Other treatments for CSP

Caesarean scar pregnancy (CSP) is an increasingly common clinical conundrum. The non-curettage surgical management of CSP can be categorised into hysteroscopic, vaginal, laparoscopic, and open removal modalities and the choice of treatment is surgeon-dependent. A systematic review of original studies reporting surgical treatment outcomes of CSP until March 2023 was conducted to evaluate the non-curettage surgical management of this highly morbid condition. A total of 60 studies of mostly weak methodological quality were identified involving 6720 CSP cases. Success rates were generally high across all treatment modalities although highest in vaginal and laparoscopic excisional approaches. Morbidity was most associated with haemorrhage although unplanned hysterectomy rates remained low across all treatment groups. Subsequent pregnancies are associated with morbidity despite being underreported and the impact of CSP treatment on future pregnancy is poorly understood. Substantive study heterogeneity precludes meta-analyses of pooled data and treatment superiority has not been demonstrated.

Efficacy and Safety of High-intensity Focused Ultrasound Compared with Uterine Artery Embolization in Cesarean Section Pregnancy: A Meta-analysis

OBJECTIVE

To investigate the efficacy and safety of high-intensity focused ultrasound (HIFU) compared with uterine artery embolization (UAE) in cesarean section pregnancy (CSP) and to calculate the success rate of HIFU.

DATA SOURCES

We searched PubMed, Cochrane, Scopus, Web of Science, and Embase on September 30, 2022, and the related studies were independently reviewed by 2 researchers.

METHODS OF STUDY SELECTION

Medical subject headings and relevant terms from other articles were used for the database search. Patients with CSP who underwent HIFU were included in this analysis. The following results were recorded: success rate, intraoperative blood loss, time for serum beta-human chorionic gonadotropin (beta-HCG) normalization and menstruation recovery, adverse events, hospitalization time, and hospitalization expenses. We used the Newcastle-Ottawa Scale scoring system and the methodological index for nonrandomized studies system to evaluate the quality of the studies.

TABULATION, INTEGRATION, AND RESULTS

Data from 6 studies were used to compare the efficacy and safety of UAE and HIFU. We pooled the success rate of HIFU by including 10 studies. No data overlap between the 10 studies. Success rate was higher in the HIFU group (odds ratio [OR] = 1.90; 95% confidence interval [CI] 1.06-3.41; p = .03; I2 = 0). We performed the meta-analysis of single rate in R 4.2.0 software, and the success rate of HIFU group was 0.94 (95% CI 0.92-0.96; p = .04; I2 = 48%). Intraoperative blood loss (mean difference [MD]= -21.94 mL; 95% CI -67.34 to 23.47; p = .34; I2 = 99%) and time for serum beta-HCG normalization (MD = 3.13 days; 95% CI 0.02-6.25; p = .05; I2 = 70%) were not significantly different. Time to menstruation recovery (MD = 2.72 days; 95% CI 1.32-4.12; p = .0001; I2 = 0) in the UAE group was shorter than that in the HIFU group. Adverse events were not significantly different between the 2 groups (OR = 0.53; 95% CI 0.22-1.29; p = .16; I2 = 81%). Hospitalization time was not significantly different between the HIFU and UAE groups (MD = -0.41 days; 95% CI -1.14 to 0.31; p = .26; I2 = 55%). Hospitalization expenses of the HIFU group were lower than those of the UAE group (MD = -7488.49 yuan; 95% CI -8460.13 to -6516.84; p <.000; I2 = 0). Heterogeneity of the time for beta-HCG normalization, adverse events, and hospitalization time were improved after excluding one study, and HIFU showed better results in the sensitivity analysis of adverse events and hospitalization time.

CONCLUSION

According to our analysis, HIFU demonstrated satisfactory treatment success, accompanied by similar intraoperative blood loss, slower normalization of beta-HCG levels, and menstruation recovery, but potentially shorter hospitalization time, lower adverse events and lower costs than UAE. Therefore, HIFU is an effective, safe, and economical treatment for patients with CSP. These conclusions should be interpreted with caution because of the significant heterogeneity. However, large and strictly designed clinical trials are required to verify these conclusions.

Reproductive outcomes of ectopic pregnancy with conservative and surgical treatment: A systematic review and meta-analysis

BACKGROUND

Ectopic pregnancy (EP), one of the most common gynecological emergencies, is the major cause of maternal death in the first trimester and increases the incidence of infertility and repeat ectopic pregnancy (REP). The aim of this study was to compare the effects of different treatment methods for tubal EP on natural pregnancy outcomes.

