TUBAL ECTOPIC PREGNANCY

Heterotopic Pregnancy After In Vitro Fertilization and Embryo Transfer After Bilateral Total Salpingectomy/Tubal Ligation: Case Report and Literature Review

Heterotopic pregnancy is defined as the simultaneous occurrence of intrauterine and ectopic pregnancy, either of which may be single or multiple. It occurs in up to 1% of pregnancies after in vitro fertilization and embryo transfer. This article reports 2 rare cases of heterotopic pregnancy after in vitro fertilization and presents a literature review. In the first case, a 28-year-old woman had previous laparoscopic bilateral total salpingectomy for a right tubal pregnancy and a left hydrosalpinx. However, she had ovarian heterotopic pregnancy after a third in vitro fertilization cycle. Emergency laparotomy was performed. The synchronous intrauterine pregnancy continued with no further complications and ended in the delivery of a singleton term pregnancy. The second case combined interstitial and intrauterine pregnancies after bilateral tubal ligation for hydrosalpinges followed by in vitro fertilization and frozen embryo transfer. The possibility of heterotopic pregnancy after bilateral total salpingectomy/tubal ligation, although extremely rare, should also be considered by gynecologists when they treat an in vitro fertilization patient even though an intrauterine pregnancy has been confirmed.

A ten year survey of 193 ectopic pregnancies

During the period 1977-86, 193 women underwent surgery for ectopic pregnancy in the Medway Health District. 1 ectopic pregnancy was found for every 233 deliveries, an incidence of 0.43%, with a rising trend. The most common presenting symptom was abdominal pain (96%) and the most frequent physical finding was abdominal tenderness (91%). Past histories of appendicectomy (24%), infertility (19%), use of IUD (15%), and pelvic infection (13%) were elicited. In 95% of the cases, the pregnancy was tubal. 56% of the patients required blood transfusions and there were no maternal deaths. These findings confirm the rising incidence of ectopic pregnancy. During the study period, the diagnosis and management of ectopic pregnancy have changed significantly. The early use of plasma hCG, ultrasonography, and laparoscopy decreases the morbidity and mortality associated with ectopic pregnancy, allowing conservative tubal surgery when indicated.

Tubal curettage: a new conservative treatment for haemorrhagic interstitial pregnancies

Haemorrhagic interstitial pregnancies are commonly treated by cornual resection. This invasive procedure may increase the risk of uterine rupture in subsequent pregnancies. We report here a case of a haemorrhagic interstitial pregnancy, associated with a viable intrauterine pregnancy in a salpingectomized woman, which was treated successfully by curettage of the uterine cornu.

Diagnosing unruptured ectopic pregnancy

OBJECTIVE

A retrospective analysis of the management of ectopic pregnancy at Korle Bu Teaching Hospital in Accra, Ghana, to assess the impact of the introduction of ultrasonography as a diagnostic tool.

METHODS

All charts of patients with ectopic pregnancies from 1 January 1986 to 31 December 1990 were analyzed. The management of those patients who had transabdominal ultrasonography was compared with those who had not.

RESULTS

The use of ultrasonography increased the number of unruptured ectopic pregnancies from 0.3% to 8.5% (P < 0.001). This also reflected a reduction in misdiagnoses, blood transfusions, and maternal deaths.

CONCLUSIONS

The reasonable use of modern technology can be of great assistance even in developing countries, as shown by the positive impact of the use of ultrasonography to aid in the diagnosis of ectopic pregnancy in Ghana, West Africa.

Ectopic pregnancy in Zimbabwe

One hundred four consecutive ectopic pregnancies were systematically analysed. During the study period, the incidence rate was 110 per 100,000 14-44 year old females per year. A history of prior pelvic infection was given by 53.8% of the cases and was suggested by surgical findings or by histological analysis among 74.9%. Serological evidence of previous chlamydial infection was much more common when ectopic pregnancy occurred in abnormal tubes than in normal tubes or compared to intrauterine pregnancies. The influence of schistosomiasis, endometriosis and ovarian cyst was limited to a very few cases. The analysis of contraceptive habits shows a much higher number of extrauterine pregnancies when the woman is using progestin-only pill than when she is on combined oral tablets.

