Elective uterine artery embolization prior to laparoscopic resection of interstitial pregnancy: two cases and literature review

Abstract

Background: Interstitial pregnancies (IP) can be treated medically or surgically. The most common complication remains hemorrhage. The risk of that may be reduced by elective uterine artery embolization (UAE) prior to surgery, which we applied in two consecutive cases with high vascularization on ultrasound. We also reviewed larger series (n ≥ 10) on medical as well as surgical management of IP on success and complication rates and reviewed the entire literature on UAE. Results: A gravida 5 (two ectopic pregnancies treated by salpingectomy) para 1 (cesarean section complicated by a niche, earlier repaired) presented with an asymptomatic IP. Primary treatment consisted of systemic methotrexate (MTX). Because of raising β-hCG and persisting heart activity 1 week later, she was referred for surgery (β-hCG = 59,000 IU/L; CRL = 10.5 mm). Another gravida 5 para 3 presented with an asymptomatic evolutive IP on dating ultrasound. Because of the size (CRL = 24.5 mm), thin overlaying myometrium, and high β-hCG (121,758 IU/L), we opted for primary surgery. Both IPs were highly vascularized with high flow rates. To prevent bleeding, a bilateral UAE was performed. The surgery was nearly bloodless. In the literature, a wide range of treatment regimens for IP is reported. Larger series report a success rate of 76% for primary systemic MTX, 88% for primary local medical treatment, and 94% for primary surgery. It was not possible to determine reliable hemorrhage or rupture rates following MTX administration. As to laparoscopic surgery, the blood transfusion rate for bleeding was 9% while the conversion rate for hemorrhage was 2%. The use of UAE to reduce the risk for hemorrhage before (n = 2) or after (n = 19) MTX administration was reported in 21 cases. This failed in two cases (90% success rate), and one patient required transfusion (5%). Two cases treated with UAE and primary surgery were reported, yet the exact indication for embolization was not elaborated. Alternative hemostatic techniques during surgical management have been proposed to reduce blood loss and operating time, yet individual outcomes were not identifiable. Conclusion: We report on the use of elective UAE prior to laparoscopic resection of IP, because of signs of strong vascularization on ultrasound. This strategy coincided with a nearly bloodless operation. Literature review suggests that this is one of the effective methods to reduce blood loss intra-operatively.