Diagnostic and management dilemmas of pregnancies at the utero-tubal junction: A case series and management algorithm.

OBJECTIVE: A pregnancy at the utero-tubal junction is a rare type of ectopic pregnancy and is associated with high maternal morbidity if it remains undetected. In the present study we discuss four cases of ectopic pregnancies at the utero-tubal junction which caused diagnostic and management dilemmas. METHODS: Four cases of early pregnancies with the gestational sac (G-sac) implanted near the utero-tubal junction are described. In case 1 this was suspected after a failed attempt at dilatation and curettage at our hospital, cases 2 and 3 presented with amenorrhea and pain abdomen and case 4 was diagnosed on first pregnancy documentation scan after frozen embryo transfer. RESULTS: As initial two-dimensional (2D) transvaginal scan (TVS) failed to diagnose the exact location of the G-sac, three-dimensional (3D) TVS helped to localize the exact location of pregnancy and subsequent individualized management. Case 1 had a partial intramural ectopic pregnancy managed by laparotomy and removal of the ectopic sac. The second and third cases were eccentric uterine pregnancies. The fourth was an interstitial ectopic pregnancy managed by a laparoscopic loop and stitch technique. CONCLUSION: This case series describes the role of 3D TVS for the evaluation of pregnancies implanted at the utero-tubal junction and individual management of eccentric intrauterine, interstitial ectopic and intramural ectopic pregnancies. A diagnostic algorithm for such types of cases and management options is discussed.

Angular Pregnancy: A Case Report.

Angular pregnancy, a rare condition, marked by implantation positioned medially to the uterotubal junction within the lateral angle of the endometrial cavity poses a risk of severe complications, such as uterine rupture, placental retention, postpartum hemorrhage, and even necessitating hysterectomy, all of which can be fatal. Distinguishing angular pregnancy from other emergent conditions, particularly interstitial and cornual pregnancies, is crucial due to similar presentations and difference in embryo viability, risk, and management. While angular pregnancies can progress to term, they are associated with an elevated complication rate. Here, we present a case of primigravida with angular pregnancy who opted for evacuation under hysteroscopic guidance subsequent to unsuccessful pregnancy.

Number of embryos transferred could possibly be associated with angular pregnancy in in vitro fertilization-embryo transfer.

OBJECTIVE: The probability of embryo implantation in an abnormal location is significantly higher in assisted reproductive technology (ART) than in natural pregnancies. Angular pregnancy is an eccentric intrauterine pregnancy with embryo implantation in the lateral superior angle of the uterine cavity. Cycle-level factors associated with angular pregnancy in patients conceived with ART needed to be explored. METHODS: A total of 11 336 clinical pregnancies cycles were included. Angular pregnancy rate was compared among groups according to the type of embryos transferred. Among them, 53 cases of angular pregnancy and 159 cases of normal intrauterine pregnancy were screened out using propensity score matching. Risk factors of angular pregnancy were explored. RESULTS: The angular pregnancy rate was 0.31% (14/4572) in the day 5 blastocyst transfer group, 0.58% (39/6764) in non-day 5 embryo transfer group, with 0.55% (29/5280) in day 3 embryo transfer and 0.67% (10/1484) in the day 6 blastocyst group, respectively. A multifactor regression analysis was performed and indicated that the number of embryos transferred was significantly associated with angular pregnancy (P = 0.031, OR, 2.23, 95% CI: 1.09-4.68). CONCLUSION: Multiple embryo transfer could possibly be associated with an increased incidence of angular pregnancy in patients conceived with ART.

Surgical Conservative Management of a Retained Placenta after Angular Pregnancy, a Case Report and Literature Review.

Angular pregnancies are rare and difficult to diagnose. Evidence suggests they are associated with a higher risk of intrauterine growth restriction and abnormal third stage of labor due to a retained placenta. The lack of standardized AP diagnostic criteria impacts on their correct identification and makes the treatment of potential complications challenging. We present a case of the successful conservative surgical management of a retained placenta after a term AP also complicated by intrauterine growth restriction. Moreover, to identify the best evidence regarding AP diagnostic criteria and retained placenta therapeutic approaches, we have realized an expert literature review.

Ipsilateral Right Angular Pregnancy After a Laparoscopic Right Salpingo-Oophorectomy: A Case Report.

