Interstitial Ectopic Pregnancy Research Articles

Diagnostic and management dilemmas of pregnancies at the utero-tubal junction: A case series and management algorithm.

A pregnancy at the utero-tubal junction is a rare type of ectopic pregnancy and is associated with high maternal morbidity if it remains undetected. In the present study we discuss four cases of ectopic pregnancies at the utero-tubal junction which caused diagnostic and management dilemmas. Four cases of early pregnancies with the gestational sac (G-sac) implanted near the utero-tubal junction are described. In case 1 this was suspected after a failed attempt at dilatation and curettage at our hospital, cases 2 and 3 presented with amenorrhea and pain abdomen and case 4 was diagnosed on first pregnancy documentation scan after frozen embryo transfer. As initial two-dimensional (2D) transvaginal scan (TVS) failed to diagnose the exact location of the G-sac, three-dimensional (3D) TVS helped to localize the exact location of pregnancy and subsequent individualized management. Case 1 had a partial intramural ectopic pregnancy managed by laparotomy and removal of the ectopic sac. The second and third cases were eccentric uterine pregnancies. The fourth was an interstitial ectopic pregnancy managed by a laparoscopic loop and stitch technique. This case series describes the role of 3D TVS for the evaluation of pregnancies implanted at the utero-tubal junction and individual management of eccentric intrauterine, interstitial ectopic and intramural ectopic pregnancies. A diagnostic algorithm for such types of cases and management options is discussed.

Laparoscopic Management of Short-Interval Interstitial Pregnancy After Recent Tubal Ectopic: A Case Report [ID 2683561

INTRODUCTION: A 24-year-old G6P2032 presents with interstitial pregnancy 3 months after ipsilateral laparoscopic salpingectomy for ruptured tubal ectopic pregnancy. This case report demonstrates the management of short-interval interstitial pregnancy after recent ipsilateral laparoscopic salpingectomy. METHODS: The patient initially presented with a right-sided ruptured tubal ectopic pregnancy. Salpingectomy was performed to completely remove the fallopian tube and desiccate it at the cornua, leaving no residual visible tubal remnants. The patient presented with ipsilateral interstitial pregnancy 3 months later and initially underwent systemic methotrexate injection, which failed to resolve the pregnancy. She then underwent laparoscopic cornuostomy and dilation and curettage (D&C). Cornuostomy was performed with injection of dilute vasopressin around the gestational sac to help minimize blood loss followed by hydrodissection and sharp dissection to remove the pregnancy. The myometrium and serosa were closed in layers. There was attention to preserve uterine myometrial tissue integrity at the cornua. The patient did well postoperatively and was discharged on postoperative day 0 (POD0). Her β-hCG trended from 11,902 mIU/mL pre-surgery to 7,726 on POD0, and 289 at 1 week. Pathology showed fragments of chorionic villi, and the D&C showed decidualized secretory endometrium. CONCLUSION: Short-interval interstitial ectopic pregnancies after prior salpingectomy for tubal ectopic are extremely rare. We demonstrated successful management with a minimally invasive laparoscopic cornuostomy after failed methotrexate. Patients should be counseled carefully about the risks of short-interval pregnancy after tubal ectopic even after care is taken to remove all visible portions of the fallopian tube.

Pregnancies at the Uterotubal Junction: A Review of Terminology (Interstitial, Cornual, and Angular) and Recommendations for Management.

Ectopic pregnancies are one of the most common causes of obstetric mortality worldwide. Interstitial ectopic pregnancies, defined as an extracavitary pregnancy within the portion of the Fallopian tube that transverses the myometrium, have reported mortality rates approximately seven times higher than all types of ectopic pregnancy combined. In contrast, intracavitary eccentric gestations, often labeled as "cornual" or "angular" pregnancies, have reportedly high rates of live birth. Unfortunately, the terms "interstitial," "cornual," and "angular" have long been used with varying diagnostic criteria and often interchangeably to describe a pregnancy near the uterotubal junction. The inconsistency in nomenclature and lack of clear diagnostic criteria to distinguish among these pregnancies has resulted in a paucity of data to provide accurate prognostic information and guide appropriate management. This review article aims to provide historical context for the terms "interstitial," "cornual," and "angular;" discuss previous and more recent innovations of diagnostic methods; and provide recommendations for concise terminology and inform management.

