Association between first-trimester ultrasound imaging of eccentric implantation and retained placenta

OBJECTIVES

To evaluate first-trimester ultrasound imaging of eccentric implantation in predicting the probability of retained placenta.

METHODS

A total of 61 cases with gestational sac eccentrically implanted in first-trimester ultrasound imaging was selected. Demographic and obstetric data were collected through data extraction of the electronic medical record at the time of delivery admission. Baseline characteristics (including age, gestational age of first-trimester ultrasound, size of gestational sac, gestational age of delivery), delivery outcomes (mode of delivery, retained placenta or placental fragments, blood loss, postpartum hemorrhage and postpartum ultrasound imaging) were collected and analyzed.

RESULTS

The risk difference for a woman with eccentric implantation to have a retained placenta was -0.18 (95% CI -0.28 to -0.08, p = 0.000) and the incidence of retained placenta in the study group was higher than in the control group (18% vs. 0%, p = 0.006). First-trimester ultrasound imaging of eccentric implantation was also found to be an independent risk factor for the incidence of inhomogeneous mass in postpartum ultrasound imaging (27.9% vs. 10.8%, adjusted OR 0.19, 95% CI 0.05 to 0.79, p = 0.012). Though 2 cases in the study group suffered postpartum hemorrhage, the risk difference for a woman with eccentric implantation to suffer postpartum hemorrhage was -0.03 (95% CI -0.08 to -0.01, not significant) and eccentric implantation did not increase postpartum hemorrhage rates (3.3% vs. 0%, not significant).

CONCLUSIONS

First-trimester ultrasound imaging of eccentric implantation was associated with an increased risk of retained placenta and inhomogeneous mass in postpartum ultrasound imaging.

Sonographic Findings of Vascular Signals for Retained Products of Conception in Women Following First-Trimester Termination of Pregnancy

OBJECTIVES

To evaluate the occurrence of retained products of conception (RPOC) after termination of pregnancy in the first trimester and to assess the vascular signals with transvaginal ultrasonography (TVUS) examination in the detection of retained products.

METHODS

A retrospective cohort study was performed using TVUS examination in patients following termination of pregnancy. In cases of RPOC, 3 scales of vascular signal were identified: type 1, no or small amount, spot flow signals; type 2, medium amount, strip-like flow signals; type 3, rich amount, circumferential-like flow signals. The correlation between vascular signals and placenta accreta spectrum (PAS) staging was proposed by sonography and histopathology findings.

RESULTS

The 3 vascular patterns were differently distributed within non-RPOC as well as RPOC patients with and without PAS: type 1 vascular signal detection rates of non-RPOC and RPOC were 97.8% (262/268) and 28.1% (18/64), respectively. Of 64 cases of RPOC, 48.4% (31/64) of the patients had type 2 vascular signals. Vascular signals were enhanced in RPOC with PAS patients whose diagnosis was confirmed by histopathology.

CONCLUSIONS

The vascularity (amount of flow), vascular pattern (spot, strip- or circumferential-like flow), and the flow penetrating myometrium were significant findings for distinguishing concomitant RPOC with and without PAS. Additionally, RPOC may contribute to PAS progression, or PAS and RPOC in coordination strengthen the observed vascular signals.

Ultrasound for diagnosis of postpartum retained products of conception-How accurate we are?

OBJECTIVE

Postpartum retained products of conception (RPOC) can cause short- and long-term complications. Diagnosis is based on ultrasound examination and treated with hysteroscopy. This study evaluated the size of RPOC that can be related to a positive pathology result for residua.

MATERIALS AND METHODS

This retrospective cohort study included women who underwent hysteroscopy for postpartum RPOC diagnosed by ultrasound, 4/2014-4/2022. Demographics, intrapartum, sonographic, intraoperative, and post-operative data were retrieved. We generated a ROC curve and found 7 mm was the statistically sonographic value for positive pathology for RPOC. Data between women with sonographic RPOC ≤ 7 mm and > 7 mm were compared. Positive and negative predictive values were calculated for RPOC pathology proved which was measured by ultrasound.

RESULTS

Among 212 patients who underwent hysteroscopy due to suspected RPOC on ultrasound, 20 (9.4%) women had residua ≤ 7 mm and 192 (90.6%) had residua > 7 mm. The most common complaint was vaginal bleeding in 128 cases (60.4%); more so in the residua > 7 mm group (62.5% vs. 40%, p = .05). Among women with residua ≤ 7 mm, the interval from delivery to hysteroscopy was longer (117.4 ± 74.7 days vs. 78.8 ± 68.8 days, respectively; p = .02). Positive pathology was more frequent when residua was > 7 mm. PPV for diagnosis of 7 mm RPOC during pathology examination was 75.3% and NPV 50%.

CONCLUSIONS

Sonographic evaluation after RPOC showed that residua > 7 mm was statistically correlated with positive RPOC in pathology and PPV of 75% and NPV of 50%. Due to the high NPV and low complication rate of office hysteroscopy, clinicians should consider intervention when any RPOC are measured during sonographic examination to reduce known long-term complications.

Retained products of conception - a retrospective analysis of 200 cases of surgical procedures for the diagnosis of residua postpartum

OBJECTIVES

Postpartum retained products of conception are a relatively rare diagnosis occurring in approximately 1% of cases after spontaneous deliveries and abortions. The most common clinical signs are bleeding and abdominal pain. The diagnosis is based on clinical signs and ultrasound examination.

MATERIAL AND METHODS

Retrospective analysis of 200 surgical procedures for the diagnosis of residua postpartum obtained in 64 months. We correlated the method and accuracy of diagnosis with definitive histological findings.

RESULTS

During 64 months, we performed 23 412 deliveries. The frequency of procedures for diagnosis of retained products of conception (RPOC) was 0.85%. Most (73.5%) of the D&C were performed within six weeks of delivery. Histologically, the correct diagnosis was confirmed in 62% (chorion + amniotic envelope). There was interestingly lower concordance of histologically confirmed RPOC in post-CS patients (only 42%). In women after spontaneous delivery of the placenta, the diagnosis of RPOC was confirmed by histological correlate in 63%, and the highest concordance occurred in women after manual removal of the placenta in 75%.

CONCLUSIONS

Concordance with histological findings of chorion or amnion was seen in 62% of cases; this means that the incidence rate in our study was around 0.53%. The lowest concordance is after CS deliveries, 42%. D&C for RPOC should be performed after adequate clinical evaluation and in the knowledge of 38% false positivity. There is certainly more space for a conservative approach under appropriate clinical conditions, especially in patients after CS.

Retained Products of Conception Fed by the Inferior Mesenteric Artery: A Case Report

Retained products of conception (RPOC) refer to the persistence of placental or fetal tissue in the uterus following delivery or miscarriage. RPOC may cause massive postpartum or post-abortion hemorrhage. Arterial embolization (AE) is an effective choice of management for postpartum hemorrhage including RPOC. We report a case of hemorrhagic RPOC, in which uterine artery embolization with transcervical resection did not achieve hemostasis, and laparotomy with uterine compression sutures was subsequently required. The RPOC was apparently fed by an aberrant branch derived from the inferior mesenteric artery (IMA). AE of IMA was not performed because of possible necrosis of the descending colon and rectum. A physician should be aware that AE is not an all-encompassing hemostatic technique for postpartum bleeding, such as with RPOC, and should keep alternatives in mind.

