AJR 2001; 177:1293-1300
© American Roentgen Ray Society
MR Imaging of Maternal Diseases in Pregnancy
Seung Eun Jung1,
Jae Young Byun2,
Jae Mun Lee1,
Sung Eun Rha2,
Hyun Kim3,
Byung Gil Choi2 and
Seong Tai Hahn1
1
Department of Radiology, St. Mary's Hospital, The Catholic University of
Korea, 62 Youido-dong Yongdungpo-gu, Seoul 150-713, Korea.
2
Department of Radiology, Kangnam St. Mary's Hospital, The Catholic University
of Korea, 505 Banpo-dong, Seocho-gu, Seoul 137-040, Korea.
3
Department of Radiology, Daejeon St. Mary's Hospital, The Catholic University
of Korea, 520-2 Daeheung-dong, Choong-gu, Daejeon 301-723, Korea.
Received February 1, 2001;
accepted after revision May 30, 2001.
Address correspondence to J. Y. Byun.
Introduction
The types of imaging techniques that can be used for pregnant patients are
limited because of the potential risks to the fetus. Sonography is the imaging
technique of choice for prenatal assessment. Like sonography, MR imaging does
not expose patients to ionizing radiation, and, to our knowledge, no clinical
or experimental evidence exists of teratogenic or other adverse fetal effects
of MR imaging during pregnancy. Furthermore, the advantages of MR imaging
include unsurpassed soft-tissue contrast enhancement and multiplanar imaging
capabilities. Therefore, MR imaging is suitable for maternal imaging during
pregnancy and is now considered to be an important imaging modality adjunct to
sonography for evaluation of abnormalities in pregnant patients
[1,2,3].
Most of the recent articles regarding MR imaging in pregnancy have focused on
fetal abnormalities. This essay discusses current applications of MR imaging
and MR imaging findings of maternal diseases of the uterus and adnexa in
pregnancy.
Spontaneous Abortion
It is often not possible to differentiate clinically between spontaneous
abortion and ectopic pregnancy. On MR imaging, the appearance of the missed,
or incomplete, abortion is a still-bulky uterus and perhaps an expanded
endometrial cavity caused by bleeding or retained products of conception.
After gadolinium injection, retained fetoplacental tissues are densely
enhanced [4,
5] (Figs.
1A,1B,1C
and
2A,2B).
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Fig. 1A. —Missed abortion in 31-year-old woman with amenorrhea for 7
weeks, 3 days. Axial T1-weighted (TR/TE, 566/11) (A) and T2-weighted
(2000/80) (B) spin-echo images show widening of endometrial cavity with
hemorrhage (arrows).
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Fig. 1B. —Missed abortion in 31-year-old woman with amenorrhea for 7
weeks, 3 days. Axial T1-weighted (TR/TE, 566/11) (A) and T2-weighted
(2000/80) (B) spin-echo images show widening of endometrial cavity with
hemorrhage (arrows).
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Fig. 1C. —Missed abortion in 31-year-old woman with amenorrhea for 7
weeks, 3 days. Axial enhanced T1-weighted spin-echo image (483/11) shows
well-enhanced fetoplacental remnant (arrow) in endometrial
cavity.
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Fig. 2A. —Incomplete abortion in 42-year-old woman at 31 weeks'
gestation. Sagittal T2-weighted fast spin-echo image (TR/TE, 3785/132) shows
mixed heterogeneous mass occupying and dilating endometrial cavity
(arrows).
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Fig. 2B. —Incomplete abortion in 42-year-old woman at 31 weeks'
gestation. Sagittal enhanced T1-weighted fast spin-echo image (612/14) shows
densely enhancing fetoplacental tissues (arrows) in mass in
endometrial cavity.
