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Saif M, Alahmar S, Saif A, Al Halabi N, Adwan D, Altanoukhi I. Rectal ectopic pregnancy: A case report. Int J Surg Case Rep 2024; 119:109798. [PMID: 38788636 PMCID: PMC11140778 DOI: 10.1016/j.ijscr.2024.109798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 05/17/2024] [Accepted: 05/21/2024] [Indexed: 05/26/2024] Open
Abstract
INTRODUCTION Abdominal pregnancy is an extremely rare form of ectopic gestation, and it presents with pelvic pain, severe bleeding, or remain asymptomatic. Its Risk factors include previous ectopic pregnancies, cesarean section, smoking, pelvic inflammatory disease, using intrauterine devices (IUD), and assisted reproductive techniques (ARTs). Accurate diagnosis of rectal ectopic pregnancy remains challenging due to the lack of well-established diagnostic criteria. CASE PRESENTATION A 25-year-old woman presented to the emergency department with a 2-day history of unresponsive lower abdominal pain and nausea. Ultrasound imaging revealed a normal-sized uterus with endometrial thickness, fluids, and clots in the abdominal cavity, but no intrauterine gestational sac was detected. Based on the clinical presentation, ectopic pregnancy was suspected. During laparotomy, the placenta and fetal tissue remnants were found on the anterior wall of the upper third of the rectum. DISCUSSION Abdominal ectopic pregnancy is a high-risk condition that can manifest with gastrointestinal symptoms such as nausea, vomiting, constipation, as well as abdominal and pelvic pain. These variable symptoms underscore the importance of considering rectal ectopic pregnancy as a differential diagnosis and ruling it out to prevent life-threatening complications, including severe bleeding. CONCLUSION Due to its rarity, diverse presentation, and similarity to other conditions, diagnosing rectal ectopic pregnancy and determining the appropriate management can be challenging. Physicians should be aware of this specific type of ectopic pregnancy to enable early-stage diagnosis and provide optimal care.
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Affiliation(s)
- Muhammed Saif
- Faculty of Medicine, Al-Sham Private University, Damascus, Syria.
| | - Shaymaa Alahmar
- Faculty of Medicine, Al-Sham Private University, Damascus, Syria
| | - Ahmed Saif
- Faculty of Medicine, Damascus University, Damascus, Syria
| | - Nahed Al Halabi
- Department of Obstetrics and Gynecology, Maternity University Hospital, Damascus, Syria
| | - Dema Adwan
- Emergency Department, Maternity University Hospital, Damascus, Syria
| | - Imad Altanoukhi
- Department of Obstetrics and Gynecology, Al-Sham Private University, Damascus, Syria
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2
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Dong Y, Zhang H, Jin K, Li H. Three-dimensional transvaginal ultrasound diagnosis of interstitial ectopic pregnancy in a unicornuate uterus: A case report. JOURNAL OF CLINICAL ULTRASOUND : JCU 2024; 52:473-477. [PMID: 38288546 DOI: 10.1002/jcu.23641] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/10/2024] [Accepted: 01/18/2024] [Indexed: 05/08/2024]
Abstract
A rare case of unicornuate uterus with interstitial ectopic pregnancy was diagnosed using three-dimensional transvaginal ultrasound (3D-TVUS). The ultrasound revealed a "lancet-shaped" endometrial corona, a gestational sac near the uterus base extending toward the uterine serosa, and visible interstitial lines. The patient underwent laparoscopic surgery for a lesion in the right fallopian tube. 3D-TVUS was crucial in precisely locating the gestational sac, aiding in effective treatment. Interstitial ectopic pregnancies risk severe hemorrhaging upon rupture. Rapid, accurate diagnosis is vital for lifesaving treatment and preventing critical complications.
