The Role of Ultrasound in the Diagnosis and Management of Pelvic Inflammatory

Disease

Word Count: 3,005 Gynaecological Ultrasound: HMSU-7030

Name: Benn Berrigan Submission Date: 28th February 2013

1. Aims & Objectives The aim of this case study is to evaluate the role of gynaelogical ultrasound in the diagnosis and management of pelvic inflammatory disease (PID). To facilitate this aim the following objectives were devised: 1. To describe and examine a case of PID with regard to the use of gynaelogical ultrasound. 2. To review peer-reviewed literature relating to PID. 3. To evaluate and compare the role of gynaelogical ultrasound with other relevant diagnostic imaging modalities in the diagnosis and management of PID.

2. Rationale Pelvic Inflammatory Disease (PID) is a common condition, characterised as the spread of bacterial infection from the vagina to the upper genital tract (Ross, 2010; Massouh, 2007), see figure 1. Encompassing all upper genital infections, PID affects 1 in 50 women of reproductive age in the United Kingdom per year (NHS Choices, 2012) and is diagnosed in around 2% of general practitioner (GP) consultations of women aged 16-45 (Healey & Quinn, 2010). Young women are predominately at the highest risk of disease, whilst the age range of this group varies within literature between 15-24 (Hodson, 2009) to 16-19 (Barrett & Taylor, 2005); for simplification, it is deemed of use to categorise this group as being 25 years or below (Raymond, 2002).

Figure 1: Pelvic female anatomy (Macdonald & Magill-Cuerden, 2010).

PID may acutely present with a range of clinical symptoms (see table 1) and is often the result of ascending bacterial infection from the endocervix, which literature has historically implicated the Neisseria gonorrhoea or Chlamydia trachomatis organisms as common causes (Raymond, 2002). However the UK national guidelines for the management of PID (Ross & McCarthy, 2011) found that these sexually transmitted organisms only account for one quarter of PID cases, with resident vaginal flora also implicated. Less commonly infection

may also develop by direct spread from existing abdominal infections, such as diverticulitis or appendicitis (Hodson, 2009). Clinical Symptoms of PID Lower abdominal pain (typically bilateral) Fever (greater than 38C) Adnexal tenderness Cervical motion tenderness Abnormal vaginal discharge Raised inflammatory blood markers and / or raised white cell count Primary Risk Factors for PID Age 25 years (Raymond, 2002) Exposure to STD (sexually transmitted disease) History of previous PID Use of IUCD (intrauterine contraceptive device) within first few weeks Multiple sexual partners Vaginal douching

Table 1: Clinical symptoms (left) suggestive of PID (Ross & McCarthy, 2011) and primary risk factors (right) associated with development of PID (Healey & Quinn, 2010).

At initial presentation PID will often be diagnosed through clinical assessment alone (Healey & Quinn, 2010), with empiric treatment to be commenced in at-risk women, especially with those at risk of STDs and where pelvic or lower abdominal pain is present (Centers for Disease Control and Prevention (CDCP), 2010). Laboratory testing may be used to confirm the presence of sexually transmitted bacterial agents that are deemed responsible for causing PID, raising the positive predictive value (PPV) of the clinical diagnosis (CDCP, 2010). However Gaitn et al. (2002) found the laboratory testing of endometrial cultures often to be imprecise, with a sensitivity of 83% but a specificity of only 26%; clinical diagnosis alone was found to be 87% and 50% respectively on admission. Significantly, literature also finds that clinical diagnosis may be equivocal, with a positive predictive value of only 65% (Jaiyeoba & Soper, 2011). PID diagnosis therefore may be challenging to predict, however misdiagnosis can result in serious long term sequelae such as recurrent infection, chronic pain, ectopic pregnancy and infertility (Ross, 2010). Increasingly diagnostic imaging is being utilised to differentiate PID from differential diagnoses, especially for patients with equivocal clinical findings, chronic disease or when the patient has developed complications (Healey & Quinn, 2010). Historically the gold
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standard diagnostic examination for PID has been laparoscopy (Jaiyeoba & Soper, 2011), a surgical procedure that directly visualises abdominal and pelvic structures through an abdominal incision. Pelvic ultrasound uses high-frequency sound waves to visualise the internal structures within the body and is now considered to be the first-line imaging investigation for PID (Healey & Quinn, 2010); it may also be of benefit in patients with equivocal clinical findings or when there is suspicion of further clinical complications (Thomassin-Naggara et al., 2012). This case study will examine a referral for possible PID to a gynaelogical ultrasound service, discuss the clinical findings and evaluate the role of ultrasound in the care pathway of the patient.

