0:01

All right, let's go on to the next case.

0:02

This is case seven.

0:03

So starting inferiorly, this was

0:06

actually done, um, as a anal protocol.

0:09

So we started a bit lower than normal, but

0:11

just to review that anatomy, you can see here's

0:13

the, we're starting inferiorly at the anal

0:16

verge, there's the external anal sphincter,

0:18

and this is the internal anal sphincter, and

0:20

that's bounded by this intersphincteric fat.

0:23

And as we move superiorly, that external

0:25

sphincter continues into the puborectalis

0:27

and levator ani muscle, and then the internal

0:30

sphincter continues into rectal mucosa.

0:34

But this is a Mullerian duct anomaly lecture, right?

0:37

Let's look at the uterus.

0:39

So there's the urethra, the

0:41

upper vagina, which is collapsed.

0:43

And then what's going on there, we have

0:45

two hypo intense stromal cervical rings.

0:47

So we have some type of cervical duplication.

0:50

And as we move more superiorly, you can

0:52

see they completely diverge immediately.

0:56

And they're very divergent.

0:57

This fundal cleft is definitely

0:58

greater than one centimeter.

1:01

So, you know, it's either a

1:02

biconior mycolis or a didelphys.

1:04

It can't be a septate and you don't

1:06

see any bridging myometrial tissue.

1:08

We do see some soft tissue at the level of the cervix.

1:11

That's okay for this diagnosis, but

1:13

you shouldn't see anything up higher.

1:16

And we also have some T2 hypo intense fibroids.

1:19

So let me just show you on the T2 fat suppressed

1:21

shows the cervical anatomy a bit more strikingly.

1:24

You can see the services.

1:26

extending out laterally with

1:29

completely divergent horns.

1:31

Uh, and this was, uh, an older patient, 67, so that's

1:34

why we're not seeing the endometrial stripe as well.

1:36

It was, it was a little thinned.

1:38

So this is an example of a uterus didelphys.

1:41

So two surfaces, no communicating myometrial tissue,

1:44

and a fundal cleft greater than one centimeter.

1:47

And then let's just look at those fibroids.

1:49

So fibroids are usually T2 dark, right?

1:52

Because of their compositive smoothness

1:54

and also be T2 dark if there's highland

1:57

degeneration or calcific degeneration.

2:00

And these are really T2 dark.

2:01

So that might make you think of calcification.

2:04

So what could you look at next to tell you, you

2:06

know, what, what type of degeneration is this?

2:09

Well, if we look at this, this is a T1.

2:11

vibe, which is a 3D spoiled gradient echo sequence.

2:15

And on gradient echo sequences, calcium and especially

2:19

gas and, and metal will have blooming artifact.

2:22

You'll see this black cloud where these structures are.

2:25

And you can see it's very dark here

2:26

about that, um, about that fibroid.

2:30

So that tells you that it's

2:31

calcified or likely calcified.

2:33

And then just for completeness sake, if you look

2:35

at the post contrast series, when you do have

2:37

degeneration, you shouldn't see any fibroid.

2:40

enhancement.

2:41

So much of it is degenerated

2:43

because of that calcific deposit.

2:44

If this was just hyaline, I'm sorry,

2:46

if this was just t2 hypo intense fluid

2:48

muscle, you'd see enhancement there.

2:51

And if it was high in the degeneration, you

2:52

wouldn't see so much as stuff to belly artifact.

2:54

It wouldn't be all that blooming.

2:57

And that's important.

2:57

If you're planning, if a patient's getting

2:59

evaluated for uterine artery embolization,

3:02

if, if all the fibroids are already

3:03

degenerated, the UAE might not be as effective.

3:09

All right, let's move on to the next case.

3:10

So this is case eight.

3:13

So this was a complex case.

3:15

This is a 13 year old female who

3:18

had a history of irregular menses.

3:20

So if we start inferiorly, again at that

3:23

anatomy, there's the urethra, collapsed

3:25

vagina, and then as we come up, there's

3:27

something in the left aspect of the vagina.

3:29

We have this T2 hyper intense fluid signal

3:33

that's expanding the left hemivagina.

