Role of us in pelvic pain final

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adenomyosis, ectopic pregnancy, ovarian cyst, fibroid, ovarian torsion

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Role of us in pelvic pain final

  1. 1. Professor Hassan Nasrat FRCS, FRCOGThe Fetal Medicine ClinicThe First ClinicJUCOG 2013Role of Ultrasound InPelvic PainMonday, June 10, 13
  2. 2. The Uterus❖Regardless Of The Scanning Approach The Uterus Is Important And ReliableLandmarkMonday, June 10, 13
  3. 3. ❖The Endometrial Echo Density Varies Depending On Water Content And CellularDensity That Fluctuates With The Hormonal Status❖Reach Trlaminar Appearance At Time Of Ovulation And Bccomes MoreHomogeneous After OvulationFollicular phasePre-ovulatorySecretory phaseMonday, June 10, 13
  4. 4. The relative position of the uterus to the cervix and to theaxis of the vaginaThe symmetryThe sizeThe TextureThe UterusMonday, June 10, 13
  5. 5. The CervixThe uterine cervix can be measured with a great degree of accuracy, especiallywith the transvaginal technique.the cervix may not be seen if the scanning tip is placed in either the anterior orposterior fornix.Monday, June 10, 13
  6. 6. The VaginaBy TA scanning it appears as a collapsed tubular structure lyinginferior to the urinary bladder and distal to the uterine cervixTATPMonday, June 10, 13
  7. 7. TA TVThe position of the ovary depends on the length of theinfundibulopelvic ligament, the presence or absence of adhesions, andother anatomic abnormalities that may displace the ovary.The OvaryMonday, June 10, 13
  8. 8. Monday, June 10, 13
  9. 9. Monday, June 10, 13
  10. 10. 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.  Monday, June 10, 13
  11. 11. Role of Ultrasound InPelvic PainMonday, June 10, 13
  12. 12. AcuteChronic: Defined By Pain For >6 MonthsMonday, June 10, 13
  13. 13. Acute or chronicDiffuse of focalCyclical or constantSharp or dull or cramping?Prior SurgeryMenopausal and hormonal statusCould she be pregnant?Correlation of Clinical History withSonographic ExaminationMonday, June 10, 13
  14. 14. UterineAdenomyosisDegeneratingFibroidsProlapsingFibroidsAbnormallyPlaced IUDOvarianSimple CystHemorrhagic CystOvarian TorsionEndometriomaDermoid CystOvarian CancerCommon Causes of Pelvic PainPIDTubo-OvarianAbscess.HydrosalpinxPyosalpinxEPTubal.CornualCervicalMonday, June 10, 13
  15. 15. UterineAdenomyosisDegeneratingFibroidsProlapsingFibroidsAbnormallyPlaced IUDOvarianCommon Causes of Pelvic PainPID EPMonday, June 10, 13
  16. 16. AdenomyosisDegenerating FibroidsProlapsing FibroidsAbnormally Placed IUDUterineMonday, June 10, 13
  17. 17. A Common Finding (5-70%) In Women OfReproductive Age. 70% Of Hysterectomy Specimens.The Diagnosis: Sonography Or MRI.The Pathologic Diagnosis: The Visualization OfEndometrial Glands And Stroma In More Than OneLow-powered Field (2.5 Mm) From The EndometrialBasalis Layer.Symptoms: Most Women Are Asymptomatic- WhenSymptomatic: Dysmenorrhea, Abnormal Bleeding,Uterine Enlargment.AdenomyosisInvasion OfThe Endometrial Glands IntoThe MyometriumMonday, June 10, 13
  18. 18. Sonographic Findings of Adenomyosis•Globular Uterine Enlargement•Generalized adenomyosis•Focal adenomyoma•Cystic Anechoic spaces•Uterine Wall Asymmetrical thickening•Obscure endometrial/myometrial borderMonday, June 10, 13
  19. 19. Globular Uterine Enlargement That Is Generally Up To 12 Cm In Uterine Length And IsNot Explained By The Presence Of Leiomyomata.Figure 3. Globular uterine enlargement with an obscure endometrial/myometrial border (arrow).Globular Uterine EnlargementMonday, June 10, 13
  20. 20. FmFigure 1. Generalized adenomyosis.Generalized adenomyosisDiffuse Disease Involving The Entire MyometriumLoss Of Normal Architecture (Loss Of OfHomogeneity) (most Predictive Of Adenomyosis)Monday, June 10, 13
  21. 21. Focal Area Of The Uterus AdenomyomaFigure 2. Focal adenomyoma (arrows).Focal AdenomyomaMonday, June 10, 13
  22. 22. Focal Area Of The Uterus AdenomyomaFigure 2. Focal adenomyoma (arrows).Focal AdenomyomaMonday, June 10, 13
  23. 23. -s-sd-fndFigure 2. Focal adenomyoma (arrows).Cystic Anechoic spacesMonday, June 10, 13
  24. 24. Uterine Wall Thickening: AnteroposteriorAsymmetry.2.3.4.5.6.7.myometrial echo texture.The Length Of A Posterior Uterine Is Greater Than That Of The Anterior Wall And Has A HeterogeneousMyometrial Echo Texture.Monday, June 10, 13
  25. 25. Uterine Wall Thickening: AnteroposteriorAsymmetry.Monday, June 10, 13
  26. 26. Figure 2. Focal adenomyoma (arrows).•Obscure endometrial/myometrial borderMonday, June 10, 13
