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 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 toward 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.

[Interstitial ectopic pregnancy: report of an unusual location]. / Embarazo ectópico cornual: reporte de una localización inusual.

Ectopic pregnancy occurs when a developing blastocyst implants at any site other than the uterine cavity. Ectopic pregnancy is most commonly found in the fallopian tube but may also occur in the cornua of the uterus (also found as interstitial in the literature), cervix, ovary, or abdominal cavity or in a cesarean scar. An estimated 2% of pregnancies are ectopic, of which an interstitial pregnancy represents an extremely rare variant of ectopic pregnancy (EP), accounting for 2% to 4 % of all cases. The aim of this report is to describe the case of a patient with suspected ectopic pregnancy of uncertain location in which an exploratory laparoscopy was performed due to the onset of symptoms, discovering a cornual ectopic pregnancy in site of a past salpingectomy because of a tubal ectopic pregnancy. A cornuotomy by laparoscopy was performed to resect the cornual ectopic pregnancy. The patient had an uneventful postoperative course, with negativization of human chorionic gonadotropin levels. This type of location is rare and is associated with high rates of maternal morbidity and mortality. It represents a diagnostic and therapeutic challenge for the gynecologist who faces it.

Se define a un embarazo ectópico cuando el blastocisto en desarrollo se implanta fuera de la cavidad uterina. La localización más frecuente es en la trompa, pero también puede ocurrir en el ovario, cérvix, cicatriz de cesárea, cuerno uterino (también mencionado como intersticial en la literatura) o abdominal. Se estima que la incidencia de embarazo ectópico es aproximadamente el 2% de todos los embarazos, siendo la localización cornual solo el 2-4% de esos casos. El objetivo de este reporte es describir el caso de una paciente con sospecha de embarazo ectópico de localización incierta a quien se le realizó una laparoscopia exploradora por inicio de síntomas, evidenciando un embarazo ectópico cornual en el lecho de una salpingectomía, producto de un embarazo ectópico tubario previo. Se realizó la cornuotomía con resección del mismo por laparoscopia y su evolución fue favorable con negativización de la subunidad beta. Este tipo de localización es rara y se asocia con grandes tasas de morbimortalidad materna. Representa un desafío diagnóstico y terapéutico para el ginecólogo que lo enfrenta.

Uso de mifepristona en embarazo ectópico intersticial: un reporte de caso / Use of mifepristone in an interstitial ectopic pregnancy: a case report

Introducción: El embarazo ectópico intersticial es una forma de presentación poco frecuente, con una incidencia del 2-4% de los embarazos ectópicos; sin embargo, a pesar de su baja incidencia la mortalidad es cinco veces mayor, impactando en las cifras de mortalidad materna y representando en torno al 10-15% de los casos. Objetivo: Presentar un caso de embarazo ectópico intersticial, cuya ocurrencia es poco frecuente, así como el abordaje satisfactorio del manejo médico con mifepristona y metotrexato. Caso clínico: Mujer de 28 años con antecedente de resección tubárica por quiste paraovárico derecho, quien acudió a urgencias por hallazgo en ecografía obstétrica de sospecha de embarazo intersticial izquierdo y se le administró manejo farmacológico con dosis de metotrexato y mifepristona, con éxito. Conclusiones: El manejo médico con metotrexato y mifepristona para el embarazo ectópico intersticial parece ser una elección eficaz en los casos con estabilidad hemodinámica y deseo de conservación de la fertilidad.

Background: Interstitial ectopic pregnancy represents a rare form of presentation, with an incidence of 2-4% of all ectopic pregnancies. However, despite its low incidence, it is associated with a five-fold increase in mortality, significantly impacting maternal mortality rates, accounting for approximately 10-15% of cases. Objective: To present a case of interstitial ectopic pregnancy, which is a rare occurrence, as well as the successful medical management approach with mifepristone and methotrexate. Case report: A 28-year-old women with a history of right paraovarian cyst tubal resection presented to the emergency department due to suspected left interstitial pregnancy identified on obstetric ultrasound. The patient was successfully managed with pharmacological treatment using doses of methotrexate and mifepristone. Conclusions: Medical management with methotrexate and mifepristone for interstitial ectopic pregnancy appears to be an effective choice in cases with hemodynamic stability and a desire for fertility preservation.

