Chronic interstitial ectopic pregnancy presenting with a negative urine pregnancy test.

The ampulla portion of the fallopian tube is the most common site of ectopic pregnancy (70%), with approximately 2% of pregnancies implanted in the interstitial portion. In general, an interstitial ectopic pregnancy (IEP) is difficult to diagnose and is associated with a high rate of complications-most patients with an IEP present with severe abdominal pain and haemorrhagic shock due to an ectopic rupture. Chronic tubal pregnancy (CTP) is an uncommon condition with an incidence of 20%. The CTP has a longer clinical course and a negative or low level of serum beta-human chorionic gonadotropin due to perished chorionic villi. This study presents a case of a woman who was diagnosed with a chronic IEP (CIEP) which was successfully treated by surgery. This case also acts as a cautionary reminder of considering a CIEP in women of reproductive age presenting with amenorrhea, vaginal bleeding and a negative pregnancy test.

Embarazo ectópico en cicatriz de cesárea: reporte de un caso

La gestación extrauterina se denomina embarazo ectópico, esta es una emergencia obstétrica del primer trimestre, que cada vez está teniendo una incidencia mayor. Una de las localizaciones en las que se pueden generar estas gestaciones es la cicatriz de cesárea previa, lo cual supone un reto para el ginecólogo tratante debido a su dificultad diagnóstica y opciones terapéuticas. Se reporta el caso de una paciente de 37 años que ingresó por el servicio de emergencia con 6 semanas de amenorrea, y con el antecedente de 2 cesáreas. Se le realizó un legrado uterino que se complicó y terminó en la realización de una histerectomía. El embarazo ectópico en cicatriz de cesárea es raro, sin embargo, es importante pensar en esta opción diagnóstica en gestantes con sangrado en el primer trimestre con antecedente de cesárea para poder buscar signos ecográficos en la evaluación.

Extrauterine gestation is called ectopic pregnancy, this is an obstetric emergency of the first trimester, which is having an increasing incidence. One of the locations in which these pregnancies can be generated is the scar from a previous cesarean section, which is a challenge for the treating gynecologist due to its diagnostic difficulty and therapeutic options. We report the case of a 37-year-old patient who was admitted to the emergency service with 6 weeks of amenorrhea, and with a history of 2 cesarean sections. She underwent a uterine curettage that was complicated and ended in a hysterectomy. Ectopic pregnancy in cesarean section scar is rare, however, it is important to consider this diagnostic option in pregnant women with bleeding in the first trimester with a history of cesarean section to be able to look for ultrasound signs in the evaluation.

Methotrexate vs expectant management for treatment of tubal ectopic pregnancy: An individual participant data meta-analysis.

INTRODUCTION: Ectopic pregnancy is an important health condition which affects up to 1 in 100 women. Women who present with mild symptoms and low serum human chorionic gonadotrophin (hCG) are often treated with methotrexate (MTX), but expectant management with close monitoring is a feasible alternative. Studies comparing the two treatments have not shown a statistically significant difference in uneventful resolution of ectopic pregnancy, but these studies were too small to define whether certain subgroups could benefit more from either treatment. MATERIAL AND METHODS: We performed a systematic review and individual participant data meta-analysis (IPD-MA) of randomized controlled trials comparing systemic MTX and expectant management in women with tubal ectopic pregnancy and low hCG (<2000 IU/L). A one-stage IPD-MA was performed to assess overall treatment effects of MTX and expectant management to generate a pooled intervention effect. Subgroup analyses and exploratory multivariable analyses were undertaken according to baseline serum hCG and progesterone levels. Primary outcome was treatment success, defined as resolution of clinical symptoms and decline in level of serum hCG to <20 IU/L, or a negative urine pregnancy test by the initial intervention strategy, without any additional treatment. Secondary outcomes were need for blood transfusion, surgical intervention, additional MTX side-effects and hCG resolution times. TRIAL REGISTRATION NUMBER: PROSPERO: CRD42021214093. RESULTS: 1547 studies reviewed and 821 remained after duplicates removed. Five studies screened for eligibility and three IPD requested. Two randomized controlled trials supplied IPD, leading to 153 participants for analysis. Treatment success rate was 65/82 (79.3%) after MTX and 48/70 (68.6%) after expectant management (IPD risk ratio [RR] 1.16, 95% confidence interval [CI] 0.95-1.40). Surgical intervention rates were not significantly different: 8/82 (9.8%) vs 13/70 (18.6%) (RR 0.65, 95% CI 0.23-1.14). Mean time to success was 19.7 days (95% CI 17.4-22.3) after MTX and 21.2 days (95% CI 17.8-25.2) after expectant management (P = 0.25). MTX specific side-effects were reported in 33 MTX compared to four in the expectant group. CONCLUSIONS: Our IPD-MA showed no statistically significant difference in treatment efficacy between MTX and expectant management in women with tubal ectopic pregnancy with low hCG. Initial expectant management could be the preferred strategy due to fewer side-effects.

