Adnexal arteriovenous malformation presenting with spontaneous massive haemoperitoneum

Arteriovenous malformations (AVMs) are vascular anomalies composed of a tangle of abnormal vessels in which one or more feeding arteries are directly connected to one or more draining veins via a nidus with no intervening capillary bed. The adnexa are particularly rare sites for the formation of such malformations. Here, we present the case of a middle-aged woman who presented with spontaneous massive haemoperitoneum occurring as a result of a ruptured adnexal AVM. The diagnosis was suspected on transabdominal sonography and confirmed on CT angiography. The patient was shifted to the interventional radiology suite for an urgent angioembolisation following which she improved haemodynamically and her symptoms resolved. The case highlights the fact that although exceedingly rare, gonadal AVMs are an important cause of spontaneous intraperitoneal bleeding. Diagnostic and interventional radiology play an important role in the early and accurate diagnosis of this entity, and angioembolisation can be lifesaving in such patients.

Transvaginal power Doppler ultrasound in pelvic congestion: A prospective comparison with transuterine venography

Purpose: Pelvic congestion is diagnosed by transuterine venography, an invasive procedure requiring sedation and irradiation. Ultrasound may be an alternative but is hindered by slow flow within pelvic veins. In an attempt to counter this, we investigated the possible role of transvaginal power Doppler ultrasound.

Material and Methods: 42 women with a clinical suspicion of pelvic congestion underwent transvaginal ultrasound. Adnexal veins were examined and a congestion score established. Planimetric measurements of adnexal vessels were obtained using power Doppler ultrasound, and uterine and ovarian morphology noted. All women then underwent transuterine venography and agreement with the ultrasound congestion score and morphologic features was determined.

Results: There was a trend towards weak positive correlation between ultrasound and venography congestion scores ( r = 0.29, p = 0.06). However, agreement between scores was poor on an individual basis (95% limits of agreement, −3.9 to +2.7). Planimetric power Doppler assessments of adnexal vascularity were unrelated to venographic congestion. Instead, there was correlation between the number and diameter of ovarian follicles and venographic congestion: women with congestion tended to have significantly more (0.04) and smaller follicles ( p = 0.001).

Conclusion: There was poor individual agreement between ultrasound and venographic estimates of congestion. However, there was a direct relationship between venographic congestion score and ovarian morphology.

Allograft en bloc vagino-utero-ovarian avascular transplant versus autograft implantation in rats

OBJECTIVES

The aim of this study was to compare the results of an allograft en bloc vagino-uteroovarian avascular transplant with those of autograft implantation in rats.

MATERIALS AND METHODS

Thirty-four inbred adult virgin female Albino rats (age range, 10 - 12 weeks) were divided into 2 groups: the control group (autograft, n=11) and the study group (en bloc vagino-utero-ovariectomy, n=23). In the study group, the uterus and adnexa and the ovaries of the donor rat were transplanted to the recipient animal. Twenty-five to 30 days after that procedure, all rats were killed, and the samples were assessed histopathologically. No immunosuppressive drugs were used.

RESULTS

Ten rats died during the postoperative period. In 16 rats, the transplanted system had survived completely at the conclusion of the study. In each of the study groups, complete survival of the uterus and ovaries was noted in 8 rats (34.8% in the study group and 72.8% in the control group). In all rats except 1, histopathologic examination did not reveal any signs of the classic criteria for tissue rejection reaction. The lack of revascularization, nonspecific signs of inflammation, and the presence of large granular lymphocytes and natural killer cells were reported.

CONCLUSIONS

Our data indicated that the outcome of both allograft and homograft avascular en bloc transplant of vagino-utero-ovariectomy in rats was successful, and that immunologic rejection did not seem to have an important role in those procedures.

Three-dimensional power Doppler vascular network assessment of adnexal masses: intraobserver and interobserver agreement analysis

OBJECTIVE

The purpose of this study was to assess intraobserver and interobserver agreement for tumor vascular network evaluation as assessed by 3-dimensional (3D) power Doppler sonography for discriminating benign from malignant adnexal masses.

METHODS

Stored 3D power Doppler angiographic volume data from 39 women with a diagnosis of a vascularized adnexal mass who were evaluated and treated at our institution were retrieved from our database for analysis. Two different examiners (observer A, with 6 years of experience in 3D sonography; and observer B, with 1 year of experience) reviewed 3D sonograms blinded to each other. Three-dimensional vascular network reconstruction was done with surface rendering in the color mode. Malignancy was considered in the presence of at least 2 of the following: irregular branching, vessel caliber changes, microaneurysms, and vascular lakes. A definitive histologic diagnosis was obtained in all cases. Intraobserver and interobserver agreement rates were estimated by calculating the kappa index.

RESULTS

Twenty (51%) tumors were malignant, and 19 (49%) were benign. Intraobserver agreement was good for observer A (kappa = 0.69) and moderate for observer B (kappa = 0.54). Interobserver agreement was moderate (kappa = 0.49).

CONCLUSIONS

We found intraobserver and interobserver agreement to be moderate for 3D power Doppler assessment of the vascular network in adnexal masses.

Intraobserver and interobserver reproducibility of 3-dimensional power Doppler vascular indices in assessment of solid and cystic-solid adnexal masses

OBJECTIVE

The purpose of this study was to assess the intraobserver and interobserver reproducibility of 3-dimensional (3D) power Doppler angiography-derived vascular indices in evaluation of vascularized solid and cystic-solid adnexal masses.

