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Age: 21

Sex: Female

Indication: Persistent bloody discharge 3 weeks following vaginal delivery

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Case #28


Findings

  • Well demarcated echogenic mass in the lower endometrial canal measuring 2.2 x 1.4 x 1 cm with avid Doppler flow extending from the posterior uterine wall into this mass
  • Normal appearance of the ovaries
  • Trace free fluid in the cul-de-sac


Diagnosis

Retained products of conception

Sample Report

Well demarcated echogenic mass in the lower endometrial canal measuring 2.2 x 1.4 x 1 cm with avid Doppler flow extending from the posterior uterine wall into this mass, which in this patient with recent history of vaginal delivery is concerning for retained products of conception.

Normal appearance of the ovaries.

Trace free fluid in the cul-de-sac.


Discussion

  • Retained products of conception (RPOC) is a relatively common complication following delivery or termination of pregnancy
  • Ultrasound findings supportive of a diagnosis of RPOC in the correct clinical setting include:
    • Focal thickening of the endometrial echo complex measuring > 1 cm in width (very sensitive, but not very specific)
    • Visualization of a discrete mass in the endometrial canal (more specific, but less sensitive)
    • Associated vascularity with low-resistance arterial waveforms (maintained antegrade flow during diastole, leading to a low calculated resistive index) on spectral Doppler analysis
  • Differential diagnosis:
    • Hematoma – may have a similar appearance on grayscale imaging but should not have internal vascularity on Doppler analysis
    • Arteriovenous malformation – may appear identical on color Doppler analysis but usually involves the myometrium and not the endometrium unlike RPOC
    • Endometrial polyp/submucosal fibroid – may have an identical appearance but should have been present prior to delivery
    • Invasive mole – patient should have an elevated and rising beta-hCG


Images

Echogenic mass centered in and focally expanding the endometrial canal (red arrow). Color Doppler analysis shows vascularity extending from the myometrium into this mass (red arrow), which is highly suggestive of retained products of conception in the correct clinical context. In a different context, an endometrial polyp could have a similar appearance.

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