Embarazo ectópico abdominal con feto vivo en el Hospital Provincial de Bié, Angola / Abdominal ectopic pregnancy with a live fetus in Bié Provincial Hospital, Angola

El embrión, en condiciones normales, es concebido en la trompa y migra al útero. Un pequeño porcentaje que no llega a completar esta migración, se convierte en embarazo ectópico. Se presentó el caso de un embarazo ectópico abdominal con feto vivo; paciente femenina de 32 años de edad, multigesta con 4 partos eutócicos a término. A las 37 semanas de edad gestacional se remitió al Hospital Provincial de Bié por presentar dolor abdominal difuso, de moderada intensidad, que se exacerbaba con los movimientos fetales. Se realizó la cesárea, se encontró un embarazo ectópico abdominal con feto vivo y placenta implantada en fondo uterino, epiplón y colon transverso. Se dejó placenta in situ para un posterior seguimiento.

The embryo, under normal conditions, is conceived into the fallopian tube and migrates to the uterus. A small percentage of the embryos that do not complete this migration become an ectopic pregnancy. We present a 32-year-old female patient with multiple gestation pregnancies and 4 normal term deliveries who had an abdominal ectopic pregnancy with a live fetus. She was referred to Bié Provincial Hospital at 37 weeks' gestation due to diffuse abdominal pain of moderate intensity, which was exacerbated by fetal movements. A cesarean section was performed; an abdominal ectopic pregnancy with a live fetus and the placenta implanted in the uterine fundus, omentum, and transverse colon was found. The placenta was left in situ for further follow-up.

Delays to Surgery in Emergency Department Cases of Ectopic Pregnancy: A Quality Improvement Study.

OBJECTIVE: Create a process map for emergency department (ED) presentations of surgical ectopic pregnancy, and identify areas of management amenable to quality improvement. METHODS: A retrospective chart review of all patients undergoing surgical management of ectopic pregnancy at a large, urban, academic tertiary care centre from 2015 to 2017 was performed. RESULTS: Seventy-three patients were included. There were 6 (8.2%) unstable A cases (recommended time to operating room [OR] 0-2 hours), 23 (31.5%) stable A cases, and 44 (60%) B cases (recommended time to OR 2-8 hours). The percent of patients who were in the OR within the recommended time window were 6 (100%) for unstable A cases, 13 (56%) stable A cases, and 29 (65.9%) stable B cases, respectively (P = 0.139). Notable time delays include the time from gynaecology referral to the time seen by gynaecology (29.7% of total wait time for stable A cases from ED to OR) and the time the OR was booked to the time the patient was brought to the OR (53.2% of total wait time for stable B cases). Of the patients seen by physician at the emergency department first, the time from triage to the OR was significantly shorter for patients that received bedside ultrasound only (0.67 ± 0.5 hours vs. 2.1 ± 1.8 hours [P = 0.007]). CONCLUSION: This is the first study to map the ED presentation of surgical ectopic pregnancy. The management of ectopic pregnancy would benefit from the development of surgical triage decision aids, a surgical care pathway, and increased use of screening bedside ultrasound.

Observation on the clinical outcomes of continued pregnancy following cesarean scar pregnancy in 55 women / 中华妇产科杂志

Objective:To observe the clinical outcomes of continued pregnancy in pregnant women with cesarean scar pregnancy (CSP).Methods:A retrospective analysis was performed on the pregnancy outcomes of 55 pregnant women who were diagnosed with CSP at the Second Affiliated Hospital of Army Medical University during the first trimester of pregnancy from August 1st, 2018 to October 31st, 2021 and strongly requested to continue the pregnancy.Results:Of the 55 pregnant women, 15 terminated the pregnancy in the first trimester, 1 underwent hysterotomy at 23 weeks of gestation due to cervical dilation, and 39 (71%, 39/55) continued pregnancy to the third trimester achieving live births via cesarean section. The gestational age of the 39 pregnant women delivered by cesarean section was 35 +6 weeks (range: 28 +5-39 +2 weeks), of whom 7 cases at 28 +5-33 +6 weeks, 20 cases at 34-36 +6 weeks, and 12 cases at 37-39 +2 weeks. The results of pathological examination were normal placenta in 3 cases (8%, 3/39), placenta creta in 4 cases (10%, 4/39), placenta increta in 9 cases (23%, 9/39) and placenta percreta in 23 cases (59%, 23/39). Among the 36 pregnant women who were pathologically confirmed as placenta accreta spectrum disorders (PAS) after surgery, the last prenatal ultrasonography showed placenta previa in 27 cases (75%, 27/36) and not observed placenta previa in 9 cases. The median intraoperative blood loss, autologous blood transfusion, and allogeneic suspended red blood cell infusion of 39 pregnant women during cesarean section were 1 000 ml (300-3 500 ml), 300 ml (0-2 000 ml) and 400 ml (0-2 400 ml), respectively. The uterine preservation rate was 100% (39/39), and only 1 case received cystostomy due to intracystic hemorrhage. The birth weight of the newborn was 2 580 g (1 350-3 800 g), and 1 case of mild asphyxia. Conclusions:Pregnant women with CSP who continue pregnancy under close monitoring after adequate ultrasound evaluation and doctor-patient communication could achieve better maternal and infant outcomes, but pregnant women with CSP are highly likely to continue pregnancy and develop into PAS. Effective hemostasis means and multidisciplinary team cooperation are needed in perinatal period for ensuring maternal and fetal safety.

