Pelvic Puzzles: Imaging Non-Traumatic Emergencies of the Female Pelvis: A Comprehensive Review.

Acute non-traumatic pelvic pain represents a frequent and complex diagnostic dilemma in pre-menopausal females presenting to the emergency department due to overlapping symptomatology across pregnancy and non-pregnancy related causes. Radiologists play a pivotal role in expediting accurate diagnosis and guiding appropriate management in these potentially life-threatening scenarios. This review provides an approach to workup and imaging selection in these patients, emphasizing the necessity of serum β-hCG testing and the central role of transabdominal and transvaginal pelvic ultrasound. An overview of female pelvic anatomy is provided. Using a multimodality imaging approach, early pregnancy related complications such as ectopic pregnancy, retained products of conception, and gestational trophoblastic disease and non-pregnancy related causes of acute pelvic pain such as ovarian torsion, ruptured ovarian cysts, pelvic inflammatory disease, endometriosis, uterine vascular malformation, ovarian vein thrombosis, ovarian hyperstimulation syndrome, and intrauterine device complications are reviewed. Finally, we propose an algorithmic approach to imaging selection and interpretation tailored to the clinical scenario, laboratory findings (notably β-hCG status), and patient demographics. This structured framework aims to support radiologists in efficiently narrowing the differential diagnosis and optimizing patient outcomes in acute, non-traumatic pelvic emergencies.