Methotrexate vs expectant management for treatment of tubal ectopic pregnancy: An individual participant data meta-analysis.

INTRODUCTION: Ectopic pregnancy is an important health condition which affects up to 1 in 100 women. Women who present with mild symptoms and low serum human chorionic gonadotrophin (hCG) are often treated with methotrexate (MTX), but expectant management with close monitoring is a feasible alternative. Studies comparing the two treatments have not shown a statistically significant difference in uneventful resolution of ectopic pregnancy, but these studies were too small to define whether certain subgroups could benefit more from either treatment. MATERIAL AND METHODS: We performed a systematic review and individual participant data meta-analysis (IPD-MA) of randomized controlled trials comparing systemic MTX and expectant management in women with tubal ectopic pregnancy and low hCG (<2000 IU/L). A one-stage IPD-MA was performed to assess overall treatment effects of MTX and expectant management to generate a pooled intervention effect. Subgroup analyses and exploratory multivariable analyses were undertaken according to baseline serum hCG and progesterone levels. Primary outcome was treatment success, defined as resolution of clinical symptoms and decline in level of serum hCG to <20 IU/L, or a negative urine pregnancy test by the initial intervention strategy, without any additional treatment. Secondary outcomes were need for blood transfusion, surgical intervention, additional MTX side-effects and hCG resolution times. TRIAL REGISTRATION NUMBER: PROSPERO: CRD42021214093. RESULTS: 1547 studies reviewed and 821 remained after duplicates removed. Five studies screened for eligibility and three IPD requested. Two randomized controlled trials supplied IPD, leading to 153 participants for analysis. Treatment success rate was 65/82 (79.3%) after MTX and 48/70 (68.6%) after expectant management (IPD risk ratio [RR] 1.16, 95% confidence interval [CI] 0.95-1.40). Surgical intervention rates were not significantly different: 8/82 (9.8%) vs 13/70 (18.6%) (RR 0.65, 95% CI 0.23-1.14). Mean time to success was 19.7 days (95% CI 17.4-22.3) after MTX and 21.2 days (95% CI 17.8-25.2) after expectant management (P = 0.25). MTX specific side-effects were reported in 33 MTX compared to four in the expectant group. CONCLUSIONS: Our IPD-MA showed no statistically significant difference in treatment efficacy between MTX and expectant management in women with tubal ectopic pregnancy with low hCG. Initial expectant management could be the preferred strategy due to fewer side-effects.

Delays to Surgery in Emergency Department Cases of Ectopic Pregnancy: A Quality Improvement Study.

OBJECTIVE: Create a process map for emergency department (ED) presentations of surgical ectopic pregnancy, and identify areas of management amenable to quality improvement. METHODS: A retrospective chart review of all patients undergoing surgical management of ectopic pregnancy at a large, urban, academic tertiary care centre from 2015 to 2017 was performed. RESULTS: Seventy-three patients were included. There were 6 (8.2%) unstable A cases (recommended time to operating room [OR] 0-2 hours), 23 (31.5%) stable A cases, and 44 (60%) B cases (recommended time to OR 2-8 hours). The percent of patients who were in the OR within the recommended time window were 6 (100%) for unstable A cases, 13 (56%) stable A cases, and 29 (65.9%) stable B cases, respectively (P = 0.139). Notable time delays include the time from gynaecology referral to the time seen by gynaecology (29.7% of total wait time for stable A cases from ED to OR) and the time the OR was booked to the time the patient was brought to the OR (53.2% of total wait time for stable B cases). Of the patients seen by physician at the emergency department first, the time from triage to the OR was significantly shorter for patients that received bedside ultrasound only (0.67 ± 0.5 hours vs. 2.1 ± 1.8 hours [P = 0.007]). CONCLUSION: This is the first study to map the ED presentation of surgical ectopic pregnancy. The management of ectopic pregnancy would benefit from the development of surgical triage decision aids, a surgical care pathway, and increased use of screening bedside ultrasound.

A Purse-String Approach to Laparoscopic Cornuotomy for Interstitial Ectopic Pregnancy.