3. Case Study A 39 year-old female presented to the hospital via the GP emergency admissions unit with menorrhagia, nausea, fever and generalised abdominal tenderness with severe bilateral iliac fossa pain. Clinical history: Negative pregnancy test Raised c-reactive protein (CRP) level of 146 mg/L Leucocytes positive urine dip Intrauterine contraceptive device (IUCD) in situ

Before this admission, the patient had no previous diagnostic imaging examinations undertaken. Chest and abdominal x-ray images (appendix 1) had been obtained that morning to rule out bowel perforation or obstruction, which demonstrated no abnormal pathology. Upon commencement of empirical antibiotic treatment, the patients symptoms failed to abate and a gynaecological ultrasound examination was requested to assess for gynaecological pathology. Due to the given clinical information and symptoms, the request was vetted to assess for gynaelogical pathology. The patients pelvis was examined using a Siemens ACUSON S1000. A transabdominal (TA) examination was first performed utilising a 4MHz curvilinear transducer. A transvaginal (TV) examination was then performed using a 9MHz curved-array transvaginal transducer. The bladder, uterus, both ovaries and both adnexae were visualised. The imaging report can be found in appendix 2.

4. Results and Images

Figure 2a: TA LS bladder view, note the well distended bladder that could not be fully visualised in the LS scan field.

Figure 2b: Line diagram of figure 2a.

Figure 3a: TA LS bladder, second view.

Figure 3b: Line diagram of figure 3a.

Figure 4a: TA TS bladder, one of two views taken due to the distended bladder. Note the large left-sided adnexal mass.

Figure 4b: Line diagram of figure 4a.

Figure 5a: TA LS uterus. Note the IUCD present in the uterine cavity.

Figure 5b: Line diagram of figure 5a.

Figure 6a: TA TS uterus.

Figure 6b: Line diagram of figure 6a.

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Figure 7a: TA endometrium, note that IUCD prevents the endometrium from being assessed.

Figure 7b: Line diagram of figure 7a.

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Figure 8a: TA left adnexal mass, measuring 5.7 x 4.2 x 4cm, which may have been the ovary. Note cystic areas within the mass.

Figure 8b: Line diagram of figure 8a.

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Figure 9a: TA right ovary. This is of a more normal size.

Figure 9b: Line diagram of figure 9a.

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Figure 10a: TV LS uterus. The IUCD prevents the endometrium from being properly assessed.

Figure 10b: Line diagram of figure 10a.

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Figure 11a: TV TS uterus. Note the position of the IUCD, which is demonstrated well here.

Figure 11b: Line diagram of figure 11a.

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Figure 12a: TV left adnexal mass, likely to be the left ovary.

Figure 12b: Line diagram of figure 12a.

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Figure 13a: The use of power Doppler imaging increases the likelihood that this was the ovary; note the internal iliac artery, which lays close to the position of the ovary.

Figure 13b: Line diagram of figure 13a.

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Figure 14a: TV TS of the right ovary. Note the complex mass to the left of this.

Figure 14b: Line diagram of figure 14a.

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Figure 15a: Sweeping to the left slightly demonstrates a tubular structure this may represent the diseased right fallopian tube.

Figure 15b: Line diagram of figure 15a.

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Figure 16a: TV TS of left adnexal mass using power Doppler, note the increased peripheral vascularity around the fluid filled tubular structure.

Figure 16b: Line diagram of figure 16a.

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Figure 17a: TV LS of the structure in 16a, note the internal iliac vessel coming into view in partial long section.

Figure 17b: Line diagram of figure 17a.

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Figure 18a: TV of the left adnexa. Note that a tubular structure appears around the mass, this may represent the left fallopian tube.

Figure 18b: Line diagram of figure 18a.

