Tubal Gestation Research Articles

Preoperative Endovaginal Sonographic Diagnosis of an Unruptured Interstitial Pregnancy

Interstitial pregnancies carry a higher maternal morbidity and mortality rate, due to the abundant ovarian and uterine arterial supply of this region, than do other tubal pregnancies. Prerupture diagnosis is crucial, inasmuch as rupture (which usually occurs at a later stage than in tubal gestations) may be followed by rapid exsanguination. Precise early diagnosis may permit conservative nonsurgical treatment with methotrexate. A case is presented in which preoperative diagnosis of an unruptured interstitial pregnancy was aided by endovaginal sonographic examination. Considerations of subsequent management are discussed.

Changes in tubal blood flow in evaluating ectopic pregnancy.

Ectopic pregnancy is not recognized in 5523% of all cases using state-of-the-art diagnostic procedures. In this study, blood flow in tubal arteries was measured using a transvaginal duplex Doppler ultrasonography system. A 3.5 MHz Doppler transducer coupled to a 5 MHz imaging transvaginal sector probe was used to depict flow characteristics in the tubal branch of the uterine artery. This was performed in 102 patients. There was a significant increase in the blood flow on the tubal gestation side (p < 0.0001; z = -4.08). This between-side difference was determined using qualitative frequency shift analysis. The mean reduction in the resistance index on the side with the ectopic pregnancy as compared to the contralateral side was 15.6%. These changes appear to be due to trophoblast invasion. Between-side differences showed no dependence on gestational age (between gestational weeks 4 and 12 postmenstruation). We compared these data with those from three control groups ('early viable intrauterine pregnancy', 'early intrauterine pregnancy failure', 'non-gravid state'). In all these control groups, the impedance to flow, expressed as 'resistance index', showed no significant between-side difference. All control groups had significantly higher mean resistance index values than the ectopic pregnancy side, but did not differ from the contralateral side of the ectopic pregnancy group. The advantages of this new method in diagnosing ectopic pregnancy are early detection, non-invasivity, and immediate results.

Diagnosis and treatment of tubal pregnancy as related to risk determinants

To evaluate whether identification of ‘high risk’ patients for ectopic pregnancy (EP) is beneficial for early recognition and treatment, 178 cases of tubal pregnancy were analysed. Patients with ‘high risk’ and ‘low risk’ for EP were compared for diagnostic procedures, clinical features and surgical management. The ‘high risk’ patients presented a shorter gestational length, lower blood loss volume, a smaller size of the tubal gestation, a lower rate of tubal rupture and underwent more conservative treatment. We conclude that identification of risk determinants may be of great importance for early recognition and hence, application of the new modalities for treatment of ectopic pregnancy.

Classification of tubal gestations by transvaginal sonography.

Transvaginal sonographic images of tubal pregnancies were correlated with the surgical findings in 191 patients having this condition. The sonographic appearance of the ectopic gestations was classified by the absence or presence of structures such as a 'tubal ring' containing the yolk sac, embryonic structures, heart activity, a sonolucent or irregularly echogenic gestational sac, dilated Fallopian tube with amorphous content, fluid in the pelvis and an empty uterus. The following classifications were made: Type Ia (n = 43) A well-defined 'tubal ring' and a beating heart with or without discrete embryonic or extra-embryonic structures. Type Ib (n = 48) A 'tubal ring' containing embryonic and/or extra-embryonic structures without heart beats. Type II (n = 64) An ill-defined or thin tubal wall containing sonolucent or an irregularly echogenic core but not embryonic or extra-embryonic structures. Type III (n = 28) Free pelvic fluid and an empty uterus in patients with positive serum beta-hCG levels. The outline of the tube cannot be visualized. Surgery revealed unruptured tubal pregnancies in 90 patients of the combined groups of Types Ia and Ib. In one additional patient, a tubal rupture was found. In the Type II patients, 26 tubal pregnancies with blood clots in the tube but no evidence of bleeding into the pelvis, and 38 tubal ruptures or abortions were diagnosed. All Type III patients had ruptured tubal pregnancies or bleeding tubal abortions. In eight patients (4.2%), the only sonographic finding was an empty uterus, and these cases were erroneously diagnosed as not having an ectopic pregnancy (false negatives). There were two false-positive cases in which a tubal ring was detected, and this was related to an hemorrhagic corpus luteum. When used for diagnosing tubal pregnancy, the transvaginal scanning technique (together with beta-hCG in Type III cases) carries a sensitivity of 95.8% and specificity of 99.9%. It is an invaluable tool in the diagnostic work-up and management of patients with suspected ectopic gestation.

Tubal Pregnancy: Associated Histopathology

Endometrial histologic characteristics are of little value in predicting ectopic pregnancy. The growing tubal gestation does not have any unique characteristics as far as the maternal-fetal tissue interface is concerned. The placentation is relatively superficial, and the growth is intraluminal. Tubal rupture occurs as a result of progressive tubal distention with focal hemorrhagic necrosis. Persistence is a reflection of incomplete evacuation combined with the noncyclic shedding of the tubal epithelium. The evacuated implantation site and conservative surgical incisions are not directly related to the recurrence of ipsilateral tubal pregnancies. The most common histologic finding related to tubal pregnancy is that of prior tubal disease.

Prostaglandin versus expectant management in early tubal pregnancy

Since ectopic pregnancy may terminate in spontaneous recovery we compared treatment by means of prostaglandin (PG) application with expectant management in laparoscopically verified tubal gestations. Twelve patients received local and systemic PG, 4 patients were treated with sodium chloride and in 7 patients laparoscopy was discontinued without medical therapy. The comparison between the PG group and the placebo groups revealed a highly significant difference with regard to a subsequent necessary surgical intervention and hospitalisation. Expectant management may only be recommended in very selected cases, whereas PG treatment seems to produce favourable results in cases of early tubal pregnancy.

Preoperative sonographic diagnosis of a unilateral tubal twin gestation with documented fetal heart activity.

Preoperative sonographic diagnosis of a unilateral tubal twin gestation with documented fetal heart activity.

Treatment of unruptured tubal pregnancy by local injection of methotrexate under transvaginal sonographic control

Seventeen unruptured tubal gestations were managed on an outpatient basis using local methotrexate (MTX) injection. A single 50-mg dose of MTX was injected into the gestational sac under transvaginal sonographic control. Follow-up included serial assays of the beta-subunit of human chorionic gonadotropin (beta-hCG), clinical and sonographic evaluation. Resolution was obtained in 13 out of 17 patients. The regression curve between days after treatment versus beta-hCG (y = 82.2 - 10.8x + 0.37x2) demonstrated a significant negative correlation (R2 = 0.77; R = 0.88; P less than or equal to 0.02). The mean beta-hCG level on day 15 was 3.2% +/- 3.1% of the initial value. Laparoscopy was performed in 4 patients. Pathological findings suggested that resolution was underway in these four cases despite a slow decline in beta-hCG. No systemic side effects were observed in any of the 17 patients. Long-term follow-up is needed to evaluate tubal patency and reproductive outcome. Our experience suggests that local injection of MTX may be an effective alternative for the treatment of unruptured ectopic pregnancy.

Reproductive outcome after laparoscopic salpingectomy for tubal pregnancy

Since 1983, we have performed laparoscopic salpingectomy as a routine procedure for ectopic pregnancy (EP) in cases where conservative management is impossible or contraindicated. The main indications are a ruptured tubal gestation, a pathological tube, a history of tuboplasty, and an ipsilateral recurrence. This technique is simple, quick, and safe. Reproductive outcome after laparoscopic total salpingectomy for EP was evaluated in 125 cases between January 1983 and December 1987. The pregnancy rate was 33.6%. In our population, there was a high proportion of patients with a pathological or absent contralateral tube (74.4%). In patients with a normal contralateral tube (32 cases), the live birth rate (46.9%) was greater but not significantly than in patients (39 cases) with a patent but pathological tube (25.6%). In vitro fertilization (IVF) was performed in 59 patients; clinical pregnancy was obtained in 40.7% of cases. These encouraging results lead us rapidly to consider IVF in patients with a pathological contralateral tube.

