Ovarian Torsion, Pelvic Congestion, RPOC, C-section

Treatments for pelvic congestion syndrome

-medical management (hormones) -ligation/ablation of incompetent veins

Examples of extrinsic compression that can cause pelvic congestion syndrome

-nutcracker syndrome -retroaortic Lt renal vein -May-Thurner syndrome (iliac vein compression syndrome)

Causes & risk factors for ovarian torsion

-ovarian cyst/cystic lesion -pregnancy -ovulation induction/hyperstimulated ovaries

What causes EMV?

-prior uterine instrumentation (D&C, myomectomy, C-section) -miscarriage

Normal sonographic findings after several months (after C-section)

-scar: thin linear echo/hypoechoic line -niche/defect (isthmocele): fluid extending into triangular defect in anterior LUS

EMV sonographic appearance

-serpiginous tubular structures in myometrium -increased flow -low-resistance, high velocity flow

Clinical presentation of ovarian torsion

-severe pelvic pain -N/V

Normal sonographic findings in early postpartum period (after C-section)

-small, echogenic foci in anterior myometrium of LUS & endometrial cavity -heterogeneity

Which two ultrasound signs are associated with a torsed/twisted ovarian pedicle?

-target sign (grayscale) -whirpool sign (color)

Causes of postpartum ovarian vein thrombosis

-venous stasis -infection

Who is usually affected by ovarian torsion?

-young women <30 y -children with ovarian lesions

In pregnancy, when is ovarian torsion most likely to occur?

1st trimester or immediately postpartum

When is postpartum ovarian vein thrombosis usually seen?

48-96 hrs after delivery

What might EMV coexist with?

RPOC

Which ovarian vein is usually affected by postpartum ovarian vein thrombosis?

Rt ovarian vein

Clinical presentation of RPOC

abnormal postpartum vaginal bleeding

Clinical presentation of EMV

abnormal vaginal bleeding

Clinical presentation of isolated fallopian tube torsion

acute pelvic pain (nonspecific)

When are RPOC usually seen?

after spontaneous abortion or medical termination of pregnancy

Where is the thrombus usually found in postpartum ovarian vein thrombosis?

at junction of Rt renal vein with IVC

Bladder flap hematoma

blood collection btw LUS & bladder

Retained products of conception (RPOC)

incomplete expulsion of products of conception

Treatment for isolated fallopian tube torsion

salpingectomy

Treatment of RPOC

D&C

Ovarian torsion sonographic appearance

-enlarged ovary -peripheral follicles -absent venous flow; arterial variable on degree of torsion -torsed/twisted pedicle -free fluid in cul-de-sac

Causes & risk factors for pelvic congestion syndrome

-incompetent ovarian vein or internal iliac vein -extrinsic compression -pregnancy (esp. multiparous women)

What other conditions have a similar clinical presentation to ovarian torsion?

-appendicitis -hemorrhagic cyst

C-section complications

-bladder flap hematoma -subfascial hematoma -uterine dehiscence (scar rupture) -abnormal placental implantation (placenta previa & accreta) -C-section scar endometrial implants (endometriosis) -C-section scar ectopic pregnancy

Complications of RPOC if left untreated?

-bleeding -infection

Pelvic congestion syndrome sonographic appearance

-dilated peri-uterine & peri-ovarian veins -slow venous flow -retrograde/reversed flow with valsalva

Sonographic appearance of postpartum ovarian vein thrombosis

-dilated tubular structure -intraluminal echogenic material -partial/complete absence of flow

Isolated fallopian tube torsion sonographic appearance

-dilated, fluid-filled tubular structure (hydro/hematosalpinx) -whirpool sign

Clinical presentation of pelvic congestion syndrome

-dull, chronic pain -varices

RPOC sonographic appearance

-echogenic mass within endometrial cavity -blood flow -calcifications

Pelvic congestion syndrome

chronic pelvic pain associated with pelvic varices

What causes subfascial hematoma?

disruption of inferior epigastric vessels

Treatment for ovarian torsion

laparoscopic detorsion

Which side is more commonly affected by pelvic congestion syndrome?

left

Does presence of flow exclude ovarian torsion?

no - could still be torsed

Isolated fallopian tube torsion

only fallopian tube is torsed - very rare

Ovarian torsion

partial/complete rotation of ovary on its vascular pedicle

Location of subfascial hematoma

posterior to rectus abdominis muscle

When is EMV usually diagnosed?

postpartum or after miscarriage

Enhanced myometrial vascularity (EMV)

rare, abnormal communication btw branches of uterine artery & venous plexuses within myometrium

Hysterotomy

transverse incision in LUS

Is ovarian torsion usually unilateral or bilateral?

unilateral

What is the gold standard for diagnosis of pelvic congestion syndrome?

venography

Which flow is compromised first in ovarian torsion?

venous

Who is usually affected by pelvic congestion syndrome?

women of reproductive age