An interstitial ectopic refers to the implantation of a pregnancy in the proximal fallopian tube where it passes through the myometrium. This type of ectopic pregnancy presents a distinct surgical challenge, as it often presents with rupture and carries a significant risk of hemorrhage at resection. This video demonstrates a four-step approach to the resection of an interstitial ectopic pregnancy with laparoscopic cornuotomy. This approach includes (1) isolating the pregnancy by performing a salpingectomy and identifying the utero-ovarian ligament; (2) ensuring hemostasis with the injection of vasopressin, followed by application of the purse string suture around the pregnancy at its equatorial line; (3) performing the resection using a linear incision; and (4) repairing the uterine defect with layered closure. The purse-string suture is shown to be a useful tool in minimizing bleeding, and this sequential approach allows for interstitial ectopic pregnancies to be excised with a minimally invasive cornuotomy, even in cases of significant anatomical distortion.

Impact of severe acute respiratory syndrome coronavirus 2 on ectopic pregnancy management in the United Kingdom: a multicentre observational study.

OBJECTIVE: To describe the impact of coronavirus disease 2019 (COVID-19) on the management of women with ectopic pregnancy. DESIGN: A multicentre observational study comparing outcomes from a prospective cohort during the pandemic [COVID-19-ectopic pregnancy registry (CEPR)] compared with a historical pre-pandemic cohort [non-COVID-19-ectopic pregnancy registry (NCEPR)]. SETTING: Five London university hospitals. POPULATION AND METHODS: Consecutive patients diagnosed clinically and/or radiologically with ectopic pregnancy (March 2020-August 2020) were entered into the CEPR and results were compared with the NCEPR cohort (January 2019-June 2019). An adjusted analysis was performed for potentially confounding variables. MAIN OUTCOME MEASURES: Patient demographics, management (expectant, medical and surgical), length of treatment, number of hospital visits (non-surgical management), length of stay (surgical management) and 30-day complications. RESULTS: Three hundred and forty-one women met the inclusion criteria: 162 CEPR and 179 NCEPR. A significantly lower percentage of women underwent surgical management versus non-surgical management in the CEPR versus NCEPR (58.6%; 95/162 versus 72.6%; 130/179; P = 0.007). Among patients managed with expectant management, the CEPR had a significantly lower mean number of hospital visits compared with NCEPR (3.0, interquartile range [IQR] [3, 5] versus 9.0, [5, 14]; P = <0.001). Among patients managed with medical management, the CEPR had a significantly lower median number of hospital visits versus NCEPR (6.0, [5, 8] versus 9, [6, 10]; P = 0.003). There was no observed difference in complication rates between cohorts. CONCLUSION: Women were found to undergo significantly higher rates of non-surgical management during the COVID-19 first wave compared with a pre-pandemic cohort. Women managed non-surgically in the CPER cohort were also managed with fewer hospital attendances. This did not lead to an increase in observed complication rates. TWEETABLE ABSTRACT: A higher rate of non-surgical management of ectopic pregnancy during the COVID-19 pandemic did not increase complication rates.

Guideline No. 414: Management of Pregnancy of Unknown Location and Tubal and Nontubal Ectopic Pregnancies.

OBJECTIVE: To provide an evidence-based algorithm to guide the diagnosis and management of pregnancy of unknown location and tubal and nontubal ectopic pregnancy. TARGET POPULATION: All patients of reproductive age. BENEFITS, HARMS, AND COSTS: The implementation of this guideline aims to benefit patients with positive ß-human chorionic gonadotropin results and provide physicians with a standard algorithm for expectant, medical, and surgical treatment of pregnancy of unknown location and tubal pregnancy and nontubal ectopic pregnancies. EVIDENCE: The following search terms were entered into PubMed/Medline and Cochrane in 2018: cesarean section, chorionic gonadotropin, beta subunit, human/blood, fallopian tubes/surgery, female, fertility, humans, infertility, laparoscopy, methotrexate, methotrexate/administration & dosage, methotrexate/therapeutic use, pregnancy (abdominal, angular, cervix, cornual, ectopic, ectopic/diagnosis, ectopic/diagnostic imaging, ectopic/drug therapy, ectopic/epidemiology, ectopic/mortality, ectopic/surgery, heterotopic, interstitial, isthmo-cervical, ovarian, tubal, unknown location), recurrence, risk factors, salpingectomy, salpingostomy, tubal pregnancy, ultrasonography, doppler ultrasonography, and prenatal. Articles included were randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: Obstetrician-gynaecologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, and residents and fellows. SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES): RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

[Preliminary study on the application of abdominal aortic balloon occlusion in the treatment of cesarean scar pregnancy].

