Systemic methotrexate (MTX) in early pregnancy: a retrospective study of a tertiary maternity hospital.

BACKGROUND: Methotrexate (MTX) is used in clinical practice as a medical treatment option in patients with early pregnancy complications like ectopic pregnancy. AIMS: To review systemic MTX therapy use in the first trimester of pregnancy in our hospital and to examine subsequent clinical outcomes. METHODS: Retrospective review of all women treated with systemic MTX in early pregnancy identified from electronic prescription records from 1 January 2018 to 31 December 2020 at Cork University Maternity Hospital, Ireland. Relevant data was transcribed from electronic health records. RESULTS: Indications for treatment were tubal ectopic pregnancy (70%, n = 51), persistent pregnancy of unknown location (22%, n = 16) and caesarean scar pregnancy (7%, n = 5). Treatment was successful in 88% (n = 44) of tubal ectopic pregnancies with 73% (n = 37) and 14% (n = 7) of women receiving a single dose and repeated doses, respectively. Only 8% (n = 4) of tubal ectopic pregnancies required emergency surgery for subsequent tubal rupture. In 93% (n = 15) of cases of persistent pregnancy of unknown location, treatment was successful with one patient requiring uterine evacuation. Women with caesarean scar pregnancy were treated with combined MTX and uterine evacuation without complication. CONCLUSIONS: The efficacy of medical treatment with systemic MTX for confirmed tubal ectopic pregnancy in our hospital is in line with national and international standards. Careful consideration should be given to treating caesarean scar pregnancy and persistent pregnancy of unknown location with systemic MTX. Systemic MTX use guided by clinicians specialised in early pregnancy complications and safe medication practices may improve treatment success and reduce adverse events.

Efficacy of letrozole for the treatment of tubal ectopic pregnancy: A meta-analysis.

BACKGROUND: Tubal ectopic pregnancy (EP) is a life-threatening condition, especially if undiagnosed or misdiagnosed, tipically in low income countries and/or where women have limited access to health care. The current management protocol of tubal EP consists of either surgical management, or medical management with methotrexate. Recent studies, while few, have suggested that letrozole, an aromatase inhibitor, may play a role in the medical treatment of tubal EP. OBJECTIVES: To evaluate the effectiveness of letrozole alone in the medical treatment of tubal EP. SEARCH STRATEGY: Electronic databases were searched until 31 December 2023. SELECTION CRITERIA: Retrospective or prospective studies reporting the treatment of tubal EP with letrozole alone were considered eligible for inclusion. DATA COLLECTION AND ANALYSIS: Pooled results were expressed as OR with 95 %CI. Heterogeneity was assessed using Higgins I2. Subgroup analysis was performed to compare outcomes according to time after intervention. Subgroup differences were checked through χ2 test. RESULTS: A total of 152 patients were included. Seventy-nine patients (51.97 %) were treated with letrozole, 39 patients (16.54 %) with methotrexate, and 34 patients (31.49 %) underwent surgical treatment. Pooled data analysis supports the consistency of the effect of letrozole in reducing ß-hCG over time at a comparable rate among studies, and that treatment with letrozole is superior to surgery and has the same efficacy as methotrexate. However, all the included studies were judged at high risk of bias in terms of study design, sample representativeness, and sampling technique. Furthermore, short and long term side effects were not reported in any of the included studies. CONCLUSIONS: Letrozole is a promising alternative to methotrexate and surgical therapy in the treatment of tubal EP. Although this meta-analysis suggests efficacy and low hazard of the drug and encourages its application, the data available today remain extremely sparse, which weakens any claims that can be made, and is not sufficient to assert that letrozole is safe and effective in the treatment of EPs. There is an absolute need for randomized studies with accurate patient selection, fixed doses, large sample sizes, and reporting of short- and long-term side effects to refute or confirm this assumption.

A Systematic Review about Cervical Pregnancy and our Experience.