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Affiliation(s)
- Yanhua Dong
- Department of Ultrasound, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongbin Zhang
- Department of Ultrasound, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ke Jin
- Department of Ultrasound, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hezhou Li
- Department of Ultrasound, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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3
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Gilmore E, Gutman S, Kim HT, Roe AH. Diagnosis and Management of an Intramyometrial Ectopic Pregnancy Within a Septate Uterus. Obstet Gynecol 2023; 142:1244-1247. [PMID: 37562025 DOI: 10.1097/aog.0000000000005312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/22/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND An intramyometrial pregnancy is a rare form of ectopic pregnancy, making up an estimated 1% of all ectopic pregnancies. Previously described management options have included surgical excision in the emergency setting. CASE A 32-year-old woman, gravida 4 para 0, at 6 0/7 weeks of gestation by last menstrual period, was noted to have a gestational sac implanted entirely within the uterine myometrium. Ultrasonography and magnetic resonance imaging confirmed the presence of an intramyometrial ectopic pregnancy within a septate uterus. The patient's abnormal pregnancy was successfully treated with multidose methotrexate. CONCLUSION Intramyometrial pregnancy is a rare entity that should be considered when it is suggested by ultrasonography or if an intrauterine pregnancy is surgically inaccessible from the endometrial cavity. In a stable patient, multidose systemic methotrexate may be a feasible management strategy.
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Affiliation(s)
- Emma Gilmore
- Department of Obstetrics and Gynecology and the Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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4
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Alvero R. The no-man's land of nontubal ectopic and cesarean section scar pregnancies. Fertil Steril 2023; 120:551-552. [PMID: 37506760 DOI: 10.1016/j.fertnstert.2023.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 07/24/2023] [Indexed: 07/30/2023]
Abstract
Nontubal ectopic pregnancy (NTEP) and cesarean section scar pregnancy (CCSP) are a relatively uncommon but potentially very dangerous conception event. If diagnosed early, they can be treated very effectively. Cesarean section scar ectopic is unique in that expectant management may allow them to persist longer, but with overwhelmingly catastrophic consequences. Reproductive endocrinologists are uniquely positioned to diagnose and treat NTEP/CCSP early, thereby avoiding long-term catastrophic consequences.
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Affiliation(s)
- Ruben Alvero
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, California; Stanford Fertility and Reproductive Health, Lucille Packard Children's Hospital, Sunnyvale, California.
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Bortoletto P, Romanski PA, Petrozza JC, Pfeifer SM. Reproductive surgery: revisiting its origins and role in the modern management of fertility. Fertil Steril 2023; 120:539-550. [PMID: 36870592 DOI: 10.1016/j.fertnstert.2023.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 02/20/2023] [Accepted: 02/22/2023] [Indexed: 03/06/2023]
Abstract
For years, reproductive surgery was the mainstay of reproductive care. With the evolution and ultimate success of in vitro fertilization (IVF), reproductive surgery became an adjuvant therapy, indicated mainly for severe symptoms or to enhance success rates with assisted reproductive technologies. As success rates for IVF have plateaued, and emerging data rekindles the enormous benefits of surgically correcting reproductive pathologies, there is renewed interest among reproductive surgeons in reviving research and surgical expertise in this area. In addition, new instrumentation and surgical techniques to preserve fertility have gained traction and will solidify the need to have skilled reproductive endocrinology and infertility surgeons in our practice.
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Affiliation(s)
- Pietro Bortoletto
- Boston IVF, Waltham, Massachusetts; Harvard Medical School, Boston, Massachusetts; Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
| | | | - John C Petrozza
- Harvard Medical School, Boston, Massachusetts; Department of Obstetrics and Gynecology, Decision of Reproductive Medicine & IVF, Massachusetts General Hospital, Boston, Massachusetts
| | - Samantha M Pfeifer
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, New York
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Sokalska A, Rambhatla A, Dudley C, Bhagavath B. Nontubal ectopic pregnancies: overview of diagnosis and treatment. Fertil Steril 2023; 120:553-562. [PMID: 37495011 DOI: 10.1016/j.fertnstert.2023.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/14/2023] [Accepted: 07/21/2023] [Indexed: 07/28/2023]
Abstract
Nontubal ectopic pregnancies occur as a result of embryo implantation outside the uterine cavity and fallopian tubes. Sites include ovary, cervix, abdominal cavity, interstitial portion of fallopian tube, and cesarean scar. Nontubal pregnancies are uncommon. Nonspecific signs and symptoms of nontubal ectopic pregnancies make diagnosis challenging and, in many cases, significantly delayed, resulting in a high rate of morbidity. Although surgical management remains the mainstay of treatment, there is growing evidence that some of these can be managed medically or with the use of a combination of medical and surgical approaches with good outcome. This review summarizes the current diagnostic modalities, therapeutic options, and outcomes for nontubal ectopic pregnancies. Diagnostic and management options may be limited, especially in resource-restricted settings. Therefore, an understanding of the available options is critical. It needs to be emphasized that the rarity of cases and the difficulties in organizing ethically justified randomized trials result in the lack of well-established management guidelines for nontubal ectopic pregnancies.
