Ectopic pregnancies after infertility treatment: modern diagnosis and therapeutic strategy

Challenges in the diagnosis and management of a ruptured heterotopic gestation following ultrasound-guided embryo transfer in low resource settings: a case report

BACKGROUND

Heterotopic pregnancies are increasing in incidence with the advent of rising prevalence of in vitro fertilization and embryo transfer (IVF-ET) globally. Although rare, this condition is a serious potentially life-threatening gynaecological complication.

CASE PRESENTATION

We present the case of a 36-year-old Ghanaian woman who conceived following IVF and presented two weeks after confirmation of intrauterine gestation with sudden onset lower abdominal pain. A diagnosis of ruptured heterotopic pregnancy was made, laparotomy and salpingectomy was done followed with further management of the intrauterine gestation.

CONCLUSION

To the best of our knowledge, this is the first reported case of heterotopic pregnancy in Ghana. A high index of suspicion for heterotopic pregnancy is required even in the presence of a confirmed intrauterine gestation following IVF-ET.

Comparison of laparoscopic and open approach in the treatment of heterotopic pregnancy following embryo transfer

PURPOSE

Heterotopic pregnancy (HP) is a rare disease with the coexistence of an intrauterine and ectopic embryos. There is no consensus on the optimal treatment of HP at present. This research aimed to compare the perioperative and pregnancy outcomes of laparoscopic (LA) and open approach (OA) in patients with HP after embryo transfer.

METHODS

Women with HP receiving surgical treatment (LA or OA) were retrospectively recruited in this study between October 2006 and December 2020. The demographic, perioperative and obstetric data were collected and compared between LA and OA group.

RESULTS

Totally, 86 patients were included in this study. Among these patients, 62 underwent LA and 24 underwent OA. There was an increase in the adoption of LA between the 2006-2012 period and the 2013-2020 period [25% (6/24) vs. 90% (56/62), p < 0.001]. Compared with OA, patients treated by LA had much less blood loss [20 (10-50) vs. 30 (20-50) ml, p = 0.036] and fewer days of hospital stay [5.0 (4.0-7.3) vs. 9.5 (7-15.3) days, p < 0.001], but a relatively higher cost (15,580 ± 3196¥ vs. 11,717 ± 3820¥, p < 0.001). During the laparoscopic procedure, no one needed to be converted to open surgery. However, the rates of first trimester miscarriage, preterm, cesarean section, birth weight, 1- and 5-min Apgar were similar between LA and OA group (all p > 0.05).

CONCLUSIONS

Compared with open approach, laparoscopy was shown to provide a comparable pregnancy outcomes and a better performance on perioperative outcomes in the treatment of HP patients with embryo transfer.

Role of Ultrasound in the Assessment and Differential Diagnosis of Pelvic Pain in Pregnancy

Pelvic pain (PP) is common in pregnant women and can be caused by several diseases, including obstetrics, gynaecological, gastrointestinal, genitourinary, and vascular disorders. Timely and accurate diagnosis as well as prompt treatment are crucial for the well-being of the mother and foetus. However, these are very challenging. It should be considered that the physiological changes occurring during pregnancy may confuse the diagnosis. In this setting, ultrasound (US) represents the first-line imaging technique since it is readily and widely available and does not use ionizing radiations. In some cases, US may be conclusive for the diagnosis (e.g., if it detects no foetal cardiac activity in suspected spontaneous abortion; if it shows an extrauterine gestational sac in suspected ectopic pregnancy; or if it reveals a dilated, aperistaltic, and blind-ending tubular structure arising from the cecum in suspicious of acute appendicitis). Magnetic resonance imaging (MRI), overcoming some limits of US, represents the second-line imaging technique when an US is negative or inconclusive, to detect the cause of bowel obstruction, or to characterize adnexal masses.

Imaging of complications following treatment with assisted reproductive technology: keep on your radar at each step

Since the advent of assisted reproductive technology (ART), the utilization of ART procedures has become increasingly popular among women seeking to establish pregnancy. Radiologists are therefore likely to encounter the various complications of ART therapy. The most common is ovarian hyperstimulation syndrome; others are multiple, ectopic, and heterotopic pregnancies. Ultrasonography is considered the initial modality to investigate ART complications, However, nonspecific symptoms might need the use of an additional imaging modality, such as computed tomography or magnetic resonance imaging, as a problem-solving tool. This article briefly discusses the steps involved in assisted reproduction. Its aim is to help radiologists become familiarized with the multimodality imaging features of the spectrum of ART-related complications. Their key imaging features and differential considerations are emphasized. This will facilitate the provision of precise and timely diagnoses, and aid the avoidance of fatal consequences.

The many faces of ectopic pregnancies: demystifying the common and less common entities

Ectopic pregnancy is a major cause of 1st trimester pregnancy deaths. It occurs in various locations in the abdominopelvic cavity. Ultrasonography is a first-line, rapid, and noninvasive modality for ectopic pregnancy evaluation. MRI can help clarify equivocal cases. When in doubt about the location, one should give an intrauterine pregnancy the benefit of the doubt with close ultrasound and hCG follow-up. Here, we will review the imaging findings and mimickers of ectopic pregnancies.

Heterotopic pregnancy: a case report

Background

Heterotopic pregnancy describes the occurrence of two pregnancies in different implantation sites simultaneously, which is rare, yet it is a challenge to diagnose such a problem due to complex clinical and laboratory findings. In the current study, we present a case of first trimester heterotopic pregnancy diagnosed by ultrasound (US) and magnetic resonance imaging (MRI) and was managed successfully.

