{"paper_id":"bca5ef03-b18a-476f-863c-1b7a203ee52a","body_text":"Basic Gynecologic Ultrasound Examination (Level I): DEGUM, ÖGUM,\nand SGUM Recommendations\nQualitätsanforderungen an gynäkologische Ultraschall-\nUntersuchungen der DEGUM-Stufe I: Empfehlungen der DEGUM,\nÖGUM und SGUM\nAuthors\nDieter Grab 1,E b e r h a r dM e r z2, Karl-Heinz Eichhorn 3,B o r i sT u t s c h e k4\n , Karl Oliver Kagan 5, Kai-Sven Heling 6,\nRenaldo Faber 7\n , Philipp Klaritsch 8\n , Andreas Rempen 9, Christiane Kähler 10, Wolfgang Henrich 11,\nGwendolin Manegold-Brauer 12\n , Samir Helmy 13, Markus Hoopmann 14\nAffiliations\n1 Obstetrics and Gynecology, University of Ulm, Germany\n2 Frankfurt, Center for Ultrasound and Prenatal Medicine,\nFrankfurt/Main, Germany\n3 Gynecology and Obstetrics, Practice of prenatal medicine,\nWeimar, Germany\n4 Prof. Tutschek, Prenatal Zurich, Zürich, Switzerland\n5 Department of Obstetrics and Gynaecology, University\nof Tuebingen, Germany\n6 Berlin, Prenatal Diagnosis and Human Genetics, Berlin,\nGermany\n7 Leipzig, Center of Prenatal Medicine, Leipzig, Germany\n8 Department of Obstetrics and Gynecology, Medical\nUniversity Graz, Austria\n9 Department of Gynecology and Obstetrics, Diakonieklinik,\nSchwäbisch Hall, Germany\n10 Obst Gyn, Practice of prenatal medicine Erfurt, Germany\n11 Obstetrics, Charité University Hospital Berlin – Virchow\nHospital Campus, Berlin, Germany\n12 Department of prenatal medicine and gynecologic\nultrasound, University Hospital Basel, Switzerland\n13 Department of Obstetrics and Gynecology, Medical\nUniversity of Vienna, Austria\n14 Department of Obstetrics and Gynaecology, University\nof Tübingen, Tübingen, Germany\nKey words\ngynecology, education, training, quality Assurance, basic\nultrasound\nreceived 22.09.2021\naccepted 28.04.2022\npublished online 15.06.2022\nBibliography\nUltraschall in Med 2023; 44: 151 –161\nDOI 10.1055/a-1851-5157\nISSN 0172-4614\n© 2022. Thieme. All rights reserved.\nGeorg Thieme Verlag KG, Rüdigerstraße 14,\n70469 Stuttgart, Germany\nCorrespondence\nProf. Dieter Grab\nKlinik für Frauenheilkunde und Geburtshilfe,\nUniversitätsklinikum Ulm, Prittwitzstr. 43, 89075 Ulm,\nGermany\nTel.: +49/73 15/0 05 87 70\ndieter.grab@uniklinik-ulm.de\nABSTRACT\nUltrasound has become an essential diagnostic tool in gyne-\ncology, and every practicing gynecologist must be able to dif-\nferentiate normal from pathologic findings, such as benign or\nmalignant pelvic masses, adnexal torsion, pelvic inflammation\ndisease, endometriosis, ectopic pregnancies, and congenital\nuterine malformations at least on a basic level. A standardized\napproach to the correct settings of the ultrasound system, the\nindications for gynecologic ultrasound investigations, and the\nsonographic appearance of normal anatomy and common\npathologic findings in the standard planes are important pre-\nrequisites for safe and confident clinical management of\ngynecologic patients. Based on current publications and dif-\nferent national and international guidelines, updated DEGUM,\nÖGUM, and SGUM recommendations for the performance of\nbasic gynecologic ultrasound examinations were established.\nZUSAMMENFASSUNG\nDie sonografische Basisuntersuchung in der Gynäkologie\numfasst Diagnostik und Differenzialdiagnostik in der tägli-\nchen Praxis: Gesundheitsvorsorge, Abgrenzung der Normal-\nbefunde von pathologischen Befunden wie kongenitale Fehl-\nbildungen, benigne und maligne Tumoren, Adnextorsionen,\nentzündliche Erkrankungen des inneren Genitals, Endo-\nGuidelines & Recommendations\n151Grab D et al. Basic Gynecologic Ultrasound … Ultraschall in Med 2023; 44: 151 –161 | © 2022. Thieme. All rights reserved.\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\nArticle published online: 2022-06-15\n\nmetriose, gestörte Frühgraviditäten und Tubargraviditäten\nsowie Fragestellungen zu Kontrazeption und Fertilität. Die\nStandardisierung der Untersuchungstechnik sowie die genaue\nDefinition der Leistungsinhalte für die Basisdiagnostik und für\ndie weiterführende Diagnostik (DEGUM-Stufe II) analog des\nschon seit Jahren in der pränatalen Diagnostik bewährten\nMehrstufenkonzepts der DEGUM sind inzwischen auch in die\ngynäkologische Sonografie implementiert worden. Als\nGrundlage für eine strukturierte Aus- und Weiterbildung im\nRahmen dieses Stufenkonzepts haben DEGUM, ÖGUM und\nSGUM die Qualitätsanforderungen und die Leistungsinhalte\nfür gynäkologische sonografische Basisuntersuchungen\n(DEGUM-Stufe I) entsprechend dem gegenwärtigen Kenntnis-\nstand sowie anhand nationaler und internationaler Standards\nund Empfehlungen aktualisiert.