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Stabile G, Cracco F, Zinicola G, Carlucci S, Mangino FP, Stampalija T, Ricci G. Subserosal pregnancy: Systematic review with proposal of new diagnostic criteria and ectopic pregnancy classification. Eur J Obstet Gynecol Reprod Biol 2024; 297:254-259. [PMID: 38701545 DOI: 10.1016/j.ejogrb.2024.04.037] [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: 07/16/2023] [Revised: 04/24/2024] [Accepted: 04/28/2024] [Indexed: 05/05/2024]
Abstract
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.
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Affiliation(s)
- Guglielmo Stabile
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71121 Foggia, Italy.
| | - Francesco Cracco
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34100 Trieste, Italy
| | - Giulia Zinicola
- Department of Woman and Child Health and Public Health, Woman Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Stefania Carlucci
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71121 Foggia, Italy
| | | | - Tamara Stampalija
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34100 Trieste, Italy; Institute for Maternal and Child Health IRCCS "Burlo Garofolo", 34100 Trieste, Italy
| | - Giuseppe Ricci
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34100 Trieste, Italy; Institute for Maternal and Child Health IRCCS "Burlo Garofolo", 34100 Trieste, Italy
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Fei H, Yin Y, Guo X, Jin X. Spontaneous Ectopic Tubal Pregnancy After Partial Salpingectomy. Int J Womens Health 2024; 16:917-922. [PMID: 38803341 PMCID: PMC11129747 DOI: 10.2147/ijwh.s455616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 05/11/2024] [Indexed: 05/29/2024] Open
Abstract
Objective To report a rare case of spontaneous ectopic pregnancy (EP) after partial salpingectomy treated by laparoscopy. Case Report A 30-year-old gravida 1 para 0 woman with a history of left adnexectomy, due to left ovarian torsion 13 years ago, was referred to our hospital. She had experienced lower abdominal pain for 1 day and amenorrhea for 1 week. Transvaginal ultrasonography did not reveal an intrauterine pregnancy, but showed a suspected extrauterine gestational sac on the left adnexal area. The patient was diagnosed with ectopic pregnancy, and laparoscopy was performed. During the operation, we found a gestational sac on the left fallopian tube stump. Conclusion The most significant risk factors for ectopic pregnancy (EP) are previous procedures and conditions that cause tubal injury. Therefore, it is necessary to be alert to the occurrence of the disease even if there is a history of tubal resection and ensure no part of the fallopian tube is left behind during removal.
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Affiliation(s)
- Huali Fei
- Department of Reproductive Endocrinology, Hangzhou Women’s Hospital, Hangzhou, People’s Republic of China
| | - Yixuan Yin
- Department of Prenatal Diagnosis Center, Hangzhou Women’s Hospital, Hangzhou, People’s Republic of China
| | - Xiaoyan Guo
- Department of Gynecology, Hangzhou Women’s Hospital, Hangzhou, People’s Republic of China
| | - Xuejing Jin
- Department of Reproductive Endocrinology, Hangzhou Women’s Hospital, Hangzhou, People’s Republic of China
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Dereli ML, Savran Üçok B, Özkan S, Sucu S, Topkara S, Fıratlıgil FB, Ercan EE, Uğur M, Akdaş Reis Y, Engin Üstün Y. The importance of blood-count-derived inflammatory markers in predicting methotrexate success in patients with tubal ectopic pregnancy. Int J Gynaecol Obstet 2024. [PMID: 38773760 DOI: 10.1002/ijgo.15696] [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: 09/06/2023] [Revised: 04/11/2024] [Accepted: 05/11/2024] [Indexed: 05/24/2024]
Abstract
OBJECTIVE To investigate the systemic immune-inflammation index (SII) and neutrophil-to-lymphocyte ratio (NLR) in predicting a successful methotrexate response in tubal ectopic pregnancy (TEP). METHODS Women treated for TEP at a tertiary hospital between 2017 and 2021 were retrospectively reviewed. A total of 502 (100%) eligible patients who received methotrexate were included and divided into two groups based on whether or not they were successfully treated with methotrexate alone. Inflammatory parameters derived from the patients' hemograms at hospital admission were compared. RESULTS In total, 434 (86.4%) patients were successfully treated with methotrexate alone (Group 1), while 68 (13.6%) patients underwent surgery after methotrexate failure (Group 2). Median neutrophil count, NLR, platelet-to-lymphocyte ratio, monocyte-to-lymphocyte ratio, SII, largest ectopic mass diameter, and β-human chorionic gonadotropin (β-hCG) were significantly lower, whereas median lymphocyte and platelet counts were significantly higher in Group 1. According to the receiver operating characteristic analysis performed for the discriminatory power of NLR, β-hCG, and SII for methotrexate response, the area under the curve values were 0.742, 0.730, and 0.699, respectively. CONCLUSION Low NLR and SII are associated with methotrexate success and could be used to refine decision making regarding β-hCG for predicting successful response to methotrexate in patients with TEP.
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Affiliation(s)
- Murat Levent Dereli
- Department of Obstetrics and Gynecology, Ankara Etlik Lady Zübeyde Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Belgin Savran Üçok
- Department of Obstetrics and Gynecology, Ankara Etlik Lady Zübeyde Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Sadullah Özkan
- Department of Obstetrics and Gynecology, Ankara Etlik Lady Zübeyde Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Sadun Sucu
- Department of Obstetrics and Gynecology, Ankara Etlik Lady Zübeyde Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Serap Topkara
- Department of Obstetrics and Gynecology, Ankara Etlik City Hospital, Ankara, Turkey
| | - Fahri Burçin Fıratlıgil
- Department of Obstetrics and Gynecology, Ankara Etlik Lady Zübeyde Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Emel Ebru Ercan
- Department of Obstetrics and Gynecology, Ankara Etlik Lady Zübeyde Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Merve Uğur
- Department of Obstetrics and Gynecology, Ankara Etlik Lady Zübeyde Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Yıldız Akdaş Reis
- Department of Obstetrics and Gynecology, Ankara Etlik Lady Zübeyde Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Yaprak Engin Üstün
- Department of Obstetrics and Gynecology, Ankara Etlik Lady Zübeyde Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
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Ntiyakunze G, Gidion D, Kyejo W, Moshi B, Jaiswal S, Moshi L, Muzo J, Chuwa H, Abeid M. Medical management of ectopic pregnancy: Case series at a private tertiary hospital, Tanzania. SAGE Open Med Case Rep 2024; 12:2050313X241252348. [PMID: 38773989 PMCID: PMC11107306 DOI: 10.1177/2050313x241252348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 04/15/2024] [Indexed: 05/24/2024] Open
Abstract
Ectopic pregnancy is a pregnancy in which the developing blastocyst implants outside the endometrial cavity. An estimated 1.3%-2.4% of pregnancies end up outside the uterus. With prompt diagnosis and efficient treatment, the risks of morbidity and mortality associated with ectopic pregnancy can be reduced. For the treatment of carefully chosen ectopic pregnancies, methotrexate therapy, a folic acid antagonist that is highly toxic to rapidly replicating tissues, produces outcomes comparable to surgery. We describe six cases of ectopic pregnancy which were successfully treated with methotrexate and on follow-up two of them successfully conceived to term delivery. For patients who are physically fit enough, medical management of an ectopic pregnancy with methotrexate should be the first line of treatment to lower surgical morbidity and mortality. Following the administration of the medication, the patient is monitored with a clinical symptom interview and weekly plasma human chorionic gonadotrophin levels checks. When initial human chorionic gonadotrophin levels are extremely high, complete resolution of an ectopic pregnancy can take 6-8 weeks instead of the usual 2-3 weeks. Early diagnosis of ectopic pregnancies is necessary to improve their prognosis. Ectopic pregnancies can be managed medically with methotrexate to preserve fertility. Compared to surgical management, methotrexate therapy appears to have more advantages.
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Affiliation(s)
- Gregory Ntiyakunze
- Department of Obstetrics and Gynecology, The Aga Khan University, Dar Es Salaam, Tanzania
| | - Daudi Gidion
- Department of Obstetrics and Gynecology, The Aga Khan University, Dar Es Salaam, Tanzania
| | - Willbroad Kyejo
- Department of Family Medicine, The Aga Khan University, Dar Es Salaam, Tanzania
| | - Brenda Moshi
- Department of Obstetrics and Gynecology, The Aga Khan University, Dar Es Salaam, Tanzania
| | - Shweta Jaiswal
- Department of Obstetrics and Gynecology, The Aga Khan University, Dar Es Salaam, Tanzania
| | - Lynn Moshi
- Department of Obstetrics and Gynecology, The Aga Khan University, Dar Es Salaam, Tanzania
| | - Jane Muzo
- Department of Obstetrics and Gynecology, The Aga Khan University, Dar Es Salaam, Tanzania
| | - Harrison Chuwa
- Department of Oncology, The Aga Khan Hospital, Dar Es Salaam, Tanzania
| | - Muzdalifat Abeid
- Department of Obstetrics and Gynecology, The Aga Khan University, Dar Es Salaam, Tanzania
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Yavuz O, Kurt S, Özgözen ME, Akdöner A. The impact of the coronavirus disease 2019 pandemic on the clinical presentation of tubal ectopic pregnancies: a retrospective cohort study. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2024; 70:e20231445. [PMID: 38775533 PMCID: PMC11101178 DOI: 10.1590/1806-9282.20231445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 01/19/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE We aimed to assess the impact of the coronavirus disease 2019 pandemic on the clinical presentation of tubal ectopic pregnancies. METHODS This retrospective cohort study was conducted at a tertiary center and included 76 cases of tubal ectopic pregnancies. The study period was divided into two groups: the pre-coronavirus disease group (January 2018 to February 2020, Group 1; n=47, 61.8%) and the coronavirus disease group (March 2020 to February 2022, Group 2; n=29, 38.2%). Subgroup analysis was also performed for tubal ruptured ectopic pregnancies as Group 1 (n=15, 62.5%) and Group 2 (n=9, 37.5%). RESULTS No statistically significant differences were observed between the pre-coronavirus disease and coronavirus disease groups in terms of demographic characteristics. Although the serum beta-human chorionic gonadotropin level was found to be higher in Group 2, the difference was not statistically significant (p=0.7). The groups appeared to be similar in treatment management, duration of hospitalization, and blood transfusion needs (p=0.3, p=0.6, and p=0.5, respectively). Additionally, no significant difference was observed between the groups in the evaluation of ruptured ectopic pregnancies (p=0.5). In the subgroup analysis of tubal ruptured ectopic pregnancies, no significant difference was observed. CONCLUSION To the best of our knowledge, there are few studies evaluating the effect of the pandemic on tubal ectopic pregnancies in the literature. Although we did not report statistically significant differences between groups in our study, given the potential prolonged duration of the pandemic, healthcare professionals should actively prompt their patients to seek necessary medical assistance.
