AJR 2000; 174:651-656
© American Roentgen Ray Society
Sonography of Obstetric and Gynecologic Emergencies
Part II, Gynecologic Emergencies
Y. Kaakaji1,
H. V. Nghiem2,
C. Nodell1 and
T. C. Winter3
1
Department of Radiology, The University of Washington Medical Center, 1959
N.E. Pacific St., Seattle, WA 98195-7115.
2
Department of Radiology, University of Michigan Health System, 1500 E. Medical
Center Dr., TC2910Q, Ann Arbor, MI 48109-0326.
3
Department of Radiology, University of Wisconsin Hospital, E3/311, CSC 600
Highland Ave., Madison, WI 53792-3252.
Received June 8, 1999;
accepted after revision August 10, 1999.
Address correspondence to H. V. Nghiem.
Introduction
Most patients with gynecologic emergencies complain of pelvic pain and/or
vaginal bleeding. In addition to clinical history, physical examination, and
laboratory data, sonography is essential in evaluating pelvic pain and vaginal
bleeding because the causes of pelvic pain and vaginal bleeding often have
suggestive or definitive sonographic findings. However, many nonobstetric and
nongynecologic conditions have similar clinical and sonographic findings. We
describe the pathophysiology and the sonographic findings of gynecologic
emergencies. We also address mimics of acute gynecologic and obstetric
emergencies such as appendicitis and diverticulitis.
Pelvic Inflammatory Disease
Pelvic inflammatory disease is the most common cause of acute pelvic pain
and at times presents with a surgical abdomen, mimicking appendicitis or
perforated viscus. Acute complications of pelvic inflammatory disease include
tuboovarian complex and abscess, pyosalpinx, and peritonitis. Disseminated
peritonitis may be further complicated by serositis of the adjacent bowel,
peritoneal adhesions and small-bowel obstruction, or perihepatitis
(Fitz-Hugh-Curtis syndrome)
[1]. Pelvic inflammatory
disease is usually bilateral, except when it is caused by the direct extension
of an adjacent inflammatory process such as appendiceal, diverticular, or
postsurgical abscesses (in which case pelvic inflammatory disease is
unilateral). Findings on pelvic sonograms frequently appear normal in the
early stages or in uncomplicated conditions. In severe or advanced conditions,
sonographic findings include endometrial thickening with or without
endometrial fluid and gas, ovarian enlargement with indistinct ovarian
borders, uterine enlargement with indistinct uterine contours, and free
intraperitoneal fluid [2].
Ascending extrauterine disease may cause tuboovarian complexes (Fig.
1A,1B,1C),
originating as a combination of dilated inflamed fallopian tubes and enlarged
inflamed ovaries, or frank tuboovarian abscess (Fig.
2A,2B,2C).
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Fig. 1B. —24-year-old woman with pelvic inflammatory disease and tuboovarian
complex. Coronal image of left adnexa reveals dilated fallopian tube (T) with
echogenic fluid. Findings are consistent with those of pyosalpinx.
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Fig. 1C. —24-year-old woman with pelvic inflammatory disease and tuboovarian
complex. Black-and-white photograph of color Doppler image reveals enlarged
hyperemic ovary, a finding consistent with oophoritis.
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Fig. 2A. —15-year-old girl with pelvic pain, fever, and bilateral tuboovarian
abscesses. Endovaginal sonogram reveals bilateral complex cystic lesions
replacing ovaries. Surgery revealed bilateral tuboovarian abscesses. LT =
right ovarian mass, RT = left ovarian mass, UT = uterus.
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Fig. 2C. —15-year-old girl with pelvic pain, fever, and bilateral tuboovarian
abscesses. Transverse endovaginal sonogram of left cystic mass.
Although this is a surgically proven case, tuboovarian abscesses typically
appear as complex multiloculated masses with variable septations, irregular
margins, and scattered internal echoes.
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Pyosalpinges are rarely complicated by torsion manifesting clinically as
sudden increase in abdominal pain in a patient with known history of pelvic
inflammatory disease (Fig. 3).
Other complications of pyosalpinges include intraperitoneal rupture and tubal
stenosis.
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Fig. 3. —30-year-old woman with torsion of chronic hydrosalpinx. Patient was
being treated for pelvic inflammatory disease and presented with sudden severe
left-sided pelvic pain. Endovaginal sonogram reveals dilated tortuous left
fallopain tube (T). Because of severe clinical symptoms, laparoscopy was
performed and revealed torsion of hydrosalpinx. Left ovary was normal.
