and Gynecologic Disorders

Impending / Inevitable Abortion


=  gestational sac with embryo having become detached from implantation site → spontaneous abortion within next few hours

•  Clinical triad: (1) bleeding > 7 days, (2) persistent painful uterine contractions, (3) rupture of membranes

•  cervix moderately effaced / dilated > 3 cm

√  sac located low within uterus (DDx: cervical ectopic with closed internal os)

√  progressive migration of sac toward / into cervical canal (on rescanning a short time later)

√  dilated cervix

√  sac surrounded by anechoic zone of blood

Threatened Abortion

=  1st trimester bleeding (after period of implantation bleed at 3–4 weeks MA) with a live embryo

Frequency:   20–25% of all pregnancies

•  Clinical triad: (1) mild bleeding, (2) cramping, (3) closed cervix


on transvaginal ultrasound

@   Cardiac activity:

√  no cardiac activity with a CRL ≥ 5 mm

√  no cardiac activity with certain GA ≥ 6.5 weeks

√  no cardiac activity with a GS diameter > 16 mm

@   Yolk sac:

√  no yolk sac with a GS diameter ≥ 20 mm

√  embryo visualized without demonstrable yolk sac

√  yolk sac diameter > 5.6 mm at < 10 weeks MA

@   GS contents:

√  fibrinous strands / residual embryonic debris (in 25%)


on transvaginal ultrasound

@   Ultrasound milestones not met as expected:

√  ≥ 5.0 weeks gestational sac first identifiable

√  ≥ 5.5 weeks yolk sac first identifiable

√  ≥ 6.0 weeks embryo and FHM first identifiable

@   Yolk sac:

√  no yolk sac with GS of 6–9 mm

√  distorted sac configuration

@   Choriodecidua

√  thinning of choriodecidual reaction with hypoechoic clefts

@   Cardiac activity:

√  no cardiac activity with GS of ≥ 9 mm

√  slow embryonic heart rate (=bradycardia):

Predictors of poor outcome:

@   Bradycardia

√  < 85 bpm during 5–8 weeks EGA

@   Small sac size = “first-trimester oligohydramnios”

[misnomer: amnionic cavity is not diminished in size but rather the chorionic cavity]

=  MSD (mean sac diameter) – CRL ≤ 5 mm (with a live embryo at 5.5–9.0 weeks)

Prognosis:   miscarriage in 94%

@   Abnormal yolk sac

√  failure to visualize yolk sac at 5.5 weeks MA = mean diameter of GS ≥ 8 mm

√  yolk sac size > 5 mm

√  calcification / debris within yolk sac

√  double appearance of yolk sac

@   Abnormal amnion

√  mean diameter of amniotic cavity > CRL

@   Subchorionic hemorrhage

Frequency:   in up to 18% of pregnancies during first half of pregnancy

N.B.:   significance controversial

Prognosis:   50% develop normally; 15–39% blighted ovum, 4% mole, 4–13% ectopic pregnancy, 0–15% incomplete abortion, 17–57% missed abortion

Complete Abortion

•  absence of transvaginal bleeding, cervix closed

•  abrupt decline of serum β-hCG

√  IUP no longer visualized although documented previously

√  thin regular endometrium (< 10–15 mm) with apposed surfaces

√  absence of central / eccentric fluid-filled sac

DDx:  nongravid state, very early IUP, ectopic pregnancy

Rx:  dilatation & curettage may be avoided if IUP was documented previously

Incomplete Abortion


=  portion of chorionic villi (placental tissue) / trophoblastic tissue (fetal tissue) remaining within uterus after spontaneous abortion (= miscarriage) / planned termination / preterm or term delivery

=  most frequent cause of secondary postpartum hemorrhage (2°PPH)

Incidence:    ›   1st trimester:    40%

›  2nd trimester     17%

›  3rd trimester:     3%

•  incomplete placenta at delivery, patulous cervix

•  continued (occasionally massive) genital bleeding (may occur months / years after last abortion / delivery)

•  normal / low levels of β-hCG


√  fetal parts / embryo / echogenic mass within uterine cavity (MOST ACCURATE SIGNS)

√  irregular / angulated small gestational sac containing amorphous echogenic material

√  ragged disrupted choriodecidual reaction

√  subchorionic fluid ± hemorrhage

√  intracavitary heterogeneously echogenic mass separate from endometrium

√  > 8–10–13 mm thickened endometrial echo complex

◊  Measurement of endometrial thickness alone is a poor test for diagnosing an incomplete miscarriage!

