[Epidemiological and anatomo-clinical features of extra-uterine pregnancies at the Dakar University Hospital Center]

It is the prospective study of 226 cases of operated ectopic pregnancies, in order to draw the epidemiological outline of such an affliction adn find out the possible etiologies. During this study, 107 swabs were anatomically exploited. An analysis of the results reveals the high frequency of disrupted ectopic pregnancies (over 90%). The ampullary localization exists in 73.45% of the cases. In the histological level, in 82.70 of the cases, the tubal pregnancy has been associated with a salpingitis or malformed lesions. The death rate is about 2.65%. In other respects, it appears that the limits of echography are actual, hence the importance of basic clinic, that mutilating surgery remains prevalent; histology also plays an unavoidable part in the diagnosis.

Chromosomal abnormalities in ectopic pregnancy chorionic villi

OBJECTIVE

To evaluate the incidence of chromosomal abnormalities in ectopic pregnancy chorionic villi.

METHODS

A prospective study of patients with the diagnosis of ectopic pregnancy was conducted, with chorionic villi obtained at the time of surgical therapy cultured and analyzed for karyotype. Review of the patient's medical record and ultrasound evaluation was then completed and findings correlated with karyotype results.

RESULTS

Twenty-two patients undergoing surgery for the diagnosis of ectopic pregnancy yielded chorionic villi for culture. Successful culture was performed in 21 patients, with 3 (14%) revealing abnormal karyotypes. Review of the medical record showed ultrasound results consistent with fetal development or a gestational sac in 15 of 18 patients with normal chromosomal analysis. Three of 6 patients without fetal development yielded abnormal chromosomal findings.

CONCLUSION

Our results confirm that a high degree of success can be achieved in the karyotype analysis of ectopic pregnancy chorionic villi and that these conceptuses have a rate of abnormality similar to that reported for intrauterine gestations. Our data further suggest that when a gestational sac or fetal pole is identified by ultrasound, there is usually a normal karyotype.

Randomized trial of conservative laparoscopic treatment and methotrexate administration in ectopic pregnancy and subsequent fertility

Methotrexate treatment was compared to laparoscopic salpingotomy for conservative management of ectopic pregnancy in a prospective randomized study. One hundred patients were randomized into two groups using random numbers. Inclusion criteria were an ectopic pregnancy visualized by ultrasound with a pre-therapeutic score <13 as assessed by the following six criteria, graded from 1 to 3: gestational age, human chorionic gonadotrophin (HCG) concentration, progesterone concentration, abdominal pain, haemoperitoneal volume and diameter of the haematosalpinx. The treatments were either 1 mg/kg of methotrexate injected transvaginally into the ectopic pregnancy without anaesthesia or administered i.m. when the pregnancy could not safely or easily be punctured (group 1), or laparoscopic salpingotomy (group 2). Success was defined as the return to normal (<10 mIU/ml) of HCG concentrations. Treatment was successful for 45 of 51 patients in group 1 (88.2%) and 47 of 49 in group 2 (95.9%). Medical treatment was significantly (P < 0.05) associated with shorter postoperative stay (24 compared with 46 h), but HCG returned to normal more quickly after laparoscopic treatment (13 compared with 29 days). Spontaneous reproductive performance was similar in both groups, but overall intrauterine pregnancy was higher, and repeat ectopic pregnancy lower, after methotrexate treatment. In selected cases of ectopic pregnancy, with a pre-therapeutic score <13, methotrexate treatment appeared as safe and efficient as conservative treatment by laparoscopy and was associated with improved subsequent fertility.

Recurrent interstitial pregnancy

As a rare form of ectopic pregnancy, interstitial pregnancy threatens the future fertility of the patient. Methods of management include observation only, medical treatment with methotrexate either systemically or locally, or surgery either with laparotomy or laparoscopy. We present the case of a woman with recurrent interstitial pregnancy. Treatment with methotrexate was successful in her first interstitial pregnancy, however the second necessitated laparotomy. Selection of patients for treatment with methotrexate and the importance of subsequent tubal investigation are emphasized.

