What Most Doctors Miss in Ultrasound | Interactive Live Session

Added: 2026-04-30

[00:00:08]Greetings from Bilmed group of institutions. Today we are taking interactive sessions uh for our registered candidates.

[00:00:18]Uh I repeat, this is not a course, this is not a class right now what we are conducting, but an interactive session for those who are already on server and uh are taking different uh you know uh server-based courses and uh those candidates are having uh uh questions at regular intervals. So, here we are taking these uh interactive doubt clearing sessions for registered candidates.

[00:00:42]Uh please make a note that uh I will not show much of uh you know uh the clips, the uh ultrasound images because uh these are uh in detail in our courses. I will be taking just questions, the doubts, and explanation if any required uh in any topic or any subject. Uh We have got uh questions from our uh registered candidates. So, the first question uh is you can read the question over here.

[00:01:15]Now, uh these are the copy-pasted questions. What I mean by copy-paste, as we got the question, we just copied and pasted, so the uh language is original.

[00:01:25]This is uh the first question by Dr. Kiran Singh uh who's from Lucknow.

[00:01:31]Endometrial thickness measurement in uh value in different phase of life.

[00:01:39]Now, I'm elaborating the question. As I told you, these are the original question, the language is original, these are copy-pasted message uh questions from our candidates. The candidate uh Kiran Singh wants to know about the endometrial uh thickness uh and the values in different uh phases.

[00:01:59]Now, the phases of life is one and the phases of cycle is second. I will take both.

[00:02:06]So, here it is not very much clear whether uh it is for the phase of life, like uh what will be the measurement in childhood, adulthood, then adolescence, and so on. Uh and second is the phase of cycle, that is completely different. So, uh I will be taking both uh phase of life as well as the phase of cycle.

[00:02:33]Just bear with me. Yeah.

[00:02:36]Now, first of all, uh let's discuss the endometrial thickness measurements in different phases.

[00:02:45]Phases of uh you know uh the uh cycle.

[00:02:48]Uh first of all, in menstrual phase, you all know it is very thin uh because the endometrium is a thing due to the shed off. Uh here the menstrual in menstrual phase, it will be about a 2 to 4 uh millimeters and it increases in uh proliferative phase. In early proliferative, it is about a 4 to 6 and in uh late uh proliferative phase, it's increasing. And in a secretory phase, it is at its maximum thickness uh over here. Uh and in post-secretory, which is the uh premenstrual uh phase, it is variable.

[00:03:26]It is variable. So, these are the measurements uh in different phases uh of the menstrual cycle. Now, uh endometrial thickness in different phases of life.

[00:03:38]Uh in uh childhood age, uh endometrium typically is a very, very thin uh due to the uh lack of the estrogen simulations. So, in uh childhood, you will not uh see much of the endometrium.

[00:03:54]Uh and in a reproductive age, the menstrual phase of the reproductive age is about a 2 to 4 millimeters. It is thin just after shedding again. And in uh proliferative phase of a reproductive age, it is about a uh 4 to 10 millimeters. And in secretory phase, it is increasing. It is like uh we just have discussed about the uh you know, different phase of the life. Uh over here in pregnancy, it is uh of course it is increased. It is more than 12 uh millimeters, but it will be variable over here. In premenopausal, uh it is variable and irregular.

[00:04:33]So, uh usually it is irregular over here. And in postmenopausal, here you have to see whether the patient is on HRT. If no HRT is there, then it has to be less than 5 millimeters.

[00:04:48]But if the patient is on HRT, then up to 8 is accepted.

[00:04:54]So, if patient is not on HRT and it is 8 uh millimeters, that is abnormal.

[00:05:00]So, on HRT, it is more than with no uh uh HRT. It is due to the hormonal therapy uh which is maintaining the thickness over here.

[00:05:11]Uh so, interpretation depends on the regime.

[00:05:15]So, these are the uh endometrial thicknesses in different phases of life as well as in different phases of the cycle.

[00:05:24]Now, the second question from uh Dr. Sakina Johar, who is from Madhya Pradesh, is that uh how to look for cord round neck.

[00:05:35]Now, this doctor wants to know uh how to look uh for a cord which is around the neck.

[00:05:43]Uh second question, how to look for cord insertion. These are two different questions. One is how to look for a cord insertion, another is how to look for a cord round neck. And the third question, which is completely different, is that how to look for an coronal ectopic pregnancy.

[00:06:04]So, these are the questions from uh Dr. uh Sakina Johar.

[00:06:09]Uh first, uh there is a detailed uh class uh on the cord cord round neck. I think uh that this uh candidate has not yet completed the cord round neck class.

[00:06:23]Uh it is strongly recommended to complete the class first, then uh go for any uh you know, uh this question. This is not a question itself, it is a topic, but I will take in brief. But uh I am requesting you to go to the class and complete the class of the cord round neck. It is about a 30 to 35 minutes class where we detailedly uh discussed about the cord round neck. We showed the patients also uh live patients also uh the cord round neck and the loop which is just uh lying around uh near the neck, how to differentiate it.

[00:07:00]So, uh the question is posted. I have to reply to over here. Now, first of all, the cord round neck.

