Ultrasonography of adnexal causes of acute pelvic pain in pre-menopausal non-pregnant women

Combined delta neutrophil index and red blood cell distribution width as a new biomarker to predict endometriosis

Objective

The aim of this study was to evaluate the use of delta neutrophil index (DNI) in predicting endometriosis.

Material and Methods

A retrospective, case-control study was performed in a tertiary care center. DNI, red cell distribution width (RDW), and other blood parameters obtained from complete blood counts of 267 patients, consisting of 122 (45.7%) endometriosis patients with proven pathology reports of stages 3-4, and a control group of 145 women who underwent laparoscopy for simple ovarian cyst and/or diagnostic purposes and had normal histopathology, were compared. Receiver operating characteristic and logistic regression analyses were performed.

Results

DNI and RDW were significantly higher in endometriosis patients than in the control group (p=0.034 and p=0.003, respectively). Other parameters obtained from complete blood counts (leukocyte, neutrophil, lymphocyte, monocytes, and platelet counts and neutrophil-to-lymphocyte ratio), did not differ (p>0.05). For DNI, at a cut-off value of 0.025, area under the curve (AUC) was 0.572 and it was statistically significant [p=0.042; 95% confidence interval (CI): 0.503-0.642, sensitivity: 45.9%, specificity: 67.6%, Youden’s index: 0.135]. For RDW, AUC: 0.601 for cut-off value of 13.65 was statistically significant (p=0.004, 95% CI: 0.553-0.669, sensitivity: 50.8%, specificity: 67.6%, Youden’s index: 0.184). The logistic regression model established with the combined marker obtained by multiplying the DNI and RDW was statistically significant (p<0.001, Nagelkerke R2=0.72, 95% CI: 2.58-47.26, B: 2.40, negative predictive value: 78.6%, positive predictive value: 37.7%).

Conclusion

DNI, a new inflammatory marker, and RDW, known to be associated with inflammation, may be useful minimally invasive biomarkers of endometriosis.

Diagnostic value of the sonographic whirlpool sign in the diagnosis of ovarian torsion: A systematic review and meta-analysis

In this review, we investigated the diagnostic value of the sonographic "whirlpool sign" in identifying ovarian torsion. This was done by performing a search in PubMed, Scopus, Embase, Web of Science, CINAHL, and Google scholar. Additional search for the grey literature was made in EThOS.bl.uk, explore.bl.uk, opengrey.eu, greylit.org, and clinicaltrials.org. A total of eight studies were included in this meta-analysis. Sensitivity and specificity of whirlpool sign were extracted from the studies and computed into the Metadisc statistical software for pooled analysis. The whirlpool sign showed a high sensitivity and specificity for the diagnosis of ovarian torsion.

Adnexal Torsion: Review of Radiologic Appearances

Adnexal torsion is the twisting of the ovary, and often of the fallopian tube, on its ligamental supports, resulting in vascular compromise and ovarian infarction. The definitive management is surgical detorsion, and prompt diagnosis facilitates preservation of the ovary, which is particularly important because this condition predominantly affects premenopausal women. The majority of patients present with severe acute pain, vomiting, and a surgical abdomen, and the diagnosis is often made clinically with corroborative US. However, the symptoms of adnexal torsion can be variable and nonspecific, making an early diagnosis challenging unless this condition is clinically suspected. When adnexal torsion is not clinically suspected, CT or MRI may be performed. Imaging has an important role in identifying adnexal torsion and accelerating definitive treatment, particularly in cases in which the diagnosis is not an early consideration. Several imaging features are characteristic of adnexal torsion and can be seen to varying degrees across different modalities: a massive, edematous ovary migrated to the midline; peripherally displaced ovarian follicles resembling a string of pearls; a benign ovarian lesion acting as a lead mass; surrounding inflammatory change or free fluid; and the uterus pulled toward the side of the affected ovary. Hemorrhage and absence of internal flow or enhancement are suggestive of ovarian infarction. Pertinent conditions to consider in the differential diagnosis are a ruptured hemorrhagic ovarian cyst, massive ovarian edema, ovarian hyperstimulation, and a degenerating leiomyoma. Online supplemental material is available for this article. ^©RSNA, 2021.

