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Table of Contents
CORRESPONDENCE
Year : 2018  |  Volume : 26  |  Issue : 3  |  Page : 168-169

Comment on an intrauterine gestational sac surrounded by thin myometrium at fundus


1 Department of Obstetrics and Gynecology, Ahmadi Hospital, Kuwait Oil Company, Ahmadi, Kuwait, Department of Obstetrics and Gynecology, Ain Shams University, Cairo, Egypt
2 Department of Obstetrics and Gynecology, Royal Medical Services, Amman, Jordan
3 Department of Normal and Topographical Anatomy, West Kazakhstan Marat Ospanov State Medical University, Aktobe, Kazakhstan
4 Department of Obstetrics and Gynecology, West Kazakhstan Marat Ospanov State Medical University, Aktobe, Kazakhstan
5 Department of Obstetrics and Gynecology, Ahmadi Hospital, Kuwait Oil Company, Ahmadi, Kuwait

Date of Web Publication14-Sep-2018

Correspondence Address:
Prof. Ibrahim A Abdelazim
Department of Obstetrics and Gynecology, Ain Shams University, Ahmadi Hospital, Kuwait Oil Company, P. O. Box 9758, Ahmadi 61008
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JMU.JMU_58_18

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How to cite this article:
Abdelazim IA, Nussair B, Zhurabekova G, Svetlana S, Abu-Faza M, Naser W. Comment on an intrauterine gestational sac surrounded by thin myometrium at fundus. J Med Ultrasound 2018;26:168-9

How to cite this URL:
Abdelazim IA, Nussair B, Zhurabekova G, Svetlana S, Abu-Faza M, Naser W. Comment on an intrauterine gestational sac surrounded by thin myometrium at fundus. J Med Ultrasound [serial online] 2018 [cited 2021 Oct 27];26:168-9. Available from: http://www.jmuonline.org/text.asp?2018/26/3/168/241146

Dear Respectable Editor,

We read the article “An Intrauterine Gestational sac Surrounded by Thin Myometrium at Fundus” [Imaging for Residents] by Shih-Ting et al., published in the J Med Ultrasound 2017;25, with great interest.

Shih-Ting et al.presented a 37-year-old, G3P1E1 woman, with a past history of laparoscopic salpingectomy for treatment of left-side tubal pregnancy, with abnormal vaginal spotting after positive pregnancy test and amenorrhea for 8 weeks.[1]

Transvaginal sonography (TVS) of the patient showed an eccentric intrauterine gestational sac located at the right lateral fundus, surrounded by thin myometrium, and an echogenic line runs from the endometrial cavity to the cornual region, abutting the interstitial gestational sac (called “interstitial line sign”). The patient managed successfully laparoscopically, and cornual wedge resection was removed, followed by hemostatic stitches. The pathology report also proved the diagnosis of cornual pregnancy [as they stated].

Shih-Ting et al. stated in the discussion that the cornual ectopic pregnancy is an uncommon variant of ectopic pregnancy, and it accounts for only 2%–4% of tubal pregnancies or approximately 1 in 2500–5000 live births. The mortality rate is as high as 2.5% (7 times greater than that of ectopic pregnancies in general).[2]

Then, Shih-Ting et al. stated that the risks of interstitial pregnancy include rudimentary horn, previous salpingectomy (ipsilateral or bilateral) or other tubal damage (tubal ligation or salpingostomy), conception after in vitro fertilization, and a history of pelvic inflammatory disease.[2],[3] In addition, they mentioned that the most common symptoms of cornual pregnancy are abdominal pain and vaginal bleeding in the first trimester of pregnancy.

Shih-Ting et al. stated that the TVS is the primary method of diagnosis of cornual pregnancies, and they described the ultrasound criteria of Timor-Tritsch et al. and the Ackerman et al. “interstitial line sign,” for the diagnosis of interstitial pregnancy.[4],[5]

Shih-Ting et al. mentioned the presented case as corneal pregnancy in some parts of their published article and as interstitial pregnancy in other parts of the published article, which is somewhat confusing to the readers.

The case should be prescribed as interstitial pregnancy, which is a rare variety of ectopic pregnancy and occurs after implantation of the fertilized ovum in the proximal tubal segment that lies within the muscular uterine wall (incorrectly called corneal pregnancy).[6] Undiagnosed interstitial pregnancy can have disturbed 8–16 weeks of amenorrhea (later than the distal tubal ectopic pregnancy).[7]

In addition, the interstitial ectopic pregnancy carries the risk of severe hemorrhage and high mortality rate (2.5%), due to the proximity of the interstitial fallopian tube to the uterine and ovarian arteries.[6],[7],[8]

The interstitial pregnancy can be diagnosed early in many cases using the TVS and beta-human chorionic gonadotropin, but the diagnosis can be challenging in some cases.[9] The missed diagnosis of interstitial ectopic pregnancy may result in life-threatening internal hemorrhage.[10]

As the authors mentioned, the criteria that may differentiate include empty uterus, with an eccentric gestational sac seen separate from the endometrium, the gestational sac more than 1 cm away from the most lateral edge of the uterine cavity, and <5-mm myometrium surrounding the gestational sac.[4] Moreover, an echogenic line (the interstitial line sign) extending from the gestational sac to the endometrium cavity represents the interstitial portion of the fallopian tube and is highly sensitive and specific.[5] In unclear cases, the three-dimensional sonography may help the diagnosis.[11]

