[Cornual pregnancy]

Cornual ectopic pregnancy is a rare entity, found in 2-4% of all ectopic pregnancies, with an estimates incidence of one in every 2500 to 5000 deliveries. It represents a high rate of maternal mortality because of the growth and secondary rupture of the zone of implantation in advanced gestational ages, resulting in severe hemodynamic decompensation. We realizes a retrospective study from January 1989 to December 1994 at Instituto Nacional de Perinatologia. Only 6 cases of ectopic cornual pregnancies were found out of 35,080 deliveries reported, and of 149 ectopic pregnancies in general. Maternal age, gestational age at time of diagnosis, signs and symptoms, surgical treatment complications, and histopathologic report were some of the data collected. Maternal age in average was found to be 31.5, gestational age at time of diagnosis between 7.1 to 24 weeks. All patients referred diffuse abdominal pain and amenorrhea, with 2 cases of transvaginal bleeding. The 100% of cases required total abdominal hysterectomy as surgical treatment, and the most important complication found was shock, hence no maternal deaths were reported. We found this pathology to have an incidence of 1 of 5846 deliveries at our Institution, representing the 0.01% Of all ectopic pregnancies, we found to have an incidence of 4.02% that agrees with world literature.

Treatment, failures and complications of ectopic pregnancy: changes over a 20 year period

Data from all 225 women operated on for ectopic pregnancy in 1992-1994 at Sahlgrenska University Hospital were collected and compared with three previous cross-sectional investigations from our hospital (1975-1979, 1981-1982 and 1986-1987) in order to evaluate the extent to which surgical treatment and post-operative complications have changed over a 20 year period. Laparoscopic surgery, which was not possible in the 1970s, was used in almost 85% of the ectopic pregnancies in 1992-1994. Conservative treatment was still the most frequently used technique. The complication rate was 1.2% in 1975-1979 when only laparotomies were carried out. After the introduction of laparoscopic surgery (1986-1987), the complication rate rose significantly (7.3%) and continued to increase even when this procedure was established as routine (14.2% in 1992-1994). Post-operative complications were most frequent after conservative laparoscopic surgery (24.4%) while there were no complications after laparotomies. In spite of increasing complication rates the frequency of patients in pre-shock, as well as the proportion of patients with heavy intra-abdominal bleeding and tubal rupture, decreased over time.

Transvaginal sonography as the ultimate diagnostic tool for the management of ectopic pregnancy: experience with 840 cases

OBJECTIVE

To evaluate the efficacy of transvaginal sonography and serum beta-hCG levels as diagnostic tools for deciding whether to perform operative laparoscopy in the treatment of presumed ectopic pregnancy (EP).

DESIGN

A prospective protocol for the evaluation and treatment of women with presumed EP.

SETTING

Department of Obstetrics and Gynecology, Haemek Medical Center, Afula, Israel.

PATIENT(S)

Eight hundred forty women with presumed EP who were seen in our emergency department from January 1988 through December 1995.

INTERVENTION(S)

On the basis of specific sonographic signs and beta-hCG levels, we performed immediate operative laparoscopy in patients with demonstrable extrauterine fetal heart activity or >100 mL of fluid in the pelvic cavity. We followed up all other patients, using defined criteria for laparoscopic intervention.

MAIN OUTCOME MEASURE(S)

The accuracy of transvaginal sonography in predicting EP was evaluated as part of the described protocol.

RESULT(S)

Overall, 380 patients were found to have EP. Of these, 331 were identified positively by transvaginal sonography and 49 were not. In 27 of 358 laparoscopies, no EP was found. The sensitivity of transvaginal sonography for the prediction of EP was 87% and the specificity was 94%. The positive and negative predictive values were 92.5% and 90%, respectively.

CONCLUSION(S)

In this protocol, which invariably captured the true location of the products of conception, using transvaginal sonography as the primary modality in the evaluation of patients with presumed EP resulted in the use of laparoscopy mainly as a treatment tool. This approach is both safe and economical.

