Management Of Ectopic Pregnancy Research Articles

Rare Types of Ectopic Pregnancies

The purpose of this review is to inform readers of recent discussions and findings regarding the underlying aetiology and clinical management of rare ectopic pregnancies. Risk factors, early diagnosis, treatment and results of rare ectopic pregnancies are discussed. New surgical/medical modalities and methods that facilitate early diagnosis are shared. With the widespread use of ultrasonography and hcg assays, the diagnosis of ectopic pregnancy is increasing. At the same time, the increase in risk factors (IVF, previous surgeries, pelvic infections) also increases the rare diagnosis of ectopic pregnancy. Accordingly, the probability of detecting rare types increases. There is no clear consensus for the treatment of rare types, but early diagnosis is important to prevent maternal morbidity and mortality, and allows fertility to be preserved in cases in the reproductive age. In conclusion, when ectopic pregnancy is suspected, as well as diagnosis of ectopic pregnancy, non-tubal and other rare types should be considered when no tubal ectopic is detected. Past medical and surgical treatments of the patient should be thoroughly questioned to determine risk factors.

Conservative approach in the management of ectopic pregnancy

Introduction. Ectopic pregnancy is defined as the implantation of a fertilized ovum outside the uterine cavity and it is one of the leading causes of maternal morbidity and mortality. Localization and risk factors. The most common localization of ectopic pregnancy is within the fallopian tube, while other localizations include abdominal organs, ovaries, scars after previous cesarean sections, and cervix. Risk factors for ectopic pregnancy include previous fallopian tube injuries, infertility including multiple embryo transfers, use of contraceptives, smoking, older age, prior history of ectopic pregnancy, intentional abortions. Diagnostic procedures. Measurement of serum beta-human chorionic gonadotropin levels along with certain ultrasonography signs, i.e. extrauterine gestational sac, with a present yolk sac and/or embryo, with or without a cardiac activity, have the highest degree of reliability in making the diagnosis, whereas uncertain signs, such as ?blob? and ?bagel? signs, also have a high positive predictive value. Therapeutic modalities. Ectopic pregnancy can be treated by surgical, medical or expectant management. Expectant and medical management are reserved for hemodynamically stable patients who are adequately informed and where monitoring and control are possible. Conservative treatment. Before the initiation of treatment with methotrexate, it is necessary to rule out a vital intrauterine pregnancy, and consider the contraindications for methotrexate therapy, based on detailed medical history and laboratory tests. The Clinic of Obstetrics and Gynecology of the Clinical Center of Vojvodina uses a two-dose protocol by which methotrexate is administered intramuscularly and which has proven to be highly successful with few side effects. Surgical treatment modalities. Candidates for emergency laparoscopy or laparotomy are women who are hemodynamically unstable and who should not receive methotrexate. Conclusion. In properly selected patients, the success rate of methotrexate therapy is around 93%.

FERTILITY OUTCOMES AFTER MEDICAL AND SURGICAL MANAGEMENT OF TUBAL ECTOPIC PREGNANCY.

SUMMARYThe objective was to investigate whether the method of treatment (surgical or medical) affects achieving a new pregnancy, as well as the time to and prognosis of the new pregnancy, in women with ectopic pregnancy (EP). Information on patients treated in our hospital between 2013 and 2014 for EP was retrieved from the computerized patient records. Data on whether these patients achieved pregnancy after EP treatment, time from treatment to new pregnancy, and prognosis of pregnancy were collected by phone interviews. A total of 101 women were analyzed. In addition to descriptive analysis, the χ2-test and Kruskal Wallis test were used to compare the groups. A new pregnancy was present in 84 (83.2%) of the women after EP treatment. There was no significant difference among the women having undergone medical treatment (methotrexate), surgical treatment, medical treatment followed by surgical treatment, or observational management approach in terms of achieving a new pregnancy after treatment and time to and prognosis of the new pregnancy. The study could not determine which treatment method would be superior in women with EP and in planning future pregnancy, but concluded that close clinical and laboratory monitoring is appropriate before deciding on aggressive interventions.