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5. Discussion Presentation and Symptoms The patient presented with a history of severe bilateral iliac fossa pain, menorrhagia, fever and abdominal tenderness. Literature identifies these symptoms as being typical of PID (Ross & McCarthy, 2011), which can cause pain due to ensuing inflammatory processes affecting the endometrium, fallopian tubes and / or ovaries. However there may be a wide variation in symptoms, as detailed within table 1 p.3, which can vary in effect from subtle, mild to severe (Jaiyeoba & Soper, 2011); PID may often be challenging to diagnose confidently. Gaitn et al. (2002) found laboratory testing for causative bacterial agents to have a specificity of only 26% (Gaitn et al., 2002) whilst clinical diagnosis alone may often be equivocal with a positive predictive value of only 65% (Jaiyeoba & Soper, 2011). Indeed no single available test provides definitive evidence of PID (Gaitn et al., 2002). Thomassin-Naggara et al. (2012) highlight that a delay in the commencement of suitable treatment, of even 24-48 hours, can result in serious long term sequelae such as recurrent infection, chronic pain, future ectopic pregnancy and infertility. Therefore in-keeping with UK national guidelines for the management of PID (Ross & McCarthy, 2011), the patient commenced empirical antibiotic treatment, as her clinical history complied with the basic criteria which are: A sexually active female of child bearing age Recent onset of bilateral lower abdominal pain Associated adnexal tenderness Negative pregnancy status

Medeiros et al. (2012) discussed that CRP levels are commonly elevated during most invasive infections, indeed the patients CRP of 146 mg/L was well in excess of the normal upper limit of 14 mg/L (Jangjoo et al., 2011). Allied with a high temperature and positive urine dip for leucocytes, the clinical picture was highly suggestive of abdominal or pelvic infection (Healey & Quinn, 2010). However Hodson (2009) reasons that such tests cannot assess the severity of disease and that a high index of suspicion and consideration for the differential diagnoses of PID (table 2) should be maintained. The most common of which is ectopic pregnancy (EP), where a developing foetus implants in an area other than the uterine cavity (McQueen, 2011). There may be around 10,000 cases of EP annually in the UK (Kirk
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& Bourne, 2011); the symptoms include abdominal pain with associated tenderness which may be localised to a specific area, nausea, amenorrhea and vaginal bleeding (Farquhar, 2005). Around 90% of ectopic pregnancies are tubal (Kirk & Bourne, 2011), where the fertilised egg is impeded within the fallopian tube, around a third of those cases are caused by tubal infection or previous surgery. A further risk factor is the use of IUCDs (Farquhar, 2005), which this patient had present in her uterine cavity.

Differential diagnoses Ectopic pregnancy Appendicitis Urinary tract infection (UTI) Endometriosis Ovarian cyst torsion / rupture Pelvic adhesions (especially if history of previous surgery) Irritable bowel syndrome Functional pain of unknown aetiology or origin Table 2: Differential diagnoses for PID (Hodson, 2009). However an EP was clinically unlikely in this case due to the negative pregnancy test, the bilateral nature of the lower abdominal pain and reported menorrhagia. Further, the patient reported that she had not missed her last menstrual period. Bates (2006) cautions that a negative pregnancy test cannot exclude EP, indeed the pregnancy test was of the urine dip variety, which are variable in sensitivity to levels of human chorionic gonadotrophin (hCG) (Cole, 2011), a hormone produced by the developing placenta during pregnancy (Bates, 2006). For this reason, the reporter asked the medical team to confirm the negative pregnancy status, preferably by blood serum test, for greater sensitivity and the ability to quantify hCG levels. Regarding the patients menorrhagia, this may have been caused by endometritis, characterised as infection of the endometrium, which would result in thickening of the endometrium and associated heavy bleeding during menstruation (Bates, 2006). Other
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possible causes of menorrhagia include fibroids or endometrial polyps; fibroids, if present, can distort the endometrium and increase the surface area from which bleeding can occur (Bates, 2006). Polyps, which are proliferative masses of the endometrial lining, often present with heavy bleeding (Gould, 2007). Appendicitis was also ruled out due to the bilateral adnexal tenderness, absence of vomiting and nausea and that the pain had failed to migrate, factors which Morishita et al. (2007) utilise to rule out appendicitis from PID with 99% sensitivity.

