Use of Magnetic Resonance Imaging (MRI) in the Management of Diagnostic Uncertainty in Low-Resource Settings: A Case Report of Cesarean Ectopic Pregnancy in a Tertiary Hospital in Ghana

Abstract

BACKGROUND Low- and middle-income countries (LMICs) account for the overwhelming majority of maternal deaths worldwide. Cesarean section rates have increased globally over the last 10 years, including in LMICs, and are an important intervention to decrease neonatal and maternal mortality. However, cesarean sections also contribute to increased complications in subsequent pregnancies, including invasive placentation and cesarean scar ectopic pregnancies (CSEP). Potential CSEP complications include rupture of the uterus, bladder invasion, and maternal mortality. CASE REPORT We present the case of a 35-year-old Ghanaian woman (gravidity 5, parity 3) with a positive urine pregnancy test and 2 months of amenorrhea. Ultrasound scanning demonstrated a gestational sac with a fetal pole and absent cardiac activity located in the lower uterine segment. Myometrium infiltration was present, with only 2 mm of anterior myometrium between the gestational sac and the urinary bladder. Owing to concern for CSEP with uncertain bladder invasion, a pelvic MRI was obtained for preoperative planning. Following the MRI, which demonstrated an intact bladder, the patient underwent an uncomplicated exploratory laparotomy and excision of the CSEP. CONCLUSIONS In LMICs, pelvic ultrasound continues to be the diagnostic tool of choice for CSEP. However, in cases with diagnostic uncertainty or possible bladder invasion, MRI is an additional imaging tool that can optimize preoperative planning and minimize the risk of maternal mortality and potential post-surgical complications.

Figure 1.

Sagittal T2 weighted magnetic resonance image through the pelvis. The posterior aspect of the gestational sac (yellow arrow) extends into the endometrial cavity of the lower uterine segment (white arrow). Urinary bladder (UB) (red arrow); upper uterine segment (green arrow).

Figure 2.

Midline sagittal T2 weighted magnetic resonance image through the pelvis. Gestational sac (yellow arrow) within the myometrium of the lower uterine segment. Anterior to the gestational sac, the myometrium is thinned (green arrow). Normal urinary bladder (UB) (red arrow).

Figure 3.

Laparotomy via Pfannenstiel incision with products of conception exposed in the prior cesarean section scar. The urinary bladder is not involved.

Figure 4.

Laparotomy via Pfannenstiel incision with products of conception exposed in the prior cesarean section scar. The urinary bladder is not involved.

Figure 5.

Cesarean scar ectopic pregnancy (CSEP) lower- and middle-income countries (LMIC) Flowchart. * Operative management options in LMICs include laparotomy or laparoscopy depending on hospital resources. ** Medical management options in LMIC include systemic methotrexate (MTX) and/or intra-gestational sac injection of MTX or potassium chloride (KCl) depending on ability for close follow-up and hospital resources. BHCG – beta-human chorionic gonadotropin; TVUS – transvaginal ultrasound; ABD US – abdominal ultrasound; CSEP – cesarean scar ectopic pregnancy; MRI – magnetic resonance imaging; DX – diagnosis.