Cornual Suture at the Time of Laparoscopic Salpingectomy Reduces the Incidence of Interstitial Pregnancy after In Vitro Fertilization

Study Objective

To investigate the effect of cornual suture at the time of laparoscopic salpingectomy on the incidence of interstitial pregnancy (IP) after in vitro fertilization (IVF).

Case report: laparoscopic treatment of a ruptured interstitial pregnancy

Interstitial pregnancy is a rare but life-threatening condition. A case of a 28-year-old woman with a partially ruptured interstitial pregnancy treated with operative laparoscopy is presented. A laparoscopic cornual resection and a left salpingectomy were performed uneventfully. Serum beta-human chorionic gonadotrophin concentrations were measured serially at weekly intervals until resolved on day 20 postoperatively. It seems, therefore, that laparoscopic treatment is still an effective option for management even in ruptured interstitial pregnancy, preserving the anatomical integrity of the uterus and future fertility, and that rupture of interstitial ectopic pregnancy is not a contra-indication for laparoscopy.     

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

Study ObjectiveTo investigate the relationship between previous ipsilateral salpingectomy and interstitial pregnancy and report on our experience of laparoscopic cornuostomy for interstitial pregnancy.DesignSingle-center, retrospective review.SettingUniversity-based hospital.PatientsAll patients who had undergone ipsilateral salpingectomy previously, diagnosed with interstitial pregnancy and treated between July 2010 and September 2018.InterventionsLaparoscopy or laparotomy as a treatment for interstitial pregnancy after ipsilateral salpingectomy.Measurements and Main ResultsA total of 414 cases of interstitial pregnancy were identified, of which 46 (11.1%) were after ipsilateral salpingectomy. Of the 46 patients, 20 (43.5%) became pregnant by in vitro fertilization and embryo transfer. Ipsilateral salpingectomy was the result of an ectopic pregnancy in 40 patients, hydrosalpinx in 5 patients, and torsion of an ovarian tumor in 1 patient. The laparoscopic approach was used to treat 78.3% of patients with history of previous salpingectomy. Patients who underwent ipsilateral salpingectomy by laparoscopy previously had a shorter interval from salpingectomy to interstitial pregnancy (24 months vs 60 months; p = .038) compared with patients who underwent ipsilateral salpingectomy by laparotomy. Laparoscopic cornuostomy was performed in 38 patients (82.6%); 12 had fetal cardiac activity, 15 had ruptured masses, and 16 used prophylactic methotrexate (MTX) intraoperatively. The median size of the ectopic mass was 2.5 cm (1.0–5.0 cm). At the time of laparoscopic cornuostomy, more patients with interstitial pregnancies with intact ectopic masses were administered prophylactic MTX (81.3% vs 45.5%; p = .043). Only 1 patient with a ruptured ectopic mass, high preoperative human chorionic gonadotropin levels, and without prophylactic MTX administration experienced a persistent ectopic pregnancy.ConclusionPatients with a history of ipsilateral salpingectomy should be cautioned regarding the possibility of interstitial pregnancy. Laparoscopic cornuostomy appears to be an appropriate treatment for interstitial pregnancy in patients wishing to preserve fertility, and the use of concomitant prophylactic MTX may reduce the risk of persistent ectopic pregnancy, especially in patients with ruptured masses and high human chorionic gonadotropin levels.     

The conservative management of interstitial pregnancy

OBJECTIVES: To evaluate the effectiveness of systemic methotrexate in the treatment of interstitial pregnancy. DESIGN: Prospective observational study. SETTING: An Early Pregnancy Assessment Unit in a London teaching hospital. SAMPLE: Twenty consecutive women diagnosed with an interstitial pregnancy. METHODS: Women were diagnosed with an interstitial pregnancy based on transvaginal ultrasound findings. Single dose, intramuscular methotrexate was administered on day 0. A second dose of methotrexate was given if the beta-hCG levels had not fallen by 15% between days four and seven. Weekly follow up continued until the serum beta-hCG < 5 IU. MAIN OUTCOME MEASURE: The resolution of serum beta-hCG levels without the need for surgical intervention. RESULTS: Two hundred and ninety-three ectopic gestations were diagnosed over a 42-month period. Twenty of these were interstitial in nature, with a median initial serum beta-hCG of 6452 IU. Of the 20 interstitial pregnancies, 17 cases received systemic methotrexate. Sixteen were treated successfully (94%), including all of the four cases with fetal heart activity present. A second methotrexate dose was given to six patients. Two cases were managed expectantly. Two cases underwent laparotomy and cornual resection: one elected for surgical management at the outset and one as a result of suspected ectopic rupture after two doses of methotrexate. There were no other complications. CONCLUSIONS: Systemic methotrexate is a safe and highly effective treatment for interstitial pregnancy. Surgery can be avoided in the majority of women with this condition. Early recognition of the cornual pregnancy with transvaginal ultrasound is essential.     