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Tuboovarian Torsion
Tuboovarian torsion is difficult to diagnose because it has clinical
findings similar to many causes of acute abdomen. Complete or partial torsion
of the ovarian vascular pedicle initially compromises the lymphatic and venous
drainage, with eventual loss of arterial perfusion. The sonographic findings
of tuboovarian torsion vary depending on the degree of vascular compromise and
the presence of an adnexal mass. The torsed ovary may be normal, particularly
in children; however, it may be displaced by adjacent structures such as
gestational uteri, or it may contain a mass such as a large physiologic cyst
or a cystic teratoma [3]
(Fig. 4). The ovary typically
appears enlarged and may mimic a solid hypoechoic or hyperechoic adnexal mass
(Fig. 5). Although infrequent,
a specific sign of ovarian torsion is the presence of multiple cortical
follicles in an enlarged ovary
[4]. The ipsilateral fallopian
tube is normally torsed with the ovary and rarely appears as an echogenic
tubular structure leading from the uterus to the torsed ovary
[5] (Fig.
6A,6B).
Free intraperitoneal fluid in the pelvis may result from lymphatic and venous
congestion or infarction with intraperitoneal hemorrhage
[3,
6]. Intraovarian artery flow
does not exclude torsion (Fig.
7A,7B).
The presence of intraovarian artery flow may simply reflect early or partial
torsion resulting from extrinsic compression and occlusion of the ovarian vein
with an intact arterial supply. Moreover, Rosado et al.
[7] raised the question of
double ovarian artery blood supply in three torsed ovaries, in which normal
Doppler arterial signals and resistive indexes were obtained. In a study by
Fleischer et al. [8], the
preservation of central venous flow in tuboovarian torsion is suggested to be
an indicator of ovarian viability (Fig.
6A,6B).
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Fig. 4. —26-year-old woman with severe acute right lower quadrant pain and
ovarian torsion of cystic teratoma. Transverse transabdominal sonogram shows
complex cystic mass in right lower quadrant with echogenic mural nodule
(arrow) and adjacent fine echogenic debris. Surgery revealed ovarian
dermoid cyst and adnexal torsion.
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Fig. 5. —30-year-old pregnant woman with surgically proven ovarian torsion.
Endovaginal sagittal sonogram reveals enlarged left ovary (calipers).
Focal hyperchoic area (arrowhead) corresponds to hemorrhage or edema.
Color flow Doppler image (not shown) revealed absence of intraovarian
flow.
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Fig. 6A. —22-year-old woman with ovarian torsion. Endovaginal sagittal
sonogram reveals enlarged right ovary (calipers) with heterogeneous
echo texture and thickened and dilated fallopian tube (arrows).
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Fig. 6B. —22-year-old woman with ovarian torsion. Black-and-white photograph
of color Doppler image with spectral tracing reveals preserved venous flow in
central ovary. Surgery detected right adnexal torsion, but viable right
ovary.
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Fig. 7A. —26-year-old woman with right-sided pelvic pain and surgically proven
ovarian torsion. Endovaginal sonogram shows enlarged right ovary (ovarian
volume, 51 cm3) with many peripheral follicles.
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Fig. 7B. —26-year-old woman with right-sided pelvic pain and surgically proven
ovarian torsion. Spectral Doppler tracing reveals arterial flow; however,
presence of arterial flow did not exclude diagnosis of ovarian torsion.
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Hemorrhagic Ovarian Cysts
Hemorrhagic physiologic ovarian cysts, from corpus luteal or follicular
origin, are frequent sonographic findings of obstetric and gynecologic
emergencies. Acute pelvic pain is caused by acute hemorrhage, adnexal torsion,
intraperitoneal rupture, or an enlarging hemorrhagic cyst. Sonographic
findings of hemorrhagic ovarian cysts depend on the age of the cyst and
include a heterogeneous hypoechoic mass with internal echoes, thin and thick
septations, fluid-debris level, echogenic retracting clot, or irregular
nodular wall (Fig.
8A,8B).
Acute intracystic hemorrhage may appear isoechoic to the ovarian stroma and
mimic an enlarged ovary by appearing isoechoic to the ovarian stroma. Enlarged
cysts are less likely to spontaneously resolve, and they may be complicated by
adnexal torsion or rupture into the peritoneal cavity (Fig.
9A,9B,9C).
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Fig. 8A. —32-year-old woman with acute pelvic pain caused by hemorrhagic
ovarian cyst. Transverse (A) and sagittal (B) endovaginal
sonograms show complex intraovarian cyst (C) surrounded by rim of healthy
ovarian tissue. Cyst contains retracting clot. Calipers indicate boundary of
ovaries.
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Fig. 8B. —34-year-old woman with acute pelvic pain caused by hemorrhagic
ovarian cyst. Transverse (A) and sagittal (B) endovaginal
sonograms show complex intraovarian cyst (C) surrounded by rim of healthy
ovarian tissue. Cyst contains retracting clot. Calipers indicate boundary of
ovaries.
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Fig. 9A. —26-year-old woman with ruptured hemorrhagic ovarian cyst and
hemoperitoneum. Sagittal transabdominal sonograms reveal complex free
echogenic fluid (f, A) in pelvis (posterior to uterus) and fluid in
Morison's pouch (arrows, B).