[00:07:07]In cord round neck, see, in cord round neck, first of all, the transverse section is important. Transverse section, not the longitudinal section.

[00:07:17]So, transversely you have to see through the neck, then only it will make sense.

[00:07:23]Otherwise, if you take a longitudinal section, maybe that you are hitting onto the cord which is just near the neck, not round the neck. That way you will be over diagnosing a case. Uh so, the moral again is that please complete the class first and then pose the question. So, anyhow, transverse section is very important uh with color uh to diagnose or to rule out any cord round neck. So, what will be you seeing on ultrasound is that there will be U-shaped loops uh which should be uh you know, uh encircling the neck.

[00:07:55]Uh and clinical uh significance is not much unless and until it is a tight loop.

[00:08:02]Uh then the next question will be here, how to look for a uh uh you know, single loop or a multiple loops uh around the neck. Uh I'm again requesting you to go to the uh server class which is uh in detail over there.

[00:08:15]So, in uh brief, you have to uh take a transverse section, uh not a longitudinal section.

[00:08:23]Second question, cord insertion uh on the placenta. How to see for a cord insertion onto the placenta.

[00:08:31]Uh now see, the cord insertion onto the placenta is very important. In each and every patient, you have to see for the cord insertion. In uh fetal ultrasound uh course, we are having about a four classes, if not uh five classes, uh regarding this cord insertion, uh why it is important, how to see for that, what is the significance.

[00:08:53]Uh so, in uh brief, uh the cord insertion, if uh you know, central insertion of cord which is normal. So, you have to make sure that it is centrally inserted because if it is not centrally inserted, it can be a battledore.

[00:09:10]Uh which is also a velamentous cord insertion. Now, this velamentous cord insertion is very, very tricky over here because if you see a velamentous insertion of cord, then you have to see for the uh the connection.

[00:09:25]Uh from the insertion of cord to the placenta. It can be direct, it can be indirect. If it is indirect, then it is very, very uh dangerous. It can be a uh you know, vasa previa case also.

[00:09:38]So, uh scan first of all, the placental surface in longitudinal as well as in transverse planes using color Doppler.

[00:09:50]Color Doppler will not show you the cord insertion, but unless and until you don't have a good grayscale image, then you have to superimpose a color color onto the the good grayscale image, then only color will work over here. So, the moral is that the placental surface has to be scanned both in longitudinal and in transverse sections using the color.

[00:10:17]Uh that was the second question. Third question is that is regarding the ectopic pregnancy, which is said we have discussed Let me discuss the coronal ectopics. In coronal ectopics, now see the point here is that in coronal ectopics, the gestational sac will be having some myometrium around it.

[00:10:43]First of all, the location where it will be. It will be somewhere in the corona.

[00:10:47]Now there will be sorry, myometrium around the gestational sac, but the important part of how much that endome- again, endometrium myometrium will be around it is less than 5 mm, which is called as the interstitial line sign. So, if you see an 5 mm less than 5 mm myometrium, that is an interstitial line sign, which is very much typically seen in these coronal ectopics. So, 5 mm less than 5 mm interstitial line sign seen will be suggestive of an coronal ectopic pregnancy. But I recommend here that high resolution transvaginal ultrasound.

[00:11:35]So, use a high resolution transvaginal ultrasound because sometimes you may not see a clear myometrium because it is very thin around the gestational sac, thereby you may not be you know very much accurate in diagnosing the coronal ectopic So, use a high resolution vaginal transvaginal ultrasound to make a or rule a rule out a diagnosis of a coronal ectopic pregnancy.

[00:12:07]Now, the next question is It's just order.

[00:12:14]Yeah.

[00:12:16]Next question from Dr. Shantanu who is from Kolkata is you know, the ovarian cancer.

[00:12:25]It is not actually a question. It is a class in itself. The two words will take me about a 10 minutes. So, ovarian cancer, what I am again requesting you that in gynecology ultrasound course in detail we have discussed there how to make a diagnosis of an you know, benign versus malignant case ovarian, I mean.

[00:12:51]So, this doctor may not have gone to that class and have posed a question over here. We will take it in brief.

[00:13:03]So First of all, what you have to see the morphology. You have to see the morphology.

[00:13:11]Uh in ovarian CA, it will be multilocular and there there has to be septations, then only you will be thinking all lines of an ovarian CA.

[00:13:24]Uh next is the solid component. These things are in detail in class.

[00:13:29]Please revise the class or maybe that you have not even touched in that class.

[00:13:33]I'm just giving you a recap over here.

[00:13:35]Solid component, this solid component if seen in a cystic area. Now see, you see a mass over there, you see a cyst over there. In that cyst, there is a solid mass. That is also a strong predictor of malignancy. Now, this solid mass has to be you know about a 7 mm.

[00:13:57]If it is less than 7 mm, say it is two or three, that is not going in favor of malignancy. And if it is less than 7 mm, it is going in favor of this mass. So, again it covered in detail in the class of the gynecology where we have in detail discussed about these ovarian CAs. Now, the papillary projections.

[00:14:23]The papillary projections if seen is highly suspicious for carcinoma.

