Arthur C. Fougner, MD

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Our patient was a 27-year-old gravida 1 para 1 female complaining of lower abdominal and pelvic pain. Ten days prior to this presentation, she was seen in the Emergency Department, where a CT scan suggested a small hemorrhagic ovarian cyst. She reports to us that she has been getting some relief with ibuprofen but still has persistent pain.

Her pelvic examination was unremarkable save for an IUD thread visible at the cervical os.[[{"type":"media","view_mode":"media_crop","fid":"27536","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_6806895681656","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2697","media_crop_rotate":"0","media_crop_scale_h":"200","media_crop_scale_w":"325","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"line-height: 1.538em; float: right;","title":"Figure 1. This 2D image shows a displaced IUD.","typeof":"foaf:Image"}}]]

A transvaginal ultrasound with 3D volume (Voluson S8, GE Medical Systems) was performed. Both ovaries appeared normal, with apparent interval resolution of the hemorrhagic cyst that had been seen on the previous CT scan. A ParaGard IUD was seen displaced inferiorly into the uterine isthmus and upper cervix (

The 3D-rendered image demonstrated that the IUD not only was displaced but also was embedded (

).[[{"type":"media","view_mode":"media_crop","fid":"27537","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_8427162514999","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2698","media_crop_rotate":"0","media_crop_scale_h":"338","media_crop_scale_w":"325","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"line-height: 1.538em; float: right;","title":"Figure 2. This 3D image clearly shows the IUD is also embedded.","typeof":"foaf:Image"}}]]

This case clearly highlights the utility of 3D ultrasound in the localization of intrauterine devices. While displacement was clear from the initial 2D image, the 3D-rendered image clearly demonstrated the extent of this patient’s problem.

It has been noted that 75% of patients presenting with pain or bleeding with an IUD in situ had a malpositioned IUD.

 Moreover, the degree of malpositioning was often only seen in the coronal plane of the 3D volume.

As our case demonstrates, 3D volume ultrasonography should be the modality of first choice in monitoring patients with an IUD.

1. Benacerraf BR, Shipp TD, Bromley B. Three-dimensional ultrasound detection of abnormally located intrauterine contraceptive devices which are a source of pelvic pain and abnormal bleeding. 

. 2009;34(1):110-115. doi: 10.1002/uog.6421.

Articles

This case demonstrates the utility of 3D ultrasound, using the coronal plane as a reference point, for patients with an IUD who have pelvic pain.

Coronal Plane and 3D Imaging Key for IUD Complications

Uterine arteriovenous malformations (AVMs) are rare lesions that can be congenital or acquired. The acquired form is most often associated with trophoblastic disease or uterine surgery. Ginsberg and colleagues¹ described a case following a suction curettage for a missed abortion in which the diagnosis was made by sonography and color Doppler imaging. Recently, we had a case of placental polyp following suction curettage for missed abortion with very similar ultrasound and color Doppler findings in which saline sonohysterography hinted at the true pathology.

Our patient is a 36-year-old woman P1021 evaluated for acute pelvic pain. She had had a dilatation and evacuation for a missed abortion at 13 weeks one month prior to presentation, where she described crampy pelvic pain since the procedure. She gave no history of vaginal bleeding, observing that bleeding seemed “unusually light.” Ultrasound was performed, revealing a slightly hyperechoic area in the central uterus with prominent cystic spaces (

). On power Doppler, these cystic spaces represented increased vascularity with prominent tortuous vessels.

Because of uterine tenderness on exam, a diagnosis of endometritis was entertained and the patient was given antibiotics. The differential diagnosis of the vascular lesion included an unusual appearance of retained products of conception, acquired uterine arteriovenous malformation or, less likely, trophoblastic disease.

The following week, ultrasound was repeated, again demonstrating hypervascularity. Pulsed Doppler of the lesion revealed a peak systolic velocity of 63.8 cm/sec and resistive index of 0.29. Introduction of saline into the uterine cavity suggested the existence of a plane of cleavage (

), favoring a diagnosis of a broad-based placental polyp rather than an AVM. Serum beta-HCG was 43 IU/mL, also favoring retained products. A repeat suction dilatation and curettage was performed. The final pathology report confirmed products of conception.

Uterine AVMs involve abnormal vascular connections and usually present as abnormal, sometimes catastrophic bleeding. Because they rarely are found in women who have never been pregnant, pregnancy seems to play a role in their formation. Since the 1990s, color Doppler has supplanted arteriography as the primary diagnostic modality in these cases. Kido et al² reported a case in which the sonographic and Doppler appearance of retained products of conception were identical to that of AVM. MÃ¼ngen³ opined that arteriography should be more widely utilized prior to definitive therapy.

In our case, because the relationship of the lesion to the uterine cavity was not clearly delineated, we performed saline instillation. The contrast provided by the saline suggested a plane of cleavage, which led to the correct diagnosis and therapy. Moreover, saline instillation is less invasive than arterial catheterization and does not involve ionizing radiation. We would suggest that when the diagnosis of uterine vascular lesions is uncertain, saline instillation sonohysterography should be considered.

1. Ginsberg NA, Hammer R, Parikh S, et al. Arteriovenous malformation of the uterus associated with a missed abortion. 

2. Kido A, Togashi K, Koyama T, et al. Retained products of conception masquerading as arteriovenous malformation. 

3. MÃ¼ngen E. Vascular abnormalities of the uterus: have we recently over-diagnosed them? 

Postabortal placental polyps and uterine arteriovenous malformations can look identical on ultrasonography. Read how saline instillation sonohysterography helped discern the diagnosis.

