The role of three-dimensional MRI in the differentiation between angular pregnancy and interstitial pregnancy.

BACKGROUND: In clinical practice it is an ongoing challenge to distinguish between angular pregnancy and interstitial pregnancy. With the three-dimensional (3D) magnetic resonance imaging (MRI) being increasingly used, it is worth exploring its role in differentiating angular pregnancy from interstitial pregnancy. This study aims to investigate how 3D MRI can help reveal the differences between these two special pregnancies in the early diagnosis. METHODS: We reviewed and analyzed the 3D MRI images of 50 patients with interstitial pregnancy and 55 patients with angular pregnancy retrospectively. Imaging features were identified to compare these two special pregnancies, and the ROC (Receiver Operating Characteristic) analysis was conducted to assess the diagnostic performance. RESULTS: The significant differences of the 3D MRI imaging features between interstitial pregnancy and angular pregnancy were found in the outline of uterus cavity (p < 0.001), involvement of junctional zone (p < 0.001), the signal of surroundings (p = 0.005), the relationship with round ligament (p = 0.042), and the overlying myometrial thickness (p = 0.041). Furthermore, the multivariate logistic regression analysis identified a series of significant indicators for angular pregnancy, including the junctional zone involvement, being-surrounded by hyper/iso-intensity on 3D images, and the asymmetric outline of uterus cavity. Combining these three imaging features, the AUC (Area under the Curve) of ROC curve was 0.87 in distinguishing interstitial pregnancy from angular pregnancy. CONCLUSIONS: This study suggests that 3D MRI can help distinguish angular pregnancy from interstitial pregnancy in clinical practice, with the advantages that conventional MRI or ultrasound does not have. Through the significant image features, 3D MRI plays an important role in improving the timing of diagnosis, avoiding unnecessary interventions, and preventing hemorrhage in clinical practice.

The elusive diagnosis and emergent management of a late-presenting ruptured interstitial pregnancy: a case report.

BACKGROUND: Interstitial pregnancies are rare and often difficult to diagnose given their proximal position to the uterine cavity, however most are identified by 12 weeks gestation. Delayed or missed diagnosis contributes to heightened incidence of poor outcomes including hemorrhage and death. CASE PRESENTATION: A 35-year-old woman at 15 weeks gestation with confirmed intrauterine pregnancy on first trimester ultrasound and prior negative MRI presented in hemorrhagic shock and was found to have a ruptured interstitial pregnancy. Exploratory laparotomy revealed the fetus to be in the abdomen as well as a large cornual defect and abnormal placentation that resulted in supracervical hysterectomy. CONCLUSIONS: Interstitial pregnancy should be considered in a patient presenting with symptoms consistent with ectopic rupture, especially in the setting of equivocal or suboptimal prior imaging. Earlier diagnosis may allow for fertility-sparing intervention and decreased risk of morbidity and mortality.

Diagnosis pitfall of interstitial pregnancy: a case report of a term pregnancy with abnormal placentation.

BACKGROUND: Interstitial Pregnancy (IP) is a lethal condition due to high risk of sudden onset massive hemorrhage. Such conditions are managed as soon as diagnosed almost in the first trimester. There are a few case reports of IP conditions terminated after the second trimester. Herein, we introduce a term interstitial pregnancy complicated by abnormal placentation. CASE PRESENTATION: In this case report, we introduce a 32-year-old lady, primigravida, with an undiagnosed IP that was in her 38 weeks of gestational with placenta increta. She developed with perforated IP presenting with acute abdomen and internal bleeding at 26 weeks of gestational age. However, with a misdiagnosis impression, she got stable in operation room. Then, the pregnancy continued till 36 weeks of gestational age that was misdiagnosed with cervical cancer in prenatal work-ups. Finally, during elective cesarean section at 38 weeks, an IP with placenta increta (placenta evading from the serosa to the myometrium of the uterus) was observed. The baby was healthy with no obvious anomaly or morbidity. CONCLUSIONS: Physicians should be aware to detect IP in all trimesters and pay attention to the coexisting complications such as placenta accreta to manage them more accurately.

Nonsurgical Management of Interstitial Pregnancies: Feasibility and Predictors of Treatment Failure.

STUDY OBJECTIVES: To describe the management of interstitial pregnancies in a tertiary medical center, identify factors associated with treatment failure, and report subsequent pregnancy outcome. DESIGN: Retrospective cohort study. SETTING: Department of Gynecology in a tertiary medical center. PATIENTS: All women who were admitted to and treated for interstitial pregnancy at our center between 2011 and 2019. INTERVENTIONS: The women were originally assigned to undergo expectant, medical, or surgical treatment. The women's background and clinical data were compared according to initial treatment modality. Nonsurgical (expectant and medical) management outcomes were analyzed to identify risk factors for treatment failure. Subsequent pregnancy outcomes were described separately. MEASUREMENT AND MAIN RESULTS: Thirty-seven cases of interstitial pregnancy were identified. There were high rates of pregnancy achieved by in vitro fertilization (45.9%) and a history of ipsilateral salpingectomy (43.2%) among these patients. At presentation, the mean age of the study cohort was 34.76 years, and the median ß-human chorionic gonadotropin level was 3853.0, and median gestational age was 7.0, respectively. The nonsurgical management success rate was 70.0%. Uterine rupture occurred during treatment in 5 cases (16.6%). Gestational sac diameter significantly affected treatment failure (p = .03), and a diameter >20 mm was observed in all cases of failed non-surgical treatment. Data on future fertility was available for 21 (58.3%) women: 13 (61.9%) had a subsequent pregnancy, 1 of which was a recurrent interstitial pregnancy. The median interpregnancy interval was 8.1 months, and all but 3 pregnancies reached third trimester and resulted in a live birth, with an overall cesarean delivery rate of 61.5%. None of the subsequent pregnancies were complicated by uterine rupture, and no serious adverse outcomes were noted in any of the subsequent intrauterine pregnancies that reached third trimester. CONCLUSION: Successful nonsurgical management of an interstitial pregnancy is feasible, although appropriate selection of cases is advised. A large gestational sac is a risk factor for treatment failure and should prompt surgical intervention. Subsequent pregnancies can generally be considered safe and with a favorable outcome.

