Imaging findings of concealed intra-amniotic hemorrhage in the setting of placenta previa and placenta accreta spectrum disorder

Placental abruption is an important cause of feto-maternal hemorrhage, with significant impact on both fetal and maternal mortality. In most cases, it presents with abdominal pain and vaginal bleeding. However, vaginal bleeding may be absent with concealed intra-amniotic hemorrhage, as in cases with placenta previa, hence confounding this diagnosis. In such cases, imaging studies may be obtained to evaluate for abdominal pain in pregnancy; hence, radiologists should be aware of the ultrasound and magnetic resonance (MR) imaging appearance of intra-amniotic hemorrhage. This includes presence of markedly echogenic amniotic fluid on US. Hemorrhage signal intensity on MR imaging varies with the duration of bleeding. In acute to subacute cases, it will present as T1 isointense and T2 hypointense amniotic fluid. This case is the first report of MR imaging findings of acute concealed intra-amniotic hemorrhage.

ACR Appropriateness Criteria® Multiple Gestations

Women with twin or higher-order pregnancies will typically have more ultrasound examinations than women with a singleton pregnancy. Most women will have at minimum a first trimester scan, a nuchal translucency evaluation scan, fetal anatomy scan at 18 to 22 weeks, and one or more scans in the third trimester to evaluate growth. Multiple gestations are at higher risk for preterm delivery, congenital anomalies, fetal growth restriction, placenta previa, vasa previa, and velamentous cord insertion. Chorionicity and amnionicity should be determined as early as possible when a twin pregnancy is identified to permit triage of the monochorionic group into a closer surveillance model. Screening for congenital heart disease is warranted in monochorionic twins because they have an increased rate of congenital cardiac anomalies. In addition, monochorionic twins have a higher risk of developing cardiac abnormalities in later gestation related to right ventricular outflow obstruction, in particular the subgroups with twin-twin transfusion syndrome or selective intrauterine growth restriction. Monochorionic twins have unique complications including twin-to-twin transfusion syndrome, twin embolization syndrome, and acardius, or twin-reversed arterial perfusion sequence. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Multimodality imaging of placental masses: a pictorial review

Placental masses are uncommonly identified at the time of obstetric ultrasound evaluation. Understanding the pathologies presenting as placental masses is key for providing a differential diagnosis and guiding subsequent management, which may include additional imaging with magnetic resonance (MR) imaging. Potential benign entities include chorioangiomas and teratomas. Larger chorioangiomas can cause fetal cardiovascular issues from volume overload. Placental mesenchymal dysplasia has an association with fetal anomalies and detailed fetal evaluation should be performed when it is suspected. Identifying other cystic masses such as partial and complete moles is crucial to prevent erroneous pregnancy termination. This review addresses normal imaging appearance of the placenta on ultrasound and MR imaging and describes various trophoblastic and nontrophoblastic placental masses. Potential placental mass mimics including uterine contractions and thrombo-hematomas are also presented.

Transvaginal Ultrasound-Guided Biopsy of Deep Pelvic Masses: How We Do It

The purpose of this review is to discuss the rationale and indications for transvaginal ultrasound-guided biopsy. Transvaginal ultrasound-guided biopsy can be a helpful tool for diagnosis and treatment planning in the evaluation of pelvic masses, particularly when the anatomy precludes a transabdominal or posterior transgluteal percutaneous biopsy approach. A step-by-step summary of the technique with preprocedure and postprocedure considerations is included.

PROMISe trial: a pilot, randomized, placebo-controlled trial of magnetic resonance guided focused ultrasound for uterine fibroids

OBJECTIVE

To evaluate the feasibility of a full-scale placebo-controlled trial of magnetic resonance-guided focused ultrasound for fibroids (MRgFUS) and obtain estimates of safety and efficacy.

DESIGN

Pilot, randomized, placebo-controlled trial.

SETTING

University medical center.

PATIENT(S)

Premenopausal women with symptomatic uterine fibroids.

INTERVENTION(S)

Participants randomized in a 2:1 ratio to receive MRgFUS or placebo procedure.

MAIN OUTCOME MEASURE(S)

PRIMARY OUTCOME

change in fibroid symptoms from baseline to 4 and 12 weeks after treatment assessed by the Uterine Fibroid Symptom Quality of Life Questionnaire (UFS-QOL); secondary outcome: incidence of surgery or procedures for recurrent symptoms at 12 and 24 months.

