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ANSWERS
CASE 100
Endometritis and Endomyometritis
1. B and D
2. D
3. C
4. D
References
Brown DL: Pelvic ultrasound in the postabortion and postpartum patient.
Ultrasound Q 2005; 21(1):27-37.
http://www.ncbi.nlm.nih.gov/pubmed/15716756 (Accessed on June 21, 2012.)
Leyendecker JR, Gorengaut V, Brown JJ: MR imaging of maternal diseases
of the abdomen and pelvis during pregnancy and the immediate postpar-
tum period. Radiographics 2004; 24(5):1301-1316.
http://www.ncbi.nlm.nih.gov/pubmed/15371610 (Accessed on June 21, 2012.)
Wachsberg RH, Kurtz AB: Gas within the endometrial cavity at postpartum
US: a normal nding after spontaneous vaginal delivery. Radiology 1992;
183(2):425-429.
http://www.ncbi.nlm.nih.gov/pubmed/1561345 (Accessed on June 21, 2012.)
Cross-Reference
Ultrasound: The REQUISITES, 2nd ed, pp 539, 573.
Comment
Etiology
Endometritis (Figures A to D) is an infection of the endometrial canal that is seen in patients with pelvic inammatory disease (microbacterial or venereal), in patients in the puerperium
(postpartum period) (Figures B and C), and in patients after
instrumentation (e.g., after dilatation and curettage). An intrauterine device can predispose a woman to endometritis. Pelvic
inammatory disease causes an ascending infection through
the vagina, which, if left untreated, infects the uterus followed
by the fallopian tubes and adnexa. These infections, which may
spread into the pelvis, can cause peritoneal signs and rarely
may manifest with right ank pain and perihepatic pain caused
by an ascending infection.
Ultrasound Findings
The incidence of endometritis or more severe endomyometritis, with inammation extending into the myometrium, is
much higher after a cesarean section than after a vaginal delivery—13% to 39% versus less than 2.7%. Ultrasound detects
a normal postpartum uterus in 50% of women with endometritis or endomyometritis. Endometritis is usually a clinical
diagnosis.
When abnormalities are detected, endometrial uid, debris,
or a uid level (Figure A) and gas may be identied. However,
endometrial gas is more commonly a normal postpartum nding, even increasing in quantity or appearing over time. However, a focal abnormality that may contain gas in the anterior
uterine wall suggests myometritis. This ultrasound nding
should not be confused with a normal cesarean section scar,
which is seen as a well-dened oval hyperechoic area or a small
(<1.5 cm) subclinical hematoma visualized in or adjacent to
the incision in many normal women.
Complications
Complications of endomyometritis include wound or pelvic
abscess, phlegmon, ovarian vein thrombosis, uterine dehiscence, bacteremia, and death from sepsis. CT and MRI are
better than ultrasound in detecting parametrial inammation.
MRI is particularly useful because of its ability to image the
sagittal plane, and it is better suited than CT for evaluating
the endometrium and anterior myometrium. Retained products of conception and uterine dehiscence (Figure D) can be
diagnosed with body CT imaging.
206
CASE 101
D
History: A 24-year-old pregnant woman presents to the
emergency department with inability to void.
A
1. What should be included in the differential diagnosis for
the ultrasound ndings seen in Figures A and B? (Choose
all that apply.)
A. Incarcerated uterus
B. Ectopic pregnancy
C. Retroverted/retroexed gravid uterus
D. Normal position of gravid uterus
E. Cervical ectopic pregnancy
2. Which of the following is not a nding of incarcerated
uterus?
A. Cervix against symphysis pubis
B. Intrauterine products of conception in the cul-de-sac
C. Maternal bladder anterior to the uterus
D. Ectopic pregnancy with products of conception out-
side the uterus, in the cul-de-sac
3. How is this condition treated?
B
A. Cesarean delivery
B. Vaginal delivery
C. Manual reduction after 14 weeks’ gestation
D. Do nothing
4. Which of the following are not risk factors for developing
this condition?
