Intramural ectopic pregnancies are ectopic pregnancies, embedded within the myometrium. They account for an estimated 1 % of all ectopic pregnancies.
These include any injury affecting the uterine wall muscle such as that following uterine curettage, myomectomy and or caesarean section. It is associated with IVF in approximately 20 % of reported cases and adenomyosis in another 19 % of cases.
Many cases are detected early in pregnancy without any symptoms during an early routine ultrasound scan, while some others present with non specific signs such as mild vaginal bleeding and abdominal pain only to be detected by an ultrasound scan after presentation. Occasionally, it may be detected during surgery following sudden severe hypovolaemic shock due to a sudden uterine rupture caused by the expanding intramural pregnancy.
Other than detailed history, clinical examination and a positive blood pregnancy test, definitive diagnosis is usually by ultrasound scan or by MRI in which an ectopic pregnancy is seen surrounded circumferentially by the myometrium when picked in an asymptomatic patient. Otherwise it may be detected intra operatively if it presents as an emergency following rupture of the uterus. It is however notoriously challenging to diagnose on ultrasound and have been mistaken for fibroids or a normal pregnancy on many occasions.
As with other types of ectopic pregnancies, management depends on patient’s clinical stability at presentation. Management however can be either by medical or surgical treatment.
This is the main stay of management employed for 1) unstable patients, 2) for those in whom medical treatment failed and 3) for those not deemed fit for medical management despite being stable.
The surgical approach is determined by a patient’s clinical stability, desire for future fertility, and location of the ectopic gestation.
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