Case presentation

A 22-year-old primigravida lady with spontaneous pregnancy was presented by increasing lower abdominal pain for 5 days with brownish vaginal discharge, nausea, and vomiting episodes. Trans-abdominal and endovaginal ultrasound was performed and revealed a viable intrauterine pregnancy of 8 weeks and 1 day, associated with a heterogeneous complex right adnexal mass. MR imaging revealed a right adnexal mass intimately anterior to the normal right ovary. Laparascopy was done; it revealed a distended right fallopian tube with pregnancy while the right ovary was not seen (impeded in the pouch of Douglas), and right salpingectomy was done. The specimen was sent for histopathology. The patient tolerated the procedure well and was then taken to the recovery room in stable condition. The histopathological report confirmed the diagnosis of ectopic pregnancy.

Conclusion

However, heterotopic is a rare condition, any pregnant woman presenting with alarming abdominal pain and adnexal abnormality; heterotopic pregnancy should be among the differential diagnosis possibilities. The patient should be thoroughly investigated using ultrasound and MRI if needed, to exclude this rare diagnosis and allow on-time proper management.

Risk factors and clinical characteristics of recurrent ectopic pregnancy: A case-control study

OBJECTIVE

To compare signs and symptoms between patients with recurrent ectopic pregnancies (REP) and primary ectopic pregnancies (PEP) and to identify potential risk factors of REP.

MATERIALS AND METHODS

Data from 2014 to 2016 were analyzed. The study included 81 women each diagnosed with REP and PEP with no recurrence of ectopic pregnancy (EP) before January 2019. Information, including historical factors and findings at presentation of both group were collected. Data were compared between the two groups. Associations between REP and the risk factors were analyzed by logistic regression.

RESULTS

The findings revealed that compared to the patients in the PEP group, REP patients had significantly lower education (P = 0.001), higher proportion of previous infertility (P < 0.001) and different methods of PEP treatment (P = 0.001). Clinical data of the last operation revealed significantly higher occurrences of pelvic and peritubal adhesions (P < 0.05). Further multiple regression analysis showed that lower educational background (odds ratio [OR] = 4.183 95% confidence interval [CI] 1.311-13.344 P = 0.016), nulliparity (OR = 12.312 95% CI 3.382-44.824 P < 0.001), history of salpingotomy (OR = 7.129 95% CI 1.022-49.748 P < 0.05) and abortion (OR for one abortion = 21.576, P = 0.001; OR for two abortions =36.794, P < 0.001; OR for three abortions or more = 119.013, P < 0.001) were significant risk factors for REP.

CONCLUSION

Active education on contraception is required for patients with lower educational level and history of abortion. Different plans should be formulated for patients with EP. For EP patients wanting fertility, the risk between fertility preservation and REP needs to be evaluated as reproductive function cannot be pursued blindly while ignoring the risk of recurrence.

Laparoscopic Strategy for Heterotopic Interstitial Pregnancy Following Assisted Reproductive Techniques

Background and Objectives

Heterotopic interstitial pregnancy (HIP) is a rare but potentially life-threatening condition that occurs more commonly in the setting of assisted reproductive technology (ART). It is significant to introduce a safe and effective laparoscopic strategy to manage HIP following the use of ART.

Methods

This study included 9 cases of patients with HIP who underwent laparoscopic management in our department. Our approach involves placement of a purse-string suture around the cornua of the uterus followed by removal of the interstitial pregnancy using a flushing technique. This is followed by repair of the uterine cornua, leaving the intrauterine pregnancy (IUP) undisturbed. The outcomes were reported regarding surgical complications during the procedure as well as outcomes for the remaining IUP including gestational age at delivery and any neonatal adverse events.

Results

Five of the 9 cases were asymptomatic at presentation. All cases underwent laparoscopic management with successful removal of the interstitial gestational product and preservation of the IUP. With the exception of one case that was lost to followup, all cases resulted in full-term delivery. The average intraoperative blood loss was 24.44 ± 14.23 mL and the average operation time was 70.44 ± 22.48 minutes. There were no postoperative complications, including persistent ectopic pregnancy, rupture of the uterus, spontaneous abortion, or preterm delivery. All newborns for whom data was available were healthy.

Conclusion

This laparoscopic strategy is a safe, relatively simple, effective, and minimally invasive approach to address the challenging case of HIP after ART in the first trimester.

Multimodality imaging of acute locoregional and systemic complications in the setting of assisted reproduction

Over the past 40 years since the first in vitro fertilization was performed, both the role of assisted reproductive technology (ART) in establishing viable pregnancy as well as the available treatment options have expanded enormously. Annually in the USA, nearly 2% of pregnancies now employ some form of ART assistance, with in vitro fertilization (IVF) being the most commonly utilized methodology. Both maternal and fetal risks are elevated in ART pregnancies, the latter including adverse outcome due to both increased gestational number as well as advanced maternal age. Maternal risks may be divided into locoregional and systemic complications. Adverse pelvic complications include those relating to gamete harvesting and transfer, ovarian hyperstimulation, the sequela of ectopic and heterotopic pregnancies, as well as ovarian torsion, all of which are elevated in the ART cohort. Ovarian hyperstimulation syndrome is the most commonly encountered complication, with both systemic and pelvic features relating to increased vascular permeability, hemoconcentration, and ascites. While life-threatening cases are relatively rare, moderate and severe manifestations may occur in up to 10% of ART cycles and, as such, are a not infrequent cause for ER visitation. Familiarity with the clinical and imaging manifestations of ART complications as well as their prognostic implications will facilitate a timely diagnosis and assist the interpreting radiologist in best expediting appropriate clinical care. In this article, we will briefly discuss the current methodology of ART then present an imaging-based multimodality review of the potentially encountered adverse maternal sequela, highlighting key diagnostic features and differential considerations as well as potential prognostic implications.

Risk factors for recurrent ectopic pregnancy: a case-control study

OBJECTIVE

To study the risk factors for recurrent ectopic pregnancy (REP).

DESIGN

A retrospective case-control study.

SETTING

A university medical centre.