\nIntroduction\nSimilar to the DEGUM ʼs well-established multi-level concept for\nprenatal diagnosis [1, 2], quali ty requirements have also been\ndefined for ultrasound imaging in gynecology [3, 4]. Standardiza-\ntion of examination techniques and precise definition of services\nto be performed for a basic examination and for a detailed exam-\nination by a specialized examiner help to ensure high-quality and\nneed-based patient care and are r equired for quality improve-\nment and control as well as for standardized training [5 –8]. Signif-\nicant advances in the further development and standardization of\nexamination techniques and evaluation criteria in ultrasound ima-\nging in gynecology have been achieved in recent years [9 –15].\nAs the foundation for structured training and specialist training\nwithin the framework of the DEGUM level concept, the quality\nrequirements for gynecological ultrasound examinations for\nDEGUM level I are being updated according to current knowledge\nand national and international standards and recommendations.\nBasic ultrasound examination\nThe basic ultrasound examination in gynecology includes diagno-\nsis and differential diagnosis within the daily routine: preventative\ncare, differentiation between normal findings and pathological\nfindings (see ▶ Table 1), and questions regarding contraception\nand fertility. For information regarding ultrasound methods for\nevaluating the pelvic floor and for performing a workup regarding\nfemale urinary incontinence (introitus and perineal ultrasound),\nrefer to the AWMF guidelines 015/091 “urinary incontinence in\nwomen” [16].\nEquipment standards\nWhen performing a workup of gynecological findings, the trans-\nvaginal ultrasound examination is the most valuable imaging\nmethod. High-frequency (at least 5 MHz) transducers (mechanical\nor electronic sector transducers) with a sector angle of at least\n100° should be used for this purpose. Electronic curved array or\nsector transducers or mechanical sector transducers with a fre-\nquency between 3.5 and 7.5 MHz should be used for transabdom-\ninal imaging. For differential diagnosis, particularly for differen-\ntiating between benign and mal ignant findings, color-coded\nDoppler ultrasound has become established as the standard\nmethod and can be helpful for basic ultrasound examination [15,\n17]. The pulse repetition frequency and the zero line must be able\nto be set to show the Doppler frequency shift.\nExamination technique\nTransvaginal examinations are performed with an empty or\nalmost empty bladder with the patient either lying in a supine\nposition on an examination table or in a lithotomy position on\nthe gynecological chair. The transducer is to be covered with a\ngel-filled cover (condom without a reservoir) and to be cleaned\nand disinfected according to manufacturer specifications after\nevery examination. After the transducer is used, the protective\nc o v e ri sr e m o v e da n dd i s p o s e do f ,a n dt h eg e li sc l e a n e df r o m\nthe transducer. Since handling of the probe, ultrasound gel, and\nprotective cover can result in smear infections and cross-contam-\nination with various pathogens, the transducer must be cleaned\nafter removal of the protective cover and disinfected with a bac-\ntericidal, fungicidal, and virucidal disinfectant. This is especially\ntrue if the protective cover ruptures during a vaginal ultrasound\nexamination and the transducer comes in direct contact with\nvaginal secretions or blood [18, 19].\nA full bladder can facilitate transabdominal examinations.\nThe examination conditions (good, sufficient, limited, e. g. due\nto obesity, intestinal overlay, etc.) should be evaluated for every\nexamination.\n▶ Table 1 Pathological findings and diseases detected during basic\nultrasound examination.