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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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Nezhat C, McGrail K. Laparoscopically assisted hysteroscopic removal of an interstitial pregnancy. Fertil Steril 2022; 119:703-704. [PMID: 36565976 DOI: 10.1016/j.fertnstert.2022.12.030] [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: 07/01/2022] [Revised: 10/28/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To illustrate a combined technique of hysteroscopy and laparoscopy for the management of interstitial ectopic pregnancies. DESIGN A description of a patient case and demonstration of a surgical technique. SETTING Tertiary referral center. PATIENT(S) A 33-year-old woman, gravida 2, para 0-0-1-0 status post in vitro fertilization cycle with single embryo transfer, was diagnosed with an unruptured right interstitial pregnancy at 5 weeks of gestation. She has a history of a pregnancy of unknown location with her first in vitro fertilization transfer and received methotrexate. The beta-human chorionic gonadotropin level was 2,726 mIU/mL. She was counseled on treatment options and declined treatment with methotrexate because of the negative side effects she experienced previously. She opted for surgical management and desired to keep her fallopian tubes if possible because she wished to try for spontaneous conception. INTERVENTION(S) The patient underwent multipuncture video laparoscopy, and a bulge was seen at the right cornua. Video hysteroscopy initially revealed an empty uterine cavity. Using atraumatic graspers, the interstitial pregnancy was gently pushed further into the uterine cavity using a milking technique. The pregnancy was then able to be visualized hysteroscopically. Products of conception were gently dislodged and removed with graspers, followed by a suction curettage. MAIN OUTCOME MEASURE(S) This technique resulted in minimal blood loss, preservation of reproductive organs, and expedient return to conception planning. RESULT(S) The postoperative course was uncomplicated, and the patient was discharged the same day as surgery. After the procedure, weekly beta-human chorionic gonadotropin was drawn until the level reached <1 mIU/mL, which occurred after 4 weeks. Hysterosalpingography was performed 2 months after the procedure and demonstrated bilateral tubal patency. CONCLUSION(S) In select patients, an early interstitial pregnancy can be safely removed using the described technique. Although hysteroscopic removal of interstitial pregnancies is not a new concept, the addition of simultaneous video laparoscopy provides the benefit of allowing for fertility-sparing removal of the pregnancy, even if it is not initially visualized hysteroscopically. The use of this technique may result in minimal blood loss and preservation of the fallopian tubes. Furthermore, with the myometrium integrity maintained, the patient may resume sooner attempts at conception.
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Affiliation(s)
- Ceana Nezhat
- Atlanta Center for Minimally Invasive Surgery and Reproductive Medicine, Atlanta, Georgia.
| | - Kaitlin McGrail
- Atlanta Center for Minimally Invasive Surgery and Reproductive Medicine, Atlanta, Georgia
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Bai X, He J, Liu M, Wang J, Wang Y. Tubal Ostium Pregnancy. J Minim Invasive Gynecol 2022; 29:1208-1211. [PMID: 35817367 DOI: 10.1016/j.jmig.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/26/2022] [Accepted: 07/04/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Xuechai Bai
- Department of Gynecology, Center for Reproductive Medicine, Zhejiang Provincial People's Hospital (People's Hospital of Hangzhou Medical College), Hangzhou, Zhejiang Province (Drs. Bai, J. Wang, and Y. Wang)
| | - Jiaoyan He
- Department of postgraduate education, Jinzhou Medical University, Jinzhou, Liaoning Province (Drs. He, Liu, and Y. Wang), China
| | - Miaomiao Liu
- Department of postgraduate education, Jinzhou Medical University, Jinzhou, Liaoning Province (Drs. He, Liu, and Y. Wang), China
| | - Jiaming Wang
- Department of Gynecology, Center for Reproductive Medicine, Zhejiang Provincial People's Hospital (People's Hospital of Hangzhou Medical College), Hangzhou, Zhejiang Province (Drs. Bai, J. Wang, and Y. Wang)
| | - Yanpeng Wang
- Department of Gynecology, Center for Reproductive Medicine, Zhejiang Provincial People's Hospital (People's Hospital of Hangzhou Medical College), Hangzhou, Zhejiang Province (Drs. Bai, J. Wang, and Y. Wang); Department of postgraduate education, Jinzhou Medical University, Jinzhou, Liaoning Province (Drs. He, Liu, and Y. Wang), China.
