Focused

- [Voiceover] A curved or phased array transducer
with an abdomen exam type is used to perform
an aorta ultrasound exam.
The entire length of the aorta from
the level of the diaphragm
to the bifurcation of the iliac arteries
must be evaluated in two planes.
The examination begins with the transducer
placed transversely in the epigastric mid line,
with the marker directed to the patient's right.
The aorta is seen as a round, pulsatile structure,
anterior to the bright reflection of the vertebrae.
The vena cava is an oval structure
immediately to the left of the aorta on the screen,
which changes in caliber with compression
or deep inspiration.
The abdominal aorta will course gradually,
becoming more superficial as it progresses distally.
The transducer is slowly moved distally
to identify the celiac trunk,
renal arteries,
superior mesenteric artery,
and bifurcation to the iliac arteries.
Note the location of any change in size
of the aorta or iliac arteries,
and measure in long and short axis views
from outer wall to outer wall
to determine the true diameter.
The transducer is returned to the epigastric area
and rotated 90 degrees clockwise,
with the orientation marker to the patient's head.
The transducer is swept side to side
to identify the maximal diameter of the aorta.
The abdominal aorta will have proximal to distal taper.
The transducer is moved distally
to evaluate the walls of the aorta
for any change in the shape or size.
If the aorta is difficult to visualize
due to overlying bowel, gentle downward transducer pressure
may encourage peristalsis of the overlying bowel.
Alternatively, consider moving the patient
into a left lateral decubitus position
to re-position the bowel away from the field of view.

Brightcove ID

5508114778001

https://youtube.com/watch?v=NI-tU5w-gzg

3D How To: eFAST RUQ

Read more about 3D How To: eFAST RUQ

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3D animation demonstrating a Right Upper Quadrant (RUQ) view while performing the eFAST exam.

Media Library Type

Media Library Tag

Subtitles

- [Voiceover] A phased array transducer
with an abdomen exam type is used to perform
the right upper quadrant view of the FAST exam.
The orientation marker is directed
towards the patients head.
The transducer is placed in a long axis orientation
along the right mid-auxiliary line between
the 7th to 9th inter-costal space.
Rotation and oblique positioning of the transducer
will help eliminate rib shadows.
To evaluate the entire area of the hepatorenal recess
for free fluid sweep the transducer
from an anterior to posterior position.
If present, fluid will appear as a dark
or aniconic strip between the kidney and the liver.
If it is difficult to visualize the hepatorenal recess.
A deep inspiration will move the diaphragm
and other structures in this area
down and below the ribs for easier access.
Sliding the transducer upward will visualize
the diaphragm and plural interface.
Sliding the transducer downward will visualize
the inferior pole of the right kidney.

Brightcove ID

5508136019001

https://youtube.com/watch?v=wgCSZkCkkeI

3D How To: eFAST Pelvis

Read more about 3D How To: eFAST Pelvis

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3D animation demonstrating the pelvis view while performing an eFAST exam.

Media Library Type

Media Library Tag

Subtitles

- [Voiceover] A phased array transducer
with an abdomen exam type
is used to perform the pelvis view of the fast exam.
Place the transducer in a transverse position
with the orientation marker to the right
at the level of the symphysis pubis.
The pelvis is evaluated in two planes.
It is easier to perform this exam
when the bladder is filled.
The bladder is used as an acoustic window
to view the cul de sac
or retrovesicular space for free fluid.
To visualize the bladder,
angle the transducer inferiorly into the pelvis.
If it is difficult to visualize the bladder,
slide to the left or right of the symphysis pubis
to bring the bladder into view.
To evaluate the pelvis for free fluid,
sweep the transducer from an inferior to superior position.
Fluid will appear hyperechoic or anechoic
and accumulate posterior to the bladder,
posterior to the uterus, and between loops of bowel.
To obtain a long access view,
rotate the transducer 90 degrees
with the orientation marker
pointed toward the patient's head.
Sweep the transducer across the pelvis from left to right
to evaluate the pelvis for free fluid.

Brightcove ID

5508134284001

https://youtube.com/watch?v=pFtpx-yZfe0

Body

3D animation demonstrating the pelvis view while performing an eFAST exam.

3D How To: eFAST LUQ

Read more about 3D How To: eFAST LUQ

/sites/default/files/EFast_Luq_EDU00453_Thumnail.jpg

3D animation demonstrating a Left Upper Quadrant (LUQ) view while performing the eFAST exam.

Media Library Type

Media Library Tag

Subtitles

- [Voiceover] A phased array transducer
with an abdomen exam type is used to perform
the left upper quadrant view of the FAST Exam.
The orientation marker is directed
toward the patient's head.
the transducer is placed in a long-access orientation
along the left-posterior axillary line
between the fifth to seventh intercostal spaces.
The sonographer's hand will touch the gurney
with the proper transducer position.
Rotation and oblique positioning of the transducer
will help eliminate rib shadows.
To evaluate the entire area of the spleenorenal recess
for free fluid, sweep the transducer
from an anterior to posterior position.
Carefully examine the spleenorenal recess
and subphrenic space.
Fluid will appear dark or anechoic.
If it is difficult to visualize the spreenorenal recess,
a deep inspiration will move the diaphragm
and other structures in this area
down and below the ribs for easier access.
Sliding the transducer in an upward direction
will visualize the diaphragm and plural interface.

Brightcove ID

5508120178001

https://youtube.com/watch?v=foyIEuUlgD0

Case: Ultrasound Guidance for Thoracentesis

Read more about Case: Ultrasound Guidance for Thoracentesis

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This video details how bedside ultrasound imaging can be used to guide thoracentesis, detect pleural fluid levels, and analyze patient anatomy. It also discusses patient positioning during the thoracentesis and probe placement.

