A scary complication: single-center study on management and outcome of cesarean scar pregnancy

Abstract A cesarean scar pregnancy (CSP) is a scary and life-threatening complication of cesarean section (CS). Nevertheless, the incidence of CS is constantly growing. The CSP incidence is 0,15% of pregnancies after CS which represents 6,1% of all ectopic pregnancies in women with condition after CS. Therefore, it should be more present in the clinical daily routine. From mild nonspecific symptoms to hypovolemic shock, diagnosis and therapy must be performed quickly. With the progressive growth of the scar pregnancy, a uterine rupture involves the risk of severe bleeding, and an emergency hysterectomy could be necessary. Prolongation of pregnancy has been successful only in a few cases.We report 11 cases from our hospital in the past 10 years. In the discussion, treatment options of this complication with an increasing incidence, which is associated with serious morbidity and mortality, are presented based on the current literature. Treatment options include drug therapy, but also surgical or combined procedures with radiological intervention.

Retrospective evaluation of patients treated for ectopic pregnancy: Experience of a tertiary center

Abstract Objective In recent years, there has been an increase in the incidence of ectopic pregnancies; therefore, it is important for tertiary centers to report their approaches and outcomes to expand and improve treatment modalities. The aim of the present study was to evaluate the general characteristics, treatment and outcomes of cases diagnosed with ectopic pregnancy. Methods In total, 432 patients treated for ectopic pregnancy between February 2016 and June 2019 were retrospectively evaluated. Results Overall, 370 patients had tubal pregnancy, 32 had cesarean scar pregnancy, 18 had pregnancy of unknown location, 6 had cervical pregnancy, and 6 had interstitial pregnancy. The most important risk factors were advanced age (> 35 years; prevalence: 31.2%) and smoking (prevalence: 27.1%). Thirty patients who did not have any symptoms of rupture and whose human chorionic gonadotropin (β-hCG) levels were ≤ 200 mIU/ml were followed-up with expectant management, while 316 patients whose β-hCG levels were between 1,500 mIU/ml and 5,000 mIU/ml did not have an intrauterine gestational sac on the transvaginal or abdominal ultrasound, did not demonstrate findings of rupture, and were treated with a systemic multi-dose methotrexate treatment protocol. In total, 24 patients who did not respond to the medical treatment, 20 patients whose β-hCG levels were > 5,000 mIU/ml, 16 patients who had shown symptoms of rupture at the initial presentation, and 6 patients diagnosed with interstitial pregnancy underwent surgery. Patients with cervical and scar pregnancies underwent ultrasound-guided curettage, and no additional treatment was needed. Conclusion The fertility status of the patients, the clinical and laboratory findings, and the levels of β-hCG are the factors that must be considered in planning the appropriate treatment.

Experiencia y manejo del embarazo ectópico cervical: revisión del tema / Experience and management of cervical ectopic pregnancy: topic review

Introducción y Objetivos: El Embarazo Cervical (EC) corresponde a una patología de muy baja frecuencia y tasa de sospecha. En la literatura actual se han propuestos diferentes tratamientos, pero se recomienda el manejo médico con Metotrexato como primera línea. Los objetivos de este estudio son describir las características relevantes de los casos de EC en el servicio de Ginecología del Hospital Dr. Sótero del Río y realizar una revisión actualizada del tema. Métodos: Estudio Retrospectivo de todas las pacientes hospitalizadas en la unidad de Ginecología entre 2004 y 2020. Análisis descriptivo de las pacientes con diagnóstico de Embarazo Cervical. Resultados: Se revisaron 33740 pacientes. 1910 presentaron diagnóstico de Embarazo ectópico, de las cuales 6 corresponden a embarazo cervical, 5 casos se sospecharon desde el ingreso y sólo 1 caso ingresó con el diagnóstico de aborto en evolución. La mayoría fue manejada con Metrotrexato, con buenos resultados y sin complicaciones. Conclusiones: El Embarazo cervical es una patología poco frecuente. El manejo médico con Metrotrexato es la opción de primera línea en pacientes hemodinámicamente estable posibilitando la fertilidad posterior.

