B超在早期宫角妊娠诊治中的临床应用价值

目的 探讨B超在早期宫角妊娠诊治中的临床应用价值.方法 选择川北医学院附属医院2005年6月至2010年6月临床拟诊早孕经B超诊断的早期官角妊娠自愿终止妊娠256例患者,年龄21～42岁.做二维或三维超声诊断,并在B超监测引导下施行人工流产或清官术,全部病例术后10d左右返院复诊.结果 全部病例经腹或经阴道B超(包括二...     

Spontaneous bilateral cornual uterine dehiscence early in the second trimester after bilateral laparoscopic salpingectomy and in-vitro fertilization: case report.

A bilateral cornual uterine dehiscence is reported, which occurred 14 weeks after in-vitro fertilization (IVF) in a patient having a medical history of previous bilateral salpingectomy via laparoscopy. Uterine rupture is a rare obstetric complication usually occurring during the third trimester of pregnancy within a uterus which has previously undergone an operation. Ectopic pregnancy is a well known complication of IVF. Post-salpingectomy cornual localization with rupture has also been published. Possible causes are discussed and the attention of the counselling physician is directed to the necessary awareness of such a complication in this high risk population. The reported case is an extreme rarity: a similar case has not been previously published in the literature.     

Tubal curettage: a new conservative treatment for haemorrhagic interstitial pregnancies

Haemorrhagic interstitial pregnancies are commonly treated by cornual resection. This invasive procedure may increase the risk of uterine rupture in subsequent pregnancies. We report here a case of a haemorrhagic interstitial pregnancy, associated with a viable intrauterine pregnancy in a salpingectomized woman, which was treated successfully by curettage of the uterine cornu.     

Surgery: Selective salpingography with an insemination catheter in the treatment of women with cornual Fallopian tube obstruction

The effectiveness of selective tubal cannulation using a simpleand inexpensive tubal insemination catheter was evaluated in23 infertile patients with cornual obstruction demonstratedby hysterosalpingography. Selective fluoroscopic tubal catheterizationwas accomplished in 95% of the patients with resulting tubalpatency in 70% of the procedures (28 recanalizations out of40 Fallopian tubes). Eight patients (34.8%, eight out of 23)became pregnant, six went on to full-term deliveries and twoexperienced spontaneous first-trimester abortions. One womanconceived twice, and delivered a singleton pregnancy after thefirst recanalization and a twin gestation after the second salpingography.No complications were reported. The results of this study emphasizethe ease, cost effectiveness and safety of this method, encouragingits use in patients with cornual Fallopian tube obstructioneither as the sole therapeutic approach or in association withother assisted conception treatment alternatives.     

Pregnancy following GnRH agonist therapy of uterine leiomyoma obstructing a single Fallopian tube

Several studies have shown that gonadotrophin-releasing hormoneanalogue (GnRHa) offers a promising medical approach in thetreatment of uterine leiomyomas. Medical management is veryimportant especially when fertility is desired. We report ona case with mechanical infertility, in which the right tubewas obstructed by cornual myoma and the left tube was resecteddue to a ruptured ectopic pregnancy. The myoma was reduced insize by GnRHa treatment and the patient subsequently conceived.     

13例宫角妊娠临床诊治分析

目的探讨宫角妊娠安全有效的诊治方案,为临床提供可靠的依据。方法对我院13例宫角妊娠做一回顾性分析。结果13例中B超提示宫角妊娠的7例,一侧宫角部不均质包块的2例;中期妊娠死胎入院引产的2例,经常规引产失败后行剖宫取胎术,术中均证实为宫角妊娠;1例死胎因腹腔大出血行剖腹探查术,术中证实为宫角妊娠破裂;1例因晚期流产后胎盘滞留入院,B超及手术后证实为宫角妊娠,行子宫切除术。结论宫角妊娠可引起各种并发症,常见的是流产、子宫破裂和胎盘滞留。根据宫角妊娠发生的类型选择个体化的治疗方法。     

