Heterotopic pregnancy in a natural conception cycle presenting with tubal rupture: a case report and review of the literature

BACKGROUND: Heterotopic pregnancy is a potentially fatal condition, rarely occurring in natural conception cycles. CASE: We report such a case in a 28-year old para 0, gravida 1 woman with no known risk factors. The ectopic pregnancy was diagnosed after rupturing at 11 weeks, 4 weeks after diagnosis of the intrauterine pregnancy, and resected via laparotomy. A healthy baby was delivered without complications at 40 weeks gestation. CONCLUSION: Heterotopic pregnancy is possible with natural conception and the survival of the intrauterine fetus is feasible.     

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.     

Twin pregnancy after diagnosis and treatment of ectopic implantation by retrograde selective salpingography and intraluminal methotrexate injection

In this case report, a patient with a right tubal pregnancy was managed by a new procedure combining retrograde salpingography and local MTX injection. A twin pregnancy occurred shortly after treatment. We conclude that retrograde tubal cannulation may provide an alternative method for the diagnosis and treatment of selected EPs.     

Ectopic pregnancy and medical abortion

OBJECTIVE: Medical abortion regimens have become more widely used to terminate early pregnancies. Medical abortion providers are concerned to diagnose and exclude women with ectopic pregnancy before initiating treatment, as with any early pregnancy termination. Yet, there is little information about whether the various pretreatment screening methods used are adequate. We reviewed published literature to determine the overall success of screening for ectopic pregnancy before medical abortion treatment. DATA SOURCES: We searched MEDLINE for articles on medical abortion regimens published before July 2003. METHODS OF STUDY SELECTION: We selected English language articles of studies of medical abortion with sample sizes greater than 100, which reported on ectopic pregnancy diagnosed after medical abortion treatment. Fifty-seven of 85 prospective studies and randomized trials (69%) met these inclusion criteria. We also included data from 2 unpublished studies because they were large and well-controlled and because they included serious adverse events known to us, which we did not deem fair to exclude from our analysis. TABULATION, INTEGRATION, AND RESULTS: Each article was reviewed by one author. Data from selected studies were compiled, and the frequency of ectopic pregnancy diagnosed after medical abortion treatment was calculated. Ectopic pregnancy was diagnosed very infrequently following medical abortion procedures, occurring in only 10 of 44,789 (0.02%) women. CONCLUSION: The very low frequency of ectopic pregnancies diagnosed after medical abortion treatment demonstrates that the various pretreatment screening methods that providers use to exclude patients with ectopic pregnancies are successful. Further, there is no evidence to suggest that medical abortion treatment leads to unusual complications for women with ectopic pregnancies.     

Absence of fetal movements and normal infants

Pregnant women feel movements from about the fifth month of pregnancy. In cases of high-risk pregnancy daily recording of fetal movements is useful in monitoring fetal well-being. Complete cessation of fetal movements points to a severely distressed fetus and impending death. We report here five women in whom failure to experience fetal movements was present from the beginning of pregnancy, or occurred after fetal movements had been felt for several weeks during the pregnancy. All the women delivered normal infants with high Apgar score.     

Neosalpingostomy for distal tubal obstruction: prognostic factors and impact of surgical technique

We reviewed the clinical records of all women who underwent microsurgical terminal neosalpingostomy for distal tubal obstruction between January 1983 and June 1988. We identified 95 women whose preoperative evaluation revealed no other contributory factors for infertility and analyzed their pregnancy outcome after this procedure. Pregnancy success was inversely related to the extent of tubal distortion (dilation, rugal integrity, and status of the fimbria) and degree of adnexal adhesions. Using our classification system for distal tubal obstruction, patients with mild disease had an 80% pregnancy rate, whereas patients with moderate and severe disease had a 31% and 16% success rate, respectively. We found no statistically significant difference in pregnancy outcome when we compared this series with our previous group, reported in 1978, where contemporary microsurgical technique was not used. Although we feel that optimal surgical technique is important to maximize success, we conclude that the most important prognostic factor in pregnancy outcome after neosalpingostomy for distal tubal disease is the anatomical and functional integrity of the tube.     

Cornual heterotopic pregnancy: a case report

Heterotopic pregnancy is the simultaneous development of an intrauterine pregnancy and ectopic pregnancy. We report a rare case of corneal heterotopic pregnancy at 9 weeks of amenorrhoea in a 30-year-old woman, after IVF. Because of the massive intraabdominal hemorrhage laparotomy was performed. Cornual resection and suture was performed and intrauterine pregnancy was evacuated. Doctors must be alert to the fact that confirming an intrauterine pregnancy does not exclude the coexistence of an ectopic pregnancy, particularly after IVF.     