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Ectopic Pregnancy
The diagnosis of an ectopic pregnancy is based on the findings of an
extrauterine embryo and an empty uterus. MR imaging can define both of these
findings and is used as a problem-solving tool after sonography. Ectopic
pregnancy is classified as either tubal or nontubal pregnancy, depending on
its location. In tubal pregnancy, the remaining fetoplacental tissue can
present as an adnexal mass showing mixed or increased signal intensity on
T1-weighted images and heterogeneity on T2-weighted images with densely
enhancing papillary solid components after administration of contrast material
[5] (Fig.
3A,3B).
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Fig. 3A. —Tubal pregnancy in 34-year-old woman with amenorrhea for 10
weeks and lower abdominal pain. Sagittal T2-weighted fast spin-echo image
(TR/TE, 5600/128) shows left adnexal mass with heterogeneous signal intensity
(arrows), representing hemorrhagic mass.
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Fig. 3B. —Tubal pregnancy in 34-year-old woman with amenorrhea for 10
weeks and lower abdominal pain. Sagittal enhanced T1-weighted fast spin-echo
image (890/14) shows peripheral rim enhancement and enhancing papillary solid
components (arrowheads), indicating remnants of fetoplacental
tissues.
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The nontubal forms of ectopic pregnancy account for approximately 1% of
ectopic pregnancies and are life-threatening. Sonographic diagnosis of the
uterine forms of ectopic pregnancy involving the cervix or the interstitial or
intramural regions may be difficult. MR imaging is especially useful in
diagnosing this rare condition in patients whose clinical findings are of low
suspicion. In patients with the uterine form, the abnormal gestational sac is
visualized as a hemorrhagic mass with heterogeneous mixed signal intensity in
the uterine wall or cervix (Fig.
4A,4B,4C).
The heterogeneity may be associated with the repeated onset of hemorrhage,
resulting in an admixture of blood of various ages. The enhancing papillary
projection in the mass has been found to be fibrin strands and villous
structures, which are remnants of fetoplacental tissue
[5].
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Fig. 4A. —Interstitial pregnancy in 34-year-old woman at 10 weeks'
gestation. Axial T2-weighted spin-echo image (TR/TE, 3600/85) shows
heterogeneous mass (solid arrows) in left interstitial portion of
uterus. Endometrial cavity is slightly distended (open arrows).
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Fig. 4C. —Interstitial pregnancy in 34-year-old woman at 10 weeks'
gestation. Axial enhanced T1-weighted spin-echo image (600/11) shows densely
enhancing papillary solid components (arrowheads) in mass,
representing remnant fetoplacental tissue.
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Gestational Trophoblastic Disease
Gestational trophoblastic disease encompasses a broad spectrum of
conditions, includes hydatidiform mole, invasive mole, choriocarcinoma, and
placental site trophoblastic tumor. Although sonography is the examination of
choice for the initial diagnosis, MR imaging has a role in the detection of
gestational trophoblastic disease and the evaluation of the extent of its
complications [4,
6].
Hydatidiform Mole
Hydatidiform mole constitutes 80% of cases of gestational trophoblastic
disease. These are noninvasive processes that show both proliferation and
hydropic swelling of the villi. On T2-weighted images, a complete mole appears
as a heterogeneous mass of high signal intensity that distends the endometrial
cavity. Numerous cystic spaces may be present in the mass
[6] (Fig.
5A,5B).
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Fig. 5A. —Hydatidiform mole in 53-year-old woman. Sagittal T2-weighted
fast spin-echo image (TR/TE, 3000/90) shows intrauterine mass representing
molar tissue. There is markedly increased signal intensity because of its
predominantly cystic components (arrows). Junctional zone is
preserved (arrowheads).
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Fig. 5B. —Hydatidiform mole in 53-year-old woman. Sagittal enhanced
T1-weighted fat-suppressed fast spin-echo image (552/14) shows "bunch of
grapes" appearance (arrows) within distended endometrial
cavity.
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Invasive Mole
An invasive mole develops in approximately 10% of patients after molar
evacuation and infrequently after other gestations. This form is defined as a
mole that penetrates and may even perforate the uterine wall. There is
invasion of the myometrium by hydropic chorionic villi, accompanied by
proliferation of trophoblast. The tumor is locally destructive and may invade
parametrial tisue and blood vessels
[6].
