[The case of intrauterine pregnancy coexisting with extrauterine pregnancy which was surgically removed]

The case of simultaneous intrauterine and ruptured ectopic pregnancy was presented. The diagnosis of coexisting intrauterine and ectopic pregnancies is difficult. The patient was admitted to the clinic because of abdominal pain and vaginal bleeding in the 10th week of pregnancy has been treated by laparotomy. The intrauterine pregnancy was continued successfully to term. The importance of careful sonographic examination of adnexal region was stressed in all symptomatic patients with first trimester pregnancy.

[A case of cervical pregnancy diagnosed by laparotomy and photographically documented]

A case deals with 33 years old primipara in the last stage of the first trimenom of pregnancy. To dispel the doubts connected with development of pregnancy and ultrasound assessments the explorative laparotomy was undertaken. The cervical pregnancy was stated. The curettage and tamponing of the cervical canal failed. The procedure was completed with hysterectomy without adnexa. The advantage of early laparotomy consisted in getting a clear view of the situation and giving the maximum of safety to the patient when the attempts to save the uterus were being carried out. The early laparotomy made it possible to take some unique photographs of the uterus "in situ" with cervical pregnancy.

Primary term ovarian pregnancy superimposed by intrauterine pregnancy: a case report

A case of primary ovarian pregnancy proceeding upto term superimposed by another intrauterine pregnancy is presented. Compound extrauterine and intrauterine pregnancy is a rare obstetric phenomenon and still rarer is a primary ovarian pregnancy proceeding upto the term. The condition was diagnosed at laparotomy during the second trimester of current pregnancy. Diagnostic laparotomy was done because the ovarian pregnancy was mimicking an ovarian tumur. The ovarian pregnancy was successfully managed by surgery. Normal vaginal delivery of a term intrauterine pregnancy occurred in due time. The difficulty of diagnosing the heterotopic pregnancy is discussed and the clinico-pathological features of primary term ovarian pregnancy is emphasized, as it is a very rare condition.

Tubal patency after laparoscopic treatment of ectopic pregnancy

OBJECTIVE

To evaluate operative course, tubal patency and reproductive performance after laparoscopic treatment of ectopic pregnancy in relation to initial human chorionic gonadotropin (hCG) values and to the kind of operation.

DESIGN

Retrospective study.

PATIENTS

Fourty-five patients affected by ectopic pregnancies: thirty-two treated with laparoscopic linear salpingotomy subvided into two groups depending on the hCG serum values < 10,000 mUl/ml (twenty patients: group 1) or > 10,000 mUl/ml (twelve patients Group 2), thirteen patients (Group 3) undergoing laparoscopic salpingectomy. Hysterosalpingographic examination was performed two or three months after surgery.

MAIN OUTCOME MEASURES

Operative time, major surgical complications, tubal patency and pregnancy rate after surgery.

RESULTS

Operative time was significantly (p < 0.05) lower in both group 1 and 3 (22.5 +/- 3.2 and 19.1 +/- 6.3, respectively) than in group 2 (39.4 +/- 5.6). Bilateral patent tubes were observed in eighteen cases of group 1 (90%) and eight cases of group 2 (60%). No statistically significant differences were found between the pregnancy rate of both group 1 (8/18) and 2 (3/8) and of group 3 (3/11).

CONCLUSIONS

Reproductive outcome is similar in both conservative and destructive laparoscopic management of ectopic pregnancy: furthermore it shows a trend of improvement, not statistically significant, in conservative treatment.

Laparoscopic management of rudimentary horn pregnancy. A case report

BACKGROUND

Rudimentary uterine horn pregnancy is a very rare condition. Removal of a rudimentary horn is required as soon as a pregnancy is confirmed because most pregnancies in a rudimentary uterine horn rupture in the first or second trimester.

CASE

A 22-year-old woman was admitted to our hospital because an ectopic pregnancy was suggested by ultrasonographic examination at another hospital. A rudimentary uterine horn pregnancy was suspected from transvaginal ultrasonography. The patient was treated with laparoscopic surgery at 7 weeks of gestation. The pregnant rudimentary horn was removed laparoscopically by use of an automatic stapling device. The postoperative course was uneventful.

CONCLUSION

This is the first report of laparoscopic resection of a pregnant rudimentary uterine horn. Laparoscopic management of such a pregnancy may reduce operating time and peritoneal damage.

