Chapter 1. GYN POCUS Overview

Women’s Point of Care Ultrasound

Welcome to the Women’s Point-of-Care Ultrasound course on Gynecology Overview.

Even if a practitioner never plans to perform gyn ultrasound routinely, the principles and techniques presented in this course are beneficial to understanding basic pelvic anatomy and scanning technique. Recognizing pelvic anatomy is necessary to properly evaluate pregnancy. The ability to correctly visualize pregnancy begins with the ability to locate and scan the pelvic structures. In addition to the uterus and ovaries, this chapter explains how to identify and describe other pelvic structures like blood vessels, bladder, and vagina.

This chapter introduces the use of transvaginal ultrasound in addition to transabdominal scanning. If the use of transvaginal scanning is not an option for a practitioner’s scope or setting, it is still useful to learn how it is done, and its value to enhancing visualization.

NOTE: The content of this course is copyrighted and may not be reproduced or used without written permission from WPOCUS.

Objectives:

By the completion of this Section the participant will be able to:

List the components of a point-of-care ultrasound performed for gynecologic indications
Describe the advantages and disadvantages of the use of transabdominal versus transvaginal scanning in the gyn ultrasound exam
Demonstrate the appropriate way to hold and insert a transvaginal probe
Learn the variations in uterine position, and describe how best to achieve an adequate image with angling the transvaginal probe for each type of uterine position
Describe shapes of the bladder in sagittal and transverse views
Learn locations of pelvic vessels in relationship to other pelvic structures, and how to use these to locate ovaries

ESSENTIAL PELVIC ANATOMY

When performing ultrasound, it is helpful to mentally visualize the location of pelvic organs and surrounding tissues/organs in the body. Women’s health practitioners already have a good understanding of anatomy, but it is helpful to review the anatomy in preparation for beginning to scan. Part of describing and documenting pelvic structures is the use of correct terminology.

^{Figure 1. Pelvic organs}

^{Figure 2. Pelvic ligaments}

ESSENTIAL POCUS EXAM COMPONENTS

When deciding to perform a gynecologic POCUS exam, standard practice includes certain component requirements.

^{Figure 3. Documentation Requirements}

1. Order for the exam. This can be a simple statement in the record for the need or indication for the exam. For example, “left pelvic pain”.

2. Images with correct measurements and annotations.

—Uterine length, width, depth

—Endometrial depth

—Ovarian measurements

—Dominant follicle measurements

—Identification of other structures (cysts, IUD, etc)

3. Impression or assessment

COMMON INDICATIONS FOR GYN POCUS

The following is a list of the most common indications for a gyn POCUS:

^{FIgure 4. Indications for performing the GYN pocus exam: World Health Organization3}

Identification of Uterus: (size, shape, orientation, endometrium)

Identification of Ovaries (size, shape, loctation, echotexture, presence of follicles)

Identification and measurement of ovarian follicles

Identification of intrauterine device and recognition of uterine placement

Recognition of abnormal findings in the pelvis

Confirmation of intrauterine pregnancy (to rule out ectopic)

*Identification of ectopic pregnancy will be covered in detail in the next course on First Trimester POCUS.^1.

TRANSABDOMINAL UTRASOUND

In preparing to do a pelvic ultrasound, several things should be considered.

First, a transvaginal (TV) transducer MAY NOT be available, and in that case, use of a transabdominal will be necessary. The woman’s condition, her body mass index, and her personal preferences can also determine which of these may be done. If she is obese, a TV scan may be preferred, since it is possible to get closer to the pelvic organs. If she is in severe pain and an ectopic pregnancy is suspected, then a transvaginal is highly recommended to see necessary detail, even though it might elicit more pain by using the TVUS. On the other hand, a transabdominal ultrasound is best to view structures high in the pelvis (such as a large fundal fibroid), since the short viewing distance of the TV transducer may not reach it. In general, the transvaginal scan is preferred for most GYN exams, but performing both can give more information. However, POCUS exams are more likely to use the transabdominal approach since many POCUS providers lack access to TV probes.

