Laparoscopic surgical alternative in the treatment of ruptured cornual heterotopic pregnancy.

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.

Diagnosis and Management of Ectopic Pregnancy: Green-top Guideline No. 21.

To present our experience with sonographically guided treatment of unusual ectopic pregnancies, defined as heterotopic pregnancies and pregnancies occurring at ectopic locations other than the extracornual portion of the fallopian tube. We retrieved and reviewed all cases of unusual ectopic pregnancies that underwent sonographically guided therapy at our institution. Twenty-seven cases were identified, from 1992 through 2003, including 18 cervical, 6 cornual, 1 tubal heterotopic, and 2 cesarean scar implantations. All of the cervical ectopic, cornual ectopic, and tubal heterotopic pregnancies were treated by sonographically guided injection of potassium chloride into the ectopic gestational sac or fetus. Guidance was via transvaginal sonography in all 18 cervical pregnancies, 3 of the 6 cornual pregnancies, and the tubal heterotopic pregnancy, and via transabdominal sonography in 3 cornual ectopic pregnancies. One of the cesarean scar pregnancies was treated by transvaginally guided potassium chloride injection, and the other was treated via transabdominally guided dilation and evacuation. Treatment was successful in 25 of the 27 patients, including all 23 patients with an ectopic pregnancy and no concomitant intrauterine pregnancy. Four patients had concomitant intrauterine and ectopic pregnancies (1 cervical, 2 cornual, and 1 tubal); in 3 the intrauterine fetuses resulted in live-born infants, and in the fourth the intrauterine pregnancy was electively terminated. Eight of the 27 patients had subsequent intrauterine pregnancies. Sonographically guided minimally invasive treatments of unusual ectopic pregnancies are safe and effective alternatives to surgical and systemic medical therapy. These treatments ablate the ectopic pregnancy, permit normal continuation of a concomitant intrauterine pregnancy, and preserve the uterus for subsequent pregnancies.

Heterotopic pregnancy is defined as the coexistence of an intrauterine and an ectopic pregnancy. The estimated incidence is one in 30,000 spontaneous pregnancies, with a tenfold increase in women who underwent assisted reproductive technologies. Diagnosis of a heterotopic pregnancy is often delayed because of the presence of the intrauterine gestational sac. Treatment of a heterotopic pregnancy should consist of termination of the ectopic pregnancy without damaging the ongoing intrauterine pregnancy. The least invasive procedure should therefore be used. We present a case of a heterotopic pregnancy consisting of a viable intrauterine pregnancy and an ectopic cornual pregnancy. Because of the viable intrauterine pregnancy, we decided to treat the cornual pregnancy laparoscopically by the endoloop technique. This technique is simple, safe, effective and nearly bloodless. It offers a good prognosis for the ongoing intrauterine pregnancy.

Expanding Horizons: Laparoscopic Management of Unruptured Cornual Heterotopic Pregnancy Safeguarding Intrauterine Pregnancy

Expectant management of a heterotopic interstitial pregnancy - a case report

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

What serial hCG can tell you, and cannot tell you, about an early pregnancy

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.

BackgroundDue to the specific nature of interstitial pregnancy (IP), there are significant risks to both the mother and the foetus in women with a heterotopic interstitial pregnancy (HIP). IP alone has been analysed as a site-specific ectopic pregnancy (EP) in previous studies; however, according to the latest European Society of Human Reproduction and Embryology criteria, IP is classified as a tubal pregnancy. If IP can be classified as a tubal pregnancy, then there is no difference in the effects of these two methods on intrauterine pregnancies (IUPs). Under the premise of timely surgery, disposing of IPs and tubal pregnancy (excluding IPs) should also have no differential effect on IUPs.MethodsPatients with heterotopic fallopian tubal pregnancy (HP-tube) and HIP seen at our hospital from January 2005 to December 2020 were included. All included patients were diagnosed by transvaginal sonography (TVS), and EPs were confirmed by surgery and pathological analysis. The IUP outcomes after surgical treatment of the EPs were compared between the HP-tube group (n = 464) and the HIP group (n = 206). The outcomes of IUPs were evaluated in patients with HIP who underwent either laparoscopy (169 cases) or laparotomy (36 cases).ResultsThere was no significant difference in postoperative miscarriage (6.90% vs. 6.80%, odds ratio (OR) = 1.859, 95% confidence interval (CI) (0.807–4.279), p = 0.145); early spontaneous miscarriage (19.61% vs. 18.93%, OR = 0.788, 95% CI (0.495–1.255), p = 0.316); or late miscarriage (0.43% vs. 0.49%, OR = 0.823, 95% CI (0.070–9.661), p = 0.877) between the HP-tube group and the HIP group. There was no significant difference between the two groups in terms of preterm birth (7.33% vs. 6.80%, OR = 1.044, 95% CI (0.509–2.139), p = 0.907), live birth rate (71.60% vs. 73.30%, OR = 1.010, 95% CI (0.670–1.530), p = 0.980), or perinatal mortality rate (2.00% vs. 0.65%, OR = 0.580, 95% CI (0.030–3.590), p = 0.620). Compared to laparotomy for HIPs, laparoscopic treatment was associated with similar rates of postoperative miscarriage (5.33% vs. 13.90%, p = 0.076), live birth rate (72.80% vs. 75.00%, p = 0.948), caesarean Sect. (83.90% vs. 77.80%, p = 0.414).ConclusionsAfter early diagnosis and treatment of EPs, patients in the HP-tube and HIP groups achieved comparable outcomes. Laparotomy and laparoscopy for treating HIPs yielded similar pregnancy outcomes.

