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European Journal of Obstetrics & Gynecology and Reproductive Biology xxx (2014) xxx–xxx

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LETTER TO THE EDITOR—BRIEF COMMUNICATION

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology andReproductive Biology

journal homepage: www.elsevier .com/ locate /e jogrb

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Laparoscopic management of an interstitial pregnancy in asub-fertility patient: a case report depicting the challenges todiagnose and manage this rare condition

Dear Editor,

The incidence of interstitial pregnancy is 2–4% of all ectopicpregnancies, and is associated with an increased maternalmortality rate of 2–2.5% due to difficult diagnosis at an earlystage [1]. Since life threatening haemorrhage resulting fromcornual rupture is a risk, conservative management is not alwayspossible or desirable. In recent years laparoscopic techniques havebeen more widely adopted [2]. We report the case of a 36-year-woman with primary sub-fertility and the growing challenges ofmanaging similar cases by laparoscopic cornuotomy.

A 36-year-old woman, in her first pregnancy presented withsymptom of acute abdominal pain. Her last menstrual cycle wasseven weeks ago. Her previous medical history include pelvicinflammatory disease which was treated. She also revealed asurgical history of bilateral salpingectomies to remove hydro-salpinges prior to commencing fertility treatment. A transvaginalultrasound revealed likely possibility of an interstitial pregnancy.

A laparoscopic cornuotomy using harmonic source of energyassisted with laparoscopic scissors was undertaken (Fig. 1).Subsequently the patient had assisted reproductive techniquetreatment and a full term caesarean section was performed as thebaby was in breech presentation at 39 weeks.

Improved surgical techniques and more accurate diagnosis hasbecome possible with transvaginal ultrasound and quantitativeHCG levels [2]. Ultrasound features described in the literaturevaries and include visualization of pregnancy outside the uterinecavity surrounded by thin layer of myometrium [3].

Fig. 1. Laparoscopic image revealing left sided interstitial ectopic pregnancy and laparscissors.

http://dx.doi.org/10.1016/j.ejogrb.2014.04.0290301-2115/ã 2014 Published by Elsevier Ireland Ltd.

Please cite this article in press as: Shah A, et al. Laparoscopic managemedepicting the challenges to diagnose and manage this rare condejogrb.2014.04.029

Early diagnosis is crucial in preventing high maternal morbidityand identifying risk factors may assist in achieving an earlydiagnosis. The risk factors include a history of previous ectopicpregnancy, previous salphingectomy, assisted reproductive tech-niques and a history of previous pelvic inflammatory disease [1].The management of interstitial pregnancy depends on the natureof the presentation, gestation of the pregnancy and life threateninghaemorrhage. Surgical techniques have traditionally involvedlaparotomy and cornual resection or hysterectomy [2,3]. Historicaldata from the 1950s report hysterectomy rates of 40%.

More conservative treatments are available, expectant man-agement with close observation has been described and medicaltreatment with methotrexate has also been introduced. Downsidesof methotrexate treatment include prolonged follow up.

Advanced laparoscopic skills and a competent minimal accesssurgeon are required to achieve a safe and effective cornuotomyand to preserve reproductive capacity. In our case, a highly skilledand experienced minimal access specialist undertook a rightsurgical approach. A meticulous full-thickness two layer suturingof the matrix using an intracorporeal knot tying with 2-0 PDS wasundertaken to achieve a hemostatic closure of the cornu. A secondlayer with 2-0 PDS was incorporated to prevent scarring to the sitegiving excellent coverage of the closure site of the cornu.

Preserving cornual integrity following laparoscopic cornuot-omy is important to prevent rare complications of uterine ruptureincreasing maternal and perinatal mortality. Though, in literaturevery few cases have been reported over 15 years ago [4]. There islack of evidence in the literature regarding management of futureantenatal care and whether caesarean section is indicated aspreferred mode of delivery. MRI and hysterosalphingogram havebeen evaluated to be valuable, alternative, noninvasive tools forevaluating the endometrial contour, myometrial integrity, andtubal patency [5]. We believe this imaging techniques may possibly

oscopic cornuotomy using harmonic source of energy assisted with laparoscopic

nt of an interstitial pregnancy in a sub-fertility patient: a case reportition. Eur J Obstet Gynecol (2014), http://dx.doi.org/10.1016/j.

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sist in managing future pregnancies and more robust evidencech as large-scale studies or meta-analyses are needed to answerese questions.It is difficult to decide to perform a surgical procedure whichrries the risk of hysterectomy especially in a patient undergoingrtility treatment. Nevertheless this case adds to the growingidence that diligent treatment of interstitial pregnancy usinginimal access surgery is safe, successful and fertility sparing.

ferences

Moawad N, Mahajan S, Moniz M, Taylor S, Hurd WW. Current diagnosis andtreatment of interstitial pregnancy. Am J Obstet Gynecol 2010;202(1):15–29.

Soriano D, Vicus D, Mashiach R, Schiff E, Seidman D, Goldenberg M.Laparoscopic treatment of cornual pregnancy: a series of 20 consecutive cases.Fertil Steril 2008;90(3):839–43.

Jermy K, Thomas J, Doo A, Bourne T. The conservative management of interstitialpregnancy. BJOG: Int J Obstet Gynecol 2004;111:1283–8.

Weissman A, Fishman A. Uterine rupture following conservative surgery forinterstitial pregnancy. Eur J Obstet Gynecol Reprod Biol 1992;44:237–9.

Choi YS, Eun DS, Choi J, Shin KS, Choi JG, Park HD. Laparoscopic cornuotomyusing a temporary tourniquet suture and diluted vasopressin injection ininterstitial pregnancy. Fertil Steril 2009;91(5):1933–7.

Please cite this article in press as: Shah A, et al. Laparoscopic managemdepicting the challenges to diagnose and manage this rare conejogrb.2014.04.029

Abhijeet Shah*Natasha L. Curtiss

Robin G.A. EdwardsSpecialty Training Registrar, Obstetrics & Gynaecology Department,Medway Foundation Hospitals NHS Trust, Gillingham, Kent ME7 5NY,

UK

Ghada SalmanObstetrics & Gynaecology Consultant, University College London

Hospital, 235 Euston Road, Greater London NW1 2BU, UK

Sadoon SadoonObstetrics & Gynaecology Consultant, Medway Foundation Hospitals

NHS Trust, Gillingham, Kent ME7 5NY, UK

* Corresponding author. Tel.: +44 7912215841.E-mail address: abhijeet.shah@nhs.net (A. Shah).

Received 27 October 2013

ent of an interstitial pregnancy in a sub-fertility patient: a case reportdition. Eur J Obstet Gynecol (2014), http://dx.doi.org/10.1016/j.