Chronic interstitial ectopic pregnancy presenting with a negative urine pregnancy test

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.

Unusual presentation of late-stage ectopic tubal pregnancy (19 weeks' gestation): Case report and literature review

Ectopic pregnancy is a medical condition in which a fertilized egg takes an unexpected detour away from the uterine cavity and the fallopian tube becomes a popular host, with the ampulla being the prime location. However, it can occur in other areas such as cervix, ovaries, or abdomen. The most common risk factors are pelvic inflammatory disease, previous pelvic or abdominal surgery, abnormal anatomy of genital organs, endometriosis, previous ectopic pregnancies, assisted reproductive technologies, endocrine disorders, and even the subtle influence of low-dose progestins from contraceptives. We will present a rare case of unrecognized late-stage tubal ectopic pregnancy. The following case report is of a 25-year-old Caucasian female patient (G2, P0) who presented to the emergency department with a 24-hour abdominal pain syndrome. The patient did not have a gynecological examination for this reason. During the examination, taking into account the clinical and ultrasound findings, a suspicion of pregnancy in a bicornuate uterus was raised, and an MRI of the pelvis was performed. MRI showed ectopic pregnancy in the left fallopian tube with a properly developed fetus that corresponded to a gestation of 19 weeks. An emergency laparotomy was performed and the left fallopian tube with the fetus was removed. The early and late course of recovery went smoothly. The patient was discharged after adequate clinical development.

Successful management of an advanced interstitial ectopic pregnancy in a resource-limited setting: a case report

BACKGROUND

Interstitial ectopic pregnancy is an ectopic gestation developing in the uterine part of the fallopian tube. The condition is rare and presents challenges for clinical as well as radiological diagnosis. This case report presents a rare case of interstitial ectopic pregnancy diagnosed intraoperatively.

CASE PRESENTATION

A 36-year-old Black woman, referred from a peripheral health facility, presented at the emergency department with severe abdominal pains, vaginal spotting, nausea, and vomiting, with a 2-month history of irregular menstrual flow. Clinical and laboratory findings were suggestive of an acute abdomen likely due to a ruptured ectopic pregnancy (ultrasound was not available). An emergency exploratory laparotomy was done, which revealed a right adnexal ruptured interstitial pregnancy of a lifeless female fetus weighing 500 g (estimated mean gestational age of 22-23 weeks). The left fallopian tube looked normal. The site of rupture was repaired, followed by cleaning and closure of the abdomen. The post-operative period was uneventful, and the patient was discharged on postoperative day 7.

CONCLUSION

Interstitial pregnancies are uncommon and rarely attain advanced gestational ages, as in this case, compared with other tubal ectopic pregnancies. However, women presenting with signs of hypovolemic shock and acute abdomen, with a positive pregnancy test, warrant a high index of suspicion.

Expectant management of tubal pregnancies with human chorionic gonadotropin up to 2000 mIU/mL

OBJECTIVE

To describe outcomes of expectant management (EM) versus methotrexate (MTX) treatment in tubal pregnancies with pretreatment human chorionic gonadotropin (hCG) less than 2000 mIU/mL.

METHODS

This retrospective cohort from two tertiary hospitals included women with confirmed tubal pregnancies and pretreatment hCG <2000 mIU/mL. Exclusion criteria were unrecorded pregnancy site, unconfirmed diagnosis, and surgical treatment upon diagnosis. The primary outcome was eventual rate of surgical treatment.

RESULTS

Between December 2009 and June 2021, 545 of 2114 (25.8%) women diagnosed with a tubal pregnancy met our inclusion criteria. We compared women who underwent EM (N = 201) with women who received MTX (N = 344). All women in the EM group had a declining trend of hCG. The MTX group had higher pretreatment hCG and higher rates of yolk sac or embryo presence on ultrasound. Eventual surgical treatment rate was higher in the MTX group compared with the EM group (39 [11.3%] vs. 9 [4.5%], P = 0.006), with no difference in the treatment failure rate or tubal rupture rate. In a subgroup analysis of women with pretreatment hCG between 1000 and 2000 mIU/mL, eventual surgical treatment, treatment failure, and tubal rupture rates did not differ between groups. Logistic regression analysis revealed that eventual surgical treatment was independently associated with hCG levels less than 1000 mIU/mL (adjusted odds ratio [aOR] 0.28, 95% confidence interval [CI] 0.14-0.56) and endometriosis (aOR 9.20, 95% CI 3.55-23.81).

CONCLUSION

Expectant management of tubal pregnancies with pretreatment hCG levels less than 2000 mIU/mL and even between 1000 and 2000 mIU/mL and with a declining trend of hCG demonstrated lower or comparable rates of eventual surgical treatment, when compared with MTX treatment.

Methotrexate treatment for peritoneal trophoblastic implants after laparoscopic salpingectomy and secondary laparoscopic excision of ectopic pregnancy

Ectopic pregnancy is a one of the primary causes of maternal mortality in first trimester. The most common site of ectopic pregnancy is the fallopian tube. Surgical management of tubal ectopic pregnancy includes salpingotomy or salpingectomy. Persistent ectopic pregnancy can happen after salpingotomy due to incomplete removal of ectopic tissue. However, it is very rare after salpingectomy. In our case, the patient had right-sided salpingectomy and histology confirmed right-sided tubal ectopic pregnancy. She presented 19 days' later with abdominal pain, haemoperitoneum and persistent high beta-HCG (B-HCG). A second laparoscopy was done and tissue implants were removed from the surface of the right ovary and the omentum, which were confirmed to be products of conception on histology. The pain settled postoperative. However, B-HCG remained high postoperative. Subsequently, methotrexate treatment was given leading to full resolution of the pregnancy with one dose.

Forensic Analysis of Eighteen Tubal Pregnancy-Related Medical Damage

OBJECTIVES

To analyze the cases of medical damage after misdiagnosis of tubal pregnancy, to explore the causes of medical damage, the causal relationship between medical malpractice and the damage consequences, as well as the causative potency, in order to provide evaluation ideas for forensic identification of such cases.

METHODS

Eighteen cases of forensic identification of tubal pregnancy related medical damage were collected and retrospectively analyzed from the aspects of age, maternity history, fertility requirements, risk factors, diagnosis and treatment, medical malpractice, damage consequences, and causative potency.

RESULTS

All 18 cases were tubal pregnancy, of which 17 cases had medical malpractice, resulting in 14 cases of affected tubal resection, 2 cases of hemorrhagic shock death, 1 case of intrauterine fetal death and affected tubal resection. The other case had the consequence of affected tubal resection, but there was no malpractice in the treatment.

