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Effect of method of anesthesia on the reproductive and obstetric outcomes of heterotopic pregnancies. Int J Obstet Anesth 2018; 34:73-78. [PMID: 29352623 DOI: 10.1016/j.ijoa.2017.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 12/01/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Anesthesia is commonly used for surgical termination of the extrauterine component of heterotopic pregnancy. We sought to evaluate the effects of general and regional anesthesia during salpingectomy on reproductive and obstetric outcomes of heterotopic pregnancies. METHODS A two-center, retrospective cohort study was conducted, and 49 heterotopic pregnancies were included. Baseline characteristics, reproductive and obstetric outcomes were compared between the general anesthesia and regional anesthesia groups. RESULTS Baseline characteristics were comparable for age, weeks of gestation at diagnosis, and duration of anesthesia. No significant difference was found in pregnancy outcome, perinatal outcome or neonatal weight (P >0.05). The rate of miscarriage in the general anesthesia group was 23.5% versus the regional anesthesia group 15.6% (P >0.05). CONCLUSION With respect to reproductive and obstetric outcomes, this retrospective study found no difference between general anesthesia and regional anesthesia used for early heterotopic pregnancy.
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Abstract
Evaluation of acute abdominal and pelvic pain in pregnancy presents a diagnostic challenge for clinicians and radiologists alike. The differential diagnosis includes obstetric and nonobstetric conditions unique to pregnancy, in addition to causes of acute abdominal and pelvic pain unrelated to the pregnancy. The clinical presentation and course of disease may be altered in pregnancy, and several pathologies are exacerbated by pregnancy. Discriminating clinical features in the diagnosis of abdominal and pelvic pain are often confounded by expected anatomic and physiologic changes in pregnancy. Moreover, while diagnostic pathways may be altered in pregnancy, the necessity for a timely and accurate diagnosis must be underscored, as delay in treatment may result in an undesirable increase in morbidity and/or mortality for both the patient and fetus. Advances in magnetic resonance imaging (MRI) through faster acquisition and motion-insensitive techniques, coupled with increased awareness and education regarding the value of MRI in diagnosing a wide range of pathology, have established MRI as a valuable strategy in the investigation of acute abdominal and pelvic pain in the pregnant patient. This review presents a practical approach to common obstetric and nonobstetric causes of acute abdominal and pelvic pain during pregnancy, as well as safety considerations for performing MRI in this patient population.
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M Sueldo C, Budinetz T, Maslow BS, Nulsen J, Engmann L, Benadiva C. Concurrent ovarian and ipsilateral tubal ectopic pregnancies after a double embryo transfer: a case report. J Assist Reprod Genet 2014; 31:1643-6. [PMID: 25256554 DOI: 10.1007/s10815-014-0338-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 09/04/2014] [Indexed: 11/27/2022] Open
Affiliation(s)
- Carolina M Sueldo
- Center for Advanced Reproductive Services, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT, 06030, USA,
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Management and outcome of 25 heterotopic pregnancies in Zhejiang, China. Eur J Obstet Gynecol Reprod Biol 2014; 180:157-61. [PMID: 25012396 DOI: 10.1016/j.ejogrb.2014.04.046] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 10/03/2013] [Accepted: 04/30/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To characterize general attributes of women with heterotopic pregnancy (HP) in order to establish an optimal management regimen. STUDY DESIGN A retrospective analysis was conducted on 25 HPs recorded at the Women's Hospital of Zhejiang University between 2007 and 2011. Data on patients' symptoms, risk factors, diagnostic features, treatment and outcome were collected and analysed. RESULTS All patients had conceived via assisted reproductive technology (ART), 72% had a history of pelvic inflammatory disease and 68% of patients were symptomatic. Fifty-six percent of patients were diagnosed with HP via routine transvaginal ultrasound examination at approximately 6-7 weeks of gestation. Eighty percent of patients underwent surgical treatment (35% laparoscopic salpingectomy, 65% laparotomy), and 20% of patients underwent medical treatment with local injection of methotrexate (MTX) or MTX in combination with potassium chloride (KCl) into ectopic sites such as the cervix or interstitium. Eighty-eight percent of patients delivered live infants without congenital anomalies, and three patients (all of whom underwent surgical treatment) miscarried. CONCLUSIONS Routine transvaginal ultrasound examination at approximately 6-7 weeks of gestation could facilitate the diagnosis of HP, although repeat ultrasound is necessary to avoid misdiagnosis. Prompt diagnosis and correct treatment, including local injection of MTX or MTX in combination with KCl into various ectopic sites, led to favourable prognoses.
