Trauma/Emergency Radiology

CT and MR Imaging of Gynecologic Emergencies

Published Online:https://doi.org/10.1148/rg.2017160170

This article reviews the clinical and imaging features of acute gynecologic diseases and highlights the CT and MR imaging findings to help radiologists increase diagnostic accuracy.

Gynecologic emergencies include various diseases that result from adnexal and uterine disorders. Adnexal disorders may be classified into the following three categories: (a) disorders that cause hemorrhage (hemorrhagic ovarian cysts and ectopic pregnancies); (b) disorders related to adnexal tumors (adnexal torsion and rupture of ovarian tumors); and (c) disorders related to pelvic inflammatory disease, such as tubo-ovarian abscesses. Unusual adnexal torsion, such as massive ovarian edema, isolated fallopian tube torsion, and paraovarian cyst torsion, has also been described. Uterine disorders in gynecologic emergencies may be classified into two categories: (a) acute fibroid complications, including red degeneration of a uterine leiomyoma, torsion of subserosal myomas, and torsion of the uterus; and (b) causes of acute uterine bleeding, including retained products of conception and uterine arteriovenous malformations. Some gynecologic diseases are self-limited, while others cause infertility or life-threatening infection or bleeding if left untreated. Therefore, prompt and accurate diagnosis is important for appropriate life-saving treatment and for the preservation of fertility. The imaging findings are important when evaluating acute gynecologic diseases because the symptoms and physical examination findings are often nonspecific and limited. Ultrasonography is the first-line imaging modality; however, when a definitive diagnosis cannot be established, computed tomography (CT) and magnetic resonance (MR) imaging may narrow the differential diagnosis. Appropriate management requires radiologists to be familiar with the CT and MR imaging features of gynecologic emergencies. With respect to rare conditions, radiologists should take into account the representative findings presented in this article to increase diagnostic accuracy.

