1. Dr. Omneya Nagy Elmakhzangy
Special Fetal Care Unit
Ain Shams University

2.  Pelvic pain and vaginal bleeding are two of the most
common presenting complaints of women examined in the
emergency department.
 In addition to clinical history, physical examination, and
laboratory data, sonography is essential in evaluating
pelvic pain and vaginal bleeding in women of childbearing
age because many causes of these two presentations have
suggestive or definitive sonographic findings

4. Pregnancy of unknown location
(PUL)

5.  The term PUL is used whenever there is no sign of
either intra or extrauterine pregnancy or retained
products of conception on transvaginal ultrasound.
 Up to 31% of women attending early pregnancy
assessment centers have a PUL though the experience
of the sonographer can reduce this to 10%.

7. Early IUP??
Ectopic pregnancy??
PUL??
How can Ultrasound answer the Question?

8. Discriminatory zone
 It refers to a defined level of hCG above which the
gestational sac of an intrauterine pregnancy should be
visible on ultrasound.
 The concept of a discriminatory zone has limitations.
Levels of hCG of 1000 iu/l, 1500 iu/l and 2000 iu/l have
been used as discriminatory levels.
 These levels are dependent upon the quality of the
ultrasound equipment, the experience of the sonographer,
prior knowledge of the woman’s risks.
 For specialised units performing high resolution vaginal
ultrasound with prior knowledge of the woman’s symptoms
and serum hCG, a discriminatory zone of 1000 iu/l can be
used. In other units offering a diagnostic transvaginal scan
without prior clinical or biochemical knowledge a
discriminatory zone of 1500 iu/l or 2000 iu/l is acceptable.
 RCOG Guideline No. 21 ,Evidence level III (2004)

9. Different Scanning Modalities

10. Gestational sac TAUS

11. Gestational sac TVUS

12. 3 D Scanning

13. Endometrial Findings Suggestive of
intrauterine Pregnancy

14. Double decidual sac sign (DDSS)
 Is a useful feature on early pregnancy ultrasound in
distinguishing between an early intrauterine
pregnancy (IUP) and a pseudogestational sac. It
consists of the decidua parietalis (that lining the
uterine cavity) and decidua capsularis (lining the
gestational sac).

16. Endometrial findings diagnostic of
intrauterine pregnancy.

17. Adenxae and ovaries

18. Corpus luteum

19. Tubal Ectopic pregnancy

20. Adenxal mass

21. Adenxal ectopic pregnancy with
positive cardiac pulsation

22. Interstitial pregnancy
 Cornual, or interstitial, gestations account for as many as
3% of all ectopic pregnancies and carry a high mortality
rate as a result of delayed rupture with extensive
hemorrhage . Original sonographic descriptions include
an eccentric intrauterine location and thinning of the
surrounding myometrial mantle to less than 5 mm.
 Care must be exercised to avoid misinterpreting a
normal intrauterine pregnancy in an anomalous
uterus—such as a septate or bicornuate uterus—as an
interstitial pregnancy

24. Ovarian Ectopic

25. Cervical Ectopic
 Cervical pregnancies have a worse prognosis than tubal
pregnancies because of the potential for uncontrollable
hemorrhage. Once a gestational sac is identified in the
cervix, a crucial part of diagnosis is to differentiate a
cervical pregnancy from an abortion in progress. Features
characteristic of a cervical pregnancy include a round or
oval noncrenated sac, the presence of fetal cardiac activity,
a closed internal os, and constant sac shape and location
on close follow-up sonogram

26. Cervical Ectopic

27. Heterotropic Pregnancy

28. Abdominal Ectopic

29.  Peritoneal cavity free pelvic fluid or haemoperitoneum in
the pouch of Douglas
 The presence of free intraperitoneal fluid in the context
of a positive beta HCG and empty uterus is
 ~70% specific for an ectopic pregnancy .
 ~63% sensitive for an ectopic pregnancy.
 The differential diagnosis of abdominal pain in a pregnant
patient is broad. An ectopic pregnancy must be excluded
with ultrasound. Other common diagnoses in this setting
include:
1- Ruptured corpus luteum.
2-Appendicitis (negative beta hCG).

30. Peritoneal Free Fluid

31. Case : Ruptured corpus Letuem Cyst with
massive heamopertonium

33. Ring of fire Sign
 The ring of fire sign also known as ring of
vascularity signifies a hypervascular lesion with
peripheral vascularity on colour or pulsed Doppler
examination of pelvis due to low impedance high
diastolic flow .
 This sign can be seen in highly vascular pelvic lesions
like:
1-corpus luteum cyst (more commonly)
2-ectopic pregnancy

36. Cervical Incompetence
 Cervical incompetence is a common cause of
pregnancy failure in the second trimester, manifesting
as painless dilatation of the cervix that leads to
preterm labor. Cervical incompetence may present
with premature rupture of membranes, resulting in
oligohydramnios.

37.  The sonographic findings include bulging of the fetal
membranes into a widened internal os and shortening
of the cervical canal.