Introduction and Objectives: Cervical Pregnancy is known as a pathology of very low frequency and suspicion rate. Different treatments have been proposed in the current literature, but medical management with Methotrexate is recommended as the first line. The objectives of this study are to describe the relevant characteristics of cervical pregnancy cases in the Gynecology Department of the Dr. Sotero del Rio Hospital and to carry out an updated review of the subject. Methods: Retrospective study of all hospitalized patients in the Gynecology unit between 2004 and 2020. Descriptive analysis of patients diagnosed with Cervical Pregnancy. Results: 33740 patients were reviewed. 1910 presented a diagnosis of ectopic pregnancy, of which 6 correspond to cervical pregnancy, 5 cases were suspected from admission and only 1 case entered with the diagnosis of abortion in progress. Most were managed with Methotrexate, with good results and without complications. Conclusion: Cervical pregnancy is a rare disease. Medical management with Methotrexate is the first line option in hemodynamically stable patients enabling subsequent fertility.

Methotrexate therapy for ectopic pregnancies: A tertiary center experience

Abstract Objective Our aim is to demonstrate the importance of methotrexate (MTX) therapy for the treatment of ectopic pregnancy (EP). Methods This retrospective study consisted of 99 patients (72 tubal EPs, 20 pregnancies of unknown location (PUL), 4 cesarean section (CS) scar EPs and 3 cervical EPs) treated with MTX. Results Methotrexate therapy was successful in 68.5% of EPs. There were statistically significant differences between the MTX success and failure groups based on ultrasonographic findings, patient complaints, gestational week and serum human chorionic gonadotropin (hCG) values. The MTX success rates in PUL and tubal pregnancies were 95% and 61.1%, respectively. The MTX success rates in single-dose, two-dose and multi-dose protocol groups were 86.9%, 28.6% and 40%, respectively. All cervical and CS scar ectopic pregnancies were treated successfully with MTX therapy. Conclusion Methotrexate might be the first-line treatment option for EPs under certain conditions. Physicians must be more cautious in cases with higher hCG values, the presence of abdominal-pelvic pain, the presence of fetal cardiac activity, larger gestational sac (GS) diameters, and more advanced gestational weeks according to the last menstrual period.

Tratamiento médico del embarazo ectópico no complicado; experiencia del hospital regional de Talca / Medical treatment of uncomplicated ectopic pregnancy: regional hospital of Talca experience

El tratamiento médico del embarazo ectópico (EE) no complicado es una alternativa para el manejo de esta patología. Existen distintos criterios para su uso y las tasas de éxito publicadas son variadas. Realizamos una revisión de 34 casos de pacientes con diagnóstico de EE no complicado en el Hospital Regional de Talca, reportándose una tasa de éxito con dosis única de metotrexato de 65%. Un 20,5% de las pacientes requirieron una dosis adicional de metotrexato. La tasa total de éxito con tratamiento médico alcanzó un 73.5%. El manejo médico es una alternativa efectiva a la cirugía en pacientes bien seleccionadas. Se debe evaluar de manera local los criterios de inclusión para el tratamiento médico del EE no complicado.

Medical treatment of non complicated ectopic pregnancy is an alternative for the management of this pathology. There are different criteria for it's use, and published success rates are heterogeneous. We reviewed 34 cases of patients with diagnosis of no complicated ectopic pregnancy in Hospital Regional de Talca, and we reported a success rate of 65% with a single dose of methotrexate. 20,5% of patients needed an additional dose of medication. The global success rate of medical treatment was 73,5%. No surgical management is an effective alternative for well-selected patients. The criteria for medical treatment of no complicated EE must be evaluated locally.

Interventional radiology and endovascular surgery in the treatment of ectopic pregnancies / Radiologia intervencionista e cirurgia endovascular no tratamento das prenhezes ectópicas

The advent of interventional radiology enabled remarkable advances in diagnosis and treatment of several situations in obstetrics and gynecology. In the field of obstetrics, these advances include temporary occlusion of the iliac arteries to the management of placenta accreta and/or prior, arteriovenous fistulas after embolization of uterine curettage and management of ectopic uterine and extra-uterine pregnancies. The non-tubal ectopic pregnancy, either cervical, abdominal, ovarian or in a cesarean scar, often represents major therapeutic challenge, especially when exists a desire to maintain fertility. Despite the systemic methotrexate therapy and surgical resection of the ectopic gestational sac be the most used therapeutic options, the interventionist approach of non-tubal ectopic pregnancies, direct injection of methotrexate in the gestational sac and intra-arterial chemoembolization of uterine arteries constitute in the currently literature viable, safe, effective modalities with low morbidity, shorter hospital stay, and rapid clinical recovery. Because of little variety of materials used, and the increase in training of specialists in the area, the radiological intervention as a treatment option in ectopic pregnancies is financially viable and present considerable accessibility in the world and at most of Brazilian medical centers.

O advento da radiologia intervencionista tornou possível avanços notáveis no diagnóstico e no tratamento de diversas situações, na área de ginecologia e obstetrícia. No campo da obstetrícia, esses avanços incluem oclusão temporária das artérias hipogástricas para o manejo de placenta acreta e/ou prévia, embolização de fístulas arteriovenosas após curetagem uterina e manejo de prenhezes ectópicas uterinas e extrauterinas. A gravidez ectópica não tubária, seja cervical, abdominal, ovariana ou na cicatriz de cesárea, muitas vezes representa grande desafio terapêutico, principalmente quando há desejo de manutenção da fertilidade. As opções terapêuticas mais utilizadas para o tratamento de prenhez ectópica não tubária, são: terapia sistêmica com metotrexato e ressecção cirúrgica do saco gestacional ectópico; porém a abordagem intervencionista com injeção direta de metotrexato no saco gestacional ou quimiembolização intra-arterial das artérias uterinas, apresentam-se na literatura recente, como modalidades terapêuticas viáveis, seguras, eficazes, com baixa morbidade, menor tempo de internação e rápida recuperação clínica. Devido ao diminuto arsenal de materiais utilizados e à crescente formação de especialistas na área, a intervenção radiológica, como opção de tratamento nas prenhezes ectópicas, é financeiramente viável e apresenta acessibilidade considerável no mundo e na maioria do centros médicos brasileiros.

Pronóstico reproductivo posterior a un embarazo ectópico según modalidad de tratamiento / Subsequent reproductive prognosis ectopic pregnancy according to treatment modality

Introducción: Entre un 20 - 60 por ciento de las pacientes que presentan un embarazo ectópico (EE) desarrollarán infertilidad en el futuro. Objetivo: Comparar las tasas de fertilidad posterior a un EE según tipo de tratamiento: médico con Metotrexato o quirúrgico, en un grupo de pacientes sin acceso a técnicas de fertilización asistida. Métodos: Presentamos un estudio de cohorte retrospectivo de pacientes con diagnóstico de EE tratadas en el Servicio de Ginecología del Hospital Padre Hurtado, entre enero de 2002 y diciembre de 2007. Se excluyeron pacientes con EE cervical o cornual, las de manejo expectante, y pacientes esterilizadas. El seguimiento mínimo fue de 4 años posterior al EE. Resultados: Se diagnosticaron 288 EE. Se excluyeron del estudio 69 pacientes. De los 219 casos restantes, se obtuvo seguimiento completo en 193 casos (88,1 por ciento). De los 193 casos analizados, 128 fueron pacientes sometidas a resolución quirúrgica, consistente en una salpingectomía de la tuba comprometida y 65 pacientes se trataron con Metotrexato. En 18 de éstas últimas, fracasó el tratamiento médico, requiriendo de una salpingectomía diferida. Excluyendo a estas 18 pacientes, la tasa de embarazo para el grupo de resolución quirúrgica fue de 83,6 por ciento (107 de 128 pacientes) y para el grupo de manejo médico con Metotrexato fue de 80,9 por ciento (38 de 47 pacientes), sin diferencia estadísticamente significativa entre ambos grupos (p=0,67). Conclusión: En este estudio, las tasas de embarazo para ambos grupos de manejo fueron similares, siendo mayores que las reportadas por la literatura.

