异位妊娠相关的高危因素

异位妊娠是早期妊娠妇女死亡的首要原因,近几十年发病率有上升趋势。对异位妊娠相关高危因素的认识有助于早期诊断、治疗及预防该病的发生。国内外对其相关高危因素的研究主要包括：盆腔炎性疾病、腹部手术史、吸烟、既往异位妊娠史、不孕史、辅助生育技术、避孕方法失败、流产和年龄等。其中盆腔炎性疾病,输卵管手术史及吸烟为异位妊娠的三大主要高危因素。异位妊娠往往是一种或多种高危因素同时作用的结果。     

异位妊娠相关的高危因素

异位妊娠是早期妊娠妇女死亡的首要原因,近几十年发病率有上升趋势。对异位妊娠相关高危因素的认识有助于早期诊断、治 疗及预防该病的发生。国内外对其相关高危因素的研究主要包括：盆腔炎性疾病、腹部手术史、吸烟、既往异位妊娠史、不孕史、辅助生育技术 、避孕方法失败、流产和年龄等。其中盆腔炎性疾病,输卵管手术史及吸烟为异位妊娠的三大主要高危因素。异位妊娠往往是一种或多种高危因 素同时作用的结果。     

Recurrent Tubal Ectopic Pregnancy Management and the Risk of a Third Ectopic Pregnancy

Study ObjectiveTo evaluate the rate of a third ectopic pregnancy according to the modality of treatment of the second ectopic pregnancy.DesignRetrospective cohort study.SettingUniversity-affiliated tertiary medical center.PatientsOne hundred eleven women who had 2 ectopic pregnancies and a third consecutive pregnancy between 2003 and 2018.InterventionsSurgery or medical treatment as required.Measurements and Main ResultsWith regard to the modality of treatment of the second ectopic pregnancy, the patients were divided into 3 groups: expectant management, medical treatment with methotrexate, and laparoscopic salpingectomy. Univariate and multivariate analyses were conducted to assess the association of various parameters of the second ectopic pregnancy with the occurrence of a third ectopic pregnancy in the consecutive pregnancy. Twenty women (18.0%) were managed expectantly, 55 (49.6%) were treated with methotrexate, and 36 (32.4%) underwent surgery. Expectant management resulted in significantly higher rates of a third ectopic pregnancy compared with treatment with methotrexate or surgical intervention (50.0% vs 18.2% and 13.8%, respectively; p = .005). In the cases of 2 ipsilateral ectopic pregnancies, the interventional approach (medical or surgical treatment) resulted in lower recurrence rates compared with expectant management (25.7% vs 60.0%, respectively; p = .043).ConclusionThe risk of a third episode of an ectopic pregnancy after expectant management of a second ectopic pregnancy is extremely high. An interventional approach by treatment with methotrexate or salpingectomy is therefore preferred for recurrent ectopic pregnancy management, especially in ipsilateral recurrences.     

Incidental Diagnosis of Ectopic Pregnancy with Unusual Clinical Presentation

EDITORIAL COMMENT: We accepted this paper to remind even those readers who are obstetricians and/or gynaecologists that ectopic pregnancy may elude diagnosis unless the possibility is considered in any women during her reproductive years who has abdominal pain, especially when associated with anaemia and disordered menstruation. The presence of pathology in another system can be a distracter from prompt diagnosis of ruptured ectopic pregnancy as shown by these 2 cases.     