It can be difficult to distinguish an interstitial pregnancy from an angular pregnancy because of the close proximity of the implantation sites. The difference in pregnancy outcomes between interstitial and angular pregnancies makes this distinction very important. A 39-year-old gravida 7 para 4 who had undergone a laparoscopic right salpingo-oophorectomy (RSO) one year ago and a pregnancy termination via dilation and curettage (D&C) three weeks ago was suspected to have a ruptured right interstitial or angular pregnancy. The patient underwent a laparoscopic total hysterectomy. The postoperative histologic diagnosis was an abortion of a right angular pregnancy. Indeed, it is essential to rule out an interstitial or angular pregnancy during adnexal surgery, even soon after elective abortion. Proper management of an angular pregnancy could prevent a fatal outcome following a rupture or massive hemorrhage.

Cornual Pregnancy.

Cornual pregnancy (CP) is a subtype of ectopic pregnancy that is implanted in the interstitial segment of the fallopian tube which is defined as the tubal section crossing uterine muscular tissue. Widely recognized risk factors for CP are endometriosis, uterine leiomyomata, or pelvic inflammatory disease; all these diseases can cause tubal anatomic changes and consequently alter embryo physiological implant process. Many treatment options are available for this condition each one must be tailored according to patient and operating scenario. The incidence of uterine ruptures in the scarred uterus appears to be low, but the fear of it remains and therefore medical treatment might be favored over cornual wedge resection. The actual risk of uterine rupture after medical treatment is unknown. Multiple testing strategies exist to diagnose CP, but caution needs to be used to avoid a false diagnosis.

Expectant treatment for angular pregnancy after assisted reproduction technology: a safe and patient-friendly treatment strategy.

Introduction: Currently, the treatment strategies for angular pregnancy in the first trimester after assisted reproduction technology (ART) are unclear. Improper treatment will cause unnecessary losses to patients, especially infertile patients, after ART. The purpose of this study was to clarify the pregnancy outcomes of expectant treatment for angular pregnancy post-ART and to provide a basis for the formulation of clinical treatment strategies. Method: This retrospective case series study was performed at the Reproductive Medicine Center of a university hospital. Maternal data and pregnancy outcomes were collected and analyzed for all patients diagnosed with angular pregnancies after ART between January 2016 and August 2021. The outcomes included live birth, term birth, premature birth, early pregnancy loss, fetal death, placental abruption, uterine rupture, maternal death, and hysterectomy. Results: A total of 78 patients were analyzed in this study, of whom 54 (69.2%) had live births, 44 (56.4%) had term births, 21 (26.9%) had an early pregnancy loss, 1 (1.3%) had mid-trimester missed abortion, 1 (1.3%) underwent mid-trimester labor induction due to fetal malformation, and 1 (1.3%) underwent uterine rupture. There were no cases of maternal death, placental abruption, or hysterectomies. Discussion: Angular pregnancy after ART is not as dangerous as that described in previous studies; most cases could be treated expectantly under close-interval follow-up and obtain live birth.

Two subtypes of surgery-categorized upper-lateral intracavitary pregnancy identified by MRI, a retrospective study.

BACKGROUND: The pregnancy outcomes in women with surgery-categorized upper-lateral intracavitary pregnancy (ULIP), previously named angular pregnancy, demonstrate higher heterogeneity than in women with ultrasonography-categorized ULIP. We aimed to use preoperative MRI and correlated clinical characteristics to explore whether the surgery-categorized ULIP comprises obstetric conditions undefined by the current ultrasonography-based diagnostic criteria. METHODS: This retrospective study involved 28 women with surgically and pathologically confirmed ULIP from January 2016 to July 2022. Two board-certified radiologists, blinded to the patients' information, independently reviewed the MRI images, and determined each MRI feature, including endometrial thickness (EMT) and peri-gestational sac (GS) endometrial interruption. Disagreements were resolved by discussion to achieve a consensus. Based on the cutoff value of EMT (11.5 mm), the patients were divided into above-cutoff EMT (n = 22) and below-cutoff EMT (n = 6) groups. RESULTS: Two subtypes of surgery-categorized ULIP were identified. Type-I ULIP (n = 22; EMT ≥ 11.5 mm), when compared to the type-II ULIP (n = 6; EMT < 11.5 mm), demonstrated lower incidence of peri-GS endometrial interruption (2/22 [9.1%] vs 6/6 [100%]; P = 0.001), higher logarithmic ß-human chorionic gonadotropin (ß-hCG) concentration (4.7 ± 0.4 mIU/ml vs 4.2 ± 0.6 mIU/ml; P = 0.026), lower rate of repeated dilatation and curettage (1/22 [4.6%] vs 4/6 [66.7%]; P = 0.003), less intraoperative blood loss (10.1 ± 6.3 ml vs 28.3 ± 18.3 ml; P = 0.001), and shorter hospital stay (2.8 ± 1.7 days vs 7.5 ± 3.8 days; P = 0.001). The peri-GS endometrial interruption negatively correlated with EMT (Odds ratio [OR] = 0.55; P = 0.001) and logarithmic ß-hCG concentration (OR = 0.08; P = 0.045). The below-cutoff EMT negatively correlated with ß-hCG concentration (OR = 0.06; P = 0.021). CONCLUSIONS: Surgery-categorized ULIP comprised two obstetric conditions among which the type-II ULIP, possessing unique imaging features undocumented in the literature, requires further attention during clinical practice.