超声对宫角妊娠与输卵管间质部妊娠的诊断分析

目的 探讨超声对早期宫角妊娠与输卵管间质部妊娠的诊断价值。方法 按病理结果,将60例患者分为宫角妊娠组（31例）及间质部妊娠组（29例）,根据超声声像图特征将其分为孕囊型及包块型,比较孕囊周边肌层厚度及孕囊与宫腔相通率,并分析超声诊断的准确性及误诊率。结果 宫角妊娠组孕囊周边肌层厚度及与宫腔相通率大于间质部妊娠组（P〈0.05）。孕囊型超声诊断的符合率为94.59%（35/37）,误诊率为5.41%（2/37）。包块型超声诊断的符合率为69.57%（16/23）,误诊率为30.43%（7/23）。结论 超声对早期宫角妊娠及间质部妊娠有一定的临床应用价值。     

Maternal serum alpha-fetoprotein levels in ectopic pregnancy

Maternal serum alpha-fetoprotein (AFP) was measured at the time of presentation in 44 women with histologically proven ectopic pregnancy. Serum AFP levels were within the reference range in 32 women. Eleven women (25%) had AFP levels above the 90th centile of the normal range, including five women with a live fetus seen ultrasonically preoperatively. The two women with a ovarian pregnancy and a cornual pregnancy had levels below the median value for gestational age.     

Spontaneous interstitial pregnancy on a tubal stump after unilateral adenectomy followed by transvaginal colour Doppler ultrasound

Transvaginal colour and angio Doppler blood flow analysis combined with serial measurement of human chorionic gonadotrophin (HCG) concentration is reported here for the first time to study the local vascularity of a cornual pregnancy and to monitor the effectiveness of medical therapy. Interestingly, a strong relationship between morphological changes of trophoblastic tissue and the intensity of neovascularization was noted. Systemic single-dose methotrexate (MTX) therapy allowed successful treatment of an interstitial ectopic pregnancy involving part of the proximal portion of a tubal stump. We suggest that, by adding colour Doppler to conventional transvaginal ultrasonography, the outpatient surveillance of ectopic pregnancy evolution following MTX therapy is greatly enhanced. This is of particular value in cornual pregnancies which are highly likely to develop harmful complications during surgical intervention or even during puncture for local MTX injection.      

Conservative laparoscopic management of a large cornual ectopic pregnancy

Cornual pregnancy traditionally has been treated with laparotomy and either cornual resection or hysterectomy. Recently, more conservative operations have been developed, and operative laparoscopy has provided yet another management option. This report describes the conservative management of a large cornual ectopic pregnancy and reviews the techniques and outcomes of conservative repair that have been described in the literature.      

Laparoscopic myomectomy and subsequent pregnancy: results in 54 patients

The laparoscopic approach to myomectomy has raised questions about the risk of uterine rupture in patients who become pregnant following surgery. It has been suggested that the rupture outside labour in pregnancies following laparoscopic myomectomy can be due to the difficulty of suturing or to the presence of a haematoma or to the wide use of radio frequencies. In this paper we describe the pregnancy outcome of 54 patients submitted to laparoscopic myomectomy at our Institution and prospectively followed during subsequent pregnancies. A total of 202 patients underwent laparoscopic myomectomy. A total of 65 pregnancies occurred in 54 patients who became pregnant following surgery. Data were collected about complications of pregnancy, mode of delivery, gestational age at delivery and birthweight of the neonates. No cases of uterine rupture occurred. Twenty-one pregnancies followed an IVF procedure. Nine patients conceived twice and one three times. Four multiple pregnancies occurred. Eight pregnancies resulted in a first trimester miscarriage and another in an interstitial pregnancy requiring laparotomic removal of the cornual gestational sac. Of the remaining 56 pregnancies, 51 (91%) were uneventful. In two cases a cerclage was performed at 16 weeks. In two cases pregnancy-induced hypertension developed. Two pregnancies ended with a preterm labour (26-36 weeks). A Caesarean section was performed in 45 cases (54/57, 80%). In terms of the safety of laparoscopic myomectomy in patients who become pregnant following surgery, our results were encouraging. However, further studies are needed to provide reliable data on the risk factors and the true incidence of uterine rupture.     

