Sonographic Evaluation of Postpartum Pain - HD

Sonographic Evaluation of Postpartum Pain

Hello, my name is Anne Kennedy.

I'm a professor of radiology at the University of Utah in Salt Lake City.

I'm going to talk about the sonographic evaluation of postpartum pain.

Because we're radiologists or I'm a radiologist and you all work in radiology departments, we do use multimodality imaging techniques, but I'm gonna show you ultrasound pictures and then maybe correlative CT and MRI as necessary.

First things first.

You may wonder why there's an x-ray on the first slide of a talk that says sonographic evaluation of postpartum pain.

However, I think it's important to remember that many, many people who've had a baby have musculoskeletal or myofascial pain and we count, always figure that out on ultrasound.

So in patients in whom you find nothing sonographic, it's worth remembering that there are other causes.

One of the things we need to decide what we're going to do is have aims for a talk and many people do not image patients who've just had a baby.

So it's important to understand what's normal in the immediate postpartum situation so that you can differentiate between that and what is abnormal.

And we're going to look at some of the common appearances primarily of the abnormal.

But I have a resource for normal findings and it's also important to understand that you can fall into traps and I'm going to illustrate a few pitfalls and interpretation of findings in the postpartum patient.

If you think about postpartum pain, this is the sort of slide that gives everyone a headache.

But it is important again to realize that you can have conditions relating to the immediate complications of the delivery to the uterus, ovaries and adnexa, to everything else that is in that woman's abdomen because people who've just had a baby can have appendicitis, people who've just had a baby can have a PE.

So you need to broaden your scope of thought and think about all of the potential causes of pain, not just things immediately related to the uterus and ovaries.

Wound Infection After Cesarean Section

One of the most important things after cesarean section is wound infection.

And there's a cute story that goes along with this image.

One of my younger sonographers had gone and done a portable study on this woman who was taken to ICU after a crash cesarean section.

The woman was extremely ill and we all worry about postpartum sepsis in that circumstance.

And when my sonographer came downstairs, she was very concerned about this appearance of high genicity speckles in the region of the cesarean section incision.

This is an appearance that can be concerning, but in this instance we went back up to the unit and we looked again and we were able to illustrate that each of these punctate echoes was in fact more linear.

This is longitudinal, this would be the fundus of the uterus.

This is coming down to the cervix and this is the area of the hysterotomy in transverse section.

Along that same area here you again see these linear bright echoes and this in fact is the suture material used to close the hysterotomy and not gas in the wound.

So it's important to be aware of the expected post-surgical changes.

This patient in fact was desperately ill and had an acute postpartum cardiomyopathy to which she succumbed, but she did not have postpartum sepsis.

In contrast, in this patient there was infection in the region of the cesarean hysterectomy and the abdominal wall incision.

So this is a CT scan and you can see that there are rim enhancing fluid collections both in the anterior myometrium and in the muscles of the abdominal wall.

And this patient had a debridement.

And two days later when we looked at the scar with ultrasound, which is what you have here, you'll note we're using a linear transducer because their clinical question was did they need to reopen the wound or not?

And this is a longitudinal view.

So this is the patient's head end, this is the patient's foot end.

This is the linear parallel echos that you see in the abdominal wall musculature and this is directly along the line of the scar and you can see that there's just an incision into the tissues and no longer any fluid collection.

A useful reference for the appearances of both normal and abnormal uterus after both cesarean and vaginal delivery is available here and it's current from Radiographics 2012.

And it is surprising just how abnormal the uterus may appear in someone who's had a cesarean section.

So again, you need to build your visual database of what are normal postoperative findings so that you can understand pathology.

Endometritis

Endometritis is very often a clinical diagnosis, but sometimes we are asked to evaluate patients.

This lady was 44 and had had a vaginal delivery after a very complicated pregnancy.

She'd been discharged and came back to the emergency room.

Febrile hypotensive generally extremely unwell on transabdominal scanning.

