Myomectomy scar ectopic pregnancy following a cryopreserved embryo transfer

Subserosal pregnancy: Systematic review with proposal of new diagnostic criteria and ectopic pregnancy classification

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.

Intramural pregnancy after in vitro fertilization and embryo transfer: A case report

BACKGROUND

Intramural pregnancy is a rare type of ectopic pregnancy, which is diagnosed by transvaginal ultrasound and magnetic resonance imaging. Management strategies vary depending on the site of the pregnancy, the gestational age and the desire to maintain fertility. The incidence of intramural pregnancy in assisted reproductive technology is higher than that in natural pregnancy.

CASE SUMMARY

We present a case of intramural pregnancy after in vitro fertilization and elective single embryo transfer following salpingectomy. The patient was completely asymptomatic and her serum β-human chorionic gonadotropin level increased from 290 mIU/mL to 1759 mIU/mL. Three-dimensional transvaginal ultrasound indicated a heterogeneous echogenic mass arising from the uterine fundus which was surrounded by myometrium and a slender and extremely hypoechoic area stretching to the uterine cavity which was thought to be a fistulous tract. Therefore, we considered a diagnosis of intramural pregnancy and laparoscopic surgery was conducted at 7 wk gestation.

CONCLUSION

Early diagnosis and treatment of intramural pregnancy is significant for maintaining fertility.

Intramural pregnancy after in vitro fertilization and embryo transfer: A case report

BACKGROUND

Intramural pregnancy is a rare type of ectopic pregnancy, which is diagnosed by transvaginal ultrasound and magnetic resonance imaging. Management strategies vary depending on the site of the pregnancy, the gestational age and the desire to maintain fertility. The incidence of intramural pregnancy in assisted reproductive technology is higher than that in natural pregnancy.

CASE SUMMARY

We present a case of intramural pregnancy after in vitro fertilization and elective single embryo transfer following salpingectomy. The patient was completely asymptomatic and her serum β-human chorionic gonadotropin level increased from 290 mIU/mL to 1759 mIU/mL. Three-dimensional transvaginal ultrasound indicated a heterogeneous echogenic mass arising from the uterine fundus which was surrounded by myometrium and a slender and extremely hypoechoic area stretching to the uterine cavity which was thought to be a fistulous tract. Therefore, we considered a diagnosis of intramural pregnancy and laparoscopic surgery was conducted at 7 wk gestation.

CONCLUSION

Early diagnosis and treatment of intramural pregnancy is significant for maintaining fertility.

Myomectomy scar pregnancy ‒ a serious, but scarcely reported entity: literature review and an instructive case

Objectives

Uterine myomas are a frequent finding in reproductive age women with an estimated incidence 12–25%. 1. Treatment of uterine myomas to facilitate good pregnancy rates and outcome, such as hysteroscopic, laparoscopic, abdominal resection uterine artery embolization among others were evaluated in terms of pregnancy outcome. While the literature is replete of the pregnancy complication of uterine rupture after myomectomies, 2–4 there are very few publications evaluate a relatively rare pregnancy complication associated with placental implantation within the uterine cavity at the site of the previous myomectomy, namely the myomectomy scar pregnancy (MSP). Despite their relative rarity, this type of pathologically adherent placenta rightfully belongs to the well-known entity of placenta accreta spectrum (PAS).

Case presentation

We present a complicated case of MSP and review the available literature to raise attention to its clinical appearance, its prenatal diagnosis so appropriate intrapartum management can be planned.

Conclusions

Despite the rarity of MSP, continuous attention should be given at every single routinely scheduled or indication driven obstetrical US scan following myomectomies to evaluate the placental site implantation regardless of the route and technique of their initial surgical procedure.

Myomectomy scar pregnancy: a case report and review of the literature

Myomectomy scar pregnancy (MSP) is a rare disease, which is defined as a gestational sac located within a previous myomectomy scar. MSP is an uncommon late complication of uterine fibroids after myomectomy. We report a case where the implantation site matched the site of the previous myomectomy, and review the existing literature. A 28-year-old pregnant woman presented with vaginal bleeding. She was diagnosed with MSP by ultrasound and magnetic resonance imaging, and then underwent laparotomic enucleation. The patient's postoperative course was uneventful. Taking into account the findings in our case and the seven other reported cases of MSP, we propose that MSP can be divided into three types and that surgical enucleation of the pregnancy mass is an effective treatment.

Live birth after laparoscopic management of a ruptured myomectomy site pregnancy and unruptured tubal gestation in a double ectopic heterotopic gestation

Myomectomy scar pregnancy is a rare intramural pregnancy in which gestational sac is implanted in the myometrium, in the previous myomectomy scar separate from endometrial cavity and fallopian tubes. Heterotopic pregnancy is presence of simultaneous gestation at two or more implantation sites. Our patient presented at 7 weeks, in-vitro fertilization (IVF) conception with previous four IVF failures and myomectomy 3 months prior. Transvaginal sonography revealed twin live pregnancies, one intrauterine and another in the posterior wall of the uterus distinctly separate from the endometrial cavity. Laparoscopy revealed a ruptured intramural pregnancy, another unruptured tubal pregnancy which was initially missed by USG. After laparoscopic management, intrauterine pregnancy continued resulting in live birth at 35 weeks. This case adds to the literature and highlights the importance of early diagnosis and timely intervention of a rare form of an ectopic gestation. This is the only reported case in literature with a heterotopic gestation and a coexistent myomectomy scar pregnancy and the only one resulting in successful live birth after laparoscopic management of a ruptured myomectomy scar pregnancy in a heterotopic gestation. Early diagnosis is important for salvaging the intrauterine gestation and one should actively look for them at viability scan especially in assisted reproductive technology (ART) conception and scarred uterus.

Minimally-invasive management of intramural ectopic pregnancy: an eight-case series and literature review

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.

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.