The diagnostic use of magnetic resonance imaging for acute abdominal and pelvic pain in pregnancy

Journal Pre-proof The Diagnostic use of Magnetic Resonance Imaging for Acute Abdominal and Pelvic Pain in Pregnancy Asma Tarannum, Haifa Sheikh, Kwabena Appiah-Sakyi, Stephen W. Lindow

PII:

S0301-2115(19)30542-1

DOI:

https://doi.org/10.1016/j.ejogrb.2019.11.027

Reference:

EURO 11080

To appear in: Biology

European Journal of Obstetrics & Gynecology and Reproductive

Received Date:

8 August 2019

Revised Date:

19 November 2019

Accepted Date:

21 November 2019

Please cite this article as: Tarannum A, Sheikh H, Appiah-Sakyi K, Lindow SW, The Diagnostic use of Magnetic Resonance Imaging for Acute Abdominal and Pelvic Pain in Pregnancy, European Journal of Obstetrics and amp; Gynecology and Reproductive Biology (2019), doi: https://doi.org/10.1016/j.ejogrb.2019.11.027

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The Diagnostic use of Magnetic Resonance Imaging for Acute Abdominal and Pelvic Pain in Pregnancy

Asma Tarannum 1 Specialist in Obstetrics and Gynaecology

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Kwabena Appiah-Sakyi 1,2 Consultant in Obstetrics and Gynaecology

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Haifa Sheikh 1 Specialist in Obstetrics and Gynaecology

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Stephen W. Lindow 1,2 Consultant in Obstetrics and Gynaecology

Correspondence to;

[email protected]

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Dr Asma Tarannum

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Sidra Medicine. Doha. Qatar

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Womens Wellness and Research Centre. Hamad Medical Corporation. Doha. Qatar

Abstract: Objectives : Acute abdomino-pelvic pain in pregnancy represents a diagnostic challenge. In many cases, radiological and laparoscopic diagnostic modalities are hazardous or contraindicated. Magnetic Resonance Imaging (MRI) is not commonly used for this indication

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and the results are not widely published. Design and Setting: A single-center retrospective observational study.

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Population: 34 cases of pregnant women with abdomino-pelvic pain who underwent MRI as

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an additional modality when clinical, laboratory and ultrasound (USS) findings were

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indeterminate.

Methods: Case notes were reviewed where pregnant women underwent a MRI investigation

excluded.

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for abdominal-pelvic pain. Primary Obstetric indications for an MRI eg placenta accreta were

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Main outcome measures: The differential diagnosis after; 1) history and physical examination and 2) with the addition of USS and 3) with the further addition of an MRI were all individually compared to the eventual diagnosis.

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Results: The diagnoses reached by MRI corresponded with the final diagnosis in 22 out of 23 cases. In the remaining 11 cases MRI accurately ruled out presence of pathology. MRI was inaccurate in 1 case.

Conclusion: The additional use of MRI was more accurate than clinical assessment and USS combined. The accurate exclusion of pathology in 11 cases is particularly significant. MRI

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should be considered in cases of abdomino-pelvic pain in pregnant women.

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Keyword: MRI, pregnancy, abdominal pain, pelvic pain, magnetic resonance imaging

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Tweetable abstract:

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MRI proved to be accurate in the diagnosis of abdomino-pelvic pain in pregnancy

Main Article:

Introduction:

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Acute abdomino-pelvic pain in pregnancy represents a diagnostic challenge. The initial assessment of a pregnant woman with acute abdomino-pelvic pain starts with a detailed history and physical examination 1,2. Maternal and fetal health are assessed and a differential diagnosis is formulated. A management plan may involve a primary treatment and it may include further investigations including blood, urine analysis, ultrasound imaging (USS) and

rarely magnetic resonance imaging (MRI) 3,4. Imaging plays an important role in guiding evaluation, diagnosis and management but in many cases, radiological (such as X-ray and computerised tomography (CT)) and laparoscopic diagnostic modalities are contraindicated or potentially hazardous in pregnancy 5,6. In pregnancy imaging is of paramount importance as patient’s presentation can be clinically elusive and an accurate diagnosis is important as surgical

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and medical decisions in pregnant women could involve harmful consequence to the mother

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and fetus3.

