K.E.M.
Radiology
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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Case of the Month
A rare presentation of uterine dehiscence in a grand multipara
Contributed by: Avani Natu
Clinical Profile:
A 45 year old G8P5L5A2 woman presented with amenorrhea for a period of three months with lower abdominal distension. She complained of lower abdominal pain and bleeding per vaginum for three days .
Ultrasonography done elsewhere was suggestive of an ectopic pregnancy; hence, exploratory laparotomy was performed. It showed a mass in the lower uterine segment protruding into the broad ligament. As it was not a tertiary care hospital and the surgeons didn't know what it could be, they closed the abdomen, suggested MRI and referred her to our hospital.
Radiological findings:
MRI of the pelvis with contrast shows a well-defined. pedunculated, T2 heterogeneously hypointense lesion with isointense areas within, arising from the endometrium. The lesion extends laterally to the left and is covered by serosa (Fig 1A). Lateral to this polypoidal lesion, an isointense soft tissue mass is seen corresponding to a fetus (Fig 1B, Fig 1C). Subtle T1 hypointense lesions as well as areas of diffusion restriction with drop in ADC values are seen within the lesion suggestive of hemorrhage. The lesion shows no appreciable post contrast enhancement (Fig 1D). Features are suggestive of incomplete (contained) uterine dehiscence involving the antero- left lateral wall with non-viable retained products of conception within the dehiscent area.
Fig. 1: Figure 1 A, B, C, D:
MRI pelvis with contrast shows a well-defined pedunculated T2 heterogenously hypointense lesion with isointense areas within seen arising from the endometrium extending laterally to the left covered by serosa. Lateral to this polypoidal lesion an isointense soft tissue mass is seen corresponding to fetus. Subtle T1 hypointense lesions as well as areas of diffusion restriction with drop in ADC values are seen within the lesion suggestive of hemorrhage. The lesion shows no appreciable post contrast enhancement.
On ultrasonography, there is a large, well defined, heterogeneously hypoechoic solid cystic mass arising from the endometrium crossing a breached myometrium and projecting exophytically into the left adnexa (Fig 2A). It shows few fetal parts. Fetal cardiac activity is absent. The placenta is seen separately extending from the endometrium to the lesion (Fig 2B). Features are suggestive of incomplete uterine dehiscence with demised fetus within a contained sac on the left side.
FIG 2 Figure 2 A, B: Ultrasonography shows a large well defined heterogeneously hypoechoic solid cystic mass lesion arising from the endometrium crossing a breached myometrium and going exophytically into the left adnexa. It shows few fetal parts. Fetal cardiac activity is absent. The placenta is seen separately going from the endometrium to the lesion.
On non contrast CT of the abdomen and pelvis there is a heterogenous, solid, exophytic lesion arising from the uterus going into the left adnexa with multiple calcific foci (Fig 3A, Fig 3B). There is no free fluid in the abdomen.
Fig. 3 : Figure 3 A, B:
On non contrast CT of the abdomen and pelvis there is a heterogenous solid exophytic lesion arising from the uterus going into the left adnexa with multiple calcific foci.
Radiological diagnosis:
Complete uterine dehiscence with non viable fetus.
Intra-operative images show the location of the fetus and the resected specimen shows the fetus and placenta.
Fig. 4 Figure 4 A, B:
Intra-operative images show the location of the fetus and the resected specimen showing the fetus and placenta.