Unruptured Interstitial Pregnancy Research Articles

Uterine artery chemoembolization for management of unruptured interstitial pregnancy diagnosed in the early first trimester

Background: With the increased frequency of diagnosis of interstitial pregnancy in the early first trimester, non-surgical management of unruptured interstitial pregnancy has become an important issue. However, management of unruptured interstitial pregnancy by uterine artery chemoembolization (UACE) with dactinomycin has never been evaluated via a case series. Methods: With this aim, a retrospective review of electronic chart records over a five-year period was performed, and a series of cases of unruptured interstitial pregnancy during the first trimester was extracted. Diagnostic procedures included ultrasonography, magnetic resonance imaging (MRI), and laparoscopic examination, if necessary. Conservative treatment regimen included UACE. Additional administration of methotrexate (MTX) was considered when an insufficient decline of serum β-hCG was noted. Clinical characteristics and treatment outcomes are described. Results: Among four women diagnosed with unruptured interstitial pregnancy at six weeks of gestation, one case was managed by laparoscopic cornuostomy due to concerns of rupture after the identification of thinning of the myometrium, whereas the other three cases were initially managed by UACE. One case of proximal interstitial pregnancy was diagnosed solely by MRI, whereas two cases of distal interstitial pregnancy was diagnosed by exploratory laparoscopy. Two cases were successfully managed by UACE alone, whereas one case required additional systemic administration of MTX to achieve resolution of gestational products after UACE. Thereafter, one patient conceived spontaneously and experienced a successful vaginal birth. Conclusions: This small case series emphasizes that UACE is a feasible minimally invasive option for the management of unruptured interstitial pregnancy identified in the early first trimester.

Laparoscopic Management of Unruptured Interstitial Pregnancy Using Purse-string Suture Technique.

Laparoscopic Management of Unruptured Interstitial Pregnancy Using Purse-string Suture Technique.

Laparoscopic Management of a Late-Presenting, Unruptured Interstitial Ectopic Pregnancy

Study Objective Interstitial pregnancies are located outside the uterine cavity in the muscular layer of the uterus and account for up to 4% of ectopic pregnancies. Mortality rate from this form of ectopic pregnancy is as high as 2.5% due to the risk of uterine rupture and hemorrhage. Late-presenting interstitial pregnancies are particularly worrisome. The objective of this video is to demonstrate the stepwise resection of a late-presenting, unruptured interstitial ectopic pregnancy by laparoscopic approach. Design Narrated step-by-step video demonstration of laparoscopic resection of a late-presenting, unruptured interstitial ectopic pregnancy. Setting Tertiary care academic medical center. Patients or Participants A 34-year-old G4P3003 presented to the emergency department with nausea and vomiting. Initial ultrasound in the emergency department showed a pregnancy at 12 w 2 d by last menstrual period consistent with ultrasound. It was initially misdiagnosed as an intrauterine pregnancy. Formal ultrasound in our Maternal-Fetal Medicine division showed a crown-rump length of 5.1 cm, and the gestational sac was surrounded by abnormal, cystic-appearing placenta. MRI confirmed an interstitial location and showed a gestational sac measuring 7.9 × 7.7 × 6.9 cm with a crown-rump length of 6.1 cm. Interventions Laparoscopic resection of an unruptured ectopic pregnancy involving the uterine cornua and fallopian tube. Measurements and Main Results The patient did well and was discharged on postoperative day 1. Quantitative beta-hCG was trended to zero in the outpatient setting. Conclusion This case illustrates that interstitial ectopic pregnancy can be safely managed laparoscopically even into the late first trimester and provides an alternative to both laparotomy as a surgical approach and hysterectomy as management, especially when future fertility is desired. This case is unique in that prior reports have demonstrated a fertility-sparing approach being feasible at a much earlier gestational age.

Combined Medical and Surgical Management of Unruptured Large Interstitial Ectopic pregnancy: Case Report and Literature Review

Combined Medical and Surgical Management of Unruptured Large Interstitial Ectopic pregnancy: Case Report and Literature Review

Therapeutic outcomes of methotrexate injection in unruptured interstitial pregnancy.

