Conservative surgical management of ruptured interstitial pregnancy

Abstract

Interstitial ectopic pregnancy accounts for 2–4% of all ectopic implantations, and can be associated with life-threatening bleeding (1). In this study, a woman with ruptured interstitial pregnancy, which was managed successfully by using a conservative surgical method, is presented. A 19-year-old nulliparous woman presented with acute onset, severe right iliac fossa pain. Her last menstrual period was 6 weeks previously and the urine pregnancy test was positive. On examination, she was found to be tachycardic, but normotensive with the signs of peritonism. Vaginal examination showed severe right adnexal tenderness. Her hemoglobin was 7.1 g/dl. She was transferred to the surgical theatre with the provisional diagnosis of ruptured ectopic pregnancy. Laparoscopy showed massive hemoperitoneum of 21 with a large (about 5 cm in diameter) ruptured right-sided interstitial pregnancy. At the time, the hemoglobin was 4.5 g/dl and the patient became hypotensive, making laparotomy imperative. As the patient was nulliparous, every effort was made to preserve future fertility. The right round ligament and the broad ligament were opened and the right ureter was identified. The right tube and ovarian ligament and uterine artery were ligated resulting in substantial reduction of the bleeding. The products of conception were removed and multiple hemostatic sutures were applied on the right cornu, which was eventually closed in two layers. As hemostasis was achieved, the right round ligament and the broad ligament were closed and the patient received 4 U of transfused blood. On the first post-operative day, a single dose of intramuscular methotrexate (50 mg/m2) was administered in order to reduce the risk of persistent trophoblastic tissue. The patient was discharged on the fourth post-operative day in good condition. Owing to the extent of the rupture, the patient was advised to have a cesarean section in any subsequent pregnancy. Serum β-hCG 20 days later had fallen from 27 724 IU/l, on admission, to 28 IU/l. Because recent evidence has suggested that intraperitoneal sperm transmigration from a patent Fallopian tube to its damaged counterpart is quite common, the patient had subsequently been counseled regarding right salpingectomy (2). Interstitial ectopic pregnancy carries a risk of severe hemorrhage because of its unique anatomical location, which commonly leads to a delay in diagnosis (1). Rupture of the uterus that progresses beyond 12 weeks of amenorrhea may occur in the case of 20% of the patients (3). Conservative management of an interstitial pregnancy includes medical treatment; administration of methotrexate and prostaglandin, and local injection of KCl have been reported (1). Hysteroscopic removal of an unruptured interstitial pregnancy has also been described (1). Traditionally, surgical treatment for interstitial tubal pregnancy consists of cornual resection (possible in 50% of patients) with the remainder of patients requiring hysterectomy (1). In few patients, laparoscopic management has been described, including cornual resection, cornuostomy, or salpingotomy. In two reports, hemostasis was achieved with laparoscopic ligation of the ascending branches of the uterine vessels in combination with cornual excision. However, in the case of all these patients, the patients were hemodynamically stable or had an unruptured interstitial ectopic pregnancy; maximum β-hCG level was 20 159 mIU/ml (3). The uterus is supplied blood by six arteries – two uterine, two flowing via the ovarian ligament, and two vaginal collaterals. The uterine cornu derives its rich blood supply from the uterine artery and the tubal branch of the ovarian artery. Selective ligation of both these branches provides a significant reduction in blood supply to the uterine cornu, but the contralateral blood supply with its anastomotic channels prevents any avascular sequelae (4). We have previously demonstrated that a uterus supplied by two of its six original vessels, as is the case at abdominal radical trachelectomy, is capable of maintaining successfully a pregnancy to term (5). In the present study, we have described a conservative surgical (ligation of the ovarian ligament and uterine artery in association with closure of the cornu at the site of the rupture after removal of the products of conception) and medical (systemic administration of methotrexate) approach in the case of a hemodynamically unstable patient with a ruptured interstitial ectopic pregnancy. This is the first report that this technique was not combined with cornual resection, which is a more extensive surgical treatment. Additionally, the size of the present ectopic pregnancy appears to be bigger than the ones that have been reported previously, as the level of β-hCG indicates. Large, ruptured interstitial ectopic pregnancies leading to massive intraperitoneal bleeding can be managed successfully by means of unilateral ligation of the ovarian ligament and uterine artery. The surgery, however, requires advanced surgical skills and may not be appropriate to be performed by unsupervised junior surgeons.