Interactive Transcript
0:01
So this is a 30-year-old patient who
0:03
had a recent miscarriage and now has
0:05
recurrent heavy bleeding with clots.
0:07
So she gets her ultrasound.
0:08
We see all of our blood vessels
0:10
out in the periphery of the uterus.
0:11
So far a normal endometrium up here,
0:13
nice and bright, relatively thin.
0:16
As we keep going, we see this
0:17
heterogeneously hypoechoic structure that it's hard to
0:20
tell is it pushing the endometrium or
0:22
is it partially in the endometrium.
0:24
Again, we've lost that interface,
0:26
the interface here, interface here, we don't
0:28
have an interface, very smooth transition
0:30
between the endometrium and myometrium here.
0:32
And we have the cystic structure.
0:36
And then some heterogeneous material as well.
0:39
So at this point, it's hard to
0:40
tell exactly what's going on.
0:41
She does have heavy bleeding with clots.
0:44
Is this a vascular malformation?
0:46
Is this retained products of conception?
0:48
Is it blood clot?
0:48
Is it both?
0:50
So let's go to our color Doppler flow.
0:52
And here we have a nice split-screen
0:53
image of your grayscale over here and
0:55
your color Doppler right next to it.
0:57
So as we scroll through here, and you can see
0:59
the endometrium has very little flow to it as it
1:01
normally should only have a little bit of flow
1:03
to it, but already in this sort of more hypoechoic
1:06
structure here, you can see blood flow coming
1:08
from the myometrium right into this structure.
1:10
So we have a quite vascular structure
1:12
right tons of blood flow here.
1:14
Here's your normal myometrial blood flow
1:16
anteriorly, a little bit here and there.
1:18
Lots of blood flow back here so this isn't normal.
1:22
And then we concentrate on
1:23
the cystic area right here.
1:24
We were thinking of, could this
1:25
be a vascular malformation?
1:27
If it is, a surgeon needs to know that before
1:29
they, they go into potentially remove this.
1:32
If you think that there's also
1:33
retained products of conception.
1:35
And so we put a color Doppler flow
1:36
and there is some filling in it.
1:37
There definitely is,
1:39
but it's incomplete flowing.
1:40
We also don't see a yin yang appearance
1:42
that you can see with, you know,
1:43
say a pseudoaneurysm, but there's
1:45
definitely flow within this structure.
1:48
And then there's definitely flow
1:49
within the material here that
1:51
I think is partially within the canal.
1:55
So in a case like this, you start to think this
1:57
is probably retained products of conception, but
1:59
again, you need the clinical diagnosis as well.
2:03
But you also need to start thinking of something
2:04
called EMV or enhanced myometrial vascularity.
2:08
We used to call all of these AVMs, but more
2:10
literature has recently shown that these
2:13
are probably not all actually true arteriovenous
2:16
malformations, but something called
2:18
EMV, which is enhanced myometrial vascularity.
2:22
And so what that is, is it
2:23
increased blood flow in the myometrium following
2:26
or associated with an abnormal pregnancy.
2:29
It can be associated with a subinvolution of
2:31
the placental bed, and it can be associated
2:33
with retained products of conception.
2:35
So I think that's what we probably have here.
2:37
We probably have some retained products of
2:38
conception that's in the endometrial canal.
2:41
Now we have all of this vascularity
2:42
that's in the myometrium, right?
2:44
It's out here where a lot of
2:45
this abnormality is, right?
2:47
But it looks very much like myometrium itself.
2:49
It's very similar density out here.
2:52
It's not heterogeneous.
2:54
So this is probably a bit of both here.
2:55
We have EMV out here and then we have
2:58
retained products of conception in here.
3:01
So EMV can be transient.
3:03
So if the bleeding is not too significant,
3:05
they can just do serial ultrasounds
3:07
as long as the patient is stable
3:08
because it may resolve on its own.
3:10
It's also important that if you see this, that
3:12
it's not necessarily a contraindication to
3:14
removal of retained products of conception.
3:16
If they're bleeding and need to have
3:17
it out, then they need to have it out.
3:19
But it's important to mention, especially
3:21
if you see a more dilated cystic, cystic
3:24
space like this, that partially fills in
3:26
on your color Doppler flow because
3:29
the surgeon needs to be aware that that's
3:31
there in case there is an actual AVM there.
3:34
They need to know it's there so they
3:36
can kind of work around it and be
3:37
aware of that in case the patient does
3:39
crash or start to bleed significantly.
3:42
So this patient ultimately did end up
3:43
going to the operating room and was proven
3:45
to have retained products of conception
3:47
and no vascular malformation was seen.
3:49
So again, one last thing to remember,
3:51
EMV, these are characterized by these
3:52
kind of cystic or tubular anechoic
3:54
structures, lots of vascularity.
3:57
If you put a color spectral Doppler box on
4:00
there, you'll get a higher peak velocity
4:02
than you would the rest of the uterus
4:04
and you'll see a low resistance waveform.
© 2024 MRI Online. All Rights Reserved.