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Hysteroscopy in the diagnosis of suspected interstitial pregnancy
Inr J Gynecol Obster, 1992, 37: I2 I- 126 International Federation of Gynecology and Obstetrics
Hysteroscopy pregnancy J.J. Kabukoba
121
in the diagnosis of suspected interstitial
and R.H.B.
de Courcy-Wheeler
All Saints Hospital, Chatham. Kent (UK) (Received May 19th, 1991) (Revised and accepted June
15th. 1991)
Abstract Three cases are reported in which interstitial pregnancy was suspected on ultrasound scan. The first was managed by scans and laparoscopy, but resulted in rupture of the uterus and hysterectomy at 20 weeks. In the following cases hysteroscopy was used to refute the diagnosis in one patient and confirm it in another within the first trimester. A case is made for the use of hysteroscopy in the assessment of patients with suspected interstitial pregnancy.
Keywords: Interstitial Laparoscopy; scopy;
pregnancy; Ultrasound;
HysteroEctopic
pregnancy. Case 1
A 30-year-old woman, para 2, underwent reversal of sterilization 3 months prior to presentation. She was complaining of vaginal bleeding and abdominal pain. She had a 6 week history of amenorrhea. Ultrasound scan and urine pregnancy test were equivocal. Evacuation of the uterus did not show products of conception. At laparoscopy the uterus and tubes appeared normal. Dye test 0020-7292/92/$05.00 0 1992 international Federation Published and Printed in Ireland
demonstrated a patent right tube. Subsequently the pregnancy test was negative and the patient was discharged. She was re-admitted 6 weeks later with lower abdominal pain. The uterus was enlarged consistent with pregnancy. The urine pregnacy test was positive. Ultrasound scan showed a gestational sac equivalent to 6.6 weeks, situated eccentrically in the right cornu of the uterus, suggestive of an interstitial pregnancy (Fig. I). The patient did not wish any intervention if there was any possibility of an intrauterine pregnancy. A repeat laparoscopy showed what appeared to be a normal gravid uterus. She was discharged home with instructions to return in the event of experiencing any further pain. There were several further admissions for pain but no bleeding. The uterus remained tender to palpation, but continued to grow and her general condition remained satisfactory. Meanwhile an ultrasound scan performed 31 days later demonstrated a centrally situated gestational sac seeming to till the uterus centrally and containing an embryo of 11 weeks (Fig. 2). Another scan at 16 weeks showed a normally growing fetus with normal liquor volume and upper anterior placenta. At 20 weeks the patient was admitted into hospital via flying squad with severe abdomiCase Report
of Gynecology
and Obstetrics
122
Fig. 1.
Kabukoba and Courcy- Wheeler
An eccentric
geatational
sac 21 nun = 6 weeks 6 days with a myometrial mantle around it.
nal pain. She was shocked with a pulse of 80 beats per min and blood pressure of 95/60 mmHg. On abdominal examination there was extreme tenderness maximal in the right iliac Int J Gynecol Obstet 37
fossa. Her hemoglobin concentration was 11.9 g/d1 and white cell count of 21 x 109/1. At laparotomy, the uterus was rupturing at the fundus with 3 1 of blood in the peritoneal
Hystrroscopy in suspecred in~rrstitial pregnancy
Fig. 2.
Same pregnancy as in Fig.
I
showing centrally placed I I week gestational
cavity. The uterus and the amniotic cavity were opened and fetus delivered. The placenta was so adherent that total abdominal hysterectomy with right salpingoophorectomy was necessary. She had a total of six units of
sac with a uniform myometrial
123
mantle around it.
