Gynecologic Emergencies - SD

Introduction

My name is Sandra Allison.
I'm from Georgetown University Hospital
and I'll be speaking about gynecologic emergencies.
This lecture is on gynecologic emergencies.
I have no disclosures.

The objectives are to discuss the sonographic features of
and pitfalls in diagnosing ovarian torsion,
discuss sonographic features of pelvic inflammatory disease
and list the sonographic features of hemorrhagic cysts
and endometriomas.

Challenge Cases

To get started, here are four challenge cases
and these cases will be covered
during these next 30 minutes,
and I invite you to look at these cases
and try to decide on their diagnoses.

Ovarian Torsion

Let's start with torsion.
There are many non-specific findings with torsion,
but the most common cited in the literature is a variant.
Enlargement is important.
That diagnosis is made as quickly as possible
as salvage rate drops over time.
And one thing I hope to convince you by the end
of this talk is that doppler is unreliable both
for viability assessment or for diagnosing torsion.

Here we have an ER patient with pelvic pain.
Notice the asymmetric size between the two ovaries.
The right ovary is enlarged.
It's increased in genicity
and the follicles are pushed over to the periphery.
Color doppler failed to reveal any vascularity,
so did spectral doppler.
This is a sagittal view through the uterus.
Here we have the cervix, the uterus,
and we see that the ovary is displaced into the cul-de-sac.
This is a patient with ovarian torsion
and which finding do you believe is the most important?
In this case, and in many cases it is displacement
of the ovary into the cul-de-sac
or can sometimes be seen above or superior to the uterus.

Here's a patient also presenting with right pelvic pain.
We have comparison views of the ovaries.
You see there's a discrepant size between the ovaries.
We don't have as much detail
because this was done transabdominally,
the patient could not get a transvaginal exam.
And from this study we see that there
is an arterial tracing
provided to demonstrate flow in the ovary.
If you look closely, it's very hard
to tell whether this tracing was obtained from within
or around the ovary.
This was a patient with ovarian torsion
and the best clue is the asymmetric size enlargement
of the affected right ovary.

Here's a 13-year-old who presented with acute pelvic pain.
You can see here the left ovary is enlarged due
to the presence of a hemorrhagic cyst.
The color Doppler failed to disclose any
vascularity in this ovary.
It's unclear whether this is
because the ovarian parenchyma is compressed
by this large cyst or whether there is lack of flow.
Here is a comparison between the two ovaries.
You see the difference in appearance
and size between the left and right ovary.
When spectral doppler was performed,
arterial flow was demonstrated in the left ovary
and here's a comparison with the right ovary.
Because there was arterial flow,
even though it was asymmetric, it was felt to be related
to compression by the hemorrhagic cyst
and the diagnosis of no torsion was given.
In re-review, you can see this is a long
or sagittal view of the uterus,
and again, the ovary is placed in the cul-de-sac.
This is the enlarged ovary with a hemorrhagic cyst
and in the operating room this ovary was torsed.
So again, the position of the ovary
was the important factor in determining that it was torsed.
Even when you don't have much detail, such
as in these images, you can see
that the ovary is enlarged in relation to the uterus.
This right ovary is found behind the uterus
on this sagittal view of the uterus.
Here we can see that the ovary is displaced
behind the uterus into the cul-de-sac.
But what is also useful is comparison with old studies
where you see that the right ovary at a time when a patient
was pregnant is located in the right ovarian fossa.
And now you can see that when it was torsed,
it was displaced into the cul-de-sac.

Now how about this case? We have patient presenting
with right pelvic pain.
We see asymmetric size between the right and left ovary.
The right ovary is enlarged.
There's echogenic stroma within the right ovary
perhaps due to hemorrhage.
The follicles are displaced and compressed
and we see that there is arterial flow in the right ovary
and although the flow is asymmetric, there is arterial flow.
Is this right ovary torsed?
Well, the pathology on this was torsion
and it's just to show that the presence
of arterial flow does not exclude the diagnosis of torsion.

How about venous flow?
Well, here's a patient presenting with left pelvic pain.
Again, we have a comparison between the left
and the right ovary.
The right ovary is normal in size and appearance.
The left ovary is enlarged. It may be displaced.
It's hard to tell due to the enlarged hemorrhage exist
or hemorrhage within the left ovary.
In this case, venous flow was found in the left ovary,
but this is a case of ovarian torsion again demonstrating
that the absence or presence of arterial venous flow is not
as reliable in making the diagnosis.

