Dr Sherif TawfeekConsultant Gynaecologist

Christchurch Gynaecology Associates

Christchurch

8:30 - 9:25 WS #142: Interpreting Gynae Ultrasounds

9:35 - 10:30 WS #152: Interpreting Gynae Ultrasounds (Repeated)

Dr Rachel BelshamConsultant Radiologist

Christchurch Women's Hospital

Christchurch

Interpreting Gynaecology Ultrasounds

Rachel BelshamFRANZCR

Women’s Radiologist, Christchurch Hospital

Sherif TawfeekFRANZCOG, FRCOG, FICS, MSc, Dip-Endoscopy

Consultant in Obstetrics and GynaecologySenior lecturer at University of Otago

Objective

• 4 x Cases with different diagnosis• Sharing the common Gynae presenting complaints

and examination findings Sudden onset of abdominal pain +/- PV bleedingNausea, +/-vomitingO/E: Abdo tenderness, mild guarding but no rebound

• Radiology report complement a tentative diagnosisby giving a degree of certainty

Case 130yr, G4P2+1Abdominal pain, with PV spottingNausea, but no vomitingInitial USS ? Molar pregnancyERPOC 12th July -histology: Decidua onlyRepeat β-HCG:

Follow up scan:

2nd July 8th July 15th July

1670 2660 2490

Image Findings:

- “empty uterus” + pseudo-sac

- Right adnexal mass

- complex free fluid

DIAGNOSIS = ruptured RIGHT tubal ectopic

Empty Uterus + pseudo-sac Right adnexal mass

Complex free fluid

ECTOPIC PREGNANCY

Diagnosis becoming more complicated

- atypical symptoms >50%

- rare types ectopic increasing (IVF, LSCS)

Cornual

Ovarian

Abdominal

Cervical

**Scar

Heterotopic

Intramural

Chronic

Ovarian Ectopic

Cornual Ectopic

Heterotopic Scar Ectopic

Abdominal Ectopic

ECTOPIC PREGNANCY

Differential Diagnosis:

1. Exo-phytic corpus luteum of pregnancy

2. Pedunculated fibroid

3. PUL – pregnancy of unknown location

CORPUS LUTEUM Usually within ovary

Can be on margin “Exophytic”

>>> Can be mistaken for tubal ectopic

>>> Corpus luteum can rupture

Solution: clips with probe pressure ….. Ectopic separates from ovary

Normal CL within ovary Exophytic CL Tubal Ectopic

Large HaemoperitoneumRuptured CL at surgery

OTHER ADNEXAL MASSES

Fibroids

pedunculated, subserosal

“Claw” sign

Endometrioma

Ovarian Mass

HELPFUL TIP:

? seen on previous scan

Follow-up scan

Right subserosal fibroid + “claw” sign

Endometrioma + adhesions + LOV cyst

E LOVA

PREGNANCY OF UNKNOWN LOCATION

DEFINITION:

- no visible pregnancy within the uterus or elsewhere in the pelvis

PITFALL:

- often mistaken for complete miscarriage!

(History bleeding)

DIFFERENTIAL:

1. Early IUP not yet visible

2. Early ectopic not yet visible (20%)

3. Complete miscarriage

HELPFUL TIP: Follow-up serum BHCG +/- FU scan

PUL

EctopicOn FU scan

ECTOPIC PREGNANCY IMAGING TIPS

Don’t put off an Ultrasound scan

- symptoms often atypical (>50%)!

Include history of IVF, Caesarean on request form

- Rare types ectopic increasing

Serum BHCG very helpful

- any ectopic

- after scan showing Pregnancy of Unknown Location

MISCARRIAGE

Many Types:

- threatened, incomplete, complete, missed

Management:

- conservative, medical (Misoprostol), surgical (ERPOC)

Many Imaging Appearances:

- retained tissue, retained pregnancy structures

- early pregnancy failure

Retained tissue “RPOC”Large empty sac“Blighted ovum” Retained fetus

Incomplete miscarriage …sac has moved down Retained placenta

EARLY PREGNANCY FAILURE

Complicated diagnosis

Previously overcalled (Doubilet et al 2013)

New diagnostic criteria

1. CRL >= 7 mm + no heartbeat

2. No heartbeat present on a FU scan when it was seen on a previous scan

If criteria not met ….

Follow-up scan often recommended by Radiologist!

CRL = 9 mm. No heartbeat.EARLY PREGNANCY FAILURE.

CRL = 3 mm + no heartbeat.DOES NOT MEET CRITERIA. Needs FU scan!

HELPFUL TIPS:

Radiologist will often advise FU scan if criteria not met History is unreliable (sure dates cannot diagnose EPF) Poor prognostic features cannot diagnose EPF

- sub chorionic hg, distorted low sac, bradycardia Serial serum BHCG is helpful (reducing BHCG suggests failure)

Key notes1. At what β-HCG level is TV-USS able to identify intrauterine pregnancy?

1500 IU/L

2. What is recurrence rate of ectopic pregnancy 15-20%

3. What is the management options are available and which management would be preferred in this particular case?

4. What is the risk factors for ectopic pregnancy

Risk factors for ectopic pregnancy

➢ Smoking➢ Previous ectopic➢ History of Infertility / infertility treatment e.g.