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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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One size does not fit all: a nuanced approach to surgical management of interstitial ectopic pregnancy. Fertil Steril 2021; 116:688-690. [PMID: 34330429 DOI: 10.1016/j.fertnstert.2021.06.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 11/22/2022]
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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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Procas-Ramon B, Gabasa-Gorgas L, Ruiz-Martinez S, Perez-Muñoz A, Sobreviela-Laserrada M. Hysteroscopic Management of an Interstitial Ectopic Pregnancy. J Minim Invasive Gynecol 2019; 26:1000-1001. [DOI: 10.1016/j.jmig.2019.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 01/30/2019] [Accepted: 02/08/2019] [Indexed: 10/27/2022]
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Dolinko AV, Vrees RA, Frishman GN. Non-tubal Ectopic Pregnancies: Overview and Treatment via Local Injection. J Minim Invasive Gynecol 2018; 25:287-296. [DOI: 10.1016/j.jmig.2017.07.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 07/10/2017] [Accepted: 07/13/2017] [Indexed: 12/11/2022]
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Comparison of Laparoscopic Cornual Resection and Cornuotomy for Interstitial Pregnancy. J Minim Invasive Gynecol 2017; 24:397-401. [DOI: 10.1016/j.jmig.2016.11.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 11/29/2016] [Accepted: 11/30/2016] [Indexed: 11/18/2022]
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Leggieri C, Guasina F, Casadio P, Arena A, Pilu G, Seracchioli R. Hysteroscopic Methotrexate Injection Under Ultrasonographic Guidance for Interstitial Pregnancy. J Minim Invasive Gynecol 2016; 23:1195-1199. [PMID: 27448506 DOI: 10.1016/j.jmig.2016.07.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 07/09/2016] [Accepted: 07/13/2016] [Indexed: 10/21/2022]
Abstract
A 36-year-old woman presented with pelvic pain and vaginal blood loss and interstitial pregnancy (a single gestational sac located in the proximity of the right uterine horn, without visualization of an embryo and/or attachments inside) on 2- and 3-dimensional ultrasonographic examination. The patient was clinically stable. Her abdomen was soft with normal peristalsis; superficial and deep palpation were painless, as was decompression. With the patient under general anesthesia, an operative hysteroscopy was performed visually via ultrasound. A slow injection of methotrexate solution was pushed through the right cornual region inside the gestational sac and into the myometrial tissue tangentially at the 4 cardinal points. Twelve weeks later, the patient exhibited normal tubal patency via sonohysterography, as well as a viable pregnancy of 7 weeks' gestation. This minimally invasive approach is well tolerated and shows promise for the management of interstitial pregnancy, with no adverse effect on potential subsequent fertility.
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Affiliation(s)
- Concetta Leggieri
- Gynecology and Physiopathology of Reproduction Section, Department of Obstetrics and Gynecology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Francesca Guasina
- Gynecology and Physiopathology of Reproduction Section, Department of Obstetrics and Gynecology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Paolo Casadio
- Gynecology and Physiopathology of Reproduction Section, Department of Obstetrics and Gynecology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
| | - Alessandro Arena
- Gynecology and Physiopathology of Reproduction Section, Department of Obstetrics and Gynecology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Gianluigi Pilu
- Gynecology and Physiopathology of Reproduction Section, Department of Obstetrics and Gynecology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Renato Seracchioli
- Gynecology and Physiopathology of Reproduction Section, Department of Obstetrics and Gynecology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Grindler NM, Ng J, Tocce K, Alvero R. Considerations for management of interstitial ectopic pregnancies: two case reports. J Med Case Rep 2016; 10:106. [PMID: 27118381 PMCID: PMC4847333 DOI: 10.1186/s13256-016-0892-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 04/01/2016] [Indexed: 11/17/2022] Open
Abstract
Background Conventional treatment of interstitial pregnancies includes systemic methotrexate, direct methotrexate injection, wedge resection, or hysterectomy. We present two cases of interstitial pregnancies that were successfully managed by different minimally invasive surgical techniques. We also report the novel use of hysteroscopic urologic stone retrieval forceps in the transvaginal removal of persistent products of conception after systemic methotrexate for an interstitial pregnancy. Case presentation Case 1 was a 28-year-old gravida 1 white woman at 8 weeks gestation; she was diagnosed with a left interstitial pregnancy. After laparoscopic confirmation of the interstitial pregnancy, successful ultrasound-guided suction dilation and curettage was performed. Case 2 was a 33-year-old gravida 3 para 1021 (one term pregnancy, no preterm pregnancies, one ectopic pregnancy and one spontaneous miscarriage, and one living child) Hispanic woman with persistent products of conception after systemic methotrexate for a left interstitial pregnancy. She underwent hysteroscopic-guided removal of the persistent products of conception, which was possible due to novel use of urologic stone retrieval forceps. Conclusions Successful minimally invasive treatment of interstitial pregnancies may be possible in certain cases. Collaboration between different specialties continues to be important for improving minimally invasive options.
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Affiliation(s)
- Natalia M Grindler
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Colorado Denver School of Medicine, Aurora, CO, USA.
| | - June Ng
- University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Kristina Tocce
- University of Colorado Denver School of Medicine, Aurora, CO, USA.,Division of Family Planning, Department of Obstetrics and Gynecology, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Ruben Alvero
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Colorado Denver School of Medicine, Aurora, CO, USA.,Division of Reproductive Endocrinology & Infertility, Department of Obstetrics and Gynecology, Warren P. Alpert School of Medicine, Brown University, Providence, RI, USA
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Magnetic Resonance Imaging and 3-dimensional Computed Tomographic Angiography for Conservative Management of Proximal Interstitial Pregnancy by Hysteroscopic Resection After Transcatheter Arterial Chemoembolization. J Minim Invasive Gynecol 2015; 22:658-62. [DOI: 10.1016/j.jmig.2015.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 12/31/2014] [Accepted: 01/04/2015] [Indexed: 11/22/2022]
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