Laparoscopic management of ectopic pregnancy

In response to the dramatic increase in the incidence of ectopic pregnancy in the United States and worldwide, diagnostic and surgical procedures have evolved to provide safe, efficacious and cost-effective resolutions of this condition. Laparoscopic management of ectopic pregnancy, developed in this regard, continues to be the subject of equivocal reviews. In an effort to further elucidate the issues surrounding the laparoscopic management of ectopic pregnancy, a retrospective investigation was undertaken of 82 women admitted to a community hospital in the Northwest for operative resolution of ectopic pregnancy. Of these patients, 81 (99%) were treated successfully by the laparoscopic approach, the majority (90%) by salpingostomy, with no occurrence of postoperative complications. In contrast to the 3-14% incidence of persistent ectopic pregnancy found in other studies of this approach, a 1% rate was noted here. A sampling of patients treated by laparoscopic and non-laparoscopic approaches demonstrated a 13% reduction in hospital charges for those treated by laparoscopy. In addition, laparoscopy involved a shorter hospital stay and fewer of the unpleasant effects associated with abdominal surgery. The results of this study further support laparoscopic management as an efficacious, safe and cost-effective approach for the resolution of ectopic pregnancy.

Thyrotoxicosis complicated by ectopic pregnancy. First reported case

The reported incidence of thyrotoxicosis during pregnancy ranges from 0.02% to 3.7%, with an average of 0.2%. Ectopic pregnancy occurs in 1 of 66 pregnancies in the United States. The signs and symptoms of thyrotoxicosis complicate the diagnosis and surgical management of an ectopic pregnancy. This is the first reported case of thyrotoxicosis complicated by an ectopic pregnancy. The patient presented with a surgical abdomen (in this case an ectopic pregnancy) coupled with thyrotoxicosis. The combination of prompt presurgical medical intervention and operative correction prevented the mortality associated with a ruptured tubal pregnancy and thyroid storm.

[Acute disease of the pelvis: differentiation between gynecologic and surgical cause]

An acute disorder of the lower abdomen requires early clarification, whether or not it is of gynaecological or surgical origin. With non-gynaecological affections, beside diverticulitis, Crohn's disease, perforations, bowel obstructions, yersiniosis, vascular diseases (acute embolism, thrombosis or dissection), urological disorders or hernias, acute appendicitis has firstly to be considered. The systematic use of the different diagnostic instruments is discussed.

Triploid abortus presenting as an ectopic pregnancy

In this article we present a case of an ectopic gestation having morphologic features of a partial hydatidiform mole and demonstrating triploidy by flow cytometry in a patient presenting at 9 weeks' gestation. We include brief comments on partial hydatidiform mole.

Tubal pregnancy associated with ampullary tubal leiomyoma

BACKGROUND

Fewer than 100 cases of leiomyoma of the fallopian tube have been described in the literature; most of them are asymptomatic.

CASE

A woman presented with a tubal pregnancy which, at laparotomy, proved to be distal to a leiomyoma of the tube.

CONCLUSION

Tubal myomas may predispose to tubal implantation of a conceptus. To our knowledge, this is the first time a tubal leiomyoma and a tubal pregnancy have been reported in the English literature.

An unusual presentation of bilateral tubal ectopic pregnancy

The diagnosis of ectopic pregnancy is sometimes difficult on clinical grounds because of the varied presentation. The clinical triad of amenorrhoea, abnormal vaginal bleeding and lower abdominal pain often raises the suspicion of the diagnosis. There are, however, instances where one or other feature of the triad may be absent.

Misdiagnosis of appendicitis in tubally sterilized women

Sterilization by tubal occlusive methods has a small but definite incidence of failure which is not well recognized among general surgeons. As a result of the failure to appreciate the possibility of ectopic pregnancy after tubal ligation, right-sided abdominal pain in this patient population is commonly misdiagnosed as appendicitis. One such case is presented, and the literature is reviewed and discussed.

