diagnostic medical sonography obstetrics and gynecology pdf

Diagnostic Medical Sonography Obstetrics And Gynecology Pdf

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A diagnostic medical sonographer is a highly skilled professional who uses specialized ultrasound equipment to record visual images of internal structures of the abdomen, pelvis and neck. They work in hospitals and outpatient settings producing these ultrasounds to assist the physician in diagnosing disease. The graduate also receives instruction in vascular sonography.

Diagnostic medical sonography. Obstetrics and gynecology

A cross-sectional retrospective study included consecutive patients who underwent emergency laparoscopy for acute pelvic pain at a teaching hospital gynecologic emergency unit, between January 1, , and December 31, The laparoscopic diagnosis was the reference standard.

Gynecologic and nongynecologic conditions requiring immediate surgery to avoid severe morbidity or death were defined as surgical emergencies. Sonograms were re-interpreted for the study, blinded to physical examination and laparoscopic findings, according to evidence-based predetermined criteria. Sensitivity, specificity, and likelihood ratios were computed for clinical data alone, sonographic data alone, and the combination of both.

Clinical and sonographic examinations performed by the residents each independently predicted a need for emergency surgery.

A prompt diagnosis is crucial to prevent severe morbidity or death[ 2 ]. The physical examination is not fully reliable[ 2 — 5 ]. Extensive use of diagnostic laparoscopy has been suggested to avoid missing gynecologic or non gynecologic disorders requiring emergency surgical treatment[ 1 , 6 ].

However, laparoscopy is an invasive procedure associated with a number of complications[ 7 ], and its use as a diagnostic tool should therefore be avoided whenever possible[ 8 ]. Since the s, transvaginal ultrasonography TVUS has become an essential diagnostic tool for gynecologic emergencies[ 9 ].

These specialized physicians are not available around-the-clock when resources are limited, as is increasingly the case in this era of patient care in the case of cost containment. In a previous study, we demonstrated that standardizing the gynecologic emergency ultrasonogram allowed scoring and quality control and also significantly improved the quality of ultrasonography in the gynecologic EDs[ 11 ].

We retrospectively reviewed the medical records of consecutive women who underwent laparoscopy for acute pelvic pain at the gynecologic ED of the Poissy-St Germain Hospital, France, a teaching hospital serving a large population.

This historical cohort was studied between January 1, , and December 31, One resident and one senior gynecologist are available at the gynecologic ED around the clock. In France, women with acute pelvic pain are evaluated either in general EDs, in which case they are then referred to a gynecologic ED, or directly in gynecologic EDs, to which all women have free access.

Thus, all patients with suspected gynecologic emergencies are seen in gynecologic EDs. Exclusion criteria were hemodynamic shock, pregnancy of more than 13 gestational weeks, secondary laparoscopy for ectopic pregnancy initially managed with methotrexate, surgery within the last month, or virgin patients.

Among patients who did not undergo emergency laparoscopy, those who were pregnant were followed until a definitive diagnostic was made[ 12 ]. In nonpregnant patients, when the findings of all examinations were thought to be normal and the pain subsided with appropriate analgesia by the end of the visit or hospitalization, a diagnosis of idiopathic acute pelvic pain was made.

After discharge, the patients were encouraged to return to our ED in case of pain recurrence. In all patients, a nurse performed an initial assessment including measurement of vital signs Heart rate, arterial pressure and temperature , a urine hCG test and a pain intensity measurement using a Numerical Rating Scale NRS. Residents were between their third and eight semester of formation in gynecology and obstetrics and were non titular of ultrasound diploma.

The senior gynecologist decided whether to perform emergency laparoscopy based on all the available data. Criteria for emergency laparoscopy were suspected adnexal torsion[ 13 ], ectopic pregnancy with a contraindication to medical treatment according to French recommendations[ 14 ], suspected tubo-ovarian abscess or peritonitis due to pelvic inflammatory disease[ 15 ], suspected massive hemoperitoneum and persistence of severe pain.

For patients who did not undergo laparoscopy and before discharge, a routine time of observation of about 24 hours is usually performed in the department of gynecology. The physical examination included palpation of the abdomen, speculum examination, and digital vaginal examination. The results were considered normal when there was no guarding, rebound, mass, or thickening on abdominal palpation 2 5 16 and no cervical motion tenderness, adnexal tenderness, or adnexal mass or thickening on vaginal examination[ 4 , 16 ].

If one of these features was present, the physical examination was considered abnormal. TVUS was performed using a 3. One to three additional views could be obtained as dictated by the abnormal ultrasound findings e. This class covered image acquisition, normal and abnormal findings and image quality criteria.