Natural history of pregnancy-related enhanced myometrial vascularity following miscarriage

OBJECTIVES

Our primary aim was to report the incidence of enhanced myometrial vascularity (EMV) in consecutive women attending our early pregnancy assessment unit, following first-trimester miscarriage. We aimed further to evaluate the clinical presentation and complications associated with expectant and surgical management of EMV in these women.

METHODS

This was a prospective cohort study conducted in a London teaching hospital between June 2015 and June 2018, including consecutive patients with an observation of EMV on transvaginal ultrasonography following first-trimester miscarriage. The diagnosis was made following the subjective identification of EMV using color Doppler ultrasonography and a peak systolic velocity (PSV) ≥ 20 cm/s within the collection of vessels. Women were followed up with repeat scans every 14 days. Management was expectant unless intervention was indicated because of excessive or prolonged bleeding, persistent presence of retained tissue in the endometrial cavity or patient choice. The final clinical outcome was recorded. Time to resolution of EMV was defined as the interval from detection of EMV until resolution.

RESULTS

During the study period, there were 2627 first-trimester fetal losses in the department and, of these, 40 patients were diagnosed with EMV, hence the incidence of EMV following miscarriage was 1.52%. All cases were associated with ultrasound evidence of retained products of conception (RPOC) at presentation (mean dimensions, 22 × 20 × 20 mm). Thirty-one patients opted initially for expectant management, of which 18 had successful resolution without intervention, five were lost to follow-up and eight subsequently had surgical evacuation due to patient choice. No expectantly managed case required emergency intervention. Nine patients chose surgical evacuation as primary treatment. No significant correlation was seen between PSV within the EMV at presentation and blood loss at surgery. Median PSV was 47 (range, 20-148) cm/s. The estimated blood loss in all cases managed surgically ranged from 20-300 mL. Presence of RPOC was confirmed in all specimens that were sent for analysis following surgery. For cases successfully managed expectantly, the mean time to resolution was 48 (range, 21-84) days. In the nine cases managed surgically from the beginning, the mean time to resolution of EMV was 10.6 (range, 3-29) days.

CONCLUSIONS

This study suggests that EMV is an uncommon finding following miscarriage and is associated with the presence of RPOC. Expectant management was a safe option in our cohort, with minimal bleeding, although it was associated with protracted time to resolution. In patients who opted for surgery, the maximum blood loss was 300 mL and no patient required blood transfusion or embolization. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Operative hysteroscopy for retained products of conception: Efficacy and subsequent fertility

Retained product of conception complicates nearly 1% of pregnancies and can lead to synechiae and compromise ulterior fertility. The aim of this study is to evaluate efficiency of operative hysteroscopy in management of retained products of conception (RPOC). Secondary objectives are assessments of intra-uterine adhesions rate and later fertility. This unicentric retrospective study includes women who undertook an operative hysteroscopy for retained products of conception between January 2012 and March 2014. Assessment of the efficiency of operative hysteroscopy is defined by a complete resection of retained products of conception confirmed by office hysteroscopy. One hundred fourteen women were included in the study. Efficiency of operative hysteroscopy for retained products of conception is 91% for women with a postoperative office hysteroscopy. The authors observed a 7.5% rate of postoperative intra-uterine adhesions. Fertility rate was 83% (30 women out of 36 with a desired pregnancy). Hysteroscopic resection of retained products of conception is an efficient procedure and seems to be a real alternative.

Postpartum Retained Products of Conception: A Novel Approach to Follow-Up and Early Diagnosis

PURPOSE

 To investigate whether ultrasound follow-up for the detection of postpartum retained products of conception (RPOC) in women considered at risk for this condition may allow for early diagnosis.

METHODS

 Parturients at risk for RPOC underwent an ultrasound exam on the second postpartum day. Based on the ultrasound findings, women were either: (1) discharged to routine postpartum care in cases of normal scans, (2) invited for follow-up in cases of abnormal scans. We retrospectively analyzed the rates of women requiring uterine evacuation due to persistent abnormal scans.

RESULTS

 761 parturients (out of 17 010 deliveries, 4.5 %) were included. Of those, 490 (64.4 %) women had a normal initial scan, but two of them were later readmitted for uterine evacuation. The remaining 271 (35.6 %) women were found to have an abnormal scan: (a) thickened endometrium > 10 mm with hypo- and hyper-echoes and negative Doppler flow considered low suspicion for RPOC was described in 260 cases, of whom 23 (8.8 %) underwent uterine evacuation with placental remnants confirmed in 12/23 (52.2 %), and (b) an echogenic mass with positive Doppler flow considered high suspicion for RPOC was described in 11 cases, all of whom underwent uterine evacuation, with placental remnants confirmed in 9/11 (81.8 %). The number of scans required to detect RPOC in one patient was 33.

CONCLUSION

 Postpartum ultrasound evaluation may allow for early diagnosis of RPOC in women considered at risk for this condition.

Clinical and Sonographic Findings in Suspected Retained Trophoblast: Correlation with Histological Findings

BACKGROUND

Different clinical and sonographic parameters have been suggested to identify patients with retained products of conception. In suspected cases, the main treatment is hysteroscopic removal.

OBJECTIVES

To compare clinical, sonographic, and intraoperative findings in cases of hysteroscopy for retained products of conception, according to histology.

METHODS

The results of operative hysteroscopies that were conducted between 2011 and 2016 for suspected retained products of conception were evaluated. Material was obtained and evaluated histologically. The positive histology group (n=178) included cases with confirmed trophoblastic material. The negative histology group (n=26) included cases with non-trophoblastic material.

RESULTS

Patient demographics were similar in the groups, and both underwent operative hysteroscopy an average of 7 to 8 weeks after delivery/abortion. A history of vaginal delivery was more common among the positive histology group. The main presenting symptom in all study patients was vaginal bleeding, and the majority of cases were diagnosed at their routine postpartum/abortion follow-up visit. Sonographic parameters were similar in the groups. Intraoperatively, the performing surgeon was significantly more likely to identify true trophoblastic tissue as such than to correctly identify non-trophoblastic tissue (P < 0.001).

CONCLUSIONS

Suspected retained trophoblastic material cannot be accurately differentiated from non-trophoblastic material according to clinical, sonographic, and intraprocedural criteria. Thus, hysteroscopy seems warranted in suspected cases.

Diagnosis and management of patients with enhanced myometrial vascularity associated with retained products of conception

OBJECTIVES

To assess the complication rate, including estimated amount of blood loss, in patients undergoing dilation and curettage (D&C) for the treatment of retained products of conception with markedly enhanced myometrial vascularity mimicking arteriovenous malformation.

METHODS

This was a retrospective medical-records review study of patients with retained products of conception with enhanced myometrial vascularity presenting to our ultrasound unit between August 2015 and August 2017. Color/power Doppler imaging was used subjectively to identify the degree and extent of vascularity. All patients underwent D&C, and their operative reports and medical records were reviewed to see if ultrasound guidance was used, to ascertain estimated blood loss and to identify complications during or after the procedure.

