Endometriosis is a common inflammatory condition that occurs when tissue similar to the endometrium (the lining of the uterus) grows in other locations around the body. In many cases, endometriosis causes discomfort, pain, and, occasionally, fertility issues. Endometriosis may affect up to one in seven women.
Despite it being a common condition, endometriosis can be challenging to diagnose due to the variability of its symptoms and their similarity to other conditions. In some women, endometriosis may be present with no symptoms at all.
Endometriosis is a common condition where ‘endometrium’, a type of tissue similar to the inside lining of the uterus, grows in other areas of the body.
Endometriosis is most commonly found around the female reproductive system, including the exterior of the uterus, fallopian tubes, ovaries and other organs within the pelvis.
The physiological effect of endometriosis include:
The presence of endometrial glands and stroma – these are called endometrial implants and usually occur outside of the uterus.
These endometrial implants are considered to be estrogen dependent which can respond to hormonal fluctuations with proliferatory and secretory activity.
Metabolic activity may include the release of cytokines and prostaglandins which can lead to chronic inflammatory response
Characterised by neovascularisation and fibrosis
Fibrosis and adhesions may lead to the physical alteration of the pelvic anatomy
Endometrium continues to behave as it normally would as if it was inside the uterus—it bleeds with each menstrual cycle. However, because it is unable to leave the body, like a normal menstrual cycle, it leads to inflammation and pain.
There are three types of endometriosis:
Superficial Endometriosis (SE): This form of endometriosis involves the growth of endometrial-like tissue on the surface of pelvic organs and structures. These superficial implants are less than 5 mm in depth.
Ovarian Endometriosis (Endometriomas): Endometriomas are cysts filled with dark, reddish-brown blood that form on the ovaries as a result of endometriosis. They can vary in size and may cause the ovaries to adhere to the fallopian tubes or the pelvic wall, leading to pain and affecting fertility.
Deep Infiltrating Endometriosis (DIE): DIE is considered the most severe form of endometriosis. It involves the infiltration of endometrial-like tissue more than 5 mm under the peritoneum, which is the lining of the abdominal cavity. DIE can be located in or around organs such as the bowel, bladder, and, less commonly, the ureters and lungs.
How common is endometriosis?
Recent Australian research suggests that endometriosis may affect as many as one in seven women. Despite its commonality, endometriosis is often underdiagnosed or diagnosed with a delay of up to nine years, sometimes due to the normalisation of menstrual pain or the variability of symptoms among affected individuals.
What are the causes of endometriosis?
There is no single known cause of endometriosis. However research suggest that these factors contribute to the risk of developing endometriosis:
Immune system disorders
Genetic predisposition
Hormonal imbalances
Environmental toxins
What are the symptoms of endometriosis?
Endometriosis presents differently in different people. Symptoms may include:
Pain around the pelvic area
Changes to menstrual frequency, duration, or heaviness
Pain going to the toilet
Infertility
Fatigue
Diarrhoea
Constipation
Bloating
Nausea
How is endometriosis diagnosed?
Your doctor may follow this process for diagnosing endometriosis:
Medical history and symptoms review: Your doctor will ask questions about your symptoms, including how severe they are and how long you’ve had them for. They may also ask about your family’s medical history.
An examination of the pelvic area: Your doctor may conduct a physical examination to check for cysts or scars, or any other physical indicators of endometriosis.
Ultrasound: A transvaginal ultrasound may be ordered to check for cysts associated with endometriosis (endometriomas) and assess the pelvis for evidence of superficial and deep endometriosis. Deep endometriosis may be detected during the ultrasound by specifically trained sonographers. Superficial endometriosis is more common, but not as easily diagnosed by ultrasound. The detection of superficial endometriosis is increasing with better technology and awareness of its subtle features.
Ultrasound video demonstrating the appearance of a normal ovary
Ultrasound image of an endometrioma in the left ovary
Magnetic Resonance Imaging (MRI): An MRI may be performed to check for endometriosis, or be used as an adjunct to a surgical procedure.
Laparoscopy: Still considered to be gold standard, this is a surgical procedure where a camera (laparoscope) is inserted into the pelvis.
Can endometriosis be cured?
There is no definitive cure for endometriosis but it is treatable. It is important to remember that sometimes endometriosis can recur after treatment.
What are the four surgical stages of endometriosis?
Endometriosis is classified into four surgical stages according to the extent, depth, location, and presence of scar tissue and endometriomas (cysts):
Stage I (Minimal): This is the mildest form of endometriosis, featuring light lesions only.
Stage II (Mild): Light lesions and shallow implants on the ovary and pelvic lining with minimal adhesions.
Stage III (Moderate): Deep implants, small cysts on one or both ovaries, and more extensive adhesions.
Stage IV (Severe): Large cysts on one or both ovaries, many deep implants, and thick adhesions. This stage may also involve implants on other organs outside of the pelvic cavity.
How can endometriosis be treated?
Treatment options vary depending on many factors, including the severity of symptoms, a desire for pregnancy, and previous treatment history. Your doctor will advise a treatment plan.
Treatments are mainly aimed at providing relief, reducing and ideally eradicating symptoms to improve your wellbeing. As described by QENDO, there are three main treatment plans that your doctor may recommend to you.
Drug therapy: used to manage endometriosis symptoms and minimise pain. This may include hormone therapies.
Surgery: used to remove the tissue from your body. This has a higher success than drug therapy and can usually be performed at the time of diagnosis. It is important the surgery is performed by a gynaecologist who is familiar with the latest treatment standards for endometriosis.
Alternative treatment: these can include herbal remedies, dietary change, acupuncture, reducing stress and exercise to reduce the pain. Endometriosis is not curable but IS treatable. But remember, sometimes endometriosis can recur after treatment.
Which parts of the body does endometriosis affect?
Endometriosis most commonly impacts the pelvic region. However it can also be found in other locations throughout the body, including but not limited to:
Peritoneum: This is the lining of the abdominal and pelvic cavity, and is the most common location for endometriosis.
