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Interstitial pregnancy: Early diagnosis by ultrasonography
Volume 146 Number 6
Communications in brief
717
REFERENCES
J., and Young J. L., Jr.: Third National Cancer Survey, Incidence Data, Natl. Cancer Inst. Monogr. 41:1, 1975. 2. Peters, R. L., Afroudakis, A. P., and Tatter, D.: The changing incidence of association of hepatitis B with hepatocellular carcinoma in California, Am. J. Clin. Pathol. 68:1, 1977. l. Cutler, S.
Interstitial pregnancy: Early diagnosis by ultrasonography R. Auslender, M.D., J. Arodi, M.D., B. Pascal, M.D., and H. Abramovici, M.D. Department of Obstetrics and Gynecowgy, Lady Davis Carmel Hospital, Haifa, Israel
Interstitial pregnancy is a rare but extremely dangerous form of ectopic pregnancy.' Although the diagnosis of this condition prior to rupture is difficult, early detection is essential in avoiding a fatal outcome. By using ultrasonography early in pregnancy (weeks 5 to 6), one can determine the exact position of the gestational sac within the uterine cavity. A fundal, very lateral location of the gestational sac raises the suspicion that pregnancy may develop into the interstitial part of the tube. The purpose of the case described here is to demonstrate the great value of ultrasonography in the early diagnosis of interstitial pregnancy. A 20-year-old woman, married with two children, was admitted to our department because of amenorrhea of 6 weeks and lower abdominal pains, which appeared a week prior to her hospitalization. Her medical history showed normal, regular menstrual periods (every 28 days, lasting 5 days) and two normal deliveries, followed by right salpingectomy because of an extrauterine tubal pregnancy. On examination, the patient lvas in good general condition with a blood pressure of 100/60 mm Hg and a pulse of 72 bpm. The abdomen was soft, presenting a slight right lower-quadrant sensitivity. The pelvic examination revealed a soft, slightly enlarged uterus without adnexal or Douglas findings. A blood test demonstrated the presence of the beta subunit of human chorionic gonadotropin. The ultrasonic examination showed a 6 weeks' intrauterine normal gestational sac which appeared to be in a very lateral position close to the right uterine cornu. The patient was kept under supervision and within 3 days the pain disappeared. The patient felt well and was discharged; however, because of the unusual lateral position of the gestational sac, we decided to follow up the development of the pregnancy in the forthcoming weeks. During the follow-up the patient remained asymptomatic, and repeat ultrasonic examinations showed findings similar to those of the first examination. After 3 weeks of ambulatory follow-up, the patient was readmitted following abdominal pains and slight vaginal bleeding. The patient's general condition was good; the abdomen was soft but sensitive in the lower right region. On gynecologic examination, the uterus was enlarged as for a Reprint requests: R. Auslender, M.D., Department of Obstetrics and Gynecology, Carmel Hospital, Haifa 34362, Israel.
Fig. I. Ultrasonogram showing 9-week pregnancy located in the right cornual area. I 0-week pregnancy and asymmetric with a very sensitive protrusion of the right cornual region. The ultrasonic examination revealed an enlarged, asymmetric uterus, with a normal 9-week pregnancy located in the right cornual area. Fetal heartbeats were present (Fig. 1). In view of the clinical symptomatology, past history (right salpingectomy) , and especially the ultrasonit: findings, the diagnosis of a right interstitial pregnancy was made, and an explorative laparotomy was carried out. During operation, the uterus was found to be enlarged, soft, and asymmetric, corresponding to a I 0-week pregnancy. The main finding was a thin-walled protrusion containing the pregnancy and located in the area of the right cornu and the tubular stump. Because of the position, the size of the findings, and the extremely thin uterine wall in the area of the pregnancy, a conservative operation was thought to be inappropriate, and a total abdominal hysterectomy was carried out. The histologic examination confirmed the diagnosis of a t}.week interstitial pregnancv. Interstitial pregnancy is a very rare form of tubal pregnancy appearing more often after salpingectomy .2 The diagnosis is very difficult because of the lack of specific symptoms. The most common clinical symptoms are amenorrhea, abdominal pain, and bleeding. These symptoms are nonspecific and can be found in diverse other conditions, e.g., threatened abortion, all forms of ectopic pregnancy, incomplete abortion, etc. Because of the lack of specific symptoms, most interstitial pregnancies noted in the literature were diagnosed during emergency operation carried out for intraperitoneal bleeding and hemorrhagic shock due to rupture of the interstitial pregnancy. This lack of definitive diagnosis is apparently the reason for the high mortality
718
Communications in brief
July 15. l9H'l
Am.
