Characterization of pelvic organs by Doppler sonography waveform shape

The purpose was to describe blood flow waveform of pelvic organs obtained by Doppler according to their unique characteristics. A prospective study was designed and 79 premenopausal and postmenopausal women were screened. Transvaginal ultrasonography combined with color Doppler was performed. Arterial blood flow of the uterus, fallopian tubes and both ovarian center and periphery were assessed, by a unique computerized program exclusively developed for this research (MATLAB language). Waveform characterization was performed by calculating alpha and beta angles, representing upward curve of each waveform and angles of refraction gamma and delta. alpha to delta angles were found significantly different for each of the pelvic organs. Significant differences in the characteristics of Doppler waveforms were also observed between pre and postmenopausal women. Luteal and follicular phase blood flow waveforms were similar. These findings contribute to our ability to classify the origin of blood vessel by processing Doppler waveforms by a computerized method.

Ectopic pregnancy confirming the transperitoneal transport of gametes/embryos--a case report

To present a rare case of spontaneous ectopic pregnancy in a non-communicating heterotopic fallopian tube associated with unicornuate uterus without a rudimentary horn. Case report.

SETTING

Tertiary referral obstetrics and gynecology center.

PATIENT

A 36-year-old woman in her fourth pregnancy (para 1, abortus 2) presented at 5th gestational week with severe abdominal pain and circulatory instability.

INTERVENTION

Heterotopic fallopian tube removal by laparotomy. Investigation of the origin of the spontaneous heterotopic fallopian tube pregnancy and exploration of the gross structural development of the urinary system. Spontaneous ectopic pregnancy in a non-communicating heterotopic fallopian tube coexisting with corpus luteum in the contralateral ovary supports the hypothesis of transperitoneal migration of gametes or embryos.

[Sonohysterosalpingography versus hysterosalpingography in the evaluation of uterine and tubal infertility]

OBJECTIVE

The evaluation of the role of sonohysterosalpingography with saline with air as a contrast solution (HYCOSY), in the assessment of uterine cavity and tubal patency, versus hysterosalpingography (HSG) and laparoscopy with dye test combined with hysteroscopy.

MATERIAL AND METHOD

Prospective study of 95 infertility patients, with ages 25-40 years (median 31), in which HYCOSY was compared with HSG regarding the diagnostic acuracy for uterine cavity pathology and tubal patency, and compared to laparoscopy with dye test combined with hysteroscopy as gold standard.

RESULTS

The sensibility, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the diagnostic of uterine cavity pathology was: HYCOSY versus hysteroscopy of 72.1%, 96.15%, 93.93% and 80.64% respectively; HSG versus hysteroscopy was 83.3%, 60.7%, 63.6% and 81.6%; both methods combined versus hysteroscopy 95.34%, 61.53%, 67.21% and 94.11%. The same parameters for the tubal patency were: HYCOSY versus dye test laparoscopy 81.39%, 87.69%, 67.30% and 97.79%; HSG versus dye test laparoscopy 61.9%, 85.3%, 56.5% and 87.9%; both methods combined versus dye test 86%, 76%, 52.9% and 94.6%.

CONCLUSION

HYCOSY can be used in combination with HSG for selecting the patients that need further more invasive investigations, in order to describe uterine and tubal pathology.

The chorionic bump in an ectopic pregnancy

The chorionic bump, an irregular, convex bulge of the choriodecidual surface into the gestational sac (GS), is a recently described, uncommon abnormality of the 1st-trimester GS and is associated with a guarded prognosis for early pregnancy. The case of this 42-year-old female demonstrates a previously unreported relationship: a transvaginal sonographic finding of a chorionic bump associated with a spontaneous tubal ectopic pregnancy. This might support the hypothesis that the chorionic bump represents a small hematoma that bulges into the GS.

Isolated torsion of the fallopian tube: the sonographic whirlpool sign

OBJECTIVE

The purpose of this series is to describe the sonographic features of isolated torsion of the fallopian tube.

