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Transabdominal sonography before uterineexploration as a predictor of retained placental

fragments

ARTICLE in JOURNAL OF ULTRASOUND IN MEDICINE: OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OFULTRASOUND IN MEDICINE JULY 2003

Impact Factor: 1.54 Source: PubMed

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4 AUTHORS, INCLUDING:

Ori Shen

Shaare Zedek Medical Center

82PUBLICATIONS 438CITATIONS

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Ron Rabinowitz

Shaare Zedek Medical Center

96PUBLICATIONS 1,370CITATIONS

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Vered H Eisenberg

Sheba Medical Center

68PUBLICATIONS 549CITATIONS

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Available from: Vered H Eisenberg

Retrieved on: 10 November 2015

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Transabdominal SonographyBefore Uterine Explorationas a Predictor of RetainedPlacental Fragments

Ori Shen, MD, Ron Rabinowitz, MD, Vered H. Eisenberg, MD,Arnon Samueloff, MD

Objective. To evaluate the diagnostic accuracy of sonography in postpartum patients thought to haveretained placental fragments. Methods. The study group consisted of 39 postpartum women in

whom inspection of the placenta brought up suspicion of retained placental fragments. All these

women underwent manual exploration of the uterine cavity. Before the procedure, all patients had

two-dimensional sonographic imaging, after which they were divided into 2 groups. The first group

comprised women who were judged to have had an empty uterus or nothing but intrauterine fluid

collection. The second group consisted of those in whom sonography showed echoes of what might

appear as residual trophoblastic tissue, that is, echogenic, hypoechoic, or mixed echo intracavitary pat-

terns. The sonographic patterns were then correlated with the presence or absence of retained pla-

cental fragments as found on uterine manual exploration and pathologic examination. Results. In 18

patients, no suspected contents were observed on sonography. In 17 of these patients, the uterus was

empty on manual uterine exploration. One of these patients had residual trophoblastic tissue, which

was of minimal quantity and clinically unimportant. In 21 patients, sonography suggested retained pla-

cental tissue. In 15 of these patients, pathologic examination confirmed residual trophoblastic tissue,

and in the remaining 6, the uterus contained blood clots, decidua, or both. Conclusions. Sonography

is an effective tool for evaluating postpartum patients thought to have retained placental fragments.

Normal sonographic findings might obviate the need for manual exploration of the uterine cavity. A

questionable sonographic result is not an effective tool for distinguishing between placental fragments

and blood clots. Key words: placenta; sonography; third stage of labor.

Received December 24, 2002, from the Departmentof Obstetrics and Gynecology, Shaare ZedekMedical Center, Jerusalem, Israel; and Ben-GurionUniversity of the Negev, Beer-Sheva, Israel. Revisionrequested January 6, 2003. Revised manuscriptaccepted for publication February 20, 2003.

Address correspondence and reprint requests toOri Shen, MD, Department of Obstetrics andGynecology, Shaare Zedek Medical Center, PO Box3235, Jerusalem 91031, Israel; e-mail: orishen@netvision.net.il.

esidual trophoblastic tissue is an infrequent com-plication of labor and delivery and might appearas an early or late postpartum hemorrhage.1 Itmight also predispose to puerperal infection.

This situation is suspected when routine examination ofthe placenta reveals an incomplete placenta.

Because accurate diagnosis of retained placental frag-ments cannot always be made from examination of theplacenta, whenever this possibility is considered, manu-al exploration of the uterine cavity is performed. Thisprocedure requires general or regional anesthesia. In anattempt to decrease the high false-positive rate of theclinical evaluation, attempts have been made to usesonography to enhance the predictive value, thus avoid-ing unnecessary interventions.

2003 by the American Institute of Ultrasound in Medicine J Ultrasound Med 22:561564, 2003 0278-4297/03/$3.50

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Longitudinal studies have been performed2,3 tostudy the appearance of the normal uterus in invo-lution during puerperium. Several studies haveattempted to describe the appearance of the

postpartum and postabortion uterus in cases ofpostpartum hemorrhage with the use of transab-dominal sonography.4,5 Others have used trans-vaginal duplex Doppler sonography in similarcases. On the basis of these studies and others,6 itwould appear that in patients with postpartum orpostabortion bleeding, an empty uterus or a uteruscontaining only fluid, especially when Dopplerstudies reveal absent or scanty high-resistance flowin the endometrium, have a high negative predic-tive value for retained placental fragments.7,8 It hasbeen suggested that unnecessary interventionsmight be avoided in such patients.