Media Library Type

Media Library Tag

Congested Heart Failure

Infection

Tumors

Increased Blood Pressure

Blocked Blood Vessels

Subtitles

- Hello, my name is Phil Perera and I'm the emergency
ultrasound coordinator at the New York Presbyterian Hospital
in New York City and welcome to SoundBytes Cases.
In this SoundBytes module I'd like to begin by discussing
the case of a patient who presented with worsening
shortness of breath
and had a chest X-ray which revealed this finding.
Notice here we have the presence of
an opacified left hemithorax
and notice here that the trachea is pushed away
from the left hemithorax
suggesting the presence of a very large pleural effusion
as the cause of our patient's dyspnea.
Now if in fact this was a large pleural effusion causing
our patient's shortness of breath
a therapeutic thoracentesis would be in order
to relieve her symptoms.
This leads into the topic for this SoundBytes module
which is the use of bedside ultrasound to perform the
thoracentesis procedure.
In this module I'd like to go through how sonography
can potentially make the thoracentesis procedure
a safer one for our patients
with a decrease in the inherent complications of the
procedure, such as pneumothorax or perforation
of the diaphragm.
Before a performance of a thoracentesis procedure
it's mandatory to look with sonography
to make sure that there's enough pleural fluid
amenable for a safe thoracentesis.
Notice here we have the patient positioned in
an upright position
so that the fluid will layer out above the level
of the diaphragm.
Notice here we note the diaphragm as shown by the red line
across the patient's anterior chest wall
Notice here we have the probe positioned along the lateral
aspect of the patient's chest with a marker dot towards
the patient's head.
We can angle the probe above the diaphragm
to look for a dark or anechoic collection of fluid
consistent with a pleural effusion.
This is the ultrasound image that corresponds to the
chest X-ray from the patient as we discussed in
the beginning of the module.
We have the probe positioned across the patient's left
side of the chest,
coming in with a probe marker toward the patient's head.
We can see here, superior towards the left and
inferior towards the right,
We note the spleen and the kidney,
inferior in the abdominal compartment
and we see the white line that is the diaphragm
moving up and down as the patient breathes.
We note above the diaphragm,
superior in the chest cavity,
the presence of a large, dark or anechoic
collection of fluid,
consistent with a very large pleural effusion,
and we fail to appreciate any lung within
this pleural effusion.
Just to emphasize the point that it's very important
to look with sonography, prior to performance of a
thoracentesis procedure,
we know this pleural effusion is taken from the right chest
we see the liver towards the inferior aspect of the patient
towards the right here,
and we note above the diaphragm here,
which is moving up and down as the patient breathes,
the presence of a dark or anechoic fluid collection,
but we also see here lung within the pleural effusion
and an attachment of the lung,
a fibrinous attachment,
that attaches the lung down to the diaphragm.
So this could be potentially a complicated performance
of a thoracentesis as the needle that goes into that
chest cavity could be pushed by that fibrinous attachment
up into the lung causing a pneumothorax.
This is the first traditional position of the patient
for the thoracentesis procedure.
This is the recumbent position in which we have the patient
lying down with the head of the bed elevated.
This will encourage the fluid to layer out above
the diaphragm,
and make it more amenable to a puncture attempt.
Here we see a pleural effusion within the left hemithorax,
note the effusion as denoted by the yellow liquid
around the red lung.
Here the black star indicates the appropriate position
for the needle for the puncture point for the thoracentesis.
When performing a thoracentesis procedure the needle should
be positioned above the level of the rib,
so as to avoid the neurovascular bundle,
which as shown in this illustration lies just below
to the rib.
Here I'm demonstrating the appropriate position of the probe
to investigate for the lateral approach to the thoracentesis
this time on the right chest.
Notice the positioning of the probe,
in this case the 3 MHz probe,
on the lateral chest wall,
right above the level of the diaphragm,
to look for a pleural effusion.
Here I'll indicate the orientation of the ribs
across the lateral chest wall,
and here's about the orientation of the diaphragm.
Now remember that that diaphragm will move up and down
as the patient breathes, so we want to place the probe
above the level of the diaphragm,
to look into the thoracic cavity
for a suitable collection of fluid.
Therefore here we note the position of the needle
for the appropriate positioning of the needle
for the lateral puncture approach
to the thoracentesis procedure.
And we note again that the level of the diaphragm,
on the lateral chest wall is shown by the red line,
and we note the needle above the diaphragm,
so that it can safely enter into the thoracic cavity
and not cause a complication such as puncture the diaphragm
during the thoracentesis procedure.
Here we note the second traditional positioning of
the patient for the thoracentesis procedure,
which is the standard upright position,
in which the needle would come in from a posterior approach.
And we note the patient bending forward over a stand
or a table.
Here we see a pleural effusion within the right chest
and we note here the patient has a puncture point
that would come in, into the pleural effusion,
below the scapula but above the layer of the diaphragm.
In this video clip I'll outline some of the surface anatomy
important for the posterior approach to the