38. Failed early Pregnancy
 Findings diagnostic of pregnancy failure
 crown-rump length (CRL) of ≥7 mm and no heart beat
 mean sac diameter (MSD) of ≥25 mm and no embryo
 absence of embryo with heartbeat ≥2 weeks after a
scan that showed a gestational sac without a yolk sac
 absence of embryo with heartbeat ≥11 days after a scan
that showed a gestational sac with a yolk sac

40.  Findings suspicious but not diagnostic of pregnancy
failure
 crown-rump length (CRL) of <7 mm and no heartbeat
 mean sac diameter (MSD) of 16-24 mm and no embryo
 absence of embryo with heartbeat 7-13 days after a scan that
showed a gestational sac without a yolk sac
 absence of embryo with heartbeat 7-10 days after a scan
that showed a gestational sac with a yolk sac
 absence of embryo ≥6 week after last menstrual period
 empty amnion (amnion seen adjacent to yolk sac, with no
visible embryo)
 enlarged yolk sac (>7 mm)
 small gestational sac in relation to the size of the embryo
(<5 mm difference between mean sac diameter and crown-
rump length)

41. Retained Products of Conception
 Retained products of conception after spontaneous or
elective abortion or full-term pregnancy may cause
secondary postpartum hemorrhage or may serve as a nidus
for uterine infection
 Predisposing factors include the presence of a
succenturiate lobe or placenta accreta, increta, or percreta,
preventing complete placental delivery. Sonographic
findings include endometrial expansion of heterogeneous
echogenic material and focal areas of hyperechogenicity
that may represent retained placental calcifications .
Retained trophoblastic tissue exhibits low-resistance
arterial flow, which is uncommonly seen with endometritis

43. Retroplacental Hematoma and
Abruptio Placentae
 Separation of the placenta from the myometrium where it
is implanted causes bleeding. When only the margin of the
placenta is separated, it is called a marginal subchorionic
hematoma .
 When the bleeding is behind the placenta, it is termed a
retroplacental bleed. The term “abruption” (abruptio
placentae) is typically reserved for premature placental
separation occurring after 20 weeks.
 Subamniotic bleeding is a collection anterior to the
placenta and limited by the umbilical cord.

44. Subchorionic hematoma .
Subchorionic hematomas manifest as crescentic collections lifting the
chorionic membrane Depending on the time elapsed since the bleeding, the
collection will have variable echotexture and size .Correlation between the
size of the subchorionic hematoma and the rate of pregnancy loss is
imperfect. In general, small- and moderate-sized subchorionic hematomas
have a better outcome than large ones . The percentage of placental
detachment is the prognostic factor most strongly associated with fetal
mortality: the frequency of fetal demise is 50% for retroplacental hematoma
versus 7% for marginal subchorionic hematoma

45. Subamniotic hematoma
Subamniotic hematomas result from the rupture
of chorionic vessels (fetal vessels) close to the cord insertion.
These lesions are rarely reported in utero; they are usually
discovered postnatally and thought to result from excessive
traction on the umbilical cord at birth. It has been postulated
that these cysts may form from subchorionic fibrin deposition

46. Retroplacental hematoma (abruptio placentae)
Abruptio placentae is one of the most serious complications of
pregnancy, accounting for up to 25% of perinatal deaths , Diagnosis
requires a high index of suspicion because the signs and symptoms are
variable, including a painful tense uterus, vaginal bleeding, premature
labor, fetal distress, and coagulopathy; most episodes remain
asymptomatic. Sonographic findings are negative in most cases, either
because of the passage of blood without accumulation behind the
placenta or because of blood being isoechoic with the placenta. The only
evidence of abruption may be the identification of an abnormally thick
placenta . The sensitivity of sonography is low, 2–20%.

47. Placenta Previa
 Routine ultrasound scanning at 20 weeks of gestation should include placental
localisation.
 Transvaginal scans improve the accuracy of placental localisation and are safe, so
the suspected diagnosis of placenta praevia at 20 weeks of gestation by abdominal
scan should be confirmed by transvaginal scan.
 In the second trimester transvaginal sonography (TVS) will reclassify 26–60% of
cases where the abdominal scan diagnosed a low-lying placenta, meaning fewer
women will need follow-up. In the third trimester, TVS changed the transabdominal
scan diagnosis of placenta praevia in 12.5% of 32 women. Leerentveld et al
demonstrated high levels of accuracy of TVS in predicting placenta praevia in 100
women suspected of having a low-lying placenta in the second and third trimester
(sensitivity 87.5%, specificity 98.8%, positive predictive value 93.3%, negative
predictive value 97.6% .
RCOG Green-top Guideline No. 27

48.  All women require follow-up imaging if the placenta covers or overlaps the
cervical os at 20 weeks of gestation. Women with a previous caesarean
section require a higher index of suspicion as there are two problems to
exclude: placenta praevia and placenta accreta. If the placenta lies anteriorly
and reaches the cervical os at 20 weeks, a follow-up scan can help identify
if it is implanted into the caesarean section scar.
 Placental ‘apparent’ migration, owing to the development of the lower
uterine segment, occurs during the second and third trimesters, but is less
likely to occur if the placenta is posterior or if there has been a previous
caesarean section.
 In cases of asymptomatic women with suspected minor praevia, follow-up
imaging can be left until 36 weeks of gestation.
 In cases with asymptomatic suspected major placenta praevia or a question
of placenta accrete, imaging should be performed at around 32 weeks of
gestation to clarify the diagnosis and allow planning for third-trimester
management, further imaging and delivery
RCOG Green-top Guideline No. 27

