Urgent Laparoscopic Surgeries during the Third Trimester of Pregnancy: A Case Series.

STUDY OBJECTIVE: Laparoscopic management of nonobstetric acute abdominal pain in the third trimester of pregnancy remains controversial with limited data regarding procedure safety and feasibility. This study aimed to investigate the feasibility, immediate complications, and short-term outcomes of laparoscopic surgery at an advanced gestational age. DESIGN: Case-series. SETTING: Sheba Medical Center, a tertiary referral center. PATIENTS: Pregnant women who underwent urgent laparoscopic surgery at 27 weeks of gestation and above. INTERVENTION: Emergent laparoscopic surgery. MEASUREMENTS AND MAIN RESULTS: Clinical data were retrospectively collected and analyzed. A telephone questionnaire was administered in cases of missing data. Clinical information obtained included detailed medical and obstetric history; preoperative, intraoperative, and postoperative data; complications; and pregnancy outcomes. Between January 2010 and July 2017, 12 patients underwent emergent laparoscopic surgeries during the third trimester of pregnancy. The gestational age at the time of the surgery ranged between 27 and 38 weeks. All women had singleton pregnancies. Laparoscopic surgeries included 7 appendectomies, 4 adnexal surgeries, and 1 diagnostic laparoscopy. No complications related to the access route for any of the 12 laparoscopic surgeries occurred. The laparoscopic surgical procedure was successfully completed in 11 patients; only 1 laparoscopic appendectomy for perforated acute appendicitis with purulent peritonitis at 30 weeks of gestation was converted to laparotomy because of a limited operative field. Two patients had preterm labor at 35 and 36 weeks of gestation, respectively. None of the women was complicated with intrauterine fetal demise or low Apgar scores. CONCLUSION: Our results demonstrate that urgent laparoscopic surgeries in the third trimester of pregnancy are feasible and can be safely performed with minimal risk for the patient and fetus. Larger prospective studies are required to validate these recommendations.

Significant increase in serum hCG levels following methotrexate therapy is associated with lower treatment success rates in ectopic pregnancy patients.

OBJECTIVE: To determine the association between early increase in the serum hCG levels (days 0-4) and treatment success rates following methotrexate therapy in ectopic pregnancy patients. STUDY DESIGN: A level II-2 case-control study of involving 140 patients treated with methotrexate for ectopic pregnancy at the gynecology department in a tertiary care hospital. RESULTS: A logistic regression model for the "failure of treatment" was fitted with serum hCG levels change between day 0 and day 4, patient age, pregnancy age at day-0, and day-0 ß-hCG level as predictors. The logistic regression analysis indicated that having more than 50% increase in the ß-hCG levels between days 0 and 4 significantly (P = 0.011) increases the risk of MTX treatment failure. CONCLUSION: The results of this study indicate that >50% increase in ß-hCG levels between days 0 and 4 significantly increases the risk of methotrexate treatment failure. This novel information could assist patients and physicians in making decisions regarding ectopic pregnancy treatment.

Laparoscopic Findings Associated with Bladder Endometriosis Are Correlated with Disease Severity.

STUDY OBJECTIVE: Bladder involvement is rare in endometriosis. The prevalence is estimated to be ∼1% in patients with endometriosis. However, this figure seems to be an underestimation. The diagnosis of bladder endometriosis might be missed during laparoscopy. The aim of this study was to determine an intraoperative visual score of pelvic lesions that help the surgeon suspect bladder endometriosis. Design, Design Classification: A retrospective analysis was performed on the intraoperative photographs and videos of 69 patients with histological confirmation of bladder endometriosis. SETTING: A tertiary referral center. PATIENTS: Sixty-nine patients with bladder endometriosis were operated on in our center over a 9-year period. INTERVENTIONS: Evaluation and analysis of intraoperative laparoscopic findings. MAIN RESULTS: We found three subtypes of laparoscopic findings that can assist with diagnosing bladder endometriosis. The most prominent sign was named "kissing round ligaments" (Type K), in which the right and left round ligaments appear closer to each other than usual or even touching one another. This sign is strongly associated with full-thickness invasion of the bladder. Other laparoscopic findings that indicated bladder endometriosis were anatomical distortion (Type A) and proximal occlusion of the tubes (Type B). We further define a scoring system for the lesion that correlates with the severity of the bladder endometriosis from superficial lesions to full thickness. CONCLUSION: Bladder endometriosis is a rare condition and often remains undiagnosed. Indeed, even during surgery, bladder endometriosis can be missed if the operator is not aware of the suggestive signs. Operative laparoscopic findings may help the surgeon to diagnose bladder endometriosis, and these signs correlate with the severity of the disease.

In Vitro Fertilization Outcomes After Placement of Essure Microinserts in Patients With Hydrosalpinges Who Previously Failed In Vitro Fertilization Treatment: A Multicenter Study.

STUDY OBJECTIVE: To investigate whether hysteroscopic proximal tubal occlusion with Essure microinserts (Conceptus Inc.; Bayer, AG, North Rhine-Westphalia, Germany) can improve pregnancy rates in patients with hydrosalpinges who had failed in vitro fertilization (IVF) treatment. DESIGN: A prospective cohort study. SETTING: University-affiliated tertiary centers. PATIENTS: Twenty-four consecutive women with hydrosalpinges who had failed IVF treatment were included. INTERVENTIONS: Hysteroscopic placement of Essure microinserts for hydrosalpinx blockage followed by IVF treatment. MEASUREMENTS AND MAIN RESULTS: Ongoing pregnancy and live birth rates were recorded. Of the 24 patients undergoing a total of 42 IVF cycles after Essure insertion, 18 (75% of patients and 42.8% of IVF cycle attempts) conceived and 16 delivered live births (66.6% of patients and 38.1% of IVF cycle attempts). CONCLUSION: Hysteroscopic proximal occlusion of hydrosalpinges with Essure microinserts is a valuable alternative to laparoscopic salpingectomy, resulting in reasonable pregnancy rates.

Fertility outcome of laparoscopic treatment in patients with severe endometriosis and repeated in vitro fertilization failures.

OBJECTIVE: To evaluate fertility outcomes in infertile women with severe endometriosis (The revised American Fertility Society classification [AFS] 3-4) and repeated IVF failures, who underwent surgery due to exacerbation of endometriosis-related symptoms. DESIGN: Retrospective cohort study. SETTING: University hospital. PATIENT(S): All women who failed IVF treatment before surgery and who underwent laparoscopic surgery for severe endometriosis between January 2006 and December 2014. INTERVENTION(S): All patients were operated by highly skilled surgeons specializing in laparoscopic surgery for advanced endometriosis. Only patients with evidence of endometriosis in the pathology specimens were included in this study. MAIN OUTCOME MEASURE(S): Delivery rate after surgery. RESULT(S): Seventy-eight women were included in the present study. All women were diagnosed with severe endometriosis during surgery (AFS 3-4) and all women had experienced failed IVF treatments before surgery. All women were symptomatic before their surgery. After surgical treatment 33 women (42.3%) delivered. Three women (9%) conceived spontaneously and all other women conceived after IVF treatment. Women who delivered were younger (32.5 [±4.1] years vs. 35.5 [±3.8] years), were less often diagnosed with diminished ovarian reserve before surgery (6% vs. 28.8%), and were more often diagnosed with normal uterine anatomy (by preoperative transvaginal ultrasound and during operation). In addition, performing salpingectomy during surgery was associated with a trend of improvement in delivery rates after surgery (70% in women who delivered vs. 51% in women who failed to deliver). CONCLUSION(S): Symptomatic women with severe endometriosis and repeated IVF implantation failures may benefit from extensive laparoscopic surgery when performed by an experienced multidisciplinary surgical team to improve IVF outcome.

Reproductive Outcome Is Favorable After Laparoscopic Resection of Bladder Endometriosis.

STUDY OBJECTIVE: To assess the reproductive outcome (spontaneous and assisted conception rates) in women who underwent laparoscopic resection of bladder endometriosis. DESIGN: This was a retrospective, observational study analyzing prospectively recorded data (Canadian Task Force classification II-2). SETTING: A tertiary referral center. PATIENTS: Over a 9-year period, we identified 69 consecutive women with symptomatic pelvic endometriosis who underwent laparoscopic resection of bladder endometriosis at our center. INTERVENTIONS: Group A patients (n = 21) had full-thickness endometriotic invasion of the bladder and underwent laparoscopic partial cystectomy. Group B (n = 48) patients had partial endometriotic bladder penetration and underwent partial-thickness excision of the detrusor muscle. Most patients (over 70%) had additional, nonbladder endometriotic lesions, which were also removed during surgery. MEASUREMENTS AND MAIN RESULTS: Fertility outcomes were analyzed in patients who wished to conceive (n = 42), and improvements in symptoms were assessed for all patients. The minimum follow-up after surgery was 36 months. Of the 42 patients who wished to conceive, 35 patients (83.3%) conceived: 16 patients spontaneously and 18 patients after IVF treatment. No difference was observed in fertility outcome between group A (partial cystectomy) and group B (partial-thickness excision of the detrusor muscle). For all patients, long-term follow-up revealed that 80% of the patients (55 patients) had no urinary/endometrial symptoms after surgery. CONCLUSION: Pregnancy rates after laparoscopic surgery for bladder endometriosis by either partial cystectomy or deep excision of the detrusor muscle are favorable, both for spontaneous pregnancy and conception after IVF treatment. Additionally, urinary symptoms were improved for the majority of patients. Based on our findings, it seems warranted to offer laparoscopic surgical management to symptomatic infertile patients diagnosed with bladder endometriosis, even after IVF failure.

Pelvic inflammatory disease in women with endometriosis is more severe than in those without.

AIMS: To determine the incidence and severity of acute pelvic inflammatory disease (PID) or tubo-ovarian abscess (TOA) in hospitalised women with and without a history of endometriosis. METHODS: Retrospective analysis of hospital records retrieved for all women hospitalised with PID or TOA between January 2008 and December 2011 in a tertiary referral centre. Women were compared with regard to a history of endometriosis for demographic, clinical and fertility data. RESULTS: 26 (15%) of the 174 women hospitalised due to PID or TOA were excluded because of age older than 45 years, leaving 148 for analysis. The mean age was 35.7 ± 9.3 years and mean duration of hospitalisation was 5.9 ± 3.7 days. The women were divided into two groups: Group 1 with endometriosis (n = 21) and Group 2 without endometriosis (n = 127). Women in Group 1 as compared with Group 2 were significantly more likely to have undergone a fertility procedure prior to being admitted to the hospital with PID (9/27 (45%) vs 22/121 (17%), P < 0.001); particularly in vitro fertilisation (IVF) (7/ 27 (33%) vs 12/121 (9%), P < 0.006); Women in Group 1 more frequently experienced a severe and complicated course involving longer duration of hospitalisation (8.8 ± 4.7 vs 4.4 ± 2.3 days, P < 0.0001) and antibiotic treatment failure (10/27 (48%) vs 8/121 (6%), P < 0.0001). CONCLUSIONS: Pelvic inflammatory disease in women with endometriosis is more severe and refractory to antibiotic treatment, often requiring surgical intervention. It is likely that endometriosis is a risk factor for the development of severe PID, particularly after IVF treatment.

Long-term follow-up after ureteral reimplantation in patients with severe deep infiltrating endometriosis.

OBJECTIVE: To investigate the intraoperative features and long-term postoperative results of patients with ureteral endometriosis who underwent ureteral reimplantation. STUDY DESIGN: In this retrospective study, we reviewed records of all patients with ureteral endometriosis treated by ureteral reimplantation. Pre-, intra- and post-operative information was collected. RESULTS: Of patients operated for endometriosis, seven were diagnosed with severe ureteral endometriosis and underwent ureteral reimplantation. Psoas hitch was the preferred technique for the ureteral reimplantation. During a mean postoperative follow up of 42.3 ± 20.0 months, all but one patient reported significant symptomatic improvement. None of the patients needed additional medical or surgical treatment and no recurrence was noted. CONCLUSION: Ureteral reimplantation performed by a multidisciplinary surgical team is a suitable technique in selected cases, gives good long-term results and has no need for repeated surgical treatment.

Deep endometriosis inflicting the bladder: long-term outcomes of surgical management.

OBJECTIVE: To assess the efficacy and safety of laparoscopic treatment of bladder endometriosis, especially in cases of full thickness endometriotic nodules. DESIGN: Retrospective review of medical records. SETTING: Tertiary medical center and a referral center for endometriosis. POPULATION: Sixty-nine patients with bladder endometriosis that underwent surgery between January 2005 and December 2011. METHODS: The records of all patients with bladder endometriosis were reviewed and the pre-, intra- and postoperative information of patients who underwent surgery was collected. MAIN OUTCOME MEASURES: Efficacy, safety and long-term outcome of laparoscopic treatment of bladder endometriosis. RESULTS: The mean age of 69 patients with bladder endometriosis was 31.3 ± 4.6 years. Preoperative urinary symptoms (such as frequency, urgency, dysuria and others) were present in 28 (40.0%) patients. Laparoscopy was performed in all patients. Deep detrusor involvement was found in 45 (65.2%) patients. Of these, 21 patients underwent partial cystectomy due to a full thickness lesion. Deep nodule resection without bladder invasion was performed in 24 (34.8%) patients and bladder nodule coagulation and ablation in the remaining 24 (34.8%) patients with superficial involvement. No intraoperative complications were noted. Postoperative follow-up results were available for all patients. After a median (range) follow-up period of 60 (4-92) months, 92.7% of the patients were asymptomatic or reported improvement in symptoms. CONCLUSIONS: After a long-term follow-up surgical management of bladder endometriosis is strongly recommended. During surgery, careful inspection and full excision of bladder lesions should be performed. Laparoscopic excision is a safe and efficacies approach.

Thoracic endometriosis syndrome is strongly associated with severe pelvic endometriosis and infertility.

STUDY OBJECTIVE: To evaluate the clinical and surgical features of thoracic endometriosis syndrome (TES) represented by catamenial pneumothorax and pelvic endometriosis and to describe their association with infertility. DESIGN: Retrospective clinical study (Canadian Task Force classification: II-2). SETTING: Academic tertiary referral endometriosis center. PATIENTS: Seven patients who had undergone surgery because of thoracic and pelvic endometriosis between 2004 and 2010. INTERVENTIONS: Thoracic and pelvic exploration and treatment and fertility treatment. MEASUREMENTS AND MAIN RESULTS: Concurrently, thoracic and pelvic endometriosis, and subsequent fertility were determined during long-term follow-up after combined surgical and pharmacologic interventions. The most frequent thoracic finding was diaphragmatic implants. Except for 1 patient with recurrent pleurodesis at 1 month after video-assisted thoracoscopy, no patients experienced recurrence of thoracic symptoms during a median (range) follow-up of 31.4 (1-61) months. Severe pelvic endometriosis was diagnosed in 6 patients with notable urologic and gastrointestinal tract involvement. Only 1 patient with catamenial pneumothorax had no macroscopic pelvic lesions. There was a considerable delay between the onset of pelvic symptoms and diagnosis. Median postoperative follow-up was 31.5 (7-84) months. Most patients who tried to conceive had primary infertility. CONCLUSION: Thoracic endometriosis syndrome, represented by catamenial pneumothorax, was strongly associated with severe pelvic endometriosis and a high rate of infertility. Inasmuch as many patients with thoracic endometriosis syndrome are treated by thoracic surgeons using video-assisted thoracoscopy, it is desirable to involve an experienced gynecologist who can diagnose and treat concurrent pelvic endometriosis.

Multidisciplinary team approach to management of severe endometriosis affecting the ureter: long-term outcome data and treatment algorithm.

STUDY OBJECTIVE: To examine the efficiency of laparoscopic ureterolysis for ureteral endometriosis and to describe appropriate treatment. DESIGN: Prospective trial (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: Forty-five patients who underwent surgery to treat ureteral endometriosis between 2005 and 2009. INTERVENTION: Laparoscopic ureteral ureterolysis. MEASUREMENTS AND MAIN RESULTS: Long-term follow up of symptoms, urinary tract anatomy and function, and the need for further intervention were performed. Ureteral endometriosis was observed in 14.2% of 315 patients with endometriosis. Of the 45 study patients, 95.5% had dysmenorrhea, 60% had dyspareunia, and 45% were infertile. Half of the patients had previously undergone laparoscopic procedures. Urinary tract symptoms were present in 15.9% of patients. Preoperative hydronephrosis or hydroureter was observed in 10 patients (22.2%), and impaired urinary function in 2 patients (4.4%). Laparoscopy demonstrated left ureteral involvement in 82.2% of patients, and deep infiltrative endometriosis in 80%. Laparoscopic ureterolysis was feasible in 91.1% of patients. In 4 patients, ureterolysis was not feasible, and primary reimplantation of the ureter was performed. Forty-one patients (91.1%) had no symptoms or had marked improvement postoperatively and required no further treatment. Two patients (4.8%) underwent repeat surgery. In 80% of patients with hydroureteronephrosis, the postoperative sonogram was normal. CONCLUSIONS: Ureteral endometriosis can be treated effectively using laparoscopic ureterolysis in almost all patients. Different treatment approaches should be based on the results of preoperative evaluation and operative findings by a multidisciplinary team. Urinary assessment is crucial because most patients demonstrate no urinary tract symptoms and initial renal investigation can prevent irreversible damage.

Long-term outcome after laparoscopic treatment of heterotopic pregnancy: 19 cases.

STUDY OBJECTIVE: To determine the long-term outcome of intrauterine pregnancies after treatment of heterotopic pregnancies. DESIGN: Retrospective cohort study (Canadian Task Force classification II-3). SETTING: Tertiary center university hospital. PATIENTS: All women who underwent surgery because of heterotopic pregnancy over 12 years. INTERVENTION: Laparoscopic surgery. MEASUREMENTS AND MAIN RESULTS: Infant development and future pregnancy. Extrauterine pregnancies were located in the tube (n = 13), uterine cornua (n = 3), ovary (n = 1), and tubal stump (n = 2). During laparoscopy, a ruptured tube was found in 6 tubal pregnancies (46%), blood transfusion was needed in 7 heterotopic pregnancies (37%), and salpingectomy was performed in 12 women with tubal pregnancies (91.7%). The pregnancy outcome consisted of 13 babies (term and preterm) taken home and 5 miscarriages. Long-term follow up demonstrated that 10 of 13 infants (76.9%) exhibited normal development. Three infants, all from 1 triplet pregnancy, exhibited borderline to normal development. Ten of 15 women achieved additional pregnancies, with 10 deliveries and only 1 extrauterine pregnancy in the tubal stump. CONCLUSIONS: Women with a heterotopic pregnancy are at high risk for late diagnosis and at risk for hypovolemic shock at diagnosis, and may require blood transfusion. The outcome of intrauterine pregnancy in association with heterotopic pregnancy requiring surgical intervention is good, and most complications were associated with multifetal pregnancy and preterm delivery.

A randomized prospective study of misoprostol or mifepristone followed by misoprostol when needed for the treatment of women with early pregnancy failure.

OBJECTIVE: To compare the effectiveness and safety of misoprostol and mifepristone, followed when needed by misoprostol, for the treatment of women with early pregnancy failure. DESIGN: Prospective randomized nonblinded controlled trial. SETTING: University-affiliated tertiary medical center. PATIENT(S): One hundred fifteen consecutive women diagnosed as having a blighted ovum or missed abortion of <9 weeks of gestation enrolled. INTERVENTION(S): The patients received orally 600 mg mifepristone (group I) or orally 800 microg misoprostol (group II). Most patients in both groups subsequently received 48 hours later orally 800 microg misoprostol. MAIN OUTCOME MEASURE(S): Failure was defined as surgical intervention due to retained gestational sac 48 hours after completion of the drug protocol, severe symptoms, or suspected retained products of conception after the menstrual period. RESULT(S): The success rate was similar in groups I and II: 38 of 58 patients (65.5%) versus 42 of 57 patients (73.6%), respectively. No cases of severe infection or bleeding necessitating blood transfusion occurred. CONCLUSION(S): Misoprostol is an effective and safe treatment for early pregnancy failure and could replace surgical curettage in over two-thirds of the patients. Mifepristone offers no advantage compared with misoprostol as initial treatment.

Transvaginal ultrasound and operative hysteroscopy in women undergoing medical termination of pregnancy as a part of routine follow-up.

Follow-up of the first cohort of 191 patients who underwent medical abortion in a tertiary medical center included postmenstruation transvaginal sonography (TVS), even in asymptomatic patients. Suspected products of gestation by TVS were found in 3.7% of the asymptomatic women, and residual products of gestation were diagnosed by hysteroscopy in 85.7% of such cases.

Placental site trophoblastic tumor: outcome of five cases including fertility preserving management.

INTRODUCTION: Placental site trophoblastic tumor (PSTT) is a rare variant of gestational trophoblastic disease that has been re-described during the 1970s. MATERIALS AND METHODS: The patients' age at presentation, presenting symptoms, description of last pregnancy, treatment, and outcome were analyzed in five patients diagnosed as PSTT in our department from 1973 to 2003. RESULTS: We describe the clinical outcome of 5 patients with PSTT, four of them were diagnosed and treated since 2001. Mean interval from last pregnancy until diagnosis was 5.1 months (range 0-10 months). Vaginal bleeding was the presenting symptom in all the five patients. Instead of standard hysterectomy followed by chemotherapy, when indicated, one patient underwent fertility preserving management using hysteroscopic resection of the tumor followed by chemotherapy. CONCLUSIONS: The combination of operative hysteroscopy and chemotherapy in women with localized disease, who want to preserve their fertility, can be a possible treatment option in highly selected patients. Repeated chemotherapy with EMA/EP, even in patients who relapsed after treatment with EMA/EP for PSTT can induce prolonged remission and even cure.

Laparoscopy versus laparotomy for detorsion and sparing of twisted ischemic adnexa.

BACKGROUND: Torsion of the ovary is an urgent event for fertile women. Until recent years, the common treatment for twisted ischemic ovaries was salpingo-oophorectomy. We have demonstrated in the past that the ovary can be salvaged provided detorsion is performed. We studied the outcome of women undergoing minimal surgery for ischemic ovaries versus the extended procedure including cystectomy in respect of ovarian function and fertility performance. METHODS: We retrospectively studied 102 women who underwent surgery for torsion of the ovary in which the macroscopic appearance of black-bluish ischemic adnexa was encountered during surgery. Detorsion without removal of the adnexa or the ovary was performed by laparoscopy in 67 patients and by laparotomy in 35 patients. Patients' files were reviewed for immediate and late outcomes. Patients were examined postoperatively with vaginal ultrasound for ovarian follicular function. Data concerning patients' further surgeries or in vitro fertilization were retrieved from the charts as well. RESULTS: Febrile morbidity was approximately 15% and 29% in the laparoscopy and laparotomy groups, respectively. Hospital stay was 2.1 +/- 1.2 and 7.4 +/- 1.5 days in the laparoscopy and laparotomy groups, respectively (P<0.001). Ultrasound follow-up was available in 60 of 67 patients who underwent laparoscopy and in 32 of 35 patients treated by laparotomy. Normal-sized ovaries with follicular development were encountered in the detorsed side in 93% and 91%, respectively. Normal macroscopic appearance of the adnexa at subsequent surgeries was reported in 9 of 9 patients in the laparoscopy group and in 4 of 5 patients in the laparotomy group. Four patients from the laparoscopy group and 2 from the laparotomy group underwent subsequent in vitro fertilization. In all 6 patients, oocytes retrieved from the previously detorsed ovary were fertilized. In both groups, none of the patients developed clinical signs of pelvic or systemic thromboembolism. CONCLUSIONS: Torsion of the ischemic adnexa should be treated laparoscopically by detorsion and adnexal sparing.

Pregnancy outcome after laparoscopy or laparotomy in pregnancy.

STUDY OBJECTIVE: To assess obstetric performance and fetal outcomes after laparoscopy or laparotomy performed during pregnancy. DESIGN: Nationwide, multicenter, retrospective chart review (Canadian Task Force classification II-2). SETTING: Seventeen hospitals throughout Israel: 12 university or university-affiliated hospitals and 5 general hospitals. PATIENTS: Three hundred eighty-nine pregnant women. INTERVENTION: Laparoscopy or laparotomy for various indications. MEASUREMENTS AND MAIN RESULTS: Of 192 laparoscopies performed, 141 were during the first, 46 during the second, and 5 during the third trimester; respective figures for 197 laparotomies were 63, 110, and 24. No intraoperative complications were reported for either procedure. Six and 25 women had complications after laparoscopy and laparotomy, respectively. There was no significant difference in abortion rates between groups. Mean gestational age at delivery and mean birthweight were comparable between groups. No significant difference was found in frequency of fetal anomalies between groups or when compared with the Israel register of anomalies. CONCLUSION: Operative laparoscopy seems to be as safe as laparotomy in pregnancy.

Diagnosis and treatment of heterotopic pregnancy compared with ectopic pregnancy.

STUDY OBJECTIVE: To compare the diagnosis and management of ectopic (EP) and heterotopic pregnancies (HP). DESIGN: Retrospective comparative study (Canadian Task Force classification II-2). SETTING: University tertiary referral center for endoscopic surgery. PATIENTS: Twelve women with HP and 210 women with laparoscopically confirmed EP. INTERVENTION: Laparoscopic treatment. MEASUREMENTS AND MAIN RESULTS: Among the 12 women with HP, all but 1 had received ovulation induction, 10 underwent in vitro fertilization-embryo transfer, and 1 conceived with clomiphen citrate. In the EP group 33 patients (15.7%) conceived spontaneously (p <0.05). Six women (50%) with HP had had previous pelvic surgery and three had a history of EP and salpingectomy. Four patients (33.4%) with HP and 29 (13.8%) with EP suffered from hypovolemic shock and required blood transfusion (p <0.05). Three of these four women with HP experienced physician and patient delays before admission. The sonographic diagnosis was correct in all women with HP and in 94.3% of women with EP. The median gestational age at diagnosis was 7.5 and 7.2 weeks for HP and EP, respectively. Six (50%) women with HP had evidence of fetal pulse in the ectopic gestation compared with 17 (8.1%) with EP (p <0.05). In addition, 66.7% and 24.7%, respectively, had ruptured tube (p <0.05). Mean +/- SD hemoperitoneum was 833.4 +/- 777 and 305 +/- 121 ml, respectively (p <0.05). Conversion to laparotomy was required in one (8.3%) and eight (3.8%) women, respectively (p <0.05). No major operative or postoperative maternal complications occurred in either group. Two women with HP had miscarriages, two have a continuing pregnancy, and eight delivered healthy newborns. CONCLUSION: Women with HP are at significantly greater risk for hypovolemic shock and requiring blood transfusion than those with EP. The diagnosis of EP in cases of HP is difficult due to the presence of an intrauterine gestational sac and hyperstimulated ovaries. A greater level of suspicion may allow early laparoscopic intervention before life-threatening intraabdominal bleeding has occurred.

Color Doppler imaging in the sonohysterographic diagnosis of residual trophoblastic tissue.

PURPOSE: The purpose of this study was to evaluate the role of color Doppler imaging during sonohysterography in the diagnosis of residual trophoblastic tissue. METHODS: This prospective cohort study involved 25 consecutive women with clinical and sonographic signs of an echogenic intrauterine mass who were referred to the sonography unit of our institution for evaluation. All women underwent saline infusion sonohysterography with color Doppler sonographic evaluation. An operative hysteroscopy with histologic examination was performed in 17 cases. RESULTS: Thirteen women (group A) had sonohysterographic features suggestive of residual trophoblastic tissue (ie, an echogenic intrauterine lesion not detached from the uterine wall after introduction of saline). The initial diagnosis was confirmed by histologic analysis in all cases. Blood flow was detected within the intrauterine mass in 6 (46%) of these 13 women; the resistance indices were low in all 6 cases (mean +/- standard error, 0.38 +/- 0.01). Twelve women (group B) had sonohysterographic findings negative for retained tissue, and no blood flow was detected within any of the intrauterine masses in this group (p < 0.05). CONCLUSIONS: Our results confirm the potential role of color Doppler sonography in the initial diagnosis of residual trophoblastic tissue. The detection of color Doppler signals, especially with low-resistance flow, within an intrauterine lesion should increase the confidence of the sonologist in the diagnosis of residual trophoblastic tissue.