Case Report of an Ectopic Molar Pregnancy in the Presence of an Intrauterine Device

BACKGROUND

Ectopic molar pregnancy is a rare phenomenon and has not been reported in the presence of an intrauterine device (IUD). Clinical diagnosis of molar pregnancy is challenging and requires careful follow-up.

CASE

A 25-year-old woman (gravida 2, para 0) with a copper IUD in place presented with a positive pregnancy test. Diagnosis of the complete hydatidiform mole was pathologically confirmed after surgery following clinical and sonographic investigations that identified a left-sided ectopic pregnancy.

CONCLUSION

Gestational trophoblastic disease (GTD) presenting as an ectopic pregnancy is a very rare occurrence. This patient recovered without event through a combined management and follow-up for ectopic pregnancy and gestational trophoblastic disease. Appropriate identification and management of this clinical problem is essential in order to prevent initial complications as well as subsequent malignant sequelae.

Analysis of risk factors for intraoperative hemorrhage of cesarean scar pregnancy

The current commonly used treatments for cesarean scar pregnancy (CSP) include multiple treatments such as medication, uterine artery embolization, curettage and surgery, and their combinations. However, every treatment option has risks of excessive hemorrhage from uterus. In this study, we retrospectively analyzed the risk factors for intraoperative hemorrhage of different treatments for CSP patients, with the hope to provide the guidance for CSP treatment.Fifty-eight cases of CSP patients who were treated with curettage after medication, curettage after uterine artery embolization, or surgery were retrospectively analyzed and compared for the clinical efficacy, length of hospital stay, and hemorrhage rate. Further, they were divided into the bleeding group (≥200 mL, 15 cases) and the control group (<200 mL, 43 cases). The hemorrhage-related risk factors were subjected to univariate analysis, including age, pregnant times, delivery times, abortion times or curettage times, the time from last cesarean section, menolipsis time, serum human chorionic gonadotropin level, ultrasound typing, maximum diameter of gestational sac or mass under ultrasound, peritrophoblastic blood flow around the mass, and the distance of gestational sac or mass from the uterine serosa layer. The significant indexes in univariate analysis were further analyzed using both receiver operating characteristic (ROC) analysis and multivariate logistic regression analysis.The success rate, length of hospital stay, and hemorrhage rate were not significantly different among the 3 treatment groups (P > .05). Univariate analysis found that patients in the bleeding group had significantly longer menolipsis time and greater maximum diameter than patients in the control group (P < .05). ROC analysis showed that the optimal cutoff for menolipsis time and maximum diameter were 51 days and 27 mm, respectively, and the areas under their corresponding ROC were 0.680 and 0.787, respectively. Multivariate analysis showed that only the maximum diameter in the retrospective equation was of significance (P < .05, odds ratio: 1.067, 95% confidence interval: 1.014∼1.123].All treatments have high success rates and no significant effects on intraoperative bleeding. Both menolipsis time and maximum diameter can be used to predict the risk of intraoperative bleeding, and the latter have a greater predictive value.

Comparison of transvaginal surgery and methotrexate/mifepristone-combined transcervical resection in the treatment of cesarean scar pregnancy

OBJECTIVE

To explore the safety and efficiency of transvaginal surgical treatment of cesarean scar pregnancy (CSP).

PATIENTS AND METHODS

A retrospective analysis of 54 CSP patients that received treatment in our hospital from October 2011 to September 2015 was performed, dividing two groups: Group A (n=34) received transvaginal cesarean scar pregnancy focus clearance surgery while Group B (n=20) received transcervical resection following methotrexate/mifepristone-combined treatment. The basic clinical findings were collected and analyzed, along with the curative effects between the two groups.

