Wo m e n ’s I m a g i n g • R ev i ew

Plunk et al.
Imaging of Postpartum Complications

Women’s Imaging
Review
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Imaging of Postpartum
FOCUS ON:

Complications: A Multimodality
Review
Matthew Plunk1 OBJECTIVE. The purpose of this article is to review common and uncommon compli-
Jean H. Lee cations of postpartum and posttermination patients and their imaging findings. A variety
Kimia Kani of imaging modalities, including ultrasound, CT, MRI, and angiography, will be presented.
Majiri Dighe Knowledge of the spectrum of normal and abnormal imaging findings as well as recognition
of the common and uncommon complications are essential for accurate diagnosis.
Plunk M, Lee JH, Kani K, Dighe M CONCLUSION. Obstetric complications are a common source of morbidity and mor-
tality for women of reproductive age. Imaging, particularly with ultrasound, is often supple-
mentary to the clinical history and examination in assessing and treating women during the
postpartum period. Radiologists should be familiar with the common abnormalities that pres-
ent in this period and their imaging findings, as well as the wide range of normal appearances
the postpartum uterus can assume.

Keywords: accreta, cesarean, endometritis, postpartum,
retained products of conception
DOI:10.2214/AJR.12.9637
Received July 17, 2012; accepted after revision
September 12, 2012.
1
All authors: Body Imaging Section, Radiology Department,
University of Washington Medical Center, 1959 NE Pacific
St, Box 357115, Seattle, WA 98195-7115. Address
correspondence to M. Plunk (mrplunk@uw.edu).
CME/SAM
This article is available for CME/SAM credit.
WEB
This is a Web exclusive article.
AJR 2013; 200:W143–W154
0361–803X/13/2002–W143
© American Roentgen Ray Society
T
he postpartum period is defined as
beginning immediately after the
delivery of the infant and placenta
and typically is considered to con-
tinue for 6–8 weeks as the physiologic changes
of pregnancy slowly revert to baseline. The pe-
riod after a spontaneous or elective abortion is
less well defined, but complications are often
grouped into early complications occurring
immediately or within the first days after the
procedure and delayed complications occur-
ring beyond that time [1, 2].
Pregnancy remains a major cause of mor-
tality in the 21st century in the United States.
A recent analysis placed the pregnancy-relat-
ed mortality rate at 14.5 deaths/100,000 live
births, with more than three quarters of deaths
occurring in the postpartum period (most com-
monly related to hemorrhagic or embolic con-
ditions) [3]. In addition to these life-threaten-
ing complications, other conditions such as
endometritis and retained products of concep-
tion (RPOC) are relatively common after birth
or termination and may require hospitalization
or additional procedures [4, 5]. Finally, almost
one third of births in the United States are now
performed by cesarean section, which results
in the possibility for both immediate and de-
layed complications [6]. Because of their prev-
alence, a radiologist must be familiar with the
various postpartum complications and the role
imaging plays in their clinical evaluation.
Imaging the Postpartum Uterus
The postpartum uterus typically requires
6–8 weeks to involute and return to its typ-
ical nongravid size and appearance on ul-
trasound [7]. Although ultrasound is often
performed in this period to evaluate for ab-
normalities such as RPOC, imaging of the
postpartum uterus is complicated: the post-
partum uterus has a variable appearance,
and there is significant overlap between the
normal and abnormal uterus (Fig. 1). For ex-
ample, echogenic material is frequently seen
within the uterus in patients with bleeding,
but this was found in one study not to be pre-
dictive of need for further intervention [8]. In
a prospective study of asymptomatic wom-
en with physiologic levels of vaginal bleed-
ing after delivery, an echogenic endometri-
al mass was present in half of the patients 7
days postpartum and in 21% of subjects at 2
weeks [9]. The entire postpartum uterus can
appear hypervascular on color Doppler im-
ages, which will typically spontaneously re-
solve without incident [10]. The presence of
gas within the endometrial cavity, either on
CT or as echogenic shadowing foci on ultra-
sound, may also be a normal finding for sev-
eral weeks after delivery [10, 11].
RPOC and Postpartum Hemorrhage
RPOC is a nonspecific term that encom-
passes residual fetal or placental tissue re-

