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Sonographic Imaging of the Female Patient with Pelvic Pain/ Bleeding Sarah A. Stahmer MD Cooper Hospital/University Medical Center.

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Presentation on theme: "Sonographic Imaging of the Female Patient with Pelvic Pain/ Bleeding Sarah A. Stahmer MD Cooper Hospital/University Medical Center."— Presentation transcript:

1 Sonographic Imaging of the Female Patient with Pelvic Pain/ Bleeding Sarah A. Stahmer MD Cooper Hospital/University Medical Center

2 Case Presentation 24 yo female presents with missed period, cramping, midline abdominal pain and spotting VS: BP 120/80HR 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

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19 Longitudinal view

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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

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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

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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)

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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)

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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

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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

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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.

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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

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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: (1)Lower abdominal pain (2)Vaginal bleeding (3)Orthostasis (4)Or 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


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