Enhancement of mononuclear cell oxidative burst by early post-transfer sera from human patients after unsuccessful embryo transfer

Early pregnancy sera were earlier shown to modulate T lymphocyte rosetting with sheep erythrocytes. We set out to investigate whether early pregnancy sera also modulate the state of activation of another immunologically relevant cell type, the monocyte. As an index of monocyte activation, we measured phorbol ester-triggered oxidative burst activity by a highly sensitive chemiluminescence method. Contrary to our expectations, incubation of mononuclear cells with sera taken early after embryo transfer from patients with a successfully developing pregnancy had no effect. Unexpectedly, such sera from patients from a control group of patients in whom no pregnancy developed after embryo transfer caused enhancement of mononuclear cell chemiluminescence. Stimulatory activity of these sera appeared between days 4 and 6 and was maximal between days 7 and 9 post embryo transfer. Whether this phenomenon is causally related to, or represents a consequence of the failure of embryo transfer, can currently not be decided.     

Successful management of a heterotopic Caesarean scar pregnancy: potassium chloride injection with preservation of the intrauterine gestation: case report

Caesarean scar pregnancy (CSP), in which the pregnancy is located in the scar of a previous Caesarean section, is a rare situation that carries a high risk of uterine rupture. Improved ultrasound imaging allows early diagnosis of this condition, but there is no standard management. We report the first case of CSP associated with a normal intrauterine pregnancy. Potassium chloride administered under transvaginal ultrasonographic guidance terminated cardiac activity in the CSP. The CSP resolved, and a healthy infant was delivered at 36 weeks. When the diagnosis is early and the patient asymptomatic, surgery can be avoided, the CSP can be terminated selectively and the intrauterine pregnancy thereby preserved.     

Early and late ovarian hyperstimulation syndrome: early pregnancy outcome and profile

BACKGROUND: Ovarian hyperstimulation syndrome (OHSS) in IVF/ICSI cycles may occur either as an early (early onset) or a late pattern (late onset). This observational study was designed to identify whether the onset pattern of OHSS is associated with the occurrence of pregnancy and the early pregnancy outcome. METHODS: Among 4376 consecutive IVF/ICSI cycles, 113 patients were hospitalized for OHSS after IVF/ICSI treatment and were included in the study. The setting was the Dutch-speaking Brussels Free University Hospital, between June 2000 and September 2002. RESULTS: Early OHSS occurred in 53 patients, and late OHSS complicated 60 patients. A total of 96.7% of the late OHSS cases occurred in a pregnancy cycle and were more likely to be severe than the early cases (P < 0.05). Although in the early group there initially was a 41.5% positive HCG rate per cycle, the clinical pregnancy rate fell to 28.3% as a result of a significantly (P < 0.05) increased preclinical pregnancy loss rate compared with the non-OHSS patients (31.8 versus 88.3%, respectively). The ongoing pregnancy rate per cycle was 14.4% in the early and 26.4% in the late group. Multiple pregnancy rates were high in both groups (40 and 45.5%, respectively), but only in the late group did the incidence reach significance compared with the non-OHSS population (45.5 versus 29.1%, P = 0.02). Estradiol levels and number of follicles on the day of HCG were significantly higher in the early OHSS group. However, there was no difference in estradiol values on the day of hospital admittance between the two groups. In addition, the number of follicles on the day of HCG administration appears to be a better prognostic indicator for the occurrence of severe OHSS than the estradiol values (87% of the severe cases had > or = 14 or follicles of a diameter > or = 11 mm, whereas only 50% of them had an estradiol value > or = 3000 ng/l). CONCLUSIONS: The early OHSS pattern is associated with exogenously administered HCG and a higher risk of preclinical miscarriage, whereas late OHSS may be closely associated with the conception cycles, especially multiple pregnancies, and is more likely to be severe. Further clarification of these two different clinical entities could have implications for research protocols as well as for preventive and management strategies for OHSS.     

