Subsequent Intrauterine Pregnancy Research Articles

Reproductive outcomes of ectopic pregnancy with conservative and surgical treatment: A systematic review and meta-analysis.

Ectopic pregnancy (EP), one of the most common gynecological emergencies, is the major cause of maternal death in the first trimester and increases the incidence of infertility and repeat ectopic pregnancy (REP). The aim of this study was to compare the effects of different treatment methods for tubal EP on natural pregnancy outcomes. We systematically searched PubMed, Embase, Cochrane Library, Web of Science, and Clinical Trials for observational studies on EP (published until October 30,2022 in English) comparing methotrexate (MTX) versus surgery, MTX versus salpingostomy, MTX versus salpingectomy, salpingostomy versus salpingectomy, and MTX versus expectant treatment. Our main endpoints included subsequent natural intrauterine pregnancy (IUP) and REP. We assessed the pooled data using Review Manager software (version 5.3) with a random effects model. Of 1274 identified articles, 20 were eligible and 3530 participants were included in our analysis. There was a significant difference in the odds of subsequent IUP in tubal EP patients who underwent MTX compared with those who were treated with surgery [odds ratios (OR) = 1.52, 95% confidence interval (CI):1.20-1.92]. No significant difference was found in the odds of REP between the 2 groups (OR = 1.12, 95% confidence interval [CI]: 0.84-1.51). There was no significant difference in the odds of subsequent IUP and REP in patients after MTX compared to those after salpingostomy (OR = 1.04,95% CI: 0.79-1.38; OR = 1.10, 95% CI: 0.64-1.90). There was a significant difference in the odds of subsequent IUP in patients after MTX compared with those after salpingectomy (OR = 2.11, 95% CI: 1.52-2.93). No significant difference was found in the odds of REP between the 2 groups (OR = 0.98, 95% CI: 0.57-1.71). There was a significant difference in the odds of subsequent IUP between patients who underwent salpingostomy and those who underwent salpingectomy (OR = 1.61, 95% CI: 1.29-2.01). No significant difference was found in the odds of REP between the 2 groups (OR = 1.21, 95% CI: 0.62-2.37). There was no significant difference in the odds of subsequent IUP and REP in patients after MTX compared with those after expectant treatment (OR = 1.25, 95% CI: 0.64-2.45; OR = 0.69, 95% CI: 0.09-5.55). For hemodynamically stable tubal EP patients, MTX has advantages over surgery, particularly salpingectomy, in improving natural pregnancy outcomes. However, MTX is not inferior to salpingostomy and expectant treatment.

Nonfulfillment of desired postpartum permanent contraception and resultant maternal and pregnancy health outcomes

Up to half of the patients requesting postpartum permanent contraception do not undergo the desired procedure. Although nonfulfillment of desired postpartum permanent contraception is associated with increased risk of pregnancy within 12 months of delivery, its long-term reproductive and maternal health outcomes are less clear. This study aimed to determine the association of fulfillment of postpartum permanent contraception with number and timing of subsequent pregnancies and maternal health outcomes. This was a retrospective single-center cohort chart review study of health outcomes in the 4 years following delivery (2016-2018) for 1331 patients with a documented contraceptive plan of female permanent contraception at time of postpartum discharge from 2012 to 2014. Rates of permanent contraception fulfillment within 90 days of delivery and clinical and demographic characteristics associated with permanent contraception were calculated. We determined number of and time to subsequent pregnancies, and diagnoses of medical comorbidities (hypertension, diabetes mellitus, depression, anxiety, asthma, anemia), sexually transmitted infection, and pregnancy comorbidities (preterm birth, gestational diabetes mellitus, gestational hypertension, preeclampsia, postpartum hemorrhage, low birthweight, intrauterine fetal demise) in the 4 years following delivery. Of the 1331 patients desiring permanent contraception postpartum, 588 (44.1%) had their requests fulfilled within 90 days of delivery and 743 (55.8%) did not. Patients who achieved permanent contraception fulfillment tended to have attended more outpatient prenatal visits, delivered via cesarean delivery, and were older, married, college-educated, and privately insured. Patients who received their desired postpartum permanent contraception were less likely to have subsequent intrauterine pregnancies (P<.001). In those who did not achieve permanent contraception, 22 (9.0%) subsequent pregnancies occurred within 6 months of previous deliveries, and 223 (91.0%) occurred after short interpregnancy intervals (within 18 months). Of 178 continued pregnancies, 26 (14.6%) were delivered preterm. There were no differences between the 2 groups in terms of ever attending an outpatient, preventive, or emergency room visit, or in most nonreproductive health outcomes investigated. Nonfulfillment of desired postpartum permanent contraception is associated with subsequent maternal reproductive and nonreproductive health ramifications. Given the barriers to permanent contraception, alternative plans for contraception should be discussed proactively if permanent contraception is not provided.

