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.

Ectopic pregnancy: a single-center experience over ten years

PURPOSE

The aim of this study was to investigate characteristics associated with ectopic pregnancy (EP) that could be utilized for predicting morbidity or mortality.

METHODS

This was a retrospective analysis of pregnancy-related records from a tertiary center over a period of ten years. Data on age, gravidity, parity, EP risk, amenorrhea duration, abdominal pain presence and location, β-human chorionic gonadotropin (β-HCG) level, ultrasound findings, therapeutic intervention, exact EP implantation site and length of hospital stay (LOS) were obtained from the database. The LOS was used as a proxy for morbidity and was tested for an association with all variables. All statistical analyses were conducted with Stata® (ver. 16.1, Texas, USA).

RESULTS

The incidence of EP in a cohort of 30,247 pregnancies over a ten-year period was 1.05%. Patients presented with lower abdominal pain in 87.9% of cases, and the likelihood of experiencing pain was tenfold higher if fluid was detectable in the pouch of Douglas. Only 5.1% of patients had a detectable embryonic heartbeat, and 18.15% had one or more risk factors for EP. While most EPs were tubal, 2% were ovarian. The LOS was 1.9 days, and laparoscopic intervention was the main management procedure. The cohort included one genetically proven dizygotic heterotopic pregnancy (incidence, 3.3 × 10^- 5) that was diagnosed in the 7th gestational week. The only association found was between the β-HCG level and LOS, with a linear regression β coefficient of 0.01 and a P-value of 0.04.

CONCLUSION

EP is a relatively common condition affecting approximately 1% of all pregnancies. β-HCG correlates with EP-related morbidity, but the overall morbidity rate of EP is low regardless of the implantation site. Laparoscopic surgery is an effective therapeutic procedure that is safe for managing EP, even in cases of heterotopic pregnancy.

Ectopic Pregnancy: Diagnosis and Management

Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. In the United States, the estimated prevalence of ectopic pregnancy is 1% to 2%, and ruptured ectopic pregnancy accounts for 2.7% of pregnancy-related deaths. Risk factors include a history of pelvic inflammatory disease, cigarette smoking, fallopian tube surgery, previous ectopic pregnancy, and infertility. Ectopic pregnancy should be considered in any patient presenting early in pregnancy with vaginal bleeding or lower abdominal pain in whom intrauterine pregnancy has not yet been established. The definitive diagnosis of ectopic pregnancy can be made with ultrasound visualization of a yolk sac and/or embryo in the adnexa. However, most ectopic pregnancies do not reach this stage. More often, patient symptoms combined with serial ultrasonography and trends in beta human chorionic gonadotropin levels are used to make the diagnosis. Pregnancy of unknown location refers to a transient state in which a pregnancy test is positive but ultrasonography shows neither intrauterine nor ectopic pregnancy. Serial beta human chorionic gonadotropin levels, serial ultrasonography, and, at times, uterine aspiration can be used to arrive at a definitive diagnosis. Treatment of diagnosed ectopic pregnancy includes medical management with intramuscular methotrexate, surgical management via salpingostomy or salpingectomy, and, in rare cases, expectant management. A patient with diagnosed ectopic pregnancy should be immediately transferred for surgery if she has peritoneal signs or hemodynamic instability, if the initial beta human chorionic gonadotropin level is high, if fetal cardiac activity is detected outside of the uterus on ultrasonography, or if there is a contraindication to medical management.

[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.

Fertility outcome analysis after surgical management of tubal ectopic pregnancy: a retrospective cohort study

OBJECTIVES

To compare the subsequent fertility and risk of recurrence of an ectopic pregnancy (EP) in women who had had an EP, according to the type of surgical treatment they received--that is, salpingectomy, salpingostomy or tubal anastomosis.

METHODS

A retrospective cohort study was carried out between January 2003 and September 2011 of 618 patients admitted to hospital with tubal EP and who had received surgical treatment (salpingectomy, n=434; salpingostomy, n=112; and tube anastomosis, n=72). Main outcomes included the first intrauterine pregnancy (IUP) and recurrent EP.

RESULTS

The crude IUP rates up to 24 months after surgery were 55.5% for salpingectomy, 50.9% for salpingostomy and 40.3% for tubal anastomosis treatments. In the multivariate-adjusted model, with the patients receiving salpingectomy as the reference group, HR for patients after salpingostomy and tubal anastomosis treatments for IUP were 0.912 (95% CI 0.762 to 2.017) and 0.619 (95% CI 0.328 to 0.927), respectively. The 2-year cumulative recurrent EP rates were found to be 8.1% for salpingectomy, 6.3% for salpingostomy and 16.7% for tubal anastomosis treatments. Taking the patients receiving salpingectomy as the reference group, the patients who received tubal anastomosis had a positively higher risk of recurrent EP (HR=2.280; 95% CI 1.121 to 4.636) in univariate analysis. Adjustment for other potential confounders only slightly attenuated the HR.

CONCLUSIONS

The patients with an EP receiving tubal anastomosis treatments appeared to have a lower 2-year rate of IUP and a higher risk of recurrent EP after adjustment for other potential risk factors.

Genital tuberculosis: an important cause of ectopic pregnancy in India

OBJECTIVE

To assess the role of genital tuberculosis as an etiological factor for ectopic pregnancy.

METHOD

A total of eighteen women of ectopic pregnancy with concomitant female genital tuberculosis and a total of one hundred thirty six patients of ectopic pregnancy over a period of three years were enrolled.

