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.

Nonsurgical Management of Interstitial Pregnancies: Feasibility and Predictors of Treatment Failure.

STUDY OBJECTIVES: To describe the management of interstitial pregnancies in a tertiary medical center, identify factors associated with treatment failure, and report subsequent pregnancy outcome. DESIGN: Retrospective cohort study. SETTING: Department of Gynecology in a tertiary medical center. PATIENTS: All women who were admitted to and treated for interstitial pregnancy at our center between 2011 and 2019. INTERVENTIONS: The women were originally assigned to undergo expectant, medical, or surgical treatment. The women's background and clinical data were compared according to initial treatment modality. Nonsurgical (expectant and medical) management outcomes were analyzed to identify risk factors for treatment failure. Subsequent pregnancy outcomes were described separately. MEASUREMENT AND MAIN RESULTS: Thirty-seven cases of interstitial pregnancy were identified. There were high rates of pregnancy achieved by in vitro fertilization (45.9%) and a history of ipsilateral salpingectomy (43.2%) among these patients. At presentation, the mean age of the study cohort was 34.76 years, and the median ß-human chorionic gonadotropin level was 3853.0, and median gestational age was 7.0, respectively. The nonsurgical management success rate was 70.0%. Uterine rupture occurred during treatment in 5 cases (16.6%). Gestational sac diameter significantly affected treatment failure (p = .03), and a diameter >20 mm was observed in all cases of failed non-surgical treatment. Data on future fertility was available for 21 (58.3%) women: 13 (61.9%) had a subsequent pregnancy, 1 of which was a recurrent interstitial pregnancy. The median interpregnancy interval was 8.1 months, and all but 3 pregnancies reached third trimester and resulted in a live birth, with an overall cesarean delivery rate of 61.5%. None of the subsequent pregnancies were complicated by uterine rupture, and no serious adverse outcomes were noted in any of the subsequent intrauterine pregnancies that reached third trimester. CONCLUSION: Successful nonsurgical management of an interstitial pregnancy is feasible, although appropriate selection of cases is advised. A large gestational sac is a risk factor for treatment failure and should prompt surgical intervention. Subsequent pregnancies can generally be considered safe and with a favorable outcome.

Interstitial Pregnancy after Ipsilateral Salpingectomy: Analysis of 46 Cases and a Literature Review.

STUDY OBJECTIVE: To investigate the relationship between previous ipsilateral salpingectomy and interstitial pregnancy and report on our experience of laparoscopic cornuostomy for interstitial pregnancy. DESIGN: Single-center, retrospective review. SETTING: University-based hospital. PATIENTS: All patients who had undergone ipsilateral salpingectomy previously, diagnosed with interstitial pregnancy and treated between July 2010 and September 2018. INTERVENTIONS: Laparoscopy or laparotomy as a treatment for interstitial pregnancy after ipsilateral salpingectomy. MEASUREMENTS AND MAIN RESULTS: A total of 414 cases of interstitial pregnancy were identified, of which 46 (11.1%) were after ipsilateral salpingectomy. Of the 46 patients, 20 (43.5%) became pregnant by in vitro fertilization and embryo transfer. Ipsilateral salpingectomy was the result of an ectopic pregnancy in 40 patients, hydrosalpinx in 5 patients, and torsion of an ovarian tumor in 1 patient. The laparoscopic approach was used to treat 78.3% of patients with history of previous salpingectomy. Patients who underwent ipsilateral salpingectomy by laparoscopy previously had a shorter interval from salpingectomy to interstitial pregnancy (24 months vs 60 months; p = .038) compared with patients who underwent ipsilateral salpingectomy by laparotomy. Laparoscopic cornuostomy was performed in 38 patients (82.6%); 12 had fetal cardiac activity, 15 had ruptured masses, and 16 used prophylactic methotrexate (MTX) intraoperatively. The median size of the ectopic mass was 2.5 cm (1.0-5.0 cm). At the time of laparoscopic cornuostomy, more patients with interstitial pregnancies with intact ectopic masses were administered prophylactic MTX (81.3% vs 45.5%; p = .043). Only 1 patient with a ruptured ectopic mass, high preoperative human chorionic gonadotropin levels, and without prophylactic MTX administration experienced a persistent ectopic pregnancy. CONCLUSION: Patients with a history of ipsilateral salpingectomy should be cautioned regarding the possibility of interstitial pregnancy. Laparoscopic cornuostomy appears to be an appropriate treatment for interstitial pregnancy in patients wishing to preserve fertility, and the use of concomitant prophylactic MTX may reduce the risk of persistent ectopic pregnancy, especially in patients with ruptured masses and high human chorionic gonadotropin levels.