[00:14:28]So, see for any papillary projections and how much the papillary projections has to be there four.

[00:14:34]So, less than four is not going in favor of more than four is strongly going in favor of the ovarian CA. So, how they will be looking like the papillary projection, the echogenic protrusions in the cystic cavity. It will be like these, you know, going inside the cyst like the papillary projections going in.

[00:14:54]And how much? Four and more.

[00:14:58]Then surface irregularities, surface irregularities lobulated or irregular outer contours is also going in favor of an ovarian cyst. Then ascites of course, if you see an ascites in a few in a patient with an ovarian mass, that is also going in favor of ovarian CA. Then you are you know, Doppler.

[00:15:24]You don't You don't have to start from Doppler. You have to end on the Doppler.

[00:15:27]So, Doppler if showing the central flow with a low resistance index is going in favor of the ovarian CA.

[00:15:38]And the size matters here. Size do matter. If the overall cyst overall cyst is 10 or more more than 10 is going in favor of an ovarian CA and less than 10 is not going in favor of ovarian CA. One criteria is not making or excluding a diagnosis. You have to put you know, multiple criterias in the basket before making the diagnosis. And if you see a bilateral involvement, sometimes it is seen in advanced cases, especially in these epithelial ovarian cancer. So, see whether it is unilateral or bilateral. So, this was a recap. I'm again repeating. This was a recap of an ovarian CA. For detailed detailed class and explanation, please complete your gynecology ultrasound course.

[00:17:03]Next question from Dr. Toyer Toyerate. Very sorry if I'm not pronouncing it rightly. Is that is there any trick to identify left ovary in TS and TVS both? I just see. I find it difficult to see left ovary. So, this is the question.

[00:17:25]So, the question in nutshell is that how to see for an ovary. Sometimes this doctor is not getting an ovary on TS or maybe on TVS. First of all, I have told you in detail in the gynecological ultrasound course that the ovarian you know, location is not fixed.

[00:17:47]It will depend.

[00:17:49]Sometimes the ovary right ovary will be here, left you will not be exactly there. Where you are expecting will be higher or lower down.

[00:17:59]So, the ovarian location is not fixed. You have to search for an ovary. First of all on transabdominal scan. Make a note.

[00:18:09]First of all, on transabdominal ultrasound, you have to start the uterus to scan in sagittal view. In sagittal section, start from the sagittal section. Keep your bladder full, which is helping you in you know, uh uh in uh penetrating the beam, I will say. Uh second is that you have to sweep probe lateral to the left adnexa.

[00:18:39]Now see, lateral to the left adnexa.

[00:18:42]Third landmark. Keep the landmark in your head. Landmark is the left iliac vessel.

[00:18:50]Ovary is just lying medial to it.

[00:18:54]So, try to see for an iliac vessel. If you are not getting the ovary, try to see the left iliac vessel because it is the landmark over there. Then keep an appearance in the mind because not always the ovary will be a round or the other shape. Usually it has to be the oval structure with small anechoic fluids, these follicles, I say.

[00:19:19]Because why I'm saying this appearance?

[00:19:21]Because sometimes you'll be cutting the you know, muscle or any tissue over there. And if you are seeing it more of round, then maybe that it is not an ovary. So, keep the appearance in your mind. Then uh the tip over here is that apply a gentle pressure. Apply a gentle pressure, not a hard. Gentle pressure. Why? Because you want to displace the bowel gases. So, apply sometimes you may have to apply a gentle pressure over here. In TVS, again, you have to begin from the sagittal section. It means from the longitudinal section. Then, rotate the probe towards the left thigh to sweep in the left adnexa.

[00:20:11]You have to be very clear about the anatomy. Sonoanatomy, I mean.

[00:20:15]Ultrasound is not about the photography.

[00:20:17]It is the real test of your neurons. So, apply your anatomy onto the screen.

[00:20:23]That is the sonoanatomy. So, here you have to rotate the handle towards the patient's left thigh to sweep into the left adnexa.

[00:20:34]Then, the landmark uh the ovary is lateral and posterior to uterus over here. And sometimes, it will be cranial.

[00:20:44]So, you have to understand. You have to now You are mature enough now.

[00:20:47]Uh if you have completed the course, you are mature You know what I mean by the lateral oblique posterior to uterus. And sometimes, it will be cranial.

[00:20:57]And appearance, again, you have to see for the stroma, and there will be multiple small follicles over there. And tip here is that use a color Doppler to confirm that there is an ovarian vessel and differentiate it from bowel.

[00:21:15]So, the teaching notes over here is that symmetry check.

[00:21:21]Compare with the right ovary for orientation.

[00:21:25]We are right now talking of the left ovary, how to scan the left ovary. So, here you have to compare it with the right ovary.

[00:21:34]Probe manipulation, small, you know, rotation, small rotation and angulations sometimes reveals the hidden ovary.

[00:21:44]And patient's position, it is also important. Slight tilt, you know, all the bladder adjustments can improve the visualization.

[00:21:53]So, these are the teaching notes to scan to get uh uh uh ovary uh in a given case. We are talking of the left ovary because this question was about to how to identify the left ovary.