Now this 26-year-old presented with left pelvic pain.
Again, we have a comparison between the right
and the left ovary.
We see the left ovary is more echogenic, it is enlarged.
There's hemorrhage within the ovary.
The follicles are pushed to the periphery.
There is high resistance arterial flow in this left ovary.
You can compare it with the flow
or the pattern of flow in the right ovary.
There was also venous flow detected in this left ovary
and since the patient's pain was improving,
the patient was sent home with the instruction to return
if the pain should return.
So at the time it was felt
that the patient may have torsed their ovary
but it was currently detorsed.
The patient again feels acute pelvic pain
and returns to the emergency room.
Again, we see size discrepancy between the ovaries.
The left ovary is enlarged.
Echogenic follicles are displaced to the periphery,
but this time the spectral Doppler shows improvement
in arterial flow to the left ovary.
Again, it was felt that perhaps
the patient had a large hemorrhagic cyst in the ovary,
which was now retracting accounting for the improved flow
and the patient was sent home.
Once again, the patient felt acute pain in the middle
of the night returned to the emergency department,
but in this case we again see the enlarged ovary,
but absence of flow on the color Doppler examination,
this patient went to the operating room
and at this point the ovary had decreased.
So this illustrates the importance
of making the diagnosis early
as the salvage rates decrease over time.
Upon re-review of the original images from the first
examination, we could see the ovary was located deep in the
cul-de-sac posterior to the uterus,
and the diagnosis of torsion
should have been made more strongly.
Other images from the original study, we see this curious
cystic structure in the left
andnexa adjacent to the left ovary.
Now this almost has the appearance of an ectopic pregnancy
and in fact, query was made as to whether the patient
presenting with pelvic pain was pregnant.
The beta HCG test came back negative,
but I want to point out here the blood vessels
that are wrapping around this structure
and this represents the twisted vascular pedicle
in the setting of torsion.
It's been sometimes described as a target sign
or a whirlpool or a snail,
and this is a blood clot in the pinched off fallopian tube.
To better illustrate this, we see a cine clip
through that adnexa.
You can see that as we scan through this,
you can see the blood vessel swirling around.
Show you one more time again illustrating the twisting
of the vascular pedicle.

In this case of torsion,
these images were provided by Dr. Fe Lang. We see a patient with left lower quadrant pain.
We again see an enlarged left ovary.
Follicles are displaced
to the periphery hemorrhage within the ovary.
On this transabdominal view, we see the uterus
and the ovary that is enlarged.
You can see its size relation to the uterus.
You can also see that the ovary is displaced into the
cul-de-sac and posteriorly.
But when Doppler was performed,
there's exuberant flow within this ovary.
Is this a case of torsion?
Well, this is a case of torsion and detorsion.
When the ovary detorses,
there is compensatory increased flow into the ovary,
which can present with its appearance.

Here is a patient who presents with suprapubic pain.
It's important in patients with ovarian torsion
to perhaps look for a leading point
or a mass that may cause the torsion.
Now because this patient presented with suprapubic pain,
a CT scan was ordered,
the on-call reading was correctly made
of a dermoid cyst involving the ovary.
You can see the fat within the cystic structure.
But because a patient was presented with pain,
a transvaginal study was performed to exclude torsion.
Images
of the right ovary demonstrate the classic appearance
of a dermoid cyst.
We have a component made out of the sebaceous material
composed of low level echoes.
We also have an echogenic nodule
and some linear echoes relating
to the hair within the dermoid.
Now doppler failed to provide any vascularity
or any detectable vascularity.
In cases such as this, it is difficult to tell
what part of the ovary can be interrogated for vascularity
as the ovarian parenchyma may be unidentifiable or stretched
or thinned by this large dermoid cyst.
So in this case, the ultrasound reading could not help
to determine the torsion,
but upon re-review of the CT images, we can see
that the ovary is displaced anterior to the uterus
and superiorly.
So we know that this was twisted on its pedicle
and this is a case of torsion
that could have been called from the CT scan.

So for torsion, it is important to use doppler,
but I suggest not betting on doppler
to make the final diagnosis.
As the presence or absence of arterial
and venous flow is not reliable in making the diagnosis,
it's more important to check
for asymmetric ovarian enlargement with enlargement
of the affected or torsed ovary.
That ovary may appear more echogenic due
to hemorrhage within that ovary.
You may see follicles that are displaced peripherally,
but more importantly to check the location of the ovary
to see whether it is twisted deep into the pelvis,
into the cul-de-sac posterior to the uterus or anterior
and superior into the midline above the uterus.

