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3D in Gyn Ultrasound
3D in Gyn Ultrasound
James M. Shwayder, MD, JD
James M. Shwayder, M.D., J.D.
Professor and Chair
Obstetrics and Gynecology
University of Mississippi Medical Center
Jackson, Mississippi
Disclosures:
•  Cook OB-Gyn: Royalties
Outline
•  3D basics
•  Uses in Gynecology
•  Uterus
•  Fallopian tube
•  Ovary and adnexa
•  Pelvic floor
3-D Imaging
Uses in Gynecology
•  Fallopian tube
•  Hydrosalpinx
•  Ectopic pregnancy
•  Ovarian and adnexal masses
•  Pelvic floor evaluation
3-D Imaging
Uses in Gynecology
•  Uterus
•  Congenital anomalies
•  IUD location and type
•  Sonohysterography (SIS)
•  Cornual ectopic pregnancy
•  Leiomyomata
•  Endometrial evaluation
3-D Imaging
Technique
•  Prescan with 2D to identify the
region of interest
•  3D image acquisition
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3-D Imaging
Technique
2-D Imaging
Typical planes
Acquire volume
•  Endovaginal usually preferable to
transabdominal
•  Exceptions
•  Large uterus
•  Midplane uterus
•  Transperineal when EV not possible
Sagittal
Transverse
3-D Orthogonal Planes
3-D Sagittal Acquisition
Plane 1
Plane A
Acquisition Plane
3-D Acquisition
Transverse
Plane 2
Sagittal
Acquisition
View
Plane C
Plane B
The volume of
data is displayed
as three
orthogonal
planes at 90°
from each other
•  A - Sagittal
•  B - Transverse
•  C - Coronal
Transverse
90° to Plane 1
“B”
“A”
Coronal
90° to both
Planes 1 & 2
3D Volume
Rendered
Transducer
Foot print
“C”
Plane 3
Transverse
“A”
Sagittal
“B”
Coronal
“C”
(Rotated)
Transducer
Footprint
Plane 4
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Displaying Uterus
Multiplaner (MPR) display shows 3
perpendicular planes through volume
•  Plane of acquisition is in upper left image of the
multiplanar display in this presentation
•  Operator will need to rotate the volume to see
standard planes: transverse, sagittal, & coronal
(C-plane)
•  Display will vary depending on equipment
and operator preference
3D Reconstruction
• 
Knobs
•  x = rotates around x-axis
•  y = rotates around y-axis
•  z = rotates around z-axis
Axis rotation
Axis Rotation
z
y
x
z = “clock face”, rotate knob left or right
Initial Acquisition
Z-Technique
•  Plane A
Sagittal
Fundus
Transverse
Cervix
•  Place reference point at the midlevel of
the endometrium
•  Align the long axis of the endometrium
along the horizontal axis using Z rotation
•  Plane B
•  Place reference point in the midportion
of the endometrium
rt
lt
lt
•  Plane C
•  Clockwise Z rotation of the coronal view
to properly orient the uterus
rt
Abuhamad. J Ultrasound Med 2006; 25:607-12.
C-plane
Courtesy Dr. D. Pretorius
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Post-rotation
Z-Technique
transverse
transverse
CervixCervix
rt
rt
Demonstration
sagittal
sagittal
lt
lt
lt
lt
Fundus
Demonstration
Fundus
rt
rt
C-plane
Cervix
Note that the cervix points towards the
left on 3D rather than the right, as it
would on 2D – when you orient the Cplane
Courtesy Dr. D. Pretorius
Uterine Anomalies
Congenital Uterine Anomalies
3DUS or MRI
Differentiate bicornuate from septate
•  Variations in fundal endometrial contour
Displaying Uterine Anomalies
• 
• 
• 
• 
•  Arcuate vs. normal
•  Multiplaner and rendered display
• 
Didelphys
• 
• 
• 
Multiplaner
Rendered
Multislice
Thick slice
Invert mode
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Mullerian Anomalies
ASRM Classification of Uterine Anomalies 1988
Ghi et al. Fertil Steril 2009; 92: 809-813.