thoracentesis procedure.
Here's about the level of the scapula on the
posterior chest wall,
and this is about the level of the diaphragm,
so the appropriate positioning for the needle for
the thoracentesis procedure
would be about the level of my finger here.
And we'll just freeze that down,
there's the scapula,
and here's about the level of the diaphragm.
Notice my finger safely above the diaphragm,
so as not to puncture through the diaphragm
into the abdominal cavity.
As shown by the black star this would be the appropriate
positioning of the needle for the thoracentesis procedure.
Prior to the thoracentesis procedure
we'll investigate the pleural effusion using a 3 MHz probe.
Notice the 3 MHz probe is placed along the
posterior chest wall,
at first with the probe marker on the long axis trajectory
with the orientation of the marker towards
the patient's head.
We can then swivel the probe into the lateral orientation,
with the probe marker lateral to further investigate
above the diaphragm,
for a suitable collection of pleural effusion amenable
to a thoracentesis procedure.
A clinical pearl that can be very helpful in further
delineating the pleural effusion with regard to the
patient's anatomy is to look further with a
10 MHz high frequency linear array type probe
prior to the thoracentesis puncture.
Notice here we're placing the high frequency probe along the
posterior chest wall in the long axis configuration with the
probe marker swiveled toward the patient's head.
We can also orient the probe in between the patient's ribs
in the lateral orientation as well,
to further investigate the anatomy.
This illustration shows what the anatomy of a pleural
effusion will look like using a high frequency 10 MHz probe.
In this illustration the probe is configured in the
long axis orientation.
So we have superior to the left and inferior to the right.
We see anteriorly the chest wall and we see the
superior rib to the left and the inferior rib to the right.
We know that the parietal pleura,
that white line just deep to the ribs,
and below the parietal pleura we can see the darker
anechoic pleural effusion.
In this illustration we're actually showing here
the visceral pleura, that coats the outside of the lung,
and we can actually see the distance between the pleura
layers, the parietal pleura and the visceral pleura,
which would be the full extent of the pleural effusion.
This would be your safety zone,
or the area in which it would be safe to place a needle.
It would be not safe to place a needle any deeper
than that safety zone,
as a needle could puncture through the visceral pleura
and into the lung, causing a pneumothorax.
Here's an ultrasound image showing a very large pleural
effusion as taken with a high frequency 10 MHz probe.
Superior towards the left, inferior towards the right.
We can see the hyperechoic, or bright bone tables of the rib
both superior and inferior,
which will show us the areas of the rib to avoid
during the thoracentesis procedure.
We'd actually want to come in over the top of the inferior
rib to avoid the neurovascular bundle.
We can see here the white line making up the parietal pleura
and deep to the parietal pleura we note a large amount of
pleural effusion.
We note here the absence of a lung in the pleural effusion
so we can place the needle pretty deeply here
without causing a pneumothorax.
This ultrasound image is again taken with a high frequency
10 MHz probe,
but in this orientation the probe is configured between
the ribs in the lateral orientation.
So, all we see is the chest wall, anteriorly,
we see the parietal pleura, that white line deep to the
chest wall,
and just deep to the parietal pleura we can see the
pleural effusion as made up by the darker anechoic
collection of fluid.
Now, note here that we also see the lungs sliding
back and forth as the patient breathes,
and we can see the full extent of the pleural effusion,
or the safety zone for performance of
the thoracentesis procedure.
In this ultrasound image,
again taken with a 10 MHz high frequency probe,
we can see the diaphragm moving back and forth as
the patient breathes,
defining the lower aspect of the thoracic cavity.
Thus, it would probably be unsafe to perform a
thoracentesis at this level of the chest wall,
because we might go through the diaphragm and into
the spleen with a needle.
So, it's important to look first to ascertain
the level of the diaphragm,
and make sure that the thoracentesis needle is going
safely above the diaphragm so as not to puncture
into the abdominal compartment.
In this video clip we'll first place the
high frequency 10 MHz probe along the posterior
aspect of the chest wall to define the proper
orientation for the puncture for the posterior approach
to thoracentesis procedure.
The needle can then come in directly underneath the probe
as shown here.
Now, I'll show a wide angle shot here and note this is
the proper position for the thoracentesis needle,
as definied by sonography from the posterior approach
to thoracentesis.
In conclusion, thanks for tuning in for this SoundBytes
module going over ultrasound guidance for the
thoracentesis procedure.
Sonography can potentially make the procedure a safer one
for our patients with a decrease in the complication rate,
such as pneumothorax or perforation of the diaphragm.
We'll want to use both the 3 MHz and higher frequency 10 MHz
probes to fully evaluate the effusion in relation to
the patient's anatomy, prior to a puncture attempt.
We can either use the static technique where we position
the patient appropriately and then mark off the
puncture spot with sonography,
prior to the thoracentesis procedure.
Or, we can use a dynamic technique,
where we place the probe in a sterile sheet
and watch the needle in real-time go into the chest cavity.
So, I hope to see you back in the future
as SoundBytes continues.

