Hysteroscopic management of cornual ectopic pregnancy

Abstract

A 32 year old woman attended the accident and emergency department with a two day complaint of vaginal bleeding and cramping lower abdominal pain, and a brown vaginal discharge since her last menstrual period which was 24 days prior to presentation. She had discontinued the combined oral contraceptive pill two months prior to her last menstrual period. Her urine pregnancy test (Guest Medical, UK) was positive. On abdominal examination, there was tenderness noted in the right iliac fossa. Vaginal examination revealed no cervical excitation but there was right adnexal tenderness. A transabdominal and transvaginal ultrasound scan (Diagnostic Sonar, multifrequency abdominal probe and 6.5 Hz transvaginal probe) revealed an empty uterus with an endometrial thickness of 11 mm. There was a right-sided ovarian cyst measuring 77 Â 54 Â 66 mm and a small amount of free fluid in the pouch of Douglas. Her serum h-hCG quantitative assay (Immulite 2000, immunoassay calibrated to WHO 3rd International Standard) at that point was 2830 IU/mL. A diagnostic laparoscopy was performed the following day to exclude an ectopic pregnancy.At laparoscopy, the finding of a right ovarian cyst was confirmed, with normal tubes, uterus and left ovary. A laparoscopic right ovarian cystectomy was performed as this was presumed to be the cause of her pain. A repeat h-hCG level the following day (48 hours after admission) was 3116 IU/mL. A repeat ultrasound scan two days later (four days after admission) showed what was presumed to be a viable intrauterine pregnancy, which was high within the uterine fundus. The possibility of a cornual pregnancy was raised. It was decided to rescan her in two weeks.A repeat ultrasound scan two weeks later revealed a left-sided cornual ectopic pregnancy, with a 25 mm gestational sac containing a 6 mm fetal pole. There was a large vascular signature from the surrounding decidual reaction, no fetal heart activity was seen and there was no free fluid in the pouch of Douglas. The serum h-hCG level at this stage was 15,208 IU/mL. Management options were discussed with the patient and she opted for surgical management.The following day, a laparoscopy and hysteroscopy were performed. The laparoscopy confirmed the diagnosis of a left-sided cornual ectopic pregnancy. A dilute solution of vasopressin (20 units in 20 mL of normal saline) was injected around the pregnancy. A hysteroscopy (5 mm, 30j forward angled scope) with normal saline showed a pregnancy beyond the left tubal ostium. The hysteroscope was advanced beyond the dilated left ostium and the sac was ruptured. The fetus was seen floating in the irrigation fluid. The hysteroscope was then withdrawn and a No. 6 flexible suction cannula (Rocket Medical, UK) inserted into the uterine cavity. Under transabdominal ultrasound guidance, the flexible suction cannula was advanced into the cornual gestation. Suction was then applied under direct laparoscopic control to ensure that the cannula did not perforate the uterine cornu. The suction evacuation yielded products of conc...

Recurrent cornual ectopic pregnancies

“…However, they also used a post-operative systemic methotrexate injection [9]. Moon et al described the vasopressin electric cauterisation method, the endoloop before evacuation of conceptus method and the encircling suture before evacuation of conceptus method [8]. However, their recommendation was that following laparoscopic management in their following pregnancies, the patients will require elective caesarean section [8].…”

“…In addition to its side effects, there remains a risk of rupture during treatment and close monitoring of serum BHCGs is required. Other forms of medical management are available including local injection of methotrexate, potassium chloride or prostaglandins under ultrasound, hysteroscopic or laparoscopic guidance [4,8].…”

Laparoscopic management of a cornual ectopic pregnancy

“…Local injection techniques are not without risks, and haemorrhage or even cornual rupture can occur [3].…”

“…Various operative laparoscopic techniques are described; the most frequently used is incision of the cornual area after vasopressin injection, drainage of the trophoblastic material through the incision, and hysterotomy suture [5-7, 9, 12]. Other laparoscopic methods use fibrin glue haemostasis [9], use the endoloop before evacuating the conceptus [3,10], or encircle the suture before evacuating the conceptus [3].…”

“…Laparoscopic treatments include cornual resection, cornuostomy, salpingostomy, or salpingectomy [11]. Hysteroscopic treatments have also been described [3,8].…”