METHODS

We systematically searched PubMed, Embase, Cochrane Library, Web of Science, and Clinical Trials for observational studies on EP (published until October 30,2022 in English) comparing methotrexate (MTX) versus surgery, MTX versus salpingostomy, MTX versus salpingectomy, salpingostomy versus salpingectomy, and MTX versus expectant treatment. Our main endpoints included subsequent natural intrauterine pregnancy (IUP) and REP. We assessed the pooled data using Review Manager software (version 5.3) with a random effects model.

RESULTS

Of 1274 identified articles, 20 were eligible and 3530 participants were included in our analysis. There was a significant difference in the odds of subsequent IUP in tubal EP patients who underwent MTX compared with those who were treated with surgery [odds ratios (OR) = 1.52, 95% confidence interval (CI):1.20-1.92]. No significant difference was found in the odds of REP between the 2 groups (OR = 1.12, 95% confidence interval [CI]: 0.84-1.51). There was no significant difference in the odds of subsequent IUP and REP in patients after MTX compared to those after salpingostomy (OR = 1.04,95% CI: 0.79-1.38; OR = 1.10, 95% CI: 0.64-1.90). There was a significant difference in the odds of subsequent IUP in patients after MTX compared with those after salpingectomy (OR = 2.11, 95% CI: 1.52-2.93). No significant difference was found in the odds of REP between the 2 groups (OR = 0.98, 95% CI: 0.57-1.71). There was a significant difference in the odds of subsequent IUP between patients who underwent salpingostomy and those who underwent salpingectomy (OR = 1.61, 95% CI: 1.29-2.01). No significant difference was found in the odds of REP between the 2 groups (OR = 1.21, 95% CI: 0.62-2.37). There was no significant difference in the odds of subsequent IUP and REP in patients after MTX compared with those after expectant treatment (OR = 1.25, 95% CI: 0.64-2.45; OR = 0.69, 95% CI: 0.09-5.55).

CONCLUSION

For hemodynamically stable tubal EP patients, MTX has advantages over surgery, particularly salpingectomy, in improving natural pregnancy outcomes. However, MTX is not inferior to salpingostomy and expectant treatment.

Caesarean scar pregnancy: is there a light in the end of the tunnel?

PURPOSE

To summarize and present a single tertiary center's 25 years of experience managing patients with caesarean scar pregnancies and their long-term reproductive and obstetric outcomes.

METHODS

A 25-year retrospective study included women diagnosed with CSP from 1996 to 2020 in one tertiary center. Data were retrieved from the medical records and through a telephone interview. Diagnosis was made by sonography and color Doppler. Treatments included methotrexate, suction curettage, hysteroscopy, embolization and wedge resection by laparoscopy or laparotomy as a function of the clinical manifestations, the physicians' decisions, patient counseling, and parental requests.

RESULTS

Analysis of the records recovered 60 cases of CSP (two of whom were recurrent). All patients had complete resolution with no indication for hysterectomy. Thirty-five patients had a long-term follow-up, of whom 24 (68.6%) attempted to conceive again and 22 (91.6%) succeeded. There were 17/22 (77.3%) patients with at least one live birth, 3/22 (13.6%) spontaneous miscarriages and 2/22 (9%) recurrent CSP. The obstetric complications included abnormal placentation 5/19 (26.3%), premature rupture of membranes 2/19 (10.5%), preterm delivery 4/19 (21%) and abnormality of the uterine scar 2/19 (10.5%). There was one case of neonatal death due to complications of prematurity 1/19 (5.2%).

CONCLUSION

CSP treatment focusing on reducing morbidity and preserving fertility has encouraging long-term reproductive and obstetric outcomes. In subsequent pregnancies, we recommend performing an early first trimester vaginal scan to map the location of the new pregnancy, followed by close monitoring given the obstetric complications mentioned above.

Case report: Two rare uterine cesarean scar mass cases

RATIONALE

Gestational trophoblastic neoplasia (GTN) located in the cesarean scar is a rare disease that has imaging appearances similar to those of an exogenous scar incision pregnancy and is often misdiagnosed due to insufficient clinical experience.