Brightcove ID

5733895862001

https://youtube.com/watch?v=6ThpUpgjSiM

Case: Detection of Pleural Fluid

Read more about Case: Detection of Pleural Fluid

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This video details the use of bedside ultrasound imaging to detect pleural fluid, grade the amount of fluid in the pleural cavity, and detect loculated pleural effusions.

Applications

Media Library Type

Media Library Tag

Congested Heart Failure

Infection

Tumors

Increased Blood Pressure

Blocked Blood Vessels

Subtitles

- Hello, my name is Phil Perera
and I'm the Emergency Ultrasound Coordinator
at the New York Presbyterian Hospital in New York City.
And welcome to SoundBytes Cases.
In this SoundBytes module,
we're going to look specifically at the
use of Bedside Ultrasound to detect Pleural Fluid.
Interestingly enough, Ultrasound has been found
to detect as little as 20 ccs of fluid
within the Pleural Space.
In contrast, a Chest X-Ray will not reliably
pick up less than 100 to 150 ccs of fluid
on an AP Film.
Now this problem is only compounded
in the Supine Trauma Patient,
where a Chest X-ray may miss a significant amount of fluid
as a Hemothorax will layer out Posteriorly
and can be very difficult to detect on this film.
For these reasons,
Bedside Ultrasound may offer a more accurate way
of diagnosing Pleural Fluid.
Here's a slide reviewing how to
perform the Ultrasound examination
for detection of Pleural Effusions.
Optimally you'll have a three megahertz probe
with a small footprint that can easily sit between the ribs
as we'll be looking into the Right Upper Quadrant
and Left Upper Quadrant areas.
In position one, we'll be coming into the
standard Right Upper Quadrant Trauma FAST exam
and position the probe into that area
just above the Liver and below the Diaphragm.
We can then angle the probe upwards into the Thoracic Cavity
to look for a Dark or Anechoic Fluid Collection
signifying Thoracic Fluid.
We can repeat the exam in the left side
as shown in probe position two.
Placing the probe into that area
of the Left Upper Quadrant Trauma FAST view.
Look first into the area above the Spleen
and below the Diaphragm
and then angle the probe upwards into
the left Thoracic Cavity.
If fluid is seen with in the Thoracic Cavity,
we can then move the probe upwards
to investigate the extent of the Effusion.
Here's a video going over how to perform the examination.
Notice here, we have a probe placed
into the Right Upper Quadrant Trauma FAST area.
Notice that we're angling the probe upwards
into the Thoracic Cavity to fully investigate
for a Pleural Effusion.
Here, I'm just superimposing
about the level of the Diaphragm
as shown in the red marker.
And notice here that the probe
is positioned coming into that area
just above the Diaphragm into the Thoracic Cavity.
Traditionally, the probe should be
in a long-axis configuration
with the marker dot towards the patient's head.
Again, if a Fluid Collection is seen,
one can then move the probe upwards
to fully investigate how big the Effusion is.
To optimize your examination,
place the patient with the head slightly upwards,
so that the fluid will layer out above the Diaphragm
allowing earlier detection of smaller amounts of fluid.
Now that we know how to perform
the Ultrasound examination for Pleural Fluid,
let's take a look at a normal Right Upper Quadrant
Pleural Examination.
The probe is configured at a long-axis type orientation
with the marker towards the patient's head.
So, we see Superior to the left, Inferior to the right.
The Liver is in the middle of the image.
And let's look above the liver.
Here we see the Diaphragm, that curving, white line
which is moving up and down as the patient breathes.
And to the left or Superior to the Diaphragm
is the Thoracic Cavity.
Now, while looking at the Thoracic Cavity here,
what we see is something called Mirror Artifact.
This occurs as a result of the sound waves
coming through the Diaphragm
and reproducing what looks like a mirror image
of the Liver within the chest.
This is a normal appearance of the Thoracic Cavity
and Mirror Artifact is something that
will be seen commonly on Bedside Sonography.
Notice, however, the absence of a Dark
or Anechoic Fluid Collection within the right chest.
Now, let's take a look at a normal
Left Upper Quadrant Pleural Exam.
Again, we're in a long-axis configuration,
so Superior to the left, Inferior to the right.
We see the Spleen in the middle of the image
and we see the Diaphragm moving up and down
as the patient breathes.
Let's look above the Diaphragm into the Thoracic Cavity.
And, again, we see that Mirror Artifact.
What it looks like is almost like
reproduction of the Spleen within the Thoracic Cavity.
So, this is a normal finding.
And one that is not to be confused with fluid.
Fluid will appear very differently
and will have the appearance of a Dark or Anechoic stripe
right above the Diaphragm.
Here's an illustration showing a positive examination
from the Right Upper Quadrant view
with a Pleural Effusion above the Diaphragm.
We're in that long-axis configuration,
so Superior to the left, Inferior to the right.
We see the Liver in the middle of the image here.
And the Diaphragm, the white line as seen
right above the Liver.
Notice in this image we have a Pleural Effusion
as represented by the Dark area of fluid,
which is immediately Superior to the Diaphragm
and tucks in there right above the Diaphragm
going up into the Thoracic Cavity.
So, this will the signature finding of a Pleural Effusion
as taken from the Trauma FAST Views,
from the Right Upper Quadrant.
And the Left Upper Quadrant will also have a similar view,
although we're just looking above the Spleen
in that orientation.
Here's a video clip showing a Small Pleural Effusion
as taken from the Left Upper Quadrant view.
Here, we see the Spleen in the middle of the image,
the Kidney Inferior to the Spleen.
And the Diaphragm, the curving white line
that's moving up and down as the patient breathes
right above the Spleen.
As we look into that area above the Diaphragm,
we actually appreciate here, the presence
of a Dark or Anechoic Fluid Collection
above the Diaphragm.
This represents a positive Pleural Effusion.
Notice that the amount of fluid is relatively small
and we can actually see the Lung moving up and down
to the left of the image here.
Here's a Moderate Plural Effusion
as taken from the Right Upper Quadrant View.
We see the Liver to the Inferior Aspect or to the right.
The curving white line making up the Diaphragm
in the middle of the image.
And fluid representing a Pleural Effusion
Superior to the Diaphragm.
Interestingly enough, we see the Lung moving around
and all the fluid compressed down
by the fluid within the chest cavity
taking on what appears to like a Liver within the chest.
And something called Hepatization of the Lung.
And this is commonly seen with a Pleural Effusion,
as it pushes in on the Lung
making it more of a solid-type organ.
Here's a Large Pleural Effusion as taken
from the Right Upper Quadrant View.
And what we see here, is the Liver Inferiorly,
the Diaphragm right above the Liver
there in the middle of the image.
And we see a large Dark or Anechoic Collection
immediately Superior to the Diaphragm.
This represents a Large Pleural Effusion.
And in the midst of the Pleural Effusion,
we can see the Lung waving around
and compressed down by all
the fluid within the Thoracic Cavity.
Again, demonstrating that Hepatization
of the Lung as it's compressed down by the Pleural Fluid.
So, this would be a Large Plural Effusion,
as there's a large amount of fluid
both Inferiorly between the Lung and the Diaphragm.
And both Anterior and Posterior to the Lung itself here.
Unfortunately, not all Plural Effusions
will be free-flowing or uncomplicated.
There are occasions where our patients
can have repeated Pleural Effusion
that can be Loculated or Complicated.
Here we see an example of a Loculated Pleural Effusion.
Notice this Lung here has an attachment
with a Fibrin area that attaches it
or glues it onto the Diaphragm Inferiorly.
Therefore, we have two Loculated areas Effusion,
both Anterior to the top of the screen and Posterior.
As the Lung is trapped within the Thoracic Cavity
by this Fibrinous Attachment to the Diaphragm,
it may be dangerous to perform an invasive procedure
like a Thoracentesis or a Chest Tube Placement.
The needle or the Chest Tube could be guided
up into the Lung causing a Pneumothorax
by the Fibrinous Attachment to the Diaphragm.
So, in conclusion, I'm glad I could share with you
this SoundBytes module going over the
Ultrasound Examination for the detection of Pleural Fluid.
As we've discussed earlier in the module,
Ultrasound may be more accurate
in detection of Pleural Fluid than a Chest X-ray.
And Ultrasound allows easy grading
of the amount of fluid within the Pleural Cavity.
It can also detect Complicated Pleural Effusions
that may be Loculated and can help determine
which patients may benefit from a Drainage Procedure
such as a Thoracentesis or a Tube Thoracostomy.
So, I hope to see you back as SoundBytes continues
and in further modules,
we'll actually look closer at
the Thoracentesis Procedure under Ultrasound guidance.

Brightcove ID

5729244712001

https://youtube.com/watch?v=X1E7OgOLzw0

Case: Intrauterine Pregnancy - Part 2

Read more about Case: Intrauterine Pregnancy - Part 2

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This video discusses how to use ultrasound to determine the gestational age of a normal pregnancy, determine a fetal heart rate, and identify markers for an abnormal pregnancy and fetal demise.

