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MR Imaging of Maternal Diseases of the Abdomen and Pelvis during Pregnancy and the Immediate Postpartum Period¹

¹ From the Department of Radiology, Wake Forest University Baptist Medical Center, Medical Center Blvd, Winston-Salem, NC 27157 (J.R.L.); and the Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (V.G., J.J.B.). Presented as an education exhibit at the 2003 RSNA scientific assembly. Received March 12, 2004; revision requested April 1 and received May 11; accepted May 12. All authors have no financial relationships to disclose. Address correspondence to J.R.L. (e-mail: jleyende@wfubmc.edu).

View larger version (144K): [in a new window]   Figure 1a.  Single-shot echo train spin-echo and steady-state gradient-echo imaging in a pregnant woman with clinical evidence of small-bowel obstruction. Arrow = fetus. (a) Coronal half-Fourier rapid acquisition with relaxation enhancement (RARE) image of the maternal abdomen shows fluid-filled loops of small intestine. (b) Coronal true fast imaging with steady-state precession (FISP) image clearly shows the dilated fluid-filled small intestine. The patient was admitted and treated conservatively.

View larger version (144K): [in a new window]   Figure 1b.  Single-shot echo train spin-echo and steady-state gradient-echo imaging in a pregnant woman with clinical evidence of small-bowel obstruction. Arrow = fetus. (a) Coronal half-Fourier rapid acquisition with relaxation enhancement (RARE) image of the maternal abdomen shows fluid-filled loops of small intestine. (b) Coronal true fast imaging with steady-state precession (FISP) image clearly shows the dilated fluid-filled small intestine. The patient was admitted and treated conservatively.

View larger version (116K): [in a new window]   Figure 2.  Renal MR angiography without intravenous contrast material for evaluation of hypertension at 31 weeks gestation. Coronal three-dimensional phase-contrast MR angiogram obtained without intravenous contrast material shows the main renal arteries and multiple branches, thus allowing exclusion of renal artery stenosis. The acquisition time was 4 minutes 9 seconds. The patient gave birth prematurely 2 weeks later, and the hypertension resolved afterward.

View larger version (137K): [in a new window]   Figure 3.  Choledocholithiasis in a 20-year-old woman with elevated liver enzyme levels and right upper quadrant pain at 34 weeks gestation. US failed to demonstrate the distal common bile duct. Coronal thick-slab MR cholangiopancreatogram shows an obstructing stone in the common bile duct (arrow). The patient subsequently underwent endoscopic stone removal. Note the hydronephrosis of pregnancy involving the right kidney (arrowhead).

View larger version (118K): [in a new window]   Figure 4a.  Hydronephrosis of pregnancy in a 25-year-old woman during the third trimester. (a) Coronal static thick-slab MR urogram shows severe right hydronephrosis (arrowhead). (b) Sagittal half-Fourier RARE image obtained through the right kidney shows tapering of the ureter (arrow) proximal to the site of compression by the uterus.

View larger version (148K): [in a new window]   Figure 4b.  Hydronephrosis of pregnancy in a 25-year-old woman during the third trimester. (a) Coronal static thick-slab MR urogram shows severe right hydronephrosis (arrowhead). (b) Sagittal half-Fourier RARE image obtained through the right kidney shows tapering of the ureter (arrow) proximal to the site of compression by the uterus.

View larger version (140K): [in a new window]   Figure 5a.  Small-bowel obstruction in a young woman with a history of abdominal surgery who presented to the emergency department during the third trimester with diffuse abdominal pain. (a) Axial half-Fourier RARE image shows a dilated small intestine (arrows), although the transition site could not be localized with certainty. (b) Coronal half-Fourier RARE image shows the site of obstruction in the jejunum (arrow). An obstructing adhesion was found at surgery.

View larger version (153K): [in a new window]   Figure 5b.  Small-bowel obstruction in a young woman with a history of abdominal surgery who presented to the emergency department during the third trimester with diffuse abdominal pain. (a) Axial half-Fourier RARE image shows a dilated small intestine (arrows), although the transition site could not be localized with certainty. (b) Coronal half-Fourier RARE image shows the site of obstruction in the jejunum (arrow). An obstructing adhesion was found at surgery.

View larger version (151K): [in a new window]   Figure 6a.  Crohn disease manifesting as abdominal pain during the late second trimester. (a) Coronal half-Fourier RARE image shows an abnormally thickened and narrowed left colon (arrows). (b) Coronal half-Fourier RARE image shows the distal extent of the colonic narrowing (arrow) and dilated proximal intestine (arrowhead).

