Diagnosis of Ectopic Pregnancy with MRI: Efficacy of T2*-weighted Imaging

Primary omental ectopic pregnancy: A rare case report

Primary abdominal pregnancy is the rarest form of ectopic pregnancy in which the fertilized ovum is directly implanted into peritoneal cavity. This condition poses significantly high risk of maternal morbidity and mortality. Here, we present a case of 5 weeks of primary omental pregnancy managed by laparotomy.

Diagnostic value of susceptibility-weighted imaging for endometrioma: preliminary results from a retrospective analysis

BACKGROUND

Endometrioma is a common manifestation of endometriosis that can be difficult to diagnose with conventional magnetic resonance imaging (MRI). Susceptibility-weighted imaging (SWI) may be more sensitive than conventional MRI in the detection of chronic, local hemorrhagic disease.

PURPOSE

To investigate whether signal voids in SWI sequences could be used in the preoperative diagnosis of endometrioma.

MATERIAL AND METHODS

This retrospective study included consecutive female patients with clinically suspected endometrioma. All patients underwent pelvic 3-T MRI (T1- and T2-weighted) and SWI within two weeks before laparoscopy. Two experienced radiologists blinded to the histopathologic/clinical diagnoses interpreted the images together, and any disagreements were resolved by consensus.

RESULTS

The final analysis included 73 patients: 46 patients (mean age=37 years; age range=22-68 years) with 85 endometrioma lesions and 27 patients (mean age=34 years; age range=15-68 years) with 34 non-endometrioid cystic lesions (18 hemorrhagic corpus luteal cysts, three simple cysts, three mucinous cystadenomas, two mature teratomas, and one endometrioid cyst with corpus luteum rupture/hemorrhage). The presenting symptoms for patients with endometrioma were chronic pelvic pain (44.6%), dysmenorrhea (31.9%), infertility (12.8%), dyspareunia (6.4%), and menstrual irregularity (4.3%). MRI identified all 119 lesions observed laparoscopically. SWI visualized punctate or curvilinear signal voids along the cyst wall or within the lesion in 67 of 85 endometriomas (78.8%) and only 3 of 31 non-endometrioid cysts (8.8%).

CONCLUSION

The use of SWI to look for signal voids in the cyst wall or within the lesion could facilitate the preoperative diagnosis of endometrioma.

Diagnostic Accuracy of Preoperative Conventional MRI for Patients With Ectopic Pregnancy

Objective

To assess the utility of preoperative magnetic resonance imaging (MRI) in the diagnosis of tubal pregnancy.

Summary of background data

Most cases of ectopic pregnancy are tubal pregnancies. Preoperative accurate diagnosis including the location of the tubal pregnancy is important.

Method

We performed a retrospective single-center cohort study evaluating patients who underwent surgery for ectopic pregnancy from April 2004 to March 2016 and who underwent preoperative MRI. Sixty patients were enrolled in the study. Chorion confirmed at the tubal pregnancy site detected by MRI was defined as a correct diagnosis.

Results

Mean estimated gestational age at the time of MRI according to the last menstrual period was 7 weeks (median: 5 weeks; range: 3–10 weeks). Ectopic pregnancy was diagnosed by MRI in 57 cases, and all cases were either left or right tubal pregnancy. In 52 cases, the actual position matched the MRI findings. In 5 cases, the location of tubal ectopic pregnancy was different from that diagnosed by MRI, or no tubal pregnancy was observed intraoperatively. In 2 cases, no ectopic pregnancy site was observed on MRI, but tubal pregnancy was confirmed by surgery. In one case, an ectopic pregnancy site was not found, and the tube showed normal findings on MRI. The sensitivity of MRI diagnosis was 96.2%, specificity was 16.7%, positive predictive value was 91.1%, and negative predictive value was 33.3%.

Conclusion

In cases of ectopic pregnancy treated surgically, the sensitivity of MRI diagnosis, including identification of the location of ectopic pregnancy, is high.