Laparoscopic surgery for heterotopic pregnancies: a case report and a brief review

A heterotopic pregnancy is in effect a multiple pregnancy with one or more intrauterine pregnancies coexisting with an ectopic pregnancy and is rarely spontaneous. With the increasing popularity of ovulation induction performed during assisted reproductive techniques, it will not be surprising to observe that this phenomenon has increased significantly. However, diagnosis is often delayed because of its rarity and difficulty. We report a case of a woman with a viable intrauterine pregnancy who had a complication of ovarian hyper-stimulation syndrome secondary to ovulation induction following in vitro fertilization and embryo transfer, but who, during hospitalization, presented with clinically progressive abdominal pain. An unruptured ectopic pregnancy of the right fallopian tube was diagnosed accidentally by laparoscopy and laparoscopic salpingectomy was immediately performed. Post-operative follow-up revealed that the intrauterine pregnancy continued normally. She delivered a normal female baby at 38 weeks of gestation. The promising neonatal outcome might suggest that laparoscopy might be safely performed to aid differential diagnosis in an uncertain condition during pregnancy: therefore, laparoscopic surgery might be an appropriate method to manage some carefully selected patients with HP. A brief review of the published literature on the role of laparoscopy in the diagnosis and management of heterotopic pregnancy is given.

Surgical and medical management of tubal and non-tubal ectopic pregnancies

This article highlights recent findings in the diagnosis and management of ectopic pregnancy. While the search for the ideal biochemical marker for ectopic pregnancy continues, new protocols have been described for the management of persistent ectopic pregnancy. The role of nuclear marker Ki-67 in trophoblastic proliferation and the only randomized trial to date involving systemic methotrexate and laparoscopic surgery are discussed. The management of cervical, interstitial and heterotopic pregnancies are reviewed.

Operative laparoscopy

Operative laparoscopy has replaced the conventional approach by laparotomy to the treatment of most benign gynecological diseases (benign adnexal cysts, ectopic pregnancy, tubal infertility, polycystic ovarian disease, endometriosis, myomas), with advantages in terms of shorter hospital stay, less discomfort and complications for the patient, minor social costs due to the early resumption of normal working activities, and comparable results in terms of reproductive outcome.

Laparoscopic treatment of interstitial pregnancy using the harmonic scalpel

OBJECTIVE

To evaluate a laparoscopic technique of cornual resection using the harmonic scalpel.

METHODS

Four patients with unruptured interstitial pregnancies were treated laparoscopically using the harmonic scalpel at Ioannina University Hospital.

RESULTS

There were no failures in the technique in any of our patients.

CONCLUSION

Our study suggests that interstitial pregnancies of a maximum gestational age of 7-8 weeks and sac diameter less than 4-5 cm may be treated laparoscopically.

Preoperative serum hCG level and intraoperative failure of laparoscopic linear salpingostomy for ectopic pregnancy

OBJECTIVE

To identify factors that predict failure of linear salpingostomy requiring salpingectomy for ectopic pregnancy.

METHODS

Using a retrospective cohort, we examined the various risk factors of women with ectopic pregnancies presenting for conservative laparoscopic management. Success or failure of laparoscopic linear salpingostomy was the primary end point.

RESULTS

One hundred fifty-seven women underwent laparoscopic linear salpingostomy for ectopic pregnancy, of whom 120 had successful procedures and 36 had unsuccessful operations because of bleeding and needed subsequent salpingectomy either by laparoscopy or laparotomy. The likelihood of success of laparoscopic linear salpingostomy was unrelated to gestational age, size of the ectopic pregnancy, surgical technique, or experience of the surgeon or resident. However, median (quartiles) serum beta hCG levels were significantly higher in patients who underwent failed salpingostomy (10,103 [3549-19,962] IU/L) compared with those who underwent successful salpingostomy (1692 [565-3971] IU/L, P < .01). Median blood loss (225 [181-562] mL versus 100 [50-200] mL, respectively, P < .01) and mean (+/- standard error of the mean [SEM]) operating times (111.1+/-6.1 minutes versus 76.8+/-2.3 minutes, P < .01) were significantly greater with failed salpingostomy followed by salpingectomy, compared with successful salpingostomy.

