<p begin="00:00:14.315" end="00:00:15.904" style="s2">- [Voiceover] Hello,<br />my name is Phil Perera</p>
<p begin="00:00:15.904" end="00:00:17.729" style="s2">and I am the emergency<br />ultrasound coordinator</p>
<p begin="00:00:17.729" end="00:00:20.635" style="s2">at the New York Presbyterian<br />Hospital in New York City.</p>
<p begin="00:00:20.635" end="00:00:22.968" style="s2">Welcome to Soundbytes Cases.</p>
<p begin="00:00:24.474" end="00:00:26.970" style="s2">In this module entitled<br />Emergency OB/GYN Ultrasound:</p>
<p begin="00:00:26.970" end="00:00:29.090" style="s2">Part 2 of Intrauterine Pregnancy,</p>
<p begin="00:00:29.090" end="00:00:30.881" style="s2">we're going to focus on<br />the further assessment</p>
<p begin="00:00:30.881" end="00:00:32.548" style="s2">of normal pregnancy.</p>
<p begin="00:00:33.740" end="00:00:35.121" style="s2">We'll look at two further things that</p>
<p begin="00:00:35.121" end="00:00:37.308" style="s2">are important to assess<br />in your pregnancies.</p>
<p begin="00:00:37.308" end="00:00:39.978" style="s2">First of all, learning how<br />to date the gestational age</p>
<p begin="00:00:39.978" end="00:00:42.169" style="s2">of the pregnancy, as well as learning</p>
<p begin="00:00:42.169" end="00:00:44.932" style="s2">how to determine the fetal heart rate.</p>
<p begin="00:00:44.932" end="00:00:47.966" style="s2">Then we'll wrap up the module<br />by examining further findings</p>
<p begin="00:00:47.966" end="00:00:50.804" style="s2">in abnormal pregnancies and<br />learning how to differentiate</p>
<p begin="00:00:50.804" end="00:00:55.012" style="s2">these findings from a normal<br />intrauterine pregnancy.</p>
<p begin="00:00:55.012" end="00:00:56.776" style="s2">The first concept that we'll focus on</p>
<p begin="00:00:56.776" end="00:00:59.182" style="s2">is dating fetal gestational age.</p>
<p begin="00:00:59.182" end="00:01:01.741" style="s2">In the first trimester, we're<br />going to use an assessment</p>
<p begin="00:01:01.741" end="00:01:03.491" style="s2">of the crown rump length.</p>
<p begin="00:01:03.491" end="00:01:05.427" style="s2">Interestingly, dating<br />in the first trimester</p>
<p begin="00:01:05.427" end="00:01:07.491" style="s2">is actually probably the<br />most accurate during all</p>
<p begin="00:01:07.491" end="00:01:09.503" style="s2">phases of pregnancy, as<br />there's a difference in</p>
<p begin="00:01:09.503" end="00:01:12.446" style="s2">the growth curve as the fetus develops.</p>
<p begin="00:01:12.446" end="00:01:14.004" style="s2">In the second trimester, we'll measure</p>
<p begin="00:01:14.004" end="00:01:16.495" style="s2">the skull biparietal diameter.</p>
<p begin="00:01:16.495" end="00:01:18.839" style="s2">And the third trimester,<br />the dating is composed</p>
<p begin="00:01:18.839" end="00:01:22.124" style="s2">of the biophysical profile,<br />focusing on the femur length,</p>
<p begin="00:01:22.124" end="00:01:25.624" style="s2">as well as other biophysical measurements.</p>
<p begin="00:01:26.709" end="00:01:28.975" style="s2">This is an image of a<br />first trimester pregnancy,</p>
<p begin="00:01:28.975" end="00:01:30.796" style="s2">and we're going to evaluate<br />the gestational age by</p>
<p begin="00:01:30.796" end="00:01:32.990" style="s2">measuring the crown rump length.</p>
<p begin="00:01:32.990" end="00:01:34.557" style="s2">Here we see the fetal<br />pole stretched across</p>
<p begin="00:01:34.557" end="00:01:37.173" style="s2">the gestational sac and<br />we see the crown located</p>
