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CASE PRESENTATION
- 1. Sonographic Imaging of theFemale Patient with Pelvic Pain/ Bleeding Michael Kyeremeh Owusu REGISTERED MEDICAL SONOGRAPHER Ghana
- 2. Case Presentation 24yo female presents with missed period, cramping, midline abdominal pain and spotting VS: BP 120/80 HR 110 Pelvic: Cervical os is closed with minimal bleeding No CMT, adenexa symmetric Urine hCG is +
- 3. Case presentation Abedside ultrasound is performed The US reveals an IUP The patient is discharged to home with threatened abortion precautions LOS = 30 minutes Applies to 60% of pts
- 4. Role of BedsideSonography Identify an IUP Establish fetal viability
- 5. Secondary Indications Hemodynamicinstability in a female pt Trauma and pregnancy Localization of IUD/foreign body Identify sources of pelvic pain in non-pregnant patients
- 6. Imaging: Transabdominal Usesa lower frequency transducer: 3.5 –5 mHz Better penetration, larger field of view It should be the initial imaging window to assess for Advanced IUP Fibroids/masses Pelvic fluid The bladder should be full to provide an acoustic window
- 7. Endovaginal Uses ahigher frequency transducer: 6.0- 7.5mHz Provides optimal imaging of: Endometrium Myometrium Cul-de-sac Ovaries A full bladder is not necessary for this approach Is usually better tolerated by patients
- 8. Scanning Protocol: Transabdominal Image the patient before obtaining a urine sample Can fill the bladder via foley and instill 300 cc NS but… If the bladder is empty, go directly to TV imaging after the pelvic exam
- 9. Probe Selection “Workhorse”probe 3.5 to 5.0 MHz Multi-frequency probe Good for most cardiac/abdominal applications
- 10. Uterus An ovalorgan located superior to the full bladder The maximum size of the non-gravid uterus is 5-7 cm x 4-5 cm The endometrial stripe is the opposed surfaces of the endometrial cavity
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- 12. Cul-de-sac Located posteriorto the uterus and upper vagina A small amount of fluid may be seen in mid cycle A small amount of fluid in the posterior cul-de-sac may be the only sonographic finding in EP
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- 14. Probe Selection EndovaginalProbe 5 to 8 mHz variable frequency probe Up to 180 degree angle of view
- 15. Endovaginal Examination Bestperformed immediately following the pelvic exam An empty bladder is required for an optimal endovaginal (EV) exam A full bladder: Displaces the anatomy beyond the focal length of the transducer Will create artifacts that will compromise imaging
- 16. Before Performing aTV Exam: Explain that the EV exam is better for seeing ovaries and early pregnancy Show the patient the probe Allow her the option of inserting it herself Inform her that it is usually more comfortable than the TA exam which requires a full bladder
- 17. The transducerprobe should be covered with a coupling gel followed by a protective probe cover Non-medicated/ non-lubricated condoms are recommended as a probe cover Patients with latex allergies will require an alternative barrier Air bubbles within the sheath may increase artifacts and compromise imaging
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- 22. The Uterus Earlyin the menstrual cycle endometrium measures 4-8mm Secretory phase endometrium measures 7-14 mm Post-menopausal patient endometrial stripe usually less than 9 mm
- 23. Endometrial Stripe (ES) Measurements In the post-partum patient, a thickened ES is suggestive of retained products of conception In the pregnant patient, an ES measurement of < 8 mm in the absence of an IUP is suggestive of EP Thickening of the endometrial stripe in the post-menopausal patient with vaginal bleeding should raise suspicions for endometrial carcinoma
- 26. Ovaries Lie posterior/lateralto the uterus Anterior to the internal iliac vessels and medial to the external iliac vessels Identified by a ring of follicles in the periphery
- 27. Ovaries After ovulationa corpus luteal cyst may be present Observed in approximately 50% of ovulating females Should not be seen beyond 72 hours into the next cycle Small amount of fluid in the rectouterine pouch may be seen during ovulation
- 28. Ovarian Cysts Follicularcyst (2.5 –10 cm) Thin, round, unilocular Functional corpus luteum cyst Normal up to 16 weeks GA Appears as a unilateral, unilocular 5-11 cm cyst Appearance can be highly variable Hemorrhage inside the cyst not uncommon