Clinical Specialties

Media Library Type

Media Library Tag

Tubal Ectopic Abdominal Ectopic

Ampullary

Ovarian

Pseudogestational Sac

Subtitles

- [Voiceover] Hello, my name is Phil Perera
and I am the emergency ultrasound coordinator
at the New York Presbyterian Hospital in New York City.
Welcome to Soundbytes Cases.
In this module entitled Emergency OB/GYN Ultrasound:
Part 2 of Intrauterine Pregnancy,
we're going to focus on the further assessment
of normal pregnancy.
We'll look at two further things that
are important to assess in your pregnancies.
First of all, learning how to date the gestational age
of the pregnancy, as well as learning
how to determine the fetal heart rate.
Then we'll wrap up the module by examining further findings
in abnormal pregnancies and learning how to differentiate
these findings from a normal intrauterine pregnancy.
The first concept that we'll focus on
is dating fetal gestational age.
In the first trimester, we're going to use an assessment
of the crown rump length.
Interestingly, dating in the first trimester
is actually probably the most accurate during all
phases of pregnancy, as there's a difference in
the growth curve as the fetus develops.
In the second trimester, we'll measure
the skull biparietal diameter.
And the third trimester, the dating is composed
of the biophysical profile, focusing on the femur length,
as well as other biophysical measurements.
This is an image of a first trimester pregnancy,
and we're going to evaluate the gestational age by
measuring the crown rump length.
Here we see the fetal pole stretched across
the gestational sac and we see the crown located
over towards the right and the rump towards the left.
If we put the calipers down from the crown across
to the rump we get a measurement of 1.46cm.
By selecting Crown Rump Length in the software package
on the ultrasound machine, we'll get an assessment
of gestational age which we can see here towards
the bottom left, seven weeks and six days.
As first trimester dating is considered one of the most
accurate during the entire pregnancy, it's nice to print
this image out and give to your patient to take for
their followup visit with their OB/GYN.
In the second trimester, dating of gestational age
focuses on skull circumference or measurement of
the biparietal diameter.
We want to measure the skull at about the level
of the thalamus in an axial orientation with the face down.
As we can see here, replacing the calipers from
the outer skull table proximally to the inner skull
table distally, and we have a measurement of 3.26cm
correlating to a 16 week one day gestational age.
In addition to measuring the gestational age of the fetus,
another very important concept is to get a measurement
of the fetal heart rate.
Normal fetal heart rates will range from 120-160
beats per minute, but lower rates down to 90 beats
per minute can be seen in early pregnancy in
the early parts of the first trimester.
M-Mode is the best method for determining fetal heart rate.
Power Doppler and Contrast gives more ultrasonic energy
to the developing heart, thus M-Mode is the preferred
way of measuring the fetal heart rate at this time.
Here, we're going to use M-Mode to determine
the fetal heart rate.
Notice we have the fetus zoomed up towards the top
of the image and replacing the M-Mode caliper directly
over the fetal heart.
Towards the bottom we see the M-Mode Motion strip
and notice the little waves showing the motion
of the fetal heart.
In this particular ultrasound machine, we need to
measure between each peak, and we see here that
we get a heart rate determination towards the bottom,
158 beats per minute.
This is something we can print out and place on the chart
to show that at the time we saw the baby there was
an actual heart beat.
While fortunately most pregnancies have a successful
outcome, unfortunately there are going to be some
abnormal pregnancies that we'll see in the emergency
department, consistent with fetal demise.
Some of the measurements we'll use to determine
abnormal pregnancy with fetal demise is a very large
gestational sac greater than 10 millimeters if
no yolk sac is seen.
Once the gestational sac is greater than 18 millimeters,
we should see a fetal pole or else this is an abnormal
pregnancy.
And many times the gestational sac in an abnormal
pregnancy will have an irregular shape with a scallop
type appearance to it.
Here's video from an abnormal pregnancy.
The first thing we notice is a very large
gestational sac without a yolk sac or discernable
fetal pole with heart beat.
We also see the presence of subchorionic hemorrhage
to the superior aspect of the gestational sac.
That's that area of dark or anechoic fluid
surrounding the gestational sac.
This is seen commonly with abnormal pregnancies
or spontaneous miscarriage.
Here, we'll put the calipers down to measure the diameter
of the gestational sac.
Note that it's very large at 2.8 centimeters by
1.6 centimeters, much larger than the one centimeter
mark that we said defined an abnormal pregnancy
if there was no yolk sac or 18 millimeters if no
fetal pole was seen.
Other indicators of an abnormal pregnancy with fetal
demise is a gestation greater than seven weeks,
which is abnormal if no fetal heart beat is seen.
And if the fetal pole is greater than five millimeters
in dimension this is abnormal if no fetal
heartbeat is seen.
This was an unfortunate case in which we see
a large a fetal pole, greater than five millimeters
without a heart beat.
This is indicative of embryonic demise and we also
see a large circular amnion within the gestational sac.
While I do think it's important we're able to pick up
the findings of the abnormal pregnancy, I'm always
going to get a confirmatory ultrasound and/or OB/GYN
consultation before giving the patient the news that
there is a fetal demise.
I'd like to conclude this module with another form
of abnormal pregnancy, which is a molar pregnancy,
which is a form of Gestational Trophoblastic Disease.
Gestational Trophoblastic Disease ranges from
a spectrum from a Benign Hydatidiform Mole to
Invasive Choriocarcinoma, a form of metastatic disease.
The majority of these are derived from paternal
chromosomes; there is no maternal chromosomes in the embryo.
The ultrasound appearance will be a cyst-like bunch
of grapes with a snowstorm-type appearance,
and classically the serum Beta-HCG will be very elevated.
Here's video from a patient who presented with
a Molar Pregnancy.
Her presenting symptoms were uncontrolled hypertension
during the pregnancy, as well as vaginal bleeding, and pain.
What we see here is the presence of a molar pregnancy
within the fundal region of the uterus.
Notice it has a cyst-like type of appearance.
Very different from the normal appearance
of a intrauterine pregnancy.
As we scan back and forth, it almost looks like
a bunch of grapes within the fundus of the uterus.
So a diagnosis of a molar pregnancy and my next move
was to get an OB/GYN consultation stat.
So thanks for tuning in to Part 2 of Emergency OB/GYN
Ultrasound, focusing on intrauterine pregnancy.
Hopefully you now have a better understanding on
how to further assess a normal pregnancy by determining
gestational age and fetal heart rate.
I hope also I've been able to give you some of
the ultrasound findings that you may see in an
abnormal pregnancy to know when you need to get
an OB/GYN consultation in the ED.
I hope to see you back as we move on to Ectopic Pregnancy,
and two modules in which we'll discuss the various
findings of ectopic pregnancies that we may see
in the emergency department.
I'll see you back as Soundbytes continues.

Brightcove ID

5750480594001

https://youtube.com/watch?v=4clxpcVLOS0

Case: Intrauterine Pregnancy - Part 1

Read more about Case: Intrauterine Pregnancy - Part 1

/sites/default/files/perera_intrauterine_part1.jpg

This video discusses the use of transvaginal and transabdominal ultrasound for detecting intrauterine pregnancies.

