0:01

So this is a 30-year-old patient who

0:03

had a recent miscarriage and now has

0:05

recurrent heavy bleeding with clots.

0:07

So she gets her ultrasound.

0:08

We see all of our blood vessels

0:10

out in the periphery of the uterus.

0:11

So far a normal endometrium up here,

0:13

nice and bright, relatively thin.

0:16

As we keep going, we see this

0:17

heterogeneously hypoechoic structure that it's hard to

0:20

tell is it pushing the endometrium or

0:22

is it partially in the endometrium.

0:24

Again, we've lost that interface,

0:26

the interface here, interface here, we don't

0:28

have an interface, very smooth transition

0:30

between the endometrium and myometrium here.

0:32

And we have the cystic structure.

0:36

And then some heterogeneous material as well.

0:39

So at this point, it's hard to

0:40

tell exactly what's going on.

0:41

She does have heavy bleeding with clots.

0:44

Is this a vascular malformation?

0:46

Is this retained products of conception?

0:48

Is it blood clot?

0:48

Is it both?

0:50

So let's go to our color Doppler flow.

0:52

And here we have a nice split-screen

0:53

image of your grayscale over here and

0:55

your color Doppler right next to it.

0:57

So as we scroll through here, and you can see

0:59

the endometrium has very little flow to it as it

1:01

normally should only have a little bit of flow

1:03

to it, but already in this sort of more hypoechoic

1:06

structure here, you can see blood flow coming

1:08

from the myometrium right into this structure.

1:10

So we have a quite vascular structure

1:12

right tons of blood flow here.

1:14

Here's your normal myometrial blood flow

1:16

anteriorly, a little bit here and there.

1:18

Lots of blood flow back here so this isn't normal.

1:22

And then we concentrate on

1:23

the cystic area right here.

1:24

We were thinking of, could this

1:25

be a vascular malformation?

1:27

If it is, a surgeon needs to know that before

1:29

they, they go into potentially remove this.

1:32

If you think that there's also

1:33

retained products of conception.

1:35

And so we put a color Doppler flow

1:36

and there is some filling in it.

1:37

There definitely is,

1:39

but it's incomplete flowing.

1:40

We also don't see a yin yang appearance

1:42

that you can see with, you know,

1:43

say a pseudoaneurysm, but there's

1:45

definitely flow within this structure.

1:48

And then there's definitely flow

1:49

within the material here that

1:51

I think is partially within the canal.

1:55

So in a case like this, you start to think this

1:57

is probably retained products of conception, but

1:59

again, you need the clinical diagnosis as well.

2:03

But you also need to start thinking of something

2:04

called EMV or enhanced myometrial vascularity.

2:08

We used to call all of these AVMs, but more

2:10

literature has recently shown that these

2:13

are probably not all actually true arteriovenous

2:16

malformations, but something called

2:18

EMV, which is enhanced myometrial vascularity.

2:22

And so what that is, is it

2:23

increased blood flow in the myometrium following

2:26

or associated with an abnormal pregnancy.

2:29

It can be associated with a subinvolution of

2:31

the placental bed, and it can be associated

2:33

with retained products of conception.

2:35

So I think that's what we probably have here.

2:37

We probably have some retained products of

2:38

conception that's in the endometrial canal.

2:41

Now we have all of this vascularity

2:42

that's in the myometrium, right?

2:44

It's out here where a lot of

2:45

this abnormality is, right?

2:47

But it looks very much like myometrium itself.

2:49

It's very similar density out here.

2:52

It's not heterogeneous.

2:54

So this is probably a bit of both here.

2:55

We have EMV out here and then we have

2:58

retained products of conception in here.

3:01

So EMV can be transient.

3:03

So if the bleeding is not too significant,

3:05

they can just do serial ultrasounds

3:07

as long as the patient is stable

3:08

because it may resolve on its own.

3:10

It's also important that if you see this, that

3:12

it's not necessarily a contraindication to

3:14

removal of retained products of conception.

3:16

If they're bleeding and need to have

3:17

it out, then they need to have it out.

3:19

But it's important to mention, especially

3:21

if you see a more dilated cystic, cystic

3:24

space like this, that partially fills in

3:26

on your color Doppler flow because

3:29

the surgeon needs to be aware that that's

3:31

there in case there is an actual AVM there.

3:34

They need to know it's there so they

3:36

can kind of work around it and be

3:37

aware of that in case the patient does

3:39

crash or start to bleed significantly.

3:42

So this patient ultimately did end up

3:43

going to the operating room and was proven

3:45

to have retained products of conception

3:47

and no vascular malformation was seen.

3:49

So again, one last thing to remember,

3:51

EMV, these are characterized by these

3:52

kind of cystic or tubular anechoic

3:54

structures, lots of vascularity.

3:57

If you put a color spectral Doppler box on

4:00

there, you'll get a higher peak velocity

4:02

than you would the rest of the uterus

4:04

and you'll see a low resistance waveform.