1.  External contour
(Fundal serosa)
2.  Fundal
endometrium
3.  Lower uterine
segment
4.  Cervix
C-Plane or Coronal Plane
C-Plane or Coronal Plane
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Mullerian Duct Anomalies
Classification
I. Segmental agenesis
or hypoplasia
•  a. vaginal
•  b. cervical
•  c. fundal
•  d. tubal
•  II. Unicornuate
•  a. w rudimentary horn
•  (+/- cavity)
•  b. w/o rudimentary horn
• 
< 1 cm
1-1.5 cm
> 1.5 cm
A. Ludwin and I. Ludwin. Human Reprod 2015; 30 (3 ):569–580.
Unicornate with
communicating rudimentary horn
Pseudo-unicornuate
Normal Endometrium
after rotation
Classification
• 
• 
Bicornuate Uterus
III. Didelphys
IV. Bicornuate
•  a. complete
•  b. partial
•  c. arcuate
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Rendered Display
Bicornuate Bicollis (Two Cervices)
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Cervix
Volume through uterus shows one cervix
Volume through cervix shows two
May need to rotate volume to
evaluate cervix if uterus is
flexed at cervix
•  Acquire separate volume to
assess cervix
• 
Courtesy of
Dr. Lev-Toaff
Classification
• 
Uterine septum – 2D
Sagittal
V. Septate
•  a. complete to
internal os
•  b. subseptate
(partial)
Uterine septum – 2D
Transverse
Uterine Septum
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Uterine Septum
Uterine Anomaly
Sagittal
Uterine Anomaly
Transverse
Uterine Anomaly
3D
Uterine Anomaly
3D
Complete Uterine Septum
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T-shaped uterus
Thick Slice Imaging
3-20 mm volumes
Reconstructed plane in image with 4D
acquired plane
•  C-plane
•  Helpful to assess uterus and adnexa
• 
• 
VI. DES exposure
Septate Uterus
Septate Uterus
Thick Slice Display
Thick Slice Display
Courtesy of Dolores Pretorius, M.D.
Multi-Slice Display
• 
• 
• 
• 
• 
• 
• 
Courtesy of Dolores Pretorius, M.D.
3DUS: Septate Uterus
Volume display w/ multiple parallel slices at
defined intervals, e.g. 1 –2 mm
Variable number of images
Similar to CT and MRI
Systematic evaluation of anatomy
Can rotate volume (all multi-slice images
simultaneously)
Potential for more extensive review of
ultrasound information
Potential for “cherry picking” desired images
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Septate Uterus
Septate Uterus
Multi-Slice at 2 mm Intervals
Multi-Slice at 2 mm Intervals
Courtesy of Dolores Pretorius, M.D.
Courtesy of Dolores Pretorius, M.D.
Septate Uterus
Septate Uterus
Multi-Slice at 2 mm Intervals
Multi-Slice at 2 mm Intervals
Courtesy of Dolores Pretorius, M.D.
Invert Mode
Invert Mode
Septate Uterus on Sonohysterogram
Volume display that shows cystic
structures or fluid-filled structures
in isolation
•  Requires special viewing angles
•  Often requires editing of volume,
i.e. removal of undesired echoes
with editing tool
• 
Timor-Tritsch, UOG 2005; 24:681
Timor-Tritsch, UOG 2005; 24:681
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Invert Mode: Applications
3D vs. MRI for Mullerian Abnormalities
Sonohysterogram
•  Polyps
•  Uterine malformations
•  Hydrosalpinx
•  Often thought to be adjacent
cysts on 2D
• 
Timor-Tritsch, UOG 2005; 24:681
Deutch and Abuhamad. J Ultrasound Med 2008; 27:413–423
3D vs. MRI for Mullerian Abnormalities
Fibroids
Deutch and Abuhamad. J Ultrasound Med 2008; 27:413–423
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Leiomyoma
Subclassification
System
AAGL Practice Report: Practice Guidelines for the
Diagnosis and Management of Submucous
Leiomyomas. JMIG (2012) 19, 152–17.
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Intramural
Endometrium
Arcuate Uterus
Submucous-Type I
Intramural
Sonohysterography
Fibroid
Endometrial Polyps and Fibroids
Courtesy: D. Pretorius, M.D.
Rendered Image on 3D:
Fibroid distorting endometrium
Fundus
Fibroid
Endometium
Courtesy: D. Pretorius, M.D.