CONCLUSIONS

Correct diagnosis is helpful to make appropriate treatment plan, prevent disease progression and reduce serious adverse consequences and the occurrence of medical disputes. Scientific and reasonable analysis of the causal relationship between medical malpractice and damage consequences and the causative potency is of great significance to the successful settlement of medical disputes.

Treatment outcomes of tubal pregnancy with tubal preservation: A meta-analysis

BACKGROUND

Ectopic pregnancy is a common gynecological emergency that poses a significant risk of maternal mortality during the first trimester. It also increases the incidence of infertility and repeated ectopic pregnancy. The aim of this study was to evaluate whether there is a difference in the degree of tubal patency between salpingostomy and systemic treatment with methotrexate (MTX), as well as the odds of intrauterine pregnancy and repeat ectopic pregnancy, and the degree of tubal patency in salpingectomy with or without tubal suturing.

METHODS

We searched PubMed, EMBASE, and the Cochrane Library up to April 2023. Four randomized controlled trials were included in the review. We analyzed the combined data using Review Manager 5.3 software and Stata 12.0 software, utilizing a random effects model.

RESULTS

When comparing salpingostomy and systemic treatment with MTX, there was no significant difference in the degree of tubal patency (OR = 1.09, 95% CI (0.54-2.38), P = .83). For salpingostomy with or without tubal suturing, there were no significant differences in the rates of intrauterine pregnancy, repeat ectopic pregnancy, and tubal patency degree [(OR = 1.05, 95% CI (0.41-2.68), P = .92), (OR = 0.68, 95% CI (0.19-2.42), P = .92), (OR = 1.68, 95% CI (0.14-20.33), P = .68)].

CONCLUSION

This meta-analysis demonstrates that systemic treatment with MTX is an effective treatment for patients who wish to preserve their fallopian tubes without undergoing surgery. This form of treatment can help avoid surgical procedures that may damage the fallopian tubes and improve fertility prospects. If choosing surgery, we believe that opting for salpingostomy without tubal suturing could reduce the operation time and minimize damage.

[Management of tubal ectopic pregnancies with methotrexate : is it an effective treatment ?]

Ectopic pregnancy is a gynecological emergency. The hCG level, the clinical presentation and the ultrasound remain the key steps for the diagnosis. The criteria tend to be more and more codified to decide on the optimal treatment, however, there is no consensus. The aim of this study was to evaluate the impact of applying a mathematical formula to predict the failure rate of metho-trexate for tubal ectopic pregnancy. A retrospective, monocentric study was conducted on a cohort of 193 patients for whom the formula could be calculated. Regarding our professional practice, the success rate of first-line metho-trexate is 93 %. It would increase to 96 % if the formula had been applied. The use of the formula would also reduce the rate of first-line surgery by 12 %.

Large unruptured tubal pregnancy mimicking abdominal pregnancy

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.

Early abdominal wall ectopic pregnancy treated with laparoscopic surgery: A case report and literature review

The abdominal wall is a rare site of ectopic implantation. Laparoscopic surgery for early abdominal pregnancy, in contrast to its use for tubal ectopic pregnancy, remains controversial because of concerns regarding heavy bleeding at the implantation site. Treatment of early abdominal pregnancy must be individualized for each implantation site. Herein, we present a case of an early abdominal pregnancy implanted in the anterior abdominal wall that was successfully treated with laparoscopic surgery. A 28-year-old multiparous woman with a 6-week amenorrhea presented with acute abdominal pain. An ectopic pregnancy was suspected because of elevated serum human chorionic gonadotropin levels without a visible gestational sac on transvaginal ultrasonography. Diagnostic laparoscopy revealed a gestational sac hanging from the anterior abdominal wall near the previous cesarean section wound. Laparoscopic surgery was successfully performed, and the patient was discharged on postoperative day three. In the present case, laparoscopic surgery was beneficial.

Abdominal ectopic pregnancy

An ectopic pregnancy (EP) accounts for 1-2% of all pregnancies, of which 90% implant in the fallopian tube. An abdominal ectopic pregnancy (AEP) is defined as an ectopic pregnancy occurring when the gestational sac is implanted in the peritoneal cavity outside the uterine cavity or the fallopian tube. Implantation sites may include the omentum, peritoneum of the pelvic and abdominal cavity, the uterine surface and abdominal organs such as the spleen, intestine, liver and blood vessels. Primary abdominal pregnancy results from fertilisation of the ovum in the abdominal cavity and secondary occurs from an aborted or ruptured tubal pregnancy. It represents a very rare form of an EP, occurring in <1% of cases. At early gestations, it can be challenging to render the diagnosis, and it can be misdiagnosed as a tubal ectopic pregnancy. An AEP diagnosed >20 weeks' gestation, caused by the implantation of an abnormal placenta, is an important cause of maternal-fetal mortality due to the high risk of a major obstetric haemorrhage and coagulopathy following partial or total placental separation. Management options include surgical therapy (laparoscopy±laparotomy), medical therapy with intramuscular or intralesional methotrexate and/or intracardiac potassium chloride or a combination of medical and surgical management. The authors present the case of a multiparous woman in her early 30s presenting with heavy vaginal bleeding and abdominal pain at 8 weeks' gestation. Her beta-human chorionic gonadotropin (bHCG) was 5760 IU/L (range: 0-5), consistent with a viable pregnancy. Her transvaginal ultrasound scan suggested an ectopic pregnancy. Laparoscopy confirmed an AEP involving the pelvic lateral sidewall. Her postoperative 48-hour bHCG was 374 IU/L. Due to the rarity of this presentation, a high index of clinical suspicion correlated with the woman's symptoms; bHCG and ultrasound scan is required to establish the diagnosis to prevent morbidity and mortality.

Conservative Management of Heterotopic Pregnancy: A Case Report and Review of Literature

BACKGROUND Tubal heterotopic pregnancy is an extremely rare complication of pregnancy, in which there is a simultaneous presence of a pregnancy in the uterine cavity and in an ectopic location, most commonly in the fallopian tube. The management of such cases is not clearly established. In the case of a desire to maintain an intrauterine pregnancy, the surgical procedure consisting of a salpingectomy or salpingostomy is the most common. Such a procedure is effective, but it involves potential complications typical of surgeries, so, in some cases, it seems reasonable to apply the expectant management. CASE REPORT A 31-year-old woman was admitted to the clinic due to pain in the right lower abdomen. An ultrasound examination revealed a gestational sac in the uterine cavity corresponding to 5 weeks of pregnancy with a yolk sac. A twin sac was found in the right fallopian tube. Due to the patient's mild symptoms, absence of bleeding into the peritoneal cavity, concerns about the safety of the embryo and the pregnant woman in case of surgery, conservative management was decided. On the 20th day, the patient was discharged from the clinic with a viable intrauterine pregnancy and a partially absorbed ectopic pregnancy. CONCLUSIONS In the case of an ectopic tubal pregnancy, if there are no symptoms of bleeding into the peritoneal cavity, it is possible to adopt a safe conservative approach with strict patient observation.

