Emergency Radiology

https://doi.org/10.1007/s10140-019-01747-3

REVIEW ARTICLE

Emergent MRI for acute abdominal pain in pregnancy—review

of common pathology and imaging appearance
Arafat Ali 1 & Katrina Beckett 2 & Carl Flink 1

Received: 23 August 2019 / Accepted: 20 December 2019

# American Society of Emergency Radiology 2020

Abstract
Acute abdominal pain in pregnancy remains a clinically challenging presentation, often requiring imaging. The threat of mor-
bidity and mortality to both mother and fetus necessitates quick and accurate imaging diagnosis, often via ultrasound. However,
many of the common causes of acute abdominal pain are not readily diagnosed with sonography, and magnetic resonance
imaging (MRI) is increasingly favored in this setting. The purpose of this review is to familiarize the reader with common
pathologies which may be encountered in pregnant females presenting with acute abdominal pain requiring emergent MRI.

Keywords Emergency . Pregnancy . MRI . Abdominal pain . Appendicitis

Introduction this article is to provide a review of the causes of acute ab-

dominal pain in pregnancy in the emergent setting. Obstetric
Abdominal pain in pregnancy is a common presenting symp- causes of pregnancy-related abdominal pain are important;
tom in the emergency room which may portend a wide variety however, imaging findings of abdominal pain from obstetric
of causes including gynecologic, gastrointestinal, etiology are outside of the scope of this article.
hepatobiliary, genitourinary, and vascular etiologies. Clinical
signs and symptoms associated with abdominal pain in preg-
nancy, including nausea, vomiting, and leukocytosis, are
MRI protocol
vague and nonspecific. Morning sickness, for example, is
common in early pregnancy and may be mistaken for acute
Current American College of Radiology (ACR) MRI safety
gastrointestinal conditions [1]. Leukocytosis is a well-
guidelines deem MR evaluation of the pregnant female as
recognized phenomenon in normal uncomplicated pregnancy
generally safe to both fetus and mother [21]. Deleterious ef-
[2, 3]. Even normal changes in anatomy from the enlarging
fects of MRI result from heating of the fetus and amniotic fluid
uterus can alter or produce pain symptoms due to stretching of
due to radiofrequency deposition [18]. However, specific ab-
the abdominal wall and displacement of the viscera [4].
sorption rate (SAR) is typically monitored and kept below the
Frequently, imaging is crucial to exclude acute etiologies of
threshold necessary increase fetal temperature to potentially
abdominal pain. Ultrasound remains the first-line imaging op-
teratogenic levels [17].
tion; however, MRI is gaining favor in the emergent setting
Most MRI protocols for imaging of acute abdominal pain
due to its increased diagnostic accuracy, relatively quick ac-
in pregnancy use a combination of triplane single-shot fast
quisition time, and excellent safety profile [5–20]. The aim of
spin-echo (SSFSE) acquisitions, axial spoiled 3D gradient
echo, axial true fast imaging with steady-state procession, ax-
* Arafat Ali ial in-phase and out-of-phase sequences, and short tau inver-
Alia4@ucmail.uc.edu sion recovery (STIR) sequences. However, the full gamut of
these sequences is not always necessary for diagnosis of many
1
Department of Radiology, University of Cincinnati Medical Center,
causes of acute abdominal pain in the pregnant female.
234 Goodman Street, Cincinnati, OH 45267, USA At our institution, the MRI protocol for acute abdominal
2
Department of Radiology, University of California Los Angeles
pain during pregnancy in the emergent setting is comprised of
Medical Center, 10833 Le Conte Avenue, Los Angeles, CA 90095, a triplane T2-weighted SSFSE sequence with and without fat
USA saturation at 1.5 T magnet strength using a field of view from

