Hysteroscopic Intact Removal of an Angular Pregnancy with a 5Fr Electrode

STUDY OBJECTIVE: Angular pregnancy is a rare and life-threatening condition in which the embryo is implanted in the lateral angle of the uterine cavity, medial to the uterotubal junction and round ligament. Angular pregnancy is associated with a high risk of uterine rupture of about 23% [1]. No consensus has been achieved regarding the diagnostic and therapeutic approach of angular pregnancy [2]. Thus, the aim of this study was to report a case of hysteroscopic treatment of an angular pregnancy in a 34-year-old women. DESIGN: Step-by-step video presentation of the surgical treatment (Canadian Task Force classification III). SETTING: Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy. PATIENT: A 34-year-old woman. Written informed consent was obtained from the patient. INTERVENTION: Hysteroscopy. MEASUREMENTS AND MAIN RESULTS: A 34-year-old woman was admitted to our Department with pelvic pain at 6 weeks of gestation. β-Human chorionic gonadotropin (β-hCG) was 5331 mIU/mL. The transvaginal ultrasound showed a gestational sac of 15 × 11 mm in the left uterine angle of an embryo without cardiac activity. The woman opted for a conservative approach with multiple-dose methotrexate [3]. Five days later the β-hCG increased to 7589 mIU/mL with no regression of pregnancy at the transvaginal ultrasound. Therefore, a surgical approach was offered to the patient [4,5]. Laparoscopy showed normal salpinges, whereas hysteroscopy identified the gestational sac in the left uterine angle. A 5Fr bipolar electrode was used to open the gestational capsular decidua. The chorionic villi were progressively separated from the implantation site. Using grasping forceps we removed the specimen for histologic examination. Histologic examination confirmed the diagnosis of angular pregnancy. On the second postoperative day β-hCG was 1131 mIU/mL, and the patient was discharged the day after. At the 1-month follow-up visit, β-hCG and transvaginal ultrasound were negative for pregnancy. The office hysteroscopy showed an empty uterine cavity at 3-months' follow-up. CONCLUSION: Our case shows that hysteroscopy may be used as a diagnostic and therapeutic tool for angular pregnancy, providing a unique image of the intact removal of the gestational sac.