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.     

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)     

Rupture of a uterine horn after laparoscopic salpingectomy. A case report

BACKGROUND: Uterine rupture after salpingectomy, especially associated with cornual resection, is a rare, serious pregnancy complication. CASE: A spontaneous uterine rupture occurred during the second trimester of pregnancy, following salpingectomy with resection of the interstitial portion. Conservative treatment was performed, and fertility was preserved. CONCLUSION: Postsalpingectomy pregnancies must be carefully and frequently monitored, with ultrasonography used at the slightest clinical symptom. A postsalpingectomy rupture must be treated surgically, preferably with conservative treatment rather than hysterectomy.     

Spontaneous Cornual Pregnancy after Homolateral Salpingectomy for an Earlier Tubal Pregnancy: A Case Report and Literature Review

Cornual pregnancy is an infrequent pathological condition with severe prognosis if not adequately recognized. Ipsilateral salpingectomy represents a unique risk factor for this clinical entity. This article reports a laparoscopically treated spontaneous cornual pregnancy after homolateral salpingectomy for an earlier tubal pregnancy in a condition of hemodynamic instability as a result of cornual rupture. We include a review of the literature, underlining the feasibility of a laparoscopic approach and new treatment options combining medical and surgical tools with specific attention to their impact on future fertility and on risk of uterine rupture in a future 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 pregnancy following homolateral salpingectomy. Report of 2 cases and a review of the literature

Interstitial pregnancy following homolateral salpingectomy is a rare occurrence, only 73 cases having previously been recorded. Two such cases are presented, together with a comprehensive review of the literature. The mechanism of fertilization and implantation is purely speculative in these cases, but both internal and external migration of the ovum has been implicated and is discussed. Ectopic pregnancy was the indication for the preceding salpingectomy in the majority of reported cases. The surgical procedures most commonly employed for the treatment of the interstitial pregnancy following the homolateral salpingectomy were cornual resection and hysterectomy.     

Recurrent heterotopic pregnancy after bilateral salpingectomy in an IVF patient: Case report

Purpose: To report a rare clinical case of recurrent heterotopic pregnancy in the same patient following bilateral salpingectomy and in-vitro fertilization (IVF) treatments. Methods: A 35 year-old woman, suffering from mechanical infertility, was treated by IVF, resulting in two episodes of heterotopic pregnancies within 2 years. The first episode ended in bilateral salpingectomy due to unilateral tubal pregnancy and contralateral severely damaged tube. The intrauterine pregnancy ended in early missed abortion. The second heterotopic pregnancy presented as bleeding cornual pregnancy, managed by laparoscopic resection of the tubal stump, and ended in a term singleton delivery. Conclusion: The possibility of cornual heterotopic pregnancy following bilateral salpingectomy, though very rare, should be considered by every gynecologist treating IVF patient.     

Intravenous methotrexate for treatment of interstitial pregnancy: a case report

BACKGROUND: Ectopic pregnancy is the leading cause of first-trimester maternal death, accounting for 9% of pregnancy-related deaths. Interstitial (cornual) pregnancies represent 6% of all ectopics but account for a disproportionately higher mortality rate. Surgical management has been the treatment of choice for interstitial pregnancies. A very limited number of articles pre have explored the use of intravenous methotrexate to treat cornual pregnancy as a possible conservative first-line therapy in selected, hemodynamically stable patients. CASE: A patient with a confirmed interstitial pregnancy was treated with intravenous methotrexate. The patient's beta-hCG levels decreased to zero within 9 weeks. CONCLUSION: Intravenous methotrexate was used successfully in the treatment of an interstitial pregnancy without complications.     

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.

     

Tratamiento médico del embarazo ectópico instersticial: descripción de un caso clínico

Traditional management of interstitial pregnancy involves laparotomy with cornual resection. Recent advances in transvaginal ultrasonography and sensitive beta-hCG assays have led to earlier diagnosis of these cases. We report a case of interstitial pregnancy successfully treated with parenteral methotrexate. Prompt recognition of interstitial pregnancy allows conservative approachment and systemic methotrexate presents as an effective and safe option.     

Twin ectopic pregnancy after ipsilateral salpingectomy: A report of cases

Background

Ectopic pregnancy continues to be a significant cause of maternal morbidity and mortality. Recurrent ectopic pregnancy in the remnant portion of the tube after a previous ipsilateral salpingectomy has only rarely been reported. We present unusual cases of ipsilateral ectopic pregnancy occurring in the stump of an ectopic site.

