The Role of Ultrasound in Women’s Health

Abstract

Ultrasound has developed into a vital medical diagnostic tool during the past 60 years. Theodore Dussik and his brother Friederich were the first to utilize ultrasound in the 1930s and 1940s to identify a brain tumor. Ultrasonography is now used for many different situations, such as disease detection, assisting with biopsy taking, monitoring previously diagnosed abnormalities, and assessing pregnancy. Unfortunately, the general public is unaware of the role of ultrasound in women’s health for purposes other than pregnancy assessment. This chapter’s major goal is to give a comprehensive overview of the various roles that ultrasound plays in women’s health. Furthermore, this chapter aims to make the general public more aware of the importance that ultrasound plays in women’s health. The authors used a wide range of sources for this work, such as books and peer-reviewed publications. The key roles of ultrasound examination in women’s health include: assessment of female reproductive organs, determination of causes of infertility, assessment of pregnancy and related problems, and assessment of the breast and abdomen. The general public should be made aware of the importance of ultrasound in women’s health.

1. Introduction

Over the past 60 years, ultrasound has become a crucial medical diagnostic tool. Ultrasound was first used in the 1930s and 1940s by the two brothers Theodore Dussik and Friederich to diagnose a brain tumor. Unfortunately, it was not widely used until the 1970s. Nowadays, ultrasonography is utilized for a variety of purposes, including disease diagnosis, guiding biopsy taking, monitoring previously identified abnormalities, and pregnancy assessment.

The evaluation of women’s health with ultrasound has become routine. Particularly, it is essential in the early diagnosis of uterine and ovarian masses as well as other conditions affecting the female reproductive organs. Moreover, ultrasound is widely used for assessing pregnancy as it is radiation-free. Ultrasound is used to determine the location of the gestational sac, determine gestational age, determine the number of fetuses, assess the fetus, monitor its growth, evaluate fetal well-being, determine fetal presentation, estimate fetal weight, and detect abnormalities of the fetus to identify the fetus [1, 2, 3, 4]. Ultrasound diagnosis of obstetric complications helps to reduce maternal morbidity. Due to its radiation-free nature, ultrasound is extensively used for fetal scanning, fetal growth monitoring, and fetal anomaly detection.

In addition, ultrasound is essential for assessing breast lesions and abdominal organs in female patients. Screening for breast cancer reduces breast cancer-related mortality. The Global Breast Cancer Initiative employs three key strategies: health promotion and early detection, timely diagnosis, and comprehensive breast cancer management [5]. Ultrasound has emerged as a primary supplemental screening modality, especially in women with dense breasts.

Ultrasonographic assessment of the female pelvis and early detection of abnormalities are critical in providing timely and comprehensive treatment. Similarly, early detection [discovery, finding] of breast and other malignancies aids in comprehensive care provision. The importance of ultrasonography in women’s health is covered in this chapter. The chapter focused on the usefulness of sonography in evaluating the female reproductive system, pregnancy and related problems, and the breast and abdomen. The authors believe it will offer a comprehensive understanding of the roles of ultrasound in women’s health.

2. Role of ultrasound in the assessment of female reproductive organs

Ultrasound imaging can be utilized to assess pelvic lesions, uterine abnormalities, ovarian lesions, and pelvic pain [6, 7, 8]. Trans-abdominal or trans-vaginal sonographic scanning methods can be employed to evaluate the female pelvis.

Ultrasound is used to examine normal female reproductive organs [9]. Similarly, it is used to assess the physiological changes in the female reproductive system. For example, the normal endometrial cavity measured up to 1.6 cm in the middle of the menstrual cycle during the premenopausal period and up to 0.5 cm during the postmenopausal period [8].

In suspected pelvic lesion, clinical assessments of female reproductive organs were difficult due to poor clinical characterization of lesion with physical examination alone [10]. Even though histopathology has been considered as a gold standard in the assessment of female pelvic lesions, the radiological imaging transformed the assessment of the lesion, characterization, guiding surgical plan, and follow-up assessments [11]. Ultrasonography and MRI are the most frequently used radiological imaging modalities in the assessment of female pelvic organs [10]. This section has discussed the role of ultrasound to diagnose lesions, abnormalities, and infertility-related problems in the female pelvic organs.

