0:00

This is an MRI of the abdomen and pelvis in a

0:03

patient who presented with persistent vaginal

0:06

bleeding following delivery of her child.

0:10

She has a history of cesarean section

0:12

and at the time of delivery with the

0:15

current pregnancy they felt that there

0:17

was incomplete removal of the placenta.

0:20

Here's a sagittal T2-weighted

0:22

image of the pelvis.

0:23

We can see that the uterus

0:25

is enlarged due to gravity.

0:27

The endometrial cavity is T2 hyperintense and

0:32

inferiorly is distended with T2 heterogeneous

0:35

material, which extends into the cervical canal.

0:39

We also have T2 hyperintense

0:41

material within the upper vagina.

0:45

These are coronal T2-weighted images of the

0:47

abdomen and pelvis for the same patient.

0:50

Again, we can see the previous postsurgical

0:52

changes consistent with cesarean section.

0:55

And distention of the inferior aspect of

0:59

the endometrial cavity with T2 heterogeneous

1:02

material, which extends superiorly toward the

1:04

uterine body and inferiorly toward the cervix,

1:07

with a significant amount of heterogeneous

1:09

T2 material within the cervical canal.

1:13

These are axial pre-contrast and post-contrast

1:17

MR images of the abdomen for the same patient.

1:19

Remember that since the patient has

1:21

already delivered, we're able to administer

1:24

gadolinium-based contrast for the exam.

1:28

As we scroll inferiorly, we can see that

1:30

on the T1 pre-contrast images, some of

1:33

the material in the lower uterine segment

1:35

demonstrates intrinsic T1 hyperintensity

1:38

consistent with blood products.

1:41

On the post-contrast images, we see

1:43

normal enhancement of the postpartum

1:45

uterus and distention of the superior

1:47

aspect of the endometrial cavity.

1:50

with hypoenhancing material.

1:52

Inferiorly, we see a significant amount

1:55

of enhancement within that region of

1:57

heterogeneity that we had previously

1:59

visualized in the inferior uterine body,

2:02

lower uterine segment, and cervical canal.

2:05

These are sagittal, fat-saturated, T1 pre-

2:08

and post-contrast images for the same patient.

2:11

I think the post-contrast images are quite

2:15

demonstrative for this case in the sense

2:18

that they really nicely show this image

2:21

focal region of enhancement within

2:24

the endometrial cavity inferiorly.

2:27

We can see that the cervical canal is

2:30

distended with material and is opposing the

2:34

vaginal fornices posteriorly, but we do see

2:37

enhancement within the material in the lower

2:40

uterine segment to a lesser extent within the

2:44

material extending into the cervical canal.

2:47

Because of the imaging findings, a diagnosis

2:50

of retained products of conception was made.

2:52

The patient was taken to the OR for dilation and

2:54

curettage for removal of the retained products.

2:58

This is an ultrasound of the pelvis

3:01

in a patient who is two weeks status

3:03

post spontaneous abortion presenting

3:06

with persistent vaginal bleeding.

3:09

On this endovaginal image of the uterus, we can

3:12

see that the endometrial cavity is distended

3:16

with heterogeneously hyperechoic material.

3:19

The endometrial thickness measures 11

3:22

millimeters, greater than expected for a

3:24

patient who recently had a spontaneous abortion.

3:29

These are long transvaginal images of the

3:31

uterus, again demonstrating significant

3:33

distension of the endometrial cavity

3:36

with heterogeneous hyperechoic material.

3:39

These are color Doppler transvaginal

3:41

ultrasound images of the pelvis.

3:44

We can see that within the uterine

3:45

myometrium, there is significant vascularity

3:48

which extends into the endometrial cavity.

3:51

There is vascularity within the

3:53

echogenic material that we previously

3:54

visualized in the endometrial cavity.

3:58

And on some of the images, the

4:00

vascularity appears fairly extensive.

4:03

Given the imaging findings, specifically

4:05

heterogeneous material within the endometrial

4:08

cavity with significant vascularity coupled

4:10

with the clinical history, a diagnosis of

4:13

retained products of conception was made.

4:16

Retained products of conception is defined

4:18

as persistent placental or fetal tissue

4:20

within the uterus following delivery,

4:22

miscarriage, or termination of pregnancy.

4:25

Imaging findings will classically include a soft

4:28

tissue lesion within the endometrial cavity.

4:31

Vascularity within the tissue is

4:33

confirmatory of a diagnosis of

4:35

retained products, but can be variable.

4:38

An additional criterion for diagnosis

4:40

of retained products of conception is

4:42

an endometrial thickness greater than

4:43

10 millimeters following a spontaneous

4:46

abortion or dilation and curettage.

4:48

And a pearl that I'd like to add for this

4:50

case is that one cannot make a diagnosis

4:53

of retained products of conception if the

4:55

patient is undergoing an abortion in progress.

4:58

So you have to use the clinical history to

5:00

guide your interpretation of the imaging

5:01

findings in this patient population.