RESULTS

The study group included 31 patients, of whom seven had retained products of conception after a vaginal delivery and 24 had retained products of conception after a first-trimester termination or miscarriage. The largest dimension of the region of enhanced myometrial vascularity ranged from 10 mm to 53 mm, with 14/31 having a width of ≥ 20 mm. Fifteen patients underwent a standard D&C procedure, 13 an ultrasound-guided procedure and three hysteroscopy. Estimated operative blood loss varied from negligible to a maximum of 400 mL. There were no intraoperative complications, although one patient was treated for presumed endometritis.

CONCLUSIONS

An increasing number of studies describe the enhanced myometrial vascularity associated with retained products of conception as 'acquired arteriovenous malformation', with some recommending management with uterine-artery embolization. Our study demonstrates that the enhanced myometrial vascularity is associated with retained products of conception, and surgical removal by D&C, possibly with the aid of ultrasound guidance or hysteroscopy, is a safe treatment option. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Evaluation of retained products of conception using pulsed continuous arterial spin-labeling MRI: clinical feasibility and initial results

OBJECTIVES

We evaluated the vascularity of retained products of conception (RPOC) using arterial spin-labeling magnetic resonance imaging (ASL-MRI) to clarify the clinical feasibility of this approach.

MATERIALS AND METHODS

A pulsed-continuous ASL sequence with echo-planar imaging (EPI) acquisitions was used. Ten consecutive patients with RPOC were enrolled. All ASL images were evaluated visually and semiquantitatively and compared with the findings of Doppler ultrasound (US) and dynamic contrast-enhanced MRI (DCE-MRI).

RESULTS

The technical success rate was 93.7% (15/16 scans). One failed case was excluded from the analysis. Six patients showed quite high signals over RPOC, while three patients showed no abnormal signals. Doppler US alone failed to detect the hypervascular area in two cases, and ASL-MRI alone failed in three. A significant linear correlation was found between semiquantitative values of ASL-MRI and DCE-MRI. All six patients showing high signals on ASL-MRI underwent follow-up MRI after therapy. High signals in five patients decreased visually and semiquantitatively, while one patient showed signal increases.

CONCLUSION

Evaluation of RPOC using ASL-MRI was clinically feasible and response to therapy could be evaluated. However, the clinical advantages over conventional imaging remain unclear and need to be evaluated.

[Convention Ultrasound and Contrast-enhanced Ultrasound Imaging in the Diagnosis of Placenta Implantation]

OBJECTIVES

To determine the value of conventional ultrasound (US) and contrast-enhanced ultrasound (CEUS) in the diagnosis of placenta residue with implantation.

METHODS

We retrospectively analyzed 112 cases of placenta remnants from Apr. 2013 to Mar. 2016, all of which were confirmed by pathological results. The cases were divided into implanted (n =74) and non-implanted (n =38) groups. We compared the characteristics of US and CEUS imaging between the two groups. Multi-variate logistic regression models were established to assess the accuracy of ultrasound imaging in predicting implantation, including the area under the curve (AUC ) of receiver operating characteristic (ROC) curves.

RESULTS

US detected intrauterine lesions, with significant differences between the two groups in the clearness of boundaries of lesions (P <0.05) . Differences between the two groups were also found in CEUS in enhanced phase, enhanced intensity, existence of clear and regular boundaries, and reduced muscle thickness in the lesion area (P <0.05). CEUS (91.1%) and US+CEUS (92.0%) had a higher prediction accuracy for placenta implantation compared with US (87.5%) (P <0.05). The AUC of CEUS (0.922) and US+CEUS (0.952) were also significantly higher than that of US (0.887) (P <0.05). No significant differences were observed between CEUS and US+CEUS.

CONCLUSION

The value of CEUS for predicting placenta implantation is higher than US.

Clinical and imaging predictors of management in retained products of conception

OBJECTIVES

To determine if clinical and ultrasound (US) imaging features help predict management in clinically suspected retained products of conception (RPOC).

METHODS

334 patients sonographically evaluated for RPOC were included in this IRB-approved retrospective study. Of the 334 patients, 176 had sonographic diagnosis of RPOC and comprised the final study group. Patients were managed expectantly, medically, or surgically in accordance with clinical judgment of treating physicians. Pelvic sonograms were retrospectively reviewed for endometrial stripe thickness and vascularity was graded on a 0-3 scale based on appearance relative to myometrium (Grade 0: no vascularity, Grade 1: minimal vascularity, Grade 2: moderate vascularity, Grade 3: marked vascularity). Clinical and imaging predictors of management were evaluated in univariate and multivariate analysis.

RESULTS

Mean patient age was 29.6 years and mean gestational age was 17.4 weeks. Most (74.4%) women presented with vaginal bleeding. 83 patients (47.2%) were treated conservatively with expectant management, 42 (23.8%) were treated medically, and 51 (29.0%) required surgical intervention. Mean endometrial stripe thickness was 21.3 mm. 47 women (26.7%) had vascularity score of 0; 50 (28.4%) had score 1; 52 (29.6%) had score 2; and 27 (15.3%) had score 3. In univariate analysis, serum hemoglobin (Hb) (p < 0.0001), endometrial stripe thickness on US (p < 0.005), presenting symptoms (p = 0.03), and US vascularity score (p < 0.005) were statistically significant predictors of final management. In multivariate logistic regression, serum Hb (OR 0.69, 95% CI 0.55-0.86, p < 0.0009), endometrial stripe thickness (OR 1.08, 95% CI 1.04-1.12, p < 0.0001), and US vascularity score (OR 1.77, 95% CI 1.16-2.70, p < 0.01) were statistically significant predictors of need for surgery.

CONCLUSIONS

Serum Hb, endometrial stripe thickness, and US vascularity score were significant predictors of clinical management, particularly the need for surgical intervention, in women with clinically suspected RPOC.

Maximum Peak Systolic Velocity and Management of Highly Vascularized Retained Products of Conception

OBJECTIVES

The purpose of this study was to evaluate blood loss and procedure-related complications during and after surgical removal of retained products of conception with high-velocity enhanced myometrial vascularity.

METHODS

We conducted a prospective study of 18 consecutive women with a diagnosis of retained products of conception and enhanced myometrial vascularity, with a peak systolic velocity (PSV) higher than 60 cm/s. All underwent ultrasound-guided surgical removal of the retained products under general anesthesia. Blood loss during the procedure was collected and recorded. The removed tissue was sent for histologic examination. An ultrasound examination was repeated within 24 hours.

RESULTS

Five patients had retained products of conception after a term delivery, 1 after a second-trimester termination of pregnancy, 7 after a spontaneous first-trimester miscarriage, and 5 after a first-trimester termination elsewhere. The PSV in the area of enhanced myometrial vascularity at diagnosis ranged from 61.0 to 152.6 cm/s (mean, 104.9 cm/s). The estimated blood loss at surgery ranged from 20 to 1000 mL (mean, 200 mL). After surgery, the PSV in the myometrium dropped dramatically (≤30 cm/s in all but 1 case). In all cases, trophoblastic tissue was confirmed at histologic examination.

