Laparoscopic Management of Unruptured Interstitial

Summary:
A 27 years old women para-1 had a complaint of dullache pain in right iliac fossa for 5 days with irregular spotting. Her previous menstrual cycle was normal but last one month she had an irregular spotting. One examination she was normotensive. Hb% was 65.There was no tenderness during per abdominal examination but tenderness during per-vaginal examination on right side. Transvaginal ultrasonography (TUVS) detected a degenerative sub serous fibroid of 3.5x 3 cm on the right fundoanterior side. Her pregnancy test was positive but signs and symptoms of pregnancy were absent. Operative plan was to intervention by laparoscope.
We found an unruptured interstitial ectopic pregnancy at the anterolateral wall of the fundus. Laparoscopic excision was done and the uterine wall sutured with 2/0 polyprolylin. Post operative outcome was good.

Introduction:
Ectopic pregnancy is a common life threatening condition affect 1 in 100 pregnancy1. Most ectopic pregnancy develops in the Fallopian tubes. Some times other site like ovary, rudimentary cornu and secondary abdominal pregnancy may happen.
Ectopic pregnancy was first described in 11th century. Until 18th century its out come was fatal and the leading cause of first trimester maternal mortality. The classic clinical triad of ectopic pregnancy is pain, amenorrhea and vaginal bleeding. Unfortunately only 50% of patient presents typically. Forty to 50% of patients of ectopic pregnancy present with vaginal bleeding, 50% have a palpable mass at the adnexal region and 75% may have abdominal tenderness. Approximately 20% of the presenting patients will have unstable hemodynamic condition and is highly suggestive of ruptured ectopic pregnancy2. Fortunately use of modern diagnostic tools is helping to diagnose an unruptured ectopic sac. In this article we are presenting our first case of unruptured interstitial ectopic pregnancy with successful laparoscopic management.

Case report:
A 27 years old woman, para – 1 was consulted with Victory Nursing & Infertility Management Center for the complaints of right sided lower abdominal dull ache for 5 days with irregular spotting one month from her last menstrual period. General examination shows normal findings. Per-abdominal examination was shown no tenderness in any area. Bimanual examination shows tenderness on right adnexal area. Ultrasonography suggests an ill defined degenerative mass attached to the right anterolateral surface of the uterus. Transvaginal ultrasonography confirms the degenerative mass was a fibroid measuring 3.5x3 cm at the mentioned site without any collection at the Cul-de-sac. Though the signs and symptoms of pregnancy were absent the pregnancy test was positive. Our finger was pointing to unruptured ectopic pregnancy and the patient prepared for laparoscopic evaluation. Under general anesthesia patient was placed in 15 degree Trendeleberge position. The Veress needle was introduced just below the umbilicus. Pneumoperitonium was made by insufflating carbondioxide at a maximum pressure of 15 mmHg. An operating 10 mm laparoscopic trocar inserted through the veress point. Two additional 5 mm trocars inserted one at the level of anterior superior iliac crest just lateral to the epigastric vessels on each side. A bulging reddish black mass detected at the right anterosuperior surface of the uterus. Both the Fallopian tubes and ovaries were healthy. No bleeding was found at the Cul- de- sac. The sac was confirmed as interstitial ectopic pregnancy at the uterine surface. Bipolar diathermy coagulation was done around the sac to reduced the vascularity followed by cut the sac and removed the old blood. Additional bleeding points were checked. Denuded surface of the uterus repaired with 2/0 polyprolylin. Proper toileting of the peritoneal cavity and closure of the trocar points were done.


Discussion:
Clinical triad of presentation for ectopic pregnancy mostly points to confirmatory investigation with b-hCG and ultrasonography.
The diagnosis of ectopic pregnancy is easy and well established by use of ultrasonography and b-hCG3. Validity of current algorithm for diagnosis of ectopic pregnancy i.e. ultrasonography and b-hCG had decreased the incidence of ruptured ectopics and mobidity and mortality. Atypical presentation makes the diagnosis difficult. Our patient had atypical presentation. Use of transvaginal ultrasonography assures the tranabdominal views. In this case the ultrasono findings were not consistent with a pregnancy sac. But b-hCG was positive for pregnancy test. Some factors may reduce the sensitivity of ultrasonography. Obesity of the patient, uterine myoma, inconclusive ultrasound findings and definitely the experience of the operator add to the list4. Laparoscopic surgery or key whole surgery is the gold standard for diagnosis and also treatment for hemodynamically stable cases. The modern treatment is dependent upon the expert surgical skills, good ultrasonic scanning and efficient laboratory testing. Interstitial ectopic pregnancy is the rarest variety of ectopics5. Thick and vascular muscle bulk of uterus may maintain the pregnancy for 12 to 16 weeks. Rupture of ectopic pregnancy from the uterine surface is more serious due to massive intraperitoncal hemorrhage occur within vary short time. Our case was hemodynamically stable. Laparoscopic intervention has become the recommended approach for hemodynamically stable cases for the last two decades. Hemodynamically stable patients also can be managed with medical therapy. This group of patients must be suitable for methotrexate therapy6. Conservative surgery and methotraxate therapy group requires weekly follow up for b-hCG level monitoring till it become zero to
ensure that treatment is complete because 5 - 15% cases the trophoblastic activity is persisted7.