METHODS

Stored 3D power Doppler angiographic volume data from 12 consecutive women with a diagnosis of a complex adnexal mass (6 cystic-solid and 6 solid) evaluated and treated at our institution were retrieved from our database for analysis. Two examiners performed the calculations blinded to each other. Calculations were performed offline in a computer using Virtual Organ Computer-Aided Analysis software (plane A, 9 degrees rotation step) to assess volume and vascularization (vascularization index, flow index, and vascularization-flow index) from solid areas within the tumor. In all cases, a definitive histologic diagnosis was obtained. Intraobserver and interobserver reproducibility was assessed by calculating the intraclass and interclass correlation coefficients for each index.

RESULTS

All tumors proved to be malignant after surgical removal. Intraobserver reproducibility for both examiners and interobserver reproducibility were high for all indices (interclass correlation coefficient > 0.95).

CONCLUSIONS

Three-dimensional power Doppler angiography is a reproducible technique for offline assessment of stored 3D volume data of vascularized adnexal masses.

Sonographic findings of ovarian torsion in children

BACKGROUND

The clinical diagnosis of ovarian torsion is challenging and findings on pelvic sonography can be pivotal in making the correct diagnosis.

OBJECTIVE

To determine the sonographic characteristics in children of surgically and pathologically proven ovarian torsion.

MATERIAL AND METHODS

We performed a retrospective review of the sonograms and medical records of 41 patients with surgically and pathologically proven ovarian torsion at a pediatric hospital between 1994 and 2005. All sonograms were reviewed retrospectively by two pediatric radiologists with attention to the size, echotexture, location, presence of peripheral round cysts, and evidence of flow on Doppler sonography within the torsed ovary. The amount of free pelvic fluid was also recorded.

RESULTS

The most common sonographic finding of ovarian torsion was an enlarged ovary/adnexal mass. All torsed adnexa were larger than the normal contralateral ovary, with the median volume 12 times that of the normal contralateral side. The majority (61%, n = 25) of the torsions occurred on the right. Color flow, either venous or arterial, was present in 62% (n = 21/34) of the torsed ovaries for which flow on Doppler sonography was documented. In 63% of the torsed ovaries (n = 26), the torsed adnexa appeared heterogeneous. Ovarian or para-ovarian pathology that may have acted as a potential lead point was present in 55% (n = 24) of torsed ovaries. The volume ratio of the torsed to normal ovary can predict the presence of an ovarian mass within the torsed ovary. In 70% of torsed ovaries with a volume ratio greater than 20, an ovarian mass was present, and in approximately 90% of those with a volume ratio less than 20, an internal mass was absent.

CONCLUSION

An enlarged heterogeneous appearing ovary is the most common finding in ovarian torsion. The presence or absence of flow by Doppler sonography is not helpful in the diagnosis. The volume ratio of the torsed to the normal ovary can predict the presence of an internal mass within the torsed adnexa.

Three-dimensional power Doppler vascular sampling: a new method for predicting ovarian cancer in vascularized complex adnexal masses

OBJECTIVE

The purpose of this study was to explore the role of a new concept ("vascular sampling") as a third step to discriminate benign and malignant lesions in B-mode and color Doppler sonographically suggestive adnexal masses.

METHODS

Forty-five women (mean age, 52.3 years; range, 17-82 years) with the diagnosis of complex adnexal masses on B-mode sonography were evaluated using 3-dimensional power Doppler sonography. Four women had bilateral masses. After a morphologic reevaluation was done, color pulsed Doppler sonography was used to obtain flow velocity waveforms, and velocimetric indices were calculated (resistive index, pulsatility index, and peak systolic velocity). Thereafter, 3-dimensional power Doppler sonography was used to assess vascularization of highly suggestive areas (gross papillary projections, solid areas, and thick septations), meaning a focused assessment ("sampling") of a suggestive area of the tumor. With a virtual organ computer-aided analysis program, vascular indices (vascularization index, flow index, and vascular flow index) were automatically calculated. A definitive histologic diagnosis was obtained in each case.

RESULTS

Forty masses (82%) were malignant and 9 (18%) were benign. Morphologic evaluation revealed 10 (20%) unilocular solid masses, 20 (41%) multilocular solid masses, and 19 (39%) mostly solid masses. Blood flow was found in all cases. Median vascularization index (15.5% versus 8.2%; P = .002), flow index (33.6 versus 20.8; P = .007), and vascular flow index (5.2 versus 2.3; P = .001) were significantly higher in malignant tumors. No differences were found in resistive index (0.43 versus 0.45; P = .770), pulsatility index (0.62 versus 0.65; P = .694), and peak systolic velocity (15.6 versus 12 cm/s; P = .162).

CONCLUSIONS

Three-dimensional power Doppler vascular sampling seems to be a promising tool for predicting ovarian cancer in vascularized complex adnexal masses. It could be better than conventional color pulsed Doppler imaging.

Power Doppler vascularity index for predicting malignancy of adnexal masses

OBJECTIVE

To assess the performance of a power Doppler vascularity index in the preoperative diagnosis of ovarian malignancy.

METHODS

Adnexal masses (n = 101) were examined prospectively with power Doppler ultrasonography before surgical treatment. The tumor vascularity index (power Doppler index, PDI) was determined by quantification of the number of pixels in a defined region of interest according to the formula: number of colored pixels/(total number of pixels minus the number of pixels in the fluid or avascular areas). It was estimated on selected frames of the tumors using an in-house color-quantifying program added to MATLAB 6.0 software. Inter- and intraobserver reproducibilities of PDI assessment were evaluated. Intratumoral blood flow velocity waveforms were obtained to determine the lowest resistance index (RI). A subjective visual score of power Doppler signals in the tumor was used to classify it as having low, moderate or high vascularity. The discriminatory ability of this score was compared to that of RI and PDI measurement.