Diagnostic dilemma between angular and interstitial ectopic pregnancy: 3D ultrasound features.

Angular pregnancy is a rare entity which is commonly confused with interstitial or cornual pregnancies. A lack of consensus about the specific ultrasound features of these 3 entities leads to inappropriate interchange between them among the literature. An angular pregnancy should be considered as a potentially viable intra-uterine eccentric pregnancy as it might be carried to term and result in a live-born baby whereas interstitial or cornual pregnancies should be considered as ectopic pregnancies which should be interrupted. We report here two cases of women at 8 weeks of pregnancy with an angular pregnancy diagnosed by vaginal 2D and 3D ultrasound and discuss about specific ultrasound features and alternative imaging modalities to distinguish it from interstitial and cornual pregnancies.

Using MRI to differentiate upper-lateral intracavitary pregnancy and interstitial pregnancy for the patients with pregnancies in the uterotubal junction during the first trimester.

OBJECTIVES: To retrospectively evaluate the diagnostic value of MRI for the uterotubal junctional pregnancies during the first trimester. METHODS: This retrospective study involved 59 patients (January 2016 to July 2021) with a preoperative imaging diagnosis of uterotubal junctional pregnancy. Using operative and pathological reports as the reference standard, we identified 22 patients with upper-lateral intracavitary (angular) pregnancy and 37 patients with interstitial pregnancy. Two senior radiologists, blinded to the patients' information, reviewed the MRI images and determined each MRI feature based on the original interpretation criteria. Any disagreement was resolved by discussion to achieve a consensus. The sensitivity and specificity of each MRI feature were calculated according to the reference standard. RESULTS: The endometrial thickness in the upper-lateral intracavitary pregnancy group was larger than in the interstitial group (p = 0.001). The cutoff value of the endometrial thickness was 11.5 mm with a sensitivity, specificity, and area under the curve that were 77.3%, 64.9%, and 0.743, respectively. Two key features to diagnose upper-lateral intracavitary pregnancy were "medial free edge" and "medial free edge plus above-cutoff endometrial thickness." The sensitivity and specificity of the medial free edge were 100% and 94.9%, respectively. The sensitivity and specificity of the medial free edge plus above-cutoff endometrial thickness were 77.3% and 100%, respectively. The key feature to diagnose interstitial pregnancy was an "intact lateral junctional zone," of which the sensitivity and specificity were 94.6% and 100%, respectively. CONCLUSIONS: MRI can be used to differentiate the upper-lateral intracavitary pregnancy and interstitial pregnancy during the first trimester. KEY POINTS: • We demonstrated MRI diagnostic criteria for the interstitial pregnancy and upper-lateral intracavitary pregnancy. • MRI might be used to identify the complex interstitial pregnancies, those with a gestational sac protruding into the uterine cavity.

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.

Spontaneous angular dichorionic diamniotic twin pregnancy: a case report.

