Early intrauterine pregnancy during major surgery: the importance of preoperative assessment and advice

We present a case of a live birth occurring post radical laparoscopic excision of endometriosis, hysteroscopy, curettage and test of tubal patency in the presence of an early intrauterine gestation.

obstetrics and gynaecology, contraception, pregnancy, surgery

This unique and interesting case demonstrates the ability of an early intrauterine gestation to survive despite a significant surgical assault. Given the potential for an undesirable outcome - the loss of a spontaneous pregnancy in a patient experiencing primary infertility - it also serves as a warning and reminder to all surgeons of the importance of preoperative contraceptive advice and day of surgery serum human chorionic gonadotropin (hCG) test. Case presentation A 26-year-old nulliparous patient with a 2-year history of cyclical pelvic pain and subfertility was referred for a gynaecological opinion and ongoing management. On questioning, her menstrual cycle was regular (5/28 days) with severe pain occurring on days 2–3. The patient had not used contraception for a period of two years but had never fallen pregnant. On bimanual examination, the pelvic organs were immobile with nodularity over the uterosacral ligaments. Pelvic transvaginal ultrasound scan demonstrated evidence of deeply infiltrating endometriosis with restricted mobility of the uterus and both ovaries, partial obliteration of the Pouch of Douglas, bilateral uterosacral ligament nodularity and thickening, two endometriomata in the left ovary measuring 10 mm and 20 mm, and a 14 mm nodule within the posterior vaginal fornix overlying a 10 mm rectovaginal septum nodule, in keeping with the pelvic examination. A decision was made to perform radical excision of endometriosis, hysteroscopy and curettage and test of tubal patency. The patient was counselled and consented for the same. Treatment Intraoperatively, deeply infiltrating endometriosis was noted which mainly involved the sigmoid colon, which was densly adherent to the rectovaginal septum and the right uterosacral ligament. Both ovaries were adherent to the pelvic side wall. The patient subsequently underwent radical laparoscopic excision of endometriosis, adhesiolysis, bilateral ureterolysis, chromotubation and cervical dilatation, hysteroscopy, and superficial endometrial curettage. The endometrial cavity was of normal and unremarkable appearance; both tubal ostiae were visualised. Bilateral tubal patency was demonstrated.Histopathological analysis of all laparoscopically obtained specimens confirmed endometriosis. Endometrial curettings were reported as ‘good quality’ and demonstrated a ’secretory endometrium'. The surgery was performed on day 19 of a twenty-eight day menstrual cycle. Preoperatively, on the day of surgery, the date of the last menstrual period was recorded and the patient was asked if she was pregnant or not, to which she responded ‘no’. Regular, unprotected sexual intercourse had occurred three to four times per week until the date of surgery, with the last episode occurring 8 days preoperatively. No urinary or serum hCG test was performed. Outcome and follow-up Postoperatively, the patient reported that her period was delayed; sexual intercourse had not occurred since the surgery. At her 6-week postoperative review, a pelvic ultrasound scan was organised revealing a single, live intrauterine pregnancy consistent with 6 weeks plus 1 day gestation, placing her at 5 days postconception on the day of surgery. All subsequent tertiary level ultrasound scans at 12 weeks, 20 weeks, 30 weeks and 36 weeks gestation corresponded with the same expected delivery date. Ongoing pregnancy was uneventful and she delivered a healthy female baby by spontaneous vaginal delivery at 39 weeks’ gestation weighing 3210 g, without complications.

Ongoing pregnancy in patients following inadvertent gynaecological surgery in the early implantation phase is clearly possible.1 2 This case suggests that the effect of surgery during the implantation phase on the developing embryo may not be as significant as assumed, especially in the very early stages. This is reflected by current literature stating that the 10.5% overall rate of pregnancy loss in patients undergoing any form of surgery in the first trimester is not greater than that of the general obstetric population, and it may not increase the rate of birth defects.3 More importantly, however, this case demonstrates the importance of preoperative advice regarding contraception or avoidance of unprotected sexual intercourse even in the ‘subfertile' population when planning any form of surgery on the reproductive organs. Qualitative serum pregnancy tests will typically detect hCG levels of 5–10 milli-international units (mIU) per mL, and the earliest hCG may be detected on a highly sensitive serum test is 6–12 days postovulation, when implantation typically occurs.4 Urinary hCG tests are less sensitive, and will usually not return a positive result until the hCG level reaches 20–50 mIU/ml. This case also highlights the importance of a day of surgery pregnancy test or serum hCG up to 2 weeks postconception, even when menses are not yet delayed, to exclude current pregnancy. If unprotected sexual intercourse has occurred within 2 weeks of surgery, serious consideration must be made towards cancellation of surgery as a negative hCG does not exclude pregnancy in the early stages, preimplantation. Learning points. The early developing embryo is tenacious and may be more resistant to surgery in the early implantation phase than previously thought. In the subfertile population undergoing surgery to assist conception, a preoperative discussion regarding contraception and unprotected sexual intercourse before surgery is essential. A day of surgery serum or urine human chorionic gonadotropin is critical for all female patients of childbearing age. Footnotes Contributors: JCP: planning of the project, conception and design, acquisition of data and records, reviewing of patient file/results/theatre records, literature review, writing of the manuscript. BMcE: planning of the project, conception and design, performing surgery and managing all patient care, reviewing records, assisting with manuscript writing, editing. Competing interests: None declared. Patient consent: Obtained. Provenance and peer review: Not commissioned; externally peer reviewed.

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