Cervix
Is it a true
border or
an edge
refraction
artifact?
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PMB/Enlarged uterus
Myometrium
Fibroid
Fibroid
•  52 yo G4P3013
•  PMB
•  Enlarged uterus
Endometrium
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3D Clear Body
Abdominal Hysterectomy
•  Leiomyosarcoma
48 y.o. with AUB-I (MR)
Endometrial Evaluation
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SIS
SIS
Sonohysterogram: Polyp
Multiplaner Display
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Endometrial Polyp
Luteal Phase
Hyperechoic mass seen without
sonohysterography à Polyp
transverse
sagittal
lt
rt
rt
lt
Courtesy of
Dr. Lev-Toaff
C-plane
2D Ultrasound
Sagittal
Fundus
Cervix
2D Ultrasound
Transverse
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AUB - 2D SIS
Multiple Endometrial Polyps
AUB - 3D SIS
Virtual Hysteroscopy
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Aligned IUD
IUD localization
Rendered IUD
IUD – Multiplaner Reconstruction
Rendered IUD
3DUS: IUD Position
66 cases
2DUS - EV
•  12% misidentified type
•  9% type not defined
•  3% misidentified position
•  3DUS - EV
•  100% IUD accurately identified
position and type
• 
• 
Bonilla-Muscoles. J Clin Ultrasound 1996;24:263.
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IUD Localization-2D
IUD Localization-3D
Paraguard IUD
IUD
Multiplaner Views
Lippe’s Loop
2DUS
3DUS
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Where is the IUD ?
IUD is in the Myometrium
Endometrium
IUD
LNG IUS
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Where’s the IUD
Sonohysterography
SIS-3D
SIS – 3D
Rendered Image
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SIS – 3D
Multiplaner Reconstruction
SIS – 3D
Rendered Image
Septate Uterus, Septate Cx
No communication
Ectopic Evaluation
Transverse Acquisition
Subseptate Uterus with
6 wk Gestation in Right Horn
Transverse
Interstitial Ectopic
Sagittal
Cornual Pregnancy
Coronal
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Interstitial Ectopic
Interstitial Ectopic
Interstitial Ectopic
Ultrasound Diagnosis of
Interstitial Pregnancy
•  Empty uterine cavity
•  Chorionic sac > 1 cm
from the lateral edge
of the uterine cavity
(endometrium)
•  Thin (<5 mm) layer of
myometrium
surrounding the
chorionic sac
Timor et al. Obstet Gynecol 1992;79:1044
Cornual Ectopic
Cornual Ectopic
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Hydrosalpinx
Hydrosalpinx – 3D
Ovarian and Adnexal Masses
3D = 3-dimensional
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3DUS: Adnexal Lesions
372 patients
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Septum or not?
Assist in differentiating ovary from adjacent
structures
Structures projecting into lumen can be
evaluated with surface rendering and
multiplanar
Assist in choosing type of surgery: laparoscopy
vs. laparotomy
Volumetric assessment
Additional information with 3D in 50% of
patients
Merz, 2nd World Congress 3DUS, 1999
Pelvic
Pain
Pelvic
Pain
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Hemorrhagic Parovarian Cyst
Pelvic
Pain
Twisted
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RIGHT OVARY
LEFT OVARY
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Pelvic Masses - 23 year old
Laparoscopy
•  Peritoneal washings
•  Right salpingoophorectomy
•  Pathology-frozen
•  Papillary serous cystadenoma-LMP
•  Left ovary
•  Ovarian cystectomy
•  Pathology-frozen
•  Papillary serous cystadenoma-LMP
Pelvic Masses - 23 year old
Final pathology
•  Peritoneal washings
•  Negative
•  Right salpingoophorectomy
•  Papillary serous cystadenoma - LMP
•  Left Ovarian cystectomy
•  Papillary serous cystadenoma - LMP
3-D Imaging
Uses in Gynecology
•  Uterus
•  Fallopian tube
•  Ovarian and adnexal masses
Thank You
James M. Shwayder, M.D., J.D.
Professor and Chair
Department of Obstetrics and Gynecology
University of Mississippi Medical Center
Jackson, Mississippi
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