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Affiliation(s)
- Onur Yavuz
- Dokuz Eylül University, School of Medicine, Department of Obstetrics and Gynecology – İzmir, Turkey
- Dokuz Eylül University Hospital – İzmir, Turkey
| | - Sefa Kurt
- Dokuz Eylül University, School of Medicine, Department of Obstetrics and Gynecology – İzmir, Turkey
- Dokuz Eylül University Hospital – İzmir, Turkey
| | - Mehmet Eyüphan Özgözen
- Dokuz Eylül University, School of Medicine, Department of Obstetrics and Gynecology – İzmir, Turkey
- Dokuz Eylül University Hospital – İzmir, Turkey
| | - Aslı Akdöner
- Dokuz Eylül University, School of Medicine, Department of Obstetrics and Gynecology – İzmir, Turkey
- Dokuz Eylül University Hospital – İzmir, Turkey
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Cao Y, Feng C, Li H. Spontaneous diaphragm rupture caused by abdominal pregnancy: A case report. Asian J Surg 2024:S1015-9584(24)00807-8. [PMID: 38714409 DOI: 10.1016/j.asjsur.2024.04.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 04/18/2024] [Indexed: 05/09/2024] Open
Affiliation(s)
- Yi Cao
- Department of General Surgery, Hangzhou Normal University Affiliated Hospital, Hangzhou, 310015, China.
| | - Chenglei Feng
- Department of General Surgery, Hangzhou Normal University Affiliated Hospital, Hangzhou, 310015, China
| | - Hang Li
- Department of General Surgery, Hangzhou Normal University Affiliated Hospital, Hangzhou, 310015, China
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Yen JC, Wu TI, Stone R, Wang TL, Visvanathan K, Chen LY, Hsu MH, Shih IM. Salpingectomy for ectopic pregnancy reduces ovarian cancer risk-a nationwide study. JNCI Cancer Spectr 2024; 8:pkae027. [PMID: 38588567 PMCID: PMC11078587 DOI: 10.1093/jncics/pkae027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/20/2024] [Accepted: 03/25/2024] [Indexed: 04/10/2024] Open
Abstract
Recent studies propose fallopian tubes as the tissue origin for many ovarian epithelial cancers. To further support this paradigm, we assessed whether salpingectomy for treating ectopic pregnancy had a protective effect using the Taiwan Longitudinal National Health Research Database. We identified 316 882 women with surgical treatment for ectopic pregnancy and 3 168 820 age- and index-date-matched controls from 2000 to 2016. In a nested cohort, 91.5% of cases underwent unilateral salpingectomy, suggesting that most surgically managed patients have salpingectomy. Over a follow-up period of 17 years, the ovarian carcinoma incidence was 0.0069 (95% confidence interval [CI] = 0.0060 to 0.0079) and 0.0089 (95% CI = 0.0086 to 0.0092) in the ectopic pregnancy and the control groups, respectively (P < .001). After adjusting the events to per 100 person-years, the hazard ratio (HR) in the ectopic pregnancy group was 0.70 (95% CI = 0.61 to 0.80). The risk reduction occurred only in epithelial ovarian cancer (HR = 0.73, 95% CI = 0.63 to 0.86) and not in non-epithelial subtypes. These findings show a decrease in ovarian carcinoma incidence after salpingectomy for treating ectopic pregnancy.
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Affiliation(s)
- Ju-Chuan Yen
- Department of Ophthalmology, Taipei Ren-Ai Branch, and Department of Education and Research, Taipei City Hospital, Taipei, Taiwan
- Graduate Institute of Biomedical Informatics, Taipei Medical University, Taipei, Taiwan
| | - Tzu-I Wu
- Department of Obstetrics and Gynecology, Wan Fang Hospital, Taipei Medical University, Cancer Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Obstetrics and Gynecology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Rebecca Stone
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tian-Li Wang
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Kala Visvanathan
- Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Li-Ying Chen
- Graduate Institute of Data Science, Taipei Medical University, Taipei, Taiwan
| | - Min-Huei Hsu
- Graduate Institute of Data Science, Taipei Medical University, Taipei, Taiwan
| | - Ie-Ming Shih
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
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May B, Friedlander H, Schust D, Bollig KJ. Pregnancies at the Uterotubal Junction: A Review of Terminology (Interstitial, Cornual, and Angular) and Recommendations for Management. Reprod Sci 2024:10.1007/s43032-024-01539-2. [PMID: 38653861 DOI: 10.1007/s43032-024-01539-2] [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: 11/20/2023] [Accepted: 04/02/2024] [Indexed: 04/25/2024]
Abstract
Ectopic pregnancies are one of the most common causes of obstetric mortality worldwide. Interstitial ectopic pregnancies, defined as an extracavitary pregnancy within the portion of the Fallopian tube that transverses the myometrium, have reported mortality rates approximately seven times higher than all types of ectopic pregnancy combined. In contrast, intracavitary eccentric gestations, often labeled as "cornual" or "angular" pregnancies, have reportedly high rates of live birth. Unfortunately, the terms "interstitial," "cornual," and "angular" have long been used with varying diagnostic criteria and often interchangeably to describe a pregnancy near the uterotubal junction. The inconsistency in nomenclature and lack of clear diagnostic criteria to distinguish among these pregnancies has resulted in a paucity of data to provide accurate prognostic information and guide appropriate management. This review article aims to provide historical context for the terms "interstitial," "cornual," and "angular;" discuss previous and more recent innovations of diagnostic methods; and provide recommendations for concise terminology and inform management.
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Affiliation(s)
- Bobby May
- Department of Obstetrics & Gynecology, Duke University Hospital, Durham, NC, USA.
- Duke University School of Medicine, DUMC 3084, 203 Baker House, 27710, Durham, NC, USA.
| | - Hilary Friedlander
- Department of Reproductive Endocrinology & Infertility, Duke University Hospital, Durham, NC, USA
| | - Danny Schust
- Department of Reproductive Endocrinology & Infertility, Duke University Hospital, Durham, NC, USA
| | - Kassie J Bollig
- Reproductive Medicine Associates, Basking Ridge, NJ, USA
- Department of Obstetrics, Gynecology and Reproductive Medicine, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Mizutani A, Nagashima M, Ohira Y, Mimura T, Onuki M, Matsuoka R, Sekizawa A, Matsumoto K. Successful laparoscopic resection of retroperitoneal ectopic pregnancy between the abdominal aorta and inferior vena cava: A case report. J Obstet Gynaecol Res 2024. [PMID: 38634201 DOI: 10.1111/jog.15947] [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: 12/27/2023] [Accepted: 04/01/2024] [Indexed: 04/19/2024]
Abstract
Retroperitoneal ectopic pregnancies are extremely rare; only a few cases having been reported. Here, we report laparoscopic removal of an asymptomatic retroperitoneal ectopic pregnancy from a 29-year-old woman who was referred to our hospital for a suspected ectopic pregnancy. Transvaginal ultrasound did not reveal a gestational sac in the uterus or pelvic cavity. However, abdominal contrast-enhanced computer tomography showed a gestational sac between the abdominal aorta and inferior vena cava. On laparoscopy, the gestational sac was confirmed to be in this retroperitoneal location and successfully removed with minimal bleeding. Histopathologic examination revealed chorionic villi surrounded by lymphatic tissue, suggesting lymphatic spread of the retroperitoneal ectopic pregnancy. In summary, contrast-enhanced computer tomography is very useful for locating the site of pregnancy in women suspected of having a retroperitoneal ectopic pregnancy. Timely diagnosis of a retroperitoneal ectopic pregnancy before bleeding occurs can enable their safe laparoscopic removal.
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Affiliation(s)
- Akane Mizutani
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Shinagawa-ku, Tokyo, Japan
| | - Minoru Nagashima
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Shinagawa-ku, Tokyo, Japan
| | - Yasuyuki Ohira
- Department of Pathology, Showa University Hospital, Shinagawa-ku, Tokyo, Japan
| | - Takashi Mimura
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Shinagawa-ku, Tokyo, Japan
| | - Mamiko Onuki
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Shinagawa-ku, Tokyo, Japan
| | - Ryu Matsuoka
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Shinagawa-ku, Tokyo, Japan
| | - Akihiko Sekizawa
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Shinagawa-ku, Tokyo, Japan
| | - Koji Matsumoto
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Shinagawa-ku, Tokyo, Japan
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Jongjakapun A, Salang L, Aueaungkul A, Kleebkaow P. Chronic interstitial ectopic pregnancy presenting with a negative urine pregnancy test. BMJ Case Rep 2024; 17:e259267. [PMID: 38589241 PMCID: PMC11015295 DOI: 10.1136/bcr-2023-259267] [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] [Indexed: 04/10/2024] Open
Abstract
The ampulla portion of the fallopian tube is the most common site of ectopic pregnancy (70%), with approximately 2% of pregnancies implanted in the interstitial portion. In general, an interstitial ectopic pregnancy (IEP) is difficult to diagnose and is associated with a high rate of complications-most patients with an IEP present with severe abdominal pain and haemorrhagic shock due to an ectopic rupture. Chronic tubal pregnancy (CTP) is an uncommon condition with an incidence of 20%. The CTP has a longer clinical course and a negative or low level of serum beta-human chorionic gonadotropin due to perished chorionic villi. This study presents a case of a woman who was diagnosed with a chronic IEP (CIEP) which was successfully treated by surgery. This case also acts as a cautionary reminder of considering a CIEP in women of reproductive age presenting with amenorrhea, vaginal bleeding and a negative pregnancy test.
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Affiliation(s)
- Apiwat Jongjakapun
- Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Lingling Salang
- Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Apiwat Aueaungkul
- Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Pilaiwan Kleebkaow
- Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Fu P, Sun H, Zhang L, Liu R. Efficacy and safety of treatment modalities for cesarean scar pregnancy: a systematic review and network meta-analysis. Am J Obstet Gynecol MFM 2024:101328. [PMID: 38485053 DOI: 10.1016/j.ajogmf.2024.101328] [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: 11/29/2023] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVE Cesarean scar pregnancy may lead to varying degrees of complications. There are many treatment methods for it, but there are no unified or recognized treatment strategies. This systematic review and network meta-analysis aimed to observe the efficacy and safety of treatment modalities for patients with cesarean scar pregnancy. DATA SOURCES MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched from their inception to January 31, 2024. In addition, relevant reviews and meta-analyses were manually searched for additional references. STUDY ELIGIBILITY CRITERIA Our study incorporated head-to-head trials involving a minimum of 10 women diagnosed with cesarean scar pregnancy through ultrasound imaging or magnetic resonance imaging, encompassing a detailed depiction of primary interventions and any supplementary measures. Trials with a Newcastle-Ottawa scale score <4 were excluded because of their low quality. METHODS We conducted a random-effects network meta-analysis and review for cesarean scar pregnancy. Group-level data on treatment efficacy and safety, reproductive outcomes, study design, and demographic characteristics were extracted following a predefined protocol. The quality of studies was assessed using the Cochrane risk-of-bias tools for randomized controlled trials and the Newcastle‒Ottawa scale for cohort studies and case series. The main outcomes were efficacy (initial treatment success) and safety (complications), of which summary odds ratios and the surface under the cumulative ranking curve using pairwise and network meta-analysis with random effects. RESULTS Seventy-three trials (7 randomized controlled trials) assessing a total of 8369 women and 17 treatment modalities were included. Network meta-analyses were rooted in data from 73 trials that reported success rates and 55 trials that reported complications. The findings indicate that laparoscopy, transvaginal resection, hysteroscopic curettage, and high-intensity focused ultrasound combined with suction curettage demonstrated the highest cure rates, as evidenced by surface under the cumulative ranking curve rankings of 91.2, 88.2, 86.9, and 75.3, respectively. When compared with suction curettage, the odds ratios (95% confidence intervals) for efficacy were as follows: 6.76 (1.99-23.01) for laparoscopy, 5.92 (1.47-23.78) for transvaginal resection, 5.00 (1.99-23.78) for hysteroscopic curettage, and 3.27 (1.08-9.89) for high-intensity focused ultrasound combined with suction curettage. Complications were more likely to occur after receiving uterine artery chemoembolization, suction curettage, methotrexate+hysteroscopic curettage, and systemic methotrexate; hysteroscopic curettage, high-intensity focused ultrasound combined with suction curettage, and Lap were safer than the other options derived from finite evidence; and the confidence intervals of all the data were wide. CONCLUSION Our findings indicate that laparoscopy, transvaginal resection, hysteroscopic curettage, and high-intensity focused ultrasound combined with suction curettage procedures exhibit superior efficacy with reduced complications. The utilization of methotrexate (both locally guided injection and systemic administration) as a standalone medical treatment is not recommended.
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Affiliation(s)
- Peiying Fu
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Haiying Sun
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Long Zhang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ronghua Liu
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Yu J, Peng Y, Yu L, Shi S. Laparoscopic surgery for ectopic pregnancy: A comparative study on the clinical benefits and impact on tubal patency and reproductive outcomes. Technol Health Care 2024:THC230920. [PMID: 38517813 DOI: 10.3233/thc-230920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
BACKGROUND Ectopic pregnancy is a major contributor to maternal morbidity and mortality across the globe. OBJECTIVE This study aims to investigate the clinical benefits of laparoscopic surgery in treating ectopic pregnancy, and its impact on tubal patency and reproductive outcomes. METHODS A clinical study was conducted to compare laparoscopic and medical conservative treatment for ectopic pregnancy. A total of 206 patients were treated for ectopic pregnancy at our hospital from January 2018 to June 2020. Among them, 46 underwent laparoscopic ipsilateral salpingectomy, 54 underwent laparoscopic ipsilateral salpingostomy with lesion removal, and 106 were treated conservatively with medication. RESULTS The age range and average age of each group are provided, with no significant differences in these general demographic characteristics (p> 0.05). Both the salpingostomy and medication groups had higher rates of ectopic pregnancy compared to the salpingectomy group, with statistically significant differences (p< 0.05). The comparison of ectopic pregnancy rates between the salpingostomy and medication groups showed no significant difference. Within three years, the salpingostomy group had 10 cases of recurrent ectopic pregnancy, with 2 cases on the same side, while the medication group had 18 cases, with 8 cases on the same side. At 3 months after the normalization of blood β-HCG, the salpingostomy group showed 43 cases of tubal patency (patency rate: 79.63%), while the medication group showed 57 cases (patency rate: 53.77%), with a statistically significant difference between the two groups (p= 0.01). CONCLUSION Laparoscopic surgery for ectopic pregnancy offers significant clinical benefits over conservative medical treatment, including higher rates of tubal patency and improved reproductive outcomes. These findings support laparoscopic surgery as an effective approach for the management of ectopic pregnancy.