Interstitial ectopic pregnancy successfully treated with methotrexate.

An ectopic pregnancy (EP) occurs when the fertilised ovum implants outside the endometrial cavity. An EP has an incidence of 1%, with the majority occurring in the fallopian tube. It has a maternal mortality of 0.2 per 1000, with about two-thirds of these deaths associated with substandard care. An interstitial pregnancy occurs when the EP implants in the interstitial part of the fallopian tube. An interstitial ectopic pregnancy (IEP) shows few early clinical symptoms, hence it is associated with serious or fatal bleeding and a mortality rate up to 2.5%. With the advent of transvaginal ultrasound scan (TV USS), correlated with serum beta human chorionic gonadotropin (BHCG) assay, earlier diagnosis of an EP can be established. An EP is often diagnosed in women who are trying to conceive; therefore, the prognosis of future fertility is one of the main concerns associated with this diagnosis. Management can be surgical, expectant or medical with methotrexate (MTX). However, the best approach is tailored to the woman's individual case. The authors present the case of a primigravida woman presenting with abdominal pain and vaginal bleeding at 6 weeks gestation following assisted reproduction. Her BHCG showed a suboptimal rise. Her TV USS showed no evidence of an intrauterine pregnancy. There was no evidence of an adnexal mass or free fluid. As her BHCG remained static, she underwent a diagnostic laparoscopy. A right sided IEP was identified. Due to the high risk of bleeding requiring transfusion or hysterectomy and her desire to preserve her fertility, she received medical management with MTX. Indeed, research has shown that women successfully managed expectantly achieve better reproductive outcomes, with the shortest time to achieve a subsequent intrauterine pregnancy. This case acts as a cautionary reminder of the challenges associated with identifying an IEP on TV USS. A high index of clinical suspicion is required to prevent maternal morbidity and mortality.

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

OBJECTIVE: To describe a conservative laparoscopic treatment of an advanced case of interstitial pregnancy diagnosed in a woman at 14 weeks of gestational age. DESIGN: A video case report with demonstration of diagnostic workup and laparoscopic management of rare subtypes of ectopic pregnancy. SETTING: University tertiary care hospital. PATIENT(S): A 32-year-old nulliparous woman at 14 weeks of gestational age, presented with moderate abdominal pain. She reported a history of irregular periods; however, no risk factor for ectopic pregnancy was identified. The human chorionic gonadotropin level was 7,345 mIU/mL. Transvaginal ultrasound revealed an empty uterine cavity and a complex heterogeneous mass of 6 cm on the left cornual region. The myometrial thickness surrounding the gestational sac was 4 mm. INTERVENTION(S): 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 the first cornuostomy attempt, we had to perform a cornual resection to achieve complete removal of the ectopic mass. Multilayer uterine sutures and anatomical restoration to prevent adhesion were 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. MAIN OUTCOME MEASURE(S): Description of laparoscopic management of huge interstitial pregnancy. RESULT(S): The overall operation time was 55 minutes, and the estimated blood loss was 55 mL. A successfully conservative treatment was achieved with no short-term complications. Postoperative ultrasound showed a normal uterus, and complete regression of human chorionic gonadotropin level was achieved 2 weeks after surgery. CONCLUSION(S): 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. Despite the dimension of the lesion, in our case, the tube was still intact and the patient was in a stable clinical condition. Although cornuostomy is a more conservative solution, in these cases, cornual resection should be preferred. Through the accomplishment of reproducible key steps, laparoscopic removal of interstitial pregnancy is a feasible method and can be proposed even for advanced cases of interstitial pregnancies.

