Prediction of Rupture by Complete Blood Count in Tubal Ectopic Pregnancies Treated with a Single-Dose Methotrexate Protocol / Predição de ruptura por hemograma completo em gestações ectópicas tubárias tratadas com protocolo de dose única de metotrexato

Abstract Objective The availability of reliable and inexpensive markers that can be used to determine the risk of rupture during methotrexate (MTX) treatment in ectopic pregnancies (EPs) is considerable. The aim of the present study is to investigate the role of systemic inflammatory markers such as leukocytes (or white blood cells, WBCs), the neutrophil-to-lymphocyte ratio (NLR), and platelet distribution width (PDW), which are among the parameters of the complete blood count (CBC), in the prediction of rupture of EPs under MTX treatment. Materials and Methods A total of 161 patients with tubal EP who underwent a single-dose methotrexate (MTX) protocol were retrospectively analyzed, and the control group (n = 83) included patients cured by MTX, while the ruptured group (n = 78) included patients who were operated on for tubal rupture during the MTX treatment. The features of EP, beta-human chorionic gonadotropin (β-hCG) levels, sonographic findings, and CBC-derived markers such as WBC, NLR, and PDW, were investigated by comparing both groups. Results The NLR was found to be higher in the ruptured group, of 2.92 ± 0.86%, and significantly lower in the control group, of 2.09 ± 0.6%. Similarly, the PDW was higher (51 ± 9%) in the ruptured group, and it was significantly lower a (47 ± 13%) in the control group (p < 0.05). Other CBC parameters were similar in both groups (p > 0.05). Conclusion Systemic inflammation markers derived from CBC can be easily applied to predict the risk of tubal rupture in Eps, since the CBC is an inexpensive and easy-to-apply test, which is first requested from each patient during hospitalization.

Resumo Objetivo A disponibilidade de marcadores confiáveis e baratos que podem ser usados para determinar o risco de ruptura durante o tratamento com metotrexato (MTX) em gestações ectópicas (GEs) é considerável. O objetivo do presente estudo é investigar o papel de marcadores inflamatórios sistêmicos, como leucócitos (ou glóbulos brancos, glóbulos brancos), a relação neutrófilo-linfócito (NLR) e largura de distribuição de plaquetas (PDW), que estão entre os parâmetros do hemograma completo (hemograma), na predição de ruptura de PEs sob tratamento com MTX. Materiais e Métodos Foram analisados retrospectivamente 161 pacientes com EP tubária submetidas a protocolo de dose única de metotrexato (MTX), sendo que o grupo controle (n = 83) incluiu pacientes curadas com MTX, enquanto o grupo roto (n = 78) incluíram pacientes operadas por ruptura tubária durante o tratamento com MTX. As características de EP, beta-gonadotrofina coriônica humana (β-hCG), achados ultrassonográficos e marcadores derivados de CBC, como WBC, NLR e PDW, foram investigados comparando os dois grupos. Resultados A RNL foi maior no grupo roto, de 2,92 ± 0,86%, e significativamente menor no grupo controle, de 2,09 ± 0,6%. Da mesma forma, o PDW foi maior (51 ± 9%) no grupo roto, e foi significativamente menor a (47 ± 13%) no grupo controle (p < 0,05). Outros parâmetros do hemograma foram semelhantes em ambos os grupos (p > 0,05). Conclusão Marcadores inflamatórios sistêmicos derivados do hemograma podem ser facilmente aplicados para predizer o risco de ruptura tubária na Eps, uma vez que o hemograma é um exame de baixo custo e fácil aplicação, solicitado primeiramente a cada paciente durante a internação.

Experience of a Tertiary Service in the Treatment of Women with Cervical Pregnancy / Experiência de um serviço terciário no tratamento de mulheres com gravidez ectópica cervical

Abstract Objective Cervical pregnancy is challenging for the medical community, as it is potentially fatal. The treatment can be medical or surgical; however, there are no protocols that establish the best option for each case. The objective of the present study was to describe the cases of cervical pregnancy admitted to a tertiary university hospital over a period of 18 years. Methods A retrospective study based on a review of the medical records of all cervical pregnancies admitted to the Women's Hospital at Universidade Estadual de Campinas, Southeastern Brazil, from 2000 to 2018. Results We identified 13 cases of cervical pregnancy out of a total of 673 ectopic pregnancies; only 1 case was initially treated with surgery because of hemodynamic instability. Of the 12 cases treated conservatively, 7 were treated with single-dose intramuscular methotrexate, 1, with intravenous and intramuscular methotrexate, 1, with intravenous methotrexate, 1, with 2 doses of intramuscular methotrexate, and 2, with intra-amniotic methotrexate. Of these cases, one had a therapeutic failure that required a hysterectomy. Two women received blood transfusions. Four women required cervical tamponade with a Foley catheter balloon for hemostasis. There was no fatal outcome. Conclusion Cervical pregnancy is a rare and challenging condition from diagnosis to treatment. Conservative treatment was the primary method of therapy used, with satisfactory results. In cases of increased bleeding, cervical curettage was the initial treatment, and it was associated with the use of a cervical balloon for hemostasis.

Resumo Objetivo A gravidez ectópica cervical é um desafio para a comunidade médica, pois pode ser fatal. O tratamento pode ser clínico ou cirúrgico, mas não existem protocolos que estabeleçam a melhor opção para cada caso. O objetivo deste estudo foi descrever os casos de gravidez ectópica cervical internados em um hospital universitário terciário durante 18 anos. Métodos Estudo retrospectivo com revisão de prontuários de todas as gestações ectópicas cervicais internadas no Hospital da Mulher da Universidade Estadual de Campinas de 2000 a 2018. Resultados Foram identificados treze casos de gestação ectópica cervical em um total de 673 gestações ectópicas; apenas 1 caso foi inicialmente tratado com cirurgia por causa de instabilidade hemodinâmica. Dos 12 casos tratados conservadoramente, 7 foram tratados com metotrexato por via intramuscular em dose única, 1, com metotrexato pelas vias intravenosa e intramuscular, 1, com metotrexato por via intravenosa, 1, com 2 doses de metotrexato por via intramuscular, e 2, com metotrexato por via intra-amniótica. Desses casos, um apresentou falha terapêutica, e realizou-se uma histerectomia. Duas mulheres receberam transfusões de sangue. Quatro mulheres necessitaram de tamponamento cervical com cateter balão de Foley para hemostasia. Não houve casos fatais. Conclusão A gravidez cervical é uma condição rara e desafiadora desde o diagnóstico até o tratamento. O tratamento conservador foi o principal método terapêutico utilizado, com resultados satisfatórios. Nos casos de sangramento aumentado, a curetagem cervical foi o tratamento inicial, e foi associada ao uso de balão cervical para hemostasia.

Tratamiento del embarazo ectópico en cicatriz de cesárea: revisión de la literatura a propósito de 3 casos / Treatment of ectopic pregnancy in a cesarean scar: review of the literature regarding 3 cases

INTRODUCCIÓN Y OBJETIVOS: El embarazo en cicatriz de cesárea previa (ECC) es una entidad poco frecuente que puede tener graves consecuencias. Hasta la fecha no existen esquemas estandarizados de tratamiento y su manejo óptimo sigue siendo controvertido. Nuestro objetivo es realizar una revisión de la literatura publicada sobre el manejo del ECC y proponer un algoritmo. También exponemos tres casos de ECC resueltos con diferentes tratamientos en el Hospital Universitario Infanta Elena MÉTODOS: Búsqueda de la literatura en bases de datos utilizando las palabras clave: "embarazo en cicatriz cesárea"," gestación ectópica en cicatriz cesárea", "tratamiento", "manejo". RESULTADOS: Las opciones terapéuticas pueden ser médicas, quirúrgicas o una combinación de ambas. Los tratamientos quirúrgicos tienen altas tasas de éxito, sin embargo, son más invasivos y no están exentos de riesgo. La combinación de tratamientos parece aumentar la tasa de éxito, no obstante, podría implicar un mayor riesgo de efectos secundarios y costes. CONCLUSIONES: El manejo de los ECC debe de ser individualizado, basado en la evidencia científica, en los medios disponibles y la experiencia de los profesionales en los distintos procedimientos, guiándonos por el tipo de ECC y su grado de vascularización e invasión, grosor del miometrio, niveles de beta-hCG, presencia de actividad cardiaca, clínica y estabilidad hemodinámica de la paciente. Deben tenerse en cuenta las circunstancias y patología intercurrente de la mujer, así como su deseo genésico o de preservación del útero.

INTRODUCTION AND OBJECTIVES: Cesarean scar pregnancy (CSP) is a rare entity that can cause serious consequences. Up to now, there are no standardized treatment schemes, and its optimal management remains controversial. Our objetive is to review the literature regarding CSP management and propose an algorithm. We also present three cases of CSP resolved with different treatments at Hospital Universitario Infanta Elena. METHODS: Literature search in databases using the following keywords: pregnancy with cesarean section, ectopic pregnancy with cesarean section, treatment, management. RESULTS: The therapeutic options can be medical, surgical or a combination of both. Surgical treatments have high success rates; however, they are more invasive and are not without risk. The combination of treatments seems to increase the success rate; however, it could imply a higher risk of side effects and costs. CONCLUSIONS: The management of CSP must be individualized; based on scientific evidence, on the means available, and on the experience of the professionals in the different procedures; guided by the type of CSP and its degree of vascularization and invasion, by the thickness of the myometrium, beta-hCG levels, presence of cardiac activity, and by clinical and hemodynamic stability of the patient. The circumstances and intercurrent pathology of the patient must be considered, as well as her desire for future pregnancy or preservation of the uterus.

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.

Local management with methotrexate of cesarean scar ectopic pregnancy with live embryo guided by transvaginal ultrasound: A case report / Tratamento local com metotrexato guiado por ultrassonografia transvaginal de gravidez ectópica em cicatriz de cesárea com embrião vivo: relato de caso

Summary Cesarean scar ectopic pregnancy is a rare type of ectopic pregnancy with high morbidity and mortality. Use of conservative conducts, including medical management with methotrexate, has avoided mutilating surgeries such as hysterectomy and spared the fertility of women. We report the case of a 30-year old patient with a cesarean scar ectopic pregnancy, with a live embryo, who was treated locally with transvaginal ultrasound-guided injection of methotrexate, complemented with various doses of systemic methotrexate.

Resumo A gravidez ectópica na cicatriz de cesárea é uma forma rara de gestação ectópica com elevada morbimortalidade. O emprego de condutas conservadoras, como o tratamento medicamentoso com metotrexato, tem evitado cirurgias mutiladoras, como a histerectomia, e preservado o futuro reprodutivo da mulher. Relatamos um caso de paciente de 30 anos, com gravidez ectópica em cicatriz de cesárea, com embrião vivo, tratada com injeção local de metotrexato guiada por ultrassonografia transvaginal, complementada com tratamento sistêmico com múltiplas doses de metotrexato.

Embarazo extrauterino abdominal / Abdominal ectopic pregnancy

El embarazo extrauterino abdominal es uno de los tipos de embarazo ectópico junto con el ovárico, menos frecuentes. El diagnóstico es difícil y suele realizarse de forma tardía, lo que contribuye a aumentar la morbimortalidad materna. Presentamos el caso de un embarazo abdominal diagnosticado a las 9 semanas de amenorrea con embrión de tamaño acorde con edad gestacional, asintomática al diagnóstico, que se resolvió satisfactoriamente mediante laparotomía(AU)

Abdominal pregnancy is one of the rarest types of ectopic pregnancy. The diagnosis is difficult and is generally delayed. We report the case of an abdominal pregnancy diagnosed at 9 weeks of amenorrea, with size of embryo according to gestational age, asymptomatic at diagnosis, whichwas resolved satisfactorily by laparotomy(AU)

Uso de metrotexato en el manejo medico de embarazo ectópico en el Hospital Primero de Mayo del Instituto Salvadoreño del Seguro Social de enero a junio 2014 / Use of methotrexate in the medical management of ectopic pregnancy at the "Primero de Mayo" Hospital of the "Instituto Salvadoreño del Seguro Social" from January to June 2014

El embarazo ectópico es una complicación médica en Ginecología y Obstetricia potencialmente mortal, sin embargo, con el advenimiento de la ultrasonografía de alta resolución y el uso de cuantificación de la hormona Gonadotropina Coriónica Humana en su fracción Beta (BHCG) es posible realizar el diagnóstico del mismo de manera precoz y así ofrecer a los pacientes métodos no invasivos para el manejo de esta patología En el Hospital primero de Mayo que es nuestro hospital escuela, se utiliza el Metrotexato que es un agonista del ácido fólico e inhibe la replicación celular, provocando en el huevo anormalmente implantado una destrucción y la consiguiente reabsorción del mismo, utilizado en las pacientes con embarazo ectópico no roto que cumplieron los criterios de inclusión establecidos por el Ministerio de Salud. El estudio surgió con el fin de analizar los resultados en las pacientes en las que se cumplió manejo con metrotexato para embarazo ectópico no roto, utilizando los criterios de inclusión recomendados por el Ministerio de Salud que rige nuestro hospital, en comparación con los resultados obtenidos por el American College of Obstetricias and Gynecologists (ACOG) obtenidos a nivel internacional. Nuestra meta fue poder analizar los resultados finales del manejo medico con metrotexato en nuestras pacientes y de estos cuales finalizaron en un acto quirúrgico y poder así comparar con los resultados internacionales del American College of Obstetricians y Gynecologists (ACOG) y además que nuestro estudio funcione como aporte para el futuro manejo médico del embarazo ectópico en nuestra institución. Como muestra se tomaron las pacientes que ingresaron al puerperio 2 con el diagnóstico de embarazo ectópico no roto y se les cumplió manejo medico con metrotexate. Resultando en un total de 30 pacientes, a quienes se les brindo manejo con metrotexate, concluyendo en base a los resultados obtenidos en nuestra investigación lo siguiente: • Se obtendrían mejores resultados para las pacientes con embarazo ectópico no roto tratadas con manejo médico, que cumplieran los criterios de BHCG menor a 5000 mIU/ml y el tamaño de la masa menor a 35 mm. • Se recomienda a las jefaturas de ginecología y obstetricia del hospital primero de mayo, redactar nuevos lineamientos a nivel institucional, recomendando la aplicación de los criterios de inclusión del ACOG, ya estos revelaron mejores resultados para un manejo médico. • Es importante el seguimiento ambulatorio de las pacientes a quienes se les da manejo con metrotexate, así como también la búsqueda de las pacientes que por diferentes motivos interrumpen el seguimiento.

Embarazo ectópico abdominal en paciente posmenopáusica / Abdominal ectopic pregnancy in postmenopausal patient

La anidación anómala del blastocito se denomina como gestación ectópica. El embarazo ectópico abdominal es una forma rara que se presenta en aproximadamente el 1 por ciento de ellos. Se define como la implantación del producto de la concepción en la cavidad peritoneal, excluyendo las localizaciones tubáricas, ováricas e intraligamentarias. Este es de difícil diagnóstico, pues en muchas ocasiones se realiza de forma tardía. El objetivo del presente trabajo es presentar el caso de una paciente posmenopáusica que tuvo un embarazo ectópico abdominal lo cual lo hace aún más raro, de esta forma aportamos un conocimiento que quizá nunca se ha visto por muchos ginecobstetras(AU)

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.

Embarazo cornual: tratamiento médico con dosis única de metotrexato / Cornual pregnancy treated with single intramuscular methotrexate dose

Presentamos un caso de embarazo cornual o intersticial diagnosticado en forma precoz a través de ecografía transvaginal, tratado exitosamente, en forma conservadora, con dosis única sistémica de metotrexato.

We present a case of cornual or interstitial pregnancy diagnosed during early stage through transvaginal ultrasound, treated successfully with single systemic intramuscular methotrexate dose.

[Cost of medical treatment with methotrexate for ectopic pregnancy. Comparative study medical versus conservative laparoscopy. Experience of Aziza Othmana's hospital]

The ectopic pregnancy can be treated surgically [conservative or radical] or medically. Currently, the choice between medical and surgical treatment is a critical issue. One of the parameters of this choice is the total cost of management. To compare the cost of the management of ectopic pregnancy by medical treatment [methotrexate, MTX] and coeliochirurgicaux. This is a prospective, comparative, nonrandomized,unicentric study, on 39 patients who have ectopic pregnancies treated with MTX versus 16 patients treated by laparoscopic surgery with conservative treatment. This study was collected at the service of Obstetrics and Gynecology Reproductive Medicine Aziza Othmana Hospital [Tunis] for a period of two years. The average cost of hospital stay per patient was 549.38 dt for the MTX group against 268.39 dt for laparoscopic surgery group [p <0.001]. There was no statistically significant difference between the two groups. In terms of overall absenteeism, there is no statistically significant difference [16.43 vs 17.5 days]. The initial treatment with MTX costs more cost than the conservative laparoscopic treatment and this is mainly due to the long period of hospitalization

Diagnóstico y manejo conservador del embarazo ectópico cervical / Diagnosis and conservative management of cervical ectopic pregnancy

Introducción: se define como embarazo ectópico cervical (EEC) a la implantación del huevo fertilizado a nivel del orificio cervical interno (OCI) o por debajo de Úl. Objetivos: presentar un caso de embarazo ectópico cervical y su estrategia de tratamiento con el uso de methotrexate. Métodos: se describe un caso de embarazo ectópico cervical de una paciente de 30 años de edad, nulípara, con gestación menor de 7 sem, diagnosticado en el Servicio de Urgencia del Hospital Ginecobstétrico Ramón González Coro mediante ecografía transvaginal. Resultados: el tratamiento se inició con methotrexate parenteral y local, y luego se asoció misoprostol por vía vaginal, como coadyuvante del tratamiento para posterior dilatación y legrado del canal cervical. Conclusión: la paciente evolucionó favorablemente sin requerir otro tipo de intervención

Introduction: it is defined as cervical ectopic pregnant (CEP) the implantation of the ovum fertilized at level of the internal cervical orifice (ICO) or underneath it. Objectives: to present a case of cervical ectopic pregnancy and its treatment strategy with the use of methotrexate. Methods: a case of cervical ectopic pregnancy is described in a patient aged 30, nullipara with a 7 weeks pregnancy diagnosed in the Emergency Service of the Ramón González Coro Gynecology and Obstetrics Hospital by transvaginal echography. Results: treatment began with parenteral and local methotrexate and then Misoprostol by vaginal route was added as treatment adjuvant for a subsequent dilation and curettage of cervical channel. Conclusion: The patient had a favorable evolution without another type of intervention

Manejo del embarazo ectópico / Management of ectopic pregnancy

Objetivo: determinar el manejo de las pacientes con posible diagnóstico de embarazo ectópico. Métodos: se realizó un estudio retrospectivo transversal y descriptivo sobre el manejo del embarazo ectópico en el Hospital Universitario Ginecobstétrico Eusebio Hernández en el periodo comprendido de enero del 2005 a diciembre del 2007. El universo estuvo constituido por 447 pacientes, las cuales ingresaron con el diagnóstico de embarazo ectópico y que el reporte anatomopatológico confirmó el diagnóstico Resultados: de los síntomas que presentaron las pacientes, el más frecuente fue el dolor abdominal en el 94,8 por ciento, seguido del sangramiento con 86,6 por ciento y dentro de los signos el más frecuente fue el dolor a la palpación con 92,1 por ciento. Al analizar los complementarios realizados el de más alta positividad fue la determinación de la hormona gonadotropina coriónica en orina en el 98,8 por ciento. El 76,1 por ciento de los casos fue diagnosticado en la fase complicada y sólo el 23,9 por ciento se diagnosticó en fase no complicada. La localización ampular fue la más frecuente con 73,8 por ciento y la operación más realizada fue la salpingectomía en el 80 por ciento de los casos. Conclusiones: las manifestaciones clínicas encontradas son similares a las que se han referido en esta entidad. La determinación de gonadotropina coriónica en orina fue la investigación con más alta positividad, resultó llamativo que el diagnóstico de la mayoría de los casos fuera en la etapa complicada

Objective: to assess the management of ectopic pregnancy. Methods: a descriptive, cross-sectional and retrospective study was conducted on the management of ectopic pregnancy in the "Eusebio Hernßndez" Gynecology-Obstetrics University Hospital from January, 2005 to December, 2007. Universe included 477 patients, who were admitted and diagnosed with ectopic pregnancy confirmed by the anatomical-pathological report related to diagnosis. Results: from the symptoms present in patients, the more frequent one was the abdominal pain in the 94.8 percent, followed by bleeding in the 86.6 percent and within the more frequent signs was the palpation pain in the 92.1 percent. Analyzing the complementary studies performed, that of more positive was the determination of chorionic gonadotropin hormone in urine in the 98.8 percent. The 76.1 percent of cases was diagnosed in the complicated phase and only the 23.9 percent was diagnosed in the non-complicated one. The ampullary location was the more frequent in the 73.8 percent and the more carried out operation was the salpingectomy in the 80 percent of cases. Conclusions: the more used surgical technique was the salpingectomy. There was radical behavior in face of the greater number of distal tubal pregnancy

Gravidez ectópica cervical com embrião vivo: o uso do metotrexato é eficiente? / Cervical ectopic pregnancy with alive embryo: the use of methotrexate is effective?

A gravidez ectópica cervical é tida como de localização excepcional, representando menos de 1% das implantações ectópicas. Embora rara, constitui patologia obstétrica de elevada gravidade. Sua letalidade, no passado, atingia índices assustadores. Estabelecido o diagnóstico, a conduta clássica era a histerectomia total, pois o sangramento intravaginal oriundo do canal cervical era frequentemente mortal, diante de tentativas de tratamento conservador por curetagem e/ou sutura local, sobretudo em nulíparas, desejosas de manter a fertilidade. Mais recentemente, tem sido proposto o uso do metotrexato por via local e/ou sistêmica, por vezes associado a técnicas de ligadura e embolização arterial, como forma de evitar a cirurgia mutiladora. Este trabalho teve como objetivo buscar evidências científicas na literatura que possam avaliar a eficácia do tratamento dessas pacientes utilizando o metotrexato.

The cervical ectopic pregnancy is considered of exceptional location, less than 1% of ectopic implantations. Although rare, is extremely serious obstetric pathology. Lethality in the past, reached frightening levels. After the diagnosis, the procedure was the classic radical hysterectomy, because the bleeding originated from intravaginal cervical canal was often fatal before the attempts of conservative treatment by curettage and/or suture, especially in nulliparous women desiring to maintain fertility. More recently, it has been suggested the use of methotrexate by local and/or systemic way, frequently associated with techniques of ligation and arterial embolization, in order to avoid mutilating surgery. This study aimed to look for evidence in the scientific literature to evaluate the effectiveness of treatment of these patients using methotrexate.

Death due to ruptured ectopic pregnancy natural death or negligence.

A young adult female of low socio-economic status, and a labourer by profession, was brought dead to the Government Medical College & hospital, Chandigarh. History provided by her husband revealed that she had pain abdomen for the last five days for which she was getting treatment from a private practitioner. She had been prescribed NSAIDs and antispasmodics for the same. However, she was not investigated upon and no attempt was made by the practitioner to arrive at any diagnosis. The autopsy was conducted on the next day and at autopsy, about two-and-a-half liters of blood was present in the abdomen and pelvic cavity. Careful internal examination revealed a ruptured ectopic pregnancy as the source of bleeding. The case is discussed with regard to establishing whether the death could have been natural, due to the negligence of the treating doctor or due to contributory negligence. However, even in cases of contributory negligence, the “last chance doctrine” may not save the physician.

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.