Heterotopic pregnancy in a spontaneous cycle

Heterotopic pregnancy, defined as the simultaneous occurrence of intrauterine and extrauterine pregnancies, is rare in a natural cycle. Assisted reproductive techniques have resulted in an increased incidence. Identification of an intrauterine pregnancy can divert attention from the possibility of a concurrent ectopic pregnancy. We describe such a case with the educational features.     

Recurrent cornual pregnancy after heterotopic cornual pregnancy successfully treated with systemic methotrexate

This report concerns a recurrent spontaneous cornual pregnancy 2 years after selective feticide of a heterotopic cornual pregnancy which occurred after IVF for tubal pathology. The recurrent cornual pregnancy was treated successfully with systemic methotrexate. Assisted reproductive techniques, especially in patients with tubal pathology, and non-invasive management of cornual pregnancies may lead to a higher incidence of recurrence.     

输卵管妊娠保守性手术96例分析

目的探讨输卵管妊娠保守性手术及不同手术方式的近期效果及妊娠结局.方法对96例未破裂型输卵管妊娠中的77例行输卵管线型切开术,19例行输卵管伞端胚囊挤出术.绒毛种植部位注射甲氨蝶呤20～30rng.结果2.4%的患者发生持续性异位妊娠,均为行伞端挤出术患者.宫内妊娠率为41.5%,重复异位妊娠率为25.6%.对侧输卵管正常者,宫内妊娠率及重复异位妊娠率分别为70.5%和22.8%;当对侧输卵管异常或已被切除者,宫内妊娠率及重复异位妊娠率为7.9%和28.8%.结论绒毛种植部位注射甲氨蝶呤可降低持续性异位妊娠率,而伞端绒毛挤出术后发生持续性异位妊娠的可能性较大,应尽量避免.     

Ruptured extrauterine pregnancy

Extrauterine pregnancies contribute substantially to maternal mortality in all parts of the world. The most common cause of these deaths is massive bleeding after rupture of the ectopic pregnancy. The advent of transvaginal ultrasonography in early pregnancy and the use of quantitative measurement of the β-unit of human chorionic gonadotropin have revolutionized the management of this condition. These diagnostic modalities allow its early detection and, in many cases, treatment before rupture occurs. There is an ever increasing body of evidence supporting expectant, medical, and surgical management of ectopic pregnancy according to certain criteria. The indications and criteria for the different management options are described in the literature and in clear guidelines from institutions such as the Royal College of Obstetricians and Gynaecologists. Methotrexate, in a single dose protocol, is widely used in the medical management of ectopic pregnancy. Surgical therapy can be either laparoscopic or via laparotomy. Be that as it may, ruptured ectopic pregnancy will continue to present as a gynecologic emergency requiring prompt and appropriate care. Resuscitation of these patients should be an organized, systematic, and rapid process with the ultimate goal of getting them to the operating theatre in the best possible hemodynamic status. The aim of surgery should be to stop active bleeding by the most expedient method. The use of autotransfusion is well established in cardiac surgery, vascular surgery, orthopedic surgery, and trauma. Using autologous blood should be considered also in the treatment of ruptured extrauterine pregnancy when faced with massive bleeding and a need for transfusion. Advanced abdominal pregnancy is a rare condition with high perinatal and maternal morbidity and mortality. Placental management at delivery remains a dilemma. The risk of massive bleeding upon removal must be balanced against the risk of infection and other complications during the long time needed for resorption of the placenta if left in situ. Despite a reduction in maternal mortality due to ectopic pregnancy in the developed world during the preceding period, it would appear that no further inroads have been made in the last two decades. In developing countries, the problem is far greater, and problems with resources and infrastructure persist. It remains a challenge to all practitioners caring for women to apply available resources and use the published evidence-based guidelines to manage these women effectively and safely.     

