Interstitial ectopic pregnancy: laparoscopic surgical management and subsequent outcome-a case report.

IEPs are rare medical conditions with significant morbidity and mortality [ 14 – 17 ]. Their prompt diagnosis and appropriate treatment is vital in ensuring good outcomes [ 2 , 5 ]. The present case outlines an IEP that was appropriately diagnosed and managed at our facility. IEPs are rare with the estimated prevalence being about 1–3% of all EPs [ 2 , 3 ]. IEPs have similar risk factors to EPs which include: a history of a previous EP, pelvic inflammatory disease (PID), infertility, in vitro fertilization (IVF), previous tubal surgery, intrauterine device failure, smoking, increasing age and endometriosis [ 4 ]. The only unique risk factor of IEP is unilateral salpingectomy from a prior EP [ 3 ]. The present case was a lady of 37 years, and her age was the only risk factor apparent. She had none of the other risk factors that have been associated with cornual ectopic pregnancies. The most common clinical presentation of IEP is abdominal pain and vaginal bleeding [ 18 , 19 ]. This usually presents 6–8 weeks after a missed period with some patients being asymptomatic [ 20 , 21 ]. IEPs can also present with symptoms of rupture which will be persistent abdominal pain and symptoms of hemorrhage like feeling faint or dizziness [ 6 ]. The rupture rate of IEPs seems to be similar to those of other EPs [ 6 ]. This present case presented with abdominal pain which is expected with IEPs. However, she had no vaginal bleeding, and her gestational age was below the expected rupture gestation. She also did not have evidence of rupture at laparoscopy. The main diagnostic tool for IEP is ultrasonography [ 15 , 22 ]. Some of the sonographic signs present in IEPs include: an interstitial echogenic line that extend from the endometrium to the interstitial mass, an eccentrically located gestational sac and failure to see myometrium surrounding the sac and communicating with the endometrium [ 22 ]. The ultrasound findings in this case were a gestational sac that was eccentrically located in the left interstitial region, it had a double decidual line with a visible fetal pole with cardiac activity. The other classical signs that have been associated with IEPs were not present. The management of IEPs can either be medical or surgical [ 6 ]. If diagnosed early and when unruptured, IEPs can be managed with methotrexate injection as with other EPs [ 8 , 23 ]. Systemic methotrexate alone is effective in treatment of IEPs but with low (31%) success rates [ 8 ]. Moreover, local injections of methotrexate to an IEP with systemic methotrexate can also be used as another treatment option with success rates as high as 70% [ 8 ]. Additionally, medical management with methotrexate after mifepristone has also been trialed as a treatment option [ 9 ]. Different surgical management options exist for the management of IEPs [ 10 – 13 ]. These can vary from cornuostomy after vasopressin injection [ 10 ], laparoscopic salpingectomy with removal of the interstitial portion of the IEP [ 11 ], hysteroscopic resection [ 12 ], a combination of hysteroscopy and laparoscopy [ 13 ], or even hysterectomy in cases of massive hemorrhage [ 24 ]. In the ipsilateral salpingectomy with complete removal of the interstitial portion technique, the branches from the ascending uterine artery are first dissected and coagulated [ 11 ]. Subsequently, the cornual serosa is incised at the junction of the IEP and the normal myometrium and finally the IEP is excised along the outer layer of the oviduct without rupturing it [ 11 ]. Hysteroscopic management is another option in clinically stable patients which involves direct visualization of the IEP and its targeted removal with good preservation of uterine integrity and fertility with minimal morbidity [ 12 ]. Its success rates are around 75% with it being a good option in low-risk patients [ 12 ]. The combination of the hysteroscopic and laparoscopic management has also been used in the management of IEPs [ 13 ]. Laparoscopic cornuostomy involves injection of dilute vasopressin into the myometrium surrounding the pregnancy [ 10 ]. Hydro dissection is subsequently done and excision of the IEP with closure of the defect with stitching [ 24 ]. A variation can be done with placement