Challenges in diagnosis and management of an interstitial ectopic pregnancy.

Presentation A 44 year old, grandmultiparous woman was reviewed in the early pregnancy clinic for a history indicated early reassurance ultrasound. Diagnosis Early pregnancy ultrasound findings were suggestive of a tubal ectopic pregnancy. A diagnostic laparoscopy and uterine curettage were both negative. A subsequent transvaginal ultrasound confirmed a non-viable interstitial ectopic pregnancy. Treatment Conservative management was employed as she remained haemodynamically stable with reducing serum ßhCG. Following ten weeks, her serum ßhCG normalised and she was discharged. Discussion IEP poses diagnostic and management complexities. Delayed diagnosis leads to elevated risks. Management options include surgical (laparotomy, uterine wedge resection) and non-surgical approaches (medical and conservative). Earlier diagnosis of smaller, stable cases facilitates medical management, while non-viable cases can be conservatively managed. This case emphasizes the importance of prompt recognition and tailored interventions to enhance patient outcomes.

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.

[Life-threatening extrauterine pregnancy after in vitro fertilization and bilateral salpingectomy]. / Livstruende ekstrauterin hjørnegraviditet efter in vitro-fertilisation og bilateral salpingektomi.

A woman with a history of bilateral salpingectomy achieved pregnancy after in vitro fertilization. At the gestational age of six weeks she experienced fatigue, haematemesis and abdominal pain. She was hospitalized on suspicion of a peptic ulcer. Several physicians rejected the possibility of an ectopic pregnancy due to the history of salpingectomy. The patient had intraabdominal bleeding and went through emergency surgery because of a ruptured interstitial pregnancy. The purpose of this case report is to recall the risk of interstitial pregnancy in pregnant women with a history of salpingectomy.

[Interstitial pregnancy: experience at Rouen's hospital]. / Grossesses interstitielles : traitement chirurgical, fertilité et devenir obstétrical. L'expérience rouennaise.

OBJECTIVE: Presenting our experience concerning interstitial pregnancies (IP) surgical management and to evaluate our patients' subsequent long-term fertility. PATIENTS AND METHOD: Twenty patients underwent surgical treatment of IP in our department over 15 years. In this retrospective study, we present symptoms that led to diagnosis, treatments, fertility and obstetrical outcome. RESULTS: Mean gestational age at diagnosis was 8SA, with a median BHCG rate of 7411 IU/L, and a patient mean age of 30 years. Ninety percent of patients had at least one risk factor for ectopic pregnancy. Pain or bleeding were the most common symptoms at admission, 4 patients were admitted in an hypovolemic shock status. Location of the interstitial ectopic pregnancy was discovered during surgery in 45 % of cases. Six patients had a large hemoperitoneum bigger than 1L, 5 patients had an IP of uterine stump after salpingectomy for a previous ectopic pregnancy. The most used surgical technique was in 60 % of cases the excision by Endo GIA stapling(®) with salpingectomy. Regarding fertility, 12 patients wished pregnancy in the aftermath of the intervention, 10 had at least one pregnancy, among them there is an ectopic contralateral ampullary pregnancy, and a contralateral recurrence of interstitial pregnancy. Four patients were delivered by cesarean section and 4 patients were delivered vaginally, some several times. No uterine rupture occured. DISCUSSION AND CONCLUSION: Interstitial pregnancy is a rare ectopic pregnancy. Its diagnosis is difficult and may involve maternal life-threatening and fertility. In subsequent pregnancies, the clinician has to be careful concerning the risks of interstitial pregnancy recurrence and uterine rupture.

Cornual, interstitial, and angular pregnancies: clarifying the terms and a review of the literature.

The terms "cornual," "interstitial," and "angular" pregnancies are used inconsistently in the literature. Some sources use "interstitial" and "cornual" synonymously, while others reserve "cornual" for gestations in bicornuate or septate uteri; others distinguish interstitial from angular pregnancy, while in practice, many physicians are unfamiliar with the latter designation. This article aims to clarify the terms and review the literature with respect to diagnosis and prognosis, with attention to the potential roles of 3D ultrasound and magnetic resonance imaging.

Legrado uterino bajo control ecográfico en embarazo ectópico intersticial / Ultrasound-guided transcervical curettage in interstitial pregnancy

El embarazo intersticial se ha visto incrementado en las últimas décadas como consecuencia del aumento de técnicas de reproducción asistida. A pesar del diagnóstico cada vez más temprano y el desarrollo de tratamientos cada vez más conservadores, presenta una morbilidad y mortalidad importantes. Presentamos 2 casos de embarazo intersticial tratado mediante legrado por aspiración bajo control ecográfico. En ambos, el procedimiento fue rápido, con mínimo sangrado y sin complicaciones. El legrado uterino ecoguiado es una alternativa efectiva y segura como tratamiento del embarazo ectópico intersticial (AU)

Interstitial pregnancy has increased in the last few decades due to greater use of assisted reproductive technology. Despite early diagnosis and the development of increasingly conservative treatment, maternal morbidity and mortality remain high. We report two cases of interstitial pregnancy treated by ultrasound-guided transcervical suction curettage. In both cases, the procedure was quick, bleeding was minimal and there were no complications. Ultrasound-guided transcervical curettage is a safe and effective alternative in interstitial pregnancy (AU)