Ovarian fibrosarcoma is a malignant mesenchymal fibroblastic tumour of the ovary that have multiple mitotic figures which is most important factor in histopathological diagnosis (4 or more mitotic figure per 10 high power fields).
Ovarian fibrosarcoma are very rare malignant ovar...
Ovarian fibrothecomas comprise tumours in the spectrum of ovarian sex cord / stromal tumours where there are components of both an ovarian fibroma and an ovarian thecoma.
Most occur in adult women, with ~66% in postmenopausal women. Although they account for ~1% of all ovarian tu...
An ovarian follicle (also known as a Graafian follicle in its mature state) is the basic unit of female reproductive biology and is composed of roughly spherical aggregations of cells. It contains a single oocyte.
An ovarian follicle can be initiated to grow and develop, culminating in ovulati...
An ovarian follicular cyst is type of simple physiological ovarian cyst.
The terms "ovarian cyst" and "ovarian follilcular cyst" are often used interchangeably. These two terms describe lesions >3 cm, and it is important to differentiate them from an "ovarian follicle" which is <3 ...
Ovarian hyperstimulation syndrome (OHSS) is a complication of ovarian stimulation treatment (ovarian induction therapy) for in vitro fertilisation. Rarely, it may also occur as a spontaneous event in pregnancy (see spontaneous ovarian hyperstimulation later in the article).
The clinical syndrom...
Ovarian hyperthecosis (OHT) is a condition where there is a presence of luteinized thecal cells within a hyperplastic ovarian stroma.
Clinical manifestations include hyperandrogenism, obesity, hypertension, and impaired glucose tolerance. Virilization has been reported to...
A hypointense ovarian lesion on T2 weighted MRI is usually a sign of benignity. The low signal is considered to be due to fibrosis and blood products 1.
Lesions that can give this appearance include 1:
Ovarian lymphoma can refer to
primary involvement of the ovaries with lymphoma (i.e. primary ovarian lymphoma): very rare
secondary ovarian involvement of the ovaries with generalised lymphoma (i.e. secondary ovarian lymphoma): more common scenario
Mucinous cystadenocarcinoma of the ovary is a rare malignant ovarian mucinous tumour. This type can account for 5-10% of all ovarian mucinous tumours. It is a type of ovarian epithelial tumour.
Retrospective studies have suggested that many mucinous carcinomas initially diagnosed as...
Mucinous cystadenoma of the ovary is at the benign end of the spectrum of mucin-containing epithelial ovarian tumours.
The estimated peak incidence is at around 30-50 years of age.
They comprise approximately 80% of mucinous ovarian tumours and 20-25% of all benign ovarian tumou...
Ovarian mucinous tumours are a subgroup of ovarian epithelial tumours. They represent ~20% of all ovarian tumours and ~10% of all malignant ovarian tumours. They are subdivided according to their malignant potential and clinical behaviour into:
ovarian mucinous cystadenoma
ovarian borderline m...
Ovarian serous cystadenocarcinoma is an ovarian epithelial tumour at the malignant end of the spectrum of ovarian serous tumours.
They account for the largest proportion of malignant ovarian tumours 1, representing over 50-80% of all malignant epithelial ovarian tumours 4. The pre...
Ovarian serous cystadenomas are a type of benign ovarian epithelial tumour at the benign end of the spectrum of ovarian serous tumours.
Serous cystadenomas account for ~60% of ovarian serous tumours 1. They are the commonest type of ovarian epithelial neoplasm. The peak incidence ...
Ovarian serous neoplasms are the commonest subtypes of the epithelial ovarian tumours, being more prevalent than the mucinous ovarian tumours. They are subdivided according to their malignant potential and clinical behaviour into:
benign serous cystadenoma / serous cystadenofibroma
Ovarian Sertoli-Leydig cell tumours (SLCT), also known as an ovarian androblastomas, are a subtype of ovarian sex cord-stromal tumour.