\nMyomas\nUterine adenomyosis\nEndometrial polyps\nEndometrial hyperplasia\nHemorrhagic cysts\nDermoid cysts\nEndometrial cysts\nCystadenoma\nInflammatory diseases of the lesser pelvis\nMasses suspicious for malignancy\nAdnexal torsion\nMiscarriage (missed abortion, molar pregnancy, incomplete abortion)\nEctopic pregnancies\n152 Grab D et al. Basic Gynecologic Ultrasound … Ultraschall in Med 2023; 44: 151 –161 | © 2022. Thieme. All rights reserved.\nGuidelines & Recommendations\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\nFor image optimization, the following parameters must be\nindividually adjusted.\n▪ Image section\n▪ Focal zone\n▪ Grayscale enhancement\n▪ Image resolution (frame rate, persistence, Tissue Harmonic\nImaging, if applicable)\n▪ Pulse repetition frequency (speed range)\n▪ Color Doppler enhancement\nWhat the examination includes\nThe basic ultrasound examination includes imaging of the internal\nreproductive organs (dynamic examination, possibly with the help\nof the examiner ʼs hand externally to control the mobility of the\norgans in the lesser pelvis). Under consideration of the patient ʼs\nmedical history, cycle phase, age, and medication, position and\nstructural changes should be identified and the most important\npathological findings and diseases of the uterus, adnexa, the\npouch of Douglas should be correctly diagnosed, classified, docu-\nmented, and reliably differentiated from functional findings (folli-\ncles, corpus luteum).\nThe basic ultrasound examination also includes a check of the\nposition of an IUD.\nNormal findings\nThe basic ultrasound examination in gynecology requires correct\nvisualization of the size, structure, and position of the uterus and\nadnexa as well as knowledge of physiological changes to the\nendometrium and ovaries in the normal cycle, early pregnancy,\nand menopause.\nUterus\nTransvaginal imaging of the uterus is performed either from the\nanterior (with the uterus in anteflexion) or the posterior vaginal\nfornix (with the uterus in retroflexion). The entire uterus is visual-\nized in a series of sagittal views and transverse views. The image\nsection and sector angle are selected so that the median sagittal\nview of the uterus fills the screen ( ▶ Fig. 1). A standardized repre-\ns e n t a t i o ni sr e c o m m e n d e df o ri m a g eo r i e n t a t i o nw i t ht h et r a n s -\nvaginal probe positioned on the lower edge of the image and the\nb l a d d e ro nt h er i g h ti nt h es a g i t t a lv i e w[ 9 ] .I nt h et r a n s v e r s ev i e w ,\nthe left side of the patient is on the right edge of the image\n(▶ Fig. 2). If the spatial relationships are unclear, a pictogram can\nbe helpful.\nIf a transvaginal view of the uterus is not possible or not fully\npossible, a transabdominal appr oach is used: Depending on the\nsize and position of the uterus as well as on the anatomical situa-\ntion (abdominal wall), a full bladder is often but not necessarily\nrequired. The selection of the image section, the sector angle,\nand the image orientation is performed as in transvaginal ultra-\nsound.\n▶ Fig. 1 Sagittal view of uterus in anteflexion a and retroflexion b acquired using a transvaginal approach. 1: Endometrial thickness, 2: ap diameter\nof the corpus uteri (= uterus height), 3: uterus length.\n▶ Fig. 2 Transvaginal image of uterus in the upper third of the corpus\nwith measurement of the width of the uterus.\n153Grab D et al. Basic Gynecologic Ultrasound … Ultraschall in Med 2023; 44: 151 –161 | © 2022. Thieme. All rights reserved.\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\nBiometry ( ▶ Fig. 1, 2).\n▪ Obligatory\n– ap diameter of the corpus uteri\n– Measurement of double the endometrium height\n▪ Optional\n– Length of the uterus (length of the cervix/corpus)\n– Transverse diameter of the corpus uteri\nAdnexa\nOvaries\nTo visualize the ovaries, the vaginal transducer is guided from the\nsagittal view laterally to the right or left until the external iliac\nvessels and the ovaries are visible. The maximum visualizable\nlongitudinal diameter of the ovary is then displayed ( ▶ Fig. 3a).\nBy turning the transducer 90°, cross sections of the ovary can be\nadditionally displayed ( ▶ Fig. 3b ). For spatial orientation, the\nimage section should be selected so that segments of the external\niliac vessels are also imaged. If the ovary cannot be visualized, the\nlocation on the corresponding side is documented so that at least\n3 cm of the external iliac artery/vein is shown.