Endoscopic treatment of interstitial pregnancy
2003; Informa; Volume: 82; Issue: 2 Linguagem: Inglês
10.1034/j.1600-0412.2002.810414.x-i1
ISSN1600-0412
Autores Tópico(s)Assisted Reproductive Technology and Twin Pregnancy
ResumoActa Obstetricia et Gynecologica ScandinavicaVolume 82, Issue 2 p. 189-191 Free Access Endoscopic treatment of interstitial pregnancy Eun-Hee Yoo, Eun-Hee Yoo From the Department of Obstetrics & Gynecology, College of Medicine, Ewha Womans University Tongdaemun Hospital, Seoul, KoreaSearch for more papers by this authorSun-Hee Chun, Sun-Hee Chun From the Department of Obstetrics & Gynecology, College of Medicine, Ewha Womans University Tongdaemun Hospital, Seoul, KoreaSearch for more papers by this authorJong-Il Kim, Jong-Il Kim From the Department of Obstetrics & Gynecology, College of Medicine, Ewha Womans University Tongdaemun Hospital, Seoul, KoreaSearch for more papers by this author Eun-Hee Yoo, Eun-Hee Yoo From the Department of Obstetrics & Gynecology, College of Medicine, Ewha Womans University Tongdaemun Hospital, Seoul, KoreaSearch for more papers by this authorSun-Hee Chun, Sun-Hee Chun From the Department of Obstetrics & Gynecology, College of Medicine, Ewha Womans University Tongdaemun Hospital, Seoul, KoreaSearch for more papers by this authorJong-Il Kim, Jong-Il Kim From the Department of Obstetrics & Gynecology, College of Medicine, Ewha Womans University Tongdaemun Hospital, Seoul, KoreaSearch for more papers by this author First published: 18 March 2003 https://doi.org/10.1034/j.1600-0412.2002.810414.x-i1Citations: 1AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Interstitial pregnancy is a rare disease accounting for 2 to 4% of all ectopic pregnancies (1). It usually ruptures later than other tubal pregnancies. It may be associated with catastrophic hemorrhage, thus carrying a risk higher of morbidity and mortality than other forms of tubal pregnancy. Conventional treatment of interstitial pregnancy has been cornual resection by laparotomy, or local or systemic injection of methotrexate (2). Recently, endoscopic treatment has been attempted with the aid of introductory serial serum human chorionic gonadotropin measurement and high resolution transvaginal ultrasonography (3, 4). We report four patients with interstitial pregnancy who undertook pelviscopic cornuostomy and repair of the uterus wall. Case reports Four patients who undertook endoscopic treatment were retrospectively reviewed. The average age of the patients was 31 years. All patients presented with amenorrhea and vaginal bleeding. The average duration of amenorrhea was 8 weeks. The average titer of β-hCG was 39 245 mIU/ml. Transvaginal ultrasound showed an empty uterus and a gestational sac with a fetal pole surrounded by a layer of myometrium on the right uterine cornue in two patients and on the left cornue in the other two patients (Fig. 1). Figure 1Open in figure viewerPowerPoint Transvaginal sonography shows a gestational sac high in the fundal region with an embryo and empty uterine cavity. Interstitial pregnancy was confirmed at laparoscopy (Fig. 2). Both the tubes and ovaries appeared normal. Laparoscopic cornuostomy was carried out using a technique similar to that for salpingostomy. Diluted vasopressin was injected around the cornual mass. A maximally infiltrating point of the mass was incised using a monopolar needle cautery, and the product of gestation was removed using a suction-irrigator. Careful hemostasis was performed with microbipolar forceps. The incised area was carefully repaired with absorbable suture material of an interrupted intracorporeal or extracorporeal knot tying technique (Fig. 3). Figure 2Open in figure viewerPowerPoint Pelviscopic finding shows a bulging ectopic mass in the right cornual region in the bicornuate uterus. Figure 3Open in figure viewerPowerPoint Postoperative finding shows three stitches of interrupted suture made on the right cornual region after cornuostomy. The average operating time was 54 min and estimated blood loss was 90 