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