Deoxyribonucleic acid synthesis in mesometrial arteries of guinea pigs during oestrous cycle, pregnancy and treatment with oestradiol benzoate

Terminal portions of mesometrial arteries which supply the myometrium and the placenta, respectively, were excised at various stages of the ovarian cycle and pregnancy, as well as after oestrogen treatment, and incubated in solutions containing [3H]thymidine. The incorporation of radioactivity into the acid-insoluble material was measured in order to evaluate the actual rate of DNA synthesis before and during pregnancy and after oestrogen administration. We found that the rate of incorporation rises 30-fold before oestrus and 40-fold in the beginning of pregnancy. A 70-fold rise in incorporation was initiated by 10 micrograms oestradiol benzoate (administered subcutaneously) in dioestrous and ovariectomized animals. We conclude that similar peaks of DNA synthesis in mesometrial arteries occur during oestrus and at the beginning of pregnancy. Oestradiol is capable of inducing the observed surge of DNA synthesis. The results are in agreement with the concept that oestradiol is a chemical regulator of arterial growth during pregnancy.     

Bilateral Ovarian Pregnancy After in Vitro Fertilization and Embryo Transfer in a Patient with Tubal Factor Infertility

Primary ovarian pregnancy is very rare event after natural pregnancy or assisted reproductive technology (ART) procedures. Although there are a few reports about unilateral ovarian pregnancy after in vitro fertilization and embryo transfer (IVF-ET), there has been no report about bilateral ovarian pregnancy. Moreover, it is difficult to diagnose an ovarian pregnancy following in vitro fertilization and embryo transfer because of enlarged ovary, fluid collection in pelvic cavity, and its low incidence. We present a case of a patient who underwent IVF-ET due to tubal factor infertility, but the patient developed bilateral ovarian pregnancy and was performed both ovarian wedge resection through laparotomy.     

Live twin birth after successful treatment of a ruptured heterotopic pregnancy by laparoscopy

We report a case of a live twin birth after laparoscopic treatment of a ruptured heterotopic pregnancy. A 29-year-old woman, with a history of right salpingectomy for ectopic pregnancy, became pregnant after transfer of three embryos at in vitro fertilization treatment. At the ninth week of gestation, she was admitted to our clinic with abdominal pain. Ultrasonographic examination revealed a triplet heterotopic pregnancy consisting of an intrauterine twin pregnancy and an ectopic pregnancy in the left fallopian tube. An immediate laparoscopy was planned and left salpingectomy was performed. In the postoperative period, intrauterine twin pregnancy continued uneventfully; at the 35th week of gestation, two healthy infants with birth weights of 2,206 and 2,426 g were delivered. Heterotopic pregnancies must be kept in mind after assisted reproductive techniques. Early diagnosis allows successful laparoscopic treatment without sequel. Laparoscopic surgery is an appropriate method to manage selected patients with heterotopic tubal pregnancy.     

Transcervical Suction of Interstitial Pregnancy under Laparoscopic and Hysteroscopic Guidance

Interstitial pregnancy is a rare but life-threatening condition. It is usually treated using cornual resection at operative laparoscopy or laparotomy; however, this may adversely affect future fertility and pregnancy. Transcervical suction using an 8F pediatric catheter placed through the cornua under laparoscopic and hysteroscopic guidance may be possible in some patients if the pregnancy is accessible vaginally. We describe a case of interstitial pregnancy treated with transcervical suction using an 8F pediatric catheter placed through the cornua under laparoscopic and hysteroscopic guidance with preservation of the uterine cornua and fallopian tube. The procedure was quick, bleeding was minimal, and there were no complications. Removal was complete, and serum β–human chorionic gonadotropin quickly became undetectable. Three months after the operation, salpingography yielded normal findings, and the patient was pregnant again 8 months after the surgery.     

Ovulation Induction and Normal Pregnancy after Panhypopituitarism due to Lymphocytic Hypophysitis

Background: Lymphocytic hypophysitis is an unusual autoimmune disease that causes partial or total hypopituitarism and often is associated with pregnancy. Only four spontaneous pregnancies have been reported after this disease. We report a case of ovulation induction in a woman with this antecedent as well as the course of the subsequent pregnancy.Case: Ovulation was induced with gonadotropins in a 31-year-old woman with panhypopituitarism secondary to lymphocytic hypophysitis, achieving an uncomplicated single intrauterine pregnancy. A term healthy infant was delivered by cesarean. Clinical course during puerperium was normal.Conclusion: Ovulation induction response was similar to that in panhypopituitarism of any other cause. Lymphocytic hypophysitis antecedent did not adversely affect pregnancy outcome nor was pregnancy-related disease relapse observed.     

Trauma and grief 2-7 years after termination of pregnancy because of fetal anomalies--a pilot study

The aim of the study was to obtain information on the long-term posttraumatic stress response and grief several years after termination of pregnancy due to fetal malformation. We investigated 83 women who had undergone termination of pregnancy between 1995 and 1999 and compared them with 60 women 14 days after termination of pregnancy and 65 women after the spontaneous delivery of a full-term healthy child. Women 2-7 years after termination of pregnancy were expected to show a significantly lower degree of traumatic experience and grief than women 14 days after termination of pregnancy. Contrary to the hypothesis, however, the results showed no significant intergroup differences with respect to the degree of traumatic experience. With the exception of one subscale (fear of loss), this also applied to the grief reported by the women. However, both groups differed significantly in their posttraumatic stress response from women who had given spontaneous birth to a full-term healthy child. The results indicate that termination of pregnancy is to be seen as an emotionally traumatic major life event which leads to severe posttraumatic stress response and intense grief reactions that are still detectable some years later.     

