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SERIES OF CORNUAL PREGNANCY - PUTRAJAYA HOSPITAL EXPERIENCE Pavani.N, E.C.DSilva, Hazim.W.A Department of Obstetrics & Gyneacology. Putrajaya Hospital.
Introduction Operative Procedures
All the operations were performed by experienced surgeons under general anaesthesia, in a dorsolithotomy position. Patients were monitored continuously for BP, ECG, Transcutaneous Oxygen saturation, and End tidal carbon dioxide pressure. Laparotomy performed with minimum of 10cm transverse suprapubic skin incision. Pelvic cavity entered by layer. Resection made on cornu of uterus to removed the POC. The Uterus was sutured using absorbable 1/0 .The Rectus was sutured in the similar manner. In Laparoscopic surgery , veress needle was inserted through the umbilicus and abdomen was inflated with CO2.Dissection of the uterus at cornu was performed with either a unipolar probe, a bipolar probe, or scissors. Hemostasis secured using bipolar forceps or sutured with absorbable 1/0. POC was removed via endobag and skin was later glued together.
Clinical Characteristics & Treatment of women with cornual pregnancies Parameters Risk Factors Total Previous pelvic surgery Salphingectomy Cesarean section Caesarean & salphingectomy Previous extrauterine pregnancy IVF IUCD Clinical presentation Ruptured Cornual pregnany Unruptured Cornual pregnancy Treatment preoperative Blood Transfusion Fluid resuscitation Primary Operative procedure laparotomy Primary laparoscopy then Converted to laparotomy Laparoscopy Surgical treatment Resection of Cornua Cornuostomy Cornuostomy & MTX Future fertility Laparoscopic group pregnant Laparotomy group pregnant Non Pregnant Defaulted 1 2 5 4 8.3 16.7 41.7 33.3 9 2 1 75.0 16.7 8.3 1 5 6 8.3 41.7 50.0 3 9 25.0 75.0 9 3 75.0 25.0 8 3 2 2 5 1 1 66.7 n % Operative Outcome Laparotomy N=6 75.83 31.85 2.670.82 Operative Time ( min) ( Mean SD) Post - operative hospital stay (day) ( Mean SD) Ruptured Cornual Ectopic Pregnancy (%) 41.7 8.3 8.3 Estimated Blood loss (ml) (Mean SD) Blood loss > 100ml (n) % Blood Transfusion (n) %

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Laparoscopy N =6 95.5032.00 2.330.52

P value

gestation is one of the most hazardous types of ectopic gestation. It is the rarest form of tubal ectopic pregnancy with an incidence of 24% of all ectopic pregnancies.[1] The diagnosis and treatment of such a pregnancy is challenging and constitutes an urgent medical attention. Medical and surgical treatments for cornual gestation exist . However surgical intervention became the gold standard of treatment. Conventionally, treatment is via laparotomy with cornual resection or hysterectomy. As surgical techniques evolved; Laparoscopy has replaced laparotomy for the surgical treatment of most ectopic pregnancies.[2} Laparoscopy has many advantages compared to laparotomy, Minimal skin incision, less post operative pain, reduced number of hospital stay and faster patient recovery. Furthermore it can be safely performed by well trained surgeon even in women with massive haemoperitoneum.[2]

Cornual

0.42 0.47

6(100) 875.00547.49 6(100) 3 (50)

3(50) 325377.82 3(50) -

0.08 0.09 0.08 0.08

We did not find any statistically significant difference when comparing the operation time, duration of hospitalization, and estimated blood loss.

Conclusions
In the rarest and dangerous form of ectopic pregnancy, laparoscopy has shown its feasibility. Until today the thought of managing cornual pregnancy laparoscopically is still probably not in ones thought. We have shown that laparoscopic surgery is safe,feasible and has lesser operative blood loss..As familiarity overcomes fear, laparoscopic cornual resection will offer potential advantages over conventional cornual resection. This includes less postoperative pain, shorter hospital stay, earlier return to social and occupational activities,better cosmetics outcome and even operative time may also eventually reduced. Future fertility can also be preserved. However case must be properly selected. The decision to decide for laparotomy should be made laparoscopically. However,In life threatening conditions the surgeon must take techniques in which they are most familiar. Finally In trained hands,laparoscopy should be considered as the initial treatment in managing these cases.

Results
There were 12 patients whom had cornual pregnancy. Mean age were 26 years old. These patient s are includes 8 Malay , 2 Chinese, 1 Indian and 1 foreigner . All had either secondary or tertiary education level. The median gravidity was 3.Gravida ranges from 1-6. 91.7% (11) were conceived spontaneously and 8.3% (1) was through IVF. 41.7%(5) had a previous ectopic pregnancy. 66.7% (8) of patients had previous pelvic surgery. The mean gestational age ( by last menstrual period ) was 61.7117.27 days (8wks ) and range(5wks --- 12wks). Three (25.0%) patients were asymptomatic on admission, 2 ( 16.7%) abnormal bleeding , 6 ( 50.0%) abdominal pain and 1(8.3%) abdominal pain and bleeding.

Objectives
1. To present our experience of Laparoscopic Management of cornual Ectopic pregnancy. 2. To determine the outcome of Laparoscopic and Laparotomy Management of Cornual Pregnancy.

Methods
This is a cross sectional descriptive analysis study. All patients confirmed of cornual ectopic pregnancy from January 2001 to February 2012 were included. Demographic distribution, clinical symptoms, sonography examinations, types of managements and outcome were gathered through the electronic medical records(EMR). Patients were interviewed by telephone over their subsequent fertility status. The statistical analysis was performed by using Student t test. P value of <0.05 was considered significant.

1 Patient post cornuostomy was given IM MTX stat post operatively and monitored beta HCG level. Beta HCG reduced to <10 u within 1 month post operation. 2 patient were pregnant post open surgery and 1 after laparoscopic surgery. All of them delivered via elective caesarean section. 1 patient was referred for IVF due to history of salphingectomy in contralateral tube and wedge resection in current surgery.

References
1. 2. 3. 4. Rock JA, Jones HW, Te Linde RW, Te Lindes. Operative Gynaecology, 10th Ed.,Philadelphia: Walters Kluwer/Lippincott Williams & Wilkins;2008. Jong HH, Jae KL, Nak WL , Kyu WL. Open cornual resection versus laparoscopy cornual resection inpatients with intertitial ectopic pregnancies. Eur J. Obstet Gynecol Reprod Biol. 156 (2011) 78 82. David S, Danielle V, Roy M, Eyal S, Daniel S, Motti G. Laparoscopic treatment of cornual pregnancy: A series of 20 consecutive cases. Fertility & Sterility.Vol90, Issue 3, Sep 2008, Pg 839 843. Selma N, Suttha H, Irene C, Bernand C & Anthony S. Laparoscopic Management of 53 cases of cornual ectopic pregnancy .Fertility &Sterility . Vol 92,No2, Aug 2009.

Table below presents a comparison between laparotomy and laparoscopic techniques for both group of patients.
**Variable is given as meanSD, N (%) or median. **P-values were obtained from a Students t test

3 Patient were presented with hypovolumic shock and all are converted to laparotomy.
TEMPLATE DESIGN 2008

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