Commentary: Three-dimensional transvaginal ultrasound diagnosis of interstitial ectopic pregnancy in a unicornuate uterus: A case report

A rare case of unicornuate uterus with interstitial ectopic pregnancy (IEP) was diagnosed using three-dimensional transvaginal ultrasound (3D-TVUS). The ultrasound revealed a "lancet-shaped" endometrial corona, a gestational sac near the uterus base extending towards the uterine serosa, and visible interstitial lines. The patient underwent laparoscopic surgery for a lesion in the right fallopian tube. 3D-TVUS was crucial in precisely locating the gestational sac, aiding in effective treatment. Interstitial ectopic pregnancies risk severe hemorrhaging upon rupture. Rapid, accurate diagnosis is vital for lifesaving treatment and preventing critical complications.

Successful management of an advanced interstitial ectopic pregnancy in a resource-limited setting: a case report

BackgroundInterstitial ectopic pregnancy is an ectopic gestation developing in the uterine part of the fallopian tube. The condition is rare and presents challenges for clinical as well as radiological diagnosis. This case report presents a rare case of interstitial ectopic pregnancy diagnosed intraoperatively.Case presentationA 36-year-old Black woman, referred from a peripheral health facility, presented at the emergency department with severe abdominal pains, vaginal spotting, nausea, and vomiting, with a 2-month history of irregular menstrual flow. Clinical and laboratory findings were suggestive of an acute abdomen likely due to a ruptured ectopic pregnancy (ultrasound was not available). An emergency exploratory laparotomy was done, which revealed a right adnexal ruptured interstitial pregnancy of a lifeless female fetus weighing 500 g (estimated mean gestational age of 22–23 weeks). The left fallopian tube looked normal. The site of rupture was repaired, followed by cleaning and closure of the abdomen. The post-operative period was uneventful, and the patient was discharged on postoperative day 7.ConclusionInterstitial pregnancies are uncommon and rarely attain advanced gestational ages, as in this case, compared with other tubal ectopic pregnancies. However, women presenting with signs of hypovolemic shock and acute abdomen, with a positive pregnancy test, warrant a high index of suspicion.

Ruptured Recurrent Interstitial Ectopic Pregnancy Successfully Managed by Laparoscopy.

Ectopic pregnancies are a frequently encountered cause of first-trimester metrorrhagia. They occur when an embryo is implanted and grows outside the normal uterine space. Uncommonly, the embryo can be implanted in the intramural portion of the uterine tube, a condition referred to as interstitial localization. This specific type of ectopic pregnancy may have an unpredictable course, potentially leading to severe uterine rupture and catastrophic bleeding if not promptly diagnosed and managed. We present a rare case of a multiparous 36-year-old female patient who underwent pelvic ultrasonography in the emergency department for intense pelvic pain associated with hypotension and moderate anemia. A history of right salpingectomy for a ruptured tubal ectopic pregnancy 10 years previously was noted. High beta-HCG levels were also detected. A pelvic ultrasound allowed us to suspect a ruptured ectopic interstitial pregnancy at 8 weeks of amenorrhea. An association with hemoperitoneum was suspected, and an emergency laparoscopy was performed. The condition was confirmed intraoperatively, and the patient underwent a right corneal wedge resection with suture of the uterine myometrium. The postoperative course was uneventful, and the patient was discharged on the fourth day postoperatively. Interstitial ectopic pregnancy is a rare yet extremely perilous situation. Timely ultrasound-based diagnosis is crucial as it can enable conservative management with Methotrexate. Delayed diagnosis can lead to uterine rupture with consecutive surgery based on a transection of the pregnancy and cornual uterine resection.