AJR:200, February 2013 W143


maining after delivery, miscarriage, or ter-
mination. The frequency of RPOC has been
variably described. It most commonly occurs
with spontaneous abortions, with a frequency
of up to 22% [4]. However, RPOC are quite
uncommon after elective termination [12].
Primary postpartum hemorrhage is de-
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fined as blood loss greater than 500 mL after
vaginal birth and greater than 1000 mL after
cesarean section. The most common cause is
an atonic uterus, which does not contract to
halt hemorrhage. Atony can result from nu-
merous causes, such as extended labor, multi-
ple gestations or a large fetus, or use of oxyto-
cin for induction or augmentation. Incomplete
delivery of the placenta is an important cause
of uterine atony and is often suspected when
the placenta fails to deliver, delivers incom-
pletely, or has evidence of fragmentation.
Secondary postpartum hemorrhage occurs
when bleeding begins more than 24 hours af-
ter delivery; it is less common than primary
hemorrhage but can cause significant mor-
bidity and mortality [13]. RPOC is an im-
portant cause of secondary hemorrhage, and
ultrasound is often requested for evaluation,
whereas RPOC causing primary hemorrhage
are often suspected and treated at the time of
delivery without imaging.
Placenta accreta is a spectrum of condi-
tions involving a placenta that is abnormally
adherent to the endometrium and is an impor-
tant cause of RPOC and postpartum hemor-
rhage [14]. Placenta accreta vera occurs when
the chorionic villi contact but do not invade
the myometrium, placenta increta occurs
when there is myometrial invasion, and pla-
centa percreta involves invasion to or through
the uterine serosa. Placenta accreta typically
develops where there is a deficiency of the de-
cidua basalis (e.g., cesarean scar) and is par-
ticularly likely in patients with placental pre-
via or multiple cesarean sections. However,
it can also occur after termination and prior
uterine procedures and with advanced mater-
nal age, uterine anomalies, Asherman syn-
drome, or subserosal fibroids [15]. The imag-
ing of placenta accreta will be discussed in
greater detail later in this article (see the De-
layed Cesarean Complications subsection).
Ultrasound Appearance of RPOC
Although it can be also be a normal post-
partum finding, the presence of an echogen-
ic mass in the endometrium appears to be
the most accurate sign of RPOC, as deter-
mined by a retrospective review of 163 pa-
tients with suspicion for RPOC that reported
W144 AJR:200, February 2013
Plunk et al.
sensitivity and specificity of 79% and 89%,
respectively [16]. Increased color Doppler
flow, which can also be physiologic in the
postpartum period, was found in the same
study to be more prevalent with RPOC than
without it (79% vs 40%) (Figs. 2 and 3). An-
other cohort study of 265 women found that
the presence of an intrauterine mass on rou-
tine postpartum ultrasound in asymptomatic
women with uneventful deliveries was found
to be predictive of future hemorrhage and the
need for surgical intervention [17]. Howev-
er, a smaller study did not show this result
[8]. The significance of apparent endometri-
al stripe thickening, typically greater than 10
or 13 mm, has been reported in one study to
be a useful indicator of RPOC [18], whereas
multiple others have not [8, 17, 19, 20].
The most important message regarding
RPOC is that no single factor has perfect positive
or negative predictive values. Because both
clinical signs and symptoms and ultrasound
findings have high false-positive rates, being
conservative in diagnosing RPOC and not
relying on a single indicator are important
principles that should guide reporting [21].
