Viable Ectopic Pregnancy Research Articles

Viable cesarean scar pregnancy from primary care perspective: A case report

Ectopic pregnancies within previous cesarean section scars are rare but potentially life-threatening complications. Diagnosis can be challenging, particularly in primary care settings, where the focus is often on routine primary care services. We present a case report of a patient who initially presented to a primary care clinic with non-specific symptoms of ectopic pregnancy and was referred to a tertiary center for incomplete miscarriage. It was found to be a viable ectopic pregnancy within a cesarean scar. This case highlights the importance of keeping an open mind in patients with a history of cesarean section and uterine manipulation procedures such as manually evacuating a retained placenta. It emphasizes prompt diagnosis and referral to a specialized healthcare facility.

Apoptosis versus necrosis in tubal ectopic pregnancies following Methotrexate.

Methotrexate administration for the treatment of tubal ectopic pregnancies has been shown to cause tubal mass enlargement. Our hypothesis was that, by administrating Methotrexate, a local necrotic reaction occurs, leading to hematoma formation and eventually fallopian tube rupture. Salpingectomy specimens were collected, analysed and divided into three equal groups: patients who received Methotrexate but who ultimately failed medical treatment, patients who had a viable ectopic pregnancy and patients with a self-resolving ectopic pregnancy that were operated due to other medical indications. The specimens were dyed using the Cleaved Caspase-3 (Asp175) Rabbit mA. Specimens were divided into three equal groups and analysed. The patients in self-resolving ectopic pregnancy group were older and had more pregnancies. Rates of apoptosis were found to be less than 1% per slide. Necrosis was not evident in any of the pathological specimens. It seems Methotrexate administration does not lead to a significant tubal necrotic reaction. Further studies are required.

Interstitial Viable Ectopic Pregnancy Managed with Systemic Methotrexate

A 29-year-old woman, 6weeks and 3 days pregnant as assessed by her last menstrual period, presented to our emergency department with vaginal bleeding and pelvic pain for 4 days. She was a gravida 3 para 0 with a history of ectopic on her first pregnancy in the left tube managed by salpingostomy, her second pregnancy was unfortunately a miscarriage at 7 wks managed by medical management and ERPC. At the time of diagnosis, she had a left interstitial ectopic pregnancy with serum B human chorionic gonadotropin (β-HCG) was 20094 mIU / mL. The ectopic pregnancy was managed by intramuscular methotrexate.

Unilateral Viable Twin Tubal Ectopic Pregnancy: A Case Report

Ectopic pregnancy is a life-threatening condition and is still considered as one of the most important causes of maternal mortality [1]. Ectopic twins is a very rare type of ectopic pregnancy. Incidence of twin tubal pregnancy is 1 out of 725-1580 tubal pregnancy and 1in 200000 pregnancies. Very limited number of viable twin ectopic pregnancies have been reported in the literature Spontaneous twin tubal ectopic pregnancy is even rarer with reported incidence of1 in every 125,000 spontaneous pregnancies [2, 4, 5]. In literature review there are more than 100 cases of twin tubal pregnancy have been reported, there are only a few cases with documented fetal heart motions in both embryos or fetuses.6

Unilateral Tubal Twin Ectopic Pregnancy: A Case Report of Failed Systemic Methotrexate Management Requiring Surgical Intervention

Abstract Background: Tubal twin ectopic pregnancy is extremely rare, with an incidence of 1:125,000 spontaneous pregnancies. We present a case of unilateral tubal twin pregnancy with fetal heartbeats that occurred in a patient submitted to in vitro fertilization. Case: A 26-year-old woman was referred to our hospital with increasing β-human chorionic gonadotropin (β-hCG) levels without an intrauterine gestation. The serum β-hCG level was 17,641 mIU/mL and ultrasound revealed two separate gestational sacs within the Lt. adnexa, each containing a live embryo. Due to stable vital signs and the small size of the gestational sacs, the patient was treated with methotrexate (MTX). Despite two courses of treatment with MTX, the therapy failed in the resolution of viable ectopic pregnancy. Conclusion: Therapy of MTX in cases of tubal twin ectopic pregnancy with fetal cardiac activity should be reconsidered. (J GYNECOL SURG 31:272)