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Bayyarapu VB, Gundabattula SR, Pochiraju M, Kavuri K, Kandi S. Laparoscopy for Rudimentary Horn and Interstitial Pregnancy. J Gynecol Surg 2014. [DOI: 10.1089/gyn.2013.0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Manjula Pochiraju
- Department of Gynaecology, Fernandez Hospital, Bogulkunta, Hyderabad, Andhra Pradesh, India
| | - Kamala Kavuri
- Department of Fetal Medicine and Ultrasound, Fernandez Hospital, Bogulkunta, Hyderabad, Andhra Pradesh, India
| | - Sujatha Kandi
- Department of Fetal Medicine and Ultrasound, Fernandez Hospital, Bogulkunta, Hyderabad, Andhra Pradesh, India
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Abstract
PURPOSE Ectopic pregnancy (EP) presents a major health problem for women of child-bearing age. EP refers to the pregnancy occurring outside the uterine cavity that constitutes 1.2-1.4 % of all reported pregnancies. All identified risk factors are maternal: pelvic inflammatory disease, Chlamydia trachomatis infection, smoking, tubal surgery, induced conception cycle, and endometriosis. These developments have provided the atmosphere for trials using methotrexate as a non-surgical treatment for EP. The diagnosis measure of EP is serum human chorionic gonadotropin, urinary hCGRP/i-hCG, progesterone measurement, transvaginal ultrasound scan, computed tomography, vascular endothelial growth factor, CK, disintegrin and metalloprotease-12 and hysterosalpingography. The treatment option of EP involves surgical treatment by laparotomy or laparoscopy, medical treatment is usually systemic or through local route, or by expectant treatment. RESULTS It was concluded that review data reflect a decrease in surgical treatment and not an actual decline in EP occurrence so that further new avenues are needed to explore early detection of the EP.
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Wright SD, Busbridge RC, Gard GB. A conservative and fertility preserving treatment for interstitial ectopic pregnancy. Aust N Z J Obstet Gynaecol 2013; 53:211-3. [DOI: 10.1111/ajo.12067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 01/26/2013] [Indexed: 01/02/2023]
Affiliation(s)
- Sarah D. Wright
- Department of Obstetrics and Gynaecology; Royal North Shore Hospital; Sydney; North South Wales; Australia
| | - Romy C. Busbridge
- Department of Critical Care; Royal North Shore Hospital; Sydney; North South Wales; Australia
| | - Gregory B. Gard
- Department of Obstetrics and Gynaecology; Royal North Shore Hospital; Sydney; North South Wales; Australia
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Badr S, Ghareep AN, Abdulla LM, Hassanein R. Ectopic pregnancy in uncommon implantation sites. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2013. [DOI: 10.1016/j.ejrnm.2012.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Kim JW, Park HM, Lee WS, Yoon TK. What is the best treatment of heterotopic cervical pregnancies for a successful pregnancy outcome? Clin Exp Reprod Med 2012; 39:187-92. [PMID: 23346531 PMCID: PMC3548079 DOI: 10.5653/cerm.2012.39.4.187] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 11/09/2012] [Accepted: 11/12/2012] [Indexed: 01/01/2023] Open
Abstract
Heterotopic pregnancy is rare event and the risk is increased with assisted reproductive technology procedures. Heterotopic cervical pregnancy is even more unusual. We report a rare case of heterotopic cervical pregnancy that was managed successfully. A 36-year-old women who conceived by IVF-ICSI was diagnosed with heterotopic cervical pregnancy. She visited the emergency room with vaginal bleeding at 5 weeks of gestation and underwent careful intracervical gestational sac reduction with forceps under abdominal guidance the next day. The postoperative course was uneventful and with regular check-ups, the intrauterine pregnancy (IUP) progressed unremarkably through 41 weeks with delivery of a healthy newborn. We reviewed a total of 37 cases of heterotopic pregnancy that have been reported in the English language literature. There have been many attempts to eliminate the cervical embryo while preserving the IUP, and complete cervical evacuation is important in order to avoid infection, bleeding, and premature birth.
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Affiliation(s)
- Ji Won Kim
- Department of Obstetrics and Gynecology, Fertility Center of CHA Gangnam Medical Center, CHA University, Seoul, Korea
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10
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He GB, Luo W, Zhou XD, Liu LW, Yu M, Ma XD. A preliminary clinical study on high-intensity focused ultrasound therapy for tubal pregnancy. Scott Med J 2012; 56:214-9. [PMID: 22089043 DOI: 10.1258/smj.2011.011161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Our aim was to explore the clinical application value of high-intensity focused ultrasound (HIFU) therapy for tubal pregnancy. Forty hospitalized patients with tubal pregnancies (28 cases of non-ruptured tubal pregnancy and 12 cases of ruptured tubal pregnancy) were selected to receive HIFU therapy. Serum human chorionic gonadotropin (β-HCG) concentrations were compared before and after treatment. Serum β-HCG was measured weekly and patients received observation only if the concentration decreased by 15% or more, compared with the previous value. Patients were given supplement HIFU therapy if the decrease in the serum β-HCG was <15% within two weeks. Ultrasound was used to detect the volume changes in the ectopic lesions before and after treatment, and changes in vital signs and complications were recorded. Contrast-enhanced ultrasonography was used to assess fallopian tube patency after treatment. HIFU treatment was successful in 33 of the 40 patients (82%). Seven patients failed HIFU treatment and received surgical therapy (18%). Before and after treatment, serum β-HCG concentrations and lesion volume were significantly different (P < 0.05, P < 0.01, respectively). Post-treatment tubal contrast-enhanced ultrasonography showed tubal patency on the affected side in 21 cases (64%) at six months and in 27 cases (82%) at 12 months. In conclusion, HIFU is safe and effective, and can be a treatment option for tubal pregnancy.
