Laparoscopic treatment of advanced interstitial pregnancy: key steps for a successful management

Objective: To describe a conservative laparoscopic treatment of an advanced case of interstitial pregnancy diagnosed in a woman at 14 weeks of gestational age. Design: A video case report with demonstration of diagnostic workup and laparoscopic management of rare subtypes of ectopic pregnancy. Setting: University tertiary care hospital. Patient(s): A 32-year-old nulliparous woman at 14 weeks of gestational age, presented with moderate abdominal pain. She reported a history of irregular periods; however, no risk factor for ectopic pregnancy was identified. The human chorionic gonadotropin level was 7,345 mIU/mL. Transvaginal ultrasound revealed an empty uterine cavity and a complex heterogeneous mass of 6 cm on the left cornual region. The myometrial thickness surrounding the gestational sac was 4 mm. Intervention(s): There were several critical strategies for this laparoscopic approach. To reduce intraoperative bleeding, the peritoneum was opened, the ureters were identified, and bulldog clamps were used to temporarily reduce uterine vascularization. An intramyometrial injection of vasopressin was performed. After the first cornuostomy attempt, we had to perform a cornual resection to achieve complete removal of the ectopic mass. Multilayer uterine sutures and anatomical restoration to prevent adhesion were then accomplished. Institutional review board approval was not required for this case report as per our institution's policy; patient consent was obtained for publication of the case. Main outcome measure(s): Description of laparoscopic management of huge interstitial pregnancy. Result(s): The overall operation time was 55 minutes, and the estimated blood loss was 55 mL. A successfully conservative treatment was achieved with no short-term complications. Postoperative ultrasound showed a normal uterus, and complete regression of human chorionic gonadotropin level was achieved 2 weeks after surgery. Conclusion(s): Interstitial ectopic pregnancy presents a high risk of maternal mortality considering that the interstitial part of the tube, because of its thickness, has a great capacity to expand before rupture. Despite the dimension of the lesion, in our case, the tube was still intact and the patient was in a stable clinical condition. Although cornuostomy is a more conservative solution, in these cases, cornual resection should be preferred. Through the accomplishment of reproducible key steps, laparoscopic removal of interstitial pregnancy is a feasible method and can be proposed even for advanced cases of interstitial pregnancies.