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Melamud K, Wahab SA, Smereka PN, Dighe MK, Glanc P, Kamath A, Maheshwari E, Scoutt LM, Hindman NM. Imaging of Antepartum and Postpartum Hemorrhage. Radiographics 2024; 44:e230164. [PMID: 38547034 DOI: 10.1148/rg.230164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Severe obstetric hemorrhage is a leading cause of maternal mortality and morbidity worldwide. Major hemorrhage in the antepartum period presents potential risks for both the mother and the fetus. Similarly, postpartum hemorrhage (PPH) accounts for up to a quarter of maternal deaths worldwide. Potential causes of severe antepartum hemorrhage that radiologists should be familiar with include placental abruption, placenta previa, placenta accreta spectrum disorders, and vasa previa. Common causes of PPH that the authors discuss include uterine atony, puerperal genital hematomas, uterine rupture and dehiscence, retained products of conception, and vascular anomalies. Bleeding complications unique to or most frequently encountered after cesarean delivery are also enumerated, including entities such as bladder flap hematomas, rectus sheath and subfascial hemorrhage, and infectious complications of endometritis and uterine dehiscence. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Javitt and Madrazo in this issue.
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Affiliation(s)
- Kira Melamud
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Shaun A Wahab
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Paul N Smereka
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Manjiri K Dighe
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Phyllis Glanc
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Amita Kamath
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Ekta Maheshwari
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Leslie M Scoutt
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
| | - Nicole M Hindman
- From the Department of Radiology, New York University Grossman School of Medicine, New York, NY (K.M., P.N.S., N.M.H.); Department of Radiology, University of Cincinnati College of Medicine, Mason, Ohio (S.A.W.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.K.D.); Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (P.G.); Department of Radiology, Mount Sinai Hospital, New York, NY (A.K.); University of Pittsburgh Medical Centre, Pittsburgh, Pa (E.M.); Departments of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Conn (L.M.S.); and Department of Radiology, NYU Langone Health, 660 1st Ave, 3rd Floor, New York, NY 10016 (N.M.H.)
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Alonso-Burgos A, Díaz-Lorenzo I, Muñoz-Saá L, Gallardo G, Castellanos T, Cardenas R, Chiva de Agustín L. Primary and secondary postpartum haemorrhage: a review for a rationale endovascular approach. CVIR Endovasc 2024; 7:17. [PMID: 38349501 PMCID: PMC10864234 DOI: 10.1186/s42155-024-00429-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/22/2024] [Indexed: 02/16/2024] Open
Abstract
Postpartum haemorrhage (PPH) is a significant cause of maternal mortality globally, necessitating prompt and efficient management. This review provides a comprehensive exploration of endovascular treatment dimensions for both primary and secondary PPH, with a focus on uterine atony, trauma, placenta accreta spectrum (PAS), and retained products of conception (RPOC). Primary PPH, occurring within 24 h, often results from uterine atony in 70% of causes, but also from trauma, or PAS. Uterine atony involves inadequate myometrial contraction, addressed through uterine massage, oxytocin, and, if needed, mechanical modalities like balloon tamponade. Trauma-related PPH may stem from perineal injuries or pseudoaneurysm rupture, while PAS involves abnormal placental adherence. PAS demands early detection due to associated life-threatening bleeding during delivery. Secondary PPH, occurring within 24 h to 6 weeks postpartum, frequently arises from RPOC. Medical management may include uterine contraction drugs and hemostatic agents, but invasive procedures like dilation and curettage (D&C) or hysteroscopic resection may be required.Imaging assessments, particularly through ultrasound (US), play a crucial role in the diagnosis and treatment planning of postpartum haemorrhage (PPH), except for uterine atony, where imaging techniques prove to be of limited utility in its management. Computed tomography play an important role in evaluation of trauma related PPH cases and MRI is essential in diagnosing and treatment planning of PAS and RPOC.Uterine artery embolization (UAE) has become a standard intervention for refractory PPH, offering a rapid, effective, and safe alternative to surgery with a success rate exceeding 85% (Rand T. et al. CVIR Endovasc 3:1-12, 2020). The technical approach involves non-selective uterine artery embolization with resorbable gelatine sponge (GS) in semi-liquid or torpedo presentation as the most extended embolic or calibrated microspheres. Selective embolization is warranted in cases with identifiable bleeding points or RPOC with AVM-like angiographic patterns and liquid embolics could be a good option in this scenario. UAE in PAS requires a tailored approach, considering the degree of placental invasion. A thorough understanding of female pelvis vascular anatomy and collateral pathways is essential for accurate and safe UAE.In conclusion, integrating interventional radiology techniques into clinical guidelines for primary and secondary PPH management and co-working during labour is crucial.
