Abstract
ObjectivesTo evaluate ultrasound (US) features associated with successful noninvasive management for suspected retained products of conception (RPOC).MethodsIn this IRB-approved retrospective study, the radiology report database was queried for pelvic US with keywords of postpartum hemorrhage (PPH) and/or RPOC over a 2-year period. Follow-up exams, US exams without clinical follow-up, suboptimal image quality, and > 1 year from delivery or pregnancy termination were excluded. Charts were reviewed for clinical presentation and management. Two radiologists reviewed images for endometrial thickness, endometrial echogenicity, endometrial vascularity, and enhanced myometrial vascularity (EMV), as well as inner myometrial peak systolic velocity (PSV) and resistive index (RI) where available. Features were assessed for associations with management approach, and test characteristics were calculated.ResultsInitial query yielded 196 exams, and 48 were excluded. A total of 148 patients were included. Mean age was 34.2 years (21–47), and mean time from delivery or pregnancy termination was 40.4 days (0–223). 81 (55%) underwent noninvasive management: 72 (48%) expectant and 9 (6%) medical. 67 (45%) underwent invasive management: 60 (41%) surgical and 7 (5%) uterine artery embolization. There was substantial inter-reader agreement for assessment of EMV (K = 0.78) and endometrial vascularity (K = 0.72). Thin endometrial stripe, avascular endometrium, and absence of EMV were associated with successful noninvasive management (p < 0.05). Thin endometrium (< 10 mm) had specificity (90%), PPV (88%), and likelihood ratio (5.91) in predicting successful noninvasive management.ConclusionEndometrial thickness < 10 mm, avascular endometrium, and absence of EMV are the sonographic features associated with successful noninvasive management for PPH or suspected RPOC.
Highlights
Postpartum hemorrhage (PPH) is a common cause of severe maternal morbidity and mortality worldwide, with an approximate yearly incidence of 3% in the United States [1]
Primary postpartum hemorrhage (PPH) occurs within 24 h of delivery, while secondary PPH occurs between 24 h and 12 weeks after delivery
In this IRB-approved, retrospective study, the radiology report database was queried for pelvic US reports containing keywords of “postpartum hemorrhage” and/or “retained products of conception” over a 2-year interval (6/1/2017–6/30/2019)
Summary
Postpartum hemorrhage (PPH) is a common cause of severe maternal morbidity and mortality worldwide, with an approximate yearly incidence of 3% in the United States [1]. While there are multiple underlying etiologies for PPH, some of the most common include uterine atony, genital trauma, coagulopathies, placenta accreta spectrum disorder (PASD), and retained products of conception (RPOC) [1]. Primary PPH occurs within 24 h of delivery, while secondary PPH occurs between 24 h and 12 weeks after delivery. RPOC accounts for 30% of secondary PPH [2]. Other causes include subinvolution of the placental implantation site, endometritis, and uterine artery pseudoaneurysm [3]. Imaging often plays a crucial role in the diagnostic workup. Up to 85% of patients with secondary PPH are evaluated with diagnostic pelvic ultrasound (US) at presentation [2]. Postpregnancy bleeding is an all-inclusive term to include bleeding after a term vaginal delivery, Cesarean section, spontaneous abortions, and both medical and surgical terminations
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