√  calcification of retained products (late finding)

Doppler US (x 2 improvement in diagnosis):

√  ± increased vascularity in endometrial echo complex / intracavitary mass (compared to myometrium)

√  flow velocity > 21 cm/sec (supplying residual trophoblastic tissue)

√  ± low-resistance internal blood flow often at endometrial-myometrial interface

Pitfalls:   uterine AVM (involves myometrium only), endometrial polyp, submucosal fibroid


√  partially / delayed enhancing heterogeneous mass on T1WI + T2WI (DDx: gestational trophoblastic disease)

Dx:  presence of chorionic villi in curettage exhibiting variable vascularity

Cx:  endometritis, myometritis, peritonitis, septic shock, diffuse intravascular coagulation (with retention > 1 month)

Rx:  expectant management, uterotonic medication (prostaglandin E1 analogs), suction D&C after IV oxytocin, hysteroscopic removal

DDx:  intraluminal blood clot, mole, blighted ovum, embryonic demise, intrauterine fetal death


=  intrauterine polypoid mass formed by a retained fragment of placental tissue after an abortion / term pregnancy

Predilection:   placenta accreta


√  hyperintense polypoid mass on T2WI

DDx:   arteriovenous malformation, trophoblastic disease, endometrial polyp, submucosal myoma


=  exceptionally rare postpartum condition characterized by failure of uterine vessels to involute following delivery

Risk factors:   atony, multiparity, cesarean section, uterine prolapse, uterine fibroids, endometritis, coagulopathy, RPOC

√  unusually large postpartum uterus

√  dilated myometrial vessels

Missed Abortion

=  dead conceptus within uterine cavity for ≥ 8 weeks occurring prior to 28 weeks MA

Time of diagnosis:   not before 13 weeks MA

•  brownish vaginal discharge, closed firm cervix

√  no cardiac activity in a well-defined embryo with CRL > 9 mm (on abdominal scan) / CRL > 5 mm (on TV scan)

√  gestation not in correspondence with menstrual age

√  sac > 25 mm in diameter without an embryo

(DDx: anembryonic pregnancy)

√  sac > 20 mm without yolk sac

√  crenated irregular / distorted angular sac configuration

√  stringlike debris within gestational sac (in 25%)

√  discontinuous / irregular / thin (2 mm) choriodecidual reaction

√  no double decidual sac

√  low sac position

√  subchorionic collection

Cx:  coagulopathy ← low plasma fibrinogen (after 4 weeks in 2nd trimester pregnancy)

Rx:  suction D&C (in 1st trimester); prostaglandin E suppositories (in 2nd trimester)

DDx:  blighted ovum



=  rare developmental anomaly of monochorionic twinning in which one twin develops without a functioning heart

Prevalence:   1÷30,000–35,000 births; in 1% of monozygotic twins


normal twin perfuses acardiac twin through artery-to-artery + vein-to-vein anastomoses in shared placenta → reversed circulation alters hemodynamic forces → abnormal cardiac morphogenesis


(1)  Holoacardia = no heart at all

(2)  Pseudoacardia = rudimentary cardiac tissue

√  proximity of the 2 cord insertions on placental surface linked by an arterioarterial anastomosis

√  reversed arterial flow in cord toward acardiac twin

√  fused placentas

√  polyhydramnios


Risk:   increased for fetal demise + preterm labor

√  morphologically normal

√  cardiac overload signs: hydrops, IUGR, hypertrophy of right ventricle, increased cardiothoracic ratio, hepatosplenomegaly, ascites


Pathophysiology:   vascular anastomosis sustains life of acardiac monster

Associated with:   monochorial placenta (= same gender); wide range of abnormalities

√  absent / rudimentary heart (“acardius”)

√  tiny / absent cranium (acephalus)

√  small upper torso ± absent / deformed upper extremities

√  marked integumentary edema + cystic hygroma

Prognosis:   mortality of 100% for perfused twin, 50% for pump twin (increased with increased size of acardiac twin)

Rx:   laser ablation of umbilical cord to acardiac twin (up to 20–22 weeks)


=  ENDOMETRIOSIS INTERNA (term no longer used)

=  focal / diffuse benign invasion of myometrium by endometrium (heterotopic “endometrial islands”) inciting reactive myometrial (smooth muscle) hyperplasia

Cause:   ? uterine trauma (parturition, myomectomy, curettage), chronic endometritis, hyperestrogenemia

Prevalence:   5–70% of hysterectomy specimens

Hormonal dependency:

ectopic endometrial glands of adenomyosis (= generally of basalis type of endometrium) do NOT respond to cyclic ovarian hormones (largely nonfunctioning ← resistance to hormonal stimulation unlike endometriosis); some degree of proliferative + secretory changes occur during menstrual cycle; tamoxifen (= nonsteroidal antiestrogen) increases incidence of adenomyosis in postmenopausal women

Path:   endometrial glands deeper than ¼ of thickness of junctional zone = 2–3 mm below endometrial-myometrial junction

Histo:   endometrial glands + stroma within myometrium surrounded by smooth muscle hyperplasia

Age:   multiparous premenopausal women > 30 years during menstrual life (later reproductive years)

Associated with:   endometriosis (in 36–40%)

Types:   diffuse form / focal (localized circumscribed) form

•  asymptomatic in 5–70%; pelvic pain, menorrhagia, dysmenorrhea (abates after menopause)