2.1 Sonographic assessment of female reproductive organs’ malformations

Uterine malformations are developmental abnormalities of the female reproductive tract and occur due to various changes in the normal development of the Müllerian ducts. These malformations can result from underdevelopment, a fusion defect, or a resorption defect in the Müllerian duct [12, 13, 14]. The ASRM Müllerian Anomalies Classification 2021 classifies Müllerian anomalies into the nine categories [15]. The ASRM identified the malformations by descriptive terminology: Müllerian agenesis, cervical agenesis, unicornuate uterus, uterus didelphys, bicornuate uterus, septate uterus, longitudinal vaginal septum, transverse vaginal septum, and complex anomalies. Acién, M. and Acién, P. (2022) proposed a system for classifying female genitourinary anomalies according to their embryologic origin, with six groups: (1) agenesis or hypoplasia of an entire urogenital ridge, (2) mesonephric anomalies, (3) isolated Müllerian anomalies, (4) gubernaculum dysfunctions, (5) anomalies of the urogenital sinus, and (6) combinations of malformations [16, 17].

Imaging techniques are being adopted to diagnose uterine abnormalities, which have a significant effect on optimizing women’s health. Ultrasound, especially 3D ultrasound, is a preferred method for detecting uterine abnormalities. Contrast-enhanced 3D sonography is currently recognized as the gold standard diagnostic technique [18]. Finding the anomalies makes it easier to identify related problems and allows for proper management. In Table 1, the anomalies and related problems are depicted.

Malformation	Clinical symptoms	Management	Purpose of treatment	Obstetric outcomes
Müllerian agenesis—Mayer-Rokitansky-Küster-Hauser Syndrome [19]	Primary amenorrhea	Surgical management	To enable satisfactory sexual intercourse with the construction of a neovagina.	Uterine factor infertility
Unicornuate uterus [20, 21, 22]	Dysmenorrhea, chronic pelvic pain, and hematometra leading to endometriosis and infertility.	The rudimentary horn can be resected in those with intractable severe dysmenorrhea, dyspareunia, and chronic pelvic pain related to endometriosis. Surgery is also recommended for patients with a functional rudimentary horn containing an endometrial cavity to prevent a complicated or dangerous pregnancy within the horn.	Symptom relief, to prevent complicated pregnancy within rudimentary horn.	First-trimester miscarriage, preterm birth
Bicornuate uterus [23, 24]	Intra- and postmenstrual dysmenorrhea, pelvic tumor, postmenstrual spotting	Surgical management with a Strassmann metroplasty	To avoid adverse obstetric outcome	Predisposed to both first- and second-trimester miscarriages
Uterus didelphys uterus	Hematocolpos, pyocolpos, hematometra, hematosalpinx	Surgical management with a Strassmann metroplasty	To improve recurrent pregnancy loss	Recurrent pregnancy loss

Table 1.

Uterine malformations.

2.2 Sonographic assessment of female pelvic lesions

Ultrasound is the imaging choice when evaluating a pelvic lesion or an undefined pelvic pain in patients. It is used to evaluate the location, size, number, and appearance of the lesions. Once the pelvic lesion has been identified by ultrasound, it is also important to track mass growth over time [8].

Leiomyomas (myomas, fibroids) are the most common uterine lesions in premenopausal women and usually detected by sonography [8, 9]. Uterine fibroids are benign tumors arising from uterine smooth muscle cells with varying amounts of the fibrous tissue. Most women having fibroids are asymptomatic. However, if the fibroid is submucosal, menorrhagia may occur, and subfertility may occur due to either the mass effect or narrowed fallopian tube, or interfere with implantation. Pain, urinary, and bowel symptoms may be experienced. In addition, fibroids also cause fetal malposition and premature uterine contraction in pregnant women [9]. Fibroids are estrogen dependent, so that they regress after the menopause. In addition, ultrasound is used to assess cervical and ovarian lesions.

