Emergent MRI for acute abdominal pain in pregnancy-review of common pathology and imaging appearance

MRI as an alternative to CT after inconclusive ultrasound in subacute/acute abdominal pain in young women: a prospective multicenter noninferiority study

OBJECTIVE

To assess the noninferiority of MRI diagnostic accuracy to CT scan as a second-line examination of acute/subacute abdominopelvic pain in a population of young women after an inconclusive ultrasound (US).

METHODS

This prospective, multicenter non-inferiority study included 18-40-year-old non-pregnant women with non-traumatic acute/subacute abdominal pain. They had an inconclusive US warranting the prescription of an additional CT scan. Within 6 h of the CT, all these women underwent abdomino-pelvic MRI. A retrospective reading of the CT and MR provided a diagnosis using a standardized list. The gold standard diagnosis, based on a 3-month follow-up, was done by a panel of experts. Statistical analysis was conducted to assess the noninferiority of the diagnostic accuracy of MRI compared to that of CT. The noninferiority margin was set at 10%. Inter-observer agreement and diagnostic performance of a conditional imaging strategy were estimated.

RESULTS

133 participants were analyzed (median: 27 years). The most common diagnoses were non-specific pain (30.1%), ovarian cyst rupture (12.8%), and appendicitis (9.7%). MRI demonstrated non-inferiority diagnostic accuracy estimated between 60.9% (81/133) and 88% (117/133) compared to CT, estimated between 64.7% (86/133) and 83.5% (111/133). The conditional imaging strategy (MRI, followed by CT when the MRI was normal) had a diagnostic accuracy of 91%.

CONCLUSION

MRI diagnostic performances are not inferior to CT for acute abdominal pain in women aged 18-40. A conditional imaging strategy based on MRI would give an accuracy of 91% and might be considered a second-line imaging modality in that context.

KEY POINTS

Question Can MRI serve as an alternative to CT as a second-line imaging modality for acute abdominopelvic pain in young women (18-40) after an inconclusive ultrasound? Findings MRI accuracy after inconclusive US ranged from 60.9 to 88%. A conditional strategy (MRI first, CT if normal) reached 91% accuracy, avoiding 59% of CTs. Clinical relevance MRI is not inferior to CT for diagnosing uncategorized causes of acute abdomino-pelvic pain in young non-pregnant women. A conditional imaging strategy based on MRI as a second-line imaging modality would give an accuracy of 91%.

How MRI imaging for an ovarian cyst led to diagnosis of short cervix

BACKGROUND

Magnetic resonance imaging (MRI) during pregnancy is a growing diagnostic modality for a variety of different indications including fetal anomalies and maternal masses. A literature search did not find any case reports diagnosing a short cervix on MRI before 20 weeks gestation.

CASE PRESENTATION

A 34-year-old female underwent magnetic resonance imaging for further evaluation of a known ovarian cyst which demonstrated a multiseptated cystic mass measuring 15.5 × 9.9 × 18.5 cm in the right adnexa at 19 weeks gestation. An incidental finding on MRI of "bulging of membranes into the cervical canal to the level of the external os" was noted. The patient had 3 prior full-term cesarean deliveries with no history of short cervix. Ultrasound confirmed dilated cervix with no measurable cervix. The patient underwent a rescue cerclage.

CONCLUSION

This case describes an unmeasurable cervix diagnosed incidentally during an MRI to characterize a large adnexal mass. In pregnancy, MRI can be a useful imaging modality to evaluate fetal anatomy, placental position and implantation, and abdominal and pelvic structures. In this case, evaluation of the uterus and cervix during imaging for an adnexal mass allowed for detection of an unmeasurable cervix and intervention with a rescue cerclage.

Case report: A rare cause of intestinal perforation in a third-trimester pregnant woman

Background

An acute abdomen is a medical emergency that requires early diagnosis and treatment. In pregnancy, this process is significantly more challenging, and radiological findings are sometimes unclear due to the enlarged uterus displacing other structures. Moreover, endometriosis-related complications are rare, and the disease is often undiagnosed.

Case presentation

We report a case of acute perforation of the cecum and appendix during pregnancy (35 weeks of gestation) caused by a previously unknown, deep infiltrating endometriosis with focal ulceration of the affected bowel wall, which sonographically seemed to be acute appendicitis.

Conclusion

Despite the relatively low risk, clinicians should be aware of possible endometriosis-associated complications in pregnancy with potentially life-threatening events, even in previously unknown endometriosis. Further studies should evaluate intestinal complications during pregnancy in relation to previous treatment of intestinal endometriosis (conservative vs. surgical).

Findings on emergent magnetic resonance imaging in pregnant patients with suspected appendicitis: A single center perspective

This study's aim is to describe the imaging findings in pregnant patients undergoing emergent MRI for suspected acute appendicitis, and the various alternative diagnoses seen on those MRI scans. This is a single center retrospective analysis in which we assessed the imaging, clinical and pathological data for all consecutive pregnant patients who underwent emergent MRI for suspected acute appendicitis between April 2013 and June 2021. Out of 167 patients, 35 patients (20.9%) were diagnosed with acute appendicitis on MRI. Thirty patients (18%) were diagnosed with an alternative diagnosis on MRI: 17/30 (56.7%) patients had a gynecological source of abdominal pain (e.g. ectopic pregnancy, red degeneration of a leiomyoma); 8 patients (26.7%) had urological findings such as pyelonephritis; and 6 patients (20%) had gastrointestinal diagnoses (e.g. abdominal wall hernia or inflammatory bowel disease). Our conclusions are that MRI is a good diagnostic tool in the pregnant patient, not only in diagnosing acute appendicitis, but also in providing information on alternative diagnoses to acute abdominal pain. Our findings show the various differential diagnoses on emergent MRI in pregnant patients with suspected acute appendicitis, which may assist clinicians and radiologists is patient assessment and imaging utilization.