POPULATION

554 women with a history of ectopic pregnancy (EP) were included. Among them were 181 women with current EP, 184 women with current intrauterine pregnancy (IUP) and 189 nonpregnant women (NonP).

METHODS

The three groups were matched at a ratio of 1:1 with respect to current age, age of initial EP and gestational week of initial EP. Socio-demographic characteristics, reproductive history, gynaecological and surgical history, and experience of contraception were compared among the three groups. A multivariable logistic regression analysis was used to adjust for confounders and calculate adjusted odds ratios (AORs).

RESULTS

The risk of REP increased with history of infertility (AOR = 3.84, 95%CI 2.16-6.86) in REP women compared with IUP controls. Compared with NonP controls, salpingotomy (AOR = 3.04, 95%CI 1.21-36.51) for previous EP was a risk factor for REP. Multiparous women were less likely to suffer REP when compared with NonP women (AOR = 0.36, 95%CI 0.18-0.62) or IUP controls (AOR = 0.35, 95%CI 0.20-0.62). Current use of an intrauterine device (IUD) (REP versus NonP, AOR = 0.02, 95%CI 0.00-0.08) or condoms (REP versus NonP, AOR = 0.16, 95%CI 0.07-0.38) significantly reduced the risk of REP compared with those not using any contraception. Similarly, previous use of condoms also prevented REP compared with those with no previous condom use (REP versus NonP, AOR = 0.20, 95%CI 0.08-0.49; REP versus IUP, AOR = 0.40, 95%CI 0.22-0.71).

CONCLUSIONS

Women with history of infertility or salpingotomy should be alert for the recurrence of EP. Multiparous women are less likely to suffer REP. We propose the use of condoms for effective prevention of REP.

TWEETABLE ABSTRACT

History of infertility and salpingotomy for last EP are risk factors for recurrent EP.

Spontaneous heterotopic triplets - A review of literature

OBJECTIVE

Spontaneous heterotopic triplets, a tubal ectopic pregnancy and a twin pregnancy, are rare disorders. The study aimed to examine all available evidence regarding signs and symptoms, imaging findings, management and newborn outcome of spontaneous heterotopic triplets.

DESIGN

A literature search in Medline and EMBASE databases from 2000 to 2016 was conducted. The following key words were employed: 'spontaneous heterotopic pregnancy', OR 'heterotopic triplets'. Only cases of spontaneous heterotopic triplets without assisted reproduction techniques were included.

RESULTS

Six cases were identified and included in the present review. All cases presented with abdominal pain and one case presented in shock. Hemoperitoneum was present in five cases. Laterouterine mass with adnexal gestational sac is not systematically described (3 cases/6), but was a good ultrasonographic sign of heterotopic pregnancy. All patients had tubal rupture, but anyone had vaginal bleeding. The surgical treatment was made by salpingectomy in five cases to ensure successful treatment. The mean and median gestational age at delivery were 29.9 and 37.54 weeks, respectively (range 6-41 weeks). The neonatal outcome was good for 6 newborns.

CONCLUSION

Spontaneous heterotopic triplets are rare. Early surgical intervention is the key to successful treatment of heterotopic triplet pregnancy and allows good neonatal outcome.

Pitfalls and tips in the diagnosis of ectopic pregnancy

Women of reproductive age with pelvic pain, vaginal bleeding, and a positive pregnancy test often require evaluation with pelvic ultrasound. In these situations, the primary role of pelvic ultrasound is to differentiate an ectopic pregnancy from either a normal or abnormal intrauterine pregnancy. While an accurately performed and interpreted pelvic ultrasound results in rapid diagnosis and management, numerous diagnostic pitfalls can lead to negative outcomes. Therefore, familiarity with the appropriate laboratory tests, sonographic technique, and imaging features of ectopic pregnancy is essential for all radiologists. We present a review of ectopic pregnancy cases from our institution with attention to common pitfalls and troubleshooting tips for physicians who perform and interpret pelvic ultrasounds. We also present recently published literature to aid in the management of first trimester pregnancy.

Extrauterine Choriocarcinoma in the Fallopian Tube Following Infertility Treatment: Implications for the Management of Early-Detected Ectopic Pregnancies

Extrauterine choriocarcinoma in the fallopian tube is very rare and is often diagnosed and treated as an ectopic tubal pregnancy. A 34-year-old woman who initially became pregnant after infertility treatment using ovulation induction with clomiphene citrate and intrauterine insemination was later diagnosed with an extrauterine choriocarcinoma in the left fallopian tube. Because of suspected left ectopic tubal pregnancy based on ultrasonography findings and a high level of β-human chorionic gonadotropin (β-hCG; 7054.3 mIU/mL), the patient underwent diagnostic laparoscopy at a gestational age of 6 weeks. Left salpingectomy was performed based on the operative diagnosis of an ectopic tubal pregnancy. No signs of tubal rupture or leakage of contents from the fallopian tube were observed during the operation. Her serum β-hCG dropped to 10.3 mIU/mL at 15 days postoperatively. Histopathology demonstrated an extrauterine choriocarcinoma in the removed fallopian tube, and the patient was referred to a regional oncologic hospital to receive additional adjuvant chemotherapy. This case indicates that conservative treatment for ectopic pregnancy should be chosen carefully, and that histopathology diagnosis and appropriate β-hCG monitoring following treatment are important not only to diagnose persistent ectopic pregnancy, but also to rule out the possibility of a tubal choriocarcinoma.

Ectopic pregnancy following in vitro fertilization: meta-analysis and single-center experience during 6 years

BACKGROUND

Ectopic pregnancy (EP) has been reported to occur in 1.4-5.4% of all clinical pregnancies resulting from in vitro fertilization (IVF) and embryo transfer (ET). Data on factors associated with abnormal embryo implantation following assisted conception are limited.