RESULTS

Histology identified 23 malignant and 78 benign lesions. The PDI was considerably higher in malignant than in benign lesions (0.34 +/- 0.04 vs. 0.12 +/- 0.06; P < 0.001). The intra- and interobserver variabilities of PDI were low (intraclass correlation coefficients of 0.99 and 0.97, respectively). The PDI cut-off value to differentiate malignant from benign tumors was set at 0.265 (26.5% of the tumor being colored). Using this cut-off, sensitivity and specificity were 100% (95% CI, 87.8-100.0) and 97.4% (95% CI, 91.0-99.7) compared to 78.3% (95% CI, 56.3-92.5) and 83.1% (95% CI, 72.9-90.7) for RI (cut-off value of 0.53) and 78.3% (95% CI, 56.3-92.5) and 94.9% (95% CI, 87.4-98.6) for visual scoring. Logistic regression demonstrated that PDI was the best parameter for differentiating between malignant and benign tumors.

CONCLUSION

The power Doppler vascularity index obtained using customized color quantifying software has high diagnostic value in discriminating between benign and malignant adnexal masses.

Spontaneous disappearance of a normal adnexa associated with a contralateral polycystic-appearing ovary

BACKGROUND

Absence of the adnexa may be congenital or acquired. However, the etiology is often uncertain.

CASE

A 27-year-old woman presented with a 3-year history of subfertility. Her irregular menstruation was associated with acne vulgaris, alopecia, and elevated body mass index. Transvaginal ultrasonography of the pelvis showed a normal uterus, a normal right ovary, but a polycystic-appearing left ovary. A hysterosalpingogram demonstrated a normal uterine cavity, prompt filling and spilling of contrast material from the left fallopian tube, but no filling on the right. Subsequent laparoscopy showed an unexpected absence of right adnexa and presence of a solitary rounded free-floating mass enshrouded in the omentum. She did not have a history of abdominal pain or surgery.

CONCLUSION

The evidence suggests that the patient might have had an asymptomatic infarction of the right adnexa.

Complex pelvic mass as a target of evaluation of vessel distribution by color Doppler sonography for the diagnosis of adnexal malignancies: results of a multicenter European study

OBJECTIVE

To compare the diagnostic accuracy of gray scale sonography and color Doppler imaging in the differential diagnosis of adnexal malignancies from benign complex pelvic masses in a multicenter prospective study.

METHODS

The study was performed as a collaborative work at 3 European university departments of obstetrics and gynecology. A total of 826 complex pelvic masses on which transvaginal sonography and evaluation of cancer antigen 125 plasma concentrations were performed before surgical exploration were included in the study. The scanning procedure was the same in the 3 institutions. An adnexal mass was first studied in gray scale sonography, and a probable histologic type was predicted. Second, solid excrescences or solid portions of the tumor were evaluated for vascular flow with color Doppler sonography (conventional or power). A mass was graded malignant if flow was shown within the excrescences or solid areas and benign if there was no flow. The overall agreement between the test result and the actual outcome was calculated by kappa statistics.

RESULTS

Color Doppler evaluation was more accurate in the diagnosis of adnexal malignancies in comparison with gray scale sonography (kappa = 0.82 and 0.65, respectively) because of significantly higher specificity (0.94 versus 0.84; P < .001). The evaluation of the cancer antigen 125 plasma concentration did not seem to increase the accuracy of either method.

CONCLUSIONS

The evaluation of vessel distribution by color Doppler sonography in complex adnexal cysts seems to increase the diagnostic accuracy of gray scale sonography in the detection of adnexal malignancies in a large study population.

Ovarian bivalving after detorsion

OBJECTIVE

To assess the efficacy of a new technique, ovarian bivalving, on facilitating adnexal recovery after adnexal torsion.

DESIGN

Retrospective case series.

SETTING

Academic medical center.

PATIENT(S)

Five patients undergoing conservative surgical management of adnexal torsion at the Children's Hospital, Boston, Massachusetts, from May 1999 to April 2000.

INTERVENTION(S)

Performance of ovarian bivalving after untwisting of adnexal torsion.

MAIN OUTCOME MEASURE(S)

Sonographic appearance of adnexa after ovarian bivalving, and postoperative complications.

RESULT(S)

After surgical treatment, four of five patients undergoing untwisting of adnexa and ovarian bivalving had sonographically confirmed normal follicular function; in three of five cases, it was confirmed with Doppler arterial flow. There were no postoperative complications.

CONCLUSION(S)

After the untwisting of ischemic adnexa, ovarian bivalving is an effective technique to decrease ovarian intracapsular pressure, increase arterial perfusion, and facilitate adnexal reperfusion and recovery.

CT and MR imaging features of adnexal torsion

In adnexal torsion, the ovary, ipsilateral fallopian tube, or both twist with the vascular pedicle, resulting in vascular compromise. Unrelieved torsion is likely to cause hemorrhagic infarction as the degree of arterial occlusion increases. Therefore, early diagnosis is important to preserve the affected ovary. Adnexal torsion commonly accompanies an ipsilateral ovarian neoplasm or cyst but can also occur in normal ovaries, usually in children. Although ultrasonography is typically the initial emergent examination, computed tomography (CT) and magnetic resonance (MR) imaging may also be useful diagnostic tools. Common CT and MR imaging features of adnexal torsion include fallopian tube thickening, smooth wall thickening of the twisted adnexal cystic mass, ascites, and uterine deviation to the twisted side. Uncommon imaging findings in adnexal torsion that are specific to hemorrhagic infarction include hemorrhage in the thickened fallopian tube, hemorrhage within the twisted ovarian mass, and hemoperitoneum. Additional imaging findings that can suggest hemorrhagic infarction include eccentric smooth wall thickening exceeding 10 mm in a cystic ovarian mass converging on the thickened fallopian tube and lack of contrast enhancement of the internal solid component or thickened wall of the twisted ovarian mass. Early diagnosis can help prevent irreversible structural damage and may allow conservative, ovary-sparing treatment.

