History:

A 48 year old female presents with pelvic pain, fever, and leukocytosis.





Imaging:









Q1. What is the name of the artifact shown in the image 2?

A) Reverberation

B) Acoustic Shadowing

C) Acoustic Enhancement

D) Wall-Echo-Shadow





Q2. What procedure most likely occurred in this patient recently?

A) Dilation and Curettage

B) Embolization of an intracavitary fibroid

C) Embolization of a subserosal fibroid

D) Biopsy of uterine epidermoid cyst





Q3. What is the size cutoff for embolization of a submucosal fibroid?

A) 3 cm

B) 5 cm

C) 6 cm

D) 10 cm





Discussion:

Recognition of post-procedural complications is important for the radiologist, even in the face of not knowing what procedure has been performed. The above images show a complication of uterine artery embolization for uterine fibroids. The infarcted fibroid is the echogenic lesion with shadowing shown in the ultrasound images. The CT shows the degree of uterine distension with retained debris. The complex nature of the fluid suggests underlying infection. The overall diagnosis in this case is pyomyoma secondary to retained fibroid after UAE.





Uterine fibroids are defined by their location anatomically. Below is a schematic created for illustrative purposes.





Subserosal fibroids are the most superficial type, and corresponds to the lesion seen within the fundus. Next are intramural fibroids which are completely embedded within the myometrium. Submucosal fibroids exert mass effect upon the endometrial canal, but are within the myometrium. Cervical fibroids are possible, but rare. Pedunculated fibroids attach to the myometrium via a stalk of tissue. Think of a ball and chain floating within the endometrial cavity.





When patients have symptoms from their fibroids, uterine artery embolization can be a treatment option rather than hysterectomy. Depending on the location, there are different risks. Verma, et al, reported in 2008 that submucosal fibroids with an interface ratio of >0.55 (i.e. >55% of the surface area) contacts the endometrial canal have an increased chance of becoming endocavitary and those >6 cm are at risk of becoming "stuck."

Transabdominal sonographic image of the pelvis shows expanded endometrial canal (rose colored highlight) with punctate areas of complex debris (red shading, green arrows). The endometrium is stretched (blue).

Echogenic lesion dependent within the uterus shows posterior hypoechogenicity due to impeded sound transmission through the calcified lesion (teal circle)

Axial CT image colored the same as ultrasound images for correlative purposes shows expanded uterus with complex fluid and a calcified mass.

Calcified mass dependent near the internal cervical os (blue arrow) accompanies complex debris within the endometrium (yellow asterisk).