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

OBJECTIVE: To perform laparoscopic salpingectomy, including the entire interstitial portion of the fallopian tube, in the management of interstitial pregnancy. DESIGN: A step-by-step explanation of the surgical procedure using video with narration. SETTING: Obstetrics and Gynecology department of a hospital. PATIENT(S): 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. INTERVENTION(S): 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. MAIN OUTCOME MEASURE(S): 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. RESULTS(S): 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. CONCLUSION(S): 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.

Multidisciplinary approach to the surgical management of interstitial ectopic pregnancy.

OBJECTIVE: 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. DESIGN: Case report. SETTING: Academic medical center. PATIENT(S): 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. INTERVENTION: 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. MAIN OUTCOME MEASURES: We present a surgical approach to suspected interstitial ectopic pregnancy that is not well-visualized at the time of laparoscopy. RESULTS: 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. CONCLUSION: 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.

Exophytic interstitial ectopic pregnancy removal: novel use of Endoloop for uterine cavity preservation.

OBJECTIVE: To demonstrate the unique use of Endoloop during laparoscopic removal of an exophytic interstitial ectopic pregnancy to ensure hemostasis, provide counter traction against a uterine manipulator, and reduce the likelihood of entry into the endometrium. DESIGN: Case report with intraoperative surgical footage. SETTING: Tertiary care referral center operating room. PATIENT(S): Single patient case report. INTERVENTION(S): A single patient with an ectopic pregnancy suspected using ultrasound and confirmed during surgery. MAIN OUTCOME MEASURE(S): Laparoscopic removal of the interstitial ectopic pregnancy via a wedge resection cornuectomy without endometrial involvement using a monopolar hook, Endoloop, and a William's cystoscopic needle for the injection of vasopressin. RESULT(S): The patient was a 32-year-old G7P1051 with a history of a left tubal ectopic pregnancy status post a laparoscopic left salpingectomy, 1 full-term vaginal delivery, 2 elective terminations, 2 early pregnancy losses, smoking (1 pack per day), and marijuana use (6 blunts per day). She initially presented in November 2020 with intermittent but worsening left lower quadrant abdominal pain and was found to have a left adnexal mass, raising concern for an ectopic pregnancy in the setting of a ß-human chorionic gonadotropin (ß-hCG) level of 6,411 mIU/mL, and no intrauterine pregnancy identified using transvaginal ultrasound. She was counseled on medical vs. surgical management and she elected to receive an injection of methotrexate in the emergency department (ED) before discharge with a scheduled follow-up visit at the clinic for standard ß-hCG trends. The patient did not attend her scheduled day 4 and 7 visits for ß-hCG levels or her 2-week appointment for ultrasound; so, she was called over the phone and asked to come to the ED as soon as possible for evaluation. Approximately 3 weeks after the injection of methotrexate, the patient was still experiencing intermittent left lower quadrant abdominal pain. A repeat ultrasound in the ED showed no intrauterine gestational sac, an endometrial thickness of 0.6 cm, a normal right ovary, a normal left ovary with a corpus luteum cyst, a small amount of free fluid in the cul-de-sac, and a left adnexal extraovarian complex cystic structure measuring 2.9 × 2.4 cm with a fetal