Total laparoscopic conservative surgery for an intramural ectopic pregnancy

Abstract

A 38-year-old woman, gravida 3, para 1 with a history of a left salpingectomy for an ectopic pregnancy was admitted for treatment of a presumed ectopic pregnancy. Transvaginal sonography revealed an ill-defined gestational sac and fetal heart beat within the fundal myometrium adjacent to the left cornua. Laparoscopy was performed for a suspected left cornual pregnancy or intramural pregnancy. A cystic mass 3 cm in diameter was visible within the fundal myometrium. Total laparoscopic removal of the gestational sac was performed, and the uterus was preserved. Pathologic evaluation of the excised mass demonstrated chorionic villi involving the myometrium. In the literature, only one other case describing the laparoscopic removal of an intramural pregnancy has been reported. However, in the prior report, the patient still required hysterectomy after conservative surgery. Therefore, this is the first report of the successful treatment of an intramural pregnancy exclusively with laparoscopy.

Figure 1

Preoperative ultrasonographic image. EM: endometrium, GS: gestational sac. GS was distinct from EM at the left side of the uterus.

Figure 2

GS: gestation sac, TUBE: residual left fallopian tube. The GS was separate from residual left tube.

Figure 3

GS: gestation sac. The uterus was cut with the harmonic scalpel, and the forceps were used to grasp the GS.

Figure 4

Histologic examination. Microscopic examination demonstrating villi within the myometrium and stroma.

Figure 5

Perioperative serum beta-hCG levels. “Preop” is one day before surgery, and “POD6” is 6 days post surgery, “POD14” is 14 days post surgery. The beta-hCG dropped rapidly postoperatively.

Figure 6

Postoperative HSG (hysterosalpingography). No filling defect is evident. Therefore the excised portion of the uterus containing the pregnancy was not one horn of a bicornuate uterus.

Figure 7

HSG prior to the pregnancy. The left tube was transected at the site of a previous ectopic pregnancy (left tubal pregnancy).