Kenneth Ma1, Navneet Kaur2, Ursula Winters2. 1. Department of Gynaecology, St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom (all authors).. Electronic address: Dr.kennethma@gmail.com. 2. Department of Gynaecology, St. Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom (all authors).
Abstract
OBJECTIVE: To demonstrate and contrast 2 techniques of laparoscopic management of interstitial ectopic pregnancies. DESIGN: Stepwise demonstration of the technique with narrated video footage. SETTING: Tertiary referral center in Manchester, United Kingdom. INTERVENTIONS: Nontubal ectopic pregnancies typically involve the cervix, ovary, myometrium, cesarean scar, and the interstitial portion of the fallopian tube. Interstitial ectopic pregnancies account for 2% of all ectopic pregnancies [1] and are caused by implantation of a fertilized embryo within the proximal and intramural portion of the fallopian tube [2]. They represent specific challenges in diagnosis and management and are associated with increased morbidity and mortality when compared with tubal ectopic pregnancies [3]. The techniques for minimal access surgical management includes laparoscopic cornuectomy and cornuostomy. We present 2 cases of interstitial ectopic pregnancies managed laparoscopically using the 2 different techniques. Case 1: A 33-year-old women, para 2+1, presented at 8 weeks' gestation with lower abdominal pain, vaginal bleeding, and an episode of loss of consciousness. An ultrasound scan showed a gestational sac lateral and posterior to the endometrial cavity with the interstitial line sign present. A yolk sac and a 2-mm fetal pole were noted with fetal heart action present. At laparoscopy, an 800 mL hemoperitoneum was noted, and a laparoscopic cornuectomy was performed (Fig. S1). Operating time was 80 minutes, and she was discharged on day 1 postoperation. Case 2: A 34-year-old women, para 1, presented at 6 weeks' gestation to her local hospital with symptoms of vaginal bleeding and intermittent abdominal pain. A diagnosis of an interstitial ectopic pregnancy was suspected on the ultrasound scan, and conservative management was started because the diagnosis was uncertain. A follow-up scan 7 days later confirmed the diagnosis of a live interstitial ectopic pregnancy, and after consultation, she presented herself to a tertiary referral unit. Serum human chorionic gonadotropin was greater than 11 000 IU/L and 2-dimensional ultrasound scan confirmed the presence of a gestational sac with a yolk sac and fetal pole within the left interstitial space. A slow fetal heart action was seen. A diagnosis of a left interstitial ectopic pregnancy was further confirmed on 3-dimensional ultrasound scan. A laparoscopic cornuostomy was performed as demonstrated in the attached video (Figs. S2-S3). Operating time was 38 minutes with minimal blood loss. At day 7, serum human chorionic gonadotropin level was 364 IU/L. CONCLUSION: Although more research is needed to determine the optimal surgical technique for the management of interstitial ectopic pregnancies, the potential risks and benefits of different techniques should be discussed with the patient, and an individual decision should be made. This decision often depends on the desire for future fertility and previous gynecologic history. Crown
OBJECTIVE: To demonstrate and contrast 2 techniques of laparoscopic management of interstitial ectopic pregnancies. DESIGN: Stepwise demonstration of the technique with narrated video footage. SETTING: Tertiary referral center in Manchester, United Kingdom. INTERVENTIONS: Nontubal ectopic pregnancies typically involve the cervix, ovary, myometrium, cesarean scar, and the interstitial portion of the fallopian tube. Interstitial ectopic pregnancies account for 2% of all ectopic pregnancies [1] and are caused by implantation of a fertilized embryo within the proximal and intramural portion of the fallopian tube [2]. They represent specific challenges in diagnosis and management and are associated with increased morbidity and mortality when compared with tubal ectopic pregnancies [3]. The techniques for minimal access surgical management includes laparoscopic cornuectomy and cornuostomy. We present 2 cases of interstitial ectopic pregnancies managed laparoscopically using the 2 different techniques. Case 1: A 33-year-old women, para 2+1, presented at 8 weeks' gestation with lower abdominal pain, vaginal bleeding, and an episode of loss of consciousness. An ultrasound scan showed a gestational sac lateral and posterior to the endometrial cavity with the interstitial line sign present. A yolk sac and a 2-mm fetal pole were noted with fetal heart action present. At laparoscopy, an 800 mL hemoperitoneum was noted, and a laparoscopic cornuectomy was performed (Fig. S1). Operating time was 80 minutes, and she was discharged on day 1 postoperation. Case 2: A 34-year-old women, para 1, presented at 6 weeks' gestation to her local hospital with symptoms of vaginal bleeding and intermittent abdominal pain. A diagnosis of an interstitial ectopic pregnancy was suspected on the ultrasound scan, and conservative management was started because the diagnosis was uncertain. A follow-up scan 7 days later confirmed the diagnosis of a live interstitial ectopic pregnancy, and after consultation, she presented herself to a tertiary referral unit. Serum human chorionic gonadotropin was greater than 11 000 IU/L and 2-dimensional ultrasound scan confirmed the presence of a gestational sac with a yolk sac and fetal pole within the left interstitial space. A slow fetal heart action was seen. A diagnosis of a left interstitial ectopic pregnancy was further confirmed on 3-dimensional ultrasound scan. A laparoscopic cornuostomy was performed as demonstrated in the attached video (Figs. S2-S3). Operating time was 38 minutes with minimal blood loss. At day 7, serum human chorionic gonadotropin level was 364 IU/L. CONCLUSION: Although more research is needed to determine the optimal surgical technique for the management of interstitial ectopic pregnancies, the potential risks and benefits of different techniques should be discussed with the patient, and an individual decision should be made. This decision often depends on the desire for future fertility and previous gynecologic history. Crown