"Nerve-sparing" laparoscopic treatment of parametrial ectopic pregnancy

Case report: Successful laparoscopic management of early abdominal pregnancy

Background

Abdominal pregnancy is characterized by the implantation of the gestational sac within the peritoneal cavity, specifically outside the fallopian tubes, ovaries, and cervix. This exceedingly rare form of ectopic pregnancy accounts for about 1% of all ectopic pregnancies. When rupture occurs, it can result in a life-threatening situation for the patient, necessitating immediate medical intervention.

Case information

In this study, we report a 33-year-old female patient who presented with abdominal pain and was subsequently diagnosed with an early abdominal pregnancy. Laparoscopic intervention revealed gestational tissue and a rupture site located in the pouch of Douglas. The gestational tissue was successfully excised via laparoscopy, and the rupture site was sutured to achieve hemostasis. Postoperative histopathological analysis confirmed the presence of chorionic villi and trophoblast cells.

Conclusion

This case highlights the critical importance of precise diagnosis and laparoscopic intervention in the management of abdominal pregnancy. It is imperative for clinicians to exercise a prudent approach in the diagnosis and treatment of abdominal pregnancy, utilizing a comprehensive assessment that integrates medical history, clinical manifestations, and auxiliary diagnostic tests to enhance the detection and comprehension of this condition.

A Case Report of Retroperitoneal Ectopic Pregnancy and Review of Literature

Background

Retroperitoneal ectopic pregnancy (REP) is a rare form of ectopic pregnancy, in which fertilised eggs are implanted in the retroperitoneal cavity. Due to its atypical location and non-specific symptoms, REP is often misdiagnosed, leading to delayed treatment. This condition poses serious risks owing to its proximity to the retroperitoneal blood vessels. Limited research and lack of specific guidelines make the management of REP challenging.

Case Report and Literature Review

A 47-year-old woman with REP was initially misdiagnosed as having acute gastroenteritis due to severe abdominal pain and gastrointestinal symptoms. She had amenorrhoea and significant lower abdominal pain, but no vaginal bleeding. After 35 days of amenorrhoea, the patient's serum beta-human chorionic gonadotropin (β-hCG) level was 16111.94 mIU/mL. Imaging revealed no intrauterine gestational sac; however, a mass was detected in the left adnexal area. Emergency laparoscopy identified a 3.0 cm ectopic mass in the retroperitoneal space, adjacent to the lower edge of the left broad ligament and near critical structures, with surface rupture and bleeding. The mass was surgically removed, and the patient's β-hCG levels returned to normal 33 days post-surgery. In addition, we reviewed previously published English literature on REP, highlighting its characteristics, pathogenesis, diagnosis, and treatment with the aim of improving the understanding and management of the condition.

Conclusion

REP is difficult to diagnose because of its rarity and nonspecific symptoms. Early diagnosis relies on serum β-hCG testing, ultrasonography, and radiological examination. When β-hCG is elevated and no gestational sac is found within the uterus or at common ectopic sites, REP should be considered. Surgical resection is the primary treatment for this condition.

Ectopic pregnancy in uterosacral ligament following in vitro fertilisation (IVF) in a patient with Allen-Masters syndrome

We describe the case of a woman with mild endometriosis and Allen-Masters syndrome after in vitro fertilisation (IVF), presenting at 7 weeks 2 days gestation with abdominal pain. A transvaginal ultrasound revealed a gestational sac with a non-viable fetus near the right ovary. Laparoscopy was performed due to escalating abdominal pain which revealed a ruptured ectopic pregnancy at the right uterosacral ligament (USL) and blood in the pouch of Douglas. A peritoneal incision along the USL facilitated drainage and removal of the ectopic pregnancy. A pathological investigation described the presence of endometrial tissue directly adjacent to products of conception, which suggested a retroperitoneal implantation that may have been facilitated by the presence of an endometriotic lesion. This case underscores the distinctive clinical trajectory of unconventional ectopic pregnancies, provides novel insights into the pathophysiological mechanism of ectopic implantation and underscores the crucial role of comprehensive patient assessment during IVF and subsequent pregnancy in ensuring effective management.