Clinical Specialties

Media Library Type

Media Library Tag

Tubal Ectopic Abdominal Ectopic

Ampullary

Ovarian

Pseudogestational Sac

Subtitles

- Hello, my name is Phil Perera,
and I'm the emergency ultrasound coordinator
at the New York Presbyterian Hospital in New York City.
And welcome to SoundBytes Cases.
In this module entitled Emergency OB/GYN Ultrasound: Part I,
we're going to focus entirely on the
ultrasound findings of intrauterine pregnancy.
Now patients with early pregnancy and vaginal bleeding
with or without abdominal pain
are frequently seen in the emergency department.
Luckily for us, emergency OB/GYN ultrasound
has evolved to be one of the most helpful
applications of sonography
in a busy emergency medicine practice.
So this module will be focused
primarily on the detection of intrauterine pregnancy
and we'll examine the ultrasound findings that define
a normal pregnancy for an emergency physician sonographer.
Before launching into the sonographic findings
of a normal intrauterine pregnancy,
let's take a moment to quickly review
the OB/GYN anatomy important for this application.
We see the uterus to the left and adnexa to the right.
Notice the areas of the uterus.
We see the lower cervix,
the intermediate body,
and the fundal region towards the top of the uterus.
Now, the fundal region is where we define
an intrauterine pregnancy to be located.
We see the area where the fallopian tube
enters into the uterus,
which is the interstitial region in a normal uterus
and the cornual region in a bicornuate uterus.
And this is where some variants of ectopics can implant.
Notice the areas of the fallopian tube to the right,
which we'll concentrate more on
with regard to ectopic pregnancy.
And we see the broad ligament there encasing
the fallopian tube and the ovary as seen to the right.
When taking care of a patient
who has vaginal bleeding in pregnancy,
there's four main classifications of diagnoses.
The first is a Threatened Abortion,
which is defined as the presence
of an intrauterine pregnancy with bleeding.
The second main classification
encompasses several different terms.
The terms that are commonly used are,
Incomplete Abortion,
Missed Abortion,
Blighted Ovum,
and Fetal Demise.
Basically, all of these mean the presence
of fetal membranes or parts,
without expected fetal growth or cardiac activity.
The third main classification is a Completed Abortion,
in which there is no further presence
of fetal membranes or parts,
and on examination, usually the cervical os will be closed.
The fourth main classification is the most dangerous,
is Ectopic Pregnancy.
Here's a table showing the structures in pregnancy
and about the time that they're seen on transvaginal
versus transabdominal sonography.
As we look in the Embryonic Structure column to the left,
we see the first structure that appears
is a gestational sac, seen on transvaginal sonography
at about 4.5 to 5 weeks,
and about a week later on transabdominal sonography.
The yolk sac is seen at about 5 to 5.5 weeks
on transvaginal sonography
and a week later on transabdominal sonography.
I have this circled in red,
as this is really the way we diagnose
an intrauterine pregnancy.
Then note the fetal pole is seen at about 5.5 to 6 weeks
on transvaginal sonography
and a week later on transabdominal sonography.
The last main finding, which is a fetal heart beat,
is seen at about six weeks on transvaginal sonography
and about at seven weeks on transabdominal sonography.
Another important concept for OB/GYN sonography,
is the correlation of the serum beta HCG
to the findings of a normal pregnancy.
As we see here for transvaginal sonography,
the discriminatory zone at which we will see
findings of an intrauterine pregnancy
are about 1,500 to 2,000 mIU.
For transabdominal sonography,
the discriminatory zone is about 6,500 mIU.
Now, this rule does not apply to ectopic pregnancies,
which secrete beta HCG at atypical levels
and are commonly seen with betas all over the map.
They can be seen with betas lower than 1,000
and as high as 30,000.
The first finding that will occur
during an intrauterine pregnancy
is going to be a gestational sac.
As we see here in the ultrasound picture to the right,
it's a small, round circle that's dark
or hypoechoic in relation to the rest of the uterus.
We actually see a gestational sac below that
that came out of a patient.
Notice that it has a translucent, membrane-type appearance.
Unfortunately, gestational sac
is not diagnostic of an intrauterine pregnancy,
as a pseudogestational sac of ectopic pregnancy
can be seen from hormonal stimulation.
As a general rule of emergency ultrasound,
is that visualization of a gestational sac
is not adequate to call an intrauterine pregnancy.
Here's two video clips showing the gestational sac.
Long Axis to the left,
and Short Axis to the right.
We see here a very small diameter gestational sac
in both of these orientations.
Unfortunately, this can be seen with a
pseudogestational sac of ectopic pregnancy.
So a small gestational sac, like this,
is in no way diagnostic of an intrauterine pregnancy
for the emergency physician sonographer.
Remember that the gestational sac is seen
at about 4.5 to 5 weeks on transvaginal sonography,
and about a week later on transabdominal sonography.
Here are the findings that we define
as indicative of an intrauterine pregnancy
for an emergency physician sonographer,
and that is the presence of a gestational sac
with a yolk sac inside.
As we see in the picture to the right,
the yolk sac has a circular-type appearance
that we call the Positive Cheerio Sign.
Let's just remember, gestational sac plus yolk sac
is indicative of intrauterine pregnancy.
However, bonus points are given
if you see a fetal pole with a heart beat
for confirmation of intrauterine pregnancy.
Here's a video clip showing a definitive
intrauterine pregnancy.
What we see here is a larger gestational sac
and as we look inside the gestational sac,
we see the positive yolk sac or Cheerio Sign.
Notice the circular yolk sac is seen
towards the inferior aspect of this gestational sac.
This would be diagnostic of an intrauterine pregnancy,
effectively ruling out an ectopic pregnancy
in the vast majority of patients.
Remember that the yolk sac is seen
at about 5 to 5.5 weeks on transvaginal sonography,
and about a week later on transabdominal sonography.
Here we see a pregnancy that is a bit further advanced.
Note we have a larger gestational sac,
that darker or hypoechoic area,
within the fundal region of the uterus,
and as we look inside the gestational sac,
we see the positive yolk sac or the Cheerio,
and looking just to the left of the yolk sac,
we see a tiny little fetal pole there.
Interestingly enough, as we zoomed up on that fetal pole,
we could make out the flicker of a heart beat.
So, a definitive intrauterine pregnancy.
Recall that the fetal pole is seen
at about 5.5 to 6 weeks on transvaginal sonography,
and about a week later on transabdominal sonography.
Here's a transvaginal short axis view
of a seven week intrautertine pregnancy.
We see the gestational sac here.
Notice that the gestational sac
is located in the center of the uterus
as seen here in short axis,
and there's a good amount of myometrial mantle
surrounding the gestational sac,
signifying a fundal location.
We see the positive Cheerio sign, or yolk sac,
to the upper right aspect of the gestational sac,
and right below, we see the fetal pole stretched out.
Notice the positive cardiac activity
as we scan back and forth through the fetal pole.
Here's another intrauterine pregnancy at about seven weeks,
again in the transvaginal short axis view.
We note the good amount of uterus
surrounding the gestational sac,
signifying the fundal location.
We see here the yolk sac or Cheerio sign,
and the fetal pole is stretched out below the yolk sac.
Notice the positive cardiac activity
within the fetal pole.
Now we see another very important finding here
on this ultrasound,
which is the amniotic membrane,
billowing out from around the fetal pole.
Eventually the amniotic membrane
will plaster down on the margins of the gestational sac
to form the amniotic cavity,
in which further growth of the fetus will occur.
Here's an interesting video clip
showing a twin pregnancy.
What we see here are two gestational sacs
signifying dichorionic twins,
and within each of the gestational sacs
we can see little fetal poles
with a flicker of heart beats.
Recall that fetal heart activity
is seen at about six weeks on transvaginal sonography
and about seven weeks on transabdominal sonography.
Here's an early second trimester pregnancy.
What we see here is the next Oscar De La Hoya.
Note the mean right hook on the baby here.
The important finding here is that
this is an intrauterine pregnancy
as we can define a good mantle of uterus
surrounding the pregnancy.
That's very important as there are some ectopics
that can grow to an advanced stage,
but they're discerned by a lack of uterus
around the pregnancy.
Here's another second trimester baby
and as I work in Northern Manhattan,
I refer to this baby as the Merengue baby.
Note the baby moving around fluidly within the amniotic sac.
A sure sign that this kid will grow up to be a slick dancer.
In conclusion, I'm glad I could share with you
this SoundBytes module
going over Emergency OB/GYN Ultrasound: Part I
of intrauterine pregnancy.
Emergency OB/GYN ultrasound is definitely
one of the most helpful sonographic applications
in a busy emergency medicine practice
and hopefully by going through the module
you now have an understanding
of the ultrasound findings diagnostic of a normal pregnancy.
I hope to see you back as we return
in OB/GYN Ultrasound Pregnancy Part 2,
focusing on further assessment of normal pregnancy
as well as looking further into
the ultrasound findings of an abnormal pregnancy.

