Design: Single case presentation

Setting: Single center academic institution. Main operating room, dorsal lithotomy position.

Patients or Participants: 30 yo G3P1102 presenting at 16w4d by LMP to the emergency room with concern for ectopic pregnancy.

Interventions: Laparoscopic left cornual wedge resection and salpingectomy

Measurements and Main Results:

Patient initially was diagnosed with an intrauterine pregnancy and underwent multiple attempts at medical and surgical termination at outside facility without success. Further imaging revealed interstitial versus cornual ectopic pregnancy. Patient desired future fertility and was counseled on surgical management including cornual wedge resection. Intraoperatively, an extremely dilated, blanched, and necrotic appearing left tubal interstitial pregnancy of an otherwise normal appearing uterus was visualized. The left fallopian tube distally appeared grossly normal. The approach to removing the ectopic pregnancy was similar to myomectomy. The endometrium was visualized during the procedure to ensure full resection of the pregnancy. The myometrium was then reapproximated in multiple layers. Patient was discharged home the same day. The resected left cornua and fallopian tube were consistent with interstitial pregnancy on pathology.

Conclusion:

Preoperative 3D ultrasound or MRI can be useful in identifying uterine contours and relation of pregnancy to the fallopian tube and endometrium. This modality is especially useful in identifying Mullerian anomalies that should be considered during surgical planning. Preoperative uterine artery embolization or intraoperative ligation can be considered if needed. Dilute vasopressin injection can also decrease blood loss during this procedure. Traction and countertraction should be employed to successfully enucleate the pregnancy from a highly vascular area. Myometrium needs to be preserved, in a similar fashion to myomectomy, to ensure adequate closure of the significant defect. Postoperatively, patients should be counseled similarly to those who have had myomectomy with significant myometrial invasion.