Laparoscopic treatment of cornual pregnancy: a series of 20 consecutive cases David Soriano, M.D., Danielle Vicus, M.D., Roy Mashiach, M.D., Eyal Schiff, M.D., Daniel Seidman, M.D., and Motti Goldenberg, M.D. Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Israel (affiliated with Tel Aviv University, Tel Aviv, Israel)
Objective: To determine the outcome of laparoscopic management of cornual pregnancy. Design: Retrospective cohort study (Canadian Task Force classification II-3). Setting: A tertiary referral hospital in Israel. Patient(s): Twenty-seven consecutive women with cornual pregnancy who were diagnosed and treated at our institute. Intervention(s): Laparoscopy was undertaken in 20 (74%) of the patients. Resection of the cornua and/or a Vicryl loop placement was performed. In 6 cases, laparoscopy was converted to laparotomy. In addition, laparotomy was performed in 2 other cases. Five cases were managed conservatively: 3 with systemic methotrexate (MTX) and leucovorin, 1 with transvaginal sonography-guided KCl injection to the amniotic sac, and 1 with hysteroscopicguided MTX injection to the amniotic sac. Further treatment after surgery was required in 4 cases: transvaginal sonography–guided KCl injection, MTX or KCl þ MTX (1 case each) injection to the amniotic sac, and systemic MTX injection. Main Outcome Measure(s): Successful laparoscopy, determined as not needing follow-up treatment. Result(s): The mean gestational age was 56 days. The average and median serum hCG levels were 31,199 and 6,653 IU/mL, respectively. Six of the women (22%) were admitted in hypovolemic shock. Nine patients (33.3%) were asymptomatic upon admission, 14 (52%) had abdominal pain, and 8 (29.6%) were evaluated for vaginal bleeding. One woman developed hypovolemic shock after admission. Only 15 (55.6%) of the 27 pregnancies were diagnosed as a cornual pregnancy by transvaginal sonography before the therapeutic procedure. Blood transfusion was given in seven cases (26%) during surgery. The mean number of days of hospitalization was 5.7 days for patients who underwent surgery and was 7.1 days for all patients. A comparison was made between the first 11 and the last 11 cases treated surgically. Although the two groups were similar in all parameters, conversion from laparoscopy to laparotomy was higher in the first group, although not at a statistically significant level. Conclusion(s): Improved laparoscopic technique, accumulated experience, and possibly earlier diagnosis have led to fewer operative failures or need to convert to laparotomy during treatment of cornual pregnancy. Conservative treatment, when possible, should be considered. If surgery is indicated, and as more laparoscopic skill is gained, laparoscopy should be considered the preferred method of treating cornual pregnancy. In experienced hands, laparoscopy is a safe and effective treatment for cornual pregnancy. (Fertil Steril 2008;90:839–43. 2008 by American Society for Reproductive Medicine.) Key Words: Cornual pregnancy, interstitial pregnancy, laparoscopy, MTX
The interstitial portion of the fallopian tube is the proximal portion that is within the muscular wall of the uterus. It is 0.7 mm wide and 1 to 2 cm long. Cornual (interstitial) pregnancy represents about 1% of the ectopic pregnancies (1). Risk factors for cornual pregnancy include past pelvic inflammatory disease, previous pelvic surgery, uterine anomalies, the use of assisted reproductive techniques, and ipsilateral salpingectomy. Ipsilateral salpingectomy is a risk factor that is unique to cornual pregnancy (2). Cornual pregnancy is associated with major diagnostic pitfalls, because it is diagnosed relatively late and presents a diagnostic challenge. Rupture of the uterus may occur in 20% of the cases Received March 23, 2007; revised and accepted July 5, 2007. Danielle Vicus, M.D., Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer, 52621 Ramat gan, Israel. (E-mail:
[email protected]).
0015-0282/08/$34.00 doi:10.1016/j.fertnstert.2007.07.1288
that progress beyond 12 weeks of amenorrhea (3). It is believed that rupture of cornual pregnancies occurs later, usually after the 12th week of gestation, because of the thickness of the uterine wall (4). The traditional treatment of cornual pregnancy was hysterectomy or cornual resection by laparotomy. Several investigators have advocated conservative management with methotrexate (MTX) (5, 6). Hysteroscopic removal of cornual pregnancy also has been reported (7). We have also advocated elsewhere the use of hysteroscopy for local MTX treatment (8). A combination of dilatation and curettage and MTX recently was suggested (9). Laparoscopic techniques that involve cornual resection, cornuostomy, salpingostomy, or salpingectomy have improved greatly over the last decade and currently are in wide use (5). The aim of this study was to assess the modern
Fertility and Sterility Vol. 90, No. 3, September 2008 Copyright ª2008 American Society for Reproductive Medicine, Published by Elsevier Inc.
