Ultrasound in Obstetric Emergencies by Dr Wannanee Meennuch
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Ultrasound of abortion, ectopic pregnancy, placenta previa, placenta abruption, etc
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Ultrasound in Obstetric Emergencies by Dr Wannanee Meennuch
- 1. Emergency OB US Dr. Wananee Meennuch 6-July-2016
- 2. Objectives • Refresh your (& my) knowledge • Experience share • Inspiration in one of your learning paths
- 3. Outlines • Normal anatomy and US findings • Common 1st trimester emergency conditions: Vaginal bleeding & pelvic pain • Common 2nd-3rd trimester emergency conditions: Vaginal bleeding +/- contraction
- 7. Yolk sac
- 8. Yolk sac
- 9. The yolk sac • No YS in GS >8 mm abnormal • No embryo in a GS >16 mm abnormal • No embryo in GS of 25 mm Dx failed pregnancy • No yolk sac or embryo on 2 scans / 7-10 days apart = definitive evidence of a failed intrauterine pregnancy
- 10. Intrauterine Fluid Collection • MSD of 2-3 mm (GA =4.5-5 weeks) • -hCG = 1,000-2,000 mIU/mL gestational sac seen on TVS • “double decidual sign”
- 11. Gestational sac : GS Ultrasound in Obstetrics and Gynecology, Vol 1 Eberhard Merz
- 12. First-trimester bleeding • 27% of pregnancies • overall risk of miscarriage about 12% serum HCG levels clinical presentation DDx
- 14. F 34 YO, GA 8 weeks Vaginal bleeding
- 15. The interval for F/U LMP/ date of assisted reproduction Patient symptoms Growth rate of the GS + rise in the levels of -hCG
- 16. Blighted ovum
- 17. FHR
- 18. Absence of cardiac activity in embryo Normal range of FHR • 6.2-7 wk = 100-120 BPM • after 7 wk = 137-144 BPM Scan mode • pulsed Doppler beam temperature in tissues •only M-mode US should be used Video clips
- 19. US findings in first-trimester bleeding with a poor outcome • Bradycardia (FHR < 100) • slow growth rate of the embryo • abnormally small or large GS /embryo • enlarged amniotic cavity • empty amniotic cavity • No cardiac activity with visualization of the amnion • abnormal size or shape of the yolk sac • low position / irregular shape of GS • GS volume after 7 weeks
- 20. Subchorionic hemorrhage common finding during the 1st trimester Moderate - large subchorinic bleeding compared to GS size poor outcome http://emedicine.medscape.com/article/404971-overview#a4
- 21. F 32 YO GA = 8 weeks, vaginal bleeding RPOC =Retained product of conceptus
- 22. F 33 YO GA = 6 week Vaginal spotting
- 23. Gestational Trophoblastic Disease -GTD • First trimester : variable appearance - a small, echogenic endometrial mass without cystic spaces - mixed echogenic and cystic material - DDx hydropic degeneration and retained products of conception. • Second trimester : distended endometrial cavity filled with innumerable small cystic spaces
- 24. Summary 1st trimester bleeding • TVS is the study of choice for early pregnancies. • TAS : useful to assess the amount of free fluid and for abnormalities beyond the FOV of TVS • correlate with the quantitative -hCG level & with the clinical presentation • The lack of an intrauterine GS does not necessarily indicate ectopic pregnancy
- 25. Summary 1st trimester bleeding • A failed pregnancy : - GS >25 mm & no yolk sac/ embryo - an embryo measuring ≥7 mm & no cardiac activity. • Use M-mode to document embryonic viability and measure heart rate • Doppler US should not be used to evaluate a normal early embryo.
- 27. Ectopic Pregnancy • Extrauterine GS with a live embryo = 100% specific • Extrauterine tubal ring with central fluid or + a yolk sac and/or a nonviable embryo • a complex, extraovarian, extrauterine mass • Color Doppler : variable Color and pulsed Doppler imaging is not necessarily useful
- 28. • MRI : unusual ectopic pregnancies, GTD, or vascular abnormalities, but should not delay urgent or emergent care in an unstable patient. • CT may be useful in trauma or acute non-gynecologic pain, for staging of malignancy, or if MRI is not possible.
- 29. Ectopic Pregnancy • 80% : ipsilateral to corpus luteum…must be distinguished from it!!!