Subserosal pregnancy: Systematic review with proposal of new diagnostic criteria and ectopic pregnancy classification

Ectopic pregnancy (EP) is a pregnancy where the growing blastocyst implants outside the endometrial cavity. EP account approximately for 0.5-1% of all pregnancies, and extrauterine implant is the leading cause of woman mortality in the first trimester of gestation. Non-tubal pregnancies (NTP) account for less than 5% of all EP. NTP are accompanied by a 7-8 times higher risk of maternal mortality when compared to tubal pregnancies, and their treatment might sometimes be very challenging. Subserosal pregnancy (SP) has been defined as rare variant of intramural pregnancy, where a portion of the gestational sac was surrounded only by the serosa of the uterus. Whereas the treatment of the ectopic pregnancies is crucial for patients' lives and for adequate fertility sparing and considering the need for surgical treatment in many cases, an early diagnosis is important; thus we believe it g might be useful to define some criteria to guide subserosal pregnancy identification, and to distinguish it from other types of non-tubal ectopic pregnancy. A systematic review on Pubmed, Scopus, Web of Science and Google Scholar was performed. Case reports, randomized controlled trials, prospective controlled studies, prospective cohort studies, retrospective studies, and case series were considered eligible. In all databases mentioned were considered manuscripts published from 1990 up to March 2023. Only four articles were eligible for inclusion in this review. All patients underwent to surgical management in laparoscopy. The main risk factors for this type of ectopic pregnancy were previous uterine surgery with opening of the endometrial cavity and assisted reproductive techniques procedures. Considering our results, we propose new classification and diagnostic criteria for subserosal pregnancy, to distinguish it from other types of non-tubal ectopic pregnancies with the aim to preserve fertility following the most correct management.

Two Consecutive Ruptured Tubal Ectopic Pregnancies after Interval Bilateral Tubal Ligation

Background

Bilateral tubal ligation (BTL) is an effective permanent method of birth control that is surgically performed to block the woman's fallopian tube and prevent the egg from meeting the sperm. It is preferred by women or couples who have achieved their reproductive potential and do not desire pregnancy. BTL carries a low risk of method failure with a subsequent pregnancy which is likely to be ectopic. We present a case of two consecutive ruptured tubal ectopic pregnancies following an interval BTL.

Case Presentation

A 40-year-old female, with 7 living children, who previously underwent an interval BTL, presented with acute abdominal pain for 2 days and amenorrhea for 6 weeks. She was stable but had generalized abdominal tenderness, guarding and rebound tenderness, and cervical motion tenderness. Her urine HCG was positive, and a trans-abdominal ultrasound scan revealed a tender echo-complex right adnexal mass, free fluid in the Cul-de-sac, and an empty uterine cavity, consistent with a ruptured right ectopic pregnancy. An emergency exploratory laparotomy was done with findings of a ruptured right distal tube containing products of conception, hemoperitoneum, and previous tubal ligation and left salpingectomy. A right total salpingectomy was done, and the excised right tube containing the mass was sent for histological examination, which revealed chorionic villi and hemorrhagic vascular decidual tissue in the fallopian tube, features suggestive of tubal ectopic pregnancy.

An Uncommon Instance of Tubal Pregnancy With a Vital Fetus at the Thirteenth Week of Gestation

Ectopic pregnancy, characterized by the aberrant implantation of blastocysts outside the uterine endometrial lining, typically occurs within the fallopian tube. Clinical presentation of tubal pregnancy ranges from asymptomatic cases to a spectrum of symptoms, including amenorrhea, pelvic pain, vaginal bleeding, and, critically, hemorrhagic shock resulting from tubal rupture. Utilizing serum beta-human chorionic gonadotropin levels and ultrasound examinations is pivotal in confirming the diagnosis. Diagnosing tubal pregnancy during the first trimester is feasible and crucial to prevent rupture, yet reports of fatal cases persist due to delays in diagnosis or misdiagnosis. This paper presents a unique case of an advanced tubal pregnancy at 13 weeks of gestation, featuring a viable fetus. This case underscores the importance of timely and accurate diagnosis to avoid life-threatening complications. It highlights the critical need for heightened medical vigilance and continuous education among healthcare professionals in managing ectopic pregnancies effectively.