<p begin="00:01:37.173" end="00:01:40.680" style="s2">over towards the right and<br />the rump towards the left.</p>
<p begin="00:01:40.680" end="00:01:43.567" style="s2">If we put the calipers<br />down from the crown across</p>
<p begin="00:01:43.567" end="00:01:47.102" style="s2">to the rump we get a<br />measurement of 1.46cm.</p>
<p begin="00:01:47.102" end="00:01:49.584" style="s2">By selecting Crown Rump<br />Length in the software package</p>
<p begin="00:01:49.584" end="00:01:51.565" style="s2">on the ultrasound machine,<br />we'll get an assessment</p>
<p begin="00:01:51.565" end="00:01:54.084" style="s2">of gestational age which<br />we can see here towards</p>
<p begin="00:01:54.084" end="00:01:57.915" style="s2">the bottom left, seven weeks and six days.</p>
<p begin="00:01:57.915" end="00:01:59.967" style="s2">As first trimester dating is<br />considered one of the most</p>
<p begin="00:01:59.967" end="00:02:02.531" style="s2">accurate during the entire<br />pregnancy, it's nice to print</p>
<p begin="00:02:02.531" end="00:02:04.920" style="s2">this image out and give to<br />your patient to take for</p>
<p begin="00:02:04.920" end="00:02:09.087" style="s2">their followup visit with their OB/GYN.</p>
<p begin="00:02:09.946" end="00:02:12.130" style="s2">In the second trimester,<br />dating of gestational age</p>
<p begin="00:02:12.130" end="00:02:14.439" style="s2">focuses on skull circumference<br />or measurement of</p>
<p begin="00:02:14.439" end="00:02:16.688" style="s2">the biparietal diameter.</p>
<p begin="00:02:16.688" end="00:02:18.285" style="s2">We want to measure the<br />skull at about the level</p>
<p begin="00:02:18.285" end="00:02:22.579" style="s2">of the thalamus in an axial<br />orientation with the face down.</p>
<p begin="00:02:22.579" end="00:02:25.066" style="s2">As we can see here,<br />replacing the calipers from</p>
<p begin="00:02:25.066" end="00:02:28.005" style="s2">the outer skull table<br />proximally to the inner skull</p>
<p begin="00:02:28.005" end="00:02:32.771" style="s2">table distally, and we have<br />a measurement of 3.26cm</p>
<p begin="00:02:32.771" end="00:02:36.854" style="s2">correlating to a 16 week<br />one day gestational age.</p>
<p begin="00:02:38.641" end="00:02:41.207" style="s2">In addition to measuring the<br />gestational age of the fetus,</p>
<p begin="00:02:41.207" end="00:02:43.443" style="s2">another very important concept<br />is to get a measurement</p>
<p begin="00:02:43.443" end="00:02:45.285" style="s2">of the fetal heart rate.</p>
<p begin="00:02:45.285" end="00:02:48.431" style="s2">Normal fetal heart rates<br />will range from 120-160</p>
<p begin="00:02:48.431" end="00:02:50.747" style="s2">beats per minute, but lower<br />rates down to 90 beats</p>
<p begin="00:02:50.747" end="00:02:53.022" style="s2">per minute can be seen<br />in early pregnancy in</p>
<p begin="00:02:53.022" end="00:02:55.804" style="s2">the early parts of the first trimester.</p>
<p begin="00:02:55.804" end="00:02:58.897" style="s2">M-Mode is the best method for<br />determining fetal heart rate.</p>
<p begin="00:02:58.897" end="00:03:01.710" style="s2">Power Doppler and Contrast<br />gives more ultrasonic energy</p>
<p begin="00:03:01.710" end="00:03:04.874" style="s2">to the developing heart,<br />thus M-Mode is the preferred</p>
<p begin="00:03:04.874" end="00:03:09.487" style="s2">way of measuring the fetal<br />heart rate at this time.</p>
