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Ultrasound and Retained Products of Conception
Journal of Medical Ultrasound (2015) 23, 63e64
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.jmu-online.com
EDITORIAL
Ultrasound and Retained Products of Conception Early pregnancy loss is a serious psychological emergency in obstetrics [1]. In this issue, Esmaeillou et al [2] offer a highly educative article entitled Accurate detection of retained products of conception after first- and secondtrimester by color Doppler sonography. Making an accurate diagnosis of retained products of conception (RPOC) is a major clinical challenge. Because RPOC may cause prolonged bleeding, endometritis, and intrauterine adhesiondAsherman’s syndromedwith subsequently impaired fertility in the future [3], therapeutic intervention is mandatory. By contrast, it is clear that the inability to diagnose RPOC with confidence leads to a significant increase in unnecessary medical interventions, which causes a significant burden on health services and may cause both psychological and physical harm to these women. The primary aids to the diagnosis of RPOC are the clinical presentation of vaginal bleeding, dilated cervical canal, and characteristic ultrasound findings [4]. Women are usually referred for curettage or hysteroscopy, both of which are carried out under general anesthesia and require surgery [4]. The blind procedure of dilatation and curettage, or suction and curettage, even under ultrasound guidance for evacuation of the uterine cavity after first- and secondtrimester miscarriage, might be associated with the risk of complications, such as hemorrhage, infection, and general anesthesia-associated morbidity and mortality [5]. Expectant management might be the most conservative therapy with few surgery-related complications if the candidate for expectant therapy can be selected. Esmaeillou et al [2] conducted this prospective interventional study to investigate the role of grayscale and color-Doppler transvaginal ultrasonography (TVS) findings in the management of first- and second-trimester miscarriages, and found the simultaneous presence of echogenic mass and vascularity was the most accurate diagnostic criteria [an accuracy rate of 88%, 95% confidence interval (CI) 79e94%], suggesting that there would be a
Conflicts of interest: All authors declare no conflicts of interest.
modest improvement (sensitivity of 88%, 95% CI 72e97%, and specificity of 89%, 95% CI 75e96%) if the two techniques (grayscale and color-Doppler TVS) were applied. Two-dimensional TVS has been thought to be a promising tool for the detection of RPOC, although necrotic decidual cells and blood clots may be very difficult to differentiate from RPOC. In addition, the value of grayscale TVS in the diagnosis of RPOC is still debated. For example, Abbasi et al [5] found that the presence of hyperechoic material on TVS is highly predictive of RPOC after spontaneous firsttrimester miscarriage, with a sensitivity of 78% and specificity of 100%, and Wolman et al [4] suggested 94% sensitivity with 98% specificity characterizes TVS as being a very efficient tool. Esmaeillou et al [2] also agreed that their study revealed that echogenic mass in grayscale ultrasound could be valuable in diagnosing RPOC. In the current article, Dr Esmaeillou highlighted the value of adding color-Doppler TVS to conventional twodimensional grayscale TVS in the detection of RPOC [2]. However, the usefulness of color Doppler in diagnosing RPOC is much more debated. Alca ´zar and Ortiz [6] found color-Doppler TVS useful for selecting patients for expectant management. Other studies found that color Doppler features of the uterus might be of practical value for the management of RPOC, however, the absence of blood flow does not exclude the diagnosis [7,8], suggesting that the addition of color Doppler TVS as an aid in the diagnosis of RPOC might not satisfy our current need. Given the above, is there any potential tool available to help make an accurate diagnosis of RPOC? All the following strategies might be possible, however, none of them has been confirmed. For example, serum b human chorionic gonadotropin (b hCG) levels could be checked, but they often contribute little to the diagnosis in the period immediately after abortion because serum b hCG levels tend to remain high during this period [4]. How about the value of hysteroscopy? Hysteroscopy, unfortunately, was shown to have a detection rate of <70%, as confirmed by histologic examination [9]. Although hysteroscopy alone might not be a good tool for the diagnosis of RPOC, the combination of TVS and hysteroscopy showed impressive results.
http://dx.doi.org/10.1016/j.jmu.2015.03.001 0929-6441/ª 2015, Elsevier Taiwan LLC and the Chinese Taipei Society of Ultrasound in Medicine. All rights reserved.
64 Investigators have been using sonohysterography as an accurate tool to diagnose RPOC with approximately 100% success rate [10]. However, sonohysterography requires additional equipment and considerable experience on the part of the examiner, and of most importance, it is an invasive procedure and is more costly and time-consuming than color Doppler TVS, a device that is available in almost every gynecologist’s office [4]. Thus, an 88% sensitivity with an 89% specificity characterizes color Doppler TVS as being a very efficient tool. This finding was published in the current issue of the Journal of Medical Ultrasound [2].
Acknowledgments Supported by grants from the Ministry of Science and Technology, Executive Yuan (MOST 103-2314-B-010-043 -MY3 to P.-H. Wang and MOST 103-2314-B-195-010 to C.-P. Chen), Taipei Veterans General Hospital (V102C-141; V103C-112; V102E4-003; and V103E4-003 to P.-H. Wang) and Mackay Memorial Hospital (MMH-E-103-04 to C.-P. Chen).
References [1] Su WH, Lee FK, Wang PH. Recurrent pregnancy loss and thrombophilia in women with PCOS. J Chin Med Assoc 2013;76: 243e4. [2] Esmaeillou H, Jamal A, Eslamian L, et al. Accurate detection of retained products of conception after first- and secondtrimester abortion by color Doppler sonography. J Med Ultrasound 2015;23:34e8. [3] Tsui KH, Li HY, Cheng JT, et al. Comprehensive treatment for interfile women with severe Asherman’s syndrome. Taiwan J Obstet Gynecol 2014;53:372e5. [4] Wolman I, Altman E, Faith G, et al. Combined clinical and ultrasonographic work-up for the diagnosis of retained products of conception. Fertil Steril 2009;92:1162e4. [5] Abbasi S, Jamal A, Eslamian L, et al. Role of clinical and ultrasound findings in the diagnosis of retained products of conception. Ultrasound Obstet Gynecol 2008;32:704e7. [6] Alca ´zar JL, Ortiz CA. Transvaginal color Doppler ultrasonography in the management of first-trimester spontaneous abortion. Eur J Obstet Gynecol Reprod Biol 2002;102:83e7. [7] Schwa ¨rzler P, Holden D, Nielsen S, et al. The conservative management of first trimester miscarriage and the use of colour Doppler sonography for patient selection. Hum Reprod 1999;14:1341e5. [8] Durfee SM, Frates MC, Luong A, et al. The sonographic and color Doppler features of retained products of conception. J Ultrasound Med 2005;24:1181e6. quiz 1188e9. [9] Zakut H, Achiron R. Intrauterine balloon catheter for ultrasound evaluation of pelvic masses. Enhancement of uterine localization. Gynecol Obstet Invest 1987;24:68e72.
Editorial [10] Zalel Y, Cohen SB, Oren M, et al. Sonohysterography for the diagnosis of residual trophoblastic tissue. J Ultrasound Med 2001;20:877e81.
Peng-Hui Wang* Department of Obstetrics and Gynecology, National Yang-Ming University School of Medicine, Taiwan Division of Gynecology, Department of Obstetrics and Gynecology, Taiwan Immunology Center, Taipei Veterans General Hospital, Taipei, Taiwan Department of Medical Research, China Medical University Hospital, Taichung, Taiwan Institute of Clinical and Community Health Nursing, National Yang-Ming University, Taiwan Chih-Yao Chen Department of Obstetrics and Gynecology, National Yang-Ming University School of Medicine, Taiwan Division of Gynecology, Department of Obstetrics and Gynecology, Taiwan Chih-Ping Chen Department of Obstetrics and Gynecology, National Yang-Ming University School of Medicine, Taiwan Institute of Clinical and Community Health Nursing, National Yang-Ming University, Taiwan Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taiwan Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan Department of Biotechnology, Asia University, Taiwan School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan *Correspondence to: Dr Peng-Hui Wang, Division of Gynecology, Department of Obstetrics and Gynecology, Taipei Veterans General Hospital and National Yang-Ming University, 201, Section 2, Shih-Pai Road, Taipei, Taiwan. E-mail addresses: [email protected], [email protected], [email protected] (P.-H. Wang) 2 March 2015
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.jmu-online.com
EDITORIAL
Ultrasound and Retained Products of Conception Early pregnancy loss is a serious psychological emergency in obstetrics [1]. In this issue, Esmaeillou et al [2] offer a highly educative article entitled Accurate detection of retained products of conception after first- and secondtrimester by color Doppler sonography. Making an accurate diagnosis of retained products of conception (RPOC) is a major clinical challenge. Because RPOC may cause prolonged bleeding, endometritis, and intrauterine adhesiondAsherman’s syndromedwith subsequently impaired fertility in the future [3], therapeutic intervention is mandatory. By contrast, it is clear that the inability to diagnose RPOC with confidence leads to a significant increase in unnecessary medical interventions, which causes a significant burden on health services and may cause both psychological and physical harm to these women. The primary aids to the diagnosis of RPOC are the clinical presentation of vaginal bleeding, dilated cervical canal, and characteristic ultrasound findings [4]. Women are usually referred for curettage or hysteroscopy, both of which are carried out under general anesthesia and require surgery [4]. The blind procedure of dilatation and curettage, or suction and curettage, even under ultrasound guidance for evacuation of the uterine cavity after first- and secondtrimester miscarriage, might be associated with the risk of complications, such as hemorrhage, infection, and general anesthesia-associated morbidity and mortality [5]. Expectant management might be the most conservative therapy with few surgery-related complications if the candidate for expectant therapy can be selected. Esmaeillou et al [2] conducted this prospective interventional study to investigate the role of grayscale and color-Doppler transvaginal ultrasonography (TVS) findings in the management of first- and second-trimester miscarriages, and found the simultaneous presence of echogenic mass and vascularity was the most accurate diagnostic criteria [an accuracy rate of 88%, 95% confidence interval (CI) 79e94%], suggesting that there would be a
Conflicts of interest: All authors declare no conflicts of interest.
modest improvement (sensitivity of 88%, 95% CI 72e97%, and specificity of 89%, 95% CI 75e96%) if the two techniques (grayscale and color-Doppler TVS) were applied. Two-dimensional TVS has been thought to be a promising tool for the detection of RPOC, although necrotic decidual cells and blood clots may be very difficult to differentiate from RPOC. In addition, the value of grayscale TVS in the diagnosis of RPOC is still debated. For example, Abbasi et al [5] found that the presence of hyperechoic material on TVS is highly predictive of RPOC after spontaneous firsttrimester miscarriage, with a sensitivity of 78% and specificity of 100%, and Wolman et al [4] suggested 94% sensitivity with 98% specificity characterizes TVS as being a very efficient tool. Esmaeillou et al [2] also agreed that their study revealed that echogenic mass in grayscale ultrasound could be valuable in diagnosing RPOC. In the current article, Dr Esmaeillou highlighted the value of adding color-Doppler TVS to conventional twodimensional grayscale TVS in the detection of RPOC [2]. However, the usefulness of color Doppler in diagnosing RPOC is much more debated. Alca ´zar and Ortiz [6] found color-Doppler TVS useful for selecting patients for expectant management. Other studies found that color Doppler features of the uterus might be of practical value for the management of RPOC, however, the absence of blood flow does not exclude the diagnosis [7,8], suggesting that the addition of color Doppler TVS as an aid in the diagnosis of RPOC might not satisfy our current need. Given the above, is there any potential tool available to help make an accurate diagnosis of RPOC? All the following strategies might be possible, however, none of them has been confirmed. For example, serum b human chorionic gonadotropin (b hCG) levels could be checked, but they often contribute little to the diagnosis in the period immediately after abortion because serum b hCG levels tend to remain high during this period [4]. How about the value of hysteroscopy? Hysteroscopy, unfortunately, was shown to have a detection rate of <70%, as confirmed by histologic examination [9]. Although hysteroscopy alone might not be a good tool for the diagnosis of RPOC, the combination of TVS and hysteroscopy showed impressive results.
http://dx.doi.org/10.1016/j.jmu.2015.03.001 0929-6441/ª 2015, Elsevier Taiwan LLC and the Chinese Taipei Society of Ultrasound in Medicine. All rights reserved.
64 Investigators have been using sonohysterography as an accurate tool to diagnose RPOC with approximately 100% success rate [10]. However, sonohysterography requires additional equipment and considerable experience on the part of the examiner, and of most importance, it is an invasive procedure and is more costly and time-consuming than color Doppler TVS, a device that is available in almost every gynecologist’s office [4]. Thus, an 88% sensitivity with an 89% specificity characterizes color Doppler TVS as being a very efficient tool. This finding was published in the current issue of the Journal of Medical Ultrasound [2].
Acknowledgments Supported by grants from the Ministry of Science and Technology, Executive Yuan (MOST 103-2314-B-010-043 -MY3 to P.-H. Wang and MOST 103-2314-B-195-010 to C.-P. Chen), Taipei Veterans General Hospital (V102C-141; V103C-112; V102E4-003; and V103E4-003 to P.-H. Wang) and Mackay Memorial Hospital (MMH-E-103-04 to C.-P. Chen).
References [1] Su WH, Lee FK, Wang PH. Recurrent pregnancy loss and thrombophilia in women with PCOS. J Chin Med Assoc 2013;76: 243e4. [2] Esmaeillou H, Jamal A, Eslamian L, et al. Accurate detection of retained products of conception after first- and secondtrimester abortion by color Doppler sonography. J Med Ultrasound 2015;23:34e8. [3] Tsui KH, Li HY, Cheng JT, et al. Comprehensive treatment for interfile women with severe Asherman’s syndrome. Taiwan J Obstet Gynecol 2014;53:372e5. [4] Wolman I, Altman E, Faith G, et al. Combined clinical and ultrasonographic work-up for the diagnosis of retained products of conception. Fertil Steril 2009;92:1162e4. [5] Abbasi S, Jamal A, Eslamian L, et al. Role of clinical and ultrasound findings in the diagnosis of retained products of conception. Ultrasound Obstet Gynecol 2008;32:704e7. [6] Alca ´zar JL, Ortiz CA. Transvaginal color Doppler ultrasonography in the management of first-trimester spontaneous abortion. Eur J Obstet Gynecol Reprod Biol 2002;102:83e7. [7] Schwa ¨rzler P, Holden D, Nielsen S, et al. The conservative management of first trimester miscarriage and the use of colour Doppler sonography for patient selection. Hum Reprod 1999;14:1341e5. [8] Durfee SM, Frates MC, Luong A, et al. The sonographic and color Doppler features of retained products of conception. J Ultrasound Med 2005;24:1181e6. quiz 1188e9. [9] Zakut H, Achiron R. Intrauterine balloon catheter for ultrasound evaluation of pelvic masses. Enhancement of uterine localization. Gynecol Obstet Invest 1987;24:68e72.
Editorial [10] Zalel Y, Cohen SB, Oren M, et al. Sonohysterography for the diagnosis of residual trophoblastic tissue. J Ultrasound Med 2001;20:877e81.
Peng-Hui Wang* Department of Obstetrics and Gynecology, National Yang-Ming University School of Medicine, Taiwan Division of Gynecology, Department of Obstetrics and Gynecology, Taiwan Immunology Center, Taipei Veterans General Hospital, Taipei, Taiwan Department of Medical Research, China Medical University Hospital, Taichung, Taiwan Institute of Clinical and Community Health Nursing, National Yang-Ming University, Taiwan Chih-Yao Chen Department of Obstetrics and Gynecology, National Yang-Ming University School of Medicine, Taiwan Division of Gynecology, Department of Obstetrics and Gynecology, Taiwan Chih-Ping Chen Department of Obstetrics and Gynecology, National Yang-Ming University School of Medicine, Taiwan Institute of Clinical and Community Health Nursing, National Yang-Ming University, Taiwan Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taiwan Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan Department of Biotechnology, Asia University, Taiwan School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan *Correspondence to: Dr Peng-Hui Wang, Division of Gynecology, Department of Obstetrics and Gynecology, Taipei Veterans General Hospital and National Yang-Ming University, 201, Section 2, Shih-Pai Road, Taipei, Taiwan. E-mail addresses: [email protected], [email protected], [email protected] (P.-H. Wang) 2 March 2015