Ovarian and adnexal torsion: spectrum of sonographic findings with pathologic correlation

OBJECTIVE

To determine the spectrum of sonographic findings on gray scale and color Doppler sonography in a series of pathologically proven cases of ovarian and adnexal torsion.

METHODS

The study population included 15 patients with surgical confirmation of ovarian or adnexal torsion, or both, who underwent sonographic examination before surgery. All sonograms were reviewed retrospectively.

RESULTS

Gray scale abnormalities included the following: complex masses in 11 (73%) of 15 patients, cystic masses in 3 (20%), and a solid mass in 1 (7%). Cul-de-sac fluid was present in 13 (87%) of 15 patients. Adnexal neoplasms were present in 4 (27%) of 15 (1 granulosa cell tumor and 3 dermoid cysts) on pathologic examination. Doppler findings were abnormal in 14 (93%) of 15 patients and normal in 1 (7%). Abnormal Doppler findings included no arterial and no venous flow in 6 (40%) of 15, decreased venous flow with no arterial flow in 5 (33%), decreased venous flow and decreased arterial flow in 2 (13%), and decreased arterial flow with no venous flow in 1 (7%). Small amounts of cul-de-sac fluid were present in 13 (87%) of 15 patients.

CONCLUSIONS

The diagnosis of ovarian and adnexal torsion remains challenging. It cannot be based solely on the absence or presence of flow on color Doppler sonography, because the presence of arterial or venous flow does not exclude the diagnosis of adnexal torsion. Comparison with the morphologic appearance and flow patterns of the contralateral ovary will aid in diagnosis.

Transvaginal color Doppler assessment of venous flow in adnexal masses

OBJECTIVE

To analyze the usefulness of transvaginal color Doppler assessment of venous flow in the differential diagnosis of adnexal masses.

MATERIAL AND METHODS

Ninety-one consecutive patients (mean age: 46.6 years, range: 16-81 years) diagnosed as having an adnexal mass were evaluated by transvaginal color Doppler sonography prior to surgery. Color Doppler was used to detect and analyze the flow velocity waveform from arterial and venous blood flow within the tumor. For arterial signals the resistance index and peak systolic velocity, and for veins the maximum venous flow velocity, were calculated. Receiver operator characteristic curves were plotted to determine the best venous flow velocity cut-off. According to our previous study using arterial Doppler, a tumor was considered as malignant when flow was detected and the lowest resistance index was < or = 0.45. Using venous Doppler a mass was considered as malignant when flow was detected and the venous flow velocity was > or = the best cut-off found on the receiver operator characteristic curve. Definitive histopathological diagnosis was obtained in all cases. Sensitivity, specificity, positive predictive value and negative predictive value for B-mode morphology (evaluation performed according to Sassone's scoring system), arterial Doppler, venous Doppler, and a combination of both arterial and venous Doppler were calculated.

RESULTS

Twenty-five masses (27.5%) were malignant and 66 (72.5%) benign. Arterial and venous flow was found more frequently in malignant than in benign masses (92% vs. 41% (P < 0.001) and 72% vs. 21% (P < 0.001), respectively). The resistance index was significantly lower in malignant tumors (0.42 vs. 0.60, P = 0.0003). No differences were found in peak systolic velocity. Venous flow velocity was significantly higher in malignant masses (18.1 cm/s vs. 8.9 cm/s, P = 0.0006). The best cut-off of venous flow velocity was 10 cm/s. Sensitivity, specificity, positive predictive value and negative predictive value for morphology, arterial Doppler, venous Doppler, and the combination of both arterial and venous Doppler were 92%, 71%, 45%, 96%; 76%, 95%, 87%, 91%; 68%, 94%, 81%, 89%; and 88%, 91%, 79%, 95%, respectively.

CONCLUSIONS

Our results indicate that preoperative evaluation by venous flow assessment of adnexal masses may be useful to discriminate between malignant and benign tumors.

Three dimensional ultrasound and power doppler in assessment of uterine and ovarian angiogenesis: a prospective study

AIM

To determine whether three-dimensional power Doppler can improve the recognition of pelvic tumor morphology and angiogenesis.

METHODS

Using this technique we analyzed 180 adnexal masses and 110 uterine lesions. Tumor volume, morphology, and vascularity were evaluated in each patient. Irregular and randomly dispersed vessels with complex branching depicted by comprehensive three dimensional display were suggestive of pelvic malignancy, while linear-like vascular morphology, single vessel arrangement and regular branching were typical for benign structures.

RESULTS

Addition of qualitative analysis of vascular architecture of adnexal tumor to morphological parameters reached 96.15% sensitivity and 98.73% specificity. When endometrial lesions were prospectively analyzed, sensitivity and specificity were 91.67% and 98.49%, respectively. Because the lowest positive predictive value of 16.67% was obtained for myometrial lesions, this method should not be advised for their eva luation.

CONCLUSION

Good results achieved by three dimensional ultrasound can be explained by improved recognition of the pelvic lesion anatomy, characterization of the surface features, detection of the tumor infiltration, and precise depiction of the size and volume. Three dimensional power Doppler imaging can detect structural abnormalities of the malignant tumor vessels, such as arteriovenous shunts, microaneurysms, tumoral lakes, disproportional calibration, coiling, and dichotomous branching. Therefore it enhances and facilitates the morphologic and functional evaluation of both benign and malignant pelvic tumors.

