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Summary: Acute Abdominopelvic Pathology During Pregnancy

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Another diagnosis to consider in

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reproductive-age women is endometriosis.

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Endometriosis is defined as the presence of

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viable estrogen-sensitive endometrial glandular

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tissue and stroma outside of the uterus.

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Endometriosis is extremely common, affecting

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6 to 10 percent of reproductive-age women.

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And although many patients begin experiencing

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symptoms early in their lives, most patients

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are not diagnosed until they are 28 years old,

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with an average time from symptom onset

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to diagnosis of seven to eight years.

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And that's because the symptoms of

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endometriosis are vague and nonspecific.

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But most patients will experience

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some form of chronic pelvic pain

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and may also experience infertility.

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Endometrial implants are influenced by hormones.

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And so in the context of pregnancy,

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endometriosis symptoms may worsen.

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Patients with endometriosis who become

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pregnant are at increased risk of

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having a tubal ectopic pregnancy, a

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spontaneous miscarriage, and peripartum

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hemorrhage near the time of delivery.

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Specific pregnancy-related complications

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in patients with endometriosis include

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spontaneous hemoperitoneum, ovarian torsion,

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or rupture of an ovarian endometrioma, or

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uterine rupture near the time of delivery.

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There are two main sequences on MRI

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which may be useful in the identification

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and diagnosis of endometrial implants

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and endometriosis as a whole.

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T2-weighted imaging is especially important

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in the identification of ovarian lesions.

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Endometriomas, or ovarian endometrial implants,

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will demonstrate a classic T2 shading pattern,

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where the lesion will become progressively

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darker as you move from the anterolateral

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to the dependent portion of the lesion.

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On T2-weighted imaging, we can also visualize

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dilated or blood-filled fallopian tubes,

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which are hydrosalpinges and

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hematosalpinges, respectively.

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T2-weighted imaging may also be useful

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in identifying scarring in patients with

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deep infiltrative endometriosis, and

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this scar tissue will appear T2-dark.

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Fat-saturated pre-contrast T1-weighted images

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are the workhorse of identifying endometriosis.

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Classic powder-burn and implant

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lesions in endometriosis will appear

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intrinsically T1 hyperintense.

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Thanks again.

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And this imaging sequence, in particular,

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is key for distinguishing an endometriosis

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lesion from a fat-containing lesion,

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particularly ovarian teratomas.

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T1-weighted imaging can also be useful

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in identifying hemoperitoneum in patients

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who have spontaneous intra-abdominal

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hemorrhage in the context of endometriosis.

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This is an axial fat-saturated T2-weighted image

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of the abdomen in a patient who has a cystic,

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multi-septated right abdominal wall

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implant, in addition to a moderate

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volume of abdominal ascites.

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This is the T1 fat-saturated pre-contrast

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image, and we can see that this lesion in the

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right abdominal wall remains intrinsically

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T1 hyperintense, in addition to the

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ascites, which is actually hemoperitoneum.

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So, this is a patient who has an

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endometriotic implant in the abdominal

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wall in addition to spontaneous

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hemoperitoneum related to her endometriosis.

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Another important consideration in patients

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who are presenting with abdominal pelvic pain

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in reproductive age is intrauterine devices.

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Intrauterine devices are an extremely

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effective method of birth control.

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It's a foreign body, typically plastic or

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sometimes made of copper, which is inserted

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into the uterus and provides either hormonal

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and/or mechanical irritation of the uterine

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lining to prevent pregnancy from occurring.

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Most IUDs are T-shaped, although some of the

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older versions have more of a serpiginous

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stacked hairpin turn appearance to them.

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Ideal placement of an intrauterine

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device is with the top of the T, the

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arms or the crossbar near the uterine

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fundus, and then the stem within the

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endometrial cavity within the uterine body.

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Complications of intrauterine

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devices most commonly include

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malpositioning, which can be painful.

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The intrauterine devices can also become

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embedded within the uterine myometrium

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or occasionally perforate the uterus.

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This is most common at the site

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of a cesarean section scar.

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It's important to identify a malpositioned

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intrauterine device for two reasons.

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One, because a malpositioned IUD may not

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be providing effective birth control for

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the patient, and also, depending on the

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degree of embedment or malpositioning,

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it may require removal under anesthesia

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rather than in the gynecology office.

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As I said, IUDs are extremely

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effective, and so coexisting pregnancy

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in a patient with an IUD is rare.

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But the risk of a concomitant

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pregnancy happening is highest in

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the first year following placement.

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Patients who become pregnant with an IUD

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in place have a higher risk of preterm

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labor, spontaneous abortion, and infection.

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When an IUD is identified within the

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uterus in a pregnant patient, the

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management of the IUD really depends

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on the gestational age of the fetus.

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If the IUD is visualized in the first

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trimester of pregnancy, the provider may

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attempt to remove it in order to allow the

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pregnancy to progress as safely as possible.

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If the IUD is identified in the second or

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third trimester of pregnancy, the risks of

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removal may outweigh the benefits of removing

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it, and this may need to be a pregnancy

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that is just monitored more frequently.

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Localizing the intrauterine device by

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imaging is key in determining how and

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whether the IUD should be removed.

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One pearl that I want to share with

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you is that all intrauterine devices,

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whether they’re plastic or metallic,

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will be radiopaque on imaging.

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So these will look hyperdense

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on CT or plain radiographs.

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On ultrasound, because they are

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relatively dense structures, they’ll

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demonstrate posterior acoustic shadowing.

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And then, because of the filament

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within the plastic IUDs and the metallic

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component of the copper IUDs, these will

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be hypo intense or more apparent on T1

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weighted imaging and gradient echo MRI.

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Here are some examples of intrauterine

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devices across imaging modalities.

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This is an ultrasound image of the

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pelvis in a patient with an IUD.

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We can see echogenic components of the IUD,

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which demonstrate posterior acoustic shadowing.

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This is a 3D image of the uterus in a

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patient who has a malpositioned IUD.

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We can see that the arms are located

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appropriately at the uterine fundus, but the

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body of the IUD is exiting the endometrial

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canal and is embedded in the uterine myometrium.

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These are T1 weighted images of the pelvis.

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In a patient who was unable to

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locate her IUD strings, it was also

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unable to be located on ultrasound.

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And so again, on T1 weighted imaging or

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gradient echo imaging, the intrauterine

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device will become more apparent.

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And so we can see a portion of the arms

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here and here on MRI in this patient.

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And then finally, this is an

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appropriately positioned IUD on CT.

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This is a classic T-shaped IUD, which

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again looks radio dense on CT imaging.

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And it's appropriately positioned within the

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endometrial cavity near the uterine fundus.

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To summarize, there is a myriad of causes

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of abdominal pelvic pain and abdominal

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pelvic pathology during pregnancy.

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Using the clinical history and the

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patient's symptoms will help you

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guide your initial imaging approach.

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Ultrasound is the first-line imaging

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modality for evaluation of the

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uterus, the ovaries, and the fetus.

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Remember that appendicitis and renal stones are

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common causes of non-obstetric abdominal pain

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in pregnancy, and that MRI can serve as a useful

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adjunct if you need to further characterize or

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troubleshoot findings on your initial imaging.

Report

Faculty

Erin Gomez, MD

Assistant Professor of Radiology

Johns Hopkins Hospital

Tags

Women's Health

Uterus

Ultrasound

Ovaries

MRI

Gynecologic (Gyn)

Gynecologic (GYN)

Genitourinary (GU)

Cervix

CT

Body

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