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Kurosawa H, Watanabe T, Sato N, Muraoka Y, Matsuzawa Y, Watanabe Y. A rare case of extraluminal interstitial pregnancy treated with laparoscopic cornuotomy. J Obstet Gynaecol Res 2024. [PMID: 38711243 DOI: 10.1111/jog.15962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 04/22/2024] [Indexed: 05/08/2024]
Abstract
We report an extremely rare case of an extraluminal interstitial pregnancy. A 36-year-old nulliparous woman visited our hospital during the fifth week of gestation. Although no intrauterine gestational sac (GS) was identified, transabdominal ultrasonography revealed a GS-like cyst was detected in the right uterine horn. She underwent laparoscopic surgery for a suspected interstitial ectopic pregnancy. After laparoscopic cornuotomy, dye leakage was observed from the fimbria rather than the incision site. Finally, the patient was diagnosed with a right extraluminal interstitial pregnancy. Hysterosalpingography performed at three postoperative months revealed bilateral tubal passage. She conceived 7 months after surgery, with safe delivery by elective cesarean section at 38 weeks.
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Affiliation(s)
- Hiroki Kurosawa
- Division of Obstetrics and Gynecology, Tohoku Medical and Pharmaceutical University Wakabayashi Hospital, Sendai, Miyagi, Japan
| | - Tadashi Watanabe
- Division of Obstetrics and Gynecology, Tohoku Medical and Pharmaceutical University Wakabayashi Hospital, Sendai, Miyagi, Japan
| | - Naoto Sato
- Division of Obstetrics and Gynecology, Tohoku Medical and Pharmaceutical University Wakabayashi Hospital, Sendai, Miyagi, Japan
- Department of Obstetrics and Gynecology, Sendai Medical Center, Sendai, Miyagi, Japan
| | - Yuma Muraoka
- Division of Obstetrics and Gynecology, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Yukiko Matsuzawa
- Division of Obstetrics and Gynecology, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Yoh Watanabe
- Division of Obstetrics and Gynecology, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
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Dong Y, Zhang H, Jin K, Li H. Three-dimensional transvaginal ultrasound diagnosis of interstitial ectopic pregnancy in a unicornuate uterus: A case report. JOURNAL OF CLINICAL ULTRASOUND : JCU 2024; 52:473-477. [PMID: 38288546 DOI: 10.1002/jcu.23641] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/10/2024] [Accepted: 01/18/2024] [Indexed: 05/08/2024]
Abstract
A rare case of unicornuate uterus with interstitial ectopic pregnancy was diagnosed using three-dimensional transvaginal ultrasound (3D-TVUS). The ultrasound revealed a "lancet-shaped" endometrial corona, a gestational sac near the uterus base extending toward the uterine serosa, and visible interstitial lines. The patient underwent laparoscopic surgery for a lesion in the right fallopian tube. 3D-TVUS was crucial in precisely locating the gestational sac, aiding in effective treatment. Interstitial ectopic pregnancies risk severe hemorrhaging upon rupture. Rapid, accurate diagnosis is vital for lifesaving treatment and preventing critical complications.
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Affiliation(s)
- Yanhua Dong
- Department of Ultrasound, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongbin Zhang
- Department of Ultrasound, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ke Jin
- Department of Ultrasound, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hezhou Li
- Department of Ultrasound, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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3
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Jongjakapun A, Salang L, Aueaungkul A, Kleebkaow P. Chronic interstitial ectopic pregnancy presenting with a negative urine pregnancy test. BMJ Case Rep 2024; 17:e259267. [PMID: 38589241 PMCID: PMC11015295 DOI: 10.1136/bcr-2023-259267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024] Open
Abstract
The ampulla portion of the fallopian tube is the most common site of ectopic pregnancy (70%), with approximately 2% of pregnancies implanted in the interstitial portion. In general, an interstitial ectopic pregnancy (IEP) is difficult to diagnose and is associated with a high rate of complications-most patients with an IEP present with severe abdominal pain and haemorrhagic shock due to an ectopic rupture. Chronic tubal pregnancy (CTP) is an uncommon condition with an incidence of 20%. The CTP has a longer clinical course and a negative or low level of serum beta-human chorionic gonadotropin due to perished chorionic villi. This study presents a case of a woman who was diagnosed with a chronic IEP (CIEP) which was successfully treated by surgery. This case also acts as a cautionary reminder of considering a CIEP in women of reproductive age presenting with amenorrhea, vaginal bleeding and a negative pregnancy test.
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Affiliation(s)
- Apiwat Jongjakapun
- Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Lingling Salang
- Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Apiwat Aueaungkul
- Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Pilaiwan Kleebkaow
- Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Sabbagh M, Othman N, Chaikha S, Sukkar R, alToto A, alQudsi L. Interstitial ectopic pregnancy: A rare case report. Int J Surg Case Rep 2024; 117:109529. [PMID: 38522306 PMCID: PMC10979090 DOI: 10.1016/j.ijscr.2024.109529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 03/07/2024] [Accepted: 03/12/2024] [Indexed: 03/26/2024] Open
Abstract
INTRODUCTION Interstitial pregnancies are a rare form of ectopic pregnancy with life threatening consequences. Thus, the aim of this report is to shed light on the importance of early diagnosis for optimal outcomes. CASE PRESENTATION Herein, we present a case of an interstitial ectopic pregnancy in a 31-year-old Syrian female who presented only with mild non-specific abdominal pain. The ultrasound showed a gestational sac in the right horn of the uterus non-communicating with the endometrial cavity suggesting an interstitial ectopic pregnancy. Cornual excision and salpingectomy were performed with laparotomy instead of laparoscopy due to resource-limited facilities. Follow-up with serum human chorionic gonadotropin β-HCG continued until the hormone levels became undetectable. DISCUSSION Interstitial ectopic pregnancies can present with non-classic symptoms. Ultrasonographic evaluation for lower abdominal pain in women at the first trimester is essential to detect interstitial ectopic pregnancies. CONCLUSION Early diagnosis is key to prevent the life threatening progression of interstitial pregnancy, so this diagnosis should be kept in mind in women presenting with first trimester abdominal pain and/or vaginal bleeding.
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Affiliation(s)
- Majd Sabbagh
- Department of Gynecology and Obstetrics, University Hospital of Obstetrics and Gynecology in Damascus, Faculty of Medicine, Damascus University, Damascus, Syria.
| | - Nehad Othman
- Department of Gynecology and Obstetrics, University Hospital of Obstetrics and Gynecology in Damascus, Faculty of Medicine, Damascus University, Damascus, Syria
| | - Salah Chaikha
- Department of Gynecology and Obstetrics, University Hospital of Obstetrics and Gynecology in Damascus, Faculty of Medicine, Damascus University, Damascus, Syria; Faculty of Medicine, Damascus University, Damascus, Syria
| | - Rehab Sukkar
- Department of Gynecology and Obstetrics, University Hospital of Obstetrics and Gynecology in Damascus, Faculty of Medicine, Damascus University, Damascus, Syria
| | - Amal alToto
- Faculty of Medicine, Damascus University, Damascus, Syria
| | - Lina alQudsi
- Faculty of Medicine, University of Algeria, Algeria; Syrian Medical Association, Dar Al Shifa'a Hospital, Damascus, Syria
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Dabreteau T, Puchar A, Nyangoh Timoh K, Fauconnier A, Legendre G, Touboul C, Lavoué V, Thubert T, Lecarpentier E, Haddad B, Dabi Y. Interstitial pregnancy management: A multicentric analysis of 98 patients from the FRANCOGENT group comparing surgery and medical treatment. Int J Gynaecol Obstet 2024; 165:125-130. [PMID: 37937363 DOI: 10.1002/ijgo.15239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 08/29/2023] [Accepted: 10/24/2023] [Indexed: 11/09/2023]
Abstract
OBJECTIVE To evaluate the outcomes associated with each therapeutic option for patients diagnosed with interstitial pregnancy (IP). METHODS We conducted a multicentric retrospective cohort study within the departments of Gynecology and Obstetrics involved in the Francogent research group. Women treated for an interstitial pregnancy between January 2008 to December 2019 were included. Three therapeutic options were evaluated: surgical treatment (ST); in situ methotrexate combined with systemic methotrexate (IS-MTX); and systemic methotrexate (IM-MTX). Success of first-line treatment was defined by hCG negativation (<5I U/L). Secondary outcomes included the need for secondary surgical procedure, secondary medical treatment, emergency surgery, postoperative complications, duration of hospitalization, and delay before hCG negativation. RESULTS A total of 98 patients were managed for IP: 42 (42.9%) patients had IM-MTX; 34 (34.7%) had IS-MTX; and 22 (22.4%) had ST. First-line treatment was successful in all patients of the ST group (22/22, 100%), in 31% of patients within the IM-MTX group (13/42) and 70.6% (24/34) in the IS-MTX group. The sole parameter associated with the risk of treatment failure was the mode of methotrexate administration. The size of the gestational sac or the presence of fetal heartbeat was not associated with decreased medical treatment (IS or IM-MTX) efficiency. CONCLUSION Either ST or IS-MTX are good options for IP treatment associated with high success rates. A single-dose regimen of IM-MTX is less efficient than IS-MTX or ST. Symptomatic patients with severity criteria should always undergo emergency surgery. IP remains a high-risk condition that should be managed, whenever possible, in referral centers to potentialize the chances of favorable outcomes.
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Affiliation(s)
- Thomas Dabreteau
- Department of Obstetrics and Gynecology, CHI Creteil, Creteil, France
| | - Anne Puchar
- Department of Obstetrics and Gynecology, Tenon Hospital, AP-HP, Sorbonne University, Paris, France
| | | | - Arnaud Fauconnier
- Department of Obstetrics and Gynecology, Intercommunal Hospital of Poissy/Saint-Germain-en-Laye, Poissy, France
| | - Guillaume Legendre
- Department of Obstetrics and Gynecology, Angers University Hospital, Angers, France
| | - Cyril Touboul
- Department of Obstetrics and Gynecology, Tenon Hospital, AP-HP, Sorbonne University, Paris, France
| | - Vincent Lavoué
- Department of Obstetrics and Gynecology, Rennes University Hospital, Rennes, France
| | - Thibault Thubert
- Department of Obstetrics and Gynecology, Nantes University Hospital, Nantes, France
| | | | - Bassam Haddad
- Department of Obstetrics and Gynecology, CHI Creteil, Creteil, France
| | - Yohann Dabi
- Department of Obstetrics and Gynecology, Tenon Hospital, AP-HP, Sorbonne University, Paris, France
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Ungureanu CO, Stanculea FC, Iordache N, Georgescu TF, Ginghina O, Mihailov R, Vacaroiu IA, Georgescu DE. Ruptured Recurrent Interstitial Ectopic Pregnancy Successfully Managed by Laparoscopy. Diagnostics (Basel) 2024; 14:506. [PMID: 38472978 DOI: 10.3390/diagnostics14050506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/13/2024] [Accepted: 02/16/2024] [Indexed: 03/14/2024] Open
Abstract
Ectopic pregnancies are a frequently encountered cause of first-trimester metrorrhagia. They occur when an embryo is implanted and grows outside the normal uterine space. Uncommonly, the embryo can be implanted in the intramural portion of the uterine tube, a condition referred to as interstitial localization. This specific type of ectopic pregnancy may have an unpredictable course, potentially leading to severe uterine rupture and catastrophic bleeding if not promptly diagnosed and managed. We present a rare case of a multiparous 36-year-old female patient who underwent pelvic ultrasonography in the emergency department for intense pelvic pain associated with hypotension and moderate anemia. A history of right salpingectomy for a ruptured tubal ectopic pregnancy 10 years previously was noted. High beta-HCG levels were also detected. A pelvic ultrasound allowed us to suspect a ruptured ectopic interstitial pregnancy at 8 weeks of amenorrhea. An association with hemoperitoneum was suspected, and an emergency laparoscopy was performed. The condition was confirmed intraoperatively, and the patient underwent a right corneal wedge resection with suture of the uterine myometrium. The postoperative course was uneventful, and the patient was discharged on the fourth day postoperatively. Interstitial ectopic pregnancy is a rare yet extremely perilous situation. Timely ultrasound-based diagnosis is crucial as it can enable conservative management with Methotrexate. Delayed diagnosis can lead to uterine rupture with consecutive surgery based on a transection of the pregnancy and cornual uterine resection.
