Multimodality imaging in secondary postpartum or postabortion hemorrhage: retained products of conception and related conditions

Embolization with gelatin foam in the management of vascularized retained products of conception: a multicenter study by the French Society of Cardiovascular Imaging

OBJECTIVES

Vascularized retained products of conception (vRPOC) are the most frequent cause of delayed hemorrhage after abortion, spontaneous miscarriage, or delivery. This study evaluated the efficacy of uterine artery embolization (UAE) with gelatin foam in the management of symptomatic of vRPOC.

MATERIALS AND METHODS

This retrospective study included patients who underwent UAE with gelatin foam for vRPOCs with vaginal bleeding between January 2018 and December 2022 in 11 French university hospitals. Embolization was performed using either gelatin foam torpedoes or sludge. The primary endpoint was the clinical success of embolization (cessation of bleeding at approximately 1 month after UAE). The secondary objectives were the success of imaging (no persistent vRPOC at imaging follow-up), the safety of UAE, and the predictive factors of clinical and imaging failure.

RESULTS

Two hundred twenty-four patients (median age, 30.5 years ± 5.7 [standard deviation]) were included. Clinical success was achieved in 212 patients (94.2%). One hundred sixty-five patients had imaging follow-ups, among whom 12 patients (7.3%) had persistent vascularization. According to the SIR classification, 30 patients (13.4%) had minor complications, and two patients (0.8%) had major complications (endometritis n = 1; ischemic uterine necrosis n = 1). No predictive factors of clinical success were found, but the presence of a hypertrophic uterine artery (OR = 0.6 [0.38-0.97], p = 0.045) and the use of gelatin foam torpedoes (OR = 0.57 [0.42-0.77], p = 0.0012) were associated with a greater risk of persistent vRPOC on imaging control.

CONCLUSION

UAE with gelatin foam is safe and effective for treating hemorrhagic vRPOC.

KEY POINTS

Question Uterine vacuity is frequently observed on ultrasound after UAE for vRPOC. Findings A hypertrophic uterine artery and the use of gelatin foam torpedoes are associated with an increased risk of persistent vRPOC. Clinical relevance Embolization with gelatin foam is efficient and safe for treating bleeding in vRPOC.

Imaging in Acute Obstetric Conditions: A Pictorial Essay

Acute abdominopelvic pain during pregnancy and the postpartum period is a diagnostic challenge owing to the overlapping symptoms of obstetric, gastrointestinal, and urinary conditions coupled with pregnancy-induced physiological changes. This pictorial essay reviews critical obstetric emergencies and categorizes cases into two phases: the first covers the preconception-to-pregnancy period, while the second focuses on the postpartum period. This essay covers key obstetric emergencies, such as ovarian hyperstimulation syndrome, hyperreactio luteinalis, ectopic pregnancy, red degeneration of fibroids, placenta accreta spectrum disorders, placental abruption, uterine rupture, retained products of conception, and uterine arteriovenous malformations, with an emphasis on their clinical and imaging characteristics. While ultrasound remains the first-line modality, MRI offers superior soft tissue contrast for more complex cases, and CT is reserved for critical scenarios in which the radiation risk is outweighed by diagnostic necessity. Timely and accurate imaging is essential for differentiating these conditions, guiding interventions, such as uterine arterial embolization and surgery, and minimizing maternal and fetal morbidity. This work aims to enhance the diagnostic precision and multidisciplinary management of obstetric emergencies, ensuring optimal clinical outcomes.

Pseudo-myometrial thinning in placental site trophoblastic tumors: a case series with multiparametric MRI

PURPOSE

Placental site trophoblastic tumor (PSTT) is a rare form of gestational trophoblastic neoplasm with few previous imaging case reports. We report multiparametric MRI findings in four cases of PSTT with special emphasis on the "pseudo-myometrial thinning" underlying the tumor.

METHODS

We reviewed multiparametric MRI and pathologic findings in four cases of PSTT from four institutions. Signal intensity, enhancement pattern, margins, and location of the tumors were evaluated, and myometrial thickness underlying the tumor and normal myometrial thickness contralateral to the tumor were measured on MRI. The myometrial thickness underlying the tumor was also measured in the resected specimen and compared with the myometrial thickness measured on MRI using the Friedman test.

