Minimally invasive abdominal curettage for an intramural twin pregnancy: a new twist to the traditional D&C

Abstract

Less than 1% of ectopic pregnancies are intramural and are located within the myometrium without connection to the fallopian tubes or endometrial cavity. Known risk factors include prior hysterotomy, uterine instrumentation, and myometrial pathology such as adenomyosis. The timely diagnosis and treatment of intramural pregnancies is important to reduce patient morbidity. This video demonstrates the laparoscopic removal of a twin intramural pregnancy in a 32-year-old primiparous patient with a history of myomectomy eight months prior to presentation. Two gestational sacs were visualized in the right fundal myometrium surrounded by only 4-6 millimeters of myometrial tissue. One sac was empty and the other with a live embryo measuring eight weeks gestation with fetal cardiac activity. After extensive counseling, the patient desired to proceed with surgical intervention. To safely excise the pregnancy without inadvertent injury to the fallopian tubes, a reverse U-shaped incision was made with electrosurgery. Dilute vasopressin was utilized to minimize blood loss and hydro-dissection was performed to assist with myometrial separation from the gestational sac. Finally, sharp curettage was performed laparoscopically to remove any remaining products of conception from the myometrium. This unique approach to curettage laparoscopically decreases the risk of endometrial disruption and perforation of a fresh hysterotomy repair, rather than if performed vaginally. We repaired the myometrial defect in multiple layers with barbed suture to avoid uterine wall weakness, which can be associated with spontaneous uterine rupture in future pregnancy. In conclusion, this video demonstrates a minimally invasive approach to the surgical treatment of an intramural pregnancy with laparoscopic resection and curettage.