Conventionally, interstitial pregnancy is treated with open laparotomy and salpingectomy with possible need for blood transfusion, and other treatment options include laparoscopic salpingectomy and systemic methotrexate for unruptured ectopic pregnancies in hemodynamically stable patients.[12]

Approximately 92% of ectopic pregnancies occur in the ampulla part of the fallopian tubes, and rupture of the ampulla ectopic pregnancy usually occurs at 8–12 weeks, whereas 2.5% of the ectopic pregnancies are interstitial ectopic pregnancies, and are less commonly cervical, ovary, and/or peritoneal.[13] Interstitial pregnancy can have disturbed 8–16 weeks of amenorrhea (later than the distal tubal ectopic pregnancy), with subsequent massive internal hemorrhage.[10]

Katz et al. reported two cases of interstitial pregnancy treated successfully with a combined hysteroscopic and laparoscopic approach.[14]

Timmerman et al. reported successful treatment of interstitial ectopic pregnancy by systemic methotrexate (multiple-dose regimen) in two out of three patients.[15]

In addition, Tanaka et al. reported successful treatment of interstitial ectopic pregnancy in 93.9% (31/33) women with bolus dose of methotrexate 100 mg followed by 200 mg of methotrexate infusion over 12 h, and four doses of 15 mg oral folinic acid posttreatment.[16]


  Conclusion Top


Interstitial pregnancy is a rare form of ectopic pregnancy and the obstetricians should be aware of rare forms of ectopic pregnancies. Interstitial pregnancy can have disturbed few days or weeks after the missed period, leading to subsequent significant morbidity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Shih-Ting L, Chih-Ping C, Chen-Ju L, Yen-Ni C, Shin-Wen C. An intrauterine gestational sac surrounded by thin myometrium at fundus. J Med Ultrasound 2017;25:255-7.  Back to cited text no. 1
    
2.
Moawaad NS, Mahajan ST, Moniz NH, Taylor SE, Hurd WW. Current diagnosis and treatment of interstitial pregnancy. Am J Obstet Gynecol 2010;202:15-29.  Back to cited text no. 2
    
3.
Doubilet P, Benson CB. Atlas of Ultrasound in Obstetrics and Gynecology: A Multimedia. Philadelphia: Lippincott, Williams & Wilkins; 2003.  Back to cited text no. 3
    
4.
Timor-Tritsch IE, Monteagudo A, Matera C, Veit CR. Sonographic evolution of cornual pregnancies treated without surgery. Obstet Gynecol 1992;79:1044-9.  Back to cited text no. 4
    
5.
Ackerman TE, Levi CS, Dashefsky SM, Holt SC, Lindsay DJ. Interstitial line: Sonographic finding in interstitial (cornual) ectopic pregnancy. Radiology 1993;189:83-7.  Back to cited text no. 5
    
6.
Tulandi T, Al-Jaroudi D. Interstitial pregnancy: Results generated from the society of reproductive surgeons registry. Obstet Gynecol 2004;103:47-50.  Back to cited text no. 6
    
7.
Chopra S, Keepanasseril A, Rohilla M, Bagga R, Kalra J, Jain V. Obstetric morbidity and the diagnostic dilemma in pregnancy in rudimentary horn: Retrospective analysis. Arch Gynecol Obstet 2009;280:907-10.  Back to cited text no. 7
    
8.
Pluchino N, Ninni F, Angioni S, Carmignani A, Genazzani AR, Cela V. Spontaneous cornual pregnancy after homolateral salpingectomy for an earlier tubal pregnancy: A case report and literature review. J Minim Invasive Gynecol 2009;16:208-11.  Back to cited text no. 8
    
9.
Walid MS, Heaton RL. Diagnosis and laparoscopic treatment of cornual ectopic pregnancy. Ger Med Sci 2010;8. pii: Doc16.  Back to cited text no. 9
    
10.
Faza MA, Abdelazim IA. Interstitial pregnancy a rare form of ectopic pregnancy: Case report. Gynecol Obstet Reprod Med 2017;24. [In Press]. [Doi: 10.21613/GORM.2017.744].  Back to cited text no. 10
    
11.
Hajenius PJ, Mol F, Mol BW, Bossuyt PM, Ankum WM, van der Veen F, et al. Interventions for tubal ectopic pregnancy. Cochrane Database Syst Rev 2007;(1):CD000324.  Back to cited text no. 11
    
12.
Tenore JL. Ectopic pregnancy. Am Fam Physician 2000;61:1080-8.  Back to cited text no. 12
    
13.
Agrawal R, Kumar P. Ectopic pregnancy in tubal stump after ipsilateral salpingo-oophorectomy: An unusual and rare case report. J Infertil Reprod Biol 2015;3:234-6.  Back to cited text no. 13
    
14.
Katz DL, Barrett JP, Sanfilippo JS, Badway DM. Combined hysteroscopy and laparoscopy in the treatment of interstitial pregnancy. Am J Obstet Gynecol 2003;188:1113-4.  Back to cited text no. 14
    
15.
Timmerman E, Roovers JP, Ankum WM, Hajenius PJ. Interstitial pregnancy: A rare type of ectopic pregnancy. Ned Tijdschr Geneeskd 2008;152:787-91.  Back to cited text no. 15
    
16.
Tanaka K, Baartz D, Khoo SK. Management of interstitial ectopic pregnancy with intravenous methotrexate: An extended study of a standardised regimen. Aust N Z J Obstet Gynaecol 2015;55:176-80.  Back to cited text no. 16
    



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