0:00

Another diagnosis to consider in

0:02

reproductive-age women is endometriosis.

0:06

Endometriosis is defined as the presence of

0:08

viable estrogen-sensitive endometrial glandular

0:11

tissue and stroma outside of the uterus.

0:15

Endometriosis is extremely common, affecting

0:18

6 to 10 percent of reproductive-age women.

0:21

And although many patients begin experiencing

0:25

symptoms early in their lives, most patients

0:27

are not diagnosed until they are 28 years old,

0:31

with an average time from symptom onset

0:33

to diagnosis of seven to eight years.

0:36

And that's because the symptoms of

0:37

endometriosis are vague and nonspecific.

0:40

But most patients will experience

0:42

some form of chronic pelvic pain

0:45

and may also experience infertility.

0:49

Endometrial implants are influenced by hormones.

0:53

And so in the context of pregnancy,

0:55

endometriosis symptoms may worsen.

0:58

Patients with endometriosis who become

1:00

pregnant are at increased risk of

1:02

having a tubal ectopic pregnancy, a

1:05

spontaneous miscarriage, and peripartum

1:08

hemorrhage near the time of delivery.

1:10

Specific pregnancy-related complications

1:14

in patients with endometriosis include

1:16

spontaneous hemoperitoneum, ovarian torsion,

1:20

or rupture of an ovarian endometrioma, or

1:23

uterine rupture near the time of delivery.

1:27

There are two main sequences on MRI

1:30

which may be useful in the identification

1:33

and diagnosis of endometrial implants

1:36

and endometriosis as a whole.

1:38

T2-weighted imaging is especially important

1:41

in the identification of ovarian lesions.

1:44

Endometriomas, or ovarian endometrial implants,

1:47

will demonstrate a classic T2 shading pattern,

1:51

where the lesion will become progressively

1:53

darker as you move from the anterolateral

1:56

to the dependent portion of the lesion.

1:58

On T2-weighted imaging, we can also visualize

2:01

dilated or blood-filled fallopian tubes,

2:05

which are hydrosalpinges and

2:06

hematosalpinges, respectively.

2:09

T2-weighted imaging may also be useful

2:11

in identifying scarring in patients with

2:13

deep infiltrative endometriosis, and

2:16

this scar tissue will appear T2-dark.

2:20

Fat-saturated pre-contrast T1-weighted images

2:23

are the workhorse of identifying endometriosis.

2:27

Classic powder-burn and implant

2:30

lesions in endometriosis will appear

2:32

intrinsically T1 hyperintense.

2:34

Thanks again.

2:34

And this imaging sequence, in particular,

2:37

is key for distinguishing an endometriosis

2:40

lesion from a fat-containing lesion,

2:42

particularly ovarian teratomas.

2:46

T1-weighted imaging can also be useful

2:48

in identifying hemoperitoneum in patients

2:52

who have spontaneous intra-abdominal

2:54

hemorrhage in the context of endometriosis.

2:57

This is an axial fat-saturated T2-weighted image

3:00

of the abdomen in a patient who has a cystic,

3:04

multi-septated right abdominal wall

3:06

implant, in addition to a moderate

3:08

volume of abdominal ascites.

3:12

This is the T1 fat-saturated pre-contrast

3:15

image, and we can see that this lesion in the

3:17

right abdominal wall remains intrinsically

3:20

T1 hyperintense, in addition to the

3:23

ascites, which is actually hemoperitoneum.

3:26

So, this is a patient who has an

3:27

endometriotic implant in the abdominal

3:30

wall in addition to spontaneous

3:32

hemoperitoneum related to her endometriosis.

3:36

Another important consideration in patients

3:39

who are presenting with abdominal pelvic pain

3:42

in reproductive age is intrauterine devices.

3:45

Intrauterine devices are an extremely

3:47

effective method of birth control.

3:50

It's a foreign body, typically plastic or

3:52

sometimes made of copper, which is inserted

3:54

into the uterus and provides either hormonal

3:58

and/or mechanical irritation of the uterine

4:01

lining to prevent pregnancy from occurring.

4:05

Most IUDs are T-shaped, although some of the

4:08

older versions have more of a serpiginous

4:11

stacked hairpin turn appearance to them.

4:14

Ideal placement of an intrauterine

4:16

device is with the top of the T, the

4:19

arms or the crossbar near the uterine

4:21

fundus, and then the stem within the

4:23

endometrial cavity within the uterine body.

