Retroperitoneal Subpancreatic Ectopic Pregnancy Following In Vitro Fertilization in a Patient with Previous Bilateral Salpingectomy: How Did It Get There?

An unusual case of retroperitoneal ectopic pregnancy is reported. The patient, a 34 year old nulligravida, underwent IVF/ET following bilateral salpingectomy. A small, degenerating, intrauterine gestational sac suggested failing intrauterine pregnancy. There was no intraperitoneal free fluid. On Day 41 after ET, the patient was hospitalized because of acute epigastric pains. A pseudocyst of the head of pancreas was demonstrated by CT scan. A day later, exploratory laparotomy, because of a precipitous drop in the hemoglobin, revealed a massive retroperitoneal hematoma and an embryo in the gestational sac attached to the head of pancreas and major blood vessels. The patient did well following surgery. The mechanisms of retroperitoneal embryo migration are discussed and literature is reviewed.Private practice     

Proximal occlusion of salpinx by placing microcoil under X-ray brought a successful uterine pregnancy for a repeated ectopic pregnancy patient

Introduction

This article provides a new method to avoid recurrent ectopic pregnancy during IVF-ET treatment in women who underwent bilateral salpingectomy.

Materials and methods

A Chinese woman who underwent bilateral salpingectomy because of previous ectopic pregnancy sought IVF-ET therapy. She got two continuous salpingocyesis in fresh cycle and frozen cycle and received conservative therapy. We suggested her to undergo the laparoscopy to find the reason of repeated ectopic pregnancy. The patient declined due to economy and fear of operation. HSG showed that the length of the left and right salpinx was 3 and 4 cm, respectively. She received microcoil device under the X-ray guidance to induce proximal occlusion of the salpinx. Another FET was performed 3 months after this intervention and she succeeded this time and delivered a healthy infant finally.

Conclusion

The proximal occlusion of the salpinx by microcoil device can be used to avoid ectopic pregnancy again during IVF-ET treatment in women who underwent bilateral salpingectomy.     

Ultrasound-assisted intraoperative localization and laparoscopic management of a previously missed unruptured retroperitoneal ectopic pregnancy

Primary retroperitoneal ectopic pregnancy represents an extremely unusual entity with a rather obscure pathogenesis. Implantation in the retroperitoneal space has been reported to occur both spontaneously and with use of assisted reproduction techniques. The pelvic and the upper retroperitoneum have both been involved, and implantation in the most unusual anatomic sites has been reported. The majority of retroperitoneal gestations are located close to large blood vessels, and laparotomy is performed because of the high risk of massive hemorrhage. Few cases have been treated with laparoscopy so far. We report the case of an early first-trimester retroperitoneal broad ligament live pregnancy occurring after spontaneous conception in a patient who had a history of an ipsilateral tubal ectopic pregnancy, previously treated with laparoscopic right salpingectomy. Current gestation had been missed during initial laparoscopy, and was located and removed during a repeat laparoscopic procedure under intraoperative ultrasonographic guidance.     

Rupture of two intact tubal pregnancies]

We report on a 24 years old patient with an acute abdominal pain and an unknown intact tubal pregnancy in the 8th gestation week. The sonographic examination confirmed an intact tubal pregnancy. Shortly after the diagnosis, it ruptured with a massive intraabdominal bleeding. Thereafter, the patient collapsed. We carried out a laparoscopy and performed salpingotomy. Because of the persistent bleeding a salpingectomy was performed. We also report on a second patient 34 years old, who was referred to our Department on suspicion of a ruptured ectopic pregnancy with acute abdominal pains and a positive pregnancy test. The transvaginal sonography revealed massive intraabdominal fluid, adnexal tumor and endometriumhyperplasia without a sign of a gestational sac or an embryo.We carried out a laparoscopy, which revealed a ruptured tubal pregnancy with a life, fetus lying in the abdominal cavity. As a result of the massive and persistent intraabdominal bleeding, we carried out laparotomy and performed salpingectomy. Using these two case reports, the etiology, symptoms, clinical course, diagnosis, as well as surgical and drug therapy are discussed.     

Ovarian pregnancy resulting from cornual fistulae in a woman who had undergone bilateral salpingectomy

OBJECTIVE: To report a case of ovarian pregnancy following in vitro fertilization-embryo transfer (IVF-ET) treatment for which the cornual fistulae was the most probable explanation of the cause. DESIGN: Case report. SETTING: University department and assisted reproduction unit. PATIENT(S): A 29-year-old woman with primary infertility. INTERVENTION(S): Hydrosalpinx of the bilateral fallopian tubes has been noted in patients who have decreased pregnancy rates in the IVF-ET treatment cycles. Salpingectomy before IVF cycles has been suggested to increase the pregnancy rate. We report a patient who presented with bilateral hydrosalpinx for whom bilateral salpingectomy was performed before IVF treatment. MAIN OUTCOME MEASURE(S): Clinical pregnancy. RESULT(S): The treatment cycle resulted in a primary ovarian pregnancy and required laparoscopic operation. A cornual fistulae was found that have might led to ectopic implantation of the embryos. CONCLUSION(S): Ovarian pregnancy may be an unexpected complication of those receiving bilateral salpingectomy before IVF treatment. The presence of cornual fistulae after salpingectomy was probably the cause of the ectopic pregnancy.     