PATIENT CONCERNS

We report 2 cases of uterine cesarean scar mass. Two patients with different diagnoses had similar clinical complaints as abnormal vaginal bleeding, enlargement of uterus isthmus by physical examination, and mixed echo mass in uterine low segment by ultrasound examination; however, their magnetic resonance imaging images showed very different features.

DIAGNOSES

One patient was diagnosed with cesarean scar pregnancy (CSP) and one patient was diagnosed with cesarean scar GTN.

INTERVENTIONS

The CSP patient underwent surgery by laparoscopy combined with hysteroscopy after uterine artery embolism and obtained pathological confirmation. The GTN patient received chemotherapy.

OUTCOMES

For the CSP patient, her serum β-human chorionic gonadotropin (hCG) concentration returned to normal 2 weeks later, and B-ultrasound showed that the niche was completely repaired 3 months after the operation. The intrauterine lesions of the GTN patient disappeared completely 3 months after serum β-hCG normalization. And her β-hCG was normal at all follow-up visits until now.

LESSONS

Clinicians should consider GTN when identifying masses at scar incision sites. Magnetic resonance imaging images improve the understanding of the imaging features in patients suspected of having CSP/GTN.

A detective of intramural ectopic pregnancy: The use of pituitrin under hysteroscopy combined with laparoscopy

RATIONALE

Intramural pregnancy is a rare ectopic pregnancy in which the gestational sac is implanted between the muscle walls. Due to the lack of specific clinical manifestations, it is easy to misdiagnose or miss them. If it is allowed to get worse, the uterus will burst, and there will be a lot of bleeding in the later stages, which could lead to the death of the patient.

PATIENT CONCERNS

The patient had no history of uterine surgery, embryo transplantation, or any other operations. She complained of having abdominal distention and swelling of the waist but no vaginal bleeding or lower abdomen discomfort.

DIAGNOSES

According to her transvaginal ultrasonography, we highly suspected ectopic pregnancy. Hysteroscopy combined with laparoscopy is an effective treatment option that can prevent life-threatening problems. During the surgery, pituitrin helped find the gestational sac, and the pathology report confirmed that it was an intramural pregnancy.

INTERVENTIONS

Hysteroscopy combined with laparoscopy is an effective treatment option that can prevent life-threatening problems. During the surgery, we used pituitrin to help find the gestational sac. The use of pituitrin can minimize bleeding during a uterine operation and indicate the location of an intramural pregnancy, helping surgeons to complete the operation successfully.

OUTCOMES

The patient recovered quickly and was discharged on the 4th day after surgery, with a significant decrease in human chorionic gonadotrophin (HCG) levels from 14,792.26 mIU/mL before surgery to 1071.40 mIU/mL at discharge. During the follow up, her HCG level dropped to 50.90 mIU/mL on the 14th day after the surgery. She monitored the HCG levels intermittently until they fell within the normal range.

LESSONS

Intramural pregnancy is a rare form of ectopic pregnancy, and it is difficult to diagnose early on. This may result in uterine rupture or even life-threatening hemorrhage. If an intramural pregnancy is suspected in early pregnancy, hysteroscopy combined with laparoscopy is advised, and if necessary, low-dose posterior pituitary hormone can enhance uterine contractions and better reveal the position of the gestational sac within the uterine wall.

Ultra-High-Risk Gestational Choriocarcinoma of the Ovary Associated with Ectopic Pregnancy

Gestational choriocarcinoma of the ovary is an exceptionally rare and highly aggressive tumor. Preoperative diagnosis of extrauterine choriocarcinoma is difficult due to nonspecific clinical presentation and its resemblance to ectopic pregnancy. Without molecular genetic analysis, it is not possible to reliably differentiate gestational from non-gestational choriocarcinoma. Here, we present a case of a 44-year-old woman who presented to our emergency department with complaints of pelvic pain, vaginal bleeding, and amenorrhea. Because of a recent history of conservatively managed ectopic pregnancy, the patient underwent emergency laparoscopy. Right-sided salpingo-oophorectomy was performed due to intraoperatively suspected ovarian ectopic pregnancy. Histopathology results revealed the diagnosis of ovarian choriocarcinoma of possible gestational origin. It was classified as FIGO stage IV and WHO ultra-high-risk, and she underwent multi-agent chemotherapy without major complications. She has remained in complete remission after a 12-month follow-up. Considering the rarity of this diagnosis, we conducted a literature review including all published cases of suspected gestational choriocarcinomas of the ovary. We conclude that due to the rarity of this entity, preoperative differentiating between ovarian ectopic pregnancy and ovarian choriocarcinoma is extremely challenging, and without molecular genetic analysis, it is not possible to identify the genetic origin of the tumor.

