Professor Hassan Nasrat FRCS, FRCOG

The Fetal Medicine Clinic The First Clinic

JUCOG 2013

Role of Ultrasound In Pelvic Pain

Monday, June 10, 13

The Uterus

❖Regardless Of The Scanning Approach The Uterus Is Important And Reliable Landmark

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❖The Endometrial Echo Density Varies Depending On Water Content And Cellular Density That Fluctuates With The Hormonal Status

❖Reach Trlaminar Appearance At Time Of Ovulation And Bccomes More Homogeneous After Ovulation

Follicular phase

Pre-ovulatory

Secretory phase

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The relative position of the uterus to the cervix and to the axis of the vagina

The symmetry

The size

The Texture

The Uterus

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The Cervix

The uterine cervix can be measured with a great degree of accuracy, especially with the transvaginal technique. the cervix may not be seen if the scanning tip is placed in either the anterior or posterior fornix.

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The Vagina

By TA scanning it appears as a collapsed tubular structure lying inferior to the urinary bladder and distal to the uterine cervix

TATP

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TA TV

The position of the ovary depends on the length of the infundibulopelvic ligament, the presence or absence of adhesions, and other anatomic abnormalities that may displace the ovary.

The Ovary

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Cul-De-Sac Fluid Accumulation

•Small  Amounts  Of  Peritoneal  Fluid  Accumulate  In  The  Inferior-­‐most  Portion  Of  The  Cul-­‐de-­‐sac  As  A  Result  Of  The  Menstrual  Cycle.  

•Massive  Accumulations  Of  Fluid  May  Exist  In  Cases  Of  Ovarian  Carcinoma.  •The  Hemoperitoneum  Of  Ruptured  Tubal  Pregnancy  Is  Apparent  During  Transabdominal  Or  Transvaginal  Scanning.  

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Role of Ultrasound In Pelvic Pain

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Acute

Chronic: Defined By Pain For >6 Months

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Acute or chronicDiffuse of focal Cyclical or constantSharp or dull or cramping?Prior SurgeryMenopausal and hormonal status Could she be pregnant?

Correlation of Clinical History with Sonographic Examination

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Uterine

Adenomyosis

Degenerating Fibroids

Prolapsing Fibroids

Abnormally Placed IUD

OvarianSimple Cyst

Hemorrhagic Cyst

Ovarian Torsion

Endometrioma

Dermoid Cyst

Ovarian Cancer

Common Causes of Pelvic Pain

PID

Tubo-Ovarian Abscess.

Hydrosalpinx

Pyosalpinx

EP

Tubal.

Cornual

Cervical

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Uterine

Adenomyosis

Degenerating Fibroids

Prolapsing Fibroids

Abnormally Placed IUD

Ovarian

Common Causes of Pelvic Pain

PID EP

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Adenomyosis

Degenerating Fibroids

Prolapsing Fibroids

Abnormally Placed IUD

Uterine

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A Common Finding (5-70%) In Women Of Reproductive Age. 70% Of Hysterectomy Specimens.

The Diagnosis: Sonography Or MRI.

The Pathologic Diagnosis: The Visualization Of Endometrial Glands And Stroma In More Than One Low-powered Field (2.5 Mm) From The Endometrial Basalis Layer.

Symptoms: Most Women Are Asymptomatic- When Symptomatic: Dysmenorrhea, Abnormal Bleeding, Uterine Enlargment.

Adenomyosis

Invasion Of The Endometrial Glands Into The Myometrium

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Sonographic Findings of Adenomyosis

•Globular Uterine Enlargement

•Generalized adenomyosis

•Focal adenomyoma

•Cystic Anechoic spaces

•Uterine Wall Asymmetrical thickening

•Obscure endometrial/myometrial border

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Globular Uterine Enlargement That Is Generally Up To 12 Cm In Uterine Length And Is Not Explained By The Presence Of Leiomyomata.

and specificity of MRI in diagnosing adenomyosis are sim-ilar to those for sonography and have been reported as77.5% and 92.5% respectively.5 In the presence of adeno-myosis, when the transvaginal ultrasound probe touchesthe corpus of the uterus, tenderness is commonly notedThe presence of leiomyomata can adversely affect the di-agnostic capability of sonography, and the presence ofleiomyomata is generally associated with adenomyosis in36% to 50% of cases.1,6

Sonographic Findings

The sonographic findings of adenomyosis, best obtainedby transvaginal sonography, include the following4–17:

1. Uterine enlargement—Globular uterine enlargementthat is generally up to 12 cm in uterine length and thatis not explained by the presence of leiomyomata is acharacteristic finding (Figure 3).

2. Cystic anechoic spaces or lakes in the myometrium—The cystic anechoic spaces within the myometriumare variable in size and can occur throughout the my-ometrium (Figure 4). The cystic changes in the outermyometrium may on occasion represent small arcuateveins rather than adenomyomas. The application ofcolor Doppler imaging at low velocity scales may helpin this differentiation.

3. Uterine wall thickening—The uterine wall thicken-ing can show anteroposterior asymmetry, especiallywhen the disease is focal (Figure 5).

4. Subendometrial echogenic linear striations—Invasionof the endometrial glands into the subendometrialtissue induces a hyperplastic reaction, which appears

as echogenic linear striations fanning out from the endometrial layer (Figure 6).

5. Heterogeneous echo texture—There is a lack of homo-geneity within the myometrium with evidence of archi-tectural disturbance (Figures 1 and 4). This finding hasbeen shown to be the most predictive of adenomyosis.

6. Obscure endometrial/myometrial border—Invasionof the myometrium by the glands also obscures thenormally distinct endometrial/myometrial border(Figures 2–6).

7. Thickening of the transition zone—This zone is alayer that appears as a hypoechoic halo surroundingthe endometrial layer. A thickness of 12 mm or greaterhas been shown to be associated with adenomyosis.

Sakhel and Abuhamad—Sonography of Adenomyosis

J Ultrasound Med 2012; 31:805–808806

Figure 3. Globular uterine enlargement with an obscure endometrial/myometrial border (arrow).

Figure 2. Focal adenomyoma (arrows).

Figure 1. Generalized adenomyosis.

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Globular Uterine Enlargement

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and specificity of MRI in diagnosing adenomyosis are sim-ilar to those for sonography and have been reported as77.5% and 92.5% respectively.5 In the presence of adeno-myosis, when the transvaginal ultrasound probe touchesthe corpus of the uterus, tenderness is commonly notedThe presence of leiomyomata can adversely affect the di-agnostic capability of sonography, and the presence ofleiomyomata is generally associated with adenomyosis in36% to 50% of cases.1,6

Sonographic Findings

The sonographic findings of adenomyosis, best obtainedby transvaginal sonography, include the following4–17:

1. Uterine enlargement—Globular uterine enlargementthat is generally up to 12 cm in uterine length and thatis not explained by the presence of leiomyomata is acharacteristic finding (Figure 3).

2. Cystic anechoic spaces or lakes in the myometrium—The cystic anechoic spaces within the myometriumare variable in size and can occur throughout the my-ometrium (Figure 4). The cystic changes in the outermyometrium may on occasion represent small arcuateveins rather than adenomyomas. The application ofcolor Doppler imaging at low velocity scales may helpin this differentiation.

3. Uterine wall thickening—The uterine wall thicken-ing can show anteroposterior asymmetry, especiallywhen the disease is focal (Figure 5).

4. Subendometrial echogenic linear striations—Invasionof the endometrial glands into the subendometrialtissue induces a hyperplastic reaction, which appears

as echogenic linear striations fanning out from the endometrial layer (Figure 6).

5. Heterogeneous echo texture—There is a lack of homo-geneity within the myometrium with evidence of archi-tectural disturbance (Figures 1 and 4). This finding hasbeen shown to be the most predictive of adenomyosis.

6. Obscure endometrial/myometrial border—Invasionof the myometrium by the glands also obscures thenormally distinct endometrial/myometrial border(Figures 2–6).

7. Thickening of the transition zone—This zone is alayer that appears as a hypoechoic halo surroundingthe endometrial layer. A thickness of 12 mm or greaterhas been shown to be associated with adenomyosis.

Sakhel and Abuhamad—Sonography of Adenomyosis

J Ultrasound Med 2012; 31:805–808806

Figure 3. Globular uterine enlargement with an obscure endometrial/myometrial border (arrow).

Figure 2. Focal adenomyoma (arrows).

Figure 1. Generalized adenomyosis.

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Generalized adenomyosis

Diffuse Disease Involving The Entire Myometrium

Loss Of Normal Architecture (Loss Of Of Homogeneity) (most Predictive Of Adenomyosis)

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Focal Area Of The Uterus Adenomyoma

and specificity of MRI in diagnosing adenomyosis are sim-ilar to those for sonography and have been reported as77.5% and 92.5% respectively.5 In the presence of adeno-myosis, when the transvaginal ultrasound probe touchesthe corpus of the uterus, tenderness is commonly notedThe presence of leiomyomata can adversely affect the di-agnostic capability of sonography, and the presence ofleiomyomata is generally associated with adenomyosis in36% to 50% of cases.1,6

Sonographic Findings

The sonographic findings of adenomyosis, best obtainedby transvaginal sonography, include the following4–17:

1. Uterine enlargement—Globular uterine enlargementthat is generally up to 12 cm in uterine length and thatis not explained by the presence of leiomyomata is acharacteristic finding (Figure 3).

2. Cystic anechoic spaces or lakes in the myometrium—The cystic anechoic spaces within the myometriumare variable in size and can occur throughout the my-ometrium (Figure 4). The cystic changes in the outermyometrium may on occasion represent small arcuateveins rather than adenomyomas. The application ofcolor Doppler imaging at low velocity scales may helpin this differentiation.

3. Uterine wall thickening—The uterine wall thicken-ing can show anteroposterior asymmetry, especiallywhen the disease is focal (Figure 5).

4. Subendometrial echogenic linear striations—Invasionof the endometrial glands into the subendometrialtissue induces a hyperplastic reaction, which appears

as echogenic linear striations fanning out from the endometrial layer (Figure 6).

5. Heterogeneous echo texture—There is a lack of homo-geneity within the myometrium with evidence of archi-tectural disturbance (Figures 1 and 4). This finding hasbeen shown to be the most predictive of adenomyosis.

6. Obscure endometrial/myometrial border—Invasionof the myometrium by the glands also obscures thenormally distinct endometrial/myometrial border(Figures 2–6).

7. Thickening of the transition zone—This zone is alayer that appears as a hypoechoic halo surroundingthe endometrial layer. A thickness of 12 mm or greaterhas been shown to be associated with adenomyosis.

Sakhel and Abuhamad—Sonography of Adenomyosis

J Ultrasound Med 2012; 31:805–808806

Figure 3. Globular uterine enlargement with an obscure endometrial/myometrial border (arrow).

Figure 2. Focal adenomyoma (arrows).

Figure 1. Generalized adenomyosis.

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Focal Adenomyoma

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Focal Area Of The Uterus Adenomyoma

and specificity of MRI in diagnosing adenomyosis are sim-ilar to those for sonography and have been reported as77.5% and 92.5% respectively.5 In the presence of adeno-myosis, when the transvaginal ultrasound probe touchesthe corpus of the uterus, tenderness is commonly notedThe presence of leiomyomata can adversely affect the di-agnostic capability of sonography, and the presence ofleiomyomata is generally associated with adenomyosis in36% to 50% of cases.1,6

Sonographic Findings

The sonographic findings of adenomyosis, best obtainedby transvaginal sonography, include the following4–17:

1. Uterine enlargement—Globular uterine enlargementthat is generally up to 12 cm in uterine length and thatis not explained by the presence of leiomyomata is acharacteristic finding (Figure 3).

2. Cystic anechoic spaces or lakes in the myometrium—The cystic anechoic spaces within the myometriumare variable in size and can occur throughout the my-ometrium (Figure 4). The cystic changes in the outermyometrium may on occasion represent small arcuateveins rather than adenomyomas. The application ofcolor Doppler imaging at low velocity scales may helpin this differentiation.

3. Uterine wall thickening—The uterine wall thicken-ing can show anteroposterior asymmetry, especiallywhen the disease is focal (Figure 5).

4. Subendometrial echogenic linear striations—Invasionof the endometrial glands into the subendometrialtissue induces a hyperplastic reaction, which appears

as echogenic linear striations fanning out from the endometrial layer (Figure 6).

