A rare case of extraluminal interstitial pregnancy treated with laparoscopic cornuotomy

We report an extremely rare case of an extraluminal interstitial pregnancy. A 36-year-old nulliparous woman visited our hospital during the fifth week of gestation. Although no intrauterine gestational sac (GS) was identified, transabdominal ultrasonography revealed a GS-like cyst was detected in the right uterine horn. She underwent laparoscopic surgery for a suspected interstitial ectopic pregnancy. After laparoscopic cornuotomy, dye leakage was observed from the fimbria rather than the incision site. Finally, the patient was diagnosed with a right extraluminal interstitial pregnancy. Hysterosalpingography performed at three postoperative months revealed bilateral tubal passage. She conceived 7 months after surgery, with safe delivery by elective cesarean section at 38 weeks.

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.

Ruptured Recurrent Interstitial Ectopic Pregnancy Successfully Managed by Laparoscopy

Ectopic pregnancies are a frequently encountered cause of first-trimester metrorrhagia. They occur when an embryo is implanted and grows outside the normal uterine space. Uncommonly, the embryo can be implanted in the intramural portion of the uterine tube, a condition referred to as interstitial localization. This specific type of ectopic pregnancy may have an unpredictable course, potentially leading to severe uterine rupture and catastrophic bleeding if not promptly diagnosed and managed. We present a rare case of a multiparous 36-year-old female patient who underwent pelvic ultrasonography in the emergency department for intense pelvic pain associated with hypotension and moderate anemia. A history of right salpingectomy for a ruptured tubal ectopic pregnancy 10 years previously was noted. High beta-HCG levels were also detected. A pelvic ultrasound allowed us to suspect a ruptured ectopic interstitial pregnancy at 8 weeks of amenorrhea. An association with hemoperitoneum was suspected, and an emergency laparoscopy was performed. The condition was confirmed intraoperatively, and the patient underwent a right corneal wedge resection with suture of the uterine myometrium. The postoperative course was uneventful, and the patient was discharged on the fourth day postoperatively. Interstitial ectopic pregnancy is a rare yet extremely perilous situation. Timely ultrasound-based diagnosis is crucial as it can enable conservative management with Methotrexate. Delayed diagnosis can lead to uterine rupture with consecutive surgery based on a transection of the pregnancy and cornual uterine resection.

Vasopressin Injection Purse-String Ectopic Resection technique for laparoscopic management of cornual ectopic pregnancy

Although cornual pregnancy is a rare form of ectopic pregnancy, the associated mortality rate is considerably higher than that of ectopic pregnancy overall. Historically, cornual ectopic pregnancy has been treated via laparotomy. With advancements in technology, equipment, and technique, laparoscopy offers a safer approach for the management of cornual pregnancy. However, laparoscopy of this nature requires excellent technique. The Vasopressin Injection Purse-String Ectopic Resection technique serves as an effective strategy for the laparoscopic management of cornual ectopic pregnancy. First, dilute vasopressin is administered into the myometrium surrounding the pregnancy. Next, a purse-string stitch is placed in the myometrium circumferential to the pregnancy. Finally, the pregnancy is excised by cornual wedge resection, and the defect is repaired using the attached remaining suture from the purse-string stitch. The Figure shows the graphical depiction of the Vasopressin Injection Purse-String Ectopic Resection technique, and the Video shows a laparoscopic recording of the Vasopressin Injection Purse-String Ectopic Resection technique. Between 2012 and 2022, 17 patients underwent a laparoscopic cornual ectopic pregnancy resection at a high-volume academic hospital and its affiliated community hospital. This case series revealed a mean operative time of 107 minutes, with a mean estimated blood loss of 41 mL for nonruptured ectopic pregnancies and 412 mL for ruptured ectopic pregnancies. No case was converted to laparotomy. Our findings suggest that the integration of the vasopressin administration and the pursue-string stitch placement minimizes blood loss and mitigates the risk of conversion to laparotomy for both nonruptured and ruptured cornual ectopic pregnancies.

Ipsilateral Right Angular Pregnancy After a Laparoscopic Right Salpingo-Oophorectomy: A Case Report

It can be difficult to distinguish an interstitial pregnancy from an angular pregnancy because of the close proximity of the implantation sites. The difference in pregnancy outcomes between interstitial and angular pregnancies makes this distinction very important. A 39-year-old gravida 7 para 4 who had undergone a laparoscopic right salpingo-oophorectomy (RSO) one year ago and a pregnancy termination via dilation and curettage (D&C) three weeks ago was suspected to have a ruptured right interstitial or angular pregnancy. The patient underwent a laparoscopic total hysterectomy. The postoperative histologic diagnosis was an abortion of a right angular pregnancy. Indeed, it is essential to rule out an interstitial or angular pregnancy during adnexal surgery, even soon after elective abortion. Proper management of an angular pregnancy could prevent a fatal outcome following a rupture or massive hemorrhage.

Nontubal ectopic pregnancies: overview of diagnosis and treatment

Nontubal ectopic pregnancies occur as a result of embryo implantation outside the uterine cavity and fallopian tubes. Sites include ovary, cervix, abdominal cavity, interstitial portion of fallopian tube, and cesarean scar. Nontubal pregnancies are uncommon. Nonspecific signs and symptoms of nontubal ectopic pregnancies make diagnosis challenging and, in many cases, significantly delayed, resulting in a high rate of morbidity. Although surgical management remains the mainstay of treatment, there is growing evidence that some of these can be managed medically or with the use of a combination of medical and surgical approaches with good outcome. This review summarizes the current diagnostic modalities, therapeutic options, and outcomes for nontubal ectopic pregnancies. Diagnostic and management options may be limited, especially in resource-restricted settings. Therefore, an understanding of the available options is critical. It needs to be emphasized that the rarity of cases and the difficulties in organizing ethically justified randomized trials result in the lack of well-established management guidelines for nontubal ectopic pregnancies.