RESULT(S)

Twenty women with a mean age of 44 years (±standard deviation 5.4 years) were enrolled, and 13 were randomly assigned to MRgFUS and 7 to placebo. Four weeks after treatment, all participants reported improvement in the UFS-QOL: a mean of 10 points in the MRgFUS group and 9 points in the placebo group (for difference in change between groups). By 12 weeks, the MRgFUS group had improved more than the placebo group (mean 31 points and 13 points, respectively). The mean fibroid volume decreased 18% in the MRgFUS group with no decrease in the placebo group at 12 weeks. Two years after MRgFUS, 4 of 12 women who had a follow-up evaluation (30%) had undergone another fibroid surgery or procedure.

CONCLUSION(S)

Women with fibroids were willing to enroll in a randomized, placebo-controlled trial of MRgFUS. A placebo effect may explain some of the improvement in fibroid-related symptoms observed in the first 12 weeks after MRgFUS.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01377519.

Value of Intraoperative Sonography in Pancreatic Surgery

The utility of intraoperative sonography for pancreatic disease has been well described for detection and evaluation of neoplastic and inflammatory pancreatic disease. Intraoperative sonography can help substantially reduce surgical time as well as decrease potential injury to tissues and major structures. Imaging with sonography literally at the point of care--the surgeon's scalpel--can precisely define the location of pancreatic lesions and their direct relationship with surrounding structures in real time during surgery. This article highlights our experience with intraoperative sonography at multiple institutional sites for both open and laparoscopic surgical procedures. We use intraoperative sonography for a wide range of pancreatic disease to provide accurate localization and staging of disease, provide guidance for enucleation of nonpalpable, nonvisible tumors, and in planning the most direct and least invasive surgical approach, avoiding injury to the pancreatic duct or other vital structures.

Impact of new society of radiologists in ultrasound early first-trimester diagnostic criteria for nonviable pregnancy

OBJECTIVES

New early first-trimester diagnostic criteria for nonviable pregnancy recommended by the Society of Radiologists in Ultrasound via a multispecialty consensus panel extended the diagnostic size criteria of crown-rump length from 5 to 7 mm for embryos without a heartbeat and mean sac diameter from 16 to 25 mm for "empty" sacs. Our study assessed the potential impact of the new criteria on the number of additional follow-up sonograms these changes would engender.

METHODS

A retrospective study of all first-trimester sonograms in women with first trimester bleeding from 1999 to 2008 was conducted. Everyone included in the study had a visible gestational sac in the uterus. There were no pregnancies of unknown location or ectopic pregnancies included in this study cohort. Pregnancy of unknown location was used to describe cases in which there were no signs of pregnancy inside or outside the uterus on transvaginal sonography despite a positive pregnancy test result. A total of 1013 patients met the inclusion criteria.

RESULTS

Seven hundred fifty-two patients (74%) had identifiable embryos, and 261 (26%) did not. Of those with an identifiable embryo, 286 (38%) had no detectable embryonic cardiac activity. The breakdown of crown-rump lengths in this group was as follows: 100 measuring less than 5 mm, 36 measuring 5 to 7 mm, and 150 measuring 7 mm or greater. The breakdown of mean sac diameters in those without a visible embryo was as follows: 120 measuring less than 16 mm, 90 measuring 16 to 25 mm, and 51 measuring 25 mm or greater.

CONCLUSIONS

When diagnosing a failed pregnancy, there can be no room for error. Only 126 of 1013 early pregnancies threatening to abort (12%) fell into the more conservative zones defined by the new compared to the former size criteria (crown-rump length, 5-7 mm; mean sac diameter, 16-25 mm). Therefore, the potential impact of the new guidelines on follow-up sonograms does not appear inordinate.

Pseudotumor of the distal common bile duct at endoscopic retrograde cholangiopancreatography

BACKGROUND

Prior studies have described a pseudocalculus appearance in the distal common bile duct as a normal variant at cholangiography. The objective of this study was to describe the occurrence of pseudotumor in the distal common bile duct at endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

Nine patients who underwent ERCP between May 2004 and July 2008 were identified as having a transient eccentric mural-based filling defect in the distal common bile duct. A single reader systematically reviewed all studies and recorded the imaging findings.

RESULTS

The mean diameter of the filling defect was 9 mm (range, 5 to 11). Eight patients had resolution of the filling defect during the same ERCP or on a subsequent ERCP, and in two of these patients the inferior border of the filling defect was not well visualized. The other patient underwent surgical resection of a presumed tumor with no evidence of malignancy on surgical pathology.