A. Anteverted position of uterus
B. Endometriosis, pelvic inammatory disease, prior
surgery
C. Fibroids, uterine malformations
D. Deep sacral concavity
C
207
ANSWERS
CASE 101
Incarcerated Uterus
1. A and C
2. D
3. C
4. A
References
Gerscovich E, Maslen L: The retroverted incarcerated uterus in pregnancy:
imagers beware. J Ultrasound Med 2009; 28(10):1425-1427.
http://www.ncbi.nlm.nih.gov/pubmed/19778896 (Accessed on June 21, 2012.)
Poder L: Ultrasound evaluation of the uterus. In Callen PW (ed): Ultrasonogra-
phy in Obstetrics and Gynecology, 5th ed. Philadelphia: Saunders, 2008,
pp 923-924.
Van Beekhuizen HJ, Bodewes HW, Tepe EM, et al: Role of magnetic reso-
nance imaging in the diagnosis of the gravid uterus. Obstet Gynecol 2003;
102(5 Pt 2):1134-1137.
http://www.ncbi.nlm.nih.gov/pubmed/14607032 (Accessed on June 21, 2012.)
Cross-Reference
Ultrasound: The REQUISITES, 2nd ed, pp 534-536.
Comment
Differential Diagnosis
The diagnosis of incarcerated uterus is usually clinical, based
on physical ndings and clinical symptoms. However, given its
very low incidence, it can be a diagnostic challenge. The rst
line of imaging should be ultrasound. If ultrasound ndings
remain indeterminate, especially later in pregnancy, MRI can
be helpful in clarifying anatomy because of its larger eld of
view and multiplanar capability. The clinical symptoms usually manifest before 15 weeks of gestation as pressure-related
symptoms from organs adjacent to the incarcerated uterus. As
the uterus enlarges, the rectum is pushed posteriorly and the
cervix, neck of the bladder, and urethra are displaced anteriorly against the pubic bones. Increased rectal pressure and
urinary symptoms such as pain and inability to void occur.
The differential diagnosis includes pelvic mass (uterine versus
adnexal), broids, and ovarian pathology. Ectopic pregnancy is
an important entity included in the differential diagnosis. The
anteriorly and superiorly displaced cervix and endocervical
canal can be misinterpreted as an empty uterus and the gestation in the cul-de-sac as an extrauterine ectopic pregnancy
displacing the uterus (Figure A).
Ultrasound Findings
The constellation of ndings as presented in Figures A to C
includes the intrauterine products of conception and pregnancy deep in the cul-de-sac. This is an important nding in
incarcerated uterus. The maternal urinary bladder lies anteriorly rather than caudal to the uterus. An important nding in
a retroverted uterus is the location of the cervix. The cervix
in incarcerated uterus is seen displaced cephalad, between the
urinary bladder and the pregnancy.
Prognosis and Management
Failure to recognize incarcerated uterus can result in compromise of uterine circulation, early pregnancy failure, or rupture
of the uterus later in pregnancy or during labor. If this entity
is recognized early in the second trimester, manual repositioning is usually easily accomplished with an excellent prognosis (Figure D). After failure of manual repositioning, more
invasive methods can be attempted, such as laparoscopic and
colonoscopic reduction. Reduction is not recommended after
20 weeks of gestation because of increased risk and potential
complications.
Vaginal delivery is not reported to be safe with persistent
incarceration. Because the anatomy can be greatly distorted,
a supraumbilical vertical skin incision, rather than low vertical
incision, is recommended. The key to successful management
of incarceration of a retroverted/retroexed gravid uterus is
early diagnosis.
Acknowledgment
Special thanks to Dr. Liina Poder for completion of this case.
208
CASE 102
A
C
B
History: A pregnant patient presents with a history of
recurrent rst-trimester pregnancy loss.
1. What is shown in the coronal transvaginal three-dimensional reconstructed image of the uterus in Figure B?
(Choose all that apply.)
A. Septate uterus
B. Uterine didelphys
C. Bicornuate uterus
D. Two endometrial cavities
2. What is the most common congenital uterine anomaly?
A. Bicornuate uterus
B. Septate uterus
C. T-shaped uterus
D. Uterine didelphys
3. What is the embryologic precursor of the uterus and
vagina?
