MDCT diagnosis of ruptured tubal pregnancy with massive hemoperitoneum

Mimics of primary ovarian cancer and primary peritoneal carcinomatosis - A pictorial review

Numerous conditions can mimic ovarian malignancy. Identifying the origin of a pelvic mass or disseminated peritoneal abnormality on imaging is important to ensure that the patient receives optimal management by the appropriate clinical team. Ovarian cancer mimics include infections and other neoplastic processes, for example, actinomycosis, lymphoma, and sarcoma. We will illustrate intraperitoneal and extraperitoneal ovarian and non-ovarian mimics. Primary peritoneal carcinomatosis mimics include processes such as deep infiltrating endometriosis and rare causes such as gliomatosis peritonei and diffuse peritoneal leiomyomatosis. We aim to illustrate the multimodality key imaging appearances of common and rarer types of mimics.

Diagnostic utility of contrast-enhanced computed tomography for ectopic pregnancy

INTRODUCTION

Contrast-enhanced computed tomography (CECT) is an emergent diagnostic imaging modality to identify the bleeding site and survey the abdominal cavity. The diagnostic utility of CECT for ectopic pregnancy (EP) has not been well-investigated. The objective of this study was to evaluate the characteristics of CECT findings in patients with EP and extract specific findings that could contribute to the identification of implantation sites.

METHOD

We conducted a retrospective study, reviewing suspected EP cases between April 2015 and March 2018 in our hospital. Clinical symptoms, blood test results, transvaginal sonography findings, and surgical and pathologic findings from the medical records were assessed. CECT images were evaluated by a certified radiologist and gynecologist retrospectively in consensus. The following were selected as positive findings for specific determination of the ectopic implantation site: the ectopic gestational sac, lateralization of the hemoperitoneum around the adnexa on either side, and extravascular leakage of the contrast agent outside the uterine cavity.

RESULTS

CECT was performed in 41 women with an EP. The ectopic implantation site was detectable on CECT in 90.2% (37/41), whereas it was noted in 70.0% (32/41) on transvaginal ultrasonography (TVS). Of nine patients with an EP with an undetectable implantation site on TVS, six were positive for the specific determination of the ectopic implantation site on CECT.

CONCLUSION

CECT has the potential to predict ectopic implantation sites with high-level sensitivity. As CECT is an urgent diagnostic imaging tool to be used in an emergent setting, it may be a good option for EP diagnosis when the availability of magnetic resonance imaging is limited.

Ectopic pregnancy: a resident's guide to imaging findings and diagnostic pitfalls

Ectopic pregnancy (EP) is a term used to describe any pregnancy which does not implant into the uterine cavity. There are several types of EPs: tubal, interstitial, ovarian, abdominal, heterotopic, cervical, and cesarean scar. Ectopic pregnancies can acutely rupture and are the number one cause of maternal death in the first trimester of pregnancy. Therefore, prompt recognition and accurate localization have significant clinical implications on patient outcome. Unfortunately, EPs have many mimickers, which can make the diagnosis challenging in certain cases. In this review, we aim to describe and illustrate sonographic findings of each type of EP, as well as present mimickers and various imaging pitfalls. We will clarify how to avoid potential misdiagnoses that could adversely affect patient outcomes. Lastly, we will briefly address management of each type of EP and discuss potential complications.

Potential imaging findings following assisted reproduction: complications and clinical implications

Recent rapid advances in assisted reproduction (ART) have led to global increase in usage of in vitro fertilization. This in turn has resulted in clinicians and imaging specialists encountering increase in complications associated with ART. The specialists dealing with infertility should be aware of potential complications associated with ART. Early diagnosis of these problems is based on clinician's suspicion and radiologist's awareness of these complications. Many of these conditions may be life threatening. Hence, early diagnosis and treatment of these complications can safeguard the fetal and maternal health.

Determination of Human Chorionic Gonadotropin in Postmortem Samples in Ectopic Pregnancies

Increased human chorionic gonadotropin levels (HCG) can be detected in femoral blood, bile, and vitreous humor collected during autopsy of pregnant women using a standard kit designed for living patients. In the study herein, the concentrations of HCG were measured in postmortem serum, vitreous, bile, cerebrospinal, and pericardial fluids in 4 cases of fatal ectopic pregnancy and 40 controls using a quantitative electrochemiluminescence immunoassay designed for living patients. No false-negative cases were identified in any of the analyzed samples in any of the ectopic pregnancy cases. No correlations were found between total HCG levels in postmortem serum and the other tested specimens. The results of this study would suggest that higher HCG in bile, vitreous, pericardial, and cerebrospinal fluids may confirm the existence of ectopic pregnancy and therefore identify other situations in which this hormone is increased, although gestational age cannot be reliably estimated using these values.