Brightcove ID

5508114751001

https://youtube.com/watch?v=gv4q8ZB25JM

Case: Ectopic Pregnancy - Part 2

Read more about Case: Ectopic Pregnancy - Part 2

/sites/default/files/youtube_ANhOwzbKe6Y_0.jpg

This video details how bedside ultrasound can help emergency medicine professionals visualize and diagnose various presentations of ectopic pregnancy, as well as differentiate between an ovarian cyst and an ectopic pregnancy.

Clinical Specialties

Media Library Type

Media Library Tag

Tubal Ectopic Abdominal Ectopic

Subtitles

- Hello, my name is Phil Perera
and I'm the Emergency Ultrasound Coordinator
at the New York Presbyterian Hospital in New York City
and welcome to SoundBytes Cases.
This module is ectopic pregnancy part two,
where we'll go over the multiple
ultrasound presentation of ectopic pregnancies.
Ectopic pregnancy is one of those
conditions that we'll not infrequently
encounter in a busy EM practice.
The most common presentation of
an ectopic pregnancy will be an empty uterus,
with or without free fluid within the pelvic cul de sac
or surrounding the uterus.
We may be actually able to visualize
the ectopic as a Bagel sign,
which constitutes a thickened Fallopian tube.
Other presentations of ectopics
include a complex pelvic mass
with a ring of fire on Doppler sonography,
hemosalpinx or blood within the Fallopian tube
or we may be actually able to visualize
the live ectopic in the adnexa,
with a fetal pole and/or heartbeat.
Here's a transvaginal long axis ultrasound
for a woman who presented with lower abdominal pain
and a positive pregnancy test.
Notice the uterus, as shown in the long axis view,
without an appreciable intrauterine pregnancy
and notice that it's surrounded
by a large amount of free fluid.
That dark or anechoic area surrounding
the uterus both anteriorly to the left,
posteriorly in the cul de sac to the right.
That is the presence of fresh blood.
Notice also the presence of blood clots
anteriorly or to the left, that more echogenic area.
So, given the absence of an intrauterine pregnancy,
we decided to scan out to the adnexa
and notice here, the presence of
a Bagel sign of a tubal ectopic pregnancy.
We see fresh fluid here, above the Bagel,
to the right, blood clot to the left
and the more hyperechoic
or lighter Bagel sign in the middle of the image.
Occasionally it can be difficult to discern
the Bagel sign of a Fallopian tube ectopic
from an ovarian cyst, as show here to the right.
But lets look closer at the two video clips
and notice that the Bagel sign
has a more hyperechoic or bright appearance,
with the single hole more in the middle.
Notice that the ovarian cyst has a different appearance,
with multiple small follicular cysts
to the outer portion of the ovary
and a single midline corpus luteum cyst.
Very different than the Bagel sign.
Here's another patient with an ectopic pregnancy
in a different presentation of ectopic.
We're scanning here from the more midline uterus,
as show there to the left, out to the right adnexa
and notice as we scan out to the right adnexa,
we notice the presence of a complex, pelvic mass.
Notice also the relatively low
serum B-HCG in this case, at 478.
So, a complex pelvic mass with
an absence of intrauterine pregnancy.
Very suspicious for an ectopic pregnancy.
And what's interesting is,
as we put Doppler flow on that complex pelvic mass,
we notice the presence of the ring of fire,
very suggestive of an ectopic pregnancy
and the reasons for the ring of fire
is that the ectopic pregnancy pulls
a huge amount of vascularity towards it
and using the Doppler,
we can see the separate ectopic from the ovary above it.
Here's another presentation of an ectopic pregnancy.
Again, we're scanning at a short axis plane
and we see there the uterus to the left
and outside the uterus, a separate structure.
We note here the presence of a thickened Fallopian tube
and inside the thickened Fallopian tube,
we see here a fetal pole with a heart beat,
consistent with a live ampullary ectopic pregnancy.
Unfortunately in this case,
the presence of a fetal pole with
a heart beat is a contraindication of methotrexate therapy
and this patient will need to undergo surgery.
We mentioned earlier that there are
a variance of ectopic pregnancies
that implant outside the fundal region of the uterus,
in an aberrant location.
This is a good example.
This patient actually has a bicornuate uterus
and as we scan at a short axis plane up the uterus,
we notice that the two limbs of endometrium
that make up the two distinct cornua.
As we go up the left cornua,
we notice here the presence of a cornual ectopic pregnancy
and we see the that it's located off to the side,
way out to the left cornua,
with a very thin myometrial mantle.
If we actually put the calipers down
and measure the endo-myometrial mantle,
we find it's very thin, at three millimeters,
defining an abnormal pregnancy.
A normal pregnancy should have
a myometrial mantle greater than eight millimeters.
Now this is a bicornuate uterus,
so this is a cornual pregnancy.
In a normal uterus,
this would be known as an interstitial pregnancy.
So in conclusion, I'm glad I could share with you
this module on ectopic pregnancy part two,
looking at the varied presentations of ectopic pregnancy.
Hopefully now you better understand
what we're searching for on bedside sonography
when we're working up a patient
with possible ectopic pregnancy.
While visualization of the adnexa
and the Fallopian tubes is an advanced technique,
but it is well within the scope
of a busy emergency medicine practice.
As a final caveat, ectopic pregnancies can
be seen at Beta-HCG levels ranging from very low,
less than 100, to very high, above 20,000
and thus we cannot use a Single Beta-HCG
level to rule out ectopic pregnancy.
It's really better to look at trends
in the hormone level over time.
With an intrauterine pregnancy,
the levels should double in 48 hours,
whereas in most ectopic pregnancy,
it will not climb to the same degree.
So, I hope that now you have a
better understanding of how to
work up the pregnant patient with
a possible ectopic pregnancy.

