Imaging of Acquired Uterine Lesions
1,3Department of Gynecology and Obstetrics, IVF Centre, ReMedika, Skopje, Republic of North Macedonia; Faculty of Medical Sciences, Goce Delchev University, Stip, Republic of North Macedonia
2Department of Obstetrics and Gynecology, School of Medicine, University of Zagreb, Zagreb, Croatia; University of Sarajevo, Sarajevo, Bosnia and Herzegovina; Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina
Corresponding Author: Zorancho Petanovski, Department of Gynecology and Obstetrics, IVF Centre, ReMedika, Skopje, Republic of North Macedonia; Faculty of Medical Sciences, Goce Delchev University, Stip, Republic of North Macedonia, Phone: +38972443114, e-mail: email@example.com
Received on: 21 October 2022; Accepted on: 28 October 2022; Published on: 26 December 2022
In general, the group of acquired uterine lesions consists of enhanced myometrial vascularity (EMV)/arteriovenous malformation (AVM), the isthmocele, intrauterine adhesions (IUAs) (Asherman’s syndrome), and nabothian cysts. Uterine AVMs can be congenital or acquired. These vascular lesions can cause severe hemorrhage that can be life-threatening for a woman, so it has been recently suggested that curettage should not be performed in a patient who presents with abnormal uterine bleeding after an abortion or a delivery when there is an ultrasound-detected hypervascular area with turbulent flow within the myometrium. Color Doppler sonography is the preferred method of diagnosing uterine EMV/AVMs. The isthmocele is a myometrial defect resembling a pouch on the anterior wall of the uterine isthmus over a previous cesarean scar. Transvaginal ultrasound (TVUS) is the initial and most usual method described to assess the integrity of the uterus wall in nonpregnant patients. IUAs are also known as intrauterine synechiae or endometrial sclerosis. The most common presentation of Asherman’s syndrome is secondary infertility. Two-dimensional (2D)/three-dimensional (3D) TVUS is useful in measuring the thickness of the endometrial lining. Also, together with or without sonohysterography (injection of sterile saline into the uterine cavity) can show the adhesions that characteristically appear as “bridging bands” of tissue that distort the cavity. Nabothian cysts are a common occurrence on the cervix. These are retention cysts of the endocervical glands caused by chronic inflammation. 3D ultrasonography gives an excellent image and the possibility of detecting nabothian cysts.
How to cite this article: Petanovski Z, Kurjak A, Kostova EP. Imaging of Acquired Uterine Lesions. Donald School J Ultrasound Obstet Gynecol 2022;16(4):298-303.
Source of support: Nil
Conflict of interest: None
Keywords: Color Doppler sonography, Enhanced myometrial vascularity/arteriovenous malformation, Intrauterine adhesions (Asherman’s syndrome), Nabothian cysts, The isthmocele, Transvaginal ultrasound, Three-dimensional ultrasonography
This paper has been previously published as Zorancho Petanovski, Asim Kurjak, Emilija Petanovska Kostova: Imaging of acquired uterine lesions. In: Petanovski Z, Kurjak A. 3D-4D Ultrasound in Gynecology. Jaypee Brothers, New Delhi, 2022, pp 58-64.
Enhanced myometrial vascularity (EMV)/AVM is a pathologic finding which shows the bloodstream between an organ’s arterial and venous supply so-called “short circuit.”1 Uterine AVMs can be congenital or acquired. Acquired lesions are believed to result from pelvic surgery, including diagnostic or therapeutic curettage,2 after unsuccessful pregnancy, cesarean delivery,3 cesarean section (SC) scar pregnancy,4 trophoblastic diseases, neoplasm, or infection.5 These vascular lesions can cause severe hemorrhage that can be life-threatening for a woman, so it has been recently suggested that curettage should not be performed in a patient who presents with abnormal uterine bleeding after an abortion or a delivery when there is an ultrasound detected hypervascular area with turbulent flow within the myometrium. Some authors, however, believe that this definition should include any detected highly vascularized map of blood vessels, even in cases of placental retention.6
Ultrasonography Characteristics of EMV/AVMs
Two-dimensional (2D) sonography has a limited role in the diagnosis of uterine EMV/AVMs and often shows an ill-deႡned uterine mass consisting of mildly echogenic tissue that is interspersed with multiple small hypoechoic spaces of varying sizes. Color Doppler sonography is the preferred method of diagnosing uterine EMV/AVMs.On color Doppler ultrasound, a uterine AVM appears as a hypervascular lesion with turbulent flow within the myometrium, so the use of blood velocity blood flow indices is useful to recognize this situation.6,7 The EMV/AVMs can be distinguished from subsequently enhanced myometrial vascularity (SEMV), pregnancy-related conditions using serum human chorionic gonadotropin measurement (Fig. 1).7,8
According to The International Society for the Study of Vascular Anomalies classification system, AVMs are clearly demarcated from vasoproliferative lesions of the uterus (uterine hemangioma and placental chorioangioma), which show increased endothelial cell turnover because they are neoplasms. Vascular malformations do not have increased endothelial cell turnover; rather, they are structural abnormalities of the capillary, venous, and arterial system.9
Enhanced myometrial vascularity (EMV)/AVM is a relatively rare pathological situation, and color Doppler is important in detecting this phenomenon.