ObjectiveTo examine the therapeutic outcomes of methotrexate (MTX) in the treatment of unruptured interstitial pregnancy.MethodsWe reviewed the medical records of patients who were diagnosed with interstitial pregnancy and received MTX as first-line treatment between January 2003 and July 2014 at CHA Gangnam Medical Center. The treatment success rates and subsequent pregnancy outcomes were examined.ResultsNinety-seven patients were diagnosed with interstitial pregnancy between January 2003 and July 2014. Of them, 38 initially received MTX treatment. The diagnosis was made at a median of 6+3 weeks (5+0 to 11+3 weeks). Thirty patients received a systemic MTX injection, while the other 8 received a local MTX injection. Systemic treatment composed of an 8-day alternating MTX regimen, single-dose regimen, or high-dose regimen (100 mg/m2 + 200 mg/m2 intravenously over 12 hours). The local injection consisted of a direct MTX injection into the gestational sac with or without systemic MTX injection. Twenty-one patients (55.3%) were successfully treated with MTX. However, MTX therapy failed in 17 patients (44.7%), who required surgery. Mode of MTX treatment was the only predictive variable of MTX treatment success (P=0.039). Treatment success was seen in 7 of 8 patients (87.5%) in the local MTX group vs. 14 of 30 patients (46.7%) in the systemic MTX group. After treatment, 13 patients attempted a successive pregnancy; of them, 10 patients had a confirmed clinical pregnancy and healthy live birth.ConclusionCombined MTX treatment including a local injection might be an initial approach to the treatment of interstitial pregnancy.

Successful transvaginal aspiration of interstitial pregnancy after failed methotrexate treatment

Interstitial pregnancy is an uncommon condition that is challenging, not only in making an accurate diagnosis, but also in the choice of treatment. Systemic methotrexate (MTX) treatment has been favored to prevent scarring of the uterus. Nevertheless, surgery is generally indicated when this treatment fails. Transvaginal aspiration of the gestational tissue has been proposed as an alternative to surgery. The authors present a case of interstitial pregnancy in which the patient failed to respond to multidose MTX treatment and was successfully treated with transvaginal sonography-guided transvaginal aspiration of the gestational tissue, thereby bypassing the risk associated with undergoing major surgery. Transvaginal aspiration of conceptive tissue may be a novel treatment for patients with unruptured interstitial pregnancy.

Medical management of unruptured interstitial pregnancy with mifepristone and methotrexate

Ectopic pregnancy is a serious complication of pregnancy in which embryo gets implanted any where other than the uterine cavity. In interstitial pregnancy, the pregnancy is located in that part of the fallopian tube that penetrates the muscular layer of the uterus. Overall incidence of ectopic pregnancy is one to two percent among which the incidence of interstitial pregnancy is only two percent. Interstitial pregnancy being the hazardous type requires immediate management. Though surgical treatment is the management of choice, its association with decreased fertility rate and increased rate of uterine rupture in future pregnancy cannot be ignored. We hereby report of medical management of interstitial ectopic pregnancy with single oral dose of Mifepristone 200mg along with single dose of Methotrexate 50miligram intramuscularly.Journal of Kathmandu Medical College, Vol. 4(1) 2015, 34-36

Prise en charge des grossesses interstitielles par traitement médical selon un protocole de méthotrexate in situ

Interstitial pregnancy accounts for 3 to 11% of ectopic pregnancy; these pregnancies are the more frequently non-tubal ectopic pregnancy. Medical treatment can be used in case of unruptured interstitial pregnancy and is used more and more frequently to avoid hemorrhagic risk and risk of conversion to radical surgery when a surgical management is decided. However, a larger use of methotrexate in interstitial pregnancy and conditions of use are not clearly defined. The aim of this study is to report a series of unruptured interstitial pregnancy managed by in situ injection of methotrexate. This retrospective observational study included women treated for an interstitial pregnancy between 2010 and 2013 in a teaching hospital. Medical management used was an in situ injection of methotrexate (1mg/kg) guided by vaginal sonography plus an intramuscular injection of methotrexate (1mg/kg) in the 48hours following in situ injection and 600mg of mifepristone when progesterone blood rate was more than 9ng/mL. A great decrease of serum hCG without surgery was considered a success. Fourteen women had an interstitial pregnancy during the study period. Six were managed surgically in 5 cases for suspicion of uterine rupture and one for pregnancy of unknown location. Eight women had a medical management and the success rate was 100%. Mean time for decrease of serum hCG until 2UI/L was 54.4 days [34.0-74.8]. No uterine rupture or immediate complication was reported. Five women out of 8 had a spontaneous pregnancy after management of interstitial pregnancy. Medical management by in situ injection of methotrexate under sonographic guidance with an intramuscular injection within the 48hours following the in situ injection and mifepristone when ectopic pregnancy was active can be proposed in first-line therapy in case of unruptured interstitial pregnancy. This treatment has a great efficiency and low rate of complications.

Magnetic resonance imaging for diagnosis and management of unruptured interstitial pregnancy.

