Acute abdomen is a frequent clinical picture in emergency diagnostics. Pathologic changes of the female genital organs play an important role. Gynecologic emergencies threaten fertility and are potentially life-threatening. Many differential diagnoses must be considered in the diagnostic process, depending on the age of the patient and any pregnancy. In particular, acute gastrointestinal symptoms often cannot be differentiated from gynecologic emergencies on clinical examination. Here, imaging makes a significant contribution to narrowing the differential diagnosis, making treatment decisions, and monitoring therapy. This review article will discuss the central role of imaging in the context of common gynecologic emergencies.

1. Roche O, Chavan N, Aquilina J, et al. Radiological appearances of gynaecological emergencies. Insights Into Imaging 2012; 3(3): 265–275.

2. Tirada N, Dreizin D, Khati NJ, et al. Imaging pregnant and lactating patients. Radiographics 2015; 35(6): 1751–1765.

3. Oto A, Ernst RD, Ghulmiyyah LM, et al. MR imaging in the triage of pregnant patients with acute abdominal and pelvic pain. Abdominal Imaging 2009; 34(2): 243–250.

4. Atri M, Leduc C, Gillett P, et al. Role of endovaginal sonography in the diagnosis and management of ectopic pregnancy. Radiographics 1996; 16(4): 755–774.

5. Masselli G, Derchi L, McHugo J, et al. Acute abdominal and pelvic pain in pregnancy: ESUR recommendations. European Radiology 2013; 23(12): 3485–3500.

6. Molins IG, Font JM, Alvaro JC, et al. Contrast-enhanced ultrasound in diagnosis and characterization of focal hepatic lesions. World Journal of Radiology 2010; 2(12): 455–462.

7. Nolsoe CP, Lorentzen T. International guidelines for contrastenhanced ultrasonography: Ultrasound imaging in the new millennium. Ultrasonography 2016; 35(2): 89–103.

8. Frohlich JM, Kubik-Huch RA. Radiographic, MR or ultrasound contrast media in pregnant or breast-feeding women: What are the key issues? RoFo 2013; 185(1): 13–25.

9. 9.0 Contrast Media Guidelines [Internet]. European Society of Urogenital Radiology; 2016. Available from: http://www.esur.org/esur-guidelines.

10. Kubik-Huch RA, Gottstein-Aalame NM, Frenzel T, et al. Gadopentetate dimeglumine excretion into human breast milk during lactation. Radiology 2000; 216(2): 555–558.

11. Posner JC, Spandorfer PR. Early detection of imperforate hymen prevents morbidity from delays in diagnosis. Pediatrics 2005; 115(4): 1008–1012.

12. Basaran M, Usal D, Aydemir C. Hymen sparing surgery for imperforate hymen: Case reports and review of literature. Journal of Pediatric and Adolescent Gynecology 2009; 22(4): e61–e64.

13. Fischer JW, Kwan CW. Emergency point-of-care ultrasound diagnosis of hematocolpometra and imperforate hymen in the pediatric emergency department. Pediatric Emergency Care 2014; 30(2): 128–130.

14. Dane C, Dane B, Erginbas M, et al. Imperforate hymen-a rare cause of abdominal pain: Two cases and review of the literature. Journal of Pediatric Adolescent Gynecology 2007; 20(4): 245–247.

15. Drakonaki EE, Tritou I, Pitsoulis G, et al. Hematocolpometra due to an imperforate hymen presenting with back pain: Sonographic diagnosis. Journal of Ultrasound in Medicine 2010; 29(2): 321–322.

16. Poll LW, Flake P. Images in clinical medicine. Imperforate hymen with hematocolpometra. New England Journal of Medicine 2011; 365: 157.

17. Krafft C, Hartin Jr CW, Ozgediz DE. Magnetic resonance as an aid in the diagnosis of a transverse vaginal septum. Journal of Pediatric Surgery 2012; 47(2): 422–425.

