Superselective uterine arterial embolization combined with transcatheter intra-arterial methotrexate infusion in 40 cases with fallopian tube ectopic pregnancy

PURPOSE

To evaluate the therapeutic results of superselective uterine artery infusion and embolization in 40 patients with fallopian tube ectopic pregnancy, and to explore the role of this minimally invasive treatment as an alternative to surgery.

MATERIALS AND METHODS

Superselective catheterization of uterine artery through cannulation of femoral artery was achieved in 40 patients with fallopian tube ectopic pregnancy (EP). Location of the lesions involved feeding arteries and active bleeding were observed through angiography. Methotrexate (MTX) diluted in saline water was slowly infused into the target artery. Small gelatin spongy particles were used to embolize the uterine artery until its branches were totally obliterated. Follow-up was undertaken to observe the results of the treatment.

RESULTS

Superselective uterine arterial infusion and embolization were successfully performed in all 40 patients without any related complications. Active bleeding in the peritoneum in 33 cases ceased soon after embolization. The embryos in 13 patients were confirmed to have died by ultrasound three days after the procedure. Beta-human chorionic gonadotropin ((beta-hCG) value dropped to below 15 IU/L at three to 21 days. Hemorrhage in the peritoneum dissolved after seven days in all cases. Mixed mass disappeared after one month. Hysterosalpingography was performed three months after the procedure in 19 patients and patent fallopians were demonstrated in 16 patients.

CONCLUSIONS

Superselective uterine arterial infusion and emboliztion is a minimally invasive procedure, which can be used to effectively treat EP by disabling the ectopic embryo and leaking arteries with the advantages of preserving the fallopian tubes.

[Heterotopic pregnancy as an complication during pregnancy and labour--the case report]

Heterotopic gravidity (HG) is a rare co-existence of intrauterine and ectopic pregnancy with higher incidence in pregnancies after in vitro fertilisation (IVF). Diagnosis of HG is demanding. HG is commonly identificated when rupture or hemoperitoneum occurs.

CASE REPORT

35-year-old woman after 3rd cycle of IVF for absolute tubar factor. Two embryos transfered. Ectopic implatation of second embryo in uterine corner occured. Patient hospitalized with acute deteriorating symptoms of hemoperitoneum in 6th week of gestation. Diagnostic laparoscopy performed with ectopic cornual gravidity detection. Decision made to retain the intrauterine gravidity. Induction of the labour in the 40th week of gestation performed. Placenta retained after the delivery of a normal newborn. Lysis manualis performed, uterine hypothonia followed. On suspicion of placenta percreta laparotomy indicated. Acute supracervical abdominal simplex hysterectomy performed. Histologic examination confirmed the diagnosis of placenta percreta.

CONCLUSION

The diagnosis of HG is based on the assesment of clinical symptoms, transvaginal ultrasound and endoscopic diagnostics with eventual intervention. In case of hemoperitoneum urgent surgical intervention indicated. Placenta percreta is a rare complication increased in incidence by the presence of myometrial dammage usually from past uterine surgery. Presence of the scar tissue and abnormal placentation might also be a random coincidence. Placenta percreta is a life threatening complication with a great risk of hemmorhage and commonly requires acute surgical intervention.

Is a standardized questionnaire useful for tubal rupture screening in patients with ectopic pregnancy?

OBJECTIVES

Physical examination, ultrasonography, and laboratory tests fail to reliably establish the preoperative diagnosis of tubal rupture in patients with ectopic pregnancy (EP), leading to a high rate of diagnostic laparoscopy. The aim of this study was to construct and to evaluate a clinical prediction rule for tubal rupture screening based on a self-assessment questionnaire, among patients with EP.

METHODS

A standardized questionnaire was constructed via semistructured interviews of patients with acute pelvic pain. Features associated with tubal rupture were then identified in 141 prospectively included patients with tubal pregnancy, including 30 with tubal rupture, in five hospitals. Multiple logistic regression was used to select the best combination of independent features for predicting tubal rupture. Cross-validation was with the jackknife method. The main outcome measure was diagnostic accuracy of the questionnaire for ruling out tubal rupture.

RESULTS

Eighty-nine items characterizing acute pelvic pain were identified. Among them, four contributed independently to the diagnosis of tubal rupture: vomiting during pain, diffuse abdominal pain, acute pain for longer than 30 minutes, and flashing pain. The presence of one or more of these features had 93% sensitivity (95% confidence interval [CI] = 84% to 100%) and 44% specificity (95% CI = 35% to 53%) for tubal rupture, with a negative likelihood ratio for ruling out tubal rupture of 0.16.

CONCLUSIONS

These results suggest that a standardized questionnaire may contribute to ruling out tubal rupture in patients with EP.

