Bilateral simultaneous tubal sextuplets: pregnancy after in-vitro fertilization--embryo transfer following salpingectomy

The presence of a damaged tube has been suggested in recent studies to have a negative effect on in-vitro fertilization (IVF) outcome. Performing bilateral salpingectomy prior to IVF to maximize pregnancy rates may also result in unnecessary surgery. This case is also an example of the occurrence of interstitial pregnancy after salpingectomy. This unusual type of ectopic pregnancy must be kept in mind when evaluating a patient suspected of a possible early abnormal gestation after assisted reproductive technolologies.

Ischemic optic neuropathy after hemorrhage from a cornual ectopic gestation

A case of ischemic optic neuropathy resulting from uterine hemorrhage is reported in which a 37-year-old white woman, gravida 1, para 0, was diagnosed at 8 weeks' gestation with a ruptured ectopic pregnancy. After diagnostic laparoscopy the patient underwent a minilaparotomy, cornual wedge resection, and right salpingectomy with a total estimated blood loss of 3000 ml. Her postoperative course was uneventful until postoperative day 4, when the patient complained of vision loss for the last 1 to 2 days, total body edema, and headache. Ophthalmologic examination revealed findings consistent with ischemic optic neuropathy. Multiple studies of the cerebrospinal fluid were negative, as were computed tomography studies and magnetic resonance imaging of the head. Ischemic optic neuropathy, whose pathogenesis is still unclear, is a rare complication of massive hemorrhage and may cause permanent vision loss.

Combined tubal and cornual pregnancy in a patient without risk factors. A case report

BACKGROUND

Ectopic pregnancy is the leading cause of pregnancy-related death during the first trimester. Bilateral ectopic pregnancy is a rare phenomenon, varying in frequency between 1 per 725 and 1 per 1,580 ectopic pregnancies. We report the case of a bilateral ectopic pregnancy (ruptured right cornual and intact left ampullary) in a patient with no known risk factors for extrauterine gestation.

CASE

A 33-year-old, black woman, gravida 2, para 1001, presented at approximately 7 weeks' gestation with the acute onset of abdominal pain. She had a rigid surgical abdomen but was hemodynamically stable. Her beta-human chorionic gonadotropin level was 6,398 mIU/mL, and transvaginal ultrasound failed to reveal an intrauterine gestation, adnexal mass or cul-de-sac fluid. Findings at laparotomy included a 500-mL hemoperitoneum and a ruptured right cornual and intact left ampullary pregnancy. Pathology of both specimens confirmed the presence of chorionic villi.

CONCLUSION

Although rare, heterotopic pregnancies can occur even in patients without risk factors.

A study of ruptured tubal ectopic pregnancy

OBJECTIVE

Ectopic pregnancy continues to be a leading cause of maternal morbidity and of reduced childbearing potential among women of reproductive age. Because of tubal rupture it is still the main cause of pregnancy-related death during the first trimester. The purpose of our study was to evaluate factors that may predispose a woman to rupture of a tubal ectopic pregnancy.

METHODS

In this retrospective study of 693 ectopic pregnancies from three McGill University teaching hospitals, we compared risk factors, preoperative ultrasound, and serum hCG levels between cases with ruptured and unruptured tubal ectopic pregnancy.

RESULTS

The age and the number of pregnancies among the two groups of women were similar. The gestational age of women with an unruptured tube was 6.9 +/- 1.9 weeks, and of those with a ruptured tube, the gestational age was 7.2 +/- 2.2 weeks. Tubal rupture was encountered more often in women with at least one child than in childless women. History of ectopic pregnancy was found in 35% of women with an unruptured tubal pregnancy and in 26% of those with a ruptured tube. Serum hCG levels at the time of treatment were not significantly different among the two groups of women. Eleven percent of women with a ruptured tube had serum beta-hCG levels of less that 100 IU/L.

CONCLUSION

Tubal rupture is encountered more often in women with no history of ectopic pregnancy and in those with at least one child. This suggests that ectopic pregnancy is less suspected in these women. Tubal rupture is encountered less often in ampullary pregnancy and in small ectopic pregnancies. There is no correlation between serum beta-hCG levels and tubal rupture, and rupture can occur even when serum beta-hCG levels are very low.

Operative laparoscopy for management of ectopic pregnancy in patients with hypovolemic shock

STUDY OBJECTIVE

To determine the safety of operative laparoscopy in the management of ectopic pregnancy in women with hypovolemic shock.

DESIGN

Retrospective chart review.

SETTING

University-affiliated hospital.

PATIENTS

Two hundred eleven women with tubal pregnancy, of whom 33 were suffering from hypovolemic shock, based on a combination of signs and symptoms including hypotension, tachycardia, anxiety, thirst, tachypnea, and slow capillary refill.

INTERVENTION

Laparoscopic surgery.

