LAPAROSCOPIC CORNUOSTOMY: A VIABLE OPTION FOR ADVANCED INTERSTITIAL ECTOPIC PREGNANCY

Miss Bushra Iqbal, Mr Kenneth Ma 

INTRODUCTION:

 Interstitial ectopic pregnancy poses a diagnostic and surgical challenge due to its rarity and high risk of rupture. This case highlights a minimally invasive approach—laparoscopic cornuostomy—as a safe, uterus-preserving solution for managing advanced presentations.

CASE REPORT:

A 32-year-old Gravida 2, Para 0 at 10 weeks gestation presented with mild pain and vaginal bleeding. Her serum hCG was 52,221 IU/L, and she had no prior risk factors for ectopic pregnancy. Transvaginal ultrasound showed a gestational sac with a yolk sac, fetal pole, and heart pulsations. The crown-rump length (CRL) of 25 mm corresponded to approximately 9 weeks and 2 days of gestation, located at the left cornual edge of the uterus, consistent with an interstitial pregnancy. No free fluid was observed.

Surgical intervention was chosen due to the advanced gestation, large ectopic pregnancy, and elevated hCG levels. Laparoscopy confirmed the left interstitial ectopic pregnancy. Vasopressin (20 IU in 100 mL saline) was injected around the ectopic mass, with 60 mL used intraoperatively. Monopolar diathermy was applied to the overlying serosa, followed by hydrodissection to separate the sac from the myometrium. The defect was closed in two layers.

The postoperative course was uneventful, and the patient was discharged the following day.

DISCUSSION:

An interstitial pregnancy (IP) is a rare form of ectopic pregnancy in which the blastocyst implants in the interstitial portion of the fallopian tube [1]. IPs account for 2–6.8% of all ectopic pregnancies [2-4].

Recent case series have demonstrated improved outcomes, with an estimated mortality rate of 2–2.5%, which is seven times higher than the average for all ectopic pregnancies [4]. There is limited evidence on interstitial pregnancies, and no consensus on the best surgical technique. However, cornual wedge resection raises the risk of uterine rupture due to myometrial loss and scarring, whereas cornuostomy reduces this risk by preserving more uterine tissue [6]. A larger ectopic pregnancy does not appear to warrant cornual resection over cornuostomy. In their studies, MacRae et al. and Watanabe et al. opted for cornuostomies for larger interstitial gestational sacs [5,6]. Intra-myometrial vasopressin can be used to control bleeding, enabling both large and small IP cases to be managed laparoscopically [1].

CONCLUSION:

This case reinforces laparoscopic cornuostomy as a viable, conservative surgical option for advanced interstitial ectopic pregnancies, with good outcomes and preserved uterine integrity.

REFERENCES:

1.     Brincat M, Bryant-Smith A, Holland TK. The diagnosis and management of interstitial ectopic pregnancies: a review. Gynecol Surg. 2019;16:1.

2.     Chan LYS, Fok WY, Yuen PM. Pitfalls in diagnosis of interstitial pregnancy. Acta Obstet Gynecol Scand. 2003;82(9):867–70.

3.     Jermy K, Thomas J, Doo A, Bourne T. The conservative management of interstitial pregnancy. BJOG. 2004;111(11):1283–8.

4.     Tulandi T, Al-Jaroudi D. Interstitial pregnancy: results generated from the Society of Reproductive Surgeons Registry. Obstet Gynecol. 2004;103:47–50.

5.     MacRae R, Olowu O, Rizzuto MI, Odejinmi F, Konje JC. Diagnosis and laparoscopic management of 11 consecutive cases of cornual ectopic pregnancy. Arch Gynecol Obstet. 2009;280(1):59–64.

6.     Watanabe T, Ishihara O, Saitoh M, Tsutsumi R. Laparoscopic cornuotomy for interstitial pregnancy and postoperative course. J Obstet Gynaecol Res. 2014;40(8):1983–8.