pole. The fetal pole corresponded with a gestation period of 6 weeks and 3 days, based on a crown-rump length of 0.59 cm, and lacked cardiac activity. The ß-hCG level at this time was 1,124 mIU/mL, and the patient strongly desired surgical management for her ongoing abdominal pain and unresolved ectopic pregnancy. The patient's vital signs and complete blood count were within normal limits. The patient desired future fertility. A repeat transvaginal ultrasound before surgery showed the extraovarian nature of the ectopic pregnancy but could not specify whether it was intrauterine or intra-abdominal in the left adnexa; so, the decision was made to proceed with a diagnostic laparoscopy. After laparoscopic entry through Palmer's point using the Veress needle and then insertion of a 5-mm trocar under direct visualization, the left exophytic interstitial ectopic pregnancy was discovered, as depicted in the video. Given the patient's desire for future fertility, a wedge resection cornuectomy without the involvement of the endometrium was the ideal surgical approach. Subsequent trocar placement consisted of a 10-mm trocar in the umbilicus and a 5-mm trocar in the left lower quadrant. The Endoloop was initially inserted into the umbilical 10-mm trocar to allow for placement around the interstitial ectopic pregnancy to achieve hemostasis and act as a tourniquet. The Endoloop suture was passed into the abdomen and then pulled laterally using an atraumatic grasper through the left lower quadrant trocar to provide counter traction against a uterine manipulator that was deviating the uterus to the patient's right side. This created an excellent plane for dissection along the myometrial base of the interstitial pregnancy to prevent the removal of excess uterine tissue and decrease the likelihood of entry into the endometrial cavity. Injection of 4 units vasopressin (20u in 50 mL of normal saline) using a William's cystoscopy catheter through the umbilical port further ensured hemostasis along the base of the ectopic pregnancy during removal using a monopolar hook. The cystoscopy catheter was chosen for its length and flexible body to maximize maneuverability. Electrocautery was used as needed for hemostasis. After the removal of the ectopic pregnancy using the monopolar hook, the myometrium and serosa were reapproximated in a running 2-layered fashion using a V-Loc suture. The ectopic pregnancy was removed from the abdomen in a specimen retrieval bag through the 10-mm umbilical port. The 10-mm port was closed using a standard fascial closure device and then the skin of all the port sites was reapproximated using 4-0 Monocryl suture. Two important factors that favored this surgical technique over hysterectomy or standard cornuectomy included the patient's strong desire for future fertility and the exophytic nature of the interstitial pregnancy. Nevertheless, as the pregnancy increases in distance from the cornua, so does the likelihood that the pregnancy will be a normal intrauterine pregnancy, which greatly impacts counseling and management if the pregnancy is desired. Postoperative care was routine and the recommendation was made to wait at least 3 months to attempt another pregnancy and to undergo saline-infused sonography for the evaluation of the endometrial cavity; however, the patient never followed up. CONCLUSION(S): This video demonstrates the unique use of Endoloop and vasopressin through a William's cystoscopy injection needle during the laparoscopic removal of an exophytic interstitial ectopic pregnancy. The Endoloop helped to ensure hemostasis, provide counter traction against the uterine manipulator, and optimize visualization to reduce the likelihood of endometrial involvement in a patient who desired future fertility.

