Transcript Fig. 1 - PosterNG

GYNECOLOGICAL EMERGENCIES
IN COMPUTED TOMOGRAPHY
ML. Parra Gordo, I. Pena Fernández, L. Del
Campo del Val, I. Rodríguez San Pedro
Baselga, A. Tejerina Bernal, M. Velasco Ruiz.
University Hospital La Princesa. Madrid. Spain
INTRODUCTION



Acute gynecologic pathology (AGP) is
characterized by lower abdominal
pain, fever, hemoperitoneum, genital
bleeding or shock.
Physical examination has a limited role.
Ultrasound (US) is the most widely used
imaging modality in patients with AGP,
although results are not always
conclusive.
INTRODUCTION

Other complementary techniques
• Computed Tomography (CT): rapid acquisition
of images, with exposure to ionizing radiation
(young women). CT is a technique in expansion
in AGP.
Shows gynecological diseases unsuspected
Clarifies unclear US findings
Complete the extension if the injury is not
fully displayed in endovaginal US
• Magnetic Resonance Imaging (MRI): Using fast
techniques and fat-suppressed sequences
allows their use in AGP. Not always available.
LEARNING OBJETIVES
To familiarize the radiologists with the
findings in CT in the diagnosis and evaluation
of acute uterine and ovarian pathology,
postpartum
complications, patients with
suspected hemoperitoneum and pelvic
inflammatory disease (PID).
 CT shows the gynecological diseases that
present with abdominal pain, ascites and
obstruction.
 To show the utility of CT in the diagnosis of
enterovaginal fistulas.

BACKGROUND
Our hospital does not have a gynecologist
on call, so many women with acute
abdominal pain depends on the radiological
diagnosis for an immediate therapeutic
approach or a hospital transfer.
 We review abdominal CT scans performed
between January 2007 and August 2009 in
the emergency departement radiology.

IMAGING FINDINGS
Multidetector CT studies were performed
after oral and intravenous administration of
contrast material.
 We performed the contrast infusion pump
with a volume of 100-120 ml at a flow rate
between 2-2,5 ml/sec and a delay of 70-80
sec, with a standard reconstruction interval.
 The spectrum of diagnoses were: uterine
injury, tubal pathology, ovarian lesions and
postpartum complications.

UTERINE INJURY
MYOMA: Most common lesion of the uterus. 20% in
women > 30 years. US diagnosis.
 Acute pain if degeneration and torsion
 Significant
vaginal
bleeding
by
prolapsed
submucosal myoma.
 If hyaline degeneration or
necrosis: cystic appearance,
with
few
contrast
enhancement
and
low
attenuation areas.

40 year old woman with mass, adominal and pelvic
pain. Uterine leiomyomas with hyaline degeneration
and free fluid. In surgery, torsion of subserous fibroid.
UTERINE INJURY




43 year old woman with irregular painful
menses and hypermenorrhea in the last two
years.
Progressive dyspnea of one month evolution
with edema, cough and expectoration.
Malaise, skin and mucosal pallor. Tachypneic.
Lower limb edema from root members. Red
cell blood count 1.63, Hb. 3, VCM 76.
Pelvic CT: Uterus presents 20 x 11 cm of
diameter with an endometrial cavity
about 9 cm thickness, markedly
distended both the corpus and the
endocervical canal.

The uterus contains a high density
material and there is no contrast
enhancement.
Diagnosis: Hydrometrocolpos secondary to a synechiae
UTERINE INJURY

ENDOMETRITIS




Pelvic inflammatory disease (PID) in early
stage
Most common cause of fever in the
postpartum period
History of uterine instrumentation
Uterus containing blood or fluid
Female, 35
years old, curettage 10 days ago.
Fever and malodorous vaginal flow. Uterus with
large endometrial cavity and hyperdense content.

ENDOMETRIAL CARCINOMA
 Fourth leading cause of female cancer
 Postmenopausal
metrorrhagia,
discharge, pelvic pain
purulent
 Age at diagnosis > 60 years old (only 5% <40
years old)
Female, 64 years old. Endometrial
nodular hyperdensity by endometrial
adenocarcinoma. Intestinal obstruction
and peritoneal carcinomatosis.
 Risk factors: family history, obesity, diabetes,
hypertension, hyperestrogenism, tamoxifen,
estrogen monotherapy
UTERINE INJURY




51 year old woman with increased
abdominal perimeter and no bowel
movements. Ascites.
Radiology and Pelvic CT: Mass of 20 cm
of pelvic origin compressing sigma.
Dilated small bowel loops secundary to
obstruction. Ascites.
Hysterectomy, bilateral oophorectomy,
partial small bowel resection and
sigmoidectomy. Extraction of 5 l. of
ascites.
Pathological findings: cytology positive
for malignancy.
Uterine leiomyosarcoma grade III, infiltrating small bowel and sigma.
UTERINE INJURY