Decidualization of an ovarian endometrioma complicated by a sigmoid fistula during pregnancy: a case report

BACKGROUND

During pregnancy, the discovery of adnexal masses remains frequent. Such masses are mostly benign. Ovarian endometrioma is a rare etiology. The diagnosis may be difficult in some situations, such as decidualization. It may be asymptomatic or result in complications for which magnetic resonance imaging is needed.

CASE PRESENTATION

We describe an unusual case of decidualization of an ovarian endometrioma complicated by a sigmoid fistula during a 7-week, 1-day pregnancy in a Arabic patient aged 38 years who developed acute pelvic pain with fever. She had a medical history of unexplored secondary dysmenorrhea. The diagnosis was suspected on the basis of magnetic resonance imaging findings. The management was based on surgery, during which exploration revealed a mass at the expense of the left ovary being very adherent and fistulized to the sigmoid. We performed adnexectomy followed by digestive ostomy. The result of pathological study with immunohistochemistry led to a diagnosis of decidualization of an ovarian endometrioma altered by infection.

CONCLUSION

Decidualization of an ovarian endometrioma can lead sometimes to unexpected complications. The decision to provide surgery must be made with caution without delaying treatment in the event of a deep suspicion of malignancy and/or complication. The particular and exceptional complication discovered in our patient is the fistulization to the sigmoid.

Usefulness of hematological parameters for differential diagnosis of endometriomas in adolescents/young adults and older women

BACKGROUND

Inflammatory processes have been considered to be involved in the pathogenesis of endometriosis. However, the predictive role of inflammatory hematological parameters in endometriosis is not clear. The aim of this study was to analyze the clinical value of hematologic markers in the differential diagnosis of endometriomas in younger and older reproductive age women.

MATERIALS AND METHODS

A retrospective chart review was done for 502 patients who underwent surgery: 267 with endometriomas (endometrioma group) and 235 with other benign adnexal cysts (control group). Patients were placed into subgroups as younger (adolescents/young adults, aged <25 years) and older (aged ≥25 years) women. Total and differential white blood cell count, neutrophil-to-lymphocyte ratio, platelet indices and platelet-to-lymphocyte ratio (PLR) were evaluated with receiver operating characteristic curve analysis for differential diagnosis of endometriomas.

RESULTS

The mean serum levels of PLR, plateletcrit (PCT), platelet count and CA-125 (reference range below 35 IU/mL) were significantly higher in the endometrioma group (p < 0.001). The area under the curve (AUC) for CA-125 was 0.85 [95% confidence interval (CI), 0.82-0.88] (p < 0.001) for the entire group. However, platelet count, PLR, and PCT showed poor discriminative ability for detecting endometriomas with AUC values of 0.59 (95% CI, 0.55-0.65, p < 0.001), 0.58 (95% CI, 0.53-0.63, p = 0.002) and 0.61 (95% CI, 0.56-0.66, p < 0.001), respectively. In age-stratified analysis, these platelet indices had also low diagnostic performance in both age groups.

CONCLUSIONS

Hematologic markers do not adequately differentiate ovarian endometriomas from other benign cysts in neither adolescents/young adults nor older women.

The role of ultrasound in the evaluation of acute pelvic pain in pregnancy and postpartum period: a review

PURPOSE OF REVIEW

Acute pelvic pain in pregnant and postpartum patients presents diagnostic and therapeutic challenges. Ultrasound remains the primary imaging modality of choice for assessing pregnant and postpartum women. The purpose of this review is to help practitioners ensure a correct diagnosis of acute pelvic pain in pregnancy and the postpartum period.

RECENT FINDINGS

This review describes the various causes and highlights the sonographic features and characteristics of acute pelvic pain in pregnancy and the postpartum period.

SUMMARY

Evaluation of acute pelvic pain in pregnancy and the postpartum period is challenging. Knowledge of the clinical settings and sonographic features of acute pelvic pain in pregnancy and the postpartum period can lead to accurate diagnosis and appropriate management of the condition.

