Images:
Image 1: SAG UTERUS with the bladder seen at the edge of the screen, inferior to the uterus. The anechoic structure is shown evaluated later on in the study.
Image 2: SAG UT with measurements. Calipers were placed at the best approximations of the organ borders.
Image 3: TRV UT seen with the endometrial stripe and other labeled structures.
Image 4: A measurement in SAG.
Image 5: Left ovary in SAG.
Image 6: Right ovary in SAG with color flow.
Image 7: Transvaginal image. Incidentally, the uterine position has changed from the transabdominal study.
Image 8: A transvaginal image of the anechoic structure seen earlier transabdominally.
Image 9: Seen with Doppler evaluation.
Image 10: Seen with further Doppler evaluation.
There are at least three findings with this case study. Please post a description of any impressions you have from the images shown, which may include observations of both the normal and abnormal. You may suggest pathologies that could be suspected based on these and the patient history, as well as any other issues that may be of concern. Thanks for looking! -Abby
Image 4: A measurement in SAG.
Image 5: Left ovary in SAG.
Image 6: Right ovary in SAG with color flow.
Image 7: Transvaginal image. Incidentally, the uterine position has changed from the transabdominal study.
Image 8: A transvaginal image of the anechoic structure seen earlier transabdominally.
Image 9: Seen with Doppler evaluation.
Image 10: Seen with further Doppler evaluation.
There are at least three findings with this case study. Please post a description of any impressions you have from the images shown, which may include observations of both the normal and abnormal. You may suggest pathologies that could be suspected based on these and the patient history, as well as any other issues that may be of concern. Thanks for looking! -Abby
16 comments:
Abby,
i think it is an ectopic intramural pregnancy. This is because the pregnancy occured next to the caesarian scar and the patient has previous c-sections. it is ectopic because you can see there is an empty gestational sac with a ring of fire surrounding it suggesting it is ectopic.
I am not sure about it is ectopic pregnancy. It doesn't look like ring of fire. It is quite full of coloring in the cyst or emty sac. I kept thinking about it, but frankly i don't know. There are fibroids seen. Left ovary looks fine to me.
Hi Grace,
Do you have any lab values? HcG, WBC maybe? Great case, very interesting!
There were no lab values accompanying the study, however, this is not a case of pregnancy. Grace is right that the anechoic area is filling with color on Doppler. Both ovaries can be seen as normal. Irene is correct that it may involve a C section scar...
Abby,
I am completely stumped! I showed one of my CIs and he is stumped, also! Are there any more clues you could give us?
Abby,
I see one fibroid labeled on the TRV transabdominal image... maybe have been calcified? Is there also an exophytic fibroid? I really don't know what the right adnexal image is showing. Could it be a ruptured artery??
As far as participation credit goes, please note that comments can be posted about what is seen in this study aside from diagnostic pathology, including but not limited to normal/ abnormal: echotexture, size, locations of lesions, Doppler characteristics, and any potential concerns for this patient considering the descriptive history. (My CI did not know what this was when she imaged it, she just documented what she saw and tried to evaluate it with all the ways she knew how!). As far as pathology, the radiologist tentatively diagnosed a condition that is usually congenital but which appears to be acquired in this case, most likely related to the scar her 3 cesarean sections must have left. It is a vascular condition, and often presents aymptomatically as it did in this case.
IT is very interesting case. The mass is belonged to the uterus. Hmm,,, There color flow with doppler as well.. What is it.... kk
As mimi stated, there are at least 2 fibroids, 1 calcified and 1 exophytic. I'll add that the 15x10cm uterus is not within normal limits for size (large) and that may be due to the 1 fibroid being 7x6.5cm in size thus prompting the hysterectomy perhaps? I have no idea what the adnexal mass is that is filled with color. I spent quite a bit of time researching possibilites and came up blank. I can't wait to find out.
A 43 yo female for pre-hysterectomy work-up. H/o 3 c-sections for 3 pregnancies. Her LMP was 28 days ago and on trv image 3 you can appreciate the luteal phase of the endometrium but not on the sagittal view of the uterus, im. 1, due to the heterogeneous myometrium of the uterus.
Image 1- Transabdominal/ anterior complex cystic mass. In image 8-10 Transvaginal images/ 6.6 x 4.9 cm (I don’t see a transverse measurement in TV) cystic structure with shadowing from a hyperechoic structure at superior pt of cystic mass (poss ligation clip from previous surg, calcification of blood?) Structure displays color and Doppler properties when applied. (Do you know why the Doppler tracing was not inverted?) I cannot see velocities or other parameters but I believe that it is arterial but not typical of uterine artery waveforms or ovarian artery waveforms.
Image 7 showing a complex 3.7 x 3.5 cm (again I do not see a transverse measurement of this structure) mass with a posterior shadowing hyperechoic structure within suggestive of a microcalcification, suggestive of a dermoid cyst.
Path 1= left adnexal mass labeled fibroid
Path 2=enlarged heterogeneous uterus
Path 3=anterior complex cystic structure with color and Doppler properties
Path 4=complex structure (image 7) suggestive of dermoid cyst
It is fairly common for the uterus to move during a pelvic exam. I am not sure that I agree that the uterus did move because on your TA exam I believe that the uterus is displayed as a retroverted uterus. Was it difficult for the sonographer to acquire a sagittal TA image?
Yeah, I think I've finally figured out the mystery pathology! It is a uterine arteriovenous malformation (AVM). AVMs usually have non-specific gray-scale appearances. However, color doppler will show a "multi-directional high velocity flow that produces a "mosaic pattern"". One usually sees a high velocity, low resistance flow. This is a rare condition. http://www.jultrasoundmed.org/cgi/content/abstract/25/11/1387
Great observations everyone! You are right Alexia, the radiologist diagnosed this as an arteriovenous malformation. He assumed it was an acquired condition, formed as a reaction to the scar area from the C sections. As this was an incidental finding, this woman must be glad she came in for this study. Could someone who hasn't commented mention why that might be?
Hello Abby
Sorry I did not comment early.
Uterine arteriovenous malformations are rare lesions with a considerable risk potential. Clinical presentation varies from no signs over various degree of menorrhagia to massive life-threatening vaginal bleeding. Clinical suspicion is essential for a prompt diagnosis and treatment.
zouliath
do you know that Arteriovenous Malformation is a rare condition in which a section of blood vessels lacks a capillary network, resulting in blood from an artery being delivered directly to a vein. This places pressure on the vein, which over time, may weaken and burst, causing a hemorrhage. It is believed this condition may be congenital or acquired.
...
Uterine arteriovenous malformation (AVM) is a rare condition.
Uterine AVMs may be congenital or acquired. Congenital AVMs have multiple vascular connections, may manifest at other sites, and involve surrounding structures. Acquired AVMs usually have a single connection between an artery and a vein. Acquired AVMs may be preceded by uterine curettage, cesarean section, gestational trophoblastic neoplasia, or endometrial carcinoma.
Post a Comment