Risk Factors for Ectopic Pregnancy After In Vitro Fertilization Treatment

ObjectiveTo identify risk factors for ectopic pregnancy after in vitro fertilization treatment.MethodsWe conducted a study among women who conceived after IVF treatment and evaluated the possible risk factors for ectopic pregnancy. The parameters evaluated were demographics of the patients, cause of infertility, and risk factors for ectopic pregnancy, including tubal infertility and previous ectopic pregnancy.ResultsOf 365 women, 18 women had an ectopic pregnancy and 347 others had an intrauterine pregnancy (control group). The incidence of IVF ectopic pregnancy was 4.9%. The mean age was 34.2 ± 1.4 years in the ectopic group and 34.3 ± 0.2 years in the control group; mean BMI was 23.8 ± 1.0 in the ectopic group and 24.5 ± 0.9 in the control group. Previous ectopic pregnancy, previous IVF ectopic pregnancy, or smoking did not affect the occurrence of ectopic pregnancy in this population. Logistic regression analysis demonstrated that tubal factor infertility and previous surgery for endometriosis were risk factors for IVF ectopic pregnancy.ConclusionsTubal factor infertility and previous surgery for endometriosis appear to be risk factors for ectopic pregnancy after IVF treatment. Other factors that usually contribute to spontaneous ectopic pregnancy, including previous ectopic pregnancy, pelvic infection, and smoking, were not risk factors for IVF ectopic pregnancy in our study.     

异位妊娠发病趋势和临床诊治分析

目的:分析10年间异位妊娠发病趋势和临床诊治的变化,为进一步临床研究提供资料.方法:收集上海市长宁区中心医院2002～ 2011年异位妊娠患者的相关临床资料,以及同期妊娠总数、妇科住院病例数;并对异位妊娠发生率的变化趋势,异位妊娠的发生部位、临床诊治的变化进行分析.结果:异位妊娠的发生率逐年升高,2002年为2.43％,2011年为4.43％,二者相比,差异有高度统计学意义(P＜0.01).2011年,异位妊娠诊治中保守治疗占20.05％,较10年前显著增加;腹腔镜手术占54.76％,已明显超过开腹手术,二者相比差异有高度统计学意义(P＜O.O1).2007 ～2011年发生剖宫产术后子宫瘢痕妊娠共23例,与2002 ～2006年相比,差异有高度统计学意义(P＜0.01).结论:异位妊娠的发生率逐年升高、剖宫产术后子宫瘢痕已成为异位妊娠的好发部位.异位妊娠采取保守治疗和腹腔镜治疗逐年增加.     

辅助生殖技术中影响异位妊娠发生的相关危险因素分析

目的:探讨辅助生殖技术(assisted reproductive technology,ART)后发生异位妊娠的危险因素。方法:收集2014年1月至2016年1月在本院生殖中心行ART治疗并获得临床妊娠的8548例患者的临床资料,包括女方年龄、体质量指数(BMI)、不孕原因、异位妊娠史、冻融胚胎移植内膜准备方式、胚胎移植类型、数目和期别。采用单因素及多因素Logistic回归分析不同因素对于ART后异位妊娠发生的影响。结果:8548例患者中,异位妊娠196例,异位妊娠率为2.29%。单因素分析结果显示,异位妊娠组盆腔输卵管因素、非男方因素、既往异位妊娠史、新鲜胚胎和D3胚胎移植比例均高于非异位妊娠组(P0.05)。将以上因素纳入多因素Logistic回归分析,结果显示,盆腔输卵管因素(OR=1.524,95%CI 1.100~2.111,P=0.011)和D3胚胎移植是行ART后异位妊娠发生的独立危险因素。且移植D6胚胎要比移植D5胚胎发生异位妊娠的风险低。进一步对盆腔输卵管因素进行分层分析,表明移植D5或D6胚胎异位妊娠发生率显著降低(P0.01)。结论:盆腔输卵管因素以及D3胚胎移植可导致ART后异位妊娠发生增加。囊胚移植,尤其是D6囊胚移植有利于降低异位妊娠发生的风险。     

Diagnosis and Management of Intramural Ectopic Pregnancy

Intramural pregnancy, a gestation completely surrounded by the myometrium located within the uterine wall with separation from the uterine cavity, is an extremely unusual form of pregnancy. Complications resulting from intramural pregnancy include inevitable uterine rupture with resultant hemorrhage and possible hysterectomy if diagnosis is not made early and treatment is not initiated. An asymptomatic patient was initially diagnosed with a missed abortion at approximately 6 weeks of gestation after a routine ultrasound. Suction curettage was performed approximately 1 month after the initial diagnosis. The pathology specimen failed to reveal placental villi. Ultimately, the diagnosis of intramural pregnancy was made via ultrasound and a computed tomography scan. She was treated with a single dose of systemically administered methotrexate. Over a period of 4 months, β-human chorionic gonadotropin levels trended downward; however, the intramural pregnancy failed to resolve completely, and a persistent mass remained. The intramural pregnancy was removed using the da Vinci laparoscopic procedure (Intuitive Surgical, Sunnyvale, CA). If the diagnosis of intramural ectopic pregnancy is made sufficiently early, conservative measures can be taken, which can preserve a patient’s future fertility.     

