Laparoscopic Strategy for Heterotopic Interstitial Pregnancy Following Assisted Reproductive Techniques

Persistent increase of β-hCG level after salpingectomy in tubal pregnancy: Good or bad news?

Heterotopic pregnancy is a rare event in natural conception (1:30000). We describe a case of a 36-year-old nulliparous. She presented to our department in the 4 + 6 gestational week with two simultaneous pregnancies intrauterine and extrauterine. Here, we compare treatment options and ultrasound findings to help examiners avoid inadequate therapeutic approaches.

Management of interstitial pregnancy in the era of laparoscopy: a meta-analysis of 855 case studies compared with traditional techniques

Interstitial pregnancy is a rare, life-threatening condition that requires high clinical suspicion for diagnosis. Most cases are discovered after complications have occurred. Many authors have described laparoscopic management. Although previous systematic reviews have compared the attributes and complications associated with interstitial pregnancy, we endeavored to complete the first systematic review and meta-analysis to compare the laparoscopic treatment of interstitial pregnancy with the open approach in the modern age of laparoscopic surgery. We systematically searched PubMed, ClinicalTrials.gov, Scopus, Web of Science, and Cochrane until June 2020 using relevant keywords and screened them for eligibility. We found a statistically significant difference in blood loss between laparoscopic and open surgery (168 mL compared to 1,163 mL). Further, cumulative meta-analysis has revealed that blood loss in laparoscopy has been decreasing over time from 1991 to 2020. Laparoscopic patients took less operative time (63.2 minutes) compared to laparotomy patients (78.2 minutes). Patients in the laparoscopic group spent less time hospitalized (3.7 days) compared to laparotomy patients (5.2 days). Our findings add strength to the position that laparoscopic approaches to interstitial pregnancy can be considered first-line in most situations. The laparoscopic approach was found to have a mean blood loss of 168 mL, and this blood loss seems to decrease over time. Increased gravidity and duration of amenorrhea are positive factors that increase bleeding during the procedure. We are unable to find enough high-quality data to significantly compare successful pregnancy following surgery or risk of mortality in these populations.

Threatened uterine rupture following laparoscopic surgery in interstitial tubal pregnancy

Contraception is recommended for a certain period following a hysterotomy; however, no consensus exists on the required duration of contraception. A 21-year-old female was brought to the emergency room in a state of shock due to intraperitoneal bleeding. An emergency laparoscopic cornuostomy indicated for ruptured interstitial pregnancy was performed. Despite contraception, the patient got pregnant 1.5 months after surgery. At 16 weeks of gestation, threatened uterine rupture was suspected, as magnetic resonance imaging (MRI) revealed hematogenous amniotic fluid and a subchorionic hematoma near the interstitial portion of the fallopian tube. An MRI at 21 weeks showed hematoma shrinkage and disappearance of the hematogenous amniotic fluid. At 37 weeks, an elective cesarean section was performed, which resulted in a live birth. Pregnancy shortly after surgery is a risk factor for uterine rupture. In such cases, MRI could be useful in the evaluation of threatened uterine ruptures.

Use of Laparoscopic Slip Knot with Purse-String Suture in Surgical Management of Unruptured Heterotopic Interstitial Pregnancies

Background

The aim of this study was to investigate the advantages and disadvantages of using laparoscopic slip knot with purse-string suture technique in the surgical management of unruptured heterotopic interstitial pregnancies compared with other surgical strategies.

Material/Methods

We retrospectively analyzed data on 13 patients with unruptured heterotopic interstitial pregnancies who underwent laparoscopy in our hospital between May 2012 and August 2018. The control group consisted of 10 patients who underwent cornual resection or cornuostomy with conventional sutures and knots. The study group consisted of 3 patients whose surgical plans involved use of the slip knot with purse-string suture technique followed by cornuostomy. We evaluated the surgical records and video to comparatively analyze their operation duration, intraoperative blood loss, and pregnancy outcomes.

Results

The average volume of intraoperative blood loss was 76.67±25 ml in the study group and 215.00±110 ml in the control group. On average, the intraoperative blood loss volume in the study group was 138 ml less than in the control group and the difference was statistically significant (P<0.05). There was no statistically significant difference in the live birth rate and operation time between the 2 groups (P>0.05). The duration of hemostasis in the study group was 11 min shorter than in the control group, while the duration of cornual electrocoagulation in the study group was 18.5 s shorter. Both groups achieved thorough hemostasis without the help of vasopressin and avoided use of embryo-killing drugs such as methotrexate. Neither group required second surgery or developed postoperative complications such as uterus rupture or persistent ectopic pregnancy.

Conclusions

This strategy is safe and reliable for gestational sac clearance while simultaneously preventing any potential harm to the intrauterine embryo. It is particularly suitable for unruptured HIP patients who have a strong desire to preserve their intrauterine embryos.