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Affiliation(s)
- Claudiu Octavian Ungureanu
- Department of Surgery, "Carol Davila" University of Medicine and Pharmacy, 37, Dionisie Lupu Street, 020021 Bucharest, Romania
- General Surgery Department, "Sf. Ioan" Clinical Emergency Hospital, 13 Vitan-Bârzeşti Road, 042122 Bucharest, Romania
| | - Floris Cristian Stanculea
- Department of Surgery, "Carol Davila" University of Medicine and Pharmacy, 37, Dionisie Lupu Street, 020021 Bucharest, Romania
- General Surgery Department, "Sf. Ioan" Clinical Emergency Hospital, 13 Vitan-Bârzeşti Road, 042122 Bucharest, Romania
| | - Niculae Iordache
- Department of Surgery, "Carol Davila" University of Medicine and Pharmacy, 37, Dionisie Lupu Street, 020021 Bucharest, Romania
- General Surgery Department, "Sf. Ioan" Clinical Emergency Hospital, 13 Vitan-Bârzeşti Road, 042122 Bucharest, Romania
| | - Teodor Florin Georgescu
- Department of Surgery, "Carol Davila" University of Medicine and Pharmacy, 37, Dionisie Lupu Street, 020021 Bucharest, Romania
- General Surgery Department, Clinical Emergency Hospital Bucharest, SplaiulIndependentei nr 168, Sect 5, 050098 Bucharest, Romania
| | - Octav Ginghina
- Department of Surgery, "Carol Davila" University of Medicine and Pharmacy, 37, Dionisie Lupu Street, 020021 Bucharest, Romania
- General Surgery Department, "Prof. Dr. Alexandru Trestioreanu" Oncological Institute, 022328 Bucharest, Romania
| | - Raul Mihailov
- General Surgery Department, "Sf. Andrei" Clinical Emergency Hospital, 177 Braila Street, 800578 Galati, Romania
| | - Ileana Adela Vacaroiu
- Department of Surgery, "Carol Davila" University of Medicine and Pharmacy, 37, Dionisie Lupu Street, 020021 Bucharest, Romania
- Nephrology and Dialysis Clinic, "Sf. Ioan" Emergency Clinical Hospital, Sos. Vitan-Barzesti nr 12, 042122 Bucharest, Romania
| | - Dragos Eugen Georgescu
- Department of Surgery, "Carol Davila" University of Medicine and Pharmacy, 37, Dionisie Lupu Street, 020021 Bucharest, Romania
- General Surgery Department, "Dr. I. Cantacuzino" Clinical Hospital, 5-7 I. Movila Street, 022904 Bucharest, Romania
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7
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Wang Y, Chen L, Tao Y, Luo M. Risk factors of ectopic pregnancy after in vitro fertilization-embryo transfer in Chinese population: A meta-analysis. PLoS One 2024; 19:e0296497. [PMID: 38166058 PMCID: PMC10760883 DOI: 10.1371/journal.pone.0296497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/14/2023] [Indexed: 01/04/2024] Open
Abstract
BACKGROUND The prevalence of ectopic pregnancy after assisted reproduction is notably high, posing a significant threat to the life safety of pregnant women. Discrepancies in published results and the lack of a comprehensive description of all risk factors have led to ongoing uncertainties concerning ectopic pregnancy after assisted reproduction. OBJECTIVE This study aimed to understand the risk factors for ectopic pregnancy after in vitro fertilization-embryo transfer in the Chinese population and provide a reference for targeted prevention and treatment. METHODS A comprehensive search of the China National Knowledge Infrastructure, Wang fang Database, China Science Technology Journal Database, Chinese Biomedical Literature Database, PubMed, Web of Science, and Embase was conducted to identify relevant literature on the risk factors for ectopic pregnancy in Chinese women after assisted reproductive technology in Chinese women. A meta-analysis of the included studies was performed using Stata17. RESULTS Overall, 34 articles were included in the analysis. The risk factors for ectopic pregnancy after in vitro fertilization-embryo transfer in the Chinese population included a thin endometrium on the day of HCG administration and embryo transplantation, a history of ectopic pregnancy, secondary infertility, a history of induced abortion, polycystic ovary syndrome, decreased ovarian reserve, tubal factor infertility, cleavage stage embryo transfer, fresh embryo transfer, artificial cycle protocols, elevated estradiol levels on the day of human chorionic gonadotropin administration, a history of tubal surgery, two or more number of embryo transfers, previous pregnancy history, and a history of pelvic surgery. CONCLUSION This study clarified the factors influencing ectopic pregnancy after in vitro fertilization and embryo transfer in the Chinese population, focusing on high-risk groups. Targeted and personalized intervention measures should be adopted to prevent and detect the disease early to reduce its incidence and harm. TRIAL REGISTRATION The protocol for this view was registered in PROSPERO (CRD42023414710).
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Affiliation(s)
- Yanbo Wang
- School of Nursing, Gansu University of Traditional Chinese Medicine, Lanzhou, Gansu Province, China
| | - Li Chen
- School of Nursing, Gansu University of Traditional Chinese Medicine, Lanzhou, Gansu Province, China
| | - Yuan Tao
- School of Nursing, Gansu University of Traditional Chinese Medicine, Lanzhou, Gansu Province, China
| | - Mengqian Luo
- School of Nursing, Gansu University of Traditional Chinese Medicine, Lanzhou, Gansu Province, China
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8
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Thanasa A, Thanasa E, Grapsidi V, Antoniou IR, Gerokostas EE, Kamaretsos E, Chasiotis A, Thanasas I. Interstitial Ectopic Pregnancy Associated With Painless and Severe Vaginal Bleeding: A Rare, Atypical Clinical Presentation. Cureus 2024; 16:e53225. [PMID: 38425637 PMCID: PMC10903376 DOI: 10.7759/cureus.53225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 03/02/2024] Open
Abstract
Interstitial ectopic pregnancy is rare (2%-4% of ectopic pregnancies). The atypical clinical presentation of interstitial ectopic pregnancy associated with massive vaginal bleeding is extremely rare and makes early preoperative diagnosis even more difficult. The presentation of our case concerns the early diagnosis and surgical treatment of a patient with an interstitial ectopic pregnancy without rupture, which presented atypically with painless, severe vaginal bleeding. A 27-year-old fourth-term pregnant woman presented with massive painless vaginal bleeding. Secondary amenorrhea was calculated at eight weeks and four days. Transvaginal ultrasound and transvaginal Doppler ultrasound combined with the quantification of beta-chorionic gonadotropin hormone raised the suspicion of interstitial ectopic pregnancy. Intraoperatively, the presence of a large swelling of the right horn of the uterus was established, and a wedge resection was performed with the removal of the corresponding fallopian tube. Three weeks after surgery, the serum beta-chorionic gonadotropin hormone value was zero. In this paper, the rarity of interstitial ectopic pregnancy, the difficulties related to early and correct preoperative diagnosis, and the selection of the appropriate available therapeutic procedures are emphasized, the correct application of which can significantly contribute to reducing the morbidity and mortality of these patients.
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Affiliation(s)
- Anna Thanasa
- Medicine, Department of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Efthymia Thanasa
- Medicine, Department of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Vasiliki Grapsidi
- Obstetrics and Gynecology, General Hospital in Trikala, Trikala, GRC
| | | | | | | | | | - Ioannis Thanasas
- Obstetrics and Gynecology, General Hospital of Trikala, Trikala, GRC
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9
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Cingiloglu P, Mooney S, Readman E, McNamara H, Choong S, Stone K, Ellett L. A Rare Case of Intramyometrial Pregnancy. J Minim Invasive Gynecol 2023; 30:861-863. [PMID: 37506877 DOI: 10.1016/j.jmig.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/15/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023]
Affiliation(s)
- Pinar Cingiloglu
- Endosurgery Department (Drs. Cingiloglu, Mooney, Readman, McNamara, Choong, Stone, and Ellett), Mercy Hospital for Women, Heidelberg, Australia.
| | - Samantha Mooney
- Endosurgery Department (Drs. Cingiloglu, Mooney, Readman, McNamara, Choong, Stone, and Ellett), Mercy Hospital for Women, Heidelberg, Australia; Department of Obstetrics and Gynaecology (Drs. Mooney, and Readman), University of Melbourne, Parkville, Australia
| | - Emma Readman
- Endosurgery Department (Drs. Cingiloglu, Mooney, Readman, McNamara, Choong, Stone, and Ellett), Mercy Hospital for Women, Heidelberg, Australia; Department of Obstetrics and Gynaecology (Drs. Mooney, and Readman), University of Melbourne, Parkville, Australia
| | - Helen McNamara
- Endosurgery Department (Drs. Cingiloglu, Mooney, Readman, McNamara, Choong, Stone, and Ellett), Mercy Hospital for Women, Heidelberg, Australia
| | - Shawn Choong
- Endosurgery Department (Drs. Cingiloglu, Mooney, Readman, McNamara, Choong, Stone, and Ellett), Mercy Hospital for Women, Heidelberg, Australia
| | - Kate Stone
- Endosurgery Department (Drs. Cingiloglu, Mooney, Readman, McNamara, Choong, Stone, and Ellett), Mercy Hospital for Women, Heidelberg, Australia
| | - Lenore Ellett
- Endosurgery Department (Drs. Cingiloglu, Mooney, Readman, McNamara, Choong, Stone, and Ellett), Mercy Hospital for Women, Heidelberg, Australia
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10
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Deshmukh S, Shelke S, Shrivastava D. A Case of Ruptured Left Interstitial Ectopic Pregnancy. Cureus 2023; 15:e45711. [PMID: 37868439 PMCID: PMC10590179 DOI: 10.7759/cureus.45711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 09/21/2023] [Indexed: 10/24/2023] Open
Abstract
Although rare, interstitial ectopic pregnancy poses a challenge in diagnosis and management. The pregnancy is implanted in the interstitial part of the fallopian tube, i.e., the proximal intramural portion. When ruptured, it results in a catastrophic event; the rupture can involve the uterine wall, as in this case, which puts the prognosis of future pregnancies at risk. Here, a case of a 35-year-old primigravida who conceived after ovulation induction is reported. Her diagnosis of ectopic pregnancy was missed; it was misdiagnosed as incomplete abortion followed by dilatation and evacuation. Post-evacuation severe pain and hemodynamic instability, and subsequent ultrasonography (USG) lead to the diagnosis of left interstitial ectopic pregnancy. Emergency laparotomy, left salpingo-oophorectomy, and cornual resection with repair were done.
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Affiliation(s)
- Snehal Deshmukh
- Obstetrics and Gynaecology, Datta Meghe Medical College, Datta Meghe Institute of Medical Sciences (DU) Wardha, Nagpur, IND
| | - Sonali Shelke
- Obstetrics and Gynaecology, Datta Meghe Medical College, Datta Meghe Institute of Medical Sciences (DU) Wardha, Nagpur, IND
| | - Deepti Shrivastava
- Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (DU) Wardha, Nagpur, IND
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11
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Bužinskienė D, Mačionytė M, Dasevičius D, Šilkūnas M. Case report: Ectopic pregnancy in the interstitial part of the fallopian tube. Front Surg 2023; 10:1197036. [PMID: 37470044 PMCID: PMC10352450 DOI: 10.3389/fsurg.2023.1197036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/20/2023] [Indexed: 07/21/2023] Open
Abstract
Ectopic pregnancy remains one of the most common causes of pregnancy-related death in the first trimester. 2.4% of ectopic pregnancies occur in the interstitial part of the fallopian tube. As the symptoms of this condition are non-specific and the localization is associated with a higher risk of bleeding, early diagnosis of interstitial pregnancies is important, based not only on clinical symptoms, but also on additional diagnostic methods. Early diagnosis leads to better treatment-related outcomes. We report a 32-year-old female patient who came to the emergency department because of pain in the lower abdomen and right iliac region and bloody vaginal discharge. During palpation of the abdomen, the pain was localized in the lower part of the abdomen. Human chorionic gonadotropin (hCG) was significantly increased in biochemical tests. Transvaginal ultrasound examination of internal genital organs, abdominal and pelvic computer tomography (CT) were per-formed. An ectopic pregnancy was suspected. Thus, the patient was hospitalized in the gynecology department for surgical treatment. A laparoscopy was performed and an ectopic pregnancy was diagnosed in the interstitial part of the right fallopian tube and in the right uterine corner, which led to right salpingectomy and right uterine angle resection. Thus, interstitial pregnancy is a rare and life-threatening gynecological condition due to the higher risk of bleeding compared to other ectopic pregnancies. However, appropriate diagnosis based on clinical signs, transvaginal ultrasound findings and hCG levels in the blood ensures early diagnosis of interstitial pregnancy, which leads to the choice of medical treatment with methotrexate or minimally invasive surgical techniques.
