Human Reproduction, Vol. 16, No. 4, 780-781,
April 2001
© 2001 European Society of Human Reproduction and Embryology
Tubal curettage: a new conservative treatment for haemorrhagic interstitial pregnancies: Case report
1 Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire de Grenoble, Grenoble and 2 Department of Obstetrics and Gynecology, Hôpital Antoine Béclère, Clamart, France
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Abstract |
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Haemorrhagic interstitial pregnancies are commonly treated by cornual resection. This invasive procedure may increase the risk of uterine rupture in subsequent pregnancies. We report here a case of a haemorrhagic interstitial pregnancy, associated with a viable intrauterine pregnancy in a salpingectomized woman, which was treated successfully by curettage of the uterine cornu.
Key words: ectopic pregnancy/interstitial pregnancy/IVF
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Introduction |
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Interstitial pregnancies rank among the rarest forms of ectopic pregnancy. Indeed, an early review of 438 ectopic pregnancies indicated that the gestational sac was situated in the interstitial portion of the Fallopian tube in only 13% of cases (Douglas, 1963
). Nonetheless, the wide use of ovarian stimulation for the treatment of infertility has not only increased their overall incidence but also fostered the association between interstitial and intrauterine embryo implantation (Reece et al., 1983; Rizk et al., 1991; Marcus et al., 1995). The associated risk of severe haemorrhage and cornual rupture limits usual therapeutic options to cornual resection or hysterectomy. We report a case of haemorrhagic interstitial pregnancy associated with a viable intrauterine pregnancy in a salpingectomized woman who had undergone in-vitro fertilization and embryo transfer (IVF–embryo transfer). Despite the presence of severe haemorrhage, this interstitial pregnancy was treated conservatively and successfully by curettage of the uterine cornu. |
Case report |
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A 37 year old woman, gravida 5, para 2, was admitted at 5 weeks gestation because of low abdominal pain. This patient suffered from tubal infertility and had undergone left salpingectomy for tubal pregnancy 3 years earlier. The current gestation was obtained by the transcervical transfer of three embryos obtained after IVF.
Physical examination showed an impaired haemodynamic status with decreased blood pressure (90/60 mmHg) and tachycardia (110 bpm). The blood cell count revealed moderate anaemia, with haemoglobin levels at 8 g/100 ml. Both transvaginal and transabdominal ultrasound examination showed a normal intrauterine gestational sac with cardiac activity, and another gestational sac, measuring 15x10 mm in diameter, without cardiac activity, positioned in the left uterine cornu at the interstitial tubal portion. A considerable volume of blood collected in the peritoneal cavity (~1 l) was also observed. The diagnosis of haemorrhagic heterotopic interstitial pregnancy was then considered.
Because of unstable clinical conditions, the patient underwent a laparotomy: it showed the presence of an interstitial gestational sac near the remaining ruptured portion of the left Fallopian tube. To avoid the resection of the uterine cornu, we performed a gentle curettage of the interstitial tubal portion through the opening of the ruptured tube. Per-operative ultrasound guidance prevented the risk of penetrating the uterine cavity with the curette and avoided damaging the intrauterine sac. This procedure allowed complete evacuation of the ectopic sac and significant reduction of the haemorrhage. Finally, the interstitial portion of the uterus was closed with a running suture of 1–0 vicryl (Etnor, Issy-Les-Moulineaux, France). Pathological analysis identified the presence of chorial villi and confirmed the diagnosis of ectopic pregnancy.
Four days after the intervention, an ultrasound scan showed an ongoing intrauterine pregnancy. During the 4 week post-operative period, the patient received 400 mg of progesterone (Utrogestan®; Besins-Iscovesco Pharmaceuticals, Paris, France) daily by the vaginal route. Clinical and ultrasonographic monitoring during pregnancy failed to show any obstetric abnormality. Because of the previous uterine scar, an elective Caesarean section was performed at the 37th week of gestation, delivering a normal female infant who weighed 2900 g. Per-operative examination of the left uterine cornu showed complete healing of the uterine wall with no signs of rupture or fragility.
