Emergency Gynecologic Imaging

Imaging findings of fibroid torsion in pregnancy: A case report

When our patient presented emergently to labor and delivery at 18 weeks pregnant with severe right abdominal pain, the common diagnoses (such as appendicitis, cholecystitis, etc.) were on the top of the differential. However, US and MRI revealed a rarer cause of her pain, a pedunculated fibroid. The most important question then became whether this fibroid had torsed, which would require surgical intervention to prevent life-threatening sequelae. Unfortunately, presurgical imaging diagnosis of fibroid torsion in pregnancy is difficult. We offer a description of our patient's imaging findings, which align with other radiologic descriptions of fibroid torsion in pregnancy in the literature, to contribute to the radiologist's diagnostic confidence in this patient population.

Color Doppler Imaging of Vascular Abnormalities of the Uterus

ABSTRACT

Many uterine abnormalities present clinically with bleeding encompassing a broad spectrum of patients from postmenopausal spotting to life-threatening hemorrhage. Color and spectral Doppler imaging of the pelvis is often the first crucial investigation used to quickly establish the correct etiology of the uterine bleeding and guide clinical decision making and patient management.

Pelvic inflammatory disease in the adolescent and young adult: An update

Pelvic inflammatory disease (PID) is an infection of the female upper genital tract that is typically polymicrobial with classic core involvement of Neisseria gonorrhoeae and/or Chlamydia trachomatis, though other endogenous flora from the vagino-cervical areas can be involved as well. It is often a sexually transmitted disease but other etiologic routes are also noted. A variety of risk factors have been identified including adolescence, young adulthood, adolescent cervical ectropion, multiple sexual partners, immature immune system, history of previous PID, risky contraceptive practices and others. An early diagnosis and prompt treatment are necessary to reduce risks of PID complications such as chronic pelvic pain, ectopic pregnancy and infertility. Current management principles of PID are also reviewed. It is important for clinicians to screen sexually active females for common sexually transmitted infections such as Chlamydia trachomatis and provide safer sex education to their adolescent and young adult patients. Clinicians should provide comprehensive management to persons with PID and utilize established guidelines such as those from the US Centers for Disease Control and Prevention (CDC).

ACR Appropriateness Criteria® Postmenopausal Acute Pelvic Pain

Acute pelvic pain is a common presenting complaint in both the emergency room and outpatient settings. Pelvic pain of gynecologic origin in postmenopausal women occurs less frequently than in premenopausal women; however, it has important differences in etiology. The most common causes of postmenopausal pelvic pain from gynecologic origin are ovarian cysts, uterine fibroids, pelvic inflammatory disease, and ovarian neoplasm. Other etiologies of pelvic pain are attributable to urinary, gastrointestinal, and vascular systems. As the optimal imaging modality varies for these etiologies, it is important to narrow the differential diagnosis before choosing the initial diagnostic imaging examination. Transabdominal and transvaginal ultrasound are the best initial imaging techniques when the differential is primarily of gynecologic origin. CT with intravenous (IV) contrast is more useful if the differential diagnosis remains broad. MRI without IV contrast or MRI without and with IV contrast, as well as CT without IV contrast may also be used for certain differential considerations. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Computed Tomography Imaging of the Acute Pelvis in Females

Sonography is the primary imaging modality for the evaluation of pelvic pain in female patients, especially if gynaecological pathology is suspected. However, computed tomography (CT) is frequently used in patients who present to emergency departments (and elsewhere) with otherwise nonspecific abdominal and pelvic pain and may be the first imaging modality to demonstrate an acute gynaecological abnormality. Computed tomography can also be used prospectively in selected patients to further evaluate findings initially identified on sonography, although to reduce radiation exposure, magnetic resonance imaging is being used more frequently in this situation. The purpose of this article is to discuss the spectrum of gynaecological findings of the acute female pelvis that may be identified on CT by the emergency radiologist and by the general radiologist, with a brief review of the imaging literature of each specific diagnosis.