Rare presentation of ectopic pregnancy following IVF-ET: live twin gestation in the same fallopian tube

We report a case of a twin ectopic pregnancy (EP) after in vitro fertilization and embryo transfer (IVF-ET). A 24-year-old nulligravida presented with lower abdominal pain and vaginal bleeding 4 weeks after embryo transfer. Serum β-HCG levels were 40 IU/mL, 90 IU/mL, and 1970 IU/mL on ET days 12, 14, and 23, respectively. Ultrasound examination revealed two ectopic gestational sacs with fetal heart beats in the left adnexa, without evidence of intrauterine pregnancy. At laparoscopy, one isthmic and another ampullary sac were detected in the left tube and left salpingectomy was performed. The patient was discharged healthy on postoperative day 2. Albeit extremely rare, ectopic pregnancies with abnormal presentation can be encountered following IVF-ET. Single embryo transfer may be advised to protect from ectopic pregnancies after IVF-ET.     

Simultaneous bilateral tubal pregnancies after in vitro fertilization and embryo transfer: report of a case.

Ectopic pregnancies continue to be a major complication of in vitro fertilization and embryo transfer (IVF-ET). A case of bilateral simultaneous tubal pregnancy after IVF-ET is described. The patient underwent ovum pick-up (OPU) through a laparotomy with concomitant pelvic surgery. Embryo transfer (ET) was performed two days after OPU; this resulted in bilateral tubal pregnancies, diagnosed and treated one month apart. There are several possible causal mechanisms for the increased rate of ectopic pregnancies following IVF-ET. It is important to recognize that care in the transfer technique, with respect to the catheter position and limiting the volume of transfer medium to 20 microL, and an awareness of previous occlusion of the tubal ostia, or of a salpingectomy before IVF-ET, can help to minimize this complication rate. Two important points are the possibility of a simultaneous bilateral tubal pregnancy after IVF-ET, and the necessity of carefully examining both adnexa at the time of surgery for an ectopic pregnancy. Early and accurate diagnosis of a simultaneous bilateral ectopic pregnancy can prevent the necessity of a second operation and reduce maternal morbidity and mortality.     

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.     

体外受精-胚胎移植术后复合妊娠研究进展

复合妊娠（heterotopic pregnancy,HP）是一种极其危险的异位妊娠,自然受孕者中HP的发生率并不高,但随着近年体外受精-胚胎移植（in vitro fertilization and embryo transfer,IVF-ET）术以及促排卵技术的普及,HP的发生率较前有所上升。HP患者早期一般仅有腹痛、阴道出血等非特异性症状,且由于宫内妊娠囊的存在使得宫外妊娠囊特别容易误诊和漏诊,从而易导致患者宫外妊娠囊继续发展,引起腹腔内大出血甚至休克等危及生命的严重后果。因此,充分了解HP的相关危险因素,在行ET术或促排卵技术前采取相应的预防HP发生的措施、发生HP后尽早进行确诊及确诊后采取有效的治疗对改善患者的预后显得尤为重要。综述近年IVF-ET后HP的诊断及管理措施进展。     

体外受精与胚胎移植前输卵管积水处理方式的探讨

目的:探讨体外受精与胚胎移植(IVF-ET)前输卵管积水的不同处理方式对IVF-ET结局的影响。方法:回顾分析2002年1月至2004年12月因输卵管因素不孕接受IVF-ET治疗的346个治疗周期的资料。按输卵管的情况分为4组,A组:输卵管阻塞,未发现输卵管积水者,共151个治疗周期;B组:IVF-ET前输卵管积水未行手术治疗者,共73个治疗周期;C组:IVF-ET前输卵管积水行输卵管伞端造口术者,共43个治疗周期;D组:IVF-ET前输卵管积水行输卵管切除术者,共79个治疗周期。结果:各组的临床妊娠率分别为48.34%、21.92%、34.88%、44.30%,异位妊娠率分别为1.37%、12.50%、6.67%、2.86%,种植率分别为20.36%、5.87%、12.28%、19.38%,B组的临床妊娠率及种植率较A组、D组明显降低,B组、C组的异位妊娠率均较A组、D组升高。结论:输卵管积水对IVF-ET的结局有负面影响,IVF-ET前输卵管积水,先行手术治疗,可改善IVF-ET的结局。较之输卵管造口术,输卵管切除术可减少异位妊娠的发生率及输卵管积水的复发率。     

