Post-Partum & Infertility

Puerperium

• period of time from expulsion of placenta to return of uterus to pre-pregnancy size and function

• Can last 6-8 weeks

Post-Partum presentation to U/S:

• C-section scars can develop hematomas and abscesses

• Retained parts of conception (placenta)

• Infection (fever, abd pain)

• Persistent bleeding

Post-Partum Anatomy

• involution of uterus

  • Reversal of the growth changes that take place during pregnancy

  • 50% reduction in size during first week postpartum

• Lactation begins at this time

  • when discontinued, the normal reproductive organ functions (ovulation and menstruation) resume

Post Partum U/S appearance:

• involution of uterus

  • Reversal of the growth changes that occur during pregnancy

  • 50% reduction in size during week 1 postpartum

• Lactation begins at this time

  • When discontinued the normal reproductive organ functions (ovulation + menstruation) occur

Post Partum U/S appearance:

• uterus may appear heterogenous due to vascular changes and resolution of tissue edema and fluid

• Endometrial cavity may measure up to 2 cm in AP

• Common finding to see free fluid in the endometrial cavity

  • Represents blood and other fluids/substances as endo sloughs after post-birth

Post Partum U/S appearance:

• uterine length can measure from 14.5 - 25 cm

• TRV / Coronal width of the uterus can range from 7-14 cm

• Size decreases w/ time

• Ligaments are flaccid after delivery

  • Assume normal pre-pregnancy firmness within a few weeks to about a month

What might or might not you see in a Post-Partum U/S?

• Broad Ligaments

  • Contains uterine vessels and fallopian tubes

  • Potential site for hematoma or abscess formation

• Ovaries seen 50% of the time

  • Usually in true pelvis in non-pregnant state

  • Extra pelvic space during much of postpartum

Post-Partum Bleeding

• Postpartum hemorrhage - blood loss >500 ml during the third stage of labor or immediately after a vaginal delivery

  • Uterine muscles must contract rapidly and firmly after delivery to occlude the uterine vessels at the point of placental separation

• The C-section delivery requires >1,000 mL loss to classify as having postpartum hemorrhage

• Occurs after 5% of all deliveries but is potentially the most lethal puerperium complication

• 35% of all maternal deaths

Post-Partum bleeding risks:

• abnormal placental attachment increases risk of hemorrhage

• Placenta accreta, increta, and percreta

• Antepartum uterine rupture → emergency delivery & hysterectomy

  • Rare

Primary (Acute) Hemorrhage

• acute hemorrhage is severe bleeding immediately following delivery

• Occurs within first 24 hours post delivery

  • Associated w/ acute clinical problems

  • Difficult labor (dystocia)

  • Chorioamnionitis

  • Placenta previa & accreta, increta or percreta

  • Incomplete manual placental removal

  • Uterine antony - not contracting

Secondary (Delayed) Hemorrhage

• occurs more than 24 hours post delivery

  • Several days to weeks later

  • Usually due to retained parts of conception and/or infection

Puerperal Infection

• uterine tenderness usually the first sign of infection

• Fever of over 100.4 on any two successive days after the first 24 hours postpartum

• Most puerperal infections are urinary tract infections, but they can also be breast infections, thrombophlebitis, or endometritis

Other Signs / Symptoms of Puerperal Infection:

• leukocytosis

• Chills, headache, malaise, anorexia

• Uterus is typically soft, tender, and large

• Lochia, or vaginal discharge, may be diminished or profuse and odorous

Endometritis

• endometrium infection

• Presents within 3-4 days post-delivery

• Usually caused by migration of normal vaginal flora, which may result in postpartum bleeding

Endometritis U/S findings:

• dilated / irregular endometrial cavity

• Shadowing echoes d/t gas

• Cul-de-sac fluid

Retained Products of Conception (RPOC)

• incomplete expulsion of miscellaneous products of conception during labor and delivery

• Can cause infection

• If left untreated, the following may result:

  • Infection

  • Bleeding

  • Intrauterine adhesions

RPOC U/S appearance:

• Hyperechoic mass in the endometrial canal

  • remnants of placental tissue (called a placental polyp), are b/c of incomplete placental expulsion from the uterus

• A heterogenous mass may contain necrotic tissue, clot, or infection

• may appear similar to endometritis

Postpartum Ovarian Vein Thrombophlebitis (POVT)

• rare

• more likely to occur w/ c-sections

• more common in Rt ovarian vein (80-90%)

• inflammation of a vein d/t a thrombus found in the lumen of the vessel

POVT relates to Virchow’s triad:

• hypercoagulability of blood during pregnancy and the postpartum period

• venous stasis

• venous wall damage as a result of uterus expansion and contraction

POVT symptoms:

• can be mistaken for other processes

• pelvic pain

• fever

• right-sided pelvic mass

What is the modality of choice evaluating POVT?