You can see here is the transducer footprint on the abdomen.

This is transverse through the uterus.

These very bright echoes in the uterine cavity with dirty shadowing beyond is highly suggestive of air in the uterine cavity and it's not abnormal to see a small amount of air, but this much is far too much.

You'll also note these areas of inhomogeneous mixed high and low level echoes that seem to be circular and cross-section.

And this lady, as I said, was 44 and she was known to have a fibroid uterus.

So part of the clinical concern was did she have infarcted fibroids or could she possibly have infection within infarcted fibroids?

We attempted a transvaginal ultrasound, which is what you see here, but the patient was unable to tolerate the placement of the transducer in the vagina.

This is the cervix, this is part of the anterior myometrium and again, you see all these bright sparkling echoes in the uterine cavity with distal shadowing and this is one of those areas of possible concern for infarction or infection in the myometrium because she was so ill, she went to the CT scanner and here is the large uterus.

Part of that is because she's postpartum.

Part of that is because she has multiple fibroids and you can see how low signal all of these areas are in the myometrium.

And here is the gas in the cavity on CT.

You'll also notice these multiple little areas of low attenuation in the liver.

And at the time we were very concerned about the possibility of hepatic abscesses, but it turned out that we had prior imaging and this lady and these were simple cysts and there is a condition called Fitz-Hugh-Curtis syndrome that I'll tell you more about later where people with pelvic sepsis get a secondary inflammation in the perihepatic spaces.

Ovarian Vein Thrombosis

Ovarian vein thrombosis occurs as a result of sepsis in the pelvis.

Very often these patients are very ill and some may have renal insufficiency, some may be unable to tolerate the contrast load.

So they're often evaluated by CT scan without intravenous contrast.

This patient had oral contrast so you can see all the white and the bowel loops.

Here's the spine posteriorly and normally we expect to see the confluence of the IVC and the distal aorta in front of the spine at this level, but there's this additional large mass here.

And one thing to remember is that the ovarian vein, although naturally a small vein is increased in size in pregnancy because 25% of the cardiac output goes to the uterus and therefore to the adnexa at the end of pregnancy.

So the vein enlarges and then when there is an area of septic thrombophlebitis, the vein enlarges even more.

So this large structure that you see anterior to the psoas muscle is indeed the ovarian vein.

Now because there's clot in the ovarian vein, it can extend to the draining vessels on the right.

The ovarian vein goes to the IVC on the left it goes to the left renal vein.

But in this case this is a CT scan and a slightly different patient who had intravenous contrast.

You can see down here there's a filling defect in the right renal vein and what happened is the thrombus from the ovarian vein extended into the inferior vena cava and from there into the renal vein, you'll also see that the kidney is edematous, it's swollen in comparison to the other side and it doesn't enhance symmetrically.

And this is the result of a partial renal vein thrombosis.

In this patient, she had septic ovarian thrombosis and had an infarction of her right ovary also had endometritis, so she ended up having a hysterectomy and a right salpingo-oophorectomy as a result of postpartum sepsis, again showing ovarian vein thrombosis.

And this is the correlation across modalities.

Here's a CT scan with the filling defect in a coronal reconstruction.

This is the contrast in the ovarian vein as it heads toward confluence with the IVC.

And here's the clot.

Here's a transverse section on MRI.

Here's the psoas muscle for orientation and here's the enlarged ovarian vein with a large filling defect within it.

If you try and scan from a more coronal approach, then you would normally you can scoot behind the bowel gas and look using the psoas muscle as a window and see at the enlarged ovarian vein anterior to the psoas.

And this is a coronal image.

So this is head end that is feet end of the patient.

These are the linear echoes again of the psoas muscle posteriorly.

And here is the lumen of the vein, which is distended with a large irregular clot.

And there isn't anything that you can use specifically on ultrasound to tell you that it's an infected clot, but usually the ovarian vein thrombosis happens as a consequence of septic conditions.

