Comparison of tubal ring and corpus luteum echogenicities: a useful differentiating characteristic

Ovarian Pregnancy

Ovarian pregnancy is a rare uncommon presentation of an ectopic pregnancy. Without any known risk factors, ovarian pregnancy seems to appear at random. A 29-year-old female patient with previous two cesarean deliveries visited the gynecology emergency department with the complaint of constant dull aching pain in the lower abdomen, aggravated by postural changes. Per vaginal examination, cervical motion tenderness was present. The patient was admitted, and her transvaginal sonography was done along with a urine pregnancy kit test for the suspicion of ectopic gestation. After the initial treatment and arrangement of two units of packed red blood cells after proper grouping and cross-matching for the patient, laparotomy was done. At the time of surgery, left-sided ruptured ovarian pregnancy was confirmed by the Spiegelberg criteria.

Hemorrhagic corpus luteum: Clinical management update

Hemorrhagic corpus luteum (HCL) is an ovarian cyst formed after ovulation and caused by spontaneous bleeding into a corpus luteum (CL) cyst. When HCL rupture happens, a hemoperitoneum results. Clinical symptoms are mainly due to peritoneal irritation by the blood effusion. The differential diagnosis is extensive and standard management is not defined. The authors elaborated a comparison of the differential diagnosis and therapeutic modalities from the laparoscopic approach to nonsurgical, medical options because hemorrhage from HCL is often self-limiting. The authors reviewed all data implicated with the development of HCL, trying to give homogeneity to literature data. The authors analyzed extensive literature data and subdivided the medical approach into many topics. The wait-and-see attitude avoids unnecessary laparoscopic surgery using supportive therapies (antifibrinolytic, analgesics, liquid infusion, transfusions and antibiotic prophylaxis). Surgical therapy: operative management should be laparoscopic, with surgical options such as luteumectomy, ovarian wedge-shaped excision or oophorectomy. Prevention: the possibility to preserve fertility is essential, mainly in patients with bleeding disorders or undergoing anticoagulant therapy; therefore, they need estro-progestinics or GnRH analogues to prevent ovulation and avoid further episodes of HCL. This review will aid physicians in making an early diagnosis of HCL, to avoid unnecessary surgery, and use the most effective treatment.

Ultrasound classification and clinical analysis of ovarian pregnancy: A study of 12 cases

OBJECTIVE

To evaluate the clinical significance of preoperative ultrasound diagnosis and classification of ovarian pregnancy (OP).

METHODS

The ultrasonographic reports, medical records, and operative summaries were reviewed for twelve women with a confirmed diagnosis of OP. According to the ultrasonographic appearance, OP was classified into two types. For every type, we analyzed the possibility and clinical significance of preoperative ultrasound diagnosis, combining with its clinical manifestations and treatments.

RESULTS

According to sonographic features, twelve cases of OP can be classified into ruptured type (n = 6) and unruptured type (n = 6), the latter was subclassified into embryo sac type (n = 2) and non-homogeneous mass type (n = 4). All the unruptured OP have the characteristic solid hyperechoic rings or masses, and 66.7% (4/6) were correctvly diagnosed by preoperative ultrasound. No characteristic ultrasonogram was detected in ruptured OP which were all diagnosed as ruptured ectopic pregnancy (EP) or corpus luteum by preoperative ultrasound. The diagnostic and surgical procedures of four cases diagnosed by preoperative ultrasound were all laparoscopy and removal of the gestational products, and their average hemoperitoneum, operation time, hospital days was 313 ± 278 ml, 57 ± 9 min, and 4.25 ± 0.5days, respectively. While ruptured OP cases (6 cases diagnosed at first visit and 1 underdiagnosed but ruptured after 6 days), the diagnostic procedures was laparoscopy(3/7) or laparotomy(4/7), the surgical procedure was removal of the gestational products(2/7), wedge resection(3/7), or adenexectomy(2/7), and their average hemoperitoneum, operation time, and hospital days was 1914 ± 1059 ml, 93 ± 17 min, and 5.9 ± 1.3days, respectively.