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Affiliation(s)
- Diana Bužinskienė
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Obstetrics and Gynecology, Institute of Clinical Medicine, Faculty of Medicine Vilnius University, Vilnius, Lithuania
| | | | - Darius Dasevičius
- National Center of Pathology, Affiliate of Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Mindaugas Šilkūnas
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Obstetrics and Gynecology, Institute of Clinical Medicine, Faculty of Medicine Vilnius University, Vilnius, Lithuania
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12
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Dhanju G, Goubran A, Zimolag L, Chartrand R, Matthew F, Breddam A. Distinguishing between cornual, angular and interstitial ectopic pregnancy: A case report and a brief literature review. Radiol Case Rep 2023; 18:2531-2544. [PMID: 37235077 PMCID: PMC10208802 DOI: 10.1016/j.radcr.2023.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/09/2023] [Accepted: 04/15/2023] [Indexed: 05/28/2023] Open
Abstract
For all clinical purposes, cornual, angular, and interstitial pregnancies are considered ectopic pregnancies that can have grave consequences for the patient. In this article, we describe and distinguish 3 types of ectopic pregnancies in the cornual region of the uterus. The authors advocate using the "cornual pregnancy" term only for ectopic pregnancies in malformed uteruses. We describe an ectopic pregnancy in a 25-year-old G2P1 patient in the cornual region of the uterus that was missed twice sonographically in the second trimester and had almost fatal consequences in the patient. Radiologists and sonographers should be aware of the sonographic diagnosis of angular, cornual and interstitial pregnancies. Whenever possible, first-trimester transvaginal ultrasound scanning is crucial for diagnosing these 3 types of ectopic pregnancies in the cornual region. In the second and third trimesters, ultrasound tends to become equivocal; hence alternate imaging, such as MRI, might add additional value to the management of the patient. A case report assessment and a comprehensive literature review comprising 61 case reports of ectopic pregnancy in the second and third trimesters are diligently undertaken in the Medline, Embase and Web of Science databases. The major strength of our study is that it is one of the few studies that describe a literature review of ectopic pregnancy in the cornual region exclusively in the second and third trimesters.
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Affiliation(s)
- Gurinder Dhanju
- Department of Public Health, University of Saskatchewan, 105 Administration Place, Saskatoon, SK S7N 5A2, Canada
- Department of Ultrasound, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Ashraf Goubran
- Department of Ultrasound, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Lukasz Zimolag
- Department of Ultrasound, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Robyn Chartrand
- Department of Ultrasound, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Frankel Matthew
- Department of Ultrasound, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Alli Breddam
- Department of Ultrasound, St. Boniface Hospital, Winnipeg, Manitoba, Canada
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Gaetani M, Di Gennaro D, Vimercati A, Vitagliano A, Dellino M, Malvasi A, Loizzi V, Pinto V, Cicinelli E, Di Naro E, Lacalandra A, Damiani GR. Cornual Pregnancy. Gynecol Minim Invasive Ther 2023; 12:130-134. [PMID: 37807987 PMCID: PMC10553601 DOI: 10.4103/gmit.gmit_10_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/09/2023] [Accepted: 03/20/2023] [Indexed: 10/10/2023] Open
Abstract
Cornual pregnancy (CP) is a subtype of ectopic pregnancy that is implanted in the interstitial segment of the fallopian tube which is defined as the tubal section crossing uterine muscular tissue. Widely recognized risk factors for CP are endometriosis, uterine leiomyomata, or pelvic inflammatory disease; all these diseases can cause tubal anatomic changes and consequently alter embryo physiological implant process. Many treatment options are available for this condition each one must be tailored according to patient and operating scenario. The incidence of uterine ruptures in the scarred uterus appears to be low, but the fear of it remains and therefore medical treatment might be favored over cornual wedge resection. The actual risk of uterine rupture after medical treatment is unknown. Multiple testing strategies exist to diagnose CP, but caution needs to be used to avoid a false diagnosis.
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Affiliation(s)
- Maria Gaetani
- Department of Biomedical Sciences and Human Oncology, Gynaecologic and Obstetrics Clinic, University of Bari, Bari, Italy
| | - Daniele Di Gennaro
- Department of Biomedical Sciences and Human Oncology, Gynaecologic and Obstetrics Clinic, University of Bari, Bari, Italy
| | - Antonella Vimercati
- Department of Biomedical Sciences and Human Oncology, Gynaecologic and Obstetrics Clinic, University of Bari, Bari, Italy
| | - Amerigo Vitagliano
- Department of Biomedical Sciences and Human Oncology, Gynaecologic and Obstetrics Clinic, University of Bari, Bari, Italy
| | - Miriam Dellino
- Department of Biomedical Sciences and Human Oncology, Gynaecologic and Obstetrics Clinic, University of Bari, Bari, Italy
| | - Antonio Malvasi
- Department of Biomedical Sciences and Human Oncology, Gynaecologic and Obstetrics Clinic, University of Bari, Bari, Italy
| | - Vera Loizzi
- Department of Biomedical Sciences and Human Oncology, Gynaecologic and Obstetrics Clinic, University of Bari, Bari, Italy
| | - Vincenzo Pinto
- Department of Biomedical Sciences and Human Oncology, Gynaecologic and Obstetrics Clinic, University of Bari, Bari, Italy
| | - Ettore Cicinelli
- Department of Biomedical Sciences and Human Oncology, Gynaecologic and Obstetrics Clinic, University of Bari, Bari, Italy
| | - Edoardo Di Naro
- Department of Biomedical Sciences and Human Oncology, Gynaecologic and Obstetrics Clinic, University of Bari, Bari, Italy
| | - Angelo Lacalandra
- Department of Biomedical Sciences and Human Oncology, Gynaecologic and Obstetrics Clinic, University of Bari, Bari, Italy
| | - Gianluca Raffaello Damiani
- Department of Biomedical Sciences and Human Oncology, Gynaecologic and Obstetrics Clinic, University of Bari, Bari, Italy
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Tavares BVG, Delfino LS, Ignarro IS, Baccaro LF. Changing Paradigms in the Initial Treatment of Ectopic Pregnancy at a University Hospital in Brazil. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:192-200. [PMID: 37224841 PMCID: PMC10208733 DOI: 10.1055/s-0043-1768999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
OBJECTIVE To evaluate the use of different treatment options for ectopic pregnancy and the frequency of severe complications in a university hospital. METHODS Observational study with women with ectopic pregnancy admitted at UNICAMP Womeńs Hospital, Brazil, between 01/01/2000 and 12/31/2017. The outcome variables were the type of treatment (first choice) and the presence of severe complications. Independent variables were clinical and sociodemographic data. Statistical analysis was carried out by the Cochran-Armitage test, chi-square test, Mann-Whitney test and multiple Cox regression. RESULTS In total 673 women were included in the study. The mean age was 29.0 years (± 6.1) and the mean gestational age was 7.7 (± 2.5). The frequency of surgical treatment decreased significantly over time (z = -4.69; p < 0.001). Conversely, there was a significant increase in the frequency of methotrexate treatment (z = 4.73; p < 0.001). Seventy-one women (10.5%) developed some type of severe complication. In the final statistical model, the prevalence of severe complications was higher in women who were diagnosed with a ruptured ectopic pregnancy at admission (PR = 2.97; 95%CI: 1.61-5.46), did not present with vaginal bleeding (PR = 2.45; 95%CI: 1.41-4.25), had never undergone laparotomy/laparoscopy (PR = 6.69; 95%CI: 1.62-27.53), had a non-tubal ectopic pregnancy (PR = 4.61; 95%CI: 1.98-10.74), and do not smoke (PR = 2.41; 95%CI: 1.08-5.36). CONCLUSION there was a change in the first treatment option for cases of ectopic pregnancy in the hospital during the period of analysis. Factors inherent to a disease that is more difficult to treat are related to a higher frequency of severe complications.
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Affiliation(s)
| | - Letícia Sathler Delfino
- Department of Obstetrics and Gynecology, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | | | - Luiz Francisco Baccaro
- Department of Obstetrics and Gynecology, Universidade Estadual de Campinas, Campinas, SP, Brazil
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15
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Li YL, Chuang FC, Lan KC. Laparoscopic management of second trimester ruptured cornual heterotopic pregnancy with subsequent live birth delivery: A case report and literature review. Taiwan J Obstet Gynecol 2023; 62:363-368. [PMID: 36965911 DOI: 10.1016/j.tjog.2022.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 03/27/2023] Open
Abstract
OBJECTIVE Heterotopic pregnancy (HP) is the coexistence of extra- and intrauterine gestation implantation sites. A rare case of a second-trimester ruptured cornual HP (CHP) treated with laparoscopic cornual resection with the primary repair is presented. Risk factors, clinical presentations, treatments, and outcomes of CHPs are also reviewed. CASE REPORT A 35-year-old pregnant woman with CHP presented with lower abdominal pain with hemoperitoneum and her hemoglobin level dropped. Laparoscopic management of a ruptured HP was performed, leaving the surplus intrauterine fetus intact. She delivered a 2360 g male infant via cesarean section at 34 weeks' gestation due to preterm premature rupture of membranes. We found a well-healed wound over the left uterine cornua during the cesarean section. CONCLUSION Ruptured CHP is a rare but life-threatening complication of an obstetric emergency. Although the pregnant uterus becomes congested and fragile, using reliable laparoscopic energy devices and barbed sutures, successful treatment is feasible.
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Affiliation(s)
- Yi-Ling Li
- Department of Obstetrics and Gynecology, Jen Ai Hospital, Taichung 412, Taiwan; Department of Obstetrics and Gynecology, Chang Chung Memorial Hospital, Kaohsiung 833, Taiwan
| | - Fei-Chi Chuang
- Department of Obstetrics and Gynecology, Chang Chung Memorial Hospital, Kaohsiung 833, Taiwan
| | - Kuo-Chung Lan
- Department of Obstetrics and Gynecology, Jen Ai Hospital, Taichung 412, Taiwan; Department of Obstetrics and Gynecology, Chang Chung Memorial Hospital, Kaohsiung 833, Taiwan.
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16
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Elbiss HM, Al Tahrawi A, Abu-Zidan FM. Primary peritoneal ectopic pregnancy: A case report. Int J Surg Case Rep 2022; 102:107847. [PMID: 36599251 PMCID: PMC9823161 DOI: 10.1016/j.ijscr.2022.107847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 12/15/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Primary peritoneal ectopic pregnancy is a rare condition that can be life-threatening. Herein, we report such a case which was managed by laparoscopy. PRESENTATION OF THE CASE A 31-year-old G1P0 woman, who had a history of pelvic infection and primary infertility, presented with lower abdominal pain and mild vaginal spotting. Abdominal and bimanual pelvic examination revealed mild left pelvic tenderness. Her serum β-human chorionic gonadotropin (β-HCG) was 7247 IU. Transvaginal ultrasound demonstrated a mass measuring around 1.5 cm in diameter with a well-defined yolk sac adherent to the left ovary. A left fallopian tube ectopic pregnancy was suspected. Laparoscopy revealed that both fallopian tubes were normal and freely moving. Peritoneal ectopic pregnancy was seen behind the uterus which was removed laparoscopically. Histopathology confirmed the diagnosis. The patient had a smooth postoperative recovery. DISCUSSION Primary peritoneal pregnancy can be life-threatening. A thorough laparoscopic examination of the entire pelvis and abdomen should be done by an experienced surgeon when the location of the suspected ectopic pregnancy could not be identified. CONCLUSION Diagnostic laparoscopy for ectopic pregnancy should include the whole pelvis and the accessible part of the abdomen when the tubes and ovaries are normal.
