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Po L, Thomas J, Mills K, Zakhari A, Tulandi T, Shuman M, Page A. Guideline No. 414: Management of Pregnancy of Unknown Location and Tubal and Nontubal Ectopic Pregnancies. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:614-630.e1. [PMID: 33453378 DOI: 10.1016/j.jogc.2021.01.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To provide an evidence-based algorithm to guide the diagnosis and management of pregnancy of unknown location and tubal and nontubal ectopic pregnancy. TARGET POPULATION All patients of reproductive age. BENEFITS, HARMS, AND COSTS The implementation of this guideline aims to benefit patients with positive β-human chorionic gonadotropin results and provide physicians with a standard algorithm for expectant, medical, and surgical treatment of pregnancy of unknown location and tubal pregnancy and nontubal ectopic pregnancies. EVIDENCE The following search terms were entered into PubMed/Medline and Cochrane in 2018: cesarean section, chorionic gonadotropin, beta subunit, human/blood, fallopian tubes/surgery, female, fertility, humans, infertility, laparoscopy, methotrexate, methotrexate/administration & dosage, methotrexate/therapeutic use, pregnancy (abdominal, angular, cervix, cornual, ectopic, ectopic/diagnosis, ectopic/diagnostic imaging, ectopic/drug therapy, ectopic/epidemiology, ectopic/mortality, ectopic/surgery, heterotopic, interstitial, isthmo-cervical, ovarian, tubal, unknown location), recurrence, risk factors, salpingectomy, salpingostomy, tubal pregnancy, ultrasonography, doppler ultrasonography, and prenatal. Articles included were randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE Obstetrician-gynaecologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, and residents and fellows. SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES) RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).
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Management of interstitial pregnancy in the era of laparoscopy: a meta-analysis of 855 case studies compared with traditional techniques. Obstet Gynecol Sci 2021; 64:156-173. [PMID: 33539687 PMCID: PMC7990998 DOI: 10.5468/ogs.20299] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/27/2020] [Indexed: 11/08/2022] Open
Abstract
Interstitial pregnancy is a rare, life-threatening condition that requires high clinical suspicion for diagnosis. Most cases are discovered after complications have occurred. Many authors have described laparoscopic management. Although previous systematic reviews have compared the attributes and complications associated with interstitial pregnancy, we endeavored to complete the first systematic review and meta-analysis to compare the laparoscopic treatment of interstitial pregnancy with the open approach in the modern age of laparoscopic surgery. We systematically searched PubMed, ClinicalTrials.gov, Scopus, Web of Science, and Cochrane until June 2020 using relevant keywords and screened them for eligibility. We found a statistically significant difference in blood loss between laparoscopic and open surgery (168 mL compared to 1,163 mL). Further, cumulative meta-analysis has revealed that blood loss in laparoscopy has been decreasing over time from 1991 to 2020. Laparoscopic patients took less operative time (63.2 minutes) compared to laparotomy patients (78.2 minutes). Patients in the laparoscopic group spent less time hospitalized (3.7 days) compared to laparotomy patients (5.2 days). Our findings add strength to the position that laparoscopic approaches to interstitial pregnancy can be considered first-line in most situations. The laparoscopic approach was found to have a mean blood loss of 168 mL, and this blood loss seems to decrease over time. Increased gravidity and duration of amenorrhea are positive factors that increase bleeding during the procedure. We are unable to find enough high-quality data to significantly compare successful pregnancy following surgery or risk of mortality in these populations.