Tissue concentration of vascular endothelial growth factor is not related to the depth of trophoblastic invasion in ampullary pregnancies-A pilot study.

Introduction: The factors that modulate trophoblastic invasion into the tubal wall remain uncertain. Moreover, it is known that the concentration of vascular endothelial growth factor (VEGF) is increased in cases of deeper trophoblastic invasion in the fallopian tubes. Objective: This study aimed to assess if there is a correlation between VEGF tissue expression and the depth of trophoblastic infiltration into the tubal wall in patients with ampullary pregnancy. Methods: A cross-sectional study was conducted in patients with a diagnosis of tubal pregnancy in the ampullary region who underwent salpingectomy. Inclusion criteria were spontaneously conceived singleton pregnancies, diagnosis of tubal pregnancy in the ampullary region, and radical surgical treatment. A lack of agreement regarding the location of the tubal pregnancy and impossibility of either anatomopathological or tissue VEGF analysis were the exclusion criteria. Histologically, trophoblastic invasion into the tubal wall was classified as grade I when limited to the tubal mucosa, grade II when it reached the muscle layer, and grade III when it comprised the full thickness of the tubal wall. A total of 42 patients fulfilled the inclusion criteria and were selected to participate in the study. Eight patients were excluded. After surgery, tissue VEGF expression was measured by immunohistochemistry and the point counting technique. Results: Histological analysis revealed that eight patients had stage I tubal infiltration, seven had stage II, and 19 had stage III. The difference between the percentage of VEGF expression in the trophoblastic tissue was not significant in relation to the degree of trophoblastic invasion (p = 0.621) (ANOVA). Trophoblastic tissue VEGF showed no statistical difference for prediction of both degrees of trophoblastic invasion (univariate multinomial regression). Conclusion: The depth of trophoblastic penetration into the tubal wall in ampullary pregnancies is not associated with tissue VEGF expression.

The risk of miscarriage following surgical treatment of heterotopic extrauterine pregnancies.

STUDY QUESTION: What is the risk of loss of a live normally sited (eutopic) pregnancy following surgical treatment of the concomitant extrauterine ectopic pregnancy? SUMMARY ANSWER: In women diagnosed with heterotopic pregnancies, minimally invasive surgery to treat the extrauterine ectopic pregnancy does not increase the risk of miscarriage of the concomitant live eutopic pregnancy. WHAT IS KNOWN ALREADY: Previous studies have indicated that surgical treatment of the concomitant ectopic pregnancy in women with live eutopic pregnancies could be associated with an increased risk of miscarriage. The findings of our study did not confirm that. STUDY DESIGN SIZE DURATION: A retrospective observational case-control study of 52 women diagnosed with live eutopic and concomitant extrauterine pregnancies matched to 156 women with live normally sited singleton pregnancies. The study was carried out in three London early pregnancy units (EPUs) covering a 20-year period between April 2000 and November 2019. PARTICIPANTS/MATERIALS SETTING METHODS: All women attended EPUs because of suspected early pregnancy complications. The diagnosis of heterotopic pregnancy was made on ultrasound scan and women were subsequently offered surgical or expectant management.There were three controls per each case who were randomly selected from our clinical database and were matched for maternal age, mode of conception and gestational age at presentation. MAIN RESULTS AND THE ROLE OF CHANCE: In the study group 49/52 (94%) women had surgery and 3/52 (6%) were managed expectantly. There were 9/52 (17%, 95% CI 8.2-30.3) miscarriages <12 weeks' gestation and 9/49 (18%, 95% CI 8.7-32) miscarriages in those treated surgically. In the control group, there were 28/156 (18%, 95% CI 12.2-24.8) miscarriages <12 weeks' gestation, which was not significantly different from heterotopic pregnancies who were treated surgically [odds ratio (OR) 1.03 95% CI 0.44-2.36]. There was a further second trimester miscarriage in the study group and one in the control group. The live birth rate in the study group was 41/51 (80%, 95% CI 66.9-90.2) and 38/48 (79%, 95% CI 65-89.5) for those who were treated surgically. These results were similar to 127/156 (81%, 95% CI 74.4-87.2) live births in the control group (OR 0.87, 95% CI 0.39-1.94). LIMITATIONS REASONS FOR CAUTION: This study is retrospective, and the number of patients is relatively small, which reflects the rarity of heterotopic pregnancies. Heterotopic pregnancies without a known outcome were excluded from analysis. WIDER IMPLICATIONS OF THE FINDINGS: This study demonstrates that in women diagnosed with heterotopic pregnancies, minimally invasive surgery to treat the extrauterine pregnancy does not increase the risk of miscarriage of the concomitant live eutopic pregnancy. This finding will be helpful to women and their clinicians when discussing the options for treating heterotopic pregnancies. STUDY FUNDING/COMPETING INTERESTS: This work did not receive any funding. None of the authors has any conflict of interest to declare. TRIAL REGISTRATION NUMBER: Research Registry: researchregistry6430.