Reproductive outcomes of ectopic pregnancy with conservative and surgical treatment: A systematic review and meta-analysis

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.

Subsequent pregnancy outcomes among women with tubal ectopic pregnancy treated with methotrexate

Lay summary

An ectopic pregnancy occurs when an embryo implants outside of the uterus, usually in a fallopian tube. When detected early, treatment is often with a medication called methotrexate. When methotrexate does not work, surgery is required. A recent clinical trial of ectopic pregnancy treatment (called GEM3) found that adding a drug called gefitinib to methotrexate did not reduce the need for surgery. We have used data from the GEM3 trial, combined with data collected 12 months after the trial finished, to investigate post-methotrexate pregnancy outcomes. We found no difference in pregnancy rates, pregnancy loss rates and recurrent ectopic pregnancy rates between those treated medically only and those who subsequently also needed surgery. The surgical technique used also did not affect pregnancy rates. This research provides reassurance that women with ectopic pregnancies treated medically who need surgery have similar post-treatment pregnancy outcomes to those treated successfully medically.

[Interstitial ectopic pregnancy: report of an unusual location]

Ectopic pregnancy occurs when a developing blastocyst implants at any site other than the uterine cavity. Ectopic pregnancy is most commonly found in the fallopian tube but may also occur in the cornua of the uterus (also found as interstitial in the literature), cervix, ovary, or abdominal cavity or in a cesarean scar. An estimated 2% of pregnancies are ectopic, of which an interstitial pregnancy represents an extremely rare variant of ectopic pregnancy (EP), accounting for 2% to 4 % of all cases. The aim of this report is to describe the case of a patient with suspected ectopic pregnancy of uncertain location in which an exploratory laparoscopy was performed due to the onset of symptoms, discovering a cornual ectopic pregnancy in site of a past salpingectomy because of a tubal ectopic pregnancy. A cornuotomy by laparoscopy was performed to resect the cornual ectopic pregnancy. The patient had an uneventful postoperative course, with negativization of human chorionic gonadotropin levels. This type of location is rare and is associated with high rates of maternal morbidity and mortality. It represents a diagnostic and therapeutic challenge for the gynecologist who faces it.

Heterotopic Pregnancy: A Case Report of Intrauterine Mole with Tubal Pregnancy

We report a rare case of intrauterine molar pregnancy along with ectopic tubal pregnancy. A 33-year woman who had never been pregnant had an ultrasound (US) after 70 days of amenorrhea suggesting partial hydatidiform mole, with a history of ovulation promotion and pathologically confirmed complete hydatidiform mole after uterine suction dilation and curettage. On 4th postoperative day, a US examination before discharge showed an inhomogeneous mass in the left adnexal region with mild lower abdominal pain. On 17th postoperative day, the blood HCG level did not drop as expected and the recheck result still indicated a mass in the left adnexal region, which did not exclude an ectopic hydatidiform mole. A hysteroscopy with a laparoscopic exploration of the left adnexal mass and salpingotomy confirmed a diagnosis of intrauterine hydatidiform mole combined with left tubal pregnancy. Key Words: Heterotopic pregnancy, Intrauterine hydatidiform mole, Tubal pregnancy.

Bilateral tubal ectopic pregnancy after spontaneous conception

OBJECTIVE

Presentation of a case report of a rare case of bilateral tubal pregnancy in a female patient after spontaneous conception.

OBSERVATION

We present a case of a 26-year-old female patient first hospitalized in the Gynecology Obstetrics Clinic of the Pilsen University Hospital, where a laparoscopy was indicated for suspicion of ectopic tubal pregnancy during which a left-sided salpingectomy was performed for a macroscopically clear finding of a tubal pregnancy on the left side, this finding was also confirmed histologically. Subsequently, the patient was discharged to home care. During a follow-up examination by a district gynaecologist, the patient complained of a recurrence of pain in the lower abdomen, on collection of hCG (human chorionic gonadotropin) its increase was detected and the patient was sent for a control gynaecological examination to Mulacova Hospital in Pilsen. On the examination in the outpatient clinic, she reported significant lower abdominal pain and collapsed during transvaginal ultrasound and was hospitalized. Subsequently, diagnostic laparoscopy was indicated during hospitalization, during which tubal pregnancy on the right and hemoperitoneum were macroscopically evident. A right-sided salpingectomy was performed for this finding with subsequent hCG drop, resolution of the discomfort and histological confirmation of tubal pregnancy on the right.

CONCLUSION

The incidence of such cases without prior ovulation stimulation is 1 out of 200,000 pregnancies and an estimated 1 out of 725 to 1 out of 1,580 ectopic pregnancies. Even so, bilateral tubal or heterotopic ectopic pregnancy should be considered in the differential diagnosis, as both conditions can be immediately life-threatening.

Management of a uterine serosal heterotopic pregnancy after in vitro fertilization in a woman with bilateral salpingectomy: A case report and literature review

RATIONALE

Heterotopic pregnancy (HP) is defined as the simultaneous presence of intrauterine pregnancy and ectopic pregnancy (EP). HP after bilateral salpingectomy is extremely rare and may lead to serious complications if it is misdiagnosed and untreated timely. Here, we presented the first reported case of uterine serosal HP in a woman after assisted reproductive technology with bilateral salpingectomy because of bilateral tubal ectopic pregnancy.

PATIENT CONCERNS

A 27-years-old pregnant woman after in vitro fertilization with bilateral salpingectomy complained of a sudden onset of unprovoked abdominal pain, which was persistent and dull. She denied vaginal bleeding.

DIAGNOSES

Serum beta-human chorionic gonadotropin levels are difficult to predict HP. Transvaginal ultrasonography demonstrated 1 gestational sac in the uterine cavity and 1 thick-walled cystic mass over the upper of the uterus, with a large amount of fluid in the Pouch of Douglas. Emergency laparotomy revealed a uterine serosal pregnancy combined with intrauterine pregnancy.

INTERVENTIONS

This patient was successfully managed via emergency laparotomy to remove residual tissue and repair the rupture of the uterine serosal pregnancy.

OUTCOMES

At postoperative 4 days, repeat transvaginal ultrosonography presented 1 intrauterine gestational sac with a visible fetal bud and cardiac tube pulsation. Now the patient recover well and is in an ongoing pregnancy.