Treatment of Cesarean Scar Pregnancy with Traditional Chinese Medicine and Warming Moxibustion.

We aimed to report the clinical characteristics of cesarean scar pregnancy (CSP), improve the understanding of uterine scar pregnancy, and assess the outcomes of our treatment strategy for CSP. We present 30 patients with CSP diagnosed by transvaginal ultrasonography. Patients received B ultrasound-guided lauromacrogol injection, followed by evacuation under B ultrasound guidance, and intrauterine balloon compression for hemostasis. Postoperatively, all patients received Bushenquyu decoction and warming moxibustion. All patients showed fast recovery and preserved fertility. The combination of lauromacrogol injection and suction curettage under hysteroscopic guidance is an effective conservative treatment for CSP that can help preserve the reproductive function. Postoperative traditional Chinese medicine and warming moxibustion may reduce the risk of ectopic pregnancy and increase the rate of subsequent intrauterine pregnancy.

Bayesian Hierarchical Approach to Modelling Risk of Miscarriage during First Trimester of Subsequent Intrauterine Pregnancy in Women

Background: Accuracy of pregnancy outcome predictions are essential for clinicians to be effective in handling pregnant women experiencing symptoms of miscarriage when presented in the Early Pregnancy Units (EPU). Therefore, the focus of this study is to improve accuracy in modeling risk of miscarriage during first trimester of subsequent intrauterine pregnancy. To achieve this, the study formulates and analyze a Bayesian two-level random intercept logistic model M2 that takes into consideration hierarchical structure in the subsequent pregnancy outcome. This research work is motivated by the recent epidemiological research works that indicated a two-level structure in the subsequent pregnancy outcome with respect to previous pregnancy outcome. Materials and Methods: The proposed Bayesian hierarchical logistic random intercept model M2 was formulated using the concept of multilevel and Bayesian modeling. Analysis of the proposed Bayesian hierarchical logistic random intercept modelM2 was implemented using the Markov Chain Monte Carlo simulation, in specific Gibbs sampling. Assessment and comparison of the proposed Bayesian hierarchical logistic random intercept model to other reviewed classical approaches using the DIC and AIC. Results: Assessment of model fitness using DIC and AIC indicates that the proposed Bayesian two-level random intercept logistic modelM2has the lowest value of DIC= 121.2 among both classical and Bayesian approaches M0, M1 and M2. This indicates that the proposed Bayesian model M2 is the most plausible approach in modeling risk of miscarriage during first trimester of subsequent intrauterine pregnancy. Assessment of the between cluster variation as a result of the two-level hierarchical structure in subsequent pregnancy outcome, and prior information which, according to this study, are revealed to be essential in modeling risk of miscarriage during first trimester of the subsequent intrauterine pregnancy in women. Relative biases for the model parameter estimates were all below maximum threshold of |0.2| thus indicating accurate model estimations. Conclusion: The proposed Bayesian two-level random intercept logistic model M2 is the most plausible approach in modeling risk of miscarriage during first trimester of subsequent pregnancy. Taking into account between previous pregnancy outcome cluster variations and updating observations with prior information is essential to improve accuracy in modeling the risk of miscarriage during first trimester of subsequent pregnancy.

