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)     

Surgical management of interstitial pregnancy

Interstitial pregnancy is a rare and potentially dangerous event. Standard treatment involves laparotomy with cornual resection or hysterectomy, with few reported cases of laparoscopic management. A 14-week, 6-cm interstitial pregnancy was treated laparoscopically, without cornual resection or hysterectomy. Gestational products were removed from the fetal side of the implantation site through a salpingotomy incision through myometrium. In selected patients, this procedure can be accomplished safely and efficaciously while preserving reproductive function and avoiding laparotomy.     

Uterine rupture following conservative surgery for interstitial pregnancy.

A case of uterine rupture following conservative surgery for interstitial pregnancy is presented. Even though the uterine cavity was not opened during removal of the ectopic pregnancy, attenuation of the muscle lead to subsequent rupture of the uterus in the second trimester. The option for medical termination of ectopic pregnancies located in the cornual portion of tubes is discussed.     

The conservative surgical management of unruptured ectopic pregnancy.

With the earlier and more accurate diagnosis of ectopic pregnancy based on rapid beta-subunit pregnancy tests and the use of ultrasound and laparoscopy, the percentage of diagnosed unruptured ectopic pregnancies is rapidly increasing. This, coupled with the earlier treatment of pelvic inflammatory disease, the use of IUDs, and increasing numbers of tubal plastic surgery, caused the authors to evaluate the problem of conservative management of ectopic pregnancy. In this study 98 patients at the Yale-New Haven Hospital who had ectopic pregnancies between 1972 and 1977 are evaluated. Fifty of these patients underwent a salpingectomy or salpingo-oophorectomy. Forty-eight patients underwent salpingostomy. This represents an increase in the conservative surgery rate from 8 to 35.5%. The overall term viable pregnancy rate was 40%, along with a 10% repeat ectopic rate. There was no advantage as far as term viable pregnancy when comparing salpingostomy and salpingectomy. Conservative surgery did not increase the repeat ectopic rate. Salpingostomy is therefore recommended in unruptured ampullar ectopic pregnancies in order to preserve reproductive function. If current trends continue, this will be an increasingly important problem. The statistics are based on a 73% follow-up, with all patients actively trying to conceive.     

Conservative surgical management of interstitial pregnancy

Conservative management of ampullary and isthmic tubal pregnancies has been increasingly advocated to preserve the affected tubes and results in excellent outcome. A similar approach to interstitial pregnancies is more difficult because of the vascularity of the cornual area. We report here a novel surgical approach to this problem in two patients. Both patients had an unremarkable postoperative course. Hysterosalpingograms performed 5 and 6 months postoperatively demonstrated bilateral tubal patency. It is suggested that conservative surgical management may replace either cornual resection or hysterectomy in selected patients with unruptured interstitial pregnancies.     

Successful conservative treatment for advanced interstitial pregnancy. A case report

BACKGROUND: Interstitial pregnancy is a relatively rare and life-threatening disease, occurring in 2-4% of all extrauterine pregnancies, and the maternal mortality rate is 2-2.5%. Laparoscopic surgery and, less commonly, methotrexate are the treatments of choice for interstitial pregnancy. However, there is another treatment, ultrasound-guided direct injection of etoposide, the effect and safety of which are unclear. CASE REPORT: In a 32-year-old woman with interstitial pregnancy at 12 weeks of gestation, ultrasound-guided direct injection of etoposide (100 mg) was used successfully after intravenous high-dose methotrexate, 300 mg (200 mg/m2), therapy failed to produce a response. The patient's posttherapeutic course was smooth. Twelve months after treatment, she conceived and later delivered a healthy infant vaginally without adverse events. CONCLUSION: Ultrasound-guided direct injection of etoposide offers another choice for treating advanced interstitial pregnancy, but further study is needed to define its efficacy and safety.     

Reproductive performance following conservative microsurgical management of tubal pregnancy

Summary. Between 1981 and 1986, 58 women underwent conservative surgery for ectopic pregnancy; 30 had both tubes present, and 28 had the operation on their single tube. Twenty-five of the 30 women with both tubes present desired pregnancy; 17 (68%) conceived again, 14 (56%) had at least one intrauterine pregnancy and 3 (12%) had a repeat extrauterine pregnancy. Twenty-six of the women with a solitary tube desired pregnancy, 12 (46%) of them had at least one intrauterine pregnancy, and 10 (38.5%) had a repeat extrauterine pregnancy. It was concluded that the incidence of intrauterine pregnancy after conservative surgery in patients with both tubes present is not lower than after radical surgery, and that the incidence of extrauterine pregnancy is not higher. The intrauterine pregnancy rate in patients with a solitary tube is high and still higher than the best results available with in-vitro fertilization and embryo transfer. Therefore conservative surgery is indicated in these patients despite the high incidence of repeat extra-uterine pregnancy. Since most of the patients who conceived did so during the first year following the operation, we recommend that patients try to conceive immediately.     

Reproductive performance following conservative microsurgical management of tubal pregnancy

Between 1981 and 1986, 58 women underwent conservative surgery for ectopic pregnancy; 30 had both tubes present, and 28 had the operation on their single tube. Twenty-five of the 30 women with both tubes present desired pregnancy; 17 (68%) conceived again, 14 (56%) had at least one intrauterine pregnancy and 3 (12%) had a repeat extrauterine pregnancy. Twenty-six of the women with a solitary tube desired pregnancy, 12 (46%) of them had at least one intrauterine pregnancy, and 10 (38.5%) had a repeat extrauterine pregnancy. It was concluded that the incidence of intrauterine pregnancy after conservative surgery in patients with both tubes present is not lower than after radical surgery, and that the incidence of extrauterine pregnancy is not higher. The intrauterine pregnancy rate in patients with a solitary tube is high and still higher than the best results available with in-vitro fertilization and embryo transfer. Therefore conservative surgery is indicated in these patients despite the high incidence of repeat extrauterine pregnancy. Since most of the patients who conceived did so during the first year following the operation, we recommend that patients try to conceive immediately.     