CONCLUSIONS

Although surgical removal of retained products of conception was uneventful in most cases, heavy bleeding has to be anticipated in cases of high-velocity flow in the myometrium underlying residual trophoblastic tissue. Accordingly, in cases of high-velocity enhanced myometrial vascularity, we advocate surgical removal of the residual tissue under ultrasound guidance by an experienced surgeon and in the presence of a fully informed anesthetist.

3D volume contrast imaging (VCI) for the visualization of placenta previa increta and uterine wall thickness in a dichorionic twin pregnancy

PURPOSE

Placenta increta is a rare event in pregnancy, but is associated with serious maternal morbidity and mortality due to life threatening hemorrhage. The incidence has increased due to high Cesarean rates. We describe a case of placenta previa increta in a dichorionic twin pregnancy, which was successfully treated conservatively, to discuss the role of ultrasound, especially 3D VCI and TUI, for diagnosis and conservative management in similar cases.

MATERIALS AND METHODS

A GE Voluson Expert 730 ultrasound system which provides both conventional 2D imaging and 3D volume acquisitions using VCI and TUI was used for diagnosis and management in a case of placenta increta in a dichorionic twin pregnancy in which the placenta previa increta of the first fetus was left in situ and the other placenta was removed.

RESULTS

The 3D VCI provided superior resolution of the anterior wall of the uterus, delineating the myometrial thickness in the area of the placental implantation site. With superior image quality, the 3D VCI technique facilitates the evaluation of the myometrial thickness and the depth of placental invasion due to significantly improved enhancement of the contrast and differentiation between various tissues compared to the 2D scan.

CONCLUSION

We describe for the first time the application of 3D VCI and TUI for the visualization of the depth of placental invasion in such a case. Preoperative ultrasound diagnosis allows appropriate preoperative preparations and the decision to leave the placenta untouched to avoid a probable fatal outcome for the patient.

Clinics in diagnostic imaging (133). Retained placenta from an intra-abdominal pregnancy

A 29-year-old Indonesian woman presented with abdominal pain seven months after an intra-abdominal pregnancy. Ultrasonography revealed a cystic mass in the pelvis and magnetic resonance imaging showed an umbilical stump within it, indicating a retained placenta. This was removed surgically, and on histology, an infarcted placenta was confirmed.

Retained products of conception: spectrum of color Doppler findings

OBJECTIVE

The purpose of this study was to characterize color Doppler imaging features of retained products of conception (RPOC) with gray scale correlation.

METHODS

Clinically suspected cases of RPOC between January 2005 and February 2008 were reviewed. Patient data and relevant color Doppler and gray scale features were recorded.

RESULTS

A total of 269 patients referred for sonographic evaluation for RPOC were identified. Thirty-five patients had confirmed pathologic diagnoses, 28 of whom had RPOC. In those with RPOC, 5 (18%) were avascular (type 0); 6 (21%) had minimal vascularity (type 1); 12 (43%) had moderate vascularity (type 2); and 5 (18%) had marked vascularity (type 3). Peak systolic velocities ranged from 10 to 108 cm/s (average, 36.1 cm/s). Resistive indices in arterial waveforms ranged from 0.33 to 0.7 (average, 0.5). Five (45%) of the patients with type 0 vascularity had RPOC; 6 (86%) of those with type 1 had RPOC; and 17 (100%) of those with types 2 and 3 had RPOC. An echogenic mass had a moderate positive predictive value (80%) but low sensitivity (29%) for RPOC.

CONCLUSIONS

Color Doppler evaluation of the endometrium is helpful in determining the presence of RPOC. Endometrial vascularity is highly correlated with RPOC, whereas the lack of vascularity can be seen in both intrauterine clots and avascular RPOC.

Sonographic appearances of the endometrium after termination of pregnancy in asymptomatic versus symptomatic women

OBJECTIVE

The purpose of this study was to describe normal sonographic appearances of the endometrium in asymptomatic women after elective termination of pregnancy (TOP) and to determine whether sonographic findings are discriminatory in symptomatic women after TOP.

METHODS

Sonographic parameters were compared in prospectively recruited women after elective TOP. The first 38 were asymptomatic. In a later group, 105 had symptoms suggestive of retained products of conception (RPOC). Endometrial thickness, cavity irregularity, echogenicity of cavity contents, color Doppler flow, and resistive indices (RIs) were assessed. In the symptomatic group, sonographic findings were correlated with symptoms and histologic results.

RESULTS

There was a marked overlap in sonographic appearances between the groups. The endometrial cavity is commonly irregular and thickened and may show prominent color Doppler flow in women with an uneventful course as well as in women with histologically proven RPOC. Differences between asymptomatic and symptomatic women were only seen for: endometrial thickness (10.8 mm [range, 1-29 mm] versus 15.3 mm [range, 1.8-34 mm]; P = .0005), and cavity irregularity was greater in symptomatic women (P = .001). Color Doppler flow mean RIs were similar. Symptoms were similar in women proceeding to curettage versus no curettage; no significant relationship was found between individual symptoms and sonographic parameters. Chorionic villi were seen in 47 of 56 women (84%) with positive histologic results.

CONCLUSIONS

Sonographic appearances and symptoms correlate poorly with each other and with histologic results. Sonography has limited benefits in triaging women with suspected RPOC after TOP in the first trimester. Our findings support a more conservative approach to suspected RPOC after TOP.

Diagnostic accuracy of sonographic and clinical parameters in the prediction of retained products of conception

OBJECTIVE

The purpose of this study was to assess the diagnostic accuracy of different parameters (clinical and sonographic) in the prediction and management of retained products of conception (RPOC) in the late postpartum period.

METHODS

This was a prospective cohort 3-year audit. Predefined data were collected and compared with histopathologic (HP) reports after uterine evacuation. The primary outcome measure was the diagnostic accuracy of different clinical and sonographic parameters, including color Doppler imaging in diagnosis of RPOC confirmed on HP reports. Secondary outcome measures were complication rates influencing maternal morbidity.

RESULTS

In total, 93 patients (0.92% of all deliveries) were selected. The presence of gestational tissue was confirmed on HP reports in 58% of cases. The likelihood ratio of sonography alone was 1.47 (95% confidence interval, 1.25-1.84), whereas that of sonography combined with color Doppler imaging was 2.16 (1.3-3.59), providing statistically significant accuracy regarding the prediction of RPOC.

CONCLUSIONS

Sonography alone or combined with color Doppler imaging has better diagnostic accuracy than the usual clinical parameters used for the prediction of RPOC.

Role of clinical and ultrasound findings in the diagnosis of retained products of conception

OBJECTIVE

To assess the role of clinical and ultrasound findings as predictors of retained products of conception (RPOC) in women with a suspicion of incomplete miscarriage.

