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Bužinskienė D, Mačionytė M, Dasevičius D, Šilkūnas M. Case report: Ectopic pregnancy in the interstitial part of the fallopian tube. Front Surg 2023; 10:1197036. [PMID: 37470044 PMCID: PMC10352450 DOI: 10.3389/fsurg.2023.1197036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/20/2023] [Indexed: 07/21/2023] Open
Abstract
Ectopic pregnancy remains one of the most common causes of pregnancy-related death in the first trimester. 2.4% of ectopic pregnancies occur in the interstitial part of the fallopian tube. As the symptoms of this condition are non-specific and the localization is associated with a higher risk of bleeding, early diagnosis of interstitial pregnancies is important, based not only on clinical symptoms, but also on additional diagnostic methods. Early diagnosis leads to better treatment-related outcomes. We report a 32-year-old female patient who came to the emergency department because of pain in the lower abdomen and right iliac region and bloody vaginal discharge. During palpation of the abdomen, the pain was localized in the lower part of the abdomen. Human chorionic gonadotropin (hCG) was significantly increased in biochemical tests. Transvaginal ultrasound examination of internal genital organs, abdominal and pelvic computer tomography (CT) were per-formed. An ectopic pregnancy was suspected. Thus, the patient was hospitalized in the gynecology department for surgical treatment. A laparoscopy was performed and an ectopic pregnancy was diagnosed in the interstitial part of the right fallopian tube and in the right uterine corner, which led to right salpingectomy and right uterine angle resection. Thus, interstitial pregnancy is a rare and life-threatening gynecological condition due to the higher risk of bleeding compared to other ectopic pregnancies. However, appropriate diagnosis based on clinical signs, transvaginal ultrasound findings and hCG levels in the blood ensures early diagnosis of interstitial pregnancy, which leads to the choice of medical treatment with methotrexate or minimally invasive surgical techniques.
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Affiliation(s)
- Diana Bužinskienė
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Obstetrics and Gynecology, Institute of Clinical Medicine, Faculty of Medicine Vilnius University, Vilnius, Lithuania
| | | | - Darius Dasevičius
- National Center of Pathology, Affiliate of Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Mindaugas Šilkūnas
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Obstetrics and Gynecology, Institute of Clinical Medicine, Faculty of Medicine Vilnius University, Vilnius, Lithuania
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Dunphy L, Haresnape C, Furara S. Interstitial ectopic pregnancy successfully treated with methotrexate. BMJ Case Rep 2023; 16:e252588. [PMID: 37185311 PMCID: PMC10151976 DOI: 10.1136/bcr-2022-252588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
An ectopic pregnancy (EP) occurs when the fertilised ovum implants outside the endometrial cavity. An EP has an incidence of 1%, with the majority occurring in the fallopian tube. It has a maternal mortality of 0.2 per 1000, with about two-thirds of these deaths associated with substandard care. An interstitial pregnancy occurs when the EP implants in the interstitial part of the fallopian tube. An interstitial ectopic pregnancy (IEP) shows few early clinical symptoms, hence it is associated with serious or fatal bleeding and a mortality rate up to 2.5%. With the advent of transvaginal ultrasound scan (TV USS), correlated with serum beta human chorionic gonadotropin (BHCG) assay, earlier diagnosis of an EP can be established. An EP is often diagnosed in women who are trying to conceive; therefore, the prognosis of future fertility is one of the main concerns associated with this diagnosis. Management can be surgical, expectant or medical with methotrexate (MTX). However, the best approach is tailored to the woman's individual case. The authors present the case of a primigravida woman presenting with abdominal pain and vaginal bleeding at 6 weeks gestation following assisted reproduction. Her BHCG showed a suboptimal rise. Her TV USS showed no evidence of an intrauterine pregnancy. There was no evidence of an adnexal mass or free fluid. As her BHCG remained static, she underwent a diagnostic laparoscopy. A right sided IEP was identified. Due to the high risk of bleeding requiring transfusion or hysterectomy and her desire to preserve her fertility, she received medical management with MTX. Indeed, research has shown that women successfully managed expectantly achieve better reproductive outcomes, with the shortest time to achieve a subsequent intrauterine pregnancy. This case acts as a cautionary reminder of the challenges associated with identifying an IEP on TV USS. A high index of clinical suspicion is required to prevent maternal morbidity and mortality.