The effects of twisted ischaemic adnexa managed by detorsion on ovarian viability and histology: an ischaemia-reperfusion rodent model

This prospective controlled follow-up study was designed to examine the effects of adnexal torsion on long-term ovarian histology and radical scavenger (FRS) activity, and subsequent viability following the detorsion of twisted ischaemic adnexa, in a primate centre of a university clinic. Adnexal torsion/occlusion was created by twisting the adnexa three times and fixing on to the side wall or by applying vascular clips in cycling female rats at 70 days of age. Following an ischaemic period of 4 to 36 h, the twisted adnexas were surgically removed and fixed. In the second group of rats, following the above ischaemic periods, the torsion/occlusion were relieved by detwisting or removing the vascular clips. Then the animals were reperfused for a week and adnexas were extirpated. After both ischaemia and reperfusion, the removed adnexas were examined histologically and tissue concentrations of glutathione peroxidase, superoxide dismutase, catalase and glutathione were determined. Regardless of the ischaemia time, all the twisted adnexas were black-bluish in appearance. Despite the gross ischaemic-haemorrhagic features, histological sections revealed negligible changes, with intact ovarian structure similar to controls in 4-24 h groups. Though decreased compared with controls, the change in tissue concentrations of FRS was not significant in 4-24 h groups. Only the 36 h group showed prominent congestion on all sections and a significant decrease in all radical scavenger concentrations studied. While no long-term reperfusion injury was observed histologically in 4-24 h groups, the 36 h group ended with adnexal necrosis. Our findings support the importance of early diagnosis and conservative surgical management (detorsion) in adnexal torsion. Lack of histological changes and unimpaired FRS metabolism are consistent with the recent data that vascular compromise is caused by venous or lymphatic stasis in early torsion and that adnexal integrity is not correlated with gross ischaemic appearance, thus providing evidence of adnexal resistance against ischaemia.

Doppler flow characteristics in patients with pelvic inflammatory disease: responders versus nonresponders to therapy

PURPOSE

The objective of this retrospective study was to evaluate the role of Doppler flow studies in predicting the response to antibiotic treatment in patients with pelvic inflammatory disease (PID).

METHODS

The resistance indices in pelvic masses of 24 patients with clinical diagnoses of PID were analyzed.

RESULTS

Twelve patients responded favorably to antibiotic treatment (the conservative treatment group), while the other patients showed no clinical improvement and underwent surgery (surgical treatment group). The mean resistance index in the conservative treatment group was significantly higher (0.60 +/- 0.15) than that in the surgical treatment group (0.52 +/- 0.08; p < 0.05).

CONCLUSIONS

In keeping with hyperemia of inflammation, fallopian arterial resistance seems to decrease with the severity of PID.

Preoperative diagnosis of primary fallopian tube carcinoma

INTRODUCTION

Transvaginal color and pulsed Doppler can detect areas of neovascularization within the tubal carcinoma and can distinguish it from other benign adnexal pathology. SUBJECTS AND METHODS. During a 7-year period eight cases of Fallopian tube carcinoma were detected using transvaginal color and pulsed Doppler.

RESULTS

Transvaginal sonography revealed complex, sausage-shaped, and/or cystic structures in the adnexal region. Additional color Doppler examination depicted low vascular impedance (RI ranged from 0.29 to 0.40). Histopathology reported different types of Fallopian tube carcinoma.

CONCLUSION

Transvaginal color Doppler may aid in diagnosis of Fallopian tube malignancy more reliably than using other costly diagnostic procedures.

Doppler findings in chronic ectopic pregnancy: case report

Chronic ectopic pregnancy is an uncommon form of tubal pregnancy manifested as a pelvic mass with minimal symptoms and a low or absent titer of human chorionic gonadotropin. For this reason, most of the reported cases have been diagnosed only after explorative laparotomy. The value of Doppler ultrasonography for preoperative diagnosis of this entity has not yet been established. We report on a 36-year-old patient who was admitted for intermittent right lower quadrant abdominal pain of 3 months' duration, and a right adnexal mass found on pelvic examination. On Doppler ultrasonography, a right complex adnexal mass was demonstrated, characterized by extensive external vascularization, aberrant vessels and arteriovenous shunting, but with no internal blood flow. Explorative laparotomy revealed a right tubal mass adherent to the omentum, and covered by numerous enlarged and tortuous blood vessels originating in the omentum. Pathological examination of the mass revealed a chronic ectopic pregnancy. The possible contribution of Doppler-specific characteristics for the diagnosis of chronic ectopic pregnancy is described and discussed.

Gray scale sonography, subjective evaluation of the color Doppler image and measurement of blood flow velocity for distinguishing benign and malignant tumors of suspected adnexal origin

OBJECTIVE

To compare the capacity of transvaginal Doppler ultrasound examination with that of gray scale sonography as an aid in distinguishing benign and malignant pelvic tumors of suspected adnexal origin.

STUDY DESIGN

One hundred and fifty-one women scheduled for laparotomy or laparoscopic surgery because of a pelvic mass of suspected adnexal origin underwent ultrasound examination including color and spectral Doppler techniques within 8 days preceding the operation. Based on the gray scale ultrasound image, each tumor was classified as being either a unilocular cyst, a multilocular cyst, a unilocular cyst with solid parts, a multilocular cyst with solid parts or a solid tumor. Tumor vascularization was visualized with the color Doppler technique, each tumor being characterized by the color content of the scan, as rated subjectively on a visual analogue scale ('tumor color score'). Blood flow velocity waveforms were obtained by placing the Doppler gate over the colored area with the tumor. The blood flow velocity waveform with the highest time averaged maximum velocity was used to characterize the tumor . The results of gray scale imaging and Doppler ultrasound examination were compared with the histology of the specimen.

