0:01

All right, we have another

0:02

patient for an IUD check.

0:04

She had bleeding and pain post-IUD

0:07

placement for about the last two weeks.

0:08

She's about 26 years old.

0:10

And here's her sagittal uterus.

0:12

We have our parametral vessels over here.

0:14

We're going to scroll through these.

0:16

And again, we already see the

0:17

endometrium starting, and we have no IUD

0:20

where it should be.

0:22

It's definitely low.

0:23

We have all of our artifacts right here.

0:25

It's not really shadowing,

0:26

but we have those artifacts.

0:27

The IUD is low.

0:28

We've got that.

0:29

And we have this structure way out here.

0:31

That's definitely shadowing.

0:32

Is that a uterine

0:34

calcification in a 26-year-old?

0:36

That would be a little weird.

0:37

And atherosclerosis again,

0:38

she's too young for that.

0:40

This thing kind of keeps going.

0:44

And so again, looking at this, trying to

0:45

figure out what the heck is happening.

0:47

Here's my measurement of approximately

0:48

how far down it was, and it's

0:50

probably even underestimated.

0:51

Definitely too low, but again,

0:53

just giving our surgeons an idea.

0:55

So then we can go to the transverse uterus,

0:57

to see if that helps us figure out exactly what's

0:59

going on as we start to scroll through here.

1:03

Right there.

1:04

That's not normal.

1:05

We have the endometrium down here, right?

1:07

This is not in the endometrium.

1:08

This is clearly and definitely

1:11

in the myometrium right there.

1:13

We follow this down.

1:14

We do get into the

1:15

endometrium right here, right?

1:16

That's good.

1:18

But then there's shadowing.

1:19

We don't see the echogenic part, but

1:20

we do see the shadowing continues

1:23

posteriorly into the myometrium.

1:25

So a 3D in this particular case

1:27

isn't going to help you because we

1:28

already know it's in the myometrium.

1:30

You're not going to get it in the right planes.

1:31

It's not in the plane of the endometrium.

1:33

So, you can pick and choose what

1:36

you even try to 3D reconstruct.

1:38

We don't need it.

1:39

Not helpful in this particular case.

1:41

What is important, we know we very clearly

1:43

have embedment, significant embedment.

1:45

Next question is, do we

1:47

have serosal perforation?

1:50

There is this echogenic structure right here

1:52

that maybe it is, but it's hard to tell.

1:54

Is this contiguous with this?

1:56

If you're following that line, is that it?

1:58

Is it not?

1:58

Because that could change

1:59

management potentially.

2:02

So we got another cine clip

2:03

and here's your IUD body.

2:05

That's the structure of it right there.

2:06

And then you have this echogenic

2:08

structure, which looks just like an arm.

2:11

And so what she did was she stayed

2:12

perfectly still in this area,

2:14

let all the bowel move around it.

2:15

So you knew this wasn't just, you know,

2:17

some echogenic bowel contents or bowel gas

2:20

in it.

2:21

This structure stays still, and as

2:23

she just breathes and things move a

2:24

little bit, this moves with the uterus.

2:26

So this structure is part of the IUD.

2:29

It has perforated through and through.

2:32

So this IUD has only a bit

2:34

of itself in the endometrium.

2:36

Most of it is in the myometrium,

2:37

both anteriorly and posteriorly, and

2:39

then perforates out through the serosa.

2:42

One thing to keep in mind is perforation is

2:44

more frequent in patients who are lactating or

2:47

who are less than six months postpartum, and

2:50

this patient actually was about eight or nine

2:52

months postpartum at that point, so she was

2:54

sort of within that window, at least close to it.

2:56

So again, this is a myometrial penetration and

3:00

then a perforation through the serosa as well.

3:02

This would have to be surgically removed.