A. Müllerian ducts for the uterus and vagina
B. Müllerian ducts for the uterus but not the vagina
C. Müllerian ducts for the uterus and the upper two thirds
of the vagina
D. Müllerian ducts for the uterus and lower one third of
the vagina
4. What organ system anomaly is related to the uterine
anomaly?
A. Respiratory anomaly
B. Genitourinary anomaly
C. Gastrointestinal anomaly
D. Skin rash
209
ANSWERS
CASE 102
Congenital Uterine Anomalies
1. A and D
2. B
3. C
4. B
References
Bocca SM, Ochninger S, Stadtmauer L, et al: A study of the cost, accuracy
and benets of 3-dimensional sonography compared with hysterosalpingography in women with uterine abnormalities. J Ultrasound Med 2012;
31:81-85.
http://www.ncbi.nlm.nih.gov/pubmed/22215773 (Accessed on June 21, 2012.)
Dunitz M: Uterine factors in infertility. In Goldstein SR, Benson CB (eds): Imag-
ing of the Infertile Couple. Oxford, UK: Blackwell Science, Inc, 2001, pp 41-53.
Troiano RN, McCarthy SM: Mullerian duct anomalies: Imaging and clinical
issues. Radiology 2004;233:19-34.
http://www.ncbi.nlm.nih.gov/pubmed/15317956 (Accessed on June 21, 2012.)
Cross-Reference
Ultrasound: The REQUISITES, 2nd ed, pp 536-538.
Comment
Etiology and Classification of Congenital Uterine
Anomalies
The uterus and proximal two thirds of the vagina arise
embryologically from the müllerian or paramesonephric ducts. Uterine anomalies (Figures A to C) are classied
into seven classes. Class I includes hypoplasia or segmental
agenesis. Class II is unicornuate uterus. Class III is uterus
didelphys. Class IV is bicornuate uterus (Figure B). Class
V is septate uterus (Figure A). Class VI is arcuate uterus.
Class VII comprises the congenital anomalies that result
from maternal exposure to diethylstilbestrol (DES) (Figure
C) during pregnancy. Because the uterine anomalies involve
the embryologic precursor of the genitourinary system, renal
anomalies are present in about 50% of cases of uterine
anomalies and include renal agenesis, ectopia, malrotation,
fusion, and duplication.
MRI of Congenital Uterine Anomalies
Comparative studies have shown that MRI is a more sensitive
and accurate modality than transvaginal ultrasound or hysterosalpingography for the detection and classication of uterine
anomalies. The accurate description of the pelvis has helped
gynecologists determine appropriate therapy.
Ultrasound of Congenital Uterine Anomalies
For distinguishing a septate uterus, MRI and transvaginal
ultrasound are very accurate and noninvasive. More recently,
three-dimensional ultrasound has been shown to improve the
accuracy of detection and differentiation of uterine anomalies, especially with the coronal reconstructed view, compared
with two-dimensional transvaginal imaging. Studies have
shown the accuracy of three-dimensional ultrasound to be
comparable to, or better than, hysterosalpingography; in addition, three-dimensional ultrasound can distinguish a bicornuate uterus from a septate uterus, which is one limitation of
hysterosalpingography.
Septate Uterus versus Bicornuate Uterus
A septate uterus (Figure A) is distinguished from a bicornuate uterus (Figure B) on transvaginal ultrasound and MRI by
showing that the fundus is convex, at, or indented by no more
than 1 cm. In addition, the superior portion of the septum is
similar in echogenicity (ultrasound) or signal intensity (MRI)
to myometrial muscle. The inferior portion is brous and
hypoechoic on ultrasound or shows decreased signal intensity
on MRI. A bicornuate uterus has divergent uterine horns and
a fundal cleft greater than 1 cm (Figure B).
210
CASE 103
A
History: An asymptomatic patient with a second-trimester
twin pregnancy undergoes imaging.