Uncommon Causes of Hemorrhage
Subinvolution of the placental site is a
likely underrecognized cause of postpar-
tum hemorrhage because it can be diagnosed
only by pathologic analysis after hysterec-
tomy or sufficient uterine curettage. In this
condition, even in the absence of a cause
such as RPOC, the uteroplacental arteries
fail to regress and result in significant bleed-
ing. There may be an immunologic basis for
this condition through a common mediator
that causes these vessels to regress prema-
turely in eclampsia [22]. This condition has
no characteristic imaging findings.
Uterine arteriovenous malformations
(AVMs) are an exceedingly rare cause of
postpartum bleeding. They can be congeni-
tal or acquired as a result of hormonal stimu-
lation, but the most common cause is likely
iatrogenic. A mass in the postpartum uterus
with vascularity on ultrasound is much more
likely to represent RPOC than AVM. AVM
can be considered when RPOC have been ex-
cluded and the mass is hypoechoic on B mode
images and located within the myometrium
[23] (Fig. 4). The presence of low-resistance
waveforms and peak velocities greater than
80 cm/s have been described as features sug-
gestive of AVM over other causes [24].
Some authors think that uterine vascular
malformations have been overdiagnosed re-
cently, because hypervascular masses that
simulate the appearance of a true vascular
malformation can develop around RPOC
in the endometrial cavity or myometrium.
The possibility of a vascular malformation
in postpartum patients may delay curettage
for fear of provoking hemorrhage, despite a
lack of definitive evidence to suggest this as
a complication [25]. Conservative therapy
and observation have been suggested for sta-
ble patients with a suspected vascular mal-
formation, and embolization or hysterectomy
is recommended only for unstable patients.
A traumatic pseudoaneurysm may appear
and behave similarly but is likewise quite
rare. Turbulent bidirectional flow within the
pseudoaneurysm may resemble the Chinese-
Taoist yin and yang symbol (yin-yang sign)
on color Doppler images, as pseudoaneu-
rysms do elsewhere in the body [26].
Interventional Radiology and Postpartum
Hemorrhage
In cases of life-threatening postpartum
hemorrhage that does not respond to uterine
massage and medical therapy, the tradition-
al method of treatment has been hysterecto-
my. Although definitive, it is an invasive pro-
cedure that sacrifices future fertility. Uterine
artery embolization is an alternative method
for treatment of postpartum hemorrhage [27].
Embolization has been used to treat uterine
atony resulting from multiple causes. Embo-
lization is the therapy of choice for rare vas-
cular causes of postpartum hemorrhage, such
as uterine pseudoaneurysms and vascular
malformations. Embolization as well as bal-
loon occlusion of the iliac arteries has also
been used in prophylaxis and treatment of
placenta accreta. Embolization has been re-
ported to be efficacious in small case series,
especially when performed as a prophylactic
measure when the diagnosis is known [28,
29]. The role of balloon occlusion of the il-
iac arteries is more controversial, with vary-
ing efficacy reported in the literature [30, 31].
The rate of successful treatment with em-
bolization is high (near 90%) and appears
to have a negligible effect on future fertil-
ity [25]. Often, uterine artery embolization
can successfully control hemorrhage even if
there is no evidence of active extravasation
(Fig. 5). Because uterine fibroid emboliza-
tion has emerged as a modality for treatment
of symptomatic uterine leiomyoma, interven-
tional radiologists are likely to be increasing-
ly comfortable utilizing similar techniques
for the control of postpartum hemorrhage.

