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Case: FAST Exam - Suprapubic Views

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This video details how using long-axis and short-axis suprapubic views during a trauma FAST ultrasound examination enables clinicians to identify fluid in a trauma patient's pelvic cavity.

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- 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'll continue
our journey looking at the Trauma Fast Exam.
I hope you've had a chance to join me prior
for modules looking at the right upper quadrant
and left upper quadrant views of the Trauma Fast Exam.
In this module we will specifically look at
the Suprapubic view, also known as the bladder or pelvic
view of the Trauma Fast Exam.
There is a lot of information we can gain
from looking at the Suprapubic view,
as we can potentially detect a smaller amount of fluid
than is required to make a positive right
upper quadrant or left upper quadrant view.
Literature suggests that only about
100 to 200 ccs of fluid can be detected
accurately on the Suprapubic view.
Here's a slide reviewing how to perform
the Suprapubic view of the Trauma Fast Exam.
In contrast to the upper quadrant views,
where we looked only in the long axis configuration,
the Suprapubic view is made up of two planes.
We want to look in both long and short axis configurations.
We'll begin at long axis with the marker dot
oriented toward the patient's head
and complete our exam by moving the probe
into short axis with the marker dot
toward the patients right side.
This way we can fully scan through the pelvis
and not miss any small amounts of fluid there.
It's optimal to perform the examination
with a full bladder as an optimal
acoustic window, so perform the
exam prior to having the patient
void or placing a foley catheter.
Here's an illustration showing the anatomy
that we'll need to know to perform
the Suprapubic view of the Trauma Fast Exam.
We see the pattern of fluid flow in a female,
to the left here, and a male, to the right.
Let's look closer at the female pelvis,
to the left, and what we see is that fluid will
preferentially develop in the pelvic
Cul de Sac, located behind the uterus.
Now, small amounts of fluid will only be
located in the pelvic Cul de Sac,
but as the amount of fluid enlarges
it will come out and increase so
that it will layer out on top of
the uterus and on top of the dome of the bladder.
But small amounts of fluid will only be found in
that pelvic Cul de Sac posterior to the uterus.
Now let's take a look at the male
pelvis to the right and we see
small amounts of fluid that will only be found
in the Retrovesical Space behind the bladder.
As the amount of fluid enlarges it
will come anterior to settle out
over the top of the dome of the bladder.
But as we emphasized in the female,
small amounts of fluid will only be
found in one place and in the male
it will be in that Retrovesical Space
immediately posterior to the bladder.
Let's begin by looking at some normal
video from the Suprapubic View.
In this case, a long axis view in a female,
superior to the left, inferior to the right.
The first structure we identify is
the bladder, the dark area, anteriorly
and posterior to the bladder we see the uterus.
Now if we look into the potential space,
the Pelvic Cul de Sac, posterior to the
uterus for any dark fluid collections, we see an
absence of any fluid on this normal video clip.
Now let's inspect a video clip from a male.
In this case a short axis view.
We see a large bladder there, anteriorly
and behind the bladder we see two
tubular structures making up the
Seminal Vesicles, a normal finding in a male.
Now if we're looking for free fluid
behind the bladder, we'd be looking
for dark or anechoic fluid collection
layering out behind the bladder.
Notice this is a normal examination.
Here's a positive examination
in a female trauma patient.
We're looking in the long axis view,
superior to the left, inferior to the right.
The first structure we identify is
the bladder, as seen inferior here.
And notice the uterus, the solid organ,
as seen superior to the bladder.
We note the parts of the uterus, the fundus
anteriorly, and the cervix more posteriorly.
Now let's look into the Pelvic Cul de Sac
immediately posterior to the uterus,
and what we see here is the presence of a
dark or anechoic fluid collection just posterior
to the cervix within the pelvic Cul de Sac.
So in the female trauma patient,
this does denote a positive examination
and can be a sign of ongoing bleeding
within the abdominal pelvic cavity.
So let's contrast this clip in which
we see a small amount of fresh
fluid within the pelvic Cul de Sac.
With this one, in which we have a female
trauma patient with a large amount
of bleeding within the pelvic cavity.
We see here, again, a long axis scan superior
to the left, inferior to the right, the bladder
we see as the dark structure inferiorly
and the uterus superior to the bladder.
Notice the fresh fluid as seen posterior
to the uterus within the Cul de Sac,
but note that the amount of fluid
comes anterior to the uterus,
as seen here between the uterus and the bladder.
So this denotes a large amount of blood within
the pelvic cavity in this female trauma patient.
If we now orient the probe to the patient's right side,
we obtain a short axis view of the same patient.
And what we see here is the uterus in the
middle of the image and notice the large amount
of fresh fluid as seen both to the top, or anterior,
to the uterus and posterior to the uterus.
Notice in this case we can see the
broad ligaments of the uterus well outlined
by all the fresh fluid within the pelvis.
So a large amount of fresh fluid, or blood,
in this case, within this female trauma patient.
Here's a positive examination
Suprapubic View, short axis in a male.
Probe is oriented towards the patient's right and
anteriorly we see a large, fluid filled bladder.
Posterior to the bladder, in the retrovesical
space we appreciate the presence of free fluid,
as shown by that dark or anechoic
fluid collection there.
Now this gives a finding known as
the double wall sign, and we see
the wall of the bladder, outlined by
the urine inside the bladder, and the
blood, in this case, outside the bladder
in the area of the retrovesical space.
To further confirm that the last patient
had a positive exam and that we're
not mistaking areas of fluid as seminal vesicles,
we'll re-scan the patient in the long axis plane,
superior to the left, inferior to the right.
We see the large circular bladder,
as seen anteriorly and superior
and posterior to the bladder in the
retrovesical space, we can see
free fluid layering out there.
This confirms that indeed the patient
has a positive exam, with blood
layering out behind the bladder.
And, again, we see the double wall sign,
urine outlining the inner wall of the
bladder, and blood, in this case,
outlining the outer wall of the bladder.
Here we're scanning a male trauma patient with
a long axis configuration and we see a large
amount of free fluid within the pelvis.
We note the bladder inferiorly,
and note all the free fluid layering
out both posterior to the bladder
in the retrovesical space and coming
anteriorly onto the dome of the
bladder as seen to the left here.
So a large amount of free fluid in this male trauma patient.
In conclusion, I'm glad I could
share with you the Soundbytes Module
covering the Suprapubic View of the Trauma Fast Exam.
This view is a very important
one to add onto the exam of your
trauma patient as we can potentially
detect a smaller amount of fluid here,
within the pelvis, than it takes to
make a positive right upper quadrant
or left upper quadrant view.
Remember that this is a two-step exam,
we'll be looking in both short
and long axis configurations to
verify fluid, and also remember
the differences between the female, where we're
looking into the pelvic Cul de Sac for fluid,
and the male, where we're looking into
the retrovesical space for fluid.
So I hope to see you back in the
future as Soundbytes continues.

