Gestación ectópica ovárica con diagnóstico en segundo trimestre de embarazo en paciente portadora de DIU

Primary ovarian location is a rare form of ectopic pregnancy. According to the existing literature, the presence of an intrauterine device is its main risk factor. Its preoperative diagnosis is difficult and is usually confirmed during surgery or through subsequent histological study. Most ovarian pregnancies end in the first trimester of gestation. Those reaching the second trimester without rupture -as in the clinical case that we describe below- remain an exception. In the case of a suspected diagnosis, urgent surgical treatment is recommended to prevent rupture of the ovarian ectopic pregnancy.     

Medical therapy (methotrexate and mifepristone) alone or in combination with another type of therapy for the management of cervical or interstitial ectopic pregnancy

Objective

To describe cases of cervical or interstitial ectopic pregnancy managed conservatively with combined medical treatment (methotrexate and mifepristone) alone or in association with other minimally invasive strategies.

Study design

We describe four cervical and two interstitial ectopic pregnancies at our hospital between 2006 and 2010. All received combined treatment with methotrexate and mifepristone. A search of MEDLINE is also described.

Results

The literature search identified only four previous cases of cervical ectopic pregnancies and no cases of interstitial ectopic pregnancy managed with combined therapy. In our study, all patients were successfully treated and had no adverse reactions with intramuscular methotrexate 50 mg/m² and oral mifepristone 600 mg, either alone or in association with minimally invasive treatment (uterine artery embolization and evacuation dilation and curettage). All patients remained asymptomatic with β-HCG levels that decreased and became negative within 14–49 days: the median hospital stay was 5.5 days. We also describe the first patient with a cervical ectopic pregnancy treated with methotrexate and mifepristone, followed by vaginal misoprostol 800 mcg for cervical evacuation.

Conclusion

Methotrexate–mifepristone, either alone or in combination with other minimally invasive strategies, could be considered an option for the treatment of both cervical and interstitial ectopic pregnancy. An individualized approach should be used in each patient, however, given the wide variety of possible clinical situations and the potential seriousness of ectopic pregnancy.     

Plasma hCG and ultrasound in suspected ectopic pregnancy

The value of plasma hCG determinations (based on the recognition of β-subunit of hCG) and ultrasound was examined in 48 cases of suspected ectopic pregnancy. In 11 patients with the final diagnosis of ectopic pregnancy (23%), the plasma hCG was clearly subnormal (0.37–3.96 IU/ml), with only one exception, where a normally developed fetus was operated from the fallopian tube (hCG 21.1 IU/ml in the 8th wk). The plasma hCG levels allowed differentiation of the non-pregnant cases from the normal intrauterine pregnancies and the ectopic cases, but not at all between the different forms of intrauterine early pregnancy failures and ectopic pregnancies. By ultrasound, however, it was possible to reliably diagnose intrauterine pregnancies from the 7th wk of amenorrhea onwards, and to classify them into the normal and pathological subgroups. The direct demonstration of ectopic pregnancy by ultrasound is problematic, but the exclusion of intrauterine pregnancy by this method, combined with the simultaneous plasma hCG determination by sensitive and rapid method, can be recommended for primary examinations in suspected ectopic pregnancy.     

Laparoscopic removal of a large 8-cm ectopic pregnancy with a negative pregnancy test

Ectopic pregnancy has been increasing in frequency over the past years. The first step in the diagnosis of ectopic pregnancy is the demonstration of pregnancy by performing a sensitive qualitative urine test; hence, a negative urine pregnancy test will generally exclude ectopic pregnancy from the differential diagnosis. The following is a report of a patient presenting with abnormal vaginal bleeding for 8 weeks with a negative urine pregnancy test and transvaginal scan suggesting a large 8-cm ectopic pregnancy. This case report demonstrates the importance of keeping the diagnosis of ectopic pregnancy in our mind even with negative urine pregnancy but with atypical presentation and how such large ectopic pregnancies can still be managed laparoscopically.     

A Pragmatic and Evidence-Based Management of Ectopic Pregnancy

The incidence of ectopic pregnancy is approximately 2% of all pregnancies, and it remains the leading cause of death in early pregnancy. Over 95% of ectopic pregnancies are tubal pregnancies, and the remainders are nontubal pregnancies. The highest risk factor for ectopic pregnancy is a previous tubal pregnancy followed by previous tubal surgery, tubal sterilization, tubal pathology, and current intrauterine device use. The apparent increase in the incidence of nontubal ectopic pregnancy including heterotopic pregnancy may be attributed to the increasing number of pregnancies because of in vitro fertilization treatment. In most cases, an ectopic pregnancy can be treated medically with a single dose of methotrexate. Surgical treatment is still needed in women who are hemodynamically unstable and in those who do not fulfill the criteria for methotrexate treatment. Usually surgical treatment can be performed by laparoscopy and in some cases by hysteroscopy. Laparotomy is rarely needed even in women with intraperitoneal bleeding.     

