Uterine artery embolization for management of interstitial twin ectopic pregnancy: case report

Local Methotrexate Plus Uterine Artery Embolization for High-Risk Interstitial Ectopic Pregnancy

Interstitial ectopic pregnancy involves the interstitial portion of the fallopian tube and is among the most hazardous of all ectopic pregnancies, with the highest risk of uterine rupture and maternal mortality. Unlike tubal ectopic pregnancy, management of interstitial pregnancy is not well standardized. Systemic methotrexate (MTX) and surgical resection are the primary treatment options; however, failure rates and risk of bleeding remain high. Alternative minimally invasive techniques have been described-including uterine artery embolization (UAE) and local injection of MTX or potassium chloride-and may confer improved success rates. We report a case of a high-risk 28-year-old female with an interstitial ectopic pregnancy successfully treated with combined local injection of MTX plus UAE. We describe our technique and the unique medical management in the setting of a known bleeding disorder.

Sonographic diagnosis of an interstitial pregnancy in an asymptomatic patient at 7 weeks' gestation

An interstitial pregnancy is an ectopic pregnancy located within the proximal intramural segment of the Fallopian tube traversing the myometrium. This type of ectopic pregnancy is relatively rare, occurring in approximately 1%-3% of all ectopic pregnancies. Given the myometrial mantle surrounding the gestational sac, which is considerably thicker than in other tubal pregnancies, patients with interstitial pregnancies classically manifest symptoms later in gestation. Thus, there is an increased risk of life-threatening intraperitoneal hemorrhage upon rupture of the myometrium encompassing the pregnancy. We present an unusual case of early sonographic diagnosis of an interstitial pregnancy in an asymptomatic patient at 7 and 3/7 weeks’ gestation, discuss predisposing factors, hallmarks of sonographic diagnosis, and review the literature regarding available clinical management modalities. With the increasing application of point of care ultrasound (POCUS) by emergency room physicians and other providers in outpatient facilities, our case emphasizes both the importance of correct sonographic identification of interstitial pregnancy and the clinical importance of uniform early first-trimester sonography, preferably no later than 7-8 weeks’ gestation.

Laparoscopic systemic devascularization of uterine cornu for cornual resection in interstitial pregnancy

Cornual pregnancies carry a greater maternal mortality risk than ampullary ectopic pregnancies and they may cause significant hemorrhage. A woman aged 36 years with a six-week history of amenorrhea, slight vaginal bleeding, and low abdominal pain of three days duration presented to our clinic. A diagnosis of right cornual ectopic pregnancy was made using ultrasonographic findings. Laparoscopic exploration confirmed the diagnosis. We occluded the uterine artery at its origin and also transected vessels within the mesosalpinx and uteroovarian ligament to successfully accomplish avascularization of a cornual pregnancy. Occlusion of the uterine arteries is reported to be a safe and blood-sparing technique. Severe hemorragia may occur during the operation; therefore, techniques to minimize blood loss are reported. In our case, occlusion of the uterine artery and transection of the mesosalpinx and uteroovarian vessels provided a bloodless operation and there was no need to bilaterally occlude vessels.

First ever case of spontaneous triplet cornual pregnancy: management of laparoscopic cornual resection with modified endoloop method

A 23-year-old woman, gravida 2 para 0, presented at 8 weeks gestation with a spontaneously conceived triplet cornual ectopic pregnancy. She was at high risk of ectopic pregnancy as she had been previously treated for pelvic inflammatory disease and had also undergone laparoscopic salpingostomy for right-sided ectopic pregnancy. She was clinically stable and her abdomen was soft and non-tender. The diagnosis was made on transvaginal ultrasound scan and this was confirmed on the three-dimensional scan. She was counselled about her treatment options and subsequently underwent laparoscopic cornual resection using the modified endoloop method. The estimated blood loss was 20 ml intraoperatively and the patient recovered well. She subsequently conceived spontaneously with an intrauterine pregnancy and underwent lower segment caesarean section at 37 weeks in view of previous laparoscopic cornual resection. Intraoperatively, the right cornua appeared normal and there was no sign of thinning.