Nonsurgical Management of Interstitial Pregnancies: Feasibility and Predictors of Treatment Failure

To describe the management of interstitial pregnancies in a tertiary medical center, identify factors associated with treatment failure, and report subsequent pregnancy outcome. Retrospective cohort study. Department of Gynecology in a tertiary medical center. All women who were admitted to and treated for interstitial pregnancy at our center between 2011 and 2019. The women were originally assigned to undergo expectant, medical, or surgical treatment. The women's background and clinical data were compared according to initial treatment modality. Nonsurgical (expectant and medical) management outcomes were analyzed to identify risk factors for treatment failure. Subsequent pregnancy outcomes were described separately. Thirty-seven cases of interstitial pregnancy were identified. There were high rates of pregnancy achieved by in vitro fertilization (45.9%) and a history of ipsilateral salpingectomy (43.2%) among these patients. At presentation, the mean age of the study cohort was 34.76 years, and the median β-human chorionic gonadotropin level was 3853.0, and median gestational age was 7.0, respectively. The nonsurgical management success rate was 70.0%. Uterine rupture occurred during treatment in 5 cases (16.6%). Gestational sac diameter significantly affected treatment failure (p = .03), and a diameter >20 mm was observed in all cases of failed non-surgical treatment. Data on future fertility was available for 21 (58.3%) women: 13 (61.9%) had a subsequent pregnancy, 1 of which was a recurrent interstitial pregnancy. The median interpregnancy interval was 8.1 months, and all but 3 pregnancies reached third trimester and resulted in a live birth, with an overall cesarean delivery rate of 61.5%. None of the subsequent pregnancies were complicated by uterine rupture, and no serious adverse outcomes were noted in any of the subsequent intrauterine pregnancies that reached third trimester. Successful nonsurgical management of an interstitial pregnancy is feasible, although appropriate selection of cases is advised. A large gestational sac is a risk factor for treatment failure and should prompt surgical intervention. Subsequent pregnancies can generally be considered safe and with a favorable outcome.

Ectopic pregnancy and outcomes of future intrauterine pregnancy

To provide information on the birth outcomes of future intrauterine pregnancies in women whose first pregnancy was ectopic. Population-based longitudinal cohort study. All hospitals in Quebec, Canada, 1989-2013. Group surgically treated for an ectopic first pregnancy: 15,823 women; comparison group with an intrauterine first pregnancy: 1,101,748 women. Not applicable. Repeat ectopic pregnancy, future delivery of a live infant, stillbirth, cesarean delivery, preterm birth, low birth weight, preeclampsia, gestational diabetes, and postpartum hemorrhage as well as other outcomes of pregnancy. The overall prevalence of ectopic first pregnancy was 14.2 per 1,000 women, of whom 10% of women with an ectopic first pregnancy had a future ectopic. Regardless of age, women with ectopic first pregnancies had an increased risk of adverse birth outcomes at future intrauterine pregnancies, including 1.27 times the risk of preterm birth (95% confidence interval [CI], 1.18-1.37), 1.20 times the risk of low birth weight (95% CI, 1.10-1.31), 1.21 times the risk of placental abruption (95% CI, 1.04-1.41), and 1.45 times the risk of placenta previa (95% CI, 1.10-1.91). Older women with a prior ectopic pregnancy had particularly elevated risks of placental abruption (risk ratio 1.42; 95% CI, 1.16-1.69). Women with ectopic first pregnancies have an increased risk of adverse birth outcomes during subsequent intrauterine pregnancies. These women may benefit from closer clinical management in pregnancy to prevent adverse birth outcomes.

Management of caesarean scar pregnancy with high dose intravenous methotrexate infusion therapy: 10-year experience at a single tertiary centre