3:36

And as we come up more superiorly, Note how there

3:38

are two services again, these T2 hypo intense

3:42

doughnuts, and then if we follow the horns out,

3:45

they're a little dilated, and T2 hyper intense,

3:48

you can see the junctional zone is very thin, it's

3:51

T2 hypo intense, and we have a very deep fundal

3:55

cleft, so if we We're going to measure that.

3:58

You can clearly see that it's more than a centimeter.

4:02

It is 2.

4:02

5 centimeters.

4:06

So this is either a didelphic

4:08

uterus or a bicornior bicollis.

4:11

And again, you want to look for

4:12

that bridging myometrial tissue.

4:14

We see some at the level of the cervix, but then

4:17

You don't really see any as we get up higher.

4:19

They completely diverge.

4:21

But there's something else that tells

4:22

you that this is a didelphys uterus.

4:25

So, let's look at this area a bit more closely.

4:27

So, on the sagittal view, you can see that T2 hyper

4:30

intense pocket is actually in the upper vagina.

4:33

It's below the level of the cervix, right?

4:36

So here's the, here are the cervices and that

4:38

left one has this ballooning out and that's

4:42

because there's a partial vaginal septum

4:44

there that's obstructing the left hemivagina.

4:47

And then remember I had said previously,

4:49

actually let me show you first.

4:52

So on the T1, this was a T1 in phase series.

4:58

You can see that that.

4:59

T2 hyper intense area in the left hemivagina is T1

5:02

bright, so that tells you that we're dealing with

5:04

hemorrhage since hemorrhage is typically T1, T2

5:06

bright on MRI, but it varies depending on the age.

5:11

So if you have hemorrhage in the vagina,

5:13

that's hematoculpos, but we don't have any

5:16

hemorrhage in the endometrial cavity, which

5:18

would be hematometra, so we have hematoculpos.

5:23

So, uh, you always want to look at

5:24

the kidneys for any renal anomalies.

5:28

And unfortunately this sequence was done a

5:30

bit low, so we didn't get a great look at

5:33

the kidneys, but fortunately the patient

5:35

had a known history of left renal agenesis.

5:38

And you can see that here, we have the

5:39

inferior pole of the right kidney, but

5:41

there's no inferior pole of the left kidney.

5:47

Let me zoom out here.

5:50

And again, you can see that there's that,

5:52

uh, didelphys uterus with an obstructed left

5:55

hemivagina and there's hemorrhage there.

5:58

So, and that's on the same side as this renal anomaly.

6:00

So we have an ipsilateral renal anomaly.

6:04

So this is actually something known as

6:06

OVIRA, O H V I R A, which is obstructed

6:10

hemivagina and ipsilateral renal anomaly.

6:13

So you see it with didelphys

6:15

when you have a vaginal septum.

6:17

leading to a blind hemivagina.

6:19

And then you also have ipsilateral renal agenesis.

6:22

So this, the treatment for this, uh, the patient was

6:25

scheduled for a vaginal septotomy to kind of open up

6:28

that vaginal septum and release the hematocle post.

6:32

Now, so this brings me to the next

6:34

question, question nine, please.

6:38

So which two MDAs can look nearly identical on MRI?

6:42

Unicornuate and didelphys?

6:44

Biconuate, unicollis, and arcuate?

6:46

Bicornuate bicollis with a longitudinal vaginal septum

6:49

and uterus didelphys, or arcuate and uterine agenesis?

6:56

Great, yes, bicornuate bicollis with a

6:58

longitudinal vaginal septum and uterus didelphys.

7:01

So if you weren't sure, you can always

7:03

go with the multiple choice default

7:04

of letter C and the longest answer.

7:08

Yeah, so, um, if you remember that bicornuate unicollis

7:11

case I showed you before, The, the horns were so

7:14

splayed, it was tough to see any bridging myometrium.

7:17

And to complicate things, bicornia

7:20

bicalis can have a longitudinal vaginal

7:22

septum in about a quarter of cases.

7:24

And, and it can really mimic this.

