Tubal patency assessment using sequential transvaginal ultrasound and hysterosalpingo-foam sonography after methotrexate treatment for tubal pregnancy.

RESEARCH QUESTION: What is the efficacy of sequential two-dimensional transvaginal ultrasound (2D-US) and hysterosalpingo-foam sonography (HyFoSy) after methotrexate (MTX) treatment for tubal pregnancy among patients who desire a future pregnancy? DESIGN: A prospective trial conducted between May 2019 and November 2020. Patients who had a suspected tubal ectopic pregnancy diagnosed by ultrasound and treated by MTX were included. These patients underwent sequential transvaginal 2D-US assessment of the pelvic organs and a complementary HyFoSy for tubal patency. The primary outcome was tubal obstruction in the affected side. RESULTS: A total of 360 women underwent sequential transvaginal 2D-US assessment of the pelvic organs and a complementary HyFoSy for tubal patency. Of these, 40 (11.1%) women fulfilling the inclusion criteria were enrolled. In six out of 40 (15%), hydrosalpinx of the affected tube was found during the initial transvaginal ultrasound examination and were excluded from further investigation. In the remaining 34 (85%) patients, HyFoSy was carried out. Tubal block was found in 10 out of 34 (29.4%) patients. Of these, eight out of 34 (23.5%) and two out of 34 (5.9%) had a proximal block of the affected tube and bilateral proximal obstruction, respectively. Hysterosalpingography confirmed the tubal obstruction in all the affected cases. No procedure-related complications were documented. CONCLUSIONS: Forty per cent of women who were treated by MTX for tubal pregnancy were diagnosed with tubal obstruction. We recommend that sequential transvaginal ultrasound and HyFoSy become part of routine follow-up for these women, thus offering them timely referral to the appropriate specialist.

Serum ß-HCG Level in Women Diagnosed as Having Retained Products Of Conception: A Prospective Cohort Study.

STUDY OBJECTIVE: Retained products of conception (RPOC) may occur after delivery or abortion, often necessitating operative hysteroscopy for their removal. A preoperative diagnosis of RPOC by ultrasonography is not always accurate and may lead to unnecessary surgical procedures. We sought to evaluate whether serum level of ß-human chorionic gonadotropin (ß-HCG) may aid in the preoperative diagnosis of RPOC. DESIGN: A prospective cohort study. SETTING: Gynecology department in a university affiliated medical center. PATIENTS: Women undergoing operative hysteroscopy for removal of RPOC between December 2019 and January 2021. INTERVENTIONS: Operative hysteroscopy for RPOC removal. Serum ß-HCG levels were obtained on the day of surgery, and level ≥5.0 mIU/mL was considered positive. All operative specimens were evaluated by pathology for the presence of trophoblastic tissue. MEASUREMENTS AND MAIN RESULTS: Of the 105 women recruited to the study, the operative pathology showed trophoblastic tissue in 81 cases (77.1%), and they were included in the data analysis. The ß-HCG level was positive in 16 of those 81 cases (19.8%). Positive ß-HCG level was significantly associated with RPOC after an abortion (surgical or medical) compared with RPOC after delivery. In addition, the mean RPOC mass was larger in the ß-HCG-positive group than the ß-HCG-negative group (29.1 ± 9.5 mm vs 23.8 ± 8.9 mm, respectively, p = .004), and the interval from termination of pregnancy to surgery was shorter (4.8 ± 1.7 weeks vs 7.5 ± 2.1 weeks, respectively, p <.001). Relatively high ß-HCG level (352 mIU/mL and 3561 mIU/mL) were found in 2 cases in which the RPOC mass was implanted on a previous cesarean section scar. CONCLUSION: ß-HCG level is noncontributory to the preoperative diagnosis of RPOC.

Torsion of Functional Adnexal Cysts in Pregnancy: Aspiration and Drainage are Important in Preventing Recurrence.