ObjectiveIncidence of caesarean scar pregnancy (CSP) is increasing due to rising caesarean section rate and advanced imaging modalities. At present, there is no consensus to recommend any specific intervention. In our centre, we have adopted the high dose intravenous methotrexate therapy followed by folinic acid for the management of CSP. In this retrospective study, we report the success rate and safety of this regimen. Study designThis was a 10-year retrospective study of women with CSP who received high dose methotrexate therapy with folinic acid at a tertiary centre from 1 st January 2008 to 31 st December 2017. Treatment regimen consisted of a bolus dose of intravenous methotrexate followed by methotrexate infusion over 12 h. Oral folinic acid rescues were given post treatment. Successful treatment was confirmed with either resolution of serum beta-human chorionic gonadotropin or subsequent intrauterine pregnancy. ResultsOf 28 women with CSP who were treated with the regimen, 24 women (85.7%) were treated successfully with methotrexate alone. 3 women (10.7%) required suction evacuation following initial treatment with methotrexate and folinic acid. There was no serious side effect from methotrexate. Advanced gestational age, higher serum β-hCG, larger gestational sac diameter and crown-rump length, and the presence of embryonic cardiac activity were associated with methotrexate failure or need for additional therapy. ConclusionsOur high dose intravenous methotrexate infusion therapy with folinic acid is effective and well tolerated. Caution is needed with factors associated with failure. Ensuring follow up ultrasound for live CSP and follow up β-hCG for all women with CSP is essential.

Factors Predicting Persistent Ectopic Pregnancy After Laparoscopic Salpingostomy or Salpingotomy for Tubal Pregnancy: A Retrospective Cohort Study

To identify factors predictive of persistent ectopic pregnancy (PEP) in women who have undergone laparoscopic salpingostomy or salpingotomy for tubal pregnancy. Retrospective cohort study (Canadian Task Force classification II-2). Tertiary referral center. Ninety-nine women who underwent laparoscopic tubal preservation surgery for ectopic pregnancy. Seventy women underwent laparoscopic salpingostomy, and the remaining 29 women underwent laparoscopic salpingotomy. Factors predicting PEP were evaluated. The change in serum beta human chorionic gonadotropin (β-hCG) levels from baseline observed between postoperative days 5 and 10 (ChCGD5-10) was a predictor of PEP (odds ratio [OR], 0.80; p = .01). Based on receiver operating characteristic (ROC) curve analysis, a cutoff value of 93.1% was determined, with an area under the ROC curve of 0.95 (sensitivity, 85.7%; specificity, 100%). Nonetheless, when considering perioperative variables only, body mass index (BMI) was identified as a predictor of PEP (OR, 0.71; p = .03). Based on the ROC analysis, a BMI cutoff value of ≤22 kg/m2 was determined, with an ROC area of 0.73 (sensitivity, 43.2%; specificity, 100%). In addition, a higher baseline β-hCG level (hazard ratio [HR], 1.0002; p = .009) and left tubal pregnancy (HR, 6.46; p = .03) were predictive of recurrent ectopic pregnancy. There were no differences in the perioperative outcomes, PEP rates, or subsequent intrauterine pregnancy rates between the salpingostomy and salpingotomy groups. In addition, surgical method was not a predictor of recurrent ectopic pregnancy. ChCGD5-10 was identified as a predictor for PEP, suggesting that it might be more clinically useful for the follow-up of PEP. When considering perioperative variables only, BMI was a predictor for PEP. In addition, there was no significant difference in clinical outcomes between the salpingostomy and salpingotomy groups.

New Evidence to Guide Ectopic Pregnancy Diagnosis and Management.

Ectopic pregnancy is a leading source of morbidity and mortality in pregnancy, accounting for 1% to 2% of all pregnancies. Timely diagnosis and management of these abnormal gestations are vital to patient safety. The objective of this study was to describe recent evidence in the risk factors, diagnosis, and management of ectopic pregnancy. Comprehensive review of the published literature. Recent literature describes newly identified risk factors for ectopic pregnancy, particularly those specific to assisted reproduction. Furthermore, evidence mounts for the utility of endometrial sampling for the diagnosis of pregnancy location, allowing a significant proportion of women to avoid methotrexate by diagnosing failing intrauterine pregnancies instead. Finally, recent, high-level evidence supports (in women with normal contralateral fallopian tubes) the equivalence of salpingectomy and salpingostomy regarding rates of subsequent intrauterine pregnancy and recurrent ectopic pregnancy. While serial serum human chorionic gonadotropin levels and transvaginal ultrasound are the mainstays of ectopic pregnancy diagnosis, recent publications revisit the utility of endometrial sampling in diagnosing pregnancy location, using manual vacuum aspiration instead of the criterion-standard dilation and curettage. Expectant management of ectopic pregnancies is the subject of ongoing research, and in the meantime, treatment remains medical or surgical (dependent on clinical parameters and patient preference); salpingostomy and salpingectomy provide equivalent subsequent pregnancy outcomes in women with contralateral fallopian tubes in place.

