초음파통계 OBGYhyster o Dop 정밀정밀 양수양수 3DBPP 합계 ~ ~

Saline Infusion Sonohysterography Sonographer 안 소 영 Lyndon M. Hill, MD Professor Obstetrics and Gynecology Medical Director Ultrasound Magee Women's Hospital Pittsburgh, PA

Sono-Hysterogram (SHG)  An ultrasound method of diagnosis uterine and endometrial abnormalities.  Common use… -To detect uterine and endometrial abnormalities -To detect cause of abnormal uterine bleeding -To aid in detection of cause of infertility.

Technique  SIS should be performed.. after menstrual bleeding, but before day 8 of the menstrual cycle.  In women with short or highly irregular cycles, it is best to use a form of birth control prior to the procedure in order to ensure that an early intrauterine pregnancy is not interrupted.  A speculum is inserted into the vagina and the cervix prepped with betadine or hibicleans in the iodine sensitive patient. A sonohysterographic catheter is filled with sterile normal saline prior to insertion into the endometrial cavity.

 In the premenopausal female, endometrial thickness and sonomorphology reflect the functional status of the ovaries. Transvaginal sonography without fluid contrast cannot adequately evaluate the echogenic endometrium of the secretory phase

In the postmenopausal patient, transvaginal sonography (TVS) can be used to narrow the differential diagnosis of vaginal bleeding. By detecting an atrophic endometrium (<= 4 mm), TVS reduces the need for invasive diagnostic testing1. Sonohysterography enhances transvaginal sonographic imaging of the postmenopausal endometrial cavity if vaginal bleeding recurs.

 Once the catheter is in place, the speculum is removed and the transvaginal transducer is inserted.  A 20 ml syringe containing sterile normal saline is attached to the catheter. Instillation of the sterile normal saline is begun slowly under direct sonographic visualization.  When the endometrial cavity remains filled with fluid, additional injections of sterile saline are not required.  If the endometrial canal collapses immediately upon instillation of normal saline then a larger bolus of fluid is required. In addition, the transvaginal transducer should be used to manipulate the uterus in an attempt to reduce the egress of fluid. The latter modifications to the technique will usually permit adequate visualization of the endometrial cavity. When visualization is still sub-optimal, the pediatric feeding tube should be removed and a balloon tipped catheter used in its place.

Endometrial Polyps  Endometrial polyps are a common causeof menometrorrhagia. - prevalence of polyps in patients with menometrorrhagia.: 23.8% - The highest incidence of endometrial polyps in patients with menometrorrhagia is in the fifth decade of life (29.3%). - Endometrial polyps are also associated with infertility. - The prevalence of polyps in infertile patients ranges : 5% ~ 44% The prevalence of polyps in asymptomatic women :1.2%. an association: endocervical~endometrial polyps. - incidence of endometrial polyps in patients with cervical polyps.: 26.7% (Coeman et al)  The risk of malignant transformation of an endometrial polyp is approximately 0.5% 12 to 0.8% 13. sensitivity, specificity, and positive predictive value of 96%, 82%, and 93%, respectively for the "bright edge sign" of an endometrial poly

 Since a secretory endometrium is hyperechoic, it tends to obscure endometrial polyps.  Transvaginal sonography has a sensitivity of 33.3% in the detection of endometrial polyps versus 84% for sonohysterography.

Tamoxifen Therapy  Tamoxifen is used as adjunctive therapy for breast cancer in postmenopausal women. Most postmenopausal women treated with tamoxifen will have an endometrial thickness > 4 mm due to the estrogen agonist effect of the medication.  in postmenopausal women on this medication endometrial thickness <= 8 mm  There is an increased prevalence of the following endometrial lesions with tamoxifen use: endometrial hyperplasia; polyps; adenocarcinoma; and subendometrial sonolucencies in the proximal myometrium.  Since the junctional area is not clearly defined, the intramyometrial cysts may be erroneously included in the measurement of the endometrial thickness Sonohysterography is particularly helpful in differentiating between intramyometrial cysts and possible endometrial pathology.

