Be it Infertility or obstetrics, USG in the basic tool for every Gynaecologist and obstetrician in the outdoor department. It is a noninvasive test used in practically all visits of the patient and gives important clues to the diagnosis of various problems. Early pregnancy diagnosis, number of fetuses, growth and fetal well being, fibroids, ovarian masses, pelvic inflammation, adenomyosis and endometriosis, all sort of basic evaluation can be derived from the first OPD Sonography.
Ultrasound provides highest resolution image and helps to diagnose
There is not too much preparation involved for a sonogram. It is dependent on the area to be examined. For instance, those who are having an abdominal sonogram may be asked not to eat or drink anything for 12 Perior so their doctor can better examine the abdomen. A pregnant woman is usually asked to drink lots of water before her sonogram, as it helps the doctor to see the fetus a little better. Loose, comfortable clothing should be worn in order to make the procedure run a little smoother. Other than that, read all the instructions provided by your doctor.
The USG protocol that is followed in pregnancy includes one 11-13+6 weeks scan as a screening scan which includes an assessment of Nuchal translucency (or NT). NT assessment is a very valuable parameter in early pregnancy and gives the sonologist an opportunity to identify a fetus at risk for trisomy 21, or other chromosomal disorders, and a wide range of genetic syndromes. The 11-13+6 weeks scan also establishes viability, accurate dating of pregnancy and detection of multiple pregnancies.
This is followed by 18-21 weeks 3D-4D anomaly scan for all antenatal mothers. These two scans together can pick up 80-90% of major and minor anomalies in the fetus. In the 18-21 weeks anomaly scan, we visualize all the fetal organs, placenta and liquor in details and also see live 3D-4D images of the unborn child. Pregnancy and organ development of baby is a continuous ongoing process of 9 months and just a single scan is not enough to stamp normalcy of fetal organs.
Hence we follow up in all patients with the growth scan and color doppler at around 28 weeks. Color doppler of umbilical artery, middle cerebral artery, fetal aorta, ductus venosus and maternal uterine arteries with calculation of RI (Resistance Index), PI (Pulsatility Index) and S/D ratio (Systolic/Diastolic ratio) gives an idea of normalcy of blood flow in fetus. Any abnormality in these indices or in blood flow pattern is a pointer towards various pathologies setting in the fetus e.g. IUGR, Brain sparing effect, pregnancy induced hypertension etc
Our infertility department, like obstetrics is also incomplete without the valuable aid of USG. Diagnosis of difficult and complicated gynaec pathologies which lead to infertility like endometriosis, adenomyosis, chocolate cysts, fibromyomas, hydrosalpinx & Tubo-Ovarian mass, poly cystic ovaries and ovarian cysts, Pelvic Inflammatory disease, intrauterine and intra pelvic adhesions, Septate uterus, Asherman’s syndrome, pelvic abscess and Ectopic pregnancy is possible with great accuracy and certainty by ultrasonography.
It is actually a whole lot of valuable, crucial information which the infertility and IVF specialist can get out of the follicular scans which are done by USG. Ovarian volume, follicular volume and size, peri follicular flow, endometrial thickness and pattern, myometrial echotexture, spiral artery blood flow, uterine artery blood flow and colour doppler; all the doppler indices like Resistance Index, Pulsatility index, Systolic/Diastolic ratio give us an idea of blood flow to endometrium and ovarian follicles. Ovum pick up and embryo transfer is also procedures done exclusively under USG guidance by the IVF specialist.
Uterine arteries supply blood to the uterus (from the internal iliac) they further divide into radial, arcuate, spiral arteries. By colour Doppler flow, we are able to assess the exact blood flow to the uterus, myometrium and endometrium. The various Doppler indices like Resistance index (RI), Pulsatility index, peak systolic velocity (PSV), end diastolic velocity (EDV), S/D ratio, gives us an idea of blood flow to endometrium and ovarian follicles. Mature follicles have high vascularity which can help in timing of hCG injection by the IVF specialist.
Fibroids, adenomas, adenomyosis, endometrial hyperplasia, endometrial polyps, ovarian tumours, ovarian masses, cervical malignancy, ovarian cancer, endometrial malignancy, all these gynace pathologies have varied vascularity patterns which are easily discernable on colour Doppler flow.
