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You can also sign up for a free trial of our premium membership to get access to

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hundreds of case-based microlearning courses across all key radiology

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subspecialties. Today we are honored to welcome Dr.

0:40

Erin Gomez for a lecture on complex and high risk OB pathology.

0:46

Multimodal case review. Dr.

0:48

Erin Gomez completed her diagnostic radiology residency in body r i

0:52

subspecialty training at the Johns Hopkins Hospital in Baltimore, Maryland.

0:57

She's an assistant professor in the diagnostic imaging division at Johns Hopkins

1:01

where she specializes in cross-sectional imaging of the female pelvis and

1:05

medical school students and resident education. At the end of the lecture,

1:09

please join Dr.

1:10

Gomez in a q and a session where she will address questions you may have on

1:14

today's topic.

1:15

Please remember to use the q and a feature to submit your questions so we can

1:19

get to as many as we can before our time is up. With that,

1:22

we are ready to begin today's lecture. Dr. Gomez, please take it from here.

1:27

Alright, awesome. Hi everyone, I'm Erin Gomez. Um,

1:31

I'm a radiologist at Johns Hopkins in Baltimore, Maryland.

1:33

And today I'm thrilled to take you through a multimodal high-risk

1:38

OB pore case review.

1:42

In today's conference we'll talk about the normal imaging appearance of the

1:45

uterus and ovaries in pregnant and non-pregnant patients and expected changes

1:49

during pregnancy. I'll also tell you about indications for ultrasound,

1:53

CT and M R I during pregnancy and then we'll talk about key imaging features of

1:58

acute abdominal pelvic pathology during pregnancy, ectopic pregnancy,

2:02

gestational trophoblastic disease,

2:04

and other risk high and other high risk OB partum processes.

2:10

Um, the gestational trophoblastic disease cases.

2:14

That'll show today our courtesy of my colleague Dr.

2:16

Jamie Marco and the A I R P archives and I'd like to thank him for sharing those

2:21

with me for today. Let's get started.

2:25

Let's talk about what you should expect to see when you're looking at the uterus

2:28

and ovaries on cross-sectional imaging pelvis.

2:32

So this is a statute teaching weight I of the pelvis.

2:35

You can see that the uterus is here.

2:37

It's a pear shaped organ and it's interposed between the bladder,

2:40

which is here anteriorly and the rectum, which is here posteriorly.

2:46

The ovaries are often lateral to the uterus.

2:48

So this is the right ovary on this axial T2 weight image of the pelvis.

2:52

And this is the left ovary and it's easy to find the ovaries because you'll

2:56

often see them along the course of the external iliac vessels.

3:00

And on T2 weed imaging of the pelvis they'll have T2 hyperintense follicles.

3:06

Let's take a more detailed look at the anatomy of the uterus and

3:11

ovaries and some of the ligaments that we can see in the pelvis,

3:14

specifically on r i. Um, so let's talk about the parts of the uterus.

3:18

First of all, the uterus can be separated into the fundus,

3:21

which is the superior most portion of the uterus and then the uterine body.

3:26

The term lower uterine segment is reserved for the context of pregnancy and it's

3:30

not something that we normally describe in non-pregnant patients.

3:34

This is the cerv on the ULT two weighted M R F, the pelvis.

3:38

This is the anterior lip of the cervix, posterior lip of the cervix.

3:41

And this is the cervical canal on M R I. We can also see the vagina.

3:46

And again, as I mentioned,

3:47

these are the ovaries looking more closely at the distinct layers

3:52

of the uterus, we can see the endometrium here centrally. It's T2 bright,

3:58

this is the junctional zone.

3:59

It's this dark band of tissue beyond the endometrium.

4:04

And the reason the junctional zone looks dark is it is also myometrial tissue

4:08

similar to this layer out here, but it's more densely packed.

4:11

Those myocytes are closer together so they have a lower water content, um,

4:16

and they won't look as bright on T2 rated imaging as the myometrium proper,

4:20

which is out here.

4:22

And then finally this thin black line that covers the uterus is the uterine

4:27

serosa.

4:28

Other structures that I'd like to point out on this POAL T2 rated image,

4:33

we can see the broad ligaments at these arrows and then the round ligaments at

4:38

the portfolio arrows.

4:41

So lots of changes happen to the uterus during pregnancy.

4:45

The uterus increases in size a lot and there is predictable growth here, right?

4:50

That's why we measure patients' bundle height.

4:52

When they come in for OB imaging or OB appointments,

4:57

the pregnancy is supported by the corpus lutetium until about 10 to 12

5:02

weeks gestation. And then the placenta takes over.

5:05

And so as the uterus ascends into the abdomen as it grows the abdominal viscera,

5:10

the ovaries and the bowel all get displaced laterally.

5:13

You also have an increase of blood volume and proliferation of the pelvic blood

5:17

vessels.

5:21

Now we're gonna talk a lot about CT and M R I today,

5:26

um, because many of the complex and high-risk OB cases that we encounter

5:31

end up requiring more advanced cross-sectional imaging of the abdomen and

5:35

pelvic.

5:35

But far and away ultrasound is the first line imaging modality in pregnancy,

5:40

right? And that's for many good reasons. It's readily available,

5:43

there's no ionizing radiation employed.

5:45

We can get really beautiful high resolution images of the uterus and the ovaries

5:49

on both TA and Transvaal imaging.

5:53

And it is definitely our go-to for evaluating first trimester pregnancy, um,

5:58

most commonly viability, but also pregnancy related complications.

6:02

This is a 3D reconstruction of a transvaginal ultrasound for a patient with

6:07

a first trimester pregnancy. We can see the amniotic stack here.

6:10

We can see the embryo and an adjacent.

6:16

Let's talk about mri cause many of the cases we'll see today are MR based

6:21

MRI is considered very safe during pregnancy.

6:24

There's no ionizing radiation employed.

6:28

And so it's a great imaging technique for patients who are pregnant.

6:31

We can get large field of view imaging with excellent tissue characterization

6:35

and that's because we can weight the images as we desire. Um,

6:39

but also the resolution is really beautiful.

6:43

The other good thing about MRI is it's often diagnostic without IV contrast.

6:49

So we don't have to administer gadolinium based contrast agents or GCs to

6:54

pregnant patients, which is um, a practice that is, um,

6:57

largely frowned upon as gadolinium based contrast. Agents cross the placenta,

7:03

they cross the placenta, enter the fetal circulation.

7:06

We know that gadolinium as a contrast agent is excreted renally.

7:10

And so because it enters the fetal circulation is excreted into the amniotic

7:15

fluid, um, by the fetus ingested again and excreted again.

7:20

And so it takes much longer to clear gadolinium based contrast from the fetal

7:24

circulation than it does the maternal circulation.

7:27

And there are some studies that suggest that there's a higher risk of

7:30

inflammatory and skin and rheumatologic conditions in fetuses who have been

7:34

exposed to gag.