Acute myeloblastic leukemia in pregnancy: a case report and review of the literature

Leukemia is a rare event during pregnancy. The presence of leukemia during pregnancy raises several concerns about the effect of pregnancy on the prognosis of leukemia, the effect of the disease on pregnancy outcome and the teratogenic and mutagenic effect of chemotherapeutic agents on the fetus. We report a case of acute myeloblastic leukemia diagnosed during the third trimester of gestation and treated with chemotherapeutic agents before delivery. The duration of pregnancy was able to be prolonged for four weeks after clinical diagnosis of the disease and then terminated by cesarean section due to the presence of signs of fetal distress.     

Heterotopic pregnancy after in vitro fertilization and embryo transfer

We have presented a second case of heterotopic pregnancy after IVF-ET. The most likely cause is direct extrusion of embryos through the tubal ostia by the hydrostatic pressure associated with ET. The diagnosis of ectopic pregnancy must be suspected clinically and not ruled out on the sonographic demonstration of an intrauterine pregnancy. Early diagnosis is essential for the prevention of significant maternal morbidity and mortality after IVF-ET.     

A Case of Ovarian Pregnancy after Ipsilateral Partial Salpingectomy

We present a case report of an ovarian pregnancy after ipsilateral partial salpingectomy. A 19-year-old woman was admitted with vaginal bleeding and right lower abdominal pain. She had a history of right partial salpingectomy caused by a tubal pregnancy. The pregnancy test result was positive, and a right adnexal mass was identified by ultrasonography. Laparoscopy revealed a right ovarian pregnancy. Thus the possibility of ipsilateral ectopic pregnancy should be considered even when the patient has a history of salpingectomy total or partial.     

Acute pulmonary edema during nicardipine and salbutamol therapy for preterm labor in twin pregnancy

We report the case of a 38-year-old parturient at 30 weeks 2 days term of a multiple pregnancy who experienced acute pulmonary edema more than 48 hours after tocolytic treatment with nicardipine and salbutamol. The patient was transferred from a level 1 perinatal center to a level 3 perinatal center by the Grenoble mobile intensive care unit in application of the in utero transfer protocol for preterm labor before 33 weeks with twin pregnancy. This case illustrates the risk of tocolytic treatment and potential adverse effects in the event of preterm labor on twin pregnancy. The question of associating a second tocolytic after failure of the first is also raised.     

Review: breast cancer and pregnancy

With an incidence of 0.3–1 per 10,000 pregnancies, breast cancer is the second most common malignant disease (after cervical cancer) associated with pregnancy. Because evidence-based data are lacking, current recommendations derive from nonrandomized experiences. We reviewed the current literature on breast cancer during pregnancy and pregnancy-associated breast cancer. The diagnosis of breast cancer during pregnancy is often made at an advanced stage with limited prognosis. With a few limitations, surgery and chemotherapy can be performed during pregnancy, whereas radiotherapy should be postponed until after delivery. Reports of endocrine treatment during pregnancy are rare and disappointing, but it should be applied after delivery in estrogen/progesterone-receptor-positive cases. Breast cancer during pregnancy remains a multidisciplinary challenge in both therapeutic and ethical aspects. Because experience and guidelines are lacking, individual decisions after intensive discussions with the pregnant patient are necessary.The first two authors contributed equally to this article.     

The significance of the zona-free hamster oocyte test for the evaluation of male fertility

Results of the zona-free hamster oocyte test were compared with pregnancy rates after coitus and after artificial insemination with donor semen (AID) in 322 primary infertile couples. Artificial donor insemination was offered if in the test the percentage of hamster oocytes with at least one decondensed sperm head (oocyte-sperm interaction rate) was less than 20. If the rate was less than 5, the pregnancy rate after coitus was significantly lower than in the group with a rate of greater than or equal to 5 to less than 20. In the former group, the pregnancy rate by AID was significantly higher than the pregnancy rate by coitus. We conclude that the zona-free hamster oocyte test is useful to predict the chance to achieve pregnancy in couples with unexplained infertility and to determine whether AID can increase this chance.     

Successful laparoscopic management of primary omental pregnancy

Omental pregnancy is an extremely rare type of ectopic pregnancy. We present a case in which a 26-year-old woman was admitted to the emergency room with abdominal pain. She was diagnosed with a ruptured ectopic pregnancy after a positive urinary pregnancy test and transvaginal ultrasound. Laparoscopic surgery showed intact pelvic organs and an ectopic mass on the omentum. The patient was treated successfully with laparoscopic partial omentectomy, and pathologic examination confirmed an omental pregnancy. As evidenced by this case, laparoscopy can be useful to diagnose and treat unusually located ectopic pregnancies.