RESUMEN

AIMS: To describe the ultrasound diagnostic features and surgical management procedures for patients with an interstitial ectopic pregnancy in our tertiary institution and associated peripheral hospital over a ten-year period. METHODS: A retrospective audit of all surgically managed cases of interstitial pregnancies over a ten-year period at a tertiary hospital and one associated peripheral hospital in New South Wales. RESULTS: Sixteen cases of surgically managed interstitial pregnancy were identified. In 43.8% of these cases, patients had previously undergone an ipsilateral salpingectomy. No cases required hysterectomy, post-operative methotrexate or return to theatre. Ten patients underwent diagnostic ultrasound prior to operative management, seven of which were correctly identified to be an interstitial ectopic pregnancy at the time. The proportion of cornuostomies being performed for interstitial pregnancy compared to wedge resection has increased over the period of this review from 33 to 60% between the two five-year periods. CONCLUSION: The combination of expert ultrasound and sophisticated laparoscopic techniques at our institution has facilitated earlier diagnosis and greater use of minimally invasive management of interstitial pregnancy.

RESUMEN

A 24-year-old woman, G6P2032, initially presented with a right-sided ruptured tubal ectopic pregnancy. Salpingectomy was performed with care to completely remove the fallopian tube. The patient then presented with ipsilateral interstitial pregnancy 11 weeks later and initially underwent systemic methotrexate injection, which failed to resolve the pregnancy. She then underwent laparoscopic cornuostomy and dilation and curettage. Cornuostomy was performed with injection of dilute vasopressin around the gestational sac to help minimize blood loss, followed by hydrodissection and sharp dissection to remove the pregnancy. Judicial electrocautery was used and the myometrium and serosa were closed in layers. Attention was given to preserve uterine myometrial tissue integrity at the cornua. The patient recovered and was discharged. Her beta-hCG level trended from 11,902 mIU/mL pre-surgery to 7726 on postoperative day 0, and 289 on postoperative day 7. Pathology from the interstitial region showed fragments of chorionic villi, and the dilation and curettage pathology demonstrated decidualized secretory endometrium. Short-interval interstitial ectopic pregnancies after prior salpingectomy for tubal ectopic pregnancy are extremely rare. This case demonstrated successful management with a minimally invasive laparoscopic cornuostomy. This case also displays that ipsilateral interstitial pregnancy can occur after salpingectomy even after care is taken to remove all visible portions of the fallopian tube. Thus, patients should be counseled carefully about the risks of short-interval pregnancy after a recent tubal ectopic pregnancy.

RESUMEN

Interstitial heterotopic pregnancy (IHP), an exceedingly rare and clinically intricate phenomenon, presents a diagnosis that challenges healthcare providers in obstetric care. This case report provides valuable insights into the complexities of diagnosing and managing IHPs, shedding light on the pivotal role of early and precise identification. Through a meticulous examination of a 28-year-old patient's clinical history and diagnostic journey, this report underscores the significance of advanced imaging techniques and swift decision making, ultimately leading to the accurate diagnosis of an IHP. Furthermore, it highlights the life-saving importance of cornuostomy as a safe and effective intervention, preserving the intrauterine pregnancy while successfully resolving the ectopic gestation. This case report serves as a compelling reminder of the critical need for timely diagnosis and individualized treatment in cases of IHPs, ultimately enhancing the understanding and management of this rare obstetric condition.

RESUMEN

Interstitial pregnancy is a rare entity that usually leads to the rupture of the uterus. The difficulty and delay in diagnosing this condition have been reported to cause high mortality rates. Here, we present the case of a 36-year-old woman who presented to the emergency department with severe epigastric pain and hemodynamic instability. Her current gestational age (GA) could not be accurately measured as she was unbooked and had irregular periods. However, by abdominal examination, the GA was estimated to be 38 weeks, whereas by ultrasound it was approximately 28 weeks. It was also noted that the uterus was empty, and the fetus was found in the abdominal cavity. Hence, a working diagnosis of uterine rupture was made and the patient was taken for emergency laparotomy. The patient delivered an alive 1.2 kg baby. Intraoperatively, the placenta was implanted in the interstitial part of the right fallopian tube. The placenta was then excised and right salpingectomy was performed, following which the abdomen was closed in layers. Postoperatively, the patient made an uneventful recovery and was discharged home in stable condition; however, the baby passed away due to complications related to extreme prematurity.

