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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 should be considered in every woman presenting with bleeding or pain in the first trimester with a positive pregnancy test. It remains a significant cause of maternal death worldwide. Transvaginal ultrasound has become the diagnostic tool of choice in diagnosing ectopic pregnancy in association with HCG and progesterone levels. Treatment modalities include surgery, medical treatment and expectant management and patients need to be individually allocated to the treatment protocol that is best suited to them. Risk of a subsequent ectopic pregnancy is increased in patients who have had a previous ectopic pregnancy.

Purpose This study was presented to investigate the clinical–pathological characteristics of gestational trophoblastic neoplasia (GTN) following non-molar pregnancy and differentiated with ectopic pregnancy (EP). Methods The clinical data of 83 patients who were admitted for suspected GTN after non-molar pregnancy at the Women’s Hospital School of Medicine Zhejiang University from January 2015 to September 2022 were selected for analysis. Results In total, 41 cases were confirmed non-molar GTN, including 31 choriocarcinoma, 9 PSTT (placental site trophoblastic tumor), and 1 ETT (epithelioid trophoblastic tumor), while 42 cases were confirmed EP. Compared with ectopic pregnancy, non-molar GTN patients had lower levels of serum progesterone compared with EP (3.81 nmol/L vs 17.70 nmol/L, P  = 0.001). Based on the ultrasound, the thickness of the endometrium was thinner in patients with non-molar GTN compared with EP (0.565 cm vs 0.70 cm, P  = 0.018). By histopathologic examination, the endothelium of non-molar GTN showed less decidual-like changes compared with EP (64.3% vs 14.6%, P  = 0.001). Conclusion A combination of serum progesterone levels, endometrium thickness, and histopathologic features of the endometrium can help to differentiate non-molar GTN and EP. Surgeries including hysteroscopy with curettage and/or laparoscopy are needed.

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.

Background Cesarean scar pregnancy (CSP) treated with either high-intensity focused ultrasound ablation (HIFU-a) or uterine artery embolization (UAE) combined with ultrasound-guided dilation and curettage (USg-D&C) was effective. However, there is insufficient comparative research evidence on clinical efficacy and subsequent pregnancy outcomes after previous CSP treatment. This study aims to investigate the efficacy, safety, and subsequent pregnancy outcomes of HIFU-a compared to UAE before USg-D&C for the treatment of CSP. Methods Between January 2016 and July 2020, a total of 272 patients received the pretreatment with HIFU-a or UAE(HIFU-a group: n  = 118; UAE group: n  = 154). The clinical characteristics, treatment success rate, postoperative pregnancy rate and outcome of the two groups were compared and analyzed. Results The demographic characteristics of the two groups were similar. After pretreatment, the adverse events rate of HIFU-a group was lower than that of UAE group (10.40% (16/154) vs. 40.70% (48/118), P  = 0.00). All patients received the USg-D&C. The HIFU-a group was of less intraoperative blood loss (10.00 (5.00–20.00) vs. 12.50 (5.00–30.00) ml, P  = 0.03). There was no statistically significant difference between the two groups in success rates. However, the HIFU-a group was of a shorter duration of postoperative vaginal bleeding (12.00 (9.00–13.00) vs. 14.00 (12.00–15.00) days, P  = 0.00). There was no significant difference between the two groups in terms of subsequent pregnancy rates ( P  = 0.317). However, the recurrent CSP (rCSP) rate in the HIFU-a group was lower than that in the UAE group (7.70% (6/78) vs. 19.70%(13/66), P  = 0.03). Conclusions CSP treated with either HIFU-a or UAE combined with USg-D&C was safe and effective. Although no significant difference was found in the subsequent pregnancy outcomes of the two groups, the rCSP was more common in the UAE group. So, we recommend HIFU-a combined with USg-D&C treatment modality.

Purpose Cesarean scar pregnancy (CSP) is one of the serious complications associated with cesarean delivery (CD). This meta-analysis aims to identify risk factors associated with massive hemorrhage during the CSP treatment. Methods Eight electronic databases were searched for case–control studies published before December 31th, 2018, which compared the possible factors causing massive bleeding during the CSP treatment. Quantitative synthesis was performed by RevMan 5.3. Sensitivity analysis and publication bias were performed by Stata 12.0. Results Total 20 case − control studies including 3101 CSP patients with previous CD met the inclusion criteria. Bleeding group had 573 patients and the control group had 2528 patients. The risk factors for massive bleeding during CSP treatment included multiple gravidities (MD = 0.15, 95% CI 0.03–0.28, P  = 0.73), big maximum diameter of gestation sac (MD = 18.49 mm, 95%CI 15.34–21.65, P  < 0.01), high gestational days (MD = 8.98 days, 95% CI 4.12–13.84, P  < 0.01), high β-HCG level (MD = 21.39 IU/ml, 95% CI 7.36–35.41, P  = 0.03; MD = 3.02 U/ml, 95% CI 0.21–5.84, P  < 0.01) and rich blood flow around the lesion (OR = 6.73, 95% CI 3.93–11.51, P  = 0.59). While, thick myometrium (MD = − 4.94 mm, 95% CI − 6.12 to − 3.75, P  < 0.01) may be protective factor. Conclusions Multiple gravidities, big gestation sac, large gestational days, high serum β-HCG level, abundant blood supply to pregnancy sac and thin myometrium maybe the risk factors for massive bleeding during the CSP treatment.