And it's a septic thrombophlebitis so Fitz-Hugh-Curtis syndrome.

Fitz-Hugh-Curtis Syndrome

This syndrome was described initially in people with sexually transmitted diseases and people with infection in the pelvis get peritoneal spread.

It's thought, although there may be component of lymphatic or hematogenous spread and it's an exaggerated immune response.

And what happens is that the perihepatic tissues become acutely inflamed.

Many times that dominates the clinical presentation and the patient comes in with right upper quadrant pain.

There's a friction rub on auscultation.

There may be ascites or a pleural effusion as a result of irritation of the pleura or peritoneum.

And it's important to think about this because many postpartum patients who come in with right upper quadrant pain may have had abnormal bile metabolism during their pregnancy.

And the assumption is that they have either gallstones or acute cholecystitis.

And of course in patients with preeclamptic toxemia in their pregnancy, they are at risk for subcapsular hematomas or spontaneous rupture of the liver.

So if you see a postpartum patient who presents primarily with right upper quadrant pain, remember always to check the pelvis as a source of inflammation.

Group A Streptococcal Infection

Peripheral sepsis was a major killer of women in Victorian times.

And it's interesting to notice that when the population moved from being largely agricultural and moved into the cities at the time of the industrial revolution, women began to be delivered in hospital because they didn't have the network and the community midwives and it was there that they started dying.

And it turns out of course that it was because they were delivered by doctors who came straight from the autopsy room where they did autopsies in people who had died of multiple infective conditions.

And this predates the use of gloves or even regular hand hygiene.

Thankfully we have moved on from there and we know better now.

But group A streptococcal infection is still extremely virulent.

And this is an example of how aggressive this condition can be.

This young woman had a vaginal delivery which was uncomplicated.

She had a very mild fever at the day of her discharge, but she was sent home.

Her husband went to the grocery store, came back and found her unresponsive, brought her back to the hospital where she had delivered and she was admitted and given intravenous fluid a CT scan was performed and she continued to deteriorate.

So she eventually was transferred to our ICU where she was intubated, required intense fluid resuscitation and pressure support.

The MFM people that I work with asked us to do an ultrasound that morning in ICU prior to them going to the operating room because they clinically had diagnosed that she had postpartum sepsis.

They just wanted to have an idea of how large the uterus was.

At the same time as this was going on, we were looking at the CT scan that had been performed in the referring hospital and it actually showed extensive necrosis of the uterus with a lot of high attenuation fluid in the abdomen.

And here on the ultrasound what you see is this is the normal posterior myometrium, this is the endometrial cavity with hypoechoic material in it and a certain amount of that is normal in the postpartum setting.

But look at the anterior myometrium here.

There's loss of the normal echogenicity all the way through and this is endometritis with inflammation extending into the muscle of the uterus basically causing uterine necrosis.

You will note this is the bladder.

So there is free fluid both anterior and posterior to the uterus and it's echogenic, which implies it's particulate.

We usually think about this in the context of ectopic pregnancy as being blood, but echogenic fluid can be pus as well because the white cells contribute to those punctate echoes that you see.

And in fact at the time of her hysterectomy, she had a liter of pus in her abdomen but she lived to tell the tale moving on from sepsis.

Hematomas in Postpartum Patients

Bladder Flap Hematoma

There are many types of hematomas that occur exclusively in the pregnant population and one important one to be aware of is the bladder flap hematoma.

So when a cesarean section is performed, there is a transverse lower uterine incision and this goes from side to side and most of the major amount of venous blood in the postpartum or pregnant patient is in the ovarian plexus.

So if there is a slow ooze from a vein following the surgery, blood accumulates anterior to the myometrium behind the bladder and often off to the side of the uterus, which makes the collection sort of eccentric in location.

This is ultrasound transvaginal.

This is the fundus of the uterus.

This is the region of the cervix.

This is the endometrial canal and here is this hematoma.