A Purse-String Approach to Laparoscopic Cornuotomy for Interstitial Ectopic Pregnancy.

An interstitial ectopic refers to the implantation of a pregnancy in the proximal fallopian tube where it passes through the myometrium. This type of ectopic pregnancy presents a distinct surgical challenge, as it often presents with rupture and carries a significant risk of hemorrhage at resection. This video demonstrates a four-step approach to the resection of an interstitial ectopic pregnancy with laparoscopic cornuotomy. This approach includes (1) isolating the pregnancy by performing a salpingectomy and identifying the utero-ovarian ligament; (2) ensuring hemostasis with the injection of vasopressin, followed by application of the purse string suture around the pregnancy at its equatorial line; (3) performing the resection using a linear incision; and (4) repairing the uterine defect with layered closure. The purse-string suture is shown to be a useful tool in minimizing bleeding, and this sequential approach allows for interstitial ectopic pregnancies to be excised with a minimally invasive cornuotomy, even in cases of significant anatomical distortion.

Clinical value of transabdominal ultrasonography versus transvaginal ultrasonography in the early diagnosis of ectopic pregnancy / 中国基层医药

Objective:To investigate the clinical value of transabdominal ultrasonography versus transvaginal ultrasonography in the early diagnosis of ectopic pregnancy. Methods:A total of 100 patients with suspected early ectopic pregnancy who received treatment in Luanping Shengjian Hospital between April 2019 and April 2021 were included in this study. All of them underwent transabdominal and transvaginal ultrasonography. Surgical pathological results were used as the gold standard to analyze the diagnostic efficacy of the two examination methods. The detection rate of ectopic pregnancy by ultrasonography was compared between the two examination methods.Results:Early ectopic pregnancy was detected in 59 cases by transabdominal ultrasonography, among which seven cases were misdiagnosed and 10 cases were missed. Early ectopic pregnancy was detected in 60 cases by transvaginal ultrasonography, among which one case was misdiagnosed and three cases were missed. The sensitivity, specificity and accuracy of transvaginal ultrasonography in the early detection of ectopic pregnancy were 95.2%, 97.4% and 96.0%, respectively, which were significantly higher than those of transabdominal ultrasonography (83.9%, 81.6%, 83.0%, χ2 =4.21, 5.03, 8.99, P = 0.040, 0.025, 0.003). Transvaginal ultrasonography showed that detection rates of accessory mass, yolk sac, embryo, intrauterine pseudopregnancy sac, pelvic effusion and original vascular fluctuation were 88.7%, 50.0%, 24.2%, 22.6%, 12.9%, 87.1%, respectively, which were significantly higher than those of transabdominal ultrasonography (64.5%, 19.4%, 4.8%, 4.8%, 1.6%, 56.5%, χ2 = 10.13, 12.85, 9.36, 8.25, 5.87, 14.37, P = 0.001, < 0.001, = 0.002, = 0.004, = 0.015, < 0.001). Conclusion:Transvaginal ultrasonography is superior to transabdominal ultrasonography in the early detection of ectopic pregnancy and has a higher detection rate of sonographic manifestation than transabdominal ultrasonography.