Incidence, diagnosis and management of tubal and nontubal ectopic pregnancies: a review.

BackgroundEctopic pregnancy is a potentially life-threatening condition occurring in 1-2 % of all pregnancies. The most common ectopic implantation site is the fallopian tube, though 10 % of ectopic pregnancies implant in the cervix, ovary, myometrium, interstitial portion of the fallopian tube, abdominal cavity or within a cesarean section scar.FindingsDiagnosis involves a combination of clinical symptoms, serology, and ultrasound. Medical management is a safe and effective option in most clinically stable patients. Patients who have failed medical management, are ineligible, or present with ruptured ectopic pregnancy or heterotopic pregnancy are most often managed with excision by laparoscopy or, less commonly, laparotomy. Management of nontubal ectopic pregnancies may involve medical or surgical treatment, or a combination, as dictated by ectopic pregnancy location and the patient's clinical stability. Following tubal ectopic pregnancy, the rate of subsequent intrauterine pregnancy is high and independent of treatment modality.ConclusionThis review describes the incidence, risk factors, diagnosis, and management of tubal and non-tubal ectopic and heterotopic pregnancies, and reviews the existing data regarding recurrence and future fertility.

Laparoscopic management of interstitial pregnancy and fertility outcomes after ipsilateral salpingectomy - three case reports.

Background: Interstitial pregnancy after ipsilateral salpingectomy is a rare event with potentially serious consequences. Optimal management strategy remains uncertain and debated. In addition, fertility sparing is determinant of the treatment choice.Cases: Here, we report three cases of interstitial pregnancy occurring after homolateral salpingectomy. We expose the therapeutic option held in all three situations, which associated laparoscopic procedure followed by intramuscular methotrexate injection with successful outcome for all patients. We also report the fertility outcome for the first patient, discussing the timing and mode of delivery. Cesarean section at term was performed for this patient.Conclusion: In these three situations, we obtained a successful result using a minimally invasive surgical approach combined with systemic methotrexate injection. Cesarean section at term for subsequent intrauterine pregnancy seems to be the safest delivery strategy, although no clear data exist in literature.

Viable intrauterine pregnancy after spontaneous bilateral tubal ectopics in a multiparous woman: a case report

IntroductionBilateral ectopic pregnancies are increasing due to an increase in the incidence of pelvic inflammatory disease and increase in assisted reproductive techniques. Spontaneous conception after bilateral ectopic pregnancies is extremely rare.Case presentationA 33-year-old Indian woman presented with ruptured ectopic pregnancy associated with hemoperitoneum for which she underwent a laparotomy. The diagnosis of bilateral ectopic pregnancies was made during surgery. Salpingectomy was done on one side and the other tube was conserved with salpingostomy. Six months after surgery, she conceived spontaneously and a transvaginal ultrasound examination revealed a 5-weeks live intrauterine pregnancy.ConclusionA meticulous surgical technique conserving one fallopian tube resulted in subsequent viable intrauterine pregnancy. The approach to such a case along with steps to minimize tubal damage is presented.

Salpingotomy vs salpingectomy – a comparison of women’s fertility after surgical treatment of tubal ectopic pregnancy during a 24-month follow-up study

