Uterine Rupture: Imaging with MRI and Ultrasound

Uterine Rupture: Imaging with Uterine Rupture: Imaging with MRI and UltrasoundMRI and Ultrasound

Kristina MirabeauKristina Mirabeau--BealeBealeHarvard Medical School Year IVHarvard Medical School Year IV

Gillian Lieberman, MDGillian Lieberman, MD

May 26, 2009

AgendaAgenda

Introduce Patient JPIntroduce Patient JPDiscuss the work up of the pregnant patient with Discuss the work up of the pregnant patient with abdominal pain abdominal pain

Review of how pregnancy affects our differential Review of how pregnancy affects our differential diagnosis diagnosis Menu of testsMenu of tests

RadiologicRadiologic findings on US and MRI in case of findings on US and MRI in case of Patient JPPatient JP

Our patient JP: HistoryOur patient JP: History

History of Present Illness: JP is a 40 yearHistory of Present Illness: JP is a 40 year--oldold-- woman (G5P1) at 29w5d presenting with woman (G5P1) at 29w5d presenting with increasing pelvic pain over past two weeks. increasing pelvic pain over past two weeks. Pain is constant, sharp, and shooting with Pain is constant, sharp, and shooting with intermittent bursts. Acutely worse in last day, intermittent bursts. Acutely worse in last day, more localized to RUQmore localized to RUQROS: +fetal movement; negative for shortness ROS: +fetal movement; negative for shortness of breath, contractions, vaginal bleeding or of breath, contractions, vaginal bleeding or leakage of fluidleakage of fluid

Our patient RS: Additional HistoryOur patient RS: Additional History

Past Medical HistoryPast Medical History•• Gestational Diabetes (GDMA1)Gestational Diabetes (GDMA1)•• GERD/IBSGERD/IBS•• Preeclampsia in prior pregnancy (cPreeclampsia in prior pregnancy (c--section at 33w in section at 33w in

2006)2006)•• AML, AML, s/ps/p BMT 1997, chemo and radiationBMT 1997, chemo and radiation

•• Social Social HxHx: 20 pack years (quit 10 years ago): 20 pack years (quit 10 years ago)•• No medications and NKDANo medications and NKDA

Our patient JP: Exam and LabsOur patient JP: Exam and Labs

Vitals: T 98.7 HR 76 BP 141/82 RR 20Vitals: T 98.7 HR 76 BP 141/82 RR 20Abdomen: soft, gravid, tender to palpation Abdomen: soft, gravid, tender to palpation diffuselydiffuselyVaginal Exam: long, closed, posterior Vaginal Exam: long, closed, posterior cervixcervixLabs: CBC, ALT, AST, Cr and UA all WNLLabs: CBC, ALT, AST, Cr and UA all WNL

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Differential Diagnosis: Abdominal Differential Diagnosis: Abdominal Pain in Pregnant PatientPain in Pregnant Patient

When evaluating the When evaluating the pregnant patient, it is pregnant patient, it is important to consider important to consider the categories of the categories of etiologies for etiologies for abdominal pain:abdominal pain:

ObstetricalObstetricalNonNon--obstetricalobstetricalGynecologicGynecologic

66Image from: http://images.google.com/imgres?imgurl=http://www.childbirthconnection.org/images/40-weeks-pregnant- internal.gif&imgrefurl=http://www.childbirthconnection.org/article.asp%3Fck%3D10243&usg=__4lMhjtDlNvmP69_meePnSP54tO0=&h=608&w=458&sz=135&hl=en&star t=2&um=1&tbnid=PQzxe3e7tvEMPM:&tbnh=136&tbnw=102&prev=/images%3Fq%3Dpregnant%2Banatomy%26hl%3Den%26um%3D1

Obstetrical EtiologiesObstetrical Etiologies

Placental abruptionPlacental abruptionUterine ruptureUterine ruptureExtrauterineExtrauterine pregnancypregnancySevere preeclampsia or HELLPSevere preeclampsia or HELLPIntraamnioticIntraamniotic infectioninfectionAcute fatty liverAcute fatty liver

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NonNon--obstetric Etiologiesobstetric Etiologies