7:26

But in this case, since we also have the uterine,

7:29

I'm sorry, the renal agenesis that points a

7:31

bit more towards ovira, and we don't really

7:34

see any definite bridging myometrial tissue.

7:38

So this would be most consistent with the didelphys.

7:43

All right, let's go on to the next case.

7:45

So this is case nine.

7:49

So this one's a little tricky,

7:50

depending on which plane you look at.

7:52

So here we have the sagittal T2 weighted

7:54

image, and you can see a normal endometrium.

7:56

The junctional zone thickness appears normal.

8:02

And the myometrial signal also appears

8:04

fairly normal, and we don't really see

8:06

much in the way of a uterine anomaly.

8:08

On the, there's the normally

8:10

formed vagina which is collapsed.

8:12

Here we get a great look at the anterior

8:15

vaginal fornix and then the posterior vaginal

8:17

fornix, adjacent to the anterior and posterior

8:19

aspects of the cervical os, respectively.

8:22

Now, if we also then look at the coronal T2, it

8:26

almost, you might almost think this is a normal uterus

8:28

because it just seems to be deviated to the left.

8:31

of the, the pelvic cavity, right?

8:34

We have a normal looking endometrial

8:36

cavity with a surrounding junctional zone.

8:38

But then let's look at the axial.

8:42

And here you can see that it

8:43

is actually an abnormal uterus.

8:44

So the fundal contour looks fine, but then

8:47

there's only one endometrial cavity, right?

8:49

It kind of, the uterus has a banana or a sausage shape.

8:53

It doesn't have that normal, uh, triangular flaring

8:57

that we typically see at the endometrial fundus

8:59

when we get that coronal Axial oblique series.

9:04

So we have a single endometrial cavity.

9:06

And then as we extend out here, you see some

9:09

kind of rudimentary myometrial tissue, but you

9:12

don't see any endometrial tissue within that.

9:15

And let's just look.

9:16

The T two fat suppress can sometimes help you.

9:19

You can use that hypo intense junctional

9:21

zone to delineate the endometrial cavity.

9:23

So here we have the left endometrial

9:25

cavity, and in that rudimentary myometrial

9:28

tissue, you don't really see any.

9:30

junctional zone to outline endometrial tissue.

9:34

So this is a unicornuate uterus with a rudimentary

9:39

horn that contains no endometrial tissue.

9:43

So why is it important to identify endometrial

9:47

tissue in a rudimentary unicornuate uterus?

9:50

Could I please have question 10?

9:53

So in a unicornuate uterus, the presence of

9:55

endometrium in a rudimentary uterine horn can

9:58

cause pelvic pain and endometriosis, miscarriage,

10:02

ectopic pregnancy, or all of the above.

10:06

Great, yes, all of the above.

10:08

So, uh, the endometriosis actually occurs because

10:12

Because you have a blind horn, the endometrium can

10:16

have retrograde menstruation and leak out into the

10:18

endometrial cavity, sorry, the pelvic cavity and

10:21

seed the, the pelvis with endometrioid implants

10:24

and endometriomas in the ovary causing adhesions.

10:28

And then, yes, you can actually get,

10:30

uh, ectopic pregnancies in that horn.

10:32

And the worst complication is uterine rupture.

10:35

So you really want to identify that

10:37

endometrial horn, uh, that endometrial

10:40

containing rudimentary horn if it's present.

10:43

But in this case, we just had a unicorn

10:45

without anything in the rudimentary horn.

10:48

And these usually don't have significant complications.

10:53

So let's go on to this next case.

10:55

So this is a case 10.

10:57

You can see here we have what looks

10:59

like a normal, this is a sagittal T2

11:01

with a normal looking left uterine horn.

11:04

But then as we move to the right, we have this expanded

11:08

heterogeneous T2 hyperintensity in this right horn.

11:11

And this was actually a pregnancy in the left horn.

11:15

Sorry, in the right horn there.

11:16

And if, uh, you can see that a

11:18

little bit better on the axials here.

11:20

This is T2 axial.

11:22

You can see there's the left horn.

11:23

We have a single cervix.

11:25

As we come up superiorly,

11:26

there's the endometrial cavity.