\nBiometry ( ▶ Fig. 3):\n▪ Obligatory\n– Measurement on one plane (ovary length, width, or height)\n▪ Optional\n– Measurement on two planes (length, width, and height of\nthe ovary)\nFallopian tubes\nFallopian tubes cannot be differentiated in B-mode unless there is\ncontrast enhancement with respect to surrounding or internal\nfluid. Tubal patency can be checked via transcervical perturbation\nwith physiological saline solution or suitable ultrasound contrast\nagents. Under physiological conditions, flow via the interstitial\nportion of the tube can be viewed directly on the B-mode image\nor using color Doppler or the duplex method.\nPouch of Douglas\nWhen acquiring a sagittal view ( ▶ Fig. 1) of the uterus, the pouch\nof Douglas must also be evaluated. This makes it possible to\ndetect or rule out fluid collections or masses. During the dynamic\nexamination, the movability between the cervix/posterior wall of\nthe uterus and the rectum is also checked. It can be difficult to\nexamine the pouch of Douglas with the uterus in retroflexion.\nPathological findings\nThe following sonomorphological indications of pathological\nchanges or diseases of the internal reproductive organs should\nbe detected:\nUterus\nDeviations from the typical shape and position\nT h eu t e r u si st y p i c a l l yp e a r - s h a p e d ,a n dt h ee n d o m e t r i u mh a sa\nstrictly central position. Deviations with respect to shape and\nposition can be caused by inflammatory or malignant processes\nin the lesser pelvis or can be attributed to benign processes like\nmyomas, endometriosis, adenomyosis, or congenital uterine\nanomalies. For the latter, the high transverse view through the\nfundus is considered critical. Separate endometrial reflections\n(“owl eyes phenomenon ”, ▶ Fig. 4) result in suspicion of a double\nuterus. A detailed ultrasound examination to confirm the finding\nand to classify the congenital uterine malformation is mandatory\nin this case.\nDisproportions between the cervix and the corpus uteri\nPhysiological changes in the proportions between the cervix and\ncorpus uteri during the life cycle must be taken into consideration:\nIn children and often also in seniors, the cervical length compared\nto the length of the corpus uteri is greater than in the reproduc-\ntive phase. Otherwise, an abnormally enlarged cervix can indicate\na cervical myoma, cervical polyps, or cervical cancer.\n▶ Fig. 3 Transvaginal ultrasound of a normal ovary with numerous immature follicles. Longitudinal scan a and transverse scan b of the organ.\n1: Ovary length, 2: Ovary height, 3: Ovary width.\n154 Grab D et al. Basic Gynecologic Ultrasound … Ultraschall in Med 2023; 44: 151 –161 | © 2022. Thieme. All rights reserved.\nGuidelines & Recommendations\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\nChanges in the uterine wall\nThe most common structural abnormalities in the myometrium\nare caused by myomas. Myomas typically manifest as circumscri-\nbed hypoechogenic masses but can also be hyperechogenic or\nisoechogenic in comparison to the uterine wall and sometimes\nhave calcifications or central necrosis.\nThe differential diagnosis between myomas ( ▶ Fig. 5 )a n d\nadenomyosis is typically possible already during the basic exami-\nnation: asymmetrical uterine wall thickness and a typical change\nin the shape of the uterine cavity are characteristic for adenomyo-\nsis (shape of a question mark, ▶ Fig. 6). If there is suspicion of\nadenomyosis, a detailed ultrasound examination should be\nperformed to verify the diagnosis [13]. Particularly in the case of\ncorresponding clinical symptoms, simultaneous ovarian endo-\nmetriosis, endometriosis of the Douglas peritoneum, or deep\nendometriosis with infiltration into the rectum, bladder, or ureters\nmust be ruled out [20].\nUterine sarcomas typically appear as masses with inhomoge-\nneous echogenicity, sometimes with cystic inclusions. Calcifica-\ntions and fan-shaped dorsal acoustic shadowing as can be ob-\nserved in myomas are less common in sarcomas. Sarcomas\ncannot be reliably differentiated from myomas or focal adeno-\nmyosis lesions [21].