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Po L, Thomas J, Mills K, Zakhari A, Tulandi T, Shuman M, Page A. Directive clinique n o 414 : Prise en charge des grossesses de localisation indéterminée et des grossesses ectopiques tubaires et non tubaires. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:631-649.e1. [PMID: 33453377 DOI: 10.1016/j.jogc.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIF Fournir un algorithme fondé sur des données probantes pour orienter le diagnostic et la prise en charge de la grossesse de localisation indéterminée et de la grossesse ectopique tubaire ou non tubaire. POPULATION CIBLE Toutes les patientes en âge de procréer. BéNéFICES, RISQUES ET COûTS: La mise en œuvre de la présente directive a pour objectif de bénéficier aux patientes ayant obtenu un résultat positif pour la sous-unité bêta de la gonadotrophine chorionique et de fournir aux médecins un algorithme normalisé pour l'expectative et le traitement pharmacologique ou chirurgical en cas de grossesse de localisation indéterminée et de grossesse ectopique tubaire ou non tubaire. DONNéES PROBANTES: Les termes de recherche suivants ont été entrés dans les bases de données PubMed-Medline et Cochrane en 2018 : cesarean section, chorionic gonadotropin, beta subunit, human/blood, fallopian tubes/surgery, female, fertility, humans, infertility, laparoscopy, methotrexate, methotrexate/administration & dosage, methotrexate/therapeutic use, pregnancy (abdominal, angular, cervix, cornual, ectopic, ectopic/diagnosis, ectopic/diagnostic imaging, ectopic/drug therapy, ectopic/epidemiology, ectopic/mortality, ectopic/surgery, heterotopic, interstitial, isthmo-cervical, ovarian, tubal, unknown location), recurrence, risk factors, salpingectomy, salpingostomy, tubal pregnancy, ultrasonography, doppler ultrasonography et prenatal. Les articles retenus sont des essais cliniques randomisés, des méta-analyses, des revues systématiques, des études observationnelles et des études de cas. Des publications supplémentaires ont été sélectionnées à partir des notices bibliographiques de ces articles. Seuls les articles en anglais ont été examinés. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la solidité des recommandations en utilisant la méthodologie GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PUBLIC VISé: Obstétriciens-gynécologues, médecins de famille, urgentologues, sages-femmes, infirmières autorisées, infirmières praticiennes, étudiants en médecine, résidents et moniteurs cliniques. DÉCLARATIONS SOMMAIRES (CLASSEMENT GRADE ENTRE PARENTHèSES): RECOMMANDATIONS (CLASSEMENT GRADE ENTRE PARENTHèSES).
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Dolinko AV, Vrees RA, Frishman GN. Non-tubal Ectopic Pregnancies: Overview and Treatment via Local Injection. J Minim Invasive Gynecol 2018; 25:287-296. [DOI: 10.1016/j.jmig.2017.07.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 07/10/2017] [Accepted: 07/13/2017] [Indexed: 12/11/2022]
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Egger E. Recurrent Interstitial Pregnancy: a Review of the Literature. Geburtshilfe Frauenheilkd 2017; 77:335-339. [PMID: 28552996 DOI: 10.1055/s-0043-100107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
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.
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Affiliation(s)
- Eva Egger
- University of Bonn, Department of Obstetrics and Gynecology/CIO, Bonn, Germany.,Florence Nightingale Hospital, Department of Obstetrics and Gynecology, Düsseldorf, Germany
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Leggieri C, Guasina F, Casadio P, Arena A, Pilu G, Seracchioli R. Hysteroscopic Methotrexate Injection Under Ultrasonographic Guidance for Interstitial Pregnancy. J Minim Invasive Gynecol 2016; 23:1195-1199. [PMID: 27448506 DOI: 10.1016/j.jmig.2016.07.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 07/09/2016] [Accepted: 07/13/2016] [Indexed: 10/21/2022]
Abstract
A 36-year-old woman presented with pelvic pain and vaginal blood loss and interstitial pregnancy (a single gestational sac located in the proximity of the right uterine horn, without visualization of an embryo and/or attachments inside) on 2- and 3-dimensional ultrasonographic examination. The patient was clinically stable. Her abdomen was soft with normal peristalsis; superficial and deep palpation were painless, as was decompression. With the patient under general anesthesia, an operative hysteroscopy was performed visually via ultrasound. A slow injection of methotrexate solution was pushed through the right cornual region inside the gestational sac and into the myometrial tissue tangentially at the 4 cardinal points. Twelve weeks later, the patient exhibited normal tubal patency via sonohysterography, as well as a viable pregnancy of 7 weeks' gestation. This minimally invasive approach is well tolerated and shows promise for the management of interstitial pregnancy, with no adverse effect on potential subsequent fertility.
