Interstitial Pregnancy
Especially among patients who have had in vitro fertilization (IVF), you may encounter interstitial pregnancy. The conventional treatment is hysterectomy or cornual resection. But with earlier diagnosis using TVUS and β-HCG assays, it can be diagnosed early and treated medically or laparoscopically.
Start with medical treatment and resort to surgery if there is any deterioration in clinical status. There are several options for surgery, including laparoscopic cornual resection, cornuostomy, or salpingotomy. In most cases, you will want to use dilute intramyometrial vasopressin at the start of the surgery to minimize blood loss. And remember the value of suturing and the option of achieving hemostasis by ligating the ascending branches of the uterine vessels.
If you perform surgery, make sure you have expertise in suturing, because you will be working in a very vascular area. Be comfortable with the procedure you are doing. I prefer laparoscopic removal of the gestation, with removal of the interstitial portion of the tube if necessary.
The risk of uterine rupture in future pregnancies after medical treatment of an interstitial pregnancy is unknown, as is the future integrity of the uterus following laparoscopic surgical treatment. We may be able to prevent future uterine rupture with proper suturing of the uterine cornu after laparoscopic treatment. Nevertheless, discuss the possibility of rupture occurring during a subsequent pregnancy with patients undergoing any treatment for interstitial pregnancy.
Likewise, monitor women with a history of interstitial pregnancy very closely. I usually recommend cesarean delivery to avoid potential uterine rupture during labor.
With any pregnancy after IVF, make sure that an ectopic pregnancy is not accompanied by pregnancy in the uterus. If you see both, you should not even consider medical therapy.
Persistent Ectopic Pregnancy
Persistent ectopic pregnancy occurs more often after salpingostomy performed with laparoscopy than after salpingostomy through laparotomy (about 8% compared with 4%). The difference used to be much greater and probably reflects the surgeon's learning curve.
Some authors have recommended weekly serum β-HCG measurements after laparoscopic salpingostomy to exclude persistent ectopic pregnancy. We perform a single serum β-HCG measurement 1 week after surgery. If the level is more than 5% of the preoperative value, we will repeat the measurement 1 week later.
If the level does not decline after the second week, we administer a single dose of MTX (50 mg/m
A large ischemic ectopic pregnancy can be painful emotionally as well as physically.
Salpingostomy has been performed and the ectopic gestation extruded outside the fallopian tube.
One suture to approximate the tubal incision has been placed, a step that requires exacting skill. Photos courtesy Dr. Togas Tulandi
Treating Ectopic Pregnancy
As editor of Master Class columns on gynecologic surgery, I am especially pleased to have Togas Tulandi, M.D., contribute this article on the current treatment of ectopic pregnancy. Dr. Tulandi is a professor of ob.gyn. and the Milton Leong Chair in Reproductive Medicine (the first Canadian chair in reproductive medicine) at McGill University in Montreal.
As a clinical researcher, Dr. Tulandi has been quite prolific. He has published more than 200 articles, 250 abstracts, 40 book chapters, and eight books. Dr. Tulandi also is the current president of the Society of Reproductive Surgeons, an affiliated society of the American Society for Reproductive Medicine.
As the readership no doubt will observe, Dr. Tulandi has a rather conservative view of treatment of ectopic pregnancy with medical therapy (methotrexate). Moreover, he provides valid reasons why laparoscopy is considered the preferred surgical treatment for ectopic pregnancy.
Although Dr. Tulandi points out that data are lacking when deciding between salpingectomy vs. salpingostomy, he does provide reasonable recommendations to assist in deciding between the two procedures.
In addition, Dr. Tulandi shares valuable insight on interstitial pregnancy as well as persistent ectopic pregnancy.
Once again, I am very proud to have Dr. Tulandi's involvement with OB.GYN. NEWS and the Master Class.