View larger version (146K): [in a new window]   Figure 6b.  Crohn disease manifesting as abdominal pain during the late second trimester. (a) Coronal half-Fourier RARE image shows an abnormally thickened and narrowed left colon (arrows). (b) Coronal half-Fourier RARE image shows the distal extent of the colonic narrowing (arrow) and dilated proximal intestine (arrowhead).

View larger version (167K): [in a new window]   Figure 7.  Retroperitoneal abscess in an obese woman with a history of resected colon cancer 2.5 years earlier who presented to the emergency department at 30 weeks gestation with right flank pain. US was performed at another institution; the results were interpreted as showing a solid right renal mass. Coronal single-shot turbo spin-echo image shows that the abnormality actually consists of fluid (arrow), which displaces the kidney (arrowhead). The diagnosis of an abscess was confirmed at drainage, although the cause was not definitively ascertained.

View larger version (129K): [in a new window]   Figure 8a.  Hemorrhagic renal mass manifesting as acute right flank pain during the second trimester. US showed an echogenic mass, but the origin of the mass (adrenal vs renal) and its composition (fat vs hemorrhage) could not be determined. (a) Coronal T1-weighted gradient-echo image shows a heterogeneous mass with areas of high signal intensity (arrow) originating from the upper pole of the right kidney. (b) Coronal T1-weighted gradient-echo image obtained with fat suppression shows persistent bright areas (arrows), which represent hemorrhage, and a central dark area (arrowhead), which represents fat within the lesion. This case demonstrates the usefulness of multiplanar imaging and the ability of MR imaging to allow differentiation between fat and hemorrhage. The patient was treated conservatively and successfully gave birth but was lost to follow-up for 2 years. When she returned for evaluation of a subsequent pregnancy, repeat MR imaging showed no interval growth of the mass (which was interpreted as an angiomyolipoma) and complete resolution of the hemorrhage.

View larger version (141K): [in a new window]   Figure 8b.  Hemorrhagic renal mass manifesting as acute right flank pain during the second trimester. US showed an echogenic mass, but the origin of the mass (adrenal vs renal) and its composition (fat vs hemorrhage) could not be determined. (a) Coronal T1-weighted gradient-echo image shows a heterogeneous mass with areas of high signal intensity (arrow) originating from the upper pole of the right kidney. (b) Coronal T1-weighted gradient-echo image obtained with fat suppression shows persistent bright areas (arrows), which represent hemorrhage, and a central dark area (arrowhead), which represents fat within the lesion. This case demonstrates the usefulness of multiplanar imaging and the ability of MR imaging to allow differentiation between fat and hemorrhage. The patient was treated conservatively and successfully gave birth but was lost to follow-up for 2 years. When she returned for evaluation of a subsequent pregnancy, repeat MR imaging showed no interval growth of the mass (which was interpreted as an angiomyolipoma) and complete resolution of the hemorrhage.

View larger version (124K): [in a new window]   Figure 9a.  Pyelonephritis in a young woman with hypercoagulable state, pulmonary embolism, and right flank pain during the second trimester. Renal vein thrombosis was suspected at clinical evaluation. (a) Axial fat-suppressed T2-weighted gradient- and spin-echo image shows an enlarged, edematous right kidney with striated signal intensity (arrow). The atrophic left kidney (arrowhead) resulted from a prior ischemic event. (b) Axial targeted maximum intensity projection image from time-of-flight MR angiography shows a patent renal vein (arrow). A urine culture yielded Escherichia coli.

View larger version (121K): [in a new window]   Figure 9b.  Pyelonephritis in a young woman with hypercoagulable state, pulmonary embolism, and right flank pain during the second trimester. Renal vein thrombosis was suspected at clinical evaluation. (a) Axial fat-suppressed T2-weighted gradient- and spin-echo image shows an enlarged, edematous right kidney with striated signal intensity (arrow). The atrophic left kidney (arrowhead) resulted from a prior ischemic event. (b) Axial targeted maximum intensity projection image from time-of-flight MR angiography shows a patent renal vein (arrow). A urine culture yielded Escherichia coli.

View larger version (140K): [in a new window]   Figure 10a.  HELLP syndrome in a 24-year-old woman who recently gave birth. (a) Axial T1-weighted gradient-echo image obtained through the liver shows a large subcapsular fluid collection containing blood products (arrow), a finding consistent with a hematoma. (b) Coronal gadolinium-enhanced T1-weighted gradient-echo image shows the hematoma (arrow) as well as poorly perfused areas of developing hepatic necrosis (arrowhead). Splenic and intrathoracic hemorrhage also developed, but the patient eventually recovered.

