Management Of Ectopic Pregnancy Research Articles

Laparoscopic Removal of Ovarian Ectopic Pregnancies

Study Objective To illustrate laparoscopic management of ovarian ectopic pregnancy in an emergent setting with preservation of the ovary. Design Case series. Setting Emergent diagnostic laparoscopy for the management of suspected ectopic pregnancy with resection of ovarian ectopic pregnancy. Patients or Participants Case series of two patients requiring emergent management of ovarian ectopic pregnancy. Interventions Ovarian ectopic pregnancies are a rare and potentially life-threatening condition1,2,3,4,5. In this video, both patients were taken from the emergency department to the operating room for diagnostic laparoscopy where they were found to have ruptured ovarian ectopic pregnancies with otherwise unremarkable pelvic anatomy. After visual confirmation of suspected diagnosis, pelvic survey, and evacuation of hemoperitoneum, both patients underwent laparoscopic resection of ovarian ectopic pregnancy with ovarian preservation. Measurements and Main Results This case series demonstrates the use of two minimally invasive laparoscopic techniques for emergent management of ovarian ectopic pregnancy. These techniques can also be applied to non-emergent patient presentations. Postoperative course was uncomplicated for both patients and they were discharged in excellent condition on the day of surgery. Ovarian ectopic pregnancy was confirmed by pathology and resolution of pregnancy demonstrated by normalization of beta-HCG at postoperative follow up for both patients. Conclusion Ovarian ectopic pregnancy can be effectively managed using minimally invasive laparoscopic technique with preservation of the ovary, including in an emergent setting. To illustrate laparoscopic management of ovarian ectopic pregnancy in an emergent setting with preservation of the ovary. Case series. Emergent diagnostic laparoscopy for the management of suspected ectopic pregnancy with resection of ovarian ectopic pregnancy. Case series of two patients requiring emergent management of ovarian ectopic pregnancy. Ovarian ectopic pregnancies are a rare and potentially life-threatening condition1,2,3,4,5. In this video, both patients were taken from the emergency department to the operating room for diagnostic laparoscopy where they were found to have ruptured ovarian ectopic pregnancies with otherwise unremarkable pelvic anatomy. After visual confirmation of suspected diagnosis, pelvic survey, and evacuation of hemoperitoneum, both patients underwent laparoscopic resection of ovarian ectopic pregnancy with ovarian preservation. This case series demonstrates the use of two minimally invasive laparoscopic techniques for emergent management of ovarian ectopic pregnancy. These techniques can also be applied to non-emergent patient presentations. Postoperative course was uncomplicated for both patients and they were discharged in excellent condition on the day of surgery. Ovarian ectopic pregnancy was confirmed by pathology and resolution of pregnancy demonstrated by normalization of beta-HCG at postoperative follow up for both patients. Ovarian ectopic pregnancy can be effectively managed using minimally invasive laparoscopic technique with preservation of the ovary, including in an emergent setting.

Laparoscopic Management of a Non-Ruptured Ectopic Pregnancy in a Rudimentary Uterine Horn

<h3>Study Objective</h3> To describe the successful laparoscopic management of a non-ruptured ectopic pregnancy with cardiac activity in a rudimentary uterine horn. <h3>Design</h3> Case report. <h3>Setting</h3> Operating room, tertiary care facility. <h3>Patients or Participants</h3> 30-year-old gravida 5, para 1, abortion 3 who presented with a 7-week ectopic pregnancy with cardiac activity in a non-communicating rudimentary uterine horn. Beta hCG level was 22,504 mIU/mL. <h3>Interventions</h3> Laparoscopic exploration revealed a left-sided unicornuate uterus with normal left-sided adnexa, and a right rudimentary horn on a 3 cm stalk enlarged and engorged with ectopic pregnancy. The right fallopian tube was removed up until the level of the rudimentary horn using a vessel sealing device. A barbed suture was then anchored medial to the stalk prior to resection. The stalk of the right rudimentary horn was then desiccated and divided using the vessel-sealing device. Bleeding was noted at the base of the stalk, so the previously anchored barbed suture was then utilized to do a 2-layer laparoscopic closure across the base. The specimen was removed using a tissue extraction bag. Total blood loss was 20cc, and patient was discharged the same day. Pathology confirmed rudimentary horn with myometrial implantation site and chorionic villi consistent with ectopic pregnancy. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> This is a unique case of laparoscopic management of a rudimentary uterine horn ectopic pregnancy with cardiac activity. Most cases reported in the literature thus far involve medical management with interval surgery. When immediate surgical management has been described for non-ruptured ectopic pregnancies in rudimentary horns, it has been in cases with lower beta hCG levels and fetuses without cardiac activity. Laparotomy has been a common approach for excision of rudimentary horns, however laparoscopy has been shown to be effective. This case highlights that laparoscopic management of an advanced non-ruptured ectopic pregnancy in a rudimentary horn is safe and feasible.