CONCLUSION

An eccentric mural-based filling defect in the distal common bile duct can be artifactual in nature and may reflect transient contraction of the sphincter of Oddi. Recognition of this pseudotumor may help avoid unnecessary surgery.

Magnetic resonance spectroscopic imaging of benign prostatic tissue: findings at 3.0 T compared to 1.5 T-initial experience

In a retrospective study of 71 voxels of benign peripheral zone tissue from 3 men who underwent endorectal magnetic resonance (MR) spectroscopic imaging of the prostate at both 1.5 and 3 T, 21 voxels that appeared more malignant at 3 T to either of two readers demonstrated significantly higher levels of choline and polyamines at 3 T compared to 1.5 T using a Wilcoxon ranked-sum test; awareness of this selective amplification of these metabolic signals at high field strength may help avoid overdiagnosis of prostate cancer.

CT and MRI of early intrauterine pregnancy

OBJECTIVE

The objective of this article is to describe the CT and MRI findings of early intrauterine pregnancy.

CONCLUSION

Early pregnancy should be considered when CT or MRI shows a fluid-filled cystlike structure in the uterus of a woman of reproductive age especially if there is a coexistent ovarian corpus luteum cyst.

Imaging malignant and apparent malignant transformation of benign gynaecological disease

Common benign gynaecological diseases, such as leiomyoma, adenomyosis, endometriosis, and mature teratoma, rarely undergo malignant transformation. Benign transformations that may mimic malignancy include benign metastasizing leiomyoma, massive ovarian oedema, decidualization of endometrioma, and rupture of mature teratoma. The aim of this review is to provide a contemporary overview of imaging findings in malignant and apparent malignant transformation of benign gynaecological disease.

Computed tomography findings mimicking appendicitis as a manifestation of colorectal cancer

The primary computed tomography (CT) signs of appendicitis can also be seen with other inflammatory or neoplastic processes. We report on two cases in which appendiceal dilatation and peri-appendiceal fluid or stranding were the dominant imaging manifestations of colorectal carcinoma in the ascending colon. This study highlights the need to closely examine the ascending colon in patients with a suspected CT diagnosis of acute appendicitis, since these findings may be secondary to an inconspicuous colorectal carcinoma.

Fetal tracheolaryngeal airway obstruction: prenatal evaluation by sonography and MRI

We reviewed the sonographic and MRI findings of tracheolaryngeal obstruction in the fetus. Conditions that can cause tracheolaryngeal obstruction include extrinsic causes such as lymphatic malformation, cervical teratoma and vascular rings and intrinsic causes such as congenital high airway obstruction syndrome (CHAOS). Accurate distinction of these conditions by sonography or MRI can help facilitate parental counseling and management, including the decision to utilize the ex utero intrapartum treatment (EXIT) procedure.

The equivocal appendix at CT: prevalence in a control population

The purpose of the study was to determine the prevalence of appendices with an equivocal appearance at computed tomography (CT) in a control population. We retrospectively identified a control population of 150 patients who underwent CT of the abdomen and pelvis for evaluation of hematuria (without abdominal pain, fever, or colonic disease). One reader measured the diameter of the appendix and noted if the appendix was either isodense in appearance or airless and fluid filled. Sixty-seven of 150 cases (44.6%) demonstrated appendiceal diameter greater than 6 mm. The appendix was collapsed or isodense in 34/150 cases (22.7%). Only ten of 150 or 6.6% of cases were isodense in combination with diameter greater than 6 mm, and none had diameter greater than 10 mm. Only one of 150 cases (0.67%) demonstrated airless fluid within the lumen, and the appendix measured less than 6 mm. While the diameter of the normal appendix is frequently greater than 6 mm, none measured greater than 10 mm in combination with ambiguous morphology. Furthermore, in the normal appendix, airless fluid filling the lumen is a rare appearance with a prevalence of less than 1%. While appendicitis could undoubtedly occur in an isodense appendix between 6 and 10 mm in diameter, such an appearance can occur in up to 6.6% of the normal population

Intrauterine umbilical cord hemorrhage with associated jejunal atresia captured by real-time ultrasound

The presence of unexplained umbilical cord ulceration and hemorrhage has been sporadically reported in fetuses with antenatally suggested intestinal atresia. This case report illustrates a patient with spontaneous intrauterine umbilical cord hemorrhage, captured by real-time ultrasonography, in the setting of jejunal atresia with volvulus of the distal jejunal segment.