Cross-sectional imaging of acute gynaecologic disorders: CT and MRI findings with differential diagnosis-part I: corpus luteum and haemorrhagic ovarian cysts, genital causes of haemoperitoneum and adnexal torsion

Acute gynaecologic disorders are commonly encountered in daily clinical practice of emergency departments (ED) and predominantly occur in reproductive-age women. Since clinical presentation may be nonspecific and physical findings are often inconclusive, imaging is required for a timely and accurate diagnosis. Although ultrasound is the ideal non-invasive first-line technique, nowadays multidetector computed tomography (CT) is extensively used in the ED, particularly when a non-gynaecologic disorder is suspected and differential diagnosis from gastrointestinal and urologic diseases is needed. As a result, CT often provides the first diagnosis of female genital emergencies. If clinical conditions and scanner availability permit, magnetic resonance imaging (MRI) is superior to CT for further characterisation of gynaecologic abnormalities, due to the excellent soft-tissue contrast, intrinsic multiplanar capabilities and lack of ionising radiation.

The purpose of this pictorial review is to provide radiologists with a thorough familiarity with gynaecologic emergencies by illustrating their cross-sectional imaging appearances. The present first section will review the CT and MRI findings of corpus luteum and haemorrhagic ovarian cysts, gynaecologic haemoperitoneum (from either ruptured corpus luteum or ectopic pregnancy) and adnexal torsion, with an emphasis on differential diagnosis. Additionally, comprehensive and time-efficient MRI acquisition protocols are provided.

Role of magnetic resonance imaging in pregnancy-associated obstetric and gynecological complications

Background

To study the role of MRI in diagnosing pregnancy-associated obstetric and gynecological complications. We prospectively studied 48 pregnant and postpartum women, aged between 20 and 45 years, who were referred for MRI between August 2016 and April 2018 with suspected pregnancy-associated obstetric and gynecological complication. MRI findings were confirmed by intra-operative or histological findings.

Results

Out of the 48 patients, there were 32 women with suspected placenta accreta, 5 pregnant women with 6 ectopic pregnancies (1 patient had two gestational sacs), 3 with ovarian pathologies, 3 with uterine pathologies, 3 with abruptio placenta, and 2 with miscellaneous pathologies. In our study, there was an accuracy of 81.6% with sensitivity of 100% and specificity of 50%. There was 100% accuracy in predicting abruptio placenta, ovarian, uterine, and miscellaneous pathologies by MRI. There was 83.4% and 75% accuracy in predicting ectopic pregnancy and placenta accreta, respectively, by MRI.

Conclusion

MRI is very useful to diagnose pregnancy-associated obstetric and gynecological complications. It will be an important complementary tool to sonography and thereby facilitate better patient management.

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.

Intramural Ectopic Pregnancy Following Myomectomy

Intramural pregnancy is a rare form of ectopic pregnancy with early diagnosis essential for prevention of severe hemorrhage and uterine rupture. We report a rare case of an intramural ectopic pregnancy at 12 weeks gestation in a woman 1 year post open myomectomy. Both transvaginal ultrasound and magnetic resonance imaging were utilized as diagnostic aids in this case. The rare nature of this clinical scenario and lack of guidelines for management made clinical decision making difficult. Due to the size and location of the gestational sac, hysterectomy was deemed to be the safest modality, and a midline laparotomy, total abdominal hysterectomy, and bilateral salpingectomy was performed.

Embarazo ectópico cervical: diagnóstico preciso y enfoque de manejo médico. Reporte de caso

<p>El embarazo ectópico cervical es una condición exótica. Su diagnóstico y manejo plantean un desafío importante, dada su asociación con desenlaces maternos graves. La sospecha clínica y la juiciosa aplicación de los criterios diagnósticos permiten establecer modalidades de terapia conservativa. Este artículo reporta un caso de embarazo ectópico cervical con diagnóstico de imágenes de ultrasonido y resonancia nuclear magnética en el que se administró tratamiento con metotrexato. El seguimiento clínico, de los exámenes paraclínicos y de ultrasonido mostraron la resolución completa de la condición. Se revisan aspectos relacionados con el diagnóstico y tratamiento.</p>

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.