Choriocarcinoma associated with ectopic pregnancy after tubal sterilisation

A 33-year-old highly parous woman developed severe abdominal pain and signs of circulatory collapse 10 months after tubal sterilisation in the absence of symptoms of pregnancy. A ruptured ectopic pregnancy sited interstitially in the right tube and extending into the myometrium and parametrium was found at laparotomy. Histopathologic examination revealed an ectopic pregnancy consisting of choriocarcinoma--a rare but life-threatening combination in a sterilised woman.

[Autohemotransfusion in patients with intraperitoneal hemorrhage. Report of 221 cases]

Autohemotransfusion was performed in 221 patients with intraperitoneal hemorrhage. The total amount of blood autotransfused was 198,760 ml, accounting for 90% of whole the blood transfused during the operations. The average amount of blood transfused was 899 ml per case, the largest amount being 3600 ml. There was no any adverse reaction observed. We consider that autohemotransfusion may avoid some shortcomings of donor's blood, and is of great importance in the treatment of patients with hemorrhagic shock when bank blood is not immediately available. The indications and contraindications of autohemotransfusion are discussed.

Simultaneous ectopic pregnancy with intra-uterine gestation after in vitro fertilization and embryo transfer

A case of combined intra-uterine and tubal ectopic pregnancy is described following in vitro fertilization and the transfer of two four-cell and one two-cell embryos. This phenomenon is known to be related to ovarian stimulation by gonadotropin therapy, and there is an increased risk with tubal disease. Techniques applied at the time of embryo transfer, the use of culture medium with 50% fetal cord serum to convey the embryos to the uterus, the catheterization method, and the position of the patient during transfer are presented. The risk of multiple pregnancies and combined intra-uterine and ectopic gestations increases with numbers of transfers and large volume of transfer medium. We would therefore recommend that after IVF-ET treatment in women with tubal disease, intensive care should be taken in the early follow-up period to rule out the possibility of ectopic pregnancy. In this case, a viable ongoing intra-uterine pregnancy was confirmed after surgery for right ampullary ectopic pregnancy. And a 2,925 g male in excellent condition was delivered by Cesarean section without complications.

Combined intrauterine and extrauterine gestation with a general surgical presentation

A case is presented of a combined intrauterine and extrauterine gestation. The diagnosis of the ectopic pregnancy was made intraoperatively with a pre-operative diagnosis of a simple intestinal obstruction, while the intrauterine pregnancy was diagnosed after a spontaneous abortion. A family history of twinning associated with a surgical evidence of chronic inflammatory disease is thought to be the cause.

Unsuspected heterotopic pregnancy in a woman without risk factors

A 27-year-old woman presented to the emergency department with abdominal pain. One week prior to this she had had an ultrasound which revealed an intrauterine pregnancy (IUP). A second ultrasound performed at our institution revealed an intrauterine pregnancy along with a concomitant ectopic pregnancy which had ruptured. This case emphasizes that coincident pregnancies may occur in women who are without risk of ectopic pregnancy or multiple gestations. In addition, ultrasound must be evaluated fully for heterotopic pregnancy in all women.

Prerupture ultrasound diagnosis of interstitial and rudimentary uterine horn pregnancy in the second trimester. A report of two cases

Pregnancies in an interstitial and rudimentary uterine horn are rare and often fatal varieties of ectopic gestation. Ruptures tend to occur in the second trimester, resulting in maternal morbidity and mortality. Only a few cases of the ultrasonographic diagnosis of unruptured second-trimester interstitial and rudimentary uterine horn pregnancy have been reported. In two such cases second-trimester ultrasonographic examination revealed an unusual pregnancy location, thin uterine wall, incomplete myometrial layer and empty uterus.

Fertility outcome following tubal pregnancy

This study was undertaken to analyze the factors associated with fertility outcome following tubal pregnancy. Eighty-six patients were analyzed in this regard. The chances of a favourable outcome (intrauterine pregnancy) decreased and an unfavorable outcome (repeated tubal pregnancy or no pregnancy) increased with a history of previous tubal pregnancy and also with an absent or diseased contralateral tube at the time of surgery. History of infertility, prior reconstructive tubal surgery, status of the ipsilateral tube at the time of surgery, the treatment modality (laparoscopy vs laparotomy) or the surgical approach (conservative vs radical) did not significantly affect fertility outcome.