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Affiliation(s)
- Juan Yu
- Department of Gynaecology and Obstetrics, Aviation General Hospital of China Medical University and Beijing Institute of Translational Medicine, Chinese Academy of Sciences, Beijing, China
| | - Yan Peng
- Department of Gynaecology and Obstetrics, Aviation General Hospital of China Medical University and Beijing Institute of Translational Medicine, Chinese Academy of Sciences, Beijing, China
| | - Liqun Yu
- Department of Gynaecology and Obstetrics, Aviation General Hospital of China Medical University and Beijing Institute of Translational Medicine, Chinese Academy of Sciences, Beijing, China
| | - Shutian Shi
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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13
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Oprescu DN, Martiniuc AE, Cirstoiu MM, Giubegeanu ET, Toader OD. Conservative Management With a Multimodal Approach of a 12-Week Cervical Ectopic Pregnancy With Fetal Megacystis. Cureus 2024; 16:e52771. [PMID: 38406068 PMCID: PMC10884779 DOI: 10.7759/cureus.52771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2024] [Indexed: 02/27/2024] Open
Abstract
Cervical ectopic pregnancy is the rarest kind of ectopic pregnancy, and it is known as the implantation of an embryo into the cervical mucosa. It is commonly associated with complications such as hemorrhage from the cervix and can lead to severe consequences if it is not treated early. For this reason, the treatment for a cervical pregnancy often requires an abdominal hysterectomy. To avoid such radical management, several conservative methods of termination have been used. In this paper, we report a complex management of one of our ectopic cervical cases, which includes embolization of the uterine arteries, treatment with methotrexate and mifepristone, evacuation of the pregnancy followed by local hemostatic sutures and application of a balloon in the cervix. The post-operative period was uneventful. After a three-day postoperative stay, the patient was discharged. The management options employed in the presented case achieved the goal of preserving fertility for our patient. There are no specific guidelines for the treatment of cervical pregnancies in advanced gestational age.
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Affiliation(s)
- Daniela Nuti Oprescu
- Obstetrics and Gynecology, Institutului Naţional pentru Sănătatea Mamei şi Copilului Alessandrescu Rusescu, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Ana Elena Martiniuc
- Obstetrics and Gynecology, Institutului Naţional pentru Sănătatea Mamei şi Copilului Polizu Bucharest, Bucharest, ROU
| | | | - Elena Theodora Giubegeanu
- Obstetrics and Gynecology, Institutului Naţional pentru Sănătatea Mamei şi Copilului, Alessandrescu Rusescu, Bucharest, ROU
| | - Oana Daniela Toader
- Institutului Naţional pentru Sănătatea Mamei şi Copilului Alessandrescu Rusescu, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
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14
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Huang J, Zuo X, Sun Y, Wu X, Zhu H, Cui W. Ectopic pregnancy adjacent to iliac vessels managed successfully by minimally invasive treatment using local methotrexate injection: An extremely rare case and literature review. J Gynecol Obstet Hum Reprod 2023; 52:102691. [PMID: 37931894 DOI: 10.1016/j.jogoh.2023.102691] [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: 09/21/2023] [Revised: 10/23/2023] [Accepted: 11/03/2023] [Indexed: 11/08/2023]
Abstract
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.
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Affiliation(s)
- Jin Huang
- Department of Gynecology and obstetrics, The Affiliated Yixing Hospital of Jiangsu University, Yixing 214200, China
| | - Xin Zuo
- Department of Gynecology and obstetrics, The Affiliated Yixing Hospital of Jiangsu University, Yixing 214200, China
| | - Yaoxiang Sun
- Department of Clinical Laboratory, The Affiliated Yixing Hospital of Jiangsu University, Yixing 214200, China
| | - Xiaoyun Wu
- Department of Ultrasound, The Affiliated Yixing Hospital of Jiangsu University, Yixing 214200, China
| | - Hongdi Zhu
- Department of Gynecology and obstetrics, The Affiliated Yixing Hospital of Jiangsu University, Yixing 214200, China
| | - Wei Cui
- Department of Gynecology and obstetrics, The Affiliated Yixing Hospital of Jiangsu University, Yixing 214200, China.
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15
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Solangon SA, Naftalin J, Jurkovic D. Ovarian ectopic pregnancy: clinical characteristics, ultrasound diagnosis and management. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023. [PMID: 38031189 DOI: 10.1002/uog.27549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 10/23/2023] [Accepted: 11/16/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVE To compare the clinical, ultrasound and biochemical characteristics of ovarian ectopic pregnancy (OEP) with those of tubal ectopic pregnancy (TEP). METHODS This was a retrospective case-control study of women with OEP and those with TEP seen at a single center between December 2010 and February 2021. OEP was defined as a pregnancy located completely or partially within the ovarian parenchyma, seen separately to a corpus luteum, if a corpus luteum was present within the ipsilateral ovary. We compared demographic features, risk factors, clinical presentation, ultrasound findings and outcomes, such as blood loss at surgery, need for blood transfusion, length of hospital stay, follow-up and future pregnancy outcome, between cases of OEP and TEP. RESULTS Overall, 20 women with OEP were identified and compared to 100 women with TEP. A total of 15/20 (75%) OEPs were diagnosed correctly on the first ultrasound scan. There was no difference between the groups in terms of maternal age, gestational age, gravidity, parity or risk factors. Compared with TEP, OEP was more likely to present with abdominal pain without vaginal bleeding (12/20 (60%) vs 13/100 (13%); odds ratio (OR), 10.0 (95% CI, 3.45-29.20); P < 0.01), contain an embryo with cardiac activity (3/20 (15%) vs 2/100 (2%); OR, 8.7 (95% CI, 1.34-55.65); P = 0.02) and have severe hemoperitoneum on ultrasound (9/20 (45%) vs 8/100 (8%); OR, 9.4 (95% CI, 3.01-29.40); P < 0.01), and had a higher volume of blood loss at surgery (median, 700 mL vs 100 mL; P < 0.01). All surgically managed OEPs had successful laparoscopic treatment (18 excisions, one wedge resection) with preservation of the ovary. Only one (5%) case of OEP required a blood transfusion. CONCLUSIONS OEP is more likely than TEP to contain an embryo and to present with severe hemoperitoneum. In a dedicated early pregnancy setting, the majority of OEPs were detected on an ultrasound scan at the initial visit, facilitating optimal minimally invasive surgical management, reducing the risk of blood transfusion and oophorectomy. Our findings can be used as a reference for clinicians who may not otherwise encounter this rare condition. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- S A Solangon
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - J Naftalin
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - D Jurkovic
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
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16
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Al-Nuaimy Y, John J, Alhomsi SM, Al-Baghdadi OO. Multiple Spontaneous Ectopic Pregnancies Following Bilateral Salpingectomy. Int Med Case Rep J 2023; 16:725-729. [PMID: 37954088 PMCID: PMC10638940 DOI: 10.2147/imcrj.s432437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/21/2023] [Indexed: 11/14/2023] Open
Abstract
Introduction Ectopic pregnancy (EP) is a significant cause of gynaecological morbidity and mortality. Salpingectomy is the preferred management modality in recurrent ectopic pregnancies; although they do not eliminate the risk of reoccurrence. The aetiology of recurrent ectopic pregnancies remains unknown but there are identifiable risk factors associated with increased likelihood of occurrence. Case Presentation We present the case of a 30-year-old woman who attended the emergency unit with her second spontaneous ectopic pregnancy following a previous bilateral salpingectomy. She had prior multiple spontaneous ectopic pregnancies: laparoscopic salpingectomy for a left cornual EP in 2017 followed by laparotomic salpingectomy for a ruptured right EP after failed medical management in 2018. Lastly, she had laparoscopic removal of an EP sac in the scar of a previous left cornual EP in 2019. She presented with a history of missed periods, pelvic pain, and vaginal spotting. Her examination revealed left lower abdominal pain, soft, non-tender abdomen, and no cervical excitation. Pelvic ultrasound revealed a thin endometrium and no intrauterine pregnancy visualised. A suspicious complex mass near the left ovary with a ring-like structure was noted. Her β-HCG was (251 IU/L) which plateaued after 48 hrs (220 IU/L). She responded well to methotrexate with no need for surgical intervention this time. Conclusion This case is unique as it highlights the importance of keeping an open mind when managing recurrent ectopic pregnancies, especially when preventative surgical measures have been performed previously.
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Affiliation(s)
- Yusor Al-Nuaimy
- College of Medicine, Ajman University, Ajman, United Arab Emirates
| | - Jacqueline John
- Department of Obstetrics and Gynaecology, Tawam Hospital, Al-Ain City, Abu Dhabi, United Arab Emirates
| | - Sousan Mohamad Alhomsi
- Department of Obstetrics and Gynaecology, Tawam Hospital, Al-Ain City, Abu Dhabi, United Arab Emirates
| | - Omaema Omar Al-Baghdadi
- Department of Obstetrics and Gynaecology, Tawam Hospital, Al-Ain City, Abu Dhabi, United Arab Emirates
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17
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Mansouri Z, Tarafdari A, Azizi S, Mehdikhani B, Shababi A, Vaghef Davari F. A case report of heterochronic presentation of a bilateral tubal pregnancy. Clin Case Rep 2023; 11:e8072. [PMID: 37900710 PMCID: PMC10600360 DOI: 10.1002/ccr3.8072] [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: 07/07/2023] [Revised: 09/15/2023] [Accepted: 10/08/2023] [Indexed: 10/31/2023] Open
Abstract
Key Clinical Message This paper highlights that diagnosis and treatment of one ectopic pregnancy does not rule out the happening of a second ectopic pregnancy in the same patient concurrently, especially if the patient has rising β-hCG and persistent symptoms. Abstract Bilateral tubal pregnancy (BTP) is the most uncommon form of tubal ectopic pregnancy. Complications can lead to maternal morbidity and mortality. We reported a case of left tubal pregnancy and the patient underwent laparoscopic salpingostomy. During the follow-up, the contralateral ectopic pregnancy was discovered and treated with MTX.