View larger version (141K): [in a new window]   Figure 10b.  HELLP syndrome in a 24-year-old woman who recently gave birth. (a) Axial T1-weighted gradient-echo image obtained through the liver shows a large subcapsular fluid collection containing blood products (arrow), a finding consistent with a hematoma. (b) Coronal gadolinium-enhanced T1-weighted gradient-echo image shows the hematoma (arrow) as well as poorly perfused areas of developing hepatic necrosis (arrowhead). Splenic and intrathoracic hemorrhage also developed, but the patient eventually recovered.

View larger version (133K): [in a new window]   Figure 11.  Gastric adenocarcinoma in a young woman who was referred for MR imaging during the third trimester for evaluation of a gastric mass. Extent of the mass could not be ascertained with endoscopy. Coronal half-Fourier RARE image shows a large tumor (arrow) extending into the gastric lumen. Serosal involvement was found at surgery, although no uterine involvement was detected with imaging or at surgery. Arrowhead = fetal bladder.

View larger version (126K): [in a new window]   Figure 12a.  Mature ovarian cystic teratoma at 9 weeks gestation. Routine obstetric US demonstrated a large right adnexal mass. (a) Axial T1-weighted image shows a heterogeneous right adnexal mass with predominantly high signal intensity (arrow). A normal right ovary was not identified with any sequence. (b) Axial T1-weighted image obtained with fat suppression shows suppression of the high-signal-intensity areas within the mass (arrow), confirming the diagnosis of teratoma. We do not routinely perform MR imaging during the first trimester. In this case, the referring obstetrician thought the clinical indication was sufficiently compelling, and consent was obtained from the patient. The mass was surgically removed during pregnancy.

View larger version (138K): [in a new window]   Figure 12b.  Mature ovarian cystic teratoma at 9 weeks gestation. Routine obstetric US demonstrated a large right adnexal mass. (a) Axial T1-weighted image shows a heterogeneous right adnexal mass with predominantly high signal intensity (arrow). A normal right ovary was not identified with any sequence. (b) Axial T1-weighted image obtained with fat suppression shows suppression of the high-signal-intensity areas within the mass (arrow), confirming the diagnosis of teratoma. We do not routinely perform MR imaging during the first trimester. In this case, the referring obstetrician thought the clinical indication was sufficiently compelling, and consent was obtained from the patient. The mass was surgically removed during pregnancy.

View larger version (118K): [in a new window]   Figure 13.  Leiomyosarcoma at 26 weeks gestation. US showed a left-sided pelvic mass, but the origin and extent of the mass could not be determined. Coronal fat-suppressed T2-weighted image shows a bilobed high-signal-intensity mass (arrows), which appears to be contiguous to the uterus. On the basis of the MR imaging findings, the diagnosis of leiomyoma was suggested; however, a myxoid leiomyosarcoma was found at surgery 2 days later.

View larger version (156K): [in a new window]   Figure 14.  Obstructing leiomyoma in a 27-year-old woman with an elevated level of ß-human chorionic gonadotropin and uncertain gestational dates. US did not allow adequate visualization of the uterine contents or pelvic structures. Sagittal T2-weighted image shows a large leiomyoma in the lower uterus (arrow). The tumor occupies most of the pelvis, creating a potential impediment to delivery.

View larger version (140K): [in a new window]   Figure 15a.  Uterus didelphys with pyocolpos at 20 weeks gestation. The patient was referred for MR imaging because of purulent discharge from the vagina and uncertain uterine anatomy at US. (a) Sagittal T2-weighted image shows a gravid uterus containing a fetus in addition to a second uterine horn (straight arrow). Fluid fills the obstructed vagina of the nongravid uterus (arrowhead). The fluid collection communicates with the patent vagina via a small fistula (curved arrow), which was confirmed in the operating room. (b) Coronal half-Fourier RARE image shows that the nongravid uterine horn is on the left side (arrow). (c) Coronal half-Fourier RARE image obtained through the abdomen shows absence of the left kidney (arrow). The renal agenesis is on the same side as the obstructed vagina and nongravid uterine horn.