RESULTS

Ultrasound morphology correctly identified all the malignant tumors, with a false-positive rate of 61%; none of the 49 unilocular or multilocular cysts without solid parts was malignant, whereas 24% (24/102) of the tumors with solid components were. Among multilocular cysts with solid parts, both tumor color scores and time average maximum blood flow velocities were significantly higher in malignant than in benign tumors, but among solid tumors there was complete overlap in Doppler results between the malignant and benign subgroups. Using Doppler examination to discriminate between benign and malignant multilocular cysts with solid parts and ultrasound morphology for differentiation of the remaining tumors, all the malignancies in the study were detected with a false-positive rate of 32 or 38% depending on which Doppler variable was used.

CONCLUSION

The present technique of Doppler ultrasound examination is helpful only in the differential diagnosis of multilocular cysts with solid parts. Therefore, the degree to which Doppler examination can contribute to the differential diagnosis of pelvic tumors will depend on the proportion of multilocular cysts with solid parts in the population studied: the greater this proportion, the greater the potential of the Doppler examination to improve diagnostic accuracy.

Adnexal infarction after conservative surgical management of torsion of a hyperstimulated ovary

OBJECTIVE

To report a case of postoperative necrosis after conservative management of torsion of a hyperstimulated ovary.

DESIGN

Case report and literature review.

SETTING

Tertiary care center.

PATIENT

Infertility patient undergoing IVF-ET.

INTERVENTIONS

Detorsion followed by unilateral salpingo-oophorectomy 2 days later.

MAIN OUTCOME MEASURE

Postoperative course.

RESULTS

Postoperative necrosis after detorsion.

CONCLUSIONS

Postoperative necrosis is an uncommon but serious complication of conservative surgical management of adnexal torsion.

[Removal of the uterus and adnexa and use of low-molecular weight heparin]

Histological changes of ligated vasa ovarica, uterina, plica lata, mesosalpinx, mesovarium etc. were studied in 30 women. Thrombus formation, damage of the vessel wall, endothelial cell and tissue bleeding was observed after 30 min. We resected the ligated stumps during the operation, before operation an injection of LMWH was given. No complete, typical occlusive thrombi developed near the ligature. In 3 cases we found evidence of parietal thrombus formation made up of platelets in the art. uterina (10.0%) and in 4 cases in veins, and in a few cases fibrin was present (13.3%). These changes were found in the same number in the vasa ovarica. LMWH reduced the vascular, endothelial damage and the incidence of tissue bleeding. Clinical gynecological experience suggests their safety and effectiveness in thromboprophylaxis. The rapid and direct obliteration of the vascular lumen is due to proliferation of tissue fibroblasts and muscle cells, no bleeding occurred after demarcation of the distal stumps and. LMWH significantly reduces intravasal changes by important intraoperative reactions against thromboplastin generation and haemostasis and can completely replace standard heparin in gynecological prophylaxis.

The value of transvaginal color Doppler in the assessment of pelvic inflammatory disease

This study compares transvaginal color and pulsed Doppler (TVCD), laparoscopic and clinical findings in 102 women with proven pelvic inflammatory disease (PID). Seventy-two (72) of them had acute symptoms, 11 presented with chronic pelvic pain and 19 patients were infertility cases suspected of tubal etiology. Uterine sonographic findings were demonstrated in 72 patients (70.6%). Free fluid in the cul-de-sac was demonstrated in 39 (38.2%) patients. Ovarian enlargement as the only finding was demonstrated in 6 (5.9%) patients, 22 (21.6%) presented with tubular adnexal structure, while in 74 (72.5%) patients it was of a complex nature. Color flow was obtained in all 6 patients presenting with ovarian enlargement, in 12 (54.5%) of those presenting with tubular adnexal structure, and in 56 (75.7%) of those with complex adnexal mass. Ovarian morphology was clearly delineated from adnexal mass in 59 patients (55.9%). The ipsilateral ovarian flow was altered in 50 of them (84.7%). The mean resistance index (RI) in patients with acute symptoms was 0.53 +/- 0.09 (+/-SD). It significantly differed from those obtained in patients with chronic pelvic pain (RI = 0.71 +/- 0.07) and infertility cases (RI = 0.73 +/- 0.09). We concluded that transvaginal color Doppler is useful additional tool in diagnosis and treatment monitoring in patients with PID.

Doppler ultrasound findings in tubo-ovarian infectious complex

Ten women with tubo-ovarian infectious complex caused by pelvic inflammatory disease were investigated with vaginal Doppler sonography during the acute and healing phase of the infection. Doppler velocity waveforms were quantitated by the resistance index (RI) and pulsatility index (PI). A low resistance blood flow was found at the margin of the infectious complex. An RI' value < 0.5 was detected in 6 patients in the acute or subacute phase of infection. The severity of the infection as determined by C-reactive protein values was inversely correlated to RI and PI. The process of angioneogenesis is speculated to be responsible for this increased flow. The tubo-ovarian infectious process must be remembered in the differential diagnosis, when an adnexal mass with low resistance blood flow is found in the ultrasound examination.

[Doppler monitoring of the treatment of inflammatory diseases of the adnexa uteri]

Twenty-five women with acute inflammations of the uterine tubes were examined using Doppler studies of the internal iliac, uterine, and ovarian arteries over the course of therapy. The systolic/diastolic ratio (A/B) and the Pourcelot resistance index were used in analysis of the spectral curves. The findings evidence that the iliac artery blood flow was unchanged over the course of therapy. Dopplerometric curves of the uterine and ovarian arteries were plotted for various periods of therapy for acute salpingo-oophoritis . The authors come to a conclusion of the usefulness of Doppler studies in clinical practice, and these conclusions are supported by the results of statistical data processing.

