Embarazo ectópico bilateral espontáneo / Spontaneous bilateral ectopic pregnancy

El embarazo ectópico bilateral espontáneo es una entidad rara y difícil de diagnosticar preoperatoriamente. Se presenta un caso diagnosticado por ecografía transvaginal en una paciente sin factores de riesgo. Se realizó salpinguectomía izquierda y salpingostomía lineal derecha por laparoscopia. Este caso es ilustrativo de la importancia del examen cuidadoso de ambos anejos cuando se lleva a cabo el examen ecográfico o la cirugía

Spontaneous bilateral ectopic pregnancy is a rare event and is difficult to diagnose preoperatively. We report a case diagnosed by transvaginal ultrasonography in a patient without risk factors. Laparoscopic left salpingectomy and right linear salpingostomy were performed. This case illustrates the importance of carefully examining both adnexa when ultrasound examination or surgery are performed

Overdiagnosis of complete and partial hydatidiform mole in tubal ectopic pregnancies.

Partial or complete hydatidiform mole (HM) affects approximately 1 in 500 to 1,000 pregnancies. Previous small series suggest that histopathologic diagnosis of HM may be difficult in tubal ectopic pregnancies. The histopathology database of a regional Trophoblastic Disease Unit was searched to identify cases with a referral diagnosis of tubal HM, and the histopathologic findings were reviewed. During the study period (1986-2004 inclusive), there were 132 cases. After central review by specialist histopathologists, the final diagnosis was ectopic partial mole in two, ectopic complete mole in five, and ectopic hydatidiform mole (not otherwise specified) in one. The final diagnosis of definite hydatidiform mole was made in eight (6%) cases, significantly less than in referred uterine curettage specimens, in which approximately 90% have a confirmatory diagnosis of HM (Z = 12.9; p < 0.0001). No cases in this series developed persistent gestational trophoblastic disease, the human chorionic gonadotropin concentration spontaneously returning to normal. Ectopic pregnancies, where managed surgically, should be submitted for histopathologic examination; however, the pathologist should be aware that the degree of extravillus trophoblastic proliferation may appear more florid compared with evacuated uterine products of conception. Molar pregnancy should only be diagnosed when strict criteria regarding morphologic abnormalities previously described in uterine evacuation material are applied.

[Diagnostic image (210). A young woman suffering from abdominal pain]. / Diagnose in beeld (210). Een jonge vrouw met buikpijn.

A 33-year-old pregnant woman presenting with low abdominal pain was diagnosed with left-sided tubal extra-uterine pregnancy, which was surgically removed.

Persistent tubal pregnancy presenting with delayed hemorrhage from a second implantation of trophoblast on the ovary: a case report.

BACKGROUND: The use of conservative surgical techniques to treat ectopic pregnancies has been reported to increase the rate of incomplete trophoblastic tissue removal and subsequent regrowth. CASE: A persistent ectopic pregnancy occurred in a woman previously treated with laparoscopic linear salpingostomy for an ampullary ectopic pregnancy. Repeat laparoscopy was performed, and bleeding from an ovarian implantation site was treated with resection of the trophoblastic site and electrocautery. A repeat linear salpingostomy was also performed at the site of the prior salpingostomy, where trophoblastic tissue also persisted. CONCLUSION: This is the first known case of hemorrhage from the probable secondary ovarian implantation of persistent trophoblastic tissue. A repeat conservative surgical procedure to treat persistent ectopic pregnancies and maintain potential fertility is advocated. This case also serves as a reminder to diligently examine all areas of the pelvis for the possible secondary implantation of persistent trophoblastic tissue should reoperation be necessary.

Time and the risk of ruptured tubal pregnancy.

OBJECTIVE: Tubal pregnancy remains an important cause of maternal morbidity and mortality. We sought to quantify the relationship of time between symptom onset and treatment and the risk of tubal rupture. METHODS: We reviewed inpatient, clinic, and physician office charts of 221 women with tubal pregnancy. We assessed the conditional risk of rupture with passing time and other factors related to rupture. RESULTS: Time between symptom onset and treatment varied from 3 hours to 66 days with an average of 7 days. There was a 32% rupture rate. The conditional risk of rupture was highest within the first 48 hours of symptom onset (5-7%). The risk dropped, leveled off, and remained fairly steady at approximately 2.5% per 24 hours of untreated symptoms. Classic tubal pregnancy signs, symptoms, and tests were not helpful in predicting rupture. CONCLUSION: The rate of rupture is highest in women with the shortest times between symptom onset and treatment. With passing time, the risk declines, but remains steady despite women's getting into care. LEVEL OF EVIDENCE: II-2

Medical treatment of ruptured with hemodynamically stable and unruptured ectopic pregnancy patients.

