1 Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire de Grenoble, Grenoble and 2 Department of Obstetrics and Gynecology, Hôpital Antoine Béclère, Clamart, France
![]() |
Abstract |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
Key words: ectopic pregnancy/interstitial pregnancy/IVF
![]() |
Introduction |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
Case report |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
Physical examination showed an impaired haemodynamic status with decreased blood pressure (90/60 mmHg) and tachycardia (110 bpm). The blood cell count revealed moderate anaemia, with haemoglobin levels at 8 g/100 ml. Both transvaginal and transabdominal ultrasound examination showed a normal intrauterine gestational sac with cardiac activity, and another gestational sac, measuring 15x10 mm in diameter, without cardiac activity, positioned in the left uterine cornu at the interstitial tubal portion. A considerable volume of blood collected in the peritoneal cavity (~1 l) was also observed. The diagnosis of haemorrhagic heterotopic interstitial pregnancy was then considered.
Because of unstable clinical conditions, the patient underwent a laparotomy: it showed the presence of an interstitial gestational sac near the remaining ruptured portion of the left Fallopian tube. To avoid the resection of the uterine cornu, we performed a gentle curettage of the interstitial tubal portion through the opening of the ruptured tube. Per-operative ultrasound guidance prevented the risk of penetrating the uterine cavity with the curette and avoided damaging the intrauterine sac. This procedure allowed complete evacuation of the ectopic sac and significant reduction of the haemorrhage. Finally, the interstitial portion of the uterus was closed with a running suture of 10 vicryl (Etnor, Issy-Les-Moulineaux, France). Pathological analysis identified the presence of chorial villi and confirmed the diagnosis of ectopic pregnancy.
Four days after the intervention, an ultrasound scan showed an ongoing intrauterine pregnancy. During the 4 week post-operative period, the patient received 400 mg of progesterone (Utrogestan®; Besins-Iscovesco Pharmaceuticals, Paris, France) daily by the vaginal route. Clinical and ultrasonographic monitoring during pregnancy failed to show any obstetric abnormality. Because of the previous uterine scar, an elective Caesarean section was performed at the 37th week of gestation, delivering a normal female infant who weighed 2900 g. Per-operative examination of the left uterine cornu showed complete healing of the uterine wall with no signs of rupture or fragility.
![]() |
Discussion |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
Tubal curettage may be a new attractive alternative in the management of heterotopic haemorrhagic interstitial pregnancies. This conservative approach avoids cornual resection and may be considered even in the presence of marked haemorrhage. In a case where the Fallopian tubes are present, a simple salpingostomy is required to proceed with cornual curettage. Although the case reported here required laparotomy because of severe bleeding, the laparoscopic aspiration of the ectopic sac is technically conceivable (Grobman and Milad, 1998).
The possibility of managing laparoscopically interstitial pregnancies has been the subject of several case reports (Reich et al., 1988; Tulandi et al., 1995
). Both authors successfully used laparoscopic cornual excision in interstitial pregnancies. This technique also seems to be applicable in the treatment of ruptured interstitial pregnancies (Reich et al., 1990). Cornual resection that potentially increases the risk of uterine rupture during pregnancy or labour should be avoided. Hence, the laparoscopic approach should be attempted only in cases in which conservative treatment is possible and safe, and operator training is adequate to convert the operation into a laparotomy, if necessary, should severe haemorrhaging occur during the surgical procedure.
In conclusion, key measures for the successful management of heterotopic interstitial pregnancies include early diagnosis, with specific ultrasound monitoring, particularly in women who have undergone ovarian stimulation. When conservative measures such as KCl administration are proscribed due to marked haemorrhage, tubal curettage may be an attractive therapeutic alternative to cornual resection or hysterectomy. Extended series of heterotopic interstitial pregnancies treated with tubal curettage are, however, required to confirm these preliminary results.
![]() |
Notes |
---|
![]() |
References |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
Fernandez, Lelaidier, C., Doumerc, S. et al. (1993) Nonsurgical treatment of heterotopic pregnancy: a case report of six cases. Fertil. Steril., 60, 428432.[ISI][Medline]
Grobman, W.A. and Milad, M.P. (1998) Conservative laparoscopic management of a large cornual ectopic pregnancy. Hum. Reprod., 13, 20022004.[Abstract]
Loret de Mola, J.R., Austin, C.M., Judge, N.E. et al. (1995) Cornual heterotopic pregnancy and cornual resection after in vitro fertilization/embryo transfer. J. Reprod. Med., 40, 606610.[ISI][Medline]
Marcus, S.F., MacNamee, M. and Brinsden, P. (1995) Heterotopic pregnancies after in-vitro fertilization and embryo transfer. Hum. Reprod., 10, 12321236.[Abstract]
Reece, E.A., Petrie, R.H., Sirmans, M.F. et al. (1983) Combined intrauterine and extrauterine gestations: a review. Am. J. Obstet. Gynecol., 146, 323330.[ISI][Medline]
Reich, H., Johns, D.A., De Caprio, J. et al. (1988) Laparoscopic diagnosis and treatment of interstitial ectopic pregnancy: a case report. Am. J. Obstet. Gynecol., 163, 587588.
Rizk, B., Tan, S.L., Morcos, S. et al. (1991) Heterotopic pregnancies after in vitro fertilization and embryo transfer. Am. J. Obstet. Gynecol., 164, 161164.[ISI][Medline]
Sharif, K., Kaufmann, S. and Sharma, V. (1994) Heterotopic pregnancy obtained after in-vitro fertilization and embryo transfer following bilateral total salpingectomy: case report. Hum. Reprod., 9, 19661967.[Abstract]
Tulandi, T., Vilos, G. and Gomel, V. (1995) Laparoscopic treatment of interstitial pregnancy. Ob. Gyn., 85, 465467.[ISI]
Submitted on August 10, 2000; accepted on January 4, 2001.