AppendicitisAppendicitisGall bladder diseaseGall bladder diseaseBowel obstructionBowel obstructionInflammatory bowel diseaseInflammatory bowel diseasePancreatitisPancreatitisPerforated ulcerPerforated ulcerTraumaTrauma

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Gynecologic EtiologiesGynecologic Etiologies

Ovarian torsion or cyst ruptureOvarian torsion or cyst ruptureFibroid degenerationFibroid degenerationPelvic inflammatory diseasePelvic inflammatory diseaseEndometritisEndometritisPelvic girdle painPelvic girdle pain

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Imaging Considerations in Imaging Considerations in PregnancyPregnancy

Safety of radiation exposure during Safety of radiation exposure during pregnancy is a common concernpregnancy is a common concernMissed or delayed diagnosis can pose a Missed or delayed diagnosis can pose a greater risk to the woman and her pregnancy greater risk to the woman and her pregnancy Potential deleterious consequences of Potential deleterious consequences of ionizing radiation can be divided into four ionizing radiation can be divided into four categories (2)categories (2)

Pregnancy loss (miscarriage, stillbirth) Pregnancy loss (miscarriage, stillbirth) Malformation Malformation Disturbances of growth or development Disturbances of growth or development Mutagenic and carcinogenic effects Mutagenic and carcinogenic effects 1010

Radiologic Tests to Evaluate Radiologic Tests to Evaluate Abdominal Pain in PregnancyAbdominal Pain in PregnancyUSUS

Primary modality for screening abdominal Primary modality for screening abdominal pathologypathologyNo ionizing radiation exposureNo ionizing radiation exposure

MRIMRIExpensive and time consumingExpensive and time consumingNo ionizing radiationNo ionizing radiation

(CT)(CT)Standard after US in nonStandard after US in non--pregnant patientspregnant patientsReserved for special circumstancesReserved for special circumstances

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Initial US: Abnormal, heaped placentaInitial US: Abnormal, heaped placenta

PACS, BIDMC

Normally, would expect placenta to lie flat against contour of uterus

Uterine lining

Initial US: placental abruptionInitial US: placental abruption

1. Chorion

2. Blood/abruption

3. Uterine wall

4. Fetus

PACS, BIDMC

Initial US: rule out appendicitis?

• Even though the appendix not clearly visualized with sonography in our patient, the findings on US consistent with abruption satisfied our radiologic search for an etiology for our patient JP’s pain.

• Patient remained afebrile without leukocytosis and peritoneal signs, also making appendicitis less likely

Placental Abruption: Definition and Placental Abruption: Definition and ManagementManagement

Separation of placenta from uterus, Separation of placenta from uterus, usually resulting in hemorrhage and usually resulting in hemorrhage and placental insufficiencyplacental insufficiencyTreatment depends on age of fetus and Treatment depends on age of fetus and amount of blood lossamount of blood lossIf EGA < 36 weeks with no maternal or If EGA < 36 weeks with no maternal or fetal distress, observation and fetal distress, observation and symptomatic managementsymptomatic management

Biophysical Profile (BPP)Biophysical Profile (BPP)

Two points each given for AFI, fetal tone, Two points each given for AFI, fetal tone, activity and breathing movementsactivity and breathing movementsOur patientOur patient’’s results: 8/8 s results: 8/8

Vertex position; AFI 13; reassuring fetal heart Vertex position; AFI 13; reassuring fetal heart raterateMaternal sharp pain with fetal movementMaternal sharp pain with fetal movement

OB/GYN Impression: Not consistent with OB/GYN Impression: Not consistent with fetal distress due to abruption, in spite of fetal distress due to abruption, in spite of initial US findingsinitial US findings

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Our Patient JP: Clinical ChangeOur Patient JP: Clinical ChangePatient observed initially Patient observed initially Worsening abdominal pain: Worsening abdominal pain:

Patient was initially able to ambulate to Patient was initially able to ambulate to bathroom on her own, then change to fetal bathroom on her own, then change to fetal position, crying and writhing in pain. position, crying and writhing in pain. Physical Exam: +peritoneal signs. Physical Exam: +peritoneal signs.

