case_images: PMC9188327_01
case_images: Sagittal (A, B) and axial (C) transvaginal ultrasound images obtained on post-operative day 18.. The images demonstrate ill-defined infiltrating echogenicity (white arrow heads) that extends into the subserosal anterior myometrium, with minimal protrusion into the endometrial canal (white arrow), raising initial concern for potential invasive placentation. However, no vascularity is noted within the area on Doppler (B, C). Parallel linear echogenicities (yellow arrows A) are consistent with sutures indicating the hysterotomy site.
case_images: j_crpm-2021-0013_fig_001.jpg
case_images: PMC9188327_01_j_crpm-2021-0013_fig_001.jpg
case_images: j_crpm-2021-0013_fig_001
case_images: The ultrasound demonstrated an ill-defined, infiltrating echogenicity extending from the anterior junctional zone into the subserosal myometrium that protruded into the endometrial canal proximally (Figure 1).
case_images: Sagittal and axial T2 MRI images (A, C) obtained on post-operative day 20.. The images demonstrate a large, relatively ill-defined hypointense area involving almost the entire anterior myometrium in the midline with a sharp line of demarcation posteriorly at the anterior junctional zone (white arrows). This corresponds to sagittal and axial precontrast T1 MRI images (B, D) from the same scan that show an ill-defined infiltrating hyperintensity in the same area (white arrow heads). A dark "hemosiderin ring" is noted on T2 (white dashed arrows). Susceptibility artifacts (yellow arrows B) indicate the hysterotomy site.
case_images: j_crpm-2021-0013_fig_002.jpg
case_images: PMC9188327_01_j_crpm-2021-0013_fig_002.jpg
case_images: j_crpm-2021-0013_fig_002
case_images: This area revealed an infiltrating pattern of poorly defined T1 hyperintensity on the pre-contrast sequences that corresponded with the area of ill-defined avascular echogenicity seen on the prior ultrasound (Figures 2 and 3).
case_images: Sagittal precontrast (A) and subtracted post-contrast (B) T1-weighted images obtained on post-operative day 20.. The images show completed absence of enhancement in the affected anterior myometrium. Note normal enhancement of the rest of the uterus. Due to characteristic appearances, these findings were consistent with a contained intramyometrial hematoma, related to Couvelaire uterus or post-surgical changes from classical cesarean delivery. Repeat MRI imaging two weeks after the initial study demonstrates interval evolution of the anterior intramyometrial hematoma. Sagittal (C, D) T2 and pre-contrast T1 weighted images demonstrate that the area is slightly smaller than the previous study, has increased T2 signal within its central aspect (C white arrow heads), possibly indicating interval liquefaction, and has a more prominent hemosiderin ring with reduced prominence of the precontrast T1 hyperintensity (D white arrow heads), especially along the anterior junctional zone. Findings are again consistent with diagnosis of intramural hematoma in the setting of the clinical diagnosis of Couvelaire uterus. There was no evidence of myometrial necrosis or abscess formation.
case_images: j_crpm-2021-0013_fig_003.jpg
case_images: PMC9188327_01_j_crpm-2021-0013_fig_003.jpg
case_images: j_crpm-2021-0013_fig_003
case_images: This area revealed an infiltrating pattern of poorly defined T1 hyperintensity on the pre-contrast sequences that corresponded with the area of ill-defined avascular echogenicity seen on the prior ultrasound (Figures 2 and 3).
case_images: Sagittal (A, B) and axial (C) postcontrast CT images obtained on post-operative day 20.. The images reveal a large heterogeneous area with patchy foci of hyperattenuation involving the anterior myometrium (white arrow heads), which corresponds to same area of abnormality on previous ultrasound and MRI imaging. These findings again support the diagnosis of large dissecting anterior intramural hematoma. The hysterotomy site is suboptimally identified on CT.
case_images: j_crpm-2021-0013_fig_004.jpg
case_images: PMC9188327_01_j_crpm-2021-0013_fig_004.jpg
case_images: j_crpm-2021-0013_fig_004
case_images: The CT images also showed a large, relatively hypodense area in the anterior myometrium that corresponded with the same area of abnormality on ultrasound and MRI (Figure 4).