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Affiliation(s)
- Concetta Leggieri
- Gynecology and Physiopathology of Reproduction Section, Department of Obstetrics and Gynecology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Francesca Guasina
- Gynecology and Physiopathology of Reproduction Section, Department of Obstetrics and Gynecology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Paolo Casadio
- Gynecology and Physiopathology of Reproduction Section, Department of Obstetrics and Gynecology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
| | - Alessandro Arena
- Gynecology and Physiopathology of Reproduction Section, Department of Obstetrics and Gynecology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Gianluigi Pilu
- Gynecology and Physiopathology of Reproduction Section, Department of Obstetrics and Gynecology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Renato Seracchioli
- Gynecology and Physiopathology of Reproduction Section, Department of Obstetrics and Gynecology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Wang J, Huang D, Lin X, Saravelos SH, Chen J, Zhang X, Li T, Zhang S. Incidence of Interstitial Pregnancy After In Vitro Fertilization/Embryo Transfer and the Outcome of a Consecutive Series of 38 Cases Managed by Laparoscopic Cornuostomy or Cornual Repair. J Minim Invasive Gynecol 2016; 23:739-47. [DOI: 10.1016/j.jmig.2016.02.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 02/23/2016] [Accepted: 02/27/2016] [Indexed: 10/22/2022]
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Debras E, Fernandez H, Pourcelot AG, Houllier M, Capmas P. [Medical management of interstitiel pregnancy by in situ methotrexate]. ACTA ACUST UNITED AC 2016; 45:673-8. [PMID: 26993077 DOI: 10.1016/j.jgyn.2015.11.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 11/06/2015] [Accepted: 11/24/2015] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Interstitial pregnancy accounts for 3 to 11% of ectopic pregnancy; these pregnancies are the more frequently non-tubal ectopic pregnancy. Medical treatment can be used in case of unruptured interstitial pregnancy and is used more and more frequently to avoid hemorrhagic risk and risk of conversion to radical surgery when a surgical management is decided. However, a larger use of methotrexate in interstitial pregnancy and conditions of use are not clearly defined. The aim of this study is to report a series of unruptured interstitial pregnancy managed by in situ injection of methotrexate. WOMEN AND METHODS This retrospective observational study included women treated for an interstitial pregnancy between 2010 and 2013 in a teaching hospital. Medical management used was an in situ injection of methotrexate (1mg/kg) guided by vaginal sonography plus an intramuscular injection of methotrexate (1mg/kg) in the 48hours following in situ injection and 600mg of mifepristone when progesterone blood rate was more than 9ng/mL. A great decrease of serum hCG without surgery was considered a success. RESULTS Fourteen women had an interstitial pregnancy during the study period. Six were managed surgically in 5 cases for suspicion of uterine rupture and one for pregnancy of unknown location. Eight women had a medical management and the success rate was 100%. Mean time for decrease of serum hCG until 2 UI/L was 54.4 days [34.0-74.8]. No uterine rupture or immediate complication was reported. Five women out of 8 had a spontaneous pregnancy after management of interstitial pregnancy. CONCLUSION Medical management by in situ injection of methotrexate under sonographic guidance with an intramuscular injection within the 48hours following the in situ injection and mifepristone when ectopic pregnancy was active can be proposed in first-line therapy in case of unruptured interstitial pregnancy. This treatment has a great efficiency and low rate of complications.
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Affiliation(s)
- E Debras
- Service de gynécologie obstétrique, hôpital Bicêtre, groupement hospitalier universitaire Sud, AP-HP, 78, avenue du Général-Leclerc, 94275 Le Kremlin-Bicêtre cedex, France
| | - H Fernandez
- Service de gynécologie obstétrique, hôpital Bicêtre, groupement hospitalier universitaire Sud, AP-HP, 78, avenue du Général-Leclerc, 94275 Le Kremlin-Bicêtre cedex, France; Inserm, centre de recherche en épidémiologie et santé des populations (CESP), U1018, 94276 Le Kremlin-Bicêtre, France; Faculté de médecine, université Paris-Sud, 94276 Le Kremlin-Bicêtre, France
| | - A-G Pourcelot
- Service de gynécologie obstétrique, hôpital Bicêtre, groupement hospitalier universitaire Sud, AP-HP, 78, avenue du Général-Leclerc, 94275 Le Kremlin-Bicêtre cedex, France; Faculté de médecine, université Paris-Sud, 94276 Le Kremlin-Bicêtre, France
| | - M Houllier
- Service de gynécologie obstétrique, hôpital Bicêtre, groupement hospitalier universitaire Sud, AP-HP, 78, avenue du Général-Leclerc, 94275 Le Kremlin-Bicêtre cedex, France; Faculté de médecine, université Paris-Sud, 94276 Le Kremlin-Bicêtre, France
| | - P Capmas
- Service de gynécologie obstétrique, hôpital Bicêtre, groupement hospitalier universitaire Sud, AP-HP, 78, avenue du Général-Leclerc, 94275 Le Kremlin-Bicêtre cedex, France; Inserm, centre de recherche en épidémiologie et santé des populations (CESP), U1018, 94276 Le Kremlin-Bicêtre, France; Faculté de médecine, université Paris-Sud, 94276 Le Kremlin-Bicêtre, France.
