Diagnostic Ultrasound - Abdomen and Pelvis
Share Embed Flag
Download ePaper

Diagnostic Ultrasound - Abdomen and Pelvis

powerstage
09.07.2019 Views

Endometritis TERMINOLOGY Synonyms • Endometrial infection Definitions • Polymicrobial infection resulting from ascending spread of organisms from cervix into uterus IMAGING General Features • Best diagnostic clue ○ Endometrial gas and fluid in patient with postpartum fever and pelvic pain • Primarily clinical diagnosis ○ Often no imaging findings in uncomplicated endometritis ○ Primary role of imaging is to evaluate for complications Ultrasonographic Findings • Pain may limit ability to perform transvaginal examination • Endometrium may appear normal • Findings often nonspecific ○ Thickened, heterogeneous endometrium ○ Endometrial fluid ○ Fluid in cul-de-sac • Hyperechoic foci within endometrial cavity ± shadowing ○ Intracavitary gas, inflammatory debris – Gas bubbles alone are not diagnostic – Endometrial gas is a normal finding for up to 3 weeks postpartum and is present in up to 21% of healthy patients ○ Large amount of echogenic fluid suspicious for pyometra • Color Doppler ○ May see increased flow, but not always present ○ Lack of ↑ flow does not rule out endometritis • Findings overlap with retained products of conception (RPOC) ○ RPOC is a risk factor for developing endometritis ○ Patients may have both RPOC and endometritis • If associated with pelvic inflammatory disease (PID), may see tubo-ovarian abscess CT Findings • Nonspecific, most useful for complications (abscess) or alternative diagnosis • Uterine enlargement, heterogeneous density • Distended endometrial cavity ○ May see air-fluid or fluid-fluid level (pus, hematoma) • Inflammatory changes around uterus better seen than with ultrasound MR Findings • T1WI: Low signal uterus and endometrial fluid • T2WI: Myometrium increased in signal intensity with loss of junctional zone • Intense enhancement with gadolinium Imaging Recommendations • Best imaging tool ○ Transvaginal ultrasound • Protocol advice ○ Always use color Doppler to evaluate for possible RPOC ○ Thorough scan of adnexa to look for parametrial or tuboovarian abscess DIFFERENTIAL DIAGNOSIS Retained Products of Conception • Echogenic endometrial mass • Significant overlap in findings with endometritis • High-velocity, low-resistance flow ○ Not always present • Presents with postpartum bleeding ○ Simple RPOC should not have fever, ↑ white count • May have RPOC with superimposed infection Intrauterine Blood/Clot • Seen in up to 24% of asymptomatic postpartum patients • May also be seen with endometritis • Should not have fever, ↑ white count • Changes rapidly with resolution on follow-up scans Asymptomatic Postpartum Endometrial Gas • Seen in up to 21% of healthy patients in postpartum period • May be present up to 3 weeks postpartum • Should not have fever, ↑ white count Endometrial Calcifications • Incidental finding in asymptomatic patient • Curvilinear calcifications along endometrium • Often history of prior instrumentation (D&C) Other Causes of Postpartum Fever • Ovarian vein thrombosis • Atelectasis • Pneumonia • Pyelonephritis • Appendicitis PATHOLOGY General Features • Etiology ○ Generally caused by ascending spread of organisms through cervix or incision site into uterus – May extend to involve myometrium and parametrium ○ More common following cesarean section than vaginal delivery ○ May progress from chorioamnionitis ○ Monomicrobial infection may occur in first 24-36 hours – Group B Streptococcus ○ Most infections are polymicrobial – Both aerobic and anaerobic – Occurs in first 48 hr ○ Common causative agents – Vaginal flora, including those associated with bacterial vaginosis – Neisseria gonorrhoeae – Enterococcus – Chlamydia and tuberculosis often seen in chronic endometritis – Etiologic agent(s) often never identified Diagnoses: Female Pelvis 767