腹腔镜早期诊治可疑异位妊娠的临床意义

目的 评估可疑异位妊娠(ectopic pregrnancy，EP)患者腹腔镜(laparoscopy，LSC)早期诊断和急诊手术的临床价值。方法 回顾分析1998年8月至2003年8月收治的经LSC手术治疗的可疑EP患者186例，均在入院24h内接受急诊LSC手术。结果 185例手术经腹腔镜完成，l例中转开腹，均无并发症发生。术中诊断EP172例(均经病理证实)，术前诊断符合率92．5％；其余病例依次为卵巢囊肿9例(4．8％)，宫内妊娠黄体破裂5例(2．7％)。32例合并不孕患者中25例有盆腔粘连，17例有输卵管卵巢病变，均行相应处理。12例少见异位妊娠(包括4例输卵管间质部妊娠，4例卵巢妊娠，3例腹腔妊娠，l例子宫肌壁间妊娠)，15例休克型异位妊娠，经腹腔镜手术亦获满意治疗效果。结论 急诊LSC手术不仅可早期确诊可疑EP患者，为保守性治疗赢得时间，而且还可同时对不孕症患者进行诊治。急诊LSC手术治疗休克型及少见异位妊娠亦是可行且安全的。     

Heterotopic pregnancy in a spontaneous cycle

Heterotopic pregnancy, defined as the simultaneous occurrence of intrauterine and extrauterine pregnancies, is rare in a natural cycle. Assisted reproductive techniques have resulted in an increased incidence. Identification of an intrauterine pregnancy can divert attention from the possibility of a concurrent ectopic pregnancy. We describe such a case with the educational features.     

Clinical analysis of ovarian pregnancy: a report of 49 cases

Objective

To clinically analyze cases of ectopic ovarian pregnancy and to generate data regarding the evaluation and management of suspected ectopic ovarian pregnancies.

Study design

We retrospectively analyzed 49 ovarian pregnancies that were surgically treated at Cheil General Hospital and Women's Healthcare Center between January 1996 and December 2009. We analyzed patient age, parity, symptoms, risk factors, preoperative diagnosis, and ovarian pregnancy type.

Results

During the study period, the incidence of ovarian pregnancy was 1.59% of all ectopic pregnancies (49/3081); 45/49 (91.8%) were primary ovarian pregnancies. At the time of diagnosis, mean age was 30.7 years (SD: ±4.4 years) and mean parity was 0.63 (SD: ±0.8). The most common presenting symptoms were abdominal pain (42.9%) and vaginal bleeding (28.6%). The most common sonographic findings were fluid surrounding the ovarian pregnancy and ovarian enlargement. In regard to surgical treatment, ovarian wedge resection was most often performed (85.7% of cases), followed by oophorectomy (8.2% of cases). The most common risk factors were endometriosis (16 patients) and a history of abdominal surgery (19 patients).

Conclusions

Ovarian pregnancies are extremely rare and difficult to diagnose both pre- and intra-operatively. Our data may assist surgeons in understanding the clinical presentation of ovarian pregnancy and in counseling patients. Larger studies are warranted to gather more data on this rare form of ectopic pregnancy.     

Non-tubal Ectopic Pregnancies: Overview and Treatment via Local Injection

Ectopic pregnancies account for 1.5% to 2% of all pregnancy in the United States. Of these, approximately 10% implant in nontubal locations, including the abdominal cavity, cervix, ovary, interstitial portion of the fallopian tube, broad ligament, the uterine cornua, or within a cesarean section scar. Because these pregnancies tend to present later than typical tubal pregnancies, they have been associated with greater maternal morbidity and mortality. Advances in ultrasound technology have allowed for earlier diagnosis of nontubal ectopic pregnancies, which in turn has led to the development of novel minimally invasive techniques to manage them. One of these methods involves the local injection of 1 of several agents directly into the ectopic pregnancy. In this article we provide a guide to this technique of local injection, including an overview of the potential agents that can be used, and review the diagnostic and specific ultrasound criteria, other possible treatment options, and overall outcomes for nontubal ectopic pregnancies.     

