Tubal Ectopic Pregnancy Research Articles

Laparoscopic Management of Short-Interval Interstitial Pregnancy After Recent Tubal Ectopic: A Case Report [ID 2683561

INTRODUCTION: A 24-year-old G6P2032 presents with interstitial pregnancy 3 months after ipsilateral laparoscopic salpingectomy for ruptured tubal ectopic pregnancy. This case report demonstrates the management of short-interval interstitial pregnancy after recent ipsilateral laparoscopic salpingectomy. METHODS: The patient initially presented with a right-sided ruptured tubal ectopic pregnancy. Salpingectomy was performed to completely remove the fallopian tube and desiccate it at the cornua, leaving no residual visible tubal remnants. The patient presented with ipsilateral interstitial pregnancy 3 months later and initially underwent systemic methotrexate injection, which failed to resolve the pregnancy. She then underwent laparoscopic cornuostomy and dilation and curettage (D&C). Cornuostomy was performed with injection of dilute vasopressin around the gestational sac to help minimize blood loss followed by hydrodissection and sharp dissection to remove the pregnancy. The myometrium and serosa were closed in layers. There was attention to preserve uterine myometrial tissue integrity at the cornua. The patient did well postoperatively and was discharged on postoperative day 0 (POD0). Her β-hCG trended from 11,902 mIU/mL pre-surgery to 7,726 on POD0, and 289 at 1 week. Pathology showed fragments of chorionic villi, and the D&C showed decidualized secretory endometrium. CONCLUSION: Short-interval interstitial ectopic pregnancies after prior salpingectomy for tubal ectopic are extremely rare. We demonstrated successful management with a minimally invasive laparoscopic cornuostomy after failed methotrexate. Patients should be counseled carefully about the risks of short-interval pregnancy after tubal ectopic even after care is taken to remove all visible portions of the fallopian tube.

Ovarian ectopic pregnancy: clinical characteristics, ultrasound diagnosis and management.

To compare the clinical, ultrasound and biochemical characteristics of ovarian ectopic pregnancy (OEP) with those of tubal ectopic pregnancy (TEP). This was a retrospective case-control study of women with OEP and those with TEP seen at a single center between December 2010 and February 2021. OEP was defined as a pregnancy located completely or partially within the ovarian parenchyma, seen separately to a corpus luteum, if a corpus luteum was present within the ipsilateral ovary. We compared demographic features, risk factors, clinical presentation, ultrasound findings and outcomes, such as blood loss at surgery, need for blood transfusion, length of hospital stay, follow-up and future pregnancy outcome, between cases of OEP and TEP. Overall, 20 women with OEP were identified and compared to 100 women with TEP. A total of15/20(75%) OEPs were diagnosed correctly on the first ultrasound scan. There was no difference between the groups in terms of maternal age, gestational age, gravidity, parity or risk factors. Compared with TEP, OEP was more likely to present with abdominal pain without vaginal bleeding (12/20 (60%) vs 13/100 (13%); odds ratio (OR), 10.0 (95% CI, 3.45-29.20); P < 0.01), contain an embryo with cardiac activity (3/20 (15%) vs 2/100 (2%); OR, 8.7 (95% CI, 1.34-55.65); P = 0.02) and have severe hemoperitoneum on ultrasound (9/20 (45%) vs 8/100 (8%); OR, 9.4 (95% CI, 3.01-29.40); P < 0.01), and had a higher volume of blood loss at surgery (median, 700 mL vs 100 mL; P < 0.01). All surgically managed OEPs had successful laparoscopic treatment (18 excisions, one wedge resection) with preservation of the ovary. Only one (5%) case of OEP required a blood transfusion. OEP is more likely than TEP to contain an embryo and to present with severe hemoperitoneum. In a dedicated early pregnancy setting, the majority of OEPs were detected on an ultrasound scan at the initial visit, facilitating optimal minimally invasive surgical management, reducing the risk of blood transfusion and oophorectomy. Our findings can be used as a reference for clinicians who may not otherwise encounter this rare condition. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Screening of single nucleotide polymorphism in matrix metalloproteinase-2 (MMP2) and tetraspanin CD63 genes in Chlamydia trachomatis-infected tubal ectopic pregnancy patients.