An invasive mole appears as a poorly defined mass displaying mixed signal
intensity on T2-weighted images and deeply invades the myometrium. Complete or
partial disruption of the junctional zone may also be seen. On T1-weighted
images, the mass is isointense to the myometrium with scattered foci of high
signal intensity because of the presence of hemorrhage. Molarlike structures
appear as tiny cystic lesions within the well-enhanced zone of trophoblastic
proliferation in a mass of the invasive mole. With the penetration of the
tumor into the myometrium, the invasive mole appears as a more aggressive
entity than does choriocarcinoma
[5,
6] (Fig.
6A,6B,6C).
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Fig. 6A. —Invasive mole in 48-year-old woman. Axial T1-weighted
spin-echo image (TR/TE, 566/11) shows ill-defined heterogeneous mass
(arrows) in uterus with large areas of hyperintensity
(arrowheads).
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Fig. 6C. —Invasive mole in 48-year-old woman. Enhanced T1-weighted
spin-echo image (556/11) shows invasive enhancing tissue to myometrium with
large area of necrosis (arrows). There are markedly increased
parametrial and uterine vascularities.
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Choriocarcinoma
Approximately 5% of cases of hydatidiform mole are followed by
choriocarcinoma. Only half the cases of choriocarcinoma arise from
hydatidiform mole. An additional 25% of cases occur after normal pregnancies,
and 25% arise after spontaneous abortion or ectopic pregnancy. At histologic
evaluation, choriocarcinomas have extensive necrosis and hemorrhage. Because
choriocarcinomas usually tend to invade the myometrium through the venous
sinuses, the tumor margins are nodular and well defined. T1-weighted images
show isointense or hyperintense masses. On T2-weighted images, the masses have
various signal intensities, depending on the length of time the patient has
had the hemorrhage. After gadolinium administration, the tumors appear as
heterogeneous masses with necrotic centers (Fig.
7A,7B,7C).
The enhancing solid component is usually located in the periphery of the mass.
Intratumoral vascularity is minimal in most patients with choriocarcinoma
compared with the vascularity of invasive mole tumors
[5,
6].
Placental Site Trophoblastic Tumor
Placental site trophoblastic tumor is a rare form of gestational
trophoblastic disease that typically occurs in women of childbearing age and
that produces small amounts of ß-human chorionic gonadotropin. A
placental site trophoblastic tumor tends to remain confined to the uterus
until late in its course but may metastasize to the lung, liver, lymph nodes,
and brain. Placental site trophoblastic tumor presents as a myometrial mass
that is isointense compared with healthy myometrium on T1-weighted images and
isointense to slightly hyperintense on T2-weighted images
[7] (Fig.
8A,8B).
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Fig. 8A. —Placental site trophoblastic tumor in 29-year-old woman.
Sagittal T2-weighted fast spin-echo image (TR/TE, 3000/85) shows well-defined
hyperintense mass (thick solid arrows) in uterine fundus. Endometrial
cavity (open arrows) is narrowed and junctional zone (long thin
arrows) is disrupted at lesion site.
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Adnexal Mass
Corpus Luteal Cyst
Corpus luteal cyst is the most common pelvic mass in the first trimester of
pregnancy. Because most corpus luteal cysts spontaneously regress by the end
of the second trimester, MR imaging is performed only if the mass persists. On
MR imaging, a corpus luteal cyst is seen as a round or oval structure with
homogeneous low signal intensity on T1-weighted images and high signal
intensity on T2-weighted images (Fig.
9A,9B).
After gadolinium administration, intense wall enhancement is seen because of
the thick well-vascularized luteinizing line
[3].