11:28

And then we have this right horn that's expanded.

11:30

You can see a bit of T2 hypo intense junctional

11:32

zone around it to give you, uh, a clue that you're

11:35

dealing with endometrium here, which we can also see

11:39

on the T2, let me show you, T2 fat suppressed axial.

11:45

Again, that T2 hypo intense junctional

11:47

zone tells you this is endometrial, an

11:50

endometrium with a pregnancy within it.

11:53

So, this was, uh, actually an undesired pregnancy.

11:56

This was a 23 year old female, and so it was

11:59

treated first with methotrexate, but because

12:02

there were no, there were no gestational products

12:05

were expelled, before the MRI, it was clinically

12:08

thought that this was a bicornuate uterus.

12:11

So, attempts for ultrasound guided surgical

12:13

removal was, was tried, but you could see why that

12:16

might not work, because even though we have what

12:18

looks like a fundal cleft here, You don't see any

12:22

communication of this cavity with the cervix, right?

12:25

You can see this cervix is communicating

12:27

here, but if you're trying to go in, uh, with

12:30

ultrasound guidance or hysteroscopically, you

12:32

won't be able to get into this right horn.

12:35

So when this was done, Uh, the, the MRI here was

12:38

done and it was, uh, diagnosed as a unicornuate with

12:43

a rudimentary horn containing an ectopic pregnancy.

12:49

So and then the patient subsequently underwent

12:51

a KCL injection and then ultimately had a

12:54

hysteroscopic resection that confirmed the diagnosis.

12:59

So, uh, it is possible to get

13:01

ectopics here in the rudimentary horn.

13:04

I'm not sure how that happens

13:05

physiologically, but it's something to look

13:08

for because it is a definite complication.

13:12

And just to show you.

13:13

The additional images on the T1 in phase series, you

13:16

can see that that, uh, gestational products there

13:19

had some T1 hyperintensity indicating hemorrhage.

13:21

And we also saw some restricted diffusion,

13:24

which is not uncommon in the setting

13:25

of hemorrhage on the diffusion series.

13:28

So this image here on the right hand.

13:32

I'm sorry, on the left hand side of your screen,

13:34

sorry, right hand side, shows this hypo intensity

13:38

indicating that there's restricted diffusion on ADC.

13:41

And then if we look at the diffusion weighted

13:43

images, so I'm starting with the low B value

13:45

diffusion weighted image, so this is a B50.

13:48

So the lower the B value, the

13:50

greater the strength of T2 weighting.

13:52

So you'll see that fluid will be bright.

13:55

This is kind of like a T2 fat suppressed series.

13:58

And also the signal to noise ratio will be pretty

14:00

good, but the strength of diffusion weighting is low.

14:04

So as we increase the B value,

14:06

so now we have a B400 here.

14:09

and then ultimately we went up to a B800.

14:12

You can see that the T2 weighting has decreased,

14:15

so the blood, the fluid in the urinary

14:16

bladder is now not hyper intense anymore,

14:19

and also the signal to noise ratio drops.

14:21

Things are a bit more grainy.

14:23

But the strength of diffusion has increased, so

14:25

anything that remains bright on the high B value

14:28

series is actually true restricted diffusion.

14:30

So you can see that area in the gestational products.

14:33

showing hyperintensity, and that

14:35

corresponds to that darkness on the ADC.

14:39

So, just an interesting aside.

14:43

And, uh, also, what are some other causes

14:45

of, quote, intrauterine ectopic pregnancy

14:48

besides an ectopic, uh, in a rudimentary horn?

14:52

Well, you can also have interstitial ectopic

14:54

pregnancies, which occur around the cornea.

14:56

You can have a ectopic in a C section

14:58

scar, and then you can rarely also have

15:01

an ectopic pregnancy in the cervix.

15:03

So, just because a, um, Gestational

15:07

products are in the uterus.

15:09

Keep looking to make sure it's not one of

15:11

these four rare ectopic pregnancies, although

15:13

the vast majority will occur in the tubes.

15:17

All right.

15:18

So moving on to this next case, this is

15:20

case 11, and this was a complex case.