5. Heterogeneous echo texture—There is a lack of homo-geneity within the myometrium with evidence of archi-tectural disturbance (Figures 1 and 4). This finding hasbeen shown to be the most predictive of adenomyosis.

6. Obscure endometrial/myometrial border—Invasionof the myometrium by the glands also obscures thenormally distinct endometrial/myometrial border(Figures 2–6).

7. Thickening of the transition zone—This zone is alayer that appears as a hypoechoic halo surroundingthe endometrial layer. A thickness of 12 mm or greaterhas been shown to be associated with adenomyosis.

Sakhel and Abuhamad—Sonography of Adenomyosis

J Ultrasound Med 2012; 31:805–808806

Figure 3. Globular uterine enlargement with an obscure endometrial/myometrial border (arrow).

Figure 2. Focal adenomyoma (arrows).

Figure 1. Generalized adenomyosis.

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Focal Adenomyoma

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and specificity of MRI in diagnosing adenomyosis are sim-ilar to those for sonography and have been reported as77.5% and 92.5% respectively.5 In the presence of adeno-myosis, when the transvaginal ultrasound probe touchesthe corpus of the uterus, tenderness is commonly notedThe presence of leiomyomata can adversely affect the di-agnostic capability of sonography, and the presence ofleiomyomata is generally associated with adenomyosis in36% to 50% of cases.1,6

Sonographic Findings

The sonographic findings of adenomyosis, best obtainedby transvaginal sonography, include the following4–17:

1. Uterine enlargement—Globular uterine enlargementthat is generally up to 12 cm in uterine length and thatis not explained by the presence of leiomyomata is acharacteristic finding (Figure 3).

2. Cystic anechoic spaces or lakes in the myometrium—The cystic anechoic spaces within the myometriumare variable in size and can occur throughout the my-ometrium (Figure 4). The cystic changes in the outermyometrium may on occasion represent small arcuateveins rather than adenomyomas. The application ofcolor Doppler imaging at low velocity scales may helpin this differentiation.

3. Uterine wall thickening—The uterine wall thicken-ing can show anteroposterior asymmetry, especiallywhen the disease is focal (Figure 5).

4. Subendometrial echogenic linear striations—Invasionof the endometrial glands into the subendometrialtissue induces a hyperplastic reaction, which appears

as echogenic linear striations fanning out from the endometrial layer (Figure 6).

5. Heterogeneous echo texture—There is a lack of homo-geneity within the myometrium with evidence of archi-tectural disturbance (Figures 1 and 4). This finding hasbeen shown to be the most predictive of adenomyosis.

6. Obscure endometrial/myometrial border—Invasionof the myometrium by the glands also obscures thenormally distinct endometrial/myometrial border(Figures 2–6).

7. Thickening of the transition zone—This zone is alayer that appears as a hypoechoic halo surroundingthe endometrial layer. A thickness of 12 mm or greaterhas been shown to be associated with adenomyosis.

Sakhel and Abuhamad—Sonography of Adenomyosis

J Ultrasound Med 2012; 31:805–808806

Figure 3. Globular uterine enlargement with an obscure endometrial/myometrial border (arrow).

Figure 2. Focal adenomyoma (arrows).

Figure 1. Generalized adenomyosis.

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Cystic Anechoic spaces

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Uterine Wall Thickening: Anteroposterior Asymmetry.

There is literature to support the observations that aglobular uterus, cystic spaces, and linear striations are themost specific findings in the diagnosis of adenomyosis.17

Chiang et al16 used color Doppler sonography to differen-tiate adenomyosis from leiomyomas. In their study, 87%of the cases of adenomyosis had randomly scattered vesselsor intramural signals. In 88% of leiomyoma cases, however,peripheral scattered vessels or outer feeding vessels werenoted. In addition, in 82% of the adenomyomas, arterieswithin or around the uterine tumors had a pulsatility indexof greater than 1.17, and 84% of leiomyomas had a pul-satility index of 1.17 or less.

Conclusions

Adenomyosis is a common finding in women of repro-ductive age. Most women with adenomyosis are asymp-tomatic. When symptomatic, adenomyosis can causepelvic pain and abnormal uterine bleeding. The diagno-sis of adenomyosis by sonography has been well definedand has diagnostic capabilities comparable to MRI. Whena diagnostic imaging modality is required for suspectedadenomyosis, sonography should be given first considera-tion given its efficacy, safety, and lower cost.

References

1. Azziz R. Adenomyosis: current perspectives. Obstet Gynecol Clin North Am1989; 16:221–235.

2. Bromley B, Shipp TD, Benacerraf B. Adenomyosis: sonographic findingsand diagnostic accuracy. J Ultrasound Med 2000; 19:529–534.

3. Katz VL. Benign gynecologic lesions. In: Katz VL, Lobo RA, Lentz G, Gershenson D (eds). Comprehensive Gynecology. 5th Edition. Philadelphia,PA: Elsevier; 2007:419–471.

4. Meredith SM, Sanchez-Ramos L, Kaunitz AM. Diagnostic accuracy oftransvaginal sonography. Am J Obstet Gynecol 2009; 201:107.e1–107.e6.

5. Bazot M, Cortez A, Darai E, et al. Ultrasonography compared with mag-netic resonance imaging for the diagnosis of adenomyosis: correlationwith histopathology. Hum Reprod 2001; 16:2427–2433.

6. Bazot M, Daraï E, Rouger J, Detchev R, Cortez A, Uzan S. Limitationsof transvaginal sonography for the diagnosis of adenomyosis, withhistopathological correlation. Ultrasound Obstet Gynecol 2002; 20:605–611.

7. Atzori E. Sonography for the diagnosis of adenomyosis. Ultrasound ObstetGynecol 2003; 21:626–627.

J Ultrasound Med 2012; 31:805–808 807

Sakhel and Abuhamad—Sonography of Adenomyosis

Figure 5. Measurement of the length of a posterior uterine wall that isgreater than that of the anterior wall (calipers) and has a heterogeneousmyometrial echo texture.

Figure 4. Anechoic cystic lacunae in the posterior uterine wall (arrow)with a heterogeneous echo texture.

Figure 6. Linear striations (arrows) in the presence of a heterogeneousecho texture.

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The Length Of A Posterior Uterine Is Greater Than That Of The Anterior Wall And Has A Heterogeneous Myometrial Echo Texture.

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Uterine Wall Thickening: Anteroposterior Asymmetry.

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and specificity of MRI in diagnosing adenomyosis are sim-ilar to those for sonography and have been reported as77.5% and 92.5% respectively.5 In the presence of adeno-myosis, when the transvaginal ultrasound probe touchesthe corpus of the uterus, tenderness is commonly notedThe presence of leiomyomata can adversely affect the di-agnostic capability of sonography, and the presence ofleiomyomata is generally associated with adenomyosis in36% to 50% of cases.1,6

Sonographic Findings

The sonographic findings of adenomyosis, best obtainedby transvaginal sonography, include the following4–17:

1. Uterine enlargement—Globular uterine enlargementthat is generally up to 12 cm in uterine length and thatis not explained by the presence of leiomyomata is acharacteristic finding (Figure 3).

2. Cystic anechoic spaces or lakes in the myometrium—The cystic anechoic spaces within the myometriumare variable in size and can occur throughout the my-ometrium (Figure 4). The cystic changes in the outermyometrium may on occasion represent small arcuateveins rather than adenomyomas. The application ofcolor Doppler imaging at low velocity scales may helpin this differentiation.

3. Uterine wall thickening—The uterine wall thicken-ing can show anteroposterior asymmetry, especiallywhen the disease is focal (Figure 5).

4. Subendometrial echogenic linear striations—Invasionof the endometrial glands into the subendometrialtissue induces a hyperplastic reaction, which appears

as echogenic linear striations fanning out from the endometrial layer (Figure 6).

5. Heterogeneous echo texture—There is a lack of homo-geneity within the myometrium with evidence of archi-tectural disturbance (Figures 1 and 4). This finding hasbeen shown to be the most predictive of adenomyosis.

6. Obscure endometrial/myometrial border—Invasionof the myometrium by the glands also obscures thenormally distinct endometrial/myometrial border(Figures 2–6).

7. Thickening of the transition zone—This zone is alayer that appears as a hypoechoic halo surroundingthe endometrial layer. A thickness of 12 mm or greaterhas been shown to be associated with adenomyosis.

Sakhel and Abuhamad—Sonography of Adenomyosis

J Ultrasound Med 2012; 31:805–808806

Figure 3. Globular uterine enlargement with an obscure endometrial/myometrial border (arrow).

Figure 2. Focal adenomyoma (arrows).

Figure 1. Generalized adenomyosis.

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•Obscure endometrial/myometrial border

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Sensitivity (95% CI )

specificity (95% CI )

+Ve LR -Ve LR

Sonography 82.5% (77.5–87.9)

84.6% (79.8–89.8)

4.7 (3.1–7.0)

0.26 (0.18–0.39)

MRI 77.5 92.5

Sonography Vs. MRI in Diagnosis of Adenomyosis

Diagnostic accuracy of transvaginal sonography for the diagnosis of adenomyosis: systematic review and metaanalysis American Journal of Obstetrics & Gynecology Volume 201, Issue 1 ,2009

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Fibroids

•Cystic Degeneration

•Prolapsing Pedunculated

Fibroid

•Pressure Effect

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Fibroid

❖Very Common-most

❖Usually Asymptomatic.

❖Classified according to their location as submucosal, intramural or subserosal.

❖MRI is the preferred modality for characterizing uterine fibroids and identifying their exact anatomical location

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Sonographic Appearance of Fibroids

✤Have Characteristic Sonographic Appearance.

✤It May Change With Degenerative Changes: Hyaline, Cystic , Myxoid, And Red Degeneration (hemorrhagic) And Calcification.

Cystic Degenerating Fibroids (4%) Can Be Challengin

DD: Endometrial Hyperplasia, A Postoperative Abscess, And A Large Simple Ovarian Cyst.

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their reproductive years.19 They are asso-ciated with a variety of symptoms includ-ing menorrhagia, dysmenorrhea, urinaryfrequency, pain, pressure, and infertility.Acute pain is usually due to acute fibroiddegeneration that occurs when a leio-myoma enlarges and outgrows its bloodsupply.20 Degeneration can be of varioustypes including hyaline or myxoid,calcific, cystic, and hemorrhagic. Localpain may be accompanied by systemicsymptoms such as low-grade fever andleukocytosis. Fibroids are hormonally re-sponsive and can increase rapidly in sizeduring pregnancy predisposing them tohemorrhagic or ‘‘red degeneration.’’21 USis usually diagnostic in detecting fibroids,with MRI used for further characteriza-tion if clinically necessary. Althoughfibroids are often incidentally seen, CT isnot useful for diagnosis or characteriza-tion of fibroids.

The most common sonographic ap-pearance of a fibroid is a well-defined,hypoechoic mass. They can, however, beheterogeneous, hyperechoic, or calcifiedwith acoustic shadowing. Anechoic, irre-gular spaces may be seen in necroticfibroids that have undergone degenera-tion (Fig. 20). Occasionally, it may bedifficult to distinguish a pedunculatedfibroid from a solid ovarian neoplasmand MRI can be useful in further char-acterization.

CT will demonstrate lobular uterineenlargement due to distortion of the uter-ine contour by the focal intrauterinemasses, and there will be a heterogeneouspattern of contrast enhancement. Coarsedystrophic calcification in a uterine massis the most specific CT sign for a leiomyo-ma; however, this is seen in only 10% ofcases.22 Fibroid degeneration results invarying degrees of liquefaction, whichcorrespond to a more cystic appearanceand diminished contrast enhancementwith areas of low attenuation (Figs. 21,22).22 With extensive degeneration, theleiomyoma may be quite large and pre-

dominantly cystic, and may be confusedwith a cystic ovarian mass (Fig. 22).Further evaluation with MRI may beneeded to exclude a lesion of adnexalorigin.

FIGURE 20. Large degenerating fibroid.Transabdominal ultrasound of the uterusshows the very heterogeneous appearance ofa degenerating fibroid (arrows), which con-tains irregular hypoechoic components.

