Successful management of interstitial pregnancy with fetal cardiac activity by laparoscopic-assisted cornual resection with preoperative transcatheter uterine artery embolization

Introduction  Interstitial pregnancy is a rare but dangerous form of ectopic pregnancy. Although various forms of minimally invasive management for this disorder have been previously reported, optimal treatment regimen has not been yet unknown due to its rarity. Case report  A 29-year-old married woman with no previous disease history was referred under suspicion of ectopic pregnancy. Serum hCG value was 95,365 mIU/mL. On ultrasonographic examination, gestational sac with a viable embryo was identified in the left cornual region. Three-dimensional computed tomographic angiography showed prominent vascular mass in the left cornual region. Preoperative transcatheter uterine artery embolization followed by laparoscopic-assisted cornual resection with local methotrexate injection was successfully performed. Conclusions  Laparoscopic-assisted cornual resection with preoperative transcatheter uterine artery embolization for interstitial pregnancy with prominent vascular flow is a safe and reliable minimally invasive procedure for woman wishing fertility preservation.     

Laparoscopic cornuostomy for interstitial pregnancy. A case report

BACKGROUND: With recent advances in laparoscopic surgery, many reports have described laparoscopic cornual resection for interstitial pregnancy as a safe alternative to laparotomy. We report a laparoscopic cornuostomy for unruptured interstitial pregnancy with myometrium reconstruction. CASE: A 32-year-old woman presented with complaints of abdominal cramps and vaginal spotting after 6 weeks of amenorrhea. Ultrasonographic examination revealed a gestational sac 7 mm in diameter in the left uterine corner. There was clear separation between the endometrium and gestational sac. A 3-mm periumbilical trocar for the laparoscope and a 3-mm trocar in the lower abdomen were used, and the left interstitial pregnancy was confirmed. An additional, 5-mm trocar was used in the lower abdomen for the laparoscopic surgery. The patient underwent a laparoscopic cornuostomy. Myometrium reconstruction was performed by suturing and tying with a laparoscopic technique. CONCLUSION: In this case, minilaparoscopy was useful in the diagnosis and treatment of interstitial pregnancy.     

各孕周宫角妊娠38例临床分析

目的 探讨各孕周宫角妊娠的临床特点、诊断和治疗方法.方法 对2006年1月至2010年8月郑州大学第一附属医院收治的38例宫角妊娠的患者进行回顾性的分析.结果 38例宫角妊娠的患者中,停经38例(100%)、不规则阴道出血27例(71.1%)和腹痛22例(57.9%).宫角妊娠术前诊断困难,误诊率近50%.38例患者中...     

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.     

宫角妊娠的治疗及对术后生育能力的影响分析

目的：分析比较宫角妊娠不同治疗方案的临床效果及对术后生育能力的影响。方法：对我院2012年1月-2015年12月收治的95例宫角妊娠患者进行回顾性分析,按照治疗方法将其分为5组：清宫术组（n=21）、开腹探查手术组（n=27）、腹腔镜手术组（n=33）、减胎术组（n=5）、药物治疗组（n=9）。分析比较不同治疗方案的临床效果及对术后生育能力的影响。结果：手术患者均获得成功,术后均未发生明显不良反应。开腹探查手术组的术中出血量最多,清宫术组最少,差异有统计学意义（P＜0.05）;清宫术组手术时间短于开腹探查手术组和腹腔镜组,差异有统计学意义（P＜0.05）,而腹腔镜手术组与开腹探查手术组的手术时间比较,差异无统计学意义（P＞0.05）;术后3 d人绒毛膜促性腺激素β亚单位（β-hCG）下降程度清宫术组显著优于开腹探查手术组和腹腔镜组,差异有统计学意义（P＜0.05）;术后住院时间比较,清宫术组最短,开腹探查手术组最长,差异有统计学意义（P＜0.05）。药物治疗组的9例患者中,有8例孕囊完全排出,孕囊排出时间3~5.5 h,平均（4.1±1.2）h;阴道出血时间5~8 d,平均（7.2±1.4）d;其余1例因不完全流产转行清宫术。随访至治疗后1年,除减胎术组5例成功分娩外,其余90例患者中,计划妊娠81例,再次宫内妊娠者41例,药物治疗组再妊娠率最高,开腹探查手术组最低,差异有统计学意义（P＜0.05）。结论：对于宫角妊娠应根据患者的病情,妊娠包块大小、位置及是否破裂,患者的意愿,以及医师的实践经验和手术技巧综合考虑,力求对患者创伤程度最低,对术后再生育能力影响最小。     

Pitfalls in Ultrasound Diagnosis of Cesarean Scar Pregnancy

Cesarean scar pregnancy (CSP) is a rare kind of ectopic pregnancy implanted in the previous cesarean scar and has an increasing incidence over the past 30 years. As the suspicion is low, the diagnosis may be delayed or misinterpreted in ultrasound, leading to treatment strategies that might end up in uterine rupture or hysterectomy. The objective here is to review the ultrasound findings in CSP with varied presentations. Transabdominal and transvaginal sonography combined with color Doppler is a reliable tool for the diagnosis of CSP. When the gestational sac is seen in lower part of the uterine cavity, differentiation between threatened miscarriage, cervical pregnancy and CSP could be difficult. Not all cases of CSP present with typical ultrasound findings and a high index of suspicion is needed for diagnosis in these cases. An attempted curettage or MTP pill taken in an undiagnosed CSP often alters the typical findings. The possibility of CSP should also be considered in cases presenting with abnormal uterine bleeding and have a prior history of cesarean section. With lack of awareness about this condition, the diagnosis can often be missed either with MRI or in ultrasound. Correct interpretation and timely diagnosis save the mother from life-threatening complications and also preserves future fertility.     

Three conservative approaches to treatment of interstitial pregnancy

Interstitial pregnancy is among the most dangerous types of ectopic pregnancy. Four such pregnancies in three women were treated by three conservative modalities with favorable results. A 10-week interstitial pregnancy was successfully treated by laparoscopic-guided local methotrexate (MTX) injection into the gestational sac. Six years later the same woman had a repeat unruptured interstitial pregnancy at 9 weeks' gestation, with the gestational sac located in the same location as the previous one. Laparoscopic cornuostomy was performed. An asymptomatic woman in the eighth week of an interstitial pregnancy was treated with systemic MTX, but despite decreasing beta-human chorionic gonadotropin levels, cornual rupture occurred. The patient was successfully treated by laparoscopic cornuostomy. The final patient was admitted in hypovolemic shock and hemoperitoneum and was treated successfully for ruptured 8-week interstitial pregnancy by laparoscopic cornuostomy. (J Am Assoc Gynecol Laparosc 8(1):154-158, 2001)     

Interstitial pregnancy: results generated from the Society of Reproductive Surgeons Registry

OBJECTIVE: To summarize management of interstitial pregnancy and its outcome among 32 reported cases in the world. METHODS: From 1999 to 2002, 32 cases of interstitial pregnancy were reported to the registry of the Society of Reproductive Surgeons. The participants completed a five-page questionnaire regarding when and how diagnosis was made, the characteristics of the pregnancy, treatment modalities, and subsequent reproductive outcome. RESULTS: History of ipsilateral salpingectomy was encountered in 37.5% of patients, and the diagnosis was made by ultrasound in 71.4% of the patients. Eight women were treated with methotrexate either systemically (n = 4), locally under ultrasound guidance (n = 2), or under laparoscopic guidance (n = 2). Eleven patients were treated by laparoscopy and 13 by laparotomy. Three patients failed systemic methotrexate treatment and subsequently required surgery. Persistently elevated serum beta human chorionic gonadotropin levels were found in one patient after laparoscopic cornual excision, and she was successfully treated with methotrexate. Fourteen cases (43.7%) of rupture of interstitial pregnancy were found. This included five cases (15.6%) of heterotopic pregnancy; all were the results of in vitro fertilization, and all ruptured at the time of diagnosis. Subsequent pregnancy was achieved in ten patients. No uterine rupture was encountered during pregnancy or labor. CONCLUSION: Ipsilateral salpingectomy, previous ectopic pregnancy, and in vitro fertilization are predisposing factors for interstitial pregnancy. Contrary to previous belief, rupture of interstitial pregnancy occurs relatively early in pregnancy. In selected patients, laparoscopic cornual excision is a viable treatment option.     