Objective: To explore the clinical value by analyzing the application of abdominal aortic balloon occlusion in the uterine curettage treatment for patients with cesarean scar pregnancy (CSP). Methods: Totally 42 CSP patients in the first Affiliated Hospital of Zhengzhou University were analyzed retrospectively, 21 cases in the observation group, placing the balloon catheter to the abdominal aorta under the renal artery under the digital substraction angiography(DSA), conducting curettage under hysteroscopy or uterine laparoscopy immediately, and making intermittent blockage in abdominal aorta blood flow during the surgery;21 patients in the control group, conducting uterine artery embolization (UAE) before operation, conducting curettage under hysteroscopy or uterine laparoscopy after 1-3 days. The fluoroscopy time under DSA, body surface radiation dose, intraoperative blood loss, operation time, incidence of postoperative adverse reactions, hospitalization time and follow-up menstruation were comparatively analyzed. Results: All patients operated and retained the uterus successfully. In the control group, all 21 patients had different degrees of fever, pain and other symptoms after UAE. In the observation group and control group, the fluoroscopy time and body surface radiation dose under DSA respectively were (7.4±1.4) s, (5.4±1.1) mGy and (1 142.8±315.5) s, (1 442.0±300.0) mGy (both P<0.01);the average amount of intraoperative blood loss were (22±15), (19±14) ml (P>0.05), the time of uterine curettage were (37±20), (42±19) minutes (P>0.05);hospitalization time were (5.0±0.9), (7.7±1.3) days (P<0.01). The follow-up period was more than 3 months, no adverse reactions were observed in the observation group; 4 cases of menstrual reduction and 1 case of intrauterine adhesions were found in the control group. Conclusion: Abdominal aortic balloon occlusion and UAE could effectively reduce intraoperative bleeding in uterine curettage for patients with CSP; abdominal aortic balloon occlusion has significant reduction of the X-ray dose, shorter hospitalization time, and fewer adverse events comparing to UAE.

MANAGEMENT OF RUPTURED CORPUS LUTEUM WITH HEMOPERITONEUM IN EARLY PREGNANCY - A CASE REPORT.

- Rupture of the corpus luteum is a frequent condition in women of reproductive age. Because of abdominal pain accompanied by hemoperitoneum, ruptured corpus luteum can easily be confused with ectopic pregnancy. The management of ruptured corpus luteum depends on the symptoms and laboratory findings, and can be just observation but laparoscopy or urgent laparotomy may also be needed. Although rare, hemoperitoneum following rupture of corpus luteum in early pregnancy should always be considered in the diagnostic process. We present a patient that was admitted to our department with amenorrhea, positive ßhCG and acute abdomen. Emergency laparoscopy was performed but no ectopic pregnancy was found, just blood, coagula and a ruptured corpus luteum. The day after the surgery, intrauterine pregnancy was found on ultrasound and the pregnancy ended with term delivery.

Twin abdominal pregnancy - A rare scenario.

Twin abdominal pregnancy is rarely encountered by gynaecologists throughout their professional career. It poses a challenge in terms of diagnosis and management. This case report is about a patient who was diagnosed and successfully managed for this complication at a peripheral hospital of Pakistan Armed Forces.

[Clinical features and outcome of cesarean scar pregnancy].

