The role of three-dimensional MRI in the differentiation between angular pregnancy and interstitial pregnancy

Interstitial ectopic pregnancy, a rare clinical phenomenon diagnosed asymptomatically on routine work up in Tanzania: Case report

INTRODUCTION

Interstitial ectopic pregnancy is a rare but life-threatening condition, accounting for 2.4 % of all ectopic pregnancies. Diagnosing it can be challenging, as the interstitial portion of the fallopian tube allows for delayed rupture due to its capacity to expand, often leading to significant haemorrhage. Early detection is critical to preventing severe complications.

CASE PRESENTATION

We report the case of a 30-year-old primigravida who presented for routine antenatal care at 12 weeks of gestation, asymptomatic with no identifiable risk factors. Routine ultrasound revealed a suspicious gestation near the left uterine horn, leading to a diagnosis of interstitial ectopic pregnancy via MRI. The patient underwent a laparotomy with successful wedge resection and salpingectomy. She recovered well without complications.

DISCUSSION

This case highlights the diagnostic challenges of interstitial ectopic pregnancy, which can remain asymptomatic longer than other types due to the anatomical features of the interstitial segment. Diagnostic imaging is vital for accurate diagnosis, especially in stable patients. Early intervention is key to avoiding catastrophic outcomes like uterine rupture and severe haemorrhage. Advances in imaging and surgical techniques have improved patient outcomes, but careful prenatal follow-up remains crucial for future pregnancies due to the increased risk of uterine rupture.

CONCLUSION

Routine antenatal care and imaging play a pivotal role in the early detection of interstitial ectopic pregnancies. Prompt diagnosis and management can significantly reduce the risk of severe complications, emphasizing the importance of vigilant prenatal monitoring in reducing maternal morbidity and mortality.

Successful delivery in a cornual pregnancy after expectant management with traditional Chinese medicine and low-molecular-weight heparin: A case report

RATIONALE

Horn pregnancy is a rare subtype of ectopic pregnancy that presents a diagnosis and treatment challenge due to its nonspecific symptoms and high risk of rupture.

PATIENT CONCERNS

A 32-year-old woman without vaginal pregnancy with history of right corner who presented with painless vaginal bleeding.

DIAGNOSES

A transvaginal ultrasound revealed a pregnancy sac implanted in the left corner of the uterus, confirming the diagnosis of a cornual pregnancy.

INTERVENTIONS

Treatment options include pharmacological or surgical interventions, and anticipatory treatment is rarely recommended. Conservative treatment was chosen after extensive consultation, and the patient was treated with low molecular weight heparin and traditional Chinese medicine.

OUTCOMES

Subsequent ultrasound tests showed stable fetal development and a successful cesarean section.

LESSONS

This case highlights the success of combining low molecular weight heparin with traditional Chinese medicine in the treatment of cornual pregnancy. Factors affecting horn pregnancy, diagnostic challenges, and treatment considerations are discussed. Further research is necessary to determine the best management strategy and to ensure safe delivery for patients with impaired fertility but a strong desire to conceive.

Pregnancies at the Uterotubal Junction: A Review of Terminology (Interstitial, Cornual, and Angular) and Recommendations for Management

Ectopic pregnancies are one of the most common causes of obstetric mortality worldwide. Interstitial ectopic pregnancies, defined as an extracavitary pregnancy within the portion of the Fallopian tube that transverses the myometrium, have reported mortality rates approximately seven times higher than all types of ectopic pregnancy combined. In contrast, intracavitary eccentric gestations, often labeled as "cornual" or "angular" pregnancies, have reportedly high rates of live birth. Unfortunately, the terms "interstitial," "cornual," and "angular" have long been used with varying diagnostic criteria and often interchangeably to describe a pregnancy near the uterotubal junction. The inconsistency in nomenclature and lack of clear diagnostic criteria to distinguish among these pregnancies has resulted in a paucity of data to provide accurate prognostic information and guide appropriate management. This review article aims to provide historical context for the terms "interstitial," "cornual," and "angular;" discuss previous and more recent innovations of diagnostic methods; and provide recommendations for concise terminology and inform management.

Interstitial Ectopic Pregnancy Associated With Painless and Severe Vaginal Bleeding: A Rare, Atypical Clinical Presentation

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.