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Hemostatic Techniques for Laparoscopic Management of Cornual Pregnancy: Double-Impact Devascularization Technique. J Minim Invasive Gynecol 2016; 23:274-80. [DOI: 10.1016/j.jmig.2015.09.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 09/02/2015] [Accepted: 09/03/2015] [Indexed: 11/18/2022]
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Nikodijevic K, Bricou A, Benbara A, Moreaux G, Nguyen C, Carbillon L, Poncelet C, Boujenah J. [Cornual pregnancy: Management and subsequent fertility]. ACTA ACUST UNITED AC 2015; 44:11-6. [PMID: 26678164 DOI: 10.1016/j.gyobfe.2015.10.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 10/14/2015] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- K Nikodijevic
- Service de gynécologie-obstétrique, université Paris XIII-Bobigny, CHU Jean-Verdier, avenue du 14-Juillet, 93140 Bondy, France
| | - A Bricou
- Service de gynécologie-obstétrique, université Paris XIII-Bobigny, CHU Jean-Verdier, avenue du 14-Juillet, 93140 Bondy, France
| | - A Benbara
- Service de gynécologie-obstétrique, université Paris XIII-Bobigny, CHU Jean-Verdier, avenue du 14-Juillet, 93140 Bondy, France
| | - G Moreaux
- Service de gynécologie-obstétrique, université Paris XIII-Bobigny, CHU Jean-Verdier, avenue du 14-Juillet, 93140 Bondy, France
| | - C Nguyen
- Service de gynécologie-obstétrique, université Paris XIII-Bobigny, CHU Jean-Verdier, avenue du 14-Juillet, 93140 Bondy, France; Université Paris 13, Sorbonne Paris cité, UFR SMBH, 93140 Bobigny, France
| | - L Carbillon
- Service de gynécologie-obstétrique, université Paris XIII-Bobigny, CHU Jean-Verdier, avenue du 14-Juillet, 93140 Bondy, France; Université Paris 13, Sorbonne Paris cité, UFR SMBH, 93140 Bobigny, France
| | - C Poncelet
- Service de gynécologie-obstétrique, université Paris XIII-Bobigny, CHU Jean-Verdier, avenue du 14-Juillet, 93140 Bondy, France; Université Paris 13, Sorbonne Paris cité, UFR SMBH, 93140 Bobigny, France
| | - J Boujenah
- Service de gynécologie-obstétrique, université Paris XIII-Bobigny, CHU Jean-Verdier, avenue du 14-Juillet, 93140 Bondy, France; Université Paris 13, Sorbonne Paris cité, UFR SMBH, 93140 Bobigny, France.
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Wang YL, Weng SS, Huang WC, Su TH. Laparoscopic management of ectopic pregnancies in unusual locations. Taiwan J Obstet Gynecol 2014; 53:466-70. [DOI: 10.1016/j.tjog.2014.01.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2014] [Indexed: 10/24/2022] Open
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Cucinella G, Calagna G, Rotolo S, Granese R, Saitta S, Tonni G, Perino A. Interstitial pregnancy: a 'road map' of surgical treatment based on a systematic review of the literature. Gynecol Obstet Invest 2014; 78:141-9. [PMID: 25060047 DOI: 10.1159/000364869] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 05/27/2014] [Indexed: 11/19/2022]
Abstract
An electronic search concerning the surgical approach in cases of interstitial pregnancy from January 2000 to May 2013 has been carried out. Fifty three studies have been retrieved and included for statistical analysis. Conservative and radical surgical treatments in 354 cases of interstitial pregnancy are extensively described. Hemostatic techniques have been reported as well as clinical criteria for the medical approach. Surgical outcome in conservative versus radical treatment were similar. When hemostatic techniques were used, lower blood losses and lower operative times were recorded. Conversion to laparotomy involved difficulties in hemostasis and the presence of persistent or multiple adhesions. Laparoscopic injection of vasopressin into the myometrium below the cornual mass was the preferred approach.
