Diagnosis of emergencies/urgencies in gynecology and during the first trimester of pregnancy

Abstract

Several surgical and/or medical emergencies/ urgencies may occur in gynecologic patients and in pregnant women during the first trimester. Particularly, ectopic pregnancies, ruptured or hemorrhagic ovarian cysts, ovarian or adnexal torsions, threatened or inevitable miscarriages, phlogistic gynecological disorders, complications involving the uterine fibroids, endometriosis, and spontaneous uterine rupture are possible acute complications. The diagnosis is suspected on the basis of symptoms (acute pelvic and/or abdominal pain, with or without vaginal bleeding or discharge, until acute abdomen with peritonitis), by means physical evaluation (abdominal, pelvic, and bimanual gynecological examinations), by means of transabdominal (TAS) and/or transvaginal (TVS) sonography, and laboratory tests. However, the diagnosis is often not that simple, especially when the symptoms and clinical signs are minimal, and ultrasound (US) examination is not diriment. The differential diagnosis of abdominal/pelvic pain is broad and includes primarily gastrointestinal and urogenital disorders. Generally, TAS should usually be used in conjunction with TVS for evaluation of the female pelvis. If the US examination is not conclusive, CT or MRI, especially in pregnant patients, should be considered.Riassunto Diverse emergenze/urgenze chirurgiche e/o mediche possono interessare le pazienti ginecologiche e le gravide al primo trimestre. In particolare, le gravidanze ectopiche, le cisti ovariche rotte o torte, le torsioni ovariche o annessiali, le minacce d'aborto o gli aborti inevitabili, le patologie infiammatorie ginecologiche, i fibromi uterini complicati, l'endometriosi e la rottura uterina spontanea rappresentano possibili complicanze acute. La diagnosi può essere sospettata in base alla sintomatologia (algie pelviche e/o addominali acute, con eventuali perdite vaginali, fino a un quadro di addome acuto con peritonite), alla visita (valutazione addominale, pelvica ed esplorazione ginecologica bimanuale), all'ecografia transaddominale (TAS) e/o transvaginale (TVS), e agli esami di laboratorio. Tuttavia, la diagnosi spesso non è semplice, soprattutto quando i sintomi e i segni clinici sono lievi e l'ecografia non è dirimente. La diagnosi differenziale del dolore addominale/ pelvico comprende un'ampia varietà di disordini, in particolare gastrointestinali e urogenitali. Generalmente, la valutazione della pelvi femminile dovrebbe essere eseguita mediante ecografia sia transaddominale che transvaginale. Se l'esame ecografico non consente di fare diagnosi, dovrebbero essere presi in considerazione la TC o, specialmente nelle donne gravide, la RMI.

Successful laparoscopic management of adnexal torsion in a third trimester pregnant woman: a case report

“…The color Doppler USG may show an absence of arterial and venous blood flow in adnexa [6]. The pregnancy confuses the clinical situation and causes difficulty for differential diagnosis of AT [7]. If AT was suspected during pregnancy, MRI may be useful for the diagnosis [8].…”

Errors in imaging the pregnant patient with acute abdomen

“…When detected, the calculus is seen as a hypointense defect in the ureter on T2W images [16]. When in the distal part of the ureter, even if not directly visualized, its presence can be revealed by the so called ''double kink sign'' consisting of a dilated ureter filled with urine with an abrupt change of caliber in the pelvic segment and at the vesicoureteral [37]. Alternatively, gestational hydronephrosis is characterized by a gradual reduction of the ureteral caliber, extrinsically compressed [38].…”

“…Particularly, in the OHSS, ovaries are both enlarged with corpus luteal cysts displaced peripherally as a wheel with spokes. If a torsion occurs on such a condition, the affected ovary can be distinguished by the presence of a marked stromal edema [37]. In pregnancy, the ovaries are even more difficult to visualize with US and the risk of a misdiagnosis is high, especially if a malignant mass is found shifting the emphasis from the emergency [40].…”

Ischemia modified albumin in experimental ovarian torsion with and without controlled reperfusion

“…Being a gynecological emergency (1,2), the torsion of the ovary is a partial or complete rotation of the ovary, the fallopian tube or both of them around their vascular axis (3). Of the total torsional cases, 70-80% occur in women of reproductive age (4). The incidence is 4.9/100000 in women under the age of 20 (1,5,6,7,8), but it may affect women at any age (9,10).…”