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Pelvic ultrasound - PowerPoint PPT Presentation


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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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Presentation Transcript
slide2
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
differential diagnosis
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
ed workup
ED Workup
  • U preg neg
  • U dip + LE, + Prot, + Blood
  • Physical exam
  • Point-of-care ultrasound of the pelvis
indications
Indications
  • Acute lower abdominal or pelvic pain
  • Acute pelvic inflammatory disease
  • Evaluation of pelvic or adnexal masses
yes no questions
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
technique
Technique
  • Transabdominal
    • Low frequency probe
    • Bladder full
    • Overall view of pelvis
  • Endovaginal
    • High frequency
    • Bladder empty
    • Better resolution, finer details
endovaginal sagittal

Head

Anterior

Posterior

Feet

Endovaginal - Sagittal
ovaries
Ovaries

Right Ovary

Left Ovary

ovarian cysts
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
fibroids
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
pelvic inflammatory disease
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
slide25
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
best practices ebm
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
pitfalls
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