European Journal of Obstetrics & Gynecology and Reproductive Biology 176 (2014) 197–202
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
LETTERS TO THE EDITOR—BRIEF COMMUNICATION Intramural pregnancy: a case report Dear Editor, We report an extremely rare case of intramural pregnancy. A 38-year-old woman (gravida 1, para 1, artificial abortion 0) who had had 24 years of primary dysmenorrhoea and had suffered from leiomyoma of the uterus for 5 years, sought medical care because of intermittent vaginal bleeding that lasted for 6 days. With haemostatic treatment, the symptoms of intermittent vaginal bleeding disappeared completely. She had not used contraception since the removal of an intra-uterine device 4 years previously, but had not conceived. The woman had no history of abortion, gestational trophoblastic disease or other gynaecological disease. Routine pre-operative laboratory tests were normal. Colour Doppler ultrasound revealed uneven echoes in the muscle layers and sufficient blood flow signals in an enlarged area of the uterus. Leiomyoma and adenomyosis were considered as the primary diagnosis. Laparoscopic subtotal hysterectomy was performed after the patient rejected routine diagnostic curettage and human chorionic gonadotrophin (hCG) measurement prior to surgery. During surgery, a bleeding site 4.5 cm in size (Fig. 1A) was found in the front uterine wall. Rapid pathological diagnosis showed villi (Fig. 1B) in haemorrhagic necrotic lesions in the muscular layer. Intra-operative b-hCG was 106.50 IU/l. Considering the patient’s medical history, the intra-operative diagnosis was intramural pregnancy. Upon sectioning, a 4.5 cm soft haemorrhagic necrotic lesion was found in the myometrium, and this lesion was clearly delineated amidst the surrounding tissue. Microscopy revealed a large number of villi, some of which showed degeneration and organization. Post operatively, b-hCG decreased to 16.55 IU/l, and data obtained at 1-year follow-up confirmed the diagnosis of intramural pregnancy. The pathogenesis of intramural pregnancy is related to: endometrial defects [1]; perimetrium inflammation [2]; ‘false passage’ in the myometrium caused by minor procedures [3]; and pregnancy with adenomyosis [4]. Based on the patient’s medical history, the condition may have been closely related to adenomyosis and ectopic endometrium. Despite not using contraception for 4 years, she did not conceive although she was fertile. Her irregular vaginal bleeding may have been due to dysfunctional uterine bleeding or ectopic pregnancy. Early diagnosis of ectopic pregnancy was difficult because the patient refused an hCG test. Currently, early diagnosis of intramural pregnancy is difficult because of its atypical manifestations. Intramural ectopic pregnancy should be considered in addition to ectopic pregnancy of the uterine cornu, choriocarcinoma and dysfunctional 0301-2115/ß 2014 Elsevier Ireland Ltd. All rights reserved.
uterine bleeding when the following symptoms are present in women of reproductive age: irregular vaginal bleeding and no villi found after curettage; instruments of curettage cannot reach the gestational sac; the effects of curettage are not ideal; and b-hCG remains high after curettage. No unified standard, however, has been established. In clinical practice, a diagnosis of intramural pregnancy is mainly based on the pathological finding of villi in the myometrium and the hCG value. Misdiagnosis of intra-uterine pregnancy or trophoblastic disease based on an ultrasound finding of homogeneous echo in the myometrium is possible [5]. Improvements in ultrasound technology have increased the early diagnosis rate but ultrasonography cannot diagnose this type of ectopic pregnancy with leiomyomata, which can cover the gestational sac. Early diagnosis
[(Fig._1)TD$IG]
Fig. 1. (A) Haemorrhagic necrotic lesion in the myometrium. (B) Villi in haemorrhagic necrotic lesion (haematoxylin and eosin, original magnification 100).