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Affiliation(s)
- Hassan M. Elbiss
- Department of Obstetrics and Gyanecology, College of Medicine and Health Sciences United Arab Emirates University, Al-Ain, United Arab Emirates,Corresponding author.
| | - Abeer Al Tahrawi
- Department of Pathology, College of Medicine and Health Sciences United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Fikri M. Abu-Zidan
- Department of The Research Office, College of Medicine and Health Sciences United Arab Emirates University, Al-Ain, United Arab Emirates
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17
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Sánchez-Prieto M, Barbany N, Platón C, Barri-Soldevila P. Laparoscopic Cornual Resection of Interstitial Ectopic Pregnancy. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2022.0094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Manuel Sánchez-Prieto
- Department of Obstetrics and Gynecology, Instituto Universitario Dexeus, Barcelona, Spain
| | - Núria Barbany
- Department of Obstetrics and Gynecology, Instituto Universitario Dexeus, Barcelona, Spain
| | - Clara Platón
- Department of Obstetrics and Gynecology, Instituto Universitario Dexeus, Barcelona, Spain
| | - Pere Barri-Soldevila
- Department of Obstetrics and Gynecology, Instituto Universitario Dexeus, Barcelona, Spain
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18
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Yan Y, Jia Y, Lategan B, Alexander Z, Awadalla A, Goubran A. Acquired uterine arteriovenous malformation in a patient with cornual pregnancy: A case report. Medicine (Baltimore) 2022; 101:e31629. [PMID: 36451408 PMCID: PMC9704990 DOI: 10.1097/md.0000000000031629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Acquired uterine arteriovenous malformation (uAVM) is a rare disease and could occur after dilation and curettage, cesarean section, or neoplastic processes. PATIENT CONCERNS A 29-year-old female presented with acute right lower abdominal pain and positive beta human chorionic gonadotropin (β-hCG). DIAGNOSIS A 6 cm ectopic right cornual pregnancy was found on ultrasound examination. INTERVENTIONS She underwent a laparoscopic resection of the cornual ectopic pregnancy. She returned with extensive vaginal bleeding 6-month post surgery, and eventually diagnosed with arteriovenous malformation at the previous surgical site by Color Dopplor endovaginal ultrasound. Percutaneous transcatheter uterine artery embolization (UAE) was attempted, however, vaginal bleeding continued. She was taken to the operation room for a hysteroscopic ablation of uAVM. OUTCOMES Complete cessation of the bleeding was achieved without hysterectomy. CONCLUSION We report an extremely unusual case of acquired uAVM after a wedge resection of cornual pregnancy. Ultrasound evaluation of patients with post-operative persistent bleeding should be considered for evaluation of a possible arteriovenous malformation.
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Affiliation(s)
- Yi Yan
- Department of Radiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Yong Jia
- Department of Pathology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Belinda Lategan
- Department of Pathology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Zarine Alexander
- International Medical Graduate Programs, Room 260 Brodie Centre 727 McDermot Avenue, University of Manitoba, Winnipeg, MB, Canada
| | - Alaa Awadalla
- Obstetrics, Gynecology and Reproductive Sciences 260 Brodie Centre, 727 McDermot Avenue University of Manitoba, Bannatyne Campus Winnipeg, MB, Canada
| | - Ashraf Goubran
- Department of Radiology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Ultrasound Department, Radiology & Diagnostic Imaging, St. Boniface General Hospital, Winnipeg, MB, Canada
- *Correspondence: Ashraf Goubran, Ultrasound Department, Radiology & Diagnostic Imaging, St. Boniface General Hospital, 409 Taché Ave, Winnipeg, MB R2H2A6, Canada (e-mail: )
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Sorrentino F, Vasciaveo L, De Feo V, Zanzarelli E, Grandone E, Stabile G, Nappi L. Interstitial Pregnancy Treated with Mifepristone and Methotrexate with High Serum β-hCG Level in a Patient Wishing to Preserve Fertility: Time to Define Standardized Criteria for Medical/Surgical Therapy? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11464. [PMID: 36141736 PMCID: PMC9516977 DOI: 10.3390/ijerph191811464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 06/16/2023]
Abstract
Interstitial pregnancy (IP) accounts for 2% of all ectopic pregnancies and has a mortality rate of 2-2.5%. The diagnosis is made by a transvaginal ultrasound and the treatment can be medical or surgical. We report the case of a 36-year-old primigravida who was 6 + 5 weeks pregnant, diagnosed with interstitial pregnancy by ultrasound, who had a very high serum β-hCG level (31,298 mIU/mL) and wanted to preserve her fertility. The patient was treated with one dose of mifepristone and a double dose of methotrexate since the decrease in the β-hCG serum level was less than 15% after the first dose. At the beginning, medical therapy was effective, as no embryonal cardiac activity was detected and serum β-hCG levels decreased early, but on the 20th day of hospitalization, the patient underwent surgery for her clinical symptoms and the evidence of free fluid in the Douglas pouch at a transvaginal ultrasound exam. Our experience showed that medical treatment should be considered, especially in women wishing to preserve their fertility. Further studies are needed to establish a standardized protocol and maybe a clinical score that can be useful in predicting the patients in which medical therapy could be most successful.
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Affiliation(s)
- Felice Sorrentino
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71121 Foggia, Italy
| | - Lorenzo Vasciaveo
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71121 Foggia, Italy
| | - Vincenzo De Feo
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71121 Foggia, Italy
| | - Erika Zanzarelli
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71121 Foggia, Italy
| | - Elvira Grandone
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71121 Foggia, Italy
- Thrombosis and Haemostasis Unit, Fondazione IRCCS “Casa Sollievo della Sofferenza”, 71013 San Giovanni Rotondo, Italy
- Ob/Gyn Department of the First I.M. Sechenov Moscow State Medical University, 119991 Moscow, Russia
| | - Guglielmo Stabile
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34100 Trieste, Italy
| | - Luigi Nappi
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71121 Foggia, Italy
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20
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Tonick S, Conageski C. Ectopic Pregnancy. Obstet Gynecol Clin North Am 2022; 49:537-549. [PMID: 36122984 DOI: 10.1016/j.ogc.2022.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Ectopic pregnancy occurs in 2% of all pregnancies and is a potentially life-threatening emergency. A high level of clinical suspicion is required for any pregnant patient who presents with vaginal bleeding and/or pelvic pain. Workup should begin with immediate triage based on vital signs, a pregnancy test, and transvaginal ultrasound. Ectopic pregnancy can be treated either medically with methotrexate or surgically with either salpingectomy or salpingostomy. Carefully counseled, asymptomatic patients may be candidates for expectant management.
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Affiliation(s)
- Shawna Tonick
- Department of OB-GYN, University of Colorado, 12631 East 17th Avenue, AO1, 4th Floor, Aurora, CO 80045, USA.
| | - Christine Conageski
- Department of OB-GYN, University of Colorado, 12631 East 17th Avenue, AO1, 4th Floor, Aurora, CO 80045, USA
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21
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Restaino S, De Gennaro E, Floris S, Stabile G, Zinicola G, Sorrentino F, Vizzielli G, Driul L. Surgical Treatment Following Failed Medical Treatment of an Interstitial Pregnancy. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58070937. [PMID: 35888656 PMCID: PMC9316431 DOI: 10.3390/medicina58070937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 11/30/2022]
Abstract
Interstitial pregnancy (IP) is a type of ectopic pregnancy in which the embryo implants in the interstitial part of the Fallopian tube. It accounts for 2% of all ectopic pregnancies. Signs and symptoms appear later than the other forms of ectopic pregnancies because of its peculiar location. The gold standard for its diagnosis is transvaginal ultrasound. The treatment can be medical or surgical. Medical treatment is based on the systemic or local injection of methotrexate (MTX); a dose of mifepristone can be added with a reported 85–90% success rate. The surgical option is laparoscopic unilateral cornuostomy or unilateral salpingectomy. The therapeutic choice is based on symptoms, serum β-human chorionic gonadotropin (β-hCG) values, and sonographic features. Furthermore, the patient’s fertility perspectives should be considered. We report a case of IP in a Caucasian woman of 29 years old, with a previous salpingectomy for ectopic pregnancy medically treated by a double dose of intramuscular MTX 50 mg/m2 combined with a single dose of leucovorin 15 mg and a single dose of mifepristone 600 mg orally. Medical therapy failed as suggested by the sudden onset of intense pelvic pain after 10 days. Because of the clinical symptoms and the sonographic suspicious of pregnancy rupture due to the modest amount of fluid in the pouch of Douglas, clinicians decided on an urgent unilateral laparoscopic salpingectomy. The hemoperitoneum was drained. The patient was discharged two days later and β-hCG serum levels became negative after 45 days. The advantages of fertility sparing should be weighted according to the patient’s reproductive perspectives. Appropriate counseling is therefore key in managing the treatment of interstitial pregnancy.
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Affiliation(s)
- Stefano Restaino
- Obstetrics and Gynecology Unit, Department of Obstetrics, Gynecology and Pediatrics, Department of Medical Area DAME, Udine University Hospital, 33100 Udine, Italy; (S.R.); (S.F.)
| | - Elena De Gennaro
- Clinic of Obstetrics and Gynecology, Department of Medical Area (DAME), Hospital of Udine, University of Udine, 33100 Udine, Italy; (E.D.G.); (G.V.); (L.D.)
| | - Stefano Floris
- Obstetrics and Gynecology Unit, Department of Obstetrics, Gynecology and Pediatrics, Department of Medical Area DAME, Udine University Hospital, 33100 Udine, Italy; (S.R.); (S.F.)
| | - Guglielmo Stabile
- Institute for Maternal and Child Health IRCCS “Burlo Garofolo”, 34100 Trieste, Italy;
| | - Giulia Zinicola
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34100 Trieste, Italy;
| | - Felice Sorrentino
- Department of Medical and Surgical Sciences, University of Foggia, 71100 Foggia, Italy
- Correspondence:
| | - Giuseppe Vizzielli
- Clinic of Obstetrics and Gynecology, Department of Medical Area (DAME), Hospital of Udine, University of Udine, 33100 Udine, Italy; (E.D.G.); (G.V.); (L.D.)
| | - Lorenza Driul
- Clinic of Obstetrics and Gynecology, Department of Medical Area (DAME), Hospital of Udine, University of Udine, 33100 Udine, Italy; (E.D.G.); (G.V.); (L.D.)
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22
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Feng Q, Zhong J, Liu Y, Li ST, Zong L. Surgical treatment of interstitial pregnancy without cornual resection: A case report. Medicine (Baltimore) 2022; 101:e29730. [PMID: 35777020 PMCID: PMC9239671 DOI: 10.1097/md.0000000000029730] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Interstitial pregnancy (IP) is a rare but extremely life-threatening form of ectopic pregnancy. The traditional surgical treatment for this anomaly is the resection of uterine cornua or fallopian tubes, which often damages their structural integrity, thereby compromising the reproductive potential for women who wish to preserve fertility. PATIENT CONCERNS A 33-year-old female was admitted to our hospital with suspected ectopic pregnancy, following a 4-weeks history of positive pregnancy tests after uterine evacuation. The patient was hemodynamically stable on arrival. Ultrasound revealed an empty uterus with an eccentric gestational sac located at the fundus and surrounded by a thin myometrium, indicative of a suspected interstitial pregnancy. DIAGNOSIS AND INTERVENTION After failed attempt at medical management with a single dose of intramuscular methotrexate, the patient was arranged for hysteroscopy-assisted laparoscopy. In surgery, the uterine cavity appeared empty, and a 2 × 2 cm bulge with increased vascularity at the right uterine courna was identified upon examination. The gestational sac was aspirated through the vagina from the right ostium of the uterine tube using a suction curette pointing at the right ostium. Sutures were not needed afterward, and the myometrial anatomy was left undisrupted. The diagnosis of IP was confirmed by the postoperative histological report. OUTCOMES Perioperative blood loss was approximately 10 ml and the operative time was 40 minutes. The patient had an uneventful postoperative recovery and was discharged after 3 days. Subsequent follow-ups showed a significant reduction in the patient serum beta hCG to 48IU/L within 5 days postoperation, and a negative result after 7 days. LESSONS This novel surgical technique is an alternative minimally-invasive approach for selected early diagnosed and hemodynamically stable IP patients. The technique represents a safe, quick, and simple approach combining the benefits of laparoscopy, such as allowing for immediate conversion of cornuectomy when uterus ruptures, and the benefits of suction curettage, such as shorter operative time and minimal blood loss. We believe patients with interstitial pregnancy who still have fertility wishes would benefit from this surgical technique to a larger extent in the future.