Retroperitoneal para-aortic ectopic pregnancies: A review of reported cases

Objective

To gain insights into the diagnosis and treatment of retroperitoneal para-aortic ectopic pregnancies (RPEP).

Methods

We conducted a review of the existing literature from the web of science, PubMed, and CNKI using the search terms "ectopic pregnancy" and "retroperitoneal." The present review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

Results

After applying the inclusion and exclusion criteria, we included a total of 54 relevant works, encompassing 55 cases. The studies have revealed that a history of artificial abortion, embryo transfer, salpingectomy, and uterine cavity operation, accounted for 65.5 ​% (36/55) of the cases. Typical symptoms of RPEP include abdominal pain (43.6 ​%, 24/55) and vaginal bleeding (36.4 ​%, 20/55), with only 32.7 ​% (18/55) of cases being asymptomatic. The most common sites of RPEP are the abdominal aorta and the inferior vena cava (74.5 ​%, 41/55). There were no statistically significant differences in the incidence of acute abdomen, diameter of the pregnancy sac, number of surgeries, and the time for postoperative hCG to normalize in different pregnant site. The most effective imaging examination for RPEP was found to be abdominal ultrasound (72.7 ​%, 40/55), and the most commonly used treatment method was laparoscopy surgery (55.3 ​% ,21/38).

Conclusion

It is crucial to consider the possibility of RPEP when a pregnancy mass cannot be located during routine examinations. Expanding the scope of the scan may significantly expedite diagnosis and treatment.

Ectopic pregnancy adjacent to iliac vessels managed successfully by minimally invasive treatment using local methotrexate injection: An extremely rare case and literature review

A case report of successfully treated retroperitoneal ectopic pregnancy (REP) is presented. A 36-year-old woman, gravida 3, para 2, was admitted to hospital for suspected ectopic pregnancy with light vaginal bleeding and mild abdominal pain for 3 days at 45 days of gestation by the last menstrual period.Multiple transvaginal ultrasonography and two times laparoscopic probes led to the diagnosis of REP located to the iliac blood vessels closely. Eventually the patient was cured with the treatment using local methotrexate injection under real-time ultrasound guidance and systemic methotrexate administration. We also summarized another 31 cases of REP to further understand this disease, sharing them to arouse clinical attention for the diagnosis and treatment of REP timely.

Retroperitoneal ectopic pregnancy: successful expectant management in condition of early pregnancy failure

BACKGROUND

Retroperitoneal ectopic pregnancy (REP) refers to abnormal implantation of the fertilized egg in the retroperitoneal cavity. REP can be divided into pelvic and abdominal positions. Extremely rare, the incidence of REP is less than 1% of ectopic pregnancy (EP). Herein, we report the first case of paraaortic-located REP in association with successful expectant management, thus raising awareness among healthcare providers, particularly in low-resource settings.

CASE PRESENTATION

A reproductive-age woman presented at our tertiary referral hospital because of amenorrhea and a positive pregnancy test. Based on serial serum β-hCG levels and imaging modalities including transabdominal ultrasound, transvaginal sonography, and magnetic resonance imaging (MRI), a REP of 7-9 weeks of gestational age adherent to abdominal paraaortic region was detected. Since the pregnancy was spontaneously arrested without clinical symptoms, expectant management was first indicated following careful evaluation. After a 1-month follow-up, the ectopic mass naturally degenerated without complications and her β-hCG concentration returned to a negative value. Therefore, the patient recovered completely and avoided unnecessary surgery as well as toxicity of medical treatment when using systemic methotrexate.

CONCLUSIONS

In addition to transvaginal and transabdominal ultrasound, MRI is necessary for the diagnosis of nonviable REP. Alongside the great vessels in the abdominal cavity should be taken into consideration in all suspected cases relating to this rare entity. Expectant management may be carefully indicated in conditions of nonviable REP and unruptured REP, where applicable.