LESSONS

It is noteworthy that HP/ectopic pregnancy is still not prevented after bilateral salpingectomy. In cases of multiple embryo transfer, even if intrauterine pregnancy has been established, it is important to rule out HP/ectopic pregnancy in time. Early diagnosis and early management can significantly improve clinical outcomes.

Tubal ectopic pregnancy in acute abdominal presentation: A case control analysis

BACKGROUND

The aim of the study was to evaluate the demographic data, clinical findings, ectopic pregnancy (EP) localization (left or right-sided), and treatments versus clinical presentation of tubal pregnancies (TP) with or without acute abdomen.

METHODS

Pregnants with a diagnosis of TP, selected for acute abdomen or not, were evaluated and compared, concerning EP local-ization (right/left), age, parity, symptoms (menstrual delay, vaginal bleeding, and groin pain), initial β-hCG value, endometrial thickness, presence of rupture, and treatment type (methotrexate and surgery).

RESULTS

On a total of 122 pregnants with TP, 32 showed acute abdomen, 45 had a TP located in the right tube and 32 in the left tube. In the acute abdomen group, parity, initial β-hCG level, and endometrial thickness were greater than non-acute abdomen group. In addition to this, the frequency of bleeding complaints, right-sided TP, rupture, and need for surgery were higher, than to the non-acute abdomen group. The frequency of the previous EP and methotrexate treatment was higher in those with the left-sided TP compared to those with the right-sided TP.

CONCLUSION

EP rate, in patients with TP who applied to the emergency department with acute abdominal symptoms, was mostly located in the right tube with greater frequency of salpingectomy in open surgery.

Extratubal secondary trophoblastic implants (ESTI) following laparoscopic bilateral salpingectomy for ectopic pregnancy: problems that have been neglected for a long time

Background: Extratubal secondary trophoblastic implants following laparoscopic salpingectomy is an extremely rare form of persistent ectopic pregnancy. These cases usually result in a small amount of vaginal bleeding and sudden lower abdominal pain thereby presenting with hemoperitoneum in emergencies. Owing to the urgency of hemoperitoneum and the uncertainty of the location of persistent ectopic pregnancy after laparoscopic salpingectomy, the risk of reoperation is increased. It is necessary to prevent in first surgery and diagnose these cases in the early following up phase.Methods: We report a case of 26-year-old woman, gravida 3, para 0, presenting a little vaginal bleeding and slight lower abdominal pain after laparoscopic bilateral salpingectomy for more than 1 month. The patient's serum β-HCG was still high (3981 mIU/ml), and no abnormalities were found through auxiliary examination (ultrasound, abdominal CT, and pelvic MRI).Results: Finally, emergency laparoscopy revealed many blue purple nodules on the surface of ovaries, small intestine, omentum, and periumbilical peritoneum, with a diameter of 3-20 mm. The lesions were completely removed as far as possible. Pathology showed trophoblastic proliferation and β-HCG soon decreased to negative after this operation.Conclusion: Therefore, it is important to follow up serum β-HCG even after salpingectomy and avoid iatrogenic dissemination of trophoblast tissue through careful operation.

Risk factors and clinical characteristics associated with a ruptured ectopic pregnancy: A 19-year retrospective observational study

Ectopic pregnancy is the most common cause of maternal mortality in the first trimester of pregnancy. The aim of this study was to find risk factors and clinical characteristics associated with ruptured ectopic pregnancies at a medical center in eastern Taiwan in a 19-year period. This was a retrospective observational study that included patients diagnosed with ectopic pregnancy between August 1999 and December 2018. Data about the demographic variables, initial presentation, pre-treatment beta-human chorionic gonadotropin levels, treatment routes (laparoscopy or laparotomy), surgical methods (salpingostomy or salpingectomy), operation time, blood loss amount, the status of ectopic pregnancy (ruptured or unruptured), the requirement for transfusion, and duration of hospital stay were collected. The categorical and continuous variables were analyzed using the correlation coefficients. This study included 225 women who were diagnosed as having an ectopic pregnancy. There were 49 and 176 women with unruptured and ruptured ectopic pregnancies, respectively. The beta-human chorionic gonadotropin levels, history of previous ectopic pregnancy, pelvic inflammatory disease, tubal surgery, abdominal history, and vaginal bleeding were not significantly different between the 2 groups. The ratio of women with abdominal pain was significantly higher in the ruptured ectopic pregnancy group than in the unruptured group (89.1% vs. 63.8%, respectively, P < .001). Preoperative hemoglobin was lower in the ruptured group compared with the unruptured group (P < .001). Blood loss, postoperative hemoglobin, and blood transfusion were significantly higher in the ruptured group than in the unruptured group (P = .000 and P = .001 for blood loss and blood transfusion, respectively). Multiple logistic regression analysis revealed that abdominal pain and blood loss were associated with ruptured tubal pregnancies (adjusted odds ratio [95% confidence intervals]: 3.42 {1.40, 8.40}; 1.01 {1.005, 1.014}, respectively). In conclusion, early pregnancy with abdominal pain, more parity, and lower preoperative hemoglobin should be aware of the possibility of ruptured ectopic pregnancy. More blood loss, transfusion and lower postoperative hemoglobin were also noted with ruptured ectopic pregnancy.

Term delivery of a heterotopic pregnancy coexisting with ruptured tubal ectopic pregnancy: A case report

Pregnancies that occur in two different implantation sites simultaneously is described as Heterotopic pregnancy (HP). In the current study, a case of term delivery of a heterotopic pregnancy coexisting with ruptured tubal ectopic pregnancy, diagnosed by ultrasound (US) and clinical examination findings, which was managed successfully. A 25 year old Nigerian female, gravida 4, para 2 (2 term gestation, 1 spontaneous abortion) presented at the Emergency room with acute abdominal pain associated with vomiting. She had 8 weeks amenorrhea and a positive pregnancy test three weeks prior to presentation. Transvaginal ultrasound scan revealed a six-weeks viable intrauterine gestation. A diagnosis of possible ectopic pregnancy was made. Further trans-abdominal ultrasonography imaging revealed viable intrauterine pregnancy with evidence of an echogenic mass measuring 6.5 x 7.5cm in the abdominal cavity with significant fluid collection, and both ovaries were visualized and separate from the mass. An emergency exploratory laparotomy with right salpingectomy was performed with minimal handling of the uterus and other pelvic structures. At 37 weeks and 5 days gestation, she had an elective C/S for a transverse lying fetus and delivered a live normal birth weight baby girl with a good Apgar score.