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Affiliation(s)
- Anna Sokalska
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, California.
| | - Anupama Rambhatla
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, California
| | - Christina Dudley
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
| | - Bala Bhagavath
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
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Leziak M, Żak K, Frankowska K, Ziółkiewicz A, Perczyńska W, Abramiuk M, Tarkowski R, Kułak K. Future Perspectives of Ectopic Pregnancy Treatment-Review of Possible Pharmacological Methods. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192114230. [PMID: 36361110 PMCID: PMC9656791 DOI: 10.3390/ijerph192114230] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/22/2022] [Accepted: 10/26/2022] [Indexed: 06/03/2023]
Abstract
Ectopic pregnancy, that is, a blastocyst occurring outside the endometrial cavity of the uterus, affects nearly 2% of pregnancies. The treatment of ectopic pregnancy is surgical or pharmacological. Since surgical management is associated with numerous serious side effects, conservative treatment is sought. The treatment of choice in the majority of cases is based on pharmacotherapy with methotrexate (MTX) in a single- or multi-dose regimen. Although the efficacy of methotrexate reaches between 70 and 90%, its use requires specific conditions regarding both the general condition of the patient and the characteristic features of the ectopic pregnancy. Moreover, MTX can cause severe adverse effects, including stomatitis, hepatotoxicity and myelosuppression. Therefore, clinicians and researchers are still looking for a less toxic, more effective treatment, which could prevent surgeries as a second-choice treatment. Some studies indicate that other substances might constitute a good alternative to methotrexate in the management of ectopic pregnancies. These substances include aromatase inhibitors, especially letrozole. Another promising substance in EP treatment is gefitinib, an inhibitor of EGFR tyrosine domain which, combined with MTX, seems to constitute a more effective alternative in the management of tubal ectopic pregnancies. Other substances for local administration include KCl and absolute ethanol. KCl injections used in combination with MTX may be used when foetal heart function is detected in cervical ectopic pregnancies, as well as in heterotopic pregnancy treatment. Absolute ethanol injections proved successful and safe in caesarean scar pregnancies management. Thus far, little is known about the use of those substances in the treatment of ectopic pregnancies, but already conducted studies seem to be promising.
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Affiliation(s)
- Milena Leziak
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland
| | - Klaudia Żak
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland
| | - Karolina Frankowska
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland
| | - Aleksandra Ziółkiewicz
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland
| | - Weronika Perczyńska
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland
| | - Monika Abramiuk
- I Chair and Department of Oncological Gynaecology and Gynaecology, Medical University of Lublin, 20-081 Lublin, Poland
| | - Rafał Tarkowski
- I Chair and Department of Oncological Gynaecology and Gynaecology, Medical University of Lublin, 20-081 Lublin, Poland
| | - Krzysztof Kułak
- I Chair and Department of Oncological Gynaecology and Gynaecology, Medical University of Lublin, 20-081 Lublin, Poland
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8
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Loh WN, Adno AM, Reid S. A 10‐year retrospective cohort study of non‐tubal ectopic pregnancy management outcomes in an Australian tertiary centre. Australas J Ultrasound Med 2022; 25:166-175. [PMID: 36405797 PMCID: PMC9644438 DOI: 10.1002/ajum.12312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Introduction Non-tubal ectopic pregnancy (NTEP) is a rare but significant early pregnancy complication which can result in maternal morbidity and mortality. There is however a lack of evidence-based guidelines for the management of NTEP. Purpose To evaluate the success rates of expectant, medical and surgical management in the treatment of NTEP at our tertiary centre. Methods Retrospective cohort study from 2010 to 2020. All NTEP were classified by ectopic sites. Primary management was classified by expectant, medical [systemic methotrexate (Sys-MTX) and/or local ultrasound-guided injection of MTX and/or KCl intra-sac (L-MTX, L-MTX/KCl)] or surgical. Primary management was considered successful if no change in intervention was required. Treatment complications were compared. Results Twenty-four NTEP were identified, which included 14 interstitial pregnancies (IP), 9 caesarean scar pregnancies (CSP) and 1 ovarian pregnancy (OP), which gave NTEP an incidence of 7.12% among all EP (4.15% for IP, 2.67% for CSP and 0.30% for OP). The success of primary surgical management was 100% (7/7), primary medical management was 76.9% (10/13) and primary expectant management was 33.3% (1/3). Primary medical management had a non-statistically significant greater mean time to serum ß-human Chorionic Gonadotrophin <5 IU/L, mean length of hospitalisation, mean number of follow-up visits and hospital re-presentation/readmissions compared to primary surgical management. There was no other difference in complication rates between the treatment management groups. Conclusion Surgery remains the most effective way to manage NTEP. However, medical management can be a safe and effective alternative option in carefully selected cases.
