VOTW: Not Ovar This - A Case of Ovarian Torsion

This VOTW was brought to you by Dr. Nguyen-Phuoc.

A 32 yoF with recent fertility treatment presented to the Bay Ridge ED with severe right pelvic pain associated with nausea and vomiting. The transvaginal ultrasound showed:

- Video 1: an enlarged, edematous right ovary with no color flow and free fluid around it

- Video 2: enlarged left ovary but with color flow

- Image 1: venous flow in L ovary

- Image 2: arterial flow in L ovary

The patient was transferred to MMC, where she was seen by GYN and consented for a diagnostic laparotomy. Intraoperatively, the right ovary was noted to be twisted 3 times and was successfully un-twisted.

Note: Fertility treatments can cause ovarian hyperstimulation syndrome (OHSS), where the ovaries become pathologically enlarged due to capillary leak and third spacing of fluid. The increase in ovarian size from OHSS predisposes patients to ovarian torsion.

Note: Ultrasound is not 100% sensitive for torsion. Doppler findings may be normal as the ovary has a dual blood supply (both ovarian and uterine arteries). If you have a high clinical suspicion despite a negative ultrasound, OBGYN should be consulted.

 Happy Scanning! 

- Ariella Cohen M.D.

References: 

https://coreem.net/core/ovarian-hyperstimulation-syndrome/

https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/m4-curriculum/group-m4-genitourinary/ovarian-torsion

VOTW: A Heart-y Effusion

Case: A 62 yoF with a PMHx of CAD presented to the ED as a notification for shortness of breath. She began to worsen and was placed on BIPAP, pressors, and given IV fluids. Despite this, her BP dropped to 57/35 and her pulses became faint. Dr. Yu a bedside echo and saw a large pericardial effusion with tamponade (video 1). She then performed an emergent pericardiocentesis under US guidance and 75 ccs of bloody fluid was removed.

Video 1: subxiphoid view showing a large pericardial effusion with the heart swinging, right atrial, and right ventricular collapse.

Video 2/image 1: Needle tip at the top of the screen inside the pericardial effusion.

Case Conclusion: The patient’s BP immediately improved to 189/94 and she was weaned off of pressors before being admitted to MICU. Cardiothoracic surgery was consulted and the patient is scheduled for a pericardial window.

For more information on how to perform a pericardiocentesis in the subxiphoid approach: https://litfl.com/pericardiocentesis/

Happy scanning! 

Ariella Cohen 

VOTW: Uterus Didelphys

Case: 29 yoF G1P0 presented to the ED with vaginal bleeding and abdominal pain. A transabdominal ultrasound was performed that did not show a definitive IUP. Beta-HCG was elevated at ~30,000. The providers then performed a TVUS that showed a gestational sac without a clear yolk sac and a concerning second structure (video 1). OBGYN was consulted to rule out ectopic pregnancy and their repeat US showed an IUP. However, they also identified 2 uteruses and a vaginal septum, leading them to believe that the patient had uterus didelphys.

Video 1: Superficially you see a collapsed bladder. On the right side of the video, you see 1 uterine horn with a thickened endometrium and no gestational sac. On the left side of the video, towards the end of the clip, you can see an endometrium with a gestational sac. 

Uterus didelphys is a rare condition where a person develops 2 uteruses. It occurs when the Mullerian ducts do not fuse during embryologic development, resulting in 2 separate uteruses, each with its own fallopian tube and ovary (image 1). Some people also have 2 cervixes and 2 vaginal canals. This condition occurs in 0.3% of the population. Pregnancies in women who have uterus didelphys are considered high risk as there is less room for fetus to develop.

Case conclusion: the patient was counseled about risks and the need for close follow-up. She has a repeat ultrasound and appointment in the outpatient clinic this week.

Happy Scanning!

- Ariella Cohen, MD

References: https://my.clevelandclinic.org/health/diseases/23301-uterus-didelphys