Susceptibility Weighted With Quantitative Phase Magnetic Resonance Imaging in Differentiation of Various Stages of Hemorrhage and Calcification in Female Pelvic Pathologies: A Preliminary Study

BACKGROUND

The purposes of this study were to assess the value of phase for characterization of female pelvic lesions with hemorrhage in various stages and to differentiate them from calcified lesions at 3.0-T magnetic resonance imaging (MRI).

METHODS

Forty-four female patients with hemorrhagic (n = 37) or calcified (n = 7) pelvic pathology underwent conventional MRI including susceptibility-weighted imaging with phase information. Hemorrhagic lesions were grouped into acute, subacute, and chronic, and calcified lesions were detected on the basis of conventional imaging findings. Phase quantification of these hemorrhagic and calcified lesions was performed.

RESULTS

The phase values significantly differed (P < 0.001) among various stages of hemorrhage, as well as calcification (chronic hemorrhage, -65.09 ± 9.09 degrees; subacute hemorrhage, -11.41 ± 4.4 degrees; acute hemorrhage, -42.30 ± 5.20 degrees; and calcified lesions, 117.55 ± 12.93 degrees).

CONCLUSIONS

Quantitative phase imaging has the potential to differentiate various stages of hemorrhagic and calcified pathologies. This may add value to the conventional MRI in improved characterization of these entities in female pelvic pathologies.

The Mechanism Causing High-signal Intensity on Diffusion-weighted Imaging in Adnexal Torsion: Two Case Reports

We report two cases with adnexal torsion to assess the mechanism of very strong signal intensity in ovarian lesions on DW imaging using MR imaging such as T2*-weighted imaging. MR imaging findings of the cases suggest that the very strong signal intensity on DW imaging is contributed to cytotoxic edema with or without vasogenic edema, as well as oxyhemoglobin or extracellular methemoglobin.

Usefulness of T2 star-weighted imaging in ovarian cysts and tumors

AIM

The aim of this study was to investigate the prevalence of hypointensity on T2 star-weighted imaging (T2*WI), which is useful for detecting hemosiderin, in endometriomas and other ovarian tumors. The efficacy of detecting adhesions around ovarian tumors was also investigated.

METHODS

Pelvic magnetic resonance (MR) examinations, including T2*WI, were carried out. The inclusion criteria were female patients with ovarian surgical treatments. One hundred seventeen patients with a total of 147 lesions were enrolled. Two radiologists retrospectively evaluated MR imaging (MRI) to predict ovarian pathology and the presence of adhesions. T2*WI hypointensity of the inside and outside along ovarian cysts/tumors was utilized to predict pathological diagnoses and the presence of adhesions, respectively. The kappa scores were calculated to measure interobserver agreement on MRI findings. The MRI interpretations were compared with the results of pathological investigation and surgical observations.

RESULTS

Hypointensity inside along the cyst walls on T2*WI was observed in 100 out of 106 lesions of endometriomas (94.3%), and three out of 41 non-endometrial ovarian cysts/tumors (7.3%). Four different patterns of T2*WI were observed in ovarian cysts/tumors. The kappa score regarding T2*WI hypointensity inside along the cyst walls was 0.633. Using conventional routine pelvic MRI, the sensitivity for detecting adhesions around ovarian cysts was 84.5%. By adding T2*WI, the sensitivity improved to 91.4% (P < 0.01). With conventional methods to predict adhesions, the kappa score was 0.660. After adding T2*WI to the conventional methods, the kappa score was 0.767.

CONCLUSION

Hypointensity on T2*WI was observed frequently in endometrioma. T2*WI also improved the sensitivity for detecting adhesions around ovarian cysts/tumors.

A case of Hickam's dictum: concurrent appendicitis and ectopic pregnancy

BACKGROUND

Both ectopic pregnancy and appendicitis are surgical emergencies that should be considered in female patients who present with right lower-quadrant pain. Deciding on the appropriate imaging modality in the pregnant patient can be difficult. The challenge of diagnosis is compounded when one considers that both pathologies may be present simultaneously.