They are rare and only account for ~0.5% of all ovarian tumours. While they can present at any age, they typically present <30 years old, with a m...
Ovarian teratomas is the most common group of ovarian germ cell tumours.
They can be divided into 3 main sub types
mature ovarian teratoma
immature ovarian teratoma
struma ovarii tumour
Ovarian thecomas are benign ovarian tumours of sex cord / stromal (mesenchymal) origin. They are thought to account for approximately 0.5-1% of all ovarian tumours. As ovarian thecomas secrete oestrogen, they are described as functional ovarian tumours.
They typically present in o...
Ovarian torsion, also sometimes termed adnexal torsion or tubo-ovarian torsion, refers to rotation of the ovary and portion of the fallopian tube on the supplying vascular pedicle.
It can be intermittent or sustained and results in venous, arterial and lymphatic stasis. It is a gynaecological ...
Ovarian transposition is a surgical procedure in which the ovaries are displaced from the pelvis before pelvic radiation therapy in order to protect them from radiation injury.
It is performed in premenopausal women with a variety of pelvic malignancies (e.g cervical cancer, rectal cancer, and ...
Ovarian tumours are relatively common and account for ~6% of female malignancies. This article focuses on the general classification of ovarian tumours. For specific features, refer to the sub-articles.
Primary ovarian tumours
Surface epithelial stromal ovarian tumours (60...
There are several ovarian tumours associated with endometrial thickening and is often due to oestrogenic effects of the ovarian tumour.
Such tumours include:
ovarian epithelial tumours
endometroid carcinoma of the ovary
may have synchronous endometrial carcinoma or endometrial hyperplasia, p...
Ovarian vein syndrome is a relatively rare condition where a dilated ovarian vein causes notching, dilatation, or obstruction of the ureter. This is usually secondary to varicoses of the ovarian vein or ovarian vein thrombosis and occurs at the point where the ovarian vein crosses the ureter.
Ovarian vein thrombosis (actually most often a thrombophlebitis) occurs most commonly in postpartum patients and can result in pulmonary emboli. A presentation is usually with acute pelvic pain in the postpartum period, then termed puerperal ovarian vein thrombosis or postpartum ovarian vein th...
Ovarian yolk sac tumours, also known as endodermal sinus tumours, are a type of ovarian germ cell tumours.
Ovarian yolk sac tumour is a rare malignant ovarian germ cell tumour that usually occurs around the second decade of life. It is considered the most common malignant germ cel...
Overlapping fetal fingers is an antenatal ultrasound observation where the fetal fingers are seen to overlap each other. It may be seen seen with a concurrent clenched fetal hand. If the hand is clenched typically the 2nd finger is seen to overlap the 3rd 4.
a well re...
P16 is a widely used immunohistochemical marker. It can be expressed in other neoplasms and in several normal human tissues. It can play an important role gynecological malignancy and is a surrogate marker for HSIL's (high-grade squamous intraepithelial lesions). It has been applied to facilitat...
Pallister-Killian syndrome (PKS) is an extremly rare chromosomal anomaly.
It may be more prevalent in woman of advanced age 4.
It is a polymalformative complex with tetrasomy of isochromosome 12p although many cases are mosaic.
The majority of cases are th...
A papillary serous carcinoma of the cervix (PSCC) is an uncommon histological type of cervical cancer. It is considered a sub type of adenocarcinoma of the cervix.
Accodring to some studies, there was a bimodal age distribution, with one peak occurring before the age of 40 years ...
Papillary serous carcinoma of the endometrium is an uncommon histological subtype of endometrial carcinoma accounting for only 5-10% of all such tumours 2. It is considered type II endometrial adenocarcinoma and has a clinically aggressive form with an early extension of the tumour via Fallopian...
Papillary squamous cell carcinoma (PSCC) of the cervix is a distinct subtype of squamous cell carcinoma of the cervix.