The Role of Diagnostic Imaging in PID Thus far the patient had not required radiological input for her diagnosis and initial treatment for PID, a common occurrence in the literature, where imaging investigations generally offer low sensitivity for the detection of subtle or mild disease (Healey & Quinn, 2010; Jaiyeoba & Soper, 2011). Indeed, PID will often be diagnosed through clinical assessment alone (Healey & Quinn, 2010), with empiric treatment commenced in at-risk women who fulfil the necessary criteria (Ross & McCarthy, 2011). However the patients worsening symptoms necessitated an imaging investigation to exclude differential diagnoses and to visualise the possible progression of disease (Thomassin-Naggara et al., 2012). Healey & Quinn (2010) found that diagnostic imaging is being increasingly used in this manner, especially for cases where patients symptoms progress despite treatment, such as with the patient in this case study. Historically the gold standard diagnostic examination for PID has been laparoscopy (Jaiyeoba
& Soper, 2011), however Gaitn et al. (2002) identified that its sensitivity may be as low as

65%, especially when disease progression is mild, due to the limitations of visualising only the superficial aspects of anatomical structures. Furthermore, laparoscopy is time intensive, requiring a staffed surgical theatre to safely perform the procedure, is surgically invasive and carries inherent risks due to the necessity for general anaesthesia (Healey & Quinn, 2010; Ross, 2010). However Jaiyeoba & Soper (2011) conclude that laparoscopy allied with endometrial biopsy is a comprehensive approach, however it is neither cost-effective nor practical. In comparison ultrasound is widely accepted as the imaging modality of choice (Jaiyeoba & Soper, 2011). It allows for the demonstration of deep soft tissue structures, is relatively inexpensive and readily available at the patients bedside if needed (Ihnatsenka & Boezaart,
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2010). Gynaecological ultrasound can be performed by two complimentary methods; with transvaginal (TV) ultrasound a curved array 4-8MHz transducer is partially introduced within the vaginal vault, providing excellent detail of the endometrium, myometrium and ovaries (Hughes, 2011, pp. 646), especially when assessing subtle pathology (Healey & Quinn, 2010). Transabdominal ultrasound uses a lower frequency curvilinear transducer, which permits a panoramic examination of the pelvis and adnexae (Hughes, 2011, pp. 645); the wide field-of-view can accommodate large pelvic masses (Bates, 2006). With Doppler ultrasound, increased blood flow related to tissue inflammation and other pathological conditions may be visualised and assessed, indeed it is considered a reliable indicator of disease (zbay & Deveci, 2011). The use of TV ultrasound in this case enabled the operator to correlate the site of the patients reported adnexal tenderness, using slight pressure from the TV transducer head, in real-time directly against the acquired images on-screen. However ultrasound is widely deemed to be an operator dependent modality (Bates, 2006). With inexperienced hands Gaitn et al. (2002) found that ultrasound sensitivity for detection of PID may be only 32%, rising however to 85% with an experienced operator acquiring optimal images. This highlights the importance of good quality training for ultrasonographers and the high diagnostic yield that an experienced sonographer may achieve. Patient preparation for gynaelogical ultrasound is fairly well tolerated by most women (Hughes, 2011, pp. 645), which for a TA scan involves having a full bladder. Whilst for a TV scan the preparation is more psychological, the patient must be given a thorough explanation of the procedure and provide verbal consent, good communication is essential in maintaining a positive rapport with the patient (Bates, 2006). The patients privacy and sense of dignity must be maintained at all times. An alternate imaging modality for PID is magnetic resonance imaging (MRI), which has been identified as more accurate than TV ultrasound (Tukeva et al., 1999). Although the value of the study must be questioned due to age and the recent advancement of ultrasound technologies. However, MRI can easily demonstrate pathological fallopian tubes, with varying signal intensity allowing the differentiation of the tubes contents (Kim et al., 2009). MRI easily differentiates between uterine tissue types, with the endometrium seen as a high signal stripe in contrast to the inner and outer myometrium (low and medium signals respectively) (Andrews, 2001). Ovarian masses seen with ultrasound may be characterised by MRI (Healey & Quinn, 2010), the use of gadolinium contrast agent allows benign and
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malignant masses to be further differentiated (Talbot, 2005). Furthermore MRI is not invasive, does not use ionising radiation and is truly multi-planar in nature. However it is expensive, time-consuming and contraindicated for early pregnancy, patients with large body habitus and those with claustrophobia (Talbot, 2005). Computed tomography (CT) may present subtle or nonspecific findings in early or mild PID (Jaiyeoba & Soper, 2011), and therefore may be of limited use in these cases; CT also carries a high dose burden of ionising radiation which is undesirable in female patients of child bearing age. However when working through differential diagnoses CT use may be justified when considering peritonitis, appendicitis, small bowel obstruction or intra-abdominal abscess (Healey & Quinn, 2010). Furthermore, Jung et al. (2011) found that whilst CT has low sensitivity towards PID, it can identify tubal thickening which is highly specific for diagnosing PID.