√  globular uterine enlargement


√  multiple small linear / saccular diverticula extending into myometrium

√  uterine cavity may be enlarged / distorted

√  irregular masslike filling defect in uterine fundus in focal adenomyosis

US (53–89% sensitive, 67–98% specific, 68–86% accurate):

√  poorly marginated hypoechoic heterogeneous areas within myometrium + myometrial cysts

√  globular / asymmetrically enlarged uterus

MR (78–93% sensitive, 66–93% specific, 85–90% accurate):

√  diffuse / focal thickening of junctional zone forming an ill-defined area of low SI ± embedded bright foci on T2WI

Cx:   infertility

Rx:   conservative medical treatment (analgesics + minimally effective menstrual suppression Rx with danazol / GnRH agonist); surgical treatment (endometrial ablation, laparoscopy, lesion excision; alternatively uterine artery embolization; hysterectomy (the only definitive cure for debilitating adenomyosis)

Cystic Adenomyosis

=  very rare well-circumscribed cystic myometrial lesion of hemorrhage in different stages of organization (in 40% of diffuse adenomyosis, in 100% of focal adenomyosis)

Path:  extensive menstrual bleeding into ectopic endometrium ← unusual response to cyclical ovarian hormones

Location:  uterine origin confirmed by (a) myometrial splaying around lesion, (b) “bridging vessel” sign (c) separate distinct identification of ovaries

√  “Swiss cheese” appearance of myometrium on US

√  miniature uterus:

√  fluid content of high SI ← hemorrhage at different stages of organization similar to endometriotic cyst

√  surrounding wall of inner zone of low SI on T1WI (= junctional zone)

√  relatively bright outer myometrium


(1)   Leiomyoma with hemorrhagic degeneration


(2)  Hematometra

Diffuse Adenomyosis (67%)

In 90% associated with:   pelvic endometriosis (in women < 36 years of age)

•  infertility ← impaired uterine contractility for directed sperm transport


√  smooth uterine enlargement (DDx: diffuse leiomyomatosis)

√  asymmetric thickening of anterior and posterior myometrial walls

√  diffuse heterogeneous myometrial echotexture (in 75%):

√  nodular / linear areas of increased myometrial echogenicity (= heterotopic endometrial tissue)

√  area of decreased myometrial echogenicity (= smooth muscle hyperplasia)

√  HIGHLY SPECIFIC < 5 mm small subendometrial cysts (in 50%) ← dilated cystic glands / hemorrhagic foci

√  widening of junctional zone > 12 mm on T2WI

√  poor definition of endomyometrial junctional zone (= endometrial tissue extending into myometrium)

√  pseudowidening of endometrium ← increased myometrial echogenicity

√  lack of uterine contour abnormality / mass effect


√  enlargement of the uterus

√  widening of junctional zone (= inner myometrium) ≥ 12 mm hypointense on T2WI, T2-weighted SE images, contrast-enhanced T1WI ← hyperplasia of smooth muscle

√  bright foci on T2WI (50%) ← islands of ectopic endometrial tissue + cystic dilatation of glands:

√  pseudowidening of endometrium (= indistinct foci of endometrial invasion of myometrium)

√  myometrial cysts + nodules, linear striations

√  foci of high SI on T1WI ← hemorrhage within ectopic endometrial tissue

√  variable degrees of enhancement always less than adjacent myometrium


(1)  Marked physiologic thickening of junctional zone during menstruation (esp. cycle days 1 + 2)
◊ Avoid imaging during menstrual phase


(2)  Myometrial contraction (ill-defined hypointense area on T2WI in up to 75%, transient nature, distortion of endometrial lining)


(3)  Muscular hypertrophy (hypoechoic inner myometrium, diffuse junctional zone thickening)


(4)  Endometrial carcinoma (error in staging if adenomyosis coexists)

Focal Adenomyosis (33%)


√  polypoid mass (= polypoid adenomyoma / adenomyomatous polyp) protruding into uterine cavity (less commonly in myometrial / subserosal location)


√  focal echogenic myometrial mass of 2–7 cm in diameter:

√  mass of oval / elongated shape with ill-defined margins

√  contiguity with junctional zone

√  penetrating vascular pattern


√  oval myometrial mass with indistinct margins of primarily low SI on all sequences ← surrounding reactive dense smooth muscle hypertrophy

√  widening of the junctional zone from 8 mm up to 12 mm

√  focal thickening of junctional zone > 12 mm

√  linear / round foci of high SI on T1WI within mass ← T1 shortening effect of methemoglobin in hemorrhagic foci

√  spotty signal voids on GRE ← T2*-shortening effect of hemosiderin in old hemorrhagic foci

√  foci of central high-intensity spots / linear striations on T2WI (= dilated endometrial glands in secretory phase / endometrial cyst, hemorrhagic focus) in 50%

