PoCUS in Early Pregnancy - Obcast...TV or TA? •1500 vs 6000 •Invasive vs Non-invasive •Great images vs good images •Can you answer enough information TA? •TV scanning is

PoCUS in Early Pregnancy

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Why do it?

Because it’s worth it

Why do it?

Because we’re good at it

TV or TA?

• 1500 vs 6000

• Invasive vs Non-invasive

• Great images vs good images

• Can you answer enough information TA?

• TV scanning is an easy and appropriate use of PoCUS

• Just ask the same questions

Performing TA PoCUS in Early Pregnancy• Supine, Bladder half-full

Performing TA PoCUS in Early Pregnancy

Performing TV PoCUS in Early Pregnancy• Pillow under buttocks, knees bent and apart

• Bladder empty

• Condom on probe

• Patient self-inserts probe

Performing TV PoCUS in Early Pregnancy

3 Basic Questions of PoCUS

1. Is there free fluid?

2. Is there an IUP?

3. Is there fetal cardiac activity?

1) Is there free fluid?

PV Bleeding + Shock

• DDx• Ectopic Pregnancy

• Miscarriage

• Hypovolaemic shock

• Cervical shock

PV bleeding + Shock

Is there intraabdominal free fluid?

Likely Ectopic

1. Resuscitate2. OT for Salpingectomy

Likely Incomplete Miscarriage

1. Speculum exam ? Cervical shock2. Resuscitate3. OT for Suction Evacuation

YES

NO

2) Is there an IUP?

• Rule in IUP effectively rules OUT ectopic pregnancy

• Heterotropic pregnancy rate ~1:4000

• Assisted fertility as low as 1:20-50

• Emergency physicians are very good at this

• Stein et al meta-analysis

• 10 studies, 2057 patient with 7.5% ectopic pregnancy rate

• Pooled sensitivity 99.3%, NPV 99.96%, Neg LR 0.08

IUP

• Earliest indicator is a gestational sac

• Earliest definitive sign is a yolk sac

• Fetal pole begins as thickening adjacent to yolk sac then becomes more recognisable

3) Is there cardiac activity?• Fetal cardiac activity is best indicator of viability

• Usually visible from CRL ~2mm

• Normal FHR 110-160

• Cardiac activity but FHR <90 = poor prognosis

• M mode preferred

Failed IUP Criteria

• Mean SAC diameter ≥ 25mm with no fetal pole

• Fetal pole with CRL ≥ 7mm with no cardiac activity• Check for at least 30sec

If above criteria NOT met

• CRL <7mm and no heart activity, repeat in 7 days, if no cardiac activity = failed pregnancy

• MSD >12mm and no fetal pole, repeat in 7 days and if no fetal pole + cardiac activity = failed pregnancy

• MSD <12mm and no fetal pole, repeat in 14 days and if no fetal pole + cardiac activity AND the MSD has NOT doubled = failed pregnancy

Anembryonic Pregnancy

• Gestational sac but no fetal pole

• MSD ≥ 25mm = failed pregnancy

MSD 26.2mm

Ectopic Pregnancy

Molar Pregnancy

• Uterus full of grapes

• Clearly abnormal

• Refer for formal scan and inpatient Ix and Mx

Dating

• LNMP [+ 7 days, - 3 months, +1 year = 280 days post-LNMP]

• Ultrasound

• <12 weeks = CRL (crown-rump length)

• >12 weeks = BPD (biparietal diameter) CRL 27mmGA 9w4d

CRL 5.6mmGA 6w2d

PoCUS in Early Pregnancy