Brightcove ID

5750496732001

https://youtube.com/watch?v=ANhOwzbKe6Y

Case: Ectopic Pregnancy - Part 1

Read more about Case: Ectopic Pregnancy - Part 1

/sites/default/files/youtube_iui0HF95XAw_0.jpg

This video details how bedside transvaginal ultrasound can help emergency medicine professionals evaluate OB/GYN anatomy to diagnose possible ectopic pregnancies.

Clinical Specialties

Media Library Type

Media Library Tag

Pseudogestational Sac

Tubal Ectopic Abdominal Ectopic

Subtitles

- Hello, my name is Phil Perrera,
and I'm the emergency ultrasound coordinator
at the New York Presbyterian Hospital in New York City,
and welcome to SoundBytes Cases.
Today's module is going to focus on ectopic pregnancy.
Ectopic pregnancies constitute
about 2% of all total pregnancies,
although they're commonly seen in the emergency department.
Ectopic pregnancy is more commonly seen in women
with a history of tubal ligation
who are using interuterine devices for contraception
or have a history of sexually transmitted diseases,
such as pelvic inflammatory disease
with scarring of the tubes.
Ectopic pregnancy is also commonly seen in women
using fertility agents,
which accounts for the increasing rate of ectopic pregnancy
over all.
As a golden rule, we must consider ectopic pregnancy
in all women with abdominal pain
and/or vaginal bleeding and a positive pregnancy test,
until ruled out by sonography.
Let's begin by reviewing the OB/GYN anatomy
that we'll need to know to perform bedside ultrasound
of the uterus and the adnexa.
We'll begin by locating the lower cervical region
of the uterus.
The portion above that, the body, and the fundal region
of the uterus above the body,
which is where we define an inter-uterine pregnancy
to be located.
Notice the intersticial region of the uterus,
that region of the uterus that abuts the fallopian tube.
In a cornual uterus this is known as cornual region.
Here we also see the portions of the fallopian tube,
the proximal isthmal region,
the distal infindibulum,
and notice the ampullary region
which comprises the majority of the fallopian tube.
We also see here, the broad ligament which encases
the fallopian tube and ovary in the lateral region
of the adnexa.
Remember that the ovary is relatively mobile
within the broad ligament.
Now let's review a transvaginal long axis scan
from a women who presented with a positive pregnancy test,
who had lower abdominal pain and vaginal bleeding.
Notice the fundus, as shown here to the left,
the cervix to the right.
We see here the presence of a thickened white
endometrial stripe in the midline of the uterus.
Notice the pelvic cul de sac that potential space
posterior to the uterus.
Notice here the absence of an inter-uterine pregnancy.
Now, confirm the absence of an IUP by scanning
in the transvaginal short axis plane.
Here we have the probe marker
oriented towards the patient's right,
and we're cutting the uterus in cross section.
Notice again the thickened endometrial stripe
in the midline of the uterus,
and the pelvic cul de sac posteriorly.
Again, we see the absence of an IUP,
and also note the absence of free fluid,
dark anechoic fluid collections
within the pelvic cul de sac.
So, given these findings we're now concerned
about the presence of an ectopic pregnancy.
So, lets begin our discussion of ectopic pregnancies
by reviewing the locations that we commonly see
ectopic pregnancies to be found.
We see here a normal uterus to the left,
and a bicornuate uterus to the right.
We remember that a fundal location is the definition
of an inter-uterine pregnancy as shown smack in the middle
of the normal uterus to the left.
However, we can have variants of ectopic pregnancies
within the uterus as shown in the interstitial location
in the normal uterus to the left,
and in the cornual region in the bicornuate uterus
to the right.
We can also have implantations low
within the cervical region of the uterus,
as shown in the normal uterus to the left.
Now, most ectopic pregnancies will be located
within the fallopian tube and of those
the majority will be found in the ampullary region
as that comprises the majority of the fallopian tube.
But we can have implantations more proximal,
within the isthmal region
or distal within the infindibular region.
Now, tough ectopics to diagnose are those that implant
within the ovary,
within the abdominal cavity,
or within the peritoneal lining.
These can be very, very hard to diagnose
and commonly grow to an advanced stage before diagnosis.
So, returning to our case, given the presence of a positive
pregnancy test and the absence of an IUP
on bedside ultrasound, we were very concerned about
ectopic pregnancy and decided to scan out
to the left adnexa.
Here, notice we're scanning out to the left adnexa,
and we have a positive finding.
What we see here is a thickened fallopian tube,
comprising what is known as the bagel sign.
Notice within the thickened fallopian tube,
we have another positive finding.
That is the presence of a fetal pole.
So, in this patient we were able to diagnose
an ampullary ectopic pregnancy and our next move
was to call OB/GYN stat for a consultation.
So, in conclusion, ectopic pregnancies constitute
the greatest cause, overall, of maternal mortality.
We must consider an ectopic pregnancy in all women
with a positive pregnancy test
where an inter-uterine pregnancy is not visualized
within the fundal part of the uterus.
Most ectopic pregnancies are going to be located
in the fallopian tube,
and we may actually visualize the ectopic
with ultrasound evaluation of the adnexa
as shown in this module.
So, we'll return with ectopic pregnancy part two
which goes over the varied manifestations
of ectopics.

Brightcove ID

5750491404001

https://youtube.com/watch?v=iui0HF95XAw

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