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Affiliation(s)
- G-B He
- Department of Ultrasonography, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, Shaanxi Province, China
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Open cornual resection versus laparoscopic cornual resection in patients with interstitial ectopic pregnancies. Eur J Obstet Gynecol Reprod Biol 2011; 156:78-82. [DOI: 10.1016/j.ejogrb.2010.12.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2010] [Revised: 11/01/2010] [Accepted: 12/15/2010] [Indexed: 11/17/2022]
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GEORGIOU EKTORASX, DOMONEY CLAUDINE, SAVAGE PHILIP, STAFFORD MICHAEL. Heterotopic abdominal pregnancy with persistent trophoblastic tissue. Acta Obstet Gynecol Scand 2011; 90:551-3. [DOI: 10.1111/j.1600-0412.2011.01093.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kamath MS, Aleyamma TK, Muthukumar K, Kumar RM, George K. A rare case report: ovarian heterotopic pregnancy after in vitro fertilization. Fertil Steril 2010; 94:1910.e9-11. [PMID: 20362282 DOI: 10.1016/j.fertnstert.2010.02.045] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2010] [Revised: 02/17/2010] [Accepted: 02/18/2010] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To report a case of ovarian heterotopic pregnancy after an IVF cycle. DESIGN Case report. SETTING Reproductive medicine unit, Christian Medical College Hospital, Vellore, India. PATIENT(S) A woman with an ovarian heterotopic pregnancy. INTERVENTION(S) Laparoscopic removal of ovarian ectopic pregnancy. MAIN OUTCOME MEASURE(S) Early detection and successful treatment of heterotopic pregnancy. RESULT(S) Successful laparoscopic management of ovarian pregnancy resulting in a single viable ongoing intrauterine pregnancy. CONCLUSION(S) Clinicians need to be aware of such rare and potentially fatal presentations after IVF, because early diagnosis and management in these cases can yield a favorable outcome.
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Affiliation(s)
- Mohan S Kamath
- Reproductive Medicine Unit, Christian Medical College Hospital, Vellore, India
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Abstract
The incidence of ectopic pregnancies is increasing. Common risk factors are tubal pathology, previous tubal surgery, previous ectopic pregnancy, intrauterine device use and embryo transfer. Levonelle-2, a progesterone-only postcoital contraceptive works by a combination of mechanisms including ovulation inhibition, prevention of fertilization, and inhibition of implantation. It is 85% effective and there have been 12 reported cases of ectopic pregnancy in the UK with its use. It is believed that progesterone slows the intratubal migration of the fertilized ovum. In the case reported here, a woman presented with an ectopic pregnancy after use of Levonelle-2 as postcoital contraception; there were no clinical predisposing risk factors. In the absence of any histological evidence of tubal damage, we suspect that the levonorgestrel from Levonelle-2 could have been responsible for delayed embryo transfer which resulted in the ectopic pregnancy.
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Affiliation(s)
- A Basu
- Department of Obstetrics and Gynecology, Stepping Hill Hospital, Stockport, Cheshire, UK
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Can sonographic endometrial pattern be an early indicator for tubal ectopic pregnancy and related tubal rupture? Arch Gynecol Obstet 2009; 281:189-94. [PMID: 19404658 DOI: 10.1007/s00404-009-1095-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2009] [Accepted: 04/14/2009] [Indexed: 12/27/2022]
Abstract
PURPOSE The present study aims to determine whether sonographic endometrial pattern can be addressed as an early indicator for tubal ectopic pregnancy and related tubal rupture in case ultrasonography reveals no adnexal mass and maternal serum beta human chorionic gonadotropin (HCG) level is below the discriminatory zone (<or=1,000 mIU/mL). METHODS The study evaluated the endometrial features of 441 naturally conceived and asymptomatic first trimester (99 tubal ectopic, 138 failing and 264 normal intrauterine) with maternal serum beta HCG levels<or=1,000 mIU/mL and indeterminate sonographic findings. RESULTS Tubal ectopic, failing intrauterine and normal intrauterine pregnancies are statistically similar in aspect of endometrial thickness. However, trilaminar endometrial pattern was significantly less frequent in failing and normal intrauterine pregnancies but significantly more frequent in ruptured tubal pregnancies. Also the relative risk of tubal rupture is significantly higher in case of trilaminar endometrial pattern. Trilaminar endometrial pattern has a sensitivity of 21.2%, specificity of 93.9%, positive predictive value of 50.0% and negative predictive value of 80.5% for distinguishing tubal ectopic pregnancy. Moreover, the sensitivity, specificity, positive and negative predictive values of the same pattern are computed to be 60.0, 95.7, 85.7 and 84.6%, respectively, in the prediction of ruptured tubal pregnancy. CONCLUSIONS Sonographic appearance of endometrium may be used to predict tubal pregnancy when ultrasonography shows no adnexal mass and maternal serum HCG<or=1,000 mIU/mL. That is, trilaminar pattern may indicate tubal pregnancy and warn about a possible related rupture in case of previous ectopic pregnancy or pelvic surgery.