Clinical effect and influencing factors of focused ultrasound ablation surgery combined with suction curettage for the treatment of mass-type cesarean scar pregnancy / 中华妇产科杂志

Objective:To investigate the clinical effect of focused ultrasound ablation surgery (FUAS) combined with suction curettage for mass-type cesarean scar pregnancy (CSP) and to analyze the influencing factors of vaginal bleeding and readmission.Methods:From January 2014 to December 2020, 88 patients with mass-type CSP were treated by FUAS combined with suction curettage in the Third Xiangya Hospital of Central South University. The clinical results and the influencing factors of bleeding and readmission for mass-type CSP were analyzed.Results:All the patients underwent one time FUAS treatment successfully. Immediately after FUAS treatment, color Doppler ultrasound showed obvious necrosis and no perfusion area in all lesions, and the blood flow in the mass-type CSP tissue significantly decreased. The median volume of blood loss in the procedure was 20 ml (range: 5-950 ml). Thirteen patients (15%, 13/88) had vaginal bleeding≥200 ml, and 15 patients (17%, 15/88) were hospitalized again. The average time for menstruation recovery was (28±8) days (range: 18-66 days). The average time needed for serum human chorionic gonadotropin-beta subunit to return to normal levels was (22±6) days (range: 7-59 days). The risk of large vaginal bleeding of patients were related to the blood supply of the mass ( OR=5.280, 95% CI: 1.335-20.858, P=0.018) and the largest diameter of the mass ( OR=1.060, 95% CI: 1.010-1.120, P=0.030). The risk of readmission were related to the largest diameter of the mass ( OR=1.055, 95% CI: 1.005-1.108, P=0.030) and the depth of the uterus cavity ( OR=1.583, 95% CI: 1.015-2.471, P=0.043). No serious complications such as intestinal and nerve injury occurred during and after FUAS treatment. Conclusions:FUAS combined with suction curettage is safe and effective in treating patients with mass-type CSP through this preliminary study. The volume of vaginal bleeding are associated with the blood supply of the mass and the largest diameter of the mass, the risk of readmission are related to the largest diameter of the mass and the depth of the uterus cavity.

Advances in the application of transvaginal ultrasound in the diagnosis and treatment of ectopic pregnancy / 中国基层医药

Ectopic pregnancy is one of the most common acute abdominal diseases in gynecology. A ruptured ectopic pregnancy can lead to hemorrhagic shock, which is life-threatening. Therefore, early diagnosis and early treatment are extremely critical for preserving fertility and achieving good prognosis in patients with ectopic pregnancy. The available diagnostic methods of ectopic pregnancy include laboratory tests such as progesterone test, human chorionic gonadotropin test and ultrasound examination. Ultrasound examination can help determine the location of uterine and adnexal masses, gestational sacs, and germ, all of which are directly related to the final diagnosis regarding ectopic pregnancy. Ultrasound examination includes abdominal ultrasound and transvaginal ultrasound. Transvaginal ultrasound accesses to the focal tissue closer than abdominal ultrasound, and it does not require a full bladder. These advantages make clinical practice of transvaginal ultrasound easier for both physicians and patients. However, application of transvaginal ultrasound in the diagnosis of ectopic pregnancy requires further investigation to guide the early diagnosis and treatment of ectopic pregnancy. .

Tratamiento del embarazo ectópico no complicado con inyección local de metotrexato / Management of uncomplicated ectopic pregnancy with local injection of methotrexate

Resumen OBJETIVO: Describir la experiencia en la atención de pacientes con embarazo ectópico no complicado con una inyección local de metotrexato guiada por ecografía. MATERIALES Y MÉTODOS: Estudio retrospectivo, descriptivo y de serie de casos llevado a cabo del 1 de enero del 2021 al 28 de febrero del 2022 en el Instituto Nacional Materno Perinatal, Lima, Perú. Las participantes tuvieron embarazo ectópico no complicado, tratado con inyección local de metotrexato guiada por ecografía. Los datos se obtuvieron de los registros en las historias clínicas. El análisis estadístico se procesó en el programa SPSS 19. RESULTADOS: Se registraron 222 casos de embarazo ectópico y se aplicaron 11 inyecciones locales con metotrexato guiadas por ecografía. De acuerdo con su localización 4 embarazos fueron tubáricos, 1 cervical y 6 en cicatriz de cesárea. La edad promedio de las embarazadas fue de 34.5 años. El promedio de semanas de embarazo fue de 7. La concentración inicial de b-hCG fue de 42812.55 mU/mL. El tamaño promedio del saco gestacional fue de 22.8 mm. El tamaño medio de los embriones fue de 7.81 mm. Se detectó actividad cardiaca embrionaria en 10 casos que recibieron una inyección intratorácica de cloruro de potasio hasta que no se evidenció el latido cardiaco. Un solo caso recibió una dosis sistémica adicional de metotrexato. Otro caso resultó con hemoperitoneo, por rotura de embarazo ectópico luego de la inyección local. CONCLUSIONES: La inyección local de metotrexato, guiada por ecografía, es una alternativa a otras técnicas quirúrgicas aplicadas para tratar pacientes con embarazo ectópico no complicado, con indicación quirúrgica.

