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