The regional versus national incidence of ectopic pregnancy in Finland from 1966 to 1986

The annual incidence of ectopic pregnancy (EP) per deliveries, per all diagnosed pregnancies and per female population at fertile age (15-44 years) were measured from 1966 to 1986 in a well-defined urban area of Southwestern Finland, the Turku Region. The incidence rates increased markedly, and were, in the mid-80s, among the highest in the world: 2.6 per 100 deliveries, 1.8 per 100 diagnosed pregnancies and 153 per 100,000 fertile-aged women. The regional incidence rate exceeded the national one in the 1970s, whereas in the 1980s the regional rate which has levelled-off during recent years has been equal to, and currently even lower than the national one. This suggests that changes in the incidence of EP in urban area(s) preceed those in the whole country.

Ectopic tubal pregnancy in Zimbabwe

A study of 441 ectopic tubal pregnancies treated at Harare Central Hospital between 1981-84 was carried out. During that time, there were 162,964 deliveries in the unit. The incidence of tubal pregnancy in this study was only 0.27%. Patients ranged in age from 13-46 years with the majority (67%) between ages 20-29. 88% of the patients were parous, the mean parity being 2.6 96% of the patients complained of abdominal pain, 78% of amenorrhea, and 64% of abnormal uterine bleeding. Abdominal tenderness (96%) and cervical excitation (91%) were the most significant signs. Paracentesis was positive in 78% of the cases. It was a little value in the diagnosis of chronic or unruptured tubal pregnancy. There was 1 maternal death.

Culdocentesis in tubal pregnancy

Culdocentesis was carried out in 92 suspected cases of ectopic pregnancy and was positive in 90%. Laparotomy confirmed the accuracy of culdocentesis in 97.5% of the cases of acute tubal rupture, 87.5% of tubal abortions and 80% of 'intact' tubal pregnancies.

A 1-hour hCG radioimmunoassay detection kit for the management of suspected ectopic pregnancy

The value of a rapid hCG kit was assessed in 60 patients undergoing laparoscopy or laparotomy for suspected ectopic pregnancy, of whom 30 were subsequently proven to be pregnant. A high degree of specificity (93%) and sensitivity (97%) was found, with one false-negative and three false-positive results. If the kit had been used as a routine on admission three patients would not have been inadvertently discharged before the diagnosis of tubal pregnancy and 27 could have avoided a laparoscopy to exclude tubal pregnancy.

Update on ectopic pregnancy

Ectopic pregnancy is the leading cause of maternal death in the first trimester. Its incidence is increasing, probably owing to the increasing incidence of pelvic inflammatory disease. Although up to 15% of patients have been reported to present in shock, a large number seek care earlier because of pelvic pain and irregular menses. With strong clinical suspicion and the use of culdocentesis, assays of the beta subunit of human chorionic gonadotropin in the blood and ultrasonography, the diagnosis can be made before rupture occurs. Although the woman's subsequent fertility has traditionally been poor, some improvement has been achieved with the use of conservative surgical techniques. Early diagnosis facilitates this approach.

New concepts in the surgical management of tubal pregnancy and the consequent postoperative results