Tubal ectopic pregnancy (EP) is a leading cause of maternal morbidity and mortality. Studies have suggested that infection-induced inflammatory responses are major risk factors for EP. The aim of the present study was to find an association between MMP2 and CD63 gene variants and risk of EP during Chlamydia trachomatis infection in an Indian population. Fallopian tube samples of 120 EP and 120 tubal ligation women were collected. C. trachomatis was detected by PCR. The genotyping of MMP2 (rs17859882 G/T, rs7201A/C) and CD63(rs2231464 C/T, rs376086542 A/G) gene variants was done by qualitative real-time PCR using allelic discrimination method (VIC- and FAM-labeled). The frequency of GG or GT genotype of MMP2 G/T polymorphism (rs17859882) was 66.6% in infected EP and 36.7% in uninfected EP and 22% in tubal ligation controls (P < 0.0001), while the frequency of AC or CC genotype of MMP2 A/C polymorphism (rs7201) was 66.6% in infected EP and 20.6% in uninfected EP and 13.5% in tubal ligation controls (P < 0.0001). The frequency of CT or TT genotype of CD63 C/T polymorphism (rs2231464) was 74% in infected EP and 21.8% in uninfected EP and 11.8% tubal ligation controls (P < 0.0001), while the frequency of AG or GG genotype of CD63 A/G polymorphism (rs376086542) was 48.1% in infected EP and 41.3% in uninfected EP and 18.6% tubal ligation controls (P < 0.0001). The present study revealed a strong association between the presence of gene variants MMP2 (rs17859882 G/T, rs7201A/C) and CD63 (rs2231464 C/T, rs376086542 A/G) and risk of tubal EP during C. trachomatis infection.

Muscular and Vascular Fallopian Tube Morphology in Ectopic Tubal Pregnancy

Muscular and Vascular Fallopian Tube Morphology in Ectopic Tubal Pregnancy

Ovarian Ectopic Pregnancy: A Rare Case Report

Ovarian ectopic pregnancy is rare and constitutes around 3% of all ectopic pregnancies. Its presentation is similar to tubal ectopic pregnancy and is difficult to diagnose based on the presentation and ultrasound findings. Here, we describe one such case which we encountered in our practice. Primigravida patient at early gestation presented with vaginal spotting and pain in lower abdomen. She was suspected as ruptured ectopic pregnancy based on examination and ultrasound findings. Immediate laparotomy was performed and patient was diagnosed to have ruptured ovarian pregnancy intraoperatively. Partial ovariotomy was performed and the case was successfully managed. Histopathology confirmed the diagnosis. Surgery is the mainstay of definitive diagnosis and treatment. Identifying these cases early is imperative as such patients can collapse suddenly and there are high chances of maternal morbidity and mortality.

Successful management of an advanced interstitial ectopic pregnancy in a resource-limited setting: a case report

BackgroundInterstitial ectopic pregnancy is an ectopic gestation developing in the uterine part of the fallopian tube. The condition is rare and presents challenges for clinical as well as radiological diagnosis. This case report presents a rare case of interstitial ectopic pregnancy diagnosed intraoperatively.Case presentationA 36-year-old Black woman, referred from a peripheral health facility, presented at the emergency department with severe abdominal pains, vaginal spotting, nausea, and vomiting, with a 2-month history of irregular menstrual flow. Clinical and laboratory findings were suggestive of an acute abdomen likely due to a ruptured ectopic pregnancy (ultrasound was not available). An emergency exploratory laparotomy was done, which revealed a right adnexal ruptured interstitial pregnancy of a lifeless female fetus weighing 500 g (estimated mean gestational age of 22–23 weeks). The left fallopian tube looked normal. The site of rupture was repaired, followed by cleaning and closure of the abdomen. The post-operative period was uneventful, and the patient was discharged on postoperative day 7.ConclusionInterstitial pregnancies are uncommon and rarely attain advanced gestational ages, as in this case, compared with other tubal ectopic pregnancies. However, women presenting with signs of hypovolemic shock and acute abdomen, with a positive pregnancy test, warrant a high index of suspicion.

Three-dimensional particle streak velocimetry based on optical coherence tomography for assessing preimplantation embryo movement in mouse oviduct in vivo.