Endometritis and Postpartum
Infection
Endometritis, or infection of the uterine
decidua, is the most common cause of post-
partum fever. Although a low-grade fever
is expected in the first 24 hours after vagi-
nal delivery or cesarean section, fever after
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this period is suspicious for endometrial in-
fection. Endometritis is more common after
cesarean section, with rates up to 30 times
higher than that after spontaneous vaginal
delivery [32]. The rates are higher when pro-
phylactic antibiotics are not used, such as for
emergent cesarean sections or some cases of
therapeutic abortions [6, 33].
Endometritis is a clinical diagnosis, but uter-
ine imaging is sometimes requested to guide
therapeutic decisions. Typically, endometritis
is treated with broad spectrum antibiotics, but
if RPOC, infected hematoma, or uterine ab-
scess are present, evacuation may be required.
Not surprisingly, the evaluation of endo-
metritis is fraught with the same issues as for
other postpartum imaging, with considerable
overlap between physiologic and abnormal
findings. Patients with clinical endometritis
can have normal ultrasound findings, echo-
genic material within the uterus can be normal
in postpartum women and may not reflect in-
fected hematoma or RPOC, and endometrial
gas can be a normal finding for up to 3 weeks
after delivery and does not always indicate in-
fection [34] (Fig. 6). Again, not being overly
reliant on or definitive according to a single
finding and integrating the imaging findings
into the complete clinical picture is crucial.
One potential but rare complication of en-
dometrial infection is pelvic septic thrombo-
phlebitis. This occurs in approximately one in
2000 deliveries and 1–2% of cases of endo-
metritis; it appears to be more prevalent when
the infection spreads to the parametrial tis-
sues [32]. CT or MRI is preferred over ultra-
sound in the evaluation of patients for whom
conventional antibiotic therapy has failed and
who are suspected of having underlying con-
ditions, such as septic thrombophlebitis or
an abscess. Both modalities will typically
show an expanded ovarian vein with internal
thrombus (Fig. 7). Enhancement of the vessel
wall may also be present. Treatment is anti-
coagulation in addition to antibiotic therapy.
Thrombotic Complications
Pregnancy has long been recognized as a
prothrombotic state. The mechanism of this
thrombophilia is thought to be due to in-
creased levels of fibrin and the other coag-
AJR:200, February 2013 W145
Imaging of Postpartum Complications
ulation factors, as well as systemic up-reg-
ulation of plasma prothrombotic mediators.
This synergizes with the slowed lower ex-
tremity venous velocities that develop in the
third trimester to predispose patients to deep
vein thrombosis and pulmonary embolism
[35]. Complications of venous thromboem-
bolism are the leading cause of mortality of
pregnant and recently pregnant women with-
in the developed world [36].
Like other changes of pregnancy, the pro-
thrombotic state of pregnancy does not im-
mediately revert to normal after delivery.
The rate of pulmonary embolism has been
found to be highest in the postpartum peri-
od, and it requires 4 weeks for the risk of ve-
nous thromboembolism to return to normal
population levels after delivery [37].
The evaluation of pregnant and postpar-
tum women with suspected pulmonary em-
bolism has been extensively discussed and
remains a controversial topic [38, 39]. In the
postpartum period, concerns about fetal ex-
posure to ionizing radiation or gadolinium
is no longer a factor. However, ionizing ra-
diation exposure to actively dividing and lac-
tating breast tissue remains an important is-
sue. Many practicing radiologists continue to
recommend CT angiography because of its
high sensitivity and specificity and its abil-
ity to evaluate for other causes of dyspnea
or chest pain [38, 40]. However, ventilation-
perfusion or perfusion-only scintigraphy has
advantages, including a lower dose to breast
tissue [41, 42]. In addition, in pregnant pa-
tients, there is a reported higher rate of non-
diagnostic CT angiograms potentially due to
alterations in maternal cardiac output [43];
this could extend into the postpartum peri-
od as well. Because of this continued debate,
provider and patient preference will likely
decide which test is favored in an institution.
Additional thrombotic complications in
pregnancy include ovarian vein thrombosis
and thrombophlebitis, as mentioned previ-
ously in this article. Thrombosis of a dural
sinus or cerebral vein is a rare but important
cause of postpartum headache, altered men-
tal status, seizure, and other neurologic symp-
toms and occurs more frequently in the post-
partum period than during pregnancy [44].
These patients tend to have better outcomes
when treated, compared with other patient
groups with venous sinus thrombosis. CT or
MR venography should be considered for the
evaluation of new neurologic symptoms in the
postpartum period. The sensitivity of unen-
hanced head CT for the detection of venous
sinus thrombosis is relatively low (25–64%).
Venous sinus thrombosis should be suspected
as a potential underlying cause of brain paren-
chymal abnormalities (e.g., edema or hemor-
rhage) in the postpartum period [45] (Fig. 8).
Finally, amniotic fluid embolism is a rare
but feared complication of labor. Because of
trauma to the ovarian veins during labor, am-
niotic fluid is able to enter the venous circu-
lation [46]. The classic clinical presentation
is rapid onset of shock and respiratory col-
lapse. Chest radiographs will typically show
new bilateral pulmonary opacities that ap-
pear similar to acute pulmonary edema.
Cesarean Delivery and Other
Surgical Complications
Immediate or Early Complications
As discussed earlier, the rate of cesarean
delivery has increased substantially in the
past two decades and is now the most com-
monly performed surgical procedure in U.S.
hospitals [6]. The potential reasons for this
increase include changing patient demo-
graphics (such as increased frequency of
multiple births), but it is more likely a reflec-
tion of changes in patient and physician pref-
erence and medicolegal concerns.
Cesarean section has a much higher rate
of endometritis compared with vaginal de-
livery, and endometritis is the most common
complication after cesarean section [47]. The
risks common to any surgical procedure are
also present after cesarean section, such as
significant bleeding and hematoma or wound
infection. Wound infection has been esti-
mated to occur in about 5% of cases, most of
which will be diagnosed and treated clinical-
ly without requiring imaging [48].
When endometritis is diagnosed, either
clinically or with the aid of imaging, the typ-
ical treatment is antibiotics. The majority of
women will do well on this treatment, al-
though a low percentage of cases (8–10%) will
be complicated by pelvic abscess or thrombo-
phlebitis [32, 49]. A rare but feared compli-
cation of endometrial infection is uterine rup-
ture due to infection and necrosis. Analogous
to infectious dehiscence of a fascial incision
or surgical anastomosis, the myometrial inci-
sion can become infected and dehisce, result-
ing in uterine rupture. This condition is rare,
with an estimated incidence of one in every
700–2400 cesarean births [50]. Uterine de-
hiscence may be suspected if the discontinu-
ity is felt on bimanual examination.
For this condition, MRI appears to have
superior accuracy over CT, which may not be