“Watchful waiting” in ectopic pregnancies: a balance between reduced success rates and less methotrexate

Many cases of ectopic pregnancy will spontaneously resolve, so that "watchful waiting" and β-hCG follow-up will separate true viable ectopic pregnancies from spontaneously resolving ectopic pregnancies. Withholding methotrexate in patients with spontaneously resolving ectopic pregnancies and administering it in only true viable ectopic pregnancies will no doubt decrease published success rates for this therapy.

Combined local and systemic methotrexate treatment of viable ectopic pregnancy: Outcomes of 31 cases

Medical treatment of viable unruptured ectopic pregnancies by systemic methotrexate (MTX) is controversial due to elevated failure rates. This study describes a combined local and systemic MTX administration and compares the outcomes between viable ectopics in different locations. This retrospective study evaluated 31 patients treated with combined local (sonographically guided) and systemic MTX for viable, unruptured ectopic pregnancies. Success was defined by pregnancy resolution without surgical intervention. Details on subsequent pregnancies were obtained via telephone questionnaires. The ectopic pregnancies were located in the fallopian tube (n = 23), cesarean section scar (n = 5), and intramural portion of the tube (interstitial pregnancy) (n = 3). beta-Human chorionic gonadotropin levels and gestational weeks were similar. The combined treatment was successful in 73.9%, 100%, and 66.7% of cases, respectively (p > 0.05). Details regarding reproductive outcomes were available for 28 women (90.3%). Eighteen of the 24 women attempting to conceive became pregnant, and 15 of these had at least one live birth. There were three subsequent tubal pregnancies, all in patients with previous tubal pregnancies. Combined MTX administration is effective and safe for treating viable cesarean scar pregnancies but is less successful for viable tubal or interstitial pregnancies. Reproductive outcomes following the combined MTX treatment are comparable to other treatment modalities for ectopic pregnancy.

The METEX study: methotrexate versus expectant management in women with ectopic pregnancy: a randomised controlled trial.

BackgroundPatients with ectopic pregnancy (EP) and low serum hCG concentrations and women with a pregnancy of unknown location (PUL) and plateauing serum hCG levels are commonly treated with systemic methotrexate (MTX). However, there is no evidence that treatment in these particular subgroups of women is necessary as many of these early EPs may resolve spontaneously. The aim of this study is whether expectant management in women with EP or PUL and with low but plateauing serum hCG concentrations is an alternative to MTX treatment in terms of treatment success, future pregnancy, health related quality of life and costs.Methods/DesignA multicentre randomised controlled trial in The Netherlands. Hemodynamically stable patients with an EP visible on transvaginal ultrasound and a plateauing serum hCG concentration < 1,500 IU/L or with a persisting PUL with plateauing serum hCG concentrations < 2,000 IU/L are eligible for the trial. Patients with a viable EP, signs of tubal rupture/abdominal bleeding, or a contra-indication for MTX will not be included. Expectant management is compared with systemic MTX in a single dose intramuscular regimen (1 mg/kg) in an outpatient setting. Serum hCG levels are monitored weekly; in case of inadequately declining, systemic MTX is installed or continued. In case of hemodynamic instability and/or signs of tubal rupture, surgery is performed. The primary outcome measure is an uneventful decline of serum hCG to an undetectable level by the initial intervention. Secondary outcomes are (re)interventions (additional systemic MTX injections and/or surgery), treatment complications, health related quality of life, financial costs, and future fertility. Analysis is performed according to the intention to treat principle. Quality of life is assessed by questionnaires before and at three time points after randomisation. Costs are expressed as direct costs with data on costs and used resources in the participating centres. Fertility is assessed by questionnaires after 6, 12, 18 and 24 months. Patients' preferences will be assessed using a discrete choice experiment.DiscussionThis trial will provide guidance on the present management dilemmas in women with EPs and PULs with low and plateauing serum hCG concentrations.Trial registrationCurrent Controlled Trials ISRCTN 48210491