Early interstitial ectopic pregnancy: A case report

No abstract available

Tubal Stump Ectopic Pregnancy with Acute Abdomen: A Rare Case Report

Ectopic pregnancy, characterized by the implantation of the gestational sac outside the uterine cavity, is a grave condition. The objective of this study is to report a case of recurrent ectopic pregnancy in the residual site of the same fallopian tube, which had undergone unilateral salpingectomy due to ectopic pregnancy five years prior. Despite its rarity in the literature, tubal stump ectopic pregnancy poses higher risks of maternal mortality and morbidity compared to other types of tubal ectopic pregnancies. It is important to note that a history of salpingectomy does not exclude the possibility of ipsilateral recurrent ectopic pregnancy. Furthermore, this is the first documented case of stump tubal ectopic pregnancy from Turkey.

Recurrent ipsilateral interstitial ectopic pregnancy after salpingectomy

Introduction: This case highlights the long-term obstetric risks following salpingectomy. These include recurrent ipsilateral interstitial ectopic pregnancy and uterine rupture. Case Report: A 29-year-old lady presented with acute abdominal pain as well as signs and symptoms of hemorrhagic shock at 14 weeks of gestation. She was subsequently diagnosed with a ruptured right-sided interstitial ectopic pregnancy, which was managed surgically. The patient had a past history of open salpingo-oophorectomy for a complicated right-sided ectopic pregnancy involving the ovary at 12 weeks of gestation in her previous pregnancy. A subsequent pregnancy a year later was complicated by impending uterine rupture at 30 weeks of gestation. A healthy baby was delivered by Cesarean section. Conclusion: A meticulous surgical technique is of the essence when performing a salpingectomy for whatever pathology. The risk of a recurrent ipsilateral interstitial ectopic pregnancy must always be considered. Also, the risk of antenatal and intrapartum uterine rupture must be addressed in future pregnancies following interstitial pregnancies.

INTERSTITIAL ECTOPIC PREGNANCY. A CASE REPORT

Interstitial ectopic pregnancy, misnamed cornual, is a rare pathology, but it implies a high morbidity and mortality if it is not diagnosed and treated on time. We present the case of a one-year-old patient who attended the emergency room due to pain, vaginal bleeding, and a 9-week period of amenorrhea. During the ultrasonographic evaluation, a gestational sac with an active embryo was evidenced at the level of the right uterine horn, for which the diagnosis of cornual ectopic pregnancy was considered and proceeding to perform an abdominal hysterectomy. The best knowledge of the natural history of the disease, as well as an early and timely diagnosis, is the key to the conservative management of this disease.

Local Methotrexate Plus Uterine Artery Embolization for High-Risk Interstitial Ectopic Pregnancy.

Interstitial ectopic pregnancy involves the interstitial portion of the fallopian tube and is among the most hazardous of all ectopic pregnancies, with the highest risk of uterine rupture and maternal mortality. Unlike tubal ectopic pregnancy, management of interstitial pregnancy is not well standardized. Systemic methotrexate (MTX) and surgical resection are the primary treatment options; however, failure rates and risk of bleeding remain high. Alternative minimally invasive techniques have been described-including uterine artery embolization (UAE) and local injection of MTX or potassium chloride-and may confer improved success rates. We report a case of a high-risk 28-year-old female with an interstitial ectopic pregnancy successfully treated with combined local injection of MTX plus UAE. We describe our technique and the unique medical management in the setting of a known bleeding disorder.

Laparoscopic treatment of advanced interstitial pregnancy: key steps for a successful management

