Emergency Ultrasound (EUS)教學(7)

重點式急診婦產科超音波之應用
新光醫院急診醫學科
陳國智醫師
中華民國醫用超音波學會指導醫師
 Scenario
25 y/o female
C/O: acute low abdominal pain
w/ cold sweating, VAS: 8/10
BP: 60/40 mmHg; HR: 130 bpm
Menstruation: 2nd day
Your impression ?
Next step ?
 2008 ACEP EUS guidelines
• Describe the relevant local anatomy of pelvic cavity
• Describe the role of focused US in first-trimester pregnancy pain and bleeding.
• Understand the role of US and quantitative β-hCG in a clinical algorithm for first-
trimester pregnancy pain and bleeding.
• Understand the differential diagnosis of early pregnancy including intrauterine
pregnancy, embryonic demise, molar pregnancy, ectopic pregnancy, and
indeterminate classes.
• Recognize the relevant focused findings and pitfalls when evaluating for early
intrauterine pregnancy and ectopic pregnancy.
– Early embryonic structures
– Location of embryonic structures in pelvis
– Findings of ectopic pregnancy
– Pseudogestational sac
– Adnexal masses
 Role of EUS for OB/GYN
• Identify an IUP
• Establish fetal viability
• Hemodynamic instability in a female patient
• Trauma and pregnancy
• Localization of IUD/foreign body
• Identify sources of pelvic pain and bleeding in
pregnant & non-pregnant patients
 Trans-abdominal US
1st choice for emergency physician
• Use a lower frequency transducer: 3.5 –5 mHz
• Better penetration, larger field of view
• It should be the initial imaging window to assess
for
– Advanced IUP
– Fibroids/masses
– Pelvic fluid
• The bladder should be full to provide an acoustic
window
 Transvaginal US
• Use 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
Normal Pelvic Anatomy
Normal Pelvic Scan
 Endovaginal probes
End-fire type Angulated type
Pelvic Scan (TVS)
TAS versus TVS
Trans-Abdominal Scan
Pelvic Sagittal View
Pelvic Sagittal View
Pelvic Transverse View
TVS: Sagittal View
Different phases of Uterus
 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)
Measurements
• 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 post-

menopausal patient with vaginal bleeding should
raise suspicions for endometrial carcinoma
TVS: Coronal View
Ovary (TVS)
 Ovaries
• After ovulation a corpus luteal cyst may be
present
– Observed in approximately 50% of ovulating
females
– Should not be seen beyond 72 hours into the
next cycle
• Small amount of fluid in the recto-uterine 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
 US Findings in IUP
• Gestational sac
• Double decidual sac sign (DDSS)
• Yolk sac
• Embryo
• Cardiac activity
Intradecidual Sign
 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)
Double Decidual Sign
 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)
Yolk Sac
Embryo & Yolk Sac
Intrauterine embryo & yolk sac
 Intrauterine fetus
and yolk sac & amnion
Dichorionic Twins
 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
 Ectopic Pregnancy
• 2% of all pregnancies, 7-13% of those who
present with pain or bleeding
• Incidence quadrupled in last 20 years
• 50% were missed before widespread use
of ultrasound
• Still the #1 cause of maternal death in
1st trimester
 Rule-out Ectopic Pregnancy
(saves time and money)
• Find an IUP
• Chance of both IUP and EP is 1/8000
• As high as 1/100 if pt takes fertility agents
 β-hCG Levels
• Correlate roughly with gestational age
• Older algorithms relied on β-hCG
• One level means almost nothing
• Serial levels are helpful
• 40% ectopics have a β-hCG level <1000
 β-hCG Levels
• Correlate roughly with gestational age
• Older algorithms relied on β-hCG
• One level means almost nothing
• Serial levels are helpful
• 40% ectopics have a β-hCG level <1000
 Correlation of Gestational Age, β‐hCG, and Pelvic Ultrasound Findings.
Transabdominal US Findings
Transvaginal US 
Gestational Age β‐hCG1,2 mIU/mL
Findings

N/A
4‐5 weeks < 1000  Intradecidual sac

N/A
5 weeks 1000‐2000  Gestational sac (± DDS)

