Role of us in pelvic pain final

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
Monday, June 10, 13

❖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
Monday, June 10, 13

The relative position of the uterus to the cervix and to the
axis of the vagina
The symmetry
The size
The Texture
The Uterus
Monday, June 10, 13

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.
Monday, June 10, 13

The Vagina
By TA scanning it appears as a collapsed tubular structure lying
inferior to the urinary bladder and distal to the uterine cervix
TA
TP
Monday, June 10, 13

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
Monday, June 10, 13

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

Role of Ultrasound In
Pelvic Pain
Monday, June 10, 13

Acute
Chronic: Deﬁned By Pain For >6 Months
Monday, June 10, 13

Acute or chronic
Diffuse of focal
Cyclical or constant
Sharp or dull or cramping
?Prior Surgery
Menopausal and hormonal status
Could she be pregnant?
Correlation of Clinical History with
Sonographic Examination
Monday, June 10, 13

Uterine
Adenomyosis
Degenerating
Fibroids
Prolapsing
Fibroids
Abnormally
Placed IUD
Ovarian
Simple 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

Uterine
Adenomyosis
Degenerating
Fibroids
Prolapsing
Fibroids
Abnormally
Placed IUD
Ovarian
PID EP
Monday, June 10, 13

Adenomyosis
Degenerating Fibroids
Prolapsing Fibroids
Abnormally Placed IUD
Uterine
Monday, June 10, 13

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 OfThe Endometrial Glands IntoThe Myometrium
Monday, June 10, 13

Sonographic Findings of Adenomyosis
•Globular Uterine Enlargement
•Generalized adenomyosis
•Focal adenomyoma
•Cystic Anechoic spaces
•Uterine Wall Asymmetrical thickening
•Obscure endometrial/myometrial border
Monday, June 10, 13

Globular Uterine Enlargement That Is Generally Up To 12 Cm In Uterine Length And Is
Not Explained By The Presence Of Leiomyomata.
Figure 3. Globular uterine enlargement with an obscure endometrial/
myometrial border (arrow).Globular Uterine Enlargement
Monday, June 10, 13

F
m
Figure 1. Generalized adenomyosis.Generalized adenomyosis
Diffuse Disease Involving The Entire Myometrium
Loss Of Normal Architecture (Loss Of Of
Homogeneity) (most Predictive Of Adenomyosis)
Monday, June 10, 13

Focal Area Of The Uterus AdenomyomaFigure 2. Focal adenomyoma (arrows).
Focal Adenomyoma
Monday, June 10, 13

-
s
-
s
d
-
f
n
d
Figure 2. Focal adenomyoma (arrows).
Cystic Anechoic spaces
Monday, June 10, 13

Uterine Wall Thickening: Anteroposterior
Asymmetry.
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 Heterogeneous
Myometrial Echo Texture.
Monday, June 10, 13

Uterine Wall Thickening: Anteroposterior
Asymmetry.
Monday, June 10, 13

Figure 2. Focal adenomyoma (arrows).
•Obscure endometrial/myometrial border
Monday, June 10, 13

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
SonographyVs. 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
Monday, June 10, 13

Fibroids
•Cystic Degeneration
•Prolapsing Pedunculated
Fibroid
•Pressure Effect
Monday, June 10, 13

Fibroid
❖Very Common-most
❖UsuallyAsymptomatic.
❖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
Monday, June 10, 13

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.
Monday, June 10, 13

so-
ud-
ary
ty.
oid
io-
od
us
id,
cal
mic
nd
re-
ize
to
FIGURE 20. Large degenerating fibroid.
Transabdominal ultrasound of the uterus
Acute Pelvic Pain 13
Transabdominal ultrasound of the uterus shows the very heterogeneous
appearance of a degenerating ﬁbroid contains irregular hypoechoic
components.
Degenerating Fibroid
Monday, June 10, 13

uterus
Broad Ligament Fibroid
Monday, June 10, 13

Broad Ligament Fibroid
Monday, June 10, 13

Degenerating Fiborid
Monday, June 10, 13

Calciﬁed
Fiborid
Degenerating
Fiborid
Monday, June 10, 13

Same Patient
Transverse view
Monday, June 10, 13

TA scan Suggest Thick
Endometrium
TV scan Shows
Endometiral Polyp
Endometrial Polyp
Monday, June 10, 13

