A 30-year-old female underwent in-vitro fertilization and preimplantation genetic testing. The patient conceived after her first frozen embryo transfer (FET). Beta-hCG was measured at 85 and was doubling appropriately. Ultrasound showed an angular pregnancy with heart beat confirmed by MRI. The patient has a deep arcuate uterus which may have predisposed to angular pregnancy. She was given 3 doses of methotrexate unsuccessfully. Due to concern of rupture, she underwent a hysteroscopic injection of methotrexate inside the gestational sac at 7 weeks. Hysteroscopy showed the gestational sac within the angular portion of the uterus as well as the needle penetrating the gestational sac to inject the 50mg methotrexate (see video). Fetal heart rate ceased and the patient passed products of conception 1 week later. The patient had no further complications and had a normal pregnancy on her next FET that resulted in a livebirth.
A 6mm diagnostic hysteroscope was then advanced through the cervical os without need for cervical dilation. Thick decidualization was noted. Hysteroscope was advanced to fundus, right ostium was visualized. Left ostium poorly visualized as it was obscured by the pregnancy, which was noted to be adherent near the ostium, approximately at 2 o'clock position. A SideKick cystoscopy needle was then advanced through the hysteroscopic port into the cavity. Methotrexate was then injected via this needle into the gestational sac, as well as into myometrium deep to the gestational sac.
The needle was removed. Examination of the uterine cavity and gestational sac was notable for excellent hemostasis. The hysteroscope was removed. All instruments were then removed and the cervix was noted to be hemostatic. The patient tolerated the procedure well. Sponge, needle and instrument counts were correct x2. The patient was taken to the recovery room in stable condition.
G2P0010 female who presents for hysteroscopic evaluation of previously diagnosed left angular pregnancy. She was undergoing in-vitro fertilization and preimplantation genetic testing and conceived after frozen embryo transfer. Ultrasound was suspicious for an angular pregnancy which was confirmed by MRI. The patient was treated with multiple doses of systemic methotrexate but failed. The decision was made after a thorough discussion with the patient and her spouse to proceed with diagnostic hysteroscopy with an injection of methotrexate into the gestational sac under direct visualization in order to preserve uterus for future fertility
Kidney and Liver disease
The patient was placed in the dorsal lithotomy position with Allen stirrups. The patient was prepped and draped in the normal sterile fashion. A bivalve speculum was inserted into the vagina, cervix was visualized, and a single tooth tenaculum was used to grasp the anterior lip of the cervix.
MRI and US
The uterus is slightly retroverted. There is a single intrauterine
pregnancy which appears to be angular on the left. Surrounding myometrium
is approximately as thin as 5 mm. Intrauterine gestational sac measuring
2.8 x 1.8 x 2.1 cm.
Allows preservation of fertility in a patient trying to conceive while minimizing operative risk
Vaginal bleeding, failed methotrexate administration, and
No disclosures
N/A
1.Bayyarapu, Vijaya B., and Sirisha R. Gundabattula. “Diagnosis and Management of ‘Cornual’ Pregnancies from 2002 to 2015 at a Tertiary Referral Centre in South India: Insights from Introspection.” Journal of Obstetrics and Gynaecology of India 67, no. 6 (2017): 414–20. https://doi.org/10.1007/s13224-017-0983-6.
2.Laus, Katharina, Pooja Louis, and Laura Douglass. “A Novel Approach to Management of Angular Pregnancies: A Case Series.” Journal of Minimally Invasive Gynecology 26, no. 1 (2019): 178–81. https://doi.org/10.1016/j.jmig.2018.08.002.
3.Nadi, M., C. Richard, L. Filipuzzi, L. Bergogne, S. Douvier, and P. Sagot. “[Interstitial, angular and cornual pregnancies: Diagnosis, treatment and subsequent fertility].” Gynecologie, Obstetrique, Fertilite & Senologie 45, no. 6 (June 2017): 340–47. https://doi.org/10.1016/j.gofs.2017.05.002.
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