King's Early Pregnancy Unit
King's Early Pregnancy Unit
King's Early Pregnancy Unit
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BMUS<br />
Advanced Gynaecological<br />
Ultrasound Study Day
King’s <strong>Early</strong> <strong>Pregnancy</strong> <strong>Unit</strong><br />
What does the clinician need to learn<br />
from the ultrasound report?<br />
King’s s College Hospital<br />
London
King’s <strong>Early</strong> <strong>Pregnancy</strong> <strong>Unit</strong><br />
Most clinicians are:<br />
• Ignorant of USS<br />
• Busy people<br />
• Surgeons
King’s <strong>Early</strong> <strong>Pregnancy</strong> <strong>Unit</strong><br />
So……<br />
• Explain the relevance of measurements /<br />
findings<br />
• Keep it salient<br />
• Make it accurate
King’s <strong>Early</strong> <strong>Pregnancy</strong> <strong>Unit</strong><br />
Indication:<br />
Suspected ectopic pregnancy.<br />
RIF pain and spotting.<br />
History:<br />
Maternal age: 32 years. Menstrual cycle regular - LMP sure, cycle length 28 days. Conception<br />
spontaneous.<br />
Gynaecological History: last period 01.09.2005, day of cycle 51. Cycle length 28 days.<br />
Contraception: none.<br />
Past gynaecological operations: lap and dye - no spill on right.<br />
Obstetric History: Living children >=37W: 1.<br />
Last period: 01.09.2005.<br />
EDD by LMP: 08.06.2006.<br />
Gestational age: 7 weeks + 1 day<br />
First Trimester Ultrasound:<br />
transvaginal US with Aloka 5500. Ultrasound view: good.<br />
<strong>Early</strong> pregnancy assessment:<br />
Last period: 01.09.2005.<br />
Gestational sac outside the uterine cavity.<br />
Ectopic pregnancy: location: right fallopian tube, size 30 mm x 18 mm x 16 mm, gestational sac<br />
visible, diameter 9.0 mm, Yolk sac, Embryo, CRL 6.5 mm, Heart action.<br />
Corpus luteum: right.<br />
Pouch of Douglas: free fluid - present, appearances: haematoperitoneum.<br />
Uterus: axial. Uterine anomalies: none.<br />
Uterine findings: endometrial thickness 22.0 mm, midline echo: intact, endometrial structure:<br />
normal.<br />
Left ovary: Size 28 mm x 20 mm x 16 mm. Volume 4.7 ml. Morphology: normal.<br />
Right ovary: Size 29 mm x 27 mm x 22 mm. Volume 9.0 ml. Morphology: normal. Corpus<br />
Luteum: solid.<br />
Diagnosis:<br />
Ectopic pregnancy.<br />
The uterus was anteverted and empty with a thick endometrium. Both ovaries were normal with<br />
the corpus luteum in the right. There was a live six weeks size ectopic pregnancy in the ampulla<br />
of the right tube. There was a haemoperitoneum of approximately 200ml consistent with a<br />
rutured/ leaking ectopic pregnancy. We will organise theatre ASAP.
King’s <strong>Early</strong> <strong>Pregnancy</strong> <strong>Unit</strong><br />
<strong>Early</strong> pregnancy problems<br />
miscarriage<br />
• Medico-legal aspect<br />
• Guide management – ERPC or expectant<br />
– size of embryo / sac, morphology of trophoblast
King’s <strong>Early</strong> <strong>Pregnancy</strong> <strong>Unit</strong><br />
<strong>Early</strong> pregnancy problems<br />
miscarriage<br />
• Guide intervention – ERPC<br />
– Uterus; anomalies, fibroids, implantation site, size<br />
of embryo / sac
King’s <strong>Early</strong> <strong>Pregnancy</strong> <strong>Unit</strong><br />
<strong>Early</strong> pregnancy problems<br />
miscarriage
King’s <strong>Early</strong> <strong>Pregnancy</strong> <strong>Unit</strong><br />
<strong>Early</strong> pregnancy problems<br />
ectopic pregnancy<br />
• Guide intervention – how? when? who?<br />
– Morphlogy and site of ectopic, amount of blood in<br />
pelvis / abdomen, presence of adhesions
King’s <strong>Early</strong> <strong>Pregnancy</strong> <strong>Unit</strong><br />
<strong>Early</strong> pregnancy problems<br />
ectopic pregnancy
King’s <strong>Early</strong> <strong>Pregnancy</strong> <strong>Unit</strong><br />
Gynaecology<br />
intermenstrual bleeding<br />
• Relevant negatives<br />
– Endometrial polyps, submucous fibroids<br />
• Check cervical canal
King’s <strong>Early</strong> <strong>Pregnancy</strong> <strong>Unit</strong><br />
Gynaecology<br />
fibroids<br />
• 70% of women have fibroids by the age of 50<br />
(Baird 2003).<br />
• If present are they causing the patient’s<br />
symptoms – comment on relation to<br />
endometrial cavity / bladder<br />
• How easy are they going to be to remove?<br />
• Learn to distinguish adenomyosis
King’s <strong>Early</strong> <strong>Pregnancy</strong> <strong>Unit</strong><br />
• Relevant negatives<br />
Gynaecology<br />
painful periods<br />
– Endometriosis, adenomyosis,
King’s <strong>Early</strong> <strong>Pregnancy</strong> <strong>Unit</strong><br />
Gynaecology<br />
IUCDs<br />
• No evidence that contraceptive efficacy related to<br />
position in cavity<br />
• Be explicit that your assessment of the endometrium<br />
will not be as accurate<br />
• If lost, have a look for site of perforation & check the<br />
adnexae
King’s <strong>Early</strong> <strong>Pregnancy</strong> <strong>Unit</strong><br />
Gynaecology<br />
Irregular periods<br />
• Guide to further investigation; biopsy/hysteroscopy<br />
• Premenopausal women emphasise endometrial<br />
morphology rather than cut off for ‘normal’ thickness<br />
• Loss of normal architecture and midline echo<br />
• Association of PCOS with simple hyperplasia
King’s <strong>Early</strong> <strong>Pregnancy</strong> <strong>Unit</strong><br />
• Relevant negatives<br />
Gynaecology<br />
infertility<br />
– Polyps, hydrosalpinges, adhesions
King’s <strong>Early</strong> <strong>Pregnancy</strong> <strong>Unit</strong><br />
Gynaecology<br />
adnexal mass<br />
• Is it gynaecological?<br />
• Is it ovarian?<br />
• Is it functional / benign / malignant?<br />
• Is it incidental?
King’s <strong>Early</strong> <strong>Pregnancy</strong> <strong>Unit</strong><br />
Points to discuss<br />
• Format of reports<br />
• Content of comments<br />
• How to optimise diagnostic accuracy?
King’s <strong>Early</strong> <strong>Pregnancy</strong> <strong>Unit</strong><br />
BMUS<br />
Advanced Gynaecological<br />
Ultrasound Study Day
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