To describe a conservative laparoscopic treatment of an advanced case of interstitial pregnancy diagnosed in a woman at 14 weeks of gestational age. Video case report with demonstration of diagnostic work-up and laparoscopic management of rare subtypes of ectopic pregnancy SETTING: University tertiary care hospital. A 32-year-old nulliparous woman at 14 weeks of gestational age, presented with moderate abdominal pain. She reported an history of irregular periods however, no risk factor for ectopic pregnancy were identified. HCG levels was 7345 mIU/mL. Transvaginal ultrasound revealed an empty uterine cavity and a complex heterogeneous mass of 6 cm on the left cornual region. Myometrial thickness surrounding the gestational sac was 4 mm. There were several critical strategies for this laparoscopic approach. To reduce intraoperative bleeding, the peritoneum was opened, the ureters were identified, and bulldog clamps were used to temporarily reduce uterine vascularization. An intramyometrial injection of vasopressin was performed. After a first cornuostomy attempt, we had to get on a cornual resection to achieve a complete removal of the ectopic mass. Multilayer uterine suture and anatomical restoration to prevent adhesion was then accomplished. Institutional review board approval was not required for this case report as per our institution's policy; patient consent was obtained for publication of the case. Description of a laparoscopic management of huge interstitial pregnancy RESULTS: The overall operation time was 55 minutes, and the estimated blood loss was 55cl. A successfully conservative treatment was achieved with no short-term complications. Postoperative ultrasound showed a normal uterus and complete regression of hCG was obtained two weeks after surgery. Interstitial ectopic pregnancy presents a high risk of maternal mortality considering that the interstitial part of the tube, because of its thickness, has a great capacity to expand before rupture.

Interstitial and Cornual Ectopic Pregnancy: A Review of the Management Options

Interstitial or cornual ectopic pregnancies are a rare form of ectopic pregnancy which account for 2% to 4% of all ectopic pregnancies. While it is a rare type of ectopic pregnancy, the mortality rate is 6–7 times higher than other ectopic pregnancies. Therefore, early recognition and accurate diagnosis of an interstitial or cornual ectopic pregnancy is critical for the safety and wellbeing of the patient especially due to the increased risk of massive hemorrhage. Treatment options include conservative medical management with methotrexate or surgical intervention with laparoscopy or laparotomy.

Management of interstitial pregnancy using laparoscopic salpingectomy with complete removal of the interstitial portion

To perform laparoscopic salpingectomy, including the entire interstitial portion of the fallopian tube, in the management of interstitial pregnancy. A step-by-step explanation of the surgical procedure using video with narration. Obstetrics and Gynecology department of a hospital. A 23-year-old woman, gravida 1 para 0, presented asymptomatically to our hospital to undergo a pregnancy test. Her last menstrual period had occurred 6 weeks previously. Transvaginal ultrasound showed an empty uterine cavity and a right interstitial mass of 3.2 × 2.6 × 2.5 cm. It contained a chorionic sac and an embryonic bud of 0.2 cm long with a heartbeat and the presence of an "interstitial line sign." The myometrial layer surrounding the chorionic sac was 1 mm. The patient's beta-human chorionic gonadotropin level was 10,123 mIU/mL. On the basis of the anatomy of the interstitial portion of the fallopian tube, we treated interstitial pregnancy using laparoscopic salpingectomy, with complete removal of the interstitial portion containing the product of conception. The interstitial fallopian tube originates at the tubal ostium and follows a tortuous intramural course, progressing laterally away from the uterine cavity toward the isthmic portion. It is lined by muscular layers and an inner epithelium layer. The main blood supply of the interstitial portion is from the uterine artery's ascending branches to the fundus, extending a branch that supplies the cornu and the interstitial portion. Our approach has 3 key steps: 1) dissecting and coagulating the branch extending from the ascending branches to the fundus of the uterine artery, 2) incising the cornual serosa at the junction of the purple-blue interstitial pregnancy and the normal color myometrium, and 3) resecting the interstitial portion containing the product of conception along the outer layer of the oviduct without rupture. The interstitial portion containing the product of conception was removed entirely along the outer layer of the fallopian tube as a natural capsule without rupture. The surgery lasted for 43 min, and the volume of intraoperative blood loss was 5 mL. The pathology was confirmatory for interstitial pregnancy. The patient's beta-human chorionic gonadotropin levels decreased optimally. She had a normal postoperative course. This approach reduces intraoperative blood loss, minimizes myometrial loss and thermal injury, and effectively avoids persistent interstitial ectopic pregnancy. It is not limited by the device used, does not increase the surgery cost, and is greatly useful in treating a selected nonruptured distally or centrally implanted interstitial pregnancy.

