<p begin="00:00:14.018" end="00:00:16.081" style="s2">- If you do a transabdominal examination</p>
<p begin="00:00:16.081" end="00:00:18.045" style="s2">of the pelvis for early pregnancy</p>
<p begin="00:00:18.045" end="00:00:19.706" style="s2">and you cannot find a definitive</p>
<p begin="00:00:19.706" end="00:00:21.944" style="s2">gestational sack inside of the uterus,</p>
<p begin="00:00:21.944" end="00:00:23.733" style="s2">the next step you need to do is</p>
<p begin="00:00:23.733" end="00:00:27.982" style="s2">an intracavitary examination of the uterus</p>
<p begin="00:00:27.982" end="00:00:30.294" style="s2">and cervix and the adnexal area</p>
<p begin="00:00:30.294" end="00:00:31.923" style="s2">to determine where the pregnancy is,</p>
<p begin="00:00:31.923" end="00:00:34.086" style="s2">whether it's intrauterine or extrauterine.</p>
<p begin="00:00:34.086" end="00:00:35.668" style="s2">So what I'm gonna do right now</p>
<p begin="00:00:35.668" end="00:00:37.365" style="s2">is walk through the steps on how</p>
<p begin="00:00:37.365" end="00:00:38.996" style="s2">you would do that examination</p>
<p begin="00:00:38.996" end="00:00:41.674" style="s2">and we're gonna use this<br />Phantom by Blue Phantom,</p>
<p begin="00:00:41.674" end="00:00:46.628" style="s2">that will actually demonstrate<br />an ectopic pregnancy.</p>
<p begin="00:00:46.628" end="00:00:49.180" style="s2">So the first stage of the prep</p>
<p begin="00:00:49.180" end="00:00:51.637" style="s2">for the intracavitary transducer</p>
<p begin="00:00:51.637" end="00:00:55.137" style="s2">is that we need to cover it with a sheath.</p>
<p begin="00:00:56.388" end="00:00:58.073" style="s2">When you do this, we need to remove</p>
<p begin="00:00:58.073" end="00:01:01.424" style="s2">any air gaps that are inside the sheath,</p>
<p begin="00:01:01.424" end="00:01:03.468" style="s2">next to the transducer face.</p>
<p begin="00:01:03.468" end="00:01:05.523" style="s2">So what we will do is put a little</p>
<p begin="00:01:05.523" end="00:01:07.856" style="s2">bit of gel inside the cover,</p>
<p begin="00:01:11.529" end="00:01:14.696" style="s2">position that over the<br />tip of the transducer</p>
<p begin="00:01:14.696" end="00:01:18.497" style="s2">and then just pull down the<br />covering over the transducer</p>
<p begin="00:01:18.497" end="00:01:20.370" style="s2">and pull this down right over the handle,</p>
<p begin="00:01:20.370" end="00:01:23.401" style="s2">so you've got good coverage.</p>
<p begin="00:01:23.401" end="00:01:25.724" style="s2">And then just make sure that<br />you examine the tip here</p>
<p begin="00:01:25.724" end="00:01:27.025" style="s2">and make sure you eliminate any</p>
<p begin="00:01:27.025" end="00:01:31.848" style="s2">air bubbles that are<br />covering the transducer face.</p>
<p begin="00:01:31.848" end="00:01:34.168" style="s2">So once you've got the<br />air bubbles eliminated,</p>
<p begin="00:01:34.168" end="00:01:36.871" style="s2">then you can move on to the next step.</p>
<p begin="00:01:36.871" end="00:01:37.704" style="s2">We're going to put a little bit</p>
<p begin="00:01:37.704" end="00:01:41.454" style="s2">of gel on the outside<br />of the latex cover now.</p>
<p begin="00:01:44.847" end="00:01:46.257" style="s2">And again, your orientation for</p>
