Risk factors for misdiagnosis of interstitial ectopic 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.

Interstitial ectopic pregnancy accounts for 2–4% of all ectopic implantations, and can be associated with life-threatening bleeding (1). In this study, a woman with ruptured interstitial pregnancy, which was managed successfully by using a conservative surgical method, is presented. A 19-year-old nulliparous woman presented with acute onset, severe right iliac fossa pain. Her last menstrual period was 6 weeks previously and the urine pregnancy test was positive. On examination, she was found to be tachycardic, but normotensive with the signs of peritonism. Vaginal examination showed severe right adnexal tenderness. Her hemoglobin was 7.1 g/dl. She was transferred to the surgical theatre with the provisional diagnosis of ruptured ectopic pregnancy. Laparoscopy showed massive hemoperitoneum of 21 with a large (about 5 cm in diameter) ruptured right-sided interstitial pregnancy. At the time, the hemoglobin was 4.5 g/dl and the patient became hypotensive, making laparotomy imperative. As the patient was nulliparous, every effort was made to preserve future fertility. The right round ligament and the broad ligament were opened and the right ureter was identified. The right tube and ovarian ligament and uterine artery were ligated resulting in substantial reduction of the bleeding. The products of conception were removed and multiple hemostatic sutures were applied on the right cornu, which was eventually closed in two layers. As hemostasis was achieved, the right round ligament and the broad ligament were closed and the patient received 4 U of transfused blood. On the first post-operative day, a single dose of intramuscular methotrexate (50 mg/m2) was administered in order to reduce the risk of persistent trophoblastic tissue. The patient was discharged on the fourth post-operative day in good condition. Owing to the extent of the rupture, the patient was advised to have a cesarean section in any subsequent pregnancy. Serum β-hCG 20 days later had fallen from 27 724 IU/l, on admission, to 28 IU/l. Because recent evidence has suggested that intraperitoneal sperm transmigration from a patent Fallopian tube to its damaged counterpart is quite common, the patient had subsequently been counseled regarding right salpingectomy (2). Interstitial ectopic pregnancy carries a risk of severe hemorrhage because of its unique anatomical location, which commonly leads to a delay in diagnosis (1). Rupture of the uterus that progresses beyond 12 weeks of amenorrhea may occur in the case of 20% of the patients (3). Conservative management of an interstitial pregnancy includes medical treatment; administration of methotrexate and prostaglandin, and local injection of KCl have been reported (1). Hysteroscopic removal of an unruptured interstitial pregnancy has also been described (1). Traditionally, surgical treatment for interstitial tubal pregnancy consists of cornual resection (possible in 50% of patients) with the remainder of patients requiring hysterectomy (1). In few patients, laparoscopic management has been described, including cornual resection, cornuostomy, or salpingotomy. In two reports, hemostasis was achieved with laparoscopic ligation of the ascending branches of the uterine vessels in combination with cornual excision. However, in the case of all these patients, the patients were hemodynamically stable or had an unruptured interstitial ectopic pregnancy; maximum β-hCG level was 20 159 mIU/ml (3). The uterus is supplied blood by six arteries – two uterine, two flowing via the ovarian ligament, and two vaginal collaterals. The uterine cornu derives its rich blood supply from the uterine artery and the tubal branch of the ovarian artery. Selective ligation of both these branches provides a significant reduction in blood supply to the uterine cornu, but the contralateral blood supply with its anastomotic channels prevents any avascular sequelae (4). We have previously demonstrated that a uterus supplied by two of its six original vessels, as is the case at abdominal radical trachelectomy, is capable of maintaining successfully a pregnancy to term (5). In the present study, we have described a conservative surgical (ligation of the ovarian ligament and uterine artery in association with closure of the cornu at the site of the rupture after removal of the products of conception) and medical (systemic administration of methotrexate) approach in the case of a hemodynamically unstable patient with a ruptured interstitial ectopic pregnancy. This is the first report that this technique was not combined with cornual resection, which is a more extensive surgical treatment. Additionally, the size of the present ectopic pregnancy appears to be bigger than the ones that have been reported previously, as the level of β-hCG indicates. Large, ruptured interstitial ectopic pregnancies leading to massive intraperitoneal bleeding can be managed successfully by means of unilateral ligation of the ovarian ligament and uterine artery. The surgery, however, requires advanced surgical skills and may not be appropriate to be performed by unsupervised junior surgeons.

