we really suspects Sinister stupid pathology.

53:33

We could see a large mass which is almost

53:36

infiltrating here. We have a huge mass

53:39

that is invading almost all the cirrusa

53:42

we can have olive oil Mass with fluid observe

53:45

the pascularity pattern whether it's

53:48

a single or multifocal or a new vascularization pattern.

53:51

We have great HD power tools and

53:54

we can understand the vascularity even

53:57

Genesis pattern and that can help

54:00

us predict whether we are looking for a million reason or

54:03

penaltation and of course

54:06

Can measure the tumor size and the tumor

54:09

free margins up to the silosa as

54:12

well and document that final of course would

54:15

be an MRI can see multiple polypoided lesions

54:18

really look in Sinister Maybe.

54:21

And you can see large mass. This one was the case

54:24

of a sarcoma. So I think almost to

54:27

the end of the session. I covered

54:30

up all the six topics. Of course, there's

54:33

another big topic of the ovaries of Fallopian tubes and

54:36

this the Deep pelvic endometriosis and

54:39

extension and there's a lot of lot of

54:42

Top is to be covered in transvaginal ultrasound

54:45

of uterus and service. However TVs is

54:48

an indispensable examination a methodical

54:51

and a systematic approach with the patient

54:54

comfort in mind and understanding patients clinical

54:57

history and scenario is very important to make

55:00

a good accurate diagnosis. Thank you very much for

55:03

your listening, and I'm happy to take the

55:06

questions. If any thank you so much you inspired me today.

55:09

Thank you.

55:12

So if you want to access that Q&A portion you do have a few questions.

55:17

So the first question is in what situations does

55:20

3D ultrasound not serve as an alternative to MRI.

55:24

There are areas. Of course.

55:28

There are areas where you have

55:31

a lot of adhesions and you have a lot of pelvic endometriosis

55:34

that you're suspecting. I

55:37

mean this question is huge this question.

55:40

There are lots of applications where 3D ultrasound will not

55:43

be able to sell because 3D ultrasound would be limited uterus right

55:46

that area only if that's what they can try to

55:49

anomalies then of course if you want to see the vascularity and

55:52

it's like it's stink and the

55:55

I measurements. Then of course, you do need an MRI and if

55:58

it's for a denomiasis, of course extension Beyond

56:01

if it's a smelly density and extension Beyond cause we

56:04

need an MRI.

56:06

Thank you. So then it's this question is

56:09

good afternoon. Thanks for the beautiful lecture. I don't understand your

56:12

explanation on the angles that help Define in our great

56:15

uterus in the outbreak uterus. So

56:18

it's an obtuse angle between the two Austria

56:21

if these are the two Austria if I'm just joining line

56:24

up to the

56:27

endometrial tip.

56:30

So this angle is a obtuse angle.

56:33

So it's like because it's not going that deep. So

56:36

this line is short less than 10 millimeters. That's what's

56:39

an arcade uterus without going to the slide. I hope I try

56:42

to keep these are the two corners and

56:45

this is the tip of the endometrial surface and

56:48

that's the line that you're trying to measure the draw. Okay, so

56:51

I hope that's clear and

56:56

so, thank you and

56:59

That's done as a physician to you operate the ultrasonic

57:02

equipment personally, or do you employ sonographer physician assistant

57:05

as well? So that's at in

57:08

country India in the hospital.

57:11

So we as Radiologists we ourselves are

57:14

analytic equipment and we are doing that.

57:18

Okay, thank you. How do we diagnose service

57:21

scientists? It's serviceitis a person in itself.

57:24

The word is a clinical diagnosis. But however, like I

57:27

did have the peaches and the slides for the cases we can

57:30

have we in a normal

57:33

you will have well opposed smooth lining of the

57:36

mucosa, right, but if you see any fuzzy masking so

57:39

they may cause any cystic a spaces

57:42

or hypery areas or any abnormal vascular chair

57:45

over there any bulging of

57:48

the Contour or any enlargement or

57:51

asymmetry of lips of the service or Contour abnormality

57:54

of a Zee margins all those

57:57

and multiple nebulances some may

58:00

have equals. Those are the situations when you think you're probably

58:03

looking at service ideas.

58:06

Okay, thank you. So next. Can you

58:09

create cervical CA using ultrasound? Yeah, so based

58:12

on those guidelines. We are not going to create it

58:15

but we are going to say that it's the possibility of extension

58:18

Beyond you can give your scoring. But

58:21

of course you will need to go for

58:24

a further Imaging if you think the disease is

58:27

beyond the bonuses standing

58:30

into the furnaces in the parametrician, but yes, you

58:33

can you can give it you can give an estimate whether

58:36

it's confined to this or extending into

58:39

the

58:40

Uterus or extending into the

58:43

vagina or going Beyond into the bladder or the

58:46

uterus? Yes, you can but if there is any like a

58:49

micro Invasion or a which is

58:52

not obvious and ultrasound. Those are the areas

58:55

where further Imaging will give more clinical assessment

58:58

of more accurate,

59:01

but you can so that's what

59:04

train ourselves to look at this area.