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Affiliation(s)
- Qian Feng
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Jie Zhong
- Department of Gynaecology, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yujie Liu
- Department of Medical Imaging, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shu-Ting Li
- Department of Gynaecology, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Lili Zong
- Department of Gynaecology, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- *Correspondence: Lili Zong, Department of Gynaecology, the First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China (e-mail: )
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23
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Li PC, Lin WY, Ding DC. Risk factors and clinical characteristics associated with a ruptured ectopic pregnancy: A 19-year retrospective observational study. Medicine (Baltimore) 2022; 101:e29514. [PMID: 35713461 PMCID: PMC9276220 DOI: 10.1097/md.0000000000029514] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 05/06/2022] [Indexed: 11/25/2022] Open
Abstract
Ectopic pregnancy is the most common cause of maternal mortality in the first trimester of pregnancy. The aim of this study was to find risk factors and clinical characteristics associated with ruptured ectopic pregnancies at a medical center in eastern Taiwan in a 19-year period. This was a retrospective observational study that included patients diagnosed with ectopic pregnancy between August 1999 and December 2018. Data about the demographic variables, initial presentation, pre-treatment beta-human chorionic gonadotropin levels, treatment routes (laparoscopy or laparotomy), surgical methods (salpingostomy or salpingectomy), operation time, blood loss amount, the status of ectopic pregnancy (ruptured or unruptured), the requirement for transfusion, and duration of hospital stay were collected. The categorical and continuous variables were analyzed using the correlation coefficients. This study included 225 women who were diagnosed as having an ectopic pregnancy. There were 49 and 176 women with unruptured and ruptured ectopic pregnancies, respectively. The beta-human chorionic gonadotropin levels, history of previous ectopic pregnancy, pelvic inflammatory disease, tubal surgery, abdominal history, and vaginal bleeding were not significantly different between the 2 groups. The ratio of women with abdominal pain was significantly higher in the ruptured ectopic pregnancy group than in the unruptured group (89.1% vs. 63.8%, respectively, P < .001). Preoperative hemoglobin was lower in the ruptured group compared with the unruptured group (P < .001). Blood loss, postoperative hemoglobin, and blood transfusion were significantly higher in the ruptured group than in the unruptured group (P = .000 and P = .001 for blood loss and blood transfusion, respectively). Multiple logistic regression analysis revealed that abdominal pain and blood loss were associated with ruptured tubal pregnancies (adjusted odds ratio [95% confidence intervals]: 3.42 {1.40, 8.40}; 1.01 {1.005, 1.014}, respectively). In conclusion, early pregnancy with abdominal pain, more parity, and lower preoperative hemoglobin should be aware of the possibility of ruptured ectopic pregnancy. More blood loss, transfusion and lower postoperative hemoglobin were also noted with ruptured ectopic pregnancy.
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Affiliation(s)
- Pei-Chen Li
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Foundation, and Tzu Chi University, Hualien, Taiwan
| | - Wen-Yu Lin
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Foundation, and Tzu Chi University, Hualien, Taiwan
| | - Dah-Ching Ding
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Foundation, and Tzu Chi University, Hualien, Taiwan
- Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
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Using MRI to differentiate upper-lateral intracavitary pregnancy and interstitial pregnancy for the patients with pregnancies in the uterotubal junction during the first trimester. Eur Radiol 2022; 32:6619-6627. [PMID: 35441841 PMCID: PMC9474412 DOI: 10.1007/s00330-022-08786-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 03/24/2022] [Accepted: 03/31/2022] [Indexed: 11/04/2022]
Abstract
Objectives To retrospectively evaluate the diagnostic value of MRI for the uterotubal junctional pregnancies during the first trimester. Methods This retrospective study involved 59 patients (January 2016 to July 2021) with a preoperative imaging diagnosis of uterotubal junctional pregnancy. Using operative and pathological reports as the reference standard, we identified 22 patients with upper-lateral intracavitary (angular) pregnancy and 37 patients with interstitial pregnancy. Two senior radiologists, blinded to the patients’ information, reviewed the MRI images and determined each MRI feature based on the original interpretation criteria. Any disagreement was resolved by discussion to achieve a consensus. The sensitivity and specificity of each MRI feature were calculated according to the reference standard. Results The endometrial thickness in the upper-lateral intracavitary pregnancy group was larger than in the interstitial group (p = 0.001). The cutoff value of the endometrial thickness was 11.5 mm with a sensitivity, specificity, and area under the curve that were 77.3%, 64.9%, and 0.743, respectively. Two key features to diagnose upper-lateral intracavitary pregnancy were “medial free edge” and “medial free edge plus above-cutoff endometrial thickness.” The sensitivity and specificity of the medial free edge were 100% and 94.9%, respectively. The sensitivity and specificity of the medial free edge plus above-cutoff endometrial thickness were 77.3% and 100%, respectively. The key feature to diagnose interstitial pregnancy was an “intact lateral junctional zone,” of which the sensitivity and specificity were 94.6% and 100%, respectively. Conclusions MRI can be used to differentiate the upper-lateral intracavitary pregnancy and interstitial pregnancy during the first trimester. Key Points • We demonstrated MRI diagnostic criteria for the interstitial pregnancy and upper-lateral intracavitary pregnancy. • MRI might be used to identify the complex interstitial pregnancies, those with a gestational sac protruding into the uterine cavity.
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Grandelis A, Shaffer R, Tonick S. Uncommon Presentations of Ectopic Pregnancy. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2022.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Anthony Grandelis
- Department of Obstetrics and Gynecology, University of Colorado, Aurora, Colorado, USA
| | - Robyn Shaffer
- Department of Obstetrics and Gynecology, University of Colorado, Aurora, Colorado, USA
| | - Shawna Tonick
- Department of Obstetrics and Gynecology, University of Colorado, Aurora, Colorado, USA
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26
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Near fatal interstitial pregnancy: A case report. Am J Emerg Med 2022; 57:235.e5-235.e8. [DOI: 10.1016/j.ajem.2022.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/28/2022] [Accepted: 04/07/2022] [Indexed: 11/22/2022] Open
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Factors Associated with Ruptured Ectopic Pregnancy: A 10-Year Review at a District Hospital in Ghana. Obstet Gynecol Int 2022; 2022:1491419. [PMID: 35295562 PMCID: PMC8920631 DOI: 10.1155/2022/1491419] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/20/2022] [Accepted: 02/11/2022] [Indexed: 11/17/2022] Open
Abstract
Background Approximately 1–2% of all pregnancies are ectopic. Despite a decline in ectopic pregnancy-related mortality, there is still a paucity of information on the factors associated with clinical presentation and outcomes in Sub-Saharan Africa which is essential in determining the most appropriate treatment modalities. Methods We performed a ten-year retrospective chart review of cases of ectopic pregnancies managed at the Lekma hospital and assessed them for peculiar risk factors, clinical presentation, and outcomes. Associations between patients' sociodemographic characteristics, clinical presentation, and treatment outcome were evaluated using multiple logistic regression and reported as adjusted odds ratios (AOR). The confidence interval (CI) was set at 95%, and a p value <0.05 were considered significant. Results Over the ten-year period, there were 115 ectopic pregnancies and 14,450 deliveries (7.9/1,000). The mean age ± standard deviation of the 115 patients was 27.61 ± 5.56. More than half of the patients were single (59/115, 51.3%). The majority (71.3%) of the patients presented with a ruptured ectopic pregnancy. After adjusting for covariates, the odds of an ectopic pregnancy presenting as ruptured among single patients was 2.63 times higher than that of married patients (AOR = 3.63, 95% CI: 1.33–9.93, p=0.01). Ectopic pregnancies located in the isthmic region of the tube had a 77% lower odds of presenting as ruptured than those located in the ampullary region (AOR = 0.23, 95% CI: 0.07–0.74, p=0.01). The odds of rupturing were 1.69 times increased for every additional week after the missed period (AOR = 2.69, 95% CI: 1.56–4.64, p < 0.01). No mortalities were reported as a result of an ectopic pregnancy. Conclusion Most of the cases of ectopic pregnancy presented ruptured. Marital status and period of amenorrhoea were significantly associated with rupture.
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Tang S, Du T, Huang J, Ye H, Zhao M, Lin J, Kuang Y. Effect of previous wedge resection for interstitial pregnancy on pregnancy and neonatal outcomes following frozen-thawed embryo transfer (FET) cycles of IVF/ICSI: a retrospective study. Reprod Biol Endocrinol 2022; 20:23. [PMID: 35105356 PMCID: PMC8805226 DOI: 10.1186/s12958-022-00896-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/17/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The present study aimed to evaluate pregnancy and neonatal outcomes in women, with a previous history of wedge resection for interstitial pregnancy, in frozen-thawed embryo transfer (FET) cycles of IVF/ICSI. METHODS The present study involved a retrospective case-control assessment of 75 cases and 375 control subjects over 6 years in a single center. To compare pregnancy and neonatal outcomes between cases, treated using wedge resection, and controls without any previous history of ectopic pregnancy, propensity score matching (1:5) was utilized. The study also compared subgroups in the case group. RESULTS Women with previous wedge resection exhibited higher rates of ectopic pregnancy and uterine rupture rate as compared to control subjects (9.1% vs 1.3%, P = 0.025 and 4.5% vs 0%, P = 0.035, respectively). No statistically significant differences were recorded between the two cohorts with regard to clinical pregnancy rate, live birth rate, and neonatal outcomes. For pregnancy type subgroup analysis, Z-score and rates of large for gestational age were recorded to be significantly lower in twin pregnancy subgroup when compared with singleton pregnancy subgroup (0.10 (- 0.59, 0.25) vs 0.50 (- 0.97, 1.39), P = 0.005; 4.5% vs 26.1%, P = 0.047, respectively). CONCLUSION The results of the present study indicated that previous wedge resection correlated to a higher risk of ectopic pregnancy and uterine rupture. However, it might not be related to an increased risk of adverse neonatal outcomes. The study recommended cesarean section in these patients. Further studies are required to verify the validity of current recommendations.
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Affiliation(s)
- Shengluan Tang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Rd, Shanghai, 200011, China
| | - Tong Du
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Rd, Shanghai, 200011, China
| | - Jialyu Huang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Rd, Shanghai, 200011, China
| | - Hongjuan Ye
- Department of Reproductive Medicine Center, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ming Zhao
- Shanghai Towako Hospital, No. 477, Fute West 1st Road, Shanghai, China
| | - Jiaying Lin
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Rd, Shanghai, 200011, China.
| | - Yanping Kuang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Rd, Shanghai, 200011, China.
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Cillard L, Dabi Y, Fernandez H, Lavoué V, Timoh KN, Thubert T, Bouet PE, Legendre G. Management of non-tubal ectopic pregnancies in France: Results of a practice survey. J Gynecol Obstet Hum Reprod 2022; 51:102330. [DOI: 10.1016/j.jogoh.2022.102330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 01/30/2022] [Accepted: 01/31/2022] [Indexed: 11/26/2022]
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Papiccio M, Boschi AC, Ferrara F, Missiroli S, Zagonari S, Paganotto MC, Comerci G. Spontaneous angular dichorionic diamniotic twin pregnancy: a case report. Fertil Steril 2021; 117:155-159. [PMID: 34961613 DOI: 10.1016/j.fertnstert.2021.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 09/03/2021] [Accepted: 09/03/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To report a peculiar case of ultrasound diagnosis of spontaneous angular twin pregnancy. In literature, the terms "angular," "interstitial," and "cornual" pregnancies are often used inappropriately. Confusion in terminology may have contributed to difficulties in developing diagnostic ultrasound criteria to differentiate these ectopic pregnancies. DESIGN Case report. SETTING Obstetrics and Gynecology, Community Hospital "S. Maria delle Croci." PATIENT A 28-year-old patient with a previous cesarean delivery was admitted to our hospital for management of a presumed angular ectopic pregnancy. Transvaginal ultrasound confirmed an ectopic dichorionic diamniotic twin pregnancy eccentrically located in the right superior angle of the uterine cavity: the first gestational sac appeared to have right angular implantation, whereas the second gestational sac seemed to deepen inside the myometrium, with a thin myometrial margin of only 3 mm. INTERVENTIONS After discussing the risks, the patient requested to proceed with termination. A single intramuscular injection of 75 mg of methotrexate was administered, followed by ultrasound-guided hysterosuction after 19 days due to severe vaginal bleeding. MAIN OUTCOME MEASURES An early and accurate ultrasound diagnosis of a high-risk condition allowed for conservative medical treatment. RESULTS The serum beta-human chorionic gonadotropin levels progressively decreased. After 1 month, a clinical and ultrasound examination showed a regular endometrial line with a regular reappearance of menstrual bleeding. CONCLUSIONS Although there are remarkable advances in ultrasound techniques, angular pregnancy remains a condition of difficult diagnosis and management; it is potentially dangerous and may lead to severe complications. An early and accurate diagnosis of this condition is necessary to avoid complications and individualize the subsequent management.
