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Sonographic Imaging of the Female Patient with Pelvic Pain/ Bleeding

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Presentation on theme: "Sonographic Imaging of the Female Patient with Pelvic Pain/ Bleeding"— 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 120/80 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 The maximum size of the non-gravid uterus is 5-7 cm x 4-5 cm
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
Left Right

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 Secretory phase
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

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 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 Clot/fluid

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

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 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:
Lower abdominal pain Vaginal bleeding Orthostasis Or risk factors for EP Positive urine preg Ultrasound

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

63 Rule - in IUP Protocol + Adenexal tenderness or CMT
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 DC to home
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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