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This can help identify them. However, the emergency physician should remember that he or she is doing this scan to identify an intrauterine preg- nancy. Performing a complete ovarian ultrasound is beyond the scope of this text. (A) (B) Figure 4.8 Transvaginal views of the uterus: ( A ) longitudinal and ( B ) transverse. Anechoic fluid in the left-hand corner of the longitudinal view is the bladder. To image the cervix on the longitudinal image, the handle of the probe would be brought up and the probe tip angled toward the posterior fornix. (A) (B) Figure 4.7 Probe positioning in transvaginal scanning. ( A ) Sagittal or longitudinal transvaginal probe positioning, with the probe marker pointed to the ceiling. ( B ) Transverse transvaginal probe positioning, with the probe marker to the patient’s right. Diagnostic ultrasound 99 First trimester ultrasound
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Ovary F F Figure 4.9 Two normal transvaginal views of the ovary. Most women will have multiple visualized follicles (F) – some may be quite prominent, depending on luteal stage. 100 Diagnostic ultrasound First trimester ultrasound
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Scanning tips Trouble with the transabdominal view Unable to see the uterus ? ± Try sliding the probe to the left or right. Sometimes the uterus is not midline. ± Adjust (increase) the depth. If the depth is too shallow the uterus and the pouch of Douglas will be out of view. Disoriented as to position of the uterus and bladder? ± Most women have an anteverted uterus. Thus if the bladder is full the bladder will push the fundus more sagittal and in the transverse plane the bladder will be above the uterus. However, if the bladder is less full, the fundus can occasionally be on top of the bladder and thus in the transverse plane the uterus will be anterior to the bladder. By scanning longitudinally as well, it is easy to distinguish these two and to ensure there is no free fluid. ± If a woman has a retroverted uterus it can be hard to find in the transverse plane. To get oriented always try a longitudinal view – and increase the depth to make sure you see the entire fundus. Trouble with the transvaginal view Unable to get oriented ? ± Think of placing the ultrasound probe in the same position as the speculum. By angling gently posterior and increasing the depth usually you can get a familiar picture to come into view. ± If there is nothing familiar coming into view, slowly fan side to side with your probe marker to the ceiling. Again, often the uterus is located slightly off midline. ± Dont forget to measure the myometrial mantle. The pregnancy should be located in the endometrial cavity with at least 8 mm of myometrium surrounding it to support a viable pregnancy. If the myometrial rim seems narrow obtain consultation or formal imaging, as this can be a sign of an irregularly placed or cornual ectopic.
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