Magnetic Resonance Imaging and 3-dimensional Computed Tomographic Angiography for Conservative Management of Proximal Interstitial Pregnancy by Hysteroscopic Resection After Transcatheter Arterial Chemoembolization

Operative hysteroscopy in the minimally invasive management of interstitial pregnancy and interstitially retained products of conception: A case report and systematic literature review

OBJECTIVE

An interstitial pregnancy is a rare form of ectopic pregnancy. Diagnosis and management can be challenging. Treatment often involves invasive uterine surgery. Conservative options such as methotrexate are important alternatives nowadays. The aim of this review is to investigate the role of operative hysteroscopy in the organ and fertility preserving management of interstitial pregnancy and interstitially retained products of conception (RPOC).

METHODS

A case is presented in which interstitially RPOC were removed using hysteroscopic morcellation under laparoscopic guidance. Consequently, a systematic literature review was performed.Medline, Embase and The Cochrane Library were used as literature resources.

RESULTS

In the literature review, 14 case reports in which operative hysteroscopy was part of the minimally invasive treatment of interstitial pregnancy and interstitially RPOC of which 11 were studied. Of these 14 cases, 11 were reported as being successful. Different techniques such as laparoscopy and suction curettage were associated. Various hysteroscopic instruments were used, hysteroscopic graspers most commonly. Reported complications were uterine perforation during suction curettage and incomplete hysteroscopic resection. Analysis of the cases did not demonstrate a clear difference between different approaches concerning safety, efficacy or subsequent fertility and pregnancy outcomes.

CONCLUSION

With the growing experience in hysteroscopy and the development of novel techniques and devices, such as hysteroscopic morcellation, operative hysteroscopy has a promising role in the minimally invasive management of interstitial pregnancy and interstitially RPOC. (Laparoscopically guided) operative hysteroscopy might be a convenient approach to avoid blind curettage and related complications such as uterine perforation.

The feasibility of laparoscopically assisted, hysteroscopic removal of interstitial pregnancies: A case series

OBJECTIVE

The study objective was to assess the feasibility of the management of interstitial pregnancy by laparoscopically assisted hysteroscopic removal.

METHODS

This retrospective study included a case series of 17 patients who were diagnosed interstitial pregnancy with dilated proximal tubal ostium by transvaginal ultrasonography at the Women's hospital, School of Medicine, Zhejiang University between August 2017 and October 2020. Laparoscopically assisted hysteroscopic removals of the products of conception were performed. Various data were collected including age, surgical and obstetric history, gestational age, preoperative symptoms, human chorionic gonadotropin level and ultrasonography results. The outcomes measured were intraoperative bleeding, pathologic findings, conversions.

RESULTS

Eleven cases were successfully resected the interstitial gestational products with laparoscopically assisted hysteroscopy. There were four cases failed of hysteroscopic removal, for the proximal tubal ostia were too small for the surgical instruments to enter. Then cornual wedge resections were performed. Two cases were identified as intramural pregnancy by hysteroscopic and laparoscopic view. Most of the intramural pregnancy tissue of one patient was removed by hysteroscopy. The other one converted to laparoscopy.

CONCLUSION

Laparoscopically assisted hysteroscopic management could be a feasible surgical option to interstitial pregnancies. Further clinical studies are needed to establish detailed criteria to select the appropriate cases for hysteroscopic management.

Chronic tubal pregnancy manifesting as a heterogeneous adnexal mass with prominent neovascularization in a woman with a negative serum β-human chorionic gonadotropin level

A 41-year-old woman (gravida 2, para 1) underwent elective termination of pregnancy at approximately 7 weeks of gestation. At 1 month after the elective abortion, she was referred due to abnormal results in a cervical cytological examination. Transvaginal ultrasonography showed a heterogeneous mass of 16 mm in diameter in the left adnexal region. At 3 months after her referral, the asymptomatic left adnexal mass had increased to 55 mm in diameter. Prominent vascular flow was detected in the solid portion by color Doppler ultrasonography. Magnetic resonance imaging showed suspected hemorrhage in the left adnexal cystic mass. Three-dimensional computerized tomographic angiography showed the prominent development of tortuous blood vessels in the left adnexal region, which originated from the left ovarian artery. The patient had a negative β-human chorionic gonadotropin (hCG) level. Left salpingectomy was performed by a single-port laparoscopic approach. A pathological examination revealed degenerated villous tissue with β-hCG-positive syncytiotrophoblasts.

Cervico-isthmic pregnancy: early diagnostic imaging and successful dual therapy for uterine-sparing treatment

Cervico-isthmic pregnancy is a rare and potentially life-threatening form of ectopic gestation in which the blastocyst implants in the uterine cervico-isthmus between the histological and anatomical internal os, followed by subsequent extension to the lower uterine segment. Early diagnosis may allow a conservative therapeutic approach that avoids catastrophic hemorrhage requiring hysterectomy. Here we report the case of a 43-year-old primigravida woman whose cervico-isthmic pregnancy complicated by massive hematometra was diagnosed at 6 weeks gestation by multimodal imaging and successfully treated by hysteroscopic resection, securing adequate hemostasis, after transcatheter arterial chemoembolization.