Background: Cervical ectopic pregnancy is a relatively rare type of ectopic pregnancy and has no standardized guidelines for management. Methods: This systematic review is based on the collection of case reports, published in PubMed/MEDLINE about the resolution of ectopic cervical pregnancies over the last decade and the presentation of a case managed in our healthcare unit. Studies involving cervical pregnancy in the first trimester with the presence of a viable embryo and ß-hCG in the serum below 100.000 mIU/mL were included, while heterotopic pregnancies were excluded. Results: Nineteen articles reporting twenty-three case reports are demonstrated explicitly emphasizing on the management techniques. There is no established approach for the management of this type of ectopic pregnancy. Conclusion: It is important to consider the conservative approaches as first-line treatment in all cases of cervical pregnancy preserving fertility. Minimally invasive methods are also described and preferred as second-line treatment, as reported in our literature review.

Ectopic pregnancy in uterosacral ligament following in vitro fertilisation (IVF) in a patient with Allen-Masters syndrome.

We describe the case of a woman with mild endometriosis and Allen-Masters syndrome after in vitro fertilisation (IVF), presenting at 7 weeks 2 days gestation with abdominal pain. A transvaginal ultrasound revealed a gestational sac with a non-viable fetus near the right ovary. Laparoscopy was performed due to escalating abdominal pain which revealed a ruptured ectopic pregnancy at the right uterosacral ligament (USL) and blood in the pouch of Douglas. A peritoneal incision along the USL facilitated drainage and removal of the ectopic pregnancy. A pathological investigation described the presence of endometrial tissue directly adjacent to products of conception, which suggested a retroperitoneal implantation that may have been facilitated by the presence of an endometriotic lesion. This case underscores the distinctive clinical trajectory of unconventional ectopic pregnancies, provides novel insights into the pathophysiological mechanism of ectopic implantation and underscores the crucial role of comprehensive patient assessment during IVF and subsequent pregnancy in ensuring effective management.

Cesarean Scar Pregnancy With Surgical and Conservative Managements: A Case Report.

A cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy. Proper diagnosis and management of CSP are incredibly important secondary to the risk of uterine rupture and life-threatening hemorrhage. Various medical and surgical management have been described previously. This report looks at two cases of CSP diagnosed at an urban hospital in Atlanta, Georgia. The first woman was 30 years old with a history of five prior CS. She was referred from an abortion clinic for CSP at 6 weeks 2 days gestation. She did not desire future fertility and opted for a hysterectomy. The second woman was 38 years old with a history of three prior CS presenting with vaginal bleeding and abdominal pain and found to have a CSP with a gestation sac measuring 5 weeks 1 day. Given the patient's desires for future fertility, she was treated with a two-dose regimen of systemic intramuscular methotrexate (MTX) at 1 mg/kg with successful resolution of CSP and subsequent intrauterine pregnancy. Due to the high risk of uterine rupture and hemorrhage with CSP, it is important to have a high index of suspicion for diagnosis. Due to the rarity of CSP, and thus difficulty creating quality prospective trials, there is no consensus on the best management yet. Although conservative treatment carries high failure risk, shared decision-making incorporating future fertility desires should be considered when determining management of CSP, and when surgical management is considered a minimally invasive approach should be the standard of care in surgical management.

Laparoscopic Management of a 12-Week Pregnancy Loss in a Rudimentary Uterine Horn.

Unicornuate uterus with rudimentary horn is a rare structural uterine anomaly resulting from incomplete Mullerian duct development and/or fusion. Pregnancy in rudimentary horn is an uncommon presentation of a Mullerian anomaly and may lead to substantial morbidity and mortality due to high risk of uterine rupture with intraabdominal hemorrhage. Medical and/or surgical management may be undertaken; however, currently, no treatment guidelines exist. We describe the management of a 12-week rudimentary horn pregnancy in a 25-year-old multiparous patient with a prior spontaneous preterm breech vaginal delivery and one spontaneous early term cephalic vaginal delivery in whom this congenital uterine condition was previously unknown. The rudimentary horn, nonviable pregnancy, and contiguous ipsilateral fallopian tube were excised laparoscopically without complication. Given the infrequency of rudimentary horn pregnancies and the high risk for obstetric complications, a high index of suspicion should be maintained. We emphasize that a history of preterm birth or malpresentation should raise suspicion for maternal Mullerian anomaly, and that a minimally invasive approach can be feasible for treatment of a rudimentary horn pregnancy.

Complete tubal abortion which didn't require salpingectomy.