MATERIALS AND METHODS

A systematic review and meta-analysis was performed to determine whether there is an association between the day (cleavage-stage, D3, versus blastocyst, D5) or the type (fresh versus frozen/thawed) of ET and EP rate. Risk factors for EP were evaluated in a retrospective study of 1194 women, who achieved pregnancy at our IVF unit between 2010 and 2016.

RESULTS

Sixteen papers were considered for the meta-analysis. EP rate did not differ between D3 and D5 fresh ET groups (RR = 0.99, 95%CI: 0.76-1.30) and was higher after fresh versus frozen ET (RR = 1.56, 95%CI: 1.25-1.95). At our clinic, 21 (1.76%) pregnancies were documented as ectopic. The risk of EP was associated with tubal pathology (OR = 3.37, 95%CI: 1.39-8.2), previous appendectomy and past chlamydial infection.

CONCLUSIONS

Present meta-analysis suggests that EP rate is similar following fresh blastocyst and cleavage ETs, but is significantly reduced after frozen compared with fresh ET. Our own findings demonstrate that tubal pathology has the major impact on EP occurrence following assisted conception.

Incidence, diagnosis and management of tubal and nontubal ectopic pregnancies: a review

BACKGROUND

Ectopic pregnancy is a potentially life-threatening condition occurring in 1-2 % of all pregnancies. The most common ectopic implantation site is the fallopian tube, though 10 % of ectopic pregnancies implant in the cervix, ovary, myometrium, interstitial portion of the fallopian tube, abdominal cavity or within a cesarean section scar.

FINDINGS

Diagnosis involves a combination of clinical symptoms, serology, and ultrasound. Medical management is a safe and effective option in most clinically stable patients. Patients who have failed medical management, are ineligible, or present with ruptured ectopic pregnancy or heterotopic pregnancy are most often managed with excision by laparoscopy or, less commonly, laparotomy. Management of nontubal ectopic pregnancies may involve medical or surgical treatment, or a combination, as dictated by ectopic pregnancy location and the patient's clinical stability. Following tubal ectopic pregnancy, the rate of subsequent intrauterine pregnancy is high and independent of treatment modality.

CONCLUSION

This review describes the incidence, risk factors, diagnosis, and management of tubal and non-tubal ectopic and heterotopic pregnancies, and reviews the existing data regarding recurrence and future fertility.

Risk of ectopic pregnancy lowest with transfer of single frozen blastocyst

STUDY QUESTION

What type of transferred embryo is associated with a lower rate of ectopic pregnancy?

SUMMARY ANSWER

The lowest risk of ectopic pregnancy was associated with the transfer of blastocyst, frozen and single embryo compared with cleavage stage, fresh and multiple embryos.

WHAT IS KNOWN ALREADY

Ectopic pregnancy is a recognized complication following assisted reproductive technology (ART) treatment. It has been estimated that the rate of ectopic pregnancy is doubled in pregnancies following ART treatment compared with spontaneous pregnancies. However, it was not clear whether the excess rate of ectopic pregnancy following ART treatment is related to the underlying demographic factors of women undergoing ART treatment, the number of embryos transferred or the developmental stage of the embryo.

STUDY DESIGN, SIZE, DURATION

A population-based cohort study of pregnancies following autologous treatment cycles between January 2009 and December 2011 were obtained from the Australian and New Zealand Assisted Reproduction Technology Database (ANZARD). The ANZARD collects ART treatment information and clinical outcomes annually from all fertility centres in Australia and New Zealand.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Between 2009 and 2011, a total of 44 102 pregnancies were included in the analysis. The rate of ectopic pregnancy was compared by demographic and ART treatment factors. Generalized linear regression of Poisson distribution was used to estimate the likelihood of ectopic pregnancy. Odds ratios, adjusted odds ratios (AOR) and 95% confidence intervals (CI) were calculated.

MAIN RESULTS AND THE ROLE OF CHANCE

The overall rate of ectopic pregnancy was 1.4% for women following ART treatment in Australia and New Zealand. Pregnancies following single embryo transfers had 1.2% ectopic pregnancies, significantly lower than double embryo transfers (1.8%) (P < 0.01). The highest ectopic pregnancy rate was 1.9% for pregnancies from transfers of fresh cleavage embryo, followed by transfers of frozen cleavage embryo (1.7%), transfers of fresh blastocyst (1.3%), and transfers of frozen blastocyst (0.8%). Compared with fresh blastocyst transfer, the likelihood of ectopic pregnancy was 30% higher for fresh cleavage stage embryo transfers (AOR 1.30, 95% CI 1.07-1.59) and was consistent across subfertility groups. Transfer of frozen blastocyst was associated with a significantly decreased risk of ectopic pregnancy (AOR 0.70, 95% CI 0.54-0.91) compared with transfer of fresh blastocyst.

LIMITATIONS, REASON FOR CAUTION

A limitation of this population-based study is the lack of information available on clinical- specific protocols and processes for embryo transfer (i.e. embryo quality, cryopreservation protocol, transfer techniques, etc.) and the potential impact on outcomes.

WIDER IMPLICATIONS OF THE FINDINGS

The lowest risk of ectopic pregnancy was associated with the transfer of a single frozen blastocyst. This finding adds to the increasing evidence of better perinatal outcomes following frozen embryo transfers. The approach of freezing all embryos in the initiated fresh cycle and transfer of a single frozen blastocyst in the subsequent thaw cycle may improve the overall pregnancy and birth outcomes following ART treatment, in part by reducing the ectopic pregnancy rate.

STUDY FUNDING/COMPETING INTERESTS

There is no funding for this study. Authors declared no competing interest related to this study.

