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Background The incidence of caesarean scar pregnancy (CSP) has significantly increased due to the increasing prevalence of caesarean deliveries and advances in diagnostic imaging. However, no consensus has yet been reached on the optimal therapeutic approach. Type II CSP leads to disease heterogeneity, characterized by multiple treatment options and the absence of a unified therapeutic approach. Hysteroscopic treatment for CSP has demonstrated a notable success rate, particularly in cases of type I CSP. High-intensity focused ultrasound (HIFU) ablation has emerged as a novel, non-invasive treatment option that minimizes intraoperative blood loss. However, its use may be excessive in low-risk cases. Here, we report a protocol for a randomized clinical trial designed to evaluate the necessity of performing HIFU in CSP treatment when combined with suction curettage under hysteroscopic guidance. Methods We aim to propose a randomized clinical trial that will enroll 140 participants. All participants will undergo surgical suction curettage guided by hysteroscopy, randomized into groups with or without HIFU pretreatment. Data on demographic characteristics, disease characteristics, ultrasound findings, and laboratory test results will be collected before the intervention. The primary outcome will be the intraoperative blood loss. Secondary outcomes will include the incidence of near haemorrhage, therapeutic success rates, and subsequent pregnancy outcomes within a 2-year follow-up period. Discussion Hysteroscopy has exhibited favourable therapeutic outcomes in the management of CSP, though it remains associated with a risk of intraoperative haemorrhage. HIFU has shown promise as a preoperative adjuvant modality. However, the comparative clinical advantages of standalone hysteroscopic intervention versus HIFU-assisted protocols are insufficiently explored in prospective clinical studies. This investigation seeks to assess both the standalone efficacy of hysteroscopic resection and the efficacy of combined therapy incorporating HIFU pretreatment for type II CSP. Trial registration Registration number: ChiCTR2000034332. Registration date: 2nd July 2020.

OBJECTIVES: Development of magnetic resonance imaging (MRI)-based radiomic models to predict the risk of intraoperative massive hemorrhage in patients with cesarean scar pregnancy (CSP). MATERIAL AND METHODS: CSP patients (n = 126) from Center 1 were randomly assigned in a 7:3 ratio into a training set (n = 88) and an internal validation set (n = 38), and patients (n = 32) from Center 2 into an external validation set. Afterward, the clinical and radiomic features related to intraoperative massive hemorrhage were fed into the k-nearest Neighbor (KNN), support vector machine (SVM), Light Gradient Boosting Machine (Light GBM), and Multi- Layer Perception (MLP) to construct predictive clinical, radiomic, and combinatorial models. The performance of these models was assessed using area under curve (AUC), Delong's test, Decision Curve Analysis (DCA), and calibration curves. Youden's index was used to determine the optimal threshold. RESULTS: Eleven radiomic characteristics were found to be substantially linked to intraoperative massive hemorrhage. The combined in the gestational sac and peripheral to the gestational sac (IP) model (AUC = 0.959), constructed by MLP, had the best performance, with an optimal risk threshold of 0.180, as compared to the clinical model (AUC = 0.500) and the nomogram (AUC = 0.283). DCA and calibration curves demonstrated the IP model’s good clinical predictive performance. CONCLUSIONS: The IP model for CSP was superior to the other models in this study in predicting the risk of intraoperative massive hemorrhage, which was significantly increased when the risk threshold exceeded 0.180. The model may help clinicians make individualized treatment decisions.

Background Ectopic pregnancy is defined as the implantation of a fertilized ovum outside the uterine cavity, most commonly occurring within the fallopian tubes and rarely in other intra-abdominal locations. While ectopic hepatic pregnancy—embryo implants into the liver parenchyma—is extremly rare type. It is characterized by diagnostic difficulties, significant management challenges, and high rates of morbidity and mortality. This report details the first documented case of a simultaneous ruptured ectopic tubal pregnancy and ectopic hepatic pregnancy, which was successfully managed through feticide and a strategy of conservative clinical observation. Case presentation A 38-year-old woman (Para 6) presented with amenorrhea and vaginal bleeding. She was shocked (BP 90/40 mmHg) due to a ruptured right tubal ectopic pregnancy, requiring emergency laparotomy and salpingectomy. Two weeks later, she complaint of with epigastric and hypochondial pain. β-hCG was found elected and Ultrasound liver scan revealed a separate, viable intrahepatic pregnancy with same gestational age. A Multidisciplinary Team (MDT) recommended termination to prevent a fatal morbidity. Ultrasound-guided feticide was performed using an intracardiac injection of 20% potasium chloride solution, which successfully achieved fetal asystole. The patient remains stable and is under conservative, antibiotic, and methotrixate with expectant management. Conclusions This case highlights the critical need to maintain a high index of suspicion for secondary or persistent abdominal gestation in patients presenting with new or unresolved pain shortly after initial ectopic pregnancy management. For deeply embedded, high-risk solid-organ ectopics, local feticide followed by conservative observation offers a safer definitive treatment pathway compared to potentially high-mortality surgical excision.

