Interstitial pregnancy with huge adenomyosis uteri managed laparoscopically by using pre‐operative and intra‐operative imaging: case report

A 38 year old woman, who was gravida 2, para 0, was admitted to another hospital with complaints of dysmenorrhea and menorrhagia and was diagnosed with adenomyosis uteri. Her menstrual cycle was regular, and she had been receiving low dose danazol therapy (100 mg/day) for three years. She wanted a baby in the future and approached our outpatient department for surgical consultation. The uterus was enlarged to a size corresponding to 12 weeks of gestation, with reduced mobility. Transvaginal ultrasound revealed a poorly defined solid tumour measuring approximately 8 cm. A MRI showed a poorly defined tumour in the posterior wall of uterus with low signal intensity on the T1-weighted image and a slightly high signal intensity on the T2-weighted image. It was diagnosed as adenomyosis of the uterus. The danazol therapy was discontinued and she was next seen with five weeks and five days amenorrhea, and a positive urine pregnancy test. Transvaginal ultrasound could not define a definitive gestational sac in the uterus. At seven weeks and three days of gestation, the serum h-hCG level was 9460 mIU/mL, and the adenomyosis uteri had enlarged to a size corresponding to 15 weeks of gestation (Fig. 1A). Because the gestational sac and embryo could not be identified by transvaginal and transabdominal ultrasound, an ectopic pregnancy was suspected. A MRI scan showed a cystic mass, measuring 3 cm 2 cm and with a low signal intensity on the T1-weighted image and a high signal intensity on the T2-weighted image, in the interstitial portion of the left fallopian tube (Fig. 1B). At laparoscopy, the operative area was completely occupied by the enlarged uterus. A contact ultrasonography (CUS) probe type UST-52109 (ALOKA, Tokyo, Japan) was placed over the interstitial portion of the left tube where the ectopic pregnancy was predicted by MRI, and a gestational sac was detected (Fig. 1C). The area of excision was established by CUS, 5 U of vasopressin diluted 100-fold in saline was injected around this, and cornual resection was performed using a monopolar needle. During incision, an embryo covered in amnion sac was found and extracted (Fig. 1D). The excision area was sutured in three layers with continuous sutures by using 0-polysobe (Tyco Healthcare, Tokyo, Japan), and the wound was closed. The intraoperative blood loss was 50 mL, and the operating time was 84 minutes. The extracted specimen weighed 10 g. Complete excision of the ectopic pregnancy mass was confirmed by histopathological examination in which the villus, decidua and embryo were found to be surrounded by the myometrium. Her post-operative course was uneventful, and she was discharged on the second postoperative day. The post-operative serum h-hCG values fell from 5139 mIU/mL on the 2nd day to 262.2 mIU/mL on the 7th day, and 1.7 mIU/mL on the 30th day.