1. Sonographic Imaging of
the Female Patient with
Pelvic Pain/ Bleeding
Michael Kyeremeh Owusu
REGISTERED MEDICAL
SONOGRAPHER
Ghana

2. Case Presentation
 24 yo 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
 A bedside 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 Bedside Sonography
 Identify an IUP
 Establish fetal viability

5. Secondary Indications
 Hemodynamic instability in a female pt
 Trauma and pregnancy
 Localization of IUD/foreign body
 Identify sources of pelvic pain in non-pregnant patients

6. Imaging: Transabdominal
 Uses a 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 a higher 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 oval organ 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

11. Transabdominal / Transverse
view
Right Left

12. Cul-de-sac
 Located posterior to 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

13. Bladder
uterus

14. Probe Selection
 Endovaginal Probe
 5 to 8 mHz variable frequency probe
 Up to 180 degree angle of view

15. Endovaginal Examination
 Best performed 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 a TV 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 transducer probe 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

19. Longitudinal view

21. Coronal view

22. The Uterus
 Early in 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/lateral to
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 ovulation a 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
 Follicular cyst (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 the Pregnant 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
 Anechoic area 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
 First embryonic 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
 Can be 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 Heart Beat
 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
 A gestational 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
 A GS 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

44. Empty gestational sac

45. Fetal demise

46. Sonographic Spectrum of EP
 Ruptured ectopic pregnancy
 Definite ectopic pregnancy
 Extrauterine empty gestational sac
 Adenexal mass
 Pseudogestational sac
 Empty uterus

47. Definite Ectopic Pregnancy
A thick, 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
Free fluid or blood in the cul-de-sac or the intra-
peritoneal gutters (hemoperitoneum)
This finding and a positive pregnancy test essentially
makes the diagnosis!

50. Clot/fluid
clot

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

52. Adenexal Mass

53. Pseudogestational Sac
 Stimulation of 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

54. Pseudogestational sac
Ectopic

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
 Correlation with
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 - in IUP 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 - in IUP Protocol
Ultrasound
Definite IUP
Can DC to home
with f/u
Definite EP
OB consultation

63. Rule - in IUP 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 - in IUP 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 intrauterine fluid 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