Intestines and rectum This leads to symptoms such as painful bowel movements, gastrointestinal pain, and irritable bowel syndrome-like symptoms.
Ultrasound video of a deep infiltrating endometriosis bowel nodule
Bladder and urinary tract. This can cause urinary urgency, frequency, and pain during urination.
Ultrasound video of a deep infiltrating endometriosis bladder nodule
Diaphragm and lungs: Though rare, endometrial-like tissue can implant in the diaphragm and even the lungs, potentially leading to chest pain and difficulty breathing.
Additionally, endometriosis lesions have been found in even more distant sites, such as the skin, scars (from previous surgeries), and in very rare cases, the brain.
How does endometriosis affect pregnancy?
Endometriosis can influence pregnancy in different ways:
Fertility issues: Endometriosis can create fertility issues in some women. This happens when ovulation and the fertilisation of the egg is interrupted by the presence of endometrial tissue.
Increased risk of complications: Pregnant individuals with endometriosis may have a higher risk of certain complications, such as miscarriage, preterm labour, and placenta previa (where the placenta covers the cervix), compared to those without the condition.
Pain management: For some, pregnancy may lead to a temporary relief of endometriosis symptoms, as menstruation halts and hormonal changes can suppress the condition. However, for others, pregnancy may not alleviate pain, and managing pain without compromising the pregnancy can be challenging.
Obstetric outcomes: Studies suggest that endometriosis may be associated with increased risks of certain obstetric outcomes, including caesarean delivery and postpartum haemorrhage, though more research is needed to fully understand these relationships.
What support is available for people with endometriosis?
Here’s a list of support organisations:
QENDO – A peak organisation providing support to those affected by endometriosis, adenomyosis, PCOS, infertility or pelvic pain, by lobbying for national programs, better healthcare access, support, offering patients tools, services and programs to understand and take control of their health.
Endometriosis Australia – A national charity aiming to increase recognition of endometriosis, provide education programs, and support research.
CHARLI – a health tracking app that can help Australians take control of the diagnosis and management of endometriosis
Pelvic Pain Foundation of Australia – Offers information and support for those suffering from pelvic pain, including endometriosis.
Jean Hailes for Women’s Health – Provides comprehensive information on endometriosis and other women’s health issues, supporting women across Australia.
The Australian Pain Management Association – Offers resources and support for people dealing with pain, including endometriosis-related pain.
Healthdirect Australia – Government-funded service providing trusted health information and advice, including support and resources for endometriosis.
These organisations provide various forms of support, including information on diagnosis and treatment options, access to support networks and communities, and advocacy for better healthcare services for individuals with endometriosis.
The information provided on this website is for educational and informational purposes only. It is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your obstetric doctor or other qualified provider with any questions you may have regarding a medical condition or treatment and before undertaking a new healthcare regimen.
The content on this website is not intended to be a comprehensive source of information on any particular topic and should not be relied upon as such. The authors and publishers of this website are not liable for any damages or injury resulting from the use or misuse of the information provided on this website.
Despite endometriosis being a relatively common condition, it is challenging to identify and diagnose. For many years, laparoscopic surgery has been the “gold standard” procedure for definitively identifying endometriosis. However, the use of transvaginal ultrasound by experienced sonographers is emerging as a complementary diagnostic method due to its greater accessibility, lower cost and non surgical approach.
The growing use of TVUS as an endometriosis diagnosis and treatment planning tool also signifies a more important role for sonographers, and specialist practices like QUFW.
Endometriosis is a relatively common inflammatory condition in which cells similar to the endometrium (the lining of the uterus) grow in other locations around the body. While endometriosis is commonly found in and around the pelvis and reproductive organs, it can also grow in other parts of the body, including the bowel, bladder, and other organs.
Common symptoms of endometriosis include abnormal and heavy bleeding, chronic pelvic pain, dysmenorrhea (painful periods) and dyspareunia (pain during or after intercourse) , which can severely affect quality of life and may affect fertility.
Facts about endometriosis:
Recent Australian research suggests that endometriosis may affect as many as one in seven women.
On average, it takes 6.5 years to be diagnosed with endometriosis, during which patients may experience discomfort, pain, and other symptoms.
Endometriosis commonly presents in three different ways:
Superficial endometriosis (SE)
Ovarian endometriosis (endometriomas)
Deep infiltrating endometriosis (DIE)
According to Delsandes et al (2024), endometriosis may lead to further complications including:
Infertility
Bowel obstruction
Renal failure
Recurrent miscarriage
Depression
Higher rates of cancer
Autoimmune conditions
Cardiovascular disease
Endometriosis is a complex condition, which makes its diagnosis and treatment difficult.
A change in the way endometriosis is diagnosed
Laparoscopic surgery has traditionally been the preferred method of diagnosing endometriosis, which involves a surgical procedure to directly visualise and surgically excise lesions. Laparoscopy, like all operations, has potential risk, expense and recovery time.
However a medical imaging process called transvaginal ultrasound (TVUS) is being utilised more effectively by suitably trained sonographers as a method for diagnosing endometriosis.
QUFW Sonographers are skilled and experienced in this process.
What is transvaginal ultrasound (TVUS)?
Transvaginal ultrasound is a diagnostic imaging technique used primarily in gynaecology to obtain detailed images of the female reproductive organs, including the uterus, ovaries, and surrounding areas. This procedure involves the insertion of a small, wand-like device, called a transducer, into the vagina. The transducer emits sound waves that bounce off internal structures, creating echoes that are then converted into images on a monitor.
This method provides higher resolution images than a transabdominal pelvic ultrasound, allowing for more accurate assessment and diagnosis of conditions such as ovarian cysts, uterine fibroids, early stages of pregnancy, and now endometriosis.