OBJECTIVES

We present a case demonstrating co-occurrence of ectopic pregnancy and appendicitis and suggest an algorithm for evaluation and management of cases with this presentation.

CASE REPORT

A 25-year-old woman presented to the Emergency Department complaining of 3 days of abdominal pain and a positive urine pregnancy test. After consultation with Obstetrics/Gynecology (OB/GYN) and General Surgery, a nondiagnostic pelvic ultrasound (US), and a magnetic resonance imaging (MRI) study consistent with appendiceal inflammation, the patient was taken to the operating room for a laparoscopic appendectomy. While removing the inflamed appendix, the general surgeon noted the right fallopian tube was enlarged, suggestive of an ectopic pregnancy. OB/GYN was consulted again intraoperatively and noted a right ectopic pregnancy. The surgical intervention was completed with a right salpingectomy.

CONCLUSION

In a pregnant patient with right lower-quadrant pain, the differential diagnosis includes ectopic pregnancy, acute appendicitis, or in rare cases, both.

Ectopic pregnancy: a review

PURPOSE

Ectopic pregnancy (EP) presents a major health problem for women of child-bearing age. EP refers to the pregnancy occurring outside the uterine cavity that constitutes 1.2-1.4 % of all reported pregnancies. All identified risk factors are maternal: pelvic inflammatory disease, Chlamydia trachomatis infection, smoking, tubal surgery, induced conception cycle, and endometriosis. These developments have provided the atmosphere for trials using methotrexate as a non-surgical treatment for EP. The diagnosis measure of EP is serum human chorionic gonadotropin, urinary hCGRP/i-hCG, progesterone measurement, transvaginal ultrasound scan, computed tomography, vascular endothelial growth factor, CK, disintegrin and metalloprotease-12 and hysterosalpingography. The treatment option of EP involves surgical treatment by laparotomy or laparoscopy, medical treatment is usually systemic or through local route, or by expectant treatment.

RESULTS

It was concluded that review data reflect a decrease in surgical treatment and not an actual decline in EP occurrence so that further new avenues are needed to explore early detection of the EP.

MR imaging findings of ectopic pregnancy: a pictorial review

Because of its lack of ionizing radiation and excellent soft-tissue contrast, magnetic resonance (MR) imaging is being increasingly used in the evaluation of acute abdominal pain in the pregnant patient. Roughly 2% of all pregnancies are ectopic. Although ectopic pregnancy is usually diagnosed on the basis of a combination of clinical, laboratory, and ultrasonographic findings, it occasionally is initially identified at MR imaging. Thus, it is imperative that the radiologist should be familiar with the variable appearance of ectopic pregnancy at MR imaging and should evaluate for ectopic pregnancy at any time when (a) a patient has positive results of a pregnancy test and (b) an intrauterine pregnancy is not definitively seen. Because of potential issues of fetal safety, a conservative approach should be used for MR imaging in pregnancy. An MR imaging protocol for the evaluation of possible appendicitis in pregnant women is detailed. Specific findings that can aid in the diagnosis of ectopic pregnancy are the lack of an intrauterine pregnancy, isolated hemoperitoneum, tubal masses, hematosalpinx, and interstitial masses. In the differential diagnosis of acute abdominal pain in pregnancy, consideration should be given to the more unusual forms of ectopic pregnancy, such as angular pregnancy, cornual pregnancy, and abdominal pregnancy. Potential mimics of ectopic pregnancy include placental abnormalities, ovarian neoplasms, and corpus luteum cysts.

Gravidez ectópica: ensaio iconográfico com enfoque em achados de tomografia computadorizada e ressonância magnética

O objetivo deste trabalho é descrever os principais achados de tomografia computadorizada e ressonância magnética em pacientes com dor abdominal aguda causada por gravidez ectópica. Para isso, dois radiologistas em consenso selecionaram e analisaram exames de tomografia computadorizada e ressonância magnética realizados entre janeiro de 2010 e dezembro de 2011 de pacientes com dor abdominal aguda comprovadamente decorrente de um quadro de gravidez ectópica. O diagnóstico por imagem de gravidez ectópica é usualmente obtido por ultrassonografia, no entanto, o uso crescente da tomografia computadorizada e ressonância magnética na avaliação do paciente com abdome agudo de origem ginecológica tem requerido que o radiologista se familiarize com os principais aspectos observados nestes métodos diagnósticos.