Note that it looks exactly like a hemorrhagic cyst.

The ovary and the muscle is intact.

Here's a transverse image and in fact the uterus is off over here.

And we're centering on this collection which is lateral to the uterus.

You have increased through transmission showing that it is in fact probably just a simple gelatinous clot and there's increased through transmission illustrating the ovarian plexus, which is the source of the hematoma.

This is a CT scan in a similar patient and I've tilted the image to show you the same orientation.

So this is uterine fundus.

These are bowel loops, this is the lumbosacral spine.

Here's the uterus, here's the bladder, here's pubic symphysis.

And here trapped between the bladder and the uterus is that hematoma and it accumulates in this space and is walled off.

It can become secondarily infected but more commonly it's just a source of pelvic pain.

And the importance of this is that you need to recognize that this does not represent uterine rupture or dehiscence.

It's simply a hematoma at the site of the C-section scar and will generally resolve without additional treatment.

Subfascial Hematoma

A subfascial hematoma extends up in the anterior abdominal wall.

So this is transverse and this is longitudinal.

You see the curved six footprint.

The uterus is big, it's immediately postpartum.

And here's this fluid collection.

And again, if this is very uncomfortable for the patient, you can put a needle in under ultrasound guidance and drain it.

And certainly if there's concern for infection in the hematoma, you can aspirate some to see.

Rectus Sheath Hematoma

One thing that we don't always think about in the pregnant population is the location of the inferior epigastric artery.

All of you that do paracentesis know that we're very careful in the population with liver disease or who have cancer and have recurrent ascites as a result of that, that when we do therapeutic paracentesis, we check to make sure that we don't puncture an abdominal wall vessel.

This is a person who had a lung maturity amniocentesis and this is rectus sheath hematoma and we didn't really need ultrasound because the patient was acutely symptomatic as soon as the needle was withdrawn.

But if there are any questions, get out the linear transducer and focus on the anterior abdominal wall.

If you don't see anything with your deeper search, this is another young lady who became acutely ill and developed DIC, which is disseminated intravascular coagulation.

And this is actually in the right upper quadrant.

This is her kidney, which you do see hydronephrosis.

And in her, although this is quite marked, it was attributed to just the physiologic dilatation of pregnancy.

But around the kidney there is this mixed echogenicity collection with increased through transmission.

Here is a longitudinal image.

This is the kidney head feet, this is the liver and you can see fluid in the perihepatic space or a Morrison's pouch.

And we don't know why this woman developed this large retroperitoneal hematoma, but here is another case, similar appearance, extensive retroperitoneal hemorrhage and this lady had bilateral rectus sheath hematomas two.

So in the patient with acute postpartum sepsis, often you have coagulation problems as well and if there is a large bleed and a lot of replacement product that can exacerbate the tendency to bleed.

Uterine Dehiscence and Rupture

Moving on to dehiscence and rupture, this was the important thing to be aware of and look at the difference in the appearance here.

This is a transabdominal scan.

This lady had had VBAC and was very pleased.

She did however, have to have manual extraction of the placenta and she came back a week postpartum was torrential vaginal bleeding.

And what you can see here is this is colored showing perfusion of the anterior myometrium.

This is the endometrial cavity and this is clot and you can see that there is direct continuity between the inside and the outside of the uterus here.

And the hematoma is centered in the myometrium at the site of the cesarean hysterectomy.

Here's to show you what it looks like in the pregnant patient with dehiscence.

So in dehiscence, the uterine scar is intact and the uterus is essentially held together just by this very fine serosal membrane.

So this is transabdominal, this is the cervix, this is the bladder, this is baby's head.

And you see the discontinuity between the stroma of the anterior lip of the cervix and the myometrium in the anterior uterus on endovaginal ultrasound, same thing, anterior lip of cervix baby head.

This is the neck of the bladder and there's discontinuity of the myometrium here.

So this is where you'll see the hematoma in the postpartum patient like this.

