GYN 7 (Ovarian torsion, RPOC, C-section findings)
causes & risk factors of ovarian torsion
-ovarian lesion or cyst -mostly in 1st trimester or immediately postpartum -ovulation induction/hyperstimulated ovaries
vascular adnexal abnormalities
-pelvic congestion syndrome -postpartum/puerperal ovarian vein thrombosis
how is EMV acquired
-prior uterine intrumentation (D&C, myomectomy, C-section)
ovarian torsion clinical presentation
-sudden onset of severe pelvic pain -nausea/vomiting (N/V)
postpartum ovarian vein thrombus (thrombophlebitis)
-venous stasis postpartum -spread of puerperal infection
when is postpartum ovarian vein thrombosis usually seen
48-96 hrs after delivery
thrombus is usually found at junction of rt renal V with ______
IVC
which ovary does pelvic congestion syndrome usually affect
Lt>rt
EMV may coexist with _______
RPOC
C-section
TRV incision in LUS
RPOC presentation
abnormal postpartum vaginal bleeding -mostly after spontaneous abortion or medical termination or pregnancy
presentation of EMV
abnormal vaginal bleeding
DDX of ovarian torsion could be
appendicitis hemorrhagic cyst
venous & lymphatic flow are compromised ________ arterial flow
before
bladder flap hematoma
bleeding between LUS & BL
RPOC complications
bleeding or infection
Retained products of conception (RPOC)
incomplete expulsion of miscellaneous products of conception
thrombophlebitis usually affects the _____ ovarian V
rt
Uterine dehiscence
scar rupture
RPOC treatment
D&C
sonographic appearance of ovarian torsion
-enlarged ovary -peripheral follicles -absent venous flow -arterial flow is variable -torsed/twisted pedicle
pelvic congestion syndrome causes & risk factors
-incompetent ovarian vein -incompetency of internal iliac vein -nutcracker syndrome -may-thurner syndrome
normal sono findings after several months
-C-section/hysterotomy scar -niche/defect
c-section complications
-bladder flap hematoma -subfascial hematoma -uterine dehiscence -placenta previa -placenta accreta -endometrial implants (endometriosis) -ectopic pregnancy
thrombophlebitis sonographic appearance
-dilated anechoic tubular structure -intraluminal echogenic material -partial or complete absence of flow in ovarian vein
pelvic congestion syndrome sonographic findings
-dilated peri-uterine and peri-ovarian veins -slow venous flow changing from retrograde/reversed flow with valsalva
RPOC sonographic findings
-echogenic mass within endometrial cavity -blood flow differentiates from blood clot -calcifications
Pelvic congestion syndrome
chronic pelvic pain associated with dilatation of pelvic veins -reflux in lt ovarian vein
ovarian/adnexal torsion
complete/partial rotation of ovary on its vascular pedicle
subfascial hematoma
disruption of the inferior epigastric vessels -posterior to rectus abdominis muscle
pelvic congestion syndrome presentation
dull chronic pain
niche/defect
fluid extending into triangular defect in anterior LUS
EMV sonographic appearance
focal area of serpiginous tubular structures in the myometrium -markedly increased flow -low resistance -high velocity
May-Thurner syndrome
iliac vein compression syndrome -lt common iliac V compressed by rt common iliac artery
ovarian torsion treatment
laparoscopic detorsion
arterial inflow obstruction occurs ______
last
nutcracker syndrome
lt renal V compressed by SMA & AO
pelvic congestion syndrome treatment
medical management (hormones) -ligation of incompetent ovarian V -ablation of incompetent veins
pelvic congestion syndrome risk during pregnancy
mostly multiparous women
pelvic veins are aka
pelvic varices
when is EMV diagnosed
postpartum or after miscarriage
Enhanced myometrial vascularity (EMV)
rare -previously known as AVM -mostly acquired
normal sonographic findings in initial postpartum period
small echogenic foci -heterogeneity in LUS
c-section/hysterotomy scar
thin linear echo/hypoechoic line
true or false, presence of flow does not exclude torsion
true
is ovarian torsion usually unilateral or bilateral
unilateral
what is the gold standard for dx of pelvic congestion syndrome
venography
which obstruction occurs first venous or arterial??
venous outflow obstruction occurs first
what age does ovarian torsion usually occur
young women <30 or children with ovarian lesions
