Introduction: Surgical uterine evacuation (D&C) without ultrasound for miscarriage, termination or retained products of conception (RPOC) can result in complications including uterine perforation, false passage, incomplete D&C or blood loss. This study evaluated rates of complication when D&C was performed blind (BD&C) or ultrasound guided (USD&C), and whether risk factors determined ultrasound use.
Methods: A retrospective cohort study (733 cases over 5 years) was undertaken. Patient records were searched for risk factors and surgical complications. Secondary outcomes were patient demographics and pre surgical complication factors. Women were assigned into two cohorts, BD&C or USD&C.
Results: The BD&C group included 421(57%) women. The USD&C group of 312(43%) women included higher gestational ages 8[7-11]weeks v BD&C 8[7-9]weeks (U=42720, p=0.0001), more previous complications (OR 1.7; 95% CI: 1.3-2.3), more terminations (OR 15.3 CI: 5.4-43.3) and post-partum cases (OR 2.3 CI:1.3-3.9). USD&C significantly reduced both volume of RPOC 0.66cm3[0.53-1.23] v BD&C 8.35cm3[1.49-18.94] and overall blood loss 20ml [10-59] v BD&C 30ml [10-53]. USD&C guidance was used intermittently by surgeons 132(42.3%) or continuously by sonographers 180(57.7%). There was a complication rate of 46(6.3%) with no association between group and complication (x2(1) =1.110, p=0.292).
Conclusion: Within a setting of experienced surgeons and sonographers, complication rates are low for BD&C and USD&C. Sonographers can provide successful continuous intervention guidance for higher risk pregnancies.
Take home message: Sonographer verbal assistance guides direction of instruments minimising endometrial trauma and RPOC during D&C. Future research on sonographer availability to provide this valuable service and training for intervention guidance is warranted.

Enhanced myometrial vascularity (EMV) refers to increased blood flow within the myometrium (uterine muscle wall), often seen after pregnancy termination, miscarriage or delivery. At Color or Power Doppler ultrasound it appears as a dense, tortuous web of vessels, often with high-velocities, extending from the endometrium into the myometrium. EMV is a reactive and acquired vascular phenomenon typically associated with retained products of conception. It should not be mistaken for an arteriovenous malformation (AVM). EMV may lead to abnormal uterine bleeding, sometimes heavy. The lecture will cover ultrasound diagnostics and management of EMV.

Introduction: Adenomyosis is a benign uterine condition characterised by the presence of endometrial glands and stroma within the myometrium. This ectopic tissue behaves like normal endometrium, thickening and bleeding with each menstrual cycle, leading to symptoms such as dysmenorrhoea, heavy menstrual bleeding, pelvic pressure and bloating. Although non-life-threatening, adenomyosis can significantly impair quality of life and often coexists with fibroids or endometriosis. Historically diagnosed only after hysterectomy, adenomyosis is now commonly identified using ultrasound imaging with greater recognition of disease. Advances in transvaginal, transabdominal, 3D imaging and operator expertise allow non-invasive diagnosis.
Methods: The internationally accepted MUSA 2022 (Morphological Uterus Sonographic Assessment) guidelines provide standardised criteria which can be used in the clinical setting for describing and classifying adenomyosis based on direct and indirect ultrasound features. Using these guidelines we can now describe the direct ultrasound features which are more specific, include myometrial cysts, hyperechogenic islands, and echogenic sub-endometrial lines or buds. Indirect features reflect secondary structural changes and include a globular uterus, asymmetrical myometrial thickening, fan-shaped shadowing, translesional vascularity and an irregular or interrupted junctional zone. The presence and number of features generally increase with disease severity. 3D ultrasound improves visualisation of the junctional zone and enhances diagnostic accuracy and reproducibility.
Results: Standardised ultrasound assessment using MUSA guidelines has improved the recognition, differentiation and diagnosis of adenomyosis reducing reliance on surgical diagnosis.
Conclusion: Awareness of both direct and indirect sonographic features combined with appropriate technique and 3D imaging is essential for accurate non-invasive diagnosis and optimal patient management.

Introduction: Hysterectomy is a widely accepted method of treating pelvic conditions. Once the cervix is removed, the superior margins of the vagina are stitched together at the anterior fornix often referred to as the vaginal vault (VV), apex or cuff. Whilst ultrasound imaging can be used to assess the VV, it is often an underappreciated area of anatomy.
Methods: This presentation aims to give an update on ultrasound appearances of the VV with reference to pathological conditions that can be seen.
Results: Transabdominal and transvaginal scanning can identify the VV with usual appearances demonstrating a tubal muscular structure abruptly terminating at the scar. Translabial/transperineal approaches may be appropriate post-operatively as patients are restricted from inserting anything into the vagina. Scar thickness varies, with mild vascularity expected, and small calcifications considered normal. Vaginal atrophy is common due to menopause or radiation treatment. Where cardinal-uterosacral ligament complexes are refigured, dimpling, sonographically seen as shadowing may be present. Once normal appearances are known, VV pathology becomes more evident. Within postoperative stages, collections or hematomas are easily identified. More challenging conditions to image include dehiscence, fistula, granuloma and adhesions. Beyond healing of the VV, we can see endometriomas, recurrent malignancy, and prolapse. Removing pelvic organs does not remove the risk of pathology. VV anatomy may seem simple, but it can have a variety of ultrasound appearances and is not immune to new or recurrent pathology.
Conclusion: Sonographers should familiarise themselves with the normal post hysterectomy VV appearances to improve pathology detection and patient outcomes.