Midgut Volvulus in Disguise: Acute Abdomen in Early Pregnancy

Small bowel obstruction (SBO) in pregnancy is a challenging diagnosis. Case rarity, non-specific presentations, and the non-practicality of using X-ray/gamma-ray imaging modalities in pregnancy contribute to the increased difficulty in timely diagnosing midgut volvulus during pregnancy, thereby increasing maternal and fetal morbidity. We report a case of midgut volvulus in a 39-year-old lady, gravida 3, para 2, with two previous cesarean sections. Her only presenting complaint was abdominal pain for three days with no other associated symptoms. The case was successfully diagnosed using magnetic resonance imaging (MRI) and subsequently treated surgically by segmental resection with side-to-side ileocecal anastomosis, thereby saving the mother and fetus. Clinicians should have a low threshold of suspicion of the varied causes of SBO in pregnancy, particularly in patients with prior abdominopelvic surgeries. Imaging is central to preoperative diagnosis, and MRI has gained popularity with safety and accuracy comparable to computed tomography. Management aims at minimizing maternal and fetal morbidity and mortality.

A rare case of small intestine torsion in pregnancy

Article's main point: This article retrospectively analyzed the clinical data of a patient with small bowel torsion during pregnancy to provide ideas for diagnosing and treating small bowel torsion during pregnancy. This case of pregnancy with small intestinal volvulus gives us the following tips in the diagnosis and treatment: 1) During pregnancy, the abdominal signs of pregnant women are usually atypical, especially in the middle and late stages of pregnancy. Diagnosing intestinal torsion is often tricky and can easily be confused with obstetric emergencies such as threatened abortion, preterm labor pain, placental abruption, and uterine rupture. It is also difficult to distinguish from surgical emergencies such as acute pancreatitis, acute appendicitis, and gastrointestinal perforation. When pregnant women experience nausea, vomiting, and abdominal pain, intestinal torsion should be considered in the differential diagnosis. 2) Abdominal CT, X-ray, and other radiological examinations may cause fetal tissue damage and dysfunction. In addition, ultrasound diagnosis is also limited by the enlarged uterus, patient conditions, and scanning scope, which has a certain risk of missed diagnosis and misdiagnosis. MRI has become an important diagnostic tool for acute abdomen in pregnancy because of its non-radiation and high resolution. 3) Intestinal torsion during pregnancy is often difficult to self-reposition and can lead to intestinal necrosis in a short time. In such cases, surgical treatment is usually the first choice. For pregnant women with acute abdomen, we should adhere to the principles of diagnosis and treatment of the acute surgical abdomen, master the indications of surgical exploration such as peritonitis, and perform surgical treatment in time to avoid further deterioration of the condition and reduce the risk of fetal loss.

Acute Abdomen in Pregnancy: A Comprehensive Review of Diagnosis and Management

An unusual diagnostic and treatment challenge is presented by an acute abdomen during pregnancy. Obstetric factors and other causes unrelated to pregnancy also contribute to acute abdominal discomfort in pregnancy. Due to the changing clinical presentations brought on by the anatomical and physiological changes of pregnancy as well as the hesitation to utilize certain radiological studies out of concern about damaging the fetus, the diagnosis of the acute abdomen during pregnancy can be challenging. Delays in identification and treatment may have negative effects on the mother as well as the fetus. This review sheds light on the importance of anatomical and physiological considerations, early diagnoses, and understanding the various modalities and etiologies of acute abdomen in pregnancy (AAP). We then move on to discuss the various diagnostic techniques that can help the physician determine the causes and plan well-informed treatment. We examine and contrast different radiographic tests, including X-rays, computed tomography, magnetic resonance imaging, and ultrasound. We also talk about the various roles that these investigational methods can play in the evaluation and treatment throughout the duration of the pregnancy. The paper additionally addresses how to handle patients who appear with AAP and the different techniques used to treat them, including pre-operative laparoscopy. Before going over some more broad points that might be useful, we eventually dive into some of the more intriguing etiologies relating to AAP, such as isolated tubal torsion and neoplastic complications.

MR imaging of acute abdominal pain in pregnancy

Abdominal pain in pregnancy is a diagnostic challenge with many potential aetiologies. Diagnostic imaging is a valuable tool in the assessment of these patients, with ultrasound commonly employed first line. MRI is an excellent problem-solving adjunct to ultrasound and has many advantages in terms of improved spatial resolution and soft tissue characterisation. This pictorial review aims to outline the role of MRI in the work up of acute abdominal pain in pregnancy and provide imaging examples of pathologies which may be encountered.

Role of Ultrasound in the Assessment and Differential Diagnosis of Pelvic Pain in Pregnancy

Pelvic pain (PP) is common in pregnant women and can be caused by several diseases, including obstetrics, gynaecological, gastrointestinal, genitourinary, and vascular disorders. Timely and accurate diagnosis as well as prompt treatment are crucial for the well-being of the mother and foetus. However, these are very challenging. It should be considered that the physiological changes occurring during pregnancy may confuse the diagnosis. In this setting, ultrasound (US) represents the first-line imaging technique since it is readily and widely available and does not use ionizing radiations. In some cases, US may be conclusive for the diagnosis (e.g., if it detects no foetal cardiac activity in suspected spontaneous abortion; if it shows an extrauterine gestational sac in suspected ectopic pregnancy; or if it reveals a dilated, aperistaltic, and blind-ending tubular structure arising from the cecum in suspicious of acute appendicitis). Magnetic resonance imaging (MRI), overcoming some limits of US, represents the second-line imaging technique when an US is negative or inconclusive, to detect the cause of bowel obstruction, or to characterize adnexal masses.