The role of 3-dimensional ultrasound for the diagnosis of congenital uterine anomalies

doi:10.4236/ojog.2011.14047

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Open Journal of Obstetrics and Gynecology, 2011, 1, 238-241

doi:10.4236/ojog.2011.14047 Published Online December 2011 (http://www.SciRP.org/journal/ojog/ OJOG

Published Online December 2011 in SciRes. http://www.scirp.org/journal/OJOG

The role of 3-dimensional ultrasound for the diagnosis of

congenital uterine anomalies

Efraim Zohav1,2*, Yaakov Melcer1,2, Ilan Tur -Kaspa3, Jacob Rabinson1,2, Eyal Y. An teby1,2, Raoul Orvieto1,2

1Department of Obstetrics and Gynecology, Barzilai M edical Center, Ashkelon, Is rael;

2Ben-Gurion University of the Negev, Beer Sheva, Israel;

3Institute for Human Reproduction (IHR), Department of Obstetrics and Gynecology, The University of Chicago, Chicago, USA.

Email: *[email protected]

Received 17 July 2011; revised 30 August 2011; accepted 18 September 2011.

ABSTRACT

Objectives: To demonstrate the value of 3-dimensional

(3-D) ultrasound (US) in the diagnosis of congenital

uterine anomalies. Methods: Fifty one infertile pa-

tients referred to our US unit during 12 years period,

with suspected diagnosis of congenital uterine ano-

malies by previous HSG or 2D US examinations, were

evaluated by transvaginal 3-D US. The 3-D US diag-

noses were compared to the initial HSG diagnosis,

and to hysteroscopic evaluation when performed. Re-

sults: 3-D scan confirmed the initial HSG diagnosis in

27 out of 51 (52.9%) women. The concordancy rates

between the initial diagnosis by HSG and 3-D US re-

sults were 30.4% for bicornuate uterus; 75% for ar-

cuate uterus; 83% for septate uterus; and 80% for

unicornuate uterus. Of the 13 cases with normal HSG

and suspicious 2-D US, 30.8% were found to be nor-

mal by 3D sonography. In cases where hysteroscopy

was done, the results were 100% in concordance with

the 3-D US evaluations. Conclusions: 3-D US is an

accurate test for the assessment of uterine congenital

anomalies. Its ability to concomitantly visualized, the

external uterine contour with the uterine cavity on

the same coronal plan, makes this noninvasive, easy

to perform test the procedure of choice for the diag-

nosis of uterine anomalies.

Keywords: Mullerian Anomalies; 3-Dimensional (3-D)

Ultrasonography; Hysterosalpingo g rap hy ; Hy st eroscopy

1. INTRODUCTION

Congenital Mullerian duct anomaly is a common cause

of infertility, first trimester abortion, preterm labor, and

fetal malpresentations [1]. Its estimated prevalence va-

ries between 0.1% - 3% [2-4] in the general population

and between 3% to 38% in patients with repeated spon-

taneous miscarriages or with infertility [5-10]. This dis-

crepancy results from the heterogeneous population sa-

mples, the clinical diversity of Mullerian anomalies and

the different diagnostic techniques used.

Several techniques are available for the evaluation of

Mullerian duct anomaly, among which the traditional

hysterosalpingography (HSG) is the most world-widely

used, with its inherent limitation resulting from its in-

ability to detect the ex ternal fund al contour of the uterus.

Therefore, an invasive method which combines hystero-

scopy and laparoscopy has been suggested as the gold

standard for achieving a final diagnosis.

Recently, noninvasive tools such as three-dimensional

(3-D) ultrasound and magnetic resonance imaging (MRI)

have been added to our armamentariu m, with their abili-

ty to demonstrate uterine contours, and therefore to im-

prove the detection and differentiation between septate

and bicornuate uteri.

The use of 3-D sonography with image reconstruction

in the diagnosis of congenital uterine anomalies has al-

ready been described [11-14], enabling the assessment

and accurate demonstration of both the internal and ex-

ternal contour of the uterin e fundus which may easily be

missed by the conventional 2-dimensional (2-D) US [15].

In the present study we aim to further evaluate the 3-D

US imaging in the diagnosis of Mullerian duct anomaly,

and its concordance with other imaging methods, such as

2-D US, HSG and hyst er oscopy.