Just for correlation, this is another patient that came through the emergency room and we had this term of SGO, which is something going on.

This lady was very sick, she was also extremely obese in a very difficult clinical exam.

We attempted ultrasound and struggled because the patient was so tender she couldn't really tolerate either transabdominal or vaginal ultrasound.

And on the CT scan you can see that there's a fluid collection within the uterus which has extended to the side heading off toward the broad ligament.

And this again is uterine rupture in the postpartum state fibroids, everybody out there knows that lots of women have fibroids.

Fibroids in Postpartum

They may get large in pregnancy and they may undergo a condition called red degeneration, which is acutely tender and they even can become secondarily infected, although that's relatively uncommon in this case, we have a helpful fetus pointing at the source of his mom's pain.

But in the postpartum circumstance we don't always have little helpers like that.

So here's the transabdominal scan.

This is the uterus and you can see the claw sign of the myometrium and circling this low level echogenicity collection.

And you can put color doppler on and see branching vessels coming from the uterus to the adnexal mass to prove that it's myometrial in origin.

This is easier than this kind of condition where you have a complex adnexal mass.

If you can find an ovary separate from this, you can be comfortable that this is not an ovarian tumor.

But if you can't it can be very confusing and it's difficult to know if you have an infarcted fibroid versus perhaps ovarian torsion with a mass.

And in those circumstances, MRI can be very helpful because you can identify a normal ovary based on the follicles and you can show that these lesions extend out of the myometrium and are indeed fibroid in origin.

Ovarian Conditions in Postpartum

Moving on to the ovary, we all know that hemorrhagic cysts can look like anything and it's important to remember that no matter what you are doing or what patient you're seeing, a common condition is more likely than a rare condition and an unusual manifestation of a common condition is still much more likely than a zebra.

And this reference talks about the different appearances of the hemorrhagic corpus luteum and it's quite useful to develop a visual database.

In this case, you can see that there is a lumpy nodular mass inside this cystic component in this ovary that's atypical for hemorrhage.

Hemorrhage usually makes linear interfaces, but there was no internal flow.

There was acute onset of pain, there was flow in the periphery of this ovary.

So we decided to wait rather than intervene.

And in fact, six weeks later this was completely resolved and it was indeed an atypical hemorrhagic cyst without evidence of torsion.

Here on a CT scan you can see an adnexal cyst on the right and a little enhancing thing on the left.

Now normal corpus luteum can do this on CT, but continuing looking, note that there's a filling defect in the left ovarian vein and a filling defect in the right ovarian vein.

And in fact, this patient had low grade postpartum sepsis, had developed a bilateral mild septic thrombophlebitis and this was in fact a hemorrhagic involvement of the ovary secondary to impaired drainage by the clot.

Ovarian Torsion

Ovarian torsion happens in pregnancy at two times.

The first is when the uterus ascends out of the pelvis and rotates an adnexal mass on its way out.

The second is after delivery.

The uterus has to involute and go back down into the pelvis and that's the second time when an adnexal mass may twist as the uterus involutes and goes down back into the true bony pelvis.

Same characteristics as you see in the non-pregnant patient.

This is an enlarged ovary with stromal edema and peripheral follicles.

And here's the whirlpool sign of the rotated vessels of the torsion itself.

Subcapsular Hematomas in HELLP Syndrome

In patients with preeclamptic toxemia and HELLP syndrome, which is hypertension, elevated liver function tests and low platelets, there is an increased risk for subcapsular hematomas around the liver.

These patients are often acutely ill and in the intensive care unit, so we can go to them and this is what you would expect on a patient with a subcapsular hematoma on ultrasound.

The liver exhibits mass effect secondary to this collection that is encasing it and there's an associated pleural effusion on this patient.

Here's similar appearance on CT and you see the mixed echogenicity of the fluid because some of it is solid clot, some of it's the serous supernatant.