15:23

So this was a 15 year old female with pelvic pain.

15:27

So I'm starting with this T1 axial series.

15:30

Just to show you that there's this

15:31

Mark T1 hyperintensity about the

15:34

uterus indicating blood products.

15:36

So something is obstructed

15:38

and there are blood products.

15:40

And the T2 axial, remember T2 is the

15:42

best for anatomy of the female pelvis.

15:45

And you can see the structure is a bit better.

15:47

So we have, um, Inferiorly here,

15:50

let's, let's start from the bottom up.

15:52

There's again, the urethra,

15:53

the vagina and the anal canal.

15:55

And then we see what looks like a cervix here,

15:58

but then on the left, we have this really

16:01

dilated cavity extending all the way out.

16:04

It's got intermediate T2 signal.

16:05

And then inferiorly, it has all these irregular.

16:09

Uh, blobs of T2 hypointensity

16:11

indicating older blood clot.

16:13

So this is all blood products.

16:15

So then the question is, what kind

16:17

of anomaly are we dealing with here?

16:19

If we look at the right horn, we can see that it

16:22

looks like a fairly normal endometrial stripe.

16:24

We have a normal junctional zone.

16:26

And coming down, it looks like a

16:28

normal, we see at least one cervix.

16:32

So, but then the horns are so divergent,

16:35

could this actually be a didelphys, or is

16:38

it a biconuate with an obstructed horn?

16:41

We can see there are normal ovaries here

16:42

on the right, there's a little fluid in the

16:45

pelvis there, normal ovary there on the left.

16:50

So if we look at the coronal images, again you

16:54

can see that really dilated left uterus, uterine

16:57

horn, there's the right horn getting displaced

17:01

by it, and then the upper vagina looks normal.

17:03

So, We don't see any blood products in there and but

17:08

then could this be a little cervix here on the left

17:11

if you can see that that was potentially questioned

17:13

as a cervix so then is could this be a didelphys

17:17

but then you have the challenge of well there does

17:19

seem to be some bridging myometrial tissue here and

17:22

then to make matters more confusing if you look at

17:24

the coronal large field of view t2 haste there's

17:27

a normal right kidney but on there's ipsilateral

17:30

renal agenesis so is this another case of ovira with

17:34

didelphic uterus and ipsilateral renal agenesis.

17:38

Well, the clue here that it's not is that this

17:41

is, this, this blood product distending the

17:44

cavity is all above the level of the vagina.

17:47

So if I go to the sagittal here, you can see

17:51

here's the cervix here by that T2 hypo intense

17:53

cervical stroma, and the collapsed vagina is here.

17:56

So there's no hematocorpus, right?

17:58

This is all hematometra.

18:00

It's all, um, hemorrhage in the uterus.

18:04

So that would kind of go against a didelphys.

18:07

Cause it with an obstructed vaginal septum, um, and

18:11

it would be a little unusual to have a biconuate

18:13

that has an obstruction at the level of the cervix.

18:16

So, um, this brings me to the next question.

18:19

If you could please show, uh, question 11.

18:22

So if the classification of the MDA is uncertain or

18:25

if it has overlapping features, what should you do?

18:28

Force the anomaly to fit a certain class,

18:31

uh, recommend a follow up CT scan, or

18:33

just describe the imaging findings.

18:35

Thanks.

18:37

Good, yes.

18:38

Just describe the imaging findings.

18:40

Uh, CT is not usually a good idea if you're

18:43

evaluating a mullerian duplication anomaly.

18:46

Uh, although you can make that diagnosis with CT

18:49

at times, MRI is much preferred or ultrasound even.

18:53

And, and you don't want to force it into a certain

18:54

class because that could be misleading to the surgeon.

18:57

It can change the patient's management

18:58

or expectation for pregnancy outcome.

19:02

So you want to just describe the findings as best

19:04

you can and and perhaps suggest a class but not be

19:08

definitive and this turned out to be a unicornuate

19:11

uterus with an obstructed rudimentary horn

19:14

containing endometrium, which makes sense since we

19:17

don't, sorry, since we don't have endometriosis.