Conservative treatment for interstitial monochorionic twin pregnancy: case report and review of the published work

Interstitial pregnancy is considered one of the most hazardous types of ectopic pregnancies, with a mortality rate of 2-2.5%. We describe a case of a viable monochorionic twin pregnancy in a 35-year-old woman successfully treated with systemic methotrexate associated with bilateral uterine arteries' embolization. β-hCG was undetectable 67 days after the first administration of methotrexate and the ultrasonography performed on day 67 showed the remnant of the gestational sac in the right uterine horn, a thin endometrium and a normal myometrial vascularization. Conservative treatment allowed us to avoid surgical treatment and to preserve the patient's fertility.

Ectopic pregnancy not within the (distal) fallopian tube: etiology, diagnosis, and treatment

Ectopic pregnancy is a very common diagnosis (2% of pregnancies), and implantation location varies. Although 97% of ectopics are implanted within the fallopian tube, associated with commonly recognized risk factors, ectopic implantation can occur in other pelvic and abdominal locations that may not have such predisposing risk factors. After an extensive review of the literature, along with the author's personal experience, implantation frequency, etiologic possibilities, and treatment options for each ectopic pregnancy location are presented. When ectopic pregnancy is diagnosed early, before rupture, regardless of location, conservative, fertility-sparing treatment options can be successful in terminating the pregnancy. Predisposing risk factors and treatment options can vary and can be ectopic-location specific.

Current diagnosis and treatment of interstitial pregnancy

The incidence of interstitial pregnancy is rising. Traditional treatment with laparotomy, hysterectomy, or cornual wedge resection is associated with high morbidity and detrimental effects on future fertility. A diverse array of alternate treatments has been introduced over the last 3 decades, with the common goal of achieving a minimally invasive, standardized management strategy. This has been facilitated by impressive strides towards prompt diagnosis, both radiologically and chemically. In this review, we explore the current state of the art diagnostic criteria and the clinically significant diverse therapeutic options with supporting literature. Finally, we propose a structured, best-practice management plan for the once-lethal interstitial pregnancy, based on the current literature.

Sonographic Evaluation of Interstitial (Cornual) Ectopic Pregnancy

Interstitial ectopic pregnancy, also referred to as a cornual ectopic pregnancy, is a rare form of ectopic pregnancy. The sonographic appearance of interstitial ectopic pregnancy is complex and varied, making an accurate diagnosis difficult and thorough clinical correlation necessary. Interstitial ectopic pregnancies carry an elevated risk of maternal mortality compared with other ectopic pregnancies, making expedient diagnosis and treatment important.

Unilateral triplet ectopic pregnancy after in vitro fertilization and embryo transfer

OBJECTIVE

To present a case report of a unilateral triplet ectopic pregnancy (EP) conceived by IVF-embryo transfer.

DESIGN

Case report.

SETTING

University Hospital, Budapest, Hungary.

PATIENT(S)

A 26-year-old infertile woman with a history of right salpingectomy, hyperprolactinemia, and male factor infertility underwent IVF-embryo transfer of three embryos. Early transvaginal sonography revealed a triplet pregnancy in the left fallopian tube (two at interstitial and one at ampullary location).

INTERVENTION(S)

Multiple dose methotrexate (MTX) therapy was applied.

MAIN OUTCOME MEASURE(S)

Follow-up pelvic ultrasounds and laboratory testing confirmed fetal cardiac activity cessation and decreasing beta-hCG levels.

RESULT(S)

In spite of the decreasing beta-hCG levels the tube's diameter increased, the patient's symptoms escalated, and finally, the level of hemoglobin and hematocrit decreased. Laparotomy was performed with the removal of the left tube and cornual part of the uterus.

