Case of the Month June 2015, Page 3

Answer: 4) Hyperstimulation syndrome

 

Hyperstimulation syndrome has a very characteristic appearance of bilateral enlarged ovaries with multiple markedly enlarged follicles, which is not what is seen here. It is an exaggerated response to medications given for ovarian follicle induction as a treatment for infertility. Note that the left ovary shows numerous small follicles, consistent with PCOS.

Mittelschmerz, or pain on ovulation, can present with a normal ultrasound. The presence of complex free fluid should raise your suspicion for pelvic inflammatory disease or a ruptured/hemorrhagic ovarian cyst. And as for ovarian torsion, you certainly can’t rule it out without at least seeing the doppler images.

You are particularly concerned about the possibility of an ovarian torsion given the emergent nature of the diagnosis and the provided history of the patient’s acute and severe right pelvic pain. You review additional doppler images of the ovaries:

For larger images, please click on Lee4 , Lee5 , Lee6 , Lee7 and Lee8 .

The first image demonstrates the overall appearance of the right ovary. The two images with the waveforms demonstrate detectable vascular flow in the ovary: The waveform demonstrating a reverse sawtooth wave pattern is the typical appearance of arterial flow, while the flat straight waveform (either above or below the “0 cm/s” line depending on the direction of flow) is characteristic of venous flow.

The last two images demonstrate the right and left ovaries side by side for direct comparison.

Which of the following is the most sensitive ultrasound finding in ovarian torsion?

1) Absence of arterial flow in the ovary
2) Absence of venous flow in the ovary
3) Ovary > 4 cm by longest dimension
4) Asymmetrically increased vascularity of the affected ovary
5) 12 or more visualized follicles in a single ovary

 

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