0:01

Our next case is a 26-year-old

0:03

who presented with abnormal uterine bleeding,

0:05

and so started with an ultrasound.

0:07

There are still images.

0:08

You can see it's a little bit of free

0:09

fluid near the rectum and the cul de sac.

0:11

We're at the level of the cervix.

0:12

This is a little bit of vaginal

0:14

tissue here, external os here,

0:16

cervix coming through here.

0:18

So far so good.

0:21

Continue through,

0:21

everything looks normal so far.

0:22

We have a nice sagittal uterus picture.

0:24

Looks very much like the normal

0:25

anatomies that we saw earlier on.

0:29

It's a little bit thin at

0:30

2.5 centimeters width though,

0:32

but maybe within normal.

0:34

As we keep going, now we're labeling this left.

0:38

We get to the 3D imaging here

0:40

where they're acquiring them.

0:40

You can already see little snippets

0:42

where we have two divergent endometriums.

0:44

And now we're labeled right.

0:46

So our technologist here is telling us that

0:48

there are two separate endometriums right here.

0:53

She's now coming up through the cervix where it

0:54

looks like there's one endometrial canal in the

0:58

lower uterine segment and then they diverge.

1:00

Again, endometrium here, endometrium here,

1:02

diverge, fairly widely

1:04

unlike the last case that we saw.

1:06

Pretty wide divergent right here.

1:09

Let me get to the ovaries.

1:10

So it's important to note here

1:12

that we can't see a fundal contour.

1:13

You can try on your cine clips and this

1:15

is going to be our transverse cine clip

1:17

here, starting at the level of the cervix

1:21

and moving up one endometrial cavity.

1:25

And they diverge,

1:28

but you can't tell what the

1:29

fundal contour looks like.

1:31

Sagittal, you can make a good educated guess.

1:34

There's going to be one horn or one endometrium.

1:36

Your contour is right here.

1:37

I'm going to leave my mouse right here.

1:39

As we scroll through it, you can see it kind

1:41

of goes down a little bit below my mouse

1:44

before it comes back up to meet the mouse.

1:46

This one actually goes a little bit higher.

1:47

So it's hard to say, you know, are we

1:49

just slightly off axis, or is there

1:51

definitely a dip in that fundal contour?

1:53

So this is when your 3Ds are going to

1:55

become really, really, really important.

1:57

So we'll skip through the rest of these images.

1:59

3D here, not particularly gorgeous images.

2:01

61 00:02:03,539 --> 00:02:04,589 It can be a little bit hard when

2:04

you have two different uterine horns

2:06

that may not be perfectly in plane.

2:07

So you can see here we have endometrium here,

2:09

endometrium here, and just like what we saw

2:12

in our cineclips, they do fuse down here.

2:14

There is a fusion.

2:15

This is not a didelphys.

2:16

We do not have two cervixes.

2:17

We have one cervix.

2:19

We do have two horns right here, and I would

2:21

argue this is definitely dipping down here.

2:24

You could measure, for example,

2:30

like this, to see how widely disparate they are.

2:32

That's 49 degrees.

2:34

But I think you can also tell just visually,

2:36

this is definitely a cleft right here.

2:39

This is going to be an incomplete

2:40

mullerian duct fusion at the fundus.

2:42

They did fuse normally down here.

2:44

And that cleft greater than one centimeter,

2:46

that external contour, which we definitely have

2:49

here, that gives us a diagnosis of bicornuate.

2:52

It is important, as I said, if you have

2:54

an obstructive vagina or vaginal septum.

2:57

It's usually going to be a didelphys

2:58

or a septate uterus, but 25%

3:01

of bicornuates also have them.

3:02

So it's important just to keep that in mind,

3:04

although it's certainly a lot less common.

3:06

You can see here too, our tech went through a

3:08

little bit trying to get you the best possible

3:10

image of that fundal contour, but you can see

3:13

there's always that kind of little divot right

3:15

there where it failed to fuse right there.

3:18

So this is a bicornuate uterus.