ARCHETYPE Imaging examination of the uterus (openEHR-EHR-CLUSTER.imaging_exam-uterus.v0)

Use to record the findings on radiological examination of the uterus, and their interpretation.

The intended scope for this archetype is to eventually record all detailed findings on radiological examination of the uterus using any modality. It is anticipated that further data elements may be added as requirements are identified and confirmed.

This archetype is designed to be nested within the 'Structured imaging findings' SLOT in the OBSERVATION.imaging_exam_result, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Use to provide a framework in which CLUSTER archetypes can be nested in appropriate SLOTs:

• Details about the imaging examination of one or more gestations will be recorded using the 'Pregnancy findings' SLOT;
• Details about the imaging examination of the uterine cervix will be recorded within the 'Cervical findings' SLOT;
• Details about the imaging examination an intrauterine device (IUD) will be recorded within the 'IUD findings' SLOT; and
• Details about other imaging findings such as structural abnormalities or lesions will be recorded using the 'Additional findings' SLOT.

• Licence: This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/.
• Custodian Organisation: openEHR Foundation
• References: Abuhamad A, Chaoui R, Jeanty P, Paladini D, Walsh E. Ultrasound in Obstetrics and Gynecology: A Practical Approach [Internet]. The Global Library of Women’s Medicine; 2014 [cited 2021 Dec 21]. 322 p. Available from: https://www.glowm.com/pdf/Ultrasound_in_obstetrics_and_gynecology-chapter11.pdf. AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Female Pelvis. J Ultrasound Med. 2020 May;39(5):E17-E23. doi: 10.1002/jum.15205. Epub 2020 Mar 9. PMID: 32150295. Available from: https://www.aium.org/resources/guidelines/femalePelvis.pdf. American Institute of Ultrasound in Medicine; Society for Reproductive Endocrinology and Infertility; American Society of Reproductive Medicine. AIUM practice guideline for ultrasonography in reproductive medicine. J Ultrasound Med. 2009 Jan;28(1):128-37. PMID: 19106372. Available from: https://www.aium.org/resources/guidelines/reproductiveMed.pdf. Leone FP, Timmerman D, Bourne T, Valentin L, Epstein E, Goldstein SR, Marret H, Parsons AK, Gull B, Istre O, Sepulveda W, Ferrazzi E, Van den Bosch T. Terms, definitions and measurements to describe the sonographic features of the endometrium and intrauterine lesions: a consensus opinion from the International Endometrial Tumor Analysis (IETA) group. Ultrasound Obstet Gynecol. 2010 Jan;35(1):103-12. doi: 10.1002/uog.7487. PMID: 20014360. Available from: https://obgyn.onlinelibrary.wiley.com/doi/10.1002/uog.7487.
• Original Namespace: org.openehr
• Original Publisher: openEHR Foundation
• Custodian Namespace: org.openehr
• MD5-CAM-1.0.1: 4E74AC49056CDB46722308BF3C171A4C
• Build Uid: dc0ed4ad-032b-4a64-8cca-be039732021d
• Ip Acknowledgements: This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact https://www.snomed.org/snomed-ct/get-snomed or info@snomed.org.
• Revision: 0.0.1-alpha

• at0.1::Uterus
  [SNOMED-CT::35039007 | Uterine structure]

• >=0.0 mm
  Limit decimal places: 0
• >=0.0 cm
  Limit decimal places: 1

• >=0.0 mm
  Limit decimal places: 0
• >=0.0 cm
  Limit decimal places: 1

• >=0.0 mm
  Limit decimal places: 0
• >=0.0 cm
  Limit decimal places: 1

• at0.26::Anteverted [The uterus is angled forward relative to the vagina.]
• at0.27::Neutral [The uterus and the vagina are in the same plane.]
• at0.28::Retroverted [The uterus is angled backward relative to the vagina.]

• at0.30::Anteflexed [The cervix-body angle faces anteriorly.]
• at0.31::Retroflexed [The cervix-body angle faces posteriorly.]

• at0.53::Homogeneous [The echotexture of the endometrium is uniform.]
• at0.54::Heterogeneous [The echotexture of the endometrium is not uniform.]

• at0.49::Hyperechoic [Increased echogenicity of the endometrium, compared to the myometrium.]
• at0.50::Isoechoic [Similar echogenicity of the endometrium, compared to the myometrium.]
• at0.51::Trilaminar [A triple line pattern of the endometrium is observed.]
• at0.63::Hypoechoic [Decreased echogenicity of the endometrium, compared to the myometrium.]

• at0.56::Uniform [Endometrium appears homogeous with symmetrical anterior and posterior sides. It may also include the three-layer pattern.]
• at0.57::Non-uniform [Endometrium appears heterogenous with asymmetrical anterior and posterior sides and cysts.]

• at0.59::Linear [A straight hyperechogenic interface within the endometrium is observed.]
• at0.60::Non-linear [A wavy hyperechogenic interface within the endometrium is observed.]
• at0.61::Irregular [An irregular or interrupted hyperechogenic interface within the endometrium is observed.]
• at0.62::Not defined [The absence of a hyperechogenic interface within the endometrium is observed.]

• at0.64::Regular [The junctional zone appears regular.]
• at0.65::Irregular [The junctional zone appears irregular.]
• at0.66::Interrupted [The junctional zone appears interrupted.]
• at0.67::Not defined [The junctional zone is not visible or well defined.]

• at0.6::Present [Evidence of one or more intrauterine pregnancies are observed - gestational sac, embryo or foetus.]
• at0.7::Absent [No intrauterine pregnancy is observed.]
• at0.8::Indeterminate [It is not possible to determine if an intrauterine pregnancy is present or absent.]

• at0.33::Present [An IUD is observed in the uterus.]
• at0.34::Absent [No IUD is observed in the uterus.]
• at0.35::Indeterminate [It is not possible to determine if an IUD is present or absent.]

• German: Natalia Strauch, Medizinische Hochschule Hannover, Strauch.Natalia@mh-hannover.de
• Norwegian Bokmål: Peter Fedorcsak, Vebjørn Arntzen, Marit Alice Venheim, University of Oslo, Oslo University Hospital, Helse Vest IKT, peterfe@uio.no, varntzen@ous-hf.no, marit.alice.venheim@helse-vest-ikt.no