Rare Occurrence of Left Ampullary Ectopic Pregnancy After Ligation of the Left Fallopian Tube: A Case Report

Purpose

Ectopic pregnancy (EP) is rare among patients having received tubal ligation; in these cases, a fertilized ovum is implanted in the proximal tube stump. Distal tubal EP cases in patients having undergone ipsilateral tubal ligation and who have relatively intact contralateral adnexa are extremely rare. Here, we report a case of pregnancy in the distal stump of the ipsilateral fallopian tube following fallopian tubal isthmus ligation.

Case Presentation

A 28-year-old woman was admitted after having experienced lower abdominal pain for 10 days and amenorrhea for 1 week and receiving a transvaginal color ultrasonography finding of a heterogeneous echo (2.1 × 1.2 × 1.4 cm) near the left ovary. The patient had a medical history of transvaginal left tubal ligation under single-port laparoscopy for a left hydrosalpinx. Postoperatively, the patient had undergone in vitro fertilization for assisted reproduction. After ovum retrieval, whole-embryo cryopreservation had been performed due to the ovarian hyperstimulation syndrome trend. This pregnancy was natural after embryo cryopreservation. After the patient was admitted, laparoscopic exploration revealed an elevated ampulla in the distal stump of the left fallopian tube. Left salpingectomy with removal of the ectopic pregnancy in the distal remnant tube was performed under the guidance of transvaginal single-port laparoscopy. Serum β-human chorionic gonadotropin levels gradually decreased. Thereafter, the patient underwent two cycles of frozen embryo transfer, both of which resulted in chemical pregnancies.

Conclusion

This case suggests that gynecologists should pay attention to the possibility of fallopian tube ectopic pregnancy in the distal tubal segment post-tubal ligation.

A Case Report of Retroperitoneal Ectopic Pregnancy After in vitro Fertilization-Embryo Transfer and Literature Review

Background

Retroperitoneal ectopic pregnancy (REP) is an extremely rare type of ectopic pregnancy that can be life threatening. The pathogenesis of REP remains inconclusive and the diagnosis and treatment modalities are unclear.

Case Presentation and Review of the Literature

A 27-year-old woman (gravida: 3; parturition: 0) underwent transvaginal ultrasound (TVS) 40 days after in vitro fertilization-embryo transfer (IVF-ET); no intrauterine gestational sac was detected. The patient was asymptomatic and had no abnormalities on physical examination. β-HCG and progesterone were 18.210 mIU/mL and 10.891 ng/mL, respectively. Transabdominal ultrasound (TAS) showed that the gestational sac had implanted adjacent to the abdominal aorta and near a branch of the iliac artery. Laparoscopic exploration was performed under general anesthesia; intraoperative findings showed that the gestational sac was approximately 2.5 cm in diameter and in the same location as suggested by preoperative ultrasound. Histopathological examination confirmed the diagnosis of EP. On day three post-surgery, the levels of β-HCG had fallen to 911 mIU/mL. We further systematically reviewed the REP cases reported in the English literature and performed a review on the diagnosis and treatment of REP.

Conclusion

Clinicians should be alert to the occurrence of REP. Combined radiological examinations including ultrasonography (TAS and TVS), CT, and MRI are essential for the early diagnosis of REP. Once a definitive diagnosis is made, appropriate treatment should be administered immediately. Although there are cases of successful drug treatment described in the literature, surgery remains as the primary treatment option for REP.

Primary peritoneal ectopic pregnancy: A case report

INTRODUCTION

Primary peritoneal ectopic pregnancy is a rare condition that can be life-threatening. Herein, we report such a case which was managed by laparoscopy.

PRESENTATION OF THE CASE

A 31-year-old G1P0 woman, who had a history of pelvic infection and primary infertility, presented with lower abdominal pain and mild vaginal spotting. Abdominal and bimanual pelvic examination revealed mild left pelvic tenderness. Her serum β-human chorionic gonadotropin (β-HCG) was 7247 IU. Transvaginal ultrasound demonstrated a mass measuring around 1.5 cm in diameter with a well-defined yolk sac adherent to the left ovary. A left fallopian tube ectopic pregnancy was suspected. Laparoscopy revealed that both fallopian tubes were normal and freely moving. Peritoneal ectopic pregnancy was seen behind the uterus which was removed laparoscopically. Histopathology confirmed the diagnosis. The patient had a smooth postoperative recovery.

