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.

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.

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.

Hysteroscopic morcellation for removal of persistent placental remnants in the uterine cornu: Two case reports.

RATIONALE: Hysteroscopic morcellation is an alternative approach for the removal of placental remnants, given its advantages of safety, efficiency and good reproductive outcomes. This superiority can be even more obvious for removing persistent placental remnants in the lateral angle of the uterine cavity after repeated dilation and curettage (D&C) of an angular pregnancy, which is rarely reported. PATIENT CONCERNS: Two patients who were both initially misdiagnosed as having missed intrauterine miscarriages underwent repeated suction-assisted D&C procedures and were found to have persistent placental remnants in the lateral angles of the uterine cavity. DIAGNOSES: Ultrasound and hysteroscopy evaluations showed that placental remnants in both cases were in the lateral uterine angles and protruding to the interstitial myometrium around the fallopian tube. We corrected the diagnosis to that of angular pregnancy according to a comprehensive consideration of the ultrasound, hysteroscopy and pathology results. INTERVENTIONS: We performed MyoSure hysteroscopic morcellation for both patients and the placental remnants were removed completely without any complication. OUTCOMES: The patients were both scheduled for a second-look hysteroscopy 1 to 3 months after surgery, which revealed normal morphology of the uterine cavities and tubal ostia. The patients both achieved normal intrauterine pregnancies several months after surgery. LESSONS: Hysteroscopic morcellation is a good alternative approach for the removal of placental remnants and should be considered in cases in which there might be a high risk of incomplete evacuation or a high risk of uterine perforation, especially in cases of angular pregnancy.

[Interstitial, angular and cornual pregnancies: Diagnosis, treatment and subsequent fertility]. / Grossesse interstitielle, angulaire et cornuale : diagnostic, traitement et futur obstétrical.

OBJECTIVE: Interstitial, angular and corneal pregnancies are not very frequent and often mistaken, each with its own definition and prognosis. The objective of this work is to relate 10 years experience of ectopic pregnancies at the UH in Dijon, based on the latest data from the literature in term of diagnosis, management and subsequent fertility. METHOD: This is a retrospective study carried out at the UH of Dijon from 01/01/2005 to 01/01/2015. From the medical records of each patient who presented a corneal, interstitial or angular pregnancy, we identified the risk factors for ectopic pregnancy (EG), the diagnostic and therapeutic means used, and the subsequent obstetrical events. RESULTS: In 10 years, 532 EG were managed including 10 interstitials, one angular and nine cornual. The main risk factors were previous EG (50%), salpingectomy (55%), curettage (45%) and smoking (40%). The localization of the EG was done in 75% by the endo-vaginal sonography, in 25% in peroperative. Thirty-five percent were treated with methotrexate, 20% had surgery and 40% had both. Seventy-five percent of patients had at least one ulterior pregnancy. In the case of caesarean section, no dehiscence of the corneal scar was identified. CONCLUSION: This study shows the presence of medical antecedents which are risk factors of the tubular EG. A methotrexate protocol should be proposed first. Even after corneal surgery, vaginal delivery may remain possible.

Right angular pregnancy at seven weeks' gestation: a case report treated by laparoscopic approach.

Angular pregnancy (AP) or implantation of the embryo in the lateral angle of the uterine cavity close to the internal ostium of the fallopian tube is a very rare event. In fact, angular pregnancy refers to implantation of the embryo just medial to the uterotubal junction, in the lateral angle of the uterine cavity. AP must be distinguished, anatomically, from interstitial pregnancy by its position in relation to the round ligament, which crosses the Müllerian duct at the side of the uterotubal junction. AP is associated with a high rate of complications such as bleeding and ruptured uterus due to delayed diagnosis. The authors present a clinical report of AP at seven weeks' gestation without uterine rupture. They performed directly operative laparoscopy because of acute intra-abdominal hemorrhage. Laparoscopy was useful in the treatment of early angular pregnancy and could avoid the need for invasive surgery or hysterectomy.

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.