Ch. 21 Pelvic Inflammatory Disease & Infertility Flashcards
Infection of the upper genital tract (uterus, ovaries, fallopian tubes)
pelvic inflammatory disease (PID)
The origin of the majority of upper genital tract infections is
ascension of an infection from the lower genital tract
Risk factors for PID
history of PID, IUD, postabortion, post childbirth, douching, multiple sexual partners, early sexual contact
A common cause of PID is STD’s like
gonorrhea, chlamydia
inflammation of the endometrium
endometritis
inflammation of the fallopian tube
salpingitis
inflammation of the myometrium, the muscular part of the uterus
myometritis
inflammation of the connective tissue adjacent to the uterus
parametritis
inflammation of the ovary
oophoritis
PID may manifest after pelvis ________, accompany tuberculosis, or occur in association with an abscessed appendix or ruptured colonic diverticulum.
surgery
about half of PID cases have non–sexually transmitted disease causes, such as vaginal flora, anaerobic Gram-negative rods, and _________bacteria. PID is characteristically a ________ condition affecting not only the uterus but also both fallopian tubes and, possibly, the ovaries.
Mycoplasma; bilateral
The sequela of PID range from a negligible _______that is relatively easy to treat, to the development of a tubo-ovarian _________. In some cases, PID may also lead to death. Potent antibiotic treatment is typically warranted.
infection; abscess
an illness resulting from another disease, trauma, or injury
sequela
a pelvic abscess involving the fallopian tubes and ovaries that is often caused by pelvic inflammatory disease
tubo-ovarian abscess
Evolution of ______
Vaginitis → Cervicitis → Endometritis → Salpingitis → Tubo-ovarian complex → Tubo-ovarian abscess
PID
an inflammatory reaction that leads to the formation of pus
purulent
Clinical Findings of _____________
1.Possible history of a sexually transmitted disease (chlamydia or gonorrhea)
2.Fever
3.Chills
4.Pelvic pain and/or tenderness
5.Purulent vaginal discharge
6.Vaginal bleeding or itchiness
7.Dyspareunia
8.Leukocytosis
Acute Pelvic Inflammatory Disease
Sonographic Findings of __________
1.Thickened, irregular endometrium (endometritis)
2.Ill-defined uterine borders
3.Tubular structures representing dilated fallopian tubes containing echogenic material (pyosalpinx)
4.Tubular structures representing dilated fallopian tubes containing simple-appearing, anechoic fluid (hydrosalpinx)
5.Cul-de-sac fluid
6.Multicystic and solid complex adnexal mass(es) (see “Tubo-ovarian Complex and Tubo-ovarian Abscess” section)
Acute Pelvic Inflammatory Disease
Clinical Findings of __________
1.Continual pelvic or abdominal pain
2.Infertility (resulting from adhesions and scaring of the fallopian tubes)
3.Possible palpable adnexal mass
4.Irregular menses
5.Purulent vaginal discharge
Chronic Pelvic Inflammatory Disease
Sonographic Findings of ________
1.Dilated fallopian tubes containing simple-appearing, anechoic fluid (hydrosalpinx)
2.Scars may be noted within the dilated tube and appear as echogenic bands within the tube
3.Development of adhesions may obliterate distinct borders of organs because they become fixated to each other
4.Multicystic and solid complex adnexal mass(es) (see “Tubo-ovarian Complex and Tubo-ovarian Abscess” section)
Chronic Pelvic Inflammatory Disease
_________is the most common initial clinical presentation in the early stages of PID.
Vaginitis
inflammation of the vagina
Vaginitis
______ can lead to excessive vaginal discharge, and in cases of PID, patient may present with a purulent, foul-smelling discharge. The progression of the infection into the cervix is termed _______. Vaginitis and cervicitis may not be apparent with sonography
Vaginitis;cervicitis
is the inflammation of the endometrium
Endometritis
time directly after giving birth and extending to about 6 weeks
postpartum
a common form of birth control in which a small device is placed within the endometrium to prevent pregnancy; also referred to as an intrauterine contraceptive device
intrauterine device
the presence of pus within the uterus
pyometra
Gas or air formation within the thickened endometrium, which is termed pneumouterus, may be seen and will produce a distinct _______. The gas formation within the endometrium results from the collection of bacteria.
