SonoCase: Pregnant pt with 1st trimester vaginal bleeding/pelvic pain in @EPMonthly #FOAMed

Drs. Teresa Wu and Brady Pregerson bring another engaging discussion to the great question: Should someone with a prior vaginal ultrasound for pregnancy evaluation get another one with repeat visits to the emergency department? Well, as they will describe, it may not be needed, but it sure does help patient satisfaction (and especially relief if they are concerned about their baby). So, if you do, it is all about your ability to interpret the images correctly. They identify some great vaginal/pelvic ultrasound pearls and pitfalls to keep in mind in the end of the following case:

“There are twenty-eight patients in the waiting room with the longest waiting 4 hours. The queue for CT scans is over 2 hours and the one for ultrasounds is even longer; a staggering 4 hours, plus another hour to get results. Lots of people are frustrated. Your next two patients are both pregnant females in their first trimester with vaginal bleeding. As you perform your H & P, you encounter more similarities between the two. Both have midline crampy pain like a period, with no fever, no vomiting, and no syncope. Both recently had ultrasounds done, one in your ED 3 days ago, and one with her obstetrician four days ago. You know why they are here. One reason – they want to see if their baby still has a heartbeat. You also know that repeating the ultrasound is not really medically indicated using the strict sense of the word. Sure it’s reasonable, even customary, but will it change management tonight? Can’t they just see their OB tomorrow? Is it really the right way to practice medicine to clog up your department even worse while simultaneously adding one more straw to the camel carrying the national healthcare budget? Who are you going to listen to? Press and Ganey? Barack Obama? Your conscience? What will the parents think and how will they react if you tell them, “Sorry, we can’t do an ultrasound tonight. You have to go home and make an appointment tomorrow to see your doctor.”?

The following ultrasound images are obtained in each patient:

Screen Shot 2013-07-03 at 6.39.47 PM Screen Shot 2013-07-03 at 6.40.19 PM

Do you know how to interpret them? Read more on vaginal ultrasound and their great pearls and pitfalls here.

Great pearls to keep in mind:

gestational sac only – early intrauterine pregnancy (IUP) or pseudosac of an ectopic pregnancy

gestational sac with yolks sac or fetal pole – early IUP

gestational sac with fetal pole and cardiac activity – LIVE IUP

For a review on the beta hcg (and if we can /should use ti anymore) and early pregnancy evaluation with ultrasound, go here.

SonoCase and Discussion of Pelvic Ultrasound: 32yr G1P0 at 7wks, c/o vaginal spotting – in WestJEM #FOAMed

Drs. Abdi, Stacy, Mailhot, and Perera once again describe a case where ultrasound made the difference in clinical management of a patient. Their case is published in WestJEM with a great tutorial video (see below) accompanying it.

Emergency physicians perform bedside ultrasound in 1st trimester abdominal pain and vaginal bleeding to “rule in” an intrauterine pregnancy, but the better way to describe how we think about it is “ruling out” any signs of an ectopic pregnancy. By doing it in the emergency department, it has been shown to decrease length of stay of these patients, and increase their satisfaction. With a full bladder, a transabdominal pelvic ultrasound is performed with a regional assessment of the pelvic organs to visualize for confirmation of an intrauterine pregnancy (yolk sac or fetal pole within a gestational sac in the uterus). You may need to empty the bladder and perform a transvaginal ultrasound if the above does not provide the information you need (I bring the ultrasound machine with me to the bedside when I first meet them so that I can do the history, physical, and ultrasound right off the bat). If there is an identifiable pregnancy then an evaluation for a fetal heart and its rate is assessed in order to characterize it as a “live” intrauterine pregnancy. But, if there is no contents within the gestational sac (a potential pseudosac), or if there is no gestational sac, then the concern for ectopic pregnancy still exists. Of course, in a recent post, we discuss that even those cases may turn out to have a normal pregnancy despite an elevated beta hcg level, calling into question whether the “discriminatory zone” should be used to guide our management.

Let’s go back to their case: The brilliance of this case, however, isn’t that they found an ectopic or illustrate what I describe above, instead it illustrates that there are other diagnoses that may be apparent on ultrasound that is causing the pelvic pain and vaginal spotting. And, if you don’t look, or if you are unfamiliar with what you are seeing on the screen, you may miss it – or mistakingly call it an intrauterine pregnancy.