RESULTS

Differences in age (30.91 ± 4.59 years vs. 31.91 ± 5.53 years) for gravidity (2.97 ± 1.24 times vs. 2.75 ± 1.48 times), cesarean section (1.24 ± 0.43 vs. 1.20 ± 0.41), time interval from last cesarean section (56.53 ± 32.93 months vs. 58.70 ± 39.44 months), menelipsis (51.35 ± 10.90 days vs. 57.85 ± 16.62 days), pre-operative serum-hCG (27953.65 ± 37517.10 mIU/L vs. 17368.24 ± 35094.14 mIU/L), operation time (43.34 ± 12.38 min vs 40.07 ± 16.88 min), menstruation recovery time (1.23 ± 0.53 months vs. 1.55 ± 0.76 months) were not statistically significant (p > 0.05). The differences in the intraoperative blood loss (43.34 ± 12.38 ml vs. 40.07 ± 16.88 ml), average hospital stay (7.61 ± 2.47 days vs. 12.42 ± 3.64 days), time for β-hCG to return to normal (18.50 ± 8.19 mIU/L vs. 29.00 ± 12.96 mIU/L) between the two groups were statistically significant (p < 0.05). Group A was significantly lower than Group B.

CONCLUSIONS

Transvaginal surgery is an effective and relatively safe treatment option for CSP patients.

Impact of hysterosalpingography after operative treatment for ectopic pregnancy in Taiwan: A 16-year Nationwide Population-Based Analysis

By retrieving records from Taiwan's National Health Insurance (NHI) system's database, the current study aimed to investigate the impacts of hysterosalpingography (HSG) to patients after ectopic pregnancy (EP) operations in Taiwan.In this retrospective cohort study, insurance claims data from 1997 to 2013, derived from a cohort of 1 million people randomly sampled to represent all NHI beneficiaries, were analyzed. Patients after ectopic pregnancy (EP) operations were identified via the inclusion of the corresponding NHI procedure codes. We further divided the patients into 2 groups by whether received subsequent HSG, EP-HSG, and EP-no-HSG. Patients with history of previous pregnancies (PP) and subsequent HSG were grouped as PP-HSG. We sought to evaluate the following pregnancies (FP) rate, interval to FP in EP-HSG compared with that in EP-no-HSG, and PP-HSG.EP-HSG had significantly higher FP rate odds ratio than EP-no-HSG (OR, 1.64; 95% CI, 1.24-2.16, P < .001). EP-HSG had lower FP rate odds ratio than that in PP-HSG, but no significant difference (33.1% vs 34.6%, P  =  .654). The INTERVAL(HSG-FP) in EP-HSG was no significantly different from that in PP-HSG (843.34 ± 82 days vs 644.72 ± 24.30 days, P  =  .077). There was significant positive correlation between FP after EP and number of HSG (r  =  0.070, P < .001). There were significant negative correlation between FP and EP age (r  =  -0.270, P < .001), FP and INTERVAL(EP-HSG) (r  =  -0.212, P  =  .001). The multivariate analysis showed that INTERVAL(EP-HSG) less than 1 year is the predictor factor of INTERVAL(EP-FP) (hazard ratio: 1.422; 95% CI: 1.130-1.788; P = .003). It was evident that the longer the INTERVAL(EP-HSG), the lower the FP rate odds ratio; and the older the EP age, the lower the FP rate odds ratio. (OR, 95% CI; >1 year: 0.59, 0.41-0.86; >2 year: 0.42, 0.32-0.55; >25 years old: 0.47, 0.38-0.57; >30 years old: 0.29, 0.24-0.35; >35 years old: 0.12, 0.08-0.18, all P < .001).Receiving HSG after EP, short INTERVAL(EP-HSG), EP age less than 30 years old, had significant positive impacts on the FP. We encourage shortening the INTERVAL(EP-HSG), and the counseling of women on the most appropriate way to conceive thereafter.

Confirmation of posterior uterine rupture in the second trimester by magnetic resonance imaging

Intrapartum uterine rupture is a life-threating and rare complication of pregnancy which seldom occurs in the second trimester. Typically, the diagnosis is made using ultrasound; however, magnetic resonance imaging can provide certain advantages in the emergent setting. We present a unique case of a posterior uterine rupture confirmed by magnetic resonance imaging involving the unscarred posterior uterine wall in a 20-year-old gravid female with two previous cesarean-sections.