7:36

There's also emerging data about gadolinium deposition within tissues in the

7:41

body, including the basal ganga. And so for all those reasons,

7:44

we do not give gaag to pregnant patients unless there's a situation, um,

7:48

that really necessitates it. Um,

7:50

like a patient who's had a fetal demise but has an abnormal placenta that

7:54

requires operative cleaning.

7:57

Another thing that I'd like to point out is that MRI can be performed in

8:00

pregnant patients at both 1.5 and three Tesla.

8:03

There used to be concerns about tissue heating and specific absorption rate,

8:08

but we know now that really most of the heat that's generated during an M R I is

8:13

actually deposited at the skin surface, which is maternal.

8:17

Any heat that does reach the fetus is dissipated by circulation of the amniotic

8:21

fluid. So pregnant patients can be imaged at 1.5 or threet.

8:25

And then there is a theoretical risk to the fetal obstacles due to noise that

8:30

happens during the exam, particularly during gradient echo imaging.

8:33

But none of that has ever panned out in human studies.

8:36

So suffice it to say that MRI is very safe during pregnancy.

8:41

Let's get right into it. Now let's talk about some pathology.

8:46

This is our general abdominal protocol. Um,

8:50

for pregnant patients, uh,

8:53

it's basically the same as our general admin protocol I,

8:55

except we've omitted the post contrast images. We start with a scalp.

8:59

We do axial and coronal T2 weight images in phase and out phase imaging.

9:05

We do diffusion with a corresponding ADC map.

9:08

We do a pre contrast axial T1 and then if the patient is having an

9:13

R C P will also add coronal single shot T2 related images.

9:19

Now this is a list of many potential causes of abdominal pelvic pathology

9:23

during pregnancy, but it's not exhaustive, right?

9:26

There are other things that could happen beyond this list and we're not even

9:30

going to discuss all of them today.

9:32

But I just wanna give you an idea for sort of the broad categories and many

9:36

different things that can result in abdominal pelvic pain in a pregnant patient

9:40

and they can be classified into GI gu.

9:43

The top two causes of abdominal pain in pregnancy are acute appendicitis and

9:48

obstructing nephro ral stone,

9:50

but obstetric and gynecologic conditions can also um,

9:54

alert patients to the attention of providers and prompt further imaging.

9:58

So let's just do a sampling of cases related to a few of these different

10:02

conditions.

10:06

So I'll start with um, these three images.

10:09

This is a patient who presenting with right upper quadrant pain at 26 weeks

10:13

gestation.

10:14

She has a history of hepatitis C and we have axial T2 weighted

10:18

images here on the left side of the screen and then a coronal Mr C P image on

10:23

the right side of the screen.

10:24

And I'll give you just a minute to take a look at it and see what you think

10:27

about these before I discuss the findings.

10:35

And we can see a little bit of the fetus here in the grab ute on the mrp.

10:40

This is blood Blood. Okay,

10:43

so one of the first things I wanna point out on this T2 rated image is all of

10:47

this edema and T2 right signal around the portal vein.

10:50

This patient has periportal edema. Additionally,

10:53

the gall bladder looks really thick but there's not a ton of per

10:58

cystic fluid.

10:59

And on the RCP image there is no intra hepatic ary ductile dilation.

11:05

So when we interviewed this patient further, she had had flu life symptoms, um,

11:10

for about a week prior to coming in and she had been taking a lot of Tylenol.

11:15

So given her background liver disease, um,

11:18

this was a patient who had acute hepatitis due to an accidental Tylenol

11:22

overdose. And so, um, the periportal edema is a classic finding in hepatitis.

11:27

And all of this thickening and emus changes within the wall of the gallbladder

11:31

is reactive in the setting of adjacent liver inflammation.

11:38

Next case is a pregnant patient at 13 weeks gestation presenting with left

11:43

inguinal pain. And so we have two coronal stir images.

11:48

Um, of the pelvis here is the Ravi uterus. This is patient right,

11:53

this is patient left.

11:54

You can see a little bit of the urinary bladder and pubic synthesis here.

11:58

Same thing on these images. We catch a little bit of the cervix,

12:01

which is here and the gravity uterus.

12:04

And so this patient is coming in with left inguinal pain.

12:06

So I'll direct your attention to this area of the image.

12:10

And this is a little bit of an eye test for symmetry,

12:14

but if you notice that the um,

12:16

left femoral iliac vessel when compared with the right, they're really engorged.

12:20

They're very dilated.

12:22

There is a T2 hyperintense filling defect within the left

12:27

femoral iliac Venus system.

12:29

We can see it extending up into the left common iliac vein.

12:33

There's a bunch of surrounding edema, these tissues here in the retro peroneum,

12:37

also low emus.

12:39

And so this is a patient who has an extensive left immoral D V T

12:47

companion case to go along with that one. This patient um,

12:51

presented with ovarian vein thrombosis and the postpartum period.

12:55

So she was 41, she just had a C-section. Um,

12:58

and she'd had a bunch of complications but she was having pretty dramatic pelvic

13:03

pain. And so we did a CT for this patient.

13:05

We can see the enlarged postpartum uterus here.

13:08

Then there's really marked thickening of the right gonadal vein.

13:12

We can see that it's expanded by this hyperdense thrombus that extends all the

13:17

way up into the I V C.

13:19

So this is another vascular complication that can occur not only in the context

13:23

of pregnancy but in the postpartum period.

13:25

Particular cation has had cesarean section.

13:31

We'll switch gears a little bit.

13:33

This is truly a potpourri of cases that are causing pain, um,

13:37

in pregnant patients. So this is a patient who is 22 weeks pregnant.

13:42

She was coming in with a little bit of pelvic discomfort and on her pelvic

13:45

ultrasound she had a complex NAL lesion.

13:49

So I'll give you a moment to look at these images.

13:51

This is an axial T2 weighted image of the pelvis. And then we have t1,

13:55

non-fat saturated and fat saturated images here on the top and bottom

13:59

respectively.

14:01

So one of the first things that we see for this patient is she has this big

14:05

cystic lesion posterior to the uterus. It has some thin little ations within it.

14:10

And then there is this nodular component along the right lateral aspect.

14:14

When we look at the non-fat saturated and fat saturated images,

14:19

this ated component seems to have something different within it,

14:23

but it's unchanged between the uh, non-fat, fat and fat saturated.

14:28

But this tiny little nodule does seem to drop out on the fat saturated

14:33

in images.

14:34

And so this patient went for surgery while she was pregnant to have this

14:38

removed and this ended up being uh,

14:41

a combination lesion of a mature cystic keratoma and a mucinous cystadenoma.

14:46

And I think we can see features of both here, right?

14:48

We have this large cystic lesion with a fatty neural nodule but also

14:53

citations within a predominantly cystic lesion,

14:56

which seem to have maybe some slightly more complex material within them.

15:04

This is another patient who um,

15:07

is having pain who was admitted to the hospital with preeclampsia and is now

15:11

got his post cesarean section. She's also in renal failure,

15:15

which is the reason for us doing this non-contrast CT of the pelvis

15:20

and sorry, chest, abdomen, and pelvis. Um,

15:22

she's also having a drop in hemoglobin.