able to differentiate phlegmon or abscess in
the region of the scar from true dehiscence
[51]. Findings that have been described on
MRI include a lack of apposition of the en-
dometrium and serosa at the incision site and
discontinuity of the myometrium with associ-
ated fluid collection, hematoma, or regions of
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low signal intensity suggestive of gas. Con-
servative management in cases of partial de-
hiscence has been proposed with some suc-
cess, but most patients undergo hysterectomy.
Although smaller bladder wall hematomas
have been seen in normal cesarean section,
the presence of large hematomas (> 5 cm) has
been associated with infective uterine rup-
ture. Although detection of uterine discon-
tinuity has been described on ultrasound, its
sensitivity compared with that of MRI or CT
has not been established in the literature.
Intraoperative complications of cesar-
ean section are not rare, especially when
the indication is emergent; one study found
a 12.1% rate of intraoperative complica-
tions. The majority of these complications
are blood loss and inadvertent injury to the
uterus, along with cervical lacerations; inju-
ry to the bladder, ureter, and bowel are more
rare (≤ 1%) [52]. Patients who require peri-
partum hysterectomy (i.e., hysterectomy per-
formed immediately after a delivery or as
part of a surgical delivery) need special at-
tention. Peripartum hysterectomy can be ei-
ther planned, as in the case of suspected ab-
normal placentation, or emergent, because of
bleeding complications. Peripartum hyster-
ectomy is associated with much higher rates
of intraoperative bleeding, urinary tract inju-
ries, infections, and the need for additional
operation or procedures [53, 54] (Fig. 9).
When imaging is requested to evaluate
for postcesarean or other surgical complica-
tions, the standard contrast-enhanced CT of
the abdomen and pelvis acquired in venous
phase is often sufficient if the clinical con-
cern is infection. If significant abdominal as-
cites is known or identified on the examina-
tion, obtaining a series in the excretory phase
or performing a CT cystogram should be
considered to evaluate for ureteral or blad-
der injury. If uterine dehiscence is suspected
either clinically or on prior CT, contrast-en-
hanced pelvic MRI appears to be the superi-
or diagnostic modality.
Delayed Cesarean Complications
In addition to the complications already
discussed, there are complications of cesare-
an section that may not become apparent until
W146 AJR:200, February 2013
Plunk et al.
weeks or months after delivery or until future
pregnancies. These complications are primar-
ily related to the uterine scar. Although long-
term complications secondary to bowel or uri-
nary tract injury are possible, they are rare.
Endometriosis at Cesarean Section Scar
Endometriosis can develop in the abdomi-
nal incision site after cesarean section (also
known as a scar endometrioma). Scar endo-
metriosis is a rare complication with a re-
ported incidence ranging from 0.03% to
1.5% [55]. However, it is still the most com-
mon manifestation of extragenital endome-
triosis [56]. This condition can have a va-
riety of clinical presentations. Pain can be
constant or cyclically related to the menstru-
al cycle. A palpable mass may or may not be
present. Patients will often not have a history
of preexisting endometriosis, and delays in
diagnosis are not rare.
On ultrasound, scar endometriomas can
have a varied appearance based on size [55].
Small-to-moderate endometriomas in the
abdominal wall are solid masses that have
less-well-defined borders and are less ho-
mogeneously hypoechoic than pelvic endo-
metriomas. As they become larger (> 3 cm),
more cystic regions and even less-well-de-
fined borders have been described. Flow may
be present on Doppler images in endometrio-
mas of any size.
Postcesarean Placenta Accreta
The frequency of placenta accreta has
been increasing in the last decades likely as
a result of increased utilization of cesarean
section. Accreta now affects one in 500 preg-
nancies; there is a high association with pla-
centa previa as well [57]. Making the diag-
nosis of placenta accreta before the delivery
is crucial because it has been shown to re-
duce maternal morbidity [58, 59].
At the time of the fetal anatomy scan (18–
20 weeks), dedicated evaluation of the pla-
centa and lower uterine segment is suggested
for any patient with a history of repeated ce-
sarean sections or with placenta previa. The
sensitivity of ultrasound for the detection of
accreta has been reported to be as high as
90% [58] and as low as 30% in a small study
of 13 patients [60]. Several ultrasound fea-
tures have been identified to suggest placenta
accreta. The most sensitive sign is the pres-
ence of multiple placental lacunae [61]. The
pathophysiology of lacunae are unknown,
but they appear as hypoechoic foci that rep-
resent abnormal clusters of vessels with less-
well-defined borders than normal venous
lakes and often will show turbulent flow
on color Doppler images. They have been
described as giving the placenta a “Swiss
cheese” or “moth-eaten” appearance. Sever-
al additional signs have been described that
include loss of the retroplacental clear space,
gap in the retroplacental blood flow, thinning
and distortion of the myometrium, irregular-
ity of the bladder-uterine interface, and bulg-
ing of the placenta into the urinary bladder.
If placenta accreta is convincing on ul-
trasound, many clinicians will proceed with
cesarean section and potential hysterec-
tomy. If the finding is unclear, MRI of the
pelvis has been suggested as an alternative
modality. The value of MRI has been vari-
ably reported: studies have shown superior
sensitivity and specificity [62] and equiva-
lent sensitivity and specificity to ultrasound,
which may be helpful in indeterminate cas-
es [63], but another study failed to show that
the information obtained by MRI changed
clinical management or outcomes [64]. The
most well-described MRI findings for pla-
cental invasion are bulging of the placenta
that distorts the normal uterine contour, the
presence of dark intraplacental bands on T2-
weighted images, and a heterogeneous ap-
pearance of the placenta [65] (Fig. 10).
Cesarean Scar Implantation or Ectopic
Pregnancy
A pregnancy that develops within a pri-
or cesarean section scar has previously been
considered one of the rarest forms of abnor-
mal implantation [66]. It has been suggest-
ed that these are not ectopic pregnancies be-
cause they can, in rare circumstances, be
carried to term; however, these are consid-
ered as ectopic pregnancies for the purpose
of this discussion because there is implanta-
tion outside of the normal decidua and a high
rate of complications.
Although rare, the incidence of cesarean
scar implantation appears to be increasing.
Again, this is likely because of the increas-
ing rate of cesarean delivery and increased
recognition [67]. On ultrasound, care must
be taken to definitively identify the gesta-
tional sac within the low transverse incision
and not in the adjacent adnexa, which can
simulate this condition (Fig. 11). Recogni-
tion of ectopic pregnancy within the uterus
itself is crucial because of the risk of uterine
rupture and catastrophic bleeding.
Although the rate of cesarean scar ectopic
pregnancy appears to be increasing, defini-

