Case of the Week | Case of the Week - 11/12/10

Case of the Week - 11/12/10

by Administrator 16. November 2010 16:33

 HISTORY: 50 year old female with abnormal bleeding.  What procedure did she have before?  What is your diagnosis?

 

CASE OF THE WEEK ANSWER - 11/12/2010

 
Answer: Failed Prior Ablation with localized hematocolpos and hematosalpinx


This week virtually everyone replied with the correct answer so for educational purposes, I’m enclosing all of your comments here below, but of course I’m omitting your names. This is just to show how good you all are!

Endometrial ablation is a procedure that destroys (ablates) the uterine lining, or endometrium. This procedure is used to treat dysfunctional or abnormal uterine bleeding. The endometrium heals by scarring, which usually reduces or prevents uterine bleeding. Different procedures have been used and are all similarly effective for destroying the uterine lining tissue. These include laser beam, electricity, freezing, heating, or microwave energyLaser beam (laser thermal ablation).Now adays, by far the most common method is by radiofrequency ablation using the Novasure method (images below). This was approved by the FDA for use in the United States in 2001, so there is not a long history of understanding long term complications. Because the procedure can be performed in the physician’s office as an outpatient, it has become very popular in recent years.

Endometrial ablation is used to control heavy, prolonged vaginal bleeding when:
  • A nonpregnant woman does not plan to become pregnant in the future.
  • Bleeding has not responded to other treatments.
  • There is no obvious cause for bleeding like polyps or submucous fibroids.
  • Patients wish to avoid a hysterectomy.

Prior to the procedure, a woman needs to have an endometrial sampling (biopsy) performed to exclude the presence of cancer. Imaging studies (ultrasound) are necessary to exclude the presence of uterine polyps or benign tumors (fibroids) beneath the lining tissues of the uterus. Polyps and fibroids are possible causes of heavy bleeding that can be simply removed without the need for ablation of the entire endometrium. Obviously, the possibility of pregnancy must be excluded, and intrauterine contraceptive devices (IUDs) must be removed prior to considering endometrial ablation.

The majority of women who undergo endometrial ablation report a successful reduction in abnormal bleeding. Up to half of women will stop having periods following the procedure. However, studies have shown that 6% to 25% of women report that their heavy bleeding pattern was unchanged one year following the procedure, and some women will require further surgery (re-ablation or hysterectomy) to control the bleeding. About 10% of women who have endometrial ablation will eventually have a hysterectomy

Most complications of endometrial ablation which have been reported are immediate postsurgical complications. Relatively little has been published regarding longer term complications, especially in regards to ultrasound. However, remember the time of followup has been relatively short. There appears to be an increasing failure rate the longer the ablation has occurred. Patients with adenomyosis or those with other underlying reasons for bleeding also have a higher failure rate. Patients with uterine duplication also have a higher failure rate because of incomplete ablation.

The problem is that after this procedure, intrauterine scarring and contracture occur. Any bleeding from persistent or regenerating endometrium behind the scar may be obstructed and cause problems such as central hematometra, cornual hematometra, postablation tubal sterilization syndrome, retrograde menstruation, and potential delay in the diagnosis of endometrial cancer. The incidence of these complications is probably understated because most radiologists and pathologists have not been educated about the findings to make the appropriate diagnosis. We are seeing an increasing number of women who present 3 or more years following endometrial ablation with symptoms of pain, sometimes severe, usually not associated with bleeding. Many of these patients present with localized blood either within the uterine cavity or sometimes dissecting between the cavity. These patients have effectively have an iatrogenic cervical stenosis due to obliteration of the endometrium and uterine cavity, so that when bleeding does occur, it often remains localized, or dissects retrograde and can even form hematosalpinx, as in this case.

Novasure procedure showing 1)introduction of the metal sheath, 2) expansion of the sheath to result in contact with the endometrium, 3) radiofrequency which destroys the endometrium and 4) subsequent scarring and obliteration of the cavity.



Responses:
This looks like maybe "trapped" blood in the uterus, backing up into the fallopian tube. possibly failed ablation?
Procedure preformed: ablation
Diagnosis: failed ablation and hydrosalpinx
The procedure was an ablation.Failed ablation with retained blood and the blood is backing up into the fallopian tube causing a pyosalpinx.
I think she had an ablation with hematosalphinx and hematometrium
This pt had what appears to be a failed partial ablation. The bleeding she is having has spilled back into her tubes (hematosalpinx) as a result of the ablation not being completely successful
I would say she has had endometrial ablation that has failed. there is a large amount of blood with some clot in the fundal portion of the endometrium, also the video shows a dialated fallopian tube/hydrosalpinx
It looks like there is echoginc material in the endo most likely blood. Possibly from a failed ablation. Im not sure what the other image is of could be an echogeninc heterogenous mass at the posterior aspect of the ut or possibly even the tube
The patient had an endometrial ablation, which appears to have failed by the collection of blood in the lining. Also, it looks like an endometrioma vs. hemorrhagic cyst on the rt ovary, causing bleeding into the fallopian tube, hematosalpinx
Previous endometrial ablation and tubal ligation. Failure of the ablation could produce the abnormal intrauterine cavity with the appearance of hematometra and possibly residual endometrial tissue. The tubes are dilated due to retrograde flow from the uterus into the blocked tubes
I believe this patient had a previous endometrial ablation and may have some stenosis and a blood collection within the endometrial cavity.
Endometrial ablation with apparent infection. Tubovarian abscess
ablation i think, and it looks like pus in the tubes. the measurement made me think ovary, but i am leaning toward pyosalpinx.
Prior procedure endometrial ablation Diagnosis; failed ablation, haematosalpingitis pid
This appears to be a failed ablation of the endometrium. There appears to be fluid within the endometrial canal and the 2.5 cm solid mass appears to be a hematometra. There also appears to be hematosalpinx in the adnexa
I'm going with... one messed up ablation! Hematometrium in addition to cystic left ovary with hematoslapinx
It appears to be a failed ablation. There is blood seen in the endometrium and most likely seen backed up into the fallopian tube.
I have two possible diagnosis. 1) Failed ablation with hematosalpinx. 2) Prior procedure tubal ligation causing hematosalpinx with cervical stenosis causing blood to accumulate with in the endometrium
This one is tough. Did she have an endometrial ablation? It looks like she has hematosalpynx, and possibly a cystic teratoma (dermoid)??
Anyway, blood/fluid in endometrial cavity, failed endometrial ablation.
I think this patient had an ablation and the blood is backing up into the fallopian tube causing hematosalpinx on that side.


Answer: Failed Prior Ablation with localized hematocolpos and hematosalpinx      

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The goal of Fetal & Women's Center of Arizona is to provide the best possible service, using the best equipment and technology available, performed by highly skilled sonographers and interpreted by leading physicians in their field.  Case of the week is used for educational training purposes only.