METHODS

Sonography was performed in 4 women with acute lower abdominal pain.

RESULTS

The uterus and ovaries were normal in the 4 women. The ipsilateral fallopian tube was distended with fluid. A round mass was seen close to the tube. A sonographic whirlpool sign was seen on rocking movement of the probe over the mass. Ipsilateral torsion of the fallopian tube was confirmed at surgery in all of them.

CONCLUSION

The sonographic whirlpool sign is the specific sign of tubal torsion.

Association between ultrasound findings and extent of trophoblastic invasion into the tubal wall in ampullary pregnancy

OBJECTIVE

Predictive factors of damage to the Fallopian tube may guide the treatment of patients with tubal pregnancy. The aim of the present study was to investigate the association between the depth of trophoblastic invasion into the tubal wall, assessed on postoperative histological examination, with the findings obtained on transvaginal sonography (TVS) in women with ampullary pregnancy.

METHODS

Women with ampullary pregnancy undergoing salpingectomy were enrolled into the study. Only women with a finding of either an embryo with cardiac activity or a tubal ring on TVS were included in the analysis, a total of 85 patients. Trophoblastic invasion was assessed postoperatively and was histologically classified as Stage I when limited to the tubal mucosa, Stage II when extending to the muscle layer and Stage III in the case of complete tubal wall infiltration. The association between findings on TVS and the stage of trophoblastic invasion was evaluated.

RESULTS

There was a significant association between the findings on TVS and the depth of trophoblastic invasion (P < 0.001). All patients in whom an embryo with cardiac activity had been identified were found to have Stage II (17.9%) or Stage III (82.1%) invasion, whereas in those patients who showed a tubal ring on TVS, Stage I invasion was the most frequent finding (41.3%).

CONCLUSIONS

In ampullary pregnancy, the finding on TVS of an embryo with cardiac activity is associated with deeper penetration of trophoblastic tissue into the tubal wall than is the finding of a tubal ring.

Spontaneous unilateral dizygotic twin tubal pregnancy

Spontaneous dizygotic unilateral twin tubal pregnancy is an extremely rare occurrence with a high risk for pregnancy-related mortality, and a diagnostic challenge for obstetricians. We present a case of a 27-year-old woman with spontaneous twin tubal pregnancy. Transvaginal color Doppler sonography revealed 2 separate gestational sacs within the right adnexa, each containing an embryo. Cytogenetic examination of the trophoblastic tissues confirmed the diagnosis of dizygotic twin ectopic pregnancy. Clinical signs and symptoms together with imaging studies help in the diagnosis of this rare variant of ectopic pregnancies.

Infertility in women: combined sonohysterography and hysterosalpingography in the evaluation of the uterine cavity

PURPOSE

To evaluate the diagnostic effectiveness of combined hysterosalpingography (HSG) and sonohysterography (SHG) in the study of infertile women.

MATERIALS AND METHODS

208 women affected by primary (184) or secondary sterility (24) were divided in two random groups. Group 1 underwent only HSG and group 2 underwent simultaneous HSG and SHG. The results obtained in the two groups were correlated with the results of hysteroscopy or laparoscopy, considered Gold Standard. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and likelihood ratio (LR) of HSG alone and combined HSG/SHG were calculated. Results were evaluated with t-test, Pearson's Chi square or Fisher exact test when appropriate and ROC analysis.

RESULTS

In group 1, hysteroscopy revealed no pathology in the uterine cavity in 70/104 patients, but evidenced 47 abnormalities related to the uterine cavity in 34 women. HSG outcome was in accordance with hysteroscopy in 27/34 cases of abnormalities, and in 64/70 cases of normal outcome. Sensitivity 0.79, specificity 0.91, PPV 0.82, NPV 0.90, LR+ 9.26. In group 2, hysteroscopy revealed no pathology in the uterine cavity in 64/104 patients but 52 abnormalities related to the uterine cavity in 40 women. HSG and SHG outcomes were confirmed by hysteroscopy in 39/40 cases of abnormalities of the uterine cavity and in 60/64 cases of normal uterine cavity. Sensitivity 0.97, specificity 0.94, PPV 0.91, NPV 0.98, LR+ 15.60. Statistical analysis showed that combined HSG and SHG yielded elevated specificity and LR+ and therefore few cases of false positive outcome.