DISCUSSION

Primary peritoneal pregnancy can be life-threatening. A thorough laparoscopic examination of the entire pelvis and abdomen should be done by an experienced surgeon when the location of the suspected ectopic pregnancy could not be identified.

CONCLUSION

Diagnostic laparoscopy for ectopic pregnancy should include the whole pelvis and the accessible part of the abdomen when the tubes and ovaries are normal.

Hysteroscopic Removal of Intrauterine Device in Pregnancy: A Scoping Review to Guide Personalized Care

Background and objectives: Pregnancies that occur with an intrauterine device (IUD) in situ are at increased risk for developing severe conditions which may affect the fetus and the mother. The incidence of such adverse consequences significantly drops after device removal. A scoping review of the literature was performed to highlight the risks, benefits, and outcomes of hysteroscopic removal of intrauterine devices in early pregnancy. Materials and Methods: PubMed, Scopus, and Web of Science were searched. The review included all reports from 1990 to October 2022. The research strategy adopted included different combinations of the following terms: ("hysteroscopy") AND ("pregnancy") AND ("intrauterine device" or "IUD") AND ("intrauterine system" or "IUS"). A scoping review of the hysteroscopic removal of IUDs during pregnancy was performed. All studies identified were listed by citation, title, authors, and abstract. Duplicates were identified by an independent manual screening performed by two researchers and then removed. For the eligibility process, two authors independently screened the titles and abstracts of all non-duplicated papers and excluded those not pertinent to the topic. Results: PRISMA guidelines were followed. Nine manuscripts were detected, accounting for 153 patients. Most IUD removals occurred during the first trimester of pregnancy. Most of the time, the procedure was safe and without consequences. Conclusions: This review highlights the safety and efficacy of operative hysteroscopy as a method of IUD removal in early pregnancy. We recommend using a 3 to 5 mm hysteroscope, avoiding cervical dilation, and maintaining low infusion pressure during the procedure to avoid potential damage to the gestational sac and IUD fragment displacement. Heating the distension media to 30 °C should be considered.

Multidisciplinary treatment of retroperitoneal ectopic pregnancy: a case report and literature review

Background

Retroperitoneal ectopic pregnancy (REP) is an extremely rare type of ectopic pregnancy, with a total of less than 32 cases reported in the English literature. Early diagnosis of REP is very difficult and all treatments entail a high risk of life-threatening complications.

Case presentation

A 29-year-old nulliparous woman presented a history of 50-day amenorrhea and 7-day upper abdominal pain without vaginal spotting. The serum beta-human chorionic gonadotropin (β-hCG) value was 65,004 m-international units per milliliter (mIU/mL), but no intrauterine gestational sac was found via transvaginal sonography (TVS). Then transabdominal ultrasonography (TAS) and abdominal contrast-enhanced computer tomography (CT) identified a retroperitoneal ectopic pregnancy (REP) tightly adjacent to the inferior vena cava and the abdominal aorta. After consultation from a multidisciplinary team, systemic methotrexate (MTX, intramuscular 20 mg daily for 5 consecutive days) combined with ultrasound-guided local potassium chloride solution injection into the gestational sac was scheduled firstly for the patient. However, serum β-hCG continued to increase and the patient experienced worsening abdominal pain. Laparotomy was performed jointly by a gynecologist and a vascular surgeon. During the operation, the gestational sac with fetal bud measuring about 4.5 × 4.0x3.0 cm, tightly adherent to the surface of inferior vena cava and the left side of abdominal aorta, was carefully dissociated out from the surrounding tissues and removed en bloc. Histopathology examination confirmed the diagnosis of REP. The patient recovered uneventfully and her serum β-hCG returned to normal range on the 23^th postoperative day.

Conclusions

Considering the possibility of REP and combined radiological examinations, such as ultrasonography and CT, are crucial for the early diagnosis of this rare condition. A multidisciplinary team is necessary to treat REP.