The case: 32 yrs old G1P0 known pregnant at 7weeks by last menstrual period with lower pelvic cramping and vaginal spotting. A bedside ultrasound is performed and the video below describes what they saw…. read more on the case here.

Since “being pregnant” is a diagnosis that can be made, we shouldn’t stop there after we have identified an intrauterine pregnancy. We shouldn’t simply state “you’re pregnant” and discharge them home without further consideration of the etiology of their pelvic pain. Something else may be causing it. (to read about other cases using pelvic ultrasound, go here.) Other findings/diagnoses to consider in 1st trimester pelvic pain or vaginal spotting:

1. Ovarian cyst or torsion (see this case report in J of EM that discussed exactly why you should continue to evaluate with bedside US).

2. Fibroid

3. Appendicitis

4. Mass/cancer

5. Infection – anywhere (Pelvic inflammatory disease, tubo-ovarian abscess, UTI, colitis/proctitis, etc)

6. Heterotopic pregnancy- consider in patients on fertility drugs

SonoStudy: Bedside Pelvic Ultrasound decreases length of stay in the emergency department

In a recent study in Pediatric Emergency Care, the folks at newark Beth Israel in New Jersey studied whether performing a pelvic ultrasound decreases length of stay. Now, we all can appreciate this – you have a pregnant patient with first trimester vaginal bleeding or abdominal pain, you see an intrauterine pregnancy without any risks/signs of heterotopic (which is incredibly rare anyway) – you’re done! You dont even have to wait for the beta hCG! Of course that decreases length of stay! Now, this wasnt the first study of it’s kind. Another study by Blaivas et al. basically did the same thing… 13 years ago! And by Burgher…. 16 years ago. And by Shih…. 16 years ago! There was a great review of pelvic ultrasound done in 2009 that shows its accuracy and utility too.

Well, here is what they state: abstract below

“OBJECTIVES: Diagnostic ultrasounds by emergency medicine (EM) and pediatric emergency medicine (PEM) physicians have increased because of ultrasonography training during residency and fellowship. The availability of ultrasound in radiology departments is limited or difficult to obtain especially during nighttime hours. Studies have shown that EM physicians can accurately perform goal-directed ultrasound after appropriate training. The goal of this study was to compare the length of stay for patients receiving an ultrasound to confirm intrauterine pregnancies. The hypothesis of this study is that a bedside ultrasound by a trained EM/PEM physician can reduce length of stay in the emergency department (ED) by 1 hour.

METHODS: This was a case cohort retrospective review for patients aged 13 to 21 years who received pelvic ultrasounds in the ED during 2007. Each patient was placed into 1 of 2 groups. Group 1 received bedside ultrasounds done by institutionally credentialed EM/PEM attending physicians. Group 2 received radiology department ultrasound only. Each group had subanalysis done including chief complaint, time of presentation, time to completion of ultrasound, length of stay, diagnosis, and disposition. Daytime was defined as presentation between 7 AM and 9 PM when radiology ultrasound technologists were routinely available.

RESULTS: We studied 330 patients, with 244 patients (74%) in the bedside ultrasound group. The demographics of both groups showed no difference in age, presenting complaints, discharge diagnoses, and ultimate disposition. Group 1 had a significant reduction (P < 0.001) in time to complete the ultrasound compared with group 2 (mean, 82 minutes [range, 1-901 minutes] vs 149 minutes [range, 7-506 minutes]) and length of stay (142 [16-2268] vs 230 [16-844]). Of those presenting during the day (66%), group 1 showed a significant reduction in length of stay (P < 0.001) compared with group 2 (220 [21-951] vs 357 [156-844]). Of those who presented at night (34%), group 1 showed a significant reduction in length of stay (P < 0.002) compared with group 2 (270 [16-2268] vs 326 [127-691]).

CONCLUSIONS: The use of ED bedside ultrasound by trained EM/PEM physicians produced a significant reduction in length of stay in the ED, regardless of radiology ultrasound technologist availability.”

Some interesting cases for your review:

SonoCase: 30 yr old with pelvic pain, LMP 5 weeks ago, stable vitals, mild tenderness in suprapubic area, pelvic exam normal. Your Transabdominal pelvic view on ultrasound shows the below. What do you do next?

