Ectopic Pregnancy in the Round Ligament Following Bilateral Salpingectomy: A Case Report

Ectopic pregnancies, characterized by the implantation of a fertilized ovum outside the uterine cavity, typically occur in the fallopian tubes. However, rare cases have been reported where implantation occurs in atypical locations. Round ligament pregnancy, a rare form of ectopic pregnancy, poses significant risks and can lead to life-threatening complications. This case report describes the presentation and management of a 31-year-old gravida four, para two (G4P2012) female who presented with acute left lower quadrant and pelvic pain. The patient's medical history included a prior bilateral salpingectomy. Physical examination revealed severe left lower quadrant tenderness with guarding. A positive urine pregnancy test and elevated serum quantitative beta-human chorionic gonadotrophin level of 1,735 mIU/mL (normal range: <5 mIU/mL) confirmed pregnancy. Transvaginal ultrasound revealed an empty intrauterine cavity with no gestational sac or fetal pole. A 2 cm cystic structure was identified attached to the left ovary. Ectopic pregnancy was diagnosed, methotrexate was administered, and the patient was discharged with a scheduled outpatient follow-up. However, she returned to the emergency room within 48 hours reporting persistent pelvic pain. At this moment, it was decided that emergent surgical intervention was required. The surgical exploration confirmed the presence of a ruptured ectopic pregnancy in the round ligament, requiring excision and hemostasis. This case report highlights the importance of considering abnormal localization of ectopic pregnancy as a differential diagnosis in women presenting with pelvic pain, even after bilateral salpingectomies. It emphasizes the challenges in diagnosis and management when ectopic pregnancy occurs in atypical sites and highlights the necessity for vigilant follow-up and prompt surgical intervention when medical management fails.

Ruptured Left Cornual Ectopic Pregnancy: A Case Report

Cornual ectopic pregnancies are rare with a mortality rate that is significantly higher than that of other ectopic pregnancy types. Due to the cornual region's location on the fallopian tube, rupture of a cornual gestation may lead to massive maternal hemorrhage resulting in hypovolemia and shock. Here, we report a 39-year-old female who presented to Hospital Corporation of America (HCA) Florida Healthcare's emergency department (ED) in a state of hypovolemic shock. She was six weeks pregnant based on an unknown and unsure last menstrual cycle. The diagnosis of a ruptured ectopic pregnancy was suspected based on a positive urine pregnancy test and a pelvic ultrasound that revealed an empty uterus and a copious amount of free fluid within the abdomen. Significant hematoperitoneum and hemodynamic instability required emergent exploratory laparotomy with findings of a ruptured left cornual ectopic pregnancy. A left cornual resection and repair was done with an uneventful postoperative period. With cornual ectopic pregnancies being a rare entity, our case emphasizes the importance of early detection and management to help prevent fatal complications.

Trophoblastic infiltration of tubal pregnancy may have an association with chronic inflammation of the fallopian tube

OBJECTIVE

To explore the factors associated with trophoblastic infiltration in ampullary pregnancy from the perspective of clinical and pathologic characteristics.

METHODS

A single-center, retrospective, clinicopathologic cohort study was conducted in women who were diagnosed with tubal pregnancy and underwent salpingectomy in the International Peace Maternal and Child Health Care Hospital from January 2018 to June 2021.

RESULTS

A total of 333 eligible women diagnosed with ampullary pregnancy were included in the analysis. Multivariate logistic analysis showed that preoperative β-human chorionic gonadotropin greater than 3000 IU/L (adjusted odds ratio [aOR] 3.77, 95% confidence interval [CI] 2.02-7.03), and vascular remodeling phenomenon (aOR 4.34, 95% CI 2.41-7.83) were positively correlated with the infiltration of extravillous trophoblasts into serosa, while presence of chronic inflammation of the fallopian tube was a negatively corellated factor (aOR 0.49, 95% CI 0.29-0.85).

CONCLUSION

The depth of trophoblastic infiltration in tubal pregnancy may be related to the presence of chronic inflammation in the fallopian tube. A tubal pregnancy in a tube with chronic salpingitis is more likely to develop into an abortive ectopic pregnancy; whereas in a fallopian tube without chronic inflammation, the risk of it developing into a ruptured ectopic pregnancy increases. Hence, early identification is needed to properly address this dangerous pregnancy situation.