Management of Late 1st Trimester Cesarean Scar Ectopic Pregnancy

<h3>Study Objective</h3> To describe the safe surgical management of late 1^st trimester cesarean scar ectopic pregnancy. <h3>Design</h3> Case report. <h3>Setting</h3> Academic tertiary care hospital. Patient placed in dorsal lithotomy in Trendelenburg position. <h3>Patients or Participants</h3> 33-year-old G8P4044 presenting with foul smelling discharge and an LMP 10 weeks prior. Her surgical history is notable for 3 prior cesarean sections and laparoscopic right salpingectomy for ectopic pregnancy. Pelvic ultrasound notable for live intrauterine pregnancy measuring 10 weeks 6 days with complete posterior placenta previa and thin myometrium in lower uterine segment concerning for cesarean scar ectopic pregnancy. <h3>Interventions</h3> Patient was diagnosed with cesarean scar ectopic pregnancy by Maternal Fetal Medicine. She underwent preoperative bilateral uterine artery embolization by Interventional Radiology. She underwent total laparoscopic gravid hysterectomy and left salpingectomy with lysis of adhesions by Benign Gynecology. <h3>Measurements and Main Results</h3> Diagnosis and management of cesarean scar ectopic pregnancy often requires multidisciplinary collaboration for safe management. Here, we present a case of a late 1^st trimester cesarean scar ectopic pregnancy managed safely with input from Maternal Fetal Medicine, Family Planning, Interventional Radiology and Benign Gynecology teams. We show the diagnosis of cesarean scar ectopic pregnancy through transvaginal ultrasound and discuss management options in the late 1^st We then show preoperative bilateral uterine artery embolization. Finally, we show technique for safe lysis of adhesions with relatively low estimated blood loss during laparoscopic total gravid hysterectomy. The final pathology was consistent with intrauterine fetus with placenta accreta. The patient was discharged home on day of surgery without any postoperative complications. <h3>Conclusion</h3> A detailed 1^st trimester ultrasound should be considered in patients who are high risk for cesarean scar ectopic pregnancy. Embolization of bilateral uterine arteries prior to gravid hysterectomy can potentially decrease intraoperative blood loss. A multidisciplinary approach is preferred for management of late 1^st trimester cesarean scar ectopic pregnancies.

Laparoscopic Management of Interstitial Ectopic Pregnancy Following Ipsilateral Salpingo-Oophorectomy for Granulosa Cell Tumor

