经脐单孔腹腔镜输卵管妊娠开窗取胚术19例分析

目的探讨经脐单孔腹腔镜输卵管妊娠开窗取胚术的可行性。方法对2010年3-9月在南方医科大学广济医院住院的20例输卵管妊娠患者行经脐单孔腹腔镜输卵管开窗取胚术。结果除1例术中发现为间质部妊娠改为三孔手术外,其余19例手术全部成功,术后监测血β-绒毛膜促性腺激素(HCG)均未发生持续性异位妊娠。结论经脐单孔腹腔镜输卵管开窗取胚术是一种安全可行、更加理想的微创术式,在实施中应注意正确、严格地选择病例,提高手术技巧,术后严密观察血β-HCG的下降。     

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.     

Tubal patency and fertility outcome after expectant management of ectopic pregnancy

Objective: To study tubal patency and fertility outcome of patients with expectantly managed ectopic pregnancy (EP).

Design: A prospective study.

Setting: Department of Obstetrics and Gynecology, Turku University Central Hospital, Turku, Finland.

Patient(s): Thirty patients who wanted to become pregnant again were treated successfully by expectant management of EP.

Intervention(s): Patients were examined with posttreatment hysterosalpingography, and they filled out a questionnaire about their subsequent pregnancies.

Main Outcome Measure(s): Free passage through open lumen showing tubal patency; number of full-term pregnancies and EPs revealing relative rate of subsequent fertility.

Result(s): A free passage through the diseased tube was seen in 93% of the cases (28 of 30). Two of the 24 patients (8.4%) who wanted to become pregnant had an obstruction in the diseased tube. One (4.2%) of them had a normal opposite tube and later had a normal pregnancy. The other (4.2%) had an obstruction in both tubes and subsequently had a repeat EP. One of the 6 patients had an EP (this patient did not want to become pregnant and did not use contraception). However, her posttreatment hysterosalpingography was normal. In total, the subsequent pregnancy rate was 88% (21 of 24), and the rate of repeat EP was 4.2% (1 of 24).

Conclusion(s): Patients who are treated with expectant management have a good long-term fertility outcome. Spontaneous regression of EP does not lead to increased harm or damage to the tube, i.e., the risk for repeat EP is low.     

Repeated ectopic pregnancy on the tubal stump after laparoscopic salpingectomy

A 40-year-old woman who had undergone laparoscopic right salpingectomy because of a tubal pregnancy 10 years ago presented to our hospital with severe lower abdominal pain. Ectopic pregnancy with internal bleeding was suspected after evaluation. With laparoscopy, repeated ectopic pregnancy on the tubal stump was diagnosed and treated successfully.     

Diagnosis and laparoscopic management of 11 consecutive cases of cornual ectopic pregnancy

Objective  To determine the pre-operative diagnosis by two dimensional ultrasound scan and the outcome of the laparoscopic management of cornual ectopic pregnancy. Design  Prospective database cohort study. Setting  Whipps Cross University Hospital, UK (District General Hospital). Patients  Eleven patients with cornual ectopic pregnancy presenting in our hospital between January 2003 and December 2007. Interventions  Laparoscopic cornuostomy or cornual resection. Outcome measures  Pre-operative diagnosis by ultrasound scan, conversion rate to laparotomy, successful laparoscopy (not requiring further treatment), complication rate and duration of hospital stay. Results  The mean gestational age was 8 ± 2 weeks. All 11 patients presented with abdominal pain and vaginal bleeding and two (18%) patients became haemodynamically unstable before laparoscopy. There were five (45%) patients with risk factors for ectopic pregnancy. The mean serum β-human chorionic gonadotropin (β-hcg) was15,263 ± 12,045 μm/ml. One patient did not have a transvaginal scan as it was decided to proceed to surgery on clinical grounds. The diagnosis of ectopic pregnancy was correct at initial scan in nine (90%) of the ten patients who had transvaginal scans as one patient was misdiagnosed at the first scan. However, an ectopic pregnancy was diagnosed on a second ultrasound scan assessment. Initial laparoscopy was negative in one of the nine patients diagnosed as having an ectopic pregnancy. The diagnosis was later confirmed following serial serum β-hcg monitoring, a repeat scan and a second laparoscopy. Ten (91%) of the 11 patients had successful operative laparoscopy as one (9%) patient had conversion to laparotomy. Among patients who had laparoscopic surgery, cornuostomy was performed in three (30%) patients while cornual resection was performed in the other seven (70%) patients. One (10%) of the patients who had laparoscopic surgery needed further treatment with systemic methotrexate. This patient had a cornual resection and was the only complication following laparoscopic surgery. The mean hospital stay was 2 days. Conclusion  This presentation of one of the larger series of patients with cornual ectopic pregnancy managed by laparoscopic surgery reveals that experience at ultrasonography and laparoscopic technique can lead to earlier diagnosis and few cases requiring laparotomy or further treatment. In addition laparoscopic surgery for cornual ectopic is safe and lends itself to conservative approach (cornuostomy) in selected cases.     