CONCLUSION

Preoperative serum beta hCG level was the only significant determinant of failure of laparoscopic linear salpingostomy for ectopic pregnancy. Morbidity due to intraoperative blood loss and operating time was significantly increased as a result of attempting and failing to complete laparoscopic linear salpingostomy.

Laparoscopic management of rudimentary horn pregnancy

A unicornuate uterus with rudimentary horn is a rare Müllerian abnormality. This uterine anomaly may cause many gynaecological and obstetric complications, including infertility, recurrent abortions, preterm deliveries and rupture of the uterus, especially when the pregnancy implants in the rudimentary horn. To date, laparotomy has been the treatment of choice when resection of a rudimentary horn was indicated. We report on the case of a woman who benefited from laparoscopic surgery of a rudimentary horn pregnancy. Laparoscopy, in these exceptional cases, is the most accurate diagnostic tool that carries significant advantages in effective surgical management, thereby avoiding laparotomy.

A casemix cost comparison of 2 treatments for ectopic pregnancy

In this paper a retrospective cost comparison between laparoscopic treatment of ectopic pregnancy and conventional laparotomy under casemix funding has been performed. The total mean cost of laparoscopic treatment was $2,930 while the total mean cost of laparotomy was $4,259 per patient.

Severe bleeding from peritoneal implants of trophoblastic tissue after laparoscopic salpingostomy for ectopic pregnancy

OBJECTIVE

To describe a case of persistent trophoblastic tissue after conservative laparoscopic treatment of an ectopic pregnancy (EP).

DESIGN

Case report.

SETTING

University hospital.

PATIENT

A 19-year-old nulliparous woman, presenting 30 days after conservative laparoscopic treatment of an EP.

INTERVENTION(S)

Emergency laparotomy, histologic examination of excised trophoblastic tissue, serial beta-hCG levels.

MAIN OUTCOME MEASURE(S)

Serum beta-hCG clearance curves after surgical treatment of an EP.

RESULT(S)

Histology confirmed multiple peritoneal implants of trophoblastic tissue, mainly situated on the sigmoid colon and the omentum majus. Serial beta-hCG levels decreased rapidly from 1,394 to 0 mU/L within 17 days.

CONCLUSION(S)

After conservative treatment of EP, patients should be followed up clinically and serial beta-hCG measurements should be obtained to ensure the absence of persistent trophoblastic tissue.

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.

[Combined pregnancy]

Simultaneous intrauterine and ectopic pregnancy is a rare entity, with a difficult preoperative diagnosis, potentially dangerous for the mother and for the intrauterine pregnancy. A case of combined intra- and extrauterine pregnancy diagnosed at 5 weeks' menstrual dates in a 31-year-old woman non treated for infertility is described. Incidence, etiology, diagnosis and treatment of this uncommon complication are discussed.

Combined interstitial and intrauterine pregnancies after in-vitro fertilization and embryo transfer

A case of combined interstitial and intrauterine pregnancies after bilateral salpingectomy and in-vitro fertilization with embryo transfer is reported. The case was incorrectly diagnosed ultrasonographically as intrauterine triplets at 7 weeks gestation. The patient suffered from intra-abdominal bleeding at 14 weeks gestation. At laparotomy, a ruptured left interstitial pregnancy with a non-viable fetus was found in the left abdominal quadrant. The uterine defect was successfully repaired and gestational contents and blood were evacuated from the abdominal cavity. The intrauterine twin pregnancy progressed without incident, and a Caesarean section was performed at 36 weeks gestation, resulting in healthy male and female infants.

Ectopic pregnancy in sterilized and nonsterilized women. A comparison

OBJECTIVE

To assess whether differences occurred in the presentation, treatment and postoperative outcomes of ectopic pregnancy in sterilized and nonsterilized women.

STUDY DESIGN

All cases of ectopic pregnancy admitted over five years at two hospitals were reviewed. Using a case-control method, patients with ectopic pregnancy and prior tubal sterilization were compared with the next nonsterilized patient with ectopic pregnancy admitted within 30 days. Statistical comparison, utilizing t tests, chi 2 tests of Fisher's exact test, when appropriate, was performed.