ml. No patient required a transfusion and there was no complication associated with laparoscopic operation. Their postoperative course was uneventful and all patients were discharged at second day postoperatively. Serial β-hCG level was gradually returned to normal range within the fourth week postoperatively. Discussion Laparoscopic treatment of interstitial pregnancy has been attempted in recent years. The first case of laparoscopic management of interstitial pregnancy was reported by Reich et al. in 1988 (5), who used the technique of laparoscopic cornual resection using bipolar forceps and scissors after the injection of vasopressin into the myometrium and removal of the surgical specimen through a colpotomy incision. Most of the techniques reported in the literature used diluted intramyometrial vasopressin at the beginning of the operation to minimize blood loss and improve visibility. One report described the use of suture-loop tourniquet applied through the avascular area of the broad ligament to minimize bleeding (12). In cases where cornuostomy was performed, removal of the products of conception was generally performed with grasping forceps, hydrodissection, aspiration, or gentle curettage (4, 6-11, 13). The endoloop has recently been used. Tulandi et al. found that the endoloop tends to slip (14), but Moon et al. used the endoloop or encircling suture to secure hemostasis and complete cornual closure in 21 patients (15). The myometrium was not been repaired in almost all the cases. The integrity of the uterine wall after treatment for interstitial pregnancy seems to be important. Weissman and Fishman reported a case of uterine rupture at the right fundal area and the uterine wall at 20 weeks of gestation in a woman who previously underwent a right salpingectomy with cornual resection for an interstitial pregnancy (16). Downey and Tuck reported a case of a right interstitial pregnancy resolving spontaneously after the excision of a corpus luteum. The subsequent pregnancy was complicated by uterine rupture from the right cornu to the fundus at 24 weeks of gestation. They stated that the myomterium overlying the site of a previous interstitial pregnancy was defective and therefore predisposed to rupture in a subsequent intrauterine pregnancy (17). The risk of uterine rupture after conservative surgical treatment of an interstitial pregnancy is unknown. Therefore, suturing of the myometrium of the uterine cornu after cornuostomy of an interstitial pregnancy is considered to be important to prevent uterine rupture in subsequent pregnancies. In this present study, the incised area was carefully repaired with absorbable suture material of an interrupted intracorporeal or extracorporeal knot tying technique. In summary, cornual resection will no longer be the first line of treatment for patients with interstitial pregnancy. We successfully treated four cases of an interstitial pregnancy with laparoscopic cornuostomy and suturing of the myometrium without complication. The integrity of the uterus after cornuostomy is unclear, so suturing of myometrium of the uterine cornu seems to be important to prevent uterine rupture in subsequent pregnancies. References 1 Rock JA, Thompson JD. Telinde's Operative Gynecology. 8th edn. Philadelphia: Lippincott-Raven, 1997. Google Scholar 2 Lau S, Tulandi T. Conservative medical and surgical management of interstitial ectopic pregnancy. Fertil Steril 1999; 72: 207 – 15. CrossrefCASPubMedWeb of Science®Google Scholar 3 Budnick SG, Jacobs SL, Nulsen JC. Metzger DA. Conservative management of interstitial pregnancy. Obstet Gynecol Surv 1993; 48: 694 – 8. CrossrefCASPubMedGoogle Scholar 4 Katz Z, Lurie S. Laparoscopic cornuostomy in the treatment of interstitial pregnancy with subsequent hysterosalpingography. Br J Obstet Gynecol 1997; 104: 955 – 6. Wiley Online LibraryCASPubMedGoogle Scholar 5 Reich H, Johns DA, DeCaprio J, McGlynn F, Reich E. Laparoscopic treatment of 109 consecutive ectopic pregnancies. 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