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Intra-Abdominal Ectopic Pregnancy

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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.

Report

Faculty

Erin Gomez, MD

Assistant Professor of Radiology

Johns Hopkins Hospital

Tags

Women's Health

Uterus

Ovaries

MRI

Gynecologic (Gyn)

Gynecologic (GYN)

Genitourinary (GU)

Cervix

Body

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