A copy of the written protocol for bedside emergency ultrasonography was also given to each resident. Standardized ultrasonography scans. The laparoscopy diagnosis was the reference standard. Patients were classified as having a surgical emergency or a benign emergency. Surgical emergencies were defined as gynecologic or nongynecologic disorders diagnosed by laparoscopy and associated with a high risk of complications likely to cause severe morbidity or death in the absence of appropriate emergency surgical treatment[ 2 ].

They included ectopic pregnancy with tubal rupture or active bleeding or cardiac activity or hemoperitoneum exceeding mL[ 17 ]; pelvic inflammatory disease complicated by tubo-ovarian abscess or peritonitis; adnexal torsion; rupture of hemorrhagic ovarian cysts with hemoperitoneum exceeding mL; appendicitis; and intestinal obstruction.

Benign emergencies , as defined for this study, included acute conditions expected to resolve spontaneously or with appropriate medical treatment such as uncomplicated ectopic pregnancy, uncomplicated pelvic inflammatory disease, uncomplicated cyst, intra-cystic hemorrhage, myoma, endometriotic lesions, and pelvic adhesions. The preoperative physical and TVUS examinations, recorded as normal or abnormal, were compared to the laparoscopy findings as indicating a surgical emergency or a benign emergency.

We used multiple logistic regression to compute the crude and adjusted diagnostic odds ratios DORs of having a laparoscopically confirmed surgical emergency depending on the preoperative clinical and TVUS results. The parameter values of the model were estimated using the maximum likelihood ratio method. The adjusted diagnostic odds ratios aDORs and their confidence intervals CIs were computed from the model coefficients and their standard deviations.

P values lower than 0. In the strategy including both examinations in combination, the results were considered to suggest a surgical emergency if the physical examination OR the TVUS OR both showed abnormalities; this strategy reflected routine use of TVUS in first line, regardless of clinical findings as we perform at our ED.

To be clinically effective and safe, a first-line diagnostic strategy had to have a low false-negative rate i. The analyses were first performed on the overall population of patients then separately in the pregnant and nonpregnant patients. The required sample size was estimated as follows. To take into account the occurrence of exclusion criteria and missing data in some patients, we planned to include patients.

Among the eligible patients, 32 had missing physical examination data or no recorded ultrasound images, leaving patients for the analysis. The characteristics of the patients with missing data did not differ from those of the patients included in the analysis. Both the physical examination alone DOR, 3. TVUS alone was better than the physical examination alone false-negative rates, 5.

The strategy combining physical examination and TVUS in first-line was better than the strategy including only physical examination according to our criteria in which surgical emergencies were suspected based on abnormal clinical OR TVUS findings.

According to our data, physical examination cannot be used alone to safely rule out a surgical emergency in a woman presenting with acute pelvic pain. This suggests the benefit of adding bedside standardized ultrasonography in the first-line diagnostic management of suspected gynecologic emergencies. One of the strengths of our study is that TVUS findings are recorded routinely at our institution using a standardized protocol[ 11 ]. This standardized protocol, with a routine recording of standardized images, allows a reviewing of those scans, even a long time after.

Furthermore, we did not have to rely on a written description of the TVUS findings in the medical record. The TVUS findings were determined by blinded observers using objective criteria. These criteria are reliable and have been proven useful for diagnosing specific gynecologic emergencies[ 9 , 10 , 13 , 15 , 21 ].

It has been demonstrated that the availability of TVUS at the initial assessment of both pregnant and nonpregnant women decreased patient time management, unnecessary admissions, outpatient follow-up examinations and also modified treatment decisions[ 22 , 23 ].

Nonetheless, we did not find any published study showing clear-cut evidence that routine ultrasonography decreases unfavorable patient outcomes. We demonstrate that including around-the-clock TVUS as a first step investigation in addition to the physical examination is an effective strategy to rule out surgical emergencies at the gynecologic ED by reducing the risk of diagnostic errors. Although, this strategy optimizes the quality of ultrasound examination, our results suggest that suspecting surgical emergencies based on the physical examination alone does not perform well for the diagnosis of gynecologic emergencies.

These examinations do not replace a standard complete ultrasound examination but are performed to obtain an immediate answer to a specific clinical question[ 24 ], as FAST scanning in EDs. Bedside abdominal ultrasonography by a surgeon was also introduced several years ago as a routine examination for patients with acute abdominal pain and produced similar results, improving the rate of correct diagnoses[ 25 ].

Furthermore, experience is a key factor in the ability of transvaginal ultrasound to manage women with pelvic pain with accuracy[ 9 ]. Nonetheless, in our center, we made important efforts to implement a standardized ultrasonography protocol[ 11 ] to reduce the heterogeneity of the quality of ultrasonography performed by residents. This quality process probably increased the usefulness of bedside TVUS for the diagnosis of gynecologic emergency.