The mammalian oviduct (or fallopian tube) is a tubular organ hosting reproductive events leading to pregnancy. Dynamic 3D imaging of the mouse oviduct with optical coherence tomography (OCT) has recently emerged as a promising approach to study the hidden processes vital to elucidate the role of oviduct in mammalian reproduction and reproductive disorders. In particular, with an intravital window, in vivo OCT imaging is a powerful solution to studying how the oviduct transports preimplantation embryos towards the uterus for pregnancy, a long-standing question that is critical for uncovering the functional cause of tubal ectopic pregnancy. However, simultaneously tracking embryo movement and acquiring large-field-of-view images of oviduct activity in 3D has been challenging due to the generally limited volumetric imaging rate of OCT. A lack of OCT-based 3D velocimetry method for large, sparse particles acts as a technical hurdle for analyzing the mechanistic process of the embryo transport. Here, we report a new particle streak velocimetry method to address this hurdle. The method relies on the 3D streak of a moving particle formed during the acquisition of a single OCT volume, where double B-scans are acquired at each B-scan location to resolve ambiguity in assessing the movement of particle. We validated this method with the gold-standard, direct volumetric particle tracking in a flow phantom, and we demonstrated its in vivo applications for simultaneous velocimetry of embryos and imaging of oviduct. This work sets the stage for quantitative understanding of the oviduct transport function in vivo, and the method fills in a gap in OCT-based velocimetry, providing the potential to enable new applications in 3D flow imaging.

Evaluation of the parameters in predicting single-dose methotrexate therapy success for ectopic pregnancy.

Methotrexate has demonstrated efficacy in treating ectopic pregnancies. This study explores factors influencing treatment success, focusing on laboratory and ultrasonographic findings, particularly the day 4 to day 1 β-hCG level ratio. Retrospective cohort study was conducted within patients diagnosed with tubal ectopic pregnancy. Patients' characteristics, ultrasound findings, laboratory data, and β-hCG levels (days 1, 4, 7), and operation findings were reviewed. Women's characteristics were investigated who were treated with single dose of MTX (50 mg/m2 ). Patients who were performed surgery after MTX treatment were identified as MTX treatment failure. Among 439 women, 259 underwent surgery due to acute symptoms. Of those treated with MTX, 143 experienced treatment success, while 37 underwent surgery after MTX (MTX failure). Comparative analysis revealed significant differences in β-hCG levels on admission (1128 and 4125 mIU/mL) and the day 4 to day 1 β-hCG ratio (0.91 and 1.25). The overall MTX success rate was 79%, reaching 93% and 89% for β-hCG levels <1000 mIU/mL and <2000 mIU/mL, respectively. Success dropped to 50% with levels exceeding 5000 mIU/mL. ROC analysis identified a crucial 2255 mIU/mL cut-off for β-hCG (sensitivity 70.3% and specificity 68.5%) and a day 4 to day 1 β-hCG ratio of 95.5% (sensitivity 84.7%, specificity 72.5%, positive predictive value 75.4%) for predicting MTX success. Establishing a β-hCG cutoff can reduce hospital stay. The day 4 to day 1 β-hCG ratio holds promise as a widely applicable predictor for MTX success or for determining MTX administration on day 4.

Ruptured Recurrent Interstitial Ectopic Pregnancy Successfully Managed by Laparoscopy.

Ectopic pregnancies are a frequently encountered cause of first-trimester metrorrhagia. They occur when an embryo is implanted and grows outside the normal uterine space. Uncommonly, the embryo can be implanted in the intramural portion of the uterine tube, a condition referred to as interstitial localization. This specific type of ectopic pregnancy may have an unpredictable course, potentially leading to severe uterine rupture and catastrophic bleeding if not promptly diagnosed and managed. We present a rare case of a multiparous 36-year-old female patient who underwent pelvic ultrasonography in the emergency department for intense pelvic pain associated with hypotension and moderate anemia. A history of right salpingectomy for a ruptured tubal ectopic pregnancy 10 years previously was noted. High beta-HCG levels were also detected. A pelvic ultrasound allowed us to suspect a ruptured ectopic interstitial pregnancy at 8 weeks of amenorrhea. An association with hemoperitoneum was suspected, and an emergency laparoscopy was performed. The condition was confirmed intraoperatively, and the patient underwent a right corneal wedge resection with suture of the uterine myometrium. The postoperative course was uneventful, and the patient was discharged on the fourth day postoperatively. Interstitial ectopic pregnancy is a rare yet extremely perilous situation. Timely ultrasound-based diagnosis is crucial as it can enable conservative management with Methotrexate. Delayed diagnosis can lead to uterine rupture with consecutive surgery based on a transection of the pregnancy and cornual uterine resection.