CONCLUSION

Combined performance of HSG and SHG can shorten diagnostic investigation time and reduce the discomfort to the patient as the injector is fed into the cervix only once. This may also reduce the patient's anxiety level as one of the causes of infertility.

Unilateral leiomyoma in the mesosalpinx of a dog

Routine ultrasonographic evaluation of the genital organs of a 3-year-old terrier bitch revealed a mass at the level of the left ovary. The mass was located next to the caudal pole of the left kidney and ventrocaudal to the left ovary. Ultrasonographically, the uterus was not enlarged and had no luminal contents. Exploratory laparotomy revealed a mass attached to the left ovarian bursa with a small and thin pedicle. The mass had smooth margins, was whitish in color, and was lobulated on cut surface. The histopathological diagnosis of the mass was leiomyoma associated with the mesosalpinx.

Torsion of normal adnexa in postmenarcheal women: can ultrasound indicate an ischemic process?

OBJECTIVE

Torsion of normal adnexa is a rare event involving steadily increasing congestion and ischemia of the ovary. We investigated whether this process can be characterized by sonographic features.

METHODS

Twelve menstrually cycling women with 14 separate episodes of laparoscopic-proven torsion of normal adnexa were identified retrospectively, and the results of their preoperative gray-scale ultrasound examinations and Doppler flow evaluations were analyzed. The cases were classified into 'short-term' (< 24 h; range, 3-24 h) and 'prolonged' (> 24 h; range, 1-10 days) duration of torsion according to the reported period of abdominal pain before admission. Absence of any additional adnexal pathology was confirmed by both intraoperative inspection and postoperative follow-up ultrasound examinations.

RESULTS

The median age of the cohort was 24.0 (interquartile range (IQR), 20.5-28.7) years, and parity ranged from 0 to 3. All affected ovaries were significantly enlarged compared with non-affected ones (median cross-sectional area, 18.1 (IQR, 12.4-26.4) cm(2) vs. 4.3 (IQR, 2.9-6.2) cm(2), P < 0.01). We could distinguish two distinct sonographic patterns of torted ovaries: there were numerous small peripheral follicles in the ovarian parenchyma in nine cases, and there was a solid-appearing mass with hypo- and hyperechogenic foci in five cases. Comparison of the ultrasound images of patients with short-term vs. long-term abdominal pain revealed that the solid-appearing ovary was more common in the latter group (0/6 vs. 5/8, P = 0.03), while there was no significant difference between groups in the presence of free pelvic fluid or median ovarian cross-sectional area. Intraovarian blood flow was diminished or absent in five of the eight patients in whom color Doppler imaging was performed.

CONCLUSIONS

Ultrasound images of twisted normal adnexa may vary according to the duration of the condition, reflecting the pathological series of events of increased ovarian congestion and necrosis. Recognition of the different sonographic features of twisted normal adnexa may assist in the correct diagnosis of these patients.

The multiple ultrasound patterns of ectopic pregnancy

Ectopic pregnancy (EP) has a variable and misleading clinical presentation contributing to the confusion with medical or other gynecological disorders. The rapid recourse to diagnostic methods, human chorionic gonadotropin (beta-hCG) titers and transvaginal ultrasonography, represents the best approach not only in the early diagnosis but also in the management and monitoring of patients with diagnosed EP. The purpose of this article is to provide a pictorial essay about EP and its multiple ultrasound (US) patterns. We present a large spectrum of EP aspects diagnosed on US and confirmed by pathology. We also review miscellaneous gynecologic diseases that may mimic EP on US. Although endovaginal US combined with quantitative (beta-hCG) analysis is an excellent tool for identifying EP, it may be normal sometimes in early pregnancies. Knowledge of all these patterns is helpful in establishing an early correct diagnosis, therefore leading to elective and conservative management in stable patients and preventing tubal rupture or substantial hemorrhage.

