0:01

Our next case is a patient who's

0:03

34 years old with imaging of the pelvis

0:06

using a female pelvis MRI protocol.

0:08

This is our large field of view,

0:09

T2, without fat saturation.

0:12

We focus on the T2-weighted images for

0:14

female pelvis imaging because it shows you

0:16

nicely the distinction between the different

0:18

tissues, particularly of the uterus.

0:20

So that's where we do a lot of our

0:23

attention on that particular area.

0:25

So this is the large field of view.

0:26

T2.

0:27

And that's important because we can

0:28

see an ovary here on the left and

0:30

then we see our right ovary over here.

0:32

We have two normal-appearing bilateral ovaries.

0:34

As we come down a little bit lower,

0:36

we see this structure right next to the left

0:38

ovary, and then you see a uterus right here.

0:42

So let's get into our smaller field

0:43

of view, T2, and get a little bit more

0:45

detail about what's going on there.

0:47

We can see bits of the ovaries again right

0:48

there, but we're not that concerned about it.

0:50

We're concerned about what this structure is,

0:53

as well as this structure.

0:54

So you can see here we

0:55

have a single uterine horn.

0:57

It's deviated to the right and maybe it's a

0:59

little bit smaller than you would normally see.

1:01

The length looks pretty normal but the width

1:03

is certainly skinnier than you'd expect.

1:06

It then does look like it connects

1:07

to this structure right here.

1:09

You have vessels down here that somewhat

1:10

look like they connect right here.

1:12

So what this is, it's not an ovarian mass.

1:15

What this is, is a unicornuate uterus,

1:18

which is right here, with a rudimentary horn.

1:21

Now what's important when you're

1:22

looking at these, is to tell,

1:24

number one, is there a rudimentary horn?

1:26

And number two, does it have endometrium?

1:29

So in this case, that's

1:30

again why you want your T2s.

1:31

Your endometrium is going to be very bright

1:32

on your T2 weighted imaging, as it is here.

1:35

And we're going to look closely in

1:36

here, and we can see some T2 bright

1:38

signal within that rudimentary horn.

1:41

Here's a fat saturated version right here.

1:42

And again, your uterus looks pretty normal.

1:44

That right horn, this person

1:46

actually had a C-section scar right there.

1:48

So this was already a known diagnosis.

1:50

And your rudimentary horn is over

1:51

here and it has T2 bright in it.

1:53

So this has endometrium.

1:56

This patient as well, we looked up at

1:58

her kidneys and they both looked normal.

2:00

They were present in normal

2:01

positions with no anomalies there.

2:04

Usually if you're going to have a

2:05

uterine anomaly, it's going to be on

2:06

the same side as the rudimentary horn.

2:09

So if we To see anything, it would

2:11

be on the left side because the

2:12

left side is the rudimentary horn.

2:15

So in these particular patients, it's

2:16

absolutely vital to tell if there's that

2:18

rudimentary horn and if it has endometrium.

2:20

And that is because they're at risk

2:23

of ectopic if they have a rudimentary

2:25

horn because they have endometrium.

2:27

If they do not have any endometrium,

2:30

there's no place for an ectopic

2:31

really to get in there and to implant.

2:33

So you're not going to have that risk.

2:34

You can leave it in place and it's fine.

2:36

But if they have it, it needs

2:37

to be surgically removed.

2:39

They can also, if this is a non-communicating

2:42

rudimentary horn, no communication to

2:44

that other, more normal-appearing right

2:46

sided horn, you can have retained blood in

2:49

there, which can be painful, can increase

2:51

your risk of miscarriage in the other

2:53

horn, whether it's communicating or not,

2:55

because it acts on this inflammatory type

2:56

process, sort of like an endometriosis.

3:01

If you have a rudimentary horn with

3:02

endometrium, again, you're at a higher risk

3:04

of miscarriage in general, and all of these

3:07

have a risk of preterm labor, and that is

3:09

because this uterus is not quite a normal size.

3:12

So you're also at risk because it may not

3:13

expand as much as normal of IUGR in your

3:16

pregnancy, or intrauterine growth retardation,

3:19

for the same reason that that uterus doesn't

3:20

expand quite as much as a normal uterus.

3:22

complete uterus would, you are at

3:24

a higher risk of uterine rupture.

3:25

So these patients are going to be

3:26

watched throughout their pregnancy

3:28

to watch to see how the fetus is

3:30

growing and how the patient is doing.

3:33

Treatment of this, you can't treat

3:34

the unicornuate horn, that is what

3:36

it is, but you can surgically resect

3:38

that rudimentary horn if you have one.

3:40

Again, if it's non-cavitary, no

3:42

endometrium, you don't need to do that.

3:45

So in general, going back to our embryology

3:48

to understand what you're seeing here,

3:49

why this looks the way it does, this

3:51

is an incomplete or complete lack of

3:54

development of one of the Müllerian ducts

3:57

while the other one develops normally.

4:00

So again, just remember one horn only

4:02

look for that rudimentary horn, look

4:04

to see if it has endometrium within it.

4:07

And then if you can look to see if they

4:09

seem to be communicating or if they're

4:11

not communicating and that will help

4:13

the surgeon decide what to do next.