Surprise Adnexal Finding

About a week ago, I scanned a 40 year old female patient complaining of pelvic pain.  I performed a transvaginal sonogram and found this right adnexal mass:

The above is in sagital and here it is in transverse:

I was unable to determine its origin so I described it as a complex tubular mass in the right adx and stated I was unable to clearly see a right ovary. The doctor sent the patient on for a CT scan, which basically repeated what I said: right adnexal mass, unable to determine origin.  The patient was scheduled for surgery, which was performed yesterday, and the doctor was shocked to find that is was a cancerous appendix! Apparently very rare. 

Lower uterine contraction

Ob scan today, patient is 20 weeks. We always do a transabdominal cervical length at this exam. When I first looked at the cervix, the patient appeared to have placenta previa and I was thinking I'd do a transvaginal at the end of the anatomy scan to confirm it.  Here is the first image:

At the end of the exam I took another look:

The placenta was completely away from the cervix and the patient avoided a transvaginal exam.  It's always good to get another look after 10-15 minutes to see if the patient was just having a contraction.

Great review of adnexal masses

I came across this Power Point presentation on adnexal masses this morning. It really gives a great explanation of the different types of masses and their characteristics.

http://radiology.bidmc.harvard.edu/learninglab/genito/kong.pdf

Interesting Ectopic

I scanned a young lady this week who presented with mild pain, no bleeding, positive hcg. Transvaginal ultrasound was performed; the uterus was empty and I noted moderate anterior and posterior cul-de-sac fluid. 

The right adnexa was very heterogeneous with masses of different textures and free fluid. I also noted a two centimeter cyst on the right ovary, which I thought was probably the corpus luteum. Transabdominally, I could see a large mass in the right adnexa slightly anterior to the uterus.

After informing the doctor, we performed a colpocentesis (which was the first time I had seen this done). Sure enough, the pelvis was full of blood. We sent her to the ER where surgery confirmed the ectopic, however it was on the left side! I was very surprised since I had seen a 4 cm mass in the right adnexa.  This area turned out to be a large blood clot. My mistake here was seeing the mass on the right and only briefly exploring the left, assuming the right would be the side of the ectopic. In the future I will be sure to adequately explore both adnexas!