Transabdominal vs Transvaginal

^{Figure 5. Comparison of transabdominal versus transvaginal ultrasound}

In preparing to do a pelvic ultrasound, several things should be considered.

First, a transvaginal (TV) transducer MAY NOT be available, and in that case, use of a transabdominal will be necessary. The woman’s condition, her body mass index, and her personal preferences can also determine which of these may be done. If she is obese, a TV scan may be preferred, since it is possible to get closer to the pelvic organs. If she is in severe pain and an ectopic pregnancy is suspected, then a transvaginal is highly recommended to see necessary detail, even though it might elicit more pain by using the TVUS. On the other hand, a transabdominal ultrasound is best to view structures high in the pelvis (such as a large fundal fibroid), since the short viewing distance of the TV transducer may not reach it. In general, the transvaginal scan is preferred for most GYN exams, but performing both can give more information. However, POCUS exams are more likely to use the transabdominal approach since many POCUS providers lack access to TV probes.

If a transabdominal scan is done, the woman should have a full bladder. The full bladder then becomes an acoustic window to enhance view of the other pelvic structures (as described in the Foundations course). There are some exceptions to this guideline; sometimes a full bladder can distort or displace a uterus, making it more difficult to view through the abdomen.

For performing a transvaginal scan, it is important for the woman to have an empty bladder, not only for comfort reasons, but to prevent displacement, distortion or obstruction of the pelvic organs.

Transabdominal

^{Figure 6. Start with sagittal position just above the pubic bone}

^{Figure 7. View of transabdominal transverse position of the probe}

One value of the transabdominal scan is that it is less invasive. For some women, such as virginal or elderly, the TVUS probe is quite uncomfortable, limiting the ability to do a complete assessment. Some women may have cultural restrictions for performing a TV scan. Another advantage for using a transabdominal scan is that we can see higher and deeper into the pelvis (beyond the range of the TVUS probe), permitting us to see structures or abnormalities that we might not see with the TV probe (such as uterine fibroids). This is the reason that sonographers in hospitals and radiology offices will perform both a TAUS and a TVUS scan on women.

The disadvantage of doing a transabdominal scan is that there is less resolution or clarity (because of lower frequency) and therefore it makes it difficult to see details of the uterine lining or ovaries, for example.

BLADDER

Often, the first pelvic structure seen is the bladder. This should be evaluated as part of the POCUS exam. This is easier to see if urine is present. With ultrasound, you can see the following bladder components:

^{Figure 8. Bladder anatomy}

Thick detrusor muscle, which thins as the bladder fills

Thin mucosa lining the inside of the bladder

Ureters are not typically seen unless they are abnormally distended with fluid.

A urine ”jet” can sometimes be seen where ureters empty into the bladder – this is seen as a “flow”-like movement in the upper part of the bladder – usually in a transverse plane. When color flow is applied, it will demonstrate a color flash. As discussed in a previous module, any movement of fluid can elicit a color flash.

Image 1. below demonstrates the bladder using a transabdominal ultrasound probe. This bladder is fairly full, and it allows a clear view of the structures behind it. It happens that the hypoechoic structure behind the lower uterus/cervix is free fluid in the cul-de-sac (annotated as FF).

Bladder Sagittal View

^{Image 1. Bladder in the sagittal view}

Bladder Transverse view

^{Image 2. Bladder in the transverse view}

Image 2. shows how the bladder appears in a transverse transabdominal view. It appears rectangular or box shaped. If a fluid filled structure is visualized and it is hard to discern if it is the bladder, rotate the probe to a transverse view and the “box” shape will help identify it as the bladder.. The hypoechoic “dot” below is the urethra. It is hypoechoic because it has some urine in it.

PERFORMING THE TRANSABDOMINAL PELVIC SCAN^2,4

STEPS

1. Select the appropriate transducer: 3.5 MHz curvilinear transducer is best; use adequate ultrasound gel

2. Select the appropriate preset in the machine

3. Place the probe midline on the woman just above the symphysis pubis in the longitudinal position. Make sure that the probe notch is facing toward the woman’s head.

