Ovarian Torsion, Pelvic Congestion Syndrome, Post-partum Ovarian Vein Thrombosis, RPOC, EMV, & Findings After C-Section Delivery

When does retained products of conception (RPOC) usually occur?

1. After spontaneous abortion (miscarriage) 2. After medical termination of the pregnancy (abortion)

What are some differential diagnoses of ovarian/adnexal torsion?

1. Appendicitis 2. Hemorrhagic cyst

What are some complications of retained products of conception (RPOC)?

1. Bleeding 2. Infection

Describe the sonographic appearance of isolated fallopian tube torsion

1. Dilated fluid-filled tubular structure (hydro/hematosalpinx) 2. Whirlpool sign

Describe the sonographic appearance of postpartum ovarian vein thrombosis (thrombophlebitis)

1. Dilated tubular structure extending from adnexa 2. Intraluminal echogenic material within ovarian vein w/ partial/complete absence of flow

What is the clinical presentation of pelvic congestion syndrome?

1. Dull chronic pain 2. Varices

Describe the sonographic appearance of retained products of conception (RPOC)

1. Echogenic mass/tissue within endometrial cavity 2. Blood flow (r/o blood clot) 3. Calcifications

Describe the sonographic appearance of ovarian/adnexal torsion

1. Enlarged edematous ovary 2. Peripheral follicles 3. Absent venous flow (arterial variable depending on degree of torsion) 4. Twisted/torsed pedicle (GS = target sign; color = whirlpool sign)

What are some causes and risk factors of pelvic congestion syndrome?

1. Incompetent ovarian vein or internal iliac vein (less common) 2. Nutcracker syndrome 3. Retroaortic lt. renal vein 4. May-Thurner syndrome 5. Pregnancy (esp. multiparous women)

What are the treatments for pelvic congestion syndrome?

1. Medical management (hormones) 2. Ligation of incompetent veins 3. Ablation of incompetent veins

Describe the sonographic appearance of pelvic congestion syndrome

1. Multiple dilated peri-uterine and peri-ovarian veins 2. Slow venous flow changing to reversed flow w/ Valsalva

What are some causes/risk factors of ovarian/adnexal torsion?

1. Ovarian lesion/cyst 2. First trimester of pregnancy or immediately postpartum 3. Ovulation induction/hyperstimulated ovaries

Describe the sonographic appearance of enhanced myometrial vascularity (EMV)/uterine arteriovenous malformations (AVM)

1. Serpiginous tubular structures in myometrium 2. Increased color flow 3. Low resistance + high velocity flow

What is the clinical presentation of ovarian/adnexal torsion?

1. Severe pelvic pain 2. Nausea/vomiting

Describe the normal sonographic appearance of a C-section in the initial postpartum period

1. Small echogenic foci in ant. myometrium of LUS + endometrial cavity (gas/sutures) 2. Possible heterogeneity myometrium of LUS (hemorrhage)

What are the causes of postpartum ovarian vein thrombosis (thrombophlebitis)?

1. Venous stasis 2. Infection

What is the patient demographic of ovarian/adnexal torsion?

1. Young women (< 30) 2. Children w/ ovarian lesions

What is the clinical presentation of retained products of conception (RPOC)?

Abnormal and excessive postpartum vaginal bleeding

What C-section complication causes the placenta to adhere at the scar site?

Abnormal placental implantation (placenta previa + placenta accreta)

What is the clinical presentation of enhanced myometrial vascularity (EMV)/uterine arteriovenous malformations (AVM)?

Abnormal vagina bleeding

What C-section complication is due to bleeding in the LUS/between the LUS and bladder?

Bladder flap hematoma

What is a rare form of torsion mostly seen in adolescents?

Isolated fallopian tube torsion

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

Junction of rt. ovarian vein w/ IVC

What is the treatment for ovarian/adnexal torsion?

Laparoscopic detorsion

Does pelvic congestion syndrome happen more on the left or right?

Left

What is a normal sequela that can happen to the myometrium superior to/between C-section scars?

May become bulbous/have convex outer contour (may mimic fibroid)

What is the complete/partial rotation of the ovary and possibly the fallopian tube?

Ovarian/adnexal torsion

What is chronic pelvic pain associated with dilatation of the pelvic veins (pelvic varices)?

Pelvic congestion syndrome

When is enhanced myometrial vascularity (EMV)/uterine arteriovenous malformation (AVM) commonly diagnosed?

Postpartum or after miscarriage

What condition is uncommon clotting in the ovarian vein usually seen 48-96 hours after delivery/abortion?

Postpartum ovarian vein thrombosis (thrombophlebitis)

How is enhanced myometrial vascularity (EMV)/uterine arteriovenous malformation (AVM) usually acquired?

Prior uterine instrumentation (D&C, myomectomy, C-section)

Is enhanced myometrial vascularity (EMV)/uterine arteriovenous malformations (AVM) rare or common?

Rare

What is the incomplete expulsion of products of conception (ex: placenta, etc.)?

Retained products of conception (RPOC)

Which vein is usually affected by postpartum ovarian vein thrombosis (thrombophlebitis)?

Right ovarian vein

What is the treatment for isolated fallopian tube torsion?

Salpingectomy

What C-section complication is found posterior to the rectus abdominis muscle and caused by disruption of the inferior epigastric vessels?

Subfascial hematoma

Describe the normal sonographic appearance of a C-section after several months

Thin linear hypoechoic line in ant. myometrium of LUS (scar)

What C-section complication is the result of a pregnancy implanting at the scar site?

Cesarean scar ectopic pregnancy

What C-section complication is a result of endometrial tissue growing in the scar site?

Cesarean scar endometrial implants (endometriosis)

What is a normal finding after a C-section that appears as fluid extending into a triangular defect in the anterior myometrium of the LUS?

Cesarean scar niche/defect (isthmocele)

What is the treatment for retained products of conception (RPOC) if the products are large (over 2cm)?

D&C

What is the abnormal communication between uterine arteries and veins within the myometrium?

Enhanced myometrial vascularity (EMV)/Uterine arteriovenous malformations (AVM)

Describe the normal findings of most C-section deliveries

Transverse incision in LUS

Is ovarian/adnexal torsion usually unilateral or bilateral?

Unilateral

What C-section scar complication is a result of the scar rupturing?

Uterine dehiscence

What is the gold standard for diagnosing pelvic congestion syndrome?

Venography

In ovarian/adnexal torsion, is venous/lymphatic or arterial flow obstructed first?

Venous/lymphatic flow first then arterial flow last