Magnetic resonance imaging in tubal and non-tubal ectopic pregnancy

Nanomedicines for Improved Management of Ectopic Pregnancy: A Narrative Review

Ectopic pregnancy (EP) - the implantation of an embryo outside of the endometrial cavity, often in the fallopian tube - is a significant contributor to maternal morbidity and leading cause of maternal death due to hemorrhage in first trimester. Current diagnostic modalities including human chorionic gonadotropin (hCG) quantification and ultrasonography are effective, but may still misdiagnose EP at initial examination in many cases. Depending on the patient's hemodynamic stability and gestational duration of the pregnancy, as assessed by history, hCG measurement and ultrasonography, management strategies may include expectant management, chemotherapeutic treatment using methotrexate (MTX), or surgical intervention. While these strategies are largely successful, expectant management may result in tubal rupture if the pregnancy does not resolve spontaneously; MTX administration is not always successful and may induce significant side effects; and surgical intervention may result in loss of the already-damaged fallopian tube, further hampering the patient's subsequent attempts to conceive. Nanomaterial-based technologies offer the potential to enhance delivery of diagnostic imaging contrast and therapeutic agents to more effectively and safely manage EP. The purpose of this narrative review is to summarize the current state of nanomedicine technology dedicated to its potential to improve both the diagnosis and treatment of EP.

Diagnostic utility of contrast-enhanced computed tomography for ectopic pregnancy

INTRODUCTION

Contrast-enhanced computed tomography (CECT) is an emergent diagnostic imaging modality to identify the bleeding site and survey the abdominal cavity. The diagnostic utility of CECT for ectopic pregnancy (EP) has not been well-investigated. The objective of this study was to evaluate the characteristics of CECT findings in patients with EP and extract specific findings that could contribute to the identification of implantation sites.

METHOD

We conducted a retrospective study, reviewing suspected EP cases between April 2015 and March 2018 in our hospital. Clinical symptoms, blood test results, transvaginal sonography findings, and surgical and pathologic findings from the medical records were assessed. CECT images were evaluated by a certified radiologist and gynecologist retrospectively in consensus. The following were selected as positive findings for specific determination of the ectopic implantation site: the ectopic gestational sac, lateralization of the hemoperitoneum around the adnexa on either side, and extravascular leakage of the contrast agent outside the uterine cavity.

RESULTS

CECT was performed in 41 women with an EP. The ectopic implantation site was detectable on CECT in 90.2% (37/41), whereas it was noted in 70.0% (32/41) on transvaginal ultrasonography (TVS). Of nine patients with an EP with an undetectable implantation site on TVS, six were positive for the specific determination of the ectopic implantation site on CECT.

CONCLUSION

CECT has the potential to predict ectopic implantation sites with high-level sensitivity. As CECT is an urgent diagnostic imaging tool to be used in an emergent setting, it may be a good option for EP diagnosis when the availability of magnetic resonance imaging is limited.

ACR Appropriateness Criteria® Acute Pelvic Pain in the Reproductive Age Group: 2023 Update

This review focuses on the initial imaging in the reproductive age adult population with acute pelvic pain, including patients with positive and negative beta-human chorionic gonadotropin (β-hCG) levels with suspected gynecological and nongynecological etiology. For all patients, a combination of transabdominal and transvaginal pelvic ultrasound with Doppler is usually appropriate as an initial imaging study. If nongynecological etiology in patients with negative β-hCG is suspected, then CT of the abdomen and pelvis with or without contrast is also usually appropriate. In patients with positive β-hCG and suspected nongynecological etiology, CT of the abdomen and pelvis with contrast and MRI of the abdomen and pelvis without contrast may be appropriate. In patients with negative β-hCG and suspected gynecological etiology, CT of the abdomen and pelvis with contrast, MRI of pelvis without contrast, or MRI of pelvis with and without contrast may be appropriate. 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 process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Gynaecological Causes of Acute Pelvic Pain: Common and Not-So-Common Imaging Findings