√  low to intermediate SI on DWI ← benign neoplastic nature

Rx:     polypectomy / myomectomy


(1)  Fibroid = leiomyoma (round hypoechoic mass anywhere in myometrium, well-defined margins, separate from junctional zone, calcifications, edge shadowing, whorled appearance, draping pattern of dilated vessels in periphery of mass, low SI on T1WI + T2WI, no small foci of high SI on T2WI)

(2)  Adenomatoid tumor of uterus

=  rare benign mesothelial tumor difficult to distinguish from leiomyoma / adenomyoma

(3)  Metastatic myometrial involvement by cancer of breast, stomach, malignant lymphoma

(4)  Low-grade endometrial stromal sarcoma (rare, young woman, extensive myometrial invasion)



=  “slash defects” in nonanatomic distribution


(a)  early amniotic rupture exposing the fetus to the injurious environment of constrictive fibrous mesodermic bands that emanate from the chorionic side of the amnion

(b)  vascular disruption events

Prevalence:   0.5–1.0÷10,000 live births

√  very thin sheet / band attached to fetus:

√  fine linear echoes that extend from fetal defect to uterine wall but are difficult to see

√  membrane that flaps with fetal movement

√  restriction of fetal motion ← entrapment of fetal parts by bands

Associated with fetal deformities in 77%:

1.   Limb defects (multiple + characteristically asymmetric)

√  simple grooves / constriction rings of limbs / digits

√  amputation of limbs / digits

√  distal syndactyly

√  clubbed feet (30%)

√  gibbus deformity of spine

2.   Craniofacial defects

=  asymmetric nonanatomic defects of skull + brain

√  pterygium, facial cleft

√  anencephaly

√  asymmetric lateral encephalocele

√  facial clefting of lip / palate

√  asymmetric microphthalmia

√  incomplete / absent cranial calcification

√  ± attachment of head to uterine wall

3.   Visceral defects

√  thoracoschisis

√  abdominoschisis ± exteriorization of liver

√  normal umbilical cord

DDx of abdominoschisis due to bands from body stalk anomaly depends on demonstration of a normal umbilical cord.

√  abdominal contents floating in amniotic fluid without clear visualization of encasing membrane


(1)  Chorioamnionic separation ← subchorionic hemorrhage


(2)  Intrauterine synechiae


(3)  Adams-Oliver syndrome (aplasia cutis, limb defects), scalp and skull defects at vertex associated with often asymmetric transverse limb defects


(4)  Body stalk anomaly



=  abnormal intrauterine pregnancy with developmental arrest prior to formation of embryo; may occur as a blighted twin

Cause:   early arrest of embryonic development related to chromosomal abnormality

•  ± vaginal bleeding

√  empty gestational sac (> 6.5 weeks MA)

√  yolk sac identified without embryo:

√  vanishing (passed) yolk sac on serial scans

√  gestational sac small / appropriate / large for dates:

√  decrease in gestational sac (GS) size

√  GS fails to grow by > 0.6 mm/day on serial scans

√  irregular weakly echogenic decidual reaction of < 2 mm

√  distorted sac shape

(a)  by transabdominal scan:

GS usually not visualized before 5.0–5.5 weeks MA; yolk sac forms at 4 weeks MA when GS is 3 mm; embryo usually visualized by 6 weeks MA

√  GS size ≥ 10 mm of mean diameter without DDS

√  GS size ≥ 20 mm of mean diameter without yolk sac

√  GS size ≥ 25 mm of mean diameter without embryo

(b)  by transvaginal scan

normal intradecidual GS routinely detected at 4–5 weeks with a mean sac diameter of 5 mm

√  GS size ≥ 8 mm of mean diameter without yolk sac

√  GS size ≥ 16 mm of mean diameter without cardiac activity

Cx:   first trimester bleeding



Associated with:   dilatation & curettage, endometrial carcinoma, gestational trophoblastic disease

•  genital bleeding, often requiring blood transfusions


√  tortuous tubular signal voids in myometrium / parametrium / protruding into endometrial cavity on T1WI + T2WI

√  vascular lake with sluggish flow hyperintense on T2WI

√  intensely enhancing lesion isointense to vessels on contrast-enhanced dynamic subtraction MR


[Joseph G. Asherman (1889–?), Czech-Israeli gynecologist in Tel Aviv]

=  association of multiple intrauterine synechiae (= adhesions consisting of fibrous tissue or smooth muscle) with menstrual dysfunction + infertility

Cause:   sequelae of endometrial trauma (vigorous instrumentation during dilatation & curettage) usually during postpartum or postabortion period / severe endometritis

Path:   scars / bands of fibrous tissue (synechiae) connect opposing sides of the endometrium by crossing the endometrial cavity; scars cause the endometrial cavity to contract resulting in an irregular surface

•  hypomenorrhea / amenorrhea; habitual abortion / sterility


√  solitary / multiple filling defects

√  bands of tissue traversing endometrial cavity

√  irregular surface contour of uterine cavity

√  small uterine cavity partially / near completely obliterated (DDx: DES exposure)


