interstitial pregnancy

武功密笈

小黃藏書

OBS
GYN
Gyn Oncology
Infertility
Urogynecology

首頁 向上 Abnormal Bleeding Endometriosis PID Cervical Pregnancy Amenorrhea Chronic Pelvic Pain Ectopic Pregnancy interstitial pregnancy Periop management Pelvic mass Acute Pelvic Pain Endoscopic Myomectomy Nutritional Support ectopic pregnancy LAVH HRT candidiasis PMS Amenorrhea

~ Interstitial/Cornual Pregnancy ~

　

§ Epidemic Data:

« Incidence: 2% to 4% of all ectopic pregnancies

« Mortality Rate: 2% to 5%, more than twice that of other tubal pregnancies

　

§ Clinical Manifestations:

« Symptoms/Signs: nonspecific, resembling those of tubal pregnancies

« In general, interstitial pregnancies are diagnosed later in gestation,

and if rupture occurs, hemorrhage is profound.

　

§ Characteristic Sonographic Signs5:

« Empty uterine cavity

« Eccentrically located or very lateral gestational sac

« Thin or incomplete myometrial mantle covering the gestational sac

« Demonstration of myometrium between sac and uterine cavity

« No gestational sac visible above the level of the internal os in the longitudinal

plane of the uterus

« Differential Diagnosis:

? Sacculation of the uterus

‚ Leiomyomatous uterus distorting normal anatomy

ƒ Pregnancy in the rudimentary horn or in a septate or otherwise

malformed uterus

„ Piskacek’s sign (temporary asymmetry of the fundus in a normal

intrauterine pregnancy before the 12th week of gestation)

　

§ Treatment:

« Medical Management: (several case reports)

-Transabdominal KCl injection into fetal heart and systemic MTX3

ò A low and declining level of s-hCG is not always associated with the resolution of

ectopic pregnancy and rupture of ectopic pregnancy still occurs. Expectant

management after medical treatment of ectopic pregnancy requires careful follow-up.

ò It has been reported that ultrasonographic follow-up of interstitial pregnancies treated

nonsurgically showed persistent lesions during the observation period up to 64 weeks, whereas normal menstrual cycles returned after 2 to 10 weeks after detection or treatment. These findings indicate that pregnancy is possible within the uterus with such lesions. These lesions require a long-term follow-up for any possible impact such as uterine rupture on future pregnancy.

ò These reports suggest that surgical treatment may be a better alternative than medical

treatment.

« Surgical Management:

? Laparoscopy: (Information regarding subsequent pregnancy is limited.)

- MTX (50 mg) (with additional dose under ultrasonographic guidance)4

- Salpingostomy1, 2: (table 1)

- Salpingotomy2:

1). Infiltrate the corneal area with diluted vasopressin solution (10 U in 100 ml N/S).

2). Open the myometrium over the ectopic gestation by monopolar needle.

3). Express the gestation through the incision (using a blunt probe).

4). Close the uterine incision by suture.

- Cornual excision2

- Endoloop method and encircling suture method:

Procedures: (figure 1, 2, and 3)

Summary of treatments of patients with interstitial pregnancy: (table 2)

Results:

1). Amount of blood loss and operation time: (table 3)

2). Levels of s-hCG after operation: (figure 4)

3). Outcomes for resumption of menstruation and subsequent

pregnancy after operation: (table 4)

ò A laparoscopic approach should only be attempted if the surgeon is well skilled in

laparoscopic technique, and has the capability to convert the operation quickly to a

laparotmy. When these conditions are met, laparoscopy provides several advantages

over laparomy: fewer post-operative hospital stay, faster return to normal activity,

and decreased health care costs.

‚ Laparotomy:

- Cornual resection: the traditional method

- Hysterectomy

« Follow-up: serial s-hCG

　

§ References:

? Hwa Sook Moon, MD, PhD, Young Joo Choi, MD, Yang Hee Park, MD, and Sang Gap Kim, MD.

New simple endoscopic operations for interstisial pregnancies.

Am J Obstet Gynecol 2000;182:114-21.

‚ W.A. Grobman and M.P. Milad. Conservative laparoscopic management of a large counual

ectopic pregnancy. Hum Reprod 1998;13(7):2002-4.

ƒ I. Aruh, B. Uran, N. Demir. Conservative approach in unruptured counual pregnancy with a

live fetus. Int J Obstet Gynecol 1997;59:43-5.

„ Sertac Batto?lu, etc. Successful treatment of cornual pregnancy by local injection of

methotrexate under laparoscopoic and transvaginal ultrasonographic guidance. Gynecol Obstet

Invest 1997;44:64-6.

… Gordan Crvenkovic, MD, etc. Diagnosis: right-sided interstitial (corneal) pregnancy.

J Ultrasound Med 1995;14:325-36.