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.