持续性异位妊娠的影响因素分析

目的：回顾性分析异位妊娠保守性手术后持续性异位妊娠发生的原因。方法：随机选取我科2008年至2010年因异位妊娠行腹腔镜下输卵管开窗取胚术患者98例,并分成AB两组,A组患者74例术中给予稀释后甲氨喋呤管残腔内注射．B组患者24例未给于药物管腔注射,两组患者于术后第3天及第5天复查血清13一HCG,同时进行相应处理,根据妊娠部位及术中是否用药与发生持续性异位妊娠的概率进行比较。结果：A组74例患者无1例发生持续性异位妊娠,B组24例患者发生持续性异位妊娠3例,其中2例妊娠部位为输卵管伞端妊娠,结论：输卵管伞端妊娠组织开窗清除术与输卵管其他部位开窗取胚术比较发生持续性异位妊娠率高（P〈O．05）。术中输卵管中未给药（甲氨喋呤）比术中给药发生持续性异位妊娠率高（P〈0．05）。     

Appendicitis in Pregnancy: Clinical Presentation and Perinatal Outcome

Objective: to determine the clinical presentation and maternal and perinatal outcomes associated with appendicitis in pregnancy.Methods: a retrospective chart review was conducted of women who underwent appendectomy during pregnancy between 1980 and 1994 at the Grace Maternity Hospital (GMH), Halifax, Nova Scotia. Presenting clinical characteristics, operative findings and maternal and perinatal outcomes were evaluated. Comparisons were made between patients with confirmed appendicitis and those with negative laparotomy. Fisher’s exact and Rank sum tests were used for statistical analysis.Results: among the 81,487 completed pregnancies during the study period there were 21 women who underwent appendectomy for suspected appendicitis. Appendicitis was confirmed by pathological evaluation in 14 patients (1 in 5,821) and nine of these (64%) were complicated by appendiceal perforation. The negative laparotomy rate was 33 percent. Presenting clinical characteristics were similar in patients with proven appendicitis and those with negative laparotomy. There were two perinatal losses (PMR = 9.5%), one associated with preterm birth and the other related to operative complications. The preterm birth rate associated with appendicitis was 36 percent. Patients with appendiceal perforation had a higher preterm birth rate (56%), longer hospital stay and increased incidence of postoperative complications.Conclusions: appendicitis in pregnancy is complicated by a high perforation rate due to the atypical presentation and delayed diagnosis. Appendiceal perforation is associated with poor maternal and perinatal outcomes. Prompt diagnosis and early intervention are essential to improve pregnancy outcome.     

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.     

Interstitial and Cornual Ectopic Pregnancy: Conservative Surgical and Medical Management

Background

Interstitial and cornual ectopic pregnancy is rare, accounting for 2–4% of ectopic pregnancies and remains the most difficult type of ectopic pregnancy to diagnose due to low sensitivity and specificity of symptoms and imaging. The classic triad of ectopic pregnancy—abdominal pain, amenorrhea and vaginal bleeding—occurs in less than 40% of patients. The site of implantation in the intrauterine portion of fallopian tube and invasion through the uterine wall make this pregnancy difficult to differentiate from an intrauterine pregnancy on ultrasound. The high mortality in this type of pregnancy is partially due to delay in diagnosis as well as the speed of hemorrhage.

Methods

Three cases of interstitial pregnancy were retrospectively analyzed.

Result

Successful laparoscopic cornuostomy and removal of products of conception were performed in two cases, while one case was successfully managed by local injection with KCL and methotrexate followed by systemic methotrexate.

Conclusion

Early diagnosis and timely management are key to the management of interstitial and cornual ectopic pregnancy. With expertise in ultrasound imaging and advances in laparoscopic skills progressively, conservative medical and surgical measures are being used to treat interstitial and cornual ectopic pregnancy successfully.