\nIn general, lesions in the uterine wall are described based on\ninternational classifications and are documented and measured\non two planes (length, height, and width) [12, 22].\nIntracavitary abnormalities\nPathological changes in the endometrium or focal masses should\nbe documented and described according to internationally\npublished standards [11]. The basis for the differential diagnosis\nof intracavitary abnormalities ( ▶ Table 2) is measurement of the\nendometrial thickness, as well as the description of the texture\nand contour of the endometrium or the mass ( ▶ Fig. 7, 8 )a n d\ndetection or exclusion of an intrauterine fluid collection. Color\nDoppler ultrasound examination of the degree of perfusion and\nthe vascular pattern can be helpful to differentiate between\nmalignant and benign findings [15].\nIn premenopausal women, an early pregnancy must be consid-\nered when evaluating intracavitary findings. If there is suspicion of\na miscarriage, proceed according to the DEGUM recommenda-\ntions regarding basic ultrasound examination in early pregnancy\n[23].\n▶ Fig. 5 Sagittal image of uterus myomatosus in anteflexion. Multiple\nintramural myomas of varying echogenicity, some with calcification,\nare seen. The linear endometrium is difficult to delimit.\n▶ Fig. 6 Sagittal view of a uterus in anteflexion with focal adeno-\nmyosis in the posterior wall A. Asymmetry of the wall thickness and\ndeformation of the cavum uteri in the basic shape of a question\nmark (dotted line).\n▶ Fig. 4 Transverse scan of the uterus (upper third of the corpus)\nwith “owl eye phenomenon ”. The two separate ultrasound reflec-\ntions of the endometrium are an indication of a longitudinal fusion\ndefect of the uterus with medial septum formation.\n155Grab D et al. Basic Gynecologic Ultrasound … Ultraschall in Med 2023; 44: 151 –161 | © 2022. Thieme. All rights reserved.\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\nAdnexa\nOvary\nAbnormal findings in the ovaries are presented, classified, and\ndocumented based on international standards [9]. In the basic\nultrasound examination, pathological findings regarding the\novary should be correctly described based on size, wall structure,\ninternal structure, and perfusion and differentiated from physio-\nlogical findings ( ▶ Fig. 9, 10).\nHemorrhagic cysts ( ▶ Fig. 11 ), cystadenomas ( ▶ Fig. 12 ),\ndermoid cysts ( ▶ Fig. 13 ), and endometriotic cysts ( ▶ Fig. 14 )\ncan be diagnosed with high validity sonomorphologically in the\nmajority of cases already in the basic ultrasound examination per\nvisual diagnosis [14, 24].\nIn the case of findings with malignancy criteria ( ▶ Fig. 15)o r\nfindings that cannot be classified as benign with high probability\n(▶ Table 3) [17], a detailed gynecological ultrasound examination\nfor differential diagnosis, risk assessment, and surgical planning, if\napplicable, is needed [14, 24 –26].\nFallopian tube\nThe most common finding regarding the fallopian tube that can\nbe diagnosed on ultrasound is sactosalpinx ( ▶ Fig. 16). The main\nsymptoms on ultrasound are tubular, incompl etely septated peri-\novarian anechoic masses (hydrosalpinx) or dispersed masses (pyo-\nsalpinx, hematosalpinx) [27]. Nodular or thickened wall structures\nand free fluid or dispersed structures in the pouch of Douglas\nindicate an inflammatory process [28]. However, tubal obstruc-\ntion is often associated with endometriosis. It is not always easy\nto differentiate from septated ovarian cysts or an obstructed\nbowel.\nIn the case of unilateral findings together with free fluid and/or\nblood clots in the pouch of Douglas, a tubal pregnancy must\nalways be considered. Ectopic pregnancies are most common by\nfar in the ampullary region of the fallopian tube but can also be\nlocated in the isthmus region or the interstitial region, or more\nrarely can be located in the cervix, the ovary, or in the pouch of\nDouglas. In the majority of cases, targeted sonographic imaging\nof an ectopic pregnancy can be achieved with the criteria shown\nin ▶ Table 4 [29–31]. A high endometrium and a fluid collection\nlocated centrally between the two sides of the endometrium\n(“pseudogestational sac ”) are often additional factors. However,\nthey do not have sufficient predictive value. The same is true for\ncolor Doppler ultrasound imaging of circumscribed vasculariza-\ntion around the ectopic gestational sac. Although this is regularly\n▶ Fig. 7 Sagittal view of the uterus in retroflexion. Thick endometrium\nwith a smooth border to the uterine wall and absence of a central\necho. Depending on menopause status and symptoms, detailed ultra-\nsound examination and histological workup are indicated.