We conducted this study to examine the diagnos-tic accuracy of combined transabdominal andtransvaginal sonography in patients with no exces-sive bleeding but who were thought to haveincomplete placentas on postpartum examina-tion. It was our intent to offer the clinician in thedelivery department an effective, simple tool thatwould allow decisions regarding the need to per-form uterine exploration in these cases.

Materials and Methods

This study was conducted in concordance withdepartmental protocol, and other than the sonog-raphy, there was no change in patient treatmentfrom the standard protocol. The study wasapproved by the local Research Committee.

The study group consisted of 39 patients in theimmediate postpartum period. All had vaginaldelivery of singleton neonates at 36 to 41 weeksgestational age (mean, 38 weeks 6 days) betweenMarch 2001 and October 2002 at Shaare ZedekMedical Center. In all cases, the placenta was deliv-ered spontaneously within 30 minutes of delivery.The mean age SD for the study group was 28 4.2years. Parity was 3.6 1.4. Twenty-five patients(64%) received regional anesthesia during laborand delivery.

In all cases, examination of the placenta by2 examiners revealed suspected incomplete pla-centas. A decision to perform manual explorationof the uterus was made by the staff on the basis ofplacental appearance alone. None of the patientshad a postpartum hemorrhage. Cases in which itwas obvious that a cotyledon was missing wereexcluded from the study.

A two-dimensional scan of the uterine cavitywas performed initially by an abdominalapproach (25 MHz, SonoAce 5500; Medison Co,Ltd, Seoul, South Korea), and if the abdominalscan showed no abnormalities, a transvaginalscan (57.5 MHz) was performed to verify the ini-tial finding. All scans were performed by an expe-rienced sonographer (O.S. or R.R.) within 1 hourof delivery. The sonographers did not examinequestionable placentas, nor did they discusstheir appearance with the staff. The scans werecategorized either as normal, signifying anempty uterus or fluid only, or as having question-able uterine content, when there was a distinctmass containing echogenic, hypoechoic, ormixed echogenic patterns measuring greaterthan 10 mm in thickness.

The clinicians performing the manual explo-ration were not informed of the sonographicfindings. Uterine exploration was performedunder general or epidural anesthesia. Any uter-ine content retrieved on exploration was sent forpathologic examination.

Results

The uterus was judged to be empty in 18 cases:17 with a midline echo measuring 10 mm or lessand 1 containing only fluid (negative sonograph-

ic findings). Figures 1 and 2 illustrate, respective-ly, 1 case with negative sonographic findings anda second case with positive findings. In 21 cases,

562 J Ultrasound Med 22:561564, 2003

Transabdominal Sonography for Retained Placental Fragments

Figure 1. Sonogram showing no questionable content.

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sonography revealed questionable uterine con-tent (distinct masses with a thickness of >10mm). In 7 of these, there was echogenic matter inthe uterine cavity, and in 14, a mixed echo pat-tern was observed. Table 1 shows a comparisonof the sonographic and clinicopathologic find-ings. In the single case with false-negative find-ings, the amount of chorionic tissue found onpathologic examination was minimal (

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transvaginal approach might be less agreeable toa postpartum patient, and it might not be avail-able in the delivery room setup. The transab-dominal approach was found to be sufficientlyaccurate for these patients. We found sonogra-phy to be insufficiently accurate in distinguish-ing retained trophoblast from blood clots ordecidua.

In this study, sonography was performed byexpert sonographers. The clinician would nothave access to such specialist consultation at alltimes. Because we think it is feasible with littleeffort to train residents to identify an emptyuterus in the postpartum patient according tothe described technique, we are now conductinga study in which, on the same patient group, res-idents with minimal training in sonography will

perform the examinations to establish whetherthese results are valid when the sonography isperformed by nonexperts.When routine examination of the placenta rais-

es suspicion of a missing placental fragment, thestandard of care is to perform uterine explorationwith anesthesia. Our data support the hypothesisthat if a transabdominal sonogram in such a casesuggests an empty uterus, invasive interventionshould be avoided. In our group, 46% of uterinecavity explorations might have been avoided.When abdominal or vaginal sonography or both

show a distinct intrauterine mass larger than 10mm thickness, uterine cavity exploration is war-ranted.

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Transabdominal Sonography for Retained Placental Fragments