RESULTS

All tumors showed heterogeneous signal intensity on T1-weighted imaging, T2-weighted imaging (T2WI), and diffusion-weighted imaging. Three of the four tumors had a hypervascular area on dynamic contrast-enhanced (DCE) MRI. A hypointense rim on T2WI and DCE-MRI was seen in all tumors. All tumors protruded into the uterine cavity to varying degrees and extended into the myometrium close to the serosa. The myometrial thickness underlying the tumor measured on MRI (median thickness, 1.2 mm) was significantly thinner than that measured on pathology (median thickness, 9.5 mm) and normal myometrial thickness contralateral to the tumor on MRI (median thickness, 10.3 mm) (P = 0.02), and there was no significant difference between the latter two.

CONCLUSIONS

The thickness of the myometrium underlying the tumor on MRI was approximately one tenth of the thickness on pathology. Thus, the tumors appeared to have almost transmural invasion even when pathologically located within the superficial myometrium. This "pseudo-thinning" of the underlying myometrium and the hypointense rim on MRI could be caused by focal compression of the myometrium by the tumor, possibly due to the fragility of the myometrium at the placental site.

"The dilemma of GTN versus benign causes of secondary PPH that were indeterminate by ultrasound examination: How to differentiate?: A new prospective diagnostic criterion of functional MRI and ultrasound"

OBJECTIVES

Early differentiation between causes of secondary postpartum hemorrhage (PPH) can sometimes be difficult and can cause serious complications if diagnosis and treatment are delayed. The study aimed to assess the efficacy of different imaging diagnostic criteria, which would help in differentiating between gestational trophoblastic neoplasia (GTN) from indeterminate benign causes; thus, aiding in making clinical decisions in a timely fashion.

METHODS

A comparative prospective study, were 33 patients complaining of 2ry PPH, with indeterminate diagnosis referred to the Radiology department female imaging unit between October 2020 and November 2022 for further assessment. Transvaginal ultrasound examination as well as functional MRI was done. The lesions were characterized and certain diagnostic criteria were evaluated.

RESULTS

The lesion epicenter, margin and depth of myometrial invasion detected by dynamic MRI have significant role to differentiate between GTN and other benign conditions mainly RPOC with higher sensitivity, specificity and accuracy of MRI compared to US. The p value, sensitivity and specificity as well as the accuracy of MRI were: 0.006, 50 %, 92 %, and 81.8 %; 0.000, 87.5 %, 92 % and 90.9 %; 0.002, 87.5 %, 92 % and 90.9 % compared to 0.5, 50 %, 64 % and 60.6 %; 0.01, 87.5 %, 64 % and 69.7 %; 0.2, 87.5 %, 40 % and 51.5 % by US respectively. The overall performance of MRI to reach accurate final diagnosis is higher than the US with accuracy rate of 97 % compared to 63.6 % in indeterminate cases.

CONCLUSIONS

MRI was found to show higher performance, compared to US in differentiating inconclusive cases of 2ry PPH.

Predictive nomogram of ultrasound indicators for the termination outcome of caesarean scar pregnancy

To develop and validate a nomogram for predicting the risk of adverse events (intraoperative massive haemorrhage or retained products of conception) associated with the termination of Caesarean scar pregnancy (CSP). Data were retrospectively collected from patients diagnosed with CSP who underwent Dilation and Curettage (D&C) at two hospitals. This data was divided into internal and external cohorts for analysis. The internal cohort was randomly split, with 70% of the data designated for a training set and 30% for an internal validation set. The external cohort served exclusively as the external validation set. LASSO and logistic regression techniques were employed to select variables and construct the nomogram. The performance of the nomogram was evaluated using various methods, including C-index, calibration curve, decision curve analysis (DCA), and clinical impact curve analysis (CICA), to assess its identification, calibration, and clinical effectiveness. The prediction nomogram included several predictors, such as scar thickness, type of CSP, gestational sac diameter, and blood flow. It demonstrated strong discrimination, with a C-index of 0.83 (95% confidence interval: 0.77-0.89). Furthermore, in the internal validation set, a high C-index of 0.78 was achieved, while in the external validation set, it reached 0.83. Additional assessments using calibration curve analysis, DCA, and CICA indicated robust agreement between the nomogram's predictions and actual observations, highlighting its utility and reliability. The developed nomogram shows excellent discriminative ability and calibration, with the potential for effective local prediction of adverse events in CSP.