CT

POVT U/S:

• dilated anechoic to hypoechoic tubular structure extending superiorly from the adnexa

• lack of a color or spectral Doppler signal

• echogenic thrombus in the lumen confirms the presence of the thrombus

• may extend into the IVC

• the thrombus also may image as a mass between the uterus and the psoas muscle

  • most common site is where the IVC and the rt ovarian vein meet

Postpartum Ovarian Vein Thrombophlebitis Treatment:

• potentially life threatening

• IV anticoagulants such as:

  • heparin

  • blood thinners (warfarin)

• IVC filters

  • helps keep the embolus from traveling into the heart /lungs

  • prevents pulmonary emboli or death

• follow-up imaging studies help in monitoring thrombus resolution

Post-Partum C-section Incision

• watch for hematoma formation

  • will present as anechoic areas along incision line of >2cm

  • may have decreased hematocrit

• VBAC - Vaginal birth after cesarean

  • increased risk of uterine rupture

Bladder Flap Hematoma

• During a C-section, the surgeon incises the peritoneum btwn the bladder and the uterus to access the lower uterine segment

  • this potential space is called the bladder flap

  • where most hematomas are found post c-section

Bladder Flap Hematoma U/S appearance:

• anechoic w/ ill-defined borders

• very small (<1cm) to very large (>15cm)

• complex masses b/c of the blood components clotting, internal septations, or debris within the hematoma

Infertility

• 80% of couples attempting pregnancy conceive naturally within their first 6 months

• when naturally conceiving doesn’t occur after 12 consecutive months, this is called infertility

• women >35 y/o w/ a failure to conceive after 6 months of attempts

Causes of infertility include:

• tubal & pelvic pathology of the female partner (35%)

• male problems (35%)

• ovulatory dysfunction in the female (15%)

• unexplained fertility (10%)

• other unusual problems (5%)

Other causes of infertility can include:

• cigarette smoking

• body weight disorder

• sexually transmitted disease

• the delay of childbearing

Female factors of causing infertility:

• ovulatory dysfunction (40%)

• Tubal dysfunction (adhesions, endometriosis) (30-50%)

• uterine dysfunction (5-10%)

• cervical (5-10%)

• immunologic (5%)

• unknown (5%)

Male factors of causing infertility:

• varicocele (40%)

• idiopathic (25%)

• testicular failure (10%)

• tubular obstruction (5-10%)

• cyptorchidism (5-10%)

• other semen disorders (10%)

With Infertility, U/S evaluates the:

• structural anatomy

  • uterine shape, check for masses

• endometrium

  • thickness + echogenicity

• ovaries

  • presence and number of follicles

  • presence of cysts for other pathology

• fallopian tubes

  • Patency - can confirm w/:

    • hyterosalpingogram (xray)

    • sonohysterogram / saline infused sonogram (SIS)

Congenital Uterine Anomalies causing infertility:

• bicornuate uteus has small association w/ fetility complications

• septate uterus has high association w/ intertility

  • 2 uterine cavities w/ single fundus

  • problems w/ implantation

T-shaped Uterus

• associated w/ DES exposure

• Diethylstillbestrol exposure in utero occurred btwn 1950-70 to help threatened AB

• high risk for cervical incompetence

What can a progesterone deficiency lead to?