15:26

And so we have stagial and axial non-contrast

15:31

CT images of the abdomen.

15:32

We also have a lung window image at the level of the lung basis.

15:38

On the sagittal image we can see the enlarged um, postpartum uterus.

15:43

You can see a little bit of tissue edema here in the lower uterine body, right?

15:47

It's no longer the lower uterine segment because the patient is no longer

15:51

pregnant. So we teach,

15:52

we see tissue edema at the site where they made the incision for the caesarean

15:56

section. And we also see an appropriate amount of gas, um,

16:00

surrounding the uterus. And in the lower pelvis, this is all post-surgical gas.

16:05

I'll now dry your attention to the axial non-contrast CT image in the center

16:10

of the screen. And so again, we see an enlarged postpartum uterus.

16:14

We see a little bit of postoperative hemoperitoneum and probably hemoperitoneum.

16:19

But then in the left anterior abdominal wall we see a fluid collection which is

16:24

demonstrating what's called hemato effect, right?

16:26

So we have hypodense material within the, um,

16:31

anterior aspect of this collection and then hyperdense material and the

16:35

dependent portion of it.

16:37

And so what this is is blood products that have separated out.

16:40

And so the more dense heme has settled to the bottom and then the plasma is left

16:45

at the top. And so this patient has a big anterior abdominal wall hematoma.

16:51

She also has at least small but probably moderate bilateral pleural

16:55

effusions, um, and a little bit of ground glass at both lung bases.

16:59

So she probably has a little bit of pulmonary edema as well.

17:03

So all of these things put together, um,

17:05

this patient who had preeclampsia is now having evidence of um,

17:10

greater than expected postoperative bleeding.

17:12

She's having end organ complications and also pulmonary edema.

17:16

This is a case of help syndrome. Help syndrome stands for hemolysis,

17:21

elevated liver enzymes and low platelets, right?

17:24

So this is a form of preeclampsia.

17:26

It is severe and it is life-threatening cause these patients bleed and they have

17:31

hepatic complications. Most commonly. This patient fortunately did not.

17:37

Um,

17:38

so common complications related to the liver include subcapsular hematoma,

17:42

peri hepatic bleeding, hepatic rupture. Um,

17:45

but you can also see just in general bleeding di cause these patients

17:50

often go on to develop D I c, um,

17:53

which is both a disorder of clotting and bleeding.

17:56

And so I suspect that this patient's abdominal hematoma is related to, um,

18:00

the D I C as a result of her health syndrome. Um,

18:04

the treatment for these patients is largely supportive. Um, they will manage,

18:10

um,

18:10

laboratory abnormalities and support the patients until organ function recovers.

18:14

And then of course anything that's actively bleeding that could be embolized or

18:18

managed by interventional radiology as taken care of as well.

18:23

This is sort of a companion case.

18:26

Now this is a patient who is at 37 weeks gestation.

18:30

She came in with right shoulder pain that was radiating all the way down to her

18:34

right point and um,

18:36

she had a CT of the abdomen and pelvis.

18:39

They suspected that she was having some kind of gallbladder pathology or maybe

18:43

even had a renal stone. Um,

18:45

but her pain was so severe that they ended up doing a ct.

18:49

And so we'll draw your attention to the right adrenal gland.

18:52

Here's the left adrenal gland hiding out on this coronal uh, CT image.

18:56

The right adrenal gland is expanded.

18:59

We really can't even differentiate the limbs.

19:01

It's hyperdense and appearance centrally.

19:03

There's a bunch of fat stranding around it.

19:05

You can see some riskiness of the fat here. Here it is again on the sagittal,

19:11

um, post contrast image of the ct.

19:13

And so this patient has a spontaneous adrenal hemorrhage. Um,

19:18

these can happen for a variety of reasons. One of the things to know about,

19:24

um, adrenal hemorrhages is that one is okay, right?

19:28

It's not ideal. It can be painful.

19:30

It's often in the setting of some other systemic abnormality or acute stress.

19:34

But one adrenal gland hemorrhage is all right.

19:37

If a patient has bilateral adrenal gland hemorrhage,

19:39

especially in the context of pregnancy, is this something that's dangerous?

19:43

Because if both of your adrenal glands are hemorrhaging and are not functioning

19:47

properly, it places the patient at risk of severe adrenal insufficiency.

19:51

And so those patients have to be monitored in the icu. Um,

19:55

but this patient was okay. Um,

19:57

on these images we can also see right hydronephrosis of pregnancy.

20:01

This is the common finding of pregnant patient due to compression of the ureter.

20:05

Um,

20:06

this patient came back about a year later and this right hemorrhage had resolved

20:09

and there was no mass or or nodule that was underlined.

20:14

Let's wrap up this section of acute abdominal path. Uh,

20:18

acute abdominal pelvic pathology during pregnancy.

20:21

Clinical history and symptoms will often guide the initial imaging because it'll

20:25

help you pick from one of those five or six categories that we briefly talked

20:29

about. Ultrasound is first line imaging for evaluating uterus, ovaries,

20:33

and fetus.

20:34

You can use CT if you need to in patients with severe or acute symptoms.

20:39

An MRI can be a really helpful adjunct imaging modality in characterizing

20:42

findings that you first see on ultrasound or for troubleshooting lesions or

20:47

pathology that you find. Next.

20:52

Let's move on to talk about advanced or complex ectopic pregnancy.

20:58

So you've all probably seen ultrasound images of an atopic pregnancy, right?

21:02

And this is atopic pregnancy refers to implantation of a fertilized o outside

21:06

the endometrial cavity.

21:08

The most plastic location is the pul of the fallopian two, right?

21:12

And that's where you're gonna see and in exel mass and on ultrasound,

21:16

you're gonna see what the ring of fire.

21:18

It's gonna be a ring-like hypervascular structure.

21:21

And that's true for all imaging modality no matter what you're using to image,

21:26

uh, and all. And atopic pregnancy will look like a hypervascular ring.

21:31

Another finding that can guide you toward atopic pregnancy

21:36

of the diagnosis is absence of an intrauterine gestation or an abnormal or

21:40

inappropriate rise in beta H C G, right? Especially in the first time trimester.

21:44

We expect the beta HCG to double every 48 to 72 hours.

21:50

Atopic pregnancy is dangerous.

21:51

These patients have the potential to severely hemorrhage if the atopic pregnancy

21:56

ruptures.

21:57

And so that's why imaging is super important in identifying the condition.

22:02

More severe or rare manifestations of atopic pregnancy can also be

22:07

really well-characterized by mri.

22:09

And so that includes things like cervical and cesarean section, scar,

22:12

atopic pregnancy.

22:16

Let's start with a quote, easy case. Um,

22:19

so this is a ruptured ectopic and I wanna clean out the features here, um,

22:24

that really highlight how dangerous this condition is.

22:27

So this is a patient who was 43.

22:29

She came into the emergency room with decreased responsiveness and she was

22:33

hypotensive and they did a fast exam right where they looked at all of the

22:37

different abdominal quads within ultrasound and they saw chemo,

22:41

peritoneum and fluid in the abdomen and pelvis.