OBJECTIVE: To report a peculiar case of ultrasound diagnosis of spontaneous angular twin pregnancy. In literature, the terms "angular," "interstitial," and "cornual" pregnancies are often used inappropriately. Confusion in terminology may have contributed to difficulties in developing diagnostic ultrasound criteria to differentiate these ectopic pregnancies. DESIGN: Case report. SETTING: Obstetrics and Gynecology, Community Hospital "S. Maria delle Croci." PATIENT: A 28-year-old patient with a previous cesarean delivery was admitted to our hospital for management of a presumed angular ectopic pregnancy. Transvaginal ultrasound confirmed an ectopic dichorionic diamniotic twin pregnancy eccentrically located in the right superior angle of the uterine cavity: the first gestational sac appeared to have right angular implantation, whereas the second gestational sac seemed to deepen inside the myometrium, with a thin myometrial margin of only 3 mm. INTERVENTIONS: After discussing the risks, the patient requested to proceed with termination. A single intramuscular injection of 75 mg of methotrexate was administered, followed by ultrasound-guided hysterosuction after 19 days due to severe vaginal bleeding. MAIN OUTCOME MEASURES: An early and accurate ultrasound diagnosis of a high-risk condition allowed for conservative medical treatment. RESULTS: The serum beta-human chorionic gonadotropin levels progressively decreased. After 1 month, a clinical and ultrasound examination showed a regular endometrial line with a regular reappearance of menstrual bleeding. CONCLUSIONS: Although there are remarkable advances in ultrasound techniques, angular pregnancy remains a condition of difficult diagnosis and management; it is potentially dangerous and may lead to severe complications. An early and accurate diagnosis of this condition is necessary to avoid complications and individualize the subsequent management.

Angular Heterotopic Pregnancy: Successful Differential Diagnosis, Expectant Management and Postpartum Care.

Heterotopic pregnancy is a rare, difficult to diagnose and life-threatening pathology, which requires timely decisions made by an experienced multidisciplinary team. In this type of multiple pregnancy there are both intrauterine and ectopic pregnancies present. Its incidence increases in pregnancies conceived by assisted reproductive technology or in pregnancies with ovulation induction. This article presents an angular heterotopic pregnancy case in a 34-year-old multigravida. The patient was admitted on the 14th week of gestation due to abdominal pain on the left side with suspicion of heterotopic pregnancy. Transabdominal ultrasound and magnetic resonance imaging (MRI) were performed to confirm the diagnosis of heterotopic angular pregnancy in the left cornu of the uterus. Multidisciplinary team made a decision to keep monitoring the growth of both pregnancies by ultrasound while maternal vitals were stable. Due to intensifying abdominal pain, diagnostic laparoscopy was performed. No signs of uterine rupture were observed, and no additional surgical procedures were performed. Maternal status and ultrasonographic findings were closely monitored. The mass in the left cornu of the uterus did not change significantly and the fetal growth of the intrauterine pregnancy matched its gestational age throughout pregnancy. At the 41st week of gestation, a healthy female neonate was born via spontaneous vaginal delivery. The incidence rate of heterotopic pregnancy tends to grow due to an increased number of pregnancies after assisted reproductive technology and ovulation induction. It is important to always assess the risk factors. The main methods for diagnosing heterotopic pregnancies are ultrasonography and MRI. The main management tactics for heterotopic pregnancy include expectant management as well as surgical or medical termination of the ectopic pregnancy. Expectant management may be chosen as an option only in a limited number of cases, if the clinical situation meets the specific criteria. When applicable, expectant management may reduce the frequency of unnecessary interventions and help to prevent patients from its complications.

Uterine artery chemoembolization followed by hysteroscopic resection for management of retained placenta accreta with marked vascularity after evacuation of first-trimester miscarriage in angular pregnancy: A case report.

BACKGROUND: Angular pregnancy is a rare form of eccentric intrauterine gestation. To determine the management strategy, angular pregnancy should be differentiated from interstitial pregnancy and cornual pregnancy. CASE: A 37-year-old woman (gravida 5, para 4) with no previous disease history was referred because of a retained placenta with hemorrhage 20 days following the manual vacuum aspiration of an intrauterine pregnancy performed after the diagnosis of miscarriage at 8 weeks of gestation. At the initial examination, a prominent vascular mass was identified in the left lateral portion of the uterus. The patient's serum ß-human chorionic gonadotropin level was 1949 IU/L. Magnetic resonance imaging revealed an enlarged angular space occupied by a suspected retained placenta with expansion of the surrounding myometrium. Three-dimensional computerized tomography showed a prominent vascular mass with a feeding left uterine artery and draining thick left ovarian vein. The diagnosis consisted of retained placenta accreta with marked vascularity after evacuation of a miscarriage in a woman with angular pregnancy. Uterine artery chemoembolization was performed followed by the administration of a single dose of systemic methotrexate. Because the gestational mass persisted and spontaneous expulsion appeared to be unlikely, despite the gradual decline of serum ß-human chorionic gonadotropin levels, hysteroscopic resection of the retained placenta was performed and the patient's subsequent recovery was uneventful.

Two cases of angular pregnancy with incomplete abortion treated with hysteroscopy: a case report and review of literature.