Saline Intrauterine Sonography
“SIS”
Monday, June 10, 13

Pain Due to Pressure Effect
Monday, June 10, 13

TA-Scan LongitudinalView
TA-Scan TransversView
Monday, June 10, 13

Postpartum Complication in a Fibroid
Monday, June 10, 13

Uterine
Adenomyosis
Degenerating
Fibroids
Prolapsing
Fibroids
Abnormally
Placed IUD
Ovarian
Simple Cyst
Hemorrhagic Cyst
Ovarian Torsion
Endometrioma
Dermoid Cyst
Ovarian Cancer
PID EP
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.
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
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.
Monday, June 10, 13

Adnexal Cyst
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.
Monday, June 10, 13

The Road Map for Management of Ovarian Cyst
Monday, June 10, 13

ovarian lesionFirst Step
Is It Ovarian
Monday, June 10, 13

ovarian lesionFirst Step
Is It Ovarian
US
Recognition
Monday, June 10, 13

ovarian lesion
Simple, Hemorrhagic, Endometrioma
Teratoma, Or Indeterminate
First Step
Is It Ovarian
US
Recognition
Monday, June 10, 13

ovarian lesion
First Step
Is It Ovarian
US
Recognition
Hige vs. Low
Risk Group
Monday, June 10, 13

ovarian lesion
ignore, follow or excise
First Step
Is It Ovarian
US
Recognition
Hige vs. Low
Risk Group
Monday, June 10, 13

ovarian lesion
ignore, follow or excise
• Symptomatic lesion versus incidental finding
• Additional findings
• Morphology on US, CT or MRI
First Step
Is It Ovarian
US
Recognition
Hige vs. Low
Risk Group
Monday, June 10, 13

Torsion
Hemorrhage
Teratoma
Endometrioma
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

larity in the complex components of the
FIGURE 12. Follicular cyst. Transvaginal
ultrasound of a follicular cyst (calipers),
which resolved on follow-up 2 months later.
The cyst is anechoic, thin-walled, and shows
posterior 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 cyst
Monday, June 10, 13

r-
c-
d
as
r-
a
er
).
e
d
e
e
n-
a
CL Cyst
✤Thicker wall
✤More Echogenic
✤Increased Vascularity
Monday, June 10, 13

Hyperstimulated Ovary
Monday, June 10, 13

Hyperstimulated Ovary
Inversion 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

Torsion
Hemorrhagic
Teratoma
Endometrioma
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
of hem
particu
ment an
are mor
It is
intrape
examin
rupture
ovarian
angular
free flu
echoes
de-sac o
On
typicall
adnexa
FIGURE 14. Hemorrhagic cyst. Transvagi-
10 Vandermeer and Wong-You-CheongSonosgraphic Features of Hemorrhagic
Ovarian Cyst
Lace like
Fish Net Pattern
Absent Color Flow
Acute hemorrhage
is isochoic
Monday, June 10, 13

the rapid evolution and/or cyst resolution
exc
•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
excluding other intra-abdominal causes
re-
hows FIGURE 16. Acute bleed from a left he-
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
Monday, June 10, 13

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

Endometriosis
Presence 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

✤Endometriomasare more commonly multiple and their appearance is
stable over time.
✤hemorrhagic cyst has changing appearance.
FIGURE 14. Hemorrhagic cyst. Transvagi-
nal ultrasound of a hemorrhagic cyst shows
the characteristic mesh of fine linear echoes
referred to as a ‘‘lacy’’ or ‘‘fish net’’ appear-
ance. Color Doppler shows absence of blood
10 Vandermeer and Wong-You-CheongHomogenously
Hypoechoic
Lace-like Interanal
Echogenicity,
Hemorrhagic Cyts
Subacute stage
Endometrioma
Endometriomas Vs. Hemorrhagic
Monday, June 10, 13