the diaphragms to the lesser trochanters. The use of this rapid
acquisition sequence decreases artifact from both maternal
bowel and fetal motion. Total estimated acquisition time
ranges between 20 and 30 min. Oral contrast is not adminis-
tered. These limited sequences suffice for the diagnosis of
most common pathology. The need for additional sequences
may be tailored to the patient presentation or imaging findings
in real time at the discretion of the interpreting radiologist. For
example, T1-weighted gradient echo sequences can be added
to better characterize hemorrhage and diffusion-weighted se-
quences may be necessary to diagnose inflammatory condi-
tions such as appendicitis or pelvic abscess. The use of
gadolinium-based contrast agents is generally not recom-
mended as they have been shown to cross the placental barrier
and the teratogenic potential of these agents are not well
established [21].
Gastrointestinal pathology
Appendicitis
Appendicitis is widely reported as the most common indica-
tion for emergent extrauterine surgery in the pregnant female
[6–12, 14]. The rate of appendicitis during pregnancy ranges
between 0.02 and 0.07%, roughly equal to that of the general
population [7, 22]. Early identification and operative manage-
ment are critical in pregnant females, as the risk of fetal mor-
tality substantially increases in cases of complicated appendi-
citis. Fetal mortality rates are reported as high as 36% in cases
of appendicitis complicated by abscess or perforation [9].
By the current American College of Radiology (ACR) ap-
propriateness criteria, ultrasound remains the first-line modal-
ity and MRI the second line for the diagnosis of appendicitis.
Due to technical difficulty in locating and adequately
compressing the appendix in pregnant females by ultrasound,
the use of MRI is increasing [13]. In fact, multiple studies
demonstrate favorable reductions in negative laparotomy rates
with routine use of MRI for pregnant females with suspected
appendicitis [7, 11].
On MRI, the normal appendix is a tubular, blind-ending
structure arising from the cecum which can be fluid-, air-, or
contrast-filled (Fig. 1a). Acute appendicitis appears as dilata-
tion of the appendix (> 7 mm), thickened appendiceal wall
(normal < 2 mm), and high T2 signal peri-appendiceal inflam-
matory change (Fig. 1b, c). Appendicoliths appear as focal
low T2 signal filling defects in the lumen of the appendix
but are not always present. Rosenbaum et al. suggest that the
presence of abscess, wall defect, or diffusion restriction within
peri-appendiceal fluid can reliably predict perforation (Fig.
1d, e) [15]. The sensitivity for detecting each individual find-
ing is low; however, in combination, the likelihood of perfo-
ration increases.
Emerg Radiol
Of note, differences in susceptibility at the interfaces of air and
soft tissue may result in poor fat suppression [23, 24]. For exam-
ple, gas within the cecum may result in poor fat suppression in
the surrounding soft tissues creating the false appearance of T2
hyperintensity surrounding the appendix (Fig. 1f, g). This artifact
should not be mistaken for acute appendicitis and if there is need
for further clarification, out-of-phase imaging may be performed.
One of the technical challenges of diagnosing appendicitis by
ultrasound in pregnancy is locating the appendix. MRI allows for
better visualization of the appendix compared with ultrasound;
however, it is important to keep in mind the atypical location.
The appendix is often displaced cranially by the gravid uterus
and can be difficult to locate, even on MRI. In a study by Oto
et al., a small cohort of pregnant patients suggested a correlation
between gestational age and appendix location [10]. First trimes-
ter patient’s appendix location was below the iliac crests, similar
to the general population. Later gestational age demonstrated
progressive cranial migration of the appendix location with a
mean of 2.6 cm above the iliac crests by the third trimester.
Infectious/inflammatory bowel disease
The peak incidence of inflammatory disease (IBD) occurs dur-
ing the reproductive years of life. A large meta-analysis of IBD
during pregnancy demonstrates low birth weight, increased in-
cidence of prematurity, and congenital abnormalities in those
with active disease [25]. The presence of active inflammatory
change and major complications such as fistula or abscess for-
mation pose a significant risk to both the fetus and mother. As
such, identifying these issues is vital to guiding management.
The frequency that Crohn’s disease affects the terminal ile-
um creates a diagnostic challenge in both clinical presentation
and imaging characteristics. Symptoms of right lower quadrant
pain, nausea, vomiting, and leukocytosis are nonspecific and
often also seen in patients with appendicitis. On MRI, findings
of wall thickening and edema are ubiquitous and may be reac-
tive in the context of appendicitis or ileitis (Fig. 2). Features of
luminal narrowing and fistula and abscess formation may be
more telling, with the latter two being associated with greatest
morbidity and mortality [26]. Additionally, the presence of
perianal disease is important to qualify, as this may be an indi-
cation for caesarian delivery [27].
Small bowel obstruction
Bowel obstruction is another important cause of acute abdom-
inal pain in pregnancy which can present with vague abdominal
pain, nausea, and vomiting. Bowel obstructions caused by ad-
hesion may be managed conservatively, while those caused by
volvulus or internal hernia require surgery [28, 29]. MRI can be
useful to characterize the etiology of obstruction and the subse-
quent need for surgery. Similar to findings on CT, dilated small
bowel and a discrete transition point will be evident on MRI
Emerg Radiol
Fig. 1 Normal and abnormal MRI appearance of the appendix in
pregnant females. Axial (a) T2-weighted SSFSE image without fat satu-
ration shows a normal appendix in a right lower quadrant retrocecal
location (arrow). Coronal (b) and sagittal (c) T2-weighted SSFSE images
show a thickened and dilated appendix with peri-appendiceal inflamma-
tory changes (arrows), compatible with acute uncomplicated appendicitis.
In a different pregnant patient, axial (d) and sagittal (e) T2-weighted
(Fig. 3). It is important to be aware that pseudostenosis may
also occur due to compression of bowel by the gravid uterus
with luminal narrowing in the absence of inflammatory change.
Biliary disease
Pregnant patients are predisposed to the development of gall-
stones and subsequent biliary complication due to bile stasis
and decreased gallbladder contraction. Incidence of
Fig. 2 Ileitis in a pregnant female.
Coronal (a) T2-weighted SSFSE
images show extensive wall
thickening and edema of the ile-
um (arrow) with free fluid in the
pelvis (arrowhead). In the same
patient, coronal image (b) dem-
onstrates a normal appendix
(arrow)
SSFSE images show a thickened and dilated appendix (arrows) with
extensive peri-appendiceal fluid and an appendicolith (arrowhead), sug-
gesting perforated appendicitis. Sagittal T2-weighted SSFSE image with
fat saturation (f) demonstrates artifactual increased signal adjacent to the
cecum (arrowhead), due to incomplete fat saturation. Corresponding T2-
weight SSFSE without fat saturation (g) demonstrates a normal appearing
appendix (arrow)
cholelithiasis is reported as high as 2–4% in pregnant females
undergoing routine ultrasound. Up to 5% of patients with
gallstones will become symptomatic [30, 31]. Ultrasound is
the first-line diagnostic modality for the diagnosis of obstruc-
tive biliary pathology; however, circumstances may require
additional imaging, such as MRCP.
Cholelithiasis and choledocholithiasis are demonstrat-
ed on MRCP as a dependent signal void in the gall-
bladder or common bile duct respectively, with or
 Emerg Radiol