Sonographic appearance of a cesarean scar pregnancy with placenta percreta invading the bladder in the first trimester and management with fertility preservation

A 36-year-old, gravida 8, para 6, woman with six prior cesarean sections presented at 6 weeks with a cesarean scar pregnancy. Medical management was performed initially; however, subsequent three-dimensional sonographic examinations revealed trophoblastic invasion into the bladder. This led to robotic-assisted partial cystectomy, fulguration of invaded pregnancy, and repair of the uterine defect. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:163-167, 2017.

Somatic Dysfunction in the Diagnosis of Uncommon Ectopic Pregnancies: Surgical Correlation and Comparison With Related Pathologic Findings

BACKGROUND

Ectopic pregnancies occur when the implantation of a fertilized ovum occurs outside the endometrial cavity. Such pregnancies occur in approximately 1.5% to 2.0% of all pregnancies and cause 6% of maternal deaths.

OBJECTIVES

To evaluate osteopathic structural examination (OSE) findings in patients with ectopic pregnancies of uncommon locations and to establish the utility of these findings in the diagnosis of these ectopic pregnancies.

METHODS

In this prospective case series, a focused OSE was performed on each patient with an ectopic pregnancy at her initial presentation after the patient history but before other diagnostic or laboratory tests were performed and surgical treatment was initiated. Chapman reflex points (CRPs) were evaluated pre- and postoperatively. For comparison, patients who had otherwise normal first pregnancies, underwent elective postpartum bilateral tubal ligation, or had simple ovarian cysts were also included and received OSEs.

RESULTS

Seven cases with ectopic pregnancies outside the fallopian tube were included. Two primary ovarian pregnancies and 1 heterotopic pregnancy (uterine and ovarian) had somatic dysfunction at the T10-T11 spinal levels and CRPs posterior for the ovary, 1 primary omental pregnancy with somatic dysfunction at the T9-T12 spinal levels and CRPs anterior and posterior for the ileum and jejunum, and 1 tubal pregnancy with somatic dysfunction at the T10-L1 spinal levels and CRPs anterior and posterior for the fallopian tube. Two cornual ectopic pregnancies were not associated with unique findings. These somatic dysfunctions and CRP findings appear to be distinct from those of comparison cases, including first pregnancies at any trimester, simple ovarian cysts, and elective bilateral tubal ligation.

CONCLUSION

The OSE findings demonstrated in these cases aided in the final diagnosis and thus can potentially prove helpful in cases of ovarian, tubal, and omental pregnancies to provide clues to abnormal ectopic pregnancy locations where diagnostic imaging results are insufficient or equivocal. Osteopathic structural examinations may allow osteopathic physicians to better prepare for treatment approaches, including surgery.

A case report of a patient with high β-hCG levels after operation because of primary broad ligament pregnancy

INTRODUCTION

A broad ligament pregnancy is an extremely rare condition and diagnosis is frequently missed and finally made during laparotomy. This is a case of a young patient with high serum beta-human chorionic gonadotropin (β-hCG) levels after operation because of broad ligament pregnancy.

CASE REPORT

A 31-year-old multipara complained of intermittent lower abdominal pain with vaginal bleeding for four months. A color ultrasonography revealed a cystic mass in the left attachment area, indicating an interstitial tubal pregnancy. However, trophoblastic disease could not be excluded. She accepted conservative treatment with methotrexate (MTX) at first, but observation showed that conservative treatment was slow and accompanied with liver function damage. Therefore, exploratory laparotomy was performed. Intraoperative situations and postoperative pathology confirmed broad ligament pregnancy. Her serum p- hCG was sustained at a high level for three months after operation. Her examinations of serum, CT, and ultrasonography could explain this situation.

CONCLUSION

Primary broad ligament pregnancy refers to pregnancy where implantation of the fertilized ovum occurs directly between the two leaves of the broad ligament. The gravid substance was removed, however serum β-hCG could not gradually re- turn to normal levels. This case should be followed-up closely to prevent adverse outcomes.

Medical management of early pregnancy failure with misoprostol with rupture of the cesarean section scar pregnancy

PURPOSE

To report a case of ruptured uterus in the first trimester with the use of misoprostol for early pregnancy tailure in a woman with unrecognized cesarean section scar pregnancy.