In female patients, acute pelvic pain can be caused by gynaecological, gastrointestinal, and urinary tract pathologies. Due to the variety of diagnostic possibilities, the correct assessment of these patients may be challenging. The most frequent gynaecological causes of acute pelvic pain in non-pregnant women are pelvic inflammatory disease, ruptured ovarian cysts, ovarian torsion, and degeneration or torsion of uterine leiomyomas. On the other hand, spontaneous abortion, ectopic pregnancy, and placental disorders are the most frequent gynaecological entities to cause acute pelvic pain in pregnant patients. Ultrasound (US) is usually the first-line diagnostic technique because of its sensitivity across most common aetiologies and its lack of radiation exposure. Computed tomography (CT) may be performed if ultrasound findings are equivocal or if a gynaecologic disease is not initially suspected. Magnetic resonance imaging (MRI) is an extremely useful second-line technique for further characterisation after US or CT. This pictorial review aims to review the spectrum of gynaecological entities that may manifest as acute pelvic pain in the emergency department and to describe the imaging findings of these gynaecological conditions obtained with different imaging techniques.

Imaging of Acute Abdominopelvic Pain in Pregnancy and Puerperium-Part I: Obstetric (Non-Fetal) Complications

Acute abdominopelvic pain in pregnant and postpartum patients presents clinical and therapeutic challenges, often requiring quick and accurate imaging diagnosis. Ultrasound remains the primary imaging investigation. Magnetic resonance imaging (MRI) has been shown to be a powerful diagnostic tool in the setting of acute abdominal pain during pregnancy and puerperium. MRI overcomes some drawbacks of US, avoiding the ionizing radiation exposure of a computed tomography (CT) scan. Although CT is not usually appropriate in pregnant patients, it is crucial in the emergency evaluation of postpartum complications. The aim of this article is to provide radiologists with a thorough familiarity with the common and uncommon pregnancy and puerperium abdominal emergencies by illustrating their imaging appearances. The present first section will review and discuss the imaging findings for acute abdominopelvic pain of obstetric (non-fetal) etiology.

Nontubal ectopic pregnancies: overview of diagnosis and treatment

Nontubal ectopic pregnancies occur as a result of embryo implantation outside the uterine cavity and fallopian tubes. Sites include ovary, cervix, abdominal cavity, interstitial portion of fallopian tube, and cesarean scar. Nontubal pregnancies are uncommon. Nonspecific signs and symptoms of nontubal ectopic pregnancies make diagnosis challenging and, in many cases, significantly delayed, resulting in a high rate of morbidity. Although surgical management remains the mainstay of treatment, there is growing evidence that some of these can be managed medically or with the use of a combination of medical and surgical approaches with good outcome. This review summarizes the current diagnostic modalities, therapeutic options, and outcomes for nontubal ectopic pregnancies. Diagnostic and management options may be limited, especially in resource-restricted settings. Therefore, an understanding of the available options is critical. It needs to be emphasized that the rarity of cases and the difficulties in organizing ethically justified randomized trials result in the lack of well-established management guidelines for nontubal ectopic pregnancies.

A delayed spontaneous second-trimester tubo-abdominal pregnancy diagnosed and managed by laparotomy in a "self-identified" infertile woman, a case report and literature review

BACKGROUND

Abdominal pregnancy, a rare form of ectopic pregnancy, is associated with high morbidity and adverse consequences for future fertility. Early recognition and management reduce mortality and allow minimal invasive and conservative treatment. In modern medicine, primitive prevention to unexpected fatal pregnancies is crucial.

CASE PRESENTATION

A divorced 33-year-old "self-identified" infertile polycystic ovary woman diagnosed as repeated implantation failure in previous in vitro fertilization with her ex-husband ever presented in surgery department with a history of 15-day abdominal pain, nausea, and vomiting and 3-h worsening abdominal pain. The serum beta-human chorionic gonadotropin value was more than 10,000 m-international units per milliliter. Sonogram findings were significant for the absence of intrauterine gestation; a placenta and well-formed living fetus of second-trimester gestation were seen in the abdomen, accompanied by hemoperitoneum. A unique spontaneously second-trimester tubo-abdominal pregnancy was confirmed in emergent laparotomy by gynecologists, she received a removing of the living fetus, a right total salpingectomy, resection of partial omentum and blood transfusion. The patient recovered uneventfully and her serum beta-human chorionic gonadotropin returned to normal range on the 30th postoperative day, till now, she has weak fertility awareness because of her catastrophic experiences in the unexpected abdominal pregnancy.

