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Adenomyosis in Pregnancy:
Diagnostic Pearls and Pitfalls
Kyle K. Jensen, MD
Chelsea Pyle, MD
Bryan R. Foster, MD
Roya Sohaey, MD
Karen Y. Oh, MD
Abbreviations: β-hCG = β–human chorionic
gonadotropin, ESS = endometrial stromal sar-
coma, GTD = gestational trophoblastic disease,
PAS = placenta accreta spectrum
RadioGraphics 2021; 41:929–944
https://doi.org/10.1148/rg.2021200120
Content Codes:
From the Department of Diagnostic Radiol-
ogy, Oregon Health & Science University, 3181
SW Sam Jackson Park Rd, L-340, Portland, OR
97239. Recipient of a Certificate of Merit award
for an education exhibit at the 2019 RSNA An-
nual Meeting. Received May 11, 2020; revision
requested June 26 and received July 25; accepted
August 4. For this journal-based SA-CME activ-
ity, the authors B.R.F. and R.S. have provided
disclosures (see end of article); all other authors,
the editor, and the reviewers have disclosed no
relevant relationships. Address correspon-
dence to K.K.J. (e-mail: jensenky@ohsu.edu).
©
RSNA, 2021
SA-CME LEARNING OBJECTIVES
After completing this journal-based SA-CME
activity, participants will be able to:
„ Identify classic imaging findings and
distribution of adenomyosis at US and
MRI.
„ Compare adenomyosis in pregnancy to
uterine and placental pathologic mimics.
„ Discuss potential maternal and fetal
complications of adenomyosis during
pregnancy.
See rsna.org/learning-center-rg.
929
WOMEN’S IMAGING
Adenomyosis is a common benign uterine disorder in which ecto-
pic endometrial glands extend into the myometrium. Adenomyosis
is increasingly diagnosed in young women, affecting 20%–35% of
women of reproductive age. Features of adenomyosis can be seen
with either US or MRI, especially with newer imaging technology.
With advances in reproductive endocrinology as well as a trend
toward later maternal age, adenomyosis is increasingly noted dur-
ing pregnancy, often while performing imaging for other reasons.
Hormonal changes during pregnancy alter the appearance of ad-
enomyosis, which includes diffuse, focal, and cystic adenomyosis.
Recognizing these imaging changes in pregnancy proves essential
for accurately diagnosing adenomyosis as a benign condition, as it
mimics serious placental and myometrial abnormalities. Using a
lower-frequency US transducer or MRI can be helpful in distin-
guishing among these entities. Describing the location of adeno-
myosis in relationship to the site of placentation is also important.
Diagnosing adenomyosis is crucial because it can be associated
with poor pregnancy outcomes, including spontaneous abortion,
preterm birth, and fetal growth restriction. Adenomyosis is also a
risk factor for preeclampsia. Intramural ectopic pregnancy is a rare
but serious condition that can mimic cystic adenomyosis, and com-
parison with prepregnancy images can help differentiate the two
conditions. The authors review the unique imaging characteristics
of adenomyosis in pregnancy, focusing on accurate diagnosis of an
underrecognized benign condition that can mimic myometrial and
placental pathologic conditions.
©
RSNA, 2021 • radiographics.rsna.org
Introduction
Adenomyosis is a common benign gynecologic disorder, affecting
20%–35% of women of reproductive age, in which ectopic endo-
metrial glands or stroma are found within the uterine myometrium
(1). These endometrial glands may undergo cyclical changes with
the menstrual cycle and changes during pregnancy (2). While up to
one-third of patients are asymptomatic, two-thirds of patients may
demonstrate a variety of symptoms associated with adenomyosis,
including menorrhagia, dysmenorrhea, and metrorrhagia.
Historically, most patients diagnosed with adenomyosis were
parous women aged 40–50 years, with rare cases in women younger
than 40 years. However, this notion is thought to be biased by data
from older studies that predominately used hysterectomy specimens
for diagnosis. In recent years, with use of less invasive diagnostic
criteria, adenomyosis is now recognized in younger women. In
symptomatic nulliparous women aged 18–30 years undergoing US,
diffuse adenomyosis was found in up to 34% (3). Furthermore, an
MRI study of symptomatic women 18–42 years of age found a nearly
identical rate of diffuse adenomyosis (with and without an additional
diagnosis of deep endometriosis) (4).
930 May-June 2021
TEACHING POINTS
„ For the gravid uterus, we identify three sonographic appear-
ances of adenomyosis: diffuse, focal, and cystic.
„ The location of the adenomyosis within the uterine paren-
chyma in relation to placentation is the most useful descrip-
tor in pregnancy, as the placental attachment on the area of
adenomyosis can be associated with third-trimester growth
restriction.
„ The ill-defined margins of the masslike area are due to inter-
digitating hypertrophied smooth muscle and ectopic endo-
metrial glands, which help distinguish focal adenomyosis or
adenomyoma from a fibroid. In general, the latter has a more
discrete sonographic appearance, even during pregnancy,
and has circumferential rather than translesional Doppler flow.
„ Occasionally in pregnancy, cystic adenomyosis is circum-
scribed by decidualized active endometrial tissue, similar to the
appearance of the decidualized endometrium within the adja-
cent uterine cavity. The wall of the cysts can become thickened
and echogenic and can mimic the trophoblastic echogenicity
of an early gestational sac. In early pregnancy, this finding can
be mistaken for intramural implantation of a gestational sac.
„ Adenomyosis is associated with many complications before
and during pregnancy, affecting both the patient and the fe-
tus. Complications include but are not limited to infertility,
early pregnancy loss, growth restriction, preterm delivery, and
preeclampsia.
Risk factors for adenomyosis include increas-
ing age, increasing parity, cesarean delivery, and
pregnancy termination, as well as excess estrogen
exposure states such as early menarche, obesity,
and short menstrual cycles. Adenomyosis is also
frequently associated with other gynecologic dis-
eases such as fibroids, polyps, and endometriosis.
Therefore, adenomyosis is a difficult disease to
study in isolation as the contribution to symp-
toms, especially in infertility, may be confounded
by other pathologic conditions (1). Although evi-
dence is inconsistent, adenomyosis is thought to
be associated with infertility, potentially because
of impaired sperm transport from dysfunctional
uterine peristalsis or defects in decidualization
leading to impaired implantation (5).
Concurrently, as maternal age trends toward
pregnancies when women are in their later 30s
and 40s, as assisted reproductive techniques
are more successful, and as US equipment is
more advanced, adenomyosis is becoming more
commonly diagnosed at routine pregnancy US
examinations and is best seen in the first trimes-
ter. Given the hormonal changes in pregnancy,
adenomyosis has unique and variable appear-
ances at US and MRI depending on the diffuse,
focal, or cystic pattern of adenomyosis present in
the prepregnancy state.
Recognizing the different manifestations of
adenomyosis is crucial to accurately identify this
otherwise benign condition. The appearance of
adenomyosis in pregnancy can mimic myometrial
radiographics.rsna.org
and placental abnormalities and is also poten-
tially associated with poor pregnancy outcomes
such as spontaneous abortion, preterm birth, and
even fetal growth restriction (6–8). In this article,
we review the imaging appearance of adenomyo-
sis before and throughout pregnancy and discuss
imaging pearls to help make the appropriate diag-
nosis and avoid pitfalls.
Cause, Pathogenesis, and
Histopathologic Findings
To date, the cause of adenomyosis remains
largely unknown, although two main theories are
generally accepted. The first proposed and most
widely accepted and investigated theory is of mi-
gration of endometrial tissue through the basalis
layer into the myometrial junctional zone. The
migration is thought to occur because of trauma
or other inciting event such as pregnancy or
surgical damage. There, the ectopic endometrial
tissue (both glands and stoma) incites inflamma-
tion and fibrosis and leads to increased uterine
peristalsis. These reactions are thought to further
induce injury in a cyclical manner, recruiting ad-
ditional endometrial migration (9).
The second and more recently proposed
theory states that adenomyosis is a congenital
disorder arising from fetal müllerian remnants
implanted in the junctional zone, or alternatively,
from differentiation of endometrial stem cells
in the myometrium. Evidence to support this
theory rests in the identical histologic findings of
deep endometriosis encountered in the posterior
outer uterine wall. In addition, case reports of
adenomyosis in patients with Mayer-Rokitansky-
Küster-Hauser syndrome, a müllerian develop-
ment anomaly often with no functional endo-
metrium, further support this hypothesis of a
congenital cause (9).
During pregnancy, hormonal changes are
facilitated predominantly by progesterone along
with additional complex molecular pathways,
inducing decidualization of endometrium both
inside and outside the uterus, which is the same
pathophysiologic mechanism as decidualized
endometriomas previously described in the
literature (10–12). Decidualized endometriosis is
an example of a well-known complication causing
a diagnostic dilemma in the pregnant patient.
Theoretically, adenomyosis is prone to similar de-
cidualization, although to date there is a paucity
of studies evaluating these mechanisms, and most
studies of this disease process are based on imag-
ing observations and outcome measures.
The ectopic endometrium causes myometrial
smooth muscle hyperplasia and hypertrophy,
which account for the gross pathologic appear-
ance of adenomyosis. Both ectopic endometrium
RG • Volume 41 Number 3
and smooth muscle hyperplasia and hypertrophy
account for a majority of the imaging findings of
adenomyosis, which are described later (13). The
pathophysiologic mechanism for myometrial cyst
and cystic adenomyosis formation is thought to
form as a result of cyclic hormonally controlled
proliferation and secretion (13). Occasionally,
these are seen as small foci of hemorrhage. The
mechanism for this is unclear, given that adeno-
myosis arises from the basal, not functional, layer
of endometrium but is likely either hormonally
controlled or a spontaneous hemorrhage (13).
Imaging Appearance of Adenomyosis
in the Nongravid Uterus
With continuously improving US and MRI tech-
niques for pelvic imaging, adenomyosis is now
more accurately diagnosed, and radiologists are
seeing more patients with this diagnosis (14–16).
Adenomyosis in the nongravid uterus is well recog-
nized at both US and MRI, as previously described
(14,17). Research shows that both modalities have
similarly high sensitivity and specificity and are
rarely both needed to make the diagnosis (15).
It is important to realize that the imaging find-
ings can be diffuse, involving the entire uterus
symmetrically, asymmetrical, or focal, involving
only one wall or focal area. US features include
heterogeneous myometrium, myometrial thicken-
ing, echogenic linear striations or nodules radiating
outward from the endometrium, venetian blind
shadows, loss of endomyometrial border distinct-
ness, subendometrial cysts (fluid-filled glands), and
increased vascularity at Doppler US (Fig 1) (14).
Saline infusion US shows saline or echogenic air
bubbles tracking into myometrial cracks, which are
focal outpouchings extending from the endometrial
cavity into the myometrium (18).
At MRI, adenomyosis can demonstrate a uni-
formly or focally thickened junctional zone, the
T2-hypointense innermost layer of myometrium,
with a cutoff of 12 mm or greater typically used
as a diagnostic criterion (15,19). While several
prospective studies have shown that a junctional
zone thickness of 12 mm or greater correlates with
adenomyosis, these studies have an older mean
participant age and also include postmenopausal
women (20).
A recent MRI-pathology correlation study in
younger women, predominantly in their 40s, has
called the 12-mm cutoff into question, showing
no correlation of the MRI junctional zone thick-
ness with the pathologic diagnosis of adenomyo-
sis. Instead, the presence of either an irregular
junctional zone or a myometrial cyst proved most
specific for diagnosing adenomyosis in this group
(20). Therefore, in this younger patient population,
a junctional zone morphologic appearance with ir-
Jensen et al 931
regularity or fingerlike projections is more specific
for adenomyosis.
Other specific MRI findings include myome-
trial cysts, which tend to be small (<5 mm) and
may show T1 hyperintensity due to hemorrhage
(13). Focal adenomyomas are also specific for
diagnosis and appear as T2-hypointense focal
masses, which tend to have vague or incomplete
borders and heterogeneity due to interdigitating
hypertrophied smooth muscle cells and ectopic
endometrial glands, unlike more well-defined
fibroids (2,13,17).
Sonographic Classification of
Adenomyosis
Patterns of adenomyosis in the nongravid uterus
are described in both the US and MRI literature,
with imaging findings predominantly reflecting
underlying fibrotic changes and smooth muscle
hyperplasia and hypertrophy surrounding ectopic
endometrial glands (13). In 2015, the interna-
tional Morphological Uterus Sonographic Assess-
ment (MUSA) group summarized the typical
sonographic findings that should be reported in
the setting of myometrial lesions (14,21). Subse-
quently, Van den Bosch et al (21) and others have
suggested a sonographic classification system spe-
cific to adenomyosis, in which findings are cate-
gorized as either diffuse or focal and may include
cystic areas within the myometrium (22,23).
Further characterization based on the appearance
of the junctional zone and depth of involvement
is not applicable to the pregnant patient, as the
junctional zone is not typically visualized after
implantation has occurred. For the gravid uterus,
we identify three sonographic appearances of
adenomyosis: diffuse, focal, and cystic.
Diffuse Adenomyosis in Pregnancy
Diffuse adenomyosis has an infiltrative appear-
ance at US: the myometrium is thickened and
heterogeneous with echogenic islands of ecto-
pic decidualized tissue dispersed throughout.
Even though not a focal abnormality, diffuse
adenomyosis can still cause a mass effect on the
gestational sac if the entire anterior or posterior
wall is involved (Fig 2). Doppler US characteris-
tics of adenomyosis are not specific but are often
unique. Uterine fibroids often show circumfer-
ential vascularity. However, color Doppler US in
adenomyosis typically shows increased and more
diffuse flow within the affected area as well as the
normal subplacental vessels, which run parallel
to the placental attachment. If the diagnosis is in
question, reviewing prepregnancy pelvic US im-
ages may be helpful in correlating the distribution
of the adenomyosis with the appearance of the
imaging finding in the gravid uterus (Fig 3).
932 May-June 2021 radiographics.rsna.org

Figure 1. Adenomyosis in a nongravid uterus in two patients. (a) Lon-

gitudinal gray-scale transvaginal US image of the uterus in a 49-year-
old woman shows the classic venetian blind appearance (arrowheads)
of the uterus with alternating linear echogenic and hypoechogenic
linear striations, which are most consistent with adenomyosis. Note
the indistinct myometrial-endometrial border (straight arrow) and
myometrial cysts (curved arrow), also referred to as subendometrial
cysts, which are sensitive and specific for adenomyosis. (b) Sagittal T2-
weighted MR image in the same patient shows a thickened junctional
zone (arrowheads), myometrial cysts (curved arrow), and irregular
fingerlike T2-hyperintense projections (straight arrow) extending from
the endometrium into the junctional zone, which is another specific
finding for adenomyosis. (c) Longitudinal gray-scale transvaginal US
image in a 36-year-old woman shows a myometrial cyst (arrowhead).

Figure 2. Diffuse adenomyosis in a gravid uterus. (a) Longitudinal gray-scale transabdominal US image in a
34-year-old woman at 10 weeks 6 days gestational age shows that the myometrium is diffusely thickened and
heterogeneous (arrow). A normal gestational sac is noted in the fundal endometrial cavity with mass effect from
the adjacent adenomyosis. (b) Longitudinal gray-scale transabdominal US image in the same patient at 12
weeks 5 days gestational age also shows the indistinct myometrial-endometrial border (arrow), which is due to
endometrium radiating into the adjacent myometrium. There are numerous echogenic foci (arrowheads) within
the myometrium representing decidualized ectopic endometrial glands.

In general, myometrial disease is described by
location and size. While exact measurements are
often difficult to acquire in adenomyosis, diffuse
changes can also be expressed as the subjective
percentage of total myometrium involved and by
location within the uterine parenchyma (anterior
wall, posterior wall, fundus, lateral uterus, or lower
uterine segment) (21,23). Unlike with fibroids,
descriptive terms indicating the depth of uterine
involvement such as submucosal, intramural, sub-
RG • Volume 41 Number 3 Jensen et al 933

Figure 3. Use of a pregravid comparison US image to diagnose adenomyosis. (a) Longitudinal gray-scale transvagi-
nal US image obtained in a 29-year-old woman at 6 weeks 2 days gestational age shows a heterogeneous thickened
anterior uterine myometrium (arrows) with mass effect on the endometrium and gestational sac. (b) Longitudinal
gray-scale transvaginal US image obtained before pregnancy shows diffuse myometrial heterogeneity that is most
conspicuous along the anterior wall (arrow), which is consistent with adenomyosis.

serosal, or pedunculated are not particularly useful
in pregnancy. More important is noting the loca-
tion of adenomyosis in the gravid uterus and its
relationship to the placental implantation site. The
location of the adenomyosis within the uterine
parenchyma in relation to placentation is the most
useful descriptor in pregnancy, as the placental
attachment on the area of adenomyosis can be
associated with third-trimester growth restriction
(Fig 4) (24).
During pregnancy, the diffuse nature of the
preexisting adenomyosis can lead to bizarre ap-
pearances at US, causing a diagnostic dilemma
(Table). In the first trimester, when florid adeno-
myosis changes are present because of decidualiza-
tion and wall thickening, potentially eccentrically
distorting the sac, it can be difficult to distinguish
the heterogeneous myometrium from decidual
reaction abnormalities. When adenomyosis under-
lies the placenta, it can be difficult to distinguish
myometrial or placental anatomy and disease
because of a poorly defined interface between the
two structures.
If the focus of adenomyosis and the placenta
are not distinguished as two separate structures,
this can lead to an incorrect diagnosis of mes-
enchymal dysplasia, a rare but serious placental
disease that shows cystic heterogeneous enlarge-
ment of the placenta with prenatal complications
and is associated with Beckwith-Wiedemann
syndrome in 20% of cases (Fig 5) (25). In some
cases, using a lower-frequency probe can help
to differentiate the placental-myometrial echo-
genicities (Fig 6). If abnormalities of placenta-
tion or myometrium cannot be differentiated,
nonenhanced MRI can provide a more global
view of the interface between the placenta and
myometrium (26,27).
Diffuse adenomyosis can also mimic diffuse
leiomyomatosis, a benign condition with numer-
ous small leiomyomas and smooth muscle pro-
liferation replacing the myometrium, resulting in
heterogeneous enlargement of the uterus, which
often requires hysterectomy (Fig 7) (28). MRI can
best differentiate the findings of leiomyomatosis
from adenomyosis owing to a lack of cystic change
in the myometrium with leiomyomatosis.
Eccentric displacement of the gestational sac by
adenomyosis may also mimic an interstitial ectopic
pregnancy, where implantation occurs within the
interstitial portion of the fallopian tube within the
uterus (Fig 8). Although rare, the mortality rate
for interstitial ectopic pregnancy is two to five
times higher than for a tubal ectopic pregnancy,
so suggesting this diagnosis can lead to an un-
necessary workup, patient concern, and potential
termination of a normal pregnancy (29).
Focal Adenomyosis in Pregnancy
Although focal adenomyosis and adenomyoma
can be distinguished at pelvic US or MRI in
the nongravid uterus on the basis of a relatively
more demarcated margin in the latter, these two
diagnoses are often indistinguishable sono-
graphically in pregnancy (30). Unlike diffuse
adenomyosis, focal adenomyosis results in focal
lesions from decidualized endometrial rests
within the myometrium appearing as heteroge-
neous rounded masslike lesions with ill-defined
margins. Typically, the masslike area contains
echogenic rests with intervening tissue that is
sonographically similar to myometrium as well
as a poorly defined transition to normal adjacent
myometrium.
Frequently, focal adenomyosis and adeno-
myomas exert mass effect on the developing
934 May-June 2021 radiographics.rsna.org

Figure 4. Adenomyosis involving the placental attachment site. (a) Longitudinal gray-scale transab-
dominal US image obtained at 13 weeks 1 day gestational age demonstrates heterogeneous myome-
trial thickening, representing decidualized adenomyosis (arrowheads), which causes mass effect on the
placenta (*) and gestational sac (arrow). (b) Longitudinal gray-scale transabdominal US image obtained
at 24 weeks 4 days gestational age shows heterogeneous myometrium underlying the site of placental
attachment (arrows), which can be associated with third-trimester growth issues. (c) Longitudinal gray-
scale transabdominal US image shows how the affected myometrium (*) can appear masslike and can
mimic a placental or myometrial pathologic condition. (d) Color Doppler US image obtained at the same
location as in c shows vascularity throughout the affected area (arrowheads), which differs from the pe-
ripheral vascularity seen in a uterine fibroid.

Mimics of Poor Junctional Zone Differentiation in Adenomyosis during Pregnancy

Diagnosis Key Points Imaging Features

PAS Mimics focal adenomyosis US: prominent vascular lacuna, abnormal color Doppler
Extremely morbid for mother and US findings
fetus and affects future fertility
MRI: uterine bulging, heterogeneous placenta, placental
bands
Placental Mimics diffuse adenomyosis Thickened heterogeneous cystic placenta
mesenchymal Beckwith-Wiedemann syndrome Use lower-frequency US transducer or MRI to better
dysplasia in 20% identify placental-myometrial interface
Partial molar Mimics adenomyosis cysts in preg- Abnormally enlarged placenta
pregnancy nancy Internal cystic changes with Swiss cheese appearance
Uterine neo- ESS mimics focal adenomyosis ESS: at MRI, infiltrative T2-hyperintense lesion with
plasms wormlike hypointense bundles
Diffuse leiomyomatosis mimics dif- Diffuse leiomyomatosis: at MRI, enlarged uterus with in-
fuse adenomyosis numerable poorly defined leiomyomas, a thin junctional
zone, and no myometrial cysts
Intramural ecto- Mimics cystic adenomyosis Gestational sac within myometrium, which can mimic the
pic pregnancy Prior images helpful for comparison circumscribed decidualization in cystic adenomyosis
Note.—ESS = endometrial stromal sarcoma, PAS = placenta accreta spectrum.
RG • Volume 41 Number 3 Jensen et al 935

Figure 5. Adenomyosis mimicking mesenchymal dysplasia in four patients. (a) Longitudinal gray-scale transabdomi-
nal US image obtained at 14 weeks 4 days gestational age demonstrates increased thickening and heterogeneity of
the myometrium (arrow). The placental-myometrial interface (arrowhead) is poorly defined. Thickened heterogeneous
myometrium of decidualized adenomyosis overlying the placenta can be confused with a single thickened enlarged
placenta and raise concern for mesenchymal dysplasia. (b) Longitudinal gray-scale transabdominal US image obtained
in a different patient at 18 weeks gestational age shows an apparent enlarged thickened placenta, which is concern-
ing for mesenchymal dysplasia. However, close inspection demonstrates a distinction (arrows) between the decidual-
ized adenomyosis (*) in the posterior myometrial wall and the anterior normal placenta. (c) Color Doppler US image
obtained in the same patient as in b helps distinguish the placental-myometrial interface (arrows) given increased
vascularity within the area of adenomyosis in the myometrium. (d) Transverse gray-scale transabdominal US image in
a different patient obtained at 31 weeks 1 day gestational age shows mesenchymal dysplasia with a thickened hetero-
geneous cystic placenta (arrow). (e) Coronal noncontrast T2-weighted MR image obtained in the same patient as in
d redemonstrates the enlarged cystic placenta and confirmed mesenchymal dysplasia (arrows). Distinguishing adeno-
myosis from mesenchymal dysplasia is key to offering appropriate prenatal genetic testing. (f) Longitudinal gray-scale
transabdominal US image in a different patient at 31 weeks 6 days gestational age shows mesenchymal dysplasia with
a heterogeneous thickened cystic placenta (arrows) without abnormal adjacent myometrium. This fetus underwent
genetic testing, confirming Beckwith-Wiedemann syndrome, which is seen in 20% of cases of mesenchymal dysplasia.
936 May-June 2021 radiographics.rsna.org

Figure 6. Delineation of placental-myometrial

attachment in a patient at 14 weeks 4 days
gestational age. (a) Transverse gray-scale trans-
abdominal US image obtained with a 9-MHz
probe shows an indistinct placental-myometrial
interface (bracket). Adenomyosis was suspected.
(b) Color Doppler US image obtained with the
same 9-MHz probe helps differentiate the decid-
ualized adenomyosis from the placenta by visu-
alizing normal uterine vasculature extending to
the base of the placenta (arrow). Adenomyosis
may be hypervascular, but this increased color
Doppler signal is located within the myome-
trium and not the placenta. (c) Transverse gray-
scale transabdominal US image obtained with
a 5-MHz probe improves the delineation of the
placental-myometrial interface (arrows).

Figure 7. Leiomyomatosis can appear similar to diffuse adenomyosis. (a, b) Sagittal (a) and axial (b) noncontrast T2-weighted MR
images obtained in a nongravid 35-year-old woman show innumerable poorly defined leiomyomas resulting in diffuse uterine en-
largement. The heterogeneous appearance with T2-hyperintense foci can mimic diffuse adenomyosis. However, the T2-hypointense
junctional zone (arrow) is uniformly thin, and other signs of adenomyosis are not present. (c, d) Sagittal (c) and coronal (d) T2-
weighted MR images obtained in a different patient show diffuse uterine enlargement with slightly more well-defined leiomyomas
(*) with a thin junctional zone (arrow in d).

gestational sac in the first trimester (Fig 9).
Depending on the size and rate of growth from
decidualization during pregnancy, these can have
the appearance of a myometrial neoplasm (Fig
10). The ill-defined margins of the masslike area
are due to interdigitating hypertrophied smooth
muscle and ectopic endometrial glands, which
help distinguish focal adenomyosis or adeno-
myoma from a fibroid. In general, the latter has
a more discrete sonographic appearance, even
during pregnancy, and has circumferential rather
than translesional Doppler flow (Fig 11).
RG • Volume 41 Number 3 Jensen et al 937

Figure 8. Adenomyosis mimicking interstitial ectopic pregnancy. (a) Longitudinal gray-scale

transvaginal US image obtained at 5 weeks 2 days gestational age shows an eccentric gesta-
tional sac (arrowhead). Given the location, concern was raised for an interstitial ectopic preg-
nancy, and the patient was referred for further workup. Note the heterogeneous thickened
anterior myometrium (*) with an indistinct myometrial-endometrial border, which was not
described at the time of examination. (b) Transverse gray-scale transvaginal US image ob-
tained at follow-up at 7 weeks 5 days gestational age redemonstrates the thickened heteroge-
neous anterior myometrium (arrowheads). Myometrial cysts (arrow) are noted in this region of
thickening, confirming the diagnosis of focal adenomyosis, which is the cause of the eccentric
gestational sac. Continuity of the sac with the endometrial cavity, although eccentric, and
normal underlying myometrial thickness (*) confirm that the gestation is not interstitial, and
the pregnancy went to term without complication.

In the absence of cystic components, the
ill-defined T2-hypointense appearance of focal
adenomyosis can also mimic placenta accreta
spectrum (PAS), an abnormal placentation disor-
der that may attach to or invade the myometrium,
depending on the severity (Fig 12) (31). PAS has
high morbidity and mortality and often requires
a complex resource-heavy multispecialty delivery.
Therefore, correctly diagnosing focal decidual-
ized adenomyosis prevents extensive workup and
patient stress.
Given the masslike heterogeneous appearance
of focal adenomyosis, it may also mimic endome-
trial stromal sarcoma (ESS), formally known as
low-grade ESS (Fig 13). At US, ESS is heteroge-
neous with ill-defined margins and can invade into
the myometrium. These similarities to adenomyo-
sis are reflected in the pathologic appearance of
ESS, which appears similar to stromal elements
of proliferating endometrium (32). At MRI, ESS
manifests as infiltrative T2-hyperintense lesions
with preserved linear wormlike hypointense mus-
cular bundles. As described in previous literature
by Takeuchi and Matsuzaki (17), ESS also shows
restricted diffusion and an elevated choline peak at
MR spectroscopy, findings that are not present in
adenomyosis.
Adenomyosis Cysts in Pregnancy
Two types of cysts can be seen with adenomyosis.
Myometrial cysts are usually simple anechoic cysts
smaller than 5 mm within the region of ectopic en-
dometrial glands and are one of the most sensitive
and specific US signs of adenomyosis (13,19). Dur-
ing pregnancy, these cysts are most often identified
in the first trimester within the area of myometrium
involved with adenomyosis and are often seen at
MRI when evaluating other maternal pathologic
conditions during pregnancy (Fig 14) (33).
Heterogeneous thickening of the myometrium
with myometrial cysts can also lead to misdiag-
nosis of gestational trophoblastic disease (GTD),
namely, a complete or partial hydatidiform mole
(Fig 15). At US, complete hydatidiform mole is
seen as an enlarged echogenic mass with mul-
tiple cystic spaces. Partial hydatidiform mole is
seen as an abnormally enlarged placenta with
internal cystic changes with a Swiss cheese ap-
pearance (34). Distinguishing the heterogeneous
and sometimes cystic myometrial thickening in
an otherwise normal pregnancy from GTD is
essential, as it prevents unnecessary subsequent
diagnostic workup, potential unwarranted termi-
nation, and patient stress.
More extensive hemorrhage within these myo-
metrial cysts leads to the distinctive diagnosis of
cystic adenomyosis, which typically manifests as
a large complex cystic intramural mass contain-
ing blood products. In contrast to myometrial
cysts, these cysts can be thick walled and con-
tain complex fluid due to intracystic secretions
or bleeding, either spontaneous or from cyclical
hormonal changes (13).
Occasionally in pregnancy, cystic adeno-
myosis is circumscribed by decidualized active
endometrial tissue, similar to the appearance
of the decidualized endometrium within the
adjacent uterine cavity. The wall of the cysts
938 May-June 2021 radiographics.rsna.org

Figure 9. Distin-
guishing among focal
adenomyosis, uterine
fibroid, and adenomy-
oma in three patients.
(a–d) Sagittal gray-scale
transabdominal US im-
age (a) obtained at 13
weeks gestational age
shows a focal hetero-
geneously hypoechoic
lesion (arrows) in the
myometrium, which
causes mass effect on
the adjacent placenta
(*) and gestational sac. Sagittal gray-scale transabdominal US image (b) obtained at 18 weeks 2 days gestational age shows the
heterogeneous myometrial lesion with indistinct borders (arrows), favoring focal adenomyosis given that fibroids have well-defined
borders. Sagittal color Doppler US image (c) obtained at the same location shows the lesion (arrows) with internal translesional areas
of vascularity, suggesting focal adenomyosis instead of a fibroid, which usually has rim vascularity. Transverse T2-weighted nonen-
hanced MR image (d) confirms a T2-hypointense region of focal adenomyosis (arrows). (e, f) Longitudinal gray-scale transabdominal
US image (e) obtained in another patient at 12 weeks 2 days gestation demonstrates a well-defined hypoechoic intramural myome-
trial lesion with well-defined borders (calipers), which is consistent with a fibroid. Transabdominal color Doppler US image (f) shows
peripheral vascularity (arrow) around the lesion (*), which is characteristic for a uterine fibroid. (g, h) Sagittal gray-scale transvaginal
US image (g) obtained in a patient in a nongravid state shows an ovoid lesion in the anterior fundal myometrium with heterogeneous
echogenicity and somewhat ill-defined incomplete borders (arrows), suggesting an adenomyoma. Sagittal gray-scale transvaginal
US image (h) obtained in the same patient at 6 weeks gestational age redemonstrates the lesion (arrows), which has increased in
size because of decidualization and is now causing mild mass effect on the gestational sac (calipers). Conversely, uterine fibroids are
usually more well defined, more hypoechoic, and can be calcified.

can become thickened and echogenic and can
mimic the trophoblastic echogenicity of an early
gestational sac. In early pregnancy, this finding
can be mistaken for intramural implantation of a
gestational sac (Fig 16) (35,36). A careful search
for a gestational sac within the endometrial
cavity should be correlated with serial β–hu-
man chorionic gonadotropin (β-hCG) levels in
cases of pregnancy of unknown location. While
intramural ectopic pregnancies are exceedingly
rare, they are thought to occur secondary to
the developing pregnancy traveling through the
tract from the ectopic endometrial rest into the
myometrium, resulting in intramural implanta-
RG • Volume 41 Number 3 Jensen et al 939

Figure 10. Focal adenomyosis mimicking a myometrial neoplasm. (a) Longitudinal gray-scale transabdominal US image ac-
quired at 14 weeks 3 days gestational age shows focal heterogeneous thickening at the posterior fundal myometrium (arrows)
with mass effect on the placenta (*) and gestational sac. This was interpreted as a mass, with a recommendation for follow-up
MRI. (b) Sagittal T2-weighted noncontrast MR image obtained at 15 weeks gestational age redemonstrates a focal masslike re-
gion (arrows) in the posterior myometrium with mass effect on the placenta (*). Concern for uterine leiomyosarcoma was raised.
(c) Remote pregravid pelvic US image shows an indistinct endometrial-myometrial junction and venetian blind appearance at the
posterior fundal myometrium (arrows), which is most consistent with focal adenomyosis. A uterine fibroid could be considered but
is less likely given the indistinct borders. (Case courtesy of Anne M. Kennedy, MB, BCh, BAO, University of Utah Medical Center,
Salt Lake City, Utah.)

Figure 11. Focal adenomyosis. (a) Transverse gray-scale transabdominal US image obtained at 20 weeks 1
day gestational age shows a rounded area of heterogeneous myometrium (arrowheads) with scattered small
myometrial cysts adjacent to the placenta (*), which is consistent with focal adenomyosis. (b) Sagittal gray-scale
US image confirms the focal rounded appearance of the subplacental (*) adenomyosis (calipers). Although
rounded, the cystic adenomyosis has somewhat ill-defined borders due to interdigitating hypertrophied smooth
muscle and ectopic endometrial glands, distinguishing it from a well-defined uterine fibroid. (c) Transverse color
Doppler US image helps identify this finding as focal adenomyosis, as translesional vascularity flows through the
region of adenomyosis (arrowheads), whereas a fibroid would have peripheral vascularity. Normal subplacental
vessels (arrow) are seen, helping distinguish the placental-myometrial interface (*) and avoid misdiagnosis of a
thickened placenta.

tion (37,38). If the patient has prepregnancy

images, this may be useful, as the cyst may have
been present previously, lending additional con-
fidence in the diagnosis of cystic adenomyosis
rather than an intramural ectopic pregnancy.

Associated Complications and

Outcomes in Pregnancy
Adenomyosis is associated with many complica-
tions before and during pregnancy that affect
both the patient and the fetus. Complications
include but are not limited to infertility, early
pregnancy loss, growth restriction, preterm
940 May-June 2021 radiographics.rsna.org

Figure 12. Adenomyosis versus PAS. (a–c) Axial T2-weighted (a) and T1-weighted (b) nonenhanced MR images obtained in a
patient in the early second trimester because of pain show irregular T2 and T1 hypointensity at the myometrial-placental interface
(arrowhead). An intramural left uterine fibroid (arrow) is heterogeneously T2 hyperintense and T1 hyperintense, which is consistent
with a degenerating fibroid. Sagittal T2-weighted nonenhanced MR image (c) shows the T2-hypointense region extending from the
myometrial-placental interface to the uterine serosa (arrow), which could be confused with an area of abnormally adherent placenta
but is actually adenomyosis. (d–f) Coronal (d) and sagittal (e) nonenhanced T2-weighted MR images obtained at 33 weeks 3 days
gestational age in a different patient with a prior cesarean birth show focal placental bulging (arrow). Color Doppler US image (f) at
the site of the placental bulge shows a large prominent vascular lacuna (arrow), which is consistent with PAS.

Figure 13. ESS appears similar to fo-

cal adenomyosis. (a) Longitudinal gray-
scale transabdominal US image in a pa-
tient with ESS shows heterogeneous en-
dometrial thickening (arrows) with an ill-
defined endometrial-myometrial border.
(b) Longitudinal gray-scale transvaginal
US image in another patient with ESS
shows ill-defined heterogeneous thick-
ening of the endometrium and adja-
cent myometrium (arrows), mimicking
adenomyosis. In contrast to the typical
intramural location of adenomyosis, ESS
is endometrial based with myometrial
involvement. Identifying the location of
the mass is key to the differential diag-
nosis, and pelvic MRI can be useful for
delineating the endometrial or myometrial origin. ESS also has characteristic imaging features described in this article.

delivery, and preeclampsia. The direct effects of
adenomyosis are not well understood, although
possible theories exist for each. Altered utero-
tubal transport, anatomic distortion of the uterus,
and dysfunctional uterine peristalsis have been
proposed as explanations for the association of
adenomyosis with infertility (7). Along the same
lines, early pregnancy loss is likely a consequence
of the downstream effects of abnormal uterine
morphology such as impaired endometrial me-
tabolism and its effect on early placentation and
gestational sac implantation.
RG • Volume 41 Number 3 Jensen et al 941

Figure 14. Myometrial cysts. (a) Trans-

verse gray-scale transabdominal US image
obtained at 10 weeks 6 days gestational
age shows myometrial cysts (arrows)
within a heterogeneously thickened re-
gion of anterior myometrium that is con-
sistent with adenomyosis, which causes
mass effect on the gestational sac (*).
(b) Sagittal noncontrast T2-weighted MR
image obtained in the same patient while
nongravid again demonstrates the myo-
metrial cysts (arrows) within a thickened
region of anterior junctional zone, con-
firming adenomyosis.

Figure 15. Molar pregnancy mimicking adenomyosis. (a) Longitudinal gray-scale transvaginal US image demonstrates a partial mo-
lar pregnancy with cystic thickening of the placenta, which is difficult to distinguish from the underlying myometrium (arrow). Mass
effect on the gestational sac (*) is noted. Adenomyosis can mimic this appearance, as seen in Figure 14a. (b) Longitudinal gray-scale
transvaginal US image obtained for dating shows a complete molar pregnancy with cystic echogenic products of conception (arrow),
which can also mimic cystic adenomyosis. (c) Longitudinal gray-scale transabdominal US image obtained in a different patient for
dating also shows cystic echogenic products of conception (arrows), representing a complete molar pregnancy. A submucosal intra-
mural fibroid (*) with a well-defined border is noted at the lower uterine segment, distorting the endometrial cavity. Since fibroids
and adenomyosis are often present together, cystic adenomyosis may be mistakenly diagnosed. Identifying the location of the cystic
areas is key for diagnosis, as molar pregnancies are contained within the endometrial cavity and only rarely is myometrial invasion
present in cases of concurrent malignant GTD. In addition, elevated serum β-hCG levels and theca lutein cysts can provide evidence
of a molar pregnancy.