198
Letters to the Editor—Brief Communication / European Journal of Obstetrics & Gynecology and Reproductive Biology 176 (2014) 197–202
and correct treatment depend on the integrated use of auxiliary examination, which can objectively show the physical condition of the body. In the case of fertile women with intermittent vaginal bleeding, pregnancy should be ruled out first. Early diagnosis can improve the prognosis. References [1] Kirk E, McDonald K, Rees J, et al. Intramural ectopic pregnancy: a case and review of the literature. Eur J Obstet Gynecol Reprod Biol 2013;168:129–33. [2] Achmatowicz L. Ectopic pregnancy inside the uterine wall in a fibromatous uterus. Lancet 1952;2:63–4. [3] Khalifa Y, Redgment CJ, Yazdani N, et al. Intramural pregnancy following difficult embryo transfer. Hum Reprod 1994;9:2427–8. [4] Lu HF, Sheu BC, Shih JC, et al. Intramural ectopic pregnancy. Sonographic picture and its relation with adenomyosis. Acta Obstet Gynecol Scand 1997;76:886–9. [5] Bannon K, Fernandez C, Rojas D, et al. Diagnosis and management of intramural ectopic pregnancy. J Minim Invasive Gynecol 2013;20:697–700.
Yu Liu Fangfang Nan* Zhiqiang Liu Shuangyan Wei Yanni Liu Guoqin Zhao Dongdong Guan Yu Liu Fangfang Nan* Zhiqiang Liu Shuangyan Wei Yanni Liu Guoqin Zhao Dongdong Guan Department of Obstetrics and Gynaecology, Binzhou Medical University Hospital, Binzhou, Shandong Province, China *Corresponding author. Tel.: +86 15266759192; fax: +86 5433258195 E-mail addresses: [email protected] (F. Nan), [email protected] (F. Nan). 15 November 2013 http://dx.doi.org/10.1016/j.ejogrb.2014.02.027
Screening for anal malignancies in men and women Dear Editor, Human papillomavirus (HPV) is the etiological agent in 10 per cent of all human cancers. The number one cancer due to HPV is cervical cancer. Due to screening we can prevent this cancer. Another important cancer that may be prevented by screening is anal cancer. The number of patients with anal cancer has increased in both sexes over the last decades, and 84% of all cases are attributable to high-risk HPV (hrHPV) [1]. Typically high-risk populations are HIV-positive women with a history of cervical intraepithelial neoplasia (CIN), men-having-sex-with-men (MSM) and HIV-positive MSM. The latter two groups have average annual incidence rates of 36/100,000 and 98/100,000, respectively, versus 14/100,000 in the general population. In women anal sex is not mentioned as a risk factor. Journal articles have always focused on HPV infection and anal cancer among homosexual men, whether or not HIV positive. In the general population, however, anal cancer is more frequent among women (1.8/100,000) than among men (1.4/100,000).
In the literature MSM is described as a risk factor for acquiring anal HPV. Indirectly, this statement associates homosexuality with promiscuous men giving and receiving anal sex. Not only homosexual men have receptive anal intercourse. Eight per cent of female primary care patients in Haiti [2] and 53% of female HIVpositive patients in San Francisco [3] reported engaging in anal intercourse. We compared the anal prevalence of HPV DNA in 149 HIV-negative colposcopy patients and in 101 HIV-negative female sex-workers, in Belgium. The groups were significantly different concerning age, smoking, number of private partners, use of condoms, and a history of sexually transmitted infections (Table 1). Seventeen per cent of colposcopy patients versus 42% of sexworkers reported anal intercourse (p < 0.0001). Anal HPV DNA was found in 47% and in 32% of patients and sexworkers, respectively (p = 0.405) [4]. In patients and sex-workers, accompanying cervical samples were HPV positive in 87.0% and 85.7%, respectively. Partial and complete concordance was found in patients in 42% and 38%, respectively; and in sexworkers in 66.7% and 0.8%, respectively. Pap smear results are mentioned in Table 1. This indicates that the presence of anal HPV depends on other factors besides anal intercourse. It is not a person’s sexual nature that is a risk factor, but it is the fact of having repetitive anal intercourse, which puts someone at risk of acquiring anal HPV. To describe the nature of sexual encounters with terms like ‘‘female sex/male sex’’, or the acronyms ‘‘MSM/MSW’’ (men-having-sex-with-women), should be avoided in the literature when the genuine risk factor is the same for men and women.
