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Sonographic Imaging of the Female Patient with Pelvic Pain/ Bleeding

Sonographic Imaging of the Female Patient with Pelvic Pain/ Bleeding. Sarah A. Stahmer MD Cooper Hospital/University Medical Center. Case Presentation. 24 yo female presents with missed period, cramping, midline abdominal pain and spotting VS: BP 120/80 HR 110 Pelvic:

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Sonographic Imaging of the Female Patient with Pelvic Pain/ Bleeding

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  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 • 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

  18. Longitudinal view

  19. Coronal view

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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)

  27. 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)

  28. 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

  29. 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

  30. 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

  31. 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

  32. Empty gestational sac

  33. Fetal demise

  34. Sonographic Spectrum of EP • Ruptured ectopic pregnancy • Definite ectopic pregnancy • Extrauterine empty gestational sac • Adenexal mass • Pseudogestational sac • Empty uterus

  35. 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.

  36. 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!

  37. clot Clot/fluid

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