Intramural Ectopic Pregnancy: Clinical Characteristics, Risk Factors for Uterine Rupture and Hysterectomy

Abstract

Background: Intramural ectopic pregnancy is defined as the gestational sac (GS) is entirely within the myometrium, separate from the endometrial cavity and fallopian tubes, which is unsustainable and potentially life-threatening. The data investigating the clinical characteristics, management strategy, and fertility outcomes after treatment of intramural ectopic pregnancies are very limited due to its extreme rarity.Methods: To investigate the clinical characteristics, treatment options, and fertility outcomes in patients with intramural ectopic pregnancy, a retrospective study included 56 patients was conducted. We also used logistic regression to identify potential risk factors for uterine rupture and hysterectomy in these patients.Results: The mean age of patients was 31.1 years, with an average gestational age (GA) of 10.0 weeks, and the majority of the patient cohort (83.9%) had uterine or endometrial surgical history. 55.4% of the intramural pregnancy was diagnosed by preoperative imaging examination and 67.7% was detected by ultrasound. There was no dominant predisposed zone of the GS. Common treatment strategies included laparotomy surgery (41.1%) and laparoscopic surgery (35.7%), followed by methotrexate (7.1%) and expectant management (5.4%). Uterine rupture occurred in 9 patients and 8 patients underwent a hysterectomy, but no maternal demise was found. Logistic regression showed that a GA >10 weeks predicted a significantly higher risk of uterine rupture (Odds ratio [OR] 8.000, 95% confidence interval [CI] 1.456–43.966, P = 0.017) and hysterectomy (OR 12.333, 95% CI 2.125–71.565, P = 0.005), and GS located in the fundus also predicted higher probability of uterine rupture (OR 7.000,95% CI 1.271–38.543, P = 0.025). Among the ten patients who had a desire for fertility, 6 of them succeeded and 4 of them successfully delivered with a GA ≥ 34 weeks.Conclusion: GA > 10 weeks was the risk factor for both uterine rupture and hysterectomy, while patients with GS located in the uterine fundus had a significantly higher risk of uterine rupture. The fertility outcomes were moderate after treatment. The management strategies should be individualized according to disease conditions and the desire for fertility, and early diagnosis is essential for optimizing clinical outcomes.

Uterine rupture in intramural ectopic pregnancy: A case report

“…Intramural ectopic pregnancies are extremely rare and represent less than 1% of all ectopic pregnancies. To date, there have been only 70 reported cases in the literature 1 . When the gestational sac is entirely within the myometrium and separate from the endometrial cavity and fallopian tube, an intramural ectopic pregnancy occurs 2 .…”

“…Gestational age >10 weeks is a risk factor for both uterine rupture and hysterectomy, while patients with a gestational sac located in the uterine fundus have a significantly increased risk of uterine rupture. As well, in most cases, fetal wastage occurs at 11–22 weeks' gestation due to maternal hemoperitoneum and hypovolemic shock 1,3–6 . The exact etiology and pathogenesis of intramural pregnancy are unclear.…”

“…To date, there have been only 70 reported cases in the literature. 1 When the gestational sac is entirely within the myometrium and separate from the endometrial cavity and fallopian tube, an intramural ectopic pregnancy occurs. 2 Pregnancy within the wall is unsustainable and life-threatening.…”

“…As well, in most cases, fetal wastage occurs at 11-22 weeks' gestation due to maternal hemoperitoneum and hypovolemic shock. 1,[3][4][5][6] The exact etiology and pathogenesis of intramural pregnancy are unclear. Researchers have proposed several risk factors such as uterine surgery, including dilation and curettage, cesarean section, myomectomy, adenomyosis, or in vitro fertilization.…”

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

“…Conversely, if intrauterine pregnancy is not viable, then there are various options for the treatment of HP, ranging from conservative medication to surgical treatment depending on the patient’s status. [ 21 ] Moreover, like this patient, because some EP of rare locations are difficult to detect by ultrasound, therefore diagnostic surgery should be considered as a first-line intervention to both clarify the diagnosis and give treatment. Another, patients with high suspicion of EP should be immediately transferred for surgery if she has peritoneal signs or hemodynamic instability.…”