- 30. Assessment of thePregnant Patient Identify gestational sac Demonstrate a myometrial mantle in the transverse view Identify yolk sac and/or fetal pole Note if there is fluid in the cul-de-sac
- 31. Gestational Sac Anechoicarea within the uterus surrounded by two bright echogenic rings Decidua vera (the outer ring) Decidua capsularis (the inner ring) This is referred to as the double decidual sac sign (DDSS)
- 33. Yolk Sac Firstembryonic structure that can be detected sonographically Visualized approximately 5-6 weeks after the last menstrual period Bright, ring like structure within the GS Should be readily seen when the GS sac is greater than 10 mm (using EVS)
- 36. Fetal Pole Canbe first seen on EV when the fetus is approximately 2 mm in size A thickened area adjacent to the yolk sac The CRL is the most accurate sonographic measurement that can be obtained during pregnancy
- 40. A Fetal HeartBeat An important prognostic indicator The rate of spontaneous abortion is extremely low (2- 4%) after the detection of normal embryonic cardiac activity The normal fetal heart rate in early pregnancy is 112- 136
- 41. Definite IUP Agestational sac with a sonolucent center (greater than 5 mm diameter) Surrounded by a thick, concentric, echogenic ring GS contains a fetal pole or yolk sac, or both
- 42. Abnormal IUP AGS larger than 10-13 mm diameter(TV) or 20mm (TA) without a yolk sac A GS larger than 18 mm (TV) or 25mm (TA) without a fetal pole A definite fetal pole without cardiac activity after 7 wks GA
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- 46. Sonographic Spectrum ofEP Ruptured ectopic pregnancy Definite ectopic pregnancy Extrauterine empty gestational sac Adenexal mass Pseudogestational sac Empty uterus
- 47. Definite Ectopic Pregnancy Athick, brightly echogenic, ring-like structure located outside the uterus with a gestational sac containing an obvious fetal pole, yolk sac or both.
- 49. Ruptured Ectopic Pregnancy Freefluid or blood in the cul-de-sac or the intra- peritoneal gutters (hemoperitoneum) This finding and a positive pregnancy test essentially makes the diagnosis!
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- 51. Extrauterine Gestational Sac Extra-uterine mass containing a thick, brightly echogenic ring surrounding an anechoic area Brightly echogenic appearance may be helpful Tubal ring
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- 53. Pseudogestational Sac Stimulationof the endometrium Decidual breakdown results in a central anechoic area Can be confused with “early IUP” Does not have double decidual sac sign Correlation with ß hCG helpful
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- 55. Interstitial Ectopic Pregnancy Implantation near the insertion of the fallopian tubes Highly vascular area Suspect when GS is not centrally located Demonstration of endometrial mantle is critical to the diagnosis
- 57. Empty Uterus Correlationwith ßhCG critical ßhCG >discriminatory zone and empty uterus is EP until proven otherwise
- 58. Discriminatory HCG Zone 5 weeks since last normal LMP ß hCG value = 1800 mIU TAS landmarks 5 to 8-mm GS TVS landmarks 5 to 8-mm GS With or w/o yolk sac
- 59. Discriminatory HCG Zone 6 weeks since last normal LMP ß hCG = 7200 TAS landmarks Yolk sac TVS landmarks Yolk sac and embryo Possibly FHM
- 60. Discriminatory HCG Zone 7 weeks since last normal LMP ß hCG = 21,000 TAS landmarks 5 to 10-mm embryo with FHM TVS landmarks 5 to 10 mm embryo with FHM
- 61. Rule - inIUP Protocol Clinically stable females with:Clinically stable females with: (1)(1) Lower abdominal painLower abdominal pain (2)(2) Vaginal bleedingVaginal bleeding (3)(3) OrthostasisOrthostasis (4)(4) Or risk factors for EPOr risk factors for EP Positive urine preg Ultrasound
- 62. Rule - inIUP Protocol Ultrasound Definite IUP Can DC to home with f/u Definite EP OB consultation
- 63. Rule - inIUP Protocol Ultrasound No IUP but… + Adenexal tenderness or CMT Free fluid in the cul de sac And/or hCG > discriminatory zone OB Consultation
- 64. Rule - inIUP Protocol Ultrasound No IUP Benign exam ßhCG > discriminatory zone DC to home F/u exam and ßhCG w/in 48 hrs
- 65. Rule-In IUP Protocol Sixty percent of patients will have IUP “Rules out” ectopic pregnancy by “ruling in” IUP What about heterotopic pregnancy? Increased in patients undergoing ovulation induction consult OB Risk is 1/30,000 in non-induced pregancy
- 66. Pitfalls Diagnosing intrauterinefluid collections as “early” IUP Low hCG does not mean “low risk” for EP Failure to determine the exact location of a gestational sac Cul-de-sac fluid may be the only sonographic finding of extrauterine pregnancy