Ultrasound Appearances The patients clinical symptoms correlated well with the ultrasound findings. The TA examination revealed bilateral adnexal pathology that likely represented chronic inflammatory change. The left adnexa contained a large mass (5.7 x 4.2 x 4cm) which contained small cystic areas, some of which contained internal echogenicity. This likely represented an enlarged ovary containing a combination of simple and possibly haemorrhagic cysts. There was no evidence of free fluid in the pelvis, which if present could indicate cyst rupture (DeFriend, 2011, pp. 682), ectopic pregnancy (Kirk & Bourne, 2011), malignancy (Bates, 2006) or PID (Massouh, 2007, pp. 106). Fluid may also be found within the endometrial space, being indicative of endometritis, which would appear as a linear hypoechoic area within the uterus (Bates, 2007). However, whilst the IUCD may have impeded the demonstration of the endometrium itself, no fluid could be seen within the cavity. The right ovary, whilst slightly enlarged (4 x 2.2 x 3.4cm) was still around normal limits (Bates, 2006) and lay immediately adjacent to a larger multi-cystic area that appeared to contain prominent tubular structures. This area likely represented the right fallopian tube, which due to the inflammatory processes, appeared distended and thickened, see figure 20; the walls of which may be noticeably thickened, literature suggests a thickness of around 5mm may be indicative of disease (Timor-Tritsch et al., 1998, cited by Bates, 2006). This
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may be classified as hydrosalpinx (containing fluid), pyosalpinx (containing pus) or a tuboovarian complex abscess (which involves both the tube and the ovary) (Lee & Swaminathan, 2011). Appearances can vary, which highlights the importance of the examination being conducted by an experienced operator (Bates, 2006).

Figure 19: Normal anatomy of a fallopian tube and ovary (left) and appearance of hydro/pyosalpinx, associated with early stage salpingo-oophoritis (right) (Kim et al, 2009).

Molander et al. (2001) found that salpingitis (infection of the fallopian tubes) may present with a solid vascularised homogenous-mass close to the ovary. There was a multi-cystic mass within the right adnexa, which may have represented salpingo-oophoritis, where the ovaries and tubes adhere together, creating an early inflammatory mass (Kim et al., 2009). This would have benefited from further differentiation with MRI (Healey & Quinn, 2010).

Treatment and Management The patient was referred to a specialist Gynae service and discharged from the hospital with a suitable empirical treatment regime. However the patient failed to attend the Gynae clinic and subsequent clinical history could not be obtained. However Ross (2010) states that following antimicrobial therapy, whilst the signs and symptoms of PID often reside, longer term sequelae are still a risk; the most common of which is chronic pain (Royal College of Obstetricians and Gynaecologists, 2008). Ultrasound may be utilised in the future to investigate differential causes for the pain, due to its stature as a first line investigation tool. Ultrasound-guided hystero-salpingography (HyCosy) may also be used in possible future
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infertility, due its ability to visualise the fallopian tubes whilst presenting no radiation burden (Bates, 2006). In cases which fail to respond to treatment, FitzHughCurtis syndrome may present as right upper quadrant pain, the result of focal peri-hepatitis (Centres for Disease Control and Prevention, 2011). Ultrasound findings may be non- specific however (Healey & Quinn, 2010) and MRI may be more sensitive to subtle inflammatory hepatic changes.

6. Conclusion Whilst imaging investigations were not initially required for this patients diagnosis and treatment, a gynaecological ultrasound examination subsequently aided the medical team to exclude appendicitis and ectopic pregnancy as differential diagnoses; identifying bilateral adnexal masses that likely represented hydrosalpinx or pyosalpinx (Massouh H, 2007). These pathologies suggest that the patients PID was in a chronic stage (Healey & Quinn, 2010). This case study identified that ultrasound has a valuable role as a first line investigation tool for abdominal or pelvic pain (Ross & McCarthy, 2011). Indeed, no other imaging modality is as flexible, cost effective and readily available (Bates, 2006). TV ultrasound also provides excellent higher resolution detail over TA techniques, allied with Doppler ultrasound, this gives clinicians an ability to identify areas of inflammatory response and increased vascularity, which may not be visible with the gold standard laparoscopic approach (Gaitn et al., 2002).