Postabortal Placental Polyp or Uterine AVM? Saline Instillation Sonohysterography as a Diagnostic Aid

 in 1898, angular pregnancy is still a relatively unknown entity. Angular pregnancy is defined as a pregnancy implanted in one of the lateral angles of the uterine cavity. It has been classified as ectopic, nearly ectopic, or intrauterine. Unlike an interstitial pregnancy, which implants in the intramural portion of the fallopian tube, an angular pregnancy can progress to term. However, 38% terminate spontaneously in miscarriage. Moreover, there is also an increased risk for both placenta accreta and uterine rupture.

Some authors have even suggested that angular pregnancy is a misnomer and that the term should not be used.

 We disagree and present a case of angular pregnancy, which was diagnosed with three-dimensional multiplanar ultrasound.

Our patient RV is a 36-year-old woman P0000 who presented with a 5-week history of amenorrhea and pelvic pain. She had been to the ED, where an ultrasound revealed no evidence of either adnexal mass or an intrauterine gestational sac. Her beta hCG titer was 450 mIU/mL. Because her clinical condition was stable, she was referred to her ob/gyn for further management.

Pelvic examination four days later was again unremarkable. Serial beta hCG levels were 1065 mIU/mL and 1310 mIU/mL respectively. A transvaginal ultrasound with three-dimensional multiplanar imaging was performed, which revealed a 4-mm gestational sac-like structure implanted eccentrically in the right decidual angle (Figure 1). 

Because the sac was intrauterine, the patient was followed expectantly, and a subsequent ultrasound demonstrated slow growth in the gestational sac. The patient then reported increasing vaginal bleeding and another sonogram demonstrated again a markedly eccentric (but still contiguous with the decidua) gestational sac (Figure 2). The poor progress in the growth of the sac and the increase in vaginal bleeding prompted the diagnosis of a pathologic pregnancy. [[{"type":"media","view_mode":"media_crop","fid":"24315","attributes":{"alt":"","class":"media-image","id":"media_crop_4406307945027","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2082","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"line-height: 1.538em; height: 350px; width: 575px; border-width: 5px; border-style: solid; margin-top: 10px; margin-bottom: 10px;","title":"Figure 2","typeof":"foaf:Image"}}]]

The location of the gestational sac raised the possibility of angular pregnancy. For these reasons, the patient received intramuscular methotrexate and, subsequently, expelled products of conception two days later.

 described two cases in 1934 as “examples of that rare variety of gestation designated ‘angular’ pregnancy, which we are inclined to think has never received sufficient recognition as a definite clinical entity.” In fact, angular pregnancy appeared even earlier in Kelly’s 

 Despite this, the mention of angular pregnancy usually results in blank looks and quizzical expressions. It is nowhere to be found in many modern textbooks. Jurkovic,

 in fact, opined that the term should be discarded as a historical relic.

Another confounding factor is that the terms cornual, interstitial, and angular are lumped together as simply cornual. In fact, a cornual pregnancy is simply pregnancy in one horn of a bicornuate uterus.

 Once we limit the use of cornual, we are left differentiating interstitial, always ectopic, and angular, which can behave as ectopic.

Anatomically, the feature that distinguishes the two is the relationship between the pregnancy and either the uterine cavity or, at laparoscopy, the round ligament. Angular pregnancy implants in the angle of the uterine cavity, while the interstitial pregnancy implants just laterally. At laparoscopy, the “bulge” of angular pregnancy is medial to the round ligament, with interstitials being lateral. With our case, the early manifestation within the decidua, best seen in the coronal plane of the three-dimensional ultrasound along with the pattern of growth, were keys to the diagnosis.

While the diagnosis can be made early by ultrasound, as the pregnancy grows and the sac expands, diagnosis becomes progressively more difficult. Recently, MRI has been utilized in some of these cases.

 As the difficulties with diagnosis increases, so do the difficulties with management. Although expectant management can be successful, the desire for a wanted pregnancy must be balanced with the risk of catastrophic rupture. In our case, the patient’s clinical signs and symptoms led to the appropriate management.

So, is the angular pregnancy intrauterine or ectopic? Jansen

 offered that angular pregnancy does not seem to be a part of the pathologic continuum of the ectopic pregnancy. Our feeling is that the answer to that question should be both.

 Vol II. New York, Appleton, 1898, pp 448-449.

2. Jansen RP, Elliott PM. Angular intrauterine pregnancy. 

3. Jurkovic D, Mavrelos D. Catch me if you scan: ultrasound diagnosis of ectopic pregnancy. 

4. Kerr JM, Anderson DF. Angular pregnancy: a clinical entity. 

5. Tarim E, Ulusan S, Kilicdag E, et al. Angular pregnancy. 

This case report features an underappreciated clinical entity-angular pregnancy. What do you know about this rare obstetric complication?

Author | Arthur C. Fougner, MD

Articles

Coronal Plane and 3D Imaging Key for IUD Complications

Postabortal Placental Polyp or Uterine AVM? Saline Instillation Sonohysterography as a Diagnostic Aid

Diagnosis of Angular Pregnancy With 3D Ultrasound