2.2.1 Sonographic assessment of uterine lesions

Ultrasonography is used to identify uterine leiomyomas and hence used to guide the treatment. They have variable sonographic appearances. On sonography, an enlarged uterus with or without irregular outline, a well-defined hypoechoic round mass within uterus, or areas of mixed echogenicity [25] is observed. And there is distortion of the endometrial outline, if there is submucosal lesion. Fibroids also undergo degeneration and calcify. Ultrasonography also localizes the fibroids as: submucosal, intramural, subserosal, or pedunculated. The location of the lesions is very important to plan treatment.

The other uterine lesion detected by ultrasonography is adenomyosis. Adenomyosis is defined as the presence of endometrial tissue within the uterine myometrium [26, 27]. It causes dysmenorrhea, menorrhagia, urinary tract dysfunction and affects fertility [28].

Ultrasound is used to diagnose adenomyosis. Adenomyosis appeared on ultrasound as an enlarged uterus, often with an asymmetric anterior and posterior myometrial walls [29]. In addition, myometrial heterogeneity caused by endometrial implants and myometrial cysts is evident on ultrasound [27].

2.2.2 Endometrial abnormalities

Whether a woman presents with or without abnormal uterine bleeding, ultrasound is helpful in identifying endometrial abnormalities. Ultrasonography is considered the gold standard for determining endometrial thickness and diagnosing benign or malignant endometrial lesions [30, 31]. It helps in the assessment of the Asherman syndrome, hematometra, endometritis, endometrial hyperplasia, endometrial polyp, and endometrial cancer.

Asherman syndrome is manifested as intrauterine adhesions caused by trauma to a gravid uterine cavity, trauma to non-gravid endometrium, infection, Müllerian duct malformations (especially septate uterus), and genetic predisposition [32]. The symptoms of Asherman syndrome include menstrual abnormalities (amenorrhea and hypomenorrhea), infertility, recurrent pregnancy loss, and spontaneous miscarriage.

Sonohysterography, which combines transvaginal sonography with intrauterine injection of saline solution, has been shown to be superior to transvaginal ultrasonography in the detection of intrauterine adhesions. The visualization of echogenic areas within the saline-filled cavity denotes the presence of intrauterine adhesions [33].

Ultrasonography is also a choice of imaging to detect hematometra. Hematometra is a collection or retention of blood in the uterus most commonly due to an imperforate hymen or transverse vaginal septum. Ultrasonography effectively evaluates hematometra [23]. It is also used to evaluate the resolution of hematometra after treatment [34].

Ultrasonography is also used to evaluate uterine infections. Uterine infections usually occur in the puerperium, postoperatively, or after septic abortion. Pyometra within endometrial cavity is seen with a cervical stenosis due to cervical mass, following radiotherapy or as a result of complication of endometritis.

Another endometrial abnormality evaluated by ultrasound is endometrial hyperplasia, the proliferation of the endometrial gland. It causes abnormal uterine bleeding, postmenopausal bleeding, and infertility. Transvaginal sonography is an appropriate diagnostic tool in premenopause and postmenopause women presenting with abnormal uterine bleeding, especially in detecting endometrial hyperplasia [11].

Endometrial polyps are also detected by ultrasound. They are focal growths of the uterine mucosa and consist of endometrial glands, stroma, and blood vessels. Even though they may be asymptomatic, polyps are commonly identified during investigations for abnormal uterine bleeding and infertility [7]. Sonohysterography is used to detect polyps [25].

A malignant adenocarcinoma arising from the endometrium, endometrial carcinoma, is also assessed using ultrasound. It is a common malignancy affecting women worldwide [35]. The most significant risk factors for endometrial carcinomas are age, race, metabolic syndrome, unopposed estrogen exposure, and genetic predispositions [36]. It clinically manifests with postmenopausal uterine bleeding. Ultrasound shows non-specific thickening of the endometrium and this can be indistinguishable from hyperplasia or polyps. There may be a disruption in irregular endometrial surface.