MEASUREMENTS AND MAIN RESULTS

Mean +/- SEM intraabdominal blood loss was significantly (p <0.01) higher in women with hypovolemic shock, 1369 +/- 149 versus 114 +/- 14 ml. Blood transfusions were given to 88% and 0.5%, respectively (p <0. 01). Laparoscopic salpingectomy was performed in all hemodynamically compromised women compared with 87% of stable women. Conversion to laparotomy was required in three patients in the hypovolemic shock group and five in the stable group. All patients had an uncomplicated postoperative course and made a full recovery.

CONCLUSION

The availability of optimal anesthesia and advanced cardiovascular monitoring, and the ability to convert rapidly to laparotomy if required, allow safe performance of operative laparoscopic surgery in most women in hypovolemic shock. In fact, the superior exposure of laparoscopy, providing rapid diagnosis and control of the source of bleeding, makes it a highly suitable approach.

Co-existing endometrial adenocarcinoma and tubal ectopic pregnancy: a case report

Adenocarcinoma of the endometrium co-existing with pregnancy is a rare event. Twelve such cases have been reported in patients with intrauterine pregnancies. Co-existence with tubal ectopic pregnancy is even more uncommon. Only one such patient with tubal ectopic pregnancy was found in the literature; the pathologic findings were not, however, illustrated. We report on a very rare event, co-existing adenocarcinoma of the endometrium and ectopic tubal pregnancy, with illustration of the pathologic finding.

Simultaneous intra- and extra-uterine pregnancy with ovarian hyperstimulation syndrome after induction of ovulation: a case report

We present a case of polycystic ovary syndrome (PCOS) that developed simultaneous intra- and extra-uterine pregnancy with ovarian hyperstimulation syndrome (OHSS) after induction of ovulation with pure FSH-HCG. At 9 weeks of pregnancy, the bilateral tubal pregnancy caused an imminent spontaneous abortion, and both Fallopian tubes were resected. After the laparotomy, the pregnancy progressed without problems until 31 weeks and 5 days of pregnancy, when signs of spontaneous abortion appeared, and healthy twin female babies were delivered by cesarean section. The incidence of heterotopic pregnancy is increasing in cases in which inducers of ovulation or ART, such as IVF-ET and GIFT, have been employed. One must be well aware that the danger of heterotopic pregnancy following induction of ovulation is imminent, particularly in cases with risk factors of multiple and/or extra-uterine pregnancy, such as PCOS, a history of tubal restoration, and sexually transmitted disease(s).

Ectopic pregnancy presenting as lower gastro-intestinal hemorrhage

A patient with ruptured tubal pregnancy presenting with lower gastrointestinal bleed is described. Colonoscopy and other investigations were not helpful; laparotomy was diagnosis as well as therapeutic.

Bilateral tubal pregnancy following in vitro fertilization and transfer of two embryos

A case of simultaneous bilateral tubal pregnancy after IVF-ET treatment is presented. This condition occurred despite the fact that only two embryos were transferred. Due to misinterpretation of repeated sonographic images, the diagnosis was delayed, and laparatomy with bilateral salpingectomy was not performed until 57 days had passed from the day of ET. Although there is a substantial risk of ectopic pregnancy following IVF-ET, this risk should be reduced as the number of embryos transferred per cycle decreases. This is, to the best of our knowledge, the first report of bilateral tubal pregnancies following the transfer of only two embryos.

[Ectopic molar pregnancy. Two cases in sixteen years]

Two cases of hydatidiform pregnancy tubal located occurred in 16 years are reported by the authors. The uncommon frequency of this pathology is difficult to state precisely due to the limited possibilities of diagnosis. Theses are inherent to the lack of statement of ectopic pregnancy, a non systematic histologic test, the genital infections main causes of ectopic pregnancy in areas where its rage of endemic. The inaugural clinic scene was the same as ectopic pregnancy one in a state of rupture. The emergency therapy is surgical, essentially the tubal resection, completed by a chemotherapy. The prognosis and the leading therapy have to be specify.

Clearance curves of serum human chorionic gonadotrophin for the diagnosis of persistent trophoblast

A well recognized hazard of conservative surgical treatment of tubal pregnancy is incomplete removal of trophoblastic tissue. Persistent trophoblast can be detected by postoperative serum human chorionic gonadotrophin (HCG) monitoring. The impact of various surgical techniques on the post-operative clearance of serum HCG was investigated in a retrospective study. The medical records of 97 patients treated surgically for tubal pregnancy in the Academic Medical Center of the University of Amsterdam, The Netherlands, between 1 January 1992 and 1 August 1994 were reviewed; 28 patients were treated by salpingostomy by laparoscopy, 16 by salpingostomy by open surgery and 53 by salpingectomy by either method. There was no difference in the post-operative clearance of serum HCG after successful conservative surgery compared to radical surgery. However, persistent trophoblast occurred in eight patients (29%) after laparoscopic salpingostomy and in only one patient (6.3%) who had a salpingostomy by open surgery (relative risk 4.57). Serum HCG clearance curves allow early identification of patients with persistent trophoblast after conservative surgical treatment. Moreover, monitoring of post-operative serum HCG until it becomes undetectable is mandatory in order to reveal late-onset types of persistent trophoblast.

[Rupture of extrauterine pregnancy during simultaneous intrauterine pregnancy]

The authors report a case of a simultaneous extrauterine and intrauterine pregnancy which posed a problem of differential diagnosis for both the surgeon and the gynecologist. After surgical treatment of the ruptured ectopic pregnancy the patient was symptom free, and later requested the interruption of her normal intrauterine pregnancy. Diagnosis was confirmed by ultrasonographic examination.

[Rare forms of ureteral fistulae occurring after obstetrical and gynecological operations]

In missed intraoperative injury to the ureter one can regularly observe retroperitoneal urinary overflow (urinary retroperitonitis). In case of postoperative ignorance of the injury the overflown urine penetrates into the vagina with formation of the ureterovaginal fistula. Less frequent there are ureterocutaneous or ureteroperitoneal, ureterointestinal fistulas after the urine breaking into the operative wound, abdominal cavity or the intestine, respectively. A case of a 37-year-old woman is reported with accidental injury to the left ureter overlooked during and after the operation. The patient developed successive ureteroperitoneal, ureterocutaneous and ureterosigmoid fistulas for which she has undergone 4 operations. After the recovery the function of the left kidney was retained.

Tubal rupture in patients with ectopic pregnancy: diagnosis with transvaginal US

PURPOSE

To determine whether sonography can help diagnose tubal rupture in patients with ectopic pregnancy.

MATERIALS AND METHODS

The authors reviewed the transvaginal ultrasound (US) scans and medical records of 132 consecutive patients with tubal pregnancy confirmed at surgery performed within 24 hours of undergoing US.

RESULTS

Adnexal masses were seen in 93 patients at US. Thirty-four patients had a tubal ring, and 59 had a complex mass. The frequency of tubal rupture was similar for both groups. The adnexal mass was significantly smaller in patients without a ruptured tube, but there was considerable overlap. Rupture was present in 21% of patients with no sign of or a trace of intraperitoneal fluid, increasing steadily to 63% in patients with a large amount of free fluid. Even though the amount of fluid was the best predictor of rupture, it was not completely reliable, as 37% of patients in whom a large amount of fluid was found had intact tubes.

CONCLUSION

No finding at transvaginal US is a reliable indicator of rupture. Contrary to findings from previous studies, the appearance of the adnexal mass, if present, is not related to tubal rupture.

Ectopic pregnancy in a blunt trauma patient

Trauma during pregnancy is a frequent occurrence, and early pregnancies are likely to be unrecognized in the routine evaluation of female trauma patients. We present the case of a 16-year-old woman injured in a motor vehicle crash who sustained a closed head injury and was found to have a right ectopic tubal pregnancy. Since several physiologic responses and pathologic conditions occur during pregnancy, which complicate the diagnosis and treatment of a pregnant patient, it is important to detect pregnancy early in the patient's evaluation. This case report demonstrates an unusual presentation of ectopic pregnancy and illustrates the merits of routine pregnancy testing of female trauma patients.

[Pregnancy in a rudimentary uterine horn: rupture in the 15th week of amenorrhea]

A case of pregnancy in a rudimentary uterine horn with rupture 15 weeks after the LMP is described. Ultrasonography at the beginning of such a pregnancy should allow the diagnosis of these uterine malformations. Closer monitoring of the pregnancy is necessary because of the seriousness of potential complications. The frequent finding of placenta accreta in such situations is pointed out. Management approaches are described.

[Pregnancy in a rudimentary uterine horn: main clinical forms. 5 cases]

Five cases of pregnancy developing in a rudimentary uterine horn are reported. The incidence of this association is 1/40,000 pregnancies. Three patients underwent surgery in a context of massive intraperitoneal bleeding due to rupture of the uterus during the second three months of pregnancy. Pregnancy continued into the third three months in 2 patients. The diagnosis was made at laparotomy, the uterus having ruptured in both cases. In the first case, rupture was clinically silent with development of the fetus in the abdominal cavity. In the second case, the pregnancy stopped developing at 34 weeks after the LMP. Histological examination of hemi-hysterectomy specimens showed that the placenta was accreta in all cases. Analysis of these 5 cases and a review of the literature form the basis of a review of the current contribution of investigations to the diagnosis of this association.

[Simultaneous pregnancy in each cavity of a bicornuate bicervical uterus with a double vagina]

A case of twin pregnancy in a bicervical uterus with double vagina is reported. The malformation was known before conception. Caesarean section was performed for premature rupture of the membranes at 34 weeks. This enabled the extraction of two low-birth-weight premature infants free of any particular pathology. The possibility of twin pregnancy in a bicervical bicornuate uterus is 1/1,000,000 and implies the maturation of at least two oocytes. This is a high risk pregnancy. Spontaneous abortions, prematurity (40%), low-birth-weight (25%) are the most notable complications. Although the probability of dynamic dystocia is multiplied by 7, vaginal delivery is not excluded when the obstetric past history is satisfactory and the presentation of both twins cephalic. Caesarean involves hysterotomy of each horn and raises no special technical problems. Double delivery increases the risk of hemorrhage.