0:02

So our next case is a patient who

0:03

presents with a positive pregnancy

0:05

test and comes in for confirmation of

0:06

pregnancy and for viability confirmation.

0:09

So we start with this ultrasound right here.

0:11

This is a cine clip.

0:14

So you can see the uterus right here in

0:16

a nice thickened endometrium, which

0:17

you want to see during pregnancy.

0:20

Except that we don't see pregnancy

0:22

in that particular endometrium,

0:23

but we do see one over here.

0:27

So in this particular cine clip,

0:28

we have a gestational sac, we have

0:29

a fetal pole, we have a yolk sac.

0:32

But in following this down, this is

0:34

separate from the structure right here.

0:35

So we have a Müllerian duct

0:37

anomaly right here.

0:39

It can be a little bit tricky to

0:40

decide what kind of anomaly you have

0:42

specifically once you're pregnant

0:43

because that can cause distortion, right?

0:45

Things are going to grow, they're

0:46

going to change, they're going

0:47

to shift due to mass effect.

0:48

So all you can do is kind of do your

0:50

best and figure out what this is.

0:52

In this particular case, you could

0:54

potentially go to MRI if you think it

0:56

will change the management at that time.

0:57

Otherwise, they should have an MRI

0:59

and follow up if it's not clear at

1:01

delivery exactly what they have.

1:02

So again, we have an IUP,

1:04

intrauterine pregnancy in one form.

1:06

This person came back later

1:10

and has an MRI here.

1:12

So here's your T2 field of view

1:16

and things that we're looking for.

1:17

Let me make that a little bit bigger.

1:19

We're going to look at our

1:19

fundal contour right here.

1:20

It's pretty flat.

1:22

We do have these sort of two disparate

1:24

horns right here, endometrium

1:25

over here, endometrium over here.

1:27

They come really close to one another

1:29

here, but they never actually fuse.

1:31

Those endometriums are still

1:32

two distinct endometriums.

1:34

They never fuse.

1:35

Then you have two openings down here

1:37

below, which would be the region of

1:39

two potential cervices.

1:42

And then we have the vagina here,

1:43

which is filled with blood products.

1:47

So trying to figure out what's going on

1:48

here, we can look at our coronals, see

1:50

if that helps us out, make a decision.

1:53

Again, the contour is better seen

1:54

on the axial field of view, but here

1:57

we can follow those endometriums.

1:59

Maybe they fuse there, maybe not.

2:02

We see two separate right here though.

2:04

Pretty much the whole time there's a structure

2:06

in between them the entire time until we get

2:08

this into the obstructed vagina right here.

2:13

This is going to be our pre-contrast.

2:15

Which isn't that helpful, except to show us

2:18

that there is surgical change right here,

2:20

and given where that is, she had a C-section.

2:22

And then we have blood

2:23

products down here as well.

2:26

This whole big structure though was

2:28

not blood products within it; there's

2:29

just little bits of blood in there.

2:32

And then finally, we have unilateral agenesis.

2:36

We have one kidney right here.

2:38

So this one, trying to figure out what we're

2:40

seeing right here, your differential, because

2:43

we have potentially two horns, two cervices,

2:46

you're going to consider uterine didelphys.

2:48

You're going to consider a bicornuate

2:50

bicollis, and bicollis means two cervices.

2:53

So, bicornuate uterus with two cervices, and

2:55

you need to consider a complete septate uterus.

2:58

So the septum goes completely all the way down.

3:01

So in that case, to differentiate between

3:02

those three structures, you're going

3:04

to need to look at the uterine contour.

3:05

In this particular case, it is flat.

3:08

This is essentially a normal uterine contour.

3:09

There's no dip.

3:10

Remember the didelphys cases; they were widely

3:13

disparate, going completely opposite directions.

3:15

There's no dip.

3:16

No concavity here.

3:17

This is a flat uterine contour that excludes

3:21

didelphys and then excludes a bicornuate uterus.

3:23

Therefore, this is a complete septate uterus.

3:26

Hard to tell that on the ultrasound itself.

3:28

If you had 3D imaging, you may

3:30

be able to figure that out.

3:32

to look at that fundal surface.

3:34

But again, once you have an IUP, that might

3:35

distort the one side of the cavity a little bit.

3:38

And it may be tricky to tell

3:39

what the true fundal contour is.

3:42

But in this particular case, the

3:43

MRI seals the deal right here.

3:45

This is a complete septate uterus.

3:47

The septum can go all the way

3:48

through the vagina as well.

3:50

It is important to keep that in mind.

3:52

And that's what happened in

3:53

this particular case too.

3:54

She did have a septum all the way through to

3:56

her vagina and that needed to be corrected.

3:59

Septate uteri do have a higher

4:03

risk of repeat miscarriages, and that

4:05

is because they can get pregnant.

4:08

But they may not be able to stay

4:09

pregnant if the embryo implants on

4:11

the septum. You can see here, it is very thin.

4:14

It might be fibrous tissue; it may not

4:16

even be myometrium right here, so

4:17

it's going to be very thin there.

4:18

It's not going to be supportive

4:20

nutrient-wise for the placenta to form this.

4:22

You often have repeated, relatively

4:24

early miscarriages in the septate uterus.

4:27

In this particular case, she had a C-section.

4:29

She did end up delivering, but

4:30

that's not always the case.

4:33

What was interesting in this case too,

4:34

this ended up being a conundrum the

4:36

entire time, and using the retrospective

4:38

scope, you could figure it out.

4:39

But at the C-section, she had it at 38 weeks; they

4:42

thought it was a didelphys, but they couldn't

4:44

definitely find that second cervix, which

4:46

was suggested, you know, in other imaging.

4:48

When they looked for retained products of

4:50

conception, because she had all that material

4:52

at that point, they only found the one cervix.

4:54

So they actually thought it

4:55

was a unicornuate uterus

4:56

with a rudimentary horn.

4:58

Although if you look at all of the imaging put

4:59

together, that's clearly not what this was.

5:02

Finally, at long last, a specialist

5:04

came in, looked over everything

5:06

again, and she was able to confidently

5:07

diagnose this as a septate uterus.

5:10

And it was such a complete septate

5:11

uterus that they had the hemi

5:13

obstructed left vagina right here.

5:15

So she reconstructed all of this.

5:18

Initially, she just did the vagina to relieve

5:20

this acute obstruction right there,

5:22

and then later resected the complete

5:23

septum to increase the patient's

5:25

fertility in the future if she wanted it.

5:28

So, teaching points for this kind

5:29

of case: the spacing of the horns.

5:32

How widely disparate are they?

5:33

Are they not that widely disparate?

5:35

If they're very wide, it's a didelphys.

5:37

If they're not that wide, consider

5:38

bicornuate, consider septate, as in this case.

5:43

Always look for a hemivagina.

5:45

If you have a hemivagina or a septum

5:47

in the vagina, then you're going

5:49

to consider didelphys or septate.

5:51

Those are the two most common to have those.

5:53

Bicornuate can, but it's much less common.

5:56

And then to decide between any of those,

5:58

depending on what else you see, you're going

6:00

to look at the fundal contour of the uterus,

6:02

and that's going to tell you whether it's

6:03

septate versus didelphys or bicornuate.