2.2.3 Sonographic assessment of cervical pathologies

Ultrasound also plays a great role in the evaluation of cervical lesions. Ultrasound is used to diagnose nabothian cysts and cervical carcinoma. Nabothian cysts (retention cysts) are formed from the occlusion of the cervical glands, which lie close to the endocervical canal. They may be single or multiple. Nabothian cysts typically contain simple fluid and are asymptomatic. Uncommonly, nabothian cysts may be complicated by hemorrhage or infection or grow to large size [37]. Cervical cancer is a common gynecologic malignancy among women. It is the fourth for both incidence and mortality in Global Cancer Statistics 2018 [38]. Cervical cancer is the leading cause of cancer-related deaths in women, especially among women living in lower-income countries [39]. Its clinical presentation includes abnormal uterine bleeding (especially after intercourse) and vaginal discharge. Ultrasound is used to detect enlarged cervix, hypoechoic mass with or without hydro- or hematometra, and its complications like hydronephrosis.

2.2.4 Sonographic assessment of ovaries

Ultrasound is the imaging of choice for the assessment of the ovaries. Ultrasound is used to assess normal ovarian changes due to age and menstrual cycles, physiological ovarian cysts, cystic ovarian lesions, solid ovarian lesions, and vascular ovarian abnormalities [6, 8].

2.2.4.1 Physiologic ovarian cyst

The majority of ovarian cysts in premenopausal women are physiologic cysts. These cysts include follicular cysts and corpus luteal cysts. A follicular cyst develops if ovulation does not occur and follicular growth continues because of the lack of the luteinizing hormone surge and excessive stimulation by follicular stimulating hormone. On the other hand, corpus luteal cyst formed after an egg is detached from a dominant ovarian follicle. Follicular cyst appeared well-defined, thin-walled, anechoic, and homogeneous internal echogenicity on ultrasound. Corpus luteal cyst appeared as thick-walled cyst demonstrating peripheral color Doppler signal. The corpus luteum may bleed internally as a result of vascularization of the inner granulosa layer following ovulation forming a hemorrhagic corpus luteum. These cysts frequently resolved spontaneously [40].

All functional cysts may undergo hemorrhagic changes, most frequently seen in corpus luteal cysts. Ultrasound is also used to evaluate hemorrhagic ovarian cysts [6]. Women with hemorrhagic ovarian cysts frequently present with acute onset of pelvic pain. Hemorrhagic ovarian cysts show a spectrum of findings because of the variable sonographic appearances of blood, amount of hemorrhage, and time of the hemorrhage [41].

Sonography is used in the assessment of polycystic ovarian syndrome. It is a multifaceted endocrinologic disorder of ovarian dysfunction and the common cause of infertility and a higher rate of early pregnancy loss [42]. On sonography, polycystic ovarian syndrome appeared as bilaterally enlarged ovaries containing multiple small follicles and increased stromal echogenicity.

2.2.4.2 Cystic ovarian lesion

Ultrasound is used to diagnose cystic ovarian lesions. Most ovarian tumors are cystic: serous cystadenoma, dermoid cyst, mucinous cystadenoma, polycystic ovarian syndrome, surface epithelial cyst, and theca lutein cyst [6, 43, 44].

The sonographic features of the cystic ovarian lesions are non-specific. But some of the cystic ovarian lesions have more specific sonographic features [8]. For instance, dermoid cyst appeared as a cystic mass with echogenic nodules projecting into lumen, posterior sound attenuation, fine internal echogenic lines, and a fluid-fluid level on sonography. While serous cystadenoma appeared as an usually large, thin-walled, and unilocular cyst, it may contain thin septations [44]. Mucinous cystadenoma appeared as a multilocular cyst with thin septations.

2.2.4.3 Solid ovarian lesions

Solid ovarian tumors are divided as epithelial, gem cells, and sex cord-stromal. Some of solid ovarian tumors include Brenner tumor, dysgerminoma, fibroma, and granulosa cell tumor. Ovarian cancer can be treated with a very good prognosis if detected in the early stages, but not after it has advanced. Ultrasound is used to identify ovarian tumors. Transvaginal ultrasound is capable of identifying changes in ovarian size and structure, and thereby detects early ovarian malignancies [45]. Transvaginal ultrasound combined with Doppler blood flow imaging and power Doppler is used to evaluate blood flow to ovarian tumors and to identify patterns of flow associated with ovarian neoplasia.

