first trimester ultrasound - UK HealthCare CECentral Trimester... · 2013-07-03 · first...
Transcript of first trimester ultrasound - UK HealthCare CECentral Trimester... · 2013-07-03 · first...
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first trimester ultrasoundtransabdominal and transvaginal ultrasound
Vicki E Noble MD
Director, Emergency UltrasoundMassachusetts General HospitalAssociate Professor, Harvard Medical SchoolBoston, MA
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• Review indications
• Transabdominal and transvaginal pelvic imaging anatomy
• Transabdominal and transvaginal pelvic scanning protocols
• Image Review
• Pitfalls
LECTURE GOALS
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Indications who and when to scan
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Indications who and when to scan
Female Patients
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INDICATIONS WHO AND WHEN TO SCAN
• Goal Directed• Is there an Intrauterine Pregnancy?
- Yes, threatened AB instructions and discharge- No
• Hemodynamically stable - •formal scanning, GYN consultation
• Hemodynamically unstable - •FAST exam, prep for OR for ruptured ectopic
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INDICATIONS DEFINITION OF INTRAUTERINE PREGNANCY
• Intrauterine heart beat• Fetal Pole• Yolk Sac
NOT gestational sac, double decidual sign or IVF patients.
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INDICATIONS DEFINITION OF INTRAUTERINE PREGNANCY
IUP effectively rules out ectopic in the ED
- Exception: heterotopic pregnancy with IVF• 1 : 30,000 low - risk pregnancies• 1 : 7000 pregnancies involving assisted reproductive
technology
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Makes your patient care better
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transabdominal imaging
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Grey’s Anatomy with permission
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transabdominal pelvic imaging
• Always easier with a full bladder• Use 2.5 - 5 Mhz abdominal probe
• Longitudinal scanning - fan side to side • Transverse scanning - fan up and down
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Transabdominal imaging anatomylongitudinal scanning planes
Images used with permission from Elselvier
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Transabdominal imaging anatomylongitudinal scanning planes
Images used with permission from Elselvier
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Transabdominal imaging anatomytransverse scanning planes
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Transabdominal imaging anatomytransverse scanning planes
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yolk sac: sac within a sac
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heart beat M-mode, zoom function
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No pulse doppler in first trimester
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interstitial / cervical ectopic pregnancy: 2-5 % of all ectopics
Myometrial mantle: 8 mmMEASURE HERE
Interstitial Ectopic
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myometrial mantle 8 mm minimum
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what does pelvic US add? Higher specifity
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transvaginal scanning
When transabdominal nondiagnostic...
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transvaginal pelvic imaging
• Always easier with an empty bladder• Use high frequency intracavitary probe
• Longitudinal scanning - fan side to side• Transverse scanning - fan up and down
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transvaginal imaging preparationlongitudinal scanning planes
• Hold probe with marker to ceiling• Longitudinal or sagittal scanning • Fan side to side
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transvaginal imaging anatomylongitudinal scanning planes
Illustration used with permission from Elselvier
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transvaginal imaging anatomylongitudinal scanning planes
Illustration used with permission from Elselvier
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transvaginal imaging anatomylongitudinal scanning planes
Illustration used with permission from Elselvier
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transvaginal imaging anatomytransverse scanning planes
Illustration used with permission from Elselvier
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transvaginal imaging anatomytransverse scanning planes
Illustration used with permission from Elselvier
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transvaginal imaging anatomytransverse scanning planes
Illustration used with permission from Elselvier
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ovaries
• Lie anterior to internal iliac vessels• Lie medial to external iliac vessles• Lie lateral & posterior to body uterus
• Discrete, hypoechoic structures• Peripheral, multiple, scattered anechoic follicles
- 3 cm long axis, 2 cm AP and transverse
• Better seen on transvaginal scanning Monday, May 6, 13
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ovarian cysts
• Simple cysts- Thin walled- Spherical- Without internal echoes or septations- Posterior enhancement- Cysts > 5 cm at risk for torsion
• Complex cysts- Complex cysts are those which do not meet the above criteria- Require repeat follow-up US in 4-6 weeks time
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Simple Ovarian Cyst
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Complex Ovarian Cyst
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Corpus luteal cysts
- dominant follicle - retain fluid for 4-5 days (approx 2-3 cm)- has a rich blood supply- if no pregnancy, CL will gradually atrophy (2 weeks)- if pregnancy occurs, CL will remain, reach max size at 8-10 weeks, & regress by 16 weeks
• Common cause of abdominal pain- simple vs. complex (hemorrhagic)- rupture, torsion• Must be distinguised from ectopic pregnancy• CL cysts are continuous & move together with ovary
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transvaginal pelvic scanning protocol
• Empty uterus and free fluid• + hcg • Greater than 1/3 of pouch of Douglas toward fundus
• very suspicious for ectopic
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image review
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Subchorionic hemorrhage
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Ectopic Pregnancy
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• If not sure you can use color doppler to look for ring of fire
• Absence does not rule out ectopic
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Cornual Ectopic
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IUD
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first trimester scanning pitfalls
• Failing to fan side to side and up and down throughout uterus
• Missing abnormal free fluid• Large ovarian cysts• Corpus luteal cysts for ectopic • Overcalling gestational sac
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Pitfall Case #1
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Pitfall Case #2
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Pitfall Case #3
Monday, May 6, 13
![Page 65: first trimester ultrasound - UK HealthCare CECentral Trimester... · 2013-07-03 · first trimester ultrasound transabdominal and transvaginal ultrasound Vicki E Noble MD Director,](https://reader034.fdocuments.us/reader034/viewer/2022042808/5f88d0e6e8bbbb57ba5b1d1e/html5/thumbnails/65.jpg)
Monday, May 6, 13
![Page 66: first trimester ultrasound - UK HealthCare CECentral Trimester... · 2013-07-03 · first trimester ultrasound transabdominal and transvaginal ultrasound Vicki E Noble MD Director,](https://reader034.fdocuments.us/reader034/viewer/2022042808/5f88d0e6e8bbbb57ba5b1d1e/html5/thumbnails/66.jpg)
questions?
Thank you.
Monday, May 6, 13