Gyn 7: Ovarian Torsion, RPOC, C-Section

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

Abnormal postpartum vaginal bleeding

What is the presentation of enhanced myometrial vascularity (EMV)?

Abnormal vaginal bleeding

When do uterine dehiscence (scar rupture) happen?

Acute event during subsequent pregnancy

What is the DDX of ovarian torsion?

Appendicitis or hemorrhagic cyst

What are complications if left untreated of retained products of conception (RPOC)?

Bleeding and infection

What is retained products of conception (RPOC)?

Incomplete expulsion of miscellaneous products of conception

Thrombus from postpartum ovarian vein thrombosis (thombophlebitis) is usually found where?

Junction of Rt renal V with IVC

What is the treatment of ovarian torsion?

Laparoscopic detorsion

What side is pelvic congestion syndrome more likely to happen?

Left

Sonographic appearance of bladder flap hematoma

Mass of variable echogenicity & no internal flow

What may enhanced myometrial vascularity (EMV) coexist with?

May coexist with RPOC

What ovary is postpartum ovarian vein thrombosis (thombophlebitis) usually seen in?

Mostly Rt ovarian V

How do you get enhanced myometrial vascularity (EMV)?

Mostly acquired but there are rare congenital situations

When is retained products of conception (RPOC) usually found?

Mostly after 2nd trimester spontaneous abortion or medical termination of pregnancy

What is the location of subfascial hematomas?

Posterior to rectus abdominis muscle

When do you often see enhanced myometrial vascularity (EMV)?

Postpartum or after miscarriage

How is enhanced myometrial vascularity (EMV) acquired?

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

If calcifications are present in retained products of conception (RPOC) what does this show?

Represents normal term placenta maturation and is highly suggestive of RPOC

Where are most C-section incisions located?

TRV incision in LUS

What age group does ovarian torsion happen in?

Young women <30, or children with ovarian lesions

What is pelvic congestion syndrome?

Chronic pelvic pain associated with pelvic varices (dilation of pelvic veins)

What is ovarian/adnexal torsion?

Complete/partial rotation of ovary *Almost always unilateral

What is the treatment of retained products of conception (RPOC)?

D&C

Bladder flap hematoma

Due to bleeding between LUS & BL

Subfascial hematomas

Due to disruption of inferior epigastric vessels

What is the presentation of pelvic congestion syndrome?

Dull chronic pain

What does a cesarean scar niche/defect look sonographically?

Fluid extending into triangular defect in anterior LUS

How do you get the highest PSV in EMV?

Gradually increase the Doppler scale (PRF) until a few vessels are seen

C-section: Normal sonographic findings after several months

-C-section/hysterotomy scar: thin linear echo/hypoechoic line -C-section scar niche/defect: triangular defect

Sonographic findings of postpartum ovarian vein thrombosis (thombophlebitis)

-Dilated anechoic/hypoechoic tubular structure -Intraluminal echogenic material (thrombus) in OV V with partial or complete absence of flow

Sonographic findings of pelvic congestion syndrome

-Dilated peri-uterine and peri-ovarian veins -Slow venous floe changing to retrograde/reversed flow with valsalva

Sonographic appearance of retained products of conception (RPOC)

-Echogenic mass/tissue within endometrial cavity -Blood flow differentiates RPOC from blood clot -Calcifications

Sonographic appearance of ovarian torsion?

-Enlarged edematous ovary -Multiple peripheral follicles -Absent venous flow -Torsed/twisted pedicle

Sonographic appearance of enhanced myometrial vascularity (EMV)

-Focal area of serpiginous tubular structures -Markedly increased flow -Low-resistance, high velocity flow

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

-Incompetent ovarian vein (or incompetency of internal iliac vein) -Nutcracker syndrome -May-Thurner syndrome (=iliac vein compression syndrome) -Pregnancy

What is the treatment of pelvic congestion syndrome?

-Medical management (hormones) -Ligation of incompetent ovarian V -Ablation of incompetent veins

What are the causes and risk factors of ovarian torsion?

-Ovarian lesion or cyst -1st trimester or immediately postpartum -Ovulation induction/hyperstimulated ovaries

What is the clinical presentation of ovarian torsion?

-Pelvic pain -N/V

C-section: Normal sonographic findings in initial postpartum period

-Small echogenic foci -Possible heterogeneity in LUS

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

-Venous stasis postpartum -Spread of puerperal infection

When is postpartum ovarian vein thrombosis (thombophlebitis) usually seen?

Uncommon; usually seen 48-96 hours after delivery or miscarriage/abortion

Enhanced myometrial vascularity (EMV) was formerly known as what?

Uterine arteriovenous malformations (AVM)

What is the gold stand for Dx for pelvic congestion syndrome?

Venography

In ovarian torsion, what vasculature is obstructed first?

Venous


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