Case Report of Placenta Accreta Spectrum and Arteriovenous Malformations with Successful Preservation of Fertility After Birth

Uterine arteriovenous malformations (UAVMs) that occur after birth are a rare cause of late postpartum hemorrhage. Acquired UAVMs usually occur in conjunction with pathology of the placenta. In the spectrum of placenta accreta (PAS), subinvolution of the placental bed plays an important role in its pathophysiology. We present a case of UAVM in a pregnant woman with PAS who presented with marked metrorrhagia after delivery, which was treated with classical management. Then, 35 days later, she presented to the emergency room with severe metrorrhagia. As it was suspected that she had placental remnants, an instrumental uterine control was performed, but the bleeding persisted, requiring further uterine packing and blood administration. Later, uterine artery embolization was performed with good results. Color Doppler ultrasound, magnetic resonance imaging, and angiography were the methods with the greatest diagnostic value. The differential diagnosis was as complex as the treatment. We hypothesize that UAVM may develop from minimal residual PAS in this late postpartum period. Moreover, they may recover rapidly after local surgical ablation. Considering the clinical condition, hemodynamic status, and desire to preserve fertility, we were able to avoid a hysterectomy, which is often chosen in such cases of severe, life-threatening bleeding complications.

Vascular Subinvolution of the Placental Implantation Site as the Cause of Hysterectomy

Background. Vascular subinvolution of the placental bed is one of the uncommon but life-threatening forms of secondary postpartum hemorrhage. Studies on subinvolution of the implantation site are sparse and there is a scarcity of practice-based literature for this diagnosis. Case presentation. A 40-year-old woman with vaginal bleeding and light-headedness was admitted a few days after spontaneous abortion. Based on her unstable condition, hysterectomy was done. Pathologic gross evaluation of the uterus identified multiple large and dilated blood vessels, and microscopically, the myometrium showed thrombosis with scattered extravillous trophoblastic cells within the vessel walls. Conclusions. We described this rare case and explored the literature focusing on the pathophysiology and helpful ancillary studies for diagnosing this situation.

Abnormal Uterine Bleeding: A Pictorial Review on Differential Diagnosis and Not-So-Common Cases of Interventional Radiology Management

Abnormal uterine bleeding (AUB) poses a multifaceted challenge in women's health, necessitating an integrated approach that addresses its diverse etiologies and clinical presentations. The International Federation of Gynecology and Obstetrics PALM-COEIN classification system provides a systematic approach to the diagnosis of AUB in non-pregnant women, based on clinical and imaging-based categorization of causes into structural (Polyps, Adenomyosis, Leiomyomas and Malignancy; PALM), and non-structural causes (Coagulopathies, Ovulatory disorders, primary Endometrial disorders, Iatrogenic and Not otherwise classified; COEIN). On the other hand, placental disorders, uterine rupture, ectopic pregnancy and retained products of conceptions are the main causes of uterine bleeding during pregnancy and in the peripartum period. Ultrasound is usually the first-line imaging technique for the differential diagnosis of causes of AUB. Computed Tomography may be useful if ultrasound findings are unclear, especially in emergency settings. Magnetic resonance imaging, when indicated, is an excellent second-line diagnostic tool for a better non-invasive characterization of the underlying cause of AUB. This pictorial review aims to illustrate the main causes of AUB from the point of view of diagnostic imaging and to show not-so-common cases that can be treated by means of interventional radiology.

Clinical Prediction of Retained Products of Conception: Combining Obstetric History and Ultrasound for Improved Accuracy in Severe Postpartum Hemorrhage

