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Percreta with Bladder Invasion

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This is an MRI of the abdomen and pelvis

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in a patient who presented at 19 weeks gestation

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from the Maternal-Fetal Medicine

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Clinic after abnormal obstetrical ultrasound.

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The patient had a history of

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multiple prior cesarean sections.

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Again, we've hung our steady-state free

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precession images on the left and our

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turbo spin-echo images on the right.

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We can see T2 heterogeneous

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myometrium in both cases.

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What's interesting about this case

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is that superior to the gestational

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sac within the uterine fundus,

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we see a T2 hyperintense structure that

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appears to be surrounded by the junctional zone.

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So this is the endometrial

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cavity for this patient.

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As we scroll inferiorly, we begin

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to see placental tissue, which

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has no overlying myometrium.

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There is frank extension of this placenta

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beyond the uterine serosa, and really there's

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an abrupt juxtaposition of myometrium here

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along the anterior aspect of the uterus.

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So there's myometrium and then

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a sharp demarcation between that

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tissue and the adjacent placenta.

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As we scroll inferiorly, we see

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additional placental tissue in the region

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of the cervix and the upper vagina.

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We also see prominent vessels in the

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left hemipelvis, which appear to be

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recruited from the left uterine artery.

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We can follow quickly the uterine

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arteries and identify their origin.

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So here's the abdominal aorta.

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This is the bifurcation.

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This is the left common iliac artery.

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It divides into external and internal divisions.

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This is the internal iliac artery.

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And then those anterior branches are

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the uterines, which seem to be directly

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recruited by the placenta here.

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These are coronal T2-weighted images of the

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abdomen and pelvis for the same patient.

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Again, in the coronal plane, we can see that

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the fundus of the uterus is relatively normal

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in appearance with T2 dark junctional zone,

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and then the T2 hyperintense endometrium.

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There is also T2 hypointense debris

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within the endometrial cavity superiorly.

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We see a sharply demarcated gestational sac

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with surrounding placenta, which is abruptly

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juxtaposed to the uterine myometrium.

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So again, we see T2 heterogeneous myometrium,

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which is directly abutting the placental tissue.

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The placenta is also heterogeneous

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with multiple placental bands, and

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it's relatively lobular in appearance.

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As we scroll anteriorly for this

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patient, we can see that there is really

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no intervening myometrium surrounding

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the placenta for this patient.

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Let's look at the sagittal

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images for this patient now.

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Again, we see the uterine fundus with a small

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amount of debris in the T2 hyperintense cavity.

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We also see the gestational sac, which

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contains a vertex presentation fetus,

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and T2 heterogeneous myometrium, which is

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directly abutting the gestational sac and

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the placenta, which we see inferiorly.

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Again, we see no overlying myometrium.

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As we try to trace it superiorly,

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there's an abrupt cutoff of the

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myometrium with the placenta located

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along the low anterior uterine segment.

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Importantly, as we scroll through the

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region of the low anterior uterine

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segment in the region of the bladder dome.

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If we attempt to trace the detrusor signal

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of the bladder, we can see that there's focal

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disruption of the bladder here posteriorly.

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And it's really only occurring on a single

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slice or one or two slices for this patient.

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And so this is the area where

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we see the bladder disrupted.

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And this was a site of focal bladder invasion.

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The appearance of this

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pregnancy is abnormal, right?

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We've not really been able to determine whether

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this gestation is within the endometrial cavity.

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And that's because this appearance is actually

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that of a cesarean scar ectopic pregnancy

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with an externalized placenta and placenta

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percreta focally invading the bladder dome.

Report

Faculty

Erin Gomez, MD

Assistant Professor of Radiology

Johns Hopkins Hospital

Tags

Women's Health

Uterus

MRI

Gynecologic (Gyn)

Gynecologic (GYN)

Genitourinary (GU)

Body

Bladder

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