Laparoscopic management of ectopic pregnancies in unusual locations

ObjectiveThe aim of this study was to evaluate the feasibility and efficacy of laparoscopic surgery for patients with ectopic pregnancies in unusual locations.Materials and methodsThis is a retrospective case series of 31 patients from 6 weeks to 10 weeks postmenstrual who were referred for diagnosis and treatment and suspected of having an unruptured cesarean scar pregnancy (CSP) or cornual pregnancy (CP). The diagnosis was confirmed with transvaginal ultrasound, and all of the patients underwent laparoscopic management.ResultsA diagnosis of CSP or CP was confirmed in all of the patients during the laparoscopic procedure. None of the patients required conversion to laparotomy. The total operative time ranged from 40 minutes to 120 minutes. The total blood loss was limited, ranging from 30 mL to 200 mL. All of the women tolerated the operation well and had uneventful recoveries.ConclusionWhen performed by a well-trained gynecologist, laparoscopy appears to be a reasonable alternative for the treatment of unruptured CSP or CP.     

Expectant Management of Post-Term Patients: Observations and Outcome

Post-term pregnancy is associated with increased perinatal mortality. In a retrospective study based on our post-term protocol from 1990 until May 1995 1,798 post-term pregnant women with reliable dating were evaluated for expectant management. A group of 2,633 pregnant women who delivered between 37 and 41 weeks during 1994 served as a control group. The perinatal mortality (0.56 per 1,000 vs. 0.75 per 1,000 in the control group) was similar in both groups. The incidence of induction of labor (7.45% vs. 7% in the control group), meconium of more than +1 (5.2% vs. 4% in the control group), shoulder dystocia (0.33% vs. 0.19%), high birthweight (>4,500 g) (1% vs. 1%), and cesarean section rates (7.5% vs. 7% in the control group) were similar. However the fetal distress rates (11.6% vs 16%; P =. 004), instrumental deliveries (10.1% vs. 13%), P =. 002), and the rate of 5-minute Apgar score of less then 7 (1.1% vs. 5%, P =. 000001) were found to be significantly lower in the post-date group than in the control group. We conclude that the expectant management and our intensive observation and follow-up in post-term is indicated for both mother and fetus.     

Primary omental pregnancy: case report and review of literature

Omental pregnancy is a very rare form of ectopic pregnancy. A 29-year-old woman presented with severe abdominal pain. History of the patient revealed use of combined oral contraceptive pills. There was no gestational sac in the endometrial cavity and no tubal ring in the adnexa, but free peritoneal fluid was detected at ultrasonography. Laparotomy was done according to pre-operative diagnosis of ruptured tubal pregnancy. Bilateral tubes and ovaries were intact; gestational sac was detected attached to the necrotic lower edge of omentum. Although 16 cases of omental pregnancy (mostly secondary) were reported in the literature, herein we describe a primary omental pregnancy without adnexal involvement.     

Cervical pregnancy treated with transvaginal ultrasound-guided intra-amniotic instillation of methotrexate

Aim Aim of the study was to investigate the efficacy of single transvaginal ultrasound-guided intraamniotic installation of methotrexate in the management of cervical pregnancy with concurrent review of the literature.Materials and methods Six patients with cervical pregnancy are included in the study. All patients were treated with single transvaginal ultrasound-guided intraamniotic installation of 70 mg of methotrexate plus folic acid p.o. The main presenting symptoms were mild to moderate vaginal bleeding and lower abdominal cramp-like pain, resembling the clinical presentation of a threatened abortion. The typical ultrasound findings were the absence of intrauterine gestational sac and the detection of a gestational sac within the cervical canal, invading the anterior or the posterior wall of the cervix and normal appearance of the adnexa, bilaterally. The hourglass-shaped cervix was not characteristic at 5 weeks of gestation but it was at 8 weeks of gestation.Discussion Ultrasound-guided intraamniotic installation of methotrexate in the management of cervical pregnancy appears to be an effective and safe method but the choice of the method should be depended on the gestational age of cervical pregnancy, the presence of active bleeding or not and its severity, the desire for preservation of future fertility, the presence of coexisting valuable intrauterine pregnancy and the experience of the physician in charge.     