Interstitial Ectopic Pregnancy: A Rare Diagnosis

An ectopic pregnancy is located outside the uterus, mostly found in the fallopian tubes. The main predisposing factors are usually related to anatomical and/or functional disturbances of the fallopian tubes. Typically, an ectopic pregnancy presents with vaginal bleeding or abdominal pain in the first trimester of pregnancy, although it may be asymptomatic. The diagnosis of ectopic pregnancy, which is based on transvaginal ultrasound associated with the serum beta fraction of human chorionic gonadotropin values, is of the highest relevance due to the mortality risk involved. We report the case of a 26-year-old woman who presented with a four-week history of amenorrhea and abdominal pain. Initially, the diagnostic hypothesis was a pelvic inflammatory disease, as the patient complained of pain during deep palpation of the lower quadrants of the abdomen, and gynecological observation detected malodorous discharge and cervical tenderness. Antibiotic treatment was initiated. The patient was later diagnosed with ectopic pregnancy, which was discovered during a routine pregnancy ultrasound. She was submitted to urgent laparotomy with intraoperative confirmation of the interstitial location of the gestational sac.

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.

Cornual Pregnancy

Cornual pregnancy (CP) is a subtype of ectopic pregnancy that is implanted in the interstitial segment of the fallopian tube which is defined as the tubal section crossing uterine muscular tissue. Widely recognized risk factors for CP are endometriosis, uterine leiomyomata, or pelvic inflammatory disease; all these diseases can cause tubal anatomic changes and consequently alter embryo physiological implant process. Many treatment options are available for this condition each one must be tailored according to patient and operating scenario. The incidence of uterine ruptures in the scarred uterus appears to be low, but the fear of it remains and therefore medical treatment might be favored over cornual wedge resection. The actual risk of uterine rupture after medical treatment is unknown. Multiple testing strategies exist to diagnose CP, but caution needs to be used to avoid a false diagnosis.

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.

Heterotopic Interstitial Pregnancy: Early Ultrasound Diagnosis of 179 Cases After In Vitro Fertilization-Embryo Transfer

OBJECTIVES

What is the role of transvaginal sonography (TVS) in the early diagnosis of hectopic interstitial pregnancy (HIP) after in vitro fertilization-embryo transfer (IVF-ET)?

METHODS

A retrospective observational study was conducted from January 2005 to December 2018. Routine two-dimensional and three-dimensional TVS were used to confirm clinical pregnancy. Women were diagnosed with HIP when an intrauterine gestational sac was combined with an extrauterine chorionic sac, which was at least 1 cm away from the uterine cavity and surrounded by a thin myometrial layer (<5 mm). Surgery and pathology results were the gold standard for diagnosing interstitial pregnancy. Non-surgical patients were excluded from the study. The performance of TVS and the pregnancy outcomes of intrauterine pregnancies (IUPs) were evaluated.

RESULTS

A total of 97,161 women underwent IVF treatment and TVS examinations in our hospital during this study. Of these, 194 patients were diagnosed with HIP, with an incidence of 0.2% (194/97,161). Surgical and pathological findings confirmed 179 interstitial pregnancies, of which 174 were diagnosed by TVS, 4 were missed, and 1 was misdiagnosed. The sensitivity of TVS diagnosis was 97.8% and the positive predictive value was 99.4%. The mean time to diagnosis was 31 days after transplantation. One hundred and thirty-nine cases of HIP (77.7%) were diagnosed at the time of initial TVS examination. In 132 patients (73.7%), IUPs resulted in live births.

CONCLUSIONS

In our practice, most HIPs following IVF-ET can be accurately diagnosed by TVS, which facilitates early management of interstitial pregnancies and enables high live birth rates for IUPs.

Management of interstitial pregnancy using laparoscopic salpingectomy with complete removal of the interstitial portion

OBJECTIVE

To perform laparoscopic salpingectomy including the entire interstitial portion of the fallopian tube in the management of interstitial pregnancy.

DESIGN

A step-by-step explanation of the surgical procedure using video with narration.

SETTING

Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China.

PATIENT

A 23-year-old woman, gravida 1 para 0, presented to our hospital asymptomatically to undergo a pregnancy test. Her last menstrual period had occurred 6 weeks previously. Transvaginal ultrasound showed an empty uterine cavity and a right interstitial mass of 3.2 × 2.6 × 2.5 cm. It contained a chorionic sac and an embryonic bud of 0.2 cm long with a heartbeat, and the presence of an "interstitial line sign". The myometrial layer surrounding the chorionic sac is 1 mm. The patient's beta human chorionic gonadotropin level was 10,123 mIU/mL.

