VOTW: Let It Snow

HPI

A 20-year-old G2P1 female presents with nausea, vomiting, and back pain x1 week. She is breastfeeding and sexually active. LMP was about 2 months prior, and she had spotting 3 weeks ago. Her vital signs are within normal limits. Patient’s urine HCG in the ED is positive. 

Ultrasound 

Transabdominal ultrasound of the pelvis reveals an irregularly shaped gestational sac with cystic structures, subchorionic hemorrhage, no definitive IUP, and no pelvic free fluid. Transverse (clip 1) and sagittal (clip 2) planes are shown below. 

Case Conclusion

Her serum beta-HCG is found to be >270,000, disproportionate with gestational age. Ultrasound images are consistent with molar pregnancy.  OBGYN was consulted for evaluation, and the patient was scheduled for an outpatient D&C.

Characteristic Findings of Molar Pregnancy on POCUS

• A complete molar pregnancy appears as a heterogeneous intrauterine mass with many anechoic, fluid-filled sacs, resembling a “snowstorm” or “grape-like” clusters from hydropic swelling of villi. A fetus is absent.

• Partial molar pregnancies may show abnormal fetal tissue alongside these features.

• Early detection facilitates timely referral for definitive management, which is important as disease can progress to persistent trophoblastic disease or choriocarcinoma

 Another grape catch on POCUS!

References:

• https://radiopaedia.org/articles/molar-pregnancy-2 

• http://brownemblog.com/blogposts/2022/7/1/molar-pregnancy-diagnosis-of-hydatidiform-mole-using-bedside-emergency-ultrasound 

• https://doi.org/10.1016/j.radcr.2023.02.032 

Happy scanning!

VOTW: Tube-y or not Tube-y: Two Cases of Ectopic Pregnancy

Case 1

33-year-old female G3P1, LMP 7 weeks ago, with a history of ectopic pregnancy, which was medically managed, presenting with 1 day of vaginal bleeding. Beta-hCG 5200. 

Transvaginal pelvic ultrasound showed no definitive intrauterine pregnancy and a cystic structure in the left adnexa by the ovary.

In the perinatal unit, ultrasound by MFM confirmed an ectopic pregnancy with a visible fetal heart rate. The patient underwent laparoscopy and salpingectomy that showed a dilated left fallopian tube and had a small amount of intraoperative blood loss. 

Case 2

36-year-old female G4P2, LMP 3 weeks ago, presenting with lower abdominal pain after a bowel movement, followed by vaginal bleeding. Beta-hCG was 230. 

Transvaginal pelvic ultrasound showed no definitive intrauterine pregnancy and a moderate to large amount of free fluid.

The patient underwent diagnostic laparoscopy with salpingectomy. 300 mL of hemoperitoneum was found intraoperatively, and the patient was diagnosed with a left ruptured tubal ectopic pregnancy.

Ectopic pregnancy on ultrasound

Approach

• Start with the curvilinear probe and switch to the endocavitary probe if better resolution is needed

• In a patient of childbearing age with abdominal pain and hypotension, start with a FAST exam to look for free fluid in Morison’s pouch

Findings suggestive of ectopic pregnancy

• Empty uterine cavity or intrauterine fluid without a yolk sac

• Abdominal free fluid 

• A “tubal ring” appearance, an echogenic ring that surrounds an unruptured ectopic pregnancy (n.b. this can be mimicked by a normal corpus luteum). See structure marked by arrow in image above. 

• Less than 5 mm of myometrium surrounding an eccentrically located gestational sac. This is a type of ectopic pregnancy called an interstitial pregnancy.

References

• https://coreultrasound.com/ectopic-pregnancy/ 

• https://www.emdocs.net/us-probe-ultrasound-for-ectopic-pregnancy/ 

• https://radiopaedia.org/articles/tubal-ring-sign

Happy scanning!

US team

VOTW: You take my breath away!

HPI: 90 yo female presenting for worsening shortness of breath and tachycardia x 3 days and right leg pain x 2 weeks with difficulty ambulating.

POCUS showed:

ECHO A4C view (see video): note the size of the RV appears larger than the LV. This is a sign of right heart strain and in the appropriate setting (such as this one) can be concerning for a pulmonary embolism!

Compression views of the common femoral vein (CFV), femoral vein (FV), and popliteal vein (PV). See the echogenic material inside the popliteal vein which is suggestive of a DVT. Remember that during the acute phase of a DVT (<14 days), the clot may appear isoechoic to the blood inside the vein so you may not see this echogenic material and should rely more on your compression exam.

Review on how to do DVT US:

Linear probe

Patient in frog leg position

4 main areas to view

• Common femoral vein (CFV)-saphenous vein junction (SFV)

  • Clot noted in the SFV within 3 cm to the junction is treated as a DVT. More distally, if there is 5 cm worth of clot noted in the SFV it is also treated as a DVT.

• CFV branching into [superficial] femoral vein and deep femoral vein

• Mid/distal femoral vein

• Popliteal vein

  • Remember the popliteal vein is on top of the popliteal artery (pop on top!)

Tips:

• You often have to go much higher in the groin than you think to find the CFV-SFV junction

• Compression testing of the deep veins should not compress the artery (if it is, you’re pressing too hard and can miss subtle DVTs)

• Deep veins are paired with arteries so identify your landmarks to ensure you are looking at the correct vessels

• Use your non-scanning hand to help with compression of deeper veins by supporting the other side of the patient’s leg

Case conclusion: Patient with elevated troponin and BNP. CTA significant for bilateral PE’s. Labs and ECHO findings consistent with submassive PE. Patient started on heparin drip and admitted to the floor!

Happy scanning!

• The US Team