ABSTRACT
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.
Subject(s)
Humans , Female , Pregnancy , Adult , Mifepristone/therapeutic use , Methotrexate/therapeutic use , Pregnancy, Interstitial/drug therapy , Pregnancy, Ectopic , Ultrasonography , Fertility Preservation , Pregnancy, Interstitial/diagnostic imagingABSTRACT
Introducción: El embarazo intersticial es poco frecuente y su mortalidad es superior a otras localizaciones. Su diagnóstico cada vez más precoz, permite escoger tratamientos menos agresivos. La piedra angular, es la hemostasia. Objetivo: Describir los resultados del tratamiento de pacientes atendidas por embarazo ectópico del cuerno. Método: Se realizó un estudio descriptivo en 18 mujeres con embarazo ectópico intersticial, atendidas en el Hospital Militar Central Dr. Luis Díaz Soto del 2010 al 2019. Fueron tratadas mediante laparotomía y sutura circular del cuerno, con posterior resección cornual y extracción del material ovular. Se estudiaron las variables edad, factores de riesgo, tiempo quirúrgico, sangramiento transoperatorio, evolución (complicaciones, recuperación, fracción beta de la gonadotropina coriónica, controles ecográficos posoperatorios) y estadía hospitalaria. Resultados: El 72 por ciento de las pacientes estuvo entre 20 - 25 años, el 61,1 por ciento tuvo antecedentes de abortos provocados, seguido de enfermedad inflamatoria pélvica en el 44,4 por ciento. La media del tiempo quirúrgico fue de 36 minutos. Ninguna paciente tuvo sangramiento en el sitio de la cirugía. La fracción beta de la gonadotropina coriónica, se negativizó a la cuarta semana y los controles ecográficos posoperatorios de todas las pacientes fueron normales el día 15. En todas las pacientes se utilizó la sutura en jareta. Conclusiones: Los resultados en el tratamiento de las pacientes atendidas por embarazo instersticial, fueron favorables, la reparación de la pared uterina se realizó mediante un procedimiento seguro que mostró la aplicabilidad de la sutura en jareta. Se evitaron las pérdidas sanguíneas y complicaciones como la histerectomía(AU)
Introduction: Interstitial pregnancy is rare and its mortality is higher than in other locations. Its increasingly early diagnosis allows the choice of less aggressive treatments. The cornerstone is hemostasis. Objective: To describe the results of the treatment of patients treated for ectopic horn pregnancy. Method: A descriptive study was carried out in 18 women with interstitial ectopic pregnancy, treated at the Hospital Militar Central Dr. Luis Díaz Soto from 2010 to 2019. They were treated by laparotomy and circular suture of the horn, with subsequent cornual resection and extraction of ovular material. The variables age, risk factors, surgical time, intraoperative bleeding, evolution (complications, recovery, beta fraction of chorionic gonadotropin, postoperative ultrasound controls) and hospital stay were studied. Results: 72 percent of the patients were between 20 - 25 years old, 61.1 percent had a history of induced abortions, followed by pelvic inflammatory disease in 44.4 percent. The mean surgical time was 36 minutes. No patient had bleeding at the surgery site. The beta fraction of chorionic gonadotropin was negative at the fourth week and postoperative ultrasound controls of all patients were normal on day 15. The drawstring suture was used in all patients. Conclusions: The results in the treatment of the patients attended for interstitial pregnancy were favorable, the repair of the uterine wall was carried out by means of a safe procedure that showed the applicability of the drawstring suture. Blood loss and complications such as hysterectomy were avoided(AU))
Subject(s)
Humans , Female , Pregnancy , Adult , Pregnancy, Ectopic/surgery , Pregnancy, Interstitial/surgery , Epidemiology, DescriptiveABSTRACT
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)
Subject(s)
Humans , Female , Pregnancy , Pregnancy, Ectopic/diagnostic imaging , Magnetic Resonance Spectroscopy , Pregnancy, Angular/diagnostic imaging , Pregnancy, Cornual/diagnostic imaging , Pregnancy, Interstitial/diagnostic imagingABSTRACT
RESUMEN Antecedentes: El embarazo intersticial es muy inusual y representa <2,4% de todos las gestaciones ectópicas. Objetivo: Se presenta el caso de un embarazo ectópico intersticial tratado de forma médica y quirúrgica. Se realiza una revisión literaria sobre las opciones de manejo y tratamiento. Caso clínico: Paciente primigesta de 36 años con gestación ectópica cornual derecha tras 11 días de la transferencia de un embrión criopreservado. Se decide tratamiento con metotrexato (MTX) sin éxito y con progresión del embarazo, obligándonos por lo tanto a realizar una evacuación quirúrgica de la gestación, exponiendo a la paciente tanto a los efectos secundarios del tratamiento médico como a los del abordaje quirúrgico. Conclusión: El embarazo ectópico intersticial sigue siendo un reto para el ginecólogo. El diagnóstico muy temprano de estas patologías, aunque difícil, podría evitar la opción quirúrgica, siendo el MTX más eficaz en los casos tratados precozmente.