Impact of patient-reported salpingitis on the outcome of hysterectomy and adnexal surgery: A national register-based cohort study in Sweden.

Salpingitis is caused by ascending microbes from the lower reproductive tract and contributes to tubal factor infertility, ectopic pregnancy, and chronic pelvic pain. The aim of this study was to analyze if the risk for complications and dissatisfaction after hysterectomy and adnexal surgery was increased in women reporting previous salpingitis. This is an observational cohort study including women undergoing gynecologic surgery from 1997 to 2020, registered in the Swedish National Quality Register of Gynecologic Surgery (GynOp). Patient-reported previous salpingitis was the exposure. Complications up to 8 weeks and satisfaction at 1 year postoperatively were the outcomes. Multivariable logistic regression and ordinal regression were performed. Results were adjusted for potential confounders including age, body mass index, smoking and year of procedure as well as endometriosis and previous abdominal surgery. Multiple imputation was used to handle missing data. In this study, 61 222 women were included, of whom 5636 (9.2%) women reported a previous salpingitis. There was an increased risk for women reporting previous salpingitis in both the unadjusted and fully adjusted models to have complications within 8 weeks of surgery (adjusted odds ratio [aOR] 1.22, 95% confidence interval [CI] 1.14-1.32). The highest odds ratios were found for bowel injury (aOR 1.62, 95% CI 1.29-2.03), bladder injury (aOR 1.52, 95% CI 1.23-1.58), and postoperative pain (aOR 1.37, 95% CI 1.22-1.54). Women exposed to salpingitis were also more likely to report a lower level of satisfaction 1 year after surgery compared with unexposed women (aOR 0.87, 95% CI 0.81-0.92). Self-reported salpingitis appears to be a risk factor for complications and dissatisfaction after gynecologic surgery. This implies that known previous salpingitis should be included in the risk assessment before gynecologic procedures.

A case series on live ectopic pregnancy

A pregnancy which develops outside uterus is called ectopic pregnancy that comprises nearly two percent of total pregnancies. In first case a 25years old female presented with lower abdominal pain and bleeding per vagina with 3 months of amenorrhea and history of irregular oral contraceptive pill use. A live ectopic pregnancy of 12 weeks 3 days gestation found on right fallopian tube during laparotomy and right salpingectomy was done. In second case, a third gravida mother presented with bleeding per vagina and lower abdominal pain with history of 2.5 months of amenorrhea and chronic pelvic inflammatory disease. During laparotomy, both sided hydrosalpinx and left sided live ectopic pregnancy found on the distal end of fallopian tube and left salpingectomy with fimbriectomy with right sided tubal ligation was done. In third case, a third gravida mother with history of lower uterine caesarean section and ruptured left sided tubal ectopic pregnancy previously, presented with lower abdominal pain with 2 months of amenorrhea. Ultrasonography diagnosed a live right sided cornual ectopic pregnancy of 6weeks 6days and conservative management with injection methotrexate was started. Later due to sudden hemodynamic instability, emergency laparotomy was done and ruptured right cornual ectopic pregnancy was found and treated with total abdominal hysterectomy. All these cases were managed successfully. This case series emphasizes that early serological and sonographic diagnosis of location of pregnancy is necessary, there should be high suspicion for ectopic pregnancy even beyond the first trimester and the decision of conservative management in early ectopic pregnancy should be taken judiciously after checking all parameters of the patient.