<h3>Study Objective</h3> To describe a unique laparoscopic surgical technique for the management of a highly unusual incidence of interstitial ectopic pregnancy following ipsilateral salpingo-oophorectomy. <h3>Design</h3> Case report <h3>Setting</h3> Patient presented to the emergency room of a community hospital where she was diagnosed with an ectopic pregnancy. She was brought to the operating room where diagnostic laparoscopy confirmed right interstitial ectopic pregnancy with prior surgically removed right ovary and fallopian tube. <h3>Patients or Participants</h3> 34-year-old G4P2012 with history of right ovarian granulosa cell tumor, status post right salpingo-oophorectomy eight months prior, presented with vaginal bleeding and pelvic pain. <h3>Interventions</h3> A unique laparoscopic surgical approach involving blunt dissection of the interstitial pregnancy followed by electrocautery of the implantation site. The patient was followed with serial bHCG levels. <h3>Measurements and Main Results</h3> A minimally invasive approach with laparoscopy was used for the management of the interstitial ectopic pregnancy. The products of conception were grasped through a thin, nearly ruptured serosa and bluntly dissected off the implantation site. The implantation site was then cauterized and two hemostatic agents were applied. There were no complications. The patient was discharged on postoperative day zero. Her postoperative course was uncomplicated. She was followed with serial bHCG levels, which progressively dropped to a negative value without the addition of methotrexate. <h3>Conclusion</h3> Interstitial pregnancy is a rare type of ectopic pregnancy. This already rare occurrence is far more unusual following an ipsilateral salpingo-oophorectomy. Only one other similar case was identified through thorough literature review. Here we describe a unique laparoscopic approach for the management of an interstitial ectopic pregnancy following ipsilateral salpingo-oophorectomy. This particular technique could have benefit compared to more standard technique, such as the wedge resection, because it allows less advanced minimally invasive surgeons to maintain a minimally invasive approach. This approach may also reduce risks to patient by avoiding the addition of methotrexate and deep myometrial incisions.

Laparoscopic Approach to Conservative Management of Ovarian Ectopic Pregnancy

Study Objective This surgical video demonstrates a conservative approach to successful removal of ectoptic that maximizes future ovarian function and fertility while preserving the complete ovary; limiting the need for oophorectomy. Design Video Design/Clinical Case. Setting Operating Theatre. Patients or Participants Single Case Study. Interventions N/A. Measurements and Main Results Unconventional Approach to Ovarian Ectopic Pregnancy. Conclusion Laparoscopic treatment and conservative appears to result in similar tubal patency and future fertility rates compared with medical treatment in the case of extrauterine ovarian pregnancy. This surgical video demonstrates a conservative approach to successful removal of ectoptic that maximizes future ovarian function and fertility while preserving the complete ovary; limiting the need for oophorectomy. Video Design/Clinical Case. Operating Theatre. Single Case Study. N/A. Unconventional Approach to Ovarian Ectopic Pregnancy. Laparoscopic treatment and conservative appears to result in similar tubal patency and future fertility rates compared with medical treatment in the case of extrauterine ovarian pregnancy.

Definitive Management of C-Section Scar Ectopic Pregnancy with Robotic-Assisted Laparoscopic Total Hysterectomy

<h3>Study Objective</h3> To describe an approach for treatment of c-section scar ectopic pregnancy in women who do not desire future fertility potential. <h3>Design</h3> This video describes the minimal invasive surgical approach for treatment of a CSP type1. <h3>Setting</h3> The robotic approach was utilized to offer better visualization and greater surgical dexterity for fine lysis of adhesions. <h3>Patients or Participants</h3> This case depicts a 38 y/o G4P2103 diagnosed as having a missed abortion at 7 weeks. However, on ultrasound a CSP was diagnosed. She was counseled on possible management approaches and elected to proceed with definitive surgical management. <h3>Interventions</h3> Intraoperatively, dense adhesions of the bladder were noted to the lower uterine segment. Once adhesiolysis was performed, CSP was identified bulging in the lower uterine segment covered by a thin layer of myometrium. Pathology confirmed gestational sac in the thin lower uterine segment consistent with the clinical impression of CSP. Excellent hemostasis was achieved. <h3>Measurements and Main Results</h3> Blood loss from surgery was 200 mL. Patient had an uncomplicated postoperative course and was discharged on POD# 0. <h3>Conclusion</h3> Robotic-assisted laparoscopic hysterectomy can be considered for treatment of CSP for women who do not desire future fertility potential.

