Interactive Transcript
0:01
Our next case is of a 32-year-old
0:03
female who has a pelvic MRI.
0:07
Again, we'll start with our T2 axial,
0:09
non-FATSAT, small image field of view.
0:13
See an ovary over here, an ovary over here.
0:17
Lots of tiny follicles.
0:19
And then we have a uterine abnormality, right?
0:21
A Müllerian duct abnormality.
0:23
We have two horns here.
0:25
Following the endometrium, that's
0:26
going to be the easiest to try
0:27
and tell if they ever fuse at all.
0:29
And so far, they don't.
0:31
We have our T2 dark junctional zone; you have
0:33
T2 dark tissue between the cervices, as we get
0:36
a little bit farther down, so they never fuse.
0:38
We're going to keep following
0:39
this down low, right?
0:40
Don't just stop when you get to the cervix.
0:41
Keep going down lower, lower, lower, to see
0:44
if we can see anything abnormal going on.
0:47
in the vaginal region.
0:48
And I'd argue right here we have a
0:49
little bit of T2 bright fluid in the
0:52
vagina right here with these otherwise
0:53
collapsed vaginal walls, which is normal.
0:56
And it's unclear right here if
0:57
these actually connect right here.
1:00
Again, right here, it almost looks like a puzzle
1:02
piece where they don't quite connect right here.
1:04
There's tissue in between
1:05
those areas right there.
1:07
So I'd be suspicious that there's a
1:09
vaginal septum or a problem down there.
1:12
So, we need to look at that contour right
1:14
that's what we need to do we know we
1:15
have two distinct horns or differential
1:17
septate versus didelphys versus bicornuate.
1:20
So let's look at that frontal contour.
1:23
Here's our uterus.
1:24
We do have, you know, two quote
1:26
unquote services at this point.
1:28
Those are two horns, but our contour
1:30
in this case is not even flat; it's
1:33
not concave. It is convex right here.
1:35
So that is a normal uterine contour.
1:38
So we know this is a septate.
1:39
And again, always check the vagina,
1:41
whichever view you can best see it.
1:43
Usually the axial I find is
1:44
helpful, but it may not always be.
1:47
So look on anyone that you find
1:48
particularly helpful to look for
1:50
a hemivagina or a vaginal septum.
1:53
Here's another.
1:53
This is the in-plane type of imaging right here,
1:56
where you can see everything is nicely laid out.
1:58
And you can see how you could
1:59
almost think this is a didelphys.
2:01
It looks like two cervices.
2:02
These never actually fuse together.
2:04
There's always something in between them.
2:06
However, that contour is completely normal,
2:09
and these horns are not that widely spaced.
2:11
Therefore, it is not a didelphys.
2:13
This is a septate uterus.
2:15
So, septates occur as a result of
2:17
incomplete resorption of the septum.
2:20
So, a didelphys is they don't fuse completely.
2:23
A septate fuses completely, but where the
2:25
walls fuse together, that needs to resorb.
2:28
The structure between them and
2:29
a septate, it does not happen.
2:32
So, because the ducts are fused, the fundal
2:35
contour is normal because, again, it is a
2:37
resorption problem, not a fusion problem.
2:39
The fundus is normal.
2:41
Okay, in this particular patient, two kidneys.
2:44
Two normal-appearing kidneys right here.
2:48
Other things to consider.
2:50
If you can, on a T2, if you can tell the surgeon
2:53
whether it is a fibrous or muscular septum,
2:55
that is helpful in their preoperative management
2:58
and how much of the septum they can take out.
3:00
This particular sample, it's T2 dark,
3:02
so most of the septum, if not almost
3:04
all of it, is going to be fibrous.
3:05
That's easy to come out.
3:07
It's also a higher risk for miscarriage
3:08
because there's not a whole lot of
3:09
vascularity to support the pregnancy there.
3:12
The myometrium is right up here, right?
3:14
That's that little dip right there.
3:15
But most of the septum is going
3:17
to be T2 dark fibrous septum.
3:20
It's important to measure
3:21
the length of the septum.
3:23
And that's because the surgeon,
3:24
again, it is helpful for them to know.
3:27
So you can also measure the angle of
3:28
the cavities to help differentiate
3:30
whether it's a septum or a
3:31
bicornuate uterus versus a didelphys.
3:35
It's in the literature what the different
3:36
angles mean, but generally less than 75-degree
3:40
angle versus a 105-degree angle, and that's
3:42
for septum versus bicornuate or didelphys.
3:45
So the septum is generally
3:46
going to be closer together.
3:49
But there is overlap, and this is
3:50
generally decided upon when they were
3:52
doing HSGs or hysterosalpingograms,
3:55
when the contour wasn't visible.
3:59
In general, the fundus should be greater than
4:01
5 millimeters from the intercornEal line.
4:04
That will help you diagnose a septate.
4:05
So the way to do that is you make
4:07
a measurement from the intercorneal
4:08
line, which would be right around here.
4:11
And then you'll measure it up to the fundus.
4:13
So it needs to be at least
4:14
5 millimeters to be a septate.
4:16
And this one's nearly 7 millimeters.
4:18
Also, again, proving that we
4:19
have a septate uterus right here.
4:22
However, the surgeon doesn't
4:23
really care about that.
4:24
That's helpful for you diagnosing,
4:26
but that's not information that
4:27
they particularly find useful in how
4:30
they're going to care for this patient.
4:32
What they want is the length of the septum
4:34
and they want it from the intercorneal line.
4:36
So we're going to delete that measurement
4:39
and you're going to measure again from
4:40
the intercorneal line right here and
4:42
you're going to measure it straight
4:43
down as far as you can see that septum.
4:45
So let's say it's approximately right here.
4:47
So that makes this septum approximately
4:49
6.1 centimeters in length, and that's
4:51
going to again help the surgeon plan
4:53
exactly what they're going to do here.
4:57
So in this case, this was presented
4:58
as an unknown as well, because from a
5:01
gynecology ultrasound, they thought it
5:02
was a didelphys, again, because it looked
5:04
like there were two services right there.
5:07
In the particular case, which I'm not showing,
5:08
there was a baby in each quote-unquote horn.
5:12
At C-section though, they found
5:13
it was a complete septate.
5:15
The patient did have a history of
5:16
infertility and a number of early
5:18
or mid-pregnancy miscarriages.
5:19
That's common with septate.
5:21
They can get pregnant.
5:22
But they may not be able to carry it to
5:25
term or can't support it even to viability.
5:28
So you can resect this septate, and you can
5:31
increase your fertility rates very successfully.
5:34
And again, always remember, look
5:36
for the hemivagina or the septum
5:38
going down into the vagina as well.
© 2024 MRI Online. All Rights Reserved.