Successful in vitro fertilization pregnancy after conservative management of endometrial cancer

OBJECTIVE: To report a successful IVF pregnancy in an infertile couple after conservative treatment of endometrial cancer. DESIGN: Case report and literature review. SETTING: University teaching hospital. PATIENT(S): A 29-year-old infertile white woman. MAIN OUTCOME MEASURE(S): Successful pregnancy after conservative management of endometrial cancer. INTERVENTION(S): Grade 1 endometrial adenocarcinoma diagnosed at hysteroscopy, followed by dilatation and curettage (D&C). On follow-up D&C, pathologic examination was normal after high-dose progesterone therapy. The patient subsequently underwent an IVF cycle with transfer of three blastocysts. RESULT(S): The patient delivered triplets by cesarean section. Laparoscopic-assisted vaginal hysterectomy and bilateral salpingo-oophorectomy was then done. No residual endometrial cancer was evident in the hysterectomy specimen, but a 1.1-cm cystic mixed endometrioid and clear cell-type adenocarcinoma was discovered in the left ovary. The patient is doing well after 3 cycles of chemotherapy; her CA-125 level is normal. The triplets are also doing well. CONCLUSION(S): In carefully chosen situations, deferring surgery in infertile patients with endometrial cancer may be a viable option permitting subsequent successful pregnancy.     

Elective vs. conservative management of ovarian tumors in pregnancy.

OBJECTIVES: To determine optimal management of the ovarian tumors in pregnancy. METHODS: This study included 89 cases of the ovarian tumor in pregnancy that required surgery at Holy Family hospital of the Catholic University from January, 1990 to December, 2001. Among 89 cases, 36 and 53 were emergency and elective surgery, respectively. Student's t-test and the chi(2)-test were used for statistical analysis and a P-value of <0.05 was considered statistically significant. RESULTS: The most common size of torsion of ovarian tumors during pregnancy was 6-10 cm and the incidence was the most frequent during the first trimester of pregnancy. The incidence of preterm delivery (<37 weeks) was higher in emergency surgery, but there was no difference in the gestational age at delivery, also no difference in the birth weight or the method of delivery. CONCLUSIONS: Although surgery for ovarian tumors in pregnancy is delayed until the onset of symptoms, adverse pregnancy outcome is not worsened when compared with that after elective surgery. We propose that conservative management would be used in optimal management of pregnant women with ovarian tumors.     

Successful conservative management of cervical ectopic pregnancy: a case series

Objective  

To report our experience of conservative treatment in four patients with cervical ectopic pregnancy.     

Conservative medical and surgical management of interstitial ectopic pregnancy.

OBJECTIVE: To review the definition and diagnosis of interstitial and heterotopic interstitial pregnancy and to evaluate the conservative management of these conditions. DESIGN: A MEDLINE computer search was used to identify relevant studies. The mean values for the duration of amenorrhea, serum beta-hCG level, size of the ectopic mass, and success rates of the various treatment modalities were calculated from the raw data in the original publications. RESULT(S): A review of 41 patients with interstitial pregnancy who were treated with methotrexate systemically, locally, or in combination revealed an overall success rate of 83%. The mean duration of amenorrhea, mean serum beta-hCG level, and mean size of the ectopic mass were 54 days, 15,127 mIU/mL, and 23 mm, respectively. Among 22 patients with interstitial pregnancy who were treated with conservative laparoscopic techniques, the overall success rate was 100%. In this group, the mean duration of amenorrhea, mean serum beta-hCG level, and mean size of the ectopic mass were 54 days, 7,572 mIU/mL, and 31 mm, respectively. There were nine cases of heterotopic interstitial pregnancy. Seven patients were managed with potassium chloride injected into the ectopic pregnancy, and two patients were treated by laparoscopy. Overall, 67% of the coexisting intrauterine pregnancies resulted in successful deliveries and the remainder ended in spontaneous abortions. CONCLUSION(S): Cornual resection or hysterectomy with a laparotomy should no longer be the first line of treatment for a hemodynamically stable patient with an interstitial pregnancy. In selected cases, methotrexate and laparoscopy can be used successfully in treating early interstitial pregnancy.     

Low-grade cervical squamous intraepithelial lesion during pregnancy: conservative antepartum management

The purpose of this retrospective study was to determine the regression rate and management of low-grade squamous intraepithelial lesions (LSIL) in pregnancy. Seventy-four women with cytological findings of LSIL were analysed during the pregnant-puerperal period (until 12 months postpartum). Age, parity, cytological and colposcopic findings, route of delivery, and postpartum follow-up were studied. The age and parity of patients ranged (average) from 12 to 32 years (21.2 +/- 4.9), 0-5 (0.89 +/- 1.14), and 9-32 years (16.1 +/- 3.5), respectively. Thirty-nine of 55 (70.9%) and 12 of 19 (63.1%) pregnant women had normal cytology after vaginal delivery and caesarean section, respectively (p > 0.05). In postpartum, eight patients (10.8%) persisted with LSIL and ten (13.5%) presented high-grade squamous intraepithelial lesions. No case of unsatisfactory colposcopy and invasive carcinoma were found. LSIL during pregnancy has a high rate of regression, regardless of the route of delivery. Conservative management with colposcopic evaluation is proposed during gestation.