Trend from laparotomy to laparoscopy in the case of treatment of ectopic pregnancy

Ectopic pregnancy is a very hazardous, life threatening complication of the women. Diagnosis and treatment previously were very conservative. When not typical symptoms were found, only waiting or observing was the main task of hospitalisation and only the beginning of typical signs came laparotomy. Nowadays, with the introduction of vaginal ultrasound, color doppler or power imaging techniques and sensitive blood HCG analysis greatly reduced hospitalisation period. The need for the change from laparotomy to laparoscopic treatment in surgical operations became everyday practice. We analyzed the data in our department for the operation procedures of ectopic pregnancies from 1990.

The role of laparoscopy in the management of pelvic pain in women of reproductive age

OBJECTIVE

To review the diagnostic and therapeutic roles of laparoscopy in women of reproductive age with acute and chronic pelvic pain.

DATA IDENTIFICATION

Studies relating to the use of laparoscopy in women with acute and chronic pelvic pain were identified through the literature and MEDLINE searches.

CONCLUSION(S)

Laparoscopy has an important place in the management of conditions that cause acute pelvic pain in women of reproductive age, including ectopic pregnancy, pelvic inflammatory disease, tubo-ovarian abscess, and adnexal torsion. The procedure frequently facilitates the diagnosis and provides the necessary access for surgical treatment. Prompt diagnosis and effective management prevent complications and help preserve fertility. The role of laparoscopy in women with chronic pelvic pain is more controversial and limited, but abnormal laparoscopic findings are detected in approximately 60% of those who have undergone a multidisciplinary investigation and received a tentative clinical diagnosis. The access provided by laparoscopy permits the effective surgical treatment of many of the conditions encountered, including endometriosis, pelvic adhesions, ovarian lesions, and symptomatic uterine retroversion.

Factors determining fertility after conservative or radical surgical treatment for ectopic pregnancy

OBJECTIVE

To examine factors determining choice of radical or conservative surgical procedure for tubal ectopic pregnancy and subsequent pregnancy rates.

DESIGN

A retrospective study collating information from the operative notes and previous gynecologic history associated with the choice of procedure and pregnancy rates and outcome over 3 years after a primary tubal ectopic pregnancy.

PATIENT(S)

Thirty-four women who had undergone conservative (tube sparing) and 56 who had undergone radical (salpingectomy) surgical treatment for tubal ectopic pregnancy at least 3 years before the study.

MAIN OUTCOME MEASURE(S)

The main outcome measure was the occurrence of a pregnancy (live birth, miscarriage, or ectopic pregnancy) over 3 years after the ectopic pregnancy.

RESULT(S)

The type of surgery performed was not affected by a previous history of infertility, known pelvic inflammatory disease, the presence of tubal adhesions, or abnormalities on the contralateral tube. Intrauterine pregnancy was not more likely after conservative treatment of ectopic pregnancy but, equally important, the risk of a further ectopic pregnancy was not increased. The single factor that was clearly associated with future fertility problems was a past history of infertility.

CONCLUSION(S)

Better results may be obtained by careful selection of operative procedure based on history and findings at the time of surgery.

Hysterectomy in women with cervical pregnancy complicated by life-threatening bleeding: a case report

A 27-year-old women, gravida 2, para 1 presented with massive vaginal bleeding. After two days of bleeding from the external cervical ostium, intracervical tamponade was performed but the bleeding did not stop. At laparotomy, abdominal hysterectomy with adnexa preservation was done because of malacia tissue and life-threatening hemorrhage. Pathological examination revealed an isthmic pregnancy, gravidic decidua, and chorion villi.

Medical treatment of ectopic pregnancy with methotrexate

OBJECTIVE

To review our experience with low-dose IM methotrexate for the medical management of ectopic pregnancy (EP).

DESIGN

Retrospective chart review.

SETTING

Magee-Womens Hospital, Pittsburgh, Pennsylvania.

PATIENT(S)

The first 50 women treated by the resident service in whom EP was diagnosed and treated with methotrexate.