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Affiliation(s)
- Louise Dunphy
- Department of Gynaecology, Leighton Hospital, Crewe, UK
| | | | - Samira Furara
- Department of Gynaecology, Leighton Hospital, Crewe, UK
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Li P, Tan X, Chen Y, Ge Q, Zhou H, Zhang R, Wang Y, Xue M, Wu R, Sun D. Successful Ultrasound-Guided Methotrexate Intervention in the Treatment of Heterotopic Interstitial Pregnancy: A Case Report and Literature Review. J Pers Med 2023; 13:jpm13020332. [PMID: 36836566 PMCID: PMC9960516 DOI: 10.3390/jpm13020332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 01/31/2023] [Accepted: 02/08/2023] [Indexed: 02/17/2023] Open
Abstract
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.
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Affiliation(s)
- Ping Li
- Department of Ultrasonography, Peking University Shenzhen Hospital, Shenzhen 518036, China
- Department of Ultrasonography, Weifang People’s Hospital, Weifang 261044, China
| | - Xiao Tan
- Department of Ultrasonography, Peking University Shenzhen Hospital, Shenzhen 518036, China
- Department of Zhuhai Campus, Zunyi Medical University, Zunyi 563006, China
| | - Yi Chen
- Department of Ultrasonography, Peking University Shenzhen Hospital, Shenzhen 518036, China
| | - Qiaoli Ge
- Department of Ultrasonography, Peking University Shenzhen Hospital, Shenzhen 518036, China
| | - Haiying Zhou
- Department of Ultrasonography, Peking University Shenzhen Hospital, Shenzhen 518036, China
| | - Renrong Zhang
- Department of Ultrasonography, Peking University Shenzhen Hospital, Shenzhen 518036, China
- Department of Zhuhai Campus, Zunyi Medical University, Zunyi 563006, China
| | - Yue Wang
- Department of Ultrasonography, Peking University Shenzhen Hospital, Shenzhen 518036, China
| | - Min Xue
- Department of Ultrasonography, Peking University Shenzhen Hospital, Shenzhen 518036, China
| | - Ruifang Wu
- Center of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen 518036, China
- Institute of Obstetrics and Gynecology, Shenzhen PKU-HKUST Medical Center, Shenzhen 518036, China
- Correspondence: (R.W.); (D.S.); Tel.: +86-0755-8392333 (D.S.)
| | - Desheng Sun
- Department of Ultrasonography, Peking University Shenzhen Hospital, Shenzhen 518036, China
- Correspondence: (R.W.); (D.S.); Tel.: +86-0755-8392333 (D.S.)
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Restaino S, De Gennaro E, Floris S, Stabile G, Zinicola G, Sorrentino F, Vizzielli G, Driul L. Surgical Treatment Following Failed Medical Treatment of an Interstitial Pregnancy. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58070937. [PMID: 35888656 PMCID: PMC9316431 DOI: 10.3390/medicina58070937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 11/30/2022]
Abstract
Interstitial pregnancy (IP) is a type of ectopic pregnancy in which the embryo implants in the interstitial part of the Fallopian tube. It accounts for 2% of all ectopic pregnancies. Signs and symptoms appear later than the other forms of ectopic pregnancies because of its peculiar location. The gold standard for its diagnosis is transvaginal ultrasound. The treatment can be medical or surgical. Medical treatment is based on the systemic or local injection of methotrexate (MTX); a dose of mifepristone can be added with a reported 85–90% success rate. The surgical option is laparoscopic unilateral cornuostomy or unilateral salpingectomy. The therapeutic choice is based on symptoms, serum β-human chorionic gonadotropin (β-hCG) values, and sonographic features. Furthermore, the patient’s fertility perspectives should be considered. We report a case of IP in a Caucasian woman of 29 years old, with a previous salpingectomy for ectopic pregnancy medically treated by a double dose of intramuscular MTX 50 mg/m2 combined with a single dose of leucovorin 15 mg and a single dose of mifepristone 600 mg orally. Medical therapy failed as suggested by the sudden onset of intense pelvic pain after 10 days. Because of the clinical symptoms and the sonographic suspicious of pregnancy rupture due to the modest amount of fluid in the pouch of Douglas, clinicians decided on an urgent unilateral laparoscopic salpingectomy. The hemoperitoneum was drained. The patient was discharged two days later and β-hCG serum levels became negative after 45 days. The advantages of fertility sparing should be weighted according to the patient’s reproductive perspectives. Appropriate counseling is therefore key in managing the treatment of interstitial pregnancy.