Role of hysterosalpingoscintigraphy in the workup of infertility

OBJECTIVE

To assess the role of hysterosalpingoscintigraphy (HSSG) in the evaluation of fallopian tube patency and function and compare the results with hysterosalpingography (HSG) and laparoscopy (LS).

DESIGN

Cross-sectional study.

PLACE AND DURATION OF STUDY

The study was conducted at Multan Institute of Nuclear Medicine and Radiotherapy (MINAR), Multan from August 2004 to February 2005.

PATIENTS AND METHODS

HSSG was performed after instillation of 4mCi (148 MBq) 99mTechnetium-macroaggregated albumin (99mTc-MAA) in posterior vaginal fornix in 65 patients. Serial static images were acquired in supine position at 1 hour, 2 hours, 3 hours and, if needed, at 24 hours. The results were compared to the findings on LS and HSG.

RESULTS

Out of 65 patients, 37 (56.9%) patients had bilateral blocked tubes, 17 (26.1%) patients had bilateral patent tubes, 6 (9.2%) patients had blocked left tube and 5 (7.1%) patients had blocked right tube. The calculated sensitivity, specificity, positive predicted value (PPV), negative predicted value (NPV) and accuracy for HSSG were 90%, 83%, 90% and 90% respectively. The agreement between HSSG and LS was found in 32 out of 35 patients and agreement between HSG and HSSG was found in 24 out of 30 patients.

CONCLUSION

This simple procedure can delineate tubal physiology; in selected cases it can replace HSG and in others augment the information gathered by HSG. HSSG should be part of the infertility workup algorithm.

Saline sonohysterosalpingographic findings in infertile Nigerian women

This paper describes the findings in the first 100 women who underwent saline sonohysterosalpingography (SHG) at two privately owned health facilities in Enugu, South East Nigeria. This was a prospective study of the first 100 consecutive women presenting with infertility to the authors at Mbanefo Hospital and Hansa Clinics, both in Enugu, South-East geopolitical zone of Nigeria from 1 May 2005 to 20 January 2006. Saline sonohysterosalpingography was carried out in the standard way in these women. The findings were analysed using simple percentages and means +/- SD. The procedure was completed in 98 women, while in two others it was not possible to cannulate the uterine cavity. A total of 61 of the women had normal uterine musculature, 37 had interstitial fibroids and two had sonographic features of adenomyosis. Regarding the endometrial cavity, 93 women had a normal endometrium, four had a submucosal fibroid, one had intrauterine adhesions, while the endometrial cavity could not be assessed in two women who could not be cannulated. No case of submucosal polyp or uterine septa or other congenital uterine anomalies was seen. As assessed sonologically, 77 of the study subjects had bilateral patent tubes, while five had unilateral tubal patency. In one woman, there was uncertainty about tubal patency or blockage; in two women, the tubes could not be assessed because of non-cannulation of the uterine cavity and in 15 women, both tubes were blocked. A total of 74 women had normal ovaries; 15 had polycystic ovaries; five had atrophic ovaries consistent with ovarian failure and six women had ovarian cysts. In 18 women, the findings at sonosalpingography (SSG) were confirmed at laparoscopy in 11 women or laparotomy (two women) or by the fact that the patients became pregnant (five women). In 15 (83.3%) of these 18 women, the findings at SSG and laparotomy/laparoscopy or of the woman becoming pregnant were compatible. SSG is a useful screening test for assessing endometrial, tubal and ovarian factors in infertile Nigerian women, thereby obviating the need for laparoscopy and hysteroscopy in the majority of cases.

