Effect of ultrasound-guided aspiration of hydrosalpingeal fluid during oocyte retrieval on the outcomes of in vitro fertilisation-embryo transfer: a randomised controlled trial (NCT01040351)

Objective.?To determine whether the ultrasound-guided aspiration of hydrosalpingeal fluid at the time of oocyte retrieval can improve the outcomes of in vitro fertilisation-embryo transfer (IVF-ET).

Patients. One hundred and ten women with ultrasound-visible hydrosalpinges were randomised to two groups based on computer generated randomisation list. Fifty-four women underwent ultrasound-guided aspiration of hydrosalpingeal fluid prior to IVF-ET and 53 women underwent IVF-ET without any prior intervention.

Results.?Patients who underwent aspiration of hydrosalpinges demonstrated a significantly increased implantation, clinical pregnancy rates. Among the patients in the aspiration group, the implantation rate and pregnancy rates were higher in the subgroup of patients with no reaccumulation of hydrosalpingeal fluid within the first 2 weeks after aspiration compared to patients with reaccumulation of hydrosalpingeal fluid within the first 2 weeks after aspiration, but this difference failed to reach statistical significance. Furthermore, no pregnancies occurred in the four patients with uterine fluid collection detected during IVF-ET cycles.

Conclusion.?The aspiration of hydrosalpingeal fluid at the time of oocyte retrieval is simple, safe and effective procedure for treatment of patients with ultrasound-visible hydrosalpinges particularly those without rapid reaccumulation of hydrosalpingeal fluid after aspiration or uterine fluid collection during the IVF-ET cycles.     

Conservative treatment of cervical ectopic pregnancy with transvaginal ultrasound-guided aspiration and single-dose methotrexate

OBJECTIVE: To present a case of cervical ectopic pregnancy successfully treated with ultrasound-guided aspiration and single-dose methotrexate administered systemically. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 27-year-old nulliparous woman with a cervical ectopic pregnancy. INTERVENTION(S): Transvaginal ultrasound-guided aspiration of the cervical ectopic pregnancy followed by single-dose methotrexate administered systemically. MAIN OUTCOME MEASURE(S): Recovery of the patient, successful conservative treatment of the cervical ectopic pregnancy, with preservation of the uterus. RESULT(S): The cervical ectopic pregnancy was successfully aborted, and the reproductive capability of the patient was preserved. CONCLUSION(S): Transvaginal ultrasound-guided aspiration in combination with single-dose methotrexate administered systemically can be safely used to treat cervical ectopic pregnancies.     

Tratamiento del embarazo ectópico cervical con metotrexato y rescate con leucovorina

Objective

To present two cases of cervical ectopic pregnancy successfully treated with systemic methotrexate.

Subjects and methods

Two women with a cervical ectopic pregnancy. Interventions: alternative day regime of methotrexate 1 mg/kg (days 1,3,5 and 7) with folinic acid rescue (days 2, 4, 6, and 8). End points: successful treatment.

Results

Two cases of ectopic cervical pregnancy were successfully treated and preserved their reproductive capability.

Conclusions

Conservative medical treatment of cervical ectopic pregnancy with systemic methotrexate is safe and effective.     

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.     

Influence of spontaneous fetal reduction on dichorionic diamniotic twin pregnancy outcomes after in vitro fertilization: a large-sample retrospective study

Objective: To examine the incidence of spontaneous fetal reduction during dichorionic diamniotic (DCDA) twin pregnancy after in vitro fertilization and embryo transfer (IVF-ET) and its influence on pregnancy outcomes.

Methods: This was a retrospective cohort study of 4447 DCDA twin pregnancies and 14,551 singleton pregnancies after IVF-ET at a single center between 2009 and 2015. The spontaneous pregnancy reduction (SPR) group included 759 women. The remaining 3688 women with DCDA twins showing no spontaneous reduction were included in the non-SPR group. Outcomes were compared to a singleton group (n?=?14,551) treated over the same period. The overall rate of spontaneous reduction and frequency distribution across gestational epochs were determined and pregnancy outcomes were compared among the three groups. Further regression analysis was conducted to investigate whether spontaneous reduction was an independent risk factor for decreased take-home baby rate.