blood transfusion and was discharged home 9 days later. Pathological examination confirmed a ruptured right interstitial ectopic pregnancy. The adjacent uterine cavity was shown to be normal. Case Report
124
Kabukoba and Courcy- Wheeler
Case 2 A 2%year-old married woman presented to hospital complaining of left sided abdominal pain. Her last menstrual period had been 8 weeks previously. She had no vaginal bleeding, discharge or dysuria. Ultrasound scan confirmed an 8 + 3 weeks pregnancy. The sac was very high and pregnancy was Interstitial eccentric. suspected. Her hemoglobin concentration was 13.3 g/d1 and white cell count was 7.3 x 109/l. Another ultrasound scan was performed 3 weeks later. The crown-rump length was equivalent to 11 + 4 weeks. The gestational sac was again situated eccentrically to the left. Interstitial pregnancy was still suspected. As the patient was still asymptomatic ultrasound scan was repeated a week later. She was now complaining of left sided abdominal pain and had some tenderness in the left iliac fossa. The gestational sac was still eccentrically placed, and an uninterrupted midline echo could be seen from the cervix to the body of the uterus. CO2 hysteroscopy was performed under general anesthesia. The cervix was held with a single volsellum and a 5 mm, 30” Storz hysteroscope (Rimmer Brothers, London) was introduced very slowly under direct vision. An intrauterine gestational sac was clearly identified. Through the membranes the face and hand of the fetus were unequivocally demonstrated. Thus an intrauterine pregnancy was confirmed. The patient was discharged 2 days later without any complications. Subsequent scans were normal. The rest of her pregnancy progressed uneventfully until 36 + 5 weeks when she was admitted complaining of leaking liquor. A day later, she delivered a healthy baby boy weighing 2.3 kg. Both were discharged home after 5 days. Case 3 A 22-year-old woman was admitted to hospital complaining of painless vaginal bleeding after 6 weeks of amenorrhea. She was generally well. Inr J Gynecol Obsret 37
An ultrasound scan showed increased echoes in the posterior wall of the uterus, and a gestational sac equivalent to 6 weeks. Another scan a week later showed a gestational sac of 7 + 3 weeks eccentrically sited in the area of the cornu of the uterus. An uninterrupted midline echo could be seen. Three other scans at weekly intervals continued to show an eccentric gestational sac but growing normally. She complained of some discomfort in the lower abdomen but was never tender there. Because of the possibility of interstitial pregnancy a diagnostic hysteroscopy was performed at 10 + 4 weeks.There was no intrauterine pregnancy. The cavity was regular without any distortion. Laparotomy was performed. At laparotomy the uterus looked pregnant with a regular outline. There was a palpable area of induration in the posterior wall of the left cornual region but the fallopian tubes were normal. It was not possible to save the uterus and a hysterectomy was performed. She had an uneventful postoperative period and was discharged home 6 days later. Pathological examination of the excised specimen confirmed an interstitial pregnancy expanding into the left cornu of the uterus. Discussion Interstitial pregnancy is known to be a rare occurence. Beckman et al. [2] estimated the incidence to be between 112500and l/5000 live births. In a 10 year survey of ectopic pregnancies occurring in Medway Health District between 1977 and 1986, during which time there were 44 885 deliveries, Dimitry [5] uncovered five cases; an incidence of 118977 deliveries and 2.6% of all ectopic pregnancies. Felmus and Pedowitz [6] had earlier reported an incidence for interstitial pregnancy of 4-6% of all ectopic pregnancies. Case 1 in which the interstitial pregnancy occurred following reversal of sterilization, appears to the first such case to be reported in the literature. The difficult problems with the diagnosis of interstitial pregnancy with its attendant high morbidity and mortality were previously
Hysteroscopy