Laparoscopically assisted hysteroscopic removal of an interstitial pregnancy.

OBJECTIVE: To illustrate a combined technique of hysteroscopy and laparoscopy for the management of interstitial ectopic pregnancies. DESIGN: A description of a patient case and demonstration of a surgical technique. SETTING: Tertiary referral center. PATIENT(S): A 33-year-old woman, gravida 2, para 0-0-1-0 status post in vitro 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 in vitro 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. INTERVENTION(S): 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. MAIN OUTCOME MEASURE(S): This technique resulted in minimal blood loss, preservation of reproductive organs, and expedient return to conception planning. RESULT(S): 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. CONCLUSION(S): 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.

Angular and Interstitial Ectopic Pregnancies: A Clarification of Terms and Literature Review.

Angular pregnancy is an exceedingly rare diagnosis, with less than 100 reported cases. Angular pregnancy is important to distinguish from ectopic pregnancies due to the fact that they have the potential to be viable while true ectopic pregnancies do not. As such, angular pregnancy requires starkly different management. Inappropriate use of the terms angular, interstitial, and cornual indicates a general misunderstanding of what makes these diagnoses unique. Misunderstanding leads to misdiagnosis and consequent mismanagement. Our experience with cases of women with angular and interstitial ectopic pregnancies is instructive as it illustrates effective diagnosis and differing management of these two diagnoses. In the two angular pregnancy cases, transvaginal ultrasonography was employed to confirm the diagnosis, which showed a lack of the interstitial line sign, contiguity of the decidua and endometrium, and an endomyometrial mantle thickness between 5 and 8 mm. One patient's angular pregnancy ultimately ruptured and was successfully managed with fully robotic cornual resection and unilateral salpingectomy, while the other progressed to term normally without complication. The patient with an interstitial ectopic pregnancy was also managed surgically, although with laparoscopic cornuotomy and salpingectomy.

Heterotopic Interstitial Pregnancy: Early Ultrasound Diagnosis of 179 Cases After In Vitro Fertilization-Embryo Transfer.

OBJECTIVES: What is the role of transvaginal sonography (TVS) in the early diagnosis of hectopic interstitial pregnancy (HIP) after in vitro fertilization-embryo transfer (IVF-ET)? METHODS: A retrospective observational study was conducted from January 2005 to December 2018. Routine two-dimensional and three-dimensional TVS were used to confirm clinical pregnancy. Women were diagnosed with HIP when an intrauterine gestational sac was combined with an extrauterine chorionic sac, which was at least 1 cm away from the uterine cavity and surrounded by a thin myometrial layer (<5 mm). Surgery and pathology results were the gold standard for diagnosing interstitial pregnancy. Non-surgical patients were excluded from the study. The performance of TVS and the pregnancy outcomes of intrauterine pregnancies (IUPs) were evaluated. RESULTS: A total of 97,161 women underwent IVF treatment and TVS examinations in our hospital during this study. Of these, 194 patients were diagnosed with HIP, with an incidence of 0.2% (194/97,161). Surgical and pathological findings confirmed 179 interstitial pregnancies, of which 174 were diagnosed by TVS, 4 were missed, and 1 was misdiagnosed. The sensitivity of TVS diagnosis was 97.8% and the positive predictive value was 99.4%. The mean time to diagnosis was 31 days after transplantation. One hundred and thirty-nine cases of HIP (77.7%) were diagnosed at the time of initial TVS examination. In 132 patients (73.7%), IUPs resulted in live births. CONCLUSIONS: In our practice, most HIPs following IVF-ET can be accurately diagnosed by TVS, which facilitates early management of interstitial pregnancies and enables high live birth rates for IUPs.

Interstitial pregnancy.

OBJECTIVE: A case report of a patient with interstitial pregnancy and a history of hyperprolactinemia. CASE REPORT: 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. CONCLUSION: 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.

Laparoscopic myomectomy to facilitate laparoscopic resection of a bleeding interstitial ectopic pregnancy.

Interstitial pregnancies present a diagnostic and management challenge and are associated with significant bleeding risk. We present a case of an interstitial ectopic pregnancy where there was a diagnostic delay due to the presence of uterine fibroids and where a laparoscopic myomectomy was required in order to perform laparoscopic resection of the ruptured interstitial pregnancy.This case demonstrates the possibilities at laparoscopy for ectopic pregnancy, highlights the benefit of a structured 'buddy' system between gynaecology surgeons and brings attention to the paucity of literature on the unique management challenges of ectopic pregnancy in the presence of leiomyoma.

Hysteroscopy-assisted laparoscopic salpingectomy for interstitial pregnancy without cornual resection.