Ectopic pregnancy (EP) is usually located in the Fallopian tube and it has a significant adverse effect on womens fertility Three types of EP treatment include: expectant, medical, and surgical radical (salpingectomy) or conservative (salpingotomy) management. The aim of the study was to compare women's fertility after surgical radical or conservative treatment of tubal ectopic pregnancy Out of the 58 patients operated because of tubal EP pregnancy 22 underwent laparoscopic salpingotomy (group 1) and 36 laparoscopic salpingectomy (group 2). EP-related data were obtained from medical documentation (the symptoms, diagnostic tests, EP risk factors, medical reproductive and surgical history clinical status during EP surgery). Follow-up data were collected by means of a telephone interview. The survey included questions focused on women's fertility during a 24-month period following the surgical treatment of EP (conception, subsequent intrauterine pregnancies and ectopic pregnancy). A 24-month follow-up period revealed that the cumulative intrauterine pregnancy rate was higher in group 1 (salpingotomy) as compared to group 2 (salpingectomy), i.e. 50% vs. 41.5%, respectively. Tubal EP returned in 13.6% cases (group 1) vs. 19.4% (group 2). All submitted results are statistically insignificant. Our findings are consistent with the literature which reports a trend of higher odds for intrauterine pregnancy after salpingotomy for surgical treatment of EP as compared to salpingectomy Moreover the risk for recurrent tubal EP is comparable for both methods. Regardless, the decision about the operating range in case of EP always depends on the actual clinical state of the patient.

To Evaluate the Efficacy of Laparoscopic versus Open Surgical Management of the Tubal Pregnancy and its Effects on Future Pregnancy

Ectopic pregnancy is the most common cause of maternal death in early pregnancy and its incidence is rising. Most of the ectopicpregnancies occur in the young age group and subsequent fertility is an important issue. There is no consensus in the literatureregarding conservative laparoscopic versus radical treatment of tubal pregnancy in terms of future reproductive performance. Thereare no randomized controlled trials of sufficient power, and meta-analysis of studies has shown different results with different investigators.But in certain studies laparoscopic surgery has advantages over open surgery and results in higher rates of subsequent intrauterinepregnancies and a lower rate of ectopic pregnancy.Background: In the treatment of tubal ectopic pregnancy (EP), laparoscopic surgery remains the cornerstone of treatment (CochraneDatabase 2007). In the absence of randomized data, the question as to whether surgical treatment should be performed eitherconservatively (salpingostomy) or radically (salpingectomy) in women with desire for future pregnancy is subject to ongoing debate (Molet al 2008).Since the first study demonstrated the potential effectiveness of salpingostomy, this treatment has been compared with salpingectomyin numerous nonrandomized studies (Stromme et al 1962, Mol et al 2008). Pooled data showed no beneficial effect of salpingostomy onintrauterine pregnancy (IUP) whereas there is an increased risk of repeat EP (Clausen 1996, Yao et al 1997, Mol et al 2008). Based onthese findings, the Royal College of Obstetricians and Gynecologists guideline advises salpingectomy as the preferred standardsurgical approach for tubal EP (RCOG 2004). However, there are good reasons to question this advice. Interpretation of the pooled datais troublesome, since many of the original studies failed to report essential details, e.g. time to pregnancy, presence of the desire forfuture pregnancy, and whether subsequent pregnancies occurred either spontaneously or after fertility treatment, such as in vitrofertilization (IVF). Only a few nonrandomized studies have taken these matters into account and came to different conclusions (Silva etal 1993, Job spira et al 1996, Mol et al 1998, Bouyer et al 2000, Bangsgaard et al 2003, Tahseen et al 2003, Mol et al 2008). The IUP rateswere higher and the time to an IUP was shorter after salpingostomy compared to salpingectomy. Especially in women with history ofbilateral tubal pathology, salpingostomy offered better IUP rates than salpingectomy, albeit at the cost of an increased risk for repeat EP(Silva et al 1993, Job spira et al 1996, Mol et al 1998, Bangsgaard et al 2003, Mol et al 2008). In women without history of tubal pathology,this benefit was less clear and also in these women there was an increased risk of repeat EP (Mol et al 1998, Mol et al 2008). In view ofthese data, it has been felt that the most effective type of surgery for women with a tubal EP in the presence of contralateral tubalpathology with desire for future pregnancy is salpingostomy. In women without contralateral tubal pathology, the most optimal surgicaltreatment is currently unknown.

