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This patient's a 32-year-old who's postpartum.

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She'd had retained products of conception

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related to this pregnancy twice and then

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represents with recurrent bleeding again.

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So here's our sagittal imaging of the

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uterus, and you can see lower down,

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we have echogenic thin endometrial stripe.

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We have a measurement there around

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eight millimeters or so, but as we keep

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scrolling, it gets thicker and thicker.

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And again, here's part of the stripe here is

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it pushed aside by this structure back here.

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And again, an anechoic tubular

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and somewhat rounded structure

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as well in this particular area.

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So she'd already gone to the operating

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room twice for retained products of

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conception, and then we found this

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structure here with her recurrent bleeding.

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We did do color Doppler flow on this,

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and you can see this completely fills in

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right here.

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So we were concerned here that this was actually

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a true AVM in her particular case and we weren't

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quite sure all of this material right here in

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the endometrium. Is this going to be recurrent

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retained products of conception for the third

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time, or is this just going to be hematoma?

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And given the presence of this, which

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wasn't there on her prior ultrasound

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when she was diagnosed with the retained

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products of conception, our gynecologist

1:15

colleagues didn't want to take her back to

1:16

the operating room a third time with this.

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So they pushed her towards CVIR intervention,

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where we're going to embolize this.

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But for embolization for IR, you cannot

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have retained products of conception,

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because if you do and you embolize

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that, the patient can become septic.

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It's also important to note here.

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Here is our low resistance waveform when

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we put our spectral Doppler on here.

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In her case, it wasn't particularly high.

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If it's greater than 80 centimeters

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per second, that is more suggestive that

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this is not going to go away on its own.

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And this one wasn't that high,

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but we got it up to around 50 or so.

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But again, she was bleeding and she

1:51

had contraindications for surgery.

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So again, jumping back, we need to make

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sure before they go to embolization

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that we're absolutely sure this is

1:58

not retained products of conception.

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And you can see on here, there really

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isn't much vascularity here, so we're

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pretty sure this was all just blood clot.

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But if we could be as sure as

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possible, that's what we wanted to be

2:07

before sending her to embolization.

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So what we did is we gave

2:10

a little bit of contrast.

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So this is your grayscale image over here.

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It's going to be a low B mode.

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So the images are not as pretty, and this

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is going to be your contrast imaging.

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So anything that's bright is enhancing, except

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for your hard acoustic interfaces here, which

2:23

are going to be intrinsically bright here.

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So we'll inject the contrast.

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You can see again, she's breathing a little bit.

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We're starting to sweep a little bit,

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and you can see the contrast bubbles

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start to come in and they fill that cystic

2:37

area very, very quickly, very quickly.

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So we thought this was most likely

2:41

going to be an AVM. And as we keep going,

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we keep sweeping through.

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The uterus itself enhances as expected,

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and then we start to get to the endometrial stripe

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here and you can see we're in that area of

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heterogeneity, right there, the stripe there.

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This is some of the

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heterogeneous portions of it.

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And it's not enhancing.

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If you have retained products of conception,

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I would expect that to enhance because

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that is a vascularized material,

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whereas a hematoma is avascular and

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you can see here, our AVM is

3:10

poking in a little bit to that

3:11

endometrial canal, but none of the

3:13

material in the endometrium is enhancing.

3:15

We could confidently diagnose that

3:17

this was all just blood product.

3:19

She did not have recurrent retained products of

3:20

conception, but she did have what is

3:22

most likely a vascular malformation.

3:25

So she did end up going to interventional

3:27

radiology and successfully embolized.

3:30

And you can see on some of her post-

3:31

contrast imaging a few weeks later,

3:35

her endometrium was great, nice and thin,

3:37

maybe a few little calcifications,

3:40

but that vascular lesion is now gone.

3:42

Her bleeding had stopped,

3:46

and so we were just going to continue to

3:47

watch her for a little bit and counsel

3:49

against getting pregnant again until we're

3:52

absolutely sure everything had resolved.

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But this was, she was embolized

3:56

with gel foam to preserve fertility.

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It's also probably going to account

3:59

for some of these little echogenic

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foci that we're seeing, not all

4:02

necessarily going to be calcifications,

4:04

but the result of the embolization products.