Objective: To analysis the clinical features of cesarean scar pregnancy (CSP), to evaluate the therapeutic effect of various treatments, especially the feasibility and advantage of Methotrexate (MTX)-Uterine artery embolization (UAE)- Sonogrphy directed-In situs aspiration sequential therapy based on the pregnancy sac three-dimensional conformation analysis (3D-MESIA). Methods: From January 2007 to December 2014, 99 subjects who were diagnosed as CSP in Chaoyang Hospital of Capital Medical University were studied retrospectively. According to different treatment, they were divided into six groups: 51 cases treated by 3D-MESIA (group A), 8 cases treated by systemic MTX injection (group B), 9 cases treated by uterine artery chemoembolization or uterine artery embolization combined with systemic MTX injection (group C), 10 cases treated by uterine curettage after systemic MTX injection (group D), 11 cases treated by uterine curettage after uterine artery embolization (group E), 10 cases treated by uterine curettage directly (group F). Each group according to the CSP classification can be divided into two subgroups: endogenous CSP and exogenous CSP. The intraoperative blood loss, operative time, ß-hCG clearance time, lesion absorption time, hospitalization time, hospitalization expenses, the success rate were compared among the six groups and two subgroups. Results: (1) The operative time and blood loss of endogenous CSP had no significant difference in different operative methods (P>0.05). ß-hCG clearance time and lesion absorption time of endogenous CSP in group B were significantly longer than the other five groups (P<0.05). (2) The intraoperative blood loss in group A and group E compared with group D and group F was decreased significantly (P<0.05). ß-hCG clearance time and lesion absorption time of exogenous CSP in group A were significantly shorter than those in the other five groups (P<0.05). (3) The hospitalization time in group E and group F were obviously shorter than that in other groups (P<0.05). The hospitalization expense in group B and group F were obviously less than that in other groups (P<0.05). (4) The success rate of endogenous CSP in group F was the lowest, but the difference had no significant statistical significance (P>0.05). The success rate of exogenous CSP in group A and group E were obviously higher than that of the other four groups (P<0.05). Conclusion: The treatment effect of MTX therapy alone or uterine artery embolization for CSP is poor. 3D-MESIA is safe and effective for endogenous CSP. It is easy to promote and can be used as the initial treatment of exogenous CSP. If it fails, the laparoscopic removal of lesions and scar repair could be the remedial measure.

[Expectant management of 11 cases of cesarean scar pregnancy].

Objective: To explore the natural courses of 11 patients with cesarean scar pregnancy (CSP) with expectant management. Methods: Eleven patients with CSP who were diagnosed in the first trimester in the Third Affiliated Hospital of Guangzhou Medical University from January 2015 to March 2017 were recruited. All of them received expectant management. Nine pregnancies continued to the third trimester (the third trimester group), and 2 patients were expected to the second trimester (the second trimester group). The gestational age at diagnosis, CSP type, gravidity, parity, miscarriage and previous cesarean section history, gestational weeks at termination, amount of postpartum hemorrhage, prenatal and postnatal hemoglobin levels, pregnancy outcomes and obstetric complications were compared between the two groups. Results: The third trimester group terminated pregnancies between 33(+2) and 36(+5) weeks. The second trimester group terminated in the second trimester because of rupture of uterus (at 17(+2), 17(+3) weeks). There was no statistical difference between the two groups regarding the number of gravidity, parity and previous cesarean section (all P>0.05) . The number of miscarriage in the second trimester group was 4.0±2.8, and in the third trimester group was 1.3±1.1 (P<0.05) . In the third trimester group, 7 cases were CSP typeⅠand 2 cases were CSPⅡ. In the second trimester group, 2 cases were both CSP type Ⅲ. Eleven cases were diagnosed placenta accreta pathologically. There was no maternal death, and 6 cases received hysterectomy (6/11). The amount of postpartum hemorrhage increased remarkably and all neonates survived (pregnancy terminated between 33(+2) and 36(+5) weeks). Conclusion: s For those diagnosed as CSP typeⅠandⅡwho urge to continue pregnancies, it's plausible to have expectant management with fully consent of obstetric hemorrhage, rupture of uterus and hysterectomy and close monitoring in tertiary hospital. The detailed expectant management of CSP is needed further exploration.

[Comparison of the safety of two treatment methods of cesarean scar pregnancy of typeâ ¡ and â ¢ in menopause within 7 weeks].

