Transvaginal sonohysterography for the evaluation and treatment of retained products of conception

Variable color Doppler sonographic appearances of retained products of conception: radiologic-pathologic correlation

OBJECT OF STUDY

Retained products of conception (RPOC) displays variable vascularity, ranging from avascular to markedly vascular on color Doppler sonography. We hypothesize that variability in sonographic vascularity may be due to histopathologic variation in the placental tissue.

MATERIALS, METHODS, AND PROCEDURES

After institutional review board approval, sonographic images and pathologic specimens were retrospectively reviewed in 26 patients with pathologically proven RPOC. Ultrasound (US) images were scored 0-3 for the degree of vascularity by two radiologists blinded to the diagnosis. Corresponding pathologic specimens were evaluated for vascularization of chorionic villi, degree of inflammation, morphology of maternal arteries, chorionic villous preservation, and percentage of clot, membranes, chorionic villi, and decidua/myometrium. Statistical analysis, including multiple linear regression, was performed.

RESULTS

RPOC with histologically avascular chorionic villi or those with markedly reduced vascularization had significantly lower US vascularity scores (p = 0.030) than those with chorionic villi showing normal or decreased vascularization. Sonographically avascular RPOC had a significantly lower percentage villi (p = 0.028) and higher percentage of decidua (p = 0.004) than specimens where US showed any Doppler vascularity. Histologic vascularity of villi (p = 0.049) and non-observation of maternal arteries (p = 0.001) were significant predictors of US vascularity scores in multivariate linear regression analysis, while inflammation of villi (p = 0.053) was a marginally significant predictor.

SIGNIFICANCE OF THE CONCLUSIONS

Histologic vascularity of villi appears to contribute to the observed variation in sonographic vascularity. This finding may underlie known differences in clinical outcomes between sonographic vascularity groups.

The use of interventional ultrasound in early pregnancy complications

Background: The use of ultrasound to establish pregnancy location, viability and gestational age in the first trimester is well established. In addition to the conventional uses of ultrasound in early pregnancy, interventional ultrasound may also be used to guide clinicians during surgical procedures for the management of early pregnancy complications (i.e. treatment of ectopic pregnancy, caesarean section scar pregnancy, molar pregnancy, retained products of conception, and removal of intra-uterine devices in early pregnancy). Aims: This review discusses the role of interventional ultrasound as it pertains to the management of first trimester complications, particularly with regard to the use of ultrasound in conjunction with surgical modalities. Materials and Methods: This review was based on recently published research, as cited in the PubMed database, regarding the use of either transvaginal or transabdominal ultrasound to assist with the management of early pregnancy complications. Conclusions: In addition to the diagnostic capabilities of ultrasound in early pregnancy, interventional ultrasound plays an important role in the management of various first trimester pregnancy complications. With the advent of more conservative approaches to early pregnancy complications, interventional ultrasound is a viable option which is not only safe in experienced hands but also enables fertility preservation.

A minimally invasive approach to an iatrogenic pelvic mass

A case report describing an unusual complication following a 17-week elective termination of pregnancy in a pediatric patient that was managed laparoscopically.

Best predictors of grayscale ultrasound combined with color Doppler in the diagnosis of retained products of conception

OBJECTIVES

To determine the best predictors of the presence of retained products of conception (RPOC) on grayscale and color Doppler transvaginal sonographic examination.

METHODS

This was a retrospective study of 91 consecutive patients who underwent transvaginal sonography (TVS) with color Doppler to evaluate for the presence of RPOC. The images of TVS studies were reviewed by two radiologists in consensus blinded to the final outcome. Data on a number of variables including endometrial measurable mass and focal increased color vascularity were collected as predictors of RPOC. The patients' ages ranged from 17 to 48 years (mean, 31.8 ± 6.8) and gestational age from 5 to 24 weeks (mean, 9.2 ± 3.8). Thirty-six were confirmed as RPOC by dilatation and curettage (D&C) and pathology. Fifty-five were considered negative, 9 based on D&C results and 46 on clinical grounds.