The Predictive Value of Decisive and Soft Ultrasound Criteria for Ectopic Pregnancy Identification in 321 Preoperative Cases

PURPOSE

 To define the predictive value of morphological types (MTs) and further criteria in diagnosing ectopic pregnancy (ECP) by transvaginal sonography (TVS) prior to operative confirmation and treatment.

MATERIALS AND METHODS

 Retrospective cohort analysis of 321 consecutive patients with suspected ECP who were advised to undergo operation.

RESULTS

 ECP was investigated by TVS in all 321 patients. Application of the five selected MTs (blob sign, bagel sign, yolk sac, embryo, heart action) resulted in 85 % of cases receiving a conclusive diagnosis and 12 % receiving a presumed ECP diagnosis. 3 % remained nondiagnostic due to large or multiple ovarian cysts, large myoma, extended hemoperitoneum, or severe pain. ECP diagnosis was confirmed intraoperatively in 97 % of cases and was otherwise (3 %) immediately followed by curettage (CUR). The assessment of free fluid by TVS was achieved in most cases and correlated significantly with free blood. In the majority of cases, free blood was not bound to transmural ECP rupture. Histology confirmed the ECP diagnosis directly or by exclusion in 99 % of cases. Three cases of tubal ECP were diagnosed by TVS but not confirmed by LSC (1 %) and, finally, histology from CUR proved miscarriage (false-positive rate 1 %).

CONCLUSION

 We confirm the high accuracy of TVS diagnosis of ECP relying on five clearly different MTs, independent of its location. The blob and bagel sign emerged as important types (75 % of all ECPs). Histology from CUR was needed when ECP could not be visualized in LSC. Assessment of free fluid was essential and accurate in predicting free blood.

Predictive factors analysis of cesarean scar pregnancy treated by local injection of Lauromacrogol combined with curettage

To explore factors related to local injection of Lauromacrogol combined with curettage in the treatment of cesarean scar pregnancy. A total of 24 successful and 8 unsuccessful cases were included. The age, gravidity, parity, times of cesarean section, interval from the last cesarean section, preoperative human chorionic gonadotropin (HCG), HCG on the first day after operation, decreasing rate of HCG on the first day after operation, average diameter of gestational sac, and preoperative vaginal bleeding days were analyzed. There were no significant differences of age, gravidity, parity, previous cesarean section times between groups. The differences of preoperative HCG, HCG on the first day after operation, the decreasing rate of HCG, gestational sac diameter, preoperative vaginal bleeding days were statistically significant between groups. The interval from the last cesarean section and the decreasing rate of HCG were protective factors, while the mean diameter of gestational sac and period of vaginal bleeding before operation were risk factors for the success of the treatment. The mean diameter of gestational sac owned the best predictive value.

Trophoblastic microcirculation occlusion as an adjunct to electric vacuum aspiration for the treatment of endogenous cesarean scar pregnancy

OBJECTIVE

To describe a simple adjunct treatment option, trophoblastic microcirculation occlusion (TMO), which could change subsequent high-risk electric vacuum aspiration in patients with an endogenous cesarean scar pregnancy (CSP) into a routine conventional surgical procedure. Electric vacuum aspiration for the treatment of CSP may be associated with several significant complications, including hemorrhage and tissue remnants. Consequently, a second intervention, such as uterine artery embolization, resectoscopy, or methotrexate, may be required, thus complicating the surgical treatment of CSP.

DESIGN

We demonstrate the principle and detailed technique of TMO treatment using animations, video clips, and slides. The study was approved by the institutional review board of Hangzhou Women's Hospital.

SETTING

Tertiary maternity hospital.

PATIENT(S)

The video shows a 30-year-old woman with a 5-week endogenous CSP. The procedural steps were repeated in another 6 patients suffering from endogenous CSP (Table 1). Written informed consent was obtained from each patient.