FIGURE 21. Fibroids, computed tomogra-phy (CT). Axial unenhanced CT shows thelobular contour of a myomatous uterus (U),which contains 2 calcified fibroids (arrow-heads) and a large, degenerating, cystic-appearing fibroid (arrow).

Acute Pelvic Pain 13

Transabdominal ultrasound of the uterus shows the very heterogeneous appearance of a degenerating fibroid contains irregular hypoechoic components.

Degenerating Fibroid

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their reproductive years.19 They are asso-ciated with a variety of symptoms includ-ing menorrhagia, dysmenorrhea, urinaryfrequency, pain, pressure, and infertility.Acute pain is usually due to acute fibroiddegeneration that occurs when a leio-myoma enlarges and outgrows its bloodsupply.20 Degeneration can be of varioustypes including hyaline or myxoid,calcific, cystic, and hemorrhagic. Localpain may be accompanied by systemicsymptoms such as low-grade fever andleukocytosis. Fibroids are hormonally re-sponsive and can increase rapidly in sizeduring pregnancy predisposing them tohemorrhagic or ‘‘red degeneration.’’21 USis usually diagnostic in detecting fibroids,with MRI used for further characteriza-tion if clinically necessary. Althoughfibroids are often incidentally seen, CT isnot useful for diagnosis or characteriza-tion of fibroids.

The most common sonographic ap-pearance of a fibroid is a well-defined,hypoechoic mass. They can, however, beheterogeneous, hyperechoic, or calcifiedwith acoustic shadowing. Anechoic, irre-gular spaces may be seen in necroticfibroids that have undergone degenera-tion (Fig. 20). Occasionally, it may bedifficult to distinguish a pedunculatedfibroid from a solid ovarian neoplasmand MRI can be useful in further char-acterization.

CT will demonstrate lobular uterineenlargement due to distortion of the uter-ine contour by the focal intrauterinemasses, and there will be a heterogeneouspattern of contrast enhancement. Coarsedystrophic calcification in a uterine massis the most specific CT sign for a leiomyo-ma; however, this is seen in only 10% ofcases.22 Fibroid degeneration results invarying degrees of liquefaction, whichcorrespond to a more cystic appearanceand diminished contrast enhancementwith areas of low attenuation (Figs. 21,22).22 With extensive degeneration, theleiomyoma may be quite large and pre-

dominantly cystic, and may be confusedwith a cystic ovarian mass (Fig. 22).Further evaluation with MRI may beneeded to exclude a lesion of adnexalorigin.

FIGURE 20. Large degenerating fibroid.Transabdominal ultrasound of the uterusshows the very heterogeneous appearance ofa degenerating fibroid (arrows), which con-tains irregular hypoechoic components.

FIGURE 21. Fibroids, computed tomogra-phy (CT). Axial unenhanced CT shows thelobular contour of a myomatous uterus (U),which contains 2 calcified fibroids (arrow-heads) and a large, degenerating, cystic-appearing fibroid (arrow).

Acute Pelvic Pain 13

Transabdominal ultrasound of the uterus shows the very heterogeneous appearance of a degenerating fibroid contains irregular hypoechoic components.

Degenerating Fibroid

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uterus

Broad Ligament Fibroid

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Broad Ligament Fibroid

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Degenerating Fiborid

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Degenerating Fiborid

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Calcified Fiborid

Degenerating Fiborid

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Same Patient Transverse view

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TA scan Suggest Thick Endometrium

TV scan Shows Endometiral Polyp

Endometrial Polyp

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Saline Intrauterine Sonography“SIS”

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Pain Due to Pressure Effect

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TA-Scan Longitudinal View

TA-Scan Transvers View

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Postpartum Complication in a Fibroid

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Uterine

Adenomyosis

Degenerating Fibroids

Prolapsing Fibroids

Abnormally Placed IUD

OvarianSimple Cyst

Hemorrhagic Cyst

Ovarian Torsion

Endometrioma

Dermoid Cyst

Ovarian Cancer

Common Causes of Pelvic Pain

PID EP

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Adnexal Cyst Causes Considerable Anxiety In Women Due To The Fear Of Malignancy.

The Vast Majority - Even In Postmenopausal Women - Are Benign.

Modesitt SC, Pavlik EJ, Ueland FR, DePriest PD, Kryscio RJ, van Nagell JR Jr.Obstet Gynecol. 2003 Sep;102(3):594-9.

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Adnexal Cyst Causes Considerable Anxiety In Women Due To The Fear Of Malignancy.

The Vast Majority - Even In Postmenopausal Women - Are Benign.

Screening Study of 15,106 women > 50 years, 2763 women (18%) were diagnosed with a unilocular ovarian cyst.

None of these isolated unilocular cysts turned out to be ovarian cancer.

Modesitt SC, Pavlik EJ, Ueland FR, DePriest PD, Kryscio RJ, van Nagell JR Jr.Obstet Gynecol. 2003 Sep;102(3):594-9.

Monday, June 10, 13

Adnexal Cyst Causes Considerable Anxiety In Women Due To The Fear Of Malignancy.

The Vast Majority - Even In Postmenopausal Women - Are Benign.

Screening Study of 15,106 women > 50 years, 2763 women (18%) were diagnosed with a unilocular ovarian cyst.

None of these isolated unilocular cysts turned out to be ovarian cancer.

Frequently They Cause Chronic, Subacute Or Acute Pelvic Pain.

Modesitt SC, Pavlik EJ, Ueland FR, DePriest PD, Kryscio RJ, van Nagell JR Jr.Obstet Gynecol. 2003 Sep;102(3):594-9.

Monday, June 10, 13

The Road Map for Management of Ovarian Cyst

Monday, June 10, 13

The Road Map for Management of Ovarian Cyst

ovarian lesionFirst StepIs It Ovarian

Monday, June 10, 13

The Road Map for Management of Ovarian Cyst

ovarian lesionFirst StepIs It Ovarian

US Recognition

Monday, June 10, 13

The Road Map for Management of Ovarian Cyst

ovarian lesion

Simple, Hemorrhagic, Endometrioma Teratoma, Or Indeterminate

First StepIs It Ovarian

US Recognition

Monday, June 10, 13

The Road Map for Management of Ovarian Cyst

ovarian lesion

Simple, Hemorrhagic, Endometrioma Teratoma, Or Indeterminate

First StepIs It Ovarian

US Recognition

Hige vs. Low Risk Group

Monday, June 10, 13

The Road Map for Management of Ovarian Cyst

ovarian lesion

Simple, Hemorrhagic, Endometrioma Teratoma, Or Indeterminate

First StepIs It Ovarian

US Recognition

Hige vs. Low Risk Group

Monday, June 10, 13

The Road Map for Management of Ovarian Cyst

ovarian lesion

Simple, Hemorrhagic, Endometrioma Teratoma, Or Indeterminate

ignore, follow or excise

First StepIs It Ovarian

US Recognition

Hige vs. Low Risk Group

Monday, June 10, 13

The Road Map for Management of Ovarian Cyst

ovarian lesion

Simple, Hemorrhagic, Endometrioma Teratoma, Or Indeterminate

ignore, follow or excise• Symptomatic lesion versus incidental finding

• Additional findings

• Morphology on US, CT or MRI

First StepIs It Ovarian

US Recognition

Hige vs. Low Risk Group

Monday, June 10, 13

Torsion

Hemorrhage

TeratomaEndometrioma

CarcinomaSimple Cyst

Ultrasound Pattern Recognition of Ovarian Cyst

Monday, June 10, 13

✤ Anechoic Lesion (posterior Acoustic Enhancement)✤ Unilocular✤ Thin, Smooth Walls✤ No Solid Or Well-vascularized Component

Simple Ovarian Cyst

Follicular cyst

CL Cyst✤Thicker wall ✤More Echogenic ✤Increased Vascularity

Monday, June 10, 13

However, both US and CT are more cost-effective than MRI and more readilyavailable. MRI, therefore, continues toplay a complementary, problem-solvingrole in the imaging evaluation of PID.

Hemorrhagic Ovarian CystFunctional (follicular and corpus luteal)ovarian cysts are a common cause of acutepelvic pain when they are associated withacute intracystic hemorrhage or intraper-itoneal rupture. The abrupt onset of paincan be severe and localized, or more dif-fuse and nonspecific. Cyst rupture may beassociated with abdominal distensionfrom associated hemoperitoneum and hy-potension, possibly leading to shock,especially in patients receiving anticoagu-lation. A ruptured EP can have a similarclinical presentation and correlation withb-HCG levels is essential in excluding thispossibility.

US should be the first study of choice;however, the nonspecific nature of thepain may prompt CT study as an alter-native. A follicular cyst shows an anec-hoic appearance with a thin wall andposterior acoustic enhancement, seen asan area of increased echogenicity poster-ior to the cyst (Fig. 12). After ovulation acorpus luteum forms which has a thickerwall with increased vascularity (Fig. 13).This appearance changes in the presenceof hemorrhage and can be quite varieddepending on the age of the bleed. Acuteintracystic hemorrhage is isoechoic to theovarian stroma and can mimic an en-larged ovary. As clot forms over time, amore characteristic lace-like, reticular or‘‘fish-net’’ pattern of internal echoes de-velops (Fig. 14) or a fluid-debris level maybe present. As the clot begins to retract, itmay appear as an echogenic mass, eithermobile or adherent to the cyst wall, po-tentially being confused with wall thick-ening (Fig. 15). Color Doppler imagingshould demonstrate an absence of vascu-

larity in the complex components of thecyst.

In the appropriate context of an ovu-lating woman with acute pelvic pain, acyst with a reticular appearance can beclassified as a hemorrhagic cyst. If the

FIGURE 12. Follicular cyst. Transvaginalultrasound of a follicular cyst (calipers),which resolved on follow-up 2 months later.The cyst is anechoic, thin-walled, and showsposterior acoustic enhancement (arrow).

FIGURE 13. Corpus luteum cyst. ColorDoppler image (shown in black and white)shows peripheral blood flow in the thick cystwall (arrow). A corpus luteum cyst has athicker, more echogenic, and vascular wallcompared with a follicular cyst.

Acute Pelvic Pain 9

✤The Cyst Is Anechoic.✤Thin-walled. ✤Shows Posterior Acoustic Enhancement.✤Resolved On Follow-up 2 Months Later.

Follicular cyst

Monday, June 10, 13

However, both US and CT are more cost-effective than MRI and more readilyavailable. MRI, therefore, continues toplay a complementary, problem-solvingrole in the imaging evaluation of PID.

Hemorrhagic Ovarian CystFunctional (follicular and corpus luteal)ovarian cysts are a common cause of acutepelvic pain when they are associated withacute intracystic hemorrhage or intraper-itoneal rupture. The abrupt onset of paincan be severe and localized, or more dif-fuse and nonspecific. Cyst rupture may beassociated with abdominal distensionfrom associated hemoperitoneum and hy-potension, possibly leading to shock,especially in patients receiving anticoagu-lation. A ruptured EP can have a similarclinical presentation and correlation withb-HCG levels is essential in excluding thispossibility.

US should be the first study of choice;however, the nonspecific nature of thepain may prompt CT study as an alter-native. A follicular cyst shows an anec-hoic appearance with a thin wall andposterior acoustic enhancement, seen asan area of increased echogenicity poster-ior to the cyst (Fig. 12). After ovulation acorpus luteum forms which has a thickerwall with increased vascularity (Fig. 13).This appearance changes in the presenceof hemorrhage and can be quite varieddepending on the age of the bleed. Acuteintracystic hemorrhage is isoechoic to theovarian stroma and can mimic an en-larged ovary. As clot forms over time, amore characteristic lace-like, reticular or‘‘fish-net’’ pattern of internal echoes de-velops (Fig. 14) or a fluid-debris level maybe present. As the clot begins to retract, itmay appear as an echogenic mass, eithermobile or adherent to the cyst wall, po-tentially being confused with wall thick-ening (Fig. 15). Color Doppler imagingshould demonstrate an absence of vascu-

larity in the complex components of thecyst.

In the appropriate context of an ovu-lating woman with acute pelvic pain, acyst with a reticular appearance can beclassified as a hemorrhagic cyst. If the

FIGURE 12. Follicular cyst. Transvaginalultrasound of a follicular cyst (calipers),which resolved on follow-up 2 months later.The cyst is anechoic, thin-walled, and showsposterior acoustic enhancement (arrow).

