Usefulness of long-jaw forceps in laparoscopic cornual resection of interstitial pregnancies

Management of interstitial pregnancy in the era of laparoscopy: a meta-analysis of 855 case studies compared with traditional techniques

Interstitial pregnancy is a rare, life-threatening condition that requires high clinical suspicion for diagnosis. Most cases are discovered after complications have occurred. Many authors have described laparoscopic management. Although previous systematic reviews have compared the attributes and complications associated with interstitial pregnancy, we endeavored to complete the first systematic review and meta-analysis to compare the laparoscopic treatment of interstitial pregnancy with the open approach in the modern age of laparoscopic surgery. We systematically searched PubMed, ClinicalTrials.gov, Scopus, Web of Science, and Cochrane until June 2020 using relevant keywords and screened them for eligibility. We found a statistically significant difference in blood loss between laparoscopic and open surgery (168 mL compared to 1,163 mL). Further, cumulative meta-analysis has revealed that blood loss in laparoscopy has been decreasing over time from 1991 to 2020. Laparoscopic patients took less operative time (63.2 minutes) compared to laparotomy patients (78.2 minutes). Patients in the laparoscopic group spent less time hospitalized (3.7 days) compared to laparotomy patients (5.2 days). Our findings add strength to the position that laparoscopic approaches to interstitial pregnancy can be considered first-line in most situations. The laparoscopic approach was found to have a mean blood loss of 168 mL, and this blood loss seems to decrease over time. Increased gravidity and duration of amenorrhea are positive factors that increase bleeding during the procedure. We are unable to find enough high-quality data to significantly compare successful pregnancy following surgery or risk of mortality in these populations.

Interstitial pregnancy: a 'road map' of surgical treatment based on a systematic review of the literature

An electronic search concerning the surgical approach in cases of interstitial pregnancy from January 2000 to May 2013 has been carried out. Fifty three studies have been retrieved and included for statistical analysis. Conservative and radical surgical treatments in 354 cases of interstitial pregnancy are extensively described. Hemostatic techniques have been reported as well as clinical criteria for the medical approach. Surgical outcome in conservative versus radical treatment were similar. When hemostatic techniques were used, lower blood losses and lower operative times were recorded. Conversion to laparotomy involved difficulties in hemostasis and the presence of persistent or multiple adhesions. Laparoscopic injection of vasopressin into the myometrium below the cornual mass was the preferred approach.

Current diagnosis and treatment of interstitial pregnancy

The incidence of interstitial pregnancy is rising. Traditional treatment with laparotomy, hysterectomy, or cornual wedge resection is associated with high morbidity and detrimental effects on future fertility. A diverse array of alternate treatments has been introduced over the last 3 decades, with the common goal of achieving a minimally invasive, standardized management strategy. This has been facilitated by impressive strides towards prompt diagnosis, both radiologically and chemically. In this review, we explore the current state of the art diagnostic criteria and the clinically significant diverse therapeutic options with supporting literature. Finally, we propose a structured, best-practice management plan for the once-lethal interstitial pregnancy, based on the current literature.

Surgical treatment of ectopic pregnancy

Ectopic pregnancy remains the leading cause of death in the first trimester of pregnancy. Today, serial serum hCG measurements and transvaginal ultrasound examination can provide early detection of most ectopic pregnancies allowing medical treatment with methotrexate. In those who require surgery, the type of procedure depends on the clinical situation and the location of the pregnancy. Most of the cases can and should be performed by laparoscopy. Compared with laparotomy, the laparoscopic approach is associated with many advantages including short hospital stay, low cost and less adhesion formation. In addition, hemoperitoneum is not a contraindication for performing laparoscopy. Linear salpingostomy is the procedure of choice when unruptured tubal pregnancy is found in women who want to preserve their fertility; otherwise, salpingectomy is performed. Fertility performance after salpingostomy and salpingectomy is comparable. Similar to the case with tubal ectopic pregnancy in general, women with non-tubal ectopic pregnancy such as cervical, interstitial, or Caesarean scar pregnancy should be first treated medically with methotrexate. These types of ectopic pregnancies may be associated with massive bleeding during surgery. Precautionary procedures should be considered and these include the placement of an angiographic catheter for possible uterine artery embolization. These pregnancies can also be treated laparoscopically.

Case report: Laparoscopic treatment of a ruptured interstitial pregnancy

Interstitial pregnancy is a rare but life-threatening condition. A case of a 28-year-old woman with a partially ruptured interstitial pregnancy treated with operative laparoscopy is presented. A laparoscopic cornual resection and a left salpingectomy were performed uneventfully. Serum beta-human chorionic gonadotrophin concentrations were measured serially at weekly intervals until resolved on day 20 postoperatively. It seems, therefore, that laparoscopic treatment is still an effective option for management even in ruptured interstitial pregnancy, preserving the anatomical integrity of the uterus and future fertility, and that rupture of interstitial ectopic pregnancy is not a contra-indication for laparoscopy.