tive guidelines for management have yet to be
outlined. A variety of treatment options have
been used, ranging from observation, medical
treatment either systemic or locally injected,
local resection utilizing hysteroscopy or lapa-
roscopy, laparotomy either for local resection
of the gestational sac or total hysterectomy,
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treatment with uterine artery embolization, to
a combination of these approaches.
Conclusion
The significant overlap between the patho-
logic and physiologic changes of the postpar-
tum uterus presents many difficulties to in-
terpreting ultrasound examinations in the
postpartum period. In addition, increasing
rates of delivery by cesarean section have the
possibility to increase the frequency of ear-
ly and late complications. It is crucial for ra-
diologists to be aware of the most common
postpartum complications on which they
will be asked to consult and the strengths
and limitations of the various imaging mo-
dalities, so that they could assist in the ap-
propriate care of these patients.
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A B C
Fig. 1—Spectrum of potentially normal postpartum findings in three different patients who were treated expectantly after these examinations, with resolution of their symptoms.
A, 26-year-old woman with postpartum bleeding after spontaneous vaginal delivery. Sagittal transvaginal ultrasound shows echogenic material (arrow) in endometrial cavity.
B, 31-year-old woman with abdominal pain and bleeding after vaginal delivery. Sagittal transabdominal ultrasound shows minimally echoic fluid distending endometrial cavity.
C, 28-year-old woman with bleeding and abdominal pain 1 week after cesarean section. Contrast-enhanced CT shows that uterus is enlarged and endometrial cavity
contains mixed-density fluid and gas.