FIGURE 13. Corpus luteum cyst. ColorDoppler image (shown in black and white)shows peripheral blood flow in the thick cystwall (arrow). A corpus luteum cyst has athicker, more echogenic, and vascular wallcompared with a follicular cyst.

Acute Pelvic Pain 9

CL Cyst

✤Thicker wall ✤More Echogenic ✤Increased Vascularity

Monday, June 10, 13

Hyperstimulated OvaryMonday, June 10, 13

Hyperstimulated OvaryInversion Mode

Monday, June 10, 13

✤Paraovarian Or Paratubal Cysts.

✤A Hydrosalpinx.

✤Cystadenomas (but Larger Cyst In A Postmenopausal Woman).

DD of Simple Ovarian Cyst

Monday, June 10, 13

Monday, June 10, 13

Monday, June 10, 13

Monday, June 10, 13

Torsion

Hemorrhagic

TeratomaEndometrioma

CarcinomaSimple Cyst

Ultrasound Pattern Recognition of Ovarian Cyst

Monday, June 10, 13

Hemorrhagic Ovarian Cyst

A Ruptured EP Can Have A Similar Clinical Presentation And Correlation With B-HCG Levels Is Essential In Excluding This Possibility.

Monday, June 10, 13

➡Acute Intracystic Hemorrhage: Is Iso-choic To The Ovarian Stroma And Can Mimic An Enlarged Ovary.

➡Over Time A Clot Is Formed Lace-like, Reticular Or ‘‘fish-net’’ Pattern

➡Color Doppler Shows Absence Of Blood Flow In The Fine Septation

sonographic or clinical features are notclassic, follow-up US or further assess-ment with MRI can be performed toexclude the possibility of an ovarian neo-plasm. Follow-up US can readily showthe rapid evolution and/or cyst resolution

of hemorrhagic cysts, whereas MRI isparticularly useful in the further assess-ment and characterization of lesions thatare more indeterminate.13

It is important to also search for freeintrapelvic fluid during the sonographicexamination; this will be present withrupture or leakage from a hemorrhagicovarian cyst. The cyst itself may have anangular or crenated appearance and thefree fluid typically contains low-levelechoes or echogenic frank clot in the cul-de-sac or adjacent to the ovary2 (Fig. 16).

On CT, hemorrhagic ovarian cyststypically manifest as a mixed-attenuationadnexal mass with a hyperdense compo-nent (45 to 100HU), and possibly a fluid-hematocrit level (Fig. 17). With rupture,hemoperitoneum will be evident as highattenuation fluid in the pelvis and possi-bly even the abdomen, if the volume islarge. The administration of intravenouscontrast allows the enhancing cyst wall ofa corpus luteal cyst to be better seen.Delayed CT images can demonstrateactive extravasation, which manifests aspooling of contrast-enhanced blood in thepelvis. CT has the added advantage ofexcluding other intra-abdominal causes

FIGURE 14. Hemorrhagic cyst. Transvagi-nal ultrasound of a hemorrhagic cyst showsthe characteristic mesh of fine linear echoesreferred to as a ‘‘lacy’’ or ‘‘fish net’’ appear-ance. Color Doppler shows absence of bloodflow in the fine septations.

FIGURE 15. Hemorrhagic cyst with re-tracting clot. Transvaginal ultrasound showsan eccentric retracting clot (arrows) adherentto the cyst wall. Fibrin strands within the clotgive it a ‘‘lacy’’ appearance.

FIGURE 16. Acute bleed from a left he-morrhagic cyst. There is a clot (arrows) pos-terior to the uterus (U) on transabdominalultrasound.

10 Vandermeer and Wong-You-CheongSonosgraphic Features of Hemorrhagic Ovarian Cyst

Lace likeFish Net Pattern

Absent Color Flow

Acute hemorrhage is isochoic

Monday, June 10, 13

sonographic or clinical features are notclassic, follow-up US or further assess-ment with MRI can be performed toexclude the possibility of an ovarian neo-plasm. Follow-up US can readily showthe rapid evolution and/or cyst resolution

of hemorrhagic cysts, whereas MRI isparticularly useful in the further assess-ment and characterization of lesions thatare more indeterminate.13

It is important to also search for freeintrapelvic fluid during the sonographicexamination; this will be present withrupture or leakage from a hemorrhagicovarian cyst. The cyst itself may have anangular or crenated appearance and thefree fluid typically contains low-levelechoes or echogenic frank clot in the cul-de-sac or adjacent to the ovary2 (Fig. 16).

On CT, hemorrhagic ovarian cyststypically manifest as a mixed-attenuationadnexal mass with a hyperdense compo-nent (45 to 100HU), and possibly a fluid-hematocrit level (Fig. 17). With rupture,hemoperitoneum will be evident as highattenuation fluid in the pelvis and possi-bly even the abdomen, if the volume islarge. The administration of intravenouscontrast allows the enhancing cyst wall ofa corpus luteal cyst to be better seen.Delayed CT images can demonstrateactive extravasation, which manifests aspooling of contrast-enhanced blood in thepelvis. CT has the added advantage ofexcluding other intra-abdominal causes

FIGURE 14. Hemorrhagic cyst. Transvagi-nal ultrasound of a hemorrhagic cyst showsthe characteristic mesh of fine linear echoesreferred to as a ‘‘lacy’’ or ‘‘fish net’’ appear-ance. Color Doppler shows absence of bloodflow in the fine septations.

FIGURE 15. Hemorrhagic cyst with re-tracting clot. Transvaginal ultrasound showsan eccentric retracting clot (arrows) adherentto the cyst wall. Fibrin strands within the clotgive it a ‘‘lacy’’ appearance.

FIGURE 16. Acute bleed from a left he-morrhagic cyst. There is a clot (arrows) pos-terior to the uterus (U) on transabdominalultrasound.

10 Vandermeer and Wong-You-Cheong

•Retracted Blood Clot (DD from thickening cyst wall)•Color Doppler Shows absence of vascularity

Hemorrhagic Ovarian Cyst With Clotted Blood

Retracted Clot

Monday, June 10, 13

Hemorrhagic cyst with a clot mimicking a neoplasm. absence of flow and good through-transmission (arrow)

Retracted Clot

Monday, June 10, 13

TA - US

sonographic or clinical features are notclassic, follow-up US or further assess-ment with MRI can be performed toexclude the possibility of an ovarian neo-plasm. Follow-up US can readily showthe rapid evolution and/or cyst resolution

of hemorrhagic cysts, whereas MRI isparticularly useful in the further assess-ment and characterization of lesions thatare more indeterminate.13

It is important to also search for freeintrapelvic fluid during the sonographicexamination; this will be present withrupture or leakage from a hemorrhagicovarian cyst. The cyst itself may have anangular or crenated appearance and thefree fluid typically contains low-levelechoes or echogenic frank clot in the cul-de-sac or adjacent to the ovary2 (Fig. 16).

On CT, hemorrhagic ovarian cyststypically manifest as a mixed-attenuationadnexal mass with a hyperdense compo-nent (45 to 100HU), and possibly a fluid-hematocrit level (Fig. 17). With rupture,hemoperitoneum will be evident as highattenuation fluid in the pelvis and possi-bly even the abdomen, if the volume islarge. The administration of intravenouscontrast allows the enhancing cyst wall ofa corpus luteal cyst to be better seen.Delayed CT images can demonstrateactive extravasation, which manifests aspooling of contrast-enhanced blood in thepelvis. CT has the added advantage ofexcluding other intra-abdominal causes

FIGURE 14. Hemorrhagic cyst. Transvagi-nal ultrasound of a hemorrhagic cyst showsthe characteristic mesh of fine linear echoesreferred to as a ‘‘lacy’’ or ‘‘fish net’’ appear-ance. Color Doppler shows absence of bloodflow in the fine septations.

FIGURE 15. Hemorrhagic cyst with re-tracting clot. Transvaginal ultrasound showsan eccentric retracting clot (arrows) adherentto the cyst wall. Fibrin strands within the clotgive it a ‘‘lacy’’ appearance.

FIGURE 16. Acute bleed from a left he-morrhagic cyst. There is a clot (arrows) pos-terior to the uterus (U) on transabdominalultrasound.

10 Vandermeer and Wong-You-Cheong

Clot

Ruptured Cyst

Ruptured or leakage from a hemorrhagic ovarian cyst

low-level echoes of frank clot in the cul- de-sac and adjacent to the ovary

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Differential diagnosis✤ Endometriomas.

✤ In The Acute Phase A Hemorrhagic Cyst May Be Completely Filled With Low-level Echoes, Simulating A Solid Mass.

✤ Clot In A Hemorrhagic Cyst May Occasionally Mimic A Solid Nodule In A Neoplasm. Clot, However, Often Has Concave Borders Due To Retraction, While A True Mural Nodule Has Outwardly Convex Borders.

✤ Hemorrhagic Cysts Typically Resolve Within 8 Weeks.

Hemorrhagic Ovarian Cyst

Monday, June 10, 13

Monday, June 10, 13

Monday, June 10, 13

Torsion

Hemorrhage

TeratomaEndometrioma

CarcinomaSimple Cyst

Ultrasound Pattern Recognition of Ovarian Cyst

Monday, June 10, 13

EndometriosisPresence Of Functional Endometrial Glands And Stroma In Sites Outside The Uterine Cavity

Affects Women In Their Reproductive Years.

10% Of Women & 30% Of Infertile Women.

Laparoscopy Remains The Gold Standard For Diagnosis

Classical Symptoms: Pelvic pain, and Infertility.

Monday, June 10, 13

80% Of All Pelvic Endometriosis Occurs In The Ovary.

Endometriotic Cysts “Endometriomas”, Have A Variety Of Appearances On US, Ranging From An Anechoic Cyst To A Complex Cystic Mass With Septations And Eterogeneous Echogenicity.

The Most Typical Appearance On An Endometrioma US:

➡Homogeneous And Hypoechoic Mass➡Diffuse Low-level Echoes (ground-glass)➡No Internal Flow At Color Doppler➡No Enhancing Nodules Or Solid Masses➡In 30% Echogenic Foci Are Seen Within Cyst Wall

Endometrioma

MRI Has A Sensitivity Of 92% And A Specificity Of Up To 98%

Monday, June 10, 13

Endometrioma: adnexal cystic mass with diffuse, low-level internal echoes and hyperechoic foci in the wall.

Hemogenous &, hypoechic

Low echos level “Ground Glass”

No inernal Doppler flow

Echogenic Foci 30%

Ultrasound Pattern Recognition of Endoemtrioma

Monday, June 10, 13

Monday, June 10, 13

✤Endometriomasare more commonly multiple and their appearance is stable over time.

✤hemorrhagic cyst has changing appearance.

sonographic or clinical features are notclassic, follow-up US or further assess-ment with MRI can be performed toexclude the possibility of an ovarian neo-plasm. Follow-up US can readily showthe rapid evolution and/or cyst resolution

of hemorrhagic cysts, whereas MRI isparticularly useful in the further assess-ment and characterization of lesions thatare more indeterminate.13

It is important to also search for freeintrapelvic fluid during the sonographicexamination; this will be present withrupture or leakage from a hemorrhagicovarian cyst. The cyst itself may have anangular or crenated appearance and thefree fluid typically contains low-levelechoes or echogenic frank clot in the cul-de-sac or adjacent to the ovary2 (Fig. 16).

On CT, hemorrhagic ovarian cyststypically manifest as a mixed-attenuationadnexal mass with a hyperdense compo-nent (45 to 100HU), and possibly a fluid-hematocrit level (Fig. 17). With rupture,hemoperitoneum will be evident as highattenuation fluid in the pelvis and possi-bly even the abdomen, if the volume islarge. The administration of intravenouscontrast allows the enhancing cyst wall ofa corpus luteal cyst to be better seen.Delayed CT images can demonstrateactive extravasation, which manifests aspooling of contrast-enhanced blood in thepelvis. CT has the added advantage ofexcluding other intra-abdominal causes

FIGURE 14. Hemorrhagic cyst. Transvagi-nal ultrasound of a hemorrhagic cyst showsthe characteristic mesh of fine linear echoesreferred to as a ‘‘lacy’’ or ‘‘fish net’’ appear-ance. Color Doppler shows absence of bloodflow in the fine septations.

