by Tammy Stearns, MS, RDMS, RVT, RT(R), FSDMS, LAS

A Couple of the Non-Negotiables of Imaging

We’ve all had those situations.  Due to the circumstances, can we quickly scan first? Typically, this situation occurs during a busy day at the Pregnancy Help Medical Clinic (PHMC) when the adrenaline is running high, with everyone feeling in a rush.  Or, it has been such a slow day, week, or month that everyone finds themselves just ready to finish the day.  Yet it is these very procedures and processes that help guide us, as imagers, to provide the mom with the most accurate information. These procedures and processes not only help ensure better quality of the scan, but they also protect us by ensuring that we have the information that we need to correctly understand her situation.   Without the following non-negotiables, as imagers, we can give a lot of possibilities, but may also find ourselves in a position of not being able to adequately know what we are possibly seeing.  As an imager, the extra time taken to ensure the presence of a positive pregnancy test and scanning with a full bladder is worth it.

Positive Pregnancy Test

“I know that we are supposed to have the pregnancy test before you scan, but could you look real quick, and we will do the test after?  She did a test at home.”

It is a common procedure to have documentation of a positive pregnancy test prior to performing the ultrasound.  Most PHMCs require the test to be performed on-site to document the results of the pregnancy test and do not rely on results from an at-home pregnancy test. This request to overlook doing the pregnancy test typically comes in one of two ways.  Either the staff performing the tests is too busy, or there is concern that once the client empties her bladder, even the smallest amount, her bladder will be completely empty for the ultrasound. 

The challenge with ultrasound is that there are many “shades of gray”.  Literally.  There are many structures that image and look alike.  There are many images that the understanding and final diagnosis of them will depend on whether the client has a positive pregnancy test or not.    The next step in her care at the Pregnancy Help Medical Clinic will be determined by the results of her pregnancy test. For example, when a client shares she is confident in her dates and is 8 weeks per her LMP, with a cystic structure being visualized on the ovary with no gestational sac seen in the endometrial cavity in the uterus, we are looking at the possibility of an ectopic pregnancy if she also had a positive pregnancy test.     If the pregnancy test is negative, then it is most likely a cyst on her ovary being imaged.  One is an emergency. The other is not.

 Another example could be a heterogenous appearance to a thickened endometrium that fills the entire endometrial cavity. The client claims she is 8 weeks by LMP.  If the pregnancy test is positive, she could have had a missed miscarriage (a miscarriage that hasn’t been evacuated from the uterus) or a molar pregnancy.  If the pregnancy test is negative, she could possibly have a missed miscarriage, as time has passed, the hormone level has dropped to insignificant levels.   Another possibility is a thickened heterogenous endometrium due to hormonal issues or infection, not pregnancy-related.

Tips to help work through the request-

• Give her a cup to empty her bladder in. This gives her a reference on how much to empty her bladder and will keep her bladder full enough to scan.
• As soon as she receives the positive pregnancy test results, give her a couple of bottles of water to drink while her mentor is spending time with her prior to bringing her over to the ultrasound exam room.

Full Bladder

“She says that she can’t fill her bladder anymore, can’t we just scan with what we’ve got?”

“She says she’s full.”

“She’s in a hurry. Can’t you just scan?”

 So many “workarounds” it seems regarding the full bladder, and yet, the full bladder is an important part of a transabdominal scan.  The full bladder gives a structural landmark that helps orient the imager to the pelvic area.    The full bladder pushes the bowel away from the area, allowing for better resolution. A full bladder will also provide what is referred to as a “sonic window”.  The sound wave travels through the fluid-filled bladder unimpeded so that when it reaches the uterus, it has a greater intensity than the portion of the sound beam that has traveled through the adjacent soft tissue.  This allows for better resolution.  Ideally, the bladder should always extend past the fundus of the uterus.  Always.  The quality of images obtained with a full bladder as opposed to a partially full or completely empty bladder is worth the wait.  A full bladder gives the imager a reference for the level of gain necessary for the exam. (This is true as long as the bladder is normal and anechoic.

A possible soft tissue area adjacent to the uterus may appear as a mass without a full bladder.  By filling the bladder, if the area is simply bowel, it may move or entirely disappear.    The anteverted or anteflexed uterus will be stretched out lengthwise with a full bladder.  With an empty bladder, it will remain in one area, making it difficult to thoroughly image the uterus.  Sometimes images can be obtained with an empty or partially filled bladder, but too often the payoff of questionable quality images or remaining questions isn’t worth the time that was saved by not filling her bladder.  The first question to be asked when evaluating a scan of the uterus will be why the bladder isn’t full.  It is standard practice transabdominally.

 Tips to help work through the request- (Same tips as above!)

• If she says her bladder is too full, let her empty her bladder a little bit. Give her a cup to empty her bladder, which gives her a reference on how much to empty her bladder, and will still keep her bladder full enough to scan.
• As soon as she receives the positive pregnancy test results, give her a couple of bottles of water to drink while her mentor is spending time with her prior to bringing her over to the ultrasound exam room.