Objective: To comparison of the safety of two treatment methods of cesarean scar pregnancy (CSP) of typeⅡ and Ⅲ in menopause within 7 weeks. Methods: Totally 70 cases of CSP of typeⅡ and Ⅲ within 7 weeks of the last menstrual period, hospitalized within Peking University First Hospital from January 2009 to May 2016, had been retrospectively studied in two groups of different treatments. The methotrexate (MTX) treatment group included 37 cases receiving ultrasound-guided complete curettage of uterine cavity combined with MTX therapy, while the uterine artery embolization (UAE) group had 33 cases treated with UAE combined with MTX therapy and subsequent ultrasound-guided complete curettage of uterine cavity. The bleeding measurements during operation had been documented and compared for the study. Results: The comparative difference of bleeding measurements between the MTX treatment group and the UAE group was insignificant from the statistical perspective (median: 5.0 vs 5.0 ml, P=0.716).The comparative difference of the duration (median: 2.0 vs 6.0 days, P<0.01) and expenses (median: 2 832.1 vs 10 147.1 yuan, P<0.01) for hospitalization between the MTX treatment group and the UAE group were significant from the statistical perspective. Conclusions: The bleeding risks may not increase during the treatment of ultrasound-guided complete curettage of uterine cavity combined with MTX therapy for CSP patients of type Ⅱ and Ⅲwithin 7 weeks of the last menstrual period. Meanwhile, the UAE adverse effects and complications will be avoided, and the duration and expenses for hospitalization will be reduced.

[Clinical comparative analysis of surgical resection of the pregnancy by hysterotomy and hysterectomy for cesarean scar pregnancy].

Objective: To assess the indication and safety of surgical resection of the pregnancy by hysterotomy (SRPH) and hysterectomy for cesarean scar pregnancy (CSP). Methods: A retrospective study of women with CSP was conducted at the Women's Hospital, School of Medicine, Zhejiang University, from Jan. 2003 to Mar. 2016. The women underwent SRPH (SRPH group, n=35) and hysterectomy (Hysterectomy group, n=14) were included. The gestational age (GA), size of gestational mass(GM), level of serum ß-hCG, previous treatments and clinical outcomes were analyzed. Results: The median GA, the mean size of GM, median serum ß-hCG level, median amount of blood loss, rate ot blood transfusion, rate of persistent CSP, and rate of motal status in SRPH group versus Hysterectomy group were 66 versus 84 days, (65±22) versus (92±36) mm, 23 755 versus 802 U/L, 400 versus 650 ml, 11% (4/35) versus 13/14, 49% (17/35) versus 12/14, 20% (7/35) versus 14/14, respectively (all P<0.05). In SRPH group, median amount of blood loss was 500 ml in patients with GA≥10 weeks versus 300 ml in patients with GA<10 weeks (P<0.05). Serious complication occurred in 7 patients: severe pelvic inflammation in 1 patient and hematomas in the uterine isthmus in 1 patient in SRPH group; severe pelvic inflammation in 2 patients and hemorrhagic shock and DIC in 3 patients in Hysterectomy group. No blaader damage occurred. Conclusions: SRPH is effective and safe for patients with CSP with GA of 9-10 weeks, a diameter of 60-90 mm and stable hemodynamics. Hysterectomy is an alternative to SRPH for patiens in motal status with advanced GA more than 12 weeks.

[Clinical analysis on hysteroscopic surgery for the treatment of type â ¡ cesarean scar pregnancy in the first trimester].