22:45

And so this patient was not doing well.

22:47

There was no time to perform an ultrasound for this patient.

22:50

She went straight to the CT scanner and here's what we saw.

22:54

So we did arterial and venous phase and it is of the abdomen and pelvis.

22:58

Down here in the pelvis we can see that there is an ovoid

23:03

structure. It has some vascularity around it, even on the arterial phase.

23:08

On the venous phase. This fills in as a hypervascular ring.

23:13

Um,

23:14

and then the way that we can prove for ourselves that this is actually an ect,

23:18

capd pregnancy is number one. This is the uterus, right? We can see it here.

23:22

We can see it here.

23:23

This structure is independent from the uterus and we are so fortunate to have a

23:28

purpose rium in the right ovary adjacent to the uterus.

23:32

So this is independent of the ovary, independent of the uterus.

23:35

It's a hypervascular ring in the right aa and there is a ton of abdominal

23:40

pelvic hemoperitoneum up here near the dom of the liver here surrounding the

23:44

spleen. Um,

23:45

along the right peric collic gutter and then down here in the pelvis.

23:49

And so this is a ruptured ectopic pregnancy until proven otherwise.

23:53

This patient was taken emergently to the operating room.

23:55

She had a laparoscopic self ectomy and um,

23:58

they confirmed a diagnosis of ruptured right tubal atopic pregnancy.

24:04

Now let's do a more complex case.

24:07

The 25 year old presenting with right sided pelvic pain.

24:11

Her last menstrual period was seven weeks ago.

24:15

She had an ultrasound which was abnormal and MRI was performed for further

24:20

characterization.

24:22

So we have an axial T2 fat saturated image of the pelvis.

24:26

You have a sagittal T2 weighted image of the pelvis and a coronal T2 weighted

24:30

image of the pelvis.

24:32

And so what I'd like to point out here are those layers of the uterus that we

24:37

looked at on those normal images first, right?

24:38

So this is T2 hyperintense and heterogeneous myometrium out here.

24:44

This is the junctional zone.

24:45

And then you see the endometrium here and within the endometrial cavity toward

24:50

the right side of the uterus heading toward that OAM where the fallopian tube

24:55

enters, we again see a cystic rin leg structure.

24:59

It's really well circumscribed,

25:01

it's thick walled and it seems to be heading out toward again the uterine corn.

25:08

And so this patient has an interstitial atopic pregnancy. Um, this is technic,

25:12

some people will use the term corn corneal atopic pregnancy interchangeably with

25:17

interstitial atopic, but they're not the same thing. Corneal atopic corn.

25:22

Corneal pregnancy refers to a pregnancy which occurs within

25:26

one formula of a bi cornal uterus.

25:29

And so interstitial atopic pregnancy really hones down more, right?

25:33

It is within the periphery of the uterus, the interstitial, um,

25:37

where the fallopian tube meets the uterus.

25:42

And so this is probably an atopic pregnancy that was on its way to becoming

25:46

tubal, but never made it there.

25:48

Interstitial atopic pregnancy is extremely dangerous.

25:51

The interstitial of the uterus,

25:53

this sort of corner or lateral super lateral aspect of the uterus is extremely

25:57

hypervascular.

25:59

And so these patients are at risk for catastrophic hemorrhage if this atopic

26:03

pregnancy measures. Here's another case.

26:07

This is a patient who again had an abnormal ultrasound in the context of

26:12

pregnancy. Um, she had a history of heavy vaginal bleeding,

26:15

but it had significantly increased within recent weeks.

26:19

And so we have sagittal coronal and axial T2 rated MR images of the pelvis.

26:24

You can see the uterus here, right?

26:25

It's fairly enlarged and she has a bunch of T2 hyperintense uterine masses.

26:30

These are fibroids and probably account for her lung history of heavy vaginal

26:35

bleeding. But I'd like to draw your attention here to the cervix.

26:40

Okay, so this is anterior lip of the cervix, posterior lip of the cervix.

26:44

Within the cervix we can see an expanded tissue mass.

26:48

It's heterogeneous, it's T2 bright.

26:52

When we look at the coronal and axial images,

26:55

we can see that the cervix is really thickened. It's very hetero heterogeneous.

26:59

We see a bunch of serpiginous, linear T2, hypo intense structures.

27:04

These are flow voids in the context of abnormal and proliferative cervical

27:09

vascularity. And then within the center here we see a cystic lesion.

27:13

This is the gestational sac. Okay? So this is t2, bright gestational sac,

27:18

and within it we can actually see a fetal pole.

27:22

And so this is a pregnancy that's centered within the cervix.

27:25

This is a cervical ectopic pregnancy. Again,

27:28

it's extremely important to manage these patients either with embolization or

27:32

methotrexate and or surgical treatment because there's a risk of catastrophic

27:36

hemorrhage of disrupt.

27:41

Next I'd like to show a case from my high risk OB mastery series with

27:46

modality. Um, this is a patient who has a known ectopic pregnancy, which was,

27:50

and she was last to follow up. Um,

27:53

she initially presented with an ectopic around seven week shift station.

27:57

She was offered medical management for it and she declined.

28:01

And then we did not see her again until she was about 26 weeks pregnant and

28:06

came back with imaging that looked like this. So lemme orient you a bit.

28:11

First, this is the patient. Uh, this is the patient on Corona T2 weight images.

28:15

And then this is an axial T2 weight image of the abdomen and pelvis.

28:19

And so let's identify all of the structures that are present here.

28:22

This is the uterus and we can again, see those distinct layers. Right?

28:26

Here's t2, bright endometrium. This is junctional zone. This is t2,

28:31

heterogeneous myometrium. And then t2, dark ci rosa. This thin black line,

28:36

this is the patient's placenta and it's very abnormal.

28:40

Normally the placenta should be uniform in its signal and thickness.

28:44

This patient has big placenta bands, um,

28:47

which are a feature of abnormal place presentation.

28:50

And then in the center of the images,

28:52

independent from both the uterus and the placenta is the fetus.

28:57

And so again, let's just point out uterus, fetus, placenta, uterus,

29:02

fetus, placenta.

29:03

And so this is a patient who has an intraabdominal atopic pregnancy.

29:07

This happens when the pregnancy implants in the abdominal cavity instead of

29:12

uterus. And um,

29:13

we can really develop in a number of different ways the pregnancy implant on the

29:18

utero, mentum on large vessels, on vital organs.

29:22

And these patients can also bleed to death if this goes undetected until late in

29:26

the pregnancy.

29:28

We use r i primarily for operative planning to locate the placenta and to see

29:32

which organs, if any, have been invaded. Um, and this patient had, um,

29:37

exploratory laparotomy at 28 weeks gestation and both mother and fetus survived.

29:44

Let's move away from ectopic pregnancy and explore some other high risk OB

29:49

topics. I'll start with a case of placental abruption.

29:53

And this is something that you may see in your practice and you may have already

29:56

seen.