Well, we see a full bladder – which is a must if you actually care about your pelvic views – and we see a gestational sac with a double decidua sign – the earliest sign of an intrauterine pregnancy, BUT it is not enough to diagnosis a definitive intrauterine pregnancy – you need a yolk sac within your gestational sac to say that! So, get your endocavitary ultrasound probe and take a look (after emptying the bladder), you may just see the yolk sac!

SonoCase: 24 yr old with pelvic pain, LMP 6 weeks ago, stable vitals, mild tenderness in suprapubic area, pelvic exam normal. Your Transabdominal pelvic view on ultrasound shows below. What is the diagnosis? What do you do next?

Well, there is an empty bladder (unfortunately), so the visualization is not its best, but while we slowly fan through the pelvis there is a fluid filled circular cystic-like structure with mild acoustic enhancement (brightness deep to it) which allows you to also see a gestational sac within the uterus. There is an ovarian cyst. Is that what’s causing the pelvic pain? Are you sure it’s not an ectopic? Not yet – get your endocavitary probe now that the bladder is empty and take a look for the yolk sac or fetal pole. If the fetal pole has cardiac activity visualized then we can say it is a LIVE intrauterine pregnancy.

SonoReview & Case: Acute pelvic pain by ultrasound, 1st trimester evaluation, and what to do when “Coming up Empty”…

In the most recent installment of the Sound Judgement Series by AIUM, Drs. Rochelle F. Andreotti and Sara M. Harvey from the Department of Radiology at Vanderbilt discuss the use, accuracy and effectiveness of ultrasound for acute pelvic pain. It seems that pelvic pain has, again, become an important issue as there are quite a few articles that have come out about it recently, likely because there are so many visits to clinics and emergency departments with this exact chief complaint. As the authors state “The diagnosis can be challenging because many symptoms and signs lack sensitivity and specificity. Urgent life-threatening conditions requiring surgical intervention (eg, ectopic pregnancy, appendicitis, a ruptured ovarian cyst, and ovarian torsion) and fertility-threatening conditions (eg, pelvic inflammatory disease [PID] and ovarian torsion) should take precedence over other disorders.” – Guess which imaging modality can evaluate all of them? Continue reading

SonoCase: 15 yr old diagnosed with pyelonephritis, persistent fevers…back in the ED

This is a guest post from my good friend and colleague, Dr. Zoe Howard, an ultrasound lover and user, part of ACEP’s medical student initiative, and helping us incorporate bedside ultrasound into the medical school curriculum. She had an amazing case where bedside ultrasound helped make the correct diagnosis for a patient who was getting worse, bounced back to the ED, and stayed in an observation unit to be seen by her (and the ultrasound machine) in the morning:

A sweet 15yo girl presented with a week of suprapubic pain and dysuria… Continue reading

SonoCase: TA Pelvic US: What’s up with that Uterus?!

Crazy case I saw recently… 38 yo female who came to the ED for vaginal bleeding that was unrelenting for 6 months, not changed with repeated PO hormonal treatment by PCP, and “I just want an answer.” Stable vitals, no sx of anemia, she was not tender on exam and pelvic was unremarkable except for some blood. In my efforts to simply appease her as I wasnt going to do much more, I did a Transabdominal Pelvic US (sagittal view shown below). Once I saw this, I started to pay more attention (of course, it should have been the other way around, but thats just my skeptical self). I asked her about weight loss (she had 15 pounds loss in 6 months (already a pretty petite girl) and no significant family history, but I realized when speaking to her for more time that she kept having an intermittent dry cough every now and again. I asked her about it, and she thought it was allergies “and I just dont think i got over that cold from a month ago.” Pretty sad case -CXR showed mets…..”platinum” scan done, admitted to Medicine, biopsy/onc/chemo underway… shows the importance of TA Pelvis for not just the 1st trimester pregnancy VB/abd pain evaluations. Continue reading

Happy Mother’s Day: a dancing baby for all US lovers!

For all the moms out there on Mother’s day! And for all who know me well, you know the baby will be dancin’ to Party Rock! If an expectant mom comes in with pelvic pain or vaginal bleeding, check for fetal dancing: Continue reading