MRI investigations of maternal diseases are deemed to be safe in pregnancy but the clinical

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utility of the use of MRI has not been well studied. The use of MRI in pregnancy has not

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become a frequently ordered test as many Obstetricians are unsure of the accuracy and would not often rely on the result 7. This work was undertaken to evaluate the clinical utility of a MRI

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investigation of maternal pathology in pregnant woman where senior clinicians were unable to confidently enter a diagnosis following history, physical examination, laboratory tests and USS

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Methods:

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evaluation.

This study was conducted in a Middle East teaching hospital, a referral centre for high risk obstetric cases with 16,000 deliveries/year. The study design was in the form of a retrospective case series. Patients who were pregnant and underwent a MRI investigation were identified from the hospital data base. The data was collected by AT and HS using a standardised data

collection form completed after a confidential review of individual medical records dating between January 2011 and December 2016. The inclusion criteria were all pregnant women who underwent an abdominal and/or pelvic non-contrast MRI at any stage of their pregnancy for further evaluation of abdominal-pelvic pathology when clinical and ultrasound imaging were indeterminate. Cases where an MRI was done for obstetric indications such as placenta

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praevia/accreta, or for evaluation of fetal pathology were excluded from the study. The presumptive diagnoses (as recorded in the patient records) reached by initial history and

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physical examination was documented and then documented again after an additional USS

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evaluation and then again after a MRI was performed. These 3 diagnoses were then compared with the final diagnosis and outcome. The accuracy of MRI in comparison with the other

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modalities was compared.

Results:

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The study was passed by the local ethics review board.

The records of 34 cases were reviewed. The demographic details are outlined in table 1. Table 2

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demonstrates the following disease process were correctly identified by MRI in 22/34 patients : ovarian torsion (n=5), ovarian malignancy (n=1), renal abscess (n=1), ectopic pregnancy (n=2), invasive mole (n=3), uterine scar dehiscence (n=1), fibroid degeneration (n =1), fibroid torsion (n=1), scar pregnancy (n=1), calculous cholecystitis (n = 3), common bile duct lithiasis (n=1), pancreatic mass (n=1), ovarian vein syndrome (n=1). MRI incorrectly diagnosed renal lithiasis in

1 case.

11 out of the 34 patients had normal findings on MRI and all of these patients had an unremarkable follow up without specific treatment being prescribed. The diagnoses in these 11 cases on USS (prior to MRI) were: suspected scar pregnancy (n=1), heterotopic pregnancy (n=1),

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common bile duct lithiasis (n=1) renal lithiasis (n=2), ectopic pregnancy (n=1), appendicitis (n=1), ovarian cysts (n = 4).

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Almost half the initial USS diagnoses of ovarian cysts were excluded by MRI, on further follow

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up these patients had uneventful pregnancy course.

None of the patients with suspected appendicitis from history or USS were confirmed by MRI,

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which eventually proved accurate in all cases.

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Table 3 demonstrates the test characteristics of history and examination, history examination plus blood results and USS and the addition of MRI respectively. The test characteristics of MRI

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are close to 100% in each category.

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Discussion:

Main findings,

There is evidence out side of pregnancy on the utility of MRI to evaluate abdominal and pelvic pathology, however, the usefulness of MRI has not been widely studied in pregnant women.

This review of 34 cases of abdomino-pelvic pain in pregnant women demonstrates the excellent test characteristics of a MRI examination. Particularly important is the accurate exclusion of pathology in 11 cases who had a normal follow-up. The fact that these women did not undergo radiological or laparoscopic examinations is significant as both can be associated with problems in pregnant women.

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A MRI was reported to be normal but was proved to be inaccurate in 1 case where USS had

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previously diagnosed renal stones. It was concluded that the stone had been passed

spontaneously. No treatment was given on the basis of the MRI result and 3 weeks later it was

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necessary to stent a ureter to relive obstruction due to renal stones. This was the only case of

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an inaccurate diagnosis made after an MRI.