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Affiliation(s)
- Maria Papiccio
- Obstetrics and Gynecology, Hospital "S. Maria delle Croci," Ravenna, Italy.
| | - Anna Chiara Boschi
- Obstetrics and Gynecology, Hospital "S. Maria delle Croci," Ravenna, Italy
| | - Filippo Ferrara
- Obstetrics and Gynecology, Hospital "S. Maria delle Croci," Ravenna, Italy
| | - Stefano Missiroli
- Obstetrics and Gynecology, Hospital "S. Maria delle Croci," Ravenna, Italy
| | - Sara Zagonari
- Obstetrics and Gynecology, Hospital "S. Maria delle Croci," Ravenna, Italy
| | | | - Giuseppe Comerci
- Obstetrics and Gynecology, Hospital "S. Maria delle Croci," Ravenna, Italy
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Mittal S, Shekhar B. Large Interstitial Ectopic Pregnancy: Management by Laparoscopic Cornuostomy Following Initial Misdiagnosis. Cureus 2021; 13:e19280. [PMID: 34877222 PMCID: PMC8645184 DOI: 10.7759/cureus.19280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2021] [Indexed: 11/20/2022] Open
Abstract
The purpose of the present report is to highlight the challenges in diagnosing interstitial ectopic pregnancy and to describe its management by laparoscopic cornuostomy. A 28-year-old gravida 3, para 1 woman was referred to us at 12 weeks period of gestation after failed medical termination following a diagnosis of missed abortion. On presenting to us, a large interstitial ectopic pregnancy was diagnosed by ultrasonography and managed by laparoscopic cornuostomy. Intra myometrial vasopressin and purse string sutures at the base of ectopic pregnancy bulge were used to reduce intra-operative bleeding. Intra-operative blood loss was 50 ml. Patient was discharged after two days of surgery. Interstitial pregnancy may be misdiagnosed as an intrauterine pregnancy, due to lack of suspicion and expertise. Large interstitial ectopic pregnancies can be successfully managed by a conservative surgical approach such as laparoscopic cornuostomy instead of cornual resection or hysterectomy.
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Affiliation(s)
- Shweta Mittal
- Centre of IVF and Human Reproduction, Department of Obstetrics and Gynaecology, Sir Gangaram Hospital, New Delhi, IND
| | - Bhawani Shekhar
- Centre of IVF and Human Reproduction, Department of Obstetrics and Gynaecology, Sir Gangaram Hospital, New Delhi, IND
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Al Dus G, Alhamoud AU, Ata Allah N, Alabdalla J. Two embryos did not implant into the womb. A rare case of non-iatrogenic bilateral ectopic pregnancy (two-tailed tubal ectopic pregnancy) case report. Ann Med Surg (Lond) 2021; 71:102840. [PMID: 34745598 PMCID: PMC8554463 DOI: 10.1016/j.amsu.2021.102840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/07/2021] [Accepted: 09/07/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction and importance Bilateral ectopic pregnancy is one of the rarest forms of ectopic pregnancy due to the difficulty of diagnosis and interference before surgery, where ectopic pregnancy cases are clinically indistinguishable from unilateral ectopic pregnancy, and many cases are discovered by chance during surgery. The Importance of this report comes from the history of a patient with four cesarean sections, who developed two-tailed tubal ectopic pregnancy without ovulation induction or any contraception methods. Case presentation Our patient after admission to the emergency department was diagnosed with a unilateral GS = 9W ectopic pregnancy in the right fallopian tube based on Doppler echography. However, during the surgery, the surgeon discovered a rupture in the left tube, which was discovered to be another left fallopian ectopic pregnancy confirmed by pathology. Clinical Discussion Our patient presented with typical symptoms of ectopic pregnancy confirmed by BHCG blood test and Doppler ultra sound but the untypical finding of bilateral ectopic pregnancy without suggestive history couldn't be discovered until laparatomy Conclusion This case reminds us to always check both adnexa before making any decisions and because of the poor presurgical diagnosis of EP, it highlights the importance of human resources and equipment which could save our patients fertility. Conclusion To preserve the integrity of the organs and the patient's future fertility the doctor who diagnoses a tubal ectopic pregnancy should always check the other tube before taking action even if the suspicion is not due to the induction of ovulation, and never fully trust imaging study only as an aiding tool to make a diagnosis; nevertheless, the patient could have been better managed and her fertility saved if better capabilities were available. Never exclude any rare pathology. Always check both adnexa before making any decisions. Never fully trust imaging study only as an aiding tool to make a differential diagnosis. Even if we have a lack of resources we should try to save the patient's fertility.
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Affiliation(s)
| | | | - Nada Ata Allah
- Department of Gynecology, Aleppo University Hospital, Aleppo, Syria
| | - Joryya Alabdalla
- Department of Gynecology, Aleppo University Hospital, Aleppo, Syria
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Mansour M, Hamza A, AlMarzook A, kanbour IM, Alsuliman T, kurdi B. A ruptured cornual pregnancy successfully managed in a patient with a history of oophorectomy and salpingectomy: A rare case report. Clin Case Rep 2021; 9:e04934. [PMID: 34691456 PMCID: PMC8517584 DOI: 10.1002/ccr3.4934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 09/13/2021] [Accepted: 09/27/2021] [Indexed: 11/11/2022] Open
Abstract
Cornual pregnancy is a rare condition that accounts for approximately 2-4% of ectopic pregnancies worldwide. Herein, we report an unstable case of a 32-year-old woman with a history of oophorectomy and salpingectomy who was admitted for a ruptured cornual pregnancy in the left cornu, which was successfully managed by laparotomy.
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Affiliation(s)
- Marah Mansour
- Faculty of MedicineTartous UniversityTartousSyrian Arab Republic
| | - Amr Hamza
- Faculty of MedicineAleppo UniversityAleppoSyrian Arab Republic
| | - AlHomam AlMarzook
- Department of NeurosurgeryIbn Al‐Nafees HospitalDamascusSyrian Arab Republic
| | - Ilda moafak kanbour
- Department of Obstetrics and GynecologyMaternity HospitalDamascusSyrian Arab Republic
| | - Tamim Alsuliman
- Hematology and Cell Therapy DepartmentSaint‐Antoine HospitalAP‐HPSorbonne UniversityParisFrance
| | - Bashar kurdi
- Chair of Department of Obstetrics and GynecologyMaternity HospitalDamascusSyrian Arab Republic
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Lee HM, Liu YC, Lee WJ. A Pregnant Woman With Sudden Abdominal Pain. Ann Emerg Med 2021; 78:e63-e64. [PMID: 34563309 DOI: 10.1016/j.annemergmed.2021.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Hsin-Min Lee
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu-Chang Liu
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Wei-Jing Lee
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan
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Interstitial Ectopic Pregnancy: The Role of Mifepristone in the Medical Treatment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18189781. [PMID: 34574706 PMCID: PMC8472240 DOI: 10.3390/ijerph18189781] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 09/15/2021] [Indexed: 02/04/2023]
Abstract
Interstitial pregnancy is defined as the presence of a gestational sac in the most proximal section of the fallopian tube. Management of interstitial pregnancy remains a debated topic. Depending on hemodynamic stability, size of pregnancy, depth of surrounding myometrium, and desires for future fertility, interstitial pregnancy can be managed medically or surgically. We reviewed the literature in December 2020 using keywords “interstitial pregnancy”, “medical treatment”, “methotrexate”, and “mifepristone”. Articles published from January 1991 until 2020 were obtained from databases EMBASE, SCOPUS, and PUBMED. We describe the case of a patient with an interstitial pregnancy that was managed with a total medical approach in August 2020 at Burlo Garofolo Hospital. The patient was asymptomatic and hemodynamically stable, with a high level of serum β-hCG (22,272 mUi/mL). We used the combination of methotrexate (MTX) and mifepristone. Medical therapy was effective leading to interstitial pregnancy resolution in 51 days without collateral effects for the patient. We found seven previous cases reported in the literature. Our purpose is to underline the efficacy of medical therapy with systemic multidose MTX associated with a single oral dose of mifepristone and also folinic acid when is present a viable fetus and a high serum β-hCG level.
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Jomaa S, Ahmad A, Adwan D. Successful diagnosis and management of prerupture rudimentary horn pregnancy in the second trimester: a case report. Radiol Case Rep 2021; 16:3068-3071. [PMID: 34429804 PMCID: PMC8365452 DOI: 10.1016/j.radcr.2021.07.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 07/18/2021] [Accepted: 07/18/2021] [Indexed: 11/21/2022] Open
Abstract
Rudimentary horn pregnancy has concerns due to the high incidence of an extreme risk of a life-threatening rupture. Thus, early diagnosis and management are essential to preserving the patient's life. We present a successful diagnosis and management of a prerupture rudimentary horn pregnancy in a 24-year-old woman presented with chronic pelvic pain and amenorrhea for the last 3 months. On physical examination, she had a mobile, nontender mass equals 16 weeks of gestation. Transvaginal ultrasound revealed an empty uterus with signs of a decidual reaction and a gestational sac adjacent to the uterus and surrounded by less than a 2 mm-in-thickness muscular wall with a positive fetal heart rate. The gestational age was 16 weeks based on biparietal diameter and femur length. Based on these findings rudimentary horn pregnancy was suspected. Laparotomy was performed, unicornuate uterus with unruptured, left rudimentary horn pregnancy was observed, and the pregnant horn with the ipsilateral tube was excised. To conclude, an empty uterus and extrauterine gestational sac surrounded by a thin muscular wall (<2 mm) on ultrasound should raise the suspicion of rudimentary horn pregnancy.
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Affiliation(s)
- Sami Jomaa
- Faculty of Medicine, Damascus University, Damascus, 97009 Syria
| | - Afaf Ahmad
- Faculty of Medicine, Damascus University, Damascus, 97009 Syria
| | - Dema Adwan
- Department of Emergency, University Hospital of Obstetrics and Gynecology, Damascus University, Damascus, 97009 Syria
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Operative hysteroscopy in the minimally invasive management of interstitial pregnancy and interstitially retained products of conception: A case report and systematic literature review. Eur J Obstet Gynecol Reprod Biol 2021; 265:54-59. [PMID: 34428687 DOI: 10.1016/j.ejogrb.2021.07.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 07/07/2021] [Accepted: 07/12/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE An interstitial pregnancy is a rare form of ectopic pregnancy. Diagnosis and management can be challenging. Treatment often involves invasive uterine surgery. Conservative options such as methotrexate are important alternatives nowadays. The aim of this review is to investigate the role of operative hysteroscopy in the organ and fertility preserving management of interstitial pregnancy and interstitially retained products of conception (RPOC). METHODS A case is presented in which interstitially RPOC were removed using hysteroscopic morcellation under laparoscopic guidance. Consequently, a systematic literature review was performed.Medline, Embase and The Cochrane Library were used as literature resources. RESULTS In the literature review, 14 case reports in which operative hysteroscopy was part of the minimally invasive treatment of interstitial pregnancy and interstitially RPOC of which 11 were studied. Of these 14 cases, 11 were reported as being successful. Different techniques such as laparoscopy and suction curettage were associated. Various hysteroscopic instruments were used, hysteroscopic graspers most commonly. Reported complications were uterine perforation during suction curettage and incomplete hysteroscopic resection. Analysis of the cases did not demonstrate a clear difference between different approaches concerning safety, efficacy or subsequent fertility and pregnancy outcomes. CONCLUSION With the growing experience in hysteroscopy and the development of novel techniques and devices, such as hysteroscopic morcellation, operative hysteroscopy has a promising role in the minimally invasive management of interstitial pregnancy and interstitially RPOC. (Laparoscopically guided) operative hysteroscopy might be a convenient approach to avoid blind curettage and related complications such as uterine perforation.