A Case of Secondary Abdominal Pregnancy after in Vitro Fertilization Pre-Embryo Transfer (IVF-ET)

The authors describe a rare case of secondary abdominal pregnancy after in vitro fertilization pre-embryo transfer (IVF-ET). Ultrasonography was applied to image ectopic gestational sac containing a yolk vesicle and located adjacent to the anterior uterine wall and left adnexa. Laparoscopy was done on the same day followed by sinistral salpingectomy due to tubal abortion indications. Intraabdominal examination showed chorionic structures penetrating pl. vesicouterina. Histological tests confirmed the EP diagnosis in the second material, i.e. indications of secondary abdominal pregnancy.

Uncommon Implantation Sites of Ectopic Pregnancy: Thinking beyond the Complex Adnexal Mass

Ectopic pregnancy occurs when implantation of the blastocyst takes place in a site other than the endometrium of the uterine cavity. Uncommon implantation sites of ectopic pregnancy include the cervix, interstitial segment of the fallopian tube, scar from a prior cesarean delivery, uterine myometrium, ovary, and peritoneal cavity. Heterotopic and twin ectopic pregnancies are other rare manifestations. Ultrasonography (US) plays a central role in diagnosis of uncommon ectopic pregnancies. US features of an interstitial ectopic pregnancy include an echogenic interstitial line and abnormal bulging of the myometrial contour. A gestational sac that is located below the internal os of the cervix and that contains an embryo with a fetal heartbeat is indicative of a cervical ectopic pregnancy. In a cesarean scar ectopic pregnancy, the gestational sac is implanted in the anterior lower uterine segment at the site of the cesarean scar, with thinning of the myometrium seen anterior to the gestational sac. An intramural gestational sac implants in the uterine myometrium, separate from the uterine cavity and fallopian tubes. In an ovarian ectopic pregnancy, a gestational sac with a thick hyperechoic circumferential rim is located in or on the ovarian parenchyma. An intraperitoneal gestational sac is present in an abdominal ectopic pregnancy. Intra- and extrauterine gestational sacs are seen in a heterotopic pregnancy. Two adnexal heartbeats suggest a live twin ectopic pregnancy. Recognition of the specific US features will help radiologists diagnose these uncommon types of ectopic pregnancy.

Effect of second-look laparoscopy on subsequent fertility outcome after laparoscopic salpingostomy for tubal pregnancy: a randomized controlled study

OBJECTIVE

To clarify the potential value of second-look laparoscopy (SLL) in improving fertility outcomes after laparoscopic salpingostomy for tubal pregnancy.

DESIGN

Randomized controlled trial.

SETTING

West China Second University Hospital, Sichuan University.

PATIENTS

216 women with future birth demand who underwent laparoscopic salpingostomy for tubal pregnancy.

INTERVENTIONS

SLL was performed in the SLL group at 3 months after the primary surgery.

MEASUREMENT AND MAIN RESULTS

In both the SLL and control groups, the subjects were assigned to a slight adhesion (SLA) or severe adhesion (SEA) subgroup. At 3-year follow-up, the fertility outcomes were compared between the SLL and control groups and also between the SLA and SEA subgroups. The intrauterine pregnancy rate was higher in the SLL group compared with the control group (63.1% vs 48.6%; p = .032), and the incidence of recurrent ectopic pregnancy was lower in the SLL group than in the control group (6.3% vs 16.2%; p = .021). In the control group, the cumulative pregnancy rate was higher in the SLA subgroup compared with the SEA subgroup (p = .017), but in the SLL group, the cumulative pregnancy rate did not differ between the 2 subgroups (p = .502). The cumulative pregnancy rate was higher in the SEA subgroup of the SLL group compared with the SEA subgroup of the control group (p = .014), but did not differ between the SLA subgroup of the SLL group and the SLA subgroup of the control group (p = .456).

CONCLUSION

SLL may improve subsequent fertility outcome after laparoscopic salpingostomy for tubal pregnancy, and may be especially recommended for women with severe and extensive pelvic adhesions.

The regulation of nitric oxide synthase isoform expression in mouse and human fallopian tubes: potential insights for ectopic pregnancy

Nitric oxide (NO) is highly unstable and has a half-life of seconds in buffer solutions. It is synthesized by NO-synthase (NOS), which has been found to exist in the following three isoforms: neuro nitric oxide synthase (nNOS), inducible nitric oxide synthase (iNOS), and endothelial nitric oxide synthase (eNOS). NOS activity is localized in the reproductive tracts of many species, although direct evidence for NOS isoforms in the Fallopian tubes of mice is still lacking. In the present study, we investigated the expression and regulation of NOS isoforms in the mouse and human Fallopian tubes during the estrous and menstrual cycles, respectively. We also measured isoform expression in humans with ectopic pregnancy and in mice treated with lipopolysaccharide (LPS). Our results confirmed the presence of different NOS isoforms in the mouse and human Fallopian tubes during different stages of the estrous and menstrual cycles and showed that iNOS expression increased in the Fallopian tubes of women with ectopic pregnancy and in LPS-treated mice. Elevated iNOS activity might influence ovulation, cilia beats, contractility, and embryo transportation in such a manner as to increase the risk of ectopic pregnancy. This study has provided morphological and molecular evidence that NOS isoforms are present and active in the human and mouse Fallopian tubes and suggests that iNOS might play an important role in both the reproductive cycle and infection-induced ectopic pregnancies.

Ultrasound imaging in the management of bleeding and pain in early pregnancy

Bleeding and pain are experienced by 20% of women during the first trimester of pregnancy. Although most pregnancies complicated by pain and bleeding tend to progress normally, these symptoms are distressing for woman, and they are also associated with an increased risk of miscarriage and ectopic pregnancy. Ultrasound is the first and often the only diagnostic modality that is used to determine location of early pregnancy and to assess its health. Ultrasound is an accurate, safe, painless and relatively inexpensive diagnostic tool, which all contributed to its widespread use in early pregnancy. Pain and bleeding in early pregnancy are sometimes caused by concomitant gynaecological, gastrointestinal, and urological problems, which could also be detected on ultrasound scan. In women with suspected intra-abdominal bleeding, ultrasound scan can be used to detect the presence of blood and provide information about the extent of bleeding. In this chapter, we comprehensively review the use of ultrasound in the diagnosis and management of early pregnancy complications. We include information about the diagnosis of gynaecological and other pelvic abnormalities, which could cause pain or bleeding in pregnancy. We also provide a summary of the current views on the safety of ultrasound in early pregnancy.

