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  • Intramural pregnancy: A rare form of ectopic pregnancy 1 2Satyaprabha Siripurapu , Sethi Pruthwiraj

    1 2Assistant Professor, Department of Obstetrics and Gynecology, Associate Professor, Department of Obstetrics and Gynecology, Prathima Institute of Medical Sciences, Karimnagar, Telangana, India.

    Address for Correspondence : Satyaprabha Siripurapu, Assistant Professor, Department of Obstetrics and Gynecology, Prathima Institute of Medical Sciences, Telangana, India.

    Email: [email protected]

    27

    Please cite this article as: Satyaprabha S, Sethi P. Intramural pregnancy: A rare form of ectopic pregnancy. Perspectives in medical research 2014;2: 27-28.

    Source of Support: Nil, Conflict of interest: None Declared

    Case Reportwww.pimr.org.in

    ABSTRACT

    An intramural ectopic pregnancy is an uncommon type of ectopic pregnancy. Identifying and treating intramural ectopic pregnancy at the earliest is a life saving intervention as the condition leads to uterine rupture and massive hemorrhage. The diagnosis of intramural ectopic pregnancy is very difficult and ultrasound (US) and magnetic resonance imaging (MRI) plays an important role in diagnosis of ectopic

    INTRODUCTION

    An intramural ectopic pregnancy is an uncommon type of ectopic pregnancy. In intramural ectopic pregnancy, the gestational sac is implanted within the myometrium, separate from the uterine cavity. There are very few case descriptions available in the

    1literature. Although the exact causes of intramural pregnancy are not clear, uterine diseases and trauma are believed to be the predisposing factors associated

    2 with the increased incidence of the condition. Identifying and treating intramural ectopic pregnancy at the earliest is a life saving intervention as the condition leads to uterine rupture and massive hemorrhage. We present a case report of 25 year old female diagnosed as intramural pregnancy during dilatation and curettage procedure.

    CASE REPORT

    A 25 year old female with gravida 3, para 2 having two live children was presented to the department of obstetrics and gynecology of the institute in the month of March 2014 with the chief complaints of bleeding per vaginum since one day. She had a history of amenorrhea for two months and her urine pregnancy test was positive for which she had

    pregnancy preoperatively. However, in most of the cases, the diagnosis of intramural ectopic pregnancy is made only after uterine rupture. We present a case report of 25 year old female diagnosed as intramural pregnancy during dilatation and curettage procedure. The patient was managed successfully through laparotomy.

    Keywords: Ectopic pregnancy, Intramural

    consulted a private practitioner and had taken oral mifepristone and misoprostol. She complained of heavy vaginal bleeding on the next day for which dilatation and curettage was done. When bleeding continued after the procedure, ultrasonography of the pelvis was done which revealed retained products of conception and patient was referred to our hospital for further evaluation and management. On admission pulse was 80/minute, blood pressure was 110/80mmHg. Per speculum examination revealed bleeding through os. On bimanual examination uterus was felt to be of 8 weeks size with soft consistency. Patient was posted for emergency dilatation and curettage under ultrasound guidance (figure 1). With progressive dilatation with Hegar dilators, curettage was done, but no product came out. On ultrasonography a sac containing fetus was visible. With a provisional diagnosis of cornual ectopic pregnancy, it was decided to perform laparotomy. On opening the abdomen, uterus was of 8 week size with mild bulging on the left side of the fundus (figure 2). An incision was given over the maximum bulged area and gestational sac along with embryo was removed. The gestational sac with embryo was entirely lying inside the myometrium and there was no continuity with endometrial cavity

    Perspectives in Medical Research | September - December 2014 | Vol 2 | Issue 3

    mailto:[email protected]

  • or fallopian tube (figure 3). Myometrial wall was closed in three layers. The patient was discharged

    thfrom the hospital on the 7 day of the postoperative period.

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    www.pimr.org.in Satyaprabha, et al

    Figure -3

    Figure -1 Figure -2

    Figure 1: Ultasonography showing gestational sac with embryo

    Figure 2: Protruding gestational sac after incision

    Figure 3: No continuity of fallopian tube with gestational sac

    DISCUSSION

    Intramural ectopic pregnancy is an uncommon condition as the entry and implantation of an embryo into the myometrium is very difficult. Several hypotheses have been proposed as an etiological factor for this condition, including caesarean section, microscopic sinus tracts associated with adenomyosis, invasion of the uterine wall by placenta accreta and subsequent growth of the fetus deep within the myometrium, in vitro fertilization and embryo transfer, or serosal implantation of

    2,3conceptus after external migration.

    The diagnosis of intramural ectopic pregnancy is very difficult and ultrasound and magnetic resonance imaging plays an important role in diagnosis of ectopic pregnancy preoperatively. However, in most of the cases, the diagnosis of intramural ectopic pregnancy is made only after uterine rupture. The early diagnosis of intramural pregnancy is of great significance as it allows us to

    manage the case conservatively preserving uterus and future fertility. The conservative management consists of administration of methotrexate locally or systemically or in combination with potassium chloride injection locally into the fetal thorax with methotrexate injected into the sac. However the medical management requires prolonged time and repeated follow up until complete resolution of the ectopic pregnancy. Traditional laparotomy and evacuation of the sac and repair of the uterine defect

    4 is done in surgical approach. In our case the condition was diagnosed when patient was posted for emergency dilatation and curettage under ultrasound guidance and we suspected it as a ectopic pregnancy as no product came out. The patient was managed by laparotomy successfully by preserving the uterus.

    To our knowledge, this was an unusual case intramural pregnancy revealed during the dilatation and curettage and obstetrician should always suspect ectopic pregnancy when no products obtained during the procedure. The patient was managed successfully through laparotomy.

    REFERENCES

    1. Kirk E, McDonald K, Rees J, Govind A. Intramural ectopic pregnancy: a case and review of the literature. Eur J Obstet Gynecol Reprod Biol. 2013 Jun;168(2):129-33.

    2. Kumtepe Y, Börekçi B, Polat P et al. The Rarest Form of Ectopic Pregnancy: Intramural Ectopic Pregnancy and Medical Treatment. J Turkish- German Gynecol Assoc, Vol. 8(4); 2007:416- 419.

    3. Wang S, Dong Y, Meng X. Intramural ectopic pregnancy: treatment using uterine artery embolization. J Minim Invasive Gynecol. 2013 Mar-Apr;20(2):241-3.

    4. Al-Nazer A, Omar L, Wahba M, Abbas T, Abdulkarim M. Ectopic intramural pregnancy developing at the site of a cesarean section scar: a case report. Cases J 2009 Dec 30;2:9404.

    Perspectives in Medical Research | September - December 2014 | Vol 2 | Issue 3