INTERVENTION(S)

In patients with a CSP, the syncytiotrophoblastic cells erode the helicine arteries in the inner uterine myometrium. The cytotrophoblastic cells extend as villi tissue into the syncytiotrophoblast. Maternal blood enters the intervillous space between the cytotrophoblast and syncytiotrophoblast. The syncytiotrophoblast, cytotrophoblast, and intervillous space constitute the trophoblastic microcirculation, which subsequently becomes the main blood supply to the gestational sac (Fig. 1). During TMO treatment, the trophoblastic microcirculation is identified by contrast-enhanced ultrasound with the cubital vein injected with sulfur hexafluoride microbubbles (Bracco, Switzerland). A 21-gauge needle (200 mm long) was punctured vaginally into the uterine myometrium surrounding the syncytiotrophoblast at 3 different points, and a total of 8 mL sclerosant was injected directly to seal the trophoblastic microcirculation. Complete compression of the helicine arteries for trophoblastic blood supply is the key to TMO treatment (Fig. 2, see video interpretation for detailed information). A repeat contrast-enhanced ultrasound was performed after injection to confirm a significant reduction of blood flow in the trophoblast. An electric vacuum aspiration was performed 24 hours after TMO treatment to remove the products of conception completely. Surgical safety was enhanced by deep sedation and concurrent transabdominal ultrasound guidance. The levels of β-human chorionic gonadotropin (β-hCG) were measured weekly until a nonpregnant level was achieved. A follow-up ultrasound then was performed to confirm that the treatment was complete.

MAIN OUTCOME MEASURE(S)

The clinical value and feasibility of TMO treatment as an adjunct before high-risk electric vacuum aspiration for the management of endogenous CSP.

RESULT(S)

The TMO treatment was performed successfully in all 7 patients; the clinical outcomes are presented in Table 2. The TMO treatment significantly reduced the risk of hemorrhage during electric vacuum aspiration. No complications were detected perioperatively. Patients were discharged on day 1 postoperatively. Follow-up ultrasound, performed when the levels of β-hCG had fallen to normal, failed to identify any remnants of the uterine corpus. One patient achieved an intrauterine pregnancy 7 months postoperatively and gave birth to a live baby at 39 weeks of gestation via repeat cesarean section. No cesarean scar dehiscence was observed.

CONCLUSION(S)

Surgical abortion of an endogenous CSP, with a high risk of intraoperative hemorrhage, can be performed with minimal blood loss in a single electric vacuum aspiration when assisted by TMO treatment. This technique provides good results in terms of bleeding reduction that are comparable to those in conventional patients. The TMO treatment can be accomplished via ultrasound-guided needle puncture, a technique that is available widely in the practice of reproductive medicine with a reduced need for consumable resources. The use of a simple adjunct treatment option, TMO, expands the indications of electric vacuum aspiration. This sequential treatment allows for completion of clinical management without the need for uterine artery embolization, resectoscopy, or methotrexate, thus simplifying the originally complicated form of surgical treatment for CSP.

Viable invasive cervical pregnancy treated with minimally invasive procedures

With an incidence of 1% of all ectopic pregnancies, cervical ectopic pregnancy (CEP) is due to possible early misdiagnosis or bleeding and rupture can become a life-threatening condition with the need for urgent hysterectomy, which has been seen in clinical practice recently. We present a case of early diagnosed invasive CEP treated with combined minimally invasive procedure (MIP) due to acute pelvic pain and bleeding. In our case, we applied several of these methods to a primigravida with early invasive CEP with fertility preservation. By combining the self-described local medications with uterotonics and cervical anaemia treatment, intravenous tranexamic acid and MIP, we were able to preserve the uterus with minimal blood loss and the possibility of future conception.

Ruptured ovarian ectopic pregnancy presenting with an acute abdomen

An ectopic pregnancy occurs in 2% of all pregnancies. A primary ovarian ectopic (OP) is a rare entity and occurs in <2% of all ectopic gestations. It may present in those individuals who take ovulatory drugs, use an intrauterine device or have undergone in vitro fertilisation or embryo transfer. Multiparity and a younger age are other recognised risk factors. Diagnosing an OP pregnancy remains a challenge and it may be misdiagnosed as a bleeding luteal cyst, a haemorrhagic ovarian cyst or a tubal pregnancy by ultrasound scan. The diagnosis is often only established at laparoscopy following histopathological examination. A ruptured OP is a potentially life-threatening condition due to its potential for haemorrhage and hemodynamic collapse. Hence, early diagnosis is crucial to prevent serious morbidity and mortality. The authors present the case of a multiparous woman in her late 30s presenting with a seizure and lower abdominal pain at 6 weeks gestation. Her beta human chorionic gonadotropin was >9000 Miu/mL. A transvaginal ultrasound scan showed no evidence of an intrauterine pregnancy. There was free fluid in the pelvis. She was hemodynamically stable. She underwent a diagnostic laparoscopy, which showed hemoperitoneum and a ruptured left OP pregnancy. She underwent a left oophorectomy. Histology confirmed chorionic villi within the ovarian stroma. This case demonstrates the challenges in preoperative diagnosis of a ruptured OP pregnancy and acts as a cautionary reminder that individuals can present with hemodynamic stability. Rarely, as in this case, an OP pregnancy can occur without the presence of risk factors. Despite its rarity, a ruptured OP pregnancy should be considered in the differential diagnosis of women of reproductive age presenting to the emergency department with acute abdominal pain and a positive pregnancy test.