Tubal abortion is characterized by the extrusion of the foetus into the abdominal (peritoneal) cavity. It can either be a complete extrusion or incomplete with residual tissue remaining in the fallopian tube. It is a type of ectopic pregnancy that is difficult to determine the exact incidence of tubal pregnancies. Identifying cases of tubal abortions is crucial for individualized care since it can lead to a more conservative treatment approach. The diagnosis should be based on ultrasound imaging, b-hCG levels and visual conformation during exploratory surgery, either open or laparoscopic. The article describes the case of a 30-year old patient who presented with lower abdominal pain and was admitted for a suspected ectopic pregnancy. Ultrasound imaging showed a mass resembling a tubal pregnancy next to the uterus with b-hCG levels of 111.8 U/L. During laparoscopic surgery, a tubal abortion was detected in the pouch of Douglas (Rectouterine pouch). This finding led us to preserve both fallopian tubes. Histopathology confirmed our clinical findings. A conservative approach can be sufficient in case of tubal abortions, which can lead to preserved fertility and tubal functions.

A 20 year experience in the management of non-tubal ectopic pregnancies in a tertiary hospital - a retrospective review.

BACKGROUND: Non-tubal ectopic pregnancies account for < 10% of all ectopic pregnancies. Due to its rarity and wide variation in clinical practice, there is no guideline or consensus for its management. We reported our 20-year experience in the management of non-tubal ectopic pregnancies in a tertiary hospital. METHODS: This is a retrospective review of all women admitted for non-tubal ectopic pregnancies from January 2003 to December 2022 in a tertiary hospital. Women with non-tubal ectopic pregnancies diagnosed by ultrasound or operation were included for analysis. RESULTS: Within the study period, 180 women were diagnosed to have non-tubal ectopic pregnancies at a mean gestation of 6.8 weeks. 16.7% (30/180) were conceived via assisted reproduction. Medical treatment was the first-line management option for 81 women, of which 75 (92.1%) women received intralesional methotrexate administered under transvaginal ultrasound guidance. The success rate of intralesional methotrexate ranges from 76.5% to 92.3%. Intralesional methotrexate was successful even in cases with a positive fetal pulsation or with high human chorionic gonadotrophin levels up to 252605U/L. Twenty seven women were managed expectantly and 40 underwent surgery. Nine (11.1%), two (6.1%), and one (2.3%) women required surgery due to massive or recurrent bleeding following medical, expectant, or surgical treatment. Hysterotomy and uterine artery embolization were necessary to control bleeding in one Caesarean scar and one cervical pregnancy. CONCLUSIONS: Intralesional methotrexate is more effective than systemic methotrexate and should be considered as first line medical treatment for non-tubal ectopic pregnancies. It has a high success rate in the management of unruptured non-tubal ectopic pregnancies even in the presence of fetal pulsations or high human chorionic gonadotrophin levels, but patients may require a prolonged period of monitoring. Close surveillance and readily available surgery were required due to the risk of heavy post-procedural intra-abdominal bleeding.

Infertility and pregnancy outcomes among adults with primary ciliary dyskinesia.