1. What is the diagnosis of one of the twins?
A. Acardiac twin
B. Anencephalic twin
C. Chylothorax
D. Cystic hygroma
2. What type of twin pregnancy is this?
A. Monochorionic
B. Monoanionic
C. Conjoined twins
D. Dichorionic
B
3. What pathologic abnormality leads to this condition?
A. Abnormal arterial anastomoses in the placenta
B. Abnormal intraplacental arterial-to-arterial and intrapla-
cental venous-to-venous anastomoses
C. Arteriovenous malformation
D. Placental arterial aneurysm
4. What is the prognosis for the normal twin?
A. Almost certainly fatal
B. Almost certainly excellent
C. 10% fatal
D. Variable
211
ANSWERS
CASE 103
Acardiac Twin
1. A
2. A
3. B
4. D
References
Fouron JC, Leduc L, Grigon A, et al: Importance of meticulous ultra-
sonographic investigation of the acardiac twin. J Ultrasound Med 1994;
13(12):1001-1004.
http://www.ncbi.nlm.nih.gov/pubmed/7877200 (Accessed on June 21, 2012.)
Hecher K, Ville Y, Nicolaides KH: Color Doppler ultrasonography in the
identication of communicating vessels in twin-twin transfusion syndrome
and acardiac twins. J Ultrasound Med 1995; 14(1):37-40.
http://www.ncbi.nlm.nih.gov/pubmed/7707475 (Accessed on June 21, 2012.)
Sepulveda W, Hasbun J, Dezerega V, et al: Successful sonographically guided
laser ablation of a large acardiac twin at 26 weeks’ gestation. J Ultrasound
Med 2004; 23(12):1663-1666.
http://www.ncbi.nlm.nih.gov/pubmed/15557310 (Accessed on June 21, 2012.)
Cross-Reference
Ultrasound: The REQUISITES, 2nd ed, p 516.
Comment
General Description
Acardiac twinning, or reversed arterial perfusion sequence, is
a rare anomaly that arises in twin gestations that share a placenta (monochorionic). It occurs in 1% of monozygotic twins.
Similar to twin-twin transfusion syndrome, intraplacental vascular anastomoses result in shunting of blood between the
normal or pump twin and the acardiac fetus. In contrast to
twin-twin transfusion syndrome with arteriovenous anastomoses, the connections in acardiac twinning are different—arterial-arterial and venous-venous. The acardiac fetus is a large
dependent mass, which places a large cardiovascular burden
on the normal twin. The cardiovascular overload can be fatal.
Ultrasound Findings
Ultrasound shows a large perfused tissue mass lacking the
upper body (Figure A, twin B) and a partially imaged normal
fetus (Figure B, twin A). Limbs may be present but truncated,
and the mass is usually acephalic (Figure A). With time, the
acardiac twin grows larger than the normal twin, creating a
large cardiovascular burden in the third trimester. The normal
twin develops heart failure and polyhydramnios. Reversal of
umbilical artery blood ow is usually present. Reports in the
literature have described identication of the communicating
intraplacental vessels with color Doppler imaging.
Treatment
Treatment begins with systemic administration of digitalis.
Interrupting blood ow to the acardiac twin may be the
only way to prevent perinatal death of the pump twin. More
aggressive treatment options include induction of intravascular thrombosis by injection of substances, selective cesarean
delivery, uterotomy, and ligation of the umbilical cord.
212
CASE 104
A
B
History: A pregnant woman presents with trauma to the
abdomen.
1. What should be included in the differential diagnosis?
(Choose all that apply.)
A. Porencephaly
B. Schizencephaly
C. Arachnoid cyst
D. Agenesis of the corpus callosum with an interhemi-
spheric cyst
E. Unilateral hydrocephalus
2. Which of the following statements concerning ultrasound
ndings of porencephaly is false?
A. There is usually a cleft or defect of the brain.
B. The defect is usually unilateral but may be bilateral.
C. It is probably secondary to internal carotid artery
infarction.
D. The defect is usually uid lled.
C
3. Which of the following statements concerning schizencephaly is false?
A. There are two types of schizencephaly; a fused cleft in
the cerebral mantle is the more commonly recognized
type in utero.
B. There is usually communication with the lateral ven-
tricles and the defect.
C. The cleft is usually lined by gray matter.
D. Polymicrogyria, gray matter heterotopias, and other cra-
nial anomalies are often associated.
4. Which of the following statements concerning the diagno-
sis and management of porencephaly is false?
A. Early delivery should be performed.
B. Patients with porencephaly may have seizure disorders.
C. Patients with porencephaly may have intellectual impair-
ment and hemiparesis.