RESULTS

Mean age of patients with ectopic pregnancy and concomitant female genital tuberculosis was twenty-six and mean parity was 0.7. Most of these patients were in poor socio-economic group. Diagnosis of female genital tuberculosis was made by presence of granuloma in histopathological examination of endometrial aspirate or tubal specimen, positive acid fast bacilli in microscopy or culture, positive polymerase chain reaction in endometrial tissue and positive findings of genital tuberculosis during laparoscopy or laparotomy. Genital tuberculosis was responsible for 13.2% of all cases of ectopic pregnancy in the present study.

CONCLUSION

Genital tuberculosis appears to be an important cause of ectopic pregnancy in India.

[Hormone replacement therapy after salpingo-oophorectomy in BRCA 1/2 mutation carriers does not increase the risk of breast cancer]

Prophylactic bilateral salpingo-oophorectomy (PBSO) reduces the risk of breast- and ovarian cancer in breast cancer gene (BRCA)1/2 mutation carriers. Women choose hormone replacement therapy (HT) to alleviate climacteric symptoms. Studies have shown a higher risk of breast cancer in healthy post-menopausal women getting HT. Further research among women with BRCA1/2 mutations is essential. No studies showed significantly that short-term use of HT alters the reduction in breast cancer risk associated with PBSO. Neither was there found any significant difference in type of HT chosen.

Laparoscopic single-site linear salpingostomy for the management of heterotopic pregnancy: a case report

BACKGROUND

The laparoscopic management of tubal pregnancy component of a heterotopic pregnancy was conducted via multiport approach. In this report we describe a new technique using a single port approach with long-term follow-up.

CASE

A 27-year-old woman, G4P1031, presented with a heterotopic pregnancy after 2 years of infertility treatment. She underwent multiple surgeries to excise left ovarian cysts, lysis of adhesions, and recanalization of the right fallopian tube. During this time she also experienced a left-sided ectopic pregnancy and was treated with a traditional operative laparoscopy. Upon diagnosis of a heterotopic pregnancy, the decision was made to perform a laparoendoscopic single-site (LESS) procedure for treatment of a right ectopic pregnancy via a salpingostomy to preserve her potential for future spontaneous conception. A linear salpingostomy procedure was performed without complications, and the patient was able to carry her intrauterine pregnancy to term.

CONCLUSION

The LESS procedure is effective in resolving an ectopic pregnancy without affecting a coexisting intrauterine pregnancy, and preserving the potential for future spontaneous pregnancies. This approach should be considered for eligible patients with a heterotopic pregnancy who desire preservation of tubal function. (J Reprod Med 2014;

Coexistence of three benign and a borderline tumor in the ovaries of a 52-year-old woman

PURPOSE OF INVESTIGATION

In this paper, the authors describe a rare case of four simultaneous ovarian tumors.

MATERIALS AND METHODS

A 52-year-old postmenopausal woman underwent total hysterectomy and bilateral salpingo-ophorectomy. Multiple slides from the ovaries were examined.

RESULTS

Histological examination revealed the presence of three ovarian tumors on the right ovary, of the following types: cystadenoma, mucinous borderline ovarian tumor and mature teratoma, and also a benign Brenner tumor on the left ovary.

CONCLUSION

Pathologists must examine multiple sections of both ovaries, regardless of the macroscopic or clinical specimen's appearance, in order to exclude the presence of malignancy, which could alter the surgical approach. Particular attention should also be paid to the frozen section of the contralateral ovary, as depending on the result, it could change the surgical approach. From the surgeon's perspective, bilateral salpingo-ophorectomy with total hysterectomy should be the treatment of choice in postmenopausal women with multiple ovarian tumors. The diagnosis of a malignant or borderline tumor on a normal-appearing ovary changes the radicality of the surgical approach. In such a case, staging surgery, including omentectomy, multiple peritoneal biopsies, and washes are required.

Ectopic pregnancy: zero in on these lab and imaging clues

Quantitative β-hCG measurements and transvaginal ultrasound findings interpreted in light of a β-hCG "cutoff" can reliably guide clinical decisions.

Fertility after tubal ectopic pregnancy: results of a population-based study

OBJECTIVE

To assess the reproductive outcome after an ectopic pregnancy (EP) based on the type of treatment used, and to identify predictive factors of spontaneous fertility.

DESIGN

Observational population based-study.

SETTING

Regional sistry.

PATIENT(S)

One thousand sixty-four women registered from 1992 to 2008.

INTERVENTION(S)

Laparoscopic (radical or conservative), or medical treatment.

MAIN OUTCOME MEASURE(S)

Epidemiologic characteristics, clinical presentation, treatments performed, reproductive outcome, recurrence.

RESULT(S)

The 24-month cumulative rate of intrauterine pregnancy (IUP) was 67% after salpingectomy, 76% after salpingostomy, and 76% after medical treatment. IUP rate was lower after radical treatment compared with conservative treatments in univariable analysis. In multivariate analysis, IUP rate was significantly lower for patients >35 years old or with history of infertility or tubal disease. For them, IUP rate was significantly higher after conservative treatment compared with salpingectomy. The 2-year cumulative rate of recurrences was 18.5% after salpingostomy or salpingectomy and 25.5% after medical treatment. History of infertility or of previous live birth would be protective, in contrast to history of voluntary termination of pregnancy.

CONCLUSION(S)

Conservative strategy seems to be preferred, whenever possible, to preserve patients' fertility without increasing the risk of recurrence. The choice between conservative treatments does not rely on subsequent fertility, but more likely on their own indications and therapeutic effectiveness. Risk factors of recurrence could be considered for secondary prevention.

[Endoscopic management of ectopic pregnancy]

Ectopic pregnancy is a common problem usually diagnosed at an early stage and often in an emergency situation. Both medical and surgical treatments can be used for its management. In case of surgical treatment, laparoscopy rather than open surgery must be practiced. Concerning the choice between salpingostomy and salpingectomy, it depends of the controlateral tubal patency. In case of altered controlateral tube, if a sparing surgery is possible it should be preferred. However, this question is still debated if the controlateral tube seems patent.

