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Donald School Journal of Ultrasound in Obstetrics and Gynecology, January-March 2016;10(1):42-49 43 Jennifer Lum, Mark Hiraoka

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Donald School Journal of Ultrasound in Obstetrics and Gynecology, January-March 2016;10(1):42-49 43 Jennifer Lum, Mark Hiraoka DSJUOG Jennifer Lum, Mark Hiraoka 10.5005/jp-journals-10009-1441 REVIEW ARTICLE Just Images: Gynecology 1Jennifer Lum, 2Mark Hiraoka ABSTRACT one cesarean section. She had a copper intrauterine device Diagnostic ultrasound is the primary imaging modality utilized (IUD) placed 4 years ago and denies any history of sexual to detect abnormalities of the female reproductive tract. The transmitted diseases. On examination, the uterus was following cases represent some of the interesting cases imaged slightly enlarged with active bleeding from the cervical at our institution. os. The IUD strings were visualized (Figs 1A to E). Objectives: Interpret ultrasound images of the female repro­ ductive tract. Assimilate the interpretation of sonographic images What is Your Diagnosis? into a differential diagnosis. Correlate sonographic imaging with clinical outcomes. • IUD arm perforated into anterior myometrium Keywords: Cornual ectopic pregnancy, Dermoid, Gestational • IUD arms not deployed properly trophoblastic disease, Intrauterine device, Ovarian torsion, • IUD in lower uterine segment Ultrasound. • IUD not present in uterus How to cite this article: Lum J, Hiraoka M. Just Images: • IUD properly placed in uterus. Gynecology. Donald School J Ultrasound Obstet Gynecol 2016;10(1):42­49. Clinical Course Source of support: Nil Patient had the IUD removed in the office setting without Conflict of interest: None incident. She declined any further contraception. Her heavy bleeding resolved. INTRODUCTION Diagnostic ultrasound is used extensively to image Discussion the female reproductive tract. Ultrasound can provide The copper IUD is very echogenic and easily seen valuable information assisting obstetrician gynecologists on ultrasound. One of the more popular IUDs is the diagnose and manage many gynecologic problems they IUD that contains 52 mg of levonorgestrel. It can be face in clinical practice. difficult to identify because only the proximal and distal The following series of interesting thought-provoking ends of the arms produce a detectable echo. A dark cases were evaluated with both transabdominal and sonographic shadow also helps with localization.1 Three- transvaginal ultrasound at our institution. These images dimensional ultrasound is often required to determine are used to develop differential diagnoses and are later the relationship between the arms of the IUD and the correlated with clinical outcomes. uterine cavity.2 Malposition may be more likely during difficult insertions, such as in patients with a retroverted CASE REPORTS uterus, adenomyosis or obesity. Approximately 10% of 3 Case 1 IUD are malpositioned, however, not all malpositioned IUD require removal. If the patient reports cramping or Fifty-year-old gravida 2 para 2002 female who presented abnormal bleeding, then consideration should be given with abdominal pain for the past 2 days and heavy to removing the IUD. Data, although limited, supports menses. She was currently on day 5 of her period and keeping the levonorgestrel IUD in place in asymptomatic was passing large clots requiring two tampons an hour. patients. Pregnancy rates seem to be similar in cases Past obstetrical history included one vaginal delivery and where the levonorgestrel IUD is located in the endocervix when compared to those in located in the fundus.4 1,2Assistant Professor Unfortunately, data involving malpositioned copper IUDs is limited. 1,2Department of Obstetrics and Gynecology and Women’s Health, John A Burns School of Medicine, University of Hawaii Perforation complicates approximately 1 in 1000 IUD Honolulu, Hawaii, USA insertions.5 Rates are similar for the levonorgestrel IUD Corresponding Author: Mark Hiraoka, Assistant Professor and copper IUD. Once perforations are recognized they Department of Obstetrics and Gynecology and Women’s Health should be removed unless surgical risks are excessive. John A Burns School of Medicine, University of Hawaii, Honolulu Intra-abdominal IUDs are often removed laparoscopically. Hawaii, USA, e­mail: [email protected] IUDs that are embedded in the myometrium may require 42 DSJUOG Just Images: Gynecology A B C D E Figs 1A to E: Intrauterine device in utero hysteroscopic removal. Prior IUD perforation is not a What is Your Diagnosis? contraindication to future IUD use; however, placement • Dysgerminoma under ultrasound guidance should be considered. • Tubo-ovarian abscess Case 2 • Borderline mucinous cystadenoma • Mature cystic teratoma (dermoid) Thirteen-year-old gravida 0 female presented with 1 day • Granulosa cell tumor. of abdominal pain. The pain was intermittent and became