Three-dimensional transvaginal sonographic diagnosis of early and asymptomatic interstitial pregnancy

Context The interstitial gestation is a rare form of tubal pregnancy which is associated with high morbidity. The diagnosis of an interstitial gestation can be reached through a bidimensional transvaginal ultrasonography (2D-TVUS), however, sometimes when making use of this technique it is not possible to appropriately evaluate the position of the gestational sac in relation to the uterine cavity. The three-dimensional transvaginal ultrasonography (3D-TVUS) allows accessibility to plans that the bidimensional does not, thus it makes it possible to reach a more accurate diagnosis and it also allows for an appropriate therapeutic planning. Case report We present a case of interstitial gestation diagnosed in the sixth week in an asymptomatic woman, who had a previous diagnosis of primary infertility. The 2D-TVUS revealed the presence of a gestational sac outside of the uterine cavity; moreover the colored Doppler and the power Doppler indicated a thriving vascular ring. The 3D-TVUS in the surface and transparency mode demonstrated that the gestational sac was located in the interstitial region of the uterine tube, and the niche mode accurately evaluated the relationship between the gestational sac and the uterine cavity. The patient was successfully treated with a local injection of methotrexate guided by a transvaginal ultrasonography. The 3D-TVUS was of great importance to confirm the diagnosis, to allow appropriate therapeutic choices and to decrease the morbidity.     

Early abdominal pregnancy with an unexpected and misleading location. The ultrasonographic interpretation

Abdominal pregnancy is a rare condition defined as an ectopic pregnancy that implants in the peritoneal cavity and is associated with important morbidity and mortality. We report a case of a 35-year-old woman with an ultrasonographic diagnosis of a left extrauterine pregnancy located proximally in the isthmus or distally in the interstitial region. In the exploratory laparotomy a gestational sac implanted anteriorly on the uterine serosa was found, with no signs of uterine perforation or tubal abortion. The pathologic examination confirmed the diagnosis of an early first trimester abdominal pregnancy. This case illustrates the importance of an early sonography in the diagnosis of an abdominal pregnancy as well as a high index of suspicion.     

Non-broken, angular, and ectopic pregnancy of 22 weeks. Case report and literature review

We present a clinical report of angular ectopic pregnancy at 22 weeks without uterine rupture. This is a rare and dangerous form of ectopic pregnancy that is very difficult to diagnose and can mimic an intrauterine normal pregnancy following by uterine rupture with hypovolemic shock and risk of maternal death. Angular pregnancy must be differentiating for others forms of ectopic pregnancy like interstitial, cornual and intramural pregnancy to meet a correct clinical and hystopahtological diagnosis, to identify the signs when the uterine rupture appear imminent, and to take the best therapeutic decision according to gestational age at presentation.     

Asymptomatic uterine rupture of a cornual pregnancy in the third trimester: a case report

BACKGROUND: Reports of cornual pregnancy persisting until fetal viability and of ultrasound diagnosis of asymptomatic uterine rupture are rare. CASE: A 24-year-old woman, gravida 6, para 5, presented for initial ultrasound evaluation at 28 5/7 weeks' gestation after registering late for prenatal care. Her history included 2 prior cesarean deliveries. Obstetric ultrasound evaluation revealed a clinically silent uterine rupture with a live fetus. The site of rupture was suspected to be the prior uterine scar. After completion of a course of antenatal corticosteroids, the patient underwent exploratory laparotomy, abdominal delivery of a live, male neonate, hysterectomy and appendectomy. The patient experienced an unremarkable postoperative course and was discharged on postoperative day 4. The infant was discharged on hospital day 83 with chronic lung disease, stage 1 retinopathy of prematurity, atrial septal defect and a right clubfoot; there were no additional findings at the 4-month follow-up. Pathologic examination demonstrated cornual implantation with subsequent uterine rupture. CONCLUSION: This case demonstrates the importance of maintaining a suspicion for ectopic pregnancy at advanced gestational ages and for uterine rupture even in the absence of symptoms. The case also illustrates that fetal survival can occur in cornual pregnancy.     