FIGURE 15. Hemorrhagic cyst with re-tracting clot. Transvaginal ultrasound showsan eccentric retracting clot (arrows) adherentto the cyst wall. Fibrin strands within the clotgive it a ‘‘lacy’’ appearance.

FIGURE 16. Acute bleed from a left he-morrhagic cyst. There is a clot (arrows) pos-terior to the uterus (U) on transabdominalultrasound.

10 Vandermeer and Wong-You-CheongHomogenously Hypoechoic

Lace-like Interanal Echogenicity,

Hemorrhagic Cyts Subacute stage

Endometrioma

Endometriomas Vs. Hemorrhagic

Monday, June 10, 13

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Monday, June 10, 13

Monday, June 10, 13

Torsion

Hemorrhage

TeratomaEndometrioma

CarcinomaSimple Cyst

Ultrasound Pattern Recognition of Ovarian Cyst

Monday, June 10, 13

Mature Cystic TeratomeUS Findings Characteristic Of A Mature Cystic Teratoma:

➡Hypoechoic Mass With Hyperechoic Nodule (Rokitansky Nodule Or Dermoid Plug)

➡Usually Unilocular (90%)

➡May Contain Calcifications (30%)

➡May Contain Hyperechoic Lines Caused By Floating Hair

➡May Contain A Fat-fluid Level, I.e. Fat Floating On Aqueous Fluid

Monday, June 10, 13

77.3

5.4

Dermoid Cyst is Unilocular in 90% of cases

Hyperechoic Nodule

(Rokatinsky Nodule)

Hypoechoic Mass

Hyperechoic line with floating hari

and faf

Ultrasound Pattern Recognition of Teratoma

Monday, June 10, 13

TV scan the 'tip-of-the-iceberg' sign: acoustic shadowing from the hyperechoic part of the dermoid cyst (arrow).

Lesion may be misinterpreted as bowel gas.

Hyperechoic line with floating hair

and fat

Calcification

Monday, June 10, 13

cystic teratoma with mixed tissues and bizarre solid tissue (red arrows).

Monday, June 10, 13

3 D Multiplaner TA image of a Cystic lesion in Pregnant Patient “cystic teratoma”

Monday, June 10, 13

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Torsion

Hemorrhage

TeratomaEndometrioma

CarcinomaSimple Cyst

Ultrasound Pattern Recognition of Ovarian Cyst

Monday, June 10, 13

Possibly Malignant

Monday, June 10, 13

Ultrasound Pattern Recognition of Neoplasm

Monday, June 10, 13

Color Doppler Of Ovary Demonstrates Blood Flow Within Irregularly Thickened Septa (red Arrows).

Predictor Of MalignancyLarge sizeVascularized septations Vascularized solid componentsVascularized thick, irregular wallSecondary findings a: e.g. Ascites

Monday, June 10, 13

Summary of The The Road Map for Management of Ovarian Cyst

Monday, June 10, 13

Summary of The The Road Map for Management of Ovarian Cyst

Monday, June 10, 13

Torsion

Hemorrhage

TeratomaEndometrioma

CarcinomaSimple Cyst

Ultrasound Pattern Recognition of Ovarian Cyst

Monday, June 10, 13

Ovarian Torsion

Prompt Identification And Treatment, Especially In Young Women.

Often Adexal Not Just Ovarian (ovary and fallopian tube)

3% of Emergency Gynecologic Surgeries.

Difficult To Diagnose Clinically Because The Presenting Symptoms Of Pain, Nausea, And Vomiting Are Nonspecific.

Monday, June 10, 13

Ovarian Torsion

In Adults: Often Associated With benign and malignant ovarian Neoplasm, (50% To 81% Of Cases).

In Children And Adolescents: Due To Increased Mobility Of The Vascular Pedicle Due To developmental abnormalities such as excessively long fallopian tubes or an absent mesosalpinx.

In Pregnancy: The Risk Is Higher (25% Of Cases Occur In Pregnant Patients) In early pregnancy (6-14 weeks) secondary to a corpus luteum cyst or laxity of the adjacent tissues.

Immediate Postpartum Period: The Risk Is Also Higher In The Immediate Postpartum Period.

Monday, June 10, 13

The Twisting Of The Ovarian Vascular Pedicle

Lymphatic

Venous

Arterial Flow

The Twisting Of The Ovarian Vascular Pedicle

Secondary Signs ❖Free Pelvic Fluid❖Underlying Ovarian Lesion❖Reduced Or Absent Vascularity❖A Twisted Dilated Tubular Structure Corresponding

To The Vascular Pedicle.

Primary Features: Ovarian Enlargement With Amorphous And Hypoechoic Appearance Due To Venous / Lymphatic Engorgement, Oedema And Haemorrhage. 

Pathogenesis Of The Sonographic Features

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Primary Sonographic Features

Monday, June 10, 13

Enlarged, Amorphous and Hypoechoic ovariesPeripherally located

Numerous Follicles

Free Fluid in the pelvisAbsence of Venous and Arterial Blood Flow

Primary Sonographic Features

Monday, June 10, 13

Enlarged Ovarian Torsion

8 yrs. Dull aching right flank pain - 3 days. No other complaints.

Enlarged Rt Ovary: 4.2 × 3.3 × 2.8 = Vol. 21 cc

Monday, June 10, 13

Normal Lt OvaryEnlarged Rt Ovary

Enlarged right ovary ( 21 cc ) compared to left ovary ( 3 cc )

Rt Ovary: 4.2 × 3.3 × 2.8 = Vol. 21 cc

Lt Ovary: 1.6 × 2.8 × 1.4 = Vol. 3 cc

Monday, June 10, 13

Enlarged Ovariana Torsion

Fluid in pelvis & Thick Rt Pedicle Monday, June 10, 13

Absent flow in Rt. ovary with normal flow in Lt. ovaryMonday, June 10, 13

Color Doppler image through the ovary (red arrowheads) shows absence of blood flow demonstrating ovarian torsion.

Monday, June 10, 13

Left ovary Normal size and follicular pattern 

and flow.

Right ovary Odematous,

peripheral small follicles

Lower Abdominal Pain - 3 days Monday, June 10, 13

Enlarged Rt Ovary: 3.9 × 5.7 × 3.6 = Vol. 43 cc

Monday, June 10, 13

Monday, June 10, 13

77.3

5.4

Dermoid CystMonday, June 10, 13

Ovarian torsion in a patient with acute pelvic pain 2 weeks postpartum. Sonography showed a markedly enlarged right ovary

channels are occluded, or to the dualarterial supply to the ovarywith occlusionof only one of the supply channels. Alter-natively, the arterial flow that is presentmay be decreased, and the relative differ-ence is difficult to appreciate unless com-parison with the contralateral side ismade.17 For these reasons, in the appro-priate clinical setting with an ovary thatdemonstrates gray-scale findings consis-tent with torsion, the diagnosis should besuggested even in the presence of docu-mented arterial flow. Color Doppler so-nography of the adnexa may reveal thetwisted vascular pedicle, termed ‘‘thewhirlpool sign’’; if flow is seen within it,this is a useful marker of ovarian viability(Fig. 19).18

ACT scanmay be performed initially ifthe diagnosis is unsuspected or the patientis being evaluated for alternative diag-noses. Both CT andMRI are more usefulin evaluating patients with suspected sub-acute or chronic torsion and those with asuspected pelvic mass. Findings of ovar-ian torsion on CT and MRI include anenlarged ovary displaced from its normallocation in the adnexa with or without anassociatedmass, deviation of the uterus tothe twisted side, obliteration of the fat

planes, thickening of the fallopian tube,and ascites. Contrast-enhanced CT mayshow engorged enhancing adnexal ves-sels, due to congestion, possibly with abeaked configuration at the periphery ofthe ovary. In the setting of hemorrhagicinfarction, there may be lack of ovarianenhancement, with hematoma or gaspresent. Contrast-enhanced dynamicsubtraction MRI has better contrast re-solution than CT and can readily demon-strate nonenhancement of the ovary.Bright ovarian signal on fat-suppressedT1-weighted images indicates the pre-sence of hemorrhage or vascular conges-tion. The combination of these findingswith a thickened tube or a twisted vascu-lar pedicle, which is often easier to see onmultiplanar CT or MRI, is very sugges-tive of hemorrhagic infarction after ovar-ian torsion.15

Fibroid DegenerationLeiomyomata (fibroids) are the mostcommon gynecologic neoplasm, occur-ring in 20% to 40% of all women during

FIGURE 18. Ovarian torsion in a patientwith acute pelvic pain 2 weeks postpartum.Sonography showed a markedly enlargedright ovary with no flow on color Doppler(not shown). FIGURE 19. ‘‘Whirlpool sign’’ of ovarian

torsion. Transvaginal ultrasound with colorDoppler (shown in black andwhite) shows thecorkscrew appearance of the twisted vascularpedicle (arrow).

12 Vandermeer and Wong-You-Cheong

Monday, June 10, 13

Uterine

Adenomyosis

Degenerating Fibroids

Prolapsing Fibroids

Abnormally Placed IUD

OvarianSimple Cyst

Hemorrhagic Cyst

Ovarian Torsion

Endometrioma

Dermoid Cyst

Ovarian Cancer

Common Causes of Pelvic Pain

PID

Tubo-Ovarian Abscess.

Hydrosalpinx

Pyosalpinx

EP

Monday, June 10, 13

✤Pelvic Inflammatory Disease (PID) Is Caused By Sexually Transmitted Infection.

✤Most Commonly Chlamydia Or Gonorrhea Or Both.PID Also Occurs As A Complication Of Appendicitis, Diverticulitis, Pelvic Abscess, And Post-abortion Or Post-delivery Infection.

✤Chronic PID Present With Pelvic Mass And Dyspareunia.

✤Most Cases Occur In Young, Sexually Active Women, Although 1-2% Of Tubo-ovarian Abscesses Are Reported In Postmenopausal Women.

Pelvic Pain - PID

Monday, June 10, 13

Pyosalpinx: pus-filled, dilated fallopian tube is recognized by the echogenic particulate matter that fills or layers within the tube.

Transvaginal image of a dilated fallopian tube (FT) containing echogenic fluid.

Monday, June 10, 13

Tubo-ovarian complex: dilated fallopian tube and inflamed ovary within a mass formed by adhesions. Pus appears as layering echogenic fluid and gas within mass.

markedly dilated fallopian tube

the ovary

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Hydrosalpinx: TV-US scan shows a tubular-shaped cystic mass separate from the ovary. The finding of indentations (arrows) on opposite sides of the tubular mass, termed the waist sign, is a good indicator of a hydrosalpinx.

Waist Sign

Hydrosalpinx

Monday, June 10, 13

Sagittal transvaginal US scan demonstrates a tubular-shaped cystic mass with several incomplete septa (typical of a hydrosalpinx when occurring in a tubular-shaped cystic mass.

Waist Sign (incomplete septa)

Hydrosalpinx

Monday, June 10, 13

TV-US scan shows a tubular-shaped cystic mass with a septum. Small nodules (arrows) in the mass are due to thickened endosalpingeal folds.

Hydrosalpinx

The Inversion mode in 3 D scanning. Definining the Diagnosis of Hydrosaplinx

The Inversion mode in 3 D of PCO

Monday, June 10, 13

Uterine

Adenomyosis

Degenerating Fibroids

Prolapsing Fibroids

Abnormally Placed IUD

OvarianSimple Cyst

Hemorrhagic Cyst

Ovarian Torsion

Endometrioma

Dermoid Cyst

Ovarian Cancer

Common Causes of Pelvic Pain

PID

Tubo-Ovarian Abscess.

Hydrosalpinx

Pyosalpinx

EP

Tubal.

Cornual

Cervical

Monday, June 10, 13

Ectopic PregnancyPregnancy with the fertilized embryo implanted

on any tissue other than the uterine lining

•95% Tubal.•1.5% abdominal.•0.5% ovarian.

•Interstitial 1-3%.

•0.03% Cervical.Interstitial portion of the fallopian tube is the section of the tube which is surrounded by the myometrium in the cornual area

Monday, June 10, 13

➡ Previous EP: 15-20 % risk of recurrence ➡ PID: 6 %.

➡ Non-laparoscopic Tubal Ligation: 12%

➡ Laparoscopic Tubal Coagulation: 50%

➡ Previous Tubal Surgery➡Ovulation Induction Or Ovarian Stimulation➡ In Vitro Fertilization 2%

➡ Progestin Only Contraceptives And Progesterone-bearing IUD's: 16% Of Pregnancies.