OBJECTIVE: To determine the success rate of methotrexate treatment of ruptured ectopic pregnancy with hemodynamically stable and unruptured ectopic pregnancy patients. STUDY DESIGN: This prospective clinical study was carried out on 161 patients with suspected tubal ectopic pregnancy. Fourty-six patients have been accepted as ruptured ectopic pregnancy with hemodynamically stable and 115 patients have been accepted as unruptured ectopic pregnancy. All patients diagnosed with ectopic pregnancy were treated by single dose (50 mg/m2) methotrexate if they have stable hemodynamia and fulfill the criteria of methotrexate treatment. Weekly beta-hCG level was measured and if this level was under 10 IU/L, the treatment has been accepted as successful. Mann-Whitney and Fisher's exact tests were used (SPSS, 10.0) for statistical analysis. RESULTS: The success rates of methotrexate treatments in ruptured ectopic pregnancy patients with hemodynamically stable and in patients with unruptured ectopic pregnancy were observed as 62% and 81%, respectively (P < 0.001). The treatment was successfully completed in all expectant management patients. CONCLUSION: Although methotrexate treatment of ruptured ectopic pregnancy with hemodynamically stable patients is not as successful as in unruptured ectopic pregnancy group, 62% success rate in this group may promise a treatment choice before surgery application.

[Comparative study of genital tract infection in patients with tubal pregnancy].

OBJECTIVE: To investigate the effects of genital tract ureaplasma urealyticum (UU), chlamydia trachomatis (CT) and cytomegalovirus (CMV) infection on tubal pregnancy. METHODS: One hundred and twenty eight women with tubal pregnancy (study group) and 50 women with ovarian cysts and without tubal pregnancy (control group) were recruited in this study. Cervical secretion and salpinx tissue samples were collected to detect UU, CT and CMV DNA using PCR. RESULTS: (1) UU DNA was detected in cervical secretions from 56 (43.8%) and 10 (20.0%) women in the study group and control group, respectively. In salpinx tissue specimens, it was detected from 48 (37.5%) and 5 (10.0%) women in the study and the control group, respectively. Both of the differences between the study and control groups were very significant statistically (P < 0.01). (2) CT DNA was detected in cervical secretions from 35 (27.3%) and 5 (10.0%) women in the study and control group, respectively. In salpinx tissue specimens, it was detected from 34 (26.6%) and 3 (6.0%) women in the study group and control group, respectively. Both the differences between the two groups were significant (P < 0.05). (3) CMV DNA was detected in cervical secretions from 21 (16.4%) and 3 (6.0%) women in the study group and control group, respectively. In tubal tissue specimens, it was detected from 25 (19.5%) and 2 (4.0%) women in the study group and control group, respectively. Both the differences between the two groups were significant (P < 0.05). (4) Pelvic adhesion occurred in 70.6% women with UU DNA positive, 77.3% women with CT DNA positive, and 16.7% women with CMV DNA positive. While it occurred in 13.3% of women without any of three DNAs detected. CONCLUSIONS: Genital tract infections of UU, CT and CMV in women with tubal pregnancy were significantly more common than in those without tubal pregnancy. UU, CT and CMV infection may be associated with an increased incidence of tubal pregnancy. Pathological change in genital tract caused by UU and CT infection may be more severe than that by CMV infection.

Severe ovarian hyperstimulation syndrome coexisting with a bilateral ectopic pregnancy.

Management of severe ovarian hyperstimulation syndrome (OHSS) includes hospitalization for fluid and electrolyte management. Abdominal paracentesis is also used as minimally invasive form of management in selected cases of severe OHSS following ovulation induction. However, if pregnancy ensues, the syndrome persists for a longer period, and the clinical manifestations of severe OHSS could mask the picture of a bleeding gestational sac. It could be easily overlooked unless the possibility of an ectopic pregnancy is kept in mind in cases of severe OHSS exacerbated by early pregnancy with or without a previous ectopic pregnancy history. We report a case of severe OHSS with simultaneous bilateral tubal pregnancy following intrauterine insemination (IUI). A 31-year-old woman with polycystic ovarian disease developed severe OHSS during the therapeutic course of IUI. An emergent exploratory laparotomy was performed 14 days after admission, and the operative findings showed persistent profuse bleeding from the bilateral fimbrial ends with marked enlargement of the ampullary portions. A linear salpingotomy was performed by a longitudinal incision along the area of maximal distension of the dilated fallopian tubes to preserve her fertility. We recommend that in cases of severe OHSS exacerbated by early pregnancy, serial serum beta-hCG and transvaginal ultrasound follow-up may be necessary due to the potential association of severe OHSS in pregnancy with an ectopic pregnancy.

Ruptured heterotopic pregnancy presenting with relative bradycardia in a woman not receiving reproductive assistance.

We report a case of heterotopic pregnancy in a woman who had not undergone in vitro fertilization or any other reproductive assistance. The patient failed to mount a tachycardic response to hemorrhagic shock. Bradycardia is a well-established phenomenon in the setting of hemoperitoneum and particularly with ruptured ectopic pregnancy. This is a case of heterotopic pregnancy with relative bradycardia in a woman without predisposing factors for heterotopic pregnancy. We make suggestions on avoiding common pitfalls in the emergency department diagnosis of heterotopic pregnancy. We also address the similar clinical presentations of heterotopic pregnancy and intrauterine pregnancy with ruptured corpus luteum cyst.