The aim of this study was to evaluate the value of magnetic resonance imaging (MRI) for the diagnosis and management of suspicious unruptured interstitial pregnancy. Only patients with unruptured interstitial pregnancy evaluated by MRI and observed for at least a year after surgery were included. Initial evaluation was performed by measurement of serum β-human chorionic gonadotrophin level and ultrasonography. In suspicious cases, emergency MRI was performed to diagnose interstitial pregnancies with the exclusion of rudimentary horn pregnancy and angular pregnancy. Three-dimensional computed tomographic (CT) angiography was additionally performed if the uteroplacental neovascularization needed to be evaluated. Then, management procedures were individually determined along with the need for preoperative transcatheter arterial chemoembolization for immediate devascularization, and for the local or systemic administration of methotrexate. Either laparoscopic cornuostomy or cornual resection was chosen to excise the gestational mass. Five consecutive women with unruptured interstitial pregnancy were enrolled. One case each of rudimentary horn pregnancy and angular pregnancy was excluded. Three-dimensional CT angiography was performed in three cases due to increased vascular flow on color Doppler ultrasonography. Preoperative devascularization by transcatheter arterial chemoembolization was performed in two cases, in which a prominent neovascularized gestational mass was identified. Uterine preservation was achieved by cornuostomy or cornual resection in all cases. Two patients with a desire to become pregnant conceived spontaneously thereafter, followed by successful cesarean birth. This small case series emphasizes that precise localization of gestational products in the interstitial portion of the fallopian tube by MRI can facilitate the minimally invasive management of unruptured interstitial pregnancy for uterine preservation.

Magnetic Resonance Imaging and 3-dimensional Computed Tomographic Angiography for Conservative Management of Proximal Interstitial Pregnancy by Hysteroscopic Resection After Transcatheter Arterial Chemoembolization

Ectopic pregnancy implanted in the interstitial portion of the fallopian tube is a rare potentially life-threatening disorder. A case of unruptured interstitial pregnancy with prominent neovascularization in a 37-year-old woman was precisely localized in the proximal interstitial portion of the fallopian tube with a dilated proximal tubal ostium by magnetic resonance imaging and 3-dimensional computed tomographic angiography. After devascularization by transcatheter arterial chemoembolization, hysteroscopic resection of the interstitial gestational products was performed with single-port laparoscopic assistance. Postoperatively, 3 rescue doses of systemic methotrexate were administered to accelerate the resolution of gestational products followed by uneventful recovery. The uterine wall structure around the interstitial portion was well preserved at the cesarean delivery in the subsequent spontaneous gestation.

Laparoscopically-assisted, Hysteroscopic Removal of an Interstitial Pregnancy With a Fertility-Preserving Technique

Described is a novel surgical management of an unruptured interstitial pregnancy with preservation of the ipsilateral fallopian tube and uterine cornua. The patient was a 34-year-old woman, gravida 3, para 1, with an unruptured left interstitial pregnancy at 9 weeks' gestation, who desired preservation of fertility. The ectopic pregnancy was entirely removed via laparoscopically assisted hysteroscopy with a fertility-preserving surgical technique, with minimal blood loss, preservation of reproductive organs, restoration of anatomy, a patent ipsilateral fallopian tube, and expedient return to normal reproductive function. After the procedure, serial human chorionic gonadotropin levels were obtained until they were <5 mIU/mL. A hysterosalpingogram obtained 2 months after the procedure showed normal uterine and fallopian tube contour and bilateral tubal patency. We conclude that this laparoscopically assisted hysteroscopic technique is a safe and efficient fertility-preserving approach to management of an unruptured interstitial pregnancy.

Laparoscopic-assisted instillation of epinephrine and levobupivacaine enables cornual excision and anatomical reconstruction in unruptured cornual pregnancy

The objective of this report is to describe the possible use of intramiometrial vasoconstrictive agents for laparoscopic management of interstitial pregnancy and the consequences in anatomical results and reproductive outcomes. Cornual resection can be performed by laparoscopy, but the high vascularization of this area may result in profuse bleeding and laparoscopic suturing under these conditions might be impossible for the majority of the surgeons. We present a case that describes the possible use of intramiometrial instillation of a solution of diluted epinephrine and levobupivacaine under laparoscopic guidance that permitted a bloodless cornual excision with complete reconstruction. Vasoactive agents might have potentially serious cardiovascular side effects and the correct election of the active principle and the dosage is essential to reduce the risk of the surgery and obtain good anatomical results and reproductive outcomes. In conclusion, unruptured interstitial pregnancies can be managed successfully with intramyometrial instillation of epinephrine and bupivacaine. This simple technique is particularly attractive as it facilitates anatomical reconstruction of the cornual area, gives enough time to perform a complete suture of the defect and reduces the risk of laparotomic conversion.