ABSTRACT Background: Interstitial pregnancy is very unusual, and it represents <2,4% of all ectopic pregnancies. Objective: We present the case of an interstitial ectopic pregnancy treated medically and surgically. A literary review is also made about the management and treatment options. Clinical case: A 36-year-old patient with a diagnosis of right cornual ectopic pregnancy after 11 days of a cryopreserved embryo's transfer. Methotrexate (MTX) treatment was applied as the initial step but without lasting results. Because of the progression of the pregnancy, further therapy was focused on its surgical evacuation exposing the patient to the side effects of both medical treatment and surgical approach. Conclusion: Interstitial ectopic pregnancy remains a challenge for the gynecologist. Very early diagnosis of these pathologies, although difficult, could avoid the surgical outcome, being MTX more effective in cases intervened initially.
Subject(s)
Humans , Female , Pregnancy , Adult , Methotrexate/therapeutic use , Pregnancy, Interstitial/surgery , Pregnancy, Interstitial/drug therapy , Laparoscopy , Pregnancy, CornualABSTRACT
OBJECTIVE: To examine the therapeutic outcomes of methotrexate (MTX) in the treatment of unruptured interstitial pregnancy. METHODS: We 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. RESULTS: Ninety-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. CONCLUSION: Combined MTX treatment including a local injection might be an initial approach to the treatment of interstitial pregnancy.
Subject(s)
Female , Humans , Pregnancy , Diagnosis , Gestational Sac , Live Birth , Medical Records , Methotrexate , Pregnancy Complications , Pregnancy Outcome , Pregnancy, InterstitialABSTRACT
El embarazo ectópico intersticial es una entidad rara pero con una elevada tasa de mortalidad. El diagnóstico puede resultar difícil y tardío, dada la localización del embarazo en una porción intrauterina de la trompa de Falopio. La gestación puede evolucionar de manera asintomática hasta el segundo trimestre de la gestación, y debutar con una rotura uterina y shock hipovolémico por la proximidad del saco gestacional a la arteria uterina. El tratamiento suele consistir en una resección cornual por vía laparoscópica, aunque se individualizará en función de cada caso, primando ante todo la clínica de la paciente. Se expone el caso de un embarazo ectópico intersticial que debutó con rotura uterina a las 13 semanas de gestación.
Interstitial ectopic pregnancy is a rare but with a high mortality rate entity. Diagnosis can be difficult and late, given the location of the pregnancy in an intrauterine portion of the fallopian tube. Pregnancy can evolve asymptomatic until the second trimester, and debuting with uterine rupture and hypovolemic shock due to the proximity of the gestational sac to the uterine artery. Treatment usually consists of a laparoscopic cornual resection, although it will be individualized according to each case, giving priority to the patient clinic condition. The case of an interstitial ectopic pregnancy who presented with uterine rupture at 13 weeks of gestation is presented.
Subject(s)
Humans , Female , Adult , Uterine Rupture/etiology , Pregnancy, Interstitial/surgery , Pregnancy, Interstitial/diagnostic imaging , Pregnancy Trimester, First , Shock/etiology , Ultrasonography , Laparoscopy , Stillbirth , Abdomen, Acute/etiologyABSTRACT
Interstitial pregnancy is a form of ectopic pregnancy in an unusual location, implanting on the intramural part of the fallopian tube. Because the myometrium is highly distensible, it may allow an interstitial pregnancy to advance up to 16 weeks where it usually presents with rupture. Its late diagnosis and severe hemorrhagic complication accounts for a higher mortality rate compared to other ectopics. On the other hand, interstitial pregnancies that progress to term or near term are extremely rare. From the 10 cases published in literature reporting the delivery of a live term or near term fetus, only 1 of these cases has antenatally diagnosed the presence of interstitial pregnancy prior to rupture by investigating a probable placenta accreta found on ultrasound. This report discusses a case of a ruptured full term interstitial pregnancy diagnosed intraoperatively which resulted to a live mother and baby, and describes retrospectively the similar ultrasound findings of placenta accreta which was realized after rupture.
