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Total Laparoscopic Conservative Surgery for an Intramural Ectopic Pregnancy
Source:https://www.hindawi.com/journals/dte/2010/504062/ | Author:Michael Conlin | Published time: 2020-08-20 | 2292 Views | Share:

Intramural pregnancy is one of the rarest types of ectopic pregnancy [1]. More than 95% of ectopic pregnancies involve the fallopian tubes. Other sites of ectopic implantation are less frequent. We performed a systemic search of PubMed (http://www.ncbi.nlm.nih.gov/pubmed/) from 1957 to 2009. The database search used the relevant medical subject heading search (MeSH) with the term “pregnancy, ectopic” and the free query term “intramural pregnancy”. Selected subheadings were human, and English, with abstract. Thirty reports were selected, and of these articles 21 articles were case reports of an intramural pregnancy. However, there were some discrepancies in the nomenclature. Three reports were corneal [3] or interstitial pregnancies (tubal pregnancy in the broad sense) [45]. Three reports were cervical pregnancy [67], and one report was a subserous pregnancy at a previous myomectomy site [8]. Therefore only 17 of the retrieved cases were intramural pregnancies by the strictest definition. Abdominal hysterectomy was utilized for five cases [912], and a conservative abdominal procedure was performed in four cases [1316]. Systemic or local methotrexate injection was used in three cases [1719], and local potassium chloride injection was used for one case [20]. In one case, the gestational sac spontaneously resolved [21]. One pregnancy was continued until fetal viability was reached, and the fetus was successfully delivered by cesarean section [22]. Only one report exists describing the laparoscopic resection of an intramural pregnancy [2]. In this case, the patient went on to require a hysterectomy. Therefore, ours is the first account of the successful laparoscopic treatment of an intramural pregnancy.

Blood flow to the gravid uterus increases significantly over baseline. Therefore, a laparoscopic procedure carries the risk of significant hemorrhage. Consequently, almost all cases of intramural pregnancy are treated with either laparotomy or medication. Historically, laparoscopy has only been used for diagnosis. Intramural pregnancies are sometimes difficult to diagnose since there may be no unusual presenting symptoms. Often, the only abnormality is sonographic. We performed a careful examination including a repeat ultrasound and determined that invasion was minimal and resection amenable to laparoscopy. We used a vasopressin solution prior to resection and fibrin glue after suturing. Finally, the surgeon was very proficient with laparoscopic suturing. These elements were essential to the successful completion of a conservative procedure.

We describe a case of an extremely rare form of ectopic pregnancy, which we were able to treat with conservative surgery. The intramural pregnancy is difficult to diagnose preoperatively; however, careful observation and early intervention enabled the uterus to be preserved. Laparoscopic management of such cases is feasible, provided that the operating team has advanced laparoscopic skills. Otherwise, such rare cases are to be dealt with the conventional open approach in order to minimize possible complications.