POINT OF CARE

ULTRASONOGRAPHY
(POCUS) for Obstetrics
Introduction
Point of care ultrasonography (POC-US) is not a substitute for formal ultrasound
examinations performed by radiologists, but a limited, goal directed examination for
healthcare providers to answer simple binary questions (yes/no) to assist in immediate
decision-making and for use in ultrasound guided bedside procedures.
POC-US may be used for the following purposes:
 Resuscitation e.g. determining the cause of shock or cardiac arrest, determine cardiac
standstill
 Diagnostic e.g. pleural effusions, ascites, pericardial effusions, intraperitoneal
bleeding from bunt abdominal trauma, ruptured ectopic pregnancy
 Symptom or sign-based e.g. determining type of shock
 Therapeutic e.g. for ultrasound guided paracentesis, pleurocentesis
Indeterminate scans and suboptimal images are common and over-interpretation thereof is
discouraged. Unless good images are obtained, the findings of the scan should not be
included in the decision-making process.

Physics
Sound is a mechanical wave, which requires a medium in which to travel. More accurately, it
is a series of pressure waves propagating through a medium.
The wavelength is the distance travelled during one cycle, the frequency of the wave is
measured in cycles per second or Hertz

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For humans audible sound ranges between 16 Hz and 20,000 Hz (20 KHz). Higher wave
frequencies are referred to as “ultrasound” (> 20 KHz)

The source of the ultrasound waves is the piezoelectric crystal in the transducer which
converts electrical current into mechanical pressure waves (ultrasound waves). When the
ultrasound waves are reflected back from within the tissues, the transducer converts them
back to electrical current. In essence, the crystal switches from ‘sending’ into ‘listening’
mode and awaits returning ultrasound echoes. Actually, > 99% of the time is spent
'listening'. This cycle is repeated several million times per second - this principle is called
'pulse echo' principle. Returning sound waves are converted into electrical current then to
images on the ultrasound monitor.

Diagnostic ultrasound used for common medical imaging uses frequencies between 2 and 20
million Hertz (Megahertz, MHz). In POC-US, frequencies of 2 - 5 MHz with a mean of 3.5
MHz are used for an adult and 5 MHz for children and smaller adults.
a) Lower frequencies (2-5 MHz) are able to penetrate deeper into tissue e.g. heart,
abdomen, but show poorer resolution.
b) On the other hand, higher frequency ultrasound (5-12 MHz) will display more detail
with a higher resolution in exchange for less depth penetration. They are used to
visualize superficial structures e.g. soft tissues, and for ultrasound guided procedures

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Probes

a) Large convex probe: Main POC-US utilization is transabdominal sonography.

Produces a sector image with a large curved top.
b) Micro convex probe: Utilized for transabdominal or transthoracic sonography.
Produces a sector shaped image with a small curved top.
c) Linear probe: Main utilization is vascular sonography or evaluation of superficial
soft tissue structures. It produces a rectangular image. The active element is
arranged in a straight line.
d) Sector probe (phased array transducer): Sector probes are also utilized in the POC-
US, especially for transthoracic sonography. They produce a pie-shaped image.
There are fewer ‘crystals’ in the sector probe with an overall lower resolution than
other probes. It has the advantage of requiring;
 only very minimal area of skin contact or
 a very small sonographic window to obtain an image e.g. in-between ribs.

Ultrasound Modes
a) The most important mode for the ultrasound-beginner is the B-mode - ‘brightness
mode’ and provides structural information utilizing different shades of grey (or
different ‘brightness’) in a two-dimensional image.
b) M-mode stands for ‘motion mode’. It captures returning echoes in only one line of
the B-mode image but displays them over a time axis. Movement of structures
positioned in that line can now be visualized. Often M-mode and B-mode are
displayed together on the ultrasound monitor.

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 c) The Doppler mode utilizes a phenomenon called ‘Doppler shift’, which is a change
in frequency from the sent to the returning sound wave. The Doppler mode
examines the characteristics of direction and speed of tissue motion and blood flow
and presents it in audible, colour or spectral displays.

Acoustic windows
The speed with which an ultrasound wave travels through a medium is determined by the
density and stiffness of the medium. The greater the stiffness, the faster the wave will travel.
This means that sound waves travel faster in solids > liquids or gases. Acoustic windows
involve areas conducive to ultrasound transmission such as the liver, intercostal muscles and
chest wall.