Pelvic Inflammatory Disease

Moving on to pelvic inflammatory disease, it is important
to point out that these patients may be confusing
and confused with torsion as they may also present
with pain, a large, complex adnexal mass.
But also important to know that patients with both torsion
and pelvic inflammatory disease can present
with leukocytosis and fever.
Pelvic inflammatory disease includes a spectrum
of abnormalities including endometritis, salpingitis,
peritonitis,
PID tub, ovarian complex, and abscess.
The findings are usually bilateral
unless they occur due to direct extension
and the source is almost always ascending from
a lower tract infection.
Features include indistinct, ovary
and uterus, thickened fallopian tubes which may sometimes
dilate and fill with pus.
This may extend to involve the ovary
where one may see a complex adnexal mass
and the involved tissues may present
with increased doppler flow.

Here is a patient who presented with pelvic pain
because of the diffuse nature of the pain.
A CT was obtained, the CT was read as
stranding or inflammatory changes on each side of the
and in front of the bladder, but no other findings
to explain pelvic pain.
A transvaginal ultrasound was performed,
which was originally read as negative.
In looking back at the ct, there are enhancing
soft tissue lesions
that are separate from the ovary in the adnexa bilaterally.
And on closer look of the ultrasound,
we see the normal appearing ovary,
the normal appearing contralateral ovary,
but extra soft tissue adjacent to this ovary.
And perhaps we may say in retrospect that there is
complex fluid or a sliver of complex fluid anterior
and posterior to the uterus.
Now here we see the normal ovary
but the extra soft tissue that is above
and adjacent to the ovary on the other end.
Next, so we see a normal ovary,
but again, all this extra soft tissue that is adjacent
to the ovary
doppler of this extra soft tissue
demonstrated increased vascularity, excluding blood
or pus as the etiology
and helping us make the diagnosis
of inflamed fallopian tubes in the setting of salpingitis.
When the extra soft tissue
or the inflamed fallopian tubes is more severe,
it may sometimes cause the appearance
of the indistinct pelvis.
It is difficult to separate in this case the ovaries from
the uterus from the fallopian tubes.
This may sometimes be difficult to distinguish from blood
or pus, but with doppler we can tell that this is vascular
material vascular tissue
representing the inflamed thickened fallopian tubes
in salpingitis.

Now, the upper part of that case demonstrated
pus around the uterus.
And perhaps in retrospect we see
that the uterus is a little indistinct
and there may be a sliver of fluid around the uterus.
This is a difficult diagnosis to make
and is more commonly made in retrospect.

Now when pus fills and dilates the tubes, we get a PID.
This presents with thickened cysts
and cystic masses in the adnexa.
You try to elongate this in a separate plane.
You may see that these are elongated into dilated tubes
and sometimes a cine, a cine clip may help
and show that these cysts interconnect.
Sometimes you may have a fluid, fluid level
or a hematocolpos.
Pinks and doppler may help you find
vascular thickened tissue with an associated salpingitis,
the plica key in the fallopian tube may thicken forming thick,
incomplete septations into the lumen of the tube.
This has been called a cogwheel sign and can be seen
and help make the diagnosis of a hydrosalpinx
or pyosalpinx.

Now this is a more severe case in this patient who presents
with diffuse abdominal pain and fever.
There's complex fluid deep too
and extending into the cul-de-sac.
Now when we increase our depth, we can see that
there's more extensive involvement.
We see complex cystic mass that appears to wrap
around the uterus in the coronal or transverse plane.
We do see that this extends laterally
and we can see the extent of the involvement better
with this increased field of view or depth.
When we look at the adnexa,
this complex cystic mass cannot be separated from the
adjacent ovary, and this is characteristic
of tubo-ovarian abscess.

Now, how can one tell the difference
between this and cancer?
And the answer is really mainly by history.
Without the appropriate history, both may present
with a similar appearance.
This is the CT scan.
In the same patient, we see a complex cystic mass
that is extending from each adnexa into the midline,
indistinguishable from the ovaries in this patient
with tubo-ovarian abscess.