Endometritis Diagnoses: Female Pelvis CLINICAL ISSUES Presentation • Most common signs/symptoms ○ Fever (> 100.4° F) within 36 hours following delivery ○ Pelvic/abdominal pain ○ Uterine tenderness on physical exam and during ultrasound ○ ↑ white blood cell count • Other signs/symptoms ○ Malodorous lochia ○ Vaginal bleeding ○ Vaginal discharge ○ Tachycardia • Clinical profile ○ Endometritis occurs in 2 clinical settings – Fever and pain in postpartum period (most common) – Associated with PID in nonobstetric patient Demographics • Epidemiology ○ Most common cause of postpartum fever ○ Occurs in 1-3% of vaginal deliveries ○ Much more common following cesarean section (15- 20%) – Prophylactic antibiotics highly effective in reducing risk of endometritis after cesarean section – 50-60% of women undergoing cesarean section without antibiotics will develop endometritis ○ Risk factors in obstetric patients – Cesarean section – Preexisting lower genital tract infection – Prolonged labor – Prolonged rupture of membranes – RPOC – Retained clots ○ Risk factors in nonobstetric patients – 70-90% of patients with PID have coexistent endometritis – May also occur after invasive gynecologic procedure – Intrauterine device ○ Uterine artery embolization – Both infectious and noninfectious endometritis reported in 0.5% of cases after uterine artery embolization ○ Chronic endometritis may occur – Associated with RPOC in obstetric population – In nonobstetric population associated with intrauterine device Natural History & Prognosis • Cure rates approach 95% with appropriate therapy • May extend to myometrium/parametrium if untreated or if caused by drug-resistant organisms ○ Potential complications include pyometrium and pelvic abscess • Rarely leads to development of pelvic septic thrombophlebitis ○ 1-2% of cases of endometritis ○ Associated with parametrial spread of infection Treatment • Parenteral broad spectrum antibiotics ○ 90-95% defervesce with 48-72 hr ○ Therapy continued until patient is afebrile for 24-48 hr and white blood cell count returns to normal • Persistent fever ○ Resistant organism → triple antibiotic therapy ○ Abscess → surgical or percutaneous drainage • RPOC, uterine hematoma → evacuation • Septic thrombophlebitis → anticoagulation in addition to antibiotics DIAGNOSTIC CHECKLIST Consider • Endometritis is predominantly a clinical diagnosis ○ Imaging findings frequently normal in uncomplicated endometritis • Imaging usually ordered to look for complications ○ Pyometrium ○ Abscess ○ RPOC Image Interpretation Pearls • In appropriate clinical setting (postpartum fever and pain) the presence of endometrial fluid and bubbles is highly suggestive of endometritis • Conversely, endometrial gas in asymptomatic postpartum patient is likely normal SELECTED REFERENCES 1. Plunk M et al: Imaging of postpartum complications: a multimodality review. AJR Am J Roentgenol. 200(2):W143-54, 2013 2. Cicchiello LA et al: Ultrasound evaluation of gynecologic causes of pelvic pain. Obstet Gynecol Clin North Am. 38(1):85-114, viii, 2011 3. Müngen E et al: Postabortion Doppler evaluation of the uterus: incidence and causes of myometrial hypervascularity. J Ultrasound Med. 28(8):1053- 60, 2009 4. Vandermeer FQ et al: Imaging of acute pelvic pain. Clin Obstet Gynecol. 52(1):2-20, 2009 5. Rufener SL et al: Sonography of uterine abnormalities in postpartum and postabortion patients: a potential pitfall of interpretation. J Ultrasound Med. 27(3):343-8, 2008 6. Faro S: Postpartum endometritis. Clin Perinatol. 32(3):803-14, 2005 7. Ledger WJ: Post-partum endomyometritis diagnosis and treatment: a review. J Obstet Gynaecol Res. 29(6):364-73, 2003 8. Savelli L et al: Transvaginal sonographic appearance of anaerobic endometritis. Ultrasound Obstet Gynecol. 21(6):624-5, 2003 9. Eckert LO et al: Endometritis: the clinical-pathologic syndrome. Am J Obstet Gynecol. 186(4):690-5, 2002 768