2.2.4.4 Vascular ovarian abnormalities

Ultrasound is also helpful in the assessment of ovarian vascular abnormalities such as: ovarian torsion. It is caused by either partial or complete rotation of the ovary over its pedicle and is commonly associated with adnexal mass [8]. Its clinical presentation is acute onset of pelvic pain. Its timely diagnosis is very essential to prevent loss of ovary. A surgical emergency is a choice of management. On ultrasound, the torsed ovary appears asymmetrically enlarged, round, heterogeneous, free fluid and may be a coexisting adnexal mass. On Doppler study, either decreased or absent arterial and venous flow to the ovary is observed.

2.2.5 Sonographic assessment of fallopian tubes

Ultrasound is used to assess the fallopian tubes [44]. Assessing fallopian tubes may help to diagnose hydrosalpinx, pyosalpinx, salpingitis, and tubo-ovarian abscess. Hydrosalpinx appears on ultrasound as thin-walled anechoic tubular adnexal mass without internal vascular flow [8, 46]. And pyosalpinx appears on ultrasound as complex tubular adnexal mass with irregular margins and sound attenuation, while tubo-ovarian abscess appears as complex multilocular adnexal mass with ill-defined wall margins [8, 44].

3. Role of sonography in the assessment of infertility

Infertility is suggested when conception does not occur within 1 year. It can be caused either by male or female reproductive abnormalities. Ultrasound is used in the assessment of some of the causes of infertility that arise from female reproductive abnormalities. Some of the causes of infertility diagnosed by ultrasound are: pelvic inflammatory disease (PID), fibroids, polycystic ovarian syndrome, uterine malformations, endometriosis, endometrial pathologies, para-ovarian cyst, peritoneal inclusion cyst, Krukenberg tumor, and endometriosis [7, 23, 43, 47, 48].

Ultrasound is used to assess the structural anatomy of the uterus and endometrium [8, 44, 49]. Uterus is assessed for any congenital anomalies and abnormalities. A septate uterus has a high incidence of infertility [8, 12, 15, 17, 18]. Saline infusion sonograms with or without 3D assessment are used to assess the uterine cavity for any abnormalities and can also be used for tubal patency assessment [50]. Ultrasound is used to assess endometrium for the presence of polyps and intrauterine adhesions (Asherman’s syndrome) [8, 32, 33, 51]. Polycystic ovarian syndrome contributes to female infertility secondary to anovulation and its sonographic findings are discussed above [44].

Pelvic inflammatory disease is an infection of the upper genital tract, usually related to Neisseria gonorrhoeae or chlamydia. It is a term used to describe a group of infections affecting the uterus, fallopian tubes, and ovaries. Adolescent females are in a higher-risk group, and thus, PID should be considered in sexually active females with pelvic pain. On ultrasound, pelvic scan may appear normal, and uterus may be enlarged and more hyperechoic, may contain a small amount of fluid in the endometrial canal, and may have indistinct margins, fluid-filled and dilated fallopian tubes (pyosalpinx), ovarian enlargement with tiny cysts, and tubo-ovarian abscess (heterogeneous adnexal mass) [8].

Ultrasound is also utilized in the assessment of endometriosis. It is the result of functional endometrium located outside the uterus causing painful periods, chronic pelvic pain, pain during and/or after sexual intercourse, painful bowel movements, painful urination, fatigue, depression or anxiety, and abdominal bloating and nausea [48, 52, 53, 54]. In addition to the above, endometriosis can cause infertility. Infertility occurs due to the probable effects of endometriosis on the pelvic cavity, ovaries, fallopian tubes, or uterus [55].

Endometriosis remains difficult to diagnose. Although further study is required to determine their accuracy, transvaginal ultrasonography and MRI show some hope in the diagnosis of endometriosis [56]. Particularly, ultrasound is helpful in the diagnosis of ovarian endometrioma, adhesions, and deep nodular forms of endometriosis.