The success following reconstructive tubal pregnancy can only be measured in terms of live births. Because the fallopian tube is not a simple conduit and has numerous complex functions, many women fail to conceive despite successful reconstructive surgery. The most effective way to prevent reocclusion or peritubal adhesion is to minimize tissue trauma. Magnification permits accurate excision and hemostasis. In this review, it has been demonstrated that tubal conservation is technically possible and safe. It is effective in increasing the number of live births postoperatively in women interested in fertility and does not increase the risk of the repaired tube for a repeat tubal gestation more than the uninvolved tube, although one of five subsequent pregnancies are again ectopic. They seem to occur equally as often in the contralateral tube as in the repaired tube. It has been shown that salpingotomy can restore tubal patency and maintain fertility. The second question was whether the number of viable pregnancies increase after conservative surgery. This question can be answered only if the repaired tube remains and the patient subsequently delivers at term. Such data have already demonstrated this outcome. Conservative operations in selected cases of tubal pregnancy seem feasible and safe and do not further impair tubal function. Because intrauterine pregnancy is more apt to occur than is repeat ectopic pregnancy, it seems logical that the involved tube should be saved whenever fertility is desired (Fig. 2). In unruptured isthmic pregnancy, Stangel and Gomel prefer segmental excision and end-to-end anastomosis during the same intervention. Gomel advocates segmental excision of the conceptus whether ruptured or not when the pregnancy is located in the isthmus or proximal half of the ampulla, and end-to-end anastomosis undertaken later as an elective procedure if necessary (Fig. 2). An ampullary gestation may be successfully treated by salpingotomy; and in the case of distal ampullary location, a tubal abortion may be performed (Fig. 2). When extensive destruction of the tube occurs, salpingectomy becomes necessary. In cases of early diagnosis of tubal gestation, conservative surgical management may be carried out via laparoscopy (Fig. 1).

Ectopic pregnancy: a seven-year survey

Seventy-five patients with ectopic pregnancy were treated at Jordan University Hospital (JUH) during a 7-yr period from January 1976 to December 1982. The ratio of ectopic pregnancies to deliveries was 1 to 162. The most common symptoms were: abdominal pain, 96%; amenorrhea, 69.3%; vaginal bleeding, 60%. No patients with pelvic inflammatory disease were found. An intrauterine contraceptive device was present in 14.6% of the patients and 10.6% of the cases had previous pelvic surgery. Culdocentesis gave false negative results in 16.7% of the patients. The treatment of choice was salpingectomy. There were no maternal deaths in this series.

Ectopic pregnancy--a brief review

Despite the advent of improved methods of diagnosis and therapy, ectopic pregnancy remains a significant cause of morbidity and mortality worldwide. The diagnosis is often difficult to make clinically, but should be included in the differential of any woman of gestational age presenting with lower abdominal pain, even with a normal menstrual history. With a high index of suspicion, improving methods of diagnosis such as the immunoassays for B-hCG and ultrasonography may lower mortality rates by enabling more diagnoses to be made before rupture. The significant infertility rate following ectopic pregnancy remains a problem despite newer, more conservative approaches to surgical therapy.

Diagnosis of ruptured ectopic pregnancy with peritoneal lavage

A case of ruptured ectopic pregnancy with a nondiagnostic culdocentesis is presented. Diagnosis was made by using open diagnostic peritoneal lavage. The patient underwent laparotomy, left salpingectomy, and cornual resection, and had no postoperative complications. In selected patients with suspected ectopic pregnancy, peritoneal lavage may serve as a helpful diagnostic procedure.

Incidence of ectopic pregnancy in Benin City, Nigeria

A study of 100 consecutive cases of ectopic pregnancy managed over a 21-month period in the University Department of Obstetrics and Gynaecology is reported. The results show that this is a common gynaecological emergency in the community. Although pelvic inflammatory disease appears to be an important aetiological factor, a significant proportion showed no evidence of previous pelvic sepsis. The usual surgical treatment of cases in our unit is, where possible, total salpingectomy rather than salpingo-oophorectomy.

The early diagnosis of ectopic pregnancy

In a survey of 235 consecutive cases of ectopic pregnancy it was found that over 50 per cent were incorrectly diagnosed by the general practitioner and 36 per cent by a hospital doctor. Ten per cent of patients were sent home before the diagnosis was made. Over 30 per cent of patients were sent to general surgical wards and these patients had different characteristics from those sent to gynaecological wards. High risk patients can be identified from their past history. The increasing use of the laparoscope has been associated with earlier detection of ectopic pregnancy before the stage of rupture.