CT findings of omental pregnancy: a case report

Omental pregnancy is an extremely rare and dangerous form of ectopic pregnancy which can be very difficult to diagnose radiologically. We report the case of an 18-year-old girl with secondary omental pregnancy who was assessed by use of contrast-enhanced computed tomography (CT). For the first time, we report the contrast-enhanced CT features of omental pregnancy. Inhomogeneous mild enhancement was observed, which is different from other kinds of ectopic pregnancy, for which enhancement is often substantial. Possible reasons for the discrepancy are discussed, as also is differential diagnosis of omental pregnancy.

Hemoperitoneum from corpus luteal cyst rupture: a practical approach in emergency room

Corpus luteum cyst rupture with consequent hemoperitoneum is a common disorder in women in their reproductive age. This condition should be promptly recognized and treated because a delayed diagnosis may significantly reduce women's fertility and intra-abdominal bleeding may be life-threatening. Many imaging modalities play a key role in the diagnosis of acute pelvic pain from gynecological causes. Ultrasound study (USS) is usually the first imaging technique for initial evaluation. USS is used to confirm or to exclude the presence of intraperitoneal fluid but it has some limitations in the identification of the bleeding source. Contrast-enhanced computed tomography (CT) is the imaging modality which could be used in the acute setting in order to recognize gynecological emergencies and to establish a correct management. Magnetic resonance imaging (MRI) nowadays is the most useful technique for studying the pelvis but its low availability and the long acquisition time of the images limit its usefulness in characterization of acute gynecological complications. We report a case of a young patient with hemoperitoneum from hemorrhagic corpus luteum correctly identified by transabdominal USS and contrast-enhanced CT.

Radiological appearances of gynaecological emergencies

Background

The role of various gynaecological imaging modalities is vital in aiding clinicians to diagnose acute gynaecological disease, and can help to direct medical and surgical treatment where appropriate. It is important to interpret the imaging findings in the context of the clinical signs and patient's pregnancy status.

Methods

Ultrasound and Doppler are readily available in the emergency department, and demonstrate features of haemorrhagic follicular cysts, ovarian cyst rupture, endometriotic cysts and pyosalpinx. Adnexal torsion may also be identified using ultrasound and Doppler, although the diagnosis cannot be safely excluded based on imaging alone. Computed tomography (CT) is not routinely employed in diagnosing acute gynaecological complications. However due to similar symptoms and signs with gastrointestinal and urinary tract pathologies, it is frequently used as the initial imaging modality and recognition of features of gynaecological complications on CT is important.

Results

Although MRI is not frequently used in the emergency setting, it is an important modality in characterising features that are unclear on ultrasound and CT.

Conclusion

MRI is particularly helpful in identifying the site of origin of large pelvic masses, such as haemorrhagic uterine fibroid degeneration and fibroid prolapse or torsion. In this article, we review the imaging appearances of gynaecological emergencies in non-pregnant patients.

Teaching points

• Ultrasonography is easily accessible and can identify life-threatening gynaecological complications.

• Tomography scanners and computed radiography are not routinely used but are important to recognise key features.

• MRI is used for the characterisation of acute gynaecological complications.

• Recognition of the overlap in symptoms between gastrointestinal and gynaecological conditions is essential.

CT imaging findings of ruptured ovarian endometriotic cysts: emphasis on the differential diagnosis with ruptured ovarian functional cysts

Objective

The purpose of this study is to assess the prevalence of abnormal CT findings in patients with surgically proven ruptured endometriotic cysts, as compared with those abnormal CT findings of ruptured ovarian functional cysts.

Materials and Methods

This study included 13 retrospectively identified patients with surgically confirmed ruptured ovarian endometriotic cysts and who had also undergone preoperative CT scanning during the previous seven years. As a comparative group, 25 cases of surgically confirmed ruptured ovarian functional cysts were included. We assessed the morphologic features of the cysts and the ancillary findings based on CT.

Results

For the endometriotic cysts, the mean maximum cyst diameter was significantly larger than that of the functional cysts (70.1 mm versus 36.4 mm, respectively, p < 0.05). The endometriotic cysts frequently had a multilocular shape and a thicker cyst wall, as compared to that of functional cysts, and these differences were statistically significant. Among the ancillary findings, endometriotic cysts showed a significantly higher prevalence of loculated ascites, ascites confined to the pelvic cavity without extension to the upper abdomen, and peritoneal strandings and infiltrations (p < 0.05). Although 11 of the 25 cases of functional cysts showed active extravasation of contrast material at the ovarian bleeding site, only one of 13 cases of endometriotic cysts showed active extravasation.

Conclusion

The diagnosis of ruptured endometriotic cyst should be suspected for a woman in whom CT reveals the presence of multilocular or bilateral ovarian cysts with a thick wall and loculated ascites confined to the pelvic cavity with pelvic fat infiltrations.

Incidental detection of interstitial pregnancy on CT imaging

Ectopic pregnancy is a potentially life-threatening condition. Detection of ectopic pregnancy on CT images is rare. In this case, we describe the CT findings of interstitial pregnancy both before and after rupture. If CT images demonstrate the presence of a strong enhancing ring-like mass in the pelvis, ectopic pregnancy should be considered.