(P-192) A Molar Pregnancy Presented as Intramural Ectopic Pregnancy in Infertile Patient: A Rare Case Report

Abstract Authors: Haya Al Jurayfani, Ghadeer Al Jahdali2, Aysha Albin Ali, Nasser Al Saad1, Hanan Al Anazi1, Yahya Al Zahrani, Haya Rawah1,

1. Reproductive Endocrinology and Infertility Department, Prince Sultan Military Medical City, Riyadh, SA, 2. College of Medicine, King Saud bin Abdulaziz

University for Health Sciences, 3. Gynecology Department, Prince Sultan Military Medical City, Riyadh, SA

Abstract Text:

Introduction:


• Intramural ectopic pregnancy is a pregnancy implanted within the myometrium, separated from

endometrial cavity and fallopian tubes or round ligament.

• It is a rare type of ectopic pregnancy reported only 70 cases. The incidence occurs in 20 per 1000

pregnancies and equal or less than 1% of cases were intramural in type.

• The presentation of intramural ectopic pregnancy such as amenorrhea, lower abdominal pain, and vaginal

bleeding is not specific, which can lead to the misdiagnosis of intramural ectopic pregnancy as myoma, or

choriocarcinoma.

• The fertility outcomes are yet well established and only scarce data in the literature. Hereby, we report a

case of infertile patient diagnosed with molar pregnancy in intramural ectopic pregnancy managed

surgically.

Case Report


This is a 29-year-old lady, 2ry infertility for 2 years and half due to male factor infertility, P0+1,

• Presented to our service with 5 weeks of amenorrhea.

• Based on her medical history, the patient had one dilation and curettage (D&C) post second trimester

abortion. Also, underwent one IVF cycle at our center in 2023 with antagonist protocol with positive

pregnancy test.

• She came for follow up, transvaginal ultrasound (TVU) showed: Gestational Sac seen measured 0.73

corresponding to 5w+3d of GA seen in fundal myometrium, ET: 1.5 cm highly vascular, adnexa were

free, both ovaries looks normal. At that time, she was totally asymptotic and hemodynamically stable.

BHCG was 41,006 and other laboratory tests were within normal ranges.

• MRI report showed: Thick-walled complex cystic lesion embedded within the right fundal myometrium,

just above the right cornea, with mass effect on the underlying endometrium, measuring 2.5 x 3 x 2.3 cm,

no appreciable fetal pole, it contains multiple signal voids indicating neovascularity, empty endometrial

cavity, Fig 1.2.

• The patient was hospitalized in the gynecology department for surgical treatment. She underwent laparoscopic resection of intramural

pregnancy clinically diagnosed as buldge in the right posterior wall in fundal area (gestational sac) site.

• Intra-operatively, the sac measures 2x3 cm, procedure started with linear incision on top of clinically visible disrupted product of

conception was sent to histopathology, diagnostic hysteroscopy done simultaneously to check the extent of the gestational sac, and to

check to disruption of endometrium and it was intact with no complications. Procedure went smoothly with no complication, She was

kept in hospital for observation and for administration of Methotrexate (MTX). Beta Human chorionic gonadotropin before MTX

injection was (20,696).

• Patient discharged uneventfully on day 2 with follow up clinic at IVF unit. She was seen then and BHCG was repeated day 4 (1,931)

day 7 (780). Histopathology result showed: Fragments of smooth muscle admixed with immature chorionic villi with hydropic

changes, revealing a bundle of smooth muscle, along with chorionic villi exhibiting hydropic changes and trophoblastic proliferation.

Patient was followed up weekly as outpatient till BHCG result was undetectable



Conclusion:


All in all, we present a unique case of molar intramural ectopic pregnancy in an infertile patient, including its diagnostic criteria and

treatment plan. TVS and MRI are important in diagnosing this type of ectopic pregnancy. Early diagnosis and treatment can prevent

serious complications.