Fig. 3 Small bowel obstruction in a pregnant female. Coronal T2- with transition point in the distal jejunum/proximal ileum in the mid
weighted SSFSE (a), coronal true FISP (b), and axial T2-weighted abdomen (arrow), suggesting small bowel obstruction in this pregnant
SSFSE (c) images show dilated loops of jejunum in the upper abdomen patient with a history of prior lysis of adhesions due to endometriosis

without intra- or extrahepatic biliary ductal dilation
(Fig. 4a).
One potential complication of cholelithiasis is the develop-
ment of acute cholecystitis, which is reported in up to 1 in
1600 to 1 in 10,000 pregnancies [5, 30, 31]. Acute cholecys-
titis is the second most common indication for surgical inter-
vention in pregnancy and it often results from an impacted
stone in the cystic duct [30, 32]. Equivocal initial ultrasound
findings may prompt the need for further imaging with MRI to
delineate calculi in the gallbladder neck or cystic duct and
abnormalities of the gallbladder wall. Typical MRI findings
of acute cholecystitis include gallbladder distension, edema/
thickening of the gallbladder wall (> 3 mm) on T2-weighted
sequences, and pericholecystic free fluid.
Pancreatitis
Pancreatitis in pregnancy typically occurs in the third trimester
and is most often a sequela of choledocholithiasis or hyperlip-
idemia [33, 34]. Abdominal pain, vomiting, and elevated li-
pase are typical presenting symptoms. MRI findings in preg-
nant patients mirror those of non-pregnant individuals. Focal
or diffuse increased T2 signal peripancreatic edema results
from release of pancreatic enzymes (Fig. 4b, c). Sequelae of

Fig. 4 Cholelithiasis and

gallstone pancreatitis in
pregnancy. Coronal oblique (a)
T2-weighted image shows multi-
ple filling defects within the distal
common bile duct (arrow), con-
sistent with choledocholithiasis.
In a separate patient, coronal (b)
and axial (c) T2-weighted se-
quences demonstrate diffuse pan-
creatic edema in the setting of
multiple obstructing
choledocholiths indicating gall-
stone pancreatitis
Emerg Radiol
acute pancreatitis such as abscess formation or pancreatic ne-
crosis are important causes of morbidity and mortality to both
mother and fetus.
HELLP syndrome
Hemolysis, elevated liver enzymes, and low platelets
(HELLP) is a complication of pregnancy, usually associated
with preeclampsia, which occurs in up to 0.5–0.9% of all
pregnancies [35]. The maternal complications of this condi-
tion include hepatic edema and hemorrhage. Imaging may
demonstrate hepatic edema, necrosis, or hemorrhage, the latter
of which may prompt surgical intervention [5, 36]. Hepatic
edema appears as focal or diffused increased T2-weighted
signal intensity and the appearance of hemorrhage is variable,
depending on the age of the hematoma.
Genitourinary pathology
Hydronephrosis
Hydronephrosis in pregnancy may be physiologic or patho-
logic. Physiologic hydronephrosis is reported in up to 90% of
pregnancies and is more often right-sided [37, 38].
Physiologic dilation of the collecting system results from a
combination of smooth muscle relaxation due to increased
circulating progesterone as well as compression of the ureter
against the psoas muscle by the gravid uterus [5]. The most
common cause of pathologic hydronephrosis in pregnancy is
obstructing calculi. Accurate diagnosis of obstructive
hydronephrosis is important due to the increased risk of pre-
mature labor and infection. Furthermore, the presence of ure-
teral obstruction may be further complicated by infection such
as pyelonephritis.
Ultrasound remains the first-line diagnostic modality for
diagnosis of hydronephrosis. However, MRI can add diagnos-
tic value by distinguishing the cause of hydronephrosis.
Physiologic hydronephrosis is characterized by smooth taper-
ing of the ureter as it is compressed against the psoas muscles
(Fig. 5a). Obstructing calculi are often visible as a signal void
within the fluid filled ureter with an abrupt change in caliber,
upstream dilation, and perinephric edema (Fig. 5b).
Pyelonephritis
Acute pyelonephritis is among the leading causes for
antepartum hospitalization and may be seen in up to 2% of
pregnancies in the USA [39]. Wing et al. also suggest in-
creased risk of anemia, septicemia, low birth weights, and
spontaneous preterm labor in patients diagnosed with pyelo-
nephritis in the antepartum period. While acute pyelonephritis
is often a clinical diagnosis, MRI can aide in the evaluation of
complications such as abscess formation.
On MRI, one or both kidneys may be enlarged with heter-
ogenous T2 signal intensity, often linear and wedge-shaped in
configuration, with associated increased T2 hyperintense
perinephric fluid (Fig. 5c) [40, 41]. One limiting factor in
pregnant patients is the inability to use gadolinium-based con-
trast agents, which would otherwise demonstrate the charac-
teristic striated or wedge-shaped pattern of renal parenchymal
enhancement. Diffusion-weighted MR sequence can help to
identify an abscess by abscesses by demonstrating restricted
diffusion.
Gynecologic pathology
Ovarian torsion
Ovarian torsion demonstrates a fivefold increased incidence in
pregnancy and occurs most often during the first trimester, in
the rapid stages of uterine enlargement [5, 16]. MRI may be
useful in cases where sonography is technically challenging or
equivocal. Furthermore, 50–81% of cases of ovarian torsion
are associated with an ipsilateral ovarian mass or cyst which
can be characterized at MR imaging [42]. Ovarian enlarge-
ment, edema, and thickening of the fallopian tube are hallmark
findings of torsion and are best seen on T2 sequences (Fig. 6).
Varied intraparenchymal hemorrhage may also be present and
is more readily detected on T1 sequences. Ovarian edema may
occur in the absence of torsion as a result of compression of
ovarian vessels between the gravid uterus and pelvic sidewall
or intermittent/partial torsion. On imaging, ovarian edema
may be indistinguishable from ovarian torsion, but a history
of weeks to months of intermittent pelvic pain suggests ovar-
ian edema.
Adnexal masses
Adnexal masses can be broadly categorized into non-
neoplastic and neoplastic lesions. They are present in approx-
imately 1–2% of pregnancies, of which only 1–3% are malig-
nant [43]. Adnexal masses are typically asymptomatic and
usually become symptomatic only if rapidly enlarging, rup-
tured, or acting as a lead point for ovarian torsion [5].
Symptomatic patients may necessitate emergent imaging and
MRI should be considered over ultrasound given its ability to
better characterize the lesion.
Non-neoplastic adnexal masses are predominantly ovarian
cysts, which are the most commonly encountered adnexal
mass in pregnancy. Ovarian cysts include corpus luteum cysts,
follicular cysts, hemorrhagic cysts, endometriomas, theca lu-
tein cysts, and tubo-ovarian abscesses.