19:20

any vaginal septum, and it would be a little

19:23

unusual to have obstruction at the level

19:25

of the cervix in, in the setting of an MDA.

19:27

It can occur, but, uh, an obstructed horn.

19:31

So, again, it's very important if you have a

19:34

unicornuate to identify whether or not there's

19:36

in the, uh, rudimentary horn, because this

19:40

could happen where it's, it's really obstructed.

19:42

And you can also see how, again, endometriosis

19:44

could form, because this is so dilated and under

19:46

pressure, it may balloon out of the fallopian

19:51

tube, and depending on how developed the tube is,

19:54

and seed the pelvis with endometriotic implants.

20:00

All right, so let's move on to the last case.

20:04

So here we have a sagittal T2 weighted

20:06

image, and this is a 17 year old female

20:10

who had a history of primary amenorrhea.

20:13

So, you know, often when you have that history,

20:15

you might be thinking, Oh, maybe this patient has

20:18

an imperfect hymen or transverse vaginal septum.

20:21

So MRI is a great way to evaluate that.

20:23

Usually you'll see something,

20:24

though, on ultrasound first.

20:26

Uh, and this patient did have an ultrasound

20:28

initially, which didn't show any evidence of

20:30

hematometrial colpos, to suggest a, a imperfect hymen.

20:36

So looking at the sagittal T2, remember

20:38

I said that's a great way to look at

20:40

the uterine anatomy and also the vagina.

20:42

You can see the bladder here, there's the

20:44

urethra, but then we don't see any uterus,

20:48

and the patient has no history of C section.

20:51

And then looking at the vagina, we don't

20:53

really see anything there either, right?

20:55

It's just some peritoneal fat.

20:57

We don't see any normal tissue.

21:00

there.

21:01

So then the question is, um, she did

21:03

have normal external female genitalia.

21:07

The, the big question is, are there ovaries or not?

21:09

Because if there are ovaries, we're

21:11

dealing with a mullerian duct anomaly.

21:13

If there are not, we might be dealing with

21:15

something else like androgen insensitivity syndrome.

21:19

So those patients will have, uh, be

21:21

genetically male and have undescended testes.

21:24

But because they don't have androgen receptors,

21:26

they develop female external genitalia and have a

21:29

shallow lower vagina with no upper vagina formed.

21:33

So your next step is to look are there ovaries or not.

21:36

And we do see a right ovary here

21:38

containing little follicles, another one

21:40

here on the left containing follicles.

21:43

If you're having trouble looking for the

21:44

ovaries, look for the Iliac, common iliac

21:46

vasculature, extending out to the external.

21:49

That's actually also where you'll typically find

21:51

undescended testes, but they should not have follicles.

21:56

So then you know we're dealing with some type of

21:58

uterine hypoplasia or agenesis, and there might be a

22:03

little bit of, uh, uterine tissue here on the right,

22:06

some, some rudimentary uh, myometrial tissue, this T2

22:10

hyper intense area, but there's very little, if any.

22:14

So then we want to look, how much

22:16

is that vagina actually developed?

22:17

So the T2 axial is a great way to further characterize

22:21

that after you do your initial sagittal T2 evaluation.

22:25

And as we come down here, you can see we're

22:28

not really seeing a normal vagina here.

22:30

Let me start, let me start inferiorly.

22:32

So there's the urethra, again the anal

22:34

canal, and then the puborectalis leading

22:36

into the levator ani, that little sling here.

22:39

And we see a very atretic, very atretic

22:45

lower vagina there.

22:48

Let me show you the sagittal of that.

22:50

So you can see we're at the lower vagina.

22:51

We do see this little vague collapsed vagina.

22:56

Let me zoom in.

22:57

And then as we come up more superiorly,

22:59

it just fades out to nothingness.

23:00

And we just have peritoneal, we just have,

23:03

sorry, extra peritoneal pelvic fat there.

23:06

So we only have a lower Vagina form, no upper

23:10

vagina, no uterus, but we do have normal ovaries.

23:14

Uh, so this is typical for a Meyer

23:17

Rokitansky Custer Hauser syndrome.

23:19

A lot of hyphens there, but that's

23:21

a complete uterine agenesis.