View larger version (126K): [in a new window]   Figure 15b.  Uterus didelphys with pyocolpos at 20 weeks gestation. The patient was referred for MR imaging because of purulent discharge from the vagina and uncertain uterine anatomy at US. (a) Sagittal T2-weighted image shows a gravid uterus containing a fetus in addition to a second uterine horn (straight arrow). Fluid fills the obstructed vagina of the nongravid uterus (arrowhead). The fluid collection communicates with the patent vagina via a small fistula (curved arrow), which was confirmed in the operating room. (b) Coronal half-Fourier RARE image shows that the nongravid uterine horn is on the left side (arrow). (c) Coronal half-Fourier RARE image obtained through the abdomen shows absence of the left kidney (arrow). The renal agenesis is on the same side as the obstructed vagina and nongravid uterine horn.

View larger version (143K): [in a new window]   Figure 15c.  Uterus didelphys with pyocolpos at 20 weeks gestation. The patient was referred for MR imaging because of purulent discharge from the vagina and uncertain uterine anatomy at US. (a) Sagittal T2-weighted image shows a gravid uterus containing a fetus in addition to a second uterine horn (straight arrow). Fluid fills the obstructed vagina of the nongravid uterus (arrowhead). The fluid collection communicates with the patent vagina via a small fistula (curved arrow), which was confirmed in the operating room. (b) Coronal half-Fourier RARE image shows that the nongravid uterine horn is on the left side (arrow). (c) Coronal half-Fourier RARE image obtained through the abdomen shows absence of the left kidney (arrow). The renal agenesis is on the same side as the obstructed vagina and nongravid uterine horn.

View larger version (173K): [in a new window]   Figure 16a.  Hydatidiform mole in a 22-year-old woman who presented at 10 weeks gestation with an elevated level of ß-human chorionic gonadotropin and no visible gestational sac at US. (a, b) T2-weighted images obtained in the coronal (a) and axial (b) planes relative to the uterus show heterogeneous but predominantly high-signal-intensity material filling the uterine cavity (arrow). No gestational sac is present. (c) Axial unenhanced fat-suppressed T1-weighted image shows that the uterine contents have increased signal intensity (arrow). A complete molar pregnancy was confirmed at pathologic analysis.

View larger version (126K): [in a new window]   Figure 16b.  Hydatidiform mole in a 22-year-old woman who presented at 10 weeks gestation with an elevated level of ß-human chorionic gonadotropin and no visible gestational sac at US. (a, b) T2-weighted images obtained in the coronal (a) and axial (b) planes relative to the uterus show heterogeneous but predominantly high-signal-intensity material filling the uterine cavity (arrow). No gestational sac is present. (c) Axial unenhanced fat-suppressed T1-weighted image shows that the uterine contents have increased signal intensity (arrow). A complete molar pregnancy was confirmed at pathologic analysis.

View larger version (141K): [in a new window]   Figure 16c.  Hydatidiform mole in a 22-year-old woman who presented at 10 weeks gestation with an elevated level of ß-human chorionic gonadotropin and no visible gestational sac at US. (a, b) T2-weighted images obtained in the coronal (a) and axial (b) planes relative to the uterus show heterogeneous but predominantly high-signal-intensity material filling the uterine cavity (arrow). No gestational sac is present. (c) Axial unenhanced fat-suppressed T1-weighted image shows that the uterine contents have increased signal intensity (arrow). A complete molar pregnancy was confirmed at pathologic analysis.

View larger version (135K): [in a new window]   Figure 17.  Placenta previa manifesting as vaginal bleeding at 30 weeks gestation. Sagittal T2-weighted image shows the placenta completely covering the internal cervical os (arrow), an appearance consistent with complete central previa.

View larger version (132K): [in a new window]   Figure 18a.  Placenta percreta in a 31-year-old woman with a history of two cesarean sections. At 28 weeks gestation, the patient was referred for evaluation of a placenta that appeared abnormal at US. Coronal T2-weighted images (a obtained posterior to b) show disruption of the normally continuous low-signal-intensity bladder dome (arrow), an appearance consistent with placenta percreta. The obstetrician was notified before cesarean section about the likelihood of placenta percreta, although the exact longitudinal extent of invasion was uncertain before surgery. During surgery, placental invasion of the midline bladder was confirmed and resulted in extensive cystotomy.

View larger version (133K): [in a new window]   Figure 18b.  Placenta percreta in a 31-year-old woman with a history of two cesarean sections. At 28 weeks gestation, the patient was referred for evaluation of a placenta that appeared abnormal at US. Coronal T2-weighted images (a obtained posterior to b) show disruption of the normally continuous low-signal-intensity bladder dome (arrow), an appearance consistent with placenta percreta. The obstetrician was notified before cesarean section about the likelihood of placenta percreta, although the exact longitudinal extent of invasion was uncertain before surgery. During surgery, placental invasion of the midline bladder was confirmed and resulted in extensive cystotomy.