CONCLUSIONS

This case highlights woman with a previous in vitro fertilization history may be in is a high risk to be delayed or missed in diagnosis in an intended ectopic pregnancy due to a fixed belief in infertility. Educational interventions and contraceptive care should be provided by fertility and healthcare practitioner. The possibility of abdominal pregnancy must always be suspected and dealt with promptly and appropriately by the astute clinician.

Definition and diagnosis of cesarean scar ectopic pregnancies

Cesarean scar ectopic pregnancy is a rare type of ectopic pregnancy, where the pregnancy implants into a myometrial defect caused by a cesarean scar. Its incidence is predicted to increase, given the global increase in cesarean deliveries. As most cesarean scar ectopic pregnancies present as failing pregnancies or patients choose termination of pregnancy, there are limited data on their natural history. However, early first trimester diagnosis is essential, given the associated significant maternal morbidity. Transvaginal sonography is generally considered to be the optimal method for diagnosing cesarean scar ectopic pregnancy. There is no evidence that MRI adds to the diagnostic accuracy, and it is therefore not recommended for routine evaluation of cesarean scar ectopic pregnancy. There is no agreed reference standard for the diagnosis of cesarean scar ectopic pregnancy; therefore, the validity of several proposed sonographic diagnostic criteria reported by different authors remains unknown. There are also various suggested classification systems for cesarean scar ectopic pregnancy, which divide them in differet types. However, the proposals are very heterogeneous, and superiority of one classification system over another is yet to be established.

Pregnancy in a rudimentary horn: multicenter's MRI features of a rare condition

PURPOSE

To describe the MRI features of rudimentary horn pregnancy (RHP) with surgical correlations.

METHODS

Nine women with a RHP underwent preoperative pelvic MRI. MRI protocol included T2- (n = 9), T1- (n = 7), and fat-suppressed contrast-enhanced T1-weighted sequences (n = 4). Two pelvic radiologists retrospectively analyzed MR images to assess the following MRI features: presence of a myometrium around the gestational sac (GS) and characteristics of its wall, GS surrounded by myometrium in contact with the round ligament, communication of the GS with the endometrial cavity of the main horn, continuity of the GS with the cervix, fibrous or muscular GS attachment to the main horn, lateral deviation, and endometrial thickness of the main horn. Ovaries and tubes were also assessed. MRI features were correlated with surgical findings.

RESULTS

Seven of the nine women [29 ± 6 SD years (range 16-37 years)] underwent surgical management. The first US diagnosed RHP in only 1/9 patients. All pregnancies were diagnosed using MRI. RHP was all located in the rudimentary horn of a unicornuate uterus. All the GS was surrounded by myometrium in contact with the round ligament. None of the RHP displayed communication with the endometrial cavity of the main horn nor with the cervix. An attachment between the RHP and the main horn was seen in 3/9 patients. All the main horns were lateralized and empty.

CONCLUSION

MRI diagnosed RHP in all patients by identifying the GS surrounded by myometrium in contact with the round ligament and the absence of continuity between the GS and the cervix.

LEVEL OF EVIDENCE

IV-retrospective study.

Diagnostic dilemma between angular and interstitial ectopic pregnancy: 3D ultrasound features

Angular pregnancy is a rare entity which is commonly confused with interstitial or cornual pregnancies. A lack of consensus about the specific ultrasound features of these 3 entities leads to inappropriate interchange between them among the literature. An angular pregnancy should be considered as a potentially viable intra-uterine eccentric pregnancy as it might be carried to term and result in a live-born baby whereas interstitial or cornual pregnancies should be considered as ectopic pregnancies which should be interrupted. We report here two cases of women at 8 weeks of pregnancy with an angular pregnancy diagnosed by vaginal 2D and 3D ultrasound and discuss about specific ultrasound features and alternative imaging modalities to distinguish it from interstitial and cornual pregnancies.

Using MRI to differentiate upper-lateral intracavitary pregnancy and interstitial pregnancy for the patients with pregnancies in the uterotubal junction during the first trimester

Objectives

To retrospectively evaluate the diagnostic value of MRI for the uterotubal junctional pregnancies during the first trimester.