29:57

And it's important to know the imaging feature cause you could save somebody's

30:00

life if you're able to recognize this. This is a 29 year old woman,

30:04

she's 38 weeks pregnant. She was in a motor vehicle collision.

30:08

She had a positive seatbelt sign, lots of abdominal pain on physical exam.

30:12

And she had a non-reassuring fetal heart rate on the tracing.

30:16

So we put her in the CT scanner, we gave contrast, right? If you're gonna do it,

30:20

do it right. And so, um, we have contrast enhanced ct.

30:24

Here are the abdomen published. These are axial images.

30:27

This is a corona and this is a sagittal image.

30:29

And so we see the Ravi uterus here, right? We see fetal parts.

30:32

This is fetal abdomen, fetal limbs. And then this is the placenta.

30:37

Now this placenta, I can tell you may not have seen a lot of placenta on ct,

30:41

but they should be bright if you're giving contrast cause they're highly

30:44

vascular and so they should be enhancing.

30:47

And so the features I wanna point out about this placenta is that it's really

30:50

heterogeneous.

30:52

There are only a few areas where there's normal appearing enhancement.

30:57

We see these big global patchy areas of pipeline enhancement within the

31:01

placenta.

31:03

Less than 50% of the placental parenchyma is demonstrating normal enhancement.

31:08

And so this is highly concerning for placental abruption.

31:11

If you scan a pregnant patient with contrast and the placenta is not enhancing

31:15

normally and they are having abdominal pain,

31:18

this is placental abruption until proven otherwise,

31:20

this patient went for emergency section, the fetus survived,

31:24

the mother survived, and a diagnosis of placental abruption was confirmed.

31:31

Here's another case.

31:33

This is a patient who had pelvic pain and when she went for her OB ultrasound

31:38

with maternal fetal medicine,

31:39

we were having a really challenging time seeing her cervix.

31:44

And so we have statutal tissue,

31:46

tissue weed image of the pelvis here and a coronal de two weight image of the

31:49

pelvis year. The patient is status kidney transplant.

31:53

And so that's what you're seeing here in the right lower quadrant.

31:56

Now I'd like to point out on the coronal image that we can see our t2,

32:00

heterogeneous my nutrient. We see the, uh,

32:03

gestational sac or the amniotic sac here with theus inside.

32:07

And then this is the urinary bladder and this is the cervical canal.

32:12

Now I challenge you to find the cervical canal on the sagittal image.

32:17

So we see this big bulge, this is the lower uterine segment here.

32:21

And then to orient you, this is the uterine fundus.

32:25

And if we follow from the vagina all the way up, this is actually the surface.

32:30

It's very elongated, it's very compressed,

32:33

it's anterior and location and is being pushed forward by the fundus of

32:38

the uterus, which is doubled back here and is resting in front of the safe belt.

32:44

So this is a case of uterine incarceration.

32:48

Uterine incarceration is defined as entrapment of a retroverted uterus in the

32:51

pelvis. It's fairly rare,

32:53

one in 3000 pregnancies and it often happens in the second trimester.

32:58

And so what'll happen is these patients will come into the office,

33:00

the bundle height on physical exam is discordant with their dates.

33:04

And then when they try to see the cervix on ultrasound, um,

33:07

it's either significantly displaced or is anteriorly located.

33:12

There are lots of different ways to try to resolve this.

33:14

They can do version maneuvers, um,

33:17

which is just physically pressing on the uterus to try to relocate it.

33:21

Sometimes this has to be done under anesthesia. Um,

33:25

and then complications of this, because the uterus is so abnormally positioned,

33:30

um, the patients are at risk of uterine rupture, right?

33:32

There's already a little bit of sort of thinning and expansion of the lower

33:36

uterine segment here or bladder ruptured due to mass effect.

33:40

This is the same patient.

33:42

Two weeks later she came in with abrupt onset abdominal pain. She had,

33:47

um, been planned to come into the office for a, uh,

33:51

version maneuver to correct the position of her uterus.

33:54

And so now on the statute teaching weighted image,

33:57

we see that the cervix is in a much more normal location and the fundus of the

34:01

uterus is now in the abdomen instead of in front of the sac inflammatory.

34:05

So the reason that this patient came in with abdominal pain is because her

34:09

uterine incarceration spontaneously resolved.

34:15

Next case,

34:16

this patient with persistent reading following a spontaneous abortion during

34:20

that pregnancy,

34:21

the patient's medical imaging had suggested a diagnosis of placenta accreta

34:26

spectrum. Now again,

34:27

placenta accreta spectrum is a range of conditions in which the placenta is

34:31

morbidly adherent to the uterus or the myometrium,

34:34

the muscular layer of the uterus. And so these patients,

34:37

if they have a spontaneous vaginal delivery, are at increased risk of bleeding,

34:41

um, because the placenta may not completely detach from the uterus.

34:46

So we have two ultrasound images of the pelvis for this patient.

34:50

We're at the level of the mid uterus and we can see that the endometrial cavity

34:54

is distended. It's some sort of heterogeneously hypoechoic material.

34:58

These are endo vaginal images. And when we come up a little bit closer,

35:02

you can see that this material is fairly vascular.

35:06

An MRI was performed for further characterization.

35:09

And so this patient, um,

35:12

this is a sagittal T2 weighted image of the pelvis.

35:15

You can see the urinary bladder here. This is the vagina and this is the uterus.

35:19

You can see that it's enlarged. Um, and is, uh, you know, um,

35:24

postpartum uterus, the patient has, um,

35:26

passed the fetal parts and the endometrial cavity is distended.

35:31

Um, it isn't that typical T2 hyperintense appearance that we expect to see.

35:36

There's probably, probably a little bit of heterogeneous material in here.

35:39

And then in the low anterior uterine body, there's this T2 bright lesion,

35:44

which seems to extend into the my,

35:47

this is a T1 pre contrast image where that, uh,

35:51

focus looks fairly homogeneous in terms of its relationship

35:56

to the rest of the uterus. And then in both contrast images,

36:00

this appears to invaginate into the my and demonstrates some enhancement

36:05

of its own. And so this is retained placenta.

36:08

It's can be more broadly classified as retained products of conception.

36:13

Retained POC is persistent placental or fetal tissue in the uterus after a

36:18

delivery of miscarriage or a termination of pregnancy.

36:21

What it's gonna look like is a soft tissue lesion within the endometrial cavity.

36:24

And it's gonna look like that on all of the different imaging modalities we

36:28

perform. The vascularity is can confirmatory of this condition,

36:31

but it can vary a lot.

36:33

One of the things that can first clue you in to retained product is an

36:38

endometrial thickness of greater than or equal to 10 millimeters following a

36:41

spontaneous abortion or a dilation of.

36:45

Now one pearl that I wanna point out to you is if we had been looking at these

36:50

ultrasound images and the patient was actively passing clots was still feeling

36:55

heavy abdominal clamping, um, you know,

36:57

and and had an appropriately following H C g hadn't had any imaging suggestive

37:02

of placenta accreta spectrum.

37:04

We say that the patient has an abortion in progress and it's a pitfall to make a

37:08

diagnosis of routine products while the patient is actively miscarrying.

