Intramural ectopic pregnancy. Sonographic picture and its relation with adenomyosis

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.

A detective of intramural ectopic pregnancy: The use of pituitrin under hysteroscopy combined with laparoscopy

RATIONALE

Intramural pregnancy is a rare ectopic pregnancy in which the gestational sac is implanted between the muscle walls. Due to the lack of specific clinical manifestations, it is easy to misdiagnose or miss them. If it is allowed to get worse, the uterus will burst, and there will be a lot of bleeding in the later stages, which could lead to the death of the patient.

PATIENT CONCERNS

The patient had no history of uterine surgery, embryo transplantation, or any other operations. She complained of having abdominal distention and swelling of the waist but no vaginal bleeding or lower abdomen discomfort.

DIAGNOSES

According to her transvaginal ultrasonography, we highly suspected ectopic pregnancy. Hysteroscopy combined with laparoscopy is an effective treatment option that can prevent life-threatening problems. During the surgery, pituitrin helped find the gestational sac, and the pathology report confirmed that it was an intramural pregnancy.

INTERVENTIONS

Hysteroscopy combined with laparoscopy is an effective treatment option that can prevent life-threatening problems. During the surgery, we used pituitrin to help find the gestational sac. The use of pituitrin can minimize bleeding during a uterine operation and indicate the location of an intramural pregnancy, helping surgeons to complete the operation successfully.

OUTCOMES

The patient recovered quickly and was discharged on the 4th day after surgery, with a significant decrease in human chorionic gonadotrophin (HCG) levels from 14,792.26 mIU/mL before surgery to 1071.40 mIU/mL at discharge. During the follow up, her HCG level dropped to 50.90 mIU/mL on the 14th day after the surgery. She monitored the HCG levels intermittently until they fell within the normal range.

LESSONS

Intramural pregnancy is a rare form of ectopic pregnancy, and it is difficult to diagnose early on. This may result in uterine rupture or even life-threatening hemorrhage. If an intramural pregnancy is suspected in early pregnancy, hysteroscopy combined with laparoscopy is advised, and if necessary, low-dose posterior pituitary hormone can enhance uterine contractions and better reveal the position of the gestational sac within the uterine wall.

Management of a uterine serosal heterotopic pregnancy after in vitro fertilization in a woman with bilateral salpingectomy: A case report and literature review

RATIONALE

Heterotopic pregnancy (HP) is defined as the simultaneous presence of intrauterine pregnancy and ectopic pregnancy (EP). HP after bilateral salpingectomy is extremely rare and may lead to serious complications if it is misdiagnosed and untreated timely. Here, we presented the first reported case of uterine serosal HP in a woman after assisted reproductive technology with bilateral salpingectomy because of bilateral tubal ectopic pregnancy.

PATIENT CONCERNS

A 27-years-old pregnant woman after in vitro fertilization with bilateral salpingectomy complained of a sudden onset of unprovoked abdominal pain, which was persistent and dull. She denied vaginal bleeding.

DIAGNOSES

Serum beta-human chorionic gonadotropin levels are difficult to predict HP. Transvaginal ultrasonography demonstrated 1 gestational sac in the uterine cavity and 1 thick-walled cystic mass over the upper of the uterus, with a large amount of fluid in the Pouch of Douglas. Emergency laparotomy revealed a uterine serosal pregnancy combined with intrauterine pregnancy.

INTERVENTIONS

This patient was successfully managed via emergency laparotomy to remove residual tissue and repair the rupture of the uterine serosal pregnancy.

OUTCOMES

At postoperative 4 days, repeat transvaginal ultrosonography presented 1 intrauterine gestational sac with a visible fetal bud and cardiac tube pulsation. Now the patient recover well and is in an ongoing pregnancy.

LESSONS

It is noteworthy that HP/ectopic pregnancy is still not prevented after bilateral salpingectomy. In cases of multiple embryo transfer, even if intrauterine pregnancy has been established, it is important to rule out HP/ectopic pregnancy in time. Early diagnosis and early management can significantly improve clinical outcomes.

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.

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.

Adenomyosis in Pregnancy: Diagnostic Pearls and Pitfalls

Adenomyosis is a common benign uterine disorder in which ectopic endometrial glands extend into the myometrium. Adenomyosis is increasingly diagnosed in young women, affecting 20%-35% of women of reproductive age. Features of adenomyosis can be seen with either US or MRI, especially with newer imaging technology. With advances in reproductive endocrinology as well as a trend toward later maternal age, adenomyosis is increasingly noted during pregnancy, often while performing imaging for other reasons. Hormonal changes during pregnancy alter the appearance of adenomyosis, which includes diffuse, focal, and cystic adenomyosis. Recognizing these imaging changes in pregnancy proves essential for accurately diagnosing adenomyosis as a benign condition, as it mimics serious placental and myometrial abnormalities. Using a lower-frequency US transducer or MRI can be helpful in distinguishing among these entities. Describing the location of adenomyosis in relationship to the site of placentation is also important. Diagnosing adenomyosis is crucial because it can be associated with poor pregnancy outcomes, including spontaneous abortion, preterm birth, and fetal growth restriction. Adenomyosis is also a risk factor for preeclampsia. Intramural ectopic pregnancy is a rare but serious condition that can mimic cystic adenomyosis, and comparison with prepregnancy images can help differentiate the two conditions. The authors review the unique imaging characteristics of adenomyosis in pregnancy, focusing on accurate diagnosis of an underrecognized benign condition that can mimic myometrial and placental pathologic conditions.^©RSNA, 2021.

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.

