Gynecologic Emergencies: Findings Beyond US and Advances in Management

Hu M, Poder L, Filly RA. Impact of new society of radiologists in ultrasound early first-trimester diagnostic criteria for nonviable pregnancy. J Ultrasound Med. 2014;33(9):1585–8. doi:10.7863/ultra.33.9.1585. •• Doubilet PM, Benson CB, Bourne T, Blaivas M, Society of Radiologists in Ultrasound Multispecialty Panel on Early First Trimester Diagnosis of M, Exclusion of a Viable Intrauterine P, et al. Diagnostic criteria for nonviable pregnancy early in the first trimester. N Engl J Med. 2013;369(15):1443–51. doi:10.1056/NEJMra1302417. With new evidence showing that previously accepted criteria for ruling out a viable pregnancy are not stringent enough to avoid false positive test results it is imperative to refine the diagnosis of nonviability. The authors recommend using a discriminatory value of beta-hCG levels ≥3000 mIU per milliliter, a follow up hCG and ultrasound before undertaking definitive treatment for ectopic pregnancy. Trabert B, Holt VL, Yu O, Van Den Eeden SK, Scholes D. Population-based ectopic pregnancy trends, 1993-2007. Am J Prev Med. 2011;40(5):556–60. doi:10.1016/j.amepre.2010.12.026. Marion LL, Meeks GR. Ectopic pregnancy: history, incidence, epidemiology, and risk factors. Clin Obstet Gynecol. 2012;55(2):376–86. doi:10.1097/GRF.0b013e3182516d7b. Creanga AA, Shapiro-Mendoza CK, Bish CL, Zane S, Berg CJ, Callaghan WM. Trends in ectopic pregnancy mortality in the United States: 1980-2007. Obstet Gynecol. 2011;117(4):837–43. doi:10.1097/AOG.0b013e3182113c10. Kirk E, Bottomley C, Bourne T. Diagnosing ectopic pregnancy and current concepts in the management of pregnancy of unknown location. Hum Reprod Update. 2014;20(2):250–61. doi:10.1093/humupd/dmt047. American College of Obstetricians & Gynecologists. ACOG Practice Bulletin No. 94: medical management of ectopic pregnancy. Obstet Gynecol. 2008;111(6):1479–85. doi:10.1097/AOG.0b013e31817d201e. • Ko JK, Cheung VY. Time to revisit the human chorionic gonadotropin discriminatory level in the management of pregnancy of unknown location. J Ultrasound Med. 2014;33(3):465–71. doi:10.7863/ultra.33.3.465. Viable intrauterine pregnancy is possible in patients with pregnancy of unknown location and hCG levels above the generally accepted discriminatory zone, supporting the need for judicious use of the hCG discriminatory level in hemodynamically stable patients with pregnancy of unknown location. A decision to intervene should not be based solely on a single hCG level. Bignardi T, Condous G, Kirk E, Van Calster B, Van Huffel S, Timmerman D, et al. Viability of intrauterine pregnancy in women with pregnancy of unknown location: prediction using human chorionic gonadotropin ratio vs. progesterone. Ultrasound Obstet Gynecol. 2010;35(6):656–61. doi:10.1002/uog.7669. •• van Mello NM, Mol F, Opmeer BC, Ankum WM, Barnhart K, Coomarasamy A, et al. Diagnostic value of serum hCG on the outcome of pregnancy of unknown location: a systematic review and meta-analysis. Hum Reprod Update. 2012;18(6):603–17. doi:10.1093/humupd/dms035. In women with PUL diagnostic strategies, meta analysis shows that using serum hCG ratios, either alone or in logistic regression models, have the best diagnostic performance in the case of EP. Well defined prospective comparative studies using standardized diagnostics and clinical application plus agreed definitions of outcome will be required to identify the best strategy to diagnose pregnancy outcome in women with PUL. Riaz RM, Williams TR, Craig BM, Myers DT. Cesarean scar ectopic pregnancy: imaging features, current treatment options, and clinical outcomes. Abdom Imaging. 2015;. doi:10.1007/s00261-015-0472-2. Parker RA 3rd, Yano M, Tai AW, Friedman M, Narra VR, Menias CO. MR imaging findings of ectopic pregnancy: a pictorial review. 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Independent risk factors for placental abruption include preterm premature rupture of membranes, gestational hypertension, preeclampsia and major multiparity. While appropriate multidisciplinary management can limit maternal morbidity and mortality, perinatal mortality, which occurs in utero, remains very significant. Glantz C, Purnell L. Clinical utility of sonography in the diagnosis and treatment of placental abruption. J Ultrasound Med. 2002;21(8):837–40. •• Masselli G, Brunelli R, Di Tola M, Anceschi M, Gualdi G. MR imaging in the evaluation of placental abruption: correlation with sonographic findings. Radiology. 