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Affiliation(s)
- Wei‐Guo Nicholas Loh
- Department of Obstetrics and Gynaecology Liverpool Hospital Sydney New South Wales Australia
- South Western Sydney Clinical School University of New South Wales Sydney New South Wales Australia
| | - Alan Maurice Adno
- Department of Feto‐Maternal Unit Liverpool Hospital Sydney New South Wales Australia
| | - Shannon Reid
- Department of Obstetrics and Gynaecology Liverpool Hospital Sydney New South Wales Australia
- Faculty of Medicine Western Sydney University Sydney New South Wales Australia
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Allegrini M, Legendre G, Dabi Y, Thubert T, Joste M, Lavoué V, Timoh KN. Local Injection of Methotrexate Ultrasound guided-transvaginal. J Gynecol Obstet Hum Reprod 2022; 51:102419. [PMID: 35667587 DOI: 10.1016/j.jogoh.2022.102419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 05/31/2022] [Accepted: 06/02/2022] [Indexed: 11/28/2022]
Abstract
Non-tubal ectopic pregnancies can be located in the uterine portion of the tube (interstitial or cornual), in the cervix (cervical), in a caesarean scar, in the ovary, or intra-abdominally. Even though they are rare, they are associated with a high mortality. Invasive surgeries such as cornuectomy and hysterectomy were common to treat them in case of hemorrhage. Thanks to recent advances in imaging techniques, diagnosis of non-tubal ectopic pregnancy is made earlier and conservative management has been developed in order to respect fertility of patients. Beyond these treatments, systemic or local injection of Methotrexate shows very good success. In the article, we aimed to describe the technics of vaginal injection of in situ methotrexate with ultrasound guidance.
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Affiliation(s)
- Marie Allegrini
- Department of Gynecology and Obstetrics and Human reproduction, CHU Rennes, Rennes, France
| | | | - Yohann Dabi
- Department of Obstetrics and Reproductive Medicine, Hôpital Tenon, Sorbonne University
| | - Thibault Thubert
- Department of Obstetrics and Gynecology, Nantes University Hospital, Nantes
| | - Marine Joste
- Department of Gynecology and Obstetrics and Human reproduction, CHU Rennes, Rennes, France
| | - Vincent Lavoué
- Department of Gynecology and Obstetrics and Human reproduction, CHU Rennes, Rennes, France
| | - Krystel Nyangoh Timoh
- Department of Gynecology and Obstetrics and Human reproduction, CHU Rennes, Rennes, France; University Rennes 1, France, INSERM, LTSI - UMR 1099
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Technical Notes Surgical treatment of a ruptured interstitial pregnancy. J Gynecol Obstet Hum Reprod 2022; 51:102403. [PMID: 35525482 DOI: 10.1016/j.jogoh.2022.102403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 04/24/2022] [Accepted: 04/26/2022] [Indexed: 11/21/2022]
Abstract
Non-tubal ectopic pregnancies represent fewer than 10% of all ectopic pregnancies. However, they are associated with a high rate of mortality due to late diagnosis and uterine horn rupture which requires radical emergency surgical management. Cornuectomy via laparoscopy is a treatment of choice. We provide here a simple description of laparoscopic cornuectomy using an Endo GIA stapling system: the Endo GIA® automatic forceps. It has the advantage of removing the mass, suturing, and achieving satisfactory haemostasis in a single step.