The effect of local aspiration and methotrexate injection on live interstitial pregnancy coexisting with live intrauterine pregnancy after assisted reproductive technology.

AIM: To share the experience of local aspiration and instillation of methotrexate (MTX) to selective reduction of live interstitial pregnancy and to evaluate its clinical effect and the outcome of intrauterine pregnancy. METHODS: Twelve patients with heterotopic interstitial pregnancy were enrolled at Women's Hospital, Zhejiang University School of Medicine, from 2006 to 2017. All the pregnancies were derived from assisted reproductive technology (ART). The transvaginal aspiration to interstitial pregnancy sac and local instillation of MTX (range from 12.5 to 30 mg) were performed for the patients under ultrasound-guide. The prognosis and pregnancy outcomes were followed up. RESULTS: No severe side effects of medical treatment were observed in all patients. Three cases underwent subsequent laparotomy cornual resection, and no perioperative complications were found in these three patients. Twelve patients gave birth to 13 healthy infants without congenital anomalies. The average birth weight and gestational age was 2837 g (SD ± 605 g) and 36.8 weeks (SD ± 2.4 weeks). No growth anomalies and mental retardation were observed in live birth offspring. CONCLUSION: The transvaginal ultrasound-guided aspiration and injection of MTX might be a feasible alternative treatment for heterotopic interstitial pregnancy when vital signs of patients are stable.

Tratamiento conservador de la gestación intersticial. A propósito de dos casos / Conservative treatment of interstitial pregnancy: 2 case reports

El tratamiento de la Gestación Intersticial (GI) puede ser quirúrgico o médico con metotrexate (MTX) vía sistémica, local o ambas. Presentamos dos casos con MTX combinado. Caso Caso 1: 38 años, gestante 6,5 semanas y antecedente de miomectomía, diagnóstico gestación intersticial. Meto-trexate intramuscular (im) y una inyección local mediante histeroscópica, resolvieron por completo el proceso. Caso 2: 32 años, gestante 6 semanas, diagnóstico gestación tubárica, se inició metotrexate intramuscular. Tras 3 dosis, se efectuó una laparoscopia que constata la localización cornual de la gestación por lo que se inyecta metotrexate local. Conclusiones: el tratamiento médico, asociado a la tecnología mínimamente invasiva, es seguro y eficaz en determinados casos de gestación intersticial

Treatment of Interstitial Pregnancy can be surgical or medical with systemic MTX, local injection or both. We present two cases with combined MTX. Case 1: 38 years, pregnant 6.5 weeks and antecedent of myomectomy, diagnosis GI. Intramuscular MTX and a local injection by hysteroscopy, solved the process successfully. Case 2: 32 years, pregnant 6 weeks, tubal pregnancy diagnosis, treated with im MTX. After 3 doses, a laparoscopy was performed, which confirms the cornual location of the gestation, thus injecting local MTX. Conclusions: Medical treatment, associated with minimally invasive technology, is safe and effective in certain cases of GI

Conservative management of interstitial pregnancies: experience of a single centre.