discussed by Felmus and Pedowitz 161, and Kalchman and Meltzer [9]. The morbidity of interstitial pregnancy is much higher than in other forms of ectopic pregnancy particularly because uterine rupture occurs at a later gestational age and is associated with severe hemorrhage [7]. The advent and widespread use of ultrasound and laparoscopy have revolutionized the diagnosis of ectopic pregnancy in general. Chandra et al. [3], Auslender et al. [2], Pevic et al. [lo] and Jafri et al. [8] have described ultrasonic features of an interstitial pregnancy as being an eccentrically located gestational sac surrounded by an asymmetric myometrial mantle and a separate empty uterine cavity. In all our three cases, the patient presented with lower abdominal pain and had all the ultrasonic features described for interstitial pregnancy. However these features disappeared after 12 weeks in cases 1 and 2. Whereas case 1 had an interstitial pregnancy, case 2 did not. Therefore while the ultrasound marker is useful in prompting suspicion and further investigation it is not a specific feature. Laparoscopy has been the definitive diagnostic procedure and has been found useful by Auslender et al. [l]. This has not been our experience in case 1 and case 3 would have been missed because there was no notable external uterine abnormality. Missing the diagnosis in case 1 was almost fatal because the pregnancy was allowed to continue until it ruptured at 20 weeks. It was the end of her obstetric career. The lesson from this is that if laparoscopy cannot confirm the diagnosis of interstitial pregnancy other investigations are necessary. When faced with the same dilemma as in case 2, after noting the ultrasonic features described earlier, we performed hysteroscopy. This confirmed an intrauterine pregnancy. Therefore it was not an interstitial pregnancy and further probing with laparoscopy was not necessary. The pregnancy progressed normally until delivery at 36 + 5 weeks. In case 3, the same line of investigation was followed, that is ultrasound and hystero-
in suspected interstitial pregnancy
I25
scopy. There was no intrauterine pregnancy seen and therefore laparotomy followed. Had laparoscopy been carried out, the interstitial pregnancy would have been missed because there was no external uterine abnormality. The unfortunate thing was inspite of the diagnosis being made prior to rupture, hysterectomy was inevitable because of the large area of muscle destruction. We would like to think an earlier hysteroscopy and laparotomy would have saved the uterus as has been reported by Confino and Gleicher [4]. In this report of three cases we have demonstrated that a high and eccentric gestional sac is an important but not specific pointer to an interstitial pregnancy; that laparoscopy is not infallible in the diagnosis of this type of ectopic pregnancy; and that COZ gas hysteroscopy can safely be employed (in expert hands and with due care) to definitively confirm an intrauterine pregnancy and thereby exclude an interstitial pregnancy. As it is clearly the only reliable way of securing a diagnosis it deserves to be known and its safety in pregnancy assessed further. References Austender
R, Arodi
J, Pascal B, Ambramvichi
H: In-
terstitial pregnancy: early diagnosis by ultrasonography. Am J Obstet Gynecol Beckman
CRB,
146; 717, 1983.
Tomas
AM,
terstitial and intra-uterine early
pregnancy
and cesarean
Obstet Gynecol Chandra
P,
Contino
Koenigsberg
delivery
ment of interstitial
M,
Romney
Am
J
SL,
Koren
2,
52: 613, 1978.
N: Conservative
pregnancy.
surgical
manage-
Fertil Steril 52: 600, 1989.
ES: A ten year survey of 193 ectopic pregnancies.
J Obstet Gynaecol
9: 309, 1989.
Felmus BL, Pedowitz
P: Interstitial
of 45 cases. Am J Obstet Gynecol Gretz
at term.
interstitial pregnancy: diagnosis
Obstet Gynecol
E, Gleicher
Dimitry
in-
149: 83, 1984.
Schulman H: Unruptured and treatment.
Jessica LT: Combined
pregnancy: cornual resection in
HF,
Gynecol
Higgins
PC:
pregnancy:
A survey
66: 1271, 1953.
Interstitial
Pregnancy.
Obstet
25: 880, 1965.
Jafri SZ, Loginsky SJ, Bouffard JA, Selis JE: Sonographic detection of interstitial
pregnancy.
J Clin Ultrasound
15:
253, 1987. Kalchman
GG,
Meltzer
following
homolateral
Gynecol
96: 1139, 1966.
RM:
Interstitial
salpingectomy.
Am
pregnancy J
Obstet
Case Report
126
Kabukoba
and Courcy- Wheeler
10 Rvic N, Neuenschwander E, Gschwind C: Interstitial pregnancy following bilateral salpingectomy and in vitro fertilization-embryo transfer. Fertil Steril 46: 701, 1986.