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Affiliation(s)
- Gaspare Cucinella
- Department of Obstetrics and Gynecology, University Hospital 'Paolo Giaccone', Palermo, Italy
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Challenges in the diagnosis and management of interstitial and cornual ectopic pregnancies. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2013. [DOI: 10.1016/j.mefs.2013.01.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Júnior JE, Musiello RB, Araujo Júnior E, Souza E, Fava JL, Guerzet EA, Camano L. Conservative management of cervical pregnancy with embryonic heart activity by ultrasound-guided local injection: an eight case series. J Matern Fetal Neonatal Med 2013; 27:1378-81. [PMID: 24134459 DOI: 10.3109/14767058.2013.856413] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate the efficacy of conservative management of cervical pregnancy with embryonic heart activity by ultrasound-guided local injection. METHODS Retrospective case series at University tertiary care Hospital. Eight patients diagnosed with cervical pregnancy with embryonic heart activity managed conservatively. The intervention was ultrasound-guided local injection of methotrexate (1 mg/kg) and potassium chloride (2 meq/mL). Measurements were occurrence of morbidity, necessity for further intervention, the initial titers of beta-hCG, interval of time in which the levels of beta-hCG became negative, period for regression of cervical pregnancy at ultrasound and future pregnancy. RESULTS All patients were treated successfully. The initial levels of beta-hCG ranged from 3013 to 71199 mUI/mL. One case evaluated with infection. There was no need for additional intervention in our series study. The interval of time for the levels of beta-hCG becomes negative range from 2 to 12 weeks. The period for the regression of the cervical pregnancy at ultrasound range from 3 to 14 weeks. In two cases intrauterine pregnancies occurred after the treatment. CONCLUSION Conservative management of cervical pregnancy with embryonic heart activity by ultrasound-guided injection is an effective treatment avoiding the need of further intervention.
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Affiliation(s)
- Julio Elito Júnior
- Department of Obstetrics, São Paulo Federal University (UNIFESP) , São Paulo - SP , Brazil
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Douysset X, Verspyck E, Diguet A, Marpeau L, Chanavaz-Lacheray I, Rondeau S, Resch B, Sergent F. [Interstitial pregnancy: experience at Rouen's hospital]. ACTA ACUST UNITED AC 2013; 42:216-21. [PMID: 23602139 DOI: 10.1016/j.gyobfe.2012.09.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 09/13/2012] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Presenting our experience concerning interstitial pregnancies (IP) surgical management and to evaluate our patients' subsequent long-term fertility. PATIENTS AND METHOD Twenty patients underwent surgical treatment of IP in our department over 15 years. In this retrospective study, we present symptoms that led to diagnosis, treatments, fertility and obstetrical outcome. RESULTS Mean gestational age at diagnosis was 8SA, with a median BHCG rate of 7411 IU/L, and a patient mean age of 30 years. Ninety percent of patients had at least one risk factor for ectopic pregnancy. Pain or bleeding were the most common symptoms at admission, 4 patients were admitted in an hypovolemic shock status. Location of the interstitial ectopic pregnancy was discovered during surgery in 45 % of cases. Six patients had a large hemoperitoneum bigger than 1L, 5 patients had an IP of uterine stump after salpingectomy for a previous ectopic pregnancy. The most used surgical technique was in 60 % of cases the excision by Endo GIA stapling(®) with salpingectomy. Regarding fertility, 12 patients wished pregnancy in the aftermath of the intervention, 10 had at least one pregnancy, among them there is an ectopic contralateral ampullary pregnancy, and a contralateral recurrence of interstitial pregnancy. Four patients were delivered by cesarean section and 4 patients were delivered vaginally, some several times. No uterine rupture occured. DISCUSSION AND CONCLUSION Interstitial pregnancy is a rare ectopic pregnancy. Its diagnosis is difficult and may involve maternal life-threatening and fertility. In subsequent pregnancies, the clinician has to be careful concerning the risks of interstitial pregnancy recurrence and uterine rupture.
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Affiliation(s)
- X Douysset
- Pôle gynécologique et obstétricale, CHU Charles-Nicolle, 1, rue de Germont, 76000 Rouen, France; Clinique universitaire de gynécologie-obstétrique, université Joseph-Fourrier et CHU de Grenoble, boulevard de la Chantourne, 38700 La Tronche, France.