Clinical characteristics and treatment outcomes of patients with tubo-ovarian abscess at a tertiary care hospital in Northern Taiwan

BACKGROUND/PURPOSE

Controversy exists regarding the need for surgical intervention in patients with tubo-ovarian abscess (TOA). This study was aimed at investigating the clinical characteristics and treatment outcomes in patients with TOA at a tertiary care hospital in Taiwan.

METHODS

The medical records of 83 patients who presented at the hospital with TOA between January 1, 2006, and December 31, 2007, were retrospectively reviewed. Outcomes of patients who received medical treatment alone or underwent surgical intervention were analyzed using univariate and logistic regression analyses.

RESULTS

Among the 83 patients with TOA, 13 patients (15.7%) underwent surgical intervention, and 70 patients (84.3%) received medical treatment alone. Significant variables related to surgical treatment in the univariate analysis were length of stay (short vs. long; t = -2.267, p = 0.026), department of admission (emergency room vs. outpatient department; χ(2) = 7.459, p = 0.006), number of live births (nulliparous vs. multiparous; χ(2) = 18.202, p = 0.001), and C-reactive protein (CRP) level (high vs. low; t = -2.250, p = 0.028). Logistic regression analysis performed to determine influential factors for surgical treatment showed that the operation odds ratio of three to four live births versus no live births was 33.995 (p = 0.043) and that of two live births versus no live births was 13.598 (p = 0.026).

CONCLUSION

Patients with TOA who underwent surgery had a longer duration of hospitalization. Among the patients who underwent surgical intervention, those admitted to the emergency room had higher CRP levels and were more likely to be multiparous.

[Gynecological emergencies: etiology and degree of gravity]

OBJECTIVE

To evaluate the type and the emergency degree of the pathologies met in gynecological emergencies.

METHODS

prospective study including 205 patients presented to the Emergency department of a maternity level 3 between the 2011 January 4 and February 15.

RESULTS

One hundred and ninety-four patients (95%) came from their own initiative. One hundred and eighty-one patients (88%) consulted for abdominal/pelvic or lumbar pain and or metrorragia. The mean age of the patients was of 31 ± 11 years and the average waiting time before being examined was of 84 ± 101 minutes. For 94 patients (46%), the diagnosis was an asymptomatic intra-uterine pregnancy in 41 cases or associated with minor symptoms. 21 patients (8.9%) consulted for menstruation with or without dysmenorrhea, 17 (8,3%) had a miscarriage, 14 (7%) a genital infection, 11 (5%) an ovarian pathology and eight (4%) an ectopic pregnancy or its follow-up. Seven patients had an axillary lymphocele or a breast tumor and four symptomatic myomas. Six patients presented with non-gynecological pathologies. In 23 cases (11%) no organic cause was found. Only 24 patients (12%) were hospitalized and nine (4.5%) operated.

CONCLUSION

Most of the patients consulted for minor obstetrical or gynecological pathologies without relation with the function of Emergency department. Ectopic pregnancy remains a rare event. Better information of the users on the significance of the urgency is desirable. Consultation of a referent physician before emergency services should be privileged.

Routine use of abdominopelvic ultrasonography in severe postpartum hemorrhage: retrospective evaluation in 125 patients

OBJECTIVE

The purpose of this study was to analyze the potential of abdominopelvic ultrasonography at the initial examination in women with severe postpartum hemorrhage.

STUDY DESIGN

One hundred twenty-five women were included in the study. The therapeutic approaches that were performed to stop the bleeding were evaluated for each category of ultrasonographic finding.

RESULTS

Seventy-one women (56.8%) had normal ultrasonography; 30 women (24%) had echogenic endometrial lining; 17 women (13.6%) had echogenic intrauterine mass, and 7 women (5.6%) had abdominopelvic free fluid effusion. Medical therapies allowed the bleeding to stop in 90.1% of women with normal ultrasonography, in 66.6% of women with echogenic endometrial lining, and in 29.4% of women with echogenic intrauterine mass. Pelvic embolization and surgery were performed less frequently in women who had normal ultrasonography results (9.9%) than in women with abnormal ultrasonography results (46.8%; P < .0001).

CONCLUSION

A normal abdominopelvic ultrasonography is associated with a favorable outcome and can be considered to be a predictor for the effectiveness of conservative, noninvasive therapeutic approaches.