• early pregnancy loss + infertility

  • can supplement w/ vaginal gel, shorts, or oral tablets

The ________ can be evaluated for changes throughout the menstrual cycle.

endometrium

Irregular endometrial shape may be caused by:

• submucosal fibroids + polyps

• evaluated by Saline Infusion Sonography (SIS)

• Polyps have narrpw base and fibroids have a more broad base

• Main problem w/ fibroids + polyps is impeded implantation

• internal uterine scars are called synechiae

When evaluating fallopian tubes for infertility, check for:

• hydrosalpinx ( fluid-filled fallopian tube)

• tubal patency - inject fluid into tube and check for spillage in the posterior cul-de-sac

  • no spillage and pain = blocked tube

Ovaries during normal ovulation period:

• follicular stage → many follicles <5mm

• FSH levels encourage growth and one follicle becomes dominant

• Dominant follicle grows 2-3mm per dat until average diameter is reached → 22mm

  • then ruptures (ovulation)

• corpus luteum is left behind

Polycystic Ovarian Syndrome (PCOS)

• follicles grow but do not develop properly

• immature follicles continue to produce estrogen and androgens while inhibiting the pituitary function (more LA than FSH)

  • prevents normal ovulation

Causes of PCOS:

• obesity

• diabetes

• thyroid, pituitary, or adrenal gland dysfunction

PCOS U/S findings:

• round ovaries w/ multiple cysts in the periphery → String of Pearls sign

• ovary may appear normal

Endometriosis

• may be diffuse or local

• ectopic placement of the endometrium outside the uterine cavity

• most common site is the ovary

  • but can spread throughout the pelvic + sometimes throughout the body

• focal form is endometrioma

Adhesions

Scar tissue tha obstructs the Fallopian tube or fimbriated ends of the tube

Infertility Treatments

• controlled follicle stimulation w/ medication and timed intercourse

• IUI (intrauterine insemination)

• IVF (invitro fetilization)

• surrogate / gestational carrier

Ovarian Induction Therapy

• ovarian stimulation achieved in a controlled setting

• baseline U/S perfoemed to assess anatomy + check for cysts that could interfere with medication

• Mediciations such as Clomiphene Citrate (Clomid) or letrozole are administered on days 3-5 of a normal cycle

• Muliple U/S’s to measure follicle size + number

• measure any follicles >1cm

• may need hCG injection to trigger ovulation

Ovarian Induction Therapy & the Endometrium

• Assess thickness & echogenicity

• thickness changes from 2-3mm to 12-14mm

• an endometrium that measures <8mm in thickness and has an irregular echogenicity has increased risk of infertility

Intrauterine Insemination (IUI)

• used to treat male factor infertility in most cases

• may use sperm donor or partner’s sperm

• sperm sample is obtained, other substances and proteins from the semen are “washed” and then the sperm are introduced to the uterine cavity with a catheter at the time of natural or induced ovulation

• donor / surrogate sperm may also be used

In Vitro Fertilization (IVF)

• fertilization of ova outside the body

• mature ova are collected through an egg retrieval procedure and mixed in a dish w/ spermatozoa

• resulting embryos are placed back into uterus

IVF treatment usually consists of:

• ovarian monitoring, needle aspiration of oocytes, incubation of oocytes, fertilization, and transferring the embryos into the uterus

• aspiration of the oocytes may be done laparoscopically, the transabdominal or transvaginal ultrasound

Intracytoplasmic Sperm Injection (ICSI)

• sometimes d/t poor sperm motility or quality, another procedure is needed to help fertilization occur

• ICSO involves the injection of one sperm into the cytoplasm of an egg, thereby improving the likelihood of fertilization and subsequent embryo development

Surrogate / Gestational Carrier

• If a couple’s infertility prevents them from carrying a pregnancy, the couple may still have a child using their own sperm + ovum, using a GA carrier

• alternatively, IVF-ET of donor sperm and/or ova also addresses a couple’s treatment needs

  • in some situations, crypto-preserved embryos are obtained from a donor couple

    • “snowflake” babies handled like an adoption, but of an embryo

Complications associated w/ assisted reproduction:

• Ovarian Hyperstimulation Syndrome (OHSS)

• Multiples

• Ectopic Pregnancy

• Heterotopic Pregnancy

Ovarian Hyperstimulation Syndrome (OHSS)

• more common in pt’s w/ PCOS

• may be mild to severe

• enlarged ovaries

• multiple cysts

• abdominal ascites

• pleural effusion

Multiples

• number of cases of multiples has decreased w/ decreased numbers of embryos transferred

  • used to be about 25-30%

  • now overall IVF birth rates have fallen to 8.4% for IVF procedures specifically

• fetal reduction is rarely done today

Ectopic & Heterotopic

• increased incidence in ectopic and heterotopic pregnancies w/ ART

• risk is about 2-5%, which is higher than the 1-2% in normal pregnancies

  • likely d/t underlying tubal infertility issues