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Affiliation(s)
- Zeinab Mansouri
- Department of Obstetrics & Gynecology, Imam Khomeini Hospital complexTehran University of Medical sciencesTehranIran
| | - Azam Tarafdari
- Department of Obstetrics & Gynecology, Imam Khomeini Hospital complexTehran University of Medical sciencesTehranIran
| | - Sepideh Azizi
- Shahid Akbarabadi Clinical Research Development Unit (ShACRDU)Iran University of Medical Sciences (IUMS)TehranIran
| | | | - Amirali Shababi
- School of MedicineIran University of Medical SciencesTehranIran
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18
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Celik HG, Celik E, Buyru F, Bastu E. Cornual Pregnancy Reaching Eight Weeks of Gestation without Uterine Rupture. J Minim Invasive Gynecol 2023; 30:857-858. [PMID: 37422050 DOI: 10.1016/j.jmig.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 06/24/2023] [Accepted: 06/27/2023] [Indexed: 07/10/2023]
Affiliation(s)
- Hale Goksever Celik
- Department of Obstetrics and Gynecology, Acibadem Mehmet Ali Aydinlar University, Faculty of Medicine, Acibadem Fulya Hospital, Istanbul, Turkey.
| | - Engin Celik
- Department of Gynecologic Oncology, University of Health Sciences, Istanbul Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Faruk Buyru
- Department of Obstetrics and Gynecology, Acibadem Fulya Hospital, Istanbul, Turkey
| | - Ercan Bastu
- Department of Obstetrics and Gynecology, Biruni University, Istanbul, Turkey
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19
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Smith KA, Parvinian A, Ainsworth AJ, Shenoy CC, Packard AT. Normal and Abnormal Appearances of the Ovaries during Assisted Reproduction: Multimodality Imaging Review. Radiographics 2023; 43:e230089. [PMID: 37883303 DOI: 10.1148/rg.230089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Infertility is a common diagnosis that prompts many couples and individuals to seek assisted reproductive technology (ART) for assistance with conception. These technologies have become increasingly used in the United States in the past several decades, with 326 468 ART cycles performed in 2020, resulting in 75 023 live births. This ubiquity of ART also increases the likelihood that radiologists will encounter both normal and abnormal imaging findings associated with these treatments. Thus, radiologists of all subspecialties should be familiar with the multimodality appearance of the ovaries and pelvis in patients undergoing ART treatments. Furthermore, it is imperative that radiologists understand the appearance expected during different stages of the ART process. During stimulated ovulatory cycles, it is normal and expected for the ovaries to appear enlarged and to contain numerous cystic follicles, often with a small to moderate volume of pelvic free fluid. After oocyte retrieval, hemorrhagic ovarian follicles and a small to moderate volume of blood products in the cul-de-sac can be expected to be seen. Multiple nonemergency and emergency complications are related to ART, many of which can be seen at imaging. The most encountered emergency complications of ART include ovarian hyperstimulation syndrome, ectopic pregnancy, heterotopic pregnancy, multiple gestations, ovarian torsion, and procedural complications related to oocyte retrieval. These complications have important clinical implications, thus necessitating accurate and timely detection by the radiologist and the clinical team. ©RSNA, 2023 Supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.
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Affiliation(s)
- Katherine A Smith
- From the Departments of Radiology (K.A.S., A.P., A.T.P.) and Obstetrics and Gynecology (A.J.A., C.C.S.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Ahmad Parvinian
- From the Departments of Radiology (K.A.S., A.P., A.T.P.) and Obstetrics and Gynecology (A.J.A., C.C.S.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Alessandra J Ainsworth
- From the Departments of Radiology (K.A.S., A.P., A.T.P.) and Obstetrics and Gynecology (A.J.A., C.C.S.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Chandra C Shenoy
- From the Departments of Radiology (K.A.S., A.P., A.T.P.) and Obstetrics and Gynecology (A.J.A., C.C.S.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Ann T Packard
- From the Departments of Radiology (K.A.S., A.P., A.T.P.) and Obstetrics and Gynecology (A.J.A., C.C.S.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
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20
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Traisrisilp K, Sethasathien S. Large unruptured tubal pregnancy mimicking abdominal pregnancy. BMJ Case Rep 2023; 16:e256090. [PMID: 37816580 PMCID: PMC10565280 DOI: 10.1136/bcr-2023-256090] [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] [Indexed: 10/12/2023] Open
Abstract
Ectopic pregnancy accounts for 1-2% of all pregnancies. Ultrasound is the primary diagnostic tool to locate pregnancy outside the uterus and identify complications such as haemoperitoneum. In inconclusive cases, MRI is an adjunctive imaging modality offering more precise tissue differentiation and helpful to location identification. Presented is an unusual case of tubal pregnancy. The patient in her 30s, who was 14 weeks into her first pregnancy, had a suspected abdominal pregnancy. Both transabdominal ultrasound and an MRI indicated an ectopic pregnancy, likely originating from the right fallopian tube. A successful laparotomy and right salpingectomy were performed without complications. Rarely, as in this case, large unruptured and advanced tubal pregnancies can mimic an abdominal pregnancy, underscoring the importance of disease recognition and familiarity with uncommon image findings. An accurate diagnosis of pregnancy location is crucial for effective case management.
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Affiliation(s)
- Kuntharee Traisrisilp
- Obstetric and Gynecology, Chiang Mai University, Faculty of Medicine, Chiang Mai, Thailand
| | - Sethawat Sethasathien
- Obstetric and Gynecology, Chiang Mai University, Faculty of Medicine, Chiang Mai, Thailand
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21
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Chi S, Ning J. A rare case of primary splenic pregnancy. Asian J Surg 2023; 46:4516-4517. [PMID: 37173244 DOI: 10.1016/j.asjsur.2023.04.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Affiliation(s)
- Shenglin Chi
- Department of Tuberculosis, First People's Hospital of Zigong City, Sichuan Province, Zigong, 643000, China
| | - Junjie Ning
- Department of Pediatrics, First People's Hospital of Zigong City, Sichuan Province, Zigong, 643000, China.
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22
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Guevara CG, Blashinsky ZA, Cardella IA. Ectopic Pregnancy in the Round Ligament Following Bilateral Salpingectomy: A Case Report. Cureus 2023; 15:e47900. [PMID: 38034262 PMCID: PMC10683708 DOI: 10.7759/cureus.47900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/29/2023] [Indexed: 12/02/2023] Open
Abstract
Ectopic pregnancies, characterized by the implantation of a fertilized ovum outside the uterine cavity, typically occur in the fallopian tubes. However, rare cases have been reported where implantation occurs in atypical locations. Round ligament pregnancy, a rare form of ectopic pregnancy, poses significant risks and can lead to life-threatening complications. This case report describes the presentation and management of a 31-year-old gravida four, para two (G4P2012) female who presented with acute left lower quadrant and pelvic pain. The patient's medical history included a prior bilateral salpingectomy. Physical examination revealed severe left lower quadrant tenderness with guarding. A positive urine pregnancy test and elevated serum quantitative beta-human chorionic gonadotrophin level of 1,735 mIU/mL (normal range: <5 mIU/mL) confirmed pregnancy. Transvaginal ultrasound revealed an empty intrauterine cavity with no gestational sac or fetal pole. A 2 cm cystic structure was identified attached to the left ovary. Ectopic pregnancy was diagnosed, methotrexate was administered, and the patient was discharged with a scheduled outpatient follow-up. However, she returned to the emergency room within 48 hours reporting persistent pelvic pain. At this moment, it was decided that emergent surgical intervention was required. The surgical exploration confirmed the presence of a ruptured ectopic pregnancy in the round ligament, requiring excision and hemostasis. This case report highlights the importance of considering abnormal localization of ectopic pregnancy as a differential diagnosis in women presenting with pelvic pain, even after bilateral salpingectomies. It emphasizes the challenges in diagnosis and management when ectopic pregnancy occurs in atypical sites and highlights the necessity for vigilant follow-up and prompt surgical intervention when medical management fails.
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Affiliation(s)
- Christian G Guevara
- Obstetrics and Gynecology, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
| | - Zachary A Blashinsky
- Obstetrics and Gynecology, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
| | - Isidro A Cardella
- Obstetrics and Gynecology, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
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23
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Ning N, Luo D, Xia W, Mou G, Zhao J, Zhang J, Li C, Wang H, Li J. Dysregulation of TMEM16A impairs oviductal transport of embryos. Am J Physiol Cell Physiol 2023; 325:C623-C632. [PMID: 37458439 DOI: 10.1152/ajpcell.00031.2023] [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: 01/27/2023] [Revised: 07/10/2023] [Accepted: 07/10/2023] [Indexed: 08/25/2023]
Abstract
Ectopic pregnancy is an acute abdominalgia in obstetrics and gynecology, especially in fallopian tubal pregnancy. The ion channel protein transmembrane protein 16A (TMEM16A) is widely distributed in various tissues, even in the oviduct. In this study, we showed that TMEM16A was expressed in the human fallopian tube and was upregulated in patients with tubal pregnancy. By measuring isolated fallopian tube tissues, we found that TMEM16A was involved in regulating not only the contraction of muscle strips but also the beat frequency of cilia. In addition, pharmacological activation or inhibition of TMEM16A could lead to retention of embryos in oviducts. Moreover, the embryos in oviducts were delayed in development and some of them had malformations and deletions. The total number of embryos in the oviducts and uterus was significantly less than that of the control group. Furthermore, we detected changes in the level of m6A methylation, where the relevant writers and readers were reduced in tubal tissues from tubal pregnancies. In m6A mRNA methylation, writers catalyze the addition of methyl groups to cytosine residues and readers bind to the methyl groups and affect gene translation. In human fallopian tube epithelial cell line FTE187, we found that interference with methyltransferase 3 (METTL3) expression increased TMEM16A, suggesting that TMEM16A might be regulated by m6A methylation. In general, our study revealed a novel regulatory point for embryo transport and development, introducing a new role for the diagnosis and treatment of tubal pregnancy.NEW & NOTEWORTHY The ion channel protein TMEM16A is expressed in the epithelium and smooth muscle of the human fallopian tube and is upregulated in patients with tubal pregnancy. TMEM16A is involved in regulating the smooth muscle contraction and the cilia beating. Dysregulated TMEM16A may result in embryo retention in the oviduct and delayed early embryo development. Our study reveals a new regulatory point for embryo transport and development.
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Affiliation(s)
- Nannan Ning
- Department of Clinical Laboratory, Qilu Hospital of Shandong University, Jinan, People's Republic of China
- Shandong Engineering Research Center of Biomarker and Artificial Intelligence Application, Jinan, People's Republic of China
| | - Dan Luo
- Department of Breast Surgery, Qilu Hospital of Shandong University, Jinan, People's Republic of China
| | - Wei Xia
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
- Shanghai Key Laboratory Embryo Original Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Guangjing Mou
- Department of Physiology, School of Basic Medical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, People's Republic of China
| | - Jiangli Zhao
- Department of Physiology, School of Basic Medical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, People's Republic of China
| | - Jian Zhang
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - Cheng Li
- Obstetrics and Gynecology Hospital, Institute of Reproduction and Development, Fudan University, Shanghai, People's Republic of China
| | - Hongchun Wang
- Department of Clinical Laboratory, Qilu Hospital of Shandong University, Jinan, People's Republic of China
- Shandong Engineering Research Center of Biomarker and Artificial Intelligence Application, Jinan, People's Republic of China
| | - Jingxin Li
- Department of Physiology, School of Basic Medical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, People's Republic of China
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24
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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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25
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Sato F, Uramoto S, Amagai T. Teardrop owl eye appearance in enhanced MDCT for diagnosis of ectopic pregnancy with tubal rupture. Radiol Case Rep 2023; 18:2577-2580. [PMID: 37255697 PMCID: PMC10225874 DOI: 10.1016/j.radcr.2023.04.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/25/2023] [Accepted: 04/27/2023] [Indexed: 06/01/2023] Open
Abstract
A 31-year-pld female patient, presented to the emergency room with vaginal bleedingand a three day history of left sided lower abdominal pain. he showed shock status and an'' as ``She came in with a hypovuoluminc shock and an enhanced 3-dimensional multidetector-computed tomography (3D-MDCT) images showed a specific teardropping owl's eye appearance consistent with an active bleeding around fetal sac and from ruptured tubal ectopic pregnancy (EP) spreading into peritoneum at the 9th gestational week. According to accurate radiological diagnosis, she has been able to receive a successful urgent transportation via helicopter to the consultee obstetricians and received an urgent salpingectomy with the diagnosis of tubal rupture in EP. Her post-surgical course was uneventful and discharged hospital on 8th day. From this case experience, an urgent diagnosis of a ruptured tubal EP in shocked female using not US but MDCT is accurately diagnosed because MDCT has radiological advantage to visualize active hemorrhage using contrast-medium.
