Nijjar, S; Bottomley, C; Jauniaux, E; Jurkovic, D; (2023) Imaging in gynecological disease: clinical and ultrasound characteristics of intramural pregnancy. Ultrasound in Obstetrics and Gynecology , 62 pp. 279-289. 10.1002/uog.26219.

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Abstract

OBJECTIVE: To describe the clinical and sonographic characteristics of intramural pregnancies, the available management options and treatment outcomes. METHODS: This was a retrospective single-center study of consecutive patients diagnosed by ultrasound with an intramural pregnancy, between 2008 and 2022. An intramural pregnancy was diagnosed on ultrasound examination when a pregnancy located within the confines of the uterus, extended beyond the decidual-myometrial junction to involve the myometrium above the level of the internal cervical os. Clinical, ultrasound, relevant surgical and histological information and outcomes were retrieved from each patient's record. RESULTS: Eighteen patients diagnosed with an intramural pregnancy were identified. Median age was 35 (range, 28-43) years. Median gestational age was 8+1 (range, 5+5 - 12+0 ) weeks. Vaginal bleeding with or without abdominal pain was the most common presenting symptom, which was recorded in 8/18 (44%) of patients. 9/18 (50%) of patients had partial and 9/18 (50%) complete intramural pregnancies. Embryonic cardiac activity was present in 8/18 (44%) of pregnancies. The majority of pregnancies [10/18 (56%)] were initially managed conservatively, including expectant management [8/18 (44%)], local injection of methotrexate [1/18 (6%)] and embryocide [1/18 (6%)]. Conservative management was successful in 9/10 (90%) of women with a median hCG resolution time of 71 (range, 32-143) days and median pregnancy resolution time of 63 (range, 45-214) days. One patient with an ongoing live pregnancy had an emergency hysterectomy for a major vaginal bleed at 20 weeks' gestation. No other patients who were managed conservatively experienced any significant complications. The remaining 8/18 (44%) patients had primary surgical treatment, which was mainly in the form of transcervical suction curettage [7/8 (88%)] whist the remaining patient presented with uterine rupture and had an emergency laparoscopy and repair. CONCLUSIONS: We describe the ultrasound features for partial and complete intramural pregnancies with demonstration of key diagnostic features. Our series suggest that when intramural pregnancies are diagnosed before 12 weeks' of gestational age they can be managed with either conservative or surgical treatment, with most women being able to preserve their future reproductive function. This article is protected by copyright. All rights reserved.

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