Results: The overall rate of spontaneous DCDA twin reduction after IVF-ET was 17.1%, with most cases (89.8%) occurring in the first trimester. Pregnancy outcome measures, including miscarriage rate, premature delivery rate, live birth rate, take-home baby rate, gestational age of delivery, and neonatal birth weight, were significantly better in the SPR group than the non-SPR group. Live birth rate, take-home baby rate, neonatal birth weight, and other primary outcome measures in the SPR group were not inferior to the singleton group. Multivariate regression analysis showed that the take-home baby rate was significantly lower in the non-SPR group (OR =0.73, 95%CI: 0.44–0.92, p?=?.008) and that SPR did not decrease the take-home baby rate.

Conclusions: Spontaneous pregnancy reduction is common in DCDA twin pregnancy after IVF-ET, but has little adverse influence on pregnancy outcomes and does not reduce the probability of taking home live babies.     

Cervical pregnancy: a case report of hysteroscopic resection and balloon compression combined with systematic methotrexate treatment

ObjectiveCervical pregnancy is a rare type of ectopic pregnancy. When the pregnancy is terminated, it will sometimes lead to persistent bleeding. In some cases, hysterectomy is inevitable and the patient loses fertility. Therefore, early diagnosis and targeted management with systemic or local injection of methotrexate is the first-line treatment. Multiple interventions of cervical pregnancy were used to prevent massive hemorrhage, including dilatation and curettage, laparoscopic resection, hysteroscopic resection combined with uterine artery embolization, or uterine artery clip.Case reportWe report a case of cervical pregnancy with a high beta-hCG level accompanied by a visible fetal heartbeat that was successfully treated with hysteroscopic cervical tissue resection and balloon compression combined with systemic administration of methotrexate.ConclusionEfficacy and safety with preserved fertility were important issues in the management of cervical pregnancy. We provide a safe, simple and effective treatment of cervical pregnancy.     

宫颈妊娠及宫内孕合并宫颈妊娠的保守治疗

目的:探讨宫颈妊娠的病因、诊断及保守性治疗方法。方法:回顾分析我院1996年1月1日至2010年12月31日收治的宫颈妊娠及体外授精胚胎移植术后宫内孕合并宫颈妊娠患者36例,探讨宫颈妊娠保守治疗方式的选择,并随访患者术后情况。结果:29例单纯宫颈妊娠:6例外院误诊为"难免流产",误诊率20.69%;10例经阴道B超引导下宫颈妊娠囊局部穿刺+MTX注射治疗,6例行子宫动脉栓塞术,6例MTX肌内注射治疗,7例腰麻下宫腔镜检查宫颈妊娠清除手术。7例宫内孕合并宫颈妊娠:1例阴道B超引导下局部妊娠囊穿刺注入KCl 1ml,3例期待疗法后清除宫颈妊娠物,3例腹部B超引导下宫颈妊娠物清除术。结论:阴道彩超用于宫颈妊娠的早期诊断有较大的价值,术前应充分评估,制定个体化的治疗方案。宫内孕合并宫颈妊娠的患者在腹部B超监测下清除宫颈妊娠物是有效的治疗方式之一,但要及时手术并且加强抗感染治疗。     

Transvaginal cervical length measurement at 22- to 26-week pregnancy in prediction of preterm births in twin pregnancies

Objective: To investigate the predictive role of transvaginal ultrasonographic measurement of cervical length (CL) at 22–26 weeks of gestation in determining preterm deliveries in twin pregnancies.