Int J Gynecol
Obster
37
Address far reprints J.J. Kabukoba 75 Sydney Road Skicup, Kent DA14 6RA, UK
Hysteroscopy pregnancy J.J. Kabukoba
121
in the diagnosis of suspected interstitial
and R.H.B.
de Courcy-Wheeler
All Saints Hospital, Chatham. Kent (UK) (Received May 19th, 1991) (Revised and accepted June
15th. 1991)
Abstract Three cases are reported in which interstitial pregnancy was suspected on ultrasound scan. The first was managed by scans and laparoscopy, but resulted in rupture of the uterus and hysterectomy at 20 weeks. In the following cases hysteroscopy was used to refute the diagnosis in one patient and confirm it in another within the first trimester. A case is made for the use of hysteroscopy in the assessment of patients with suspected interstitial pregnancy.
Keywords: Interstitial Laparoscopy; scopy;
pregnancy; Ultrasound;
HysteroEctopic
pregnancy. Case 1
A 30-year-old woman, para 2, underwent reversal of sterilization 3 months prior to presentation. She was complaining of vaginal bleeding and abdominal pain. She had a 6 week history of amenorrhea. Ultrasound scan and urine pregnancy test were equivocal. Evacuation of the uterus did not show products of conception. At laparoscopy the uterus and tubes appeared normal. Dye test 0020-7292/92/$05.00 0 1992 international Federation Published and Printed in Ireland
demonstrated a patent right tube. Subsequently the pregnancy test was negative and the patient was discharged. She was re-admitted 6 weeks later with lower abdominal pain. The uterus was enlarged consistent with pregnancy. The urine pregnacy test was positive. Ultrasound scan showed a gestational sac equivalent to 6.6 weeks, situated eccentrically in the right cornu of the uterus, suggestive of an interstitial pregnancy (Fig. I). The patient did not wish any intervention if there was any possibility of an intrauterine pregnancy. A repeat laparoscopy showed what appeared to be a normal gravid uterus. She was discharged home with instructions to return in the event of experiencing any further pain. There were several further admissions for pain but no bleeding. The uterus remained tender to palpation, but continued to grow and her general condition remained satisfactory. Meanwhile an ultrasound scan performed 31 days later demonstrated a centrally situated gestational sac seeming to till the uterus centrally and containing an embryo of 11 weeks (Fig. 2). Another scan at 16 weeks showed a normally growing fetus with normal liquor volume and upper anterior placenta. At 20 weeks the patient was admitted into hospital via flying squad with severe abdomiCase Report
of Gynecology
and Obstetrics
122
Fig. 1.
Kabukoba and Courcy- Wheeler
An eccentric
geatational
sac 21 nun = 6 weeks 6 days with a myometrial mantle around it.
nal pain. She was shocked with a pulse of 80 beats per min and blood pressure of 95/60 mmHg. On abdominal examination there was extreme tenderness maximal in the right iliac Int J Gynecol Obstet 37
fossa. Her hemoglobin concentration was 11.9 g/d1 and white cell count of 21 x 109/1. At laparotomy, the uterus was rupturing at the fundus with 3 1 of blood in the peritoneal
Hystrroscopy in suspecred in~rrstitial pregnancy
Fig. 2.
Same pregnancy as in Fig.
I
showing centrally placed I I week gestational
cavity. The uterus and the amniotic cavity were opened and fetus delivered. The placenta was so adherent that total abdominal hysterectomy with right salpingoophorectomy was necessary. She had a total of six units of
sac with a uniform myometrial
123
mantle around it.
