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624
7. Okai T, Kobayashi K, Ryo E, Kagawa H, Kozuma S,
Taketani Y. Transvaginal sonographic appearance of hemor-
rhagic functional ovarian cysts and their spontaneous regression.
Int J Gynaecol Obstet 1994; 44: 47–52.
8. Brown DL, Doubilet PM, Miller FH, Frates MC, Laing FC,
DiSalvo DN, Benson CB, Lerner MH. Benign and malignant
ovarian masses: selection of the most discriminating gray-
scale and Doppler sonographic features. Radiology 1998; 208:
103–110.
9. Schelling M, Braun M, Kuhn W, Bogner G, Gruber R, Gnirs J,
Schneider KT, Ulm K, Rutke S, Staudach A. Combined trans-
vaginal B-mode and color Doppler sonography for differential
diagnosis of ovarian tumors: results of a multivariate logistic
regression analysis. Gynecol Oncol 2000; 77: 78–86.
10. Redman CWE, Jones SR, Luesly DM, Nicholl SE, Kelly K,
Buxton EJ, Chan KK, Blackledge GRP. Peritoneal trauma
releases CA 125? Br J Cancer 1988; 58: 502–504.
Transvaginal sonographic appearance of
anaerobic endometritis
The diagnosis of endometritis is often a challenging
task, as signs and symptoms are non-specific and the
sonographic findings are variable, including thickening
and irregularity of the endometrium and fluid or debris
accumulated within the endometrial cavity1 . We report
a case in which the diagnosis was suggested by the
transvaginal sonographic demonstration of gas within
the endometrial cavity.
A 39-year-old woman was referred to our hospital
for infertility. A transvaginal ultrasound scan revealed
a subserous/partly intramural leiomyoma measuring
4 cm on the right uterine cornu. The right ovary was
slightly enlarged due to the presence of a luteal cyst.
The preoperative CA 125 plasma level was above the
normal upper value (113 IU/mL). On bimanual pelvic
examination the uterus was found to be enlarged and
irregular in morphology. After counseling a laparoscopic
myomectomy was scheduled. At laparoscopy both
adnexa appeared to have normal morphology and
dimensions. The cul-de-sac was obliterated and several
endometriotic implants 2–10 mm in diameter were seen
dispersed throughout the pelvic peritoneum. The uterus
showed a slight prominence on the right side that
was thought to be the subserous/intramural myoma
identified at sonography. Enucleation of the mass was
performed with a monopolar hook; it proved difficult
due to the absence of a plane of cleavage from the
surrounding myometrium. The incision extended to the
endometrial cavity, and a small amount of chocolate-
like liquid was seen leaking from the uterus. The
myometrium and serosa were sutured. Pathology of
the specimen revealed an adenomyoma within several
small leiomyomas. Two days after surgery the patient
developed pelvic pain and high, remittent fever, and
was treated with a combination of antibiotics including
tobramicin, ceftriaxon, imipenem and cilastatin. Her
general condition worsened as the fever was unresponsive
to antibiotics. At transvaginal sonography the uterus
was found to be enlarged (longitudinal diameter, 11 cm;
Copyright  2003 ISUOG. Published by John Wiley & Sons, Ltd.
Letters to the Editor
anteroposterior diameter, 7 cm; transverse diameter,
7 cm) with an irregular myometrial echogenicity that,
in the light of the pathological diagnosis, was considered
to be compatible with diffuse adenomyomatosis. The
endometrial cavity was filled with a layer of high-level
echoes casting a shadow, suggesting the presence of gas
accumulated within the endometrial cavity (Figure 1).
Both ovaries had normal volume and morphology.
Moreover, on power Doppler a highly vascularized
complex mass was seen beside the right ovary, with
the appearance of an inflamed appendix2 . No free fluid
was detected in the pouch of Douglas. An explorative
laparotomy confirmed the presence of a pneumatometra
and a pelvic abscess: the uterus appeared enlarged and
softened, with a grayish serosal surface, and during the
maneuvers a crackling was perceived, as if air were
entrapped inside the cavity. Removal of the uterus, both
Fallopian tubes, appendix and right ovary was performed.
Pathology revealed acute inflammation of the appendix
extending to the right salpinx. Acute endometritis was
histologically demonstrated by the presence of more than
five neutrophils visible per 400 × field in the superficial
epithelium, and more than one plasma cell per 120 × field
in the endometrial tissue3 (Figure 2). The patient soon
recovered after laparotomy and was discharged from the
hospital 14 days later.
The presence of gas in the uterine cavity has been
reported following spontaneous, uncomplicated vaginal
delivery4,5 . This is a normal finding at least for the
first 3 weeks of the puerperium and does not indicate
the presence of endometritis. It should, however, be
suspected in a patient complaining of fever and pelvic pain
in whom a pneumatometra is demonstrated. Although
such a condition has been previously documented at
Figure 1 Transverse vaginal sonographic image of the uterus. The
endometrial stripe is thick and hyperechoic and difficult to
delineate with respect to the surrounding myometrium. Several
cones of shadow from the endometrium obscure the posterior
uterine wall. This appearance is suggestive of the presence of
endometritis associated with gas formation (arrow) within the
endometrial cavity.
Ultrasound Obstet Gynecol 2003; 21: 619–625.

Letters to the Editor
Figure 2 Histological specimen of the same patient as in Figure 1
demonstrating an abundance of plasma cells in the endometrial
stroma.
computed tomography in a postmenopausal patient with
cervical stenosis6 , we describe the case of an anaerobic
endometritis suspected at transvaginal ultrasound on
visualization of gas filling the uterus. On gray-scale
imaging the accumulation of gas produced a hyperechoic
image within the uterus and ‘dirty’ acoustic shadowing
behind it.
In this case, surgery resulted in the opening of the
endometrial cavity, which we speculate was the main
cause of the unusual clinical evolution. Anaerobic bacteria
are particularly common in infections following surgery
and gas-producing microorganisms are often involved in
the pathogenesis of acute appendicitis7 as well as pelvic
inflammatory disease8 . We speculate that the occurrence
of a pelvic infection, either appendicitis or salpingitis,
Copyright  2003 ISUOG. Published by John Wiley & Sons, Ltd.
14690705, 2003, 6, Downloaded from https://obgyn.onlinelibrary.wiley.com/doi/10.1002/uog.107 by TESTREGPROV3, Wiley Online Library on [28/01/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
625
resulted in the extension of the inflammatory process to
the endometrium through the myometrial incision.
L. Savelli*†, G. Pilu†, B. Valeri‡ and L. Bovicelli†
†Department of Obstetrics and Gynecology, and
‡Department of Pathology, University of Bologna, Italy
*Correspondence.
(Via F. Schiassi 9, 40138 Bologna, Italy
e-mail: lucasavelli@rocketmail.com)
DOI: 10.1002/uog.107
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