  27. 27. Sensitivity(95% CI )specificity(95% CI )+Ve LR -Ve LRSonography 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 92.5SonographyVs. MRIin Diagnosis of AdenomyosisDiagnostic accuracy of transvaginal sonography for the diagnosis of adenomyosis: systematic review andmetaanalysis American Journal of Obstetrics & Gynecology Volume 201, Issue 1 ,2009Monday, June 10, 13
  28. 28. Fibroids•Cystic Degeneration•Prolapsing PedunculatedFibroid•Pressure EffectMonday, June 10, 13
  29. 29. Fibroid❖Very Common-most❖UsuallyAsymptomatic.❖Classified according to their location assubmucosal, intramural or subserosal.❖MRI is the preferred modality for characterizinguterine fibroids and identifying their exactanatomical locationMonday, June 10, 13
  30. 30. 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 BeChallenginDD: Endometrial Hyperplasia, A PostoperativeAbscess,And A Large Simple Ovarian Cyst.Monday, June 10, 13
  31. 31. so-ud-aryty.oidio-odusid,calmicndre-izetoFIGURE 20. Large degenerating fibroid.Transabdominal ultrasound of the uterusAcute Pelvic Pain 13Transabdominal ultrasound of the uterus shows the very heterogeneousappearance of a degenerating fibroid contains irregular hypoechoiccomponents.Degenerating FibroidMonday, June 10, 13
  32. 32. so-ud-aryty.oidio-odusid,calmicndre-izetoFIGURE 20. Large degenerating fibroid.Transabdominal ultrasound of the uterusAcute Pelvic Pain 13Transabdominal ultrasound of the uterus shows the very heterogeneousappearance of a degenerating fibroid contains irregular hypoechoiccomponents.Degenerating FibroidMonday, June 10, 13
  33. 33. uterusBroad Ligament FibroidMonday, June 10, 13
  34. 34. Broad Ligament FibroidMonday, June 10, 13
  35. 35. Degenerating FiboridMonday, June 10, 13
  36. 36. Degenerating FiboridMonday, June 10, 13
  37. 37. Monday, June 10, 13
  38. 38. CalcifiedFiboridDegeneratingFiboridMonday, June 10, 13
  39. 39. Same PatientTransverse viewMonday, June 10, 13
  40. 40. TA scan Suggest ThickEndometriumTV scan ShowsEndometiral PolypEndometrial PolypMonday, June 10, 13
  41. 41. Saline Intrauterine Sonography“SIS”Monday, June 10, 13
  42. 42. Pain Due to Pressure EffectMonday, June 10, 13
  43. 43. Monday, June 10, 13
  44. 44. TA-Scan LongitudinalViewTA-Scan TransversViewMonday, June 10, 13
  45. 45. Monday, June 10, 13
  46. 46. Monday, June 10, 13
  47. 47. Monday, June 10, 13
  48. 48. Monday, June 10, 13
  49. 49. Postpartum Complication in a FibroidMonday, June 10, 13
  50. 50. Monday, June 10, 13
  51. 51. Monday, June 10, 13
  52. 52. Monday, June 10, 13
  53. 53. Monday, June 10, 13
  54. 54. UterineAdenomyosisDegeneratingFibroidsProlapsingFibroidsAbnormallyPlaced IUDOvarianSimple CystHemorrhagic CystOvarian TorsionEndometriomaDermoid CystOvarian CancerCommon Causes of Pelvic PainPID EPMonday, June 10, 13
  55. 55. Adnexal CystCauses Considerable Anxiety In Women DueTo The Fear Of Malignancy.The Vast Majority - Even In PostmenopausalWomen - Are Benign.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
  56. 56. Adnexal CystCauses Considerable Anxiety In Women DueTo The Fear Of Malignancy.The Vast Majority - Even In PostmenopausalWomen - Are Benign.Screening Study of 15,106 women > 50 years, 2763women (18%) were diagnosed with a unilocular ovariancyst.None of these isolated unilocular cysts turned out to beovarian 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
  57. 57. Adnexal CystCauses Considerable Anxiety In Women DueTo The Fear Of Malignancy.The Vast Majority - Even In PostmenopausalWomen - Are Benign.Screening Study of 15,106 women > 50 years, 2763women (18%) were diagnosed with a unilocular ovariancyst.None of these isolated unilocular cysts turned out to beovarian cancer.Frequently They Cause Chronic, SubacuteOr 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
  58. 58. The Road Map for Management of Ovarian CystMonday, June 10, 13
  59. 59. The Road Map for Management of Ovarian Cystovarian lesionFirst StepIs It OvarianMonday, June 10, 13
  60. 60. The Road Map for Management of Ovarian Cystovarian lesionFirst StepIs It OvarianUSRecognitionMonday, June 10, 13
  61. 61. The Road Map for Management of Ovarian Cystovarian lesionSimple, Hemorrhagic, EndometriomaTeratoma, Or IndeterminateFirst StepIs It OvarianUSRecognitionMonday, June 10, 13
  62. 62. The Road Map for Management of Ovarian Cystovarian lesionSimple, Hemorrhagic, EndometriomaTeratoma, Or IndeterminateFirst StepIs It OvarianUSRecognitionHige vs. LowRisk GroupMonday, June 10, 13