Methods

This retrospective study involved 59 patients (January 2016 to July 2021) with a preoperative imaging diagnosis of uterotubal junctional pregnancy. Using operative and pathological reports as the reference standard, we identified 22 patients with upper-lateral intracavitary (angular) pregnancy and 37 patients with interstitial pregnancy. Two senior radiologists, blinded to the patients’ information, reviewed the MRI images and determined each MRI feature based on the original interpretation criteria. Any disagreement was resolved by discussion to achieve a consensus. The sensitivity and specificity of each MRI feature were calculated according to the reference standard.

Results

The endometrial thickness in the upper-lateral intracavitary pregnancy group was larger than in the interstitial group (p = 0.001). The cutoff value of the endometrial thickness was 11.5 mm with a sensitivity, specificity, and area under the curve that were 77.3%, 64.9%, and 0.743, respectively. Two key features to diagnose upper-lateral intracavitary pregnancy were “medial free edge” and “medial free edge plus above-cutoff endometrial thickness.” The sensitivity and specificity of the medial free edge were 100% and 94.9%, respectively. The sensitivity and specificity of the medial free edge plus above-cutoff endometrial thickness were 77.3% and 100%, respectively. The key feature to diagnose interstitial pregnancy was an “intact lateral junctional zone,” of which the sensitivity and specificity were 94.6% and 100%, respectively.

Conclusions

MRI can be used to differentiate the upper-lateral intracavitary pregnancy and interstitial pregnancy during the first trimester.

Key Points

• We demonstrated MRI diagnostic criteria for the interstitial pregnancy and upper-lateral intracavitary pregnancy.

• MRI might be used to identify the complex interstitial pregnancies, those with a gestational sac protruding into the uterine cavity.

The role of three-dimensional MRI in the differentiation between angular pregnancy and interstitial pregnancy

Background

In clinical practice it is an ongoing challenge to distinguish between angular pregnancy and interstitial pregnancy. With the three-dimensional (3D) magnetic resonance imaging (MRI) being increasingly used, it is worth exploring its role in differentiating angular pregnancy from interstitial pregnancy. This study aims to investigate how 3D MRI can help reveal the differences between these two special pregnancies in the early diagnosis.

Methods

We reviewed and analyzed the 3D MRI images of 50 patients with interstitial pregnancy and 55 patients with angular pregnancy retrospectively. Imaging features were identified to compare these two special pregnancies, and the ROC (Receiver Operating Characteristic) analysis was conducted to assess the diagnostic performance.

Results

The significant differences of the 3D MRI imaging features between interstitial pregnancy and angular pregnancy were found in the outline of uterus cavity (p < 0.001), involvement of junctional zone (p < 0.001), the signal of surroundings (p = 0.005), the relationship with round ligament (p = 0.042), and the overlying myometrial thickness (p = 0.041). Furthermore, the multivariate logistic regression analysis identified a series of significant indicators for angular pregnancy, including the junctional zone involvement, being-surrounded by hyper/iso-intensity on 3D images, and the asymmetric outline of uterus cavity. Combining these three imaging features, the AUC (Area under the Curve) of ROC curve was 0.87 in distinguishing interstitial pregnancy from angular pregnancy.

Conclusions

This study suggests that 3D MRI can help distinguish angular pregnancy from interstitial pregnancy in clinical practice, with the advantages that conventional MRI or ultrasound does not have. Through the significant image features, 3D MRI plays an important role in improving the timing of diagnosis, avoiding unnecessary interventions, and preventing hemorrhage in clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04470-z.

Imaging of complications following treatment with assisted reproductive technology: keep on your radar at each step

Since the advent of assisted reproductive technology (ART), the utilization of ART procedures has become increasingly popular among women seeking to establish pregnancy. Radiologists are therefore likely to encounter the various complications of ART therapy. The most common is ovarian hyperstimulation syndrome; others are multiple, ectopic, and heterotopic pregnancies. Ultrasonography is considered the initial modality to investigate ART complications, However, nonspecific symptoms might need the use of an additional imaging modality, such as computed tomography or magnetic resonance imaging, as a problem-solving tool. This article briefly discusses the steps involved in assisted reproduction. Its aim is to help radiologists become familiarized with the multimodality imaging features of the spectrum of ART-related complications. Their key imaging features and differential considerations are emphasized. This will facilitate the provision of precise and timely diagnoses, and aid the avoidance of fatal consequences.