Background The current challenge is how to improve the management of postpartum hemorrhage (PPH) to reduce the maternal mortality rate further. This study aimed to investigate whether a combined specific obstetric history and ultrasonographic findings can improve the predictive accuracy of retained products of conception (RPOC) with severe PPH. Methods This retrospective study included 56 patients who were diagnosed with RPOC. We extracted the following clinical data: obstetric history of second-trimester miscarriage, the time at which there was clinical suspicion of RPOC after the previous pregnancy (TIME), grayscale ultrasonographic finding (RPOC long-axis length [SIZE]), and color Doppler ultrasonographic finding based on the Gutenberg classification (RPOC hypervascularity). In this study, we defined cases requiring blood transfusion therapy or transcatheter arterial embolization as severe PPH. The patients were divided into two groups according to the presence or absence of severe PPH. The predictors of severe PPH were evaluated using logistic regression models. Model A comprised a combination of second-trimester miscarriage and TIME, Model B comprised a combination of Model A and long-axis SIZE, and Model C comprised a combination of Model B and RPOC hypervascularity. Results The multivariable analysis showed that long-axis SIZE was the only significant predictor of severe PPH (odds ratio [OR], 10.38; 95% confidence interval [CI], 2.06-63.86) independent of second-trimester miscarriage, TIME, and RPOC hypervascularity. The c-statistic was higher in Model C (OR, 0.863; 95% CI, 0.731-0.936) than in Model A (OR, 0.723; 95% CI, 0.551-0.847) and Model B (OR, 0.834; 95% CI, 0.677-0.923). Conclusion Combining a specific obstetric history (second-trimester miscarriage and TIME) and ultrasonographic findings (long-axis SIZE and RPOC hypervascularity) improves the predictive accuracy of RPOC with severe PPH. This prediction model may be a useful clinical screening tool for RPOC with severe PPH.

Clinical value of ultrasonic indicators in predicting the outcome of caesarean scar pregnancy after pregnancy termination

BACKGROUND

To investigate the predictive value of ultrasound indicators in early pregnancy for the outcome of caesarean scar pregnancy (CSP) after pregnancy termination.

METHODS

This study retrospectively analysed the ultrasound images of 98 CSP patients who underwent transabdominal ultrasound-guided hysteroscopic curettage during early pregnancy at Changsha Hospital for Maternal and Child Health Care between January 2017 and October 2021. Patients were equally divided into a case group and a control group. The case group included 49 CSP patients with postoperative complications, such as intraoperative blood loss ≥ 200 ml or retained products of conception (RPOC). The remaining 49 CSP patients, with similar age and gestational age and with good postoperative outcomes, such as intraoperative blood loss ≤ 50 ml and no RPOC, were included in the control group. CSP was classified into three types according to the location of the gestational sac (GS) relative to the uterine cavity line (UCL) and serosal contour. Differences in ultrasound indicators between the case and control group were compared.

RESULTS

There were significant differences between the case and control groups in the mean gestational sac diameter (MGSD), residual myometrium thickness (RMT) between the GS and the bladder, blood flow around the GS at the site of the previous caesarean incision, and types of CSP (P < 0.05). The rs of each ultrasound indicator were as follows: 0.258, -0.485, 0.369, 0.350. The optimal threshold for predicting good postoperative outcomes, such as intraoperative blood loss ≤ 50 ml and no RPOC, by receiver operating characteristic (ROC) curve analysis of the RMT was 2.3 mm.

CONCLUSION

Our findings show that the RMT, blood flow around the GS at the site of the previous caesarean incision, and types of CSP have a low correlation with postoperative complications, such as intraoperative blood loss ≥ 200 ml or RPOC, of early pregnancy termination in patients with CSP. To some extent, this study may be helpful for clinical prognostic prediction of patients with CSP and formulation of treatment strategies. Given the low correlation between these three indicators and postoperative complications, further studies are needed to identify indicators that can better reflect the postoperative outcomes of CSP patients.

Imaging of Acute Abdominopelvic Pain in Pregnancy and Puerperium-Part I: Obstetric (Non-Fetal) Complications

Acute abdominopelvic pain in pregnant and postpartum patients presents clinical and therapeutic challenges, often requiring quick and accurate imaging diagnosis. Ultrasound remains the primary imaging investigation. Magnetic resonance imaging (MRI) has been shown to be a powerful diagnostic tool in the setting of acute abdominal pain during pregnancy and puerperium. MRI overcomes some drawbacks of US, avoiding the ionizing radiation exposure of a computed tomography (CT) scan. Although CT is not usually appropriate in pregnant patients, it is crucial in the emergency evaluation of postpartum complications. The aim of this article is to provide radiologists with a thorough familiarity with the common and uncommon pregnancy and puerperium abdominal emergencies by illustrating their imaging appearances. The present first section will review and discuss the imaging findings for acute abdominopelvic pain of obstetric (non-fetal) etiology.