Fig. 5 Physiologic hydronephrosis, obstructive hydronephrosis, and
acute uncomplicated pyelonephritis in pregnancy. Sagittal (a) T2-
weighted SSFE image shows gradual tapering of the distal ureter as it is
compressed between the gravid uterus and psoas muscle (asterisk).
Coronal (b) T2-weighted SSFE images in a different patient shows an
On MRI, corpus luteum and follicular cysts demonstrate
high T2 and intermediate to low T1 signal (Fig. 7a, b). Corpus
luteum cysts demonstrate a characteristic irregular thick-
walled appearance while follicular cysts are typically thin-
walled and homogeneous in signal. Hemorrhagic cysts and
endometriomas demonstrate T1 shortening and do not lose
signal on the fat-saturated sequences due to the presence of
blood products (Fig. 7c). Endometriomas are usually thicker
walled and demonstrate intermediate to low T2 signal com-
pared with hemorrhagic cysts. This phenomenon of T2 signal
shortening has been described as “the Shading Sign” and is
attributed to the dense protein and iron content of
endometriotic cysts acquired through repetitive bleeding
[44]. Conversely, hemorrhagic cysts usually remain bright
on T2-weighted sequences as their contents are typically not
as viscous as endometriomas. Theca lutein cysts are rarely
encountered in the emergent setting and MRI adds little addi-
tional diagnostic value.
Tubo-ovarian abscess (TOA) is extremely rare in the set-
ting of pregnancy with only a small number of cases reported
Fig. 6 Ovarian torsion in pregnancy. Axial T2-weighted SSFSE se-
quence demonstrates an enlarged and edematous right ovary with multi-
ple cysts (arrow), concerning for torsion
Emerg Radiol
obstructive calculus as a signal void (arrow) with upstream dilation of the
collecting system in a pregnant female with obstructive hydronephrosis.
Axial (c) T2-weighted SSFE image demonstrates edema signal along the
superior aspect of the right kidney with striated appearance (arrow), sug-
gesting acute pyelonephritis
in the literature [45–48]. Ultrasound, in combination with a
clinical presentation of fever, leukocytosis, and vaginal dis-
charge, frequently provides sufficient information for accurate
diagnosis of TOA. If encountered on MRI, TOA frequently
presents as an ill-defined fluid-filled adnexal mass with
hypointense T1 and hyperintense T2 signal contents.
Thickened irregular walls are also a typical finding. Cystic
ovarian malignancy may have a similar appearance to TOA
on MRI. Restricted diffusion is more characteristic of TOA
and the addition of a diffusion sequence may be beneficial in
this context [49].
Neoplastic adnexal masses include surface-epithelial stro-
mal tumors, germ cell ovarian tumors, sex cord/stromal ovar-
ian tumors, lymphoma, and metastasis. Epithelial tumors are
the most common ovarian neoplasm in adults and comprise a
group of predominantly cystic tumors including serous and
mucinous tumors, endometrioid and clear cell carcinomas.
Benign serous and mucinous cystadenomas are the most com-
mon subtypes of epithelial tumors [50, 51]. Serous
cystadenomas typically appear as unilocular cystic masses
with thin walls and homogenous low T1 and high T2 signal
characteristics. Mucinous cystadenomas tend to be
multilocular with cysts of varying signal intensity, depending
on the concentration of mucin within each cyst. The presence
of solid components, papillary projections, central necrosis, or
mural/septal wall thickening is more characteristic of border-
line ovarian epithelial neoplasia or cystadenocarcinoma, rath-
er than benign cystadenomas (Fig. 8a, b). Several authors have
proposed wall thickness less than 3 mm as a predictor of
benignity [52, 53]. However, this criterion is not highly spe-
cific and benign lesions such as sex cord stromal tumors and
cystadenofibromas may present with some solid components
or thickened walls (Fig. 8c).
Mature ovarian teratoma (dermoid cyst) is the most com-
mon ovarian tumor found in pregnancy and comprises up to
20% of ovarian tumors in adults [51, 54–56]. The MRI
Emerg Radiol
Fig. 7 Benign ovarian cysts pregnancy. Axial (a) T2-weighted SSFSE
image shows a rounded, thick-walled, and centrally T2 hyperintense cyst
in the right ovary, characteristic of a corpus luteal cyst. Coronal (b) T2-
appearance of this lesion is heterogeneous and largely depen-
dent upon the various germ cell layer derivations present with-
in the tumor. Large cystic components are typically T2 hyper-
intense and T1 hypointense. Fatty components are T1 hyper-
intense and intermediate to low in signal on T2 sequences.
The distinguishing characteristic of this tumor is loss of signal
on fat-saturated sequences due to the presence of macroscopic
fat (Fig. 9).
Leiomyoma
Fibroids are an unusual cause of abdominal pain in the preg-
nant female which may necessitate acute imaging. Altered
blood flow in pregnancy results in decreased size of
leiomyomas; however, large fibroids may undergo hemor-
rhagic infarction resulting in pelvic pain [5, 16, 57, 58].
Coronado et al. also cite fibroids as a risk factor for abnormal
uterine bleeding, placental abruption, premature rupture of
membranes, and preterm delivery. On MRI, non-degenerated
Fig. 8 Cystic ovarian masses in pregnancy. Axial (a) and coronal (b) T2-
weighted SSFSE show enlarged ovaries with multiple cystic foci, solid
components, and papillary projections. Pathology revealed borderline
serous ovarian tumor. Sagittal (c) T2-weighted SSFSE in a different
weighted SSFSE images with fat saturation in a different patient shows a
thin-walled T2 hyperintense follicular cyst. Axial (c) T2-weighted SSFSE
image demonstrates T2 shading in a hemorrhagic cyst
leiomyomas appear as well-circumscribed masses with low
T2 signal intensity when compared with the adjacent
myometrium. Degenerated leiomyomas can appear variable
on T2-weighted sequences. Calcifications have low signal in-
tensity and areas of cystic degeneration, edema, and necrosis
have high signal intensity on T2-weighted imaging.
T1 signal characteristics of leiomyomas can also vary from
peripheral or diffuse T1 hyperintensity depending on the con-
tent of protein or methemoglobin (Fig. 10) [59].
Vascular pathology
Venous thromboembolic disease
Pregnancy is a well-established risk factor for venous throm-
boembolism (VTE), which occurs as a result of hypercoagu-
lability and venous stasis. VTE occurs at a frequency between
0.76 and 1.72 per 1000 pregnancies, which is four times the
patient shows a T2 hyperintense cyst with irregular mural thickening,
concerning for borderline ovarian tumor or cystadenocarcinoma.
However, subsequent pathology revealed a benign cystadenofibroma

