[Interstitial pregnancy: experience at Rouen's hospital]

A case report of hemorrhagic shock from rare ruptured intertitial pregnancy

Introduction and importance

Interstitial pregnancy is rare and exhibit a mortality rate notably higher than that observed in other types of ectopic pregnancies.

Case presentation

The authors report a 38-year-old female admitted for a hemorrhagic shock. She was 10 weeks pregnant. The suspicion of a ruptured ectopic pregnancy arose based on amenorrhea accompanied by abdominal pain and a pelvic ultrasound showing an empty uterus and abundant free fluid in the abdomen. Emergent exploratory laparotomy was indicated by hemodynamic instability, revealing a ruptured left interstitial ectopic pregnancy.

Discussion

The use of three-dimensional ultrasonographic imaging specially in the first trimester improves the rate for early detection. The medical or surgical management of an interstitial pregnancy depends on the patient's hemodynamic stability considering the rupture of the pregnancy.

Conclusion

Interstitial pregnancy is linked to elevated morbidity. Early diagnosis and adequate management both can avoid its catastrophic outcomes.

Cornual pregnancy as a rare entity of ectopic pregnancy: A case report

INTRODUCTION AND IMPORTANCE

Cornual pregnancy, an infrequently reported form of ectopic pregnancy occurring in the uterine horn, is inadequately documented in medical literature, with an incidence below 2 %. This condition poses a substantial risk to maternal health due to delayed diagnosis and the potential for life-threatening bleeding after rupture.

CASE PRESENTATION

We present a case report following the SCARE guidelines that details a 32-year-old woman with abdominal pain and abnormal uterine bleeding. Clinical examination, β-HCG levels, and endovaginal ultrasound confirmed the presence of a 4 cm unruptured right cornual pregnancy. The patient underwent a minilaparotomy, which revealed the ectopic pregnancy, followed by a successful cornuostomy and right salpingectomy. Postoperative recovery was uneventful.

CLINICAL DISCUSSION

Cornual pregnancy, comprising around 2 % of ectopic pregnancies, is associated with increased risks of rupture and maternal morbidity. Major risk factors include a history of pregnancy termination, miscarriage, STIs, and smoking. Diagnosis is often delayed, leading to an increased risk of bleeding. Pelvic pain is a common presenting symptom, and sonographic findings aid in accurate diagnosis.

CONCLUSION

Cornual pregnancy, though rare, represents a serious condition with a significant risk of maternal morbidity and mortality. A timely diagnosis is crucial for effective treatment, with ultrasound playing a pivotal role, complemented by the essential contribution of laparoscopy. This case underscores the importance of prompt intervention to mitigate the associated risks and improve patient outcomes.

Ruptured interstitial ectopic pregnancy: A case report and review of the literature

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.

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Interstitial ectopic pregnancy is a rare entity.

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Diagnosis should be made in any woman of childbearing age presenting with pelvic pain and/or breakthrough bleeding.

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Treatment is either surgical by laparoscopy or medical by administration of methotrexate.

Technical Notes Surgical treatment of a ruptured interstitial pregnancy

Non-tubal ectopic pregnancies represent fewer than 10% of all ectopic pregnancies. However, they are associated with a high rate of mortality due to late diagnosis and uterine horn rupture which requires radical emergency surgical management. Cornuectomy via laparoscopy is a treatment of choice. We provide here a simple description of laparoscopic cornuectomy using an Endo GIA stapling system: the Endo GIA® automatic forceps. It has the advantage of removing the mass, suturing, and achieving satisfactory haemostasis in a single step.

Management of a cornual ectopic pregnancy

Cornual pregnancy is rare. Treatment involves expulsion of the pregnancy and hemostasis of the cornus if required by hemorrhagic rupture. Two techniques are proposed to achieve hemostasis of the uterine cornus, cornuotomy with suture, or corneal resection with salpingectomy, generally laparoscopically.

Recurrent Interstitial Pregnancy: a Review of the Literature

Interstitial pregnancies account for 2-4 % of all ectopic pregnancies. Despite its rarity, various treatment options exist. However, no gold standard has yet been defined and data regarding recurrence of interstitial pregnancies in subsequent pregnancies after different treatments are sparse. This makes it very difficult to provide adequate patient counselling for treatment options with regards to the treatment-related risk of recurrence. The present literature review demonstrates that recurrent interstitial pregnancy is a rare condition and more likely when additional anatomy-related risk factors for ectopic pregnancies are present, such as hydrosalpinges, blocked tubes, endometriosis, fibroids or prior tubal ectopic pregnancies. Therefore, at first appearance and in absence of additional anatomy-related risk factors, methotrexate intravenously, intramuscularly or into the amnion may be the first choice. In case of anatomical risk factors, cornual wedge resection seems to be first choice. In case of recurrence, cornual wedge resection is particularly justified in patients with anatomical alterations of the salpinges. The role of conservative surgical treatments in recurrence as cornuotomy, salpingectomy, endoloop ligation and resection and curettage under laparoscopic guidance remains unclear due to sparse data.

[Cornual pregnancy: Management and subsequent fertility]

OBJECTIVE

Cornual pregnancy is a rare entity, representing 2% of ectopic pregnancies. Its management is poorly codified and often guided by the clinical situation. The aim of our study was to describe the management of cornual pregnancies, subsequent fertility, and obstetric outcomes according to the management.

METHODS

Observational retrospective unicentric study. Nineteen patients hospitalized for cornual pregnancy between 2006 and 2015 were included. The data was collected with medical records and a phone standardized questionnaire. Patients were managed according to hemodynamic status by either systemic or local methotrexate injection or surgical corneal resection.

RESULTS

Among the 19 patients, 32% (6) were treated by systemic injection (one failure treated by surgical treatment) and 68% (13) underwent surgical treatment by cornual resection. The median HCG rate decrease was 33 days (16-62). Among the twelve patients with a desire for a new pregnancy, 7 (58%) became pregnant without assisted reproductive technology (2 following medical treatment and 5 following surgical resection). Histological analysis of uterine horn showed proximal fallopian tube lesions in 76.9% of case (chronic salpingitis, endosalpingiosis and adenomyosis).

CONCLUSION

Cornual pregnancies are at high risk of hemorrhagic rupture. Ectopic recidive may occur. Fertility and obstetrical outcomes following cornual pregnancy are not affected whatever the initial treatment. Other studies are needed to aid clinical management according to HCG level and ultrasound features.