Concomitant abdominal and intrauterine pregnancy after in vitro fertilization in a woman with bilateral salpingectomy. A case report

BACKGROUND: Abdominal pregnancy is a rare event, and the concomitant presence of an intrauterine pregnancy is very exceptional. CASE: A case of concomitant abdominal and intrauterine pregnancy following in vitro fertilization and embryo transfer (IVF-ET) occurred in a woman with bilateral salpingectomy. The abdominal pregnancy was successfully treated surgically, with preservation of the intrauterine pregnancy. CONCLUSION: A careful ultrasound examination should be performed on women who have undergone IVF-ET, and the possibility of abdominal pregnancy should be kept in mind in the differential diagnosis of acute abdomen.     

Laparoscopic treatment of recurrent ectopic pregnancy in the ipsilateral salpinx after ovulation induction and intrauterine insemination

ObjectiveTo report a case of recurrent ectopic pregnancy in the ipsilateral salpinx after and intrauterine insemination treated by laparoscopy.Case reportA 33-year-old woman with unexplained infertility sought evaluation at our hospital due to pelvic pain after ovulation induction and intrauterine insemination. She had a history of a right salpingectomy. Transvaginal ultrasonography did not reveal an intrauterine pregnancy, but showed a suspected extrauterine gestational sac on the operated adnexal area with free fluid in the pouch of Douglas. The patient was diagnosed with a recurrent ruptured ectopic pregnancy and an emergency laparoscopy was performed.ConclusionRecurrent ectopic pregnancy in the ipsilateral fallopian tube is rare, but it is important to be suspicious of the diagnosis to prevent serious morbidity. This case also demonstrates transtubal or transperitoneal migration of the gametes because ovulation and ectopic pregnancy occurred on opposite sides.     

Simultaneous bilateral tubal pregnancies and intrauterine pregnancy with five fetuses

A 28-year-old woman with severe right lower abdominal pain and vaginal bleeding at 7 weeks' (+/- 2 days') gestation was seen in the emergency room of our institution. The pregnancy was the result of natural conception after ovarian stimulation with gonadotropins. Transvaginal sonography revealed five intrauterine gestational sacs containing five live embryos. A positive fetal heartbeat was detected in the fallopian tube on the right. Laparoscopic findings disclosed the enlarged uterus with the unruptured right ectopic pregnancy in the ampullary region and an extrauterine pregnancy in the left tube as well. A linear salpingotomy was performed on the right tubal pregnancy. We decided to perform salpingectomy on the left tube because it was impossible to preserve the tube, and exploration of it showed the existence of another gestational sac. It is necessary to decry inappropriate and injudicious use of assisted reproductive technologies, especially by individuals with little or no training in monitoring the agents and treatments prescribed. In 2003, still waiting for official legislation from the Italian Parliament on assisted reproductive technology, we have to face dramatic situations, such as this very unique case of heterotopic pregnancy.     

Gestación heterotópica en un embarazo espontáneo

Heterotopic pregnancy consists of simultaneous intra and extrauterine pregnancy. The incidence is low in spontaneous pregnancies, but these pregnancies are more common when assisted reproductive technologies are used; therefore, diagnosis requires a high index of suspicion. We report the case of a 34-year-old woman with no history of interest and a spontaneous pregnancy, who presented with spotting and hypogastralgia. An ultrasound scan showed an intrauterine gestational sac and left adnexal mass consistent with ectopic pregnancy. As a heterotopic pregnancy was suspected, laparoscopic salpingectomy and curettage of the miscarriage were performed. Pathological analysis confirmed the diagnosis.     

Retroperitoneal Ectopic Pregnancy: A Case Report

A retroperitoneal ectopic pregnancy is an extremely rare type of ectopic pregnancy and is difficult to diagnose and treat. Owing to its occult onset, it is life-threatening and often associated with high mortality. A 28-year-old woman was admitted to the emergency department of our hospital owing to soreness of the left lower quadrant of the abdomen and amenorrhea for 60 days. Dilatation and curettage were performed at a local hospital to induce abortion, but no gestational sac was found. Elevated plasma human chorionic gonadotropin levels suggested an ectopic pregnancy. An ultrasound showed an approximately 4.0 cm × 3.0 cm mass in front of the middle and upper poles of the left kidney. The plasma beta–human chorionic gonadotropin level was 99 286.00 mIU/mL. Under laparoscopy, an ovoid mass measuring approximately 4.0 cm × 5.0 cm below the left renal vessels and the abdominal aorta was successfully resected. Methotrexate (50 mg/m²) was locally injected, and the retroperitoneum was sutured. Villi were observed in histopathologic sections. This case report highlights the importance of considering the possibility of a retroperitoneal ectopic pregnancy for patients with abdominal pain. Laparoscopic surgery by an experienced surgeon is the preferred method of treatment for this condition.     