VAGINAL FISTULA
 Causes:
Congenital,
surgical
(yatrogenic),
obstetrics,
cancer,
infections, radiation and trauma
 Types: vesicovaginal, rectovaginal,
ureterouretrovaginal, peritoneovaginal
 Causes:
hysterectomy,
prolonged
expulsive, tumors.
 Four cases listed: 3 cervix carcinomas
and 1 acute diverticulitis.
Woman 72 years old. Subtotal hysterectomy.
Paravesical right mass. Hyperdense contrast of sigma
in the vagina.
Enterovaginal fistula secundary to carcinoma of
cervix.
TUBAL PATHOLOGY

TUBAL NORMAL ANATOMY
 Ampullar portion <8 mm
 Isthmian portion <4 mm
 Infundibular portion <10 mm
 It is considered thickened if > 10 mm

TUBAL TORSION
 Rare cause of abdominal pain, with delayed diagnosis
 More common in right side (2:1), periovulation
 Predisposing factors: hydrosalpinx, tubal ligation,
pelvic adhesions.
TUBAL PATHOLOGY

TUBAL TORSION: CT findings
 Tubal hemorrhage (> 50 Hounsfield Unit (HU) in unenhanced CT
 Increased tubal diameter > 15 mm
 Cystic mass, solid or mixed, in contact with uterine horn (yellow arrow)
 Contralateral normal ovary
 Thickening of the suspensory ligament surrounding the hypodense mass with
mouse tail image
 Density increase of the adjacent fat
Female 23 years old. 6 days abdominal pain located in the right iliac fossa, with nausea, vomiting and
fever of 38°C. In surgery, uterine horn with marked hemorrhage, congestion and foci of hemorrhagic
necrosis. Diagnosis:
Right fallopian tube torsion.
TUBAL PATHOLOGY

RUPTURED
ECTOPIC
PREGNANCY IN RIGHT
FALLOPIAN TUBE
 Patient 30 years old, with
urinary
infection
.
Abdominal pain and
lower abdominal mass
 Hb 9.8, WBC 16,680 with
neutrophilia.
Positive
pregnancy test.
 CT: hemoperitoneum.
Active bleeding signs in
cystic lesion in the right
adnexal area (yellow
arrows)
TUBAL PATHOLOGY

PELVIC INFLAMMATORY DISEASE (PID)
 Affects




one million women with 275.00 annual
hospitalizations
Ascending cervicovaginal infection, generally produced
by Chlamydia, Neisseria gonorrhoeae, E. coli,
Bacteroides, peptococci (30 - 40% are polymicrobial
origin)
Risk factors: young women, multiple sexual partners, high
coital frequency, IUDs, low socioeconomic status
It is associated with increased risk of ectopic pregnancy,
PID, chronic pelvic pain, infertility
Clinical findings
• 20% afebrile and with no increase in leukocyte levels
• Fever, abdominal or pelvic pain, vaginal secretion, uterine
bleeding, dyspareunia, dysuria, nausea, vomiting
TUBAL PATHOLOGY

EARLY PID
 Pelvic edema with loss of fat planes
 Uterosacral ligament thickening
 Endometritis: endometrial enhancement
and fluid in the endocervical channel (Fig. 1) 1
 Cervicitis: cervical/pericervical enlargement, enhancement
and inflammation (Fig. 2)
 Salpingitis: fallopian tube thickening
 Oophoritis: ovarian increase with
hypercaptation (Fig. 3)
2
3
TUBAL PATHOLOGY

ADVANCED PID
 Piosalpinx
 Dilated
fallopian
tube
with
enhancement of the thickened wall and
liquid content inside
 Pelvic and tubo-ovarian abscess
 Liquid collection / mixed cystic and solid
mass with thick wall, internal septa and
gas-fluid or fluid-fluid levels inside
 Anterior displacement of mesosalpinx

PID COMPLICATIONS
 Adynamic ileus / intestinal obstruction
 Renal or ureteral obstruction
 Sd Fitz-Hugh-Curtis: inflammation of the
peritoneal surface in right upper quadrant
and right hepatic lobe by direct extension
through the right paracolic gutter
 Uterosacral ligament thickening
OVARIAN LESIONS

OVARIAN TORSION
 Ultrasound is the technique of choice
 More common in children with hypermobility and adult women
with ovarian masses or ovarian cysts.
 Ovary with increased peripheral follicles, lack of vascularization

TC FINDINGS
 Uterine deviation toward the side of
the torsion
 Presence of mass or cyst
 Ovary large, displaced
 Ascites, loss of fat planes
 Increased vascularity (congestion) or
hemorrhagic
stroke
(lack
of
enhancement, hematoma, gas)
Twisted Teratoma (yellow arrow)
OVARIAN LESIONS

FOLLICULAR CYST RUPTURE
 Female
27 years in secretory
phase of her cycle.
 Pelvic
pain
with
negative
pregnancy test
 Hemoperitoneum in presence of
sentinel clot (yellow arrow)
 Right ovary with increased density
(white arrow)
 Conservative
treatment.
Disappearance of ascites and
normal ovaries appearance in
ultrasound after 10 days.
OVARIAN LESIONS