Uterine Inversion

A condition that's rare but important to recognize is uterine inversion and I don't actually have a case.

So I pull this one off the internet and my first response looking at images like this, which are transabdominal, is that oh, one of the residents had the transducer upside down because this is the bladder, therefore the uterine fundus should be here, but it's actually down here.

And when you look in transverse section again you go, oh yeah, there's a uterus, it's big, the lady just had a baby, but it has this sort of donut or target appearance and it's because the uterus has essentially turned inside out just like a sock.

This is extremely painful for the patient because it compromises the blood supply and is an emergency to get reduced as soon as possible.

And this article explains it very nicely.

I recommend that you will read it.

This is an intraoperative photo of a similar situation and again, this is a low transverse abdominal incision.

This is the retractor pulling back the tissues of the abdominal wall and where you would expect to see the uterine fundus sitting looking at you.

You see the inside out sock appearance because the uterine fundus is inverted and is actually facing down into the vaginal canal.

Retained Surgical Items

Moving on to more chronic pain.

You always have to remember in people who've had an operative delivery that there may be some sutures or swabs or even surgical implements remaining.

We have come a long way in trying to avoid that and everyone does their timeouts and their instrument counts and sponge counts.

But this is a nice article that shows you the appearances of the pieces of stuff that are as they are on the tray in the operating room and then what they look like on x-ray.

In the ultrasound world, I actually have never seen a patient with a retained sponge.

I have seen them on x-ray, but I found this example again on the internet and it makes sense because anytime that there is something abnormal in the body, your body's response is to wall it off and just have it be sequestered.

And anywhere where there is sequestration or scar tissue in the body and stasis there tends to be calcification.

So this is the appearance on a transverse view through the liver.

This is the IVC over here for orientation and this dense calcification is the rim of the organized fibrous tissue that has walled off that sponge to prevent it from going and wandering about in the peritoneal cavity.

Endometriosis

Endometriosis of course is common and people who have endometriosis in one place often have endometriosis in others.

And it may be that your patient who had a baby has perhaps forgotten that she had chronic pelvic pain before or maybe she has come back and it's worse.

And what you have to think about is that the classic endometrioma appearance, which we all recognize in the ovary is not the only manifestation of endometrial cysts.

And the thing to look for are endometrioid implants.

So just as when you're looking for an appendix on ultrasound, if you ask the patient where is the pain and you focus on that area, you may be able to see lesions such as this.

This little soft tissue nodule was very persistent on the anterior bladder wall and this is an endometrioid implant.

Similarly, here's another one that's older, it's got some punctate calcifications with it.

There's no internal flow, it doesn't look like a soft tissue tumor and it's on the wall of one of the hollow organs and that's a classic place to find endometrial implants.

There are several references here that you can use to see pictures of similar stuff.

This was a young lady that came to us actually from our sarcoma surgeons and she had a palpable mass in her lower anterior abdominal wall and it was tender when we did the ultrasound.

And you'll note that we had the linear transducer here so that we get great resolution of the soft tissues.

We noted that she had a scar and she had had a cesarean delivery some years earlier.

So we invoke the possibility of this being an endometrial implant.

She also had an MRI of the abdominal wall because that's often how the surgeons evaluate the extent of soft tissue sarcomas.

And you'll see that this is a very irregular, quite nasty appearance on the T2.

It's distorting the surrounding fat on T1.

It's not high signal.

After the contrast administration, there is some enhancement in the area and when we use MR for an endometrioma in the ovary, it's very helpful because we can see high signal from the blood products.

But in endometrioid implant, the primary thing that's going on is a soft tissue fibrotic reaction and we don't always see that.

So we biopsied it with ultrasound and we prove that it was an endometriosis implant with scarring and fibrosis.

And interestingly enough, when she knew that it was not a tumor, a lot of her symptoms resolved and we saved her an extensive resection of tissue.

Other Surgical Complications

Other surgical complications to think about.