OBJECTIVE: To illustrate a novel surgical management technique for interstitial ectopic pregnancies (IP). DESIGN: Video description of the case, demonstration of the surgical technique, reevaluation at the 6-week postoperative follow-up, and review of the advantages of this surgical technique for IP. SETTING: Tertiary referral center. PATIENT(S): A 42-year-old gravida 2 para 1-0-0-1, underwent a successful in vitro fertilization (IVF) cycle with a single embryo transfer and had an early ultrasound diagnosis of IP with cardiac activity. After failed medical management with a single dose of methotrexate, she was referred to us for surgical management. Transvaginal ultrasound revealed fluid in the cul-de-sac and confirmed a right interstitial ectopic pregnancy with an estimated gestational age of 6 weeks. The myometrium at the periphery of the implantation site was 1-1.5 mm, and the "interstitial line sign" was seen. After counseling for possible treatment modalities, the patient opted for surgical management, planning for further IVF treatment. Her preoperative ß-human chorionic gonadotropin level (ß-hCG) was 3241 IU/L. Her surgical history was significant for a previous myomectomy via laparotomy and an elective lower transverse C-section. INTERVENTION(S): Hysteroscopy assisted by multipuncture video laparoscopy surgery was performed. Hysteroscopic resection was not feasible as the ectopic was not visualized as described previously. Using normal saline as the distension media and with the hysteroscope aimed at the right ostium, the hydrostatic pressure was increased transiently to dissect the ectopic pregnancy and facilitate the next surgical step. Laparoscopically, the ectopic pregnancy was milked with atraumatic graspers and mobilized from the cornua into the tube creating enough proximal length for salpingectomy. Right salpingectomy was achieved using high-frequency bipolar with no complications. MAIN OUTCOME MEASURE(S): Hysteroscopy-assisted laparoscopy technique allows for several advantages, including a short operative time and minimal blood loss. No sutures were required and the myometrial architecture was left undisrupted. RESULT(S): The postoperative course was uncomplicated, and the patient was discharged on the same day of surgery. The patient's ß-hCG level dropped from 3,241 to 139 IU/L after 48 hours. Two weeks later, the ß-hCG level was 3 IU/L. A follow-up ultrasound was performed six weeks postoperatively confirming the integrity of the myometrium without defects and proportional wall thickness on both sides. The patient was referred back to her infertility specialist to resume IVF treatment with no remarkable delay. CONCLUSION(S): In select cases and the presence of a proficient laparoscopic surgeon, early diagnosed IP can be removed safely using the described novel technique. While an interval conception of 3-6 months is recommended after conventional surgical procedures for IP, this technique can be comparable to salpingectomy.

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

OBJECTIVE: To present a confident tool for the diagnosis of interstitial ectopic pregnancy. 3-Dimensional US helps to reach a more proper diagnosis and enables to arrange therapeutic and surgical strategies. CASE REPORT: A 36-year-old, gravida 4 para 2, woman was referred from the local medical department in the suspicion of ectopic pregnancy. Transabdominal ultrasound revealed an empty uterine cavity but an 8-week-old gestational sac located eccentrically on the right side of the uterine fundus. The Three-dimensional sonography (3D US) demonstrated a gestational sac (GS) over the right cornual region separated from the endometrial cavity. Interstitial pregnancy was impressed. Laparoscopic surgery was then arranged. After entering the pelvic cavity, a bulging mass was found over the utero-tubal junction, compatible with interstitial pregnancy. The wedge resection of interstitial ectopic pregnancy and right salpingectomy were undertaken. The patient was discharged within 2 days after the surgery. CONCLUSION: The conventional sonography still remained the primary tool to diagnose the ectopic pregnancy, but 3D US played an indispensable role in demonstrating the precise location of GS. Interstitial ectopic pregnancy was symptomatically late in gestation and rupture of an interstitial pregnancy causes catastrophic consequence due to massive bleeding, so prompt and accurate diagnosis was definitely life-saving. Appropriate therapy or surgical intervention could be arranged.