Isolated torsion of the fallopian tube in a 14-year-old adolescent

OBJECTIVE

Torsion of adnexa is relatively common, but isolated torsion of the fallopian tube is rare. It should be considered in all adolescents who present with acute pelvic pain. Laparoscopy or laparotomy is often necessary to establish the diagnosis. This report focuses on a 14-year-old girl with isolated tubal torsion who presented with acute pelvic pain.

CASE REPORT

A 14-year-old adolescent was admitted to our hospital because of acute right-sided abdominal pain without vomiting and diarrhea. Pelvic ultrasound showed an adnexal mass. Conservative treatment was given but did not improve her condition. Emergent laparoscopy was performed due to persistent symptoms, which later confirmed the diagnosis of isolated torsion of the fallopian tube. Pathology showed hemosalpinx with necrosis.

CONCLUSION

Isolated torsion of the fallopian tube is an uncommon event, especially in adolescents. It must be kept in mind whenever a young girl presents with low abdominal pain and pelvic mass on ultrasound. Prompt laparoscopic intervention may allow for early diagnosis, treatment and preservation of the tube if possible.

Sonohysterography: is the hysterosalpingographic vacuum cup a valid alternative device for cannulation of the cervical Os?

PURPOSE

To determine whether sonohysterography (SHG) should be performed with Plexiglas hysterosalpingographic vacuum cups instead of standard catheters.

MATERIALS AND METHODS

In a prospective setting, 226 women randomly classified into 2 groups underwent SHG. The method used for cervical cannulation was a two-way catheter in the first group (n = 108) and a Plexiglas hysterosalpingographic vacuum cup in the second one (n = 118). Diagnostic reliability, easy applicability for the physician, discomfort for the patients and cost of the instruments were assessed for both devices.

RESULTS

226/226 (100 %) complete sonohysterographic examinations were performed. As regards uterine cavity distension the same diagnostic reliability was reported for vacuum cups and two-way catheters. The standard catheter obscured the cervical canal because of the dilation of the balloon. Both methods were judged as easy to use, and no statistically significant difference was found as far as the time required for cervical cannulation (p > 0.05). A little more discomfort was recorded by women who underwent sonohysterography with standard balloon catheters but a greater interpersonal variability was noticed in this group (SD 3.65 vs. 1.13 in the vacuum cup group). Vacuum cups were by far the most economical devices (unit cost: 16.70 euro vs. catheter unit cost 46.20 euro).

CONCLUSION

Vacuum cups allow sonohysterography to be correctly performed. As they are inexpensive, easy to use, better tolerated by the patients and more helpful for visualisation of the lower third of the uterine cavity, vacuum cups should be considered a serious alternative to standard catheters in the performance of SHG.

Isolated tubal torsion: a rare cause of pelvic pain at menarche. Sonographic and MR findings

Isolated torsion of the fallopian tube is a rare clinical entity, especially in adolescents and at menarche. The diagnosis is essentially made at laparoscopy or at laparotomy because of nonspecific clinical signs. We present a case of isolated tubal torsion in a 12-year-old girl a few days after menarche, highlighting the sonographic and MR findings. Both techniques demonstrated the enlarged and tortuous fallopian tube with normal ovaries and uterus, but MR was also able to characterize contained blood and absent vascular supply. Although this condition is uncommon it should be considered as a cause of acute pelvic pain in adolescents because of the possibility of salvage surgery with early diagnosis. Sonography and MRI have a complementary role in this diagnosis.

Sonography, CT, and MRI appearance of the Essure microinsert permanent birth control device

OBJECTIVE

The purpose of this article is to describe the appearance and location of the Essure permanent birth control device on sonography, CT, and MRI.

CONCLUSION

The Essure device has a distinct appearance and typical location that allow it to be accurately identified on sonography, CT, and MRI scans.