37:12

Do you have to use the clinical history to guide your interpretation of these

37:15

images? Next case,

37:19

this is a patient with abdominal cramping.

37:22

She has a history of prior cesarean section.

37:25

She had an abnormal ultrasound with maternal fetal medicine.

37:28

This a stage T2 weighted image of the pelvis.

37:32

You can see the placenta here anteriorly. It's really lovely. Um,

37:36

it's very homogeneous, uh,

37:38

on these images and it has a little bit of peripheral tapering,

37:41

which is angular. So the majority of this placenta is very normal.

37:45

You can see t2, heterogeneous myometrium covering it.

37:48

There's a little bit of increased sub placental vascularity.

37:52

The penis is in a transverse position here, right? It's here had is here.

37:57

What I'd like to point out for this patient is this really dumbbell shaped

38:00

appearance of the amniotic sac. And we can see that on the coronal as well.

38:05

If we follow the my down. It gets very,

38:08

very thin here and it looks like the lower uterine segment is almost

38:13

being buttressed or supported by the dome of the urinary bladder.

38:18

If you measure this, the myometrium gets as thin as one to two millimeters here.

38:22

And then the bladder dome, you know,

38:25

combined this measurement is probably five to six milliliters.

38:29

There is one area of the placenta in on the left side that does look

38:34

abnormal is heterogeneous.

38:35

And this patient probably has a little bit of focal placenta of RTA here as

38:39

well. But let's focus on the imaging findings here.

38:42

These imaging findings raise concern for uterine des.

38:46

Now I wanna make it clear that you can't call uterine des unless you have

38:51

complete separation of the endometrium and myometrium. So for this patient,

38:55

we still see a thin, thin,

38:57

thin layer of myometrium measuring two millimeters here. Um,

39:02

this is distinct from a uterine rupture,

39:04

which includes separation of the serosa in the postpartum period.

39:09

When you're thinking about like a uterine dehi C-section CT is the imaging

39:13

modality of choice, but this patient was still pregnant. Um,

39:17

and so it's really important to monitor these patients.

39:20

Once the combined thickness of the myometrium and the bladder dome get

39:25

between four and six millimeters combined,

39:27

you have to monitor these patients very closely because they are at,

39:31

at seriously high risk of true dehiscence,

39:34

uterine rupture and significant postpartum coverage.

39:37

So this patient does not technically have a diagnosis of uterine dehiscence.

39:41

She has marked myometrial thinning, which may progress to uterine dehiscence,

39:45

but she's still being monitored very closely prior to delivering.

39:51

Let's switch gears one more time. This is the last component of our OB pry.

39:56

Now we're gonna talk about gestational trophoblastic disease.

39:59

Before I take your questions,

40:01

gestational trophoblastic disease can be classified as either benign or

40:05

malignant, right?

40:06

You probably remember studying these different conditions if you were in medical

40:10

school or during residency. And so the benign, uh,

40:14

classifications of gestational trophoblastic disease,

40:16

which I'll refer to as GT V from here on out include complete MO or

40:21

partial mole malignant trophoblastic disease or gestational trophoblastic

40:26

neoplasia,

40:26

which I'll refer to here on out as GT N includes invasive mo

40:31

choriocarcinoma, placental site trophoblastic tumor,

40:34

and epithelioid trophoblastic tumor.

40:37

And what I'd like to point out is that the pathophysiology of gestational

40:41

trophoblastic disease is very similar to placenta accreta spectrum

40:46

in the sense that all G T D originates from placental trophoblast,

40:51

which are the cells which are migrating abnormal in placenta accreta spectrum,

40:55

same cell lineage that's responsible here.

41:00

Let's talk first about worm mole. It can either be complete or partial mole.

41:04

And I have some path images here, um, to show the spectrum.

41:08

So a complete mole, you'll see early uniform enlargement of a potential vili.

41:13

There are no villous capillaries here in a partial mole,

41:17

you do have a functioning circulation, a functioning villus circulation.

41:21

You may, um,

41:22

in many cases also see identifiable fetal or embryonic tissue

41:29

imaging findings for molar pregnancy, including enlarged uterus,

41:33

a heterogeneous endometrial canal with that snowstorm or Swiss cheese

41:37

appearance, which is a buzzword on exams.

41:39

You can also see hyper vascularity of the endometrial canal.

41:43

And in a molar pregnancy, um, you may not see a normal embryo.

41:47

Many of these patients will also have bilateral fecal lutein sits.

41:52

And that's because of hyperstimulation from elevated beta H c g, uh,

41:56

from the trophoblasts.

42:01

But this is the case, oh, sorry, I my watch. Ok,

42:04

so this is a case of molar pregnancy. This is the ultrasound image, right?

42:09

And we can see that this patient has an expanded endometrial cavity,

42:13

all of these cystic spaces. Um, and this nicely matches the gross specimen, um,

42:18

for this patient, which has this kinda cystic CT of brace appearance.

42:23

Oops, sorry. Um, this is another case of, um,

42:27

a patient with more pregnancy. This is the ultrasound.

42:31

We can see again those cystic spaces with some vascularity on the ultrasound

42:35

image.

42:35

And then this is a DT where we see intervening enhancing tissue in a background

42:40

of the cystic cluster of grave spaces.

42:45

This is an mri, um, for a similar patient. Um,

42:49

and we have the gross specimen to correlate with it.

42:53

And so on the SAG T two weighted image, we can see, um,

42:56

all of the cystic foci expanding the endometrial cavity.

43:00

Here's the corresponding ultrasound and then the gross.

43:07

Here's another example. We're looking at post contrast t1, um,

43:11

images where we can see again cystic spaces with intervening

43:15

heterogeneously enhancing tissue.

43:18

This is a T2 weighted image of the pelvis, um, where we can see, again,

43:22

a lot of cystic foci within this soft tissue lesion.

43:26

We can also see some fetal parts here within the endometrial

43:31

cavity. Um, and then on the axial T2 weighted image,

43:34

I also wanna point out the, um, really enlarged appearance of both ovaries.

43:40

Um, which, uh, is, um,

43:43

indicative of the bilateral fecal

43:47

treatment of molar pregnancy. Um,

43:50

includes suction and dilation curettage d dnc.

43:53

They also follow the beta HCG to zero complications of this include

43:57

invasive mole, which develops in 15 to 20% of complete moles.

44:01

Less than 5% of partial moles and choal carcinoma can develop in five to 8% of

44:06

complete moles, less than 1% of partial moles.

44:09

So complete mole has a much higher risk of progressing to either invasive mole

44:13

or choal carcinoma.

44:17

The figo criteria for diagnosis of post molar gestational trophoblastic

44:22

neoplasia include a plateau of the beta HCG levels lasting longer than four

44:27

measurements over a period of three weeks or longer rise in beta htg.

44:31

Sorry about that. Um,

44:33

for three consecutive weekly measurements over a period of two weeks or longer,

44:37

a beta HTG that's elevated for greater than or equal to six months,

44:40

or a histologic diagnosis of choal carcinoma.