INTERVENTION

Based on the anatomy of the interstitial portion of the fallopian tube, we treated interstitial pregnancy using laparoscopic salpingectomy with complete removal of the interstitial portion containing the product of conception. The interstitial fallopian tube originates at the tubal ostium and follows a tortuous intramural course, progressing laterally away from the uterine cavity towards the isthmic portion. It is lined by muscular layers and an inner epithelium layer. The main blood supply of the interstitial portion is from the uterine artery's ascending branches to the fundus extending a branch which supplies the cornu and the interstitial portion. Our approach has three key steps: 1) dissecting and coagulating the branch extending from the ascending branches to the fundus of the uterine artery, 2) incising the cornual serosa at the junction of the purple-blue interstitial pregnancy and the normal color myometrium, and 3) resecting the interstitial portion containing the product of conception along the out layer of the oviduct without rupture.

MAIN OUTCOME MEASURE

The interstitial portion containing the product of conception was removed entirely along the out layer of the tube as a natural capsule without rupture.

RESULTS

The surgery lasted for 43 min, and the volume of intraoperative blood loss was 5 mL. The pathology was confirmatory for interstitial pregnancy. The patient's beta human chorionic gonadotropin decreased optimally. She had a normal post-operative course.

CONCLUSION

This approach reduces intraoperative blood loss, minimizes myometrial loss and thermal injury, and effectively avoids PIP. It is not limited by the device used, does not increase the surgery cost, and is greatly useful in treating a selected non-ruptured distally or centrally implanted interstitial pregnancy.

Interstitial Pregnancy Treated with Mifepristone and Methotrexate with High Serum β-hCG Level in a Patient Wishing to Preserve Fertility: Time to Define Standardized Criteria for Medical/Surgical Therapy?

Interstitial pregnancy (IP) accounts for 2% of all ectopic pregnancies and has a mortality rate of 2-2.5%. The diagnosis is made by a transvaginal ultrasound and the treatment can be medical or surgical. We report the case of a 36-year-old primigravida who was 6 + 5 weeks pregnant, diagnosed with interstitial pregnancy by ultrasound, who had a very high serum β-hCG level (31,298 mIU/mL) and wanted to preserve her fertility. The patient was treated with one dose of mifepristone and a double dose of methotrexate since the decrease in the β-hCG serum level was less than 15% after the first dose. At the beginning, medical therapy was effective, as no embryonal cardiac activity was detected and serum β-hCG levels decreased early, but on the 20th day of hospitalization, the patient underwent surgery for her clinical symptoms and the evidence of free fluid in the Douglas pouch at a transvaginal ultrasound exam. Our experience showed that medical treatment should be considered, especially in women wishing to preserve their fertility. Further studies are needed to establish a standardized protocol and maybe a clinical score that can be useful in predicting the patients in which medical therapy could be most successful.

Surgical Treatment Following Failed Medical Treatment of an Interstitial Pregnancy

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.

Surgical treatment of interstitial pregnancy without cornual resection: A case report

RATIONALE

Interstitial pregnancy (IP) is a rare but extremely life-threatening form of ectopic pregnancy. The traditional surgical treatment for this anomaly is the resection of uterine cornua or fallopian tubes, which often damages their structural integrity, thereby compromising the reproductive potential for women who wish to preserve fertility.

PATIENT CONCERNS

A 33-year-old female was admitted to our hospital with suspected ectopic pregnancy, following a 4-weeks history of positive pregnancy tests after uterine evacuation. The patient was hemodynamically stable on arrival. Ultrasound revealed an empty uterus with an eccentric gestational sac located at the fundus and surrounded by a thin myometrium, indicative of a suspected interstitial pregnancy.

DIAGNOSIS AND INTERVENTION

After failed attempt at medical management with a single dose of intramuscular methotrexate, the patient was arranged for hysteroscopy-assisted laparoscopy. In surgery, the uterine cavity appeared empty, and a 2 × 2 cm bulge with increased vascularity at the right uterine courna was identified upon examination. The gestational sac was aspirated through the vagina from the right ostium of the uterine tube using a suction curette pointing at the right ostium. Sutures were not needed afterward, and the myometrial anatomy was left undisrupted. The diagnosis of IP was confirmed by the postoperative histological report.

OUTCOMES

Perioperative blood loss was approximately 10 ml and the operative time was 40 minutes. The patient had an uneventful postoperative recovery and was discharged after 3 days. Subsequent follow-ups showed a significant reduction in the patient serum beta hCG to 48IU/L within 5 days postoperation, and a negative result after 7 days.

LESSONS

This novel surgical technique is an alternative minimally-invasive approach for selected early diagnosed and hemodynamically stable IP patients. The technique represents a safe, quick, and simple approach combining the benefits of laparoscopy, such as allowing for immediate conversion of cornuectomy when uterus ruptures, and the benefits of suction curettage, such as shorter operative time and minimal blood loss. We believe patients with interstitial pregnancy who still have fertility wishes would benefit from this surgical technique to a larger extent in the future.

Spontaneous angular dichorionic diamniotic twin pregnancy: a case report

OBJECTIVE

To report a peculiar case of ultrasound diagnosis of spontaneous angular twin pregnancy. In literature, the terms "angular," "interstitial," and "cornual" pregnancies are often used inappropriately. Confusion in terminology may have contributed to difficulties in developing diagnostic ultrasound criteria to differentiate these ectopic pregnancies.

DESIGN

Case report.

SETTING

Obstetrics and Gynecology, Community Hospital "S. Maria delle Croci."

