Objective
We sought to report the safety and effectiveness of bleeding control using a large amount of highly diluted vasopressin in laparoscopic management of interstitial pregnancy.
Study Design
This was an uncontrolled retrospective review of 20 patients who were laparoscopically treated for interstitial pregnancy using a large amount of highly diluted vasopressin. For hemostasis, 1 ampule of vasopressin was diluted in 1000 mL of normal saline (1000-fold) and 150-250 mL of diluted vasopressin was injected in the uterus below interstitial pregnancy.
Results
Mean patient age and gestational age was 33.5 years and 6.7 weeks, respectively. Mean blood loss was 24 mL. The mean serum human chorionic gonadotropin level was 10,950, 4065, and 959 mIU/mL on the day of operation and postoperative days 1 and 4, respectively.
Conclusion
Laparoscopic management of interstitial pregnancy using a large amount of highly diluted vasopressin is safe and effective in hemostasis with minimal blood loss and no complications.
Interstitial pregnancy, which is noted in 2-4% of all ectopic pregnancies, can be fatal with a reported mortality rate of 2-2.5%. Recently, the incidence of interstitial pregnancy is increasing due to various factors including pelvic inflammatory disease, previous pelvic surgery, and assisted reproductive techniques. Traditional treatment of interstitial pregnancy consisted of cornual resection or hysterectomy via laparotomy. However, such conventional management has adverse effects on fertility rate in future gestations. In this regard, minimally invasive treatment of interstitial pregnancy is desirable and advantageous to the patient in terms of comfort, safety, and maintaining fertility.
Laparoscopic technology and associated techniques have been recently advocated as an alternative method to the traditional treatment of interstitial pregnancy. Hemostasis and cornual closure are the most critical steps in conservative laparoscopic operation for bleeding control and prevention of uterine rupture in the subsequent pregnancy. To date, several hemostatic techniques in laparoscopic procedures were reported including vasopressin injection, electrocauterization, coagulating surgical devices, and fibrin glue. We have also previously reported 2 effective methods for hemostasis: Endoloop ligation and encircling suture before evacuation of the conceptus.
Vasopressin has been widely used for bleeding control in conservative laparoscopic surgeries due to its potent vasoconstrictive effect in smooth muscles including uterine muscles and intestinal tract. However, local injection of vasopressin during laparoscopy may have systemic adverse effects such as transient hypertension, bradycardia, delayed bleeding, and pulmonary edema. Therefore, one must be cautious when using vasopressin.
We have recently employed a new method for more simple and effective hemostasis, which is infiltrating a large amount of highly diluted vasopressin. This study was aimed to report the efficacy of this method with regard to bleeding control in laparoscopic management of interstitial pregnancy.
Materials and Methods
Thirty-two women with interstitial pregnancy were treated at our center between May 2003 and December 2006. Thirty women were treated by laparoscopic surgery and 2 women were treated with methotrexate (MTX) alone. Of the 30 women treated laparoscopically, 10 patients including 9 patients who were applied by Endoloop ligation method before evacuation of conceptus and 1 patient who was referred to our center for persistent interstitial pregnancy after surgery at another hospital were excluded from this study. The remaining 20 patients who were treated with a large amount of highly diluted vasopressin were subjected to retrospective review. Institutional review board approval was obtained to extract data from patient’s medical records.
Patients’ characteristics, including age, pregnancy history, gestational age, and clinical presentation including sonographic size of the mass, serial serum β-hCG levels, and time to resumption of menstruation after surgery were reviewed.
Interstitial pregnancy was diagnosed in all patients when they met the 3 following ultrasonographic criteria in the presence of positive serum β-hCG titer indicating pregnancy: nonvisualized gestational sac in the uterine cavity, an eccentric location of the gestational sac within the uterus or in close proximity to the uterus, and a thin myometrial layer surrounding the gestational sac or thicker wall around the ectopic gestational sac. Color Doppler ultrasonography was also used and confirmed increased vascularity in the wall surrounding gestational sac in all cases.
Serum β-hCG level was measured with chemiluminescent immunoassay kit (Johnson and Johnson Diagnostics Inc, Rochester, NY) on the day of surgery and postoperative days 1, 4, and 7 to evaluate the success of the operation, and was checked weekly or biweekly thereafter until no longer detectable. The time period from operation to the resumption of menstruation was reviewed and the outcomes of subsequent pregnancies were followed up for at least 1 year after operation (12-70 months). The operative findings on cesarean section were obtained from the operation records.
Telephone interviews on subsequent pregnancy outcomes after laparoscopic surgery, if any, were performed twice in December 2007 and 2008.
Operative procedures
Excessively vascularized and enlarged cornua was laparoscopically confirmed ( Figure 1 , A). For hemostasis, 1 ampule (20 U) of vasopressin (Hanlim Pharm, Busan, Korea) was diluted in 1000 mL of normal saline (1000-fold) and 150-250 mL of the highly diluted vasopressin (0.02 U/mL) was injected using a 17-gauge needle in the uterine wall just below the site of interstitial pregnancy. As soon as vasopressin was injected, immediate blanching of the uterus was observed ( Figure 1 , B-1) and a constriction band at the base of interstitial pregnancy with strangulated appearance of mass was observed ( Figure 1 , B-2).