√  echogenic bands bridging the uterine cavity

◊  Thick fibrotic bands may prevent complete uterine distension


√  small thin irregular endometrial cavity


[Caspar Bartholin the Younger (1655–1738), Danish anatomist and physician]

=  retention cyst

Origin:   derived from urogenital sinus, female homologue of male (bulbourethral) Cowper glands

Cause:   chronic inflammation / infection of gland → ductal obstruction from purulent material / thick mucus

Histo:   lined by mucinous transitional cell / columnar epithelium

Location:   posterolateral inferior ⅓ of vaginal introitus medial to labia minora at / below level of pubic symphysis

Size:   1–4 cm

√  unilocular cyst hyperintense on T2WI

√  variable T1 hyperintensity depending on proteinaceous / mucinous contents

Rx:   administration of silver nitrate; marsupialization; surgical excision


[John Bruce Beckwith (1933–?), pediatric pathologist at Children’s Orthopedic Hospital in Seattle, WA]

[Hans Rudolf Wiedemann (1915–2006), chair of pediatrics at the University of Kiel, Germany]

=  EMG SYNDROME (Exomphalos = omphalocele, Macroglossia, Gigantism)

=  common autosomal dominant overgrowth syndrome with reduced penetrance + variable expressivity related to short arm of chromosome 11; sporadic in 85%

Prevalence:   1÷13,700 to 1÷14,300 live births; M÷F = 1÷1

4% risk for developing embryonal tumors:

nephro-, hepato-, pancreatoblastoma, rhabdomyosarcoma

•  neonatal polycythemia

√  advanced bone age


(1)   Hemihypertrophy    13–33%

(2)   Hyperplastic visceromegaly:    57%

kidney, liver (hepatomegaly), spleen, pancreas, clitoris, penis, ovaries, uterus, bladder

(3)   Abdominal wall defects

(a)  Omphalocele    76%

(b)  Umbilical hernia    49%

(c)  Diastasis recti    33%

(4)   Macroglossia    98%

(5)   Facial nevus flammeus    63%

(6)   Ear lobe creases and pits    66%

(7)   Prominent eyes with intraorbital creases

(8)   Infraorbital hypoplasia    81%

(9)   Gastrointestinal malrotation    83%

(10)   Pancreatic islet hyperplasia → hyperglycemia

(11)   Cardiac anomalies

(12)   Natal / postnatal gigantism    77%

@   Adrenal gland

Histo:   adrenocortical hyperplasia, hyperplastic adrenal medulla, cystic adrenal cortex, bilateral adrenal cytomegaly (= enlargement of fetal cortical cells)

@   Kidney

Histo:   disordered lobar arrangement, medullary dysplasia

√  nephromegaly

√  increased cortical echogenicity ← glomeruloneogenesis

√  accentuation of corticomedullary definition

√  medullary sponge kidney

√  pyelocalyceal diverticula


√  LGA fetus with growth along 95th percentile

√  polyhydramnios (51%)

√  thickened placenta

√  long umbilical cord


(1)  Development of malignant tumors (in 4%)


(2)  Neonatal hypoglycemia (50–61%)


[Fritz Brenner (1877–1969), German physician and pathologist practicing in German South West Africa and Johannesburg]

=  almost always benign uncommon epithelial-stromal ovarian tumor

Frequency:   1.5–2.5%

Histo:   transitional epithelial cells (similar to urothelium) within prominent fibrous connective tissue stroma

Associated with:   mucinous cystadenoma / other epithelial tumor in 20–30%

Peak age:   40–70 years

•  may have estrogenic activity

Size:   most 1–2 cm (up to 30 cm) in diameter; bilateral in 5–7%

√  ± extensive calcifications


√  usually hypoechoic solid homogeneous tumor with well-defined back wall


√  markedly hypointense tumor component on T2WI (fibrous component + calcifications)

√  moderate enhancement (DDx: hypovascular fibrothecoma)


◊  Most common gynecologic malignancy in developing countries; 3rd most common gynecologic malignancy (after endometrial + ovarian cancer) in USA; 6th most common cause of death from cancer in women

Highest prevalence:   Central + South America > South Central Asia > parts of Africa

Incidence:   12÷100,000 women annually; 12,990 new cases + 4,120 deaths in USA (2016)

Peak age:   45–55 years

Histo:   squamous cell carcinoma (80–95%) arising low in endocervical canal, adenocarcinoma (5–20%) arising from endocervical columnar epithelium, clear cell adeno-carcinoma (unusual) in women exposed to DES in utero

Risk factors:   lower socioeconomic standing, Black race, early marriage, multiparity, early age at first intercourse, multiple sexual partners, cigarette smoking, immuno- suppressed state, use of oral contraceptives, human papilloma virus infection (HPV serotypes 16, 18, 31, 33, 56 → > 80% of all invasive cervical carcinomas)