These tumours are characterised by a papillary architecture containing fibrovascular cores and moderate to severe dysplasia without any of frank keratinization and k...
The parametrium is a band of fibrous tissue that separates the supravaginal portion of the cervix from the bladder. It extends on to its sides and laterally between the layers of the broad ligaments.
The uterine artery and ovarian ligament are located in the parametrium.
The parametrium is imp...
Paraovarian cysts (POCs) are remnants of Wolffian duct in the mesosalpinx that do not arise from the ovary. They account for ~10-20% of adnexal masses 3-4.
They typically occur in women at the ages of 20-40 years old.
Most are asymptomatic, although patient...
Paraovarian cystadenoma is a usually benign adnexal tumour that does not arise from the ovary. There is an association with Von Hippel Lindau syndrome.
typically seen as a unilateral cystic adnexal lesion
may be a simple cyst, or contain solid nodular ...
A parasitic leiomyoma is a considered a type of extra-uterine leiomyoma and presents as peritoneal pelvic benign smooth-muscle masses separate from the uterus.
It likely originates as a pedunculated subserosal leiomyoma that twists and torses from its uterine pedicle. The contact wi...
Partial hydatidiform mole (PHD) is a sub type of a hydatidiform mole which in turn falls under the spectrum of gestational trophoblastic disease.
Clinical signs and symptoms such as abdominal pain, cramps of the lower abdomen and vaginal bleeding during pregnancy are non...
Parturition-induced pelvic instability is a rare condition seen in women following vaginal delivery.
The incidence of symphyseal rupture after vaginal delivery ranges from one in 600 to one in 30,000 deliveries 1.
Predisposing factors include multiparity, complicated delivery, ...
Patau syndrome (also known as trisomy 13) is considered the 3rd commonest autosomal trisomy.
This along with Down syndrome (T21) and Edward syndrome (T18) are the only three trisomies to be compatible with extrauterine life. However, few infants live more than a few days.
Pelvic actinomycosis infection is rare but serious infection caused by Actinomyces sp, an opportunistic gram-positive bacteria usually introduced by foreign bodies specially IUCDs, surgery, or trauma. It generally falls under the broader spectrum of pelvic inflammatory disease.
A dedicated pelvic MRI protocol is very useful for imaging assessment of cervical carcinoma.
Although the FIGO is a clinical staging, the 2009 revised FIGO staging encourages the use of MRI to complement clinical staging.
Imaging is optimally performed after three hours of fasting...
Pelvic congestion syndrome is a condition that results from retrograde flow through incompetent valves in ovarian veins. It is one of commonly missed and potentially treatable cause of chronic abdominal or pelvic pain.
It tends to be more common in multiparous, premenopausal wome...
Pelvic inflammatory disease (PID) is a broad term that encompasses a spectrum of infection and inflammation of the upper female genital tract, resulting in a range of abnormalities.
The highest incidence is seen among sexually active women in their teens, with 75% cases being und...
Pelvic lipomatosis (also known as pelvic fibrolipomatosis) represents excessive deposition of fat in pelvis due to overgrowth of adipose cells leading to compression of pelvic organs.
The condition usually presents in patients 20-50 years of age. The condition is predominantly (2/...
Pelvic masses in females carry a broad differential diagnosis:
benign adnexal cyst: 34%
pelvic malignancy: 14%
pelvic inflammatory disease: 8%
Extra-gynaecological masses, e.g. colorectal carcino...
A dedicated MRI protocol is crucial for accurate MRI evaluation of endometrial carcinomas.
Imaging is optimally peformed after 3 hours of fasting to reduce bowel peristalsis and following administration of an anti-peristaltic agent unless contra-indicated.
Supine position using a pelvic phased...
It is important to have a systematic way of approaching a case with pelvic pain in the exam.
Most examinations are performed using ultrasound. Always say that you would further assess the uterus with 3D ultrasound. You may also say that in my department we would perform a sonohysterogram. Only...