4. Adjust the gain to achieve an adequate brightness on the screen – the bladder is most anterior and should be dark black or hypoechoic. The myometrium should appear uniformly darker grey, and the endometrium lighter grey.

5. Maneuver the probe (right to left or up and down) to visualize the endometrium and cervical canal as continuous.

6. Enlarge the view of the uterus using Zoom or depth to so the size fills at least half of the view on the display

7. Slide the probe side to side in the sagittal position to view the right and left areas of the pelvis.

8. Return to midline and rotate the probe 90 degrees to view the pelvis in a transverse manner. Be sure that the probe notch is facing toward the woman’s right

9. While in transverse, slide the probe up and down to view the entire uterus and adnexa in the transverse

10. Identify the vaginal stripe, which will direct you to the cervix

11. Identify the cervix and angle the probe upward to see the uterus

12. Measure the uterus in the sagittal view (length, depth, and endometrial thickness

13. Rotate the probe and slide up to near the uterine fundus transversely to obtain a transverse measurement of the uterus.

14. Return to midline and slide the probe sagittaly to the woman’s right until you no longer see the uterus; this region is where you look for the right ovary. Look for the right iliac blood vessels to help you identify the outer boundaries for where the ovary should be located.

15. Measure the ovary’s length (the longest axis) and depth. Then rotate the probe (notch to the woman’s right) to obtain a transverse view of the ovary. Then measure the width of the ovary.

16. Repeat this process (step 14-15) on the woman’s left side to identify and measure the left ovary.

17. Scan the area behind the uterus and cervix (culdesac) and note if there is any fluid (seen as a dark area

18. Be sure to record each view, properly measure, and annotate so that a report can be generated at the end of the scan.

UTERUS

The uterus is typically seen behind the bladder. As shown below, the uterus can have normal variations in angle and flexion. This is very important to note while trying to find and describe the direction and angle of the uterus.

^{Figure 9. Uterine position variations}

The variation shown in Figure 9 ,of angle and position, often determine whether a transabdominal or transvaginal scanning is the best approach. For example, if a uterus is tilted “backward”, either retroverted or retroflexed, it is difficult to visualize both uterus and ovaries with a transabdominal probe. And if scanning with a transvaginal probe, the probe needs to be angled more anteriorly or posteriorly depending on where the uterus is tilted or flexed.

^{Image 3. Anteverted position versus retroverted position of uterus as seen on ultrasound}

^{Figure 10 and images 4 and 5. Diagram of how uterus is “sliced” sagittaly using the TA utlrasound. Photo demonstrated proper technique using a phantom}

When scanning with a transabdominal probe, we are creating a vertical “slice” of the object of interest. Then the computer generates the image based on the information that is returned to the transducer from the beams in that “slice”. Each angle that you scan creates a slice from a different location.

Trans abdominal, transverse view of the uterus

^{Images 6 and 7. Demonstration of holding a TA probe correction to obtain a transverse view of the uterus}

To find a transverse view of the uterus, look for the sagittal view of the uterus, move up toward the fundus, and then rotate the probe 90-degrees, bringing the transverse view at the fundus into view.

VAGINA

^{Image 8. View of vaginal stripe on transabdominal ultrasound}

Once the bladder and uterus are seen, the vaginal stripe can be seen in midposition, typically behind and below the cervix. This is only seen on the transabdominal view. This stripe is a thin echogenic line where the anterior and posterior walls of the vagina meet, creating a bright echo. Once the stripe is located, the cervix is easier to find by angling the probe slightly posterior, then sliding the probe upward (caudally) until the stripe ends at the cervix.

The vaginal stripe is not seen with a TVUS, since the transducer is IN the vagina, instead of viewing it from above through the abdomen.

PELVIC MUSCULATURE

Muscle tissue appears when scanning beyond the pelvic organs laterally in the pelvis. Seeing muscle tissue indicates that the probe is angled out of the pelvis proper, and into the pelvic muscular sidewalls. When the horizontal striated bands (muscle) are seen, this indicates the need to redirect the transducer more centrally.

