Most common non-OB surgical condition Fetal loss >30% if ruptured, <2% if not

1. APPENDICITIS • Most common non-OB surgical condition • Fetal loss >30% if ruptured, <2% if not • Difficult clinical diagnosis: • Majority of cases afebrile • Physiologic increase WBC 6-16,000 & up to 30,000 in labor • N/V common in pregnancy • Site of pain may be unusual Ax T1w: normal appendix

2. MR SAFETYRECOMMENDATIONS • No known adverse fetal effects • Safety concern: energy deposition • MR only if US not adequate • Depending on risk/benefit: • Avoid MR in first trimester • Avoid Gadolinium (FDA pregnancy category C)

3. Preparation & Positioning • NPO x 4 hours • Supine or decubitus position • LLD: better for IVC compression • Phased array coil • Large patient: 2 phased array or body coil

4. Maternal MR: Technique • 3 plane 6mm T2w HASTE (Seimens) or SSFSE (GE) • Coronal, axial T2/T1w True-FISP • Review to determine need for additional sequences or gadolinium

5. Additional Noncontrast Sequences • Fat-suppressed T2w • Inflammation, especially if no gad • T1w or fat-suppressed T1w • Blood products, fat vs. blood, endometriosis • Thick slab T2w echo train spin echo • MRCP, MR Urography • Phase contrast/time of flight: vascular

6. Gadolinium • Dynamic imaging if needed • Vascular tumor, accreta • Delayed fat-suppressed T1W • Infection, inflammation

7. APPENDIX ON MR Appendix seen in 10/12 pregnant patients with suspected appendicitis (AJR 2004;183:671-5) Thin slices and cross-referencing tool helpful

8. APPENDICITIS Pregnant with abdominal pain T2w T2w FS

10. 34 yo RLQ pain

13. DEGENERATING FIBROID Courtesy of Aytekin Oto, M.D.

14. RUPTURED APPENDICITS Courtesy of Aytekin Oto, M.D.

15. RUPTURED APPENDICITIS 33 yo at 31 weeks, right-sided pain

16. 10 weeks pregnant, abdominal pain and fever COLITIS Courtesy of Aytekin Oto, M.D.

17. PELVIC ABSCESS Courtesy of Aytekin Oto, M.D.

18. DIVERTICULAR ABSCESS

19. ULCERATIVE COLITIS

20. PERITONITIS Pregnant, history of Crohn dz now with pain and fever

21. DEGENERATING FIBROID

22. Fibroids & Pregnancy • Pain during pregnancy can be severe • Rapid growth • Degeneration • Torsion • Degeneration may lead to premature labor

23. DEGENERATING FIBROID

24. 35 yo 19 weeks pregnant with severe RLQ pain

25. DEGENERATING FIBROID

26. SHORT CERVIX

27. 18 yo 17 weeks pregnant, RLQ pain x 2 mos, now acutely worse

28. TORSED FIBROID Surgery: pedunculated fibroid, stalk twisted 360 degrees

29. SMALL BOWEL OBSTRUCTION • Adhesions > volvulus >> other causes • High incidence of necrotic bowel • Fetal mortality 20-26% • Only 1/3 complete to term after surgery • Most significant contributor to mortality: delayed diagnosis and treatment • MR: Ultra-fast sequences (HASTE, FISP) helpful due to minimal motion artifact

30. 30 yo at 36 weeks with abdominal & pelvic pain

31. SMALL BOWEL OBSTRUCTION Surgery: sbo, multiple adhesions

32. INTUSSUSCEPTION Pregnant with abdominal and pelvic pain, nausea and vomiting

33. CHOLECYSTITIS

34. OVARIAN TORSION • Pregnant women predisposed to torsion • Ultrasound diagnostic unless ovaries poorly visualized due to pregnancy • MR appearance: enlarged ovary with increased stromal SI on T2w • Increased SI on T1w suggests hemorrhage or vascular congestion • Gadolinium may be diagnostic

35. OVARIAN TORSION Courtesy of David McFadden, MD

36. 25 yo 15 weeks pregnant with RLQ pain

37. OVARIAN TORSION T2w

38. OVARIAN TORSION 25 yo 15 weeks pregnant with RLQ pain and adnexal mass on ultrasound

39. PYELONEPHRITIS 19 yo pregnant woman with right-sided pain and fever

40. Sickle Beta Thalassemia