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Pelvic ultrasound
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Case
35 yo G3P1, LMP “4 wks ago”, lower abdominal pain and “dizziness”
IUD in place
R > L, sharp, subjective fever, nausea, dysuria, brown vaginal discharge
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Differential diagnosisGastrointestinal
Appendicitis
IBD
IBS
Constipation
Urinary tract
Cystitis
Pyelonephritis
Nephrolithiasis
Reproductive
Ectopic pregnacy
IUP
PID
TOA
Ovarian cyst
Hemorrhagic cyst
Ovarian torsion
Fibroids
Endometriosis
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ED Workup
U preg neg
U dip + LE, + Prot, + Blood
Physical exam
Point-of-care ultrasound of the pelvis
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Indications
Acute lower abdominal or pelvic pain
Acute pelvic inflammatory disease
Evaluation of pelvic or adnexal masses
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Yes/No questions
Is there a life or organ-threatening gynecologic emergency?
Ovarian torsion
Tubo - ovarian abscess
Are there other gynecologic abnormalities?
Ovarian cysts
Fibroids
Other
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TechniqueTransabdominal
Low frequency probe
Bladder full
Overall view of pelvis
Endovaginal
High frequency
Bladder empty
Better resolution, finer details
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Transabdominal Sagittal Transabdominal Sagittal Anterio
r
Posterior
Feet
Head
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Transabdominal TransverseTransabdominal Transverse
R L
Anterior
Posterior
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Endovaginal - SagittalEndovaginal - Sagittal
Head
Feet
Anterior Posterior
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Endovaginal - Endovaginal - TransverseTransverse
R L
Feet
Head
.
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QuickTime™ and a decompressor
are needed to see this picture.
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OvariesOvaries
Right Ovary Left Ovary
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Ovarian cystsMost common ovarian masses in non-pregnant
Thin-walled, unilocular anechoic spheres
Hemorrhagic cysts have heterogenic internal echoes
Physiologic <2.5 cm
Follicular 2.5 - 14 cm
Corpus luteum cysts up to 13 cm
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QuickTime™ and a decompressor
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Fibroids
Most common gynecologic tumor
May present with dysuria, dysmenorrhea, constipation or low back pain
Discrete masses within uterine wall
May be hyper or hypoechoic
Shadowing
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Pelvic inflammatory disease
Inflammation of tubal mucosa
Lumen fills with pus then spills to cul de sac
Pyosalpinx with blockage of fallopian tube
Hydrosalpinx with thinning of walls and distention
Erosion through the distended wall and purulent material spills into ovary
Tubo - ovarian abscess when pus becomes walled off
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•Role of Bedside TransvaginalUltrasonography in the diagnosis of Tubo - ovarian Abscess in the ED J Emerg Med 2008 Jan 31 (Epub)
•Retrospective review of 20 patients with TOA
•H & P factors unreliable:
•PID hx 35%, 45% with CMT or Adnx tender, 5% fever
•Ultrasound abnormalities in most
•70% complex adnx mass, 25% echogenic fluid
•15% pyosalpinx
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Pyosalpinx
QuickTime™ and aPhoto - JPEG decompressor
are needed to see this picture.
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Hydrosalpinx
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Tubo - ovarian abscess
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Other masses
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Endometrial polyps
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Ovarian masses
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IUDs
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Best practices - EBM•ED endovaginal ultrasound in nonpregnant women with right lower quadrant pain.
• Tayal, et al. Am J Emerg Med 2008
Non-pregnant females presenting with RLQ
Pelvic ultrasound performed looking for:
• enlarged ovary or uterus
• fluid in cul de sac
• tubal dilatation
• large cystic mass
• multitissue density
• la
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Failing to provide adequate analgesia
Confusing uterine vasculature with follicles within the ovary
Confusing large ovarian follicles with fallopian tubes
Confusing ovarian cysts with hydrosalpinx
Pitfalls