Considerations for management of interstitial ectopic pregnancies: two case reports

Abstract

BackgroundConventional treatment of interstitial pregnancies includes systemic methotrexate, direct methotrexate injection, wedge resection, or hysterectomy. We present two cases of interstitial pregnancies that were successfully managed by different minimally invasive surgical techniques. We also report the novel use of hysteroscopic urologic stone retrieval forceps in the transvaginal removal of persistent products of conception after systemic methotrexate for an interstitial pregnancy.Case presentationCase 1 was a 28-year-old gravida 1 white woman at 8 weeks gestation; she was diagnosed with a left interstitial pregnancy. After laparoscopic confirmation of the interstitial pregnancy, successful ultrasound-guided suction dilation and curettage was performed. Case 2 was a 33-year-old gravida 3 para 1021 (one term pregnancy, no preterm pregnancies, one ectopic pregnancy and one spontaneous miscarriage, and one living child) Hispanic woman with persistent products of conception after systemic methotrexate for a left interstitial pregnancy. She underwent hysteroscopic-guided removal of the persistent products of conception, which was possible due to novel use of urologic stone retrieval forceps.ConclusionsSuccessful minimally invasive treatment of interstitial pregnancies may be possible in certain cases. Collaboration between different specialties continues to be important for improving minimally invasive options.

Early Diagnosis of Interstitial Pregnancy Associated to Assisted Reproductive Techniques Case Report

“…However, bilateral tubal occlusion is the only risk factor exclusively associated to interstitial pregnancy. Moreover, in patients without bilateral tubal occlusion (BTO), peritubal or intratubal adhesions associated to endometriosis can also be a risk factor [6][7][8][9]. In the present case, the patient suffered from severe endometriosis, history of a previous tubal surgery and underwent assisted reproductive technique.…”

“…However, literature sometimes differentiates between the terms by stating that a cornual pregnancy is found in the endometrium of the cornus of a bicornual/unicornual uterus, or even outside the endometrial cavity, while an interstitial pregnancy is found within the union of the uterus and the proximal portion of the Fallopian tube [6][7][8].…”

“…The interstitial portion of the fallopian tube crosses the uterine muscle wall in a transverse direction, originating from the tubal ostium and traversing upwards and laterally in relation to the uterine cavity, up to the isthmic portion of the fallopian tube where it exits from the uterine fundus. This is a highly irrigated region due to the presence of the uterine-ovarian artery anastomosis [3][4][5][6]. This portion has a diameter of 0.7 mm to 1.2 cm, and despite its narrowness, it has a greater capacity of distension before rupture in comparison to distal portions of the fallopian tube.…”

“…Furthermore, pregnancies in this region can show no symptoms of rupture up to 7 to 16 weeks of gestation and because of this, timely diagnosis and treatment are pivotal in this pathology due to the risk of hemorrhage and hypovolemic shock thanks to the anatomic qualities that provide its rich irrigation [3,4,6]. Diagnosis can be challenging, as it is based on a combination of clinical findings, laboratory tests and imaging studies [4,6]. Recently, assisted-reproduction techniques have increased the prevalence of ectopic pregnancies, which poses a potentially catastrophic impact on maternal death incidence due to the risk of massive haemorrhage.…”

“…This portion has a diameter of 0.7 mm to 1.2 cm, and despite its narrowness, it has a greater capacity of distension before rupture in comparison to distal portions of the fallopian tube. Furthermore, pregnancies in this region can show no symptoms of rupture up to 7 to 16 weeks of gestation and because of this, timely diagnosis and treatment are pivotal in this pathology due to the risk of hemorrhage and hypovolemic shock thanks to the anatomic qualities that provide its rich irrigation [3,4,6]. Diagnosis can be challenging, as it is based on a combination of clinical findings, laboratory tests and imaging studies [4,6].…”