Spontaneous angular dichorionic diamniotic twin pregnancy: a case report

OBJECTIVE

To report a peculiar case of ultrasound diagnosis of spontaneous angular twin pregnancy. In literature, the terms "angular," "interstitial," and "cornual" pregnancies are often used inappropriately. Confusion in terminology may have contributed to difficulties in developing diagnostic ultrasound criteria to differentiate these ectopic pregnancies.

DESIGN

Case report.

SETTING

Obstetrics and Gynecology, Community Hospital "S. Maria delle Croci."

PATIENT

A 28-year-old patient with a previous cesarean delivery was admitted to our hospital for management of a presumed angular ectopic pregnancy. Transvaginal ultrasound confirmed an ectopic dichorionic diamniotic twin pregnancy eccentrically located in the right superior angle of the uterine cavity: the first gestational sac appeared to have right angular implantation, whereas the second gestational sac seemed to deepen inside the myometrium, with a thin myometrial margin of only 3 mm.

INTERVENTIONS

After discussing the risks, the patient requested to proceed with termination. A single intramuscular injection of 75 mg of methotrexate was administered, followed by ultrasound-guided hysterosuction after 19 days due to severe vaginal bleeding.

MAIN OUTCOME MEASURES

An early and accurate ultrasound diagnosis of a high-risk condition allowed for conservative medical treatment.

RESULTS

The serum beta-human chorionic gonadotropin levels progressively decreased. After 1 month, a clinical and ultrasound examination showed a regular endometrial line with a regular reappearance of menstrual bleeding.

CONCLUSIONS

Although there are remarkable advances in ultrasound techniques, angular pregnancy remains a condition of difficult diagnosis and management; it is potentially dangerous and may lead to severe complications. An early and accurate diagnosis of this condition is necessary to avoid complications and individualize the subsequent management.

Diagnostic performance of magnetic resonance imaging and ultrasonography on the detection of cesarean scar pregnancy: A meta-analysis

BACKGROUND

: There is still a debate on which imaging method is the best to diagnose cesarean scar pregnancy (CSP). Accordingly, this study aimed to analyze the diagnostic performance of magnetic resonance imaging (MRI) and ultrasonography (US) on the detection of CSP based on current evidence in the literature.

METHODS

PubMed, Embase, Cochrane, Chinese Biomedical Documentation Service System, WanFang, and China National Knowledge Infrastructure databases were searched up to June 2020. The included studies were all comparisons of MRI and US in the diagnosis of CSP that adopted postoperative histological examination as the reference standard. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and area under the summary receiver operating characteristic curve (AUC) were calculated for MRI and US.

RESULTS

Thirteen studies were included, with a total sample size of 948 patients. The pooled sensitivity, specificity, PLR, NLR, and AUC of MRI in diagnosing CSP were 0.93 (95% CI, 0.91-0.95), 0.83 (95% CI, 0.75-0.89), 5.46 (95% CI, 3.70-8.05), 0.08 (95% CI, 0.06-0.11), and 0.96 (95% CI, 0.93-0.97), respectively; for US they were 0.84 (95% CI, 0.79-0.88), 0.73 (95% CI, 0.62-0.81), 3.06 (95% CI, 2.22-4.21), 0.23 (95% CI, 0.18-0.28), and 0.86 (95% CI, 0.83-0.89), respectively.

CONCLUSION

We found that both MRI and US effectively diagnosed CSP; however, MRI had a higher diagnostic performance in detecting CSP than US.

Imaging of acute pelvic pain

Acute pelvic pain (APP) requires urgent medical evaluation and treatment. Differential diagnosis of APP is broad, including a variety of gynecologic and non-gynecologic/ urinary, gastrointestinal, vascular and other entities. Close anatomical and physiological relations of pelvic structures, together with similar clinical presentation of different disorders and overlapping of symptoms, especially in the emergency background, make the proper diagnosis of APP challenging. Imaging plays a crucial role in the fast and precise diagnosis of APP. Ultrasonography is the first-line imaging modality, often accompanied by CT, while MRI is utilized in specific cases, using short, tailored protocols. Recognizing the cause of APP in females is a challenging task, due to the wide spectrum of possible origin and overlap of their imaging features. Therefore, the radiologist has to be familiar with the possible causes of APP, and, relying on clinical presentation, together with laboratory findings, choose the best imaging strategy in order to establish a fast and accurate diagnosis.