A 1- to 1.5-cm incision was made using unipolar electric cautery on the thinnest area. Then, conceptual tissues were removed with 10-mm spoon forceps and suction. After confirming no remnant placenta tissue, cornual closure was done using Dexon 2-0 (Syneture, Gosport, UK) or chromic cat gut 1-0 (Ailee, Busan, Korea) endoloop ligation ( Figure 2 , A) or endosuture ( Figure 2 , B). Endoloop ligation was primarily applied and if there was not enough tissue for Endoloop ligation, interrupted endosuturing was done. A Silastic drain (Yusin Medical, Bucheon, Korea) was placed in the pelvic cavity and was removed on postoperative day 1.
Results
Patient age ranged from 28-38 years, with a mean ± SD of 33.5 ± 3.2 years. Mean gestational age was 6.7 ± 1.2 weeks. Mean blood loss and operating time were 24 ± 26 mL and 30.3 ± 26.2 minutes, respectively. Mean time to next menstruation was 31.3 ± 10.1 days in 12 patients excluding 1 patient (case no. 2) with persistent interstitial pregnancy in whom it took 127 days for menstruation to resume. This case presented with initial preoperative serum β-hCG of 9836 mIU/mL and decreased to 5676 mIU/mL on postoperative day 1, but remained at a plateau (4628 mIU/mL) until postoperative day 4. With the impression of persistent ectopic pregnancy, systemic MTX treatment was initiated and a decrease in the level of serum β-hCG was finally achieved ( Table ).
| Case no. | Age, y | G/P | GA | Mass size, cm | Cornual status at operation | Method of closure | Postoperative serum hCG levels, mIU/mL | Time to resumption of menstruation, d | ||
|---|---|---|---|---|---|---|---|---|---|---|
| Day 0 | Day 1 | Day 4 | ||||||||
| 1 | 38 | 3/2 | 8 wk | 3.1 × 2.5 | Unruptured | Endosuture | 24,234 | 7249 | 1174 | − |
| 2 | 32 | 2/0 | 6 wk 2 d | 1.3 × 1.4 | Unruptured | Endoloop | 9836 | 5876 | 4628 | 127 |
| 3 | 32 | 2/1 | 6 wk 1 d | 1.6 × 1.4 | Unruptured | Endosuture | 4252 | 1308 | 241 | 25 |
| 4 | 35 | 3/2 | 4 wk 5 d | 1.0 × 1.0 | Unruptured | Endoloop | 3565 | 1184 | 199 | − |
| 5 | 32 | 1/0 | 10 wk | 2.9 × 2.1 | Ruptured | Endoloop | 13,238 | 5424 | 1333 | − |
| 6 | 37 | 4/1 | 8 wk 3 d | 5.0 × 5.0 | Unruptured | Endosuture | 31,962 | 10,188 | 1813 | 43 |
| 7 | 32 | 2/1 | 8 wk 3 d | 2.1 × 1.8 | Unruptured | Endoloop | 6867 | 1818 | 217 | 31 |
| 8 | 33 | 3/1 | 6 wk 4 d | 3.6 × 3.1 | Unruptured | Endoloop | 39,508 | 19,514 | 3694 | 31 |
| 9 | 35 | 3/2 | 6 wk 6 d | 4.0 × 3.0 | Unruptured | Endoloop | 12,596 | 5204 | 891 | − |
| 10 | 31 | 3/1 | 6 wk | 4.0 × 4.0 | Unruptured | Endoloop | 1970 | 647 | 128 | 15 |
| 11 | 37 | 4/2 | 6 wk 1 d | 2.0 × 2.0 | Unruptured | Endoloop | 6378 | 2226 | 522 | 31 |
| 12 | 31 | 4/2 | 6 wk 5 d | 1.4 × 1.4 | Unruptured | Endoloop | 18,383 | 4954 | 1117 | − |
| 13 | 28 | 2/0 | 7 wk 3 d | 3.0 × 3.0 | Unruptured | Endoloop | 12,286 | 6018 | 1237 | 30 |
| 14 | 29 | 1/0 | 7 wk | 1.2 × 1.2 | Unruptured | Endosuture | 2552 | 700 | 90 | 38 |
| 15 | 38 | 7/2 | 6 wk 6 d | 3.2 × 3.3 | Unruptured | Endoloop | 23,330 | 5865 | 1260 | 27 |
| 16 | 37 | 4/2 | 8 wk 5 d | 5.0 × 5.3 | Unruptured | Endosuture | 177 | 40 | 4.8 | − |
| 17 | 36 | 1/0 | 6 wk 2 d | 1.0 × 1.1 | Unruptured | Endoloop | 536 | 297 | 54 | 53 |
| 18 | 28 | 1/0 | 7 wk 1 d | 2.3 × 2.7 | Ruptured | Endosuture | 987 | 525 | 119 | 32 |
| 19 | 35 | 2/0 | 7 wk 2 d | 1.6 × 1.9 | Unruptured | Endoloop | 3348 | 1186 | 252 | 19 |
| 20 | 35 | 2/0 | 7 wk 2 d | 1.8 × 1.9 | Unruptured | Endoloop | 3004 | 1089 | 208 | − |
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