The benefits of TVUS
It has been suggested that transvaginal ultrasound can be used as a first-line imaging method for assessing women with suspected endometriosis (Deslandes Et Al 2024). The assessment however, needs to be performed according to well standardised, established protocols. Transvaginal ultrasound is a noninvasive examination that is not only easily accessible, it is inexpensive but allows for preoperative planning in cases that require surgery.
Diagnostic features of endometriosis can be very subtle and it is important that the scan is performed by a skilled sonographer. At QUFW we believe that endometriosis assessment should be part of every routine gynaecological examination.
QUFW has continued interest in continued professional development for our sonographers and has collaborated with leading experts in the field to ensure that we are at the forefront of diagnostic imaging for our patients. Our sonographers have undergone advanced training in detecting endometriosis on ultrasound and follow the International Deep Endometriosis Analysis (IDEA)consensus. This is a four step systematic approach.
The International Deep Endometriosis Analysis (IDEA) consensus has outlined a four-step assessment approach, using TVUS, for the detection of endometriosis:
Assessment Step 1: Uterus and ovaries
Pathology detected:
Adenomyosis
3D coronal ultrasound image of a uterus demonstrating hyperechogenic myometrial islands commonly seen in adenomyosis.
Ultrasound image of an endometrioma in the left ovary
Assessment Step 2: Ovarian mobility and site-specific tenderness
Pathology detected:
Ovarian adhesions
Sites of tenderness which may indicate endometriosis
Assessment of mobility and tenderness of the right ovary by using “probe palpation” via a transvaginal transducer
Ultrasound video clip demonstrating “kissing ovaries”
Nodules of deep endometriosis within the posterior compartment
Ultrasound video of a deep infiltrating endometriosis bowel nodule
The growing importance of sonographers
The importance and relevance of transvaginal ultrasound in the detection of endometriosis places sonographers at the forefront of diagnosis.
This is due to:
The nuanced skills required to use ultrasound as a medical imaging modality: Sonographers not only use their advanced imaging skills to detect deep endometriosis, but also rely and utilise dynamic imaging to assess for mobility. Assessing mobility is a limitation of MRI in assessment of endometriosis.
Identification of subtle signs: Sonographers provide expertise in spotting the specific markers of endometriosis, which can be challenging to detect via other non-invasive means.
Patient comfort and communication: Sonographers play a key role in ensuring patient comfort during the procedure.
Collaborative care: Sonographers are vital in the multidisciplinary approach to managing endometriosis, working alongside doctors to tailor patient care.
Potential for future advancements
Emerging techniques and technological developments will continue to advance TVUS as a valuable method for diagnosing endometriosis. Some of these are:
SonoPODography
SonoPODography is an innovative ultrasound-based technique designed for the direct visualisation of superficial endometriosis. This procedure involves the infusion of saline into the pouch of Douglas (POD) via an intrauterine balloon catheter, creating an acoustic window that enhances the ultrasound beam’s ability to visualise the surrounding structures of the pelvis. This method allows for the assessment of the presence or absence of superficial endometriosis using pre-defined features.
Elastography
Elastography is a medical imaging technique that measures the elasticity or stiffness of soft tissue, to detect changes that may indicate disease. It’s often used alongside ultrasound or magnetic resonance imaging (MRI) to add important information about the mechanical properties of tissues. By applying slight pressure and analysing how tissue deforms in response, elastography can help in identifying lesions or abnormalities.
Artificial Intelligence
Artificial Intelligence (AI) can enhance the diagnostic process of endometriosis via transvaginal ultrasound (TVUS) by enabling more accurate analysis of imaging data. AI algorithms can be trained to recognize specific patterns and markers indicative of endometriosis, which may not be easily discernible by the human eye. This can help in identifying the presence and extent of endometriosis with greater precision, supporting sonographers in making more informed decisions and potentially leading to earlier detection and treatment of the condition. However, don’t worry, AI won’t be replacing sonographers any time soon.
This advancement in imaging technology enhances diagnostic precision and also significantly improves the overall management of endometriosis. By offering a less invasive diagnostic option, TVUS minimises patient discomfort and anxiety, allowing for a smoother journey through endometriosis diagnosis and treatment.
Reference
Deslandes, A., Panuccio, C., Avery, J., Condous, G., Leonardi, M., Knox, S., Chen, H., Hull, M. 2024. Are sonographers the future ‘gold standard’ in the diagnosis of endometriosis? Sonography.https://doi.org/10.1002/sono.12402
The information provided on this website is for educational and informational purposes only. It is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your obstetric doctor or other qualified provider with any questions you may have regarding a medical condition or treatment and before undertaking a new healthcare regimen.
The content on this website is not intended to be a comprehensive source of information on any particular topic and should not be relied upon as such. The authors and publishers of this website are not liable for any damages or injury resulting from the use or misuse of the information provided on this website.
As you approach your upcoming ultrasound, it’s natural to have questions about what to expect, how to prepare, and what insights the procedure can provide about your baby’s health and development. Ultrasounds are an important part of prenatal care, offering you and your healthcare team valuable information about your pregnancy. This fact sheet is designed to demystify the process, addressing common concerns and queries you might have before your appointment.
Ultrasound imaging, also known as sonography, involves the use of a small device called a transducer which emits high-frequency sound waves that are above the range of human hearing. When the transducer is placed on your abdomen, it sends these sound waves into your body where they travel until they hit tissue boundaries, such as the fluid and tissues of your baby.
Different tissues reflect these sound waves back to the transducer at different rates. For instance, bones reflect more sound waves than soft tissues. The transducer picks up these reflected waves and sends them to the ultrasound machine, which processes the data to construct an image based on the time it took for the echoes to return and their strength. This image appears on the monitor, providing a real-time view of your baby’s shape, position, and movements. The process is safe for both mother and baby, as it uses sound waves instead of radiation.
Early dating assessment of an 8 week fetus by measurement of Crown-Rump Length (CRL)
Is ultrasound safe for the baby and me?