The isthmocele is a myometrial defect resembling a pouch on the anterior wall of the uterine isthmus over a previous cesarean scar.10 The increase in the incidence of isthmocele is the result of an increase in the percentage of births by SC, which has been a trend over the last decades. The prevalence of isthmocele ranges from 24 to 70% in women with one or more previous SC.11 Several risk factors have been related to the development of the isthmocele; duration of labor (dilatation >5 cm is related to larger isthmoceles), dilatation, stage of the presenting part, a lower position of the cesarean section pregnancy (CSP) hysterotomy, surgical technique, concerning an incomplete closure of the uterine wall,12 and the single-layer myometrial closure appears to increase the risk of isthmocele development when compared to double-layer closure (Fig. 2).13 Early adhesion development in the hysterotomy scar with the anterior abdominal wall and patient individual/genetic predisposition to poor hemostasis, inflammation, or adhesion formation.14
In general, most isthmoceles are asymptomatic, being found incidentally on ultrasound. Gynecological complications of ishthmocele include abnormal uterine bleeding, postmenstrual spotting, dysmenorrhea, pelvic pain, and infertility15 or obstetric such as placenta accreta, placenta praevia, scar dehiscence, uterine rupture, and ectopic pregnancy in cesarean scar defects.16 All these say how important it is to detect isthmocele, not only because of the described possible complications but also to provide timely information to the patient on how to manage and carry on the next pregnancy.
Transvaginal ultrasound (TVUS) is the initial and most usual method described to assess the integrity of the uterus wall in nonpregnant patients. The defect has been described on TVUS as an anechoic triangle defect in the myometrium, with the base communicating to the uterine cavity or a deformity (wedge, shape, concavity, or sacculation) on the anterior isthmus (Fig. 3).17 Some authors classified the findings according to the size of the defect: a large defect is described as a myometrial reduction of >50% of the wall thickness18 or even >80% by some authors (Fig. 4).12,19 For management purposes, Marotta et al. adopted the cutoff of RM (remaining myometrial thickness) >3 mm for resectoscope treatment by hysteroscopy (Fig. 5).3 Diagnosis, when compared to the TVUS, saline infusion sonography (SIS) presented better results by detecting more defects and more often classifying them as larger on average of 1–2 mm.20 Gel instillation sonography also presents a higher prevalence in detecting the defect when compared to TVUS (49.6% against 64.5%).15
The increased incidence of SC also brings complications such as isthmocele. 2D and especially 3D ultrasonography gives a clear picture of the degree of the extensiveness of the defect itself and certainly in the risk assessment for the next pregnancy and the complications that follow it.
IUAS “ASHERMAN’S SYNDROME”
Intrauterine adhesions (IUAs) are also known as intrauterine synechiae or endometrial sclerosis, as should be defined by the presence of adhesions inside the uterine cavity and/or endocervix leading to clinical manifestations such as amenorrhea, hypomenorrhea, recurrent pregnancy loss, infertility, and a history of abnormal placentation.21 The most common presentation of Asherman’s syndrome is secondary infertility. These patients have a higher risk of recurrent miscarriages, second-trimester loss, preterm delivery, incompetent cervix, uterine rupture, and placenta accreta.22
Two-dimensional (2D)/three-dimensional (3D) TVUS is useful in measuring the thickness of the endometrial lining. Also, together with or without sonohysterography (injection of sterile saline into the uterine cavity) can show the adhesions that characteristically appear as “bridging bands” of tissue that distort the cavity. The bands may vary in thickness, but their echogenicity is usually the same as the echogenicity of the adjacent myometrium. According to the International Endometrial Tumor Analysis group scoring system, IUAs on ultrasound is seen as bands of myometrium tissue traversing the endometrial cavity and adjoining the opposing uterine walls. The bands may vary in thickness, but their echogenicity is usually the same as that of the adjacent myometrium.23 One of the typical ultrasound Ⴁnding is the presence of hypoechoic areas with interruptions of the endometrial layer (skip lesions representing entrapped menstrual blood or secretions from preserved functioning endometrium) and obliteration of the uterine cavity can be focal, partial, or complete (Figs 6 to 8).24
Three-dimensional ultrasound scanning can provide images for clinicians that are detailed and self-explanatory with information regarding the location and extent of cavity obliteration and obstruction.24 In addition, the extent of uterine cavity damage should be quantified by measuring the size of the obliterated area in the coronal plane and comparing it with the total surface area of the uterine cavity. This could be expressed as an obliteration ratio: obliterated area (O)/total cavity area (C) × 100 (%), where O is the obliterated area and C is the total cavity area (Fig. 5). The areas of obstruction could be described in a similar fashion, stating the level of obstruction and percentage of the uterine cavity involved. The same approach should be used for both preoperative assessments and following surgical division of IUAs adopted.23 A 3D-SIS has recently been proposed for the diagnosis of intrauterine lesions. 3D-SIS, carried out in combination with 3D power Doppler (3D-PD), was found to have sensitivity and specificity of 91.1 and 98.8%, respectively, for all kinds of intrauterine lesions, including synechiae.25
Even the experience of 3D ultrasound for the detection and evaluation of IUAs is limited, but some studies have suggested that it may be superior to hysterosalpingogram (HSG) for the detection of uterine intracavitary pathology.26
As for other classification scoring systems that use HSG and/or hysteroscopy as a method, there are several: The American Fertility Society devised a classification system that, for the first time, took into consideration the menstrual pattern as a prognostic marker.27 More recently, the classification scoring system included not only the menstrual symptoms but also the obstetric history of the woman.28
Nabothian cysts are a common occurrence on the cervix. These are retention cysts of the endocervical glands caused by chronic inflammation. They are generally small in diameter and completely asymptomatic, but large cysts may be misdiagnosed with other cervical pathology and even malignant neoplasms. Multilocular cervical cysts must be clearly differentiated, whether they are benign or malignant, because each glandular proliferation gives a multilocular picture.29,30
Three-dimensional (3D) ultrasonography gives an excellent image and the possibility of detecting nabothian cysts. Generally, these are cystic formations up to 4 cm that has hypoechoic density. In addition, detection of changes in intracystic space by this method is possible, and color Doppler will detect neoangiogenesis if it is present (Figs 9 and 10).31
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