3D-4D ULTRASOUND IN UTERINE SEPTUM EVALUATION

1. PROF.NARENDRA MALHOTRA
M.D., F.I.C.O.G., F.I.C.M.C.H, F.R.C.O.G.,F.I.C.S.,F.M.A.S.,F.I.A.P.
• Prof. Dubrovnick International University
• V.P. WAPM(world association of prenatal medicinne)
• Imm Past President ISAR
• Presiddent ISPAT
• Sec Gen SAFOG
• Member FIGO guidelines committee
• President FOGSI (2008-2009)
• Dean I.C.M.U. (2008)
• Director Ian Donald School of Ultrasound
• National Tech. Advisor for FOGSI-G.O.I.—Mc Arthur Foundation EOC Course
• Managing Director GLOBAL RAINBOW HEALTH CARE
• Director ART-RAINBOW –IVF
• Practicing Obstetrician Gynecologist at Agra. Special Interest in High Risk Obs., Ultrasound, Laparoscopy
and Infertility, ART & Genetics
• Member and Fellow of many Indian and international organisations
• Awarded best paper and best poster at FOGSI : 5 times, Ethicon fellowship, AOFOG young gyn. award,
Corion award, Man of the year award, Best Citizens of India award
• Over 50 published and 200 presented papers
• Over 100 guest lectures given in India & Abroad and 24 ORATIONS
• Organised many workshops, training programmes, travel seminars and conferences
• Editor 18 books, many chapters, on editorial board of many journals
• Editor of series of STEP by STEP books
• Revising editor for Jeatcoate’s Textbook of Gynaecology 7th and 8th edition (2015)
• Very active Sports man, Rotarian and Social worker
MALHOTRA NURSING & MATERNITY HOME PVT. LTD.
GLOBAL RAINBOW HEALTH CARE,AGRA
84, M.G. Road, Agra-282 010
Phone : (O) 0562-2260275/2260276/2260277, (R) 0562-2260279, (M) 98370-33335; Fax : 0562-2265194

2. 3 D ULTRASOUND
Role in uterine cavity evaluation
narendra malhotra
www.rainbowhospitals.org
mnmhagra3@gmail.com
thnx to sonal panchal, ashok khurana,asim kurjack ,jaideep malhotra
for their inputs on 3d and 4 d

3. This is because..
• Introduction of volume ultrasound has
significantly increased the information
available through imaging, especially in
reproductive medicine.
3D gives idea about the global structure and morphology.
3D power doppler assesses global vascularity
Thus both are believed to be more accurate in assessment of ovary-follicle, uterus-
endometrium.

4. OBSTETRICS GYNECOLOGY

5. OBSTETRICS GYNECOLOGY
The image in 2D is the bisectrix of the sweep angle
Combination of transvaginal scanning and volume ultrasound has significantly increased
the information available through imaging, especially for uterus, ovaries and fallopian
tubes .

6. OBSTETRICS GYNECOLOGY
RIC5-9-D Volume
Endocavity Probe
Helping you see more anatomical information displayed in a
single image

7. OBSTETRICS GYNECOLOGY
Advantages of 3D ultrasound
1. Surface rendering
2. Multi-planar imaging
3. Exact volume measurement
4. Power Doppler quantification
5. Inversion mode
6. Automation
7. Virtual scan

8. OBSTETRICS GYNECOLOGY
This is because..
• 3D gives idea about the structure and morphology of the
whole volume, instead of a plane.
• It explains the anatomy better.
• 3D power Doppler assesses global vascularity.
• Can calculate volumes more accurately.

9. OBSTETRICS GYNECOLOGY
3D 4 D Approach
• cervix
• Uterus
• Ovary
• Fallopian tubes
• Others

10. OBSTETRICS GYNECOLOGY
Uterus…
 Shape of uterine (endometrial) cavity
 Mullerian Anomalies
 Health of the uterus
 Endometrial lesions
 Myometrial lesions
 Receptivity of endometrium

11. OBSTETRICS GYNECOLOGY
Shape of the endometrial cavity
• Normal shape of the endometrial cavity is
triangular anteroposteriorly and pear shaped in
sagittal section and it is a potential cavity.

12. OBSTETRICS GYNECOLOGY
Shape of the endometrial cavity is distorted by...
• Congenital uterine abnormalities:
 These can diagnosed based on external
fundal contour and endometrial contour.
• Acquired lesions distorting or invading endometrium.

13. OBSTETRICS GYNECOLOGY
Greatest advantage of 3D is the coronal plane.

14. OBSTETRICS GYNECOLOGY
Unicornuate uterus:
3D is the modality for diagnosis

15. OBSTETRICS GYNECOLOGY
And 3D US has an
advantage of assessing
both these contours at a
time.
Differential diagnosis of congenital duplication
abnormalities of uterus like bicornuate, septate and
arcuate is based on external fundal contour and
contour of the endometrial cavity.