of a purse string suture, in the myometrium circumferential to the IEP, after injection of vasopressin. The IEP is then excised and the defect repaired using the remaining suture from the purse string stitch [ 10 ]. Both variants of this method have similar outcomes with the hydro dissection one having a shorter operating time [ 25 ]. The present case was managed by injection of vasopressin then subsequently hydro dissecting the IEP then excision and then repair of the defect with stitching. The prognosis of IEPs is good with favorable outcome even in the subsequent pregnancy [ 26 , 27 ]. There have been reports of uterine rupture in the subsequent pregnancy in around 30% of the cases with an increased incidence of elective cesarean deliveries [ 26 ]. The present case also had a good outcome with the patient conceiving an intrauterine pregnancy after a year, for which she had a term delivery. In conclusion, IEPs are rare pregnancies with seldom specific risk factors. They present with the classical EP symptoms of vaginal bleeding and abdominal pain with symptoms of rupture if it has occurred. Ultrasonography is the gold standard in diagnosis with several pathognomonic features identified in literature. Its surgical management involves cornuostomy which can be performed laparoscopically as in the described case. The prognosis is usually good with few untoward pregnancy complications. This case represents one of the few documented cases of laparoscopically managed IEPs in the region. It adds to the few studies in Africa—3 at the time of drafting this paper that document this rare but clinically significant condition.

Interstitial ectopic pregnancy (IEP) is a rare form of ectopic pregnancy (EP) [ 1 , 2 ]. They account for 1–3% of all EPs but can have significant morbidity and mortality associated with them [ 3 , 4 ]. IEPs which are also known as cornual pregnancies have similar risk factors to other EPs which include previous ectopic pregnancy, pelvic inflammatory disease, infertility, in vitro fertilization, tubal reconstructive surgery, intrauterine contraceptive methods, smoking, increasing age and endometriosis [ 4 , 5 ]. However, IEPs have a unique risk factor which is prior ipsilateral salpingectomy [ 5 ]. IEPs are easily misdiagnosed as intrauterine due to their location, and they rupture as early as other EPs causing significant morbidity and mortality [ 6 ]. IEPs usually present with abdominal pain with or without vaginal bleeding [ 6 ]. The main stay of diagnosis is still ultrasound with certain distinct sonographic features observed in IEPs [ 7 ]. Their management can either be medical or surgical. Medical management mostly includes the use of methotrexate either locally, systemically or in combination [ 8 ]. Additionally, mifepristone prior to methotrexate has also been shown to be effective in the treatment of IEPs [ 9 ]. Surgical management involves resection of the IEP either through traditional cornual wedge resection, vasopressin injection followed by purse string placement and then resection, or even resection with ipsilateral salpingectomy [ 10 , 11 ]. Hysteroscopic management has also been described in literature [ 12 ] with its combination with a laparoscopic approach also documented with good success rates [ 13 ]. We present a case of IEP that was surgically managed with vasopressin injection and excision with its subsequent outcome and literature review. A 37-year-old Kenyan woman with two prior term vaginal deliveries presented at accident and emergency with a history of amenorrhea for 5 weeks and pelvic pain. The pain was continuous and progressive with localization on the left pelvic region. It was moderate in intensity requiring analgesics (acetaminophen) occasionally. The previous two deliveries were vaginal and their conceptions were natural. Additionally, she had no history of tubal surgery. She had done a pregnancy test a week earlier which was positive but had not performed an ultrasound scan. On examination, she was of good general condition with normal range vital signs. Her pelvic examination revealed moderate pelvic tenderness that was localized in the left region but no palpable mass abdominally. The rest of her systemic examination was normal. She had laboratory tests and an ultrasound scan that revealed the following: a hemoglobin of 12.3 g per deciliter (g/dl); a β human chorionic gonadotrophin level of 27,399 milli-international units per milliliter (miu/ml). The pelvic ultrasound revealed a gestational sac with a double decidual reaction in the left cornual region. It had a yolk sac and a fetal pole of a crown–rump length of 8.7 mm (mm) with fetal cardiac activity (Fig.  1 ). The gestational age corresponded to 6 weeks and 6 days. The uterus was normal in size and shape with an endometrial thickness of 4.9 mm. No fluid was seen in the pouch of Douglas. The pelvic scan concluded that the patient had a cornual (interstitial) ectopic pregnancy (Fig.  2 ). Fig. 1 Sonographic images for the patient with the interstitial ectopic pregnancy. a An empty endometrial cavity with a thickness of 4.9 mm. b An eccentrically located gestational sac with a fetal pole and cardiac activity. It is non-communicating with the endometrial cavity. c Crown–rump length of the interstitial ectopic corresponding to 6 weeks and 6 days. d Ring of fire appearance showing abundant blood supply to the interstitial ectopic pregnancy Fig. 2 Sonographic report of cornual ectopic Sonographic images for the patient with the interstitial ectopic pregnancy. a An empty endometrial cavity with a thickness of 4.9 mm. b An eccentrically located gestational sac with a fetal pole and cardiac activity. It is non-communicating with the endometrial cavity. c Crown–rump length of the interstitial ectopic corresponding to 6 weeks and 6 days. d Ring of fire appearance showing abundant blood supply to the interstitial ectopic pregnancy Sonographic report of cornual ectopic Treatment options were discussed with the patient with preference to surgical treatment in view of her β human chorionic gonadotrophin level and the presence of fetal cardiac activity. She also had prior normal pregnancies with good outcome and hence was not keen on fertility preservation. The patient was booked for a diagnostic laparoscopy with salpingectomy and excision of the ectopic pregnancy. Intraoperatively, a left interstitial EP was found that involved the left fallopian tube (Fig.  3 ). The right fallopian tube and both ovaries appeared normal. First, a left total salpingectomy was done using bipolar coagulation and scissors (Fig.  4 ). Then after this, 6 units of dilute vasopressin (20 units in 200 ml of 0.9% sodium chloride solution) was injected around the junction of the interstitial EP and the myometrium. Blanching of the area was observed (Fig.  5 ). Bipolar coagulation was applied to this area to further reduce the chance of bleeding and there after a monopolar hook was used to excise the interstitial EP after (Fig.  6 ). This was done till all the chorionic tissue was excised. All the tissue was placed in an endobag and retrieved from the abdomen and sent for histological examination. The myometrial defect was closed in 2 overlapping layers using a 2/0 polyglactin barbed suture (Fig.  7 ). Hemostasis was confirmed and a surgicel was overlayed over the area (Fig.  8 ). The estimated blood loss was 100 ml. Fig. 3 Left interstitial ectopic pregnancy is visualized Fig. 4 A total left salpingectomy is carried out Fig. 5 Infiltration of diluted Vasopressin at base of the interstitial ectopic pregnancy Fig. 6 Excision of the interstitial ectopic pregnancy with a monopolar hook Fig. 7 Stitching of the myometrial defect in layers to close the defect Fig. 8 Final look after overlay with surgicel Left interstitial ectopic pregnancy is visualized A total left salpingectomy is carried out Infiltration of diluted Vasopressin at base of the interstitial ectopic pregnancy Excision of the interstitial ectopic pregnancy with a monopolar hook Stitching of the myometrial defect in layers to close the defect Final look after overlay with surgicel The patient had an uneventful post-operative stay and was discharged home after a one night stay. She was reviewed in clinic after 2 weeks where histology confirmed chorionic villi and decidua in the specimen with a non-dilated fallopian tube (Fig.  9 ). Fig. 9 Final histology report of the excised ectopic and left fallopian tube Final histology report of the excised ectopic and left fallopian tube The patient has subsequently conceived a normal intrauterine pregnancy and had a term delivery with no complications.