BACKGROUND: Adnexal torsion in pregnancy is often associated with functional adnexal cysts, especially in pregnancies conceived by ovulation induction (OI) or in-vitro fertilization (IVF). During laparoscopy for adnexal de-torsion, drainage of the functional cysts can be attempted, although this procedure may cause bleeding. OBJECTIVES: To investigate the characteristics of ovarian torsion in pregnancy associated with functional cysts and to compare the rate of torsion recurrence following de-torsion alone versus cyst drainage. METHODS: All cases of surgically diagnosed adnexal torsion occurring during pregnancy between January 2007 and April 2019 in our department were retrospectively analyzed. The cases of torsion associated with presumed functional ovarian cysts were selected. The rate of recurrent torsion during the same pregnancy was compared for de-torsion alone versus de-torsion and cyst aspiration. RESULTS: Of the 113 women who experienced adnexal torsion during pregnancy, 71 (67.0%) of torsion cases were caused by presumed functional ovarian cysts. Among women with torsion of functional ovarian cysts, the rate of torsion recurrence was significantly higher in patients who underwent de-torsion alone (n=28) compared to women who underwent aspiration and drainage of the ovarian cysts (n=43) (14.3% vs. 0, P = 0.021). There were no cases of intra- or post-operative bleeding in the study cohort. CONCLUSIONS: Functional ovarian cysts are the most common adnexal pathology encountered in pregnant women with torsion. Intra-operative cyst aspiration and drainage may reduce the risk of recurrent torsion. Further multi-center studies are required to validate our data prospectively.

Adnexal Torsion in Pregnancy Managed by Laparoscopy Is Associated with Favorable Obstetric Outcomes.

STUDY OBJECTIVE: Most cases of adnexal torsion in pregnancy are currently managed by laparoscopy, which may be associated with increased risks for spontaneous abortion and preterm delivery. We sought to evaluate the obstetric outcomes of these women, with emphasis on their live birth rate and gestational age at delivery. DESIGN: Retrospective cohort study and telephone questionnaire. SETTING: University-affiliated obstetrics and gynecology department. PATIENTS: All pregnant women who underwent laparoscopy for adnexal torsion between 2007 and 2017. Their obstetric outcomes were obtained by retrospective review of medical records and a telephone questionnaire. INTERVENTIONS: Laparoscopy for adnexal detorsion, with or without cyst drainage or cystectomy. MEASUREMENTS AND MAIN RESULTS: The study cohort included 94 women. Most torsion cases (71, 75.5%) were diagnosed in the first trimester of pregnancy, whereas 21 (22.3%) cases and 2 (2.1%) cases were diagnosed in the second and third trimesters, respectively. Conception was achieved by in vitro fertilization or by ovulation induction in 45 (47.9%) cases. The information on pregnancy outcomes was available for 93 women. Of those, live birth was reported for 86 (92.5%) pregnancies, while 6 (6.5%) women had a spontaneous abortion, and 1 woman experienced an intrauterine fetal death. Five cases of spontaneous abortion were diagnosed in the first trimester, all within 3 weeks of surgery. Preterm delivery before 37 gestational weeks was reported for 18 (19.4%) pregnancies and was significantly associated with twin pregnancy (p = .002) and with conception following in vitro fertilization and ovulation induction (p = .03). On logistic regression analysis, preterm delivery was only associated with twin vs singleton gestation (odds ratio, 6.7; 95% confidence interval, 1.3-34.8; p = .02). CONCLUSION: The obstetric outcomes of pregnant women who underwent laparoscopy for adnexal torsion are generally favorable. However, there is a risk for preterm delivery, which is primarily associated with multiple gestations.

A fetal reduction from twin to singleton based on sonography and cell-free fetal DNA testing: A sequential approach to old pitfalls.

OBJECTIVE: We examined the potential value of combining ultrasound and non-invasive prenatal screening (NIPS) of maternal blood to screen for major aneuploidies as an early approach before selective fetal reduction from twin pregnancy to singleton. STUDY DESIGN: The sample was composed of pregnant women with di-chorionic di-amniotic twins who chose to undergo fetal reduction to singleton at 12-24 weeks of gestation. These women were asked to provide a blood sample for cell-free fetal DNA (cffDNA) testing prior to fetal reduction. RESULTS: A total of 24 pregnant women with a twin pregnancy prior to fetal reduction to singleton were enrolled. There were 8 cases with structural anomalies (33.3%) in one twin that dictated fetal reduction. The proportion of patients who underwent selective fetal reduction for fetal abnormalities was larger than in several other studies. The NIPS identified 1 case of Trisomy 13 (4.2%). The other 15 cases (62.5%) had no structural or chromosomal anomalies. The decision to undergo elective reduction of twin pregnancy to singleton was made for social reasons or upon the parents' request. Given the 33% of structural anomalies in the cohort, a cost analysis indicated that this procedure was 6.6-fold less expensive (vs. 4.6-fold with 4% structural anomalies in other publications) than conducting invasive procedures for the entire cohort. CONCLUSION: The findings suggest that an early anatomical scan and cffDNA can increase the overall safety margin and reduce interventional procedures before elective reduction of twin pregnancy to singleton. However, a larger cohort is needed to confirm these results.