23:23

So again, the key is to determine

23:25

if you can, the extent of how much

23:26

vaginal, uh, development there is and.

23:29

are there ovaries and are they normal?

23:32

And so the treatment for this, uh, the patient

23:35

can have dilation with vaginal cylinders, which

23:38

is what this patient initially chose to, to

23:41

try to expand the vaginal cavity, or they may

23:44

undergo surgery with creation of a neo vagina

23:47

with often used with portions of intestine.

23:50

So that brings me to the last question.

23:52

If you could please bring up Question 12.

23:55

So, which of the following MDA is

23:57

most likely to require surgery?

23:59

Biconuate, arcuate, a unicornuate with no

24:04

endometrium in the rudimentary horn, or a septate?

24:08

And again, sometimes these uteri may require

24:10

surgery, but which one is most likely to?

24:15

Uh, we have it split.

24:16

So, uh, septate is actually the one that's most likely

24:19

to, if, if the unicornuate had endometrium in the

24:23

rudimentary horn, then it would need surgery likely.

24:25

But if it doesn't have any endometrium

24:27

in that horn, then that horn is just

24:29

some rudimentary myometrial tissue.

24:31

It probably won't cause much problem.

24:34

Um, but a septate is more likely to

24:35

cause miscarriage, but it depends too.

24:37

If you have a unicornuate that also has, uh, a

24:40

vaginal septum and that that might need surgery.

24:44

Great.

24:44

So, and then just to show you to be aware, you might

24:48

get faked out when you're evaluating the vagina.

24:50

There's this normal vaginal venous plexus

24:53

that you can see here nicely on the T2s, and

24:56

you might confuse this with vaginal tissue,

24:58

but this is just physiologic vasculature, and

25:01

it can be quite prominent in some patients.

25:03

It doesn't mean the patient has pelvic

25:04

congestion syndrome or anything.

25:06

You might just see prominent

25:07

T2 hyper intense tissue there.

25:10

Uh, signal.

25:11

And it could even fake you out

25:12

further because it is a venous plexus.

25:15

If you look at the sagittal

25:15

images here, it, they enhance.

25:17

So you might think, oh, this is,

25:19

there is actually vaginal tissue here.

25:21

It's enhancing, but no, just make sure you look at

25:24

all the series that the sagittal post contrast, the

25:27

T2 fat suppressed, and then especially again, just

25:30

the straight T2 you'll see there is no vaginal tissue.

25:36

Sorry, let me bring up, there's the T2 axial again.

25:38

We don't see any vaginal tissue there.

25:42

All right, that was my last case.

25:44

I'm happy to answer any questions that you might have.

25:48

All right, if there are no questions, then

25:50

I'll just quickly summarize some of the points.

25:53

So with arcuate uterus and septate,

25:55

they'll both have a convex or flat outer

25:58

uterine contour with no fundal cleft.

26:00

And then you can differentiate an

26:01

arcuate from a subseptate uterus by the

26:04

bulge of the fundal miometrium will be.

26:07

More than 1.

26:08

5 centimeters for a subseptate, but less than 1.

26:11

5 for an arcuate.

26:12

An arcuate will also be broad based inward

26:15

contour with an obtuse angle with the

26:17

endometrium, whereas a septate will be more of

26:19

a sharp, uh, Indentation with a acute angle.

26:23

Biconuate and didelphous will both have a deep

26:26

external fundoclef greater than a centimeter.

26:28

And I should also add that that, that

26:30

indentation is actually 100 percent

26:33

specific and sensitive to differentiate

26:35

biconuate slash didelphous from the other.

26:37

The other abnormalities like septate and arcuate.

26:40

And biconuate can occasionally have

26:42

a two services, but usually has one.

26:46

And then a didelphys always will and

26:47

should have no bridging myometrial tissue.

26:50

And again, with that uniconuate uterus, look for

26:52

the presence of endometrium in the rudimentary horn.

26:56

And with uterine agenesis or hyperplasia, look

27:00

to see if there are ovaries because that can help

27:02

guide the next step in the patient's management.

27:05

Thank you.