Table 1 Demographics, prevalence of HPV types in anal smears and PAP results of corresponding cervical smears. Sex workers (n = 99) %
Colposcopy clinic (n = 149) %
p-Value
Age mean (yrs) Smoking tobacco >1 private sexual partner Private condom use Anal sexual contact STI in the past
30.3 (0.05) 55.8 29 34.8 42 23.4
36.4 (0.06) 32.9 17.4 22.1 16.9 6.7
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
LETTERS TO THE EDITOR—BRIEF COMMUNICATION Intramural pregnancy: a case report Dear Editor, We report an extremely rare case of intramural pregnancy. A 38-year-old woman (gravida 1, para 1, artificial abortion 0) who had had 24 years of primary dysmenorrhoea and had suffered from leiomyoma of the uterus for 5 years, sought medical care because of intermittent vaginal bleeding that lasted for 6 days. With haemostatic treatment, the symptoms of intermittent vaginal bleeding disappeared completely. She had not used contraception since the removal of an intra-uterine device 4 years previously, but had not conceived. The woman had no history of abortion, gestational trophoblastic disease or other gynaecological disease. Routine pre-operative laboratory tests were normal. Colour Doppler ultrasound revealed uneven echoes in the muscle layers and sufficient blood flow signals in an enlarged area of the uterus. Leiomyoma and adenomyosis were considered as the primary diagnosis. Laparoscopic subtotal hysterectomy was performed after the patient rejected routine diagnostic curettage and human chorionic gonadotrophin (hCG) measurement prior to surgery. During surgery, a bleeding site 4.5 cm in size (Fig. 1A) was found in the front uterine wall. Rapid pathological diagnosis showed villi (Fig. 1B) in haemorrhagic necrotic lesions in the muscular layer. Intra-operative b-hCG was 106.50 IU/l. Considering the patient’s medical history, the intra-operative diagnosis was intramural pregnancy. Upon sectioning, a 4.5 cm soft haemorrhagic necrotic lesion was found in the myometrium, and this lesion was clearly delineated amidst the surrounding tissue. Microscopy revealed a large number of villi, some of which showed degeneration and organization. Post operatively, b-hCG decreased to 16.55 IU/l, and data obtained at 1-year follow-up confirmed the diagnosis of intramural pregnancy. The pathogenesis of intramural pregnancy is related to: endometrial defects [1]; perimetrium inflammation [2]; ‘false passage’ in the myometrium caused by minor procedures [3]; and pregnancy with adenomyosis [4]. Based on the patient’s medical history, the condition may have been closely related to adenomyosis and ectopic endometrium. Despite not using contraception for 4 years, she did not conceive although she was fertile. Her irregular vaginal bleeding may have been due to dysfunctional uterine bleeding or ectopic pregnancy. Early diagnosis of ectopic pregnancy was difficult because the patient refused an hCG test. Currently, early diagnosis of intramural pregnancy is difficult because of its atypical manifestations. Intramural ectopic pregnancy should be considered in addition to ectopic pregnancy of the uterine cornu, choriocarcinoma and dysfunctional 0301-2115/ß 2014 Elsevier Ireland Ltd. All rights reserved.
uterine bleeding when the following symptoms are present in women of reproductive age: irregular vaginal bleeding and no villi found after curettage; instruments of curettage cannot reach the gestational sac; the effects of curettage are not ideal; and b-hCG remains high after curettage. No unified standard, however, has been established. In clinical practice, a diagnosis of intramural pregnancy is mainly based on the pathological finding of villi in the myometrium and the hCG value. Misdiagnosis of intra-uterine pregnancy or trophoblastic disease based on an ultrasound finding of homogeneous echo in the myometrium is possible [5]. Improvements in ultrasound technology have increased the early diagnosis rate but ultrasonography cannot diagnose this type of ectopic pregnancy with leiomyomata, which can cover the gestational sac. Early diagnosis
[(Fig._1)TD$IG]
Fig. 1. (A) Haemorrhagic necrotic lesion in the myometrium. (B) Villi in haemorrhagic necrotic lesion (haematoxylin and eosin, original magnification 100).