Criteria for Transvaginal sonographic diagnosis of ectopic pregnancy

Transvaginal ultrasonography was performed in 1150 patients suspected of having an ectopic gestation. The criteria for transvaginal sonographic diagnosis of ectopic pregnancy were established by targeted scanning of the pelvic organs and spaces. Sonographic assessment of tubal pregnancy and its differential diagnosis were based on six criteria: (1) the presence or absence of gestational structures within the fallopian tube, (2) the presence or absence of amorphous material in a dilated fallopian tube, (3) the presence or absence of indirect signs of ectopic pregnancy within the pelvis, (4) the echogenicity of a suspected finding relative to the ovary, (5) the presence or absence of flow (of lacunar origin) within the suspected sonographic finding, and (6) the relationship of a suspected sonographic sign to an intentionally displaced ovary. The latter 3 criteria help differentiate between tubal gestation and a corpus luteum. We believe these diagnostic criteria should be applied when performing transvaginal sonographic scanning of patients suspected of having an ectopic gestation.

Reproductive outcome after conservative surgery for unruptured tubal pregnancy—a 15-year experience

The fertility outcome is presented in 118 patients after conservative surgery for unruptured tubal pregnancies. This patient group experienced 142 pregnancies, 127 of which were intrauterine (89.4%). The intrauterine pregnancies (IUPs) occurred in 83 patients (70.3%) and 63.5% (75/118) had live births. The recurrence rate of tubal pregnancy was 12.7%. Of the 65 patients with a normal contralateral tube 53 (81.5%) followed surgery with an IUP, 76.1% a live birth, and 7.7% a recurrent tubal pregnancy. Fifty-seven percent of the patients with a single tube followed with an IUP, and 47.6% had a live birth. The recurrence of tubal pregnancy in this group was 28.5%. Of the patients who underwent expression of tubal gestation, 60.6% followed with an IUP, and 57.5% with a live birth with no recurrence of tubal pregnancy.

Conservative management of ectopic gestation

The management of ectopic gestation has become more challenging than ever before. The recent progress in diagnostic modalities, i.e., ultrasound and sensitive beta-hCG assays, has enabled early detection of ectopic gestation and a change in treatment goals. The traditional catastrophic presentation of a ruptured ectopic gestation and hemoperitoneum no longer is common. Today this condition is typically diagnosed before a rupture occurs, while the patient is only minimally symptomatic. Accordingly, treatment has shifted from an immediate life-saving intervention, into conservative methods of management, directed at preserving fertility and reducing morbidity. As experience is being gained rapidly in the various conservative treatment methods, their respective merits can be evaluated. Laparoscopic linear salpingostomy is the treatment of choice for small, unruptured, isthmic or ampullary gestations. Laparoscopic segmental resection is most suitable for ruptured tubal gestations. These procedures should be performed via laparotomy only if the patient is hemodynamically unstable. In selected cases, nonsurgical treatment methods, i.e., expectant management or methotrexate, may be considered. Serial serum beta-hCG measurements following a conservative treatment is mandatory to rule out persistence of trophoblastic tissue. Further prospective randomized studies are needed, to compare different conservative treatment methods in regard to their respective safety, reproductive outcome, and economic feasibility.