<p begin="00:03:09.487" end="00:03:11.120" style="s2">Here, we're going to<br />use M-Mode to determine</p>
<p begin="00:03:11.120" end="00:03:12.421" style="s2">the fetal heart rate.</p>
<p begin="00:03:12.421" end="00:03:14.750" style="s2">Notice we have the fetus<br />zoomed up towards the top</p>
<p begin="00:03:14.750" end="00:03:17.127" style="s2">of the image and replacing<br />the M-Mode caliper directly</p>
<p begin="00:03:17.127" end="00:03:18.841" style="s2">over the fetal heart.</p>
<p begin="00:03:18.841" end="00:03:21.036" style="s2">Towards the bottom we see<br />the M-Mode Motion strip</p>
<p begin="00:03:21.036" end="00:03:23.675" style="s2">and notice the little<br />waves showing the motion</p>
<p begin="00:03:23.675" end="00:03:25.603" style="s2">of the fetal heart.</p>
<p begin="00:03:25.603" end="00:03:27.781" style="s2">In this particular ultrasound<br />machine, we need to</p>
<p begin="00:03:27.781" end="00:03:29.965" style="s2">measure between each<br />peak, and we see here that</p>
<p begin="00:03:29.965" end="00:03:32.800" style="s2">we get a heart rate<br />determination towards the bottom,</p>
<p begin="00:03:32.800" end="00:03:34.550" style="s2">158 beats per minute.</p>
<p begin="00:03:35.920" end="00:03:38.223" style="s2">This is something we can print<br />out and place on the chart</p>
<p begin="00:03:38.223" end="00:03:41.298" style="s2">to show that at the time<br />we saw the baby there was</p>
<p begin="00:03:41.298" end="00:03:43.048" style="s2">an actual heart beat.</p>
<p begin="00:03:44.545" end="00:03:46.320" style="s2">While fortunately most<br />pregnancies have a successful</p>
<p begin="00:03:46.320" end="00:03:49.155" style="s2">outcome, unfortunately<br />there are going to be some</p>
<p begin="00:03:49.155" end="00:03:51.226" style="s2">abnormal pregnancies that<br />we'll see in the emergency</p>
<p begin="00:03:51.226" end="00:03:54.077" style="s2">department, consistent with fetal demise.</p>
<p begin="00:03:54.077" end="00:03:55.398" style="s2">Some of the measurements<br />we'll use to determine</p>
<p begin="00:03:55.398" end="00:03:58.151" style="s2">abnormal pregnancy with<br />fetal demise is a very large</p>
<p begin="00:03:58.151" end="00:04:00.698" style="s2">gestational sac greater<br />than 10 millimeters if</p>
<p begin="00:04:00.698" end="00:04:02.918" style="s2">no yolk sac is seen.</p>
<p begin="00:04:02.918" end="00:04:05.644" style="s2">Once the gestational sac is<br />greater than 18 millimeters,</p>
<p begin="00:04:05.644" end="00:04:08.172" style="s2">we should see a fetal pole<br />or else this is an abnormal</p>
<p begin="00:04:08.172" end="00:04:09.689" style="s2">pregnancy.</p>
<p begin="00:04:09.689" end="00:04:11.939" style="s2">And many times the<br />gestational sac in an abnormal</p>
<p begin="00:04:11.939" end="00:04:14.697" style="s2">pregnancy will have an<br />irregular shape with a scallop</p>
<p begin="00:04:14.697" end="00:04:16.530" style="s2">type appearance to it.</p>
<p begin="00:04:17.517" end="00:04:19.920" style="s2">Here's video from an abnormal pregnancy.</p>
<p begin="00:04:19.920" end="00:04:22.274" style="s2">The first thing we notice is a very large</p>
<p begin="00:04:22.274" end="00:04:24.461" style="s2">gestational sac without<br />a yolk sac or discernable</p>
<p begin="00:04:24.461" end="00:04:26.817" style="s2">fetal pole with heart beat.</p>
<p begin="00:04:26.817" end="00:04:28.698" style="s2">We also see the presence<br />of subchorionic hemorrhage</p>