Catch me if you scan: ultrasound diagnosis of ectopic pregnancy

In recent years, ultrasound has become an essential tool in the assessment of women with suspected early pregnancy complications1. A large number of studies has already been published, describing the value of ultrasound in the diagnosis of ectopic pregnancy2,3. So, why write yet another review on this topic? We run a busy Early Pregnancy Unit in the area with the highest prevalence of ectopic pregnancy in the UK, which also receives many referrals from other hospitals of women with an uncertain diagnosis of ectopic pregnancy. The most interesting fact that we have learned over the years is that the majority of women referred with suspected ectopic pregnancies in fact had intrauterine ones that were either missed on ultrasound examination or misinterpreted as ectopics. This may sound surprising to many, as ultrasound diagnosis of intrauterine pregnancy is considered to be relatively simple and accurate. In many cases, ultrasound examination failed to identify a small amount of retained products of conception, due in part to inconsistencies in the sonographic diagnosis of incomplete miscarriage; this is often based on the use of arbitrary cut-off levels for endometrial thickness4. In other cases, however, sonographers were unable to decide whether a visible gestational sac represented an intrauterine or an ectopic pregnancy. In some cases with uncertain diagnosis, women had already received medical treatment with methotrexate prior to referral, leading to the loss of wanted normal intrauterine pregnancies. Another common problem is difficulty in differentiating between the various types of ectopic pregnancy. An accurate differential diagnosis is important in ectopics, as the management often differs depending on the type and exact location of the pregnancy. The purpose of this review is to summarize the sonographic criteria for the diagnosis of both intrauterine and ectopic pregnancies and to describe the principles of differential diagnosis of various types of ectopic pregnancy. We will not cover management of pregnancies of unknown location, as this issue has been covered extensively in recent publications5.

Treatment of viable cesarean scar ectopic pregnancy with suction curettage

Objective Pregnancy in previous cesarean scar is the rarest form of ectopic pregnancy. All reported cases in the literature that were treated with uterine curettage either become unsuccessful or complicated. We aimed to present a case of cesarean scar ectopic pregnancy that was successfully treated with suction curettage without any additional therapy. Case A 32-year-old asymptomatic woman, gravida 2, para 1 was referred to our hospital with the possible diagnosis of cervical ectopic pregnancy. Transvaginal and transabdominal sonographic examination revealed the diagnosis of viable ectopic pregnancy in a previous cesarean scar. Suction curettage with carman canulles was performed under transabdominal ultrasonographic guidance. β-hCG decreased progressively postoperatively. Conclusion Suction curettage under ultrasonography guidance can be used in termination of selected cases (early diagnosed, without symptoms that necessitates emergency intervention) of cesarean scar pregnancy.

Ectopic pregnancy: advances in early diagnosis made by color Doppler and three-dimensional ultrasound

ABSTRACTEctopic pregnancy is known as a great masquerader in clinical presentation and therefore any tool that can facilitate correct diagnosis is very welcome. This review article provides new insights on diagnosis and treatment of various locations of ectopic pregnancy. Development of ultrasonographic techniques and introduction of more accurate β-hCG tests shorten the diagnostic process and render a less invasive approach to this life-threatening condition. Transvaginal probes with the ability for color and pulsed Doppler blood flow analysis permit more accurate determination of functional characteristics of ectopic pregnancy. Three-dimensional ultrasound helps in spatial delineation of adnexal structures, while the use of three-dimensional power Doppler enables monitoring of the vascular changes in tubal arteries caused by ectopic pregnancy. The differentiation between viable ectopic pregnancy with trophoblastic activity and dissolving tubal abortion could facilitate the decision to proceed with conse...