STUDY QUESTION: What is the prevalence of infertility and ectopic pregnancies among individuals with primary ciliary dyskinesia (PCD)? SUMMARY ANSWER: We found that 39 of 50 men (78%) and 72 of 118 women (61%) with PCD were infertile and that women with PCD had an increased risk of ectopic pregnancies (7.6 per 100 pregnancies, 95% CI 4.7-12.2). WHAT IS KNOWN ALREADY: PCD is a heterogeneous multiorgan disease caused by mutations in genes required for the function and structure of motile cilia. Previous studies identified a link between PCD and infertility, but original data on prevalence of infertility and risk of ectopic pregnancies, the use and efficacy of medically assisted reproduction (MAR), and the association of fertility with PCD genotype are extremely limited. STUDY DESIGN SIZE DURATION: We performed a cross-sectional survey about fertility within the Living with PCD study (formerly COVID-PCD). Living with PCD is an international, online, participatory study that collects information directly from people with PCD. People with PCD of any age from anywhere in the world can participate in the study. At the time of the survey, 482 adults with PCD were registered within the Living with PCD study. PARTICIPANTS/MATERIALS SETTING METHODS: We sent a questionnaire on fertility on 12 July 2022, to all participants older than 18 years enrolled in the Living with PCD study. Responses were collected until 8 March 2023. The fertility questionnaire covered topics related to pregnancy attempts, use of MAR, and pregnancy outcomes. Data were collected via the Research Electronic Data Capture (REDCap) platform. We defined infertility as failure to achieve a clinical pregnancy after 12 months or use of MAR for at least one pregnancy. MAIN RESULTS AND THE ROLE OF CHANCE: In total, 265 of 482 adult participants (55%) completed the fertility questionnaire. Among 168 adults who had tried to conceive, 39 of 50 men (78%) and 72 of 118 women (61%) were infertile. Of the infertile men, 28 had tried MAR, and 17 of them (61%) fathered a child with the help of MAR. Among infertile women, 59 had used MAR, and 41 of them (69%) became pregnant with the help of MAR. In our population, women with PCD showed a relatively high risk of ectopic pregnancies: 1 in 10 women who became pregnant had at least one ectopic pregnancy and 7.6% of pregnancies were ectopic (95% CI 4.7-12.2). We evaluated the association between fertility and affected PCD genes in 46 individuals (11 men, 35 women) with available genetic and fertility information, and found differences between genotypes, e.g. all five women with a mutation in CCDC40 were infertile and all five with DNAH11 were fertile. LIMITATIONS REASONS FOR CAUTION: The study has limitations, including potential selection bias as people experiencing problems with fertility might be more likely to fill in the questionnaire, which may have influenced our prevalence estimates. We were unable to validate clinical data obtained from participant self-reports owing to the anonymous study design, which is likely to lead to recall bias. WIDER IMPLICATIONS OF THE FINDINGS: The study underlines the need for addressing infertility in routine PCD care, with a focus on informing individuals with PCD about their increased risk. It emphasizes the utility and efficacy of MAR in PCD-related infertility. Additionally, women attempting conception should be made aware of the increased risk of ectopic pregnancies and seek systematic early consultation to confirm an intrauterine pregnancy. Fertility, efficacy of MAR, and risk for adverse pregnancy outcomes differ between people with PCD-depending on genotypes-and close monitoring and support might be needed from fertility specialists to increase chances of successful conception. STUDY FUNDING/COMPETING INTERESTS: Our research was funded by the Swiss National Science Foundation, Switzerland (SNSF 320030B_192804), the Swiss Lung Association, Switzerland (2021-08_Pedersen), and we also received support from the PCD Foundation, USA; the Verein Kartagener Syndrom und Primäre Ciliäre Dyskinesie, Germany; the PCD Support UK, UK; and PCD Australia, Australia. M. Goutaki received funding from the Swiss National Science Foundation, Switzerland (PZ00P3_185923). B. Maitre participates in the RaDiCo-DCP funded by INSERM France. The study authors participate in the BEAT-PCD Clinical Research Collaboration supported by the European Respiratory Society. All authors declare no conflict of interest. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov ID NCT04602481.

Ectopic pregnancy with full implantation of the gestational sac in the caesarean section scar managed successfully with laparotomy.

Caesarean scar pregnancy represents one of the rarest locations of ectopic pregnancies. It occurs when the blastocyst is implanted in a scar from a previous caesarean section. A dramatic increase of its prevalence has been observed for the last decades, reaching about 21% globally. Early diagnosis and treatment are crucial to avoid maternal morbidity and mortality. Our case presents the characteristic appearance of a caesarean scar pregnancy with full implantation of the gestational sac in the scar, which was managed successfully with laparotomy.

Bilateral tubal ectopic pregnancy following induction ovulation can be missed in emergent ultrasonography: Case report.

INTRODUCTION: Bilateral tubal ectopic pregnancy (BTP) is a rare and potentially life-threatening condition that is, often challenging to diagnose preoperatively. PRESENTATION OF CASE: We present a case of BTP in a 25-year-old primigravid woman with a history of infertility due to polycystic ovarian syndrome. She was receiving letrozole when she presented with severe abdominal pain and vaginal bleeding. Initial evaluation revealed a ruptured ectopic pregnancy in the right fallopian tube, prompting an emergency laparotomy. During surgery, a second intact ectopic mass was discovered in the left fallopian tube, highlighting the diagnostic complexity of BTP. Management involved a salpingectomy on the right side and salpingostomy on the left to preserve fertility. DISCUSSION: This case underscores the importance of considering BTP in the differential diagnosis of ectopic pregnancies and the necessity for thorough preoperative imaging studies, namely ultrasonography and surgical exploration, to prevent missed diagnoses. CONCLUSION: BTP is a rare and challenging clinical entity that requires a comprehensive approach to diagnosis and management. Early recognition, prompt intervention, and close surveillance are essential to mitigate the risk of maternal morbidity and mortality associated with this condition.

