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Laparoscopic management of interstitial pregnancy
International Journal of Gynecology and Obstetrics (2005) 88, 51 — 52
www.elsevier.com/locate/ijgo
BRIEF COMMUNICATION
Laparoscopic management of interstitial pregnancy M.C. Huang, T.H. Su*, M.Y. Lee Department of Obstetrics and Gynecology, Mackay Memorial Hospital and Mackay Medicine, Nursing and Management College, Taipei, Taiwan Received 2 June 2004; received in revised form 1 September 2004; accepted 2 September 2004
KEYWORDS Interstitial pregnancy; Laparoscopy; Hemostatic suturing technique
Interstitial pregnancy is relatively rare, accounting for only 2—4% of all ectopic pregnancies. Conventionally, it is treated by laparotomy with cornual resection or hysterectomy. Conservative medical management consists of systemic or local injection of methotrexate, with an overall success rate of 83% [1]. However, if the serum h-hCG decreases slowly or the gestational sac continues to grow despite methotrexate, surgery must be considered. Laparoscopic cornuostomy causes less cornual trauma than open surgery. However, hemorrhage remains a major problem and has been the main cause of failure in this procedure. Most techniques use diluted intramyometrial vasopressin in the
* Corresponding author. Tel.: +886 2 2858 4180; fax: +886 2 2531 4723. E-mail address: [email protected] (T.H. Su).
affected cornu to minimize blood loss. Bipolar electrocauterization, tamponade with Surgicel, fibrin glue, and ligation of the ascending uterine artery have all been tried, but these are not always sufficient to control hemorrhage, particularly at the placental implantation site. Recently, a hemostatic square suturing technique was reported by Cho et al. [2] for management of uncontrollable cesarean hemorrhage in order to preserve the uterus. This technique approximates the anterior and posterior uterine walls, thus controlling the bleeding by compression. This method was successfully used in laparoscopic surgery for interstitial pregnancies in four cases. In this series, all four interstitial pregnancies were confirmed by laparoscopy. The average duration of amenorrhea was 9 weeks, and the average serum h-hCG before surgery was 53,395 IU/L. A 2cm longitudinal incision of the cornual wall was made. The products of conception were evacuated by using grasping forceps. A 2-0 chromic catgut suture was carried through the posterior and anterior cornual walls laparoscopically. It was then carried back through the anterior and then the posterior wall at a point 2 cm lateral to the initial pass. The knot was tied intracorporeally, achieving hemostasis by compression. Finally, the cornual
0020-7292/$ - see front matter D 2004 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2004.09.003
52
M.C. Huang et al.
Figure 1 Gross appearance and operative technique for conservative laparoscopic management of interstitial pregnancy with a simple square suturing technique. (A) Left-sided, 4.5-cm interstitial pregnancy. (B) Products of conception removed with grasping forceps. (C) Hemostatic compression suture with 2-0 chromic (arrowheads). (D) Uterine incision closed with running 2-0 vicryl suture.
incisions were closed with a running 2-0 vicryl suture (Fig. 1). The average time required for the operation was 64 min. The serum h-hCG fell rapidly after surgery in all four cases and returned to the normal range between 19 and 32 days (mean, 27) postoperatively. No adjuvant therapy was given (Table 1). Cornual resection or hysterectomy by laparotomy need no longer be the first line of treatment in a hemodynamically stable patient with an interstitial pregnancy. When operative laparoscopy is indicated, the simple compression suturing techni-
que we used is a fast and effective method for achieving hemostasis.
References [1] Lau S, Tulandi T. Conservative medical and surgical management of interstitial ectopic pregnancy. Fertil Steril 1999; 72(2):207 — 15. [2] Cho JH, Jun HS, Lee CN. Hemostatic suturing technique for uterine bleeding during cesarean delivery. Obstet Gynecol 2000;96(1):129 — 31.
Table 1
Clinical data in four cases of interstitial pregnancy
Case no.