44:44

This is the staging for gestational trophoblastic neoplasia. Um,

44:48

stage one is confined to the uterus.

44:50

Stage two extends outside the uterus but is limited to the genital structure.

44:55

Stage three extends to the lungs with or without genital tract involvement.

44:59

And stage four disease involves other metastatic sites. And so this patient,

45:04

uh, is at least stage three with this chest radi graft.

45:07

And then creating multiple canonball lesions in the lungs by

45:12

here's a companion case of gestational fibroblastic disease. Um,

45:16

this is a 30 year old patient with history of molar pregnancy.

45:20

She had a D N C and she presented with markedly elevated beta H C G.

45:24

We did a C2 scan for her. There's an arter, the enhancing mass,

45:28

occupying the endometrial cavity.

45:30

There's persistent enhancement here on the venous phase. Um,

45:35

and on the lung windows, the patient had multiple, uh,

45:39

metastatic pulmonary nodules.

45:41

And so this patient had a confirmed diagnosis of poeo carcinoma.

45:45

She got chemotherapy, um,

45:47

and three months later the lung nodules had significantly increased in size and

45:51

the endometrial mass had evolved.

45:56

This is a case of an invasive mole on ultrasound. Um,

46:00

so we have the gray scale image here, again,

46:02

showing this endometrial lesion that's invading the myometrium.

46:05

We have cystic spaces here that's due to the presence of the VIIs structures.

46:11

Um, and then the soft tissue is hypervascular.

46:14

And then this is the gross specimen showing the deep mytral invasion.

46:19

Here's another example of an invasive mo. Um,

46:22

we can see a mass with solid and cystic areas on the ultrasound.

46:26

And there's invasion of the myometrium on this ultrasound image.

46:30

The CT shows a lot of paper vascularity as well as Abbott enhancement.

46:35

And then we have the growth image here that shows myometrial invasion.

46:40

This is a choal carcinoma at ct.

46:42

There's a heterogeneous endometrial or myometrial mass.

46:46

You can see it sort of protruding from the right lateral aspect of the uterus.

46:51

It's really hypervascular. It has that sort of enhancing ring appearance to it.

46:55

The low density regions in the center like they represent necrosis or

46:59

hemorrhage. Um,

47:01

and we have an intraop image also showing the invasive nature of this lesion.

47:08

Here's another example. We have a T2 weighted M R i. Um,

47:12

in the superior aspect of the screen here we see a big heterogeneous uterine

47:17

mass with bilateral ovarian cysts. Do the elevated beta H c G,

47:21

we see similar findings. These are the ovarian cysts on ct.

47:24

And then this is the operative image showing the really enlarged ovaries

47:28

bilateral Last example.

47:32

This is to show that the mass may be small. Um,

47:35

so this one is T2 dark, it's due to hemorrhage,

47:39

which we can nicely see on both the gross and histopathology here.

47:43

And this patient also has lung attack disease

47:47

treatment for gestational trophoblastic neoplasia, low risk disease. Um,

47:52

these patients will get single agent chemotherapy and almost all of these

47:55

patients survive high risk disease.

47:59

That's stage four or high risk stage two or three.

48:02

They get multimodal chemotherapy, um,

48:04

with or without adjuvant surgery or radiation.

48:07

And many of these patients also do very well.

48:10

Survival rates are up to 80 to 90%.

48:15

So let's wrap things up here to conclude.

48:17

Ultrasound is the first line imaging modality in pregnancy,

48:21

but you're gonna see with these more complex cases, a lot of CT and MR.

48:26

CT is gonna help you with those incidental findings or identifying etiologies

48:31

with vague symptoms. MRI is safe during pregnancy,

48:34

it can help you characterize acute pathology.

48:37

MRI protocols for evaluating acute pathology in pregnancy should be focused and

48:42

efficient.

48:43

And then recognizing the imaging findings in each of these conditions is key to

48:47

diagnosing and treating them. These are my references.

48:51

I'd like to thank you for your time and attention. And now, uh,

48:55

let's get to the q&a. Ok.

49:00

Um, so the first one we have, um, is from an anonymous attendee. They said,

49:04

can you comment on current guidelines for imaging of suspected PE and pregnancy?

49:10

Um, so at our institution, um, we no longer, um,

49:15

perform shielding, uh, pediatric or pregnant patients. Um,

49:19

if the patient has, um,

49:22

sufficient evidence to suggest that they have a pulmonary embolism,

49:27

um, in many cases we will perform a C t a chest PE protocol.

49:32

Um, you know, we found that the really,

49:34

the risk of radiation to the patient and the fetus is, is fairly low.

49:38

And so we go ahead with the C T A.

49:43

Um, I have one question that says,

49:45

do they keep the ectopic intraabdominal pregnancy? Um,

49:49

so I'm not sure what exactly you mean by this question, but, um,

49:53

so this patient did choose to, uh,

49:56

pursue the pregnancy and when they, uh,

49:59

did a laparoscopy for her, um, the fetus was viable.

50:03

And so both the mother and fetus survived in this case.

50:09

I have a question from Kai Kim that says,

50:12

in the case shown teratoma and mucinous ca did surgical resection have

50:17

waited until the delivery, um,

50:21

along with percutaneous drainage to make room for the fetus to grow?

50:24

This is a great question. I love this question. So, um,

50:28

in suspected cases of ovarian cancer or ovarian neoplasms including

50:33

teratoma, uh, we never wanna puncture the lesion, right?

50:36

Cause we risk spilling the contents into the peritoneal cavity.

50:40

You could get peritonitis if you rupture a dermoid. Um,

50:44

you could also potentially seed the peritoneal cavity if you have a malignant

50:48

ovarian lesion. The second part of this question says,

50:52

what is the cutoff gestational age for the fetus to do reasonably well if

50:56

delivery is the only option? Um, so,

50:58

so if you chose to deliver this fetus and you know,

51:01

and then manage the ovarian tumor, um,

51:04

we try to get patients to at least 28 weeks.

51:07

But really 32 weeks is a goal where the fetus does a lot better, um,

51:11

once they're delivered with NICU care. Um, for this patient,

51:14

she was having intermittent pain. They,

51:16

they were worried that she may eventually force the ovary,

51:20

which would provide a more emergent trip to the OR for her.

51:23

And so they chose to laparoscopically resect this ovarian lesion. Um,

51:27

and then she delivered, uh, at like 38 weeks later in her pregnancy.

51:35

Um, we have a question that says,

51:36

how do you approach justifying CT examinations in pregnancy,

51:39

especially with contrast? This is a great question.

51:41

There's a lot of controversy about doing CT for pregnant patients. Um,

51:47

the bottom line is that if you think the patient has a condition that is severe

51:51

enough and urgent enough that they would be taken for a procedure or a surgery

51:56

or some kind of emergent management, um,

51:58

you have to weigh the risk of not doing that imaging with, um,

52:03

the risk of potentially, you know, exposing the fetus to radiation. Now,

52:07

CT contrast is not as big of a deal as gadolinium based.