Significance of tumor size:

> 4 cm:   nodal metastases (80%), local recurrence (40%), distant metastases (28%)

< 4 cm:   nodal metastases (16%), local recurrence (5%), distant metastases (0%)


(a)  direct extension to lower uterine segment + vagina + paracervical space along uterosacral and broad ligaments

(b)  lymphatic: paracervical > parametrial > hypogastric + obturator > external iliac > common iliac + presacral > para-aortic nodes

(c)  hematogenous: lung, liver, bone

•  leukorrhea ± abnormal vaginal bleeding (< 30%)

•  intermenstrual / postcoital bleeding / metrorrhagia

Clinical staging:   limited accuracy of 66% stage I (78%), stage III (25%)


arises almost exclusively from transformation zone (= squamo- columnar junction)

(a)  on cervix (in young woman)

(b)  in endocervical canal (older woman)

with protrusion into vagina / invasion of lower myometrium

Tumors tend to be exophytic in younger patients + endophytic in older patients ← variable location of transformation zone with advancing age


@   Primary tumor

√  small tumor isoechoic to mucosa difficult to detect

√  altered echotexture + distortion of normal cervical morphology + lack of compressibility with increasing size

√  color Doppler US may facilitate visualization and delineation of tumor ← hypervascular tumor (in 95%)


@   Primary tumor

√  growth pattern: exophytic, infiltrating, endocervical

√  bulky enlargement of cervix > 3.5 cm (DDx: cervical fibroid)

√  iso- (50%) / hypoattenuating after IV contrast ← necrosis, ulceration, reduced vascularity

√  gas within tumor (necrosis / prior biopsy)

√  fluid-filled uterus (blood, serous fluid, pus) ← obstruction

√  hypoattenuating lesion of myometrium / with vaginal distension

@   Parametrial spread (30–58% accuracy):

√  parametrial soft-tissue mass

√  ureteral encasement

√  thickening of ureterosacral ligaments

√  > 4-mm soft-tissue strands of increased attenuation extending from cervix into parametria, cardinal / sacrouterine ligaments

√  obliteration of fat planes

√  ill-defined irregular cervical margins

√  eccentric parametrial enlargement

DDx:   parametrial inflammation ← instrumentation, ulceration, infection, prior pelvic surgery, endometriosis

@   Pelvic side wall disease

√  tumor < 3 mm from side wall

√  enlarged piriform / obturator internus muscles

√  encasement of iliac vessels

√  destruction of pelvic bones

@   Pelvic visceral disease (60% PPV)

√  loss of perivesical / perirectal fat plane

√  asymmetric nodular thickening of bladder / rectal wall

√  intraluminal mass

√  air in bladder ← fistula

@   Lymphatic spread (65–77–80% accuracy)

√  nodes > 1 cm in diameter (> 7 mm for internal iliac nodes, > 9 mm for common iliac nodes, > 10 mm for external iliac nodes) with 44% sensitivity

√  lymph node necrosis (100% PPV)

DDx:   adenopathy from secondary tumor infection

MR (76–78–91% accuracy for staging, 82–94% accuracy for parametrial involvement):

@   Primary tumor

√  focal bulge / mass in cervix:

√  mass isointense on T1WI

√  hyperintense on T2WI compared with fibrous stroma (DDx: postbiopsy changes, inflammation, nabothian cysts)

√  size of tumor accurately depicted (on T2WI rarely overestimated due to inflammation / edema)

◊  Tumor diameter and probability of recurrence + metastases are related; tumor diameter > 4 cm (stage IB2) means no surgical treatment

√  early contrast enhancement on fat-saturated T1WI

√  blurring + widening of junctional zone (retained secretions in uterine cavity) ← obstruction of cervical os

√  disruption of hypointense vaginal wall by hyperintense thickening on T2WI

√  disruption of hypointense cervical fibrous stromal ring on T2WI by nodular / irregular tumor SI

@   Parametrial invasion (best seen on T1WI):

√  low-intensity spiculated areas of soft tissue radiating from periphery of cervical mass

√  irregular lateral margins of cervix = linear stranding around cervical mass

√  thickening of uterosacral ligament

@   Pelvic sidewall invasion

√  tumor involves obturator internus, piriform, levator ani m.

