Diagnostic Ultrasound - Abdomen and Pelvis

Hemorrhagic Cyst
Diagnoses: Female Pelvis
• May see echogenic fluid in cul-de-sac due to inflammatory
exudate
• Pelvic inflammatory disease → edema → loss of tissue
planes → difficulty identifying structures
○ May be associated with purulent discharge
○ Often extremely tender during sonography
• Appendix abscess may form in pelvis (remember
nongynecologic causes)
PATHOLOGY
General Features
• Majority occur as result of bleeding into functional ovarian
cyst; follicular/corpus luteum
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Acute pelvic pain
• Other signs/symptoms
○ May be asymptomatic
– In 1 series of 112 patients, only 38% presented with
acute pain
– Remaining cases detected during sonography for
other indications, most commonly palpable mass on
pelvic examination
○ Mittelschmerz
– Ovulation pain
○ May complicate ovulation induction in assisted
reproduction
– Rupture may lead to significant hemorrhage
– Acute pain related to hemorrhagic cyst can be
confused for torsion or hyperstimulated ovary
○ Neonatal presentation
– Fetal ovarian cysts are well described
□ Usually appear in 3rd trimester
– Development of fluid-fluid level in utero is very
suspicious for hemorrhage/torsion
Demographics
• Epidemiology
○ 1 series of 112 patients
– 71% in nulliparous patients
– 29% multiparous
– 77% in luteal phase of menstrual cycle
– 12% in proliferative phase
– 11% in early gestation
Natural History & Prognosis
• Majority resolve spontaneously
○ Severe pain resolves within hours in > 90%
○ Mass will disappear in > 90% within 8 weeks
• Larger cysts more likely to cause acute pain/presentation
with acute abdomen
• If large may predispose to adnexal torsion
• May rupture
○ Supportive treatment adequate in most
Treatment
• Society ofRadiologists inUltrasound (SRU) consensus
statement on ovarian cyst management
○ Hemorrhagic cyst
– Reproductive age
□ ≤ 5 cm: No follow-up needed
□ > 5 cm: 6-12 week follow-up
– Early postmenopausal
□ Follow-up US to ensure resolution
– Late postmenopausal
□ Consider surgical evaluation
• Surgical treatment for severe symptoms
○ Ovarian torsion
○ HC rupture with significant intraperitoneal hemorrhage
• If recurrent consider ovulation suppression
DIAGNOSTIC CHECKLIST
Consider
• Look for rind of ovarian tissue containing follicles: "Claw"
sign around hemorrhagic cyst
○ Confirms intraovarian process
• Increased through transmission suggests cystic entity
rather than solid mass
• Hemorrhage can be cause or effect of ovarian torsion
Image Interpretation Pearls
• 90% of hemorrhagic ovarian cysts will exhibit fibrin strands
or retracting clot
○ Lacy interstices due to fibrin strands are characteristic of
acute clot
○ "Mass" with angular margins suggests fragmented clot
rather than papillary projections from neoplasm
• Beware of ring-of-fire sign
○ If intraovarian, related to corpus luteum
○ If extraovarian, consider ectopic pregnancy
○ Majority of hemorrhagic cysts can be managed
conservatively, unlike ruptured ectopic pregnancies
• Reported cause or false-positive F-18 FDG uptake in PET
scans
○ Consider US for any unexpected ovarian mass on PET
scans
SELECTED REFERENCES
1. Nakamura M et al: Postnatal Outcome in Cases of Prenatally Diagnosed
Fetal Ovarian Cysts under Conservative Prenatal Management. Fetal Diagn
Ther. ePub, 2014
2. Valentin L et al: Risk of malignancy in unilocular cysts: a study of 1148
adnexal masses classified as unilocular cysts at transvaginal ultrasound and
review of the literature. Ultrasound Obstet Gynecol. 41(1):80-9, 2013
3. Patel MD: Pitfalls in the sonographic evaluation of adnexal masses.
Ultrasound Q. 28(1):29-40, 2012
4. Alcázar JL et al: Diagnostic performance of transvaginal gray-scale
ultrasound for specific diagnosis of benign ovarian cysts in relation to
menopausal status. Maturitas. 68(2):182-8, 2011
5. Levine D et al: Management of asymptomatic ovarian and other adnexal
cysts imaged at US: Society of Radiologists in Ultrasound Consensus
Conference Statement. Radiology. 256(3):943-54, 2010
6. Patel MD et al: The likelihood ratio of sonographic findings for the diagnosis
of hemorrhagic ovarian cysts. J Ultrasound Med. 24(5):607-14; quiz 615,
2005
7. Swire MN et al: Various sonographic appearances of the hemorrhagic corpus
luteum cyst. Ultrasound Q. 20(2):45-58, 2004
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