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A B
Fig. 2—29-year-old woman with continued bleeding after spontaneous abortion (retained products of conception).
A, Sagittal transabdominal ultrasound shows heterogeneous echogenic material expanding endometrial cavity.
B, Color Doppler sonography shows increased vascularity in anterior portion of endometrial mass (arrow), representing mix of retained products of conception anteriorly
with blood clot or necrotic placental tissue more posteriorly. Gestational trophoblastic disease was considered in differential diagnosis on ultrasound, but pathologic
examination found mixed hemorrhage and chorionic villi without fetal parts or other evidence of molar pregnancy.

Fig. 3—34-year-old woman with persistent vaginal

bleeding 4 weeks after uneventful vaginal delivery
(retained products of conception).
A, Sagittal transvaginal ultrasound confirmed
presence of echogenic material (arrow) within
endometrial cavity. Internal flow was noted with
color Doppler images (not shown).
B, Echogenic material (arrow) is also present in cervix
on coronal image. Pathologic examination after dilation
and curettage confirmed necrotic chorionic villi.
A B

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A B C

D E F
Fig. 4—Uterine arteriovenous malformation (AVM) in two different patients.
A and B, 36-year-old woman who presented with persistent hemorrhage after dilation and curettage for retained products of conception (RPOC). Transverse images from
transvaginal ultrasound (A) show echogenic material within uterine cavity, with increased flow on color Doppler sonography (B). Spectral Doppler sonography shows low-
resistance waveform and peak systolic velocity of approximately 60 cm/s (not shown). Possibility of AVM was raised. Pathologic examination after hysterectomy revealed
adherent RPOC and no AVM.
C–F, 22-year-old woman who presented with intermittent heavy vaginal bleeding 6 weeks after elective first trimester termination. Physiologic bleeding was noted in first
month after procedure, which accelerated 2 weeks before presentation. Serum β-HCG was nondetectable. Transvaginal ultrasound (C) shows clot within endometrial
cavity with eccentric vascular mass in fundus. Waveform on spectral Doppler sonography was low resistance, with peak systolic velocity greater than 90 cm/s (not
shown). Vascular malformation was suspected, and patient was referred for angiography. Multiple images from pelvic angiogram show prominent right uterine arteries
(arrow, D). Subsequently, there is vascular blush of presumed AVM in fundus (arrow, E) and then early filling of draining vein (arrow, F). This was embolized with cessation
of patient bleeding. No pathologic analysis was available to confirm vascular malformation. Although history and angiographic features were suggestive of AVM, chronic
RPOC can simulate ultrasound and angiographic appearance of AVM and cannot be excluded as reason for bleeding in this case.

