2019, Ultrasonography of Complicated Gynecology Cases

ULTRASONOGRAPHY
OF COMPLICATED
GYNECOLOGY CASES
ANDI DARMA PUTRA, MD
Oncology Division, Obstetric and Gynecology Departement
Cipto Mangunkusumo Hospital, Jakarta
Adhesions
Disease Associated with Adhesions
1. Endometrioma1
2. Tuboperitoneal abnormalities : Fimbrial, peritubal, peri-

ovarian adhesions2
1. Guerriero S, Ajossa S, Garau N, et al. Diagnosis of pelvic adhesions in patients with endometrioma: the role of trasnvaginal ultrasonography. American Society for Reproductive Medicine. 2010;94(2):742-746.
2. Guerriero S, Ajossa S, Lai MP, Mais V, Paoletti AM, Melis GB. Transvaginal ultrasonography in the diagnosis of pelvic adhesions. Hum Reprod. 1997;12(12):2849-53.
Problem of Adhesions
1. Limiting factors for correct laparoscopic surgery1
2. May be conversion to laparotomy1
3. Increase the difficulty of surgery and operating time1
4. Infertility (15-20%)2,3
5. Ectopic pregnancy3
2. Guerriero S, Ajossa S, Lai MP, Mais V, Paoletti AM, Melis GB. Transvaginal ultrasonography in the diagnosis of pelvic adhesions. Human Reproduction. 1997;12(12):2649-2653
3. Liakakos T, Thomakos N, Fine PM, Dervenis C, Young RL. Peritoneal adhesions: etiology, pathophysiology, and clinical significance. Digestive Surgery. 2001;18(4):260-273.
Endometrioma Associated with Adhesion Etiology
Endometriosis is one of the most common causes of pelvic pain
and infertility in women of reproductive age.1
Fibrous adhesion often form as a response to chronic irritation of

the peritoneal surface by the endometriotic implant and its
secretory product. 1
Ultrasonography Limitation
1. The size of endometrioma measured by transvaginal
ultrasound does not correlate with extent of adhesive disease
Transvaginal Ultrasonography Techniques
1. Find the endometrioma : circular homogeneous, hypoechoic
“tissue” without papillary proliferation and a clear demarcation
from the ovarian parenchyma was present.
2. Assess ovarian mobility with gentle pressure to the probe and

gentle abdominal palpation.
3. The tip of the probe gently squeeze the vaginal fornix

