**7.2 Surgical management**

#### **7.2.1 Surgical techniques**

Surgical management depends mainly on the presenting condition of the patient and the skills of the operating surgeon. Cornual ectopic has been reported to be treated by variation of procedures mainly cornuotomy, cornual resection and a more radically a hysterectomy. The latter has only a role in a life saving condition when other methods has been tried and exhausted. However, in experienced hand, it is nearly always possible to avoid a hysterectomy even in haemodynamically unstable patients with ruptured ectopic pregnancy.

In cornuotomy or cornual resection, the usage of diathermy or harmonic scalpel in the dissection can help in the reduction of blood loss. Intracorporeal knots of the PDS or Vicryl stitches can be used to close the cornual resection site. The round ligament could be used to

Modern Management of Cornual Ectopic Pregnancy 245

It is also possible that it would have less effect on fertility than abdominal approach and further intrauterine pregnancies could be managed as low risk with no increase chance of uterine rupture and hence normal vaginal delivery could be the choice of the mode of

Serial serum hCG should be measured after any conservative surgical treatment of corneal ectopic to ensure complete resolution. The duration of the monitoring is of little significant but a declining titre is essential and needs monitoring at intervals till resolution. (Kamrava

Cornual ectopics are associated with high risk of rupture that could occur as late as 10 – 16 weeks. . (Abraham D& Silkowski C, 2010).Rupture of a corneal ectopic at that late gestation can cause profuse intraperitoneal bleeding which can be life threading. The Confidential Enquiry into Maternal and Child Health (CEMACH) report for 2000–02 confirmed that 4 out of 11 deaths due to ectopic pregnancies (36%) were corneal ectopics. (Confidential Enquiry

Therefore, expectant management has no place in confirmed cornual ectopic.( Kok-Min S et

With regard future fertility, cornual ectopic is associated with higher risk of recurrent ectopic compared with other types of ectopic pregnancy. If the uterus is conserved, there is an increased incidence of uterine rupture at the surgical site in future pregnancies in the 2nd and 3rd trimesters especially in the cases where the sac excision leads to defective myometrium &/or the uterine cavity has been opened. However, the data about the absolute increase in such risk is still conflicting. (Lau S& Tulandi T, 1999; Weissman A& Fishman A,

There is a view about reinforcing the uterine wall with the use of round ligament especially if the cavity is opened. Again, no evidence yet has shown a proven benefit of such

With regard the mood of delivery in subsequent pregnancy, caesarean section is recommended by many clinicians however, no evidence yet available to evaluate the safety of caesarean section versus vaginal delivery after cornual ectopic treatment. (Downey GP&

Abraham D, & Silkowski C .(2010 ). Emergency Medicine Sonography 1st ed, 264-274

Api M, & Api O.(2010). Laparoscopic cornuotomy in the management of an advanced interstitial ectopic pregnancy: a case report. Gynecol Endocrinol.;26(3):208–212. Banerjee S, Aslam N, Zosmer N, Woelfer B, & Jurkovic D. (1999) The expectant management

of women with early pregnancy of unknown location. Ultrasound Obstet Gynecol,

**8. Effect of cornual ectopic treatment on future fertility** 

delivery.

MM et al, 1983)

al, 2004)

1992)

Tuck S, 1994)

**9. References** 

14:231–6.

**7.2.4 Serum hCG clearance** 

**7.3 Expectant management** 

into Maternal and Child Health, 2004)

techniques.( Chatterjee J et al, 2009)

cover the cornual resection site aiming to reduce post operative adhesions and to facilitate the closure of resection site especially when large size ectopics are removed. (Api M& Api O, 2010; MacRae R et al, 2009; Tinelli A et al, 2010; Moon HS et al, 2000).

No clear data is available to compare risks of subsequent ectopic and the chances of persistent trophoblastic disease after cornual resection versus cornuotomy. Preservation of fertility following these surgical techniques has been confirmed. However, there is an expected reduction in chances of conception due to loss of the function of that tube. Future pregnancy is usually ending by a caesarean section due to the risk of uterine rupture. (Lindheim SR et al, 2006)

Uterine artery ligation may help to conserve the uterus in ruptued corneal ectopic as it can aid the homeostasis if conservative surgery attempted via open approach (Khawaja N et al, 2005).

## **7.2.2 Open approach versus laparscopic approach**

Laparotomy is preferred in hemodynamically unstable patients with signs and symptoms of hypovolaemic shock. Senior operator is necessary in such situation where the bleeding might be sever and life threatening because of the enormous blood supply to the uterine cornue especially when the gestation is advanced at time of ectopic rupture. (Grimbizis GF et al, 2004)

Laparoscopic approach is preferred over the laparotomy for unruptured cases provided a skilled laparoscopic surgeon is available. (Hill GA et al, 1989; Grobman WA& MP Milad , 1998) Laparoscopic approach is associated with less intra-operative bleeding, less post operative pain and analgesia requirement, shorter hospital stay and fewer post operative adhesions. (Royal College of Obstetricians and Gynaecologists, 2004)

No clear data available to compare chances of having a subsequent intrauterine pregnancy between the open versus the laparoscopic approaches for cornual ectopics however the latter is though to be possibly associated with less risk of recurrent ectopics.

#### **7.2.3 Vaginal approach**

In the last decade, trans-cervical approach for the treatment of cornual ectopic has been advocated. The cornual ectopic is disturbed under hyteroscopic, laparoscopic or even ultrasound guidance. (Thakur Y et al, 2004)

It avoids extensive surgery and can be useful for women who are reluctant to undergo medical treatment with Methorexate or in whom this treatment failed.(Pal B et al, 2003)

The approach involves identification and disturbance of ectopic sac through a vaginal approach using a curette. The products of conception then removed using polyp forceps or a suction curette. (Minelli L et al, 2003; MeyerWR& Mitchell DE, 1989; Sanz LE& Verosko J, 2002) The use of laparoscopic or ultrasonic guidance is recommended due to the high risk of perforation. (Marian Morgan et al, 2009) Also this approach is not aimed at evacuation of all the product of conception as this could be associated with perforation. It is only aiming at disturbing the pregnancy and removing some of the product safely. (Marian Morgan et al, 2009) Therefore, follow-up is essential to ensure complete resolution of the pregnancy. In severe bleeding, laparoscopic local injection of vasopressin may reduce intraoperative bleeding. (Pal B et al, 2003)

This approach is simple and associated with less morbidity than abdominal approach. It is associated with less bleeding as the myometrium remained undisturbed, rapid recovery and a shorter post-operative stay resulting in financial and psychological benefits.

It is also possible that it would have less effect on fertility than abdominal approach and further intrauterine pregnancies could be managed as low risk with no increase chance of uterine rupture and hence normal vaginal delivery could be the choice of the mode of delivery.