A rare case of bilateral tubal pregnancy

Diagnosis of ectopic pregnancy continues to be an important challenge. Here a case of incidental diagnosis of bilateral tubal ectopic pregnancy is reported. There was a ruptured tubal ectopic pregnancy on the left side and chronic ruptured tubal ectopic pregnancy on the right side. Leading cause of first trimester maternal deaths is due to complications of ectopic pregnancy. Here an unusual case of ectopic pregnancy is reported in which the patient had spontaneous bilateral tubal ectopic pregnancy which presented with left tubal rupture and subsequently emergency exploratory laparotomy revealed bilateral tubal mass, which on histopathological examination confirmed tubal pregnancy.

Heterotopic pregnancy in natural conception -- our initial experience: case report

Heterotopic pregnancy refers to the presence of simultaneous pregnancies at two different implantation sites. Heterotopic pregnancy is rare, estimated to occur in 1 per 30,000 pregnancies. We report a case of a 27-year-old woman presented to the emergency department with the diagnosis of ruptured ectopic pregnancy. Careful ultrasound assessment indicated the diagnosis of heterotopic pregnancy. Right salpingectomy with removal of the hemoperitoneum and suction curettage were performed. Our operative diagnosis of heterotopic pregnancy was confirmed by histopathology. Heterotopic pregnancy can occur in the absence of any predisposing risk factors, and the detection of intrauterine pregnancy does not exclude the possibility of the simultaneous existence of ectopic pregnancy. Transvaginal ultrasound and assessment of the whole pelvis, even in the presence of intrauterine pregnancy, can be an important aid in the diagnosis of heterotopic pregnancy.

[Spontaneous heterotopic pregnancy. Case report]

BACKGROUND

Heterotopic pregnancy has increased in frequency due to the increasing number of assisted reproductive procedures. The diagnosis is difficult even with ultrasonography.

OBJECTIVE

To report the case of a patient with heterotopic pregnancy without a history of in vitro fertilization or fertility treatment.

CONCLUSIONS

Heterotopic pregnancy is a rarity that requires a high diagnostic suspicion, specialized desk studies and early surgical care to ensure a favorable outcome to the embryo.

Placental growth factor: a promising diagnostic biomarker for tubal ectopic pregnancy

CONTEXT

Tubal ectopic pregnancy is common, but accurate diagnosis is difficult and costly. There is currently no serum test to differentiate tubal from intrauterine implantation, and an effective biomarker of ectopic pregnancy would be a major clinical advance.

OBJECTIVE

A key feature of successful intrauterine implantation is the establishment of a supportive vascular network, and this has been associated with the activity of placental growth factor (PIGF). We hypothesized that the local decidual environment facilitates PIGF-dependent angiogenesis and that this pathway is not active in tubal implantation. We aimed to determine whether tubal implantation is manifest by an attenuation of the normal trophoblast PIGF response and whether serum PIGF levels are different in ectopic compared with intrauterine pregnancy.

DESIGN AND SETTING

Tissue and serum analysis was done at a large United Kingdom teaching hospital.

PATIENTS

Tissue and sera were collected from gestation-matched pregnant women undergoing surgical termination of pregnancy (viable intrauterine) (n = 15), evacuation of uterus for embryonic missed miscarriage (nonviable intrauterine) (n = 10) and surgery for tubal ectopic pregnancy (n = 15).

INTERVENTIONS

Trophoblast was examined by immunohistochemistry and quantitative RT-PCR, and serum was analyzed by ELISA.

RESULTS

PIGF was localized to the cytotrophoblast cells. Expression of PIGF mRNA was reduced in trophoblast isolated from women with ectopic compared with intrauterine pregnancies (P < 0.05). Serum PIGF was undetectable in women with tubal ectopic pregnancies and reduced, or undetectable, in miscarriage compared with viable intrauterine pregnancies (P < 0.01).

CONCLUSIONS

Serum PIGF is a promising novel diagnostic biomarker for early pregnancy location and outcome, and large-scale studies are now required to determine its clinical utility.

[Intact twin tubal pregnancy]

A case of a unilateral eight-week twin ectopic pregnancy diagnosed with transvaginal sonography is presented here. This ectopic pregnancy was found in the right Fallopian tube of a 35-year old woman. After the surgical procedure conducted by the method of transversal laparotomy, we removed the right Fallopian tube with two gestational sacs So far only a hundred of such cases of ectopic twin pregnancy have been described worldwide.