BACKGROUND: Angular pregnancy is characterized as implant medial to the uterotubal junction in lateral angular of uterine. It was a rare obstetric complication with severe complications like uterine rupture and retained placenta. CASE PRESENTATION: We report a case of 2 incomplete aborted angular pregnancy that was diagnosed and treated with hysteroscopy. In this case, both of patient were performed operative hysteroscopy for incomplete abortion, and with the assistance of hysteroscopy, the angular pregnancy was detected. CONCLUSIONS: Hysteroscopy can more intuitively display the conditions inside the uterine cavity, reduce the intraoperative and postoperative complications, and shorten the hospitalization time of patients. During hysteroscopy, angular pregnancy can be visualized in the upper lateral side of the uterine cavity. Based on the investigation results of clinical cases, this is the first case report of hysteroscopy in the treatment of incomplete aborted angular pregnancy.

Angular Pregnancy: An Eccentric Implantation Within Uterine Cavity.

Angular ectopic is a rare form of ectopic pregnancy which is diagnosed as intrauterine pregnancy on ultrasound but may rupture in second trimester leading to maternal mortality. We present a case of a 32-year-old primigravida who presented at 18 weeks gestation to the emergency department of national hospital Lahore with complaint of dizziness, sweating and epigastric pain for one hour. She had an episode of diarrhoea and vomiting at hospital followed by rapidly increased abdominal distension and signs of hypovolemic shock. Urgent ultrasound suggested rupture of posterior uterine wall and massive hemoperitoneum. An urgent laparotomy was done. Uterus was perforated by pregnancy posteriorly. baby was inside the sac and alive. But died soon after birth. Uterus was repaired in two layers. Stepwise devascularization of uterus was done due to continuous bleeding. 6 units whole blood 6 FFP were transfused. The abnormal location of this pregnancy makes it antenatal diagnosis difficult. A high index of suspicion is needed in pregnant women presenting in shock even when intrauterine location of pregnancy is diagnosed in first trimester.

Conservative management for adherent placenta after live birth in angular or interstitial pregnancies: A new entity "angular placenta attachment".

OBJECTIVE: Angular and interstitial pregnancies have been reported with live births and are often complicated by adherent placentas. Most cases had been treated with hysterectomy or corneal resection. CASE REPORT: We successfully treated four patients with conservative management (including one reported previously). Case 1 had a vaginal delivery, but the placenta remained attached. We maintained the patient under observation and delivered the placenta on postpartum day 9. Case 2 underwent a C-section. Uterine artery embolization controlled the hemorrhage without placenta removal. The placenta had disappeared by postpartum day 136. Case 3 underwent a C-section. The right uterine angle, where the placenta was attached, was bulging. We manually removed the placenta. CONCLUSION: We propose a new entity in angular or interstitial pregnancies called "angular placenta attachment" that could be diagnosed during C-sections or after vaginal delivery without placental separation. Expectant management may be considered for adherent placentas in these cases.

Differentiating pregnancies near the uterotubal junction (angular, cornual, and interstitial): a review and recommendations.

Eccentrically located intracavitary pregnancies, which include pregnancies traditionally termed as cornual and/or angular, have long presented complex diagnostic and management challenges given their inherent relationship to interstitial ectopic pregnancies. This review uses the existing literature to discriminate among interstitial, cornual, and angular pregnancies. Current arguments propose the outright abandonment of the terms cornual and angular may be justified in favor of the singular term, eccentric pregnancy. Disparate definitions and diagnostic approaches have compromised the literature's ability to precisely describe prognosis and ideal management practices for each of these types of pregnancies. Standardizing the classification of these pregnancies near the uterotubal junction is important to unify conservative, yet safe and effective management strategies. We advocate the use of early first trimester ultrasound to correctly differentiate between eccentric pregnancy and interstitial ectopic pregnancy as current research suggests substantially better outcomes with correctly diagnosed and expectantly managed eccentric pregnancies than past investigations may have shown. The expectant management of eccentric pregnancies will often result in a healthy term pregnancy, while interstitial ectopic pregnancies inherently have a poor likelihood of progressing to viability. When the terms and diagnosis of cornual, angular, and interstitial pregnancy are indistinct, there is substantial risk of intrauterine pregnancies to be inappropriately managed as ectopic pregnancies. Until we standardize terms and criteria, it will remain difficult, if not impossible, to determine true risk for pregnancy loss, preterm labor, abnormal placentation, and uterine or uterotubal rupture. The development of best practice guidelines will require standardized terminology and diagnostic techniques.