Abstract OBJECTIVE: To describe the experience in the care of patients with uncomplicated ectopic pregnancy with ultrasound-guided local injection of methotrexate. MATERIALS AND METHODS: Retrospective, descriptive, case series study conducted from January 1, 2021 to February 28, 2022 at the Instituto Nacional Materno Perinatal, Lima, Peru. Participants had uncomplicated ectopic pregnancy treated with ultrasound-guided local injection of methotrexate. Data were obtained from medical records. Statistical analysis was processed in SPSS 19. RESULTS: 11 ultrasound-guided local methotrexate injections were performed. According to their location 4 pregnancies were tubal, 1 cervical and 6 in cesarean scar. The average age of the pregnant women was 34.5 years. The average number of weeks of pregnancy was 7. The initial b-hCG concentration was 42812.55 mU/mL. The mean gestational sac size was 22.8 mm. The mean embryo size was 7.81 mm. Embryonic cardiac activity was detected in 10 cases that received an intrathoracic injection of potassium chloride until no heartbeat was evident. A single case received an additional systemic dose of methotrexate. Another case resulted in hemoperitoneum, due to rupture of ectopic pregnancy after local injection. CONCLUSIONS: Ultrasound-guided local injection of methotrexate is an alternative to other surgical techniques applied to treat patients with uncomplicated ectopic pregnancy with surgical indication.

[Ectopic pregnancy on uterine scar from cesarean section] / Embarazo ectópico sobre cicatriz uterina por cesárea.

Ectopic pregnancy is defined as the implantation of the fertilized egg outside the uterine cavity. About 95% of ectopic pregnancies are located in the tube. Non-tubal forms, in particular on the scar of a cesarean section, are a very rare entity whose early diagnosis and treatment are essential to avoid serious complications and preserve fertility.

El embarazo ectópico se define como la implantación del óvulo fecundado fuera de la cavidad uterina. Alrededor del 95% de los embarazos ectópicos se localizan en la trompa. Las formas no tubáricas, en concreto sobre la cicatriz de una cesárea, son una entidad muy poco frecuente cuyo diagnóstico y tratamiento precoz son imprescindibles para evitar complicaciones graves y preservar la fertilidad.

Impact of severe acute respiratory syndrome coronavirus 2 on ectopic pregnancy management in the United Kingdom: a multicentre observational study.

OBJECTIVE: To describe the impact of coronavirus disease 2019 (COVID-19) on the management of women with ectopic pregnancy. DESIGN: A multicentre observational study comparing outcomes from a prospective cohort during the pandemic [COVID-19-ectopic pregnancy registry (CEPR)] compared with a historical pre-pandemic cohort [non-COVID-19-ectopic pregnancy registry (NCEPR)]. SETTING: Five London university hospitals. POPULATION AND METHODS: Consecutive patients diagnosed clinically and/or radiologically with ectopic pregnancy (March 2020-August 2020) were entered into the CEPR and results were compared with the NCEPR cohort (January 2019-June 2019). An adjusted analysis was performed for potentially confounding variables. MAIN OUTCOME MEASURES: Patient demographics, management (expectant, medical and surgical), length of treatment, number of hospital visits (non-surgical management), length of stay (surgical management) and 30-day complications. RESULTS: Three hundred and forty-one women met the inclusion criteria: 162 CEPR and 179 NCEPR. A significantly lower percentage of women underwent surgical management versus non-surgical management in the CEPR versus NCEPR (58.6%; 95/162 versus 72.6%; 130/179; P = 0.007). Among patients managed with expectant management, the CEPR had a significantly lower mean number of hospital visits compared with NCEPR (3.0, interquartile range [IQR] [3, 5] versus 9.0, [5, 14]; P = <0.001). Among patients managed with medical management, the CEPR had a significantly lower median number of hospital visits versus NCEPR (6.0, [5, 8] versus 9, [6, 10]; P = 0.003). There was no observed difference in complication rates between cohorts. CONCLUSION: Women were found to undergo significantly higher rates of non-surgical management during the COVID-19 first wave compared with a pre-pandemic cohort. Women managed non-surgically in the CPER cohort were also managed with fewer hospital attendances. This did not lead to an increase in observed complication rates. TWEETABLE ABSTRACT: A higher rate of non-surgical management of ectopic pregnancy during the COVID-19 pandemic did not increase complication rates.

Guideline No. 414: Management of Pregnancy of Unknown Location and Tubal and Nontubal Ectopic Pregnancies.