     

An Atypical Presentation of Ectopic Pregnancy With Unicornuate Uterus and Undescended Fallopian Tube

Background

Müllerian duct abnormalities are common and may be related to pregnancy complications. Few cases of ectopic pregnancy within an undescended Fallopian tube have been reported, and they present a diagnostic challenge.

Review of the Management of Ectopic Pregnancy in a Major Teaching Hospital: Laparoscopic Surgical Treatment and Persistent Ectopic Pregnancy

Summary: Two hundred and three cases of ectopic pregnancy were examined to determine the current management trends at the Royal Women's Hospital during a period where laparoscopic and conservative therapies were being increasingly used. Only 25% of patients were managed by the previous method of laparotomy and salpingectomy. Ten (8.8%) of 114 cases treated by laparoscopic procedures had persistent trophoblast activity and 8 of these required further surgical or medical treatment. Seven (14.9%) of 47 cases treated by laparoscopic salpingostomy resulted in persistent ectopic pregnancy (PEP). The postoperative beta HCG profiles of 41 patients were examined to identify differences between the 'persistent ectopic' and 'resolved ectopic' groups. Postoperative serum beta HCG monitoring should be performed at day 4 and day 7 to enable the early detection of treatment failure. The risk of developing a PEP after laparoscopic salpingostomy was significantly increased (p <0.01) if the preoperative serum beta HCG was greater than 3,000 IU/L. A laparoscopic salpingectomy should be performed in cases where the preoperative beta HCG is above 3,000 IU/L and the contralateral tube appears normal.     

Chronic Ectopic Pregnancy: A Clinical Analysis of 62 Cases

Chronic ectopic pregnancy is a form of tubal pregnancy in which salient minor ruptures or abortions of an ectopic pregnancy, instead of a single episode of bleeding, incites an inflammatory response often leading to the formation of a pelvic mass. Its clinical features are often confusing, and laboratory evaluations are often misleading. Surgery for chronic ectopic pregnancy is frequently difficult since chronic inflammatory changes and adhesions distort the normal anatomy. In the present retrospective study, its incidence was found to be 20.3% (n=62) in a series of 305 ectopic pregnancies. A pelvic mass of varying sonographic appearance, mostly with a nonhomogenous echo pattern, was demonstrated in all 55 patients in whom transvaginal sonographic evaluation was performed preoperatively. Although most of the patients [91.9% (n=57)] had a positive serum beta HCG value, 5 patients had a negative test value. Laparotomy resulted in 40 salpingectomies, 19 salpingo-oophorectomies, and 3 total abdominal hysterectomies with salpingo-oophorec-tomies. One patient had an incidental cystotomy and 2 an incidental colotomy. We conclude that chronic ectopic pregnancy is not rare, although little is mentioned about it as a clinical entity in the gynaecological literature. With increased awareness of its mildly symptomatic and protracted clinical course, and with proper interpretation of laboratory evaluations, a preoperative diagnosis can be made in the majority of the cases.     

Retrospective Study on Laparoscopic Management of Ectopic Pregnancy

Purpose

To evaluate various laparoscopic methods for management of tubal ectopic pregnancy and study the incidence of ectopic pregnancy including the incidence of cornual ectopic pregnancy and conversion to laparotomy during laparoscopic procedure.

Methods

A retrospective study was conducted in North Point Hospital, Delhi, on all laparoscopies conducted in 4 years, i.e., from January 2008 to December 2011.

Results

Incidence of ectopic pregnancy was 4.62 % (out of all laparoscopic surgeries over 4 years) and that for cornual pregnancy was 4.65 % (out of all ectopic pregnancies); no laparotomy was done for the management of ectopic pregnancy. The site of ectopic pregnancy in the tubal pregnancy varied, with 76.75 % in the ampullary region, 16.27 % isthumic, 2.33 % fimbrial, and 4.65 % in the cornual region. Salpingectomy was done in 53.5 % cases and 46.5 % of patients underwent a conservative approach in the form of salpingostomy.

Conclusion

The laparoscopic management of ectopic pregnancy is a safe and effective option with greatly reduced morbidity.