Increase rate of ruptured tubal ectopic pregnancy during the COVID-19 pandemic.

OBJECTIVE: During the 2020 COVID-19 pandemic there was a decrease in emergency room arrivals. There is limited evidence about the effect of this change in behavior on women's health. We aimed to evaluate the impact of the COVID-19 pandemic on the diagnosis, treatment and complications of women presenting with a tubal Ectopic Pregnancy (EP). STUDY DESIGN: This is a single centre retrospective cohort study. We compared the clinical presentation, treatment modalities and complications of all women presenting in our institution with a tubal EP during the COVID-19 pandemic between 15 March and 15 June 2020, with women who were treated in our institution with the same diagnosis in the corresponding period for the years 2018-2019. RESULTS: The study group included 19 cases of EP (N = 19) that were treated between the 15 March 2020 and 15 June 2020. The control group included 30 cases of EP (N = 30) that were admitted to in the corresponding period during 2018 and 2019. Maternal age, parity, gravity and mode of conception (natural vs. assisted) were similar between the two groups. There was no difference in the mean gestational age (GA) according to the last menstrual period. In the study group more women presented with sonographic evaluation of high fluid volume in the abdomen than in the control group (53 % vs 17 %, P value 0.01). This finding is correlated with a more advanced disease status. In the study group there was a highly statistically significant 3-fold increase in rupture among cases (P < 0.005) and a 4-fold larger volume of blood in the entrance to the abdomen (P < 0.002). We found that there were no cases of ruptured EP in the group of women who were pregnant after assisted reproduction. CONCLUSION: We found a higher rate of ruptured ectopic pregnancies in our institution during the COVID-19 pandemic. Health care providers should be alerted to this collateral damage in the non-infected population during the COVID-19 pandemic.

Is scanning for vasa previa important for singleton pregnancies that started as multiple conceptions?

OBJECTIVES: Vasa previa (VP) is a congenital placentation disorder in which fetal vessels run across the internal os of the cervix under the fetal presentation. This rare condition is associated with a high rate of perinatal morbidity and mortality when undetected before delivery. Roughly 85% of all cases of VP can be associated with one or more identifiable risk factors including in-vitro fertilization (IVF), multiple gestations, bilobed, succenturiate or low-lying placentas, and velamentous cord insertion (VCI). Recent evidence indicates the need for standardized prenatal targeted scanning protocols of pregnancies at risk of VP. The present study reports on pregnancies that began with multiple gestations but ended with a single fetus diagnosed with VP. STUDY DESIGN: We retrospectively collected and reviewed medical records from 2006 to 2018 of early multiple pregnancies that ended with a single fetus diagnosed with VP in our medical center, including three cases of twin gestation complicated by a vanishing twin and a case of multifetal reduction in triplet pregnancy. This retrospective cohort study was approved by our Institutional Clinical Research Committee. RESULTS: The database search identified 50 pregnancies that started as multiple gestations but continued as singletons. Of these, 4 pregnancies were diagnosed with VP, for a prevalence of 8.0%. For two of the four cases, the diagnosis was made during delivery as expressed by a low Apgar score at 1 and 5 min, a low cord blood pH value, newborn resuscitation, blood product transfusion, and NICU supervision. There was a statistically significant difference in the prevalence of VP in pregnancies that started as multiple gestations but continued later as singletons compared to multiple pregnancies (8.0% vs. 0.2% respectively, p < 0.0001). The OR for VP in pregnancies that started as multiple gestations but continued as singletons was 41.1 (95% CI, 12.77-131.94). CONCLUSIONS: Our findings suggest there is an increased risk of VP in conceptions that started as viable multiple gestations but continued later as singletons. If our findings supported by others, it may be prudent to consider all twins at the beginning of pregnancy to be at risk for VP, irrespective of the actual number of life fetuses at later stages of gestation.