Combined hysteroscopy and laparoscopy in the treatment of interstitial pregnancy

Traditional management of interstitial pregnancy involves laparotomy with cornual resection. Increasingly sensitive human chorionic gonadotropin assays and ultrasonography has led to earlier diagnosis of interstitial pregnancy. We report two cases of interstitial pregnancy treated with a combined hysteroscopic and laparoscopic approach. Early diagnosis of interstitial pregnancy can lead to conservative treatment options.     

Low-dose methotrexate treatment for interstitial pregnancy. A case report

BACKGROUND: Only a small number of case reports have described medical treatment of interstitial ectopic pregnancies. Almost all of the reported patients were treated with repeated high doses (1 mg/kg) of methotrexate. CASE: At 6 weeks of gestation, a 31-year-old woman, gravida 5, para 4, was diagnosed with a 0.96 x 1.36-cm right cornual pregnancy. As the patient desired future fertility, she received 100 mg of intramuscular methotrexate (50 mg/m2). She was then followed on an outpatient basis, with serum human chorionic gonadotropin values appropriately declining. Serial ultrasound also showed decreasing size of the gestational sac. Twenty-one days after the methotrexate dose, the patient experienced rupture of the right posterior cornu, necessitating exploratory laparotomy. CONCLUSION: Extreme caution should be used when treating interstitial gestations with single-dose methotrexate. All patients should be extensively counseled regarding the significantly increased risk of failure, possibility of rupture and need for emergency surgery.     

Cornual heterotopic pregnancy: contemporary management options

This review covers the clinical presentations, treatments, and outcomes of cornual heterotopic pregnancies reported in the literature. Infertile women with a history of ectopic pregnancy, tubal surgery, or disease are at increased risk for cornual heterotopic pregnancy when they undergo in vitro fertilization. Women who have undergone bilateral salpingectomy also seem to be predisposed to this condition when they undergo in vitro fertilization. We recommend that these patients be followed up closely after a successful in vitro fertilization cycle with monitoring of serum beta-human chorionic gonadotropin levels and serial transvaginal ultrasonography because of the high associated morbidity. Laparotomy remains the treatment of choice for rupture of a cornual heterotopic pregnancy. In the absence of cornual rupture, however, medical management is an option that eliminates the risk of surgery and anesthesia and results in outcomes similar to those associated with surgical treatment. Currently there is insufficient evidence to recommend any single treatment modality, and the decision should be based on such factors as clinical presentation, surgeon's expertise, side effects, overall cost, and the patient's preference.     

Successful treatment of ruptured interstitial pregnancy with laparoscopic surgery. A report of 2 cases

BACKGROUND: Laparoscopic surgery is generally considered contraindicated in women with ruptured interstitial pregnancy as it is associated with profound bleeding and hypovolemic shock. CASES: Two cases of ruptured interstitial pregnancy were treated with laparoscopic surgery. Laparoscopic cornuostomy and removal of products of conception were performed in 1 case and laparoscopic cornual resection in the other. Laparoscopic tubal occlusion performed 4 and 6 months later showed the cornu region to be well healed in both cases. CONCLUSION: With increasing experience with the laparoscopic technique, ruptured interstitial pregnancy can be managed safely and successfully with laparoscopic surgery.     

Surgical management of ectopic pregnancy

Laparoscopic salpingostomy remains the definitive and universal treatment of ectopic pregnancy in patients who are hemodynamically stable and who wish to preserve their fertility. The reproductive performance after salpingostomy appears to be equivalent or better than salpingectomy, but the recurrent ectopic pregnancy rate may be slightly greater. Expectant management has a poor efficacy and unproven benefit in subsequent reproductive outcome. Its use should be limited to situations in which the ectopic pregnancy is suspected but cannot be detected by transvaginal ultrasound. Methotrexate is an alternative to surgical treatment in selected patients who fulfill strict inclusion criteria, including compliance with follow-up evaluation. A large, prospective, randomized trial with significant power is needed, however, to study the prognostic factors for methotrexate success. The most practical and efficient method of methotrexate administration is a single intramuscular injection. Those who do not meet the criteria for methotrexate therapy should be treated surgically, which can be done by laparoscopy. Interstitial pregnancy also can be treated with methotrexate. Otherwise, a cornual resection or salpingotomy can be done. Although, it is feasible by laparoscopy, the laparoscopic approach should be done only by those who have an expertise in laparoscopic suturing. Abdominal and ovarian pregnancies are best treated surgically. Further, the diagnosis usually is established by laparoscopy, and an appropriate surgical treatment can be conducted at the same time.