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Huang Y, Huang Q, Liu J, Guo M, Liu Y, Lai D. Concurrent Ovarian and Tubal Ectopic Pregnancy After IVF-ET: Case Report and Literature Review. Front Physiol 2022; 13:850180. [PMID: 35444560 PMCID: PMC9013932 DOI: 10.3389/fphys.2022.850180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/08/2022] [Indexed: 11/13/2022] Open
Abstract
Ovarian pregnancy (OP) coupled with tubal ectopic pregnancy is rare. We present a case of coexistent ovarian and tubal ectopic pregnancies in the same adnexa resulting from in vitro fertilization and embryo transfer (IVF-ET) for tubal occlusion. The patient presented with mild vaginal bleeding without abdominal pain. OP was diagnosed via sonographic findings of an ectopic gestational sac (GS) and yolk sac that seemed to be inside her left ovary. Laparoscopic exploration confirmed this diagnosis, and ipsilateral tubal ectopic pregnancy was suspected during surgery. The patient underwent left salpingectomy and resection of the ovarian lesion. A subsequent histopathological examination verified the diagnosis of coexistent ovarian and tubal ectopic pregnancy. Though the mechanism underlying concurrent OP and tubal ectopic pregnancy is still unclear, clinicians should be cautious of potential combined ectopic pregnancy when dealing with patients who have received more than one embryo transfer.
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Affiliation(s)
- Yating Huang
- School of Medicine, The International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Qin Huang
- School of Medicine, The International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Jinglan Liu
- School of Medicine, The International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Mengxi Guo
- School of Medicine, The International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Yuan Liu
- School of Medicine, The International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Dongmei Lai
- School of Medicine, The International Peace Maternity and Child Health Hospital, Shanghai Jiaotong University, Shanghai, China
- Shanghai Key Laboratory of Embryo Original Disease, School of Medicine, Shanghai Jiaotong University, Shanghai, China
- *Correspondence: Dongmei Lai,
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Coulter-Nile S, Balachandar K, Ward H. A diagnostic dilemma of an 18-week cervical ectopic pregnancy: A case report. Case Rep Womens Health 2022; 33:e00385. [PMID: 35198413 PMCID: PMC8841278 DOI: 10.1016/j.crwh.2022.e00385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/07/2022] [Accepted: 01/10/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Cervical ectopic pregnancy (CEP) is characterised by the implantation of trophoblastic tissue within the cervical canal and is associated with a significant risk of maternal morbidity and mortality. This case report addresses a second-trimester CEP with unusual sonographic features suspicious of placenta accreta spectrum (PAS), which was successfully managed with an abdominal hysterectomy. Case Presentation A 27-year-old woman, G6P2, presented to the labour ward of a rural hospital at 18 weeks of gestation with premature rupture of membranes. The index pregnancy was complicated by an absence of any antenatal care, as well as a history of cigarette smoking and cannabis use. An ultrasound scan demonstrated a live pregnancy with the foetal head within the cervical canal. A termination of pregnancy was arranged with misoprostol 200 mg orally followed by an oxytocin induction. However, a repeat ultrasound scan, after 12 h of oxytocin infusion, which failed to terminate the pregnancy, demonstrated a still live foetus as well as increased vascularity, concerning for PAS. The patient underwent an emergency abdominal hysterectomy, with an intraoperative diagnosis of a CEP. The postoperative course was unremarkable, and the patient was discharged home on day 3 post-operatively. Discussion Appropriate antenatal care and early booking-in would have identified a CEP early in gestation and allowed for minimally invasive management and potential conservation of fertility. When this is not possible in such cases, meticulous pre-operative planning by a gynaecologist with experience in advanced pelvic surgery can minimise the associated morbidity and mortality. Cervical ectopic pregnancies are rare and at a late gestation can be difficult to diagnose A multigravida woman at 18 weeks gestation presented in preterm labour with ultrasound concern for placenta accreta Intraoperatively she was found to have a cervical ectopic pregnancy An abdominal hysterectomy was required in management Early antenatal care is vital in diagnosis of cervical ectopic pregnancy and can potentially conserve fertility
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Ectopic pregnancy: a resident's guide to imaging findings and diagnostic pitfalls. Emerg Radiol 2021; 29:161-172. [PMID: 34618256 DOI: 10.1007/s10140-021-01974-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/20/2021] [Indexed: 10/20/2022]
Abstract
Ectopic pregnancy (EP) is a term used to describe any pregnancy which does not implant into the uterine cavity. There are several types of EPs: tubal, interstitial, ovarian, abdominal, heterotopic, cervical, and cesarean scar. Ectopic pregnancies can acutely rupture and are the number one cause of maternal death in the first trimester of pregnancy. Therefore, prompt recognition and accurate localization have significant clinical implications on patient outcome. Unfortunately, EPs have many mimickers, which can make the diagnosis challenging in certain cases. In this review, we aim to describe and illustrate sonographic findings of each type of EP, as well as present mimickers and various imaging pitfalls. We will clarify how to avoid potential misdiagnoses that could adversely affect patient outcomes. Lastly, we will briefly address management of each type of EP and discuss potential complications.