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Affiliation(s)
- Alberto Alonso-Burgos
- Radiology Department, Vascular Surgery and Interventional Radiology Unit, University Clinic of Navarra, Clínica Universidad de Navarra, Marquesado de Santa Marta 1, 28027, Madrid, Spain.
| | - Ignacio Díaz-Lorenzo
- Radiology Department, Interventional Radiology Unit, University Hospital La Princesa, Madrid, Spain
| | - Laura Muñoz-Saá
- Gynaecology and Obstetrics, University Clinic of Navarra, Madrid, Spain
| | | | | | - Regina Cardenas
- Gynaecology and Obstetrics, University Clinic of Navarra, Madrid, Spain
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Liao YC, Tsang LLC, Yang TH, Lin YJ, Chang YW, Hsu TY, Kung FT. Unscarred uterine rupture with catastrophic hemorrhage immediately after vaginal delivery: diagnosis and management of six consecutive cases. J Matern Fetal Neonatal Med 2023; 36:2243366. [PMID: 37586890 DOI: 10.1080/14767058.2023.2243366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND To describe and explore the risk factors, clinical presentations, timely diagnostic approaches, and management in patients experiencing unscarred uterine rupture with catastrophic hemorrhage. METHODS We retrospectively analyzed clinical and imaging data from women who encountered postpartum hemorrhage (PPH) and were diagnosed with unscarred uterine rupture within a three-year timeframe (2018-2020). The data were extracted from medical records obtained from a multi-hospital 24-hour emergency PPH transfer system. RESULTS Six patients were identified as having unscarred uterine rupture after vaginal delivery. All six women were para 2, with four of them undergoing vacuum-assisted delivery. One patient experienced out-of-hospital cardiac arrest (OHCA), while five patients presented with hypovolemic shock. Abdominopelvic ultrasound revealed a boggy lower uterine segment. Initially, five patients underwent transarterial embolization (TAE) of the internal iliac arteries in an attempt to achieve hemostasis, but this approach proved unsuccessful. Abdominopelvic computed tomography (CT) confirmed the diagnosis of ruptured uterus by demonstrating disrupted myometrium and hemoperitoneum. Immediate exploratory laparotomy followed by life-saving hysterectomy was performed in all cases. The median estimated total blood loss was 2725 mL ± 900 mL (ranging from 1600 mL to 7100 mL). Lower segment lacerations were observed in all patients, with more extensive uterine damage noted in those who underwent vacuum extraction. The length of hospital stay varied between 9 and 38 days. CONCLUSION Instrument-assisted obstetric delivery is a possible contributing factor to unscarred uterine rupture in our study. In specific cases, the use of abdominopelvic CT prior to initiating transarterial embolization (TAE) offers valuable information to complement ultrasound findings. This comprehensive approach helps in accurately identifying the underlying cause of intractable postpartum hemorrhage (PPH). Immediate conversion to laparotomy is essential to explore the intra-abdominal factors causing PPH that cannot be controlled by TAE. The rational etiologies of uterine rupture must be clarified while generating practical guideline in the future.
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Affiliation(s)
- Yi-Chiao Liao
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital; Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Leo Leung-Chit Tsang
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital; Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tsai-Hwa Yang
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital; Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Ju Lin
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital; Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Wei Chang
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital; Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Te-Yao Hsu
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital; Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Fu-Tsai Kung
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital; Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Obstetrics and Gynecology, Xiamen Chang Gung Hospital, Xiamen, Fujian, China
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Thanasa E, Thanasa A, Kamaretsos E, Paraoulakis I, Grapsidi V, Gerokostas EE, Thanasas I. Large bladder flap haematoma following a caesarean section associated with right hydroureteronephrosis: A case report and a mini‑review of the literature. MEDICINE INTERNATIONAL 2023; 3:48. [PMID: 37745154 PMCID: PMC10514564 DOI: 10.3892/mi.2023.108] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 09/04/2023] [Indexed: 09/26/2023]
Abstract
Post-caesarean section bladder flap haematoma is a rare postpartum complication. There are currently no specific treatment protocols, at least to the best of our knowledge. In general, the failure of conservative treatment with antibiotics requires the re-operation and surgical drainage of the haematoma. The present study describes the case of a primiparous pregnant woman who, at 40 weeks of pregnancy, delivered by caesarean section. On the 3rd post-operative day, the puerperant, haemodynamically stable, developed febrile infection. During the evaluation, the presence of bladder flap haematoma associated with moderate right hydroureteronephrosis was found. The failure of conservative management led to the decision to perform a re-laparotomy 1 week later. During the surgery, a large bladder flap haematoma was found with a retroperitoneal extension into the right parametrium. The surgical drainage of the haematoma and thorough haemostasis in the area of the vesicouterine pouch was performed. The patient was discharged from the clinic on the 5th post-operative day following the re-operation. After 2 weeks, an ultrasound revealed the complete repair of the lesions in the vesicouterine pouch and the right kidney. In the present study, a brief review of literature is also provided regarding the diagnostic and therapeutic management of patients with post-caesarean section bladder flap hematoma.
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Affiliation(s)
- Efthymia Thanasa
- Department of Health Sciences, Medical School, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Anna Thanasa
- Department of Health Sciences, Medical School, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Evangelos Kamaretsos
- Department of Obstetrics and Gynecology, General Hospital of Trikala, 42100 Trikala, Greece
| | - Ioannis Paraoulakis
- Department of Obstetrics and Gynecology, General Hospital of Trikala, 42100 Trikala, Greece
| | - Vasiliki Grapsidi
- Department of Obstetrics and Gynecology, General Hospital of Trikala, 42100 Trikala, Greece
| | | | - Ioannis Thanasas
- Department of Obstetrics and Gynecology, General Hospital of Trikala, 42100 Trikala, Greece
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Yu K, Ding Z, Yang J, Han X, Li T, Miao H. Bibliometric Analysis on Global Analgesia in Labor from 2002 to 2021. J Pain Res 2023; 16:1999-2013. [PMID: 37337609 PMCID: PMC10277021 DOI: 10.2147/jpr.s416142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/10/2023] [Indexed: 06/21/2023] Open
Abstract
Background Maternal pain during labor is one of the most important factors contributing to increased cesarean delivery rates and poor pregnancy outcomes, and this pain can be managed by labor analgesia. Many studies exist on labor analgesia, and the quantity and quality of these studies have not been reported. Therefore, we aimed to perform a bibliometric analysis of studies from 2002 to 2021. Methods We used the Web of Science database to obtain publications related to labor analgesia from January 2002 to December 2021. Various bibliographic information was collected, including country; author; journal; grant; discipline; institution and research hotspot. A total of 4536 papers were included. Results A total of 4536 articles were included in the study. The country with the most published articles on labor analgesia and the country of the funding agency was the United States. Most articles were published in the disciplines Anesthesiology and Obstetrics & Gynecology. The journal that published the most articles in this category was International Journal of Obstetric Anesthesia. In addition, we found different research hotspots for labor analgesia in the United States, Japan, and China. Conclusion This paper provides a bibliometric analysis of research on labor analgesia and highlights the differences in research hotspots for labor analgesia between countries.
