In pursuit of understanding interstitial pregnancies: a rare yet high-risk ectopic pregnancy

Interstitial ectopic pregnancy: A rare case report

INTRODUCTION

Interstitial pregnancies are a rare form of ectopic pregnancy with life threatening consequences. Thus, the aim of this report is to shed light on the importance of early diagnosis for optimal outcomes.

CASE PRESENTATION

Herein, we present a case of an interstitial ectopic pregnancy in a 31-year-old Syrian female who presented only with mild non-specific abdominal pain. The ultrasound showed a gestational sac in the right horn of the uterus non-communicating with the endometrial cavity suggesting an interstitial ectopic pregnancy. Cornual excision and salpingectomy were performed with laparotomy instead of laparoscopy due to resource-limited facilities. Follow-up with serum human chorionic gonadotropin β-HCG continued until the hormone levels became undetectable.

DISCUSSION

Interstitial ectopic pregnancies can present with non-classic symptoms. Ultrasonographic evaluation for lower abdominal pain in women at the first trimester is essential to detect interstitial ectopic pregnancies.

CONCLUSION

Early diagnosis is key to prevent the life threatening progression of interstitial pregnancy, so this diagnosis should be kept in mind in women presenting with first trimester abdominal pain and/or vaginal bleeding.

Successful Ultrasound-Guided Methotrexate Intervention in the Treatment of Heterotopic Interstitial Pregnancy: A Case Report and Literature Review

PURPOSE

This study aims to share the experience of minimally invasive ultrasound-guided methotrexate intervention in the treatment of heterotopic interstitial pregnancy (HIP) with good pregnancy outcomes, and to review the treatment, pregnancy outcomes, and impact on the future fertility of HIP patients.

METHODS

The paper describes the medical history, clinical manifestations, treatment history, and clinical prognosis of a 31-year-old woman with HIP, and reviews cases of HIP from 1992 to 2021 published in the PubMed database.

RESULTS

The patient was diagnosed with HIP by transvaginal ultrasound (TVUS) at 8 weeks after assisted reproductive technology. The interstitial gestational sac was inactivated by ultrasound-guided methotrexate injection. The intrauterine pregnancy was successfully delivered at 38 weeks of gestation. Twenty-five HIP cases in 24 studies published on PubMed from 1992 to 2021 were reviewed. Combined with our case, there were 26 cases in total. According to these studies, 84.6% (22/26) of these cases were conceived by in vitro fertilization embryo transfer, 57.7% (15/26) had tubal disorders, and 23.1% (6/26) had a history of ectopic pregnancy; 53.8% (14/26) of the patients presented with abdominal pain and 19.2% (5/26) had vaginal bleeding. All cases were confirmed by TVUS. In total, 76.9% (20/26) of intrauterine pregnancies had a good prognosis (surgery vs. ultrasound interventional therapy 1:1). All fetuses were born without abnormalities.

CONCLUSIONS

The diagnosis and treatment of HIP remain challenging. Diagnosis mainly relies on TVUS. Interventional ultrasound therapy and surgery are equally safe and effective. Early treatment of concomitant heterotopic pregnancy is associated with high survival of the intrauterine pregnancy.

A Purse-String Approach to Laparoscopic Cornuotomy for Interstitial Ectopic Pregnancy

An interstitial ectopic refers to the implantation of a pregnancy in the proximal fallopian tube where it passes through the myometrium. This type of ectopic pregnancy presents a distinct surgical challenge, as it often presents with rupture and carries a significant risk of hemorrhage at resection. This video demonstrates a four-step approach to the resection of an interstitial ectopic pregnancy with laparoscopic cornuotomy. This approach includes (1) isolating the pregnancy by performing a salpingectomy and identifying the utero-ovarian ligament; (2) ensuring hemostasis with the injection of vasopressin, followed by application of the purse string suture around the pregnancy at its equatorial line; (3) performing the resection using a linear incision; and (4) repairing the uterine defect with layered closure. The purse-string suture is shown to be a useful tool in minimizing bleeding, and this sequential approach allows for interstitial ectopic pregnancies to be excised with a minimally invasive cornuotomy, even in cases of significant anatomical distortion.

Hysteroscopy-assisted laparoscopic salpingectomy for interstitial pregnancy without cornual resection

OBJECTIVE

To illustrate a novel surgical management technique for interstitial ectopic pregnancies (IP).