[Hemodynamics in the organs of small pelvis during complex treatment using electromagnetic fields in patients with tubal infertility of inflammatory etiology]

Hydrotubation treatment of uterine tube impotency of an inflammatory origin results in many cases in stubborn hemodynamic disorders in the small pelvis organs, that may be normalized after exposure to a permanent magnetic field (magnetophores). Multiple-modality treatment results in recovery of the uterine tube patency in 50% of cases and in pregnancy coming within a year in 22.6% of cases.

Functional and therapeutic aspects of counter current transfer in the female adnexa

Counter current transfer of many substances, including steroids and peptide hormones, takes place from the veins and lymph vessels to the arterial blood in the female adnexa. The vascular system to the ovaries, tubes, uterus, and vagina is involved, and transfer from one organ to another is possible due to the anatomy and physiology of the vessels. Examples of physiological importance are given: regulation of luteolysis, unilateral effects on the functions of the ovary and tube. The transfer may be used as a therapeutic tool in order to obtain high local concentrations of drugs. It is postulated that a hormone releasing intra-uterine device (IUD) may have a local effect on the tubes and ovaries. It is also postulated that intrauterine instillation of cytotoxic drugs may be used before surgery in order to obtain a high concentration in local arterial blood when compared to the concentration in peripheral blood, thus obtaining a favourable therapeutic index between local beneficial and general toxic effects. The treatment may also create a high concentration of the drug in the local lymph glands and thus have a direct therapeutic effect on eventual metastasis.

Pregnancy outcome after unwinding of twisted ischaemic-haemorrhagic adnexa

Six women who became pregnant after human menopausal gonadotrophin/human chorionic gonadotrophin (hMG/hCG) treatment regimens were operated on between 6 and 21 weeks gestation with an intra-operative diagnosis of twisted ischaemic-haemorrhagic adnexa. During operation unwinding of the adnexa was performed in all patients. Monitoring of the pregnancy before and after operation by ultrasonography was normal. The postoperative period and the rest of the pregnancy were uneventful. Three women were delivered normally at term. One patient was delivered by caesarean section because of twin pregnancy with malpresentation, and two pregnancies are still ongoing beyond the first trimester. This preliminary study suggests that detorsion of ischaemic-haemorrhagic adnexa during pregnancy is an option that is not associated with subsequent complications. This approach might be adopted relatively safely when preservation of future fertility is a goal.

The arterial blood supply of the parametrium

The possible influence of tubal sterilization on the ovarian function is still debated. In this study, we have investigated the course of the main arteries in the parametrium. This study concludes that it is unlikely, from an anatomical point of view, that the ovarian function can be disturbed after tubal sterilization with bipolar cautery, silicone-rings or Filshieclips due to changes in the arterial blood supply.

Counter current transfer in the female adnex

The utero-ovarian veins and lymph vessels are intimately connected with the ovarian artery in the human female and in domestic animals, with the exception of the horse and the human female. A direct, local exchange of molecules from veins and lymph vessels to arteries (counter current transfer) has been documented for this anatomic structure. Countercurrent transfer of certain inert gases (133xenon, 85krypton), of prostaglandins (PGF2 alpha), of steroid hormones (e.g. progesterone, estradiol, testosterone), and of small peptide hormones (oxytocin, relaxin) has been shown to occur in laboratory and domestic animals as well as in the human female. The transfer of the inert gases takes place within seconds. The transfer of steroid hormones and peptides is detectable within minutes while the transfer of PGF2 alpha is delayed for 20 minutes. Red blood cells or albumin are not transferred. The existence of the local transfer is postulated to be of importance for: 1) the pregnancy/non-pregnancy signal from the uterus and tube to the ovary. The signal may be a combination of a luteotrophic signal from the embryo and lack of a "non-pregnant" luteolytic signal from the endometrium, the latter probably being PGF2 alpha in some species; 2) the unilateral influence of the ovarian hormones on the function of the ovarian, tubal, and possibly uterine tissues. An active corpus luteum may create in a mono-ovulatory animal a higher progesterone level in arterial blood supplying the ipsilateral tube and ovarian interstitial tissue than on equivalent contralateral organs.

Counter current transfer and back transport of 3H-PGF2 alpha in the cow's broad ligament vasculature ipsilateral and contralateral to the corpus luteum

Eight cows of similar age (5-7 years) were chosen for the experiment. Isolated reproductive tract was supplied with autologous oxygenated and heated (40 degrees C) blood through the uterine artery and ovarian artery. 3H-PGF2 alpha in total dose of 2 MBq (10(7) cpm) was injected into each of the uterine lumen of isolated organ. Blood samples were collected at 5 min intervals during 120 min of experiment using cannulae inserted into the branches of uterine arteries about 1 cm below the horns and from ovarian arteries inserted 0.5 cm below the ovaries. The concentration of 3H-PGF2 alpha found in blood plasma taken from uterine artery or from ovarian artery on the side with active corpus luteum (CL) was significantly lower (p less than 0.001) compare with contralateral side to active CL. Radioactive PGF2 alpha found in branches of uterine arteries on both ipsilateral and contralateral side to CL was significantly higher (p less than 0.001) compare to ovarian artery of the same side. It is concluded that absorption of 3H-PGF2 alpha from uterine lumen into venous blood as well as its counter current transfer in area of broad ligament vasculature were reduced on the side of uterine horn with active CL probably as an effect of estrogen:progesterone ratio on vascular constriction in area of uterine vasculature.