IVF➢ Previous tubal surgery➢ Previous ectopic pregnancy➢ Contraception e.g. IUCD / progesterone only pill

Case 2

16yr, P0RIF pain Nausea & vomiting,Tender on right sideBlood=N, CRP <3

USS:

Image Findings:

- enlarged heterogeneous avascular ovary

- dilated thick-walled fallopian tube + internal haemorrhage

- free fluid

DIAGNOSIS: Torsion right ovary and right fallopian tube

Enlarged avascular ovary Fallopian tube with haemorrhage

ROV

OVARIAN TORSION

Classic Torsion: - normal ovaries ( increased mobility ) - pre-pubertal girls, pregnancy- highly sensitive - uncommon

Non-classic Torsion:- abnormal ovaries ( pre-existing cyst/mass )- older women- low sensitivity- common

BEWARE!

Vascularity does not exclude Torsion!

- Dual blood supply

- Varying twisting

- Intermittent/partial Torsion

Classic Torsion – 16 yr Non-classic Torsion – 35 yrOvarian cyst

Classic Torsion 13 weeks pregnant

Torsion – 13 weeks pregnant

OVARIAN TORTION

Differential diagnosis ( RIF pain ) :

Haemorrhagic cyst/follicle

Ovarian dermoid

Appendicitis

Mesenteric adenitis

Crohn’s (terminal ileum)

Renal

No cause seen

LOV haemorrhagic cyst - 13 yr girl

Appendicitis 16 yr

OVARIAN TORTION

IMAGING TIPS:

• Sudden onset severe pain suggestive

• At risk: pre-pubertal girls, pregnancy

pre-existing ovarian lesions

• Pelvic USS first investigation

• Classic >>>>> highly sensitive!

• Most cases Non-classic >>>>> USS cannot confirm Torsion

Final management should be based on clinical grounds.

Question

1. What is the incidence of ovarian torsion? A. 5% B. 10% C. 15%

1. What is the risk factor(s) for ovarian torsion?A. Ovarian cystB. SterilisationC. IVF treatment cycleE. Hysterectomy with conservation of ovaries

Key notes

➢Torsion of the ovary is a common diagnostic challenge in the emergency setting

➢Diagnosis can be difficult and is mainly based on clinical symptoms (non-specific) and imaging (A normal ultrasound scan does not exclude adnexal torsion)

➢Treatment is traditionally surgical removal of the ovary, however, there is increasing evidence for conservative surgery, such as de-torsion and oophoropexy, particularly in younger women.

Key notes

Symptoms of ovarian torsion (non-specific)

General

Pelvic or abdominal pain,

fluctuating, radiating to loin or thigh

Nausea

Vomiting

Signs

GeneralPyrexia

Tachycardia

Abdominal examination Generalised abdominal tenderness, localised guarding, rebound

Vaginal examination Cervical excitation, adnexal tenderness, adnexal mass

Case 333yr, P2 NVDSudden onset of RIFNausea & vomitingSmokerMirena in situO/E: Abdo tenderness, no guarding or rebound

USS:

Image Findings:

- “Lace like” septations

- Echogenic foci

- Complex free fluid (haemorrhage)

DIAGNOSIS: haemorrhagic cyst with rupture

Hg cystFree fluid

Haemorrhagic Ovarian Cyst.

Ovarian Cyst complications:- rupture- haemorrhage- ovarian Torsion

Ultrasound Features:- classic features >>>>> diagnostic

Differential Diagnosis: 1. endometrioma2. dermoid3. abscess4. neoplasia

Classic Ultrasound Features:

- “lace-like” internal architecture

- “asymmetric” internal material

- mobile internal blood products

“Lace-like” architecture Asymmetric materialClot retraction

Mobile layering blood products

Physiological follicleSmall < 30 mm

Dermoid: Fat, fluid, hair, calcification.

Tubo ovarian abscess. Thick walled cyst, dilated tube, fever, WCC

Tooth

ENDOMETRIOSIS

Superficial lesions not visible on imaging >>>>> laparoscopy

Deep Infiltrating Endometriosis:

1. Ultrasound - endometriomas retroverted uterusuterus surface plaques, bowel lesionsureter lesionsorgan mobility (adhesions ) >>>> reduced “sliding”

2. MRI - endometriomas plaques (peritoneum, serosa, POD, Uterosacral ligaments)tethering (adhesions)

Large bilateral endometriomas Rectal wall deposit

“Kissing ovaries” in POD Posterior uterus plaque + rectal tethering

Normal Sliding Uterus

Abnormal Sliding Grade 4 Endometriosis

OVARIAN NEOPLASIAHaemorrhagic cyst Ovarian Neoplasia

Solid nodules, projections Rarely Often present

Thick irregular septations Absent Often present

Internal vascularity Absent Often present

Tumour markers Negative Often high (endos, TOA also high)

HAEMORRHAGIC OVARIAN CYST

IMAGING TIPS:

1. Classic Features are diagnostic

2. Otherwise need to exclude other differentials

3. ? Follow-up ultrasound

- classic dermoid ………… refer to Gynaecology

- likely neoplasia ………… refer to Gynaecology

? Haemorrhagic cyst vs ? Endometrioma ……… Follow up scan in 8 weeks

1. haemorrhagic cyst resolves

2. endometrioma persists/progresses

Risk factors for Ovarian cancer➢Age: most common in women 50 to 60 years.