High-intensity focused ultrasound ablation combined with systemic methotrexate treatment of intramural ectopic pregnancy: A case report

RATIONALE

Intramural ectopic pregnancy (IMP) is a rare ectopic pregnancy with an unclear etiology, and standard treatment guidelines currently remain unclear. The main treatment option is local excision of IMP via laparoscopy or laparotomy.

PATIENT CONCERNS

A 32-year-old woman with adenomyosis presented with amenorrhea for 7 weeks and a serum β-human chorionic gonadotropin (HCG) level of 6882 IU/L. The patient had a history of laparotomy for adenomyosis 5 years previously. Three-dimensional ultrasonography showed a live gestational sac (GS) of 9 × 15 × 18 mm located in the left posterior wall of the uterus and a sinus tract connecting the sac and the endometrial cavity. MRI revealed the GS located in the adenomyosis and a 1.0-cm sinus tract connecting the GS and the endometrial cavity.

DIAGNOSES

IMP with adenomyosis.

INTERVENTIONS

High-intensity focused ultrasound (HIFU) treatment combined with systemic methotrexate (MTX) was performed to treat IMP, which would avoid operation and massive bleeding.

OUTCOMES

Serum β-HCG levels decreased to normal 4 weeks after HIFU treatment and the GS was not found on MRI after 4 months. The sinus tract was significantly shortened after the HIFU treatment.

LESSONS

HIFU ablation combined with systemic MTX is effective for the treatment of IMP and is favorable for maintaining fertility.

Tubal ectopic pregnancy in acute abdominal presentation: A case control analysis

BACKGROUND

The aim of the study was to evaluate the demographic data, clinical findings, ectopic pregnancy (EP) localization (left or right-sided), and treatments versus clinical presentation of tubal pregnancies (TP) with or without acute abdomen.

METHODS

Pregnants with a diagnosis of TP, selected for acute abdomen or not, were evaluated and compared, concerning EP local-ization (right/left), age, parity, symptoms (menstrual delay, vaginal bleeding, and groin pain), initial β-hCG value, endometrial thickness, presence of rupture, and treatment type (methotrexate and surgery).

RESULTS

On a total of 122 pregnants with TP, 32 showed acute abdomen, 45 had a TP located in the right tube and 32 in the left tube. In the acute abdomen group, parity, initial β-hCG level, and endometrial thickness were greater than non-acute abdomen group. In addition to this, the frequency of bleeding complaints, right-sided TP, rupture, and need for surgery were higher, than to the non-acute abdomen group. The frequency of the previous EP and methotrexate treatment was higher in those with the left-sided TP compared to those with the right-sided TP.

CONCLUSION

EP rate, in patients with TP who applied to the emergency department with acute abdominal symptoms, was mostly located in the right tube with greater frequency of salpingectomy in open surgery.

Ectopic Pregnancy

Ectopic pregnancy occurs in 2% of all pregnancies and is a potentially life-threatening emergency. A high level of clinical suspicion is required for any pregnant patient who presents with vaginal bleeding and/or pelvic pain. Workup should begin with immediate triage based on vital signs, a pregnancy test, and transvaginal ultrasound. Ectopic pregnancy can be treated either medically with methotrexate or surgically with either salpingectomy or salpingostomy. Carefully counseled, asymptomatic patients may be candidates for expectant management.