Comparing the effectiveness of letrozole versus methotrexate for treatment of ectopic pregnancy: A randomized controlled trial.

OBJECTIVE: To evaluate the efficacy of two different regimens of Letrozole, an aromatase inhibitor, in the management of ectopic pregnancy compared to methotrexate. STUDY DESIGN: This randomized controlled trial was conducted on 88 women diagnosed with ectopic pregnancy with a baseline level of serum beta-human chorionic gonadotropin under 3000 mIU/mL between June 30, 2023, and December 30, 2023, at the Department of Obstetrics and Gynecology of the Vali-e-Asr Hospital affiliated with Tehran University of Medical Sciences. Participants were allocated into either methotrexate (n = 43), 5-day course Letrozole (n = 24), or 10-day course Letrozole (n = 21) treatments. The methotrexate group received a single dose of 50 mg/m2 dosage intramuscular methotrexate. The 5-day Letrozole group received a 2.5 mg Letrozole tablet three times daily for 5 days, whereas the 10-day Letrozole group received a 2.5 mg Letrozole tablet twice daily for 10 days. The primary outcome was the treatment response, defined as the achievement of a negative serum beta-human chorionic level without the need for additional methotrexate treatment or surgery. The secondary outcomes were the need for additional methotrexate dose or laparoscopic surgery intervention. The trial protocol was prospectively registered in ClinicalTrials.gov with code NCT05918718. RESULTS: The treatment response rates in methotrexate, 5-day Letrozole, and 10-day Letrozole groups were 76.7 %, 75.0 %, and 90.5 %, respectively, with no significant differences between the groups (P-value = 0.358). A total of 10 (23.3 %) patients from the methotrexate group, 3 (12.5 %) from the 5-day Letrozole group, and 2 (9.5 %) from the 10-day Letrozole group required an additional methotrexate dose, with no significant differences between the groups (P-value = 0.307). Furthermore, only 3 (12.5 %) patients, all from the 5-day Letrozole group, were suspected of tubal rupture and underwent surgery (P-value = 0.016). CONCLUSION: Our findings suggest Letrozole as a safe alternative to methotrexate in treating stable ectopic pregnancies, with a favorable treatment response rate. However, there is still a need for future larger studies to determine the applicability of Letrozole in the EP management. Also, the non-significant higher effectiveness of the 10-day Letrozole regimen than the 5-day Letrozole group underscores the need for future research to determine the optimal Letrozole regimen for the management of ectopic pregnancy.

An Uncommon Encounter: Obstetric Management of a Bicornuate Bicollis Uterus With a Longitudinal Vaginal Septum.

This case report describes a rare presentation of a bicornuate bicollis uterus with a longitudinal vaginal septum in a 25-year-old woman presenting with a ruptured ectopic pregnancy. The patient's obstetric history revealed a previous cesarean section due to oligohydramnios. The diagnosis was confirmed through intraoperative assessment and MRI findings. Despite successful management of the ectopic pregnancy, the case underscores the importance of early detection and tailored management of Mullerian anomalies to optimize pregnancy outcomes. This report highlights the need for continued research to improve diagnostic accuracy and therapeutic approaches for such complex anatomical variations.

Stump Ectopic Pregnancy: A Rare Presentation.

Ectopic pregnancy is a significant cause of maternal morbidity and mortality in women of reproductive age group. Tubal ectopic in an unstable patient is a medical emergency. Tubal stump ectopic is a rare presentation. It is difficult to diagnose. Early diagnosis can prevent significant morbidity and mortality. Here, we present a case of ruptured tubal stump ectopic pregnancy in a 33-year-old female who had undergone salpingectomy previously for ectopic pregnancy.

Laparoscopic Excision of Cesarean Scar Ectopic Pregnancy: An Optimum Management Option.

