Case of the Month May 2015, Page 2

Answer: 2) Pelvic ultrasound

 Pelvic ultrasound is the first-line recommendation for acute pelvic pain in women within the reproductive age group. This is true whether the serum beta-HCG is positive or negative. Both trans-abdominal and trans-vaginal views should be obtained if possible.

MRI pelvis is the next choice if the ultrasound is inconclusive or nondiagnostic. The decision to give intravenous gadolinium contrast depends on the beta-HCG: If negative, then contrast should be given if possible. If positive, then contrast should not be given.

The pelvic ultrasound is done, and you review the images. You see that the uterus is normal. You also review the following additional images:

For larger images, please click on Lee1 , Lee2 and Lee3 .


The area labeled “FF” on the image labeled “COR CUL-DE-SAC” demonstrates free pelvic fluid. “SAG” and “COR” are short for “sagittal” and “coronal,” just indicating the plane in which the images were acquired. You can also see length measurements (if any) at the right side of each ultrasound image.

Note that the free pelvic fluid demonstrates low-level signals. Its appearance is not that of clear water, which would be echolucent (completely black).

Which of the following conditions can you rule out based on these ultrasound findings?

1. Mittelschmerz

2. Ovarian torsion

3. Pelvic inflammatory disease

4. Hyperstimulation syndrome

5. Ruptured/hemorrhagic ovarian cyst


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