CONCLUSIONS

Ultrasound plays a significant role in diagnosis of OP, and part of the unruptured OP based on the typical sonographic characteristics could be correctly diagnosed by an experienced sonographer, this is beneficial and effective in terms of the risk of patient's operation and life. Whereas ruptured OP were generally diagnosed as ruptured EP or corpus luteum because there were no characteristic ultrasound manifestations.

Pitfalls and tips in the diagnosis of ectopic pregnancy

Women of reproductive age with pelvic pain, vaginal bleeding, and a positive pregnancy test often require evaluation with pelvic ultrasound. In these situations, the primary role of pelvic ultrasound is to differentiate an ectopic pregnancy from either a normal or abnormal intrauterine pregnancy. While an accurately performed and interpreted pelvic ultrasound results in rapid diagnosis and management, numerous diagnostic pitfalls can lead to negative outcomes. Therefore, familiarity with the appropriate laboratory tests, sonographic technique, and imaging features of ectopic pregnancy is essential for all radiologists. We present a review of ectopic pregnancy cases from our institution with attention to common pitfalls and troubleshooting tips for physicians who perform and interpret pelvic ultrasounds. We also present recently published literature to aid in the management of first trimester pregnancy.

Radiological appearances of corpus luteum cysts and their imaging mimics

PURPOSE

To review the radiological appearances of corpus luteum cysts and their imaging mimics.

CONCLUSION

Corpus luteum cysts are normal post-ovulatory structures seen in the ovaries through the second half of the menstrual cycle and the first trimester of pregnancy. The typical appearance, across all modalities, is of a 1- to 3-cm cyst with a thick crenulated vascularized wall. Occasionally, similar imaging findings may be seen with endometrioma, ectopic pregnancy, tuboovarian abscess, red degeneration of a fibroid, and ovarian neoplasia. In most cases, imaging findings are distinctive and allow for a confident and accurate diagnosis that provides reassurance for patients and referring physicians and avoids costly unnecessary follow-up.

Sonographic Detection of Ovarian Ectopic Pregnancy

Sonography is the imaging modality of choice to evaluate suspected intrauterine and extrauterine pregnancies. Determining the anatomic location of an ectopic pregnancy can be challenging, particularly when the ectopic is located external to the fallopian tube. Ovarian ectopic pregnancy is one of the rarest forms of nontubal ectopics. This report documents one such uncommon case of ovarian pregnancy in a woman presenting with light vaginal bleeding in early pregnancy, with subsequent rupture and laparotomy. Histopathologic analysis confirmed the diagnosis of ovarian ectopic pregnancy.

Incidence, diagnosis and management of tubal and nontubal ectopic pregnancies: a review

BACKGROUND

Ectopic pregnancy is a potentially life-threatening condition occurring in 1-2 % of all pregnancies. The most common ectopic implantation site is the fallopian tube, though 10 % of ectopic pregnancies implant in the cervix, ovary, myometrium, interstitial portion of the fallopian tube, abdominal cavity or within a cesarean section scar.

FINDINGS

Diagnosis involves a combination of clinical symptoms, serology, and ultrasound. Medical management is a safe and effective option in most clinically stable patients. Patients who have failed medical management, are ineligible, or present with ruptured ectopic pregnancy or heterotopic pregnancy are most often managed with excision by laparoscopy or, less commonly, laparotomy. Management of nontubal ectopic pregnancies may involve medical or surgical treatment, or a combination, as dictated by ectopic pregnancy location and the patient's clinical stability. Following tubal ectopic pregnancy, the rate of subsequent intrauterine pregnancy is high and independent of treatment modality.

CONCLUSION

This review describes the incidence, risk factors, diagnosis, and management of tubal and non-tubal ectopic and heterotopic pregnancies, and reviews the existing data regarding recurrence and future fertility.