RESULTS

Thirty-eight (18%) of 208 patients with ectopics during the study period had undergone prior sterilization. This group, when compared with the 38 nonsterilized patients with ectopics, was similar for gestational age at diagnosis, frequency of pelvic inflammatory and sexually transmitted diseases, and mean human chorionic gonadotropin (hCG) level; the preoperative sonographic findings were also similar in the two groups. Sterilized patients were less likely than controls to have had serial hCG levels, while their mean duration of symptoms at admission was shorter. Although both groups had a similar distribution of surgical management (laparoscopy, laparotomy or both) and postoperative complications, there were trends toward a higher risk of ectopic rupture and hemoperitoneum in sterilized patients.

CONCLUSION

Ectopic pregnancies following tubal sterilization have clinical manifestations and surgical outcomes similar to those occurring without prior sterilization, except for less frequent determination of serial hCGs, probably related to a shorter duration of reported preceding symptoms. The trend toward more frequent rupture and hemoperitoneum in this group suggests that sterilized patients are less likely to heed the early warnings of this complication.

An unusual presentation of ectopic pregnancy

Abdominal pregnancy is a rare form of ectopic gestation. When it occurs, its early diagnosis is difficult, owing to the atypical presentation and the low index of suspicion for the condition. The characteristic history is that of abdominal pain, vaginal bleeding and symptoms related to the gastrointestinal tract. These symptoms are occasionally overlooked and the diagnosis is often missed. The following report describes a case of a 12-week abdominal pregnancy presenting as an acute abdomen with placental attachment to the anterior abdominal wall muscle. Transabdominal ultrasound was successfully used to make the diagnosis preoperatively. Surgical intervention resulted in removal of the complete sac together with the placental disc in toto. The important features of this rare but morbid condition are discussed, and the important role of sonographic imaging in cases of acute abdomen in pregnancy is stressed.

Single-dose methotrexate for unruptured ectopic pregnancy

OBJECTIVES

To compare the effectiveness of single-dose methotrexate (MTX) and laparoscopic salpingostomy in the treatment of unruptured ectopic pregnancy (UEP).

METHODS

75 patients entered a prospective non-randomized study. Thirty-seven women were submitted to a single-dose methotrexate (Group 1) and 38 underwent laparoscopic salpingostomy (Group 2). Methotrexate (1 mg/kg) was given intramuscularly on an out-patient basis if the beta-hCG level was < 5000 IU/I and the hematosalpinx diameter was < 3 cm and the peritoneal fluid < 300 cm3 on TVS. The follow-up consisted of serial clinical examinations, beta-hCG assays, liver tests and blood cell counts. Laparoscopic salpingostomy was decided in other cases of UEP or when patients refused or could not comply with the follow-up.

RESULTS

Group 1 patients (91.8%) were cured with 1-3 doses of MTX, the remainder required a laparoscopy. Seventy-three percent of them were treated on an out-patient basis. The mean time to resolution of hCG was 26.7 days. The initial beta-hCG level significantly correlated with the necessity of a surgical option and the time to resolution of beta-hCG. Whenever beta-hCG was < 3600 IU/l, all patients were cured with a single injection, without hospitalization and with a follow-up of < 27 days. Group 2 patients (81.6%) were cured with laparoscopy and 15.8% required a MTX injection for persistent EP. The mean hospital stay was significantly longer than for those that required the MTX injection (2.7 vs. 0.6; P = 0.0001), but the follow-up was shorter and required significantly less clinical examinations, sonograms and biologic tests. Finally the effectiveness of single-dose MTX and laparoscopic salpingostomy were similar (P = 0.2, 95% CI of the difference: -0.15-0.04).

CONCLUSIONS

Single-dose MTX was as effective as laparoscopy in the treatment of UEP. A rigorous selection of the patients for the treatment option is mandatory to guarantee high success rates, in an out-patient basis and a short follow-up.

