Hysteroscopic Management of Interstitial Ectopic Pregnancy скачать в хорошем качестве

Hysteroscopic Management of Interstitial Ectopic Pregnancy

This video demonstrates the hysteroscopic management of a proximal interstitial ectopic pregnancy and highlights key steps in diagnosis and treatment. The patient is a healthy 38-year-old G3P0 who had a recent miscarriage managed with dilation and curettage (D&C). Persistent spotting and a beta-hCG of 37 two months later prompted referral. Ultrasound showed a normal-sized anteverted uterus with a thin endometrium and a 2 cm avascular area in the left fundal region bulging from the interstitial portion of the fallopian tube with minimal residual myometrial thickness. Sonohysterogram confirmed a lesion communicating with the uterine cavity, suggesting a proximal interstitial implantation. An interstitial ectopic pregnancy occurs when implantation is in the intramural segment of the fallopian tube. Although rare, it carries a 2.5% mortality—seven times higher than other ectopic pregnancies—making early diagnosis critical. Ultrasound criteria include an empty uterine cavity, a gestational sac at least 1 cm from the lateral uterine edge, and a myometrial layer of 5 mm or less surrounding the sac. The most specific sign is the interstitial line, an echogenic line connecting the sac to the endometrial cavity. A classification system based on implantation site within the 1–2 cm interstitial segment guides surgical planning. Distal implantations may be treated with retrograde milking or salpingectomy; central lesions often require cornuectomy or cornuostomy; proximal implantations can be treated hysteroscopically. Laparoscopy confirmed a proximal implantation. Differentiating a proximal interstitial pregnancy from a cornual intrauterine pregnancy is essential, as the latter may be viable. At laparoscopy, interstitial pregnancy shows lateral uterine distension and upward–medial displacement of the round ligament, while a cornual intrauterine pregnancy causes outward displacement. Hysteroscopy revealed an empty cavity with bilateral ostia and calcified products of conception implanted in the proximal left interstitial tube. Step 1: Location confirmation with laparoscopy and hysteroscopy. Step 2: Vasopressin injection into the cervix or myometrium to reduce bleeding. Step 3: Hysteroscopic resection under laparoscopic guidance using a 6 mm hysteroscope and a mechanical tissue removal system. Laparoscopic transillumination allowed real-time assessment of residual myometrial thickness and identification of any remaining products of conception. Hydrodissection can distort anatomy, so a laparoscopic assistant gently probed the fallopian tube to delineate the cavity, isthmic portion, and interstitial segment. Correlating hysteroscopic and laparoscopic views ensured accurate resection. Final hysteroscopic inspection showed an empty left cornua with no residual tissue. Step 4: A tubal dye test confirmed bilateral patency and demonstrated the previous implantation site, along with the characteristic upward and medial displacement of the round ligament. At eight weeks post-operation, the patient’s menses had normalised, beta-hCG was negative, and hysterosonogram showed a normal uterine cavity with good myometrial thickness and no residual bulge. This case illustrates that precise diagnosis of proximal interstitial ectopic pregnancy allows successful treatment with hysteroscopic resection, avoiding more invasive procedures such as cornuectomy or salpingectomy.