Utilization of the Endoloop in Laparoscopic Removal of an Interstitial Ectopic Pregnancy

<h3>Study Objective</h3> To demonstrate the use of the Endoloop in the laparoscopic removal of an interstitial ectopic pregnancy. <h3>Design</h3> A surgical video case report. <h3>Setting</h3> An academic hospital in the United States. <h3>Patients or Participants</h3> 32yo G3P1011 diagnosed with an unruptured right interstitial ectopic pregnancy after presenting to an obstetric emergency room with right lower quadrant pain. Ultrasound evaluation showed an approximately 2cm right adnexal pregnancy measuring 6 weeks with fetal heart rate of 144. <h3>Interventions</h3> Laparoscopic removal of right interstitial ectopic pregnancy with assistance of the Endoloop. <h3>Measurements and Main Results</h3> The patient was taken to the operating room for a laparoscopic right salpingectomy using bipolar sealing electrocautery. The interstitial location of the ectopic pregnancy made electrocautery ligation of the right fallopian tube at the cornua difficult given the tissue thickness. The Endoloop was introduced and secured at the right cornua, proximal to the ectopic pregnancy to create a pedicle for ligation. This allowed for removal of the right fallopian tube and the ectopic pregnancy at the right cornua with sharp dissection and unipolar electrocautery while maintaining hemostasis and limiting disruption of the myometrium. <h3>Conclusion</h3> The Endoloop can be utilized for laparoscopic surgical management of an interstitial ectopic pregnancy.

The Pregnant Surgical Patient

The most vulnerable time for a fetus is during embryogenesis in the first 8 to 10 weeks of pregnancy, when women may be unaware of their pregnancy. Once pregnancy is established, a standard approach to the pregnant patient is the optimal way to ensure medical and surgical decisions are made within the context of maintaining the safety of both mother and fetus. This review describes the approach to the pregnant patient for surgical conditions within the context of physiologic changes of the patient and fetus at each trimester, anesthesia and critical care in pregnancy, imaging and drugs safe for use in pregnancy, and nongynecologic surgery in the pregnant patient and specific surgical conditions. Tables outline the classification of abortion, the assessment of pregnancy viability, physiologic changes in pregnancy, laboratory changes in pregnancy, imaging modality and radiation dose, and antibiotics and safety in pregnancy. Figures include a diagram of types of hysterectomy, respiratory changes in pregnancy, and enlargement of the uterus. Algorithms outline the approach to abdominal pain in the pregnant patient and diagnosis and management of ectopic pregnancy. This review contains 5 figures, 6 tables, and 85 references.

Successful management of cervical ectopic pregnancy following invitro fertilisation

We report a case of a 45-year-old woman with successful management of cervical ectopic pregnancy using ultrasound guided suction evacuation and balloon tamponade. The case report owes its significance to the high morbidity and mortality associated with this form of ectopic pregnancy in our environment, because of misdiagnosis and late presentation.

Management of Cervical Ectopic Pregnancies: A Scoping Review

(Abstracted from Obstet Gynecol 2021;138(1):33–41) Cervical ectopic pregnancies represent fewer than 0.1% of all ectopic pregnancies but carry increased risk of significant hemorrhage and long-term reproductive consequences if not managed properly. In part due to the rarity of their occurrence, a standard-of-care protocol for management of cervical ectopic pregnancy (EP) other than hysterectomy does not exist.

The Effect of Laparoscopic Tubal Disconnection or Laparoscopic Salpingectomy on Ovarian Reserve.

Background: Fertility of a woman is the most important job in her life, thus preserving the elements of this fertility is much important. The biological age and ovarian reserve are of the most agonizing issues for women, especially in their late thirties and forties. The uterine tubal disconnection versus uterine tubal excision is usually indicated in subfertile patient suffering from tubal disease or indicated in surgical management of ectopic tubal pregnancy. Objective: To study the effect of laparoscopic tubal disconnection or laparoscopic salpingectomy on ovarian reserve. Patients and methods: This study is a prospective cohort study that was conducted at the Endoscopy Unit, Obstetrics and Gynecology Department, Al-Azhar University Hospitals, throughout the period from Oct. 2019 to Sep. 2020. It included 44 patients of the outpatient clinic with a diagnosis of tubal factor infertility or tubal ectopic pregnancy. 22 patients underwent laparoscopic proximal tubal disconnection, and 22 patients underwent laparoscopic salpingectomy. In both groups, basal antral follicle count (AFC) and mean ovarian volume (OVVOL) were evaluated by transvaginal sonography (TVS) before and 3 months after surgery. Results: The mean of the basal AFC and mean OVVOL before and after laparoscopic tubal disconnection were the same suggesting no effect on ovarian reserve, while the mean AFC and OVVOL before and after laparoscopic salpingectomy were different. Both decreased, suggesting negative effect. It was insignificant negative difference in basal AFC and hardly significant negative difference in mean OVVOL. Conclusion: Laparoscopic tubal disconnection does not affect ovarian reserve, while salpingectomy has a negative effect on ovarian reserve estimated by OVVOL three months after the surgical intervention.