Ruptured spontaneous heterotopic pregnancy

The coexistence of intrauterine and ectopic pregnancy (heterotopic pregnancy) occurs in 1/30,000 of spontaneous pregnancies, 1/900 in Clomiphene citrate induced pregnancies and rises to 1% in assisted reproduction. It is a life-threatening condition with diagnostic and therapeutic complexities. There is strong association between infertility and ectopic pregnancy. Risk factors for ectopic pregnancy are past history, assisted reproduction, and adhesions due to pelvic infection or surgery. Our patient was diagnosed initially as having an intrauterine singleton pregnancy, with urinary tract infection. At presentation pain out of proportion to primary diagnosis led to urgent ultrasonographic review that diagnosed heterotopic pregnancy. It was followed by laparoscopic salpingectomy. Human chorionic gonadotrophin (HCG) after laparoscopy in the subsequent days along with a sonographic evaluation revealed a viable intrauterine pregnancy. This ended in missed miscarriage and medical expulsion at 16 weeks of gestation. Issues discussed here are rarity, delayed, or misdiagnosis with its sequel.

[Outcome and relevant factors of tubal pregnancy treated with laparoscopic conservative surgery]

OBJECTIVE

To investigate the therapeutic outcome and its influencing factors after laparoscopic conservative surgery in treatment of tubal pregnancy.

METHODS

From January 2003 to December 2008, 226 cases with tubal pregnancy were treated by laparoscopic conservative surgery. The tubal patency was evaluated in 152 cases given by hysterosalpingography (HSG) and 6 cases given by second laparoscopic exploration at 3 - 6 months after surgery. In their first laparoscopic surgeries, 209 got successful treatment and 19 underwent fail treatment. At 3 - 6 months after surgery, 89 cases with tubal patency among 207 cases with successful treatment were enrolled in group A. Nineteen cases who were failed in their first laparoscopic conservative surgery and treated by salpingectomy and 63 cases with tubal obstruction were enrolled in group B. The rate of tubal patency was calculated on patients with characteristics of gestational sac less or more than 5 cm, the level serum human chorionic gonadotropin (hCG) less than 2000 IU/L, 2000 IU/L to 5000 IU/L, and more than 5000 IU/L.

RESULTS

There was no significant difference in age, parity, amenorrhea, location of tubal pregnancy, rupture, pelvic adhesion between group A and group B. Two hundred and seven cases (91.6%, 207/226) were successfully treated at initial laparoscopy. One hundred and fifty-two cases got follow up and 55 cases lost follow up at 3 to 6 months after surgery. There was statistical difference in preoperative hCG value which median were 980 (55 - 12 000) IU/L in group A, 3150 (570 - 40 000) IU/L in group B (P < 0.01); the diameter of tubal gestational sac were (3.4 +/- 1.3) cm in group A and (5.0 +/- 1.7) cm in group B (P < 0.01); respectively, the volume of peritoneal bleeding were 200 (0 - 1500) ml and 300 (0 - 1600) ml, the rate of live tubal embryo was 2% (2/89) in group A and 11% (9/82) in group B, which all reached statistical difference (P < 0.05). Among 171 cases in both group A and B, the rate of tubal patency were 65% (67/103) in 103 cases with maximal diameter of tubal gestational sac less than 5 cm and 32% (22/68) in 68 cases with maximal diameter of tubal gestational sac more than 5 cm, which reached statistical difference (P < 0.01). The rate were 72% (73/102) in patients with serum level of hCG less than 2000 IU/L, 29% (12/42) in patients with 2000 IU/L to 5000 IU/L and 15% (4/27) in patients with more than 5000 IU/L, which also showed statistical difference (P < 0.05). It was observed that preoperative serum hCG level (OR = 0.277, P < 0.01), the maximal diameter of gestational sac (OR = 0.577, P < 0.01) and the volume of peritoneal bleeding (OR = 0.999, P < 0.05) were significant factors influencing successful laparoscopy treatment by logistical regression analysis.

CONCLUSION

In order to preserve fertility, laparoscopic conservative surgery was a safe and feasible approach in treatment of tubal pregnancy. Preoperative serum hCG levels, size of tube gestational sac were significant factors influencing successful laparoscopic surgery.

Current diagnosis and treatment of interstitial pregnancy

The incidence of interstitial pregnancy is rising. Traditional treatment with laparotomy, hysterectomy, or cornual wedge resection is associated with high morbidity and detrimental effects on future fertility. A diverse array of alternate treatments has been introduced over the last 3 decades, with the common goal of achieving a minimally invasive, standardized management strategy. This has been facilitated by impressive strides towards prompt diagnosis, both radiologically and chemically. In this review, we explore the current state of the art diagnostic criteria and the clinically significant diverse therapeutic options with supporting literature. Finally, we propose a structured, best-practice management plan for the once-lethal interstitial pregnancy, based on the current literature.

Tubal ectopic pregnancy in the north of Jordan: presentation and management

OBJECTIVE

To evaluate and compare the current approach to the management of ectopic pregnancy between the main two civil hospitals in the north of Jordan.

DESIGN

A retrospective study.