Methods: The study included 150 twin pregnancies. CL was measured by transvaginal ultrasonography at 22–26 weeks. Signs of preterm labor, ruptured membranes, vaginal bleeding, patients with systemic disease, and cervical incompetencies were excluded. The patients had monthly digital cervical examinations but no routine TVCL ultrasound examinations. The primary outcome was spontaneous preterm birth at before 37 weeks of gestation.

Results: Ninety-two percent of twin pregnancies delivered by cesarean section and 16% babies had a neonatal intensive care unit requisitioned. Ninety-two patients were delivered in smaller than 37 gestational weeks and the mean CL measurement (CLM) was <37.64?±?6.23?mm. According to the ROC curve analysis, CLM was found to be a discriminating parameter in patients. The area under the curve, cutoff values, sensitivity, and specificity were 0.794, 34.95, and 70–80%; respectively (p?=?0.029).

Conclusion: In women with twin pregnancy, the risk of preterm birth can be evaluated using the ultrasonographic measurement of CL at 22–26 weeks of gestation.     

Management of ectopic pregnancies with poor prognosis through ultrasound guided intrasacular injection of methotrexate,series of 14 cases

Purpose  

The purpose of this study is to describe our experience in cases of tubal ectopic pregnancy with heartbeat, abdominal, interstitial (corneal) and cervical ectopic pregnancies treated with intrasacular injection of methotrexate (MTX) administered under ultrasound guidance associated with a single systemic dose of MTX.     

Emergency cervical cerclage: Predictors of success

Objective.?To document predictors of success of emergency cervical cerclage.

Methods.?This is a retrospective cohort study of 8 years at a university hospital. Emergency cerclage was defined as when the membranes were at or beyond the external os and was only performed where evidence of infection or labour were absent. Outcomes used were interval between cerclage and delivery, gestation at delivery; a ‘good outcome’ was defined as delivery after 32 weeks and healthy at discharge. Predictive factors for a successful pregnancy outcome were analysed using odds ratios (OR) with 95% confidence intervals.

Results.?Forty-five emergency cerclages were performed, including 11 twin pregnancies. Twenty-one (47%) had a ‘good outcome’, including two twin pregnancies; 20 (44%) pregnancies reached 36 weeks. In 79.2% of ‘poor outcomes’ chorioamnionitis was found. Prolapsed membranes, advanced cervical dilatation, maternal symptoms and equivocal markers of infection were associated with a poor outcome, but not consistently enough to dictate management.

Conclusions.?Given the poor natural history of an open external os, emergency cerclage appears beneficial. That this might apply to twin pregnancies has implications for their management. Although success is indeed partly predictable, it can still be achieved even when there is advanced dilatation, prolapse, bleeding or discomfort.     

Conservative medical management of advanced cervical ectopic pregnancies

Cervical ectopic pregnancy is the rarest form of ectopic gestation. Viable cervical ectopic pregnancies of 10 weeks' gestation or more are even rarer. It is unclear whether these advanced cervical ectopic gestations should be managed primarily by surgical evacuation or by more conservative medical management with chemotherapeutic agents. Cases of medical treatment of viable cervical ectopic gestations reported in the literature are reviewed. An additional case of a 10.6 weeks of gestation, viable cervical ectopic pregnancy treated with methotrexate, intrafetal potassium chloride, and intramuscular methotrexate is added to the previously reported literature. Advanced cervical ectopic pregnancies with fetal cardiac activity at 10 or more weeks' gestation may be successfully managed with chemotherapeutic agents. Ultrasound-guided intrafetal injection of feticidal agents may be preferable to maternal systemic chemotherapy alone.     

Multidose methotrexate treatment of cervical pregnancy

BackgroundCervical pregnancy is a rare form of ectopic pregnancy. The treatment ranges from medical treatment with methotrexate to hysterectomy.CasesWe report two cases of cervical pregnancy with fetal cardiac activity that were successfully treated with multidose methotrexate.ConclusionDue to the possible severe complications of cervical pregnancy and its surgical management, multidose methotrexate treatment in hemodynamically stable women is an appropriate option.     

