Interactive Transcript
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Okay, so our first lesson is
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Müllerian duct abnormalities,
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so we'll have to go all the way back to
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embryology, which is everyone's favorite topic.
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So, during embryology, you have
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paired embryologic structures,
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which are the Müllerian ducts.
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You have development, you have fusion, and
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then you have resorption, all occurring in
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utero at approximately the 6 to 11 week mark.
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And this forms the uterus, the
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fallopian tubes, the cervix, and the
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proximal two-thirds of the vagina.
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And that's important because that's what
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you're going to see when errors occur.
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That's going to result in your Müllerian duct
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abnormalities in those specific structures.
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So that's what you'll need to look for.
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So, interruption of these events, these result
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in the MDAs, the Müllerian Duct Anomalies.
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They can be associated with renal anomalies,
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remember the GU system, but they are
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not associated with ovarian anomalies.
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That's a different system
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there with how these form.
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So why are these important?
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It's important because 15 percent of patients
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who have repeated miscarriages end up having
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an MDA and that can be either fixed or
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counseled to figure out what you can do next.
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So in general, if you think
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you're up against an M.
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D.
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A.
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and trying to figure out what exactly it
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is that you're seeing to help guide the
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surgeon or the OBGYN about what to do next.
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You always consider the number
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of horns that are present.
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Is it one or is it two?
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And then the spacing of those horns.
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Are they together?
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Are they widely divergent?
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You want to note how many cervixes there are.
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Are there one or are there two?
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And then the fundal contour of the uterus.
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Is it flat?
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Is it concave?
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Is it convex, or how much so?
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And that's going to help you decide what it
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is that you're looking at and help with surgical
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planning if it's a surgical type of case.
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So different types.
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We have the agenesis on one side where different
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parts of the Müllerian ducts don't form at all.
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And then you have the arcuate uterus.
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That one is a little bit tricky, whether that's
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actually an anomaly or not, or just a border
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of a normal variant, particularly right there.
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We'll talk about that a little bit more later.
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The rest of these are going to be
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either fusion problems or they're
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going to be resorption problems.
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And that's a good way to think of it when
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you're trying to figure out what's going on.
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I will note that this list is not inclusive.
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For example, a lot of this stuff
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is going to be on a spectrum.
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Even just starting with agenesis, you can have
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varying degrees of hypoplasia or agenesis.
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Something may not fit particularly
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into a single category.
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And if that's what you find that you have
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in front of you at that particular time,
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the best thing to do is just describe it
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for that surgeon to be able to figure out what
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they're seeing, if they're going to take them
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to the operating room and to best counsel them.
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Overall, it's estimated about 5
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percent of women will have an M.
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D.
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A.
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There are differing reports, though,
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as to what the most common is.
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But most people think that it's likely
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the septate uterus that is most common.
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Jumping back to that argument, that's
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an incomplete resorption problem.
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The two ducts fuse together, but then the wall
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in between them doesn't completely resorb,
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but it results in a near-normal appearance and
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usually does not have an effect on fertility.
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Generally, you don't get surgery for
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these or anything to correct them.
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But if you have repeated pregnancy loss
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without any other imaging factors, they
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may consider it on a case-by-case basis.
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It's also important to know that you're usually
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going to start these on ultrasound due to
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the presenting symptoms and the availability.
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So these may be a little bit difficult
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to talk about the contour of the uterus,
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which is one of the important things,
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but with the availability of 3D, you're
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really going to need to rely on that.
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However, if it's complex or it's unclear
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and you're not sure what's going on, MRI
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is the gold standard of imaging for this,
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but you do need a very specific protocol.
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So it is important to keep in mind
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you'll need a small T2 field of view.
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And again, we'll go over these in a little bit.
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You need a plane to lay out the uterus
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as much as possible so that you can
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measure a septum if it's present.
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So the surgeon knows what they
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are going to see and how much they
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may need to potentially operate.
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And then you need to appreciate that
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frontal contour, which is why you need
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the uterus to lay out in one single plane.
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You also need T1 to look for retained
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blood products, and you should get
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a view of the kidneys as well to
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look for any associated anomalies.
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And you can do that via MRI or ultrasound.
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In general, about 30 to 50 percent
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of these will have a renal anomaly.
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The most common is unilateral agenesis,
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but you can also see things such as atresia,
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hypoplasia, fusion, malrotation, and duplication.
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