电视腹腔镜下诊治异位妊娠——附56例

目的:探讨腹腔镜对异位妊娠诊治的价值。方法:在腹腔镜下应用不同手术方法治疗56例异位妊娠。结果:56例异位妊娠全部在腹腔镜下得到进一步诊治,无中途转为剖腹。结论:腹腔镜诊治异位妊娠具有创伤小、疼痛轻、恢复快、并发症少等优点。术中输卵管是否保留要根据患者生育情况及输卵管破坏程度决定。     

Tubal pregnancy after clomiphene treatment: are you sure is not bilateral?

The estimated prevalence of ectopic pregnancy (EP) is 1–2% worldwide. Bilateral tubal pregnancies represent the rarest form of heterotopic pregnancy, and spontaneously conceived are extremely unusual, as many cases are derived from assisted reproductive techniques. We describe a case of bilateral tubal pregnancy after clomiphene therapy and sexual intercourse in which the second EP was not contemporarily revealed.     

异位妊娠与IUD关系的探讨(附107例分析)

本文根据我院1984～1990年间62,321妊娠妇女的资料分析,宫内妊娠与异位妊娠的发病率发生了高度显著的变化(P<0.01)。特别是带器异位妊娠与未带器异位妊娠、带器异位妊娠与带器宫内妊娠之间的比例,1990年与1984年相比,差别高度显著(P<0.01),说明带器异位妊娠发病率极显著地上升。进一步对107例带器异位妊娠进行分析,发现与环位异常有一定的关系,经B超测定环位异常者占53%(35/66);且大部分发生在带器1～4年期间(68%);输卵管病理未能证实与炎症有关。指出带器异位妊娠发病率逐年增高,应予重视,与IUD之间的关系仍需进一步探讨。     

Laparoscopic management of a primary ectopic ovarian pregnancy and vaginal douching as a possible cause

Case report Ovarian pregnancy is a rarely seen form of ectopic pregnancies. We present a 34-year-old women who had a diagnosis of ovarian ectopic pregnancy based on clinical and laboratory findings. Laparoscopic surgery was performed for conservative management of the case. Risk factors are outlined and vaginal douching as a possible cause for ectopic pregnancies have been discussed. Conclusion We suppose that frequent vaginal douching may be a risk factor for the development of ovarian ectopic pregnancies.     

Cost-effectiveness of presumptively medically treating women at risk for ectopic pregnancy compared with first performing a dilatation and curettage

OBJECTIVE: To compare the cost and complication rate of two alternative strategies for the diagnosis and medical management of ectopic pregnancy when ultrasound is nondiagnostic. DESIGN: A decision tree was constructed to compare [1] dilatation and curettage (D&C) followed by treatment of all ectopic pregnancies with methotrexate versus [2] empiric treatment of all patients with possible ectopic pregnancies with methotrexate without D&C. SETTING: University setting. PATIENT(S): Ten thousand hypothetical women with nonviable pregnancies and a known incidence of ectopic pregnancy were entered into a computer model. MAIN OUTCOME MEASURE(S): The two approaches were compared with respect to the number of missed ectopic pregnancies, complications, procedures performed, admissions to the hospital, and cost. RESULT(S): The D&C group had 1% more failed managements of ectopic pregnancies and 13.4% fewer patients with a miscarriage undergo a second treatment for resolution. The D&C group had 13.7% fewer complications including 6.3% fewer hospitalizations. D&C costs $173 to $223 more than empiric use of methotrexate per patient. CONCLUSION(S): Empirically treating women at risk for ectopic pregnancy with methotrexate does not reduce complications or save money. In the absence of such savings, the desire to make an accurate and definitive diagnosis, allowing objective prognosis on future fertility and risk of repeat ectopic pregnancy, supports the need to distinguish a miscarriage from ectopic pregnancy before treatment with methotrexate.     