Yes, ultrasound is considered safe for both you and your baby. It uses sound waves, not radiation, to create images. Ultrasounds have been used in pregnancy for decades and extensive studies have shown no direct harm to patients or their unborn children from standard diagnostic ultrasound.
The sound waves are of low energy and the device is designed to be used for short periods of time to minimise any potential risk, even though no risks have been conclusively proven. Sonographers, doctors, and other health specialists who use ultrasound are trained to use the lowest power settings and the shortest exposure times possible while still obtaining the needed information. This is known as the ALARA principle (“As Low As Reasonably Achievable”)
It is recommended that ultrasound is still utilised for medically indicated reasons, however the emotional benefits of ultrasound in pregnancy is also well known and documented.
What can ultrasounds show about my baby’s health?
Ultrasounds can provide valuable information about your baby’s health and development throughout pregnancy. Here are some key aspects that ultrasounds can help assess:
Viability and Heartbeat: An early ultrasound can confirm the pregnancy is viable by detecting the baby’s heartbeat.
Growth and Development: Regular ultrasounds check if the baby is growing normally. Measurements of the baby’s head, abdomen, and limbs help estimate fetal weight and growth.
Anatomical Structures: During the 20 week morphology scan, the ultrasound can examine the baby’s brain, heart, kidneys, limbs, and other organs to ensure they are developing properly.
Amniotic Fluid Volume: The ultrasound checks the amount of amniotic fluid surrounding the baby, which is important for the baby’s movement and development.
Placenta Position: It assesses the position of the placenta, which is crucial for a safe delivery.
Birth Defects: Ultrasound can help in identifying certain physical abnormalities or potential genetic disorders. For instance, it can detect conditions like spina bifida or cleft lip.
Multiple Pregnancies: For twin or multiple pregnancies, ultrasounds determine the number of fetuses, their growth patterns, and their positions.
Overall Health: Ultrasound can help monitor the general health of the fetus, including heart rate and movement, which indicate the baby’s well-being.
Will the ultrasound be able to tell the sex of the baby?
Yes, an ultrasound can usually determine the sex of the baby, provided conditions are favourable, such as clear visibility of the relevant anatomy and the baby being in a suitable position. This is typically done during the second trimester ultrasound, around 20-22 weeks into the pregnancy. At this stage, the genitals are usually developed enough to be visibly distinguished on the ultrasound. There are medical conditions or genetic conditions where ambiguous genitalia may be seen. This is why, at QUFW, we document the gender of all babies. If you do not wish to know your baby’s gender, please let your sonographer know prior to your ultrasound.
However, the accuracy of determining the sex depends on factors like the position of the baby, the amount of amniotic fluid, the mother’s abdominal wall thickness, and the experience of the ultrasound technician. While the prediction is generally accurate, there is still a chance of error, so it’s not 100% guaranteed.
3D image of a 20-week fetus
What should I do to prepare for an ultrasound?
To prepare for an ultrasound, you can follow these steps to ensure the process is smooth and the images obtained are clear:
Follow Instructions on Drinking Water: For many ultrasounds in early pregnancy, you might be asked to have a full bladder, which helps improve the visibility of the uterus and the baby by pushing the bowel out of the way. Drink the amount of water recommended by your healthcare provider about an hour before the scan and try not to urinate until after the ultrasound. If you are feeling uncomfortable, it is important to discuss this with the QUFW team prior to your scan.
Wear Comfortable Clothing: Choose two-piece clothing that allows easy access to your abdomen. This makes it easier for the technician to apply the ultrasound transducer without discomfort. However, dresses are often more comfortable during pregnancy. We are also equipped with modesty sheets to cover you during the scan.
Know Your Medical History: Be prepared to provide your medical and obstetric history, as well as details of any previous pregnancies and ultrasounds, which can be important for comparative analysis.
Check Hospital or Clinic Protocols: Especially under current health guidelines, check if there are any specific protocols about bringing a support person. Some places might restrict visitors to reduce health risks.
Ask About the Procedure: If you have any concerns or questions about the ultrasound, don’t hesitate to ask your healthcare provider beforehand. Knowing what to expect can help ease any anxiety.
How long does an ultrasound take?
The duration of an ultrasound can vary depending on the type of scan and the specific objectives, but most routine ultrasounds during pregnancy typically take about 30 to 45 minutes.
Early ultrasounds might be quicker, often completed in about 15 minutes, as they are generally simpler and focus on confirming the pregnancy and checking basic measures like the presence of a heartbeat.
More detailed scans, like the 13 week early anatomy scan and the 20 week morphology anatomy scan, can take longer, sometimes up to 45 minutes, especially if the baby is not in an ideal position to see all the structures clearly or if there are multiple babies.
If the ultrasound is being conducted to address specific concerns or to monitor a particular condition, the duration might also vary based on what needs to be examined. We always recommend to be aware that you may be in the department for approximately 90 minutes.
Will I need a full bladder for the ultrasound?
Whether you need a full bladder for an ultrasound depends on how far along you are in your pregnancy:
Early Pregnancy: For ultrasounds done in the first trimester, especially those before 12 weeks, a full bladder is often required. The full bladder helps to lift the uterus up and out of the pelvis, providing a clearer view of the developing fetus. It is also known as an ‘acoustic window’, where we can look through the fluid within the bladder and see the uterus and pregnancy sitting behind the bladder.
Later Pregnancy: For ultrasounds performed in the second and third trimesters, a full bladder is usually not necessary. By this stage, the uterus is large enough to be easily visible without the need for a full bladder. We recommend to have a small amount of fluid within your bladder, but not to the point where you are feeling uncomfortable.
Does an ultrasound hurt?
No, an ultrasound does not hurt. It is a painless procedure. During the ultrasound, a handheld device called a transducer is used to send and receive sound waves. This transducer is moved over your abdomen with a gel that helps improve contact between the device and your skin. You might feel some pressure as the technician moves the transducer to get the best images, but this should not be painful. If you experience any discomfort during any type of ultrasound, you can communicate this to the sonographer who will try to make adjustments to ease your discomfort.