CASE

A 27-year-old woman, gravida 5 para 3+1, presented with abdominal pain and vaginal bleeding. Transvaginal ultrasonography revealed a fetus without fetal heart activity at nine weeks gestation, making the diagnosis of early pregnancy failure. Her previous deliveries were by cesarean section. She was managed medically with misoprostol. Seven hours after misoprostol administration, she developed sudden onset of severe abdominal pain. Repeat transvaginal ultrasonography diagnosed cesarean section scar pregnancy. Laparotomy revealed hemoperitoneum with rupture of cesarean section scar pregnancy. Subtotal hysterectomy was performed.

CONCLUSIONS

Failure to recognize cesarean section scar pregnancy can result in a ruptured uterus in the first trimester with the use of misoprostol for early pregnancy failure. Increased awareness of the unexpected consequences of cesarean section is of paramount importance.

Abdominal ectopic pregnancy after in vitro fertilization and single embryo transfer: a case report and systematic review

BACKGROUND

Ectopic pregnancy is the leading cause of maternal morbidity and mortality during the first trimester and the incidence increases dramatically with assisted-reproductive technology (ART), occurring in approximately 1.5-2.1 % of patients undergoing in-vitro fertilization (IVF). Abdominal ectopic pregnancy is a rare yet clinically significant form of ectopic pregnancy due to potentially high maternal morbidity. While risk factors for ectopic pregnancy after IVF have been studied, very little is known about risk factors specific for abdominal ectopic pregnancy. We present a case of a 30 year-old woman who had an abdominal ectopic pregnancy following IVF and elective single embryo transfer, which was diagnosed and managed by laparoscopy. We performed a systematic literature search to identify case reports of abdominal or heterotopic abdominal ectopic pregnancies after IVF. A total of 28 cases were identified.

RESULTS

Patients' ages ranged from 23 to 38 (Mean 33.2, S.D. = 3.2). Infertility causes included tubal factor (46 %), endometriosis (14 %), male factor (14 %), pelvic adhesive disease (7 %), structural/DES exposure (7 %), and unexplained infertility (14 %). A history of ectopic pregnancy was identified in 39 % of cases. A history of tubal surgery was identified in 50 % of cases, 32 % cases having had bilateral salpingectomy. Transfer of two embryos or more (79 %) and fresh embryo transfer (71 %) were reported in the majority of cases. Heterotopic abdominal pregnancy occurred in 46 % of cases while 54 % were abdominal ectopic pregnancies.

CONCLUSIONS

Our systematic review has revealed several trends in reported cases of abdominal ectopic pregnancy after IVF including tubal factor infertility, history of tubal ectopic and tubal surgery, higher number of embryos transferred, and fresh embryo transfers. These are consistent with known risk factors for ectopic pregnancy following IVF. Further research focusing on more homogenous population may help in better characterizing this rare IVF complication and its risks.

Early pregnancy likely caused by an intravesical intrauterine device

A 42-year-old female with remote history of intrauterine device (IUD) placement presented with gross hematuria, urinary urgency, and dyspareunia. Cystoscopy showed an encrusted, free-floating intravesical foreign body consistent with a heavily calcified IUD. It was removed endoscopically using holmium laser cystolitholapaxy. The patient remained symptom free postoperatively. While most intravesical IUDs are thought to be the result of migration after several months, this patient became pregnant within 4 weeks after initial insertion. Therefore this may represent a case either of early intravesical migration or of accidental IUD placement into the bladder at the time of initial insertion.

Successful Laparoscopic Management of Type I Cesarean Scar Pregnancy A Case Series

OBJECTIVE

To explore the efficacy of laparoscopic surgery without auxiliary treatment for type II cesarean scar pregnancy (CSP-II).

STUDY DESIGN

This was a case series of 7 patients with CSP-II who underwent laparoscopic surgery without auxiliary treatment between April 2014 and April 2015. All cases were diagnosed by ultrasound, confirmed by laparoscopy, and managed by laparoscopic resection of scar and gestational tissue and wound repair.