Live tubal ectopic pregnancy managed with localised injection of methotrexate into gestational sac

Ectopic pregnancy is a pregnancy outside the uterine cavity and is, in majority of cases, a non-viable pregnancy. There are multiple methods of managing patients with ectopic pregnancy including expectant, medical and surgical management. Live tubal ectopic pregnancies, also known as ectopic pregnancies present in the fallopian tube with fetal heartbeat still present, are most commonly treated via surgical route. This case outlines the presentation and an unusual method of management of a patient diagnosed with a live tubal ectopic pregnancy with extensive medical and surgical history.

FERTILITY OUTCOMES AFTER MEDICAL AND SURGICAL MANAGEMENT OF TUBAL ECTOPIC PREGNANCY

The objective was to investigate whether the method of treatment (surgical or medical) affects achieving a new pregnancy, as well as the time to and prognosis of the new pregnancy, in women with ectopic pregnancy (EP). Information on patients treated in our hospital between 2013 and 2014 for EP was retrieved from the computerized patient records. Data on whether these patients achieved pregnancy after EP treatment, time from treatment to new pregnancy, and prognosis of pregnancy were collected by phone interviews. A total of 101 women were analyzed. In addition to descriptive analysis, the χ²-test and Kruskal Wallis test were used to compare the groups. A new pregnancy was present in 84 (83.2%) of the women after EP treatment. There was no significant difference among the women having undergone medical treatment (methotrexate), surgical treatment, medical treatment followed by surgical treatment, or observational management approach in terms of achieving a new pregnancy after treatment and time to and prognosis of the new pregnancy. The study could not determine which treatment method would be superior in women with EP and in planning future pregnancy, but concluded that close clinical and laboratory monitoring is appropriate before deciding on aggressive interventions.

Preservation of the fallopian tube in ectopic tubal pregnancy. An analysis of the outcome of two laparoscopic surgical approaches

INTRODUCTION

The application of laparoscopic partial tubal resection with end-to-end anastomosis can reduce the incidence of persistent ectopic pregnancy.

AIM

We aim to compare the therapeutic effects of laparoscopic fenestration and laparoscopic partial tubal resection with end-to-end anastomosis in the treatment of tubal ectopic pregnancy.

MATERIAL AND METHODS

The patients were randomly divided into the observation group (the group treated with laparoscopic partial tubal resection with end-to-end anastomosis, n=238) and the control group (the group treated with laparoscopic fenestration, n=213). The average operation time, intraoperative blood loss, postoperative exhaust time and hospital stay were observed to evaluate the clinical effect. In addition, the time required for the β-HCG to drop to normal level, the patency of the fallopian tubes and the ovarian function were observed in the two groups after the operation.

RESULTS

There was no significant difference between observation group operation time, intraoperative hemorrhagic amount, blood β-HCG recovery time and hospital time and control group (P > 0.05). The postoperative fallopian tube patency rate in the observation group was 67.58%, significantly higher than the control group (P < 0.05). In addition, there was no significant difference in ovarian function between the two groups.

CONCLUSIONS

The method of laparoscopic partial tubal resection with end-to-end anastomosis is more effective in the treatment of tubal ectopic pregnancy, and has less impact on ovarian function, which can effectively improve the probability of normal pregnancy after the operation.

KEY WORD

Fallopian tube, Ectopic pregnancy, Laparoscopic fenestration, Laparoscopic partial tubal resection with end-to-end anastomosis.

Dual extrauterine ectopic pregnancy: double management

A 30-year-old nulliparous woman was referred with suspected left ovarian ectopic pregnancy. She had undergone laparoscopic left salpingectomy for ruptured tubal ectopic pregnancy 3 weeks earlier, following treatment with medications for ovulation induction. Sonological examination revealed a left ovarian ectopic pregnancy corresponding to 8 0/7 weeks with cardiac activity. She underwent ultrasound-guided intrasac therapy with intrasac instillation of 3 mEq of potassium chloride followed by 50 mg of methotrexate. She was followed with weekly measurements of serum beta human Chorionic Gonadotropin (hCG) which returned to baseline after 65 days of the intrasac therapy. This case not only highlights the need for continued follow-up of the serum beta hCG after definitive management of an ectopic pregnancy in cases with multiple ovulations, but also the option of medical management in cases of advanced ovarian ectopic pregnancy. It also accentuates the necessity for adequate counselling to avoid conception in a multiple ovulation cycle.

Guideline No. 414: Management of Pregnancy of Unknown Location and Tubal and Nontubal Ectopic Pregnancies

OBJECTIVE

To provide an evidence-based algorithm to guide the diagnosis and management of pregnancy of unknown location and tubal and nontubal ectopic pregnancy.

TARGET POPULATION

All patients of reproductive age.

BENEFITS, HARMS, AND COSTS

The implementation of this guideline aims to benefit patients with positive β-human chorionic gonadotropin results and provide physicians with a standard algorithm for expectant, medical, and surgical treatment of pregnancy of unknown location and tubal pregnancy and nontubal ectopic pregnancies.

EVIDENCE

The following search terms were entered into PubMed/Medline and Cochrane in 2018: cesarean section, chorionic gonadotropin, beta subunit, human/blood, fallopian tubes/surgery, female, fertility, humans, infertility, laparoscopy, methotrexate, methotrexate/administration & dosage, methotrexate/therapeutic use, pregnancy (abdominal, angular, cervix, cornual, ectopic, ectopic/diagnosis, ectopic/diagnostic imaging, ectopic/drug therapy, ectopic/epidemiology, ectopic/mortality, ectopic/surgery, heterotopic, interstitial, isthmo-cervical, ovarian, tubal, unknown location), recurrence, risk factors, salpingectomy, salpingostomy, tubal pregnancy, ultrasonography, doppler ultrasonography, and prenatal. Articles included were randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

Obstetrician-gynaecologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, and residents and fellows.

SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES)

RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Ectopic pregnancy management by V-NOTES technique

Ectopic pregnancy is a frequent and life-threatening risk of childbearing. Its management represents a mainstay of emergency gynecological surgery, and laparoscopy is the surgical gold standard technique. The technique of transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) for the management of ectopic pregnancy is presented herein. The procedure is illustrated by an instructive video article that standardizes the essential steps to make the technique ergonomic and easy to perform (step-by-step explanations). This surgical technique allows to consider vaginal salpingectomy using a combined cœlio-vaginal approach. After a posterior colpotomy, an Alexis retractor was inserted in the pouch of Douglas followed by the placement of a dedicated platform on which three trocars were fixed. Pneumoperitoneum was then achieved. Once the diagnosis of ruptured tubal ectopic pregnancy was established, a salpingectomy was performed. As a minimally invasive approach, this procedure has high patient acceptance and seems to improve favorable clinical outcomes.