Sperm DNA fragmentation: paternal effect on early post-implantation embryo development in ART

BACKGROUND: The relationship between early embryo post-implantation development in couples undergoing assisted reproductive techniques (ARTs) and sperm chromatin alterations has not been satisfactorily explained. The aim of this study was to assess the relationship between sperm DNA fragmentation in IVF/ICSI patients, sperm parameters (concentration, motility and morphology) and ART outcome, especially with regard to clinical pregnancy and pregnancy loss (spontaneous miscarriage or biochemical pregnancy). METHODS: DNA fragmentation was evaluated by TUNEL assay, performed on sperm suspensions after density gradient separation, in 132 men undergoing an ART cycle (82 IVF and 50 ICSI) and correlated with sperm parameters and ART outcome. RESULTS: A highly significant negative correlation was found between DNA fragmentation and sperm parameters. There was a close relationship between DNA fragmentation and post-implantation development in ICSI patients: the clinical pregnancy and pregnancy loss rates significantly differed between patients with high and low sperm DNA fragmentation (P = 0.007 and P = 0.009, respectively). CONCLUSIONS: Sperm DNA fragmentation seems to affect embryo post-implantation development in ICSI procedures: high sperm DNA fragmentation can compromise 'embryo viability', resulting in pregnancy loss.     

Early transvaginal embryo aspiration: a safer method for selective reduction in high order multiple gestations.

Assisted reproduction technologies and ovulation induction for treatment of infertility continue to cause high order multiple gestations. Increased perinatal morbidity and mortality, as well as maternal morbidity, may complicate these pregnancies. Selective fetal reduction, an acceptable therapeutic approach in these cases, is usually performed at or after the ninth week of gestation, with KCl injected in the vicinity of the fetal heart, and is associated with a total pregnancy loss rate of 11.7%. We report our experience with 90 women who underwent early (mean 7.5 weeks gestation, range 7. 0-8.0 weeks) transvaginal selective embryo aspiration. The mean number of viable embryos before and after reduction was 3.5 and 2.1 respectively. Six (6.7%) pregnancies were lost before 24 gestational weeks. One miscarriage occurred at the tenth gestational week. The other five pregnancies were aborted at 17.3-21.6 weeks gestation. Additional interventions were performed in three of these pregnancies: genetic amniocentesis in two cases and cervical suture in one case. In the subset of 39 patients with>/=4 embryos, only one (2.6%) pregnancy loss was recorded. This loss rate is significantly lower (P < 0.05) than the 15.3% loss rate in patients with >/=4 fetuses calculated from other work. Four (4.4%) other pregnancies were complicated by premature delivery (25-28 weeks gestation). Mean gestational age of delivered pregnancies in our series was 35.7 weeks. In conclusion, early transvaginal embryo aspiration is a simple and relatively safe method for multiple pregnancy reduction. The overall pregnancy loss rate associated with early embryo aspiration is similar to that of procedures performed at later gestational age, but is significantly lower when the initial number of embryos is four or greater.     

Basal FSH concentrations as a marker of ovarian ageing are not related to pregnancy outcome in a general population of women over 30 years

BACKGROUND: Previous studies suggest that elevated basal FSH concentrations are related to aneuploid pregnancies. However, there have been no prospective studies evaluating the incidence of aneuploidies in relation to basal FSH concentrations. Since the majority of aneuploid conceptions end in early pregnancy loss or abortion of a recognized pregnancy, these determinants are appropriate intermediate end-points to study aneuploidy. METHODS: We performed a prospective study in 129 women without a history of subfertility pursuing a spontaneous pregnancy. Basal FSH concentrations were measured during three menstrual cycles. Urinary HCG levels were measured during menstruation for a maximum of six menstrual cycles, to detect early pregnancy loss. We estimated the effect of basal FSH concentrations on pregnancy outcome, taking into account possible confounders. RESULTS: We observed no significant effect of basal FSH concentrations on the incidence of early pregnancy loss or abortion of clinically recognized pregnancies. CONCLUSIONS: We conclude that in a population of women without a history of subfertility, pursuing a spontaneous pregnancy, basal FSH concentrations are not related to the incidence of early pregnancy loss or abortions. This prospective study therefore fails to confirm a relationship between signs of decreased ovarian reserve and aneuploid pregnancies.     