2. PATIENTS AND METHODS

The medical files of all women who underwent 3-D US

during a 12 year period (1998-20 10). Fo r the purp oses of

this study, patients who were referred with the diagnosis

of suspected Mullerian anomaly by previous HSG or

2-D US examinations were included in this study.

Patients underwent transvaginal 3-D US examinations

using Voluson 530 and Voluson 730 expert (GE medical

System) with transvaginal probes (3-D V-DW5-8B and

RIC 5-9H respectively). All examinations were perfor-

E. Zohav et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 238-241 239

med by the same experienced sonographer (EZ) who was

blinded to the clinical history and HSG/2D US eval uations.

Patients underwent 3-D US during the late follicular

phase of the menstrual cycle [16], because of the in-

creased thickness and echogenicity of the endometrium

compared with the surrounding myometrium, which ena-

bles an easy and accurate interpretation.

Initial 3-D static volume acquisition with high resolu-

tion and sweep angle of 90 degree was done on 2-D ul-

trasound in mid-sagittal view of the uterus. All 3 per-

pendicular planes (sagittal, transverse and coronal sec-

tions) were displayed immediately after volume acquisi-

tion. The plans could be rotated simultaneously for the

complete review of the anatomy. Reconstructed 3-D i-

mages in the coronal plan were further studied to differ-

rentiate major uterine anomalies.

The diagnosis of Mullerian anomaly was made when

good quality imag e showing bo th uterine cavity and fun-

dus in coronal rendered plane was displayed. Mullerian

anomalies were classified according to the American Fe-

rtility Society classification system [1]:

To distinguish bicornate from septate uteri we used c-

riteria based on the presence or absence of fundal inden-

tation of 1 cm or greater above the line connecting the

two tips of the endometrial horns and divergent uterine

horns with an intercornual distance exceeding 4 cm [17,18].

The crite r ia for th e d iag no s is of an arcuate uterus were

a rounded endometrial indentation of the fundus and nor-

mal fundal contour.

Patients’ 3-D US diagnoses were compared to their

HSG and/or 2-D US imaging evaluations. Moreover, if a

patient had undergone a further hysteroscopic evaluation,

the result was also included in our analysis.

Data on patient age and infertility work-up evaluation

were collected from their medical files. The results are

expressed as means and standard deviations.

The study was approved by the institutional Clinical

Research Committee.

3. RESULTS

Fifty one patients met the inclusion criteria. Mean pa-

tients’ age at diagnosis was 32 ± 6.9 years. Mean patients’

gravidity and parity were 0.88 ± 1.38 and 0.29 ± 0.57,

respectively. Among the 51 women, 35 had a diagnosis

of infertility with a mean duration of 4 ± 2.7 years and

16 suffered from repeated miscarriages.

The results of the initial 2-D US and HSG evaluation s

and the subsequent 3-D US and hysteroscopic examina-

tions of the study group are shown in Figure 1.

3-D US confirmed the initial HSG diagnosis in 27 out

of 51 (52.9%) women. Among the 23 cases that were

initially diagnosed by HSG as bicornuate uterus, the 3-D

sonography confirmed the diagnosis in 7 (30.4% con-

cordance), while in the remaining 16 patients, 7 were

diagnosed as having arcuate and 9 with septate uterus.

Hysteroscopy confirmed the 3-D US diagnosis in 1 case

of bicornuate uterus and 4 cases of septate uterus.

Figure 1. Two di mensional-US and HSG evaluatio ns and the subsequent 3D-US and hy steroscopic

examinations of the study group.

E. Zohav et al. / Open Journal of Obstetrics and Gynecology 1 (2011 ) 238-241

240

Four patients were initially diagnosed by HSG as ha-

ving an arcuate uterus. The 3-D sonography confirmed

the diagnosis in 3 (75% concordance) out of 4, and the

fourth case was diagnosed as having septate uterus. Hy-

steroscopy confirmed the 3-D US diagnosis in the case

of septate uterus. Moreov er, in 6 cases that were initially

diagnosed by HSG as suffering from septate uterus, the

diagnosis was also confirmed by 3-D sonography in 5

cases (83% concordance) and hysteroscopy (done in 4

cases).