Management of ectopic tubal pregnancy: experience of a tertiary center in Lithuania

Management of ectopic tubal pregnancy: experience of a tertiary center in Lithuania

A Unique Case of Heterotopic Pregnancy

Heterotopic pregnancy, characterized by simultaneous intrauterine and extrauterine pregnancies, is a rare but potentially life-threatening condition. Its incidence has increased, attributed to factors such as pelvic inflammatory disease and assisted reproductive technologies. We present a case of spontaneous heterotopic pregnancy in a 28-year-old woman with lower abdominal pain. Initial examination revealed a ruptured left tubal ectopic pregnancy alongside a live intrauterine pregnancy. Prompt diagnosis via transvaginal ultrasonography led to emergency laparotomy, confirming sonographic findings. The ruptured ectopic pregnancy was successfully removed, preserving intrauterine gestation. Follow-up ultrasounds demonstrated a progressing intrauterine pregnancy. This case underscores the diagnostic challenges and emphasizes the importance of early recognition and intervention in heterotopic pregnancies, especially in the absence of predisposing risk factors. Increased awareness, thorough pelvic examination, and close follow-up are crucial for optimal outcomes in both pregnancies.

Curative effect of high‐intensity focused ultrasound in management of different types of ectopic pregnancy: A systematic review

AbstractEctopic pregnancy (EP) could be defined as any embryo that got implanted in any site rather than the endometrial cavity. Lately, different types of EP were reportedly managed by high‐intensity focused ultrasound (HIFU). We aimed to pool all available data in a systematic review without meta‐analysis and investigate the efficacy and safety tendencies of HIFU among different types of EP. We applied our comprehensive terms in Google Scholar, PubMed, Scopus, Ovid, and PubMed Central databases from their inception until September 23. Retrieved references were gathered using EndNote in which we omitted the duplicates and exported the record for screening. Data regarding characteristics, safety and efficacy outcomes, and baseline information of the enrolled population were extracted. The eligible case reports were assessed using a tool by Murad and colleagues, while the quality of the included cohorts was appraised using the NIH tool. We retrieved 6637 studies, which were scrutinized by titles and abstracts. We scrutinized the full texts of 36 studies and ultimately included a total of 17 studies. All studies were conducted in China, and on different types of ectopic pregnancy including tubal, cervical, intramural, caesarian scar, and corneal ectopic pregnancy. The mean age of enrolled patients was 33.03 years, and we pooled a total sample of 853 patients. The follow‐up period varied widely among the included studies, ranging from 1.3 months to up to 69 months. Normal menstruation recurred after a mean of 35 days, as reported by nine studies. Most of the included studies reported normal β‐HCG after around 30–40 days. Twelve studies with 757 patients reported a cumulative incidence of 179 cases of abdominal pain after HIFU. Neither of the enrolled patients reportedly complained of skin burn after HIFU. We suggested managing EP patients with HIFU, especially when seeking further conceiving. High‐quality randomized controlled trials are required to draw a stronger level of evidence.

Effect of prior cesarean delivery on the outcomes of intracytoplasmic sperm injection.

This study was conducted to investigate the impact of previous delivery mode on pregnancy outcomes in patients with secondary infertility after frozen-thawed embryo transfer. This prospective observational study included 140 patients experiencing secondary infertility. Of these, 70 patients had a previous cesarean delivery (CD), while the remaining 70 patients had a previous normal vaginal delivery (NVD). The primary outcome was the implantation rate. The secondary outcomes included rates of clinical pregnancy, chemical pregnancy, miscarriage, and ectopic pregnancy. The comparison of all fertility outcomes between the two groups revealed no statistically significant differences. The implantation rate was 40.4% in the CD group and 41.7% in the NVD group (p=0.842). The clinical pregnancy rate was 50% in the CD group and 49.3% in the NVD group (p=0.932), while the chemical pregnancy rate was 14.6% in the CD group and 19% in the NVD group (p=0.591). The miscarriage rates in the CD and NVD groups were 20% and 17.6%, respectively (p=0.803). One case of tubal ectopic pregnancy occurred in the NVD group (1.4%). The mode of prior delivery did not significantly impact pregnancy outcomes following frozen-thawed embryo transfer.

Histopathological and Immunohistochemical Analysis of Ruptured Tubal Ectopic Pregnancy

Ectopic Pregnancy (EP) is reported to be causative of high incidence of maternal death and morbidity. It must be diagnosed during the first trimester immediately after symptoms of severe bleeding, abdominal pain, and cramping. Ultrasonography is the only possible detection method to confirm EP. Patients are at greater risk of EP due to inefficient early detection methods. An early detection of the EP based on cellular markers would possibly improve the diagnosis and clinical management. Therefore, an attempt was made to study the histoarchitecture of, and to identify the biomarkers in, the fallopian tube during rupture of ectopic pregnancy. Histological analysis revealed the formation of hematosalpinx and hydrosalpinx in the fallopian tube. Further, immunohistochemical study of the fallopian tissue of EP patients showed remarkable evidence of protein markers such as Bcl2 and desmin which may be considered as potential cellular markers for the detection of EP.