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laparoscopic management of cornual pregnancy and to examine how advances in laparoscopy may have influenced treatment during the last 2 decades in a large series from one tertiary-care medical center. MATERIALS AND METHODS Twenty-seven women with cornual pregnancy were treated at our department from September 1991 to January 2006. We performed a retrospective search through our computerized database, which includes all admissions and has several codes regarding extrauterine pregnancies. We manually reviewed all of the files catalogued under the codes ‘‘ectopic pregnancy—non tubal’’ and ‘‘ectopic pregnancy—other.’’ We identified 24 historic cases of cornual pregnancy, and three additional women were treated during the preparation of this article. Demographic features, clinical symptoms, transvaginal sonography (TVS) examinations, type of management, and outcome were reviewed by using archived medical files. Because the data collected present a summary of our routine surgical protocol and this is not an interventional study, approval was not obtained from the institutional review board. All women were evaluated by physical examination and TVS and by assessing complete blood count (CBC), liver function tests (LFTs), and serum hCG levels. Choice of treatment was made by the attending physician, considering the hemodynamic status of the patient, the status of the pregnancy (heterotropic or not, sonographic appearance, and hCG level), the patient’s history, desire for fertility preservation, and the laparoscopic capabilities of the staff present. After surgery, all patients were hospitalized for R2 days. Absolute indications for operative treatment of ectopic pregnancy in our department are unstable hemodynamic state, sonographically detectable fetal heart beat, serum hCG of >10,000 IU/L, and second MTX failure. A relative indication for operative treatment is hCG of >5,000 IU/L. These indications were assigned to cornual pregnancy. Statistical Analysis Statistical analysis was performed by using Student’s t-test, Fisher’s exact test, or c2 test, as appropriate. A P value of < .05 was considered significant. P values in the range of .05 to .12 are shown in Tables 2 and 3 to indicate a significant trend. Conservative Treatment When used systemically, MTX was given IM, either as a onetime dose (50 mg per m2 of body area) or in multiple doses (four doses, with leucovorin, on sequential days: an IM dose of 1 mg of MTX per kg of body weight was given on days 1, 3, 5, and 7, and 3 injections of 0.1 mg of leucovorin per kg of body weight [folinic acid] were given, on days 2, 4, and 6). CBC and LFT were sampled every other day. Leucovorin was administered with MTX, even though its admin840
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istration is no longer advocated. Although several medical protocols for ectopic pregnancy have been used over the years, in our department, the protocol did not change during the years of this study. Guided injection of MTX was performed either under TVS guidance or by hysteroscopy, as described elsewhere (8). Operating Procedures All of the operations were performed by experienced surgeons under endotracheal intubation and general anesthesia, in a modified dorsolithotomy position. Patients were monitored continually for blood pressure, electrocardiogram, transcutaneous oxygen saturation, and end tidal carbon dioxide pressure. In all cases of laparoscopic surgery, a Veress needle was inserted through the umbilicus, and the abdomen was inflated with CO2. Blunt and sharp dissection of the uterus and cornua was performed with either a unipolar probe, a bipolar probe, or scissors. Bipolar forceps were used for hemostasis. In some of the cases, a Vicryl loop (Endoloop; Ethicon, Cincinnati, OH) was used to tie the area of the cornua, either before or after dissection of the cornua. During laparotomy, the cornua was dissected with scissors, the pregnancy was expelled, and the cornua was stitched with Vicryl sutures. Strict hemostasis and hemoperitoneal evacuation were performed in all operations. RESULTS The study group consisted of 27 women who had cornual pregnancy. The median (range) gravidity and parity were 3 (1–6) and 1 (0–4), respectively. Nineteen pregnancies (70.3%) were conceived spontaneously, and 8 (29.7%), through IVF. Thirteen women (48.1%) had a previous ectopic pregnancy (Table 1). Previous pelvic operation was noted in 18 (75%) patients. The type of surgery performed is detailed in Table 1. In two of the six patients who did not have a previous operation, bilateral tubal occlusion was noted during infertility workup. The mean (SD) gestational age (by last menstrual period) was 8.2 2.1 weeks. The median hCG at admission was 7,200 IU/mL, but the range was wide, between 740 and 360,000 IU/mL. The mean hemoglobin at admission was 12.3 g/dL, with a range between 6.8 and 14.3 g/dL. Nine (33.3%) of the 27 women were asymptomatic at admission, 8 (29.6%) had vaginal bleeding, and 13 (48.1%) had abdominal pain. Six patients (22.2%) were admitted with hypovolemic shock and therefore were rushed to the operation room while receiving intravenous fluids. All 6 of those women were treated by laparoscopy. One of these patients was treated with systemic MTX later in hospitalization because of plateauing hCG. All 6 were treated with blood Vol. 90, No. 3, September 2008
injection to the amniotic sac; and one, with hysteroscopicguided KCl injection to the amniotic sac.
