Via Research Recognition Day 2024 VCOM-Carolinas

Clinical Case-Based Reports

NAVIGATING AN INTERSTITIAL HETEROTOPIC PREGNANCY: A CASE REPORT Rayhan Karimi, OMS-III, Rachael McCabe, M.D. VCOM Carolinas, Spartanburg, SC.

Purpose: To increase medical knowledge, treatment, and patient presentation of an Interstitial Heterotopic Pregnancy

Introduction

Discussion

Case Report

• Currently, the standard for treatment of an IHP is cornual resection. Resection has the risk of infertility, uterine rupture, and IUP demise [2]. This case differs in that cornuostomy was used to resolved the ectopic pregnancy. • Cornuostomy offers a minimally invasive treatment for an IHP, which allows for persevered fertility to the mother, decreased hospital stay, and safety to the IUP. Future fertility is a large patient consideration and should be discussed with the patient. • One limitation of the case is the lack of a vasoconstrictor such as epinephrine or vasopressin. This resulted in

§ The cornua, or uterine horns, represent the uppermost part of the uterus where the fallopian tubes meet, forming a triangle-like structure. § Interstitial heterotopic pregnancies are the simultaneous occurrences of an intrauterine pregnancy (IUP) and an ectopic located in the cornua of the uterus. § One in 30,000 pregnancies are heterotopic and out of those, less than 4% are interstitial heterotopic [1]. § Currently, treatment options encompass a spectrum of interventions, such as cornual resection, KCl or methotrexate injections, expectant management, and cornuostomy. § This case is unique from other ectopic events as the anatomy of the cornua is highly vascularized and the minute distance from the implantation of IUPs. § These cases pose a challenge due to the potential for severe hemorrhage, uterine rupture, fetal anomalies, and the demise of the IUP. § Vasopressin and epinephrine are often used in surgeries but are debated when an IUP is present.

• Patient presented asymptomatic for routine pregnancy screening. • Ultrasound showed concurrent 8-week pregnancies. One was an IUP and the other an ectopic. • Patient was taken to the OR for immediate removal of the ectopic. • Upon visualization of the ectopic, it was discovered that it was cornual, rather than tubal. • Attempts were made to remove the ectopic laparoscopically but were hindered by hemorrhage. • The surgical team • Cornustomy was performed to effectively extract the ectopic products with subsequent repair of the cornua. • The patient went on to the deliver the IUP at 36 weeks via C-section. changed to exploratory laparotomy.

P rPeCasleti inneitncst t o

Table 1. Ultrasound of both pregnancies. The IUP (right) and the ectopic (left)

TratnosfOeRrred

hemorrhage and lack of operative visibility. Subsequently, the surgical team converted to laparotomy .

Conclusions

• In reflection of this patient’s case presentation, it is shown that in hemodynamically stable patients, cornuostomy can be used as first line therapy and results in favorable outcomes for the mother and the IUP. • For clinicians managing interstitial heterotopic pregnancies, it is recommended to begin with laparoscopic cornuostomy for hemodynamically stable patients as it has been shown to have decreased hospital stay, intraoperative blood loss, and operation time [3]. If the patient becomes hemodynamically unstable, then the approach should be changed to laparotomy. • The use of epinephrine or vasopressin for hemostasis should be used in cases of IHP for better visualization and to mitigate risk of hemorrhage. Studies have shown safety to the IUP [4].

LE ax pp al or ro at ot omr yy

Table 2. Ultrasound of the ectopic pregnancy in the right cornua

Cornuostomy

Diagnosis

Due to the presence of an intrauterine pregnancy concurrent with an ectopic pregnancy in the cornua of the

Table 3. Laparoscopic images showing the cornual ectopic

uterus, this patient was diagnosed with: Interstitial Heterotopic Pregnancy

Acknowledgements and References

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2024 Research Recognition Day