Trans vaginal, Abdominal, linear, Volume (probe for 3D and 4D) probes, Colour Doppler and Pulsed wave Doppler facility and facility for Interventional sonography. We have five state of the art ultrasonography units. USG is must with clinical findings to monitor and understand ovulation physiology and pathology. It is non invasive, reproducible, and does not interfere with physiological process TVS has excellent resolution and is easily available, and is a must to diagnose all sorts of pathologies.
It is a technique of prenatal diagnosis performed around 16-17 wks of pregnancy. The amniotic fluid obtained contains desquamated fetal cells that can be grown in tissue culture and Karyotyped or used for metabolic assays or DNA extraction genetic evaluation.
For amniocentesis, a preliminary USG is performed to confirm gestational age, fetal number, placental localization, fetal anomaly. After painting the abdomen with iodone antiseptic, skin and subcutaneous tissues are infiltrated with local anaesthetic, the position of amniotic fluid pocket is re-confirmed and a 22gauge, 3.5 inch spinal needle is inserted under direct ultrasound visualization. The obturator is then removed, a syringe is attached to the needle and 15-20ml of amniotic fluid is withdrawn after discarding the first 0.5ml to avoid maternal blood contamination.
Chorion Villus biopsy/ sampling can be done much earlier at around 10 to 12 weeks. It can be done by transcervical insertion of sampling catheter or a transabdominal approach, both under ultrasound guidance.
Certain benign ovarian cysts (appear anechoic or black on USG with clear fluid within) can be treated as a two minute ultrasound guided aspiration procedure. Recurrent benign functional or non-functional ovarian cysts usually less than 6-7 cm in diameter can be treated this way. The Trans vaginal ultrasound probe, attached with an automated and retractable needle puncture, is introduced into the patient’s vagina. Guided by the sonographic images, the gynaecologist can advance the needle through the vaginal wall into the ovary to drain fluid from the cyst. The fluid is then collected and sent for cyto-pathology. This procedure can be done as a simple out-patient procedure without any anaesthesia.
In 30% of cases, the fluid may re-accumulate which may necessitate repetition of the procedure.
Its advantages over laparoscopic cyst removal are significantly lower cost of aspiration and the minimal recovery period after the procedure.
Chronic non-functioning follicles not responding to OCP withdrawl can be aspirated transvaginally similar to the technique of transvaginal aspiration of benign ovarian cysts. This can be done as an out-patient procedure without anaesthesia.
For ovum retrieval in IVF cycles, General anaesthesia is required and the procedure is done in IVF operation theatre. After the requisite aseptic preparation (as for any major surgery), a sterilized needle guide is attached to the probe, sterilized lubricating jelly is applied on the tip and the probe is carefully inserted into the vagina.
Multifetal pregnancy reduction is suggested with three or more fetuses present. (a common occurance with ART procedures). Multiple gestations are at higher risk of fetal, neonatal and maternal complications as well as complete pregnancy loss compared to singleton pregnancies. Selective fetal reduction is done between nine and twelve weeks (around 11 weeks) gestation and is most successful early in pregnancy. Mostly the reduction is done to two fetuses. The process is done under anaesthesia in operation theatre. A needle is inserted, either through abdomen or vagina guided by ultrasound and Potassium chloride is given to the selected fetus (es) in the heart. Usually the fetus which is lying uppermost is chosen for the procedure.
Unruptured live tubal ectopic pregnancies can sometimes be treated conservatively. Achieving asystole via sonographically guided injection of potassium chloride (KCl) along with systemic methotrexate can improve treatment outcome. Under sonographic guidance, KCl is injected into the fetal heart to achieve cardiac asystole, or systemic methotrexate is injected.
Transvaginal ultrasound guided aspiration of tubal ectopic pregnancy and instillation of hyperosmolar glucose injection with 16 gauge needle can also be performed.
Cervical ectopic pregnancy or heterotypic pregnancy (simultaneous uterine and extrauterine pregnancy) can also be treated with transvaginal ultrasound guided aspiration of ectopic and instillation of KCl or hyperosmolar glucose injection.