PoCUS in Early Pregnancy - Obcast...TV or TA? •1500 vs 6000 •Invasive vs Non-invasive •Great...
Transcript of PoCUS in Early Pregnancy - Obcast...TV or TA? •1500 vs 6000 •Invasive vs Non-invasive •Great...
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PoCUS in Early Pregnancy
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? Insert photo from FijiIntroduce speakersAcknowledge Jay
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Why do it?
Because it’s worth it
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Why do it?
Because we’re good at it
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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
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Performing TA PoCUS in Early Pregnancy• Supine, Bladder half-full
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Performing TA PoCUS in Early Pregnancy
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Performing TV PoCUS in Early Pregnancy• Pillow under buttocks, knees bent and apart
• Bladder empty
• Condom on probe
• Patient self-inserts probe
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Performing TV PoCUS in Early Pregnancy
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3 Basic Questions of PoCUS
1. Is there free fluid?
2. Is there an IUP?
3. Is there fetal cardiac activity?
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1) Is there free fluid?
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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
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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
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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
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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
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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
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Anembryonic Pregnancy
• Gestational sac but no fetal pole
• MSD ≥ 25mm = failed pregnancy
MSD 26.2mm
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Ectopic Pregnancy
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Molar Pregnancy
• Uterus full of grapes
• Clearly abnormal
• Refer for formal scan and inpatient Ix and Mx
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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
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PoCUS in Early Pregnancy