Interstitial pregnancy: a 'road map' of surgical treatment based on a systematic review of the literature

Interstitial pregnancy: A retrospective case series of surgically managed patients over a ten-year period

AIMS

To describe the ultrasound diagnostic features and surgical management procedures for patients with an interstitial ectopic pregnancy in our tertiary institution and associated peripheral hospital over a ten-year period.

METHODS

A retrospective audit of all surgically managed cases of interstitial pregnancies over a ten-year period at a tertiary hospital and one associated peripheral hospital in New South Wales.

RESULTS

Sixteen cases of surgically managed interstitial pregnancy were identified. In 43.8% of these cases, patients had previously undergone an ipsilateral salpingectomy. No cases required hysterectomy, post-operative methotrexate or return to theatre. Ten patients underwent diagnostic ultrasound prior to operative management, seven of which were correctly identified to be an interstitial ectopic pregnancy at the time. The proportion of cornuostomies being performed for interstitial pregnancy compared to wedge resection has increased over the period of this review from 33 to 60% between the two five-year periods.

CONCLUSION

The combination of expert ultrasound and sophisticated laparoscopic techniques at our institution has facilitated earlier diagnosis and greater use of minimally invasive management of interstitial pregnancy.

Interstitial ectopic pregnancy: A rare case report

INTRODUCTION

Interstitial pregnancies are a rare form of ectopic pregnancy with life threatening consequences. Thus, the aim of this report is to shed light on the importance of early diagnosis for optimal outcomes.

CASE PRESENTATION

Herein, we present a case of an interstitial ectopic pregnancy in a 31-year-old Syrian female who presented only with mild non-specific abdominal pain. The ultrasound showed a gestational sac in the right horn of the uterus non-communicating with the endometrial cavity suggesting an interstitial ectopic pregnancy. Cornual excision and salpingectomy were performed with laparotomy instead of laparoscopy due to resource-limited facilities. Follow-up with serum human chorionic gonadotropin β-HCG continued until the hormone levels became undetectable.

DISCUSSION

Interstitial ectopic pregnancies can present with non-classic symptoms. Ultrasonographic evaluation for lower abdominal pain in women at the first trimester is essential to detect interstitial ectopic pregnancies.

CONCLUSION

Early diagnosis is key to prevent the life threatening progression of interstitial pregnancy, so this diagnosis should be kept in mind in women presenting with first trimester abdominal pain and/or vaginal bleeding.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Navigating Interstitial Heterotopic Pregnancy: A Case Report

Interstitial heterotopic pregnancy (IHP), an exceedingly rare and clinically intricate phenomenon, presents a diagnosis that challenges healthcare providers in obstetric care. This case report provides valuable insights into the complexities of diagnosing and managing IHPs, shedding light on the pivotal role of early and precise identification. Through a meticulous examination of a 28-year-old patient's clinical history and diagnostic journey, this report underscores the significance of advanced imaging techniques and swift decision making, ultimately leading to the accurate diagnosis of an IHP. Furthermore, it highlights the life-saving importance of cornuostomy as a safe and effective intervention, preserving the intrauterine pregnancy while successfully resolving the ectopic gestation. This case report serves as a compelling reminder of the critical need for timely diagnosis and individualized treatment in cases of IHPs, ultimately enhancing the understanding and management of this rare obstetric condition.

Case report: Ectopic pregnancy in the interstitial part of the fallopian tube

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.

Successful Management of a Ruptured Interstitial Pregnancy: A Case Report

Interstitial pregnancy is a rare entity that usually leads to the rupture of the uterus. The difficulty and delay in diagnosing this condition have been reported to cause high mortality rates. Here, we present the case of a 36-year-old woman who presented to the emergency department with severe epigastric pain and hemodynamic instability. Her current gestational age (GA) could not be accurately measured as she was unbooked and had irregular periods. However, by abdominal examination, the GA was estimated to be 38 weeks, whereas by ultrasound it was approximately 28 weeks. It was also noted that the uterus was empty, and the fetus was found in the abdominal cavity. Hence, a working diagnosis of uterine rupture was made and the patient was taken for emergency laparotomy. The patient delivered an alive 1.2 kg baby. Intraoperatively, the placenta was implanted in the interstitial part of the right fallopian tube. The placenta was then excised and right salpingectomy was performed, following which the abdomen was closed in layers. Postoperatively, the patient made an uneventful recovery and was discharged home in stable condition; however, the baby passed away due to complications related to extreme prematurity.

