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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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Damiani GR, Di Gennaro D, Vimercati A, Cicinelli E, Perrone AM, De Iaco P, Malvasi A, Gaetani M, Cascardi E, Cazzato G, Dellino M, Pellegrino A, Vitagliano A. Office intrauterine morcellation for retained products of conception. MINIM INVASIV THER 2023; 32:323-328. [PMID: 37493491 DOI: 10.1080/13645706.2023.2227694] [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: 01/28/2023] [Accepted: 06/02/2023] [Indexed: 07/27/2023]
Abstract
OBJECTIVE Proposing hysteroscopic morcellation (HM) as a surgical-therapeutic approach in the treatment of retained products of conception (RPOC) to prevent intrauterine adhesions (IUAs). DESIGN Prospective analysis. SETTING A teaching and university hospital. PATIENTS Women with RPOC. INTERVENTIONS Office -HM with 'Truclear 5 C'. MATERIAL AND METHODS Twenty-two consecutive patients presenting with trophoblastic residue retention after miscarriage and interruption of pregnancy or placenta remnants after cesarean section or delivery were enrolled. These women underwent office-HM with 'Truclear 5 C'. Primary outcomes were median time and rate of hospitalization. The quality of the specimen was also analyzed. A hysteroscopic second look for IUAs was performed. RESULTS Mean procedure time was six minutes (SD ± 5). Tissue samples had a mean collection size 2.5 cm3+0.9. 38% of the samples had spotting or abnormal vaginal discharge. Dilatation of the cervical canal was not performed in any case. Second-look hysteroscopy did not show any de novo IUAs in any of the enrolled patients. CONCLUSIONS In the hysteroscopic treatment of RPOC, HM is a valid choice in an office setting without the use of cervical dilatation. Removal of RPOC was uneventful in all cases, simple and carried out faster without any adverse outcomes.
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Affiliation(s)
| | - Daniele Di Gennaro
- Department of Obstetrics and Gynecology, Policlinico of Bari, University of Bari, Bari, Italy
| | - Antonella Vimercati
- Department of Obstetrics and Gynecology, Policlinico of Bari, University of Bari, Bari, Italy
| | - Ettore Cicinelli
- Department of Obstetrics and Gynecology, Policlinico of Bari, University of Bari, Bari, Italy
| | - Anna Myriam Perrone
- Department of Obstetrics and Gynecology, Unit of Oncologic Gynecology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Pierandrea De Iaco
- Department of Obstetrics and Gynecology, Unit of Oncologic Gynecology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Antonio Malvasi
- Department of Obstetrics and Gynecology, Policlinico of Bari, University of Bari, Bari, Italy
| | - Maria Gaetani
- Department of Obstetrics and Gynecology, Policlinico of Bari, University of Bari, Bari, Italy
| | - Eliano Cascardi
- Department of Obstetrics and Gynecology, Policlinico of Bari, University of Bari, Bari, Italy
| | - Gerardo Cazzato
- Department of Obstetrics and Gynecology, Policlinico of Bari, University of Bari, Bari, Italy
| | - Miriam Dellino
- Department of Obstetrics and Gynecology, Policlinico of Bari, University of Bari, Bari, Italy
| | | | - Amerigo Vitagliano
- Department of Obstetrics and Gynecology, Policlinico of Bari, University of Bari, Bari, Italy
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Sokalska A, Rambhatla A, Dudley C, Bhagavath B. Nontubal ectopic pregnancies: overview of diagnosis and treatment. Fertil Steril 2023; 120:553-562. [PMID: 37495011 DOI: 10.1016/j.fertnstert.2023.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/14/2023] [Accepted: 07/21/2023] [Indexed: 07/28/2023]
Abstract
Nontubal ectopic pregnancies occur as a result of embryo implantation outside the uterine cavity and fallopian tubes. Sites include ovary, cervix, abdominal cavity, interstitial portion of fallopian tube, and cesarean scar. Nontubal pregnancies are uncommon. Nonspecific signs and symptoms of nontubal ectopic pregnancies make diagnosis challenging and, in many cases, significantly delayed, resulting in a high rate of morbidity. Although surgical management remains the mainstay of treatment, there is growing evidence that some of these can be managed medically or with the use of a combination of medical and surgical approaches with good outcome. This review summarizes the current diagnostic modalities, therapeutic options, and outcomes for nontubal ectopic pregnancies. Diagnostic and management options may be limited, especially in resource-restricted settings. Therefore, an understanding of the available options is critical. It needs to be emphasized that the rarity of cases and the difficulties in organizing ethically justified randomized trials result in the lack of well-established management guidelines for nontubal ectopic pregnancies.