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King AE, Wheelhouse N, Cameron S, McDonald SE, Lee KF, Entrican G, Critchley HO, Horne AW. Expression of secretory leukocyte protease inhibitor and elafin in human fallopian tube and in an in-vitro model of Chlamydia trachomatis infection. Hum Reprod 2008; 24:679-86. [DOI: 10.1093/humrep/den452] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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17
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Ruptura de embarazo ectópico cornual en segundo trimestre de gestación. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2008. [DOI: 10.1016/s0210-573x(08)75110-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Madendag Y, Col-Madendag I, Kanat-Pektas M, Danisman N. Predictive power of serum CA-125 and LDH in the outcome of first trimester pregnancies with human chorionic gonadotropin levels below discriminatory zone. Arch Gynecol Obstet 2008; 279:661-6. [DOI: 10.1007/s00404-008-0798-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2008] [Accepted: 09/02/2008] [Indexed: 11/29/2022]
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Horne AW, van den Driesche S, King AE, Burgess S, Myers M, Ludlow H, Lourenco P, Ghazal P, Williams AR, Critchley HOD, Duncan WC. Endometrial inhibin/activin beta-B subunit expression is related to decidualization and is reduced in tubal ectopic pregnancy. J Clin Endocrinol Metab 2008; 93:2375-82. [PMID: 18381568 DOI: 10.1210/jc.2008-0136] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CONTEXT Ectopic pregnancy is common but remains difficult to diagnose accurately. There is no serum test to differentiate ectopic from intrauterine gestation. OBJECTIVE Our objective was to investigate differential gene expression in decidualized endometrium of ectopic pregnancy. DESIGN Tissue and serum analysis informed by microarray study was performed. SETTING The study was performed at a large United Kingdom teaching hospital. PATIENTS OR OTHER PARTICIPANTS Women undergoing surgical termination of pregnancy (n = 8), evacuation of uterus for miscarriage (n = 6), and surgery for tubal ectopic pregnancy (n = 11) were included in the study. Endometrium was collected from normally cycling women undergoing hysterectomy. INTERVENTIONS Decidualized endometrium was subjected to microarray analysis, morphological assessment, and immunohistochemistry. Endometrial stromal fibroblasts were cultured in the presence of decidualizing stimuli. MAIN OUTCOME MEASURES Differential expression of potentially secreted molecules was calculated. RESULTS Inhibin/activin beta-B expression was lower in decidualized endometrium from ectopic pregnancies when compared with that of ongoing pregnancies (P < 0.01) or miscarriages (P < 0.01). The localization of the beta-B subunit was more marked in decidualized than nondecidualized stroma. Decidualization of stromal fibroblasts in vitro was associated with increased beta-B expression (P < 0.05). Endometrial stroma of ectopic pregnancies was less decidualized morphologically (P < 0.05), with lower prolactin (P < 0.01) and IGF binding protein-1 (P < 0.005) expression. Serum activin B was lower in ectopic pregnancies (P < 0.005) than in intrauterine pregnancies, whereas there was no difference in progesterone concentrations. CONCLUSIONS Despite similar concentrations of progesterone, the endometrium of ectopic pregnancies is less decidualized than intrauterine pregnancies. Expression of the beta-B subunit is related to decidualization and can be detected in the circulation as activin B. Serum activin B concentrations are lower in ectopic pregnancy.
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Affiliation(s)
- A W Horne
- Obstetrics and Gynaecology, University of Edinburgh, Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, United Kingdom.
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Dennert IM, van Dongen H, Jansen FW. Ectopic pregnancy: a heart beating case. J Minim Invasive Gynecol 2008; 15:377-9. [PMID: 18439517 DOI: 10.1016/j.jmig.2007.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2007] [Revised: 12/09/2007] [Accepted: 12/15/2007] [Indexed: 11/27/2022]
Abstract
Abdominal pregnancy is a rare event that occurs in western countries in 1.3% of ectopic gestations. Delayed diagnosis and attempted removal of the fetus have occasionally resulted in massive and even fatal intraperitoneal hemorrhage. We present a case of an ectopic pregnancy at the intraabdominal surface of the left diaphragm, which was removed successfully with laparoscopic hydrodissection. This case report demonstrates that awareness of this condition is important when the location of the pregnancy cannot be found in the lower abdominal cavity, especially if the patient has unexplained complaints such as shoulder pain.
