Heterotopic Cesarean Scar Pregnancy

Heterotopic cesarean scar pregnancy is a rare, life‐threatening form of ectopic pregnancy. To provide information regarding the clinical manifestations, diagnosis, management, and prognosis of this condition, we reviewed all cases reported in the English literature. All literature on heterotopic cesarean scar pregnancy was retrieved by searching the PubMed database and tracking references of the relevant literature. Full texts were reviewed, and clinical manifestations, diagnostic methods, and the relationship between the treatment and prognosis were summarized. A total of 14 patients with heterotopic cesarean scar pregnancies were identified, including 6 spontaneous pregnancies and 8 following in vitro fertilization–embryo transfer. Gestational ages at diagnosis ranged from 5 weeks to 8 weeks 4 days. Only 5 cases presented with vaginal bleeding, and the others were asymptomatic. All 14 cases were diagnosed by transvaginal sonography. One patient with no future fertility requirements underwent pregnancy termination by methotrexate. Of the remaining 13 patients who desired to preserve their intrauterine gestations, 10 were treated by sonographically guided selective embryo reduction in situ (by embryo aspiration, drug injection, or both); 2 underwent laparoscopic and hysteroscopic excision of the ectopic pregnancy masses; and 1 was treated by expectant management. All operations were successful and maintained a living intrauterine gestation. Twelve cases resulted in live births by cesarean delivery (3 at term and 9 preterm). One patient underwent pregnancy termination at 12 weeks because of a fetal malformation confirmed by sonography. The possibility of heterotopic cesarean scar pregnancy after cesarean delivery should be considered, especially when pregnancy follows assisted reproductive technology. Transvaginal sonography is an important tool for diagnosis and management. Despite the many options, the best treatment for this condition remains unclear. Selective embryo reduction in situ with sonographic guidance is the main treatment modality and can result in a successful intrauterine gestation, albeit at high risk.     

Heterotopic pregnancy diagnosed by emergency ultrasound

We present a case of heterotopic pregnancy rapidly diagnosed by an emergency physician. To the best of our knowledge, this is the first report of an emergency physician using bedside ultrasound to diagnose an ectopic pregnancy present simultaneously with an intrauterine pregnancy. Other unique features of this case include the diagnosis being made on initial evaluation and the patient's lack of risk factors for heterotopic pregnancy. A review of the cases of heterotopic pregnancy reported in the emergency medicine literature, the rising prevalence of the disease, and factors that may facilitate in making the diagnosis are discussed as well.     

Free Fluid in Morison's Pouch on Bedside Ultrasound Predicts Need for Operative Intervention in Suspected Ectopic Pregnancy

Background Ectopic pregnancies are frequently present in women who present to the emergency department with pregnancy and abdominal pain or bleeding, a subset of whom may require operative intervention.
Objectives To prospectively determine if emergency physician (EP)-performed transabdominal pelvic ultrasonography (US) with determination of free abdominal fluid in the hepatorenal space predicted the need for operative intervention.
Methods Patients who were suspected to have an ectopic pregnancy were prospectively enrolled over a ten-month period. An EP-performed bedside transabdominal pelvic US that included a view of the hepatorenal space (Morison's pouch) for free fluid. The EP US was classified as intrauterine pregnancy (IUP) or no definitive IUP, with Morison's pouch classified as positive or negative. The majority of patients had a subsequent transvaginal pelvic US performed by the Department of Radiology. Patients were followed up for radiology results, need for operative intervention, and ultimate outcome of the pregnancy.
Results There were 242 patients enrolled, with an average time to complete the EP US of 4 minutes and 27 seconds. There were 28 ectopic pregnancies diagnosed (11.6%), of which 18 patients underwent operative intervention. Free fluid in Morison's pouch was identified in ten patients, nine of whom underwent operative intervention, yielding a positive likelihood ratio of 112 (95% confidence interval = 15 to 831) for patients with suspected ectopic pregnancy who required operative intervention.
Conclusions Free intraperitoneal fluid found in Morison's pouch in patients with suspected ectopic pregnancy may be rapidly identified at the bedside by EP-performed US and predicts the need for operative intervention.     

Point-of-Care Ultrasound Diagnosis of Cesarean Scar Ectopic Pregnancy: A Case Series

BackgroundA cesarean scar pregnancy (CSP) is a clinically important form of ectopic pregnancy that carries a high risk of maternal morbidity and mortality. As the rate of cesarean sections has risen, this diagnosis is becoming an increasingly important consideration for providers caring for patients in early pregnancy.Case ReportWe present three cases of CSPs in which point-of-care ultrasound expedited the diagnosis and treatment in the emergency department.Why Should an Emergency Physician Be Aware of This?Given the risks of an undiagnosed CSP, the increasing incidence of CSP, and the number of effective treatment options available in early gestation, the prompt and accurate diagnosis of CSP remains crucial to its successful management. As such, it is an important diagnosis for the emergency physician to consider when evaluating a patient in early pregnancy.     