Management of Hypervascular Retained Products of Conception With Massive Bleeding

Retained products of conception (RPOC) could be a factor for massive postpartum hemorrhage; however, a management protocol is yet to be established. Performing a surgical intervention is controversial due to the potential for natural healing. Herein, we report the management of a hypervascular RPOC case with massive bleeding. Abortion was performed in a 40-year-old patient with gravida 2 and para 0, at 20 weeks and five days of gestation following the detection of Down's syndrome on prenatal screening. Post-delivery transvaginal ultrasonography identified an intrauterine mass measuring 4cm × 5cm × 5cm. The patient was then followed up in the outpatient department. One month after the abortion, the patient developed abnormal vaginal bleeding. Transvaginal ultrasonography revealed a hypervascular myometrial RPOC with turbulent flow. Although the bleeding stopped upon her admission to our hospital, the patient developed recurrent abnormal vaginal bleeding after nine days of hospitalization, which resulted in a hemoglobin level drop to 5.9 g/dL. CT and MRI scan findings raised the suspicion of hypervascular RPOC or uterine artery pseudoaneurysm. Uterine artery embolization was performed, leading to diminished vascularity in the RPOC, which was confirmed through color Doppler ultrasonography. The remnant placenta was successfully resected hysteroscopically, and a subsequent transvaginal ultrasonography showed a decrease in blood flow. In conclusion, hypervascular RPOC, previously reported as uterine artery pseudoaneurysms, should be considered when detecting hypervascular myometrial lesions in postpartum ultrasonography. Hypervascular RPOC with hemorrhage might benefit from hysteroscopic resection after achieving hemostasis with uterine artery embolization. This case report highlights the potential risks of awaiting spontaneous resolution in large RPOC and suggests that timely surgical intervention is both effective and essential.

Clinical significance of retained products of conception in placenta previa: a retrospective analysis

BACKGROUND

Retained products of conception (RPOC) often cause severe postpartum hemorrhage (PPH) but the clinical significance of RPOC in placenta previa is unclear. This study aimed to investigate the clinical significance of RPOC in women with placenta previa. The primary outcome was to evaluate risk factors of RPOC and the secondary outcome was to consider risk factors of severe PPH.

METHODS

Singleton pregnant women with placenta previa who underwent cesarean section (CS) and placenta removal during the operation at the National Defense Medical College Hospital between January 2004 and December 2021 were identified. A retrospective analysis was performed to examine the frequency and risk factors of RPOC and the association of RPOC with severe PPH in pregnant women with placenta previa.

RESULTS

This study included 335 pregnant women. Among these, 24 (7.2%) pregnant women developed RPOC. Pregnant women with prior CS (Odds Ratio (OR) 5.98; 95% Confidence Interval (CI) 2.35-15.20, p < 0.01), major previa (OR 3.15; 95% CI 1.19-8.32, p < 0.01), and placenta accreta spectrum (PAS) (OR 92.7; 95% CI 18.39-467.22, p < 0.01) were more frequent in the RPOC group. Multivariate analysis revealed that prior CS (OR 10.70; 95% CI 3.47-33.00, p < 0.01,) and PAS (OR 140.32; 95% CI 23.84-825.79, p < 0.01) were risk factors for RPOC. In pregnant women who have placenta previa with RPOC or without RPOC, the ratio of severe PPH were 58.3% and 4.5%, respectively (p < 0.01). Furthermore, the occurrence of prior CS (OR 9.23; 95% CI 4.02-21.20, p < 0.01), major previa (OR 11.35; 95% CI 3.35-38.38, p < 0.01), placenta at the anterior wall (OR 3.44; 95% CI 1.40-8.44, p = 0.01), PAS (OR 16.47; 95% CI 4.66-58.26, p < 0.01), and RPOC (OR 29.70; 95% CI 11.23-78.55, p < 0.01) was more in pregnant women with severe PPH. In the multivariate analysis for severe PPH, prior CS (OR 4.71; 95% CI 1.29-17.13, p = 0.02), major previa (OR 7.50; 95% CI 1.98-28.43, p < 0.01), and RPOC (OR 13.26; 95% CI 3.61-48.63, p < 0.01) were identified as risk factors.