METHODS

This was a retrospective study of 91 patients admitted for suspected RPOC after spontaneous first-trimester miscarriage who were evacuated surgically, and for whom histopathological reports were available. All the women underwent transvaginal sonography after their miscarriage. The decision to evacuate the uterus was based on vaginal bleeding, lower abdominal pain and/or sonographic findings of hyperechoic material or endometrial thickness more than 8 mm. Maternal age, gestational age, clinical signs and symptoms and sonographic findings were recorded. Clinical and sonographic findings were compared with the histopathological reports and the sensitivity and specificity of vaginal bleeding, abdominal pain and sonographic appearance of the endometrium for detecting the products of conception were assessed.

RESULTS

Histopathological analysis confirmed the presence of chorionic villi in 55 women (60%) and decidua in 36 (40%). Vaginal bleeding was more frequent in women with RPOC (P < 0.001), whilst lower abdominal pain was a more frequent symptom in those with decidua (P = 0.019). The ultrasound finding of hyperechoic material had a sensitivity of 78%, specificity of 100% and positive and negative predictive values of 100% and 75%, respectively, in predicting RPOC. Vaginal bleeding as a predictor of RPOC had a sensitivity of 93%, specificity of 50%, and positive and negative predictive values of 74% and 82%, respectively. The combination of hyperechoic material and/or vaginal bleeding increased the sensitivity to 98% and negative predictive value to 95%. There was no significant difference in endometrial thickness between the two groups.

CONCLUSION

The ultrasound finding of hyperechoic material is the best predictor for diagnosing RPOC. In the absence of hyperechoic material and vaginal bleeding, RPOC are extremely unlikely.

Sonographic characteristics of the uterine cavity following first-trimester uterine evacuation

OBJECTIVE

To characterize the sonographic appearance of the uterine cavity after first-trimester uterine evacuation and to follow the evolution of these findings in an attempt to reduce the number of unnecessary surgical interventions following evacuation.

METHODS

We studied retrospectively the sonographic characteristics of the uterine cavity in 599 women, 5-8 days after first-trimester uterine evacuation. The patients were grouped according to the sonographic appearance of the uterine cavity. Patients with abnormal sonographic patterns were followed weekly until sonographic resolution.

RESULTS

Group 1 included 351 (58.6%) women with normal endometrium; Group 2 included 130 (21.7%) women with hypoechoic endometrial content only; Group 3 included 69 (11.5%) patients with mixed type (hypoechoic and hyperechoic) endometrial content; Group 4 included 49 (8.2%) patients with hyperechoic endometrial content only. The time needed until the uterine cavity was considered normal was significantly longer in Group 4 (median, 12 days) compared with Groups 3 and 2 (8 and 9 days, respectively, P < 0.0001). The duration of vaginal bleeding after the surgical procedure was longer in Group 4 (median, 10 days) compared with Groups 3, 2 and 1 (9, 7 and 5 days, respectively, P < 0.0001). Clinically, the patients were divided into two groups: asymptomatic (575 patients) and symptomatic (24 patients). The thickness of the abnormal endometrial content in the asymptomatic patients gradually decreased until normalization, around the time of menstruation. There was no such change in the symptomatic patients, who eventually needed surgical intervention.

CONCLUSIONS

An abnormal intrauterine sonographic pattern 5-8 days following first-trimester uterine evacuation is common and usually resolves spontaneously around menses. Therefore, in asymptomatic patients, we recommend a conservative approach.

[Clinical value of transcervical resection under hysteroscope for placental remnants]

OBJECTIVE

To study the clinical value of transcervical resection under hysteroscope in treatment of placental remnants.

METHODS

From March 2003 to April 2006, 14 cases of placental remnants were treated with transcervical resection under hysteroscope. They included 3 cases of term birth, and 11 cases of midtrimester induction of labor. Drug pretreatment was performed for those who had more than 80 U/L of blood beta-human chorionic gonadotropin (beta-hCG) level, including mifepristone (RU486), Chinese herbs and methotrexate (MTX). RU486 was taken orally at 25 mg, three times daily and misoprostol was given 600 microg at one dose on the third day. MTX was given by deep intramuscular injection at 1 mg/m(2) if beta-hCG was higher than 150 U/L. Bipolar evaporation was used in the operation with alternation of resection and forceps holder under ultrasonographic supervision. After operation a circular contraceptive device was placed followed by hormone periodic treatment such as estradiol valerate for 2 - 4 months.

RESULTS

Under the monitoring by ultrasonography, 14 operations were all performed smoothly. The follow-up was from 6 months to 2 years. Menstruations in almost all the cases were recovered, and 3 cases of those were pregnant and delivered smoothly 4, 6 and 7 months after operation.

CONCLUSION

The transcervical resection under hysteroscope is useful in treatment of placental remnants with obvious effects, little trauma and few complications.

Cervical diameter in relation to uterine and cervical EMG activity in early postpartum dairy cows with retained placentas after PGF2alpha induced calving

The cervix must regain its normal diameter after parturition. Until now, little has been known about the pattern of cervical closure and the possible influences of myometrial and cervical contractions in this process. We continuously measured the cervical diameter with ultrasound cervimetry during the first 48h after calving in six cows with retained fetal membranes, while uterine (n=6) and cervical outer muscular layer (n=4) electromyographic (EMG) activity was measured with bipolar EMG electrodes. We found that the cervical diameter which was 6.2cm (+/-0.7) at 1.4h after calving, initially increased to 9.0cm (+/-1.0) during the first 14.8h (+/-2.8) postpartum. After this time, the diameter decreased gradually to 5.3cm (+/-1.0) at 48h after calving. The overall EMG activity after parturition decreased by 59% (+/-6) and 35% (+/-17) for the uterus and cervix, respectively. The decrease in EMG activity was due to a 50% (+/-7) decrease in EMG amplitudes of the myometrium; the EMG amplitudes of the cervix decreased by only 8% (+/-21) (P>0.05). At the same time in the cervix, burst frequency decreased by 69% (+/-17), while the decrease in burst frequency of the myometrium was only 11% (+/-5) (P>0.05). Uterine myometrial and cervical EMG activity after parturition showed burst patterns. These contractions of the uterus and cervix were accompanied by and correlated with transient dilatations of the caudal cervix. This could have functional relevance in the evacuation of the uterus.

Clinical application of grey scale and colour Doppler sonography during abnormal third stage of labour

AIM

The purpose of the study was to investigate whether colour Doppler sonography is helpful in the surveillance of abnormal third stage of labour.

MATERIALS AND METHODS

20 patients were enrolled in the prospective study. Inclusion criteria were third stage of labour > 15 min and/or clinical suspicion of retained placenta. By means of grey scale and colour Doppler sonography the length of distinct phases of third stage of labour and length of visualisation of blood flow between myometrium and placenta were measured. These data were compared with previously published normal values.

RESULTS

The patients were allocated into four groups: 1. Patients with prolonged third stage of labour, but normal vaginal delivery of the placenta (Group 1, 8 cases). 2. Patients with clinically suspected retained placental parts (Group 2, 4 cases). 3. Patients with manual removal of the placenta without confirmation of placenta accreta (Group 3, 4 cases). 4. Patients with manual removal of the placenta with confirmation of placenta accreta (Group 4, 4 cases). A significant longer latent phase was responsible for the prolonged third stage of labour in Group 1 (p < 0.05). Blood flow between myometrium and placenta was significantly longer visible in Group 4 than in the normal cohort (p < 0.0001).