Risk Factors for Ectopic Pregnancy

Heterotopic Pregnancy In The General Population (1:7000 Pregnancies). But Much Higher Risk (1:100) With ART.

Monday, June 10, 13

The Clinical Impression Of The Gynecologist Is The Most Important Factor In Making A Timely Diagnosis Of EP.

HCG Titers And Risk Ectopic Pregnancies

Daus et al, Journal of Reproductive Medicine, February, 1989, p.162

7

36

57

Falling Abnormaly Rising

Normaly Rising

Risk of EP

<1000 <3000 <5000 <10000 >1000

9101521

45

Risk of EP Relation hCG Trend

Risk of EP Relation to hCG value

Risk of EP

Monday, June 10, 13

Rules for use of hCG

✓The hCG level should rise at least 66% in 48 hours, and at least double in 72 hour

HCG and US in the Diagnosis of EP

✓A a normal pregnancy can be seen at hCG level of 2000 mIU/ml

✓By 5 - 6 wks. normal pregnancies in the uterus should be seen.

Rules for use of TV-US

Day after HCG Average High Lower

14 48 119 17

15 59 147 17

16 95 223 33

17 132 429 17

18 292 758 70

19 303 514 111

20 522 1690 135

21 1061 4130 324

22 1287 3279 185

23 2034 4660 506

24 2637 10000 540

HCG levels from normal singleton pregnancies:

Levels are listed for various days after the ovulatory HCG injection or LH surge

"High" is highest seen in this group of pregnancies"Low" is lowest seen in this group of pregnancies

First (same as Third) International Reference Preparation

There Is A Large Variation In A "normal" HCG Level For Any Given Time In Pregnancy

Monday, June 10, 13

Sonographic Appearance of EP

❖The Most Common Sonographic Abnormality: Complex Adnexal Mass And Empty Uterus Is Highly

❖Conclusive Diagnosis Of Ectopic By Ultrasound Can Only Be Made If A Fetus Or Fetal Cardiac Motion Is Seen Outside The Uterus (only In 20% Of EP)

❖20-30% Of Ectopics Have No Detectable Abnormality On Ultrasound

Monday, June 10, 13

Ultrasound Landmarks in Normal Pregnancy

GS Visualization and

hCG value

YS Visualization and

Mean Sac Diambeter

FH Beat Embryo Visualization and

MSD

FHB and Embryo length

4.5-5 Wks 5.5-6 Wks 6-6.5 Wks 6-6.5 WksMonday, June 10, 13

Ultrasound Landmarks in Normal Pregnancy

TV TA

1800

1000

GS Visualization and

hCG value

YS Visualization and

Mean Sac Diambeter

FH Beat Embryo Visualization and

MSD

FHB and Embryo length

4.5-5 Wks 5.5-6 Wks 6-6.5 Wks 6-6.5 WksMonday, June 10, 13

Ultrasound Landmarks in Normal Pregnancy

TV TA

1800

1000

TV TA

18

8

GS Visualization and

hCG value

YS Visualization and

Mean Sac Diambeter

FH Beat Embryo Visualization and

MSD

FHB and Embryo length

4.5-5 Wks 5.5-6 Wks 6-6.5 Wks 6-6.5 WksMonday, June 10, 13

Ultrasound Landmarks in Normal Pregnancy

TV TA

1800

1000

TV TA

18

8

TV TA

25

16

GS Visualization and

hCG value

YS Visualization and

Mean Sac Diambeter

FH Beat Embryo Visualization and

MSD

FHB and Embryo length

4.5-5 Wks 5.5-6 Wks 6-6.5 Wks 6-6.5 WksMonday, June 10, 13

Ultrasound Landmarks in Normal Pregnancy

TV TA

1800

1000

TV TA

18

8

TV TA

25

16

TV TA

5

GS Visualization and

hCG value

YS Visualization and

Mean Sac Diambeter

FH Beat Embryo Visualization and

MSD

FHB and Embryo length

4.5-5 Wks 5.5-6 Wks 6-6.5 Wks 6-6.5 WksMonday, June 10, 13

Ultrasound Landmarks in Normal Pregnancy

TV TA

1800

1000

TV TA

18

8

TV TA

25

16

TV TA

5

GS Visualization and

hCG value

YS Visualization and

Mean Sac Diambeter

FH Beat Embryo Visualization and

MSD

FHB and Embryo length

4.5-5 Wks 5.5-6 Wks 6-6.5 Wks 6-6.5 WksMonday, June 10, 13

pelvic pain and a positive pregnancy test.With an incidence of approximately 1 outof every 200 diagnosed pregnancies, EPremains the leading cause of maternaldeath in the first trimester and the secondleading cause of maternal mortality over-all.1,2 US is the most important tool in theevaluation of suspected EP and should becombined with measurement of quantita-tive b-human chorionic gonadotropin(b-HCG) for appropriate interpretation.

The first goal of US evaluation is todetermine whether an intrauterine preg-nancy is present. If an intrauterine preg-nancy can be demonstrated, an EP can bereasonably excluded, as synchronous in-trauterine and EPs are exceedingly rare inthe general population (1:7000 pregnan-cies).3 However, it is important to notethat the risk is much higher in patientswho have undergone assisted reproduc-tion (1:100 pregnancies).3,4 An intrauter-ine gestational sac should be seen onendovaginal US when the b-HCG levelis greater than 2000mIU/mL by the thirdInternational Reference Preparation. Itfirst manifests as the ‘‘intradecidual sacsign,’’ a small, round, well-defined fluidcollection completely surrounded byechogenic decidual tissue. It is eccentri-cally located adjacent to the hyperechoicline representing the opposing walls of theendometrium (Fig. 1). This sign, however,has limited utilitywith a sensitivity of only34% to 66% and a specificity of 55% to73%.4 The ‘‘double-decidual sac sign’’ isusually easier to identify and forms as theround fluid collection embedded in thedecidua enlarges and develops the appear-ance of an echogenic double layer ofdecidua along its border with the endo-metrial cavity. The 2 decidual layers, thedecidua capsularis and the decidua parie-talis, are separated by the hypoechoicendometrial cavity (Fig. 2). Color Dop-pler evidence of trophoblastic blood flowaround the fluid collection further sup-ports the diagnosis of an intrauterinepregnancy. Pulsed Doppler should be

avoided because of concerns regardingheat deposition in the developing embryo.

The double-decidual sac sign must bedistinguished from a pseudosac, an in-trauterine fluid collection, which formsin response to the hormonal influenceson the endometrium in the presence of

FIGURE 1. Intradecidual sac sign. Trans-vaginal ultrasound of the uterus shows asmall, round anechoic fluid collection (arrow-head), eccentrically implanted within theechogenic endometrium (arrow), consistentwith a very early intrauterine pregnancy.

FIGURE 2. Double decidual sac sign.Transabdominal ultrasound of the uteruswith an intrauterine gestational sac (* )showsa double layer of echogenic decidua (arrows)separated by the hypoechoic endometrial cav-ity (arrowhead).

Acute Pelvic Pain 3Pseudocac

Small, Rounded and well defined

Completely Surrounded by

Echogenic decidual tissue

Eccentrically located within the opposing endometiral lining

I: ‘‘Intradecidual Sac”

•Sensitivity 34% To 66% •Specificity 55% To 73%

Monday, June 10, 13

an EP. In contrast to the double decidualsac of an intrauterine pregnancy, thepseudosac has a single echogenic layerof endometrium surrounding an ovoid,elongated, centrally located collection ofendometrial fluid (Fig. 3). Only 5% to10% of patients with EP will demonstratea pseudosac on US.3 More commonlythe uterus will show neither a true nor apseudosac. Correlation with the clinicalpresentation, specifically with respect topain and amount of bleeding, quantitativeb-HCG, and a meticulous sonographicsearch of the adnexae is necessary todetermine if the findings represent anintrauterine pregnancy which is too smallto be seen sonographically, a recent spon-taneous abortion or an EP.

The ovary provides a landmark forevaluation of the adnexa, as it is usuallylocated near the ampullary portion of thefallopian tube, which is the most frequentsite of ectopic implantation. The areasurrounding the ovary should be evalu-ated thoroughly for any extraovarianabnormality. Although the sonographicappearance of EP can be quite varied, it

most commonly manifests as a ring-shaped structure with an anechoic centerand a thick echogenic periphery, the ‘‘tu-bal ring sign’’ (Fig. 4). A yolk sac and fetalpole may be present, with or withoutcardiac activity, providing the most spe-cific sonographic finding of an EP (speci-ficity of 100%) (Fig. 5). However, thisappearance is the least sensitive findingin EP (15% to 20%).3More commonly anEP is identified as a complex adnexalmassin a patient with a positive pregnancy testand no intrauterine pregnancy. Althoughmost EPs are located between the ovaryand the uterus, they may implant any-where in the pelvis and it is necessary tocarefully search the regions adjacent tothe uterine fundus, cul-de-sac and lateralmargins of the pelvis.

An uncommon but important typeof EP is an interstitial pregnancy, whichoccurs in 2% to 3% of EPs.5 Aninterstitial pregnancy results from im-plantation within the interstitial or intra-myometrial portion of the fallopiantube. In this location, the EP can growlarger before becoming symptomatic.

FIGURE 3. Pseudosac in the setting of ecto-pic pregnancy. Sagittal transvaginal ultra-sound of the uterus shows an elongated fluidcollection (arrow) located centrally within thecavity. It is surrounded by a single, echogeniclayer (arrowhead) of endometrium. An ecto-pic pregnancy (not shown) was identified inthe right adnexa.

FIGURE 4. Tubal ring sign of ectopic preg-nancy. Transverse ultrasound of the rightadnexa shows a cystic structure with a thickechogenic rim (closed arrow), consistent withan ectopic gestational sac, located betweenthe uterus (arrowhead) and the right ovary(open arrow), which contains a corpus luteumcyst (* ).

4 Vandermeer and Wong-You-Cheong

pelvic pain and a positive pregnancy test.With an incidence of approximately 1 outof every 200 diagnosed pregnancies, EPremains the leading cause of maternaldeath in the first trimester and the secondleading cause of maternal mortality over-all.1,2 US is the most important tool in theevaluation of suspected EP and should becombined with measurement of quantita-tive b-human chorionic gonadotropin(b-HCG) for appropriate interpretation.

The first goal of US evaluation is todetermine whether an intrauterine preg-nancy is present. If an intrauterine preg-nancy can be demonstrated, an EP can bereasonably excluded, as synchronous in-trauterine and EPs are exceedingly rare inthe general population (1:7000 pregnan-cies).3 However, it is important to notethat the risk is much higher in patientswho have undergone assisted reproduc-tion (1:100 pregnancies).3,4 An intrauter-ine gestational sac should be seen onendovaginal US when the b-HCG levelis greater than 2000mIU/mL by the thirdInternational Reference Preparation. Itfirst manifests as the ‘‘intradecidual sacsign,’’ a small, round, well-defined fluidcollection completely surrounded byechogenic decidual tissue. It is eccentri-cally located adjacent to the hyperechoicline representing the opposing walls of theendometrium (Fig. 1). This sign, however,has limited utilitywith a sensitivity of only34% to 66% and a specificity of 55% to73%.4 The ‘‘double-decidual sac sign’’ isusually easier to identify and forms as theround fluid collection embedded in thedecidua enlarges and develops the appear-ance of an echogenic double layer ofdecidua along its border with the endo-metrial cavity. The 2 decidual layers, thedecidua capsularis and the decidua parie-talis, are separated by the hypoechoicendometrial cavity (Fig. 2). Color Dop-pler evidence of trophoblastic blood flowaround the fluid collection further sup-ports the diagnosis of an intrauterinepregnancy. Pulsed Doppler should be

avoided because of concerns regardingheat deposition in the developing embryo.

The double-decidual sac sign must bedistinguished from a pseudosac, an in-trauterine fluid collection, which formsin response to the hormonal influenceson the endometrium in the presence of

FIGURE 1. Intradecidual sac sign. Trans-vaginal ultrasound of the uterus shows asmall, round anechoic fluid collection (arrow-head), eccentrically implanted within theechogenic endometrium (arrow), consistentwith a very early intrauterine pregnancy.