Conclusion:
It is very difficult to diagnose interstitial ectopic pregnancy before rupture. Asymmetric enlargement of uterus is confused with lateral flexion of gravid uterus, pregnancy associated with fibroid, pregnancy in bicornuate uterus or angular pregnancy. b-hCG, transvaginal ultrasonography and laparoscopic intervention is helpful for confirmation of interstitial pregnancy. Laparotomy should be avoided as far possible. Methotraxate is contraindicated for a good number of cases. Laparoscopic treatment is a standard option for all hemodynamically stable cases with maximum success and minimum complications.

Reference:
1. Gazvani MR, Baruah DN, Alfirevic Z et al: Mibepristone in combinationwith methotrexate for the medical treatment of tubal pregnancy: A randomized controlled trail. Hum report 13:7,1998.
2. Vicken Sepilian MD – Ectopic pregnancy. www.emedicine.com/medtopic 3212.htm, nov 24, 2004, 1 – 16.
3. Herman, A. Weinraub, Z, Avrech, O et al. Follow-up and outcome of isthmic pregnancy located in a previous cesarean scar. Br. J. Obstel. 1995, 11-14.
4. Gracia CR, Bamhart KT. Diagnosing ectopic pregnancy: decision analysis comparing six strategies. Obstet Gynecol 2001;93;464-70.
5. Fylstra DL: Tubal pregnancy: a review of current diagnosis and treatment. Obstet Gynecol surv 1998 May;53(5):3.
6. Ranson MX, Garcia AJ, Bohrer M et al: Serum progesterone as a predictor of methotrexate success in the treatment of ectopic pregnancy. Obstet Gynecol 1994 Jun;83(6):1033-7.
7. Nieuwesk PT, Hajenius Pj, Van der veen F et al: Systemic methotrexate therapy versus laparoscopic salpingostomy. Fertil Steril 1998 Sep; 70(3):518-22(Med line).

AWARENESS OF PITFALLS DURING TRADITIONAL BIPOLAR ELECTROTHERMY METHOD OF TOTAL LAPAROSCOPIC HYSTERECTOMY.

Objectives: To report our experience on traditional electrothermal coagulation and cutting of uterine pedicles and vessels for total laparoscopic hysterectomy and its pitfalls

Measurements and Main Results: Between June 2001 and December 2004 we performed total laparoscopic hysterectomy in 358 patients for the indications of Fibroid uterus, Adenomyosis, DUB, Ovarian cyst, post-menopausal bleeding and stage I and II endometriosis. We excluded large fibroid and any genital malignancy and stage III – IV endometriosis. . Bipolar electrothermal coagulation and cutting of all uterine pedicles and vessels are used as the primary method of hemostasis. Uterine weight, operating time, blood loss, intra-operative and post-operative complications and hospital stay were recorded. Time required for the completion of operation was 70 to 120 minutes. Blood loss was 30ml – 400 milliliter. Hospital stay was 2 to 3 days. All instruments were reusable. Two patients needed conversion of total laparoscopic hysterectomy to total abdominal hysterectomy. One of them had previous caesarean section and leads to dense bladder adhesions and the second one for stage III endometriosis that had rectal adhesions. Operative complications were incomplete injury to the bladder wall, and inadequate coagulation of uterine vessels leading to difficult hemostasis. One patient has uretero-vault fistula which was corrected by reimplantation of ureter into the bladder after six weeks.

Laparoscopic Management of Atypical Ectopic Pregnancy

Abstract: To analyzes 22 ectopic pregnancies clinically presented as an atypical from for accuracy of diagnosis, operative details and post operative morbidity.

Design: Three year, retrospective analysis.

Setting: Victory Nursing and infertility management centre.

Patients: twenty two hemodynamically stable patients.

Intervention: Laparoscopic Surgery.

Measurement and Main results: Twenty two patients with atypical presentation of ectopic pregnancy were successfully managed Laparoscopically. All patients have dullache or severe pain in lower abdomen or any one iliac fossa. Regular and irregular menstrual pattern were 54.5% and 45.4% respectively ultrasound findings were complex heterogeneous mass without any free fluid 8 cases, definitive gestational sac 6, saclike 8 cases. Urimay ß – HCG was positive in 40.9% and negative was 59%. Pre-operative diagnoses were chronic ectopic pregnancy 11, ruptured corpers Luteum 6 and chocolate cyst 5. Operating diagnosis were chronicectopic pregnancy 14, unruptured tubal pregnancy 5, ovarian ectopic 3. Surgical procedure was salpingostomy, salpingectomy, salpingophrectomy and partial ovarian resection. Average operating time was 30 – 120 minutes. The average post-operative stay was 24 – 48 hours without any complications.

Conclusion: Ectopic pregnancy dose not present always typical form. In suspected cases these guidelines should help the gynaecologist’s decision making for best obstetric outcome and able them to understand diffident possibilities.