  63. 63. The Road Map for Management of Ovarian Cystovarian lesionSimple, Hemorrhagic, EndometriomaTeratoma, Or IndeterminateFirst StepIs It OvarianUSRecognitionHige vs. LowRisk GroupMonday, June 10, 13
  64. 64. The Road Map for Management of Ovarian Cystovarian lesionSimple, Hemorrhagic, EndometriomaTeratoma, Or Indeterminateignore, follow or exciseFirst StepIs It OvarianUSRecognitionHige vs. LowRisk GroupMonday, June 10, 13
  65. 65. The Road Map for Management of Ovarian Cystovarian lesionSimple, Hemorrhagic, EndometriomaTeratoma, Or Indeterminateignore, follow or excise• Symptomatic lesion versus incidental finding• Additional findings• Morphology on US, CT or MRIFirst StepIs It OvarianUSRecognitionHige vs. LowRisk GroupMonday, June 10, 13
  66. 66. TorsionHemorrhageTeratomaEndometriomaCarcinomaSimple CystUltrasound Pattern Recognition ofOvarian CystMonday, June 10, 13
  67. 67. ✤ Anechoic Lesion (posterior Acoustic Enhancement)✤ Unilocular✤ Thin, Smooth Walls✤ No Solid Or Well-vascularized ComponentSimple Ovarian CystFollicular cystCL Cyst✤Thicker wall✤More Echogenic✤Increased VascularityMonday, June 10, 13
  68. 68. larity in the complex components of theFIGURE 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).Acute Pelvic Pain 9✤The Cyst Is Anechoic.✤Thin-walled.✤Shows Posterior Acoustic Enhancement.✤Resolved On Follow-up 2 Months Later.Follicular cystMonday, June 10, 13
  69. 69. r-c-dasr-aer).edeen-aCL Cyst✤Thicker wall✤More Echogenic✤Increased VascularityMonday, June 10, 13
  70. 70. Hyperstimulated OvaryMonday, June 10, 13
  71. 71. Hyperstimulated OvaryInversion ModeMonday, June 10, 13
  72. 72. ✤Paraovarian Or Paratubal Cysts.✤A Hydrosalpinx.✤Cystadenomas (but Larger Cyst In A Postmenopausal Woman).DD of Simple Ovarian CystMonday, June 10, 13
  73. 73. Monday, June 10, 13
  74. 74. Monday, June 10, 13
  75. 75. Monday, June 10, 13
  76. 76. TorsionHemorrhagicTeratomaEndometriomaCarcinomaSimple CystUltrasound Pattern Recognition ofOvarian CystMonday, June 10, 13
  77. 77. Hemorrhagic Ovarian CystA Ruptured EP Can Have A Similar ClinicalPresentation And Correlation With B-HCGLevels Is Essential In Excluding ThisPossibility.Monday, June 10, 13
  78. 78. ➡Acute Intracystic Hemorrhage: Is Iso-choic To The Ovarian Stroma And Can Mimic AnEnlarged Ovary.➡Over Time A Clot Is Formed Lace-like, Reticular Or ‘‘fish-net’’Pattern➡ Color Doppler Shows Absence Of Blood Flow In The Fine Septationof hemparticument anare morIt isintrapeexaminruptureovarianangularfree fluechoesde-sac oOntypicalladnexaFIGURE 14. Hemorrhagic cyst. Transvagi-10 Vandermeer and Wong-You-CheongSonosgraphic Features of HemorrhagicOvarian CystLace likeFish Net PatternAbsent Color FlowAcute hemorrhageis isochoicMonday, June 10, 13
  79. 79. the rapid evolution and/or cyst resolutionexc•Retracted Blood Clot (DD from thickening cyst wall)•Color Doppler Shows absence of vascularityHemorrhagic Ovarian Cyst WithClotted BloodRetracted ClotMonday, June 10, 13
  80. 80. Hemorrhagic cyst with a clot mimicking a neoplasm.absence of flow and good through-transmission (arrow)Retracted ClotMonday, June 10, 13
  81. 81. TA - USexcluding other intra-abdominal causesre-hows FIGURE 16. Acute bleed from a left he-ClotRuptured CystRuptured or leakage from ahemorrhagic ovarian cystlow-level echoes of frank clot in thecul- de-sac and adjacent to the ovaryMonday, June 10, 13
  82. 82. Monday, June 10, 13
  83. 83. Monday, June 10, 13
  84. 84. Monday, June 10, 13
  85. 85. Differential diagnosis✤ Endometriomas.✤ In The Acute Phase A Hemorrhagic Cyst May Be CompletelyFilled With Low-level Echoes, Simulating A Solid Mass.✤ Clot In A Hemorrhagic Cyst May Occasionally Mimic A SolidNodule In A Neoplasm. Clot, However, Often Has ConcaveBorders Due To Retraction, While A True Mural Nodule HasOutwardly Convex Borders.✤ Hemorrhagic Cysts Typically Resolve Within 8 Weeks.Hemorrhagic Ovarian CystMonday, June 10, 13
  86. 86. Monday, June 10, 13
  87. 87. Monday, June 10, 13
  88. 88. TorsionHemorrhageTeratomaEndometriomaCarcinomaSimple CystUltrasound Pattern Recognition ofOvarian CystMonday, June 10, 13
  89. 89. EndometriosisPresence Of Functional Endometrial Glands And Stroma InSites Outside The Uterine CavityAffects Women In Their ReproductiveYears.10% Of Women & 30% Of InfertileWomen.Laparoscopy Remains The GoldStandard For DiagnosisClassical Symptoms: Pelvic pain, and Infertility.Monday, June 10, 13