Brightcove ID

5508114789001

https://youtube.com/watch?v=Pa3z9zWNfB8

How to: Female Pelvis: Transvaginal View

Read more about How to: Female Pelvis: Transvaginal View

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Obtaining a transvaginal view of the female pelvis

Clinical Specialties

EMED

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How To Videos

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- If you do a transabdominal examination
of the pelvis for early pregnancy
and you cannot find a definitive
gestational sack inside of the uterus,
the next step you need to do is
an intracavitary examination of the uterus
and cervix and the adnexal area
to determine where the pregnancy is,
whether it's intrauterine or extrauterine.
So what I'm gonna do right now
is walk through the steps on how
you would do that examination
and we're gonna use this Phantom by Blue Phantom,
that will actually demonstrate an ectopic pregnancy.
So the first stage of the prep
for the intracavitary transducer
is that we need to cover it with a sheath.
When you do this, we need to remove
any air gaps that are inside the sheath,
next to the transducer face.
So what we will do is put a little
bit of gel inside the cover,
position that over the tip of the transducer
and then just pull down the covering over the transducer
and pull this down right over the handle,
so you've got good coverage.
And then just make sure that you examine the tip here
and make sure you eliminate any
air bubbles that are covering the transducer face.
So once you've got the air bubbles eliminated,
then you can move on to the next step.
We're going to put a little bit
of gel on the outside of the latex cover now.
And again, your orientation for
this examination is very important.
So for the long ax or sagittal view,
we want the orientation marker up
and then when we go to the coronal view,
we're gonna turn that so it faces the patient's right.
After we've inserted the transducer in a long axis view,
the first thing that we're gonna
see is a long ax of the uterus.
In this Phantom representation of the uterus,
we see an endometrial stripe,
which is represented by the white line.
So if I was doing this as a real pelvic exam,
I would scan to the right of the patient,
all the way through to the right adnexa
and then back over, all the way back through the uterus,
over to the left adnexa.
And the reason I'm doing this
is because I don't see the pregnancy inside the uterus,
so I'm suspecting that it's extrauterine
or an ectopic pregnancy.
I do have some hints here though, using this Phantom.
In the posterior cul de sac region,
I'm seeing a black anechoic area,
which would represent free fluid or blood.
If I scan all the way over to the left adnexa, in this case,
the first structure I come across,
this echogenic area represents the ovary.
If I keep scanning to the left, in the pelvis,
I encounter this other area
and this represents, in this case, our ectopic pregnancy.
When I'm medial, just right beside the uterus,
I see the ovary and I scan out a little bit more
and this represents the ectopic pregnancy.
And this is what you should see,
a round, circular structure like this,
with a bright, echogenic brim.
And it is possible to sometimes
to see a fetal heartbeat inside
the ectopic pregnancy as well.
Now, I'm gonna change the orientation of the transducer,
so I'm in a coronal view.
To do that, I'm gonna turn the transducer counterclockwise.
The uterus will appear circular,
because I'm cutting a cross sectional view of it
and I tilt the handle of the transducer up,
to move inferiorly, down to the region of the cervix
and then bring the transducer handle
down to scan superiorly,
into the area of the fundus of the uterus.
Again, in this case, I can see that
there's no pregnancy inside the uterus itself.
If I scan over to the left of the Phantom,
again, we see the left ovary and then right beside it,
we see our representation of the ectopic pregnancy.
This bright, circular area.
Moving back towards the midline,
the anechoic area just posterior to the uterus
is represented as free fluid or blood, in this case.
So those are the views that you
would need to do a thorough assessment
of the pelvis for early pregnancy.

