POCUS in Obstetrics and Gynecology: ISUOG 2025 Protocol
What is POCUS in Obstetrics and Gynecology
POCUS — point-of-care ultrasound, is a targeted bedside ultrasound performed by a clinician at the time of decision-making. In obstetrics and gynecology, it is not a shortened version of an expert examination but a separate clinical tool: to confirm or exclude a specific sign, choose the patient's route, accelerate intervention, or determine the need for an urgent specialist call.
According to the ISUOG 2025 guidelines, POCUS is especially useful in emergency care, delivery wards, triage, resource-limited settings, and bedside procedures. The limitation is fundamental: if the question goes beyond the prepared protocol or the finding is uncertain, a comprehensive ultrasound by a specialist is required.
Clinical Logic: Not Diagnosis at Any Cost, but Answer to a Question
Before turning on the device, one or more bedside questions are formulated. For example: is there an intrauterine pregnancy; is there cardiac activity of the embryo or fetus; what is the fetal presentation before urgent intervention; is there free fluid in case of instability; are there gross signs of retained uterine contents after childbirth or abortion.
This task formulation protects against two errors: excessive interpretation of an incomplete study and delay in treatment for details that do not affect immediate decision-making. POCUS should be integrated into clinical examination, hemodynamic assessment, laboratory data, and local care pathways.
Classification of POCUS Scenarios by ISUOG
| Scenario Class | Typical Clinical Question | Role of POCUS | When Formal Scan is Needed |
|---|---|---|---|
| Obstetric Emergency Care | Viability, fetal position, signs of bleeding, placental or postpartum complications | Rapid triage and preparation for treatment | With uncertain visualization, planning tactics outside of an emergency decision |
| Gynecological Emergency Care | Pregnancy of unknown location, acute pelvic pain, suspicion of ectopic pregnancy or complicated mass | Identification of high-risk signs and routing | With suspicion of complex adnexal pathology, tumor, torsion, or abscess |
| Resuscitation and Trauma Context | Is there free fluid, massive bleeding, cause of instability | Support immediate decision-making along with clinical assessment | After stabilization or when clinical and ultrasound findings diverge |
| Procedural Guidance | Navigation of puncture, drainage, uterine or pelvic intervention | Increase accuracy and safety of the procedure | If anatomy is unclear or expert planning is required |
| Resource-Limited Settings | Minimally necessary information for routing | Early identification of high-risk patients | At the first opportunity — confirmatory study according to standard |
Indications in Obstetrics
In obstetrics, POCUS is applicable for pain, bleeding, trauma, acute dyspnea or shock, decreased or absent fetal movements, before emergency surgery, suspicion of abnormal fetal position, postpartum bleeding, and delayed recovery. In early stages, the main bedside tasks are pregnancy localization, presence of an embryo, cardiac activity, and signs of complication.
In the second half of pregnancy, POCUS can quickly determine presentation, fetal cardiac activity, gross amniotic fluid volume, placental location in the context of bleeding, and signs of free fluid in the abdominal cavity. However, assessment of fetal anatomy, growth, Doppler studies, chromosomal anomaly screening, and expert placentology are not tasks of the bedside protocol.
Indications in Gynecology
In gynecological emergency care, POCUS is used for acute pelvic pain, suspicion of pregnancy of unknown location, syncope, bleeding, septic picture, post-procedural complications, suspicion of pelvic fluid, or gross adnexal pathology. The method helps differentiate situations where outpatient reassessment is possible from those requiring urgent consultation, surgical readiness, or transfer.
It is important not to substitute POCUS for oncogynecological or expert transvaginal examination. Detection of a complex mass, severe pain syndrome with inconclusive findings, clinical suspicion of torsion, abscess, or ectopic pregnancy requires further evaluation regardless of how brief the bedside examination was.
Minimum Protocol Execution
The protocol begins with patient identification, clinical question, and access choice. Transabdominal access is convenient for quick triage, second half of pregnancy, trauma, and hemodynamically unstable conditions. Transvaginal access provides better detail for early pregnancy, uterus, and adnexa if clinically, technically appropriate, and with consent.
- Formulate the indication: what bedside question needs to be resolved.
- Assess safety: stability, need for immediate treatment, infection control, privacy.
- Select the probe and access, obtain a minimal set of images sufficient to answer.
- Record key frames or clips, note visualization quality.
- Formulate a conclusion in a limited format: positive, negative, or indeterminate answer.
- Assign the next action: treatment, observation, consultation, formal ultrasound, transfer.
Documentation of Results
POCUS conclusions should be brief and reproducible. They should include date and time, operator, indication, access, visualization quality, answer to the clinical question, limitations, and decision made. The wording should avoid excessive diagnoses unless confirmed within a full protocol.
For example, it is more accurate to write: bedside transabdominal ultrasound for bleeding; fetal cardiac activity visualized; cephalic presentation; placenta anterior, edge not assessed within POCUS; formal ultrasound indicated. Such a record preserves the benefit of a quick answer and does not create a false sense of completeness.
Limitations and Typical Errors
The main limitations of POCUS are operator dependence, incomplete visualization, obesity, pain, adhesions, bowel gas, early pregnancy, multiple gestations, emergency setting, and inability to save images. A negative result does not always exclude dangerous pathology, especially if clinical risk is high.
Typical errors: using POCUS for detailed screening of developmental anomalies; excluding ectopic pregnancy based solely on incomplete examination; ignoring pain with a normal picture; not documenting uncertainty; delaying surgical or resuscitation assistance for further examination. According to the ISUOG consensus, bedside ultrasound should expedite assistance, not compete with clinical decision-making.
Training, Competencies, and Quality Control
POCUS requires structured training: indications, scanning technique, recognition of normal and threatening patterns, competency limits, infection safety, data storage, and result communication. Competence should be confirmed not only by the number of studies performed but also by observed practice, image review, and compliance with local protocol.
For the department, unified report templates, a list of permitted POCUS scenarios, escalation rules, audit of discrepancies with expert ultrasound, and regular skill updates are important. This approach makes POCUS a safe team tool, not an individual improvisation at the device.
Practical Conclusion for Emergency Care
POCUS in obstetrics and gynecology is advisable when the answer immediately changes triage, treatment, or routing. The bedside protocol is especially valuable in bleeding, pain, instability, early pregnancy of unknown location, postpartum complications, and before urgent interventions.
The optimal application formula: clinical question, limited scanning, documented answer, acknowledgment of limitations, and timely escalation. In this format, the ISUOG 2025 guidelines position POCUS as a supplement to standard obstetric-gynecological care, not a replacement.
Frequently asked questions
Can bedside POCUS replace expert ultrasound?
No. POCUS answers a limited clinical question at the patient's bedside. Screening of fetal anatomy, growth assessment, Doppler studies, oncogynecological evaluation, and complex adnexal masses require formal examination.
When is POCUS most useful in obstetric emergencies?
In cases of bleeding, pain, trauma, hemodynamic instability, suspected early pregnancy complications, postpartum bleeding, and before urgent interventions when the result immediately changes the route or treatment.
How should POCUS conclusions be documented?
Indication, access, visualization quality, specific answer to the question, limitations, and further action should be noted. If the answer is indeterminate, it should be explicitly recorded with a referral for expert ultrasound or consultation.