Intramural ectopic pregnancy: a case and review of the literature

Diagnosis and management of heterotopic intramural pregnancy after in vitro fertilization: an eight-case series

PURPOSE

To analyze the ultrasound characteristics, clinical management, and pregnancy outcomes of heterotopic intramural pregnancies (HIMPs) after embryo transfer.

METHODS

This was a retrospective observational study of women who were diagnosed with HIMPs. The ultrasound characteristics, clinical treatment, and pregnancy outcomes of patients with HIMPs were evaluated.

RESULTS

Eight women with HIMPs were included. Among them, 6 patients were diagnosed by transvaginal sonography, and 2 patients were misdiagnosed with heterotopic interstitial pregnancy. The diagnostic accuracy was 75% (6/8). Five patients with HIMPs were diagnosed at the time of the initial scan (5+6-6+3 weeks). An intramural gestational sac was observed in all 6 patients, and an embryo with cardiac activity was detected in one patient on the follow-up scans. Intrauterine pregnancies (IUPs) were revealed in all 6 patients, and embryo(s) with cardiac activity were observed in 5 patients at the time of the initial diagnosis or later. The patients receiving expectant treatment all presented with bagel signs, while patients with embryos with cardiac activity all underwent surgery. Among the 6 diagnosed women, 1 patient was initially treated medically, 4 were treated expectantly, and 1 was treated surgically. Among the 6 diagnosed patients, the IUPs of 5 patients resulted in live infants.

CONCLUSION

Single ET should be recommended to decrease the possibility of HIMP. An accurate diagnosis of HIMP was reached in most cases by detailed ultrasound early in the first trimester. Most IUPs of HIMPs seem to have good outcomes with timely and proper management. Expectant management might be a possible choice for nonviable intramural pregnancies.

Intramural pregnancy at 6 and 8 weeks gestation with no predisposing factors: As two uncommon case reports

Ectopic pregnancies are extremely rare causing severe consequences such as uterine rupture and may lead to death. The clinical symptomatology is very atypical, essentially pelvic pain and metrorrhagia, for this reason, a misdiagnosis can be fatal. Here we report two cases of an intramural pregnancy in a 33-year-old primigravida at 6 weeks gestation after a medically assisted reproduction and a 26-year-old primigravida at 8 weeks gestation with no predisposing factors, making the diagnosis more challenging.

Total laparoscopic wedge resection for an intramural ectopic pregnancy using an intraoperative ultrasound system: A case report

Intramural pregnancy is a rare form of ectopic pregnancy, and the optimal treatment remains uncertain. We describe a 33-year-old woman (gravida 2, para 0) who visited our hospital with suspected ectopic pregnancy. The patient was asymptomatic and hemodynamically stable. Transvaginal ultrasonography revealed pregnancy at 6 weeks of gestation and a gestational sac and fetal heartbeat in the anterior muscular layer of the uterus, away from the endometrium. The fetal sac measured 26 mm. The serum human chorionic gonadotropin (hCG) level had increased to 27 655 mIU/mL. Accordingly, the patient was diagnosed with an intramural ectopic pregnancy and underwent total laparoscopic wedge resection using intraoperative ultrasonography. The postoperative course was uneventful, and she was discharged after 4 days. Her serum hCG level normalized at 26 days postoperatively. This case indicates that intraoperative laparoscopic ultrasonography seems viable for treating intramural pregnancies.

Intramural ectopic pregnancy: An individual patient data systematic review

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.

From intramural ectopic pregnancy to hysterectomy: A case report

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.

Uterine rupture in intramural ectopic pregnancy: A case report

Intramural pregnancy is a rare form of ectopic pregnancy. It is defined by a gestation within the uterine wall, completely surrounded by myometrium and separated from the uterine cavity and the fallopian tube. We report a rare case of intramural ectopic pregnancy. If a patient has a history of intrauterine surgery or myomectomy, the possibility of intramural pregnancy, although rare, should not be ruled out.

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

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.

Intramural Ectopic Pregnancy: Clinical Characteristics, Risk Factors for Uterine Rupture and Hysterectomy

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.

Hysteroscopic management of intramural ectopic pregnancy

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.

The many faces of ectopic pregnancies: demystifying the common and less common entities

Ectopic pregnancy is a major cause of 1st trimester pregnancy deaths. It occurs in various locations in the abdominopelvic cavity. Ultrasonography is a first-line, rapid, and noninvasive modality for ectopic pregnancy evaluation. MRI can help clarify equivocal cases. When in doubt about the location, one should give an intrauterine pregnancy the benefit of the doubt with close ultrasound and hCG follow-up. Here, we will review the imaging findings and mimickers of ectopic pregnancies.

A Case of Intramural Pregnancy: Differential Diagnosis for Distinguishing from Retained Products of Conception and Gestational Trophoblastic Disease

Intramural pregnancy refers to the implantation of fertilized eggs in uterine musculature, separated from the uterine cavity and tube. We report a case of intramural pregnancy previously misdiagnosed as retained products of conception and gestational trophoblastic disease. This case highlights the difficulty in the diagnosis of intramural pregnancy. Clinicians should be clear about the risk factors of the disease. Judicious selection of the appropriate imaging modalities is vital to making an accurate diagnosis and providing effective treatment.