OC06.07: Pre‐treatment 48‐hour β‐hCG ratio to predict success of medical and expectant management of ectopic pregnancy

OC06.07: Pre‐treatment 48‐hour β‐hCG ratio to predict success of medical and expectant management of ectopic pregnancy

Fertility-preserving Management of Cervical Ectopic Pregnancy in a Nigerian Teaching Hospital

Cervical Ectopic Pregnancies (CEPs) are commonly associated with adverse outcomes due to diagnostic and treatment challenges. This report describes the successful management of an initially misdiagnosed CEP. A 30-year-old G4P2+1(Alive 2) presented to the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile-Ife, Nigeria, with vaginal bleeding following 11 weeks amenorrhea. The patient was haemodynamically stable, with minimal bleeding per vaginam, and ultrasonography had previously diagnosed complete miscarriage. However, transvaginal ultrasonography demonstrated classical hour-glass uterus. The ballooned cervix contained a gestational sac and foetal node without cardiac activity. The patient was managed with a single dose of intramuscular methotrexate injection. Her serum B-HCG concentration declined from 460.8mIU/ml at presentation to &lt;5mIU/ml on the 10th day post-methotrexate injection, with a complete clinical and ultrasonographic resolution of the features. A high index of suspicion and appropriate ultrasonographic skills are necessary for prompt diagnosis of a CEP. Medical management could minimise the risk of intractable haemorrhage and hysterectomy.

Cervical ectopic pregnancy

We performed dilation and curettage and cervical balloon placement in a cervical ectopic pregnancy after treatment with Methotrexate, KCI and bilateral uterine artery embolization. A minimally invasive approach was used in the case as the patient desired future fertility. We present the potential challenges in management of cervical ectopic pregnancy as well as approaches to treatment.

Profile of Ectopic Pregnancy Cases in a Tertiary Hospital.

An ectopic or extra uterine pregnancy is one in which the blastocyst implants anywhere other than the endometrial lining of the uterine cavity. The objective of the study was to find incidence, risk factors, clinical presentation and mode of management of ectopic pregnancy. Observational study was conducted at Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu. All the relevant data were recorded in performa. The collected data were entered in MS Excel and exported into SPSS 26 version for statistical analysis. About one third of the patients 10 (33.3%) was of 25-29 age group.The most common risk factor was pelvic infection in 23 (76.6%) cases, abortion in 11 (36.7%), and abdominal surgery in 8 (26.7%) of cases. The of classic triad of amenorrhea (100%), pain abdomen (99.7%) and per vaginal bleeding (66.7%). Ruptured ectopic seen in 26 (86.7%) cases, unruptured status in 1 (3.3%) case, tubal abortion in 1(3.3%) case and organized ectopic in 2(6.7%) cases. The most common site was found to be ampulla in 23 (76.7%) cases, fmbria 3(10%) cases, corneal in 3(10%) cases and ithmus in 1 (3.3%) case. All the cases managed surgically, of them unilateral salphingectomy, unilateral salphingo-opherectomy and wedge resection for corneal pregnancy were done in 25(83.3%), 2(6.7%) and 3(10%) cases respectively. Ectopic pregnancy mostly present as ruptured form in young females in our context. Pelvic infection is the commonest risk factor with ampulla being the commonest site. All cases required surgical intervention in form of unilateral salphingo-opherectomy and wedge resection.