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Affiliation(s)
- Stefano Restaino
- Obstetrics and Gynecology Unit, Department of Obstetrics, Gynecology and Pediatrics, Department of Medical Area DAME, Udine University Hospital, 33100 Udine, Italy; (S.R.); (S.F.)
| | - Elena De Gennaro
- Clinic of Obstetrics and Gynecology, Department of Medical Area (DAME), Hospital of Udine, University of Udine, 33100 Udine, Italy; (E.D.G.); (G.V.); (L.D.)
| | - Stefano Floris
- Obstetrics and Gynecology Unit, Department of Obstetrics, Gynecology and Pediatrics, Department of Medical Area DAME, Udine University Hospital, 33100 Udine, Italy; (S.R.); (S.F.)
| | - Guglielmo Stabile
- Institute for Maternal and Child Health IRCCS “Burlo Garofolo”, 34100 Trieste, Italy;
| | - Giulia Zinicola
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34100 Trieste, Italy;
| | - Felice Sorrentino
- Department of Medical and Surgical Sciences, University of Foggia, 71100 Foggia, Italy
- Correspondence:
| | - Giuseppe Vizzielli
- Clinic of Obstetrics and Gynecology, Department of Medical Area (DAME), Hospital of Udine, University of Udine, 33100 Udine, Italy; (E.D.G.); (G.V.); (L.D.)
| | - Lorenza Driul
- Clinic of Obstetrics and Gynecology, Department of Medical Area (DAME), Hospital of Udine, University of Udine, 33100 Udine, Italy; (E.D.G.); (G.V.); (L.D.)
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Herondelle C, Spiers A, Nyangoh-Timoh K, Thubert T, Fauconnier A, Moquet PY, Bouet PE, Legendre G. Efficacy of In Situ Methotrexate Injection in the Treatment of Nontubal Ectopic Pregnancies: A Retrospective Multicenter Study. J Minim Invasive Gynecol 2021; 29:243-249. [PMID: 34400353 DOI: 10.1016/j.jmig.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 08/03/2021] [Accepted: 08/09/2021] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE Evaluation of the efficacy of different injection sites of methotrexate in the treatment of nontubal ectopic pregnancies. DESIGN Retrospective multicenter study. SETTING Multicenter, including 3 teaching hospitals, an intercommunal hospital, and a clinic. PATIENTS A total of 106 patients with nontubal ectopic pregnancies, including 59 interstitial, 39 cesarean scar, and 8 cervical or isthmic. INTERVENTIONS Overall, 58 patients received methotrexate via intramuscular injection (IM group), 35 received methotrexate via in situ injection (IS group), and 13 received a combination of both in situ and intramuscular injections of methotrexate (IS + IM group). MEASUREMENTS AND MAIN RESULTS The main end point of this study was measured via the primary success rate (defined as a negative β-human chorionic gonadotropin level without recourse to any additional treatment) of treatment with methotrexate according to injection site. The primary success rate was 46.55% in the IM group, 60% in the IS group, and 61.54% in the IS + IM group, respectively. In the multivariate analysis, the primary success rate of treatment was significantly correlated to the in situ injection of methotrexate, either solely or in conjunction with an intramuscular injection of methotrexate administered the following day, (odds ratio = 2.7; 95% confidence interval, 1.03-7.14). CONCLUSION Solely an intramuscular injection of methotrexate is a less efficient first-line treatment strategy for the conservative management of nontubular ectopic pregnancy. The use of an in situ injection of methotrexate should therefore be preferred.