Uncommon Implantation Sites of Ectopic Pregnancy: Thinking beyond the Complex Adnexal Mass

Ectopic pregnancy occurs when implantation of the blastocyst takes place in a site other than the endometrium of the uterine cavity. Uncommon implantation sites of ectopic pregnancy include the cervix, interstitial segment of the fallopian tube, scar from a prior cesarean delivery, uterine myometrium, ovary, and peritoneal cavity. Heterotopic and twin ectopic pregnancies are other rare manifestations. Ultrasonography (US) plays a central role in diagnosis of uncommon ectopic pregnancies. US features of an interstitial ectopic pregnancy include an echogenic interstitial line and abnormal bulging of the myometrial contour. A gestational sac that is located below the internal os of the cervix and that contains an embryo with a fetal heartbeat is indicative of a cervical ectopic pregnancy. In a cesarean scar ectopic pregnancy, the gestational sac is implanted in the anterior lower uterine segment at the site of the cesarean scar, with thinning of the myometrium seen anterior to the gestational sac. An intramural gestational sac implants in the uterine myometrium, separate from the uterine cavity and fallopian tubes. In an ovarian ectopic pregnancy, a gestational sac with a thick hyperechoic circumferential rim is located in or on the ovarian parenchyma. An intraperitoneal gestational sac is present in an abdominal ectopic pregnancy. Intra- and extrauterine gestational sacs are seen in a heterotopic pregnancy. Two adnexal heartbeats suggest a live twin ectopic pregnancy. Recognition of the specific US features will help radiologists diagnose these uncommon types of ectopic pregnancy.

Pearls and pitfalls in first-trimester obstetric sonography

Ultrasound is the primary imaging modality used in the evaluation of first-trimester vaginal bleeding and pelvic pain. This article will summarize the ultrasound findings in normal first-trimester pregnancy, failed pregnancy, ectopic pregnancy, subchorionic hemorrhage, retained products of conception, and gestational trophoblastic disease. Mastery of the spectrum of sonographic findings in the normal and abnormal first-trimester pregnancy allows the radiologist to make accurate diagnoses and helps to appropriately guide patient management.

Ultrasound evaluation of the first trimester

Ultrasound is a valuable diagnostic test throughout the first trimester of pregnancy. Early in this trimester, it is used to distinguish between normal intrauterine, failed intrauterine, and ectopic pregnancies. Later it can be used with maternal blood tests to screen for trisomy 21 and other forms of aneuploidy, and in some centers to assess fetal anatomy and diagnose structural anomalies. First trimester sonography is also useful for accurate assessment of gestational age. This article reviews these applications, the approach to establishing diagnoses, and ways to avoid diagnostic mistakes that can lead to serious errors in patient management and adverse pregnancy outcome.

Ultrasound evaluation of gynecologic causes of pelvic pain

Ultrasound should be considered the first-line imaging modality of choice in women presenting with acute or chronic pelvic pain of suspected gynecologic or obstetric origin because many, if not most, gynecologic/obstetric causes of pelvic pain are easily diagnosed on ultrasound examination. Since the clinical presentation of gynecologic causes of pelvic pain overlaps with gastrointestinal and genitourinary pathology, referral to CT or MRI, especially in pregnant patients, should be considered if the US examination is nondiagnostic.

Diagnosis and laparoscopic management of 12 consecutive cases of ovarian pregnancy and review of literature

We sought to determine the outcome of the laparoscopic management of ovarian ectopic pregnancy (OEP) in a United Kingdom district general hospital and reviewed the literature. We conducted a 5-year prospective cohort study of the management of OEP cases between January 2003 and January 2008. Twelve patients had OEP confirmed with histology among a cohort of 421 ectopic pregnancies. The mean gestational age was 45 days. All 12 patients had abdominal pain and 4 (33%) had vaginal bleeding. One (8%) patient became hypovolemic before laparoscopy. Four (33%) women had risk factors for ectopic pregnancy, 2 of whom were current intra-uterine contraceptive users. Preoperative diagnosis of ectopic pregnancy was made in 11 (92%) of 12 patients by transvaginal ultrasonography and OEP in 9 (75%) patients. All cases were managed by laparoscopic surgery with no conversion to laparotomy. The ovarian pregnancy was resected and the ovary conserved in 11 (92%) patients with only 1 requiring an oophorectomy. The mean operating time was 49 minutes. None of the patients needed further treatment. No complications occurred after laparoscopic surgery and the mean hospital stay was 2 days. Considering the rarity of ovarian pregnancy, this is one of the largest series of patients with OEP treated exclusively by laparoscopic surgery and highlights our recent experience of performing conservative laparoscopic surgery for most of our patients.