PATIENT

A 28-year-old patient with a previous cesarean delivery was admitted to our hospital for management of a presumed angular ectopic pregnancy. Transvaginal ultrasound confirmed an ectopic dichorionic diamniotic twin pregnancy eccentrically located in the right superior angle of the uterine cavity: the first gestational sac appeared to have right angular implantation, whereas the second gestational sac seemed to deepen inside the myometrium, with a thin myometrial margin of only 3 mm.

INTERVENTIONS

After discussing the risks, the patient requested to proceed with termination. A single intramuscular injection of 75 mg of methotrexate was administered, followed by ultrasound-guided hysterosuction after 19 days due to severe vaginal bleeding.

MAIN OUTCOME MEASURES

An early and accurate ultrasound diagnosis of a high-risk condition allowed for conservative medical treatment.

RESULTS

The serum beta-human chorionic gonadotropin levels progressively decreased. After 1 month, a clinical and ultrasound examination showed a regular endometrial line with a regular reappearance of menstrual bleeding.

CONCLUSIONS

Although there are remarkable advances in ultrasound techniques, angular pregnancy remains a condition of difficult diagnosis and management; it is potentially dangerous and may lead to severe complications. An early and accurate diagnosis of this condition is necessary to avoid complications and individualize the subsequent management.

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.

Cornual Pregnancy After Ipsilateral Salpingectomy

Ectopic pregnancy is a serious diagnosis occurring in 1-2% of all pregnancies, causing significant morbidity and mortality if unrecognized. Management of ruptured ectopic pregnancy typically includes salpingectomy, which decreases the risk for repeat ectopic pregnancies. In rare cases after salpingectomy, non-viable implantation may occur on the ipsilateral side of prior surgery. We present a patient with a cornual pregnancy on the ipsilateral side of her prior ectopic pregnancy and salpingectomy.

Interstitial Ectopic Pregnancy: The Role of Mifepristone in the Medical Treatment

Interstitial pregnancy is defined as the presence of a gestational sac in the most proximal section of the fallopian tube. Management of interstitial pregnancy remains a debated topic. Depending on hemodynamic stability, size of pregnancy, depth of surrounding myometrium, and desires for future fertility, interstitial pregnancy can be managed medically or surgically. We reviewed the literature in December 2020 using keywords “interstitial pregnancy”, “medical treatment”, “methotrexate”, and “mifepristone”. Articles published from January 1991 until 2020 were obtained from databases EMBASE, SCOPUS, and PUBMED. We describe the case of a patient with an interstitial pregnancy that was managed with a total medical approach in August 2020 at Burlo Garofolo Hospital. The patient was asymptomatic and hemodynamically stable, with a high level of serum β-hCG (22,272 mUi/mL). We used the combination of methotrexate (MTX) and mifepristone. Medical therapy was effective leading to interstitial pregnancy resolution in 51 days without collateral effects for the patient. We found seven previous cases reported in the literature. Our purpose is to underline the efficacy of medical therapy with systemic multidose MTX associated with a single oral dose of mifepristone and also folinic acid when is present a viable fetus and a high serum β-hCG level.

Treatment and management of interstitial pregnancy with laparoscopic cornual resection

To show how interstitial pregnancy can be safely managed with a laparoscopic resection.

A Purse-String Approach to Laparoscopic Cornuotomy for Interstitial Ectopic Pregnancy

An interstitial ectopic refers to the implantation of a pregnancy in the proximal fallopian tube where it passes through the myometrium. This type of ectopic pregnancy presents a distinct surgical challenge, as it often presents with rupture and carries a significant risk of hemorrhage at resection. This video demonstrates a four-step approach to the resection of an interstitial ectopic pregnancy with laparoscopic cornuotomy. This approach includes (1) isolating the pregnancy by performing a salpingectomy and identifying the utero-ovarian ligament; (2) ensuring hemostasis with the injection of vasopressin, followed by application of the purse string suture around the pregnancy at its equatorial line; (3) performing the resection using a linear incision; and (4) repairing the uterine defect with layered closure. The purse-string suture is shown to be a useful tool in minimizing bleeding, and this sequential approach allows for interstitial ectopic pregnancies to be excised with a minimally invasive cornuotomy, even in cases of significant anatomical distortion.

The feasibility of laparoscopically assisted, hysteroscopic removal of interstitial pregnancies: A case series

OBJECTIVE

The study objective was to assess the feasibility of the management of interstitial pregnancy by laparoscopically assisted hysteroscopic removal.

METHODS

This retrospective study included a case series of 17 patients who were diagnosed interstitial pregnancy with dilated proximal tubal ostium by transvaginal ultrasonography at the Women's hospital, School of Medicine, Zhejiang University between August 2017 and October 2020. Laparoscopically assisted hysteroscopic removals of the products of conception were performed. Various data were collected including age, surgical and obstetric history, gestational age, preoperative symptoms, human chorionic gonadotropin level and ultrasonography results. The outcomes measured were intraoperative bleeding, pathologic findings, conversions.

RESULTS

Eleven cases were successfully resected the interstitial gestational products with laparoscopically assisted hysteroscopy. There were four cases failed of hysteroscopic removal, for the proximal tubal ostia were too small for the surgical instruments to enter. Then cornual wedge resections were performed. Two cases were identified as intramural pregnancy by hysteroscopic and laparoscopic view. Most of the intramural pregnancy tissue of one patient was removed by hysteroscopy. The other one converted to laparoscopy.

CONCLUSION

Laparoscopically assisted hysteroscopic management could be a feasible surgical option to interstitial pregnancies. Further clinical studies are needed to establish detailed criteria to select the appropriate cases for hysteroscopic management.