CONCLUSION(S)

Our case represents a very rare condition, a unilateral triplet EP after IVF-embryo transfer-the first one ever reported in the literature. After IVF-embryo transfer early ultrasound examinations are important to identify EPs at an early stage when medical management can still be taken into consideration. Strict monitoring is necessary to identify the success of medical intervention or the need for surgery.

MR features of ectopic pregnancy

Ectopic pregnancy (EP), in which a fertilized ovum implants outside the uterine cavity, is the leading cause of pregnancy-related death in the first trimester. EP is usually suspected by a positive pregnancy test and an empty uterus on transvaginal sonography (TVS). Although TVS is the initial modality of choice, it may occasionally fail to demonstrate the implantation site. When TVS findings are indeterminate, magnetic resonance imaging (MRI) may provide better delineation of the focus of EP owing to its excellent tissue contrast. The key MRI features of EP include gestational sac (GS)-like structures that typically appear as a cystic sac-like structure, frequently associated with surrounding acute hematoma of distinct low intensity on T2-weighted images. In tubal pregnancy, an enhanced tubal wall on postcontrast images may be another diagnostic finding. Ruptured EP is inevitably associated with acute hematoma outside these structures. In intrauterine EP, recognition of the relationship between GS-like structure and the myometrium can aid in differentiating from normal pregnancy. Diagnostic pitfalls include heterotopic pregnancy, decidual changes in endometrial cyst and theca lutein cysts mimicking GS-like structures. Knowledge of a spectrum of clinical and MRI features of EP is essential for establishing an accurate diagnosis and determining appropriate management.

Selective uterine artery embolization for management of interstitial ectopic pregnancy

Interstitial ectopic pregnancy is a rare condition of pregnancy and may be very dangerous if not identified and treated urgently. We report a case of successful treatment of an interstitial pregnancy using selective uterine artery embolization. A 27-year-old woman with interstitial pregnancy was treated by uterine artery embolization after failure of systemic methotrexate treatment. Her serum beta-human chorionic gonadotropin (β-hCG) was undetectable one month after the therapeutic embolization and transvaginal sonography 31 days after embolization showed normal endometrium and cornu. The patient achieved a normal pregnancy eight months after embolization.

The use of 3D rendering, VCI-C, 3D power Doppler and B-flow in the evaluation of interstitial pregnancy with arteriovenous malformation treated by selective uterine artery embolization

Cornual pregnancy is a rare form of ectopic pregnancy. We describe a case of cornual pregnancy suspected by two-dimensional ultrasonography (2DUS) and confirmed by three-dimensional volume contrast imaging in the C-plane. Three-dimensional power Doppler showed a particularly rich blood supply and two-dimensional color Doppler mapping demonstrated arteriovenous malformation (AVM). The feeding vessel originating from the right uterine artery and AVM were demonstrated with B-flow spatio-temporal image correlation (STIC) modality. Conservative management was chosen to preserve the uterus. Angiography confirmed the diagnosis of AVM; embolization with polyvinyl alcohol particles and embolization coils was performed through the right uterine artery until occlusion of the AVM and feeding vessels had occurred. Postprocedure color Doppler mapping and B-flow STIC modalities demonstrated absence of flow in the AVM. Serum human chorionic gonadotropin (hCG) levels gradually fell to non-pregnant levels during the ensuing 5 weeks. To the best of our knowledge this is the first report of cornual pregnancy with AVM. We demonstrate here the value of new three-dimensional ultrasound modalities in the diagnosis of cornual pregnancy and the use of embolization as an effective therapeutic option when conservative treatment with uterine preservation is desired.

Conservation de la fertilité après embolisation sélective d'une grossesse cornuale

Subsequent pregnancy following an interstitial pregnancy is rare. The risk of uterine rupture may be increased in this situation. Uterine selective embolization has been proposed as an effective treatment. However, no further pregnancy has ever been described after this method of management. We are reporting a case of subsequent pregnancy following interstitial pregnancy managed by embolization. The pregnancy was uneventful. A healthy male infant was delivered by C-section. This case supports the hypothesis that selective embolization for interstitial pregnancy may respect fertility. However, as actual risk of uterine rupture in subsequent pregnancies remains unknown, a C-section is advised.

