Laparoscopic Management of 42 Cases of Tubal Stump Pregnancy and Postoperative Reproductive Outcomes

Changing Paradigms in the Initial Treatment of Ectopic Pregnancy at a University Hospital in Brazil

OBJECTIVE

 To evaluate the use of different treatment options for ectopic pregnancy and the frequency of severe complications in a university hospital.

METHODS

 Observational study with women with ectopic pregnancy admitted at UNICAMP Womeńs Hospital, Brazil, between 01/01/2000 and 12/31/2017. The outcome variables were the type of treatment (first choice) and the presence of severe complications. Independent variables were clinical and sociodemographic data. Statistical analysis was carried out by the Cochran-Armitage test, chi-square test, Mann-Whitney test and multiple Cox regression.

RESULTS

 In total 673 women were included in the study. The mean age was 29.0 years (± 6.1) and the mean gestational age was 7.7 (± 2.5). The frequency of surgical treatment decreased significantly over time (z = -4.69; p < 0.001). Conversely, there was a significant increase in the frequency of methotrexate treatment (z = 4.73; p < 0.001). Seventy-one women (10.5%) developed some type of severe complication. In the final statistical model, the prevalence of severe complications was higher in women who were diagnosed with a ruptured ectopic pregnancy at admission (PR = 2.97; 95%CI: 1.61-5.46), did not present with vaginal bleeding (PR = 2.45; 95%CI: 1.41-4.25), had never undergone laparotomy/laparoscopy (PR = 6.69; 95%CI: 1.62-27.53), had a non-tubal ectopic pregnancy (PR = 4.61; 95%CI: 1.98-10.74), and do not smoke (PR = 2.41; 95%CI: 1.08-5.36).

CONCLUSION

 there was a change in the first treatment option for cases of ectopic pregnancy in the hospital during the period of analysis. Factors inherent to a disease that is more difficult to treat are related to a higher frequency of severe complications.

Comparisons of Fertility Outcomes Following a Salpingectomy and a Salpingotomy with or Without Suturing for a Tubal Ectopic Pregnancy

Objective

This study aimed to compare fertility outcomes in patients who underwent different laparoscopic surgeries and to determine the most beneficial surgical treatment for tubal ectopic pregnancy (EP) patients who wished to become pregnant in the future.

Methods

In this retrospective study, patients aged 18–36 years, who had been diagnosed with a tubal EP in our hospital, were enrolled. Based on the treatment methods, the patients were divided into three groups, ie a salpingectomy group, a salpingotomy with suturing group and a salpingotomy without suturing group. The follow-up time for the enrolled patients was more than three years. Serum beta (β)-human chorionic gonadotropin (β-HCG) levels were monitored after surgery. The intrauterine pregnancy (IUP) rate at 12, 24 and 36 months postoperatively, and recurrent EP rate were compared.

Results

The median time for β-HCG level returning to normal in the salpingectomy group was much shorter than in the salpingotomy with suturing or salpingotomy without suturing groups (P < 0.001). The 12, 24 and 36-month IUP rates among the three groups were not significantly different. A recurrent EP was found in only one patient in the salpingotomy with suturing group and two patients in the salpingotomy without suturing group.

Conclusion

In this study, we found that salpingectomy and salpingotomy with or without suturing methods reflected no significant differences in fertility outcomes for tubal EP patients.

Time to pregnancy in women with previous ectopic pregnancy undergoing in vitro fertilization treatment: a retrospective cohort study

We aimed to investigate the difference in the time to pregnancy (TTP) between women with previous ectopic pregnancy (EP) and control women following in vitro fertilization (IVF) treatment and the association between TTP and the number of oocytes retrieved and embryos available. A retrospective study involving 1097 women, 547 of which had previous EP and 550 were control women whose previous pregnancy were abortion, was conducted. Women in the EP group had significantly longer median TTP than those in the control group (36; range, 12–252 vs 28; range, 12–220; P = 0.019). For women with previous EP, > 48 months TTP was most likely associated with low numbers of oocytes retrieved and embryos available compared to TTP of ≤ 24 months or 25–48 months, and women with younger age had a shorter TTP, higher numbers of oocytes retrieved and embryos available. A Cox proportional hazards model showed that maternal age was significantly related to the pregnancy over the TTP (adjusted hazard ratio, 0.934; P < 0.001). In conclusion, women with previous EP have a significantly increased TTP than control women with previous abortion. For women with previous EP, TTP is negatively associated with the numbers of oocytes retrieved and embryos available.