RESUMEN

STUDY OBJECTIVE: To demonstrate and discuss the technique of cornuostomy for surgical management of interstitial ectopic pregnancy. DESIGN: Stepwise demonstration of the technique with narrated video footage. SETTING: Tertiary referral center in Manchester, United Kingdom. INTERVENTION: Interstitial ectopic pregnancies are rare but are associated with a higher mortality rate than other ectopic pregnancies [1,2]. It occurs when the fertilized embryo implants in the interstitial portion of the fallopian tube traversing the vascularized myometrium. When undiagnosed they present late in the second trimester associated with rupture and catastrophic bleeding, with a mortality rate of 2% to 2.5%.2 Diagnosis requires a degree of vigilance from the ultrasound operator because it is commonly misdiagnosed as intrauterine pregnancies. Surgical management options include laparoscopic cornual resection or cornuostomy. There is no consensus on the optimal surgical technique but cornuostomy is a more conservative approach associated with less disruption to uterine anatomy and loss of myometrium [3,4]. A 22-year-old gravida 4 woman presented at 7 weeks' gestation with right iliac fossa pain. Initial serum human chorionic gonadotropin was 18 136 IU/L. Transvaginal ultrasound scan showed an empty endometrial cavity and an echogenic "donut"-shaped mass within the right interstitial space, within the uterine serosa but outside the endometrial cavity (Supplemental Video 1). At laparoscopy the diagnosis of a right interstitial ectopic pregnancy was confirmed (Supplemental Video 2). Vasopressin 20 IU diluted in 80 mL of normal saline was injected around the base of the ectopic pregnancy. Monopolar diathermy was used to incise the overlying serosa followed by hydrodissection to separate the ectopic gestational sac from the myometrial attachment. The resulting defect was inspected and closed in 2 layers. Total operating time was 46 minutes. CONCLUSION: Although there is no clear evidence to guide the management of all interstitial ectopic pregnancies, an individualized approach taking into account the woman's previous history and future fertility plans and wishes is essential. In this case, given the woman's previous contralateral salpingectomy and her wishes for a conservative approach, a laparoscopic cornuostomy was likely the best option.

Asunto(s)

RESUMEN

Interstitial pregnancy is a rare type of ectopic pregnancy that commonly results in uterine rupture and life-threatening haemorrhage. Interstitial ectopic pregnancies are associated with a 2-5% mortality rate and a high risk of uterine rupture before 12 weeks of gestation when compared to tubal pregnancy. Due to the thickness and distensibility of the interstitial segment of the Fallopian tube, ectopic pregnancy in this location attains a considerable size before complications arise. Unfortunately, this clinical entity may prove to be a diagnostic challenge, leading to delays in treatment and significant morbidity and mortality in women of reproductive age. Herein, we report a case of a ruptured interstitial ectopic pregnancy occurring at 17 weeks of gestation that was successfully managed with surgical intervention, after proving to be a diagnostic challenge.

RESUMEN

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 ß-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 ß-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 ß-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.

Asunto(s)

RESUMEN

Introduction: Interstitial pregnancy is a rare type of ectopic pregnancy. The aim of our publication is to describe the diagnosis and treatment of this entity. Case report: We report the case of a ruptured interstitial pregnancy diagnosed in a 32 years old patient admitted for acute abdominal pain. Discussion: The main symptom was severe pelvic pain in a context of amenorrhea. The ultrasound found the ectopic pregnancy in the form of an eccentric gestational sac with an empty uterine cavity as well as intraperitoneal effusion. A ruptured ectopic pregnancy was suspected and the patient was admitted immediately for emergency laparotomy with cornusotomy and salpingectomy. Conclusion: Interstitial ectopic pregnancy is associated with high morbidity. Its diagnosis and management should be early and adequate in order to avoid complications and preserve fertility.

RESUMEN

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.