Effects of trophoblast invasion on the distribution of leukocytes in uterine and tubal implantation sites

Objective: To distinguish endocrine and paracrine influences on leukocyte subpopulations at uterine and tubal implantation sites. Design: Retrospective immunohistochemical study. Setting: Departments of Anatomy, and Obstetrics and Gynecology, School of Medicine, RWTH University of Aachen, Aachen, Germany. Patient(s): Ten women with a viable ectopic pregnancy (EP), 25 women who had undergone elective first-trimester termination of pregnancy, and 4 women who had undergone hysterectomy with adnexectomy. Intervention(s): None. Main Outcome Measure(s): Quantitative analysis of leukocyte subpopulations at the implantation sites and their corresponding noninvaded tissues, decidual tissue from patients with EP, and tubal mucosa from normal menstrual cycle. Result(s): Similar numbers and characteristic distribution patterns of macrophages, T cells, and B cells were found at both normal intrauterine and tubal implantation sites. Natural killer (NK) cells were always absent from tubal mucosa. The number and distribution of leukocytes within decidual tissue from women with EP corresponded to those in the noninvaded decidual compartment in intrauterine pregnancy (IUP). Conclusion(s): Leukocyte populations present in the tubal and uterine mucosa are an intrinsic characteristic of these tissues. The distinct leukocyte distribution pattern at the implantation sites suggests that the invading trophoblast exerts a paracrine influence on endometrial and endosalpingeal leukocytes. The absence of natural killer cells from the tubal wall may be one reason for the higher degree of invasiveness of the trophoblast at the tubal implantation site.

Differentiating tubal abortion from viable ectopic pregnancy with serum CA-125 and β-human chorionic gonadotropin determinations

Objective: To determine whether serum CA-125 and serial β-hCG levels can be used to distinguish between tubal abortion and viable ectopic pregnancy (EP). Design: Retrospective cohort study. Setting: A tertiary care institution. Patient(s): Twenty-six women with EPs of 7–12 weeks’ duration were studied retrospectively. Five had laparoscopically proved tubal abortions and 21 had active, viable EPs at the time of entry into the study. All but 3 of the latter group were managed surgically; the others were given a single dose of methotrexate. Intervention(s): Surgical removal of EPs by means of laparoscopy or laparotomy, or medical treatment of the disease. Main Outcome Measure(s): Serum CA-125 and β-hCG determinations were used to differentiate tubal abortion and viable EP. The results were compared with the findings at surgery. Result(s): The mean (±SD) CA-125 level was 112.2 ± 11.9 IU/mL for the patients with tubal abortion and 30.1 ± 15.3 IU/mL for the patients with viable EP. The mean (±SD) β-hCG level was 3,643 ± 3,718 IU/L for the patients with tubal abortion and 10,755 ± 11,465 IU/L for the patients with viable EP. Linear regression analysis showed a statistically insignificant inverse relation between serum CA-125 and β-hCG levels. Conclusion(s): The use of CA-125 levels as an adjunct to serial β-hCG levels shows promise as a means for differentiating tubal abortion from viable EP.

Different placentation patterns in viable compared with nonviable tubal pregnancy suggest a divergent clinical management

Objective: In contrast to tubal abortions, viable ectopic pregnancies in color Doppler ultrasonography exhibit a signal-intensive ring around the gestational sac. We investigated the underlying differences in implantation and placentation. Study Design: Histologic sections of fallopian tubes carrying viable tubal pregnancies (13 patients) and tubal pregnancies that aborted (8 patients) were immunostained for cytokeratin, MIB-1, CD-34, and CD-68. The data were studied by computer-aided image analysis followed by statistical evaluation (Student t test, P < .05). Results: In contrast to tubal abortions, viable tubal pregnancies are characterized by implantation at the mesosalpingial rather than at the antimesosalpingial side of the organ. They exhibit deeper trophoblast invasion into the thickened tubal wall, more intense trophoblast proliferation ( P < .001), and increased villous vascularization ( P < .001). Conclusion: The morphologic findings correlate with preoperative Doppler ultrasonography. They suggest that trophoblast invasion, placental growth, and the fate of tubal pregnancies depend on the implantation site. They encourage a conservative management of anti–mesosalpingially implanted, nonviable ectopic pregnancies in clinically stable patients. (Am J Obstet Gynecol 1999;181:615-20.)