Evaluation of known endometriosis with MRI requires a slightly different protocol to a routine pelvic MRI (see Pelvic MRI protocol: routine), and should probably be reserved for known cases of endometriosis rather than for the assessment of pelvic pain.
IV (or IM) Buscopan® is administered to r...
Pelvic ultrasound is the usually the initial modality for imaging gynaecologic pathology, including acute pelvic pain and chronic pelvic pain. The exam normally involves two components: a transabdominal (TA) evaluation and a transvaginal (TV) / endovaginal (EV) evaluation.
Normal ultrasound ana...
The term pelvis can refer to either the bony pelvis or the pelvic cavity.
The bony pelvis is formed by the sacrum and coccyx and a pair of hip bones ("ossa coxae"), which are part of the appendicular skeleton. Its primary function is the transmission of forces from the axial skelet...
Perigestational haemorrhage refers to haemorrhage that occurs around the fetus during the gestational period. The spectrum of haemorrhage includes:
chorionic haemorrhage: caused by the separation of the chorion from the endometrium
subchorionic haemorrhage: most common type, occurs between th...
Getting a film with perigestational haemorrhage in the exam is one of the many exam set-pieces that can be prepared for.
Transabdominal and transvaginal pelvic ultrasound show an anteverted uterus with an intrauterine gestational sac. MSD is 20 mm in TV study with a single, live e...
Perinatal lethal hypophosphatasia (PLH) is the most severe form of hypophosphatasia. If untreated, it is lethal in all cases.
The estimated incidence is at ~1:100,000 live births.
As with all hypophosphatasia cases, this is due to a mutation in chromosome 1q3...
The perineum is a diamond shaped region below the pelvic diaphragm and is divided by an imaginary line drawn between the ischial tuberosities into anteriorly the urogenital triangle and posteriorly the anal triangle.
The perineum is bounded by the pubis anteriorly, the ischial tu...
Peritoneal inclusion cyst (PIC) (also known as a peritoneal pseudocyst) is a type of cyst-like structure that appears in relation to the peritoneum and results from a non neoplastic reactive mesothelial proliferation.
Peritoneal inclusion cysts occur almost exclusively in premenop...
There are several peri-urethral cystic lesions. These include:
female genitourinary tract:
Gartner duct cyst
epidermal inclusion cyst of the vagina
Skene duct cyst
Bartholin gland cyst
endometrial cyst of perineal - vulval - vaginal region
Perivascular epithelioid cells tumours (PEComas) are a group of related mesenchymal tumours and tumour-like conditions found in many locations. This group includes:
clear cell 'sugar' tumour of the lung
clear cell myomelanocytic tumour (CCM...
A persistent right umbilical vein (PRUV) is an uncommon vascular anomaly which is often detected in utero.
The estimated prevalence is at ~2 per 1000 births 1-2.
In the normal situation, the right umbilical vein begins to obliterate in the ~4th week of gestation and di...
It is important to have a systematic way of approaching a case with per vaginal bleeding in the exam.
intrauterine fetal demise
Phocomelia is an extremely rare congenital skeletal disorder that characteristically affects the limbs. It can affect either the upper limbs or lower limbs or both. Phocomelia is also a descriptive term to describe the characteristic limb anomalies occurring with its associated conditions.
Physiological gut herniation is a natural phenomenon that occurs in early pregnancy. It usually occurs from around 6-8 weeks up until 12-13 weeks in-utero, after which the bowel returns to the abdominal cavity.
It occurs as a result of the bowel (particularly ileum) growing faster ...
Physiological pelvic intraperitoneal fluid refers to the presence of a small volume of free fluid in the pelvis, particularly the pouch of Douglas. It occurs in young females of reproductive age and can be a mimic of traumatic free fluid in abdominal trauma.
Unfortunately, pelvic free fluid may...
Getting a film with placental abruption (premature separation of placenta from uterus) in the exam is one of the many exam set-pieces that can be prepared for.