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Affiliation(s)
- Kang Yu
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, People’s Republic of China
| | - Zhigang Ding
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, People’s Republic of China
| | - Jiaojiao Yang
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, People’s Republic of China
| | - Xue Han
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, People’s Republic of China
| | - Tianzuo Li
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, People’s Republic of China
| | - Huihui Miao
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, People’s Republic of China
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Kizaki Y, Samejima K, Matsunaga S, Nagai T, Takai Y. An old uterine rupture repaired 2 months postpartum using laparoscopy aided by hysteroscopy: A case report. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2022. [DOI: 10.1016/j.lers.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Menon BE, Kaufman CS, Kennedy AM, Ingraham CR, Monroe EJ. Postpartum hemorrhage - what the interventional radiologist should know. CVIR Endovasc 2021; 4:86. [PMID: 34902107 PMCID: PMC8669075 DOI: 10.1186/s42155-021-00277-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/07/2021] [Indexed: 11/21/2022] Open
Abstract
Postpartum hemorrhage is a leading cause of maternal morbidity and mortality around the world and can be caused by multiple etiologies. Distinguishing between the various etiologies that lead to PPH and identifying high risk features are crucial to implementing effective clinical management. In this review, the diagnostic imaging features and management principles of some of the most important causes of postpartum hemorrhage are discussed, with an emphasis on the pearls and pitfalls when minimally invasive treatment via interventional radiologic techniques are employed.
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Affiliation(s)
- Blaine E Menon
- Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA
| | - Claire S Kaufman
- Department of Radiology & Imaging Sciences, University of Utah, 30 North 1900 East, Salt Lake City, Utah, 84132-2140, USA.
| | - Anne M Kennedy
- Department of Radiology & Imaging Sciences, University of Utah, 30 North 1900 East, Salt Lake City, Utah, 84132-2140, USA
| | - Christopher R Ingraham
- Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA
| | - Eric J Monroe
- Department of Radiology, University of Wisconsin, 1675 Highland Avenue, Madison, WI, 53792, USA
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Wada Y, Takahashi H, Suzuki H, Ohashi M, Ogoyama M, Nagayama S, Baba Y, Usui R, Suzuki T, Ohkuchi A, Fujiwara H. Expectant management of retained products of conception following abortion: A retrospective cohort study. Eur J Obstet Gynecol Reprod Biol 2021; 260:1-5. [PMID: 33689917 DOI: 10.1016/j.ejogrb.2021.02.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 02/01/2021] [Accepted: 02/25/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To clarify the natural history of retained products of conception (RPOC) following abortion at less than 22 weeks of gestation, and those who show major bleeding during course observation. STUDY DESIGN We retrospectively reviewed 640 patients who had spontaneous or artificial abortion at less than 22 weeks of gestation between January 2011 and August 2019 in our institute. Of those, patients with RPOC were included. The maternal background, RPOC characteristics, and subsequent complications including additional interventions were reviewed. RESULTS Fifty-four patients with RPOC were included. The incidence of RPOC was 6.7 %. The median (interquartile range: IQR) RPOC length was 29 (20-38) mm. RPOC hypervascularity was observed in 26 (48 %) patients. The median (IQR) periods of RPOC flow disappearance and RPOC disappearance on ultrasound from abortive treatment were 50 (28-76) and 84 (50-111) days, respectively. Of the 54, 44 patients were selected for expectant management. Of the 44, 34 (77 %) patients were observed without intervention (recovery group); the other 10 (23 %) patients required additional interventions associated with subsequent bleeding (intervention group). Compared with the recovery group, heavy bleeding (> 500 mL) at abortion (6/10: 60 %) and RPOC hypervascularity (8/10: 80 %) were more frequently observed in the intervention group. CONCLUSION Expectant management was successful in almost 80 % of patients with RPOC following abortion. The additional interventions were required in patients with heavy bleeding at abortion and RPOC hypervascularity.