blood transfusion and was discharged home 9 days later. Pathological examination confirmed a ruptured right interstitial ectopic pregnancy. The adjacent uterine cavity was shown to be normal. Case Report
124
Kabukoba and Courcy- Wheeler
Case 2 A 2%year-old married woman presented to hospital complaining of left sided abdominal pain. Her last menstrual period had been 8 weeks previously. She had no vaginal bleeding, discharge or dysuria. Ultrasound scan confirmed an 8 + 3 weeks pregnancy. The sac was very high and pregnancy was Interstitial eccentric. suspected. Her hemoglobin concentration was 13.3 g/d1 and white cell count was 7.3 x 109/l. Another ultrasound scan was performed 3 weeks later. The crown-rump length was equivalent to 11 + 4 weeks. The gestational sac was again situated eccentrically to the left. Interstitial pregnancy was still suspected. As the patient was still asymptomatic ultrasound scan was repeated a week later. She was now complaining of left sided abdominal pain and had some tenderness in the left iliac fossa. The gestational sac was still eccentrically placed, and an uninterrupted midline echo could be seen from the cervix to the body of the uterus. CO2 hysteroscopy was performed under general anesthesia. The cervix was held with a single volsellum and a 5 mm, 30” Storz hysteroscope (Rimmer Brothers, London) was introduced very slowly under direct vision. An intrauterine gestational sac was clearly identified. Through the membranes the face and hand of the fetus were unequivocally demonstrated. Thus an intrauterine pregnancy was confirmed. The patient was discharged 2 days later without any complications. Subsequent scans were normal. The rest of her pregnancy progressed uneventfully until 36 + 5 weeks when she was admitted complaining of leaking liquor. A day later, she delivered a healthy baby boy weighing 2.3 kg. Both were discharged home after 5 days. Case 3 A 22-year-old woman was admitted to hospital complaining of painless vaginal bleeding after 6 weeks of amenorrhea. She was generally well. Inr J Gynecol Obsret 37
An ultrasound scan showed increased echoes in the posterior wall of the uterus, and a gestational sac equivalent to 6 weeks. Another scan a week later showed a gestational sac of 7 + 3 weeks eccentrically sited in the area of the cornu of the uterus. An uninterrupted midline echo could be seen. Three other scans at weekly intervals continued to show an eccentric gestational sac but growing normally. She complained of some discomfort in the lower abdomen but was never tender there. Because of the possibility of interstitial pregnancy a diagnostic hysteroscopy was performed at 10 + 4 weeks.There was no intrauterine pregnancy. The cavity was regular without any distortion. Laparotomy was performed. At laparotomy the uterus looked pregnant with a regular outline. There was a palpable area of induration in the posterior wall of the left cornual region but the fallopian tubes were normal. It was not possible to save the uterus and a hysterectomy was performed. She had an uneventful postoperative period and was discharged home 6 days later. Pathological examination of the excised specimen confirmed an interstitial pregnancy expanding into the left cornu of the uterus. Discussion Interstitial pregnancy is known to be a rare occurence. Beckman et al. [2] estimated the incidence to be between 112500and l/5000 live births. In a 10 year survey of ectopic pregnancies occurring in Medway Health District between 1977 and 1986, during which time there were 44 885 deliveries, Dimitry [5] uncovered five cases; an incidence of 118977 deliveries and 2.6% of all ectopic pregnancies. Felmus and Pedowitz [6] had earlier reported an incidence for interstitial pregnancy of 4-6% of all ectopic pregnancies. Case 1 in which the interstitial pregnancy occurred following reversal of sterilization, appears to the first such case to be reported in the literature. The difficult problems with the diagnosis of interstitial pregnancy with its attendant high morbidity and mortality were previously
Hysteroscopy