Risk factors for rupture in tubal ectopic pregnancy: definition of the clinical findings

Objectives

The aim of this study is to determine the risk factors for rupture of an ectopic pregnancy (EP) to help physicians identify those women who are at greatest risk.

Study design

The study group comprised the cases of EP treated in our department from January 2003 to September 2009. The following parameters were retrospectively examined: rupture status, past history of pelvic infection or EP, use of an intrauterine device (IUD), parity and gestational age. Women with tubal rupture were compared to those without rupture. Where appropriate, univariate and multivariate analyses were used to identify predictors of the outcome of EP.

Results

Two hundred and thirty-two cases of EP were retrieved. Eighty-eight of them (37.9%) were cases with ruptured EP and 144 (62.1%) were cases with unruptured EP. No significant associations existed regarding IUD use, smoking, previous ectopic pregnancy, past history of pelvic inflammatory disease (PID) or history of endometriosis. The mean gestation (in weeks) since the last menstrual period and the mean level of βhCG were significantly higher in patients with ruptured EP compared with patients with unruptured EP (7.8 ± 1.09 versus 6.4 ± 1.2, p < 0.0001; and 8735.3 ± 11317.8 IU/ml versus 4506 ± 5673.7 IU/ml, p < 0.0001, respectively). Logistic regression analysis revealed that 6-8 weeks of amenorrhoea (OR: 3.67; 95% CI: 1.60-8.41) and >8 weeks of amenorrhoea (OR: 46.46; 95% CI: 14.20-152.05) and also 1501-5000 IU/ml of βhCG level (OR: 4.11; 95% CI: 1.53-11.01) and >5000 IU/ml of βhCG levels (OR: 4.40; 95% CI: 1.69-11.46) were the significant risk factors for tubal rupture.

Conclusions

Higher βhCG levels and higher gestational age seem to be significant risk factors for rupture of an EP.     

异位妊娠保守治疗分析

目的 分析异位妊娠保守治疗的方法与效果。方法将340例异位妊娠按治疗方案分为5组,其中I组为期待治疗,Ⅱ组为中药治疗,Ⅲ组为甲氨蝶呤(MTX)50mg肌肉注射单次治疗,Ⅳ组为MTX 50mg多次肌肉注射治疗,V组为MTX 20 mg肌内注射,1次/日,连用5 d。结果MTX50mg单次治疗与MTX 20 mg连用5 d治疗效果相似。治疗前血β-HCG<500mIU/ml时,期待治疗与药物治疗成功率差异无显著性,而β—HCG>500 mIU时,治疗效果明显降低,β—HCG>1 000 mIU时,中药治疗效果明显不如MTXC,β-HCG>3 000 mIU/ml,MTX 50mg单次治疗成功率明显下降。β—HCG>5 000mIU/ml,MTX50mg im多次治疗成功率也明显下降,但仍高于单次治疗。结论 血β—HCG是指导和监测EP治疗的重要指标。治疗前β—HCG<3 000 mIU/ml时,MTX50 mg im单次治疗是有效而安全的;>3 000 mIU/ml,推荐MIX多次用药。     

Human chorionic gonadotropin level as a predictor of trophoblastic infiltration into the tubal wall in ectopic pregnancy: a blinded study