Fetal growth restriction and preterm delivery
may be associated with increased uterine inflam-
mation and free radicals as well as junctional zone
changes, creating a hostile environment for the
placenta that restricts adequate fetal exchange
with the maternal blood supply, possibly through a
vascular steal mechanism (6–8). The implications
of growth restriction and preterm delivery are
significant and put the fetus at risk for serious ad-
verse events such as lung immaturity, brain injury,
and long-term postnatal health issues.
Another known complication of adenomyosis
in pregnancy is preeclampsia, which puts maternal
health at risk and predisposes her to stroke, organ
failure, and hemolysis, elevated liver enzymes, and
low platelet count (HELLP) syndrome. Because of
the effects on maternal health, preeclampsia is also
a risk factor for fetal prematurity and demise.
Overall, the various potential complications
associated with adenomyosis in pregnancy can be
serious for both the patient and fetus, with pos-
sible long-term sequelae. While pathophysiologic
mechanisms for each complication as it relates to
adenomyosis in pregnancy are not fully under-
stood, closer fetal monitoring and referral to a
tertiary or subspecialty center are imperative when
abnormal myometrium is identified.
Conclusion
In summary, adenomyosis is a benign uterine
disorder that is increasingly diagnosed in young
women, affecting 20%–35% of women of repro-
ductive age. Adenomyosis during pregnancy is
seen with increasing frequency given the trend
toward later maternal age and better imaging
techniques.
942 May-June 2021 radiographics.rsna.org

Figure 16. Cystic adenomyosis mimicking intramural ectopic pregnancy. (a) Longitudinal gray-scale trans-
vaginal US image obtained for dating after a positive pregnancy test shows a thick-rimmed echogenic focus
(arrow) adjacent to the endometrium (arrowhead) at the lower uterine segment. (b) Coronal three-dimensional
reformation from US confirms the subendometrial location (arrow). No endometrial gestational sac (arrowhead)
is identified, raising concern for intramural ectopic pregnancy. Subsequently, this pregnancy failed in the first tri-
mester. (c) Longitudinal transvaginal color Doppler US image obtained during a subsequent dating examination
in the same patient during another pregnancy shows a thick-walled echogenic subendometrial focus (arrow)
near the lower uterine segment with decidualized endometrium (*). Again, no gestational sac was identified in
the endometrial cavity. Given the prior US image, this thick-walled echogenic subendometrial focus was favored
to represent decidualized cystic adenomyosis. (d) Longitudinal gray-scale transvaginal US image obtained at
follow-up shows a normal gestational sac (arrowhead) at the fundal endometrium, unrelated to the subendome-
trial cystic adenomyosis near the lower uterine segment (arrow). (e) Longitudinal transvaginal color Doppler US
image in the same patient when nongravid shows the nondecidualized appearance of the subendometrial cystic
adenomyosis (arrow) with nondecidualized endometrium (*). While the thickened echogenic wall of decidual-
ized cystic adenomyosis mimics an ectopic pregnancy, cystic adenomyosis does not have increased peripheral
vascularity like an ectopic pregnancy. (f) Transverse gray-scale transvaginal US image obtained in another pa-
tient shows decidualized endometrium (white line) with an echogenic ovoid focus within the myometrium (ar-
row). After close monitoring and follow-up, a normal gestational sac was seen within the fundal endometrium,
and the diagnosis of cystic adenomyosis was made.
RG • Volume 41 Number 3
The appearance of adenomyosis during
pregnancy is altered by hormonal changes and
can mimic serious myometrial and placental
pathologic conditions, including neoplasms. The
appearance of adenomyosis in pregnancy differs
on the basis of the patterns of distribution of the
ectopic endometrial glands within the myome-
trium, which include diffuse, focal, and cystic
patterns. Correctly identifying adenomyosis in
pregnancy is essential for both fetal and maternal
health, as it is associated with poor pregnancy
outcomes such as spontaneous abortion, preterm
birth, and fetal growth restriction as well as be-
ing a risk factor for preeclampsia and associated
maternal complications.
Describing the relationship between the area
of adenomyosis and site of placentation is impor-
tant because of an increased risk for fetal growth
restriction, often requiring additional surveillance
during pregnancy. Review of the prepregnancy
images of the pelvis can be helpful in determin-
ing the distribution of adenomyosis and in some
cases helps differentiate between cystic adenomy-
osis and an intramural ectopic pregnancy, a rare
but serious mimic. Accurate identification and
diagnosis of adenomyosis during pregnancy is es-
sential for clinical management, helping address
potential maternal and fetal complications of this
otherwise benign entity.
Disclosures of Conflicts of Interest.—B.R.F. Activities related to
the present article: disclosed no relevant relationships. Activities
not related to the present article: consultant to Bot Image; royal-
ties from Elsevier. Other activities: disclosed no relevant rela-
tionships. R.S. Activities related to the present article: disclosed
no relevant relationships. Activities not related to the present ar-
ticle: expert testimony in legal cases; annual conference orga-
nizer through World Class CME; royalties from Elsevier. Other
activities: disclosed no relevant relationships.
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