^{Figure 11 and Image 9. Sonographic appearance of pevlic musculature}

PELVIC VASCULATURE

Ovaries are often difficult to see in some women, but if iliac vasculature is seen, it can assist in identifying the general location of the ovaries. The common iliac arteries and veins on each side are typically lateral to the ovaries on either side. These landmarks allow for the person scanning to be certain which ovary he or she is viewing. If the iliac artery and vein are seen on the left side of the screen, the right ovary should be found proximally to those vessels, between the vessels and the uterus. The reverse is true for looking at the woman’s left side.

^{Figure 12. Pelvic vasculature}

Image 10. shows a LEFT ovary: the iliac vein and artery are lateral to it (the woman’ left), and the uterus is on the opposite side.

^{Image 10. View of left iliac vessels lateral to the left ovary}.

The ovary seen in Image 11. below is the RIGHT ovary, because the vessels are lateral to it the woman’s right side.

^{Image 11. View of right iliac vessels lateral to the right ovary}

Remember that the iliac vessels are almost always lateral to the ovaries

NOTE: This reiterates the importance of correct transducer orientation when scanning, so that left and right are not mistakenly labeled.

When using simple 2-D imaging, a blood vessel may appear anechoic (no echoes since blood is fluid). If unsure whether the structure is a blood vessel, simply turn on color flow doppler and blood vessels will light up with either red or blue, indicating the structure is a blood vessel. As described in the Foundations course, color does not differentiate between artery or vein. The constancy of the color or the pulsatility of the color indicate moving blood inside a vessel. Color simply indicates the direction of the flow in relationship to the probe. (either toward the probe or away from the probe).

^{Image 12. Cross-sectional (transverse) view of right ovary and adjacent iliac vessels.}

The iliac artery is smaller than the iliac vein, and the notable characteristic is pulsing. Pulsing can be seen even in 2D mode with out color flow.

The iliac vein is larger, and although it does not pulse, it is easy to identify by the flow of venous blood through it, detectable by color flow ultrasound.

TRANSVAGINAL ULTRASOUND

The next section reviews the basics of transvaginal ultrasound. Even those learners who will not be using transvaginal scanning at this time should read through this and become familiar with the concepts and terminology to help to understand reports generated from another source, such as an imaging department. If a woman is referred for additional imaging, it is helpful for you to interpret the findings. It also helps you to prepare the woman ahead of time to know why and how the procedure is begin done.

Some facilities are not equipped to provide enough privacy for a woman to have a transvaginal scan. This scan should ideally be performed in a private room adequate privacy curtains.

^{Figure 13. Pros and cons of transvaginal ultrasound}

The transvaginal scan, as already stated, is the preferred method of performing a pelvic scan.

ADVANTAGES of transvaginal scanning include the following:

--Greater resolution or clearer image

--Improved cervical images because the transducer is adjacent to the cervix.

--Greater detail of ovarian cysts/masses due to closer proximity to the ovaries

--Improved view of gestational sacs and embryos at earlier gestation

--Greater detail in the adnexa and improved viewing of possible ectopic

DISADVANTAGES of transvaginal scanning include the following:

--Shallower penetration.

For example, a fibroid deep in the pelvis above the uterine fundus may be missed because it is out of range of the TVUS probe’s field of view.

--Additional cleaning and disinfecting time

Performing this exam can create a greater workflow interruption than with a transabdominal scan. It may also be problematic if you do not have the proper high level disinfecting solutions.

--Discomfort or embarrassment for some women.

Informed consent for transvaginal ultrasound

Because the transvaginal ultrasound is invasive, a woman should be told ahead of time that a TVUS is being recommended. She needs to understand why this method is helpful, and what more can be learned by doing this procedure versus doing a TA scan. She should be allowed to decline the exam if she requests. If she does decline the exam, and this compromises the ability to see clearly, then document that she declined the exam after explaining the potential benefits.

Some facilities require an informed consent form to be reviewed and signed by the patient for documentation. It is always prudent to document that the procedure was discussed with the patient and verbal consent was obtained.