CONCLUSION

Grey scale sonography can help to distinguish between uncomplicated and complicated prolonged third stage of labour. Colour Doppler sonography can detect persistent blood flow between myometrium and placenta during third stage of labour in cases of placenta accreta. In these instances, the patient may benefit from colour Doppler sonography-guided curettage.

The value of measuring endometrial thickness and volume on transvaginal ultrasound scan for the diagnosis of incomplete miscarriage

OBJECTIVE

To identify ultrasound measurements that are the best predictors of the presence of retained products of conception (RPOC) within the uterine cavity in women with clinical diagnosis of incomplete miscarriage.

METHODS

This was a prospective observational study, set in a dedicated early pregnancy assessment unit in a London teaching hospital. Endometrial thickness and the volume of suspected retained products of conception were measured by transvaginal ultrasound scan preoperatively. Indications for surgical intervention were heavy vaginal bleeding or continuous bleeding lasting > 7 days. The main outcome measure was histological evidence of chorionic villi in surgical specimens.

RESULTS

Among the patients, 109 (85%) had evidence of chorionic villi on histology, whilst decidua was only found in the remaining 19 (15%). There was no identifiable cut-off for endometrial thickness or volume that could be used to differentiate between retained products of conception and decidua.

CONCLUSION

Measurements of endometrial thickness or volume on ultrasound scan are not good tests for diagnosing an incomplete miscarriage.

Ultrasound finding of an echogenic mass in women with secondary postpartum hemorrhage is associated with retained placental tissue

OBJECTIVES

To describe sonographic findings associated with retained placental tissue in patients with secondary postpartum hemorrhage, and to compare these findings with those of women with a normal puerperium.

METHODS

This was a prospective observational study of 79 women with secondary postpartum hemorrhage. Ultrasound examinations were performed on the day the patients presented with clinical symptoms and were scheduled for postpartum days 1, 3, 7, 14, 28 and 56, continuing until uterine surgical evacuation was performed or until the bleeding stopped. The maximum anteroposterior (AP) diameters of the uterus and uterine cavity were measured and morphological findings in the cavity were recorded. The findings were compared with previously published results from a normal population.

RESULTS

The patients were divided into two groups. Group 1 (n = 18) underwent surgery and Group 2 (n = 61) was treated conservatively. Sonography revealed an echogenic mass in the uterine cavity in 17 patients from Group 1, and in 14 of these patients histology confirmed placental tissue. The AP diameter of the uterine cavity was above the 90(th) percentile in all but two of the 18 Group 1 patients. In 18 patients from Group 2 the cavity was empty and in 43 a mixed-echo pattern was found. The uterine cavity was wider compared with the controls, but the values largely overlapped.

CONCLUSION

This report supports the opinion that the sonographic finding of an echogenic mass in the uterine cavity in women with secondary postpartum hemorrhage is associated with retained placental tissue.

The sonographic and color Doppler features of retained products of conception

OBJECTIVE

The purpose of this study was to identify the sonographic features of retained products of conception (RPOCs).

METHODS

Cases of clinically suspected RPOCs referred for pelvic sonography between September 1994 and July 2001 were identified. Patient age, indication, gestational age at delivery, and days postpartum were recorded and sonographic findings were reviewed. Outcomes were determined from medical records and pathology reports.

RESULTS

One hundred sixty-three cases were identified. Indications for pelvic sonography included vaginal bleeding in 82 (50%), pelvic pain in 77 (47%), and fever in 55 (34%). Gestational age at delivery ranged from 14 to 43 weeks (mean, 37 weeks), and the sonographic examination was performed from 0 to 95 days postpartum (mean, 21 days). Thirty-six patients underwent surgical intervention, and 28 of these had RPOCs. The remaining 127 patients were followed clinically. An endometrial mass was the most sensitive (79%) and specific (89%) sonographic feature for RPOCs. The isolated finding of either complex fluid in the endometrial canal or a thick endometrium measuring greater than 10 mm had low sensitivity, specificity, and negative and positive predictive values. None of the patients with RPOCs had normal sonographic findings. The absence of an endometrial mass or complex fluid and an endometrial thickness of less than 10 mm were considered normal findings. Color Doppler flow was detected in the endometrium somewhat more often when RPOCs were present than in the absence of RPOCs (75% versus 40%).

CONCLUSIONS

An endometrial mass is the most sensitive finding for RPOCs. If no mass or endometrial fluid is seen and the endometrial thickness is less than 10 mm, RPOCs are extremely unlikely. The absence of blood flow does not exclude the diagnosis of RPOCs.

Follow up of the regression of the placenta left in situ in an advanced abdominal pregnancy using the Cavalieri method

In this abdominal pregnancy, the dead fetus was delivered through an abdominal incision at the 36th gestational week. The placenta invaded the small intestine and the omentum was left in situ. The placental degeneration was monitored using serial serum beta-human chorionic gonadotropin values. In certain periods, the follow up of the placental regression was carried out using the Cavalieri method with abdominal ultrasound. It was seen that the placental volume had decreased by 83% at the end of 1 year. To the best of our knowledge, this is the first time this method has been used for this purpose.

Retained products of gestation in miscarriage: an evaluation of transvaginal ultrasound criteria for diagnosing an "empty uterus"

OBJECTIVE

The purpose of this study was to compare clinical outcomes of conservative management versus surgical evacuation of retained products of gestation after misoprostol treatment for first trimester spontaneous miscarriage using less restrictive transvaginal ultrasound criteria for diagnosing "empty uterus," which were managed conservatively.

STUDY DESIGN

This was a prospective, randomized, controlled trial.

RESULTS

Forty-six patients who had sonographic features previously regarded as significant retained products of gestation after misoprostol treatment, ie, homogenous intrauterine dimension of more than 11 cm 2 in combined transverse and sagittal plane, or those with heterogeneous intrauterine contents were consented to randomization. The short-term complication rates of those managed conservatively were significantly higher than surgical evacuation ([9/24] 37.5% vs [0/21] 0%, P < .05).

CONCLUSION

Our previously reported transvaginal ultrasound criteria of homogenous intrauterine dimension of less than 11 cm 2 in combined transverse and sagittal planes for defining "empty uterus," which requires no further treatment, cannot be "relaxed" without incurring additional complications.

Postpartum uterine arteriovenous fistula

BACKGROUND

Uterine arteriovenous communications are uncommon lesions that may be associated with life-threatening postpartum and postinstrumentation hemorrhage.

CASE

A primigravida presented with infected retained products of conception. Excessive hemorrhage of unclear etiology occurred at dilation and curettage. After a second episode of bleeding, the patient received a diagnosis of uterine arteriovenous fistula.

CONCLUSION

Uterine arteriovenous communications should be included in the differential diagnosis in patients with excessive postpartum or postinstrumentation bleeding. Color and spectral flow Doppler can aid diagnosis and clinical management.