Objective: To investigate the safety and efficacy of hysterosopic management of type Ⅱ cesarean scar pregnancy (CSP) and the value of prophylactic uterine artery embolization (UAE). Methods: Totally 104 patients with type Ⅱ CSP treated with hysteroscopic surgery at the Women's Hospital, School of Medicine, Zhejiang University, during Jan. 2009 to Jun. 2016 were analyzed retrospectively, 67 patients combined with UAE (UAE group) and 37 patients without combined with UAE (non-UAE group). Laparoscopy or sonography guidance was conducted simultaneously. The following clinical parameters were compared, including: primary cure rate, uterine packing rate, uterine perforation rate, hemoglobin level change, the time for the mass absorption and the return of ß-hCG to normal, complications, hospital days and hospital stay cost. Results: Median gestational age, size of mass, thickness of the anterior myometrium and ß-hCG level in UAE group versus non-UAE group were 47 versus 47 days, 30 versus 30 mm,2 versus 2 mm, 36 524 versus 32 226 U/L (all P>0.05). Out of 104, 100 patients were managed successfully with hysteroscopic surgery, and 4 patients transformed to laparoscopic or laparotomy surgery. Hysteroscopic surgery was effective in 63 out of 67 patients (94%) in UAE group and 34 out of 37 patients (92%) in non-UAE group (P>0.05). There was no significant differences regarding uterine perforation rate, uterine packing rate, hemoglobin change and recovery time between UAE group and non-UAE group (all P>0.05). The median hospital day was 7 days in UAE group versus 5 days in non-UAE group (P<0.01). The median hospital stay cost was 13 654 yuan in UAE group versus 9 108 yuan in non-UAE group (P<0.01). Serious complication occurred in 4 patients (6%, 4/67) in UAE group and 2 patients (5%, 2/67) in non-UAE group (P=0.906). Conclusions: Hysteroscopic surgery is effective and safe for patients with type Ⅱ CSP in the first trimester with size ≤30 mm in diameter and gestation age<7 weeks. The value of prophylactic UAE is uncertain.

An Unusual Case of Live Caesarean Scar Ectopic Pregnancy: A Common Entity in an Uncommon Location.

BACKGROUND: Scar pregnancy is an extremely rare type of ectopic pregnancy, where there is implantation of the gestational sac onto the anterior wall of the uterus at the site of previous LSCS scar in a multipara female. Due to a poor vascular supply to the lower uterine segment, caesarean scars may heal improperly predisposing it to be a site of improper implantation of the gestational sac. RESULTS: The characteristic features are empty uterus and cervix, gestational sac in the anterior part of lower uterine segment with a history of painless vaginal bleeding. It carries a high risk of morbidity related to uterine rupture and extensive haemorrhage. CONCLUSIONS: In case of a previous LSCS delivery in a female with a viable gestational sac in the lower uterine segment and elevated B-Hcg levels, the possibility of scar ectopic pregnancy should be considered. KCl or methotrexate can be injected directly into the foetal pole under transvaginal ultrasound guidance in order to stop the cardiac activity in the foetus. The knowledge of the specific ultrasound features of uncommon locations of ectopic pregnancies such as an ectopic scar is crucial for a correct diagnosis and early management in order to prevent complications.

The Risk Factors and Pregnancy Outcomes of 48 Cases of Heterotopic Pregnancy from a Single Center.

The purpose of this study was to investigate risk factors that are associated with heterotopic pregnancy (HP) following in vitro fertilization (IVF)-embryo transfer (ET) and to demonstrate the outcomes of HP after the surgical treatment of ectopic pregnancies. Forty-eight patients from a single center, who were diagnosed with HP between 1998 and 2012 were included. All of the patients had received infertility treatments, such as Clomid with timed coitus (n = 1, 2.1%), superovulation with intrauterine insemination (n = 7, 14.6%), fresh non-donor IVF-ET (n = 33, 68.8%), and frozen-thawed cycles (n = 7, 14.6%). Eighty-four additional patients were randomly selected as controls from the IVF registry database. HP was diagnosed at 7.5 ± 1.2 weeks (range 5.4-10.3) gestational age. In six cases (12.5%), the diagnosis was made three weeks after the patients underwent treatment for abortion. There were significant differences in the history of ectopic pregnancy (22.5% vs. 3.6%, P = 0.002). There were no significant differences in either group between the rates of first trimester intrauterine fetal loss (15.0% vs. 13.1%) or live birth (80.0% vs. 84.1%) after the surgical treatment for ectopic pregnancy. The risk factors for HP include a history of ectopic pregnancy (OR 7.191 [1.591-32.513], P = 0.010), abortion (OR 3.948 [1.574-9.902], P = 0.003), and ovarian hyperstimulation syndrome (OHSS) (OR 10.773 [2.415-48.060], P = 0.002). In patients undergoing IVF-ET, history of ectopic pregnancy, abortion, and OHSS may be risk factors for HP as compared to the control group of other IVF patients. The surgical treatment of HP does not appear to affect the rates of first trimester fetal loss or live birth.