Ectopic pregnancy: an analysis of 62 cases

Sixty-two cases of ectopic pregnancy admitted in the Department of Obstetrics and Gynaecology, Jinnah Postgraduate Medical Centre, Karachi from July, 1989 to December, 1990 were analysed to determine the incidence, risk factors, diagnostic features and management. During this period a total number of 10,798 patients were delivered giving an incidence of 1:174 births or 5.7 per 1000 births. In 48.3% cases the cause was unknown, 16.1% followed by pelvic inflammatory disease, 16.1% had history of D & E for abortion, 6.4% had history of different type of pelvic surgery, 4.8% had IUCD in situ, 1.6% had recurrent ectopic pregnancy. Diagnosis was made clinically in 80.6% cases. Culdocentesis was performed in all cases except one and was diagnostic in 90.1% cases. Ultrasound was performed in 51 cases and showed positive results in 90.1% cases. Laparoscopy was performed in only 10 cases and had 100% accurate results. After thorough re-suscitation laparotomy was performed in all cases. Partial salpingectomy was done in 53.2%, salpingectomy and tubal ligation in 32.2%. (They had already completed their family) and salpingo-oophorectomy in 4.8% cases. Tubes were conserved in 6.2% cases (all of them were primigravidas). In single abdominal pregnancy, dead fetus and placenta was removed from the peritoneal cavity very carefully. The mortality rate in this study was 1.6%.

Leukemia inhibitory factor (LIF) production by human decidua and its relationship with pregnancy hormones

The expression of leukemia inhibitory factor (LIF) by murine uterus was shown to be regulated by maternal hormones and was not dependent on the presence of an embryo. The objective of this study was to investigate whether in humans the secretion of LIF during early pregnancy is under maternal control and whether its production is correlated with pregnancy hormones, progesterone and beta-human chorionic gonadotropin (beta hCG). To exclude the possibility of paracrine interaction of decidua with trophoblast, we examined the secretion of LIF in women with extrauterine pregnancy. The present study was designed as a prospective, blinded, clinical and immunobiochemical study. The endometrial biopsies were performed on 12 women during surgery for ectopic pregnancy. On the same day, the level of progesterone and beta hCG in maternal plasma was examined. LIF concentration was determined in supernatants taken from cultured decidual explants. LIF production by decidual culture explants was found in all women with an ectopic pregnancy (Median 5015 pg, range 1389-19,304 pg). There was no correlation between the LIF production and the term of pregnancy, or with the level of circulated beta hCG (p > 0.05). However, when the concentration of progesterone in circulating plasma was less than 5 ng/ml, the secretion of LIF was 2.3-fold higher as compared to women who had progesterone levels of more than 5 ng/ml (p < 0.01). Therefore, we conclude that LIF is actively produced by human decidua and that the production of this cytokine does not depend on the presence of fetotrophoblast. This study demonstrates for the first time that progesterone downregulates the secretion of LIF in the decidua during early pregnancy.

A woman with three ectopic pregnancies after in-vitro fertilization and embryo transfer

Although a higher incidence of ectopic pregnancy has been reported after in-vitro fertilization (IVF) and embryo transfer, three ectopic pregnancies in the same woman is very rare. A patient of 32 years underwent IVF-embryo transfer six times within 3 years. Three of four conceptions resulted in ectopic pregnancies. The first involved simultaneous intrauterine and left tubal pregnancy, the second was a right tubal pregnancy, and the third was a right interstitial pregnancy. In IVF-embryo transfer, bilateral salpingectomy does not remove the risk of interstitial or cornual pregnancy.

Ultrasound studies in ectopic pregnancies

Early diagnosis of ectopic pregnancy reduces the mortality and morbidity associated with the disease, and the morbidity associated with the therapy. When diagnosis was limited to the cases presenting with tubal rupture, salpingectomy was the only possible treatment. If ectopic pregnancy can be diagnosed earlier, clinicians are able to use new therapies such as laparoscopic microsurgery or medical therapy with methrotrexate, which are less invasive and less tissue destructive. Transvaginal ultrasound has proven to be an essential tool in the early diagnosis of ectopic pregnancy. Colour Doppler capacities further enhance the diagnostic sensitivity of transvaginal ultrasound for the early recognition of abnormal and normal intrauterine pregnancy, and small extrauterine masses. The aim of this paper is to provide an overview of the major sonographic signs and pitfalls in the ultrasound diagnosis of ectopic pregnancy.

[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.