Interactive Transcript
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This is an MRI of the abdomen and pelvis in a
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patient presenting at 24 weeks gestation with
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abnormal maternal-fetal medicine ultrasound.
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The patient was seen early on in her
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pregnancy in the first trimester and
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was diagnosed with ectopic pregnancy.
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However, due to her personal beliefs,
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she did not seek additional treatment
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for the ectopic pregnancy until she
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returned at 24 weeks gestation with
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abdominal pain and vaginal bleeding.
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Here we have axial T2-weighted
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images of the abdomen and pelvis.
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We can see that this patient has very mild
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left-sided hydronephrosis of pregnancy.
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As we scroll inferiorly, we begin to
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see three distinct structures within the
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lower abdomen above the pelvic inlet.
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The first is a well-circumscribed
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structure with T2 heterogeneous tissue,
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which we know is the myometrium.
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This is the T2 hypo-intense junctional zone
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and the T2 hyper-intense endometrial cavity.
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The patient does have several T2 hypo-
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intense uterine fibroids present.
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We can follow the endometrial cavity all
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the way down to the level of the cervix.
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Medial to the uterus, we see a well-
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circumscribed amniotic sac, which
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contains a late second-trimester fetus.
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The fetus is in cephalic presentation,
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and the gestational sac is
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clearly extra-uterine in location.
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Lateral to the amniotic sac and to the
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fetus is a T2 heterogeneous structure,
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which is lobulated with internal
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parenchymal heterogeneity and multiple
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wedge-like T2 hypo-intense bands.
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So identifying these structures from
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right to left, we have the uterus,
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an intra-abdominal gestational sac with a
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second-trimester fetus, and the placenta.
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Looking at this patient in coronal view,
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we can clearly see the relationship
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again between these three structures.
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We can nicely visualize the T2
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heterogeneous myometrium of the uterus,
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the T2 hyper-intense endometrial
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cavity, and the T2 dark junctional zone.
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Medial to the uterus, we
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see the gestational sac.
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There is mild subjective
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oligohydramnios present for this fetus.
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There is a small, less than expected amount
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of amniotic fluid present around the fetus.
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And again, the fetus is in cephalic presentation.
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Lateral to the fetus, we see the placenta, which
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is lobular, it's rounded in appearance, it's
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very heterogeneous with significant abnormal
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vascularity and multiple placental bands.
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If we were to place this placenta into the lower
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uterine segment in an intrauterine gestation, we
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would certainly call it suspicious for placenta
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accreta spectrum given the features present.
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One of the things to note about
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intra-abdominal ectopic pregnancy
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is that the placenta will recruit
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vasculature from different structures in
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the pelvis, depending on the location of
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the implantation, and will establish a
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blood supply that can support the pregnancy.
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This can include the adjacent solid organs,
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the greater omentum, or occasionally
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the uterine or ovarian vasculature.
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This patient presented at 24 weeks
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gestation and desired to keep the pregnancy.
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She was kept on bed rest in the hospital for an
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additional four weeks until it was felt that the
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fetus was viable enough to withstand surgery.
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She underwent midline laparotomy and
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successful delivery of the fetus.
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The baby survived in the NICU
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with excellent NICU care.
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And a final diagnosis at pathology was made
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of intra-abdominal ectopic pregnancy with
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placenta implanted on the left ovary and
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recruitment of the left ovarian vasculature.
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