Mrs. NS, aged 31 years, married for 3 ½ years came to
us on 29/11/2006 for primary infertility. She had
irregular periods with scanty flow. The ultrasound
examination revealed a uterus size of 5.4 x 2.8cm with
solid right ovary, while the left ovary was not visualized.
Her husband's semen analysis revealed
Oligoasthenozoospermia. Her previous surgical
history included a diagnostic laparoscopy, which was
converted to a laparotomy, in February 2005 at another
private hospital, for bilateral huge dermoid cysts. The
surgeon had performed a left salpingo-oopherectomy
and right partial oopherectomy with reconstruction.
She had subsequently undergone 3 IUI cycles in
November 2005 but failed to get pregnant.
At our centre she was advised a diagnostic laparoscopy
and a combination of estrogen and progesterone
therapy to grow the uterus size to normal size. Owing
to personal reasons they chose to undergo the
hormone therapy first and subsequently reported to us
later that year. In September 2007, a repeat laparoscopy
was done to perform adhesiolysis and assess the
remaining tubo ovarian relationship. The right tube was
distorted and adherent owing to the previous surgery,
patent but nonfunctional. Hence a decision was taken
to detach the right cornua to prevent a possible future
ectopic. The rest of the pelvis had dense intestinal and
omental adhesions and adhesiolysis was done as much
as possible.
Owing to her previous history, subsequent poor ovarian reserve and response, the couple was inducted in the donor oocyte programme and consent was taken for the same. She then underwent the treatment cycle with down regulation and hormone replacement therapy. Donor oocytes were fertilized by ICSI. Four grade III embryos were transferred on February 2008. Her ß-hCG values post procedure was 363.8 mIU/ml and 719.3 mIU/ml subsequently.
She had her confirmatory scan on the 38th day when a single intrauterine sac was visualized. Subsequent weekly scans were done which showed normal progression of an intrauterine pregnancy.
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On 10/3/2008, at 7-8 weeks during her routine ultrasound she complained of pain abdomen with tenderness in the right adnexa. To our surprise it was a right cornual ectopic probably in the stump because of the earlier procedure.
In view of heterotropic pregnancy, severe pain
abdomen and impending rupture she was taken up for
laparoscopy and proceed. Owing to dense intestinal
adhesions to anterior abdomen wall and inability to
approach the right adnexa the laparoscopy was
converted to laparotomy. The abdomen itself was
opened with great difficulty resulting in serosal injury
to the sigmoid colon and devascularisation of 6 cms of
the small bowel due to extensive adhesiolysis, in order
to approach the right adnexa. The right cornual stump
was resected and haemostasis was secured using 1-0
vicryl. Resection nastomosis of the damaged ileal
loop was performed using 2-0vicryl and 2-0 mersilk
ensuring viability and patency. Sigmoid serosal injury
was repaired using the same.
The post operative period was uneventful and an
ultrasound also confirmed a viable intrauterine pregnancy. A cervical cerclage was done on 9/5/2008 at 15-16 weeks of pregnancy for shortened cervix. She has currently completed 7th month of pregnancy and her progress so far has been uneventful.
LESSONS LEARNED
This case has been presented to highlight the
management of a ruptured right cornual heterotopic
pregnancy in a precious series case, complicated by a
previous laparotomy with dense intestinal adhesions.
Intestinal injury was inevitable owing to large
segments of bowel adherent to the anterior abdominal
wall making it extremely difficult to approach the right
adnexa. A combined effort on the part of the surgeon
and gynecologist is absolutely essential. Although we
would look for heterotopic pregnancies in DUAL
procedures (Tubal & Embryo transfer) and sequential
transfers more often than in embryo transfers alone, it
just shows that very small adnexal sacs tend to be
inconspicuous and asymptomatic in the early weeks. In
this case we thought we had been fool proof in
preventing a heterotopic or an ectopic by performing
prophylactic cornual detachment but a fool proof plan
may not always be a saving grace !
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