Interstitial Ectopic Pregnancy: Laparoscopic Cornuostomy

Study Objective To demonstrate and discuss the technique of cornuostomy for surgical management of interstitial ectopic pregnancy. Design Stepwise demonstration of the technique with narrated video footage. Setting Tertiary referral center in Manchester, United Kingdom. Intervention Interstitial ectopic pregnancies are rare but are associated with a higher mortality rate than other ectopic pregnancies [ 1 Marchand G Masoud AT Sainz K et al. A systematic review and meta-analysis of laparotomy compared with laparoscopic management of interstitial pregnancy. Facts Views Vis Obgyn. 2020; 12: 299-308 Google Scholar , 2 Brincat M Bryant-Smith A Holland TK The diagnosis and management of interstitial ectopic pregnancies: a review. Gynecol Surg. 2019; 16: 2 Crossref Scopus (25) Google Scholar ]. It occurs when the fertilized embryo implants in the interstitial portion of the fallopian tube traversing the vascularized myometrium. When undiagnosed they present late in the second trimester associated with rupture and catastrophic bleeding, with a mortality rate of 2% to 2.5%.2 Diagnosis requires a degree of vigilance from the ultrasound operator because it is commonly misdiagnosed as intrauterine pregnancies. Surgical management options include laparoscopic cornual resection or cornuostomy. There is no consensus on the optimal surgical technique but cornuostomy is a more conservative approach associated with less disruption to uterine anatomy and loss of myometrium [ 3 Lee MH Im SY Kim MK Shin SY Park WI Comparison of laparoscopic cornual resection and cornuotomy for interstitial pregnancy. J Minim Invasive Gynecol. 2017; 24: 397-401 Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar , 4 Pramayadi CT Bramantyo A Gunardi ER Successful procedure in conservative management of interstitial (cornual) ectopic pregnancy. Gynecol Minim Invasive Ther. 2018; 7: 172-174 Crossref PubMed Scopus (8) Google Scholar ]. A 22-year-old gravida 4 woman presented at 7 weeks’ gestation with right iliac fossa pain. Initial serum human chorionic gonadotropin was 18 136 IU/L. Transvaginal ultrasound scan showed an empty endometrial cavity and an echogenic “donut”-shaped mass within the right interstitial space, within the uterine serosa but outside the endometrial cavity (Supplemental Video 1). At laparoscopy the diagnosis of a right interstitial ectopic pregnancy was confirmed (Supplemental Video 2). Vasopressin 20 IU diluted in 80 mL of normal saline was injected around the base of the ectopic pregnancy. Monopolar diathermy was used to incise the overlying serosa followed by hydrodissection to separate the ectopic gestational sac from the myometrial attachment. The resulting defect was inspected and closed in 2 layers. Total operating time was 46 minutes. Conclusion Although there is no clear evidence to guide the management of all interstitial ectopic pregnancies, an individualized approach taking into account the woman's previous history and future fertility plans and wishes is essential. In this case, given the woman's previous contralateral salpingectomy and her wishes for a conservative approach, a laparoscopic cornuostomy was likely the best option.