Effect of the venereal diseases epidemic on the incidence of ectopic pregnancy -- implications for the evaluation of contraceptives

This paper identifies a basis for quantifying the risk of ectopic pregnancy in pregnancy seekers and in users of the major means of contraception, with and without prior tubal infection. The doubling, in U.S. in recent years, of both numbers of ectopic pregnancies and the prevalence of nonsurgical sterility is correlated with the epidemic of gonorrhea and other sexually transmitted, salpingitis-producing diseases. The risk of ectopic pregnancy in women who have once had salpingitis is shown, on the basis of Weström's landmark prospective study and many retrospective studies, to be approximately 10-fold that of normal women. Fertilization-preventing contraceptives reduce uterine and ectopic pregnancies in the same proportion and in both categories of users--that is, in normal-risk and high-risk (post-salpingitis) women. Intrauterine contraceptives, however, markedly reduce uterine pregnancies, but have little effect on the incidence of ectopic pregnancy. Among IUD users, therefore, the incidence of ectopic pregnancy will be disproportionately great in relation to the fraction of high-risk women in the population of users. This disproportionate influence of prior salpingitis may confuse the comparative evaluation of contraceptive safety because the proportions of normal-risk and high-risk women probably vary widely, since public health data show extremely wide geographic differences in the incidence of gonorrhea -- the best known but not the only sexually transmitted, salpingitis-producing disease.

Tubal pregnancy in a 'low-risk' population: occasional association with follicular salpingitis

Long-standing tubal inflammatory lesions occurred in 35 (14%) of 250 tubal pregnancy patients, aged from 14 to 45 yrs, encountered from 1948 to 1969 in an eastern Canadian population where clinically manifest pelvic inflammation is not prevalent and 1/180 is the approximate ratio of ectopic pregnancy to live births. Present in 24 of these 35 patients was follicular salpingitis. For most of the eccyeses, functional derangements appear likely to have been responsible more often than structural alterations of the oviducts; but possible roles for 'physiological salpingitis' in leading to tubal pregnancy may be worthy of investigation.

The use of a radioreceptorassay of human chorionic gonadotropin for the diagnosis and management of ectopic pregnancy

The radioreceptorassay of human chorionic gonadotropin (hCG), with a sensitivity of 50 pg or 3 mIU/ml of plasma, has provided almost 100% reliability in detecting pregnancy after the first missed cycle. This test may be performed within 1 hour and is ideally suited to the clinical detection of ectopic pregnancy, especially in patients who require immediate surgical intervention. Thirteen patients with suspected ectopic pregnancy were evaluated by the radioreceptorassay, one of whom was followed with four separate determinations. The results of the assay were subsequently compared with those of hemagglutination pregnancy tests, clinical symptoms, and pathologic findings. All of the patients were diagnosed accurately by the radioreceptorassay, even when hemagglutination tests yielded a false indication of pregnancy. By this assay, the hCG levels during ectopic pregnancies are generally lower than those found during a normal intrauterine pregnancy; in addition, pregnancy may be detected much earlier (prior to the rupture) than is possible by hemagglutination tests. Furthermore, the diagnosis of ectopic pregnancy may be excluded for patients admitted to the hospital with acute abdominal emergencies.

Ovarian pregnancy associated with an intrauterine device

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Ectopic pregnancy in Nairobi, Kenya

One hundred and nineteen cases of ectopic pregnancy treated in the Department of Gynaecology, Kenyatta National Hospital, Nairobi, are described. Ectopic pregnancy accounted for almost one third of the abdominal operations performed in the department. Pelvic inflammatory disease seemed to be the cause of this high incidence. Culdocentesis proved useful for diagnosis, but should be employed with caution in a population in whom pelvic sepsis is common.

The value and safety of auto-transfusion is emphasised.

Delayed haemorrhage from the ruptured spleen

Delayed haemorrhage from a ruptured spleen is a not uncommon syndrome, and it may well be encountered more frequently in the future. The condition has a higher mortality than simple uncomplicated rupture of the spleen, and this is believed to be due to difficulty and subsequent delay in making a diagnosis. Three cases are reported which illustrate many of the important features of delayed haemorrhage. The diagnosis of delayed haemorrhage is discussed, with particular reference to the importance of shoulder pain (Kehr's sign).