# Misdiagnosis of occult heterotopic intramural ectopic pregnancy by two-dimensional ultrasound: Two case reports

## TL;DR

Two cases of hard-to-detect ectopic pregnancies near the uterus were misdiagnosed with 2D ultrasound and required advanced imaging for correct diagnosis.

## Contribution

Highlights the limitations of 2D ultrasound and the need for multimodal imaging in diagnosing HIMP.

## Key findings

- HIMP cases near the uterine fundus or horn are difficult to detect with early 2D transvaginal sonography.
- Multimodal imaging combined with β-hCG levels improved diagnostic accuracy and guided hysteroscopic removal.
- Clinical vigilance is crucial to avoid misdiagnosis and prevent severe outcomes.

## Abstract

We report two cases of heterotopic intramural ectopic pregnancy (HIMP) following multiple abortions, with lesions located near the uterine fundus or uterine horn. These cases are particularly challenging to diagnose using early two-dimensional transvaginal sonography (TVS). We analyzed multimodal imaging in combination with transabdominal ultrasound (TAS), color Doppler flow imaging (CDFI), three-dimensional TVS, and magnetic resonance imaging (MRI) for early diagnosis and ultimately removed the gestational sac tissue via hysteroscopy. The combination of multimodal imaging techniques, serum β-human chorionic gonadotropin (β-hCG) levels, and clinical vigilance should be considered to prevent the catastrophic consequences of HIMP, particularly when conventional two-dimensional TVS results are equivocal or misleading.