4. The role of ultrasound in the assessment of pregnancy

Since 1978, ultrasound has been used in clinical obstetrics. With technological advancements, resolution has improved, allowing for far better imaging of the fetus. This, together with recent discoveries in the field of screening for pregnancy problems, has led to a change in the clinical application of ultrasonography in the management of routine low-risk pregnant women [57].

The use of obstetric ultrasound in pregnant women is considered a safe and reliable method [5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60]. Its utilization in pregnancy is crucial, as it allows for early detection of various fetal abnormalities, assessment of fetal biometry, and ultimately improves the quality of antenatal care and pregnancy outcomes [58, 61, 62]. The World Health Organization (WHO) recommends all pregnant women get at least one obstetric US before 24 weeks of gestational age (GA) [63].

The use of ultrasound in obstetrics can be either elective or reactive. Elective or planned use of ultrasound implies scanning to detect potential problems in an otherwise seemingly uncomplicated pregnancy (screening), whereas reactive use is the application of ultrasound to help in the management of a clinical problem such as suspected fetal growth restriction [57].

Planned use of ultrasound includes: pregnancy dating, assessment of multiple pregnancies, placental location, amniotic fluid volume, and screening (of chromosomal aneuploidy, congenital heart defects, neural tube defects, pre-eclampsia and intra-uterine growth restriction, and preterm delivery) [4, 8, 44].

Reactive use of ultrasound includes: assessment of fetal growth (small for gestational age, large for gestational age, reduced fetal movements, antepartum hemorrhage, ruptured membranes, and prolonged pregnancy) [61, 64, 65].

4.1 Ultrasound imaging in the first trimester

First-trimester ultrasonography is a common procedure performed within the first 14-week post-conception [63]. It may be used as part of the standard prenatal evaluation or to interpret other problematic signs and symptoms. It can be done trans-abdominally (with the transducer placed over the abdomen) or trans-vaginally (the transducer is narrow and placed in the vagina). Both procedures can be done at the same time in some cases [66].

4.1.1 Indications

First-trimester ultrasonography can be done for a variety of reasons. Pelvic pain, suspected ectopic pregnancy, suspected twin pregnancy, vaginal bleeding, suspected trophoblastic disease, assessment for fetal growth abnormalities, nuchal translucency measurement, evaluation of pelvic masses or uterine abnormalities, and as an adjunct to chorionic villus sampling are common indications [64].

Additionally, asymptomatic patients in the first trimester may also be scheduled for a regular ultrasound if resources are available to determine an accurate gestational age [67].

The main objectives of ultrasound examination in the first trimester are establishing pregnancy location, confirmation of viability (cardiac activity in the embryo/fetus), assessment of gestational age (pregnancy dating), detection of signs of early pregnancy failure, assessment of basic anatomy after 11 weeks, and assessment of the existence of multifetal gestations [66].

4.2 The role of ultrasound in reducing maternal mortality in the first trimester

Ultrasound plays a significant role in reducing maternal and perinatal mortality. The common first-trimester conditions that can result in maternal mortality are ectopic pregnancy, abortion, and gestational trophoblastic diseases (GTDs), due to the possibility of severe hemorrhage, shock, or sepsis [51]. To diagnose these early trimester disorders correctly, ultrasound imaging is of utmost value. Therefore, it is critical to rule out early pregnancy pathology in any woman of reproductive age who presents with amenorrhea, unusual bleeding, and/or discomfort utilizing diagnostic ultrasound imaging and beta-human chorionic gonadotropin (HCG).

Ultrasound imaging also plays a crucial role in perinatal mortality reduction by identifying indicators of chromosomal aberrations and structural problems in the fetus to enable early intervention or close monitoring.

4.3 Ultrasound imaging in the second trimester

The second trimester is the most common time for a routine prenatal ultrasound. In many countries, the mid-trimester ultrasound (also known as the second-trimester anatomy scan) is a routine examination used to check fetal anatomy and diagnose any congenital malformations [68].

An ultrasound scan performed between 18 and 22 weeks of gestation provides information to the pregnant woman and her care provider about many aspects of her pregnancy. It is commonly used to assess the number of fetuses, viability, gestational age, anatomical survey, placental location, amniotic fluid, and maternal pelvic organs [69].

4.3.1 The role of ultrasound in reducing maternal mortality in the second trimester

Between 18 and 24 weeks of gestation, ultrasound imaging of the second trimester is commonly carried out. To examine the fetal and maternal structures for abnormalities that could cause maternal and/or perinatal mortality, ultrasound imaging is used.

Fetal anatomy, fetal biometry, amniotic fluid volume, the placenta, the mother’s cervix, and uterine and umbilical artery Doppler velocimetry are among the features assessed. The goal is to rule out results connected to preterm labor, IUGR, pre-eclampsia, and fetal chromosomal abnormalities [70].

To optimize pregnancy outcomes, early detection of pre-eclampsia and intrauterine growth restriction using ultrasound imaging in the second trimester are critical and they are significant causes of maternal and newborn mortality that must be identified as early as possible.

4.4 Ultrasound imaging in the third trimester

Ultrasound is commonly used during the third trimester of pregnancy in patients who present asymptomatically or with symptoms. Ultrasound can be used to identify fetal and maternal pathology as well as to follow the progression of a pregnancy.

In the third trimester, ultrasound is indicated for the evaluation and determination of fetal anatomy, fetal anomalies, gestational age, fetal growth, fetal presentation, suspected multiple gestations, placental location, cervical insufficiency, and pelvic mass [71].

4.4.1 The role of ultrasound in reducing maternal mortality in the third trimester

Third-trimester pregnancy complications, such as antepartum hemorrhage, hypertensive disorders, thromboembolism, chorioamnionitis, heart disease, anemia (sickle cell disease), rupture of uterine scar, can all result in maternal death [51].

Ultrasound imaging plays a key role in the assessment of fetal development and health, presentation, placental position, and ultrasound-guided operations are all important factors to consider when deciding whether to carry out an intervention to improve survival rates [65].

Hypertensive disorders are one of the leading causes of maternal deaths globally. These disorders include gestational hypertension, pregnancy-induced hypertension that can progress to pre-eclampsia (mild or severe) and eclampsia, chronic hypertension, chronic hypertension with superimposed pre-eclampsia and/or superimposed eclampsia, and chronic hypertension with superimposed eclampsia [72].

Due to the precise date of gestational age provided by ultrasound imaging, especially when performed in the first trimester, it is helpful to prevent maternal and neonatal death. To enable early intervention when necessary, ultrasound is also utilized to monitor fetal growth and health.

4.5 The role of ultrasound in intrapartum care

A woman in labor is typically evaluated and managed based on clinical findings. The digital assessment of cervical dilatation and fetal head station and position plays a major role in the diagnosis of labor arrest and decisions about the timing or kind of intervention. However, a clinical examination of the head station and position is unreliable and subjective, particularly when the caput succedaneum makes it difficult to feel the sutures and fontanels [73]. The use of ultrasound has been proposed to aid in the management of labor [74].

Intrapartum ultrasound (ultrasound in labor) is a relatively new concept that has emerged in the last 10 years and is getting more popular in developed nations as a component of the assessment of labor progress [75]. It can be performed using a trans-abdominal approach mainly to determine fetal head and spine positions, fetal heart rate, amniotic fluid, and presentation [76], or a transperineal approach, for the assessment of head station and position at low stations [77]. It could also be used to monitor labor progress and, possibly, predict how the labor will turn out [78].

Indication for ultrasound evaluation in labor includes:

• Slow progress or arrest of labor in the first stage.

• Slow progress or arrest of labor in the second stage.

• Ascertainment of fetal head position and station before or when performing instrumental vaginal delivery.

• Objective assessment of fetal head malpresentation and amniotic fluid volume.