RESUMEN

STUDY OBJECTIVE: To investigate the relationship between previous ipsilateral salpingectomy and interstitial pregnancy and report on our experience of laparoscopic cornuostomy for interstitial pregnancy. DESIGN: Single-center, retrospective review. SETTING: University-based hospital. PATIENTS: All patients who had undergone ipsilateral salpingectomy previously, diagnosed with interstitial pregnancy and treated between July 2010 and September 2018. INTERVENTIONS: Laparoscopy or laparotomy as a treatment for interstitial pregnancy after ipsilateral salpingectomy. MEASUREMENTS AND MAIN RESULTS: A total of 414 cases of interstitial pregnancy were identified, of which 46 (11.1%) were after ipsilateral salpingectomy. Of the 46 patients, 20 (43.5%) became pregnant by in vitro fertilization and embryo transfer. Ipsilateral salpingectomy was the result of an ectopic pregnancy in 40 patients, hydrosalpinx in 5 patients, and torsion of an ovarian tumor in 1 patient. The laparoscopic approach was used to treat 78.3% of patients with history of previous salpingectomy. Patients who underwent ipsilateral salpingectomy by laparoscopy previously had a shorter interval from salpingectomy to interstitial pregnancy (24 months vs 60 months; p = .038) compared with patients who underwent ipsilateral salpingectomy by laparotomy. Laparoscopic cornuostomy was performed in 38 patients (82.6%); 12 had fetal cardiac activity, 15 had ruptured masses, and 16 used prophylactic methotrexate (MTX) intraoperatively. The median size of the ectopic mass was 2.5 cm (1.0-5.0 cm). At the time of laparoscopic cornuostomy, more patients with interstitial pregnancies with intact ectopic masses were administered prophylactic MTX (81.3% vs 45.5%; p = .043). Only 1 patient with a ruptured ectopic mass, high preoperative human chorionic gonadotropin levels, and without prophylactic MTX administration experienced a persistent ectopic pregnancy. CONCLUSION: Patients with a history of ipsilateral salpingectomy should be cautioned regarding the possibility of interstitial pregnancy. Laparoscopic cornuostomy appears to be an appropriate treatment for interstitial pregnancy in patients wishing to preserve fertility, and the use of concomitant prophylactic MTX may reduce the risk of persistent ectopic pregnancy, especially in patients with ruptured masses and high human chorionic gonadotropin levels.

Asunto(s)

Asunto(s)

RESUMEN

During laparoscopic enucleation of an interstitial pregnancy, adequate hemostatic control is of paramount importance due to the high vascularization of the uterine cornus. However, no consensus or guidance exists regarding the optimal hemostatic technique. We report laparoscopic reversible uterine arteries occlusion as hemostatic technique during laparoscopic enucleation by cornuostomy of an interstitial pregnancy at advanced gestational age (46 × 40 mm gestational sac). Preliminary identification of the uterine arteries and bilateral reversible occlusion by Hem-o-Lok clips allowed bleeding control during surgery. The laparoscopic procedure was performed without complications and with limited blood loss. The reported case reinforces the feasibility of this minimally invasive technique in interstitial pregnancy.

Asunto(s)

RESUMEN

BACKGROUND: Interstitial and cornual ectopic pregnancy is rare, accounting for 2-4% of ectopic pregnancies and remains the most difficult type of ectopic pregnancy to diagnose due to low sensitivity and specificity of symptoms and imaging. The classic triad of ectopic pregnancy-abdominal pain, amenorrhea and vaginal bleeding-occurs in less than 40% of patients. The site of implantation in the intrauterine portion of fallopian tube and invasion through the uterine wall make this pregnancy difficult to differentiate from an intrauterine pregnancy on ultrasound. The high mortality in this type of pregnancy is partially due to delay in diagnosis as well as the speed of hemorrhage. METHODS: Three cases of interstitial pregnancy were retrospectively analyzed. RESULT: Successful laparoscopic cornuostomy and removal of products of conception were performed in two cases, while one case was successfully managed by local injection with KCL and methotrexate followed by systemic methotrexate. CONCLUSION: Early diagnosis and timely management are key to the management of interstitial and cornual ectopic pregnancy. With expertise in ultrasound imaging and advances in laparoscopic skills progressively, conservative medical and surgical measures are being used to treat interstitial and cornual ectopic pregnancy successfully.

