Sonographic Imaging of the Female Patient with Pelvic Pain/ Bleeding

Sonographic Imaging of the
Female Patient with Pelvic
Pain/ Bleeding
Sarah A. Stahmer MD
Cooper Hospital/University
Medical Center
Case Presentation
24 yo female presents with missed period,
cramping, midline abdominal pain and
 VS: BP 120/80
HR 110
 Pelvic:
– Cervical os is closed with minimal bleeding
– No CMT, adenexa symmetric
Urine hCG is +
Case presentation
A bedside ultrasound
is performed
The US reveals an IUP
The patient is
discharged to home
with threatened
abortion precautions
LOS = 30 minutes
Applies to 60% of pts
Role of Bedside Sonography
Identify an IUP
Establish fetal viability
Secondary Indications
Hemodynamic instability in a female pt
Trauma and pregnancy
Localization of IUD/foreign body
Identify sources of pelvic pain in nonpregnant patients
Imaging: Transabdominal
Uses a lower frequency transducer: 3.5 –5 mHz
 Better penetration, larger field of view
 It should be the initial imaging window to assess
– Advanced IUP
– Fibroids/masses
– Pelvic fluid
The bladder should be full to provide an acoustic
Uses a higher frequency transducer: 6.0-7.5mHz
 Provides optimal imaging of:
– Endometrium
– Myometrium
– Cul-de-sac
– Ovaries
A full bladder is not necessary for this approach
 Is usually better tolerated by patients
Scanning Protocol: Transabdominal
Image the patient before obtaining a urine
Can fill the bladder via foley and instill 300
cc NS but…
If the bladder is empty, go directly to TV
imaging after the pelvic exam
 3.5 to 5.0 MHz
 Multi-frequency probe
 Good for most
An oval organ located
superior to the full bladder
 The maximum size of the
non-gravid uterus is 5-7
cm x 4-5 cm
The endometrial stripe is
the opposed surfaces of
the endometrial cavity
Transabdominal / Transverse view
Located posterior to the
uterus and upper vagina
A small amount of fluid
may be seen in mid cycle
A small amount of fluid in
the posterior cul-de-sac
may be the only
sonographic finding in EP
Probe Selection
Endovaginal Probe
 5 to 8 mHz variable
frequency probe
 Up to 180 degree angle
of view
Endovaginal Examination
Best performed immediately following the pelvic
 An empty bladder is required for an optimal
endovaginal (EV) exam
 A full bladder:
– Displaces the anatomy beyond the focal length of the
– Will create artifacts that will compromise imaging
Before Performing a TV Exam:
Explain that the EV exam is better for
seeing ovaries and early pregnancy
 Show the patient the probe
 Allow her the option of inserting it herself
 Inform her that it is usually more
comfortable than the TA exam which
requires a full bladder
The transducer probe should be covered with a
coupling gel followed by a protective probe
Non-medicated/ non-lubricated condoms are
recommended as a probe cover
Patients with latex allergies will require an
alternative barrier
Air bubbles within the sheath may increase
artifacts and compromise imaging
Longitudinal view
Coronal view
The Uterus
Early in the menstrual cycle
– endometrium measures 4-8mm
Secretory phase
– endometrium measures 7-14 mm
Post-menopausal patient
– endometrial stripe usually less than 9 mm
Endometrial Stripe (ES)
In the post-partum patient, a thickened ES is
suggestive of retained products of conception
In the pregnant patient, an ES measurement of < 8
mm in the absence of an IUP is suggestive of EP
Thickening of the endometrial stripe in the postmenopausal patient with vaginal bleeding should
raise suspicions for endometrial carcinoma
Lie posterior/lateral to the
Anterior to the internal
iliac vessels and medial to
the external iliac vessels
Identified by a ring of
follicles in the periphery
After ovulation a corpus luteal cyst may be
– Observed in approximately 50% of ovulating
– Should not be seen beyond 72 hours into the
next cycle
 Small amount of fluid in the rectouterine pouch
may be seen during ovulation
Ovarian Cysts
Follicular cyst (2.5 –10 cm)
– Thin, round, unilocular
Functional corpus luteum cyst
– Normal up to 16 weeks GA
– Appears as a unilateral, unilocular 5-11 cm cyst
– Appearance can be highly variable
– Hemorrhage inside the cyst not uncommon
Assessment of the Pregnant Patient
Identify gestational sac