Author's reply: Ultrasound-guided transcervical forceps extraction of unruptured interstitial pregnancy

Author's reply: Ultrasound-guided transcervical forceps extraction of unruptured interstitial pregnancy

Ultrasound-guided transcervical forceps extraction of unruptured interstitial pregnancy

Ultrasound-guided transcervical forceps extraction of unruptured interstitial pregnancy

Ultrasound‐guided transcervical forceps extraction of unruptured interstitial pregnancy

This report introduces a method for ultrasound-guided transcervical forceps extraction (UTCE) of unruptured interstitial pregnancies; this method does not necessitate elective caesarean delivery for future pregnancies. This report also compares this technique with conventional methods. A retrospective review was conducted involving 16 women treated for interstitial pregnancies. Among these women, UTCE was successfully performed in six of 16 women, with only one woman requiring additional intervention; conventional treatment was performed in the other ten women. UTCE is a safe, effective and minimally invasive option for treating interstitial pregnancies and should be considered as an alternative treatment modality.

A conservative and fertility preserving treatment for interstitial ectopic pregnancy

This is a case series of women presenting to a tertiary care centre with a diagnosis of interstitial pregnancy. Dilatation and evacuation was performed under ultrasound control with systemic methotrexate post-operatively. All women had successful termination of their interstitial pregnancy. Although described in the international literature, this is the first time that this technique has been documented in Australia, and it may ultimately prove to be a relatively safe and simple fertility preserving method of treating women with unruptured interstitial pregnancies.

Successful management of unruptured interstitial pregnancy in 17 consecutive cases by using laparoscopic surgery

To analyse the optimal laparoscopic surgical techniques for the treatment of interstitial pregnancy to minimise bleeding during the operative procedure and the safety of the subsequent pregnancy. Advanced bipolar coagulator was used to achieve haemostasis. The mean gestational age was 55 ± 5.1 days. All 17 women with an interstitial pregnancy were successfully treated by laparoscopic surgery without any complication. No surgery was converted to laparotomy. The mean pre-operative beta-human chorionic gonadotropin (β-hCG) serum concentration was 14 696 ± 11 705 mIU/mL. This value decreased to 1911 ± 1769 mIU/mL at 3-day post-operation. Among women who underwent laparoscopic surgery, a cornual resection was performed in 16 (94.1%) cases. One (5.8%) woman underwent a laparoscopic evacuation of the conceptus and received a local injection of 10 mg methotrexate. The volume of blood loss was <25 mL in 16 cases. However, one woman experienced a rupture at the beginning of the operation and lost 250 mL of blood. The mean hospital stay was 4.5 days. Four of the nine women who chose to retain their reproductive function had subsequent normal pregnancies, but all received an elective caesarean delivery prior to labour. The laparoscopic management of women with unruptured interstitial pregnancy can frequently be performed without haemorrhage or complication using advanced bipolar coagulation. The small sample of successful subsequent pregnancies demonstrates the safety and effectiveness of this technique, but this finding should be confirmed by further investigations.

Interstitial (Cornual) Pregnancy: Advantages of Methotrexate Treatment

Background: Ectopic pregnancy is a serious gynecologic condition that requires early diagnosis before rupture leads to severe hemorrhage with consequent significant morbidity and mortality. Case: A 34-year-old woman presented with pelvic pain and positive βhCG. A pelvic sonogram showed a right interstitial pregnancy with a normal endometrial stripe. Methotrexate treatment was effective in the presence of high βhCG levels and positive fetal heart activity. Results: Follow- up hysterosalpingogram revealed patency of both tubes. Conclusions: medical treatment for unruptured interstitial (cornual) pregnancy is effective and prevents uterine surgery that may have complications for future pregnancy. (J GYNECOL SURG 27:147)

Laparoscopic Uterine Vessels Occlusion for the Treatment of Interstitial Pregnancy

Interstitial pregnancy is a rare form of ectopic pregnancy, but it results in significant maternal morbidity and mortality. In this paper, describe a case of interstitial pregnancy that was successfully managed by laparoscopic occlusion of the ipsilateral ascending branch of uterine artery and the communication of the ovarian artery. It would help to minimize the active bleeding and allow removing the gestation sac, placental tissue, and repair the interstitial tube. In this case, the operative bleeding was 80 mL only, and the operative time was 70 minutes. The patient shared good postoperative recovery, and serum beta human chorionic gonadotropin decreased to below normal levels within 1 month after the operation. This procedure should be considered as a treatment option for unruptured interstitial pregnancy and may allow for conserving the patient's uterus and fallopian tube and preserving the future fertility.

Conservative surgical management of ruptured interstitial pregnancy

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.