FIGURE 2. Double decidual sac sign.Transabdominal ultrasound of the uteruswith an intrauterine gestational sac (* )showsa double layer of echogenic decidua (arrows)separated by the hypoechoic endometrial cav-ity (arrowhead).

Acute Pelvic Pain 3Pseudocac

Centrally located

Surrounded with single echogenic layer of

endometrium

Small, Rounded and well defined

Completely Surrounded by

Echogenic decidual tissue

Eccentrically located within the opposing endometiral lining

I: ‘‘Intradecidual Sac”

•Sensitivity 34% To 66% •Specificity 55% To 73%

Monday, June 10, 13

an EP. In contrast to the double decidualsac of an intrauterine pregnancy, thepseudosac has a single echogenic layerof endometrium surrounding an ovoid,elongated, centrally located collection ofendometrial fluid (Fig. 3). Only 5% to10% of patients with EP will demonstratea pseudosac on US.3 More commonlythe uterus will show neither a true nor apseudosac. Correlation with the clinicalpresentation, specifically with respect topain and amount of bleeding, quantitativeb-HCG, and a meticulous sonographicsearch of the adnexae is necessary todetermine if the findings represent anintrauterine pregnancy which is too smallto be seen sonographically, a recent spon-taneous abortion or an EP.

The ovary provides a landmark forevaluation of the adnexa, as it is usuallylocated near the ampullary portion of thefallopian tube, which is the most frequentsite of ectopic implantation. The areasurrounding the ovary should be evalu-ated thoroughly for any extraovarianabnormality. Although the sonographicappearance of EP can be quite varied, it

most commonly manifests as a ring-shaped structure with an anechoic centerand a thick echogenic periphery, the ‘‘tu-bal ring sign’’ (Fig. 4). A yolk sac and fetalpole may be present, with or withoutcardiac activity, providing the most spe-cific sonographic finding of an EP (speci-ficity of 100%) (Fig. 5). However, thisappearance is the least sensitive findingin EP (15% to 20%).3More commonly anEP is identified as a complex adnexalmassin a patient with a positive pregnancy testand no intrauterine pregnancy. Althoughmost EPs are located between the ovaryand the uterus, they may implant any-where in the pelvis and it is necessary tocarefully search the regions adjacent tothe uterine fundus, cul-de-sac and lateralmargins of the pelvis.

An uncommon but important typeof EP is an interstitial pregnancy, whichoccurs in 2% to 3% of EPs.5 Aninterstitial pregnancy results from im-plantation within the interstitial or intra-myometrial portion of the fallopiantube. In this location, the EP can growlarger before becoming symptomatic.

FIGURE 3. Pseudosac in the setting of ecto-pic pregnancy. Sagittal transvaginal ultra-sound of the uterus shows an elongated fluidcollection (arrow) located centrally within thecavity. It is surrounded by a single, echogeniclayer (arrowhead) of endometrium. An ecto-pic pregnancy (not shown) was identified inthe right adnexa.

FIGURE 4. Tubal ring sign of ectopic preg-nancy. Transverse ultrasound of the rightadnexa shows a cystic structure with a thickechogenic rim (closed arrow), consistent withan ectopic gestational sac, located betweenthe uterus (arrowhead) and the right ovary(open arrow), which contains a corpus luteumcyst (* ).

4 Vandermeer and Wong-You-Cheong

5% to 10% of patients with EP demonstrate a pseudosac

pelvic pain and a positive pregnancy test.With an incidence of approximately 1 outof every 200 diagnosed pregnancies, EPremains the leading cause of maternaldeath in the first trimester and the secondleading cause of maternal mortality over-all.1,2 US is the most important tool in theevaluation of suspected EP and should becombined with measurement of quantita-tive b-human chorionic gonadotropin(b-HCG) for appropriate interpretation.

The first goal of US evaluation is todetermine whether an intrauterine preg-nancy is present. If an intrauterine preg-nancy can be demonstrated, an EP can bereasonably excluded, as synchronous in-trauterine and EPs are exceedingly rare inthe general population (1:7000 pregnan-cies).3 However, it is important to notethat the risk is much higher in patientswho have undergone assisted reproduc-tion (1:100 pregnancies).3,4 An intrauter-ine gestational sac should be seen onendovaginal US when the b-HCG levelis greater than 2000mIU/mL by the thirdInternational Reference Preparation. Itfirst manifests as the ‘‘intradecidual sacsign,’’ a small, round, well-defined fluidcollection completely surrounded byechogenic decidual tissue. It is eccentri-cally located adjacent to the hyperechoicline representing the opposing walls of theendometrium (Fig. 1). This sign, however,has limited utilitywith a sensitivity of only34% to 66% and a specificity of 55% to73%.4 The ‘‘double-decidual sac sign’’ isusually easier to identify and forms as theround fluid collection embedded in thedecidua enlarges and develops the appear-ance of an echogenic double layer ofdecidua along its border with the endo-metrial cavity. The 2 decidual layers, thedecidua capsularis and the decidua parie-talis, are separated by the hypoechoicendometrial cavity (Fig. 2). Color Dop-pler evidence of trophoblastic blood flowaround the fluid collection further sup-ports the diagnosis of an intrauterinepregnancy. Pulsed Doppler should be

avoided because of concerns regardingheat deposition in the developing embryo.

The double-decidual sac sign must bedistinguished from a pseudosac, an in-trauterine fluid collection, which formsin response to the hormonal influenceson the endometrium in the presence of

FIGURE 1. Intradecidual sac sign. Trans-vaginal ultrasound of the uterus shows asmall, round anechoic fluid collection (arrow-head), eccentrically implanted within theechogenic endometrium (arrow), consistentwith a very early intrauterine pregnancy.

FIGURE 2. Double decidual sac sign.Transabdominal ultrasound of the uteruswith an intrauterine gestational sac (* )showsa double layer of echogenic decidua (arrows)separated by the hypoechoic endometrial cav-ity (arrowhead).

Acute Pelvic Pain 3Pseudocac

Centrally located

Surrounded with single echogenic layer of

endometrium

Small, Rounded and well defined

Completely Surrounded by

Echogenic decidual tissue

Eccentrically located within the opposing endometiral lining

I: ‘‘Intradecidual Sac”

•Sensitivity 34% To 66% •Specificity 55% To 73%

Monday, June 10, 13

pelvic pain and a positive pregnancy test.With an incidence of approximately 1 outof every 200 diagnosed pregnancies, EPremains the leading cause of maternaldeath in the first trimester and the secondleading cause of maternal mortality over-all.1,2 US is the most important tool in theevaluation of suspected EP and should becombined with measurement of quantita-tive b-human chorionic gonadotropin(b-HCG) for appropriate interpretation.

The first goal of US evaluation is todetermine whether an intrauterine preg-nancy is present. If an intrauterine preg-nancy can be demonstrated, an EP can bereasonably excluded, as synchronous in-trauterine and EPs are exceedingly rare inthe general population (1:7000 pregnan-cies).3 However, it is important to notethat the risk is much higher in patientswho have undergone assisted reproduc-tion (1:100 pregnancies).3,4 An intrauter-ine gestational sac should be seen onendovaginal US when the b-HCG levelis greater than 2000mIU/mL by the thirdInternational Reference Preparation. Itfirst manifests as the ‘‘intradecidual sacsign,’’ a small, round, well-defined fluidcollection completely surrounded byechogenic decidual tissue. It is eccentri-cally located adjacent to the hyperechoicline representing the opposing walls of theendometrium (Fig. 1). This sign, however,has limited utilitywith a sensitivity of only34% to 66% and a specificity of 55% to73%.4 The ‘‘double-decidual sac sign’’ isusually easier to identify and forms as theround fluid collection embedded in thedecidua enlarges and develops the appear-ance of an echogenic double layer ofdecidua along its border with the endo-metrial cavity. The 2 decidual layers, thedecidua capsularis and the decidua parie-talis, are separated by the hypoechoicendometrial cavity (Fig. 2). Color Dop-pler evidence of trophoblastic blood flowaround the fluid collection further sup-ports the diagnosis of an intrauterinepregnancy. Pulsed Doppler should be

avoided because of concerns regardingheat deposition in the developing embryo.

The double-decidual sac sign must bedistinguished from a pseudosac, an in-trauterine fluid collection, which formsin response to the hormonal influenceson the endometrium in the presence of

FIGURE 1. Intradecidual sac sign. Trans-vaginal ultrasound of the uterus shows asmall, round anechoic fluid collection (arrow-head), eccentrically implanted within theechogenic endometrium (arrow), consistentwith a very early intrauterine pregnancy.

FIGURE 2. Double decidual sac sign.Transabdominal ultrasound of the uteruswith an intrauterine gestational sac (* )showsa double layer of echogenic decidua (arrows)separated by the hypoechoic endometrial cav-ity (arrowhead).

Acute Pelvic Pain 3

Decidua Paraitalis

II: ‘‘Double-Decidual Sac Sign’’Decidua

Capsularis

Hypoechoic endometiral cavity

Monday, June 10, 13

Significantly higher morbidity and mor-tality due to uterine rupture and massivehemorrhage are seen than with a tubalEP. The classic transvaginal sonographicfinding of an interstitial pregnancy is the‘‘interstitial line sign’’ (Fig. 6). The signrefers to a thin, straight, echogenic lineextending from the endometrial cavity to

the eccentrically located gestational sac inthe uterine fundus. The line represents the2 opposing layers of coapted endome-trium when the sac is large or the intra-mural portion of the tube when the sac issmall. The sac is incompletely surroundedby myometrium that may become pro-gressively thinned or absent laterally asthe sac grows.

Other sites of extratubal EP are evenrarer; intraovarian EPs account for lessthan 1% and cervical EPs, approximately0.15%.3 A simple or complex intraovar-ian lesion should not raise concern for anEP, as it is statistically much more likelyto represent the corpus luteum (Figs. 4,5B). Differentiating between an extra-ovarian EP and an exophytic or intrao-varian corpus luteum can be aided bygently pushing on the area with the en-dovaginal probe. Independent movementof the lesion and the ovary, separate fromeach other, confirms the extraovarianlocation of the adnexal ring seen with anEP, whereas a corpus luteum will movewith the ovary. The corpus luteumusuallyhas a less echogenic wall than an ovarian

FIGURE 5. Ectopic pregnancy with a yolksac and fetal pole. (A) Sagittal transabdom-inal ultrasound of the uterus shows a smallcentral fluid collection (open arrow), consis-tent with a pseudosac. A ring-shaped struc-ture (closed arrow) adjacent to the uteruscontains a fetal pole (arrowhead), confirmingan ectopic pregnancy. (B) Transvaginal ultra-sound of the right adnexa in the same patientbetter demonstrates the ectopic pregnancy(E), with a yolk sac (arrowhead) and fetal pole(arrow), separate from the right ovary (OV),which contains a corpus luteum (* ).

FIGURE 6. Interstitial line sign. Transva-ginal ultrasound of the uterus shows no evi-dence of a normal intrauterine pregnancy.The 2 layers of the echogenic endometriumare coapted (arrow) and extend to the centerof a small round fluid collection (arrowheads)eccentrically located in the myometrium.

Acute Pelvic Pain 5

Significantly higher morbidity and mor-tality due to uterine rupture and massivehemorrhage are seen than with a tubalEP. The classic transvaginal sonographicfinding of an interstitial pregnancy is the‘‘interstitial line sign’’ (Fig. 6). The signrefers to a thin, straight, echogenic lineextending from the endometrial cavity to

the eccentrically located gestational sac inthe uterine fundus. The line represents the2 opposing layers of coapted endome-trium when the sac is large or the intra-mural portion of the tube when the sac issmall. The sac is incompletely surroundedby myometrium that may become pro-gressively thinned or absent laterally asthe sac grows.