ENDOMETRIOSIS can appear in
ovaries, suspensory ligaments of the
uterus, peritoneal surface, small and
large intestines, ureters, bladder,
vagina, surgical scars or pleura.
Incidence of 10-15% of women
between 25 and 44 years old.
Predisposing factors: direct family
history, first pregnancy at age over 30
years old, caucasian ethnicity,
abnormal uterus.
Between 25 and 50% of infertile
women have endometriosis.
Female 33 years old. Abdominal pain and left flank
mass. In abdominal CT, cystic mass of 26 cm
.
Pathological diagnosis: Endometrioma
OVARIAN LESIONS

HEMORRHAGIC OVARIAN CYST
Hemorrhage in a corpus luteum or follicular cyst: mixed density mass with
values between 45-100 HU (white arrow)
› It is associated to hemoperitoneum with ascites > 50 HU (yellow arrow)
› Cyst wall enhacement after IV contrast injection. Contrast extravasation
in pelvis in late phase
› CT excludes liver adenoma rupture
›
OVARIAN LESIONS

OVARIAN TUMORS
 Women 57 years old with acute abdominal pain. In
pelvic CT, heterogeneous mass in right iliac fossa displacing
the uterus (U). In surgery, ovarian mass with signs of
congestion and necrosis was found.
Pathological findings: Twisted fibrotecoma
U
OVARIAN LESIONS

OVARIAN TUMORS
 Female, 70 years old with
abdominal mass. In pelvic
CT, heterogeneous mass with
areas of fat density and a
solid nodule inside.
Pathological findings: Giant
teratoma with Rokitansky
nodule
OVARIAN LESIONS

OVARIAN TUMORS
 Woman 87 years old with
bowel sub-occlusion. Pelvic
mass on examination.
In pelvic CT, cystic mass
without septa or solid poles.
Pathological findings:
adnexal cystadenoma
left
OVARIAN LESIONS

OVARIAN TUMORS
 Woman
36 years old.
Abdominal growth simulating
advanced pregnancy. Pelvic
mass on examination.
In pelvic CT, cystic mass with
solid poles. Ascites.
Pathological findings: Bilateral
cystadenocarcinoma
POSTPARTUM COMPLICATIONS
 OVARIAN VEIN THROMBOSIS



Female 46 years old with
eutopic delivery 10 days ago.
Lower abdominal pain
On CT, ovarian vein thrombus
is displaced (white arrow)
Enlarged postpartum uterus
and abdominal free fluid.
POSTPARTUM COMPLICATIONS

OVARIAN TORSION
› 37 year old woman in the
fourth day postpartum.
› Severe abdominal pain.
US inconclusive.
› CT
pelvic: Postpartum
uterus.
Enlarged
right
ovary without contrast
enhancement.
Pathological diagnosis: Piece of right oophorectomy
with hemorrhagic infarction and abscess related to
ovarian torsion.

CONCLUSIONS

Although ultrasound is the first imaging
technique is the initial evaluation of
abdominal-pelvic pain in women, CT
shows characteristic findings in many
gynecological diseases and guidance
on the clinical management of these
patients.
CONCLUSIONS

Pelvic masses diagnoses involves the
transfer of patients to the maternal
reference hospital, except ectopic
pregnancy and ruptured tubo-ovarian
torsion that require urgent surgery.
KEYWORDS
Pelvic pain
 Acute female pelvic disease
 Tuboovarian disorders
 Postpartum complications
 Uterine disorders

REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
Cano Alonso R, Borruel Nacenta S, Díez Matínez P, Navallas Irujo M,
Ibáñez Sanz L, Sabía Galíndez E. Role of multidetector CT in the
management of acute female pelvis disease. Emerg Radiol 2009; 16: 453472
Dohke M, Watanabe Y, Okumura A, Amoh Y, Hayashi T, Yoshizako T et al.
Comprehensive MR imaging of acute gynecologic diseases.
RadioGraphics 2000, 20: 1551-1566
Skinner S, Voyvodic F, Scroop R, Sanders T. Isolated tubal torsion: CT
features. Clin Radiol 2001; 56: 155-6
Rha SE, Byun JY, Jung SE, Jung JI, Choi BG, Kim BS et al. CT and MR
imaging features of adnexal torsion. RadioGraphics 2002; 22: 283-294
Bennett GL, Slywotzky CM, Giovanniello G. Gynecologic causes of acute
pelvis pain: Spectrum of CT findings. RadioGraphics 2002; 22: 785-801
Sam JW, Jacobs JE, Birnbaum BA. Spectrum of CT finding in acute
pyogenic pelvic inflammatory diseases. RadioGraphics 2002; 22: 13271334
Kim SH, Kim SH, Yang DM Kim KA. Unusual causes of tubo-ovarian
abscess: CT and MR imaging findings. RadioGraphics 2004; 24:1575-1589
J. Sandoval, C. Santa, P. Paz. Fístulas vaginales: 173 casos observados en
18 años. Ginecol Obstet. 1998; 44:208-15