The MRI was only used when clinicians were unsure of the diagnosis therefore the 34 cases

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represent a group where there was a diagnostic challenge. More obvious cases had been diagnosed and treated if clinically indicated thus the 34 cases represent a sample biased

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towards diagnostic difficulty.

Appendicitis is one of the commonest non obstetric causes of an acute abdomen in pregnant women occurring in approximately 1 in 500 to 1 in 2000 pregnancies 8. The diagnosis can be

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difficult as the physiological changes occurring in pregnancy alter the anatomical location of the appendix, hence making a diagnosis more challenging. Although surgery is the mainstay treatment in acute appendicitis, surgery following a history and physical examination for suspected non perforated appendicitis has revealed a normal appendix in between 5 and 50 % of cases 9. MRI can be a useful diagnostic aid in further confirming or refuting the need of

surgical intervention in such cases. Further studies are needed to assess the accuracy of MRI in accurately diagnosing appendicitis, which may potentially reduce the number of unwarranted surgical interventions in pregnant women 10. As a Middle East teaching hospital, a diverse population is cared for comprising of multitude of ethnicities with many women who have a predisposition to develop uterine fibroids 11. Fibroids

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in pregnancy, particularly large ones, may undergo hemorrhagic infarction or degeneration,

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resulting in abdominal pain. This can increase the incidence of premature labour 12. In our study a case of fibroid degeneration was accurately diagnosed by MRI and upon receiving appropriate

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treatment progressed to term.

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In 11 cases, MRI as a diagnostic tool ruled out pathology after the initial USS diagnosis and pregnancies successfully continued to term. The initial diagnoses by USS included renal abscess,

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scar pregnancy, heterotopic pregnancy, ovarian pregnancy and uterine scar dehiscence.

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A previous study in pregnant women revealed similar accurate results using MRI when the diagnosis was unsure 13. In this study, 40 cases were evaluated and in 21 cases there was an accurate diagnosis and in 19 cases pathology was accurately excluded13 . Obstetricians traditionally have not utilised MRI on a frequent basis. USS has been the preferred diagnostic

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modality but as we have shown the accuracy of MRI was at times superior to USS and the use of MRI in the evaluation of the pregnant patient continues to expand 13. Outside of pregnancy MRI provides the most accurate diagnoses in the investigation of hepatic, adrenal, and pancreatic disease and either CT or MRI may be the most appropriate first imaging

study for the diagnosis of renal pathology. Perhaps it is time for Obstetricians to embrace MRI

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for the investigation of abdomino-pelvic pathology when the initial diagnosis is unclear 14.

Conclusion: The results of MRI examinations in pregnant women with abdomino-pelvic pain

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when there was diagnostic difficulty were more accurate than clinical assessment and USS combined. The accurate exclusion of pathology in 11 out of 11 cases is particularly significant.

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We recommend that MRI is considered when there is diagnostic difficulty in pregnant women presenting with abdomino-pelvic pain.

Given the accuracy of MRI in difficult cases the evaluation of MRI as an initial diagnostic

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modality should be studied.

Strengths: There were 34 cases all treated in the same institution over a 5-year period. A wide variety of pathologies were assessed with follow up until delivery. All outcomes were assessed. Limitations : Our sample was made up of patients who represented a diagnostic difficulty and

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the wider application of our results is speculative.

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Declaration of interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:

References:

1) Sharp HT The acute abdomen during pregnancy. Clin Obstet Gynecol 2002; 45: 405–413

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2) Cappell MS, Friedel D Abdominal pain during pregnancy. Gastroenterol Clin N Am 2003; 32: 1–58

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3) Stone K Acute abdominal emergencies associated with pregnancy. Clin Obstet Gynecol 2002; 45: 553–561

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4) Sharp HT Gastrointestinal surgical conditions during pregnancy. Clin Obstet Gynecol 1994; 37: 306–315