DESIGN

Video description of the case, demonstration of the surgical technique, reevaluation at the 6-week postoperative follow-up, and review of the advantages of this surgical technique for IP.

SETTING

Tertiary referral center.

PATIENT(S)

A 42-year-old gravida 2 para 1-0-0-1, underwent a successful in vitro fertilization (IVF) cycle with a single embryo transfer and had an early ultrasound diagnosis of IP with cardiac activity. After failed medical management with a single dose of methotrexate, she was referred to us for surgical management. Transvaginal ultrasound revealed fluid in the cul-de-sac and confirmed a right interstitial ectopic pregnancy with an estimated gestational age of 6 weeks. The myometrium at the periphery of the implantation site was 1-1.5 mm, and the "interstitial line sign" was seen. After counseling for possible treatment modalities, the patient opted for surgical management, planning for further IVF treatment. Her preoperative β-human chorionic gonadotropin level (β-hCG) was 3241 IU/L. Her surgical history was significant for a previous myomectomy via laparotomy and an elective lower transverse C-section.

INTERVENTION(S)

Hysteroscopy assisted by multipuncture video laparoscopy surgery was performed. Hysteroscopic resection was not feasible as the ectopic was not visualized as described previously. Using normal saline as the distension media and with the hysteroscope aimed at the right ostium, the hydrostatic pressure was increased transiently to dissect the ectopic pregnancy and facilitate the next surgical step. Laparoscopically, the ectopic pregnancy was milked with atraumatic graspers and mobilized from the cornua into the tube creating enough proximal length for salpingectomy. Right salpingectomy was achieved using high-frequency bipolar with no complications.

MAIN OUTCOME MEASURE(S)

Hysteroscopy-assisted laparoscopy technique allows for several advantages, including a short operative time and minimal blood loss. No sutures were required and the myometrial architecture was left undisrupted.

RESULT(S)

The postoperative course was uncomplicated, and the patient was discharged on the same day of surgery. The patient's β-hCG level dropped from 3,241 to 139 IU/L after 48 hours. Two weeks later, the β-hCG level was 3 IU/L. A follow-up ultrasound was performed six weeks postoperatively confirming the integrity of the myometrium without defects and proportional wall thickness on both sides. The patient was referred back to her infertility specialist to resume IVF treatment with no remarkable delay.

CONCLUSION(S)

In select cases and the presence of a proficient laparoscopic surgeon, early diagnosed IP can be removed safely using the described novel technique. While an interval conception of 3-6 months is recommended after conventional surgical procedures for IP, this technique can be comparable to salpingectomy.

Use of Laparoscopic Slip Knot with Purse-String Suture in Surgical Management of Unruptured Heterotopic Interstitial Pregnancies

Background

The aim of this study was to investigate the advantages and disadvantages of using laparoscopic slip knot with purse-string suture technique in the surgical management of unruptured heterotopic interstitial pregnancies compared with other surgical strategies.

Material/Methods

We retrospectively analyzed data on 13 patients with unruptured heterotopic interstitial pregnancies who underwent laparoscopy in our hospital between May 2012 and August 2018. The control group consisted of 10 patients who underwent cornual resection or cornuostomy with conventional sutures and knots. The study group consisted of 3 patients whose surgical plans involved use of the slip knot with purse-string suture technique followed by cornuostomy. We evaluated the surgical records and video to comparatively analyze their operation duration, intraoperative blood loss, and pregnancy outcomes.

Results

The average volume of intraoperative blood loss was 76.67±25 ml in the study group and 215.00±110 ml in the control group. On average, the intraoperative blood loss volume in the study group was 138 ml less than in the control group and the difference was statistically significant (P<0.05). There was no statistically significant difference in the live birth rate and operation time between the 2 groups (P>0.05). The duration of hemostasis in the study group was 11 min shorter than in the control group, while the duration of cornual electrocoagulation in the study group was 18.5 s shorter. Both groups achieved thorough hemostasis without the help of vasopressin and avoided use of embryo-killing drugs such as methotrexate. Neither group required second surgery or developed postoperative complications such as uterus rupture or persistent ectopic pregnancy.

Conclusions

This strategy is safe and reliable for gestational sac clearance while simultaneously preventing any potential harm to the intrauterine embryo. It is particularly suitable for unruptured HIP patients who have a strong desire to preserve their intrauterine embryos.