[00:22:08]Next question from Dr. Bhamidipati is that how should I differentiate CBD stones from CBD tumor?

[00:22:22]I'll see.

[00:22:24]First, give a thought.

[00:22:26]If there is a stone, what the ultrasound picture will look like?

[00:22:33]And if there is a CBD tumor, what that will look like?

[00:22:41]The stone, first of all, the stone will be hypoechoic.

[00:22:46]The tumor will not be always hyperechoic. It will be hypoechoic.

[00:22:51]The stone will have, you know, defined contours.

[00:22:56]The tumor will not have defined contours.

[00:22:59]CBD stones will give you acoustic shadowing.

[00:23:03]The tumor will not give you acoustic shadowing.

[00:23:07]The CBD itself will have abrupt tapering.

[00:23:12]Where is the stone? Then, there will be abrupt tapering. Whereas, in CBD tumors, it will not be there.

[00:23:20]So, these are the practical tips which will make you understand whether this the stone or a tumor. Now, let me elaborate this.

[00:23:30]First of all, echogenicity.

[00:23:32]So, CBD stones are more hypoechoic.

[00:23:35]Okay, try to understand. It will It has to be more hypoechoic as compared to the tumor. Whereas, the CBD tumors, those are hypoechoic or sometimes isoechoic. But, it will never be hyperechoic.

[00:23:51]Margins.

[00:23:52]Just now I told you, well defined and round or oval if CBD stones. And why a tumor will be having a you know, well defined and area?

[00:24:03]Why Why the margins will be well defined in case of a CBD? So, CBD will be Sorry, tumor CBD tumor will have an irregular or nodular surface. Whereas, the margins will be sharp in case of a stone.

[00:24:18]Now, one more thing. CBD stones So, stones can, you know, change the position.

[00:24:26]So, sometimes, you will be seeing not always, but sometimes if you see a mobility in an area, and if you are thinking on lines of a tumor, it is not tumor at all. Why a tumor will move? So, CBD stones may have I'm using one may may have a you know, changing change in the position. So, it will be mobile. So, you have to change the patient's position to see whether it is mobile or not. And why a CBD tumor will have any type of mobility. So, it has to be fixed only if it [clears throat] is CBD tumor.

[00:25:03]So, location. Location also matters.

[00:25:06]The CBD stones are often distal.

[00:25:10]I'll see. Try to understand. These are distal.

[00:25:13]So, if you see a distal uh thing, then it is going in favor of uh the CBD stones.

[00:25:21]Whereas, these tumors can occur anywhere.

[00:25:26]Tumors can occur anywhere. But, if it is stone, it is usually uh you know, at the distal CBD or maybe at ampulla.

[00:25:35]So, ductal dilatation. Just now I told you in the start of this explanation that the ductal dilatation proximal biliary dilatation will be there, and there will be abrupt cut off at the stone level.

[00:25:52]So, abrupt cut off at the stone at the area is going in favor of CBD stone. Whereas, gradual tapering or irregular narrowing of the duct is going in favor of tumor.

[00:26:06]And your magic stick, whatever you say magic stick, is not actually a magic stick.

[00:26:12]This color Doppler. Color Doppler is not with this stack. So, with color Doppler, you have to add to the case. Then, you will be putting sometimes the color Doppler to see whether there is any vascularity.

[00:26:25]And if there is any vascularity, that is going in favor of tumor. And why a stone will have any type of vascularity.

[00:26:33]So, of course, the associated findings in CBD, many a times, not, you know, rarely, many a times, you will be seeing some gallstones. So, if you see some gallstones, and you are thinking on lines of a CBD tumor, think twice.

[00:26:52]It is usually seen in a CBD stone. So, if you are thinking on lines of CBD tumor, and there are some gallstones, you have to double-check it.

[00:27:04]So, this way uh you will be differentiating whether I am dealing with a CBD stone or a CBD tumor.

[00:27:15]Now, the next question, let me go to the next question. Before next question, the diagnostic tips over here is that try to use a high-frequency linear probe.

[00:27:27]So, there is a linear probe. If there is a linear probe with you, so try to put a linear probe because with the linear probe, the resolution is very high. The only drawback or with these linear probes is that the penetration is the issue. So, if the patient is thin, and you are having a linear probe, try to put a linear probe.

[00:27:47]Because the clarity will be very high with these linear probes. And uh if you are having any type of confusion, you can uh you know, go for this edition for for this thematic.

[00:28:04]Now, somebody is posting, "What is this?"

[00:28:09]So, what is the name? Dr. Tas Tasneem Fatima is posting, "Is this a fibroid?"

[00:28:16]I'll see.

[00:28:17]We are not photographers here.

[00:28:20]One image will not make a diagnosis.

[00:28:24]You have to put multiple things.

[00:28:27]Uh you have to put all your knowledge.

[00:28:28]You have to put uh your anatomy, uh your clinical knowledge over there, your probe orientation. So, then we can make a diagnosis. So, this is not accepted uh but it is already passed. To me, uh this picture I have to comment. First of all, see this thing.