- 31. Ectopic pregnancy • 4% unusual location • Intrauterine ectopic locations interstitial, cervical, and within a Cesarean section scar • Heterotopic pregnancies = intrauterine + extrauterine preg. (extremely rare, but much higher incidence from assisted reproduction
- 32. A 34 YO female S/P IVF Vaginal bleeding for 1 day
- 33. ACUTE PELVIC PAIN IN THE REPRODUCTIVE AGE GROUP Gynecologic - obstetrical Nongynecologic hemorrhagic ovarian cysts appendicitis pelvic inflammatory disease inflammatory bowel disease ovarian torsion infectious enteritis ectopic pregnancy diverticulitis spontaneous abortion/ labor urinary tract calculi placental abruption pyelonephritis pelvic thrombophlebitis
- 34. ACUTE PELVIC PAIN IN THE REPRODUCTIVE AGE GROUP • EE >21 mm virtually excludes the possibility of ectopic pregnancy • Absence of an intrauterine pregnancy when the β-hCG level > 3510 mIU/mL : strongly suggestive of ectopic pregnancy • TVS should be used whenever possible • TAS is recommended for larger FOV. • Doppler imaging should be avoided in the setting of developing intrauterine pregnancy • •Low-dose NCE- CT for acute pelvic pain in pregnancy for non- Gyne condition, 2nd/3rd trimester
- 35. SECOND & THIRD TRIMESTER BLEEDING • placenta previa (most common) • placenta accreta (highest risk of life threatening) • placental abruption • vasa previa
- 36. SECOND & THIRD TRIMESTER BLEEDING • bloody vaginal discharge (“bloody show”) • cervical infection or neoplasm • uterine rupture : severe pain in late pregnancy (had prior C/S and uterine Sx)
- 40. F. 36 YO vaginal bleeding Placenta previa? 18 weeks10 weeks
- 41. Placenta previa • painless bleeding • near the end of 2nd- 3rd trimester • 2.8/1,000 in singleton pregnancies • 3.9/1,000 in twin pregnancies • risk factors: age over 30, multiparity, prior C/S, and prior abortions
- 42. Placenta previa 4 types: (1) complete previa—covers the internal os (central or asymmetric) (2) partial previa—partially covering (3) marginal—placental edge going to the internal os (4) low-lying—to within 2 cm of the internal os
- 43. • placental edge <2 cm from internal os measure placental edge - internal os distance • placental edge >2 cm from internal os exclude placenta previa • Safety? TVS: safe for previa, including pt. with vag. bleeding • Contraindication to TVS: incompetent Cx with a bulging amniotic sac/ suspected preterm PROM Transperineal US
- 44. Placenta Accreta • abnormally adherent to the uterus • increased C/S • incidence = 1 in 533 deliveries RadioGraphics, http://pubs.rsna.org/doi/abs/10.1148/rg.287085060
- 45. Placenta Accreta Risks: • placenta previa & multiple C/S • Advanced maternal age • Multiparity • Asherman’s syndrome (Uterine synechiae) • Fibroids
- 46. • Placenta increta : chorionic villi invading the myometrium • Placenta percreta : penetration of chorionic villi through the uterus
- 47. Placenta Accreta: US findings • loss of the normal retroplacental hypoechoic zone • localized thinning of the myometrium • increased vascularity at placental-myometrial interface on CDUS
- 48. Placenta Accreta: US findings • “Numerous coherent vessels” at the placental base: • inseparable cotyledon (fetal villous) and intervillous (maternal) circulations with extreme hypervascularity
- 50. Risk factors • HT • pre-eclampsia • PROM • cigarette smoking • cocaine abuse • thrombophilias • abdominal trauma. www.cardiosmart.org
- 51. Placental Abruption • Marginal • Retroplacental • Preplacental Nonconcealed VS. Concealed
- 52. Placental Abruption: US findings • Thickened, with rounded bulging • heterogeneous echotexture • loss of normal basal plate interface • Hematoma: variable RadioGraphics, http://pubs.rsna.org/doi/abs/10.1148/rg.295085242
- 53. Vasa Previa • umbilical vessels traverse the fetal membranes in the lower uterine segment in front of the presenting part and cross over the internal cervical os unprotected by the placental or umbilical cord • http://vasaprevia.com/
- 54. Vasa Previa • high risk of fetal death • Neurologic deficit due to fetal exsanguination • Incidence is 1/2,500 deliveries
- 55. Type 1 velamentous insertion of the cord Type 2 succenturiate lobe, with interconnecting vessels between it & the main placenta traversing the internal os
- 56. Figure 13 Vasa previa. Transvaginal power Doppler US image obtained at 18 weeks gestation shows an anterior placenta (P). There is vascular flow in a vessel (V) that is closely applied to the internal cervical os (O). Follow-up US at 32 weeks gestation showed resolution of the vasa previa, thus allowing subsequent uneventful vaginal delivery. RadioGraphics, http://pubs.rsna.org/doi/abs/10.1148/rg.295085242 Published in: Khaled M. Elsayes; Andrew T. Trout; Aaron M. Friedkin; Peter S. Liu; Ronald O. Bude; Joel F. Platt; Christine O. Menias; RadioGraphics 2009, 29, 1371-1391. DOI: 10.1148/rg.295085242 © RSNA, 2009 One PowerPoint slide of each figure may be downloaded and used for educational, non-promotional purposes by an author for slide presentations only. The RSNA citation line must appear in at least 10-point type on all figures in all presentations. Pharmaceutical and Medical Education companies must request permission to download and use slides, and authors and/or publishing companies using the slides for new article creations for books or journals must apply for permission. For permission requests, please contact the publisher at permissions@rsna.org
- 57. Summary Vaginal bleeding in the 2nd or 3rd trimester ass. with increased risks Mother & Fetus. TAS = primary imaging TVS needed for visualization of Cx & internal os (+/- transperineal US)
- 58. Summary : Placenta previa Decribe distance of the placental edge to the internal os Reevaluated during pregnancy for a potential resolution depending on the degree of attachment to the opposing wall.
- 59. Summary :Placental abruption • clinical diagnosis • emergency US : placental thickening, heterogeneity, and a periplacental hematoma
- 60. Summary: Placental accreta • Prior C/S increase the risk of placental accreta • US findings: intraplacental lacunes, increased vascularity, myometrial thinning, and focal placental bulge • MRI improves Dx confidence
- 61. Summary: Vasa previa • Serious risk that needs to be recognized and requires a planned C/S. • Velamentous cord insertion VS. interconnecting vessels of accessory placental lobe (succenturiate lobe), over internal Cx os