Author Information
Kumari M*, Gupta AS**
(* Third Year Resident, ** Professor
Department of Obstetrics and Gynaecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)
Department of Obstetrics and Gynaecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)
Abstract
An interesting case of
intramyometrial pregnancy managed conservatively with methotrexate is
reported. Patients condition was not diagnosed for 9 months. She underwent
multiple Dilatation and curettage procedures for retained products of
conception and was again misdiagnosed as a case of arterio-venous malformation
for which she was referred to us; a clinical suspicion combined with a MRI
confirmed the suspicion of an intramyometrial pregnancy. As the patient was
young and desired childbearing and was averse to further surgical management
she was successfully managed by methotrexate.
Introduction
Intramyometrial pregnancy or
intramural pregnancy is a rare type of ectopic pregnancy and is very difficult
to diagnose. Its exact incidence is unknown due to its rare occurrence and the
fact that only isolated case reports are
documented till date. The fertilized ovum or the conceptus implants in the myometrium
and the gestational sac is located within the uterine wall wholly surrounded by
the myometrium and unconnected to the uterine cavity, fallopian tube, or round
ligament.[1]
Case Report
A 26 years old gravid 2,
abortion 1 was referred to us in February 2013
in view of uterine arteriovenous malformation. She complained of pain in
abdomen and 6 weeks of amenorrhea. Her menstrual cycles had been irregular for preceding
9 months. She had undergone a blunt
curettage in April 2012 after a spontaneous abortion. Curettings were not sent
for histopathological examination. Dilatation and curettage was again done in
July 2012 as she continued to bleed irregularly, ultrasonography suggested
retained products of conception and serum β-HCG level was 25,000 mIU/ml. The procedure was repeated by another consultant.
Histopathological report showed no chorionic villi. Her complaints persisted. A
pelvic ultrasonography in December 2012 showed uterine arterio-venous
malformation and she was then referred to us. Her vital parameters were within
normal limits. General and systemic examination showed no abnormality. She was
mildly anaemic. Her abdomen was soft. Vaginal examination
showed no pelvic tenderness or masses. The uterus was of 12 weeks size, fundus
bulky, soft, and anteverted. There was no active bleeding. Ultrasonography showed retained products of
conception. Serum β-HCG value was 25,900 mIU/ml. Her haematological indices,
serum chemistry, and chest radiograph were all within normal parameters. With a
diagnosis of an incomplete abortion, a blunt curettage was done. In view of
scanty curettage sample, an intramyometrial pregnancy was suspected. MRI was
done. It showed a well defined rounded lesion seen in anterior myometrium
measuring 3.36x3.23x2.9 cm size in anteroposterior,
transverse and longitudinal dimensions. Multiple cystic spaces are seen within
it with foci of haemorrhage. Post contrast imaging revealed peripheral
enhancement of the lesion with homogenous enhancement of the rest of the
lesion. Endometrial cavity was empty and not connected to the this mass.
Engorged parametrial vessels were seen on the left side. Both ovaries were
normal. These findings were suggestive of
an intramyometrial pregnancy with
cystic changes and haemorrhage inside. Histopathological study of the
curetting’s did not show any chorionic villi.
Figure 1. MRI of the uterus. C: is the empty endometrial cavity; IM: the intramural pregnancy in its Gestational
sac.
In view of stable condition of patient and patient and her husband’s
desire for future childbearing and her aversion to further surgery conservative
management was started. Methotrexate 50mg/m 2 was administered
intramuscularly. Her serial serum β-HCG
values fell progressively reaching less than1.2 mIU/ml at end of 3
months. Ultrasonography at that time showed calcification of lesion which had
decreased in size to 2x2 cm . Her
regular menstrual cycles resumed.
Discussion
An intramyometrial pregnancy is associated with factors causing trauma
to the endometrium disrupting its continuity thus technically creating a path
for the conceptus to gain entry into the myometrium for implantation. Such
trauma occurs in a caesarean section ,
curettage, misplaced IUD, adenomyosis, placenta accreta, and necrosis of a
uterine leiomyma after uterine artery embolization.[2, 3, 4] It may
follow in vitro fertilisation.[5] Usually the diagnosis of intramural
pregnancy cannot be made until uterine rupture
occurs, which usually occurres between about 11 and 30 weeks of gestation. An intramural pregnancy is
difficult to be seen on ultrasonography and is easily confused with a degenerating myoma , products of conception
or congenital uterine anomaly.[3,5] In a hemodynamically stable patient who wants a future pregnancy, this
condition can be managed conservatively
by local administration of KCL or Methotrexate or by systemic methotrexate
either in single dose or as multiple dose regimen. [2,6,7,8] A nonradical
surgical management in form of wedge resection or enucleation with
myometrial reconstruction can be performed too. A patient with uterine rupture
and hemodyamic instability requires a hysterectomy.
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Citation