Sudden Death Due to Rupture of Ectopic Pregnancy in a Young Lactating Mother

The incidence of ectopic pregnancy in India is increasing over time along with a considerable mortality rate. The common site for ectopic pregnancy is the fallopian tubes and is also associated with a higher incidence of mortality following the tubal rupture. Even though lactational amenorrhea prevents pregnancy to some extent, the probability of pregnancy increases when the frequency of lactation decreases. Rupture of ectopic pregnancy can occur abruptly without any serious symptoms as well. One should not ignore even mild symptoms in females of reproductive age group especially those who are sexually active. A 25-year-old female with an alleged history of sudden onset of severe abdominal pain was taken to AIIMS Bhopal, where she was declared brought dead and her body was sent for autopsy. She got married at the age of 23 years and was still breastfeeding her 11-month-old child. The autopsy revealed 2.2 liters of fluid and clotted blood in the peritoneal cavity. The right fallopian tube enlarged along with a tear of size 1cm x 1cm evident on the anterior aspect. Meticulous dissection revealed a membranous sac of size 4cm x 2cm x 2cm containing a placenta of size 1cm x 1cm and an embryo of size 2cm x 1cm. All other organs were pale and normal. The uterine cavity was found empty. The cause of death was attributed to ruptured ectopic pregnancy.

Ovarian Pregnancy

Ovarian pregnancy is a rare uncommon presentation of an ectopic pregnancy. Without any known risk factors, ovarian pregnancy seems to appear at random. A 29-year-old female patient with previous two cesarean deliveries visited the gynecology emergency department with the complaint of constant dull aching pain in the lower abdomen, aggravated by postural changes. Per vaginal examination, cervical motion tenderness was present. The patient was admitted, and her transvaginal sonography was done along with a urine pregnancy kit test for the suspicion of ectopic gestation. After the initial treatment and arrangement of two units of packed red blood cells after proper grouping and cross-matching for the patient, laparotomy was done. At the time of surgery, left-sided ruptured ovarian pregnancy was confirmed by the Spiegelberg criteria.

Ectopic Pregnancy With Low Beta-Human Chorionic Gonadotropin (HCG) Managed With Methotrexate and Progressed to Rupture

Ectopic pregnancies are one of the most common obstetric diagnoses made in the emergency department. Once diagnosed, patients can be managed expectantly, medically, or surgically. Decisions regarding patient management are made using evidence-based protocols. Hemodynamically stable patients with reduced beta-human chorionic gonadotropin (HCG) levels and a small mass on ultrasonography are managed with methotrexate therapy. Although most patients adequately treated with methotrexate resolve, there are a few rare instances where patients progress to develop a ruptured ectopic despite having low and declining beta-HCG levels. These patients must be taken for surgical evacuation at the earliest opportunity to prevent life-threatening hemorrhage. Hence, obstetricians must be prepared for such potential complications of low-risk ectopic pregnancies.

Comparing Time to Diagnosis and Treatment of Patients with Ruptured Ectopic Pregnancy Based on Type of Ultrasound Performed: A Retrospective Inquiry

BACKGROUND

Hemorrhage from ruptured ectopic pregnancy is the leading cause of first trimester mortality in North America.

OBJECTIVES

Our objective was to compare patients with a ruptured ectopic pregnancy who had an emergency department (ED) point-of-care ultrasound (PoCUS) with those who received a radiology department-performed ultrasound (RADUS). Four time intervals were measured: ED arrival to ultrasound interpretation, obstetric consultation, operating room (OR) arrival, and ultrasound interpretation to OR arrival.

METHODS

This was a retrospective cohort study of patients with ruptured ectopic pregnancy seen between February 2012 and September 2018 at an urban tertiary care hospital. Patients who received an ultrasound in the ED, went directly to the OR, and had confirmed rupture were included.