View larger version (120K): [in a new window]   Figure 19a.  Retained products of conception in a postpartum woman with vaginal bleeding who was referred for evaluation of a possible uterine arteriovenous malformation. (a) Coronal gadolinium-enhanced T1-weighted image obtained at another institution shows enhancing tissue within the endometrial cavity (arrow). (b) Coronal arterial phase gadolinium-enhanced MR angiogram from the same study shows increased vascularity of the uterus (arrow). This finding was thought to represent a uterine arteriovenous malformation. Subsequent dilation and curettage revealed retained products of conception, and MR imaging was repeated after 6 weeks. (c) Repeat coronal gadolinium-enhanced MR angiogram shows normal pelvic vascularity. (d) Repeat sagittal T2-weighted image shows a normal endometrium (arrow).

View larger version (103K): [in a new window]   Figure 19b.  Retained products of conception in a postpartum woman with vaginal bleeding who was referred for evaluation of a possible uterine arteriovenous malformation. (a) Coronal gadolinium-enhanced T1-weighted image obtained at another institution shows enhancing tissue within the endometrial cavity (arrow). (b) Coronal arterial phase gadolinium-enhanced MR angiogram from the same study shows increased vascularity of the uterus (arrow). This finding was thought to represent a uterine arteriovenous malformation. Subsequent dilation and curettage revealed retained products of conception, and MR imaging was repeated after 6 weeks. (c) Repeat coronal gadolinium-enhanced MR angiogram shows normal pelvic vascularity. (d) Repeat sagittal T2-weighted image shows a normal endometrium (arrow).

View larger version (115K): [in a new window]   Figure 19c.  Retained products of conception in a postpartum woman with vaginal bleeding who was referred for evaluation of a possible uterine arteriovenous malformation. (a) Coronal gadolinium-enhanced T1-weighted image obtained at another institution shows enhancing tissue within the endometrial cavity (arrow). (b) Coronal arterial phase gadolinium-enhanced MR angiogram from the same study shows increased vascularity of the uterus (arrow). This finding was thought to represent a uterine arteriovenous malformation. Subsequent dilation and curettage revealed retained products of conception, and MR imaging was repeated after 6 weeks. (c) Repeat coronal gadolinium-enhanced MR angiogram shows normal pelvic vascularity. (d) Repeat sagittal T2-weighted image shows a normal endometrium (arrow).

View larger version (121K): [in a new window]   Figure 19d.  Retained products of conception in a postpartum woman with vaginal bleeding who was referred for evaluation of a possible uterine arteriovenous malformation. (a) Coronal gadolinium-enhanced T1-weighted image obtained at another institution shows enhancing tissue within the endometrial cavity (arrow). (b) Coronal arterial phase gadolinium-enhanced MR angiogram from the same study shows increased vascularity of the uterus (arrow). This finding was thought to represent a uterine arteriovenous malformation. Subsequent dilation and curettage revealed retained products of conception, and MR imaging was repeated after 6 weeks. (c) Repeat coronal gadolinium-enhanced MR angiogram shows normal pelvic vascularity. (d) Repeat sagittal T2-weighted image shows a normal endometrium (arrow).

View larger version (138K): [in a new window]   Figure 20a.  Uterine dehiscence in a 24-year-old woman with vaginal bleeding and pelvic pain approximately 1 month after cesarean section. US findings were suggestive of a blood clot anterior to the uterus, but a myometrial defect could not be identified. (a) Sagittal T2-weighted image shows a large, anterior, transmural myometrial defect (arrows). No normal myometrial coverage is visible, and an adjacent complex fluid collection is present. (b) Axial fat-suppressed T1-weighted image shows that the fluid anterior to the uterus has high signal intensity (arrow), a finding consistent with blood products. At surgery, transmural myometrial necrosis was present in addition to retained placental tissue, which was suspicious for placenta accreta.

View larger version (140K): [in a new window]   Figure 20b.  Uterine dehiscence in a 24-year-old woman with vaginal bleeding and pelvic pain approximately 1 month after cesarean section. US findings were suggestive of a blood clot anterior to the uterus, but a myometrial defect could not be identified. (a) Sagittal T2-weighted image shows a large, anterior, transmural myometrial defect (arrows). No normal myometrial coverage is visible, and an adjacent complex fluid collection is present. (b) Axial fat-suppressed T1-weighted image shows that the fluid anterior to the uterus has high signal intensity (arrow), a finding consistent with blood products. At surgery, transmural myometrial necrosis was present in addition to retained placental tissue, which was suspicious for placenta accreta.