198
Letters to the Editor—Brief Communication / European Journal of Obstetrics & Gynecology and Reproductive Biology 176 (2014) 197–202
and correct treatment depend on the integrated use of auxiliary examination, which can objectively show the physical condition of the body. In the case of fertile women with intermittent vaginal bleeding, pregnancy should be ruled out first. Early diagnosis can improve the prognosis. References [1] Kirk E, McDonald K, Rees J, et al. Intramural ectopic pregnancy: a case and review of the literature. Eur J Obstet Gynecol Reprod Biol 2013;168:129–33. [2] Achmatowicz L. Ectopic pregnancy inside the uterine wall in a fibromatous uterus. Lancet 1952;2:63–4. [3] Khalifa Y, Redgment CJ, Yazdani N, et al. Intramural pregnancy following difficult embryo transfer. Hum Reprod 1994;9:2427–8. [4] Lu HF, Sheu BC, Shih JC, et al. Intramural ectopic pregnancy. Sonographic picture and its relation with adenomyosis. Acta Obstet Gynecol Scand 1997;76:886–9. [5] Bannon K, Fernandez C, Rojas D, et al. Diagnosis and management of intramural ectopic pregnancy. J Minim Invasive Gynecol 2013;20:697–700.
Yu Liu Fangfang Nan* Zhiqiang Liu Shuangyan Wei Yanni Liu Guoqin Zhao Dongdong Guan Yu Liu Fangfang Nan* Zhiqiang Liu Shuangyan Wei Yanni Liu Guoqin Zhao Dongdong Guan Department of Obstetrics and Gynaecology, Binzhou Medical University Hospital, Binzhou, Shandong Province, China *Corresponding author. Tel.: +86 15266759192; fax: +86 5433258195 E-mail addresses: [email protected] (F. Nan), [email protected] (F. Nan). 15 November 2013 http://dx.doi.org/10.1016/j.ejogrb.2014.02.027
Screening for anal malignancies in men and women Dear Editor, Human papillomavirus (HPV) is the etiological agent in 10 per cent of all human cancers. The number one cancer due to HPV is cervical cancer. Due to screening we can prevent this cancer. Another important cancer that may be prevented by screening is anal cancer. The number of patients with anal cancer has increased in both sexes over the last decades, and 84% of all cases are attributable to high-risk HPV (hrHPV) [1]. Typically high-risk populations are HIV-positive women with a history of cervical intraepithelial neoplasia (CIN), men-having-sex-with-men (MSM) and HIV-positive MSM. The latter two groups have average annual incidence rates of 36/100,000 and 98/100,000, respectively, versus 14/100,000 in the general population. In women anal sex is not mentioned as a risk factor. Journal articles have always focused on HPV infection and anal cancer among homosexual men, whether or not HIV positive. In the general population, however, anal cancer is more frequent among women (1.8/100,000) than among men (1.4/100,000).
In the literature MSM is described as a risk factor for acquiring anal HPV. Indirectly, this statement associates homosexuality with promiscuous men giving and receiving anal sex. Not only homosexual men have receptive anal intercourse. Eight per cent of female primary care patients in Haiti [2] and 53% of female HIVpositive patients in San Francisco [3] reported engaging in anal intercourse. We compared the anal prevalence of HPV DNA in 149 HIV-negative colposcopy patients and in 101 HIV-negative female sex-workers, in Belgium. The groups were significantly different concerning age, smoking, number of private partners, use of condoms, and a history of sexually transmitted infections (Table 1). Seventeen per cent of colposcopy patients versus 42% of sexworkers reported anal intercourse (p < 0.0001). Anal HPV DNA was found in 47% and in 32% of patients and sexworkers, respectively (p = 0.405) [4]. In patients and sex-workers, accompanying cervical samples were HPV positive in 87.0% and 85.7%, respectively. Partial and complete concordance was found in patients in 42% and 38%, respectively; and in sexworkers in 66.7% and 0.8%, respectively. Pap smear results are mentioned in Table 1. This indicates that the presence of anal HPV depends on other factors besides anal intercourse. It is not a person’s sexual nature that is a risk factor, but it is the fact of having repetitive anal intercourse, which puts someone at risk of acquiring anal HPV. To describe the nature of sexual encounters with terms like ‘‘female sex/male sex’’, or the acronyms ‘‘MSM/MSW’’ (men-having-sex-with-women), should be avoided in the literature when the genuine risk factor is the same for men and women.
Table 1 Demographics, prevalence of HPV types in anal smears and PAP results of corresponding cervical smears. Sex workers (n = 99) %
Colposcopy clinic (n = 149) %
p-Value
Age mean (yrs) Smoking tobacco >1 private sexual partner Private condom use Anal sexual contact STI in the past
30.3 (0.05) 55.8 29 34.8 42 23.4
36.4 (0.06) 32.9 17.4 22.1 16.9 6.7