Heterotopic cornual pregnancy refers to the co-existence of intrauterine and extrauterine cornual pregnancies. This is rare, but the incidence increases in pregnancies associated with in vitro fertilization and embryo transfer (IVF-ET). A 36 year old gravida 2 para 0 woman with a history of bilateral salphingectomy underwent IVF-ET and was diagnosed with a heterotopic cornual pregnancy. She underwent diagnostic laparoscopy and wedge resection of the right cornual ectopic pregnancy. The intrauterine pregnancy progressed uneventfully and was delivered via caesarean section at 36 + 6 weeks. This case report illustrates the importance of early diagnosis of the condition, and how meticulous surgical technique is effective in removing the cornual ectopic pregnancy while preserving the intrauterine pregnancy.

Objective: To assess the effectiveness and safety of non-surgical management for six heterotopic interstitial pregnancies.Material and methods: We retrospectively analyzed the data of six women diagnosed with heterotopic interstitial pregnancies who underwent non-surgical treatment at the CHA Bundang Medical Center between January 2007 and December 2017. Three heterotopic interstitial pregnancies were treated with sono-guided potassium chloride (KCl) injections. Two cases were managed expectantly. One heterotopic quadruplet pregnancy with twin, left interstitial, and tubal pregnancy was treated by sono-guided KCl injection and laparoscopic left salpingectomy. Complications and outcomes were measured.Results: Three cases were treated with sono-guided KCl injection and the intrauterine pregnancy continued to term. Intrauterine pregnancies were vaginally delivered without complications. One case that was treated expectantly was delivered at full term, while the other case resulted in spontaneous abortion. Quadruplet heterotopic pregnancy was successfully managed with sono-guided KCl injection and laparoscopic salpingectomy. Intrauterine twin pregnancy was successfully delivered by elective cesarean section at 37 + 0 weeks of gestation with healthy babies. Conclusions: KCl injection under ultrasonographic guidance could be a safer and more effective treatment option than surgical treatment in hemodynamically stable patients with fetal cardiac activity in interstitial pregnancy. Expectant management could be an option for patients with no fetal cardiac activity.

7675 Tri-Topic Pregnancy: A Case of Spontaneous Triplets in Three Distinct Locations

Laparoscopic management of a heterotopic cornual pregnancy following first-trimester miscarriage – A case report and literature review

Heterotopic pregnancy is the coexistence of intrauterine and extrauterine (ectopic) pregnancies. This is a relatively rare phenomenon with an incidence of 1 in 30,000 in spontaneously conceived pregnancies and 1 in 100 pregnancies achieved through assisted reproduction. Due to its relative rarity, diagnosis can be challenging. The presence of adnexal cystic masses complicating pregnancies can obscure the examination of the pelvis to rule in/out heterotopic pregnancy further adding to the complexity of the diagnosis. In this study, we present a 26-year-old primigravid, ethnic Tigrayan lady from the Tigray region of Ethiopia. She presented to our hospital with the complaint of progressively worsening abdominal pain of three days duration. She also had a subjective period of amenorrhea of 2 months duration. Pregnancy test was positive a few days prior to her current presentation. She reported that she had a history of treatment for pelvic inflammatory disease three months prior to her current conception. At presentation to our hospital, she was acutely ill-looking in pain, tachycardic, and hypotensive. Pelvic ultrasound showed an adnexal mass, hemoperitoneum, and an intrauterine pregnancy at 7 weeks + 5 days gestation. With the impression of ruptured ovarian cyst to rule out heterotopic pregnancy emergency, an explorative laparotomy was done which was pertinent for significant hemoperitoneum, ruptured left tubal ectopic pregnancy, and intact left ovarian cyst. Physicians should consider a broad range of differential diagnosis in pregnant mothers who present with acute abdominal pain. Moreover, in the presence of an adnexal mass and hemoperitoneum, there is a need to maintain a low threshold for rare but life-threatening complications such as heterotopic pregnancy. The presence of an intrauterine gestation does not rule out extrauterine gestation. Thus, the presence of a viable intrauterine gestation should not stop physicians from carefully examining patients for the coexistence of an ectopic pregnancy.