  90. 90. 80% Of All Pelvic Endometriosis Occurs In The Ovary.Endometriotic Cysts “Endometriomas”, Have A Variety OfAppearances On US, Ranging From An Anechoic Cyst To AComplex Cystic Mass With Septations And EterogeneousEchogenicity.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 WallEndometriomaMRI Has A Sensitivity Of 92% And A Specificity Of Up To 98%Monday, June 10, 13
  91. 91. Endometrioma:adnexal cystic mass with diffuse, low-level internal echoes andhyperechoic foci in the wall.Hemogenous &,hypoechicLow echos level“Ground Glass”No inernalDoppler flowEchogenic Foci30%Ultrasound Pattern Recognition of EndoemtriomaMonday, June 10, 13
  92. 92. Monday, June 10, 13
  93. 93. ✤Endometriomasare more commonly multiple and their appearance isstable over time.✤hemorrhagic cyst has changing appearance.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 blood10 Vandermeer and Wong-You-CheongHomogenouslyHypoechoicLace-like InteranalEchogenicity,Hemorrhagic CytsSubacute stageEndometriomaEndometriomas Vs. HemorrhagicMonday, June 10, 13
  94. 94. Monday, June 10, 13
  95. 95. Monday, June 10, 13
  96. 96. Monday, June 10, 13
  97. 97. Monday, June 10, 13
  98. 98. TorsionHemorrhageTeratomaEndometriomaCarcinomaSimple CystUltrasound Pattern Recognition ofOvarian CystMonday, June 10, 13
  99. 99. Mature Cystic TeratomeUS Findings Characteristic Of A Mature CysticTeratoma:➡Hypoechoic Mass With Hyperechoic Nodule(Rokitansky Nodule Or Dermoid Plug)➡Usually Unilocular (90%)➡May Contain Calcifications (30%)➡May Contain Hyperechoic Lines Caused By FloatingHair➡May Contain A Fat-fluid Level, I.e. Fat Floating OnAqueous FluidMonday, June 10, 13
  100. 100. 77.35.4Dermoid Cyst is Unilocular in 90% of casesHyperechoicNodule(RokatinskyNodule)HypoechoicMassHyperechoic linewith floating hariand fafUltrasound Pattern Recognition of TeratomaMonday, June 10, 13
  101. 101. TV scan the tip-of-the-iceberg sign: acoustic shadowing from thehyperechoic part of the dermoid cyst (arrow).Lesion may be misinterpreted as bowel gas.Hyperechoic linewith floating hairand fatCalcificationMonday, June 10, 13
  102. 102. cystic teratoma with mixed tissues and bizarre solid tissue(red arrows).Monday, June 10, 13
  103. 103. 3 D Multiplaner TA image of a Cystic lesion in PregnantPatient “cystic teratoma”Monday, June 10, 13
  104. 104. Monday, June 10, 13
  105. 105. Monday, June 10, 13
  106. 106. TorsionHemorrhageTeratomaEndometriomaCarcinomaSimple CystUltrasound Pattern Recognition ofOvarian CystMonday, June 10, 13
  107. 107. Possibly MalignantMonday, June 10, 13
  108. 108. Ultrasound Pattern Recognition of NeoplasmMonday, June 10, 13
  109. 109. Color Doppler Of Ovary Demonstrates Blood Flow Within Irregularly ThickenedSepta (red Arrows).Predictor Of MalignancyLarge sizeVascularized septationsVascularized solid componentsVascularized thick, irregular wallSecondary findings a: e.g. AscitesMonday, June 10, 13
  110. 110. Summary of TheThe Road Map for Management of Ovarian CystMonday, June 10, 13
  111. 111. Summary of TheThe Road Map for Management of Ovarian CystMonday, June 10, 13
  112. 112. TorsionHemorrhageTeratomaEndometriomaCarcinomaSimple CystUltrasound Pattern Recognition ofOvarian CystMonday, June 10, 13
  113. 113. Ovarian TorsionPrompt Identification And Treatment,EspeciallyInYoungWomen.Often Adexal Not Just Ovarian (ovary and fallopian tube)3% of Emergency Gynecologic Surgeries.Difficult To Diagnose Clinically Because The Presenting SymptomsOfPain,Nausea,AndVomitingAreNonspecific.Monday, June 10, 13
  114. 114. Ovarian TorsionIn Adults: Often Associated With benign and malignant ovarianNeoplasm, (50% To 81% Of Cases).In Children And Adolescents: Due To Increased Mobility OfThe Vascular Pedicle Due To developmental abnormalities such asexcessively long fallopian tubes or an absent mesosalpinx.In Pregnancy: The Risk Is Higher (25% Of Cases Occur InPregnant Patients) In early pregnancy (6-14 weeks) secondary to acorpus luteum cyst or laxity of the adjacent tissues.Immediate Postpartum Period: The Risk Is Also Higher In TheImmediate Postpartum Period.Monday, June 10, 13
  115. 115. The Twisting Of TheOvarian Vascular PedicleLymphaticVenousArterial FlowTheTwistingOfTheOvarianVascularPedicleSecondary Signs❖Free Pelvic Fluid❖Underlying Ovarian Lesion❖Reduced Or Absent Vascularity❖A Twisted Dilated Tubular Structure CorrespondingTo The Vascular Pedicle.Primary Features:Ovarian Enlargement With Amorphous AndHypoechoic Appearance Due To Venous /Lymphatic Engorgement, Oedema AndHaemorrhage. Pathogenesis Of The Sonographic FeaturesMonday, June 10, 13
