Laparoscopic Management of a Primary Posterior Cul-de-sac Abdominal Ectopic Pregnancy

Abstract

Study Objective To report a case of laparoscopic management of a primary posterior cul-de-sac abdominal ectopic pregnancy (AEP). Design Video abstract. Setting Academic center. Patients or Participants A 40-year-old G5P3013 woman at approximately 7 weeks gestation who was referred to our emergency room due to abnormally rising β-human chorionic gonadotropin (hCG) levels. Transvaginal ultrasonography revealed a cystic structure measuring 2.8 × 1.6 × 1.9 cm in the posterior cul-de-sac distinct from the cervix. The mass was noted to have peripheral hypervascularity and a thickened wall. A small amount of free fluid was noted adjacent to the mass. Interventions Laparoscopic excision of a primary posterior cul-de-sac AEP and evacuation of hemoperitoneum. Measurements and Main Results The patient's baseline β-hCG and hematocrit (HCT) was 6810.7 mIU/mL and 42.4%, respectively. Diagnostic laparoscopy revealed normal uterus, normal right ovary, normal left ovary with a corpus luteal cyst and normal bilateral fallopian tubes without dilatation or hemorrhage. The AEP was noted in the right posterior cul-de-sac and was dissected from the underlying peritoneum. The left lateral aspect of the AEP extended into the posterior vaginal wall. The patient was admitted for overnight observation and her post-operative HCT was 35.1%. Conclusion AEPs are extremely rare and account for 1% of all ectopic pregnancies. Approximately 90% of AEPs require surgical management. Historically, AEPs were treated with laparotomy given the high risk of hemorrhage and hemodynamic instability. However, as exemplified by the current case, laparoscopy is a safe and feasible option for the surgical management of AEPs.