Transabdominal and transvaginal pelvic ultrasound show a single live fetus with gestational age of 27 weeks. The cervix i...
Placental calcification has been considered a manifestation of “ageing” of the placenta. It commonly increases with gestational age.
Delayed placental calcification
Accelerated placental calcification
normal placental maturity
maternal thrombotic disorde...
Placental chorioangiomatosis is an extremely rare condition where numerous placental chorioangiomas involve the placenta. The individual chorioangiomas can be of varying size.
Recognised complications include
precipitation of fetal hydrops 2
fetal cerebral embo...
Placental fusion is a phenomenon that can occur in a twin pregnancy. This can occur to varying degrees. Determination of chorionicity on ultrasound can sometimes be difficult if there has been a placental fusion.
Placental grading (Grannum classification) refers to a ultrasound grading system of the placenta based on its maturity. This primarily affects the extent of calcifications. In some countries the use of placental grading has fallen out of obstetric practice due to a weak correlation with adverse ...
Placental infarction refers to a localised area of ischaemic villous necrosis. It is a significant cause of placental insufficiency.
A localized infarction can occurs in up to ~12.5% (range 5-20%) of all gestations.
It usually results from an interrupted maternal blo...
Placental mosaicism is a situation where there discrepancy between the chromosomal makeup of the cells in the placenta. According to one study fetal mosaicism was found in 50% of cases with placental mosacism. When the fetal cells are normal in chromosomal composition, this is then known as conf...
A placental septal cyst is a placental cyst typically located in a mid placenta. It forms between the cotyledons of the placenta. The cysts contain gelatinous material and are usually 5-10 mm in diameter. They may be present in 10-20% of placentas from full term uncomplicated pregnancies.
Placental site trophoblastic tumour (PSTT) is a rare and one of the least common (~ 0.2% 7) forms of gestational trophoblastic disease (GTD).
PSTT typically occurs in women of reproductive age with the average age around 30. It may occur after a normal pregnancy, molar pregnancy o...
Placental surface cysts are often related to cystic change in an area of subchorionic fibrin. They can be variable in size.
subchorionic cyst: commonest type 2
amniotic epithelial inclusion cyst
Most placental surface cysts are associated with a normal pregnancy outco...
A placental teratoma is a very rare placental tumour.
A placental teratoma is benign and almost never associated with congenital deformities in the fetus.
May show a heterogeneous mass at the placental margin. Hyperechoic foci consisten...
Placental thickness tends to gradually increase with gestational age in a linear fashion. Sonographically, this can be seen to be approximately 1 mm per week and the thickness of the placenta can be used to approximate gestational age:
approximate gestational age (in weeks) = placental thicknes...
Placental trophotropism refers to a phenomenon where there is dynamic migration of the placenta at its insertion through gestation. The placenta tends to grow in areas of good blood supply and nutrition and atrophies in areas with poor blood supply and poor nutrition. It may play a role in the d...
There are many tumours that can involve the placenta.
These can be of very different pathology and can include
placental chorioangioma (considered the most common primary tumour of the placenta 1)
placental site trophob...
Placental venous lakes refer to a phenomenon of formation of hypoechoic cystic spaces centrally within the placenta. Finding placental lakes during a second trimester ultrasound scan is not associated with any uteroplacental complication or with an adverse pregnancy outcome. They can, however, b...
Placentomegaly is a term applied to an abnormally enlarged placenta.
It can be associated with number of maternal and fetal disorders which include:
chronic intrauterine infections
Polycystic ovarian syndrome (PCOS), recently referred also as hyperandrogenic anovulation, is a chronic anovulation syndrome associated with androgen excess.
The diagnosis is made on the combined clinical, biochemical and sonographic grounds. The revised 2003 ASRM/ESHRE Rotterdam consensus cri...
Getting a film with polycystic ovarian syndrome in a subfertile patient is one of the many exam set-pieces that can be prepared for.