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Rokhgireh S, Gorginzadeh M, Mehdizadehkashi A, Tahermanesh K, Alizadeh S. Broad ligament pregnancy in the presence of an intrauterine contraceptive device: A case report. Int J Surg Case Rep 2021; 79:421-423. [PMID: 33529821 PMCID: PMC7851414 DOI: 10.1016/j.ijscr.2021.01.080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 01/15/2021] [Accepted: 01/15/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Abdominal pregnancy though scarce is associated with considerable morbidity and mortality. Few cases till now have been diagnosed or managed by laparoscopy. CASE PRESENTATION In this study, a case of an abdominal pregnancy in a woman with intrauterine contraceptive device (IUD) in situ and a history of cesarean section is described. CLINICAL DISCUSSION Our case was a brief description of a broad ligament pregnancy as a subcategory of abdominal pregnancy .It was located medial to the pelvic sidewall, lateral to the uterus, inferior to the fallopian tube and superior to the pelvic floor. CONCLUSION The pregnancy was in the location of the left broad ligament which was diagnosed on laparoscopic evaluation.
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Affiliation(s)
- Samaneh Rokhgireh
- Endometriosis Research Center, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Mansoureh Gorginzadeh
- Endometriosis Research Center, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | | | - Kobra Tahermanesh
- Endometriosis Research Center, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Shima Alizadeh
- Department of Obstetrics & Gynecology, Emam Complex, Vali-e-Asr Hospital, Tehran University of Medical Science(TUMS), Tehran, Iran.
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15
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Controversies in family planning: Management of cesarean-scar ectopic pregnancy. Contraception 2020; 103:208-212. [PMID: 33359510 DOI: 10.1016/j.contraception.2020.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 12/14/2020] [Accepted: 12/17/2020] [Indexed: 11/23/2022]
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Management of Non-Tubal Ectopic Pregnancies: A Single Center Experience. Diagnostics (Basel) 2020; 10:diagnostics10090652. [PMID: 32878097 PMCID: PMC7555978 DOI: 10.3390/diagnostics10090652] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 08/27/2020] [Accepted: 08/29/2020] [Indexed: 01/13/2023] Open
Abstract
Non-tubal ectopic pregnancies (NT-EPs) are rare but potentially life-threatening conditions. The incidence ranges are between 5-8.3% of all ectopic pregnancies. For this retrospective observational study, 16 patients with NT-EP and treated from January 2014 to May 2020 were recruited. Demographic details, symptoms, Beta human chorionic gonadotrophin (β-hCG) levels, ultrasound findings, management and treatment outcomes were presented. In hemodynamically stable patients, diagnosis was made using ultrasounds and β-hCG levels. Laparoscopy was essential to identify and remove the ectopic pregnancy in clinical unstable patients. A radical laparoscopic approach was chosen in one case of cervical pregnancy diagnosed late in the first trimester. Medical treatment and minimally invasive procedure, alone or combined, resulted in effective strategies in asymptomatic women with an early diagnosis of NT-EP. We report cases of cervical pregnancies successfully treated by hysteroscopy alone or combined with medical treatment, the first case of scar pregnancy treated by mini-reseptoscope and curettage and the fifth case of interstitial pregnancy treated with Methotrexate and Mifepristone. In this manuscript we report a single center experience in the management of NT-EPs with the aim of outlining the importance of the early diagnosis for a minimally invasive treatment in order to reduce maternal morbidity and mortality and preserve future fertility.