Brightcove ID

5750481386001

https://youtube.com/watch?v=0CqicUl0hw8

How To: Female Pelvis: Transabdominal View

Read more about How To: Female Pelvis: Transabdominal View

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Learn the basics of female transabdominal pelvic scanning.

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- [Voiceover] A curved, or phased array transducer,
with a pelvis exam type,
is used to perform the pelvis ultrasound exam.
A full bladder is used as an acoustic window
to view the pelvic organs.
The pelvis is evaluated in two plains.
Place the transducer in a long axis position
with the orientation marker to the patient's head,
at the level of the symphysis pubis.
Angle the transducer inferiorly into the pelvis.
The bladder appears in the near-field of the image,
as a hypoechoic triangular structure.
The uterus is gray in appearance
and located either directly posterior
or superior to the bladder.
The endometrial stripe will appear as
a bright echogenic line from the fundus to the cervix.
The uterus does not always lay directly in the midline
so it may be necessary to slightly rotate the transducer
to view the entire length of the uterus.
Sweep the transducer from side to side
to see the entire uterus.
The ovaries may be seen by sweeping the transducer
to the lateral aspects of the pelvis.
They are almond-shaped and slightly hypoechoic structures.
Follicles may appear as multiple
hypoechoic, cystic structures within the ovaries.
Some follicles may be quite prominent,
depending upon the luteal stage.
To obtain a transverse view of the uterus,
rotate the transducer 90 degrees,
so the orientation marker is to the patient's right.
The bladder appears more rectangular in shape in this view.
Sweep the transducer superiorly
from the level of the cervix to the fundus
to see the entire uterus.
The ovaries will be seen on either side of the uterus
and can vary in location,
from a superior to inferior position.

Brightcove ID

5750473717001

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

How To: FAST Exam: Female Pelvis

Read more about How To: FAST Exam: Female Pelvis

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Learn to examine the female pelvis for free fluid.

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- We're gonna do the FAST exam,
the pelvic view in a female now.
Again we have the phase array transducer,
here's our probe marker right here,
I'm gonna start off with a sagittal view.
And ideally, the (slurred) bladder is full.
So you go just above the symphysis pubis,
so we're scanning down here sagittaly,
and some of the anatomic landmarks
that we're looking at,
at the very top of the screen is the bladder,
which is an anechoic structure,
fluid filled, obviously with urine,
it's got nice walls around it.
Just below that is the uterus,
which is a pear-shaped organ.
You can see it well visualized
because the bladder is full.
And just below that
is a potential space, the Cul de Sac,
where we can look for, very carefully,
small amounts of free fluid.
When we scan this patient,
in this view, in the sagittal view,
from the patient's left to the patient's right.
And we're slowly slowly scanning to see
if there's any evidence of free fluid.
Once we finish the sagittal view,
we want to go ahead and do a transverse view.
What we're gonna do now
is point the transducer marker toward the patient's right.
So we're gonna rotate that transducer,
toward the patient's right.
Again, we see the bladder in the center of the screen.
We're now gonna scan from inferior,
just below the symphysis, to more superior,
and in between we're also gonna identify the uterus.
So we're going right to the very top of the bladder,
to about mid-bladder,
we can see the uterus here in the center.
A very small amount of free fluid here,
which can be physiological as well.
So we're scanning all the way inferiorly,
to more superiorly, we see the uterus,
we actually see part of the ovary there,
and then we're gonna go all the way more superiorly.

Brightcove ID

5508120185001

https://youtube.com/watch?v=HxQE2gYH3Sk

3D How To: Female Pelvis Exam

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3D animation demonstrating a Female Pelvis ultrasound exam.

Publication Date

Thu, 05/05/2016 - 12:00

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How To Videos

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Subtitles

Brightcove ID

5750473717001

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

3D How To: eFAST Pelvis

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

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- [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.

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

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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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