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Anesthetic Management of Abdominal Hysterectomy for second trimester Cornual Ectopic Pregnancy in a Super Obese Woman
Abstract Number: FCI-189
Abstract Type: Case Report Case Series
Ectopic pregnancies have been estimated to occur at a rate of 6-20 / 1000 pregnancies.(1,2) Cornual pregnancies are rare and comprise 2-3% of all ectopics.(3) Cornual pregnancies are rarely compatible with a viable fetus and are often diagnosed at the time of rupture. Therefore, these pregnancies are treated promptly in the first trimester with either methotrexate or surgery.
A 34 year-old G11P2 female with BMI of 53 kg/m2 was transferred to our tertiary care centre at 20 wks gestational age after having failed multiple doses of methotrexate for termination of a suspected cornual pregnancy. Repeat MRI and US imaging confirmed a viable 19 week cornual pregnancy encased in a thin layer (less than 3 mm) of myometrium/serosa. Past medical history was significant for asthma, smoking, type I diabetes, hypertension, hypothyroidism, and GERD. Due to the risk of rupture, decision was made to terminate the pregnancy via abdominal hysterectomy with vertical midline incision extending above the umbilicus. It was delayed until 21 + 6 weeks gestation as the patient had wanted to proceed with the pregnancy despite counselling regarding the risks of rupture, hemorrhage, fetal risks of methotrexate exposure, and maternal mortality.
After placement of an 18g peripheral catheter, rapid sequence induction was performed with midazolam, remifentanil, lidocaine, propofol, and succinylcholine in a semi-sitting position. An arterial line, 16g peripheral intravenous catheter, and 8.5 fr cordis sheath were placed. Cell salvage was available in the theatre. The patient had declined epidural analgesia. Within the peritoneal cavity, a small amount of free blood was noted and an omental adhesion to the uterus was present sealing off a small area of uterine dehiscence. The uterus appeared intact with a large bulging gestation sac covered by a thin layer of serosa/myometrium from the right cornual region. The pregnancy and uterus were removed en bloc without complication. Intraoperatively analgesia consisted of ketamine, hydromorphone, and bilateral transversus abdominis plane (TAP) block at the end of the procedure. Estimated blood loss was 700 ml. The patient was extubated and transferred to PACU. On the ward she required SpO2 monitoring for suspected obstructive sleep apnea. She had an uneventful post-operative course.
Though this case proceeded smoothly, this patient was at high risk for rupture and life-threatening hemorrhage with the added challenge of her body habitus. In future cases, we would still prepare for massive hemorrhage. The case was also emotionally distressing for the patient as her fetus was still living prior to her hysterectomy.
1. Obstet Gynecol 2010;115(3):495
2. Obstet Gynecol 2005;105(5):1052
3. BFertil Steril 2011;95(3):867