1. How can point of care obstetric ultrasound be used in austere locations ?
Dr Taranpal Bansal MBBS BSc (Hons) Dr Oscar Barnick
Dr Richard Beese BSc (Hons) MRCP FRCR
Ultrasound department, Queen Elizabeth Hospital, Woolwich, London
What is the major issue for pregnant patients in austere locations?
Women living in the world’s least developed countries are 300 times more likely to die from pregnancy related complicated compared to those living in developed countries (UNICEF). Part of this problem lies in the fact that in austere locations, very limited facilities exist and hence anticipating these complications prove difficult. Should possible complications be anticipated early through imaging, complications may be prevented.
Can ultrasound be of use?
Ultrasound is widely used in pregnancy. It is convenient, immediate, and safe compared to other imaging modalities. Furthermore it is relatively inexpensive and becoming more widely available with point of care ultrasound thus it makes an ideal imaging modality for use in austere locations with limited medical facilities.
i phone based wireless ultrasound for point of care general and obstetric ultrasound
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Placenta position- the placenta appears as a homogenous echogenic structure in early pregnancy, During later pregnancy, the placenta may become heterogenous with calcifications and cavity formation. The placenta position is important in late pregnancy if the placenta is low placenta previa can be diagnosed. This would require management in a hospital.
Single fetus – The embryo can be visualised from week 5 onwards. The number of fetuses should be checked and the site of pregnancy confirmed within the uterine cavity.
Multiple pregnancy – Ultrasound informs us of the number of fetuses. .
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Dead fetus (Spalding sign) – Overlapping skull bones of the fetus due to collapse of the brain is known as Spalding sign (arrow). It is seen beyond a week after fetal death.
Fetal position ; Breech -  Late in pregnancy the feet of the fetus can be seen closest to the cervical os.
Fetal viability ; Non-viable pregnancy – Intrauterine pregnancy with fetal pole >7mm and no cardiac activity suggesting non viable pregnancy.  
Conclusion ;
Ultrasound is an indispensable tool in obstetrics, and its convenience, accuracy and accessibility make it ideal for use in austere locations
Ultrasound can confirm the presence of pregnancy, the number of fetuses, fetal growth and the correct location of pregnancy.
Ultrasouind can be used to differentiate healthy and unhealthy pregnancy. Examples of common obstetric problems include abnormalities of fetal position, placental localization, non-viable pregnancy and abnormal fetal development.
If pregnancy abnormalities are detected, patients can be referred to specialist centres with better facilities for appropriate management and follow up.
Studies have shown ultrasound can play a key role in austere locations. What is required is basic training of midwives and doctors perform point of care ultrasound. Images can be reviewed remotely by experts.
The State of the World’s Children UNICEF
Obstetric Ultrasound: How, Why and When. Trish Chudleigh
Improved maternity care if midwives learn to perform ultrasound: a qualitative study of Rwandan midwives’ experiences and views of obstetric ultrasound. S Holmlund

2. How to diagnose fractures of bone with ultrasound
Dr Richard Beese Bsc ( Hons) MRCP FRCR
Ultrasound department, Darenth Valley Hospital, Kent.
What is the big question in A/E in patients with minor trauma ?
Answer; is the injury a bone fracture or is the injury a soft tissue injury.
Can ultrasound be of use ?
Traditionally ultrasound was thought to be of no use in the examination of bone due to its density and being highly reflective , however when a bone is fractured , it bleeds and this is fluid, the periosteal fluid can easily be seen with ultrasound .
The use of ultrasound to diagnose diaphyseal fractures
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Example the cortex is seen as a highly reflective white line
There is a fracture of the cortex with a subperiosteal haematoma
The use of ultrasound to diagnose intra articular fractures .
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An anterior and posterior fat pad sign of the elbow indicating an intra articular fracture.
Intra articular fluid can be seen with ultrasound.
A horizontal beam lateral showing a lipoheamarthrosis of the knee indicating an intra articular fracture.
Intra articular fluid can be seen with ultrasound
A hip effusion in the presence of trauma would indicate an intra articular fracture of the hip ‘anterior fat pad sign of the hip’, refer for further imaging MRI
According to the world health organisation WHO what percentage of the world’s population
Have access to Xray ?
Answer 25 % : thus 6 billion people have no access to xrays , in remote areas of Canada and Australia where modern medicine is practised in remote locations doctors are using ultrasound to determine between soft tissue injury and bone injury.
Conclusion ;
Ultrasound can differentiate between soft tissue injury and bone injury, this of use in remote location with no access to xrays , but also in A/E to increase diagnostic accuracy especially in non displaced fractures which are not visible on xray such as rib, sternum , hip and children’s tibia .
Note we are not looking for the fracture just the presence or absence of fluid.
Studies have demonstrated ultrasound to be 100% sensitive for the diagnosis of bone fracture.
A verbal audit of fracture clinic currently in our hospital 1 in 3 patients referred to fracture clinic have a bone fracture.
See pointofcareultrasoundinfo.com for further information.
Sonography: a simple way to visualize rib fractures. AJR 1994 Nov;163(5):1268.
Sonography compared with radiography in revealing acute rib fracture. AJR 1999 Dec;173 (6):
Sonography as a screening test for Occult hip fractures2009;28: