0:01

This is a 21-year-old patient who

0:03

presented to the emergency room, soaking

0:05

a pad approximately every one hour.

0:07

She'd had a medically induced abortion

0:09

approximately two weeks prior.

0:11

Bleeding had pretty much stopped until

0:13

it repeated and got very intense.

0:16

So she started with her ultrasound imaging,

0:18

and you can see there's abnormal thickening

0:20

where we expect the endometrial stripe to be.

0:25

And it's very heterogeneous.

0:27

You can see normal, or more normal, occurring

0:29

endometrium up towards the fundus where the

0:31

normal thickness, it's very well defined.

0:33

You can see the interface between

0:35

the endometrium and the myometrium.

0:37

But as you come down here,

0:38

it's much harder to see that.

0:39

You have all of this echogenic material.

0:42

And then we lose the interface,

0:43

particularly right here, almost like

0:45

there's an attachment right there.

0:46

If you sat on this, you could see

0:50

if this is mobile or not to see what

0:52

part of this is blood or how much of

0:53

this is potentially

0:56

retained products of conception.

0:58

You can also do color Doppler flow to

1:00

see if there's vascularity to this.

1:01

If it's all hematoma, there should

1:03

be no color Doppler vascularity.

1:05

Whereas in this case, you can see

1:07

there's not only a lot of vascularity

1:09

internal within it, but almost all of the

1:11

vessels lead to this space right here.

1:15

So scroll through that.

1:16

And that corresponds to this area right

1:18

here where we lost that interface of the

1:20

endometrium and myometrium right here.

1:23

So this is going to be a diagnosed

1:25

residual fetal or placental tissue,

1:28

meaning retained products of conception.

1:30

So these can have a very variable appearance.

1:33

They're usually going to be heterogeneous

1:34

and echogenic, and that's going to be

1:36

the most accurate, but they're not always

1:38

going to be heterogeneously echogenic.

1:41

And again, you do have to remember there's

1:42

going to be blood product in there.

1:43

The patient comes in with vaginal bleeding.

1:45

So you kind of have to almost look around

1:47

that blood product, like the color Doppler to

1:49

help you with that too, because you can see

1:51

what sort of non vascular and sort of ignore

1:54

that part of it and look at the rest of it.

1:57

Most routine products will have vascularity,

1:59

approximately 79% or 80% of them.

2:02

You can also look for thickened stripe has

2:04

been reported of at least 10 millimeters,

2:06

but that's not highly supported.

2:07

And you can imagine if you have a lot of

2:09

blood product in there, you're going to

2:10

have a thickened stripe regardless there.

2:12

So that's kind of a confounders.

2:13

We have a lot of clots.

2:15

It's also important to know

2:16

that there's a significant false

2:17

positive rate with ultrasounds.

2:19

So this diagnosis is not based purely

2:21

off of imaging but is also clinical.

2:23

So the gynecology, our gynecology colleagues

2:26

may end up just watching and waiting on

2:27

some of these if clinically they don't

2:29

think it's necessarily routine products

2:31

to see if it resolves on their own.