rate which has been published so far. 2 • 3 The methods described in the literature which may help in making an early diagnosis of interstitial pregnancy are laparoscopy, culdocentesis, hysterosaipingography, etc. All of these methods are invasive, difficult to carry out serially for follow-up if the finding is unclear, require general anesthesia, and in some cases even result in spontaneous abortion. As our case showed, ultrasonography is an excellent, noninvasive method of diagnosing an early interstitial pregnancy by locating the exact position of the early gestational sac. The ultrasonographic finding of a gestational sac in a very lateral fundal position, as was found in our patient, is suggestive of an interstitial
J. Obstet.
Gynerol
pregnancy in clinically suspected cases (e.g., amenorrhea, bleeding, pains) and even in asymptomatic cases. These patients must be under constant clinical and ultrasonic surveiliance so that the diagnosis can be made before rupture of the interstitial pregnancy.
REFERENCES l. Novak's TextbookofGynecology,ed. 10, Baltimore, 1981, The Williams & Wilkins Company, p. 653.
2. Kalchman, G. G., and Meltzer, M. R.: Interstitial pregnancy following homolateral salpingectomy, AM. ]. OBSTET. GYNECOl.. 96:1139, 1966. 3. Gretz, F. H., and Higgins, C. P.: Interstitial pregnancy, Obstet. Gynecol. 25:880, 1965.
Communications in brief
717
REFERENCES
J., and Young J. L., Jr.: Third National Cancer Survey, Incidence Data, Natl. Cancer Inst. Monogr. 41:1, 1975. 2. Peters, R. L., Afroudakis, A. P., and Tatter, D.: The changing incidence of association of hepatitis B with hepatocellular carcinoma in California, Am. J. Clin. Pathol. 68:1, 1977. l. Cutler, S.
Interstitial pregnancy: Early diagnosis by ultrasonography R. Auslender, M.D., J. Arodi, M.D., B. Pascal, M.D., and H. Abramovici, M.D. Department of Obstetrics and Gynecowgy, Lady Davis Carmel Hospital, Haifa, Israel
Interstitial pregnancy is a rare but extremely dangerous form of ectopic pregnancy.' Although the diagnosis of this condition prior to rupture is difficult, early detection is essential in avoiding a fatal outcome. By using ultrasonography early in pregnancy (weeks 5 to 6), one can determine the exact position of the gestational sac within the uterine cavity. A fundal, very lateral location of the gestational sac raises the suspicion that pregnancy may develop into the interstitial part of the tube. The purpose of the case described here is to demonstrate the great value of ultrasonography in the early diagnosis of interstitial pregnancy. A 20-year-old woman, married with two children, was admitted to our department because of amenorrhea of 6 weeks and lower abdominal pains, which appeared a week prior to her hospitalization. Her medical history showed normal, regular menstrual periods (every 28 days, lasting 5 days) and two normal deliveries, followed by right salpingectomy because of an extrauterine tubal pregnancy. On examination, the patient lvas in good general condition with a blood pressure of 100/60 mm Hg and a pulse of 72 bpm. The abdomen was soft, presenting a slight right lower-quadrant sensitivity. The pelvic examination revealed a soft, slightly enlarged uterus without adnexal or Douglas findings. A blood test demonstrated the presence of the beta subunit of human chorionic gonadotropin. The ultrasonic examination showed a 6 weeks' intrauterine normal gestational sac which appeared to be in a very lateral position close to the right uterine cornu. The patient was kept under supervision and within 3 days the pain disappeared. The patient felt well and was discharged; however, because of the unusual lateral position of the gestational sac, we decided to follow up the development of the pregnancy in the forthcoming weeks. During the follow-up the patient remained asymptomatic, and repeat ultrasonic examinations showed findings similar to those of the first examination. After 3 weeks of ambulatory follow-up, the patient was readmitted following abdominal pains and slight vaginal bleeding. The patient's general condition was good; the abdomen was soft but sensitive in the lower right region. On gynecologic examination, the uterus was enlarged as for a Reprint requests: R. Auslender, M.D., Department of Obstetrics and Gynecology, Carmel Hospital, Haifa 34362, Israel.
