Laparoscopic Treatment of Heterotopic Pregnancy

Abstract

Heterotopic pregnancy poses difficulty for diagnosis and for management. The challenge is to treat the ectopic component without risking the mother and ensuring the intrauterine conception progresses safely to full term. There are no studies comparing the various treatment modalities and their outcomes. The authors present a case of laparoscopic treatment of heterotopic pregnancy and literature review. (J GYNECOL SURG 19:49) CASE REPORTA 32-YEAR-OLD West Indian patient presented at the Early Pregnancy Assessment Unit (EPAU) with a 3-week history of sharp intermittent suprapubic pain and a 5-week history of slight blood loss per vaginam. Her last menstrual period was reported to be 9 weeks earlier. She had a regular 28-day cycle and used condoms for contraception.Her obstetric history included three full-term uncomplicated pregnancies. There was no history of early pregnancy loss or termination of pregnancy. From her past medical history, there were recurrent episodes of genital herpes simplex infection.On examination she looked fit and healthy. Her pulse was 72 beats per minute, regular, and of good volume. Her blood pressure was 120/75 mm Hg and she was apyrexial. The abdomen was soft and nontender with no signs of rebound tenderness or guarding. Pelvic examination revealed a 10-week size anteverted, nontender uterus. Tenderness was elicited on the left adnexa where a 10-cm mass was palpable. Speculum examination did not reveal blood loss at that time.Her hemoglobin was 8.5 g/dL with a white cell count of 8.75 3 10 9 /L and a platelet count of 315 3 10 9 /L. Ultrasound scanning (transvaginal and transabdominal) detected a 10.5 weeks viable intrauterine pregnancy with a regular gestation sac. The crown-rump length (CRL) of the fetus measured 38.9 mm (Fig. 1). Between the left ovary and the uterus a second gestational sac was present containing a 10-week fetus (CRL 33.6) with positive cardiac activity (Fig. 2).The patient was counseled to undergo laparoscopic treatment. Laparoscopy revealed a 6-cm-long distention of the distal portion of the left fallopian tube. There was bleeding from the fimbrial end, but there was no apparent rupture. The right adnexa appeared normal and the uterus was enlarged, compatible with the gestational age. Two chromic catgut endo-loops were applied on the proximal end of the left tube and the tube was dissected with laparoscopic scissors. Attempts to remove the ectopic pregnancy with laparoscopic bag failed due to the size of the dissected tube and a small (4-cm) suprapubic incision was performed to remove it. Postoperative course was complicated by paralytic ileus that was managed conservatively. The patient was discharged on the 5th postoperative day.Histopathologic examination confirmed the presence of tubal pregnancy. The fetal umbilical cord was 5 cm long. No other significant histologic findings were revealed. 49