Emergent complications of assisted reproduction: expecting the unexpected

With the increasing popularity of assisted reproductive technology (ART), radiologists are more likely to encounter associated complications, especially in an emergency setting. These complications include ovarian hyperstimulation syndrome (OHSS), ovarian torsion, and ectopic and heterotopic pregnancy. OHSS occurs following ovulation induction or ovarian stimulation and manifests with bilateral ovarian enlargement by multiple cysts, third-spacing of fluids, and clinical findings ranging from gastrointestinal discomfort to life-threatening renal failure and coagulopathy. Enlarged hyperstimulated ovaries are at risk for torsion. Clinical symptoms are often nonspecific, and ovarian torsion should be suspected and excluded in any female patient undergoing infertility treatment who presents with severe abdominal pain. The most consistent imaging finding is asymmetric enlargement of the twisted ovary. There is also an increased risk for ectopic pregnancy following ART, with a relative increased risk for rarer and more lethal forms, including interstitial and cervical ectopic pregnancies. Heterotopic pregnancy refers to simultaneous intrauterine and ectopic pregnancies and has an incidence of 1%-3% in ART patients. Careful evaluation of the adnexa is critical in this patient population, even when an intrauterine pregnancy has been confirmed. Ultrasonography is the first-line imaging modality for the evaluation of complications of ART, although nonspecific symptoms may sometimes lead to cross-sectional imaging being performed. Familiarity with the multimodality imaging appearance of these entities will allow accurate and timely diagnosis and help avert potentially fatal consequences.

The association between polycystic ovary syndrome and ectopic pregnancy after in vitro fertilization and embryo transfer

OBJECTIVE

We sought to assess the association between polycystic ovary syndrome (PCOS) and ectopic pregnancy after in vitro fertilization-embryo transfer (ET).

STUDY DESIGN

In this retrospective cohort study, we included 5339 women who had clinical pregnancies after in vitro fertilization treatment (PCOS, 205 women; non-PCOS, 5134 women) at Nanjing Medical University (China) between 2007 and 2011. Fresh and cryo-thawed ET cycles were analyzed respectively. The primary outcome measure was the occurrence of ectopic pregnancy. Multivariate logistic regression analysis was used to adjust for important confounders.

RESULTS

In fresh ET cycles of women who were undergoing controlled ovarian hyperstimulation (COH; n = 3303), women with PCOS had 3.06 times higher risk of ectopic pregnancy compared with those without PCOS (7.0% vs 2.4%; adjusted odds ratio [aOR], 3.06; 95% confidence interval [CI], 1.34-6.96). In the stratified analysis, for women without PCOS, the high estradiol group (>4085 pg/mL) had higher ectopic pregnancy rates compared with the low estradiol group (≤4085 pg/mL; 3.4% vs 2.0%; aOR, 1.99; 95% CI, 1.19-3.35); however, for women with PCOS, both high and low estradiol groups had high ectopic pregnancy rates (5.6% vs 7.7%; aOR, 0.92; 95% CI, 0.15-5.67). In cryo-thawed ET cycles without COH (n = 2036), the ectopic rates between women with and without PCOS were similar (2.2% vs 2.0%; aOR, 0.94; 95% CI, 0.22-4.07).

CONCLUSION

PCOS was associated with an increased risk of ectopic pregnancy after COH in fresh ET cycles, but not in cryo-thawed ET cycles. A possible explanation is that, compared with women without PCOS, women with PCOS appear to hold a lower threshold of hyperphysiologic estradiol level that triggers the occurrence of ectopic pregnancy after COH.

MR imaging findings of ectopic pregnancy: a pictorial review

Because of its lack of ionizing radiation and excellent soft-tissue contrast, magnetic resonance (MR) imaging is being increasingly used in the evaluation of acute abdominal pain in the pregnant patient. Roughly 2% of all pregnancies are ectopic. Although ectopic pregnancy is usually diagnosed on the basis of a combination of clinical, laboratory, and ultrasonographic findings, it occasionally is initially identified at MR imaging. Thus, it is imperative that the radiologist should be familiar with the variable appearance of ectopic pregnancy at MR imaging and should evaluate for ectopic pregnancy at any time when (a) a patient has positive results of a pregnancy test and (b) an intrauterine pregnancy is not definitively seen. Because of potential issues of fetal safety, a conservative approach should be used for MR imaging in pregnancy. An MR imaging protocol for the evaluation of possible appendicitis in pregnant women is detailed. Specific findings that can aid in the diagnosis of ectopic pregnancy are the lack of an intrauterine pregnancy, isolated hemoperitoneum, tubal masses, hematosalpinx, and interstitial masses. In the differential diagnosis of acute abdominal pain in pregnancy, consideration should be given to the more unusual forms of ectopic pregnancy, such as angular pregnancy, cornual pregnancy, and abdominal pregnancy. Potential mimics of ectopic pregnancy include placental abnormalities, ovarian neoplasms, and corpus luteum cysts.