Optimal treatment for patients with ectopic pregnancies and a history of fertility-reducing factors

With most ectopic pregnancy (EP) cases now diagnosed and treated early, a major concern has become future reproductive outcome. The aim of this study was to evaluate long-term reproductive outcome after salpingotomy versus salpingectomy in patients with and without additional fertility-reducing factors. As part of a prospective follow-up study, 261 patients underwent laparoscopic management of EP at our institution. History was taken specifically looking at preexisting risk factors for reduced fertility. Patients were then followed with regard to future reproductive events. Of 261 patients, 196 (75%) reported a subsequent desire for pregnancy. 145 patients had undergone salpingotomy and 51 salpingectomy. In patients without prior history of fertility-reducing factors, the subsequent intrauterine pregnancy rates were >90% for both salpingotomy and salpingectomy groups irrespective of the surgical approach. In patients with preexisting fertility-reducing factors, postoperative intrauterine pregnancy rates were 75% in the salpingotomy group, but only 40% in the salpingectomy group (p<0.05), showing maximal effect for conservative surgery. Laparoscopic salpingotomy is of particular benefit for patients with additional fertility-reducing factors desirous of future pregnancy. Reproductive outcome is excellent in patients without such risk factor, irrespective of the surgical approach.

LAPAROSCOPIC SURGICAL APPROACH FOR ECTOPIC PREGNANCY

The objective of our study is evaluation of therapeutic laparoscopy in the treatment of ectopic pregnancy. This is a prospective study carried out for the period from October 2000 till June 2004, in the department of obstetric and Gynaecology in Azadi General Hospital in Kirkuk city, north of Iraq. Surgical Laparoscopic approach was performed for 40 women with the provisional diagnosis of ectopic pregnancy. The duration of the operation ranged between 20- 70 minutes. Salpingostomy was carried out for 22 patients (55%), 7 patients (17.5%) had salpingectomy, one patient (2.5%) had fimbrial expression, 3 patients (7.5%) had wedge resection of ovarian ectopic, one patient (2.5%) had segmental resection, two patients (5%) had complete tubal abortion with no active bleeding, and 4 patients (10%) were converted to laparotomy. Most of the involved patients had no major intraoperative or postoperative complications with shorter hospital stay. Subsequent intrauterine pregnancy rate was 80%. No recurrent ectopic was elected in this series. In conclusion, inspite of the limited number of patients, the obtained results proved the usefulness of operative laparoscopy in the treatment of ectopic pregnancy with maximum safety and efficiency. The follow up of patients showed improvement in future fertility. More work is needed to confirm our results.

Ectopic pregnancy: an update.

This review discusses recent publications that investigate the epidemiology, diagnosis and treatment of ectopic pregnancy. Transvaginal ultrasound is being used with increasing confidence for the diagnosis of ectopic pregnancy, and methotrexate now has an established role in the treatment of ectopic pregnancy. No serum markers have been found that can reliably differentiate intrauterine from extrauterine pregnancy. As more experience has been gained with medical therapy, it is apparent that it is possible to identify a subgroup of women in whom it is unlikely to succeed. The use of adjunctive therapy such as mifepristone does not appear to increase the effectiveness of methotrexate. Screening for ectopic pregnancy in at-risk women has been suggested, but it may be of only limited value. In the surgical management of ectopic pregnancy the effect on fertility of salpingotomy and salpingectomy remains uncertain, although recent cohort studies suggest that salpingotomy may be associated with a better subsequent intrauterine pregnancy rate than salpingectomy. A number of case reports of pregnancies at unusual sites continue to be published, but in the last 2 years there has been a dramatic increase in the number of caesarean scar pregnancies reported. Medical therapy now has an established role in the treatment of ectopic pregnancy, but it is clear that careful patient selection is essential. In the surgical management of ectopic pregnancy the effects of salpingotomy and salpingectomy on subsequent fertility are uncertain and need further investigation.

Sonographically guided minimally invasive treatment of unusual ectopic pregnancies.