| | - E Verspyck
- Pôle gynécologique et obstétricale, CHU Charles-Nicolle, 1, rue de Germont, 76000 Rouen, France
| | - A Diguet
- Pôle gynécologique et obstétricale, CHU Charles-Nicolle, 1, rue de Germont, 76000 Rouen, France
| | - L Marpeau
- Pôle gynécologique et obstétricale, CHU Charles-Nicolle, 1, rue de Germont, 76000 Rouen, France
| | - I Chanavaz-Lacheray
- Maternité du Belvédère, 72, rue Louis-Pasteur, 76130 Mont Saint-Aignan, France
| | - S Rondeau
- Clinique pédiatrique, CHU Charles-Nicolle, 1, rue de Germont, 76000 Rouen, France
| | - B Resch
- Pôle gynécologique et obstétricale, CHU Charles-Nicolle, 1, rue de Germont, 76000 Rouen, France
| | - F Sergent
- Clinique universitaire de gynécologie-obstétrique, université Joseph-Fourrier et CHU de Grenoble, boulevard de la Chantourne, 38700 La Tronche, France
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Rheinboldt M, Ibrahim S. Atypical presentation of a large interstitial pregnancy. Emerg Radiol 2012; 20:251-4. [PMID: 23250569 DOI: 10.1007/s10140-012-1096-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 11/21/2012] [Indexed: 11/30/2022]
Abstract
We report the case of a 20-year-old female who presented to the ER with a 1-week history of worsening abdominal pain and intermittent vaginal bleeding for the previous 5 days. Physical exam was notable for bilateral adnexal tenderness and a closed cervix without motion tenderness or discharge. Laboratory data demonstrated a beta HCG level of 7,787 IU/L, and pelvic ultrasound with transvaginal imaging was subsequently performed. Neither an adnexal mass nor a normal intrauterine pregnancy was demonstrable; however, a focal right fundal 7-cm area of heterogeneous echogenicity was observed. Initial findings were felt indeterminate with considerations including potential degenerating leiomyoma coexistent with a nonvisualized intrauterine pregnancy, ectopic pregnancy, or recent spontaneous abortion versus atypical interstitial ectopic pregnancy. The patient, initially declining further clinical intervention, returned within 24 h with continued pain. A repeat ultrasound demonstrated a relatively static and unchanged appearance with only a minimal concurrent interval increase in beta HCG levels. MRI was performed for further elucidation and demonstrated a heterogeneously hypervascular right fundal interstitial 6-cm mass, which, in the clinical context, was most suspicious for an ectopic pregnancy. Confirmatory laparoscopic cornual wedge resection and salpingectomy was subsequently performed.
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Affiliation(s)
- Matthew Rheinboldt
- Department of Emergency Radiology, Henry Ford Hospital, Detroit, MI, USA.
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Muglu J, Uchil D, Sau A, Zamblera D, Jolaoso A. Recurrent Uterine Rupture After Laparoscopic Surgery for Interstitial Ectopic Pregnancy. J Gynecol Surg 2012. [DOI: 10.1089/gyn.2011.0058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Javaid Muglu
- Department of Obstetrics and Gynaecology, Princess Alexandra Hospital, Harlow, Essex, United Kingdom
| | - Diraj Uchil
- Department of Obstetrics & Gynaecology University Hospital, Lewisham, London, United Kingdom
| | - Ashish Sau
- Department of Obstetrics & Gynaecology University Hospital, Lewisham, London, United Kingdom
| | - Dan Zamblera
- Department of Obstetrics & Gynaecology University Hospital, Lewisham, London, United Kingdom
| | - Adeboye Jolaoso
- Department of Obstetrics & Gynaecology University Hospital, Lewisham, London, United Kingdom
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Fylstra DL. Ectopic pregnancy not within the (distal) fallopian tube: etiology, diagnosis, and treatment. Am J Obstet Gynecol 2012; 206:289-99. [PMID: 22177188 DOI: 10.1016/j.ajog.2011.10.857] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Revised: 09/29/2011] [Accepted: 10/16/2011] [Indexed: 12/16/2022]
Abstract
Ectopic pregnancy is a very common diagnosis (2% of pregnancies), and implantation location varies. Although 97% of ectopics are implanted within the fallopian tube, associated with commonly recognized risk factors, ectopic implantation can occur in other pelvic and abdominal locations that may not have such predisposing risk factors. After an extensive review of the literature, along with the author's personal experience, implantation frequency, etiologic possibilities, and treatment options for each ectopic pregnancy location are presented. When ectopic pregnancy is diagnosed early, before rupture, regardless of location, conservative, fertility-sparing treatment options can be successful in terminating the pregnancy. Predisposing risk factors and treatment options can vary and can be ectopic-location specific.
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Affiliation(s)
- Donald L Fylstra
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC, USA
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Muglu J, Uchil D, Sau A, Zamblera D, Jolaoso A. Recurrent Uterine Rupture After Laparoscopic Surgery for Interstitial Ectopic Pregnancy. J Gynecol Surg 2012. [DOI: 10.1089/gyn.2011.0059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Javaid Muglu
- Department of Obstetrics & Gynaecology, Princess Alexandra Hospital, Harlow, Essex, United Kingdom
| | - Dhiraj Uchil
- Department of Obstetrics & Gynaecology, University Hospital Lewisham, London, United Kingdom
| | - Ashish Sau
- Department of Obstetrics & Gynaecology, University Hospital Lewisham, London, United Kingdom
| | - Dan Zamblera
- Department of Obstetrics & Gynaecology, University Hospital Lewisham, London, United Kingdom
| | - Adeboye Jolaoso
- Department of Obstetrics & Gynaecology, University Hospital Lewisham, London, United Kingdom
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Siow A, Ng S. Laparoscopic management of 4 cases of recurrent cornual ectopic pregnancy and review of literature. J Minim Invasive Gynecol 2011; 18:296-302. [PMID: 21441075 DOI: 10.1016/j.jmig.2011.02.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Revised: 02/01/2011] [Accepted: 02/02/2011] [Indexed: 12/20/2022]
Abstract
The objectives of this retrospective case series were to report our experience with laparoscopic management of recurrent cornual ectopic pregnancy in a tertiary care center and to present a review of the literature. Four patients experienced recurrent cornual ectopic pregnancy, and 1 patient had 2 consecutive recurrences. Laparoscopic surgery was performed to treat recurrent cornual ectopic pregnancy in all 4 patients. These 4 cases together with 10 cases collated from the literature review confirm that this entity is rare. Cornual ectopic pregnancy can recur as early as 4 months and as late as 5 years after the first ectopic pregnancy. There seems to be no correlation between the treatment method of the first ectopic pregnancy and the risk of recurrence. The etiology of recurrent cornual ectopic pregnancy is not fully understood, although it shares similar risk factors with tubal ectopic pregnancy. Both medical therapy and surgery are used to treat recurrent cornual ectopic pregnancy, with surgery often performed via laparotomy. These 4 cases constitute the largest case series of recurrent cornual ectopic pregnancy treated laparoscopically. Our experience with laparoscopic management of recurrent cornual ectopic pregnancy in a tertiary care center reveals that it is effective and safe.
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Affiliation(s)
- Anthony Siow
- Minimally Invasive Surgery Centre, KK Women's and Children's Hospital, Singapore.
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Protective effect of calcium folinate against methotrexate-induced endosalpinx damage in rats. Fertil Steril 2011; 95:1526-30. [DOI: 10.1016/j.fertnstert.2010.08.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2010] [Revised: 07/16/2010] [Accepted: 08/13/2010] [Indexed: 11/21/2022]
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Moawad NS, Mahajan ST, Moniz MH, Taylor SE, Hurd WW. Current diagnosis and treatment of interstitial pregnancy. Am J Obstet Gynecol 2010; 202:15-29. [PMID: 20096253 DOI: 10.1016/j.ajog.2009.07.054] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2009] [Revised: 07/04/2009] [Accepted: 07/20/2009] [Indexed: 01/01/2023]
Abstract
The incidence of interstitial pregnancy is rising. Traditional treatment with laparotomy, hysterectomy, or cornual wedge resection is associated with high morbidity and detrimental effects on future fertility. A diverse array of alternate treatments has been introduced over the last 3 decades, with the common goal of achieving a minimally invasive, standardized management strategy. This has been facilitated by impressive strides towards prompt diagnosis, both radiologically and chemically. In this review, we explore the current state of the art diagnostic criteria and the clinically significant diverse therapeutic options with supporting literature. Finally, we propose a structured, best-practice management plan for the once-lethal interstitial pregnancy, based on the current literature.
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Affiliation(s)
- Nash S Moawad
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital of the University of Pittsburgh Medical Center, PA, USA.
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Ng S, Hamontri S, Chua I, Chern B, Siow A. Laparoscopic management of 53 cases of cornual ectopic pregnancy. Fertil Steril 2008; 92:448-52. [PMID: 18930204 DOI: 10.1016/j.fertnstert.2008.08.072] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2008] [Revised: 08/08/2008] [Accepted: 08/11/2008] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To present our experience of laparoscopic management of cornual ectopic pregnancy. DESIGN Retrospective review of 53 cases of cornual pregnancy treated laparoscopically. SETTING K.K. Women's and Children's Hospital, Singapore. PATIENT(S) Patients who were treated for cornual pregnancy via laparoscopic surgery from 2001 to 2006. INTERVENTION(S) Laparoscopic surgery as a treatment modality for cornual pregnancy. MAIN OUTCOME MEASURE(S) Success rate of laparoscopic surgery and future reproductive outcome. RESULT(S) Fifty-two cases were managed by laparoscopy, and one was converted to laparotomy. Laparoscopic wedge resection was carried out in 33 patients, cornuostomy in 13 patients, and salpingectomy in 7 patients. Nine patients received methotrexate injection after surgery because of persistently high serum beta-hCG. Eighteen patients became pregnant, four had early miscarriages, and ten had pregnancies beyond 24 weeks' gestation. Five delivered vaginally, and three had cesarean section at term. Two patients traveled back to their native countries for delivery. There were no cases of uterine rupture or dehiscence reported. CONCLUSION(S) Laparoscopic treatment of cornual pregnancy can be safely carried out with good results in an institution with trained laparoscopist and adequate facilities.