How to control cruise ship disease risk? Inspiration from the research literature

The COVID-19 pandemic once brought the global cruise industry to a standstill. This has led to the realization that the development of viable disease risk management policies and measures will guarantee the sustainability of cruise tourism. The purpose of this study is to identify and develop a framework for risk management of cruise ship disease based on the research literature of cruise diseases in the Web of Science from 1996 to 2019. The study analyzed the characteristics of the literature researchers, the relationships between their research institutions organizations, the main cruise ship disease cases and measures. Based on the discussion of COVID-19 on cruise ships，risk management factors of cruise ship diseases were proposed，which include the port country's epidemic prevention capacity, the mode of disease transmission, the relevant regulations on international public health disposal, the design and construction of cruise ships, the medical and health conditions on cruise ships, and the characteristics of cruise tourism activities. A timeline and system framework for cruise ship disease risk management is proposed. A special "maritime mobile community prevention and control system" should be established, and a cooperation mechanism consisting of the government, non-governmental organizations, trade groups and industry experts should be established. The port should be capable of border isolation, detection and establishment of temporary shelter hospitals. At the same time, big data technologies such as disease tracking, investigation and health data are also important components of the risk management system.

Laparoscopic Management of a Heterotopic Pregnancy in the Tubal Stump

STUDY OBJECTIVE

To demonstrate how a heterotopic tubal stump pregnancy can be safely managed with laparoscopy, preserving the intrauterine pregnancy.

DESIGN

Stepwise demonstration of the technique by means of a video tutorial.

SETTING

The management of pregnancies in the tubal stump after salpingectomy involves either a surgical intervention or systemic therapy. In case of a simultaneous intrauterine pregnancy, although the prognosis for the fetus remains good with live births in approximately 70% of the cases, the surgical management of the tubal stump pregnancy is challenging owing to the risk of bleeding from the uterine horn [1-5]. We present an effective and reproducible laparoscopic technique on the basis of a 31-year-old patient with 2 prior right fallopian tube pregnancies, which were later treated with salpingectomy. The patient is now presenting in the sixth week of gestation after transfer from 2 oocytes with a pregnancy in the tubal stump and a concomitant vital intrauterine pregnancy.

INTERVENTIONS

The key steps of laparoscopic surgery include (1) continuous absorbable monofilament suture on the uterine horn around the tubal stump to achieve hemostasis and exposure of the proximal part of the tube, (2) removal of ectopic pregnancy, and (3) closure of the excision site with continuous absorbable polyfilament suture. The instillation of vasoconstrictive substances and the use of electrical coagulation should be avoided.

CONCLUSION

The demonstrated laparoscopic technique is a feasible method of removal of a tubal stump pregnancy without interfering with the vital intrauterine pregnancy. The blood loss can be minimized, and laparotomy can be avoided.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Tubal Stump Pregnancy

OBJECTIVE

To demonstrate a case of left tubal stump pregnancy successfully treated using our 2-step technique for transvaginal natural orifice transluminal endoscopic surgery (vNOTES).

DESIGN

Demonstration of the technique using surgical video footage.

SETTING

Tertiary university hospital.

INTERVENTIONS

A 27-year-old gravida 3 para 0 patient with a history of laparotomy, left salpingectomy owing to a ruptured tubal pregnancy, was referred to our hospital because of a pregnancy of unknown location. Her serum β human chorionic gonadotropin level was 8400 U/L, and a transvaginal ultrasound revealed an ectopic pregnancy in the left tubal stump. After discussing medical and surgical treatment options, the patient underwent a 2-step vNOTES approach. First, a diagnostic vNOTES was performed using a 5-mm trocar with autoretracting blade. After confirmation of the diagnosis, the trocar was removed, and the incision was enlarged with blunt dissection. A self-constructed pessary port was then placed through the enlarged colpotomy, and the ectopic pregnancy in the left tubal stump was excised using an advanced bipolar device. The colpotomy was closed with running resorbable sutures. The duration of the surgery was 36 minutes, and the patient was discharged on postoperative day 1 without any complications.

CONCLUSION

Tubal stump pregnancy is a rare form of ectopic pregnancy with an incidence of approximately 0.4% of all ectopic pregnancies [1]. Treatment options include conservative medical management using methotrexate and surgery. Successful surgical treatment using laparoscopy has been previously reported [1,2]. This case demonstrates that vNOTES may be a minimally invasive option for the surgical treatment of tubal stump pregnancy in selected cases.