4.6 The postpartum ultrasound scan

The postpartum period begins immediately after the delivery of the infant and placenta and lasts for approximately 6–8 weeks, as the reproductive tract anatomically and physiologically returns to the non-pregnant state [79]. Postpartum complications involving the uterus occur in approximately from 8 to 10% of cases. Immediate and late postpartum hemorrhage, puerperal sepsis, and septic pelvic thromboembolism are still potentially fatal conditions [80]. According to WHO data, severe bleeding after childbirth—postpartum hemorrhage (PPH)—is the leading cause of maternal mortality worldwide. Each year, about 14 million women experience PPH resulting in about 70,000 maternal deaths globally [81].

Ultrasound assessment of the postpartum uterus plays an important role in the evaluation of a large proportion of symptomatic puerperal women. It is a preferred imaging modality for excluding the retained placental tissue. Proper application of postpartum ultrasound may allow for more accurate identification of women requiring surgical intervention, resulting in reduced patient morbidity and clinical workload [82].

Common indications for postpartum ultrasound are as follows: Referral to ultrasound may be indicated for a variety of reasons, including suspected retained products of conception or pelvic sepsis, which frequently presents with excessive or erratic bleeding, and primary postpartum hemorrhage (PPH).

5. Ultrasonography assessment of breast

Breast ultrasound is a type of imaging exam that employs sound waves to produce pictures of the internal structures of the breast. It is an important imaging modality commonly utilized for the detection and characterization of lesions in the breast including breast cancer screening [83].

Breast ultrasound is a safe, rapid, widely available, low-cost imaging modality that does not require ionizing radiation and non-invasive procedure without any complications of the procedure itself [83, 84]. Ultrasound (US) is both an adjunct and a complement breast exam and used to help with the diagnosis of breast masses or other abnormalities found during a physical exam, or mammography, or magnetic resonance imaging (MRI) [85, 86, 87]. However, in symptomatic women with a lump or localized pain in the breast, ultrasound is a good initial technique for examination.

The following are common indications for breast ultrasound [83, 88]:

• Evaluation and characterization of breast-related complaints and other palpable masses.

• Analyses of abnormalities seen on mammography or breast magnetic resonance imaging.

• A palpable lump discovered during a clinical breast examination.

• Breast implant rupture suspicion is used to distinguish between intracapsular and extracapsular ruptures.

• Percutaneous breast biopsy with needle guidance.

• Patients who underwent follow-up after neoadjuvant chemotherapy.

Ultrasound can also be utilized as an adjuvant breast cancer screening technique in women with dense breast tissue and a negative mammography. These breast US applications have broadened the spectrum of sonographic features currently examined, even permitting the identification of a non-invasive disease, a significant advancement beyond the early basic cyst-versus-solid assessment.

6. Abdominal ultrasound

Most people, aside from women when they hear ultrasound, associate it with pregnancy and how it is used in monitoring the development of a baby in the womb. However, ultrasound can be used to diagnose and help in the treatment of many health issues related to women. Abdominal ultrasound imaging is performed to evaluate kidneys, liver, gallbladder, bile ducts, pancreas, spleen, and abdominal aorta and other blood vessels of the abdomen [8].

Ultrasound is used to help diagnose a variety of conditions, such as abdominal pain or distention, assessment of liver condition, gall stones, enlarged abdominal organ, kidney problems, vascular problems like an abdominal aortic aneurysm, and provide guidance for biopsies [41, 44]. Abdominal ultrasound may also help to pinpoint the cause of an unexplained abdominal pain [89]. Doppler ultrasound also helps to see and evaluate: blockages to blood flow, narrowing of vessels, tumors and congenital vascular malformations, reduced or absent blood flow to various organs, and increased blood flow [9, 90].

7. Conclusion

Ultrasonography plays a significant role in women’s health, in the assessment of female reproductive organs and related malformation/lesions, in the determination of infertility, in the assessment of breast, and abdominal examinations. It also plays an important role during antenatal period in determining fetal biometry, in assessing pregnancy and related problems, and in reducing maternal mortality. In general, the addition of ultrasound examination in the evaluation of women’s health plays a vital role.

Conflict of interest

The authors declare no conflict of interest.