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Affiliation(s)
- Fumikazu Sato
- Department of Medicine, Kikai Tokushukai Hospital, Kagoshima, Japan
- Department of Emergency Medicine, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Satoshi Uramoto
- Department of Medicine, Kikai Tokushukai Hospital, Kagoshima, Japan
| | - Teruyoshi Amagai
- Department of Medicine, Kikai Tokushukai Hospital, Kagoshima, Japan
- Faculty of Health Care Sciences, Department of Clinical Engineering, Jikei University of Health Care Sciences, 1-2-8, Miyahara, Yodogawa-Ku, Osaka, 532-0003, Japan
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26
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Zhang Y, Li M, Liu X, Yang W, Dong Q, Wang D, Wang J, Tian W, Song X. A delayed spontaneous second-trimester tubo-abdominal pregnancy diagnosed and managed by laparotomy in a "self-identified" infertile woman, a case report and literature review. BMC Pregnancy Childbirth 2023; 23:511. [PMID: 37442982 DOI: 10.1186/s12884-023-05793-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 06/15/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Abdominal pregnancy, a rare form of ectopic pregnancy, is associated with high morbidity and adverse consequences for future fertility. Early recognition and management reduce mortality and allow minimal invasive and conservative treatment. In modern medicine, primitive prevention to unexpected fatal pregnancies is crucial. CASE PRESENTATION A divorced 33-year-old "self-identified" infertile polycystic ovary woman diagnosed as repeated implantation failure in previous in vitro fertilization with her ex-husband ever presented in surgery department with a history of 15-day abdominal pain, nausea, and vomiting and 3-h worsening abdominal pain. The serum beta-human chorionic gonadotropin value was more than 10,000 m-international units per milliliter. Sonogram findings were significant for the absence of intrauterine gestation; a placenta and well-formed living fetus of second-trimester gestation were seen in the abdomen, accompanied by hemoperitoneum. A unique spontaneously second-trimester tubo-abdominal pregnancy was confirmed in emergent laparotomy by gynecologists, she received a removing of the living fetus, a right total salpingectomy, resection of partial omentum and blood transfusion. The patient recovered uneventfully and her serum beta-human chorionic gonadotropin returned to normal range on the 30th postoperative day, till now, she has weak fertility awareness because of her catastrophic experiences in the unexpected abdominal pregnancy. CONCLUSIONS This case highlights woman with a previous in vitro fertilization history may be in is a high risk to be delayed or missed in diagnosis in an intended ectopic pregnancy due to a fixed belief in infertility. Educational interventions and contraceptive care should be provided by fertility and healthcare practitioner. The possibility of abdominal pregnancy must always be suspected and dealt with promptly and appropriately by the astute clinician.
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Affiliation(s)
- Yanfang Zhang
- Tianjin Key Laboratory of Female Reproductive Health and Eugenics, Tianjin, China
| | - Mengying Li
- Tianjin Key Laboratory of Female Reproductive Health and Eugenics, Tianjin, China
| | - Xiaomei Liu
- Tianjin Key Laboratory of Female Reproductive Health and Eugenics, Tianjin, China
| | - Wen Yang
- Tianjin Key Laboratory of Female Reproductive Health and Eugenics, Tianjin, China
| | - Qingyun Dong
- Tianjin Key Laboratory of Female Reproductive Health and Eugenics, Tianjin, China
| | - Dan Wang
- Tianjin Key Laboratory of Female Reproductive Health and Eugenics, Tianjin, China
| | - Jinghua Wang
- Laboratory of Epidemiology, Tianjin Neurological Institute & Department of Neurology, Tianjin Medical University General Hospital, Tianjin, China
| | - Wenyan Tian
- Tianjin Key Laboratory of Female Reproductive Health and Eugenics, Tianjin, China
| | - Xueru Song
- Tianjin Key Laboratory of Female Reproductive Health and Eugenics, Tianjin, China.
- Department of Obstetrics and Gynecology, Tianjin Medical University General Hospital, 154 Anshan Road, He Ping District, Tianjin, 300052, China.
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Bužinskienė D, Mačionytė M, Dasevičius D, Šilkūnas M. Case report: Ectopic pregnancy in the interstitial part of the fallopian tube. Front Surg 2023; 10:1197036. [PMID: 37470044 PMCID: PMC10352450 DOI: 10.3389/fsurg.2023.1197036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/20/2023] [Indexed: 07/21/2023] Open
Abstract
Ectopic pregnancy remains one of the most common causes of pregnancy-related death in the first trimester. 2.4% of ectopic pregnancies occur in the interstitial part of the fallopian tube. As the symptoms of this condition are non-specific and the localization is associated with a higher risk of bleeding, early diagnosis of interstitial pregnancies is important, based not only on clinical symptoms, but also on additional diagnostic methods. Early diagnosis leads to better treatment-related outcomes. We report a 32-year-old female patient who came to the emergency department because of pain in the lower abdomen and right iliac region and bloody vaginal discharge. During palpation of the abdomen, the pain was localized in the lower part of the abdomen. Human chorionic gonadotropin (hCG) was significantly increased in biochemical tests. Transvaginal ultrasound examination of internal genital organs, abdominal and pelvic computer tomography (CT) were per-formed. An ectopic pregnancy was suspected. Thus, the patient was hospitalized in the gynecology department for surgical treatment. A laparoscopy was performed and an ectopic pregnancy was diagnosed in the interstitial part of the right fallopian tube and in the right uterine corner, which led to right salpingectomy and right uterine angle resection. Thus, interstitial pregnancy is a rare and life-threatening gynecological condition due to the higher risk of bleeding compared to other ectopic pregnancies. However, appropriate diagnosis based on clinical signs, transvaginal ultrasound findings and hCG levels in the blood ensures early diagnosis of interstitial pregnancy, which leads to the choice of medical treatment with methotrexate or minimally invasive surgical techniques.
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Affiliation(s)
- Diana Bužinskienė
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Obstetrics and Gynecology, Institute of Clinical Medicine, Faculty of Medicine Vilnius University, Vilnius, Lithuania
| | | | - Darius Dasevičius
- National Center of Pathology, Affiliate of Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Mindaugas Šilkūnas
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Obstetrics and Gynecology, Institute of Clinical Medicine, Faculty of Medicine Vilnius University, Vilnius, Lithuania
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28
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Hao HJ, Feng L, Dong LF, Zhang W, Zhao XL. Reproductive outcomes of ectopic pregnancy with conservative and surgical treatment: A systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e33621. [PMID: 37115078 PMCID: PMC10145868 DOI: 10.1097/md.0000000000033621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 04/01/2023] [Accepted: 04/04/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Ectopic pregnancy (EP), one of the most common gynecological emergencies, is the major cause of maternal death in the first trimester and increases the incidence of infertility and repeat ectopic pregnancy (REP). The aim of this study was to compare the effects of different treatment methods for tubal EP on natural pregnancy outcomes. METHODS We systematically searched PubMed, Embase, Cochrane Library, Web of Science, and Clinical Trials for observational studies on EP (published until October 30,2022 in English) comparing methotrexate (MTX) versus surgery, MTX versus salpingostomy, MTX versus salpingectomy, salpingostomy versus salpingectomy, and MTX versus expectant treatment. Our main endpoints included subsequent natural intrauterine pregnancy (IUP) and REP. We assessed the pooled data using Review Manager software (version 5.3) with a random effects model. RESULTS Of 1274 identified articles, 20 were eligible and 3530 participants were included in our analysis. There was a significant difference in the odds of subsequent IUP in tubal EP patients who underwent MTX compared with those who were treated with surgery [odds ratios (OR) = 1.52, 95% confidence interval (CI):1.20-1.92]. No significant difference was found in the odds of REP between the 2 groups (OR = 1.12, 95% confidence interval [CI]: 0.84-1.51). There was no significant difference in the odds of subsequent IUP and REP in patients after MTX compared to those after salpingostomy (OR = 1.04,95% CI: 0.79-1.38; OR = 1.10, 95% CI: 0.64-1.90). There was a significant difference in the odds of subsequent IUP in patients after MTX compared with those after salpingectomy (OR = 2.11, 95% CI: 1.52-2.93). No significant difference was found in the odds of REP between the 2 groups (OR = 0.98, 95% CI: 0.57-1.71). There was a significant difference in the odds of subsequent IUP between patients who underwent salpingostomy and those who underwent salpingectomy (OR = 1.61, 95% CI: 1.29-2.01). No significant difference was found in the odds of REP between the 2 groups (OR = 1.21, 95% CI: 0.62-2.37). There was no significant difference in the odds of subsequent IUP and REP in patients after MTX compared with those after expectant treatment (OR = 1.25, 95% CI: 0.64-2.45; OR = 0.69, 95% CI: 0.09-5.55). CONCLUSION For hemodynamically stable tubal EP patients, MTX has advantages over surgery, particularly salpingectomy, in improving natural pregnancy outcomes. However, MTX is not inferior to salpingostomy and expectant treatment.
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Affiliation(s)
- Hong-Juan Hao
- Department of Gynecology, The Fourth Hospital of Shijiazhuang, Shijiazhuang, Hebei, China
| | - Li Feng
- Department of Gynecology, The Fourth Hospital of Shijiazhuang, Shijiazhuang, Hebei, China
| | - Li-Fei Dong
- Department of Gynecology, The Fourth Hospital of Shijiazhuang, Shijiazhuang, Hebei, China
| | - Wei Zhang
- Department of Gynecology, The Fourth Hospital of Shijiazhuang, Shijiazhuang, Hebei, China
| | - Xiao-Li Zhao
- Department of Gynecology, The Fourth Hospital of Shijiazhuang, Shijiazhuang, Hebei, China
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29
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Matlac DM, Ribbat‐Idel J, Stroschein K, Perner S, Rody A, Offermann D. Disseminated ectopic pregnancy after salpingotomy in a 30-year-old patient. Clin Case Rep 2023; 11:e7160. [PMID: 37070088 PMCID: PMC10105034 DOI: 10.1002/ccr3.7160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/23/2023] [Accepted: 03/11/2023] [Indexed: 04/19/2023] Open
Abstract
We present a case of a 30-year old patient who devoloped a disseminated abdominal pregnancy after receiving a salpingotomy due to a prior tubal pregnancy.
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Affiliation(s)
- D. M. Matlac
- Department of Obstetrics and GynecologyUniversitätsklinikum Schleswig‐HolsteinLübeckGermany
| | - J. Ribbat‐Idel
- Department of PathologyUniversitätsklinikum Schleswig‐HolsteinLübeckGermany
| | - K. Stroschein
- Department of Obstetrics and GynecologyUniversitätsklinikum Schleswig‐HolsteinLübeckGermany
| | - S. Perner
- Department of PathologyUniversitätsklinikum Schleswig‐HolsteinLübeckGermany
| | - A. Rody
- Department of Obstetrics and GynecologyUniversitätsklinikum Schleswig‐HolsteinLübeckGermany
| | - D. Offermann
- Department of Obstetrics and GynecologyUniversitätsklinikum Schleswig‐HolsteinLübeckGermany
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30
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Densley A, Shonnard M, Conklin M, Menghani V, Reddy-Moolamalla S. Angular and Interstitial Ectopic Pregnancies: A Clarification of Terms and Literature Review. Curr Probl Diagn Radiol 2023; 52:84-88. [PMID: 36456402 DOI: 10.1067/j.cpradiol.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/25/2022] [Accepted: 11/14/2022] [Indexed: 11/18/2022]
Abstract
Angular pregnancy is an exceedingly rare diagnosis, with less than 100 reported cases. Angular pregnancy is important to distinguish from ectopic pregnancies due to the fact that they have the potential to be viable while true ectopic pregnancies do not. As such, angular pregnancy requires starkly different management. Inappropriate use of the terms angular, interstitial, and cornual indicates a general misunderstanding of what makes these diagnoses unique. Misunderstanding leads to misdiagnosis and consequent mismanagement. Our experience with cases of women with angular and interstitial ectopic pregnancies is instructive as it illustrates effective diagnosis and differing management of these two diagnoses. In the two angular pregnancy cases, transvaginal ultrasonography was employed to confirm the diagnosis, which showed a lack of the interstitial line sign, contiguity of the decidua and endometrium, and an endomyometrial mantle thickness between 5 and 8 mm. One patient's angular pregnancy ultimately ruptured and was successfully managed with fully robotic cornual resection and unilateral salpingectomy, while the other progressed to term normally without complication. The patient with an interstitial ectopic pregnancy was also managed surgically, although with laparoscopic cornuotomy and salpingectomy.
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Affiliation(s)
- Ashton Densley
- Department of Radiology, CHI Health Creighton University Medical Center Bergan Mercy, Omaha, NE
| | - Michael Shonnard
- Department of Radiology, CHI Health Creighton University Medical Center Bergan Mercy, Omaha, NE..
| | - Mary Conklin
- Department of Obstetrics and Gynecology, Rutgers Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Vikas Menghani
- Department of Radiology, Three Crosses Regional Hospital, Las Cruces, NM
| | - Surjit Reddy-Moolamalla
- Department of Obstetrics and Gynecology, MountainView Regional Medical Center, Las Cruces, NM
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31
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Kakinuma T, Kakinuma K, Matsuda Y, Yanagida K, Ohwada M, Kaijima H. Efficacy of transvaginal ultrasound-guided local injections of absolute ethanol for ectopic pregnancies with intrauterine implantation sites. World J Clin Cases 2023; 11:788-796. [PMID: 36818618 PMCID: PMC9928688 DOI: 10.12998/wjcc.v11.i4.788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/27/2022] [Accepted: 01/12/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Cervical pregnancies, interstitial tubal pregnancies, and cesarean scar pregnancies, which are ectopic pregnancies with intrauterine implantation sites exhibit increasing trends with the recent widespread use of assisted reproductive technologies and increased rate of cesarean deliveries. The development of high-sensitivity human chorionic gonadotropin testing reagents and the increased precision of transvaginal ultrasonic tomography have made early diagnosis possible and have enabled treatment. Removal of ectopic pregnancies using methotrexate therapy and/or uterine artery embolization has been reported. However, delayed resumption of infertility treatments after methotrexate therapy is indicated, and negative effects on the next pregnancy after uterine artery embolization have been reported.
AIM To examine the efficacy and safety of ultrasound-guided topical absolute ethanol injection in ectopic pregnancies with an intrauterine implantation site.
METHODS In this study, we retrospectively examined the medical records of 21 patients who were diagnosed with an ectopic pregnancy with an intrauterine implantation site at our hospital, between April 2010 and December 2018, and underwent transvaginal ultrasound-guided local injections of absolute ethanol to determine the treatment outcomes. We evaluated the treatment methods, treatment outcomes, presence of bleeding requiring hemostasis measures and blood transfusion, complications, and treatment periods. Successful treatment was defined as the completion of treatment using transvaginal ultrasound-guided local injections of absolute ethanol alone.
RESULTS There were 21 total cases comprising 10 cervical pregnancies, 10 interstitial tubal pregnancies, and 1 cesarean scar pregnancy. All patients completed treatment with this method. No massive hemorrhaging or serious adverse reactions were observed during treatment. The mean gestation ages at the time of diagnosis were 5.9 wk (SD, ± 0.9 wk) for cervical and 6.9 wk (SD, ± 2.1 wk) for interstitial tubal pregnancies. The total ethanol doses were 4.8 mL (SD, ± 2.2 mL) for cervical pregnancies and 3.3 mL (SD, ± 2.2 mL) for interstitial pregnancies. The treatment period was 28.5 days (SD, ± 11.7 d) for cervical pregnancies and 30.0 ± 8.1 d for interstitial pregnancies. Positive correlations were observed between the blood β- human chorionic gonadotropin level at the beginning of treatment and the total ethanol dose (r = 0.75; P = 0.00008), as well as between the total ethanol dose and treatment period (r = 0.48; P = 0.026).
CONCLUSION Transvaginal ultrasound-guided local injections of absolute ethanol could become a new option for intrauterine ectopic pregnancies when fertility preservation is desired.
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Affiliation(s)
- Toshiyuki Kakinuma
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Nasushiobara 329-2763, Japan
| | - Kaoru Kakinuma
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Nasushiobara 329-2763, Japan
| | - Yoshio Matsuda
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Nasushiobara 329-2763, Japan
| | - Kaoru Yanagida
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Nasushiobara 329-2763, Japan
| | - Michitaka Ohwada
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Nasushiobara 329-2763, Japan
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King SA, Salerno A, Sommerkamp S. Ultrasound in Pregnancy. Emerg Med Clin North Am 2023; 41:337-353. [PMID: 37024168 DOI: 10.1016/j.emc.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
This article reviews the use of ultrasound in pregnancy pertinent to the emergency physician. The techniques for transabdominal and transvaginal studies are detailed including approaches to gestational dating. Diagnosis of ectopic pregnancy is reviewed focusing on the potential pitfalls: reliance on beta-human chorionic gonadotropin, pseudogestational sac, interstitial pregnancy, and heterotopic pregnancy. Techniques for the identification of placental issues and presenting parts during the second and third trimesters are reviewed. Ultrasound is a safe and effective tool for the experienced emergency physician and is integral to providing high-quality care to pregnant women.
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MR of Fallopian Tubes. Magn Reson Imaging Clin N Am 2023; 31:29-41. [DOI: 10.1016/j.mric.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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34
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Muacevic A, Adler JR. The Utility of Monitoring Beta-Human Chorionic Gonadotropin Levels in an Ectopic Pregnancy. Cureus 2023; 15:e34063. [PMID: 36699108 PMCID: PMC9867943 DOI: 10.7759/cureus.34063] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2023] [Indexed: 01/24/2023] Open
Abstract
Ectopic pregnancy, a rare complication involving embryo nidation outside the uterus, significantly impacts women's lives worldwide. About 95% of ectopic pregnancies occur in the Fallopian tubes. If not diagnosed early, the patient may suffer from tubal rupture, resulting in hemorrhage and lethal consequences. Transvaginal ultrasound (TVUS) is typically used to diagnose an ectopic pregnancy. However, over the last decade, monitoring beta-human chorionic gonadotropin (β-hCG) levels in ectopic pregnancy have evolved to detect ectopic pregnancy. But there are inconsistencies in its utility in monitoring or diagnosing ectopic pregnancy in clinical practice. This systematic review highlights the potential of monitoring β-hCG levels to accurately diagnose ectopic pregnancy. Furthermore, it showcases if β-hCG levels can determine effective treatment options to successfully resolve an ectopic pregnancy. We performed a literature search between January 2022 through December 2022 following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The clinical evidence demonstrated that monitoring β-hCG levels, combined with TVUS, accurately diagnosed an ectopic pregnancy. Moreover, pre-treatment β-hCG levels higher than 5000 international units per liter (IU/L), statistically significant, indicated surgical management for a successful resolution of an ectopic pregnancy. Whereas lower β-hCG levels showed successful management through expectant and methotrexate treatment. Interestingly, patients who failed non-surgical treatment developed increased β-hCG levels and required surgical intervention. However, there was conflicting evidence on whether β-hCG levels could indicate tubal rupture. Nevertheless, as highlighted in this review, monitoring β-hCG levels could be crucial in the early diagnosis of ectopic pregnancy. Besides, it might significantly aid in monitoring and deciding on effective treatment options for patients with ectopic pregnancy, which could be vital to saving their lives and preserving fertility.
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35
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Liu Z, Jing C. A Case Report of Retroperitoneal Ectopic Pregnancy After in vitro Fertilization-Embryo Transfer and Literature Review. Int J Womens Health 2023; 15:679-693. [PMID: 37168275 PMCID: PMC10166142 DOI: 10.2147/ijwh.s408319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 04/27/2023] [Indexed: 05/13/2023] Open
Abstract
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.
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Affiliation(s)
- Zesi Liu
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Dalian Medical University, Dalian, People’s Republic of China
| | - Chunli Jing
- Department of Ultrasound of Gynecology and Obstetrics, The Second Affiliated Hospital of Dalian Medical University, Dalian, People’s Republic of China
- Correspondence: Chunli Jing, Department of Ultrasound of Gynecology and Obstetrics, The Second Affiliated Hospital of Dalian Medical University, Dalian, People’s Republic of China, Tel +86-133-522-31070, Fax +86-82866055, Email
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36
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Poxon A, Clarfield L, Cherniak R, Page A, Po L. Delays to Surgery in Emergency Department Cases of Ectopic Pregnancy: A Quality Improvement Study. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:21-26. [PMID: 36436806 DOI: 10.1016/j.jogc.2022.11.004] [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: 09/21/2022] [Revised: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Create a process map for emergency department (ED) presentations of surgical ectopic pregnancy, and identify areas of management amenable to quality improvement. METHODS A retrospective chart review of all patients undergoing surgical management of ectopic pregnancy at a large, urban, academic tertiary care centre from 2015 to 2017 was performed. RESULTS Seventy-three patients were included. There were 6 (8.2%) unstable A cases (recommended time to operating room [OR] 0-2 hours), 23 (31.5%) stable A cases, and 44 (60%) B cases (recommended time to OR 2-8 hours). The percent of patients who were in the OR within the recommended time window were 6 (100%) for unstable A cases, 13 (56%) stable A cases, and 29 (65.9%) stable B cases, respectively (P = 0.139). Notable time delays include the time from gynaecology referral to the time seen by gynaecology (29.7% of total wait time for stable A cases from ED to OR) and the time the OR was booked to the time the patient was brought to the OR (53.2% of total wait time for stable B cases). Of the patients seen by physician at the emergency department first, the time from triage to the OR was significantly shorter for patients that received bedside ultrasound only (0.67 ± 0.5 hours vs. 2.1 ± 1.8 hours [P = 0.007]). CONCLUSION This is the first study to map the ED presentation of surgical ectopic pregnancy. The management of ectopic pregnancy would benefit from the development of surgical triage decision aids, a surgical care pathway, and increased use of screening bedside ultrasound.
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Affiliation(s)
- Amanda Poxon
- Temerty School of Medicine, University of Toronto, Toronto, ON.
| | - Lauren Clarfield
- Department of Obstetrics and Gynaecology at the University of Toronto, Toronto, ON
| | - Rebecca Cherniak
- Department of Obstetrics and Gynaecology at the University of Toronto, Toronto, ON
| | - Andrea Page
- Department of Obstetrics and Gynaecology at the University of Toronto, Toronto, ON; DAN Women and Babies Program at Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
| | - Leslie Po
- Department of Obstetrics and Gynaecology at the University of Toronto, Toronto, ON; Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
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37
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Xu H, Lin G, Xue L, Wu W, Ding J, Liu C. Ectopic pregnancy in China during 2011-2020: a single-centre retrospective study of 9499 cases. BMC Pregnancy Childbirth 2022; 22:928. [PMID: 36496359 PMCID: PMC9737753 DOI: 10.1186/s12884-022-05269-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 12/01/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Previous studies have shown that the incidence of ectopic pregnancy (EP) is increasing in China. It is unclear, however, whether the incidence of EP has changed after the implementation of the universal two-child policy in the context of China's aging population and declining fertility rate. METHODS Data concerning EP from January 2011 to December 2020 were collected from the hospital's electronic medical records, which included the annual number of delivery, caesarean section rate, ectopic pregnancies, treatment of tubal pregnancy, and average costs and length of hospitalization. Trends of the EP incidence were analysed and annual percentage change (APC) was calculated using connected point regression analyses. RESULTS A total of 9499 cases of EP were collected, among which caesarean scar pregnancy (CSP) accounts for the second highest (6.73%). The EP per 100 deliveries revealed a downward trend, from 7.60% in 2011 to 4.28% in 2020 with an APC of -1.87 (P < 0.05). The maternal age was increased, especially after the implementation of the universal two-child policy. The constituent ratio for the advanced maternal age (≥ 35) and the caesarean section rate, but not the CSP, were also increased. Laparoscopic salpingectomy was the main surgical method, whereas the adoption of laparotomy and laparoscopic salpingostomy was decreasing year by year. CONCLUSIONS Although no obvious effect of the two-child policy on EP has been observed under the conditions of this study, the change in EP especially in advanced-age women after the policy implementation needs further evaluation. A decreased caesarean section rate, in primipara is beneficial to reducing the CSP.