18. Beranger-Gibert S, Sakly H, Ballester M, et al. Diagnostic value of MR imaging in the diagnosis of adnexal torsion. Radiology 2016; 279(2): 461–470

19. Damigos E, Johns J, Ross J. An update on the diagnosis and management of ovarian torsion. The Obstetrician & Gynaecologist 2012; 14(4): 229–236.

20. Hibbard LT. Adnexal torsion. American Journal of Obstetrics and Gynecology 1985; 152(4): 456–461.

21. Duigenan S, Oliva E, Lee SI. Ovarian torsion: Diagnostic features on CT and MRI with pathologic correlation. American Journal of Roentgenology 2012; 198(2): W122–W131.

22. Chang HC, Bhatt S, Dogra VS. Pearls and pitfalls in diagnosis of ovarian torsion. Radiographics 2008; 28(5): 1355–1368.

23. Pena JE, Ufberg D, Cooney N, et al. Usefulness of Doppler sonography in the diagnosis of ovarian torsion. Fertility and Sterility 2000; 73(5): 1047–1050

24. Chiou SY, Lev-Toaff AS, Masuda E, et al. Adnexal torsion: new clinical and imaging observations by sonography, computed tomography, and magnetic resonance imaging. Journal of Ultrasound in Medicine 2007; 26(10): 1289–1301.

25. Wilkinson C, Sanderson A. Adnexal torsion—A multimodality imaging review. Clinical Radiology 2012; 67(5): 476–483.

26. Lee EJ, Kwon HC, Joo HJ, et al. Diagnosis of ovarian torsion with color Doppler sonography: Depiction of twisted vascular pedicle. Journal of Ultrasound in Medicine 1998; 17(2): 83–89.

27. Albayram F, Hamper UM. Ovarian and adnexal torsion: Spectrum of sonographic findings with pathologic correlation. Journal of Ultrasound in Medicine 2001; 20(10): 1083–1089.

28. Lourenco AP, Swenson D, Tubbs RJ, et al. Ovarian and tubal torsion: Imaging findings on US, CT, and MRI. Emergency Radiology 2014; 21(2): 179–187.

29. Rha SE, Byun JY, Jung SE, et al. CT and MR imaging features of adnexal torsion. Radiographics 2002; 22(2): 283–294.

30. Hiller N, Appelbaum L, Simanovsky N, et al. CT features of adnexal torsion. American Journal of Roentgenology 2007; 189(1): 124–129.

31. Rajkotia K, Veeramani M, Macura KJ. Magnetic resonance imaging of adnexal masses. Topics in Magnetic Resonance Imaging 2006; 17(6): 379–397.

32. Moribata Y, Kido A, Yamaoka T, et al. MR imaging findings of ovarian torsion correlate with pathological hemorrhagic infarction. Journal of Obstetrics and Gynaecology Research 2015; 41(9): 1433–1439.

33. Emans SJ, Laufer MR. Pediatric and adolescent gynecology. Baltimore, Md: Lippincott Williams & Wilkins; 2005. p. 369.

34. Hiller N, Sella T, Lev-Sagi A, et al. Computed tomographic features of tuboovarian abscess. The Journal of Reproductive Medicine 2005; 50(3): 203–208.

35. Jeong WK, Kim Y, Song SY. Tubo-ovarian abscess: CT and pathological correlation. Clinical Imaging 2007; 31(6): 414–418.

36. Lee DC, Swaminathan AK. Sensitivity of ultrasound for the diagnosis of tubo-ovarian abscess: A case report and literature review. Journal of Emergency Medicine 2011; 40(2): 170–175.

37. Wilbur AC, Aizenstein RI, Napp TE. CT findings in tuboovarian abscess. American Journal of Roentgenology 1992; 158(3): 575–579.

38. Ellis JH, Francis IR, Rhodes M, et al. CT findings in tuboovarian abscess. Journal of Computer Assisted Tomography 1991; 15(4): 589–592.

