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
Management of emergency care
Anna Sarah Erem, Thomas Okpoti Konney, Adu Appiah-Kubi, Kwasi Ankomah, Adu Tutu Amankwa, John Jude Kweku Annan, Augustine Tawiah, Benjamin Kwame Amoako-Adjei, Kwabena Fosu Lartey, Emma R. Lawrence
Department of Obstetrics and Gynecology, Saba University School of Medicine, Saba, Netherlands Antilles
Am J Case Rep 2020; 21:e927496
Available online: 2020-11-09
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.
Keywords: Cesarean Section, Ghana, Magnetic Resonance Imaging, Pregnancy, Ectopic, Ultrasonography