Persistent tubal ectopic gestation: patterns of circulating β-human chorionic gonadotropin and progesterone, and management options

To aid in the clinical decision making involved with persistent ectopic gestation, a total of 329 operative procedures for tubal gestation were reviewed. Six of 114 (5.3%) cases treated conservatively had persistent trophoblastic activity. The decline in serum beta-human chorionic gonadotropin (hCG) and progesterone (P) at 3 and 6 days postoperatively was similar in the "persistent ectopic" and the "resolved ectopic" groups. However, beyond day 6 both beta-hCG percentage of baseline and P level were significantly higher in the "persistent ectopic" (greater than 22.6 +/- 6.6%, greater than 3.4 +/- 0.7 ng/ml, respectively) than the "resolved ectopic" group (less than 2.7 +/- 0.8%, less than 0.2 +/- 0.05 ng/ml, respectively). Four patients underwent a second operation, whereas two were managed expectantly. These data suggest that the diagnosis of persistent ectopic gestation is best made by an initial measurement of serum beta-hCG or P at 6 days postoperatively, and at 3 day intervals thereafter. The choice of management may be determined by various factors including serum beta-hCG and patient's symptoms.

Transvaginal Ultrasonographic Study of the Fallopian Tube

The use of transabdominal/transvesical sonography in gynecologic diagnosis is limited by the physical properties of the transducers used as well as the lack of sufficient acoustic interfaces. Therefore, delicate tubal structures cannot be visualized adequately. Transvaginal application of a 6.5-MHz transducer probe (with a 10-mm crystal) enables the effective use of higher frequencies, enhancing resolution. This higher resolution improves picture quality and increases potential diagnostic power in evaluating the female pelvis in general and the fallopian tube in particular. This report presents the sonographic picture of the normal and pathologic tube. Tubal pathology should be described in terms of the tubal cavity, walls, and content, as well as location and mobility. The more frequently encountered clinical entities, such as the fluid-filled tube, tubo-ovarian inflammatory processes, and tubal gestation are discussed.

Reproductive outcome after fimbrial evacuation of tubal pregnancy

Thirty-one ectopic pregnancies were manually expressed (i.e., "milked out") by the tubal fimbria during a 13-year period. Reproductive histories and operative findings were unremarkable when compared with the general population with ectopic gestation. The subsequent reproductive performance was evaluated in 27 patients who attempted conception. Twenty-five (92%) of the 27 patients subsequently conceived, 23 (85%) had at least one successful term pregnancy, and the remaining 2 (7%) had abortions only. There was no repeat ectopic pregnancy. Average follow-up time was 38.5 months. Previous experience with this technique has been disappointing with low postoperative rates of successful term pregnancies. Favorable outcomes after fimbrial expression have been reported only in small numbers of patients. It is suggested that the procedure is appropriate for distal tubal gestations that are loosely adherent within the tubal lumen; these are usually expressed with minimal efforts. However, if the gestational mass does not yield to gentle milking of the tube or evacuation has been incomplete, the surgeon can always use a linear salpingotomy. More experience is obviously needed to verify these preliminary results, suggesting that fimbrial evacuation is simple, safe, and advantageous in properly selected cases.

Fertility following conservative surgery for tubal pregnancy.

Eighty seven conservative surgical interventions for unruptured tubal pregnancy were performed on 83 patients. Salpingotomy was performed in 66 cases and expression of tubal pregnancy in 21 cases. In this patient group, 76.7% (56 out of 73) experienced intra-uterine pregnancy following surgery and 71.2% (52 out of 73) had a live birth. The recurrence rate of tubal pregnancy was 12.3%. Of the 42 patients with a normal contralateral tube, 36 (85.7%) had an intra-uterine pregnancy, 80.9% had a live birth and 7.1% had a recurrent tubal pregnancy. Sixty percent of the patients who underwent operation on their single tube, had a live birth and 66.6% had an intra-uterine pregnancy; the recurrence of tubal pregnancy in this group was 26.6%. No recurrence of tubal pregnancy was found in the group of patients who underwent expression of tubal gestation. It is suggested that the expression of tubal gestation (milking) is a safe procedure for conserving future fertility, and that the indications for conservative surgical management in patients with unruptured tubal gestation should be broadened to include all patients interested in future pregnancies, regardless of the current state of the contralateral tube.