➢ Inherited gene mutation. BRCA1, BRCA2, Lynch syndrome

➢Family history

➢Obesity

➢Estrogen hormone replacement therapy

➢Age when menstruation started and ended.

➢Nulliparity

➢Fertility treatment

Case 4

32 year old, P0Pelvic painSevere dysmenorrhoeamenorrhagia

USS:

Imaging Findings: Diagnosis:

- central uterus mass Submucosal fibroid

- mild vascularity

- poorly seen endometrium

FIBROIDS “LEIOMYOMA”

Types: submucosal intramural subserosal pedunculated

Complications:Calcificationcystic degenerationprolapse Torsion (pedunculated) renal obstructionmiscarriageunstable lie

FIBROIDS

Differential Diagnosis:

1. Polyp

2. Thickened endometrium : hyperplasia, Tamoxifen, carcinoma

3. Focal adenomyoma

4. Ovarian fibroma (pedunculated)

Huge fibroid uterus 25 cm

Pedunculated fibroid

Fibroids MRI

Fibroids

Fibroids CT

Tamoxifen Endometrial polyp

Ovarian FibromaEndometrial Carcinoma Cervical cancer

Polyp saline infusion

ADENOMYOSIS

Endometrial glands within the myometrium

Diffuse + focal

Bulky uterus, myometrial cysts, “venetian blind”

coarsened heterogeneous myometrium

Sub endometrial cysts Bulky “venetian blind” MRI

FIBROIDS

IMAGING TIPS:

First investigation Pelvic Ultrasound

MRI for pre op planning (myomectomy)

Saline infusion USS ? Polyp ? submucosal fibroid extent into endometrial cavity

Treatment – Mirena, medical, surgical, embolisation

If Treatment not working consider alternative diagnosis

i.e.. Focal adenomyosis

Necrosis post emb

Question

Q. What treatment options are approved for uterine fibroid?

A. Uterine artery embolisationB. Gonadotropin-releasing hormone analogues (Zoladex)D. Hysteroscopic myomectomyE. Laparoscopic myomectomyF. HysterectomyG. Levonorgestrel intrauterine system (Mirena)H. All of the above

Key notes

➢ Fibroids are the most common uterine growth - 20-30%

➢ Management options are affected by the woman's symptoms, age, desire to conceive and local resources.

➢ Pharmacological agents are effective in alleviating symptoms and may improve women’s quality of life.

➢ Interventional radiology procedures may prevent the need for hysterectomy.

➢ Conventional surgical procedures and minimal access surgery are important in management of fibroids.

TEST 1

35 year old woman, positive pregnancy test, vague lower abdominal discomfort and PV bleeding, history of previous miscarriages, she is SURE she has passed products …….

Early Pregnancy USS shows empty uterus and no ectopic

(Pregnancy of Unknown Location).

What do you do?

A tell her it must be a complete miscarriage and discharge her

B perform a FU BHCG just to be sure

TEST 1

A week later BHCG has slightly risen and she says she is still spotting and now feels a bit lightheaded

What is the diagnosis?

A miscarriage

B ruptured left ectopic pregnancy

Empty uterus L adnexal mass and complex free fluid

mass

ff

ff

LOV

TEST 2

30 year woman sure dates 8 weeks,

PV spotting, BHCG 15,000.

Ultrasound CRL = 3 mm (6 weeks) but no heartbeat and small sub chorionic haemorrhage

What do you do?

A tell her she has had a miscarriage and arrange ERPOC

B arrange a follow up USS in 10-14 days +/-

follow up BHCG

CRL 3 mm no FHB small SCH

GSacSCHg

TEST 2

What is the USS diagnosis?

A failed early pregnancy

B single live intrauterine pregnancy

Initial scan at 8 weeks gestation by datesCRL = 3 mm no heartbeat (app 6 week size)

Follow up scan in 10 days CRL = 5 mmWith Heartbeat present = 125 bpm

TEST 3

Which of these COULD be Torsion?

A B C All None

If Ultrasound is indeterminate, but patient has severe pain typical for Torsion what next?

- assume hg cyst give pain relief and send home when settled

- cannot exclude Torsion based on clinical so theatre arranged

A B

C

ROV

Ut

Enlarged ROV with haemorrhage 16 yr

Large ROV Cyst25 yr

Large AvascularLOV 19 yr

TEST 4

Which one is the haemorrhagic cyst?

A or B

If cyst could be an endometrioma but not certain what is recommended further management?

A tell the patient she has cancer

B refer straight to a Gynaecologist

C order a follow up USS in 8 weeks and then review

A B

TEST 5

Which one is the fibroid? A or B

If treatment not working most common alternative diagnosis:

- polyp

- tumour

- adenomyosis/adenomyoma

A B

TEST 6

Spot the abnormality