RESULTS

Sensitivity, specificity, negative- and positive-predictive and accuracy values were 81% (CI: 68%-94%), 71% (CI: 59%-83%), 85% (CI: 74%-95%), 64% (CI: 50%-78%), and 75% (CI: 66%-84%) to detect RPOC when a mass was present. The corresponding numbers for the presence of focal color vascularity were 94% (CI: 87%-100%) (p = 0.07), 67% (CI: 55%-80%) (p > 0.05), 95% (CI: 88%-100%) (p = 0.1), 65% (CI: 52%-78%) (p > 0.05), and 78% (CI: 70%-87%) (p > 0.05). Of the patients with confirmed RPOC on pathology, five had focal increased vascularity and no massand none had a mass without focal increased vascularity.

CONCLUSION

An area of focal increased vascularity with or without a mass is the best predictor of the presence of RPOC.

Review of intrauterine adhesions

This article has been produced to review the literature on symptomatic and asymptomatic intrauterine adhesions. Electronic resources including Medline, PubMed, CINAHL, The Cochrane Library (including the Cochrane Database of Systematic Reviews), Current Contents, and EMBASE were searched using the Medical Subject Headings (MeSH), including all subheadings, and the keywords "Asherman syndrome," "Hysteroscopic lysis of adhesions," "Hysteroscopic synechiolysis," "Hysteroscopy and adhesion," "Intrauterine adhesions," "Intrauterine septum and synechiae," and "Obstetric outcomes after intrauterine surgery." The vast majority of evidence in the literature consists of uncontrolled case series, with only intrauterine adhesion barriers being assessed in a randomized controlled format. This article reviews epidemiology, pathologic features, classification systems, and treatments. Seven classification systems are described, with no universal acceptance of any one system and no validation of any of them. Hysteroscopy is the mainstay of both diagnosis and treatment, with medical treatments having no role in management. There is a wide range of treatment techniques with no controlled comparative studies, and assessments are descriptive and report fertility and menstrual outcomes, with more severe adhesions having the worst clinical outcomes. One of the most important features of treatment is prevention of recurrence, with the best available evidence demonstrating that newly developed adhesion barriers such as hyaluronic acid show promise for preventing new adhesions.

Asherman syndrome--one century later

OBJECTIVE

To provide an update on the current knowledge of Asherman syndrome.

DESIGN

Literature review.

SETTING

The worldwide reports of this disease.

PATIENT(S)

Patients with Asherman syndrome who presented with amenorrhea or hypomenorrhea, infertility, or recurrent pregnancy loss.

INTERVENTION(S)

Hysteroscopy and hysteroscopic surgery have been the gold standard of diagnosis and treatment respectively for this condition.

MAIN OUTCOME MEASURE(S)

The etiology, pathology, symptomatology, diagnosis, treatment, and reproductive outcomes were analyzed.

RESULT(S)

This syndrome occurs mainly as a result of trauma to the gravid uterine cavity, which leads to the formation of intrauterine and/or intracervical adhesions. Despite the advances in hysteroscopic surgery, the treatment of moderate to severe Asherman syndrome still presents a challenge. Furthermore, pregnancy after treatment remains high risk with complications including spontaneous abortion, preterm delivery, intrauterine growth restriction, placenta accrete or praevia, or even uterine rupture.

CONCLUSION(S)

The management of moderate to severe disease still poses a challenge, and the prognosis of severe disease remains poor. Close antenatal surveillance and monitoring are necessary for women who conceive after treatment.

Postpartum curettage: An audit of 200 cases

AIM

To assess whether delivery details, clinical features at presentation and laboratory investigations could accurately predict the presence of retained products of conception (RPOC) following a postpartum curettage (PPC) and to assess the morbidity associated with this procedure.

METHODS

A retrospective chart review of patients who underwent a PPC at a tertiary referral hospital over a 5-year period.

RESULTS

Two hundred patients were included in the study and 50% of patients who had histological evaluation demonstrated retained product of conception. Mode of delivery, placental status at delivery and immediate postpartum haemorrhage was unrelated to final histology however, patients presenting with pelvic infection were significantly less likely to have RPOC, chi(2 )= 6.358 (P = 0.042). The sensitivity and specificity of ultrasound in detecting RPOC was 94% and 16%, respectively; the presence of an echogenic focus together with a thickened endometrium of more than 10 mm was the most accurate ultrasound feature of RPOC (positive predictive value 80%). Seventeen (8.5%) patients experienced major morbidity following curettage and 14 (7%) underwent a repeat procedure with further morbidity. Patients presenting with pelvic infection were more likely to experience postoperative morbidity.