Mature Cystic Teratome
US 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

7
7.3
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

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 Malignancy
Large size
Vascularized septations
Vascularized solid components
Vascularized thick, irregular wall
Secondary findings a: e.g. Ascites
Monday, June 10, 13

Summary of The
Monday, June 10, 13

Ovarian Torsion
Prompt 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 Symptoms
OfPain,Nausea,AndVomitingAreNonspecific.
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
TheTwistingOfThe
OvarianVascularPedicle
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
Monday, June 10, 13

Primary Sonographic Features
Monday, June 10, 13

Enlarged,Amorphous
and Hypoechoic ovariesPeripherally located
Numerous Follicles
Free Fluid in the pelvisAbsence ofVenous 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. ovary
Monday, 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

7
7.3
5.4
Dermoid Cyst
Monday, June 10, 13

Ovarian torsion in a patient with acute pelvic pain 2 weeks postpartum. Sonography showed a
markedly enlarged right ovaryFIGURE 18. Ovarian torsion in a patient
with acute pelvic pain 2 weeks postpartum.Monday, June 10, 13

Uterine
Adenomyosis
Degenerating
Fibroids
Prolapsing
Fibroids
Abnormally
Placed IUD
Ovarian
Simple Cyst
Hemorrhagic Cyst
Ovarian Torsion
Endometrioma
Dermoid Cyst
Ovarian Cancer
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
Monday, June 10, 13

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

Ectopic Pregnancy
Pregnancy with the fertilized embryo implanted
onanytissueotherthantheuterinelining
•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 MakingATimely 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
910
15
21
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 Wks
Monday, June 10, 13

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 Wks
Monday, June 10, 13

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 Wks
Monday, June 10, 13

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 Wks
Monday, June 10, 13

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 Wks
Monday, June 10, 13

and a positive pregnancy test.
cidence of approximately 1 out
00 diagnosed pregnancies, EP
he leading cause of maternal
e first trimester and the second
use of maternal mortality over-
s the most important tool in the
of suspected EP and should be
with measurement of quantita-
man chorionic gonadotropin
or appropriate interpretation.
t goal of US evaluation is to
whether an intrauterine preg-
resent. If an intrauterine preg-
be demonstrated, an EP can be
y excluded, as synchronous in-
and EPs are exceedingly rare in
l population (1:7000 pregnan-
wever, it is important to note
FIGURE 1. Intradecidual sac sign. Trans-
vaginal ultrasound of the uterus shows a
small, round anechoic fluid collection (arrow-
head), eccentrically implanted within the
echogenic endometrium (arrow), consistent
with a very early intrauterine pregnancy.
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

ted thoroughly for any extraovarian
bnormality. Although the sonographic
ppearance of EP can be quite varied, it
and a thick echogenic periphery,
bal ring sign’’ (Fig. 4). A yolk sac a
pole may be present, with or
cardiac activity, providing the m
cific sonographic finding of an EP
ficity of 100%) (Fig. 5). Howev
appearance is the least sensitive
in EP (15% to 20%).3
More comm
EP is identified as a complex adne
in a patient with a positive pregna
and no intrauterine pregnancy. A
most EPs are located between th
and the uterus, they may impla
where in the pelvis and it is nece
carefully search the regions adj
the uterine fundus, cul-de-sac an
margins of the pelvis.
An uncommon but importa
of EP is an interstitial pregnancy
occurs in 2% to 3% of EP
interstitial pregnancy results fr
plantation within the interstitial
myometrial portion of the f
IGURE 3. Pseudosac in the setting of ecto-
ic pregnancy. Sagittal transvaginal ultra-
ound of the uterus shows an elongated fluid
ollection (arrow) located centrally within the
avity. It is surrounded by a single, echogenic
ayer (arrowhead) of endometrium. An ecto-
ic pregnancy (not shown) was identified in
Centrally located
Surrounded with
single echogenic layer of
endometrium
deﬁned
Completely
Surrounded by
Echogenic decidual
tissue
within the opposing
endometiral lining
Monday, June 10, 13

