After a basic understanding of the developmental abnormality,
we’ll move on to the assorted complications,
the standard imaging modality with protocols and classification of the various MDA at our centre.
MODALITIES:
- Hysterosalpingography (HSG) is used as the first line of evaluation of infertility; where the uterine cavity and fallopian tube patency is assessed,
limiting the evaluation of the external uterine contour.
- In younger patients or in patients presenting with as abdominal emergency,
Ultrasonography (US) is the modality of choice because it is easily available,
inexpensive and does not use radiation.
- Magnetic resonance imaging (MRI) however is the best and preferred choice in assessing detailed anatomy and presentation of MDA.
Fig. 2: Images of HSG demonstrating normal uterine contour, USG pelvis and coronal MRI abdomen and pelvis (left to right)
PROTOCOLS:
- The MRI protocols we use in our department is as follows;
- T2_ Tse_Sag- plan axial and coronal in relation to the utero-cervical axis.
- T2_Tse_Cor
- T1_Tse_Tra
- T2_Tse_Tra
- T1_fs_Tra
- Coronal T2 abdomen: for assessment of kidneys and spine.
For practical purposes;
- The female reproductive tract is best seen on T2-weighted images.
- T1-weighted à useful for identification of high-signal-intensity blood products as in endometriosis/ hematometra/hematocolpos.
- Sagittal T2-weighted à helpful to determine a diagnosis of uterine anatomy,
agenesis or hypoplasia
DISCUSSION:
The various consequences we encountered at our centre were;
- Hematometra involving one of the uterine horns in a case of Uterine Didelphis (Bicornis Bicollis).
Fig. 3: T2 axial (A, B) and coronal MRI images (C, D) showing complete duplication of uterine horns (blue arrow indicating the right uterine horn and red arrow indicating the left uterine horn). Features are suggestive of Uterine Didelphis (Bicornis Bicollis).
Fig. 4: T2 axial MRI image (G) showing complete duplication of uterine horns and cervices with widely separated horns located along the supero-lateral aspect of urinary bladder (blue arrow indicating the right and red arrow indicating the Left).
T1 FS MRI images (E) demonstrates hyperintense fluid seen in right uterine horn (blue arrow) suggestive of Hematometra.
T2 sagittal MRI (F) image of mid pelvis, showing absent uterus in the midline.
- Hemato-pyometra involving one of the uterine horns in a case of Bicornuate unicollis.
Fig. 5: T2 axial (B) and coronal images MRI images (A,C) demonstrating Bicornuate unicollis uterus, with large communicating endometrial and myometrial collections (blue arrow) through a focal defect as described above with severe thinning of myometrium (pink arrow) suggestive of Hemato-pyometra.
A cavity (blue star) which is communicating with another large myometrial collection (pink star) large T2 hyperintense collection within the endometrial cavity) through a focal defect.
Diffuse adenomyosis in the right horn (yellow arrow) and fibroids in the left horn (brown arrow).
Fig. 6: T2 sagittal (D) and coronal MRI images (E, F) demonstrate a single vaginal and cervical cavity (green arrows) and a communication between the endometrial cavities (red arrow).
T2 sagittal (D) and coronal images MRI images (F) demonstrate diffuse Adenomyosis in the right horn (yellow arrow) and fibroids in the left horn (brown arrow). Features fit into Class IV Mullerian duct anomalies.
- Left hydrosalpinx in a case of Unicornuate uterus with non-communicating contralateral left rudimentary horn.
Fig. 7: T2 axial (A) and coronal (B) STIR axial (C) and T2 sagittal MRI images (D) demonstrate two separate uterine horns (light and dark blue) with the right horn communicating with the cervical canal. No obvious communication between left uterine horn with the right horn or cervical canal. Endometrial cavity seen in the rudimentary horn- Features fitting into Class II b Mullerian duct anomaly.
Mild left Hydrosalpinx (pink arrows).
- Bilateral Hydrosalpinx in Type 1 Mullerian duct anomaly
Fig. 20: T2 sagittal (A), and axial (B,C,D) MRI images demonstrates 2 separate vaginas and 2 ill-defined soft tissue structure in bilateral adnexa's (brown arrow/outline) which could be hypoplastic uteruses, bilateral Hydrosalpinx (star)
Features suggestive of Type 1 Mullerian duct anomaly
- Gravid right uterine horn in Uterine didelphys.