Large Interstitial Ectopic Pregnancy: Management by Laparoscopic Cornuostomy Following Initial Misdiagnosis

The purpose of the present report is to highlight the challenges in diagnosing interstitial ectopic pregnancy and to describe its management by laparoscopic cornuostomy. A 28-year-old gravida 3, para 1 woman was referred to us at 12 weeks period of gestation after failed medical termination following a diagnosis of missed abortion. On presenting to us, a large interstitial ectopic pregnancy was diagnosed by ultrasonography and managed by laparoscopic cornuostomy. Intra myometrial vasopressin and purse string sutures at the base of ectopic pregnancy bulge were used to reduce intra-operative bleeding. Intra-operative blood loss was 50 ml. Patient was discharged after two days of surgery. Interstitial pregnancy may be misdiagnosed as an intrauterine pregnancy, due to lack of suspicion and expertise. Large interstitial ectopic pregnancies can be successfully managed by a conservative surgical approach such as laparoscopic cornuostomy instead of cornual resection or hysterectomy.

Management of interstitial pregnancy in the era of laparoscopy: a meta-analysis of 855 case studies compared with traditional techniques

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.

Spontaneous Intraoperative Rupture of a Large Interstitial Pregnancy: Laparoscopic Management

We present a case of a large interstitial pregnancy which was intraoperatively ruptured, but was eventually laparoscopically treated. The patient experienced 9 weeks of amenorrhea, and a right cornual pregnancy measuring 6 cm was diagnosed. The patient consented on having a minimal surgical treatment, and a laparoscopic right cornuotomy was decided. During surgery, and prior to any manipulation to the uterus, there was a spontaneous rupture of the ectopic which resulted in excessive bleeding. Temporal pressure at the bleeding site and ligation of the superior branches of the right uterine artery allowed for a careful dissection of the right uterine cornua and achieved hemostasis. The surgery proceeded uneventfully thereafter. Although surgical intervention in such cases entails a high risk of hemorrhage, successful completion of the laparoscopy lies on the meticulous preoperative planning and the controlled precise surgical steps during the procedure.

Novel laparoscopic cornual resection of interstitial pregnancy using the Endo GIA™ Universal Stapler (Medtronic): A series of 12 cases

BACKGROUND

The maternal mortality of interstitial pregnancy is five times greater than that of other ectopic gestations due to potential haemorrhage. Minimal access surgical techniques usually comprise cornual resection and cornuostomy, requiring laparoscopic suturing skills.

AIM

To describe a case series using a laparoscopic automatic stapling device with reloadable cartridges to resect the cornu, enabling surgeons less familiar with intracorporeal suturing to avoid laparotomy when managing interstitial pregnancy.

MATERIALS AND METHODS

Twelve cases of laparoscopic cornual resections for interstitial pregnancies with the Endo GIA™ Universal Stapler (Medtronic) were collected prospectively over eight years. Outcome measures include human chorionic gonadotropin beta subunit (hβCG) levels, successful laparoscopic completion, estimated blood loss, intra-and post-operative complications and length of stay.

RESULTS

Median age and gestation at surgery were 31 years (range: 20-44) and eight weeks (range: 5-12), respectively. All involved live interstitial gestations, and 4/12 cases had significant haemoperitoneum at laparoscopy. The median blood loss was 300 mL (range 100-3500), and five women had blood loss >500 mL. The median serum hβCG level was 6429 IU/L (range: 1800-58690), and the median ectopic size was 4 cm (range 2-6). All cases were completed laparoscopically with no intra- or post-operative complications, although two women required blood transfusions. Median length of stay was 40 h. Further pregnancies could only be followed in 2/12 cases due to the migratory nature of our local population.

CONCLUSION

We describe a case series of 12 laparoscopic cornual resections for interstitial pregnancies using Endo GIA™ Universal Stapler, which simultaneously staples and transects the tissues, thus minimising the need for laparoscopic intracorporeal suturing.

Interstitial Pregnancy after Ipsilateral Salpingectomy: Analysis of 46 Cases and a Literature Review

STUDY OBJECTIVE

To investigate the relationship between previous ipsilateral salpingectomy and interstitial pregnancy and report on our experience of laparoscopic cornuostomy for interstitial pregnancy.

DESIGN

Single-center, retrospective review.

SETTING

University-based hospital.

PATIENTS

All patients who had undergone ipsilateral salpingectomy previously, diagnosed with interstitial pregnancy and treated between July 2010 and September 2018.

INTERVENTIONS

Laparoscopy or laparotomy as a treatment for interstitial pregnancy after ipsilateral salpingectomy.

MEASUREMENTS AND MAIN RESULTS

A total of 414 cases of interstitial pregnancy were identified, of which 46 (11.1%) were after ipsilateral salpingectomy. Of the 46 patients, 20 (43.5%) became pregnant by in vitro fertilization and embryo transfer. Ipsilateral salpingectomy was the result of an ectopic pregnancy in 40 patients, hydrosalpinx in 5 patients, and torsion of an ovarian tumor in 1 patient. The laparoscopic approach was used to treat 78.3% of patients with history of previous salpingectomy. Patients who underwent ipsilateral salpingectomy by laparoscopy previously had a shorter interval from salpingectomy to interstitial pregnancy (24 months vs 60 months; p = .038) compared with patients who underwent ipsilateral salpingectomy by laparotomy. Laparoscopic cornuostomy was performed in 38 patients (82.6%); 12 had fetal cardiac activity, 15 had ruptured masses, and 16 used prophylactic methotrexate (MTX) intraoperatively. The median size of the ectopic mass was 2.5 cm (1.0-5.0 cm). At the time of laparoscopic cornuostomy, more patients with interstitial pregnancies with intact ectopic masses were administered prophylactic MTX (81.3% vs 45.5%; p = .043). Only 1 patient with a ruptured ectopic mass, high preoperative human chorionic gonadotropin levels, and without prophylactic MTX administration experienced a persistent ectopic pregnancy.

CONCLUSION

Patients with a history of ipsilateral salpingectomy should be cautioned regarding the possibility of interstitial pregnancy. Laparoscopic cornuostomy appears to be an appropriate treatment for interstitial pregnancy in patients wishing to preserve fertility, and the use of concomitant prophylactic MTX may reduce the risk of persistent ectopic pregnancy, especially in patients with ruptured masses and high human chorionic gonadotropin levels.

Evidence-based management of non-tubal ectopic pregnancies

Recent advances in ultrasonography and the use of other modalities including magnetic resonance imaging scans have led to the early and more accurate diagnosis of non-tubal ectopic pregnancies (NTE). As a result, the management of these pregnancies has evolved. This article addresses the management options currently available for NTE. While surgical management remains the mainstay of treatment for ovarian, abdominal and cornual ectopics, there is growing evidence that some of these can be managed medically. Many authors have utilised a combination of medical and surgical approaches in the management of cervical and caesarean section (CS) scar ectopic pregnancies with good outcome. The availability of dedicated early pregnancy units has further improved diagnosis and more importantly the follow-up care for these patients. The rarity of cases and the difficulty of ethically organising randomised trials for NTE remain a problem in formulating consistent pathways for optimum management of women with NTE.

Robotic versus laparoscopic sacrocolpopexy for apical prolapse: a case-control study

The apical prolapse has always been considered the most complex of the defects of the pelvic floor, for both the difficulty of the surgical corrective technique and for the high post-surgical recurrence rate. Today, the laparoscopic sacrocolpopexy can be considered the standard treatment for apical prolapse. In the last years, several author performed robotic sacrocolpopexy, obtaining positive results. So, we developed a casecontrol study in order to compare the surgical outcome of robotic group with a control group of laparoscopic approach in patients with symptomatic apical pro-lapsed between January 2015 and December 2015 at University Hospital Policlinico "P. Giaccone" and Ospedali Riuniti "Villa Sofia-Cervello", Palermo. Our experience shows that robotic sacrocolpopexy can be considered in positive way for clinical results obtained: all procedures were executed with no complications, we noted a lower intraoperative blood loss and a shorter hospital stay than in laparoscopic group. Although the mean operative time and the economic costs are higher in robotic surgery, this study demonstrates that the use of robotic platform for repairing of symptomatic apical vaginal prolapse is feasible, safe and associated with short-term satisfactory results, representing therefore a valid alternative to laparoscopic approach.

Diagnosis and Management of 'Cornual' Pregnancies from 2002 to 2015 at a Tertiary Referral Centre in South India: Insights from Introspection

Purpose

Interstitial, angular and rudimentary horn pregnancies have all been referred to as cornual pregnancies despite definite diagnostic criteria. Angular pregnancies can be followed up expectantly under close surveillance while interstitial and rudimentary horn pregnancies are terminated by medical or surgical methods. This study aimed to assess accuracy of ultrasound in the diagnosis of 'cornual pregnancy' and evaluate management.

Methods

Data pertaining to clinical features, ultrasound findings and treatment modalities of the aforementioned conditions between January 2002 and December 2015 at a tertiary perinatal centre were retrieved from the medical records. The ultrasound images and surgical videos were reviewed by the authors.

Results

Of 62 cases, 35 were interstitial, 26 were angular/eccentric intrauterine, and 1 was a rudimentary horn pregnancy. The accuracy of ultrasonography in the diagnosis of interstitial and angular pregnancies was 71.0 and 46.8%, respectively. Medical management was successful in 33.3% of interstitial pregnancies. Fifteen women with interstitial pregnancy had subsequent pregnancies and nine (75.0%) were Caesarean deliveries. Rupture and recurrence rates of interstitial pregnancy were 34.2 and 2.9%, respectively. The rudimentary horn pregnancy was managed by laparoscopic excision followed by a subsequent term delivery.

Conclusion

This study identified frequent occurrences of imprecise nomenclature that resulted in mismanagement of a few potentially viable angular pregnancies. It is imperative for clinicians and sonologists to use unambiguous nomenclature and avoid the term 'cornual pregnancy' altogether.

Intact Cornual Ectopic Pregnancy and Dermoid Cyst With Intraoperative Rupture

Of ectopic pregnancies encountered in clinical practice, more than 95% are located within the fallopian tube, and 2% to 4% are cornual. A cornual ectopic pregnancy is a serious clinical condition and poses diagnostic and therapeutic challenges. Thus, understanding the clinical course and treatment options is essential. The authors describe the case of a 29-year-old woman who presented to the Department of Obstetrics and Gynecology. The patient was suspected of having a cornual pregnancy, and a dermoid cyst had been detected during routine ultrasonography. In the absence of maternal symptoms, the clinical scenario is potentially dangerous and must be treated promptly and efficiently to decrease morbidity and mortality.

Endoloop technique for laparoscopic cornuectomy: A safe and effective approach for the treatment of interstitial pregnancy

Interstitial pregnancy (IP) occurs within the intramural portion of the tube and accounts for 2% of ectopic pregnancies. Surgery is considered the most definitive treatment for IPs, although there is no clear consensus regarding the optimal approach. In this paper we describe the advantages of cornual resection performed using the Endoloop technique and present three patients who were successfully treated using this approach. IP diagnosis was confirmed at two and three-dimensional ultrasound and laparoscopy in all cases. Fertility sparing surgery with cornuectomy by Endoloop ligature technique demonstrated low mean operating time and blood loss, and allowed the quick recovery and discharge of all patients. Laparoscopy has become the gold standard surgical approach for IP. Cornual resection or excision is the most commonly performed procedure. In our case series, the Endoloop technique showed excellent treatment outcomes in terms of effectiveness, blood loss, operative time, recovery and post-procedure fertility. Because of these features, Endoloop appears to be a suitable option for the laparoscopic management of IPs, both in elective and emergency settings.

Magnetic resonance imaging for diagnosis and management of unruptured interstitial pregnancy

AIM

The aim of this study was to evaluate the value of magnetic resonance imaging (MRI) for the diagnosis and management of suspicious unruptured interstitial pregnancy.

MATERIAL AND METHODS

Only patients with unruptured interstitial pregnancy evaluated by MRI and observed for at least a year after surgery were included. Initial evaluation was performed by measurement of serum β-human chorionic gonadotrophin level and ultrasonography. In suspicious cases, emergency MRI was performed to diagnose interstitial pregnancies with the exclusion of rudimentary horn pregnancy and angular pregnancy. Three-dimensional computed tomographic (CT) angiography was additionally performed if the uteroplacental neovascularization needed to be evaluated. Then, management procedures were individually determined along with the need for preoperative transcatheter arterial chemoembolization for immediate devascularization, and for the local or systemic administration of methotrexate. Either laparoscopic cornuostomy or cornual resection was chosen to excise the gestational mass.

RESULTS

Five consecutive women with unruptured interstitial pregnancy were enrolled. One case each of rudimentary horn pregnancy and angular pregnancy was excluded. Three-dimensional CT angiography was performed in three cases due to increased vascular flow on color Doppler ultrasonography. Preoperative devascularization by transcatheter arterial chemoembolization was performed in two cases, in which a prominent neovascularized gestational mass was identified. Uterine preservation was achieved by cornuostomy or cornual resection in all cases. Two patients with a desire to become pregnant conceived spontaneously thereafter, followed by successful cesarean birth.

CONCLUSION

This small case series emphasizes that precise localization of gestational products in the interstitial portion of the fallopian tube by MRI can facilitate the minimally invasive management of unruptured interstitial pregnancy for uterine preservation.