CONCLUSIONS

Prior CS and PAS were identified as risk factors for RPOC in placenta previa and RPOC is closely associated with severe PPH. Therefore, a new strategy for RPOC in placenta previa is needed.

Management of Symptomatic Vascularized Retained Products of Conception by Proximal Uterine Artery Embolization with Gelatin Sponge Torpedoes

PURPOSE

To evaluate the effectiveness and safety of temporary proximal uterine artery embolization (UAE) for the treatment of highly vascularized retained products of conception (RPOCs).

MATERIALS AND METHODS

This retrospective analysis included women who underwent treatment for vaginal bleeding after abortion, miscarriage, or delivery, with highly vascularized RPOCs detected by Doppler ultrasound (US) (ie, presence of an enhanced myometrial vascularity, a low resistance index of <0.5, and a peak systolic velocity of ≥0.7 m/s). A unilateral or bilateral embolization with torpedoes of gelatin foam was performed. From November 2017 to January 2021, 24 women with a median age of 30 years (interquartile range, 26.0-34.5 years) with symptomatic highly vascularized RPOCs were included. Clinical success was defined as bleeding arrest between the UAE and 1-month follow-up. Technical success was defined as the complete obstruction of at least 1 uterine artery supplying vascular abnormalities. The safety of the procedure according to the classification of the Society of Interventional Radiology and evolution of lesions on US were also reported.

RESULTS

Technical success was achieved in all 24 (100%) patients, with bilateral arterial embolization in 19 (79%) patients and unilateral embolization in 5 (21%) patients. Clinical success was achieved in all 24 (100%) patients. Five patients still had uterine retention at the 1-month follow-up, including 2 patients with highly vascularized RPOCs. Two patients benefited from hysteroscopy, and 3 had noninvasive management. Four minor adverse events were reported (1 patient had infectious endometritis and 3 patients had a postembolization syndrome).

CONCLUSIONS

Proximal UAE with torpedoes of gelatin foam is safe and effective for the management of symptomatic highly vascularized RPOCs.

Iatrogenic uterine injury leading to uterine arteriovenous malformation

The incidence of acquired uterine arteriovenous malformation has risen significantly because of increased instrumentation. Hysterectomy used to be the treatment of choice, but currently uterine artery embolisation is the preferred treatment. Here, the case of a 34-year-old woman who presented with uncontrolled uterine bleeding after iatrogenic uterine injury and who underwent successful management is described.

Subinvolution of the placental site as the cause of hysterectomy in young woman

Subinvolution of placental sites (SPSs) is a rare but severe cause of secondary postpartum haemorrhage (PPH). SPS is characterised by the abnormal persistence of large, dilated, superficially modified spiral arteries in the absence of retained products of conception. It is an important cause of morbidity and mortality of young women. In this study, we present a case of secondary PPH in a young woman after uncomplicated caesarean delivery who was deemed clinically unstable, and finally, underwent emergent total abdominal hysterectomy. We reviewed the literature with an emphasis on the pathophysiology of this situation. Treatment of patients with SPS includes conservative medical therapy, hysterectomy and fertility-sparing percutaneous embolotherapy.

Angiographic findings and outcomes after embolization of patients with suspected postabortion uterine arteriovenous fistula

INTRODUCTION

The purpose of this study is to assess the angiographic incidence of uterine arteriovenous fistula (UAVF) in women referred for a high ultrasonographic suspicion in a postabortion setting and to evaluate the safety, efficacy and impact on further fertility of uterine artery embolization (UAE) in this indication.

MATERIALS AND METHODS

A monocentric retrospective study of 31patients managed by uterine artery embolization for suspected UAVF after spontaneous or induced first trimester abortion. The diagnosis of UAVF was confirmed when an early venous drainage was identified on the angiogram. Technical success was defined as complete exclusion of the vascular lesion. Clinical success was defined as the absence of bleeding during the clinical follow-up and during the surgery in case of hysteroscopic resection. Information about further fertility was gathered by phone calls to the patients.