  116. 116. Primary Sonographic FeaturesMonday, June 10, 13
  117. 117. Enlarged,Amorphousand Hypoechoic ovariesPeripherally locatedNumerous FolliclesFree Fluid in the pelvisAbsence ofVenous andArterial Blood FlowPrimary Sonographic FeaturesMonday, June 10, 13
  118. 118. Enlarged Ovarian Torsion8 yrs. Dull aching right flank pain - 3 days. No other complaints.Enlarged Rt Ovary: 4.2 × 3.3 × 2.8 =Vol. 21 ccMonday, June 10, 13
  119. 119. Normal Lt OvaryEnlarged Rt OvaryEnlarged right ovary ( 21 cc ) compared to left ovary ( 3 cc )Rt Ovary:4.2 × 3.3 × 2.8 =Vol. 21 ccLt Ovary:1.6 × 2.8 × 1.4 =Vol. 3 ccMonday, June 10, 13
  120. 120. Enlarged Ovariana TorsionFluid in pelvis & Thick Rt PedicleMonday, June 10, 13
  121. 121. Absent flow in Rt. ovary with normal flow in Lt. ovaryMonday, June 10, 13
  122. 122. Color Doppler image through the ovary (red arrowheads) showsabsence of blood flow demonstrating ovarian torsion.Monday, June 10, 13
  123. 123. Left ovaryNormal size andfollicular pattern and flow.Right ovaryOdematous,peripheral smallfolliclesLower Abdominal Pain - 3 daysMonday, June 10, 13
  124. 124. Enlarged Rt Ovary: 3.9 × 5.7 × 3.6 =Vol. 43 ccMonday, June 10, 13
  125. 125. Monday, June 10, 13
  126. 126. 77.35.4Dermoid CystMonday, June 10, 13
  127. 127. Ovarian torsion in a patient with acute pelvic pain 2 weeks postpartum. Sonography showed amarkedly enlarged right ovaryFIGURE 18. Ovarian torsion in a patientwith acute pelvic pain 2 weeks postpartum.Monday, June 10, 13
  128. 128. UterineAdenomyosisDegeneratingFibroidsProlapsingFibroidsAbnormallyPlaced IUDOvarianSimple CystHemorrhagic CystOvarian TorsionEndometriomaDermoid CystOvarian CancerCommon Causes of Pelvic PainPIDTubo-OvarianAbscess.HydrosalpinxPyosalpinxEPMonday, June 10, 13
  129. 129. ✤Pelvic Inflammatory Disease (PID) Is Caused By SexuallyTransmitted 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 ReportedIn Postmenopausal Women.Pelvic Pain - PIDMonday, June 10, 13
  130. 130. Pyosalpinx: pus-filled, dilated fallopian tube is recognized by the echogenicparticulate matter that fills or layers within the tube.Transvaginal image of a dilated fallopian tube (FT) containing echogenic fluid.Monday, June 10, 13
  131. 131. Tubo-ovarian complex: dilated fallopian tube and inflamed ovary within a massformed by adhesions. Pus appears as layering echogenic fluid and gas within mass.markedly dilatedfallopian tubethe ovaryMonday, June 10, 13
  132. 132. Hydrosalpinx: TV-US scan shows a tubular-shaped cystic mass separate from theovary. The finding of indentations (arrows) on opposite sides of the tubular mass,termed the waist sign, is a good indicator of a hydrosalpinx.Waist SignHydrosalpinxMonday, June 10, 13
  133. 133. Sagittal transvaginal US scan demonstrates a tubular-shaped cystic mass with severalincomplete septa (typical of a hydrosalpinx when occurring in a tubular-shaped cysticmass.Waist Sign(incomplete septa)HydrosalpinxMonday, June 10, 13
  134. 134. TV-US scan shows a tubular-shaped cystic mass with aseptum. Small nodules (arrows)in the mass are due to thickenedendosalpingeal folds.HydrosalpinxThe Inversion mode in 3 D scanning.Definining the Diagnosis ofHydrosaplinxThe Inversion modein 3 D of PCOMonday, June 10, 13
  135. 135. UterineAdenomyosisDegeneratingFibroidsProlapsingFibroidsAbnormallyPlaced IUDOvarianSimple CystHemorrhagic CystOvarian TorsionEndometriomaDermoid CystOvarian CancerCommon Causes of Pelvic PainPIDTubo-OvarianAbscess.HydrosalpinxPyosalpinxEPTubal.CornualCervicalMonday, June 10, 13
  136. 136. Ectopic PregnancyPregnancy with the fertilized embryo implantedonanytissueotherthantheuterinelining•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 themyometrium in the cornual areaMonday, June 10, 13
  137. 137. ➡ 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 IUDs: 16% Of Pregnancies.Risk Factors for Ectopic PregnancyHeterotopic Pregnancy In The General Population (1:7000 Pregnancies).But Much Higher Risk (1:100) With ART.Monday, June 10, 13
  138. 138. The Clinical Impression Of The Gynecologist Is The Most ImportantFactor In MakingATimely Diagnosis Of EP.HCG Titers And Risk Ectopic PregnanciesDaus et al, Journal of Reproductive Medicine,February, 1989, p.16273657Falling AbnormalyRisingNormalyRisingRisk of EP<1000 <3000 <5000 <10000 >1000910152145Risk of EPRelation hCG TrendRisk of EPRelation to hCG valueRisk of EPMonday, June 10, 13