Diagnosis of heterotopic pregnancy using ultrasound and magnetic resonance imaging in the first trimester of pregnancy: a case report

Heterotopic pregnancy is a condition characterized by implantation of one or more viable embryos into the uterine cavity while another one is implanted ectopically, particularly into the uterine tube. Its occurrence has increased drastically over the last few years due to assisted reproduction procedures. In general, the diagnosis is made during the first trimester by using endovaginal two-dimensional ultrasound (2DUS), through observing a complex para- or retrouterine mass in association with a viable uterine pregnancy. However, under some conditions such as atypical ultrasonographic presentations, 2DUS does not clarify the situation whereas magnetic resonance imaging (MRI) of the pelvis is able to do so. We present the case of a pregnant woman in her fifth pregnancy, with a clinical condition of lower abdominal pain and pallor. Endovaginal 2DUS showed a complex voluminous mass in the left pelvic region in association with a viable intrauterine pregnancy. 2DUS in power Doppler mode showed “ring” vascularization, compatible with an ectopic gestational sac. MRI was of great importance in that it suggested that the mass had hematic content, which together with the clinical features, indicated that laparotomy should be performed. This surgical choice was essential for the woman to achieve a clinical improvement and for good continuation of the intrauterine pregnancy.

Ectopic pregnancies with unusual location and an angular pregnancy: Report of eight cases

OBJECTIVE

The increased use of assisted reproduction techniques has been accompanied by an increase in ectopic pregnancies with unusual location being associated with significant maternal morbidity and mortality. This article reports on seven cases of ectopic pregnancies with unusual location and an angular pregnancy. Diagnostic and therapeutic strategies are discussed and a brief review of literature is presented.

STUDY DESIGN

Case series of seven cases with ectopic pregnancy in unusual location, following assisted reproductive technique or conceived spontaneously (cesarean scar pregnancy and early abdominal pregnancy in mesoappendix) and an angular pregnancy, having presented at our hospital during the last eight years. Retrospective analyses.

RESULTS

Interstitial pregnancy, cornual pregnancy, cesarean scar pregnancy, early abdominal pregnancy in omentum majus, heterotopic (cervical) pregnancy, early abdominal pregnancy in mesoappendix, angular pregnancy. All patients were surgically treated.

CONCLUSION

Diagnosis of ectopic pregnancy with unusual location may be difficult, and differentiation of intact intrauterine or extrauterine pregnancy with adequate consideration of the area of uterine ostium of the fallopian tube may be delicate. Moreover, varying treatment strategies and high rates of complications aggravate the situation.

Methotrexate treatment of ectopic pregnancy: experience at nizwa hospital with literature review

OBJECTIVES

Ectopic pregnancy occurs when the embryo fails to implant within the uterine cavity. Methotrexate, a folic acid antagonist has been widely used to treat ectopic pregnancy. The aim of this study is to determine the efficacy of methotrexate treatment for ectopic pregnancies in our settings which will in-turn help us reduce maternal mortality and morbidity.

METHODS

This was a retrospective review of 60 cases of ectopic pregnancy treated with single dose methotrexate in Nizwa hospital, Oman. Demographic data, clinical presentation, treatment progress, outcome, side effects and future fertility follow up were analysed using a computer database. Selection criteria included hemodynamically stable women with ß-hcg level of ≤5000 mIU/ml, adnexal mass ≤4 cm, absent cardiac activity and hemoperitoneum less than 100 ml. Human chorionic gonadotrophin (hcg) assay and clinical presentation were used to determine cases which warranted surgical intervention.

RESULTS

The success rate of single dose methotrexate therapy in our study was 65% (n=39) and 35% (n=21) required surgical intervention compared to reported success rate of 67-100% published in various studies. Careful selection of cases and confining strictly to the criteria improved the success rate from 40% to 60% in five and half years of the study. The mean average time of resolution of ectopic pregnancy was 32 days for a single dose and 58 days for repeat second or third doses. Eight cases of pregnancy of unknown location were treated successfully with Methotrexate. No major side effects were noted. A successful fertility outcome of 30% in the first year followed by 13.3% in the subsequent second year with a secondary infertility rate of 11.6% was observed in this study.

CONCLUSION

Methotrexate treatment of ectopic pregnancies is safe and effective with no major side effects. Intramuscular methotrexate has the advantage of tubal conservation and saves patients from requiring surgery. It is easier to administer than intraoperative route, which is by laparoscopy and needs expertise. Our study showed single dose methotrexate to be an effective treatment option for selected patients with unruptured tubal ectopic pregnancy.

Treatment of cornual heterotopic pregnancy via selective reduction without feticide drug

STUDY OBJECTIVE

To treat heterotopic pregnancy with a minimally invasive procedure, absent a feticide drug.

DESIGN

Retrospective study (Canadian Classification III).

SETTING

University-affiliated hospital, center of reproductive medicine, department of obstetrics and gynecology, central south university, Changsha Hunan China.

PATIENTS

A total of nine patients' diagnosed cornual heterotopic pregnancy resulted from assisted reproduction technology. Among nine, five patients selected the cornual embryo reduction.

INTERVENTIONS

Cornual embryo reduction and preservation of intrauterine embryo were done under guidance of transvaginal ultrasonography at 4-6 weeks after embryo transfer. No drug was given.

MEASUREMENTS

Safety of operative procedure and pregnancy outcome.

MAIN RESULTS

All five patients who underwent selective embryo reduction has no intraoperative or postoperative complication, however 3 of them delivered healthy babies while two aborted.

CONCLUSION

An early intervention should be carried in vital stable patients by means of puncturing and aspirating cornual heterotopic pregnancy under transvaginal ultrasound guidance.

Chinese herbal medicine in the treatment of ectopic pregnancy

BACKGROUND

Traditionally Chinese herbal medicine (CHM) has been used widely in Chinese hospitals to treat ectopic pregnancy. Many studies have been published supporting its use but the evidence has not been systematically reviewed. This is and update of the review published in 2007.

OBJECTIVES

To determine the effectiveness and safety of CHM in the treatment of ectopic pregnancy.

SEARCH STRATEGY

Computerised databases (CENTRAL (The Cochrane Library), MEDLINE, EMBASE, Chinese Biomedical Database, China National Knowledge Infrastructure, VIP, Traditional Chinese Medicine Database System) were searched from their inception to November 2010 for relevant trials.

SELECTION CRITERIA

Randomised controlled trials (RCT) on the use of CHM for the treatment of ectopic pregnancy.

DATA COLLECTION AND ANALYSIS

Original authors of the identified studies were contacted to determine the trial design and identify authentic RCTs. Two review authors extracted and analysed the data.

MAIN RESULTS

The search identified 281 trials. Only two studies involving a total of 157 participants were confirmed to be authentic RCTs (Li 2004c; Zhao 2000). Both were of poor methodological quality with a high risk of conflicted interest and potential for bias in favour of the intervention. We could not reach a definitive conclusion from the results. The pooled result showed that adding a Western medicine to CHM resulted in a significantly higher treatment success rate than with CHM alone (RR 1.33, 95% CI 1.08 to 1.63). When CHM plus Western medicine was compared to CHM alone for the time to disappearance of abdominal pain, again the results favoured the arm that included Western medicine (RR -2.09, 95% CI -4.14 to -0.04). Results were inconsistent for the time required for human chorionic gonadotropin (beta-hCG) to return to normal. One study favoured CHM plus Western medicine over Western medicine (with or without placebo) (MD -6.68, 95% CI -11.49 to -1.87); when CHM plus Western medicine was compared to CHM alone the results favoured the arm that included Western medicine (MD -8.12, 95% CI -10.89 to -5.53).

AUTHORS' CONCLUSIONS

We have not found any well-designed trials investigating Chinese herbal medicines in the treatment of ectopic pregnancy. We cannot support or refute any CHM preparation for clinical use on the basis of evidence from randomised controlled trials.

Modification of conservative treatment of heterotopic cervical pregnancy by Foley catheter balloon fixation with cerclage sutures at the level of the external cervical os: a case report

Introduction

Conservative treatment of a heterotopic cervical pregnancy was performed with a modification of the fixation of a Foley catheter at the level of the external cervical os, followed by the ligature of the descending cervical branches of the uterine arteries and systemic methotrexate application.

Case presentation

A 34-year-old Caucasian woman was diagnosed with double gestation after 6 weeks of in vitro fertilization treatment. A gynecological examination and color Doppler ultrasound scan revealed intra-uterine and cervical gestational sacs both containing live fetuses. A Foley catheter balloon was inserted into the cervical canal, inflated and fixed by a cerclage suture at the level of the external cervical os, followed by ligation of the descending cervical branches of the uterine arteries. Systemic methotrexate was applied. Three days after removal of the Foley catheter, an evacuation of the intra-uterine gestational sac was performed. Hemorrhage from the implantation site was controlled immediately and a pregnancy termination was successfully performed. The procedure was uneventful and our patient was discharged with a preserved uterus.

Conclusions

Conservative treatment of cervical pregnancy using a Foley catheter balloon is more efficacious if the Foley catheter balloon is attached in the correct position with a cerclage suture at the level of the external os, followed by ligation of the descending cervical branches of the uterine arteries, thereby exerting maximal pressure on the bleeding vessels.

Heterotopic triplets: tubal ectopic and twin intrauterine pregnancy. A review of obstetric outcomes with a case report

INTRODUCTION

Heterotopic triplets hardly take place, but nowadays the extended use of assisted reproductive technologies is increasing the ectopic pregnancies rate and subsequently the heterotopic pregnancies, leading to a potentially dangerous condition for the woman and the intrauterine pregnancy.

MATERIAL AND METHODS

Fourteen cases previously reported in the literature of patients presenting an intrauterine twin pregnancy which became complicated by a tubal ectopic pregnancy have been reviewed. The case of a patient following a homologous intrauterine insemination treatment, resulting in live birth of both twins, is also described.

CONCLUSION

Although the diagnosis of heterotopic triplets with tubal ectopic is challenging, a timely surgical treatment will preserve intrauterine gestation with a great chance of a successful obstetric outcome for both twins.

Intramyometrial ectopic pregnancy in an ICSI patient following uterine artery embolization

Myometrial pregnancy represents a rare subtype of ectopic pregnancy. A history of uterine artery embolization (UAE) because of symptomatic uterine fibroids, and assisted reproductive treatment may predispose to this unusual implantation site. A 40-year-old woman with a history of uterine fibroids underwent a transfer of two embryos after intracytoplasmic sperm injection treatment. The combined findings on transvaginal ultrasound scan, pelvic magnetic resonance imaging scan, suction curettage, diagnostic hysteroscopy and laparoscopy were compatible with a diagnosis of ectopic pregnancy within the myometrium, at the site of a necrotized intramyometrial fibroid following UAE. Treatment with systemic methotrexate resulted in successful resolution of this ectopic pregnancy. In conclusion, this study reports a pregnancy within a previously necrotized fibroid. Findings suggest that in patients with a history of UAE for the treatment of uterine fibroids and who subsequently undergo assisted reproductive treatment, the risk of an ectopic pregnancy within the myometrium has to be considered.

Ectopic pregnancy treatment by laparoscopy, a short glimpse

Ectopic pregnancy is a life-threatening emergency, the incidence of which is increasing globally. There are a number of factors predisposing to this condition; today, the most common of these is salpingitis. Due to advancements in diagnostic technology it is possible to diagnose this condition early and thus try to achieve a favourable outcome for the patient. Treatment options in the form of medical and surgical modalities are widely available. As minimally invasive therapy techniques are rapidly advancing, laparoscopic treatment has become the most popular and preferred method for treating ectopic pregnancy. Both salpingotomy as well as salpingectomy can be performed through the laparoscope. This paper gives a short glimpse at the predisposing factors and the diagnostic investigations available for ectopic pregnancy and an insight into its laparoscopic treatment. It also reviews the pregnancy outcome and laparoscopic treatment of cases at the Department of Obstetrics and Gynaecology, Campus Kiel, University Hospitals Schleswig-Holstein.