Management of analysis in case of ectopic pregnancy--own material

INTRODUCTION: Apart from increasing frequency of ectopic pregnancy occurrence during recent years there is still a need to diagnose and treat these pathology as early as possible. Delay in diagnosing subsequently cause severe threat to patients life. Recognition improvement means equally decrease in mortality connected to ectopic pregnancy. AIM: The aim of the study was diagnosis and treatment efficiency evaluation in cases of ectopic pregnancy. MATERIAL AND METHODS: In this paper 68 cases of women hospitalised between May 1999 and September 2002 in our Clinic with suspicion of ectopic pregnancy were analysed. Diagnostic procedures included clinical examination, biochemical assessment of beta HCG level, sonography and diagnostic laparoscopy. Therapeutic management included salpingotomy with evacuation of gestational sac, salpingectomy and uterine cornu excision. RESULTS: In 11 cases the presence of pregnancy was excluded according to non-invasive diagnostics. Laparotomy was performed in two cases. Laparoscopy was performed in 50 cases what equals to 73% of all subjects. Laparoscopy was negative in 7 cases. Misdiagnosis resulted from pathologies in adnexal area. The most frequent ectopic pregnancy localisation was oviduct, one case of cervical and one intramural localisation was diagnosed. In one case two salpingostomies were performed in two years apart period. CONCLUSIONS: Complex diagnostic management is the only diagnostic way in case of ectopic pregnancy. Any confusion should be solved by immediate invasive diagnostics. In our opinion the most efficient method in ectopic pregnancy diagnosing and treatment is early laparoscopy.     

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.     

Giant malignant ovarian fibrothecoma involved with retroperitoneal structures mimicking a retroperitoneal sarcoma

Introduction  Ovary is located inside peritoneal cavity. However, a huge malignant ovarian tumor may get involved with retroperitoneal structures. Case report  We reported a case of a 70-year-old woman presented with a 2-month history of increased abdominal distention and was subsequently found to have a giant abdominal mass. A huge low signal intensity mass with the involvement of retroperitoneal structures was showed on MRI. At operation, we found that the tumor pushed mesentery and small bowel upwards with the encasement of 10 cm jejunum and was fixed posteriorly to vena cava, aorta, right iliac vessels, and right ureter. It was dissected from the retroperitoneal structures and resected en bloc with the involved jejunum. Conclusion  Although ovary is located inside peritoneal cavity, a huge malignant ovarian tumor may get involved with retroperitoneal structures. So, great care should be taken not to injury the retroperitoneal structures as vena cava, mesenteric vessels, iliac vessels, and ureters.     

Heterotopic pregnancy

We report a case of combined intrauterine and extrauterine (tubal) pregnancy in 24-year-old woman. The patient was admitted to the Clinic at 9 weeks gestational age with abdominal pain lasting 2 hours. Pelvic ultrasonography revealed alive 9-week intrauterine pregnancy, free fluid in the peritoneal cavity and left adnexal mass. A left salpingectomy was performed, with removal of ruptured ampulla with ectopic pregnancy, without complications. The intrauterine pregnancy proceeded uneventfully to 39 weeks, was terminated by cesarean section, resulting in birth of a healthy female infant of 3630 grams.     

Prenatal diagnosis of congenital fetal arrhythmias by simultaneous pulsed Doppler velocimetry of the fetal abdominal aorta and inferior vena cava

Various methods have been used for the diagnosis of congenital fetal arrhythmias. Currently, M-mode echocardiography is the most widely used method. However, good tracings are often difficult to obtain because of unfavorable fetal positions, resulting in long durations of examination. In early gestation, the fetal heart is often too small for clear M-mode echocardiography. Doppler velocity waveforms of the fetal inferior vena cava represent the right atrial activity, whereas those of the aorta reflect ventricular contraction. Because of the proximity of the vessels, it is easy to obtain simultaneous recording in opposite channels of Doppler waveforms from both vessels. A visual relationship between the atrial and ventricular contractions may be clearly established and a diagnosis may be made. The findings of simultaneous pulsed Doppler velocimetry of the fetal aorta and inferior vena cava were assessed in different types of congenital fetal arrhythmia: congenital heart block, premature atrial ectopic contractions, premature ventricular ectopic contractions, and supraventricular tachycardia. The correct diagnosis was made as early as 13 weeks' gestation, showing the application of this method in early pregnancy.