Paraovarian/paratubal cysts: comparison of transvaginal sonographic and pathological findings to establish diagnostic criteria

OBJECTIVES

To describe the sonographic features of paraovarian cysts and to compare these features with pathological findings in order to define the best treatment options (surgical vs. conservative).

METHODS

Fifty patients (mean age 48 (range, 14-68) years), each with a surgically proven paraovarian cyst, were retrospectively recruited. Preoperative transvaginal ultrasonographic B-mode and power Doppler observations were re-evaluated and histological reports were analyzed.

RESULTS

All cysts were correctly diagnosed as paraovarian at preoperative transvaginal sonography (TVS). Paraovarian cysts appeared as unilocular ('simple') cysts in 33 (66%) cases and multilocular in two (4%). In 15 patients (30%) the cyst showed a variable number of papillary projections growing from the cyst wall (unilocular-solid cysts). Power Doppler examination of the papillae showed the presence of blood vessels in four of these patients (27%). Histological analysis of the masses containing papillary projections diagnosed eight cystadenofibromas, five cystadenomas and two serous papillary borderline tumors, while analysis of paraovarian cysts without papillations revealed benign, serous cysts of paramesonephric or mesothelial origin.

CONCLUSIONS

Paraovarian cysts can show a wide range of sonographic features. Their risk of malignancy is low if no papillary projections are detected at transvaginal sonography, but when mural proliferations are present a borderline tumor can be found at pathological examination.

Hydrosalpinx with adnexal torsion in an adolescent virgin patient--A diagnostic dilemma: case report and review of the literature

Hydrosalpinx is one of the predisposing factors of adnexal torsion. However, because the incidence of hydrosalpinx in adolescent virgin patients is very rare, it may cause diagnostic dilemma, leading sometimes to suboptimal treatment. We present the case of an 18-yr-old female, not sexually active, presenting with acute lower right abdominal pain. The working diagnosis was of a simple ovarian cyst, so aspiration was performed. Abdominal symptoms reoccurred and sonography revealed a large hemorrhagic cystic mass adjacent to an edematous right ovary. The patient was referred to immediate laparoscopy due to suspected right adnexal torsion. On laparoscopy, the right adnexa was twisted three times causing an edematous ovary with a hematosalpinx. Detorsion was performed. Five weeks later, transabdominal ultrasound reviled normal bilateral ovaries and the hematosalpinx disappeared. In conclusion, hydrosalpinx, although very rare in adolescence, must be considered in the differential diagnosis. Aspiration in such cases is not the treatment of choice and moreover, it may cause complications.

Contrast infusion sonography to assess microinsert placement and tubal occlusion after Essure®

OBJECTIVE

To develop a technique for contrast infusion sonography and assess the possible use in determining microinsert placement and tubal status after Essure sterilization.

DESIGN

Techniques and instrumentation.

SETTING

Healthy women in an academic multispecialty group.

PATIENT(S)

Ten women desiring permanent sterilization who have recently undergone Essure hysteroscopic sterilization.

INTERVENTION(S)

Contrast infusion sonography, an adaptation of hysterosalpingo contrast sonography, performed at 3-23 weeks after Essure placement.

MAIN OUTCOME MEASURE(S)

To determine how readily tubal status and microinsert location could be assessed with this adaptation of hysterosalpingo contrast sonography.

RESULT(S)

All microinserts were readily identified and tubal status was assessed by identification or absence of real-time contrast agent flow.

CONCLUSION(S)

This technique is very promising and could represent a convenient alternative to hysterosalpingogram (HSG) 3 months after Essure placement.

Hysterography -- new techniques

For many years hysterosalpingography has provided images of the lumen of the fallopian tubes and the uterine cavity that were not available by other diagnostic modalities. In our days the development of new imaging and endoscopic techniques has limited its indications. In this paper we will discuss the current use of hysterosalpingography and the new techniques that have been developed such as sonohysterography.