Cystic Degeneration of Uterine Fibroid Mimicking Heterotopic Pregnancy with Interstitial Pregnancy: A Case Report

In recent years, ultrasound has become an essential tool in the assessment of women with suspected early pregnancy complications1. A large number of studies has already been published, describing the value of ultrasound in the diagnosis of ectopic pregnancy2,3. So, why write yet another review on this topic? We run a busy Early Pregnancy Unit in the area with the highest prevalence of ectopic pregnancy in the UK, which also receives many referrals from other hospitals of women with an uncertain diagnosis of ectopic pregnancy. The most interesting fact that we have learned over the years is that the majority of women referred with suspected ectopic pregnancies in fact had intrauterine ones that were either missed on ultrasound examination or misinterpreted as ectopics. This may sound surprising to many, as ultrasound diagnosis of intrauterine pregnancy is considered to be relatively simple and accurate. In many cases, ultrasound examination failed to identify a small amount of retained products of conception, due in part to inconsistencies in the sonographic diagnosis of incomplete miscarriage; this is often based on the use of arbitrary cut-off levels for endometrial thickness4. In other cases, however, sonographers were unable to decide whether a visible gestational sac represented an intrauterine or an ectopic pregnancy. In some cases with uncertain diagnosis, women had already received medical treatment with methotrexate prior to referral, leading to the loss of wanted normal intrauterine pregnancies. Another common problem is difficulty in differentiating between the various types of ectopic pregnancy. An accurate differential diagnosis is important in ectopics, as the management often differs depending on the type and exact location of the pregnancy. The purpose of this review is to summarize the sonographic criteria for the diagnosis of both intrauterine and ectopic pregnancies and to describe the principles of differential diagnosis of various types of ectopic pregnancy. We will not cover management of pregnancies of unknown location, as this issue has been covered extensively in recent publications5.

What are the surgical, pharmacological or conservative treatment options for abdominal pregnancy?

Ruptured heterotopic interstitial pregnancy: rare case of acute abdomen in a Jehovah's Witness patient

Expectant management of a cornual pregnancy followed up by serial transvaginal color power Doppler angiography and serum beta human chorionic gonadotropin levels

Diagnosis and management of a spontaneous heterotopic pregnancy: Rare case report

Heterotopic pregnancy is the simultaneous occurrence of two or more implantation sites. A 25-year-old infertile patient with a history of bilateral salpingectomy, uterine septum resection, and left cornual resection was diagnosed with heterotopic pregnancy in her second in vitro fertilization trial. She attended our clinic when she was 7-week pregnant, complaining initially of severe abdominal pain. Findings associated with peritoneal irritation were positive during the physical examination. Transvaginal ultrasound revealed right cornual ectopic pregnancy with a live fetus in the middle of the uterine cavity. Also free fluid was noted in the pelvis. A diagnosis of heterotopic pregnancy with rupture of the cornual pregnancy was made. She underwent emergency laparoscopy with aspiration of the ruptured ectopic pregnancy, suturing to the entire visible cornual margins, and assurance of good haemostasis. Her recovery was uneventful and she continued receiving care in our obstetric unit. She delivered a healthy newborn by cesarean section at term.

To evaluate the incidence, predisposing factors, early diagnosis and treatment options of heterotopic pregnancy (HP) following in vitro fertilization and embryo transfer (IVF-ET) procedure. A retrospective review study was performed to identify the HP cases after IVF-ET at the Reproductive Centre in Guangdong Women and Children's Hospital in China between the years of 2002-2007. Twelve out of 1,476 pregnancies (0.81%) were diagnosed for HP, of which nine patients elected for exploratory salpingectomy, two patients received selective fetal reduction by embryo aspiration under ultrasound guidance, and one patient opted for expectant treatment. Postoperatively, four intrauterine pregnancies were continued to develop until term while two were delivered at 35 weeks of gestation. The achievement ratio of continuous pregnancy was 66.7% (6/9). The incidence of HP is increasing due to the widespread use of assisted reproductive technology. An early transvaginal sonography performed by experienced radiologist/radiographer is considered to be essential and beneficial in establishing early diagnosis of HP. Both salpingectomy and selective fetal reduction by embryo aspiration can be administered as one of the effective therapies for HP with the optimal outcome of intrauterine pregnancy.