RESUMEN

The aim of this study was to compare the effect of local intracavitary methotrexate (MTX) injection and laparoscopic (L/S) cornuostomy in the treatment of interstitial pregnancy (IP) in terms of clinical and reproductive outcome. The data of patients with IP (n:10) who were treated between September 2011 and December 2016 with either an intra-amniotic MTX injection (n:7) or L/S cornuostomy (n:3) were retrospectively evaluated. All cases (7/7) in the local injection group and two (2/3) in the L/S group were successfully treated with the initial treatment. One case (1/3, 33%) in L/S group needed systemic MTX due to an elevated ß-hCG. No serious complication or secondary surgical intervention was observed in the study group. Five (71.4%) women in MTX group and two (66%) women in the L/S group had pregnancy after index case (p > .05). Post-treatment (hysterosalpingography) HSG results revealed that tubal patency was significantly higher in the MTX group (7/7 (100%) vs. 0/3 (0%) p < .05). Conservative treatment of IP with both methods was generally successful with regard to maternal morbidity and reproductive function. However, local MTX was superior for tubal patency compared to L/S cornuostomy. Since this is a retrospective study including a small study population, our results should be confirmed with larger prospective studies. Impact Statement What is already known on this subject? Earlier diagnosis of an interstitial pregnancy (IP) enables clinicians to pursue more conservative treatment modalities that can prevent morbidity (severe bleeding, rupture and massive transfusion, etc.) and loss of fertility. MTX treatment and conservative laparoscopic surgical procedures are gaining importance. High serum ß-hCG levels and positive foetal cardiac activity are known as unfavourable pre-treatment prognostic predictors for systemic MTX treatment in patients with an ectopic pregnancy. Local MTX treatment is widely used for caeserean scar pregnancies or cervical pregnancies. L/S cornuostomy is an attractive alternative to L/S cornual resection, because it preserves the normal uterine myometrium. What the results of this study add? In the present study, we showed that the local MTX and laparoscopic cornuostomy were successful methods in IP patients and did not impair the fertility potential of the patients. We also demonstrated that local MTX application is superior to L/S cornuostomy in terms of the post-treatment tubal patency and this fact should be kept in mind when tailoring the treatment in patients desiring pregnancy. What the implications are of these findings for clinical practice and/or further research? The value of local MTX injection in cases with IP and high ß-hCG levels should be further clarified.

Asunto(s)

RESUMEN

OBJECTIVE: To report on our experience of laparoscopic cornuostomy or cornual repair for cornual heterotopic pregnancy. STUDY DESIGN: A single center, retrospective review of patients who were diagnosed as cornual heterotopic pregnancy, which developed after in vitro fertilization and embryo transfer (IVF/ET) between January 2009 and June 2014. All patients were managed by laparoscopic cornuostomy or cornual repair. RESULTS: 14 patients were enrolled and 4 patients were finally confirmed to have a ruptured cornu. 4/4 presented as acute abdominal pain and 3/4 as metrorrhagia. The blood pressure of all the patients were stable. The earliest ruptured patient of this series happened at 23 days after IVF/ET. The hemoglobin levels of the 4 ruptured patients were significantly lower than the other patients (8.6 ±â€¯1.8 g/dl versus 12.2 ±â€¯1.1 g/dl, p < 0.001). Internal bleeding before operation was significantly higher in the ruptured patients than in the intact patients (1050.0 ±â€¯369.8 ml versus 0.0 ±â€¯0.0 ml, p < 0.001). All 14 patients were managed by laparoscopic cornuostomy or cornual repair. No one was converted to laparotomy. Post-operation pregnancy was uneventful. All neonates were delivered by cesarean section with no evident complications. CONCLUSION: Laparoscopic cornuostomy or cornual repair appears to be an effective treatment for cornual heterotopic pregnancy, even in ruptured ones. These operations can be safely performed in an institution with well-trained gynecological laparoscopists with experienced support teams.

