Intramural pregnancy is the rarest form of ectopic pregnancy; it is characterized by a gestation within the uterine wall, completely surrounded by myometrium and separated from the uterine cavity and the fallopian tube. It has been first reported in 1913 by Doderlein et al. [
We report a case of a ruptured intramural pregnancy treated conservatively.
A 38-year-old woman, gravida 5, para 1, abortion 2, with a history of secondary infertility and salpingectomy for an ectopic pregnancy, was referred for a suspicion of a pregnancy developing in a rudimentary cornua at 13 weeks’ gestation. She was completely asymptomatic. Physical examination revealed stable vital signs while bimanual examination revealed an enlarged uterus with no adnexal masses. Transvaginal ultrasound revealed a gestational sac with a heartbeating fetus along with measurements corresponding to 13 weeks’ gestation. The endometrial cavity was quite near in the right cornual region, but there was no evident communication between them. Both the endometrium and gestational sac appeared to be surrounded by myometrium. The diagnosis of intramural pregnancy was suspected and a Magnetic Resonance Imaging (MRI) was indicated. It revealed a gestational sac with a fetus developing inside the fundic uterine wall (Figure
The gestational sac develops from the fundus with the presence of a sign of the spur (short arrow) and an extension of the contents of the bag in the thickness of the myometrium (long arrow). Note the exophytic development of trophoblastic tissue.
The wall of the gestational sac (double arrows) separates its contents from the uterine lumen (arrow).
A uterine artery embolization (UAE) was selected in order to reduce bleeding during laparotomy. While preparing the patient for embolization, she developed signs suggesting an acute abdomen (diffuse distention and tenderness and rebound tenderness on abdominal examination) and a hypovolemic shock. An emergency laparotomy was performed. About 300 mL of blood and clot was detected, the uterus was ruptured, and the placenta was actually percreta but did not invade any abdominal organ. The fetus was still in the gestational sac. Enucleation and removal of the gestational sac then padding of the residual myometrial cavity were performed. Trophoblastic tissue was removed easily, and we did not need to perform any myometrial resection or subtotal hysterectomy. She had a satisfactory recovery.
Intramural pregnancy refers to a conceptus implanting within the myometrium without connection with the fallopian tubes and endometrial cavity [
Abdominal pain and metrorrhagia in the presence of a positive pregnancy test are the hallmark signs of ectopic pregnancy. However, early diagnosis may not be easy, and ultrasound may not easily localize the gestation. Usually, the diagnosis of intramural pregnancy is not made until uterine rupture, and surgery is performed [
The intramural pregnancy treatment depends on the stage in which it is diagnosed. With uterine rupture and hypovolemic shock, emergency hysterectomy is often necessary. If intramural pregnancy is discovered prior to rupture, conservative or expectant management could be considered, including surgical enucleation, systemic, or local methotrexate injection [
The diagnosis of intramural pregnancy in the early gestational age is of a great importance, because it allows medical or conservative surgical treatment, thus, preventing severe morbidities, hysterectomy, and sparing fertility.
Intramural pregnancy is the rarest form of ectopic pregnancy. The association of transvaginal ultrasound and MRI provides important information for the diagnosis by achieving the delineations of gestational sac within the myometrium. Early diagnosis is necessary for a conservative treatment.