Introduction: It is estimated that 20-60 percent of patients with ectopic pregnancy, will develop infertility on the future, but knowledge about this matter is scarce. Aims: To compare fertility rates after ectopic pregnancy, among medical treatment with methotrexate and surgery, in patients without opportunity for assisted reproductive techniques. Methods: Retrospective cohort study of patients diagnosed with ectopic pregnancy, treated in Hospital Padre Hurtado's gynecology service, Santiago - Chile, between January 2002 and December 2007. Patients with cervical or cornual ectopic pregnancy, expectant management, or patients, who didn't want future pregnancies, were excluded from the analysis. Follow up was for at least 4 years. Results: 288 ectopic pregnancies were diagnosed; 69 patients were excluded. From the 219 participants, 193 cases (88.1 percent) with complete follow, were included for analysis. Surgical management, which consisted of salpingectomy of the compromised tube, was done on 128 patients. Medical management was done on 65 patients, but 18 patients required differed salpingectomy for treatment failure. Excluding those 18 patients, the pregnancy rates for the surgical management group was of 83.6 percent (107/128) and 80.9 percent (38/47) for the medical management group, not statistically significant (p=0.67). Conclusion: There are similar pregnancy rates for surgical and medical management for patients with ectopic pregnancy history; although these were higher than those reported in literature.

Video laparoscopic intervention for an interstitial pregnancy after failure of clinical treatment / Intervenção videolaparoscópica na gestação intersticial após falha com o tratamento clínico

CONTEXT: Interstitial pregnancy is a rare form of ectopic pregnancy for which the best therapeutic course of action has yet to be determined. Surgical intervention entails a high risk of hemorrhage due to the great vascularization of the cornual region of the uterus. Case descriptions facilitate the analysis of results and aid clinicians in determining the most appropriate course of action in these situations. CASE REPORT: In a patient with an ultrasound diagnosis of interstitial pregnancy, clinical treatment using methotrexate was chosen. However, after one week, there was a marked decline in the serum level of the β subunit of chorionic gonadotropin hormone, although an ultrasound examination revealed embryonic cardiac activity. A second dose of the chemotherapy was administered. Embryonic cardiac activity persisted 48 hours later. Video laparoscopy was performed to achieve right-side cornual resection, which resulted in satisfactory resolution of the case.

CONTEXTO: A gestação intersticial é uma forma rara de gestação ectópica. A melhor opção terapêutica ainda não está definida, havendo risco de hemorragia com o tratamento cirúrgico, em decorrência da grande vascularização na região cornual uterina. A descrição de casos facilitam a análise dos resultados e ajuda os clínicos a determinarem a melhor conduta nessas situações. RELATO DE CASO: Em paciente com diagnóstico ultrassonográfico de gestação intersticial, optou-se por tratamento clínico com administração de metotrexate. Após uma semana, houve declínio acentuado do nível sérico da sub-unidade β do hormônio gonadotrófico coriônico, porém, na ultrassonografia, foi detectada a presença de atividade cardíaca embrionária. Foi administrada uma segunda dose do quimioterápico. Após 48 horas, a atividade cardíaca persistia. Realizou-se vídeo-laparoscopia para ressecção cornual direita, com resolução satisfatória do caso.

Gestación ectópica cervical tratada mediante punción ecoguiada intrasacular de metotrexato / Cervical pregnancy treated with local injection of methotrexate guided by transvaginal ultrasonography

El embarazo cervical es una forma infrecuente de gestación ectópica. El examen ecográfico permite el diagnóstico precoz, y una actuación conservadora. Se describe el caso clínico de una gestación ectópica cervical diagnosticada en el Servicio de Urgencias de Obstetricia y Ginecología del Hospital Universitario Miguel Servet (Zaragoza, España). Paciente nulípara de 31 años que consultó por sangrado genital. El diagnóstico se realizó mediante ecografía transvaginal, objetivándose un embarazo ectópico cervical con embrión vivo acorde a 8 semanas de edad gestacional. Se realizó tratamiento conservador con metotrexato mediante inyección local intrasacular asociado a administración sistémica. Seguimiento con determinaciones seriadas de gonodotrópica coriónica humana, objetivándose un descenso progresivo de ésta. Se efectuaron controles ecográfcos periódicos, evidenciando la reabsorción de la gestación confirmándose el éxito del tratamiento.