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Affiliation(s)
- Yoshimitsu Wada
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, 329-0498, Japan
| | - Hironori Takahashi
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, 329-0498, Japan.
| | - Hirotada Suzuki
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, 329-0498, Japan
| | - Mai Ohashi
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, 329-0498, Japan
| | - Manabu Ogoyama
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, 329-0498, Japan
| | - Shiho Nagayama
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, 329-0498, Japan
| | - Yosuke Baba
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, 329-0498, Japan
| | - Rie Usui
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, 329-0498, Japan
| | - Tatsuya Suzuki
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, 329-0498, Japan
| | - Akihide Ohkuchi
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, 329-0498, Japan
| | - Hiroyuki Fujiwara
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, 329-0498, Japan
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Uyeda JW, George E, Reinhold C, Akin EA, Ascher SM, Brook OR, Henrichsen TL, Henwood PC, Learman LA, Maturen KE, Patlas MN, Robbins JB, Sadowski EA, Saphier C, Wall DJ, Glanc P. ACR Appropriateness Criteria® Postpartum Hemorrhage. J Am Coll Radiol 2020; 17:S459-S471. [PMID: 33153557 DOI: 10.1016/j.jacr.2020.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 09/01/2020] [Indexed: 11/16/2022]
Abstract
Postpartum hemorrhage (PPH) can be categorized as primary or early if occurring in the first 24 hours after delivery, whereas late or delayed PPH occurs between 24 hours and 6 weeks. Most of the causes of PPH can be diagnosed clinically, but imaging plays an important role in the diagnosis of many causes of PPH. Pelvic ultrasound (transabdominal and transvaginal with Doppler) is the imaging modality of choice for the initial evaluation of PPH. Contrast-enhanced CT of the abdomen and pelvis and CT angiogram of the abdomen and pelvis may be appropriate to determine if active ongoing hemorrhage is present, to localize the bleeding, and to identify the source of bleeding. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Elizabeth George
- Research Author, University of California San Francisco, San Francisco, California
| | | | - Esma A Akin
- George Washington University Hospital, Washington, District of Columbia
| | - Susan M Ascher
- Georgetown University Hospital, Washington, District of Columbia
| | - Olga R Brook
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Patricia C Henwood
- Brigham & Women's Hospital & Harvard Medical School, Boston, Massachusetts; American College of Emergency Physicians
| | - Lee A Learman
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia; American College of Obstetricians and Gynecologists
| | | | | | | | | | - Carl Saphier
- Women's Ultrasound, LLC, Englewood, New Jersey; American College of Obstetricians and Gynecologists
| | | | - Phyllis Glanc
- Specialty Chair, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Gonzalo-Carballes M, Ríos-Vives MÁ, Fierro EC, Azogue XG, Herrero SG, Rodríguez AE, Rus MN, Planes-Conangla M, Escudero-Fernandez JM, Coscojuela P. A Pictorial Review of Postpartum Complications. Radiographics 2020; 40:2117-2141. [PMID: 33095681 DOI: 10.1148/rg.2020200031] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The postpartum period, also known as the puerperium, begins immediately after delivery of the neonate and placenta and ends 6-8 weeks after delivery. The appearance of physiologic uterine changes during puerperium can overlap with that of postpartum complications, which makes imaging interpretation and diagnosis difficult. Obstetric and nonobstetric postpartum complications are a considerable source of morbidity and mortality in women of reproductive age, and the radiologist plays an important role in the assessment of these entities, which often require a multimodality imaging approach. US and contrast material-enhanced CT are the techniques of choice in the emergency department, and they can show characteristic radiologic findings that enable differentiation between normal and abnormal features to help radiologists and emergency department practitioners to reach a correct diagnosis and provide timely treatment. The spectrum of postpartum complications ranges from relatively self-limiting to life-threatening conditions that can be divided into six categories: infectious conditions (endometritis), thrombotic complications (eg, deep vein thrombosis, ovarian vein thrombophlebitis, HELLP [hemolysis, elevated liver enzymes, and low platelet count] syndrome, or cerebral sinus thrombosis), hemorrhagic conditions (eg, uterine atony, trauma of the lower portion of the genital tract, retained products of conception, uterine artery arteriovenous malformations, or uterine artery pseudoaneurysm), cesarean delivery-related complications (eg, bladder flap hematoma, subfascial hematoma, rectus sheath hematoma, abscess formation, uterine dehiscence, uterine rupture, vesicovaginal fistula, or abdominal wall endometriosis), iatrogenic conditions (eg, uterine perforation), and nonobstetric complications (eg, acute cholecystitis, acute appendicitis, uterine fibroid degeneration, renal cortical necrosis, pyelonephritis, posterior reversible encephalopathy syndrome, or pituitary gland apoplexy). The online slide presentation from the RSNA Annual Meeting is available for this article. ©RSNA, 2020.
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Affiliation(s)
- Marta Gonzalo-Carballes
- From the Department of Radiology, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Miguel Ángel Ríos-Vives
- From the Department of Radiology, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Eva Castellà Fierro
- From the Department of Radiology, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Xavier Gurí Azogue
- From the Department of Radiology, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Susana Gispert Herrero
- From the Department of Radiology, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Alberto Escudero Rodríguez
- From the Department of Radiology, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - María Neus Rus
- From the Department of Radiology, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Marina Planes-Conangla
- From the Department of Radiology, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Jose Miguel Escudero-Fernandez
- From the Department of Radiology, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Pilar Coscojuela
- From the Department of Radiology, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
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11
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Kim MJ, Kim IJ, Kim S, Park IY. Postpartum hemorrhage with uterine artery embolization: the risk of complications of uterine artery embolization. MINIM INVASIV THER 2020; 31:276-283. [PMID: 32662700 DOI: 10.1080/13645706.2020.1789662] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The purpose of this study was to evaluate the efficacy and adverse effects of uterine artery embolization (UAE) to treat postpartum hemorrhage (PPH) and determine the factors associated with clinical outcomes. MATERIAL AND METHODS This study included 117 patients who underwent UAE for PPH between January 2010 and November 2018. Their medical records were retrospectively reviewed to assess the mode of delivery, causes of bleeding, detailed laboratory results, clinical outcomes, time from delivery to UAE, and embolizing material used. RESULTS The clinical UAE success rate was 99.1%. Late complications were found in 11 patients. Two total hysterectomies were performed. Most PPH cases treated with UAE had early-onset PPH caused by uterine atony. Late-onset PPH was caused by placenta-related problems (remnant placenta, placenta accreta). Body mass index, cesarean section, the use of mixed embolizing materials, placenta abruption as the cause of PPH, and transferred patients were associated with uterine necrosis. Age, re-embolization, and the use of mixed embolizing materials were associated with adverse complications. CONCLUSIONS Although UAE is a safe and effective way to manage PPH, a long-term follow-up is needed to determine the complications of UAE. When uterine necrosis is suspected, prompt and adequate treatment should be performed due to the effects of necrosis on menstrual cycles, fertility, and subsequent pregnancies.
