Evidence-based management of intramural pregnancy: A comprehensive systematic review

Stabile, Guglielmo;Mazzola, Bianca Maria;Cracco, Francesco;Carlucci, Stefania;Saponara, Stefania;Michele, Stefano Di;Vitale, Salvatore Giovanni;Angioni, Stefano;Nappi, Luigi

2025-01-01

---

Abstract

Background: Intramural pregnancy (IMP) is a rare and potentially life-threatening form of ectopic pregnancy, representing less than 1 % of all ectopic cases. Its diagnosis is challenging, and currently no standardized guidelines exist for its management. Objective: To analyze reported cases of intramural pregnancy to identify relevant clinical parameters that may support decision-making in the choice between medical and surgical management, and to assess factors influencing treatment outcomes. Search strategy: A systematic review was conducted according to PRISMA guidelines. Three databases (PubMed, Scopus, Web of Science) were searched for studies published from 1990 to March 2024 using relevant MeSH terms and keywords. Only studies in English and French were included. Selection criteria: Studies reporting cases of intramural or intramyometrial pregnancies, excluding cervical, interstitial, cesarean scar, and subserosal pregnancies, were eligible. A total of 71 studies (96 cases) were included after full-text screening and duplicate removal. Data collection and analysis: Data were independently extracted and analyzed regarding patients’ clinical features, imaging findings, treatment modalities (expectant, medical, surgical), and outcomes. Risk of bias was assessed using the JBI Critical Appraisal Checklist. Parameters including gestational age, β-hCG, gestational sac diameter, and residual myometrial thickness were examined. Main results: IMP was primarily managed surgically (68.8 %). Expectant and medical management showed success in selected cases with favorable characteristics. Higher β-hCG levels (>20,000 mIU/ml), gestational age >60 days, sac diameter >30 mm, and residual myometrial thickness <4 mm were more frequently associated with surgical treatment. Medical therapy was less effective in cases with subserosal features or large gestational sacs. Conclusions: Intramural pregnancy requires early diagnosis and individualized management. Clinical parameters such as gestational age, β-hCG levels, sac diameter, myometrial thickness, and subserosal features may help guide treatment choice. Surgical management is often preferred in higher-risk cases, while medical or expectant approaches may be suitable for selected patients.