2011;259(1):222–30. doi:10.1148/radiol.10101547. If clinical stability allows, MR is the best next step after a negative US for patients with high suspicion for abruption, with a sensitivity of almost 100%. MR can also determine the age of the bleed, which is useful for prognosis. Oyelese Y, Ananth CV. Placental abruption. Obstet Gynecol. 2006;108(4):1005–16. doi:10.1097/01.AOG.0000239439.04364.9a. Manriquez M, Srinivas G, Bollepalli S, Britt L, Drachman D. Is computed tomography a reliable diagnostic modality in detecting placental injuries in the setting of acute trauma? Am J Obstet Gynecol. 2010;202(6):611.e1–615. doi:10.1016/j.ajog.2010.01.027. Durfee SM, Frates MC, Luong A, Benson CB. The sonographic and color Doppler features of retained products of conception. J Ultrasound Med. 2005;24(9):1181–6 quiz 8-9. •• 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):781–96. doi:10.1148/rg.333125177. US is the gold standard imaging modality for abruption. Both gray-scale and color Doppler are complimentary with findings of increased endometrial echo complex with vascularity extending from the myometrium to the endometrium. Sadan O, Golan A, Girtler O, Lurie S, Debby A, Sagiv R, et al. Role of sonography in the diagnosis of retained products of conception. J Ultrasound Med. 2004;23(3):371–4. Ustunyurt E, Kaymak O, Iskender C, Ustunyurt OB, Celik C, Danisman N. Role of transvaginal sonography in the diagnosis of retained products of conception. Arch Gynecol Obstet. 2008;277(2):151–4. doi:10.1007/s00404-007-0436-z. • Kamaya A, Krishnarao PM, Folkins AK, Jeffrey RB, Desser TS, Maturen KE. Variable color Doppler sonographic appearances of retained products of conception: radiologic-pathologic correlation. Abdom Imaging. 2015. doi:10.1007/s00261-015-0424-x. Retained products of conception (RPOC) displays variable vascularity, ranging from avascular to markedly vascular on color Doppler sonography. Histologic vascularity of villi appears to contribute to the observed variation in sonographic vascularity, possibly underlying known differences in clinical outcomes. Atri M, Rao A, Boylan C, Rasty G, Gerber D. 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Doppler sonography and 3D CT angiography of acquired uterine arteriovenous malformations (AVMs): report of two cases. J Clin Diagn Res. 2014;8(2):187–9. doi:10.7860/JCDR/2014/6499.4056. Laifer-Narin SL, Kwak E, Kim H, Hecht EM, Newhouse JH. Multimodality imaging of the postpartum or posttermination uterus: evaluation using ultrasound, computed tomography, and magnetic resonance imaging. Curr Probl Diagn Radiol. 2014;43(6):374–85. doi:10.1067/j.cpradiol.2014.06.001. •• Kim T, Shin JH, Kim J, Yoon HK, Ko GY, Gwon DI et al. Management of bleeding uterine arteriovenous malformation with bilateral uterine artery embolization. Yonsei Med J. 2014;55(2):367–73. doi:10.3349/ymj.2014.55.2.367. Bilateral UAE regardless of imaging findings produces better technical success and avoidance of repeat procedures or hysterectomy with outcomes favoring fertility preservation than unilateral UAE. Vilos AG, Vilos GA, Hollett-Caines J, Rajakumar C, Garvin G, Kozak R. 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Am J Obstet Gynecol. 2012;206(4):356.e1–4. doi:10.1016/j.ajog.2012.01.006. In a group of 30 low-risk postpartum patients undergoing elective MRI, a high prevalence of definite pelvic vein intraluminal filling defects were identified. This study suggests that some pelvic vein intraluminal thrombus may be a normal finding after uncomplicated vaginal delivery. Harris K, Mehta S, Iskhakov E, Chalhoub M, Maniatis T, Forte F, et al. Ovarian vein thrombosis in the nonpregnant woman: an overlooked diagnosis. Ther Adv Hematol. 2012;3(5):325–8. doi:10.1177/2040620712450887. Twickler DM, Setiawan AT, Evans RS, Erdman WA, Stettler RW, Brown CE, et al. Imaging of puerperal septic thrombophlebitis: prospective comparison of MR imaging, CT, and sonography. AJR Am J Roentgenol. 1997;169(4):1039–43. doi:10.2214/ajr.169.4.9308461. Bilgin M, Sevket O, Yildiz S, Sharifov R, Kocakoc E. Imaging of postpartum ovarian vein thrombosis. Case Rep Obstet Gynecol. 2012;2012:134603. doi:10.1155/2012/134603. 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