An updated guide to the diagnosis and management of cesarean scar pregnancies

PURPOSE OF REVIEW

To review the current literature on the diagnosis and management of cesarean scar pregnancies RECENT FINDINGS: The incidence of cesarean scar pregnancies (CSPs) is increasing as a result of the increasing cesarean section rate, improved diagnostic capabilities, and a growing awareness. CSPs are associated with significant morbidity and early diagnosis is key. Diagnosis is best achieved with transvaginal ultrasound. Sonographic diagnostic criteria have been developed over decades and recently endorsed by the Society for Maternal-Fetal Medicine and other professional societies. The current categorization system differentiates CSPs that are endogenic or 'on the scar' from those that are exogenic or 'in the niche'. Following diagnosis, the challenge remains in determining the optimal management as multiple modalities can be considered. Studies have demonstrated the favorable outcomes with combined local and systemic methotrexate, surgical excision through multiple routes, and adjunctive therapies, such as uterine artery embolization or uterine balloons. The current evidence is insufficient to identify a single best treatment course and a combined approach to treatment is often required.

SUMMARY

Successful outcomes while minimizing complications can be achieved with a multidisciplinary, collaborative effort. Guidelines for cesarean scar pregnancies will continue to evolve as the published reports grow.

Magnetic Resonance Imaging Evaluation of Ectopic Pregnancy: A Value-Added Review

ABSTRACT

Ectopic pregnancy (EP) is a known cause of maternal mortality and may be misdiagnosed in up to 50% of pregnant female individuals (Ann Emerg Med. 1996;28(1):10-17). Magnetic resonance imaging, with its superior soft tissue resolution, is a valuable alternative diagnostic modality to diagnose EP when transvaginal ultrasound results are inconclusive. Although an extrauterine gestational sac is the most specific finding, there are other key MRI findings that can aid in diagnosing EP. As availability of MRI access in the emergency department setting increases across the nation, its utility in women with a positive pregnancy test has also increased. Specific MRI findings that are diagnostic of EP include absence of intrauterine pregnancy, adnexal mass separate from the ovary, and hemoperitoneum. In addition, intrauterine ectopic locations, especially intramural, cornual, and cervical pregnancies, can be diagnosed with increased accuracy with the help of MRI. Magnetic resonance imaging is also useful in excluding potential mimics of EP, including adnexal cysts, ovarian neoplasms, and fibroids. In summary, providing an accurate diagnosis and determining the precise location of an EP, which is supported by the use of MRI, is imperative for guiding a patient's treatment to prevent a potentially fatal outcome.

The feasibility of laparoscopically assisted, hysteroscopic removal of interstitial pregnancies: A case series

OBJECTIVE

The study objective was to assess the feasibility of the management of interstitial pregnancy by laparoscopically assisted hysteroscopic removal.

METHODS

This retrospective study included a case series of 17 patients who were diagnosed interstitial pregnancy with dilated proximal tubal ostium by transvaginal ultrasonography at the Women's hospital, School of Medicine, Zhejiang University between August 2017 and October 2020. Laparoscopically assisted hysteroscopic removals of the products of conception were performed. Various data were collected including age, surgical and obstetric history, gestational age, preoperative symptoms, human chorionic gonadotropin level and ultrasonography results. The outcomes measured were intraoperative bleeding, pathologic findings, conversions.

RESULTS

Eleven cases were successfully resected the interstitial gestational products with laparoscopically assisted hysteroscopy. There were four cases failed of hysteroscopic removal, for the proximal tubal ostia were too small for the surgical instruments to enter. Then cornual wedge resections were performed. Two cases were identified as intramural pregnancy by hysteroscopic and laparoscopic view. Most of the intramural pregnancy tissue of one patient was removed by hysteroscopy. The other one converted to laparoscopy.

CONCLUSION

Laparoscopically assisted hysteroscopic management could be a feasible surgical option to interstitial pregnancies. Further clinical studies are needed to establish detailed criteria to select the appropriate cases for hysteroscopic management.