  139. 139. Rules for use of hCG✓The hCG level should rise atleast 66% in 48 hours, and atleast double in 72 hourHCG and US in the Diagnosis of EP✓A a normal pregnancy can beseen at hCG level of 2000 mIU/ml✓By 5 - 6 wks. normal pregnanciesin the uterus should be seen.Rules for use of TV-USDay after HCG Average High Lower14 48 119 1715 59 147 1716 95 223 3317 132 429 1718 292 758 7019 303 514 11120 522 1690 13521 1061 4130 32422 1287 3279 18523 2034 4660 50624 2637 10000 540HCG levels from normal singleton pregnancies:Levels are listed for various days after the ovulatory HCGinjection or LH surge"High" is highest seen in this group of pregnancies"Low" is lowest seen in this group of pregnanciesFirst (same as Third) International Reference PreparationThere Is A Large Variation In A "normal" HCGLevel For Any Given Time In PregnancyMonday, June 10, 13
  140. 140. Sonographic Appearance of EP❖The Most Common Sonographic Abnormality:Complex Adnexal Mass And Empty Uterus Is Highly❖Conclusive Diagnosis Of Ectopic By Ultrasound Can OnlyBe Made If A Fetus Or Fetal Cardiac Motion Is SeenOutside The Uterus (only In 20% Of EP)❖20-30% Of Ectopics Have No Detectable Abnormality OnUltrasoundMonday, June 10, 13
  141. 141. Ultrasound Landmarks in Normal PregnancyGSVisualization andhCG valueYSVisualization andMean Sac DiambeterFH BeatEmbryoVisualization andMSDFHBand Embryo length4.5-5 Wks 5.5-6 Wks 6-6.5 Wks 6-6.5 WksMonday, June 10, 13
  142. 142. Ultrasound Landmarks in Normal PregnancyTV TA18001000GSVisualization andhCG valueYSVisualization andMean Sac DiambeterFH BeatEmbryoVisualization andMSDFHBand Embryo length4.5-5 Wks 5.5-6 Wks 6-6.5 Wks 6-6.5 WksMonday, June 10, 13
  143. 143. Ultrasound Landmarks in Normal PregnancyTV TA18001000TV TA188GSVisualization andhCG valueYSVisualization andMean Sac DiambeterFH BeatEmbryoVisualization andMSDFHBand Embryo length4.5-5 Wks 5.5-6 Wks 6-6.5 Wks 6-6.5 WksMonday, June 10, 13
  144. 144. Ultrasound Landmarks in Normal PregnancyTV TA18001000TV TA188TV TA2516GSVisualization andhCG valueYSVisualization andMean Sac DiambeterFH BeatEmbryoVisualization andMSDFHBand Embryo length4.5-5 Wks 5.5-6 Wks 6-6.5 Wks 6-6.5 WksMonday, June 10, 13
  145. 145. Ultrasound Landmarks in Normal PregnancyTV TA18001000TV TA188TV TA2516TV TA5GSVisualization andhCG valueYSVisualization andMean Sac DiambeterFH BeatEmbryoVisualization andMSDFHBand Embryo length4.5-5 Wks 5.5-6 Wks 6-6.5 Wks 6-6.5 WksMonday, June 10, 13
  146. 146. Ultrasound Landmarks in Normal PregnancyTV TA18001000TV TA188TV TA2516TV TA5GSVisualization andhCG valueYSVisualization andMean Sac DiambeterFH BeatEmbryoVisualization andMSDFHBand Embryo length4.5-5 Wks 5.5-6 Wks 6-6.5 Wks 6-6.5 WksMonday, June 10, 13
  147. 147. and a positive pregnancy test.cidence of approximately 1 out00 diagnosed pregnancies, EPhe leading cause of maternale first trimester and the seconduse of maternal mortality over-s the most important tool in theof suspected EP and should bewith measurement of quantita-man chorionic gonadotropinor appropriate interpretation.t goal of US evaluation is towhether an intrauterine preg-resent. If an intrauterine preg-be demonstrated, an EP can bey excluded, as synchronous in-and EPs are exceedingly rare inl population (1:7000 pregnan-wever, it is important to noteFIGURE 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.Acute Pelvic Pain 3PseudocacSmall, Rounded and welldefinedCompletelySurrounded byEchogenic decidualtissueEccentrically locatedwithin the opposingendometiral liningI: ‘‘Intradecidual Sac”•Sensitivity 34% To 66%•Specificity 55% To 73%Monday, June 10, 13
  148. 148. ted thoroughly for any extraovarianbnormality. Although the sonographicppearance of EP can be quite varied, itand a thick echogenic periphery,bal ring sign’’ (Fig. 4). A yolk sac apole may be present, with orcardiac activity, providing the mcific sonographic finding of an EPficity of 100%) (Fig. 5). Howevappearance is the least sensitivein EP (15% to 20%).3More commEP is identified as a complex adnein a patient with a positive pregnaand no intrauterine pregnancy. Amost EPs are located between thand the uterus, they may implawhere in the pelvis and it is nececarefully search the regions adjthe uterine fundus, cul-de-sac anmargins of the pelvis.An uncommon but importaof EP is an interstitial pregnancyoccurs in 2% to 3% of EPinterstitial pregnancy results frplantation within the interstitialmyometrial portion of the fIGURE 3. Pseudosac in the setting of ecto-ic pregnancy. Sagittal transvaginal ultra-ound of the uterus shows an elongated fluidollection (arrow) located centrally within theavity. It is surrounded by a single, echogenicayer (arrowhead) of