Methotrexate injection for interstitial pregnancy: Hysteroscopic conservative mini-invasive approach

Background

Interstitial localisation of ectopic pregnancy is associated with high rates of maternal morbidity and mortality. Considering the rarity of interstitial pregnancy, the optimal treatment regimen remains unclear. We propose the management of interstitial pregnancy with local methotrexate injection using a combined hysteroscopic and ultrasonographic approach.

Technique

Hysteroscopy was performed under local anaesthesia in the operating room, using a 2.9-mm Hopkins II Forward-Oblique Telescope 30° endoscope with a 4.3-mm inner sheath and 5 FR instruments. A needle was pushed into the cornual region injecting methotrexate solution directly into the gestational sac and into the myometrial tissue tangentially at the four cardinal points. A contemporary transabdominal ultrasound (US) was performed in order to reduce risks of complications.

Experience

Five patients with an US diagnosis of interstitial ectopic pregnancy admitted to our department between January 2016 and September 2019 were managed with a local hysteroscopic injection of methotrexate. The technique was effective in all patients and no surgical complications occurred during or after the procedure. Three patients were evaluated for tubal patency with contrast ultrasonography confirming bilateral tubal patency 9 months from treatment, while one patient had a spontaneous birth 22 months from their initial surgery.

Conclusion

The hysteroscopic ultrasound-guided approach combined with the local injection of methotrexate is a minimally invasive conservative approach that seems to be promising in the management of interstitial ectopic pregnancy.

Threatened uterine rupture following laparoscopic surgery in interstitial tubal pregnancy

Contraception is recommended for a certain period following a hysterotomy; however, no consensus exists on the required duration of contraception. A 21-year-old female was brought to the emergency room in a state of shock due to intraperitoneal bleeding. An emergency laparoscopic cornuostomy indicated for ruptured interstitial pregnancy was performed. Despite contraception, the patient got pregnant 1.5 months after surgery. At 16 weeks of gestation, threatened uterine rupture was suspected, as magnetic resonance imaging (MRI) revealed hematogenous amniotic fluid and a subchorionic hematoma near the interstitial portion of the fallopian tube. An MRI at 21 weeks showed hematoma shrinkage and disappearance of the hematogenous amniotic fluid. At 37 weeks, an elective cesarean section was performed, which resulted in a live birth. Pregnancy shortly after surgery is a risk factor for uterine rupture. In such cases, MRI could be useful in the evaluation of threatened uterine ruptures.

Interstitial Pregnancy: Case Report of Atypical Ectopic Pregnancy

Interstitial or cornual implantation of the blastocyst is rare, accounting for 2% to 3% of ectopic pregnancies, being considered not viable. The important complications of interstitial pregnancy are uterine rupture and massive bleeding, which usually occur before 12 weeks of pregnancy. The authors report a case of a 36-year-old woman with complaints of transvaginal bleeding and abdominal pain associated with amenorrhea for seven weeks and positive beta-human chorionic gonadotropin (HCG). Transvaginal ultrasound and exploratory laparotomy were performed, confirming the diagnosis of interstitial ectopic pregnancy. The patient underwent a salpingectomy and cornual resection on the left, evolving with clinical improvement and hospital discharge.

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.

Arteriovenous uterine malformation developed from an interstitial pregnancy on residual tubal stump: A critical managment in a fertile woman

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.

Non-surgical management and obstetric outcomes of heterotopic interstitial pregnancies

Objective: To assess the effectiveness and safety of non-surgical management for six heterotopic interstitial pregnancies.Material and methods: We retrospectively analyzed the data of six women diagnosed with heterotopic interstitial pregnancies who underwent non-surgical treatment at the CHA Bundang Medical Center between January 2007 and December 2017. Three heterotopic interstitial pregnancies were treated with sono-guided potassium chloride (KCl) injections. Two cases were managed expectantly. One heterotopic quadruplet pregnancy with twin, left interstitial, and tubal pregnancy was treated by sono-guided KCl injection and laparoscopic left salpingectomy. Complications and outcomes were measured.Results: Three cases were treated with sono-guided KCl injection and the intrauterine pregnancy continued to term. Intrauterine pregnancies were vaginally delivered without complications. One case that was treated expectantly was delivered at full term, while the other case resulted in spontaneous abortion. Quadruplet heterotopic pregnancy was successfully managed with sono-guided KCl injection and laparoscopic salpingectomy. Intrauterine twin pregnancy was successfully delivered by elective cesarean section at 37 + 0 weeks of gestation with healthy babies. Conclusions: KCl injection under ultrasonographic guidance could be a safer and more effective treatment option than surgical treatment in hemodynamically stable patients with fetal cardiac activity in interstitial pregnancy. Expectant management could be an option for patients with no fetal cardiac activity.

Disturbed Interstitial Pregnancy: A First Case of Successful Treatment Using a Mini-Laparoscopic Approach

Interstitial ectopic pregnancy (EP) is a life-threatening condition due to the risk of massive hemorrhage in the event of its disturbance. We present the case of a 27-year-old patient who was admitted with massive hemoperitoneum, caused by the rupture of an interstitial pregnancy in the area of the fallopian tube stump, which had been removed after a previous ectopic pregnancy. The condition was overcome using a mini-laparoscopic approach (2.6 mm, 30° optics), with one 3 mm port for micro-laparoscopic instruments and one 10 mm port. Such an approach has not yet been reported in the available literature, among the casuistically reported cases of pregnancy in the tubal stump. We consider that the technique is safe, completely in the interest of the patient, applicable by an experienced team, and in agreement with modern trends regarding the minimization of operative access.

An evident asymmetrical uterus during cesarean delivery

If an obstetrician determines the presence of an asymmetrical uterus during cesarean delivery, the likelihood of an interstitial pregnancy complicated by placenta accreta should be considered. The figures in this article should help advance the current knowledge about a rare type of full-term interstitial pregnancy complicated by placenta accreta.

Successful Procedure in Conservative Management of Interstitial (Cornual) Ectopic Pregnancy

A 35-year-old woman presented with spotting and lower abdominal pain. Follow-up sonography was suggestive of interstitial ectopic pregnancy. Laparoscopic cornuostomy was carried out. Before incision, diluted vasopressin was injected around the site of interstitial pregnancy. Removal of the conceptual tissues was conducted smoothly through a 1.5 cm incision. The overall blood loss was 50 mL. The operative time was 50 min, and there were no intraoperative complications. We successfully performed laparoscopic cornuostomy, which was followed by an unremarkable postoperative course. Laparoscopic surgery is a safe and effective minimally invasive surgical intervention for interstitial ectopic pregnancy if performed by the experienced surgeon. Local vasopressin injection is a good alternative for bleeding control in conservative laparoscopic surgery.

Interstitial and angular pregnancies: Case reports and differential diagnosis

Interstitial and angular pregnancies are rare and have high rates of morbidity and mortality. These terms continue to create confusion and are frequently misused. The standardization of terminology and differentiation of cases is necessary to distinguish between different outcomes. This article aims to report one case of angular and another case of interstitial pregnancies and to discuss clinical and radiological characteristics, prognosis and treatment. These pathologies continue to be confused with each other and with ectopic pregnancy tubal. Therefore, correct diagnosis facilitates appropriate management.

Comparative Study on Surgical Outcomes between Laparoscopic and Open Cornuotomy in Urban Tertiary Center of Malaysia

STUDY OBJECTIVE

The objective of the study was to evaluate the prevalence of interstitial ectopic pregnancy and to compare the surgical outcomes of laparoscopic cornuotomy (LC) and laparotomy (open) cornuotomy (OC) of cornual ectopic pregnancy and to analyze its associated factors.

MATERIALS AND METHODS

A cross-sectional study was conducted involving cases of interstitial ectopic in Hospital Putrajaya, Putrajaya, Malaysia, over a 10-year period (2005-2014). Data on sociodemographic, clinical profile, perioperative, and postoperative were obtained from the electronic medical records.

MEASUREMENT AND MAIN RESULTS

The prevalence of cornual pregnancy was 4.0% (n = 14) out of total 347 cases of all ectopic pregnancies in Putrajaya Hospital. The mean ± standard deviation age of patient in the LC group and OC group was 29.3 ± 5.9 years and 31.4 ± 7.3 years, respectively. The duration of hospitalization and mean operating time were both significantly shorter in the LC group than in the OC group (1.43 ± 0.54 versus 2.57 ± 0.79 and 61.4 ± 15.7 min versus 97.1 ± 38.2 min, respectively, P < 0.05).There were no statistically significant differences between both groups for the estimated blood loss, requirement of blood transfusion, complications, and future fertility.

CONCLUSION

Laparoscopic cornual resection (cornuotomy) is a safe and less invasive procedure with a comparable complication rate. It has shown that it is feasibility and should be considered as initial treatment in managing those cases in trained hand surgeons.

A Rare Case of Gestational Choriocarcinoma Presenting as Cornual Ectopic Pregnancy

BACKGROUND

Choriocarcinoma associated with cornual pregnancy is extremely rare. To our knowledge, only three other cases have been reported in the literature.

CASE

A 38-year-old woman was found to have a left cornual ectopic pregnancy on ultrasound after presenting with abdominal pain, irregular vaginal bleeding, and a positive pregnancy test. Laparoscopy confirmed the diagnosis and she underwent total abdominal hysterectomy. Three weeks later, she presented with vaginal bleeding. A solid ulcerating lesion was found arising from the vaginal wall and biopsy revealed metastatic gestational choriocarcinoma.

CONCLUSION

Careful histopathological examination of the surgical specimen and diligent monitoring of β-human chorionic gonadotropin to zero is crucial to prevent potentially missing this very malignant, but highly curable disease. Early systemic metastases are common and presentation can include bleeding from vaginal metastases.

Management and outcome of heterotopic interstitial pregnancy: Case report and review of literature

Objective

To report a case of heterotopic interstitial pregnancy after in vitro fertilization-embryo transfer (IVF-ET), presenting with a second trimester uterine rupture. To review the clinical presentations, risk factors, treatment options, and outcome of heterotopic interstitial pregnancies.

Methods

We describe the clinical presentation, management, and outcome of a patient with a heterotopic interstitial pregnancy, diagnosed following second trimester rupture of the interstitial pregnancy. We reviewed all published cases of heterotopic interstitial pregnancies.