[00:28:48]Looks like a fibroid. Looks like a fibroid. Why it looks like a fibroid?

[00:28:52]Because there are some calcifications.

[00:28:54]Looks like there are actual calcifications over here.

[00:28:59]And yes, going in favor of uh a fibroid. This area is hypoechoic.

[00:29:07]Goes in favor of a fibroid.

[00:29:10]So, uh what will be the polyp echogenicity? Polyps are usually hypoechoic because as is the mother father, so will be the son. That is already covered in the classes. Because this five These fibroids are derivatives of myometrium. Whereas, the uh this uh polyps are derivatives of endometrium.

[00:29:32]Endometrium is more echogenic as compared to myometrium. So, the fibroids, which are in derivatives of myometrium, will be hypoechoic. So, looks like hypoechoic.

[00:29:46]Looks like there are some eggshell classifications so these two findings are going in favor of fibroid. Third one.

[00:29:53]Third one, what can I make out with the still image is that the contours now see the contours are regular over here. The contours are regular. Looks like it is going in favor of fibroid.

[00:30:05]So whether it is an intramural or a pan mural on the still image I cannot make out but it is not a subserous fibroid.

[00:30:14]It's not distorting the the contours.

[00:30:19]Looks like a fibroid but I have to see more cine loops and more clips but yes it looks like a fibroid.

[00:30:31]Next question, how to differentiate clearly an unobliterated uterine cavity and a subchorionic bleed?

[00:30:40]Doctor Kala Muna from Kerala is posting this question. For this we have to recall all our early pregnancy classes. In our early pregnancy classes we have discussed in detail about this unobliterated uterine cavity and how to differentiate it from a subchorionic bleed.

[00:31:04]Location first. Location here in unobliterated uterine cavity is central.

[00:31:11]Whereas in case of an hematoma it will be not in the center always.

[00:31:18]Relationship to the gestational sac.

[00:31:21]So if it is an unobliterated uterine cavity I know who has not completed the early pregnancy ultrasound course may not understand what I am saying about but those who are already have completed the early pregnancy ultrasound will understand it better. So a relationship to the gestational sac here is you know within the cavity.

[00:31:47]Sac lies within the cavity. Cavity surrounds the sac.

[00:31:53]Whereas over here it is often lifting the chorion up.

[00:31:59]Over here the appearance. The appearance here in unobliterated uterine cavity it is you know not the blood. Try to understand. Then I'll not be telling you uterine cavity you could have blood. So it will be an echoic or hypoechoic. So it will be isoechoic.

[00:32:17]Whereas here it will be heterogeneous because sometimes I will be have old blood, fresh blood, clot over there. So here the question of heterogeneous does not arise. So the appearance, the echogenicity is telling me the shape.

[00:32:33]Shape here it will be symmetrical.

[00:32:37]Whereas here it will be crescentic. The margins here will be smooth because it is not an hematoma. It is an unobliterated uterine cavity.

[00:32:46]So the margins has to be smooth over here. Whereas the bleed will have an irregular margins. Clinical context, it is normally seen this unobliterated uterine cavity is a normal finding.

[00:33:00]Which is seen in a very early pregnancy.

[00:33:04]Whereas if there is a subchorionic bleed it is associated with the risk of the miscarriages and the risk depends on the size. So the take home points is that unobliterated uterine cavity is usually seen in very early pregnancy. I am using word very.

[00:33:27]Very early pregnancy whereas the subchorionic bleeds appears as a separate hypoechoic area outside of the sac which is lifting the chorion.

[00:33:40]So the probe manipulations sometimes sweeping in multiple planes helps to confirm whether I am dealing with this or that.

[00:33:49]So clinical correlations you all know that the subchorionic hematomas are you know linked with the threatened abortion whereas the unobliterated cavity is a normal early pregnancy finding.

[00:34:05]Last question probably Doctor Anita from UAE is posting how to diagnose anterior posterior wall submucosal fibroids.

[00:34:17]That is first. And the second is how to diagnose ovarian torsion.

[00:34:22]This candidate Doctor Anita has not yet completed the class. I am very much sure. Has not yet completed the class all classes I mean of gynecological ultrasound otherwise the question would not arise.

[00:34:36]So now if we are talking of the fibroids fibroids anterior wall fibroids will distort the anterior uterine contour.

[00:34:48]And it can compress onto the bladder also. So if you are seeing a distortion in the anterior uterine contour it is an anterior fibroid. It can be due to the anterior wall fibroid. And posterior will distort the posterior contours and can compress on the rectum.

[00:35:04]So if patient is having just give you a clinical you know correlation if patient is having any urinary incontinence that can be due to the anterior wall fibroid and if patient is having you know some something related to the rectum maybe she is having a she is having some something which is not relating her that is Sorry. That is due to the compression on the rectum so you have to >> [clears throat] >> you have to see it clinically also. Now the submucosal fibroids are protruding into the endometrial cavity. These are very dangerous fibroids because if there are submucosal fibroids patient may have many clinical findings and if it is an infertile case that can be due to the submucosal fibroids because it is protruding into the endometrial cavity. And intramural is within the myometrium. So if you see a hypoechoic mass like we just saw fibroid where somebody was posting whether it is a fibroid or not that was intramural and neither distorting the contour nor compressing onto the endometrial cavity. That is the intramural. So subserosal is projecting outside the uterine surfaces. These are pedunculated and sometimes they can mimic you know the adnexal masses. So these are different types of fibroids. Then coming to the ovarian torsion the next question ovarian torsion.