39. Eshed I, Halshtok O, Erlich Z, et al. Differentiation between right tubo-ovarian abscess and appendicitis using CT—A diagnostic challenge. Clinical Radiology 2011; 66(11): 1030–1035.

40. Noone TC, Semelka RC, Worawattanakul S, et al. Intraperitoneal abscesses: Diagnostic accuracy of and appearances at MR imaging. Radiology 1998; 208(2): 525–528.

41. Dohke M, Watanabe Y, Okumura A, et al. Comprehensive MR imaging of acute gynecologic diseases. Radiographics 2000; 20(6): 1551–1566.

42. Kim SH, Kim SH, Yang DM, et al. Unusual causes of tubo-ovarian abscess: CT and MR imaging findings. Radiographics 2004; 24(6): 1575–1589.

43. Bakir B, Bakan S, Tunaci M, et al. Diffusion-weighted imaging of solid or predominantly solid gynaecological adnexal masses: Is it useful in the differential diagnosis? British Journal of Radiology 2011; 84(1003): 600–611.

44. Fujii S, Kakite S, Nishihara K, et al. Diagnostic accuracy of diffusion-weighted imaging in differentiating benign from malignant ovarian lesions. Journal of Magnetic Resonance Imaging 2008; 28(5): 1149–1156.

45. Rezvani M, Shaaban AM, Kennedy AM. The role of multimodality imaging after cesarean delivery. Ultrasound Quaterly 2015; 31(1):5–18.

46. Brown CE, Stettler RW, Twickler D, et al. Puerperal septic pelvic thrombophlebitis: Incidence and response to heparin therapy. American Journal of Obstetrics and Gynecology 1999; 181(1): 143–148.

47. Josey WE, Staggers Jr SR. Heparin therapy in septic pelvic thrombophlebitis: A study of 46 cases. American Journal of Obstetrics and Gynecology 1974; 120(2): 228–233.

48. Garcia J, Aboujaoude R, Apuzzio J, et al. Septic pelvic thrombophlebitis: Diagnosis and management. Infectious Diseases in Obstetrics and Gynecology 2006; 2006: 1–4.

49. Kominiarek MA, Hibbard JU. Postpartum ovarian vein thrombosis: An update. Obstetrical & Gynecological Survey 2006; 61(5): 337–342.

50. De Cuyper K, Eyselbergs M, Bernard P, et al. Added value of diffusion-weighted MR imaging in the diagnosis of postpartum ovarian vein thrombosis. Jbr-btr 2014; 97(4): 242–244.

51. Kataoka ML, Togashi K, Kobayashi H, et al. Evaluation of ectopic pregnancy by magnetic resonance imaging. Human Reproduction 1999; 14(10): 2644–2650.

52. Della-Giustina D, Denny M. Ectopic pregnancy. Emergency Medicine Clinics in North America 2003; 21: 565–584.

53. Tamai K, Koyama T, Togashi K. MR features of ectopic pregnancy. European Radiology 2007; 17(12): 3236–3246.

54. Refaat B, Dalton E, Ledger WL. Ectopic pregnancy secondary to in vitro fertilization-embryo transfer: Pathogenic mechanisms and management strategies. Reproductive Biology and Endocrinology 2015; 13(1): 30.

55. Baron KT, Babagbemi KT, Arleo EK, et al. Emergent complications of assisted reproduction: Expecting the unexpected. Radiographics 2013(1); 33: 229–244.

56. Braffman BH, Coleman BG, Ramchandani P, et al. Emergency department screening for ectopic pregnancy: A prospective US study. Radiology 1994(3); 190: 797–802.

57. Condous G, Okaro E, Khalid A, et al. The accuracy of transvaginal ultrasonography for the diagnosis of ectopic pregnancy prior to surgery. Human Reproduction 2005; 20(5): 1404–1409.

58. Shalev E, Yarom I, Bustan M, et al. Transvaginal sonography as the ultimate diagnostic tool for the management of ectopic pregnancy: Experience with 840 cases. Fertility and Sterility 1998; 69(1): 62–65.