Intramural pregnancy (IMP) is a rare and potentially life‐threatening uterine ectopic pregnancy implanted within the myometrium. Despite its recognition as a distinct clinical entity, diagnostic challenges and a lack of standardized management protocols persist. IMP occurs when a gestational sac implants into the myometrium beyond the endometrial‐myometrial junction, often following uterine trauma. Diagnosis is hindered by non‐specific symptoms and frequent misclassification. While ultrasound is the primary diagnostic tool, magnetic resonance imaging (MRI) may be needed in unclear cases. Treatment options range from expectant management to surgical intervention, but no consensus exists on the optimal approach. To enhance understanding and improve clinical outcomes, we propose an international IMP registry to collect data on diagnosis, treatment, and fertility outcomes. This collaborative effort aims to inform evidence‐based guidelines, facilitating accurate early diagnosis and optimized patient care.

Ectopic pregnancy (EP) is a term used to describe any pregnancy which does not implant into the uterine cavity. There are several types of EPs: tubal, interstitial, ovarian, abdominal, heterotopic, cervical, and cesarean scar. Ectopic pregnancies can acutely rupture and are the number one cause of maternal death in the first trimester of pregnancy. Therefore, prompt recognition and accurate localization have significant clinical implications on patient outcome. Unfortunately, EPs have many mimickers, which can make the diagnosis challenging in certain cases. In this review, we aim to describe and illustrate sonographic findings of each type of EP, as well as present mimickers and various imaging pitfalls. We will clarify how to avoid potential misdiagnoses that could adversely affect patient outcomes. Lastly, we will briefly address management of each type of EP and discuss potential complications.

Background Intramural pregnancy, a rare ectopic pregnancy with the gestational sac implanted within the myometrium, poses significant diagnostic and therapeutic challenges. Current diagnostic criteria lack anatomical precision, leading to delayed management and high morbidity. This study proposes a novel diagnostic framework integrating the International Federation of Gynecology and Obstetrics (FIGO) leiomyoma classification system and advanced 3D transvaginal ultrasound, enabling anatomical risk stratification and individualized management. Methods We retrospectively analyzed four intramural pregnancies, assessing clinical history, laboratory results, 2D/3D sonographic findings, treatment methods and outcomes. All cases underwent comprehensive evaluation using high-resolution transvaginal 2D/3D ultrasound (GE Voluson E8 or S8 systems with 5-6.5 MHz transvaginal probes). Lesions were systematically mapped according to the FIGO leiomyoma classification system, with particular attention to their spatial relationship with the uterine cavity and surrounding myometrium. Treatment strategies were tailored based on lesion characteristics, β-hCG levels, and fertility goals. Results Two distinct sonographic patterns were identified: gestational sac-type (Cases 1–2) and heterogeneous mass-type (Cases 3–4). The FIGO classification system (Types 2–5) effectively predicted the depth of myometrial invasion and guided therapeutic decisions. Type 3 (Case 1): Medical management with methotrexate (MTX) achieved resolution. Type 2–5 (Case 2): Ultrasound-guided fetal reduction preserved intrauterine pregnancy to term. Type 4 and Type 5 (Cases 3–4): Laparoscopic excision prevented uterine rupture, with lesions demonstrating significant myometrial thinning or serosal protrusion. High risk factors and key sonographic features are summarized, and diagnostic criteria are proposed. Conclusion The integration of FIGO-based anatomical staging with advanced 3D sonographic evaluation provides a robust framework for early diagnosis and risk-stratified management of intramural pregnancy. This innovative approach significantly enhances diagnostic accuracy, facilitates appropriate treatment selection, and optimizes fertility preservation outcomes.

Adnexal masses can have gynecologic or nongynecologic etiologies, ranging from normal luteal cysts to ovarian cancer to bowel abscesses. Women who report abdominal or pelvic pain, increased abdominal size or bloating, difficulty eating, or rapid satiety that occurs more than 12 times per month in less than a year should be evaluated for ovarian cancer. Pelvic examination has low sensitivity for detecting an adnexal mass; negative pelvic examination findings in a symptomatic woman should not deter further workup. Ectopic pregnancy must be ruled out in women of reproductive age. A cancer antigen 125 (CA 125) test may assist in the evaluation of an adnexal mass in appropriate patients. CA 125 levels are elevated in conditions other than ovarian cancer. Because substantial overlap in CA 125 levels between pre- and postmenopausal women may occur, this level alone is not recommended for differentiating between a benign and a malignant adnexal mass. Transvaginal ultrasonography is the first choice for imaging of an adnexal mass. Large mass size, complexity, projections, septation, irregularity, or bilaterality may indicate cancer. If disease is suspected outside of the ovary, computed tomography may be indicated; magnetic resonance imaging may better show malignant characteristics in the ovary. Serial ultrasonography and periodic measurement of CA 125 levels may help in differentiating between benign or potentially malignant adnexal masses. If an adnexal mass larger than 6 cm is found on ultrasonography, or if findings persist longer than 12 weeks, referral to a gynecologist or gynecologic oncologist is indicated.