RESULTS

All 7 patients had successful surgeries without complication. Uterine scar and gestational tissues were resected, while also preserving the uterus. The operation time was 70.1 ± 16.3 min and blood loss was 65.7 ± 32.1 mL. Serum β-hCG levels 24 hours after surgery declined by 84.8 ± 9.4%. Serum β-hCG levels went back to <5 IU/L in all 7 patients by 14.4 ± 4.3 days after surgery. The time interval between surgery and first menstruation was 35.3 ± 4.5 days.

CONCLUSION

These results suggest the possibility that skilled surgeons could use laparoscopy without auxiliary pretreatment to remove gestational tissues and uterine scar defect and to repair the wound in patients with CSP-II.

Caesarian Scar Pregnancy- a Diagnostic Dilemma

Caesarean scar pregnancy is one of the rarest forms of ectopic pregnancy. Transvaginal ultrasound and color flow Doppler provides a high diagnostic accuracy. A delay in diagnosis and treatment can lead to uterine rupture, major hemorrhage, hysterectomy and serious maternal morbidity and mortality. Early diagnosis can offer treatment options of avoiding uterine rupture and hemorrhage, thus preserving the uterus and future fertility. Primary health care provider should know about this rare entity, because if diagnosed timely, and referral to specialized centre is done without delay will definitely save maternal morbidity and mortality. Management plan should be individualized. Termination of pregnancy is the treatment of choice in the first trimester. Expectant treatment has a poor prognosis because of risk of rupture. In this case report we aim to discuss the associated diagnostic dilemma, most appropriate methods of diagnosis and management, with their implications in clinical practice.

Surgical treatment of Cesarean scar ectopic pregnancy: efficacy and safety of ultrasound-guided suction curettage

OBJECTIVES

To assess the efficacy of ultrasound-guided suction curettage for management of pregnancies implanted into the lower uterine segment Cesarean section scar.

METHODS

This was a retrospective study including women diagnosed with Cesarean section scar pregnancy at two large tertiary referral early pregnancy units between 1997 and 2014. Surgical evacuation was offered to selected women presenting in the first trimester ≤ 14 weeks' gestation. All procedures were performed transcervically under ultrasound guidance using suction curettage. A modified Shirodkar cervical suture was used in women who required additional measures to secure hemostasis.

RESULTS

A total of 232 women with Cesarean section scar pregnancy were seen at the referral units; 191/232 (82.3%) women were treated surgically. The median intraoperative blood loss was 100 mL (range, 10-3000 mL); 9/191 (4.7% (95% CI, 1.7-7.7%)) women required blood transfusion and, in one (0.5% (95% CI, 0-1.5%)), life-saving hysterectomy had to be performed because of uncontrollable intraoperative bleeding. Of the women who attended for follow-up, 7/116 (6.0% (95% CI, 1.7-10.3%)) required a repeat surgical procedure because of retained products of conception. Multivariable analysis showed that the gestational sac diameter (odds ratio (OR), 1.10 (95% CI, 1.03-1.17)) and pregnancy vascularity on Doppler examination (OR, 3.41 (95% CI, 1.39-8.33)) were significant predictors of heavy intraoperative blood loss (> 1000 mL).

CONCLUSIONS

Ultrasound-guided suction curettage is an effective method for the treatment of pregnancies implanted into a lower uterine segment Cesarean section scar and is associated with a low risk of blood transfusion and hysterectomy. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Primary Hepatic Ectopic Pregnancy: A Case Report

BACKGROUND

Hepatic pregnancy is a very rare form of ectopic pregnancy, potentially life-threatening for the mother.

CASE

A 33-year-old woman presented with intermittent pain in the upper abdomen of 5 days' duration. An abdominopelvic ultrasound scan was performed, which demonstrated hepatic pregnancy. Later, abdominal computed tomography (CT) and magnetic resonance imaging (MRI) in coronal and axial confirmed the findings and delineated exactly the regional anatomy before surgery. Laparotomy was successfully performed according to the preoperative diagnosis.

CONCLUSION

The application of imaging techniques (ultrasound, CT, and MRI scan) is very useful in hepatic pregnancy for defining the regional anatomy in greater detail and is critical in minimizing surgical injury.

Laparoscopic Approach has Benefits in Gynecological Emergencies - Even for Massive Hemoperitoneum

OBJECTIVE

The purpose of this study is to compare the laparoscopic with the open approach in hemoperitoneum of gynecological origin.