Medical therapy (methotrexate and mifepristone) alone or in combination with another type of therapy for the management of cervical or interstitial ectopic pregnancy

Objective

To describe cases of cervical or interstitial ectopic pregnancy managed conservatively with combined medical treatment (methotrexate and mifepristone) alone or in association with other minimally invasive strategies.

Study design

We describe four cervical and two interstitial ectopic pregnancies at our hospital between 2006 and 2010. All received combined treatment with methotrexate and mifepristone. A search of MEDLINE is also described.

Results

The literature search identified only four previous cases of cervical ectopic pregnancies and no cases of interstitial ectopic pregnancy managed with combined therapy. In our study, all patients were successfully treated and had no adverse reactions with intramuscular methotrexate 50 mg/m² and oral mifepristone 600 mg, either alone or in association with minimally invasive treatment (uterine artery embolization and evacuation dilation and curettage). All patients remained asymptomatic with β-HCG levels that decreased and became negative within 14–49 days: the median hospital stay was 5.5 days. We also describe the first patient with a cervical ectopic pregnancy treated with methotrexate and mifepristone, followed by vaginal misoprostol 800 mcg for cervical evacuation.

Conclusion

Methotrexate–mifepristone, either alone or in combination with other minimally invasive strategies, could be considered an option for the treatment of both cervical and interstitial ectopic pregnancy. An individualized approach should be used in each patient, however, given the wide variety of possible clinical situations and the potential seriousness of ectopic pregnancy.     

Treatment with methotrexate of a cornual pregnancy following endometrial resection

ABSTRACT

Objectives Endometrial resection is a procedure often performed for treatment of menorrhagia. Despite the fact that amenorrhoea frequently ensues, some normal endometrium can remain present and become the implantation site of a pregnancy. Such an event is uncommon (0.7%); however, the likelihood of an ectopic pregnancy is increased. This case report calls the reader's attention to the risk of intra- and extrauterine pregnancies and the necessity for contraception after endometrial resection, even in cases where amenorrhoea supervenes.

Case A 46-year-old woman with prior endometrial resection and subsequent amenorrhoea, was diagnosed with a cornual pregnancy. She was successfully treated with systemic methotrexate, which was given in an outpatient clinic.

Conclusion Clinicians should be aware of the increased likelihood of an ectopic pregnancy after endometrial resection. All women submitting to this procedure should be counselled about the need for contraception, even in cases where amenorrhoea develops.     

Unilateral tubal twin ectopic pregnancy treated with single-dose methotrexate

Background  

Spontaneous tubal twin pregnancy is a rare condition with an incidence of 1 in every 125,000 pregnancies. We present the case of a unilateral tubal twin ectopic pregnancy treated with single-dose methotrexate.     

Acute Hemorrhage Related to a Residual Cervical Pregnancy: Management with Curettage,Tamponade, and Cerclage

Cervical ectopic pregnancy is uncommon, with no universally accepted protocol for conservative management of acute hemorrhage due to residual cervical ectopic pregnancy. Herein is presented the case of a 33-year-old woman with profuse vaginal bleeding 3 months after receiving treatment including intraamniotic potassium chloride injection, systemic methotrexate, and uterine artery embolization because of a cervical ectopic pregnancy. A residual cervical pregnancy was suspected. Hemorrhage was controlled using curettage, tamponade with a Bakri balloon, and cerclage. The balloon and cerclage were removed on postoperative day 2, with no recurrence of symptoms. Our experience suggests that a combination of curettage, balloon tamponade, and cerclage may be considered in the management of cervical ectopic pregnancies with acute hemorrhage, in particular in patients desiring future childbearing.     