Background Conservative treatment remains a viable option for selected patients with ectopic pregnancy (EP), but failure may lead to rupture and serious complications. Currently, serum β -hCG is the main predictor for treatment outcomes, yet its accuracy is limited. This study aimed to develop and validate a predictive model that integrates radiomic features derived from super-resolution (SR) ultrasound images with clinical biomarkers to improve risk stratification. Methods A total of 228 patients with EP receiving conservative treatment were retrospectively included, with 169 classified as treatment success and 59 as failure. SR images were generated using a deep learning-based generative adversarial network (GAN). Radiomic features were extracted from both normal-resolution (NR) and SR ultrasound images. Features with intraclass correlation coefficient (ICC) ≥ 0.75 were retained after intra- and inter-observer evaluation. Feature selection involved statistical testing and Least Absolute Shrinkage and Selection Operator (LASSO) regression. Random forest algorithms were used to construct NR and SR models. A clinical model based on serum β -hCG was also developed. The Clin-SR model was constructed by fusing SR radiomics with β -hCG values. Model performance was evaluated using area under the curve (AUC), calibration, and decision curve analysis (DCA). An independent temporal validation cohort ( n  = 40; 20 failures, 20 successes) was used to validation of the nomogram derived from the Clin-SR model. Results The SR model significantly outperformed the NR model in the test cohort (AUC: 0.791 ± 0.015 vs. 0.629 ± 0.083). In a representative iteration, the Clin-SR fusion model achieved an AUC of 0.870 ± 0.015, with good calibration and net clinical benefit, suggesting reliable performance in predicting conservative treatment failure. In the independent validation cohort, the nomogram demonstrated good generalizability with an AUC of 0.808 and consistent calibration across risk thresholds. Key contributing radiomic features included Gray Level Variance and Voxel Volume, reflecting lesion heterogeneity and size. Conclusions The Clin-SR model, which integrates deep learning-enhanced SR ultrasound radiomics with serum β -hCG, offers a robust and non-invasive tool for predicting conservative treatment failure in ectopic pregnancy. This multimodal approach enhances early risk stratification and supports personalized clinical decision-making, potentially reducing overtreatment and emergency interventions.

Retroperitoneal ectopic pregnancy is an extremely rare form of ectopic pregnancy that can be life-threatening due to severe intra-abdominal hemorrhage. Retroperitoneal ectopic pregnancy is frequently misdiagnosed because of its atypical location and nonspecific symptoms. To the best of our knowledge, no previous cases of ectopic pregnancy localized to the mesorectum have been reported to date. Here, we present the case of a woman in her mid-30s with retroperitoneal ectopic pregnancy localized to the mesorectum. The condition was initially misdiagnosed as gastroenteritis due to atypical symptoms, which resulted in delayed treatment. This study aimed to improve the clinical recognition of mesorectal ectopic pregnancy among physicians.

Background Abdominal ectopic pregnancy is a rare form of ectopic pregnancy, and diaphragmatic ectopic pregnancy is even rarer. We described a case of an ectopic pregnancy implanted on the diaphragm’s surface, diagnosed using multimodality imaging techniques, including ultrasonography, X-ray computed tomography, and magnetic resonance imaging. Case presentation A 39-year-old Han Chinese female presented with abdominal pain and was diagnosed with subcapsular hemorrhage of the liver on the basis of computed tomography imaging. The patient had experienced paroxysmal severe pain in the right abdomen, without any history of trauma, vomiting, or diarrhea. Her vital signs were stable, and she did not exhibit signs of hemorrhagic shock. She reported that her last menstrual period ended 13 days before the onset of symptoms and that she had a regular menstrual cycle. However, her blood human chorionic gonadotropin levels were significantly elevated. Based on multimodality imaging techniques, including ultrasonography, computed tomography, and magnetic resonance imaging, ectopic pregnancy was considered as a possible diagnosis. To further investigate, laparoscopic exploration was performed. During the procedure, minimal adherent tissue and a small clot were found on the diaphragm’s surface. Histological examination confirmed the clot to be a mixture of chorion and blood. The patient remained stable postoperatively and was discharged 1 week after surgery. Conclusion Using multimodality imaging techniques for diagnosis prior to treatment is of great significance for patients with ectopic pregnancy with atypical clinical presentations. These techniques enable clear delineation of tissue planes, thereby facilitating accurate diagnosis and preoperative planning by the surgical team.