Imaging of Acute Abdominopelvic Pain in Pregnancy and Puerperium-Part I: Obstetric (Non-Fetal) Complications

Acute abdominopelvic pain in pregnant and postpartum patients presents clinical and therapeutic challenges, often requiring quick and accurate imaging diagnosis. Ultrasound remains the primary imaging investigation. Magnetic resonance imaging (MRI) has been shown to be a powerful diagnostic tool in the setting of acute abdominal pain during pregnancy and puerperium. MRI overcomes some drawbacks of US, avoiding the ionizing radiation exposure of a computed tomography (CT) scan. Although CT is not usually appropriate in pregnant patients, it is crucial in the emergency evaluation of postpartum complications. The aim of this article is to provide radiologists with a thorough familiarity with the common and uncommon pregnancy and puerperium abdominal emergencies by illustrating their imaging appearances. The present first section will review and discuss the imaging findings for acute abdominopelvic pain of obstetric (non-fetal) etiology.

Ipsilateral Right Angular Pregnancy After a Laparoscopic Right Salpingo-Oophorectomy: A Case Report

It can be difficult to distinguish an interstitial pregnancy from an angular pregnancy because of the close proximity of the implantation sites. The difference in pregnancy outcomes between interstitial and angular pregnancies makes this distinction very important. A 39-year-old gravida 7 para 4 who had undergone a laparoscopic right salpingo-oophorectomy (RSO) one year ago and a pregnancy termination via dilation and curettage (D&C) three weeks ago was suspected to have a ruptured right interstitial or angular pregnancy. The patient underwent a laparoscopic total hysterectomy. The postoperative histologic diagnosis was an abortion of a right angular pregnancy. Indeed, it is essential to rule out an interstitial or angular pregnancy during adnexal surgery, even soon after elective abortion. Proper management of an angular pregnancy could prevent a fatal outcome following a rupture or massive hemorrhage.

Distinguishing between cornual, angular and interstitial ectopic pregnancy: A case report and a brief literature review

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.

Cornual Pregnancy

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.

Two subtypes of surgery-categorized upper-lateral intracavitary pregnancy identified by MRI, a retrospective study

BACKGROUND

The pregnancy outcomes in women with surgery-categorized upper-lateral intracavitary pregnancy (ULIP), previously named angular pregnancy, demonstrate higher heterogeneity than in women with ultrasonography-categorized ULIP. We aimed to use preoperative MRI and correlated clinical characteristics to explore whether the surgery-categorized ULIP comprises obstetric conditions undefined by the current ultrasonography-based diagnostic criteria.

METHODS

This retrospective study involved 28 women with surgically and pathologically confirmed ULIP from January 2016 to July 2022. Two board-certified radiologists, blinded to the patients' information, independently reviewed the MRI images, and determined each MRI feature, including endometrial thickness (EMT) and peri-gestational sac (GS) endometrial interruption. Disagreements were resolved by discussion to achieve a consensus. Based on the cutoff value of EMT (11.5 mm), the patients were divided into above-cutoff EMT (n = 22) and below-cutoff EMT (n = 6) groups.

RESULTS

Two subtypes of surgery-categorized ULIP were identified. Type-I ULIP (n = 22; EMT ≥ 11.5 mm), when compared to the type-II ULIP (n = 6; EMT < 11.5 mm), demonstrated lower incidence of peri-GS endometrial interruption (2/22 [9.1%] vs 6/6 [100%]; P = 0.001), higher logarithmic ß-human chorionic gonadotropin (ß-hCG) concentration (4.7 ± 0.4 mIU/ml vs 4.2 ± 0.6 mIU/ml; P = 0.026), lower rate of repeated dilatation and curettage (1/22 [4.6%] vs 4/6 [66.7%]; P = 0.003), less intraoperative blood loss (10.1 ± 6.3 ml vs 28.3 ± 18.3 ml; P = 0.001), and shorter hospital stay (2.8 ± 1.7 days vs 7.5 ± 3.8 days; P = 0.001). The peri-GS endometrial interruption negatively correlated with EMT (Odds ratio [OR] = 0.55; P = 0.001) and logarithmic ß-hCG concentration (OR = 0.08; P = 0.045). The below-cutoff EMT negatively correlated with ß-hCG concentration (OR = 0.06; P = 0.021).

CONCLUSIONS

Surgery-categorized ULIP comprised two obstetric conditions among which the type-II ULIP, possessing unique imaging features undocumented in the literature, requires further attention during clinical practice.