TABLE 1 Clinical characteristics and treatment of women with cornual pregnancies. Parameter
n
%
Risk factors Previous pelvic surgery 18 75.0 Salpingectomy or tubal ligation 13 Cesarian section 4 Myomectomy (2) 1 Previous extrauterine pregnancies 13 54.1 Previous pelvic inflammatory 3 12.5 disease IVF 8 29.7 Clinical presentation Ruptured cornua 6 22.2 Hemoperitoneum 6 22.2 Treatment Blood transfusion 7 25.9 Laparoscopy 20 74.0 Resection of cornua 5 25.0 Vicryl loop placement 7 35.0 Vicryl loop þ cornua resection 4 20.0 Primary laparotomy 2 Conservative treatment 5 Conversion to laparotomy 6 Additional treatment after surgery 4 Failed Vicryl loop 2 Surgically misdiagnosed 2 Soriano. Laparoscopy for cornual pregnancy. Fertil Steril 2008.
transfusion, until they were hemodynamically stable, before they entered the operating room. One additional patient was misdiagnosed with a missed (intrauterine) abortion. During a standard dilatation and curettage procedure, the patient went into hypovolemic shock without sufficient vaginal blood loss to explain her hemodynamic status. A laparoscopy was performed immediately, and a bleeding cornual pregnancy was diagnosed. The surgeon then decided to convert to laparotomy. Sonographic examination was performed before surgery in 26 of 27 cases. In one case, the patient was operated on immediately after admission because of the presence of hypovolemic shock and a positive urine pregnancy test. The correct diagnosis of a cornual pregnancy was made by TVS in 15 cases (55.6%). Six cases were misdiagnosed by TVS: three cases (11.1%), as an intrauterine missed abortion, and three cases (11.1%), as an extrauterine tubal pregnancy. In five cases (18.5%), the location of the pregnancy could not be determined ultrasonographically. Five cases were managed conservatively: three, with systemic MTX and leucovorin; one, with TVS-guided KCl Fertility and Sterility
Twenty-two patients were treated surgically (81.4%): 20 by primary laparoscopy and 2 by primary laparotomy. Six of the women treated primarily by laparoscopy (27.3%) underwent a conversion to laparotomy during the procedure as a result of either hemoperitoneum, in 2 cases, or of technical difficulty, in 4 patients. The surgeon preferred laparotomy in the 2 primary-laparotomy cases because of expected technical difficulty. The cases in which conversion from laparoscopy occurred, as with the cases in which primary laparotomy was preferred, were not statistically significantly different from the cases that were treated by laparoscopy in terms of hemodynamic stability, the amount of blood loss (as perceived by the surgeon and as measured by the drop in serum hemoglobin), and the sonographic criteria (mass size and existence of fetal pulse) or the method of conception (IVF or spontaneous). Four of the patients who were treated by conversion to laparotomy had had prior abdominal surgery, and 2 had a mechanical factor (bilateral tubal occlusion). During the laparoscopic procedures, a resection of the cornua was performed in five cases, a Vicryl loop was used in seven cases, and a combination of the two procedures was used in four cases. Further postoperative treatment was needed in four cases. Two cases after use of a Vicryl loop and two additional cases after a diagnostic laparoscopy did not succeed in diagnosing the cornual pregnancy. The individual treatments after the Vicryl loop failure were as follows: [1] systemic MTX injection and [2] TVS-guided MTX and KCl injection to the amniotic sac and then systemic MTX injection. The treatments after the diagnostic laparoscopy misdiagnosis were as follows: [1] TVS-guided MTX and KCl injection, and then a surgical laparoscopy that was performed by using a Vicryl loop and [2] hysteroscopic MTX injection to the amniotic sac. The mean overall length of hospitalization was 7.1 days. Table 2 presents a comparison between the first 11 and the last 11 cases that were treated surgically. The first cases were treated during 1991–1999, and the last cases, during 2000– 2006. Although the two groups were similar in all parameters, conversion from laparoscopy to laparotomy was higher in the first group, although not statistically significantly so (P¼.15). The last cases in which primary laparotomy was preferred or conversion from laparoscopy to laparotomy was decided upon occurred in 2000 and 2002, respectively. The demographic features of the patients; information on the pregnancy age at admission (by last menstrual period and hCG level); operating times, including both types of surgery and laparoscopy alone; and the duration of hospitalization are given in Table 2. The demographic features were similar. The level of hCG was significantly lower in the later group (P¼.0001), and the gestational age at admission (by last menstrual period) was younger, although not statistically significantly so (P¼.08). The duration of hospitalization was shorter in this group (P¼.049). The duration of surgery, in the case of both types and of laparoscopic surgery alone, was shorter in the later 841
TABLE 2 Comparison between early and late cases treated surgically. Parameter Year, range Age (y) Gravidity Parity Serum hCG level (IU/mL) Serum hCG level in IU/mL, median (range) Pregnancy age (d), by LMP Hemoglobin level at admission (g/dL) Length of hospitalization (d) Primary laparotomy, n (%) Conversion, n (%) Ended in laparoscopy, n (%) Operation time (min) Operation time for laparoscopy (min) Hemoperitoneum (>1 L of blood) at surgery, n (%)
First 11 cases
Last 11 cases
1991–1999 34.3 5.8 3.7 1.8 1.5 1.4 70,115 5,851 9,134 (2,488–360,000) 59.1 14.7 12.3 0.8 6.6 3.4 1/11 (9) 5/11 (45) 5/11 (45) 120 80 110 71 2/11 (18)
2000–2006 35.2 4.3 4.3 2.1 1.7 1.3 7,535 7,019 6,106 (1,463–22,460) 49.7 8.4 11.9 2.3 4.3 1.6 1/11 (9) 1/11 (9) 9/11 (82) 73.6 20 68.3 18 5/11 (45)
P value NS NS NS .0001 .080 NS .049 NS NS NS .077 .112 NS
Note: Data are mean SD unless otherwise indicated. LMP ¼ last menstrual period; NS ¼ no statistical significance. Soriano. Laparoscopy for cornual pregnancy. Fertil Steril 2008.
group than in the earlier one but not statistically significantly so (P¼.112 and P¼.077, respectively). Table 3 presents a comparison between laparotomy and laparoscopic techniques for the entire group of patients. We did not find a statistically significant difference when comparing the operation time, duration of hospitalization (total and postoperative), or hCG levels.
DISCUSSION To our knowledge, this is the largest reported case series of cornual pregnancies that were treated in a single hospital. In a tertiary academic general hospital, knowledge is preserved through the years, although because of the emergency nature of cornual pregnancy management, this knowledge is not always used. Analysis of the cases reveals that over the years, the will and ability of the surgeons in our department
to choose laparoscopy over laparotomy and to choose complete treatment by laparoscopy has increased enormously. Only 1 of the last 11 cases, vs. 5 among the first 11 cases, was converted to laparotomy. This may be due to our improved experience with laparoscopic surgery, as well as to our acquired knowledge of this particular situation. We found prior abdominal surgery or bilateral tubal occlusion to be a determining factor of conversion to laparotomy. We did not find other factors that were assessed to be predictive of conversion. This is a manifestation of our understanding that laparoscopy is a safe method of treating cornual pregnancy. As was described elsewhere by Soriano et al. (10), laparoscopy can be performed even in cases of ectopic pregnancy and hypovolemic shock. The advantages of laparoscopy over laparotomy are well known. The gestational age at diagnosis in the later group is lower (P¼.08), probably as a result of the high index of suspicion
TABLE 3 Comparison between laparotomy and laparoscopic surgery. Parameter
Laparoscopy (n [ 11)
Laparotomya (n [ 11)
P value
Operation duration (min) Hospitalization (d) Postoperative hospitalization duration (d) HCG at admission (IU/mL) HCG at admission, median (range)
83.7 45.1 5.7 3.7 3.3 2.2 18,397 39,860 7,200, 1,463–150,000
1,249 84.6 5.9 1.0 4.1 1.0 99,149 174,069 16,300, 4,000–360,000
NS NS NS .120
Note: Data are average SD unless otherwise indicated. NS ¼ no statistical significance. a Primary or conversion laparotomy. Soriano. Laparoscopy for cornual pregnancy. Fertil Steril 2008.