ring-down artifact
________appears sonographically as a thickened or irregular-appearing endometrium that may contain some intraluminal fluid. Gas formation within the thickened endometrium may be seen and will produce a distinct ring-down artifact
Endometritis
Clinical Findings of ________
1.History of recent abortion, postpartum, D&C, PID, surgery, or IUD
2.Pelvic tenderness
3.Fever
4.Leukocytosis
Endometritis
Sonographic Findings of ________
1.Thickened echogenic or irregular-appearing endometrium
2.Endometrial fluid
3.Ring-down artifact from gas or air within the endometrium
4.Color Doppler may yield hyperemia
Endometritis
in cases where _________ is present and the tube is not distended, it may be difficult to determine whether ________ is present with sonography. In these instances, the sonographic evidence of _________ can be depicted by documenting hyperemic flow within or around the tube. In addition, there may be signs of nodular thickening in the wall of the affected tube
salpingitis
an increase in blood flow
hyperemic
Patients suffering from salpingitis from PID may present clinically with symptoms resembling _______.
cholecystitis
pelvic infections, such as chlamydia or gonorrhea, can actually lead to a perihepatic infection and the subsequent development of adhesions located between the liver and the diaphragm. As a result, the liver capsule can become inflamed, thus leading to a clinical presentation much like gallbladder disease. This event is called perihepatitis or _________
Fitz-Hugh–Curtis syndrome
peritoneal space located between the liver and the right kidney; also referred to as Morison pouch
hepatorenal space (Morison pouch)
a perihepatic infection that results in liver capsule inflammation from pelvic infections such as gonorrhea and chlamydia
Fitz-Hugh–Curtis syndrome
inflammation of the gallbladder
cholecystitis
PID has been linked with infertility and ________. This is secondary to the formation of scarring within the formerly inflamed opening of the fallopian tube.If conception does occur, the development of scar tissue within the fallopian tube increases the possibility of the pregnancy implanting in the tube, thus leading to an ectopic pregnancy
ectopic pregnancy
Clinical Findings of ________
Findings consistent with PID
Pelvic tenderness
Fever
Leukocytosis
Salpingitis
Sonographic Findings of ________
1.Distended fallopian tube filled with echogenic material (pus) or anechoic fluid
2.Hyperemic flow within or around the affected fallopian tube depicted with color Doppler
3.Nodular, thickened wall of the fallopian tube
Salpingitis
How is endometritis treated?
antibiotics or curettage
Inability to conceive a child after 1 year of unprotected sex
infertility
As PID progresses and reaches beyond the fallopian tubes, the ovaries and peritoneum become involved, adhesions develop within the pelvis that lead to the fusion of the ovaries and the dilated tubes, a condition known as _________ and beyond this stage leads to _________
,tubo-ovarian complex, tubo-ovarian abscess
Treatments for these two conditions (tubo-ovarian and abscess) differ in that drainage is required only when an _______ has developed.
abscess
With _________, the ovaries and tubes are more readily recognized as distinct structures, but the ovaries will not be able to be separated from the tube by pushing with the vaginal probe.
tubo-ovarian complex
when a __________ is present within the pelvis, there will be a complete loss of borders of all adnexal structures and the development of a conglomerated adnexal (possibly bilateral) mass
tubo-ovarian abscess
Clinical Findings of Tubo-Ovarian Complex and Tubo-Ovarian Abscess
Findings consistent with _______
PID
Sonographic Findings of _______
1.Thickened, irregular endometrium
2.Pyosalpinx or hydrosalpinx
3.Cul-de-sac fluid
4.Multicystic and solid complex adnexal mass(es)
5.Complete loss of borders of all adnexal structures and the development of a conglomerated adnexal (possibly bilateral) mass
Tubo-Ovarian Abscess
Sonographic Findings of _______
1.Thickened, irregular endometrium
2.Pyosalpinx or hydrosalpinx
3.Cul-de-sac fluid
4.Multicystic and solid complex adnexal mass(es)
5.Ovaries and tubes recognized as distinct structures, but the ovaries will not be separated from the tube by pushing with the vaginal probe
Tubo-Ovarian Complex
______is a common cause of infertility
PID
Congenital uterine malformations (especially ______uterus), endometriosis, polycystic ovary syndrome (PCOS), tubal causes, Asherman syndrome, and uterine _______, impacts female infertility
septate; leiomyomas
Uterine malformation often lead to ___ as a result of structural abnormalities within the uterus.