Emergent ultrasound evaluation of the pediatric female pelvis

Ultrasound is the primary imaging modality of the pediatric female pelvis and is often requested to evaluate girls with pelvic or abdominal pain or abnormal bleeding. The US interpretation can help guide the clinician toward medical or surgical management. Here we discuss the normal US anatomy of the female pelvis and illustrate, through case examples, conditions encountered when performing emergent pelvic US for common and uncommon clinical scenarios.

Pattern of benign ovarian cysts in Qatari women

Objective: To study the age distribution, histopathological types, lateral distribution and surgical interventions performed for benign ovarian cysts in Qatari women undergoing surgical intervention for an ovarian cyst. Design: A retrospective descriptive study. Setting: Obstetrics and Gynecology Department, Al-Ahli Hospital, Doha, Qatar. Patients and methods: Data were collected retrospectively from clinical records of Qatari women who underwent surgical intervention from 1 January 2013 to 31 December 2015 at Al-Ahli Hospital for an ovarian or paraovarian cyst. The age distribution, frequencies and percentages were calculated for each type of ovarian cyst and the side of the ovary involved was recorded. Results were statistically analysed by IBM SPSS, version 23. Results: A total of 81 women had an ovarian or paraovarian cyst. Age ranged from 16 to 58 years. The maximum number of women were in the 21–30-year-old age group. Benign epithelial cysts were found to be most common (32; 39.5%), of which the majority were for endometriotic cysts (15; 18.5%), serous cystadenoma (13; 16%) and mucinous cystadenoma (4; 4.9%). This was followed by physiological cysts (26; 32.1%), which included corpus luteal cysts (15; 18.5%) and simple follicular cysts (11; 13.6%). The other categories of ovarian tumours were for mature cystic teratoma (14; 17.3%), benign sex cord–stromal tumours (1; 1.2%) which included stromal cell tumours (1; 1.2%), borderline ovarian tumour (1; 1.2%) and paraovarian cysts (7; 8.6%). There was bilateral ovarian involvement in 9 cases (11.1%) and unilateral involvement in 72 (88.9%). The right ovary was involved in more cases (39; 48.1%), than for the left ovary (33; 40.7%). Conclusion: Benign epithelial tumours were found to be the most common type of ovarian tumour in Qatari women. Endometriotic cysts followed by serous cystadenomas were the most common types of benign epithelial tumours. The right ovary was found to be involved in more cases than the left ovary.

Acute abdominal pain caused by hematometra in an adolescent female: a case report

Background

Hematometra is a pathologic collection of blood in the uterus. It is a rare condition that is most commonly associated with congenital anomalies or prior surgical procedures causing an obstruction of the genitourinary outflow tract. We present an unusual case of hematometra in a healthy and active adolescent female with no prior risk factors. This is a rare and important case report due to the complexity of diagnosis when a young female presents with an acute abdomen. In addition, for a patient who presents with no prior risk factors for hematometra, such as in our patient, the diagnosis and workup may become overly complicated, adding strain to patient care and health care cost. To the best of our knowledge and based on an extensive literature search, there has not been a reported case of hematometra in an adolescent female without any aforementioned risk factors.

Case presentation

Our patient is a healthy 18 year-old white woman with no significant prior medical or surgical history. Her only medication was depot medroxyprogesterone acetate use for contraception. She presented to a local emergency department with acute abdominal pain, accompanied by emesis and nausea. Workup with ultrasonography showed uterine distention most likely caused by hematometra, although no obvious cause was noted. She was treated with dilation and curettage; she was also advised to discontinue depot medroxyprogesterone acetate use. She was symptom free without recurrence of hematometra at 6-month follow-up.

Conclusions

Due to the high prevalence of abdominal pain, this case report has a wide breadth of implications for health care providers ranging from general family practitioners to emergency room physicians and obstetricians/gynecologists. This case report provides potential future advancement in management and differential diagnosis in adolescent females presenting with acute abdominal pain. In addition, the use of depot medroxyprogesterone acetate contributing to or causing hematometra cannot be ruled out in our patient and warrants further investigation.