Theca Lutein Cyst
Theca lutein cyst develops in response to high levels of ß-human
chorionic gonadotropin. These cysts are commonly found in patients with
hydatidiform moles, but they may also develop after overstimulation of the
ovaries by clomiphene or gonadotropins
[5]. Ovarian hyperstimulation
syndrome is a complication occurring in the luteal phase of a menstrual cycle
in patients who have had ovulation induction or ovarian hyperstimulation used
in assisted reproduction techniques
[8]. Imaging findings are
bilateral symmetric enlarged ovaries with multiple, variably sized cystic
lesions (Figs.
10A,10B
and
11A,11B,11C).
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Fig. 10A. —Bilateral theca lutein cysts and right tubal pregnancy in
31-year-old woman with amenorrhea for 12 weeks. Coronal T1-weighted
fat-suppressed spin-echo image (TR/TE, 450/11) shows hyperintense nodular
lesion (arrows) in right adnexal region, indicating hemorrhagic tubal
pregnancy. Multiseptated cystic mass (arrowheads) is visible in right
adnexal region.
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Fig. 10B. —Bilateral theca lutein cysts and right tubal pregnancy in
31-year-old woman with amenorrhea for 12 weeks. Sagittal T2-weighted spin-echo
image (1800/80) shows another multiseptated cystic mass (arrows) with
thin wall and septa in rectouterine pouch.
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Fig. 11A. —Ovarian hyperstimulation syndrome in 29-year-old woman with
amenorrhea for 12 weeks after receiving gonadotrophin stimulation therapy.
Coronal T2-weighted fast spin-echo image (TR/TE, 3200/99) shows massively
enlarged ovaries with multiple cysts in both adnexal regions.
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Fig. 11B. —Ovarian hyperstimulation syndrome in 29-year-old woman with
amenorrhea for 12 weeks after receiving gonadotrophin stimulation therapy.
Axial enhanced T1-weighted fast spin-echo image (660/14) shows uniformly
enhanced thin septa. Cysts are enlarged luteinized follicles.
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Fig. 11C. —Ovarian hyperstimulation syndrome in 29-year-old woman with
amenorrhea for 12 weeks after receiving gonadotrophin stimulation therapy.
Follow-up axial T2-weighted fast spin-echo image (3200/99) obtained 6 months
later shows reduced size of follicles (arrows).
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Uterine Fibroids (Leiomyomas)
Uterine fibroids have the same imaging characteristics during pregnancy as
found in the nongravid uterus (Fig.
12A,12B).
However, because of continued estrogen stimulation, uterine fibroids tend to
enlarge during pregnancy. With rapid growth, they may outgrow their vascular
supply, resulting in hemorrhagic infarction and necrosis. Multiple and large
fibroids are accompanied by a higher incidence of malpresentation, whereas
fibroids in the lower uterine segment may preclude vaginal delivery
[3].
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Fig. 12A. —Uterine leiomyoma in 27-year-old woman with amenorrhea for 8
weeks after gonadotropin-releasing analog hormone therapy for 3 months.
Coronal (A) and axial (B) half-Fourier acquisition single-shot
turbo spin-echo images (TE, 90) show early intrauterine pregnancy (open
arrows, A). Uterus is markedly enlarged and contains huge
intramural leiomyoma (solid arrows) with low signal intensity and
whirling pattern. Endometrial cavity (arrowheads, B) is
compressed by leiomyoma.
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Fig. 12B. —Uterine leiomyoma in 27-year-old woman with amenorrhea for 8
weeks after gonadotropin-releasing analog hormone therapy for 3 months.
Coronal (A) and axial (B) half-Fourier acquisition single-shot
turbo spin-echo images (TE, 90) show early intrauterine pregnancy (open
arrows, A). Uterus is markedly enlarged and contains huge
intramural leiomyoma (solid arrows) with low signal intensity and
whirling pattern. Endometrial cavity (arrowheads, B) is
compressed by leiomyoma.
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Acknowledgments
We thank Bonnie Hami, Department of Radiology, University Hospitals Health
System, Cleveland, OH, for editorial assistance in preparing the
manuscript.
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Top
Introduction
Spontaneous Abortion