Diagnosis and management of intramural ectopic pregnancy

Background: Intramural pregnancy is a rare form of ectopic pregnancy where the embryo is implanted within the myometrium, separate from the endometrial cavity. Preoperative diagnosis of intramural pregnancy is difficult and it can easily be misdiagnosed for other diseases such as intrauterine pregnancy or gestational trophoblastic disease. Medical therapy and surgery are used to treat intramural pregnancy, with surgery often being performed via laparotomy and also including hysterectomy. Case: We present a case of intramural pregnancy that was misdiagnosed and wrongly managed by a local hospital. It was finally diagnosed correctly and managed in our hospital by combining hysteroscopy and laparoscopy under the guidance of intra-abdominal ultrasound. Our experience again highlights the difficulty in diagnosing intramural pregnancy preoperatively due to the lack of standard diagnostic criteria. This can in turn lead to inappropriate treatments. Earlier surgical intervention would allow faster diagnosis and also simultaneous treatment of the disease. The majority of intramural ectopic pregnancies have high blood flow that can cause severe hemorrhage and are therefore treated by medication or laparotomy and hysterectomy. Conclusion: Our experience reveals that a minimally invasive procedure is also safe and effective in select cases where advanced endoscopic expertise is available.

The Effective Role of Adding Letrozole to Methotrexate in the Management of Tubal Ectopic Pregnancies, a Randomized Clinical Trial.

Ectopic pregnancy (EP) is considered a main reproductive health challenge. According to the side effects of using methotrexate (MTX), it is rational to find safer drugs in the management of EP. This randomized controlled trial aimed to evaluate the efficacy and safety of adding letrozole to the single-dose MTX in the management of EPs. This study was conducted in an academic hospital affiliated to Tehran University of Medical Sciences. Women with EP and stable vital signs with β-hCG levels ≤3500 were assigned randomly to receive MTX + placebo or MTX + letrozole. The regression pattern of β-hCG, need for further surgery, and potential side effects were compared between groups. A total of 90 women were assigned equally to the study groups and were matched in age, body mass index (BMI), serum biochemistry, and primary levels of β-hCG. No drug-related side effects were observed in groups. The rates of further surgery (p = 0.614) and second dose of MTX (p = 0.809) were not significant between groups. In the MTX + placebo group, we observed a minor increase in β-hCG levels on day 4 followed by a decreasing pattern on days 7 and 14. But, in MTX + letrozole group, a decreasing pattern in β-hCG levels from day 1 through day 14 was perceived. The results support using MTX + letrozole to treat stable women diagnosed with tubal EP as a safe and efficient method. Further studies are required to evaluate letrozole alone as an alternative therapy in EPs.

A Perspective on Ectopic Pregnancy Epidemiology, Complications, Diagnosis, Treatment and Management

A Perspective on Ectopic Pregnancy Epidemiology, Complications, Diagnosis, Treatment and Management

Surgical results and current status of management for ectopic pregnancy in unusual sites: a single-center study.

Surgical results and current status of management for ectopic pregnancy in unusual sites: a single-center study.

Controversies in family planning: Management of cesarean-scar ectopic pregnancy

The incidence of pregnancies located within a cesarean scar or “cesarean-scar ectopics” has risen with increasing rates of cesarean delivery [1] and likely with advances in imaging technology and diagnostic awareness. The incidence of pregnancies located within a cesarean scar is estimated to be 1 in 2000 pregnancies and cesarean-scar ectopic pregnancies accounts for 6.1% of ectopic pregnancies in women with a cesarean scar [2–4]. These pregnancies are now recognized as part of the continuum of morbidly adherent placenta including placenta accreta [1] and pose a significant risk to not only a patient's health, but also her future fertility.

Recurrent Tubal Ectopic Pregnancy Management and the Risk of a Third Ectopic Pregnancy

To evaluate the rate of a third ectopic pregnancy according to the modality of treatment of the second ectopic pregnancy. Retrospective cohort study. University-affiliated tertiary medical center. One hundred eleven women who had 2 ectopic pregnancies and a third consecutive pregnancy between 2003 and 2018. Surgery or medical treatment as required. With regard to the modality of treatment of the second ectopic pregnancy, the patients were divided into 3 groups: expectant management, medical treatment with methotrexate, and laparoscopic salpingectomy. Univariate and multivariate analyses were conducted to assess the association of various parameters of the second ectopic pregnancy with the occurrence of a third ectopic pregnancy in the consecutive pregnancy. Twenty women (18.0%) were managed expectantly, 55 (49.6%) were treated with methotrexate, and 36 (32.4%) underwent surgery. Expectant management resulted in significantly higher rates of a third ectopic pregnancy compared with treatment with methotrexate or surgical intervention (50.0% vs 18.2% and 13.8%, respectively; p = .005). In the cases of 2 ipsilateral ectopic pregnancies, the interventional approach (medical or surgical treatment) resulted in lower recurrence rates compared with expectant management (25.7% vs 60.0%, respectively; p = .043). The risk of a third episode of an ectopic pregnancy after expectant management of a second ectopic pregnancy is extremely high. An interventional approach by treatment with methotrexate or salpingectomy is therefore preferred for recurrent ectopic pregnancy management, especially in ipsilateral recurrences.