Use of magnetic resonance analysis for clinical evaluation of the peripheral area of gestational sac in bleeding and non-bleeding ectopic pregnancy cases

Purpose

To evaluate preoperative magnetic resonance (MR) imaging features of bleeding and non-bleeding ectopic pregnancy (EP) by comparison with surgical findings.

Methods

Eighteen suspected EP cases underwent preoperative MR imaging. We classified 8 cases as the bleeding group and 7 cases as the non-bleeding group with or without intra-abdominal bleeding and/or hematoma at the site of EP, and compared, retrospectively, gestational sac (GS)-like structure, particularly the peripheral area of the GS via MR analysis. Excluded were 3 cases that were insufficient for assessing extrauterine GS-like structure: ruptured tubal pregnancy and uterine horn pregnancy.

Results

GS-like structures were typically observed as low intensity on T1-weighted image (T1WI) and as high intensity on T2-weighted image (T2WI). In non-bleeding cases, most peripheral areas of the GS were of intermediate intensity on T1WI and high intensity on T2WI. Most bleeding cases were of high intensity on T1WI and low to high intensity on T2WI. Furthermore, the peripheral area of the GS was of higher intensity on T1WI with fat suppression than on T1WI.

Conclusions

It is clear that MR imaging is effective for diagnosis of cases of suspected EP. EP conditions may be predicted by signal intensity of the peripheral area of the GS via MR analysis.

Primary abdominal pregnancy following intra-uterine insemination

Primary abdominal pregnancy is an extremely rare type of extrauterine pregnancy. It has been reported from many unusual intra-abdominal sites. We report a case of primary abdominal pregnancy following intra-uterine insemination (not reported earlier to our knowledge). Implanted on the anterior surface of the uterus possibly related to an endometriotic foci. Early diagnosis enabled laparoscopic management of this case.

Magnetic resonance imaging of adnexal masses

Adnexal masses are common in women of all ages. A range of physiological and benign ovarian conditions that develop in women, especially in the reproductive age, and adnexal malignancies can be evaluated with magnetic resonance imaging (MRI). Management of women with adnexal masses is frequently guided by imaging findings; therefore, precise characterization of adnexal pathology should be performed whenever possible. Magnetic resonance imaging is useful in characterization of adnexal masses that are not completely evaluated by ultrasound because it can provide additional information on soft tissue composition of adnexal masses based on specific tissue relaxation times and allows multiplanar imaging at large field of view to define the origin and extent of pelvic pathology. The patients most likely to benefit from MRI are pregnant women and those who are premenopausal and have masses that have complex features on ultrasound but do not have raised cancer antigen 125 tumor marker levels. The overlap in imaging appearance among different cell type malignancies makes it difficult to predict exact histology based on MRI appearance; however, MRI has a high accuracy in differentiating benign from malignant masses. Teratomas, endometriomas, simple and hemorrhagic cysts, fibromas, exophytic or extrauterine fibroids, and hydrosalpinges can be diagnosed with high confidence. In this article, the authors review the histopathologic background and MRI features of adnexal masses and discuss the role of MRI in the differentiation of benign from malignant adnexal pathologies.

Sonographic Evaluation of Ectopic Pregnancy

Ectopic pregnancy is a high-risk condition that occurs in 1.9% of reported pregnancies. Although the clinical triad of pain, bleeding, and amenorrhea is considered very specific for an ectopic pregnancy, ultrasound plays important role in detecting the exact location of the ectopic pregnancy and also in providing guidance for minimally invasive treatment. This article discusses the main sonographic features of ectopic pregnancy at various common and unusual locations. In addition, it provides insight into the role of hormonal markers in the diagnosis and management of ectopic pregnancy.