If you do experience discomfort or pain during the scan, please inform your sonographer at the time.
If you have a transvaginal ultrasound, where the transducer is inserted into the vagina for better imaging in early pregnancy, you might feel some discomfort, but it should not be painful. If you experience any discomfort during any type of ultrasound, you can communicate this to the sonographer who will try to make adjustments to ease your discomfort.
Can I get pictures or a video from the ultrasound?
At QUFW, we utilise the Tricefy app to send images or short video clips during your ultrasound. However, the quality of the images and video clips is dependent on the position of your baby and other factors such as placental position and maternal habitus that we cannot control. We will always endeavour to send some images through to your mobile phone, however sometimes the number and quality of the images may be not within your expectations prior to the scan.
Further reading
Take a look at these pages to learn more about the pregnancy ultrasound scans we provide:
If you have another question about your upcoming ultrasound at QUFW, please write them down and bring them to your scan. Your sonographer or doctor will discuss them with you.
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Content Disclaimer
The information provided on this website is for educational and informational purposes only. It is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your obstetric doctor or other qualified provider with any questions you may have regarding a medical condition or treatment and before undertaking a new healthcare regimen.
The content on this website is not intended to be a comprehensive source of information on any particular topic and should not be relied upon as such. The authors and publishers of this website are not liable for any damages or injury resulting from the use or misuse of the information provided on this website.
We sat down with QUFW co-owner, Dr. Jackie Chua, to learn more about her unique contribution to obstetrics and gynaecology in Queensland, her passion for women’s health, the vision she has for QUFW, and more.
Dr. Jackie Chua is a RANZCOG-accredited sub-specialised Obstetrics and Gynaecology sonologist. She is currently the Head of Discipline in Obstetrics and Gynaecology for the Diploma of Diagnostic Ultrasound for the Australasian Society for Ultrasound in Medicine. She also represents Queensland on the COGU subcommittee at RANZCOG and the Australian Association for Obstetrical and Gynaecological Ultrasonologists committee. Dr. Chua has a special interest in fertility scanning and endometriosis assessment, and is the co-owner of QUFW.
Dr. Jackie Chua’s story is an inspiring blend of familial legacy, relentless self-education, and an unyielding advocacy for women’s health.
As we sit down to speak, it doesn’t take long for Dr. Chua to demonstrate why she has become an accomplished figure in Australia’s obstetrics and gynaecology space. Like many groundbreaking clinicians, her career ‘formula’ is unique. And it began with an origin story that started much earlier than her peers.
An early interest in obstetrics and gynaecology
Dr. Chua’s father, a medical school graduate from the University of Queensland, and her mother, a nurse from Toowoomba, instilled strong family values in their daughter from a young age. Moving from Australia to a small Canadian town when she was six months old, Dr. Chua was able to experience the colours of small-town medical life.
“When I was young, I would sit in the doctor’s waiting room waiting for my father, and I would sometimes hear ladies crying and screaming,” she recalls.
“But then every so often, I’d hear a baby.”
“And then, as I grew up, I thought, that’s very special.”
This backdrop of community care, and the vivid memories of experiencing the cries and joy of childbirth, sparked an interest in her future career.
However, despite these early influences, Dr. Chua’s path to medicine was not straightforward. After initially pursuing science in Canada, a family holiday back to Brisbane led to an impromptu, and successful, application to university.
Starting in pharmacy, she later transitioned into medicine and completed her medical training at the University of Queensland. An internship experience in an obstetrics and gynaecology (“O&G”) placement at the Mater hospital appealed to her.
“I liked obstetrics and gynaecology because it gave me a mix between medicine and surgery,” she explains.
“And I thought, well, that’s cool. You are able to use surgical skills and medical skills, rather than having to think you have to just do ‘medicine’ or you just have to do ‘surgery’.”
“And I felt that there must be somewhere I can actually actually help people, especially women, so that they understood their health better and weren’t scared by their bodies.”
“That’s why I wanted to do O&G when I graduated,” she explains.
“After doing my internship at the Mater, I decided to go and do my second year at Southampton General Hospital in the UK.”
Early career, inspiring role models
It was at this time in her career that Dr. Chua was influenced by two inspirational clinicians.
“At that time, one of the doctors I knew of was Dr. Aldo Vacca. He’s the gentleman who invented what’s called the Kiwi Cup, a vacuum suction cup for delivering babies.”
“He gave back to charity, went back to PNG and worked there every so often, and invented a vacuum extraction device that makes deliveries safer and better.”
“He unfortunately passed away quite a few years ago, but he was amazing,” Dr. Chua explains.
Dr. Chua also recalls her admiration for the late Professor Fung Yee Chan, a no-nonsense, fiercely intelligent female clinician who was the founder of, and a role model in, a department that was predominantly male at the time.
“She was no nonsense and she was smart. She was very dedicated. She was someone that you just sit and go, wow!”
“As a female doctor in a position of that type of departmental type of position, it was really cool because everyone at that time were actually all boys,” she explains.
When Dr. Chua returned to Australia, she embarked on a six-year O&G training program. Her decision to sub-specialise in ultrasound was sparked during her fifth year, after the program’s curriculum opened her eyes to the possibilities within the field.
When she completed her training, Dr. Chua found herself as the only COGU subspecialist in Queensland—a distinction she held for over a decade.
A graceful attitude towards patient care
Dr. Chua doesn’t rush appointments, despite the pressures of a busy clinic, and she is attentive to the underlying fears that might accompany a patient’s visit.
“I just stop and I listen,” she says.
“And I go back and say… look, I understand what you’re saying.”
“And please don’t feel like you can’t ask me a question. I will always listen.”
She explains her use of empathy as both a clinical tool and an instrument for putting her patients at ease.
“And I try to find out what it is that they’re scared of as well, which can be very relieving once they open and up and discuss it.”