Intact HCG, free HCG beta subunit and HCG beta core fragment: longitudinal patterns in urine during early pregnancy

BACKGROUND: Detecting and monitoring early pregnancy depend on the measurement of HCG. Little is known about how production of various forms of HCG may evolve over the earliest weeks of pregnancy, particularly in naturally conceived pregnancies. METHODS: We describe the daily excretion of three urinary HCG analytes during the first 6 weeks post-conception in 37 naturally conceived pregnancies ending in singleton birth. We assayed daily first morning urine samples for intact HCG, free beta subunit and beta?core fragment, plus the combined measurement of these HCG forms. We calculated doubling times for each analyte and the inter- and intra-subject day-to-day variation. RESULTS: Intact HCG and the free beta subunit were initially the predominant forms of HCG, with the beta core fragment emerging as the predominant form in the fifth week after conception. Intact HCG and the free beta subunit showed the most day-to-day variability, and were transiently undetectable even 10 days after detection of pregnancy. The most stable estimate of doubling time was provided by the combined measurement of all these forms. CONCLUSIONS: Although intact HCG is usually regarded as the main analyte for detection and monitoring of early pregnancy, it can fluctuate markedly during early pregnancy. This variability could affect pregnancy test results based on early pregnancy urine, and may distort estimates of doubling time. Assays that combine several forms of HCG may be more reliable.     

Return of reproductive performance after expectant management and local treatment for ectopic pregnancy.

The purpose of this study was to examine hysterosalpingographic findings and reproductive performance in patients previously managed non-surgically for ectopic pregnancy. Forty-nine patients with unruptured ectopic pregnancies were treated either by expectant management (n = 16) or medically (n = 33), using transvaginal methotrexate or sulprostone injection. The treatment was successful in 35 patients (71.5%), 12 out of 16 and 23 out of 33 in the two groups respectively. For all patients, follow-up currently varies from 3 to 52 months with a median follow-up of 16.6 +/- 11.2 months and 7.3 +/- 4.3 months in the two groups respectively. Hysterosalpingography was performed in 25 out of 26 patients who desired further pregnancy. We found evidence of tubal patency on the ectopic pregnancy treated side in 23 cases (92%). In this group, no recurrent ectopic pregnancy was observed. In the expectant management group, eight out of nine patients became pregnant, and the mean time to achieve pregnancy was 16.6 +/- 11.2 months. In the medical treatment group, eight out of 17 patients became pregnant and the mean time to achieve pregnancy was 8.6 +/- 4.2 months. In this last group, seven out of nine non-pregnant patients have had only a short follow-up, 4.5 +/- 3.2 months since treatment completion. No recurrent ectopic pregnancy was observed in this successfully treated group of patients who desired further pregnancy. We conclude that the medical approach to unruptured ectopic pregnancy is associated with a high rate of tubal patency and a reproductive performance similar to conservative surgical methods.     

A woman with three ectopic pregnancies after in-vitro fertilization and embryo transfer

Although a higher incidence of ectopic pregnancy has been reported after in-vitro fertilization (IVF) and embryo transfer, three ectopic pregnancies in the same woman is very rare. A patient of 32 years underwent IVF-embryo transfer six times within 3 years. Three of four conceptions resulted in ectopic pregnancies. The first involved simultaneous intrauterine and left tubal pregnancy, the second was a right tubal pregnancy, and the third was a right interstitial pregnancy. In IVF-embryo transfer, bilateral salpingectomy does not remove the risk of interstitial or cornual pregnancy.