Five-year follow-up of placental involution after abdominal pregnancy

A 29-year-old woman with an abdominal pregnancy was admitted to the hospital at 29 weeks' menstrual age. At 30 weeks, laparotomy was performed, and a live fetus, wrapped in membrane remnants, was taken from the abdominal cavity. The placenta, inserted in the right hemipelvis, was left in situ. The patient's postoperative recovery was uneventful, and she was monitored periodically as follow-up. At her 5-year follow-up visit, we assessed placental involution by measuring serum beta human chorionic gonadotropin and by using color and pulsed Doppler sonography. The dynamics of the regression of placental volume yielded a bimodal curve: a phase of decrease over the first 2 months, coincident with a reduction in vascularization, followed by stability that lasted 6-8 months, and a second phase of gradual volume reduction. At 5 years, the placenta appeared as a small residual echogenic mass with no vascularity. The use of MRI in this case provided no additional information to what we found using sonography.

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.

Color Doppler and gray-scale ultrasound evaluation of the postpartum uterus

OBJECTIVES

To evaluate the color Doppler and gray-scale sonographic appearance of the uterus after pregnancy, with special attention to the occurrence of areas of enhanced vascularity and placental remnants.

PATIENTS AND METHODS

Cross-sectional observational study involving 385 consecutive women presenting at their first visit after pregnancy. The uterus was evaluated using ultrasound with color Doppler. In the presence of placental remnants, blood was sampled for measurement of beta human chorionic gonadotropin (beta hCG), hemoglobin (Hb) and infectious parameters. If indicated, a dilatation and curettage was performed.

RESULTS

In 8.3% of women, areas of enhanced vascularity were detected with color Doppler examination. Most cases (68.9%) were focal areas of one or more vessels. In 2.6% of patients abnormal vascularity extended over a large area of the whole myometrium. In 6.75% of cases, placental remnants were detected. In 46% of these, blood sampling revealed beta hCG levels below 30 mIU/mL; serological infection parameters and Hb concentration were within the normal range.

CONCLUSIONS

Areas of enhanced vascularity of the uterus, ranging from a focal vascular pedicle to a larger area of the myometrium, are relatively common after pregnancy. They are predominantly seen in the presence of placental remnants, in the early postpartum period and after instrumental or manual delivery of the placenta. There are no clear risk factors for retained placental tissue, besides the history of blood transfusion in the early postpartum, and perhaps multigravidity. Serology is of little help in the diagnosis of retained gestational products. The knowledge of the ultrasound and color Doppler features of the uterus after pregnancy may prove of practical value for the management of abnormal uterine bleeding in the postpartum period.

Embolization for advanced abdominal pregnancy with a retained placenta. A case report

BACKGROUND

Abdominal pregnancy is not encountered commonly, and management of the placenta is controversial.

CASE

A 33-year-old woman presented with an abdominal pregnancy at 33 weeks' gestation with fetal death. The placental vasculature was embolized preoperatively. Following operative delivery. of the fetus, the placenta was left in situ in efforts to preserve fertility given its implantation on the reproductive organs. The patient suffered prolonged postoperative ileus but otherwise did well. Placental function ceased after two months.

CONCLUSION

Placental vasculature embolization is a management option for a retained placenta associated with abdominal pregnancy.

Transvaginal color Doppler ultrasonography in the management of first-trimester spontaneous abortion

OBJECTIVE

To evaluate the role of transvaginal color Doppler ultrasonography in the management of first-trimester spontaneous abortion, clinically thought to be complete.

STUDY DESIGN

A prospective interventional non-randomized study was performed in a tertiary care University hospital. Sixty-two women with suspected first-trimester spontaneous abortion, clinically thought to be complete were included in the study. All women were evaluated on admission by transvaginal color Doppler ultrasonography. The amount of blood flow within the myometrium or in the endometrium-myometrium interface was assessed. Those women with suspected retained tissue on color Doppler were scheduled to undergo dilatation and curettage (D&C). Those patients with no suspected retained tissue on color Doppler were scheduled for expectant management.

RESULTS

Eighteen women had suspected retained tissue and 44 women did not. A total of 16 out of 18 (88.9%) patients had retained trophoblastic tissue confirmed on histopathologic analysis. There were two false negative cases. Outcome of all patients managed expectantly was optimal with no complications.

CONCLUSIONS

Transvaginal color Doppler ultrasonography is useful to detect or to rule out the presence of retained trophoblastic tissue after first-trimester spontaneous abortion and to select patients for expectant management.

Ultrasonographic evaluation of the postpartum uterus

OBJECTIVES

To define the ultrasonographic appearance of the uterus and the uterine cavity, including its contents, in normal women making an uncomplicated postpartum recovery.

METHODS

Forty women were scanned on days 7, 14, and 21 postpartum. At each scan the uterine and cavity volumes were estimated, and the appearance of the uterine cavity contents was documented. The amount and duration of postpartum vaginal bleeding, and method of infant feeding were also recorded.

RESULTS

The mean duration of postpartum bleeding was 24.5 (range 14-45) days. Fifty-one percent (95% confidence interval 34-68) of the subjects scanned at 7 days postpartum, 21%(8-36) at 14 days, and 6%(0.8-20) at 21 days, had an echogenic mass within the uterine cavity. Statistical analysis revealed no difference, in terms of bleeding duration, between women with a uterine cavity echogenic mass noted at 7, 14, or 21 days postpartum, and those without (unpaired t-test, P = 0.42, 0.39, and 0.06). The presence of an echogenic mass was not associated with heavier bleeding at the time of any of the scans (chi-squared test, P = 0.58, 0.56, and 0.28). Statistical analysis revealed no correlation between the duration or amount of bleeding, and the uterine or cavity volume, at any of the three scans.

CONCLUSION

In this study, ultrasound evaluation of the uterine cavity revealed an echogenic mass in 51% of women with normal postpartum bleeding at 7 days, 21% at 14 days, and 6% at 21 days postpartum. This questions the significance of echogenic material within the uterine cavity in the postpartum period.

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

Diagnosing retained products of conception in a woman presenting with postpartum or postabortion bleeding presents a clinical challenge. Although ultrasonographic examination may be potentially useful in detecting retained products of conception, its accuracy has not yet been established. Saline infusion sonohysterography is a simple ultrasonographic technique for enhanced transvaginal sonographic imaging of the endometrial cavity by the instillation of saline into the uterine cavity during ultrasonographic evaluation. This technique enhanced our ability to diagnose retained products of conception, and we describe our experience in evacuating them under sonographic guidance while performing saline infusion sonohysterography.

Complicated third stage of labor: time to switch on the scanner

This Editorial chronicles the current experience in ultrasound usage during pathologic events occurring in the third stage of labor. Further improvement in the technology for carrying out clinical research will improve our knowledge so that more information can be gleaned from this modality to bestow optimal management for such potentially dangerous conditions. Awareness of the capabilities of sonography may provide the motivation for its use, and obstetricians are encouraged to scan the third stage of normal deliveries for better recognition of normal findings and improved assessment of abnormal ones. Although final decisions should be based mainly upon sound clinical judgement, we contend that complicated third stage of labor warrants turning on the scanner.

