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Complete Septate MRI (Fibrous Septum)

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Our next case is of a 32-year-old

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female who has a pelvic MRI.

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Again, we'll start with our T2 axial,

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non-FATSAT, small image field of view.

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See an ovary over here, an ovary over here.

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Lots of tiny follicles.

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And then we have a uterine abnormality, right?

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A Müllerian duct abnormality.

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We have two horns here.

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Following the endometrium, that's

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going to be the easiest to try

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and tell if they ever fuse at all.

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And so far, they don't.

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We have our T2 dark junctional zone; you have

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T2 dark tissue between the cervices, as we get

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a little bit farther down, so they never fuse.

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We're going to keep following

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this down low, right?

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Don't just stop when you get to the cervix.

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Keep going down lower, lower, lower, to see

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if we can see anything abnormal going on.

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in the vaginal region.

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And I'd argue right here we have a

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little bit of T2 bright fluid in the

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vagina right here with these otherwise

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collapsed vaginal walls, which is normal.

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And it's unclear right here if

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these actually connect right here.

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Again, right here, it almost looks like a puzzle

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piece where they don't quite connect right here.

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There's tissue in between

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those areas right there.

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So I'd be suspicious that there's a

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vaginal septum or a problem down there.

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So, we need to look at that contour right

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that's what we need to do we know we

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have two distinct horns or differential

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septate versus didelphys versus bicornuate.

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So let's look at that frontal contour.

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Here's our uterus.

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We do have, you know, two quote

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unquote services at this point.

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Those are two horns, but our contour

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in this case is not even flat; it's

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not concave. It is convex right here.

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So that is a normal uterine contour.

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So we know this is a septate.

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And again, always check the vagina,

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whichever view you can best see it.

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Usually the axial I find is

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helpful, but it may not always be.

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So look on anyone that you find

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particularly helpful to look for

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a hemivagina or a vaginal septum.

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Here's another.

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This is the in-plane type of imaging right here,

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where you can see everything is nicely laid out.

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And you can see how you could

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almost think this is a didelphys.

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It looks like two cervices.

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These never actually fuse together.

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There's always something in between them.

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However, that contour is completely normal,

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and these horns are not that widely spaced.

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Therefore, it is not a didelphys.

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This is a septate uterus.

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So, septates occur as a result of

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incomplete resorption of the septum.

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So, a didelphys is they don't fuse completely.

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A septate fuses completely, but where the

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walls fuse together, that needs to resorb.

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The structure between them and

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a septate, it does not happen.

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So, because the ducts are fused, the fundal

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contour is normal because, again, it is a

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resorption problem, not a fusion problem.

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The fundus is normal.

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Okay, in this particular patient, two kidneys.

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Two normal-appearing kidneys right here.

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Other things to consider.

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If you can, on a T2, if you can tell the surgeon

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whether it is a fibrous or muscular septum,

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that is helpful in their preoperative management

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and how much of the septum they can take out.

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This particular sample, it's T2 dark,

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so most of the septum, if not almost

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all of it, is going to be fibrous.

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That's easy to come out.

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It's also a higher risk for miscarriage

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because there's not a whole lot of

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vascularity to support the pregnancy there.

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The myometrium is right up here, right?

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That's that little dip right there.

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But most of the septum is going

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to be T2 dark fibrous septum.

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It's important to measure

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the length of the septum.

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And that's because the surgeon,

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again, it is helpful for them to know.

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So you can also measure the angle of

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the cavities to help differentiate

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whether it's a septum or a

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bicornuate uterus versus a didelphys.

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It's in the literature what the different

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angles mean, but generally less than 75-degree

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angle versus a 105-degree angle, and that's

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for septum versus bicornuate or didelphys.

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So the septum is generally

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going to be closer together.

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But there is overlap, and this is

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generally decided upon when they were

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doing HSGs or hysterosalpingograms,

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when the contour wasn't visible.

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In general, the fundus should be greater than

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5 millimeters from the intercornEal line.

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That will help you diagnose a septate.

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So the way to do that is you make

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a measurement from the intercorneal

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line, which would be right around here.

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And then you'll measure it up to the fundus.

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So it needs to be at least

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5 millimeters to be a septate.

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And this one's nearly 7 millimeters.

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Also, again, proving that we

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have a septate uterus right here.

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However, the surgeon doesn't

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really care about that.

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That's helpful for you diagnosing,

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but that's not information that

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they particularly find useful in how

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they're going to care for this patient.

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What they want is the length of the septum

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and they want it from the intercorneal line.

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So we're going to delete that measurement

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and you're going to measure again from

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the intercorneal line right here and

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you're going to measure it straight

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down as far as you can see that septum.

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So let's say it's approximately right here.

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So that makes this septum approximately

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6.1 centimeters in length, and that's

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going to again help the surgeon plan

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exactly what they're going to do here.

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So in this case, this was presented

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as an unknown as well, because from a

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gynecology ultrasound, they thought it

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was a didelphys, again, because it looked

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like there were two services right there.

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In the particular case, which I'm not showing,

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there was a baby in each quote-unquote horn.

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At C-section though, they found

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it was a complete septate.

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The patient did have a history of

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infertility and a number of early

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or mid-pregnancy miscarriages.

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That's common with septate.

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They can get pregnant.

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But they may not be able to carry it to

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term or can't support it even to viability.

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So you can resect this septate, and you can

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increase your fertility rates very successfully.

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And again, always remember, look

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for the hemivagina or the septum

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going down into the vagina as well.

Report

Faculty

Kathryn McGillen, MD

Assistant Professor of Radiology, Medical Director of Ultrasound

Penn State University Milton S Hershey Medical Center

Tags

Uterus

MRI

Gynecologic (GYN)

Body

Acquired/Developmental

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