Risk factors associated with the occurrence of breast cancer after bilateral salpingo-oophorectomy in high-risk women

INTRODUCTION

Bilateral salpingo-oophorectomy (BSO) is a common procedure for preventing breast and ovarian cancer in high-risk women. The goal of this study was to determine the incidence of subsequent breast cancer (BC) in a high-risk population and to identify clinical and epidemiological predictors of BC following BSO.

MATERIALS AND METHODS

One hundred and thirty-three consecutive high-risk women, tested for BRCA1 and BRCA2 mutations due to family history, underwent preventive or therapeutic BSO at one of the study hospitals. One hundred and three patients had breast tissue at risk and were considered evaluable for the event-free survival analysis. Twenty-five women harbored a deleterious mutation in BRCA1 and 25 in BRCA2 genes.

RESULTS

Fifteen cases of invasive BC were diagnosed with a median interval of 49 months after BSO. Multivariate analysis showed that a prior BC after 50 years of age (p=0.004), age over 50 years at the time of BSO (p=0.005), and prior replacement or contraceptive hormonal treatment (p=0.007) were significantly associated with a shorter event-free survival.

CONCLUSION

In conclusion, age at prior diagnosis of cancer, age at BSO and prior hormonal treatment may be predictors of breast cancer after BSO.

Struma Ovarii with a focus of follicular variant of papillary thyroid cancer: a case report

BACKGROUND

Struma Ovarii is a mature ovarian teratoma that consists mainly of thyroid tissue. Mature cystic teratomas may contain small amounts of thyroid tissue. Carcinomatous change in Struma Ovarii is extremely rare. No guidelines exist regarding the staging and treatment of malignant Struma Ovarii.

OBJECTIVES

To report a case of Struma Ovarii with a focus follicular variant papillary thyroid cancer.

CASE

A 36 year old nulligravid patient presented with a pelvic mass palpated on her routine annual exam. Struma Ovarii with a focus of follicular variant of papillary thyroid cancer was diagnosed during the subsequent laparoscopy and ovarian cystectomy.

INTERVENTION

She then underwent a staging laparotomy, total hysterectomy, bilateral salpingoophorectomy, and infracolic omentecomy.

FOLLOW-UP

Tumor markers, thyroid studies, thyroid scan, and whole body scans were normal.

CONCLUSION

Optimal treatment and surveillance of malignant struma ovarii has yet to be determined.

[Guidelines for the management of painful endometriosis]

OBJECTIVE

To establish guidelines for the medical and surgical management of painful endometriosis.

MATERIAL AND METHODS

An exhaustive review on Medline and Cochrane Database between 1980 and 2006 was performed.

RESULTS

GnRH agonists, progestins, continuous monophasic oral contraceptives and danazol have a suppressive effect on dysmenorrhoea, nonmenstrual pain and dyspareunia (grade A). Surgical treatment is effective in painful endometriosis (grade B). Complete surgical excision of deep endometriotic lesions with conservation of uterus and ovaries has a limited term efficacy on pain relief (grade C). A multidisciplinary approach is recommended (grade C). The use of the psychotherapy improves the management of chronic pain (grade A). There is a lack of information concerning the therapeutic strategy able to prevent recurrences. Whether endometriosis recurrences occur, medical treatment should be the first line approach (expert opinion). A hysterectomy with salpingo-oophorectomy and complete excision of the lesions is efficient in women with pain recurrence who no longer desire pregnancy (grade C).

CONCLUSIONS

Medical and surgical treatments have a limited term efficacy on painful endometriosis (grade A). The benefit/risk ratio, depending on side-effects, should be assessed on a case to case basis.

Sertoli-Leydig cell tumor: a rare ovarian neoplasm. Case report and review of literature

BACKGROUND

Sertoli-Leydig cell tumor is a gonadal tumor of the sex cord-stromal type. It is a rare tumor comprising 0.1 to 0.5% of all ovarian tumors. Management of these cases poses a difficult therapeutic challenge.

CASE

A 13-year-old girl presented with acute urinary retention, excessive hair growth and deepening of the voice. A mass the size of a 28-week gravid uterus was arising from the pelvis. Serum testosterone level was raised to 145.2 ng/dl. Computed tomography revealed a heterogeneously hypoechoic, solid cystic mass arising from the left adnexa. Left salpingo-oophorectomy was done. A histopathological diagnosis of Sertoli-Leydig cell tumor (intermediate, Meyers type II) was given.

CONCLUSION

Patients with Sertoli-Leydig cell tumors present with signs of defeminization followed by masculinization. Age of the patient, stage of the disease and degree of tumor differentiation based on morphology are the most important factors to consider in the management of the case.

Fertility outcomes following expectant management of tubal ectopic pregnancy

OBJECTIVES

To evaluate fertility outcome after the expectant management of tubal ectopic pregnancy.

METHODS

Our dedicated early pregnancy database was searched for all women diagnosed with a tubal ectopic pregnancy between January 1999 and June 2003 who were either managed expectantly or underwent a salpingectomy. They were contacted to enquire about their ability to conceive following the ectopic pregnancy and about the outcomes of any subsequent pregnancies.