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Valsky DV, Yagel S. Ectopic pregnancies of unusual location: management dilemmas. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2008; 31:245-251. [PMID: 18307196 DOI: 10.1002/uog.5277] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Ross R, Lindheim SR, Olive DL, Pritts EA. Cornual gestation: a systematic literature review and two case reports of a novel treatment regimen. J Minim Invasive Gynecol 2007; 13:74-8. [PMID: 16431329 DOI: 10.1016/j.jmig.2005.11.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2005] [Accepted: 08/08/2005] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE To introduce a novel tubal-sparing regimen for the treatment of nonruptured cornual pregnancies. DESIGN Case report and systematic review of the literature. SETTING Tertiary Care University setting. PATIENTS Two patients referred for care in our subspecialty clinic. INTERVENTIONS Laparoscopic surgery, dilation and evacuation, and postoperative methotrexate injection. Systematic review of the literature. MEASUREMENTS AND MAIN RESULTS Both medical and surgical treatments for cornual gestation exist; however, each is not without its shortcomings. Medical treatment is associated with failure rates that may result in uterine rupture and catastrophic hemorrhage. Surgical treatment that involves hysterectomy causes a loss of future childbearing capability. Surgical treatment that involves resection of the involved cornual region is associated with decreased fertility rates and increased rates of uterine rupture in future pregnancies. Our treatment regimen is safe and effective and conserves future fertility. CONCLUSION A cornual gestation is one of the most hazardous types of ectopic gestation. The diagnosis and treatment of such a pregnancy is challenging and constitutes an urgent medical situation. We herein introduce a novel regimen for the treatment of nonruptured cornual pregnancies. The existing treatment regimens are also systematically reviewed.
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Affiliation(s)
- Reneita Ross
- Department of Obstetrics and Gynecology, University of Wisconsin, Madison, USA
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Han SH, Jee BC, Suh CS, Kim SH, Choi YM, Kim JG, Moon SY. Clinical Outcomes of Tubal Heterotopic Pregnancy: Assisted vs. Spontaneous Conceptions. Gynecol Obstet Invest 2007; 64:49-54. [PMID: 17259714 DOI: 10.1159/000099014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2006] [Accepted: 11/01/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND It has not been established whether the clinical outcomes of tubal heterotopic pregnancy resulting from assisted conception are different to those of spontaneous conception. The aim of this study was to compare the clinical course and the outcome of intrauterine gestation following surgical treatment for tubal heterotopic pregnancy according to the method of pregnancy. METHODS Medical records of 13 cases of tubal heterotopic pregnancy experienced in Seoul National University Hospital during 1990-2004 and 30 case reports of tubal heterotopic pregnancy published in the Korean Journal of Obstetrics and Gynecology during 1980-2004 were reviewed retrospectively. The clinical outcomes were compared between the assisted (n = 23) and spontaneous conception groups (n = 20). RESULTS The assisted conception group had a significantly higher preoperative systolic blood pressure and a previous history of pelvic pathology. The spontaneous group had a higher incidence of tubal rupture and hemoperitoneum. The assisted conception group had a higher live birth rate than the spontaneous group (47.8 vs. 20%, p = 0.056). CONCLUSIONS In tubal heterotopic pregnancy, the assisted conception group had a more favorable clinical course and intrauterine gestation outcome following surgical treatment when compared with the spontaneous conception group.
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Affiliation(s)
- Sang Hoon Han
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Korea
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Abstract
Ectopic pregnancy and ovarian torsion are 2 of the most common causes of acute abdominal pain in early pregnancy. The following article will discuss the physiology and pathophysiology, evaluation, diagnosis, clinical management options, and nursing considerations for ovarian torsion and ectopic pregnancy. Both conditions require timely diagnosis to prevent mortality and minimize morbidity, and both may require surgical management.
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Affiliation(s)
- Elizabeth Stevens
- Division of Midwifery and Community Health, Baystate Medical Center, Springfield, MA 01199, USA.
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Heterotopic pregnancy: two cases and a comparative review. Fertil Steril 2006; 87:417.e9-15. [PMID: 17074353 DOI: 10.1016/j.fertnstert.2006.05.085] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2005] [Revised: 05/01/2006] [Accepted: 05/01/2006] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To analyze the incidence, diagnostic, and therapeutic management of heterotopic pregnancy by comparing a review for the 1971-1993 period with the one carried out in the present study (1994-2004). DESIGN Review of the literature. SETTING University teaching assisted reproductive technology (ART) center. PATIENT(S) Two case reports included in a comparative review of the literature on heterotopic pregnancy. INTERVENTION(S) Review of the published literature from January 1994 to December 2004 was performed by means of MEDLINE database. Medical subject heading words used were: heterotopic pregnancy, assisted reproductive technology, and ectopic pregnancy. A comparison with a previously reported review, including cases from 1971 to 1993. MAIN OUTCOME MEASURE(S) Comparative study of the diagnosis and treatment of ectopic pregnancy. RESULT(S) During the 1971-1993 period the definitive diagnosis of heterotopic pregnancy was performed by laparoscopy or laparotomy in 59% of cases. This proportion increased to 74% from 1994 to 2004. Likewise, the percentage of cases in which an early diagnosis was possible (performed before the ninth week of pregnancy) did not vary in any of the time periods evaluated (71% vs. 74%). CONCLUSION(S) Despite the increased medical knowledge and use of improved reproductive technologies, heterotopic pregnancy still remains a diagnostic and therapeutic challenge to practitioners.