Gestational sac
(+ DDS)
Yolk sac 
5‐6 weeks >2000 
(± embryo)

Yolk sac
(+ embryo)
Embryo with cardiac 
6 weeks 10,000‐20,000 
activity

Embryo with
cardiac activity
7 weeks >20,000  Embryonic torso/head 

1Significant individual variation in β‐hCG levels at a given gestational age may occur.
2 In multiple pregnancy (twins, triplets) levels will be much higher at a given gestational age.
 Discriminatory Zone
• Def:
– The level of β-hCG at which findings of an
IUP are expected on sonography
• Titinalli
– TVS 1500 mIU/mL; TAS 6000 mIU/mL
• Rosen
– TVS 3000 mIU/mL; TAS 6500 mIU/mL
 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 1/8,000 in non-induced pregancy
ß-hCG >discriminatory zone and empty
uterus is EP until proven otherwise
 Sonographic Spectrum of EP
• Ruptured ectopic pregnancy
• Definite ectopic pregnancy
• Extrauterine empty gestational sac
• Adenexal mass
• Pseudogestational sac

• Empty uterus
Ectopic Pregnancy
Ectopic Pregnancy
Empty uterus & free fluid in CDS
Empty Uterus & Complex fluid in CDS
 clot
Clot/fluid
 Empty Uterus &
Free fluid in CDS & hepatorenal space
Tubal Ring
Complex adnexal mass
Adenexal Mass
Pseudogestational sac

Ectopic
Ring of Fire: ectopic mass
 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
Embryonic demise
Empty gestational sac
Fetal demise
Embryonic demise
Embryonic demise
Inevitable abortion
Embryonic demise with inevitable
abortion
Subchorionic hemorrhage
 Empty uterus after
a completed spontaneous abortion
Retained products of conception
Molar pregnancy
Goad-directed US in
2nd & 3rd trimesters
Main Goals in Late Pregnancy
• Determination of gestational age
• Fetal cardiac activity, fetal movement
• Head position
• Placenta - placenta previa
GA estimation
Estimation of GA
 Pregnancy Dating
Crown Rump Length (CRL)
Biparietal Diameter
Femur Length
Fetal Heart Rate Determination
Location of the placenta
Placenta Previa
Placental abruption
Types of breech presentation
Fetal position
Fetal position
Fetal position
Amniotic fluid index measurement
Location of appendix
 Main Goals in Non-pregnant
Patients
• Determining the etiology of abdominal pain -
pelvic organs or other etiology
• Hemorrhagic ovarian cyst
• Ovarian torsion
• Ovarian hyperstimulation syndrome (OHSS)
• Tubo-ovarian abscess
• Fibroid (Leiomyoma)
Follicular cyst
Hemorrhagic ovarian cyst
Corpus luteum cyst
Ruptured corpus luteum cyst
Large complex pelvic mass
Ovarian torsion
Ovarian torsion
PID
PID
Tubo-Ovarian Abscess
Intrauterine Device
Vaginal hematoma
Uterine Fibroids
Uterine Fibroids
Nabothian Cysts
39F_33wk + ABD pain
 ACEP recommendation
• Primary indications
– To evaluate for the presence of IUP

• Secondary indications
– Ovarian cysts
– Fibroid
– Tubo-ovarian abscess
– R/O ovarian torsion by ruling out cyst or mass
– Indentifying suspected ectopic pregnancy
 Pitfalls
• Not performing pelvic sonography because of a recent LMP or a low β-hCG
• Attributing an empty uterus to a very early intrauterine pregnancy or a
completed spontaneous abortion
• Mistaking a pseudogestational sac for a gestational sac
• Misidentifying an early intrauterine pregnancy
• Overestimating the ability to identify subtle signs of ectopic pregnancy
• Performing a transvaginal ultrasound without a transabdominal scan
• Identifying a normal appearing pregnancy but not recognizing its location in
relation to the uterus
• Mistaking an interstitial pregnancy for an intrauterine pregnancy
• Failure to identify heterotopic pregnancy