RESULTS

Four hundred and forty-four women had a diagnosis of tubal ectopic pregnancy, and 173 (39%) were successfully contacted. A total of 146/173 (84.4%; 95% CI, 79-89.8%) tried for another pregnancy: 49/59 (83.1%; 95% CI, 73.4-92.6%) in the expectant management and 97/114 (85.1%; 95% CI, 78.4-91.6%) in the salpingectomy group (P > 0.05). Spontaneous intrauterine pregnancy occurred in 41/49 (83.7%; 95% CI, 73.3-94.2%) women managed expectantly and in 62/97 (63.9%; 95% CI, 54.4-73.5%) women managed surgically (odds ratio 2.89; 95% CI, 1.22-6.86%). The risk of recurrent ectopic pregnancy was not significantly different between the two management groups.

CONCLUSIONS

Fertility outcomes following the expectant management of tubal ectopic pregnancy are comparable to those following salpingectomy.

Treatment of hydrosalpinx in the patient undergoing assisted reproduction

PURPOSE OF REVIEW

Patients with hydrosalpinx are a recognized group with poor prognosis in in-vitro fertilization. This review presents evidence for the effectiveness of different treatment options.

RECENT FINDINGS

Theories explaining the mechanisms behind the impaired outcome of in-vitro fertilization still focus on the hydrosalpingeal fluid. Gamete and embryotoxic effects have been demonstrated, but it is not a consistent finding. Endometrial receptivity may be altered by the reduced expression of cytokines and integrins important to implantation, and reduced endometrial and subendometrial blood flows may play a role. The rationale for treatments to improve the results of in-vitro fertilization is based on interruption of the leakage of hydrosalpinx fluid into the uterine cavity. Laparoscopic salpingectomy has been evaluated in a large randomized trial and proved effective in restoring birth rates. Proximal tubal ligation may also be effective according to one smaller randomized trial. Other suggested methods such as transvaginal drainage have been poorly investigated.

SUMMARY

Pre-in-vitro fertilization salpingectomy is the only method that has proved effective in restoring birth rates in patients with hydrosalpinx. The underlying mechanism explaining reduced implantation and embryo development awaits further research.

Leiomyosarcoma of the Uterus With Sphenoid Bone and Orbital Metastases

A 55-year-old woman presented with a 1-week history of vision loss in the right eye associated with proptosis and diplopia. Past medical history was significant for high-grade leiomyosarcoma of the uterus status post total abdominal hysterectomy and bilateral salpingo-oophorectomy and postoperative pelvic radiation 18 months prior to presentation. Staging studies at the time of initial diagnosis of uterine leiomyosarcoma showed no evidence for metastatic disease. At presentation, CT and MRI showed a well-circumscribed 3.0 cm x 3.6 cm x 2.4 cm mass centered in the right greater sphenoid wing, extending into the middle cranial fossa and the superior and lateral orbital wall. Biopsy of the orbital mass revealed a poorly differentiated high-grade leiomyosarcoma, consistent with recurrent metastatic disease from the uterus. The patient subsequently underwent radiation treatment followed by a left orbital exenteration 6 months after the orbital biopsy. A left thoracostomy was performed 8 months after the orbital biopsy for a metastatic nodule in the left lower lobe of the lung. The clinicopathologic findings of this rare metastatic orbital lesion are presented.

[Conservative, laparoscopic and medical treatment of ectopic pregnancy]

BACKGROUND

Ectopic pregnancy is that in which implantation of fertilized zygote occurs out of the uterine cavity mucosa (fallopian tube ampulla, isthmus, interstice, cervix, ovary or abdomen). Patients with ectopic pregnancy history have bad forecast on subsequent fertility.

OBJECTIVE

To describe conservative, laparoscopic and medical treatment to ectopic pregnancy (estimation of results).

MATERIAL AND METHODS

Revision of 65 files of ectopic pregnancy with salpingocentesis, lineal salpingostomy and methotrexate terapy.

RESULTS

Salpingocentesis and lineal salpingostomy prove tube permeability in 81.4 to 90% of cases. The number of intrauterine pregnancies has a 60 to 67% of variation. Presently we take care four intrauterine pregnancies, two with each surgical procedure.

CONCLUSION

It is important to asses prophylactic administration of methotrexate to avoid ectopic pregnancy. This drug was prescribed in six successful cases with a unique dosage of 25 mg. Determination of HCG and gynecologic ultrasonography facilitate ectopic pregnancy diagnosis.

Bilateral ectopic pregnancy

Bilateral simultaneous ectopic pregnancy is a very rare clinical condition. Two different subsets of patients can be distinguished: women presenting with the disease as a result of spontaneous conception and those with the condition after undergoing assisted reproduction procedures. This article reviews and analyzes 42 cases of bilateral ectopic pregnancies reported in the last 10 years, proposes a new classification of the disease, and presents some data that should be useful for the clinician who confronts this difficult entity.

Excision of large cystic ovarian tumors: combining minimal invasive surgery techniques and cancer surgery--the best of both worlds

BACKGROUND/PURPOSE

Cystic ovarian lesions can be massive, and preoperative evaluations can often not distinguish benign from malignant tumors. Up to 57% of malignant ovarian tumors have a cystic component. We present an approach to these neoplasms that adheres to oncologic principles using minimally invasive techniques.

METHODS

A 5-cm Pfannensteil incision is performed followed by peritoneal washings. The mass is identified and dried. Dermabond (Ethicon, Johnson & Johnson, New Jersey) is applied to an area of the capsule (measuring 3 x 3 cm) and to a sterile plastic ultrasound bag. The bag is then applied directly to the exposed capsule. BioGlue (Cyrolife Inc, Kennesaw, GA) is then injected into and around the bag/mass interface and allowed to solidify. A veress needle decompresses the cyst, and the ovary is delivered out of the peritoneal cavity for either cystectomy or an oophorectomy. Routine surveillance of the omentum, lymph nodes, contralateral ovary, and peritoneal surface is then performed.