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Affiliation(s)
- Charlyne Herondelle
- Department of Obstetrics and Gynecology, Angers University Hospital (Drs. Herondelle, Bouet, and Legendre and Mr. Spiers), Angers; Department of Obstetrics and Gynecology, Nantes University Hospital (Drs. Herondelle and Thubert), Nantes
| | - Andrew Spiers
- Department of Obstetrics and Gynecology, Angers University Hospital (Drs. Herondelle, Bouet, and Legendre and Mr. Spiers), Angers
| | - Krystel Nyangoh-Timoh
- Department of Obstetrics and Gynecology, Rennes University Hospital (Dr. Nyangoh-Timoh)
| | - Thibault Thubert
- Department of Obstetrics and Gynecology, Nantes University Hospital (Drs. Herondelle and Thubert), Nantes
| | - Arnaud Fauconnier
- Department of Obstetrics and Gynecology, Intercommunal Hospital of Poissy/Saint-Germain-en-Laye (Dr. Fauconnier), Poissy
| | - Pierre-Yves Moquet
- Department of Obstetrics and Gynecology, La Sagesse Clinic (Dr. Moquet), Rennes
| | - Pierre-Emmanuel Bouet
- Department of Obstetrics and Gynecology, Angers University Hospital (Drs. Herondelle, Bouet, and Legendre and Mr. Spiers), Angers
| | - Guillaume Legendre
- Department of Obstetrics and Gynecology, Angers University Hospital (Drs. Herondelle, Bouet, and Legendre and Mr. Spiers), Angers; CESP UMR Inserm 1018 - Center for Research in Epidemiology and Public Health (Dr. Legendre), Villejuif, France.
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6
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Delplanque S, Le Lous M, Flévin M, Bauville E, Moquet PY, Dion L, Fauconnier A, Guérin S, Leveque J, Lavoué V, Nyangoh Timoh K. Effectiveness of conservative medical treatment for non-tubal ectopic pregnancies: a multicenter study. J Gynecol Obstet Hum Reprod 2020; 49:101762. [PMID: 32325266 DOI: 10.1016/j.jogoh.2020.101762] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 04/04/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess the effectiveness of conservative treatment for the management of non-tubal ectopic pregnancies (NTEP) METHODS: Retrospective cohort study in three centers (two referral centers) of patients managed for NTEP diagnosed by 2D or 3D ultrasonograhy. Patients underwent one of the following: expectant management, systemic methotrexate (MTX) injection, local MTX injection, combined MTX injection (local and systemic), local injection of hyperosmolar glucose, or misoprostol administration. The primary endpoint was final success defined by resolution of hCG level without need for emergency surgical treatment. Sixty-four patients diagnosed with NTEP were included: 37 (57%) had an interstitial pregnancy, 23 (35.9%) a cesarean scar pregnancy, two (3.1%) a cervical pregnancy and two (3.1%) an ovarian pregnancy. RESULTS Six patients (9.4%) underwent expectant management, 24 (37.5%) a systemic MTX injection, 28 (43.8%) a local injection of MTX, three (4.7%) a combined MTX injection, one (1.6%) a local injection of hyperosmolar glucose (1.6%), and two (3.1%) were administered misoprostol. The median age was 32 years (22-45) and mean follow-up was 41 months. The final success rate overall was 92.2%: 100% for expectant management, 87.5% for systemic MTX, 96.4% for local MTX, 100% for combined injection of MTX, 100% for local injection of hyperosmolar glucose, and 50% for misoprostol. No patient required a hysterectomy. Nine (14.1%) patients required surgery, including five (7.8% (5/64)) following a rupture of the NTEP. CONCLUSIONS Our results suggest that conservative medical management of NTEP is effective and safe and should be the first-line treatment for pauci-symptomatic patients with an NTEP.
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Affiliation(s)
- Sophie Delplanque
- Department of Obstetrics and Gynecology, CHU Rennes Hospital, 35000 Rennes, France; Université de Rennes 1 : 2 avenue de Professeur Léon Bernard, 35000, Rennes, France
| | - Maela Le Lous
- Department of Obstetrics and Gynecology, CHU Rennes Hospital, 35000 Rennes, France; Université de Rennes 1 : 2 avenue de Professeur Léon Bernard, 35000, Rennes, France; SAFE CIC 1414 Thematic Team, University Hospital Rennes, Rennes, France; INSERM, UMR 1099, Rennes, F-35000, France; Université de Rennes 1, LTSI, Rennes, F-35000, France
| | - Marie Flévin
- Department of Obstetrics and Gynecology, CHU Rennes Hospital, 35000 Rennes, France
| | - Estelle Bauville
- Department of Obstetrics and Gynecology, CHU Rennes Hospital, 35000 Rennes, France; Department of Gynecology and Obstetrics, CHI Poissy-St-Germain, 78300 Poissy, France; SAFE CIC 1414 Thematic Team, University Hospital Rennes, Rennes, France
| | - Pierre Yves Moquet
- Department of Gynecology and Obstetrics, Clinique mutualiste La sagesse, 35 000 Rennes, France
| | - Ludivine Dion
- Department of Obstetrics and Gynecology, CHU Rennes Hospital, 35000 Rennes, France; Université de Rennes 1 : 2 avenue de Professeur Léon Bernard, 35000, Rennes, France; SAFE CIC 1414 Thematic Team, University Hospital Rennes, Rennes, France
| | - Arnaud Fauconnier
- Department of Gynecology and Obstetrics, Clinique mutualiste La sagesse, 35 000 Rennes, France
| | - Sonia Guérin
- Department of Obstetrics and Gynecology, CHU Rennes Hospital, 35000 Rennes, France; Université de Rennes 1 : 2 avenue de Professeur Léon Bernard, 35000, Rennes, France
| | - Jean Leveque
- Department of Obstetrics and Gynecology, CHU Rennes Hospital, 35000 Rennes, France; Université de Rennes 1 : 2 avenue de Professeur Léon Bernard, 35000, Rennes, France; SAFE CIC 1414 Thematic Team, University Hospital Rennes, Rennes, France
| | - Vincent Lavoué
- Department of Obstetrics and Gynecology, CHU Rennes Hospital, 35000 Rennes, France; Université de Rennes 1 : 2 avenue de Professeur Léon Bernard, 35000, Rennes, France; SAFE CIC 1414 Thematic Team, University Hospital Rennes, Rennes, France
| | - Krystel Nyangoh Timoh
- Department of Obstetrics and Gynecology, CHU Rennes Hospital, 35000 Rennes, France; Université de Rennes 1 : 2 avenue de Professeur Léon Bernard, 35000, Rennes, France; SAFE CIC 1414 Thematic Team, University Hospital Rennes, Rennes, France; INSERM, UMR 1099, Rennes, F-35000, France; Université de Rennes 1, LTSI, Rennes, F-35000, France
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7
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Ben-David A, Meyer R, Mohr-Sasson A, Mashiach R. Nonsurgical Management of Interstitial Pregnancies: Feasibility and Predictors of Treatment Failure. J Minim Invasive Gynecol 2020; 27:625-632. [DOI: 10.1016/j.jmig.2019.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 05/24/2019] [Accepted: 06/10/2019] [Indexed: 10/26/2022]
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8
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Parisi S, Garofalo A, Alemanno MG, Chiado Fiorio Tin M, Petruzzelli P, Viora E. Arteriovenous uterine malformation developed from an interstitial pregnancy on residual tubal stump: A critical managment in a fertile woman. J Obstet Gynaecol Res 2019; 46:176-180. [PMID: 31608528 DOI: 10.1111/jog.14144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 09/28/2019] [Indexed: 10/25/2022]
Abstract
Uterine arteriovenous malformations are rare conditions with diverse clinical presentation that range from asymptomatic patients to different degrees of menorrhagia, commonly associated with previous pregnancy or uterine trauma. This case report describes a 36-year-old woman who presented with ultrasound diagnosis of interstitial pregnancy on residual right tube stump 4 months after a laparoscopic salpingectomy for extrauterine pregnancy. She started treatment with methotrexate; afterwards serum human chorionic gonadotropin levels and ultrasound follow-ups were scheduled. While serum human chorionic gonadotropin levels were progressively reducing, transvaginal ultrasound follow-ups showed a persistent anechoic mass on right rube stump, with increased peripheral high flow vascularity: highly suspicious for a uterine arteriovenous malformation. A laparoscopy was performed with a tumorectomy of the mass. The histopathological exam of the specimen confirmed uterine arteriovenous malformation. Patient successfully became pregnant 2 years later, with an eventless pregnancy and a vaginal delivery without complications.
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Affiliation(s)
- Silvia Parisi
- Gynecology and Obstetrics, Department of Surgical Sciences, City of Health and Science, University of Turin, Turin, Italy
| | - Anna Garofalo
- Gynecology and Obstetrics, Department of Surgical Sciences, City of Health and Science, University of Turin, Turin, Italy
| | - Maria Grazia Alemanno
- Gynecology and Obstetrics, Department of Surgical Sciences, City of Health and Science, University of Turin, Turin, Italy
| | - Michela Chiado Fiorio Tin
- Gynecology and Obstetrics, Department of Surgical Sciences, City of Health and Science, University of Turin, Turin, Italy
| | - Paolo Petruzzelli
- Gynecology and Obstetrics, Department of Surgical Sciences, City of Health and Science, University of Turin, Turin, Italy
| | - Elsa Viora
- Gynecology and Obstetrics, Department of Surgical Sciences, City of Health and Science, University of Turin, Turin, Italy
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Prevention, diagnosis, and management of interstitial pregnancy: A review of the literature. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2019. [DOI: 10.1016/j.lers.2018.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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10
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Garzon S, Laganà AS, Pomini P, Raffaelli R, Ghezzi F, Franchi M. Laparoscopic reversible occlusion of uterine arteries and cornuostomy for advanced interstitial pregnancy. MINIM INVASIV THER 2018; 28:359-362. [PMID: 30514139 DOI: 10.1080/13645706.2018.1547764] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
During laparoscopic enucleation of an interstitial pregnancy, adequate hemostatic control is of paramount importance due to the high vascularization of the uterine cornus. However, no consensus or guidance exists regarding the optimal hemostatic technique. We report laparoscopic reversible uterine arteries occlusion as hemostatic technique during laparoscopic enucleation by cornuostomy of an interstitial pregnancy at advanced gestational age (46 × 40 mm gestational sac). Preliminary identification of the uterine arteries and bilateral reversible occlusion by Hem-o-Lok clips allowed bleeding control during surgery. The laparoscopic procedure was performed without complications and with limited blood loss. The reported case reinforces the feasibility of this minimally invasive technique in interstitial pregnancy.
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Affiliation(s)
- Simone Garzon
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Paola Pomini
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Ricciarda Raffaelli
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Massimo Franchi
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
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11
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Conti V, Luciano G, Pecoraro G, Iovieno R, Filippelli A, Guida M. Multidosing Intramuscular Administration of Methotrexate in Interstitial Pregnancy With Very High Levels of β-hCG: A Case Report and Review of the Literature. Front Endocrinol (Lausanne) 2018; 9:363. [PMID: 30042729 PMCID: PMC6048239 DOI: 10.3389/fendo.2018.00363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 06/18/2018] [Indexed: 01/17/2023] Open
Abstract
Ectopic pregnancy (EP) is the implantation of an embryo outside the endometrial cavity of the uterus. Signs and symptoms of EP may arise between the 6th and the 8th week of gestation and include vaginal bleeding, lower abdominal and pelvic pain. Frequently EPs implant in the fallopian tubes. A rare EP is the interstitial pregnancy, a life-threatening condition being responsible for nearly 20% of all deaths caused by EPs. Because of its unique location, the diagnosis is difficult and based on signs and specific criteria together with measuring of serum β-hCG. Usually, EP is treated by surgical approach, which is associated with increased morbidity, decreased fertility and increased likelihood of hysterectomy and uterine rupture in a subsequent pregnancy. Early diagnosis is crucial to life saving and allowing alternative therapeutic interventions such as pharmacological treatments. Methotrexate (MTX) represents the mainstay therapy. There is no standard care for the interstitial pregnancy for what concerns either surgical or pharmacological approaches. We reported a case of a 36-year-old woman admitted to the Hospital of Salerno-Italy with a value of serum β-hCG of 35,993 IU/L. Transvaginal ultrasonography revealed an empty uterine cavity and a mass of 35.7 mm in diameter characterized by a hypoechoic central area. The patient was in stable haemodynamic condition and no haematologic, renal and hepatic impairments were recorded. Despite the high serum β-hCG levels, a pharmacological approach was preferred to a surgical one. The patient was treated with intramuscular administration of MTX in daily dose of 1 mg/Kg alternated with 0.1 mg/kg folinic acid for 5 days. The patient remained hospitalized for 20 days and no side effects were reported. The decrease of the serum β-hCG was monitored and more than 15% reduction was detected between the 4th and the 7th day after the beginning of the treatment. The serum β-hCG became undetectable 35 days after. A multidosing intramuscular administration of MTX was effective and safe even in the presence of very high serum β-hCG levels. Together with similar cases reported in literature, the present results can contribute to improve the decision making in the treatment of the interstitial pregnancy.
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Affiliation(s)
- Valeria Conti
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Fisciano, Italy
| | - Giovanni Luciano
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Fisciano, Italy
| | - Giovanni Pecoraro
- Unit of Gynecology and Obstetrics of “San Giovanni di Dio e Ruggi d'Aragona”, University Hospital, Salerno, Italy
| | - Roberto Iovieno
- Unit of Gynecology and Obstetrics of “San Giovanni di Dio e Ruggi d'Aragona”, University Hospital, Salerno, Italy
| | - Amelia Filippelli
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Fisciano, Italy
| | - Maurizio Guida
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Fisciano, Italy
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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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Therapeutic outcomes of methotrexate injection in unruptured interstitial pregnancy. Obstet Gynecol Sci 2017; 60:571-578. [PMID: 29184866 PMCID: PMC5694732 DOI: 10.5468/ogs.2017.60.6.571] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/06/2017] [Accepted: 06/22/2017] [Indexed: 11/08/2022] Open
Abstract
Objective To examine the therapeutic outcomes of methotrexate (MTX) in the treatment of unruptured interstitial pregnancy. Methods We reviewed the medical records of patients who were diagnosed with interstitial pregnancy and received MTX as first-line treatment between January 2003 and July 2014 at CHA Gangnam Medical Center. The treatment success rates and subsequent pregnancy outcomes were examined. Results Ninety-seven patients were diagnosed with interstitial pregnancy between January 2003 and July 2014. Of them, 38 initially received MTX treatment. The diagnosis was made at a median of 6+3 weeks (5+0 to 11+3 weeks). Thirty patients received a systemic MTX injection, while the other 8 received a local MTX injection. Systemic treatment composed of an 8-day alternating MTX regimen, single-dose regimen, or high-dose regimen (100 mg/m2 + 200 mg/m2 intravenously over 12 hours). The local injection consisted of a direct MTX injection into the gestational sac with or without systemic MTX injection. Twenty-one patients (55.3%) were successfully treated with MTX. However, MTX therapy failed in 17 patients (44.7%), who required surgery. Mode of MTX treatment was the only predictive variable of MTX treatment success (P=0.039). Treatment success was seen in 7 of 8 patients (87.5%) in the local MTX group vs. 14 of 30 patients (46.7%) in the systemic MTX group. After treatment, 13 patients attempted a successive pregnancy; of them, 10 patients had a confirmed clinical pregnancy and healthy live birth. Conclusion Combined MTX treatment including a local injection might be an initial approach to the treatment of interstitial pregnancy.
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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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Grindler NM, Ng J, Tocce K, Alvero R. Considerations for management of interstitial ectopic pregnancies: two case reports. J Med Case Rep 2016; 10:106. [PMID: 27118381 PMCID: PMC4847333 DOI: 10.1186/s13256-016-0892-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 04/01/2016] [Indexed: 11/17/2022] Open
Abstract
Background Conventional treatment of interstitial pregnancies includes systemic methotrexate, direct methotrexate injection, wedge resection, or hysterectomy. We present two cases of interstitial pregnancies that were successfully managed by different minimally invasive surgical techniques. We also report the novel use of hysteroscopic urologic stone retrieval forceps in the transvaginal removal of persistent products of conception after systemic methotrexate for an interstitial pregnancy. Case presentation Case 1 was a 28-year-old gravida 1 white woman at 8 weeks gestation; she was diagnosed with a left interstitial pregnancy. After laparoscopic confirmation of the interstitial pregnancy, successful ultrasound-guided suction dilation and curettage was performed. Case 2 was a 33-year-old gravida 3 para 1021 (one term pregnancy, no preterm pregnancies, one ectopic pregnancy and one spontaneous miscarriage, and one living child) Hispanic woman with persistent products of conception after systemic methotrexate for a left interstitial pregnancy. She underwent hysteroscopic-guided removal of the persistent products of conception, which was possible due to novel use of urologic stone retrieval forceps. Conclusions Successful minimally invasive treatment of interstitial pregnancies may be possible in certain cases. Collaboration between different specialties continues to be important for improving minimally invasive options.
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Affiliation(s)
- Natalia M Grindler
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Colorado Denver School of Medicine, Aurora, CO, USA.
| | - June Ng
- University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Kristina Tocce
- University of Colorado Denver School of Medicine, Aurora, CO, USA.,Division of Family Planning, Department of Obstetrics and Gynecology, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Ruben Alvero
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Colorado Denver School of Medicine, Aurora, CO, USA.,Division of Reproductive Endocrinology & Infertility, Department of Obstetrics and Gynecology, Warren P. Alpert School of Medicine, Brown University, Providence, RI, USA
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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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Anderson ML, Ogunwale A, Clark BA, Kilpatrick CC, Mach CM. Preferences and Outcomes for Chemotherapy Teaching in a Postgraduate Obstetrics and Gynecology Training Program. JOURNAL OF SURGICAL EDUCATION 2015; 72:936-941. [PMID: 26119096 DOI: 10.1016/j.jsurg.2015.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 01/30/2015] [Accepted: 04/13/2015] [Indexed: 06/04/2023]
Abstract
PURPOSE To determine whether chemotherapy teaching is a desired component of postgraduate training programs in obstetrics and gynecology and assess its effect on practicing clinicians. METHOD After obtaining institutional review board approval, 99 individuals who completed postgraduate training at a single academic medical center between 2005 and 2013 were invited to complete an online survey. Descriptive statistics were used to summarize responses. RESULTS Of the 99 individuals, 68 (68%) completed the survey. Respondents included physicians currently practicing in both academic medicine (n = 36, 52.9%) and private practice (n = 24, 35.2%). Most respondents (n = 60, 88.2%) indicated that chemotherapy teaching was a desired feature of their training and expressed a preference for both formal didactics and direct clinical involvement (n = 55, 80.2%). Benefits identified by respondents included improved insight into the management of symptoms commonly associated with chemotherapy (n = 55, 82.1%) and an enhanced ability to counsel patients referred for oncology care (n = 48, 70.5%). All respondents who pursued training in gynecologic oncology following residency (n = 6) indicated that chemotherapy teaching favorably affected their fellowship experience. Of the 6 gynecologic oncologists, 3 (50%) who responded also indicated that chemotherapy teaching during residency improved their performance in fellowship interviews. CONCLUSION Chemotherapy teaching was a desired feature of postgraduate training in general obstetrics and gynecology at the institution studied. Consideration should be given to creating curricula that incorporate the principles and practice of chemotherapy and address the needs of obstetrics and gynecology trainees who intend to pursue both general and subspecialty practice.
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Affiliation(s)
- Matthew L Anderson
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas.
| | - Abayomi Ogunwale
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Brian A Clark
- Department of Clinical Sciences and Administration, University of Houston, Houston, Texas
| | - Charlie C Kilpatrick
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Claire M Mach
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas; Department of Clinical Sciences and Administration, University of Houston, Houston, Texas
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