 If a patient on tamoxifen has vaginal bleeding, sonohysterography should be considered, regardless of the endometrial thickness. Saline infusion sonohysterography should also be performed in patients on tamoxifen with vaginal bleeding and a negative endometrial biopsy. Hann et al 20 found endometrial pathology in 12 of 19 (63%) sonohysterograms performed on women on tamoxifen with a negative endometrial biopsy.  Sonohysterography is more effective and acceptable than office hysteroscopy for detecting endometrial pathology in postmenopausal women who are on tamoxifen. In a study by Timmerman et al 21 19% of office hysteroscopies failed, accounting for the low sensitivity of this technique in the evaluation of the endometrium.

Leiomyomas  Leiomyomas may obscure visualization of the endometrial lining. It is difficult for conventional transvaginal sonography to determine whether a centrally located leiomyoma is in the uterine cavity or in the myometrium adjacent to the cavity.  The site and depth of attachment of a submucous or intracavitary leiomyoma is important when planning its surgical excision.

 Sonohysterography is equivalent to hysteroscopy in detecting submucous leiomyomas.  An advantage of sonohysterography is that this technique can determine the intramural component of submucous leiomyomas.  If a leiomyoma is entirely intracavitary or extends into the myometrium 50% into the myometrium, transcervical resection should only be attempted in specific cases 24

Endometrial Hyperplasia  On transvaginal sonography endometrial hyperplasia characteristically appears as a thickened, echogenic endometrium and may contain tiny cysts).  However, hyperplasia may be detected in endometrial linings measuring < 5 mm. With sonohysterography focal or generalized hyperplasia can be distinguished based on the irregular boundaries of the uterine cavity caused by hyperplasia. Localized areas of hyperplasia may resemble endometrial polyps. Sonohysterography can also be used to evaluate the endometrium after the medical management of hyperplasia.  In postmenopausal patients with a thickened endometrial lining, a biopsy can yield scant tissue, insufficient for diagnosis. In this particular case, sonohysterography is particularly helpful in evaluating the entire uterine cavity and localizing a specific site for biopsy.

Endometrial Carcinoma  On saline sonohysterography an endometrial carcinoma may present as a mass, an irregular thickening of the endometrium or be indistinguishable from endometrial hyperplasia. In contrast to a polyp, power Doppler reveals multiple vessels entering an endometrial carcinoma.  One characteristic that has been commented upon by several authors is the poor distensibility of the endometrial cavity with saline infusion. It should be emphasized that sonohysterography does not play a significant role in diagnosing endometrial carcinoma. The diagnosis of endometrial carcinoma is usually based on an endometrial biopsy in a patient with postmenopausal bleeding.

 There has been some concern about the theoretical risk of transporting malignant cells into the peritoneal cavity during saline infusion.  Alcázar et al performed saline infusion sonohysterography with an 8-French pediatric Foley in 14 patients with Stage I endometrial carcinoma at the time of laparotomy. There was not any spillage of fluid from the fallopian tubes in 9 patients. Malignant cells were detected in the fluid obtained from the peritoneal cavity of 1 of the remaining 5 patients (1 in 14; 7.1%). The viability of the cells that were flushed through the tubes was not assessed. The lower pressure infusion of saline with a patent cervix (i.e., utilization of a pediatric feeding tube) should carry a lower theoretical risk of cell dissemination to the peritoneal cavity.

Uterine Adhesions  On conventional transvaginal sonography, a subtle irregularity of the endometrial lining in the proliferative phase suggests that an adhesion may be present. When the uterine cavity is distended with fluid, synechiae are more easily detected.  Adhesions should be described as filmy or dense. In addition, the extent of cavity involvement should be recorded. Saline infusion sonohysterography has a 75% sensitivity and 93% specificity for the detection of uterine adhesions.