Ultrasound is essential for evaluating pelvic pain and vaginal bleeding in women of childbearing age. It can identify many potential causes of these presentations including pregnancy location, ectopic pregnancies, retained products of conception, and complications of pregnancy. Transvaginal ultrasound in particular provides high resolution imaging of the pelvis and adnexal structures to accurately diagnose conditions. Doppler ultrasound further aids evaluation by identifying blood flow patterns.

1. ROLE OF ULTRASOUND IN
OBSTETRIC EMERGENCY
DR.SHREEDHAR VENKATESH
PROF.&HOD
OBSTETRICS AND GYNAECOLOGY

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)

6. HOW CAN ULTRASOUND ANSWER THE QUESTION?

7. 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 1000iu/l,1500iu/l and 2000iu/l have
been used discriminatory zone.
 These levels are dependent upon the quality of the ultrasound equipment, the experience of the
sonographer, prior knowledge of woman’s risk.
 For specialized units performing high resolution vaginal ultrasound with prior knowledge of the woman’s
symptoms and serum hCG, a discriminatory zone of 1000iu/l can be used. In other units offering a
diagnostic transvaginal scan without prior clinical or laboratory knowledge a discriminatory zone of 1500iu/l
or 2000iu/l is acceptable
RCOG Guideline No.21,Evidence level III

8. DIFFERENT SCANNING MODALITIES

9. Gestational sac TAUS

10. GESTATIONAL SAC TVUS

11. 3D Scanning

12. ENDOMETRIAL FINDINGS SUGGESTIVE OF
UTERINE PREGNANCY

13. DOUBLE DECIDUAL SIGN
 To distinguish between an early pregnancy intrauterine pregnancy and a
pseudogestational sac
 Consists of the decidua parietalis(that lining the uterine cavity) and decidua
capsularis(lining the gestational sac)

16. ADNEXAE AND OVARIES

17. CORPUS LUTEUM

18. TUBAL ECTOPIC PREGNANCY

19. ADNEXAL MASS

20. ADNEXAL ECTOPIC PREGNANCY WITH
POSITIVE CARDIAC PULSATION

21. 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 haemorrhage. Original sonographic descriptions include an eccentric
intrauterine location and thinning of the surrounding myometrial mantle to less
than 5mm.
 Care must be exercised to avoid misinterpreting a normal intrauterine pregnancy
in an anomalous uterus-such as separate or bicornuate uterus- as an interstitial
pregnancy.

23. OVARIAN ECTOPIC

24. CERVICAL ECTOPIC
 Bad prognosis-potential for uncontrollable haemorrhage
 Differentiate from an abortion in progression
 Round or oval non crenated sac , fetal cardiac activity, present, closed internal os,
constant sac shape and location on follow-up sonogram

25. CERVICAL ECTOPIC

26. HETEROTROPIC PREGNANCY

27. ABDOMINAL ECTOPIC

28.  Peritoneal cavity free fluid or haemoperitoneum in the pouch of douglas.
 Differentiated from- ruptured corpus luteum, appendicitis(negative beta hCG)

29. PERITONEAL FREE FLUID

30. RING OF FIRE SIGN OR RING OF
VASCULARITY
 Signifies a hypervascular lesion with peripheral vascularity on color or pulsed
Doppler exmination of pelvis due to low impedance high diastolic flow.
 Seen in highly vascular pelvic lesions like:
Corpus luteum cyst
Ectopic pregnancy

33. RETAINED PRODUCTS OF CONCEPTION
 Retained products of conception after spontaneous or elective abortion or full
term pregnancy may cause secondary post partum haemorrhage or may serve as
nidus for uterine infection.
 Predisposing factors include the presence of a succenturiate lobe or placenta
accrete,increta, or percreta, preventing complete placental delivery. Sonographic
findings include endometrial expansion of heterogenous 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.

35. RETROPLACNTAL HEMATOMA AND
ABRUPTIO PLACENTA
 Seperation of placenta from myometrium where it is implanted causes bleeding.
When only the margin of the placenta is separated , its called marginal
subchorionic hematoma.
 When the bleeding is behind the placenta , it is termed as retroplacental bleed.
The term abruption is typically reserved for premature placental separation
occurring after 20 weeks.
 Subamniotic bleeding is a collection anterior to the placenta and limited by
umbilical cord.

36. SUBCHORIONIC HEMATOMA

37. RETROPLACENTAL HEMATOMA
 Abruptio placenta is one of the most serious complications of pregnancy,
accounting for upto 25% of perinatal deaths, Diagnosis requires a high degree 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 the sonogram is low, 10-20%.

39. PLACENTA PREVIA
 Routine ultrasound scanning at 20 weeks of gestation should include placental
localization.
 Transvaginal scans improve the accuracy of placental localization and are safe , so
the suspected diagnosis of placenta previa at 20 weeks of gestation by abdominal
scan must be confirmed by transvaginal scan.
 In the second trimester TVS will reclassify 25-60% 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
previa in 12.5% of 32 women. Leerentveld et al demonstrated high levels of
accuracy of TVS in predicting placenta previa in 100 women suspected of having a
low lying placenta in the second and third trimester.

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

42. TRANSLUCENCY ZONE

43. COLOR DOPPLER

44. SIGNS SUGGESTIVE OF PLACENTAL
INVASION BY 3D DOPPLER
 Numerous coherent vessels involving the whole uterine serosa-bladder junction
 Hypervascularity
 Inseperable cotyledonal and intervillous circulations, chaotic branching, detour
vessels.

45. UTERINE DEHISCENCE AND RUPTURE

47. RED OR CARNEOUS FIBROID
DEGENERATION

48. THANK YOU