Transferred to labor and delivery for Transferred to labor and delivery for r/or/ochorioamnionitischorioamnionitis, appendicitis, worsening , appendicitis, worsening placental abruption. placental abruption.

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Diagnostic DilemmaDiagnostic Dilemma

Radiology: US shows likely abruption; but Radiology: US shows likely abruption; but appendix not visualizedappendix not visualizedOB/GYN: BPP was not consistent with OB/GYN: BPP was not consistent with abruptionabruptionGeneral Surgery ConsultGeneral Surgery Consult-- Exam not Exam not consistent with appendicitisconsistent with appendicitisPlan: Proceed with additional imagingPlan: Proceed with additional imaging

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2020

Additional Imaging Concerns

Given JP’s pregnancy was high risk, OB/GYN had concern over ability to continuously monitor fetus during further imaging studiesHowever, the risk of ionizing radiation to fetus were considered of greater significanceAvailability of MRI at our institution with experienced fetal imagers made this the next step, in spite of the acknowledged rapidity of a CT scan





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MRI: retroperitoneal abnormalitiesMRI: retroperitoneal abnormalities

Bilateral hydronephrosis right > left

Fluid in Morrison’s pouch

Fetus

PACS, BIDMC

Coronal T2 MRI

MRI: Liver with MRI: Liver with ascitesascites

Ascites around liver

PACS, BIDMC axial T2 MRI

Disrupted outline of myometrium

Free fluid in abdomen

MRI: Myometrial defect and ascites

PACS, BIDMC coronal T2 MRI

MRI: Oligohydramnios


Outline of uterus- oligohydramnios

MRI: MRI: MyometrialMyometrial silhouettesilhouette

Outline of myometrium


MRI: MRI: MyometrialMyometrial defectdefect

Defect in myometrium

Fetal parts in LLQ


Defect in myometriumFetal parts in LLQ

MRI: Additional Defect in Myometrium

PACS, BIDMC axial T2 MRI

Funnel shaped, short cervix

PACS, BIDMC

Sagittal T2 MRI

MRI: Shortened Cervix

Umbilical cord protruding out of uterine defect (flow voids)

Free fluid in maternal pelvis

MRI: Free Fluid in Pelvis

PACS, BIDMC sagittal T2 MRI

Image courtesy of Deb Levine

Sagittal T2 MRI

Funnel shaped, short cervix

Umbilical cord protruding out of uterine defect

Defect in myometrium

MRI: Umbilical cord in myometrial defect

Fetal parts

Myometrium

Maternal abdominal wall

Image Courtesy of Deb LevineAxial T2 MRI

MRI: Fetal parts abutting maternal body wall

Uterine RuptureUterine Rupture

Complete breach in Complete breach in myometrialmyometrial wall with wall with fetal parts in maternal peritoneal cavityfetal parts in maternal peritoneal cavitySymptoms: abdominal pain, vaginal Symptoms: abdominal pain, vaginal bleeding, changes in fetal heart rate, bleeding, changes in fetal heart rate, maternal maternal hypovolemichypovolemic shockshockRisk factors: prior uterine surgery (Risk factors: prior uterine surgery (ieie cc--sections)sections)

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Management of our patientManagement of our patientUrgent CUrgent C--sectionsectionPer operative report: uterine rupture was Per operative report: uterine rupture was immediately apparent; defect in wall of immediately apparent; defect in wall of lower uterine segment along area of prior lower uterine segment along area of prior hysterotomyhysterotomy. Defect extended inferiorly . Defect extended inferiorly within 1 cm of bladder; infant and within 1 cm of bladder; infant and placenta delivered in normal fashion placenta delivered in normal fashion without further complication. No evidence without further complication. No evidence of abruption was noted. of abruption was noted. HysterotomyHysterotomy repaired in usual fashion. repaired in usual fashion.

