Laparoscopic Cornual Resection of Interstitial Ectopic Pregnancy

Introduction

Interstitial ectopic pregnancy occurs when a pregnancy develops within the proximal and intramural portion of the fallopian tube that is surrounded by the myometrium. ¹ This pregnancy is difficult to distinguish from an intrauterine pregnancy on ultrasound (US) due to the implantation site of the fallopian tubes and the invasion through the uterine wall. Interstitial ectopic pregnancy is a rare entity, representing 2%–4% of ectopic pregnancies. ² The high mortality rate in this type of pregnancy is due, in part, to the delay in diagnosis, as well as massive intraperitoneal hemorrhage. ³

The aim of this article and online video (Supplementary Video S1; Supplementary data are available online at www.liebertonline.com/GYN) is to show a laparoscopic approach for managing interstitial ectopic pregnancies to reduce the risk of uterine rupture and to preserve future fertility. To minimize surgical blood loss, both uterine arteries are temporary occluded with surgical clips.

Technique

We present a case of interstitial ectopic pregnancy with initial medical treatment and later with cornual resection, with the aim of reducing the risk of uterine rupture and preserving future fertility.

To minimize blood loss during enucleation of the gestational sac, both uterine arteries and gonadal vessels are temporarily occluded with clips. A circular incision is made in the left horn, until reaching the gestational sac (Fig. 1). The cornual capsule and ipsilateral fallopian tube are removed. The gestational sac is enucleated in its entirety (Fig. 2). The myometrial bed is sutured, and the incision is repaired with Vicryl #1 (Fig. 3).

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FIG. 1.

Circular incision in the left uterine horn.

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FIG. 2.

Enucleation of the gestational sac.

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FIG. 3.

Uterine incision repair.

Video footage of the surgical technique is available online in Supplementary video S1.

Illustrative Case

A 36-year-old woman, with a diagnosis of a septate uterus and an obstetric history of a spontaneous twin pregnancy, that was monochorionic monoamniotic in one hemicavity and had a single gestational sac in the other hemicavity. She reported that the twin pregnancy was spontaneously interrupted in the first trimester. At 20 weeks' gestation, she was admitted to an outer center for premature membrane rupture due to an unknown cause, and received antibiotic therapy. Anhydramnios was found, so she decided to legally terminate the pregnancy. Remains evacuation curettage was performed. Subsequently, multiple intracavitary adhesions were visualized by gynecologic US and confirmed in a diagnostic hysteroscopy. Adhesiolysis of uterine synechiae was performed by surgical hysteroscopy. Another hysteroscopy was performed to perform a partial septoplasty.

After a diagnosis of ectopic interstitial gestation from an outer center in January 2019, she came to our center, stable and asymptomatic, in May 2019. She provided reports that described 2 curettages with US controls in which no gestational sac located in the area that had been reached. A posterior hysteroscopy was performed, in which a septal uterus and Asherman's syndrome were found. Adhesiolysis was performed without reaching the gestational sac. Due to this patient's clinical and hemodynamic stability—and a laboratory analysis showing a ß–human chorionic gonadotropin (ß-hCG) level of 127 mIU/mL—medical treatment with intramuscular methotrexate (MTX) was administered; this required 2 doses to reduce her ß-hCG level of 24 mIU/mL successfully was verified.

Gynecologic US was performed in our center, and visualization of the gestational sac remained in the vascularized left horn in its periphery (Fig. 4).

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FIG. 4.

Nodular image in the left horn compatible with vascularized blood material.

An analytical control visualization was performed, resulting in a hemogram and coagulation tests compatible with normality and negative ß -hCG.

A surgical approach was agreed on to lessen the risk of uterine rupture in future pregnancies. She underwent laparoscopic left cornual resection.

Her The postoperative period was uneventful. The histopathologic report confirmed the products of gestation.

At 3 months, an US control was performed, without observing a gestational sac or adhesions. The patient was informed about the risk of uterine rupture in a next pregnancy, as well as the need to end it by elective caesarean section.

Discussion

Despite the fact that interstitial pregnancy is one of the most lethal types of ectopic pregnancy, there is no agreement about its management due to its rarity. Conservative treatment of these cases includes MTX injection, administered systemically or locally in the uterus. ⁴ Cornual-wedge resection is the most commonly used surgical intervention for interstitial pregnancy. The main disadvantage of this treatment is that it disrupts the myometrial lining, which reduces fertility potential. ⁴ Newer, less-invasive, surgical procedures, such as hysteroscopy with US assistance and uterine evacuation under laparoscopic supervision, have been shown to be both safe and effective. These novel techniques minimize blood loss during surgery while maintaining the uterine lining for potential future pregnancies. ⁴

Occluding both uterine arteries with surgical clips also has the potential to reduce intraoperative blood loss. In a recent case-controlled study, this procedure reduced average blood loss by ∼50% during laparoscopic myomectomy. ⁵

In the future, the eventual recurrence rate, pregnancy rate, and pregnancy complications should be investigated.

Conclusions

In patients who want to preserve their fertility, laparoscopic corneal resection appears to be an effective treatment for interstitial pregnancy. Temporary occlusion of bilateral uterine arteries with surgical clips is a safe and effective blood-sparing intraoperative technique.