This lady had a horribly horrible experience with her delivery.

She required a crash C-section, she was desperately ill.

She ended up having a plain film of the abdomen following intravenous contrast as a sort of mini IVP and you can see here there's hydronephrosis on the right.

The ureter comes down into the pelvis, it's dilated, but it actually is normal caliber lower down at the level of the UVJ and the other kidney drains fine.

You may end up seeing these people in ultrasound when you're asked to do an ultrasound because their urine output is decreased or their creatinine is elevated.

She had a CT scan his dilated loops of bowel with ileus, his extensive amounts of free fluid in the abdomen.

Here's the hydronephrosis on the right and down in the right hemipelvis there's this large enhancing mass.

And so the question we had is, well, could this be a pseudoaneurysm or an AV fistula that someone had a crash C-section?

Is it possible a vessel was nicked?

And the surgeons weren't terribly happy with us for suggesting that and they said that couldn't possibly be the case, but we continued to worry.

She was in the ICU, she was treated aggressively with antibiotics and her overall condition improved, but she developed walled-off abscesses and my IR colleagues were consulted to place a drain.

And again, they found this large thing in the pelvis and funnily enough, the ureter couldn't drain because of this big vascular structure.

So we persuaded the clinical team to allow us to investigate that further.

And here is the angiogram.

And this is a pseudoaneurysm with some AV shunting with early filling of the vein.

So this was embolized and in fact this was far more important as a potential risk of catastrophic hemorrhage in the pelvis rather than just obstruction to drainage.

IUD Complications

In the further out postpartum condition, many women will have an IUD placed so that they don't get pregnant again immediately.

Sometimes placing the IUD in the immediate postpartum period makes you an increased risk for complication because the uterus is larger and softer.

This is a 3D reconstruction and you can see this is the endometrial cavity, this triangle, you would want the side arms of IUD to be sitting up here in the cornua and in fact they're low in the uterus and penetrating the myometrium on both sides.

So this is a source of pain for the patient.

Here's also using 3D, but rather than doing the surface reconstruction, you do a series of slices.

Here is the endocervical canal going up into the endometrial cavity.

And here is the IUD penetrating the myometrium of the posterior lip of the cervix and the posterior uterine body.

So these are both potential sources of pain.

Unusual Case: Abdominal Pregnancy

And lastly, I'm going to show you this very unusual case.

This is a woman who was referred to us at 24 weeks with an abdominal pregnancy.

And indeed the baby was in the peritoneum, not in the uterus.

And there were three separate chunks of placenta, which we did an MRI to map in an effort to help the MFM docs figure out how they were going to get the baby out when the time came.

Luckily for her, she was safely delivered of a live baby and the placental tissue was left in situ because it was impossible to consider how you would dissect it off of the psoas muscle, out of the abdominal wall and off of the greater omentum and colon.

Early on, this was the appearance, there was still perfusion of these placental tissues and you'll see how it's adherent to the colon here.

Over time, it involuted and shrunk down to this mass and she had chronic pain and there were several people who felt that perhaps she was drug seeking.

But eventually one of our gynecologists who specializes in pelvic pain said, look, her pain localizes to the anterior abdominal wall.

She's got this thing, let me resect it.

He did and her pain was cured.

So you're probably never gonna see one of these, but it's an interesting story.

Chronic Pain and Conclusion

Last but not least, if you see these women and you've evaluated everything you can evaluate with ultrasound and you still can't find anything, remember there is myofascial pain and orthopedic causes of pain and the patients may be very helped by a course of physical therapy.

And as we move towards using ultrasound more for musculoskeletal evaluation, there may be things that we will look for using our linear transducers and approaching some of the bony structures in addition to the uterus and ovaries.

This is important because everybody tells you what to expect when you're expecting.

Nobody tells you that you might hurt after baby.

And if we have moms who are looking like this rather than like this, we need to try and help them so that they can move on with a very important job of raising those children.

Thank you.