between the uterus and ovary
Ultrasonography Techniques
4. The adhesion was suspected when after the maneuvers, the
ovary remained linked to the uterus.
Ultrasound Sensitivity and Specificity
Source Sensitivity Specificity
Guerriero et al, 1997 - 86%1
Ubaldi et al,1998 61%2 -
Ezacoustos et al, 2003 91%3 -
Okaro et al, 2006 72%4 52%4
Yazbek et al, 2007 44%5 98%5
Guerriero et al, 2010 74%6 -
1. Guerriero S, Ajossa S, Lai MP, Mais V, Poletti AM, Melis GB. Transvaginal ultrasonography in the diganosis of pelvic adhesions. Hum Reprod. 1997;12:2649-53.
2. Ubaldi F, Wisanto A, Camus M, Tournaye H, Clasen K, Devroey P. The role of transvaginal ultrasonography in the detection of pelvic pathologies in the infertility workup. Hum Reprod. 1998;13:330-3.
3. Exacoustos C, Zupi E, Carusotti C, Rinaldo D, Marconi D, Lanzi G. Staging of pelvic endometriosis: role of sonographic appearance in determining extension of disease and modulating surgical approach. J Am Assoc Gynecol
Laparosc. 2003;10:378-82.
4. Okaro E, Condous G, Khalid A, Timmerman D, Ameye L, Huffel S, Bourne T. The use of ultrsound-based “soft markers” for the prediction of pelvic pathology in women with chronic pelvic pain-can we reduce the need for laparoscopy?
BJOG. 2006;113(3):251-256.
5. Yazbek J, Helmy S, Ben-Nagi J, Holland T, Sawyer E, Jurkovic D. Value of preoperative ultrasound examination in the selection of women with adnexal masses for laparoscopic surgery. Ultrasound in Obstetrics and Gynecology.
2007;30(6):883-888.
Tuboperitoneal Abnormalities Etiology
Fibrial, peritubal and peri-ovarian adhesions are a significant
cause of infertility and pelvic pain. 1
The adhesions may impair the reproductive prognosis, impairing
results of IVF, and with ovarian function.1
Paraovarian peritubal adhesions inhibit follicular growth by
possible ovarian entrapment from adhesions around the ovaries.2
Peritubal and intratubal adhesions may affect tubal motility and
ovum transport. This lead to infertility or ectopic pregnancy. 2
Transvaginal USG Role
1. Monitoring ovarian follicle growth
2. Monitoring ovulation and corpus luteum formation
3. Evaluating the normal anatomy of the uterus and cervix and
their cyclical responses to ovarian steroids
Transvaginal Ultrasonography Findings
1. Blurring of the margins of the ovary, defined as the
absence of the exact contour of the ovary in more than
three-quarters of the ovary.
2. Adhesion from the ovary to the uterus, which persisted
with abdominal palpation (fixation)
3. Augmentation of the usual distance of the ovary from
the probe which persisted with abdominal palpation
(distance). The maximum distance from the probe 11
mm is the cut-off value.
Therapeutical Strategies
1. Detect tubal patency using transvaginal
hysterosalpingo-contrast songraphy with an echo
contrast agent
2. Laparoscopy to confirm the diagnosis and to remove
the adhesions
3. Adhesiolysis is an effective treatment of infertility and
associated with a good pregnancy rate.
Ultrasound Sensitivity and Specificity
Method Sensitivity Specificity
Fixation 43% 62%
Distance 31% 61%
Margins 51% 45%
At least one positive test 62% 38%
Three positive tests 20% 68%
Haemorrhagic Cyst Rupture
(Haematoperitoneum)
Introduction
Haematoperitoneum is a serious complication of ovarian
haemorrhagic cyst rupture1
Presenting symptoms : acute abdominal pain radiating to the
back or shoulder tip, nausea/vomiting, bloating/distension,
pain intensely exacerbated by movement, decreased urine
output, cold peripheries and decreased consciousness.2
2. Nyhsen C, Mahmood SU. Life-threatening haemoperitoneum secondary to rupture of simple ovarian cyst. BMJ Case Rep. 2014:1-4.
Etiology of Haematoperitoneum
1. Gynecological pathologies : rupture of ovarian cysts is the
most common cause, often presenting with pain. Most
incidental ovarian cysts resolve within 60 days without
intervention, serial USG is needed for follow up.
2. Hepatic pathologies : spontaneous rupture of liver lesions
may occur most commonly due to hepatocellular
carcinoma. Other causes are metastasis although rare,
and larger adenocarcinoma often present with massive
bleeding.
3. Splenic pathologies : most common causes is infection
(cytomegalovirus, Epstein-Barr virus or malaria) and splenic
infiltration in cases of lymphoma or leukaemia. Other cause
are focal splenic lesions or diffuse infiltration of the spleen
(amyloidosis or Gaucher’s disease)
4. Vascular pathologies : ruptured aneurysms may lead to
spontaneous massive haemoperitoneum. Massive
haemorrhage from venous origins is usually related with
varices (particularly in patients with cirrhosis and portal
hypertension).
5. Coagulopathies : patients with congenital coagulopathies
(such as haemophilia or congenital factor X deficiency).
Imaging Role
1. CT Scan : the modality of choice if significant haemorrhage is
suspected and if the cause is unclear. It has the advantage of
demonstrating acute extravasation of contrast if present.
Indicating the possible location of bleeding and urgency of
emergency surgery.
2. USG : helpful in acute setting. Superior imaging modality when
pelvic pathology is suspected. TVUS demonstrates female pelvic
organs more clearly than CT scan.
Imaging Role
Categorization of the amount of pelvic fluid :
