A Rare Localization of Ectopic Pregnancy: Intramyometrial Pregnancy in Twin Pregnancy following IVF

Intramyometrial pregnancy is a rare form of ectopic pregnancy. It makes a diagnostic and therapeutic challenge. If misdiagnosed the intramyometrial pregnancy can cause a uterine rupture and become life-threatening condition. We report a case of intramyometrial pregnancy in twin pregnancy following IVF with spontaneous abortion of the first twin At 9 weeks of gestation. The 10 weeks scan showed a normal fetus which was described to be highly localized in the uterus but the diagnosis of intramyometrial pregnancy was not suspected. The patient was admitted at 14 weeks of gestation with pelvic pain, hemorrhage, and shock. She was operated and the diagnosis of ruptured intramyometrial pregnancy was done and managed conservatively. This case illustrates the diagnostic difficulties of intramyometrial pregnancy. We discuss pathophysiology, diagnosis, and treatment of this exceptional form of ectopic pregnancy. 1. Introduction Intramyometrial pregnancy is the rarest subtype of ectopic pregnancy. The first case of intramural pregnancy was reported in 1924. Preoperative diagnosis is difficult and hysterectomy is always required because of delayed diagnosis. 2. Case Report We report a case of intramyometrial pregnancy in twin pregnancy following IVF. The 32-year-old patient had a history of 4 years of unexplained infertility with 3 implantation failures following IVF. She became pregnant of a twin after an IFV-ET of 2 embryos in our department. The embryo transfer was easy and without touching the uterine wall. A spontaneous abortion of the first twin occurred at 9 weeks of gestation. The 10 weeks scan showed a normal fetus which was described to be highly localized in the uterus but the diagnosis of intramyometrial pregnancy was not suspected. The patient was admitted at 14 weeks of gestation with pelvic pain, hemorrhage, and shock. Ultrasound showed an exocentric gestational sac with cardiac activity and suspected rupture of intramyometrial pregnancy. The patient was immediately operated. Surgical exploration showed a partial rupture of the right lateral uterine wall with a conceptus adherent to myometrium without communication with the uterine cavity (Figures 1 and 2). The conceptus was removed and the uterine wall closed with a 2 layers of resorbable sutures. Followup was free of complications and a postoperative hysterosalpingogram (3 months after the surgery) demonstrated no uterine parietal defect nether uterine diverticulitis. The patient had become spontaneously pregnant 11 months after the surgery and is actually at 32 weeks of gestation. Figure 1: