Cornual heterotopic pregnancy: conservative treatment with transvaginal embryo reduction

Objective The objective was to discuss a case of heterotopic cornual pregnancy managed with transvaginal embryo reduction.Methods A 22-year-old woman with heterotopic cornual pregnancy was treated with ultrasonographically guided transvaginal injection of potassium chloride into the thorax of ectopic fetus.Results Sixteen days after the procedure, the patient presented with pelvic pain and miscarriage ensued. Control examination 1 month and 3 months later revealed normal uterine cavity and partially resorbed ectopic material.Conclusion This minimally invasive approach in a hemodynamically stable patient can be considered in the management of a first trimester heterotopic cornual pregnancy. However the patient must be informed for the risk of abortion related to the procedure. Nevertheless this approach can be a treatment option in cornual pregnancies without a simultaneous intrauterine gestation.     

Progressive formation of uterine arteriovenous fistula after laparoscopic-assisted myomectomy

Introduction  Laparoscopic-assisted myomectomy (LAM) is a minimally invasive procedure with many advantages. However, progressive formation of uterine arteriovenous fistula (AVF) after LAM is not described as a significant complication. Case report  A 39-year-old nulligravida underwent LAM for multiple myomas. On ultrasonography obtained 13 days after LAM, a prominent vascular mass was identified in the post-myomectomy scar. Computed tomographic angiography showed AVF originating from the left uterine artery. Uterine AVF was endovascularly embolized by metallic coils to avoid future hemorrhage. Conclusions  Development of uterine AVF after LAM is a potentially life-threatening complication. Early diagnosis and endovascular management can provide a significant benefit for a woman wishing uterine preservation.     

Molar cornual ectopic pregnancy

BACKGROUND: Few cases of ectopic molar pregnancies have been reported. We present one such case of a molar cornual pregnancy.CASE: A woman at 12 weeks’ gestation by last menstrual period presented with ultrasound evidence of a molar pregnancy and a surgical abdomen. Diagnostic laparoscopy revealed a large amount of free intraperitoneal blood. Laparotomy revealed villous-appearing tissue with numerous fluid-filled cysts erupting from the posterior aspect of the right uterine cornu. A cornual resection was performed, followed by a suction dilation and curettage (D&C). The pathologic findings from the cornual resection were consistent with a partial molar pregnancy, while the material from the suction D&C demonstrated no villi or trophoblastic tissue.CONCLUSION: A molar cornual ectopic pregnancy is presented.     

Repair of Uterine Rupture in Twin Gestation after Laparoscopic Cornual Resection

Spontaneous uterine rupture in the course of pregnancy is a rare event that usually occurs in a scarred uterus. The event occurs mostly during the intrapartum period and is potentially catastrophic for both mother and fetus. We report a case of 2-cm cornual rupture in a pregnant woman at 13 weeks twin gestation with previous history of cornual pregnancy successfully managed via laparoscopy. Sudden onset of abdominal pain and vaginal bleeding was noted first. Physical examination revealed stable vital signs, lower abdominal tenderness, and mild rebounding pain. Pelvic ultrasonography revealed twin pregnancy at 13 weeks with extrauterine saccular structure 6 cm in diameter located on the left fundus and contiguous with an intrauterine oligohydramnics twin. Exploratory laparotomy was promptly performed, and a small rupture about 2 cm in diameter was observed on the upper portion of the left fundus, the site of a previous laparoscopic cornual resection scar. A protruding amniotic sac of about 6 cm diameter and containing some part of the umbilical cord was seen. The uterine rupture site was repaired directly after aspiration of amniotic fluid from the protruding sac. After surgery, the patient received antibiotics, 17-OH-progesterone for potential rupture of membranes and prematurity. Tocolysis with Ritodrine for irregular uterine contractions was given at 22 weeks gestation. Steroids were given at 24 weeks gestation. The pregnancy ended with a successful delivery by cesarean section because of uncontrollable uterine contractions at 30 5/7 weeks gestation. In conclusion, although termination of pregnancy would normally be recommended when uterine rupture occurs, a different approach to management may now be accepted.     

Temporary Simultaneous 2 Arterial Occlusions during Laparoscopic Management for Cornual Ectopic Pregnancy

Study Objective

To demonstrate a new technique of temporary simultaneous 2 arterial occlusions (TESTOs) of the uterine and ovarian (or utero-ovarian) artery to reduce operative blood loss during laparoscopic cornual resection for cornual ectopic pregnancy.

Diagnosis and laparoscopic management of 11 consecutive cases of cornual ectopic pregnancy

Objective  To determine the pre-operative diagnosis by two dimensional ultrasound scan and the outcome of the laparoscopic management of cornual ectopic pregnancy. Design  Prospective database cohort study. Setting  Whipps Cross University Hospital, UK (District General Hospital). Patients  Eleven patients with cornual ectopic pregnancy presenting in our hospital between January 2003 and December 2007. Interventions  Laparoscopic cornuostomy or cornual resection. Outcome measures  Pre-operative diagnosis by ultrasound scan, conversion rate to laparotomy, successful laparoscopy (not requiring further treatment), complication rate and duration of hospital stay. Results  The mean gestational age was 8 ± 2 weeks. All 11 patients presented with abdominal pain and vaginal bleeding and two (18%) patients became haemodynamically unstable before laparoscopy. There were five (45%) patients with risk factors for ectopic pregnancy. The mean serum β-human chorionic gonadotropin (β-hcg) was15,263 ± 12,045 μm/ml. One patient did not have a transvaginal scan as it was decided to proceed to surgery on clinical grounds. The diagnosis of ectopic pregnancy was correct at initial scan in nine (90%) of the ten patients who had transvaginal scans as one patient was misdiagnosed at the first scan. However, an ectopic pregnancy was diagnosed on a second ultrasound scan assessment. Initial laparoscopy was negative in one of the nine patients diagnosed as having an ectopic pregnancy. The diagnosis was later confirmed following serial serum β-hcg monitoring, a repeat scan and a second laparoscopy. Ten (91%) of the 11 patients had successful operative laparoscopy as one (9%) patient had conversion to laparotomy. Among patients who had laparoscopic surgery, cornuostomy was performed in three (30%) patients while cornual resection was performed in the other seven (70%) patients. One (10%) of the patients who had laparoscopic surgery needed further treatment with systemic methotrexate. This patient had a cornual resection and was the only complication following laparoscopic surgery. The mean hospital stay was 2 days. Conclusion  This presentation of one of the larger series of patients with cornual ectopic pregnancy managed by laparoscopic surgery reveals that experience at ultrasonography and laparoscopic technique can lead to earlier diagnosis and few cases requiring laparotomy or further treatment. In addition laparoscopic surgery for cornual ectopic is safe and lends itself to conservative approach (cornuostomy) in selected cases.     

Medical therapy (methotrexate and mifepristone) alone or in combination with another type of therapy for the management of cervical or interstitial ectopic pregnancy

Objective

To describe cases of cervical or interstitial ectopic pregnancy managed conservatively with combined medical treatment (methotrexate and mifepristone) alone or in association with other minimally invasive strategies.

Study design

We describe four cervical and two interstitial ectopic pregnancies at our hospital between 2006 and 2010. All received combined treatment with methotrexate and mifepristone. A search of MEDLINE is also described.

Results

The literature search identified only four previous cases of cervical ectopic pregnancies and no cases of interstitial ectopic pregnancy managed with combined therapy. In our study, all patients were successfully treated and had no adverse reactions with intramuscular methotrexate 50 mg/m² and oral mifepristone 600 mg, either alone or in association with minimally invasive treatment (uterine artery embolization and evacuation dilation and curettage). All patients remained asymptomatic with β-HCG levels that decreased and became negative within 14–49 days: the median hospital stay was 5.5 days. We also describe the first patient with a cervical ectopic pregnancy treated with methotrexate and mifepristone, followed by vaginal misoprostol 800 mcg for cervical evacuation.

Conclusion

Methotrexate–mifepristone, either alone or in combination with other minimally invasive strategies, could be considered an option for the treatment of both cervical and interstitial ectopic pregnancy. An individualized approach should be used in each patient, however, given the wide variety of possible clinical situations and the potential seriousness of ectopic pregnancy.     

Pregnancy outcomes following treatment for fibroids: uterine fibroid embolization versus laparoscopic myomectomy

PURPOSE OF REVIEW: The management of uterine fibroids in patients requiring treatment who desire future fertility remains controversial. Myomectomy has been the most common operative procedure to improve pregnancy rates and outcomes. Uterine fibroid embolization is an increasingly popular, minimally invasive treatment for fibroids. This review aims to provide critical analysis of available data on pregnancy following myomectomy and uterine artery embolization. RECENT FINDINGS: Patients with distorted uterine cavities due to submucosal fibroids of more than 2 cm have higher pregnancy rates following hysteroscopic resection. Pregnancy rates following myomectomy, both via laparoscopy and laparotomy, are in the 50-60% range, with most having good outcomes. Pregnancy rates following uterine artery embolization have not been established. Pregnancies following uterine artery embolization had higher rates of preterm delivery (odds ratio 6.2, 95% confidence interval 1.4-27.7) and malpresentation (odds ratio 4.3, 95% confidence interval 1.0-20.5) than pregnancies following laparoscopic myomectomy. SUMMARY: Both myomectomy and uterine artery embolization are safe and effective fibroid treatments, which should be discussed with appropriate candidates. Pregnancy complications, most importantly preterm delivery, spontaneous abortion, abnormal placentation and postpartum hemorrhage, are increased following uterine artery embolization compared to myomectomy. Although most pregnancies following uterine artery embolization have good outcomes, myomectomy should be recommended as the treatment of choice over uterine artery embolization in most patients desiring future fertility.     

Uterine artery embolization as an adjunctive measure to decrease blood loss prior to evacuating a cervical pregnancy

Background  Cervical ectopic pregnancy accounts for less than 1% of all ectopic gestations. The most effective, fertility sparing treatment of a cervical ectopic pregnancy is still unclear due to limited reported experience. Case  The diagnosis and management of a 32-year-old with a cervical ectopic pregnancy after in vitro fertilization and embryo transfer is described. The patient had multiple risk factors, including Asherman’s syndrome following an abdominal myomectomy and three uterine curettages, for a cervical ectopic pregnancy. Due to her desire for future childbearing, conservative management strategies were chosen. This patient was successfully treated with uterine artery embolization followed by immediate dilation and evacuation of the pregnancy. Conclusions  This report demonstrates that UAE followed by immediate evacuation of a cervical ectopic pregnancy effectively terminates a viable gestation with minimal blood loss while maintaining fertility capacity.     

Interstitial ectopic pregnancy: A more confident diagnosis with three-dimensional sonography

ObjectiveTo present a confident tool for the diagnosis of interstitial ectopic pregnancy. 3-Dimensional US helps to reach a more proper diagnosis and enables to arrange therapeutic and surgical strategies.Case reportA 36-year-old, gravida 4 para 2, woman was referred from the local medical department in the suspicion of ectopic pregnancy. Transabdominal ultrasound revealed an empty uterine cavity but an 8-week-old gestational sac located eccentrically on the right side of the uterine fundus. The Three-dimensional sonography (3D US) demonstrated a gestational sac (GS) over the right cornual region separated from the endometrial cavity. Interstitial pregnancy was impressed. Laparoscopic surgery was then arranged. After entering the pelvic cavity, a bulging mass was found over the utero-tubal junction, compatible with interstitial pregnancy. The wedge resection of interstitial ectopic pregnancy and right salpingectomy were undertaken. The patient was discharged within 2 days after the surgery.ConclusionThe conventional sonography still remained the primary tool to diagnose the ectopic pregnancy, but 3D US played an indispensable role in demonstrating the precise location of GS. Interstitial ectopic pregnancy was symptomatically late in gestation and rupture of an interstitial pregnancy causes catastrophic consequence due to massive bleeding, so prompt and accurate diagnosis was definitely life-saving. Appropriate therapy or surgical intervention could be arranged.     

Uterine Artery Pseudoaneurysm in a Pregnant Patient with Retrocervical Endometriosis

A pseudoaneurysm of the uterine artery or its branches is usually a result of vascular trauma during invasive procedures such as a cesarean section, vaginal delivery, myomectomy, hysterotomy, or dilatation and curettage. A uterine artery pseudoaneurysm rupture is a rare, yet life-threatening event. Deep infiltrating endometriosis usually involves a decrease in symptoms and imaging findings throughout pregnancy, with the notable exception of the phenomenon of decidualization. We present the case of a pregnant woman with a recent diagnosis of endometriosis, who conceived spontaneously and presented with disabling pain at 13 weeks’ gestation. She was diagnosed with a left, huge (and rapidly growing) retrocervical endometriosis nodule encompassing a uterine artery pseudoaneurysm. Selective transarterial embolization was performed at 22 weeks’ gestation owing to enlargement of the pseudoaneurysm sac, and the pseudoaneurysm was obliterated successfully. The patient was followed intensively throughout the pregnancy and the baby was delivered at term by cesarean section. After delivery, the nodule returned to the pregestational size.     

Ectopic pregnancy after successful treatment with percutaneous transcatheter uterine arterial embolization for congenital uterine arteriovenous malformation: a case report

INTRODUCTION: Uterine arteriovenous malformation (AVM) is a rare disease. Percutaneous transcatheter uterine arterial embolization (UAE) has been performed in patients who wish to preserve their ability to conceive. UAE is considered to be a safe and effective procedure, but its long-term effect on fertility has not been fully elucidated. We present a case of ectopic tubal pregnancy after conservative treatment with UAE for uterine AVM. CASE: A 30-year-old Japanese woman was admitted for the treatment of unruptured right tubal pregnancy at 6 weeks of gestation. She had conceived spontaneously and delivered a healthy baby at term, 3 years previously. Subsequently, she was successfully treated with UAE for a large congenital uterine AVM. Transvaginal color Doppler ultrasonography revealed no evidence of residual AVM vessels. After the diagnosis of ectopic pregnancy, the patient underwent right tubectomy. At laparotomy, there were no adhesions or structural anomalies in the pelvic cavity that might affect tubal function. The patient's postoperative course was uneventful, and she is now healthy without conception 24 months after surgery. CONCLUSION: Prior uterine arterial embolization may have affected the tubal function in the present case, allowing tubal pregnancy to occur.     

Curetaje cornual como tratamiento conservador del embarazo ectópico accidentado

The classical treatment of cornual ectopic pregnancy is cornual resection or hysterectomy. Currently, a more conservative approach is feasible. We describe a case of cornual ectopic pregnancy treated with tubal cornual curettage and review the various options in the management of this entity. This technique may reduce the risk of uterine rupture in future pregnancies, even though studies on this topic are lacking.     

A case of placental polyp treated with an intraoperative injection of prostaglandin F<Subscript>2α</Subscript> followed by hysteroscopic resection

A 27-year-old woman had massive genital bleeding after an artificial abortion. Color Doppler ultrasonography showed a hypervascular mass. Hysteroscopy revealed a placental polyp. Serum hemoglobin level was decreased to 7.7 g/dl. Although uterine artery embolization (UAE) followed by hysteroscopic resection has been used for treatment of a placental polyp, UAE may not be an ideal option for patients with intent for future pregnancy because of the risk of ovarian function failure. This report presents a case of a placental polyp managed successfully with intracervical injection of prostaglandin F_2α, as an alternative UAE, followed by hysteroscopic resection.     

Laparoscopical management of cornual pregnancies: a report of three cases

Objective

Cornual pregnancy refers to the implantation and development of a gestation in one of the upper and lateral portions of the uterus; authors report their experience in laparoscopic therapeutic procedures on three singleton cornual pregnancies.

Study design

Three healthy women were admitted in General Hospitals with suspect of cornual pregnancies by clinical examination, increasing of β-hCG value and transvaginal ultrasonography. One of them had a haemoperitoneum. Surgeons performed all operative laparoscopies, by incision and enucleating of ectopic cornual mass, coagulating of its surrounding vessels and suturing of the uterine incision site.

Results

Patients were successfully treated only by laparoscopy, post-operative recovery period was normal in all women, with no further therapeutically intervention in the follow-up course. The aftermath was uneventful at the follow-up of 2 years.

Conclusion

In cornual pregnancies, the minimally invasive surgical treatment by salpingotomy or resection of the cornual region of the uterus and the suturing of the incision site, should be the option in women interested in future fertility.     

Hysteroscopic management of cornual ectopic pregnancy

BACKGROUND:Cornual ectopic pregnancies have traditionally been treated with systemic methotrexate, cornual resection, or hysterectomy.CASE:A 36-year-old newly gravida presented with an 8-week history of amenorrhea and a positive home pregnancy test. A transabdominal sonogram revealed a left cornual ectopic pregnancy. The patient was treated with multiple methotrexate doses, but the gestational sac persisted. Through the hysteroscope, the sac was ruptured, and the placental tissue was removed from the left cornu under sonographic guidance. Two weeks postoperatively, the patient’s β-human chorionic gonadotropin level was negative, and she had a normal pelvic examination and sonogram.CONCLUSION:Hysteroscopic removal under sonographic guidance after methotrexate treatment is a conservative option for the treatment of cornual ectopic pregnancy in some patients.     

Intramural Ectopic Pregnancy: Treatment Using Uterine Artery Embolization

Herein is described the case of a 28-year-old woman in whom uterine artery embolization (UAE) was performed to treat intramural ectopic pregnancy. The intramural ectopic pregnancy was diagnosed at magnetic resonance imaging, which showed a gestational sac surrounded completely by myometrium. The UAE procedure was uncomplicated, with satisfactory results. Intramural ectopic pregnancy may be treated using UAE, which aids in maintaining fertility.     

Clinical experience and fertility outcome after uterine artery occlusion and embolization

We evaluated the effects of uterine artery occlusion and embolization on clinical results and pregnancy outcome using information provided by the literature published in the MEDLINE biomedicine database. Uterine artery occlusion has the potential to compromise fibroid growth and its symptoms. There were only a few complications and adverse events associated with laparoscopic uterine artery occlusion (LUAO) and fibroid embolization. LUAO and uterine artery embolization (UAE) procedures are both minimally invasive operating procedures that preserve the uterus and ovarian blood supply and allow achievement of pregnancy in women with symptomatic fibroids. Women who became pregnant after uterine artery occlusion and embolization had increased risk of abortion, pre-term birth, malpresentation, and/or caesarean delivery.     

Laparoscopic management of second trimester ruptured cornual heterotopic pregnancy with subsequent live birth delivery: A case report and literature review

ObjectiveHeterotopic pregnancy (HP) is the coexistence of extra- and intrauterine gestation implantation sites. A rare case of a second-trimester ruptured cornual HP (CHP) treated with laparoscopic cornual resection with the primary repair is presented. Risk factors, clinical presentations, treatments, and outcomes of CHPs are also reviewed.Case reportA 35-year-old pregnant woman with CHP presented with lower abdominal pain with hemoperitoneum and her hemoglobin level dropped. Laparoscopic management of a ruptured HP was performed, leaving the surplus intrauterine fetus intact. She delivered a 2360 g male infant via cesarean section at 34 weeks’ gestation due to preterm premature rupture of membranes. We found a well-healed wound over the left uterine cornua during the cesarean section.ConclusionRuptured CHP is a rare but life-threatening complication of an obstetric emergency. Although the pregnant uterus becomes congested and fragile, using reliable laparoscopic energy devices and barbed sutures, successful treatment is feasible.     

Successful management of a cornual pregnancy with a single high-dose laparoscopic methotrexate injection

Cornual (interstitial) pregnancy, a very rare form of ectopic pregnancy, accounts for 2–4% of all tubal pregnancies in which conception is located in the proximal interstitial portion of the fallopian tube. Cornual resection by laparotomy is generally the preferred method of treatment, although more conservative approaches have also been described. We report a case of cornual pregnancy that was successfully treated with a single dose of 100 mg methotrexate injected into the mass of the ectopic cornual pregnancy. The serum human chorionic gonadotropin (hCG) level decreased to undetectable levels on the 60th post-operative day.