Other sites of extratubal EP are evenrarer; intraovarian EPs account for lessthan 1% and cervical EPs, approximately0.15%.3 A simple or complex intraovar-ian lesion should not raise concern for anEP, as it is statistically much more likelyto represent the corpus luteum (Figs. 4,5B). Differentiating between an extra-ovarian EP and an exophytic or intrao-varian corpus luteum can be aided bygently pushing on the area with the en-dovaginal probe. Independent movementof the lesion and the ovary, separate fromeach other, confirms the extraovarianlocation of the adnexal ring seen with anEP, whereas a corpus luteum will movewith the ovary. The corpus luteumusuallyhas a less echogenic wall than an ovarian

FIGURE 5. Ectopic pregnancy with a yolksac and fetal pole. (A) Sagittal transabdom-inal ultrasound of the uterus shows a smallcentral fluid collection (open arrow), consis-tent with a pseudosac. A ring-shaped struc-ture (closed arrow) adjacent to the uteruscontains a fetal pole (arrowhead), confirmingan ectopic pregnancy. (B) Transvaginal ultra-sound of the right adnexa in the same patientbetter demonstrates the ectopic pregnancy(E), with a yolk sac (arrowhead) and fetal pole(arrow), separate from the right ovary (OV),which contains a corpus luteum (* ).

FIGURE 6. Interstitial line sign. Transva-ginal ultrasound of the uterus shows no evi-dence of a normal intrauterine pregnancy.The 2 layers of the echogenic endometriumare coapted (arrow) and extend to the centerof a small round fluid collection (arrowheads)eccentrically located in the myometrium.

Acute Pelvic Pain 5

Yolk Sac And Fetal PoleSagittal TA View

Pseudosac

Fetal Pole

Transvaginal View

Yolk Sac

Fetal Pole

Rt Ovary with CL

The Most Specific Sonographic Finding Of An EP (specificity Of 100%)

Sonographic Feature Of Tubal Pregnancy EP

Monday, June 10, 13

an EP. In contrast to the double decidualsac of an intrauterine pregnancy, thepseudosac has a single echogenic layerof endometrium surrounding an ovoid,elongated, centrally located collection ofendometrial fluid (Fig. 3). Only 5% to10% of patients with EP will demonstratea pseudosac on US.3 More commonlythe uterus will show neither a true nor apseudosac. Correlation with the clinicalpresentation, specifically with respect topain and amount of bleeding, quantitativeb-HCG, and a meticulous sonographicsearch of the adnexae is necessary todetermine if the findings represent anintrauterine pregnancy which is too smallto be seen sonographically, a recent spon-taneous abortion or an EP.

The ovary provides a landmark forevaluation of the adnexa, as it is usuallylocated near the ampullary portion of thefallopian tube, which is the most frequentsite of ectopic implantation. The areasurrounding the ovary should be evalu-ated thoroughly for any extraovarianabnormality. Although the sonographicappearance of EP can be quite varied, it

most commonly manifests as a ring-shaped structure with an anechoic centerand a thick echogenic periphery, the ‘‘tu-bal ring sign’’ (Fig. 4). A yolk sac and fetalpole may be present, with or withoutcardiac activity, providing the most spe-cific sonographic finding of an EP (speci-ficity of 100%) (Fig. 5). However, thisappearance is the least sensitive findingin EP (15% to 20%).3More commonly anEP is identified as a complex adnexalmassin a patient with a positive pregnancy testand no intrauterine pregnancy. Althoughmost EPs are located between the ovaryand the uterus, they may implant any-where in the pelvis and it is necessary tocarefully search the regions adjacent tothe uterine fundus, cul-de-sac and lateralmargins of the pelvis.

An uncommon but important typeof EP is an interstitial pregnancy, whichoccurs in 2% to 3% of EPs.5 Aninterstitial pregnancy results from im-plantation within the interstitial or intra-myometrial portion of the fallopiantube. In this location, the EP can growlarger before becoming symptomatic.

FIGURE 3. Pseudosac in the setting of ecto-pic pregnancy. Sagittal transvaginal ultra-sound of the uterus shows an elongated fluidcollection (arrow) located centrally within thecavity. It is surrounded by a single, echogeniclayer (arrowhead) of endometrium. An ecto-pic pregnancy (not shown) was identified inthe right adnexa.

FIGURE 4. Tubal ring sign of ectopic preg-nancy. Transverse ultrasound of the rightadnexa shows a cystic structure with a thickechogenic rim (closed arrow), consistent withan ectopic gestational sac, located betweenthe uterus (arrowhead) and the right ovary(open arrow), which contains a corpus luteumcyst (* ).

4 Vandermeer and Wong-You-CheongTubal Ring Sign

Ectopic Pregnancy

Corpus Luteum Uterus

Sonographic Feature Of Tubal Pregnancy EP

EP located in the ampullary portion of the tube. The ovary being an important landmark. However Carful Search of the whole pelvis: the regions adjacent to the uterine fundus, cul-de-sac and lateral margins of the pelvis is necessary since EP may implant anywhere in the pelvis

Monday, June 10, 13

an EP. In contrast to the double decidualsac of an intrauterine pregnancy, thepseudosac has a single echogenic layerof endometrium surrounding an ovoid,elongated, centrally located collection ofendometrial fluid (Fig. 3). Only 5% to10% of patients with EP will demonstratea pseudosac on US.3 More commonlythe uterus will show neither a true nor apseudosac. Correlation with the clinicalpresentation, specifically with respect topain and amount of bleeding, quantitativeb-HCG, and a meticulous sonographicsearch of the adnexae is necessary todetermine if the findings represent anintrauterine pregnancy which is too smallto be seen sonographically, a recent spon-taneous abortion or an EP.

The ovary provides a landmark forevaluation of the adnexa, as it is usuallylocated near the ampullary portion of thefallopian tube, which is the most frequentsite of ectopic implantation. The areasurrounding the ovary should be evalu-ated thoroughly for any extraovarianabnormality. Although the sonographicappearance of EP can be quite varied, it

most commonly manifests as a ring-shaped structure with an anechoic centerand a thick echogenic periphery, the ‘‘tu-bal ring sign’’ (Fig. 4). A yolk sac and fetalpole may be present, with or withoutcardiac activity, providing the most spe-cific sonographic finding of an EP (speci-ficity of 100%) (Fig. 5). However, thisappearance is the least sensitive findingin EP (15% to 20%).3More commonly anEP is identified as a complex adnexalmassin a patient with a positive pregnancy testand no intrauterine pregnancy. Althoughmost EPs are located between the ovaryand the uterus, they may implant any-where in the pelvis and it is necessary tocarefully search the regions adjacent tothe uterine fundus, cul-de-sac and lateralmargins of the pelvis.

An uncommon but important typeof EP is an interstitial pregnancy, whichoccurs in 2% to 3% of EPs.5 Aninterstitial pregnancy results from im-plantation within the interstitial or intra-myometrial portion of the fallopiantube. In this location, the EP can growlarger before becoming symptomatic.

FIGURE 3. Pseudosac in the setting of ecto-pic pregnancy. Sagittal transvaginal ultra-sound of the uterus shows an elongated fluidcollection (arrow) located centrally within thecavity. It is surrounded by a single, echogeniclayer (arrowhead) of endometrium. An ecto-pic pregnancy (not shown) was identified inthe right adnexa.

FIGURE 4. Tubal ring sign of ectopic preg-nancy. Transverse ultrasound of the rightadnexa shows a cystic structure with a thickechogenic rim (closed arrow), consistent withan ectopic gestational sac, located betweenthe uterus (arrowhead) and the right ovary(open arrow), which contains a corpus luteumcyst (* ).

4 Vandermeer and Wong-You-CheongTubal Ring Sign

Ectopic Pregnancy

Corpus Luteum Uterus

Sonographic Feature Of Tubal Pregnancy EP

EP located in the ampullary portion of the tube. The ovary being an important landmark. However Carful Search of the whole pelvis: the regions adjacent to the uterine fundus, cul-de-sac and lateral margins of the pelvis is necessary since EP may implant anywhere in the pelvis

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Transvaginal image of an extrauterine sac (red arrow) shows a tubal ring sign with thick echogenic wall and contains a yolk sac (red arrowhead). The presence of the yolk sac is diagnostic of extrauterine gestation.

Tubal Ring Sign

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Transvaginal image of an extrauterine sac (red arrow) shows a tubal ring sign with thick echogenic wall and contains a yolk sac (red arrowhead). The presence of the yolk sac is diagnostic of extrauterine gestation.

Tubal Ring Sign

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Transvaginal image of an extrauterine sac (red arrow) demonstrating the tubal ring sign adjacent to an ovary (red arrowhead). The tubal sign alone is less specific than a tubal sign with a yolk sac.

extrauterine sac ovary

Tubal Ring Sign

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The combination of adnexal mass and echogenic cul-de-sac fluid makes very high risk of ectopic pregnancy.

Echogenic fluidAcute Bleed Usually Anechoic But May Be Very Echogenic When Blend In With The Pelvic Fat In The Cul-de-sac And Be Missed

Sonographic Feature Of Tubal Pregnancy EP

Fluid In The Cul-de-sac

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❖1-3% Of EP

❖Can Reach Higher Gestational Age Because Of Greater Compliance Of The Surrounding Myometrium.

Interstitial (Cornual) EP

❖With Increasing Gestational Age, The Threshold For Surgical Intervention Becomes Higher, Both For The Patient And The Physician.

❖Late Diagnosis And Late Rupture With More Catastrophic Hemarrhage (Serious Morbidity And Up To >2% Mortality)

❖More Likely To Be Mistaken For Normal Intrauterine Pregnancy With Progressive Rising Of BHCG

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‘‘interstitial Line Sign’’

❖The Sac Is Incompletely S u r r o u n d e d B y Myometrium. It Becomes Progressively Thinned Or Absent On One Side As The Sac Grows

Interstitial EP

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Enables Correct Depiction Of The Sac And Its Location

Sonographic Features Of Interstitial EPTwo-dimensional Sonography

May Reveal A Gestational Sac Located Outside The Uterine Cavity, But May Not Be Able To Define Its Exact Anatomic Position.

Typical Signs Of Cornual Pregnancy:

1.The Eccentric Location Of GS And Its Separation From The Endometrium By A

Thin Rim Of Myometrial Tissue Surrounding The GS.

2.Thin Myometrial Mantle Of Less Than 5 Mm Between GS And Abdominal Cavity.

3D Sonography

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The GS Located

Outside

Sonographic Features Of Interstitial EP

Two-dimensional Sonography

DD eccentrically positioned intrauterine pregnancy

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3D Sonography

Sonographic Features Of Interstitial EP

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3D Sonography

Sonographic Features Of Interstitial EP

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Color Doppler

Sonographic Features Of Interstitial EP

Color Doppler flow pattern in ectopic pregnancy:Usually the pregnancy is non-viable and CD appear as randomly dispersed multiple small vessels with low resistance indices. In viable ectopic pregnancies (only up to 8%), the intense ring of vascular signals, so called "ring of fire" in 2D, or "net of fire" in 3D US are visualized.

"Ring Of Fire"

"Net Of Fire"

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Transvaginal image of a cornual ectopic pregnancy (red arrow). The uterus is demonstrating a decidual reaction (red arrowhead)

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•Associated With Potential Uncontrollable Hemorrhage.

•Sonographic Features Are Those Of An Early Pregnancy Embedded Within The Cervical Stroma.

•DD Include Abortion In Progress

Cervical EP

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24n year old patient, G1P0, with menstrual delay of 7 days, with Beta-hCG levels of 14.000 mU/ml.

•Ultrasound Shows An Empty Uterine Cavity

•A Gestational Sac In The Posterior Lip Of The Uterine Cervix.

Cervical Pregnancies

The patient required two doses of Methotrexate to achieve complete decline in the levels of Beta-hCG

Cervical EPs: 0.15%.

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Non Gyn Casues Of Pain

✤Ureteric Stone

✤Crohn’s Disease (bowel Causes)

✤Hernia In Intra-abdomean Wall

✤Inflamed Appendix

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•US Imaging Using 2D, 3D, And Color Modalities Are The Primary And Often The Only Investigation Needed In Evaluation And Diagnosis Of Women With Pelvic Pain.

•Careful Examination, Incorporating Clinical Background With Sonographic Findings Is Essential.

•Gynecologist With Experience In Sonography Are The Ones Most Capable For Such Job.

•High-quality Gynecological Ultrasound Can Be Highly Beneficial, But Poor-quality Gynecological Ultrasound Can Do Harm

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ThanksMonday, June 10, 13

Important reference:http://www.radiologyassistant.nl/

Management of Asymptomatic Ovarian and Other Adnexal Cysts Imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statementby Deborah Levine et al September 2010 Radiology, 256, 943-954.

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