16. OBSTETRICS GYNECOLOGY
Duplication abnormalities …
Ultrasound sensitivity specificity
TVS 95.21 % 92.21%
TVCD PD 99.29% 97. 23%
Volume USG 98.38% 100%
Sonohysterography 98.18% 100%
(Richman TS et al. 1984)
Sonohysterography is therefore not an investigation
required for congenital uterine abnormalities,if u have 3D

18. OBSTETRICS GYNECOLOGY
Two cervical canals
Uterus didelphys: two uterine horns

19. OBSTETRICS GYNECOLOGY
Differential diagnosis between septate and bicornuate
uterus is the most important as it is the septate uterus
that has highest negative impact on fertility outcome.

20. OBSTETRICS GYNECOLOGY

21. OBSTETRICS GYNECOLOGY
D/D of bicornuate from septate uterus…
Bicornuate uterus Septate uterus

22. OBSTETRICS GYNECOLOGY
Bicornuate Septate
Dimple on the fundus in bicornuate uterus(red line), Convex or
flat fundus in septate uterus ( white line).

23. OBSTETRICS GYNECOLOGY
< 5mm > 5mm
If a line is drawn touching the tips of both endometrial leaves, the
distance between this line and the deepest point in the fundus in the
centre is < 5mm in bicornuate uterus and is > 5mm in Septate uterus.
Bicornuate Septate

24. OBSTETRICS GYNECOLOGY
Medial margins of endometrial leaves is usually convex medially in
bicornuate uterus, where as these are straight medially in septate
uterus. Barbot J et al. 1995.
Bicornuate Septate

25. OBSTETRICS GYNECOLOGY
Angle between two leaves of endometrial cavity is obtuse in
bicornuate uterus and is acute in septate uterus.
Bicornuate Septate

26. OBSTETRICS GYNECOLOGY
Bicornuate uterus shows infolding of the endometrium as sublte
hypoechoic curved lined parallel to the medial endometrial margin
(dotted black line).
Bicornuate Septate

27. OBSTETRICS GYNECOLOGY
3D US can show the length, thickness and depth
of the septum and can guide the surgical plan.

28. OBSTETRICS GYNECOLOGY
It is a complete septum if it extends upto
the internal os

29. OBSTETRICS GYNECOLOGY
Differentiating Subseptate from arcuate uterus
Subseptate uterus Arcuate uterus

30. OBSTETRICS GYNECOLOGY
Subseptate Arcuate
Acute Obtuse
Angle between two endometrial leaves is acute in subseptate uterus but
is obtuse in arcuate uterus, though in both the fundal contour is convex
or flat.

31. OBSTETRICS GYNECOLOGY
> 10 mm
< 10 mm
A line is drawn touching the tips of both endometrial leaves and
distance of this line to the deepest point between the endometrial
leaves is > 10mm in subseptate uterus and is > 10mm in arcuate uterus.
Subseptate Arcuate

32. OBSTETRICS GYNECOLOGY
T shaped uterus
It is when the angle between the horizontal part and vertical part of
the uterus is almost 90°. The two commonest etiologies for this is DES
exposure and tuberculosis..

33. OBSTETRICS GYNECOLOGY
But even on 3D US there is a possibility
of misinterpreting an arcuate uterus for normal,
or a bicornuate for a septate..
This is because of erroneous rendering.

34. OBSTETRICS GYNECOLOGY
To prevent this and to standardize the results,
guidelines are developed for rendering the
uterus
By aligning the sectional planes in true orthogonal planes

35. OBSTETRICS GYNECOLOGY
Rendering is difficult when the uterus is
curved..
Curved rendering line may help, but when the curve is acute

36. OBSTETRICS GYNECOLOGY
Omniview is the answer…

37. OBSTETRICS GYNECOLOGY
This case of an arcuate uterus is the best demonstration that a straight section may
not be the best way to analyze a curvilinear organ like the uterus.
The straight coronal section demonstrated in is clearly inadequate to describe the
shape fo the uterine cavity.
When a curvilinear section is employed the entire cavity is displayed demonstrating
that the dome of the cavity is bending low suggesting an uterine malformation that
has clinical implication.
This is confirmed by the axial section
Advanced VCI in arcuate uterus
Straight
section
Curvilinear
section

38. OBSTETRICS GYNECOLOGY
3D US is an excellent tool for
differential diagnosis of endometrial
lesions and lesions invading/distorting
the endometrium……

39. OBSTETRICS GYNECOLOGY
Health of the uterine cavity…
Evaluation of junctional zone is much more
accurate on 3D US than on 2D US and
hysteroscopy

40. OBSTETRICS GYNECOLOGY
Junctional zone is damaged in
 Endometritis: acute or chronic
 Adenomyosis
 Malignancy

41. OBSTETRICS GYNECOLOGY
Endometritis
 Acute endometritis shows obliteration of endometrio-
myometrial junction and increased vascularity of the
endometrium in early proliferative phase.
 Chronic endometritis shows obliterated junctional zone
and absent vascularity in proliferative and secretory
phase.

42. OBSTETRICS GYNECOLOGY
Another lesion that would lead alteration in junctional zone
is adenomyosis…

43. Septal resorption
• Septal resorption involves subsequent resorption of
the central septum once the ducts have fused. Defects
in this stage result in a septate or arcuate uterus.

