Page 94 - World Journal of Laparoscopic Surgery

Laparoscopic Management of Uncommon Presentations of Ectopic Pregnancy
Blind uterine curettage is strongly discouraged as it causes scar
rupture and severe hemorrhage, as has been seen in the second
8
case we have discussed. Hysteroscopic evacuation is a safer
alternative with short operating time, less blood loss, and short
9
postoperative stay. With laparoscopy, cesarean scar ectopic mass
is incised and pregnancy tissue removed in endobag. Bleeding
can be minimized by local injection of vasopressin and hemostasis
achieved by bipolar diathermy and defect closed by endosuturing. 10
Laparotomy is mandatory when uterine rupture is strongly
suspected. Hysterectomy is done when all other treatment
modalities fail to control bleeding or repair the defect. 11

Interstitial Pregnancy
Interstitial pregnancies (IP) constitute 2–6.8% of all ectopic
pregnancies. Because of distensibility of myometrium, they tend
to grow to an advanced gestation before rupture. Due to proximity
to the intramyometrial arcuate vasculature, the bleeding occurring
Fig. 6: Rudimentary horn pregnancy after excision
as a consequence of rupture may be catastrophic and this is the
reason why IP is associated with mortality rate of 2–2.5% (seven
to the uterus and the bleeding points were coagulated (Fig. 6). HPE times the average for all ectopic pregnancies). “The diagnosis of IP
revealed products of conception in the rudimentary horn.
by ultrasound is based on the following criteria: the GS is located
outside the uterine cavity; the interstitial part of fallopian tube is
dIscussIon seen adjoining the lateral aspect of the uterine cavity and GS; and
Cesarean Scar Pregnancy the myometrial mantle extends laterally to encircle the GS”. 12,13
2,4
Cesarean scar pregnancy occurs in 1 in 2,000 pregnancies. Medical management with methotrexate can be considered
Incidence is on an increasing trend because of increasing primary if the patient is hemodynamically stable with no signs of rupture,
4
CS rate. First case of cesarean scar ectopic was mentioned in i.e., large GS or rapidly increasing β-hCG levels.
5
the English Medical Literature in 1978 by Larsen and Solomon. Surgical management of IP includes cornual wedge resection,
Improper implantation at prior hysterotomy site occurs due to cornuostomy, and hysterectomy either by laparotomy or
disruption of the endometrium and the myometrium. 1,5 laparoscopy. For ruptured cornual pregnancy, laparotomy is
In cesarean scar ectopic pregnancy either the implanted preferred. Hysterectomy is reserved to cases in which hemorrhage
gestational sac grows into the uterine cavity or grows toward the is profuse and life threatening. Other management options include
serosal surface of the uterine wall. The former might proceed to term ultrasound-guided transcervical forceps extraction (UTCE) and
with a viable fetus with an increased risk of life-threatening massive transcervical suction under laparoscopic and hysteroscopic
13
postpartum hemorrhage whereas the latter carries the risk of rupture guidance which have been reported in a few recent case reports.
and hemorrhage during the first trimester of pregnancy. 1,6 In our patient, cornuostomy was done as it carries lesser risk of
uterine rupture in subsequent pregnancy compared with cornual
Criteria for cesarean scar ectopic pregnancy include:
wedge resection.
• Gestational sac embedded eccentrically in the lower uterine
segment Rudimentary Horn Pregnancy
• Implantation in the location of a prior cesarean delivery scar Rudimentary horn pregnancy, another rare ectopic pregnancy
• Empty uterine cavity and cervical canal with incidence of 1 in 76,000 pregnancies, occurs due to the
• Attenuated myometrium over the scar transperitoneal migration of sperm/fertilized ovum from
• Extensive Doppler vascular flow in the area of the cesarean contralateral side or through a microscopic fistulous tract with
delivery scar. unicornuate uterus. 14
• Negative sliding sign—inability to displace the gestational sac Natural fate of rudimentary horn ectopic when left
from its position at the level of internal OS by gentle pressure untreated is usually rupture during the last two trimesters due
applied by the transabdominal probe. 1,2,5
to underdevelopment, poor distensibility of myometrium, and
In both the cases of cesarean scar pregnancy described in this dysfunctional endometrium. Only 10% have been reported to
case series, initial ultrasound missed in the diagnosis. Hence high have progressed to full term among which 2% have survived. 15,16
index of suspicion is the key to early diagnosis. Ultrasound and MRI aid in the diagnosis.
Conservative medical management is indicated in unruptured The following criteria have been suggested by Tsafri et al
ectopic pregnancy of <8 weeks gestation with myometrial thickness for sonographic diagnosis of rudimentary horn pregnancy: (1)
<2 mm between cesarean scar pregnancy and bladder when the pseudo-pattern of an asymmetrical bicornuate uterus, (2) absent
patient is hemodynamically stable. Systemic administration of visual continuity between the cervical canal and the lumen of
methotrexate and local intrasac administration of embryocides the pregnant horn, and (3) the presence of myometrial tissue
like methotrexate, potassium chloride, hyperosmolar glucose, surrounding the gestational sac. 17
or crystalline trichosanthin under ultrasound guidance are other Late presentation of rudimentary horn pregnancy is difficult
modalities of treatment which have been tried with varied success to treat by local/systemic methotrexate but there a few case
18
rates. 7 reports describing successful management with methotrexate.

92 World Journal of Laparoscopic Surgery, Volume 15 Issue 1 (January–April 2022)