Ectopic pregnancy in the ampulla of the fallopian tube at 16 gestational weeks: lessons from a case report

Background

It is uncommon to find ampullary tubal pregnancy in the second trimester.

Methods

A 35-year-old G4P3 at 16 gestational weeks presented with a day history of sudden severe lower abdominal pain and no vaginal bleeding. The patient had a normal pulse of 82/minutes, haemoglobin concentration of 6.3 g/dl and ultrasonography showed an empty uterus with an alive fetus in the right adnexa. She was provisionally diagnosed to have an abdominal pregnancy.

Results

The patient had an emergency laparotomy where 2.2 L of haemoperitoneum and a slow-leaking right ampullary tubal pregnancy were found. Right total salpingectomy was performed and she had an uncomplicated post-operative follow-up. Histology of the lesion confirmed tubal pregnancy.

Conclusion

The growth of a pregnancy in the ampulla beyond the first trimester is possibly due to increased thickness and or distensibility of the fallopian tube. A tubal pregnancy may present with a normal pulse despite significant haemorrhage.

Ectopic pregnancy following in vitro fertilization after bilateral salpingectomy: A review of the literature

Ectopic pregnancy after bilateral salpingectomy is rare and is therefore easily misdiagnosed. To provide information regarding the clinical manifestations, diagnosis, management, mechanism and prognosis of this condition, we reviewed all cases reported in the English literature. All English language reports on ectopic pregnancy after bilateral salpingectomy were retrieved from the PubMed database. A total of 19 English language articles were collected and 20 cases of ectopic pregnancy were reported. Eleven of the 19 patients had a history of tubal pregnancy on one or both sides. All of these pregnancies were by IVF-ET. The site of ectopic pregnancy was the tubal stump in 8 cases, the abdominal cavity in 4 cases, the ovary in 3 cases, the retroperitoneum in 3 cases, and the uterine cornua in 2 cases. All patients underwent successful resection of the ectopic pregnancy, of which 10 were laparoscopic surgery and 10 were laparotomy. Six of 8 cases of heterotopic pregnancy were successful gestation to the last trimester and were delivered after treatment. Ectopic pregnancy is still possible following IVF-ET after bilateral salpingectomy. The location of these ectopic pregnancies is complex and it is necessary to beware of the possibility of a heterotopic pregnancy.

Simplified two-step technique for transvaginal natural orifice transluminal endoscopic surgery

OBJECTIVE

To describe our simplified two-step technique for transvaginal natural orifice transluminal endoscopic surgery (vNOTES) and to demonstrate the application of the technique.

DESIGN

Step-by-step description of the technique and demonstration of its application using surgical video footage from two different cases.

SETTING

Tertiary university hospital.

PATIENT(S)

Patient 1 was a 27-year-old G0P0 woman who presented with right lower quadrant pain. Transvaginal ultrasound scan revealed a right ovarian torsion. Patient 2 was a 25-year-old G3P2 woman. She presented with vaginal bleeding and left lower quadrant pain. Her serum β-human chorionic gonadotropin level was 28,313 U/L, and transvaginal ultrasound scan revealed an ectopic pregnancy in the left tube. The decision to perform vNOTES was made for both patients.

INTERVENTION(S)

As the first step, patients underwent diagnostic vNOTES. The patient was placed in lithotomy position under general anesthesia. By use of a 5-mm trocar with autoretracting blade, a colpotomy was performed on the posterior vaginal wall. Pneumoperitoneum was achieved, and the patient was placed in a Trendelenburg position. A 5-mm 30° rigid endoscope was introduced, and the diagnosis was confirmed. After the confirmation of the diagnosis, we proceeded to the second step. The colpotomy was enlarged with blunt dissection by using Metzenbaum scissors. A self-constructed pessary port was placed through the colpotomy, and pneumoperitoneum was achieved. The therapeutic procedure was then performed. Patient 1 underwent ovarian detorsion with a 5-mm laparoscopic grasper. After the ovary was detorsioned, a 5-mm bipolar instrument was used to achieve hemostasis. Patient 2 underwent left salpingectomy with a 5-mm advanced bipolar device. Hemostasis was verified, and the specimen was extracted through the colpotomy. Procedures ended with the closure of colpotomy with running resorbable sutures.

MAIN OUTCOME MEASURE(S)

Description of the technique and demonstration of its applicability in two common gynecological emergencies.

RESULT(S)

Both patients were treated successfully by vNOTES. The operating times were 25 minutes and 38 minutes for patient 1 and patient 2, respectively. Patients were discharged on postoperative day 1 without any complications.

CONCLUSION(S)

Our simplified two-step technique described and demonstrated in this video article is a feasible and practical approach to perform vNOTES. The first step allows the confirmation of the diagnosis and facilitates the colpotomy. The use of the self-constructed pessary port enables to perform surgery with already existing equipment without the need for specialized equipment and without increasing the costs.

Bilateral simultaneous tubal pregnancy

OBJECTIVE

We present a rare case of peroperatively diagnosed bilateral tubular pregnancy.

DESIGN

Case report.

SETTING

Department of Obstetrics and Gynekology, Novy Jicin Hospital.

CONCLUSION

In the case of ectopic pregnancy always think about the possibility of contralateral pathology and during the surgical revision remember a thorough inspection of both fallopian tubes.

Unexpected rupture of an expectantly managed tubal ectopic pregnancy: a reminder for enhanced diligence

Expectant management of tubal ectopic pregnancies is a feasible and possibly preferable method of management in asymptomatic women with low serum β-human chorionic gonadotropin (hCG). This involves serial monitoring of β-hCG until negative, after which it is deemed as spontaneously resolved ectopic pregnancy. We describe a case of tubal ectopic pregnancy which was expectantly managed with an initial β-hCG of 585 mIU/mL until undetectable. This patient presented with ruptured ectopic pregnancy 8 weeks after the original diagnosis, at the level of 5 mIU/mL. This highlights the importance of close monitoring in the expectant management of tubal ectopic pregnancies, with the incorporation of imaging, even when serial β-hCG shows a persistently reducing trend.