RESULTS

Nine female patients (mean age, 14.1 +/- 2 years) were treated. All had normal alpha-fetoprotein and human chorionic gonadotropin. Computed tomographic scans demonstrated cystic lesions ranging from 8.9 to 27 cm in diameter (17.1 +/- 2.6 cm2). Operative procedures were: 4 salpingooophorectomies and 5 unilateral oophorectomies. In a single case, the contralateral ovary had a suspicious lesion, which was biopsied. No tumors spills occurred. The pathology included 2 simple cysts, 3 serous cyst adenomas, 3 mature cystic teratomas, and 1 immature teratoma with grade 2 to 3 immature elements. Peritoneal washings were negative. All patients were discharged within 48 hours and are well 15 months to 3.1 years postoperatively.

CONCLUSIONS

The containment of the ovarian cyst with the application of surgical adhesives and a plastic sleeve offers a significant advancement in our ability to safely treat these lesions. This approach markedly reduces the length of the surgical incision while insuring the prevention of peritoneal contamination with cystic fluid.

Hydrosalpinx and IVF: assessment of treatments implemented prior to IVF

It is well known that the success of artificial reproductive techniques, especially IVF, for patients with tubal pathologies such as hydrosalpinx is reduced by half compared with patients without hydrosalpinx. Notably, there are also substantial increases in both early pregnancy loss and ectopic pregnancies. Alterations in the outcome of these patients generally reflect a detrimental effect of hydrosalpinx. However, although many theories have been published, a single explanation has not yet been found over a period of decades. Therefore, the negative effects of hydrosalpinx have generally been attributed largely to: (i) mechanical effects; (ii) embryo and gametotoxicity; (iii) alterations in endometrial receptivity markers; or dwindled cross talk between embryo-endometrium resulting in hindered implantation, and (iv) direct effect on endometrium, leading to intrauterine fluid formation. On the other hand, the most important question is selection of the preferred treatment option with either surgical or medical therapies. How should hydrosalpinx be managed? Does selection of the surgical method, either proximal obstruction or salpingectomy, depending on patients' clinical findings, differ in outcome, or is routine prophylactic salpingectomy needed? Additionally, the requirement for IVF or intracytoplasmic sperm injection is still controversial in patients with unilateral hydrosalpinx who have been treated with unilateral salpingectomy.

Surgical Treatment of Ectopic Pregnancy

In most cases of ectopic pregnancy, medical treatment with methotrexate is successful. However, some cases still require surgery and laparoscopy is an effective approach. The candidates for surgical treatment include women who are not suitable to or have failed methotrexate treatment, those with heterotopic pregnancy, or those who are hemodynamically unstable. In women of reproductive age with tubal pregnancy, salpingostomy is the preferred surgical method. Conversely, salpingectomy is a better treatment for women with severely damaged fallopian tube, recurrent ectopic pregnancy in the same tube, uncontrolled bleeding after salpingostomy, large tubal pregnancy (> 5 cm), heterotopic pregnancy, and for those who have completed their family. Similar to treatment of a tubal pregnancy, cervical and interstitial pregnancy could be treated medically first. Most abdominal pregnancies are diagnosed late in pregnancy. However, when the diagnosis is made early, laparoscopic removal of the pregnancy should be performed.

Local Treatment of Ectopic Pregnancy

The treatment of ectopic pregnancies has evolved from a purely surgical route with routine removal of the fallopian tube to one with multiple options. Medical treatment can be administered systemically or via local injection. Local delivery of chemotherapeutic agents is a safe and proven modality that is especially indicated for pregnancies in which a laparoscopic approach is not ideal and systemic therapy either has failed or is not desired. Local therapy has the potential to document immediately the cessation of fetal heart activity. Nontubal ectopic pregnancies may be ideally suited to local therapy, especially when there is a fetal heart present. Transvaginal ultrasound is the preferred mode for guidance and laparoscopic guidance has a limited role. Although a multitude of agents have been proposed, methotrexate, KCl, and hyperosmolar glucose are the most widely used and readily available. Local therapy has an important place in the armamentarium of the treatment of ectopic pregnancies.

Extrauterine choriocarcinoma of the greater omentum after tubal pregnancy: case report

Extrauterine choriocarcinoma is a rare form of gestational trophoblastic tumor. Extrauterine choriocarcinoma of the greater omentum is extremely rare in the literature. A 24-year-old female with irregular vaginal bleeding, mimicking as ectopic pregnancy, underwent emergency exploratory laparotomy and local excision of the greater omentum mass. The serum beta-human chorionic gonadotropin level decreased rapidly after operation; however, it rose up again before long. Pathology showed choriocarcinoma in the greater omentum. No evidence showed lesions on uterus. No other metastasis was found. Multiple courses of combined chemotherapy were effective for this case. Surgical excision and combined chemotherapy were effective for extrauterine choriocarcinoma of the greater omentum.

Interventions for tubal ectopic pregnancy

BACKGROUND

Treatment options for tubal ectopic pregnancy are; (1) surgery, e.g. salpingectomy or salpingo(s)tomy, either performed laparoscopically or by open surgery; (2) medical treatment, with a variety of drugs, that can be administered systemically and/or locally by various routes and (3) expectant management.

OBJECTIVES

To evaluate the effectiveness and safety of surgery, medical treatment and expectant management of tubal ectopic pregnancy in view of primary treatment success, tubal preservation and future fertility.

SEARCH STRATEGY

The Cochrane Menstrual Disorders and Subfertility Group's Specialised Register, Cochrane Controlled Trials Register (up to February 2006), Current Controlled Trials Register (up to October 2006), and MEDLINE (up to October 2006) were searched.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing treatments in women with tubal ectopic pregnancy.