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Affiliation(s)
- Anna Sokalska
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, California.
| | - Anupama Rambhatla
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, California
| | - Christina Dudley
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
| | - Bala Bhagavath
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
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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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Conservative Management for Retained Products of Conception in Late Pregnancy. Healthcare (Basel) 2023; 11:healthcare11020168. [PMID: 36673536 PMCID: PMC9859269 DOI: 10.3390/healthcare11020168] [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: 12/05/2022] [Revised: 01/02/2023] [Accepted: 01/04/2023] [Indexed: 01/06/2023] Open
Abstract
This retrospective study aims to compare the early manual removal of placenta (MROP) and conservative management of retained products of conception (RPOC) after 34 weeks of gestation. Nineteen cases underwent MROP within 24 h of delivery, of which nine patients had no symptoms requiring emergent treatment. These 9 patients (group M) were compared with 22 patients who were treated conservatively (group C). Massive bleeding was observed in 5 (56%) patients in group M and 11 (50%) patients in group C, with no significant difference in frequency. However, the lowest hemoglobin level within 72 h after massive bleeding was lower in group M (median: 6.7 vs. 7.7 g/dL, p = 0.029), suggesting that massive bleeding occurred in a short period of time. On the other hand, a retained placenta was observed in four patients in group M after the MROP; however, the placenta disappeared more quickly than in group C (median; 1.0 vs. 99.0 days, p = 0.009). In group C, all bleeding and infection occurred within 60 days of delivery, including heavy bleeding in six cases during the placental-extraction trial. Human chorionic gonadotropin in group C fell below the measurable threshold at a median of 67 days postpartum. In conclusion, for RPOC without urgent symptoms, early MROP and conservative treatment have their advantages and disadvantages. Randomized controlled trials are needed to determine which of those treatments is superior.
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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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Najib FS, Vafaei H, Foroughi AA, Namazi N. Diagnosis pitfall of interstitial pregnancy: a case report of a term pregnancy with abnormal placentation. BMC Pregnancy Childbirth 2021; 21:699. [PMID: 34663251 PMCID: PMC8522083 DOI: 10.1186/s12884-021-04153-1] [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: 06/25/2021] [Accepted: 09/28/2021] [Indexed: 11/10/2022] Open
Abstract
Background Interstitial Pregnancy (IP) is a lethal condition due to high risk of sudden onset massive hemorrhage. Such conditions are managed as soon as diagnosed almost in the first trimester. There are a few case reports of IP conditions terminated after the second trimester. Herein, we introduce a term interstitial pregnancy complicated by abnormal placentation. Case presentation In this case report, we introduce a 32-year-old lady, primigravida, with an undiagnosed IP that was in her 38 weeks of gestational with placenta increta. She developed with perforated IP presenting with acute abdomen and internal bleeding at 26 weeks of gestational age. However, with a misdiagnosis impression, she got stable in operation room. Then, the pregnancy continued till 36 weeks of gestational age that was misdiagnosed with cervical cancer in prenatal work-ups. Finally, during elective cesarean section at 38 weeks, an IP with placenta increta (placenta evading from the serosa to the myometrium of the uterus) was observed. The baby was healthy with no obvious anomaly or morbidity. Conclusions Physicians should be aware to detect IP in all trimesters and pay attention to the coexisting complications such as placenta accreta to manage them more accurately.
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Affiliation(s)
- Fatemeh Sadat Najib
- Infertility Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Obstetrics and Gynecology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Homeira Vafaei
- Department of Obstetrics and Gynecology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.,Maternal-fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amin Abolhasan Foroughi
- Medical Imaging Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Radiology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Niloofar Namazi
- Infertility Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. .,Department of Obstetrics and Gynecology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
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