The Role of Ultrasound in Obstetric and Gynaecology

Max Brinsmead PhD FRANZCOG May 2006

Potential uses for ultrasound in obstetrics 1:

Locate the pregnancy exclude ectopic Assess viability assessment of threatened miscarriage Determining gestation & dates

Crown rump length

Diagnosis of twins the importance of zygosity Assessment of other pelvic masses

e.g. fibroids, functional ovarian cysts & neoplasms Nuchal fold measure, anencephaly etc.

Screening for abnormalities first trimester

Assisting CVS and amniocentesis Diagnosis of molar pregnancy

Potential uses for ultrasound in obstetrics 2:

Second trimester dating (+/- 10 days)

Biparietal diameter, head & abdominal circumference, femur length

Screening for abnormalities

e.g. spina bifida, cardiac, renal

Screening for placenta previa Cervical length monitoring

>30 mm before 18w & >25 mm before 28 w = low risk of pre term delivery

Assessment of APH Assessment of fetal growth

Asymmetrical and symmetrical

Evaluation of polyhydramnios and hydrops

Potential uses for ultrasound in obstetrics 3:

Assessment of fetal welfare

Amniotic fluid index or deepest pool Fetal breathing Fetal movements and tone (the Biophysical Profile) In umbilical arteries Fetal middle cerebral artery Uterine arteries

Doppler flow studies

Diagnosis and management of malpresentation

Breech and unstable or transverse lie

e.g. transfusion for hydrops, catheter for urethral stricture

Directing intrauterine interventions

Placental grading (of doubtful value) Assessment of the postpartum uterus

Proven uses for ultrasound in pregnancy:

Dating the gestation

30% of women cannot provide a LMP Another 25% have a LMP that is >2w different from USS dates When dates are known aneuploidy screening is accurate and errors of delivery are avoided, fewer inductions for post dates etc. Twins have a perinatal mortality that is 2-4x singletons Monitoring for discordant growth with Doppler reduces risk ECV reduces the rate of Caesarean section

Identification of multiple pregnancy

Identification of breech in the third trimester

Few RCTs of routine ultrasound have shown any effect on overall perinatal mortality and morbidity

Unproven uses for ultrasound in pregnancy:

Screening for Aneuploidy

Cost effectiveness of universal screening debated Ethical issues and patient choice involved Sensitivity is 13 50% depending on expertise & equipment And only half of these before 20 w gestation False positives occur

Screening for structural malformations

Screening for IUGR in the 3rd trimester

Sensitivity is 80-90% But the positive predictive value of neonatal morbidity is only 2550% The rest have constitutional smallness

Harmful Effects of ultrasound in pregnancy:

It is not ionising radiation However, thermal effects and cavitation can occur in tissues exposed to high power ultrasound One RCT of repeated routine ultrasound with Dopplers in the 3rd trimester found a small but significant decrease in birth weight in the exposed cohort

Potential uses for ultrasound in gynaecology 1:

Assessment of adnexal pelvic masses

Compound B scan Doppler vessel studies

Diagnosis of polycystic ovaries Investigation of postmenopausal bleeding

Imaging and measure of endometrial thickness Fibroids and adenomyosis

Investigation of menorrhagia

Monitoring of follicle number and growth for IVF Egg recovery for IVF and ICSI Evaluation of pelvic pain

A limited role
Too many false positives

Screening for ovarian cancer

Potential uses for ultrasound in gynaecology 2:

IUCD and Implanon location

Treatment of ovarian cysts (aspiration) and ectopic pregnancy (methotrexate) Saline hysterography for delineation of the uterine cavity

Tubal patency studies in infertility

Evaluation of primary amenorrhoea