[00:36:53]First of all the size.

[00:36:55]The size of the ovary will be increased.

[00:36:58]Why it is increased? Because I am having a congestion over here that can be due to the venous or the lymphatic congestion.

[00:37:06]So overall ovarian size will be increased.

[00:37:10]Follicular pattern. So peripheral displacement of the follicle the string of appearance will be very much prominent over here in case of ovarian torsion.

[00:37:21]Stroma. Stroma here will be hypoechoic.

[00:37:24]This again is due to the edema or sometimes the hemorrhage.

[00:37:30]Color Doppler. Over here if it is an ovarian torsion the color Doppler will show me absent or reduced venous flow and sometimes the arterial flow also.

[00:37:44]So the color Doppler is essential for confirmation over here. Not always color Doppler is useful but in some cases you cannot make a 100% diagnosis without a color Doppler. So in case of an ovarian torsion the color Doppler if showing an absent or reduced venous flow is a very positive sign for you to make a diagnosis of an ovarian torsion.

[00:38:10]Whirlpool sign. So twisted vascular pedicles are seen on color Doppler which is very much pathognomonic for these ovarian torsions and sometimes free fluid is seen.

[00:38:24]If it is seen it is also going in favor of these ovarian torsions.

[00:38:32]So the take home message is that fibroid diagnosis the location depends on the relationship to the endometrium and the uterine contour. Submucosal fibroids are seen if they are distorting the endometrial stripe.

[00:38:51]And ovarian torsions requires a color Doppler. Absence of the flow is more sensitive than venous is more sensitive than this arterial. Always correlate with clinical symptoms. This ovarian torsion always you have to correlate with the clinical you know symptoms when you are talking of this ovarian torsion.

[00:39:17]We have more questions.

[00:39:19]Yes.

[00:39:21]Now see Doctor Sweta from Maharashtra is posting these questions this set of questions. Uterine findings of fibroids.

[00:39:29]Differential differentiate uterine AV malformation from how to differentiate placental dysplasia from trophoblastic disease.

[00:39:44]How is peritoneal fluid volume calculated? Why are POCs blood flow in transverse and not in longitudinal section? I told you these are copy-pasted questions. The language is origin from the candidate.

[00:39:59]We want to don't want to change the you know the language of the questions.

[00:40:05]So, UAE findings of the oophoritis.

[00:40:07]First of all, the ovary Ovary itself will be enlarged. So, if you see an enlarged ovary with an heterogeneous echotexture. Now, see this enlarged ovary was seen in the torsions also.

[00:40:24]So, but here the ovarian capsule will be thickened.

[00:40:29]And the vascularity, now see the importance of vascularity color Doppler.

[00:40:33]Just now told you that color Doppler is very important for in those cases because over here the vascularity will be increased.

[00:40:41]Whereas, in case of torsion, vascularity will be decreased. Sometimes the tubo-ovarian masses or abscesses can form and it has to be have an association with a pelvic inflammatory disease or you'll be expecting some free fluid also in case of oophoritis. Now, the next question is differentiating how to differentiate any uterine AV malformation from an RPOC. Now, see the AV malformation uh where we'll be seeing these malformations is in the myometrium. Now, try to try to understand here. In the myometrium. Whereas, these RPOCs are in the endometrial cavity.

[00:41:26]So, location matters here.

[00:41:29]And Doppler. Now, see this Doppler will show me high velocity with low resistance.

[00:41:36]It means that this diastolic flow is more.

[00:41:40]Whereas, in case of these RPOCs, it has to be moderate and usually low velocity.

[00:41:47]So, high velocity is going in favor of AV malformation, but location matters over here. This is in the myometrium and this is in the endometrium. Location is intramyometrial whereas, the location in RPOCs is endometrial cavity. So, of course the clinical correlation, if the patient is post pregnancy or post you know what I teach, then you'll be thinking on lines of uterine mal- AV malformation. Whereas, if it is post delivery or abortions with bleeding, then it can be case of RPOCs.

[00:42:31]I told you in the beginning that we'll not show you much of slides over here because these these are question and answer sessions.

[00:42:39]In detail, we are covering all these topics in the course.

[00:42:44]Enrollment drawings, okay. What is next over here?

[00:42:53]So, next is how to differentiate a placental disc uh dysplasia from a trophoblastic disease.

[00:43:05]Now, first of all, appearance.

[00:43:08]First of all, the appearance. The placental dysplasia will be localized. Try to understand. It has to be localized abnormal tissue.

[00:43:17]Localized over here. Whereas, trophoblastic disease will be diffuse.

[00:43:22]So, Doppler here helps me by showing a variable or maybe a reduced flow over here. But in case of this trophoblastic disease, it's markedly vascular with a high velocity flow.