CONCLUSION

A PPC has a low diagnostic yield and is associated with a significant complication rate. While the therapeutic benefit of this procedure is unclear, expectant management is appropriate especially in the presence of pelvic sepsis.

MR imaging of retained products of conception

OBJECTIVE

The objective of this article is to describe the MR imaging appearances of retained products of conception.

CONCLUSION

Retained products of conception appear on MR imaging as an intracavitary uterine soft-tissue mass with variable amounts of enhancing tissue and variable degrees of myometrial thinning and obliteration of the junctional zone. These findings should not be misinterpreted as indicating gestational trophoblastic disease, particularly in the setting of a postpartum patient with a normal or minimally elevated beta-human chorionic gonadotropin level. MR imaging may also be helpful in showing anatomic variants that hinder successful instrumentation of the uterine cavity in patients with suspected retained products of conception.

Retained products of conception masquerading as acquired arteriovenous malformation

This case documents a seldom-described event of retained products of conception masquerading as an acquired arteriovenous malformation (AVM) of the uterus. The patient presented with sudden onset of heavy vaginal bleeding 6 weeks after artificial abortion. Ultrasonography and magnetic resonance imaging revealed a diffuse intramural lesion predominantly consisting of prominent vessels, which raised suspicion of an AVM. Hysterectomy revealed retained products of placenta that were necrotic and encroached into thin myometrium.

[Hysterosonography]

Hysterosonography, which consists in the injection of some cc of saline in the uterine cavity during sonography, allows an exploration of the uterine cavity and of the endometrium. Accuracy of hysterosonography is similar to that of office hysteroscopy. Hysterosonography distinguishes normal cavities from pathologic ones, endometrial atrophy from mucosal anomalies, polyps from myomas. Conversely, endometrial biopsy is still necessary for diagnosis of hyperplasia or cancer. Hysterosonography can also be proposed for first trimester bleedings, trophoblast retention or ectopic pregnancy. In the near future it could be applied to therapeutic goals such as sonographic section of polyps.

Color Doppler imaging in the sonohysterographic diagnosis of residual trophoblastic tissue

PURPOSE

The purpose of this study was to evaluate the role of color Doppler imaging during sonohysterography in the diagnosis of residual trophoblastic tissue.

METHODS

This prospective cohort study involved 25 consecutive women with clinical and sonographic signs of an echogenic intrauterine mass who were referred to the sonography unit of our institution for evaluation. All women underwent saline infusion sonohysterography with color Doppler sonographic evaluation. An operative hysteroscopy with histologic examination was performed in 17 cases.

RESULTS

Thirteen women (group A) had sonohysterographic features suggestive of residual trophoblastic tissue (ie, an echogenic intrauterine lesion not detached from the uterine wall after introduction of saline). The initial diagnosis was confirmed by histologic analysis in all cases. Blood flow was detected within the intrauterine mass in 6 (46%) of these 13 women; the resistance indices were low in all 6 cases (mean +/- standard error, 0.38 +/- 0.01). Twelve women (group B) had sonohysterographic findings negative for retained tissue, and no blood flow was detected within any of the intrauterine masses in this group (p < 0.05).

CONCLUSIONS

Our results confirm the potential role of color Doppler sonography in the initial diagnosis of residual trophoblastic tissue. The detection of color Doppler signals, especially with low-resistance flow, within an intrauterine lesion should increase the confidence of the sonologist in the diagnosis of residual trophoblastic tissue.

Saline infusion sonohysterogram as initial investigation of the endometrium and uterine cavity

The results of 54 consecutive saline infusion sonohysterograms (SIS) are presented. Sonohysterogram, in conjunction with Pipelle endometrial sampling, was found to be a reliable and accurate method of initial investigation of the endometrium and uterine cavity with good correlation with other methods of investigation. It was well tolerated in an outpatient setting, saved two out of three of the women from needing a hysteroscopy and curettage, and yielded information beyond that available from hysteroscopy and curettage.