\n▶ Fig. 8 Sagittal view a of the uterus in retroflexion, endometrium with poorly defined border to the myometrium, focal perfusion pattern suspicious\nfor malignancy b. Histological workup after detailed ultrasound examination is indicated.\n▶ Table 2 Pathological intracavitary findings: Differential diagnoses.\nEndometrial hyperplasia\nEndometrial polyp\nSubmucosal myoma\nEndometrial cancer\nEndometrial stromal sarcoma\nMiscarriage\n156 Grab D et al. Basic Gynecologic Ultrasound … Ultraschall in Med 2023; 44: 151 –161 | © 2022. Thieme. All rights reserved.\nGuidelines & Recommendations\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\npresent in tubal pregnancies, the corpus luteum has a comparable\nperfusion pattern. Basic ultrasound examination can lead to a\ncorpus luteum being confused with a tubal pregnancy resulting\nin a false-positive diagnosis. I n the case of sonomorphological\ncriteria of a tubal pregnancy ( ▶ Table 4 and ▶ Fig. 17), the urgen-\ncy of a surgical intervention depends on the clinical status of the\npatient and the estimated amount of intraabdominal blood. If the\npatient does not have any symptoms, the further approach is\nbased on the combination of the evaluation of transvaginal ultra-\nsound and the serum beta HCG concentration over time [30]. In\nunclear cases, particularly in the case of suspected heterotopic\npregnancy or in ectopic pregnancies outside the fallopian tube\n(cervix, c-section scar, ovary, abdominal cavity), a detailed sono-\ngraphic examination is recommended as long as the patient is in\nstable clinical condition.\n▶ Fig. 9 Ovary with mature follicle (normal finding).\n▶ Fig. 10 Corpus luteum (normal finding).\n▶ Fig. 11 Hemorrhagic ovarian cyst with fresh bleeding. Masses with\na smooth border with intracystic free-floating, web-like structures\nare pathognomonic here. In follow-up examinations after approxi-\nmately 6 –8 weeks, such findings have usually regressed.\n▶ Fig. 12 Simple anechoic ovarian cyst with a smooth border. The\nfinding is typical for a serous cystadenoma.\n▶ Fig. 13 Simple ovarian cyst with smooth border and mixed internal\necho with hyperechogenic streak-like reflections, round hyperecho-\ngenic portion (*) and dorsal acoustic shadowing (arrow) at the upper\nedge of an otherwise normal ovary with corpus luteum (CL). The\nfinding is typical for a dermoid cyst.\n157Grab D et al. Basic Gynecologic Ultrasound … Ultraschall in Med 2023; 44: 151 –161 | © 2022. Thieme. All rights reserved.\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\nAdnexal torsion\nThe diagnosis of adnexal torsion is based on a combination of\nclinical picture and sonographic criteria (edema and enlargement\nof the ovary and/or fallopian tube and Doppler ultrasound\nimaging of the twisted vascular pedicle = whirlpool sign), which\nare discussed in greater detail in the quality requirements for\ngynecological examinations for DEGUM level II [32]. Since suspi-\ncion of adnexal torsion represents an emergency, the diagnosis\nshould be able to be made in the basic ultrasound examination.\nPouch of Douglas\nFluid collections in the pouch of Douglas should be quantified\n(measurement on 2 planes perpendicular to one another: length,\nwidth, height). The echogenicity of the fluid is also evaluated:\n▪ anechoic = serous fluid,\n▪ dispersed = pus\n▪ inhomogeneous with blood clots = blood.\nIn the reproductive phase small quantities of serous fluid in the\npouch of Douglas are physiological. Sometimes, small blood clots\nare visible in connection with ovulation.\n▶ Fig. 14 Simple ovarian cyst with a smooth border with homo-\ngeneous internal echo with ground glass appearance. The finding is\ntypical for an endometriotic cyst.\n▶ Fig. 15 Cystic-solid adnexal tumor with papillary solid internal\nstructure a and very strong vascularization (color score 4 based on\nIOTA criteria [17]) b. Due to suspicion of malignancy, detailed\nultrasound examination is indicated as the next imaging method.