剖宫术后瘢痕妊娠经腹部及经阴道彩色多普勒联合应用的误诊分析

目的：经手术及病理证实的67例剖宫术后瘢痕妊娠经腹部彩色多普勒（TAS）及经阴道彩色多普勒（TVS）超声表现及对其中12例误诊原因进行回顾分析,提高超声对其诊断准确率。方法：对67例本院经手术及病理证实的剖宫产术后瘢痕妊娠经腹部及经阴道彩色多普勒检查结果进行回顾性对比分析,并查找其中12例误诊原因。结果：剖宫术后瘢痕妊娠（Caesarean Scar Pregnancy,cps）,TAS＋TVS诊断符合率81％,TAS＋TVS检查诊断符合率较TAS诊断符合率显著提（P〈0．01）。结论：TAS＋TVS可提高剖宫术后瘢痕妊娠的早期诊断准确率,同时能动态观察病灶及血供情况,对指导临床治疗方案及监测治疗效果等方面具有重要意义,停经时间短、妊娠囊占据宫腔、妊娠囊过小及只贴着瘢痕表面、混合包块型者、血供多少以及结合临床不紧密是误诊的重要原因。     

Misdiagnosis of interstitial pregnancy followed by uterine cornual rupture during induced midtrimester abortion.

We present a case of interstitial pregnancy causing uterine cornual rupture during induction of prostaglandin midtrimester abortion. As the clinical and ultrasonographic diagnosis of advanced ectopic gestation may be difficult, the possibility of ectopic pregnancy should be considered in cases of unsuccessful attempts of induced abortion.     

罕见部位异位妊娠的超声诊断

目的:分析和总结罕见部位异位妊娠的超声图像特点。方法:采用回顾性方法分析腹腔妊娠、残角子宫妊娠、卵巢妊娠、子宫肌壁妊娠的二维、彩色多普勒超声图像,与手术及病理结果对照分析。结果:腹腔妊娠表现为子宫腔空虚,腹腔内可见胎儿回声;残角子宫妊娠表现孕囊周围可见肌层回声,其旁可见正常子宫声像;卵巢妊娠未发生破裂时典型特征卵巢上可见孕囊回声;子宫肌壁妊娠术前超声确诊困难,需靠病理才能确诊。结论:掌握罕见部位异位妊娠的声像图特点,可提高超声对异位妊娠的诊断能力。     

Fertility Outcome after Cornual Resection for Interstitial Pregnancies

Study ObjectiveTo evaluate future pregnancy rates beyond gestational week 24 after cornual resections for interstitial pregnancies, subsequent modes of delivery, and the rate of later uterine ruptures.DesignA single-center historic cohort with follow-up registry data (Canadian Task Force classification II-2).SettingDepartment of Gynecology, Oslo University Hospital, Oslo, Norway.PatientsForty consecutive women with interstitial ectopic pregnancies were treated in the study period from 2005 to 2016, 33 of whom were treated with laparoscopic cornual resection (3 converted to laparotomy). Twenty-six of the 33 women were presumed still fertile after treatment (cases) and thereby age and parity matched with a reference group of 52 women with an equal follow-up time having undergone salpingectomy for tubal (noninterstitial) ectopic pregnancies (controls) (ratio 1:2). Subsequent fertility data for both groups were retrieved from medical records and the national Medical Birth Registry of Norway.InterventionsNone, data extracted from the patients’ medical records and the Medical Birth Registry of Norway.Measurements and Main ResultsThe incidence of interstitial pregnancies among the ectopic pregnancies was 3%. The median time to follow-up for cases and controls was 76 and 71 months, respectively. Subsequent pregnancy rates beyond gestational week 24 were equal in both groups (46% [cases] and 54% [controls]). Cesarean delivery in subsequent pregnancies was more common among women having undergone cornual resections (60% vs 18%, p = .006). Only 2 subsequent uterine ruptures were encountered.ConclusionCornual resection as treatment for interstitial pregnancies seems to have no added detrimental effect on subsequent pregnancy rates compared with salpingectomy for noninterstitial tubal ectopic pregnancies. However, they more often lead to elective cesarean deliveries in subsequent pregnancies.     

