Laparoscopic resection of an intramural pregnancy under transvaginal ultrasound guidance: A case report
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Published on: January 17, 2019
Shiyu Liu1,2, Furong Tang1,2, Xia Yin1,2
1Department of Obstetrics and Gynecology, West China Second Hospital, Sichuan University, Chengdu, P.R. China.
Rationale:
Intramural pregnancy is a rare form of ectopic pregnancy in which the gestational sac is embedded entirely within the myometrium, with no connection to the uterine cavity. Early diagnosis and timely management are challenging.
Patient Concerns:
A 35-year-old Chinese woman presented with persistent abnormal uterine bleeding for 4 months following an induced abortion for a presumed embryonic arrest. Initial management at a local clinic included dilation and curettage, with no pathological villi identified, and a course of oral mifepristone. However, her serum beta-human chorionic gonadotropin levels exhibited intermittent elevation.
Diagnoses:
A case of intramural pregnancy was identified, in which intraoperative transvaginal ultrasonography (TVUS) enabled real-time diagnosis and facilitated precise, minimally invasive surgical management.
Interventions:
Subsequent TVUS at our center revealed a 1.5 × 1.1-cm heteroechoic lesion within the myometrium adjacent to the right uterine fundus and pelvic computed tomography confirmed a myometrial lesion. Hysteroscopy revealed an empty uterine cavity, which ruled out retained products of conception. The retained intramural mass was completely resected laparoscopically via hysteroscopy under real-time TVUS guidance, which enabled precise localization and preservation of healthy myometrium. Histopathological analysis confirmed the diagnosis of intramural pregnancy.
Outcomes:
The patient's postoperative course was uneventful. Serum beta-human chorionic gonadotropin levels dropped to 11.4 mIU/mL on postoperative day 1 and became undetectable within 1 week. Menstrual function resumed 6 weeks after surgery. At the 3-month follow-up, the patient remained asymptomatic, with no pelvic pain or abnormal bleeding.
Lessons:
In cases where the lesion's location remains unclear during laparoscopy, TVUS can assist in accurate localization and enable complete resection of the lesion.