Fig. 9 Mature ovarian teratoma in
pregnancy. Axial T2-weighted
SSFSE (a) shows a predominate-
ly T2 intermediate mass arising
from the left ovary which loses
signal (arrows) on fat-saturated
T2-weighted images (b), most
compatible with a mature ovarian
teratoma. Intermittent torsion
resulting from this lead point was
suspected as the cause of recur-
rent abdominal pain
incidence of the non-pregnant population [60]. The majority
of thrombosis occurs within the lower extremities; however,
pregnant patients are also at risk for VTE elsewhere including
the pelvic, hepatic, mesenteric, and gonadal vessels. There is a
predilection for left lower extremity venous thrombosis in
pregnancy, which is attributed in increased left lower extrem-
ity venous stasis from the left iliac vein compression by the
right iliac artery and added compressive effects of the gravid
uterus [61]. Pulmonary embolism is the leading cause of ma-
ternal death; therefore, prompt recognition of VTE is critical
to prevent delay in therapy initiation [60].
Gadolinium-enhanced MR venography has been shown to
be superior to both conventional venography and unenhanced
MR venographic techniques for the diagnosis of VTE [62,
63]. However, the need for contrast precludes its use for preg-
nant females. Thrombosis can still be detected, although with
lower sensitivity, on traditional MRI sequences. On T2 se-
quences, the absence of a low signal intensity flow voids
raises suspicion for thrombus. MRI with 2D time of flight
(TOF) sequences may also be helpful; however, image
Fig. 10 Leiomyomas in pregnancy. Coronal T2-weighted SSFSE image
shows a gravid uterus containing multiple leiomyomas with heteroge-
neous central T2 hyperintensity characteristic of edema and necrosis
(arrow) in a degenerating fibroid
Emerg Radiol
acquisition is time-consuming and this sequence is subject to
artifact from flow directionality and turbulence, which may be
incorrectly interpreted as thrombus [64]. True fast imaging
with steady-state procession (FISP) can aid in detection of
thrombus as well, although at lower sensitivity compared with
enhanced MR venography [65]. Presence of flow appears as
normal high signal intensity within the vessel and absence of
flow appears as low signal intensity on both MRI with 2D
TOF and true FISP sequences.
Conclusion
Acute abdominal pain in a pregnant female presents a number
of unique diagnostic challenges. MRI is increasingly utilized
in the emergent setting as it is generally considered safe and
offers greater diagnostic utility than sonography. As such, it is
increasingly important for the radiologist to be aware of the
typical causes of abdominal pain in the emergent setting and
their imaging features.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
References
1. American College of Obstetricians and Gynecologists (2018)
Nausea and vomiting of pregnancy. ACOG Practice Bulletin No.
189. Obstet Gynecol 131:e15–e30
2. Pitkin RM, Witte DL (1979) Platelet and leukocyte counts in preg-
nancy. JAMA 242(24):2696–2698
3. Lurie S, Rahamim E, Piper I, Golan A, Sadan O (2008) Total and
differential leukocyte counts percentiles in normal pregnancy. Eur J
Obstet Gynecol Reprod Biol 136(1):16–19. https://doi.org/10.
1016/j.ejogrb.2006.12.013
4. Parangi S, Levine D, Henry A, Isakovich N, Pories S (2007)
Surgical gastrointestinal disorders during pregnancy. Am J Surg
193(2):223–232. https://doi.org/10.1016/j.amjsurg.2006.04.021
5. Spalluto LB, Woodfield CA, DeBenedectis CM, Lazarus E (2012)
MR imaging evaluation of abdominal pain during pregnancy:
Emerg Radiol
appendicitis and other nonobstetric causes. Radiographics 32(2):