A detailed study of methotrexate treatment in ectopic pregnancy

Methotrexate is a folic acid antagonist, it works by inhibiting the dihydrofolate by interfering with the DNA synthesis. Ectopic pregnancy is a life threatening condition that may cause maternal mortality. The main aim of this review to show the efficacy of systemic methotrexate and shows the importance of methotrexate treatment in management of ectopic pregnancy with surgical treatment and dosage regimen with protocol treatment. The selection criteria of candidates in this review is pregnant women with <5000miu/ml, adrenal mass <4cm, presence of peritoneum <100mland no sign of cardiac activity. Data collections are made from most relevant article between the periods of 1987-2020. Ectopic pregnancy is an emergency condition if not timely diagnosed and most of the cases where identified in first trimester.

The Use of Single Dose Methotrexate in the Management of Ectopic Pregnancy and Pregnancy of Unknown Location: 10 Years' Experience in a Tertiary Center.

ObjectiveTo study factors associated with the success of single dose methotrexate (MTX) treatment in women with ectopic pregnancy.MethodsThis is a retrospective study of women (n=110) with ectopic pregnancy and treated with single dose of MTX. The clinical presentations, transvaginal sonography (TVS) findings, pretreatment beta-human chorionic gonadotropin (β-HCG), and progesterone values were compared between the treatment success (Group S) and treatment failure (Group F) groups.ResultsThe overall success rate of treatment with single dose of MTX was 75.45%. The majority of patients in both groups presented with pain and bleeding (~55%), and bleeding only was the presenting symptom in about 20% of patients. Only 3 patients (3.61%) in Group S required a repeat dose of MTX. In contrast, 51.8% of the Group F patients required a repeat dose. The mean pretreatment β-HCG level was 2.3 times higher in Group F than in Group S (1734±1684 vs 4036±2940 IU/L). The data showed a β-HCG level of 3924IU/L as a suitable cut-off value with 76.19% sensitivity and 62.5% specificity to predict MTX treatment success. History of ectopic pregnancy had no relation with success/treatment failure or a repeat dose. None of the TVS findings were related to the outcome of the treatment, whereas pretreatment HCG level was a significant predictor.ConclusionThe single dose MTX treatment was successful in 75.45% (83/110) of cases, with 3.61% (3/83) requiring a repeat dose of the drug. Pretreatment β-HCG level is a significant predictor of the treatment outcome.

Robotic CSP Resection and Hysterotomy Repair

To demonstrate a technique for the robot-assisted laparoscopic surgical management of cesarean section scar ectopic pregnancy (CSP) and hysterotomy repair. Step-by-step presentation of the procedure using video. CSP is a rare form of ectopic pregnancy. The incidence of CSP has been increasing with rising cesarean deliveries and is estimated to range from 1 of 1800 to 1 of 2500 of all pregnancies. Various management of CSP have been used such as systemic or local methotrexate, surgical resection, and uterine artery chemoembolization. Exogenic or deep CSP occurs when the gestational sac is deeply embedded in the scar and the surrounding myometrium and grows toward the bladder. Surgical resection of this type of CSP seemed reasonable, which could shorten hospitalization and follow-up time and reduce the failure rate of treatment. For its magnification of the 3-dimensional laparoscope, flexibility endo-wrist, and stabilization of instruments within the surgical field, robot-assisted laparoscopic resection can be performed to manage this type of complex procedure. In this video, we describe our technique for robot-assisted laparoscopic management of a CSP and a hysterotomy repair. We present the case of a 34-year-old gravida 2 para 1 woman with the finding of a 7-week pregnancy embedded in the cesarean section scar. The patient had undergone 1 previous uncomplicated cesarean section at term. On presentation, her β-human chorionic gonadotropin level was 9212 IU/L. In this case, the gestational sac was deeply embedded in the scar and the surrounding myometrium and was growing toward the bladder. A decision was made to proceed with surgical treatment in the form of a robot-assisted laparoscopic resection of the ectopic pregnancy and the hysterotomy repair. The surgery was uneventful, and the patient was discharged home within 48 hours of her procedure. No residual scar defect was visible on follow-up ultrasonography 1 month after surgery. Forty days after surgery, the patient had resumed normal menstruation and was followed up for 3 years with regular menstruation and no abnormal uterine bleeding. Robot-assisted laparoscopic excision of CSP and hysterotomy repair is an effective procedure for the management of this increasingly more common condition. The use of a cervix dilator and robot-assisted laparoscopic suturing can prevent hemorrhage and peripheral tissue damage and allow for the safe removal of the ectopic pregnancy with multilayer repair of the uterine defect.