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Goldberg JM, Bedaiwy MA. Transvaginal local injection of hyperosmolar glucose for the treatment of heterotopic pregnancies. Obstet Gynecol 2006; 107:509-10. [PMID: 16449167 DOI: 10.1097/01.aog.0000187947.71490.d1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We report the technique and long-term outcome after a conservative approach for the treatment of heterotopic pregnancy. CASE Two women aged 31 and 30 years presented with heterotopic pregnancies after controlled ovarian hyperstimulation intrauterine insemination. Transvaginal ultrasound-guided needle aspiration of the ectopic gestational sac and instillation of hyperosmolar glucose were performed. The ectopic pregnancies resolved without further intervention in both cases. The intrauterine pregnancies resulted in live births by cesarean delivery. Bilateral tubal patency was subsequently confirmed in both patients. CONCLUSION Local injection of 50% glucose after aspiration of the tubal gestational sac fluid under transvaginal ultrasonographic guidance proved effective in resolving the ectopic pregnancy without adversely affecting the concurrent intrauterine pregnancy. This is a simple and inexpensive treatment modality.
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Affiliation(s)
- Jeffrey M Goldberg
- Department of Gynecology and Obstetrics, the Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Naki MM, Tekcan C, Uysal A, Güzin K, Yücel N. Heterotopic pregnancy following ovulation induction by clomiphene citrate and timed intercourse: a case report. Arch Gynecol Obstet 2006; 274:181-3. [PMID: 16463167 DOI: 10.1007/s00404-006-0121-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2005] [Accepted: 12/28/2005] [Indexed: 11/25/2022]
Abstract
We report a combined intra-uterine and unruptured tubal pregnancy following ovulation induction by clomiphene citrate (CC) and timed intercourse. The diagnosis of heterotopic pregnancy (HP) is the major problem until occurrence of tubal rupture. Because HP is a life-threatening condition, the diagnosis should be made as soon as possible. In a spontaneous conception, HP is a rare event. The risk of HP significantly increases after ovulation induction. Clomiphene itself could be associated with a high HP rate. We present a case with normally developing intra-uterine singleton pregnancy successfully managed by salpingectomy of synchronous tubal pregnancy following ovulation induction by CC and a review of the literature.
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Affiliation(s)
- M Murat Naki
- Department of Obstetrics and Gynecology, Göztepe Research and Training Hospital, Istanbul, Turkey.
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Abstract
A case of advanced tubal pregnancy at 30 weeks is described. The placenta was implanted on the salpinx. Most tubal pregnancies become symptomatic within the first 12 weeks. A small number of tubal pregnancies have progressed beyond this. We present this unusual case of a 30-week tubal pregnancy situated in the proximal half of the tube that created a diagnostic dilemma.
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Affiliation(s)
- Idris Koçak
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ondokus Mayis University, Samsun, Turkey.
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Gerton GL, Fan XJ, Chittams J, Sammel M, Hummel A, Strauss JF, Barnhart K. A serum proteomics approach to the diagnosis of ectopic pregnancy. Ann N Y Acad Sci 2004; 1022:306-16. [PMID: 15251976 DOI: 10.1196/annals.1318.046] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
An ectopic pregnancy (EP) occurs when implantation of the embryo occurs outside of the uterus. If left untreated, the developing fetus will continue to grow, leading to life-threatening consequences for the mother. A major difficulty with the diagnosis of ectopic pregnancy is that methods of detection are limited, and some, such as ultrasound, are not very reliable in the earliest days of gestation. Currently, no effective serum test exists to distinguish an ectopic pregnancy from a normal intrauterine pregnancy. The incidence of ectopic pregnancy is increasing and has doubled in the last 20 years. It is now the second most common cause of maternal death in the first trimester of pregnancy. To address this issue, we initiated a project to identify serum markers of ectopic pregnancy. The subjects for these studies presented at the Hospital of the University of Pennsylvania. We obtained over 140 serum samples from women with suspected ectopic pregnancy: women presenting with pain and/or bleeding in the first trimester of pregnancy. The approximate racial breakdown of the subjects is as follows: African American, 36%; Caucasian, 3%; Asian, 2%; Hispanic, 1%; unknown, 58%. Serum samples from 139 women (62 with ectopic pregnancy and 77 with a normal intrauterine pregnancy) were applied to WCX2 (weak ion exchange) protein chip surfaces and analyzed for serum markers using surface-enhanced laser desorption/ionization time-of-flight mass spectrometry (SELDI-TOF-MS). Several proteins in the 7500-18,000 Da mass range were identified that may discriminate an ectopic pregnancy from an intrauterine pregnancy. The most promising markers were analyzed using classification and regression tree analysis (CART) with and without clinical variables (serum hCG value, length of amenorrhea). Two different algorithms were developed that classify the patients on the basis of sensitivity (number of EPs who screen positive/# of EPs) or specificity (# of healthy patients who screen negative/# of healthy). Our current approach is to refine these two "rule sets" to segregate patients into three groups: those who need immediate intervention for a probable ectopic pregnancy, those who appear to have a normal pregnancy, and those who need further monitoring for diagnosis.