DATA COLLECTION AND ANALYSIS

Data extraction and quality assessment was done independently by two reviewers. Differences were resolved by discussion with all reviewers.

MAIN RESULTS

Thirty five studies have been analysed on the treatment of tubal ectopic pregnancy, describing 25 different comparisons.

SURGERY

Laparoscopic salpingostomy is significantly less successful than the open surgical approach in the elimination of tubal ectopic pregnancy (2 RCTs, n=165, OR 0.28, 95% CI 0.09, 0.86) due to a significant higher persistent trophoblast rate in laparoscopic surgery (OR 3.5, 95% CI 1.1, 11). However, the laparoscopic approach is significantly less costly than open surgery (p=0.03). Long term follow-up (n=127) shows no evidence of a difference in intra uterine pregnancy rate (OR 1.2, 95% CI 0.59, 2.5) but there is a non significant tendency to a lower repeat ectopic pregnancy rate (OR 0.47, 95% 0.15, 1.5). Salpingostomy alone is significantly less successful than when combined with a prophylactic single shot methotrexate (2 RCTs, n=163, OR 0.25, 95% CI 0.08-0.76) to prevent persistent trophoblast.

MEDICAL TREATMENT

Systemic methotrexate in a fixed multiple dose intramuscular regimen has a non significant tendency to a higher treatment success than laparoscopic salpingostomy (1 RCT, n=100, OR 1.8, 95% CI 0.73, 4.6). No significant differences are found in long term follow-up (n=74): intra uterine pregnancy (OR 0.82, 95% CI 0.32, 2.1) and repeat ectopic pregnancy (OR 0.87, 95% CI 0.19, 4.1). One single dose intramuscular methotrexate is significantly less successful than laparoscopic salpingostomy (4 RCTs, n=265, OR 0.38, 95% CI 0.20, 0.71). With a variable dose regimen treatment success rises, but shows no evidence of a difference compared to laparoscopic salpingostomy (OR 1.1, 95% CI 0.52, 2.3). Long term follow-up (n=98) do not differ significantly (intra uterine pregnancy OR 1.0, 95% CI 0.43, 2.4, ectopic pregnancy OR 0.54, 95% CI 0.12, 2.4). The efficacy of systemic single dose methotrexate alone is significantly less successful than when combined with mifepristone (2 RCTs, n=262, OR 0.59, 95% CI 0.35, 1.0). The same goes for the addition of traditional Chinese medicine (1 RCT, n=78, OR 0.08, 95% CI 0.02, 0.39). Local medical treatment administered transvaginally under ultrasound guidance is significantly better than a 'blind' intra-tubal injection under laparoscopic guidance in the elimination of tubal ectopic pregnancy (1 RCT, n=36, methotrexate OR 5.8, 95% CI 1.3, 26; 1 RCT, n=80, hyperosmolar glucose OR 0.38, 95% CI 0.15, 0.93). However, compared to laparoscopic salpingostomy, local injection of methotrexate administered transvaginally under ultrasound guidance is significantly less successful (1 RCT, n=78, OR 0.17, 95% CI 0.04, 0.76) but with positive long term follow up (n=51): a significantly higher intra uterine pregnancy rate (OR 4.1, 95% CI 1.3, 14) and a non significant tendency to a lower repeat ectopic pregnancy rate (OR 0.30, 95% CI 0.05, 1.7). EXPECTANT MANAGEMENT: Expectant management is significantly less successful than prostaglandin therapy (1 RCT, n=23, OR 0.08, 95% CI 0.02-0.39).

AUTHORS' CONCLUSIONS

In the surgical treatment of tubal ectopic pregnancy laparoscopic surgery is a cost effective treatment. An alternative nonsurgical treatment option in selected patients is medical treatment with systemic methotrexate. Expectant management can not be adequately evaluated yet.

Comparison of the effects of tibolone and estrogen therapy on hemostasis in surgical menopause: a randomized, double-blind, placebo-controlled study

OBJECTIVE

To examine the effects of unopposed estrogen (E) and tibolone therapy on coagulation and natural anticoagulant systems in surgical menopause.

DESIGN

A randomized, double-blind, placebo-controlled study.

SETTING

University hospital clinic in Turkey.

PATIENT(S)

Ninety healthy surgically postmenopausal women.

INTERVENTION(S)

Ninety surgically postmenopausal women were randomized into three groups: unopposed conjugated ET (0.625 mg/d, group 1), tibolone (2.5 mg/d, group 2), and identical tablets of placebo (group 3).

MAIN OUTCOME MEASURE(S)

Effects on parameters in the clotting cascade at baseline and after 24 weeks of treatment.

RESULT(S)

After 6 months, fibrinogen, lipoprotein (a), and factor VIIa were decreased, and activated partial thromboplastin time was increased significantly in the ET group compared with in the placebo group. However, tibolone significantly decreased only the serum levels of factor VIIa and factor IX and prolonged the activated partial thromboplastin time, compared with placebo group. In addition, conjugated ET caused a significantly greater decrease in serum fibrinogen level than did tibolone.

CONCLUSION(S)

Neither E nor tibolone therapy led to activation of coagulation in the surgically menopausal women. Both preparations changed the overall hemostatic balance to a more fibrinolytic state.