repeated abortions
A common structural defect of the uterus that could lead to fertility troubles
bicornuate uterus
a common uterine anomaly in which the endometrium divides into two horns; also referred to as bicornis unicollis
bicornuate uterus
congenital malformation of the uterus that results in a single septum that separates two endometrial cavities
septate uterus
A septate uterus usually requires surgical intervention to reduce the division of the uterine cavity called
hysteroscopic uterine septoplasty
Functional ectopic endometrial tissue (typically 25-35 years)
endometriosis
Endometriosis can be located anywhere throughout the pelvis but most common location of endometriosis is the
ovary
With endometriosis ectopic tissue does undergo physiologic changes as a result of stimulation by the hormones of the menstrual cycle. Hemorrhage of this tissue often occurs, resulting in focal areas of bloody tumors known as ________or _________
endometriomas; chocolate cysts
Clinical Findings of _________
1.Patient may be asymptomatic
2.Pelvic pain
3.Infertility
4.Dysmenorrhea
5.Menorrhagia
6.Dyspareunia
7.Painful bowel movements
Endometriosis
Sonographic Findings of an ________
1.Predominantly cystic mass with low-level internal echoes (may resemble a hemorrhagic cyst)
2.Anechoic or complex mostly cystic mass with posterior enhancement and may contain a fluid–fluid level
Endometriosis
Clinical Findings of _______
1.Stein–Leventhal syndrome (anovulation,amenorrhea, hirsutism, and obesity)
2.Infertility
3.Oligomenorrhea
4.Hyperandrogenism
*acne
Polycystic Ovary Syndrome
Sonographic Findings of _______
1.“String of pearls” sign or “necklace” sign describes the presence of many small cysts measuring along the periphery of the ovary
2.Many small cysts scattered throughout the ovary
3.Bilateral enlargement of the ovaries
4.Increased stroma and increased stromal echogenicity
5.One or both ovaries should contain 12 or more follicles that measure between 2 and 9 mm in diameter
6.Ovarian volume greater than 10 mL
7.Threshold of 25 small follicles can also be used
Polycystic Ovary Syndrome
syndrome characterized by anovulatory cycles, infertility, hirsutism, amenorrhea, and obesity; may also be referred to as Stein–Leventhal syndrome
Stein–Leventhal syndrome
PCOS has been cited as the most common cause of _______ excess, which is termed hyperandrogenism, and hirsutism in women
androgen
The established criteria for the diagnosis of PCOS include oligomenorrhea or amenorrhea, blood work indicative of hyperandrogenism, and sonographic findings consistent with PCOS. A patient must have _____ of the three criteria to be diagnosed with PCOS.
two
a hormone, such as testosterone, that is responsible for male characteristics
androgen
lack of ovulation
anovulation
excessive hair growth in women in areas where hair growth is normally negligible
hirsutism
overweight to the point of causing significant health problems and increased mortality
obesity
Sonographically, the ovaries are often enlarged and contain multiple, small follicles along the periphery or throughout the ovary, with prominent echogenic stromal elements. The sonographic “string of pearls” sign or “necklace” sign denotes the presence of many small cysts along the ______ of the ovary, whereas another manifestation is many small cysts dispersed ______ the ovary
periphery, throughout
For the imaging diagnosis of PCOS, one or both ovaries should contain ___or more follicles that measure between __ and __ mm in diameter, and the ovarian volume should exceed ___ mL. A threshold of ____ small follicles can also be used.
12; 2 and 9mm; 10; 25
high levels of unopposed estrogen stimulation on the endometrium, as seen in patient suffering from PCOS, have also been linked to the subsequent development of ________and ________cancer.
endometrial; breast cancer
__________, also referred to as Stein–Leventhal syndrome, is an endocrinologic ovarian disorder linked with infertility.
PCOS
______ is the accumulation of fluid within the fallopian tube. It is often the result of obstruction of the fimbriated end of the fallopian tube by adhesions. The presence of ________ within the tube can prevent the normal peristaltic motion that typically occurs. Adhesion development can occur as a result of long-standing PID, endometriosis, and tubal surgery.
hydrosalpinx; adhesions
The endometrium may not develop appropriately in the luteal phase of the endometrial cycle as a result of reduced progesterone production by the ovary; this is termed _______
“luteal phase deficiency.”
when the endometrium does not develop appropriately in the luteal phase of the endometrial cycle as a result of reduced progesterone production
luteal phase deficiency
The endometrium becomes thickened and echogenic in appearance during the normal ovarian luteal phase (_____ phase of the endometrial cycle). However, this abnormality “luteal phase deficiency” is typically diagnosed with endometrial biopsy.
secretory
_________is the presence of intrauterine adhesions or synechiae within the uterine cavity that typically occur as a result of scar formation after uterine surgery, especially after a D&C. Adhesions within the uterine cavity often prevent implantation or lead to recurrent early pregnancy loss.
