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.

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.

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.

Hysteroscopic Intact Removal of an Angular Pregnancy with a 5Fr Electrode.

STUDY OBJECTIVE: Angular pregnancy is a rare and life-threatening condition in which the embryo is implanted in the lateral angle of the uterine cavity, medial to the uterotubal junction and round ligament. Angular pregnancy is associated with a high risk of uterine rupture of about 23% [1]. No consensus has been achieved regarding the diagnostic and therapeutic approach of angular pregnancy [2]. Thus, the aim of this study was to report a case of hysteroscopic treatment of an angular pregnancy in a 34-year-old women. DESIGN: Step-by-step video presentation of the surgical treatment (Canadian Task Force classification III). SETTING: Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy. PATIENT: A 34-year-old woman. Written informed consent was obtained from the patient. INTERVENTION: Hysteroscopy. MEASUREMENTS AND MAIN RESULTS: A 34-year-old woman was admitted to our Department with pelvic pain at 6 weeks of gestation. ß-Human chorionic gonadotropin (ß-hCG) was 5331 mIU/mL. The transvaginal ultrasound showed a gestational sac of 15 × 11 mm in the left uterine angle of an embryo without cardiac activity. The woman opted for a conservative approach with multiple-dose methotrexate [3]. Five days later the ß-hCG increased to 7589 mIU/mL with no regression of pregnancy at the transvaginal ultrasound. Therefore, a surgical approach was offered to the patient [4,5]. Laparoscopy showed normal salpinges, whereas hysteroscopy identified the gestational sac in the left uterine angle. A 5Fr bipolar electrode was used to open the gestational capsular decidua. The chorionic villi were progressively separated from the implantation site. Using grasping forceps we removed the specimen for histologic examination. Histologic examination confirmed the diagnosis of angular pregnancy. On the second postoperative day ß-hCG was 1131 mIU/mL, and the patient was discharged the day after. At the 1-month follow-up visit, ß-hCG and transvaginal ultrasound were negative for pregnancy. The office hysteroscopy showed an empty uterine cavity at 3-months' follow-up. CONCLUSION: Our case shows that hysteroscopy may be used as a diagnostic and therapeutic tool for angular pregnancy, providing a unique image of the intact removal of the gestational sac.

A Novel Approach to Management of Angular Pregnancies: A Case Series.

Cornual, interstitial, and angular pregnancies are terms that are often used interchangeably in both the literature and clinical setting to describe various ectopic pregnancies. The diagnosis of these pregnancies can be difficult, and fear of disrupting an intrauterine pregnancy can cause hesitation during evaluation and management. In our 2 cases, a combination of transvaginal and 3-dimensional ultrasound images provided assistance in the accurate diagnosis of angular ectopic pregnancies. Traditional management of these pregnancies includes a wedge resection for pregnancy resolution. In this set of 2 cases, we describe a unique surgical approach to resolve these pregnancies using operative hysteroscopy.

Distinguishing between interstitial and angular pregnancies: Is there a role for saline infusion sonohysterography?

OBJECTIVE: Interstitial pregnancy occurs in the intramural segment of the Fallopian tubes, while angular pregnancy is one that is located in one of the lateral angles of the uterine cavity. The differential diagnosis and treatment of these conditions are important. We have used saline infusion sonohysterography (SIS) to help in differential diagnosis. CASE REPORT: A 36-year-old female with a case of suspected left interstitial ectopic pregnancy was admitted. Her diagnostic laparoscopy showed no tubal ectopic pregnancy, and D&C demonstrated no villi. She underwent SIS which showed a sac in the interstitial part but close to the tubal ostium. The second case involves a 21-year-old female who was 9-weeks pregnant. Ultrasonography could not differentiate between interstitial and angular pregnancy. SIS clearly demonstrated angular pregnancy with a missed abortion, and therapeutic D&C was done smoothly. CONCLUSION: From reviewing past literature, SIS does not appear to have any proven adverse effect on the pregnancy although it is not widely accepted. This article highlights the benefits of using SIS to aid in the differential diagnosis between the two conditions, especially in unusual cases like ours.

Interstitial and angular pregnancies: Case reports and differential diagnosis.

Interstitial and angular pregnancies are rare and have high rates of morbidity and mortality. These terms continue to create confusion and are frequently misused. The standardization of terminology and differentiation of cases is necessary to distinguish between different outcomes. This article aims to report one case of angular and another case of interstitial pregnancies and to discuss clinical and radiological characteristics, prognosis and treatment. These pathologies continue to be confused with each other and with ectopic pregnancy tubal. Therefore, correct diagnosis facilitates appropriate management.

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.