To present our experience with sonographically guided treatment of unusual ectopic pregnancies, defined as heterotopic pregnancies and pregnancies occurring at ectopic locations other than the extracornual portion of the fallopian tube. We retrieved and reviewed all cases of unusual ectopic pregnancies that underwent sonographically guided therapy at our institution. Twenty-seven cases were identified, from 1992 through 2003, including 18 cervical, 6 cornual, 1 tubal heterotopic, and 2 cesarean scar implantations. All of the cervical ectopic, cornual ectopic, and tubal heterotopic pregnancies were treated by sonographically guided injection of potassium chloride into the ectopic gestational sac or fetus. Guidance was via transvaginal sonography in all 18 cervical pregnancies, 3 of the 6 cornual pregnancies, and the tubal heterotopic pregnancy, and via transabdominal sonography in 3 cornual ectopic pregnancies. One of the cesarean scar pregnancies was treated by transvaginally guided potassium chloride injection, and the other was treated via transabdominally guided dilation and evacuation. Treatment was successful in 25 of the 27 patients, including all 23 patients with an ectopic pregnancy and no concomitant intrauterine pregnancy. Four patients had concomitant intrauterine and ectopic pregnancies (1 cervical, 2 cornual, and 1 tubal); in 3 the intrauterine fetuses resulted in live-born infants, and in the fourth the intrauterine pregnancy was electively terminated. Eight of the 27 patients had subsequent intrauterine pregnancies. Sonographically guided minimally invasive treatments of unusual ectopic pregnancies are safe and effective alternatives to surgical and systemic medical therapy. These treatments ablate the ectopic pregnancy, permit normal continuation of a concomitant intrauterine pregnancy, and preserve the uterus for subsequent pregnancies.

A comparative case-controlled study of laparoscopic vs. laparotomy management of ectopic pregnancy: an evaluation of reproductive performance after radical vs. conservative treatment of tubal ectopic pregnancy

Ectopic pregnancy is the most common cause of maternal death in early pregnancy (RCOG 1997-1999) and its incidence is rising. Most of the ectopic pregnancies occur in the young age group and subsequent fertility is an important issue. Laparoscopic surgery has advantages over open surgery and results in higher rates of subsequent intrauterine pregnancies and a lower rate of ectopic pregnancy (Fernandez, 1998). There is no consensus in the literature regarding conservative versus radical treatment of tubal pregnancy in terms of future reproductive performance (Hajenius, 2000). There are no randomised controlled trials of sufficient power, and meta-analysis of studies has shown different results with different investigators (Yao, 1997; Clausen, 1996). Most of the studies have shown higher intrauterine pregnancy (IUP) rates after salpingotomy (2-23% higher IUP rates) than after salpingectomy. We carried out this study in the East Birmingham Hospitals (Teaching) NHS Trust, West Midlands UK, to contribute to the ongoing debate.

P105: Medical treatment of ectopic pregnancy: experience of a third referral centre

To evaluate the efficacy of single dose systemic methotrexate (MTX) in the treatment of ectopic pregnancy. We retrospectively reviewed the cases of tubal pregnancy occurred in our Department from 1990 to 1999. Conservative non-surgical management has been proposed according to Stovall and Ling. Single dose MTX regimen, 50 mg/m2 of body surface, has been used for medical treatment. Serial evaluations of serum hCG were made at days 0–2–4–7 and weekly thereafter until hCG values felt below 5–10 mUI/mL (resolution). Primary success was defined if resolution of tubal pregnancy occurred after single dose treatment. The need of surgical treatment indicated the failure of conservative management. The following reproductive outcome variables were also evaluated: 1. Tubal patency (hysterosalpingogram); 2. Subsequent intrauterine pregnancy rate; 3. Recurrent ectopic pregnancy rates. During the study period we observed 57 cases eligible for non-surgical treatment. 20 cases were managed expectantly, while 37 cases were treated with systemic MTX. The following were the characteristics of MTX-treated group: mean value of hCG on day of treatment 2626 ± 2619 mUI/mL, embryo/yolk sac present in 6 cases (16.2%). Resolution occurred in 94.5% of the cases with a primary success rate of 91.8%. Only one case required multiple doses (2.8%). The mean time of resolution was 21.03 ± 8.95 days. Surgical treatment (salpingectomy) was necessary in 2 cases (5.4%). As for the reproductive outcome, 27 cases were eligible for the analysis. The overall pregnancy rate was 44.4% (12/27) with a 3.7% rate of recurrent ectopic pregnancy. Tubal patency was assessed in 19 cases. It was preserved in 84.2% (16/19). According to the studies in literature, our results support the use single dose MTX for the treatment of unrupted tubal pregnancy in carefully selected cases.