Acute type A aortic dissection requires immediate surgical treatment, but the correct diagnosis is often delayed. This study aimed to analyse how initial misdiagnosis affected the time intervals before surgical treatment, symptoms associated with correct or incorrect initial diagnosis and the potential of the Aortic Dissection Detection Risk Score to improve the sensitivity of initial diagnosis. We conducted a retrospective analysis of 350 patients with acute type A aortic dissection. Patients were divided into two groups: initial misdiagnosis (group 0) and correct initial diagnosis of acute type A aortic dissection (group 1). Symptoms were analysed as predictors for the correct or incorrect initial diagnosis by multivariate analysis. Based on these findings, the Aortic Dissection Detection Risk Score was calculated retrospectively; a result ⩾2 was defined as a positive score. The early suspicion of aortic dissection significantly shortened the median time from pain to surgical correction from 8.6 h in patients with an initial misdiagnosis to 5.5 h in patients with the correct initial diagnosis (p<0.001). Of all acute type A aortic dissection patients, 49% had a positive Aortic Dissection Detection Risk Score. Of all initial misdiagnosed patients, 41% had a positive score (⩾2). The presence of lumbar pain (p<0.001), any paresis (p=0.037) and sweating (p=0.042) was more likely to lead to the correct initial diagnosis. An early consideration of acute aortic dissection may reduce the delay of surgical care. The suggested Aortic Dissection Detection Risk Score may be a useful tool to improve the preclinical assessment.

3D Ultrasound Preoperative Planning for a Laparoscopic Cornual Wedge Resection

Interstitial ectopic pregnancy is a term loosely used in the literature to describe three different entities. The first is the true interstitial ectopic pregnancy, which occurs in the interstitial or intramural segment of the Fallopian tubes. The term cornual ectopic pregnancy should be reserved for pregnancy in women with a single uterine horn, a bicornuate uterus, or a septate uterus. Angular pregnancy is a term that is rarely used and should be limited to a pregnancy in one of the angles of the uterus, but not inside the Fallopian tube. Historically, interstitial pregnancy was considered safe to manage conservatively until over 12 weeks because of the delayed risk of rupture as a result of the protection offered by the muscle of the uterus. However, over the last decade evidence now suggests that early rupture is not uncommon. The management of an interstitial pregnancy should be ascertained by ultrasonography, particularly three-dimensional ultrasonography. Depending on the size and viability of the pregnancy, management should be planned accordingly. Laparoscopic management is ideal for surgeons comfortable with the principles of laparoscopic surgery and suturing. However, laparotomy is a suitable alternative that will always provide a safe outcome. Adequate suturing of uterine cornua could prevent the risk of rupture during subsequent pregnancies. Minimizing blood loss during and after surgery is a priority.

The term intramural (interstitial) ectopic pregnancy refers to a pregnancy developing outside the uterine cavity, with a gestational sac implanted into the interstitial part of the Fallopian tube, surrounded by a layer of the myometrium. The prevalence rate of interstitial pregnancy (IP) is 2-4% of all ectopic pregnancies. Surgery is the primary treatment for interstitial ectopic pregnancy; the pharmacological management of ectopic pregnancy, including IP, in asymptomatic patients includes systemic administration of methotrexate. In this report, we present two cases of this rare pregnancy type, reviewing our management technique and treatment ways presented in the literature. In our patients, the management was initially conservative and included methotrexate, administered as intravenous bolus injection, regular beta-human chorionic gonadotropins (β-HCG) level measurements in peripheral blood, and monitoring of the patient's general condition. Due to signs of intra-abdominal bleeding in patient A and inadequate β-HCG level reduction in patient B, both patients eventually underwent laparoscopic cornual resection. Pregnancy, implanted into the interstitial part of the Fallopian tube and surrounded by myometrial tissue with myometrial invasion of the trophoblast, poses a serious diagnostic challenge to modern gynecology due to particularly low sensitivity and specificity of symptoms, and may require both pharmacological and surgical treatment.