Ectopic pregnancy: a pictorial review

Ultrasound has remained the primary modality for investigating the pelvis of women in the reproductive age group, especially in an emergency setting. Recognition of different sonographic presentations, including typical and atypical findings of ectopic pregnancy, is important to determine surgical or nonsurgical management. This pictorial review article will exemplify different sonographic presentations of ectopic pregnancy.

MDCT diagnosis of ruptured tubal pregnancy with massive hemoperitoneum

We report a case of ruptured tubal pregnancy with massive life-threatening hemoperitoneum. The 38 year-old woman presented with gynaecologic haemorrhage, pelvic pain and hypovolemic shock. Without any ambiguity, the diagnosis was directly made during contrast enhanced Multidetector Computed Tomography (MDCT). Massive hemoperitoneum with fresh blood clots in the hypogastric area, active free peritoneal extravasation of intravascular contrast material and dramatic peripheral enhancement, - "ring of fire" sign - of an adnexal cystic structure were the key signs. These signs must be known by the emergency radiologist because of the more and more use of CT as the first imaging modality in emergency departments particularly for patients with abdominal pain and presenting life-threatening symptoms.

Diagnosis and management of ectopic pregnancy using bedside transvaginal ultrasonography in the ED: a 2-year experience

OBJECTIVES

The objective of this study was to describe diagnosis and management of ectopic pregnancy using bedside transvaginal ultrasound (US) in an established emergency US program.

METHODS

This was a retrospective study on patients presenting over a 2-year period performed at a level I urban academic emergency department (ED). The ED sees 78,000 patients annually and has a residency and active US program. Patients were eligible for inclusion if they were pregnant, seen in the ED for a first-trimester complication, and underwent a bedside emergency US suggesting an ectopic pregnancy. Emergency department US logs were reviewed for findings suggestive of ectopic pregnancy. Medical records were reviewed for history, physical examination findings, laboratory results, additional diagnostic testing, management, hospital course, and a discharge diagnosis by the admitting obstetric service (OB). Patients with incomplete data were excluded from analysis. Statistical analysis consisted of descriptive statistics.

RESULTS

Seventy-four patients ranging in age from 16 to 39 years (mean, 25 years) were included in the study. Eight patients with incomplete data were excluded from analysis. Emergency-physician US diagnoses included definite ectopic pregnancy (6/74), probable ectopic pregnancy (28/74), and possible ectopic pregnancy (40/74). Forty-seven (64%) of these patients were eventually diagnosed with definite ectopic pregnancy by the OB. During initial consultation, the OB disagreed with the diagnosis of ectopic pregnancy in 15 (32%) of the 47 eventual patients with ectopic pregnancy, calling them miscarriages. Other eventual diagnoses included 9 (12%) patients with possible ectopic pregnancy, 11 (14%) patients with miscarriage, and 7 (9%) with intrauterine pregnancy. Emergency sonologists found tubal rings in 9 (19%) patients with eventual ectopic pregnancy, complex adnexal mass in 29 (61%) patients, and a large amount of echogenic fluid in the cul-de-sac in 10 (21%) patients. Six (13%) patients had live ectopic pregnancy. The OB ordered a radiology US in 10 cases but did not change the diagnosis or management. Beta-human chorionic gonadotropin (beta-hCG) levels ranged from 41 to 59846 mIU/mL (mean, 4602 mIU/mL), but for live ectopic pregnancy, the range was 2118 to 59,846 mIU/mL (mean, 36,341 mIU/mL). Seventeen (36%) patients had beta-hCG levels of lower than 1000 mIU/mL. Of 47 eventual ectopic pregnancies, 29 (62%) patients underwent operative intervention, 17 (36%) patients received methotrexate, and 1 patient left against medical advice. Five (11%) of these patients with definite ectopic pregnancy were initially managed by emergency physicians with follow-up ED visits and serial US examinations without OB consultation.

CONCLUSION

Our study demonstrates that with increased experience, emergency sonologists can accurately diagnose ectopic pregnancy. Furthermore, patients at risk for ectopic pregnancy should not be denied US examinations if their beta-hCG levels fall below an arbitrary discriminatory zone.