Asunto(s)

RESUMEN

STUDY OBJECTIVE: To determine the incidence of interstitial pregnancy after in vitro fertilization/embryo transfer (ET) treatment and report on our experience of laparoscopic cornuostomy or cornual repair for interstitial pregnancy. DESIGN: Single-center, retrospective review (Canadian Task Force classification II-3). SETTING: University hospital. PATIENTS: Thirty-eight women diagnosed with interstitial pregnancy, which developed after 10,143 ET cycles, managed in our center between April 2011 and April 2014. INTERVENTIONS: All 38 cases of interstitial pregnancy were managed by laparoscopic cornuostomy or cornual repair. No patient was converted to laparotomy. MEASUREMENTS AND MAIN RESULTS: Of 43 cases of interstitial pregnancy, 38 were managed in our department. The overall incidence of interstitial pregnancy was .4% per ET cycle (43/10 143), or .8% per pregnancy (43/5297), but comprising 35.5% of all ectopic pregnancy cases. The risk factors for interstitial pregnancy included tubal infertility, cleavage ET, and frozen ET. Twenty-seven subjects (71.1%) had undergone bilateral salpingectomy. Among the 38 cases, 27 were intact, with no persistent ectopic pregnancy after surgery, but there were 3 cases (28.3%) of persistent pregnancy in the 11 ruptured cases. Among the 38 subjects, 15 conceived again with 14 live births and 1 ongoing pregnancy, without uterine rupture. CONCLUSION: Laparoscopic cornuostomy or cornual repair appears to be an effective treatment in intact cases, although it sometimes needs to be combined with methotrexate therapy in ruptured cases complicated by persistent disease.

Asunto(s)

RESUMEN

El embarazo ectópico es la implantación del embrión fuera de la cavidad endometrial. La localización más frecuente es en la trompa de Falopio en su porción ampular. La localización en la porción intersticial representa el sitio menos probable de implantación de un embarazo ectópico tubario. El diagnóstico y tratamiento oportuno previo a su ruptura son de importancia significativa, debido a que tiene una alta morbimortalidad materna en caso de presentarse la ruptura. El diagnóstico se realiza mediante sospecha clínica y la ayuda del ultrasonido, de preferencia endovaginal, y los niveles séricos de hCG. El tratamiento puede ser a base de metotrexate solamente, cirugía radical (cornuectomía e incluso histerectomía) y manejo conservador (cornuostomía) por laparotomía o laparoscopia. El objetivo del estudio es presentar el caso de una paciente con diagnóstico de embarazo ectópico intersticial no roto a la que se realizó cirugía laparoscópica conservadora, describir la técnica quirúrgica y revisión de la literatura.

Ectopic pregnancy is the embryo implantation outside the endometrial cavity. The most common location is the ampular region of Fallopian tube. The interstitial ectopic pregnancy represents the least probable site of implantation for a tubal ectopic pregnancy. The diagnosis and treatment, prior to rupture are important because its high morbidity and mortality when rupture occurs. Diagnosis is done by clinical suspicion, ultrasound and hCG blood levels. Treatment options are medical (metotrexate), radical surgery (cornuectomy or hysterectomy), and conservative management (cornuostomy) either by laparotomy or laparoscopy. The aim of this study is to report the case of a woman with an unruptured interstitial ectopic pregnancy who was managed by laparoscopic conservative management, describe the surgical technique and review of the literature.

RESUMEN

We report a successful laparoscopic management of an interstitial pregnancy of a 24- year-old single woman, treated by cornuostomy. The patient was first managed with methotrexate treatment. After the 2. methotrexate administration, the patient suffered from low abdominal pain, and intraabdominal bleeding signs were reported by transvaginal ultrasonograpy. The hemoglobin level was decreased from 12.8 gr/dl to 11.8 gr/dl and the beta hCG level was increased from 8,314 mIU/l to 11,541 mIU/l. The laparoscopic approach to interstitial pregnancy was presented and other management strategies such as medical treatment and laparotomy have been reviewed.

RESUMEN

Interstitial pregnancy is a rare but very dangerous event if it would be ruptured and it occurs in about 1% of ectopic pregnancy. With recent advances in laparoscopic surgery many reports have been described laparoscopic cornual resection for interstitial pregnancy or laparoscopic cornuostomy as a safe alternative to laparotomy. We report two cases of unruptured interstitial pregnancy treated by laparoscopic cornuostomy with suction and evacuation of conceptus. This might be a safer and less destructive method by minimal incision of cornual lesion and suction/evacuation of the ectopic conceptus without myometrial reconstruction.

Asunto(s)