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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.