[Immunopathological and histopathological aspects of ectopic implantation with possible effect on fertility disorders]. / Imunopatologické a histopatologické aspekty ektopické nidace s mozným ovlivnením plodnosti.

OBJECTIVE: To evaluate leucocytic infiltration of fetomaternal interface in ectopic pregnancy and to evaluate the changes in cell immunity against trophoblast (AT-CMI) in women with extrauterine pregnancy (GEU) in their medical history. To assess the effect of these factors on possible fertility disorders in a woman. DESIGN: A retrospective study. SETTING: Mother and Child Care Institute, Prague. METHODS: In most of the patients, we addressed GEU through laparoscopy. The tube was extirpated in toto and immediately fixed in Baker's solution. Thereafter, it was prepared in a dissection microscope and then processed in a standard way. In order to identify the intensity of AT-CMI, we used the leucocyte migration inhibition test. The cytotrophoblastic cell line JAR was used as an antigen. The degree of inhibition of the migration was monitored by means of a computer image analyser. Inhibition of migration below 75% was rated as favourable. RESULTS: We monitored the presence of inflammatory infiltrate in the place of implantation and correlated the findings with the hCG levels and the presence of the foetal ovum or its part in the tube. In 28 patients (23.5%) of the total number of 119 patients in the group, we observed an inflammatory infiltrate in the place of implantation. In these patients, the hCG levels were lower and in 17 of them (60.7%) we did not prove the presence of a foetal ovum or its parts. In women with GEU in their medical history, the AT-CMI positivity was established in 61.1% of the women 1 year after surgery, in 56.8% of the women 1-3 years after surgery and in 41.2% of the women 3 years after surgery. CONCLUSION: Ectopic pregnancy involves a pathological fetomaternal interface. The leucocytic infiltrate in the area of implantation may be of secondary character and may cause gradual destruction of the ectopically positioned product of conception. The results of our study indicate a possible participation of the increased AT-CMI in the destruction of the ectopically located trophoblast. Persisting anti-trophoblast immunity may influence the occurrence and course of further gravidities.

Embarazo tubárico bilateral / Bilateral ectopic pregnancy

En este artículo se presenta el inusual caso de un embarazo tubárico bilateral, en una paciente de 27 años de edad, con dos embarazos previos, uno de ellos gemelar. Cinco años atrás se había realizado un Pomeroy

Live birth of healthy twins after a heterotopic tubal and intrauterine twin pregnancy in a woman who was stimulated with clomiphene citrate.

OBJECTIVE: To report a heterotopic pregnancy with successful delivery of monochorionic-diamniotic twins after rupture of the tubal ectopic gestation. DESIGN: Case report. University teaching hospital. PATIENT(S): A patient with heterotopic twin monochorionic-diamniotic pregnancy. INTERVENTION(S): Surgical removal of the ectopic pregnancy. MAIN OUTCOME MEASURE(S): Pregnancy course and outcome. The patient successfully delivered twins. CONCLUSION(S): Heterotopic pregnancy after clomiphene citrate administration may have a complicated course, but could end in successful live birth of twins.

Advanced tubal pregnancy associated with severe fetal growth restriction: a case report.

A case is described of advanced tubal pregnancy associated with severe fetal growth restriction delivered at 27 weeks. The placenta was implanted on the salpinx and on the uterotubal angle. Progressing tubal pregnancy and its placental histological characteristics could be a model of placental dysfunction typically associated with intrauterine growth restriction.

Simultaneous tubal pregnancy and twisted ovarian cyst.

BACKGROUND: Simultaneous or concomitant bilateral adnexal pathology is rare. But simultaneous tubal pregnancy and twisted ovarian cyst is even rarer. CASE: A 25-year-old woman, gravida 2, parity 0, presented with acute abdomen after 12 weeks of amenorrhea. Simultaneous right tubal pregnancy and twisted left ovarian cyst were intraoperatively diagnosed. Right salpingostomy and left salpingo-oophorectomy were performed. The follow-up serum beta-hCG was negative at the nineteenth postoperative day. She was well at discharge and throughout the 4-week follow-up period. CONCLUSION: Although simultaneous or concomitant bilateral adnexal pathology is uncommon, a careful assessment of both adnexa is mandatory especially in the cases with inconsistent site of symptom and pathology in order to avoid undiagnosed simultaneous pathologies that may be missed.

Heterotopic pregnancy in a natural conception cycle presenting with tubal rupture: a case report and review of the literature.

BACKGROUND: Heterotopic pregnancy is a potentially fatal condition, rarely occurring in natural conception cycles. CASE: We report such a case in a 28-year old para 0, gravida 1 woman with no known risk factors. The ectopic pregnancy was diagnosed after rupturing at 11 weeks, 4 weeks after diagnosis of the intrauterine pregnancy, and resected via laparotomy. A healthy baby was delivered without complications at 40 weeks gestation. CONCLUSION: Heterotopic pregnancy is possible with natural conception and the survival of the intrauterine fetus is feasible.