<p begin="00:01:46.257" end="00:01:48.341" style="s2">this examination is very important.</p>
<p begin="00:01:48.341" end="00:01:51.441" style="s2">So for the long ax or sagittal view,</p>
<p begin="00:01:51.441" end="00:01:54.325" style="s2">we want the orientation marker up</p>
<p begin="00:01:54.325" end="00:01:55.967" style="s2">and then when we go to the coronal view,</p>
<p begin="00:01:55.967" end="00:02:00.569" style="s2">we're gonna turn that so it<br />faces the patient's right.</p>
<p begin="00:02:00.569" end="00:02:04.081" style="s2">After we've inserted the<br />transducer in a long axis view,</p>
<p begin="00:02:04.081" end="00:02:05.111" style="s2">the first thing that we're gonna</p>
<p begin="00:02:05.111" end="00:02:08.323" style="s2">see is a long ax of the uterus.</p>
<p begin="00:02:08.323" end="00:02:11.648" style="s2">In this Phantom<br />representation of the uterus,</p>
<p begin="00:02:11.648" end="00:02:14.512" style="s2">we see an endometrial stripe,</p>
<p begin="00:02:14.512" end="00:02:17.010" style="s2">which is represented by the white line.</p>
<p begin="00:02:17.010" end="00:02:19.884" style="s2">So if I was doing this<br />as a real pelvic exam,</p>
<p begin="00:02:19.884" end="00:02:22.635" style="s2">I would scan to the right of the patient,</p>
<p begin="00:02:22.635" end="00:02:25.844" style="s2">all the way through to the right adnexa</p>
<p begin="00:02:25.844" end="00:02:30.081" style="s2">and then back over, all the<br />way back through the uterus,</p>
<p begin="00:02:30.081" end="00:02:31.768" style="s2">over to the left adnexa.</p>
<p begin="00:02:31.768" end="00:02:32.940" style="s2">And the reason I'm doing this</p>
<p begin="00:02:32.940" end="00:02:37.204" style="s2">is because I don't see the<br />pregnancy inside the uterus,</p>
<p begin="00:02:37.204" end="00:02:39.476" style="s2">so I'm suspecting that it's extrauterine</p>
<p begin="00:02:39.476" end="00:02:41.811" style="s2">or an ectopic pregnancy.</p>
<p begin="00:02:41.811" end="00:02:44.414" style="s2">I do have some hints here<br />though, using this Phantom.</p>
<p begin="00:02:44.414" end="00:02:46.721" style="s2">In the posterior cul de sac region,</p>
<p begin="00:02:46.721" end="00:02:49.013" style="s2">I'm seeing a black anechoic area,</p>
<p begin="00:02:49.013" end="00:02:52.513" style="s2">which would represent free fluid or blood.</p>
<p begin="00:02:54.243" end="00:02:58.377" style="s2">If I scan all the way over to<br />the left adnexa, in this case,</p>
<p begin="00:02:58.377" end="00:03:00.228" style="s2">the first structure I come across,</p>
<p begin="00:03:00.228" end="00:03:02.611" style="s2">this echogenic area represents the ovary.</p>
<p begin="00:03:02.611" end="00:03:06.444" style="s2">If I keep scanning to<br />the left, in the pelvis,</p>
<p begin="00:03:09.227" end="00:03:11.560" style="s2">I encounter this other area</p>
<p begin="00:03:14.662" end="00:03:18.908" style="s2">and this represents, in this<br />case, our ectopic pregnancy.</p>
<p begin="00:03:18.908" end="00:03:21.964" style="s2">When I'm medial, just<br />right beside the uterus,</p>
<p begin="00:03:21.964" end="00:03:25.780" style="s2">I see the ovary and I<br />scan out a little bit more</p>
<p begin="00:03:25.780" end="00:03:29.280" style="s2">and this represents the ectopic pregnancy.</p>