50. Morbidly adherent placenta
Sensitivity
(%)
Specificity
(%)
Positive
predictive
value (%)
Risk
Grey scale 95 76 82 93
Colour
Doppler
92 68 76 89
Three-
dimensional
power
Doppler
100 85 88 100
RCOG Green-top Guideline No. 27

51. Abnormal intraplacental lacunae
 Visualization of lacunae had the highest sensitivity (79%) in
the 15–20-week range and a sensitivity of 93% in the 15–40-
week gestational age time frame (ISUOG 2005).

52. Myometrial thickness
 Measurement of the thickness of the lower uterine segment in
women who had had a previous Cesarean section and had a
low-lying anterior placenta or placenta previa by measuring
between the bladder wall and the retroplacental vessels, as seen
by color Doppler.
 All patients later proven to have placenta accreta had
myometrium of less than 1 mm, which was as predictive of
accreta as lacunae

53. Translucency zone

54. Color Doppler
Color Doppler image of a tornado-shaped sinus

55. Signs Suggestive of Placental invasion by 3D
Power Doppler
 Numerous coherent vessels involving the whole uterine serosa–
bladder junction (basal view)
 Hypervascularity (lateral view)
 Inseparable cotyledonal and intervillous circulations, chaotic
branching, detour vessels (lateral view).

56. Uterine Dehiscence and Rupture
 Although uterine rupture may occur in previously normal
uteri, old cesarean scars most commonly cause uterine
dehiscence.
 Uterine rupture may be limited to dehiscence of the ends of
the cesarean scar with an intact overlying serosal layer of
the uterine wall. This type of dehiscence does not involve
extrusion of fetal parts into the peritoneal cavity, and
therefore results in minimal vaginal bleeding or
intraperitoneal hemorrhage.
 Conversely, full-thickness uterine rupture, with direct
communication of the uterine and peritoneal cavities,
results in massive hemoperitoneum and carries high fetal
and maternal morbidity and mortality rates

57. Sagittal transabdominal
sonogram shows enlargement
and heterogenicity of
postpartum uterus.

58.  An unusual cause of abdominal pain and shock in
pregnancy is Spontaneous uterine rupture caused by
placenta percreta in first and second trimester.

59. Red or carneous fibroid
degeneration
 Is one of a five main types degeneration that can
involve a uterine leiomyoma. While it is an uncommon
type degeneration it is thought to be most common
form of degeneration of a leiomeyoma during
pregnancy.

61. Fetal Emergency

62.  Is an obstetric complication in which fetal blood
vessels cross or run in close proximity to the external
orifice of the uterus. These vessels are at risk of rupture
when the supporting membranes rupture, as they are
unsupported by the umbilical cord or placental tissue.
 If these fetal vessels rupture the bleeding is from the
fetoplacental circulation, and fetal exsanguination will
rapidly occur, leading to fetal death.
Vasa Previa

63.  On ultrasound and gross examination, the normal
umbilical cord sheath is contiguous with the chorionic
plate. With a velamentous insertion, the cord can end
several centimeters from the placenta, at which point
the umbilical vessels separate from each other and
cross between the amnion and chorion before
connecting to the subchorionic vessels of the placenta
. This typically occurs at the margin of the placenta
(within 1 cm of the placental edge), but can also occur
at the apex of the gestational sac. In monochorionic
twins, the velamentous vessels often occur in the
dividing membranes.

66. Diagnosis of Fetal Distress by
Ultrasound
 In the preterm SGA fetus with umbilical artery AREDV
detected prior to 32 weeks of gestation, delivery is
recommended when DV Doppler becomes abnormal or UV
pulsations appear, provided the fetus is considered viable
and after completion of steroids. Even when venous
Doppler is normal, delivery is recommended by 32 weeks of
gestation and should be considered between 30–32 weeks
of gestation.
 RCOG Green-top Guideline No. 31 January 2014

68.  If MCA Doppler is abnormal but U.A is reserved ,
delivery should be recommended no later than 37
weeks of gestation.
 RCOG Green-top Guideline No. 31 January 2014

69.  When umbilical artery Doppler flow indices are
abnormal (resistance index > +2 SDs above mean for
gestational age) and delivery is not indicated repeat
surveillance twice weekly in fetuses with end–diastolic
velocities present and daily in fetuses with
absent/reversed end–diastolic frequencies.
 RCOG Green-top Guideline No. 31 January 2014

71. Nuchal Cord

72.  Nuchal cord is very common, present in 20% to 30% of
birth.
 The presence of two or more coils is estimated to
affect 2.5-8.3 % of all pregnancies.
 Single Nuchal cord usually doesn’t compromise the
fetal well being and so management should not be
altered
 Multiple Nuchal cords , esp. 4 or more should be
managed with special care because of high risk of cord
compression.