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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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Peng Y, Dai Y, Yu G, Jin P. High-intensity focused ultrasound ablation combined with systemic methotrexate treatment of intramural ectopic pregnancy: A case report. Medicine (Baltimore) 2022; 101:e31615. [PMID: 36401379 PMCID: PMC9678570 DOI: 10.1097/md.0000000000031615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
RATIONALE Intramural ectopic pregnancy (IMP) is a rare ectopic pregnancy with an unclear etiology, and standard treatment guidelines currently remain unclear. The main treatment option is local excision of IMP via laparoscopy or laparotomy. PATIENT CONCERNS A 32-year-old woman with adenomyosis presented with amenorrhea for 7 weeks and a serum β-human chorionic gonadotropin (HCG) level of 6882 IU/L. The patient had a history of laparotomy for adenomyosis 5 years previously. Three-dimensional ultrasonography showed a live gestational sac (GS) of 9 × 15 × 18 mm located in the left posterior wall of the uterus and a sinus tract connecting the sac and the endometrial cavity. MRI revealed the GS located in the adenomyosis and a 1.0-cm sinus tract connecting the GS and the endometrial cavity. DIAGNOSES IMP with adenomyosis. INTERVENTIONS High-intensity focused ultrasound (HIFU) treatment combined with systemic methotrexate (MTX) was performed to treat IMP, which would avoid operation and massive bleeding. OUTCOMES Serum β-HCG levels decreased to normal 4 weeks after HIFU treatment and the GS was not found on MRI after 4 months. The sinus tract was significantly shortened after the HIFU treatment. LESSONS HIFU ablation combined with systemic MTX is effective for the treatment of IMP and is favorable for maintaining fertility.
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Affiliation(s)
- Yan Peng
- Department of Gynecology, Affiliated Shenzhen Maternity & Child Healthcare Hospital, Southern Medical University, Shenzhen, Guangdong, China
- *Correspondence: Yan Peng, Department of Gynecology, Affiliated Shenzhen Maternity & Child Healthcare Hospital, Southern Medical University, Shenzhen 518000, Guangdong, China (e-mail: )
| | - Yu Dai
- Department of Gynecology, Affiliated Shenzhen Maternity & Child Healthcare Hospital, Southern Medical University, Shenzhen, Guangdong, China
| | - Guiyuan Yu
- Department of Gynecology, Affiliated Shenzhen Maternity & Child Healthcare Hospital, Southern Medical University, Shenzhen, Guangdong, China
| | - Ping Jin
- Department of Gynecology, Affiliated Shenzhen Maternity & Child Healthcare Hospital, Southern Medical University, Shenzhen, Guangdong, China
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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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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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Intramural pregnancy: A case report. Case Rep Womens Health 2020; 27:e00215. [PMID: 32695612 PMCID: PMC7360977 DOI: 10.1016/j.crwh.2020.e00215] [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: 04/07/2020] [Revised: 04/30/2020] [Accepted: 05/04/2020] [Indexed: 11/23/2022] Open
Abstract
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. An 8-week, viable, intramural ectopic pregnancy in an asymptomatic woman after c-section 5 months earlier is reported. Management of such a case may be medical or surgical. The patients elected to have surgery. Follow-up is requiered until human chorionic gonadotropin levels have normalized.
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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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You SH, Chen PC, Chueh HY, Huang KG, Wang HS, Yen CF. Perforating Scar of Intrauterine Device with Subsequent Intramural Pregnancy and Uterine Rupture. J Minim Invasive Gynecol 2019; 26:591-592. [DOI: 10.1016/j.jmig.2018.08.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 08/09/2018] [Accepted: 08/13/2018] [Indexed: 10/28/2022]
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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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