Ruptured ectopic pregnancy management in the COVID-19 pandemic era: a case report

Introduction. COVID-19 protocol and the unavailability of proper instruments in the isolation room had complicated the usual protocol to diagnose and manage the medical and surgical conditions. Â This article is about the first ruptured ectopic pregnancy cases encountered during the COVID-19 pandemic in Sanglah General Hospital. Considering the unique circumstances and the difficulty during establishing the diagnosis and conducting the management, we ought to present our experience through this article.Case Description. This case report reviews a 24-years-old female, an asymptomatic COVID-19 case, who was diagnosed with ruptured ectopic pregnancy during appendectomy surgery in Sanglah General Hospital, Denpasar, Bali-Indonesia. The patient complained about mild lower right abdominal pain, with a clinical picture that supports acute appendicitis. However, the history taking revealed a history of post-curettage 15 days prior to admission due to vaginal bleeding suspected for incomplete abortion. Except for a positive pregnancy test, the clinical picture did not support a pregnancy nor a ruptured ectopic pregnancy. We still consider an ectopic pregnancy as no histopathological examination result was available to supports the previous vaginal bleeding was an intrauterine pregnancy. Further to complicate the problem, the patient was reactive for the COVID-19 screening test, thus requiring a COVID-19 protocol. As an ultrasound device was unavailable at the time in the isolation room, we could not assess for extrauterine pregnancy. Only during the surgical procedure for appendectomy, our surgical college notified us of the accompanying presence of sign of ruptured right ampullary pregnancy.Conclusion. The COVID-19 isolation protocol and the unavailability of essential equipment and diagnostic tools in the isolation room could hinder the usual protocol used to diagnose and manage various medical and surgical problems. We hope this article could illustrate how COVID-19 had complicated unusual cases, thus reflect how important clinical judgment and infrastructure in our health care system.

Surgical Management of Interstitial Ectopic Pregnancy

Study Objective To demonstrate a minimally invasive surgical technique for management of interstitial ectopic pregnancy Design N/A Setting Operating room Patients or Participants Patients with interstitial ectopic pregnancy requiring surgical management Interventions Removal of interstitial ectopic pregnancy Measurements and Main Results N/A Conclusion Management of interstitial ectopic pregnancy has traditionally been performed via cornual wedge resection. We present a minimally invasive approach using a four step process: (1) identify the location of the interstitial pregnancy, (2) utilize hemostatic measures such as vasopressin, vessel occlusion, or tranexamic acid, (3) create a circumferential linear incision over the specimen leaving a tissue pedicle, and (4) complete a double layer running closure for re-approximation and hemostasis.

Laparoscopic Management of Cesarean Scar Ectopic Pregnancy after Failed Medical Management

