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Pelvic ultrasound

Pelvic ultrasound. 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. Gastrointestinal Appendicitis IBD IBS Constipation Urinary tract Cystitis Pyelonephritis Nephrolithiasis.

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Pelvic ultrasound

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  1. Pelvic ultrasound

  2. 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

  3. Gastrointestinal Appendicitis IBD IBS Constipation Urinary tract Cystitis Pyelonephritis Nephrolithiasis Reproductive Ectopic pregnacy IUP PID TOA Ovarian cyst Hemorrhagic cyst Ovarian torsion Fibroids Endometriosis Differential diagnosis

  4. ED Workup • U preg neg • U dip + LE, + Prot, + Blood • Physical exam • Point-of-care ultrasound of the pelvis

  5. Indications • Acute lower abdominal or pelvic pain • Acute pelvic inflammatory disease • Evaluation of pelvic or adnexal masses

  6. 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

  7. Technique • Transabdominal • Low frequency probe • Bladder full • Overall view of pelvis • Endovaginal • High frequency • Bladder empty • Better resolution, finer details

  8. Posterior Head Anterior Feet Transabdominal Sagittal

  9. Posterior R Anterior L Transabdominal Transverse

  10. Head Anterior Posterior Feet Endovaginal - Sagittal

  11. R L Head Feet Endovaginal - Transverse .

  12. Ovaries Right Ovary Left Ovary

  13. Ovarian cysts • Most 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

  14. 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

  15. 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

  16. 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

  17. Pyosalpinx

  18. Hydrosalpinx

  19. Tubo - ovarian abscess

  20. Other masses

  21. Endometrial polyps

  22. Ovarian masses

  23. IUDs

  24. 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

  25. Pitfalls • 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

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