MATERIALS AND METHODS

Retrospective study of patients admitted to a tertiary emergency hospital between January 2013 - January 2015.

RESULTS

There were 56 patients, 27 in the laparoscopic group (LG) and 28 in the open group (OG). The gynecological emergency was a ruptured ovarian cyst in 20 (74%) versus 17 (59%) cases, and an ectopic pregnancy with tubal rupture in 7 (26%) versus 12 (41%) patients in both the laparoscopic and open approaches, respectively. The main outcome - mean intraoperative hemoglobin decrease - was 1.5 +- 1.2 g/dl in the laparoscopic and 1.9 ‚+-1.4 in the open approach (p=0.344). There were no differences regarding red blood transfusion rate, needs for analgesics, postoperative complications and in-hospital stay.

CONCLUSION

The laparoscopic approach in acute abdomen of gynecologic origin is non-inferior to open surgery.

[Cesarean scar ectopic pregnancy]

OBJECTIVE

To summarize current knowledge about cesarean scar pregnancy and to provide a review about available managements of this serious pregnancy pathology.

DESIGN

Review article.

SETTING

Department of Gynecology and Obstetrics, District Hospital Náchod.

RESULTS

Cesarean scar pregnancy is likely to be a result of impaired healing of the scar along with an increased affinity of trophoblast cells to extracellular matrix. A transvaginal ultrasonography represents a key tool in the cesarean scar pregnancy identification. The main goal of the cesarean scar pregnancy treatment is to preserve fertility. There are different approaches how to manage this pregnancy complication. A surgical treatment is characterized by an exstirpation of ectopic pregnancy. This approach makes a repair of lower uterine segment possible and it may improve a prognosis for subsequent pregnancy. However, the most common management is a conservative treatment with a methotrexate administration. Recently, an innovative mini-invasive treatment with a Foley catheter has been reported. A regular evaluation of βhCG concentrations and a transvaginal ultrasound examination are used for a follow-up. Subsequent pregnancy is possible, yet it should be considered as a high-risk.

CONCLUSION

Despite the fact the frequency of cesarean scar pregnancy increases, cesarean scar pregnancy still represents a rare but serious pregnancy pathology. In case of an early diagnosis, it should be managed with respect to preserve fertility.

[COMPLICATION AFTER UNRECOGNIZED ECTOPIC PREGNANCY--A CASE REPORT]

The authors present a clinical case of performing an abortion at patient with unrecognized ectopic pregnancy and subsequent complication- perforation of the uterus and the colon and life-threatening haemoperitoneum.

Laparoscopic temporary clipping of uterine and ovarian arteries for the treatment of interstitial ectopic pregnancy

PURPOSE OF INVESTIGATION

To assess the effect of laparoscopic temporary clipping of uterine and ovarian arteries for the treatment of interstitial ectopic pregnancy.

MATERIALS AND METHODS

A 29-year-old woman with vaginal bleeding and pelvic pain was admitted to the current clinic. She had secondary amenorrhea for nine weeks. Transvaginal ultrasonography revealed normal empty uterus and right interstitial ectopic pregnancy with viable embryo. Laparoscopic temporary clipping of uterine and ovarian arteries, interstitial pregnancy resection, and primary myometrial suturing was performed.

RESULTS

Following dissection Latzko pararectal space for the visualization of both uterine arteries, four vascular clips were placed (two to uterine arteries, two to infundibulopelvic ligaments). Excision of interstitial pregnancy and primary myometrial suturing was performed with minimal blood loss. The patient was discharged from the hospital after one day without any remarkable complications.

CONCLUSIONS

To the best of the authors' knowledge, this is the first case of interstitial pregnancy that was successfully treated by temporary laparoscopic clipping of uterine and ovarian vessels prior to interstitial ectopic pregnancy resection.

[Clinical comparison of four treatment methods for cesarean scar pregnancy]

OBJECTIVE

To explore the best approach to treatment of cesarean scar pregnancy (CSP).