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Affiliation(s)
- Min Jung Kim
- Department of Obstetrics and Gynecology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Il Jung Kim
- Department of Radiology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Shinyoung Kim
- Department of Obstetrics and Gynecology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - In Yang Park
- Department of Obstetrics and Gynecology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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12
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Deng L, Naidu S. Ultrasound of a late onset postpartum broad ligament haematoma. SONOGRAPHY 2020. [DOI: 10.1002/sono.12223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Lin Deng
- Medical Imaging Department Logan Hospital Meadowbrook Queensland Australia
| | - Sumant Naidu
- Medical Imaging Department Logan Hospital Meadowbrook Queensland Australia
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13
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Gui B, Corvino M, Grimaldi PP, Russo L, Di Marco M, Valentini AL, Carducci B, Lanzone A, Manfredi R. Multidetector CT appearance of the pelvis after vaginal delivery: normal appearances and abnormal acute findings. Diagn Interv Radiol 2019; 25:210-218. [PMID: 31063140 PMCID: PMC6521907 DOI: 10.5152/dir.2019.18127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 04/30/2018] [Accepted: 10/12/2018] [Indexed: 12/12/2022]
Abstract
Vaginal delivery is the most commonly performed delivery in the world and accounts for nearly two-thirds of all deliveries in the United States. It is a secure method but may be associated with some acute complications, especially in the immediate postpartum days, which can potentially be fatal for the mother. The most frequent acute complications are hemorrhages/hematomas, uterine rupture, endometritis, retained product of conception (RPOC), ovarian thrombosis and HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count). A first evaluation of the clinical status of the patients is executed by the clinicians who, depending on their experience, perform ultrasonography by themselves and eventually may request further radiologic exams in doubtful cases. Radiologists may play an important role recognizing early postpartum complications and differentiating them from physiologic postoperative findings. In this setting, the use of multidetector computed tomography (MDCT) is important for diagnosis of suspected postpartum complications. The aim of this article is to review the normal and abnormal post vaginal delivery MDCT aspects in order to help the clinical management by preventing misdiagnoses and tailoring the best medical treatments.
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Affiliation(s)
- Benedetta Gui
- From the Departments of Radiological Sciences (B.G. , M.C., P.P.G., L.R., M.D.M., A.L.V., R.M.) and Obstetrics and Gynecology (B.C., A.L.), Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy; Department of Radiological Sciences (M.C., P.P.G., L.R., M.D.M., A.L.V., R.M.), Università Cattolica del Sacro Cuore, Roma, Italy; Department of Obstetrics and Gynecology (A.L.), Università Cattolica del Sacro Cuore, Roma, Italy
| | - Miriam Corvino
- From the Departments of Radiological Sciences (B.G. , M.C., P.P.G., L.R., M.D.M., A.L.V., R.M.) and Obstetrics and Gynecology (B.C., A.L.), Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy; Department of Radiological Sciences (M.C., P.P.G., L.R., M.D.M., A.L.V., R.M.), Università Cattolica del Sacro Cuore, Roma, Italy; Department of Obstetrics and Gynecology (A.L.), Università Cattolica del Sacro Cuore, Roma, Italy
| | - Pier Paolo Grimaldi
- From the Departments of Radiological Sciences (B.G. , M.C., P.P.G., L.R., M.D.M., A.L.V., R.M.) and Obstetrics and Gynecology (B.C., A.L.), Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy; Department of Radiological Sciences (M.C., P.P.G., L.R., M.D.M., A.L.V., R.M.), Università Cattolica del Sacro Cuore, Roma, Italy; Department of Obstetrics and Gynecology (A.L.), Università Cattolica del Sacro Cuore, Roma, Italy
| | - Luca Russo
- From the Departments of Radiological Sciences (B.G. , M.C., P.P.G., L.R., M.D.M., A.L.V., R.M.) and Obstetrics and Gynecology (B.C., A.L.), Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy; Department of Radiological Sciences (M.C., P.P.G., L.R., M.D.M., A.L.V., R.M.), Università Cattolica del Sacro Cuore, Roma, Italy; Department of Obstetrics and Gynecology (A.L.), Università Cattolica del Sacro Cuore, Roma, Italy
| | - Margò Di Marco
