0:01

Our next case is a 31-year-old

0:03

who came in for an IUD check.

0:05

We'll start with the cine clips.

0:06

So on our transverse cine clip through it again,

0:08

trying to figure out how that IUD is placed,

0:13

see a little bit of shadowing over here.

0:15

There's your IUD off to one

0:16

side, which is abnormal.

0:19

So you come down towards the cervix,

0:20

you see a sort of branch point.

0:22

So maybe these are the arms down here and it's

0:24

really hard to tell honestly what's going on

0:26

there, except that it's definitely abnormal.

0:29

Maybe it's completely flipped

0:31

upside down and tilted.

0:34

The still images didn't really

0:37

help either, as you could imagine.

0:38

But we got 3D images on this particular patient.

0:42

This was an older machine, so the 3D technology

0:44

was a little bit different at that point.

0:46

So this is all what our sonographer

0:48

had to actually manually take out.

0:50

And so she gave us a couple of different

0:51

examples, and that's why these are

0:53

going to look a little bit different

0:54

from some of the 3Ds I've shown before.

0:56

This is going to be in general

0:57

your fundal contour up here.

0:59

And here you can see a shadowing

1:00

of an IUD right here, right?

1:02

Those look like the arms right here.

1:04

She tries a little bit more to figure

1:06

out if this, you know, is the better view.

1:07

And here, I think you can really

1:09

see the contour a bit better.

1:10

You can even see the endometrial cavity

1:12

up here, and now you can see the arms a

1:14

little bit better, and here's the body of

1:16

that IUD. And so what's happening here is

1:19

if you follow the endometrium right here,

1:21

you see it's almost tenting right here.

1:23

It's pushed right here, and that's by this

1:25

arm right here, so this is not embedded in the

1:27

myometrium per se. It's just pushing on, it's

1:31

kind of tenting there; it didn't go through it.

1:33

However, this one just kind of

1:34

keeps going and going and going.

1:36

So we thought this right arm was

1:38

embedded into the myometrium.

1:40

And sometimes they can remove these if

1:42

it's just embedded a little bit, but if

1:44

it looks to be significantly embedded,

1:46

and again, that's a subjective term.

1:49

They might need hysteroscopic removal

1:50

with some sedation to get that out.

1:52

So it's important to note whether it's embedded

1:54

into the myometrium, and if so, how much.

1:58

Again, embedded is referring

1:59

to the myometrium itself.

2:02

And perforation is in regard to going

2:04

through the uterine serosa, either partially

2:06

or totally into the abdominal cavity.

2:08

And those are always going

2:09

to be surgical management.

2:11

Here's another one that she tried.

2:12

This was a grayscale one.

2:13

We flipped it onto its side right here.

2:15

The endometrium is over here.

2:16

The fundus would be somewhere up here.

2:18

Again, there's your IUD right there.

2:20

Again, we're just kind of playing around,

2:21

trying to figure out the best way to show

2:23

you that this one was tenting and that

2:24

this one was going through and through,

2:26

embedding deep into the myometrium.

2:28

And it's always important to remember,

2:30

too, that if you do not find the IUD, you

2:33

can try and look with an ultrasound to

2:34

see if you can see it nearby the uterus.

2:36

I've had luck with that one time, one time only.

2:39

But your differential then is either it

2:41

expelled and the patient didn’t know, which

2:42

is more common than you might imagine.

2:44

But you always need to get an abdominal

2:46

X-ray at that point to look to see if

2:48

it’s in the abdominal cavity or not.

2:50

Because that’s a diagnosis

2:51

of exclusion is an expulsion.

2:53

Otherwise, you have to look

2:54

for it in the abdominal cavity.