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Affiliation(s)
- Haihua Xu
- grid.256112.30000 0004 1797 9307The Department of Obstetrics, Fujian Provincial Maternity and Children’s Hospital, Affiliated Hospital of Fujian Medical University, No. 18 Daoshan Road, 350001 Fuzhou, China
| | - Guan Lin
- grid.256112.30000 0004 1797 9307The Department of Gynaecology, International Science & Technology Cooperation Base for Environmental Factors on Early Development, Fujian Provincial Maternity and Children’s Hospital, Affiliated Hospital of Fujian Medical University, No. 18 Daoshan Road, 350001 Fuzhou, China
| | - Lifang Xue
- grid.256112.30000 0004 1797 9307The Department of Gynaecology, International Science & Technology Cooperation Base for Environmental Factors on Early Development, Fujian Provincial Maternity and Children’s Hospital, Affiliated Hospital of Fujian Medical University, No. 18 Daoshan Road, 350001 Fuzhou, China
| | - Weifang Wu
- grid.256112.30000 0004 1797 9307The Department of Gynaecology, International Science & Technology Cooperation Base for Environmental Factors on Early Development, Fujian Provincial Maternity and Children’s Hospital, Affiliated Hospital of Fujian Medical University, No. 18 Daoshan Road, 350001 Fuzhou, China
| | - Jinlian Ding
- grid.256112.30000 0004 1797 9307The Department of Obstetrics, Fujian Provincial Maternity and Children’s Hospital, Affiliated Hospital of Fujian Medical University, No. 18 Daoshan Road, 350001 Fuzhou, China
| | - Chaobin Liu
- grid.256112.30000 0004 1797 9307The Department of Gynaecology, International Science & Technology Cooperation Base for Environmental Factors on Early Development, Fujian Provincial Maternity and Children’s Hospital, Affiliated Hospital of Fujian Medical University, No. 18 Daoshan Road, 350001 Fuzhou, China
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Yun JH, Horrow MM, Goykhman I, Rodgers SK. The Confounding Ultrasound Diagnosis of Ectopic Pregnancy: Lessons From Peer Learning. Ultrasound Q 2022; 38:272-283. [PMID: 35439236 DOI: 10.1097/ruq.0000000000000608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT As the treatment of ectopic pregnancy (EP) has shifted increasingly to medical therapies, the ultrasound (US) diagnosis of EP must necessarily favor specificity over sensitivity. Our review of peer learning cases of EP and early intrauterine pregnancies found several types of pitfalls and problems, which will be described in this essay. These issues include the following: differentiation of tubal EP from a corpus luteum by echogenicity relative to ovarian parenchyma, push technique, and claw sign; how to distinguish interstitial EP from eccentrically located intrauterine pregnancies (angular); use of trophoblastic flow in abnormal intrauterine locations to help identify cesarean scar or cervical implantations; recognition that hemoperitoneum without visualized EP may be due to EP or hemorrhagic cyst; and that distinguishing an abortion in progress from a pregnancy of unknown location may not always be possible and requires clinical follow-up. This essay will also illustrate the consensus terminology that our radiology department has developed in conjunction with our obstetrics and gynecology colleagues to communicate clear diagnoses and reduce the risk of misdiagnosis and adverse outcomes.
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Yıldız Ş, Karakaş S, Kaya C, Kural A, Gedikbaşı A, Ekin D, Serhanoğlu Z, Çaypınar SS, Ekin M. Evaluation of HSP70 levels in ectopic pregnancy, abortus imminens and intrauterine pregnancy. Biomark Med 2022; 16:1251-1258. [PMID: 36820610 DOI: 10.2217/bmm-2022-0550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
Aim: To assess the serum levels of HSP70 concentrations in ectopic pregnancy (EP) patients compared with abortus imminens (AI) patients and healthy controls. Materials & methods: Age-matched patients were divided into three groups, with 30 patients in each group: EP, AI and healthy intrauterine pregnancy groups. Blood samples were taken from the antecubital vein and kept for HSP70 analysis. Results: The HSP70 levels were higher in the EP group than in AI patients and healthy controls (p < 0.05). The area under the curve for the serum HSP70 assay reached a value of 0.81 for a cutoff point of 11.12 pg/ml, which identified women with EP. Conclusion: Serum HSP70 levels increased in women with EP compared with healthy controls and women with AI.
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Affiliation(s)
- Şükrü Yıldız
- University of Health Sciences Istanbul, Bakirkoy Dr. Sadi Konuk Training & Research Hospital, Department of Obstetrics & Gynecology, Istanbul, 34180, Turkey
| | - Sema Karakaş
- University of Health Sciences Istanbul, Bakirkoy Dr. Sadi Konuk Training & Research Hospital, Department of Obstetrics & Gynecology, Istanbul, 34180, Turkey
| | - Cihan Kaya
- Acıbadem Mehmet Ali Aydınlar University, Department of Obstetrics & Gynecology, Acıbadem Bakirkoy Hospital, Istanbul, 34200, Turkey
| | - Alev Kural
- University of Health Sciences Istanbul, Bakirkoy Dr. Sadi Konuk Training & Research Hospital, Department of Biochemistry, Istanbul, 34180, Turkey
| | - Asuman Gedikbaşı
- Institute of Child Health, Istanbul University Faculty of Medicine, Istanbul, 34200, Turkey
| | - Deniz Ekin
- University of Bristol, Faculty of Life Sciences, Bristol, BS8 1TH, United Kingdom
| | - Zınar Serhanoğlu
- University of Health Sciences Istanbul, Bakirkoy Dr. Sadi Konuk Training & Research Hospital, Department of Obstetrics & Gynecology, Istanbul, 34180, Turkey
| | - Sema S Çaypınar
- University of Health Sciences Istanbul, Başakşehir Çam ve Sakura Training & Research Hospital, Department of Perinatology, Istanbul, 34280, Turkey
| | - Murat Ekin
- University of Health Sciences Istanbul, Bakirkoy Dr. Sadi Konuk Training & Research Hospital, Department of Obstetrics & Gynecology, Istanbul, 34180, Turkey
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Iv Kyrazis C, Rajderkar D. A Pictorial Review of Pelvic Pain-Beyond the Genitourinary System. Ultrasound Q 2022; 38:304-315. [PMID: 36194672 DOI: 10.1097/ruq.0000000000000625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
ABSTRACT Pelvic pain may be caused by disorders of the reproductive, urinary, or gastrointestinal systems. In the pediatric population, pelvic pain is often first evaluated with ultrasonography, with other imaging modalities reserved for further workup or specific indications. Radiologists must be aware of the findings associated with common pelvic emergencies to allow prompt diagnosis and prevention of life-threatening complications. Although the range of pelvic pathology is extensive, this pictorial review presents ultrasound examples of common nontraumatic causes of pelvic pain encountered in the pediatric population, with a brief discussion about multimodality imaging features.
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Affiliation(s)
| | - Dhanashree Rajderkar
- Department of Radiology, Division of Pediatric Radiology, University of Florida, Gainesville, FL
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Althagafi NFA, Galal M, Abdul Rab S, Alkhudari A, Raheel HM. Primary omental pregnancy in a subseptate uterus: A novel case report and literature review. Ann Med Surg (Lond) 2022; 84:104924. [PMID: 36582853 PMCID: PMC9793226 DOI: 10.1016/j.amsu.2022.104924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 11/07/2022] [Accepted: 11/13/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction and importance Ectopic pregnancy is defined as a pregnancy in which the fertilized ovum implants itself in a location other than the uterine endometrium. Abdominal ectopic pregnancies involve the implantation and development of the embryo within the peritoneal cavity. Primary omental pregnancies are the rarest form of abdominal pregnancy and possibly the rarest extrauterine gestation. Case presentation We report the first case of a primary omental pregnancy in a subseptate uterus in literature. Our patient, a 33-year-old female, G8P4+3, presented with nausea, severe abdominal pain, and vaginal spotting at 6 weeks' gestational age. She had mild tenderness below the umbilicus, with positive cervical and right adnexal tenderness. 2D-ultrasound revealed a subseptate uterus, normal ovaries and fallopian tubes, absence of a gestational sac, and a 4x3x2.5 cm mass in the right adnexa. A mini-laparotomy was performed due to suspicion of ruptured tubal pregnancy, revealing a primary omental pregnancy which was managed via partial omentectomy. Clinical discussion Ectopic pregnancies have ambiguous presentations, however correct diagnosis and management is crucial to prevent complications. A high index of suspicion must be exercised to make an accurate diagnosis of primary omental pregnancy. A subseptate uterus is a subtype of the most common uterine anomaly and should be investigated via 3D-ultrasound and magnetic resonance imaging as it causes increased risk of primary omental implantation. Conclusion Correct identification of subseptate or septate uteri is vital. Greater research is needed to elucidate the association between septate or subseptate uteri and ectopic pregnancy, particularly primary omental pregnancy.
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Affiliation(s)
| | - Maad Galal
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Saleha Abdul Rab
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia,Corresponding author. College of Medicine, Alfaisal University, Takhassusi Road, Riyadh, 11533, Saudi Arabia.
| | - Anas Alkhudari
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
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Muacevic A, Adler JR, Kumari S. Predictors of Successful Medical Management With Methotrexate in Unruptured Tubal Ectopic Pregnancy. Cureus 2022; 14:e31923. [PMID: 36580082 PMCID: PMC9792717 DOI: 10.7759/cureus.31923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction Medical treatment with methotrexate (MTX) is a safe and effective alternative to surgery in carefully selected cases of ectopic pregnancies diagnosed early prior to rupture. Aim To determine the optimal pre-treatment levels of beta human chorionic gonadotropin (𝛽-hCG) and its changing trends most likely to have a successful outcome with medical management. Material and methods A prospective observational study was conducted in a tertiary teaching hospital from December 2018 to May 2021. "Single-dose" MTX regime was used for medical management of ectopic pregnancy in patients fulfilling the selection criteria. The 𝛽-hCG levels were recorded at baseline and on day 4 and day 7 of MTX injection. Thereafter, at weekly intervals till complete resolution or surgical intervention due to failure of medical management. In addition, receiver operating characteristic (ROC) curve analysis for a pre-treatment 𝛽-hCG cut-off value and changing trends in post-treatment 𝛽- hCG levels most likely to have a successful outcome with MTX treatment were determined. Results Fifty patients fulfilling the inclusion criteria were included in the study, with successful medical management in 33 (66%). The mean pre-treatment 𝛽-hCG levels in women with successful medical management were 3270.97 (+/- 901) compared to 5249.17 (+/-808.02) for those with treatment failure (p=0.00001). The mean 𝛽-hCG level in the failed treatment group was significantly higher on day 4 than the pre-treatment levels (6742.56 +/- 572 vs. 5249.17+/- 808.02; p<0.05). Inadequate reduction of 𝛽-hCG level on day 7 (<15% of day 4 levels) requiring repeat dosage of MTX was more likely to have an unsuccessful outcome (p=0.00001). The area under curve (AUC) value of 0.905 (95% CI: 0.814-0.996) depicted that pre-treatment 𝛽-hCG level of 4000 mIU/ml taken as the cut-off value was able to predict levels ≤4000 mIU/ml had a greater likelihood of successful outcome with MTX, having a sensitivity of 84.5%, specificity of 83.3%, positive predictive value (PPV) of 90.3%, and negative predictive value (NPV) of 75% (p< 0.05). Demographic variables or previous clinical history, considered risk factors for ectopic pregnancy, did not affect the outcome of medical management in this study. Conclusion Medical management of ectopic pregnancy is a viable first-line treatment option in carefully selected patients. In this study, the most important predictors for the successful outcome of medical management were the pre-treatment β-hCG levels and their fall on day 4 and day 7 after MTX therapy.
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Tonick S, Conageski C. Ectopic Pregnancy. Obstet Gynecol Clin North Am 2022; 49:537-549. [PMID: 36122984 DOI: 10.1016/j.ogc.2022.02.018] [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] [Indexed: 11/17/2022]
Abstract
Ectopic pregnancy occurs in 2% of all pregnancies and is a potentially life-threatening emergency. A high level of clinical suspicion is required for any pregnant patient who presents with vaginal bleeding and/or pelvic pain. Workup should begin with immediate triage based on vital signs, a pregnancy test, and transvaginal ultrasound. Ectopic pregnancy can be treated either medically with methotrexate or surgically with either salpingectomy or salpingostomy. Carefully counseled, asymptomatic patients may be candidates for expectant management.