<p begin="00:04:28.698" end="00:04:31.468" style="s2">to the superior aspect<br />of the gestational sac.</p>
<p begin="00:04:31.468" end="00:04:34.724" style="s2">That's that area of dark or anechoic fluid</p>
<p begin="00:04:34.724" end="00:04:37.053" style="s2">surrounding the gestational sac.</p>
<p begin="00:04:37.053" end="00:04:39.552" style="s2">This is seen commonly<br />with abnormal pregnancies</p>
<p begin="00:04:39.552" end="00:04:42.570" style="s2">or spontaneous miscarriage.</p>
<p begin="00:04:42.570" end="00:04:44.506" style="s2">Here, we'll put the calipers<br />down to measure the diameter</p>
<p begin="00:04:44.506" end="00:04:46.060" style="s2">of the gestational sac.</p>
<p begin="00:04:46.060" end="00:04:48.759" style="s2">Note that it's very large<br />at 2.8 centimeters by</p>
<p begin="00:04:48.759" end="00:04:52.659" style="s2">1.6 centimeters, much larger<br />than the one centimeter</p>
<p begin="00:04:52.659" end="00:04:56.087" style="s2">mark that we said defined<br />an abnormal pregnancy</p>
<p begin="00:04:56.087" end="00:04:58.559" style="s2">if there was no yolk sac<br />or 18 millimeters if no</p>
<p begin="00:04:58.559" end="00:05:01.056" style="s2">fetal pole was seen.</p>
<p begin="00:05:01.056" end="00:05:03.262" style="s2">Other indicators of an<br />abnormal pregnancy with fetal</p>
<p begin="00:05:03.262" end="00:05:05.888" style="s2">demise is a gestation<br />greater than seven weeks,</p>
<p begin="00:05:05.888" end="00:05:09.095" style="s2">which is abnormal if no<br />fetal heart beat is seen.</p>
<p begin="00:05:09.095" end="00:05:11.503" style="s2">And if the fetal pole is<br />greater than five millimeters</p>
<p begin="00:05:11.503" end="00:05:14.094" style="s2">in dimension this is abnormal if no fetal</p>
<p begin="00:05:14.094" end="00:05:15.594" style="s2">heartbeat is seen.</p>
<p begin="00:05:16.567" end="00:05:18.222" style="s2">This was an unfortunate<br />case in which we see</p>
<p begin="00:05:18.222" end="00:05:20.477" style="s2">a large a fetal pole,<br />greater than five millimeters</p>
<p begin="00:05:20.477" end="00:05:22.364" style="s2">without a heart beat.</p>
<p begin="00:05:22.364" end="00:05:25.662" style="s2">This is indicative of<br />embryonic demise and we also</p>
<p begin="00:05:25.662" end="00:05:29.369" style="s2">see a large circular amnion<br />within the gestational sac.</p>
<p begin="00:05:29.369" end="00:05:31.668" style="s2">While I do think it's<br />important we're able to pick up</p>
<p begin="00:05:31.668" end="00:05:33.904" style="s2">the findings of the abnormal<br />pregnancy, I'm always</p>
<p begin="00:05:33.904" end="00:05:37.046" style="s2">going to get a confirmatory<br />ultrasound and/or OB/GYN</p>
<p begin="00:05:37.046" end="00:05:39.475" style="s2">consultation before giving<br />the patient the news that</p>
<p begin="00:05:39.475" end="00:05:41.893" style="s2">there is a fetal demise.</p>
<p begin="00:05:41.893" end="00:05:43.638" style="s2">I'd like to conclude this<br />module with another form</p>
<p begin="00:05:43.638" end="00:05:46.486" style="s2">of abnormal pregnancy,<br />which is a molar pregnancy,</p>
<p begin="00:05:46.486" end="00:05:49.992" style="s2">which is a form of Gestational<br />Trophoblastic Disease.</p>
<p begin="00:05:49.992" end="00:05:52.301" style="s2">Gestational Trophoblastic<br />Disease ranges from</p>
<p begin="00:05:52.301" end="00:05:55.493" style="s2">a spectrum from a Benign<br />Hydatidiform Mole to</p>
