Nonsurgical Management of Interstitial Pregnancies: Feasibility and Predictors of Treatment Failure

Pregnancies at the Uterotubal Junction: A Review of Terminology (Interstitial, Cornual, and Angular) and Recommendations for Management

Ectopic pregnancies are one of the most common causes of obstetric mortality worldwide. Interstitial ectopic pregnancies, defined as an extracavitary pregnancy within the portion of the Fallopian tube that transverses the myometrium, have reported mortality rates approximately seven times higher than all types of ectopic pregnancy combined. In contrast, intracavitary eccentric gestations, often labeled as "cornual" or "angular" pregnancies, have reportedly high rates of live birth. Unfortunately, the terms "interstitial," "cornual," and "angular" have long been used with varying diagnostic criteria and often interchangeably to describe a pregnancy near the uterotubal junction. The inconsistency in nomenclature and lack of clear diagnostic criteria to distinguish among these pregnancies has resulted in a paucity of data to provide accurate prognostic information and guide appropriate management. This review article aims to provide historical context for the terms "interstitial," "cornual," and "angular;" discuss previous and more recent innovations of diagnostic methods; and provide recommendations for concise terminology and inform management.

Interstitial pregnancy management: A multicentric analysis of 98 patients from the FRANCOGENT group comparing surgery and medical treatment

OBJECTIVE

To evaluate the outcomes associated with each therapeutic option for patients diagnosed with interstitial pregnancy (IP).

METHODS

We conducted a multicentric retrospective cohort study within the departments of Gynecology and Obstetrics involved in the Francogent research group. Women treated for an interstitial pregnancy between January 2008 to December 2019 were included. Three therapeutic options were evaluated: surgical treatment (ST); in situ methotrexate combined with systemic methotrexate (IS-MTX); and systemic methotrexate (IM-MTX). Success of first-line treatment was defined by hCG negativation (<5I U/L). Secondary outcomes included the need for secondary surgical procedure, secondary medical treatment, emergency surgery, postoperative complications, duration of hospitalization, and delay before hCG negativation.

RESULTS

A total of 98 patients were managed for IP: 42 (42.9%) patients had IM-MTX; 34 (34.7%) had IS-MTX; and 22 (22.4%) had ST. First-line treatment was successful in all patients of the ST group (22/22, 100%), in 31% of patients within the IM-MTX group (13/42) and 70.6% (24/34) in the IS-MTX group. The sole parameter associated with the risk of treatment failure was the mode of methotrexate administration. The size of the gestational sac or the presence of fetal heartbeat was not associated with decreased medical treatment (IS or IM-MTX) efficiency.

CONCLUSION

Either ST or IS-MTX are good options for IP treatment associated with high success rates. A single-dose regimen of IM-MTX is less efficient than IS-MTX or ST. Symptomatic patients with severity criteria should always undergo emergency surgery. IP remains a high-risk condition that should be managed, whenever possible, in referral centers to potentialize the chances of favorable outcomes.

A 10‐year retrospective cohort study of non‐tubal ectopic pregnancy management outcomes in an Australian tertiary centre

Introduction

Non-tubal ectopic pregnancy (NTEP) is a rare but significant early pregnancy complication which can result in maternal morbidity and mortality. There is however a lack of evidence-based guidelines for the management of NTEP.

Purpose

To evaluate the success rates of expectant, medical and surgical management in the treatment of NTEP at our tertiary centre.

Methods

Retrospective cohort study from 2010 to 2020. All NTEP were classified by ectopic sites. Primary management was classified by expectant, medical [systemic methotrexate (Sys-MTX) and/or local ultrasound-guided injection of MTX and/or KCl intra-sac (L-MTX, L-MTX/KCl)] or surgical. Primary management was considered successful if no change in intervention was required. Treatment complications were compared.

Results

Twenty-four NTEP were identified, which included 14 interstitial pregnancies (IP), 9 caesarean scar pregnancies (CSP) and 1 ovarian pregnancy (OP), which gave NTEP an incidence of 7.12% among all EP (4.15% for IP, 2.67% for CSP and 0.30% for OP). The success of primary surgical management was 100% (7/7), primary medical management was 76.9% (10/13) and primary expectant management was 33.3% (1/3). Primary medical management had a non-statistically significant greater mean time to serum ß-human Chorionic Gonadotrophin <5 IU/L, mean length of hospitalisation, mean number of follow-up visits and hospital re-presentation/readmissions compared to primary surgical management. There was no other difference in complication rates between the treatment management groups.

Conclusion

Surgery remains the most effective way to manage NTEP. However, medical management can be a safe and effective alternative option in carefully selected cases.

Diagnosis pitfall of interstitial pregnancy: a case report of a term pregnancy with abnormal placentation

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.

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.

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.