Multidisciplinary approach to the surgical management of interstitial ectopic pregnancy

Hysteroscopy Assisted Wedge Resection of an Interstitial Ectopic Pregnancy

Interstitial ectopic pregnancy: A more confident diagnosis with three-dimensional sonography

Robotic Management of Large and Ruptured Interstitial Ectopic Pregnancy

8407 Interstitial Ectopic Pregnancy: A Case Series with Practical Tips for Surgical Management

Purpose of investigation: To assess the effect of laparoscopic temporary clipping of uterine and ovarian arteries for the treatment of interstitial ectopic pregnancy. Materials and Methods: A 29-year-old woman with vaginal bleeding and pelvic pain was admitted to thecurrent clinic. She had secondary amenorrhea for nine weeks. Transvaginal ultrasonography revealed normal empty uterus and right interstitial ectopic pregnancy with viable embryo. Laparoscopic temporary clipping of uterine and ovarian arteries, interstitial pregnancy resection, and primary myometrial suturing was performed. Results: Following dissection Latzko pararectal space for the visualization of both uterine arteries, four vascular clips were placed (two to uterine arteries, two to infundibulopelvic ligaments). Excision of interstitial pregnancy and primary myometrial suturing was performed with minimal blood loss. The patient was discharged from the hospital after one day without any remarkable complications. Conclusions: To the best of the authors’ knowledge, this is the first case of interstitial pregnancy that was successfully treated by temporary laparoscopic clipping of uterine and ovarian vessels prior to interstitial ectopic pregnancy resection.

A 35-year-old woman presented with spotting and lower abdominal pain. Follow-up sonography was suggestive of interstitial ectopic pregnancy. Laparoscopic cornuostomy was carried out. Before incision, diluted vasopressin was injected around the site of interstitial pregnancy. Removal of the conceptual tissues was conducted smoothly through a 1.5 cm incision. The overall blood loss was 50 mL. The operative time was 50 min, and there were no intraoperative complications. We successfully performed laparoscopic cornuostomy, which was followed by an unremarkable postoperative course. Laparoscopic surgery is a safe and effective minimally invasive surgical intervention for interstitial ectopic pregnancy if performed by the experienced surgeon. Local vasopressin injection is a good alternative for bleeding control in conservative laparoscopic surgery.

Eccentrically located intracavitary pregnancies, which include pregnancies traditionally termed as cornual and/or angular, have long presented complex diagnostic and management challenges given their inherent relationship to interstitial ectopic pregnancies. This review uses the existing literature to discriminate among interstitial, cornual, and angular pregnancies. Current arguments propose the outright abandonment of the terms cornual and angular may be justified in favor of the singular term, eccentric pregnancy. Disparate definitions and diagnostic approaches have compromised the literature’s ability to precisely describe prognosis and ideal management practices for each of these types of pregnancies. Standardizing the classification of these pregnancies near the uterotubal junction is important to unify conservative, yet safe and effective management strategies. We advocate the use of early first trimester ultrasound to correctly differentiate between eccentric pregnancy and interstitial ectopic pregnancy as current research suggests substantially better outcomes with correctly diagnosed and expectantly managed eccentric pregnancies than past investigations may have shown. The expectant management of eccentric pregnancies will often result in a healthy term pregnancy, while interstitial ectopic pregnancies inherently have a poor likelihood of progressing to viability. When the terms and diagnosis of cornual, angular, and interstitial pregnancy are indistinct, there is substantial risk of intrauterine pregnancies to be inappropriately managed as ectopic pregnancies. Until we standardize terms and criteria, it will remain difficult, if not impossible, to determine true risk for pregnancy loss, preterm labor, abnormal placentation, and uterine or uterotubal rupture. The development of best practice guidelines will require standardized terminology and diagnostic techniques.

Semantics and pitfalls in the diagnosis of cornual/interstitial pregnancy