Bilateral interstitial pregnancy after in vitro fertilization and embryo transfer with bilateral fallopian tube resection detected by transvaginal sonography

Management of a uterine serosal heterotopic pregnancy after in vitro fertilization in a woman with bilateral salpingectomy: A case report and literature review

RATIONALE

Heterotopic pregnancy (HP) is defined as the simultaneous presence of intrauterine pregnancy and ectopic pregnancy (EP). HP after bilateral salpingectomy is extremely rare and may lead to serious complications if it is misdiagnosed and untreated timely. Here, we presented the first reported case of uterine serosal HP in a woman after assisted reproductive technology with bilateral salpingectomy because of bilateral tubal ectopic pregnancy.

PATIENT CONCERNS

A 27-years-old pregnant woman after in vitro fertilization with bilateral salpingectomy complained of a sudden onset of unprovoked abdominal pain, which was persistent and dull. She denied vaginal bleeding.

DIAGNOSES

Serum beta-human chorionic gonadotropin levels are difficult to predict HP. Transvaginal ultrasonography demonstrated 1 gestational sac in the uterine cavity and 1 thick-walled cystic mass over the upper of the uterus, with a large amount of fluid in the Pouch of Douglas. Emergency laparotomy revealed a uterine serosal pregnancy combined with intrauterine pregnancy.

INTERVENTIONS

This patient was successfully managed via emergency laparotomy to remove residual tissue and repair the rupture of the uterine serosal pregnancy.

OUTCOMES

At postoperative 4 days, repeat transvaginal ultrosonography presented 1 intrauterine gestational sac with a visible fetal bud and cardiac tube pulsation. Now the patient recover well and is in an ongoing pregnancy.

LESSONS

It is noteworthy that HP/ectopic pregnancy is still not prevented after bilateral salpingectomy. In cases of multiple embryo transfer, even if intrauterine pregnancy has been established, it is important to rule out HP/ectopic pregnancy in time. Early diagnosis and early management can significantly improve clinical outcomes.

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.

Interstitial twin pregnancy: A unique case presentation

Early recognition and timely treatment of an interstitial pregnancy is imperative to avoid the high morbidity and mortality of this type of ectopic pregnancy. We report a case of twin interstitial pregnancy that was initially missed on initial sonogram and was subsequently recognized at our institution by transvaginal sonography. The patient underwent open laparoscopic surgery with cornual wedge resection but suffered infundibulopelvic ligament hemorrhage and subsequently required ipsilateral salpingo-oophorectomy. She did well and was discharged home a day later.

Heterochronic bilateral ectopic pregnancy after ovulation induction

Ectopic pregnancy is identified with the widely-applied assisted reproductive technology (ART). Bilateral ectopic pregnancy is a rare form of ectopic pregnancy which is difficult to be diagnosed at the pre-operation stage. In this paper, we presented an unusual case of heterochronic bilateral ectopic pregnancy after stimulated intrauterine insemination (IUI), where there has been a delay of 22 d between the diagnoses of the two ectopic pregnancies. Literature was reviewed on the occurrence of bilateral ectopic pregnancy during the past four years in the MEDLINE database. We found 16 cases of bilateral ectopic pregnancy reported since 2008, and analyzed the characteristics of those cases of bilateral ectopic pregnancy. We emphasize that ovulation induction and other ARTs may increase the risk of bilateral ectopic pregnancy. Because of the difficulty in identification of bilateral ectopic pregnancy by ultrasonography, the clinician should be aware that the treatment of one ectopic pregnancy does not preclude the occurrence of a second ectopic pregnancy in the same patient and should pay attention to the intra-operation inspection of both side fallopian tubes in any ectopic pregnancy case.