INTERVENTION(S)

Intramuscular methotrexate, 50 mg/m2. Serum beta-hCG was evaluated 4 and 7 days after treatment and then weekly thereafter. The dose was repeated if the beta-hCG level did not drop > or = 15% between days 4 and 7 or if a plateau or rise was noted during weekly follow-up evaluation. Surgery was performed if significant abdominal pain occurred in the presence of hemodynamic instability or signs of peritoneal irritation on physical examination.

MAIN OUTCOME MEASURE(S)

Resolution of the EP without surgical intervention.

RESULT(S)

Two patients were lost to follow-up and one was treated without a certain diagnosis of EP. Forty-three of the remaining 47 women (91.5%; 95% confidence interval, 83.5%, 99.5%) were treated successfully with methotrexate. Of these, 36 women were treated with a single dose, and 7 required a second dose. Four women were treated surgically after medical management failed. The time from initiation of treatment to cure in women who were treated successfully was 25 +/- 15 days (mean +/- SD). Thirteen patients (27.7%) made additional visits to the emergency department because of increased abdominal pain.

CONCLUSION(S)

As medical therapy for EP becomes common practice, familiarity with its side effects may lead to greater success rates. The decision to abandon medical treatment and proceed with surgery should be based on defined guidelines, such as the development of peritoneal signs, decreasing hemoglobin levels, or hemodynamic instability.

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.

[Is the treatment of ectopic pregnancy still exclusively surgical?]

At the end of the 19th century, ectopic pregnancy became a surgical procedure. A century later, one third of ectopic pregnancies are treated medically. In the meantime, early detection of ectopic pregnancy became possible due to sensitive serum hCG and progesterone combined assays with transvaginal sonography and a knowledge of risk factors. Consequently, a nonsurgical approach appears to be an attractive alternative to surgery. Expectant management is recommended with a plateau or decreasing hCG and an initial level < or = 1.000 mIU/ml in asymptomatic women. Medical treatment by local or parenteral methotrexate is recommended in patients with clear evidence of an unruptured pregnancy in based on initial hCG and progesterone level, size of hemoperitoneum, ultrasound diameter of hematosalpinx and absence of clinical pain. Laparoscopy remains the gold standard but in prospective randomized trials between medical treatment and laparoscopy, in selected patients, the non-surgical approach appears to be equivalent with a similar reproductive performance.

[Laparoscopic image of pelvic minor organs in women after ovary surgery]

An analysis of indications to laparoscopy and an evaluation of the abdominal cavity organs in patients who earlier in their history have undergone laparotomy, is the object of this report. A group of 86 patients was studied and in all cases laparoscopy followed previous laparotomy. Infertility, PPS, and pelvic mass were found to be the most frequent indications to laparoscopy. In 74.4% of patients who had laparotomy in their history, our laparoscopy revealed pelvic adhesions and in 9.3% of patients--endometriosis. Laparoscopy constitutes safe diagnostic and therapeutic procedure, complications occurred in 2.3% of patients.

Rapid hospital discharge following laparoscopy for ectopic pregnancy. A promise unfulfilled?

This study was done to determine whether laparoscopy for ectopic pregnancy in the United States is associated with rapid postoperative discharge, defined as 2 days or less, and to estimate how often ambulatory treatment of ectopic pregnancy occurs without subsequent hospital admission. We used the National Hospital Discharge Survey to estimate the frequency of ectopic pregnancy admissions, operations, and length of hospital stays in 1990. We used the National Ambulatory Medical Care Survey to estimate the number, type, and disposition of office visits for ectopic pregnancy in 1990. According to National Hospital Discharge Survey data, tubal pregnancy led to an estimated 57,000 hospital admissions in 1990. Most (70%) of the 26,000 patients treated with laparoscopy were in the hospital 3 days or more, and most (73%) underwent salpingectomy. The number of ambulatory visits for ectopic pregnancy was too low to estimate reliably according to the standards of the National Center for Health Statistics. We found that laparoscopy was used frequently for the treatment of ectopic pregnancy but was not associated with rapid postoperative discharge. Further research is needed to determine whether these findings persist and whether reimbursement incentives, patient preference, or problems with the diffusion of technology are responsible.

