Interactive Transcript
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So our next case is a patient who
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presents with a positive pregnancy
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test and comes in for confirmation of
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pregnancy and for viability confirmation.
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So we start with this ultrasound right here.
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This is a cine clip.
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So you can see the uterus right here in
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a nice thickened endometrium, which
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you want to see during pregnancy.
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Except that we don't see pregnancy
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in that particular endometrium,
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but we do see one over here.
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So in this particular cine clip,
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we have a gestational sac, we have
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a fetal pole, we have a yolk sac.
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But in following this down, this is
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separate from the structure right here.
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So we have a Müllerian duct
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anomaly right here.
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It can be a little bit tricky to
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decide what kind of anomaly you have
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specifically once you're pregnant
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because that can cause distortion, right?
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Things are going to grow, they're
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going to change, they're going
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to shift due to mass effect.
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So all you can do is kind of do your
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best and figure out what this is.
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In this particular case, you could
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potentially go to MRI if you think it
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will change the management at that time.
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Otherwise, they should have an MRI
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and follow up if it's not clear at
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delivery exactly what they have.
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So again, we have an IUP,
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intrauterine pregnancy in one form.
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This person came back later
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and has an MRI here.
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So here's your T2 field of view
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and things that we're looking for.
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Let me make that a little bit bigger.
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We're going to look at our
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fundal contour right here.
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It's pretty flat.
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We do have these sort of two disparate
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horns right here, endometrium
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over here, endometrium over here.
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They come really close to one another
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here, but they never actually fuse.
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Those endometriums are still
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two distinct endometriums.
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They never fuse.
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Then you have two openings down here
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below, which would be the region of
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two potential cervices.
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And then we have the vagina here,
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which is filled with blood products.
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So trying to figure out what's going on
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here, we can look at our coronals, see
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if that helps us out, make a decision.
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Again, the contour is better seen
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on the axial field of view, but here
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we can follow those endometriums.
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Maybe they fuse there, maybe not.
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We see two separate right here though.
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Pretty much the whole time there's a structure
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in between them the entire time until we get
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this into the obstructed vagina right here.
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This is going to be our pre-contrast.
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Which isn't that helpful, except to show us
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that there is surgical change right here,
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and given where that is, she had a C-section.
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And then we have blood
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products down here as well.
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This whole big structure though was
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not blood products within it; there's
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just little bits of blood in there.
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And then finally, we have unilateral agenesis.
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We have one kidney right here.
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So this one, trying to figure out what we're
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seeing right here, your differential, because
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we have potentially two horns, two cervices,
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you're going to consider uterine didelphys.
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You're going to consider a bicornuate
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bicollis, and bicollis means two cervices.
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So, bicornuate uterus with two cervices, and
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you need to consider a complete septate uterus.
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So the septum goes completely all the way down.
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So in that case, to differentiate between
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those three structures, you're going
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to need to look at the uterine contour.
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In this particular case, it is flat.
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This is essentially a normal uterine contour.
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There's no dip.
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Remember the didelphys cases; they were widely
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disparate, going completely opposite directions.
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There's no dip.
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No concavity here.
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This is a flat uterine contour that excludes
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didelphys and then excludes a bicornuate uterus.
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Therefore, this is a complete septate uterus.
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Hard to tell that on the ultrasound itself.
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If you had 3D imaging, you may
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be able to figure that out.
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to look at that fundal surface.
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But again, once you have an IUP, that might
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distort the one side of the cavity a little bit.
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And it may be tricky to tell
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what the true fundal contour is.
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But in this particular case, the
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MRI seals the deal right here.
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This is a complete septate uterus.
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The septum can go all the way
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through the vagina as well.
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It is important to keep that in mind.
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And that's what happened in
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this particular case too.
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She did have a septum all the way through to
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her vagina and that needed to be corrected.
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Septate uteri do have a higher
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risk of repeat miscarriages, and that
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is because they can get pregnant.
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But they may not be able to stay
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pregnant if the embryo implants on
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the septum. You can see here, it is very thin.
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It might be fibrous tissue; it may not
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even be myometrium right here, so
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it's going to be very thin there.
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It's not going to be supportive
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nutrient-wise for the placenta to form this.
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You often have repeated, relatively
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early miscarriages in the septate uterus.
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In this particular case, she had a C-section.
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She did end up delivering, but
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that's not always the case.
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What was interesting in this case too,
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this ended up being a conundrum the
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entire time, and using the retrospective
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scope, you could figure it out.
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But at the C-section, she had it at 38 weeks; they
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thought it was a didelphys, but they couldn't
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definitely find that second cervix, which
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was suggested, you know, in other imaging.
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When they looked for retained products of
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conception, because she had all that material
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at that point, they only found the one cervix.
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So they actually thought it
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was a unicornuate uterus
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with a rudimentary horn.
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Although if you look at all of the imaging put
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together, that's clearly not what this was.
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Finally, at long last, a specialist
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came in, looked over everything
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again, and she was able to confidently
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diagnose this as a septate uterus.
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And it was such a complete septate
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uterus that they had the hemi
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obstructed left vagina right here.
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So she reconstructed all of this.
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Initially, she just did the vagina to relieve
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this acute obstruction right there,
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and then later resected the complete
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septum to increase the patient's
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fertility in the future if she wanted it.
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So, teaching points for this kind
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of case: the spacing of the horns.
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How widely disparate are they?
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Are they not that widely disparate?
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If they're very wide, it's a didelphys.
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If they're not that wide, consider
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bicornuate, consider septate, as in this case.
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Always look for a hemivagina.
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If you have a hemivagina or a septum
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in the vagina, then you're going
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to consider didelphys or septate.
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Those are the two most common to have those.
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Bicornuate can, but it's much less common.
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And then to decide between any of those,
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depending on what else you see, you're going
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to look at the fundal contour of the uterus,
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and that's going to tell you whether it's
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septate versus didelphys or bicornuate.
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