A Practical Approach to the Ultrasound Characterization of Adnexal Masses

Because pelvic ultrasound is commonly used to evaluate adnexal masses, it is important to understand the most useful sonographic features for predicting benign and malignant masses. Determining whether an adnexal mass is of ovarian or extraovarian origin is key in arriving at the most likely diagnosis. Most adnexal masses are benign, and each of the most common benign ovarian lesions has a typical sonographic appearance. Additionally, most malignant ovarian neoplasms have a solid component with detectable flow by Doppler ultrasound, allowing one to strongly suggest the diagnosis. We will review an approach to the ultrasound diagnosis of adnexal masses that progresses through a series of 4 questions to help lead one to the most likely diagnosis.

Imaging of pelvic pain in the first trimester of pregnancy

Pelvic pain during the first trimester of pregnancy can pose a challenge to the clinician. The noninvasive nature, safety, and reliability of ultrasonography make it the diagnostic method of choice for pregnant patients who have pelvic pain. Sonography provides information that allows for diagnosis of both pregnancy-related pain, such as a ruptured ectopic pregnancy, miscarriage, or threatened abortion; and may be useful in the diagnosis of pain unrelated to pregnancy, such as that seen in appendicitis and nephrolithiasis.

Reliability of adnexal mass mobility in distinguishing possible ectopic pregnancy from corpus luteum cysts

OBJECTIVE

The purpose of this study was to evaluate the utility of paraovarian pelvic mass mobility as an indicator of mass identity, corpus luteum versus other, in ruling out ectopic pregnancy.

METHODS

This was a retrospective study of all pelvic sonographic examinations on patients with first-trimester complications seen over an 18-month period at a large urban emergency department. All pregnant patients with signs or symptoms of concern for ectopic pregnancy were scanned to evaluate for intrauterine pregnancy. Masses suggestive of either a corpus luteum or an ectopic pregnancy were separated from the ovary with abdominal palpation and endovaginal transducer movement. The ultrasound director and assistant director reviewed videos of all scans. Results of mass separation and outcome were recorded. Independent movement of a mass and ovary was defined as movement of the mass away from the ovary, sliding past the ovary or rotation past the ovary. Statistical analysis included descriptive statistics, inter-rater reliability, the Fisher exact test, and sensitivity, specificity, and negative and positive predictive values.

RESULTS

A total of 78 patient scans fit the criteria, and in 27 of them, the mass separated from the ovary. Twenty-three patients had ectopic pregnancy as the final diagnosis, and in 2 of these, no independent mass movement occurred. Lack of independent movement of the mass and ovary was significantly more common in patients without a final diagnosis of ectopic pregnancy (P < .0001). The negative predictive value was 96.1%.

CONCLUSIONS

Lack of independent movement of an adjacent mass and ovary was strongly associated with absence of ectopic pregnancy.

The ultrasonographic appearance of ovarian ectopic pregnancies

OBJECTIVE

To evaluate the ultrasonographic findings of ovarian ectopic pregnancies.

METHODS

The ultrasonographic reports, videotapes, medical records, and operative summaries were reviewed for all women with a confirmed diagnosis of an ovarian ectopic pregnancy. Examinations were personally conducted by a physician who was either a radiologist-obstetrician or an obstetrician-maternal-fetal medicine specialist.

RESULTS

Six cases were identified in the 13-year period studied. Menstrual ages ranged from 6 to 9 2/7 weeks. Most (5/6) patients had abdominal pain, with 3 demonstrating it before or at 7 weeks gestation. A wide echogenic ring with an internal echolucent area was seen in 5 of 6 patients; 1 of these also contained a yolk sac, and in another, fetal heart motion could be seen. The echogenic ring seemed to be on the surface of the ovary or within the substance of the ovary in all 5 patients. The echogenicity of the ring was greater than that of the ovary in the 5 patients in whom it was identified. At surgery, the ovarian pregnancies had the appearance of a hemorrhagic ovarian cyst in all 6 patients. In the patient in whom no echogenic ring was seen the pregnancy had ruptured. All 6 cases were biopsy proven.

CONCLUSION

Ovarian pregnancies usually appeared on or within the ovary as a cyst with a wide echogenic outside ring. A yolk sac or embryo was less commonly seen. The appearance of the contents lagged in comparison with the gestational age. Early abdominal pain was common.