[00:43:38]So, clinically focal placental abnormality and over here the elevation of the beta hCG will be seen with the uterine enlargement.

[00:43:51]So, last question is peritoneal fluid calculation. Now, see it has to be quantitative.

[00:43:58]That has to be fact. It has to be quantitative. First of all, it has to be quantitative.

[00:44:03]What we are taking, we are taking a rough estimate of the volume by the depth of the fluid in the pelvis.

[00:44:12]Which is measured over there. So, it is the rough estimate of the volume and we use the formula to calculate the approx this uh quantity by taking the depth, width, length and the direction factors. So, in practice we give the minimal and moderate and massive. We don't exactly We cannot exactly measure the peritoneal fluid. So, this is a rough calculation where we are giving the minimal, moderate and massive fluid calculations.

[00:44:56]Uh next.

[00:44:59]Next is why RPOC flows are seen in transverse section. So, this is a very good question. I appreciate this question. Why RPOC flow is seen more in transverse section is because the vascular channels in RPOC are oriented itself in the RPOC. They are oriented across the endometrial cavity.

[00:45:25]So, try to understand. The reason is that the exact orientation of these vessels in RPOC is transversely across the endometrial cavity. That is why it is more better seen in transverse sections.

[00:45:44]In longitudinal planes, you may miss due to the angle dependence. So, teaching notes.

[00:45:53]Always use color Doppler to differentiate vascular lesions, that is AV malformations from RPOCs. Snow pattern is the classic for trophoblastic disease. Transverse Doppler orientation is the key for RPOC evaluation. And of course the clinical correlation, that is the history of pregnancy. Great bleeding is essential for accurate diagnosis.

[00:46:20]So, this is all for now.

[00:46:25]Ah, I am having something else. Now, let me clear everything first.

[00:46:35]Now, see what is this?

[00:46:38]I have read that in gray scale uh angle should be used for 90. Let me first read this very quickly at 90°.

[00:46:50]In the biology separate to discuss.

[00:46:54]Oh my god.

[00:46:58]Doctor Gurudashan Iqbal Singh from Punjab is trying to understand. I got him.

[00:47:08]He's trying to understand the complete physics. I appreciate. This is very good. This is a good sign.

[00:47:17]Look, if we will talk about these all points, it will take you know, 15 to 20 days.

[00:47:26]These points only.

[00:47:28]And whole of the physics actually is a 6-month course.

[00:47:33]Not available with Vimar.

[00:47:35]Because if we start a 6-month course of SPI, these are SPI questions. Should have been posted by Dr. Singh from Punjab. These are SPI questions. If you are very much interested, you have to register yourself for a 6-month course with ARDMS.

[00:47:55]We are the first to introduce the physics to this Indian subcontinent and we are giving a very basic of physics.

[00:48:03]And if we start talking of physics, then it has to be a minimum of 6 months and people will not tolerate it.

[00:48:12]So, let me take one question. Let it be the starting one. Yeah. Now, see the question here. First one.

[00:48:21]In gray scale ultrasound, angle should be 90° for better resolution with the organ striking the beam.

[00:48:31]But should be lesser than 60 or 60 in Doppler. So, he means that when he is when anybody is scanning the gray scale, the angle has to be 90. Very good. But in case of a Doppler, the angle has to be 60 or less. Very good.

[00:48:50]But my question, it is his question. But my question is without actually seeing the angle. Try to understand his question. This These are very good questions.

[00:49:00]But Indian subcontinent doctors will not digest more of physics. They will run away.

[00:49:05]Thus, but bear with me for a couple of minutes with this physics. But his question is that seeing the exact angle of beam when it is inside the body and hitting the vessel at 45°.

[00:49:24]How can I know that it is 35, 45 or 60 or maybe 100 or maybe a 90?

[00:49:35]Are you able to understand his question?

[00:49:37]This question is that how can I make my make understand to myself that I am hitting with a 45 60 or 35 because it is sometimes something which is inside the body. How I can go over there and measure whether it is hitting with 90 or 60 degree. So, let me take this question.

[00:50:07]Dr. Singh, keep it up. Keep it up. Very good. Appreciated.

[00:50:11]But it will take some time. You have to go far and I think that this doctor is going trying to go to US to clear the ARDMS. But you have to be very you know, you have to do a hard work for that because in US they first you have to clear the SPE. That is the physics. Then the clinical side. Now see, coming to my question first question.

[00:50:43]This is the vessel. Now try to understand. This is the vessel.

[00:50:48]Any vessel over here it is the you have to aorta. So, any vessel over here in given case the aorta the beam is coming this way. Now see, the beam is coming this way.

[00:51:04]Now this part try to understand.

[00:51:08]This part this part of the vessel is hitting by about a 90 degree.

[00:51:19]Now, you don't have to measure it. You don't have to put a scale on the ultrasound monitor. But visual impression is telling me that this part now see, this part is being hit by 90 degree.

[00:51:31]Whereas the flow in this vessel is this side.

[00:51:37]And I am hitting it this way.

[00:51:41]So, this angle now see, this angle is about a 45 degree.

