High-intensity focused ultrasound ablation combined with systemic methotrexate treatment of intramural ectopic pregnancy: A case report

Abstract

Rationale: Intramural ectopic pregnancy (IMP) is a rare ectopic pregnancy with an unclear etiology, and standard treatment guidelines currently remain unclear. The main treatment option is local excision of IMP via laparoscopy or laparotomy.

Patient concerns: A 32-year-old woman with adenomyosis presented with amenorrhea for 7 weeks and a serum β-human chorionic gonadotropin (HCG) level of 6882 IU/L. The patient had a history of laparotomy for adenomyosis 5 years previously. Three-dimensional ultrasonography showed a live gestational sac (GS) of 9 × 15 × 18 mm located in the left posterior wall of the uterus and a sinus tract connecting the sac and the endometrial cavity. MRI revealed the GS located in the adenomyosis and a 1.0-cm sinus tract connecting the GS and the endometrial cavity.

Diagnoses: IMP with adenomyosis.

Interventions: High-intensity focused ultrasound (HIFU) treatment combined with systemic methotrexate (MTX) was performed to treat IMP, which would avoid operation and massive bleeding.

Outcomes: Serum β-HCG levels decreased to normal 4 weeks after HIFU treatment and the GS was not found on MRI after 4 months. The sinus tract was significantly shortened after the HIFU treatment.

Lessons: HIFU ablation combined with systemic MTX is effective for the treatment of IMP and is favorable for maintaining fertility.

Figure 1.

Intramural pregnancy in a 32-year-old woman. (A) Three-dimensional transvaginal showing a GS in the left posterior side of the myometrium and a sinus tract (arrow) connecting the sac and endometrial cavity. (B) Sagittal and (C) transverse views of preoperative T2-weighed images showing adenomyosis and intramural pregnancy sac lesions in the posterior wall of the uterus and a sinus with the length of 1.0 cm (arrows) connecting the sac with the endometrial cavity. GS = gestational sac.

Figure 2.

MR image obtained from the adenomyosis patient with IMP. (A) Sagittal and (B) transverse views of preoperative T1-weighed contrast enhanced images showing adenomyosis and intramural pregnancy sac lesions in the posterior wall of the uterus. (C/E) Sagittal and (D/F) transverse views of postoperative T1-weighed contrast enhanced images showing the nonperfused region at the posterior wall of the uterus at post-HIFU (C/D) and 4 months after HIFU (E/F). (G) Sagittal and (H) transverse views of postoperative T2-weighed images only showing adenomyosis lesions in the posterior wall of the uterus 4 months after HIFU. HIFU = high-intensity focused ultrasound, IMP = intramural ectopic pregnancy.

Figure 3.

Hysteroscopy revealing a uterine sinus tract (3 × 3 × 3 mm) (arrow)in the left posterior wall of uterus near the corner 4 months later after HIFU. HIFU = high-intensity focused ultrasound.