RESULTS

Of 262 patients diagnosed with ectopic pregnancy during the study period, 36 (14%) were ruptured and 32 were enrolled. Comparing times between PoCUS (n = 10) and RADUS (n = 22) groups, the mean time from ED arrival to ultrasound interpretation was 15 vs. 138 min (difference 123, 95% confidence interval [CI] 88-158), from ED arrival to obstetric consultation was 35 vs. 150 min (difference 115, 95% CI 59-171), from ED arrival to OR arrival was 160 vs. 381 min (difference 222, 95% CI 124-320), and from ultrasound interpretation to OR arrival was 145 vs. 243 min (difference 98, 95% CI 12-184).

CONCLUSION

ED patients with a ruptured ectopic pregnancy who received a PoCUS first had shorter times to diagnosis, obstetric consultation, and OR arrival compared with those who received RADUS.

Partial Hydatidiform Mole in an Ectopic Tubal Pregnancy

Fallopian tubal molar pregnancy is extremely rare, and the main diagnostic tool is the post-operative histopathological diagnosis, as the pre-operative diagnosis is difficult. We report a case of ectopic partial molar pregnancy in the right fallopian tube of a 35-year-old lady that was sent for routine histopathological examination with the clinical diagnosis of ectopic pregnancy and the histopathology report revealed an unusual result.

A Live 13 Weeks Ruptured Ectopic Pregnancy: A Case Report

Ectopic pregnancy is a pregnancy that occurs outside the uterus, most commonly in the fallopian tube. It is usually suspected if a pregnant woman experiences any of these symptoms during the first trimester: vaginal bleeding, lower abdominal pain, and amenorrhea. An elevated BhCG level above the discriminatory zone (2000 mIU/ml) with an empty uterus on a transvaginal ultrasound is essential for confirming ectopic pregnancy diagnosis. Such pregnancy can be managed medically with methotrexate or surgically via laparoscopy or laparotomy depending on the hemodynamic stability of the patient and the size of the ectopic mass. In this case study, we report on a 38-year-old woman, G3P2+0 who presented to King Abdulaziz University Hospital's emergency department with a history of amenorrhea for three months. She was unsure of her last menstrual period and her main complaint was generalized abdominal pain. Upon examination, she was clinically unstable and her abdomen was tender on palpation and diffusely distended. Her BhCG level measured 113000 IU/ml and a bedside pelvic ultrasound showed an empty uterine cavity, as well as a live 13 weeks fetus (measured by CRL). The fetus was seen floating in the abdominal cavity and surrounded by a moderate amount of free fluid, suggestive of ruptured tubal ectopic pregnancy. The patient's final diagnosis was live ruptured 13 weeks tubal ectopic pregnancy which was managed successfully through an emergency laparotomy with a salpingectomy.

Insights of efferocytosis in normal and pathological pregnancy

Efferocytosis, which is known as the phagocytic clearance of dying cells by professional as well as non-professional phagocytes, including a great number of intracellular/extracellular factors and signals, is interrelated with the immune system, contributing to local and systemic homeostasis, especially in tissues with high constitutive rates of apoptosis. Accumulating studies have indicated that immune dysregulation is associated with the pathogenesis of the female reproductive system, which causes preeclampsia (PE), recurrent spontaneous abortion (RSA), ruptured ectopic pregnancy, and so on. And some studies have revealed the pleiotropic and essential role of efferocytosis in these obstetrical disorders. More specifically, the occurrence and development of these diseases were in connection with some efferocytosis-related factors and signals, such as C1q, MBL, and IL-33/ST2. In this review, we systematically review the diverse impacts of efferocytosis in immune system and discuss its relevance to normal and pathological pregnancy. These findings may instruct future basic researches as well as clinical applications of efferocytosis-related factors and signals as latent predictors or therapeutic targets on the obstetrical disorders.

[Simple technique for autologous transfusion in ruptured ectopic pregnancy: Report of six cases managed at the Yaoundé University Hospital in Cameroon]

Ruptured ectopic pregnancies are life-threatening emergencies, especially in developing countries, where many patients do not consult until rupture, sometimes with the patient already in hemorrhagic shock. In this situation, immediate blood transfusion is essential. Homologous blood products are not always available. Furthermore, homologous transfusion carries the risk of transmitting viruses such as HIV and hepatitis B and C. Autologous transfusion (intraoperative blood salvage) may thus be helpful. The authors present 6 cases of autologous transfusion performed at the Yaounde University Hospital (Cameroon) and recommend this method in developing countries where good quality blood cannot always be obtained rapidly.