OBJECTIVE: To provide an evidence-based algorithm to guide the diagnosis and management of pregnancy of unknown location and tubal and nontubal ectopic pregnancy. TARGET POPULATION: All patients of reproductive age. BENEFITS, HARMS, AND COSTS: The implementation of this guideline aims to benefit patients with positive ß-human chorionic gonadotropin results and provide physicians with a standard algorithm for expectant, medical, and surgical treatment of pregnancy of unknown location and tubal pregnancy and nontubal ectopic pregnancies. EVIDENCE: The following search terms were entered into PubMed/Medline and Cochrane in 2018: cesarean section, chorionic gonadotropin, beta subunit, human/blood, fallopian tubes/surgery, female, fertility, humans, infertility, laparoscopy, methotrexate, methotrexate/administration & dosage, methotrexate/therapeutic use, pregnancy (abdominal, angular, cervix, cornual, ectopic, ectopic/diagnosis, ectopic/diagnostic imaging, ectopic/drug therapy, ectopic/epidemiology, ectopic/mortality, ectopic/surgery, heterotopic, interstitial, isthmo-cervical, ovarian, tubal, unknown location), recurrence, risk factors, salpingectomy, salpingostomy, tubal pregnancy, ultrasonography, doppler ultrasonography, and prenatal. Articles included were randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: Obstetrician-gynaecologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, and residents and fellows. SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES): RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Angular Pregnancy: An Eccentric Implantation Within Uterine Cavity.

Angular ectopic is a rare form of ectopic pregnancy which is diagnosed as intrauterine pregnancy on ultrasound but may rupture in second trimester leading to maternal mortality. We present a case of a 32-year-old primigravida who presented at 18 weeks gestation to the emergency department of national hospital Lahore with complaint of dizziness, sweating and epigastric pain for one hour. She had an episode of diarrhoea and vomiting at hospital followed by rapidly increased abdominal distension and signs of hypovolemic shock. Urgent ultrasound suggested rupture of posterior uterine wall and massive hemoperitoneum. An urgent laparotomy was done. Uterus was perforated by pregnancy posteriorly. baby was inside the sac and alive. But died soon after birth. Uterus was repaired in two layers. Stepwise devascularization of uterus was done due to continuous bleeding. 6 units whole blood 6 FFP were transfused. The abnormal location of this pregnancy makes it antenatal diagnosis difficult. A high index of suspicion is needed in pregnant women presenting in shock even when intrauterine location of pregnancy is diagnosed in first trimester.

Surgical methods and clinical efficacy of different types of cesarean scar pregnancy / 中国基层医药

Objective:To compare surgical methods and clinical efficacy among different types of cesarean scar pregnancy (CSP).Methods:A total of 158 patients with CSP who received treatment in Yuncheng Central Hospital from January 2016 to June 2019 were included in this study. According to Expert Consensus on Diagnosis and Treatment of Cesarean Scar Pregnancy (2016 version), type I CSP was found in 55 patients, type II in 86 patients and type III in 17 patients. These patients were divided into groups A (ultrasound-guided suction curettage), B (uterine artery chemoembolization + ultrasound-guided suction curettage) and C (laparoscopic scar pregnancy lesion resection + scar repair) according to different surgical methods. The amount of intraoperative blood loss, the difference in human chorionic gonadotropin (HCG) level between before and after surgery, the time to postoperative HCG level returning to normal level, menstruation recovery, and re-pregnancy were compared between groups.Results:The amount of intraoperative blood loss in the groups A, B and C was (43.33 ± 72.31) mL, (34.41 ± 17.16) mL, (65.71 ± 70.52) mL, respectively. There was significant difference between groups ( F = 8.51, P = 0.014]. The difference in HCG level between before and after surgery in groups A, B and C was (0.64 ± 0.18), (0.79 ± 0.10), (0.76 ± 0.19), respectively. There was significant difference in the difference in HCG level between groups ( F = 19.21, P < 0.001). There was significant difference in the incidence of postoperative menstrual volume reduction between group B and the other two groups ( χ2 = 6.73, P = 0.003). After surgery, intrauterine pregnancy occurred in 12 patients, including 8 patients in group A (type I CSP in 2 patients, type II CSP in 3 patients, type III CSP in 3 patients), 4 patients in group B (type I CSP in 3 patients, type II CSP in 1 patient). Finally, full-term fetus delivery by cesarean section was performed in 6 patients (4 patients in group A and 2 patients in group B). Conclusion:Uterine artery chemoembolization combined with uterine curettage had less blood loss, during surgery and leads to an obvious decrease in HCG level, but it can result in reduction of menstrual volume. Ultrasound-guided suction curettage is preferred for type I and type II CSP. Balloon compression can be used to stop bleeding if massive bleeding occurs. Laparoscopic scar pregnancy lesion resection plus scar repair is recommended for type III CSP.