Subject(s)
Humans , Female , Adult , Pregnancy , Pregnancy, Interstitial , Fallopian Tubes , Placenta Accreta , Myometrium , Mothers , Delayed Diagnosis , Term Birth , FetusABSTRACT
Ectopic pregnancies are unsuccessful pregnancies that result from implantation of fertilized ovum occurring inan aberrant area. Aside from an emergency case, the early diagnosis of ectopic pregnancy is very difficultparticularly in a case with insidious onset and mild clinical manifestations. Early diagnosis not only reduces thedanger, but also simplifies the management of ectopic pregnancy. Ultrasonography has been an indispensablediagnostic tool in obstetrics and Gynecology. In the authors' experience, clinical suspected ectopic pregnancy wasone of the common indications for performing ultrasonography. Since Kobayashi et al. reported the appearances ofextopic preganancy utilizing bistable B-scan ultrasonography, the ultrasonic findings of ectopic pregnancy havebeen reported by many authors. But, its accuracy and reliablity in the diagnosis of ectopic pregancy are stillopen to controversy. The authors studied 65 cases of clinically suspected ectopic pregnancy with Picker 80 L grayscale ultrasonography from Aug. 1982 to Jun. 1983. There were 29 confirmed cases, of which 15 were proved to haveextopic pregnancy and 14 were proved to have disease other than ectopic pregnancy by surgical andhistopathological study or by laparoscopy and histopatholoigcal study or by laparoscopy and follow up study. 29confirmed cases were reviewed. The resuls were as follows; 1. Among 15 ectopic pregnancies, there were 12ampullary pregnancies, 2 isthmic pregnancies and 1 interstitial pregancy. Among 14 cases of no ectopic pregnancy,there were 5 intrauterine pregnancies, 3 myoma uteri, 2 P.I.D., and 1 case of dermoid cyst, cystic teratoma,h-mole and tubal hematoma due to previous tubal ligation, respectively. 2. The age distribution of ectopicpregnancy was from 22 to 41 years. The common clinical manifestations of extopic pregnancy were lower abdominalpain (73.3%), vaginal spotting or bleeding (73.3%) and amenorrhea(66.7%). 3. Positive results of urine immunologicpregnancy test was 28.6% in ectopic pregnancy. 4. Ultrasonic findings of ectopic preganncy were as follows; 1) Nointrauterine gestational sac was observed in all cases except 1 interstitial pregnancy. Intrauterine fluidcollection was observed in 3 cases. Uterine displacement was observed in 10 cases. 2) Among 5 cases of rupturedtubal pregnancy, we observed predominantly cystic adnexal mass in 3 cases, mixed echogenic adnexal mass in 2cases, and cul-de-sac fluid in all cases. Among 9 cases of unruptured tubal pregnancy, we observed predominantlycystic adnexal mass in 2 cases, mixed echogenic adnexal mass in 7 cases, and cul-de- sac fluid in 3 cases. 3) Anechodense ring like structure was observed outside the uterus in 9 cases of tubal pregnancy. 4) In the case ofinterstitial pregnancy, eccentrically located gestational sac with overlying thin myometrium was observed withinthe uterus. 5) Fetal heart activity was noted outside the uterus with real time scanning in only 1 case of ectoicpregnancy. 5. Of 19 sonographically ectopic pregnancies, a correct positive ultrasonic diagnosis was made n 14cases (73.7%). Of 29 confirmed cases, overall diagnostic accuracy of ultrasound was 79.3%. 6. By demonstrationintrauterine pregnancy or disease other than ectopic pregnancy such as myoma uteri, homole or ovarian cyst,ectopic pregnancy was ultrasonically excluded in 10 cases. Among above 10 cases, 1 case of ultasonically bilateralovarian cyst was proved to have ruptured tubal pregnancy combined with ovarian cyst. The accuracy of ultrasonicexclusion of ectopic pregnancy was 90%. In the authors'experience, ultrasonography was very helpful in theexclusion of extopic pregnancy.