Department of Obstetrics and Gynaecology (Drs. L. Eghdami and M. A. Bedaiwy), Division of Reproductive Endocrinology and Infertility (Dr. M. A. Bedaiwy), University of British Columbia, Vancouver, BC, Canada; Department of Obstetrics and Gynecology and Women’s Health Institute, Cleveland Clinic, Cleveland, OH, USA (Drs. S. Elguero and B. Patel).

ABSTRACT

An interstitial pregnancy is an ectopic pregnancy that is implanted in the interstitial segment of the fallopian tube and embedded within the muscular layer of the uterus. Because of the rich vascular supply of this region, maintaining hemostasis during surgical management of interstitial pregnancies is a recognized challenge. Visualizing the entirety of the gestational sac beneath the uterine serosa can also present a challenge, especially in cases of uncomplicated interstitial ectopic pregnancies. Here we present a case in which intraoperative transvaginal ultrasound was used to assist with a laparoscopic cornual wedge resection in a 24-year-old woman with a confirmed interstitial pregnancy. The use of intraoperative transvaginal ultrasound during the laparoscopy helped accurately delineate the location and extent of invasion of the interstitial pregnancy. It guided the placement of the uterine incision and helped ensure that the entire gestational sac and products of conception had been removed. This case demonstrates that transvaginal ultrasound can be used as an intraoperative tool to enhance surgical safety and minimize patient risk.

Key Words: Ultrasonography, Pregnancy, Ectopic, Laparoscopy.

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Division of Reproductive Endocrinology and Infertility, University of British Columbia, Vancouver, Canada (Drs. Zang, Bedaiwy). Department of Obstetrics and Gynecology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA (Drs. Abdelhafez, Bedaiwy, Liu).

ABSTRACT

Introduction: Müllerian anomalies can be challenging to diagnose. We describe a patient with uterus didelphys and cervical atresia who presented with a symptomatic pelvic mass that was incompletely diagnosed as an endometrioma. Consequently, it was inadequately treated at the time of laparotomy, necessitating a laparoscopic hemihysterectomy for definitive management.

Case Description: A 17-year-old nulligravida presented with abdominal pain and pelvic pressure. Computed tomographic imaging showed an 18-cm pelvic mass and left renal agenesis. The patient underwent an exploratory laparotomy with resection of a large endometrioma and left salpingo-oophorectomy. During the operation, an enlarged left uterine horn was observed and was kept intact. She made an uneventful recovery, but returned 6 months later with pelvic pain and pressure. Ultrasonography and hysterosalpingogram diagnosed uterus didelphys with left cervical atresia causing an obstructed hemiuterus. Laparoscopic hemihysterectomy with extensive adhesiolysis was performed, and the patient’s symptoms resolved.

Discussion: Endometrioma is rare in adolescents, and its presence should raise suspicion of a mu¨llerian anomaly. Laparoscopic management, while safe and feasible, is more challenging in the setting of dense adhesions from a prior laparotomy. Preoperative magnetic resonance imaging is recommended in adolescents who present with chronic pelvic pain and a symptomatic pelvic mass, to rule out a congenital anomaly and avoid a needless second surgery.

Key Words: Cervical atresia, Endometrioma, Hemihysterectomy, Müllerian anomaly, Uterus didelphys.

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