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Unknown case – Septate (Complete Septate Uterus)

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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.

Report

Faculty

Kathryn McGillen, MD

Assistant Professor of Radiology, Medical Director of Ultrasound

Penn State University Milton S Hershey Medical Center

Tags

Uterus

MRI

Genitourinary (GU)

Body

Acquired/Developmental

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