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Affiliation(s)
- G L Gerton
- Center for Research on Reproduction and Women's Health, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania 19104-6080, USA.
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Abstract
OBJECTIVE To describe the trends in ectopic pregnancy mortality in Michigan from 1985 through 1999 and compare to those of previous time periods. METHODS We reviewed all cases of maternal mortality from ectopic pregnancy in Michigan from 1985 through 1999. We extracted data from death certificates, hospital inpatient and emergency department records, medical examiner autopsy reports, and reviews by the Michigan Maternal Mortality Study. The Health Data Development Section of the Michigan Department of Community Health provided data on live births and maternal deaths RESULTS Of the 268 pregnancy-related deaths, 16 (6%) were caused by complications of ectopic pregnancy. Mean age at death was 27 (+/- 6) years. Thirteen deaths were to African-American women and 3 were to white women (P < .01). African-American women had an ectopic mortality ratio 18 times higher than white women (3.25/100,000 live births, compared with 0.18/100,000) Three cases of pregnancy-related death due to complications of ectopic pregnancy were considered preventable, and 2 others were of unknown preventability. CONCLUSION Ectopic pregnancy treatment has changed in the last 20 years coincident with a decrease in maternal mortality from ectopic pregnancy. Sudden death was the presenting scenario in 75% of nonpreventable ectopic deaths, an increase from previous analyses. A large racial disparity is apparent. Ideally, pregnancy care should start as soon as possible after the first missed menses; however, systemwide changes are needed to create a new norm promoting early access to pregnancy care and promoting education and testing to rule out pregnancy abnormalities. LEVEL OF EVIDENCE II-2
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Affiliation(s)
- Frank W J Anderson
- Department of Obstetrics and Gynecology, University of Michigan, 1500 East Medical Center Drive L4000 WH, Ann Arbor, MI 48109, USA.
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Cenk Sayin N, Yardim T. Live birth of healthy twins after a heterotopic tubal and intrauterine twin pregnancy in a woman who was stimulated with clomiphene citrate. Fertil Steril 2003; 80:1265-7. [PMID: 14607586 DOI: 10.1016/s0015-0282(03)02168-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To report a heterotopic pregnancy with successful delivery of monochorionic-diamniotic twins after rupture of the tubal ectopic gestation. DESIGN Case report. University teaching hospital. PATIENT(S) A patient with heterotopic twin monochorionic-diamniotic pregnancy. INTERVENTION(S) Surgical removal of the ectopic pregnancy. MAIN OUTCOME MEASURE(S) Pregnancy course and outcome. The patient successfully delivered twins. CONCLUSION(S) Heterotopic pregnancy after clomiphene citrate administration may have a complicated course, but could end in successful live birth of twins.
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Affiliation(s)
- N Cenk Sayin
- Trakya University, Faculty of Medicine, Edirne, Turkey.
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Radaelli T, Bulfamante G, Cetin I, Marconi AM, Pardi G. Advanced tubal pregnancy associated with severe fetal growth restriction: a case report. J Matern Fetal Neonatal Med 2003; 13:422-5. [PMID: 12962269 DOI: 10.1080/jmf.13.6.422.425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
A case is described of advanced tubal pregnancy associated with severe fetal growth restriction delivered at 27 weeks. The placenta was implanted on the salpinx and on the uterotubal angle. Progressing tubal pregnancy and its placental histological characteristics could be a model of placental dysfunction typically associated with intrauterine growth restriction.
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Affiliation(s)
- T Radaelli
- Department of Obstetrics and Gynecology, DMCO San Paolo, University of Milan, Milan, Italy
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Bryan S. Current challenges in the assessment and management of patients with bleeding in early pregnancy. Emerg Med Australas 2003; 15:219-22. [PMID: 12786641 DOI: 10.1046/j.1442-2026.2003.00462.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Bleeding in early pregnancy occurs in approximately 20% of clinically diagnosed pregnancies. History and physical examination are unable to reliably determine the anatomical location of the pregnancy (ectopic or intrauterine) or whether or not the fetus is alive. Ultrasound is the best tool for assessing these clinical questions and it is increasingly being used in the ED. This article looks at some of the common ultrasound findings and discusses the management options for failed and ectopic pregnancies.