Orientation
 Transverse Plane - Also known as an axial plane or cross section. It separates the
superior from the inferior, or, the head from the feet.
 Sagittal Plane - Oriented perpendicular to the ground, separating left from right. The
"mid-sagittal plane" is a sagittal plane that is exactly in the middle of the body.
 Coronal Plane - Also known as the frontal plane. It separates the anterior from the
posterior or the front from the back.
 Oblique Plane - The probe is oriented neither parallel to, nor at right angles from,
coronal, sagittal or transverse planes.
 Longitudinal Plane - The longitudinal plane is perpendicular to the transverse plane
and can be either the coronal plane or sagittal plane.

Imaging
The picture on the monitor is essentially a displayed version of the ultrasound “beam” that
emanates from the transducer face. Structures closest to the transducer are displayed at the
top of the image deemed the near field. The deeper structures are displayed at the bottom
of the screen in the far field. The focal zone is that area of greatest resolution (usually
marked with a carat) that indicates the transition from the near to far field.
Remember to confirm or refute findings seen on 1 view with a second or multiple views.
Findings seen on a single view may be secondary to artefact or may under- or over-represent
an abnormal finding. Be sure to interrogate any abnormal finding from multiple different
views in order to confirm and better characterize the finding. Avoid arriving at a final
impression until multiple views have been attempted and used.

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Echogenicity
Echogenicity of the tissue refers to the ability to reflect or transmit US waves in the context
of surrounding tissues. Whenever there is an interface of structures with different
echogenicities, a visible difference in contrast will be apparent on the screen.

Based on echogenicity, tissue can be characterized as;

1. Isoechoic – equal to surrounding structures
2. Hyperechoic – brighter than surrounding structures (white on the screen)
3. Hypoechoic – darker than surrounding structures (grey on the screen)
4. Anechoic - black on the screen

Attenuation
This is the decrease in intensity and amplitude of sound waves as they travel through a
medium. This is the reason why echoes from deeper structures are weaker than echoes from
superficial areas.
Scatter - Scatter occurs when ultrasound waves encounter a medium with a non-
homogeneous surface. A small portion of the sound wave is scattered in random directions
while most of the original wave continues to travel in its original path.

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Artefacts
 Shadowing: This artefact is caused by partial or total reflection or absorption of

the sound energy. A much weaker signal returns from behind a strong reflector (air)
or sound-absorbing structure (gallstone, kidney stone, bone)

 Posterior Enhancement: In posterior enhancement, the area behind an echo-weak or

echo-free structure appears brighter (more echogenic) than its surrounding structures.
This occurs because neighbouring signals had to pass through more attenuating
structures and return with weaker echoes

 Edge Shadowing: The lateral edge shadow is a thin acoustic shadow that appears
beyond the edges of cystic structures. Sound waves encountering a cystic wall or a
curved surface at a tangential angle are scattered and refracted, leading to energy loss
and the formation of a shadow.

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 Propagation Artefacts:
a) Reverberation: Reverberation occurs when ultrasound waves encounter two
highly reflective layers e.g. layers of fascia. The waves are bounced back and
forth between the two layers before travelling back. The probe will detect a
prolonged travelling time and assume a longer travelling distance and display
additional ‘reverberated’ images in a deeper tissue layer.

b) Comet Tail: A comet tail artefact is similar to reverberation. It is produced by

the front and back of a very strong reflector (air bubble, BB gun pellet). The
reverberations are spaced very narrowly and blend into a small band.

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 Mirror Imaging: If a structure is located close to a highly reflective interface (such
as the diaphragm), it is detected and displayed in its normal position. However, the
strong reflector causes additional sound waves to bend towards the neighbouring
anatomy, from where they are bounced back towards the strong reflector and return to
the transducer. These sound waves have a longer travel time and are perceived as an
additional anatomic structure. The image is duplicated on the other side of the strong
reflector.

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Ultrasound in pregnancy
Adapted from the Participant Handbook: Basic Obstetric Ultrasound Training for Healthcare Providers,
collaboratively developed by the University Of Washington Department Of Radiology and the University of
Washington International Training and Education Centre for Health (I‐TECH).