317–334. https://doi.org/10.1148/rg.322115057
6. Israel GM, Malguria N, McCarthy S, Copel J, Weinreb J (2008)
MRI vs. ultrasound for suspected appendicitis during pregnancy. J
Magn Reson Imaging 28(2):428–433. https://doi.org/10.1002/jmri.
21456
7. Pedrosa I, Lafornara M, Pandharipande PV, Goldsmith JD, Rofsky
NM (2009) Pregnant patients suspected of having acute appendici-
tis: effect of MR imaging on negative laparotomy rate and
appendiceal perforation rate. Radiology 250(3):749–757. https://
doi.org/10.1148/radiol.2503081078
8. Pedrosa I, Zeikus EA, Levine D, Rofsky NM (2007) MR imaging
of acute right lower quadrant pain in pregnant and nonpregnant
patients. Radiographics 27(3):721–743; discussion 743-753.
https://doi.org/10.1148/rg.273065116
9. Oto A, Ernst RD, Ghulmiyyah LM, Nishino TK, Hughes D,
Chaljub G, Saade G (2009) MR imaging in the triage of pregnant
patients with acute abdominal and pelvic pain. Abdom Imaging
34(2):243–250. https://doi.org/10.1007/s00261-008-9381-y
10. Oto A, Srinivasan PN, Ernst RD, Koroglu M, Cesani F, Nishino T,
Chaljub G (2006) Revisiting MRI for appendix location during
pregnancy. AJR Am J Roentgenol 186(3):883–887. https://doi.
org/10.2214/AJR.05.0270
11. Rapp EJ, Naim F, Kadivar K, Davarpanah A, Cornfeld D (2013)
Integrating MR imaging into the clinical workup of pregnant pa-
tients suspected of having appendicitis is associated with a lower
negative laparotomy rate: single-institution study. Radiology
267(1):137–144. https://doi.org/10.1148/radiol.12121027
12. Singh AK, Desai H, Novelline RA (2009) Emergency MRI of acute
pelvic pain: MR protocol with no oral contrast. Emerg Radiol 16(2):
133–141. https://doi.org/10.1007/s10140-008-0748-8
13. Hansen W, Moshiri M, Paladin A, Lamba R, Katz DS, Bhargava P
(2017) Evolving practice patterns in imaging pregnant patients with
acute abdominal and pelvic conditions. Curr Probl Diagn Radiol
46(1):10–16. https://doi.org/10.1067/j.cpradiol.2016.06.002
14. Cobben LP, Groot I, Haans L, Blickman JG, Puylaert J (2004) MRI
for clinically suspected appendicitis during pregnancy. AJR Am J
Roentgenol 183(3):671–675. https://doi.org/10.2214/ajr.183.3.
1830671
15. Rosenbaum DG, Askin G, Beneck DM, Kovanlikaya A (2017)
Differentiating perforated from non-perforated appendicitis on
contrast-enhanced magnetic resonance imaging. Pediatr Radiol
47(11):1483–1490. https://doi.org/10.1007/s00247-017-3900-3
16. Woodfield CA, Lazarus E, Chen KC, Mayo-Smith WW (2010)
Abdominal pain in pregnancy: diagnoses and imaging unique to
pregnancy–review. AJR Am J Roentgenol 194(6 Suppl):WS14–
WS30. https://doi.org/10.2214/AJR.07.7139
17. Hand JW, Li Y, Thomas EL, Rutherford MA, Hajnal JV (2006)
Prediction of specific absorption rate in mother and fetus associated
with MRI examinations during pregnancy. Magn Reson Med 55(4):
883–893. https://doi.org/10.1002/mrm.20824
18. Gowland PA, De Wilde J (2008) Temperature increase in the fetus
due to radio frequency exposure during magnetic resonance scan-
ning. Phys Med Biol 53(21):L15–L18. https://doi.org/10.1088/
0031-9155/53/21/L01
19. Kotecha HM, McIntosh LJ, Lo HS, Chen BY, Dupuis CS (2017)
What to expect when they are expecting: magnetic resonance im-
aging of the acute abdomen and pelvis in pregnancy. Curr Probl
Diagn Radiol 46(6):423–431. https://doi.org/10.1067/j.cpradiol.
2016.12.007
20. Baheti AD, Nicola R, Bennett GL, Bordia R, Moshiri M, Katz DS,
Bhargava P (2016) Magnetic resonance imaging of abdominal and
pelvic pain in the pregnant patient. Magn Reson Imaging Clin N
Am 24(2):403–417. https://doi.org/10.1016/j.mric.2015.11.007
21. Expert Panel on MRS, Kanal E, Barkovich AJ, Bell C, Borgstede
JP, Bradley WG Jr, Froelich JW, Gimbel JR, Gosbee JW, Kuhni-