^{Figure 14. Patient permission and education for using transvaginal ultrasound}

PERFORMING THE TRANSVAGINAL PELVIC SCAN^2,5

STEPS

Preparing the probe

Be sure that the probe is adequately covered with a commercially-manufactured TV probe sheath which is non-latex. If none are available, it is appropriate to cover the probe with a condom. Sheaths or condoms must be removed right after using it with the patient and must never be reused. Do not perform the exam without a probe cover.

^{Figure 15. Probe basics}

Inserting the probe

When you insert a vaginal probe, be certain she is adequately draped for her privacy. You should also ask her if she wants to reach down and insert the probe herself. Every effort should be made to make the woman feel covered and assured of privacy.

Removing and cleaning of the transducer is reviewed in the class on Ultrasound Safety in the Foundations course.

TRANSVAGINAL ULTRASOUND TECHNIQUE

The next section of this chapter describes transvaginal ultrasound technique (TVUS). For those practitioners who will not be performing this technique, it is still helpful to understand. This knowledge provides a greater understanding of sonography reports and findings from other providers.

^{Figure 16. Transvaginal probe creates a vertical slice of sound waves}

Just like the TA scan, the transvaginal scan is simply a slice that is vertical to the transducer orientation. However, instead of imaging downward from on top of the abdomen, the pelvic structures are approached from inside the vagina, viewed inwardly. This allows closer proximity to the structure, enhancing imaging detail. Learning orientation of transvaginal scanning is a bit more challenging due to the imaging perspective. This is aided by visualizing in one’s mind how the organs are being approached.

Orientation of the Transvaginal Probe

TV orientation is helped by thinking of the probe as an extension of one’s hand – similar to doing a manual pelvic exam. While holding the ultrasound probe, you your thumb should be pointing up. Figure 17. demonstrates the correct position for viewing organs in a sagittal mode with a TV probe. Then if a transverse view is required, rotate the probe to the patient’s right, which automatically places the scanner’s thumb to the woman’s right. Figure ___illustrates this.

^{Figure 17. How to hold the transvaginal probe (above)}

Figure 18. below shows how it will look while moving the probe inside the vagina. In the sagittal view the thumb is pointed up, and in the transverse view the thumb is pointed to the woman’s right. Please note, ALWAYS WEAR GLOVES WHILE DOING A TV scan.

^{Figure 18. Orienting the probe to the woman’s anatomy}

When using a transvaginal probe, the “notch” is at the top of the probe when held correctly. It should be pointing either toward the anterior surface of the woman, or to the right side of her pelvis to maintain correct orientation. This means that the dot (or insignia) on the top left of the display indicates either the probe is either angling upward (toward the woman’s abdominal surface) or toward her right pelvis.

It is helpful to mentally visualize where the organ would generally be found in the pelvis, and then consider dissecting that image with a vertical slice from the transvaginal probe, (see FIgure 19.).

^{Figure 19. How the sound beam creates a sagittal slice through the ovary}

When inserting the probe, remember that the anterior tip of the probe (what is pointed upward) is what is seen at the colored dot or insignia at the top of the screen image. Insert the probe slightly downward (the same angle as inserting a speculum). Advance the probe slowly and observe the screen image while advancing. This can help visualize vaginal wall or urethral abnormalities. Angling downward usually allows the cervix to come into view first. The cervix then serves as a reference point to look for the uterus and other structures. Although a woman may void prior to the scan, there may still be some urine in the bladder, especially if the woman has had to wait. If the bladder appears to be too full to see other pelvic structures, the woman can be asked to empty her bladder again.

Once the cervix is seen with confidence, the first movements to make with the probe are anterior and posterior (up and down) in the pelvis. Using the introitus as a fulcrum allows the practitioner to view more of the pelvis without causing the woman pain. Movement of the probe is somewhat restricted, since the vaginal walls limit lateral movement. Rotating the transvaginal probe to the left (woman’s right), allows showing pelvic structures in the transverse plane. From that position, the probe can be directed midline anteriorly/posteriorly (up and down) and then laterally (side to side). This gives the view of the entire pelvis in the transverse plane.