- From the Departments of Radiological Sciences (B.G. , M.C., P.P.G., L.R., M.D.M., A.L.V., R.M.) and Obstetrics and Gynecology (B.C., A.L.), Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy; Department of Radiological Sciences (M.C., P.P.G., L.R., M.D.M., A.L.V., R.M.), Università Cattolica del Sacro Cuore, Roma, Italy; Department of Obstetrics and Gynecology (A.L.), Università Cattolica del Sacro Cuore, Roma, Italy
| | - Anna Lia Valentini
- From the Departments of Radiological Sciences (B.G. , M.C., P.P.G., L.R., M.D.M., A.L.V., R.M.) and Obstetrics and Gynecology (B.C., A.L.), Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy; Department of Radiological Sciences (M.C., P.P.G., L.R., M.D.M., A.L.V., R.M.), Università Cattolica del Sacro Cuore, Roma, Italy; Department of Obstetrics and Gynecology (A.L.), Università Cattolica del Sacro Cuore, Roma, Italy
| | - Brigida Carducci
- From the Departments of Radiological Sciences (B.G. , M.C., P.P.G., L.R., M.D.M., A.L.V., R.M.) and Obstetrics and Gynecology (B.C., A.L.), Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy; Department of Radiological Sciences (M.C., P.P.G., L.R., M.D.M., A.L.V., R.M.), Università Cattolica del Sacro Cuore, Roma, Italy; Department of Obstetrics and Gynecology (A.L.), Università Cattolica del Sacro Cuore, Roma, Italy
| | - Antonio Lanzone
- From the Departments of Radiological Sciences (B.G. , M.C., P.P.G., L.R., M.D.M., A.L.V., R.M.) and Obstetrics and Gynecology (B.C., A.L.), Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy; Department of Radiological Sciences (M.C., P.P.G., L.R., M.D.M., A.L.V., R.M.), Università Cattolica del Sacro Cuore, Roma, Italy; Department of Obstetrics and Gynecology (A.L.), Università Cattolica del Sacro Cuore, Roma, Italy
| | - Riccardo Manfredi
- From the Departments of Radiological Sciences (B.G. , M.C., P.P.G., L.R., M.D.M., A.L.V., R.M.) and Obstetrics and Gynecology (B.C., A.L.), Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy; Department of Radiological Sciences (M.C., P.P.G., L.R., M.D.M., A.L.V., R.M.), Università Cattolica del Sacro Cuore, Roma, Italy; Department of Obstetrics and Gynecology (A.L.), Università Cattolica del Sacro Cuore, Roma, Italy
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Chen C, Lee SM, Kim JW, Shin JH. Recent Update of Embolization of Postpartum Hemorrhage. Korean J Radiol 2018; 19:585-596. [PMID: 29962865 PMCID: PMC6005941 DOI: 10.3348/kjr.2018.19.4.585] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 12/06/2017] [Indexed: 12/14/2022] Open
Abstract
Postpartum hemorrhage (PPH) is a life-threatening condition and remains a leading cause of maternal mortality. Transcatheter arterial embolization (TAE) is an effective therapeutic strategy for PPH with the advantages of fast speed, repeatability, and the possibility of fertility preservation. We reviewed the vascular anatomy relevant to PPH, the practical details of TAE emphasizing the timing of embolization, and various clinical conditions of PPH according to a recent literature review.
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Affiliation(s)
- Chengshi Chen
- Department of Radiology, Henan Cancer Hospital, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, China.,Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Sang Min Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Jong Woo Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea
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15
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De Winter J, De Raedemaecker H, Muys J, Jacquemyn Y. The value of postpartum ultrasound for the diagnosis of retained products of conception: A systematic review. Facts Views Vis Obgyn 2017; 9:207-216. [PMID: 30250654 PMCID: PMC6143083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The goal of this review is to evaluate the value of ultrasound for detection of retained products of conception (RCOP) after delivery. METHODS A systematic search was performed using 'postpartum', 'retained placenta', 'retained products' and 'ultrasound' resulting 82 publications, after screening titles and abstracts, 30 remained. RESULTS On gray scale ultrasound, one must be focus on a thickened endometrial echo complex (EEC) with a cut off value of 10 mm and on an intracavitary mass. If these features are not visible, RPOC is rare. However, these findings are neither specific nor conclusive for RPOC and can even be seen in a normal postpartum uterus. Detection of hypervascularity in a thickened EEC or intracavitary mass with color Doppler ultrasound is very sensitive for RPOC but still not specific nor can it exclude RPOC. MRI seems best in differentiating RPOC, arteriovenous malformations and gestational trophoblastic disease. CONCLUSION There is no consensus on a standardised method for postpartum ultrasound. More research and standardization are necessary to differentiate of normal and pathological findings in the postpartum uterus.
