Transcript Alternate Diagnosis in Pre-Embolization Imaging for Fibroids

Acute Female Pelvic
Pain: U/S Features
Melissa Kern,
PGY-4
Courtesy Drs. M. Atri A.
Menard, H. Dua
Introduction

Female pelvic pain common presenting
complaint in ER radiology

TV U/S best first-line imaging modality
More SN and SP than CT
No radiation or contrast
Direct patient contact
Clinical Relevance
A normal pelvic U/S high
negative predictive value
for serious pelvic
pathology.
Common Causes of ER ♀ Pelvic
Pain

Gynecologic





Ovarian cyst rupture or hemorrhage
PID
Ovarian torsion
Ectopic pregnancy
Non-gynecologic



Ureterolithiasis
Appendicitis
Diverticulitis
Ovarian Cysts…. the basics
Estrogen phase: follicles are at their
smallest (typically < 5mm)
 By day 10, one dominates and increases
in size to about 2-2.5cm (rest regress)
 LH surge at mid cycle causes mature
follicle to rupture and release egg – follicle
then normally loses its fluid, rapidly shrinks
and becomes corpus luteum

Ovarian Cysts

Pain may occur:
 As
follicle matures and ovarian capsule is stretched
 At time of ovulation
 Due to cyst rupture

Dominant follicle fails to expel oocyte the follicle may further
enlarge into a cyst
 Due

to cyst hemorrhage
After shrinking, CL may internally bleeds and re-expands =
hemorrhagic cyst
Typically reserve the term cyst for
structures larger than 2.5-3.0cm
TV U/S Findings

Ruptured Ovarian Cyst
 No
detectable ovarian cyst
 Collapsed
 Free
cyst
pelvic fluid (3-5 ml physiologic)
TV U/S Findings

Hemorrhagic Cyst
 Typically,
complex mass with internal echoes and
some degree of through transmission
 Fresh
blood may be anechoic initially
 In
the first 24hrs…. low-level echoes in a fine,
lacelike, reticular pattern
 Solid
pelvic mass
 Amorphous
 Echogenic
blood clot
free pelvic fluid
Hemorrhagic Cyst


The Many Faces of Hemorrhagic
Cysts
Vascular Ring Sign


Mixed solid cystic hemorrhagic cyst.
Vascularity of the periphery of a mass is a very helpful sign to differentiate a
functional mass from an endometrioma or a cancer .
Ovarian cancers are not usually predominantly solid (exception: rare granulosa cell
tumor). Cystic cancers do not show a vascular ring in the absence of a vascular solid
component.
Retractile clot
Hemorrhagic Cysts….the Bottom
Line
 Can
be any size and echogenicity
 Caution in post menopausal women
 Helpful signs:
Almost all will resolve
within 1-2 menstrual
Vascular ring
cycles
Through transmission



Retractile clot
??? Hemorrhagic Cyst
Endometrioma
Endometrioma
Affect ~10% premenopausal women
 Complex cystic masses with homogenous
low-level echoes or ground glass
appearance (due to repeated episodes of
cyclic bleeding)
 Follow-up imaging may be necessary to
differentiate endometriomas from
hemorrhagic ovarian cysts

Pelvic Inflammatory Disease
Complication of STDs (chlamydia, gonorrhea)
 Estimated incidence US – 1 million acute
cases per year
 Can lead to infertility or ectopic pregnancy
 PID is a clinical and laboratory diagnosis
and a negative u/s doesn’t exclude milder
forms

Utility of U/S

Determine the extent of disease

Evaluate the non-responders to
treatment

Follow-up patients post treatment

Approach to drain abscesses
PID: U/S Findings

*Thickened vascular fallopian tube (often bilateral)
• Fluid-filled +/- debris (non-specific)
• Collapsed

Increased volume and indistinct margins of ovaries

Adnexal inflamed fat and tenderness

Tubo-ovarian abscess

Echogenic pelvic fluid
Thickened Fallopian Tube
PID
OV


RIGHT FT

OV

LEFT FT
PID
OV

OV

RIGHT FT

OV






LEFT FT
Pyosalpinx
OV




RIGHT FT


Pyosalpinx



Surrounding inflammation
Ovarian Torsion
 Partial
or complete twist of ovarian
pedicle
obstruction 
ovarian edema  arterial
compromise  ischemia/infarction
 Venous/lymphatic
Ovarian Torsion
♀: idiopathic
 Adults: often associated with benign
mass
 Pre-pubertal
 Often
present with acute pain +
vomiting
Ovarian Torsion - Treatment
 Emergent
surgical de-torsion
 Salvage rates better for ovarian vs.
testicular torsion
 Symptom duration does not always
predict viablility
U/S Findings:

Twisting (whorl) sign
Presence
of Doppler
Increased ovarian volume
(stromal edema)
Multipleflow
small peripheral
ovarian
cysts
does
not
Multiple
echogenic cysts
in the same ovary
exclude
torsion!




Free fluid

Associated mass
U/S Findings:

Absence or high resistance to arterial flow
with absent venous flow, particularly
when accompanied by ovarian
enlargement is highly suggestive of
ovarian torsion
The “Whorl” Sign
Ovarian Torsion
Ectopic Pregnancy




Implantation of fertilized ovum outside
endometrial lining
2% of all pregnancies
Leading cause of death during 1st
trimester
9-14% mortality rate
Ectopic Pregnancy

Symptoms:

5-9wk hx amenorrhea
 Mild pelvic pain
 Vaginal spotting
 Asymptomatic (50%)
Ectopic Pregnancy

Risk Factors:
 Previous
hx ectopic pregnancy
 Tubal surgery
 PID
 Use of IUD
 Previous c-section
 IVF
 Congenital uterine anomalies
(12%)
(2-4%)
(70%)
(11%)
(1-3%)
(<1%)
(<1%)

fallopian tubes (95%)
Intra-abdominal: 0.03-1%
Heterotopic: 1-3% IVF pts
Ectopic Pregnancy - Treatment

Medical (Methotrexate)
 Hemodynamically stable
 No evidence of tube rupture
(small volume free fluid)
 ßHCG and size criteria (site specific)

Surgical
 Salpingotomy
 Salpinectomy

US-guided local injection of Methotrexate or KCL
 Preferred for cornual or cervical ectopics
U/S Criteria


Discriminatory level for detecting IUP is
ßHCG > 2000
If ßHCG > 2000 and no IUP:
 EP
 Early

pregnancy failure
If ßHCG < 2000 and no IUP:
 EP
 Early
pregnancy failure
 Normal early IUP
U/S Findings

Normal IUP:
 Intradecidual
sign (4.5wks): small collection of
fluid eccentrically located within the
endometrium
 Double decidual sign (5wks): 2 concentric
hyperechoic rings that surround an anechoic
gestational sac
 Yolk sac (5.5wks): when GS reaches 8mm
Double decidual sac sign in a normal IUP
EP: U/S Findings



No IUP
Normal endometrium
Thin-walled decidual cysts (found at junction endo- and
myometrium in normal and abnormal pregnancies)

“Pseudogestational sac” sign:
 Thick
decidual reaction surround
intrauterine fluid (no double decidual sign)
 Located centrally within endometrial canal
 10% patients with EP
Pseudogestational sac in an ectopic pregnancy
EP: U/S Findings

Tubal/adnexal mass SEPARATE FROM
OVARY
 “Tubal ring” sign: hyperechoic ring surround
an extra-uterine gestational sac
 *“Ring
of fire” sign: peripheral
hypervascularity of hyperechoic ring
*non-specific, may also be seen surrounding
normal maturing follicle, CL….. confirm that
separate from the ovary.
EP: U/S Findings

Echogenic free-fluid in cul-de-sac

U/S completely negative in 5-10%

85% of ectopics on same side as CL
EP vs. CLC
CLC
EP
EP vs. CLC
CLC
EP
EP vs. CLC
Ring of Fire
Tubal Ectopic
CLC
EP
Acute pelvic pain
and + ßHCG is EP
until proven
otherwise!
Follow-up
Average doubling time ßHCG in a normal,
viable IUP is ~48hrs
 If no IUP, no ectopic identified in ßHCG
+’ve ♀, suggest serial ßHCG and f/u u/s
as clinically indicated
 In EP’s serum HCG levels rise at much
slower rate

Case 1
Case 2


Case 3
Case 4
Case 5
Case 6
Case 7
Case 8
Case 9
THANK YOU!!!!