4:26

Complications of intrauterine

4:28

devices most commonly include

4:30

malpositioning, which can be painful.

4:33

The intrauterine devices can also become

4:35

embedded within the uterine myometrium

4:38

or occasionally perforate the uterus.

4:41

This is most common at the site

4:42

of a cesarean section scar.

4:45

It's important to identify a malpositioned

4:48

intrauterine device for two reasons.

4:50

One, because a malpositioned IUD may not

4:53

be providing effective birth control for

4:55

the patient, and also, depending on the

4:57

degree of embedment or malpositioning,

5:00

it may require removal under anesthesia

5:03

rather than in the gynecology office.

5:06

As I said, IUDs are extremely

5:08

effective, and so coexisting pregnancy

5:10

in a patient with an IUD is rare.

5:13

But the risk of a concomitant

5:14

pregnancy happening is highest in

5:16

the first year following placement.

5:19

Patients who become pregnant with an IUD

5:21

in place have a higher risk of preterm

5:23

labor, spontaneous abortion, and infection.

5:27

When an IUD is identified within the

5:29

uterus in a pregnant patient, the

5:31

management of the IUD really depends

5:34

on the gestational age of the fetus.

5:37

If the IUD is visualized in the first

5:39

trimester of pregnancy, the provider may

5:42

attempt to remove it in order to allow the

5:45

pregnancy to progress as safely as possible.

5:48

If the IUD is identified in the second or

5:50

third trimester of pregnancy, the risks of

5:53

removal may outweigh the benefits of removing

5:56

it, and this may need to be a pregnancy

5:58

that is just monitored more frequently.

6:01

Localizing the intrauterine device by

6:03

imaging is key in determining how and

6:07

whether the IUD should be removed.

6:10

One pearl that I want to share with

6:11

you is that all intrauterine devices,

6:14

whether they’re plastic or metallic,

6:16

will be radiopaque on imaging.

6:19

So these will look hyperdense

6:20

on CT or plain radiographs.

6:22

On ultrasound, because they are

6:24

relatively dense structures, they’ll

6:26

demonstrate posterior acoustic shadowing.

6:29

And then, because of the filament

6:31

within the plastic IUDs and the metallic

6:34

component of the copper IUDs, these will

6:36

be hypo intense or more apparent on T1

6:39

weighted imaging and gradient echo MRI.

6:43

Here are some examples of intrauterine

6:45

devices across imaging modalities.

6:48

This is an ultrasound image of the

6:50

pelvis in a patient with an IUD.

6:52

We can see echogenic components of the IUD,

6:56

which demonstrate posterior acoustic shadowing.

6:59

This is a 3D image of the uterus in a

7:02

patient who has a malpositioned IUD.

7:04

We can see that the arms are located

7:07

appropriately at the uterine fundus, but the

7:09

body of the IUD is exiting the endometrial

7:12

canal and is embedded in the uterine myometrium.

7:16

These are T1 weighted images of the pelvis.

7:19

In a patient who was unable to

7:21

locate her IUD strings, it was also

7:24

unable to be located on ultrasound.

7:26

And so again, on T1 weighted imaging or

7:28

gradient echo imaging, the intrauterine

7:31

device will become more apparent.

7:32

And so we can see a portion of the arms

7:35

here and here on MRI in this patient.

7:39

And then finally, this is an

7:40

appropriately positioned IUD on CT.

7:44

This is a classic T-shaped IUD, which

7:46

again looks radio dense on CT imaging.

7:49

And it's appropriately positioned within the

7:51

endometrial cavity near the uterine fundus.

7:55

To summarize, there is a myriad of causes

7:58

of abdominal pelvic pain and abdominal

8:00

pelvic pathology during pregnancy.

8:03

Using the clinical history and the

8:05

patient's symptoms will help you

8:07

guide your initial imaging approach.

8:10

Ultrasound is the first-line imaging

8:11

modality for evaluation of the

8:13

uterus, the ovaries, and the fetus.

8:16

Remember that appendicitis and renal stones are

8:19

common causes of non-obstetric abdominal pain

8:21

in pregnancy, and that MRI can serve as a useful

8:24

adjunct if you need to further characterize or

8:27

troubleshoot findings on your initial imaging.