Demonstrate a myometrial mantle in the
transverse view
Identify yolk sac and/or fetal pole
Note if there is fluid in the cul-de-sac
Gestational Sac
Anechoic area within the uterus surrounded
by two bright echogenic rings
– Decidua vera (the outer ring)
– Decidua capsularis (the inner ring)
This is referred to as the double decidual
sac sign (DDSS)
Yolk Sac
First embryonic structure that can be
detected sonographically
 Visualized approximately 5-6 weeks after
the last menstrual period
 Bright, ring like structure within the GS
 Should be readily seen when the GS sac is
greater than 10 mm (using EVS)
Fetal Pole
Can be first seen on EV when the fetus is
approximately 2 mm in size
 A thickened area adjacent to the yolk sac
 The CRL is the most accurate sonographic
measurement that can be obtained during
A Fetal Heart Beat
An important prognostic indicator
The rate of spontaneous abortion is
extremely low (2- 4%) after the detection of
normal embryonic cardiac activity
The normal fetal heart rate in early
pregnancy is 112-136
Definite IUP
A gestational sac
with a sonolucent
center (greater than
5 mm diameter)
 Surrounded by a
thick, concentric,
echogenic ring
 GS contains a fetal
pole or yolk sac, or
Abnormal IUP
A GS larger than 10-13 mm diameter(TV)
or 20mm (TA) without a yolk sac
A GS larger than 18 mm (TV) or 25mm
(TA) without a fetal pole
A definite fetal pole without cardiac activity
after 7 wks GA
Empty gestational sac
Fetal demise
Sonographic Spectrum of EP
Ruptured ectopic pregnancy
Definite ectopic pregnancy
Extrauterine empty gestational sac
Adenexal mass
Pseudogestational sac
Empty uterus
Definite Ectopic Pregnancy
A thick, brightly echogenic, ring-like
structure located outside the uterus with a
gestational sac containing an obvious fetal
pole, yolk sac or both.
Ruptured Ectopic Pregnancy
Free fluid or blood in the cul-de-sac or the
intra-peritoneal gutters (hemoperitoneum)
This finding and a positive pregnancy test
essentially makes the diagnosis!
Extrauterine Gestational Sac
Extra-uterine mass
containing a thick,
brightly echogenic
ring surrounding an
anechoic area
 Brightly echogenic
appearance may be
 Tubal ring
Adenexal Mass
Pseudogestational Sac
Stimulation of the endometrium
 Decidual breakdown results in a central
anechoic area
 Can be confused with “early IUP”
 Does not have double decidual sac sign
 Correlation with ß hCG helpful
Pseudogestational sac
Interstitial Ectopic Pregnancy
Implantation near the insertion of the
fallopian tubes
 Highly vascular area
 Suspect when GS is not centrally located
 Demonstration of endometrial mantle is
critical to the diagnosis
Empty Uterus
Correlation with ßhCG
ßhCG >discriminatory
zone and empty uterus
is EP until proven
Discriminatory HCG Zone
5 weeks since last normal
– ß hCG value = 1800 mIU
TAS landmarks
– 5 to 8-mm GS
TVS landmarks
– 5 to 8-mm GS
– With or w/o yolk sac
Discriminatory HCG Zone
6 weeks since last
normal LMP
– ß hCG = 7200
TAS landmarks
– Yolk sac
 TVS landmarks
– Yolk sac and
– Possibly FHM
Discriminatory HCG Zone
7 weeks since last
normal LMP
– ß hCG = 21,000
TAS landmarks
– 5 to 10-mm embryo
with FHM
 TVS landmarks
– 5 to 10 mm embryo
with FHM
Rule - in IUP Protocol
Clinically stable females with:
(1) Lower abdominal pain
(2) Vaginal bleeding
(3) Orthostasis
(4) Or risk factors for EP
Positive urine preg
Rule - in IUP Protocol
Definite IUP
Definite EP
Can DC to home
with f/u
OB consultation
Rule - in IUP Protocol
No IUP but…
+ Adenexal tenderness or CMT
Free fluid in the cul de sac
And/or hCG > discriminatory zone
Rule - in IUP Protocol
Benign exam
ßhCG > discriminatory zone
DC to home
F/u exam and
ßhCG w/in 48 hrs
Rule-In IUP Protocol
Sixty percent of patients will have IUP
– “Rules out” ectopic pregnancy by “ruling
in” IUP
 What about heterotopic pregnancy?
– Increased in patients undergoing
ovulation induction
consult OB
– Risk is 1/30,000 in non-induced pregancy
Diagnosing intrauterine fluid collections as
“early” IUP
 Low hCG does not mean “low risk” for EP
 Failure to determine the exact location of a
gestational sac
 Cul-de-sac fluid may be the only sonographic
finding of extrauterine pregnancy

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