Abdominal pain in late pregnancy (≥24 weeks’ gestation)

Abdominal pain in late pregnancy is a common presentation and can pose a diagnostic and management dilemma to clinicians. For this article we have defined late pregnancy as ≥ 24 weeks gestation. An acute abdomen affects 1 in 500 pregnancies with approximately 0.5–2% of pregnant women needing surgical interventions in pregnancy. The majority of acute abdominal complaints will present in a similar manner to the non-pregnant patient; however the anatomical and physiological changes of pregnancy can complicate the diagnosis and management options. Appendicitis remains the most common cause of an acute abdomen in pregnancy. Management should be tailored depending on the patient and the severity of the condition. Special consideration should be made for the fetus but the life of the mother should be of primary concern. Surgery can therefore be performed at any stage of pregnancy if, on balance, it is the most appropriate option. Clinicians should not neglect obstetric causes of pain and endeavour to always diagnose the underlying cause of the abdominal pain to aid management. This article explores the different aetiologies of pain in late pregnancy and latest advances in management.     

Abdominal pain in late pregnancy

Abdominal pain in late pregnancy is a common presentation and can pose a diagnostic and management dilemma to clinicians. An acute abdomen affects 1 in 500 pregnancies with approximately 0.5%–2% of pregnant women needing surgical interventions in pregnancy. The majority of acute abdominal complaints will present in a similar manner to the non-pregnant patient, however the anatomical and physiological changes of pregnancy can complicate the diagnosis and management options. Appendicitis remains the most common cause of an acute abdomen in pregnancy. Management should be tailored depending on the patient and the severity of the condition. Special consideration should be made for the fetus but the life of the mother should be of primary concern. Surgery can therefore be performed at any stage of pregnancy if, on balance, it is the most appropriate option. Clinicians should not neglect obstetric causes of pain and endeavour to always diagnose the underlying cause of the abdominal pain to aid management. This article explores the different aetiologies of pain in late pregnancy and latest advances in management.     

多胎妊娠中孕期选择性减胎术

中孕期妊娠选择性减胎术主要目的是减少多胎妊娠胎儿数、减灭异常胎儿,改善多胎妊娠结局。在排除单绒毛膜双胎的情况下,药物减胎比较成熟和安全,一般在妊娠 11～24 周实施,妊娠成功率接近自然双胎。对于单绒毛膜双胎采用血管闭塞的技术进行选择性减胎,国内多采用射频消融,一般选择在15～27周。手术适应证、手术时机、手术方法以及术者的熟练程度与妊娠结局有关。减胎术前应行超声检查判断绒毛膜性、诊断早期胎儿异常和识别双胎特殊并发症。     

Simultaneous cul-de-sac and tubal pregnancy following in vitro fertilization

Objective

The aim of this study is to share a valuable experience of heterotopic pregnancy following in vitro fertilization.

罕见部位异位妊娠的超声诊断

目的:分析和总结罕见部位异位妊娠的超声图像特点。方法:采用回顾性方法分析腹腔妊娠、残角子宫妊娠、卵巢妊娠、子宫肌壁妊娠的二维、彩色多普勒超声图像,与手术及病理结果对照分析。结果:腹腔妊娠表现为子宫腔空虚,腹腔内可见胎儿回声;残角子宫妊娠表现孕囊周围可见肌层回声,其旁可见正常子宫声像;卵巢妊娠未发生破裂时典型特征卵巢上可见孕囊回声;子宫肌壁妊娠术前超声确诊困难,需靠病理才能确诊。结论:掌握罕见部位异位妊娠的声像图特点,可提高超声对异位妊娠的诊断能力。     

宫内外复合妊娠的诊治

随着辅助生殖技术的广泛应用,宫内外复合妊娠发病率逐渐升高。超声检查是诊断宫内外复合妊娠的主要方式,但由于警惕性不足,临床表现缺乏特异性,容易漏诊。宫内外复合妊娠的治疗以保守治疗和手术治疗为主。由于多数患者要求保留宫内妊娠,治疗时需要综合考虑到对宫内妊娠的影响和患者的安全性,个体化选择治疗方案。     

Exocervical pregnancy

A case of cervical pregnancy with implantation of the fertilized ovum on the exocervix is described. This pregnancy was mistaken for an endometriotic lesion and treated by simple surgical excision. Discussion is centered on etiology, predisposing factors and management. Received: 26 August 1996 / Accepted: 3 February 1997