Diagnosis and management of intramural ectopic pregnancy in the second trimester-a case report

Intramural ectopic pregnancy is one of the rarest types of ectopic pregnancy, with risk of 1:30000. Confirmation of intramural ectopic pregnancy is difficult and is often performed intraoperatively. Intramural ectopic pregnancy often requires hysterectomy to avoid life-threatening haemorrhage. We present a case of intramural ectopic pregnancy in the second trimester, including its diagnostic criteria and treatment plan. Transvaginal ultrasound and MRI are important non-invasive methods in diagnosing this type of ectopic pregnancy. Clinicians should provide consideration to a combination of strategies and do their best to preserve patients’ uteri and fertility. In this case, clinicians excluded the gestational sac, repaired the uterus and saved the patient’s fertility.

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.

Distinguishing between intramural pregnancy and choriocarcinoma: A case report

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.

Adenomyosis: Epidemiology, Risk Factors, Clinical Phenotype and Surgical and Interventional Alternatives to Hysterectomy

Adenomyosis is an important clinical challenge in gynecology and healthcare economics; in its fully developed form, hysterectomy is often used to treat it in premenopausal and perimenopausal women. Symptoms of adenomyosis typically include menorrhagia, pelvic pain and dysmenorrhea. Moreover, adenomyosis and leiomyomas commonly coexist in the same uterus, and differentiating the symptoms for each pathological process can be problematic. Although it has been recognized for over a century, reliable epidemiological studies on this condition are limited, because only postoperative diagnoses were possible in the past. Minimally invasive surgical techniques (endometrial ablation/resection, myometrial excision/reduction, myometrial electrocoagulation, uterine artery ligation) have had limited success in the treatment of adenomyosis, and the reported data for these procedures have been obtained from case reports or small case series with only short follow-up times. However, newer techniques including uterine artery embolization (UAE) and magnetic resonance imaging guided focused ultrasound (MRgFUS) show promise in treating adenomyosis. The data is strongest for UAE; these studies have the largest patient cohorts. However, none of the UAE studies were randomized or controlled. Thus, despite the clinical importance of adenomyosis, there is little evidence on which to base treatment decisions. The objective of this review is to summarize the epidemiology, risk factors, clinical phenotype and to evaluate the accrued experience with surgical and interventional alternatives to hysterectomy.

Ruptured intramural pregnancy with myometrial invasion treated conservatively

Background. Intramural pregnancy is a rare form of ectopic pregnancy, difficult to diagnose and generally complicated by uterine rupture. Case. A 38-year-old woman, gravida 5 para 1, was diagnosed with intramural pregnancy by ultrasound and confirmed with MRI. A uterine rupture occurred, which lead to laparotomy and a conservative treatment. Conclusion. Early diagnosis is necessary for conservative treatment.

Communication of adenomyosis with the endometrial cavity: visualization with saline contrast sonohysterography

We report four cases of a finding of communication between the endometrial cavity and adenomyotic lesions observed during saline contrast sonohysterography. In each case there was a saline-filled defect extending from the endometrial cavity into the myometrium in the region of previously suspected adenomyosis. We believe this finding represents the sonohysterographic correlate of endometrium invading the myometrium, as has been described histologically.

Sonographic diagnosis and successful medical management of an intramural ectopic pregnancy

We report a case of posterior wall intramural pregnancy in a 36-year-old primigravida at 6 weeks gestation. Sonographic examination showed a viable intramural pregnancy distorting the contour of the uterus. The pregnancy was terminated by intrafetal injection of potassium chloride followed by intra-amniotic methotrexate injection.

[Adenomyosis: update on a frequent but difficult diagnosis]

Adenomyosis is a frequent entity, with difficult diagnosis, often obtained by pathological analysis performed after hysterectomy. This condition can cause abnormal uterine bleeding and dysmenorrhea, frequent reasons for consultation and hysterectomy. The development of ultrasonographic and magnetic resonance imaging techniques allow preoperative diagnosis. They also permit the use of hysteroscopic techniques for conservative uterine surgery, and have brought diagnosis and management of this disease to the front of the scene. This article reviews the pathological description of the disease, its epidemiology, clinical presentations, useful and necessary explorations, etiopathogeny and available therapies.

Diagnosis of early intramural ectopic pregnancy

Intramural ectopic pregnancy is a very rare diagnosis. Establishing a diagnosis is difficult and is often made intraoperatively. Demonstration of a live extrauterine gestation is the only specific sign of such a pregnancy. A small number of ectopic pregnancies are interstitial or cornual pregnancies. Rupture of an intramural ectopic pregnancy is a serious clinical complication. Diagnosis of this ectopic pregnancy can sometimes be made using 2-dimensional transvaginal ultrasound (TVS), but it may also require 3-dimensional TVS. We present the case of a 25-year-old gravida 0, para 0 woman with amenorrhea lasting 6(+5) weeks. Previous surgery included a right adnexectomy for torsion of a right dermoid cyst. The patient's serum hCG was elevated. TVS provided a detailed view of the endometrial cavity. The results of 2-dimensional TVS suggested the presence of an ectopic pregnancy. The sonogram showed a gestational sac with an embryonic pole and a yolk sac, which was separated from the endometrium. Use of 3-dimensional TVS demonstrated a live embryo in a gestational sac surrounded by myometrium below the right cornu lying outside the endometrium. This finding was confirmed by laparotomy and the conceptus was excised. The patient had an uneventful postoperative course and was discharged 7 days after surgery. In our case, the previous adnexectomy was an identifiable risk factor. Nonetheless, making a diagnosis of an intramural pregnancy was challenging. Suspicion may arise when sonography has revealed an intramural gestational sac.