Now this is a case that proved
to be difficult without the proper history.
The original report
or the original request read pelvic pain exclude torsion.
We can see that the ovary appears enlarged.
It is posterior to
or perhaps displaced posterior to the uterus,
perhaps in a cul-de-sac as we can see here.
And it's unclear whether there was reliable doppler flow.
So in the setting of acute pelvic pain torsion
can definitely present
with an appearance similar such as this case.
But when the referring team came to discuss the case,
they provided a very different history of acute pelvic pain,
fever, discharge, and severe tenderness on examination.
And in that case, tub ovarian abscess can be raised,
which in fact was the case when this patient
went to the operating room.

Now there are some pitfalls because endometriosis
and hemorrhagic cysts may also cause acute pelvic pain
and present with a similar
or overlapping appearance is important to make sure
that the patient is not pregnant
as ectopic pregnancy would be included in
that differential diagnosis.
It's also important not to forget
that non gynecologic causes can also cause pelvic pain.

Hemorrhagic Cysts and Endometriomas

Hemorrhagic cysts have many appearances
and may be difficult to distinguish from
other ovarian pathology.
A retracting clot may present as a mural nodule.
However, retracting clots tend to have concave margins.
Fibrin strands may also appear
to represent septations in malignancies.
However, fibrin strands are thinner, less reflective
and with no flow on Doppler hemorrhagic cyst walls tend
to be smooth or in malignancies.
The wall can be irregular.
Hemorrhagic cyst will resolve over time
and it's much more common for a hemorrhagic cyst
to mimic a neoplasm rather than the opposite.

Now here are some images showing evolution
of a hemorrhagic cyst acutely they may appear solid
more echogenic, but over time as the clot evolves,
we see more cystic spaces forming.
There's no flow within a hemorrhagic cyst over time
as the clot retracts, it may form some concave
or straight margins, such as in these cases
and with even more time these thin,
poorly reflective fibrin strands may be seen.

Here is a patient who presented with left pelvic pain
and the question of a hemorrhagic mass
with hemorrhage extending into the pelvis, it's much easier
to make the diagnosis of a hemorrhagic cyst.
On ultrasound, we see a hemorrhagic corpus luteum cyst
in the left ovary.
But again, it is difficult
to tell whether the left ovary is displaced due
to the size of the cyst.
And when the cyst is large.
It may be difficult to find flow in the ovary due
to stretching of the parenchyma
or even inability to find parenchyma to interrogate.
And even with all the technology, it may be difficult
to tell whether this ovary is torsed.

The endometriosis presents with intermittent
or cyclic pelvic pain.
80% of endometriosis is found in the ovary.
Endometriomas appear with uniform low level internal echoes.
They may present with hypoechoic wall foci.
The cyst may be irregular in shape
and multiple in bilateral.
Here are some examples.
You see well-defined, cystic structures
with uniform, low level internal echoes.
You may see bilateral cysts
or cyst with irregular shapes rather than perfectly round.
You may see echogenic foci along the walls
and the periods of repeated bleeding may cause adhesions
that lead to hydrosalpinx.

Now this is a patient who presents with endometriosis,
diffuse pelvic pain
and fever, multiple prior ultrasounds
that had a very similar appearance to this complex
adnexal masses fluid, fluid levels,
low level internal echoes, all of which can be explained
by the diagnosis of endometriosis.
However, blood is a setup for infection
and in this patient with diffuse pelvic pain
and fever, the question of pelvic inflammatory disease
and tub ovarian abscess should be raised,
which was found in this patient at pathology.

Now here is a 38-year-old who presents
with abdominal pain and distension.
We have a sagittal view of the uterus,
some complex fluid in the cul-de-sac
and posterior to the uterus.
We see this dilated tubular structure
coming to a point.
As we scan towards the adnexa,
we see perhaps a cystic structure in this area.
And further to the right we see the right ovary
with the cystic structure adjacent to it
shows the right ovary, the cystic structure,
and this dilated tube that is coming to a point
where we see the cyst with low level internal echoes.
This is a case of endometriosis causing
a small bowel obstruction.
Here is the dilated small bowel loop and the echogenic,
or sorry, hyper attenuating endometrioma trying
causing a narrowing of that loop.

Conclusion

This brings me back to the four challenge
cases I showed at the beginning.
This was a tubo-ovarian abscess that had the appearance
of torsion, a hemorrhagic cyst within a torsed
ovary, a hemorrhagic cyst, and a non-torsed ovary,
and a case of endometriosis.
Thank you for your attention.