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Fig. 9B. —26-year-old woman with ruptured hemorrhagic ovarian cyst and
hemoperitoneum. Sagittal transabdominal sonograms reveal complex free
echogenic fluid (f, A) in pelvis (posterior to uterus) and fluid in
Morison's pouch (arrows, B).
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Conditions that Mimic Obstetric and Gynecologic Emergencies
Gastroenteritis, diverticulitis, appendicitis, pyelonephritis, and renal
calculi may develop in women of childbearing age with clinical features that
mimic those of obstetric and gynecologic emergencies.
Although acute diverticulitis predominantly affects the elderly, it can
also affect younger women. In acute diverticulitis, muscular spasms and
inflammation-induced edema cause thickening of the colonic wall. A study by
Wilson and Toi [9] suggests
colonic diverticula (outpouchings beyond the lumen of the thick-walled bowel)
revealed on sonography are suggestive of diverticulitis. Other sonographic
findings of this condition include pericolic or intramural fluid collections
(Fig.
10A,10B,10C),
edema of the pericolic fat, and, rarely, intramural sinus tracts
[9].
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Fig. 10A. —49-year-old woman with fever, left lower quadrant pain caused by
acute diverticulitis, and pericolic abscess. Transabdominal sonogram of left
lower quadrant shows complex fluid collection (solid arrows) and
multiple echogenic foci with shadowing (open arrow).
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Fig. 10B. —49-year-old woman with fever, left lower quadrant pain caused by
acute diverticulitis, and pericolic abscess. Endovaginal sonography reveals
presence of gas (open arrow) in fluid collection (solid
arrows).
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Fig. 10C. —49-year-old woman with fever, left lower quadrant pain caused by
acute diverticulitis, and pericolic abscess. Enhanced CT scan reveals
thick-walled abscess with rim enhancement (arrows).
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Appendicitis (Fig. 11) is
the most common cause of surgical abdomen in young adults and a common
surgical emergency during pregnancy. Many gynecologic conditions have findings
that mimic those of acute appendicitis. The perigestational diagnosis of
appendicits is further hampered by the superior displacement of the appendix
by the gravid uterus. After the first trimester of pregnancy, patients with
appendicitis often present with acute right upper quadrant abdominal pain
[10].
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Fig. 11. —44-year-old woman with right lower quadrant pain caused by
surgically proven acute appendicitis. Transabdominal sonogram shows
thick-walled dilated appendix with small appendicolith (arrow).
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The sonographic features of acute appendicitis include the presence of a
blind-ended nonperistaltic tubular structure arising from the base of the
cecum measuring more than 6 mm in diameter
[11]. Other sonographic
features include inflamed mesenteric fat, periappendiceal fluid collection,
and appendicolith.
References
-
Schoenfeld A. Ultrasound findings in perihepatitis associated with
pelvic inflammatory disease. J Clin Ultrasound
1992;20:339-342[Medline]
-
Patten RM. Pelvic inflammatory disease: endovaginal sonography with
laparoscopic correlation. J Ultrasound Med
1990;9:681-689[Abstract]
-
Helvie MA, Silver TM. Ovarian torsion: sonographic findings.
J Clin Ultrasound
1989;17:327-332[Medline]
-
Graif M, Itzchak Y. Sonographic evaluation of ovarian torsion in
childhood and adolescence. AJR
1988;150:647-649[Abstract/Free Full Text]
-
Caspi B, Ben-Galim P, Weissman A, Appleman Z. Engorged fallopian
tube: new sonographic sign for adnexal torsion. J Clin
Ultrasound
1995;23:505-507[Medline]
-
Graif M, Shalev J, Strauss S, Engelberg S, Mashiach S, Itzchak Y.
Torsion of the ovary: sonographic features. AJR
1994;143:1331-1334
-
Rosado WM Jr, Trambert MA, Gosnik BB, Pretorius DH. Adnexal
torsion: diagnosis by using Doppler sonography. AJR
1992;159:1251-1253[Free Full Text]
-
Fleischer AC, Stein SM, Cullinan JA, et al. Color Doppler
sonography of adnexal torsion. J Ultrasound Med
1995;14:523-528[Abstract]
-
Wilson SR, Toi A. The value of sonography in the diagnosis of acute
diverticulitis of the colon. AJR
1990;154:1199-1202[Abstract/Free Full Text]
-
Halvorsen AC, Brandt B, Andreasen JJ, Bock JE. Pregnancy
complicated by acute diverticulitis. Acta Obstet Gynecol Scand
1991;70:183-184[Medline]
-
Worrell JA, Drolshagen LF, Kelly TC. Graded compression ultrasound
on the diagnosis of appendicitis: a comparison of diagnostic criteria.
J Ultrasound Med
1990;9:145-150[Abstract]
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Introduction
Pelvic Inflammatory Disease