Ectopic pregnancy managed medically at St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia

Background: Ectopic pregnancy, a pregnancy in which the embryo implants outside the endometrial cavity, is an important cause of maternal mortality, especially in developing countries. It can be managed medically using methotrexate. In Ethiopia, limited evidence exists regarding the treatment outcome of this approach.Methods: This retrospective study was conducted based on medical records of ectopic pregnancies managed medically using methotrexate. The data of women who had unruptured ectopic pregnancy and who were managed medically in the study period at St. Paul’s Hospital Millennium Medical College were included. Data were extracted from patients’ medical records and analysed using SPSS software.Results: During the 5-year period 2015 to 2019, 81 women with unruptured ectopic pregnancy were managed medically using methotrexate with 93.8% (n=76) success. Methotrexate was administered intramuscularly to all patients in either single dose or multiple doses. Five out of the 81 patients underwent surgical intervention for either ectopic rupture or persistent ectopic mass. There were no fatal complications.Conclusion: Methotrexate is a successful and safe alternative to surgical management of unruptured ectopic pregnancy in our settings. It should be given a trial in patients who meet the selection criteria in a setting ready for emergency surgical intervention and blood transfusions.

Risk factors, clinical presentation and management of ectopic pregnancy in a rural tertiary care centre- An observational study

: Ectopic pregnancy is a challenging and life-threatening emergency, which can cause significant maternal morbidity and mortality. The present study aims at determining the risk factors, clinical features at presentation, diagnostic tools, management modalities and outcome of ectopic pregnancies in a tertiary care teaching hospital.: This was an observational study of 90 cases of ectopic pregnancies admitted to the Department of Obstetrics and Gynaecology at a tertiary care teaching hospital from February 2019 to August 2020. Relevant data of the 90 patients was tabulated and descriptive analysis was done. : Chi square and Fischer exact test: Majority of the patients belonged to 21-30 yrs age group. Maximum number of cases (57%) had a history of previous abdomino pelvic surgery. The predominant symptom was amenorrhea (96.6%) and classical triad of amenorrhea, bleeding per vagina and abdominal pain was seen in 30% of the study population. Majority of the patients i.e 76.7% underwent surgical intervention.: Most common age group at presentation is 21-30years. History of previous abdominal surgery being the most important risk factor whereas amenorrhea was the most common symptom. Surgical intervention was the main mode of management in ruptured ectopic pregnancy.

Efficacy of In Situ Methotrexate Injection in the Treatment of Nontubal Ectopic Pregnancies: A Retrospective Multicenter Study

Evaluation of the efficacy of different injection sites of methotrexate in the treatment of nontubal ectopic pregnancies. Retrospective multicenter study. Multicenter, including 3 teaching hospitals, an intercommunal hospital, and a clinic. A total of 106 patients with nontubal ectopic pregnancies, including 59 interstitial, 39 cesarean scar, and 8 cervical or isthmic. Overall, 58 patients received methotrexate via intramuscular injection (IM group), 35 received methotrexate via in situ injection (IS group), and 13 received a combination of both in situ and intramuscular injections of methotrexate (IS+IM group). The main end point of this study was measured via the primary success rate (defined as a negative β-human chorionic gonadotropin level without recourse to any additional treatment) of treatment with methotrexate according to injection site. The primary success rate was 46.55% in the IM group, 60% in the IS group, and 61.54% in the IS+IM group, respectively. In the multivariate analysis, the primary success rate of treatment was significantly correlated to the in situ injection of methotrexate, either solely or in conjunction with an intramuscular injection of methotrexate administered the following day, (odds ratio=2.7; 95% confidence interval, 1.03-7.14). Solely an intramuscular injection of methotrexate is a less efficient first-line treatment strategy for the conservative management of nontubular ectopic pregnancy. The use of an in situ injection of methotrexate should therefore be preferred.