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Discussion |
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Modern conservative management of heterotopic pregnancies includes either abstention, local KCl administration (Rizk et al., 1991
; Fernandez et al., 1993), laparoscopic salpingotomy or salpingectomy (Fernandez et al., 1993; Marcus et al., 1995), or laparotomic salpingotomy or salpingectomy (Loret de Mola et al., 1995). These approaches are inherently proscribed in the presence of severe haemorrhage. In these cases, radical treatments including cornual resection or even hysterectomy may be necessary (Sharif et al., 1994). However, these procedures are markedly invasive, and cornual resection may dramatically increase the risk of uterine rupture in subsequent pregnancies.
Tubal curettage may be a new attractive alternative in the management of heterotopic haemorrhagic interstitial pregnancies. This conservative approach avoids cornual resection and may be considered even in the presence of marked haemorrhage. In a case where the Fallopian tubes are present, a simple salpingostomy is required to proceed with cornual curettage. Although the case reported here required laparotomy because of severe bleeding, the laparoscopic aspiration of the ectopic sac is technically conceivable (Grobman and Milad, 1998).
The possibility of managing laparoscopically interstitial pregnancies has been the subject of several case reports (Reich et al., 1988; Tulandi et al., 1995). Both authors successfully used laparoscopic cornual excision in interstitial pregnancies. This technique also seems to be applicable in the treatment of ruptured interstitial pregnancies (Reich et al., 1990). Cornual resection that potentially increases the risk of uterine rupture during pregnancy or labour should be avoided. Hence, the laparoscopic approach should be attempted only in cases in which conservative treatment is possible and safe, and operator training is adequate to convert the operation into a laparotomy, if necessary, should severe haemorrhaging occur during the surgical procedure.
In conclusion, key measures for the successful management of heterotopic interstitial pregnancies include early diagnosis, with specific ultrasound monitoring, particularly in women who have undergone ovarian stimulation. When conservative measures such as KCl administration are proscribed due to marked haemorrhage, tubal curettage may be an attractive therapeutic alternative to cornual resection or hysterectomy. Extended series of heterotopic interstitial pregnancies treated with tubal curettage are, however, required to confirm these preliminary results.
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Notes |
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3 To whom correspondence should be addressed at: Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire de Grenoble, BP 185, 38042, Grenoble, France. E-mail: Jamayou{at}aol.com
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References |
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Douglas, C.P. (1963) Tubal ectopic pregnancy. Br. Med. J., 2, 838–841.
Fernandez, Lelaidier, C., Doumerc, S. et al. (1993) Nonsurgical treatment of heterotopic pregnancy: a case report of six cases. Fertil. Steril., 60, 428–432.[Web of Science][Medline]
Grobman, W.A. and Milad, M.P. (1998) Conservative laparoscopic management of a large cornual ectopic pregnancy. Hum. Reprod., 13, 2002–2004.
Loret de Mola, J.R., Austin, C.M., Judge, N.E. et al. (1995) Cornual heterotopic pregnancy and cornual resection after in vitro fertilization/embryo transfer. J. Reprod. Med., 40, 606–610.[Web of Science][Medline]
Marcus, S.F., MacNamee, M. and Brinsden, P. (1995) Heterotopic pregnancies after in-vitro fertilization and embryo transfer. Hum. Reprod., 10, 1232–1236.
Reece, E.A., Petrie, R.H., Sirmans, M.F. et al. (1983) Combined intrauterine and extrauterine gestations: a review. Am. J. Obstet. Gynecol., 146, 323–330.[Web of Science][Medline]
Reich, H., Johns, D.A., De Caprio, J. et al. (1988) Laparoscopic diagnosis and treatment of interstitial ectopic pregnancy: a case report. Am. J. Obstet. Gynecol., 163, 587–588.
Rizk, B., Tan, S.L., Morcos, S. et al. (1991) Heterotopic pregnancies after in vitro fertilization and embryo transfer. Am. J. Obstet. Gynecol., 164, 161–164.[Web of Science][Medline]
Sharif, K., Kaufmann, S. and Sharma, V. (1994) Heterotopic pregnancy obtained after in-vitro fertilization and embryo transfer following bilateral total salpingectomy: case report. Hum. Reprod., 9, 1966–1967.
Tulandi, T., Vilos, G. and Gomel, V. (1995) Laparoscopic treatment of interstitial pregnancy. Ob. Gyn., 85, 465–467.
Submitted on August 10, 2000; accepted on January 4, 2001.
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