Revisiting original US in hindsightRevisiting original US in hindsight

Bladder wall

Abnormal uterine contour

Fetus

PACS, BIDMC

US Interpreted initially as placental US Interpreted initially as placental abruptionabruption

1. Chorion

2. Blood/abruption

3. Uterine wall

4. Fetus

PACS, BIDMC

In lieu of MRI findings, this interpreted was revisited

1. Uterine wall

2. Fetus

3. Fluid in abdomen

Findings consistent with uterine rupture

Revisiting original US in hindsight: Uterine Rupture

PACS, BIDMC

Defect in myometrium/uterine

wall

US: Myometrial defect

PACS, BIDMC

This image was from the original US sequence, but was not initially considered because of the earlier image which was believed to clearly show abruption

Putting it all together: hindsightPutting it all together: hindsightOur patient JP had gestational diabetes Our patient JP had gestational diabetes and and polyhyramniospolyhyramniosLeakage of fluid from Leakage of fluid from myometrialmyometrial defect defect

normal appearing AFI on initial BPPnormal appearing AFI on initial BPPPrior CPrior C--section a risk for uterine rupturesection a risk for uterine ruptureCervical changes on MRI indicate JP was Cervical changes on MRI indicate JP was also in preterm labor, which may have also in preterm labor, which may have contributed to her changing pain.contributed to her changing pain.

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Lessons LearnedLessons LearnedUltrasound is a good screening test for Ultrasound is a good screening test for imaging pregnant women with abdominal imaging pregnant women with abdominal pain.pain.Beware of satisfaction of search: consider Beware of satisfaction of search: consider clinical pictureclinical pictureMRI provides detailed crossMRI provides detailed cross--sectional imaging sectional imaging without the hazards of ionizing radiation on without the hazards of ionizing radiation on the fetusthe fetusMRI is a reliable modality for providing MRI is a reliable modality for providing valuable diagnostic imaging in pregnant valuable diagnostic imaging in pregnant patients with abdominal pain (1)patients with abdominal pain (1)

Update on Patient JPUpdate on Patient JP

PostPost--operative course uneventful, patient operative course uneventful, patient discharged on POD #4discharged on POD #4Infant daughter had surgery at ChildrenInfant daughter had surgery at Children’’s s Hospital for Hospital for tracheotracheo--esophageal fistula, esophageal fistula, then spent 2 weeks in NICUthen spent 2 weeks in NICUMother and baby both doing well at Mother and baby both doing well at subsequent follow upsubsequent follow up

AcknowledgementsAcknowledgements

Patient JP and her daughterPatient JP and her daughterNeely Hines, MDNeely Hines, MDGillian Lieberman, MDGillian Lieberman, MDMaria Maria LevantakisLevantakisDeborah Levine, MDDeborah Levine, MD

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ReferencesReferences(1) (1) EyvazzadehEyvazzadeh, A. et al. , A. et al. ““MRI of RightMRI of Right--Sided Abdominal Pain in Sided Abdominal Pain in Pregnancy.Pregnancy.”” American Journal of American Journal of RoentgenologyRoentgenology: 184, October 2004: 184, October 2004(2) (2) KruskalKruskal, JB. , JB. ““Diagnostic imaging procedures during pregnancy.Diagnostic imaging procedures during pregnancy.””UpToDateUpToDate(3) Kilpatrick, C. and (3) Kilpatrick, C. and OrejuelaOrejuela, F. , F. ““Approach to abdominal pain and Approach to abdominal pain and the acute abdomen in pregnant women.the acute abdomen in pregnant women.”” UpToDateUpToDate. . (4) (4) WelischarWelischar, J. , J. ““Trial of Labor after cesarean section.Trial of Labor after cesarean section.”” UpToDateUpToDate(5) Brent, RL. (5) Brent, RL. ““Saving lives and changing family histories: Saving lives and changing family histories: appropriate counseling of pregnant women and men and women of appropriate counseling of pregnant women and men and women of reproductive age, concerning the risk of diagnostic radiation reproductive age, concerning the risk of diagnostic radiation exposures during and before pregnancy. Am J exposures during and before pregnancy. Am J ObstetObstet Gynecol. 2009 Gynecol. 2009 Jan;200(1):4Jan;200(1):4--24. 24. (6) Hall, EJ. (6) Hall, EJ. ““Scientific view of lowScientific view of low--level radiation riskslevel radiation risks””RadiographicsRadiographics 1991 May;11(3):5091991 May;11(3):509--18. 18.

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Uterine Rupture: Imaging with MRI and Ultrasound

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