RESULTS

The mean age of the patients was 30.8 (±6.0) years. The diagnosis of UAVF was angiographically confirmed in 6 patients (19.4 %). Angiographic findings of retained product of conception (RPOC) with varying degrees of vascularity were observed in remaining patients. The technical success rate of UAE was 100 %, mostly through a proximal and bilateral embolization using a resorbable agent (27/31 patients, 87.1 %). The clinical success rate of UAE was 100 % in the group treated by a single UAE. We did not notice any bleeding during the surgery in the group of patients who needed a further hysteroscopic resection. 14 patients led at least one subsequent pregnancy to term without any difficulty.

CONCLUSION

UAVF is a rare condition. We supposed it may constitute the ultimate stage in the natural history of the retained products of conception with "marked vascularity". UAE seems to be an effective and safe first-line treatment.

A Pictorial Review of Postpartum Complications

The postpartum period, also known as the puerperium, begins immediately after delivery of the neonate and placenta and ends 6-8 weeks after delivery. The appearance of physiologic uterine changes during puerperium can overlap with that of postpartum complications, which makes imaging interpretation and diagnosis difficult. Obstetric and nonobstetric postpartum complications are a considerable source of morbidity and mortality in women of reproductive age, and the radiologist plays an important role in the assessment of these entities, which often require a multimodality imaging approach. US and contrast material-enhanced CT are the techniques of choice in the emergency department, and they can show characteristic radiologic findings that enable differentiation between normal and abnormal features to help radiologists and emergency department practitioners to reach a correct diagnosis and provide timely treatment. The spectrum of postpartum complications ranges from relatively self-limiting to life-threatening conditions that can be divided into six categories: infectious conditions (endometritis), thrombotic complications (eg, deep vein thrombosis, ovarian vein thrombophlebitis, HELLP [hemolysis, elevated liver enzymes, and low platelet count] syndrome, or cerebral sinus thrombosis), hemorrhagic conditions (eg, uterine atony, trauma of the lower portion of the genital tract, retained products of conception, uterine artery arteriovenous malformations, or uterine artery pseudoaneurysm), cesarean delivery-related complications (eg, bladder flap hematoma, subfascial hematoma, rectus sheath hematoma, abscess formation, uterine dehiscence, uterine rupture, vesicovaginal fistula, or abdominal wall endometriosis), iatrogenic conditions (eg, uterine perforation), and nonobstetric complications (eg, acute cholecystitis, acute appendicitis, uterine fibroid degeneration, renal cortical necrosis, pyelonephritis, posterior reversible encephalopathy syndrome, or pituitary gland apoplexy). The online slide presentation from the RSNA Annual Meeting is available for this article. ^©RSNA, 2020.

ACR Appropriateness Criteria® Gestational Trophoblastic Disease

Gestational trophoblastic disease (GTD), a rare complication of pregnancy, includes both benign and malignant forms, the latter collectively referred to as gestational trophoblastic neoplasia (GTN). When metastatic, the lungs are the most common site of initial spread. Beta-human chorionic gonadotropin, elaborated to some extent by all forms of GTD, is useful in facilitating disease detection, diagnosis, monitoring treatment response, and follow-up. Imaging evaluation depends on whether GTD manifests in one of its benign forms or whether it has progressed to GTN. Transabdominal and transvaginal ultrasound with duplex Doppler evaluation of the pelvis are usually appropriate diagnostic procedures in either of these circumstances, and in posttreatment surveillance. The appropriateness of more extensive imaging remains dependent on a diagnosis of GTN and on other factors. The use of imaging to assess complications, typically hemorrhagic, should be guided by the location of clinical signs and symptoms. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The efficacy of uterine artery embolization with gelatin sponge for retained products of conception with bleeding and future pregnancy outcomes

BACKGROUND

Retained products of conception (RPOC) with hemorrhage need intervention when RPOC persist and remain symptomatic. The safety and efficacy of uterine artery embolization (UAE) for RPOC using gelatin sponge (GS) alone, and fertility after UAE for RPOC remain unknown. The purpose of this study is to retrospectively investigate the efficacy of UAE for RPOC with bleeding and future pregnancy outcomes.