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Affiliation(s)
- Shawna Tonick
- Department of OB-GYN, University of Colorado, 12631 East 17th Avenue, AO1, 4th Floor, Aurora, CO 80045, USA.
| | - Christine Conageski
- Department of OB-GYN, University of Colorado, 12631 East 17th Avenue, AO1, 4th Floor, Aurora, CO 80045, USA
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Shen YT, Yang YY, Zhang PG, He LM, Che RH, Li Z, Lu W. Tubal ectopic pregnancy: a retrospective cohort study on clinical characteristics, treatment options and reproductive outcomes within 5 years. Arch Gynecol Obstet 2022; 306:2055-2062. [PMID: 36036288 DOI: 10.1007/s00404-022-06690-2] [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: 02/22/2022] [Accepted: 06/19/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE To investigate the association between different treatments of tubal ectopic pregnancy (EP) -expectant management, methotrexate (MTX), selected or recommended laparoscopic surgery-and the subsequent reproductive outcomes. METHODS We conducted a retrospective cohort study including 228 EPs. The patients were divided into four treatment groups: 28 (12.3%) with expectant management successfully, 60 (26.3%) with MTX successfully, 140 patients with laparoscopic salpingectomy, of which 47 (20.6%) were assigned to selected surgery group because they opted for surgical treatment versus MTX, 93 (40.8%) were assigned to recommended surgery group as recommended by the attending physician. RESULTS The recommended surgery group had the lowest rate of intrauterine pregnancy (IUP) (77.42%) and live birth (LB) (72.04%), while the incidence of recurrent EP (REP) (20.43%) was the highest, but the statistical differences were not significant. We did not observe significant differences of the EP-IUP time interval, rates of LB and miscarriage (MIS) between the four groups. Compared to the MTX group, recommended surgery was negatively associated with IUP (adjusted OR, 95%CI: 0.34, 0.11-1.03) and LB (0.35, 0.14-0.92), while it had higher risk for REP (3.48, 1.03-11.74) in the subsequent pregnancy. Further, compared to selective surgery group, recommended surgery was negatively associated with IUP (0.15, 0.03-0.68) and LB (0.23, 0.07-0.74), while it had higher risk for REP (6.83, 1.43-32.67) in the subsequent pregnancy. Expectant treatment was negatively associated with assisted reproductive technology (ART) (0.08, 0.02-0.40) compared with MTX. Of the185 patients who had LBs, all adverse outcomes were not statistically different between the four groups. CONCLUSION Patients with recommended laparoscopic salpingectomy had worse reproductive outcomes than the other treatment groups. The disease status of EP may play an important role in the association rather than the surgery alone.
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Affiliation(s)
- Yu-Ting Shen
- Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, People's Republic of China
| | - Ying-Ying Yang
- Clinical Research Center, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, People's Republic of China
| | - Ping-Gui Zhang
- Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, People's Republic of China
| | - La-Man He
- Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, People's Republic of China
| | - Rong-Hua Che
- Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, People's Republic of China
| | - Zhen Li
- Clinical Research Center, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, People's Republic of China.
| | - Wen Lu
- Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, People's Republic of China.
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Elachi FA, Egwuda K, Egbodo CO, Olubiyi DO. Cervical Ectopic Pregnancy Presenting With Ruptured Posterior Cervical Lip: A Case Report. Cureus 2022; 14:e28508. [PMID: 36185909 PMCID: PMC9514881 DOI: 10.7759/cureus.28508] [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] [Accepted: 08/26/2022] [Indexed: 11/13/2022] Open
Abstract
Cervical ectopic pregnancy (CEP) is a rare but fatal early pregnancy complication. A rare case of cervical ectopic gestation with rupture of the posterior cervical lip is reported due to the rarity of this presentation and the need to consider it in patients presenting with miscarriages. We present a 19-year-old G2P0+1 at a gestational age of 11 weeks and six days who presented with a cervical ectopic gestation with rupture of the posterior cervical lip. Transvaginal ultrasound showed features of a cervical ectopic gestation. The products of conception were evacuated through the cervical defect posteriorly after infiltration of vasopressin and the defect on the posterior lip was repaired. A ruptured cervical lip is a possible presentation of CEP. It may present the clinician with a diagnostic challenge. A high index of suspicion and proficiency in transvaginal ultrasonography is required for prompt diagnosis.
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Russo J, Harken T. Abortion and Abnormal Implantation. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2022.0057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jennefer Russo
- Department of Obstetrics and Gynecology, University of California–Los Angeles, Los Angeles, California, USA
- Planned Parenthood of the Pacific Southwest, San Diego, California, USA
| | - Tabetha Harken
- Department of Obstetrics and Gynecology, University of California–Irvine, Irvine, California, USA
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The Very First Romanian Unruptured 13-Weeks Gestation Tubal Ectopic Pregnancy. Medicina (B Aires) 2022; 58:medicina58091160. [PMID: 36143837 PMCID: PMC9505551 DOI: 10.3390/medicina58091160] [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: 07/24/2022] [Revised: 08/17/2022] [Accepted: 08/23/2022] [Indexed: 11/17/2022] Open
Abstract
Tubal ectopic pregnancies remain a challenging and life-threatening obstetric condition in the early stages that unavoidably lead to abortion or rupture, further reflected by the associated maternal mortality. Therefore, in the present case report, we report the experience of a 36-year-old woman who presented to our Emergency Department with a history of moderate hypogastric pain, mild vaginal bleeding, and bilateral mastalgia, symptoms that started 20 days ago after uterine curettage for a declarative eight-week pregnancy. On admission, a physical examination showed regular standard signs. The ultrasound examination revealed in the left abdominal flank a gestational sac with a live fetus corresponding to the gestational age of 13 weeks. Given the position of the gestational sac, we suspected a possible abdominal pregnancy. Independently on her human chorionic gonadotropin (hCG) of 33.980 mIU/mL and hemoglobin (Hb) of 13.4 g/dL, the exact location of the pregnancy following ultrasound was hard to establish. Magnetic resonance imaging (MRI) examination was requested, after which we suspected the diagnosis of ovarian pregnancy. Given the paraclinical and clinical context of the worsening of painful symptoms, we decided to perform an exploratory laparoscopy in the multidisciplinary team (digestive and vascular surgeon) that showed the existence of a tubal pregnancy.
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Tang P, Li X, Li W, Li Y, Zhang Y, Yang Y. The trend of the distribution of ectopic pregnancy sites and the clinical characteristics of caesarean scar pregnancy. Reprod Health 2022; 19:182. [PMID: 35987835 PMCID: PMC9392275 DOI: 10.1186/s12978-022-01472-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 07/10/2022] [Indexed: 12/02/2022] Open
Abstract
Background Ectopic pregnancy is a life-threatening occurrence and is an important cause of pregnancy-related mortality. We launched the study to investigate the distribution and its variation trend of the ectopic pregnancy sites and the clinical characteristics of caesarean scar pregnancy, to provide information for further clinical practice.
Methods A total of 3915 patients were included in our study to calculate the distribution of the implantation sites of ectopic pregnancies. Then, we performed a χ2 test for trend and calculated the quantity of each type of ectopic pregnancy during 2012–2015 and 2016–2019 to analyse the variation trend. Results (1) The proportion of each site of ectopic pregnancy was as follows: tubal pregnancy (84.70%), ovarian pregnancy (1.56%), caesarean scar pregnancy (8.63%), abdominal pregnancy (0.61%), cornual pregnancy (2.68%), cervical pregnancy (0.49%), heterotopic pregnancy (0.43%). (2) Through the χ2 test for trend, the ratio of caesarean scar pregnancy to ectopic pregnancy showed an upward trend (P = 0.005). From 2012 to 2015 and 2016–2019, the ratio of caesarean scar pregnancy to ectopic pregnancy increased from 5.74 to 11.81% (P < 0.001). (3) A total of 72.78% (246/338) caesarean scar pregnancy patients had one caesarean delivery, 25.15% (85/338) had two caesarean deliveries, and 2.07% (7/338) had three caesarean deliveries. A total of 80.18% (271/338) had aborted before. The most common clinical manifestations were amenorrhea (98.52%), abdominal pain (25.74%) and vaginal bleeding (67.76%), the most common sign was uterine enlargement (46.75%). Conclusion As the ratio of caesarean scar pregnancy increases, the caesarean delivery rate should be decreased to decrease the morbidity of caesarean scar pregnancy. Ectopic pregnancy occurs when a fertilized ovum implants outside the endometrium of the uterine cavity, which is a life-threatening occurrence and is an important cause of pregnancy-related mortality. With the increase in pelvic and intrauterine operations, the distribution of ectopic sites has been changing, but the variation has been insufficiently studied. To investigate the distribution of ectopic sites and its variation trend in depth, we collected the data of 3915 ectopic pregnancy cases from the third affiliated hospital of Sun Yat-Sen University. Through χ2 test for trend, the ratio of caesarean scar pregnancy to ectopic pregnancy showed an upward trend (P = 0.005). From 2012 to 2015 and 2016–2019, the ratio of caesarean scar pregnancy to ectopic pregnancy increased from 5.74 to 11.81% (P < 0.001). As the increasing of the ratio of caesarean scar pregnancy to ectopic pregnancy, the clinical characteristics of caesarean scar pregnancy was analysed. A total of 72.78% (246/338) caesarean scar pregnancy patients had one caesarean delivery, 25.15% (85/338) had two caesarean deliveries, and 2.07% (7/338) had three caesarean deliveries. A total of 80.18% (271/338) had aborted before. The most common clinical manifestations were amenorrhea (98.52%), abdominal pain (25.74%) and vaginal bleeding (67.76%), the most common sign was uterine enlargement (46.75%). As the ratio of caesarean scar pregnancy increases, the caesarean delivery rate should be decreased to decrease the morbidity of caesarean scar pregnancy.
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Interstitial pregnancy is one of the most serious and uncommon ectopic pregnancies: Case report. Int J Surg Case Rep 2022; 95:107195. [PMID: 35609475 PMCID: PMC9126789 DOI: 10.1016/j.ijscr.2022.107195] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/08/2022] [Accepted: 05/10/2022] [Indexed: 11/25/2022] Open
Abstract
Background Ectopic pregnancies are a dreaded and common cause of first-trimester metrorrhagia. They refer to the implantation and development of the embryo outside the uterine cavity. Interstitial localization is uncommon and corresponds to implantation of the embryo in the intramural part of the uterine tube. It has an unforeseen evolution with a risk of cataclysmic hemorrhage by uterine rupture in the absence of early diagnosis and management. Case presentation We herein present the uncommon case of a 26-year-old female patient, second gestation, nulliparous, who underwent a pelvic ultrasonography in the emergency department for pelvic pain associated with a two-month amenorrhea. A past history of left salpingectomy for a ruptured tubal ectopic pregnancy 3 years ago was found. Pelvic ultrasound allowed us to detect a ruptured ectopic interstitial pregnancy at 7 weeks of amenorrhea. Significant hemoperitoneum and hemodynamic instability required emergency laparotomy. The condition was confirmed preoperatively and the patient underwent a corneal resection. The postoperative course was uneventful and the patient was discharged on day 4 postoperatively. Conclusions The interstitial ectopic pregnancy is an uncommon and life-threatening condition. The importance of early ultrasound detection is of paramount importance to allow conservative treatment with methotrexate injections. Delayed diagnosis requires cornual uterine resection with all the complications that it implies. Interstitial ectopic pregnancy is an uncommon and life-threatening condition. Conservative management with methotrexate injections can only be proposed after an early diagnosis. The importance of early ultrasound screening is emphasized, especially in cases of previous ectopic pregnancies.
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Time to resolution of tubal ectopic pregnancy following methotrexate treatment: A retrospective cohort study. PLoS One 2022; 17:e0268741. [PMID: 35609041 PMCID: PMC9129037 DOI: 10.1371/journal.pone.0268741] [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: 04/11/2021] [Accepted: 05/06/2022] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To determine the time to resolution of tubal ectopic pregnancy after methotrexate treatment. METHODS A 14-year retrospective cohort study was performed from 2004-2018 and assessed 216 women treated with single-dose methotrexate for tubal ectopic pregnancy. Women were treated using a single-dose protocol of intramuscular methotrexate (50mg/m2) for confirmed tubal ectopic pregnancy on ultrasound. Ectopic pregnancies were included if the ectopic pregnancy mass was <35mm, no evidence of rupture and no embryonic cardiac activity. Serum hCG was measured on day 1, 4 and 7 of treatment and then at standard weekly intervals until resolution. Where there was not a ≥15% decline in hCG from day 4 and day 7, a second dose of methotrexate was administered. The primary outcome was time to resolution (days), with serum hCG <5 IU/L considered resolved. The secondary outcome was need for rescue surgery. RESULTS Among women who did not proceed to surgery, the median time to resolution was 22 days (IQR 14,34). Time to resolution and need for rescue surgery increased with baseline hCG. When hCG was <1000 IU/L, the median was 20 days (IQR 13,29) but 34.5 days (IQR 22,48) with hCG >2000 IU/L. Early hCG trends were predictive of time to resolution and likelihood of rescue surgery; a hCG rise of >1000 IU/L between Days 1-4 increased time to resolution to 61 days (IQR 35,80) and an odds ratio of rescue surgery of 28.6 (95% C.I. 5.3,155.4). CONCLUSION The median time to resolution for ectopic pregnancies treated with methotrexate is 22 days and associated with baseline hCG levels. The predictive value of baseline hCG may be useful in clinical decision making and counselling women considering methotrexate for ectopic pregnancy.
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