Clinical analysis of surgical treatment of cornual pregnancy of 109 cases / 中华妇产科杂志

Objective:To study the clinical characteristics of cornual pregnancy and compare the effects of various surgical methods on the outcomes.Methods:This was a single-center retrospective study. The clinical records of patients with cornual pregnancy who underwent surgery in Peking Union Medical College Hospital from June 2012 to December 2020 were collected. Surgical interventions included curettage (guided by ultrasound or monitored by laparoscope), and cornuostomy/cornectomy (the surgical approach by laparoscopy or laparotomy). The baseline data, perioperative treatment and whether persistent ectopic pregnancy (PEP) occurred after surgery were collected and analyzed statistically.Results:A total of 109 patients with cornual pregnancy diagnosed by surgical treatment were included in this study, whose average age was (32.9±4.8) years. Among them, the incidence of postoperative PEP was 16.5% (18/109). The risk of PEP in multipara was significantly higher than that in nulliparous women ( OR=7.639, 95% CI: 2.063-28.279, P=0.001). The risk of PEP in patients with the maximum diameter of lesion<1.5 cm was significantly higher than that in patients with the maximum diameter of lesion≥1.5 cm ( OR=8.600, 95% CI: 2.271-32.571, P=0.002). Among all surgical approaches for cornual pregnancy, the proportion of PEP in curettage under ultrasound monitoring was the highest (56.0%, 14/25), which was higher than that in curettage under laparoscope monitoring (1/10; χ2=6.172， P=0.013); the proportion of PEP in curettage group (42.9%, 15/35) was higher than that in cornuostomy/cornectomy group (4.1%, 3/74; χ2=25.950， P<0.01). Neither salpingectomy in the operation nor the routine use of methotrexate (MTX) in perioperative period could significantly reduce the incidence of PEP (all P>0.05). Conclusions:Among the patients with cornual pregnancy, multipara, the maximum diameter of lesion<1.5 cm and ultrasound-guided curettage are the risk factors of PEP after operation. Cornuostomy or cornectomy is recommended for patients with cornual pregnancy. If the patients would perform the curettage operation, laparoscopic monitoring is recommended. For patients with possible satisfactory operation outcome, it is not recommended to use MTX as a routine preventing measure.

Evaluation of the diagnosis and treatment of cesarean scar pregnancy induced in the second trimester: a national multicenter retrospective study / 中华妇产科杂志

Objective:To study the risk factors of adverse pregnancy outcomes for induced abortion of cesarean scar pregnancy in midtrimester.Methods:A national multicenter retrospective study was conducted. A total of 154 singletons pregnant women with cesarean scar pregnancy during the second trimester induced abortion by various reasons in 12 tertiary A hospitals were selected, their pregnant outcomes were observed and the risk factors of serious adverse outcomes were analyzed with univariate and multivariate logstic regression; the role of ultrasound and MRI in predicting placenta accreta and severe adverse outcomes was evaluated, the effectiveness of uterine artery embolization (UAE) in preventing hemorrhage in pregnant women with and without placenta accreta was compared.Results:Among 154 subjects, the rate of placenta accreta was 42.2% (65/154), the rate of postpartum hemorrhage≥1 000 ml was 39.0% (60/154), the rate of hysterectomy was 14.9% (23/154), the rate of uterine rupture was 0.6% (1/154). The risk factor of postpartum hemorrhage≥1 000 ml and hysterectomy was placenta accreta ( P<0.01). For each increase in the number of parity, the risk of placenta accreta increased 2.385 times (95% CI: 1.046-5.439; P=0.039); and the risk of placenta accreta decreased with increasing ultrasound measurement of scar myometrium thickness ( OR=0.033, 95% CI: 0.001-0.762; P=0.033). The amount of postpartum hemorrhage and hysterectomy rate in the group with placenta accreta diagnosed by ultrasound combined with MRI were not significantly different from those in the group with placenta accreta diagnosed by ultrasound only or MRI only (all P>0.05). For pregnant women with placenta accreta, there were no significant difference in the amount of bleeding and hysterectomy rate between the UAE group [median: 1 300 ml; 34% (16/47)] and the non-embolization group (all P>0.05); in pregnant women without placenta accreta, the amount of bleeding in the UAE group was lower than that in the non-embolization group (median: 100 vs 600 ml; P<0.01), but there was no significant difference in hysterectomy rate [2% (1/56) vs 9% (3/33); P>0.05]. Conclusions:(1) Placenta accreta is the only risk factor of postpartum hemorrhage≥1 000 ml with hysterectomy for induced abortion of cesarean scar pregnancy in midtrimester; multi-parity and ultrasound measurement of scar myometrium thickness are risk factors for placenta accreta. (2) The technique of using ultrasound and MRI in predicting placenta accreta of cesarean scar pregnancy needs to be improved. (3) It is necessary to discuss of UAE in preventing postpartum hemorrhage for induced abortion of cesarean scar pregnancy in midtrimester.