3. EL DESARROLLO DEL PENSAMIENTO SEGÚN PIEGET
3.2. ESTADIOS O ETAPAS DEL DESARROLLO DE LA INTELIGENCIA
An Esaote high resolution real time scanner with multifreqency (2.5to 3.5MHz) curvilinear transducer and multifreqency (5.0 to7.5MHz) transvaginal transducer was used to scan the patients.
Each patient had transabdominal and transvaginal sonographic evaluation of her dominant follicular size and endometrial thickness on day 10 of their menstrual cycle (i.e. before ovulation), with transabdominal technique immediately preceding transvaginal technique in a single scanning session.
Images of the follicles obtained on the transabdominal scan were stored and were compared with follicular images obtained on the transvaginal scan to ensure that the same follicule is being measured during the single scanning session.
Image quality was assessed by the ability of each sonographic technique to resolve the endometrium into a trilamilar echo pattern as expected during the pre-ovulatory phase of the menstrual cycle and by the definition of the ovarian follicular margin which was graded as well defined or poorly defined.
Transabdominal Scan
Each patient was asked to drink water so as to attain optimal full bladder which displace overlying bowel from the area of interest enabling adequate interaction with the ultrasound waves. Overtly distended bladder that could lead to flattening and stretching of the endometrium which may result in false endometrial thickness measurements was avoided by intermittent bladder voiding. The study was done with the patient lying supine on the examination couch. Ultrasound gel was applied to the suprapubic region. The uterus and the ovaries were scanned in the longitudinal, transverse and the oblique planes.
Scanning began with the use of 3.5MHz curvilinear probe, just above the pubic symphysis in a longitudinal axis. The ultrasound probe was moved laterally from side to side through the entire width of the uterus in the
longitudinal plane to visualize the endometrium which appears as an echogenic line, in its long axis. The probe was then rotated through 1800 to align it in a transverse plane just above the pubic symphysis, directed down towards the uterus to visualize the endometrium in its transverse axis. In the transverse position, the left and the right adenexa was scanned to visualize the ovaries respectively using the iliac vessel located anteriorly to the ovaries as landmark.
Caudal and cephalad angulation were carried out as the needs arise in visualizing the ovaries70.
Transvaginal Scan
The patients were asked to empty their bladder in other to reduce patient discomfort, artifacts and uterine distortion from over distended bladder. The study was performed in the presence of a chaperon with the patient in lithotomy position. The uterus and the ovaries was scanned longitudinally, transversely and in the oblique plane.
A 7.5MHz transvaginal transducer, covered with a probe cover that has been lubricated inside out with an ultrasound gel to ensure smooth transmission of ultrasound waves was carefully introduced into the vaginal canal adjacent to the cervix to begin a transvaginal ultrasound in the longitudinal axis. The longitudinal scan began with the visualization of the endometrium which appears as an echogenic stripe in the midline, the uterus was then scanned from right to left through its entire length.
Once scanning was completed in the longitudinal axis, the probe was rotated 90 degrees counterclockwise so that the probe is now in the transverse plane. The transverse scan began with identification of the endometrial stripe in its transverse orientation and then moves throughout the entire length of the uterus. In order to help locate the ovaries, the cornual flare portion of the uterus was identified. Once the cornual flare was located, the probe was moved laterally and necessary posterior-anterior and medio-lateral probe angulations was performed to locate the ovary. Ovaries were identified by the presence of
Measurements
The internal diameters of the dominant follicle was measured using the electronic calipers. In the sagittal view the long axis of the dominant follicle was measured as its length, while in the transverse, and anterio Posterior views the short axis of the follicles were measured as their depth and width respectively. The mean of these measurements was taken as the dominant follicularsize70,71 Fig 9 and 9b
Endometrial thickness was measured using the electronic calipers as the distance from the anterior stratum basalis-myometrial junction to the posterior stratum basalis-myometrial junction in the mid sagittal section. The transverse and sagittal plane of section that represent the largest dimension of the endometrium were used for all measurements and the mean of these measurements was taken as the endometrial thickness. Fig 10 and 10b
Figure 9: Sagittal transvaginal sonogram showing the ovary (braces) and a dominant follicule (a) being measured along its longitudinal axis (corresponding to follicular length),and in its anterio-posterior axis (corresponding to the follicular width) with the electronic callipers.
Figure 9b: Transverse transvaginal sonogram showing the ovary (braces)
and
a dominant follicule (a) being measured along its short axis (corresponding to follicular depth) with the electronic callipers.
a a
Figure 10: Sagittal transvaginal sonogram showing the trilamilar pattern
of the endometrium (braces)
being measured at its widest dimension from the anterior stratum basalis-myometrial junction (a) to the posterior stratum basalis-myometrial junction (p) with the electronic callipers.
Figure 10b:
Transverse transvaginal sonogram showing the trilamilar pattern of the endometrium (braces)
being measured at its widest dimension from the anterior stratum basalis-myometrial junction (a) to the posterior stratum basalis-myometrial junction (p) with the electronic callipers.a
p
a
p
2.4 COLLECTION OF DATA