MRI of Acute Gynecologic Conditions

Although usually not a first-line imaging modality in the setting of acute pelvic pain, magnetic resonance imaging (MRI) is able to depict and characterize a wide range gynecologic diagnoses with high accuracy. Lack of ionizing radiation renders MRI particularly useful for assessment of pregnant women and children. Furthermore, inherent high soft-tissue resolution of MRI allows accurate diagnosis without intravenous contrast use, which is advantageous for patients with renal insufficiency and pregnant patients. Familiarity with the typical MRI appearance of various acute gynecologic conditions helps establish the correct diagnosis. This article reviews the common MRI findings of acute gynecologic processes, in both pregnant and nonpregnant patients. Level of Evidence: 3 Technical Efficacy Stage: 3 J. Magn. Reson. Imaging 2020;51:1291-1309.

Magnetic resonance imaging of common, uncommon, and rare implantation sites in ectopic pregnancy

OBJECTIVE

To review the MRI appearances of tubal and non-tubal implantation sites in ectopic pregnancy.

CONCLUSION

Transvaginal ultrasound is the primary imaging modality in ectopic pregnancy and MRI is used as a problem-solving tool in selected indications as detailed in the article. MRI features of tubal, interstitial, cervical, cesarean scar, cornual, ovarian, abdominal, and heterotopic pregnancies are provided to familiarize the radiologists with their appearances thereby assisting them in making early and accurate diagnosis.

False diagnosis of and needless therapy for presumed gestational trophoblastic disease in women with an unusual site of residual pregnancy

Objective

This study aimed to determine the diagnostic value of magnetic resonance imaging (MRI), hysteroscopy, and laparoscopy to avoid unnecessary treatment when patients present with clinical manifestations that are close to those of gestational trophoblastic neoplasia (GTN).

Methods

Three patients who were falsely diagnosed with presumed GTN and received needless chemotherapy in our hospital from July 2011 to March 2012 were studied. We also reviewed data of patients with similar clinical features who were diagnosed as having residual pregnancy in recent years. Clinical manifestations were evaluated.

Results

All three patients had persistently high serum β-human chorionic gonadotrophin levels and a mass with abundant blood supply in the uterus after termination of pregnancy. The patients were diagnosed with GTN and underwent chemotherapy. They responded poorly to chemotherapy and underwent surgery. The pathological diagnosis in all patients was residual pregnancy. In recent years, no patients were misdiagnosed because pelvic MRI, hysteroscopy, or laparoscopy was used when residual pregnancy could not be excluded.

Conclusion

Gynecologists should diagnose carefully when patients present with clinical manifestations that are close to those of GTN to avoid unnecessary treatment. MRI, hysteroscopy, and laparoscopy could be important examinations for excluding residual pregnancy.

To evaluate the feasibility of magnetic resonance imaging in predicting unusual site ectopic pregnancy: a retrospective cohort study

OBJECTIVE

To evaluate the accuracy of pelvic MRI in the diagnosis of unusual ectopic pregnancy (EP), when ultrasound (US) examination is inconclusive.

METHODS

We retrospectively reviewed the medical records of 150 patients with suspected EP. Clinical, US and MRI features of 15 unusual EPs were analysed. Two radiologists independently reviewed each case resolving by consensus any diagnostic discrepancy. Interobserver agreement was assessed using the Cohen κ test.

RESULTS

MRI displayed a gestational sac-like structure surrounded by a thick wall in all cases. The thick wall displayed hyperintensity in 41 %, isointensity in 35 % and hypointensity in 24 % of cases on T1-weighted images. Diffusion- and fat saturation T1-weighted images were the most accurate sequences, as they enabled identification of 15/15 and 14/15 patients, respectively. Although US was false negative in detecting cervical and uterine infiltration underlying the caesarean scar, MRI was able to identify the invasion. Interobserver agreement was very good for all sequences (κ=0.892-1.0).

CONCLUSIONS

MRI plays an important role in the early diagnosis of unusual EP. It should be considered after negative US findings, providing accurate evaluation of the site and the possible infiltration of these lesions, which help in the management of these patients.

KEY POINTS

• MRI is being increasingly used as a problem-solving modality in ectopic pregnancy. • MRI plays an important role in early diagnosis of unusual ectopic pregnancy. • Knowledge of MRI features in EP is essential to determinate appropriate management.