Ruptured chronic ectopic pregnancy presenting with a negative urine pregnancy test

An acute ectopic pregnancy is one of the most common gynaecological emergencies in clinical practice. The diagnosis is usually established by a combination of clinical examination findings, correlated with sonographic and laboratory results. However, a chronic ectopic pregnancy (CEP) may occur when the ectopically implanted gestation, mostly in the fallopian tubes, invades the underlying structures, causing protracted destruction at the site of implantation. Individuals may present with subacute or chronic abdominal pain, abnormal vaginal bleeding, amenorrhoea and a low bHCG. The correct diagnosis is often only established following laparoscopy or even histologically after the operation. The authors present the case of a woman in her 30 s presenting with severe right sided abdominal pain and a failing pregnancy at 10 weeks gestation. Her urine pregnancy test was negative, but her serum bHCG was 18 IU/L. A transvaginal ultrasound scan confirmed a ruptured right tubal ectopic pregnancy. A laparoscopic salpingectomy was performed. This case provides an important reminder that a CEP should always be considered in the differential diagnosis of women of reproductive age presenting with acute lower abdominal pain, despite a negative urine pregnancy test.

Extratubal secondary trophoblastic implants (ESTI) following laparoscopic bilateral salpingectomy for ectopic pregnancy: problems that have been neglected for a long time

Background: Extratubal secondary trophoblastic implants following laparoscopic salpingectomy is an extremely rare form of persistent ectopic pregnancy. These cases usually result in a small amount of vaginal bleeding and sudden lower abdominal pain thereby presenting with hemoperitoneum in emergencies. Owing to the urgency of hemoperitoneum and the uncertainty of the location of persistent ectopic pregnancy after laparoscopic salpingectomy, the risk of reoperation is increased. It is necessary to prevent in first surgery and diagnose these cases in the early following up phase.Methods: We report a case of 26-year-old woman, gravida 3, para 0, presenting a little vaginal bleeding and slight lower abdominal pain after laparoscopic bilateral salpingectomy for more than 1 month. The patient's serum β-HCG was still high (3981 mIU/ml), and no abnormalities were found through auxiliary examination (ultrasound, abdominal CT, and pelvic MRI).Results: Finally, emergency laparoscopy revealed many blue purple nodules on the surface of ovaries, small intestine, omentum, and periumbilical peritoneum, with a diameter of 3-20 mm. The lesions were completely removed as far as possible. Pathology showed trophoblastic proliferation and β-HCG soon decreased to negative after this operation.Conclusion: Therefore, it is important to follow up serum β-HCG even after salpingectomy and avoid iatrogenic dissemination of trophoblast tissue through careful operation.

Reproductive outcomes of cesarean scar pregnancies treated with uterine artery embolization combined with curettage

OBJECTIVE

The aim of this study was to review the reproductive outcomes of women with a cesarean scar pregnancy (CSP) treated with dilation and curettage (D&C) after uterine artery embolization (UAE).

MATERIALS AND METHODS

This was a retrospective study to review women who received UAE followed by D&C for CSP between January 2010 and December 2019 at the Changhua Christian Hospital, Changhua in Taiwan. Data were collected from both electronic and paper medical records. Patients were contact via phone call to follow up reproductive outcomes between January 2021 and March 2021. These subsequent reproductive outcomes (including pregnancy rate, secondary infertility rate, miscarriage rate, live birth rate, and recurrent CSP rate) were recorded and analyzed.

RESULTS

A total of 53 cases of women who received UAE followed by D&C for CSP were identified. The women's average age was 34.8 ± 5.1 years. The mean gestational age at diagnosis was 6.2 ± 1.1 weeks. The mean level for human chorionic gonadotropin was 23,407.7 ± 29,105.5 mIU/ml. The average of blood loss during D&C was 19.2 ± 43.6 ml. The average hospitalization time after D&C was 3.5 ± 1.1 days. Of the 53 cases, 10 patients were lost to follow-up and 43 patients agreed to follow-up on reproductive outcomes in 2021. Twenty-three patients who desired to conceive were analyzed. Nineteen out of these 23 women (82.6%) succeeded in conceiving again and gave birth to 15 healthy babies (78.9%). Only one woman (1/19, 5.3%) experienced recurrence of CSP. The average time interval between previous CSP treatment and subsequent conception was 10.4 ± 6.7 months.

CONCLUSION

UAE combined with curettage treatment in CSP patients results in a positive rate of subsequent pregnancy outcomes. This minimally invasive procedure may be considered as one of the treatment options for CSP, as it enables preservation of fertility after treatment.