1. None or trace
2. Small (limited to the cul-de sac)
3. Moderate (fluic around the liver, paracolic gutter, and pelvis)
4. Large (additional fluid between the small bowel loops and colon)
Imaging Role
3. MRI : not usually used as first line but may be helpful in unclear
bleeding sources.
Imaging Findings
1. USG :
• Peritoneal/pelvic free fluid is seen with low level echoes in the
pouch of Douglas, Morison’s pouch or in the least upper
quadrant.1,2,3,5
• The cyst may have a crenated appearance. 1,5
• Hemoperitoneum shown as blood tracking into the upper
quadrants of the abdomen. 3,4
1. Roche O, Chavan N, Aquilina J, Rockall A. Radiological appearances of gynecological emergencies. Insights imaging. 2012;3(3):265-275.
2. Baby V, Morgan MA, et al. Ruptured ovarian cyst, Radiopaedia. [accessed in 13/01/2019] https://radiopaedia.org/articles/ruptured-ovarian-cyst
3. Dupuis CS, Kim Yh. Ultrasonography of adnexal causes of acute pelvic pain in pre-menopausal non-pregnant women. Ultrasonography. 2015;34:258-267.
5. Singhal M, Tiwari O. Sonographic appearance of bilateral hemorrhagic cysts of the ovaries with rupture on transvaginal sonography. 2010.JDMS;26:46-49.
Imaging Findings
2. CT : contrast-enhanced blood pooling in the pelvis. CT has
limitation to identify the ovaries separately from surrounding
anatomical structures so it can be challenging to distinguish the
lesions origin.
2. Baby V, Morgan MA, et al. Ruptured ovarian cyst, Radiopaedia. [accessed in 13/01/2019] https://radiopaedia.org/articles/ruptured-ovarian-cyst
3. Dupuis CS, Kim Yh. Ultrasonography of adnexal causes of acute pelvic pain in pre-menopausal non-pregnant women. Ultrasonography. 2015;34:258-267.
Imaging Findings
3. MRI : free peritoneal fluid with areas of both low and high signal
intensity depending on the extent of blood clot formation. 1
If clots develop, layers of low signal intensity fluid levels are often
seen on T2-weighted images mixed with high signal intensity fluid. 1
In haemorrhagic ascites, the signal intensity is higher than urine on
T1 and lower on T2.1
Dermoid Cyst Rupture
Introduction
Dermoid cysts are the most common ovarian neoplasm, the
prevalence berween 10-25% of ovarian tumors, it happens bilateral
in 8-15% of the cases.
Complications include torsion (16%), malignant degeneration (2%),
rupture (1-2%), and infection (1%).
1. Fibur TF. Intraperitoneal rupture of a benign cystic ovarian teratoma: findings at CT and MR imaging. AJR. 2000:174
Clinical Presentation
Spontaneous rupture is rare because usually thick capsule
present.1,2
Two clinical presentations are associated with the intraperitoneal
rupture of benign cystic teratomas. 1
1. Acute peritonitis caused by the sudden rupture of tumor contents,
occur spontaneously or more commonly in association with
torsion, trauma, infection, or labor. 1
2. Nitinavakarn B, Prasertjaroensook V, Kularkaew C. Spontaneous rupture of an ovarian dermoid cyst associated with intra-abdominal chemical peritonitis: characteristic CT findings and
literature review. J Med Assoc Thai. 2006;89(4):513-517.
Clinical Presentation
2. Chronic granulomatous peritonitis resulting from a chronically
leaking dermoid, which can be characterized by multiple small
white peritoneal implants, dense adhesions, and variable ascites
that simulate carcinomatosis or tuberculous peritonitis.
Imaging Findings
Dispersed globules of fat within the peritoneum and signs of a
chemical peritonitis with stranding in the peritoneal fat.
CT Scan Findings
1. Rupture of sebaceous materal into the peritoneal cavity, including
fatty-fluid layering ascites and fatty implants.
2. The fat globules may embed in the peritoneal cavity or visceral
surface, such as the liver.
Endometriotic Cyst Rupture
Introduction
Endometriosis cysts generally occur within the ovaries as the result
of repeated cyclic hemorrhage within a deep implant.
Acute cyst rupture is a relatively uncommon
May be associated with severe peritonitis and systemic disturbance
followed by adhesion formation
1. Lee YR. CT imaging finfings of ruptured ovarian endometriotic cysts: emphasis on the differential diagnosis with ruptured ovarian functional cysts. Korean J Radiol. 2011;12(1):59-65.
Etiology
Blood and endometrial cells shed into the peritoneal cavity may
irritate and stimulate the peritoneum and resulting in ascites.
1. Lee YR. CT imaging finfings of ruptured ovarian endometriotic cysts: emphasis on the differential diagnosis with ruptured ovarian functional cysts. Korean J Radiol. 2011;12(1):59-65.
Imaging Findings
Multilocular/bilateral ovarian cysts with a thick wall and have
loculated ascites confined to the pelvic cavity with pelvic fat
infiltration on CT.

2019, Ultrasonography of Complicated Gynecology Cases

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ULTRASONOGRAPHY

2. Tuboperitoneal abnormalities : Fimbrial, peritubal, peri-

2. May be conversion to laparotomy1

3. Increase the difficulty of surgery and operating time1

Fibrous adhesion often form as a response to chronic irritation of

2. Assess ovarian mobility with gentle pressure to the probe and

3. The tip of the probe gently squeeze the vaginal fornix

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