^{Figure 20. The introitus as a fulcrum for the transvaginal probe}

Using the introitus as a fulcrum, angle the probe downward on the outside so that it angles upward inside the vagina, to see more anterior structures. To do this, it is important to have the woman’s hips elevated (with pillow/towel roll, or with use of stirrups to enable her hips to slide to the end of the table). This allows greater downward angling of the probe externally to see more anterior pelvic structures.

^{Figure 21. Straightforward angle of the transvaginal probe in the vagina}

Begin by slowly inserting the probe in a slightly downward angle as it enters the vagina while observing the screen to locate the cervix. A common saying is “the vagina will always lead to the cervix”. Sometimes if a probe is entered too deeply initially, the probe will go behind the cervix, making it difficult to see any pelvic structure. If that is the case, pull back on the probe and re-angle to locate the cervix. From there it will be easier to find the uterus.

When inserting the probe straight forward, part of the uterus or cervix will be seen, but not the entire uterus. This requires angling upward and downward (and side to side) to see the entire uterus. The first move is usually to angle the probe upward.

^{Figure 22. Transvaginal transducer angled upward}

If the uterus is anteverted or anteflexed (forward tilting), the mid to upper part of the cervix will be seen in this view. Angling a bit further upward will allow you to see the uterine fundus. Sometimes the probe needs to be angled slightly side to side to see the uterus if the uterus is displaced. Next the probe can be angled downward.

^{Figure 22. Transvaginal transducer angled downward.}

Angling the transducer downward allows viewing the cervix, as well as a retroflexed uterus. Sometimes it is possible to slide the probe more posterior and deeper into the pelvis to bypass the cervix and view the retroflexed uterus more directly. It also allows the ovaries to be seen if they are posterior. Colon peristalsis is typically seen in this view.

If looking for the bladder, angle upward while withdrawing the probe slightly before angling. This can minimize discomfort. Also, the woman’s hips should be elevated to allow upward and downward movement. This can be done by placing pillows or a wedge under her buttocks, or by putting her feet in stirrups.

^{Figure 23. Demonstration of how more anterior views of the pelvis are made easier by moving a woman to the end of the table, or elevating hips so the transducer can move downward}

Just to review, an anteverted/anteflexed uterus will appear to be deflected toward the screen’s LEFT , while a retroverted/retroflexed uterus will appear deflected toward the RIGHT of the screen, and appear to be upside down.

^{Image 13. Comparison of anteverted versus retroverted uterus}

Anteflexed uterus

When entering the vagina with the probe, the cervix should be seen first. Sweeping anteriorly, the uterus should come into view if the uterus is anteverted (tilted toward the bladder) or anteflexed (flexed toward the bladder). The ultrasound image on the left depicts what the image would look like if it were a true copy of what is being viewed. However, on the screen, it will be “turned” so that the probe footprint will be toward the top of the screen. Because of this, an anteverted or anteflexed uterus will have the fundus pointing to the left of the screen.

^{Image 14. and Figure 24. Diagram and ultrasound view of an anteflexed uterus}

Retroflexed uterus

^{Image 15. and Figure 25. Diagram and ultrasound view of a retroflexed uterus}

In the Figure above (25), as the probe is swept anteriorly, the uterus does not come into view. Instead the cervix and the bladder may be the only thing seen. Angling the probe posteriorly, will allow the uterus to be brought into view. This ultrasound image on the left depicts what the image would look like if it were a true copy of what you are viewing. However, on the screen, it will be “turned” so that the probe footprint will be toward the top of the screen. Because of this, retroverted or retroflexed uterus will have the fundus pointing to the right of the screen.

^{Figure 26. Midpositon uterus}

There is yet another position the uterus can assume, and that is called midposition or sometimes called “military” position. It means that the uterus itself is straight, and lies straight along the vertical axis of the woman’s body. This means that the only way to effectively view the uterus is with a full bladder and a transabdominal probe. To try to view it with a transvaginal probe will limit the depth scanning depth from the end of the probe, making it difficult to see the entire uterus.