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Niu X, Tang Y, Li S, Ni S, Zheng W, Huang L. The feasibility of laparoscopically assisted, hysteroscopic removal of interstitial pregnancies: A case series. J Obstet Gynaecol Res 2021; 47:3447-3455. [PMID: 34227727 DOI: 10.1111/jog.14924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/15/2021] [Accepted: 06/26/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The study objective was to assess the feasibility of the management of interstitial pregnancy by laparoscopically assisted hysteroscopic removal. METHODS This retrospective study included a case series of 17 patients who were diagnosed interstitial pregnancy with dilated proximal tubal ostium by transvaginal ultrasonography at the Women's hospital, School of Medicine, Zhejiang University between August 2017 and October 2020. Laparoscopically assisted hysteroscopic removals of the products of conception were performed. Various data were collected including age, surgical and obstetric history, gestational age, preoperative symptoms, human chorionic gonadotropin level and ultrasonography results. The outcomes measured were intraoperative bleeding, pathologic findings, conversions. RESULTS Eleven cases were successfully resected the interstitial gestational products with laparoscopically assisted hysteroscopy. There were four cases failed of hysteroscopic removal, for the proximal tubal ostia were too small for the surgical instruments to enter. Then cornual wedge resections were performed. Two cases were identified as intramural pregnancy by hysteroscopic and laparoscopic view. Most of the intramural pregnancy tissue of one patient was removed by hysteroscopy. The other one converted to laparoscopy. CONCLUSION Laparoscopically assisted hysteroscopic management could be a feasible surgical option to interstitial pregnancies. Further clinical studies are needed to establish detailed criteria to select the appropriate cases for hysteroscopic management.
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Affiliation(s)
- Xiaocen Niu
- Women's Hospital, School of Medicine, Zhejiang University, Zhejiang, P.R. China
| | - Yibo Tang
- Women's Hospital, School of Medicine, Zhejiang University, Zhejiang, P.R. China
| | - Songyue Li
- Women's Hospital, School of Medicine, Zhejiang University, Zhejiang, P.R. China
| | - Shanshan Ni
- Women's Hospital, School of Medicine, Zhejiang University, Zhejiang, P.R. China
| | - Wanren Zheng
- Women's Hospital, School of Medicine, Zhejiang University, Zhejiang, P.R. China
| | - Lili Huang
- Women's Hospital, School of Medicine, Zhejiang University, Zhejiang, P.R. China
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Restaino S, Vidiri A, Anchora Pedone L, Finelli A, Distefano M, Scambia G. Recurrent ectopic pregnancy on tubal remnant treated by laparoscopic resection: loop and stitch. Facts Views Vis Obgyn 2021; 13:183-186. [PMID: 34184849 PMCID: PMC8291983 DOI: 10.52054/fvvo.13.2.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Ectopic pregnancies occur in about 1-2 % of all pregnancies, with a high rate of maternal mortality due to bleeding caused by the rupture of the ectopic pregnancy. Ipsilateral ectopic pregnancy on a tubal remnant after salpingectomy is rare and it is associated with a higher mortality rate when compared to other ectopic pregnancies. Diagnosis and treatment of these pregnancies can be difficult, requiring a multidisciplinary management to plan the best treatment for the patient. The objective of this video is to show the laparoscopic removal of a tubal pregnancy on the stump of a previous salpingectomy with the application of three laparoscopic rings/endoloops ® to isolate the tubal portion from the uterus.
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Nezhat C, Youssef Y, Toledo AA. Hysteroscopy-assisted laparoscopic salpingectomy for interstitial pregnancy without cornual resection. Fertil Steril 2021; 116:909-911. [PMID: 34116833 DOI: 10.1016/j.fertnstert.2021.05.082] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/23/2021] [Accepted: 05/07/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To illustrate a novel surgical management technique for interstitial ectopic pregnancies (IP). DESIGN Video description of the case, demonstration of the surgical technique, reevaluation at the 6-week postoperative follow-up, and review of the advantages of this surgical technique for IP. SETTING Tertiary referral center. PATIENT(S) A 42-year-old gravida 2 para 1-0-0-1, underwent a successful in vitro fertilization (IVF) cycle with a single embryo transfer and had an early ultrasound diagnosis of IP with cardiac activity. After failed medical management with a single dose of methotrexate, she was referred to us for surgical management. Transvaginal ultrasound revealed fluid in the cul-de-sac and confirmed a right interstitial ectopic pregnancy with an estimated gestational age of 6 weeks. The myometrium at the periphery of the implantation site was 1-1.5 mm, and the "interstitial line sign" was seen. After counseling for possible treatment modalities, the patient opted for surgical management, planning for further IVF treatment. Her preoperative β-human chorionic gonadotropin level (β-hCG) was 3241 IU/L. Her surgical history was significant for a previous myomectomy via laparotomy and an elective lower transverse C-section. INTERVENTION(S) Hysteroscopy assisted by multipuncture video laparoscopy surgery was performed. Hysteroscopic resection was not feasible as the ectopic was not visualized as described previously. Using normal saline as the distension media and with the hysteroscope aimed at the right ostium, the hydrostatic pressure was increased transiently to dissect the ectopic pregnancy and facilitate the next surgical step. Laparoscopically, the ectopic pregnancy was milked with atraumatic graspers and mobilized from the cornua into the tube creating enough proximal length for salpingectomy. Right salpingectomy was achieved using high-frequency bipolar with no complications. MAIN OUTCOME MEASURE(S) Hysteroscopy-assisted laparoscopy technique allows for several advantages, including a short operative time and minimal blood loss. No sutures were required and the myometrial architecture was left undisrupted. RESULT(S) The postoperative course was uncomplicated, and the patient was discharged on the same day of surgery. The patient's β-hCG level dropped from 3,241 to 139 IU/L after 48 hours. Two weeks later, the β-hCG level was 3 IU/L. A follow-up ultrasound was performed six weeks postoperatively confirming the integrity of the myometrium without defects and proportional wall thickness on both sides. The patient was referred back to her infertility specialist to resume IVF treatment with no remarkable delay. CONCLUSION(S) In select cases and the presence of a proficient laparoscopic surgeon, early diagnosed IP can be removed safely using the described novel technique. While an interval conception of 3-6 months is recommended after conventional surgical procedures for IP, this technique can be comparable to salpingectomy.
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Affiliation(s)
- Ceana Nezhat
- Atlanta Center for Minimal Invasive Surgery and Reproductive Medicine, Atlanta, Georgia.
| | - Youssef Youssef
- Department of Obstetrics and Gynecology, Hurley Medical Center, Michigan State University College of Human Medicine, Flint Campus, Flint, Michigan
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Oshodi O, Castaneda J. Use of the Purse-String Suture to Conservatively Manage a Cornual Ectopic Pregnancy. Cureus 2021; 13:e14249. [PMID: 33959439 PMCID: PMC8093125 DOI: 10.7759/cureus.14249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We report the successful management of a 31-year-old female, treated by cornual wedge resection. The patient suffered from vaginal spotting and lower abdominal pain. Transvaginal ultrasonography revealed a 4-5 cm right cornual pregnancy and beta-human chorionic gonadotropin was measured to be 614.7 IU/L. This ectopic pregnancy was removed via a laparotomy with cornual wedge resection and right salpingectomy.
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Affiliation(s)
- Oluwatofunmi Oshodi
- Obstetrics and Gynecology, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Jose Castaneda
- Obstetrics and Gynecology, Bethesda Hospital East, Boynton Beach, USA
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Casadio P, Arena A, Verrelli L, Ambrosio M, Fabbri M, Giovannico K, Magnarelli G, Seracchioli R. Methotrexate injection for interstitial pregnancy: Hysteroscopic conservative mini-invasive approach. Facts Views Vis Obgyn 2021; 13:73-76. [PMID: 33889863 PMCID: PMC8051194 DOI: 10.52054/fvvo.13.1.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Interstitial localisation of ectopic pregnancy is associated with high rates of maternal morbidity and mortality. Considering the rarity of interstitial pregnancy, the optimal treatment regimen remains unclear. We propose the management of interstitial pregnancy with local methotrexate injection using a combined hysteroscopic and ultrasonographic approach. Technique Hysteroscopy was performed under local anaesthesia in the operating room, using a 2.9-mm Hopkins II Forward-Oblique Telescope 30° endoscope with a 4.3-mm inner sheath and 5 FR instruments. A needle was pushed into the cornual region injecting methotrexate solution directly into the gestational sac and into the myometrial tissue tangentially at the four cardinal points. A contemporary transabdominal ultrasound (US) was performed in order to reduce risks of complications. Experience Five patients with an US diagnosis of interstitial ectopic pregnancy admitted to our department between January 2016 and September 2019 were managed with a local hysteroscopic injection of methotrexate. The technique was effective in all patients and no surgical complications occurred during or after the procedure. Three patients were evaluated for tubal patency with contrast ultrasonography confirming bilateral tubal patency 9 months from treatment, while one patient had a spontaneous birth 22 months from their initial surgery. Conclusion The hysteroscopic ultrasound-guided approach combined with the local injection of methotrexate is a minimally invasive conservative approach that seems to be promising in the management of interstitial ectopic pregnancy.
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Affiliation(s)
- P Casadio
- Division of Gynaecology and Human Reproduction Physiopathology Unit, DIMEC, IRCCS Azienda Ospedaliero- Universitaria di Bologna, Italy
| | - A Arena
- Division of Gynaecology and Human Reproduction Physiopathology Unit, DIMEC, IRCCS Azienda Ospedaliero- Universitaria di Bologna, Italy
| | - L Verrelli
- Division of Gynaecology and Human Reproduction Physiopathology Unit, DIMEC, IRCCS Azienda Ospedaliero- Universitaria di Bologna, Italy
| | - M Ambrosio
- Division of Gynaecology and Human Reproduction Physiopathology Unit, DIMEC, IRCCS Azienda Ospedaliero- Universitaria di Bologna, Italy
| | - M Fabbri
- Division of Gynaecology and Human Reproduction Physiopathology Unit, DIMEC, IRCCS Azienda Ospedaliero- Universitaria di Bologna, Italy
| | - K Giovannico
- Division of Gynaecology and Human Reproduction Physiopathology Unit, DIMEC, IRCCS Azienda Ospedaliero- Universitaria di Bologna, Italy
| | - G Magnarelli
- Division of Gynaecology and Human Reproduction Physiopathology Unit, DIMEC, IRCCS Azienda Ospedaliero- Universitaria di Bologna, Italy
| | - R Seracchioli
- Division of Gynaecology and Human Reproduction Physiopathology Unit, DIMEC, IRCCS Azienda Ospedaliero- Universitaria di Bologna, Italy
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Shetty V, Padavagodu Shivananda R, Vasudeva A, Shetty J. Successful management of three cases of interstitial pregnancies with local instillation of potassium chloride: avoiding a potential cornuostomy. BMJ Case Rep 2021; 14:e239918. [PMID: 33758046 PMCID: PMC7993249 DOI: 10.1136/bcr-2020-239918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2021] [Indexed: 11/03/2022] Open
Abstract
Here, we present three cases of women with interstitial pregnancy who were managed with local instillation of potassium chloride. These women were in their 20s-30s and presented in stable condition. Of them, two had a history of previous ectopic pregnancy. Interstitial pregnancy was diagnosed by transvaginal sonography which showed an empty uterine cavity with a gestational sac 1 cm away from the lateral edge of the uterine cavity, with <5 mm myometrium surrounding it in all planes. Two of the three cases failed to respond to methotrexate injection. Due to the presence of high-end ultrasound machine and technical expertise, local instillation of potassium chloride was offered as an alternative to surgical treatment, which is definitive, and all three patients had a successful outcome. One patient returned with pain in the abdomen, which required inpatient monitoring and was later diagnosed with urinary tract infection and was given appropriate antibiotics.
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Affiliation(s)
- Vineetha Shetty
- Obstetrics and Gynecology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Roopa Padavagodu Shivananda
- Obstetrics and Gynecology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Akhila Vasudeva
- Obstetrics and Gynecology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Jyothi Shetty
- Obstetrics and Gynecology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Listijono DR, Rosen DMB, Choi S, Bukhari M, Cario GM, Chou D. Cultivating the Apprentice-Mentor Model for Minimally Invasive Gynaecology in the Era of Surgically Scarce Training: A Case Report of Laparoscopic Cornuostomy for Interstitial Ectopic Pregnancy by a Trainee. Case Rep Obstet Gynecol 2021; 2021:5560309. [PMID: 33747585 PMCID: PMC7960069 DOI: 10.1155/2021/5560309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/13/2021] [Accepted: 02/24/2021] [Indexed: 11/29/2022] Open
Abstract
Over the last few years, there is an apparent growing concern amongst O&G trainees of the inadequacy in exposure to minimally invasive gynaecology surgical training, which has been inadvertently compounded by the more stringent working hour regulations and disproportionately increasing number of trainees relative to surgical volume. Therefore, it is vitally important for trainees to maximise opportunities in the operating theatre and develop autonomy in carrying out more complex surgical procedures. This case report outlines the step-by-step approach of laparoscopic excision of a cornual ectopic pregnancy performed by a trainee under the supervision of a surgical mentor. This manuscript highlights key characteristic traits of a trainee that serve to foster surgical trust and simple but effective steps to foster surgical preparedness.