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7. References Andrews A. (2001). Uterine pathology in Dewbury K, Meire H, Cosgrove D, Farrant P .(ed). Ultrasound obstetrics and gynaecology. (2nd edition). Churchill Livingston: London. pp. 19-34. Barrett S, Taylor C. (2005). A review on pelvic inflammatory disease. International Journal of STD & AIDS; 16: 715-721. Bates J. (ed.) (2006). Practical gynaelogical ultrasound. (2nd edition). Cambridge University Press: London. Centres for Disease Control and Prevention. (2010). Sexually Transmitted Diseases Treatment Guidelines. MMWR; 59(12): 63-67. Available online: http://www.cdc.gov/std/treatment/2010/ [Accessed 12th January 2013]. Cole LA. (2011). The hCG assay or pregnancy test. Clinical Chemistry and Laboratory Medicine; 50 (4): 617630. DeFriend D. (2011) Gynaecology: ovaries in Allan PL, Baxter GM, Weston MJ. (ed.) Clinical Ultrasound. (3rd edition). London: Churchill Livingston. pp 682. Farquhar CM. (2005). Ectopic pregnancy. Lancet; 366: 583-591. Gaitn H, Angel E, Diaz R, Parada A, Sanchez L, Vargas C. (2002). Accuracy of five different diagnostic techniques in mild-to-moderate pelvic inflammatory disease. Infectious Diseases in Obstetrics and Gynaecology; 10(4): 171-180. Gould D. (2007). Menorrhagia: causes, diagnosis and treatment options. Nursing Standard; 21 (24): 44-52. Healey PR, Quinn D. (2010).Imaging pelvic inflammatory disease. Ultrasound; 18; 119-124. Hodson, A. (2009). Pelvic inflammatory disease. InnovAiT; 2 (9): 517-521. Hughes T. (2011). Pelvic anatomy and scanning techniques in Allan PL, Baxter GM, Weston MJ. (ed.) Clinical Ultrasound. (3rd edition). London: Churchill Livingston. pp 646. Ihnatsenka B, Boezaart AP. (2010). Ultrasound: basic understanding and learning the language. International Journal of Shoulder Surgery; 4 (3): 55-62.
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Jaiyeoba O, Soper DE. (2011). A practical approach to the diagnosis of pelvic inflammatory disease. Infectious Diseases in Obstetrics and Gynecology; 2011: 1-6. Available online: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3148590/pdf/IDOG2011-753037.pdf [Accessed 20th January 2013]. Jangjoo A, Varasteh AR, Bahar MM, Meibodi NT, Aliakbarian M, Hoeininejad M, Esmaili H, Amouzeshi A. (2011). Is C-reactive protein helpful for early diagnosis of acute appendicitis? Acta Chirurgica Belgica; 111 (4): 219-222. Jung SI, Kim YJ, Park HS, Jeon HJ, Jeong KA. (2011). Acute pelvic inflammatory disease: diagnostic performance of CT. The Journal of Obstetrics and Gynaecology Research; 37 (3): 228-235. Kim MY, Rha SE, Oh SN, Jung SE, Lee YJ, KimYS, Byun JY, Lee A, Kim MR. (2009). MR imaging findings of hydrosalpinx: a comprehensive review. Radiographics; 29: 495-507. Kirk E, Bourne T. (2011). Ectopic pregnancy. Obstetrics, Gynaecology and Reproductive Medicine; 21 (7): 207-211., Lee DC, Swaminathan AK. (2011). Sensitivity of ultrasound for the diagnosis of tuboovarian abscess: a case report and literature review. The Journal of Emergency Medicine; 40 (2): 170175. Macdonald S, Magill-Cuerden J. (2010). Mayes' Midwifery: A Textbook for Midwives. (14th Ed.) Edinburgh: Elsevier. pp 290, illus. McQueen A. (2011). Ectopic pregnancy: risk factors, diagnostic procedures and treatment. Nursing Standard; 25 (37): 49-56. Massouh H. (2007). Ultrasound in the acute pelvis in Bates J. (ed.) Practical Gynaelogical Ultrasound. London: Cambridge University Press. pp. 106. Medeiros IL, Terra RM, Choi EM, Pego-Fernandes PM, Jatene FB. (2012). Evaluation of serial C-reactive protein measurements after surgical treatment of pleural empyema. Clinics; 67 (3): 243-247. Available online: http://www.scielo.br/pdf/clin/v67n3/a07v67n3.pdf [Accessed 8th February 2013].