52:11

MR contrast in terms of fetal exposure. Um,

52:14

there's less convincing data that the fetus could be harmed by administration of

52:18

IOD donated CT contrast. Um,

52:21

there's also emerging data to show that, um, you know,

52:24

really recalculating some of the radiation exposure data we largely

52:29

have from Roland Nagasaki, um,

52:31

is that some of the fetal exposures that we have previously estimated on CT are

52:36

probably as not as great as they were, um, estimated to be in the past.

52:41

That being said,

52:42

fetal radiation exposure is still a serious consideration when you're thinking

52:46

about ordering an imaging study,

52:47

but you have to weigh the risks and benefits of imaging versus not imaging based

52:52

on the patient's clinical condition.

52:55

We have a question about placenta and creta spectrum is my favorite. Um,

52:59

what are the more reliable signs on M R I for placenta aquita spectrum and

53:03

what's the best gestational age window for imaging this diagnosis?

53:07

So the features of placenta aquita spectrum on M R I will include placental

53:12

heterogeneity, abnormal placental, vascularity,

53:16

placental bands, which are probably placental inks or hemorrhage.

53:21

You'll also see myometrial thinning,

53:24

placental bulge and abnormal or rounded placental contour.

53:29

And then in cases of more advanced p a s,

53:31

you may also see invasion of adjacent structures like the bladder,

53:35

vagina or abdominal wall.

53:37

The best gestational age window for imaging placenta accreta spectrum is in the

53:41

second trimester.

53:42

We like to image these patients somewhere between 24

53:47

and 28 weeks gestation,

53:49

and that gives us plenty of time to plan for a delivery that usually happens

53:52

around 32 to 34 weeks.

53:57

Next question. What are the M R I features of ovarian torsion? Um,

54:01

so they're similar to the features that you'll see on ultrasound and ct.

54:05

You'll see an enlarged indemnities ovary.

54:08

You may see peripheral displacement of the ovarian follicles.

54:12

You can see peri uh, peri follicular, um, hemorrhage. Um,

54:17

you can see free fluid in the pelvis and the patient will often have exquisite

54:20

pelvic pain.

54:21

Sometimes on I or p coronal images are so good that you can see even that

54:26

twisting or whirlpool sign in the vascular pedicle of the taurist ovary.

54:31

And I have a case ovarian corgen in my high-risk OB course on modality if you're

54:35

interested in seeing it. Next question is non-contrast.

54:40

M r i safe for the first trimester as well? Yes.

54:43

So you can do an M r I in any trimester of pregnancy, um,

54:47

and is considered safe.

54:51

Next question,

54:53

can we differentiate between a hemorrhagic cyst and an endometrioma? Yeah,

54:57

this is a great question. Um, so endometriosis is a chronic condition. You know,

55:02

patients will have, um,

55:03

cyclic pelvic pain and it's important to be able to diagnose a hemorrhagics from

55:08

an endometrioma on imaging. Um, so on ultrasound, um,

55:12

hemorrhagics have a very classic appearance, right?

55:14

They have a lace like internal appearance and endometrioma will have

55:19

low level homogeneous internal echoes.

55:22

That's called the chocolate cyst sign of an endometrioma. On an mri,

55:26

the diagnosis can be a little bit more challenging because both of the,

55:32

um, lesions will look bright on T1 weighted imaging. Um,

55:36

but a hemorrhagic cyst will resolve and an endometrioma will also

55:40

have usually other features, um, like T2 shading, um,

55:45

which is a common feature of endometrioma.

55:47

You may see other sites of endometriosis in the public,

55:49

which may sway you as well. Uh,

55:52

Kai Kim is asking for the reference pages again, here they are.

55:55

I'll put this one up and then I'll switch to the next one. Um, let's see.

56:00

Uh, what is the full form of p a s? Um, it is,

56:06

uh, placenta accreta spectrum. Some people will call it, um,

56:10

placenta accreta spectrum disorder or P A S D. I apologize for the abbreviation.

56:18

Next question.

56:20

You have shown some intrabdominal topics to these cases, um,

56:25

opt to continue the pregnancy or should they be terminated for fear of rupture?

56:29

Um, this is something that is largely up to the patient. Um,

56:33

the team obviously would recommend in these cases that the pregnancy be

56:37

terminated because of the risk of rupture and catastrophic hemorrhage.

56:42

Um,

56:42

but obviously as physicians we can only make recommendations to our patients.

56:46

Their, it's their body and, and they have a choice about what they can do, um,

56:51

to manage any of their medical conditions.

56:53

And so this patient opted to continue her pregnancy despite the risk of rupture

56:57

hemorrhage and she got really lucky, um,

56:59

that she did not suffer a catastrophic bleed.

57:04

Um, next question. Uh, we have um,

57:06

what is the evaluation of placenta in creta? A preta and perreta? Um,

57:12

so this is a diagnosis that is first encountered often on,

57:17

um, ultrasound.

57:19

So the patient will come in usually for their anatomy scan or, uh, for,

57:23

you know, late first trimester scan and they'll see an abnormal placenta.

57:28

There are very characteristics of a, uh,

57:30

very characteristic findings of a normal placenta on ultrasound. Um,

57:34

there's this zone, um, um,

57:37

hypo aoic signal that's deep to placenta called the retro placental

57:42

clear space. Um,

57:43

and on ultrasound you'll see that space kind of disappear and you'll see

57:48

placental tissue extending toward the myometrium. And often that's good enough,

57:52

but in some cases if they're not able to see the placenta,

57:55

well if it's a complex case and they think that there is placenta perreta with

58:00

an invasion of adjacent structures, if the placenta is posterior,

58:03

which is notoriously challenging on ultrasound, they'll do mri.

58:07

And our MR protocol is a multiplanar t2, um,

58:12

weighted imaging.

58:13

And so we will do steady state precession and also turbo spin echo images for

58:17

these patients.

58:18

And so it's just multiplanar sagittal coronal and axial steady state precession

58:24

and turbo spin echo.

58:26

Some places will add diffusion weighted imaging or non-contrast t1.

58:31

I don't know that they're necessary.

58:34

So your goal of doing an M R I for a patient with placenta accreta spectrum is

58:38

to determine number one,

58:40

that there truly are features of placenta accreta spectrum present, but two,

58:44

to exclude a diagnosis of placenta for accreta.

58:49

Any other questions? Thanks so much for engaging and for,

58:53

and for asking such great questions.

58:55

I really appreciate your time and attention.

58:58

Thank you so much, uh, for your lecture today, Dr. Gomez.

59:02

Thank you so much and thanks to everyone, uh,

59:05

for participating in our noon conference.

59:07

You can access the recording of today's conference and all our previous noon

59:11

conference by creating a free m r I online account.

59:15

Be sure to join us next week on Thursday, June 22nd at 12:00 PM Eastern,

59:20

featuring Dr.

59:21

Emily f Conant for a lecture on abbreviated breast MRI for

59:26

supplemental screening early outcomes and tips for implementation.

59:30

You can register for this free lecture@mrionline.com and follow us on social

59:35

media for updates on future noon conferences. Thanks again and have a great day.