endometrium. An ecto-ic pregnancy (not shown) was identified inand a positive pregnancy test.cidence of approximately 1 out00 diagnosed pregnancies, EPhe leading cause of maternale first trimester and the seconduse of maternal mortality over-s the most important tool in theof suspected EP and should bewith measurement of quantita-man chorionic gonadotropinor appropriate interpretation.t goal of US evaluation is towhether an intrauterine preg-resent. If an intrauterine preg-be demonstrated, an EP can bey excluded, as synchronous in-and EPs are exceedingly rare inl population (1:7000 pregnan-wever, it is important to noteFIGURE 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.Acute Pelvic Pain 3PseudocacCentrally locatedSurrounded withsingle echogenic layer ofendometriumSmall, Rounded and welldefinedCompletelySurrounded byEchogenic decidualtissueEccentrically locatedwithin the opposingendometiral liningI: ‘‘Intradecidual Sac”•Sensitivity 34% To 66%•Specificity 55% To 73%Monday, June 10, 13
  149. 149. ted thoroughly for any extraovarianbnormality. Although the sonographicppearance of EP can be quite varied, itand a thick echogenic periphery,bal ring sign’’ (Fig. 4). A yolk sac apole may be present, with orcardiac activity, providing the mcific sonographic finding of an EPficity of 100%) (Fig. 5). Howevappearance is the least sensitivein EP (15% to 20%).3More commEP is identified as a complex adnein a patient with a positive pregnaand no intrauterine pregnancy. Amost EPs are located between thand the uterus, they may implawhere in the pelvis and it is nececarefully search the regions adjthe uterine fundus, cul-de-sac anmargins of the pelvis.An uncommon but importaof EP is an interstitial pregnancyoccurs in 2% to 3% of EPinterstitial pregnancy results frplantation within the interstitialmyometrial portion of the fIGURE 3. Pseudosac in the setting of ecto-ic pregnancy. Sagittal transvaginal ultra-ound of the uterus shows an elongated fluidollection (arrow) located centrally within theavity. It is surrounded by a single, echogenicayer (arrowhead) of endometrium. An ecto-ic pregnancy (not shown) was identified in5% to 10% of patients withEP demonstrate a pseudosacand a positive pregnancy test.cidence of approximately 1 out00 diagnosed pregnancies, EPhe leading cause of maternale first trimester and the seconduse of maternal mortality over-s the most important tool in theof suspected EP and should bewith measurement of quantita-man chorionic gonadotropinor appropriate interpretation.t goal of US evaluation is towhether an intrauterine preg-resent. If an intrauterine preg-be demonstrated, an EP can bey excluded, as synchronous in-and EPs are exceedingly rare inl population (1:7000 pregnan-wever, it is important to noteFIGURE 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.Acute Pelvic Pain 3PseudocacCentrally locatedSurrounded withsingle echogenic layer ofendometriumSmall, Rounded and welldefinedCompletelySurrounded byEchogenic decidualtissueEccentrically locatedwithin the opposingendometiral liningI: ‘‘Intradecidual Sac”•Sensitivity 34% To 66%•Specificity 55% To 73%Monday, June 10, 13
  150. 150. DeciduaParaitalisII: ‘‘Double-Decidual Sac Sign’’DeciduaCapsularisHypoechoicendometiral cavityMonday, June 10, 13
  151. 151. FIGURE 6. Interstitial line sign. Trginal ultrasound of the uterus showsdence of a normal intrauterine pregThe 2 layers of the echogenic endomare coapted (arrow) and extend to theAcute Pelvic PaiFIGURE 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-Yolk SacAnd Fetal PoleSagittal TA ViewPseudosacFetal PoleTransvaginal ViewYolk SacFetal PoleRt Ovarywith CLTheMostSpecificSonographicFindingOfAnEP(specificityOf100%)Sonographic Feature Of Tubal Pregnancy EPMonday, June 10, 13
  152. 152. ualtheyeroid,oftoatenlyr acaltoivehic FIGURE 4. Tubal ring sign of ectopic preg-ngTubal Ring SignEctopicPregnancyCorpus LuteumUterusSonographic Feature Of Tubal Pregnancy EPEPlocatedintheampullaryportionofthetube.Theovarybeinganimportantlandmark.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 EPmay implant anywhere in the pelvisMonday, June 10, 13
  153. 153. ualtheyeroid,oftoatenlyr acaltoivehic FIGURE 4. Tubal ring sign of ectopic preg-ngTubal Ring SignEctopicPregnancyCorpus LuteumUterusSonographic Feature Of Tubal Pregnancy EPEPlocatedintheampullaryportionofthetube.Theovarybeinganimportantlandmark.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 EPmay implant anywhere in the pelvisMonday, June 10, 13