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and/or the improved sonographic equipment, which caused a higher detection rate. The index of suspicion should be high, especially in women who have risk factors for cornual pregnancy, such as previous pelvic surgery, a previous ectopic pregnancy, pelvic inflammatory disease, and pregnancy after IVF treatment. The risk factors found in our study are similar to the ones found in other reports (4). With regard to operating technique, acceptable treatment options include placing a Vicryl loop on the cornua and/or performing a wedge resection to extract the pregnancy. One must take into consideration that the loop can be placed laterally to the pregnancy. This happened in two cases in our series; therefore, postoperative recovery should be carefully monitored. In some cases, postsurgical MTX treatment or guided KCl injection to the amniotic sac is needed to succeed in termination of the pregnancy. In cases of heterotopic pregnancy with intrauterine pregnancy and cornual pregnancy, the diagnosis can be even more difficult and challenging. In these cases, MTX treatment is contraindicated; therefore, laparoscopy should be performed as soon as possible (11). We agree with Ross et al. (9) that after removing most of the pregnancy sac and obtaining good hemostasis, the surgeon does not have to attempt to fully extract the pregnancy sac. This will lead to further bleeding, or even a need for hysterectomy. In two of the cases in our series in which this situation occurred, although postoperative retention of pregnancy was detected by ultrasound or by plateau of blood hCG level, conservative management was effective in terminating the pregnancy. In 11 cases (42%), a hemostatic suture was deemed necessary; therefore, knowledge of laparoscopic suturing is a prerequisite for the treatment of cornual pregnancies. We conclude that cornual pregnancy remains a challenging and potentially dangerous situation. Selection of treatment
Fertility and Sterility
depends on various parameters. Laparoscopy allows an earlier diagnosis, and an early laparoscopy is advised in cases of abdominal pain and of uncertainty regarding the exact location of the pregnancy. When managing a cornual pregnancy, experience plays a great role. Conservative treatment, when possible, should be considered. If surgery is indicated, and as more laparoscopic skill is gained, laparoscopy should be considered the preferred method of treating cornual pregnancy. In experienced hands, laparoscopy is a safe and effective treatment for cornual pregnancy.
REFERENCES 1. Rock JA, Thompson JD, eds. Te Linde’s operative gynecology. 8th ed. Philadelphia: Lippincott-Raven, 1997:505–20. 2. Simpson JW. Interstitial pregnancy following homolateral salpingectomy. Am J Obstet Gynecol 1961;82:1173–9. 3. Felmus LB, Pedowitz P. Interstitial pregnancy: a survey of 45 cases. Am J Obstet Gynecol 1953;66:1271–9. 4. Tulandi T, Al-Jaroudi D. Interstitial pregnancy: results generated from the Society of Reproductive Surgeons Registry. Obstet Gynecol 2004;103:47–50. 5. Lau S, Tulandi T. Conservative medical and surgical management of interstitial ectopic pregnancy. Fertil Steril 1999;72:207–15. 6. Tanaka T, Hayashi H, Kutsuzawa T, Fujimoto S, Ichinoe K. Treatment of interstitial ectopic pregnancy with methotrexate: report of a successful case. Fertil Steril 1982;37:851–2. 7. Meyer W, Mitchell D. Hysteroscopic removal of an interstitial ectopic gestation. A case report. J Reprod Med 1989;34:928–9. 8. Goldenberg M, Bider D, Oelsner G, Admon D, Mashiach S. Treatment of interstitial pregnancy with methotrexate via hysteroscopy. Fertil Steril 1992;58:1234–6. 9. Ross R, Lindheim SR, Olive DL, Pritts EA. Cornual gestation: a systematic literature review and two case reports of a novel treatment regimen. J Minim Invasive Gynecol 2006;13:74–8. 10. Soriano D, Yefet Y, Oelsner G, Goldenberg M, Mashiach S, Seidman DS. Operative laparoscopy for management of ectopic pregnancy in patients with hypovolemic shock. J Am Assoc Gynecol Laparosc 1997;4:363–7. 11. Soriano D, Shrim A, Seidman DS, Goldenberg M, Mashiach S, Oelsner G. Diagnosis and treatment of heterotopic pregnancy compared with ectopic pregnancy. J Am Assoc Gynecol Laparosc 2002;9:352–8.
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