Cesarean scar ectopic pregnancy is a leading cause of life-threatening complications in the first trimester. It poses a diagnostic and management challenge; if not diagnosed and adequately treated in early pregnancy, it may lead to considerable maternal morbidity and mortality. We report a case series of cesarean scar ectopic pregnancies managed successfully by laparoscopy. Laparoscopic excision is the gold standard management approach for cesarean scar ectopic pregnancy.

Surgical Outcomes and Trends in Incidence of Ectopic Pregnancy.

Objectives: We aimed to evaluate the surgical results for ectopic pregnancy (EP) treated at Fukushima Red Cross Hospital for over a 20-year period from 2002 to 2021. Materials and Methods: We evaluated the incidence, surgical procedures, site of implantation, amount of hemoperitoneum, and the proportion of cases with risk factors of EP. Results: Two hundred and fifty-nine cases of EP were treated surgically. The incidence of EP seemed to be gradually decreasing in recent years. By pregnancy site, 235 (90.7%) of EPs were tubal pregnancies (TPs), 13 in interstitial pregnancies (IPs), 7 in ovarian pregnancies, and 4 in peritoneal pregnancies. For IPs, human chorionic gonadotropin (hCG) levels were statistically higher than with TP and intraperitoneal bleeding was less than with other EP sites. Thirty-nine patients (15.0%) were with massive hemoperitoneum (>500 mL), and laparoscopic surgery was performed in all patients with massive hemoperitoneum except in two patients. The proportion of cases with risk factors for EP such as Chlamydia trachomatis infection or history of smoking was 5.4% and 40.6%, respectively. Epidemiological research shows that the number of patients with chlamydia infection, rates of smokers, or the occurrence of EP with assisted reproductive technology has been decreasing in recent years in Japan. Conclusion: Appropriate surgical intervention should be selected while considering such as facility capabilities, context, and surgeon skill, especially in critical cases, such as cases involving massive hemoperitoneum and hemorrhagic shock. The recent presumed decrease in the occurrence of EP may partly be associated with the decrease in the occurrence of risk factors.

Expression of E-Cadherin and Ber-EP4 in the Trophoblastic Tissues of Intrauterine and Ectopic Tubal Pregnancies.

Introduction: We investigated the role of E-cadherin and Ber-EP4 in tubal pregnancy by comparing their expressions in epithelial and trophoblastic cells both in ectopic tubal and intrauterine pregnancies. Methods: The Formalin-fixed paraffin embedded blocks of 17 intrauterine and 17 tubal pregnancies were immunohistochemically stained with E-cadherin and Ber-EP4. Results: E-cadherin was expressed in the epithelium, villous and extravillous trophoblast in tubal and intrauterine pregnancies but not in the syncytiotrophoblast. The staining intensity was lower in the extra-villous trophoblast in tubal ectopic pregnancies compared with intrauterine pregnancies. Ber-EP4 was expressed in the epithelium of tubal and intrauterine pregnancies and only in villous cytotrophoblast. The intensity of staining in tubal pregnancy was higher than in intrauterine pregnancy. Discussion: The loss of E-cadherin expression in extra-villous trophoblast and increased expression of Ber-EP4 in the villous cytotrophoblast may play a role in the formation of tubal pregnancy by allowing the blastocyst to attach to the tubal epithelium.

Navigating Diagnostic Challenges: Heterotopic Pregnancy Versus Hyperdecidual Reaction in Ectopic Gestation.