OBJECTIVE: To determine the relationship between gestational age, tubal ultrasonographic diameter, and serum hCG levels and different stages of trophoblastic infiltration of the tubal wall in ectopic pregnancy. DESIGN: Blinded prospective study. SETTING: University-based clinic in Italy. PATIENT(S): Thirty-seven consecutive patients with an ampullary ectopic pregnancy. INTERVENTION(S): Laparoscopic salpingectomy. MAIN OUTCOME MEASURE(S): Gestational age, diameter of the tubal mass as determined by transvaginal ultrasonography. and hCG level on the day of surgery. Ectopic pregnancy was classified according to the depth of trophoblastic infiltration: trophoblast limited to the tubal mucosa (stage I), extension to the tubal muscularis (stage II), or complete tubal wall infiltration up to the serosa discontinued by trophoblastic cells (stage III). RESULT(S): Fifteen patients (40.5%) had stage I tubal infiltration, 14 (37.8%) had stage II infiltration, and 8 (21.6%) had stage III infiltration. Gestational age and diameter of the tube did not differ among the three groups. The median hCG level was 1,710.5 mIU/mL (range, 113-5,635 mIU/mL) for patients with stage I infiltration. 4,690.0 mIU/mL (range, 150-21,531 mIU/mL) for patients with stage II infiltration, and 15,700.0 mIU/mL (range, 13,809-21,650 mIU/mL) for patients with stage III infiltration. All the patients with hCG levels > 6,000 mIU/mL had stage II or III invasion. CONCLUSION(S): These findings may explain why the conservative treatment of ectopic pregnancy is less successful in patients with high hCG levels than in patients with low levels. Use of radical procedures may be justified in the former group.     

Tubal patency after clinical treatment of unruptured ectopic pregnancy.

OBJECTIVE: To evaluate tubal patency using hysterosalpingography after clinical treatment of tubal pregnancy. METHOD: Of 80 patients who underwent hysterosalpingography after clinical treatment of tubal pregnancy from April 1994 to February 2002, 30 were treated with a single 50 mg/m(2) dose of methotrexate intramuscularly (n=30) and 50 were followed up expectantly. RESULTS: 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 and 92% after expectant management. There were no statistically significant differences between the groups. CONCLUSION: Findings from this study suggest similar tubal patency rates after methotrexate treatment and expectant management.     

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.     

Diagnosis and management of tubal pregnancy: effect on fertility outcome

We analysed 188 ectopic pregnancies seen during a 2-year period. They represented 2.2% of the live births that occurred during the same time interval. Overall, 53% of the tubal pregnancies had ruptured at the time of examination. Location was ampullary in 51% of the cases, isthmic in 28%, and 10% had aborted. Sixty-nine (38%) patients had an IUD. Diagnostic sensitivity was 58%-93% for pregnancy tests, 79% for culdocentesis, 41% for ultrasound examination, 43% for dilatation and curettage, and 100% for laparoscopy. Salpingectomy was performed in 47% of the cases, salpingotomy in 27%, and tubal resection in 19%. During a follow-up of 116 women (mean 1.5 years, range 0.5-3 years) 49% delivered, 10% had repeat ectopic pregnancy, 10% had abortion, 17% were infertile and 15% practised birth control. Among those who delivered no difference was found between those who underwent salpingectomy and those who underwent conservative surgery.     

Audit of changing surgical management of ectopic pregnancies in a large district general hospital in the United Kingdom

Over the 5 years form 1997 to 2001 we audited all 384 ectopic pregnancies that were treated surgically. The rate of surgically treated ectopic pregnancies expressed as a proportion of maternities ranged from 1.17 to 1.5%. During this time the proportion of these pregnancies treated laparoscopically rose from 28% to 66%, with the most rapid increases occurring following the appointment of gynaecologists with a special interest in laparoscopic surgery. The mean time taken to treat ectopic pregnancies surgically was the same regardless of whether the procedure was performed by laparotomy of laparoscopy.     

Factors determining fertility after conservative or radical surgical treatment for ectopic pregnancy

Objective: To examine factors determining choice of radical or conservative surgical procedure for tubal ectopic pregnancy and subsequent pregnancy rates.Design: A retrospective study collating information from the operative notes and previous gynecologic history associated with the choice of procedure and pregnancy rates and outcome over 3 years after a primary tubal ectopic pregnancy.Patient(s): Thirty-four women who had undergone conservative (tube sparing) and 56 who had undergone radical (salpingectomy) surgical treatment for tubal ectopic pregnancy at least 3 years before the study.Main Outcome Measure(s): The main outcome measure was the occurrence of a pregnancy (live birth, miscarriage, or ectopic pregnancy) over 3 years after the ectopic pregnancy.Result(s): The type of surgery performed was not affected by a previous history of infertility, known pelvic inflammatory disease, the presence of tubal adhesions, or abnormalities on the contralateral tube. Intrauterine pregnancy was not more likely after conservative treatment of ectopic pregnancy but, equally important, the risk of a further ectopic pregnancy was not increased. The single factor that was clearly associated with future fertility problems was a past history of infertility.Conclusion(s): Better results may be obtained by careful selection of operative procedure based on history and findings at the time of surgery.     