√  dilatation of ureter + hydronephrosis

@   Pelvic visceral disease

√  disruption of hypointense walls of bladder / rectum (DDx: hyperintense thickening of bladder wall on T2WI ← bullous edema)

@   Lymphatic spread

√  lymphadenopathy > 10 mm, hyperintense compared with muscle / blood vessels on T2WI


Indication:  staging, restaging, evaluation of response to therapy


(1)  Cyclical endometrial uptake during ovulatory + menstrual phases

(2)  Attenuation correction artifact with metallic prosthetic implants, IUD, surgical clips

(3)  Physiologic ovarian uptake in premenopausal women by corpus luteum

(4)  Uptake by uterine leiomyoma

(5)  Uptake by postsurgical healing, radiation fibrosis, infection

Prognosis:   depending on tumor stage + volume of primary mass + histologic grade + lymph node metastases; in 30% recurrent / persistent disease (usually within 2 years)

5-year survival rate: tumor diameter ≤ 1 cm    84%
  tumor diameter > 4 cm    67%
  stage IIB    65%
  stage III    40%
  stage IVA <    20%

Cx:   stenosis + obstruction of cervical canal → hydrometra, hematometra, pyometra


(1)  Surgery for stages < IIA / tumor < 4 cm


(2)  Radiation therapy ± chemotherapy for stages > IIB

Prevention:   human papillomavirus vaccine


(1)  Endometrial polyp / adenocarcinoma (centered in endometrial cavity protruding into endocervical canal)


(2)  Prolapsed submucosal fibroid (more hypointense on T2WI)

Recurrent Cervical Carcinoma

=  local tumor growth / development of distant metastasis ≥ 6 months after complete regression

@   Pelvic recurrence

Prevalence:   varies with stage, histologic type, adequacy of therapy, host response; 11% in stage IB

Site:   cervix, uterus, vagina / vaginal cuff, parametria, ovaries, bladder, ureters, rectum, anterior abdominal wall, pelvic side wall

•  lower extremity swelling ← lymphatic obstruction

•  pain ← nerve compression, ureteral obstruction

√  hydrometra ← obstruction by preserved cervix

√  rectovaginal fistula

√  hydronephrosis (70% by autopsy)

√  vesicovaginal fistula

√  pelvic side wall mass

DDx:   radiation fibrosis (82% MR accuracy)

@   Nodal recurrence

◊  Prognosis worsens as nodal involvement progresses!

(a)  primary: paracervical, parametrial, internal + external iliac, obturator nodes (= medial group of the external iliac nodes)

Frequency:   in 75% of adenocarcinoma, in 61% of squamous cell carcinoma (autopsy)

(b)  secondary: sacral, common iliac, inguinal, paraaortic nodes

Frequency:   in 62% of adenocarcinoma, in 30% of squamous cell carcinoma (autopsy)

@   Solid abdominal organ recurrence

Location:   liver (33%) > adrenal gland (15%) > spleen, pancreas, kidney

@   Peritoneal recurrence

1.   Peritoneal carcinomatosis (5–27% by autopsy)

2.   Tumor deposits in mesentery + omentum

•  Sister Joseph nodule = umbilical metastasis developing from anterior peritoneal surface

@   GI tract recurrence

Location:   rectosigmoid junction (17%), colon, small bowel

√  fistula formation

√  focal bowel wall thickening + tethering

√  intestinal obstruction (12% by autopsy)

Prognosis:  immediate cause of death in 7%

@   Chest recurrence

1.   Lung metastases (33–38% by autopsy)

2.   Pleural metastases associated with hydrothorax

3.   Pericardial metastasis

4.   Lymphangitic carcinomatosis (< 5%)

5.   Mediastinal / hilar adenopathy + pleural lesions / effusion

@   Osseous recurrence

Prevalence:   15–29% by autopsy

Location:   vertebra > pelvis > rib > extremity

Mechanism:   direct extension from paraaortic nodes (most common) / lymphatic / hematogenous spread

@   Skin + subcutaneous tissue recurrence (in up to 10%)


(a)  normally seen < 16 weeks MA

Cause:   incomplete fusion of amniotic membrane with chorionic plate

(b)  abnormal > 17 weeks MA

Cause:   hemorrhage / amniocentesis (10%)

√  membrane extends over fetal surface + stops at origin of umbilical cord

√  elevated membrane thinner than chorionic membrane

Cx:   rupture of amniotic membrane → may lead to amniotic band syndrome

DDx:   amniotic band syndrome, uterine synechia, fibrin strand after amniocentesis, cystic hygroma (moves with embryo)


=  benign vascular malformation of proliferating capillaries (= hamartoma) without malignant potential

Prevalence:   0.5–1.0% of pregnancies; > 5 cm in 1÷3,500 to 1÷16,000 births

◊  Most common tumor of the placenta

Histo:   angiomatous (capillary), cellular, degenerative subtypes

Location:   usually near the umbilical cord insertion site supplied by fetal circulation

•  elevated maternal serum α-fetoprotein level (rare)


√  well-circumscribed hypo- / hyperechoic rounded intraplacental mass protruding from the fetal surface of the placenta into amniotic cavity

√  contains anechoic cystic areas (= vessels)

√  arterial signal on Doppler ultrasound in angiomatous chorioangioma


√  placental mass with high T2 SI (similar to hemangioma)

√  heterogeneous SI ← acute infarction + degenerative changes

Prognosis:   regression after infarction

Maternal Cx:   preterm labor, toxemia, placental abruption, preeclampsia, hemorrhage