<p begin="00:03:31.412" end="00:03:32.613" style="s2">And this is what you should see,</p>
<p begin="00:03:32.613" end="00:03:34.864" style="s2">a round, circular structure like this,</p>
<p begin="00:03:34.864" end="00:03:37.520" style="s2">with a bright, echogenic brim.</p>
<p begin="00:03:37.520" end="00:03:39.301" style="s2">And it is possible to sometimes</p>
<p begin="00:03:39.301" end="00:03:42.336" style="s2">to see a fetal heartbeat inside</p>
<p begin="00:03:42.336" end="00:03:44.836" style="s2">the ectopic pregnancy as well.</p>
<p begin="00:03:46.410" end="00:03:49.351" style="s2">Now, I'm gonna change the<br />orientation of the transducer,</p>
<p begin="00:03:49.351" end="00:03:50.637" style="s2">so I'm in a coronal view.</p>
<p begin="00:03:50.637" end="00:03:55.568" style="s2">To do that, I'm gonna turn the<br />transducer counterclockwise.</p>
<p begin="00:03:55.568" end="00:03:57.688" style="s2">The uterus will appear circular,</p>
<p begin="00:03:57.688" end="00:04:00.765" style="s2">because I'm cutting a<br />cross sectional view of it</p>
<p begin="00:04:00.765" end="00:04:04.128" style="s2">and I tilt the handle<br />of the transducer up,</p>
<p begin="00:04:04.128" end="00:04:08.295" style="s2">to move inferiorly, down<br />to the region of the cervix</p>
<p begin="00:04:09.749" end="00:04:11.291" style="s2">and then bring the transducer handle</p>
<p begin="00:04:11.291" end="00:04:13.838" style="s2">down to scan superiorly,</p>
<p begin="00:04:13.838" end="00:04:17.275" style="s2">into the area of the fundus of the uterus.</p>
<p begin="00:04:17.275" end="00:04:18.594" style="s2">Again, in this case, I can see that</p>
<p begin="00:04:18.594" end="00:04:23.112" style="s2">there's no pregnancy<br />inside the uterus itself.</p>
<p begin="00:04:23.112" end="00:04:26.207" style="s2">If I scan over to the left of the Phantom,</p>
<p begin="00:04:26.207" end="00:04:30.059" style="s2">again, we see the left ovary<br />and then right beside it,</p>
<p begin="00:04:30.059" end="00:04:34.314" style="s2">we see our representation<br />of the ectopic pregnancy.</p>
<p begin="00:04:34.314" end="00:04:36.564" style="s2">This bright, circular area.</p>
<p begin="00:04:42.023" end="00:04:43.748" style="s2">Moving back towards the midline,</p>
<p begin="00:04:43.748" end="00:04:47.995" style="s2">the anechoic area just<br />posterior to the uterus</p>
<p begin="00:04:47.995" end="00:04:52.162" style="s2">is represented as free fluid<br />or blood, in this case.</p>
<p begin="00:04:53.025" end="00:04:54.214" style="s2">So those are the views that you</p>
<p begin="00:04:54.214" end="00:04:55.624" style="s2">would need to do a thorough assessment</p>
<p begin="00:04:55.624" end="00:04:58.457" style="s2">of the pelvis for early pregnancy.</p>

<p begin="00:00:07.318" end="00:00:09.711" style="s2">- [Voiceover] A curved, or<br />phased array transducer,</p>
<p begin="00:00:09.711" end="00:00:11.431" style="s2">with a pelvis exam type,</p>
<p begin="00:00:11.431" end="00:00:14.568" style="s2">is used to perform the<br />pelvis ultrasound exam.</p>
<p begin="00:00:14.568" end="00:00:16.987" style="s2">A full bladder is used<br />as an acoustic window</p>
<p begin="00:00:16.987" end="00:00:18.989" style="s2">to view the pelvic organs.</p>
<p begin="00:00:18.989" end="00:00:22.579" style="s2">The pelvis is evaluated in two plains.</p>