Haemorrhage associated with avulsion of liver capsule during laparoscopic salpingectomy for ectopic pregnancy

Laparoscopic salpingectomy is the preferred treatment for ectopic pregnancy. Fitz Hugh Curtis syndrome (FHCS) is a well known extra hepatic complication of chlamydial infections leading to perihepatic adhesions. Pneumoperitoneum created during laparoscopy can cause avulsion of the adhesions between the liver and diaphragm and can cause liver capsule tear. We report a case of haemorrhage associated with liver capsule tear during laparoscopic salpingectomy for ectopic pregnancy.     

Risk factors for conversion to laparotomy during laparoscopic management of an ectopic pregnancy

Objective: To identify risk factors for conversion to laparotomy during laparoscopic management of ectopic pregnancy. Methods: A retrospective chart review of patients who underwent laparoscopy for treatment of ectopic pregnancy, during a 32-month period (6/1999–2/2002), at the University of Miami Jackson Memorial Hospital. We identified 229 patients; 201 had a successful laparoscopy (non-converted group) and 28 who were converted to laparotomy (converted group).Variables analyzed between the two groups were demographic data, patient-related risk factors available to the surgeon prior to the surgery (previous laparotomy, previous laparoscopy, history of PID, history of endometriosis, diameter of ectopic pregnancy as measured by ultrasound, amount of free fluid on ultrasound, BMI), and surgeons’ experience. Results: Out of the 229 laparoscopies, 28 were converted to laparotomy (12.2%). The rate of conversion was significantly higher for less experienced compared to experienced surgeon (OR=6.1, 95% CI=2.35–15.88). Significantly more women had a BMI>30 kg/m² in the converted group compared to the non-converted group (42% vs. 14%; OR=4.28, 95% CI=1.7–10.75) and the converted group had significantly higher rate of large free fluid reported on ultrasound compared to the non-converted group (21.42% vs. 7.46%; OR =3.38, 95% CI=1.04–10.61). Conclusion: Less experienced surgeon, BMI>30 kg/m², and large amount of free fluid on ultrasound increase the risk of conversion to laparotomy during laparoscopic management of ectopic pregnancy.     

Serial serum human chorionic gonadotropin (hCG) levels in ectopic pregnancy and first trimester miscarriage

Serial serum hCG levels were measured in 50 patients with a tubal ectopic pregnancy and 50 patients with spontaneous miscarriage of an intrauterine pregnancy. Serum samples were obtained at intervals of 3–5 d and more frequently if clinically indicated. The final diagnosis was confirmed by laparoscopy and/or dilatation and curettage. Data were analyzed using a linear regression model. Initial hCG concentrations ranged from 91 to 3,050 mIU/mL. Eighty percent of ectopic pregnancies and 35% of miscarriages were associated with rising hCG concentrations and no significant differences were noted in daily increments of hCG in the two groups (210 ± 30 mIU/mL/day for ectopic pregnancies versus 311 ± 55 mIU/mL/d for miscarriages). Twenty percent of ectopic pregnancies and 65% of miscarriages had falling hCG concentrations and significant differences were noted in the daily decrements of hCG for EP and AB (270 ± 52 mIU/mL/day for ectopic pregnancies versus 578 ± 28 mIU/mL/d for miscarriages (P≤ 0.05). Received: October 1999 / Accepted: 13 December 1999     

Ectopic tubal pregnancy after hysterectomy and tubal ligation

Posthysterectomy ectopic pregnancy is an unusual condition that may present soon after hysterectomy or several years later. Similarly, although tubal ligation is a widespread method of contraception, tubal pregnancy after tubal ligation is not common either. If any of these conditions are rare, having an ectopic pregnancy after hysterectomy and tubal ligation is even more infrequent and only one of such cases was found in our review of the literature. We describe the case of a 35-year-old patient, with history of bilateral tubal ligation and vaginal hysterectomy that looked for medical attention due to abdominal pain. A pregnancy test was positive and a transvaginal ultrasound demonstrated the presence of a gestational sac at the vaginal cuff, adjacent to the ovary. An exploratory laparotomy showed a ruptured ectopic pregnancy located in the distal portion of the left fallopian tube. The occurrence of an ectopic pregnancy several years following tubal ligation and vaginal hysterectomy is a rare phenomenon that appears to be secondary to a fistulous connection into the peritoneal cavity.