Kaminski E, Larson PA, Lester JW Jr, Nyenhuis J, Schaefer DJ,
Sebek EA, Weinreb J, Wilkoff BL, Woods TO, Lucey L, Hernandez
D (2013) ACR guidance document on MR safe practices: 2013. J
Magn Reson Imaging 37(3):501–530. https://doi.org/10.1002/jmri.
24011
22. Lee RA, Johnson CE, Symmonds RE (1965) Appendicitis during
pregnancy. JAMA 193:966–968. https://doi.org/10.1001/jama.
1965.03090110104035
23. Yang RK, Roth CG, Ward RJ, deJesus JO, Mitchell DG (2010)
Optimizing abdominal MR imaging: approaches to common prob-
lems. Radiographics 30(1):185–199. https://doi.org/10.1148/rg.
301095076
24. Delfaut EM, Beltran J, Johnson G, Rousseau J, Marchandise X,
Cotten A (1999) Fat suppression in MR imaging: techniques and
pitfalls. Radiographics 19(2):373–382. https://doi.org/10.1148/
radiographics.19.2.g99mr03373
25. Cornish J, Tan E, Teare J, Teoh TG, Rai R, Clark SK, Tekkis PP
(2007) A meta-analysis on the influence of inflammatory bowel
disease on pregnancy. Gut 56(6):830–837. https://doi.org/10.1136/
gut.2006.108324
26. Palomba S, Sereni G, Falbo A, Beltrami M, Lombardini S, Boni
MC, Fornaciari G, Sassatelli R, La Sala GB (2014) Inflammatory
bowel diseases and human reproduction: a comprehensive
evidence-based review. World J Gastroenterol 20(23):7123–7136.
https://doi.org/10.3748/wjg.v20.i23.7123
27. Stern MD, Kopylov U, Ben-Horin S, Apter S, Amitai MM (2014)
Magnetic resonance enterography in pregnant women with Crohn’s
disease: case series and literature review. BMC Gastroenterol 14:
146–149. https://doi.org/10.1186/1471-230X-14-146
28. Webster PJ, Bailey MA, Wilson J, Burke DA (2015) Small bowel
obstruction in pregnancy is a complex surgical problem with a high
risk of fetal loss. Ann R Coll Surg Engl 97(5):339–344. https://doi.
org/10.1308/003588415X14181254789844
29. Vassiliou I, Tympa A, Derpapas M, Kottis G, Vlahos N (2012)
Small bowel ischemia due to jejunum volvulus in pregnancy: a case
report. Case Rep Obstet Gynecol 2012:485863. https://doi.org/10.
1155/2012/485863
30. Sharp HT (2002) The acute abdomen during pregnancy. Clin Obstet
Gynecol 45(2):405–413
31. Melnick DM, Wahl WL, Dalton VK (2004) Management of general
surgical problems in the pregnant patient. Am J Surg 187(2):170–
180. https://doi.org/10.1016/j.amjsurg.2003.11.023
32. Catalano OA, Sahani DV, Kalva SP, Cushing MS, Hahn PF, Brown
JJ, Edelman RR (2008) MR imaging of the gallbladder: a pictorial
essay. Radiographics 28 (1):135–155; quiz 324. doi:https://doi.org/
10.1148/rg.281065183
33. Sun L, Li W, Geng Y, Shen B, Li J (2011) Acute pancreatitis in
pregnancy. Acta Obstet Gynecol Scand 90(6):671–676. https://doi.
org/10.1111/j.1600-0412.2011.01072.x
34. Mali P (2016) Pancreatitis in pregnancy: etiology, diagnosis, treat-
ment, and outcomes. Hepatobiliary Pancreat Dis Int 15(4):434–438
35. Haram K, Svendsen E, Abildgaard U (2009) The HELLP syn-
drome: clinical issues and management. A review. BMC
Pregnancy Childbirth 9:8. https://doi.org/10.1186/1471-2393-9-8
36. Nunes JO, Turner MA, Fulcher AS (2005) Abdominal imaging
features of HELLP syndrome: a 10-year retrospective review.
AJR Am J Roentgenol 185(5):1205–1210. https://doi.org/10.
2214/AJR.04.0817
37. Spencer JA, Chahal R, Kelly A, Taylor K, Eardley I, Lloyd SN
(2004) Evaluation of painful hydronephrosis in pregnancy: magnet-
ic resonance urographic patterns in physiological dilatation versus
calculous obstruction. J Urol 171(1):256–260. https://doi.org/10.
1097/01.ju.0000102477.19999.b2
38. Peake SL, Roxburgh HB, Langlois SL (1983) Ultrasonic assess-
ment of hydronephrosis of pregnancy. Radiology 146(1):167–170.
https://doi.org/10.1148/radiology.146.1.6849041