MATERIAL AND METHODS

A retrospective review was made of the records of all patients with confirmed ectopic pregnancy admitted to Princess Badea Teaching Hospital (PBTH), and King Abdullah University Hospital (KAUH) between January 1, 2005 and December 31, 2005. The total number of deliveries for the same period was obtained from the labor ward records of hospitals. Information regarding demographic data, presenting symptoms, methods of diagnosis and treatment were extracted from individual patient records.

RESULTS

There were 50 cases of confirmed ectopic pregnancy in PBTH compared with 20 cases in KAUH. The total number of deliveries at PBTH was 9,000 (1 ectopic/180 deliveries) while at KAUH, the number of deliveries was 3,000 so the ratio was 1: 150. The majority of patients (82%) had ruptured ectopic pregnancy at presentation. All cases at PBTH were managed by laparotomy. Of the 20 cases at KAUH, five cases were managed laparoscopically and three received medical treatment for their ectopics. There was no maternal mortality from ectopic pregnancy or its management at either hospital.

CONCLUSION

The management of ectopic pregnancy in our community is still suboptimal. We recommend the development of clinical protocols for early diagnosis and referral, training in transvaginal scanning and an increase in the use of laparoscopy for the management of ectopic pregnancy.

[Very early diagnosis of tubal unruptured pregnancy: the role of echography in urgency for early surgical resolution]

AIM

To emphasize the role of clinical suspect and echographic approach to heterotopic pregnancy in young women complaining of acute abdominal pain.

MATERIAL OF STUDY

Tubal pregnancy in a young woman has been reported. Diagnostic clinical suspect, also supported by serum hormonal substances (beta HCG), has been confirmed by US in urgency; transabdominal investigation requires skilled operator, preferably surgically trained, to identify early study of heterotopic pregnancy (fifth week of gestation), which has undergone left salpingectomy in our experience.

RESULTS

The early diagnosis of unruptured tubal pregnancy in our experience prevented hemorragic shock and other potential fatal complications, usually occurring in this condition.

DISCUSSION

Ectopic pregnancy is a life threatening condition, rarely occurring during natural cycle; however its incidence is increasing, considering the wider and wider use of assisted reproductive techniques and of gynecological surgical diagnostic and therapeutic procedures. The rupture of ectopic part causes acute abdomen and potentially fatal hemorrhage, whose only solution relies on surgical operation in urgency.

CONCLUSIONS

Clinical and anamnestic evaluation, ultrasonography and serum gonadotropin concentration are the first choice approach to fertile women suffering from abdominal recurrent pain, when no other causes are suspected. The heterotopic tubal pregnancy described is a very rare condition; in spite of early diagnosis, radical surgery consisting in left salpingectomy has been the only surgical feasible option, patient's life-sparing.

Sonographic diagnosis of ectopic pregnancy 2 years after total hysterectomy

We report a case of a 35-year-old multigravida with a chief complaint of 8 days of mild pain in the lower abdomen with history of vaginal hysterectomy 2 years prior. Ultrasonography and MRI showed a gestational sac-like structure with a fetal pole in the pelvis. Urine pregnancy test was positive with increased beta-HCG levels. Diagnosis of ectopic pregnancy was made. Surgical exploration and subsequent histopathology confirmed the sonographic findings.

[Bilateral tubal pregnancy]

Bilateral tubal pregnancies are extremely rare and they are usually found after assisted reproductive techniques have been applied. A rare case of bilateral tubal pregnancy after natural conception, occurring in a woman without any predisposing factors for ectopic pregnancy, is presented. The condition was diagnosed during laparoscopic surgery, and she was optimally treated with conservative tubal surgery. A short review of the literature is provided and discussed along with the clinical features, diagnostic difficulties and treatment options of bilateral tubal pregnancy.

Ruptured tubal ectopic pregnancy with negative serum beta hCG--a case for ongoing vigilance?

A 25-year-old female with a history of recent miscarriage presents with haemodynamic shock and a negative serum beta hCG. She presents to six different healthcare facilities within a single metropolitan area, during which a pelvic ultrasound scan showed an empty uterus with a subnormal rise in serum beta hCG. Suspected ruptured tubal ectopic pregnancy was confirmed following laparoscopy and salpingectomy, with histopathological confirmation of chorionic villi in the extirpated fallopian tube. This case report highlights the ongoing clinical diagnostic challenges that are associated with ectopic pregnancy; illustrates the importance of teamwork; and perhaps also draws attention to the need for a robust protocol to facilitate consistent, good-quality early pregnancy care for all women.

[A case of heterotopic pregnancy]

Heterotopic pregnancy is the simultaneous occurrence of intrauterine and ectopic pregnancy. Because of the increasing use of assisted reproductive technology techniques, the frequency of heterotopic pregnancy rises during the past years. We present a case of simultaneous occurrence of ruptured extrauterine /tubal/pregnancy and intrauterine /twin/pregnancy after IVF and ET.