Heterotopic pregnancy after in vitro fertilization

Maternal mortality related to ruptured ectopic pregnancy remains elevated. A case is presented of heterotopic pregnancy in a patient whose pregnancy was assisted with in vitro fertilization. The patient's diagnosis was delayed, potentially because of lack of tachycardia associated with the hypotension. The clinical presentation of heterotopic pregnancy is similar to that of ectopic pregnancy. The risk factors for heterotopic pregnancy are the same as those for ectopic pregnancy, with the addition of in vitro fertilization, which increases the risk substantially.     

关于亮氨酸氨基转移酶对鉴别异位妊娠意义的探讨

目的：探讨LAP在鉴别异位妊娠时的意义。方法：LAP可催化L－亮氨酸－P－硝基苯胺水解生成L－亮氨酸和P－硝基苯胺，测定405nm处P－硝基苯胺吸光度的增加速度，求得LAP活性。结果：正常妊娠组与异位妊组相对比LAP活性存在显著差异。结论：LAP的活性检测对于鉴别异位妊娠是有临床意义的。     

二维超声及彩超诊断未破型宫外孕

目的　探讨未破型宫外孕的超声诊断方法。方法　选择１６ 例经二维超声与彩色多普勒血流显像首诊,临床确诊的未破型宫外孕病例,对其超声检查资料进行分析。结果　全部病例均显示附件包块。１２ 例（７５ ％ ） 显示肿块内相对周围组织增多的彩色血流信号。频谱多普勒表现附件肿块内低阻血流频谱。ＲＩ值０４２ ±０．０８,子宫动脉及卵巢血流无特征性变化。结论　附件区肿块,肿块内相对周围组织增多的彩色血流信号是超声诊断未破型宫外孕的关键。输卵管妊娠的病理生理改变与超声图像表现相关。疑为宫外孕时,耐心细致地寻找附件包块至关重要。     

超声在异位妊娠诊断中的临床价值

目的：探讨超声在异位妊娠中的诊断及鉴别诊断价值。方法：回顾性分析我院超声诊断45例异位妊娠,并与手术及病理检查结果进行对照。结果：经超声诊断异位妊娠正确率达88.9%（40/45）。结论：超声对异位妊娠的诊断和鉴别诊断均具有较好的临床价值。     

阴道超声对30例未破裂型输卵管妊娠予米非司酮保守治疗的观察与分析

目的： 探讨阴道超声（ＴＶＳ） 对未破裂型输卵管妊娠保守治疗过程中监测的必要性。方法： 对未破裂型输卵管妊娠患者分别于服药前及服药后连续动态观察异位妊娠组织及非均质包块的形成、发展与转归。结果：本文３０ 例, 未破裂型输卵管妊娠予米非司酮保守治疗６～８ 周内异位妊娠包块消失２４ 例 （８０％ ）; 未破裂流产型４例（１３．３３％ ）; 无效２例 （６．６７％ ） 其中服药６００ｍｇ 后无效一例, 服药４００ｍ ｇ 后破裂一例。结论： ＴＶＳ可对异位妊娠提早做出准确诊断, 协助临床随时掌握病情变化, 指导临床及时采取有效治疗措施有重要意义。     

Outcome Prediction for Treatment of Tubal Pregnancy Using an Intramuscular Methotrexate Protocol

Objective. The purpose of this study was to determine the outcome predictors of intramuscular methotrexate therapy for tubal pregnancy. Methods. This retrospective study was approved by our Institutional Review Board. Fifty‐five consecutive women (mean age, 31 years; range, 18–45 years) who were treated with intramuscular methotrexate therapy for tubal pregnancy were retrospectively reviewed. Clinical data (maternal age, gestational age, and serum β‐human chorionic gonadotropin [β‐hCG] level) and transvaginal sonographic findings (size, gross appearance, presence of a gestational product or heartbeat, and amount of the fluid collection) were assessed as potential predictors of the treatment outcome. The Fisher exact test was used for categorical variables, and the Wilcoxon signed rank sum test was used for continuous variables. Treatment failure was defined as the need for surgical intervention. Results. Women with successful treatment differed from women with unsuccessful treatment with respect to the serum β‐hCG level, the gross appearance of tubal pregnancy, and the presence of a gestational product such as a yolk sac or embryo (P <.001; P = .01; and P =.008, respectively). All of the tubal pregnancies with a gestational product appeared as a tubal ring on transvaginal sonography. A high serum β‐hCG level of greater than 2390 mIU/mL and a transvaginal sonographic appearance of a tubal ring were the important predictors associated with failure of intramuscular methotrexate therapy for tubal pregnancy. Conclusions. Measurement of the serum β‐hCG level and evaluation of the transvaginal sonographic appearance of tubal pregnancy are helpful for predicting treatment outcomes in women who receive intramuscular methotrexate therapy for tubal pregnancy.     