ted thoroughly for any extraovarian
bnormality. Although the sonographic
ppearance of EP can be quite varied, it
and a thick echogenic periphery,
bal ring sign’’ (Fig. 4). A yolk sac a
pole may be present, with or
cardiac activity, providing the m
cific sonographic finding of an EP
ficity of 100%) (Fig. 5). Howev
appearance is the least sensitive
in EP (15% to 20%).3
More comm
EP is identified as a complex adne
in a patient with a positive pregna
and no intrauterine pregnancy. A
most EPs are located between th
and the uterus, they may impla
where in the pelvis and it is nece
carefully search the regions adj
the uterine fundus, cul-de-sac an
margins of the pelvis.
An uncommon but importa
of EP is an interstitial pregnancy
occurs in 2% to 3% of EP
interstitial pregnancy results fr
plantation within the interstitial
myometrial portion of the f
IGURE 3. Pseudosac in the setting of ecto-
ic pregnancy. Sagittal transvaginal ultra-
ound of the uterus shows an elongated fluid
ollection (arrow) located centrally within the
avity. It is surrounded by a single, echogenic
ayer (arrowhead) of endometrium. An ecto-
ic pregnancy (not shown) was identified in
5% to 10% of patients with
EP demonstrate a pseudosac
Centrally located
Surrounded with
single echogenic layer of
endometrium
deﬁned
Completely
Surrounded by
Echogenic decidual
tissue
within the opposing
endometiral lining
Monday, June 10, 13

Decidua
Paraitalis
II: ‘‘Double-Decidual Sac Sign’’
Decidua
Capsularis
Hypoechoic
endometiral cavity
Monday, June 10, 13

FIGURE 6. Interstitial line sign. Tr
ginal ultrasound of the uterus shows
dence of a normal intrauterine preg
The 2 layers of the echogenic endom
are coapted (arrow) and extend to the
Acute Pelvic Pai
FIGURE 5. Ectopic pregnancy with a yolk
sac and fetal pole. (A) Sagittal transabdom-
inal ultrasound of the uterus shows a small
central fluid collection (open arrow), consis-
Yolk SacAnd Fetal Pole
Sagittal TA View
Pseudosac
Fetal Pole
Transvaginal View
Yolk Sac
Fetal Pole
Rt Ovary
with CL
TheMostSpecificSonographicFindingOfAnEP(specificityOf100%)
Sonographic Feature Of Tubal Pregnancy EP
Monday, June 10, 13

ual
the
yer
oid,
of
to
ate
nly
r a
cal
to
ive
hic FIGURE 4. Tubal ring sign of ectopic preg-
ng
Tubal Ring Sign
Ectopic
Pregnancy
Corpus Luteum
Uterus
EPlocatedintheampullaryportionofthetube.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 pelvis
Monday, June 10, 13

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
Monday, June 10, 13

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 sacovary
Tubal Ring Sign
Monday, June 10, 13

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
Fluid In The Cul-de-sac
Monday, June 10, 13

❖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
Monday, June 10, 13

‘‘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
Monday, June 10, 13

Enables Correct Depiction Of The Sac And Its Location
Sonographic Features Of Interstitial EP
Two-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
Monday, June 10, 13

The GS Located
Outside
Two-dimensional Sonography
DD eccentrically positioned intrauterine pregnancy
Monday, June 10, 13

3D Sonography
Monday, June 10, 13

Color Doppler
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"
Monday, June 10, 13

Transvaginal image of a cornual ectopic pregnancy (red arrow).
The uterus is demonstrating a decidual reaction (red
arrowhead)
Monday, June 10, 13

•Associated With Potential Uncontrollable Hemorrhage.
•Sonographic Features Are Those Of An Early Pregnancy
Embedded Within The Cervical Stroma.
•DD IncludeAbortion In Progress
Cervical EP
Monday, June 10, 13

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%.
Monday, June 10, 13

Non Gyn Casues Of Pain
✤Ureteric Stone
✤Crohn’s Disease (bowel Causes)
✤Hernia In Intra-abdomean Wall
✤Inﬂamed Appendix
Monday, June 10, 13

•US Imaging Using 2D,3D,And Color ModalitiesAreThe
Primary And Often The Only Investigation Needed In
EvaluationAnd Diagnosis OfWomenWith 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
Monday, 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.
Monday, June 10, 13

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