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Molander P, Sjberg J, Paavonen J, Cacciatore B. (2001). Transvaginal power Doppler findings in laparoscopically proven acute pelvic inflammatory disease. Ultrasound in Obstetrics & Gynecology; 17 (3): 233-238. Morishita K, Gushimiyagi M, Hashiguchi M, Stein GH, Tokuda Y. (2007). Clinical prediction rule to distinguish pelvic inflammatory disease from acute appendicitis in women of childbearing age. American Journal of Emergency Medicine; 25: 152-157. NHS Choices. (2012). Pelvic inflammatory disease. National Health Service. Online: http://www.nhs.uk/conditions/pelvic-inflammatory-disease/Pages/Introduction.aspx [Accessed 2nd January 2013]. zbay K, Deveci S. (2011). Relationships between transvaginal colour Doppler findings, infectious parameters and visual analogue scale scores in patients with mild acute pelvic inflammatory disease. European Journal of Obstetrics & Gynaecology and Reproductive Biology; 156 (2011): 105108. Raymond RH. (2002). Pelvic Inflammatory Disease: A clinical challenge. Topics in Emergency Medicine; 24(4):40-46. Ross, J. (2010). Pelvic inflammatory disease. Medicine; 38 (5): 255-259. Available online: http://www.medicinejournal.co.uk/article/S1357-3039(10)00025-3/ [Accessed 19th December 2012]. Ross J, McCarthy G. (2011). UK national guideline for the management of pelvic inflammatory disease. London: Clinical Effectiveness Group - British Association for Sexual Health and HIV. Available online: http://www.bashh.org/guidelines [Accessed 7th January 2013. Royal College of Obstetricians and Gynaecologists. (2008). Management of acute pelvic inflammatory disease. (2nd ed.). London: Royal College of Obstetricians and Gynaecologists. Available online: http://www.rcog.org.uk/files/rcog-corp/uploadedfiles/T32PelvicInflamatoryDisease2008MinorRevision.pdf [Accessed 7th January 2013].# Talbot J. (2005) Magnetic Resonance Imaging in Carver E, Carver B. Medical imaging: techniques, reflection & evaluation. Edinburgh: Churchill Livingston.

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Thommassin-Naggara I, Darai E, Bazot M. (2012). Gynecological pelvic infection: What is the role of imaging? Diagnostic and Interventional Imaging; 93: 491-499. Timor-Tritsch IE, Lerner JP, Monteagudo A, Murphy KE, Heller DS. (1998). Transvaginal sonographic markers of tubal inflammatory disease. Ultrasound in Obstetrics and Gynecology; 12: 56-66 cited in Bates J. (2006). Practical Gynaelogical Ultrasound. (2nd edition). London: Cambridge University Press. Tukeva TA, Aronen HJ, Karjalainen PT, Molander P, Paavonen T, Paavonen J. (1999). MR imaging in pelvic inflammatory disease: comparison with laparoscopy and US. Radiology; 210: 209-216.

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Appendix 1: Previous Diagnostic Imaging

Figure 21: Abdominal x-ray, note the IUCD in the pelvic rim

Figure 22: Upper abdominal x-ray.

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Figure 23: Chest x-ray.

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Appendix 2: Imaging Report Normal bladder outline. Normal uterus with IUCD in good position in the endometrial cavity. Both adnexal regions are abnormal. On the left there is a 5.7 x 4.2 x 4cm mass-like area which is probably the left ovary containing small cystic areas, within which there are internal echoes ? blood ? infection. Right ovary of more normal size, with a prominent tubular structure and a large complex multi-cystic area extending into the pouch of Douglas. With the given clinical history, the concern is of an inflammatory condition; possibly with pyosalpinx bilaterally. There was no free fluid noted in the pelvis. The bilateral nature would be against appendicitis. Please reconfirm no missed period.

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