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Affiliation(s)
- Dave R. Listijono
- Sydney Women's Endosurgery Centre (SWEC), Sydney, Australia
- IVF Australia, Sydney, Australia
| | | | - Sarah Choi
- Sydney Women's Endosurgery Centre (SWEC), Sydney, Australia
| | | | | | - Danny Chou
- Sydney Women's Endosurgery Centre (SWEC), Sydney, Australia
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Management of interstitial pregnancy in the era of laparoscopy: a meta-analysis of 855 case studies compared with traditional techniques. Obstet Gynecol Sci 2021; 64:156-173. [PMID: 33539687 PMCID: PMC7990998 DOI: 10.5468/ogs.20299] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/27/2020] [Indexed: 11/08/2022] Open
Abstract
Interstitial pregnancy is a rare, life-threatening condition that requires high clinical suspicion for diagnosis. Most cases are discovered after complications have occurred. Many authors have described laparoscopic management. Although previous systematic reviews have compared the attributes and complications associated with interstitial pregnancy, we endeavored to complete the first systematic review and meta-analysis to compare the laparoscopic treatment of interstitial pregnancy with the open approach in the modern age of laparoscopic surgery. We systematically searched PubMed, ClinicalTrials.gov, Scopus, Web of Science, and Cochrane until June 2020 using relevant keywords and screened them for eligibility. We found a statistically significant difference in blood loss between laparoscopic and open surgery (168 mL compared to 1,163 mL). Further, cumulative meta-analysis has revealed that blood loss in laparoscopy has been decreasing over time from 1991 to 2020. Laparoscopic patients took less operative time (63.2 minutes) compared to laparotomy patients (78.2 minutes). Patients in the laparoscopic group spent less time hospitalized (3.7 days) compared to laparotomy patients (5.2 days). Our findings add strength to the position that laparoscopic approaches to interstitial pregnancy can be considered first-line in most situations. The laparoscopic approach was found to have a mean blood loss of 168 mL, and this blood loss seems to decrease over time. Increased gravidity and duration of amenorrhea are positive factors that increase bleeding during the procedure. We are unable to find enough high-quality data to significantly compare successful pregnancy following surgery or risk of mortality in these populations.
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Galani A, Zikopoulos A, Moulias E, Paschopoulos M, Zikopoulos K. Successful conservative medical management of an interstitial ectopic pregnancy at 10 weeks of gestation: A case report. Case Rep Womens Health 2021; 29:e00284. [PMID: 33489785 PMCID: PMC7807208 DOI: 10.1016/j.crwh.2020.e00284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/12/2020] [Accepted: 12/22/2020] [Indexed: 11/26/2022] Open
Abstract
Background Interstitial pregnancy is a rare type of ectopic pregnancy, accounting for 2–6% of ectopic pregnancies, but it can be life threatening. There is no clear consensus on management, either surgical or medical, and it depends on hemodynamic stability and whether fertility-sparing treatment is requested. Case Presentation We present the case of a 35-year-old woman (G2, P1) who was diagnosed with an interstitial pregnancy at 10 weeks of gestation following in vitro fertilization. She was hemodynamically stable and requested fertility-sparing treatment. She was managed successfully with methotrexate and folinic acid with a hospital stay of 17 days. Conclusion Interstitial pregnancy can be managed medically. However, these patients require close monitoring. Iterstitial ectopic pregnancy accounts for 2-6% of ectopic pregnancies. Management may be either surgical or medical. Successful medical management with methotrexate regimen of a 10-week interstital pregnancy is described.
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Affiliation(s)
- A. Galani
- University Hospital of Ioannina, Department of Obstetrics and Gynecology, Ioannina, Greece
- Corresponding author.
| | - A. Zikopoulos
- Obstetrics and Gynecology Royal Cornwall Hospital, Cornwall, UK
| | - E. Moulias
- University Hospital of Ioannina, Department of Obstetrics and Gynecology, Ioannina, Greece
| | - M. Paschopoulos
- University Hospital of Ioannina, Department of Obstetrics and Gynecology, Ioannina, Greece
| | - K. Zikopoulos
- University Hospital of Ioannina, Department of Obstetrics and Gynecology, Ioannina, Greece
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Conservative Treatment of Interstitial Ectopic Pregnancy with the Combination of Mifepristone and Methotrexate: Our Experience and Review of the Literature. BIOMED RESEARCH INTERNATIONAL 2020; 2020:8703496. [PMID: 32802882 PMCID: PMC7421079 DOI: 10.1155/2020/8703496] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 06/25/2020] [Indexed: 12/03/2022]
Abstract
Introduction Interstitial pregnancy (IP) is an ectopic pregnancy (EP) located in the portion of the fallopian tube that penetrates the uterine muscular layer. Incidence increased in the last two decades with the widespread use of the assisted reproductive techniques. It is estimated in 1-6% of all the EPs, with a maternal mortality rate of 2.0-2.5%. Clinical presentation, gestational age at diagnosis, beta-human chorionic gonadotropin (β-hCG) levels, ultrasound features, and patient preference, should be considered to determine the best management: surgical, medical treatment, or close observation. We report two cases of IP successfully managed with systemic MTX and Mifepristone: in one case β-hCG was >10.000 mIU/mL and a vital embryo was present. Materials and Methods A literature search was carried out on MEDLINE, EMBASE, and PUBMED. We identified two cases of IP referred to the Institute for Maternal and Child Burlo Garofolo, Trieste. Data related to clinical presentation, β-hCG, and ultrasound scan at the moment of the diagnosis were recorded. In one of the cases, the β-hCG level was >10.000 mIU/mL, and a vital embryo was testified at an ultrasound scan. The patient was asymptomatic and she was treated using multidose systemic Methotrexate (MTX) combined with Mifepristone. In the second case, in the presence of a clinically stable patient with β − hCG > 10.000 mIU/mL, it was chosen that the administration of Mifepristone combined with a double dose of MTX. β-hCG levels and ultrasound examinations were performed weekly until a complete resolution of the IP. Results In the first case, β-hCG dropped down in 5 days and became undetachable in 30 days. In the second case, β-hCG became undetectable in 47 days. The first-line therapy in asymptomatic women could be addressed to a combined protocol, consisting of a systemic multidose MTX regimen with a single oral dose of Mifepristone. Conclusions Clinical management of IP remains a debated topic. In selected cases, a systemic multidose MTX regimen combined with a single oral dose of Mifepristone could be considered also in the presence of high serum β-hCG.
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Finlinson AR, Bollig KJ, Schust DJ. Differentiating pregnancies near the uterotubal junction (angular, cornual, and interstitial): a review and recommendations. FERTILITY RESEARCH AND PRACTICE 2020; 6:8. [PMID: 32391161 PMCID: PMC7199330 DOI: 10.1186/s40738-020-00077-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 04/06/2020] [Indexed: 12/02/2022]
Abstract
Eccentrically located intracavitary pregnancies, which include pregnancies traditionally termed as cornual and/or angular, have long presented complex diagnostic and management challenges given their inherent relationship to interstitial ectopic pregnancies. This review uses the existing literature to discriminate among interstitial, cornual, and angular pregnancies. Current arguments propose the outright abandonment of the terms cornual and angular may be justified in favor of the singular term, eccentric pregnancy. Disparate definitions and diagnostic approaches have compromised the literature’s ability to precisely describe prognosis and ideal management practices for each of these types of pregnancies. Standardizing the classification of these pregnancies near the uterotubal junction is important to unify conservative, yet safe and effective management strategies. We advocate the use of early first trimester ultrasound to correctly differentiate between eccentric pregnancy and interstitial ectopic pregnancy as current research suggests substantially better outcomes with correctly diagnosed and expectantly managed eccentric pregnancies than past investigations may have shown. The expectant management of eccentric pregnancies will often result in a healthy term pregnancy, while interstitial ectopic pregnancies inherently have a poor likelihood of progressing to viability. When the terms and diagnosis of cornual, angular, and interstitial pregnancy are indistinct, there is substantial risk of intrauterine pregnancies to be inappropriately managed as ectopic pregnancies. Until we standardize terms and criteria, it will remain difficult, if not impossible, to determine true risk for pregnancy loss, preterm labor, abnormal placentation, and uterine or uterotubal rupture. The development of best practice guidelines will require standardized terminology and diagnostic techniques.
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Affiliation(s)
- Alex R Finlinson
- Department of Obstetrics, Gynecology and Women's Health, MU Institute for Women's Health Research, University of Missouri School of Medicine, 500 North Keene Street, Columbia, MO 65201 USA
| | - Kassie J Bollig
- Department of Obstetrics, Gynecology and Women's Health, MU Institute for Women's Health Research, University of Missouri School of Medicine, 500 North Keene Street, Columbia, MO 65201 USA
| | - Danny J Schust
- Department of Obstetrics, Gynecology and Women's Health, MU Institute for Women's Health Research, University of Missouri School of Medicine, 500 North Keene Street, Columbia, MO 65201 USA
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Refining Angular Pregnancy Diagnosis in the First Trimester: A Case Series of Expectant Management. Obstet Gynecol 2020; 135:175-184. [PMID: 31809430 DOI: 10.1097/aog.0000000000003595] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe the natural history and outcomes of a large cohort of expectantly managed angular pregnancies diagnosed in the first trimester by specific ultrasound criteria. METHODS We conducted a prospective case series of women with prenatally diagnosed angular pregnancy at a single academic tertiary care center from March 2017 to February 2019. Participants were identified at first-trimester ultrasound scan using specifically proposed diagnostic criteria for angular pregnancy and followed prospectively. Maternal and fetal data were gathered from the medical record. RESULTS Forty-two cases of angular pregnancy were identified at first-trimester ultrasound scan. At presentation, 33 patients (79%) were asymptomatic, eight (19%) had vaginal bleeding, and two (5%) had pain. The mean gestational age at diagnosis was 7.4±1.0 weeks; the mean myometrial thickness was 5.1±1.6 mm (95% CI 4.6-5.6). At initial follow-up about 2 weeks later, 23 patients (55%) had ultrasound scans that normalized, 13 (31%) cases persisted as angular pregnancies, and six (14%) resulted in early pregnancy loss. After each gestation had been followed until completion, 33 (80%) pregnancies resulted in live birth and eight (20%) in early pregnancy loss. One patient was lost to follow-up. Of the 33 live births, 24 (73%) were vaginal deliveries, nine (27%) were cesarean deliveries, 27 (82%) were term deliveries, and six (18%) were preterm deliveries. There were no cases of uterine rupture, maternal death, abnormal placentation, or hysterectomy. CONCLUSIONS In 42 cases of angular pregnancy diagnosed by first-trimester ultrasound examination, outcomes were largely positive, with an 80% live-birth rate and a 20% early pregnancy loss rate. Early diagnosis of angular pregnancy using the described criteria may represent an entity that more closely resembles a normal, noneccentric intrauterine pregnancy rather than an ectopic pregnancy. Therefore, most cases can be closely observed and efforts made to expectantly manage pregnancies while awaiting viability.
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Spontaneous Intraoperative Rupture of a Large Interstitial Pregnancy: Laparoscopic Management. Case Rep Obstet Gynecol 2020; 2020:5626783. [PMID: 32351748 PMCID: PMC7178462 DOI: 10.1155/2020/5626783] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 11/29/2019] [Indexed: 12/05/2022] Open
Abstract
We present a case of a large interstitial pregnancy which was intraoperatively ruptured, but was eventually laparoscopically treated. The patient experienced 9 weeks of amenorrhea, and a right cornual pregnancy measuring 6 cm was diagnosed. The patient consented on having a minimal surgical treatment, and a laparoscopic right cornuotomy was decided. During surgery, and prior to any manipulation to the uterus, there was a spontaneous rupture of the ectopic which resulted in excessive bleeding. Temporal pressure at the bleeding site and ligation of the superior branches of the right uterine artery allowed for a careful dissection of the right uterine cornua and achieved hemostasis. The surgery proceeded uneventfully thereafter. Although surgical intervention in such cases entails a high risk of hemorrhage, successful completion of the laparoscopy lies on the meticulous preoperative planning and the controlled precise surgical steps during the procedure.
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