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Affiliation(s)
- J De Winter
- Antwerp University Hospital UZA, Department of Obstetrics and Gynaecology, Wilrijkstraat 10, 2650 Edegem,Belgium
| | - H De Raedemaecker
- Antwerp University Hospital UZA, Department of Obstetrics and Gynaecology, Wilrijkstraat 10, 2650 Edegem,Belgium
| | - J Muys
- Antwerp University Hospital UZA, Department of Obstetrics and Gynaecology, Wilrijkstraat 10, 2650 Edegem,Belgium
| | - Y Jacquemyn
- Antwerp University Hospital UZA, Department of Obstetrics and Gynaecology, Wilrijkstraat 10, 2650 Edegem,Belgium
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16
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Iraha Y, Okada M, Toguchi M, Azama K, Mekaru K, Kinjo T, Kudaka W, Aoki Y, Aoyama H, Matsuzaki A, Murayama S. Multimodality imaging in secondary postpartum or postabortion hemorrhage: retained products of conception and related conditions. Jpn J Radiol 2017; 36:12-22. [PMID: 29052024 DOI: 10.1007/s11604-017-0687-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 09/27/2017] [Indexed: 12/18/2022]
Abstract
Secondary postpartum hemorrhage (PPH) and postabortion hemorrhage are rare complications. Retained products of conception (RPOC) is among the most common causes of both secondary PPH and postabortion hemorrhage. Other less common causes of secondary PPH are uterine vascular abnormalities such as arteriovenous malformations and pseudoaneurysms. These are usually related to a history of a procedure such as dilation and curettage or cesarean delivery. Subinvolution of the placental site is an idiopathic cause of secondary PPH; this condition may be underrecognized and therefore could have a higher incidence than currently reported. Gestational trophoblastic disease is rare but commonly presents as secondary PPH and resembles RPOC in radiologic appearance. The first-line imaging modality for secondary PPH is ultrasound, but computed tomography and magnetic resonance imaging may be used if the ultrasound findings are indeterminate. Angiography is an important tool for the definitive diagnosis of uterine vascular abnormalities. Appropriate management requires radiologists to be familiar with the multimodality imaging features of secondary PPH or postabortion hemorrhage.
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Affiliation(s)
- Yuko Iraha
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan.
| | - Masahiro Okada
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Masafumi Toguchi
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Kimei Azama
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Keiko Mekaru
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Tadatsugu Kinjo
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Wataru Kudaka
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Yoichi Aoki
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Hajime Aoyama
- Department of Pathology and Oncology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Akiko Matsuzaki
- Department of Pathology and Oncology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Sadayuki Murayama
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
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Kassam Z, Petkovska I, Wang CL, Trinh AM, Kamaya A. Benign Gynecologic Conditions of the Uterus. Magn Reson Imaging Clin N Am 2017; 25:577-600. [DOI: 10.1016/j.mric.2017.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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18
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Gui B, Danza FM, Valentini AL, Laino ME, Caruso A, Carducci B, Rodolfino E, Devicienti E, Bonomo L. Multidetector CT appearance of the pelvis after cesarean delivery: normal and abnormal acute findings. Diagn Interv Radiol 2017; 22:534-541. [PMID: 27756714 DOI: 10.5152/dir.2016.15593] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Cesarean section (CS) may have several acute complications that can occur in the early postoperative period. The most common acute complications are hematomas and hemorrhage, infection, ovarian vein thrombosis, uterine dehiscence and rupture. Pelvic hematomas usually occur at specific sites and include bladder flap hematoma (between the lower uterine segment and the bladder) and subfascial or rectus sheath hematoma (rectus sheath or prevescical space). Puerperal hemorrhage can be associated with uterine dehiscence or rupture. Pelvic infections include endometritis, abscess, wound infection, and retained product of conception. Radiologists play an important role in the diagnosis and management of postoperative complications as a result of increasing use of multidetector CT in emergency room. The knowledge of normal and abnormal postsurgical anatomy and findings should facilitate the correct diagnosis so that the best management can be chosen for the patient, avoiding unnecessary surgical interventions and additional treatments. In this article we review the surgical cesarean technique and imaging CT technique followed by description of normal and abnormal post-CS CT findings.
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Affiliation(s)
- Benedetta Gui
- Department of Radiological Sciences, Catholic University of Sacred Heart, Agostino Gemelli Hospital, Rome, Italy.
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Abstract
Pain has been documented as a major concern for women in the postpartum period. Management of postpartum pain, however, is a relatively neglected area of clinical research. As a result, evidence to support interventions to alleviate the discomforts associated with childbirth is sparse. This paucity of research on postpartum pain management is particularly surprising given that in the United States alone nearly 4 million women give birth each year. Inadequate pain relief in the hours to months following childbirth can interfere with maternal-newborn bonding and feeding and, by impeding mobility, can increase the risk of postpartum complications. In addition, pain that is not adequately managed may increase the risk of chronic pain that lasts beyond the postpartum period. In this article, the more common causes of pain following childbirth are reviewed and recommendations for pain management based on available evidence are outlined. Considerations for pain management in lactating women and for hospital discharge are discussed.
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20
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Gynecologic Emergencies: Findings Beyond US and Advances in Management. CURRENT RADIOLOGY REPORTS 2015. [DOI: 10.1007/s40134-015-0126-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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21
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Kawamura Y, Kondoh E, Hamanishi J, Kawasaki K, Fujita K, Ueda A, Kawamura A, Mogami H, Konishi I. Treatment decision-making for post-partum hemorrhage using dynamic contrast-enhanced computed tomography. J Obstet Gynaecol Res 2013; 40:67-74. [PMID: 23937115 DOI: 10.1111/jog.12123] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 03/04/2013] [Indexed: 11/30/2022]
Abstract
AIM Post-partum hemorrhage (PPH) is the leading cause of maternal mortality. Identification of the precise bleeding site is generally important to control hemorrhage, but such an approach has not been fully established in the context of PPH. We postulated that visualization of bleeding sites could aid treatment decisions in the management of PPH. METHODS We conducted a prospective review of 26 patients who underwent dynamic computed tomography (CT) for PPH. RESULTS A total of 17 cases presented with uterine bleeding, eight with vaginal hematomas, and one with hemoperitoneum. Overall, dynamic CT identified contrast media extravasation in the arterial phase in 12 of 26 (46.2%) cases: the upper (n = 4) and the lower uterine segment including the cervix (n = 2), subfascial space (n = 1) and vagina (n = 5). Identification of precise arterial bleeding sites using CT provided informative guidance about where to place balloons for intractable uterine bleeding, and how to manage hemoperitoneum and vaginal hematomas. In addition, dynamic CT revealed the existence of a subtype of uterine atony, which is characterized by focal active arterial bleeding in the upper uterine segment. Furthermore, negative contrast extravasation extracted cases of PPH that were well controlled without the need for surgical or radiological intervention. No patient required emergency hysterectomy to control PPH. CONCLUSION Dynamic CT has potential clinical utility in treatment decision-making for PPH.
