Predicting necrosis in adnexal torsion in women of reproductive age using magnetic resonance imaging.

PURPOSE: To identify the diagnostic performance of magnetic resonance (MR) imaging for patients with adnexal torsion and to develop a predictive model for necrosis related to torsion. METHODS: The institutional ethics committee approved this retrospective study. A total of 56 women with a preoperative pelvic MR scan and a surgical and pathologic diagnosis of adnexal torsion were enrolled from five institutions. Three radiologists reviewed the MR images independently. The kappa value of interrater agreement was assessed. Differences between patients treated with conservative surgery and adnexectomy were evaluated by univariate and multivariate logistic regression analyses. Receiver operating characteristic (ROC) curve analysis was used to assess the ability of the model to predict ovarian necrosis. RESULTS: Fifty-six patients were divided into the conservative surgery group (24/56, 42.9%) or the adnexectomy group (32/56, 57.1%) depending on the surgical outcomes. The radiographic features related to torsion were interpreted by three raters retrospectively with substantial interrater agreement (kappa > 0.60). Older reproductive age and pedicle hemorrhagic infarction were significantly associated with adnexectomy (p < 0.05). At multivariate analysis, pedicle hemorrhagic infarction (odds ratio = 10.476 [95% confidence interval 1.103, 99.504; p = 0.041]) was associated with adnexectomy. Using the predictive model (older reproductive age and pedicle hemorrhagic infarction), a receiver operating characteristic curve was generated with an area under the curve (AUC = 0.870 ± 0.049). CONCLUSION: The presence of pedicle hemorrhagic infarction and older reproductive age can predict necrosis of adnexal torsion and may be used to guide the optimal treatment strategy. KEY POINTS: • Pedicle hemorrhagic infarction and older reproductive age are predictors of necrosis in adnexal torsion in patients of reproductive age (AUC = 0.870 ± 0.049). • Cystic wall thickening, enlarged vascular pedicle, tubal thickening, and uterine deviation are associated with a high risk for adnexal torsion, occurring in more than half of the cases in this study. • MR findings are useful for the definitive diagnosis of adnexal torsion and for the prediction of adnexal necrosis.

Transvaginal and transperineal ultrasound follow-up after laparoscopic correction of uterine retrodisplacement in women with posterior deep infiltrating endometriosis.

BACKGROUND: Retrodisplacement of the uterus (retroflexion and/or retroversion) may be associated with pelvic pain symptoms and posterior deep infiltrating endometriosis (DIE). Previous studies in symptomatic women with retrodisplacement of the uterus showed the efficacy of hysteropexy in terms of pain symptoms improvement. AIM: To evaluate sonographic, clinical and surgical outcomes of a hysteropexy technique MATERIALS AND METHODS: Laparoscopic round ligament plication and tilting of the uterine fundus in women with uterine retrodisplacement and posterior deep infiltrating endometriosis was performed. Forty-two symptomatic women were enrolled and the sonographic data of each (angle of uterine version and uterine flexion, uterine mobility) was assessed before and after surgery with transvaginal and transperineal approaches. Women were also evaluated at 1, 6 and 12 months after surgery for pain symptoms with a numerical rating scale (dysmenorrhoea, dyspareunia and chronic pelvic pain), intraoperative data and surgical complications. RESULTS: The additional mean operative time of hysteropexy procedure was 8 ± 3 min. At early follow-up both the uterine angles were significantly (P < 0.001) reduced. At 12-month follow-up, seven patients (16.7%) presented a retroverted uterus, while 12 (28.6%) presented a retroflexed uterus; the sliding sign remained negative in four patients (9.5%). A significant improvement of symptoms (P < 0.001) was observed during the follow-up. CONCLUSION: Laparoscopic hysteropexy appears as an effective additional surgical procedure, which can temporarily correct the uterine position in order to reduce the risk of postoperative adhesions.

Magnetic resonance imaging of the placenta and gravid uterus: a pictorial essay.

The placenta is commonly overlooked on magnetic resonance imaging of the pregnant patient, which is frequently performed for alternative reasons such as to characterize fetal or uterine anomalies or to investigate the etiology of acute pelvic pain in pregnancy. Placental disorders have potential for significant maternal and fetal morbidity and peripartum complications if not recognized and treated in a timely manner. The radiologist must be familiar with normal placental variants and the spectrum of benign to life-threatening conditions affecting the placenta so that the Obstetrician can be promptly notified and patient management altered, if necessary. In this pictorial essay, we will describe our MR protocol for placental imaging, provide an image-rich review of the normal placenta, placental variants, and a variety of pathological conditions affecting the placenta and gravid uterus.

Vaginal Repair of Cesarean Section Scar Diverticula Diagnosed in Non-pregnant Women.