<p begin="00:00:22.579" end="00:00:25.534" style="s2">Place the transducer<br />in a long axis position</p>
<p begin="00:00:25.534" end="00:00:28.254" style="s2">with the orientation marker<br />to the patient's head,</p>
<p begin="00:00:28.254" end="00:00:31.254" style="s2">at the level of the symphysis pubis.</p>
<p begin="00:00:32.384" end="00:00:36.384" style="s2">Angle the transducer<br />inferiorly into the pelvis.</p>
<p begin="00:00:38.036" end="00:00:40.705" style="s2">The bladder appears in the<br />near-field of the image,</p>
<p begin="00:00:40.705" end="00:00:43.616" style="s2">as a hypoechoic triangular structure.</p>
<p begin="00:00:43.616" end="00:00:45.800" style="s2">The uterus is gray in appearance</p>
<p begin="00:00:45.800" end="00:00:48.233" style="s2">and located either directly posterior</p>
<p begin="00:00:48.233" end="00:00:50.087" style="s2">or superior to the bladder.</p>
<p begin="00:00:50.087" end="00:00:52.139" style="s2">The endometrial stripe will appear as</p>
<p begin="00:00:52.139" end="00:00:55.945" style="s2">a bright echogenic line from<br />the fundus to the cervix.</p>
<p begin="00:00:55.945" end="00:00:58.877" style="s2">The uterus does not always<br />lay directly in the midline</p>
<p begin="00:00:58.877" end="00:01:02.209" style="s2">so it may be necessary to<br />slightly rotate the transducer</p>
<p begin="00:01:02.209" end="00:01:04.732" style="s2">to view the entire length of the uterus.</p>
<p begin="00:01:04.732" end="00:01:07.015" style="s2">Sweep the transducer from side to side</p>
<p begin="00:01:07.015" end="00:01:09.219" style="s2">to see the entire uterus.</p>
<p begin="00:01:09.219" end="00:01:12.192" style="s2">The ovaries may be seen<br />by sweeping the transducer</p>
<p begin="00:01:12.192" end="00:01:14.615" style="s2">to the lateral aspects of the pelvis.</p>
<p begin="00:01:14.615" end="00:01:18.536" style="s2">They are almond-shaped and<br />slightly hypoechoic structures.</p>
<p begin="00:01:18.536" end="00:01:20.605" style="s2">Follicles may appear as multiple</p>
<p begin="00:01:20.605" end="00:01:24.688" style="s2">hypoechoic, cystic structures<br />within the ovaries.</p>
<p begin="00:01:27.166" end="00:01:29.314" style="s2">Some follicles may be quite prominent,</p>
<p begin="00:01:29.314" end="00:01:31.981" style="s2">depending upon the luteal stage.</p>
<p begin="00:01:34.855" end="00:01:37.375" style="s2">To obtain a transverse view of the uterus,</p>
<p begin="00:01:37.375" end="00:01:39.869" style="s2">rotate the transducer 90 degrees,</p>
<p begin="00:01:39.869" end="00:01:42.788" style="s2">so the orientation marker<br />is to the patient's right.</p>
<p begin="00:01:42.788" end="00:01:46.581" style="s2">The bladder appears more<br />rectangular in shape in this view.</p>
<p begin="00:01:46.581" end="00:01:48.775" style="s2">Sweep the transducer superiorly</p>
<p begin="00:01:48.775" end="00:01:51.181" style="s2">from the level of the cervix to the fundus</p>
<p begin="00:01:51.181" end="00:01:53.284" style="s2">to see the entire uterus.</p>
<p begin="00:01:53.284" end="00:01:56.324" style="s2">The ovaries will be seen on<br />either side of the uterus</p>
<p begin="00:01:56.324" end="00:01:57.941" style="s2">and can vary in location,</p>
<p begin="00:01:57.941" end="00:02:01.024" style="s2">from a superior to inferior position.</p>