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
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
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