Ectopic pregnancies after in vitro fertilization and embryo transfer

Objective Our objective was to analyze the risk factors, stimulation characteristics, and future fecundity of patients with ectopic pregnancies after in vitro fertilization (IVF).Methods We retrospectively evaluated all cases of ectopic pregnancy occurring between January 1989 and March 1993 (Cornell series 1 to 17). A case-control group of intrauterine pregnancies was used for comparison of the stimulation and transfer characteristics.Results Twenty-seven of 1123 pregnancies (2.4%) were ectopic, following 2812 fresh IVF embryo transfers, while 8 of 105 pregnancies (7.6%) were ectopic, following 405 frozen-thawed embryo transfers. Tubal factor was the cause of infertility in the majority (85.7%) of ectopic pregnancies. No difference was found between the ectopics and the matched controls in stimulation and transfer characteristics. Thirty ectopic pregnancies were ampullary, two were interstitial, two were cervical, and one was heterotopic. Twenty of the patients subsequently underwent 29 IVF attempts, with a pregnancy rate of 41.4% per transfer.Conclusions Ectopic pregnancy after IVF appears to be related to preexisting tubal pathology; embryo transfer of cryopreserved thawed embryos in a natural cycle may result in a higher ectopic rate in these patients; in subsequent IVF cycles the intrauterine pregnancy rate of these patients is not decreased.     

Expectant management of suspected ectopic pregnancies even with risingβ-subunit human chorionic gonadotropin levels

A prospective study was undertaken to evaluate possibility of expectant management of ectopic pregnancy in a selected group of patients with few symptoms, no gestational sac on sonography, and rising but lowβhCG levels. Using the above mentioned criteria, 26 patients were enrolled during prospective study period of 24 month. Five patients (19.2%) had a ruptured tubal pregnancy during the period of observation. Ten patients (38.5%) underwent laparoscopy with subsequent surgery for tubal pregnancy. The indication for laparoscopy in all 10 cases was abdominal pain. In all these 10 patients the pregnancy was unruptured. The remaining 11 patients (42.3%) escaped surgical intervention. Three had intrauterine pregnancies. In the remaining 8 patients the diagnosis remained presumed ectopic. The mean interval from admission toβhCG level of <5 mIU/ml in these 8 patients was 19.2 ± 8.4 days. They were inpatients until theβhCG level begun to decline. Thereafter, the patients were observed as outpatients. We conclude that in carefully selected cases of suspected ectopic pregnancies with rising but lowβhCG levels, expectant management is appropriate as long as the patient remains relatively asymptomatic.     

Distinguishing between interstitial and angular pregnancies: Is there a role for saline infusion sonohysterography?

Objective

Interstitial pregnancy occurs in the intramural segment of the Fallopian tubes, while angular pregnancy is one that is located in one of the lateral angles of the uterine cavity. The differential diagnosis and treatment of these conditions are important. We have used saline infusion sonohysterography (SIS) to help in differential diagnosis.

Sonographic evolution of cornual pregnancies treated without surgery.

Transvaginal sonography allows early and accurate diagnosis of cornual pregnancy, as well as providing a means for puncture injection treatment of certain ectopic pregnancies. We describe four cases of cornual pregnancy managed nonsurgically and followed with transvaginal sonography for 47-64 weeks. Sonographic evidence of cornual pregnancy persisted throughout the period of follow-up, despite resumption of normal menstrual cyclicity. We conclude that some early live cornual pregnancies can be managed by puncture injection, and cornual pregnancies in which the embryo has died can be followed conservatively.     

Methotrexate and Ectopic Pregnancy: Is there a Place for Medical Management?

Objective: to evaluate the success of methotrexate as a treatment for ectopic pregnancy in our centre. Based on these results and a review of the literature, to propose an updated protocol for the use of methotrexate in treating ectopic pregnancy.Methods: retrospective review of all charts coded for ectopic pregnancy in two tertiary-care hospitals between July 1993 and June 1995. Attending physicians were also surveyed to locate any cases of ectopic pregnancy treated with methotrexate without admission to hospital.Results: during the study period, 265 ectopic pregnancies occurred in 258 patients. Forty-eight of these patients were treated with methotrexate using a protocol similar to that published by Stovall. Of the 48 patients treated with methotrexate, two patients were lost to follow-up, 16 patients suffered a treatment failure requiring surgery and 30 patients were treated successfully.Conclusion: our success rate of 63 percent in treating ectopic pregnancies with methotrexate is lower than the more favourable results published by Stovall. Further evidence of the efficacy of methotrexate is required.     

宫外孕多普勒超声的影像特征

目的:探讨超声检查诊断异位妊娠的临床价值,提高输卵管妊娠的早期检出率。方法:对113例早期异位妊娠患者经腹超声的声像图特征进行回顾性分析。结果:超声检查具有捕获图像清晰、准确、快速的特点,对不典型、未破裂的输卵管妊娠可获得早期诊断。结论:超声是诊断异位妊娠的最直接、最重要的方法,并对早期诊断输卵管妊娠有重要的临床价值。