44. Imaging modalities for diagnosis
• Hysterosalpingography
• Ultrasonography
• Magnetic resonance imaging

45. Hysterosalpingography
• Hysterosalpingography (HSG) allows for assessment
of the uterine cavity and tubal patency but is limited
at visualising the external uterine contour.

46. Ultrasound
• Quick, readily available, economical and lacks radiation.
• Modality of choice for study of uterine abnormalities.
• Transvaginal route is the preferred route.
• During secretory phase the endometrium is echogenic and this is
the best time to do the scan to exclude MDAs.

47. Ultrasound - limitation
• But ultrasound leads to poor quality image
with large patients, overlying bowel gas, and
the external contour may be difficult to
visualise.
It is in these cases that MRI is more informative.

48. MRI
• MRI is radiation free and provides clear delineation of
both the internal and the external uterine anatomy. –
major advantage over B mode US.
• MRI has been shown to have excellent agreement with
the clinical diagnosis of the subtypes of MDA.
• Mueller GC, Hussain HK, Smith YR, Quint EH, Carlos RC, Johnson TD, et al.
Müllerian duct anomalies: comparison of MRI diagnosis and clinical
diagnosis. AJR Am J Roentgenol. 2007;189:1294–302 .

49. MRI
• Standard pelvic MR imaging
protocols include axial T1-
weighted and T2-weighted
images
• T2-weighted imaging is essential
for evaluation of uterine
anatomy.

50. Volume USG, 3D and 4D USG has a major role
to play in the diagnosis of uterine anomalies :
Virtual hysteroscopy
Sensitivity of the Volume USG for the
detection of congenital uterine abnormalites
is > 98%.

51. MAGIC STICKS FOR UTERINE
EVALUATION &TREATMENT

52. HSG
advantages/disadvantages
• outpatient
procedure
• is relatively
inexpensive,
• does not require
general anesthesia,
and
• is associated with a
therapeutic effect.
Speroff L. Clinical Gynecology and Infertility. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.
 Using iodinated
contrast
 Exposure to
radiation
 Is extremely painful
 Needs sedation and
sometimes even
anesthesia
 Needs to be done in
a radiology set up
advantages disadvantages

53. Volume USG, 3D and 4D USG has a major
role to play in the diagnosis of uterine
anomalies :
Virtual hysteroscopy
Sensitivity of the Volume USG for
the detection of congenital uterine
abnormalites is > 98%.

55. defects max asso. with RSA
• Best diagnostic tool :USG-TVS/3 D
• Best treatment tool endoscopy
ANATOMIC FACTOR

56. Abnormal uterine shape is due to congenitaluterine abnormalities

57. Coronal views of uterus
Normal uterus
Arcuate uterus
Septate uterus
Bicornis uterus

58. Septate uterus
• 50 % SYMPTOMATIC
• SPONTANEOUS ABORTION :
20 - 45 % IN THE 1ST
TRIMESTER
5 % IN THE 2ND TRIMESTER
Gaucherand et al., Eur J Obstet Gynecol Reprod Biol 1994

59. Septae may be of variable length and
thickness.

60. PRIMARY INFERTILITY IN
SEPTATE UTERUS
SCANTY VASC. ESTROGENS
POOR ESTROGENIC
MATURATION
POOR DECIDUALIZATION & PLACENTATION

61. INFERTILITY IN
SEPTATE UTERUS
 AMOUNTS OF
MUSCLE TISSUE
INCOORDINATE
CONTRACTILITY
SPONTANEOUS ABORTION

62. • OUTLINES CONTOUR OF
THE UTERUS
• FRONTAL VIEW ALLOWS
DETECTION OF UTERINE
ANOMALIES

63. SEPTATE
UTERUS

64. Septate uterus
OPERATIVE HYSTEROSCOPY
PREGNANCY RATES
75 % TO 88.7 %
Cararach et al., Hum Reprod 1994
Goldenberg et al., Hum Reprod 1995
Shawki et al 2006

65. Author N. cases Conclusions
Heinonen et al
2000
17 Women with uterine anomalies who underwent
ART had
low implantation rates
Pabuccu et al 2004 61 11% spontaneous misc. after metroplasty (9
cerclage
Dendrinos et al.
2005
411 Treatment significantly reduced the miscarrage
rate
Pace et al.2006 40 75 % spontaneous pregnancy aceived
Kormanyos et al.
2006
94 Removal even of small residual septa > 1 cm after
metroplasty
Ban & Tomaževič et al
2007
31 Resection of small uterine septa, improves
implantation rate in IVF cycles.

66. Conclusion
• Volume ultrasound is the modality of
choice for uterincavity assessment &
endometrial pathology
• With 3D contrast even the fallopian
tubes can mow we visualised nicely
• Volume USG – VOCAL and colour
histogram –in our experience have
proved to be of added value in
evaluation of ovarian response,
endometrial receptivity and Pre HCG
follicular and endometrial
evaluation.

68. 4 of our latest books released

69. THANK YOU
CONGRATULATIONS TO ALL ON 35YRS OF
ART

70. THANKYOU