This holistic approach to patient care—balancing technical expertise with compassionate communication—is undoubtedly one of the traits that have contributed to her career trajectory.
When probed for a feel-good patient story, Dr. Chua, with a chuckle, admits the challenge in articulating a single moment. To her, each patient is a chapter, and while she may be a crucial part of their healthcare journey, the collective gratitude expressed by those she helps stands out more than any one experience.
“Some patients stop and just say thank you. Thank you for explaining it well. I didn’t understand. Thank you for actually listening or taking the time and explaining it,” she says.
Helping women understand their bodies
One of Dr. Chua’s passions is helping women understand, and not fear, their bodies.
She does this by delivering definitive diagnoses as best she possibly can, particularly in complex conditions like endometriosis. She tries to offer patients not just medical insights but also validation and relief from the angst of the unknown.
“Some ladies feel frustrated when their pain goes undiagnosed.”
“In my work in gynaecology, I’m sometimes able to say to some ladies that, yes, there is something wrong with you, even if other avenues haven’t been able to visibly see anything,” she explains.
“It gives patients the realisation that their pain is real.”
She considers herself a link in the healthcare chain, aiding fertility specialists by advising on the viability of natural conception or the need for IVF, assisting gynaecologic oncologists by identifying potential cancers, and ensuring that fetal abnormalities are appropriately managed through collaborative care.
Dr. Chua is humble and reluctant to celebrate her career. Yet the significance of her role transcends the technicalities of her specialty.
The limitations of ultrasound
Dr. Chua is also eager to address a common misunderstanding of medical ultrasound technology: while ultrasound is adept at revealing structural aspects of the body, it cannot ascertain functionality.
This limitation is a frequent source of misunderstanding among patients who seek absolute reassurance about their health, or the health of their unborn child.
“Patients often come with the hope of hearing that everything is perfect,” she explains.
“They say, ‘all I want is a healthy baby,’ and naturally so.”
“But the reality of what ultrasound can deliver in terms of answers is sometimes at odds with these expectations.”
She confronts the difficult task of conveying that, while she can identify the presence of vital organs and limbs, the ultimate functioning of these structures remains beyond the scope of the scan. Her clinical process becomes a delicate combination of providing clear information and managing patient expectations.
Additionally, in the world of gynaecology, Dr. Chua faces similar challenges. Women suffering from years of pelvic pain may expect a definitive diagnosis through ultrasound, which is not always possible.
“Ultrasound, on its own, is not meant to definitively diagnose conditions like endometriosis,” she asserts.
The task then becomes one of education, helping patients to understand that while ultrasound is a powerful tool, it has its bounds.
On professional and clinical developments
In discussing how she keeps herself and her clinic at the cutting edge, Dr. Chua reveals a commitment to continuous learning, jokingly referring to ‘osmosis from her peers’ before delving into more substantial methods.
“That’s why I like to teach. I like to learn. I always say… I’m not done learning.”
“At least I’m done having exams. At least I think I am,” she chuckles.
“But I don’t think I know everything and I’m always happy to learn.”
Dr. Chua’s approach to medicine is dynamic; she sees every procedure as a collective effort, influenced by various practitioners, where learning and teaching are reciprocal processes.
She maintains an affiliation with the public hospital system, not solely for the sake of helping more people but also to teach and learn from others.
Looking towards the future, Dr. Chua hopes to continue enhancing the standards of ultrasound in women’s health by building on the clinic’s achievements and fostering an environment of continuous improvement.
The future of her practice
Dr. Chua is passionate about QUFW’s future, ensuring the clinic’s longevity by welcoming junior fellows without overwhelming them. She envisions a collaborative future, not just within her immediate team of sonographers but extending into the wider medical community, including GPs, to optimise care for women.
What sets QUFW apart, in Dr. Chua’s view, is her team’s approachability and willingness to engage in dialogue. She believes in maintaining open lines of communication, where questions are welcomed, and answers are given thoughtfully—a philosophy that may be understated but is deeply valued.
Dr. Chua jumps at the chance to describe her team as exceptionally skilled.
“They’re darn good at what they do and I feel like I’m the support act sometimes to them, but hopefully, I’m a good support act,” she says.
In ten years from now, Dr. Chua sees QUFW growing and evolving while retaining the core team that makes it exceptional. Her modesty is clear when discussing the clinic’s success, highlighting her preference for service over self-promotion.
When asked about the next decade, she says she hopes QUFW will be, “slightly bigger, slightly older, and still with the great team.”
“And just continuing to work hard.”
A doting family figure
Dr. Chua finds solace in family life, allowing the comforts of home to provide rejuvenation. She emphasises the importance of leaving work at the door–a strategy to preserve her own well-being amidst the demands of her career.
“I do try to leave it at the doorstep and, if occasionally it does come home with me, that’s fine,” she says.
In a final reflection on her career, Dr. Chua considers the possibility of maintaining her surgical skills but ultimately expresses contentment with her chosen path, affirming that specialising has allowed her to excel in her field.
If she could offer her younger self a piece of advice, it would simply be, “you’ll get there,” a nod to the patience and perseverance that have been hallmarks of her journey in medicine.
As the interview concludes, Dr. Chua’s gentle, confident, yet humble nature is evident. Her pioneering spirit, commitment to her work, and the care of her patients and team speaks louder than any self-praise.
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March 2024
Content Disclaimer
The information provided on this website is for educational and informational purposes only. It is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition or treatment and before undertaking a new healthcare regimen.
The content on this website is not intended to be a comprehensive source of information on any particular topic and should not be relied upon as such. The authors and publishers of this website are not liable for any damages or injury resulting from the use or misuse of the information provided on this website.
Placenta accreta spectrum is a potentially life-threatening obstetric condition where the placenta grows too deeply into the wall of the uterus. This abnormality may prevent the placenta from detaching after childbirth, causing significant maternal bleeding and other complications for both the mother and her baby.