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Affiliation(s)
- Yosuke Kawamura
- Department of Gynecology and Obstetrics, Kyoto University, Kyoto, Japan
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22
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Sellmyer MA, Desser TS, Maturen KE, Jeffrey RB, Kamaya A. Physiologic, Histologic, and Imaging Features of Retained Products of Conception. Radiographics 2013; 33:781-96. [DOI: 10.1148/rg.333125177] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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23
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Sierra A, Burrel M, Sebastia C, Radosevic A, Barrufet M, Albela S, Buñesch L, Domingo MA, Salvador R, Real I. Utility of Multidetector CT in Severe Postpartum Hemorrhage. Radiographics 2012; 32:1463-81. [DOI: 10.1148/rg.325115113] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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24
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Pinto A, Niola R, Brunese L, Pinto F, Losco M, Romano L. Postpartum hemorrhage: what every radiologist needs to know. Curr Probl Diagn Radiol 2012; 41:102-10. [PMID: 22459890 DOI: 10.1067/j.cpradiol.2011.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Postpartum hemorrhage is among the most common causes of maternal morbidity and mortality. Postpartum hemorrhage is defined as a blood loss of greater than 500 mL or any amount that, if not replaced, could cause shock or death in the mother. The most common cause of postpartum hemorrhage is uterine atony. This occurs when the normal myometrium fails to contract after delivery of the placenta. The initial treatment involves the administration of intravenous oxytocin and uterine massage. If the initial maneuvers fail to stop the postpartum hemorrhage, other techniques, such as uterine packing, suture techniques, uterine or hypogastric artery ligation, can be considered. In the last 30 years, a new angiographic approach for treatment of postpartum hemorrhage has emerged. Pelvic arterial embolization, after emerging as a treatment option to control and prevent pregnancy-related hemorrhage, has been established to be safe and effective. The goal of treatment for all causes of postpartum hemorrhage is cessation of bleeding in a timely fashion, before the onset of consumptive coagulopathy and end organ damage.
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Affiliation(s)
- Antonio Pinto
- Department of Diagnostic Imaging, Section of General and Emergency Radiology, "A. Cardarelli" Hospital, Naples, Italy.
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Evaluation of compliance and outcomes of a management protocol for massive postpartum hemorrhage at a tertiary care hospital in Pakistan. BMC Pregnancy Childbirth 2011; 11:28. [PMID: 21489279 PMCID: PMC3087691 DOI: 10.1186/1471-2393-11-28] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Accepted: 04/13/2011] [Indexed: 11/10/2022] Open
Abstract
Background Massive postpartum hemorrhage is a life threatening obstetric emergency. In order to prevent the complications associated with this condition, an organized and step-wise management protocol should be immediately initiated. Methods An evidence based management protocol for massive postpartum hemorrhage was implemented at Aga Khan University Hospital, Karachi, Pakistan after an audit in 2005. We sought to evaluate the compliance and outcomes associated with this management protocol 3 years after its implementation. A review of all deliveries with massive primary postpartum hemorrhage (blood loss ≥ 1500 ml) between January, 2008 to December, 2008 was carried out. Information regarding mortality, mode of delivery, possible cause of postpartum hemorrhage and medical or surgical intervention was collected. The estimation of blood loss was made via subjective and objective assessment. Results During 2008, massive postpartum hemorrhage occurred in 0.64% cases (26/4,052). No deaths were reported. The mean blood loss was 2431 ± 1817 ml (range: 1500 - 9000 ml). Emergency cesarean section was the most common mode of delivery (13/26; 50%) while uterine atony was the most common cause of massive postpartum hemorrhage (14/26; 54%). B-lynch suture (24%) and balloon tamponade (60%) were used more commonly as compared to our previously reported experience. Cesarean hysterectomy was performed in 3 cases (12%) for control of massive postpartum hemorrhage. More than 80% compliance was observed in 8 out of 10 steps of the management protocol. Initiation of blood transfusion at 1500 ml blood loss (89%) and overall documentation of management (92%) were favorably observed in most cases. Conclusion This report details our experience with the practical implementation of a management protocol for massive postpartum hemorrhage at a tertiary care hospital in a developing country. With the exception of arterial embolization, relatively newer, simpler and potentially safer techniques are now being employed for the management of massive postpartum hemorrhage at our institution. Particular attention should be paid to the documentation of the management steps while ensuring a stricter adherence to the formulated protocols and guidelines in order to further ameliorate patient outcomes in emergency obstetrical practice. More audits like the one we performed are important to recognize and rectify any deficiencies in obstetrical practice in developing countries. Dissemination of the same is pivotal to enable an open discourse on the improvement of existing obstetrical strategies.
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