Chronic interstitial ectopic pregnancy presenting with a negative urine pregnancy test.

The ampulla portion of the fallopian tube is the most common site of ectopic pregnancy (70%), with approximately 2% of pregnancies implanted in the interstitial portion. In general, an interstitial ectopic pregnancy (IEP) is difficult to diagnose and is associated with a high rate of complications-most patients with an IEP present with severe abdominal pain and haemorrhagic shock due to an ectopic rupture. Chronic tubal pregnancy (CTP) is an uncommon condition with an incidence of 20%. The CTP has a longer clinical course and a negative or low level of serum beta-human chorionic gonadotropin due to perished chorionic villi. This study presents a case of a woman who was diagnosed with a chronic IEP (CIEP) which was successfully treated by surgery. This case also acts as a cautionary reminder of considering a CIEP in women of reproductive age presenting with amenorrhea, vaginal bleeding and a negative pregnancy test.

The risk of miscarriage following surgical treatment of heterotopic extrauterine pregnancies.

STUDY QUESTION: What is the risk of loss of a live normally sited (eutopic) pregnancy following surgical treatment of the concomitant extrauterine ectopic pregnancy? SUMMARY ANSWER: In women diagnosed with heterotopic pregnancies, minimally invasive surgery to treat the extrauterine ectopic pregnancy does not increase the risk of miscarriage of the concomitant live eutopic pregnancy. WHAT IS KNOWN ALREADY: Previous studies have indicated that surgical treatment of the concomitant ectopic pregnancy in women with live eutopic pregnancies could be associated with an increased risk of miscarriage. The findings of our study did not confirm that. STUDY DESIGN SIZE DURATION: A retrospective observational case-control study of 52 women diagnosed with live eutopic and concomitant extrauterine pregnancies matched to 156 women with live normally sited singleton pregnancies. The study was carried out in three London early pregnancy units (EPUs) covering a 20-year period between April 2000 and November 2019. PARTICIPANTS/MATERIALS SETTING METHODS: All women attended EPUs because of suspected early pregnancy complications. The diagnosis of heterotopic pregnancy was made on ultrasound scan and women were subsequently offered surgical or expectant management.There were three controls per each case who were randomly selected from our clinical database and were matched for maternal age, mode of conception and gestational age at presentation. MAIN RESULTS AND THE ROLE OF CHANCE: In the study group 49/52 (94%) women had surgery and 3/52 (6%) were managed expectantly. There were 9/52 (17%, 95% CI 8.2-30.3) miscarriages <12 weeks' gestation and 9/49 (18%, 95% CI 8.7-32) miscarriages in those treated surgically. In the control group, there were 28/156 (18%, 95% CI 12.2-24.8) miscarriages <12 weeks' gestation, which was not significantly different from heterotopic pregnancies who were treated surgically [odds ratio (OR) 1.03 95% CI 0.44-2.36]. There was a further second trimester miscarriage in the study group and one in the control group. The live birth rate in the study group was 41/51 (80%, 95% CI 66.9-90.2) and 38/48 (79%, 95% CI 65-89.5) for those who were treated surgically. These results were similar to 127/156 (81%, 95% CI 74.4-87.2) live births in the control group (OR 0.87, 95% CI 0.39-1.94). LIMITATIONS REASONS FOR CAUTION: This study is retrospective, and the number of patients is relatively small, which reflects the rarity of heterotopic pregnancies. Heterotopic pregnancies without a known outcome were excluded from analysis. WIDER IMPLICATIONS OF THE FINDINGS: This study demonstrates that in women diagnosed with heterotopic pregnancies, minimally invasive surgery to treat the extrauterine pregnancy does not increase the risk of miscarriage of the concomitant live eutopic pregnancy. This finding will be helpful to women and their clinicians when discussing the options for treating heterotopic pregnancies. STUDY FUNDING/COMPETING INTERESTS: This work did not receive any funding. None of the authors has any conflict of interest to declare. TRIAL REGISTRATION NUMBER: Research Registry: researchregistry6430.

