Interactive Transcript
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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.
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