[00:51:48]YOU DON'T HAVE TO BEND YOUR body like this and that.

[00:51:52]You don't have to lean on the patient to make this angle. Automatically in a single vessel over here in case of this aorta some part is hitting by 90 degree some part is hitting by 45 some part is hitting by 30 some part So, lower the angle more acute the angle good is the flow.

[00:52:14]And if it is at the right angle, 90 degree it is worst because now see, this is the vessel over here.

[00:52:24]The flow is this way or that way. But the point here is that I am hitting with this this way because this is the footprint of the machine.

[00:52:33]This is the footprint. So, the beam is hitting this way.

[00:52:39]That is why in this vessel I am not able to see the flow.

[00:52:46]Because this vessel is automatically getting hit by 90 degree. 90 is a good angle for 2D ultrasound. But 90 is worst angle for Doppler. So, this way you can make out whether you are hitting with 90 45 or more acute or 90 degree.

[00:53:12]Now see over here.

[00:53:17]From here try to understand here. The beam is coming this way. See, beam is coming this way.

[00:53:25]The vessels the bunch of vessels over here are not getting hit by 90 degree now see.

[00:53:34]Bunch of vessels over here are not getting hit by 90 degree but the vessels over here try to understand this part.

[00:53:42]They are hitting by a 90 degree over here. That is why in this part I am not seeing any color whereas across it is seen over here. I am erasing.

[00:53:55]See it myself. I am not seeing any flow where the beam is hitting the 90 degree but lesser the angle better the flow you see on ultrasound. Now see over here.

[00:54:10]These are hepatic veins. Now forget about hepatic veins. This this is the vessel this is the area over here. Over here now see, try to understand this is very beautiful image.

[00:54:21]In these vessel this is very clearly seen on ultrasound.

[00:54:26]I mean gray scale ultrasound. This is very clearly seen.

[00:54:31]So, I have even seen the walls over here. Now see, the walls are really must seen over here.

[00:54:37]I am not seeing very clear picture over here. I am not seeing very clear picture over here.

[00:54:44]Now I am putting you a question. You means everybody.

[00:54:48]On gray scale the 90 is the good angle.

[00:54:51]90 is the best angle. That is why I am seeing even these walls over here and these are this is the vessel which is getting hit by 90 degree on gray scale.

[00:55:02]I am yet to put Doppler over here.

[00:55:05]Now because 90 degree is very good for gray scale. BUT THIS 90 DEGREE IS WORST FOR COLOR DOPPLER. Now question.

[00:55:17]Let me label this. This is let me erase first.

[00:55:23]This is vessel number one. This is vessel number two.

[00:55:27]And this is vessel number three.

[00:55:30]In vessel number three vessel number three I am seeing very good gray scale image.

[00:55:38]Vessel number one and two I am not seeing a good gray scale image. Let's post in the comment box now.

[00:55:45]If you put a color Doppler which vessel will show you a good flow?

[00:55:54]First one or third one? In your comment boxes now.

[00:55:59]Forget about second one.

[00:56:00]Okay, take second one. Forget about this one.

[00:56:04]The second one or third one?

[00:56:08]If you put a color box onto these this image will you see a good flow in third vessel or second vessel?

[00:56:19]In your comment boxes now. Hurry up. 10 seconds only.

[00:56:28]Dr. Prince Shaila third one.

[00:56:32]Dr. Fatima first and second.

[00:56:35]Dr. Pooja second one third one. Very good. Now see.

[00:56:40]If you put a color Doppler you will not see a good flow in third one because this third one is having an angle which is near to 90 degree.

[00:56:53]Whereas this second one is having a lesser angle now see, this is having a lesser Let me erase all these things.

[00:57:03]First.

[00:57:04]So, this is having a lesser angle now see.

[00:57:09]This is having a lesser angle whereas this is having a more oblique this perpendicular angle. So, lesser angle good for Doppler.

[00:57:25]You are hitting by 90 degree you will not see much of color. You are hitting with 90 degree you are seeing a good gray scale image. So, these are uh the angle which are being hit automatically by your ultrasound whenever you are scanning.

[00:57:48]Now see, over here I am not seeing a good color over here. So, but in this vessel I am seeing a very good color because this vessel is not getting hit by 90 degree. Whereas this vessel is getting about a 90 maybe a 95 96 degree.

[00:58:06]So, perpendicular [clears throat] not good for gray scale. Sorry, for color perpendicular you have to hit when you are taking the uh gray scale image. So, these were all questions which I hope that I have done justice with these replies.

[00:58:32]Thank you very much. But again requesting all of you to first complete the topic. Now see, first complete the topic at least touch the topic. At least touch the topic before posting a question because I am taking these classes in detail and if you don't even touch the class and post the class that will be a class or in these interactive sessions. So, next time please at least start the topic before posting your question.

[00:59:07]Thank you very much. God bless all of you. We are taking these types of question and interactive interactive sessions at regular intervals. For about a week I am going to Russia and Baku for a CME.

[00:59:25]So, I will not be available for about a 10 days but after 10 days will be again taking these intraday two sessions. Stay tuned.

[00:59:35]God bless all of you. Thank you very much.