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 Imaging of Postpartum Complications

Fig. 5—28-year-old woman with severe primary

postpartum hemorrhage from uterine atony after
cesarean section. Patient had 5 L of estimated
blood loss but desired future fertility and wished to
avoid hysterectomy, so catheter embolization was
performed for postpartum hemorrhage.
A, Pelvic angiogram shows increased vascularity
of postpartum uterus but with smooth diffuse
narrowing of vessels representing vasospasm from
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hypovolemia.
B, Superselective catheterization of right uterine
artery identified active extravasation (arrow). Right
uterine artery was successfully embolized, as was
contralateral side. Patient tolerated procedure well
with cessation of further bleeding. No hysterectomy
was required.

A B

A B
Fig. 6—34-year-old woman with retained products of conception after vaginal delivery and failed medical therapy who presented with fever and cramping.
A and B, Sagittal (A) and coronal (B) images from transvaginal ultrasound show echogenic retained products of conception and foci of higher echogenicity representing
gas (arrows) in uterus. Endometritis was suggested on imaging and confirmed clinically. Patient was treated with dilation and evacuation.

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A B
Fig. 7—41-year-old woman with abdominal pain who had spontaneous vaginal
delivery at 27 weeks’ gestation 2 weeks before presentation.
A, Axial contrast-enhanced CT image shows small filling defect (arrow) at level of
right renal vein, in expected position of right ovarian vein.
B, More inferiorly, right ovarian vein is expanded by thrombus (arrow) with mild
surrounding fat stranding.
C, Thrombus (arrow) is still present in right ovarian vein at level of ovary
(arrowhead).

A B C
Fig. 8—21-year-old woman with history of recent vaginal delivery with headache and altered mental status.
A, Unenhanced head CT was initially interpreted as normal, but in retrospect showed hyperattenuation (arrow) of straight sinus and left transverse sinus.
B, CT venogram was ordered because of concern for venous sinus thrombosis. Images confirmed thrombosis in straight and left transverse sinuses (not shown). In
addition, observe filling defect (arrow) in superior sagittal sinus.
C, T2*-weighted gradient-recalled echo MRI shows extensive susceptibility artifact in posterior fossa bilaterally due to thrombosed superficial veins.

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A B
Fig. 9—34-year-old woman with history of postpartum hemorrhage secondary to placenta increta requiring
emergent peripartum hysterectomy who presented after discharge 8 days after surgery with shortness of
breath and abdominal pain.
A, Abdominal CT shows large amount of abdominal ascites, which was suspected clinically to be urine.
B, Delayed CT examination obtained next morning confirmed urinary tract injury with excreted contrast agent
in peritoneal cavity.
C, Image from retrograde urogram confirms right ureteral injury with extravasation of contrast agent (arrow)
into pelvis.

Fig. 10—43-year-old woman with two prior cesarean

sections.
A, Transabdominal ultrasound shows anterior-
inferior placenta that covers internal os. Placenta
has multiple irregular peripheral hypoechoic foci
consistent with lacunae. Lacunae (arrow) extend to
bladder surface without intervening myometrium.
B, Subsequent MRI confirms findings. Additionally,
there is loss of normal bladder mucosa (arrow)
consistent with placenta percreta.
A B

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A B
Fig. 11—34-year-old woman with pelvic pain and serum β-HCG.
A, Axial transvaginal ultrasound shows gestational sac with embryo located
eccentrically within left lower uterine segment.
B, Sagittal view of endometrium shows hypoechoic scar (arrow) from patient’s
prior low transverse cesarean section.
C, Sagittal image more laterally shows gestational sac situated within scar
(arrow). Gestational sac extended into left adnexa (not shown). Implantation into
cesarean scar was confirmed on hysterectomy.

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