Fetal Cx (30–50%):

polyhydramnios (in ⅓), fetal hydrops, fetal hemolytic anemia, fetal thrombocytopenia, cardiomegaly, IUGR, congenital anomalies, fetal demise (with large / multiple lesion)

Rx:   expectant management with serial US imaging (6–8 week intervals for small tumors, 1–2 week intervals for large tumors); serial fetal transfusion, fetoscopic laser coagulation, chemosclerosis with absolute alcohol, endoscopic surgical devascularization

DDx:   partial hydatidiform mole, placental hematoma, teratoma, metastasis, leiomyoma


=  remarkably aggressive

Frequency:   < 1%

Primary Ovarian Choriocarcinoma


Prevalence:   extremely rare; 50 cases in world literature

Age:     < 20 years

Associated with:   germ cell tumor / epithelial neoplasm

•  ↑ serum hCG (100% sensitive, 100% specific)

•  isosexual precocity (50%)

√  usually unilateral

√  vascular predominantly solid tumor with areas of hemorrhage + necrosis + cyst formation

Prognosis:  90% 5-year survival in spite of typically late diagnosis at advanced stage

DDx:  ectopic pregnancy (frequently mistaken diagnosis!), metastasis to ovary from gestational choriocarcinoma (reproductive age)

Gestational Ovarian Choriocarcinoma

Cause:  metastasis from uterine choriocarcinoma (frequently bilateral ovarian masses); arising from ectopic ovarian pregnancy (extremely rare)

Age:     reproductive age

Gestational Uterine Choriocarcinoma

Prevalence:   5% of gestational trophoblastic diseases

Age:     child-bearing age

Histo:  biphasic pattern including syncytiotrophoblastic + cytotrophoblastic proliferation without villous structures; extensive necrosis + hemorrhage; early + extensive vascular invasion

Preceded by:   mnemonic:   MEAN

Mole (hydatidiform)    in 50.0%

Ectopic pregnancy    in 2.5%

Abortion, spontaneous    in 25.0%

Normal pregnancy    in 22.5%

•  continued elevation of hCG after expulsion of molar / normal pregnancy (25%); continued vaginal bleeding


√  mass enlarging the uterus

√  mixed hyperechoic pattern (hemorrhage, necrosis)

CT (useful for staging):

√  heterogeneous predominantly hypoattenuating intrauterine tissue

√  detection of distant metastases


√  heterogeneous hyperintense mass on T2WI

√  focal signal voids (= vessels) on T1WI + T2WI

√  disruption of hypointense myometrium (= local invasion)

√  marked enhancement ← high vascularity

√  enhancing parametrial tissue (= local spread)


(a)  hematogenous (usually): lung, kidney (10–50%), brain

√  radiodense pulmonary masses with hazy borders ← hemorrhage + necrosis

√  hyperechoic hepatic foci

(b)  lymphatic: pelvic lymph nodes

(c)  direct extension (occasionally): vagina

Prognosis:  85% cure rate (even with metastases); fatal with spread to kidneys + brain


(1)   Chemotherapy: methotrexate, actinomycin D ± cyclophosphamide


(2)  Hysterectomy (if at risk for uterine rupture)

DDx:   mnemonic:   THE CLIP

True mole

Hydropic degeneration of placenta

Endometrial proliferation

Coexistent mole and fetus

Leiomyoma (degenerated)

Incomplete abortion

Products of conception (retained)



=  almost always invasive carcinoma

Frequency:   2–5–10% of all ovarian cancers

Histo:   clear cells (cuboidal cells with clear cytoplasm) + hobnail cells (columnar cells with large nuclei projecting into the lumina of glandular elements); identical to clear cell carcinoma of endometrium, cervix, vagina, kidney; ~ 100% malignant

Not associated with:   in utero DES exposure (like lesions of the vagina + cervix)

•  75% of patients present with stage I disease

√  frequently unilocular cyst + mural nodule(s)

Prognosis:   50% 5-year survival rate (better than for other ovarian cancers)


=  exstrophy of all structures forming cloaca (rectum, bladder, lower GU tract) similar to bladder exstrophy

Prevalence:   1÷200,000–400,000 live births; M < F

Cause:   ? premature rupture of cloacal membrane; ? abnormal overdevelopment of lower cloaca preventing mesenchymal tissue migration: ? abnormal fusion of genital tubercle below cloacal membrane; ? abnormal caudal position of body stalk; ? failure of mesenchymal ingrowth

Associated abnormalities:   OEIS

(a)  lumbosacral (common): vertebral column / spinal cord abnormalities, tethered cord, lipomeningocele, lipomyelocystocele

(b)  genitourinary (in up to 60%): hydronephrosis, renal developmental variants, abnormal genitalia, oligohydramnios ← renal obstruction

•absent anal dimple ← anal atresia

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Jun 29, 2017 | Posted by in GENERAL RADIOLOGY | Comments Off on and Gynecologic Disorders

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