Ultrasound Case of the Month

Case: submitted by Dr. Paul Cohen

This is a 30-year-old female, who presented to the ED with lower abdominal pain. She received a FAST exam in the urgent area of the ED for abdominal pain, which was positive, and she was then transferred to the critical care area for further evaluation. The patient reports having intercourse earlier in the evening and developed 9/10, sharp, non-radiating, suprapubic pain and NBNB emesis. Her LMP was ~6 weeks prior and she endorses using condoms. Her HCG was negative.

Whats the diagnosis?

Ruptured ovarian cyst with hemoperitoneum

Discussion:

The image was taken with the curvilinear probe in the suprapubic area, with the probe marker facing the patient’s right side in the transverse plane. This is the pelvic view in the FAST exam. Typically, one would see the bladder most anteriorly, followed by the uterus and then pouch of Douglas. The adnexa can be seen lateral to the uterus on either side.  The image shows, from anterior to posterior: the bladder, the uterus and a 5.7 cm cyst.

The next ultrasound was the RUQ view from the FAST exam of the same patient. The curvilinear probe was placed in the mid-axillary line, at the level of the xiphoid process with the probe marker pointing to the patient’s head to obtain a coronal plain. Free fluid is evident in Morrison’s pouch. Recall that there are four areas that need to be thoroughly interrogated in a FAST exam:

1. RUQ: Fan through to visualize above and below the diaphragm, Morrison’s pouch, and the inferior pole of the kidney

2. LUQ: Fan through to view above and below the diaphragm as well as the splenorenal recess and the inferior pole of the kidney. It is very important to visualize underneath the diaphragm on the LUQ view as this is where fluid often collects first on this side

3. Pelvic view: Fan through to visualize rectovesicle pouch (men) or rectouterine pouch (female)

4. Cardiac subxiphoid

Ovarian cyst rupture is a relatively common occurrence in women of child-bearing age. They are more common in conditions that promote ovulation induction and are less common with the use of OCPs. Additionally, vaginal intercourse has been noted to be a risk factor for ovarian cyst rupture. Pelvic ultrasound is the test of choice for diagnosis given that it is sensitive and relatively inexpensive. Most women with ovarian cyst rupture have an uncomplicated case and are managed expectantly. Initial evaluation should look for signs of hemodynamic instability, significant bleeding and ongoing blood loss (serial Hgb), signs of infection, and signs of malignancy. In terms of management of cysts, the single most important factor for malignancy is the sonographic appearance of the mass (solid, nodular, thick septations). For simple cysts in the premenopausal female, < 5 cm cysts do not require follow-up; 5-7 cm cysts are considered likely benign and should be followed annually; and cysts > 7 cm, may require an MRI or surgery depending on the clinical situation.

This patient was admitted for hemodynamic monitoring and pain control and discharged the next day. She was started on OCPs for ovarian suppression and reported significant improvement in her pain and nausea at her one-week follow-up appointment.

Faculty Reviewer: Dr. Kristin Dwyer

Additional Resources:

1. Alcázar, J. L., Castillo, G., Jurado, M. & García, G. L. Is expectant management of sonographically benign adnexal cysts an option in selected asymptomatic premenopausal women? Hum. Reprod. 20, 3231–3234 (2005).

2. Bottomley, C. & Bourne, T. Diagnosis and management of ovarian cyst accidents. Best Pract Res Clin Obstet Gynaecol 23, 711–724 (2009).

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