<p begin="00:05:55.493" end="00:05:59.926" style="s2">Invasive Choriocarcinoma, a<br />form of metastatic disease.</p>
<p begin="00:05:59.926" end="00:06:02.003" style="s2">The majority of these<br />are derived from paternal</p>
<p begin="00:06:02.003" end="00:06:05.598" style="s2">chromosomes; there is no maternal<br />chromosomes in the embryo.</p>
<p begin="00:06:05.598" end="00:06:07.432" style="s2">The ultrasound appearance<br />will be a cyst-like bunch</p>
<p begin="00:06:07.432" end="00:06:09.594" style="s2">of grapes with a<br />snowstorm-type appearance,</p>
<p begin="00:06:09.594" end="00:06:14.110" style="s2">and classically the serum<br />Beta-HCG will be very elevated.</p>
<p begin="00:06:14.110" end="00:06:16.156" style="s2">Here's video from a<br />patient who presented with</p>
<p begin="00:06:16.156" end="00:06:17.394" style="s2">a Molar Pregnancy.</p>
<p begin="00:06:17.394" end="00:06:20.232" style="s2">Her presenting symptoms were<br />uncontrolled hypertension</p>
<p begin="00:06:20.232" end="00:06:24.211" style="s2">during the pregnancy, as well<br />as vaginal bleeding, and pain.</p>
<p begin="00:06:24.211" end="00:06:26.855" style="s2">What we see here is the<br />presence of a molar pregnancy</p>
<p begin="00:06:26.855" end="00:06:29.024" style="s2">within the fundal region of the uterus.</p>
<p begin="00:06:29.024" end="00:06:31.707" style="s2">Notice it has a cyst-like<br />type of appearance.</p>
<p begin="00:06:31.707" end="00:06:33.665" style="s2">Very different from the normal appearance</p>
<p begin="00:06:33.665" end="00:06:35.918" style="s2">of a intrauterine pregnancy.</p>
<p begin="00:06:35.918" end="00:06:37.918" style="s2">As we scan back and forth,<br />it almost looks like</p>
<p begin="00:06:37.918" end="00:06:41.205" style="s2">a bunch of grapes within<br />the fundus of the uterus.</p>
<p begin="00:06:41.205" end="00:06:44.286" style="s2">So a diagnosis of a molar<br />pregnancy and my next move</p>
<p begin="00:06:44.286" end="00:06:47.671" style="s2">was to get an OB/GYN consultation stat.</p>
<p begin="00:06:47.671" end="00:06:50.437" style="s2">So thanks for tuning in to<br />Part 2 of Emergency OB/GYN</p>
<p begin="00:06:50.437" end="00:06:53.921" style="s2">Ultrasound, focusing on<br />intrauterine pregnancy.</p>
<p begin="00:06:53.921" end="00:06:55.725" style="s2">Hopefully you now have a<br />better understanding on</p>
<p begin="00:06:55.725" end="00:06:58.082" style="s2">how to further assess a normal<br />pregnancy by determining</p>
<p begin="00:06:58.082" end="00:07:01.344" style="s2">gestational age and fetal heart rate.</p>
<p begin="00:07:01.344" end="00:07:02.992" style="s2">I hope also I've been<br />able to give you some of</p>
<p begin="00:07:02.992" end="00:07:04.858" style="s2">the ultrasound findings<br />that you may see in an</p>
<p begin="00:07:04.858" end="00:07:06.994" style="s2">abnormal pregnancy to<br />know when you need to get</p>
<p begin="00:07:06.994" end="00:07:10.218" style="s2">an OB/GYN consultation in the ED.</p>
<p begin="00:07:10.218" end="00:07:13.722" style="s2">I hope to see you back as we<br />move on to Ectopic Pregnancy,</p>
<p begin="00:07:13.722" end="00:07:15.849" style="s2">and two modules in which<br />we'll discuss the various</p>
<p begin="00:07:15.849" end="00:07:18.311" style="s2">findings of ectopic<br />pregnancies that we may see</p>
<p begin="00:07:18.311" end="00:07:20.525" style="s2">in the emergency department.</p>
<p begin="00:07:20.525" end="00:07:24.025" style="s2">I'll see you back as Soundbytes continues.</p>