STUDY OBJECTIVE: Cesarean section scar diverticulum (CSD) lead to many long-term complications. CSD is more prevalent in patients with a retroflexed uterus than in those with an anteflexed uterus. Therefore, we wanted to estimate the association between flexion of the uterus and the outcome of treatment for CSD treated by vaginal repair. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: A total of 241 women with a CSD were enrolled at the Shanghai First Maternity & Infant Hospital between May 2014 and Oct 2016. INTERVENTIONS: Vaginal excision and suture of CSD. MEASUREMENT AND MAIN RESULTS: A high failure rate was reported in remodeling of the scar by other surgeries in women with retroflexed uteri. Clinical information was obtained from medical records. Because intermenstrual bleeding was a presenting symptom of CSD, duration of menstruation was compared between groups. Patients were required to be followed at 1, 3, and 6 months to record their menstruation situation and to measure the CSD. The thickness of the residual myometrium (TRM) in the retroflexion group was much thinner than that in the anteflexion group before treatment (2.5 ± 1.2 mm vs 2.9 ± 1.1 mm, p < .05). There was no statistical difference in pretreatment menstruation duration between groups (p > .05). The duration of menstruation in the anteflexion group was 8.2 ± 2.1 days and 8.5 ± 2.1 days and in the retroflexion group was 7.6 ± 2.0 days and 7.7 ± 3.1 days at 3 and 6 months after surgery, respectively (p < .05). In all 58.6% of patients (140/239) who had a retroflexed uterus, 60.0% (84/140) reached ≤7 days of menstruation at 6 months after surgery (p < .05). Although about 40% patients still had CSD after repair, menstruation duration and TRM were improved significantly (p < .05). CONCLUSION: We propose that vaginal repair can relieve symptoms and improve TRM for CSD patients, especially for those who have a retroflexed uterus. However, 40% of patients still had a defect postoperatively.

Intrauterine device embedded in omentum of postpartum patient with a markedly retroverted uterus: a case report.

BACKGROUND: The intrauterine device is a popular form of long-acting reversible contraception. Although generally safe, one of the most serious complications of intrauterine device use is uterine perforation. Risk factors for perforation include position of the uterus, force exerted during intrauterine device insertion, postpartum period, and breastfeeding. This case is important and needs to be reported because it highlights the need to assess risk factors for uterine perforation. It adds to the medical literature because it examines the relationship between position of the uterus and the location of uterine perforation. This case report is unusual in that it describes the mechanism and specific location of uterine perforation in relation to the position of the uterus. CASE PRESENTATION: We present a case of an intrauterine device found in the omentum of a 30-year-old white postpartum woman with a significantly retroverted uterus after the intrauterine device threads were not visualized on speculum examination during a 6-week placement check. The intrauterine device was located and removed via laparoscopy without complication. CONCLUSIONS: This case report will be of interest to women's health practitioners because it illustrates the importance of identifying patients with risk factors for uterine perforation, examining the relationship between uterine position and location of perforation. This is especially significant because the true incidence of perforation may be higher than the numbers reported in the literature. There is no specific diagnostic code for uterine perforation and it is unlikely that retrospective studies can accurately identify all cases.

Necessity of CT-MRI based treatment planning for cervical tumors with retroverted uterus: A case report with review of literature.

Treatment of carcinoma cervix is a complex issue influenced by numerous factors, including the patient's age, clinical stage of the disease, position of the uterus, comorbidities, etc. The major drawback of the conventional four-field box technique is the lack of complete information about the flexion of the uterus and topography of the tumor. These are further influenced by bladder and rectal filling, which may lead to geographical miss of the clinical target volume (CTV). This problem was noticed mainly in the anterior and posterior borders of the lateral fields and in the superior and lateral borders of the anteroposterior fields. We demonstrate the need for computed tomographic-magnetic resonance imaging (MRI)-based 3D planning of each patient and necessity of sagittal MRI for designing lateral portal in case of conventional four-field technique through an example of a patient's sagittal MRI of pelvis showing retroverted uterus.

Case report: incarceration of the gravid uterus: a radiologic and obstetric challenge.

We will present the fourth case in the English-language literature of a mid-gestational colonoscopy-assisted manual reposition of an incarcerated uterus. Despite the ready availability of ultrasound, a great number of incarcerations are not recognized before term. Since early diagnosis is the key to a successful treatment, it is important that providers acquire prompt knowledge of this obstetric disorder. Magnetic Resonance Imaging has an important additional value to ultrasound in the detailed scanning of this potentially perilous condition.

Anteverted retroflexed uterus: a common consequence of cesarean delivery.