Intramural pregnancy: A case report

A 24-year-old woman, who had undergone neither fertility treatment nor uterine surgery other than a cesarean section, presented with an intramural ectopic pregnancy. A laparotomy with uterine wedge resection including the embryonic tissue was performed. The postoperative course was uneventful, with falling βHCG levels. Two months after surgery she presented again with an intrauterine pregnancy.

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An 8-week, viable, intramural ectopic pregnancy in an asymptomatic woman after c-section 5 months earlier is reported.

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Management of such a case may be medical or surgical.

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The patients elected to have surgery.

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Follow-up is requiered until human chorionic gonadotropin levels have normalized.

Uterine-conserving approach in ruptured intramyometrial ectopic pregnancy

Intramyometrial ectopic pregnancy (IMEP) is a rare form of ectopic pregnancy. It is defined as a conceptus implanted within the myometrium and is completely surrounded by myometrium with clear separation from both the uterine cavity and tubes. IMEP possesses not only diagnostic but also therapeutic challenge. The majority of reported cases were managed by hysterectomy. Early management of unruptured IMEP using methotrexate may help to preserve fertility. We, for the first time, report a case of ruptured IMEP managed successfully using suction and curettage followed by Bakri balloon tamponade and avoiding hysterectomy. Post-procedure, the patient received two doses of intramuscular methotrexate 50 mg/m2 due to plateauing serial beta human chorionic gonadotropin (β-hCG) levels and subsequently achieved undetectable level 10 weeks post-methotrexate. She also had complete resolution of the ectopic intramyometrial mass.

Intramyometrial pregnancy after cryopreserved embryo transfer: a case report

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.

Intramural ectopic pregnancy following pelvic adhesion: case report and literature review

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.

Application of contrast-enhanced ultrasound for scar pregnancy cases misdiagnosed as other diseases

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.

Myomectomy scar ectopic pregnancy following a cryopreserved embryo transfer

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.

Intramural Ectopic Pregnancy Following Myomectomy

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.

Ultrasound diagnosis of intramural pregnancy

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.

Treatment of Intramyometrial Pregnancy by In Situ Injection of Methotrexate

Intramyometrial ectopic pregnancies are rare, and various management modalities have been described. We report a patient with intramyometrial pregnancy who was successfully treated by in situ injection of methotrexate (MTX) after the failure of 2 intramuscular injections of MTX. We emphasize the difficult management of intramyometrial pregnancy and show that in situ MTX injection may be indicated for this particular type of ectopic pregnancy.

Ectopic Pregnancy in Uncommon Implantation Sites: Intramural Pregnancy and Rudimentary Horn Pregnancy

Ectopic pregnancy is commonly located in the fallopian tube. Nevertheless, two unusual types of ectopic pregnancy, intramural pregnancy and rudimentary horn pregnancy, seriously threaten maternal life. The diagnosis and treatment of these unusual implantation sites present a clinical challenge. In this study, we illustrated the two unusual types of ectopic pregnancy and summarized the current data regarding diagnosis and optimal treatment from our experience.

Incidence, diagnosis and management of tubal and nontubal ectopic pregnancies: a review

BACKGROUND

Ectopic pregnancy is a potentially life-threatening condition occurring in 1-2 % of all pregnancies. The most common ectopic implantation site is the fallopian tube, though 10 % of ectopic pregnancies implant in the cervix, ovary, myometrium, interstitial portion of the fallopian tube, abdominal cavity or within a cesarean section scar.

FINDINGS

Diagnosis involves a combination of clinical symptoms, serology, and ultrasound. Medical management is a safe and effective option in most clinically stable patients. Patients who have failed medical management, are ineligible, or present with ruptured ectopic pregnancy or heterotopic pregnancy are most often managed with excision by laparoscopy or, less commonly, laparotomy. Management of nontubal ectopic pregnancies may involve medical or surgical treatment, or a combination, as dictated by ectopic pregnancy location and the patient's clinical stability. Following tubal ectopic pregnancy, the rate of subsequent intrauterine pregnancy is high and independent of treatment modality.

CONCLUSION

This review describes the incidence, risk factors, diagnosis, and management of tubal and non-tubal ectopic and heterotopic pregnancies, and reviews the existing data regarding recurrence and future fertility.

[Intramural ectopic pregnancy: about a case]

La grossesse intra-murale est la variété la plus rare de grossesse extra-utérine. Il s'agit de la localisation de l’œuf dans l’épaisseur du myomètre. En cas de retard diagnostic, l’évolution peut être catastrophique avec rupture utérine et hémorragie cataclysmique. L’échographie permet dans certains cas un diagnostic pré opératoire. Les auteurs rapportent un cas survenu chez une patiente aux antécédents de curetage.