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Stabile G, Cracco F, Zinicola G, Carlucci S, Mangino FP, Stampalija T, Ricci G. Subserosal pregnancy: Systematic review with proposal of new diagnostic criteria and ectopic pregnancy classification. Eur J Obstet Gynecol Reprod Biol 2024; 297:254-259. [PMID: 38701545 DOI: 10.1016/j.ejogrb.2024.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 04/24/2024] [Accepted: 04/28/2024] [Indexed: 05/05/2024]
Abstract
Ectopic pregnancy (EP) is a pregnancy where the growing blastocyst implants outside the endometrial cavity. EP account approximately for 0.5-1% of all pregnancies, and extrauterine implant is the leading cause of woman mortality in the first trimester of gestation. Non-tubal pregnancies (NTP) account for less than 5% of all EP. NTP are accompanied by a 7-8 times higher risk of maternal mortality when compared to tubal pregnancies, and their treatment might sometimes be very challenging. Subserosal pregnancy (SP) has been defined as rare variant of intramural pregnancy, where a portion of the gestational sac was surrounded only by the serosa of the uterus. Whereas the treatment of the ectopic pregnancies is crucial for patients' lives and for adequate fertility sparing and considering the need for surgical treatment in many cases, an early diagnosis is important; thus we believe it g might be useful to define some criteria to guide subserosal pregnancy identification, and to distinguish it from other types of non-tubal ectopic pregnancy. A systematic review on Pubmed, Scopus, Web of Science and Google Scholar was performed. Case reports, randomized controlled trials, prospective controlled studies, prospective cohort studies, retrospective studies, and case series were considered eligible. In all databases mentioned were considered manuscripts published from 1990 up to March 2023. Only four articles were eligible for inclusion in this review. All patients underwent to surgical management in laparoscopy. The main risk factors for this type of ectopic pregnancy were previous uterine surgery with opening of the endometrial cavity and assisted reproductive techniques procedures. Considering our results, we propose new classification and diagnostic criteria for subserosal pregnancy, to distinguish it from other types of non-tubal ectopic pregnancies with the aim to preserve fertility following the most correct management.
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Affiliation(s)
- Guglielmo Stabile
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71121 Foggia, Italy.
| | - Francesco Cracco
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34100 Trieste, Italy
| | - Giulia Zinicola
- Department of Woman and Child Health and Public Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Stefania Carlucci
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71121 Foggia, Italy
| | | | - Tamara Stampalija
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34100 Trieste, Italy; Institute for Maternal and Child Health IRCCS "Burlo Garofolo", 34100 Trieste, Italy
| | - Giuseppe Ricci
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34100 Trieste, Italy; Institute for Maternal and Child Health IRCCS "Burlo Garofolo", 34100 Trieste, Italy
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Ntafam CN, Sanusi-Musa I, Harris RD. Intramural ectopic pregnancy: An individual patient data systematic review. Eur J Obstet Gynecol Reprod Biol X 2024; 21:100272. [PMID: 38269031 PMCID: PMC10805919 DOI: 10.1016/j.eurox.2023.100272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 12/12/2023] [Accepted: 12/16/2023] [Indexed: 01/26/2024] Open
Abstract
Intramural pregnancies (IMP) are very rare and represent about 1% of ectopic pregnancies (EPs). Despite a few reported cases, there is limited awareness & knowledge among sonographers and physicians. Moreover, no established diagnostic or treatment protocol exists for such a condition. This study identifies and synthesizes what is known about IMP, including etiology and pathophysiology, common clinical presentations, imaging features, laparoscopic and hysteroscopic findings, and management. PUBMED and Google Scholar were queried to identify eligible studies. All articles on IMP in human subjects available in English and French languages were included. Other types of ectopic pregnancies, including cesarean scar and cervical ectopic pregnancies, were excluded. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines and a narrative synthesis approach were used to systematically review the medical literature. 82 cases distributed around 27 countries with an average maternal age of 32.07 years and gestational age of 9.27 weeks were eventually selected for this study. History of curettage was the most common risk factor reported in 30 (36.58%) patients, followed by history of salpingectomy, assisted reproduction with embryo transfer, and previous cesarean delivery, in 10(12.19%), 10(12.19%), and 9(10.97%) patients respectively. Ultrasound was performed in 80(97.56%) cases. Of the 66 reported ultrasound findings, 29 were diagnostic or suggestive of IMP. MRI, laparoscopy (both diagnostic & surgical) and diagnostic hysteroscopy were carried out on 18(21.95%), 36(43.9%) and 22(26.83%) patients respectively. Histopathologic examination mainly performed after surgery was the gold standard for confirming the diagnosis. Management involved conservative (3.65%) approach, medical treatment with methotrexate or potassium chloride (23.17%), and surgical interventions. The latter includes laparoscopic surgery (25.61%), laparotomic surgery (23.17%), and hysterectomy (13.41%). IMP is a rare but potentially lethal clinical entity. A significant proportion of patients are asymptomatic and have no known risk factors. Correlation between clinical history and imaging findings is vital to establish a prompt diagnosis and reduce the risk of a catastrophic outcome.
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Affiliation(s)
- Carnot N. Ntafam
- Detroit Medical Center Sinai-Grace Hospital, Detroit, MI 48235, USA
| | | | - Robert D. Harris
- Drexel University College of Medicine, Allegheny Health Network, Pittsburg, PA 15237, USA
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Harris R, Awal W, Jacob-Rogers S, Walker G. From intramural ectopic pregnancy to hysterectomy: A case report. Case Rep Womens Health 2024; 41:e00600. [PMID: 38605933 PMCID: PMC11007569 DOI: 10.1016/j.crwh.2024.e00600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 03/23/2024] [Accepted: 03/25/2024] [Indexed: 04/13/2024] Open
Abstract
An intramural ectopic pregnancy is one of the rarest types of ectopic pregnancy, and due to the scarcity of reported cases there are no clear guidelines regarding diagnosis and management of the condition. We report a case of a non-viable intramural ectopic pregnancy managed with intravenous methotrexate, in a patient with no previous pregnancies but a history of uterine cornual cyst excision. The patient subsequently developed a uterine arteriovenous malformation, which was embolised. Following this, she had two pregnancies, one culminating in an elective caesarean section at term, and the other a medical termination of pregnancy at 19 weeks of gestation. As a result of post-traumatic stress disorder attributed to this complicated history, the patient requested a hysterectomy. This case demonstrates the complexity of the management of intramural ectopic pregnancy and highlights the impacts the condition can have on a patient's physical and mental health.
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Affiliation(s)
- Rhys Harris
- Gold Coast Hospital and Health Service, 1 Hospital Boulevard Southport, QLD 4215, Australia
- School of Medicine and Dentistry, Griffith University, 1 Parklands Dr, Southport, QLD 4215, Australia
| | - Wasim Awal
- Gold Coast Hospital and Health Service, 1 Hospital Boulevard Southport, QLD 4215, Australia
| | - Sebastian Jacob-Rogers
- Gold Coast Hospital and Health Service, 1 Hospital Boulevard Southport, QLD 4215, Australia
| | - Graeme Walker
- Gold Coast Hospital and Health Service, 1 Hospital Boulevard Southport, QLD 4215, Australia
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Dewilde K, Groszmann Y, Van Schoubroeck D, Grewal K, Huirne J, de Leeuw R, Bourne T, Timmerman D, Van den Bosch T. Enhanced myometrial vascularity secondary to retained pregnancy tissue: time to stop misusing the term arteriovenous malformation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:5-8. [PMID: 37676250 DOI: 10.1002/uog.27476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/21/2023] [Accepted: 08/24/2023] [Indexed: 09/08/2023]
Affiliation(s)
- K Dewilde
- Department of Obstetrics & Gynecology, University Hospital Leuven, Leuven, Belgium
| | - Y Groszmann
- Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - D Van Schoubroeck
- Department of Obstetrics & Gynecology, University Hospital Leuven, Leuven, Belgium
| | - K Grewal
- Early Pregnancy and Acute Gynaecology Unit, Department of Obstetrics and Gynaecology, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK
| | - J Huirne
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - R de Leeuw
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - T Bourne
- Early Pregnancy and Acute Gynaecology Unit, Department of Obstetrics and Gynaecology, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK
- Department of Development & Regeneration, KU Leuven, Leuven, Belgium
| | - D Timmerman
- Department of Obstetrics & Gynecology, University Hospital Leuven, Leuven, Belgium
- Department of Development & Regeneration, KU Leuven, Leuven, Belgium
| | - T Van den Bosch
- Department of Obstetrics & Gynecology, University Hospital Leuven, Leuven, Belgium
- Department of Development & Regeneration, KU Leuven, Leuven, Belgium
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Nijjar S, Bottomley C, Jauniaux E, Jurkovic D. Imaging in gynecological disease (25): clinical and ultrasound characteristics of intramural pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:279-289. [PMID: 37058401 DOI: 10.1002/uog.26219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/21/2023] [Accepted: 03/30/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE To describe the clinical and sonographic characteristics of intramural pregnancy, as well as the available management options and treatment outcomes. METHODS This was a retrospective single-center study of consecutive patients with a sonographic diagnosis of intramural pregnancy between November 2008 and November 2022. An intramural pregnancy was diagnosed on ultrasound when a pregnancy was implanted within the uterine corpus, above the level of the internal cervical os and separate from the interstitial section of the Fallopian tube, and extended beyond the decidual-myometrial junction. Clinical, ultrasound, relevant surgical and histological information and outcomes were retrieved from each patient's record and analyzed. RESULTS Eighteen patients were diagnosed with an intramural pregnancy during the study period. Their median age was 35 (range, 28-43) years and the median gestational age at diagnosis was 8 + 1 (range, 5 + 5 to 12 + 0) weeks. Vaginal bleeding with or without abdominal pain was the most common presenting symptom, recorded in eight patients. Nine (50%) patients had a partial and nine (50%) had a complete intramural pregnancy. Embryonic cardiac activity was present in eight (44%) pregnancies. The majority of pregnancies (n = 10 (56%)) were initially managed conservatively, including expectant management in eight (44%) cases, local injection of methotrexate in one (6%) and embryocide in one (6%). Conservative management was successful in nine of the 10 (90%) pregnancies, with a median time to serum human chorionic gonadotropin resolution of 71 (range, 35-143) days. One patient with an ongoing live pregnancy had an emergency hysterectomy for a major vaginal bleed at 20 weeks' gestation. No other patient managed conservatively experienced any significant complication. The remaining eight (44%) patients had primary surgical treatment, comprising transcervical suction curettage in seven (88%) of these cases, while one patient presented with uterine rupture and underwent emergency laparoscopy and repair. CONCLUSIONS We describe the ultrasound features of partial and complete intramural pregnancy, demonstrating key diagnostic features. Our series suggests that, when intramural pregnancy is diagnosed before 12 weeks' gestation, it can be managed either conservatively or by surgery, with preservation of reproductive function in most women. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- S Nijjar
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK
| | - C Bottomley
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK
| | - E Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK
| | - D Jurkovic
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK
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Truong DP, Pham TH, Nguyen PN, Ho QN. Misdiagnosis of intramural ectopic pregnancy and invasive gestational trophoblastic disease on ultrasound: A challenging case at Tu Du Hospital in Vietnam in COVID-19 pandemic peak and mini-review of literature. Radiol Case Rep 2022; 17:4821-4827. [PMID: 36238215 PMCID: PMC9550589 DOI: 10.1016/j.radcr.2022.09.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/05/2022] [Accepted: 09/11/2022] [Indexed: 11/07/2022] Open
Abstract
Differentiation between intramural ectopic pregnancy and molar ectopic pregnancy is very difficult because of their exceptional rarity. Herein, we present a misdiagnosed case of intramural pregnancy and invasive trophoblastic disease on ultrasound. A 45-year-old female patient was admitted to our tertiary referral hospital due to abdominal pain and unusual ultrasonography findings. Initially, a diagnosis of intramural ectopic pregnancy was identified based on transvaginal color Doppler ultrasonography, 3-dimensional ultrasound, and serial serum beta-human chorionic gonadotropin, thus the patient underwent laparotomy with hysterectomy. However, the histopathological endpoint showed an invasive trophoblastic disease. Clinically, this pathology should be included in the differential diagnosis of intramural ectopic pregnancy since an imaging scan remains quite unclear.
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Affiliation(s)
- Diem Phuong Truong
- Department of Obstetrics Bloc M, Tu Du Hospital, Ho Chi Minh City, Vietnam
| | - Thanh Hai Pham
- Tu Du Clinical Research Unit, Tu Du Hospital, Ho Chi Minh City, Vietnam
| | - Phuc Nhon Nguyen
- Tu Du Clinical Research Unit, Tu Du Hospital, Ho Chi Minh City, Vietnam,Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao ward, District 1, Ho Chi Minh City, 730000, Vietnam,Corresponding author.
| | - Quang Nhat Ho
- Department of Post-operative Care, Tu Du Hospital, Ho Chi Minh City, Vietnam
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Jauniaux E, Jurkovic D, Hussein AM, Burton GJ. New insights into the etiopathology of placenta accreta spectrum. Am J Obstet Gynecol 2022; 227:384-391. [PMID: 35248577 DOI: 10.1016/j.ajog.2022.02.038] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/07/2022] [Accepted: 02/21/2022] [Indexed: 11/19/2022]
Abstract
Placenta accreta has been described as a spectrum of abnormal attachment of villous tissue to the uterine wall, ranging from superficial attachment to the inner myometrium without interposing decidua to transmural invasion through the entire uterine wall and beyond. These descriptions have prevailed for more than 50 years and form the basis for the diagnosis and grading of accreta placentation. Accreta placentation is essentially the consequence of uterine remodeling after surgery, primarily after cesarean delivery. Large cesarean scar defects in the lower uterine segment are associated with failure of normal decidualization and loss of the subdecidual myometrium. These changes allow the placental anchoring villi to implant, and extravillous trophoblast cells to migrate, close to the serosal surface of the uterus. These microscopic features are central to the misconception that the accreta placental villous tissue is excessively invasive and have led to much confusion and heterogeneity in clinical data. Progressive recruitment of large arteries in the uterine wall, that is, helicine, arcuate, and/or radial arteries, results in high-velocity maternal blood entering the intervillous space from the first trimester of pregnancy and subsequent formation of placental lacunae. Recently, guided sampling of accreta areas at delivery has enabled accurate correlation of prenatal imaging data with intraoperative features and histopathologic findings. In more than 70% of samples, there were thick fibrinoid depositions between the tip of most anchoring villi and the underlying uterine wall and around all deeply implanted villi. The distortion of the uteroplacental interface by these dense depositions and the loss of the normal plane of separation are the main factors leading to abnormal placental attachment. These data challenged the classical concept that placenta accreta is simply owing to villous tissue sitting atop the superficial myometrium without interposed decidua. Moreover, there is no evidence in accreta placentation that the extravillous trophoblast is abnormally invasive or that villous tissue can cross the uterine serosa into the pelvis. It is the size of the scar defect, the amount of placental tissue developing inside the scar, and the residual myometrial thickness in the scar area that determine the distance between the placental basal plate and the uterine serosa and thus the risk of accreta placentation.
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Affiliation(s)
- Eric Jauniaux
- Faculty of Population Health Sciences, Elizabeth Garrett Anderson Institute for Women's Health, Faculty of Population Health Sciences, London, United Kingdom.
| | - Davor Jurkovic
- Faculty of Population Health Sciences, Elizabeth Garrett Anderson Institute for Women's Health, Faculty of Population Health Sciences, London, United Kingdom
| | - Ahmed M Hussein
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, Egypt
| | - Graham J Burton
- Department of Physiology, Development, and Neuroscience, University of Cambridge, Cambridge, United Kingdom
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Chen X, Gao L, Yu H, Liu M, Kong S, Li S. Intramural Ectopic Pregnancy: Clinical Characteristics, Risk Factors for Uterine Rupture and Hysterectomy. Front Med (Lausanne) 2021; 8:769627. [PMID: 34778327 PMCID: PMC8583088 DOI: 10.3389/fmed.2021.769627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/05/2021] [Indexed: 01/02/2023] Open
Abstract
Background: Intramural ectopic pregnancy is defined as the gestational sac (GS) is entirely within the myometrium, separate from the endometrial cavity and fallopian tubes, which is unsustainable and potentially life-threatening. The data investigating the clinical characteristics, management strategy, and fertility outcomes after treatment of intramural ectopic pregnancies are very limited due to its extreme rarity. Methods: To investigate the clinical characteristics, treatment options, and fertility outcomes in patients with intramural ectopic pregnancy, a retrospective study included 56 patients was conducted. We also used logistic regression to identify potential risk factors for uterine rupture and hysterectomy in these patients. Results: The mean age of patients was 31.1 years, with an average gestational age (GA) of 10.0 weeks, and the majority of the patient cohort (83.9%) had uterine or endometrial surgical history. 55.4% of the intramural pregnancy was diagnosed by preoperative imaging examination and 67.7% was detected by ultrasound. There was no dominant predisposed zone of the GS. Common treatment strategies included laparotomy surgery (41.1%) and laparoscopic surgery (35.7%), followed by methotrexate (7.1%) and expectant management (5.4%). Uterine rupture occurred in 9 patients and 8 patients underwent a hysterectomy, but no maternal demise was found. Logistic regression showed that a GA >10 weeks predicted a significantly higher risk of uterine rupture (Odds ratio [OR] 8.000, 95% confidence interval [CI] 1.456-43.966, P = 0.017) and hysterectomy (OR 12.333, 95% CI 2.125-71.565, P = 0.005), and GS located in the fundus also predicted higher probability of uterine rupture (OR 7.000,95% CI 1.271-38.543, P = 0.025). Among the ten patients who had a desire for fertility, 6 of them succeeded and 4 of them successfully delivered with a GA ≥ 34 weeks. Conclusion: GA > 10 weeks was the risk factor for both uterine rupture and hysterectomy, while patients with GS located in the uterine fundus had a significantly higher risk of uterine rupture. The fertility outcomes were moderate after treatment. The management strategies should be individualized according to disease conditions and the desire for fertility, and early diagnosis is essential for optimizing clinical outcomes.
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Affiliation(s)
- Xiaoran Chen
- Department of Ultrasound, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Lingyun Gao
- Department of Ultrasound, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Hongna Yu
- Department of Ultrasound, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Meijuan Liu
- Department of Ultrasound, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Shujun Kong
- Department of Obstetrics and Gynecology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Sijian Li
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Auer-Schmidt MM, Rahimi G, Wahba AH, Schmidt T. Hysteroscopic management of intramural ectopic pregnancy. BMJ Case Rep 2021; 14:e244514. [PMID: 34728506 PMCID: PMC8565562 DOI: 10.1136/bcr-2021-244514] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2021] [Indexed: 11/03/2022] Open
Abstract
The uterine myometrium is the rarest location for an ectopic pregnancy resulting in the so-called 'intramural or intramyometrial ectopic pregnancy'. It presents a particular diagnostic and therapeutic challenge for the treating physician. If passed undiagnosed can lead to life-threatening uterine rupture, which may warrant hysterectomy, leaving the woman with irreversible infertility. Different treatment modalities have been proposed for the management of this condition. In this case report, we are describing a rare case of intramural ectopic pregnancy and reporting the use of hysteroscopy for the surgical management of this case for the first time in the literature.
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Affiliation(s)
- Maximilian Mattes Auer-Schmidt
- Department of Gynecologic Endoscopy, PAN-Klinik, Cologne, Germany
- Department of Obstetrics and Gynecology, Cologne University Hospital, Cologne, Germany
| | - Gohar Rahimi
- Department of Endocrinology and Reproductive Medicine, Cologne University Hospital, Cologne, Germany
| | - Amr H Wahba
- Department of Gynecologic Endoscopy, PAN-Klinik, Cologne, Germany
- Department of Obstetrics and Gynecology, Cairo University Hospital, Cairo, Egypt
| | - Torsten Schmidt
- Department of Gynecologic Endoscopy, PAN-Klinik, Cologne, Germany
- Department of Obstetrics and Gynecology, Cologne University Hospital, Cologne, Germany
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10
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Minimally-invasive management of intramural ectopic pregnancy: an eight-case series and literature review. Eur J Obstet Gynecol Reprod Biol 2020; 253:180-186. [PMID: 32871441 DOI: 10.1016/j.ejogrb.2020.08.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 08/04/2020] [Accepted: 08/21/2020] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Intramural pregnancy (IMP) is a rare type of ectopic pregnancy and potentially fatal. Early diagnosis and management of IMP are important to preserve patient fertility. Here, we describe the use of minimally-invasive surgery for early IMP. STUDY DESIGN We retrospectively analyzed the clinical data of eight patients with IMP treated at our center (January 2010 to December 2018) and reviewed the literature describing minimally-invasive treatment of IMP. RESULTS All eight patients had at least one risk factor for IMP. Two cases were confirmed by ultrasound, but ectopic pregnancy or gestational trophoblastic disease were initially suspected in the other cases. Surgery (laparoscopic in three patients, hysteroscopic in one patient, and laparoscopic combined with hysteroscopic in four patients) was successful in all cases, and all patients recovered well without complications. The literature review identified 14 articles describing 17 cases of IMP managed with minimally-invasive surgery. Laparoscopic surgery was used successfully as a sole treatment in 10 cases and after failure of hysteroscopic surgery in six cases. Only one case was treated with a combination of hysteroscopic surgery and methotrexate. Interestingly, one case at our center presented with a sinus connecting the gestational sac and uterine cavity and was treated successfully using hysteroscopic surgery during early pregnancy. CONCLUSIONS Laparoscopic surgery is a feasible management option for most cases of early IMP. Hysteroscopic surgery may be appropriate for cases where a sinus connects the gestational sac with the uterine cavity or when cornual ectopic pregnancy needs to be excluded.
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11
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Liu Y, Wu Y. Intramyometrial pregnancy after cryopreserved embryo transfer: a case report. BMC Pregnancy Childbirth 2020; 20:90. [PMID: 32041575 PMCID: PMC7011315 DOI: 10.1186/s12884-020-2784-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 01/31/2020] [Indexed: 02/07/2023] Open
Abstract
Background Intramyometrial pregnancy is a rare subtype of ectopic pregnancy. The cases following IVF-ET were few reported in recent years. The etiological factors include previous uterine trauma like myomectomy, salpingectomy, dilatation and curettage, assisted reproductive technologies and adenomyosis. Early diagnosis is difficult to make due to its various manifestation. The medical treatment includes conservative management with surgical excision, aortic balloon occlusion, uterine artery embolization, MTX etc. Sometimes hysterectomy was performed due to delayed diagnosis. Case presentation In this article, we presented a case of a 28 years old woman who had cryopreserved embryo transfer with a history of right side salpingectomy. We suspected it a right adnexa ectopic pregnancy at the first place, especially the right fallopian interstitial or right uterus cornu due to ultrasonography and medical history. The product of conception was discovered embedded in the myometrium and protruding out from the right side of the posterior uterine wall, with seemingly no connection with uterine cavity nor fallopian tubes. The diagnosis of intramural pregnancy was made intraoperatively and validated after pathological report. The interventions were made early enough that exploratory laparoscopy, hysteroscopy and conservative surgical excision were successfully performed at 7 weeks’ gestation preserving the fertility. Conclusions It is important for clinicians to be aware of risk factors of intramural pregnancy and maintain an index of suspicion in ART treatment. Ultrasound and laparoscopy are essential managements for early diagnose which make conservative treatment possible and prevent life-threatening consequences.
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Affiliation(s)
- Yuan Liu
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiaotong University School of Meidicine, Shanghai, China
| | - Yu Wu
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiaotong University School of Meidicine, Shanghai, China.
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12
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Barmase M, Deewan D. Rare case of intramural pregnancy. JOURNAL OF MARINE MEDICAL SOCIETY 2020. [DOI: 10.4103/jmms.jmms_39_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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13
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Zhang Q, Xing X, Liu S, Xie X, Liu X, Qian F, Liu Y. Intramural ectopic pregnancy following pelvic adhesion: case report and literature review. Arch Gynecol Obstet 2019; 300:1507-1520. [PMID: 31729562 DOI: 10.1007/s00404-019-05379-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 11/06/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Intramural pregnancy is an uncommon type of ectopic pregnancy, where the gestational sac is completely encircled by myometrium and unconnected with endometrial cavity, fallopian tubes or round ligament. Owing to its potentially life-threatening hemorrhage and uterine rupture, early diagnosis and management are urgently required. We present a case of a woman undergoing zigzag medical procedures, which featured non-consensus preoperative diagnosis of intramural and interstitial pregnancy and an intramural ectopic pregnancy ultimately confirmed and successfully removed by emergency laparoscopy. Additionally, we present a review of the related literature and discuss its varied clinical features, imageological characters, diagnosis, differential diagnosis and multiple treatments. METHODS A comprehensive bibliographic search through PubMed, using keywords: intramural ectopic pregnancy. Relevant literatures published from January 2013 to April 2019 were reviewed. RESULTS Twenty-four cases in total for intramural ectopic pregnancy including this report were reviewed. Diagnoses were mainly made by ultrasound images. Most patients had a history of uterine surgery or intrauterine operation and had been surgically resected. None of the mothers were in danger, but only one case had live birth at 37 weeks of gestation. CONCLUSION Non-specific clinical presentation and non-uniform ultrasound criteria pose a challenge for us to make timely and accurate management. Integrated radiological examinations and communication and cooperation between sonographers and gynecologists play a vital role in diagnostic accuracy and selecting the optimal therapeutic method of an intramural pregnancy.
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Affiliation(s)
- Qi Zhang
- Department of Medical Ultrasound, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Xiaoxiao Xing
- Department of Medical Ultrasound, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Shuiqing Liu
- Department of Medical Ultrasound, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Xiao Xie
- Department of Medical Ultrasound, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Xia Liu
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Feng Qian
- Department of Medical Ultrasound, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Yanping Liu
- Department of Medical Ultrasound, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China.
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14
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Dhombres F, Maurice P, Guilbaud L, Franchinard L, Dias B, Charlet J, Blondiaux E, Khoshnood B, Jurkovic D, Jauniaux E, Jouannic JM. A Novel Intelligent Scan Assistant System for Early Pregnancy Diagnosis by Ultrasound: Clinical Decision Support System Evaluation Study. J Med Internet Res 2019; 21:e14286. [PMID: 31271152 PMCID: PMC6636237 DOI: 10.2196/14286] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 06/11/2019] [Accepted: 06/11/2019] [Indexed: 01/26/2023] Open
Abstract
Background Early pregnancy ultrasound scans are usually performed by nonexpert examiners in obstetrics/gynecology (OB/GYN) emergency departments. Establishing the precise diagnosis of pregnancy location is key for appropriate management of early pregnancies, and experts are usually able to locate a pregnancy in the first scan. A decision-support system based on a semantic, expert-validated knowledge base may improve the diagnostic performance of nonexpert examiners for early pregnancy transvaginal ultrasound. Objective This study aims to evaluate a novel Intelligent Scan Assistant System for early pregnancy ultrasound to diagnose the pregnancy location and determine the image quality. Methods Two trainees performed virtual transvaginal ultrasound examinations of early pregnancy cases with and without the system. The ultrasound images and reports were blindly reviewed by two experts using scoring methods. A diagnosis of pregnancy location and ultrasound image quality were compared between scans performed with and without the system. Results Each trainee performed a virtual vaginal examination for all 32 cases with and without use of the system. The analysis of the 128 resulting scans showed higher quality of the images (quality score: +23%; P<.001), less images per scan (4.6 vs 6.3 [without the CDSS]; P<.001), and higher confidence in reporting conclusions (trust score: +20%; P<.001) with use of the system. Further, use of the system cost an additional 8 minutes per scan. We observed a correct diagnosis of pregnancy location in 39 (61%) and 52 (81%) of 64 scans in the nonassisted mode and assisted mode, respectively. Additionally, an exact diagnosis (with precise ectopic location) was made in 30 (47%) and 49 (73%) of the 64 scans without and with use of the system, respectively. These differences in diagnostic performance (+20% for correct location diagnosis and +30% for exact diagnosis) were both statistically significant (P=.002 and P<.001, respectively). Conclusions The Intelligent Scan Assistant System is based on an expert-validated knowledge base and demonstrates significant improvement in early pregnancy scanning, both in diagnostic performance (pregnancy location and precise diagnosis) and scan quality (selection of images, confidence, and image quality).
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Affiliation(s)
- Ferdinand Dhombres
- Service de Médecine Fœtale, Sorbonne Université, Assistance Publique - Hôpitaux de Paris / Hôpitaux Universitaires Est Parisiens, Hôpital Armand Trousseau, Paris, France.,Medical Informatics and Knowledge Engineering for eHealth Lab, INSERM, Paris, France
| | - Paul Maurice
- Service de Médecine Fœtale, Sorbonne Université, Assistance Publique - Hôpitaux de Paris / Hôpitaux Universitaires Est Parisiens, Hôpital Armand Trousseau, Paris, France.,Medical Informatics and Knowledge Engineering for eHealth Lab, INSERM, Paris, France
| | - Lucie Guilbaud
- Service de Médecine Fœtale, Sorbonne Université, Assistance Publique - Hôpitaux de Paris / Hôpitaux Universitaires Est Parisiens, Hôpital Armand Trousseau, Paris, France
| | - Loriane Franchinard
- Service de Médecine Fœtale, Sorbonne Université, Assistance Publique - Hôpitaux de Paris / Hôpitaux Universitaires Est Parisiens, Hôpital Armand Trousseau, Paris, France
| | - Barbara Dias
- Service de Médecine Fœtale, Sorbonne Université, Assistance Publique - Hôpitaux de Paris / Hôpitaux Universitaires Est Parisiens, Hôpital Armand Trousseau, Paris, France
| | - Jean Charlet
- Medical Informatics and Knowledge Engineering for eHealth Lab, INSERM, Paris, France.,Direction de la Recherche et de l'Innovation, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Eléonore Blondiaux
- Service de Radiologie, Sorbonne Université, Assistance Publique - Hôpitaux de Paris / Hôpitaux Universitaires Est Parisiens, Hôpital Armand Trousseau, Paris, France
| | - Babak Khoshnood
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Biostatistics and Epidemiology, INSERM, Paris, France
| | - Davor Jurkovic
- Gynaecology Diagnostic and Outpatient Treatment Unit, University College Hospital and Institute for Women's Health, University College London, London, United Kingdom
| | - Eric Jauniaux
- Gynaecology Diagnostic and Outpatient Treatment Unit, University College Hospital and Institute for Women's Health, University College London, London, United Kingdom
| | - Jean-Marie Jouannic
- Service de Médecine Fœtale, Sorbonne Université, Assistance Publique - Hôpitaux de Paris / Hôpitaux Universitaires Est Parisiens, Hôpital Armand Trousseau, Paris, France.,Medical Informatics and Knowledge Engineering for eHealth Lab, INSERM, Paris, France
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15
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Liu D, Gu X, Liu F, Shi F, Yang M, Wu Q. Application of contrast-enhanced ultrasound for scar pregnancy cases misdiagnosed as other diseases. Clin Chim Acta 2019; 496:134-139. [PMID: 31173731 DOI: 10.1016/j.cca.2019.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 05/31/2019] [Accepted: 06/04/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To demonstrate the feasibility of utilizing contrast-enhanced ultrasound (CEUS) in scar pregnancies misdiagnosed by transvaginal ultrasound (TVS). METHODS CEUS was performed in three patients with clinically suspected abnormal pregnancy, and the diagnosis were inconclusive by TVS. Clinical manifestations and features of TVS and CEUS in these cases were analyzed. RESULTS Three cases included an intramural pregnancy (IMP) after hysteromyomectomy, and two mass-based cesarean scar pregnancy (CSP), the mass was caused by curettage and spontaneous abortion, respectively. In all these cases, early enhancement with high intensity was observed by CEUS at the site of implantation. Moreover, prominently enhanced signal was detected inside the mass, with or without peritrophoblastic ring. No enhancement was detected in clots or masses after effective treatment. CONCLUSION CEUS can be used as a supplementary method to diagnose scar pregnancy and evaluate the treatment efficacy, especially in cases with ambiguous results by TVS.
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Affiliation(s)
- Dongmei Liu
- Department of Ultrasound, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100026, China
| | - Xiaoning Gu
- Department of Ultrasound, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Fang Liu
- Department of Ultrasound, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Fuwen Shi
- Department of Ultrasound, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Min Yang
- Department of Ultrasound, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China.
| | - Qingqing Wu
- Department of Ultrasound, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100026, China.
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16
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Ishiguro T, Yamawaki K, Chihara M, Nishikawa N, Enomoto T. Myomectomy scar ectopic pregnancy following a cryopreserved embryo transfer. Reprod Med Biol 2018; 17:509-513. [PMID: 30377408 PMCID: PMC6194266 DOI: 10.1002/rmb2.12212] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 05/21/2018] [Indexed: 12/18/2022] Open
Abstract
CASE A 40 year old woman with a history of a myomectomy visited the Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan, following 2 years of infertility. Magnetic resonance imaging detected an abnormal endometrial-like pseudo-cavity. A hysterosalpingography also revealed an abnormal accumulation of contrast medium at the myometrial scar site. A transvaginal ultrasound showed a thin myometrium at the lower uterine body. The patient conceived via in vitro fertilization under a luteal phase down-regulation protocol (long protocol) for controlled ovarian stimulation, followed by a cryopreserved embryo transfer during her natural ovulation cycle. After the embryo transfer, the gestational sac was located at the subserosal site of the myomectomy scar. OUTCOME An emergent laparoscopic operation was performed and the embryo was removed successfully via laparoscopy under transvaginal ultrasonography. CONCLUSION A subserosal uterine pregnancy is a rare form of intramural pregnancy, which is a rare subtype of an ectopic pregnancy, which could occur at the myomectomy site, especially after an embryo transfer. It is believed that this rare ectopic pregnancy resulted from embryo implantation under the serosa through a micro-sinus tract that was a site of suture failure of the myomectomy scar and was partially affected by the embryo transfer. Clinicians should consider the possibility of an ectopic pregnancy after uterine surgery, including a myomectomy.
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Affiliation(s)
- Tatsuya Ishiguro
- Department of Obstetrics and GynecologyNiigata University Medical and Dental HospitalNiigataJapan
| | - Kaoru Yamawaki
- Department of Obstetrics and GynecologyNiigata University Medical and Dental HospitalNiigataJapan
| | - Makoto Chihara
- Department of Obstetrics and GynecologyNiigata University Medical and Dental HospitalNiigataJapan
| | - Nobumichi Nishikawa
- Department of Obstetrics and GynecologyNiigata University Medical and Dental HospitalNiigataJapan
| | - Takayuki Enomoto
- Department of Obstetrics and GynecologyNiigata University Medical and Dental HospitalNiigataJapan
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17
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Vagg D, Arsala L, Kathurusinghe S, Ang WC. Intramural Ectopic Pregnancy Following Myomectomy. J Investig Med High Impact Case Rep 2018; 6:2324709618790605. [PMID: 30046624 PMCID: PMC6056775 DOI: 10.1177/2324709618790605] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 06/03/2018] [Accepted: 06/23/2018] [Indexed: 11/20/2022] Open
Abstract
Intramural pregnancy is a rare form of ectopic pregnancy with early diagnosis
essential for prevention of severe hemorrhage and uterine rupture. We report a
rare case of an intramural ectopic pregnancy at 12 weeks gestation in a woman 1
year post open myomectomy. Both transvaginal ultrasound and magnetic resonance
imaging were utilized as diagnostic aids in this case. The rare nature of this
clinical scenario and lack of guidelines for management made clinical decision
making difficult. Due to the size and location of the gestational sac,
hysterectomy was deemed to be the safest modality, and a midline laparotomy,
total abdominal hysterectomy, and bilateral salpingectomy was performed.
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Affiliation(s)
- Deanne Vagg
- Royal Women's Hospital, Parkville, Victoria, Australia
| | - Lima Arsala
- Royal Women's Hospital, Parkville, Victoria, Australia
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18
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Ramkrishna J, Kan GR, Reidy KL, Ang WC, Palma-Dias R. Comparison of management regimens following ultrasound diagnosis of nontubal ectopic pregnancies: a retrospective cohort study. BJOG 2017. [PMID: 28626980 DOI: 10.1111/1471-0528.14752] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To review management options for nontubal ectopic pregnancies. DESIGN Retrospective cohort study. SETTING Tertiary hospital in Melbourne, Australia. POPULATION A total of 100 nontubal pregnancies: 1 abdominal, 32 caesarean scar, 14 cervical, 41 cornual-interstitial, 12 ovarian. METHODS Cases were classified according to ectopic site. Management categories were medical, surgical, combination or expectant. Use of minimally invasive approaches (ultrasound-guided intra-sac injections or selective surgical techniques) was identified. Primary management was considered to be successful if no further unplanned interventions were required. MAIN OUTCOME MEASURES Success of primary management and frequency of unplanned interventions. RESULTS A high rate of success (82%) was demonstrated for all management regimens, with minimal morbidity and no deaths occurring. A high success rate was shown when the primary management regimen was systemic methotrexate or ultrasound-guided intra-sac injection (88%). The success rate for primary surgical management was 57%. High success rates were reported for both primary management with ultrasound-guided injections or in combination with systemic methotrexate (94%) and for primary management with systemic methotrexate alone (81%). Seventy-five per cent of women managed with minimally invasive surgical approaches avoided the need for more extensive surgery, but required longer follow up and additional interventions. CONCLUSION Minimally invasive approaches were found to be safe and effective treatment for women desiring to conserve fertility. Ultrasound-guided intra-sac injection and laparoscopic ectopic removal procedures aimed at preserving reproductive organs should be included as minimally invasive primary management tools in addition to the well-recognised option of systemic methotrexate. TWEETABLE ABSTRACT Nontubal ectopics: minimally invasive procedures a safe alternative to surgery in selected cases.
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Affiliation(s)
- J Ramkrishna
- Ultrasound Department, Pauline Gandel Women's Imaging Centre, The Royal Women's Hospital, Parkville, Vic., Australia.,Department of Gynaecology, The Royal Women's Hospital, Parkville, Vic., Australia
| | - G R Kan
- Ultrasound Department, Pauline Gandel Women's Imaging Centre, The Royal Women's Hospital, Parkville, Vic., Australia.,Department of Gynaecology, The Royal Women's Hospital, Parkville, Vic., Australia
| | - K L Reidy
- Ultrasound Department, Pauline Gandel Women's Imaging Centre, The Royal Women's Hospital, Parkville, Vic., Australia.,Department of Gynaecology, The Royal Women's Hospital, Parkville, Vic., Australia
| | - W C Ang
- Department of Gynaecology, The Royal Women's Hospital, Parkville, Vic., Australia.,Department of Obstetrics and Gynaecology, The Royal Women's Hospital, The University of Melbourne, Parkville, Vic., Australia
| | - R Palma-Dias
- Ultrasound Department, Pauline Gandel Women's Imaging Centre, The Royal Women's Hospital, Parkville, Vic., Australia.,Department of Obstetrics and Gynaecology, The Royal Women's Hospital, The University of Melbourne, Parkville, Vic., Australia.,Pregnancy Research Centre, Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, Vic., Australia
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19
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Liu NN, Han XS, Guo XJ, Sun LT, Kong XC. Ultrasound diagnosis of intramural pregnancy. J Obstet Gynaecol Res 2017; 43:1071-1075. [PMID: 28422362 DOI: 10.1111/jog.13322] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Revised: 01/10/2017] [Accepted: 01/28/2017] [Indexed: 11/29/2022]
Abstract
Intramural pregnancy is a rare type of ectopic pregnancy, where the gestational sac is implanted inside the myometrium instead of the endometrial and fallopian tubes. Preoperative diagnosis remains very difficult. Ultrasonic findings vary according to the anatomical location or duration of pregnancy. In this study, we summarized the ultrasonic characteristics of intramural pregnancy by assessing three cases. We also propose a set of ultrasonic characteristics to facilitate differential diagnosis between intramural pregnancy and other types of ectopic pregnancy.
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Affiliation(s)
- Na-Na Liu
- Ultrasound Department, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xue-Song Han
- Ultrasound Department, Suihua First Hospital, Suihua, China
| | - Xi-Juan Guo
- Ultrasound Department, Shijiazhuang Fourth Hospital, Shijiazhuang, China
| | - Li-Tao Sun
- Ultrasound Department, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xian-Chao Kong
- Department of Gynecology and Obstetrics, Second Affiliated Hospital of Harbin Medical University, Harbin, China
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20
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Su S, Chavan D, Song K, Chi D, Zhang G, Deng X, Li L, Kong B. Distinguishing between intramural pregnancy and choriocarcinoma: A case report. Oncol Lett 2017; 13:2129-2132. [PMID: 28454372 PMCID: PMC5403629 DOI: 10.3892/ol.2017.5737] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 12/06/2016] [Indexed: 12/17/2022] Open
Abstract
Intramural pregnancy is a rare type of ectopic pregnancy with an unclear etiology. It may be associated with uterine wall injury and/or abnormal uterine conditions, such as adenomyosis, in certain cases. In the present report, a case of intramural pregnancy associated with adenomyosis is discussed. The patient was 34 years old and presented with amenorrhea for 40 days. Ultrasonography and magnetic resonance imaging revealed a mixed echogenic mass located within the posterior wall of the uterine fundus with abundant blood flow. In addition, the patient's β-human chorionic gonadotropin levels were markedly elevated; however, these levels demonstrated a declining tendency. Clinically, it was difficult to distinguish the diagnosis of the case between intramural pregnancy and choriocarcinoma. Following initial treatment with methotrexate-based chemotherapy, a laparotomy was performed to confirm the diagnosis and excise the lesion. Pathological analysis confirmed a diagnosis of intramural pregnancy and adenomyosis within the uterine wall. The results of the present case report suggest that surgical intervention should be the first action performed when intramural pregnancy is suspected, in order to confirm the diagnosis and treat the disease.
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Affiliation(s)
- Shan Su
- Department of Obstetrics and Gynecology, Qilu Hospital Affiliated to Shandong University, Jinan, Shandong 250012, P.R. China.,Reproductive Medicine Center, Qilu Hospital Affiliated to Shandong University, Jinan, Shandong 250012, P.R. China
| | - Devendra Chavan
- Department of Obstetrics and Gynecology, Qilu Hospital Affiliated to Shandong University, Jinan, Shandong 250012, P.R. China
| | - Kun Song
- Department of Obstetrics and Gynecology, Qilu Hospital Affiliated to Shandong University, Jinan, Shandong 250012, P.R. China
| | - Dennis Chi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA
| | - Guiyu Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital Affiliated to Shandong University, Jinan, Shandong 250012, P.R. China
| | - Xiaohui Deng
- Department of Obstetrics and Gynecology, Qilu Hospital Affiliated to Shandong University, Jinan, Shandong 250012, P.R. China.,Reproductive Medicine Center, Qilu Hospital Affiliated to Shandong University, Jinan, Shandong 250012, P.R. China
| | - Li Li
- Department of Obstetrics and Gynecology, Qilu Hospital Affiliated to Shandong University, Jinan, Shandong 250012, P.R. China.,Reproductive Medicine Center, Qilu Hospital Affiliated to Shandong University, Jinan, Shandong 250012, P.R. China
| | - Beihua Kong
- Department of Obstetrics and Gynecology, Qilu Hospital Affiliated to Shandong University, Jinan, Shandong 250012, P.R. China
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21
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Chida H, Kikuchi A, Murai M, Sasaki Y, Kanasugi T, Isurugi C, Oyama R, Sugiyama T. Intramural Pregnancy Implanted Into a Myometrial Defect Caused by Curettage: Diagnosis With Transvaginal Sonography and Preconception and Postconception Magnetic Resonance Imaging. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:2066-2067. [PMID: 27574126 DOI: 10.7863/ultra.15.11071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Hideyuki Chida
- Department of Obstetrics and Gynecology Iwate Medical University School of Medicine Morioka, Japan
| | - Akihiko Kikuchi
- Department of Obstetrics and Gynecology Iwate Medical University School of Medicine Morioka, Japan
| | - Masatoshi Murai
- Department of Obstetrics and Gynecology Iwate Medical University School of Medicine Morioka, Japan
| | - Yuri Sasaki
- Department of Obstetrics and Gynecology Iwate Medical University School of Medicine Morioka, Japan
| | - Tomonobu Kanasugi
- Department of Obstetrics and Gynecology Iwate Medical University School of Medicine Morioka, Japan
| | - Chizuko Isurugi
- Department of Obstetrics and Gynecology Iwate Medical University School of Medicine Morioka, Japan
| | - Rie Oyama
- Department of Obstetrics and Gynecology Iwate Medical University School of Medicine Morioka, Japan
| | - Toru Sugiyama
- Department of Obstetrics and Gynecology Iwate Medical University School of Medicine Morioka, Japan
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22
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Li S, Liu H, Li X, Liu Z, Li Y, Li N. Transfemoral temporary aortic balloon occlusion in surgical treatment of second trimester intramural ectopic pregnancy. J Obstet Gynaecol Res 2016; 42:716-718. [PMID: 26989891 DOI: 10.1111/jog.12968] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Revised: 12/28/2015] [Accepted: 01/10/2016] [Indexed: 11/29/2022]
Abstract
Intramural ectopic pregnancy is a rare type of ectopic pregnancy that may lead to life-threatening hemorrhage. In the present case, a 20-year-old woman at 18.5 weeks of gestation, G1 P0 , was diagnosed with intramural ectopic pregnancy on ultrasound and magnetic resonance imaging, which showed a 14-cm × 14-cm gestational sac on the right posterior lateral side of the uterus fundus, surrounded completely by myometrium. Considering the increased risk of bleeding during surgery, transfemoral temporary aortic balloon occlusion was performed during laparotomy. The intramural ectopic gestational sac was successfully resected without life-threatening obstetric hemorrhage. This procedure could offer an alternative approach to classic uterine artery embolization in reducing intraoperative bleeding thus avoiding blood transfusion. Aortic balloon occlusion is the temporary occlusion of the aorta, therefore it does not influence future fertility. In conclusion, transfemoral temporary aortic balloon occlusion is an effective procedure in the surgical treatment of intramural ectopic pregnancy diagnosed beyond the first trimester.
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Affiliation(s)
- Shuhong Li
- Department of Obstetrics and Gynecology, Yantai Yuhuangding Hospital, Yantai, China
| | - Honjie Liu
- Department of Obstetrics and Gynecology, Yantai Yuhuangding Hospital, Yantai, China
| | - Xiaoyan Li
- Department of Obstetrics and Gynecology, Yantai Yuhuangding Hospital, Yantai, China
| | - Zhifen Liu
- Department of Obstetrics and Gynecology, Yantai Yuhuangding Hospital, Yantai, China
| | - Yan Li
- Central Laboratory, Yantai Yuhuangding Hospital, Yantai, China
| | - Ning Li
- Central Laboratory, Yantai Yuhuangding Hospital, Yantai, China
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23
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Amin TN, Saridogan E, Jurkovic D. Ultrasound and intrauterine adhesions: a novel structured approach to diagnosis and management. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:131-139. [PMID: 26094824 DOI: 10.1002/uog.14927] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 06/08/2015] [Indexed: 06/04/2023]
Affiliation(s)
- T N Amin
- Institute for Women's Health, University College London, London, UK
| | - E Saridogan
- Institute for Women's Health, University College London, London, UK
| | - D Jurkovic
- Institute for Women's Health, University College London, London, UK
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24
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Chukus A, Tirada N, Restrepo R, Reddy NI. Uncommon Implantation Sites of Ectopic Pregnancy: Thinking beyond the Complex Adnexal Mass. Radiographics 2015; 35:946-59. [PMID: 25860721 DOI: 10.1148/rg.2015140202] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Ectopic pregnancy occurs when implantation of the blastocyst takes place in a site other than the endometrium of the uterine cavity. Uncommon implantation sites of ectopic pregnancy include the cervix, interstitial segment of the fallopian tube, scar from a prior cesarean delivery, uterine myometrium, ovary, and peritoneal cavity. Heterotopic and twin ectopic pregnancies are other rare manifestations. Ultrasonography (US) plays a central role in diagnosis of uncommon ectopic pregnancies. US features of an interstitial ectopic pregnancy include an echogenic interstitial line and abnormal bulging of the myometrial contour. A gestational sac that is located below the internal os of the cervix and that contains an embryo with a fetal heartbeat is indicative of a cervical ectopic pregnancy. In a cesarean scar ectopic pregnancy, the gestational sac is implanted in the anterior lower uterine segment at the site of the cesarean scar, with thinning of the myometrium seen anterior to the gestational sac. An intramural gestational sac implants in the uterine myometrium, separate from the uterine cavity and fallopian tubes. In an ovarian ectopic pregnancy, a gestational sac with a thick hyperechoic circumferential rim is located in or on the ovarian parenchyma. An intraperitoneal gestational sac is present in an abdominal ectopic pregnancy. Intra- and extrauterine gestational sacs are seen in a heterotopic pregnancy. Two adnexal heartbeats suggest a live twin ectopic pregnancy. Recognition of the specific US features will help radiologists diagnose these uncommon types of ectopic pregnancy.
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Affiliation(s)
- Anjeza Chukus
- From the Department of Radiology, Mount Sinai Medical Center, 4300 Alton Rd, Miami Beach, FL 33140 (A.C., N.I.R.); Department of Radiology, George Washington University School of Medicine, Washington, DC (N.T.); and Department of Radiology, Miami Children's Hospital, Miami, Fla (R.R.)
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25
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Wang J, Xie X. Sonographic diagnosis of intramural pregnancy. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2013; 32:2215-2217. [PMID: 24277907 DOI: 10.7863/ultra.32.12.2215] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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