\n▶ Table 3 Basic ultrasound examination of adnexal tumors (IOTA\nsimple rules [17]).\nMalignancy criteria\nIrregular solid tumor\nAscites\nTumor includes at least 4 papillary structures\nIrregular multicystic solid tumor with a maximum diameter > 10 cm\nVery strong vascularization (color score 4)\nBenignity criteria\nUnilocular cyst\nLargest solid portion < 7 mm\nDorsal acoustic shadow\nMultilocular tumor with smooth border < 100 mm\nNo vascularization visible (color score 1)\nEvaluation criteria\nOne or more malignancy criteria, no benignity criteria: Malignant\nOne or more benignity criteria, no malignancy criteria: Benign\nBoth benignity and malignancy criteria\nor\nNeither benignity criteria nor malignancy criteria Unclear*\n* Detailed ultrasound examination is necessary.\n▶ Fig. 16 Sactosalpinx. A tubular shape, incomplete septation, and\nnodular wall structures are characteristic.\n158 Grab D et al. Basic Gynecologic Ultrasound … Ultraschall in Med 2023; 44: 151 –161 | © 2022. Thieme. All rights reserved.\nGuidelines & Recommendations\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\nIn the case of larger fluid collections in the pouch of Douglas,\npapillary peritoneal deposits, masses, or suspicion of obliteration\nof the pouch of Douglas, detailed gynecological ultrasound exam-\nination is indicated as the next diagnostic measure.\nWritten report and documentation\nThe written report includes:\n▪ Date of examination\n▪ Patient data\n▪ Medical issue or indication for the examination\n▪ Image documentation of the following parameters\n– Longitudinal section of the uterus with visualization of the\ncavum/endometrium (measurement of the ap diameter\nand double the endometrium height)\n–\nBoth ovaries (measurement of length and width or height), if\none or both ovaries cannot be imaged, documentation of the\nrelevant adnexal region (with visualization of the external\niliac vessels)\n▪ Abnormal findings (imaging and measurement on 2 perpendicular\nplanes: length, width, and height)\n▪ Description and evaluation of the finding\n▪ Diagnosis\n▪ Further approach\n▪ Examiner\n▶ Table 4 Sonographic criteria for the presence of a tubal pregnancy.\nIntrauterine pregnancy not detected\nInhomogeneous, non-cystic mass next to the ovary (blob sign)\nHyperechogenic ring next to the ovary (bagel sign)\nPositive sliding sign – ability to move the tubal pregnancy toward the\novary\nEctopic gestational sac with detection of embryonic components and/or\nyolk sac\nEctopic gestational sac with embryo with or without detection of cardiac\nactivity\n▶ Fig. 17 Various types of tubal pregnancy: a inhomogeneous, non-cystic mass next to the ovary. b hyperechogenic, ring-shaped mass next to the\novary. c hyperechogenic, ring-shaped mass next to the ovary with free fluid. d hematosalpinx with detection of a gestational sac and a yolk sac\ncontained therein, free fluid.\n159Grab D et al. Basic Gynecologic Ultrasound … Ultraschall in Med 2023; 44: 151 –161 | © 2022. Thieme. All rights reserved.\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\nIn the case of unclear findings in the lesser pelvis, suspicion of a\nmalignancy, or prior to surgical interventions, detailed ultrasound\nexamination is indicated [32].\nConflict of Interest\nThe authors declare that they have no conflict of interest.\nReferences\n[1] Eichhorn KH, Schramm T, Bald R et al. Qualitätsanforderungen an die\nDEGUM-Stufe I bei der geburtshilflichen Ultraschalldiagnostik im Zeitraum\n19–22 Schwangerschaftswochen. Ultraschall in Med 2006; 28: 185 –187\n[2] Merz E, Eichhorn KH, von Kaisenberg C et al. Aktualisierte Qualitäts-\nanforderungen an die weiterführende differenzierte Ultraschallunter-\nsuchung in der pränatalen Diagnostik (=DEGUM-Stufe II) im Zeitraum\nvon 18+0 bis 21+6 Schwangerschaftswochen. 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Basic Gynecologic Ultrasound … Ultraschall in Med 2023; 44: 151 –161 | © 2022. Thieme. All rights reserved.\nGuidelines & Recommendations\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.\n\n\nThis document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.","source_license":"CC0","license_restricted":false}