O papel da ressonância magnética na distinção das gestações intersticial, cornual e angular / The role of magnetic resonance imaging in distinguishing interstitial, cornual and angular pregnancies

Apesar da melhora no diagnóstico e tratamento, a gravidez ectópica ainda é a principal causa de mortalidade materna no primeiro trimestre da gravidez. Formas raras podem apresentar um desafio diagnóstico e, sem um diagnóstico adequado, a incidência de complicações e a mortalidade materna estão relacionadas a aumento de seus índices. Os termos "gravidez cornual" e "gravidez intersticial" têm sido utilizados de forma inconsistente na literatura, sendo frequentemente usados como sinônimos do termo "gravidez angular". Uma distinção estrita entre essas entidades pode ter implicações clínicas importantes, porque o curso natural, a propedêutica e os resultados diferem entre eles. A ressonância magnética não é o padrão-ouro para o diagnóstico de gravidez ectópica, no entanto possui relevância significativa no diagnóstico de possíveis complicações decorrentes dessa afecção. Nesse contexto, esta revisão aborda a importância da ressonância magnética na distinção dos tipos de gravidez mencionados, ilustrados por meio de casos do nosso serviço.(AU)

Despite the improvement in diagnostics and treatment, ectopic pregnancies are still the main cause of maternal mortality in the first trimester of pregnancy. Rare forms may present a diagnostic challenge and without adequate diagnosis, the incidence of complications and maternal mortality is greatly increased. The terms "cornual pregnancy" and "interstitial pregnancy" have been used inconsistently in the literature, frequently been used as synonyms and even used interchangeably with the term "angular pregnancy". A strict distinction among these entities can have important clinical implications because the natural course, management and outcomes differ among them. Magnetic resonance imaging is not the gold standard for the diagnosis of ectopic pregnancy, however, it can be useful in the diagnosis of complicated presentations of such ailment. In this context, this review highlights the importance of MRI in distinguishing the aforementioned types of pregnancies, illustrated with few cases from our service.(AU)

Combination methotrexate and gefitinib: A potential medical treatment for inoperable nontubal ectopic pregnancy.

Nontubal ectopic pregnancies present as a therapeutic challenge. A 35-year-old primigravida at 7 weeks gestation had a live interstitial ectopic pregnancy and contraindications to surgery. The patient was treated with a multidose methotrexate regimen combined with oral gefitinib (250 mg daily for 7 days). The peak human chorionic gonadotropin (hCG) of the patient was recorded at 19 510 IU/L and began declining from day 4 of combination therapy (day 6 of initial treatment). Successful resolution of the ectopic was demonstrated by cessation of the fetal heart by day 15 and hCG falling to 23 IU/L by day 42. A 10-year review of all nontubal ectopic pregnancies treated with methotrexate identified 46 cases, which had a comparable time to resolution to combination therapy. However, for cases where cardiac activity was present, the median time to resolution following methotrexate treatment was 64 days (47-87 days), 22 days longer than combination therapy. Combination therapy may provide a safe medical treatment for inoperable nontubal ectopic pregnancy.

Distinguishing between interstitial and angular pregnancies: Is there a role for saline infusion sonohysterography?

OBJECTIVE: Interstitial pregnancy occurs in the intramural segment of the Fallopian tubes, while angular pregnancy is one that is located in one of the lateral angles of the uterine cavity. The differential diagnosis and treatment of these conditions are important. We have used saline infusion sonohysterography (SIS) to help in differential diagnosis. CASE REPORT: A 36-year-old female with a case of suspected left interstitial ectopic pregnancy was admitted. Her diagnostic laparoscopy showed no tubal ectopic pregnancy, and D&C demonstrated no villi. She underwent SIS which showed a sac in the interstitial part but close to the tubal ostium. The second case involves a 21-year-old female who was 9-weeks pregnant. Ultrasonography could not differentiate between interstitial and angular pregnancy. SIS clearly demonstrated angular pregnancy with a missed abortion, and therapeutic D&C was done smoothly. CONCLUSION: From reviewing past literature, SIS does not appear to have any proven adverse effect on the pregnancy although it is not widely accepted. This article highlights the benefits of using SIS to aid in the differential diagnosis between the two conditions, especially in unusual cases like ours.