Conservative medical and surgical management of interstitial ectopic pregnancy

The aims of this study were to summarize the clinical features of patients with heterotopic pregnancy (HP) following embryo transfer (ET) and explore the risk factors for miscarriage after surgery. All patients with HP following ET treated by surgery between August 2014 and August 2015 in Chongqing Health Center for Women and Children were retrospectively reviewed. Fifty-five patients were identified, including 40 with tubal HP, 9 interstitial HP and 6 cornual HP. The most frequent manifestations before diagnosis was abdominal pain (29.1%), while 19 patients (34.5%) had no symptoms before diagnosis. The sensitivity of symptoms for HP was 65.5%. Gestational age atsymptomonset of these patients with symptoms (n=36) was 5.8weeks (range 4.7-8.1). Forty-seven patients (85.5%) were suspected of HP when they received first transvaginal ultrasonography (TVS). The mean gestational age at diagnosis was 6.3weeks (range 4.7-8.3, 16-41days after ET). First TVS suggesting HP (P=0.000) and first TVS performed before day 27 (P=0.000) were two independent predictors for gestational age at diagnosis. Gestational age at surgery day was 6.7weeks (range 5.3-10.7). Fifty-one patients (92.7%) resulted in a live birth. Gestational age at surgery day was the only independent risk factor for miscarriage in patients with HP treated by laparotomy (OR 0.003, 95%CI 0.001-0.604). Routine TVS at day 27 after ET could facilitate the diagnosis of HP, symptoms onset before or after day 27 are clues to early diagnosis. Prompt surgery after diagnosis may improve the prognosis of HP following ET.

Objective To investigate the treatment of heterotopic pregnancy (HP) after in vitro fertilization and embryo transfer (IVF-ET), and to explore the effect of clinical treatment of transvaginal ultrasound-guided embryo aspiration at the early stage of pregnancy. Methods Two successful cases of heterotopic interstitial tubal pregnancy treated with transvaginal ultrasound-guided ectopic embryo aspiration in early pregnancy and relevant literature review were discussed. Results After the treatment of transvaginal ultrasound-guided embryo aspiration in the early diagnosed interstitial tubal pregnancy with cardiac activity, the retained intrauterine fetal continues to be pregnant and a healthy baby will be delivered at term. Conclusion Transvaginal ultrasound-guided embryo aspiration can be considered to be a management of heterotopic interstitial tubal pregnancy in the first trimester. However, the follow-up is important because of the potential in the growth of retained villi tissue. Key words: Heterotopic pregnancy (HP); Interstitial tubal pregnancy; Transvaginal ultrasound embryo aspiration

To discuss four cases of heterotopic cornual pregnancy managed with transvaginal potassium chloride (KCl) injection of cornual pregnancy. Between December 2005 and January 2011, four women were diagnosed with heterotopic pregnancy. Every cases were treated ultrasonographically guided KCl injection of cornual pregnancy. Under general anesthesia, a 17-gauge needle was introduced into the sac using puncture instrument showing the path to be followed when the needle is inserted (GIP, Wilson-Cook). After entering the sac and aspiration of the celomic fluid, transvaginal sonography (TVS) guided KCl (1 ml of 2 mEq/ml) was injected directly into the fetal thorax until the cessation of fetal heart movements was observed. One case was a 30-year-old woman with twin pregnancy with a left cornual and a tubal pregnancy. The heterotopic cornual pregnancy was treated with ultrasonographically guided transvaginal injection of KCl into the thorax of ectopic fetus, and the tubal pregnancy was treated with laparoscopic left salpingectomy. In three cases, sonography reveals were intrauterine single live fetus and corneal pregnancy. After complete ablation of the cornual & tubal pregnancy, the subject had no complications or side effects for the duration of her pregnancy up to the full term. Every cases allowed the birth of healthy babies and of normal development. Minimally invasive approach should be considered in a hemodynamically stable patient to treat a first trimester heterotopic pregnancy to maintain the intrauterine pregnancy with a satisfactory outcome.

Heterotopic Pregnancy

Minimally invasive surgical management of a cornual ectopic pregnancy, with and without a concurrent intrauterine pregnancy

Guideline No. 414: Management of Pregnancy of Unknown Location and Tubal and Nontubal Ectopic Pregnancies.

PurposeThe aim of the study is to review the clinical characteristics and risk factors that influence the timing of diagnosis and rupture of interstitial pregnancy, and to evaluate the outcomes of interstitial heterotopic pregnancies after ipsilateral tubal surgery.MethodsA retrospective statistical analysis was performed on the case data of patients with interstitial pregnancy who met the inclusion criteria and were treated in a single institution.ResultsA total of 885 patients with interstitial pregnancy were included in the study, including 55 patients with heterotopic interstitial pregnancies. The gestational age of patients with interstitial rupture was less than those that were diagnosed prior to rupture (P < 0.01). The risk of interstitial pregnancy rupture was higher in women with a history of ipsilateral fallopian tube surgery P < 0.01). In the > 42-day rupture group, the gestation age was less in those with a history of ipsilateral surgery than those without, and the difference was statistically significant (P = 0.005). The shorter the interval, the higher the risk of interstitial pregnancy rupture (P = 0.001).ConclusionPatients with a history of ipsilateral tubal surgery have a higher risk of interstitial pregnancy rupture. The shorter the interval between ipsilateral tubal surgery and interstitial pregnancy, the higher the risk of rupture. For patients with a combined intrauterine and interstitial pregnancy, timely treatment may improve the chances of achieving term live birth.