Counter current transfer of PGF2 alpha in the mesometrial vessels as a mechanism for prevention of luteal regression in early pregnancy

A new concept has been presented on the mechanism protecting the corpus luteum during oestrous cycle, early pregnancy and pseudopregnancy induced by oestrogens. The concept is based on the recently discovered mechanism of back transfer of prostaglandin F2 alpha from the broad ligament vasculature into the uterus and on the participation of oestrogen in this process. The morphological facilitates for counter-current transfer of PGF2 alpha in the area of mesometrial vasculature and ability the uterus to bind PGF2 alpha were presented. It has been concluded that the process of PGF2 alpha back-transfer from mesometrial vasculature into the uterus may reduce in uterine venous blood the amplitude of PGF2 alpha pulses and by this way may reduce the penetration of prostaglandin into subovarian area and from there to the corpus luteum.

[Angioscintigraphy in benign tumors of the uterus and adnexa uteri]

Angioscintigraphy was used for examination of 128 patients, of them 91 had tumors of the genital organs, 22 inflammatory adnexal processes and 15 various extragenital diseases. Statistical scintigraphy was performed 5-40 min. after RP intravenous injection at 175-555 MBq. RP injection was followed by dynamic studies, the rate of recording being 1 frame per min. An anterioposterior direct projection with alignment of a gamma-chamber detector over the small pelvic area was used. 99mTc-human serum albumin and erythrocytes labeled in vivo with 99mTc-pyrophosphate served as radioactive markers of the blood pool. A scintigraphic picture in normal and pathology (tumors and inflammatory processes) in the uterus and appendages had characteristics features. Data on a degree of tumor vascularization could be used for recognition of disease as well as for adequate assessment of therapeutic efficacy. The sensitivity of the method was 97%, its specificity--59%, its accuracy--88%.

Ultrasonic visualization of varicosities in the female genital tract

The characteristic ultrasonic appearance of varicosities in the female genital tract is demonstrated by examinations of three pregnant and four nonpregnant patients. The ease and importance of differentiating this entity from pelvic masses and its role as a cause of painful symptoms are indicated.

Mesosalpingeal vessel ligation for conservative treatment of ectopic pregnancy

Mesosalpingeal vessel ligation improves hemostasis during conservative tubal surgery for ectopic pregnancy. We used this method is a series of 39 patients to reduce the risk of recurrent hemorrhage from the fallopian tube.

Pregnancy after autografting and allografting vascularized ovaries and en bloc vascularized ovaries with adnexa in rabbits

Initially, techniques for autografting ovaries with or without adnexa were developed but a 30% vascular failure rate was experienced by day 14. Of the technically successful grafts, 50% proved fertile. Single vascularized ovaries with their oviducts were then allografted into bilaterally ovariectomized rabbits by microsurgical techniques and the vascular failure rate was reduced to 5% of 40 grafts. The time-course of rejection in untreated recipients was mapped by histological examination and by 24-h culture of fallopian tubes after autopsy at different times after transplantation. Control allografts were consistently rejected by day 20. Striking prolongation of both types of graft was obtained with a short 17-day course of cyclosporin A at 10 or 15 mg day-1 kg-1. Indeed, significant evidence of rejection was found in only two ovaries out of 20 so far examined histologically. Mating behaviour, ovulation, ciliary function and transport of ova appeared normal in 80% of the recipients as long as 18 weeks after stopping cyclosporin A treatment. Only one of the ovarian allografted rabbits has so far been mated and this produced seven normal young 126 days after transplantation. However, none of the five animals mated after being allografted with en bloc adnexa have so far become pregnant.

[Clinical significance of arteriovenous shunt malformations in the uterine and adnexal region (author's transl)]

This case report describes and discusses the entity of arteriovenous shunt malformations in the uterine and adnexal region. The diagnostic measurements and clinical importance of this disease is also outlined. The condition is rare, but should be considered in cases of severe hemorrhage when routine investigations have been normal. For the first time bloodgas-analytic measurements showing the extent of the shunting have been performed with such a disease.

[Angiographic diagnosis of ovarian cancer (author's transl)]

The methods of examination which are usually used in cases of tumours of the lower abdomen are mostly not able to determine the site of origin of the lesion of its histology unequivocally. Angiographic examination techniques enable the definition of such tumours and very often allow the differentiation between benign and malignant lesions. Both hypogastric arteries are selectively or semiselectively catheterized using Seldinger's technique. Additionally, in most patients, aortography and selective catheterization of the inferior mesenteric artery is performed. So far the diagnosis of an adnexal tumour was made by angiography in 6 out of 30 patients. The typical angiographic criteria of ovarian carcinoma are cited and discussed. Our results show that in selected cases of suspected ovarian tumours angiography offers good results and, therefore, it deserves an important place among the different available clinical examination techniques.

[Congenital arteriovenous fistula of the broad ligament. 1 case]

Following a case report of a congenital arterio-venous fistula of the broad ligament, the authors set out the different types of vascular malformation seen in the pelvic region and they attempt to define the place of treatment. The treatment of these lesions involves embolisation of the vascular pedicle and an attempt at surgical excision, alone or one after another.

The anatomical basis for a possible counter current exchange mechanism in the human adnexa

A counter current mechanism for exchange of prostaglandins between veins and arteries in the ovarian pedicle has earlier been demonstrated in the sheep. The existance of a corresponding vascular arrangement in the human ovarian pedicle has been doubted predominantly on basis of functional data which do not support a role of prostaglandins for human luteolysis. However, the present study demonstrates norphological evidence for a similar vascular anatomy in the human as in the sheep. In 43 human adnexa studied, tortuous arteries in close contact with veins were consistently found. Microscopical sections revealed thinning of the vein walls at contact areas. The possible functional significance of this finding is discussed.