Conservative management of cervical pregnancy with embryonic heart activity by ultrasound-guided local injection: an eight case series

Abstract

Objective: To evaluate the efficacy of conservative management of cervical pregnancy with embryonic heart activity by ultrasound-guided local injection.

Methods: Retrospective case series at University tertiary care Hospital. Eight patients diagnosed with cervical pregnancy with embryonic heart activity managed conservatively. The intervention was ultrasound-guided local injection of methotrexate (1?mg/kg) and potassium chloride (2?meq/mL). Measurements were occurrence of morbidity, necessity for further intervention, the initial titers of beta-hCG, interval of time in which the levels of beta-hCG became negative, period for regression of cervical pregnancy at ultrasound and future pregnancy.

Results: All patients were treated successfully. The initial levels of beta-hCG ranged from 3013 to 71199 mUI/mL. One case evaluated with infection. There was no need for additional intervention in our series study. The interval of time for the levels of beta-hCG becomes negative range from 2 to 12 weeks. The period for the regression of the cervical pregnancy at ultrasound range from 3 to 14 weeks. In two cases intrauterine pregnancies occurred after the treatment.

Conclusion: Conservative management of cervical pregnancy with embryonic heart activity by ultrasound-guided injection is an effective treatment avoiding the need of further intervention.     

In vitro fertilization-embryo transfer pregnancy was a risk factor for hemorrhagic shock in women with placental polyp

Objective: The aim of this study was to determine the risk factors for hemorrhagic shock in women with placental polyp.

Materials and methods: Twelve women (group A) developed hemorrhagic shock (shock index?Results: When compared with group B, group A had higher in vitro fertilization-embryo transfer (IVF-ET) pregnancy rate (58.3 versus 12.0%, p?p?p?p?Conclusions: For the first time, IVF-ET pregnancy was found to be a risk factor for the development of hemorrhagic shock in women with placental polyp.     

Reduction of twin pregnancy to singleton: does it improve pregnancy outcome?

Objective.?To compare pregnancy complications, obstetrical and neonatal outcome of twin pregnancies reduced to singleton, with both non-reduced twin pregnancies and singleton pregnancies.

Methods.?A retrospective case–control study was performed at the Obstetrics and Gynecology Ultrasound unit of a tertiary referral medical center. Patient's population included 32 bi-chorionic bi-amniotic twin pregnancies reduced to singleton and 35 non-reduced twin pregnancies. Thirty-six patients with singleton pregnancies comprised the second control group. Main outcome measures were rates of pregnancy complications, preterm delivery (both before 37 weeks of gestation and before 34 weeks of gestation), late abortions, intra-uterine growth retardation, cesarean section, mean birth weights, and mean gestational age at delivery.

Results.?The reduced twin pregnancies group had similar rates of total pregnancy complications, preterm deliveries, and cesarean section as non-reduced twins. Gestational age at delivery and mean birth weight were also similar to non-reduced twins and significantly different compared with singletons. Preterm delivery and late abortion incidences were significantly higher when reduction was beyond 15 weeks gestation.

Conclusions.?Reduction of twin pregnancy to singleton does not change significantly pregnancy course and outcome. Favorable obstetrical and neonatal outcomes could be achieved by performing early, first trimester reductions.     

Delayed spontaneous expulsion of a cervical ectopic pregnancy: a case report

Cervical ectopic pregnancy is an uncommon event. Modern diagnostic and treatment options provide an opportunity for conservative treatment of this condition. A case of a profuse hemorrhage associated with delayed spontaneous expulsion of a cervical ectopic pregnancy is described, and the management is discussed. In this patient, the cervical ectopic pregnancy was treated successfully using systemic methotrexate and selective uterine artery embolization. The patient returned 1 week later with spontaneous expulsion of the ectopic pregnancy associated with profuse hemorrhage. The bleeding subsided following tamponade using a transcervical Foley catheter. We conclude that conservative treatment of cervical ectopic pregnancy is feasible, with careful posttreatment surveillance.