Various Sonographic Appearances of the Hemorrhagic Corpus Luteum Cyst

Although hemorrhagic corpus luteum cysts are frequently seen during sonography of the female pelvis, their diagnosis is often challenging as a result of variations in size, thickness of the cyst wall, and internal echo pattern depending on the formation and lysis of the clot. There are cases in which hemoperitoneum is the most obvious finding. The differential diagnosis is extensive and includes ectopic pregnancy, adnexal torsion, neoplasm, and pelvic inflammatory disease. This review describes and illustrates the diverse appearances of the hemorrhagic corpus luteum, as well as other etiologies of adnexal pathology that can mimic the appearance of a hemorrhagic corpus luteum sonographically.

Computed Tomography of Corpus Luteal Cysts

OBJECTIVE

To describe the computed tomography (CT) features of corpus luteal cysts.

METHODS

We retrospectively identified 10 patients with a diagnosis of corpus luteal cysts established by ultrasound who had also undergone contemporaneous CT. A single attending radiologist, without knowledge of other clinical or radiologic findings, recorded the morphologic features of the cysts based on the CT images.

RESULTS

The corpus luteal cyst seen at sonography was visible at CT in all 10 patients. All cysts were unilocular, with a mean density of 25 HU (range, 12 to 45). The mean maximum axial cyst diameter was 2.2 cm (range, 1.4 to 2.9). The mean cyst wall thickness was 3 mm (range, 2 to 4). All cyst walls were crenulated. Cyst wall enhancement was hyperdense in 6 cases, isodense in 3 cases, and hypodense in 1 case. Free fluid was seen in 9 of 10 patients.

CONCLUSIONS

At CT, corpus luteal cysts are typically less than 3 cm in diameter and are characterized by a thick, crenulated, or hyperdense wall. Recognition of these CT findings should prevent misinterpretation or inappropriate management.

Adnexal mass with pelvic pain

In a pregnant woman who presents with acute pelvic pain and an adnexal mass, pregnancy-related etiologies, such as ectopic pregnancy or ovarian torsion, are typically the first diagnoses to be considered. Many other causes of pelvic pain associated with an adnexal mass can occur in pregnant patients, however. Some causes are benign and others require urgent management and treatment. Clinical presentation and physical examination can be misleading in pregnancy. The location of pain may be atypical for the pathologic entity, the pain may be muted, and in the case of infection, fever and leukocytosis can be absent. US examination is a safe and effective method for evaluating these patients. Sonographic characterization of adnexal masses may make a definitive diagnosis or focus the differential, which allows for prompt and appropriate treatment of patients.

Sonographic comparison of the tubal ring of ectopic pregnancy with the corpus luteum

OBJECTIVE

Pregnant patients without a sonographically visible intrauterine pregnancy and with a thick-walled cystic adnexal structure present a dilemma. This study compared the utility of various sonographic features in differentiating between the tubal ring of ectopic pregnancy and the corpus luteum.

METHODS

Retrospective review of first-trimester transvaginal sonograms revealed a cystic adnexal structure in 79 women. Each structure was evaluated for 6 specific sonographic characteristics: echogenicity of its wall compared with that of the ovary and endometrium, wall thickness in 2 planes, color Doppler flow distribution and percentage of wall circumference, and internal texture.

RESULTS

Forty-one (52%) of the 79 women had ectopic pregnancies, and 38 (48%) had corpora lutea. Eleven (32%) of 35 ectopic walls were more echogenic than the endometrium, compared with none of the corpora lutea. A cyst wall less echogenic than the endometrium was more likely in corpora lutea (84% versus 31%; P < .0001). More than twice as many ectopic rinds were more echogenic than ovarian tissue compared with corpora lutea (76% versus 34%; P < .0001). The only predictive internal texture feature was a clear pattern, which was more common in the corpora lutea (P < .01, Fisher exact test). There was no significant difference in mural flow distribution or extent between the 2 groups.

CONCLUSIONS

Ancillary sonographic signs to distinguish between an ectopic pregnancy and a corpus luteum include decreased wall echogenicity compared with the endometrium and an anechoic texture, which suggests a corpus luteum.