D. Amniocentesis is usually not offered in these
pregnancies.
213
ANSWERS
CASE 104
Porencephaly
1. A and B
2. C
3. A
4. A
References
Govaert P: Prenatal stroke. Semin Fetal Neonatal Med 2009; 14(5):250-266.
http://www.ncbi.nlm.nih.gov/pubmed/19664975 (Accessed on June 22,
2012.)
Gul A, Gungorduk K, Yildirim G, et al: Prenatal diagnosis of porencephaly
secondary to maternal carbon monoxide poisoning. Arch Gynecol Obstet
2009; 279(5):697-700.
http://www.ncbi.nlm.nih.gov/pubmed/18777036 (Accessed on June 22, 2012.)
Kalache KD, Eder K, Esser T, et al: Three-dimensional ultrasonographic
reslicing of the fetal brain to assist prenatal diagnosis of central nervous
system anomalies. J Ultrasound Med 2006; 25(4):509-514.
http://www.ncbi.nlm.nih.gov/pubmed/16567440 (Accessed on June 22, 2012.)
Cross-Reference
Ultrasound: The REQUISITES, 2nd ed, p 379.
Comment
Differential Diagnosis
The differential diagnosis of a lateral intracranial cystic structure includes porencephaly and schizencephaly. These anomalies may be difcult to separate in utero by ultrasound. MRI
may be helpful postnatally. Unilateral hydrocephalus may
occur in utero, but usually the defect is not wedge shaped. Cystic neoplasms are rare, and often both cystic and solid components are present. Arachnoid cysts are cysts with mass effect,
are usually rounded or oblong, and generally would be considered less likely.
Ultrasound Findings
Ultrasound ndings include a cleft or defect of the cerebral cortex, which is usually unilateral but occasionally bilateral (Figures A and B). The defect is a uid-lled cavity that
communicates with the cerebral ventricles and extends to the
calvaria. In most cases the cleft is lined with white matter;
however, this is not usually identied until postnatal MRI is
performed. In contrast, in schizencephaly, the defect is usually lined by gray matter. Schizencephaly often has associated
intracranial and migrational abnormalities, which would be less
common with porencephaly. A postnatal CT scan is included
in this case (Figure C).
Prognosis and Management
Obstetric management is usually standard. In one series,
porencephaly was not identied until the late third trimester after a normal second-trimester scan. This series would
potentially indicate cerebral infarction, infection, hemorrhage,
and periventricular leukomalacia as potential etiologies of
porencephaly. Amniocentesis is usually not warranted unless
there are associated abnormalities. Cesarean section may be
performed if macrocrania with fetopelvic disproportion is
present.
214
CASE 105
A
History: An asymptomatic patient with a third-trimester
pregnancy undergoes ultrasound imaging.
1. What should be included in the differential diagnosis of the
cystic abnormality (depicted by cursors on Figures A and B)
arising from the umbilical cord? (Choose all that apply.)
A. Wharton’s jelly cyst
B. Allantoic cyst
C. Umbilical cord hematoma
D. Umbilical vessel dilation
2. Which specic genitourinary anomaly is associated with an
allantoic cyst?
A. Patent urachus
B. Crossed fused ectopia of the kidneys
C. Prune-belly syndrome
D. Solitary kidney
3. Which of the following statements is true?
A. Allantoic duct remnants are usually found at the pla-
centa end of the cord.
B. Allantoic duct remnants are usually found at the fetal
end of the cord.
C. An allantoic duct cyst can be distinguished from an
omphalomesenteric duct cyst by the fact that allantoic
duct remnants are usually eccentric and omphalomesenteric duct cysts are usually centrally located.
D. Cutting the umbilical cord is not associated with any
risk for cutting the urachus.
B
4. Which of the following is not a use of color Doppler imaging of the cystic mass area of the umbilical cord to clarify
the mass further?
A. One use is to determine if the vessels of the umbilical
cord are compressed.
B. One use is to determine if the vessels of the umbilical
cord are thrombosed.
C. One use is to determine if the umbilical cord is a one-
vessel cord (one artery only).
D. One use is to determine if the umbilical cord has a vas-
cular anomaly.
215