Gray scale and color Doppler sonography in the third stage of labor for early detection of failed placental separation

OBJECTIVE

The purpose of this study was the characterization of normal and abnormal third stage placental separation using gray scale and color Doppler sonography.

METHODS

The third stage of labor was examined in 62 patients using gray scale and color Doppler sonography. After identification of placental basal plate vessels by color Doppler sonography, the placentation site was examined throughout the third stage with combined gray scale and color Doppler mode. Placental separation from the myometrium was defined clinically and correlated to cessation of color Doppler detected blood flow in basal plate vessels.

RESULTS

Three sonographic phases of placental separation were: (1) latent = interval between delivery of the fetus and beginning placental separation; (2) detachment = mono- or multiphasic shearing off of the placenta and (3) expulsion = interval between completed separation and vaginal delivery of the placenta. In 57 cases with clinically normal placental separation blood flow between placenta and myometrium ceased immediately after delivery of the fetus during the latent period. In five cases manual or instrumental removal was necessary because of placenta adhaerens in one case and placenta accreta in four cases. The latter showed maternal blood flow from the myometrium deep into the placenta beyond the latent phase.

CONCLUSION

Cessation of blood flow between the basal placenta and myometrium following delivery of the baby is the sonographic hallmark of normal placental separation. Persistent blood flow demonstrated by color Doppler sonography is suggestive of placenta accreta.

Predictive value of sonographic examination to visualize retained placenta directly after birth at 16 to 28 weeks

A prospective study was performed to assess the predictive value of an ultrasonographic examination directly after a spontaneous birth at 16 to 28 weeks' gestation to exclude the possibility of retained placental tissue. The aim of this procedure is to prevent routine curettage, which can induce Asherman's syndrome, uterine perforation, and anesthetic complications. Over a 2 year period the clinical course in 64 women, who had been delivered of their infants at 16 to 28 weeks' gestation, was followed through 6 weeks post partum. Sonographic examination was performed within 30 min after delivery of the placenta independent of macroscopic judgment of completeness of placenta. The examination was classified into three categories (with subsequent clinical interpretation): sharp lining of echogenic uterine wall with translucent cavity (uterine cavity containing fluid blood), sharp lining of the wall with echogenic area in cavity not continuous with the wall (uterine cavity with blood clot), and irregular lining with echogenic area continuous with the uterine wall and extending into the cavity (uterine cavity containing retained placental tissue). Women with sharp uterine lining without (n = 32) or with (n = 7) echogenicity in the cavity had no direct operative removal of placental tissue; 3 underwent curettage at a later stage (17, 18, and 34 days, respectively). A direct digital removal of placenta or curettage was performed on 25 women who revealed echogenicity continuous with the uterine wall. The 25 of 28 operatively obtained tissues were examined microscopically for trophoblasts. The sensitivity of the sonographic examination to find retained placental tissue was 85% (17 of 20) at 95% confidence intervals of 62 to 97%, the specificity was 88% (36 of 41) at 95% confidence intervals of 74 to 96%, and there were 25% (5 of 20) false positive judgments and 8% (3 of 39) false negative judgments. The positive predictive value of ultrasonography to find retained placenta of 68% (17 of 22) at 95% confidence interval of 55 to 92% combined with the negative predictive value of 92% (36 of 39) is sufficient to strongly suggest that curettage should not be performed routinely in these pregnancies at high risk for retained placental tissue.

[The diagnosis and management in suspected retained placenta in the late puerperal period]

The aim of this retrospective study is to find out the reasons for RICU in late postpartum period and the reliability of methods for diagnosis of retained placental pieces. We investigated the medical records of all cases with RICU from 24th ours postpartum up to 2 weeks after it. The rate is 0.9% of all births. Hystological confirmation of retained placental tissue there are in 25% of cases. Our data shows that the anamnesis does not help in the diagnosis of retained placental tissue in late puerperium. Most often the curettage is undertaken because of hemorrhage and ultrasound data of retained placental tissue. At the same time the transabdominal ultrasound is of low diagnostic value for residua post partum. The febrility, the subinvolution of the uterus and the number of symptoms in given case are of no importance in the diagnosis of retained placental tissue. The suspicion in the integrity of the placenta after its birth is a reason for RICU in spite of well contracted uterus and lack of hemorrhage. As the diagnosis of retained placental tissue in late puerperium is uncertain the RICU should be undertaken after failed conservative management.

Sonographic evaluation of induced abortion--experience in Nigeria

A sonographic evaluation of forty-six patients with suspected complications of unsafe induced abortion was performed prospectively. The sonographic features were correlated with surgical findings. Based on the sonographic findings, the patients were categorised into three groups. There was no clear association between the severity of sonographic or pathological findings and the time of presentation for ultrasound after the termination of pregnancy, but most of the patients presenting after 5 days belonged to groups II and III, i.e. had uterine complications with or without abdomino-pelvic complications. The commonest complication, sepsis, is variably expressed sonographically in all groups. Although, the sonographic appearances of sepsis are similar to those seen in pelvic inflammatory disease (PID), some features seen with post-abortal sepsis are peculiar. Apart from sepsis, other complications of abortion presented non-specific sonographic features. "Pseudouterus" appearance was demonstrated in one patient after hysterectomy. The likelihood of pre-operative diagnosis of uterine perforation is high when the presentation is early before the formation of complex echopatterns of sepsis or in the absence of free intraperitoneal gas from bowel perforation or gas-forming organism. Routing manual vacuum aspiration or therapeutic endometrial curettage is unnecessary where sonography shows no evidence of retained products post abortion.

Appearance of the uterus by ultrasound immediately after placental delivery with pathologic correlation

The purpose of this study was to compare the ultrasound appearance of the uterus immediately after the placenta was delivered with the gross and histologic findings obtained by manual exploration and sponge curettage. One hundred thirty-one patients underwent a sonographic assessment of the uterus within 5 minutes of placental delivery. A manual exploration and sponge curettage were performed with 2 minutes of the ultrasound examination, and the specimens were assessed for gross and histologic evidence of retained products of conception. Twenty-four (18.8%) of the patients had documented evidence of retained products of conception either by gross inspection or histologic assessment. Nineteen (15%) of the patients had what appeared to be retained products on ultrasound examination. Using our sonographic description of retained products of conception, the sensitivity, specificity, positive predictive value, and negative predictive value of ultrasound in detecting retained products was 44%, 92%, 58%, and 87%, respectively. The ultrasound findings in patients with retained products of conception were: a normal endometrial cavity in 9 (37.5%), echogenic mass in 6 (25%), heterogenous mixed density mass in 5 (21%), and fluid only in 4 (16.6%). Of the 6 cases with an echogenic mass, all were associated with retained products of conception. The ultrasound appearance of retained products of conception in the immediate time period after placental delivery is highly variable.

Accurate diagnosis of postabortal placental remnant by sonohysterography and color Doppler sonographic studies

The decision whether to perform uterine curettage for postabortal bleeding depends on the ability to demonstrate placental remnants in the uterine cavity. However, diagnosis of postabortal trophoblastic residua by conventional ultrasonography may be inconclusive. We report our experience with the use of combined sonohysterography and color Doppler to demonstrate a placental polyp after early pregnancy termination.