One application of this process would that these scans could be performed by anyone involved in gynecologic emergencies management with appropriate training ie ED physicians, Family Medical doctors, midwife or advanced nurse practitioners.

Thus, this accreditation could decrease the heterogeneity of ultrasound examination and allow correct interpretation in order to make correct clinical decision regarding surgical emergencies.

Nonetheless, our study has several limitations. First, we were not able to have the physical examination and TVUS done by two different individuals, in contrast to another group[ 23 ]. The physical examination was performed before TVUS, and its results may therefore have influenced the recording of the images. However, calculating the conditional statistics of one examination according to the result of the other showed no differences with the main results data not shown.

Second, our strategy of including only women who underwent laparoscopy may have led to verification bias. We chose to select patients with laparoscopy to ensure that the final diagnosis was established with certainty. However, the decision to perform laparoscopy was taken by a senior physician, based possibly on the result of the physical and TVUS findings by the resident, which may have artificially increased Se and decreased Sp of both examinations.

Third, our follow-up data on patients in whom emergency laparoscopy was deemed unnecessary may have been incomplete. We believe that the risk of missing a surgical emergency among patients who leave the ED without undergoing laparoscopy is low as pregnant women received very close follow-up after ED discharge until the hCG test became negative and patients discharged with undiagnosed surgical emergencies would eventually come back to our ED, which serves a vast geographic area.

The use of a standardized TVUS protocol and stringent objective criteria for interpreting the images may play a role in the beneficial effects of routine TVUS. Am J Emerg Med. Huchon C, Fauconnier A: Adnexal torsion: a literature review.

Fertil Steril. Gynecol Obstet Invest. Hum Reprod. Ann Surg. Okaro E, Condous G: Diagnostic and therapeutic capabilities of ultrasound in the management of pelvic pain.

Curr Opin Obstet Gynecol. Ultrasound Obstet Gynecol. Obstet Gynecol. Google Scholar. Clin Exp Obstet Gynecol. Ann Emerg Med. World J Emerg Surg. Surg Radiol Anat.

Condous GS: Ultrasound diagnosis of ectopic pregnancy.

Atlas of Ultrasound in Obstetrics and Gynecology: A Multimedia Reference

Benacerraf MD Author. This comprehensive visual tutorial is split into two distinct sections: obstetrical ultrasound and gynecological ultrasound. Each section covers normal and abnormal anatomy, pathology, and interventional procedures. Note : We will send ebook download link after confirmation of payment via paypal success. Payment methods: Visa or master card Paypal. Arthur C. Login Login with email.

The terms and definitions described may form the basis for prospective studies to predict the risk of different myometrial pathologies, based on their ultrasound appearance, and thus should be relevant for the clinician in daily practice and for clinical research. The sonographic features and use of terminology for describing the two most common myometrial lesions fibroids and adenomyosis and uterine smooth muscle tumors are presented. Keywords: adenomyosis; consensus; fibroids; leiomyosarcoma; myometrium; ultrasonography; uterus. Publication types Consensus Development Conference.

Packed with more sonographic images than ever before, the third edition of the Atlas of Ultrasound in Obstetrics and Gynecology helps you better understand and interpret sonographic imagery, and improve diagnostic accuracy of ultrasound images. This comprehensive visual tutorial is split into two distinct sections: obstetrical ultrasound and gynecological ultrasound. Each section covers normal and abnormal anatomy, pathology, and interventional procedures. About Ovid What's New. Request Info. Description Packed with more sonographic images than ever before, the third edition of the Atlas of Ultrasound in Obstetrics and Gynecology helps you better understand and interpret sonographic imagery, and improve diagnostic accuracy of ultrasound images. Features: Includes more than 1, ultrasound images that highlight normal and abnormal anatomy, pathological conditions, and procedures.

PART 2 • OBSTETRIC SONOGRAPHY Development Conference on Diagnostic Ultrasound. Imaging in gynecologist attempted a pelvic exam, which caused.

Atlas of Ultrasound in Obstetrics and Gynecology, 3rd Edition PDF

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A cross-sectional retrospective study included consecutive patients who underwent emergency laparoscopy for acute pelvic pain at a teaching hospital gynecologic emergency unit, between January 1, , and December 31, The laparoscopic diagnosis was the reference standard.

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Presented by an international team of experts, the new edition of Diagnostic Imaging: Gynecology features an exhaustive collection of imaging findings in gynecologic diseases. Note: Only Radiology member can download this ebook. Learn more here! Your email address will not be published. Completely revised content , updated reference lists, and new high-quality images keep you abreast of the latest knowledge in the field.

Ultrasound in Obstetrics & Gynecology: A Practical Approach

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