©RSNA, 2017

References

  • 1. Marin D, Boll DT, Mileto A, Nelson RC. State of the art: dual-energy CT of the abdomen. Radiology 2014;271(2):327–342.
  • 2. Aran S, Daftari Besheli L, Karcaaltincaba M, Gupta R, Flores EJ, Abujudeh HH. Applications of dual-energy CT in emergency radiology. AJR Am J Roentgenol 2014;202(4):W314–W324.
  • 3. Bennett GL, Slywotzky CM, Giovanniello G. Gynecologic causes of acute pelvic pain: spectrum of CT findings. RadioGraphics 2002;22(4):785–801.
  • 4. Kim JH, Lee SM, Lee JH, et al. Successful conservative management of ruptured ovarian cysts with hemoperitoneum in healthy women. PLoS One 2014;9(3):e91171.
  • 5. Potter AW, Chandrasekhar CA. US and CT evaluation of acute pelvic pain of gynecologic origin in nonpregnant premenopausal patients. RadioGraphics 2008;28(6):1645–1659.
  • 6. Dohke M, Watanabe Y, Okumura A, et al. Comprehensive MR imaging of acute gynecologic diseases. RadioGraphics 2000;20(6):1551–1566.
  • 7. Kanso HN, Hachem K, Aoun NJ, et al. Variable MR findings in ovarian functional hemorrhagic cysts. J Magn Reson Imaging 2006;24(2):356–361.
  • 8. Kao LY, Scheinfeld MH, Chernyak V, Rozenblit AM, Oh S, Dym RJ. Beyond ultrasound: CT and MRI of ectopic pregnancy. AJR Am J Roentgenol 2014;202(4):904–911.
  • 9. Chang HC, Bhatt S, Dogra VS. Pearls and pitfalls in diagnosis of ovarian torsion. RadioGraphics 2008;28(5):1355–1368.
  • 10. Lourenco AP, Swenson D, Tubbs RJ, Lazarus E. Ovarian and tubal torsion: imaging findings on US, CT, and MRI. Emerg Radiol 2014;21(2):179–187.
  • 11. Duigenan S, Oliva E, Lee SI. Ovarian torsion: diagnostic features on CT and MRI with pathologic correlation. AJR Am J Roentgenol 2012;198(2):W122–W131.
  • 12. Rha SE, Byun JY, Jung SE, et al. CT and MR imaging features of adnexal torsion. RadioGraphics 2002;22(2):283–294.
  • 13. Patil AR, Nandikoor S, Rao A, et al. Multimodality imaging in adnexal torsion. J Med Imaging Radiat Oncol 2015;59(1):7–19.
  • 14. Fujii S, Kaneda S, Kakite S, et al. Diffusion-weighted imaging findings of adnexal torsion: initial results. Eur J Radiol 2011;77(2):330–334.
  • 15. Kato H, Kanematsu M, Uchiyama M, Yano R, Furui T, Morishige K. Diffusion-weighted imaging of ovarian torsion: usefulness of apparent diffusion coefficient (ADC) values for the detection of hemorrhagic infarction. Magn Reson Med Sci 2014;13(1):39–44.
  • 16. Kilickesmez O, Tasdelen N, Yetimoglu B, Kayhan A, Cihangiroglu M, Gurmen N. Diffusion-weighted imaging of adnexal torsion. Emerg Radiol 2009;16(5):399–401.
  • 17. Moribata Y, Kido A, Yamaoka T, et al. MR imaging findings of ovarian torsion correlate with pathological hemorrhagic infarction. J Obstet Gynaecol Res 2015;41(9):1433–1439.
  • 18. Praveen R, Pallavi V, Rajashekar K, Usha A, Umadevi K, Bafna U. A clinical update on massive ovarian oedema: a pseudotumour? Ecancermedicalscience 2013;7(1):318.
  • 19. Lee AR, Kim KH, Lee BH, Chin SY. Massive edema of the ovary: imaging findings. AJR Am J Roentgenol 1993;161(2):343–344.
  • 20. Chiou SY, Lev-Toaff AS, Masuda E, Feld RI, Bergin D. Adnexal torsion: new clinical and imaging observations by sonography, computed tomography, and magnetic resonance imaging. J Ultrasound Med 2007;26(10):1289–1301.
  • 21. Yamashiro T, Inamine M, Kamiya H, Kinjo A, Murayama S, Aoki Y. Massive ovarian edema with torsion: unusual hemorrhage and the recovery of contrast enhancement. Emerg Radiol 2008;15(2):115–118.
  • 22. Geist RR, Rabinowitz R, Zuckerman B, et al. Massive edema of the ovary: a case report and review of the pertinent literature. J Pediatr Adolesc Gynecol 2005;18(4):281–284.
  • 23. Cheng MH, Tseng JY, Suen JH, Yang CC. Laparoscopic plication of partially twisted ovary with massive ovarian edema. J Chin Med Assoc 2006;69(5):236–239.
  • 24. Lo LM, Chang SD, Lee CL, Liang CC. Clinical manifestations in women with isolated fallopian tubal torsion: a rare but important entity. Aust N Z J Obstet Gynaecol 2011;51(3):244–247.
  • 25. Vijayaraghavan SB, Senthil S. Isolated torsion of the fallopian tube: the sonographic whirlpool sign. J Ultrasound Med 2009;28(5):657–662.
  • 26. Harmon JC, Binkovitz LA, Binkovitz LE. Isolated fallopian tube torsion: sonographic and CT features. Pediatr Radiol 2008;38(2):175–179.
  • 27. Casey RK, Damle LF, Gomez-Lobo V. Isolated fallopian tube torsion in pediatric and adolescent females: a retrospective review of 15 cases at a single institution. J Pediatr Adolesc Gynecol 2013;26(3):189–192.
  • 28. Toyoshima M, Mori H, Kudo K, et al. Isolated torsion of the fallopian tube in a menopausal woman and a pre-pubertal girl: two case reports. J Med Case Reports 2015;9:258.
  • 29. Rezvani M, Shaaban AM. Fallopian tube disease in the nonpregnant patient. RadioGraphics 2011;31(2):527–548.
  • 30. Gross M, Blumstein SL, Chow LC. Isolated fallopian tube torsion: a rare twist on a common theme. AJR Am J Roentgenol 2005;185(6):1590–1592.
  • 31. Kiseli M, Caglar GS, Cengiz SD, Karadag D, Yılmaz MB. Clinical diagnosis and complications of paratubal cysts: review of the literature and report of uncommon presentations. Arch Gynecol Obstet 2012;285(6):1563–1569.
  • 32. Yilmaz Y, Ozen IO, Caliskan D, Dilmen U. Paraovarian cyst torsion in children: report of two cases. Pediatr Int 2013;55(6):795–797.
  • 33. Fibus TF. Intraperitoneal rupture of a benign cystic ovarian teratoma: findings at CT and MR imaging. AJR Am J Roentgenol 2000;174(1):261–262.
  • 34. Ayhan A, Bukulmez O, Genc C, Karamursel BS, Ayhan A. Mature cystic teratomas of the ovary: case series from one institution over 34 years. Eur J Obstet Gynecol Reprod Biol 2000;88(2):153–157.
  • 35. Hosokawa T, Sato Y, Seki T, Maebara M, Ito K, Kuribayashi S. Malignant transformation of a mature cystic teratoma of the ovary with rupture. Jpn J Radiol 2010;28(5):372–375.
  • 36. Dai X, Jin C, Hu Y, et al. High CA-125 and CA19-9 levels in spontaneous ruptured ovarian endometriomas. Clin Chim Acta 2015;450:362–365.
  • 37. Lee YR. CT imaging findings of ruptured ovarian endometriotic cysts: emphasis on the differential diagnosis with ruptured ovarian functional cysts. Korean J Radiol 2011;12(1):59–65.
  • 38. Kurata H, Sasaki M, Kase H, Yamamoto Y, Aoki Y, Tanaka K. Elevated serum CA125 and CA19-9 due to the spontaneous rupture of ovarian endometrioma. Eur J Obstet Gynecol Reprod Biol 2002;105(1):75–76.
  • 39. Corwin MT, Gerscovich EO, Lamba R, Wilson M, McGahan JP. Differentiation of ovarian endometriomas from hemorrhagic cysts at MR imaging: utility of the T2 dark spot sign. Radiology 2014;271(1):126–132.
  • 40. Kim SH, Kim SH, Yang DM, Kim KA. Unusual causes of tubo-ovarian abscess: CT and MR imaging findings. RadioGraphics 2004;24(6):1575–1589.
  • 41. Ha HK, Lim GY, Cha ES, et al. MR imaging of tubo-ovarian abscess. Acta Radiol 1995;36(5):510–514.
  • 42. Sam JW, Jacobs JE, Birnbaum BA. Spectrum of CT findings in acute pyogenic pelvic inflammatory disease. RadioGraphics 2002;22(6):1327–1334.
  • 43. Koh DM, Collins DJ. Diffusion-weighted MRI in the body: applications and challenges in oncology. AJR Am J Roentgenol 2007;188(6):1622–1635.
  • 44. Ueda H, Togashi K, Konishi I, et al. Unusual appearances of uterine leiomyomas: MR imaging findings and their histopathologic backgrounds. RadioGraphics 1999;19(Spec Issue):S131–S145.
  • 45. Roche O, Chavan N, Aquilina J, Rockall A. Radiological appearances of gynaecological emergencies. Insights Imaging 2012;3(3):265–275.
  • 46. Kawakami S, Togashi K, Konishi I, et al. Red degeneration of uterine leiomyoma: MR appearance. J Comput Assist Tomogr 1994;18(6):925–928.
  • 47. Roy C, Bierry G, El Ghali S, Buy X, Rossini A. Acute torsion of uterine leiomyoma: CT features. Abdom Imaging 2005;30(1):120–123.
  • 48. Marcotte-Bloch C, Novellas S, Buratti MS, Caramella T, Chevallier P, Bruneton JN. Torsion of a uterine leiomyoma: MRI features. Clin Imaging 2007;31(5):360–362.
  • 49. Gupta S, Manyonda IT. Acute complications of fibroids. Best Pract Res Clin Obstet Gynaecol 2009;23(5):609–617.
  • 50. Matsumoto H, Ohta T, Nakahara K, Kojimahara T, Kurachi H. Torsion of a nongravid uterus with a large ovarian cyst: usefulness of contrast MR image. Gynecol Obstet Invest 2007;63(3):163–165.
  • 51. Nicholson WK, Coulson CC, McCoy MC, Semelka RC. Pelvic magnetic resonance imaging in the evaluation of uterine torsion. Obstet Gynecol 1995;85(1, pt 2):888–890.
  • 52. Jeong YY, Kang HK, Park JG, Choi HS. CT features of uterine torsion. Eur Radiol 2003;13(suppl 6):L249–L250.
  • 53. Sharma D, Usha M. Torsion of a non-gravid uterus: a rare cause of acute abdomen. Int J Reprod Contracept Obstet Gynecol 2013;2(2):234–236.
  • 54. Luk SY, Leung JL, Cheung ML, So S, Fung SH, Cheng SC. Torsion of a nongravid myomatous uterus: radiological features and literature review. Hong Kong Med J 2010;16(4):304–306.
  • 55. Hawes CH. Acute axial torsion of the uterus. Ann Surg 1935;102(1):37–40.
  • 56. Sellmyer MA, Desser TS, Maturen KE, Jeffrey RB Jr, Kamaya A. Physiologic, histologic, and imaging features of retained products of conception. RadioGraphics 2013;33(3):781–796.