Study Objective We describe a step-by-step approach of laparoscopic resection of cesarean scar ectopic pregnancy. Design A case report video. Setting Teaching hospital. Patients or Participants A 29-year-old gravida 4 para 1 woman who underwent a cesarean section two years back. She was diagnosed with cesarean scar ectopic pregnancy by transvaginal ultrasound scan with a 6-week live pregnancy. The patient received 2 doses of intramuscular injections of methotrexate. But on monitoring, the size of the ectopic sac remained the same with decline in the beta hCG. Suction evacuation was planned and post suction evacuation, patient started bleeding through os profusely for which uterine tamponade was done. After keeping patient in observation for 24 hours, the bleeding had not stopped. Thus, patient was considered for life saving laparoscopic excision of cesarean scar ectopic pregnancy. Interventions Laparoscopic management of cesarean scar ectopic pregnancy. Measurements and Main Results The diagnosis of cesarean scar ectopic pregnancy was confirmed laparoscopically. The lower uterine segment was extremely thinned out. The uterovesical fold of peritoneum was dissected and bladder was pushed caudally. Adhesiolysis was done between the previous cesarean scar and the bladder. The ectopic gestational sac was identified, and incision was given at the most prominent site of the cesarean scar. The products of conception were evacuated in an EndoBag and extracted through the infra-umbilical port. The specimen was sent for histopathological examination. The margins of the previous scar were excised, and the uterine defect was repaired in two layers. Hemostasis was achieved. Intraoperative blood loss was minimal. Patient tolerated the procedure well and was discharged on POD3. Conclusion Laparoscopy is a safe and effective procedure of managing cesarean scar ectopic pregnancy after failed medical management. This gives an advantage of minimal blood loss, decrease post-operative pain and better cosmetic results.

Surgical Management of an Interstitial Ectopic Molar Pregnancy

Surgical Management of an Interstitial Ectopic Molar Pregnancy

Step-By-Step Guide to the Surgical Management of Recurrent Interstitial Ectopic Pregnancy

Step-By-Step Guide to the Surgical Management of Recurrent Interstitial Ectopic Pregnancy

Complications Associated with Cesarean Scar Ectopic Pregnancies

Study Objective The aim of this study is to present and discuss complications that were encountered during the surgical management of cesarean scar ectopic pregnancies. Design This is a video case series of two patients with cesarean scar ectopic pregnancies. Setting Both patients were positioned in dorsal lithotomy position prior to the start of the surgeries. A primary surgeon and assistant were placed on either side of the patient. Patients or Participants Two patient case series. Patients with a diagnosis of cesarean scar ectopic pregnancy desiring laparoscopic hysterectomy were recruited. Interventions Both patients received total laparoscopic hysterectomies for the management of their cesarean scar ectopic pregnancies. Measurements and Main Results In both cases significant adhesions were noted leading to complications including uterine artery laceration, bleeding from the cesarean scar ectopic pregnancy implantation site and inadvertent cystotomy. We present in this video dissection techniques used and management of these complications. Conclusion Cesarean scar ectopic pregnancies can be difficult to managesurgically as they are often associated with significant adhesions between the anterior abdominal wall, bladder and uterus. Care should be taken to avoid inadvertent laceration of these structures when managing these cases surgically. In these surgeries, surgeons should feel comfortable with methods of laparoscopic suturing to control bleeding and repair any injuries.

Hysteroscopic Management of Cesarian Scar Ectopic Pregnancy

Study Objective To determine the efficacy of hysteroscopy in managing cesarian scar ectopic pregnancy. Design Case series. Setting Hysteroscopy under general anaesthesia in the dorsal lithotomy position. Patients or Participants 15 patients diagnosed with cesarian scar ectopic pregnancy with no hemodynamic instability or signs of hemoperitoneum. Interventions Hysteroscopic management of the pregnancy sac or products of conception at the site of the cesarian scar following methotrexate injection. Cold loop and electrocautery were both used to resect the entirety of the chorionic tissue. Measurements and Main Results Ultrasonography performed postoperatively to determine the efficacy of complete removal of the cesarian scar ectopic pregnancy and HCG levels serially monitored. Intra-operative blood loss measured. 14/15 patients had complete removal of the ectopic tissue in one setting, 1/15 patients required a second setting due to failure of resolution of her symptoms. None of the patients had significant blood loss in the procedure. Conclusion Hysteroscopy can be used to manage Cesarian Scar ectopic pregnancy in a minimally invasive approach.

Laparoscopic Management of Cesarean Scar Ectopic Pregnancy: A Step-By-Step Approach

Study Objective The objective of this video is to present an overview of diagnosis and management of cesarean scar ectopic pregnancy and demonstrate a step-by-step approach for laparoscopic management. Design N/A Setting University teaching hospital. Patients or Participants N/A Interventions Laparoscopic resection of cesarean scar ectopic pregnancy. Measurements and Main Results N/A Conclusion Cesarean scar ectopic pregnancy is a rare type of ectopic pregnancy and is associated with risks including life threatening hemorrhage, uterine rupture, hysterectomy, and complications in future pregnancies. Minimally Invasive Surgery is a safe and feasible management option for this serious condition.