Dopplersonographische Vitalitätskriterien bei klinisch stabiler Extrauteringravidität - eine Entscheidungshilfe für die Therapie

The differentiation between viable ectopic pregnancies with trophoblastic activity and tubal abortions could be a therapeutic aid for the determination of an operative versus a conservative management. Since the typical sonographic picture of an ectopic pregnancy - an extrauterine gestational sac surrounded by an echogenic ring - corresponds histologically to the oedematous tube in combination with the trophoblast, good vascularisation within this structure should indicate the chorionic activity of the ectopic pregnancy and thereby its viability. In 34 patients with sonographically definitely confirmed ectopic pregnancy from the 6 th to 10 th week of gestation who presented with typical but not acute symptoms of an EP (bleeding disorders, positive pregnancy test together with an empty uterus in sonography, slight ache in the lower abdomen or sonographic proof of an ectopic pregnancy in private practice) we therefore examined this echogenic ring by transvaginal colour Doppler sonography (Acuson 128 XP/10, 5 Mhz transvaginal probe EV 519) in a prospective study. Subsequently 29 patients underwent laparoscopy or laparotomy where 16 tubes had to be removed partially or completely. The histological examination of the removed tissue was performed by haematoxyline-eosine staining as well as by immune histochemical methods (factor VIII-antibody, Dako, Heidelberg, FRG) to identify and precisely localise the vessels in the area of the ectopic pregnancy seen in the Doppler sonographic examination. In accordance with the increasing experience with this technique, five patients were treated by conservative methods (single i.v. administration of methotrexate, 30mg). Whereas viable ectopic pregnancies (n=11) exhibited a ring of vessel spots at the rim of this echogenic ring, there were only three or less weak vessel spots or even no vessel spots at all in tubal abortion (n=23). The Doppler sonographic findings could also be verified on histological examination; this correlation was statistically significant also after subtracting the five ectopic pregnancies with positive heart beat (p<0.01; Fisher's exact test). The major therapeutic problem especially of the conservative approach was the slow normalisation of the pregnancy hormone. Even if this is taken into account, Doppler sonography of the echogenic ring around the extrauterine gestational sac is nevertheless an additional help for counselling the clinically stable patient concerning further therapeutic procedures, since it is a fast and simple method for determining the viability of an ectopic pregnancy. It provides a certain independence of the laboratory concerning the determination of the pregnancy hormone and it correlates with the ensuing;histological examination.

Doppler sonographic criteria for viability in symptomless ectopic pregnancies

With the increasing tendency towards conservative therapy, the distinction between ectopic pregnancies that will resolve spontaneously and those that will rupture is essential.1 Usually patients without acute symptoms and declining human chorionic gonadotropin (hCG) values are treated conservatively.2 However, secondary ruptures have been reported in patients with low initial hCG concentrations.3 The differentiation between viable ectopic pregnancies with trophoblastic activity and dissolving tubal abortions could facilitate the decision to proceed with conservative or operative treatment.

Diagnosis of intrauterine and ectopic pregnancy at 5-7 postmenstrual weeks.

The potential of the combined use of vaginosonography and serum beta-hCG levels for early diagnosis of intrauterine and ectopic pregnancies (5-7 weeks postmenstrual) was investigated in a multicentric study. Three hundred and forty-nine patients underwent vaginosonographic examination and determination of serum beta-hCG. When the first examination failed in establishing a precise diagnosis, repeat examinations were performed on alternate days. During the first 3 weeks after the missed menses, vaginosonography can detect practically all viable intrauterine pregnancies, half of the nonviable intrauterine and viable ectopic pregnancies, and one quarter of nonviable ectopic pregnancies, respectively. It was not possible to differentiate intrauterine and ectopic pregnancies by serum beta-hCG levels. Vaginosonographic screening, ideally at 2 weeks after the missed menses, permits detection, localization, and dating in 80%-90% of suspected pregnancies.

Unsuccessful methotrexate treatment of a tubal pregnancy with a live embryo

Two cases with unsuccessful local and systemic methotrexate (MTX) therapy of tubal pregnancy with fetal heart rate activity are reported. The three modes of therapy, the first with local potassium chloride solution injection, the second with local MTX injection, and the third with systemic MTX injection, failed in the resolution of viable ectopic pregnancy. Therapy of MTX in cases of tubal pregnancy with demonstrable fetal heart rate beats, should be reconsidered.

Medicosurgical approach to diagnosis and treatment of ectopic pregnancy

Early ectopic pregnancy screening using vaginal ultrasonographic technology together with measurement of beta human chorionic gonadotropin (beta-hCG) and human chorionic somatomammotropin is possible within the first 2 weeks of the missing menses, prior to the appearance of symptoms. This article summarizes the main available treatment modalities, focusing primarily on the pelviscopic surgical tube-conserving approach and on instillation of intrachorionic drugs (methotrexate alone or in combination with ornipressin) and injection of prostaglandin F2 alpha. While the pelviscopic surgical approach can be applied in nearly all cases of ectopic pregnancy, irrespective of pregnancy duration, the pelviscopic medicosurgical approach is only appropriate for the treatment of early ectopic pregnancies until the 8th week of gestation in patients without fluid collection in the pouch of Douglas and beta-hCG values below 2000 mU/mL. The transvaginal intrachorionic drug instillation as a simple medicosurgical approach performed under ultrasonographic guidance without anesthesia remains restricted to the treatment of early viable ectopic pregnancy. A brief account of the expectant treatment of patients with nonviable ectopic pregnancy is given, underlining the prerequisites of decreasing beta-hCG values and the absence of fluid in the pouch of Douglas. Although spontaneous resorptions have been observed in a number of cases of the disease, no clear evidence is available on the reconstitution of tubal function and patency.

Ectopic pregnancy treatment using pelviscopic or vaginosonographically-guided intrachorionic injection of methotrexate and POR 8®

It is believed by some that the basis of modern first-trimester pregnancy care should involve screening for ectopic pregnancy using vaginal ultrasonography. This has led to this condition being diagnosed in most cases at an earlier stage than has previously been possible. This advance in diagnostic ability has introduced the concept of conservative management for this condition. The authors describe the conservative management of nine cases of ectopic pregnancy using intrachorionic injection of either methotrexate alone or in combination with POR 8. In all cases less than 9 weeks had passed since the last menstrual period, and the ectopic pregnancies treated under ultrasound control were all thought to be viable. Five cases were treated using pelviscopy, whilst in another four the needle was guided using vaginal ultrasonography. There were no procedure-related complications. Following therapy, the women were followed up using serial levels of serum beta-hCG. In seven cases there was a gradual reduction to normal levels. There were two treatment 'failures'. In both these cases methotrexate alone, rather than in combination with POR 8, was used for injection. Although formal tests of tubal patency have not been performed in all cases, one woman in the series has since conceived and has a normal intrauterine pregnancy. It is concluded that vaginal instillation of methotrexate is an alternative treatment for early ectopic pregnancy. It should be limited to viable ectopic pregnancies whose chorionic cavities are less than 2.0 cm in diameter. A plan for the management of ectopic pregnancy is presented, involving selection for both ultrasound-guided injection and pelviscopic surgery. Laparotomy is not considered to be a treatment option in the majority of cases.