39. Wing DA, Fassett MJ, Getahun D (2014) Acute pyelonephritis in
pregnancy: an 18-year retrospective analysis. Am J Obstet Gynecol
210 (3):219 e211-216. doi:https://doi.org/10.1016/j.ajog.2013.10.
006
40. Craig WD, Wagner BJ, Travis MD (2008) Pyelonephritis:
radiologic-pathologic review. Radiographics 28 (1):255–277; quiz
327-258. doi:https://doi.org/10.1148/rg.281075171
41. Das CJ, Ahmad Z, Sharma S, Gupta AK (2014) Multimodality
imaging of renal inflammatory lesions. World J Radiol 6(11):865–
873
42. Rha SE, Byun JY, Jung SE, Jung JI, Choi BG, Kim BS, Kim H, Lee
JM (2002) CT and MR imaging features of adnexal torsion.
Radiographics 22(2):283–294. https://doi.org/10.1148/
radiographics.22.2.g02mr02283
43. Telischak NA, Yeh BM, Joe BN, Westphalen AC, Poder L, Coakley
FV (2008) MRI of adnexal masses in pregnancy. AJR Am J
Roentgenol 191(2):364–370. https://doi.org/10.2214/AJR.07.3509
44. Glastonbury CM (2002) The shading sign. Radiology 224(1):199–
201. https://doi.org/10.1148/radiol.2241010361
45. Matsunaga Y, Fukushima K, Nozaki M, Nakanami N, Kawano Y,
Shigematsu T, Satoh S, Nakano H (2003) A case of pregnancy
complicated by the development of a tubo-ovarian abscess follow-
ing in vitro fertilization and embryo transfer. Am J Perinatol 20(6):
277–282. https://doi.org/10.1055/s-2003-42772
46. Dudley AG, Lee F, Barclay D (1970) Ovarian and tubo-ovarian
abscess in pregnancy: report of a case and a review of the literature.
Mil Med 135(5):403–406
47. Davey MM, Guidozzi F (1987) Ruptured tubo-ovarian abscess late
in pregnancy. a case report. S Afr Med J 71(2):120–121
48. Hunt SM, Kincheloe BW, Schreier PC (1974) Tubo-ovarian ab-
scess in pregnancy. Obstet Gynecol 43(1):57–60
49. Wang T, Li W, Wu X, Yin B, Chu C, Ding M, Cui Y (2016) Tubo-
ovarian abscess (with/without pseudotumor area) mimicking ovar-
ian malignancy: role of diffusion-weighted MR imaging with ap-
parent diffusion coefficient values. PLoS One 11(2):e0149318.
https://doi.org/10.1371/journal.pone.0149318
50. Jung SE, Lee JM, Rha SE, Byun JY, Jung JI, Hahn ST (2002) CT
and MR imaging of ovarian tumors with emphasis on differential
diagnosis. Radiographics 22(6):1305–1325. https://doi.org/10.
1148/rg.226025033
51. Jeong YY, Outwater EK, Kang HK (2000) Imaging evaluation of
ovarian masses. Radiographics 20(5):1445–1470. https://doi.org/
10.1148/radiographics.20.5.g00se101445
52. Outwater EK, Dunton CJ (1995) Imaging of the ovary and adnexa:
clinical issues and applications of MR imaging. Radiology 194(1):
1–18. https://doi.org/10.1148/radiology.194.1.7997533
53. Outwater EK, Siegelman ES, Talerman A, Dunton C (1997)
Ovarian fibromas and cystadenofibromas: MRI features of the fi-
brous component. J Magn Reson Imaging 7(3):465–471. https://
doi.org/10.1002/jmri.1880070303
54. Imaoka I, Wada A, Kaji Y, Hayashi T, Hayashi M, Matsuo M,
Sugimura K (2006) Developing an MR imaging strategy for
Emerg Radiol
diagnosis of ovarian masses. Radiographics 26(5):1431–1448.
https://doi.org/10.1148/rg.265045206
55. Outwater EK, Siegelman ES, Hunt JL (2001) Ovarian teratomas:
tumor types and imaging characteristics. Radiographics 21(2):475–
490. https://doi.org/10.1148/radiographics.21.2.g01mr09475
56. Caspi B, Levi R, Appelman Z, Rabinerson D, Goldman G, Hagay Z
(2000) Conservative management of ovarian cystic teratoma during
pregnancy and labor. Am J Obstet Gynecol 182(3):503–505.
https://doi.org/10.1067/mob.2000.103768
57. Coronado GD, Marshall LM, Schwartz SM (2000) Complications
in pregnancy, labor, and delivery with uterine leiomyomas: a
population-based study. Obstet Gynecol 95(5):764–769. https://
doi.org/10.1016/s0029-7844(99)00605-5
58. Birchard KR, Brown MA, Hyslop WB, Firat Z, Semelka RC (2005)
MRI of acute abdominal and pelvic pain in pregnant patients. AJR
Am J Roentgenol 184(2):452–458. https://doi.org/10.2214/ajr.184.
2.01840452
59. Murase E, Siegelman ES, Outwater EK, Perez-Jaffe LA, Tureck
RW (1999) Uterine leiomyomas: histopathologic features, MR im-
aging findings, differential diagnosis, and treatment. Radiographics
19(5):1179–1197. https://doi.org/10.1148/radiographics.19.5.
g99se131179
60. Marik PE, Plante LA (2008) Venous thromboembolic disease and
pregnancy. N Engl J Med 359(19):2025–2033. https://doi.org/10.
1056/NEJMra0707993
61. Ginsberg JS, Brill-Edwards P, Burrows RF, Bona R, Prandoni P,
Buller HR, Lensing A (1992) Venous thrombosis during pregnan-
cy: leg and trimester of presentation. Thromb Haemost 67(5):519–
520
62. Thornton MJ, Ryan R, Varghese JC, Farrell MA, Lucey B, Lee MJ
(1999) A three-dimensional gadolinium-enhanced MR venography
technique for imaging central veins. AJR Am J Roentgenol 173(4):
999–1003. https://doi.org/10.2214/ajr.173.4.10511166
63. Fraser DG, Moody AR, Davidson IR, Martel AL, Morgan PS
(2003) Deep venous thrombosis: diagnosis by using venous en-
hanced subtracted peak arterial MR venography versus convention-
al venography. Radiology 226(3):812–820. https://doi.org/10.1148/
radiol.2263012205
64. Finn JP, Zisk JH, Edelman RR, Wallner BK, Hartnell GG, Stokes
KR, Longmaid HE (1993) Central venous occlusion: MR angiog-
raphy. Radiology 187(1):245–251. https://doi.org/10.1148/
radiology.187.1.8451422
65. Pedrosa I, Morrin M, Oleaga L, Baptista J, Rofsky NM (2005) Is
true FISP imaging reliable in the evaluation of venous thrombosis?
AJR Am J Roentgenol 185(6):1632–1640. https://doi.org/10.2214/
AJR.04.1323
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