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Affiliation(s)
- Sheila Bryan
- Royal Women's Hospital, Melbourne, Victoria, Australia.
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Davies S, Byrn F, Cole LA. Human chorionic gonadotropin testing for early pregnancy viability and complications. Clin Lab Med 2003; 23:257-64, vii. [PMID: 12848444 DOI: 10.1016/s0272-2712(03)00026-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Human chorionic gonadotropin (hCG) is a heterogeneous molecule that is the marker of choice for detecting pregnancy and indicating ectopic pregnancies and spontaneous abortions. This article describes the use of hCG in detecting pregnancy, and how pregnancy detection is complicated by the extreme variation in individual hCG results and by the varying structure of hCG. The problems of false-positive pregnancy tests due to early pregnancy losses or heterophilic antibodies, and of false-negative pregnancy tests due to delayed implantation, are discussed. Different kinds of pregnancy tests, professional laboratory assays, point-of-care, and home devices are compared. The use of hCG measurement and hCG doubling rates, progesterone measurements, and transvaginal ultrasound in identifying ectopic pregnancies and failing pregnancies also is reviewed.
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Affiliation(s)
- Suzy Davies
- The United States Human Chorionic Gonadotropin Reference Service, Department of Obstetrics and Gynecology, University of New Mexico, 2211 Lomas Boulevard Northeast, Albuquerque, NM 87131, USA
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Abstract
Numerous medical, surgical, psychiatric, gynecologic, and obstetric disorders can cause abdominal pain during pregnancy. The patient history, physical examination, laboratory data, and radiologic findings usually provide the diagnosis. The pregnant woman has physiologic alterations that affect the clinical presentation, including atypical normative laboratory values. Abdominal ultrasound is generally the recommended radiologic imaging modality; roentgenograms are generally contraindicated during pregnancy because of radiation teratogenicity. Concerns about the fetus limit the pharmacotherapy. Maternal and fetal survival have recently increased in many life-threatening conditions, such as ectopic pregnancy, appendicitis, and eclampsia, because of improved diagnostic technology, better maternal and fetal monitoring, improved laparoscopic technology, and earlier therapy.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, Department of Medicine, Woodhull Medical Center, 760 Broadway Avenue, Brooklyn, NY 11206, USA
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Abstract
Problems associated with menstruation affect 75% of adolescent females and are a leading reason for visits to physicians. This chapter begins with a review of the timing and characteristics of normal menstruation during adolescence. It then discusses the evaluation and management of adolescents with amenorrhoea, dysmenorrhoea and abnormal uterine bleeding. An approach to adolescent amenorrhoea is presented that utilizes primary versus secondary amenorrhoea, delayed versus normal pubertal development, and the presence or absence of hyperandrogenism as nodal points for decision making. The differential diagnosis of dysmenorrhoea and the management of primary dysmenorrhoea and endometriosis are reviewed. The section on abnormal uterine bleeding contrasts anovulatory dysfunctional uterine bleeding (DUB) with bleeding secondary to problems of pregnancy, uterine pathology, exogenous hormone use and systemic bleeding disorders.
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Affiliation(s)
- Gail B Slap
- Division of Adolescent Medicine (ML-4000), Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, Ohio, 45229, USA.
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Oyawoye S, Chander B, Pavlovic B, Hunter J, Gadir AA. Heterotopic pregnancy: successful management with aspiration of cornual/interstitial gestational sac and instillation of small dose of methotrexate. Fetal Diagn Ther 2003; 18:1-4. [PMID: 12566766 DOI: 10.1159/000066374] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2001] [Accepted: 02/01/2002] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Terminating a corneal pregnancy without jeopardizing a coexistent intrauterine pregnancy. METHODS A 29-year-old woman with a 4-year history of primary infertility became pregnant after in-vitro fertilization and embryo transfer. A heterotopic pregnancy with a left cornual and intrauterine sacs was confirmed by early transvaginal scan examinations. The ectopic sac was aspirated under ultrasound guidance followed by local injection of 12.5 mg methotrexate. This was followed by serial ultrasound scans and serum betahCG assays. RESULTS The fetal pole in the ectopic pregnancy disappeared following the procedure. She had no significant vaginal bleeding or any other unusual symptoms. The intrauterine pregnancy progressed satisfactorily until spontaneous onset of labour and vacuum extraction delivery at 39 weeks. The baby weighed 2.9 kg. CONCLUSIONS Local injection of low-dose methotrexate following aspiration of a cornual pregnancy proved effective in halting the ectopic trophoblasts' growth without adversely affecting a coexistent intrauterine pregnancy. The injected ectopic trophoblasts resolved quickly despite the small dose of methotrexate used. This technique avoided a more costly surgical treatment with its associated risks in subsequent pregnancies.
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Affiliation(s)
- Seye Oyawoye
- Department of Obstetrics and Gynaecology, Royal Free Campus, Royal Free and University College Medical School, London, UK
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Current Awareness. Prenat Diagn 2001. [DOI: 10.1002/pd.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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