Fig. 8: 30 Year old female with 11 weeks pregnancy and suspected uterine malformation.
T2 axial MRI images (A, B, C) demonstrates Class III Mullerian duct anomaly - Uterine Didelphys with gravid right horn.
Complete duplication of cervical canal (pink arrows) and uterine horns (yellow arrows) without any communication between them. Right horn is in gravid state with amniotic sac, fetus and posteriorly attached placenta (green star)
- Uterine fibroids in Bicornuate unicollis.
Fig. 9: T2 FS axial (A) and coronal (B, C, D) MRI images demonstrating Mullerian duct anomaly - class IV b: (Bicornuate unicollis)
Two discrete uterine horns are noted with widened intercornual distance and separate non-communicating endometrial cavities seen in upper part (green arrows).
A submucosal lesion seen in left horn - fibroid (red arrow)
Fig. 10: Two discrete uterine horns noted with widened intercornual distance with likely partial division with single cervical canal (green arrow)suggesting Mullerian duct anomaly -Bicornuate unicollis -class IV B
Small subserosal (right side, orange arrow) and submucosal (left side, red arrow) in bilateral uterine horns, uterine Fibroids
- Hematometra and Haematosalpinx involving one of the uterine horns and fallopian tubes in a case of Uterine Didelphyis.
Fig. 12: T2 coronal (A) and T1 axial (B) MRI images demonstrates left Haematosalpinx (orange arrows).
STIR FS -axial (C,D) and T1 axial (E) MRI images demonstrates Uterine Didelphyis with left Hematometra.
- Imperforated right hemivagina and hematocolpos in a case of Uterine Didelphys.
Fig. 14: T2 sagittal (A), axial (B) and coronal (C) MRI images demonstrates two separate uterine cavities (red arrows) and cervical canals (pink arrows). The endometrial cavity is distended and fluid filled.
Fig. 15: T2/T1 FS axial (A, D) and coronal (B, C) MRI images demonstrates a septated right vagina which is distended with fluid within the vaginal cavity (pink arrow) compressing and displacing the left vaginal cavity (yellow arrow). The features are suggestive of uterine Didelphys with imperforated right Hemivagina and Hematocolpos.
- Endometriosis in a Mayer Rokitansky Kuster Hauser syndrome type II.
Fig. 16: T1 (A, C) and T2 (B, C) axial MRI images demonstrates Unicornuate uterus with small cervix, incompletely visualized, suggestive of cervical agenesis.
Multiple multiloculated cysts (mustard arrows) in the left adnexa suggestive of Endometriotic cysts with non-visualization of left ovary and fallopian tube and mild degree free fluid in the pelvis with thin internal septations, possible menstrual bleed into left ovary and fallopian tube and into the peritoneal cavity (brown arrow)
Associated anomalies;
We encountered absent unilateral kidneys in 3 cases.
Fig. 13: A young patient presented with amenorrhoea; On T2 coronal (A) sagittal (B) axial (C,D) MRI images absent left kidney and absent uterus (star), bilateral ovaries seen (arrows)- Features fitting into Mayer-Rokitansky-Küster-Hauser syndrome (MRKH)
Fig. 18: T2 coronal (A, C) sagittal (B) and axial (D) MRI images demonstrate ill-defined soft tissue extending to the adnexa's (yellow outline) could be hypoplastic uterus/fallopian tubes. Ovaries are seen bilaterally (blue arrow). Upper 1/3rd vagina is well seen (orange arrow). However distal vagina is likely absent. Absent Right Kidney (star) - The features are suggestive of Type IE Mullerian duct anomaly
Fig. 19: T2 sagittal (A), coronal (B, C) and axial (D) MRI images demonstrate absent vagina, uterus, fallopian tube and right kidney (brown star). The bilateral ovaries are well seen (blue arrow).
Features fit into Mayer Rokitansky Kuster Hauser syndrome variety
Also partial sacral agenesis and coccygeal agenesis in 1 case.
Fig. 17: On T2 sagittal (E) MRI image S5 and coccyx are not visualized, suggestive of partial sacral agenesis and coccygeal agenesis (blue arrow).
Absent vagina (red arrow) on T1 axial MRI image (F). The right ovary is well seen (purple arrow).
The bilateral kidneys were seen on trans-abdominal ultrasound.