METHODS

Between 2007 and 2016, 14 patients (mean age, 33 years old) diagnosed as RPOC with bleeding received UAE using GS at our institution. Pregnancy outcomes were vaginal delivery (n = 7), miscarriage (n = 4), and termination (n = 3). Four patients received dilation and curettage/evacuation (D&C/E) for treatment of RPOC before bleeding occurred. The mean time interval from the end of pregnancy to bleeding was 28 days. Technical success, clinical success, complications, angiographic features and fertility after UAE were retrospectively assessed.

RESULTS

Technical success was achieved in 13 patients (93%) and clinical success was achieved in all 14 patients. No major complications occurred. The angiographic features of RPOC were tortuous feeders with flow into a focal blush of contrast (n = 14). Additional findings were pseudoaneurysm (n = 6), early venous return (n = 4), and extravasation (n = 2). Pseudoaneurysm was observed significantly more often in patients who received D&C/E before UAE compared to those who received conservative treatment alone (P = 0.015). The mean follow-up period was 29 months. Six patients achieved six pregnancies an average of 29 months after UAE.

CONCLUSION

UAE using GS may be an effective and safe treatment for RPOC with hemorrhage that can preserve fertility.

Using Interventional Radiology to Treat Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is a serious complication of giving birth that can result in death. Interventional radiology allows for the use of uterine artery embolization and transcatheter arterial embolization to prevent and treat PPH. These procedures are minimally invasive options that use the uterine or internal iliac arteries to place either a balloon or embolic material to stop the bleeding. These techniques also can be used as a preventive treatment for women with known placental abnormalities who are at an increased risk of hemorrhaging. This article discusses causes, early recognition, and treatment of PPH. It also discusses nursing care for patients with PPH and presents a case report describing the use of interventional radiology before cesarean delivery for a patient with placenta accreta.

Ultrasonographic vascularity assessment for predicting future severe hemorrhage in retained products of conception after second-trimester abortion

Objectives: To investigate the spontaneous outcomes of vascularized retained products of conception (RPOC) detected by ultrasonography after second-trimester abortion, and to identify the predictive factors for the development of severe postpartum hemorrhage (SPPH).Study design: This is a retrospective cohort study on all cases after second-trimester abortion managed at our institute between January 2014 and December 2016. We assessed the associations between the occurrence of SPPH requiring invasive treatment and clinical factors including ultrasonographic findings (size and the vascularity status of RPOC classified as follows: type 1: vascularity confined to endometrium, type 2: vascularity reaching <1/2 myometrium, and type 3: vascularity reaching ≥1/2 myometrium) in vascularized RPOC cases.Results: Among 103 cases after second-trimester abortion, 19 patients (18.4%) were diagnosed as RPOC, and five patients eventually failed expectant management due to SPPH. Of them, 66.7% (4/6) of patients with type 3 developed SPPH as compared with 7.7% (1/13) of patients with type 1/type 2 (p < .05). The maximum vascularized mass diameter was significantly greater among the five patients who experienced SPPH than among the 14 patients who demonstrated spontaneous remission (43.0 ± 12.0 mm versus 20.7 ± 8.3 mm, p < .01). Patients with type 3 RPOC and a maximum vascularized mass diameter ≥30 mm, compared with other patients, demonstrated sensitivity, specificity, and risk ratio related to SPPH of 80, 92.9%, and 11.2, respectively.Conclusions: Our findings suggest that the ultrasonographic assessment of RPOC focused on the depth of vascularity in combination with the measurement of its size appears to be essential in determining women with RPOC who are at high risk for SPPH.

The role of ultrasound in the evaluation of acute pelvic pain in pregnancy and postpartum period: a review

PURPOSE OF REVIEW

Acute pelvic pain in pregnant and postpartum patients presents diagnostic and therapeutic challenges. Ultrasound remains the primary imaging modality of choice for assessing pregnant and postpartum women. The purpose of this review is to help practitioners ensure a correct diagnosis of acute pelvic pain in pregnancy and the postpartum period.

RECENT FINDINGS

This review describes the various causes and highlights the sonographic features and characteristics of acute pelvic pain in pregnancy and the postpartum period.

SUMMARY

Evaluation of acute pelvic pain in pregnancy and the postpartum period is challenging. Knowledge of the clinical settings and sonographic features of acute pelvic pain in pregnancy and the postpartum period can lead to accurate diagnosis and appropriate management of the condition.