Vaginal douching and the risk of tubal pregnancy

To explore the possible association between vaginal douching and tubal pregnancy, we interviewed 273 women who were diagnosed with tubal pregnancy at Group Health Cooperative between September 31, 1981 and October 1, 1986. Their responses were compared with responses of a random sample of 722 female members of Group Health Cooperative who were assumed to be at risk of becoming pregnant at the time the cases conceived. After adjusting for differences between cases and controls with regard to other measured risk factors, we found a modest increase in risk associated with having douched more than two times per year in the past (RR = 1.3, 95% CI: 0.9-1.8). Among women who had more than one sexual partner during their lifetime, however, the risk for those who had douched more than twice per year was somewhat higher (RR = 1.6, 95% CI: 1.1-2.3). There was an indication that women who had been exposed to Chlamydia trachomatis, as indicated by elevated antibody titers, may further increase their risk for tubal pregnancy by douching (RR = 2.4, 95% CI: 0.8-7.3). The associations found in other studies between douching and pelvic inflammatory disease, and between pelvic inflammatory disease and subsequent tubal pregnancy, argue that a relation between douching and tubal pregnancy might be anticipated. Our results offer further support for this hypothesis.

Can the status of tubal pregnancy be predicted with transvaginal sonography? A prospective comparison of sonographic, surgical, and serum hCG findings

Results of transvaginal sonography were compared prospectively with surgical findings and levels of serum human chorionic gonadotropin in 120 women with a proved tubal pregnancy. The most common sonographic finding was a saclike adnexal ring, which was seen in 74 of the women (61.7%). This finding was strongly associated with functioning trophoblasts and with an intact fallopian tube. In 39 of the women (32.5%) an adnexal mass with a complex texture was found. Of these 39 women, 20 had a tubal hematoma and six had a ruptured fallopian tube. The size of the tubal mass created by ectopic pregnancy was predicted precisely (r = .91, P less than .001), and transvaginal sonography enabled detection of hemoperitoneum with a sensitivity of 91% (68 of 75 women). This study suggests that the status of a tubal pregnancy can be predicted reliably on the basis of transvaginal sonographic findings.

Accessory fallopian tube. A case report

Accessory fallopian tubes may be found during an evaluation for infertility. The true incidence is unknown but may be as high as 6%. A patient had an ectopic pregnancy in an accessory fallopian tube; its rupture led to emergency surgery. During the next six months, five infertility patients were noted to have accessory fallopian tubes among 100 surgical infertility patients and 398 surgical gynecology patients. The accessory tubes were removed using a microsurgical technique. Three of the five patients had had prior laparoscopy, and their operative reports stated that the pelvis was normal. We suggest a careful evaluation of the pelvis in each patient. If accessory tubes are noted during surgery, one should correct the anatomy to avoid potentially life-threatening situations.

Histopathology of fallopian tubes with recurrent tubal pregnancy

Fifteen fallopian tubes in which a previous ipsilateral eccyesis was managed by conservative surgical techniques were examined. The condition of the tube relative to the previous surgical management and the resolution of the previous implantation sites were correlated with the recurrent tubal pregnancy. All previous incisions were identified and all were well-healed, except for one fistula. Residual histologic evidence was present in only five of 16 previous implantation sites. The recurrent eccyeses were related to previous surgical management in only three women, two after anastomosis and one because of inadvertent obstruction of the tube. The cases of tubal obstruction and tuboperitoneal fistula formation were thought to reflect a lack of understanding of the pathologic changes associated with tubal pregnancy during conservative surgery. The previous tubal incision sites were all remarkably well-healed regardless of whether they were primarily closed or left open, and independent of location. Infundibular or fimbrial "milk-outs" were without histologic evidence of damage. The underlying tubal disease (chronic salpingitis, follicular salpingitis, or salpingitis isthmica nodosa) seems to be the major factor identified that is associated with, and probably the cause for, the recurrent tubal gestation.