In the intricate field of obstetrics and gynecology, few scenarios present as complex a diagnostic challenge as the differentiation between heterotopic pregnancy, hyperdecidual reaction, and ectopic pregnancy. These conditions, while distinct, often blur together in clinical presentation, necessitating a nuanced understanding to achieve accurate diagnosis and timely intervention. A heterotopic pregnancy is a rare and potentially life-threatening condition in which a woman simultaneously carries two pregnancies in different locations. One pregnancy is typically located within the uterus (an intrauterine pregnancy), while the other is located outside the uterus, most commonly in one of the fallopian tubes (an ectopic pregnancy). This condition is sometimes referred to as a combined intrauterine and extrauterine pregnancy. The diagnosis of heterotopic pregnancy can be challenging because the symptoms can mimic those of a normal intrauterine pregnancy or an ectopic pregnancy. A combination of clinical symptoms, physical examination, and imaging studies, such as transvaginal ultrasound, can help in the diagnosis. After surgical or medical treatment, close monitoring and follow-up with a healthcare provider are essential. The remaining intrauterine pregnancy will need careful observation to ensure it continues to develop normally. However, in some cases of ectopic pregnancy, there will be hyperdecidual reaction within the uterus, which may sometimes create confusion with intrauterine pregnancy. Here, a case of ectopic pregnancy that was radiologically misdiagnosed as heterotopic pregnancy is presented to highlight the possibility of ectopic pregnancies being misdiagnosed as heterotopic pregnancy due to the hyperdecidual reaction. The index case underwent laparoscopic salpingectomy for tubal ectopic and dilatation and evacuation for suspected failed intrauterine pregnancy. The histopathological report of the intrauterine products of conception confirmed it to be decidua without any trophoblastic tissue.

Induced abortion and ectopic pregnancy: A systematic review and meta-analysis.

OBJECTIVE: Existing evidence of the relationship between induced abortion and ectopic pregnancy has not been assessed rigorously. This systematic review provides a comprehensive evaluation to examine whether induced abortion (IA) can increase the rate of ectopic pregnancy (EP). METHODS: We searched PubMed, EMBASE, Web of Science, Cochrane, CNKI, WanFang, and Sinomed databases since their inception until February 2023. Eligibility criteria included case-control studies and cohort studies that analyzed induced abortion associated with ectopic pregnancy. Data analyses were conducted by using R-studio Version 1.1.383 software. RESULTS: A total of 33 case-control studies and 7 cohort studies involving 132,926 participants were included. In case-control studies, there was a significant association between induced abortion and ectopic pregnancy by using single-factor analysis data (OR = 2.32, 95% CI = 1.81-2.98). Subgroup analysis by region suggested no statistical significance in the Americas (OR = 1.15, 95% CI = 0.92-1.43) and Eastern Mediterranean (OR = 3.64, 95% CI = 0.88-15.18). The relationship was significant by using multiple regression analysis data (OR = 1.97, 95% CI = 1.38-2.80). In cohort studies, statistical significance was found (OR = 1.42, 95% CI = 1.001-2.018) after omitting one study in sensitivity analysis. The combined results of the two types of studies suggested that induced abortion would increase the risk of ectopic pregnancy to some degree, but the conclusion needs to be considered with caution. CONCLUSION: This study indicated that IA could increase the risk of EP to some degree and the times of IA had a negative impact on the risk. Safe abortion and avoiding repeat abortion due to unintended pregnancy could protect women's fertility.

Combined uterine injury and high rectal perforation complicating abdominal ectopic pregnancy: A case report.

INTRODUCTION AND IMPORTANCE: Abdominal pregnancy is a rare and potentially fatal variant of ectopic pregnancy, presenting unique clinical challenges. This report discusses an unusual case of abdominal pregnancy associated with uterine and high rectal perforations, complications that are rarely reported in clinical practice. CASE PRESENTATION: We report a case involving a 31-year-old woman from a rural area, with a psychiatric history, presenting severe abdominal pain, vomiting, and constipation. Initial investigations revealed a hemopneumoperitoneum and a fetal skeleton in the pelvic area by CT, leading to a diagnosis of abdominal pregnancy. Surgical findings included a nonviable fetus, approximately 5 months gestational age, and perforations in both the rectum and the posterior uterine wall. CLINICAL DISCUSSION: The patient underwent extensive surgery, including placental dissection, anterior rectal resection, Hartmann's colostomy, hysterorrhaphy, and drainage of the peritoneal cavity. The complexity of managing abdominal pregnancy, especially with additional complications such as organ perforations, poses significant surgical challenges. This case emphasizes the need to consider abdominal pregnancy in differential diagnoses of abdominal pain in women, due to the risk of misdiagnosis and complex surgical requirements. CONCLUSION: This case highlights the critical importance of prompt diagnosis and comprehensive care in managing rare and life-threatening presentations of abdominal pregnancy. It underscores the need to increase awareness among clinicians for timely intervention and provides information on the complexities of surgical management in cases with additional organ perforations.