Controversies in the management of ectopic pregnancy

Ectopic pregnancy is a common clinical problem, but there appears to be much controversy surrounding the surgical management of its occurence. This paper reviews the available evidence on the management of ectopic pregnancy. The discussion focuses initially around the choice of medical versus surgical treatment. Next, the question is addressed that if surgical management is deemed necessary, whether the approach should be laparoscopic or via open laparotomy. Lastly, if surgery is undertaken, should salpingectomy or salpingotomy be performed? Laparoscopy will remain the main method of treatment for women with ectopic pregnancy, as it provides obvious advantages over open surgery. On balance, salpingotomy should be the surgical treatment of choice for the majority of women with ectopic pregnancy, as it results in a higher subsequent pregnancy rate, although there is a slightly higher recurrent ectopic pregnancy rate and persistent trophoblastic disease rate when compared with women treated with salpingectomy. There is also a place for medical treatment of women with low concentrations of human chorionic gonadotrophin. A variable dosing methotrexate regimen is more effective compared with single dose regimen, and the fixed multiple regimen is associated with a high rate of side effects.

A profile of ectopic pregnancy at nepal medical college teaching hospital

A retrospective study of ectopic pregnancy at Nepal Medical College Teaching Hospital between January 2001 to June 2006 was carried out to determine incidence, demographic features, clinical presentation, duration at presentation and treatment, and the management protocol. A total of 36 cases of ectopic pregnancy were treated giving the incidence of ectopic pregnancy of 10.2/1000 deliveries and 7.3 /1000 pregnancies. The mean age is 30.1 years (range 23-45 years) and the mean parity is 1.2 with nulliparous at 49%. The mean gestational age is 6.9 weeks (range 5-11 weeks). Among the ethnicity, Mongolians constituted at 54.6%. The commonest risk factors present were infertility (33.3%), previous ectopic pregnancy (16.7%), pelvic inflammatory disease (13.9%) and tubal surgery (13.9%). The commonest symptoms at presentation are abdominal pain (94.4%), amenorrhea (72.2%) and abnormal vaginal bleeding (58.3%); and commonest signs were abdominal tenderness (91.7%), adnexal tenderness (72.2%) and cervical excitation (50.0%). The mean time from symptom to treatment was 176.58 hours and mean time from admission to treatment was 12.88 hours. Ectopic pregnancy was correctly diagnosed clinically in 85.0% patients including 42.5% (12/36) of ruptured ectopic pregnancy. Abdominal ultrasound and urinary â-hCG tests (ELISA test) were additional diagnostic tools. Sixty one percent (22/36) presented in subacute condition. Two cases (5.6%) were presented late causing diagnostic problem and more morbidity like anaemia, blood transfusion, adhesion needing major operations. Salpingectomy is the mainstay of treatment. Only one case has conservative surgery. Late presentation and ruptured ectopic pregnancy is associated with increased morbidity and mortality. High index of suspicion and early recourse to laparotomy save the life from this obstetric disaster.

[Retained ovarian remnant carcinoma: a case report]

Ovarian remnant syndrome is defined as residual ovarian tissue non intentionally left in place by the surgeon during a bilateral salpingo-oophorectomy. Patients present various symptoms usually including chronic pelvic pain, pelvic mass, bowel obstruction, hydronephrosis due to ureteral compression. We report a case of adenocarcinoma arising in such an ovarian remnant revealed by vaginal bleeding 5 years after total abdominal hysterectomy and bilateral oophorectomy for uterine fibroids. It was regarded as stage IIIc according to the FIGO classification because of common iliac lymph node involvement while there was no ascitis, no peritoneal nor omental implant but a unilateral hydronephrosis induced by extrinsec ureteral obstruction. Complete cytoreductive surgery was achieved including partial bladder and lower ureteral resection with colpectomy, omentectomy, pelvic and para-aortic lymphadenectomy. Paclitaxel-Platinum combination chemotherapy was given for nine cycles.

Tubal patency following surgical and clinical treatment of ectopic pregnancy

CONTEXT AND OBJECTIVE

As there is little information about fertility outcomes among women following clinical treatment (methotrexate and expectant management) and surgery (salpingectomy) consequent to ectopic pregnancy, we evaluate the results from hysterosalpingography subsequent to treatment. The objective was to evaluate contralateral tubal patency using hysterosalpingography following surgery and clinical treatment of tubal pregnancy.

DESIGN AND SETTING

This was a prospective study at the Department of Obstetrics of Universidade Federal de São Paulo, a tertiary center.

METHOD

Among 115 patients who underwent hysterosalpingography following surgery and clinical treatment of tubal pregnancy between April 1994 and February 2002, 30 were treated with a single intramuscular dose of methotrexate (50 mg/m(2)), 50 were followed up expectantly and 35 underwent salpingectomy.

RESULTS

The patency of the ipsilateral tube was 84% after methotrexate treatment and 78% after expectant management. In addition, contralateral tubal patency was 97% after methotrexate treatment, 92% after expectant management and 83% after salpingectomy. There were no statistically significant differences between the clinical treatment and surgery groups.

CONCLUSIONS

The findings from this study suggest similar contralateral tubal patency rates following salpingectomy, methotrexate treatment and expectant management.

Ectopic pregnancy in a preexisting hydrosalpinx during a spontaneous pregnancy

OBJECTIVE

To discuss the possible role of abnormal embryo migration as a cause of ectopic pregnancy during IVF with hydrosalpinges.

DESIGN

Case report.

SETTING

University-based reproductive endocrinology and fertility clinic.

PATIENT(S)

A patient presenting with a tubal ectopic pregnancy after spontaneous conception in a preexisting hydrosalpinx.

INTERVENTION(S)

Laparoscopic salpingectomy.

MAIN OUTCOME MEASURE(S)

Ultrasound and operative findings.

RESULT(S)

Case demonstration of abnormal embryo migration into a surgically documented preexisting hydrosalpinx during a spontaneous conception.

CONCLUSION(S)

The mechanism of increased tubal ectopic pregnancy rates during IVF with hydrosalpinges remains unexplained. This case supports abnormal embryo migration due to the hydrosalpinx as a contributing factor.