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5) De Wilde JP, Rivers AW, Price DL A review of the current use of magnetic resonance imaging in pregnancy and safety implications for the fetus. Prog Biophys Mol Biol 2005; 87(2–3):335–353

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6) Nishino M, Hayakawa K, Iwasaku K, et al. Magnetic resonance imaging findings in gynecologic emergencies. J Comput Assist Tomogr 2003; 27: 564–570

7) Kanal E, Barkovich AJ, Bell C, et al. ACR guidance document for safe MR practices: 2007. AJR 2007; 188:1–27

8) Kilpatrick CC, Orejuela FJ. Management of the acute abdomen in pregnancy: a review. Curr Opin Obset Gynecol 2008; 534- 9

9)Pedrosa I, Lafornara M, Pandharipande PV, et al. Pregnant patients suspected of having acute appendicitis: Effect of MR imaging on negative laparotomy rate and appendiceal perforation rate. Radiology. 2009; 250: 749-57.

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10) ACOG Committee Opinion number 299. Guidelines for diagnostic imagining during pregnancy. Obstet Gynecol 2004; 104: 647 – 51

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11) Day Baird D, Dunson DB, Hill MC, et al. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol. 2003;188:100–7

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12) Rice JP, Kay HH, Mahony BS. The clinical significance of uterine leiomyomas in pregnancy. Am J Obstet Gynecol. 1989; 160:1212–16

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13) Masselli G1, Brunelli R, Casciani E, Polettini E, Bertini L, Laghi F, Anceschi M, Gualdi G. Acute abdominal and pelvic pain in pregnancy: MR imaging as a valuable adjunct to ultrasound? Abdom Imaging 2011; 36: 596 – 603

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14) Stoker J, Randen A, Lameris W, Boermeester MA. Imaging patients with acute abdominal pain. Radiology. 2009;253:31-46

Table 1

Demographic data in 34 patients (1 patient had diabetes and hypertension)

Demographic

N (%)

Gulf states

3 (9.4%)

North Africa

7 (21.9%)

Europe

1 (3.1%)

Filipino/far east

3 (9.4%)

Indian subcontinent

4 (12.5%) (21.9%)

Previous medical history

1 (3.1%)

Diabetes

5 (15.6%)

Gestational diabetes

1 (3.1%)

Hepatitis C

1 (3.1%)

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Pneumonia

Hypertension

2 (6.3%)

Hypothyroid

1 (3.1%)

Irritable bowel 1 (3.1%) Neurofibroma tosis

1 (3.1%)

Ovarian mass

1 (3.1%)

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Others

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9 (28.1%)

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Qatari

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ethnicity of patient

Severe preeclampsia

1 (3.1%)

None

18 (56.3%)

Previous gynecological history Fibroid

1 (3.1%)

Miscarriage

5 (15.5%)

Ovarian cancer

1 (3.1%)

PCOS

3 (9.4%)

None

22 (68.8%)

Previous Surgical History Appendicecto my

1 (3.1%)

LSCS x 1

2 (6.3%)

LSCS x 2

4 (12.6%)

LSCS x 3

3 (9,4%)

LSCS x 5

1 (3.1%)

Nasal surgery

1 (3.1%)

Oophorectom y

1 (3.1%)

None

15 (46.9%)

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1 (3.1%)

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Gastric balloon

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1 (3.1%)

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Gall bladder surgery

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Cholecystecto 2 (6.3%) my

Table 2 The final diagnosis compared to the diagnosis after 1) history and physical examination (H&P), 2) H&P plus abdomino-pelvic ultrasound scan (USS) and 3) H&P plus abdomino-pelvic ultrasound scan plus magnetic resonance imaging (MRI) in 34 pregnant women with undiagnosed abdomino-pelvic pain. H&P

USS

Yes Yes

OBSTETRIC CAUSES (LABOUR, ABRUPTIO PLACENTAE) (n=8)

No

7

21

Yes

0

0

No

15

19

Yes

6

No

12

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URINARY TRACT PATHOLOGY (INFECTION, STONES) (n=1)