Organ-saving surgery of tubal pregnancy

Recently a number of authors have published their results of conservative treatment in tubal gestations. Numerous operative techniques have been described. This review tries to summarize the different operative approaches under special consideration of microsurgical techniques in regard to the authors experience. As a general rule conservative management of tubal gestation can be performed more extensively in the future.

Ectopic Pregnancy

The diagnosis of ectopic pregnancy has become precise and reliable. Consequently, the management of ectopic pregnancy has progressed to the point where the physician is often able to preserve fertility. Therefore, conservative surgery is indicated if the patient desires future fertility and conditions are appropriate. The combination of ultrasound, beta-hCG pregnancy testing, and laparoscopy has led to a rising incidence of diagnosed ectopic pregnancy prior to rupture. This has greatly facilitated the use of the conservative approach to the management of tubal pregnancy. Although ectopic pregnancy can be diagnosed early and managed conservatively, it is, and will remain a potentially life-threatening disease and must be approached as such. Table 3 summarizes our proposed surgical management of tubal pregnancy. Table 4 summarizes the results of conservative surgery for tubal pregnancy.

Amniotic fluid prolactin levels in tubal gestation: Support for the unique role of decidua

a 35-week intrauterine gestation, and no fetal movement or heart motion could be detected. The patient was sent home with instructions to return when uterine contractions began. Seventeen days later the patient noted uterine contractions; however, after several hours of observation and no change in cervical dilatation noted, the patient was discharged and asked to return when the contractions increased in intensity and frequency or if vaginal bleeding, rupture of the membranes, or fever was noted. The patient was not seen in the follow-up until 14 months later when she was admitted with abdominal pain and fever. A pelvic ultrasound verified the presence of an intrauterine fetal death. An induction of labor with pros-

New concepts in the surgical management of tubal pregnancy and the consequent postoperative results

The success following reconstructive tubal pregnancy can only be measured in terms of live births. Because the fallopian tube is not a simple conduit and has numerous complex functions, many women fail to conceive despite successful reconstructive surgery. The most effective way to prevent reocclusion or peritubal adhesion is to minimize tissue trauma. Magnification permits accurate excision and hemostasis. In this review, it has been demonstrated that tubal conservation is technically possible and safe. It is effective in increasing the number of live births postoperatively in women interested in fertility and does not increase the risk of the repaired tube for a repeat tubal gestation more than the uninvolved tube, although one of five subsequent pregnancies are again ectopic. They seem to occur equally as often in the contralateral tube as in the repaired tube. It has been shown that salpingotomy can restore tubal patency and maintain fertility. The second question was whether the number of viable pregnancies increase after conservative surgery. This question can be answered only if the repaired tube remains and the patient subsequently delivers at term. Such data have already demonstrated this outcome. Conservative operations in selected cases of tubal pregnancy seem feasible and safe and do not further impair tubal function. Because intrauterine pregnancy is more apt to occur than is repeat ectopic pregnancy, it seems logical that the involved tube should be saved whenever fertility is desired (Fig. 2). In unruptured isthmic pregnancy, Stangel and Gomel prefer segmental excision and end-to-end anastomosis during the same intervention. Gomel advocates segmental excision of the conceptus whether ruptured or not when the pregnancy is located in the isthmus or proximal half of the ampulla, and end-to-end anastomosis undertaken later as an elective procedure if necessary (Fig. 2). An ampullary gestation may be successfully treated by salpingotomy; and in the case of distal ampullary location, a tubal abortion may be performed (Fig. 2). When extensive destruction of the tube occurs, salpingectomy becomes necessary. In cases of early diagnosis of tubal gestation, conservative surgical management may be carried out via laparoscopy (Fig. 1).