Cervical ectopic pregnancy is an unusual form of ectopic pregnancy. Ultrasound examination makes early diagnosis possible and permits to perform conservative treatment. We describe a case of cervical ectopic pregnancy diagnosed in the Emergency Section of Miguel Servet University Hospital (Zaragoza, Spain). A 31 year-old nullipara pregnant woman came to our Hospital because of genital bleeding. Ultrasound trans-vaginal examination demonstrated a cervical pregnancy with an 8 weeks embryo. Conservative treatment was prescribed using US-guided injection and systemic methotrexate. After treatment, weekly quantitative human chorionic gonadotrophin levels were determined and decreased progressively. Serial ultrasound exams were performed demonstrating how pregnancy products underwent resorption and confirming therapy success.

Tratamento clínico da gravidez ectópica com metotrexato / Medical treatment of ectopic pregnancy with methotrexate

A gravidez ectópica é uma importante causa de morbimortalidde materna no primeiro trimestre gestacional. As dosagens hormonais seriadas e a ultrassonografia endovaginal, realizadas atualmente, facilitaram o diagnóstico e tratamento da gravidez ectópica, antes que ocorresse a ruptura tubária. O tratamento clínico medicamentoso com o metotrexato, um antagonista do ácido fólico altamente tóxico a tecidos em rápida replicação, é bastante utilizado em gestações ectópicas íntegras, adequadamente selecionadas. Muitos estudos vêm sendo realizados a fim de tentar definir quais grupos de pacientes se beneficiariam desse tratamento e, qual seria o melhor esquema de administração dessa droga, com redução dos efeitos colaterais e melhores taxas de sucesso. Esta revisão expõe as opções de tratamento medicamentoso mais estudadas para tratamento da gravidez ectópica íntegra, com ênfase nas taxas de sucesso de tratamento (cura, persistência de tecido trofoblástico e permeabilidade tubária) e no prognóstico a longo prazo.

Ectopic pregnancy is a significant cause of morbity and mortality in the first trimester of pregnancy. Serial hormone assays and transvaginal ultrasonography facilitate the diagnosis and treatment of ectopic pregnancy before rupture occurs. Early nonsurgical diagnosis and appropiate treatment have resulted in diversity of management options and decline in mortality, due to this pathology. Treatment with methotrexate, a folic acid antagonist, highly toxic to rapidly replicating tissues, can be applied on selected patients with non-ruptured ectopic pregnancy. Many studies have been developed intending to define which patients would be benefited by this treatment and how to administer this drug, with low side effects and good successful rates. This review refers to the best practice on non-ruptured ectopic pregnancy, with emphasis on treatment success rates (cure rate, incidence of persistent trophoblast and tubal patency) and long-term prognosis.

Embarazo ectópico ístmico-cervical en cicatriz de cesárea previa / Ectopic pregnancy within the scar of a previous cesarean of isthmic-cervical location

El embarazo localizado dentro de una cicatriz de cesárea previa es el menos frecuente de los embarazos ectópicos y no existe un tratamiento estándar. Se presenta el caso clínico de una paciente con embarazo ectópico ístmico-cervical sobre una cicatriz de cesárea. Se hospitaliza por el riesgo de ruptura uterina, evolucionó con invasión trofoblástica de la histerorrafia culminando en muerte embrionaria. No hubo complicaciones maternas. Se trató con metotrexato para evitar la progresión de la invasión trofoblástica, con buen resultado materno.

Unruptured tubal pregnancy: different treatments for early and late diagnosis

CONTEXT AND OBJECTIVE: There is evidence that ectopic pregnancies present different behavioral patterns. These distinct evolutions of ectopic pregnancies represent two different natural histories. To evaluate these evolution patterns, we compared patients undergoing medical treatment and expectant management according to their gestational age and initial beta-hCG levels. DESIGN AND SETTING: Prospective study at the Department of Obstetrics of Universidade Federal de São Paulo, a tertiary center. METHODS: Among 119 cases of unruptured ectopic pregnancies diagnosed from April 1999 to February 2004, 57 received systemic treatment with methotrexate 50 mg/m² (body surface area) intramuscularly and 62 were managed expectantly. In this study we evaluated the beta-hCG levels at presentation and amenorrhea duration. RESULTS: There was a significant difference between the two groups regarding amenorrhea duration and initial beta-hCG levels (p < 0.001). The group with decreasing beta-hCG levels (managed expectantly) had longer amenorrhea (mean: 8.87 ± 1.71 weeks) and lower initial beta-hCG levels (mean: 648.8 ± 754.7 mIU/ml). On the other hand, the group treated with methotrexate had shorter amenorrhea (mean: 6.81 ± 1.88 weeks) and higher beta-hCG levels at presentation (2642.7 ± 2315.1 mIU/ml). CONCLUSIONS: The data suggest that ectopic pregnancies can be categorized into two groups: those with early diagnosis and shorter amenorrhea, increasing or maintained beta-hCG levels over 24 and 48-hour intervals and higher beta-hCG levels requiring medical treatment; and those with late diagnosis and longer amenorrhea, decreased beta-hCG levels over 24 and 48-hour intervals and lower beta-hCG levels requiring expectant management.

CONTEXTO E OBJETIVO: A gravidez ectópica apresenta comportamentos diferentes. Para avaliar as diferentes evoluções da gravidez ectópica, nós comparamos as pacientes submetidas ao tratamento medicamentoso e à conduta expectante de acordo com a idade gestacional e os valores iniciais de beta-hCG. TIPO DE ESTUDO E LOCAL: Estudo prospectivo, realizado no Departamento de Obstetrícia da Universidade Federal de São Paulo, hospital terciário. MÉTODOS: Foram diagnosticados 119 casos de gravidez ectópica íntegra no período de abril de 1999 a fevereiro de 2004. O tratamento com metotrexato 50 mg/m² de superfície corpórea intramuscular foi realizado em 57 casos e a conduta expectante, em 62 casos. Neste estudo, nós avaliamos os valores iniciais de beta-hCG e o período de amenorréia. RESULTADOS: Houve diferença estatística significante entre os dois grupos com relação ao período de amenorréia e os valores iniciais de beta-hCG (p < 0,001). O grupo com títulos de beta-hCG em regressão (conduta expectante) apresentaram período de amenorréia mais longo (média:8,87 ± 1,71 semanas) e valores iniciais de beta-hCG mais baixos (648,8 + 754,7 mUI/ml). Por outro lado, o grupo tratado com metotrexato teve período menor de amenorréia (média 6,81 + 1,88 semanas) e valores de beta-hCG mais altos (2642,7 +2315,1 mUI/ml). CONCLUSÕES: Os resultados deste estudo sugerem que a gravidez ectópica pode ser categorizada em dois grupos: aquelas com diagnóstico precoce com período curto de amenorréia e valores elevados de beta-hCG que requerem tratamento com metotrexato, e aquelas com diagnóstico tardio com período longo de amenorréia e valores baixos de beta-hCG que requerem a conduta expectante.

Medical treatment of ectopic pregnancy: a ten-year review of 106 cases at Maharaj Nakorn Chiang Mai Hospital.

OBJECTIVE: To evaluate the effectiveness of single-dose intramuscular methotrexate in the treatment of ectopic pregnancy at Maharaj Nakorn Chiang Mai Hospital MATERIAL AND METHOD: A retrospective review of the patient records was performed on the patients with diagnosis of ectopic pregnancy and treatment with single-dose methotrexate according to the protocol of Stovall et al between 1996 and 2005. The successful treatment was defined as no need for surgical intervention. RESULTS: As many as 96 out of 106 (90.6%) were successfully treated with methotrexate, though four required a second dose. Pretreatment /f-human chorionic gonadotropin (beta-hCG) levels were significantly lower in women who responded to single-dose therapy than either in those who required two doses or who had a failure of medical management (p < 0. 01). The mean pretreatment level of beta-hCG was 873 mlU/ml. The median time to resolution of beta-hCG was 21 days. In addition, all cases with failed medical treatment had adnexal masses larger than 3.5 centimeters in diameter CONCLUSION: In the present series, treatment of ectopic pregnancy with single-dose methotrexate was as high as 90% successful. Women with a high pretreatment beta-hCG level and large sonographic adnexal masses had a greater probability of requiring either surgical intervention or multiple doses of methotrexate.

Tubal patency following surgical and clinical treatment of ectopic pregnancy

CONTEXT AND OBJECTIVE: As there is little information about fertility outcomes among women following clinical treatment (methotrexate and expectant management) and surgery (salpingectomy) consequent to ectopic pregnancy, we evaluate the results from hysterosalpingography subsequent to treatment. The objective was to evaluate contralateral tubal patency using hysterosalpingography following surgery and clinical treatment of tubal pregnancy. DESIGN AND SETTING: This was a prospective study at the Department of Obstetrics of Universidade Federal de São Paulo, a tertiary center. METHOD: Among 115 patients who underwent hysterosalpingography following surgery and clinical treatment of tubal pregnancy between April 1994 and February 2002, 30 were treated with a single intramuscular dose of methotrexate (50 mg/m²), 50 were followed up expectantly and 35 underwent salpingectomy. RESULTS: The patency of the ipsilateral tube was 84 percent after methotrexate treatment and 78 percent after expectant management. In addition, contralateral tubal patency was 97 percent after methotrexate treatment, 92 percent after expectant management and 83 percent after salpingectomy. There were no statistically significant differences between the clinical treatment and surgery groups. CONCLUSIONS: The findings from this study suggest similar contralateral tubal patency rates following salpingectomy, methotrexate treatment and expectant management.

CONTEXTO E OBJETIVO: Como existem poucas informações a respeito do futuro reprodutivo das pacientes tratadas de gravidez ectópica através do tratamento clínico (metotrexato e conduta expectante) e da cirurgia (salpingectomia), avaliamos as histerossalpingografias após o tratamento da gravidez ectópica. O objetivo foi avaliar a permeabilidade da tuba contralateral pela histerossalpingografia após o tratamento cirúrgico e clínico da gravidez tubária. TIPO DE ESTUDO E LOCAL: Estudo prospectivo realizado no Departamento de Obstetrícia da Universidade Federal de São Paulo (centro terciário). MÉTODOS: Foram realizadas 115 histerossalpingografias após o tratamento clínico e cirúrgico da gravidez tubária no período de 1994 a 2002, sendo que 30 após o tratamento com dose única de metotrexato (50 mg/m²) intramuscular, 50 após a conduta expectante e 35 após a salpingectomia. RESULTADOS: A permeabilidade tubária ipsilateral foi de 84 por cento após o tratamento com metotrexato e de 78 por cento após a conduta expectante. A permeabilidade da tuba contralateral foi de 97 por cento após o tratamento com metotrexato, 92 por cento após a conduta expectante e 83 por cento após a salpingectomia. Não houve diferença estatisticamente significante entre os grupos de tratamento cirúrgico e clínico. CONCLUSÃO: Os dados deste estudo sugerem que a permeabilidade tubária contralateral é similar após a salpingectomia, o tratamento com metotrexato e a conduta expectante.

Embarazo cervical: una decisión dificil de tomar / Cervical pregnancy: a difficult decision to take

Se presenta el caso de una paciente con embarazo cervical, la dificultad diagnóstica ultrasonográfica, lo difícil de tomar una decisión terapéutica adecuada, su evolución y resultado final.

Manejo laparoscópico conservador de embarazo cornual / Conservative laparoscopical handling of cornual pregnancy

Se presenta el abordaje laparoscópico conservador de un embarazo Cornual izquierdo, diagnosticado en forma precoz por ecotomografía transvaginal, en que se realiza una Cuernostomía, extracción del saco más embrión, raspado del cuerno y sutura con puntos laparoscópicos con nudos endoscópicos, se discute su cuadro clínico, complicaciones y tratamiento.

Demographic characteristics of women with self use of misoprostol for pregnancy interruption attending Maharaj Nakorn Chiang Mai Hospital.

OBJECTIVE: To ascess the demographic characteristics of pregnant women and their partners including details of self use of misoprostol for pregnancy interruption. STUDY DESIGN: Prospective descriptive study. SETTING: Department of Obstetrics and Gynecology, Maharaj Nakorn Chiang Mai Hospital. SUBJECTS: 103 pregnant women with self use of misoprostol for pregnancy interruption from June 1999 to June 2001. METHOD: All subjects were interviewed use the same set of questionnaires. RESULTS: The mean age of the women and their partners were 20.81 +/- 4.10 and 22.46 +/- 5.05 years old respectively. The mean gestational age was 13.85 +/- 5.37 weeks. The most common reason for pregnancy interruption was that they wanted to continue studying. The number of misoprostol tablets used ranged from 1-11 and 87.4 per cent of the women applied this drug via the vaginal route. The main source of drug purchasing was from friends, while the mean total cost was 663.16 +/- 711.32 Baht. No major side effect was detected in the present study. CONCLUSION: Misoprostol, the agent primarily used for gastric and duodenal ulcer prevention, is now used by pregnant women to interrupt their pregnancies. The present study is only the evidence reflecting the tip of the iceberg in this society, changing in sexual behavior, change in abortion techniques, and knowledge on contraception. Though major complications were not found in this study, misoprostol should not be considered safe, because several patients have encountered bleeding or incomplete abortion and required hospital stay.

Tratamiento médico del embarazo ectópico: evaluación prospectiva de la fertilidad / Medical treatment of ectopic pregnancy: prospective evaluation of fertility

Se presenta la evaluación reproductiva, a través del método de las tablas de vida, aplicado a una cohorte de 16 pacientes tratadas con metotrexato parenteral por embarazo ectópico, en el período comprendido entre julio de 1993 y julio de 2002. Estudio realizado en el Instituto de Investigaciones Materno-Infatil, Universidad de Chile y Servicio de Ginecología. Hospital San Borja-Arriarán e Integramédica, división Ginecología. Todas las pacientes negativizaron la gonadotrofina coriónica. La permeabilidad tubaria fue evaluada en 12 de 16 pacientes, siendo permeable la trompa ipsilateral en 75% de los casos. La tasa acumulativa de embarazo intrauterino a los 24 meses fue de un 57%, con una fecundabilidad de 2%. En los casos con trompa única, la tasa acumulativa de embarazo normal fue de 40%, con una fecundabilidad de 1,6% a los dos años. Al evaluar la recidiva de embarazo ectópico, encontramos una tasa acumulativa de 48% a los 24 meses. Los resultados obtenidos en esta serie en términos de permeabilidad tubaria y embarazo intrauterino son satisfactorios. La recidiva de embarazo ectópico y la baja fecundabilidad se asociarían al daño tubario previo. El tratamiento médico del embarazo ectópico es una alternativa válida en casos bien seleccionados, con resultados reproductivos aceptables.

Our group performed a survival analysis of fertility after pregnancy of 16 patients treated with intramuscular methotrexate, between july 1993 and july 2002, in the Instituto de Investigaciones Materno-Infantil, Obstet Gynecol Dept., San Borja-Arriarán Hospital, University of Chile and a private health center; Integramédica, división of Gynecology. All cases normalized chorionic gonadotropin. Tubal patency has been evaluated in 12 of 16 patients; 75% of the cases had patent tube in the involved side. The cumulative intrauterine pregnancy rate was 57% at 2 years with a fecundity of 2%. In the cases with a single tube, the cumulative intrauterine pregnancy rate was 40% with a 1.6% fecundity at 24 months. The ectopic pregnancy recurrence had a cumulative pregnancy rate of 48% at 2 years. The results in terms of tubal and intrauterine pregnancy obtained in this series are adequate. The ectopic pregnancy recurrence and low fecundity are probably associated to previous tubal damage. Medical treatment of ectopic pregnancy is a valid choice in selected cases with an acceptable reproductive outcome.

Effects of misoprostrol on pentylenetetrazol-induced seirures in mice

The effects of prostaglandin E - analogue misoprostol on the susceptibility to pentilenetetrazol (PTZ) - induced seizures were examined in mice. Misoprostol (200-800 mug/kg), given subcutaneously 45 min before the subconvulsive dose of PTZ (30 mg/kg, i.p) provoked dose-dependent clonic-tonic seizures (30 to 100 percent) and mortality in mice. At 300 g/kg, s.c., misoprostol pretreatment significantly (p<0.05) lowered the onset latency to first convulsion as well as the latency to mortality induced by a convulsive dose of PTZ (60 mg/kg, i.p.). At this dose misoprostol was found to lower the CD50 and Ld50 values for PTZ by 21 percent and 36 percent respectively. The results suggest that prostaglandins are likely to lower the threshold for convulsions.