Left uterus and adnexa

^{Figure 27. Angling the probe to achieve the best LEFT adnexal view.}

In viewing the ovaries with a TVUS, there are a few movements that make it easier. Movements should include viewing the adnexa anteriorly, posteriorly, and transverse, one adnexa at a time. Angling the outer transducer handle to your left swings the end of the transducer to patient’s left

Right uterus and adnexa

^{Figure 28. Angling the probe to achieve the best RIGHT adnexal view.}

To view the right ovary or adnexa, angling the outer transducer handle to your right swings the end of the transducer to patient’s right.

DOCUMENTATION: ⁶

Documentation should include:

--Indication for the exam

--Patient and provider identification

--Date of scan

--Type of probe used

--Saved images

--Report of findings

--Report of impression and follow up

Summary - GYN I Overview

1. Components of a POCUS performed for gynecologic indications are:

-Position and measurement of uterus & ovaries

-Location and measurement of ovarian follicles

-Identification of intrauterine device

-Recognition of abnormal findings in the pelvis

-Identification of intrauterine pregnancy (rule out ectopic)

2. Both Transabdominal and Transvaginal ultrasound techniques can be used for the gyn exam; each has advantages and disadvantages

3. Transvaginal ultrasound is useful in seeing more detail of the pelvic structures and helping with visualization of a retroflexed uterus.

4. Other pelvic organs to identify are the bladder, the pelvic vessels and other pelvic structures.

5. Ovaries are identified lateral to the uterus and medial to the iliac vessels on either side.

ADDITIONAL MATERIAL:

Video on performing a GYN ultrasound. Shwayder, J. AIUM, re-presented online as ACOG Webinar

https://www.acog.org/education-and-events/webinars/basics-of-gynecologic-ultrasound

Skills list for performing the GYN POCUS Ref DDowdy

Verify patent
Describe procedure and indication to patient
Determine whether patient bladder is to be full or empty depending on type of scan
Drape patient to provide comfort and privacy
Machine/Lumify Basics --Connect and turn on Lumify --Enter Patient ID and details --Select appropriate scan type --Identify and demonstrate machine options such as gain, focus, zoom --Identify correct use of presets and caliper placement --Image capture and archiving --Machine/transducer disinfection and storage
Select appropriate transducer and presets/calculation package (monitoring MI and TI settings) for either gyn or ob
Demonstrate correct hold on the probe to obtain correct orientation to the body or structure
Scanning: --Demonstrate how to obtain longitudinal and transverse planes --Demonstrate correct orientation of probe --Demonstrate correct use of image optimization, including depth, gain, and focus

Locate bladder, then cervix
Scan the entire uterus in longitudinal plane, including fundus and cervix
Sweep to each adnexa in the longitudinal plane
Rotate the transducer to sweep through the pelvis in the transverse plane
Determine uterine position (anteflexed, retroflexed)
View entire myometrium in longitudinal and transverse views, note asymmetry, contour irregularities, or texture irregularities
Visualize culdesac and note any fluid

Measure endometrial thickness in the longitudinal plane at its thickest area: anterior to posterior
Verify entire endometrium is uniform in size, and texture is homogenous in appearance

Scan each adnexa in longitudinal plane to identify ovaries, follicles, and abnormal masses
Scan each adnexa in transverse plane to identify ovaries, follicles, and abnormal masses
Locate ovaries by identifying broad ligament and/or iliac vessels
Measure each ovary in at least 2 dimensions (length, depth, and width)
Identify largest follicles; identify abnormal cysts

YOU MAY NOW TAKE THE QUIZ AND MOVE TO THE NEXT CHAPTER. YOU WILL NOT BE ABLE TO OPEN THE NEXT CHAPTER UNTIL YOU COMPLETE AND PASS THE QUIZ WITH 100%. YOU WILL HAVE AS MANY TRIES AS YOU NEED TO GET ALL THE ANSWERS CORRECT!

Women's Point-of-Care Ultrasound: Gynecology

Chapter 1. GYN Overview