Interstitial Ectopic Pregnancy: Laparoscopic Cornuostomy

To demonstrate and discuss the technique of cornuostomy for surgical management of interstitial ectopic pregnancy. Stepwise demonstration of the technique with narrated video footage. Tertiary referral center in Manchester, United Kingdom. Interstitial ectopic pregnancies are rare but are associated with a higher mortality rate than other ectopic pregnancies [1,2]. It occurs when the fertilized embryo implants in the interstitial portion of the fallopian tube traversing the vascularized myometrium. When undiagnosed they present late in the second trimester associated with rupture and catastrophic bleeding, with a mortality rate of 2% to 2.5%.2 Diagnosis requires a degree of vigilance from the ultrasound operator because it is commonly misdiagnosed as intrauterine pregnancies. Surgical management options include laparoscopic cornual resection or cornuostomy. There is no consensus on the optimal surgical technique but cornuostomy is a more conservative approach associated with less disruption to uterine anatomy and loss of myometrium [3,4]. A 22-year-old gravida 4 woman presented at 7 weeks' gestation with right iliac fossa pain. Initial serum human chorionic gonadotropin was 18136 IU/L. Transvaginal ultrasound scan showed an empty endometrial cavity and an echogenic "donut"-shaped mass within the right interstitial space, within the uterine serosa but outside the endometrial cavity (Supplemental Video 1). At laparoscopy the diagnosis of a right interstitial ectopic pregnancy was confirmed (Supplemental Video 2). Vasopressin 20 IU diluted in 80 mL of normal saline was injected around the base of the ectopic pregnancy. Monopolar diathermy was used to incise the overlying serosa followed by hydrodissection to separate the ectopic gestational sac from the myometrial attachment. The resulting defect was inspected and closed in 2 layers. Total operating time was 46 minutes. Although there is no clear evidence to guide the management of all interstitial ectopic pregnancies, an individualized approach taking into account the woman's previous history and future fertility plans and wishes is essential. In this case, given the woman's previous contralateral salpingectomy and her wishes for a conservative approach, a laparoscopic cornuostomy was likely the best option.

Multidisciplinary approach to the surgical management of interstitial ectopic pregnancy

To present a multidisciplinary approach to localize and resect suspected interstitial ectopic pregnancies. Interstitial ectopic pregnancies are distinct from eccentric intracavitary pregnancies and are defined by ultrasound-based criteria, including an empty uterine cavity, gestational sac located >1 cm from the cavity, thin overlying myometrium <5 mm, and the interstitial line sign. Case report. Academic medical center. Here, we present the case of a 28-year-old patient at 6 weeks of gestation by last menstrual period who presented to the emergency department with spotting. Initial pelvic ultrasound findings demonstrated a gestational sac and yolk sac that were believed to be located eccentrically within the uterine cavity. Follow-up imaging was performed 2 weeks later that revealed the pregnancy was located at the uterotubal junction and distinct from the endometrial cavity, consistent with an interstitial ectopic. The patient had ongoing light spotting with mild cramping, a benign clinical exam, and normal laboratory findings. Accurate assessment of pregnancy location is critical given that the mortality rate from interstitial pregnancies is twice that of other ectopics. In contrast, live birth rates for eccentric intracavitary pregnancies may be up to 69%, and some clinicians consider expectant management of asymptomatic patients in the first trimester. The patient was recommended for inpatient admission with expedited surgical management of interstitial ectopic pregnancy. On laparoscopic entry, the pregnancy was not well-visualized because it did not deform the uterine serosa. We present a surgical approach to suspected interstitial ectopic pregnancy that is not well-visualized at the time of laparoscopy. The following principles are explored: the use of multiple minimally invasive modalities (laparoscopy and hysteroscopy) to perform a thorough evaluation of the pregnancy location; incorporation of intraoperative ultrasound; temporary vessel ligation and injection of intramyometrial vasopressin; complete enucleation of the products of conception; and closure of the myometrial defect. We emphasize the benefits of a multidisciplinary approach for the localization and resection of interstitial ectopic pregnancy. This patient was discharged home in good condition with no complications.

