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Ectopic Pregnancy Showing Interesting Findings on MR Imaging

Kobe University School of Medicine Kobe 650-0017, Japan
Kawasaki Medical School Okayama 701-0192, Japan

Transvaginal sonography and MR imaging combined with a positive finding on a human chorionic gonadotropin test are often useful in the diagnosis of ectopic pregnancy. We report a case of ectopic pregnancy showing interesting MR findings.

A 40-year-old woman, gravida 1, para 0, presented with acute abdominal pain. Laboratory data showing severe anemia (hemoglobin, 5.0 g/dL) and a positive finding on a human chorionic gonadotropin test made ruptured ectopic pregnancy a possible diagnostic concern. Sonography could not disclose a definitive gestational sac or a fetus and revealed a heterogeneous solid mass around the left adnexa. MR imaging, which was performed to rule out a left adnexal tumor, showed a well-demarcated large mass measuring 13 x 10 x 8 cm located outside and adjacent to the left-posterior side of the uterus. The mass showed distinctive signal patterns consisting of various intensities on T1- and T2-weighted images lying concentrically like onion peels. Intermediate signal intensity on T1-weighted images and low signal intensity on T2-weighted images suggested acute hemorrhage, and high signal intensity on T1- and T2-weighted images suggested chronic hemorrhage (Figs. 3A and 3B). In the center of the mass, there appeared to be a fluid area showing low and high signal intensities on T1- and T2-weighted images, respectively. A soft-tissue nodular component was also suspected in the fluid area. These findings were not typical of any neoplasm and were suggestive of ectopic pregnancy with recurrent hemorrhage. However, the clinical information—indicating the patient's last menstrual period had occurred 4 weeks earlier—left the diagnosis more confusing.

View larger version (180K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A. —40-year-old woman with acute lower abdominal pain. T1-weighted sagittal MR image shows mass of intermediate and high signal intensities lying concentrically like onion peels. In center of mass, low-signal-intensity area is visualized, which contains nodule of intermediate signal intensity (arrow).

View larger version (168K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B. —40-year-old woman with acute lower abdominal pain. T2-weighted sagittal MR image also shows concentric signal pattern consisting of low and high signal intensities. In center of mass, high-signal-intensity area is visualized, which contains nodule of high signal intensity (arrow).

Laparotomy revealed a hematoma adjacent to the left fallopian tube, and a fetus at 8-9 weeks' gestation was observed on the cut surface of the resected hematoma (Fig. 3C). Thus, the definitive diagnosis was ectopic pregnancy. The patient's last vaginal bleeding was considered to have been abnormal bleeding occurring incidentally at the same time as expected regular menstruation. There were no histologic findings of chorionic villi in the fallopian tube, and the fimbriae tubae uterinae seemed to be the most likely site of development of the ectopic pregnancy.

View larger version (85K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C. —40-year-old woman with acute lower abdominal pain. Cut surface of resected hematoma shows fetus at 8-9 weeks' gestation (arrow).

In general, sonography combined with a positive finding on a human chorionic gonadotropin test can establish the diagnosis in most patients with ectopic pregnancy [1], and MR imaging may be omitted in cases of acute abdominal emergency. This may be why published MR findings of ectopic pregnancy have been limited [2]. The diagnosis is easily established when a gestational sac and a fetus are visualized. Otherwise, although a hemorrhagic lesion or tubal wall enhancement is suggestive of possible ectopic pregnancy [3, 4], MR imaging findings cannot always suggest a specific diagnosis. In the current patient, postoperative examination revealed that the fluid area in the center of the mass corresponded to the gestational sac, and the soft-tissue component was considered to correspond to some part of the fetus or the umbilical cord. To our knowledge, there are no reports in the radiology literature of such a large and localized hematoma associated with ectopic pregnancy. It is interesting that such a hematoma developed with little ascites, which seems to be clinically rare.

References

1. Brown DL, Doubilet PM. Transvaginal sonography for diagnosing ectopic pregnancy: positivity criteria and performance characteristics. J Ultrasound Med 1994;13:259 -266[Abstract]
2. Ha HK, Jung JK, Kang SJ, et al. MR imaging in the diagnosis of rare forms of ectopic pregnancy. AJR 1993;160:1229 -1232[Free Full Text]
3. Kataoka ML, Togashi K, Kobayashi H, Inoue T, Fujii S, Konishi J. Evaluation of ectopic pregnancy by magnetic resonance imaging. Hum Reprod 1999;14:2644 -2650[Abstract/Free Full Text]
4. Nyberg DA, Porter BA, Olds MO, Olson DO, Andersen R, Wesby GE. MR imaging of hemorrhagic adnexal masses. J Comput Assist Tomogr 1987;11:664 -669[Medline]

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This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Yoden, E. Articles by Kohno, I. Search for Related Content PubMed PubMed Citation Articles by Yoden, E. Articles by Kohno, I. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?