  154. 154. Transvaginal image of an extrauterine sac (red arrow) shows a tubal ring sign with thickechogenic wall and contains a yolk sac (red arrowhead). The presence of the yolk sac isdiagnostic of extrauterine gestation.Tubal Ring SignMonday, June 10, 13
  155. 155. Transvaginal image of an extrauterine sac (red arrow) shows a tubal ring sign with thickechogenic wall and contains a yolk sac (red arrowhead). The presence of the yolk sac isdiagnostic of extrauterine gestation.Tubal Ring SignMonday, June 10, 13
  156. 156. Transvaginal image of an extrauterine sac (red arrow) demonstrating the tubal ring signadjacent to an ovary (red arrowhead). The tubal sign alone is less specific than a tubalsign with a yolk sac.extrauterine sacovaryTubal Ring SignMonday, June 10, 13
  157. 157. The combination of adnexal mass and echogenic cul-de-sac fluid makes very high risk ofectopic pregnancy.Echogenic fluidAcute Bleed UsuallyAnechoic But May BeVery Echogenic WhenBlend In With ThePelvic Fat In The Cul-de-sac And Be MissedSonographic Feature Of Tubal Pregnancy EPFluid In The Cul-de-sacMonday, June 10, 13
  158. 158. ❖1-3% Of EP❖Can Reach Higher Gestational Age Because Of Greater Compliance Of TheSurrounding Myometrium.Interstitial (Cornual) EP❖With Increasing Gestational Age, The Threshold For Surgical InterventionBecomes Higher, Both For The Patient And The Physician.❖Late Diagnosis And Late Rupture With More Catastrophic Hemarrhage (SeriousMorbidity And Up To >2% Mortality)❖More Likely To Be Mistaken For NormalIntrauterine Pregnancy With Progressive RisingOf BHCGMonday, June 10, 13
  159. 159. Monday, June 10, 13
  160. 160. ‘‘interstitial Line Sign’’❖The Sac Is IncompletelyS u r r o u n d e d B yMyometrium. It BecomesProgressively Thinned OrAbsent On One Side As TheSac GrowsInterstitial EPMonday, June 10, 13
  161. 161. Enables Correct Depiction Of The Sac And Its LocationSonographic Features Of Interstitial EPTwo-dimensional SonographyMay 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 AThin Rim Of Myometrial Tissue Surrounding The GS.2.Thin Myometrial Mantle Of Less Than 5 Mm Between GS And Abdominal Cavity.3D SonographyMonday, June 10, 13
  162. 162. The GS LocatedOutsideSonographic Features Of Interstitial EPTwo-dimensional SonographyDD eccentrically positioned intrauterine pregnancyMonday, June 10, 13
  163. 163. 3D SonographySonographic Features Of Interstitial EPMonday, June 10, 13
  164. 164. 3D SonographySonographic Features Of Interstitial EPMonday, June 10, 13
  165. 165. Color DopplerSonographic Features Of Interstitial EPColor Doppler flow pattern in ectopic pregnancy:Usually the pregnancy is non-viable and CD appear as randomly dispersedmultiple small vessels with low resistance indices.In viable ectopic pregnancies (only up to 8%), the intense ring of vascularsignals, so called "ring of fire" in 2D, or "net of fire" in 3D US arevisualized."Ring Of Fire""Net Of Fire"Monday, June 10, 13
  166. 166. Transvaginal image of a cornual ectopic pregnancy (red arrow).The uterus is demonstrating a decidual reaction (redarrowhead)Monday, June 10, 13
  167. 167. •Associated With Potential Uncontrollable Hemorrhage.•Sonographic Features Are Those Of An Early PregnancyEmbedded Within The Cervical Stroma.•DD IncludeAbortion In ProgressCervical EPMonday, June 10, 13
  168. 168. 24n year old patient, G1P0, with menstrual delay of 7days, with Beta-hCG levels of 14.000 mU/ml.•Ultrasound Shows An EmptyUterine Cavity•A Gestational Sac In ThePosterior Lip Of The UterineCervix.Cervical PregnanciesThe patient required two doses of Methotrexate toachieve complete decline in the levels of Beta-hCGCervical EPs: 0.15%.Monday, June 10, 13
  169. 169. Non Gyn Casues Of Pain✤Ureteric Stone✤Crohn’s Disease (bowel Causes)✤Hernia In Intra-abdomean Wall✤Inflamed AppendixMonday, June 10, 13
  170. 170. •US Imaging Using 2D,3D,And Color ModalitiesAreThePrimary And Often The Only Investigation Needed InEvaluationAnd Diagnosis OfWomenWith Pelvic Pain.•Careful Examination, Incorporating Clinical BackgroundWith Sonographic Findings Is Essential.•Gynecologist With Experience In Sonography Are TheOnes Most Capable For Such Job.•High-quality Gynecological Ultrasound Can BeHighly Beneficial, But Poor-quality GynecologicalUltrasound Can Do HarmMonday, June 10, 13
  171. 171. Monday, June 10, 13
  172. 172. ThanksMonday, June 10, 13
  173. 173. 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 DeborahLevine et alSeptember 2010 Radiology, 256, 943-954.Monday, June 10, 13

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