Use of point-of-care ultrasonography in pregnancy centres on;

 detection of an intrauterine pregnancy (IUP),
 detection of an ectopic pregnancy,
 detection of foetal heart rate in all stages of pregnancy,
 dating of the pregnancy, and
 detection of significant free fluid.
Bedside pelvic ultrasound during the first trimester of pregnancy can be used to exclude
ectopic pregnancy by demonstrating an intrauterine pregnancy. When intrauterine foetal
anatomy is visualized at the bedside, ectopic pregnancy is ruled out with a negative
predictive value of essentially 100%.

Early pregnancy scanning (1st Trimester)

One in every thirteen women presenting to the emergency department (ED) in their first
trimester of pregnancy with abdominal or pelvic pain or vaginal bleeding will eventually be
diagnosed with an ectopic pregnancy. Pelvic ultrasound performed in the emergency
department significantly shortens emergency department length of stay for women with an
intrauterine pregnancy and reduces the incidence of ectopic pregnancy rupture in discharged
patients.

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 a) Identifying the gestational sac (GS)
- Earliest can see is about 6 weeks gestational age (GA).
- An intrauterine sac is NOT definitive evidence of an intrauterine pregnancy
until a yolk sac or foetal pole can be visualized.

UTERINE
FUNDUS BLADDER

UTERINE CERVIX
BODY

Normal female longitudinal pelvic view Many authors consider a clear double
decidual sign as the first definitive
evidence of an intrauterine pregnancy.
The double decidual sign is two concentric
echogenic rings surrounding a gestational
sac.

GS
GS

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b) Measuring mean GS diameter to determine gestational age:
 Use mean gestational sac diameter to determine gestational age only if you can
see only a gestational sac or a yolk sac.
 Measure the greatest length, width and height of the sac.

 Calculate the average (Add the 3 values and divide by 3). This is compared to the
standard table to determine the GA. Sometimes the machine will do an automatic
calculation for you.
c) Identify the yolk sac
- Visible when the gestational sac is 10-15mm in size.
- A yolk sac is a sure sign of intrauterine pregnancy

YOLK SAC
YOLK SAC

GS GS

- If you see a gestational sac but no yolk sac, repeat scan in 2 weeks to confirm
pregnancy

d) Identify foetal cardiac activity

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 e) Measure crown rump length
 Once you can see the foetus, use the crown rump length to determine the
gestational age. This is accurate to 3-7 days of the actual age

 Use mid-sagittal plane.

 Foetus should be in neutral position
and in profile (can see face).
 Measure from the top of the head to
the outer edge of the rump (greatest
length)
 Do NOT include the foetal limbs or the
yolk sac.
 Do not change due date after first
ultrasound with heartbeat, even if more
measurements are taken later.

Ectopic pregnancy
An ectopic pregnancy should be suspected in the presence of both a positive urine
pregnancy test and an absent gestational sac or a pseudo-gestational sac on
ultrasonography. The pseudo-gestational sac is an intrauterine anechoic sac-like structure
that may be mistaken for an early viable pregnancy. It actually represents endometrial
breakdown in the presence of an ectopic pregnancy. A pseudo-gestational sac may be
differentiated from a true gestational sac by its central location, oval shape, and lack of a
thick echogenic ring of chorionic villi, a yolk sac or foetal pole.

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The endometrial sac does not have a surrounding chorionic ring and free fluid is visible in the
posterior cul-de-sac. This patient was found to have a ruptured ectopic pregnancy in the
operating room.

Always visualize the hepatorenal space in addition to the pelvic region when suspecting an
ectopic pregnancy. Free fluid in the pelvic cul-de-sac is a frequent normal physiologic
finding in women but should never track more than one third of the way up the
posterior wall of the uterus. Quantity of free fluid should always be evaluated as it is also
associated with both ruptured (more commonly) and un-ruptured ectopic
pregnancies. Additionally, the likelihood of rupture increases as the quantity of free fluid
increases. Since clotted blood in the pelvic cul-de-sac after tubal rupture can obscure active
haemorrhage, a brief scan through the hepatorenal space can often lead to quick identification
of free fluid. In the first trimester, the presence of free fluid in the hepatorenal space of a
symptomatic patient without an intrauterine pregnancy is virtually diagnostic of a
ruptured ectopic pregnancy. Immediate obstetrical consultation is advised in this scenario.