“Nerve-sparing” laparoscopic treatment of parametrial ectopic pregnancy

To demonstrate laparoscopic surgical management of parametrial ectopic pregnancy. Video presentation of laparoscopic nerve-sparing treatment of parametrial pregnancy. Tertiary university center. A 33-year-old patient, nullipara at 8 weeks of gestation, with no comorbidity and no previous surgery, was admitted to a spoke hospital for acute abdominal pain. During hospitalization, a transvaginal gynecologic ultrasound revealed pregnancy with ectopic localization. Free pelvic fluid was detected, and a subsequent diagnostic laparoscopy was performed because of worsening symptoms. During the procedure, hemoperitoneum drainage was instituted and American Society of Reproductive Medicine stage III pelvic endometriosis was diagnosed. A round formation approximately 3 cm in diameter was found at the left posterior parametrium (Fig.1). Due to the pregnancy position and β-human chorionic gonadotropic (β-hCG; 820 mUI /mL) values, conservative treatment was chosen. Thus, methotrexate at 50 mg/m2 body surface area was administered. A second dose of methotrexate was administered seven days after the first one, and the β-hCG increased to 1068 mUI. On day 14 after treatment, the β-hCG was 1053 mUI/mL. Therefore, surgical treatment was chosen, and the patient was transferred to our center. An ultrasound assessment confirmed the ectopic pregnancy with a live fetus in the left posterior parametrium. The patient underwent operative laparoscopy to remove the ectopic pregnancy. Surgery was performed using a 3-dimensional optical system (TIPCAM 1, S D3-LINK; Karl Storz SE & Co., Tuttlingen, Germany). After drainage of the hemoperitoneum, the gestational sac was identified in the left posterior parametrium. The uterus, tubes, and ovaries showed normal morphology. Pelvic endometriosis was confirmed. After accessing the left pelvic retroperitoneum with the medial and lateral pararectal spaces' opening and development, ipsilateral ureterolysis was necessary to isolate the parametrial pregnancy in close contact with it. Coagulation and sectioning of the deep uterine veins were essential to control hemostasis. Identification of the left hypogastric nerve, which was partially infiltrated by the chorionic villi, and the pelvic splanchnic nerves, was required to safeguard them (Fig.2). Subsequently, the surgeon decided to place a ureteral stent to prevent urologic complications. The laparoscopic approach proved to be safe and feasible to manage parametrial pregnancy. The pregnancy was removed entirely. The patient was discharged 72 hours after the procedure with an uneventful postoperative course. The histologic report confirmed the diagnosis of parametrial pregnancy on decidualized endometriotic tissue. The β-hCG serum level became negative in 20 days. Extrauterine pregnancies represent one of the leading causes of maternal death in the first trimester and constitute approximately 1%-2% of total pregnancies. Of these percentages, only 5%-8.3% are nontubal. Cases of abdominal pregnancy are even rarer, estimated at <1%, and among these, according to a recent review, only 20 cases of retroperitoneal pregnancy were described in the literature. The intraoperative finding of multiple endometriotic implants on the parietal peritoneum above the retroperitoneal pregnancy, together with the decidualized endometriosis result of the histologic examination have been considered to explain the pathogenesis of the condition. It is plausible to suppose that endometriosis has represented the access route for the fertilized ovum, which implanted on endometriotic superficial tissue and then moved toward the retroperitoneal vascularized structures. The diagnosis and treatment are challenging for the gynecologist. Medical treatment is a valid approach to uninterrupted early ectopic pregnancies; however, symptomatic patients' medical therapy failure is one indication for a surgical procedure. The laparoscopic method is optimal, especially in cases like the reported one, in which minimally-invasive techniques allowed complete removal of the pregnancy, respecting the anatomic structures of the retroperitoneum using nerve-sparing techniques. Furthermore, it ensured a safe ureteral stent placement without imaging. The laparoscopic surgical approach can be a safe and feasible option. It allows an early discharge, with a minimum risk of dysfunctional complications, and improves life quality compared to more destructive interventions. In conclusion, to control vascular, nervous, and urinary tract structures, surgical treatment should be based on anatomic knowledge of retroperitoneal anatomy to guarantee the best surgical outcome.

Successful Use of Myosure in the Management of Cesarean Scar Ectopic Pregnancy: a case report

Successful Use of Myosure in the Management of Cesarean Scar Ectopic Pregnancy: a case report