59:07

We just straight away run to the funders the fibroids of

59:10

the polyps or anything. But before we actually going if you're

59:13

actually focusing that area, there's a lot of information that

59:16

we can get.

59:18

Okay, so we can create then

59:21

let's just can be diagnosed and title and always on

59:24

2D. Yes. Of course, you can suspect them

59:27

but diagnosis you will need a 3D

59:30

like for example, it's I'm doing a transverse sweep

59:33

and I see two echogenic endometrial lining. So

59:36

they're just coming in the funders and then I can try and get

59:39

an ideas and taking a transfer sweep as it there

59:42

to intermittent Linings that are there separated. Okay, so

59:45

I see bottom and the service I

59:48

see funny area and then I just go up and

59:51

I see two separate individual line. So that's what I'm beginning

59:54

to suspect. Of course. I will need for their Imaging and even

59:57

in longitudinous people. Okay and taking a

60:00

sweep. I saw the intermittently then

60:03

it disappeared and some high very quick area and then I

60:06

can't see any endometrium. So that means there's something

60:09

that is probably splitting the two the best when

60:12

we suspected and of course for that you do

60:15

need a 3D or MRI to diagnose but yes.

60:18

Can suspect it. But actually what

60:21

kind of an abnormality is you will need.

60:25

A further Imaging right?

60:27

So we are

60:30

here we've done KitchenAid longlist. And it's

60:33

this do you systematically perform a TVs use?

60:36

Of course? That's that's very important.

60:39

Thank you.

60:41

the elaborate and the hormonal replacement changes

60:46

On changes or charges could you elaborate

60:49

on the home and replacement changes? I mean we

60:52

are not doing the treatment part so I do not know what that

60:55

so

60:56

Are the changes I do mean the changes that

60:59

you see in Ultrasound with hrp. Is that

61:02

for the endometrium the cystic endometri the democrine

61:06

or a

61:09

I mean if that's what the endometrium the Democracy pantheistic endometrial

61:12

changes. Yeah, we do measure and

61:15

we monitor these patients periodically for the

61:18

thinking the endometrial thickness and appearance of

61:22

the cystic changes and suggest for

61:25

that Imaging and management appropriately as and

61:28

when required, okay, thanks. So

61:31

the needs to we have to use copious Daily

61:34

4 so I can see

61:36

I mean, we not for

61:39

cycle CA like you just have to insert the proof. So

61:42

you will need a comfortable reason monetary within

61:45

the probe and outside for every

61:48

examination.

61:50

So because the probe is actually just going up

61:53

to the vagina. So it's not got anything to

61:56

do with the vehicle CA and

61:59

having more children. I haven't I haven't changed my Pro

62:02

preparation based on what pathology I'm

62:05

expecting to look at. It's the standard and it's to be

62:08

it's to be prepared such that I don't

62:11

have any air bubble in it and it's prepared well, and

62:14

it's so of course, I have an assistant to

62:17

do all the do the patient preparation and problem

62:20

supporting the provincial and all this

62:23

stuff. So and of course there is no air bubble.

62:27

Yeah, so the comfort of the patient and reference

62:30

of the patient, that's the most important

62:33

part.

62:34

Thank you. So when you suspect unicorn weight and

62:37

routine scans again, like if you see the corner that's a

62:40

little bit pointed like on one side.

62:44

It's hard to suspect on routine scan. So it's

62:47

actually been an incidental diagnosis or on 3D

62:51

imaging but icon weeks

62:54

have suspected on today. But unique on it. I personally

62:57

don't remember but maybe if you see any centrically deviated

63:00

individual and you could probably suspected but

63:03

what happens is the whole thing is eccentrically created. So

63:06

right so I guess it's a I

63:09

haven't diagnosed it on

63:12

a two day to be honest.

63:14

So next. Hmm.

63:16

Could you elaborate on cervical incompetency? Okay,

63:19

that's a part of a gratitude resource. So

63:22

we have not covered it in this because I was

63:25

asked to do non gravity uterus. But yeah,

63:28

that's a huge big Topic in itself

63:31

and I could too full lecture

63:34

on that course.

63:36

Thank you. And can we go to TV a

63:39

in an area where we Channel examination often

63:42

refused because of culture?

63:47

Oh, you mean you do a transfer channel to sound

63:50

because you can do in its amination clinical examination, I

63:53

mean, it's like the same thing you're going to insert the probe or

63:56

the thing, I mean that's again a cultural answer

63:59

so patient reference. So any examination begins

64:02

with a patient consent, that's the first thing you

64:05

have to take and informed consent. So as

64:08

per the guidelines your law of land or whatever is

64:11

second International guidelines, so you can't proceed without

64:14

a consent. Okay. Thank you very much

64:17

for all your interaction for your lovely questions and enjoyed

64:20

interacting with all of you. Thank you Matt.

64:23

I online for wonderful opportunity. Thank you so much.

64:26

Thank you so much for that. Great talk. I learned a

64:29

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64:32

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