Risk factors and clinical characteristics associated with a ruptured ectopic pregnancy: A 19-year retrospective observational study

Ectopic pregnancy is the most common cause of maternal mortality in the first trimester of pregnancy. The aim of this study was to find risk factors and clinical characteristics associated with ruptured ectopic pregnancies at a medical center in eastern Taiwan in a 19-year period. This was a retrospective observational study that included patients diagnosed with ectopic pregnancy between August 1999 and December 2018. Data about the demographic variables, initial presentation, pre-treatment beta-human chorionic gonadotropin levels, treatment routes (laparoscopy or laparotomy), surgical methods (salpingostomy or salpingectomy), operation time, blood loss amount, the status of ectopic pregnancy (ruptured or unruptured), the requirement for transfusion, and duration of hospital stay were collected. The categorical and continuous variables were analyzed using the correlation coefficients. This study included 225 women who were diagnosed as having an ectopic pregnancy. There were 49 and 176 women with unruptured and ruptured ectopic pregnancies, respectively. The beta-human chorionic gonadotropin levels, history of previous ectopic pregnancy, pelvic inflammatory disease, tubal surgery, abdominal history, and vaginal bleeding were not significantly different between the 2 groups. The ratio of women with abdominal pain was significantly higher in the ruptured ectopic pregnancy group than in the unruptured group (89.1% vs. 63.8%, respectively, P < .001). Preoperative hemoglobin was lower in the ruptured group compared with the unruptured group (P < .001). Blood loss, postoperative hemoglobin, and blood transfusion were significantly higher in the ruptured group than in the unruptured group (P = .000 and P = .001 for blood loss and blood transfusion, respectively). Multiple logistic regression analysis revealed that abdominal pain and blood loss were associated with ruptured tubal pregnancies (adjusted odds ratio [95% confidence intervals]: 3.42 {1.40, 8.40}; 1.01 {1.005, 1.014}, respectively). In conclusion, early pregnancy with abdominal pain, more parity, and lower preoperative hemoglobin should be aware of the possibility of ruptured ectopic pregnancy. More blood loss, transfusion and lower postoperative hemoglobin were also noted with ruptured ectopic pregnancy.

Caesarean Scar Pregnancy: A Case Report and a Literature Review

Background and Objectives: Caesarean scar pregnancy (CSP) refers to placental implantation on or in the scar of a previous caesarean section and represents a potentially life-threatening condition. CSP is considered a diagnostic challenge in obstetrics, with the diagnosis relying mainly on transvaginal ultrasound (TVS) and the management depending upon case presentation and available healthcare infrastructures. Case Presentation: We present a case of 34-year-old G3P2 with a history of two-previous caesarean sections referred to the outpatient gynaecology clinic of our Department at the 7th week (7/40) of gestation with abnormal early pregnancy TVS findings, illustrating the gestational sac attached to the caesarean scar and a foetal pole with evidence of foetal cardiac activity. We discuss the outcome of an alternative combined medical and surgical approach we followed as well as an updated review of the current literature. Conclusions: The ideal management of CSP requires tertiary centers, equipment availability and experienced healthcare professionals capable of dealing with any possible complication, as well as individualized treatment based on each case presentation.

Successful management of a patient with ovarian ectopic pregnancy by the end of the first trimester: a case report

BACKGROUND

Among all ectopic pregnancies, between 0.5% and 3.5% are ovarian ectopic pregnancies, a potentially life-threatening condition when ruptured due to its serious potential for hemorrhaging. A majority of ovarian ectopic pregnancies are diagnosed by the 7th week of pregnancy when the patient becomes symptomatic, and ultrasound can be used to diagnose this condition.

CASE PRESENTATION

We present the case of a 39-year-old Persian woman in the 12th week of gestation who presented with vaginal bleeding and abdominal pain and was diagnosed with ovarian ectopic pregnancy. Her notable laboratory finding was β-human chorionic gonadotropin > 15,000, which indicates definite pregnancy. Transvaginal ultrasound (TVS) revealed no evidence of intrauterine pregnancy, but a well-circumscribed gestational sac in the left ovary. The patient was successfully treated with resection of the gestational sac and partial left salpingo-oophorectomy. Histopathological studies confirmed the diagnosis of ovarian ectopic pregnancy.

CONCLUSION

The case emphasizes the ability of ovarian ectopic pregnancy to develop asymptomatically through the course of pregnancy and points to the necessity for high-quality prenatal care and the importance of determining the fetal site during pregnancy.