PELVIC ULTRASOUND

ECCU

Tuesday, 19 November 13

OBJECTIVES
Review the normal ultrasound anatomy of the female pelvis. Demonstrate features of a normal 1st trimester pregnancy. Discuss the utility of ultrasound in the diagnosis of ectopic pregnancy.

Tuesday, 19 November 13

CASE
HAND OVER: 28 yr old female presents with abdominal cramping for three hours vomiting and diarrhea. Used cocaine and dilaudid IV last 6 hours ago. Off to XRay?? HR 100 BP100/80 RR 20 SaO2 100% RA T 37.8 G0 P0. LMP 4 weeks ago. No PV bleeding. PMHx nil. Abdomen soft, minimally tender RLQ. Pelvic exam normal except slight tenderness RLQ.

Tuesday, 19 November 13

CASE

Urine Pregnancy Test:

Positive!

Tuesday, 19 November 13

ANATOMY

Tuesday, 19 November 13

US PELVIC ANATOMY
Trans-Abdominal
Low frequency probe for penetration Full bladder

Trans-Vaginal
High frequency probe for resolution Empty bladder

Tuesday, 19 November 13

TRANS-ABDOMINAL - LONGITUDINAL VIEW

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Tuesday, 19 November 13

TA TRANSVERSE VIEW
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Tuesday, 19 November 13

TRANS-VAGINAL ANATOMY
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Sagittal (Longitudinal) View

Coronal (Transverse) View

Tuesday, 19 November 13

NORMAL 1ST TRIMESTER PREGNANCY

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Tuesday, 19 November 13

NORMAL 1ST TRIMESTER PREGNANCY

Is there an IUP?

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Tuesday, 19 November 13

NORMAL 1ST TRIMESTER PREGNANCY

Is there an IUP? Is there a live IUP?

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Tuesday, 19 November 13

ULTRASOUND FINDINGS OF 1ST T PREGNANCY

Gestational Sac TV ~ 5 wk TA ~ 6 wk

Yolk Sac TV ~ 5.5 wk TA ~ 6.5 wk

Fetal Pole TV ~ 6 wk TA ~ 7 wk

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Tuesday, 19 November 13

GESTATIONAL SAC

Tuesday, 19 November 13

GESTATIONAL SAC

Can we safely diagnose this patient as an IUP?

Tuesday, 19 November 13

YOLK SAC

Tuesday, 19 November 13

YOLK SAC

Can we safely diagnose this patient as an IUP?

Tuesday, 19 November 13

FETAL POLE

Tuesday, 19 November 13

CARDIAC ACTIVITY

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Tuesday, 19 November 13

ECTOPIC PREGNANCY

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Tuesday, 19 November 13

ECTOPIC PREGNANCY
Is there an IUP?

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Tuesday, 19 November 13

ECTOPIC PREGNANCY
Is there an IUP? Is there an ectopic pregnancy?

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Tuesday, 19 November 13

ECTOPIC PREGNANCY
Is there an IUP? Is there an ectopic pregnancy? Is there free fluid in the pelvis?

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Tuesday, 19 November 13

B-HCG DISCRIMINATORY ZONE

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Tuesday, 19 November 13

B-HCG DISCRIMINATORY ZONE

Level at which you should be able to see a NORMAL IUP on ultrasound.
TV: ~1500 2000 TA: ~6500

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Tuesday, 19 November 13

B-HCG DISCRIMINATORY ZONE

Level at which you should be able to see a NORMAL IUP on ultrasound.
TV: ~1500 2000 TA: ~6500

An empty uterus above these levels is suspicious for an ectopic (or non-viable).
No IUP and large amount free uid - presume ruptured ectopic

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Tuesday, 19 November 13

B-HCG DISCRIMINATORY ZONE

Level at which you should be able to see a NORMAL IUP on ultrasound.
TV: ~1500 2000 TA: ~6500

An empty uterus above these levels is suspicious for an ectopic (or non-viable).
No IUP and large amount free uid - presume ruptured ectopic

An empty uterus below these levels:

DDx: early IUP, ectopic, non-viable pregnancy

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Tuesday, 19 November 13

B-HCG DISCRIMINATORY ZONE

Level at which you should be able to see a NORMAL IUP on ultrasound.
TV: ~1500 2000 TA: ~6500

An empty uterus above these levels is suspicious for an ectopic (or non-viable).
No IUP and large amount free uid - presume ruptured ectopic

An empty uterus below these levels:

DDx: early IUP, ectopic, non-viable pregnancy

Presence of an IUP makes ectopic very unlikely

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Tuesday, 19 November 13

WHEN SHOULD AN IUP NOT BE USED TO RULE-OUT AN ECTOPIC?

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Tuesday, 19 November 13

WHEN SHOULD AN IUP NOT BE USED TO RULE-OUT AN ECTOPIC?

If heterotopic pregnancy is suspected
Heterotopic = 1 uterine and 1 ectopic pregnancy Heterotopic pregancy risk is 1:7000 in normal population Risk increased to 1:100 with IVF

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Tuesday, 19 November 13

WHEN SHOULD AN IUP NOT BE USED TO RULE-OUT AN ECTOPIC?

If heterotopic pregnancy is suspected
Heterotopic = 1 uterine and 1 ectopic pregnancy Heterotopic pregancy risk is 1:7000 in normal population Risk increased to 1:100 with IVF

Unstable patient

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Tuesday, 19 November 13

WHEN SHOULD AN IUP NOT BE USED TO RULE-OUT AN ECTOPIC?

If heterotopic pregnancy is suspected
Heterotopic = 1 uterine and 1 ectopic pregnancy Heterotopic pregancy risk is 1:7000 in normal population Risk increased to 1:100 with IVF

Unstable patient High clinical suspicion

Ultrasound does not replace clinical gestalt

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Tuesday, 19 November 13

FREE FLUID IN THE PELVIS

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Tuesday, 19 November 13

FREE FLUID IN THE PELVIS

Pelvic free fluid is present in 20% of NORMAL IUPs.

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Tuesday, 19 November 13

FREE FLUID IN THE PELVIS

Pelvic free fluid is present in 20% of NORMAL IUPs. Pelvic free fluid in the following settings should be considered abnormal:
Hemodynamically unstable patient. Free fluid extending beyond pelvis (Morrisons Pouch). Free fluid in a pregnant patient with an empty uterus (no IUP visible).

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Tuesday, 19 November 13

NORMAL FREE FLUID

Tuesday, 19 November 13

BACK TO OUR CASE...

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Tuesday, 19 November 13

CASE - TRANSVERSE VIEW

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Tuesday, 19 November 13

CASE - LONGITUDINAL VIEW

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Tuesday, 19 November 13

CASE

Tuesday, 19 November 13

CASE
BP 80/60, HR 120 shortly after ultrasound. Patient was resuscitated with IVF and pRBCs. Obstetrics was consulted STAT and the patient was taken immediately to the OR for ruptured ectopic pregnancy. Patient survived with no adverse outcome.

Tuesday, 19 November 13

CONCLUSION
On trans-abdominal ultrasound, the uterus is identified by its location adjacent to the bladder and the endometrial stripe. The early diagnosis of an IUP requires visualization of the yolk sac and/or fetal pole within the uterine myometrium. An IUP essentially rules-out an ectopic pregnancy if the patient did not undergo assisted reproduction.

Tuesday, 19 November 13

PELVIC ULTRASOUND

Tuesday, 19 November 13