Interstitial and Cornual Ectopic Pregnancy: Conservative Surgical and Medical Management

Background

Interstitial and cornual ectopic pregnancy is rare, accounting for 2–4% of ectopic pregnancies and remains the most difficult type of ectopic pregnancy to diagnose due to low sensitivity and specificity of symptoms and imaging. The classic triad of ectopic pregnancy—abdominal pain, amenorrhea and vaginal bleeding—occurs in less than 40% of patients. The site of implantation in the intrauterine portion of fallopian tube and invasion through the uterine wall make this pregnancy difficult to differentiate from an intrauterine pregnancy on ultrasound. The high mortality in this type of pregnancy is partially due to delay in diagnosis as well as the speed of hemorrhage.

Methods

Three cases of interstitial pregnancy were retrospectively analyzed.

Result

Successful laparoscopic cornuostomy and removal of products of conception were performed in two cases, while one case was successfully managed by local injection with KCL and methotrexate followed by systemic methotrexate.

Conclusion

Early diagnosis and timely management are key to the management of interstitial and cornual ectopic pregnancy. With expertise in ultrasound imaging and advances in laparoscopic skills progressively, conservative medical and surgical measures are being used to treat interstitial and cornual ectopic pregnancy successfully.

     

经阴道超声结合VCI-C平面及3D-Glassbody成像模式在诊断异位妊娠中的应用

目的:探讨容积对比成像技术(VCI-C平面)、三维玻璃体模式(3D-Glassbody)及经阴道彩色多普勒超声诊断异位妊娠(EP)的特征性依据,以提高EP诊断的准确性。方法:对188例疑似早期EP的患者,进行二维经阴道(必要时结合经腹)彩超及VCI-C平面+Glassbody模式,观察包块滋养动脉血流分布及频谱。结果:188例中及时确诊183例。①附件区的妊娠囊内可见胎芽和(或)卵黄囊,17例(9.0%)有胎心搏动。②Donut征(输卵管环),其中98例有Donut征,占52.1%。③附件区内可探及混合性包块,有时伴有少量积液,共60例,占31.9%。④另有8例仅表现为盆腔积液,占4.3%。诊断符合率97.3%。误诊5例,均为宫内妊娠合并卵巢黄体破裂,误诊率为2.7%。结论:经阴道超声结合彩色多普勒(CDFI)/能量多普勒(CDE),能准确迅速地取得EP的诊断证据,VCI-C平面超声成像结合3D-Glassbody成像模式,信息量大,提高了对比分辨率与信噪比,可较二维超声提供更详尽的信息。     

经阴道彩色多普勒超声诊断剖宫产切口瘢痕妊娠的临床价值

目的探讨经阴道彩色多普勒超声诊断剖宫产切口瘢痕妊娠(CSP)的临床价值。方法收集2012年10月至2014年10月沈阳市妇婴医院收治的64例经阴道超声诊断为剖宫产切口瘢痕妊娠患者的影像及临床资料,分析其超声声像图特征及与临床结局的关系。结果超声诊断为CSP的64例患者中59例(92.2%)经病理证实,5例为难免流产。根据超声声像图特征将59例CSP分为2型:孕囊型(41例)和混合回声型(18例)。孕囊型分为3个亚型:I型妊娠囊边缘位于切口处(24例),Ⅱ型妊娠囊陷入切口内(15例),Ⅲ型妊娠囊向膀胱方向凸出(2例)。I型治疗以宫腔镜为主,Ⅱ型、Ⅲ型及混合回声型治疗以腹腔镜为主。结论经阴道彩色多普勒超声为诊断CSP的有效方法,正确的超声分型及对切口瘢痕厚度的准确测量有助于临床医生选择更加适合患者的个体化治疗方案。     

Term angular pregnancy: successful expectant management

Interstitial pregnancy sometimes is mistakenly referred to as cornual pregnancy and is frequently confused with angular pregnancy. A strict distinction among these three conditions is clinically important because their findings, management and outcomes are different. We report an unusual case of pregnancy where interstitial pregnancy was diagnosed at 6 weeks of pregnancy, located close to the right cornual portion of the uterus. Prenatal monitoring was carried out until birth at 36 weeks' gestation with uterine conservation. Ultrasound scan and magnetic resonance imaging were realized to confirm the diagnosis and to monitor the evolution.