[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.