Date
1
May 2002 December 2002 November 2003 March 2004
2 3 4
Duration of amenorrhea (weeks)
Crown-rump length (cm)
Fetal heart beat
Serum h-hCG (IU/L) at surgery
Time to resolution of h-hCG (days)
Operative time (min)
Blood loss (ml)
Postopereative adjuvant therapy
9
1.7
( )
39,933
19
51
200
( )
9
1.8
(+)
74,551
32
85
650
( )
11
4.1
(+)
58,483
26
57
200
( )
8
1.2
(+)
40,613
31
62
350
( )
www.elsevier.com/locate/ijgo
BRIEF COMMUNICATION
Laparoscopic management of interstitial pregnancy M.C. Huang, T.H. Su*, M.Y. Lee Department of Obstetrics and Gynecology, Mackay Memorial Hospital and Mackay Medicine, Nursing and Management College, Taipei, Taiwan Received 2 June 2004; received in revised form 1 September 2004; accepted 2 September 2004
KEYWORDS Interstitial pregnancy; Laparoscopy; Hemostatic suturing technique
Interstitial pregnancy is relatively rare, accounting for only 2—4% of all ectopic pregnancies. Conventionally, it is treated by laparotomy with cornual resection or hysterectomy. Conservative medical management consists of systemic or local injection of methotrexate, with an overall success rate of 83% [1]. However, if the serum h-hCG decreases slowly or the gestational sac continues to grow despite methotrexate, surgery must be considered. Laparoscopic cornuostomy causes less cornual trauma than open surgery. However, hemorrhage remains a major problem and has been the main cause of failure in this procedure. Most techniques use diluted intramyometrial vasopressin in the
* Corresponding author. Tel.: +886 2 2858 4180; fax: +886 2 2531 4723. E-mail address: [email protected] (T.H. Su).
affected cornu to minimize blood loss. Bipolar electrocauterization, tamponade with Surgicel, fibrin glue, and ligation of the ascending uterine artery have all been tried, but these are not always sufficient to control hemorrhage, particularly at the placental implantation site. Recently, a hemostatic square suturing technique was reported by Cho et al. [2] for management of uncontrollable cesarean hemorrhage in order to preserve the uterus. This technique approximates the anterior and posterior uterine walls, thus controlling the bleeding by compression. This method was successfully used in laparoscopic surgery for interstitial pregnancies in four cases. In this series, all four interstitial pregnancies were confirmed by laparoscopy. The average duration of amenorrhea was 9 weeks, and the average serum h-hCG before surgery was 53,395 IU/L. A 2cm longitudinal incision of the cornual wall was made. The products of conception were evacuated by using grasping forceps. A 2-0 chromic catgut suture was carried through the posterior and anterior cornual walls laparoscopically. It was then carried back through the anterior and then the posterior wall at a point 2 cm lateral to the initial pass. The knot was tied intracorporeally, achieving hemostasis by compression. Finally, the cornual
0020-7292/$ - see front matter D 2004 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2004.09.003
52
M.C. Huang et al.
Figure 1 Gross appearance and operative technique for conservative laparoscopic management of interstitial pregnancy with a simple square suturing technique. (A) Left-sided, 4.5-cm interstitial pregnancy. (B) Products of conception removed with grasping forceps. (C) Hemostatic compression suture with 2-0 chromic (arrowheads). (D) Uterine incision closed with running 2-0 vicryl suture.
incisions were closed with a running 2-0 vicryl suture (Fig. 1). The average time required for the operation was 64 min. The serum h-hCG fell rapidly after surgery in all four cases and returned to the normal range between 19 and 32 days (mean, 27) postoperatively. No adjuvant therapy was given (Table 1). Cornual resection or hysterectomy by laparotomy need no longer be the first line of treatment in a hemodynamically stable patient with an interstitial pregnancy. When operative laparoscopy is indicated, the simple compression suturing techni-
que we used is a fast and effective method for achieving hemostasis.
References [1] Lau S, Tulandi T. Conservative medical and surgical management of interstitial ectopic pregnancy. Fertil Steril 1999; 72(2):207 — 15. [2] Cho JH, Jun HS, Lee CN. Hemostatic suturing technique for uterine bleeding during cesarean delivery. Obstet Gynecol 2000;96(1):129 — 31.
Table 1
Clinical data in four cases of interstitial pregnancy
Case no.
Date
1
May 2002 December 2002 November 2003 March 2004
2 3 4
Duration of amenorrhea (weeks)
Crown-rump length (cm)
Fetal heart beat
Serum h-hCG (IU/L) at surgery
Time to resolution of h-hCG (days)
Operative time (min)
Blood loss (ml)
Postopereative adjuvant therapy
9
1.7
( )
39,933
19
51
200
( )
9
1.8
(+)
74,551
32
85
650
( )
11
4.1
(+)
58,483
26
57
200
( )
8
1.2
(+)
40,613
31
62
350
( )