  • 57. Kamaya A, Petrovitch I, Chen B, Frederick CE, Jeffrey RB. Retained products of conception: spectrum of color Doppler findings. J Ultrasound Med 2009;28(8):1031–1041.
  • 58. Kido A, Togashi K, Koyama T, et al. Retained products of conception masquerading as acquired arteriovenous malformation. J Comput Assist Tomogr 2003;27(1):88–92.
  • 59. Kitahara T, Sato Y, Kakui K, Tatsumi K, Fujiwara H, Konishi I. Management of retained products of conception with marked vascularity. J Obstet Gynaecol Res 2011;37(5):458–464.
  • 60. Cura M, Martinez N, Cura A, Dalsaso TJ, Elmerhi F. Arteriovenous malformations of the uterus. Acta Radiol 2009;50(7):823–829.
  • 61. Huang MW, Muradali D, Thurston WA, Burns PN, Wilson SR. Uterine arteriovenous malformations: gray-scale and Doppler US features with MR imaging correlation. Radiology 1998;206(1):115–123.
  • 62. Müngen E, Dundar O, Babacan A. Postabortion Doppler evaluation of the uterus: incidence and causes of myometrial hypervascularity. J Ultrasound Med 2009;28(8):1053–1060.

Article History

Received: June 29 2016
Revision requested: Sept 16 2016
Revision received: Nov 10 2016
Accepted: Jan 17 2017
Published online: July 28 2017
Published in print: Sept 2017