OBJECTIVE: The purpose of this study was to determine in a sequential unselected sample of nonpregnant women whether an anteverted retroflexed uterine position develops after cesarean delivery and to see whether the amount of myometrial thinning related to cesarean delivery affects the development of an anteverted retroflexed uterine position. MATERIALS AND METHODS: Images from 641 consecutive transvaginal ultrasound examinations performed between 2008 and 2011 in which a uterus was present were reviewed and archived. The series was analyzed in three groups: patients who underwent cesarean delivery, patients who were parous but had not undergone cesarean delivery, and patients who were nulliparous. The uterine axis was categorized as anteverted, anteverted and anteflexed, retroverted, retroverted and retroflexed, anteverted and retroflexed, retroverted and anteflexed, and axial, that is, in the same axis as the vagina. RESULTS: An anteverted retroflexed uterine position was found in 27% of women after cesarean delivery. It was rare when no cesarean section had been performed, being found in 1% of those women, and was not seen in nulliparous women. CONCLUSION: An anteverted retroflexed uterine position is a common consequence of cesarean delivery but is rarely seen in other parous women.

The incarcerated uterus: a review of MRI and ultrasound imaging appearances.

OBJECTIVE: The objective of this article is to review the MRI and ultrasound appearances of incarcerated uterus. CONCLUSION: Incarcerated uterus is a rare but serious complication of pregnancy in which the gravid uterus becomes trapped in the posterior pelvis. Characteristic MRI and ultrasound imaging features enable definitive diagnosis of incarcerated uterus, which reduces risks of complications that can lead to maternal and fetal morbidity and mortality.

Trans-abdominal ultrasound guided transvaginal hydrolaparoscopy is associated with reduced complication rate.

OBJECTIVE: To evaluate the feasibility and value of abdominal ultrasound guided access for transvaginal hydrolaparoscopy (THL). STUDY DESIGN: One hundred and ninety-three infertile women were retrospectively included. A total of 31 subjects were included in the study group, and 162 cases performed prior to the introduction of transabdominal ultrasound guidance constituted a comparison group. The indications for THL were: inconclusive hysterosalpingogram findings and ovarian drilling for clomiphene-resistant polycystic ovarian disease. The total of complications arising from trocar needle insertions are compared between the study (ultrasound guidance) and comparison (without ultrasound guidance) groups. RESULTS: In the study group, two cases were transferred to standard laparoscopy without vaginal needle insertion because of no obvious fluid in the cul-de-sac. One of these cases was confirmed to have severe adhesions and the other had no pathology in the pelvic cavity. One further case was transferred due to severe adhesions found by THL. Twenty-nine patients had successful vaginal access including seven cases with a retroverted uterus (24.1%), as against only one case with retroverted uterus in the comparison group (0.6%). The difference was statistically significant (P<0.05). There were three cases of intestinal perforation and one case of uterine injury in the comparison group, but no case of complication in the study group. Fifteen cases were fully conducted by two novel medical doctors monitored by a senior doctor. CONCLUSIONS: Trans-abdominal ultrasound guided vaginal access increases the safety of THL, especially in patients with a retroverted uterus, by seeking out a better puncture spot, and making training more intuitive and safe.

Significance of pelvic magnetic resonance imaging in preoperative diagnosis of incarcerated retroverted gravid uterus with a large anterior leiomyoma: a case report.

BACKGROUND: Incarceration of the gravid uterus is a rare but serious complication of pregnancy. The often required cesarean section is technically complicated, and preoperative planning is critical. An important initial surgical step is to lift the fundus out of the pelvis prior to creating the hysterotomy in order to facilitate adequate visualization of the pelvic anatomy. CASE: A 38-year-old primigravida with uterine incarceration from a large anterior leiomyoma underwent cesarean delivery at 29 weeks' gestation. In this case, a failure of the fundal height to increase was not appreciated as the anterior leiomyoma was palpated to represent the fundus. Intraoperatively the uterus was unable to be repositioned because of the leiomyoma. However, the surgery did proceed smoothly primarily due to the highly detailed images obtained on pelvic magnetic resonance imaging. CONCLUSION: Although uterine incarceration is rare, knowledge of this condition is important. Magnetic resonance imaging is a useful tool in that it enables the detailed evaluation of the pelvic anatomy in cases with suspected uterine incarceration.

ACR Appropriateness Criteria® assessment of gravid cervix.

It is well recognized that preterm birth is the leading cause of perinatal mortality and morbidity. There is a significant association between cervix length and preterm birth risk. Most authorities consider a cervical length <3 cm as the lower limit of normal. A cervical length >3 cm has a high negative predictive value for delivery less than 34 weeks. A cervical length of <15 mm is moderately predictive (∼ 70%) of preterm birth within 48 hours. Cervical length is normally distributed and should remain relatively constant until the third trimester. Transabdominal US is the least reliable method of cervical length assessment. The most reliable method of documenting cervical length is transvaginal ultrasound (TVUS). Transperineal US is an alternative for imaging if TVUS is contraindicated, such as with premature rupture of membranes. However, the resolution is decreased compared to TVUS. Short cervix length is the single most important predictive finding for premature delivery. This observation should prompt consultation for high risk obstetrical care and consideration of other management options such as cerclage or activity restriction.The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed biennially by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging.