Bilateral tubal ectopic pregnancy following induction ovulation can be missed in emergent ultrasonography: Case report.

INTRODUCTION: Bilateral tubal ectopic pregnancy (BTP) is a rare and potentially life-threatening condition that is, often challenging to diagnose preoperatively. PRESENTATION OF CASE: We present a case of BTP in a 25-year-old primigravid woman with a history of infertility due to polycystic ovarian syndrome. She was receiving letrozole when she presented with severe abdominal pain and vaginal bleeding. Initial evaluation revealed a ruptured ectopic pregnancy in the right fallopian tube, prompting an emergency laparotomy. During surgery, a second intact ectopic mass was discovered in the left fallopian tube, highlighting the diagnostic complexity of BTP. Management involved a salpingectomy on the right side and salpingostomy on the left to preserve fertility. DISCUSSION: This case underscores the importance of considering BTP in the differential diagnosis of ectopic pregnancies and the necessity for thorough preoperative imaging studies, namely ultrasonography and surgical exploration, to prevent missed diagnoses. CONCLUSION: BTP is a rare and challenging clinical entity that requires a comprehensive approach to diagnosis and management. Early recognition, prompt intervention, and close surveillance are essential to mitigate the risk of maternal morbidity and mortality associated with this condition.

Screening of single nucleotide polymorphism in matrix metalloproteinase-2 (MMP2) and tetraspanin CD63 genes in Chlamydia trachomatis-infected tubal ectopic pregnancy patients.

OBJECTIVE: Tubal ectopic pregnancy (EP) is a leading cause of maternal morbidity and mortality. Studies have suggested that infection-induced inflammatory responses are major risk factors for EP. The aim of the present study was to find an association between MMP2 and CD63 gene variants and risk of EP during Chlamydia trachomatis infection in an Indian population. METHODS: Fallopian tube samples of 120 EP and 120 tubal ligation women were collected. C. trachomatis was detected by PCR. The genotyping of MMP2 (rs17859882 G/T, rs7201A/C) and CD63(rs2231464 C/T, rs376086542 A/G) gene variants was done by qualitative real-time PCR using allelic discrimination method (VIC- and FAM-labeled). RESULTS: The frequency of GG or GT genotype of MMP2 G/T polymorphism (rs17859882) was 66.6% in infected EP and 36.7% in uninfected EP and 22% in tubal ligation controls (P < 0.0001), while the frequency of AC or CC genotype of MMP2 A/C polymorphism (rs7201) was 66.6% in infected EP and 20.6% in uninfected EP and 13.5% in tubal ligation controls (P < 0.0001). The frequency of CT or TT genotype of CD63 C/T polymorphism (rs2231464) was 74% in infected EP and 21.8% in uninfected EP and 11.8% tubal ligation controls (P < 0.0001), while the frequency of AG or GG genotype of CD63 A/G polymorphism (rs376086542) was 48.1% in infected EP and 41.3% in uninfected EP and 18.6% tubal ligation controls (P < 0.0001). CONCLUSIONS: The present study revealed a strong association between the presence of gene variants MMP2 (rs17859882 G/T, rs7201A/C) and CD63 (rs2231464 C/T, rs376086542 A/G) and risk of tubal EP during C. trachomatis infection.

Superfetation and heterotopic pregnancy: Case report of two rare phenomena coexisting and implications in the era of assisted reproductive technologies.

Key Clinical Message: To raise awareness about the increasing incidence of superfetation and heterotopic pregnancy in patients with ovarian induction, their insidious symptoms of abdominal pain, anemia, and hemodynamic instability in early pregnancy, and the usefulness of transvaginal ultrasound (TVUS) and quantitative beta human chorionic gonadotrophin (b-hCG) for diagnosis. Abstract: Superfetation, occurrence of ovulation, fertilization, and implantation during an ongoing pregnancy and heterotopic pregnancy (HP) simultaneous presence of intrauterine and extrauterine pregnancies are infrequent phenomena. We report a case where both coexisted, challenges in diagnosis and management and association with the widespread use of assisted reproductive technologies (ARTs). A 32-year-old woman, who previously underwent ovulation induction therapy, presented with abdominal pain at 8 weeks pregnancy according to her last menstrual period. The patient had high quantitative serum beta-human chorionic gonadotropin (b-hCG) (30,883 mIU/mL). She was vitally stable and not anemic. Transvaginal ultrasound (TVUS) revealed two pregnancies at different gestational ages: an intrauterine pregnancy at 5 weeks and 3 days, and a right intact tubal ectopic pregnancy at 10 weeks and 5 days. Superfetation resulting in HP was then diagnosed. Subsequently, the patient underwent right laparoscopic salpingectomy. The intrauterine pregnancy progressed normally, resulting in delivery of a healthy full-term neonate via Cesarean section at 38 weeks. Superfetation is typically rare from suppression of follicular development and ovulation during pregnancy. Various theories have been proposed to explain its etiology, including polyovulation, delayed blastocyst implantation, and abnormal estrogen and b-hCG surges. In superfetation, an embryo resulting from a previous conception coexists with another embryo, either intrauterine, resulting in diamniotic dizygotic twins with significantly different gestational ages, or extrauterine resulting in HP. Despite being particularly challenging to diagnose because its presenting symptoms can overlap with those of other more common clinical conditions in early pregnancy, HP is increasingly seen with ARTs. In addition, the treatment of HP is versatile, ranging from expectant management to laparoscopic surgery. High level of suspicion for HP and superfetation is crucial in patients who, after ART, present with abdominal pain, hemodynamic instability, or anemia. Additionally, patients planning to undergo subsequent ART cycles should be thoroughly screened with b-hCG and TVUS to exclude an ongoing intrauterine or extrauterine pregnancy.

Unusual presentation of late-stage ectopic tubal pregnancy (19 weeks' gestation): Case report and literature review.

Ectopic pregnancy is a medical condition in which a fertilized egg takes an unexpected detour away from the uterine cavity and the fallopian tube becomes a popular host, with the ampulla being the prime location. However, it can occur in other areas such as cervix, ovaries, or abdomen. The most common risk factors are pelvic inflammatory disease, previous pelvic or abdominal surgery, abnormal anatomy of genital organs, endometriosis, previous ectopic pregnancies, assisted reproductive technologies, endocrine disorders, and even the subtle influence of low-dose progestins from contraceptives. We will present a rare case of unrecognized late-stage tubal ectopic pregnancy. The following case report is of a 25-year-old Caucasian female patient (G2, P0) who presented to the emergency department with a 24-hour abdominal pain syndrome. The patient did not have a gynecological examination for this reason. During the examination, taking into account the clinical and ultrasound findings, a suspicion of pregnancy in a bicornuate uterus was raised, and an MRI of the pelvis was performed. MRI showed ectopic pregnancy in the left fallopian tube with a properly developed fetus that corresponded to a gestation of 19 weeks. An emergency laparotomy was performed and the left fallopian tube with the fetus was removed. The early and late course of recovery went smoothly. The patient was discharged after adequate clinical development.

A Rare Case of Adnexal Pregnancy After Bilateral Tubal Clamping.

An adnexal pregnancy after tubal clamping is a very rare entity. Very few such cases have been reported in the past. Here, we discuss a case of such an occurrence. A 35-year-old female with third gravida and a history of two abortions with secondary infertility conceived via in vitro fertilization was admitted to the ward for observation with a history of amenorrhea of one and a half months and a known case of hypothyroidism. The ultrasonography showed left ectopic adnexal pregnancy that was managed conservatively. With a previous history of left ectopic pregnancy, the patient was managed with exploratory laparotomy with left partial salpingectomy. This case is used to illustrate the need to gather a complete medical history and take ectopic pregnancy into account in women who are of reproductive age and have a history of ectopic pregnancies.

A Spontaneous Heterotopic Pregnancy Presenting as Acute Appendicitis.

Heterotopic pregnancy (HP) occurs when there is a simultaneous intrauterine and extrauterine pregnancy, either viable or non-viable. Although spontaneous HP is rare, it is important to consider this possibility. Acute appendicitis (AA) is a common non-obstetric surgical emergency in pregnant women. Diagnosing HP can be challenging, particularly in pregnant women who present with symptoms such as right iliac fossa pain and an acute abdomen. As HP may not be initially suspected in the presence of a viable intrauterine pregnancy, we present an intriguing case of spontaneous HP initially presenting as AA, along with a literature review. Our objective is to raise awareness of HP among trainee obstetricians and general surgeons.

Ruptured Left Cornual Ectopic Pregnancy: A Case Report.

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

Chlamydia trachomatis infection regulates the expression of tetraspanins, activin-A, and inhibin-A in tubal ectopic pregnancy.

Mechanism of Chlamydia trachomatis causing tubal ectopic pregnancy (EP) is not well understood. Tetraspanins (tspans), activin-A, and inhibin-A might play a role in the development of pathological conditions leading to EP. The study aimed to elucidate the expression of tspans, activin-A, and inhibin-A with a role of associated cytokines in C. trachomatis-associated EP and analyze interacting partners of DEGs, with an expression of a few important interacting genes. Fallopian tissue and serum were collected from 100 EP (Group I) and 100 controls (Group II) from SJH, New Delhi, India. Detection of C. trachomatis was done by polymerase chain reaction (PCR) and IgG antibodies were detected by enzyme-linked immunosorbent assay. Expression of tspans, activin-A, inhibin-A, and cytokines was analyzed by real time (RT)-PCR and their interacting genes were assessed by STRING. Expression of few disease-associated interacting genes was studied by RT-PCR. A total of 29% (Group I) were C. trachomatis positive. Tspans and activin-A were significantly upregulated, while inhibin-A was significantly downregulated in Group Ia. ITGA1, TLR-2, ITGB2, and Smad-3 were a few interacting genes. Expression of ITGA1, TLR-2, and Smad-3 was significantly upregulated in C. trachomatis-positive EP. Results suggested dysregulated tspans, activin-A, and inhibin-A might play a role in C. trachomatis-infected tubal EP.

Subsequent pregnancy outcomes among women with tubal ectopic pregnancy treated with methotrexate.

Lay summary: An ectopic pregnancy occurs when an embryo implants outside of the uterus, usually in a fallopian tube. When detected early, treatment is often with a medication called methotrexate. When methotrexate does not work, surgery is required. A recent clinical trial of ectopic pregnancy treatment (called GEM3) found that adding a drug called gefitinib to methotrexate did not reduce the need for surgery. We have used data from the GEM3 trial, combined with data collected 12 months after the trial finished, to investigate post-methotrexate pregnancy outcomes. We found no difference in pregnancy rates, pregnancy loss rates and recurrent ectopic pregnancy rates between those treated medically only and those who subsequently also needed surgery. The surgical technique used also did not affect pregnancy rates. This research provides reassurance that women with ectopic pregnancies treated medically who need surgery have similar post-treatment pregnancy outcomes to those treated successfully medically.

Early (Days 1-4) post-treatment serum hCG level changes predict single-dose methotrexate treatment success in tubal ectopic pregnancy.

STUDY QUESTION: What is the capacity of the change between Day 1 and Day 4 post-treatment serum human chorionic gonadotropin (hCG) levels for predicting single-dose methotrexate treatment success in tubal ectopic pregnancy? SUMMARY ANSWER: Any fall in Days 1-4 serum hCG signified an 85% (95% CI 76.8-90.6) likelihood of treatment success for women with tubal ectopic pregnancy (initial hCG of ≥1000 and ≤5000 IU/l) managed with single-dose methotrexate. WHAT IS KNOWN ALREADY: For those with tubal ectopic pregnancy managed by single-dose methotrexate, current guidelines advocate intervention if Days 4-7 hCG fails to fall by >15%. The trajectory of hCG over Days 1-4 has been proposed as an early indicator that predicts treatment success, allowing early reassurance for women. However, almost all prior studies of Days 1-4 hCG changes have been retrospective. STUDY DESIGN, SIZE, DURATION: This was a prospective cohort study of women with tubal ectopic pregnancy (pre-treatment hCG of ≥1000 and ≤5000 IU/l) managed with single-dose methotrexate. The data were derived from a UK multicentre randomized controlled trial of methotrexate and gefitinib versus methotrexate and placebo for treatment of tubal ectopic pregnancy (GEM3). For this analysis, we include data from both treatment arms. PARTICIPANTS/MATERIALS, SETTING, METHODS: Participants were categorized according to single-dose methotrexate treatment success or failure. Treatment success for this analysis was defined as complete and uneventful resolution of tubal ectopic pregnancy to serum hCG <30 IU/l following single-dose methotrexate treatment without additional treatment. Patient characteristics of the treatment success and failure groups were compared. Changes in Days 1-4, 1-7, and 4-7 serum hCG were evaluated as predictors of treatment success through receiver operating characteristic curve analysis. Test performance characteristics were calculated for percentage change ranges and thresholds including optimal classification thresholds. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 322 women with tubal ectopic pregnancy were treated with single-dose methotrexate. The overall single-dose methotrexate treatment success rate was 59% (n = 189/322). For any fall in serum hCG on Days 1-4, likelihood ratios were >3, while for any fall of serum hCG >20% on Days 1-7, likelihood ratios reached 5. Any rise of serum hCG on Days 1-7 and 4-7 strongly reduced the chance of success. Any fall in Days 1-4 hCG predicted single-dose methotrexate treatment success with a sensitivity of 58% and specificity 84%, resulting in positive and negative predictive values of 85% and 57%, respectively. Any rise in Days 1-4 serum hCG <18% was identified as an optimal test threshold that predicted treatment success with 79% sensitivity and 74% specificity, resulting in 82% positive predictive value and 69% negative predictive value. LIMITATIONS, REASONS FOR CAUTION: Our findings may be limited by intervention bias resulting from existing guidelines which influences evaluation of hCG changes reliant on Day 7 serum hCG levels. WIDER IMPLICATIONS OF THE FINDINGS: Examining a large prospective cohort, we show the value of Days 1-4 serum hCG changes in predicting single-dose methotrexate treatment success in tubal ectopic pregnancy. We recommend that clinicians provide early reassurance to women who have a fall or only a modest (<18%) rise in Days 1-4 serum hCG levels, that their treatment will likely be effective. STUDY FUNDING/COMPETING INTEREST(S): This project was supported by funding from the Efficacy and Mechanism Evaluation programme, a Medical Research Council and National Institute for Health Research partnership (grant reference number 14/150/03). A.W.H. has received honoraria for consultancy for Ferring, Roche, Nordic Pharma and AbbVie. W.C.D. has received honoraria from Merck and Guerbet and research funding from Galvani Biosciences. L.H.R.W. has received research funding from Roche Diagnostics. B.W.M. is supported by a NHMRC Investigator grant (GNT1176437). B.W.M. also reports consultancy for ObsEva and Merck and travel support from Merck. The other authors declare no competing interests. TRIAL REGISTRATION NUMBER: This study is a secondary analysis of the GEM3 trial (ISRCTN Registry ISRCTN67795930).

Case report of a lithopedion of tubal location, in a young woman.

Lithopedion is a rare situation, corresponding to an ectopic pregnancy which evolves beyond the first trimester toward death and fetal calcification. This ectopic pregnancy is most often abdominal in location. Through this case report, we report the case of a lithopedion of left tubal localization in a young woman, diagnosed on CT scan following abdominal pain and confirmed by laparotomy with excision.

The Utility of Monitoring Beta-Human Chorionic Gonadotropin Levels in an Ectopic Pregnancy.

Ectopic pregnancy, a rare complication involving embryo nidation outside the uterus, significantly impacts women's lives worldwide. About 95% of ectopic pregnancies occur in the Fallopian tubes. If not diagnosed early, the patient may suffer from tubal rupture, resulting in hemorrhage and lethal consequences. Transvaginal ultrasound (TVUS) is typically used to diagnose an ectopic pregnancy. However, over the last decade, monitoring beta-human chorionic gonadotropin (ß-hCG) levels in ectopic pregnancy have evolved to detect ectopic pregnancy. But there are inconsistencies in its utility in monitoring or diagnosing ectopic pregnancy in clinical practice. This systematic review highlights the potential of monitoring ß-hCG levels to accurately diagnose ectopic pregnancy. Furthermore, it showcases if ß-hCG levels can determine effective treatment options to successfully resolve an ectopic pregnancy. We performed a literature search between January 2022 through December 2022 following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The clinical evidence demonstrated that monitoring ß-hCG levels, combined with TVUS, accurately diagnosed an ectopic pregnancy. Moreover, pre-treatment ß-hCG levels higher than 5000 international units per liter (IU/L), statistically significant, indicated surgical management for a successful resolution of an ectopic pregnancy. Whereas lower ß-hCG levels showed successful management through expectant and methotrexate treatment. Interestingly, patients who failed non-surgical treatment developed increased ß-hCG levels and required surgical intervention. However, there was conflicting evidence on whether ß-hCG levels could indicate tubal rupture. Nevertheless, as highlighted in this review, monitoring ß-hCG levels could be crucial in the early diagnosis of ectopic pregnancy. Besides, it might significantly aid in monitoring and deciding on effective treatment options for patients with ectopic pregnancy, which could be vital to saving their lives and preserving fertility.

Mechanism of Human Tubal Ectopic Pregnancy Caused by Cigarette Smoking.

In the past few decades, the smoking rate of women of childbearing age has increased. Epidemiological data has repeatedly shown that smoking women have an increased risk of various reproductive diseases, including ectopic pregnancy (EP), decreased fertility, adverse pregnancy outcomes, and failure of assisted reproduction. The oviduct was the target of cigarette smoke in many in vivo and in vitro studies. The fallopian tube is a well-designed organ. Its function is to collect and transport the ova to the fertilized site and provide a suitable environment for fertilization and early embryonic development. Lastly, the fallopian tube transports the pre-implantation embryo to the uterus. Various biological processes can be studied in the fallopian tubes, making it an excellent model for toxicology. This paper reviews the roles of the fallopian tube in gametes and embryo transportation, and the possible mechanism tobacco smoke contributes to tubal EP. A possible signal pathway might be a model to develop intervention of EP for pregnant women exposed to smoking.

Predictors of Successful Medical Management With Methotrexate in Unruptured Tubal Ectopic Pregnancy.

Introduction Medical treatment with methotrexate (MTX) is a safe and effective alternative to surgery in carefully selected cases of ectopic pregnancies diagnosed early prior to rupture. Aim To determine the optimal pre-treatment levels of beta human chorionic gonadotropin (𝛽-hCG) and its changing trends most likely to have a successful outcome with medical management. Material and methods A prospective observational study was conducted in a tertiary teaching hospital from December 2018 to May 2021. "Single-dose" MTX regime was used for medical management of ectopic pregnancy in patients fulfilling the selection criteria. The 𝛽-hCG levels were recorded at baseline and on day 4 and day 7 of MTX injection. Thereafter, at weekly intervals till complete resolution or surgical intervention due to failure of medical management. In addition, receiver operating characteristic (ROC) curve analysis for a pre-treatment 𝛽-hCG cut-off value and changing trends in post-treatment 𝛽- hCG levels most likely to have a successful outcome with MTX treatment were determined. Results Fifty patients fulfilling the inclusion criteria were included in the study, with successful medical management in 33 (66%). The mean pre-treatment 𝛽-hCG levels in women with successful medical management were 3270.97 (+/- 901) compared to 5249.17 (+/-808.02) for those with treatment failure (p=0.00001). The mean 𝛽-hCG level in the failed treatment group was significantly higher on day 4 than the pre-treatment levels (6742.56 +/- 572 vs. 5249.17+/- 808.02; p<0.05). Inadequate reduction of 𝛽-hCG level on day 7 (<15% of day 4 levels) requiring repeat dosage of MTX was more likely to have an unsuccessful outcome (p=0.00001). The area under curve (AUC) value of 0.905 (95% CI: 0.814-0.996) depicted that pre-treatment 𝛽-hCG level of 4000 mIU/ml taken as the cut-off value was able to predict levels ≤4000 mIU/ml had a greater likelihood of successful outcome with MTX, having a sensitivity of 84.5%, specificity of 83.3%, positive predictive value (PPV) of 90.3%, and negative predictive value (NPV) of 75% (p< 0.05). Demographic variables or previous clinical history, considered risk factors for ectopic pregnancy, did not affect the outcome of medical management in this study. Conclusion Medical management of ectopic pregnancy is a viable first-line treatment option in carefully selected patients. In this study, the most important predictors for the successful outcome of medical management were the pre-treatment ß-hCG levels and their fall on day 4 and day 7 after MTX therapy.

Spontaneous Bilateral Ectopic Pregnancy Treated With Combination of Methotrexate, Unilateral Salpingectomy, and Unilateral Expulsion of Pregnancy.

Spontaneous bilateral ectopic pregnancies are rare. In the majority of case reports, treatments prescribed were methotrexate, bilateral salpingectomy, or salpingectomy/salpingostomy. A 31-year-old gravida 3 para 0 at our institution underwent diagnostic laparoscopy due to ruptured ectopic pregnancy, and based on visual inspection, had a bilateral ectopic pregnancy. She underwent right salpingectomy for a ruptured ectopic pregnancy and had spontaneous expulsion of the left ectopic pregnancy with mobilization of the fallopian tube. She received methotrexate as per the two-dose protocol and was followed with a negative beta-human chorionic gonadotropin (b-hCG). Pathology confirmed bilateral tubal ectopic pregnancies. Spontaneous bilateral tubal ectopic pregnancy requires a high level of clinical suspicion. If a tubal pregnancy has expulsion of tissue intraoperatively, a two-dose protocol for methotrexate administration may be used for treatment, especially in the case of a bilateral ectopic pregnancy with fertility desires.

Interstitial Pregnancy Treated with Mifepristone and Methotrexate with High Serum ß-hCG Level in a Patient Wishing to Preserve Fertility: Time to Define Standardized Criteria for Medical/Surgical Therapy?

Interstitial pregnancy (IP) accounts for 2% of all ectopic pregnancies and has a mortality rate of 2-2.5%. The diagnosis is made by a transvaginal ultrasound and the treatment can be medical or surgical. We report the case of a 36-year-old primigravida who was 6 + 5 weeks pregnant, diagnosed with interstitial pregnancy by ultrasound, who had a very high serum ß-hCG level (31,298 mIU/mL) and wanted to preserve her fertility. The patient was treated with one dose of mifepristone and a double dose of methotrexate since the decrease in the ß-hCG serum level was less than 15% after the first dose. At the beginning, medical therapy was effective, as no embryonal cardiac activity was detected and serum ß-hCG levels decreased early, but on the 20th day of hospitalization, the patient underwent surgery for her clinical symptoms and the evidence of free fluid in the Douglas pouch at a transvaginal ultrasound exam. Our experience showed that medical treatment should be considered, especially in women wishing to preserve their fertility. Further studies are needed to establish a standardized protocol and maybe a clinical score that can be useful in predicting the patients in which medical therapy could be most successful.

Local injection of methotrexate ultrasound guided-transvaginal.

Non-tubal ectopic pregnancies can be located in the uterine portion of the tube (interstitial or cornual), in the cervix (cervical), in a cesarian scar, in the ovary, or intra-abdominally. Even though they are rare, they are associated with a high mortality. Invasive surgeries such as cornuectomy and hysterectomy were common to treat them in case of hemorrhage. Thanks to recent advances in imaging techniques, diagnosis of non-tubal ectopic pregnancy is made earlier and conservative management has been developed in order to respect fertility of patients. Beyond these treatments, systemic or local injection of Methotrexate shows very good success. In the article, we aimed to describe the technics of vaginal injection of in situ methotrexate with ultrasound guidance.

Technical notes surgical treatment of a ruptured interstitial pregnancy.

Non-tubal ectopic pregnancies represent fewer than 10% of all ectopic pregnancies. However, they are associated with a high rate of mortality due to late diagnosis and uterine horn rupture which requires radical emergency surgical management. Cornuectomy via laparoscopy is a treatment of choice. We provide here a simple description of laparoscopic cornuectomy using an Endo GIA stapling system: the Endo GIA® automatic forceps. It has the advantage of removing the mass, suturing, and achieving satisfactory haemostasis in a single step.

Concurrent Ovarian and Tubal Ectopic Pregnancy After IVF-ET: Case Report and Literature Review.

Ovarian pregnancy (OP) coupled with tubal ectopic pregnancy is rare. We present a case of coexistent ovarian and tubal ectopic pregnancies in the same adnexa resulting from in vitro fertilization and embryo transfer (IVF-ET) for tubal occlusion. The patient presented with mild vaginal bleeding without abdominal pain. OP was diagnosed via sonographic findings of an ectopic gestational sac (GS) and yolk sac that seemed to be inside her left ovary. Laparoscopic exploration confirmed this diagnosis, and ipsilateral tubal ectopic pregnancy was suspected during surgery. The patient underwent left salpingectomy and resection of the ovarian lesion. A subsequent histopathological examination verified the diagnosis of coexistent ovarian and tubal ectopic pregnancy. Though the mechanism underlying concurrent OP and tubal ectopic pregnancy is still unclear, clinicians should be cautious of potential combined ectopic pregnancy when dealing with patients who have received more than one embryo transfer.

Management of non-tubal ectopic pregnancies in France: Results of a practice survey.

INTRODUCTION: Non-tubal ectopic pregnancies (NTEP) in France constitute approximately 5% of ectopic pregnancies (EP). A NTEP can be abdominal, ovarian, cervical, interstitial, on a caesarean scar, or cornual. These pregnancies, which are sometimes difficult to diagnose and are often diagnosed late, carry a high risk of complications, particularly haemorrhages. Many treatments have been described for treating these NTEP. Our objective is to assess how they are cared for in terms of diagnosis, treatment and monitoring. EQUIPMENT AND METHODOLOGY: An online questionnaire was sent out to all members of the French Society of gynecologic and Pelvic Surgery (SCGP) in September 2020. The questionnaire was in the form of two clinical cases on interstitial and caesarean scar pregnancies. RESULTS: 141 SCGP members responded (36%). For diagnosis, 58% of respondents enlisted the help of a specialist sonographer. MRI is rarely used for diagnosis to the extent that it was only requested in 7% of cases for interstitial pregnancy and 23.6% of cases for caesarean scar pregnancy. In the case of stable interstitial pregnancy without signs of complications, treatment is predominantly medical (90%), with the use of methotrexate (MTX) by intramuscular injection in 33.3% of cases, by in situ injection in 30.7% of cases, or a combination of the two in 36% of cases. If there were signs of pre-rupture, the majority of respondents performed laparoscopic surgical treatment (79.3%). In terms of caesarean scar pregnancies, the treatment was predominantly medical (78.2%) with the use of MTX only, as an intramuscular injection in 23.3% of cases, in situ in 36% of cases, and as a combination of intramuscular and in situ in 37.2% of cases. DISCUSSION: Non-tubal ectopic pregnancies are sometimes difficult to diagnose in the first trimester and constitute a significant haemorrhage risk for patients. In France, there is currently no specific recommendation on this subject and there is huge disparity in practice.