Unilateral live twin tubal ectopic pregnancy presenting at 12 weeks of gestation: A case report

RATIONALE

Abdominal pain in pregnancy represents a demanding diagnostic challenge in the emergency department (ED) due to the extensive list of differential diagnoses to be considered, coupled with the possibility of each disease having nonclassical, atypical signs and symptoms, resultant from the patient's pregnant state. Additionally, emergency physicians (EPs) face limitations on investigative imaging modalities because of the need to minimize fetal radiation exposure. EPs have to tackle this diagnostic challenge while performing a balancing act to maximize both maternal and fetal outcomes in a time-sensitive manner, becauser any delays in decision-making at the ED may threaten the safety of mother and child. Two common causes of abdominal pain in pregnancy presenting to the ED are acute appendicitis and ectopic pregnancy. The latter is almost always diagnosed by 10 weeks of gestation. Here, we report an extremely rare case of unilateral live spontaneous twin tubal ectopic pregnancy presenting past 12 weeks of gestation, diagnosed after magnetic resonance imaging (MRI) of the abdomen.

PATIENT CONCERNS

A 37-year-old gravida 2 para 1 at 12 weeks and 6 days of gestation presented to our ED with a 2-day history of right iliac fossa pain, not associated with vaginal bleeding, fever, diarrhea, and vomiting. On examination, she was tachycardic (pulse rate 124 beats/min) and hypertensive (blood pressure 142/88 mm Hg). There was marked tenderness and guarding at the lower abdomen.

DIAGNOSES

Blood investigations were unremarkable, while abdominal ultrasonography found a live twin gestation with foetal heartbeats of 185 and 180 beats/min. MRI of the abdomen revealed an empty uterine cavity; 2 amniotic sacs and fetuses of diameter 10 cm, and a single placenta were noted in the right uterine adnexa. The patient was diagnosed with right live monochorionic diamniotic twin tubal pregnancy.

INTERVENTION

Our patient underwent emergency laparoscopic right salpingectomy.

OUTCOMES

The operation was successful and her postoperative care remained uneventful up to discharge.

LESSONS

Ectopic pregnancy cannot be ruled out based on prior normal antenatal examinations and gestational age of >10 weeks. EPs should not hesitate to order MRI scans for further evaluation if ultrasonography and laboratory findings are equivocal.

An uncommon spontaneous right distal tubal pregnancy post bilateral laparoscopic sterilization: A case report

RATIONALE

Tubal sterilization as a contraception method has a high success rate; however, it also carries a low risk of incidental pregnancy. A majority of these pregnancies are ectopic. In this study, we report a rare case of spontaneous right distal tubal pregnancy after bilateral laparoscopic tubal sterilization.

PATIENT CONCERNS

A 36-year-old woman who had undergone bilateral laparoscopic tubal sterilization presented with abdominal pain and a positive test for pregnancy.

DIAGNOSIS

Ectopic pregnancy was suspected based on absence of gestational sac in the uterine cavity on ultrasound and elevated beta-human chorionic gonadotropin (β-hCG) level.

INTERVENTION

Since the patient had unstable vitals, emergency laparoscopic surgery was performed, which revealed a right distal fallopian tube pregnancy. We performed a complete bilateral residual tubal stump excision.

OUTCOMES

The patient recovered well after surgery, with a reduction in β-hCG level, and was discharged after 3 days.

LESSONS

To ensure complete sterilization, the gap at the excised end needs to be adequately widened and enhanced with electro-destruction to prevent formation of a fistula.

Cornual uterine diverticulum following a failed pregnancy

The discovery of a uterine diverticulum is a rare event. Diverticula can lead to outcomes including pelvic pain, ectopic pregnancy, and diverticula rupture and should be considered in cases of uterine cystic masses. We report a case of a 32-year-old G3P0030 with a complicated pregnancy and surgical history who presented to us following an abnormal laparoscopy for severe pelvic pain four years after salpingectomy for a tubal pregnancy. This laparoscopy reported a cornual uterine cystic structure. Saline infusion sonohysterography was performed with fluid filling a uterine cornual cystic mass. On hysteroscopy, no outpouching was identified. With chromopertubation on laparoscopy, methylene blue filled the diverticulum. The diverticulum was laparoscopically removed. Pathology examination was consistent with a diverticulum containing a placental implantation site and necrotic chorionic villi.

A spontaneous bilateral tubal pregnancy: A case report

RATIONALE

Ectopic pregnancy (EP) is a condition in which a fertilized oocyte implants outside the uterine. Spontaneous bilateral tubal pregnancies are the rarest form of ectopic and are considered spontaneous when no fertility treatments are involved. There are few prior cases. Here I report a case of spontaneous bilateral tubal pregnancy.

PATIENT CONCERNS

A 24-year-old female with long lasting vaginal bleeding of 29 days duration.

DIAGNOSES

Transvaginal ultrasound observed small complex masses on both adnexal sides without intrauterine gestational sac, and the hCG level was 21438 IU/L. But diagnosing based only on imaging findings and blood test result was difficult.

INTERVENTIONS

Operative laparoscopy with salpingectomy bilaterally.

OUTCOMES

Villi were clearly shown in both resected tubes. A spontaneous bilateral tubal pregnancy was confirmed finally and the patient recovered uneventfully.

LESSONS

Women of reproductive age with irregular menstruation should get access to diagnosis and appropriate treatment without delay. Salpingotomy should also be considered if the patient had a strong wish for future pregnancy. Developments of diagnosis and management of such condition are strongly called for.

Comparison of single-port and three-port laparoscopic salpingectomy in the management for tubal pregnancy

BACKGROUND

To compare the short-term outcome of patients undergoing single-port laparoscopic salpingectomy (SP-LS) and conventional three-port laparoscopic salpingectomy (C-LS).

METHODS

A retrospective evaluation of 112 patients with tubal pregnancies treated by one surgeon at a single teaching hospital. Among these, 47 patients were treated with SP-LS and the remaining 65 were treated with C-LS.

RESULTS

The characteristics of patients were similar in both groups. There were no statistically significant differences in operative time, estimated blood loss, intraoperative and immediate postoperative complications, and length of hospital stay between both groups. Time to bowel recanalization (6.2 ± 1.0 vs. 7.2 ± 1.4 h, p < 0.05) and postoperative visual analog scale for pain scores (3.0 ± 0.5 vs. 3.6 ± 0.6, p < 0.005) were significantly lower in the SP-LS group compared with those in the C-LS group.

CONCLUSION

Our study demonstrated the feasibility to use the single-port laparoscopic salpingectomy in the management of women with tubal pregnancy, which showed the similar or better outcome compared with the use of conventional three-port laparoscopic salpingectomy.

[Hysteroscopically assisted laparoscopic salpingostomy in the treatment of tubal pregnancy]

OBJECTIVE

To present a case of conservative - Fallopian tube preserving - surgical therapy of tubal pregnancy.

DESIGN

Case report.