METHODS

A total of 138 patients with CSP treated between January and December, 2013 were retrospectively analyzed. The patients were treated with conservative drug therapy, direct curettage, uterine curettage after embolization, or open or transvaginal surgery. The amount of blood loss, proportion of patients with blooding loss greater than 50 mL, hospitalization days, and hospitalization expenses were compared among the groups.

RESULTS

The median volume of blood loss was 370 mL in the conservative treatment group, 59 mL in direct curettage group, 67 mL in interventional therapy group, and 1425 mL in the surgical group, and the proportion of patients with blood loss over 50 mL was 76.9%, 38.8%, 27.5%, and 100% in the 4 groups, respectively. The midian hospital stay of the 4 groups was 9.0, 4.0, 6.0 and 10.0 days, with median hospitalization expenses of 12281.0, 3843.5, 14805.0, and 17202.2 RMB Yuan, respectively. All these data were significantly different among the 4 groups (P<0.05).

CONCLUSION

Direct curettage surgery should be encouraged for treatment of CSP. Embolization therapy can reduce the risk of bleeding but is associated with potential complications and more costly, and should be performed with caution. Open or trasnvaginal surgery can be considered in difficult cases of CSP, and its combination with interventional therapy is an option to better preserving the uterus.

[Vaginal impingement of uterine arteries (Zea technique) prior to cervical curettage in cervical ectopic pregnancy: three case report and literature review]

Cervical ectopic pregnancy is a rare and danger clinical presentation because it has high risk of massive bleeding. The incidence is reported in 1:2500 pregnancies and has high relation with a history of cervical dilatation and curettage and assisted reproductive techniques. Advances in ultrasound resolution and use of beta fraction of human chorionic gonadotropin allow early diagnosis and provide conservative treatment with decreased morbidity, mortality and fertility preservation. Various techniques have been reported associated with cervical curettage, to reduce bleeding at the implantation site. In this report three cases of cervical ectopic pregnancy managed with cervical curettage, prior vaginal impingement of uterine arteries (Zea Technique) at the Instituto Nacional de Perinatología Isidro Espinosa de los Reyes are described. The Zea technique represents an effective option in the control of obstetric hemorrhage, including patients diagnosed with cervical ectopic pregnancy in who the bleeding volume decrease after its placement. The Zea Technique is easy to apply and preserves fertility. The success of combining this technique with endocervical curettage for the management of cervical ectopic pregnancy is demonstrated. Training for performing this technique does not require highly specialized or highly complex resources since the required material is the usual every area of obstetric care.

Pregnancy of unknown location: Outcome in a tertiary care hospital

OBJECTIVE

To find out the outcome of a cohort of women with pregnancy of unknown location presenting to a tertiary care hospital.

METHODS

The prospective study was conducted from January to December, 2011, at Early Pregnancy Assessment Unit, King Faisal Military Hospital, Khamis Mushait, Saudi Arabia. Data was collected for women with early pregnancy or with history of amenorrhoea, bleeding or pain. These women were investigated with serum beta-human chorionic gonadotrophin levels twice weekly and transvaginal ultrasonography weekly. Expectant management was done for failing pregnancy of unknown location while medical or surgical management was considered for persistent pregnancy of unknown location and ectopic pregnancy.

RESULTS

During study period, 7215 patients were admitted, and, of them, 2212(30.6%) were patients with early pregnancy. Meeting the inclusion criteria were 183(2.53%) patients who formed the study sample. There were 131(71.6%) patients presenting with amenorrhoea, 90(49.2%) had bleeding and 93(50.8%) presented with pain. Outcome of 100(54.6%) patients was failing pregnancy of unknown location, 58(31.7%) had intrauterine pregnancy, 14(7.7%) converted to ectopic pregnancy, while 11(6%) had persistent pregnancy of unknown location. All patients with persistent pregnancy of unknown location and 5(36%) patients with ectopic pregnancy were medically treated. Five (36%) patients having ectopic pregnancy were managed surgically.

CONCLUSIONS

Management of choice for asymptomatic patients having pregnancy of unknown location is expectant management. Most of the patients suspected to have Most of the patients with persistent pregnancy of unknown location and ectopic pregnancy can be managed medically.