Background To investigate factors associated with different reproductive outcomes in patients with Caesarean scar pregnancies (CSPs). Methods Between May 2017 and July 2022, 549 patients underwent ultrasound-guided uterine aspiration and laparoscopic scar repair at the Gynaecology Department of Hubei Maternal and Child Health Hospital. Ultrasound-guided uterine aspiration was performed in patients with type I and II CSPs, and laparoscopic scar repair was performed in patients with type III CSP. The reproductive outcomes of 100 patients with fertility needs were followed up and compared between the groups. Results Of 100 patients, 43% had live births (43/100), 19% had abortions (19/100), 38% had secondary infertility (38/100), 15% had recurrent CSPs (RCSPs) (15/100). The reproductive outcomes of patients with CSPs after surgical treatment were not correlated with age, body mass index, time of gestation, yields, abortions, Caesarean sections, length of hospital stay, weeks of menopause during treatment, maximum diameter of the gestational sac, thickness of the remaining muscle layer of the uterine scar, type of CSP, surgical method, uterine artery embolisation during treatment, major bleeding, or presence of uterine adhesions after surgery. Abortion after treatment was the only risk factor affecting RCSPs (odds ratio 11.25, 95% confidence interval, 3.302–38.325; P  < 0.01) and it had a certain predictive value for RCSP occurrence (area under the curve, 0.741). Conclusions The recurrence probability of CSPs was low, and women with childbearing intentions after CSPs should be encouraged to become pregnant again. Abortion after CSP is a risk factor for RCSP. No significant difference in reproductive outcomes was observed between the patients who underwent ultrasound-guided uterine aspiration and those who underwent laparoscopic scar repair for CSP.

One of the extremely rare locations for an ectopic pregnancy is myometrium. Intramyometrial ectopic pregnancy is characterised by an unusual form of implantation wherein the gestational sac is situated deep in the myometrium, separated from the endometrial cavity and fallopian tubes. It accounts for <1% of all ectopic pregnancies. The preoperative diagnosis based on ultrasound findings may mimic a degenerated leiomyoma, thereby posing further diagnostic challenges. We report a case of a woman in her late 20s presenting with abnormal uterine bleeding diagnosed ultrasonographically as posterior wall fibroid. Histopathological evaluation of the myomectomy specimen revealed chorionic villi lined by trophoblastic cells, thereby confirming the diagnosis. This case report aims to increase the awareness about the possibility of this potentially life-threatening rare entity even with normal serum beta-human chorionic gonadotropin levels.

Background Bilateral ectopic pregnancy is extremely rare, with a tremendous maternal mortality and morbidity risk, requiring rapid diagnosis and management. This condition is usually diagnosed during surgery, as radiologists may not pay enough attention to the contralateral side of interest. Therefore, reminding of this rare but emergent situation can be beneficial for both radiologists and gynecologists. Here we report a case of bilateral ectopic pregnancy, which was first diagnosed with ultrasound and was confirmed during laparoscopy. Case presentation A 34 years old woman complaining of light vaginal bleeding at 6 weeks of gestation by her last menstrual period presented to our institute. The serum β -HCG levels were analyzed and followed during patient’s admission. Unfortunately, serum levels weren’t decreasing and blood test titration before surgery were as: 851,894,975 IU/l (checked daily and not every 48 h because of patient’s status and being bilateral). There was no evidence of intrauterine pregnancy at the transvaginal ultrasound, but heterogeneous adnexal masses were seen at both adnexa, suspected of bilateral ectopic pregnancy. She underwent laparoscopic exploration, which confirmed the diagnosis. Bilateral salpingostomy was done to preserve fertility, and the patient’s recovery was uneventful. Conclusions Even with a unilateral report of ectopic pregnancy preoperatively in ultrasonography, surgeons should always be aware of the probability of bilateral ectopic pregnancies anytime facing susceptible cases, especially in patients with known risk factors. Also, it is an important reminder for radiologists to check both adnexa when facing a unilateral adnexal mass resembling ectopic pregnancy.

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.