SETTING

Department of Obstetrics and Gynecology, Strakonice Hospital.

CASE DESCRIPTION

Due to the desire to preserve the Fallopian tube in a hemodynamically stable primigravida, we decided for laparoscopic salpingostomy using hysteroscopy for assisted removal of pregnancy tissue from the oviduct.

CONCLUSION

In well-selected cases, this treatment is an effective method of choice and can be performed even under conditions of a smaller hospital performing a common spectrum of laparoscopic surgery.

Ruptured secondary abdominal pregnancy after primary laparoscopic treatment for tubal pregnancy: A case report

INTRODUCTION

Most secondary abdominal pregnancies happen after spontaneous abortion of tubal pregnancy or ruptured intrauterine pregnancy. However, we presented a case of ruptured secondary abdominal pregnancy after primary laparoscopic treatment of tubal pregnancy.

CASE REPORT

The ectopic pregnant lesion in the affected tube was thoroughly removed in the primary laparoscopy, and nothing abnormal was detected in abdomen or pelvis. Beta human chorionic gonadotropin levels dropped significantly after surgery, but the patient came back again for severe abdominal pain with beta human chorionic gonadotropin increasing, and free peritoneal fluid in the pouch of Douglas was detected at ultrasonography. The secondary laparoscopy was done according to the intraperitoneal hemorrhage and unstable vital signs. The secondary pregnancy was found ruptured in the splenic flexure of the colon. Although several cases of secondary abdominal pregnancies were reported in the literature, herein we describe a case secondary to the salpingotomy of the primary tubal pregnancy.

CONCLUSION

After surgery for ectopic pregnancy, the patient's serum beta human chorionic gonadotropin levels should be closely followed until negative. When persistent ectopic pregnancy was suspected after surgery, physicians should keep in mind a rare possibility of secondary abdominal pregnancy.

[Persistent trophoblast tissue after salpingectomy]

We present a case of persistent trophoblast tissue (PT) five weeks after salpingectomy for tubal pregnancy. The fallopian tube-sparing method (salpingotomy) has a greater risk of PT than removal of the whole fallopian tube (salpingectomy) has. A 32-year-old woman was treated with salpingectomy on suspicion of a bleeding ectopic pregnancy and was readmitted due to PT. There is no evidence for measuring the human chorionic gonadotropin (hCG) level as routine follow-up after salpingectomy, but it is important to be aware of the risk of PT and if in doubt measure the levels of hCG.

Negative histology with surgically treated tubal ectopic pregnancies - A retrospective cohort study

OBJECTIVE

To determine the outcome of histological examinations of surgical specimens obtained from treatment of tubal ectopic pregnancy and to correlate with clinical findings, pre-operative ultrasound scans and the type of surgery.

STUDY DESIGN

A retrospective cohort study of 941 women diagnosed with a tubal ectopic pregnancy in the Early Pregnancy Unit and having surgical treatment at King's College Hospital, London. Clinical and ultrasound data had been entered contemporaneously on our electronic early pregnancy database and hospital clinical records over an 11year period from 2004 to 2014. Demographic data, clinical history, ultrasound scan parameters, type of surgical management and histological diagnosis were recorded. The primary outcome measure was the presence or absence of chorionic villi in the surgical specimen. Data were analysed using Mann Whitney U test for non-parametric data, relative risk for categorical data and binomial logistic regression.

RESULTS

A surgical specimen was obtained in 925 cases. Of these, 881/925 (95.2%) were positive for the presence of chorionic villi on histological examination. Patients with negative histology had a lower median gestational age, smaller ectopic pregnancies and lower serum human chorionic gonadotrophin levels. The relative risk of negative histology was significantly higher with a solid ectopic pregnancy on ultrasound (RR1.91, 95% CI 1.07-3.4) and with conservative surgery (RR 3.68, 95% CI 1.25-10.77). The relative risk was significantly lower with the presence of embryonic cardiac activity (RR 0.12, 95% CI 0.02-0.85). Only the serum hCG level was a significant predictor of negative histology on logistic regression analysis (p=0.048). In 39/44 women with negative histology, the human chorionic gonadotrophin level declined after surgery with no further intervention. Five of the 44 required a second surgical procedure as the ectopic pregnancy had been missed at the initial surgery and did not resolve.

CONCLUSION

There is lack of histological confirmation of sonographically diagnosed and surgically confirmed ectopic pregnancies in approximately 5% of cases, making this a relatively common finding following surgical treatment of tubal ectopic pregnancy. Clinicians should be aware of this when counselling women with tubal ectopic pregnancies about to undergo surgery, include this risk in the consent process and plan post-surgical follow up with this in mind.

Heterotopic Triplet Pregnancy in Gonadotropin Stimulation Cycle: A Case Report

BACKGROUND

Heterotopic pregnancy is defined as the simultaneous presence of 2 or more pregnancies at different implantation sites, most commonly one intrauterine and one ectopic. Triplet heterotopic pregnancy refers to the presence of specifically 3 concurrent gestations with at least 1 being abnormally implanted. Heterotopic pregnancy is a potentially life-threatening condition that requires thorough diagnostic workup and prompt intervention.

CASE

We report the fourth case of triplet heterotopic pregnancy after ovarian stimulation with gonadotropins. A 24-year-old woman, G0, presented at 6 weeks of gestation with bilateral tubal ectopic pregnancies and a nonviable intrauterine pregnancy (IUP) after gonadotropin stimulation cycle. Bilateral tubal pregnancies were removed laparoscopically and the nonviable IUP via dilation and curettage.

CONCLUSION

Although rare, heterotopic pregnancy of 2 or more gestations must be kept in mind when managing patients undergoing treatment with ART. Careful examination of bilateral adnexa and consideration of uterine sampling at the time of surgery for ectopic pregnancy is advisable, even for patients with few or no risk factors.

Ruptured Primary Omental Pregnancy Mimicking Adnexal Implantation

Ectopic pregnancies occur when the implantation of a fertilized ovum occurs outside of the endometrial cavity. The majority of ectopic pregnancies encountered in clinical practice are located within the fallopian tube. Abdominal pregnancies represent 1% of all ectopic pregnancies. Primary omental pregnancy, in which the extrauterine site of implantation is the greater omentum, is the least common form of abdominal pregnancy. The rarity of an ectopic pregnancy in the omentum and the absence of clinical symptoms often delays diagnosis and proper identification before rupture. The authors describe the case of a 23-year-old woman who had hemoperitoneum from a ruptured omental ectopic pregnancy that mimicked adnexal implantation. Her omental pregnancy was diagnosed through intraoperative exploration and osteopathic structural examination findings.