Interstitial Ectopic Pregnancy with Enhanced Myometrial Vascularity: A Rare Case Successfully Treated with Uterine Artery Embolization

AbstractEnhanced myometrial vascularity (EMV) is a rare disorder associated with various obstetrical and gynecological pathologies. We describe a unique case of interstitial ectopic pregnancy associated with EMV successfully managed with bilateral uterine artery embolization.

A Cautionary Tale of the Tubal Stump

A 22 year-old G2A1 female, with a history of prior right salpingectomy for a ruptured ectopic pregnancy, presented to hospital with diffuse abdominal pain and vaginal spotting. Her b-HCG was over 16 000 mIU/mL. A pelvic ultrasound demonstrated a gestational sac with a fetal pole at the right utero-tubal junction, outside of the endometrial cavity (Figure 1), suggesting a pregnancy contained in the interstitium of the tubal stump remnant. Laparoscopy confirmed imaging findings (Figure 2). Dilute vasopressin was injected into the adjacent myometrium. A transverse incision was made along the most dependent area of the interstitial pregnancy, the products of conception were expressed from the uterine cornua, tubal stump removed, and the defect repaired (Figure 3). Figure 2Laparoscopy confirms an interstitial ectopic pregnancy within the tubal stump from prior salpingectomy. View Large Image Figure Viewer Download Hi-res image Figure 3Image of the pelvis after removal of ectopic pregnancy and repair View Large Image Figure Viewer Download Hi-res image

Interstitial pregnancy.

A case report of a patient with interstitial pregnancy and a history of hyperprolactinemia. A 30-year-old woman was hospitalized for a suspicion of ectopic pregnancy and referred for laparoscopy. During the laparoscopic surgery, interstitial pregnancy was dia-gnosed and solved with cornuostomy. Ectopic interstitial pregnancy represents a serious worldwide issue because unrecognized, it can endanger a womans life, despite advances in ultrasound examination, the dia-gnosis often remains inaccurate. Laparoscopic surgical approach with evacuation of pregnancy with subsequent uterus suture represents one of the possible approaches. This method is minimally invasive and safe.

Laparoscopically assisted hysteroscopic removal of an interstitial pregnancy

To illustrate a combined technique of hysteroscopy and laparoscopy for the management of interstitial ectopic pregnancies. A description of a patient case and demonstration of a surgical technique. Tertiary referral center. A 33-year-old woman, gravida 2, para 0-0-1-0 status post invitro fertilization cycle with single embryo transfer, was diagnosed with an unruptured right interstitial pregnancy at 5 weeks of gestation. She has a history of a pregnancy of unknown location with her first invitro fertilization transfer and received methotrexate. The beta-human chorionic gonadotropin level was 2,726 mIU/mL. She was counseled on treatment options and declined treatment with methotrexate because of the negative side effects she experienced previously. She opted for surgical management and desired to keep her fallopian tubes if possible because she wished to try for spontaneous conception. The patient underwent multipuncture video laparoscopy, and a bulge was seen at the right cornua. Video hysteroscopy initially revealed an empty uterine cavity. Using atraumatic graspers, the interstitial pregnancy was gently pushed further into the uterine cavity using a milking technique. The pregnancy was then able to be visualized hysteroscopically. Products of conception were gently dislodged and removed with graspers, followed by a suction curettage. This technique resulted in minimal blood loss, preservation of reproductive organs, and expedient return to conception planning. The postoperative course was uncomplicated, and the patient was discharged the same day as surgery. After the procedure, weekly beta-human chorionic gonadotropin was drawn until the level reached <1 mIU/mL, which occurred after 4 weeks. Hysterosalpingography was performed 2 months after the procedure and demonstrated bilateral tubal patency. In select patients, an early interstitial pregnancy can be safely removed using the described technique. Although hysteroscopic removal of interstitial pregnancies is not a new concept, the addition of simultaneous video laparoscopy provides the benefit of allowing for fertility-sparing removal of the pregnancy, even if it is not initially visualized hysteroscopically. The use of this technique may result in minimal blood loss and preservation of the fallopian tubes. Furthermore, with the myometrium integrity maintained, the patient may resume sooner attempts at conception.