The aim of this study was to compare the effect of local intracavitary methotrexate (MTX) injection and laparoscopic (L/S) cornuostomy in the treatment of interstitial pregnancy (IP) in terms of clinical and reproductive outcome. The data of patients with IP (n:10) who were treated between September 2011 and December 2016 with either an intra-amniotic MTX injection (n:7) or L/S cornuostomy (n:3) were retrospectively evaluated. All cases (7/7) in the local injection group and two (2/3) in the L/S group were successfully treated with the initial treatment. One case (1/3, 33%) in L/S group needed systemic MTX due to an elevated ß-hCG. No serious complication or secondary surgical intervention was observed in the study group. Five (71.4%) women in MTX group and two (66%) women in the L/S group had pregnancy after index case (p > .05). Post-treatment (hysterosalpingography) HSG results revealed that tubal patency was significantly higher in the MTX group (7/7 (100%) vs. 0/3 (0%) p < .05). Conservative treatment of IP with both methods was generally successful with regard to maternal morbidity and reproductive function. However, local MTX was superior for tubal patency compared to L/S cornuostomy. Since this is a retrospective study including a small study population, our results should be confirmed with larger prospective studies. Impact Statement What is already known on this subject? Earlier diagnosis of an interstitial pregnancy (IP) enables clinicians to pursue more conservative treatment modalities that can prevent morbidity (severe bleeding, rupture and massive transfusion, etc.) and loss of fertility. MTX treatment and conservative laparoscopic surgical procedures are gaining importance. High serum ß-hCG levels and positive foetal cardiac activity are known as unfavourable pre-treatment prognostic predictors for systemic MTX treatment in patients with an ectopic pregnancy. Local MTX treatment is widely used for caeserean scar pregnancies or cervical pregnancies. L/S cornuostomy is an attractive alternative to L/S cornual resection, because it preserves the normal uterine myometrium. What the results of this study add? In the present study, we showed that the local MTX and laparoscopic cornuostomy were successful methods in IP patients and did not impair the fertility potential of the patients. We also demonstrated that local MTX application is superior to L/S cornuostomy in terms of the post-treatment tubal patency and this fact should be kept in mind when tailoring the treatment in patients desiring pregnancy. What the implications are of these findings for clinical practice and/or further research? The value of local MTX injection in cases with IP and high ß-hCG levels should be further clarified.

Incidence of Interstitial Pregnancy After In Vitro Fertilization/Embryo Transfer and the Outcome of a Consecutive Series of 38 Cases Managed by Laparoscopic Cornuostomy or Cornual Repair.

STUDY OBJECTIVE: To determine the incidence of interstitial pregnancy after in vitro fertilization/embryo transfer (ET) treatment and report on our experience of laparoscopic cornuostomy or cornual repair for interstitial pregnancy. DESIGN: Single-center, retrospective review (Canadian Task Force classification II-3). SETTING: University hospital. PATIENTS: Thirty-eight women diagnosed with interstitial pregnancy, which developed after 10,143 ET cycles, managed in our center between April 2011 and April 2014. INTERVENTIONS: All 38 cases of interstitial pregnancy were managed by laparoscopic cornuostomy or cornual repair. No patient was converted to laparotomy. MEASUREMENTS AND MAIN RESULTS: Of 43 cases of interstitial pregnancy, 38 were managed in our department. The overall incidence of interstitial pregnancy was .4% per ET cycle (43/10 143), or .8% per pregnancy (43/5297), but comprising 35.5% of all ectopic pregnancy cases. The risk factors for interstitial pregnancy included tubal infertility, cleavage ET, and frozen ET. Twenty-seven subjects (71.1%) had undergone bilateral salpingectomy. Among the 38 cases, 27 were intact, with no persistent ectopic pregnancy after surgery, but there were 3 cases (28.3%) of persistent pregnancy in the 11 ruptured cases. Among the 38 subjects, 15 conceived again with 14 live births and 1 ongoing pregnancy, without uterine rupture. CONCLUSION: Laparoscopic cornuostomy or cornual repair appears to be an effective treatment in intact cases, although it sometimes needs to be combined with methotrexate therapy in ruptured cases complicated by persistent disease.

Magnetic resonance imaging for diagnosis and management of unruptured interstitial pregnancy.

AIM: The aim of this study was to evaluate the value of magnetic resonance imaging (MRI) for the diagnosis and management of suspicious unruptured interstitial pregnancy. MATERIAL AND METHODS: Only patients with unruptured interstitial pregnancy evaluated by MRI and observed for at least a year after surgery were included. Initial evaluation was performed by measurement of serum ß-human chorionic gonadotrophin level and ultrasonography. In suspicious cases, emergency MRI was performed to diagnose interstitial pregnancies with the exclusion of rudimentary horn pregnancy and angular pregnancy. Three-dimensional computed tomographic (CT) angiography was additionally performed if the uteroplacental neovascularization needed to be evaluated. Then, management procedures were individually determined along with the need for preoperative transcatheter arterial chemoembolization for immediate devascularization, and for the local or systemic administration of methotrexate. Either laparoscopic cornuostomy or cornual resection was chosen to excise the gestational mass. RESULTS: Five consecutive women with unruptured interstitial pregnancy were enrolled. One case each of rudimentary horn pregnancy and angular pregnancy was excluded. Three-dimensional CT angiography was performed in three cases due to increased vascular flow on color Doppler ultrasonography. Preoperative devascularization by transcatheter arterial chemoembolization was performed in two cases, in which a prominent neovascularized gestational mass was identified. Uterine preservation was achieved by cornuostomy or cornual resection in all cases. Two patients with a desire to become pregnant conceived spontaneously thereafter, followed by successful cesarean birth. CONCLUSION: This small case series emphasizes that precise localization of gestational products in the interstitial portion of the fallopian tube by MRI can facilitate the minimally invasive management of unruptured interstitial pregnancy for uterine preservation.