Transabdominal and transvaginal pelvic ultrasound show an anteverted uterus with a normal size. There is diffuse thickening of the endometrium to 17...
Polycystic ovaries (PCO) is an imaging descriptor of a particular type of change in ovarian morphology. A proportion of women with polycystic ovaries will have the polycystic ovarian syndrome (PCOS), which in turn requires additional clinical as well as biochemical criteria. Otherwise PCO can be...
Polydactyly refers to the situation where there are more than the usual number of digits (five) in a hand or foot. It can be broadly classified as:
pre-axial polydactyly: extra digit(s) towards the 1st digit (radially)
post-axial polydactyly: extra digit(s) towards 5th digit (ulnar)
Polyhydramnios refers to a situation where the amniotic fluid volume is more than expected for gestational age.
It is generally defined as:
amniotic fluid index (AFI) > 25 cm
largest fluid pocket depth (maximal vertical pocket (MVP)) greater than 8 cm 6: although some centres particularly in ...
Polysyndactyly refers to the combined presence of polydactyly as well as syndactyly involving either the hands or feet.
Polysyndactyly can be associated with a number of syndromes which includes:
type I: Noack syndrome
type II: Carpenter syndrome (typically...
Popcorn calcification refers to amorphous calcifications often with rings and arcs that resemble popped corn kernels. This type of calcification may be seen in many radiological settings including 1:
chondroid lesions (e.g enchondroma, chondrosarcoma)
Post-ablation tubal sterilisation syndrome (PATSS) is a recognised delayed complication seen in patients who have undergone both endometrial ablation and tubal sterilisation. It has been reported in 6-8% of these patients and occurs when bleeding from residual endometrium is obstructed due to su...
Post-axial polydactyly refers to polydactyly where the additional digit is on the ulnar margin of the hand, or lateral to the 5th toe.
Post-axial polydactyly is more common than pre-axial polydactyly, with an estimated incidence of 1 in 3000.
Post dates fetus is when there is prolonged gestation when the fetus remains in-utero beyond 2 weeks beyond expected date of delivery (>42 weeks gestation).
The reported frequency is at approximately 3-12% of pregnancies.
Posterior urethral valves (PUVs), also referred as congenital obstructing posterior urethral membranes (COPUM), are the most common congenital obstructive lesion of the urethra and a common cause of obstructive uropathy in infancy.
Posterior urethral valves are congenital and only...
Post partum haemorrhage (PPH) refers to uterine bleeding after delivery and remains one of the major worldwide causes of maternal mortality.
A post partum haemorrhage can be board classified as primary or secondary.
Primary post partum haemorrhage
This is the most ...
The Potter sequence is a constellation of findings demonstrated postnatally as a consequence of severe, prolonged oligohydramnios in utero.
It consists of
pulmonary hypoplasia: often severe and incompatible with life
growth restriction (IUGR)
abnormal facies (Potter fa...
Predominantly solid ovarian neoplasms account for a minority of ovarian neoplasms. They include a wide pathological spectrum:
epithelial tumours: ~28% of all solid ovarian tumours 1
germ cell tumours: ~22% 1
ovarian teratoma: noncystic type
sex cord / s...
Premature rupture of membranes (PROM) refers to a rupture of the amniotic sac and chorion (membranes) occurring prior to the onset of uterine contractions. When this occurs prior to 37 weeks it is then termed a pre term premature rupture of membranes (PPROM). By this definition, PROM is classifi...
Preterm premature rupture of membranes (PPROM) refers to rupture of membranes prior to 37 weeks of gestation.
It is thought to occur in 0.4-2% of all pregnancies. It however may account for up to one-third of all preterm births (particularly in the United States 5).
Primary fallopian tube carcinoma (PFTC) is an extremely rare malignancy that arises from the fallopian tube. They account for ~1 (0.2-1.1)% all gynaecological malignancies (least common of all gynaecological malignancies 3).
The estimated incidence is at ~3-4 per million women 3. ...