Placenta accreta was traditionally classified into different types based on the severity and depth of placental invasion (accreta, increta and percreta). Often, however, the only way to determine this is after delivery. As a result, all disorders of abnormal placentation are now referred to collectively as placenta accreta spectrum (or PAS)
PAS is often diagnosed during pregnancy through ultrasound, although it may sometimes only be detected during delivery. It requires advanced diagnosis and careful management by a multidisciplinary medical team.
‘Placenta accreta spectrum disorder’ (PAS) is a pregnancy-related condition where the placental villi abnormally invade the myometrium during the first trimester of pregnancy.
Normally, the placenta separates from the wall of the uterus after childbirth. However, in cases of PAS, this detachment does not occur as it should.
Animated portrayal of placenta accreta spectrum (PAS) – John Hopkins Medicine
A study covering Australia and Aotearoa New Zealand found that the occurrence of PAS is around 44.2 in every 100,000 women (or 1 in 2000) who are giving birth, although there are some risk factors which make PAS much more likely in some patients.
What are the different types of PAS?
PAS is classified into three types based on the depth of placental invasion into the wall of the uterus. This differentiation can only definitively be made after delivery, on histopathological assessment.
Placenta accreta: This is the most common. In placenta accreta, the placenta attaches itself deeply into the uterine wall but does not penetrate the muscle of the uterus. This can lead to difficulties in placental detachment during childbirth.
Placenta increta: In this form, the condition is more severe. The placenta invades into the muscles of the uterus, embedding itself more deeply than in placenta accreta. This increases the risk of severe bleeding during delivery and can pose more significant health risks.
Placenta percreta: This is the most severe form of the condition. In placenta percreta, the placenta penetrates through the entire uterine wall and can attach to other organs, like the bladder or intestines. This type poses the highest risk of severe complications, including severe bleeding, and may require extensive surgical intervention, and earlier delivery.
The severity and extent of PAS significantly impacts the approach to delivery and the type of medical intervention required. Early and accurate diagnosis is essential for managing these risks and planning a safe delivery strategy.
PAS is typically diagnosed through a combination of imaging tests and clinical assessment. The most common diagnostic methods include:
Ultrasound: Ultrasound is the first line imaging modality for diagnosing PAS. A detailed ultrasound can show abnormal placental attachment and blood flow. Doppler ultrasound, which visualises blood flow, can be particularly useful in identifying unusual blood vessels that may suggest the presence of PAS.
Magnetic Resonance Imaging (MRI): If ultrasound results are inconclusive or if a more detailed view is needed, an MRI can be used. MRI has similar sensitivity in detection of PAS as ultrasound, but can be useful when ultrasound is limited (e.g. in higher BMI, or when the placenta is posterior) .
Clinical History and Risk Factor Assessment: A thorough assessment of the patient’s medical history, including previous caesarean sections, uterine surgeries, and other risk factors, is important. This information (also known as the pre-test probability, or likelihood), combined with imaging results, helps in making a diagnosis.
Early diagnosis is crucial for planning appropriate medical care to manage the condition and reduce the risk of complications during delivery. Women with known risk factors for PAS are typically monitored more closely with these diagnostic tools, and an accurate antenatal diagnosis of PAS impacts delivery planning.
Placenta praevia completely covering the internal cervical os with placenta accreta
What risk factors may contribute to PAS?
There is some thought that PAS may be a later gestation manifestation of caesarean-scar pregnancy, or a pregnancy which implants within the prior caesarean scar. Rather than being an abnormality innate to the placenta itself, the abnormal invasion and development of the placenta may relate to the location in which it implanted, and the nature of the scar tissue.
PAS is known to be associated with several risk factors, each contributing to the increased likelihood of its occurrence:
Previous Caesarean Delivery: A history of caesarean delivery is a major risk factor for PAS. With each subsequent caesarean, the risk of PAS increases. This is because the surgical scar in the uterus can be a site where the placenta abnormally adheres in future pregnancies.
Low-Lying Placenta or Placenta Previa: When the placenta is positioned low in the uterus or covers the cervix (placenta previa), the risk of PAS is higher. This abnormal positioning can lead to a deeper implantation of the placenta into the uterine wall. However, placenta accreta spectrum is still relatively rare in placenta praevia, unless a patient has also had prior caeasarean sections.
Advanced Maternal Age: Women who are older, typically over the age of 35, have a higher risk of developing PAS.
Multiparity: Having multiple pregnancies increases the risk of PAS.
Previous Uterine Surgery Including Myomectomy, D&C, Cornual Resection, or Endometritis: Any previous uterine surgery, such as the removal of fibroids (myomectomy), dilation and curettage (D&C), cornual resection, or a history of endometritis (inflammation of the uterine lining), can leave scars or changes in the uterus. These alterations can create areas where the placenta can attach too deeply, increasing the risk of PAS.
Transvaginal ultrasound image demonstrating placenta praevia with suggestion of placenta increta. Bladder wall appears intact.
What are the symptoms of PAS?
PAS often does not present with multiple distinct symptoms, especially early in pregnancy, which is why it is frequently diagnosed through routine imaging in at-risk patients. However, there are a few signs and symptoms that may suggest the presence of PAS, particularly as a pregnancy progresses:
Vaginal Bleeding: This is the most common symptom and usually occurs in the second or third trimester of pregnancy. The bleeding can range from light to heavy.
Fetal malpresentation: The baby may persistently remain in a non-cephalic (breech or transverse) position because the abnormally implanted placenta (when covering the cervix) prevents the baby descending in the pelvis.
It’s important to note that many women with PAS do not experience any noticeable symptoms, and the condition is often detected during routine prenatal imaging in women who have risk factors for the condition.
What are the risks associated with PAS?
PAS carries several significant risks and potential complications, mainly due to the abnormal attachment of the placenta to the uterine wall. These risks can impact both the mother and the baby:
Severe Maternal Haemorrhage: This is the most significant risk. The deep attachment of the placenta can lead to severe bleeding during attempts to remove the placenta after childbirth. This can result in a life-threatening situation requiring immediate medical intervention.