Endometritis<br />

TERMINOLOGY<br />

Synonyms<br />

• Endometrial infection<br />

Definitions<br />

• Polymicrobial infection resulting from ascending spread of<br />

organisms from cervix into uterus<br />

IMAGING<br />

General Features<br />

• Best diagnostic clue<br />

○ Endometrial gas <strong>and</strong> fluid in patient with postpartum<br />

fever <strong>and</strong> pelvic pain<br />

• Primarily clinical diagnosis<br />

○ Often no imaging findings in uncomplicated<br />

endometritis<br />

○ Primary role of imaging is to evaluate for complications<br />

Ultrasonographic Findings<br />

• Pain may limit ability to perform transvaginal examination<br />

• Endometrium may appear normal<br />

• Findings often nonspecific<br />

○ Thickened, heterogeneous endometrium<br />

○ Endometrial fluid<br />

○ Fluid in cul-de-sac<br />

• Hyperechoic foci within endometrial cavity ± shadowing<br />

○ Intracavitary gas, inflammatory debris<br />

– Gas bubbles alone are not diagnostic<br />

– Endometrial gas is a normal finding for up to 3 weeks<br />

postpartum <strong>and</strong> is present in up to 21% of healthy<br />

patients<br />

○ Large amount of echogenic fluid suspicious for pyometra<br />

• Color Doppler<br />

○ May see increased flow, but not always present<br />

○ Lack of ↑ flow does not rule out endometritis<br />

• Findings overlap with retained products of conception<br />

(RPOC)<br />

○ RPOC is a risk factor for developing endometritis<br />

○ Patients may have both RPOC <strong>and</strong> endometritis<br />

• If associated with pelvic inflammatory disease (PID), may<br />

see tubo-ovarian abscess<br />

CT Findings<br />

• Nonspecific, most useful for complications (abscess) or<br />

alternative diagnosis<br />

• Uterine enlargement, heterogeneous density<br />

• Distended endometrial cavity<br />

○ May see air-fluid or fluid-fluid level (pus, hematoma)<br />

• Inflammatory changes around uterus better seen than with<br />

ultrasound<br />

MR Findings<br />

• T1WI: Low signal uterus <strong>and</strong> endometrial fluid<br />

• T2WI: Myometrium increased in signal intensity with loss of<br />

junctional zone<br />

• Intense enhancement with gadolinium<br />

Imaging Recommendations<br />

• Best imaging tool<br />

○ Transvaginal ultrasound<br />

• Protocol advice<br />

○ Always use color Doppler to evaluate for possible RPOC<br />

○ Thorough scan of adnexa to look for parametrial or tuboovarian<br />

abscess<br />

DIFFERENTIAL DIAGNOSIS<br />

Retained Products of Conception<br />

• Echogenic endometrial mass<br />

• Significant overlap in findings with endometritis<br />

• High-velocity, low-resistance flow<br />

○ Not always present<br />

• Presents with postpartum bleeding<br />

○ Simple RPOC should not have fever, ↑ white count<br />

• May have RPOC with superimposed infection<br />

Intrauterine Blood/Clot<br />

• Seen in up to 24% of asymptomatic postpartum patients<br />

• May also be seen with endometritis<br />

• Should not have fever, ↑ white count<br />

• Changes rapidly with resolution on follow-up scans<br />

Asymptomatic Postpartum Endometrial Gas<br />

• Seen in up to 21% of healthy patients in postpartum period<br />

• May be present up to 3 weeks postpartum<br />

• Should not have fever, ↑ white count<br />

Endometrial Calcifications<br />

• Incidental finding in asymptomatic patient<br />

• Curvilinear calcifications along endometrium<br />

• Often history of prior instrumentation (D&C)<br />

Other Causes of Postpartum Fever<br />

• Ovarian vein thrombosis<br />

• Atelectasis<br />

• Pneumonia<br />

• Pyelonephritis<br />

• Appendicitis<br />

PATHOLOGY<br />

General Features<br />

• Etiology<br />

○ Generally caused by ascending spread of organisms<br />

through cervix or incision site into uterus<br />

– May extend to involve myometrium <strong>and</strong> parametrium<br />

○ More common following cesarean section than vaginal<br />

delivery<br />

○ May progress from chorioamnionitis<br />

○ Monomicrobial infection may occur in first 24-36 hours<br />

– Group B Streptococcus<br />

○ Most infections are polymicrobial<br />

– Both aerobic <strong>and</strong> anaerobic<br />

– Occurs in first 48 hr<br />

○ Common causative agents<br />

– Vaginal flora, including those associated with bacterial<br />

vaginosis<br />

– Neisseria gonorrhoeae<br />

– Enterococcus<br />

– Chlamydia <strong>and</strong> tuberculosis often seen in chronic<br />

endometritis<br />

– Etiologic agent(s) often never identified<br />

Diagnoses: Female <strong>Pelvis</strong><br />

767

logo

products

Resources

Company

Terms of service
Privacy policy
Cookie policy
Cookie settings
Imprint
Change language
Made with love in Switzerland
© 2024 Yumpu.com all rights reserved

Hooray! Your file is uploaded and ready to be published.

Saved successfully!

Ooh no, something went wrong!