Unicornuate uterus was initially diag nosed by HSG in

5 cases. While the 3-D sonography confirmed the diag-

nosis in 4 (80% concordance), in the fifth case the diag-

nosis was a bicornuate uterus. Hysteroscopy confirmed

the 3-D US diagnosis in 2 cases of unicornuate uterus.

Thirteen patients were referred to 3-D sonography be-

cause of suspicious Mullerian anomalies by 2-D sono-

graphy despite a normal HSG. 3-D US undertaken in

these patients resulted in 4 normal cases (30.8% concor-

dance), 1 case of unicornuate uterus and 8 cases of ar-

cuate uteri. Hysteroscopy confirmed the 3-D US diagno-

sis in 1 case of normal uterus and 1 case of arcuate uterus.

4. DISCUSSION

In the present study, 3-D US study of patients with sus-

pected uterine mullerian anomalies by 2-D US and HSG

confirmed the initial diagnosis in 52.9% of women.

Clear visualization and satisfactory images of the uterine

cavity were obtained in all patients without exclusion.

The best concordance between 3-D US results and the

initial 2-D US and HSG diagnosis was with regard to

septate uterus (83% concordancy), while in unicornuate,

arcuate and bicornuate uteri the concordancy rates were

80%, 75% and 30.4%, respectively. Of patients with

normal HSG and suspicious 2-D US, 3-D US revealed

uterine mullerian anomalies in 69.2%. In the 14 patients

undergoing hysteroscopic evaluation, all results were in

agreement with the 3D US studies (100% concordancy).

Our results support other studies demonstrating that

3-D US should become an important method for the as-

sessment and the diagnosis of congenital uterine anoma-

lies. In 1995 Jurkovic et al. [13] compared 2-D and 3-D

ultrasound and HSG, finding both ultrasound modalities

to have high predictive value for larger anomalies, espe-

cially in the differentiation of bicornuate and partially

septate uteri. Raga et al. [14] found 3-D US to have a

91.6% accuracy in the study of the fundus and 100% in

that of the cavity, compared to laparoscopy and HSG,

respectively. Wu et al. [19], while comparing the 3-D US

with laparoscopy and/or hysteroscopy, found 3-D ultra-

sound to have a 92% accuracy in the diagnosis of septate

uterus and 100% for bicornuate uterus. Further studies

comparing 3-D US to endoscopy revealed sensitivity of

97% - 100%, specifity of 96% - 100%, positive predic-

tive value of 92% and negative predictive value of 99%

in the diagnosis of Mullerian anomalies [20,21] with a

96% concordance between ultrasound and endoscopy

with respect to the type of anomaly diagnosed [21].

Compared to 3-D US, the 2-D US, while being a sen-

sitive method for detection of uterine anomalies [15,18],

it provides only a limited view of the uterine fundus and

therefore cannot reliably differentiate between arcuate,

bicornuate, and septate uteri [17,22]. HSG provides in-

formation on uterine cavity contour and tubal patency,

however, its limitations results from its inability to clas-

sify the different subtypes of congenital uterine anoma-

lies and to patients’ exposure to ionizing radiation [23].

Hysteroscopy, on the other hand, is the gold standard

diagnostic technique for endometrial cavity abnormali-

ties, which can help revealing fundal septa suspected or

unrecognized on HS G or ul trasound examinations [24] .

3-D US overcomes th e limitation of 2-D US and HSG

by providing a coronal view of the uterus, which can

rarely be seen by conventional 2-D US [13]. Recently

[25], the value of 3D ultrasound in detecting congenital

mullerian anomalies was found as accurate as MRI.

The coronal view enables th e visualization of both th e

endometrial cavity and uterine fundus, thus providing all

information necessary for a complete assessment of the

nature and extent of the congenital anomaly and also

facilitating the differential diagnosis between various

fusion defects. The examination is performed in a stan-

dardized plane using corneal-interstitial portions of the

fallopian tubes as the reference point, which enables

quantitative description of uterine morphology. In addi-

tion, 3-D volumes can be stored on disk and re-examined

later, which facilitates audit and independent v erification

of the diagnosis [13,14,19 ].

In conclusion, 3-D US is an excellent, noninvasive, and

accurate technology, which can serve as the gold standard

in the assessment of congenital uteri ne anomalies.

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