Fig. I. Ultrasonogram showing 9-week pregnancy located in the right cornual area. I 0-week pregnancy and asymmetric with a very sensitive protrusion of the right cornual region. The ultrasonic examination revealed an enlarged, asymmetric uterus, with a normal 9-week pregnancy located in the right cornual area. Fetal heartbeats were present (Fig. 1). In view of the clinical symptomatology, past history (right salpingectomy) , and especially the ultrasonit: findings, the diagnosis of a right interstitial pregnancy was made, and an explorative laparotomy was carried out. During operation, the uterus was found to be enlarged, soft, and asymmetric, corresponding to a I 0-week pregnancy. The main finding was a thin-walled protrusion containing the pregnancy and located in the area of the right cornu and the tubular stump. Because of the position, the size of the findings, and the extremely thin uterine wall in the area of the pregnancy, a conservative operation was thought to be inappropriate, and a total abdominal hysterectomy was carried out. The histologic examination confirmed the diagnosis of a t}.week interstitial pregnancv. Interstitial pregnancy is a very rare form of tubal pregnancy appearing more often after salpingectomy .2 The diagnosis is very difficult because of the lack of specific symptoms. The most common clinical symptoms are amenorrhea, abdominal pain, and bleeding. These symptoms are nonspecific and can be found in diverse other conditions, e.g., threatened abortion, all forms of ectopic pregnancy, incomplete abortion, etc. Because of the lack of specific symptoms, most interstitial pregnancies noted in the literature were diagnosed during emergency operation carried out for intraperitoneal bleeding and hemorrhagic shock due to rupture of the interstitial pregnancy. This lack of definitive diagnosis is apparently the reason for the high mortality
718
Communications in brief
July 15. l9H'l
Am.
rate which has been published so far. 2 • 3 The methods described in the literature which may help in making an early diagnosis of interstitial pregnancy are laparoscopy, culdocentesis, hysterosaipingography, etc. All of these methods are invasive, difficult to carry out serially for follow-up if the finding is unclear, require general anesthesia, and in some cases even result in spontaneous abortion. As our case showed, ultrasonography is an excellent, noninvasive method of diagnosing an early interstitial pregnancy by locating the exact position of the early gestational sac. The ultrasonographic finding of a gestational sac in a very lateral fundal position, as was found in our patient, is suggestive of an interstitial
J. Obstet.
Gynerol
pregnancy in clinically suspected cases (e.g., amenorrhea, bleeding, pains) and even in asymptomatic cases. These patients must be under constant clinical and ultrasonic surveiliance so that the diagnosis can be made before rupture of the interstitial pregnancy.
REFERENCES l. Novak's TextbookofGynecology,ed. 10, Baltimore, 1981, The Williams & Wilkins Company, p. 653.
2. Kalchman, G. G., and Meltzer, M. R.: Interstitial pregnancy following homolateral salpingectomy, AM. ]. OBSTET. GYNECOl.. 96:1139, 1966. 3. Gretz, F. H., and Higgins, C. P.: Interstitial pregnancy, Obstet. Gynecol. 25:880, 1965.