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GASTROINTESTINAL PATHOLOGY (DIVERTICULITIS, COLITIS, INTESTINAL OBSTRUCTION, PEPTIC ULCER DISEASE) (n=0)

HEPATOBILIARY (GALL STONES, CHOLECYSTITIS, HEPATITIS, LIVER TUMOURS) (n=4)

PANCREATIC PATHOLOGY (n=1)

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THROMBOEMBOLIC PHENOMENA (n=1)

ABDOMINAL TRAUMA (n=0)

COMBINATION OF PATHOLOGIES (n=0)

NO CLINICAL PROBLEMS (n=11)

No 6

Yes 0

No 6

0

4

24

0

28

0

0

0

0

5

29

0

34

2

5

3

8

0

14

4

22

0

26

Yes

1

1

2

0

2

0

No

3

29

0

32

0

32

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UTERINE PATHOLOGY (n=2)

1

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APPENDIX (n=0)

5

Yes

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OVARIAN PATHOLOGY (n=6)

No

MRI

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Final diagnosis

Yes

1

0

1

0

1

0

No

11

22

2

31

1

32

Yes

0

0

0

0

0

0

No

5

29

4

30

0

34

Yes

4

0

3

1

4

0

No

4

26

2

28

0

30

Yes

0

1

1

0

1

0

No

2

31

0

33

0

33

Yes

0

1

1

0

1

0

No

0

33

0

33

0

33

Yes

0

0

0

0

0

0

No

0

34

0

34

0

34

Yes

0

0

0

0

0

0

No

1

33

1

33

0

34

Yes

0

11

1

10

11

0

No

1

22

0

23

0

23

Table 3 The sensitivity and specificity of the diagnosis after 1) history and physical examination (H&P), 2) H&P plus abdomino-pelvic ultrasound scan (USS) and 3) H&P plus abdomino-pelvic ultrasound scan plus magnetic resonance imaging (MRI) in 34 pregnant women with undiagnosed abdomino-pelvic pain. The final diagnosis was the reference standard. H&P

OBSTETRIC CAUSES (PTL, ABRUPTIO PLACENTAE)

83.3%

100.0%

100.0%

Specificity

75.0%

85.7%

100.0%

Sensitivity

0.0%

0.0%

0.0%

Specificity

55.9%

85.3%

100.0%

Sensitivity

75.0%

62.5%

100.0%

Specificity

53.8%

84.6%

100.0%

Sensitivity

50.0%

100.0%

100.0%

Specificity

90.6%

100.0%

100.0%

Sensitivity

100.0%

100.0%

100.0%

Specificity

66.7%

93.9%

97.0%

Sensitivity

0.0%

0.0%

0.0%

Specificity

85.3%

88.2%

100.0%

Sensitivity

100.0%

75.0%

100.0%

Specificity

86.7%

93.3%

100.0%

Sensitivity

0.0%

100.0%

100.0%

Specificity

93.9%

100.0%

100.0%

Sensitivity

0.0%

100.0%

100.0%

Specificity

100.0%

100.0%

100.0%

Sensitivity

0.0%

0.0%

0.0%

Specificity

100.0%

100.0%

100.0%

Sensitivity

0.0%

0.0%

0.0%

Specificity

97.1%

97.1%

100.0%

Sensitivity

0.0%

9.1%

100.0%

Specificity

95.7%

100.0%

100.0%

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UTERINE PATHOLOGY

Sensitivity

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URINARY TRACT PATHOLOGY (UTI, STONES)

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GASTROINTESTINAL PATHOLOGY (DIVERTICULITIS, COLITIS, INTESTINAL OBSTRUCTION, PEPTIC ULCER DISEASE)

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HEPATOBILIARY (GALL STONES, CHOLECYSTITIS, HEPATITIS, LIVER TUMOURS)

PANCREATIC PATHOLOGY

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THROMBOEMBOLIC PHENOMENA

ABDOMINAL TRAUMA

COMBINATION OF PATHOLOGIES

NO CLINICAL PROBLEMS

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APPENDIX

MRI

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OVARIAN PATHOLOGY

USS

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