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Ultrasound, pregnant uterus, real time with image documentation, transvaginal

CPT4 code

Name of the Procedure:

Ultrasound, pregnant uterus, real time with image documentation, transvaginal
Common Names: Transvaginal ultrasound, endovaginal ultrasound

Summary

A transvaginal ultrasound is a diagnostic imaging procedure used to visualize the pregnant uterus and developing fetus. It involves inserting an ultrasound probe into the vaginal canal to capture detailed images in real time.

Purpose

This procedure is designed to monitor the early stages of pregnancy, evaluate the health and development of the fetus, and assess the condition of the uterus and surrounding structures. It can help detect complications such as ectopic pregnancy, fetal abnormalities, and issues with the placenta.

Indications

  • Confirmation of early pregnancy
  • Investigation of abnormal bleeding or pain during pregnancy
  • Assessment of fetal heart rate
  • Evaluation of suspected ectopic pregnancy
  • Monitoring high-risk pregnancies
  • Checking for abnormalities in the uterus or ovaries

Preparation

  • Patients may be instructed to have an empty bladder before the procedure.
  • No specific fasting or medication adjustments are typically required.
  • A preliminary abdominal ultrasound may be performed.

Procedure Description

  1. The patient will lie on an examination table and place her feet in stirrups.
  2. A protective cover is placed over the ultrasound probe, which is lubricated with gel.
  3. The probe is gently inserted into the vagina.
  4. Real-time images of the uterus and fetus are displayed on a monitor.
  5. The ultrasound technician or radiologist maneuvers the probe to obtain different views and document images.
  6. The procedure generally does not require anesthesia or sedation.

Duration

The procedure typically takes between 20 to 30 minutes.

Setting

Performed in a hospital radiology department, outpatient clinic, or specialized ultrasound unit.

Personnel

  • Radiologist or Obstetrician-Gynecologist (OB/GYN)
  • Ultrasound Technician (Sonographer)
  • Nursing staff for support

Risks and Complications

  • Minimal risk associated with the procedure.
  • Rare slight discomfort or pressure during probe insertion.
  • No significant complications expected.

Benefits

  • High resolution images of the uterus and fetus, especially in early pregnancy stages.
  • Early detection of potential pregnancy complications.
  • Accurate monitoring of fetal development and health.

Recovery

  • No recovery time required; patients can resume normal activities immediately.
  • Post-procedure instructions typically are not needed.
  • Follow-up appointments may be scheduled based on findings.

Alternatives

  • Abdominal ultrasound: Less invasive, but may be less effective for early pregnancy evaluation.
  • MRI: Used in specific situations where more detailed imaging is required, though less common.

Patient Experience

  • Patients may feel mild discomfort or pressure during probe insertion and manipulation.
  • Most patients tolerate the procedure well without the need for pain management.
  • The procedure is generally quick, and patients can expect to leave the clinic shortly afterward.

Medical Policies and Guidelines for Ultrasound, pregnant uterus, real time with image documentation, transvaginal

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