Transvaginal natural orifice endoscopic surgery for tubal ectopic pregnancy: A more suitable surgical approach for enhanced recovery after surgery

ObjectiveWe aimed to determine the safety of Vaginal natural orifice transluminal endoscopic surgery (vNOTES) in terms of the Enhanced Recovery after Surgery (ERAS) concept for tubal pregnancy surgery and provide a detailed process of vNOTES for tubal pregnancy surgery, including experience and key points for surgeons performing this procedure. MethodsThe Longitudinal Vaginal Natural Orifice Transluminal Endoscopic Surgery Study (LovNOTESS), which was conducted in Chengdu, China. A total of 219 patients who underwent tubal ectopic pregnancy surgery between September 2021 and March 2022. The patients underwent salpingectomy or salpingostomy using transumbilical laparoendoscopic single-site surgery (LESS) or vNOTES, according to their preferences. This study prospectively collected perioperative and one-year follow-up data on tubal pregnancy outcomes after vNOTES and compared them with those after LESS. ResultsThe vNOTES group showed a shorter surgical duration, hospitalization duration, and postoperative exhaust time and a lower analgesic medication usage rate, but it showed a higher surgical conversion rate. The vNOTES approach reduced the postoperative exhaust time by approximately 9 h (95% confidence interval [CI]: −11.93, −5.57 h, p < .001) and the risk of postoperative analgesic drug use by 77% (odds ratio, 0.23; 95% CI: 0.10, 0.61, p = .023). ConclusionvNOTES can shorten the exhaust time and duration of hospitalization, reduce postoperative pain, and avoid surface surgical scars in tubal pregnancy surgeries, consistent with the ERAS concept. However, more comprehensive preoperative evaluation of patients who choose vNOTES is required to reduce the occurrence of intraoperative conversion.Trial registration: ChiCTR2100053483.

The impact of the coronavirus disease 2019 pandemic on the clinical presentation of tubal ectopic pregnancies: a retrospective cohort study.

We aimed to assess the impact of the coronavirus disease 2019 pandemic on the clinical presentation of tubal ectopic pregnancies. This retrospective cohort study was conducted at a tertiary center and included 76 cases of tubal ectopic pregnancies. The study period was divided into two groups: the pre-coronavirus disease group (January 2018 to February 2020, Group 1; n=47, 61.8%) and the coronavirus disease group (March 2020 to February 2022, Group 2; n=29, 38.2%). Subgroup analysis was also performed for tubal ruptured ectopic pregnancies as Group 1 (n=15, 62.5%) and Group 2 (n=9, 37.5%). No statistically significant differences were observed between the pre-coronavirus disease and coronavirus disease groups in terms of demographic characteristics. Although the serum beta-human chorionic gonadotropin level was found to be higher in Group 2, the difference was not statistically significant (p=0.7). The groups appeared to be similar in treatment management, duration of hospitalization, and blood transfusion needs (p=0.3, p=0.6, and p=0.5, respectively). Additionally, no significant difference was observed between the groups in the evaluation of ruptured ectopic pregnancies (p=0.5). In the subgroup analysis of tubal ruptured ectopic pregnancies, no significant difference was observed. To the best of our knowledge, there are few studies evaluating the effect of the pandemic on tubal ectopic pregnancies in the literature. Although we did not report statistically significant differences between groups in our study, given the potential prolonged duration of the pandemic, healthcare professionals should actively prompt their patients to seek necessary medical assistance.

Sequential Letrozole and Methotrexate Therapy Safely improved the outcomes of Medical treatment of Tubal Ectopic Pregnancy

Sequential Letrozole and Methotrexate Therapy Safely improved the outcomes of Medical treatment of Tubal Ectopic Pregnancy

Evaluation of Spontaneous Fertility after Medical Treatment of Tubal Ectopic Pregnancy in Two Hospitals in the City of Yaounde

Evaluation of Spontaneous Fertility after Medical Treatment of Tubal Ectopic Pregnancy in Two Hospitals in the City of Yaounde