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Affiliation(s)
- Selma Ng
- Penang Maternity Hospital, Penang, Malaysia
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Ross R, Lindheim SR, Olive DL, Pritts EA. Cornual gestation: a systematic literature review and two case reports of a novel treatment regimen. J Minim Invasive Gynecol 2007; 13:74-8. [PMID: 16431329 DOI: 10.1016/j.jmig.2005.11.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2005] [Accepted: 08/08/2005] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE To introduce a novel tubal-sparing regimen for the treatment of nonruptured cornual pregnancies. DESIGN Case report and systematic review of the literature. SETTING Tertiary Care University setting. PATIENTS Two patients referred for care in our subspecialty clinic. INTERVENTIONS Laparoscopic surgery, dilation and evacuation, and postoperative methotrexate injection. Systematic review of the literature. MEASUREMENTS AND MAIN RESULTS Both medical and surgical treatments for cornual gestation exist; however, each is not without its shortcomings. Medical treatment is associated with failure rates that may result in uterine rupture and catastrophic hemorrhage. Surgical treatment that involves hysterectomy causes a loss of future childbearing capability. Surgical treatment that involves resection of the involved cornual region is associated with decreased fertility rates and increased rates of uterine rupture in future pregnancies. Our treatment regimen is safe and effective and conserves future fertility. CONCLUSION A cornual gestation is one of the most hazardous types of ectopic gestation. The diagnosis and treatment of such a pregnancy is challenging and constitutes an urgent medical situation. We herein introduce a novel regimen for the treatment of nonruptured cornual pregnancies. The existing treatment regimens are also systematically reviewed.
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Affiliation(s)
- Reneita Ross
- Department of Obstetrics and Gynecology, University of Wisconsin, Madison, USA
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Abstract
Ultrasound represents the cornerstone of the emergent evaluation of pregnancy-related complaints. Knowledge of the potential and the limitations of this imaging modality, regardless of who performs it, is important for physicians who evaluate and manage these patients and their unborn children in the ED.
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Affiliation(s)
- Christopher Moore
- Section of Emergency Medicine, Yale University School of Medicine, PO Box 208062, Suite 260, New Haven, CT 06519, USA
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Grimbizis GF, Tsalikis T, Mikos T, Zepiridis L, Athanasiadis A, Tarlatzis BC, Bontis JN. Case report: Laparoscopic treatment of a ruptured interstitial pregnancy. Reprod Biomed Online 2004; 9:447-51. [PMID: 15511347 DOI: 10.1016/s1472-6483(10)61282-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Interstitial pregnancy is a rare but life-threatening condition. A case of a 28-year-old woman with a partially ruptured interstitial pregnancy treated with operative laparoscopy is presented. A laparoscopic cornual resection and a left salpingectomy were performed uneventfully. Serum beta-human chorionic gonadotrophin concentrations were measured serially at weekly intervals until resolved on day 20 postoperatively. It seems, therefore, that laparoscopic treatment is still an effective option for management even in ruptured interstitial pregnancy, preserving the anatomical integrity of the uterus and future fertility, and that rupture of interstitial ectopic pregnancy is not a contra-indication for laparoscopy.
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Affiliation(s)
- Grigoris F Grimbizis
- 1st Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Greece, Tsimiski 51, 546 23 Thessaloniki, Greece.
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Vilos GA. Laparoscopic ligation and resection of two ipsilateral interstitial pregnancies in the same patient. THE JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS 2001; 8:299-302. [PMID: 11342742 DOI: 10.1016/s1074-3804(05)60595-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A 31-year-old woman had bilateral interstitial-isthmic tubal anastomoses. After one spontaneous abortion and one term vaginal delivery, she had a right unruptured interstitial pregnancy that was laparoscopically ligated with endoloops and resected. Ten months later she experienced a second unruptured interstitial pregnancy on the same side. This was also laparoscopically suture-ligated and resected uneventfully. The contralateral patent tube was ligated at the same time.
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Affiliation(s)
- G A Vilos
- Department of Obstetrics and Gynecology, University of Western Ontario, St. Joseph's Health Care Centre, 268 Grosvenor Street, London, Ontario N6A 4V2, Canada
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