Interstitial Pregnancy
Interstitial pregnancy is the implantation of the gestational sac into the proximal portion of
the fallopian tube within the muscular wall of the uterus. Ultrasound findings suggestive of
interstitial pregnancy include;
 an eccentrically located gestational sac surrounded by a thin (< 5 mm) or incomplete
myometrial mantle,
 an empty uterine cavity, and
 the “interstitial line” sign: an echogenic line extending from the endometrium into
the cornual region and abutting the midportion of the interstitial mass or gestational
sac.

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Cervical Pregnancy
Cervical pregnancy is defined as implantation of the gestational sac within the cervix below
the level of the internal os. Although relatively uncommon (1% of all ectopic pregnancies),
cervical pregnancy may result in massive haemorrhage. Therefore, when a gestational sac is
identified within the cervix, it is imperative to distinguish ectopic pregnancy from the
cervical phase of an abortion.

Sonographic findings suggestive of cervical implantation include:

 An empty uterine cavity
 An hour-glass shaped uterus
 A gestational sac containing a yolk sac, foetal pole or heart beat within the cervix
 A gestational sac within the cervix with a closed internal os
 Peritrophoblastic blood flow on colour Doppler

yolk sac

Sonographic findings suggestive of spontaneous abortion include:

 A crenated or collapsing gestational sac
 Absence of foetal heart activity by week 8 of gestation
 Sliding of the gestational sac within the cervix when the transducer is gently pressed
against the cervix (the “sliding sign”)
 A dilated internal os
 Movement or regression of the gestational sac on repeat ultrasound

Anembryonic gestation (or blighted ovum), in which the embryo never develops within the
gestational sac, is defined as the absence of an embryo when the mean gestational sac
diameter is > 20 mm.

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Late pregnancy scanning (2nd and 3rd Trimesters)
a) Identify foetal cardiac activity
b) Correctly identify foetal position and foetal number: ROBUST (Rapid Obstetric
Ultrasound Survey)

c) Accurately measure biparietal diameter

 Measure at the level of the thalamus and cavum septum pellucidum (CSP)

Falx
cebri
+

 Make sure that :

- Entire skull looks smooth and oval
- Brain structures are equal on both sides

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  Measure from the outer edge of the skull to the inner edge
 The line between the cursors should be perpendicular (90o) to the falx.
 Measure at least two times to get an accurate measurement
 If you can’t see the head well, do not take these measurements for foetal
dating.

d) Accurately measure head circumference

 Measure at the same level as BPD

 Position ellipse at the outer margin of skull on the skin

 Entire skull should appear smooth and oval.

e) Accurately measure abdominal circumference

 Measure at the level of the umbilical vein

 Make sure you SEE the stomach and spine
 Make sure you DON’T SEE the kidneys
and bladder
 Abdomen should appear round
 Position ellipse at outer edge of skin
 Make 2 measurements to confirm accuracy
 If you can’t see the abdomen well, do not
take these measurements for foetal dating.

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f) Accurately measure femur length
 Rotate the transducer until the femur is as long as possible.

 Measure the greatest length of the bone.

 Note: If you see two bones next to each other or fingers or toes, you are
not at the femur!

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Placenta

a) Identifying the position of the placenta

Anterior Posterior

PL

PL

Fundal Lateral

PL PL

The placenta should be over 2 cm from the internal os of the cervix. If placenta is in
normal position on the first ultrasound in the 1st or 2nd trimester, praevia will not
develop later in pregnancy. Low-lying or marginal praevia seen early in the 2nd
trimester will often be normal by the time of delivery.

CAUTION!

A full bladder can make the placenta appear lower than it is. Repeat the ultrasound
with empty bladder.

 Contractions can push the placenta toward the os. Repeat the ultrasound in 30
minutes if you suspect low-lying placenta or praevia.

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b) Placenta Praevia
If the placenta is less than 2 cm from the edge of the internal os of the cervix, this is
placenta praevia. It may be marginal praevia (< 2cm off the edge of cervical internal
os) or complete placenta praevia if the placenta completely obstructs the internal os.

Marginal Placenta Praevia

Complete Placenta Praevia

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c) Placenta abruptio

BLOOD

PL

Ultrasound cannot rule out placental abruption because the abruption may have been
decompressed externally and a hematoma may not be visible. If no placenta praevia is
seen, presume vaginal bleeding in late pregnancy to be abruption. Immediate
involvement of an obstetrician in the decision-making process is warranted in
suspected placenta praevia or placental abruption.

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