Surgical Techniques of Managing Interstitial Pregnancy Miss Christina Aung Trainee in Obstetrics and Gynaecology East Kent Hospitals University Foundation Trust UK Me-her-ba

Objectives: Background on interstitial pregnancies Cases series and surgical techniques used References

Background Interstitial pregnancy is pregnancy developing in portion of proximal fallopian tube that lies within the muscular wall of the uterus. Incidence: 2-4% Mortality: 2-2.5% Management: Conservative Medical Surgical Incidence of ectopics11 per 1000 pregnancies. IP incidence is 2-4% of all ectopic pregnancies. Increased mortality due to difficulty in diagnosing at early stage of pregnancy leading to life threatening haemorrhage. Mx is challenging: Conservative/Expectent-not always possible or desirable - Medical with methotrexate and prolonged close follow-up -Laparotomy and cornual resection/cornuotomy or hysterectomy. Laparoscopy and cornual resection with salpingostomy/salpingectomy.

Cornuotomy with harmonic scalpel & Cornuotomy with Ligasure and bipolar forceps Subsequently the patient had assissted reproductive technique treatment and had a CS at 39 weeks for breech presentation.

Wedge resection with Ligasure and closure of myometrium

Cornuectomy with Ligasure using vasopressin and endo-loops Intrauterine injection with 7 units of vasopressin diluted in normal saline was performed. The interstitial pregnancy was encapsulated with three endo- loops to de-vascularise and form a plane. A laparoscopic cornuectomy with right salpingectomy using Covidien LigaSure™ Maryland jaw laparoscopic sealer and divider source of energy followed by coagulation with bipolar scissors was undertaken. She made uneventful recovery with blood loss less than 100 ml.

Conclusion Different energy sources and techniques can be used to achieve the wanted results Preserving cornual integrity following laparoscopic cornuotomy & cronual resection is important The incidences of subsequent uterine rupture and dehiscence associated with corneal resection have been reported as 30%. Laparoscopic treatment of interstitial pregnancies is effective -Effective and safe treatment especially with the growing number of skilled laparoscopic surgeons. It is sage, successful and fertility sparing -Harmonic scalpal, diathermy scissors, ligasure, suturing, bipolar forceps -To prevent rare complications of uterine rupture increasing maternal and perinatal mortality. Mode of delivery needs to be considered as well.

References Moawad N, Mahajan S, Moniz M, Taylor S, Hurd WW (2010) Current Diagnosis and treatment of interstitial pregnancy. American Journal of Obstetrics & Gynaecology 202(1): 15-29 Soriano D, Vicus D, Mashiach R, Schiff E, Seidman D, Goldenberg M (2008). Laparoscopic treatment of cornual pregnancy: a series of 20 consecutive cases, Fertility and Sterility 90(3): 839-843 Jermy K, Thomas J, Doo A, Bourne T (2004) The conservative management of interstitial pregnancy. BJOG: An International Journal of Obstetrics & Gynaecology 111: 1283–1288  Weissman A, Fishman A (1992) Uterine rupture following conservative surgery for interstitial pregnancy. Eur J Obstet Gynecol Reprod Biol 44: 237-9. Choi YS, Eun DS, Choi J, Shin KS, Choi JG, Park HD (2009) Laparoscopic cornuotomy using a temporary tourniquet suture and diluted vasopressin injection in interstitial pregnancy. Fertil Steril 91(5):1933-7. Ter-sher-ku