Asherman syndrome
Sonographic detection for Asherman syndrome is difficult without a
sonohysterography (findings include bright bands of tissue traversing the uterine cavity)
Clinical Findings of _________
1.History of D&C, trauma, and uterine surgery
2.Recurrent pregnancy loss
3.Amenorrhea or hypomenorrhea
Asherman Syndrome
Sonographic Findings of _______
1.Bright areas within the endometrium
2.Sonohysterography findings include bright bands of tissue traversing the uterine cavity
Asherman Syndrome
Fibroids that are ___ or ___ in location distort the endometrium thus preventing implantation of early products of conceptions.
intracavitary or submucosal
A uterine ________ is a benign, smooth muscular tumor of the uterus that may also be referred to as a fibroid or uterine myoma.
leiomyoma
Great advances in assisted reproductive technology (ART) have occurred since the 1970s. Sonography is often used to monitor ovulation and follicular growth and to assist during reproductive therapies such as ______ and _______.
follicular aspiration, oocyte retrieval
technique used for in vitro fertilization in which follicles are drained for oocyte retrieval
follicular aspiration
the removal of oocytes from ovarian follicles by aspiration
oocyte retrieval
________ requires that a mature ovum be extracted from the ovary. Fertilization takes place outside the body, and four to eight developing embryos are placed into the uterus by means of a catheter. This often results in multiple gestations.
In vitro fertilization
_______, also referred to as multifetal pregnancy reduction, is the means by which twins, triplets, quadruplets, and quintuplet pregnancies are reduced.
Selective reduction
fertility treatment that requires that a mature ovum be extracted from the ovary, with fertilization taking place outside the body
In vitro fertilization
a method of reducing the number of pregnancies in a multiple gestation, whereby certain embryos/fetuses are terminated
Selective reduction
gamete intrafallopian tube transfer _____. ______requires that oocytes and sperm be placed in the fallopian tube by means of laparoscopy.
(GIFT)
_________ is another method that requires the zygote to be inserted into the fallopian tube
Zygote intrafallopian transfer
Sonographers should be aware that patients who are being treated with assisted reproductive therapy are an increased risk for _______ pregnancy, heterotopic pregnancy, multiple gestations, and ________(OHS).
ectopic, ovarian hyperstimulation syndrome.
infertility treatment in which oocytes and sperm are placed in the fallopian tube by means of laparoscopy
gamete intrafallopian tube transfer (GIFT)
infertility treatment where the zygote is placed into the fallopian tube
Zygote intrafallopian transfer
coexisting ectopic and intrauterine pregnancies
heterotopic pregnancy
a syndrome resulting from hyperstimulation of the ovaries by fertility drugs; results in the development of multiple, enlarged follicular ovarian cysts
ovarian hyperstimulation syndrome (OHS)
Clinical Findings of a _____
1.Pelvic pressure
2.Menorrhagia
3.Palpable abdominal mass
4.Enlarged, bulky uterus (if multiple)
5.Urinary frequency
6.Dysuria
7.Constipation
8.Infertility
Uterine Leiomyoma
Sonographic Findings of a ________
1.Hypoechoic mass within the uterus
2.Posterior shadowing from mass
3.Degenerating fibroids may have calcifications or cystic components
4Multiple fibroids appear as an enlarged, irregular shaped, diffusely heterogeneous uterus
Uterine Leiomyoma
Ovulation induction medications increase the risks of
multiple gestations & OHS
___ can initiate renal failure, thromboembolism, and acute respiratory distress syndrome
ovarian hyperstimulation syndrome (OHS)
the stimulation of the ovaries by hormonal therapy in order to treat infertility
Ovulation induction
_____, or clomiphene citrate, is a drug that is used to stimulate the _______ gland to secrete increased amounts of follicle-stimulating hormone (FSH). The increased level of FSH encourages the development of multiple follicles on the ovaries.
Clomid, pituitary
infertility medicine used to stimulate the follicular development of the ovaries
Pergonal
fertility drug used to treat anovulation
Clomoid or clomiphene citrate
It is a hormone extracted from the urine of postmenopausal women that is often used when Clomid administration is not successful. ______ consists of a mixture of FSH and luteinizing hormone and is often given in conjunction with human chorionic gonadotropin (hCG). Other infertility drugs include letrozole and gonadotropin therapy.
