Diagnostic challenges of rare ectopic pregnancy locations. Case report- Intramural pregnancy and systematic literature review

Author(s): Irena Gosheva


Uncommon sites of ectopic pregnancy, can present as intramural, cervical, hysterotomy scar, rudimentary uterine horn, interstitial, ovarian, and abdominal pregnancy. They all have very low incidence, especially the intramural pregnancy, for which so far nearly 50 cases are reported in the literature. Intramural pregnancy is a rare form of ectopic pregnancy where the gestational tissue is located entirely or partially inside the myometrium. The clinical presentation is generally determined by many factors, including exact location within the uterus, depth of myometrial involvement as well as the gestational age. The etiology of intramural pregnancy remains unknown, though different surgical procedures that cause myometrial defects are postulated, such as D&C, hysteroscopy and myomectomy. The diagnosis is difficult due to different locations within the uterus and the varying degrees of the depth of uterine involvement. There is no unified consensus regarding the diagnostic approach, including the ultrasound diagnostic criteria, nor about the utility of other imaging techniques and modalities, such as MRI. Namely, reviewing the published data, some authors have recommended an initial diagnostic approach. A case report - intramural ectopic pregnancy and our diagnostic is presented. In conclusion, we believe that adequate utilize of the published data can form an initial pool and further create diagnostic algorithms. If the diagnostic approach is unified, then this type of pregnancy wouldn’t be misdiagnosed with other intrauterine ectopic pregnancies and with normal pregnancy as well. Adequate diagnostic criteria can help to differentiate between intramural and other rare ectopic pregnancies. Prompt and early diagnosis and adequate treatment, can prevent life –threatening complications such as uterine rupture and hemorrhage. The management of intramural pregnancy is individualized and treatment modalities have wide spectrum, ranging from conservative- local or systemic with methotrexate, up to various surgical treatment.

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