Sonographic monitoring of systemic and local methotrexate (MTX) therapy in patients with intact interstitial pregnancies

OBJECTIVE

After the confirmation of an intact interstitial pregnancy through sonographic diagnosis and laparoscopy, systemic and local methotrexate therapy is a well established conservative treatment to preserve the uterus. The parameters of successful treatment are the course of serum hCG value and sonographic changes. In this case series we describe sonographic monitoring under methotrexate (MTX) application and the residual sonographic findings after completing therapy.

METHODS

Three consecutive patients (two singleton and one twin pregnancy) with intact interstitial pregnancies were diagnosed and treated with MTX between 2000 and 2004. During the treatment we recorded the hCG values, maximum size of the interstitial lesion, vitality of the pregnancy, and vascularization.

RESULTS

In all patients the sonographic diagnosis of an interstitial pregnancy was confirmed by laparoscopy. Following systemic MTX therapy, the hCG values normalised within 8 weeks in the singleton pregnancies and in 10 weeks in the twin pregnancy. During conservative therapy vascularization in the lesion withered continuously. The size of the primary myometrial lesion decreased at a slow rate and part of the lesion persisted in all three patients.

CONCLUSION

Despite decreasing hCG levels, residual sonographic patterns of an interstitial ectopic pregnancy persist in the uterine wall.

Experience with Conservative Strategy of Uterine Artery Embolization in the Treatment of Placenta Percreta in the first Trimester of Pregnancy

OBJECTIVE

There is little prospective experience in the conservative treatment of placenta percreta during the first trimester in order to preserve uterine fertility. We describe herein our experience with uterine artery embolization (UAE) in the management of placenta percreta at 9 weeks of gestation.

CASE REPORT

A 36-year-old woman, gravida 3, para 1, was referred for ultrasonographic evaluation because of suspected molar pregnancy due to persistent vaginal spotting at 9 weeks of gestation. A Grade 3+ lacunar flow pattern with multiple bizarre and large irregular sonolucent spaces were observed. Color Doppler imaging revealed extensive turbulent lacunar blood flow perfusing throughout the whole surrounding uteroplacental tissues and fetus. The patient was informed of the situation and she had a strong desire to avoid surgery. Conservative management with bilateral UAE was performed using polyvinyl alcohol particles to promote involution and shedding of the abnormally adherent placenta. However, an unsatisfactory vessel-occluding effect caused by extensive collateral supply was still detected after repeated UAE. We, therefore, performed hysterectomy, and the patient had an uneventful postoperative course.

CONCLUSION

The efficacy and complications of UAE as a therapeutic modality for the conservative management of invasive placentation in the first trimester of pregnancy are not clear, as this is the first report of its kind. However, although UAE had failed in this case, it may still be a useful procedure as a prophylactic measure before surgical intervention, and hysterectomy can also be performed for better control of operative hemorrhage.

Management of Interstitial Pregnancy Using Selective Uterine Artery Embolization

BACKGROUND

Interstitial pregnancy is a rare and dangerous form of ectopic pregnancy which is treated by surgery, medical treatment, or both. Management options are not standardized. Currently, conservative nonsurgical treatment seems to be an alternative method in case of interstitial pregnancy.

CASE

A right interstitial pregnancy was diagnosed in a 28-year-old woman. She was successfully treated by 2 courses of systemic methotrexate (1 mg/kg) 24 hours apart followed by selective uterine artery embolization. The postembolization course was uneventful, and no rupture occurred. Ten weeks after embolization, human chorionic gonadotropin level was negative.

CONCLUSION

Uterine embolization associated with methotrexate can be used successfully in treating selected cases of early interstitial pregnancy. We hypothesize that this procedure combined with methotrexate could reduce hemorrhagic risk.