Spontaneous twin tubal ectopic gestation

We present a case of a viable spontaneous unilateral twin ectopic pregnancy in the right fallopian tube that was diagnosed with transvaginal sonography and subsequently treated with laparotomy and salpingectomy.

Mature cystic teratoma of the fallopian tube

A mature cystic teratoma within the fallopian tube was discovered at the time of laparoscopy for dysmenorrhea, dyspareunia, and infertility. A linear salpingostomy was performed with fulguration of the pedicle attaching the mass to the fallopian tube and removal of the dermoid cyst.

Orbital metastasis from ovarian carcinoma in a patient with BRCA-2 mutation

A 45-year-old woman with BRCA-2 mutation-positive ovarian carcinoma had pain, swelling, and proptosis of her left eye. CT demonstrated a mass in the left orbit. Fine-needle aspiration and lateral orbitotomy were used to obtain tissue for diagnosis. Pathology confirmed poorly differentiated tumor cells consistent with ovarian carcinoma. Cytopathologic testing confirmed receptor and hormonal markers within the orbital specimen that were identical to specimens removed 4 years prior.

Emergency gynaecology

The management of gynaecological emergencies is directed at the preservation of life, health, sexual function and the perpetuation of fertility. Ectopic pregnancy (EP), pelvic inflammatory disease (PID) and miscarriages are common gynaecological emergencies and early recognition and appropriate treatment is essential to avoid unwanted sequelae. Controversy will always exist in clinical medicine because management is mainly based on uncontrolled studies, expert opinion and personal experiences. It is estimated that only 10% of clinical treatments have been validated by prospective, randomised trials. Recent advances have led to earlier diagnosis and more conservative treatment on an outpatient or day care basis in EP and miscarriages.

[Contribution of laparoscopy in improving the therapy in patients with tubal infertility]

The aim of this study is to estimate the advantages of laparoscopy for a correct diagnosis and an adequate treatment in cases of tubal infertility. The group of study included 141 patients, hospitalised and treated in the 2-nd Clinic of Obstetrics and Gynecology Iaşi. We used diagnostic laparoscopy to elaborate the adhesion score and the tubal score. The stage of tubal lesions, estimated by these two scores, orientated the surgical technique: adhesiolysis (43.26% of cases), distal tubal reconstruction--fimbrioplasty (45.39% of cases) or neo-salpingostomy (21.98% of cases)--followed by ovarian drilling. The incidence of the uterine pregnancies obtained (30.10%) was statistically correlated with favorable prognostic factors: minimal adhesion score, minimal and moderate tubal score, type of tubal surgical reconstruction. The favorable correlation between laparoscopy and the results obtained confirms a good case selection and the possibility to use minimal invasive methods in the treatment

Spontaneous triplet, tubal ectopic gestation

Only six cases of spontaneous, unilateral, triplet ectopic gestations have previously been reported. We now present a seventh case. The patient's prior obstetrical history was significant for a term stillbirth and a term cesarean section for breech. Quantitative betahCG was normal for gestational age; however, the increased trophoblastic mass of an inappropriately implanted multiple gestation may produce sufficient betahCG to mimic an intrauterine singleton gestation. Resolution was achieved via salpingostomy. This case is significant for being spontaneously conceived and not the result of assisted reproductive technologies. Furthermore, this case supports an association between prior cesarean section and ectopic gestation.

Non-Puerperal Uterine Inversion due to Uterine Sarcoma

BACKGROUND

Uterine inversion is a very rare pathological condition that usually occurs in puerperium. Non- puerperal uterine inversion is exceptional and to our knowledge only a few cases of uterine inversion due to a uterine sarcoma have been reported.

CASE REPORT

A 79-year-old woman, gravida 0, para 0, presented with vaginal bleeding. Pelvic examination under anesthesia revealed a huge mass coming from the cervix filling the vagina to the introitus, and rectal examination could not identify the uterus. Diagnosis of uterine inversion was made and the patient was submitted to total abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic lymph node sampling. The postoperative course was uneventful and the patient was discharged on the 5th postoperative day. She underwent postoperative pelvic radiation, and no recurrence was found during the 19-month follow-up period.

CONCLUSION

Chronic non-puerperal uterine inversion can be considered a rare complication of malignant mixed mullerian tumor of the uterus.

[Effects of combined therapy of salpingostomy and Bushen Huoxue drugs on fallopian tube obstructive infertility]

OBJECTIVE

To compare the effect of treatment of fallopian tube obstructive infertility by salpingostomy alone and in combination with TCM drugs for Bushen Huoxue (invigorating Shen and promoting blood circulation).

METHODS

To all the patients, salpingostomy was performed 3 to 7 days after menstruation and hydrotubation with Xiangdan Injection (XI) was applied once in the next menstrual cycle. Bushen Huoxue Decoction (BHD) was administrated additionally to patients in the treated group, 1 dose every day starting from the 5th day of menstrual cycle for 14 days. Three months' treatment was taken as one therapeutic course and the observation lasted for 4 courses.

RESULTS

The condition of follicular development, thickness of endometrium and level of serum estradiol in the preovulatory phase after treatment were all significantly increased in the two groups (P < 0.05 and P < 0.01); but the improvement in the treated group was significantly superior to that in the control group, showing significant difference. Moreover, the pregnancy rate was also higher in the former than in the latter (P < 0.05).

CONCLUSION

The combined therapy of salpingostomy and TCM drugs for invigorating Shen and promoting blood circulation is an effective therapy for fallopian tube obstructive infertility, it has the effect of enhancing follicular development and increasing thickness of endometrium, and could elevate the pregnancy rate in patients.