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Italiano S, Tong S, Readman E, Tassone M, Hastie R, Pritchard N. Combination methotrexate and gefitinib: A potential medical treatment for inoperable nontubal ectopic pregnancy. J Obstet Gynaecol Res 2019; 46:531-535. [PMID: 31814216 DOI: 10.1111/jog.14169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 11/14/2019] [Indexed: 11/29/2022]
Abstract
Nontubal ectopic pregnancies present as a therapeutic challenge. A 35-year-old primigravida at 7 weeks gestation had a live interstitial ectopic pregnancy and contraindications to surgery. The patient was treated with a multidose methotrexate regimen combined with oral gefitinib (250 mg daily for 7 days). The peak human chorionic gonadotropin (hCG) of the patient was recorded at 19 510 IU/L and began declining from day 4 of combination therapy (day 6 of initial treatment). Successful resolution of the ectopic was demonstrated by cessation of the fetal heart by day 15 and hCG falling to 23 IU/L by day 42. A 10-year review of all nontubal ectopic pregnancies treated with methotrexate identified 46 cases, which had a comparable time to resolution to combination therapy. However, for cases where cardiac activity was present, the median time to resolution following methotrexate treatment was 64 days (47-87 days), 22 days longer than combination therapy. Combination therapy may provide a safe medical treatment for inoperable nontubal ectopic pregnancy.
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Affiliation(s)
| | - Stephen Tong
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Heidelberg, Victoria, Australia.,Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Emma Readman
- Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | | | - Roxanne Hastie
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Heidelberg, Victoria, Australia.,Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Natasha Pritchard
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Heidelberg, Victoria, Australia.,Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
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Gilbert SB, Alvero RJ, Roth L, Polotsky AJ. Direct Methotrexate Injection into the Gestational Sac for Nontubal Ectopic Pregnancy: A Review of Efficacy and Outcomes from a Single Institution. J Minim Invasive Gynecol 2019; 27:166-172. [PMID: 30930212 DOI: 10.1016/j.jmig.2019.03.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 03/09/2019] [Accepted: 03/24/2019] [Indexed: 11/15/2022]
Abstract
STUDY OBJECTIVE To evaluate the efficacy of nontubal ectopic pregnancy (NTEP) management with direct methotrexate (MTX) injection into the gestational sac. DESIGN A retrospective chart review. SETTING A tertiary academic and teaching hospital. PATIENTS All cases of confirmed NTEP were retrospectively identified from 2012 to 2017. INTERVENTIONS Ultrasound-guided direct injection of MTX into the fetal pole and surrounding gestational sac and a single dose of systemic MTX with or without fetal intracardiac injection of potassium chloride. MEASUREMENTS AND MAIN RESULTS Treatment failure, complications from treatment, operating time, and days to negative serum human chorionic gonadotropin (hCG) after treatment were measured. Fourteen women (age 34 ± 5.2 years) with NTEP underwent direct MTX injection (cesarean scar, n = 4; interstitial, n = 6; cervical, n = 4). The mean estimated gestational age was 49 ± 11, CI (43, 56 days). One patient required laparoscopic intervention with a failure rate of 1 of 14 (a double interstitial, heterotopic pregnancy). There were no other major complications. The time in the operating room was similar for all NTEP types. The average time to negative serum hCG was not different for cesarean scar (84.5 ± 36 days), cervical pregnancies (70.5 ± 19 days), or interstitial pregnancies (45.3 ± 38 days, p = .15). CONCLUSION Direct MTX injection into the gestational sac for NTEP treatment is safe and effective. The failure rate of 7% is considerably lower than what was previously reported for a failure of systemic MTX in similar cases (25%). Resolution of serum hCG after treatment can be quite prolonged even in uncomplicated cases.