Need for Hysterectomy: Most commonly, a hysterectomy (surgical removal of the uterus) is necessary following delivery, as the placenta will not detach from the uterine wall.
Preterm Birth: PAS can increase the risk of preterm labour and delivery, which carries risks for the baby, including respiratory distress syndrome, developmental delays, and other prematurity-related complications. This can be either iatrogenic (planned preterm birth to reduce potential complications), or spontaneous, in which case delivery may be indicated in the scenario of a large bleed.
Blood Transfusions and Surgery: Due to the risk of severe bleeding, blood transfusions and multiple surgical interventions may be required.
Damage to Other Organs: In severe cases, particularly in placenta percreta, the placenta can invade other organs like the bladder or intestines, leading to additional complications and the need for more complex surgery.
Mental Health Impact: The diagnosis and management of PAS, including the potential loss of fertility and the stress of a high-risk pregnancy, can have significant emotional and psychological impacts.
For the baby, the risks are mainly associated with premature birth and the potential complications that can arise from being born early. There is also a risk of fetal growth restriction associated with placenta accreta spectrum, and this is why serial ultrasound is recommended to monitor fetal growth.
Transvaginal ultrasound image demonstrating colour flow in placenta accreta.
How is PAS treated?
The treatment of PAS primarily focuses on managing the risks during childbirth and addressing potential complications, especially severe bleeding. The treatment plan depends on the severity of the condition, the health of the mother and baby, and the stage of pregnancy.
Common treatment strategies include:
Planned Caesarean Hysterectomy: Women with PAS will be recommended to deliver by planned caesarean section. This is often planned around 34-36 weeks of gestation, to minimise the risk of spontaneous labour, which could lead to uncontrollable bleeding. In most cases, with the exception of small focal placenta accreta spectrum, a hysterectomy (removal of the uterus) is planned as a part of the same operation and performed immediately after the delivery of the baby. This is often necessary to control bleeding and can be a life-saving measure.
Blood Transfusions: Due to the high risk of severe bleeding, arrangements for blood transfusions are usually made in advance of the delivery.
Medication Management: Medications may be used to control bleeding, manage pain, and prevent infection during and after the delivery.
Follow-up Care: Postpartum care is crucial, especially if a hysterectomy is performed. Monitoring for complications like infection, bleeding, or psychological impact is important.
Each case of PAS is unique, and the treatment plan is tailored to the individual’s specific situation. Early diagnosis and careful planning are key to the successful management of PAS.
Will I need a Caesarean section if I have PAS?
If you have PAS, a caesarean section will be recommended for delivery. This is because the abnormal attachment of the placenta to the uterine wall in PAS makes it impossible for the placenta to separate naturally and safely during vaginal delivery. Attempting a vaginal birth in such cases could lead to severe, life-threatening bleeding.
In many cases a hysterectomy (surgical removal of the uterus) will be planned immediately after the delivery of the baby during the same surgical procedure. This is done to control bleeding and is often a necessary step in managing the condition.
It’s important to discuss your specific case with your healthcare provider, who can advise on the best approach for delivery based on the extent of the PAS and your overall health. They will also consider other factors, such as whether the PAS is considered likely to be focal (a small area which may be able to be resected) or more diffuse.
Can PAS be prevented?
Preventing PAS can be challenging because the exact cause of the condition is not entirely understood. However, there are certain measures and considerations that can help reduce the risk:
Limiting Caesarean Deliveries: Since a major risk factor for PAS is previous caesarean deliveries (Caesarean sections), limiting the number of Caesarean sections when medically possible can reduce the risk.
Careful Management of Uterine Surgeries: Procedures that involve the uterus, such as myomectomy (removal of uterine fibroids), can increase the risk of PAS in future pregnancies. This is more the case when fibroidectomy is cavity breaching.
Early Prenatal Care: Early and regular prenatal care is important, especially for women with risk factors for PAS. Early detection of potential issues allows for better planning and management.
Family Planning and Birth Spacing: Thoughtful family planning and spacing between pregnancies can help minimise the cumulative risk associated with multiple pregnancies and Caesarean sections.
Can I still have a vaginal birth with PAS?
Most cases of placenta accreta spectrum also occur in the setting of a low lying or praevia placenta, which will often prevent descent of the baby into the birth canal to allow a vaginal delivery.
Additionally, when the placenta is abnormally adherent, even if the baby can be delivered vaginally, the PAS will prevent placental separation warranting operative management following delivery to manage bleeding and retained placenta.
The information provided on this website is for educational and informational purposes only. It is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your obstetric doctor or other qualified provider with any questions you may have regarding a medical condition or treatment and before undertaking a new healthcare regimen.
The content on this website is not intended to be a comprehensive source of information on any particular topic and should not be relied upon as such. The authors and publishers of this website are not liable for any damages or injury resulting from the use or misuse of the information provided on this website.
From a young age, Kate knew she wanted a family. But what she didn’t know then, was the journey to motherhood would be more complicated than expected. After experiencing miscarriages previously, Kate and her husband Aaron were nervous when they got pregnant again, but were relieved when they found out that baby Ruby had a heartbeat! With the finish line in sight, at their 36 weeks scan, the pair faced a new hurdle when they were told that their baby girl may not live a full and healthy life. However, thanks to new and improved ultrasound technology Dr. Robert Cincotta, Maternal Fetal Medicine Specialist, and the team at Queensland Ultrasound For Women were able to detect her intracerebral bleed and make an early diagnosis.
This video was produced by BBC StoryWorks Commercial Productions on behalf of GE HealthCare.
It was at this time in her career that Dr. Chua was influenced by two inspirational clinicians.
Dr. Chua is passionate about QUFW’s future, ensuring the clinic’s longevity by welcoming junior fellows without overwhelming them. She envisions a collaborative future, not just within her immediate team of sonographers but extending into the wider medical community, including GPs, to optimise care for women.