Intramural pregnancy with negative maternal serum beta-hCG. A case report

BACKGROUND

Intramural pregnancy is the rarest form of ectopic pregnancy. The diagnosis depends upon the sonographic finding of intramural gestational sac-like growth and persistent high beta-human chorionic gonadotropin (beta-hCG) levels after dilatation and curettage. No authors mentioned negative beta-hCG result in such situation. Rarely has the literature contained preoperative sonograms and photographs of postoperative gestational tissue.

CASE

A 31-year-old woman presented with vaginal spotting for five months. Six months earlier she underwent dilatation and curettage for blighted ovum at 8 weeks' gestation. Since then, incidental vaginal spotting was noted. Sonography demonstrated an intramural cyst with fetal pole-like growth. Serum beta-hCG, diagnostic dilatation and curettage, and hysteroscopic examination were negative. Laparotomy for excision of the cyst confirmed an intramural pregnancy.

CONCLUSION

Because of the long period after fetal wastage, negative serum beta-hCG was noted in this case. Negative serum beta-hCG was unreliable in the exclusion of intramural pregnancy. With the sonographic appearance of intramural gestational sac-like growth, in spite of a negative serum beta-hCG the clinician should be alert to the possibility of intramural pregnancy.

Ectopic pregnancy presenting with obturator nerve pain

A 27 year old woman had a three day history of pain in the cutaneous distribution of the left obturator nerve before she developed the classical picture of ectopic pregnancy with lower abdominal pain and vaginal bleeding. A left tubal pregnancy was subsequently confirmed by laparoscopy. Referred pain along the obturator nerve has been reported in other pelvic conditions, but has not previously been reported as a manifestation of ectopic pregnancy. Ectopic pregnancy may present with a very wide range of signs and symptoms and should be excluded in females of child bearing age with unexplained symptoms including pain anywhere from the shoulder down to the knee.

The apparent late half-life of human chorionic gonadotropin (hCG) after surgical treatment for ectopic pregnancy. A new approach to diagnose persistent trophoblastic activity

OBJECTIVE

The disappearance kinetic of human chorionic gonadotropin (hCG) follows a biexponential decay with a rapid initial fall followed later by a slow disappearance. This kinetic is characterised by two half-lives: an early and a late. The objective of this study was to determine if and which half-life could be used clinically to detect persistent trophoblast after conservative surgery in patients with ectopic pregnancy.

DESIGN

Retrospective analysis of patients having undergone salpingostomy by laparoscopy for an ectopic tubal pregnancy between January 1990 and October 1993.

SETTING

Gynaecology Department of an University Hospital.

PATIENTS

104 women with diagnosed tubal ectopic pregnancy were treated by salpingostomy performed under laparoscopy. In seven cases, persistent trophoblast was diagnosed on the basis of plateauing or increasing peripheral hCG values.

MAIN RESULTS

From the individual disappearance curves of hCG we calculated the early half-life (early T0.5, from samples obtained between 0 and 48 h postsurgery) and the late half-life (late T0.5, from samples obtained between 2 and 7 days postsurgery). Late T0.5 but not early T0.5 were significantly (P<0.0001 and P=0.416 respectively) longer in women (n =7) in whom a persistent trophoblast was diagnosed. Early T0.5 was dependant on the preoperative value of hCG, whereas late T0.5 was independent. We propose to use late T0.5 as a parameter to follow ectopic pregnancies after treatment.

Nine year survey of 138 ectopic pregnancies

During the nine years (1986-1994), 138 women underwent surgery for ectopic pregnancies (One for every 213 deliveries). The commonest presenting symptom was abdominal pain (96%) followed by vaginal bleeding (83%). Four patients were asymptomatic and were diagnosed at a routine antenatal ultrasound scan. The most frequent physical findings were abdominal tenderness (87%) and followed by adnexal tenderness (57%). Histories of infertility in 17%, use of intrauterine contraceptive device (13%), and previous ectopic pregnancy in 11% were elicited. Eleven patients (8%) had a false negative urinary pregnancy test and subsequently required surgery. The ectopic pregnancies were tubal in 97% of the cases. There were 3 ovarian ectopics and one cervical ectopic.