Postoperative day 1 serum human chorionic gonadotropin level as a predictor of persistent ectopic pregnancy after conservative surgical management

OBJECTIVE

To determine characteristics predictive of persistent ectopic pregnancy (EP).

DESIGN

Retrospective cohort study.

SETTING

Tertiary care, university hospital.

PATIENT(S)

All women treated surgically for an EP whose postoperative hCG levels were followed until complete resolution or determination of a persistent EP over a 54-month period.

MAIN OUTCOME MEASURE(S)

Final outcome defined as successful treatment or persistent EP.

RESULT(S)

Twenty-six (17.7%) of 147 patients were diagnosed with a persistent EP. An inverse relationship was noted between the percent decrease in hCG at postoperative day 1 and the incidence of persistent EP. A significantly greater percentage of persistent EPs were noted when the postoperative day 1 hCG fell < 50% from the initial preoperative hCG level (relative risk = 3.51 [1.25 to 6.68]). No case of persistent EP was noted if the postoperative day 1 hCG declined by > or = 77%. Surgical time differed significantly (129 minutes versus 101 minutes) between cases treated successfully as compared with cases in which conservative treatment failed. No other preoperative or intraoperative variables were found to be significantly different.

CONCLUSION(S)

Although no single postoperative hCG value is predictive of conservative surgical treatment for EP, a day-1 postoperative hCG value may be used as a predictor of persistent EP.

Fertility after organ-preserving surgery of ectopic pregnancy: results of a multicenter study

OBJECTIVE

To evaluate the postoperative fertility rate after ectopic pregnancy (EP) and to compare the impact of different surgical techniques.

DESIGN

Prospective, multicenter trial.

SETTING

Twenty-five centers with microsurgical facilities.

PATIENT(S)

A total of 1,025 patients with EP were enrolled between 1984 and 1990.

INTERVENTION(S)

Organ-preserving operation and at least one patent remaining tube. Evaluation of postoperative outcome by standardized questionnaires.

MAIN OUTCOME MEASURE(S)

Postoperative fertility in terms of pregnancy rate (PR) and recurrent ectopic implantation.

RESULT(S)

The PR was similar after wedge resection (45.9%) and salpingotomy or milk out (42.0%). The recurrence rates did not differ between both groups (7.5% versus 8.2%). In patients with a blocked or absent contralateral tube, the PR was poor (31.2%), and the recurrence rate of EP was high (16.0%), indicating that most pregnancies are achieved through the contralateral tube.

CONCLUSION(S)

The postoperative fertility rate after an EP is reduced. The type of surgery usually has no significant impact. In the case of a blocked or absent contralateral tube, the patient must be informed about the significantly reduced fertility rate and the elevated risk for EP recurrence.

Medical treatment of interstitial pregnancy. A report of three unsuccessful cases

BACKGROUND

Medical management of ectopic pregnancy is effective in selected cases and is recommended to treat interstitial pregnancy to avoid surgery that may limit future fertility. Although successful medical management of interstitial pregnancy has been reported, evidence does not support success rates equal to that in other ectopic locations.

CASES

Four cases of interstitial ectopic pregnancy were identified. Only one of the four was successfully treated with medical therapy. Case 1 was a confirmed, 2.5-cm interstitial pregnancy that failed a multiple-dose methotrexate protocol. Case 2 was an unrecognized interstitial pregnancy that failed single-dose therapy. Case 3 was a rupture of a medically managed interstitial pregnancy despite complete resolution of serum human chorionic gonadotropin. A literature review demonstrated an overall combined failure rate of 35% (7/20).

CONCLUSION

Compared with an isthmic or ampullary pregnancy, a disproportionate number of patients with interstitial pregnancy fail medical management and require emergency surgery. The presence of a documented interstitial pregnancy is not an absolute contraindication to medical management. Patients should be counseled that medical management of an interstitial pregnancy may not have the same rate of success as it does in other locations in the fallopian tube. Surgery in this case may be the preferred treatment option.