甲氨蝶呤联合B超监视妇科手术仪在持续性异位妊娠治疗中的应用

目的:探讨甲氨蝶呤联合B超监视妇科手术仪在持续性异位妊娠治疗中的应用价值。方法:将60例持续性异位妊娠患者分成观察组和对照组各30例,观察组在B超监视妇科手术仪监视下经阴道宫旁注射甲氨蝶呤(MTX)50 mg,对照组予MTX75 mg肌肉注射。比较两组治疗后血β-人绒毛膜促性腺激素(β-HCG)下降百分比及不良反应的发生率。结果:观察组的血β-HCG下降百分比和不良反应发生率均明显优于对照组(P0.05)。结论:在B超监视妇科手术仪监视下经阴道宫旁注射MTX50 mg对持续性异位妊娠治疗较MTX75mg肌肉注射更安全有效。     

Heterotopic pregnancy after a spontaneous conception a case report with a review of clinical,laboratory and imaging findings

Heterotopic pregnancy (HP) describes the simultaneous presence of two pregnancies at different implantation sites. Usually, one pregnancy is intrauterine and the other one is ectopic. The incidence of HP after assisted reproductive technologies reaches 1:3900, but is very rare after a spontaneous pregnancy, with a reported incidence of 1 to 30,000 pregnancies.Due to its rarity, complex clinical picture, and laboratory findings, it is challenging to diagnose HP. We present a case of spontaneous HP diagnosed in the first trimester by ultrasound (US) and magnetic resonance imaging (MRI) and subsequently managed successfully. We present an analysis of the clinical and laboratory findings as well as imaging, including MRI that we used to diagnose the condition. Additionally, we performed a literature review.ConclusionsHP is a very rare condition frequently faced in obstetrics, gynecology, and emergency departments that requires a high index of clinical suspicion. US remains the imaging modality of choice in diagnosing a HP, however, in some cases, an MRI with a reported safety in the first trimester, can be used to provide additional information over US.     

Bedside Contrast‐Enhanced Sonography of Critically Ill Patients

The transfer of critically ill patients to the radiology department is, in itself, potentially dangerous, so radiologists are frequently asked to perform bedside sonographic studies in the intensive care unit, surgical or medical department, sterile area, and operating room. In these circumstances, injection of a contrast agent may give the radiologist relevant additional information, which is useful for diagnosis and for better therapeutic management of these critically ill patients. Contrast‐enhanced sonography may allow detection of findings not recognizable on baseline sonography or even color Doppler imaging. In this pictorial essay, we highlight the value of real‐time contrast‐enhanced sonography when performed at the bedside in critically ill patients.     

经阴道超声检查对早期宫外孕的诊断价值

目的 探讨应用经阴道超声检查对早期宫外孕的诊断价值。方法对临床疑诊为宫外孕但经腹部超声检查不明确的186例患者进行经阴道超声检查，记录宫外孕肿块超声图像、彩色血流特点及彩色血流阻力指数。结果经阴道超声诊断结合血液HCG检查结果诊断早期宫外孕179例，漏诊7例，超声诊断符合率96．2％。结论经阴道超声检查，对早期宫外孕的诊断具有重要的价值，为诊断早期宫外孕的首选方法。     

Cesarean Scar Pregnancy

A cesarean scar (ectopic) pregnancy occurs when a pregnancy implants on a cesarean scar. This condition is an uncommon but potentially devastating occurrence. The incidence is increasing as cesarean deliveries become more common. Early recognition of the salient sonographic findings is critical because a delay can lead to increased maternal morbidity and mortality. Magnetic resonance imaging is a valuable troubleshooting tool when sonography is equivocal or inconclusive before therapy or intervention. Early diagnosis by sonography directs therapy and improves outcomes by allowing preservation of the uterus and future fertility. We review the imaging features, differential diagnosis, complications, and treatment of cesarean scar pregnancies in the first trimester.     

Unusual Ectopic Pregnancies

Ectopic pregnancy is a considerable source of morbidity and mortality for women of childbearing age. Improved detection and increased risk factors have led to a dramatic rise in the incidence of ectopic pregnancy in recent years. Early diagnosis is critical for the health of the patient as well as the success rate of future pregnancies. Besides laparoscopy, sonography is the mainstay for evaluating ectopic pregnancy. It is important to understand the sonographic features of ectopic pregnancies, including unusual cases that occur outside the fallopian tube.