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Affiliation(s)
- Sara Babcock Gilbert
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado (all authors).
| | - Ruben J Alvero
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado (all authors)
| | - Lauren Roth
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado (all authors)
| | - Alex J Polotsky
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado (all authors)
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Gao T, Sun M, Yao L, Jiang W. False diagnosis of and needless therapy for presumed gestational trophoblastic disease in women with an unusual site of residual pregnancy. J Int Med Res 2018; 47:673-681. [PMID: 30409101 PMCID: PMC6381454 DOI: 10.1177/0300060518807600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective This study aimed to determine the diagnostic value of magnetic resonance imaging (MRI), hysteroscopy, and laparoscopy to avoid unnecessary treatment when patients present with clinical manifestations that are close to those of gestational trophoblastic neoplasia (GTN). Methods Three patients who were falsely diagnosed with presumed GTN and received needless chemotherapy in our hospital from July 2011 to March 2012 were studied. We also reviewed data of patients with similar clinical features who were diagnosed as having residual pregnancy in recent years. Clinical manifestations were evaluated. Results All three patients had persistently high serum β-human chorionic gonadotrophin levels and a mass with abundant blood supply in the uterus after termination of pregnancy. The patients were diagnosed with GTN and underwent chemotherapy. They responded poorly to chemotherapy and underwent surgery. The pathological diagnosis in all patients was residual pregnancy. In recent years, no patients were misdiagnosed because pelvic MRI, hysteroscopy, or laparoscopy was used when residual pregnancy could not be excluded. Conclusion Gynecologists should diagnose carefully when patients present with clinical manifestations that are close to those of GTN to avoid unnecessary treatment. MRI, hysteroscopy, and laparoscopy could be important examinations for excluding residual pregnancy.
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Affiliation(s)
- Tong Gao
- 1 Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,2 Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Mingming Sun
- 1 Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,2 Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Liangqing Yao
- 1 Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,2 Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
| | - Wei Jiang
- 1 Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.,2 Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China
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Second Trimester Cervical Ectopic Pregnancy and Hemorrhage: A Case Report and Review of the Literature. Case Rep Obstet Gynecol 2018; 2018:3860274. [PMID: 30225155 PMCID: PMC6129320 DOI: 10.1155/2018/3860274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 08/05/2018] [Accepted: 08/09/2018] [Indexed: 12/27/2022] Open
Abstract
Cervical ectopic pregnancies are a rare occurrence in the United States. Here we present the interdisciplinary and conservative management approach to a cervical ectopic at an advanced gestational age. In addition, we review the surgical management of hemorrhage from cervical ectopic pregnancies, which is often catastrophic and life-threatening.
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Karasu Y, Akselim B. Feasibility of single-incision laparoscopy for ruptured ectopic pregnancies with hemoperitoneum. MINIM INVASIV THER 2018; 28:46-50. [PMID: 29741420 DOI: 10.1080/13645706.2018.1470538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND The aim of this study was to compare single-incision laparoscopic surgery (SILS) and conventional laparoscopy in ectopic pregnancies accompanied by severe hemoperitoneum. MATERIAL AND METHODS The main outcome measures were duration of surgery, intraoperative bleeding quantity, complications, post-operative pain scores, additional analgesic requirements, and length of hospital stay. RESULTS A total of 53 women, 28 in the conventional laparoscopy group and 25 in the SILS group, participated in the study. There were no differences in demographic characteristics between the two groups. There were no differences in terms of variables including gestational week, beta human chorionic gonadotropin (βhCG) levels, and operation time. No intraoperative complications were observed in either group. The groups exhibited no significant differences regarding additional analgesic requirements or postoperative pain scores. However, pain at the sixth postoperative hour was lower in the SILS group. This effect was not observed at 12 and 24 hours. CONCLUSION SILS appears to be effective and safe for the treatment of ruptured ectopic pregnancies accompanied by hemoperitoneum.
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Affiliation(s)
- Yetkin Karasu
- a Obstetrics and Gynecology , Ankara Training and Research Hospital , Ankara , Turkey
| | - Burak Akselim
- a Obstetrics and Gynecology , Ankara Training and Research Hospital , Ankara , Turkey
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