Tissue concentration of vascular endothelial growth factor is not related to the depth of trophoblastic invasion in ampullary pregnancies-A pilot study.

Introduction: The factors that modulate trophoblastic invasion into the tubal wall remain uncertain. Moreover, it is known that the concentration of vascular endothelial growth factor (VEGF) is increased in cases of deeper trophoblastic invasion in the fallopian tubes. Objective: This study aimed to assess if there is a correlation between VEGF tissue expression and the depth of trophoblastic infiltration into the tubal wall in patients with ampullary pregnancy. Methods: A cross-sectional study was conducted in patients with a diagnosis of tubal pregnancy in the ampullary region who underwent salpingectomy. Inclusion criteria were spontaneously conceived singleton pregnancies, diagnosis of tubal pregnancy in the ampullary region, and radical surgical treatment. A lack of agreement regarding the location of the tubal pregnancy and impossibility of either anatomopathological or tissue VEGF analysis were the exclusion criteria. Histologically, trophoblastic invasion into the tubal wall was classified as grade I when limited to the tubal mucosa, grade II when it reached the muscle layer, and grade III when it comprised the full thickness of the tubal wall. A total of 42 patients fulfilled the inclusion criteria and were selected to participate in the study. Eight patients were excluded. After surgery, tissue VEGF expression was measured by immunohistochemistry and the point counting technique. Results: Histological analysis revealed that eight patients had stage I tubal infiltration, seven had stage II, and 19 had stage III. The difference between the percentage of VEGF expression in the trophoblastic tissue was not significant in relation to the degree of trophoblastic invasion (p = 0.621) (ANOVA). Trophoblastic tissue VEGF showed no statistical difference for prediction of both degrees of trophoblastic invasion (univariate multinomial regression). Conclusion: The depth of trophoblastic penetration into the tubal wall in ampullary pregnancies is not associated with tissue VEGF expression.

[Ectopic pregnancy on uterine scar from cesarean section] / Embarazo ectópico sobre cicatriz uterina por cesárea.

Ectopic pregnancy is defined as the implantation of the fertilized egg outside the uterine cavity. About 95% of ectopic pregnancies are located in the tube. Non-tubal forms, in particular on the scar of a cesarean section, are a very rare entity whose early diagnosis and treatment are essential to avoid serious complications and preserve fertility.

El embarazo ectópico se define como la implantación del óvulo fecundado fuera de la cavidad uterina. Alrededor del 95% de los embarazos ectópicos se localizan en la trompa. Las formas no tubáricas, en concreto sobre la cicatriz de una cesárea, son una entidad muy poco frecuente cuyo diagnóstico y tratamiento precoz son imprescindibles para evitar complicaciones graves y preservar la fertilidad.

Angular Pregnancy: An Eccentric Implantation Within Uterine Cavity.

Angular ectopic is a rare form of ectopic pregnancy which is diagnosed as intrauterine pregnancy on ultrasound but may rupture in second trimester leading to maternal mortality. We present a case of a 32-year-old primigravida who presented at 18 weeks gestation to the emergency department of national hospital Lahore with complaint of dizziness, sweating and epigastric pain for one hour. She had an episode of diarrhoea and vomiting at hospital followed by rapidly increased abdominal distension and signs of hypovolemic shock. Urgent ultrasound suggested rupture of posterior uterine wall and massive hemoperitoneum. An urgent laparotomy was done. Uterus was perforated by pregnancy posteriorly. baby was inside the sac and alive. But died soon after birth. Uterus was repaired in two layers. Stepwise devascularization of uterus was done due to continuous bleeding. 6 units whole blood 6 FFP were transfused. The abnormal location of this pregnancy makes it antenatal diagnosis difficult. A high index of suspicion is needed in pregnant women presenting in shock even when intrauterine location of pregnancy is diagnosed in first trimester.