Results

A 35-year-old pregnant woman with a past history of right adnexectomy and 16 weeks pregnant with dichorionic diamniotic twins following IVF-ET, was admitted to our department with unexplained recurrent abdominal pain and anemia. Further investigation showed a hemoperitoneum and because of hypovolemic shock an emergency laparotomy was performed, with diagnosis of a ruptured heterotopic interstitial pregnancy. The uterine defect was sutured using simple interrupted sutures. The intrauterine pregnancy progressed uneventful afterwards.We found 86 cases in the published literature, reporting on heterotopic interstitial pregnancies. 80.2% (69/86) occurred after IVF-ET. History of uni- or bilateral salpingectomy is a major risk factor, present in 39.5% (34/86). 37.2% (32/86) presented with cornual rupture. Surgery was performed in 53.5% (46/86) of cases. Medical management was possible in case of unruptured, early diagnosed heterotopic interstitial pregnancy (32.6% (28/86)). Watchful waiting was only possible when the interstitial pregnancy miscarried (5.8% (5/86)). The live birth rate of the intrauterine pregnancy, when viable at presentation, was 70.0% (56/80). The live birth rate of the interstitial pregnancy was only 4.7% (4/86).

Conclusions

The majority of cases are diagnosed by detailed ultrasound in the setting of early follow-up after IVF-ET and are asymptomatic at diagnosis. Yet, a substantial number of patients present with cornual rupture. Risk factors are IVF-ET and a history of salpingectomy. Depending on clinical presentation, treatment options include watchful waiting, medical treatment, or surgery. Unfortunately, the interstitial pregnancy is generally lost, and only has a chance of survival in case of presentation at a viable gestational age. The outcome of the coexisting intrauterine pregnancy is generally good.

Recurrent Interstitial Pregnancy: a Review of the Literature

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.

Spontaneous uterine cornual rupture at 26 weeks' gestation in an interstitial heterotopic pregnancy following in vitro fertilization

Interstitial implantation in a heterotopic pregnancy is extremely rare, and despite currently available diagnostic modalities, early identification of an interstitial ectopic pregnancy remains difficult. This report describes a case of spontaneous cornual rupture at 26 weeks' gestation in a woman with diamniotic dichorionic twins that resulted in live births. The patient had previously undergone laparoscopic bilateral salpingectomy, and the pregnancy was conceived with in vitro fertilization. Interstitial implantation in a heterotopic pregnancy can go unrecognized, resulting in increased maternal and infant morbidity and mortality. © 2015 Wiley Periodicals, Inc. J Clin Ultrasound 44:322-325, 2016.

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.

Sonographic diagnosis of spontaneous uterine rupture at the site of cornual wedge resection scar - a case report

Introduction: Uterine rupture and uterine dehiscence during pregnancy are known complications of a scarred uterus. Spontaneous uterine rupture at the site of prior cornual wedge resection has been previously reported in the literature, however remains rare.

Discussion: We present a case of uterine rupture at 30 weeks gestation. This woman had previous right sided interstitial pregnancy treated with uncomplicated laparoscopic cornual wedge resection at eight weeks gestation. The index pregnancy occurred eight months after surgery. An emergency ultrasound prompted by non‐specific abdominal pain and tenderness at 30 weeks gestation enabled diagnosis of uterine dehiscence. At emergency caesarean section four hours later full thickness wall rupture and haemoperitoneum were found. Surgical intervention resulted in a good outcome for both mother and baby.

Conclusion: A brief account on uterine rupture in late pregnancy and relevant sonographic features related to this case are presented. This case demonstrates the value of ultrasound in the assessment of subtle clinical signs and symptoms in patients at risk of uterine rupture.

Laparoscopic systemic devascularization of uterine cornu for cornual resection in interstitial pregnancy

Cornual pregnancies carry a greater maternal mortality risk than ampullary ectopic pregnancies and they may cause significant hemorrhage. A woman aged 36 years with a six-week history of amenorrhea, slight vaginal bleeding, and low abdominal pain of three days duration presented to our clinic. A diagnosis of right cornual ectopic pregnancy was made using ultrasonographic findings. Laparoscopic exploration confirmed the diagnosis. We occluded the uterine artery at its origin and also transected vessels within the mesosalpinx and uteroovarian ligament to successfully accomplish avascularization of a cornual pregnancy. Occlusion of the uterine arteries is reported to be a safe and blood-sparing technique. Severe hemorragia may occur during the operation; therefore, techniques to minimize blood loss are reported. In our case, occlusion of the uterine artery and transection of the mesosalpinx and uteroovarian vessels provided a bloodless operation and there was no need to bilaterally occlude vessels.

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.

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.

Interstitial pregnancy treated with a single-dose of systemic methotrexate: A successful management

Interstitial pregnancy is an ectopic pregnancy at high hemorrhagic risk. It often poses a diagnostic and therapeutic challenge to the clinician, with a significant risk of morbidity and mortality. It presents a difficult management problem with no absolute standard of care; the most appropriate treatment technique for these pregnancies remains controversial. We describe a case of unruptured interstitial pregnancy successfully treated with a single-dose of systemic methotrexate with subsequent ultrasound and serum beta human chorionic gonadotropin monitoring. Medical management can be a safe and successful option in selected cases that satisfy specific criteria and in women who are able to be monitored after treatment.