59. Brown DL, Doubilet PM. Transvaginal sonography for diagnosing ectopic pregnancy: Positivity criteria and performance characteristics. Journal of Ultrasound in Medicine 1994; 13(4): 259–266.

60. Sadek AL, Schiotz HA. Transvaginal sonography in the management of ectopic pregnancy. Acta Obstetricia et Gynecologica Scandinavica 1995; 74(4): 293–296.

61. Yoshigi J, Yashiro N, Kinoshita T, et al. Diagnosis of ectopic pregnancy with MRI: Efficacy of T2*-weighted imaging. Magnetic Resonance in Medical Sciences 2006; 5(1): 25–32.

62. Murase E, Siegelman ES, Outwater EK, et al. Uterine leiomyomas: Histopathologic features, MR imaging findings, differential diagnosis, and treatment. Radiographics 1999; 19(5): 1179–1197.

63. McLucas B. Diagnosis, imaging and anatomical classification of uterine fibroids. Best Practice & Research Clinical Obstetrics & Gynaecology 2008; 22(4): 627–642.

64. Furey EA, Bailey AA, Pedrosa I. Magnetic resonance imaging of acute abdominal and pelvic pain in pregnancy. Topics in Magnetic Resonance Imaging 2014; 23(4): 225–242.

65. Ueda H, Togashi K, Konishi I, et al. Unusual appearances of uterine leiomyomas: MR imaging findings and their histopathologic backgrounds. Radiographics 1999; 19(suppl.1): 131–145.

66. Potter AW, Chandrasekhar CA. US and CT evaluation of acute pelvic pain of gynecologic origin in nonpregnant premenopausal patients. Radiographics 2008; 28(6): 1645–1659.

67. Roy C, Bierry G, El Ghali S, et al. Acute torsion of uterine leiomyoma: CT features. Abdominal Imaging 2005; 30(1): 120–123.

68. Hueppchen N, Ling FW. Ectopic pregnancy and abortion. 6th ed. In: Beckmann CR, Ling FW, Smith RP, et al. (editors). Obstetrics and gynecology. Baltimore, Md: Lippincott Williams & Wilkins; 2010. p. 142–143.

69. Katz DS, Khalid M, Coronel EE, et al. Computed tomography imaging of the acute pelvis in females. Canadian Association of Radiologists Journal 2013; 64(2): 108–118.

70. Kim JC, Kim SS, Park JY. “Bridging vascular sign” in the MR diagnosis of exophytic uterine leiomyoma. Journal of Computer Assisted Tomography 2000; 24(1): 57–60.

71. Nishino M, Hayakawa K, Iwasaku K, et al. Magnetic resonance imaging findings in gynecologic emergencies. Journal of Computer Assisted Tomography 2003; 27(4): 564–570.

72. Grand DJ, Mayo-Smith WW, Woodfield CA. Practical body MRI: Protocols, applications and image interpretation. Cambridge: Cambridge University Press; 2012.

73. Walsh CA, Reardon W, Foley ME. Unexplained prelabor uterine rupture in a term primigravida. Obstetrics & Gynecology 2007; 109(2 Part 1): 455.

74. Pepin M, Schwarze U, Superti-Furga A, et al. Clinical and genetic features of Ehlers-Danlos syndrome type IV, the vascular type. New England Journal of Medicine 2000; 342(10): 673–680.

75. Khabbaz AY, Usta IM, El-Hajj MI, et al. Rupture of an unscarred uterus with misoprostol induction: Case report and review of the literature. Journal of Maternal-Fetal Medicine 2001; 10(2): 141–145.

76. Moshiri M, Osman S, Bhargava P, et al. Imaging evaluation of maternal complications associated with repeat cesarean deliveries. Radiologic Clinics of North America 2014; 52(5): 1117–1135.

77. Rodgers SK, Kirby CL, Smith RJ, et al. Imaging after cesarean delivery: Acute and chronic complications. Radiographics 2012; 32(6): 1693–1712.