Pergonal
An IUD should be located where
the fundal portion of the endometrium
___ can initiate renal failure, thromboembolism, and acute respiratory distress syndrome
ovarian hyperstimulation syndrome (OHS)
Remember that hCG is administered as part of ovulation induction, and theca lutein cysts occur as a result of _______ levels of hCG.
high
Women who are undergoing ovulation induction by means of hormone administration are at an increased risk for developing OHS. The ovaries can enlarge, often measuring between ___ and ____ cm.The ovary will also contain multiple large follicles known as _____
5 and 12; theca lutein cysts
functional ovarian cysts that are found in the presence of elevated levels of human chorionic gonadotropin; also referred to as a theca luteal cyst
theca lutein cysts
scant or decreased urine output
oliguria
the formation of clot within a blood vessel with the potential to travel to a distant site and cause an occlusion
thromboembolism
the buildup of fluid within the air sacs or alveoli within the lungs
acute respiratory distress syndrome
Clinical Findings of _______
1.Fertility treatment, including ovulation induction
2.Electrolyte imbalance
3.Oliguria
4.Nausea
5.Vomiting
6.Abdominal distension
7.Ovarian enlargement (the patient could suffer from ovarian torsion, resulting in acute pelvic pain.)
Ovarian Hyperstimulation Syndrome
Sonographic Findings of _______
1.Cystic enlargement of the ovaries greater than 5 cm
2.Ascites
3.Possible pleural effusion
Ovarian Hyperstimulation Syndrome
synthetic progesterone secreted by some intrauterine devices to regulate menstrual flow
progestin
a small plastic T-shaped intrauterine device
Mirena
intrauterine contraceptive device that utilizes copper in its composition to inhibit sperm transport, or to prevent fertilization or transplantation
ParaGard
An ____ is a reversible form of contraception. An ___ is placed in the uterine cavity and prevents implantation of the fertilized ovum.
IUD
_______, a small plastic T-shaped IUD, distorts the uterine cavity and also releases small amounts of progestin to impede implantation and produce lighter menstrual bleeding. Other newer IUDs include Liletta, Skyla, and Kyleena, all of which are T shaped
Mirena
The _________is another T-shaped IUD, although it utilizes copper in its composition to inhibit sperm transport or to prevent fertilization or transplantation
ParaGard
IUDs create _______and have been described as producing an “entrance and exit echo” on a sonogram. A sonographic examination may be indicated when the _______ of an IUD cannot be found on physical examination. A sonographic description of these devices must include the location of the IUD in relation to the _______.
posterior shadowing; string; endometrium
Patients might complain of irregular/heavy bleeding and cramping if the IUD has
perforated
IUDs have been linked to
PID, ectopic pregnancy, spontaneous abortions
If a patient presents to the sonography department with a history of tubal ligation and a positive pregnancy test, what should be suspected?
ectopic pregnancy
Birth control pills produce an anovulatory cycle by suppressing, primarily, the secretion of _______ hormone by the anterior pituitary gland.
luteinizing
Other forms of contraception include the formally utilized_____device. The ______ device is no longer sold in the United States.
Essure
Essure
tubal sterilization
tubal ligation
Female tubal sterilization, in the form of ______, and male sterilization, in the form of a ________, offer _________pregnancy prevention.That is to say, although rare, pregnancy can occur, even though the patient may have had a previous tubal ligation.
tubal ligation; vasectomy; permanent
Intrauterine Contraceptive Device:
Copper 7
Sonographic Findings:
_____________
Shadowing number “7”-shaped device
Intrauterine Contraceptive Device:
Copper T
Sonographic Findings:
_____________
Shadowing letter “T”-shaped device
Intrauterine Contraceptive Device:
Lippes Loop (*although you may encounter these, the flexible polythylene Lippes loop is used throughout the world except in the United States)
Sonographic Findings:
_____________
Five equally spaced shadowing structures
Intrauterine Contraceptive Device:
Dalkon shield
Sonographic Findings:
_____________
Shadowing ovoid shape device
Intrauterine Contraceptive Device:
Mirena (Liletta, Skyla, and Kyleena) (*approved lifespan of 5yrs)
Sonographic Findings:
_____________
Shadowing letter “T”-shaped device
Intrauterine Contraceptive Device:
Paragard (*uses copper, approved lifespan of 10yrs)
Sonographic Findings:
_____________
Shadowing letter “T”-shaped device
