International Journal of Biomedical And Advance Research ISSN: 2229-3809 (Online) Journal DOI:10.7439/ijbar CODEN:IJBABN IJBAR (2014) 05 (12) www.ssjournals.com Case Report Interstitial Pregnancy - A Clinico - Sonographic Diagnostic Dilemma Surekha Tayade 1* , Atul Tayade 2 , Poonam V Shivkumar 1 and Priya Kale 2 1 Department of Obstetrics and Gynecology, Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha, Maharashtra, India 2 Department of Radiology, Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha, Maharashtra, India *Correspondence Info: Dr. Surekha Tayade, E/4, Senior Staff Quarters, KHS Campus, MGIMS, Sewagram, Wardha, Maharashtra, India, 442102 E-mail: surekhatayademgims@yahoo.co.in 1. Background Ectopic pregnancy is one of the leading causes of maternal mortality. The majority of ectopic pregnancies are tubal and located within the fallopian tubes. However, implantation in the cervix, interstitial tubal segment, ovary and at various intra-abdominal sites is also known. The diagnosis and management of pregnancies in these unusual implantation sites present dilemmas to the attending physician 1 . Ectopic pregnancy in the interstitial part of the fallopian tube is a rare event, constituting only 2-4 % of all tubal ectopic pregnancies and is associated with a high rate of complications. This condition presents a challenge for clinical as well as radiological diagnosis. While all ectopic pregnancies are associated with a risk of hemorrhage, interstitial pregnancies are associated with the highest risk of massive, uncontrollable bleeding 2,3 . There is a higher risk of maternal mortality due to delayed diagnosis and high vascularity of the myometrium 4,5 . The maternal mortality quoted for interstitial pregnancy is 2-2.5 % as compared to 0.14 % for tubal ectopic pregnancies 6 . In contrast to the common clinical notion that rupture occurs only between 12 and 16 weeks, in interstitial pregnancies, rupture could happen at any time in early pregnancy too. Hence, diagnosing an interstitial pregnancy at an early stage becomes imperative to prevent catastrophic hemorrhage. This should involve expert ultrasonographic assistance and good clinical acumen; otherwise, rupture could happen suddenly 4 . An abdominal ultrasound can be deceptive in evaluating interstitial ectopic pregnancies and transvaginal ultrasonography is more sensitive in its diagnosis 5 . We are reporting a case where the diagnostic dilemma persisted in a case of an early interstitial pregnancy and the expertise of two different sonologists was sought. The pregnancy was allowed to continue with conservative management, however, follow up scans revealed typical sonographic features of a gestational sac in an eccentric position and a thinning myometrial mantle around it. Clinically the woman showed signs of intraperitoneal bleed which allowed decision for intervention in the form of laparotomy. 2. Case report A 36 years old primigravida reported to the obstetric outpatient unit of a rural hospital of central India with the history of amenorrhea of 39 days followed by slight vaginal bleeding. She had history of primary infertility for which she was being managed in the infertility clinic. There was past history of pulmonary tuberculosis for which the woman had received 6 months of anti tuberculosis treatment. However, endometrial culture did not reveal mycobacterium and both tubes were found patent on hysterosalphingography. This pregnancy was conceived after 3 cycles of ovulation induction and intrauterine insemination. She was clinically stable with normal vital signs and per abdominal examination revealed no abnormality. Ultrasound examination done by consultant sonologist revealed an empty uterine cavity with the evidence of a 5.5 weeks old gestation sac (GS) located eccentrically in right high lateral fundal region of uterus with no yolk sac or embryo. The possibility of right interstitial pregnancy was expressed in the report, however, in view of position of gestation sac the possibility of a right far lateral intrauterine pregnancy was also kept. To overcome this dilemma the sonography was done from a second sonologist who clearly stated that it was an intrauterine pregnancy of 5.5 weeks (GSD 1.48 cm) placed at the right cornu. As the woman was stable hemodynamically with a very early gestation the decision was taken to manage her conservatively. However, the obstetric scan was repeated after 2 weeks wherein a deformed gestation sac of 1.67 cm was seen with no yolk sac or embryo in the right cornual region. Ultrasound report given was missed abortion for which evacuation procedure was done. Post evacuation on day 2 it was noted that the woman had tenderness in the lower abdomen. However, vital parameters (pulse and blood pressure) were normal. Follow up transvaginal scan at the institutional ultrasonograhy unit showed a complex mixed echogenic mass of size 4.2x3.1x3.3 cm in the right cornual region with significant echogenic fluid in the pelvis. A thinning myometrial mantle around it was seen. Suspecting a ruptured interstitial ectopic pregnancy, laparotomy was done. Intraoperatively we found hemoperitoneum of about 500 ml, a mass of size 5x 5 cm was seen at the right cornu of uterus. The uterine end of the right fallopian tube was embedded in the mass and rest of the tube was clearly visible attached to the mass confirming the diagnosis of right interstitial pregnancy. The right ovary had corpus luteum cyst. Cornual excision was done and complete hemostasis was achieved. Left fallopian tube and ovary were found to be normal. The woman recovered well after the surgery. Abstract Ectopic pregnancy in the interstitial part of the fallopian tube is a rare event, constituting only 2-4 % of all tubal ectopic pregnancies and is associated with a high rate of complications. While all ectopic pregnancies are associated with a risk of hemorrhage, interstitial pregnancies are associated with the highest risk of massive, uncontrollable bleeding. There is a higher risk of maternal mortality due to delayed diagnosis and high vascularity of the myometrium. It presents a challenge for clinical as well as radiological diagnosis. We are reporting a case where the diagnostic dilemma persisted in a case of an early interstitial pregnancy and the expertise of two different sonologists was sought. The ectopic nature of the pregnancy could be confirmed in the follow up ultrasound after 2 weeks and appropriate management was instituted. Classical interstitial line sign with eccentrically placed gestational sac and thin endometrial mantle around it is diagnostic. Keywords: Interstitial pregnancy, Ectopic Pregnancy, Cornual Pregnancy