progressively worse and constant. She reported nausea Clinical Course and vomiting. She denied fever or chills. She reported menarche at age 11, irregular menses, and denied sexual The patient was taken to surgery and underwent an uncom- activity. She was tender to palpation in bilateral lower plicated mini-laparotomy with right ovarian cystectomy. quadrants with guarding (Figs 2A to D). Pathology revealed a mature cystic teratoma (Figs 3A and B). Donald School Journal of Ultrasound in Obstetrics and Gynecology, January-March 2016;10(1):42-49 43 Jennifer Lum, Mark Hiraoka A B C D Figs 2A to D: Thirteen-year-old with an ovarian mass A B Figs 3A and B: Dermoid cyst Discussion of the cyst (bone, hair, teeth and fat) cause intense echoes. Thin echogenic lines can represent strands of hair. The Dermoid cysts are also known as mature cystic teratomas. absence of color flow in the solid areas on Doppler They are benign tumors that contain ectoderm, mesoderm examination is a key characteristic of these lesions.6 and endoderm. They often contain fat, teeth, bone and Dermoid cysts can be mistaken for endometriomas, hair. The classic sonographic appearance of a dermoid fibromas and struma ovarii. Surgical removal is the cyst is an echogenic mass with acoustic shadowing. This treatment of choice once a dermoid cyst is suspected shadowing can obscure the back wall of the cyst, making to prevent complications, such as torsion, rupture or it difficult to obtain accurate measurements. The contents malignant transformation. 44 DSJUOG Just Images: Gynecology Case 3 performed without complication. Pathology revealed Forty-seven-year-old gravida 0 female with right lower a benign cyst with hemorrhage consistent with torsion quadrant pain that she rated 10/10, decreased appetite (Figs 5A to C). and some nausea. She previously had a total laparoscopic hysterectomy for fibroids and heavy uterine bleeding. Discussion Her right and left ovary were normal at that time. She Ovarian torsion is defined as the twisting by at least presented to an outside hospital where a computed one complete turn of the ovary or tube around the tomography (CT) scan and transvaginal ultrasound were infundibulopelvic ligament and tubo-ovarian ligament. both inconclusive. She was given pain medications and This results in decreased blood supply and subsequent sent home. ischemia. Delayed diagnosis can lead to irreversible Pain continued so she had repeat ultrasound at our tissue ischemia and eventual loss of the torsed tube institution 4 days later (Figs 4A to D). or ovary. On ultrasound, a torsed ovary typically is large, edematous with multiple, small follicles along What is Your Diagnosis? the periphery and ovarian tissue with a heterogeneous • Hemorrhagic cyst echotexture. Often the low pressure venous flow is the • Abscess first to be eliminated, while higher pressure arterial • Endometrioma flow continues to send blood to the ovary and tube. This • Hydrosalpinx leads to the enlarged, edematous appearance. Inability • Ovarian torsion. to demonstrate blood flow on color Doppler can help with the diagnosis, however, the presence of blood flow Clinical Course cannot be used to confidently rule out torsion. The flow The patient underwent a laparoscopy which confirmed may be intermittent or diminished. Doppler studies may right ovarian torsion and a right oophorectomy was reveal a spiral appearance of the vessels. This is known as A B C D Figs 4A to D: Forty-seven-year-old with right lower quadrant pain Donald School Journal of Ultrasound in Obstetrics and Gynecology, January-March 2016;10(1):42-49 45 Jennifer Lum, Mark Hiraoka A B C Figs 5A to C: Ovarian torsion on laparoscopy (Case 3) the ‘whirlpool’ sign and represents the twisted vascular What is Your Diagnosis? pedicle. The presence of the whirlpool sign has a high • Normal intrauterine pregnancy positive predictive value for diagnosing torsion.7,8 • Tubal ectopic pregnancy—ampullary region Management of suspected ovarian torsion is surgical. • Tubal ectopic pregnancy—fimbria The decision to proceed with surgical evaluation is • Cornual ectopic pregnancy based on clinical findings. The goal of surgery is to • Ovarian ectopic pregnancy. confirm the diagnosis of torsion and then to evaluate the viability of the ovary and tube. Determining viability Clinical Course is sometimes difficult. Many women (even those with The beta-hCG = 6081 2 days later and she received a dose an ovary that is blue or black) retain ovarian function of methotrexate at that time. Four days later the beta-hCG 9 following detorsion. Therefore, ovarian conservation = 5450 and she received another dose of methotrexate. Two in premenopausal women is recommended unless weeks later her beta-hCG had dropped to 70 and finally there is a high degree of certainty that the ovary is not went negative a month later. No surgery was required. viable. Discussion Case 4 Cornual (or interstitial) ectopic
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