Effectiveness of medical treatment with methotrexate for interstitial pregnancy.

BACKGROUND: In the last three decades, systemic methotrexate (MTX) has become widely accepted as the primary treatment for unruptured tubal pregnancy. This has prompted investigations into the use of MTX in the management of interstitial pregnancy. AIM: To determine the effectiveness of methotrexate for treatment of interstitial pregnancy. METHODS: We retrospectively reviewed 17 haemodynamically stable women admitted to our tertiary, university-affiliated medical centre with an intact interstitial pregnancy from January 2003 through February 2013. First-line treatment consisted of intramuscular MTX 1 mg/kg/day x4 alternating with folinic acid 0.1 mg/kg or, in cases of low beta-human chorionic gonadotropin (ß-hCG) and no embryonic pole, one dose of 50 mg/m(2) body surface area. Uterine artery MTX injection was administered on the ipsilateral side of the pregnancy followed by uterine artery embolisation as second-line treatment. Failure criteria were <15% decrease in ß-hCG or sonographic evidence of pregnancy development. Second-line failures were referred for surgery. RESULTS: Twelve women (70.5%) underwent successful first-line treatment and 5 (29.5%) required second-line treatment. Baseline characteristics were similar except for a higher rate of two previous ectopic pregnancies in the first-line failures (80% versus 8.3%, P = 0.01). Two women eventually required surgery, both with two previous ectopic pregnancies. Of the three women with fetal cardiac activity on admission, two had successful first-line treatment and one required surgery. CONCLUSION: Systemic MTX is effective for treatment of intact interstitial pregnancy in haemodynamically stable women. The success rate is increased with uterine artery MTX injection as second-line treatment.

Management and outcome of 25 heterotopic pregnancies in Zhejiang, China.

OBJECTIVE: To characterize general attributes of women with heterotopic pregnancy (HP) in order to establish an optimal management regimen. STUDY DESIGN: A retrospective analysis was conducted on 25 HPs recorded at the Women's Hospital of Zhejiang University between 2007 and 2011. Data on patients' symptoms, risk factors, diagnostic features, treatment and outcome were collected and analysed. RESULTS: All patients had conceived via assisted reproductive technology (ART), 72% had a history of pelvic inflammatory disease and 68% of patients were symptomatic. Fifty-six percent of patients were diagnosed with HP via routine transvaginal ultrasound examination at approximately 6-7 weeks of gestation. Eighty percent of patients underwent surgical treatment (35% laparoscopic salpingectomy, 65% laparotomy), and 20% of patients underwent medical treatment with local injection of methotrexate (MTX) or MTX in combination with potassium chloride (KCl) into ectopic sites such as the cervix or interstitium. Eighty-eight percent of patients delivered live infants without congenital anomalies, and three patients (all of whom underwent surgical treatment) miscarried. CONCLUSIONS: Routine transvaginal ultrasound examination at approximately 6-7 weeks of gestation could facilitate the diagnosis of HP, although repeat ultrasound is necessary to avoid misdiagnosis. Prompt diagnosis and correct treatment, including local injection of MTX or MTX in combination with KCl into various ectopic sites, led to favourable prognoses.

Conservative treatment for interstitial monochorionic twin pregnancy: case report and review of the published work.

Interstitial pregnancy is considered one of the most hazardous types of ectopic pregnancies, with a mortality rate of 2-2.5%. We describe a case of a viable monochorionic twin pregnancy in a 35-year-old woman successfully treated with systemic methotrexate associated with bilateral uterine arteries' embolization. ß-hCG was undetectable 67 days after the first administration of methotrexate and the ultrasonography performed on day 67 showed the remnant of the gestational sac in the right uterine horn, a thin endometrium and a normal myometrial vascularization. Conservative treatment allowed us to avoid surgical treatment and to preserve the patient's fertility.