Three-dimensional sonography in the differential diagnosis of interstitial, angular, and intrauterine pregnancies in a septate uterus

Interstitial, angular, and cornual pregnancies and intrauterine pregnancies in an anomalous uterus are separate entities, and the impact of each condition on obstetric outcomes is completely different. However, there is considerable confusion in understanding and managing the natural course of each condition due to a lack of uniform terminology. The single most important factor for differentiating these types of pregnancies is to make an early diagnosis. The differences between interstitial, angular, and cornual pregnancies on 2-dimensional (2D) sonography are subtle. Although magnetic resonance imaging can be used to differentiate these conditions, it is not preferred as the initial assessment tool because of its limited availability and cost-effectiveness. Three-dimensional (3D) sonography has the advantage of providing views of the uterus that cannot be obtained with conventional 2D sonography. We describe 3 cases of interstitial, angular, and intrauterine pregnancies in a septate uterus that were clearly differentiated by 3D sonography. We demonstrate the differences in diagnostic imaging findings and emphasize the importance of 3D sonography in differentiating these entities.

Transabdominal ultrasound-guided injection of methotrexate in the treatment of ectopic interstitial pregnancies

PURPOSE

In a retrospective observational study, we evaluated the feasibility and safety of medical therapy with transabdominal ultrasound-guided injection of methotrexate (MTX) into the gestational sac (GS) in patients with interstitial ectopic pregnancies.

METHODS

Fourteen interstitial ectopic pregnancies were treated with transabdominal ultrasound-guided injection of MTX (25 mg). All patients were hemodynamically stable. In all patients, the 10-cm distance between the GS and vaginal fornices was ≥10 cm, making transvaginal injection difficult. To evaluate feasibility and safety of the procedure, we assessed complications clinically and with imaging during a 1-year follow-up.

RESULTS

In all 14 patients, MTX injected locally into the GS successfully terminated the interstitial pregnancy, thereby avoiding surgery. There was no complications during follow-up.

CONCLUSIONS

The successful outcome in our patients suggests that the transabdominal route is feasible and safe as a nonsurgical option for terminating an ectopic interstitial pregnancy in patients in whom the transvaginal route is contraindicated or difficult, provided the patients are properly selected and operators have sufficient experience with the technique.

Laparoscopic management of interstitial pregnancy and fertility outcomes after ipsilateral salpingectomy - three case reports

Background: Interstitial pregnancy after ipsilateral salpingectomy is a rare event with potentially serious consequences. Optimal management strategy remains uncertain and debated. In addition, fertility sparing is determinant of the treatment choice.

Cases: Here, we report three cases of interstitial pregnancy occurring after homolateral salpingectomy. We expose the therapeutic option held in all three situations, which associated laparoscopic procedure followed by intramuscular methotrexate injection with successful outcome for all patients. We also report the fertility outcome for the first patient, discussing the timing and mode of delivery. Cesarean section at term was performed for this patient.

Conclusion: In these three situations, we obtained a successful result using a minimally invasive surgical approach combined with systemic methotrexate injection. Cesarean section at term for subsequent intrauterine pregnancy seems to be the safest delivery strategy, although no clear data exist in literature.

The endomyometrial thickness measurement for abnormal implantation evaluation by pelvic sonography

Emergency physicians, obstetrician-gynecologists, and other medical specialists use pelvic sonography when caring for patients presenting with early pregnancy-related symptoms. A thin endomyometrial mantle and eccentric placement of a gestational sac should raise the suspicion for an abnormally implanted pregnancy. In such cases, an interstitial ectopic pregnancy or a cornual pregnancy, two clinically distinct entities, must be considered. This article reviews the literature and guidelines on the sonographic measurement of the endomyometrial mantle as a criterion for determining a pregnancy at risk for an abnormal implantation location. We sought to clarify the history and evolution of this measurement to determine what should be considered an abnormal measurement and to understand its diagnostic utility and management implications for the clinician using sonography.

Interstitial pregnancy resulting in a viable infant coexistent with massive perivillous fibrin deposition: a case report and literature review

Objective The objective of this report is to describe a rare case of interstitial pregnancy ultimately resulting in a viable infant coexistent with massive perivillous fibrin deposition (MPFD). Study Design This study is a case report and literature review. Results A 35-year-old female patient underwent cesarean section at 32 weeks of gestation due to fetal growth restriction (FGR) and breech presentation. During the operation, a diagnosis of interstitial pregnancy was established. There was no evidence of placental separation. We decided to complete surgery without removal of the placenta and waited until the placenta delivered spontaneously. The conservative management was successful, and the patient was discharged on postoperative day 13. The pathologic examination showed MPFD. Conclusion If interstitial pregnancies are not diagnosed at an early gestational age, it can result in a viable fetus, but such pregnancies may be associated with FGR or placenta accreta.

Conservative treatment for interstitial monochorionic twin pregnancy: case report and review of the published work

Interstitial pregnancy is considered one of the most hazardous types of ectopic pregnancies, with a mortality rate of 2-2.5%. We describe a case of a viable monochorionic twin pregnancy in a 35-year-old woman successfully treated with systemic methotrexate associated with bilateral uterine arteries' embolization. β-hCG was undetectable 67 days after the first administration of methotrexate and the ultrasonography performed on day 67 showed the remnant of the gestational sac in the right uterine horn, a thin endometrium and a normal myometrial vascularization. Conservative treatment allowed us to avoid surgical treatment and to preserve the patient's fertility.

Diagnosis and laparoscopic treatment of cornual ectopic pregnancy

Cornual (interstitial) ectopic pregnancy is an uncommon variant of ectopic pregnancy which often poses a diagnostic and therapeutic challenge with a significant risk of rupturing and bleeding. We present a ruptured right cornual pregnancy and explain how to deal with such a case laparoscopically.