discussed by Felmus and Pedowitz 161, and Kalchman and Meltzer [9]. The morbidity of interstitial pregnancy is much higher than in other forms of ectopic pregnancy particularly because uterine rupture occurs at a later gestational age and is associated with severe hemorrhage [7]. The advent and widespread use of ultrasound and laparoscopy have revolutionized the diagnosis of ectopic pregnancy in general. Chandra et al. [3], Auslender et al. [2], Pevic et al. [lo] and Jafri et al. [8] have described ultrasonic features of an interstitial pregnancy as being an eccentrically located gestational sac surrounded by an asymmetric myometrial mantle and a separate empty uterine cavity. In all our three cases, the patient presented with lower abdominal pain and had all the ultrasonic features described for interstitial pregnancy. However these features disappeared after 12 weeks in cases 1 and 2. Whereas case 1 had an interstitial pregnancy, case 2 did not. Therefore while the ultrasound marker is useful in prompting suspicion and further investigation it is not a specific feature. Laparoscopy has been the definitive diagnostic procedure and has been found useful by Auslender et al. [l]. This has not been our experience in case 1 and case 3 would have been missed because there was no notable external uterine abnormality. Missing the diagnosis in case 1 was almost fatal because the pregnancy was allowed to continue until it ruptured at 20 weeks. It was the end of her obstetric career. The lesson from this is that if laparoscopy cannot confirm the diagnosis of interstitial pregnancy other investigations are necessary. When faced with the same dilemma as in case 2, after noting the ultrasonic features described earlier, we performed hysteroscopy. This confirmed an intrauterine pregnancy. Therefore it was not an interstitial pregnancy and further probing with laparoscopy was not necessary. The pregnancy progressed normally until delivery at 36 + 5 weeks. In case 3, the same line of investigation was followed, that is ultrasound and hystero-
in suspected interstitial pregnancy
I25
scopy. There was no intrauterine pregnancy seen and therefore laparotomy followed. Had laparoscopy been carried out, the interstitial pregnancy would have been missed because there was no external uterine abnormality. The unfortunate thing was inspite of the diagnosis being made prior to rupture, hysterectomy was inevitable because of the large area of muscle destruction. We would like to think an earlier hysteroscopy and laparotomy would have saved the uterus as has been reported by Confino and Gleicher [4]. In this report of three cases we have demonstrated that a high and eccentric gestional sac is an important but not specific pointer to an interstitial pregnancy; that laparoscopy is not infallible in the diagnosis of this type of ectopic pregnancy; and that COZ gas hysteroscopy can safely be employed (in expert hands and with due care) to definitively confirm an intrauterine pregnancy and thereby exclude an interstitial pregnancy. As it is clearly the only reliable way of securing a diagnosis it deserves to be known and its safety in pregnancy assessed further. References Austender
R, Arodi
J, Pascal B, Ambramvichi
H: In-
terstitial pregnancy: early diagnosis by ultrasonography. Am J Obstet Gynecol Beckman
CRB,
146; 717, 1983.
Tomas
AM,
terstitial and intra-uterine early
pregnancy
and cesarean
Obstet Gynecol Chandra
P,
Contino
Koenigsberg
delivery
ment of interstitial
M,
Romney
Am
J
SL,
Koren
2,
52: 613, 1978.
N: Conservative
pregnancy.
surgical
manage-
Fertil Steril 52: 600, 1989.
ES: A ten year survey of 193 ectopic pregnancies.
J Obstet Gynaecol
9: 309, 1989.
Felmus BL, Pedowitz
P: Interstitial
of 45 cases. Am J Obstet Gynecol Gretz
at term.
interstitial pregnancy: diagnosis
Obstet Gynecol
E, Gleicher
Dimitry
in-
149: 83, 1984.
Schulman H: Unruptured and treatment.
Jessica LT: Combined
pregnancy: cornual resection in
HF,
Gynecol
Higgins
PC:
pregnancy:
A survey
66: 1271, 1953.
Interstitial
Pregnancy.
Obstet
25: 880, 1965.
Jafri SZ, Loginsky SJ, Bouffard JA, Selis JE: Sonographic detection of interstitial
pregnancy.
J Clin Ultrasound
15:
253, 1987. Kalchman
GG,
Meltzer
following
homolateral
Gynecol
96: 1139, 1966.
RM:
Interstitial
salpingectomy.
Am
pregnancy J
Obstet
Case Report
126
Kabukoba
and Courcy- Wheeler
10 Rvic N, Neuenschwander E, Gschwind C: Interstitial pregnancy following bilateral salpingectomy and in vitro fertilization-embryo transfer. Fertil Steril 46: 701, 1986.
Int J Gynecol
Obster
37
Address far reprints J.J. Kabukoba 75 Sydney Road Skicup, Kent DA14 6RA, UK